Notes from MCQs

Question 1

Area of the heart supplied by leads V1-2? V3-4? V5-6? V1-6? Leads II, III and aVF?

Answer 1

Anterior
Septal
Lateral
Anterolateral
Inferior

Question 2

Artery supplying anterior area of the heart (leads V1-2)? Septal area (leads V3-4)? Lateral area (leads V5-6)? Anterolateral area (V1-6)? Inferior area (leads II,III and aVF)?

Answer 2

LCA: diagonal LAD branch
LCA: septal LAD branch
LCA: left circumflex artery
LCA: left main stem disease
RCA: posterior descending branch

Question 3

Signs of LVF? RVF? AF usually sign of what valvular dysfunction?

Answer 3

Pulmonary oedema(bibasal crepitations, pleural effusions on CXR, upper lobe blood diversion, Kerley B lines
Raised JVP, bilateral pedal oedema
Mitral stenosis- enlarged atrium disrupts the normal electrical pathways

Question 4

Murmur loudest on inspiration points to what? Signs associated with aortic regurgitation? Narrow pulse pressure signifies what?

Answer 4

Right-sided valve lesion
Corrigan’s (visibly exaggerated pulsating carotids,) de Mussets, Traubes, Quinkes, Duroziez
Aortic stenosis

Question 5

Management for CHAD2 score of 0? 1? 2 or above?

Answer 5

Aspirin
Warfarin or aspirin
Warfarin unless CI

Question 6

Signs of myocardial ischaemia on ECG? Infarction? What is an aborted MI?

Answer 6

Inverted T waves and ST depression
ST elevation, Q waves and raised troponin
A patient with STEMI who goes on to have negative troponin

Question 7

Signs of a PE? Scoring system for predicting the risk of a PE? Mild, moderate and high scores? RFs?

Answer 7

Pleural rub, coarse crackles and AF
Massive= raised JVP, RR, HR and hypotension
Geneva: <=3, 4-10 and >11
>65 y/o, previous DVT/PE, surgery/ fracture<=4 weeks, malignancy, unilateral leg pain, unilateral oedema, haemoptysis, HR 75-94, HR>95

Question 8

What is heard with Barlow syndrome(mitral valve prolapse)? Austin flint murmur? Graham Steell murmur?

Answer 8

Mid-systolic click followed by a late systolic murmur heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole

Question 9

What is a pleural rub common in?

Answer 9

Pleurisy, PE and pneumonia

Question 10

What can PSA levels be raised by in men? What is raised in testicular cancer? What are they raised by?

Answer 10

Prostate cancer, BPH, older age, UTIs and prostatitis
AFP and B-hCG- yolk sac elements/ seminomas

Question 11

What is raised in colorectal cancers? What can CA-125 be raised by? What is raised in bladder cancer?

Answer 11

CEA
Ovarian cancer, endometriosis, liver disease, PID and fibroids
Fibrin

Question 12

Gold standard Ix for diagnosing bladder cancer?

Answer 12

Cystoscopy

Question 13

Serum creatinine and urine output criteria for stage 1 AKI? Stage 2? Stage 3?

Answer 13

Increased level >/=0.3 mg/dl or 150-200% increase from baseline + production <0.5ml/kg/hr for >6 hours
Increased creatinine>200-300% + production <0.5ml/kg/hour for >12 hours
Increased creatinine from baseline or >/=4mg/ dl(acute increase of >/=0.5mg/dl) + urine<0.3ml/kg/hour x 24 hours or anuria in 12 hours
Persistent ARF= complete loss of RF>4 weeks
ESKD>3 months

Question 14

Topical Abx used to treat otitis externa? Plus what if really inflamed/ stenosed/ obscured by debris/ fever/ lymphadenopathy?

Answer 14

Ciprofloxacin or gentamicin
Steroids

Question 15

Tx for otitis media?

Answer 15

Analgesia, amoxicillin after 2-3 days if no sx improvement/ perforation/ systemically unwell
Myringotomy and drainage if no improvement after 1-2 weeks

Question 16

Tx for mastoiditis?

Answer 16

Broad-spec IV ABx, not getting better/ intracerebral spread–> mastoidectomy and grommets, COMPS= VI/ VII palsy, abscess

Question 17

Type of nystagmus seen on Dix-Hallpike test for BBPV?

Answer 17

Rotary nystagmus

Question 18

Large volumes of 0.9% saline lead to an increased risk of what? Hartmann’s should not be used in patients with what?

Answer 18

Hyperchloraemic metabolic acidosis
Hyperkalaemia- contains potassium

Question 19

O2 is only indicated for MI if SATs are below what %? What drugs should be indicated following an MI?

Answer 19

94%
ACEi/ ARB, dual antiplatelet therapy- clopidogrel and aspirin, Beta blocker, statin- CCBs only if Beta blockers are CI

Question 20

What things may show ST elevation on an ECG?

Answer 20

Prinzmetal angina, STEMI and pericarditis

Question 21

What 2 things are used during an episode of bradycardia to speed the heart up?

Answer 21

Atropine and adrenaline

Question 22

2 most common heart murmurs? 2 less common murmurs?

Answer 22

Aortic stenosis–> ejection-systolic murmur and mitral regurg–> pan-systolic murmur
Aortic regurg–> early diastolic murmur, mitral stenosis–> mid-diastolic murmur

Question 23

Resus council’s algorithm for anaphylaxis?

Answer 23

1) ABCDE 2) Check for obvious potential diagnosis 3) Call for help 4) Adrenaline (500mcg of 1:1000 IM) 5) Establish airway/ high flow O2/ IV fluid challenge/ chlorphenamine(antihistamine takes 15-20 minutes to work)/ hydrocortisone

Question 24

What is terbutaline sulfate? What is formoterol fumarate?

Answer 24

A selective Beta2-adrenergic agonist
Long-acting β2 agonist (LABA)

Question 25

What is a common cause of HAP?

Answer 25

Pseudomonas aeruginosa

Question 26

Who are most likely to suffer from a spontaneous PE? What also increases the risk?

Answer 26

Young males with a low BMI, Marfan's syndrome

Question 27

Where is the most appropriate site for a needle thoracostomy for tension pneumothorax?

Answer 27

Over the upper edge of the rib in the 5th IC space on the MC line on the same side as the pneumothorax

Question 28

Which signs would support a diagnosis of tension pneumothorax?

Answer 28

Tracheal deviation away from the affected lung, hypotension and hypoxia

Question 29

How does large SBO present compared to LBO?

Answer 29

Constipation before vomiting due to being more distal in the tract SBO= shorter hx of constipation and vomiting before the constipation

Question 30

What is Mirrizi's syndrome? Sx?

Answer 30

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder Jaundice, fever, and right upper quadrant pain

Question 31

What is UC associated with?

Answer 31

PSC- >75% patients with PSC have UC

Question 32

Most common antibiotics causing c.diff infections?

Answer 32

Clindamycin, cephalosporins, quinolones, co-amoxiclav and aminopenicillins

Question 33

Which drugs are known to cause drug-induced hepatitis?

Answer 33

NSAIDs, paracetamol, statins, methotrexate, antibiotics

Question 34

Mnemonic for APL syndrome? 3 main associated antibodies? Primary thromboprophylaxis? Secondary thromboprophylaxis?

Answer 34

CLOT: coagulopathy, livedo reticularis, obstetric emergencies, thrombocytopenia Anticoagulant, anti-cardiolipin, anti beta2-GP1

Question 35

How do complex partial seizures compare to simple partial seizures?

Answer 35

Complex= awareness affected and confused after, simple= don't affect awareness and there are no post-ictal symptoms

Question 36

What is complicated malaria characterised by?

Answer 36

Vascular occlusion which can affect different organs therefore causing specific sx e.g. cerebral malaria= micro-infarcts and sx= drowsiness, increased intracerebral pressure causing seizures and coma

Question 37

What is imatinib? What is rituximab given in? What is dexamethasone used in treating?

Answer 37

A tyrosine kinase inhibitor given in CML alongside chemo CLL Multiple myeloma

Question 38

Which condition elevates bilirubin levels?

Answer 38

TTP- deficiency in ADAMTS13 enzyme causes the vWF to form thromboses, the body breaks down these clots down to prevent ischaemic damage to organs--> haemolytic anaemia

Question 39

When should systemic treatment with oral antibacterials be used? What about topical/ oral erythromycin or clindamycin? What about systemic antibacterial (e.g. oral tetracycline)? Oral retinoid?

Answer 39

Moderate- severe acne or when topical preparations are not tolerated/ ineffective If non-antibiotic antimicrobials e.g. benzoyl peroxide/ azelaic acid aren't effective Inflammatory acne if topical tx is ineffective/ CI For systemic tx of severe acne(TERATOGENIC)

Question 40

Flow of psoriasis tx?

Answer 40

Emollient--> topical steroid (e.g. hydrocortisone) and a vitamin D analogue (e.g. calcitriol)--> derm referral for phototherapy or oral drugs (e.g. methotrexate, cyclosporin)--> biological immunotherapy- NOT NSAIDs

Question 41

Most common cause of cellulitis (2/3 cases)?

Answer 41

S.pyogenes, 2nd= s.aureus

Question 42

1st and 2nd line treatment for eczema?

Answer 42

Topical corticosteroids, 2nd= topical calcineurin inhibitor

Question 43

What can raised RBCs? What can cause neutrophilia?

Answer 43

Smoking, drinking alcohol or conditions such as PV Chemo comp, viral infection e.g. Hep B/C, HIV, meds e.g. antipsychotics, carbimazole, AI disorders

Question 44

When is the 6-in-1 vaccine given? What is in the 6-in-1 vaccine? MMR vaccine?

Answer 44

8 weeks, 12 weeks and 16 weeks in the thigh(8w= DTaP/ IPV/ Hib/ Hep B/ Men B, Rotavirus, 12w= DTaP/ IPV/ Hib/ Hep B, PCV, Rotavirus, 16w= DTaP, IPV, Hib, Hep B, Men B) 1 and 3 y/o

Question 45

When is the Men B booster given? When is the 4th dose of DTap/ IPV given? When is 4th dose of Hib and Men C also given? PCV booster?

Answer 45

1 y/o 3 y/o 1 y/o 1 y/o

Question 46

When is the HPV vaccine given? Tetanus/ diphtheria/ polio, Men ACWY? When is the influenza vaccine given?

Answer 46

12-13 y/o, 14 y/o Children of primary school age and those in year 7, also from 6m to those at high risk

Question 47

What is congenital adrenal hyperplasia?

Answer 47

An autosomal recessive disorder where there is reduced production of cortisol and aldosterone, adrenal crisis--> metabolic acidosis/ hyperkalaemia and hyponatraemia

Question 48

What is the first component of the extrinsic pathway of the coagulation cascade? How can the severity of haemophilia A be assessed?

Answer 48

By looking at % factor VIII functionality and severity of bleeding

Question 49

Who is Non-Hodgkin lymphoma more common in? What about Hodgkin lymphoma?

Answer 49

Childhood, adolescence

Question 50

Examples of B symptoms?

Answer 50

Unexplained fever, unexplained weight loss, drenching sweats (particularly at night)- can be seen in HIV too

Question 51

1st line tx for acute manic/ mixed episode in bipolar affective disorder? For a depressive episode? Long-term maintenance? What can be added if this doesn't work?

Answer 51

Atypical antipsychotic Atypical antipsychotic + SSRI i.e. olanzapine and fluoxetine Lithium Valproate

Question 52

What is midazolam and what could it be prescribed in? Once alcohol detoxification is established, what should be started? When should be started to prevent relapse?

Answer 52

Rapid-acting benzo- status epilepticus or as an adjunct in a confused and agitated psych patient Acamprosate and disulfiram- 6-12 months

Question 53

Tx for delirium tremens?

Answer 53

IV Pabrinex (Vitamin B1) and high dose Benzo

Question 54

1st rank sx of schizophrenia?

Answer 54

3rd person auditory hallucinations and/ or thought echo, passivity phenomenon(believing thoughts/ actions are being controlled by external force,) thought alienation, encompassing withdrawal, broadcast or insertion and delusional perception

Question 55

Results you'd expect in neuroleptic malignant syndrome?

Answer 55

Raised CK due to muscle rigidity, raised WCC, deranged LFTs, acute renal failure--> abnormal U&Es, metabolic acidosis--> low pH, low HCO3

Question 56

Tx for mild PID?

Answer 56

Start ABx immediately before swab rsults Prescribe doxycycline, metronidazole + IM ceftriaxone Leave in recently inserted coil No response in 48 hours, remove the coil and prescribe any other necessary emergency contraceptives

Question 57

Risk of nitrofurantoin in the 3rd trimester? Sulfonamides? Tetracyclines in general? Trimethoprim in the 1st trimester?

Answer 57

Haemolytic anaemia in neonate with G6PD deficiency Kernicterus Permanent staining of the baby's teeth, issues with skeletal development Neural tube defects

Question 58

1st line tx for stress incontinence? If this doesn't work?

Answer 58

3 months of pelvic floor training Duloxetine/ surgery

Question 59

If after 48 hours you see Beta hCG doubling what is it? If this is seen, what is done in 1-2 weeks to confirm? Rising but not doubling? Falls by half or more?

Answer 59

Intrauterine pregnancy- USS scan Ectopic- needs further monitoring Miscarriage

Question 60

Clinical sx of chorioamnionitis?

Answer 60

Fetal tachycardia, maternal tachycardia, maternal pyrexia, rising leucocyte count, rising CRP, irritable or increased tender uterus

Question 61

What does the Wolffian duct develop into? Testes develop due to the influence of what gene on the Y chromosome?

Answer 61

Rete testis, the ejaculatory ducts, the epididymis, the ductus deferens and the seminal vesicles SRY gene- doesn't require the presence of androgen nor a functional androgen receptor--> testicular development

Question 62

What are the genetics and phenotype in androgen sensitivity syndrome?

Answer 62

Male/ female

Question 63

What sx do you get with secondary syphilis? How soon after infection?

Answer 63

Widespread rash, neurological sx and GN 6-8 weeks

Question 64

To diagnose syphilis, non-specific enzymes are looked using what? React how for a +ve result? What tests look for IgG which remains after tx to confer immunity? Features of congenital syphilis?

Answer 64

Cardiolipin based tests(e.g. VDRL) With cardiolipin to be positive--> negative after tx Specific treponemal antibody tests Generalised lymphadenopathy, hepatosplenomegaly, rash, skeletal malformations

Question 65

Comps of chlamydia in pregnancy? Neonatal meningoencephalitis can be caused by what?

Answer 65

Chorioamnionitis, neonatal conjunctivitis, neonatal pneumonia, prelabour rupture of membranes Group B strep

Question 66

Common sx of NEAs?

Answer 66

Arms flexing and extending, pelvic thrusting, eyes are usually closed, prolonged often>30 minutes, sx wax and wane

Question 67

Why is there a weak left-sided pulse in aortic dissection?

Answer 67

Due to involvement of the subclavian artery

Question 68

Signs of PE on a CXR? ECG features?

Answer 68

Fleischner sign= dilated pulmonary vessel, Westermark sign= collapse of vasculature distal to PE, Hampton's hump= wedge-shaped infarct Sinus tachycardia and/ or ST depression

Question 69

When is colchicine given in pericarditis?

Answer 69

Recurrent/ continued sx beyond 14 days

Question 70

How can post- ACS meds be remembered?

Answer 70

Block An ACS: Beta blocker, ACE-i, aspirin, clopidogrel, statin

Question 71

Presentation of a Wilm's tumour?

Answer 71

Between the age of 5-10 y/o, abdominal mass and painless haematuria

Question 72

What is used to reverse the sedative effects of benzos?

Answer 72

Flumazenil

Question 73

What heart abnormality is lithium associated with? Sx and tx of lithium toxicity?

Answer 73

Ebstein's anomaly- enlarged atrium, shrunken right ventricle + pansystolic murmur caused by defective tricuspid valve Fine tremor, dry mouth, GI dis, increased thirst and urination, drowsy, thyroid dys 12 hours or more- coarse tremor, CNS dis, arrhythmias, visual disturbance Serious tox= >2mmol/ litre Ix= serum lithium, electrolyte levels, TFTs, U&Es, ECG Elec balance, U&Es, seizure control, IV fluid therapy and urine alk, benzos- agitation and seizures, haemodialysis if poor renal function/ haemodialysis, cons gastric lavage/ whole-bowel irrigation

Question 74

How does placental abruption present compared to placenta praevia, uterine rupture and vasa praevia?

Answer 74

Abdominal pain with mild vaginal bleeding- can get concealed abruption with maternal distress and haemorrhage much greater than vaginal loss

Question 75

You would only test for FSH, LH and serum karyotype if there was what? Testicular biopsy?

Answer 75

Azoospermia (no sperm present) Suspect arrested spermatogenesis= less common than abnormal semen

Question 76

How does a missed miscarriage present? Cervix open or closed? USS findings?

Answer 76

Variable presentation from no sx--> light vaginal bleeding, pregnancy sx may decrease Closed Non- viable fetus

Question 77

How does a inevitable miscarriage present? Cervix open or closed? USS findings?

Answer 77

Vaginal bleeding, uterine cramps, possible intrauterine fetus w/ HB Open Fetus with possible HB

Question 78

How does a incomplete miscarriage present? Cervix open or closed? USS findings?

Answer 78

Vaginal bleeding with passage of large clots/ tissue, uterine cramps, products of conception often visualised in dilated cervical os Open Products of conception often in cervix

Question 79

How does a threatened miscarriage present? Cervix open or closed? USS findings?

Answer 79

Variable amount of vaginal bleeding, pregnancy can proceed to viable birth Closed Viable pregnancy

Question 80

How does a septic miscarriage present? Cervix open or closed? USS findings?

Answer 80

Fever, malaise, signs of sepsis, foul-smelling vaginal discharge, cervical motion + uterine tenderness, rarely after spontaneous abortion, usually with induced abortions can be life-threatening Usually retained products of conception

Question 81

1st line tx of Alzheimer's and Lew body dementia?

Answer 81

Donepezil, rivastigmine

Question 82

For most paediatric cases, what bolus is given in shock? In DKA + HF due to fluid comps e.g. cerebral oedema? Estimated weight? For non-shocked patients with DKA calculation for hourly rate? If they were in DKA and shocked, then you would not do what? Assume what fluid deficit in mild DKA? Moderate? Severe?

Answer 82

20ml/kg, 10ml/ kg 0.9% saline over 15 minutes/ 60 minutes (Age+4) x2 ((Deficit- initial bolus)/ 48 hours) + maintenance per hour Minus the initial bolus 5%, 7%, 10%

Question 83

Fluid choice? Holliday- Segar formula for maintenance fluids? Neonates?

Answer 83

0.9% NaCl with 20mmol KCl in 500ml (40mmol per litre) until blood glucose levels are less than 14 mmol/l 1st 10kg= 100ml/ kg/ day, next 10kg= 50ml/kg/day, >20kg= 20ml/kg/day Birth to day 1: 50-60 ml/kg/day Day 2: 70-80 mL/kg/day Day 3: 80-100 mL/kg/day Day 4: 100-120 mL/kg/day Days 5-28: 120-150 mL/kg/day

Question 84

High prolactin prevents the release of which hormone? This decreases the release of what hormones?

Answer 84

GnRH FSH + LH

Question 85

Bi temporal inferior quadrantanopia is caused by what? Classically associated with what? Most common presentation?

Answer 85

Lesion of the optic chiasm Craniopharyngioma Amenorrhoea

Question 86

What is homonymous hemianopia with macular sparing seen in? Why does macular sparing occur?

Answer 86

Posterior circulation stroke affecting the contralateral occipital lobe Collateral flow from the MCA

Question 87

What is homonymous inferior quadrantanopia caused by?

Answer 87

A lesion in the parietal lobe affecting the upper division of the optic radiations- parietal stroke/ tumour(same quadrant in each eye)

Question 88

What causes homonymous superior quadrantanopia?

Answer 88

Temporal lobe lesion affecting the lower division of the optic radiations (Meyer's loop)- stroke/ tumour

Question 89

What anti-anginal medication do patients commonly develop tolerance to?

Answer 89

Standard release isosorbide mononitrate

Question 90

What are the two shockable rhythms? Tx how? What for non-shockable rhythms? What is given to those who are in VF/ pulseless VT after 3 shocks?

Answer 90

VF and pulseless VT- with unsynchronised defibrillation at 120-200 J immediately, single shock followed by 2 minutes of CPR Adrenaline 1mg ASAP- once chest compressions have restarted after the 3rd shock during a VF/VT cardiac arrest Amiodarone 300mg, further 150mg after 5 shocks administered

Question 91

Following successful resus, oxygen should be titrated to achieve sats of what? Reversible causes of cardiac arrest (the Hs and Ts)?

Answer 91

94-98% Hypoxia, hypovolaemia, hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia, hypothermia Thrombosis, tension pneumothorax, tamponade- cardiac, toxins

Question 92

What is trifascicular block also known as? It means there are signal problems with what? What about a bifascicular block? What are they characterised by?

Answer 92

Complete heart block- with the right bundle branch and both left fascicles making up the left bundle branch The right bundle branch and one of the two left fascicles RBBB with left axis deviation, features of bifascicular + a 1st-degree heart block- PR interval prolongation

Question 93

Causes of RBBB?

Answer 93

Normal variant- more common with increasing age, RVH, chronically increased right ventricular pressure e.g. cor pulmonale, PE, MI, atrial septal defect, cardiomyopathy or myocarditis

Question 94

Way of remembering LBBB and RBBB?

Answer 94

WiLLiaM MaRRoW--> RBBB= 'M' in V1 + 'W' in V6 and vice versa for LBBB

Question 95

When is ivabradine as a third-line option for HF tx? 1st + 2nd line txs?

Answer 95

When EF<35% ACE-i= ramipril, Beta-blocker= bisoprolol, aldosterone antagonist= spironolactone

Question 96

ACE-i and Beta-blockers have no effect on mortality in HF with what? ACE-i and beta blockers cause what?

Answer 96

Preserved ejection fraction Hyperkalaemia- K+ should be monitored

Question 97

When is digoxin strongly indicated in HF?

Answer 97

If there is co-existent AF

Question 98

What is S1 heart sound caused by? S2? S3? S4?

Answer 98

Closure of mitral and tricuspid valves, soft if long PR/ mitral regurg, loud in mitral stenosis Closure of aortic and pulm valves, soft in aortic stenosis, splitting during inspiration is normal Diastolic filling of the ventricle- normal if <30 y/o, may persist in women up to 50 y/o, in LVF e.g. dilated cardiomyopathy, constrictive pericarditis + mitral regurg Aortic stenosis, HOCM, HTN, atrial contraction against a stiff ventricle- P wave on ECG

Question 99

Tx for symptomatic bradycardia?

Answer 99

Atropine infusion 500mcg IV - up to max 3mg, transcutaneous pacing, isoprenaline/ adrenaline infusion titrated to response Specialist help for transvenous pacing if no response

Question 100

Sx of labyrinthitis?

Answer 100

Hearing loss, vertigo, may experience tinnitus

Question 101

Peripheral causes of vertigo? Central causes? 3 components of the HINTS test? CIs for head-impulse test?

Answer 101

BPPV, vestibular neuronitis, Meniere's disease Stroke, MS, medication toxicity, trauma, posterior fossa tumours, migraine(more in elderly) Head impulse test, evaluation of nystagmus, test of skew Head & neck trauma, severe cervical spine osteoarthritis

Question 102

Positive head impulse test means what? Unilateral nystagmus? Changes direction or is vertical? Bidirectional nystagmus?

Answer 102

Issue with vestibulocochlear nerve on ipsilateral side Peripheral origin/ central pathologies Stroke- movement beats in direction looking, then changes direction with gaze

Question 103

How to perform skew test? Associated with what and specific for what?

Answer 103

Look at your nose, cover one of their eyes, then move hand to cover other eye- look for movement in uncovered eye, repeat on other eye Vertical diplopia- central cause of vertigo

Question 104

Genes ass w/ Parkinson's? Alzheimer's? MND? Drugs to help?

Answer 104

SNCA, Parkin Apolipoprotein E4 variant TARDBP, FUS Cholinesterase inhibitors e.g. donepezil, galantamine NMDA receptor partial antagonists e.g. memantine

Question 105

CIs for thrombolysis?

Answer 105

Seizure at onset of stroke, sx suggestive of SAH, LP in previous week, previous IC haemorrhage, major surgery or serious trauma within 2 weeks

Question 106

Possible positive antibodies in MG? Tests?

Answer 106

Anti-MuSK, anti-LRP4 Tensilon test, ice test, repetitive nerve stimulation, mediastinal imaging

Question 107

1st, 2nd and 3rd generation cephalosporin examples?

Answer 107

Cefazolin and cephalexin Cefuroxime and cefoxitin Ceftriaxone and ceftazidime

Question 108

Abnormal gene and translocation of Philadelphia chromosome?

Answer 108

t(9:22) BCR/ ABL

Question 109

Medical & surgical tx for Cushing's?

Answer 109

Metyrapone, others= Ketonazole, Mifepristone and Pasireotide, steroid replacement post-operatively Pituitary surgery or radiotherapy

Question 110

Glasgow score of what indicates transfer to ITU/ HDU for intensive monitoring and aggressive fluid resus? Based on degree of what potential complications? PANCREAS mnemonic?

Answer 110

Necrosis of surrounding tissues & saponification, reduced hormone output & ARDS PaO2<8kPa, age> 55 y/o, neutrophils WBC>15 x 109/L, calcium<2mmol/L, urea>16 mmol, AST/ALT>200iu/L or LDH>600 IU/L, albumin<32g/L, glucose>10mmol/L

Question 111

Tx for acute pancreatitis? Chronic?

Answer 111

Fluid resus urine output>30ml/hour, catheterisation, analgesia, anti-emetics, IV ABx for necrotising pancreatitis, calcium if hypocalcaemia, insulin in hyperglycaemia Ethanol abstinence & good diet, analgesia, insulin, enzyme replacement, coeliac plexus block/ pancreatectomy

Question 112

Ix for acute vs chronic pancreatitis? Other causes raised amylase?

Answer 112

Bloods FBC, U&Es, LFTs, lipase> amylase(amylase x3 upper limit suggestive,) USS, MRCP, ERCP, CT at later for comps AXR, CT- both calcification, faecal elastase and fasting glucose/ OGTT test Duodenal ulcer, cholecystitis, mesenteric infarction

Question 113

FATSHEEP drug cases of pancreatitis?

Answer 113

Furosemide, azathioprine/ asparaginase, thiazides/ tetracyclines, statins/ sulfonamides/ sodium valproate/ hydrochlorothiazide, estrogens, ethanol, protease inhibitors & NRTIs

Question 114

Tx of grade 1, 2, 3 and 4 haemorrhoids?

Answer 114

(No prolapse)- conservatively +/- topical corticosteroids (Prolapse on straining which spontaneously reduces)- rubber band ligation, sclerotherapy or infrared photocoagulation (Prolapse and requires manual reduction)- rubber band ligation (Prolapse and can't be manually reduced)- not responding to less invasive= surgical haemorrhoidectomy, diet rich in fibre and fluids

Question 115

4x tx for hyperkalaemia?

Answer 115

Insulin 15 units + dextrose 50% 50mls, 10% calcium gluconate, calcium resonium, salbutamol nebs

Question 116

SEs of alpha-1 blockers? 5 alpha reductase inhibitors?

Answer 116

Hypotension, retrograde ejaculation Diminished libido, ED

Question 117

Tx for non-muscle and muscle invasive bladder cancer?

Answer 117

TURBT, chemo, BCG immunotherapy (T2+)- cystectomy with urinary diversion(w/o co-morbidities + no mets) + urinary diversion after removal- ileal conduit, neo-bladder, mitrofanoff Non-surgical= radiotherapy or chemo

Question 118

GnRH analogues and androgen antagonists for prostate cancer? GnRH antagonists?

Answer 118

Goserelin, Leuprolide Bicalutamide and enzalutamide Degarelix

Question 119

Classification system of open fractures?

Answer 119

Gustilo and Anderson

Question 120

Lymph nodes enlarged in tonsillitis?

Answer 120

Jugulodigastric lymph nodes

Question 121

Branches of facial nerve?

Answer 121

Zygomatic, temporal, buccal, marginal mandibular, cervical branch

Question 122

Stages of wound healing?

Answer 122

Haemostasis, inflammation, proliferation, remodelling

Question 123

Grades 1, 2, 3 and 4 of hypertensive retinopathy?

Answer 123

Vascular attenuation, 2= above and AV nipping, 3= above and retinal haemorrhages, hard exudates and cotton wool spots 4= above and optic nerve oedema

Question 124

RFs for miscarriage? Ectopic pregnancy? HG?

Answer 124

Foetal= genetics, placental failure Maternal= uterine abnormality, PCOS, poorly controlled diabetes/ thyroid disease PID, genital infection, IUD/ IUS, assisted reproduction, previous ectopic, old age, smoking More severe in molar pregnancies and multiple pregnancies, 1st pregnancy, overweight and obese, urinary infection

Question 125

RFs for molar pregnancy? VTE?

Answer 125

Maternal age>20 or >35 y/o, previous gestational trophoblastic disease/ miscarriage, use of COCP Pre-existing= thrombophilia, co-morbidities, age>35, BMI> 30, parity>3, smoking/ obstetric= multiple pregnancy, pre-eclampsia, C-section, prolonged labour, stillbirth Transient= any surgical procedure of puerperium, dehydration

Question 126

RFs for GD? Pre-eclampsia? Abruption? Praevia/ accreta/ increta? Vasa praevia?

Answer 126

Previous GD, macrosomic>4kg, BMI>30, previous stillbirth/ perinatal death Moderate= nulliparity, maternal age>40, maternal BMI>35, family hx, multiple pregnancy High= chronic HTN, pre-eclampsia/ eclampsia in previous pregnancy, diabetes, SLE/ APS Previous abruption, pre-eclampsia/HTN, bleeding early on, IUGR, increased maternal age, smoking APH, emergency C-section, emergency hysterectomy, maternal anaemia, preterm birth, stillbirth Accreta= previous curettage procedures, previous C-section, multigravida, increased maternal age, low-lying placenta/ praevia Low-lying placenta, IVF, pregnancy, multiple pregnancy

Question 127

RFs for APH? Shoulder dystocia? Cord prolapse?

Answer 127

Praevia, abruption, vasa praevia, uterine rupture, pre-eclampsia, smoking, IUGR Large foetus, previous dystocia, high maternal BMI/ oxytocin, prolonged 1st & 2nd stage of labour Polyhydramnios, abnormal lie, breech, ARM

Question 128

5 components of the Bishop score? Apgar score?

Answer 128

Cervical dilatation, position, effacement and consistency of cervix, station of foetal head Appearance, pulse, grimace, activity, respiration

Question 129

4 or more RFs in pregnancy warrant what VTE tx? 3 RFs? If DVT shortly before delivery, continue for how long? Avoid what in pregnancy?

Answer 129

Immediate LMWH until 6 weeks post-natal LMWH from 28 weeks until 6 weeks postnatal At least 3 months(same as provoked DVTs)

Question 130

Where do dermoid cysts typically occur?

Answer 130

Midline of the neck, external angle of the eye and posterior to the pinna of the ear

Question 131

SEs of lithium? Avoid what when taking lithium? ECG?

Answer 131

LITHIUM: lethargy, insipidus- nephrogenic, fine tremor, hypothyroidism- thyroid enlargement, insides- GI N&V/ diarrhoea, urine- increased, metallic taste NSAIDs, breastfeeding T wave flattening/ inversion, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism and resultant hypercalcaemia

Question 132

Baseline Ix for antipsychotics? Clozapine monitoring? What can increase levels?

Answer 132

ECG, BP & pulse, BMI, FBC, U&Es, LFTs, HbA1C, lipids, baseline trop for clozapine Weekly FBC--> fortnightly after 18w Smoking

Question 133

If major bleeding on warfarin- tx?

Answer 133

Stop Give IV vit K 5mg Prothrombin complex concentrate- not available--> FFP(takes time to defrost)

Question 134

(On warfarin,) INR>8.0 and minor bleeding?

Answer 134

Stop IV Vit K 1-3mg Repeat dose if INR still too high after 24 hours Restart warfarin when INR<5.0

Question 135

(On warfarin,) INR>8.0 and no bleeding?

Answer 135

Stop Oral vit K 1-5mg by mouth, repeat dose if too high after 24 hours restart when INR<5.0

Question 136

(On warfarin,) INR 5-8 and minor bleeding?

Answer 136

Stop warfarin IV Vit K 1-3mg Restart when INR<5.0

Question 137

(On warfarin,) INR 5-8 and no bleeding?

Answer 137

Withhold 1 or 2 doses warfarin Reduce subsequent maintenance dose

Question 138

Management of diabetic nephropathy?

Answer 138

Dietary protein restriction, tight glycaemic control, BP control<130/80 mmHg, ACE-i or angiotensin-II receptor antagonist- start if urinary ACR of 3mg/ mmol or more (don't start ACE-i and angiotensin-II receptor antagonist dual therapy,) control dyslipidaemia e.g. statins

Question 139

When is insertion of a chest drain contraindicated? Complications?

Answer 139

INR>1.3, platelet count<75, pulmonary bullae, pleural adhesions Failure of insertion, bleeding, infection, penetration of the lung, re-expansion pulmonary oedema

Question 140

Senior review for meningococcal septicaemia?

Answer 140

Rapidly progressive rash, poor peripheral perfusion, RR<8 or >30/ min or pulse <40 or >140/ min pH<7.3 or WBC<4x 10^9/L or lactate > 4mmol/ L, GCS<12 or a drop of 2 points

Question 141

When should LP be delayed in meningococcal septicaemia?

Answer 141

Signs of severe sepsis or rapidly evolving rash Severe resp/ cardiac compromise Significant bleeding risk, signs of raised ICP, papilloedema, continuous or uncontrolled seizures, GCS

Question 142

Who is adenosine contraindicated in?

Answer 142

Asthmatics

Question 143

How does TGA present? Presentation on CXR, ECG, echo and hyperoxia (nitrogen washout) test?

Answer 143

Low SpO2, loud single S2, murmur only if associated septal defect or patent ductus arteriosus 'Egg on side appearance' Normal Anatomical abnormalities, septal defects and patency of ductus arteriosus Ix cyanotic heart disease in neonates

Question 144

Tx TGA?

Answer 144

Prostaglandin infusions to maintain ductal patency Balloon atrial septostomy Definitive= arterial switch 1st few weeks life

Question 145

Reduced or increased reticulocytes in aplastic crises? Sequestration crises? Presentations?

Answer 145

Reduced Increased Sudden fall in Hb (infection with parvovirus) Worsening of anaemia

Question 146

How many risk factors warrants treatment with LMWH in pregnancy? Until when? What if 3 RFs?

Answer 146

4/ more until 6 weeks post-natal From 28w--> 6w post-natal

Question 147

Tx for epistaxis? If not stopped after 10-15 minutes?

Answer 147

Sit with torso forward and mouth open, pinch cart area--> topical antiseptic, self-care advice and possible admission if co-morbidities Cautery/ packing- if visible/ not visible Admit if HD unstable Failed emergency department--> sphenopalatine ligation

Question 148

When is HG most common?

Answer 148

Between 8 and 12 weeks- may persist up to 20 weeks

Question 149

Causes of LBBB?

Answer 149

MI, HTN, aortic stenosis, cardiomyopathy

Question 150

Cause, sx and tx acute haemolytic reaction? Comps?

Answer 150

Mismatch blood group--> intravascular haemolysis= RBC destruction by IgM-type antibodies Fever, abdo pain, hypotension Stop transfusion, check patient ID/ name on blood product, send blood for direct Coombs test, repeat typing and cross-matching, fluid resus DIC & renal failure

Question 151

Cause, sx and tx non-haemolytic febrile reaction?

Answer 151

WBC HLA antibodies Sensitisation by previous pregnancies or transfusions Slow or stop transfusion, paracetamol, monitor

Question 152

Cause, sx and tx transfusion associated acute lung injury(TRALI)?

Answer 152

ARDS within 6 hours transfusion Hypoxia, pulm infiltrates on CXR, fever, hypotension Stop transfusion Oxygen, supportive care

Question 153

Cause, sx and tx transfusion-associated circulatory overload (TACO)?

Answer 153

Excessive rate of transfusion, pre-existing HF Pulm oedema, HTN Slow or stop transfusion Consider IV Loop diuretic and O2

Question 154

Sx and tx minor allergic reaction--> blood transfusion?

Answer 154

Pruritus, urticaria Temp stop transfusion, antihistamine, monitor

Question 155

When is peritoneal lavage indicated? Absolute contraindication?

Answer 155

Blunt abdominal trauma with haemodynamic instability Stab wound to abdomen penetrating fascia Multiple trauma with shock of unclear aetiology Obvious clinical indications for laparotomy

Question 156

Where to place ECG limb leads? Chest leads?

Answer 156

Ride Your Green Bike- clockwise from right wrist (ulnar styloid process) V1= 4th IC space at right sternal angle V2= 4th IC left sternal angle V3= between V2 and V4 V4= 5th IC space in midclavicular line V5= same as V4 left anterior axillary line V6= left mid-axillary line same as V4 and V5

Question 157

ACPVU?

Answer 157

Alert Confusion- new or worsening Voice- responds to verbal stimulus Pain- responds to pain stimulus Unresponsive- to verbal or pain stimulus

Question 158

ACVPU- new onset/ deteriorating confusion is what? Score on NEWS scale who are CVPU(not fully awake)? Score below 8 GCS?

Answer 158

Red flag- use A-E approach 3- consider calculating GCS Urgent assessment by anaesthetics

Question 159

Tx of reactive arthritis?

Answer 159

NSAIDs, severe= oral or intraarticular corticosteroids Persistent= conventional synthetic DMARDs

Question 160

Mnemonic for lytic bone lesion?

Answer 160

FEGNOMASHIC- fibrous dysplasia, enchondroma, giant cell tumour, non-ossifying fibroma, osteoblastoma, mets/ myeloma, aneurysmal bone cyst, hyperparathyroidism, infection/ infarction, chondroblastoma

Question 161

Meds that may worsen osteoporosis?

Answer 161

SSRIs, antiepileptics, PPIs, glitazones, long-term heparin therapy, aromatase inhibitors e.g. anastrozole

Question 162

Ix for osteoporosis?

Answer 162

Hx & exam, FBC, U&Es, LFTs, bone profile, CRP, TFTs

Question 163

Ix for osteomalacia? Tx?

Answer 163

Bloods- vitamin D, calcium, phosphate, U&Es, bone biopsy= GOLD standard Imaging e.g. X-rays for pseudofractures or other bone abnormalities Replenishing vitamin D, calcium, phosphate, addressing causes of deficiency, regular monitoring

Question 164

Most common cause of primary hyperaldosteronism? 1st line Ix?

Answer 164

Idiopathic adrenal hyperplasia, adrenal adenoma- Conn's syndrome Aldosterone/ renin ratio--> high aldosterone alongside low renin levels High res CT abdomen and adrenal vein sampling

Question 165

Sx of myxoedema coma? Tx?

Answer 165

Hypothermia and confusion IV thyroid replacement, fluids, IV corticosteroids, electrolyte imbalance correction, sometimes rewarming

Question 166

What is Kallman syndrome caused by? Hormone levels?

Answer 166

Failure of GnRH- secreting neurons to migrate to the hypothalamus Sex hormones low, LH, FSH low/ normal

Question 167

General findings in Cushing's syndrome? Ix?

Answer 167

Hypokalaemic metabolic alkalosis w/ IGT, ectopic ACTH= very low K+ Overnight low-dose dex test, 24hr urinary free cortisol x2 Bedtime salivary cortisol- x2

Question 168

When are localisation tests for Cushing's? Other?

Answer 168

9am and midnight plasma ACTH and cortisol levels ACTH suppressed= adrenal adenoma CRH stimulation- cortisol rises if pituitary source, ectopic/ adrenal= no change Petrosal sinus sampling- pituitary vs ectopic ACTH Insulin stress test true vs pseudo-Cushing's

Question 169

Ix in SLE?

Answer 169

Autoantibodies: ANA, anti-dsDNA= highly specific, anti-Sm FBC- anaemia of chronic disease and reduced platelets and WCCs Reduced C3 & C4 Urinalysis and urine protein: creatinine ratio= proteinuria in lupus nephritis Renal biopsy for lupus nephritis

Question 170

Drugs causing drug-induced lupus? Antibodies?

Answer 170

Sulfadiazine, hydralazine, procainamide, isoniazid, methyldopa, quinidine, minocycline, chlorpromazine ANA, anti-histone

Question 171

Comps of Sjogren's syndrome? Histology from salivary gland biopsy?

Answer 171

Pneumonia Bronchiectasis Non-Hodgkins lymphoma Peripheral neuropathy Vasculitis Renal impairment Focal lymphocytic infiltration

Question 172

Meds that may worsen osteoporosis?

Answer 172

SSRIs, antiepileptics, PPIs, glitazones, long-term heparin therapy, aromatase inhibitors

Question 173

Causes osteomalacia?

Answer 173

Vit d deficiency, lack of sunlight, diet, CKD, drug induced- anticonvulsants, inherited- hypophosphataemic rickets, liver disease e.g. cirrhosis, coeliac disease

Question 174

Sx of granulomatosis with polyangiitis? Tx?

Answer 174

Epistaxis, hearing loss, sinusitis, saddle-shaped nose due to nasal bridge collapse, cough/ wheeze/ haemoptysis, glomerulonephritis CXR= cavitating lesions Renal biopsy= epithelial crescents in Bowman's capsule Steroids, cyclophosphamide, plasma exchange

Question 175

Sx of eosinophilic granulomatosis with polyangiitis? What might precipitate disease?

Answer 175

Severe asthma, sinusitis, allergic rhinitis Raised eosinophilia on FBC LTRAs

Question 176

Main feature of microscopic polyangiitis?

Answer 176

Renal failure with glomerulonephritis, cough/ dyspnoea/ haemoptysis

Question 177

What is Goodpasture's syndrome?

Answer 177

Anti-GBM antibodies against type IV collagen- more common in men Bimodal incidence HLA DR2 Pulm haemorrhage, rapidly progressive GN- rapidly onset AKI--> proteinuria, haematuria

Question 178

Ix and tx of Goodpasture's?

Answer 178

Renal biopsy- linear IgG along basement membrane Raised transfer factor secondary to pulm haemorrhages Plasma exchange, steroids, cyclophosphamide

Question 179

What can polyarteritis nodosa be secondary to? Sx?

Answer 179

Idiopathic or secondary to infections- particularly hepatitis B, more in middle-aged men Renal impairment, HTN, tender erythematous skin nodules, MI, stroke, mesenteric adenitis, unilateral orchitis, livedo reticularis

Question 180

Ix, tx and comps of polyarteritis nodosa?

Answer 180

·↑ESR and/or CRP ·HBsAg ·Biopsy: shows transmural fibrinoid necrosis ·If Hep B negative – corticosteroids + cyclophosphamide ·If Hep B positive – antiviral agent, plasma exchange and corticosteroids ●GI perforation & haemorrhages, Arthritis, Renal infarcts, Strokes, MI

Question 181

Sx of Kawasaki's disease?

Answer 181

High fever> 5 days, widespread red maculopapular rash, skin peeling palms and soles, bilateral conjunctivitis, strawberry tongue, cervical lymphadenopathy High dose aspirin, IV IGs, ECHO screening for coronary artery aneurysms

Question 182

Peak incidence of GCA? Features?

Answer 182

70s Rapid onset<1 month, headache, jaw claudication, vision testing for AION- may--> amaurosis fugax, tender palpable temporal artery raised ESR, CRP, temporal artery biopsy- may show skip lesions, Duplex USS= hypoechoic halo sign and stenosis of temporal artery High dose pred before biopsy/ IV methylpred if evolving visual loss w/ PPI, aspirin, bisphosphonates, calcium, vitamin D Urgent oph review Bisphos, low-dose aspirin

Question 183

Sx PMR?

Answer 183

Rapid onset<1m, aching morning stiffness in proximal limb muscles- shoulders, pelvic girdle, neck Worse after rest Raised ESR- before steroids= FBC, U&Es, LFTs, calcium, serum protein electrophoresis, TSH, CK, RF, urine dip Prednisolone, 1w follow-up reducing regime

Question 184

When does Takayasu's arteritis first present? Ix? Tx?

Answer 184

Before age 40 in younger females and Asian people- fever, malaise, muscle aches, may be claudication sx, aortic regurg, renal artery stenosis CT/ MRI angiography Steroids

Question 185

Gene related to Behcet's disease? How often mouth ulcers?

Answer 185

HLA B51- more in men and eastern Mediterranean/ young adults At least 3 times a year- painful sharply circumscribed with a red halo occurring on the oral mucosa and heal over 2-4 weeks, genital= similar, with anterior uveitis Thrombophlebitis and DVT, arthritis, neurological involvement, erythema nodosum Positive pathergy test--> erythema and induration (also Sweet's syndrome or pyoderma gangrenosum) Topical steroids, systemic steroids, colchicine, topical anaesthetics, immunosuppressants, biologics

Question 186

Comps of Behcet's?

Answer 186

Vision loss, ruptured pulm aneurysms, bowel perforation, neuro-Behcet's disease

Question 187

Most common and least severe of Ehlers- Danlos syndrome? What can result? What are classical prone to? Vascular prone to?

Answer 187

Hypermobile- autosomal dominant--> POTS Also stretchy skin- hernias, prolapses, mitral regurg, aortic root dilatation, abnormal wound healing= autosomal dominant GI perforation and spontaneous pneumothorax

Question 188

Sx of kyphoscoliotic Ehlers- Danlos? Score to support Ix?

Answer 188

Initially hypotonia--> kyphoscoliosis as grow, joint hypermobility, joint dislocation more common, AUTOSOMAL RECESSIVE Beighton score= one point for each side of body with max of 9 Palms flat on floor with straight legs (score 1) Elbows hyperextend Knees hyperextend Thumb can bend to touch the forearm Little finger hyperextends past 90 degrees

Question 189

Ix for EDS? Tx?

Answer 189

Clinical for hypermobile and genetic for other types= helpful Physio, OT, moderating activity, psychology

Question 190

What is subclinical hyperthyroidism? Repeat TFTs after how often if suspected?

Answer 190

TSH is suppressed below the normal reference range- FT4 and FT3 are within the normal reference range 3 months

Question 191

Comps of hyperthyroidism?

Answer 191

Graves' orbitopathy, thyrotoxic crisis, large goitre--> compression sx, AF, HF

Question 192

What does a thyroglossal cyst move with?

Answer 192

Swallowing and tongue protrusion

Question 193

Epidemiology of Still's disease? Sx?

Answer 193

Bimodal distribution 15-25 and 35-46 y/o Arthralgia, elevated serum ferritin, salmon-pink MP rash, pyrexia in later afternoon/ early evening accomp by worsened sx and rash, lymphadenopathy

Question 194

Criteria and tx for Still's disease?

Answer 194

Yamaguchi disease NSAIDs for at least 1 week--> steroids for sx not prognosis Methotrexate, IL-1 or anti-TNF therapy

Question 195

What is Prinzmetal angina caused by? Decubitus angina caused by what?

Answer 195

CA spasm Lying flat

Question 196

Diet and exercise changes for CVD?

Answer 196

Total fat= <30% calories- mono and polyunsaturated- saturated<7% calories Reduced sugar, wholegrain options, 5/day F&V, 2/week fish, 4/week legumes, seeds and nuts Aerobic activity 150 mins/week mod activity/ 75 mins vigorous, strength 2 days/ week

Question 197

How often do people have a health check between 40-74 y/o? What is used to calc primary prev CVD meds for 25-84 year olds?

Answer 197

Every 5 years Q-risk3 (lifetime risk)

Question 198

Do not do a Q-risk score(10-years) in who? Also assess what?

Answer 198

People with CVD, high risk- T1DM/ eGFR<6, has familial hypercholesterolaemia, aged 85 or above HbA1C and kidney function

Question 199

What is Q-risk underestimated in?

Answer 199

Those tx for HIV, w/serious mental health issues, taking drugs cause dyslipidaemia- some APs, immunosuppressants and corticosteroids, AI conditions- SLE, taking antihypertensive/ lipid mod therapy/ recently given up smoking

Question 200

Factors in Q-risk score?

Answer 200

Age, sex, ethnicity, postcode, smoking/ diabetes/ angina or MI 1st degree relative<60/ CKD stage 3,4 or 5/ AF/ on BP tx/ have migraines/ RA/ SLE/ severe mental illness/ on atypical APs/ regular steroids/ ix or tx for ED status Cholesterol/ HDL ratio Systolic BP, SD of at least 2 most recent sys BP readings, BMI

Question 201

Advice for Q-risk<10%?

Answer 201

Advise on lifestyle factors- smoking, HTN, abnormal lipids/ weight loss if overweight or obese- assess about sleep apnoea/ alcohol Review co-morbidities

Question 202

Tx for Q-risk>10%? How do they function?

Answer 202

Before= assess for familial lipid disorder, exclude secondary causes- excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome Discuss lifestyle mod- alcohol, BP, BMI, smoking, diabetes control/ optimise other RFs and co-morbidities Offer statin e.g. atorvastatin 20mg, also CKD & T1DM for >10 years/ or are >40 y/o/ aged above 85 y/o Inhibit HMG CoA reductase

Question 203

Bloods before starting primary prev lipid therapy CVD? When should lipids and LFTs be checked when starting statins? When should statins not be stopped with raised transaminases? When to repeat HbA1c?

Answer 203

Initial lipid profile(non-fasting)- total chol, HDL-C, non-HDL-C & triglycerides, TSH & renal function, LFTs, HbA1C, U&Es, CK 3m and 12m- aim for reduction in non-HDL of >40%, then review annually- consider low/ medium intensity statin vs high intensity <3 times upper limit at 3m

Question 204

When to measure CK before starting statins?

Answer 204

If persistent generalised, unexplained muscle pain- if>5 times upper limit- repeat after 7 days, if remains>5- do NOT start statin, <5= start at lower dose

Question 205

Action ezetimibe (w/ bempedoic acid)? Evolocumab and alirocumab? Max number statins before specialist advice?

Answer 205

Inhibits absorption of cholesterol/ ACL inhibitor- lowers LDL cholesterol PCSK9 inhibitors-MABs lower cholesterol as SC injection every 2-4w 3

Question 206

4 As for secondary prevention following CV event?

Answer 206

Antiplatelet meds, atorvastatin, atenolol/ alt Beta blocker, ACE-i titrated to max dose/ BACAS- Beta blocker, ACE-i, clop, aspirin, statin- 80mg DAP therapy- aspirin 75mg daily continued & clop/ tic for 12m before stopping High-risk emboli= warfarin 3-6m

Question 207

Lipid profile consists of what? 3 situations when measured?

Answer 207

Total cholesterol, HDL- good, non-HDL including LDL- BAD, total cholesterol: HDL ratio, triglycerides 1) Recent CV event 2) Monitoring- high lipids/ CV event 3) Screening- 40-74 y/o every 5y, used as part of Q-risk 3/ has tendon xanthoma, xanthelasma or corneal arcus

Question 208

When should lipid profile not be performed? Results in severe hyperlipidaemia?

Answer 208

Within 6w any acute illness/ injury Total cholesterol >7.5mmol/L (hypercholesterolaemia) and/or Non-HDL-C >5.9 mmol/L (hypercholesterolaemia) and/or Triglycerides >4.5mmol/L (hypertriglyceridaemia)

Question 209

Inheritance of familial hypercholesterolaemia? Criteria for making Ix? 3 important features?

Answer 209

AD- hetero or homozygous--> extremely high cholesterol above 7.5mmol/L in an adult/>9 in people aged over 30 y/o Simon Broome criteria Family hx of prem CVD, very high cholesterol, tendon xanthomata

Question 210

Ix if familial hypercholesterolaemia is suspected? Tx?

Answer 210

2 x LDL measurements, assessed for signs, exclude secondary high cholesterol, SBC used to make Ix, specialist referral confirm Ix and initiate cascade testing Lifestyle advice, high intensity lipid-mod therapy- reduce LDL>50% from baseline, consider aspirin and anti-HTN, follow-up Homozygous/ in children= specialist tx

Question 211

Target cholesterol levels?

Answer 211

Total cholesterol: should be 5mmol/L or less HDL-C: should be >1 mmol/L in men and >1.2 mmol/L in women Total cholesterol to HDL ratio: should be <6

Question 212

Scoring and ix stable angina?

Answer 212

1= central, tight radiation to arms, jaws and neck 2= prec by exertion 3= relieved by rest 3/3= typical 2/3= atypical 1/3= non-anginal pain ECG- ST depression, T-wave inversion, exercise ECG/ stress ECHO- monitor how long, ST dep= late-stage ischaemia, CT angio= GOLD, invasive= in cath lab CT scan calcium scoring SPECT/ myoview Cardiac catheterisation, bloods- FBC, U&Es, TFTs, lipids, HbA1c, anaemia, CXR

Question 213

Tx stable angina?

Answer 213

Modify RFs, pharm: Aspirin, statins, GTN BB/CCB- diltiazem or verapamil(avoid in HF w/ reduced EF,) switch, combine, 3rd= isosorbide mononitrate, ivabradine, nicorandil, ranolazine PCI- stenting= brachial/ femoral artery, CABG= saphenous vein, internal thor/ mammary artery, radial artery Secondary prevention- 4 As

Question 214

Other things causing a raised troponin? Additional bloods & Ix?

Answer 214

CKD, sepsis, myocarditis, aortic dissection, PE FBC, U&Es, LFTs, lipid profile and glucose, CXR, Echo- LV function ECG Trop= rise within 3-12h peak@24-48h and return to baseline by 5-14 days- above 30ng/L CK-MB= rise within 3-12h onset pain Myoglobin= rises within 1-4h onset pain

Question 215

Pathological Q waves typically appear how many hours after onset sx? 5 types MI?

Answer 215

6> 25% QRS height and wider than ONE small square 1= spontaneous w/ ischaemic due to primary coronary event 2= secondary to ischaemia due to increased O2 demand/ decreased supply 3,4,5= sudden cardiac death related to PCI and CABG

Question 216

Murmur in MI? ECG in STEMI & NSTEMI?

Answer 216

4th heart sound + pansystolic murmur ST elevation at least two contiguous limb leads of >1mm or (1 small square)/ >2mm in 2 or more chest leads/ new LBBB Subsequent Q waves ST depression >0.5mm in >2 contiguous leads= ischaemia/ T wave inversion- other than V1 and III

Question 217

Features of digoxin toxicity? Tx?

Answer 217

N&V, anorexia, diarrhoea SVT and slow ventricular response, frequent PVCs- ventricular bigeminy and trigeminy, sinus bradycardia, slow AF, any AV block type, VT, downsloping ST depression- 'reverse tick,' slight PR interval prolongation, biphasic/ flattened and shortened QT interval Stop digoxin, administer digifab

Question 218

Troponin how long after MI pain? If not elevated? Also what within 3-12 hours and within 1-4h?

Answer 218

6 hours, another 3 hours- peak at 24 and 48 hours CK-MB Myoglobin

Question 219

What are Q waves?

Answer 219

Any negative deflection that precedes an R wave

Question 220

Tx for low risk GRACE score <3%? Tx for low and intermediate/ high >3%

Answer 220

Consider conservative without angiography Offer aspirin + P2Y12 inhibitor- ticagrelor unless high bleeding risk--> clop or aspirin alone Assess left ventricular function- consider assessing for unstable angina Cardiac rehab and secondary prevention

Question 221

Tx for intermediate/ higher-risk GRACE score >3%?

Answer 221

Offer immediate angiography if clinical condition unstable Consider angiography with within 72 hours if no CI such as comorbidity or active bleeding Prasugrel or ticagrelor with aspirin- pras only when PCI intended + systemic unfrac hep if having PCI

Question 222

Reduced ejection fraction in heart failure? Mid-range? Preserved? In systolic HF? Diastolic?

Answer 222

<40%, 40-49%, >50% <40% >50%

Question 223

NY heart association classification?

Answer 223

I= no limitation on activity II= comfortable at rest, but sx with ordinary activities III= sx with any activity IV= sx at rest

Question 224

Tx for chronic heart failure? Other?

Answer 224

ABAL: ACE-i/ ARB, Beta-blocker- atenolol, aldosterone antagonist- not controlled with A and B/ REF, Loop diuretics e.g. furosemide or bumetanide CCB and other- hydralazine with a nitrate Digoxin Ivabradine SGLT2 inhibitor e.g. dapagliflozin Sacubitril with valsartan

Question 225

Procedural tx for HF?

Answer 225

ICD- previous vent tachy/ VF CRT- severe with EF< 35% involves biventricular pacemakers with leads in RA, RV and LV Severe= heart transplant

Question 226

SODIUM tx for acute LVF?

Answer 226

Sit up Oxygen<95% Diuretics, GTN if systolic BP above 90mmHg IV fluids should be stopped Underlying causes identify and tx e.g. MI Monitor fluid balance- daily weights reduce by 0.5kg/day Diamorphine- consider CPAP

Question 227

Tx for PEF HF? REF? Both?

Answer 227

Manage co-morbidities, offer cardiac rehab programme unless condition unstable Offer ACE-i and BB- consider hydralazine and nitrate if intolerant of ACE-i and ARB, MRA if sx continue + cardiac rehab programme Offer annual influenza and one-off pneumococcal vaccine

Question 228

Consider one of what if sx of HF continue?

Answer 228

Replace ACE-i with sacubitril valsartan if EF<35% Add ivabradine for HR>75--> sinus rhythm Add hydralazine w/nitrate if Afro-Caribbean HF w/ sinus rhythm= digoxin

Question 229

Bifascicular block commonly presents as what on ECG?

Answer 229

RBBB with LAD (LAFB is more susceptible to ischaemia)

Question 230

What is adenosine CI in?

Answer 230

ASTHMA

Question 231

Normal QT interval? QTc? Normal QRS complex width?

Answer 231

Men= 350-450ms Women= 360-460 <430ms in males and <450ms in females 80-100ms, >120= abnormal

Question 232

Indications for LTOT in COPD?

Answer 232

PaO2<7.3kPa on 2 readings more than 3w apart and are non-smokers OR PaO2 of 7.3-8kPa alongside: nocturnal hypoxia, polycythaemia, peripheral oedema and pulmonary hypertension LTOT can be also described for patients with terminal illness

Question 233

2nd step of COPD management if FEV1>50% and persistent exacerbations?

Answer 233

LABA or LAMA LABA AND ICS/ LAMA

Question 234

Sx blue bloaters vs pink puffers?

Answer 234

Pink(emphysema)= near normal Pa02 and normal or low PaCO2- SOB NOT cyanosed, quiet chest, may progress to type 1 respiratory failure Blue bloaters(chronic bronchitis)- polcythaemia, peripheral oedema, rhonchi and wheezing (low PaO2 and high PaCO2,) cyanosed but not SOB, may develop cor pulmonale

Question 235

What is TCLO low in? High in?

Answer 235

Severe emphysema, fibrosing alveolitis, anaemia, pulmonary HTN, idiopathic pulmonary fibrosis, COPD Pulmonary haemorrhage- more RBCs available due to bleeding

Question 236

How long before spirometry should SABAs be stopped? LABAs? How is reversibility then tested?

Answer 236

6 hours 12 hours 400mcg salbutamol administered and spiro repeated after 15 minutes

Question 237

FEV1, FVC and ratio in obstructive vs restrictive disease?

Answer 237

Ob= FEV1<80%, reduced FVC to lesser extent and FEV10.7,) normal PEFR

Question 238

Causes of hypoxia(

Answer 238

V/Q mismatch, hypoventilation, abnormal diffusion, R-->L cardiac shunts- V/Q= commonest

Question 239

What is KCO (gas transfer coefficient) low in? High in?

Answer 239

Emphysema and ILD/ alveolar haemorrhage

Question 240

S&S of COPD?

Answer 240

SOB, wheeze, exercise intolerance, chronic/ recurrent cough, regular sputum production Tachypnoea, use of accessory muscles in respiration, hyperinflation, reduced CS distance<3cm, reduced CE, resonant percussion, quiet breath sounds, cyanosis, cor pulmonale

Question 241

Ix COPD? Comps?

Answer 241

Info on condition & RFs, smoking cessation, pneumo and in vaccination, pulm rehab, tx comorbidities, self-management plan FBC, CXR, ECG, ABG, lung function tests- spiro, DLCO, trial steroids- look for >15% in FEV1, 30mg pred/24h PO for 2 weeks Acute exacerbations +/- infection, polycythaemia, resp failure, cor pulmonale, pneumothorax, lung carcinoma

Question 242

Tx COPD?

Answer 242

General= smoking cessation, encourage exercise, tx poor nutrition/ obesity, inf and pneu vaccination, pulm rehab, NIPPV, PRN SABA or SAMA, review meds and inhaler technique/ adherence Mild/mod= inhaled LAMA or LABA Severe= LABA + CS e.g. Symbicort- bud + formeterol or tiotropium Remain Sx: tiotropium and ICS + LABA, refer to specialist, home nebs, theophylline Pulm HTN- assess need for LTOT, diuretics for oedema

Question 243

Tx for advanced COPD? Indications for surgery?

Answer 243

Pulm rehab, LTOT if PaO2<7.3kPa Recurrent pneumothoraces, isolated bullous disease; lung volume surgery NIV if high CO2 on LTOT Air travel risky if FEV1<50% or PaO2<6.7kPa Assess home support and tx depresison

Question 244

Indications for specialist referral for COPD? Pulm rehab referral?

Answer 244

Uncertain Ix/ suspected severe COPD/ rapid decline in FEV1, onset cor pulmonale, bullous lung disease, assessment for oral CSs, neb therapy or LTOT, <10 pack years smoking or COPD<40 y/o, sx disprop to lung function, frequent infections, suspected bronchiectasis Functionally disabled, recent hospitalisation for acute exacerbation

Question 245

Increased risk of what with ICS? Monitor for what? When is theophylline considered? Mucolytic therapy?

Answer 245

Pneumonia Osteoporosis After trial of short-acting and long-acting bronchodilators or can't use inhaled therapy- monitor plasma levels and interactions Stable COPD develops chronic cough productive of sputum- continue if improvement in sx

Question 246

When should prophylactic macrolide ABx therapy in COPD be considered?

Answer 246

More than 3 exacerbations needing steroid therapy and at least one exacerbation needing hospital admission in previous Azithromycin 500mg 3x week minimum 6-12 months

Question 247

Do what before commencing proph ABx in COPD? After starting? Severe disease despited ICS and non-pharm?

Answer 247

ECG-QTC int, LFTs, counsel on SEs, arrange microbiological assessment sputum for NTM, consider CT scan SEs= 250mg x3/ week LFTs after 1 month and then every 6 months, ECG after 1m- stop if QTc prolonged Follow up at 6m and 12m Oral PDE4-i

Question 248

4 stages of COPD?

Answer 248

1=>80% FEV1 2=50-79% 3= 30-49% 4=<30%

Question 249

Pre flight resp assess in COPD?

Answer 249

Sig resp sxs, severe COPD, bullous lung disease, comorbid conditions worsened by hypoxia, discharged within 6w, recent pneumothorax, risk of/ previous VTE, pre-existing need for oxygen, CPAP or ventilator support(CI>4L needed) Assess= walk test and or hypoxic challenge test

Question 250

Sx of acute exacerbation of COPD? Severe?

Answer 250

Worsening SOB, cough, wheeze, fever without obvious source, URTI in past 5 days, increased RR/ pulse 20% above baseline Marked SOB, tachypnoea, pursed-lip breathing and/or use accessory muscles at rest, new-onset cyanosis or peripheral oedema, acute confusion/ drowsiness, marked reduction in ADLs

Question 251

When to arrange hospital admission for person with acute ex of COPD?

Answer 251

Severe SOB, inability to cope at home, poor/ det condition, rapid onset sx, acute confusion or impaired consciousness, cyanosis, worsening peripheral oedema, new arrhythmia, failure to respond to initial tx, receiving LTOT, changes on CXR, O2<90% on pulse ox- give 2-3l/min Venturi 24% or 28% 1-2l/min target sats 88-92%

Question 252

Tx person with COPD not needing admission?

Answer 252

Increase doses/ freq SABAs, if fatigued- use nebuliser, consider ICS for increase SOB- 30mg oral pred for 5 days, consider need for AB- based on sx severity, risk comps, previous sputum culture, risk antimicrobial resistance & current ABx prophylaxis

Question 253

Follow-up of exacerbation COPD?

Answer 253

Assess residual/ changed sx- consider need for further Ix, optimise non-pharm and pharm, use of meds, consider need for referral to specialist/ for pulm rehab Offer short course oral steroids and AB keep at home if: ex in last year and remain at risk, understand when and how to take, know when to seek help Review self-management plan

Question 254

Factors ass w/ increased risk mortality in people with COPD? Tx?

Answer 254

Freq and severity exacerbations Hosp during ex Poor lung function on spiro Low BMI CMBs Ensure has ACP, optimise sx- SOB, cough, secretions, pain, insomnia, depression, anxiety, discuss admission to hospice, family/ carer support

Question 255

Sx? Signs on examination in during asthma attack?

Answer 255

Dyspnoea, cough- may be nocturnal, chest tightness, diurnal variation, sx may worsen following exercise, weather changes or following use of NSAIDs/ Beta blockers Reduced chest expansion, prolonged expiratory time, bilateral expiratory polyphonic wheezes, tachypnoea, hyperinflated chest, hyperresonance on chest percussion, decreased air entry

Question 256

Ix asthma?

Answer 256

RCP3 Qs- recent nocturnal waking/ usual asthma symptoms in day/ interference with ADLs FeNO testing, spirometry- obstructive, BDR>12% or more of FEV1 and increase in volume of 200ml or more(children just 12%,) PEF variability>20% on >/=3d for 2w diagnostic lower in mornings, bronchial challenge testing with histamine or methacholine(PC20 value of 8mg/ml or less) Asthma control test: 25= well controlled, 20-24= on target, <20= off target Lung function- PEFR on waking, prior to taking BD and before bed after BD, spirometry, CO test= normal asthma Exercise CS trial ENO Blood and sputum tests- eosinophilia- sputum= more specific, raised total IgE CXR

Question 257

Ix asthma?

Answer 257

Presence of more than one variable sx wheeze, cough, SOB and chest tightness Personal/ family hx of other atopic conditions- atopic eczema/ dermatitis and/ or allergic rhinitis(previous skin prick tests) Results FeNO testing>40ppb adults/ 35 ppb in children

Question 258

Tx chronic asthma?

Answer 258

Smoking cessation, avoidance factors, review inhaler technique, teach PEF X2/ day, emergency advice, written action plan--> relaxed breathing(Papworth)

Question 259

Ask specifically about what during asthma history?

Answer 259

Precipitants- cold air, exercise, emotion , allergens- house dust mite, pollen fur/ infection, smoking, pollution, NSAIDs, beta-blockers Diurnal variation Exercise tolerance Disturbed sleep- nights/ week Acid reflux-tx improves spirometry Other atopic disease- eczema, hayfever, allergy or family hx Home- pets, carpet, feather pillows or duvet, floor cushions/ soft furnishings Job- PEF at work (paint-sprayers, food processors, welders, and animal handlers) and home Days per week off school or school

Question 260

Monitoring asthma? Uncontrolled asthma?

Answer 260

At least annually Adherence, inhaler technique, review if tx needs changing, ask about occupational asthma- refer to OT if needed, questionnaire Spiro or PEF 3 or more days week w/ sx or 3 or more days a week with required use of SABA for relief or 1 or more nights week with awakening

Question 261

When should inhaler technique be reviewed?

Answer 261

At every consultation relating to asthma attack, when deterioration in asthma control, when inhaler device changed, at every annual review, if person asks

Question 262

People on long-term steroids or needing frequent courses offer what?

Answer 262

Monitoring of BP, urine or blood sugar, cholesterol, BMD, vision- cataracts or glaucoma If meds adjusted- review response in 4-8 w

Question 263

Hx for acute asthma attack?

Answer 263

Usual and recent tx, previous acute episodes and severity best PEFR, admitted to ICU note agitation, consciousness, signs exhaustion- cyanosis, use accessory muscles Examine chest- RR, pulse, BP, best of 3 PEFR, pulse oximetry

Question 264

Features of moderate acute asthma attack? Acute severe? Life-threatening?

Answer 264

PEFR>50-75% best / predicted and normal speech, no features acute severe or life-threatening PEFR 33-50%, RR at least 25, inability to complete sentence in one breath, accessory muscle use, O2 at least 92%, pulse>110bpm PEFR<33%, O2<92% or altered consciousness or exhaustion or cardiac arrhythmia or hypotension/ cyanosis/ poor resp effort/ silent chest/ confusion(WARN ICU if severe or life-threatening)

Question 265

Ix in acute asthma?

Answer 265

ABG- T2RF= life-threatening, tachypnoeic= resp alkalosis(low PaCO2 and high PaO2) Falling RR= sign of patient fatigue, PaCO2 to normal= URGENT ESCALATION Bloods- FBC, CRP CXR- exclude

Question 266

Tx for acute asthma?

Answer 266

Ensure patent airway(AE) O2 if SATS below 94%- target 94-98% Salb/ ipratropium nebs- O2 driven(every 20-30 minutes if intermittent or over 30-60 minutes if continuous) (If not available- 4 puffs metered-dose inhaler with large-volume spacer--> 2 puffs every 2 minutes up to 10 puffs, repeat every 10-20 minutes if needed) Ipra if life-threatening or severe/ poor resp to salb Oral pred/ IV hydrocortisone Monitor PEFR and oxygen, ECG- arrhythmias IV MgSO4 if severe IV aminophylline if severe and inadequate BD response from nebs--> ICU(no improvement)- invasive ventilation

Question 267

Tx acute asthma not in hosp? Follow-up?

Answer 267

Salb large vol spacer- 4 puffs, then 2 puffs every 2 mins up to 10 puffs, repeat every 10-20 minutes Short course oral pred Return to SABA up to QDS once sx gone Monitor PEFR Within 48 hours and 2 days discharge- sx, PEFR, inhaler technique, consider increasing ICS dose, address RFs, lifestyle, recognising poor control, keep oral CSs at home

Question 268

Consider referral to resp physician if person has what?

Answer 268

2 asthma attacks within 12 months

Question 269

3 e.g. of ABGs in context?

Answer 269

Normal PaO2 on high-flow oxygen Normal PaCO2 in hypoxic asthmatic patient- NEED ITU intervention Very low PaO2 in someone who looks well, not SOB and normal O2 SATS

Question 270

In someone receiving oxygen therapy, what should their PaO2 be in relation to their inspired conc?

Answer 270

10kPa less than % inspired conc e.g. 40%- PaO2 of 30kPa

Question 271

Simple face masks can deliver a maximum FiO2 of approximately what at a flow rate of 15L/min- NEVER LESS THAN 5L/min? Reservoir masks e.g. non-rebreather? Venturi masks?

Answer 271

40-60% 60-90% at 10-15L/min 24, 28, 35, 40 and 60%(24 and 28% for those at risk of CO2 retention)

Question 272

Normal and abnormal PaO2 and PaCO2 levels?

Answer 272

11-15, <10= hypoxaemic, <8= severely hypoxaemic- RF 4.6-6.4kPa, <6= normocapnic, >6kPa= hypercapnic(T2RF)

Question 273

Causes of type 1 and type 2 RF?

Answer 273

Type 1= V/Q mismatch- PE most commonly, pulm oedema Type 2= hypoventilation- COPD, pneumonia, rib fractures, obesity, GBS, MND, opiates

Question 274

High HCO3- means what on ABG? Low HCO3-? CO2 and HCO3- in mixed acidosis/ alkalosis? Causes?

Answer 274

Metabolic alkalosis/ comp respiratory acidosis Metabolic acidosis or comp respiratory alkalosis Move in opposite directions Cardiac arrest, multi-organ failure= acidosis Liver cirrhosis in addition to diuretic use, HG, excessive ventilation in COPD= alkalosis

Question 275

Causes of resp acidosis? Resp alkalosis? Normal anion gap met acidosis? High anion met acidosis? Met alkalosis?

Answer 275

Resp depression, GBS, asthma COPD, iatrogenic Anxiety, pain, hypoxia, PE, pneumothorax, PE, iatrogenic GI, renal tubular disease, Addison's disease DKA, lactic acidosis, aspirin overdose, renal failure GI loss, renal loss H+, iatrogenic

Question 276

Anion gap formula? Normal value?

Answer 276

Na+- (Cl- + HCO3-) 4-12 mmol/L

Question 277

How can changes in CO2 be compensated? HCO3-?

Answer 277

By increasing/ decreasing levels HCO3- increasing/ decreasing levels CO2

Question 278

What can a VBG be used to comment on and not?

Answer 278

To exclude resp acidosis and and T2RF, determining response--> treatment, resp function in comb with pulse ox Oxygen levels- ABG needed

Question 279

Tx for pneumonia?

Answer 279

ABC- O2 if SATS<88%, 24-28% if COPD/ hypercapnia- maintain between 94-98% Tx hypotension/ shock- consider IV fluid ABx- WITHIN 4 HOURS Paracetamol/ NSAID CPAP if still hypoxic, hypercapnic= intubation Discuss with ICU if rising PaCO2 or remains hypoxic

Question 280

ABx for CAP? Atypical?

Answer 280

Mild= amoxicillin/ clar/ doxy Moderate= amox + clar/ doxy(amox + clar if IV) Severe= co-amox or cephalosporin + clarithromycin Add fluclo +/- rif if staph suspected; vanc if MRSA suspected

Question 281

If legionella pneumophilia suspected? Chlamydophila species? Pneumocystis jiroveci? Necrotising/ other features PVL--> s.aureus? Pseudomonas- CF & bronchiectasis?

Answer 281

Levofloxacin and clari/ rifampicin if severe- HYPONATRAEMIA AND LYMPHOPENIA COMMON Tetracycline- doxy/ lymecycline High dose co-trimoxazole- DRY COUGH, EXERCISE-INDUCED DESATS & ABSENCE CHEST SIGNS IV linezolid, IV clindamycin, IV rifampicin IV ceftazidime w/ gent/ tobramycin- consider dual therapy minimise resistance

Question 282

Tx for HAP? Aspiration? Neutropenic?

Answer 282

IV aminoglycoside e.g. gentamicin(Hartford protocol)-risk of oto & nephrotoxicity once-daily dosing + antipseudomonal penicillin e.g. ticarcillin/ piperacillin with tazobactam (Ceftazidime or Tazocin) IV ceph + metro Aminogly + antipseudomonal/ 3rd gen caph Consider antifungals after 48h

Question 283

CXR findings in s.pneumoniae, aureus and legionella? S.aureus? Klebsiella? Tx?

Answer 283

Multi-lobar, multiple abscesses, upper lobe cavity- EXCLUDE TB Cefotaxime/ imipenem

Question 284

Ix pneumonia?

Answer 284

Bloods: FBC- WBCs for severity, ESR & CRP, U&Es- severity, LFTs, pulse ox and ABG if O2 <94% HIV test, sputum culture and sens +/- Gram stain, blood culture, serology- viruses and atypical

Question 285

Comps of pneumonia? When would someone with CAP have a CXR 6 weeks after?

Answer 285

Resp failure, hypotension, parapneumonic effusion and empyema, pleural effusion, septicaemia, brain abscess, myocarditis, cholestatic jaundice, pericarditisƒ S&S persist despite tx, higher risk malignancy- >50 y/o and smokes

Question 286

Indications of empyema? Ix? Tx? ABx?

Answer 286

Ongoing fever, failure of fever/ WBC/CRP to settle, pain deep inspiration, signs pleural collection Pleural tap--> pH<7.2, low glucose, fluid- yellow and turbid Chest drain Co-amoxiclav, pip-taz, meropenem- anaerobic

Question 287

CXR for lung abscess? Seen in who? Organisms? Tx?

Answer 287

Cavity formation Aspiration- alcoholics, oesophageal obstruction, inadequate tx CAP, TB, foreign body, septic emboli- staph S.milleri, Klebsiella, GRAM-VE bacteria Prolonged ABx up to 6w- surgical drainage may be required

Question 288

Idiopathic interstitial pneumonia group non-infective causes pneumonia including what? Comp of what?

Answer 288

Cryptogenic organising pneumonia- form bronchiolitis as comp of RA or amiodarone therapy

Question 289

Discharge advice if in past 24h pneumonia patients have had 2 or more of what?

Answer 289

NOT DISCHARGE- temp>37.5 degrees, RR>24, HR>100, sys BP<90, O2<90% on RA, abnormal mental status, inability eat without assistance

Question 290

Resolution pneumonia sx?

Answer 290

Fever= 1w Chest pain & sputum= 4w Cough & SOB= 6w Most resolve except fatigue- 3m 6m= back to normal

Question 291

S&S of TB?

Answer 291

FEVER- gradual onset and low-graded Dyspnoea, initial dry cough--> productive> 3 months Night sweats Weight loss Pleurisy/ chest pain/ SOB Pleural effusion/ consolidation, pulm collapse from compression lobar bronchus Anorexia Can be hoarse voice

Question 292

Sx of extrapulmonary TB?

Answer 292

swollen lymph nodes +/- discharge Pericarditis Pain/ swollen joints, Potts disease- spinal Abdo- ascites, abdo LNs, ileal malabsorption Epididymitis, LUTs, haematuria CNS= raised ICP sx, low grade meningitis, random CN palsies Skin- lupus vulgaris, erythema nodosum Eyes(retinal/ ocular)- blurred vision and light sensitivity

Question 293

Ix Latent TB? Active TB? Active non-resp TB?

Answer 293

Mantoux/ tuberculin test 48-72 hours response--> type 4 HS reaction- +ve(immunity) - consider interferon-gamma testing- use ESAT-60 and CFP10 dis between M.tub between BCG vaccine or environmental mycobacteria(indicate exposure but not active) MILIARY/ IMMUNOSUPPRESSED WON'T TEST If CXR suggests- take sputum samples>/= 3 samples- MC&S for AFB resist acid on Ziehl-Neelsen staining/ bronchoscopy and lavage if not possible/ pleural fluid or lung biopsy Culture- up to 6 weeks with Lowenstein-Jensen agar, lquid media= rapid results within 1-3 weeks Sputum, pleura and pleural fluid, early morning urine samples for dipstick, microscopy and mycobacteria culture, pus, ascites, peri, bone marrow/ CSF samples & LP for non-resp, TB culture by micro, ECHO, CT- chest/ CNS/ bones & joints CXR- patchy/ nodular shadows in upper zones with loss volume and fibrosis w or w/o cavitation, consol, mediastinal/ hilar lymphadenopathy PCR(NAAT,) histology= caseating granulomata

Question 294

Tx active TB? Do what before and after tx? Tx latent TB?Check what? Reduce rif dose by 50% in what situation? Monitor what for ethambutol?

Answer 294

NOTIFY PHE & contact tracing- all household members, close contacts, most work colleagues, isolate until 2 weeks after starting tx Rx before culture results Fully sens TB= 6m tx, CNS= 12m(R&I, P&E during 1st 2m): First 8 weeks= pyrazinamide- 2.5g 3 times a week Ethambutol 30mg x3 times/ week/ streptomycin Rifampicin 600-900mg x3 times a week for 6 months Isoniazid= 15mg/ kg 3 times/ week max 900mg for 6m GIVEN IN DOTS- direct observed therapy Consider steroids for meningeal/ pericardial TB 3m isoniazid and rifampicin OR 6m isoniazid Colour vision and visual acuity If pre-tx creatinine clearance 10-50ml/min, U&Esp

Question 295

Monitoring and SEs of TB drugs?

Answer 295

Sputum samples- M & C at monthly intervals R= hepatitis, red urine, drug inter- the pill I= hepatitis, neuropathy P= hepatitis, arthralgia/ gout & rash E= optic neuritis- COLOUR VISION

Question 296

Common regime for resistant TB? Extensively drug-resistant TB?

Answer 296

Levo + bedaquiline + linezolid At least 5 of fluoroquinolone, bedaquoline, linezolid and additional New alternative= 26-week regimen of bedaquiline, pretomanid and linezolid

Question 297

TB comps?

Answer 297

Haemoptysis, pneumothorax, bronchiectasis, pulm destruction, fistula, tracheobronchial stenosis, malignancy, chronic pulm aspergillosis TB effusions and empyema Miliary TB Septic shock

Question 298

How is TB screened for? In who? BCG vaccine?

Answer 298

Mantoux and IGRAs- active/ +ve--> CXR, sputum stain and culture, people starting immunosuppressant treatment e.g. anti-TNF- infliximab- should be screened Recent exposures, healthcare workers, homeless shelters and prisons, increased risk reactivation- HIV, travellers from high-incidence countries Live from m.bovis- children in high-risk region, healthcare

Question 299

Features of mycoplasma pneumoniae? Ix? Comps? Tx?

Answer 299

Flu-like sx followed by cough CXR= reticular nodular shadowing/ patchy consolidation often of 1 lower lobe and worse than signs suggest PCR sputum or serology Erythema multiforme, SJS, meningoencephalitis or myelitis, GBS Clarithromycin or doxycycline or cipro

Question 300

Predominant pathogens in acute sinusitis? Tx? Comps?

Answer 300

S.pneumoniae, h.influenzae & Moraxella catarrhalis, rhinoviruses Facial pain, nasal discharge, nasal obstruction Analgesics, decongestants, intranasal corticosteroids and saline irrigation, ABx- fail to improved after 7-10 days- phenoxy or co-amoxiclav if systemically unwell, sx more serious, high-risk comps Orbital cellulitis, subperiosteal formation and intracranial extension --> meningitis or brain abscesses

Question 301

Most common cause epiglottitis? Sx? Tx?

Answer 301

Hib Severe sore throat and odynophagia- painful swallowing + drooling, muffled voice, stridor, resp distress, high-grade fever, tripod/ sniffing position- DON'T EXAMINE THROAT Lateral neck radiograph= THUMB SIGN only if stable, flexible fiberoptic laryngoscopy- only if stable, blood cultures and throat swabs Urgent endotracheal intubation, tracheostomy IV ceftazidime, supportive, close monitoring, vaccination in children

Question 302

Most PE clots from which veins? rarer causes?

Answer 302

Pelvic and abdominal veins- but femoral and occasionally axillary thrombosis Right vent thrombus- post MI, septic emboli, fat embolism- long bone fracture, air embolism, amniotic fluid embolism, neoplastic cells, parasites, foreign material during IV drug misuse

Question 303

Other causes of PE? Sx?

Answer 303

Immobility Recent surgery Long-haul travel Pregnancy Hormone therapy with oestrogen (e.g., combined oral contraceptive pill or hormone replacement therapy) Malignancy Polycythaemia (raised haemoglobin) Systemic lupus erythematosus Thrombophilia SOB, tachypnoea, pleuritic chest pain, haemoptysis, dizziness, syncope, pyrexia, cyanosis, past hx or family hx Gallop rhythm, raised JVP, loud P2, right vent heave, pleural rub, AF, DVT

Question 304

Ix PE?

Answer 304

FBC, U&E baseline clotting, D-dimers, ABG--> reduced PaO2 and PaCO2 CXR- often normal, decreased vascular markings, small pleural effusion, wedge-shaped area infarction, atelectasis, pulm oligaemia ECG- sinus tachy, RAD, RBBB, AF, "SIQIIITIII," RV strain ABG- T1RF Two-level Wells score unless HD unstable, pregnant or has given birth within 6 weeks Serum D-dimer- rules out CTPA- interim anticoagulation--> V/Q scan- also if RENAL IMPAIRMENT/ CONTRAST ALLERGY/ AT RISK FROM RADIATION

Question 305

Tx of PE?

Answer 305

Immediate admission if pregnant/ HD unstable- cardiac arrest, obstructive shock, sys BP<90, eng-organ hypoperfusion, persistent hypotension/given birth within the past 6 weeks Wells score>4 immediate CTPA/ interim anticoagulation-->V/Q scan <4= D-dimer with results within 4 hours- if not--> anticoagulation, -ve= stop anticoag + consider alt +ve--> CTPA/ interim anticoag

Question 306

Features in Wells score for PE?

Answer 306

Clinical S& S of DVT PE is number 1 diagnosis/ equally likely HR>100 Immobilisation at least 3 days OR surgery in previous 4 weeks Previous Ix PE/ DVT Haemoptysis Malignancy w/ tx within 6m or palliative

Question 307

Follow-up after PE confirmed and AC started?

Answer 307

Adequate monitoring, info booklet, alert card, verbal and written info on AC treatment, Ix for unprovoked, hereditary thrombophilia testing where appropriate Ix for unprovoked= FBC, U&Es, LFTs, APTT, PT, physical exam If planned to stop AC- consider AP antibodies, hereditary thrombophilia for 1st degree relative with DVT/PE

Question 308

If clinical suspicion is low for PE, consider using what to determine further Ix? Use of score?

Answer 308

PERC: Age>50, HR>/=100, O2 sat on room air<95%, unilateral leg swelling, haemoptysis, recent surgery/ trauma, prior PE/ DVT, hormone use All absent to rule out PE

Question 309

Options for interim anticoagulation in PE? blood tests?

Answer 309

Apixaban or rivaroxaban/ LMWH for at least 5 days followed by dabigatran or edoxaban LMWH with vit K ant(warfarin) at least 5 days FBC, U&Es, LFTs, PT and APTT- don't wait for results to tx

Question 310

Tx for PE?

Answer 310

Oxygen if hypoxic 10-15L/min Morphine 5-10mg IV w/ anti-emetic if pain/ distressed LMWH unless CI e.g. active bleeding/ existing AC w/ DOAC/ warfarin Anti-embolic stocking unless CI e.g. PAD HD= immediate thrombolysis + cont infusion fibrinolytic unfrac heparin/ LMWH e.g. alteplase, streptokinase- IV/ catheter-directed OR embolectomy- less common IVC filters- repeat despite adequate AC

Question 311

Score for considering OP tx in PE?

Answer 311

PESI: age, sex, hx cancer/ HF/ chronic lung disease, HR>/=110, sys BP<100, RR>30, temp<36, altered mental status, O2<90%

Question 311

AC following PE Ix?

Answer 311

Apixaban or rivaroxaban Unsuitable= LMWH--> dabigatran or edoxaban/ LMWH--> VKA e.g. warfarin at least 5 days until INR 2 Renal impair<15ml/min= LMWH, unfrac heparin/ LMWH--> VKA APS= LMWH--> VKA, target INR= 2-3 Pregnancy= LMWH

Question 312

Length AC in PE? Score for assessing risk of bleeding on AC?

Answer 312

3 months- provoked Unprovoked/ recurrent/ irreversible cause e.g. thrombophilia= 6m 3-6m in active cancer, then review HASBLED (mainly AF)- HTN>160mmHg, renal disease, liver disease, stroke hx, prior major bleeding/ predis--> bleeding, labile INR, age>65, med predis--> bleeding, alcohol use>/=8 drinks/ week

Question 313

Give what in PE if BP<90mmHg? Still reduced after 500ml? Still low? Still<90 after 30-60 min standard tx? If BP>90 mmHg?

Answer 313

Colloid infusion+ ICU input Dobutamine- aim for BP>90 mmHg IV noradrenaline infusion Consider thrombolysis- unless already given Warfarin loading regimen e.g. 5-10mg PO- confirm Ix

Question 314

Comps of PE?

Answer 314

Acute RVF, cardiogenic shock, arrhythmias-SVT/VT, resp failure, infarction & lung necrosis, pleural effusion, pneumothoax CTEPH= pulm HTN + right HF eventually

Question 315

Legionella pneumophilia features? Ix? Tx?

Answer 315

Flu-like, dyspnoea and dry cough, anorexia, D&V, hepatitis, renal failure, confusion and coma CXR= bi-basal consolidation Bloods= lymphopenia, hyponatraemia, deranged LFTs, urinalysis may show haematuria Legionella urine antigen/ culture Fluoroquin(cipro) for 2-3 weeks/ clari

Question 316

Chlamydophila pneumoniae features? Ix? Tx?

Answer 316

Biphasic- pharyngitis, hoarsenss, otitis, followed by pneumonia Chlam complement fixation test, PCR invasive samples Tx= doxy/ clari

Question 317

Chlamydophila psittaci features? Ix? Tx?

Answer 317

Causes psittacosis- from infected birds Headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V Meningo-encephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly Chlam serology Doxy/ clari

Question 318

Pneumocystis pneumonia features? Ix? Tx?

Answer 318

Pneumonia in immunosuppressed- dry cough, ex dyspnoea, reduced PaO2, fever, bilateral creps CXR- may be normal or show bil perihilar interstitial shadowing Visual organism in induced sputum, bronch lavage/ lung biopsy High dose co-trimoxazole/ pentamidine for 2-3w Steroids in severe hypoxaemia Prophylaxis if CD4<200x10^6/ after first attack

Question 319

Mnemonic for causes upper lobe fibrosis?

Answer 319

CHARTS= coal workers' pneumoconiosis, histiocytosis, ankylosing spondylitis/ allergic bronchopulmonary aspergillosis, radiation, tuberculosis, silicosis/ sarcoidosis

Question 320

Drugs causing secondary pulmonary fibrosis? Conditions?

Answer 320

Nitrofurantoin, bleomycin, amiodarone- also causes grey/ blue skin, sulfasalazine, busulfan, cyclophosphamide, methotrexate ALAT deficiency, RA, SLE, systemic sclerosis, sarcoidosis

Question 321

2 medications licensed for idiopathic pulm fibrosis?

Answer 321

Pirfenidone Nintedanib- inhibits tyrosine kinase

Question 322

Drugs that cause secondary pulmonary fibrosis? Conditions?

Answer 322

Amiodarone, cyclophosphamide, methotrexate, nitrofurantoin A1AT deficiency, RA, SLE, systemic sclerosis, sarcoidosis

Question 323

EXPLAIN mnemonic for causes of pulmonary fibrosis?

Answer 323

Exogenous drugs- sulfonylureas or insulin Pituitary insufficiency Liver failure Addison's disease Islet cell tumours- insulinomas Non-pancreatic neoplasms

Question 324

What can you not get above with hernias?

Answer 324

A hernia or an infantile hydrocele due to a patent processus vaginalis- is irreducible, testis is impalpable and has no cough impulse

Question 325

RILE mnemonic for murmurs?

Answer 325

Right-sided= best on inspiration Left-sided= best on expiration

Question 326

Causes of bronchiectasis?

Answer 326

Idiopathic, pneumonia, whooping cough, TB, A1AT deficiency, connective- rheumatoid arthritis, CF, yellow nail syndrome, primary ciliary dyskinesia, allergic BP aspergillosis (CAPT Kangaroo has Mounier-Kuhn)

Question 327

Most common organisms in bronchiectasis?

Answer 327

H.influenzae, pseudomonas, Klebsiella, s.pneumoniae

Question 328

A1AT deficiency is caused by what?

Answer 328

Lack of protease inhibitor normally produced by the liver Ch 14- autosomal recessive fashion(SERPINA1 gene) Alleles classified by their electrophoretic mobility- M for normal, S for slow and Z for very slow(most common) Normal= PiMM, heterozygous= PiMZ

Question 329

Normal A1AT levels in homozygous PiSS and PiZZ? Ass w/ A1AT?

Answer 329

50% and 10%- manifest disease= usually PiZZ genotype, PIMZ= asymptomatic, S only symptomatic with Z(PISZ) Asthma, pancreatitis, aneurysms, including intracranial aneurysms

Question 330

Apical vs basal fibrosis mnemonic?

Answer 330

TEARS IN THE SKY- TB, extrinsic allergic alveolitis, AS/ allergic bronchopulmonary aspergillosis, radiation, silicosis/ sarcoidosis/ berylliosis/ pneumoconiosis- coal worker's CRABS ON THE FLOOR- cryptogenic fibrosing alveolitis (IPF,) rheumatoid arthritis/ systemic sclerosis, asbestosis/ aspiration/ A1AT deficiency, busulfan/bleomycin/ bronchiectasis, scleroderma

Question 331

Staging of ABPA? Major and minor criteria?

Answer 331

1= acute, II= remission, III= recurrent exacerbation, IV= steroid-dependent asthma, V= pulmonary fibrosis Major= asthma, pulmonary opacities, central bronchiectasis, blood eosinophilia, elevated IgG or IgE against A. fumigatus, IgE>1000IU/ ml Minor= fungal elements in sputum, expectoration of brown plugs/ flecks, delayed skin reactivity to fungal antigens

Question 332

What may be seen in the sputum of people with bronchial asthma and ABPA?

Answer 332

Charcot-Leyden crystals

Question 333

Light's criteria for pleural fluid interpretation? If though transudative, but Light's suggest exudate what done?

Answer 333

Pleural fluid: serum protein>0.5 Fluid: serum LDH>0.6 Fluid LDH> 2/3 upper limit normal serum value Serum- pleural fluid protein gradient

Question 334

Pleural fluid LDH>1000 IU/L? Low pleural glucose <3.4mmol/L? <1.6?

Answer 334

Empyema, malignancy or rheumatoid effusion Empyema, rheumatoid pleuritis ass w/ TB, malignancy and oesophageal rupture Empyema and rheumatoid disease

Question 335

Low pleural pH <7.3? High amylase above 110 IU/L?

Answer 335

Same pathologies causing low pleural fluid glucose levels Pancreatitis, malignancy or ruptured oesophagus

Question 336

WBCs in transudative or exudates? Lymphocytosis? Neutrophils?

Answer 336

Exudates>50,000 cells/ microL Trans<1000 cells/ microL TB, sarcoidosis or malignancy Empyema or PE

Question 337

Triglyceride and cholesterol levels in chylothorax and pseudochylothoax diagnoses?

Answer 337

Tri>1.24mmol/L, chol<5.18 mmol/L Tri<0.56mmol/L, chol>5.18

Question 338

Causes of resp acidosis and alkalosis?

Answer 338

COPD, life-threatening asthma, opiates overdose, benzos, NM disease, obesity hypoventilation syndrome PE, anxiety--> hyperventilation, CNS disorders- stroke, SAH, encephalitis, altitude, pregnancy, salicylate poisoning

Question 339

Diagnostic criteria for OHS? Tx? Ass w what?

Answer 339

BMI>/= 30kg/ m^2, daytime PaCO2>45mmHg, ass sleep-breathing disorder, absence of other known causes of hypoventilation Return to normal body weight, severe= bariatric, assisted ventilation supp by O2 CHF, pulm HTN, cor pulmonale, angina

Question 340

Ix for OHS?

Answer 340

ABGs- daytime hypercapnia and hypoxaemia, serum HCO3- exclude in low-risk, nocturnal oximetry for sleep apnoea, CXR, ECHO- RVH, ECG- RBBB, pulm function- flow volume loop (exp volume by spirometry against flow rate--> sawtooth pattern,) FVC + exp reserve volume reduced and airways resistance increased Overnight polysomnography- hypovent, hypoxia and hypercapnia during sleep, especially in children and adolescents, FBC & TFTs- anaemia and mxyoedema

Question 341

Features indicating urgent CXR within 2 weeks aged 40 and over for suspected lung cancer/ mesothelioma?

Answer 341

Persistent or recurrent chest infection, finger clubbing, SC lymphadenopathy or persistent cervical lymphadenopathy, chest signs cons, thrombocytosis

Question 342

CXR recommended to patients over 40 y/o who have never smoked with two or more of what sx (one or more if they have ever smoked/ had asbestos exposure)

Answer 342

Cough, SOB, chest pain, fatigue, weight loss, appetite loss

Question 343

Ix for lung cancer?

Answer 343

Staging CT, PET-CT, bronchoscopy with endobronchial ultrasound(EBUS,) histological diagnosis needs biopsy by bronchoscopy or percutaneous biopsy through skin Cytology from sputum and pleural fluid FBC MRI= spread to brain or bones

Question 344

Sites of met spread from lung cancer?

Answer 344

Liver, bone, adrenal glands, brain(more common to spread TO lung) Breast, bowel, kidney- MOST COMMONLY, bladder

Question 345

TNM class of lung cancer?

Answer 345

T1<3cm, T2>3cm, T3= chest wall, diaphragm and pericardium, T4= mediastinum, heart, great vessels, trachea, oesophagus, vertebra, carina, malignant effusion, mets in same lobe N1= hilar nodes, N2= same side mediastinal nodes or subcarinal, N3= contralateral mediastinum/ supraclavicular M1a= tumour same side, M1b= tumour elsewhere

Question 346

What is pulm HTN defined as?

Answer 346

mPAP above 25mmHg as measured at right heart catheterisation and secondary right ventricular failure

Question 347

5 groups of causes of pulmonary hypertension?

Answer 347

Idiopathic/ CTD e.g. SLE Left heart failure- MI/ systemic HTN Chronic lung disease- COPD/ pulm fibrosis Pulmonary vascular disease- PE Miscellaneous- sarcoidosis, glycogen storage disease and haematological disorders

Question 348

Gene involved in Goodpasture's syndrome? Antibodies?

Answer 348

HLA-DRB1 Anti-GBM vs alpha-3 chain of type IV collagen

Question 349

Auto-antibodies in Wegener's granulomatosis (granulomatosis with polyangiitis)? Drugs? Nasal carriage of what?

Answer 349

PR3-ANCA(cANCA,) A1AT, HLA-DP, raised ESR & CRP Propylthiouracil, hydralazine, sulfasalazine, phenytoin and allopurinol Silica dust, mercury S.aureus

Question 350

Presentation of GPA?

Answer 350

Fever, malaise, arthralgias and weight loss--> rhinosinusitis, cough, dyspnoea, hearing loss, purpura, urinary sediment or neurological dysfunction Upper(90%)= sinusitis, nasal crusting, subglottic stenosis, otitis media, hearing loss, ear pain Dyspnoea, cough, pleuritis, haemoptysis, pulm infiltrates Micro haematuria, urinary sediment, pauci-immune RPGN--> CKD 60%= scleritis/ episcleritis, orbital mass, 50%= cutaneous skin lesions, 15%= mononeuritis multiplex, peripheral sensorimotor polyneuropathy, cranial neuropathy

Question 351

Sx of Churg- Strauss syndrome/ eosinophilic granulomatosis with polyangiitis?

Answer 351

Asthma, pneumonitis, haemoptysis Allergic rhinitis, paransal sinusitis, nasal polyposis HF, myocarditis and MI Leukocytoclastic angiitis, livedo reticularis, urticardia GN, HTN, advanced CKD Peripheral neuropathy

Question 352

ANCA autoantibodies in CSS?

Answer 352

p-ANCA, elevated CRP & ESR, eosinophilia and anaemia on FBC, elevated serum creatinineSus

Question 353

Suspect atelectasis in dyspnoea and hypoxaemia how long after surgery? Also?

Answer 353

72 hours Pyrexia in first 48 hours--> chest physio and breathing exercises

Question 354

5 groups of pulmonary hypertension?

Answer 354

Idiopathic/ CTD e.g. SLE Left heart failure Chronic lung disease- COPD/ pulm fibrosis Pulmonary vasc- PE Misc- sarcoidosis, haem disorders, glycogen storage

Question 355

Levine scale for murmurs?

Answer 355

Grade I= very fine- may only be heard by an expert, not heard in all positions, no thrill II= soft, heart in all positions- no thrill III= moderately loud, no thrill IV= loud and associated with palpable thrill V= very loud with thrill, heard with stethoscope partly off chest VI= loudest with thrill, heard with stetho entirely off chest (just above precordium)

Question 356

SE of cyclophosphamide?

Answer 356

Haemorrhagic cystitis

Question 357

Mnemonic for causes erythema nodosum?

Answer 357

NO/DOSOUM- no cause, drugs- antibiotics, oral contraceptives, sarcoidosis/ Lofgren's syndrome, UC/ Crohn's/ Behcet's, micro- TB/ viral/ bacterial/ psittacosis/ parasitic

Question 358

Naegele's rule?

Answer 358

Add 1 year and 7 days to first day of LMP and then subtract 3 months

Question 359

Tx for mild-moderate acne?

Answer 359

12-weeks of topical adapalene with topical benzoyl peroxide(0.1 or 0.3% with 2.5%) Topical retinoin with topical clindamycin (0.025% with 1% clindamycin) Topical BP + clindamycin (3 or 5% with 1% clindamycin) Mono= topical benzoyl peroxide Once or twice a week--> daily if tolerated

Question 360

Moderate- severe acne?

Answer 360

12w of topical ada w/ topical BP ON Topical retinoin with topical clindamycin ON Ada with topical benzoyl peroxide ON w/ oral lymecycline 408mg/ oral doxy Topical azelaic acid BD with oral lym 408mg/ oral doxy 100mg OD Topical benzoyl peroxide (Trimeth or oral macro instead of lymecycline or oral doxy)

Question 361

Last-line option acne? Most effective contraception for acne?

Answer 361

Oral retinoids- isotretinoin (pregnant only 1 month after) Co-cyprindiol (Dianette)- discontinue 3 months after controlled, also spiro- CI IN PREGNANCY TOO

Question 362

Refer who to on-call derm team within 24 hours? To consultant led team?

Answer 362

Acne fulminans Ix uncertainty, acne conglobata, nodulo-cystic acne Consider if mild-moderate not responded to x2 completed courses tx/ not responses to previous tx including oral AB, acne w/ scarring/ w/ pigmentary changes, causing psych distress

Question 363

Follow-up acne patients when? Taking oral isotretinoin?

Answer 363

12 weeks- review ABx at 3-monthly intervals- stop ASAP Review after 1 week- monitor for suicidal ideation, sexual function, dry skin & lips, photosensitivity--> sunlight, rarely= SJS & TEN STOP FOR 1 MONTH AT LEAST BEFORE BECOMING PREGNANT

Question 364

Surgical sieve?

Answer 364

VITAMIN DEF

Question 365

Ix for acne rosacea?

Answer 365

At least one of phymatous changes, persistent erythema/ two of: Major= flushing/ transient erythema, papules and pustules, telangiectasia, ocular (Minor= skin and/ or stinging sensation, skin dryness, oedema)

Question 366

Tx for rosacea? Refer to dermatologist? Oph?

Answer 366

Persistent erythema= topical brimonidine Topical ivermectin for mild-moderate papules/ pustules Oral doxy for moderate- to-severe papules/ pustules depending on CIs Persistent erythema or papules/ pustules not responded to optimal management in primary care, severe telangiectasia Keratitis/ anterior uveitis

Question 367

4x things for examining skin?

Answer 367

1) Inspect- general, site & number lesions- pattern distribution and configuration 2) Describe: SCAM- size/ shape, colour, ass secondary change, morphology/ margin If pigmented: ABCDE- asymmetry, irregular border, two or more colours within lesion/ pink/ grey/ white, diameter>6mm, E- quick growing or rapid appearance changes 3) Palpate- surface, consistency, mobility, tenderness, temperature, tenderness, edge- induration?, bleeding? 4) Systematic- nails, scalp, hair and mucous membranes, general examination OR LOOK, FEEL, MOVE, REGIONAL LYMPHATIC DRAINAGE, SPECIAL TESTS- peripheral pulses, light touch & pressure sensation, evidence bony involvement, additional examination from PC

Question 368

Tx for eczema?

Answer 368

Emollients, consider topical steroids for red, inflamed skin- lowest potency and amount of topical corticosteroid Persistent severe itch or urticaria= 1 month trial non-sedating antihistamine Affecting sleep= short course sedating antihistamine Severe extensive eczema= short course oral CSs Weeping, crusting/ pustules w/ fever or malaise= consider 2 bacterial infection

Question 369

Thin vs thick greasy emollients for eczema?

Answer 369

E45, Diprobase, Oilatum, Aveeno, Cetraben, Epaderm 50:50, hydromol, diprobase, cetraben, epaderm ointments

Question 370

Steroid ladder for eczema(ONLY INFLAMED AREAS)? Severe eczema? 2nd line tx?

Answer 370

Hydrocortisone 0.5, 1 and 2.5% Eumovate- clobetasone butyrate 0.05% Betnovate- betamethasone 0.1% Very potent- Dermovate- clobetasol proprionate 0.05% Ciclosporin, azathioprine, phototherapy UVA, antihistamines e.g. chlorphenamine Oral corticosteroids e.g. 30mg pred for 1 week Topical calcineurin inhibitors- less SE, more useful for sensitive areas e.g. tacrolimus or pimecrolimus--> burning/ stinging

Question 371

When should corticosteroids be continued for? Delicate areas skin? Review emollients? Topical CSs? Non-sedating antihistamines?

Answer 371

48 hours after flare controlled 5 days max Annually 3-6 monthly, 3 months

Question 372

Refer within 2w to derm for eczema? Routine?

Answer 372

If severe and not responded to optimum topical tx after 1 week Ix uncertain, adverse reaction--> emollients, facial eczema not responding, contact allergic dermatitis suspected, social/ psych issues

Question 373

Tx for infected eczema?

Answer 373

Flucloxacillin/ clarithromycin/ localised= fusidic acid Not respond--> refer within 2 weeks

Question 374

Amount and freq emollient eczema?

Answer 374

250-500g/ week child 500-750g/ week for adult

Question 375

LAMBSKIN for exacerbating factors for psoriasis? Drugs causing mnemonic?

Answer 375

Lithium/ UVA exposure, alcohol, meds- chloroquine & derivatives, steroid withdrawal, M, stress/ smoking, infection with Group A strep, N Relieving= sunlight BALI: beta blockers, anti-malarials, lithium, indomethacin- NSAIDs

Question 376

Tx for psoriasis?

Answer 376

Emollients Topical CSs- potent no longer than 8 weeks at time Vit D analogues e.g. calcipotriol/ Dovobet Coal tar Short-contact dithranol CV review every 5y, advice reducing VTE risk- if severe

Question 377

Derm referral for psoriasis?

Answer 377

Uncertainty, extensive>10%, mod-severe, resistant in primary care, not tolerated, severe nail disease, psych effects Specialist treatments

Question 378

Referral to rheumatologist for psoriasis? Severity tool? QOL tool? Rules of 9 for body surface area?

Answer 378

3/more out of 5 on PEST tool PGA- 6 points DLQI/ CDLQI Arm-9%, head-9%, neck- 1%, leg- 18%, anterior trunk- 18%, posterior trunk- 18% Lund and Browder chart

Question 379

Types of psoriasis?

Answer 379

Pustular, erythrodermic, chronic plaque, scalp, facial, flexural, guttate, nail

Question 380

Review psoriasis after how many weeks?

Answer 380

4 weeks, at least annually if using multiple courses potent topical corticosteroids CV risk every 5 years, advice reduce risk VTE

Question 381

Specialist tx for psoriasis? Advice?

Answer 381

Skin biopsy Calcineurin inhibitors- tacrolimus and pimecrolimus- flexural/ facial psoriasis UVB phototherapy- mild-moderate/ guttate Severe= methotrexate, ciclosporin, acitretin, apremilast- severe plaque/ nail disease/ high-impact sites (phototherapy ineffective/CI/rapid relapse within 3 months) Contraception, effects during conception and pregnancy, vaccines= CI, regular influenza and pneumococcal jabs Anti-TNF for mod-severe plaque- target IL-17 and IL-23 (after phototherapy when conventional failed/ not tolerated/ CI)

Question 382

Tx for flexural psoriasis? Guttate? Palmoplantar?

Answer 382

Topical mild-mod corticosteroids- short course Top vit D analogue Topical mild-mod CSs, UVB, coal tar Emollients, salicylic acid, potent topical CSs, UVA, oral retinoid alongside phototherapy, anti-TNF only once systemic FAILED- IV inflix/ etan/ adalimumab

Question 383

What is the Parkland formula for calculating fluid requirements in burns?

Answer 383

Total body surface area % x body weight (kg) x 4 ml

Question 384

Mnemonic for multiple myeloma?

Answer 384

CRABBI: calcium- high/ renal- light chain deposition, amyloidosis, nephrocalcinosis, nephrolithiasis/ anaemia/ bleeding/ bones- pathological fractures/ infection Also: carpal tunnel, neuropathy, hyperviscosity

Question 385

Major and minor criteria for diagnosing multiple myeloma?(one minor and major/ three minor)

Answer 385

Plasmacytoma, 30% plasma cells in bone marrow sample, elevated levels of M protein in blood or urine 10-30% plasma in bone marrow sample, minor elevations in level M protein in blood or urine, low levels antibodies in blood

Question 386

What is group and save and crossmatching for?

Answer 386

Blood loss is not anticipated but blood may be required if greater blood loss is expected- DONE BEFORE XMATCH Mix patient with donor blood to see if any immune reaction takes place- if none, donor blood can be issued Done if blood loss anticipated BOTH TAKE 40 MINUTES

Question 387

What is Wallace's Rule of Nine?

Answer 387

Head & neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen

Question 388

What are the thresholds and targets for Hb g/L in patients without and with ACS? Rate in non-urgent?

Answer 388

Without= 70g/L- target= 70-90 With ACS= 80g/L- target= 80-100g/L STORED AT 4 DEGREES PRIOR TO TRANSFUSION 90-120 minutes- 3 hours with HF, urgent= STAT

Question 389

Common causes of an itch with a rash? With no rash?

Answer 389

urticari, atopic eczema, psoriasis, scabies Renal failure, jaundice, iron deficiency, lymphoma- Hodgkin's, polycythaemia, pregnancy, drugs, diabetes, cholestasis, ageing

Question 390

Fitzpatrick scale for skin?

Answer 390

1= never tans, always burns 2= usually tans, always burns 3= always tans, sometimes burns 4= always tans, rarely burns- olive skin 5= sunburn and tanning after extreme UV exposure 6= black skin, never tans/ burns

Question 391

Causes of DIC? Blood picture?

Answer 391

Sepsis, trauma, obstetric, malignancy Low platelets, fibrinogen, high PT & APTT, high fibrinogen deg products, schistocytes

Question 392

Possible cause of pityriasis rosea? Versicolor?

Answer 392

HHV-6 or HHV-7 Gold, ACE-i, penicillamine, biologics BCG, hep B & pneumococcal vaccine Malassezia fungi

Question 393

Ix and tx of pityriasis versicolor?

Answer 393

Wood lamp exam--> yellow-green fluorescence Dermoscopy microscopy of skin scrapings- hyphae and yeast cells that resemble spag and meatballs Dermoscopy= pallor- background faint pigment network Fungal culture Skin biopsy- fungal elements within outer cells of stratum corneum Topical antifungal shampoo- selenium sulfide(not in pregnancy or breastfeeding,) ketoconazole/ econazole, oral if extensive/ topical ineffective Small areas= imidazole cream Terbinafine gel (Refer pregnant/ breastfeeding--> derm) Resolve within 2-3 months

Question 394

Is relapse of pityriasis versicolor common?

Answer 394

Yes- usually when warm weather, regular use topical tx minimises risk- ket shampoo OD for max 3 days prior to exposure

Question 395

Sx of pityriasis alba?

Answer 395

1-20 patches/ thin plaques on face on cheeks/ chin, may appear on neck, shoulders, upper arms 0.5-5cm diameter, slightly scaly pink patch/ plaque--> hypopigment patch/ plaque with fine surface scale--> post-inflam hypopigment macule without scale--> resolution May have well-demarcated or/ poorly defined edges Minimal/ absent itch Hypopigment noticeable in summer Dryness more in winter

Question 396

Ix and tx of pityriasis alba?

Answer 396

Wood lamp- hypopig doesn't enhance, no fluorescence, mycology scrapings= negative Skin biopsy= rarely needed No tx- maybe moisturiser, mild topical steroid, calcineurin inhibitors USE SUNSCREEN, usually clears after one year

Question 397

Cause and presentation of lichen planus(6 Ps)?

Answer 397

T-cell mediated AI disorder- attack unknown protein within skin and mucosal keratinocytes Genetics, physical & emotional stress, injury--> skin, herpes zoster, hep C, contact, drugs- gold, quinine, quinidine, others--> lichenoid rash, vit D deficiency 10%= nails, 50%= oral- W>M Pruritic- not painful, purple- except palms and soles= yellowish- brown, polygonal, planar, papules and plaques- interspersed with Wickham striae Often wrists, lower back and ankles, also genitals

Question 398

Ix and tx lichen planus?

Answer 398

Clinically- skin biopsy often recommended(lichenoid tissue reaction affecting epidermis), patch testing for oral those affecting gums & amalgam fillings Avoid soaps and shower gels, use emollients regularly, sedating antihistamines MOST RESOLVE WITHIN COUPLE YEARS

Question 399

Drugs causing lichenoid eruption? Fixed drug eruption?

Answer 399

Absent Wickham's striae, usually 2m before, affects trunk, ACE-i, BBx, nifedipine, diuretics- thiazide, NSAIDs, anticonvulsants, TB meds, antifungals, hydroxychloroquine, gold, allopurinol, tetracyclines Quinine MOST RESOLVE BY 12M SPONT Paracetamol, tetracyclines, sulfonamides, aspirin

Question 400

Types lichen planus?

Answer 400

Planopilaris, nail, oral, cutaneous, pigmentosus, actinicus- sunlight, lichenoid drug eruption, bullous & pemphigoides

Question 401

Ix and tx or vitiligo?

Answer 401

Wood's lamp= enhances white patches Dermoscopy= white glow Skin biopsy sometimes Blood tests- other autoimmune e.g. TFTs, ANA and B12 levels Loose fitting clothing, cosmetic camouflage, sun protection, topical CSs, calcineurin inhibitors Topical vitamin D derivatives Ruxolitinib cream- JK1 and JK2 inhibitor, topical tacrolimus, phototherapy- UVB twice weekly for 3-4 months

Question 402

ABPI values indicating arterial disease? Features and tx venous ulcers?

Answer 402

Below 0.9, >1.3 Diabetes, RA, vasculitis, SCD, malignancy, drugs- nicorandil, corticosteroids, NSAIDs, radiotherapy, hydroxycarbamide, varicose veins, DVT Gaiter area- ankle--> mid calf, chronic venous changes, after minor injury larger than arterial, more superficial than arterial, irregular gently sloping border, more likely to bleed, less painful than arterial, pain relieved by elevation and worse on lowering, pulses present Normal ABPI, Doppler exclude arterial disease- every 6-12 months Clean and dress wound, high compression 4 layered bandage, leg elevation, ABx for infection, analgesia, support stockings for life Pentoxifylline improves healing- NOT LICENSED Regular walking, avoiding leg trauma, emollient frequently No healing after 2 weeks comp therapy= specialist referral Recurrent ulcer= refer for superficial venous surgery

Question 403

Comps venous ulcers?

Answer 403

Allergic contact dermatitis, infection- osteomyelitis, sepsis, nec fas, chronic pain, malignant transformation= Marjolin's ulcer, sinus formation and fistula In hx- ASK ABOUT LATEX ALLERGY

Question 404

Sx and Ix of arterial ulcers?

Answer 404

Feet, heels or toes, from diabetes, smoking, high blood fat and cholesterol, renal failure, obesity, RA, clotting and circulation disorders, other arterial disease Typically punched out out appearance, painful- particularly at night or when the legs are at rest and elevated, may be areas of gangrene, cold with no palpable pulses, smaller than venous ulcers, well defined borders, less likely to bleed, NO OEDEMA Low ABPI measurements<0.9, severe=<0.5 Bloods- FBC, CRP, HbA1C, CRP, charcoal swab- infection, skin biopsy in suspected skin cancer- 2 week wait referral CRT, Buerger test, Doppler- transcutaneous oximetry<20mmHg= severe insufficiency

Question 405

Tx arterial ulcers?

Answer 405

Lifestyle- stop smoking, change diet to reduce blood lipids and cholesterol and blood sugar, wound care, tx wound infection Skin grafting/ skin flap

Question 406

Sx, Ix and tx of neuropathic ulcers?

Answer 406

Often painless, abnormal sensation, hx diabetes/ neuro disease Pressure sites Variable size and depth, granulating base, may be surrounded/ underneath hyperkeratotic lesions Warm skin, normal peripheral pulses, peripheral neuropathy ABPI<0.8 neuroischaemic ulcer, XR exclude osteomyelitis Wound debridement Regular repositioning, footwear, good nutrition

Question 407

Vasculitis causing ulcers? Causes? Tx?

Answer 407

LCV/ angiitis--> symmetrical palpable purpura- don't blanch with pressure from glass slide Idiopathic, drugs, infection, inflammatory disease, malignant disease, often settles spont Analgesia, support stockings, Dapsone/ prednisolone

Question 408

Which layers does TEN affect? Drugs causing? Sx and tx?

Answer 408

Between epidermis and dermis>30% body surface area(10-30%= mixed TEN/ SJS,) +ve Nikolsky's sign, pyrexia, tachycardia Phenytoin, sulfonamides, allopurinol, penicillins, carbamazepine, NSAIDs Herpes simplex, mycoplasma pneumonia, CMV, HIV Stop prec factor, supportive in burns unit/ICU-IVIG recommended, immunosuppressants, plasmapheresis Can lead to infection, permanent skin damage, visual comps

Question 409

Sx and tx of SJS? Comps?

Answer 409

Vague upper respiratory tract sx occur 2–3w after starting a drug and 2 days before a rash that affects <10% body surface Signs: Painful erythematous macules evolving to form target lesions Severe mucosal ulceration of ≥2 surfaces eg conjunctivae, oral cavity, labia, urethra Tx= same as TEN- supportive Secondary infection- cellulitis & sepsis, perm skin damage, visual complications

Question 410

Epi, cause, sx, Ix and tx erythema multiforme?

Answer 410

20-40y/o Herpes simplex, mycoplasma pneumoniae, sulfonamides, antiepileptics Cytotoxic T cells inhibit apoptosis of keratinocytes HLA-DQB1 0301 allele Target lesions peripheries--> centrally usually symmetrical extensor surfaces, may be painful, pruritic or swollen, x3 concentric rings Favours oral membranes Comp blood exam, LFTs, ESR, serology, CXR, skin biopsy- histopath and direct immunofluoro Self-resolve within 4 weeks Eyes can--> keratitis, conjunct scarring, uveitis, perm visual impairment- OPH REFERRAL Recurrent= 6m aciclovir

Question 411

What is erythroderma? Causes? Erythrodermic psoriasis?

Answer 411

When more than 95% of the skin is involved in a rash of any kind, M>F, any age Eczema, psoriasis, drugs e.g. gold, lymphomas, leukaemias, idiopathic May result from progression of chronic disease to an exfoliative phase with plaques covering most of the body- ass w/ systemic upset, scaling 2-6 days after onset of erythema as fine flakes or large sheets May be triggered by withdrawal of systemic steroids Blood count- anaemia, white cell count abnormalities, eosinophilia, hypoalbuminaemia, >20% Sezary cells--> Sezary syndrome Need admitting- emollients, wet-wraps, topical steroids Secondary infection, fluid loss, electrolyte imbalance, hypothermia, high-output cardiac failure and capillary leak syndrome

Question 412

Ass w/ necrotising fasciitis? PP?

Answer 412

DIABETES, CKD, cirrhosis, chronic HF, obesity, alcohol abuse, SLE, immunodeficiency e.g. due to HIV, chemo regimes Trauma/ wound: type 1- polymicrobial multiple anaerobic on trunk/ perineum- diabetics post-op II= monomicrobial s.pyogenes- younger patients affecting limbs> trunk III= clostridium species also vibrios species in IV drug users IV= fungal candida in immunocompromised aggressive and extensive

Question 413

Layers, features, Ix and tx nec fasc?

Answer 413

Initially spares skin- SC tissue and fascia--> swelling, pain, erythema, induration, pain severe and exaggerated compared to normally suspected from soft tissue infection, blistering & bullae, failure to respond--> broad-spec ABx Grey dusky skin--> crackling feeling to touch, D&V, tachy, fever, hypotension, tachypnoea, signs sepsis Crepitus- SC emphysema Perineal, genitalia, perianal= Fournier gangrene

Question 414

Ix and tx nec fasc?

Answer 414

Soft tissue gas on XR, raised CRP, very raised WCC, tx aggressively and promptly- surgical debridement Broad spec ABx- IV fluclox, IV benz, IV metronidazole, IV clindamycin, IV gentamicin

Question 415

Factors involved in LRINEC scoring system for nec fasc?

Answer 415

Hb>13.5-0, <11-2 WCC-<15= 0, 15-25-1, >25-2 Na+<135- 2 Creatinine>141-2 Glucose>10- 1 CRP>150- 4 Wound culture, plain X-rays, CT & MRI imaging, incisional biopsy w/ frozen section evaluation Positive finger test

Question 416

What does cellulitis affect? Cause?

Answer 416

The dermis and deeper SC tissues S.pyogenes or less commonly s.aureus Venous insufficiency and PVD Obesity Skin breaks Lymphoedema Previous cellulitis Surgery--> lower limb including saphenectomy Tinea pedis Skin conditions disrupting dermis- eczema, psoriasis, chronic venous ulcers, T2DM, IVDU, alcoholism, immunosuppression, pregnancy

Question 417

Features of cellulitis? Classification for managing?

Answer 417

Commonly on shins- usually unilateral, erythema, blisters & bullae with more severe disease, systemic- fever, malaise, nausea Eron classification: 1= no signs systemic toxicity or uncontrolled comorbidities 2= systemically unwell/ well with a comorbidity 3= systemic upset/ limb-threatening infection due to vascular compromise 4= sepsis/ life-threatening infection e.g. nec fasc

Question 418

Ix cellulitis? Tx for cellulitis?

Answer 418

FBC- leucocytosis/ neutrophilia, U&Es, CRP or ESR, blood cultures Admit class III or class IV cellulitis, severe/ rapidly deteriorating cellulitis, very young<1 y/o or frail, immunocompromised, significant lymphoedema, facial cellulitis/ periorbital cellulitis--> IV co-amox- for near eyes or nose/ clindamycin/ cefuroxime/ ceftriaxone MRSA= vancomycin/ teicoplanin/ linezolid Other= oral antibiotics- flucloxacillin/ clari/ erythromycin/ doxy if PenA/ pregnancy Mark area erythema, elevate the leg, paracetamol/ ibuprofen for pain/ fever Might--> systemic infection, SC abscess formation, myositis, fasciitis, possible recurrence, death

Question 419

What does erysipelas affect? Causes? Presentation?

Answer 419

Dermis and upper SC tissue S.pyogenes and s.aureus Immunosuppression, wounds, leg ulcers, toeweb intertrigo, minor skin injury Most lower limbs, swelling, erythema, warmth, lymphangitis, syst unwell, abrupt in onset Infants= umbilicus/ diaper/ napkin region WELL-DEFINED RED BORDER

Question 420

Ix, tx and comps of erysipelas?

Answer 420

Clinically, bloods, cultures- raised WCC, CRP, MRI & CT for deep infection Cold packs and analgesics, elevation, compression stockings, wound care w/ saline dressings frequently changed Oral/ IV flucloxacillin/ ery in allergy, facial by MRSA- vancomycin for 10-14 days Long term penicillin tx for recurrence, abscess, gangrene, thrombophlebitis, chronic leg swelling, IE, septic arthritis, bursitis, tendonitis, post-strep GN, cavernous sinus thrombosis, strep toxic shock syndrome

Question 421

Who gets erythema annulare centrifugum/ marginatum?

Answer 421

Most often in 40 years old- cutaneous fungal infection, internal malignancy, adverse reaction--> medications, pregnancy, haem disorders, endocrine disorders, rheumatic disease Blue cheese, tomatoes, stress

Question 422

Sx, Ix and tx of erythema annulare centrifugum/ marginatum?

Answer 422

Thighs, buttocks and upper arms- small pink papule gradually enlarges over several weeks--> annular plaques with central clearing, can vary in size Outer erythematous edge with inner scaly edge, may be itchy Clinically, skin biopsy Toenail clippings and skin scrapings for mycology if onychomycosis, tinea pedis or tinea corporis

Question 423

What is erythema marginatum?

Answer 423

Annular erythema in about 10% first attacks of ARF in children- rare in adults Trunk and upper arms and legs Pink/ red macules or papules spread outwards in circular shape--> raised and red, centre clears, not itchy or painful May persist for weeks to months- even after successful tx

Question 424

What is Lyme disease caused by? Rash? Comps?

Answer 424

Borrelia burgdorferi bacteria from woodland and fields, increased duration tick attachment (Ixodes tickets- scapularis in USA and ricinus in Europe) Erythema migrans- bull's eye rash within 30 days usually painless >5cm + flu-like- fever, malaise, joint aches--> neuro, cardiac and MSK involvement Also facial nerve palsy, meningitis, carditis w/ heart block and migratory joint pain Late= chronic arthritis, encephalopathy, or peripheral neuropathy

Question 425

Ix for Lyme disease?

Answer 425

Clinically if erythema migrans present- indication to START ABx ELISA antibodies to Borrelia burgdorferi 1st-line test If negative and still suspected- repeat in 4-6 weeks, >12w--> immunoblot test- negative--> refer to specialist

Question 426

Tx for Lyme disease?

Answer 426

Remove tick using fine-tipped tweezers grasping tick as close to skin as possible and pulling upwards firmly, washed following NOT FOR TICK BITE BUT LYME- doxy if early disease, amoxicillin if doxy CI(pregnancy) Disseminated disease= ceftriaxone Jarisch- Herxheimer reaction sometimes seen after initiating- fever, rash, tachycardia after 1st dose- more commonly seen in syphilis

Question 427

Comps of Lyme disease? Prevention?

Answer 427

Severe neuro sx, acrodermatitis chronica atrophans, Lyme arthritis, post-tx Lyme disease syndrome Avoid areas, wear white clothes in high grass/ woodland with long sleeves, trousers tucked in, repellents/ pesticides, change clothes after, check body for ticks, remove tick, watch site for several weeks

Question 428

What is scabies caused by?

Answer 428

Sarcoptes scabiei- infestation with low number of mites Crusted(Norweigan)= hyperinfestation with 1000s/ millions mites in exfol scales skin Close contact, high levels poverty and social deprivation, crowded living conditions, winter months Crusted= immunosuppression, reduced ability to scratch, learning difficulties/ neuro disorders, elderly

Question 429

Sx, Ix and tx of scabies?

Answer 429

Intense pruritus due to delayed- type IV HS reaction--> mites/ eggs about 30 days after initial infection Linear burrows on side of fingers, interdigital webs and flexor aspects of wrist Infants= face and scalp Excoriation, infection Hx & exam Ix--> skin scraping biopsy

Question 430

Tx of scabies?

Answer 430

Permethrin 5% = 1st-line Malathion 0.5%= second line Pruritus= up to 4-6 weeks Avoid close contact until tx is complete, household and close contacts= tx at same time Launder, iron or tumble dry clothing, bedding, towels etc on 1st day of tx Cool, dry skin- fingers & toes, under nails, armpit area, creases of skin- wrist and elbow, dry and leave on skin for 8-12 hours permethrin/ 24 hours malathion before washing off Reapply if removed during tx period, repeat tx 7 days later Crusted= cons dermatologist, Ix for immunodeficiency

Question 431

What is erythema nodosum?

Answer 431

Inflammatory affecting SC fats--> tender red nodules on anterior shins

Question 432

Sx, Ix, comps and tx of erythema nodosum?

Answer 432

Fever & joint pain Resolve within 6w Encapsulated fat necrosis Inflammation of septa between SC fat lobules without vasculitis--> bruise-like discolouration as resolve FBC, CRP, CXR, throat swab, viral serology, stool culture and evaluation for ova and parasites, Mantoux test, deep incisional/ excisional skin biopsy Colchicine, NSAIDs, venous comp therapy, sys CSs, oral KI-

Question 433

What is pyoderma gangrenosum?

Answer 433

Rapidly growing, very painful recurring nodulo- pustular ulcers, with tender red/ blue overhanging necrotic edge Often preceded by a tender pustule Site: leg; abdomen; face. 50%= idiopathic, myeloproliferative disorders/ lymphoma/ myeloid leukaemias/ IgA monoclonal gammopathy, granulmatosis with polyangiitis, IBD- UC/ Crohn's, RA/ SLE, PBC Isotretinoin, propylthiouracil and sunitib

Question 434

PP, sx pyoderma gangrenosum?

Answer 434

Neutrophilic dermatosis- dense infiltration of neutrophils in affected tissue often seen on biopsy Typically lower limb soften site of minor injury- pathergy where skin prick test causes papule/ pustule/ ulcer, often starts suddenly small pustule, red bump or blood-blister, later= ulcer often painful, edge often purple, fever & myalgia

Question 435

Tx pyoderma granulosum?

Answer 435

Oral steroids, immunosuppressives for larger ulcers- ciclosporin and infliximab, prednisolone, baricitinib, postpone surgery until controlled Skin grafting once active disease settled Expert wound care, pain management, taper systemic therapy over several months Avoid trauma to trigger new ulcer

Question 436

What is bullous pemphigoid?

Answer 436

Type II HS reaction to hemidesmosomal proteins BP180- type XVII collagen and BP230- dystonin Elderly Pruritus, erythematous plaques, urticarial lesions, large tense blisters w/ serous/ haemorrhagic fluid around flexures trunk and limbs, severe= mucosal, Nik sign -ve

Question 437

Ix and tx of bullous pemphigoid?

Answer 437

Skin biopsy- immunfluorescence shows IgG and C3 at dermoepidermal junction Derm referral for biopsy and confirmation Oral corticosteroids Topical corticosteroids, immunosuppressants and ABx

Question 438

What is pemphigus vulgaris?

Answer 438

Blistering affects middle-aged Auto-ABs against antigens within epidermis targeting desmoglein proteins Painful, usually mucosal flaccid bullae Nik often +VE Often trunk, face, scalp and intertriginous areas Can--> cellulitis, impetigo/ sepsis, hyperpigmentation/ scarring, nutritional deficiencies, dysphagia

Question 439

Presentation basal cell carcinoma?

Answer 439

Most common malignant skin cancer- ulcer with raised rolled edge, prominent fine blood vessels around lesion or nodule on skin Non-pigmented in 95%- can resemble melanoma when pigmented Most in elderly on head and neck Ulcerate= rodent ulcer Tumour basal keratinocytes Later in life, less metastatic and aggressive than SCC Slow growing Locally invasive

Question 440

Tx BCC?

Answer 440

Routine referral Surgically excised with wide borders and histology Superficial= cryotherapy, photodynamic therapy, radiotherapy unable tolerate surgery

Question 441

RFs for leukaemia?

Answer 441

Down's syndrome, Klinefelter syndrome, Noonan syndrome, Fanconi's anaemia Li Fraumeni syndrome Ataxia telangiectasia Nijmegen breakage syndrome Exposure to ionising radiation Pesticides Viruses such as Epstein-Barr virus (EBV), human immunodeficiency virus (HIV)

Question 442

Comps of chemo for leukaemia?

Answer 442

Failure to treat the leukaemia, stunted growth and development, immunodeficiency and infections, neurotoxicity, infertility, secondary malignancy, cardiotoxicity

Question 443

Sx leukaemia?

Answer 443

Fatigue, malaise, bone and joint pain- legs, dyspnoea, dizziness & palpitations, recurrent and/ or severe infections, fevers, thrombocytopenia- bleeding tendency Wt loss, pallor, petechial rash, bruising, tachycardia, flow murmur, distension, hepatomegaly and/ or splenomegaly, lymphadenopathyU

Question 444

Urgent specialist assessment/ FBC within 48 hours when?

Answer 444

Unexplained petechiae, hepatosplenomegaly Pallor, persistent fatigue, unexplained fever, persistent infection, generalised lymphadenopathy, unexplained bruising/ bleeding, persistent/ unexplained bone pain

Question 445

Ix for leukaemia?

Answer 445

FBC, blood film, bone marrow biopsy- diagnosis and monitoring/ minimal residual disease- blast cell count<5% for "remission,"- presence= more intensive chemo lymph node biopsy CXR, CT, LP, genetic analysis and immunophenotyping- disease classification

Question 446

Tx and comps leukaemia?

Answer 446

ECHO- prior to chemo, radiotherapy BM transplant, surgery Failure to treat, stunted growth and development, immunodeficiency and infections, infertility, secondary malignancy, cardiotoxicity

Question 447

Classification of ALL & AML?

Answer 447

FAB- morphology and cytochemical staining of leukaemic cells WHO- cytogenetics and immunogenotyping

Question 448

Chemo regimen in ALL?

Answer 448

Induction- 4-6w hydration and allopurinol/ rasburicase to prevent tumour lysis syndrome LP w/ intrathecal methotrexate prevent spread--> CNS Delayed intensification Tx 2y in girls and 3y in boys- oral or IV chemo, steroids and intrathecal tx

Question 449

Tx regimen for AML?

Answer 449

Induction destroy leukaemic cells- post-remission tx= x2 further courses chemo destroy residual cells, bone marrow tests following Also BM transplant, testicular radiotherapy, CNS treatments Supportive: education, broad-spec ABx, proph antimicrobials, blood transfusions, allopurinol, insertion of central venous catheter for chemo and blood sampling, G-CSF support cell counts, psychosocial support

Question 450

Comps leukaemia?

Answer 450

Neutropenic sepsis, thrombocytopenia, blast cell lysis, leucostasis, CNS infiltration CS SEs, tumour lysis syndrome, mucositis, GI inflammation, renal and hepatic toxicity, neurotoxicity, VTE, alopecia Secondary, avascular necrosis, cardiotoxicity, reduced GH, fertility issues

Question 451

Electrolytes in tumour lysis syndrome? Tx?

Answer 451

High PO43-, high potassium, hypocalcaemia, hyperuricaemia AKI, cardiac arrhythmias, N&V, seizures Proph hydration and allopurinol prior to chemo Rasburicase if WCC>50- breaks down uric acid

Question 452

What causes most cases anaemia in infancy?

Answer 452

Physiological anaemia of infancy Anaemia of prematurity, blood loss, haemolysis, twin-twin transfusion Haemolysis= haemolytic disease of newborn ABO/ resus incomp HS, G6PD deficiency

Question 453

Causes anaemia in older children?

Answer 453

Iron deficiency secondary to dietary insufficiency, blood loss- menstruation in older girls, sickle cell, thalassaemia, leukaemia, HS, hereditary eliptocytosis, sideroblastic anaemia Helminth infection- roundworms, hookworms or whipworms in developing countries--> albendazole or mebendazole single dose

Question 454

TAILS microcytic anaemia? 3 As and 2 Hs for normocytic anaemia?

Answer 454

Thalassaemia, anaemia of chronic disease, iron deficiency anaemia, lead poisoning, sideroblastic anaemia Acute blood loss, aplastic anaemia, haemolytic anaemia, hypothyroidism

Question 455

2 types macrocytic anaemia? Causes?

Answer 455

Megaloblastic- B12, folate def Normo= alcohol, reticulocytosis, hypothyroidism, liver disease, drugs- azathioprine

Question 456

Sx anaemia?

Answer 456

Tiredness, SOB, headaches, dizziness, palpitations, worsening of other conditions Pica- dietary cravings for abnormal things, hair loss Pale skin, conjun pallor, tachy, raised RR

Question 457

Signs of anaemia?

Answer 457

Koilonychia, angular chelitis, atrophic glossitis, brittle hair and nails, jaundice in haemolytic, bone deformities

Question 458

Ix anaemia?

Answer 458

FBC, blood film, ret count, ferritin, B12 and folate, bilirubin, direct Coombs test- AI haemolytic, Hb electrophoresis

Question 459

How does TIBC and transferrin change with iron def/ overload? Relationship between ferritin and TIBC?

Answer 459

Both increase in def Decrease in overload Inverse

Question 460

Inheritance and cause of hereditary spherocytosis? Sx?

Answer 460

Autosomal dominant Jaundice, anaemia, gallstones, splenomegaly Haemolytic crises often triggered by infection, aplastic crisis--> anaemia, haemolysis & jaundice--> high reticulocytes Aplastic= no ret response- PARVOVIRUS TRIGGER

Question 461

Ix HS, tx?

Answer 461

Family hx and clinical features, spherocytes on blood film, MCHC raised on FBC, high reticulocytes & uric acid Folate, splenectomy, cholecystectomy, transfusions may be needed during acute crises

Question 462

Ix in iron def anaemia? Tx in children?

Answer 462

Low MCV, serum iron, transferrin, ferritin, high TIBC Input from a dietician- ferrous sulfate/ fumarate unsuitable if malabsorption

Question 463

Defective synthesis what in sideroblastic anaemia?

Answer 463

Protoporphyrin synthesis--> lack of haem Congenital= ALAS, also Wolfram's syndrome Acquired= alcoholism, lead poisoning, vitamin B6 def- co-factor for ALAS, myeloma, polycythaemia rubra vera, myelosclerosis, leukaemias Hepatosplenomegaly in 1/3-1/2 people, anaemia, infection, bruising, haemorrhage

Question 464

Ix in sideroblastic anaemia? Tx?

Answer 464

FBC, serum ferritin and iron levels, blood film, BM biopsy--> iron deposition and ringed sideroblasts High iron, high %, high ferritin, low TIBC Avoid alcohol or other toxins, chelation therapy after 20-25 units of red cells, reduce vitamin C intake EPO, G-CSF, hereditary- pyridoxine(vitamin B6)--> peripheral stem cell transplantation

Question 465

What does thalassaemia affect? Ix findings? S&S?

Answer 465

Globin gene- alpha or beta + severity- major, minor or trait(both autosomal recessive) Microcytic anaemia-LOW MCV, fatigue, pallor, jaundice, gallstones, splenomegaly, poor growth and development, pronounced forehead and malar eminences

Question 466

Ix for thalassaemia?

Answer 466

FBC, Hb electrophoresis globin abnorm, DNA for genetics, pregnant= screening at booking Monitor ferritin levels

Question 467

Iron overload in thalassaemia?

Answer 467

Fatigue, liver cirrhosis, infertility, impotence, HF, arthritis, diabetes, osteoporosis & joint pain

Question 468

Ch for alpha and beta thalassaemia? Tx alpha?

Answer 468

Ch 16, Ch 11 Monitor FBC, comps, blood transfusions, splenectomy, BM transplant

Question 469

3x types Beta thalassaemia?

Answer 469

Minor, intermedia, major Mild microcytic anaemia, only need monitoring- isolate microcytosis & mild anaemia, ferritin= usually normal or high More significant microcytic anaemia- monitoring and occasional blood transfusions- may need iron chelation Severe anaemia@3-9m age and failure to thrive, reduced MCHC, increased reticulocytes, splenomegaly, bone deformities Regular transfusions, iron chelation- desferrioxamine via SC pump over 2-5 days each week/ deferiprone orally in x3 divided doses/ desferasirox--> 3m ferritin, annual cardiac/ liver T2 MRI, endocrine tests, audiology and ophthalmology, hydroxycarbamide to boost HbF levels, splenectomy, BM transplant from sibling or matched unrelated donor Anisopoikilocytosis, target cells and nucleated RBCs, teardrop cells

Question 470

x2 defective copies alpha-thalassaemia trait? x3? x4?

Answer 470

Trait- mild asymp anaemia HbH disease- microcytic anaemia, haemolysis, splenomegaly, normal survival, hydrops fetalis

Question 471

Comps B-thalassaemia?

Answer 471

Cardiomyopathy, cardiac arrhythmia/ cardiac failure, AF= older Acute sepsis- CV catheter infection- broad-spec ABx Liver cirrhosis, portal HTN and acute deocmp Endocrine- hypocalc w/ tetany, diabetes, iron overload Death= usually HF

Question 472

Screening for thalassaemia?

Answer 472

Gen counselling and prenatal testing for homo and heterozygous Test partner if patient has FOQ and FBC and if required of father too If maternal<27pg, iron studies and HPLC are performed- if negative--> DNA studies/ analyses for alpha-thalassaemia Major= CVS sampling

Question 473

Most common cause iron def in adults? Causes raised ferritin? Ix? Tx?

Answer 473

Blood loss- menorrhagia, GI tract Cancer, oesophagitis, gastritis, peptic ulcers, IBD, angiodysplasia Inflammation, liver disease, iron supplements, haemochromatosis Colonoscopy and OGD Oral--> const and black stools, infusion--> allergic reactions, transfusion

Question 474

Causes of anaemia of chronic disease?

Answer 474

Autoimmune, IBD, chronic- TB, HIV, osteomyelitis, malignancies, CKD, CLD- hepcidin release altered due to IL-1 and IL-6

Question 475

Ix and tx in anaemia of chronic disease? Tx?

Answer 475

FBC- low Hb and MCV Blood film- thrombocytosis in chronic haemorrhage Serum iron- low iron, normal/ high ferritin CRP & ESR BM aspiration and biopsy EPO stimulating agents

Question 476

Hb in sickle cell disease?

Answer 476

HbS- autosomal recessive, affecting beta-globin on Ch11, one abnormal= sickle-cell trait More likely to survive malaria

Question 477

Ix in sickle cell anaemia?

Answer 477

High reticulocytes, high serum uric acid, blood film- sickling erythrocytes and features of hyposplenism including target cells and Howell-Jolly bodies

Question 478

Comps sickle cell disease?

Answer 478

Anaemia, increased infection risk, CKD, sickle cell crises, acute chest syndrome, stroke, avascular necrosis in large joints, pulmonary HTN, gallstones, priapism

Question 479

Most common sickle cell crisis? Also? Tx?

Answer 479

Vaso-occlusive--> distal ischaemia Pain in swelling in hands and feet also chest, back and other areas, fever, priapism Sickle cell crises- low threshold admission--> hospital, keep warm, good hydration, analgesia- avoid NSAIDs in renal impairment

Question 480

Splenic crises in sickle cell can lead to what? Tx?

Answer 480

Severe anaemia and hypovolaemic shock Supportive, transfusions and fluid resus, hypsplenism, infection susc due to encapsulated bacteria- s. pneumoniae and h.influenzae Splenectomy prevents crises

Question 481

Significant anaemia? Management?

Answer 481

Aplastic- supportive- resolve within around week

Question 482

Acute chest syndrome caused by what? Tx?

Answer 482

Vessels supplying lungs become clogged w/ RBCs- can be triggered by VO crisis, fat embolism or infection Fever, SOB, CP, cough and hypoxia--> pulm infiltrates on CXR Analgesia, good hydration, ABx, antivitals, blood transfusions for anaemia, incentive spirometry, resp support w/ O2, NIV or mechanical ventilation

Question 483

General tx for sickle cell disease?

Answer 483

Avoid triggers for crisis, up to date vaccines, ABx prophylaxis, hydroxycarbamide, crizanlizumab= MAB tagrets P-selecti, blood transfusions, BM transplant

Question 484

Cause, sx, Ix and tx of paroxysmal nocturnal haemoglobinuria?

Answer 484

Reticulocyte normal, serum uric acid increased Activation clotting cascade on RBCs Red urine morning- Hb and haemosiderin, anaemia, thrombosis & smooth muscle dystonia Eculizumab/ BM transplantation= MAB vs C5

Question 485

Inheritance of G6PD? Ix?

Answer 485

X-linked recessive--> crises triggered by infections, meds or broad beans Increased reticulocytes Increased serum uric acid

Question 486

Sx, Ix and tx G6PD?

Answer 486

Neonatal jaundice, anaemia, intermittent jaundice, gallstones, splenomegaly Blood film--> Heinz bodies, bite and blister cells may be seen G6PD enzyme assay Avoid triggers- primaquine, ciprofloxacin, nitro, trimeth, sulfonylureas, sulfasalazine and other sulfonamides

Question 487

Aplastic anaemia characterised by what? Causes?

Answer 487

Pancytopaenia and hypoplastic bone marrow Idiopathic, Fanconi anaemia, dyskeratosis congenita Drugs- cytotoxics, chloramphenicol, sulf, phenytoin, gold Toxins- benzene Parvo, hepaitis, radiation

Question 488

Sx and tx aplastic anaemia?

Answer 488

Normochromic normocytic anaemia, leucopenia, thrombocytopaenia, minority--> paroxys noc haemoglobinuria or myelodysplasia Blood products, prevention and tx of infection ATG and ALG- steroid cover given, immunosuppression, stem cell transplant

Question 489

Causes haemolytic anaemia?

Answer 489

HS, hereditary elliptocytosis, thalassaemia, sickle cell anaemia, G6PD AI Alloimmune- transfusion & haemolytic disease newborn, paroxysmal nocturnal haemoglobinuria, microangiopathic, prosthetic valve-related

Question 490

Sx and Ix haemolytic anaemia?

Answer 490

Anaemia, splenomegaly, jaundice, FBC- normocytic, blood film= schistocytes, direct Coombs= AI haemolytic anaemia Drugs- methyldopa, penicillin

Question 491

Types of immune haemolytic anaemia? Ix findings?

Answer 491

IgG-mediated- extravascular IgM-mediated- intravascular Increased reticulocytes, increased serum uric acid

Question 492

Types autoimmune haemolytic anaemia? Tx?

Answer 492

Warm- more common, at normal or above-normal temps, usually idiopathic Cold-reactive/ cold agglutinin disease<10 degrees,--> agglutination (due to lymphoma, leukaemia, SLE & infections) FBC, reticulocytosis, blood film, LFTs= raised bilirubin, raised LDH, raised urinary urobilinogen, DAT, electrophoresis, blood film examination Blood transfusions, pred, rituximab, splenectomy

Question 493

2x scenarios alloimmune haemolytic anaemia?

Answer 493

Transfusion reactions and haemolytic disease of newborn- prev by anti-D prophylaxis

Question 494

Causes of non-autoimmune haemolytic anaemia?

Answer 494

Microangiopathic PNH Physical lysis HUS DIC

Question 495

Cause of microangiopathic HA? Blood film?

Answer 495

Destruction of RBCs through circulation- HUS, DIC, TTP, SLE, cancer Schistocytes

Question 496

Meds reducing B12 absorption? Ix? Neurological symptoms? Ix?

Answer 496

PPIs and metformin Antibodies vs parietal cells/ intrinsic factor, FBC- high LDH, low reticulocytes, blood film- circulating megaloblasts, megaloblastic changes in bone marrow, megaloblastic changes in bone marrow, serum cobalamin & MMA and Hcy- elevated HoloTC Peripheral neuropathy, loss virbation sense, proprioception, visual changes, mood and cognitive changes IF antibodies, gastric parietal cell antibodies

Question 497

Tx B12 def? Maintenance?

Answer 497

4 micrograms/d More animal products, urgent referral- haem, GI, dietetic issues No neuro sx= IM hydroxocobalamin x3 weekly for 2 weeks, maintenance= 1mg x2 a year diet-related, non-diet related= once every 2-3 months Neuro sx= alternate days until no further improvement 2-3 monthly injections for life Oral cyanocobalamin/ twice-yearly injections Check FBC within 7-10 days, no response= check serum folate, iron and folate 8 weeks after- MCV should be within normal range

Question 498

Giving folic acid when B12 def can lead to what? Signs of late B12 def?

Answer 498

Subacute combined degeneration of the cord--> extensor plantar, brisk knee reflex, absent ankle jerk, tone & power reserved, UMN signs lower limbs MRI- inverted V, pairs of binocular and dot signs Pallor, petechial rash, glossitis, angular cheilitis Severe= HF, hepatomegaly, splenomegaly

Question 499

Issues with pernicious anaemia?

Answer 499

Increased risk gastric cancer, spont abortion, IUGR, LBW, neural tube defects, temporary infertility

Question 500

Drugs causing folate deficiency? Ix? Causing non-megaloblastic macrocytic anaemia?

Answer 500

Hydroxycarbamide, azathioprine, cytosine arabinoside, azidothymidine Increased serum homocysteine, normal serum MMA Liver disease, alcohol, hypothyroidism, myelodysplastic syndrome, hypothyroidism, pregnancy- mild macrocytosis

Question 501

Blood film and FBC show what in macrocytic anaemia? Also what?

Answer 501

Hypersegmented neutrophils TFTs, LFTs, antibodies, bilirubin, DAT testing, LDH

Question 502

Fraser guidelines and Gilick competency apply to what? Fraser guidelines?

Answer 502

Fraser= contraceptive advice, Gillick= general issues the young person understands the professional's advice the young person cannot be persuaded to inform their parents the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent

Question 503

Causes of biliary atresia? Sx?

Answer 503

Genetics and environmental factors Prolonged jaundice >14 days in term babies and 21 in premature babies

Question 504

Differentials of jaundice in newborn? Neonatal hepatitis?

Answer 504

Alagille syndrome- peripheral pulmonary artery stenosis and facial features Choledochal cyst- abdo pain, jaundice and abdominal mass Jaundice, hepatosplenomegaly and elevated liver enyzmes Inborn errors of metabolism- galactosemia and tyrosinemia--> jaundice, poor feeding and developmental delay

Question 505

Ix for biliary atresia?

Answer 505

Bloods- raised conjugated bilirubin and deranged LFTs- raised GGT USS- triangular cord sign, hepatic artery changes, gallbladder ghost triad Hepatic scintigraphy- poor excretion--> the bowel & good hepatic uptake Abdominal USS- echogenic fibrosis Cholangiography- fail to show architecture of biliary tree

Question 506

Tx biliary atresia? Comps?

Answer 506

Surgical- hepatoportoenterostomy Kasai procedure by 45 days of life- new pathway from liver--> gut bypasses fibrosed bile ducts, ABx and bile acid enhancers following surgery Liver transplant may be required in end-stage liver failure w/ pruritus & coagulopathy, portal HTN & comps, growth retardation non-responsive to intensive nutritional support Ascending cholangitis and portal HTN

Question 507

Comps and types biliary atresia?

Answer 507

Unsuccessful anastomosis formation, progressive liver disease, cirrhosis with eventual HCC 1= patent proximal ducts, atresia of common bile duct 2= atresia of CBD and hepatic duct 3= atresia of almost all extrahepatic ducts including porta hepatis>90% cases

Question 508

Treatments for CF who are homozygous for delta F508 mutation?

Answer 508

Lumacaftor/ Ivacaftor

Question 509

When should meconium be passed? Other presentations ileus? Ddx? Ix?

Answer 509

Within 24 hours- bilious vomiting, abdominal distension Not= sign of cystic fibrosis Hirschsprung's disease, intestinal atresia, malrotation of the bowel AXR, blood tests, sweat/ genetic testing for CF

Question 510

Tx meconium ileus?

Answer 510

Suctioning of airways at birth in case MAS, bowel rest and decompression for meconium ileus, ABx prevent infection, surgical in severe cases/ perforation/ peritonitis

Question 511

What is meconium aspiration syndrome?

Answer 511

Passage of meconium from amniotic fluid--> fetal lungs- meconium in amniotic fluid More common in post-term deliveries, hx maternal HTN, pre-eclampsia, chorioamnionitis, smoking/ substance abuse

Question 512

Ddx for meconium aspiration? Ix and tx?

Answer 512

Hirschsprung, neonatal sepsis, intestinal atresia Assess amniotic fluid for meconium, CXR, clinical exam for bowel obstruction signs, AXR/ USS confirm, sweat test Immediate suctioning after birth, O2 therapy, potentially ABx

Question 513

Neonatal hypoglycaemia level? Causes? Sx? Tx?

Answer 513

<2.6mmol/L Preterm birth<37 weeks, maternal DM, IUGR, hypothermia, neonatal sepsis, inborn errors of metabolism, nesidioblastosis, Beckwith-Wiedemann syndrome May be asymptomatic, jittery, tachypnoea, pallor, poor feeding/ sucking, weak cry, drowsy, hypotonia, seizures Apnoea, hypothermia Encourage normal feeding, monitor BG Sx/ very low= admit--> neonatal unit, IV 10% dextrose infusion

Question 514

Sx CF in neonates, infants, toddlers and older children?

Answer 514

Ch 7- CFTR gene F508 del mutation--> meconium ileus Salty sweat when kissing, faltering growth, recurrent chest infections Faltering growth, recurrent chest infections, malabsorption syndromes Faltering growth, recurrent chest infections, malabsorption, delayed puberty onset Other= nasal polyps, short stature, DM, rectal prolapse, male infertility- bilateral absence of vas deferens & female subfertility, biliary cirrhosis, distal intestinal obstruction syndrome

Question 515

Ddx for CF?

Answer 515

Bronchiectasis, asthma, COPD, GORD, coeliac disease

Question 516

Ix and tx CF?

Answer 516

Sweat test, neonatal blood spot test-raised blood immunoreactive trypsinogen--> genetics, lung functioning= obstructive, urine dip- diabetes, FBC, CRP, U&Es, fasting glucose, LFTs, vit A, C and E levels, sputum culture and sensitivity, faecal elastase, CXR, high res-CT chest, CT angiography Daily chest physio, proph ABx, bronchodilators, dornase alfa Regular influenza and pneumococcal vaccines Consideration for bilateral lung transplant with end-stage pulm disease

Question 517

Cause of PCD/ Kartagener's syndrome? Sx? Ix and tx?

Answer 517

AR trait--> dynein arm defect Sinusitis, situs inversus and bronchiectasis Recurrent RT infections--> CXR, semen analysis Sample of ciliated epithelium of upper airway through nasal brushing or bronchoscopy Daily physio, high calorie diet and ABx

Question 518

Sx infantile colic?

Answer 518

<5m age- recurrent and prolonged periods infant crying/ irritability, no faltering growth/ fever/ illness Late afternoon/ evening crying, drawing up knees, clenching fists

Question 519

Tx infantile colic?

Answer 519

Reassurance, holding baby, gentle motion, white noise, winding techniques, rest, support, continue BF wherever possible, follow-up

Question 520

Cause and sx of scarlet fever? What is an outbreak classed as?

Answer 520

S.pyogenes- group A strep Inc period 2-3 days- can be infectious for 2-3 weeks after onset sx- BETWEEN 2-8 Y/O Two or more probable / confirmed scarlet fever cases attending same school/ nursery notified within 10 days of each other

Question 521

Comps of scarlet fever?

Answer 521

Otitis media, peritonsillar abscess, acute sinusitis Acute rheumatic fever, acute post-strep GN Pneumonia, meningitis, streptococcal toxic shock syndrome or nec fasc

Question 522

Sx scarlet fever? Tx?

Answer 522

Initial sore throat, fever, headache, fatigue, nausea and vomiting Pinpoint sandpaper-like blanching rash on trunk 12-48 hours after initial sx before--> body and flexures Possibly strawberry tongue, cerv lymphadenopathy, circumoral pallor Urgent hospital admission if severe sx/ serious comp--> 10 days phenoxymethylpenicillin/ clarithromycin/ azithromycin, notify local health protection team within 3 days, self-care measures, follow-up not improved after 7 days Exclusion at least 24 hours after starting ABx, avoid sharing utensils and towels

Question 523

Sx of Kawasaki disease? Ix? Tx?

Answer 523

<5 years old High-grade fever>5 days + 4/5 of CREAM: conjunctivitis, rash- widespread erythematous maculopapular rash and desquamation on palms and soles, oedema/ erythema of hands and feet, adenopathy- unilateral and non-tender, mucosal involvement- strawberry tongue/ oral fissures Acute, subacute and convalescent stages (fever, rash lymphadenopathy--> arthralgia--> coronary aneurysms regress) FBC, LFTs, ESR, urinalysis raised WCCs ECHO- coronary aneurysms- regular ECHOs, close monitoring, CRP & ESR IVIg- high dose aspirin

Question 524

Age affecting for transient synovitis?

Answer 524

3-10 w/ recent URTI Limp, refusal to weight bear, groin/ hip pain- presents in flexion, abduction and external rotation, limited range motion- most commonly hip abduction & internal rotation, mild low grade temperature --> normal obs, afebrile USS & joint aspirate if septic arthritis

Question 525

Tx transient synovitis?

Answer 525

Aged 3-9 y/o= manage in primary care if limp present for <48 hours and otherwise well- need safety netting if worsen/ fever- follow up at 48 hours and 1 week Bed rest, activity restriction, paracetamol & NSAIDs, physio Improve after 24-48 hours and resolve within 1-2 weeks

Question 526

What is Perthe's disease? What age and gender do they get it? Sx?

Answer 526

Avascular necrosis of the femoral head in children M>F- 3-10 years old Gradual onset of limp, hip pain which may be referred to the knee Loss of internal rotation and abduction, antalgic gait, muscle spasms, leg length discrepancy Pain> 4 weeks Multifactorial

Question 527

Ix and tx of Perthe's disease?

Answer 527

Bilateral AP pelvic X-ray and 'frog-leg' lateral X-ray--> sclerosis and fragmentation of the epiphysis Arthrography under GA w/ conventional fluoroscopy for femoral head vs acetabulum, Deformity of femoral head, congruence, containment Bone scans <50%= conservative measures- non-weight bearing and traction >50%/ age>8 y/o, non-surgical unsuccessful- plaster cast to keep hip abducted or even an osteotomy- risk of degenerative arthritis

Question 528

Radiographic findings of Perthes' disease?

Answer 528

Those of osteonecrosis- reduction in epiphysis size, lucency--> fragmentation, destruction, width femoral neck increases (coxa magna) Stage 4= coxa plana- femoral head widening and flattening, coxa magna- proximal femoral neck deformity, "sagging rope sign"- sclerotic line running across across the femoral neck Asymmetrical femoral epiphyseal size, increased density of femoral head epiphysis "Crescent's sign"- late stages= subchondral fracture

Question 529

What is SUFE? Sx?

Answer 529

Slipped capital femoral epiphysis- head of femur displaced along growth plate Average age 12 in boys- slightly earlier in females, M>F, >obese children, hypothyroidism, hypogonadism, AC & Hispanic Hx minor trauma/ chemo/ radiotherapy Vague- hip pain & limp, referred pain--> knee Reduced ROM- particular upon hip flexion (preferred external rotation, restricted internal rotation) + Trendelenburg gait

Question 530

Ix SUFE? Tx? Comps?

Answer 530

AL frog-leg X-rays- shortened, displaced epiphysis & widened growth plate, Trethowan sign- line of Klein cannot intersect epiphysis Bloods- TFTs and GH for endocrine disorders, normal, technetium bone scan, CT & MRI Surgery- in situ fixation with a screw, bone graft epiphysiodesis, spica cast, in situ fixation with multiple pins Degen osteoarthritis, osteonecrosis femoral head, chondrolysis- acute cartilage necrosis, deformity, femoroacetabular impingement, limb length discrepancy

Question 531

Who gets OSD? Sx?

Answer 531

M>F Rep traction on tibial tubercle from patellar tendon during rapid growth periods in adolescence- also tight quadriceps muscle group and poor flexibility Unilateral anterior knee pain localised to tibial tubercle- exacerbated by activities- severe= visible/ palpable lump over tibial tuberosity

Question 532

Ddx for OSD?

Answer 532

Patellofemoral pain syndrome- ex by prolonged activities Sinding-Larsen Johansson syndrome- lower pole patella rather than tibial tuberosity Tibial tubercle fractures- acute severe pain unable to weight bear Prepatellar bursitis- front patella pain

Question 533

Ix and tx OSD? Rare comp?

Answer 533

ROUTINE XR NOT NEEDED- RULE OUT OTHER CAUSES Analgesia- NSAIDs, knee pads and ice packs, exercise modification and muscle stretching exercises Doesn't improve/ worsen--> paediatrician or orthopaedic surgeon, consider physio referral, temporary immobilisation with a knee brace or cast Avulsion fracture

Question 534

Cause, sx and Ix septic arthritis? Tx?

Answer 534

Cause= s.aureus/ n.gonorrhoea/ s.pyogenes, h.influenzae, E.coli, mainly < 4 y/o, common and important comp of joint replacement- higher in REVISION SURGERY Hot, swollen, red painful joint- hip/ knee Refusing to weight bear Stiffness and reduced ROM Synovial fluid analysis- analysis, gram stain, culture, cell count, crystal analysis, may be purulent FBC, CRP, ESR, blood cultures XR- joint space widening/ effusion, MRI/ USS- more detailed images Surgical drainage by arthroscopy or open surgery Empirical antibiotics- IV typically needed initially followed by oral ABx, usually 3-6 weeks May be drainage and washout

Question 535

Cause and where does osteomyelitis affect? RFs?

Answer 535

S.aureus/ coag -ve staph, metaphysis of lone Seeding from haematogenous infection/ adjacent tissues or joints, direct inoculation of infection into bone due to wound contamination Open bone fractures, orthopaedic surgery, immunocompromised, sickle cell anaemia, HIV, TB, diabetes, PVD

Question 536

Sx osteomyelitis? Ix and tx?

Answer 536

Refusing to use limb/ weight bear, pain, swelling, tenderness, may have low grade fever/ high if septic MRI, bloods= raised CRP & ESR, WCCs, blood cultures, BM aspiration or bone biopsy with histology and culture ABx minimum 4-6 weeks chronic= at least 12 weeks to 3-6 months- fusidic/ rifampicin/ vancomycin if MRSA suspected, pen allergic= clindamycin Chronic= deferred until culture and sens results Drainage and debridement of infected bone for chronic

Question 537

What is JIA?

Answer 537

AI inflammation in the joints without any other cause >6 weeks in patient under age 16- systemic, polyarticular, oligoarticular, enthesitis related, juvenile psoriatic F>M

Question 538

Sx JIA?

Answer 538

Systemic signs followed by joint sx- fever, malaise, salmon pink rash Joints= can be single/ multiple--> pain, swelling, stiffness, limited ROM Systemic/ Still's disease: salmon-pink rash, high-swinging fevers, lymphadenopathy, wt loss, joint inflammation and pain, splenomegaly, muscle pain, pleuritis and pericarditis--> raised inflam markers, platelets and serum ferritin MAS= DIC, anaemia, low platelets, bleeding and non-blanching rash- LOW ESR Polyarticular=>4 joints: small and large joints, minimal systemic sx= seronegative, older= often sero+ve Oligoarticular/ pauciarticular up to and including 4 joints: single larger joint often knee or ankles more <6 y/o, anterior uveitis- refer--> ophthalmologist, no systemic sx, inflam normal or mildly elevated, ANA often +ve, RF usually negative Enthesitis related: >6 y/o, enthesitis from repetitive strain or AI process--> MRI, HLA B27 +ve, psoriasis sx, IBD, anterior uveitis (IP joints in the hand Wrist Over the greater trochanter on the lateral aspect of the hip Quadriceps insertion at the anterior superior iliac spine Quadriceps and patella tendon insertion around the patella Base of achilles, at the calcaneus Metatarsal heads on the base of the foot) Juvenile psoriatic: sero-ve, can symmetrical affecting small joints/ asymmetrical affecting large joints--> plaques, nail pitting, onycholysis, dactylitis, enthesitis

Question 539

Tx of JIA? Comps?

Answer 539

NSAIDs, steroids- oral, IM, intra-articular in oligo DMARDs, biologic- TNF inhibitors Flexion contractures- physical therapy and splinting, joint destruction--> prostheses at young age, growth failure, anterior uveitis

Question 540

What is osteochondritis dissecans? Sx, ix?

Answer 540

Small piece subchondral bone begins to separate from its surrounding area due to disturbance to blood supply- MOSTLY IN KNEE M>F Swelling particularly after exercise, joint locking, decreased ROM XR- lucencies in articular epiphysis, MRI- bone and cartilage CT Scintigraphy

Question 541

Tx osteochondritis dissecans?

Answer 541

Conservative- avoid activities that ex sx Arthroscopy- more severe- cons not yielded Surgical intervention- screws/ drilling techniques

Question 542

Sx chondromalacia patellae?

Answer 542

Anterior knee pain when walking up or down stairs 3:1 for F:M

Question 543

5 Fs for RFs for developmental dysplasia of the hip? Method for classification of DDH severity?

Answer 543

Females, firstborn, family hx, frank breech, low amniotic fluid levels- more in LEFT HIP Also torticollis Graf method

Question 544

Sx and Ix for DDH?

Answer 544

Different leg lengths in 3-6m, restricted abduction on one side, significant bilateral abduction, difference in knee level when hips flexed, clunking of hips on special tests- Ortolani(relocation in hip abduction) & Barlow (tests for posterior dislocation,) +Trendelenburg and toe walking may be seen>1 y/o USS of hips esp<6 months age, X-rays can also be helpful particular in older infants

Question 545

Tx DDH?

Answer 545

Pavlik harness if presents<6 months age- holds femoral head- keeps baby's hips flexed and abducted Removed usually after 6-8 weeks Surgery when harness fails or Ix made after 6 months age- after= closed reduction and hip spica cast used Open reduction= for children older than 2 y/o/ closed reduction is unsuccessful- femoral/ pelvic osteotomies may be needed, regular monitoring and clinical exams

Question 546

What is calcaneal apophysitis (Sever's disease) caused by?

Answer 546

Micro-fractures of the calcaneal apophysis at the site of attachment of the achilles tendon Typically 8-14 y/o- commoner in more active children especially in weight-bearing sports

Question 547

Sx Sever disease?

Answer 547

Gradual onset heel pain worse on standing and with activity typically relieved by rest- can be unilateral but often bilateral Medial and lateral compression of the heel causes pain May have pain on ankle dorsiflexion especially on active toe raise, mild heel swelling, calcaneal enlargement- only if chronic which is rare

Question 548

Ix Sever disease? Tx?

Answer 548

Clinical- X ray to exclude fractures/ tumour- may be normal/ non-specific sclerosis CT/MRI exclude osteomyelitis Red flags= rest pain, night pain or large swelling Conservative, avoid sports for 2 months- continue non- weight bearing exercises Physio, footwear advice, heel pads, consider NSAIDs in severe, rarely needs orthopaedic referral

Question 549

What is torticollis? Most common cause in 1st few weeks life?

Answer 549

A twisted/ wry neck Sternomastoid tumour- later= muscular spasm, secondary to ENT infection, spinal tumour, CS arthritis

Question 550

Sx torticollis?

Answer 550

Mobile non-tender nodule can be felt within the body of the sternocleidomastoid muscle May be restriction of head turning and tilting of the head- usually resolves in 2-6 months Muscles supporting neck on one side become painful- come on quickly often overnight- wake up with pain and stiffness down one side of your neck Difficult to straighten neck May spread to back of head/ shoulder Muscles may be tender Pressure may trigger ‘spasm’ of these muscles Movement restricted

Question 551

Ix and tx torticollis?

Answer 551

Clinical diagnosis If persistent- physio helps by lengthening the muscle; surgical division is more drastic

Question 552

Cause of osteogenesis imperfecta?

Answer 552

Mutations in COLA1 and COL1A2 genes- ALPHA CHAINS TYPE 1 COLLAGEN--> decrease amount collagen produced/ abnormal collagen molecules AUTOSOMAL DOMINANT

Question 553

Sx osteogenesis imperfecta?

Answer 553

x8 types Type 1= blue sclerae- 50%= hearing loss- fractures typically before puberty 2= many fractures, blue sclera, dwarfism, recessive 3= severe, recessive, fractures at birth & progressive spinal and limb deformity--> short stature, blue/ white sclerae, transparent/ discoloured teeth 4= moderate, AD, fragile bones, white sclerae after infancy

Question 554

Ix osteogenesis imperfecta? Tx?

Answer 554

Many fractures, osteoporotic bones with thin cortex and deformity of long bones Immature unorganised bone with abnormal cortex on histology Genetics, audiologic- hearing loss Prevent injury, physio, rehab, OT, osteotomies may correct, IM rods sometimes, bisphosphonates

Question 555

What is achondroplasia?

Answer 555

Most common form disproportionate short stature due to reduced growth cartilaginous bone AD from sporadic mutation of FGFR3 on Ch4--> abnormal function of epiphyseal plates, 80%= spontaneous Short digits, bow legs- genu varum, disproportiante skull, foramen magnum stenosis, flattened mid-face and nasal bridge, frontal bossing XR= short proximal long bones and wide epiphyses Tx= leg lengthening surgery- osteotomy- distraction (creating gap between bones)--> chronic pain and reduced function, monitoring potential comps- obesity and psychosocial comps, GH been tried

Question 556

Ass w/ achondroplasia?

Answer 556

Recurrent otitis media, kyphoscoliosis, spinal stenosis, OSA, obesity, foramen magnum stenosis--> cervical cord compression and hydrocephalus

Question 557

What is osteopetrosis?

Answer 557

Lack of diff between cortex and medulla of bone- failure osteoclastic bone resorption--> dense hard marble bones Anaemia, thrombocytopaenia, deafness, optic atrophy

Question 558

What is scoliosis?

Answer 558

Curvature of the spine in the coronal plane- lateral curvature w/ secondary vertebral rotation- Cobb angle>10^4(risk progression= higher with greater Cobb angles)--> structural and non-structural Commonest adolescent females Postural= disappears on manoeuvres such as bending forwards

Question 559

Cause, sx and tx scoliosis?

Answer 559

Structural=>1 vertebral body--> idiopathic, congenital and NM in origin- not correct by posture Idiopathic= most common Girls more likely to progress Severe= bil rod stabilisation of spine Refer to measure Cobb angle Surgery<7 y/o- attempts optimise further growth spine and lungs- older if deformity causing issues- deformity correction with spinal fusion and stabilisation IO spinal cord monitoring prevents paralysis EXCLUDE OSTEOID OSTEOMA, OSTEOBLASTOMA, SPONDYLOLISTHESIS AND SPINAL TUMOURS IN YOUTH PAIN AT NIGHT

Question 560

Causes of kyphosis?

Answer 560

TC spine>40 degrees, sometimes with lordosis lumbar spine- congenital, osteoporosis, spina bifida, calve's vertebrae, cancer; wedge fractures, TB, polio, Paget's disease, AS

Question 561

What is talipes? Equinovarus? Cause? Associations? Calcaneovalgus?

Answer 561

Fixed abnormal ankle position Plantar flexion and supination- M>F, 50%= bilateral Idiopathic- spina bifida, cerebral palsy, Edward's syndrome, oligohydramnios, arthrogryposis Dorsiflexion and pronation

Question 562

Ix and tx of talipes? Positional/ equinovarus?

Answer 562

Clinical Cons- Ponseti method- manipulation and progressive casting from birth- corrected after 6-10 weeks Achilles tenotomy in 85% cases under local anaesthetic Night braces until aged 4 y/o- "boots and bars" Physio referral- resolves with time

Question 563

What is discoid meniscus? Ix? Tx?

Answer 563

Hypertrophic and crescent shaped meniscus Squaring lateral condyle with cupping of lateral tibial plateau on XR MRI= Wrisberg Obs for asymptomatic- continued pain and sx e.g. inability to extend knee= arthroscopic meniscectomy and saucerization

Question 564

When is neonatal sepsis? Causes/ RFs?

Answer 564

Within 28 days of life- early onset within 72 hours, late-onset 7-28 days Listeria, toxoplasma, rubella, CMV(TP,) cervical= group B strep, e.coli Late= s.aureus, s.epidermidis, e.coli, pseudomonas, Klebsiella from genital tract/ transplacental infections or hospital/ infant's intestinal flora in late onset Prem birth, multiple pregnancies, prolonged rupture of membranes, maternal IP fever, GBS previous, mat temp>38 degrees, chorioamnionitis Black= RF for group B strep-related sepsis

Question 565

Sx and red flags for GBS?

Answer 565

Fever- more in terms/ hypothermic in pre-term, reduced tone and activity, resp distress/ apnoea, vomiting, tachy/ bradycardia, hypoxia, jaundice within 24 hours, seizures, hypoglycaemia Confirmed/ suspected sepsis mother, shock signs, seizures, term baby needing mechanical ventilation, resp distress>4 hours after birth, presumed sepsis in another baby in multiple

Question 566

Ix and tx neonatal sepsis?

Answer 566

2x blood cultures, FBC- abnormal neutrophils, CRP for tx progress Blood gas- met acidosis= concerning Urine microscopy, culture and sensitivity- more in late-onset LP IV benzylpenicillin w/ gentamicin/ cefotaxime- START IF SINGLE RED FLAG/ 2 OR MORE RFs WITHIN 1 HOUR DECISION MADE BASELINE FBC & CRP CRP 24 hours after given ABx & cultures at 36 hours- cease at 48 hours with CRP< 10mg/ L and -ve blood culture, clinically well, LP if CRP>10 Usually 10 days treatment- maintain O2, fluids, electrolytes, hypoglycaemia, met acidosis

Question 567

Components to APGAR score?

Answer 567

Appearance, pulse, grimace, activity, respiration

Question 568

Cause and ass of group B infection in pregnancy?

Answer 568

S.agalactiae- bowel commensal Preterm prelabour rupture of membranes and preterm delivery

Question 569

Tx of women with previous group B infection? Swabs timing? When else is IAP offered? What AB?

Answer 569

Told risk is 50%- offer intrapartum ABx prophylaxis (IAP) or testing in late pregnancy and then ABx if still positive 35-37 weeks / 3-5 weeks prior to anticipated delivery date In preterm labour regardless of their GBS status, women with temp >38 degrees Benzylpenicillin onset labour and at least 2h before delivery

Question 570

Sx, CT shows and tx in cerebral toxoplasmosis in HIV?

Answer 570

Headache, confusion, drowsiness, CT- single/ multiple ring-enhancing lesions, mass effect may be seen Pyrimethamine plus sulphadiazine at least 6 weeks, spiramycin

Question 571

How does Erb's palsy present?

Answer 571

Dermatomal sensory loss in C5-6 dis, "waiter's tip"- shoulder adduction, elbow extension, forearm pronation, wrist flexion Subscapular, musculocutaneous and axillary nerves--> paralysis of supraspinatus, infraspinatus, biceps, brachialis, deltoid, teres minor Winged scapula Can result from shoulder dystocia/ breech presentation- exclude fractured clavicle & arrange physio- not resolved by 6 months unlikely to improve

Question 572

How does Klumpke's palsy present?

Answer 572

Dermatomal sensory loss in C8-T1 distribution- median and ulnar nerves, weakness intrinsic hand muscles, potential ipsilateral Horner's syndrome if T1 involved Claw hand, arm held in adduction, extension at MCP joints, flexion at DIP/PIP joints due to loss of lumbrical

Question 573

Tx Erb's palsy?

Answer 573

Daily physical therapy from 3 weeks- prevent joint contracture, surgery after -6 months- nerve graft/ transfer, release contractures, tendon transfer, reduction joints, osteotomy

Question 574

Do what once a baby is born?

Answer 574

IM vitamin K in thigh- helps prevent bleeding- intracranial, umbilical stump and GI bleeding/ orally- needs doses at birth, 7 days and 6 weeks, label baby, measure weight and length, skin--> skin contact Dry baby- stimulates breathing, keep warm with warm delivery rooms and management under a heat lamp <28 weeks= placed in a plastic bag while still wet and managed under a heat lamp Initial check- tone, pulse, RR Place baby's head in a neutral position to keep airway open- towel under shoulder can help keep it neutral If not breathing/ gasping- check for obstruction i.e. meconium and consider aspiration under direct visualisation Give 5 rescue breaths x2 cycles, low HR and no response= 30 seconds ventilation breaths- still no= chest compressions coordinated w/ ventilation breaths 3:1- still below <60bpm- consider venous or osseous access and administering drugs

Question 575

What is given for inflation breaths in term/ near term babies and pre-term babies? Prolonged hypoxia increases risk of what?

Answer 575

Air Air and oxygen- aim for gradual rise- not exceeding 95% Hypoxic-ischaemic encephalopathy- consider IV drugs and intubation in severe, near/ at term- might benefit from therapeutic hypothermia with active cooling

Question 576

Delaying cord clamping does what?

Answer 576

Leads to improved Hb, iron stores, BP and reduction in IV haemorrhage and NEC Increase in neonatal jaundice potentially needing more phototherapy- AT LEAST 1 MINUTE Needing resus- should have sooner to prevent delays in getting baby to resus team

Question 577

What happens as soon as the baby is outside of the delivery room?

Answer 577

Initiate breast feeding/ bottle feeding as soon as baby is alert enough First bath when baby is warm and stable, newborn exam within 72 hours, blood spot test, newborn hearing test

Question 578

9 conditions tested for on day 5 in bloodspot test?

Answer 578

SCD, cystic fibrosis, congenital hypothyroidism, phenylketonuria, MCADD, MSUD, IVA, GA1, homocystin- takes 6-8 weeks to come back

Question 579

What is HIE (hypoxic ischaemic encephalopathy higher in)? Causes?

Answer 579

Premature & LBW infants Placental abruption, cord compression, prolonged resp arrest- can cause cerebral palsy

Question 580

Suspected HIE when events could lead to hypoxia?

Answer 580

pH<7 on umbilical artery blood gas, poor APGAR scores, features of mild/ moderate/ severe HIE or evidence of multi organ failure Maternal shock, intrapartum haemorrhage, prolapsed cord, nuchal cord(anything--> asphyxia)

Question 581

Ix HIE? Tx?

Answer 581

EEG monitoring, multiple MRI scans Resp support, anticonvulsants, fluid balance and electrolyte monitoring, use inotropes- BP and cardiac function, cooling therapy- induce mild hypothermia prevent further damage from secondary reperfusion injury, some= therapeutic hypothermia- blankets and hat target 33-34 degrees using rectal probe continued for 72 hours after--> warmed to normal temp over 6 hours

Question 582

Who are at risk of vitamin K deficiency? Sx? Ddx?

Answer 582

Exclusively breastfed & no prophylaxis at birth Easy bruising/ petechiae, bleeding from nose/ gums, blood in stool/ urine, prolonged clotting times, severe= internal bleeding Haemophilia, DIC, Von Willebrand disease

Question 583

Ix vitamin K deficiency? Risks?

Answer 583

Coagulation studies- PT and aPTT which will be prolonged, assess vit K levels Haemorrhagic disease of the newborn Can rapidly progress into haemorrhagic shock

Question 584

What is cephalohaematoma? Sx?

Answer 584

Bleeding between periosteum and skull- most common site= parietal region within 24-48 hours following delivery (Traumatic subperiosteal haematoma) Fluctuant non-pulsatile swelling overlying one or more cranial bones, well-defined margins, firm yet resilient without signs tenderness/ warmth--> indurated resolves- DOES NOT CROSS SUTURE Jaundice may result Takes up to 3 months to resolve- USS= vs subgaleal haemorrhage & extent

Question 585

Tx acute asthma child <3 y/o?

Answer 585

Inhaled/ nebulised salbutamol via a spacer using a close-fitting mask in a child <3 y/o--> inhaled/ nebulised ipratropium--> IV magnesium sulfate--> IV aminophylline 1 puff every 30-60 seconds up to max 10 puffs Mild= outpatient with regular salbutamol inhalers via spacer 4-6 puffs every 4 hours Not controlled by repeat beta-2 agonist= refer to hospital Steroid therapy= all with exacerbation for 3-5 days (pred oral or IV hydrocortisone) Supplementary O2 if needed<94% or working hard ABx only if bacterial cause suspected e.g. amoxicillin or erythromycin

Question 586

Moderate- severe acute asthma approach?

Answer 586

Salb inhalers via space device 10 puffs every 2 hours Salb/ iptratropium bromide nebs Oral pred IV hydrocortisone IV MgSO4 IV salbutamol IV aminophylline--> anaesthetist and ICU- intubation and ventilation Review before next dose of bronchodilator, look for cyanosis, tracheal tug, subcostal recessions, hypoxia, tachypnoea/ wheeze on auscultation - step down if well--> 10 puffs 4 hourly--> 6 puffs 4 hourly--> 4 puffs 6 hourly- MONITOR POTASSIUM FOR HYPOKALAEMIA, BLOOD GLUCOSE IN DIABETICS FOR HYPERGLYCAEMIA AND KETOACIDOSIS WHEN GIVEN IV

Question 587

When can a child be discharged with asthma?

Answer 587

6 puffs 4 hourly for 48 hours Then 4 puffs 6 hourly for 48 hours Then 2-4 puffs as required Finish course steroids if these were started- typically 3 days Safety netting Individualised asthma action plan

Question 588

Ix chronic asthma (in child>5 y/o)?

Answer 588

Spirometry w/ reversibility testing Direct bronchial challenge test w/ histamine or methacholine FeNO Peak flow variability- peak flow several times a day for 2-4 weeks

Question 589

Tx chronic asthma in Paeds <5 y/o?

Answer 589

SABA + ICS/ LTRA- add other option from step 2 Refer--> specialist

Question 590

Tx chronic asthma in Paeds 5-12 y/o?

Answer 590

SABA Regular low dose CS LABA e.g. salmeterol- continue salmeterol only if good response Titrate up CS inhaler--> medium dose- Consider adding LTRA , oral theophylline Increase corticosteroid--> high dose Referral--> specialist- may need daily oral steroids

Question 591

Tx chronic asthma in Paeds >12 y/o?(same as adults)

Answer 591

SABA Low dose CS inhaler LABA- continue if good response Titrate CS--> medium dose, consider trial LTRA, oral theophylline or inhaled LAMA Titrate up CS--> high dose Combine CS, LTRA, LAMA Oral steroids@ lowest dose

Question 592

RFs and sx viral induced wheeze? Tx?

Answer 592

RSV/ rhinovirus Maternal smoking during and/ or after pregnancy Prematurity, NO ATOPIC HISTORY, multiple trigger wheeze- also cold air, dust, animal dander, exercise Only during viral infections 1-2 days prior= SOB, signs resp distress, expiratory wheeze throughout chest Same as acute asthma in children

Question 593

Age group for croup?

Answer 593

6 months- 2 y/o during autumn and winter months URTI--> oedema in larynx Parainfluenza, influenza, adenovirus, RSV Used to be cause by diphtheria- leads to epiglottitis

Question 594

Sx croup? Ddx? Ix croup?

Answer 594

Barking/ seal-like cough, stridor, fever, increased work of breathing e.g. retractions or nasal flaring, agitation/ lethargy in severe Bacterial tracheitis, epiglottitis, inhaled foreign body or laryngomalacia, asthma Viral throat swabs for viral PCR XR neck--> steeple sign/ wine bottle sign, PA view CXR- subglottic narrowing in severe or atypical

Question 595

Tx mild/ moderate and severe croup?

Answer 595

May be sent home if settles e.g. with dex PO/ pred if not available- regardless of severity High flow oxygen, nebulised budesonide, nebulised adrenalin, intubation & ventilation

Question 596

Admit who with croup?

Answer 596

Moderate/ severe croup, <3m age, known upper airway abnormalities e.g. laryngomalacia, Down's, uncertainty about diagnosis

Question 597

Cause of epiglottitis? Sx?

Answer 597

Haemophilus influenzae type B High fever, sore throat, stridor, drooling, rapid increase resp difficulty over hours, tendency to sit upright with open mouth to optimise airway patency, minimal or absent cough, tripod position

Question 598

Ix for epiglottitis? Tx? Common complication?

Answer 598

Lateral XR- thumb sign/ thumbprint sign, neck XR for excluding a foreign body, cultures may be taken DO NOT EXAMINE WITHOUT SENIOR- possible endotracheal intubation, once secure= culture and examination, IV ABx- typically cefuroxime Epiglottic abscess

Question 599

Common age for bacterial tracheitis? Most common cause? Sx?

Answer 599

1-6 y/o, both genders= equally affected S.aureus High fever, stridor, barking cough, tachypnoea, difficulty breathing, dyspnoea, cyanosis

Question 600

Ix for bacterial tracheitis? Tx?

Answer 600

Blood tests- signs of infection, throat swabs for causative, CXR- airway obstruction/ pneumonia, CT scan- more detailed IV ABx- often broad- spectrum Intubation in severe Airway humidification and chest physio may assist in clearance

Question 601

Causes and sx of pneumonia in children?

Answer 601

S.pneumoniae, group A strep pyogenes, group B in pre-vacc infants, s.uareus--> pneumatoceles and consolidations in multiple lobes, h.influenzae, mycoplasma pnuemonia atypical w/ extra-pulm e.g erythema multiforme RSV, parainfluenza, influenza

Question 602

Sx and Ix in pneumonia?

Answer 602

Cough, high fever, tachypnoea, tachycardia, increased WOB, lethargy, delirium, hypoxia, hypotension, confusion Bronchial breath sounds, focal coarse crackles, dullness to percussion CXR in doubt, sputum cultures, throat swabs and viral PCR, sepsis= BLOOD CULTURES, capillary blood gas analysis

Question 603

Tx pneumonia?

Answer 603

Amoxicillin- macrolide for atypical e.g. erythromycin, clari, azithromycin, monotherapy in penicillin allergy O2>92%

Question 604

Ix for recurrent LRTIs?

Answer 604

Hx, examination, assess for reflux, neurological disease, heart disease, asthma, CF, PCD, immune deficiency FBC, CXR, serum Igs, IgGs= Ig class-switch recombination deficiency, sweat test, HIV test if Mum's status unknown or positive

Question 605

Gender that laryngomalacia is more common in? Types?

Answer 605

Males>females Type 1= tightening of the aryepiglottic folds Type 2= redundant tissue in supraglottic region 3= ass w/ other disorders e.g. NM disease/ GORD

Question 606

Sx, Ix and tx of laryngomalacia?

Answer 606

Inspiratory stridor- usually intermittent occurring in supine position - increase in severity during first 8 months, resolve by 18-24 months- PEAK@6 months Resp distress, failure to thrive, cyanosis= rare O2 saturations monitored and blood gases taken, laryngoscopy and bronchoscopy if severe features or if there is diagnostic difficulty Sx relief by hyperextending neck during stridor episodes Severe resp distress= tracheostomy, laryngoplasty, excision redundant mucosa, laser epiglottoplexy/ laser division of aryepiglottic folds

Question 607

Ix for anaphylaxis? Tx?

Answer 607

Serum mast cell tryptase- rises within an hour Adrenaline, removing trigger, early call for help, placing patient--> supine position and raising legs, managing airway and high flow oxygen, IV fluids in shock, hydrocortisone when not urgent, attach patient --> monitoring equipment Monitor for 6-12 hours after initial presentation, upon discharge= counselling on adrenaline auto-injectors, supply x2 auto-injectors, written advice, referral--> local allergy service follow-up

Question 608

Between what layers is a subgaleal haemorrhage?

Answer 608

Galea aponeurotica and periosteum- can croos suture lines unlike cephalohaematoma- may present with pallor, tachycardia, hypotension and shock due to significant blood loss

Question 609

Comps from a cephalohaemtoma?

Answer 609

Infection, calcification, rare= intraosseous haematoma Anaemia- monitor Hb levels Jaundice Cosmetic deformity

Question 610

Where does caput succedaneum present?

Answer 610

Outside periosteum- CROSSES SUTURE LINES, usually from pressure on cervix/ ventouse delivery May have USS- usually resolves spontaneously Usually no/ mild discolouration of the skin Presents within days birth and resolves within few days

Question 611

Tx facial paralysis?

Answer 611

Usually resolves spontaneously within few months- may need neurosurgical input

Question 612

What is a fractured clavicle associated?

Answer 612

Shoulder dystocia, traumatic/ instrumental delivery and LBW Lack movement/ asymmetry movement in affected arm Asymmetry shoulders - affected lower than normal shoulder Pain and distress on movement of arm USS/ XR Conservative management occasionally with immobilisation of affected arm- comp= brachial nerve palsy

Question 613

Ix for jaundice in the newborn?

Answer 613

FBC & blood film, blood type testing for ABO/ rhesus incompatibility, direct Coombs test for haemolysis, TFTs for hypothyroid, blood & urine cultures for infection, G6PD deficiency Transcutaneous bilirubinometer in >35/40 gestation + >24 hours old for first measurement first 72 hours life- low threshold in pre-term babies and dark-skin tone/ serum bilirubin if <35/40 gestation, <24 hours old or TCB>250micromol/L

Question 614

Sx haemolytic disease of the newborn?

Question 615

RFs for neonatal jaundice?

Answer 615

Breastfed babies, significant bruising/ cephalohaematoma, preterm babies

Question 616

CSF in SAH? MS? GBS?

Answer 616

Blood-stained initially w/ xanthochromia>12 hours later, elevated protein, RBC and RBC, WBC, normal glucose PERFORM CT WITHIN 6 HOURS Oligoclonal bands, primarily lymphocytes, normal appearance, pressure, glucose, protein mildly elevated Normal appearance, WBC, glucose level, pressure= normal/ elevated, protein markedly elevated>5.5g/L- may not be seen in first week illness

Question 617

Sx of whooping cough?

Answer 617

Catarrhal phase similar to viral URTI around 1-2 weeks long Paroxysmal phase where cough increases in severity- bouts worse@night and after feeding, may be ended by vomiting and associated central cyanosis, inspiratory whoop not always present, may have spells of apnoea, persistent coughing may cause subconjunctival haemorrhages/ anoxia--> syncope/ seizures, between 2-8 weeks Cough subsides over weeks to months

Question 618

Ix of whooping cough? Tx?

Answer 618

Per nasal swab within 2-3 weeks onset sx/ anti-pertussis toxin IgG>2 weeks cough in oral fluid 5-16 y/o/ blood >17 y/o- PCR and serology now increasingly used <6m old= admit, notifiable disease Oral clari/ azithromycin/ erythromycin/ co-trimoxazole if onset cough within previous 21 days, household contacts= AB prophylaxis, 48hour exclusion after commencing antibiotics

Question 619

Comps whooping cough?

Answer 619

Subconjunctival haemorrhage, pneumonia, bronchiectasis, seizures, pneumothorax Women 16-32 weeks pregnant= offered vaccine

Question 620

Definition of enuresis, primary and seconday?

Answer 620

Involuntary discharge of urine by day or night or both in child aged 5 years or older in absence congenital or acquired defects of nervous system or urinary tract Never achieved continence- family history, overactive bladder, increase intake before bed/ has been dry for at least 6 months before- diabetes, psych distress, chronic constipation, UTI, learning disability, cerebral palsy

Question 621

Tx enuresis?

Answer 621

Look for constipation, diabetes mellitus, UTI if recent onset Gen advice= fluid intake, encourage empty bladder during day and before sleep, lifting and waking Star charts >5 y/o== enuresis alarm= generally first-line, sensor pads sense wetness, high success rate >7y/o- desmopressin- short-term/ alarm ineffective/ not effective to family Not responded to alarm/ need rapid control= trial DDAVP can be considered

Question 622

Ix for enuresis?

Answer 622

Hx & exam, urine dip Secondary= urine dip, urine osmolarity & renal USS, 2w toileting diary, possibly urinalysis

Question 623

Who does cow's milk protein allergy affect?

Answer 623

First 3 months life in formula fed infants and/ or family hx atopic conditions- IgE and non-IgE mediated Immediate reaction= CMPA/ mild-moderate delayed= CMPI

Question 624

Sx CMPA? TX?

Answer 624

Abdo pain, diarrhoea, vomiting, bloating and wind Allergic= urticarial rash, angio-oedema, cough/ wheeze, sneezing, watery eyes, eczema Skin prick testing can help, total IgE and specific IgE (RAST) Hydrolysed formulas, severe= elemental formulas made of basic amino acids- most outgrow by 3 y/o often earlier Every 6m= try on first step milk ladder

Question 625

Sx CMPI?

Answer 625

Same sx without allergic features- can tolerate with GI sx Grow out by 2-3 y/o- fed with breast milk, hydrolysed formulas weaned to foods not containing cow's milk After one year age--> started on milk ladder

Question 626

Tx CMPI in breastfed?

Answer 626

Continue breastfeeding, eliminate cow's milk protein from maternal diet, consider Ca2+ supplements for those have/ suspected to have CMPI, eHF when breastfeeding stops until 12m age and at least for 6 months

Question 627

Cause mesenteric appendicitis?

Answer 627

Inflammation of mesenteric lymph nodes- EBV, adenovirus, enterovirus, Yersinia, campylobacter, mycobacterium, salmonella, strep

Question 628

Sx mesenteric adenitis, Ix and tx?

Answer 628

Diffused abdo pain mistaken for appendicitis, low-grade fever, generalised abdo pain, pharyngitis/ sore throat, unaltered appetite FBC- typically normal US abdomen- enlarged mesenteric lymph nodes, normal appendix Observation and reassurance, consider surgical with caution

Question 629

What is Meckel's diverticulum? Epidemiology?

Answer 629

Remnant of vitellointestinal duct in distal ileum within 100cm ileocaecal valve 2% population, 2% symptomatic, usually less than 2 y/o, M>F

Question 630

Sx Meckel's diverticulum?

Answer 630

Painless rectal bleeding, abdo pain, symptomless, intussusception, volvulus/ diverticulitis, obstruction if trapped in a hernia- Littre's hernia, reduction in Hb

Question 631

Ix and tx Meckel's diverticulum?

Answer 631

CT scan 99mTC scan ectopic gastric mucosa, small bowel enema in some cases NG tube if obstruction, surgical resection of diverticulum by wedge excision/ small bowel resection and anastomosis

Question 632

Sx, RFs and Ix TOF?

Answer 632

Unrepaired--> hypercyanotic tet spells= tachypnoea and severe cyanosis often when upset/ in pain/ has fever Ejection systolic murmur= due to pulm stenosis(AT 1-2m- TGA= more common at birth) Rubella, increased age of mother, alcohol consumption in pregnancy, diabetic mother, Down's, DiGeorge syndrome CXR= boot-shaped heart, ECG= RVH, ECHO using Doppler flow studies, cardiac catheter might be needed

Question 633

Tx for tet spell in tetralogy of Fallot?

Answer 633

Supplementary oxygen, Beta blockers, IV fluids, morphine- decreases resp drive, sodium bicarbonate- buffers metabolic acidosis, phenylephrine infusion

Question 634

Definitive tx of TOF?

Answer 634

Prostaglandin to maintain PDA, total surgical repair by open heart surgery

Question 635

Definition precocious puberty?

Answer 635

Sexual char<8y/o females, 9 y/o in males- F>M GT dependent- prem act H-P-G axis FSH & LH raised GT independent- FSH & LH low Females= idiopathic/ familial Organic= rare- rapid onset, neuro sx and signs and dissonance e.g. McCune Albright syndrome

Question 636

Who does intussusception affect? Ass w/ what conditions?

Answer 636

6m-2 y/o Usually boys Invagination one portion bowel--> lumen adjacent bowel commonly around ileo-caecal region Meckel diverticulum, viral illness, HSP, CF, intestinal polyps

Question 637

Sx & tx intussusception?

Answer 637

Intermittent, severe, crampy, progressive abdominal pain, inconsolable crying , during paroxysm- draws knees up and turns pale, red-currant jelly stool= late sign, sausage- shaped mass RUQ USS- target-like mass Rectal air insufflation/ contrast enema if stable, operative reduction if non-op failed, peritonitis/ perforation, HD stable

Question 638

Hearing test done if otoacoustic emission test abnormal? @6-9 months? 18m-2.5 years? >2.5 years? >3 years?

Answer 638

Auditory brainstem response test Distraction test- x2 trained staff Recognition familiar objects Performance testing Speech dis tests- Kendall toy/ McCormick Toy Pure tone audiometry- school entry

Question 639

Cause and sx of H, F & M disease?

Answer 639

Coxsackie A16 and enterovirus 71 Tired, sore throat, dry cough, raised temp- after 1-2 days= small mouth ulcers followed by blistering red spots across body, painful ulcers on tongue- rash may be itchy

Question 640

Ix and tx of hand, foot and mouth disease? Comps?

Answer 640

Hydration, analgesia, NO NEED TO EXCLUDE, resolve after a week- 10 days Avoid sharing towels, bedding, washing hands, careful handling dirty nappies Dehydration, bacterial superinfection, encephalitis

Question 641

Test for cardiac vs non-cardiac causes cyanosis in neonates?

Answer 641

Nitrogen washout test- 100% oxygen given for 10 minutes before ABGs taken, PaO2< 15kPa= cyanotic congenital heart disease

Question 642

Sx Edward's syndrome (trisomy 18)? Vs Patau (trisomy 13)?

Answer 642

Rocker bottom feet Micrognathia- small jaw, low-set ears, overlapping fingers Rocker bottom feet, microcephalic, small eyes, cleft lip/ palate, polydactyly, scalp lesions

Question 643

When does nausea and vomiting occur in pregnancy?

Answer 643

Between 4th and 7th week gestation- peaks at 9th-16th, resolves by 20th weeks

Question 644

When do women usually feel fetal movements? When do you get an USS? Qs to ask about vaginal bleeding?

Answer 644

16-24 weeks 18-20+6 weeks Pain, trauma, fever/ malaise, recent USS results, cervical screening history, sexual history, past medical history, fatigue, sx hypovolaemic shock e.g. pre-syncope/ syncope

Question 645

Qs to ask about current pregnancy in obs history?

Answer 645

Growth fetus, placental position, fetal anomalies Down's screening, Rhesus status and presence of antibodies, Hep B, HIV and syphilis Singleton/ multiple Folic acid prior to conception and during first trimester Planned mode delivery, illness during pregnancy Flu, whooping cough, hep B vaccinations Screen for depression, bipolar, schizophrenia, previous diagnoses, self-harm/ suicide

Question 646

Qs regarding term pregnancies >24 weeks? <24 weeks? Gynae hx?

Answer 646

Gestation, birth weight, mode delivery, comps, assisted reproduction, stillbirths Trimester, medical/ surgical tx miscarriage, gestation & medical/ surgical tx for terminations Site & tx of ectopic pregnancy Cervical screening any treatments, previous gynae conditions and treatments

Question 647

Conditions for family hx in obs history?

Answer 647

Inherited- CF/ SCD, T2DM, pre-eclampsia

Question 648

Mnemonic for exploring psychiatric symptoms?

Answer 648

Nature, onset, triggers, exacerbating/ relieving factors, progression, associated symptoms, disability

Question 649

Family hx in gynaecological history?

Answer 649

Ovarian, endometrial, breast cancer Bleeding disorders e.g. Von Willebrand's disease, VTE in first- degree relative

Question 650

Things included in a mental state examination?

Answer 650

Appearance Behaviour Speech- rate, quantity, tone, volume, fluency and rhythm Mood & affect- range and mobility, intensity, congruency of affect Thought- form- speed, flow & coherence of thoughts/ content- delusions, obsessions, compulsions, overvalued ideas, suicidal thoughts, homicidal/ violent thoughts/ possession- insertion, withdrawal, broadcasting Perception- hallucinations, pseudo-hallucinations, illusions, depersonalisation, derealisation Cognition Insight and judgment Risk to self and others

Question 651

Mutation in Fragile X syndrome?

Answer 651

FMR1 gene on X chromosome- fragile X mental retardation protein--> CGG repeat expansion MALES ALWAYS AFFECTED- FEMALES CAN VARY Mother phenotypically normal= affected child may have inherited X chromosome from mother or may result from de novo mutation

Question 652

Sx Fragile X syndrome?

Answer 652

Intellectual disability, long, narrow face, large ears, large testicles after puberty, hypermobile joints, ADHD, autism, seizures

Question 653

Sx Down's syndrome?

Answer 653

Hypotonia, brachycephaly, short neck, short stature, flattened face & nose, prominent epicanthic folds, upward sloping palpebral fissures, single palmar crease, Brushfield spots in iris, duodenal atresia, Hirschsprung's disease

Question 654

Comps Down's syndrome?

Answer 654

Learning dis, recurrent otitis media, deafness, Eustachian tube anomalies, visual issues- myopia, strabismus and cataracts, hypothyroidism, ASD/ VSD/ patent ductus arteriosus/ tetralogy of Fallot/ endocardial cushion defect, atlantoaxial instability, leukaemia, dementia Subfertility, ALL, Alzheimer's

Question 655

Tx Down's syndrome?

Answer 655

OT, SLT, physio, dietician, paediatrician, GP, health visitor, cardiologist, ENT, audiologist, optician, social services, charities Regular TFTs, echo, regular audiometry, regular eye checks

Question 656

What does cleft lip and palate result from? Issues and tx?

Answer 656

Fronto-nasal and maxillary processes to fuse Palate= palatine processes and nasal septum to fuse Speech therapy, increased otitis media for cleft palate babies Cleft lip= repaired earlier than palate 1 week-3m Palate= 6-12m

Question 657

ORBIT score risk groups?

Answer 657

0-2 = low, 3= medium, 4-7= high

Question 658

Sx meningitis? When is LP indicated? 2x tests?

Answer 658

Non-blanching rash- DIC, hypotonia, poor feeding, lethargy, hypothermia and bulging fontanelle Lethargy, headache, fever, rigors and vomiting, hypovolaemic shock, adrenal haemorrhage= Waterhouse- Friderichsen syndrome Under 1m w/ fever, 1-3 m w/ fever and are unwell Under 1 unexplained fever and other features serious illness Kernig's and Brudzinski's test

Question 659

Ix meningitis? Tx?

Answer 659

Blood cultures, PCR testing for n.meningitidis, LP prior to starting antibiotics- WITHIN HOUR ARRIVING AT HOSPITAL, FBC, clotting, blood culture, glucose, blood gases Pre-hospital= IM benzylpenicillin <3m= cefotaxime + amoxicillin- for listeria during pregnancy >3m= ceftriaxone Recent foreign travel or prolonged antibiotics= vancomycin Dex QDS 4 days >3 months if LP suggestive bacterial Notify PHE Close prolonged contacts within 7 days= prophylactic ciprofloxacin within 24hours initial diagnosis Encephalitis= IV aciclovir for HSV encephalitis

Question 660

CI to LP?

Answer 660

Raised ICP- reduced or fluctuating consciousness, bradycardia and HTN, focal neuro signs, abnormal posturing, abnormal pupil reflexes, papilloedema, bulging fontanelle GCS<9, HD unstable, active seizures or post-ictal

Question 661

Comps of meningitis? Meningitis follow-up?

Answer 661

Hearing loss, seizures, epilepsy, cognitive impairment and learning disability, memory loss, cerebral palsy w/ focal neuro deficits such as limb weakness or spasticity Review w/ Paediatrician within 4-6 weeks- viral= usually complete resolution within 10 days

Question 662

Most common causes encephalitis in children?

Answer 662

HSV-1 from cold sores- neonates= HSV-2 from genital herpes during birth VZV, cmv ass w/ immunodeficiency, EBV, enterovirus, adenovirus and influenza Vaccinations- polio, mumps, rubella, measles

Question 663

Sx and Ix encephalitis?

Answer 663

Altered cognition, consciousness, behaviour, acute onset focal neuro sx, acute onset focal seizures, fever LP--> viral PCR, CT if LP= CI, MRI after LP, EEG in mild/ ambiguous sx, throat and vesicle swabs, HIV testing recommended

Question 664

Tx encephalitis? Follow-up?

Answer 664

Aciclovir in HSV & VZV Ganciclovir in CMV Repeat LP prior to stopping antivirals Lasting fatigue and prolonged recovery, change in personality/ mood, changes to memory and cognition, learning disability, headaches, chronic pain, sensory disturbance, seizures, hormonal imbalance

Question 665

What can't you get above with scrotal swellings? Test for epididymitis vs testicular torsion?

Answer 665

Infantile hydrocele- irreducible, has no cough impulse and testes is impalpable and hernia Prehn's test- reduction in pain on lifting= epididymitis

Question 666

Sx and ix for VUR?

Answer 666

Antenatal= hydronephrosis on USS, recent childhood UTIs Reflux nephropathy- chronic pyelonephritis secondary to VUR Recurrent UTIs, persistent bacteriuria, unexplained fevers, abdominal/ flank pain, severe= HTN and CKD MCUG, DMSA= for renal scarring

Question 667

When is an MCUG indicated?

Answer 667

Children<6m old for atypical/ recurrent UTIs, family hx VUR, dilatation of the ureter on USS/ poor urinary flow Proph ABx given 3 days

Question 668

Tx of VUR? Comps?

Answer 668

Avoid constipation, avoid excessively full bladder, proph antibiotics, surgical input from Paed urology- ureteral reimplantation in severe/ cons management fails Recurrent UTIs, pyelonephritis, renal scarring and CKD, HTN

Question 669

Grading 1-5 of VUR?

Answer 669

1= reflux--> ureter only no dilatation 2= reflux into renal pelvis on micturition, no dilatation 3= mild/ mod dilatation of ureter, renal pelvis and calyces 4= dilation of renal pelvis and calyces with moderate ureteral tortuosity 5= gross dilatation of ureter, pelvis and calyces with ureteral tortuosity

Question 670

Causes of UTIs in children?

Answer 670

E.coli, Klebsiella, proteus- more common in boys, pseudomonas- may indicate structural abnormality, strep faecalis, staph saprophyticus Incomplete bladder emptying/ constipation/ VUR Isolated dysuria= cystitis OR girls= vulvitis, uncircumcised boys= balanitis

Question 671

Sx UTI<3m old? Aged 3-12m? >1 y/o?

Answer 671

Fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, jaundice, haematuria, offensive urine Fever, poor feeding, abdo pain, vomiting Frequency, dysuria, abdo pain Fever= less common in children over 1 y/o

Question 672

Ix UTI in children?

Answer 672

Clean catch- urine sample--> nitrites, leucocytes, leucocyte esterase- NOT AS SENSITIVE Send MSU sample to microbiology lab to be cultured and have sensitivity testing

Question 673

Features of atypical UTI? Pyelonephritis?

Answer 673

Non E-coli, failure respond--> ABx within 48 hours, septicaemia, poor urine flow, abdominal/ bladder mass, raised creatinine Fever + systemic involvement/ loin pain/ tenderness

Question 674

Tx UTI in <3m old w/ fever?

Answer 674

Immediate IV ABx and septic screen, blood cultures, bloods, lactate, consider LP Consider oral ABx>3m if otherwise well

Question 675

Ix recurrent UTIs<6m? Atypical UTIs? What 4-6 months after the illness?

Answer 675

Abdominal USS within 6 weeks/ during illness if there are recurrent UTIs or atypical bacteria DMSA

Question 676

Tx for UTI in children?

Answer 676

<3m= refer--> Paediatrician >3m w/ upper UTI= consider admission to hospital Not admitted= oral ABx 7-10 days >3m with pyelo= cefalexin/ co-amoxiclav >3m w/ cystitis/ lower UTI= oral trimethoprim/ nitro if eGFR>45ml/ minute/ amoxicillin if culture results available and susceptible/ cefalexin Bring back in if unwell after 24-48 hours

Question 677

When is GORD in children usually? RFs?

Answer 677

<8 weeks, resolve by 1 years of age- vomiting/ regurgitation, milky vomit after feeds may occur after being laid flat, excessive crying whilst feeding especially Premature birth, parental hx heartburn or acid regurg, obesity, hiatus hernia, hx congenital diaphragmatic hernia/ oesophageal atresia Neurodisability

Question 678

Tx simple GORD in children? More bothersome?

Answer 678

Sleep on backs, not overfeed, smaller and more frequent feeds, burping regularly to help milk settle, keep upright after feeding Gaviscon mixed with feeds, thickened milk/ formula- NOT AT SAME TIME, PPIs- unexplained feeding difficulties, distressed behaviour, faltering growth

Question 679

Red flags for GORD in children? Further Ix?

Answer 679

Not keeping down feeds, projectile/ forceful vomiting, bile stained vomit, haematemesis/ melena, abdominal distension, reduced consciousness, bulging fontanelle/ neuro signs, resp sx, blood in stools, signs infection, rash/ angioedema/ allergy, apnoeas Barium meal and endoscopy, surgical fundoplication

Question 680

Sx febrile convulsions? Simple vs complex?

Answer 680

Early in viral infection, less than 5 minutes, tonic-clonic, 6m-5y/o Generalised<15 minutes, only once during febrile illness Partial/ focal seizures >15 minutes/ multiple times during same febrile illness

Question 681

Features of Sandifer's syndrome?

Answer 681

Torticollis and dystonia- tends to resolve as reflux is treated/ improves- refer for assessment to rule out West syndrome and seizures

Question 682

When would would someone with febrile convulsion be admitted?

Answer 682

First febrile seizure, child<18m age, complex febrile seizures, diagnostic uncertainty/ recent antibiotic use/ parental anxiety Refer--> Paeds if developmental delay Ensure vaccinations completed

Question 683

Most common delayed milestones in children with CP? RFs?

Answer 683

Not sitting by 8m, not walking by 18m, asymmetry hand function before 1 year Antenatal= H-I encephalopathy, infection Birth asphyxia/ trauma Postnatal= meningitis, trauma, haemorrhage, medication toxicity, kernicterus

Question 684

Sx spastic cerebral palsy?

Answer 684

Pyramidal weakness- clasp-knife spasticity, scissor gait, HYPERTONIA, hemi/ di- mainly legs affected= UMN LESION- leg extended with plantar flexion of feet and toes/ quadriplegia- often seizures, speech disturbance and other impairments Dyskinetic- damage to basal ganglia, choreiform movements, oro-motor problems, HYPER & HYPOTONIA Ataxia- cerebellar signs Mixed High stepping gait= foot drop/ LMN lesion, waddling gait= pelvic muscle weakness due to myopathy

Question 685

Comps and tx cerebral palsy?

Answer 685

IX= MRI Learning disability, epilepsy, kyphoscoliosis, muscle contractures, hearing and visual impairment, GORD Physio, OT, SLT, dieticians, ortho surgeons- tenotomy, paeds- muscle relaxant e.g. baclofen, anti-epileptics, glycopyrronium bromide for drooling, social workers, charities and support groups

Question 686

Who is affected in roseola infantum?

Answer 686

HHV6--> 6m-2 y/o High fever--> MP rash, nagayama spots, febrile convulsions, diarrhoea and cough commonly seen Aseptic meningitis, hepatitis SCHOOL EXCLUSION NOT NEEDED

Question 687

Cause measles? Sx?

Answer 687

Morbillivirus RNA paramyxovirus- resp droplets/ direct contact with nasal/ throat secretions Infective from prodrome until 4d after rash starts Irritable, conjunctivitis, fever, Koplik spots- white spots buccal mucosa, before rash- behind ears--> whole body- desquamation sparing palms and soles may occur after a week

Question 688

Ix and tx measles? Comps?

Answer 688

IgM antibodies within few days rash onset- measles PCR swabs taken 1-3 days after rash onset Supportive- admission in immunosuppressed/ pregnant, notifiable--> PHE Vitamin A<2 y/o Otitis media, pneumonia- most common cause death, encephalitis, subacute sclerosing panencephalitis, febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhoea, increased appendicitis incidence, myocarditis Offer MMR WITHIN 72 HOURS

Question 689

Who gets pyloric stenosis? Sx?

Answer 689

6-8w, M>F, first-borns Projectile vomiting, thin, pale, failure to thrive, firm, round mass in upper abdomen Blood gas= hypochloric metabolic alkalosis USS= thickened pylorus Lap pyloromyotomy- Ramstedt's operation

Question 690

Tx pyloric stenosis?

Answer 690

Supportive- NBM, IV fluids, fluid resus may be needed

Question 691

Inheritance of Down's syndrome?

Answer 691

Gamete non-dysjunction, Robertsonian translocation, mosaic Down syndrome

Question 692

Cause retinoblastoma? Sx & tx?

Answer 692

AD RB1 on Ch12 Absence red reflex replaced by white pupil- leukocoria, strabismus, visual problems Enucleation, external beam radiation therapy, chemo and photocoagulation

Question 693

Cause and sx Turner's?

Answer 693

Short stature, wide space nipples, webbed neck, bicuspid aortic valve, coarctation of the aorta- increased risk aortic dilatation and dissection, primary amenorrhoea, cystic hygroma, high-arched palate, short 4th metacarpal, multiple pig naevi, lymphoedema in neonates, elevated GT levels, hypthyroidism, horseshoe kidney, AI thyroiditis and Crohn's disease, cubitus valgus, recurrent otitis media, osteoporosis

Question 694

Tx for Turner syndrome?

Answer 694

GH therapy, oestrogen and progesterone replacement, fertility treatment- manage HTN & hypothyroidism

Question 695

Cyanotic causes of congenital HD?

Answer 695

VSD, ASD, PDA, coarctation of the aorta, aortic valve stenosis VSD>ASD, ASD more in adults

Question 696

Sx of nephrotic syndrome in children?

Answer 696

Low serum albumin<25g/L, high urine protein content >3+ protein on urine dip, oedema BETWEEN 2 & 5 Y/O Deranged lipids- high cholesterol, triglyceries and LDLs, high BP, hypercoagulability, predisposition to infection MOST MINIMAL CHANGE DISEASE

Question 697

secondary causes nephrotic syndrome in children?

Answer 697

Intrinsic- focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis HSP, diabetes, infection- HIV, hepatitis and malaria

Question 698

Ix for nephrotic syndrome?

Answer 698

Urine dip= proteinuria, urine analysis= raised A:creatinine ratio, small molecular weight proteins and hyaline casts in MCD Renal biopsy- all adults and children w/ atypical presentation- steroid unresponsive, haematuria, under 1 y/o or over 12 y/o

Question 699

Tx minimal change disease? Tx in steroid resistant?

Answer 699

High dose steroids 4w and weaned over 8 weeks- pred(steroid dependant or resistant,) low salt diet, diuretics for oedema, albumin infusions in severe, ABx proph in severe ACE-i, immunosuppressants e.g. cyclosporin, tacrolimus or rituximab

Question 700

Comps nephrotic syndrome?

Answer 700

Infection- urinary loss Iggs, VTE- loss antithrombin III, hyperlipidaemia- increased hepatic production, hypovolaemia, acute/ chronic renal failure, relapse

Question 701

Cause of malrotation? Sx? Ix and tx?

Answer 701

Abnormal rotation and fixation of midgut during embryonic development during 4th-12th week gestation Bilious vomiting- often occurring within first day of life Upper GI contrast study- proximal bowel= corkscrew appearance/ coffee bean sign Urgent surgery

Question 702

Most common type of congenital DH? Sx? Ix & tx?

Answer 702

Failure of pleuroperitoneal canal to close completely Left-sided posterolateral Bochdalek hernia= 85% cases Respiratory distress, bowel sounds in chest, absent breath sounds on one side, failure to respond to resuscitation, displaced apex beat, scaphoid abdomen Prenatal USS screening NG tube passed & suction applied to prevent distension of intrathoracic bowel then repaired surgically after stabilisation

Question 703

Cause of ITP? Sx and Ix? Tx?

Answer 703

Immune-mediated reduction in platelet count antibodies against glycoprotein IIb/ IIIa Type II hypersensitivity <10 y/o over 24-48 hours, chronic= HIV, hepatitis C and SLE Urgent FBC for platelet count Blood film, BM examination- atypical = LN enlargement/ splenomegaly, high/ low white cells, failure to resolve/ respond to tx No tx- 80% resolve within 6 months with/ without treatment, avoid trauma, low platelet count/ significant bleeding= oral/ IV corticosteroid, IV immunoglobulins, platelet transfusion in emergency

Question 704

Comps of ITP?

Answer 704

Chronic ITP, anaemia, intracranial and SAH, GI bleeding

Question 705

Inheritance, sx and Ix haemophilia?

Answer 705

X-linked recessive Bleeding early on in life--> joints etc, bleeding--> muscles= compartment syndrome Factor VIII/IX assay High APTT, vWF antigen= normal in A type, defective platelet function

Question 706

Minor bleeds in haemophilia A tx with what? Mild and moderate haemophilia?

Answer 706

Desmopressin- stimulate Von Willebrand factor, gene therapy Antifibrinolytics e.g. TXA- avoid in muscle haematomas, haemarthrosis and urinary bleeding--> fibrosis Hep B vaccination, hydrotherapy, ortho and dental advice IV clotting VIII or IX either regularly/ in response to bleeding- comp= antibodies against tx

Question 707

RFs for NEC?

Answer 707

Prematurity, formula feeds, resp distress and assisted ventilation, PDA and other congenital heart disease, LBW, non-breast-milk feeds, sepsis, acute hypoxia, poor intestinal perfusion--> bowel necrotic--> perforation, peritonitis and shock

Question 708

Sx NEC?

Answer 708

Intolerance--> feeds, vomiting- green bile, unwell, distended tender abdomen, absent bowel sounds, blood in stools FBC- low platelets and neutropenia CRP, cap blood gas- met acidosis, blood culture for sepsis AXR- supine position and lateral decubitus- dilated loops bowel, bowel wall oedema, pneumatosis intestinalis- gas in bowel wall, pneumoperitoneum, gas in portal veins Bell's classification, Riglers sign and Football sign

Question 709

Tx for NEC? Comps?

Answer 709

NBM, TPN & ABx, refer--> neonatal surgical team- may be left with temporary stoma if significant bowel removed Perforation and peritonitis, sepsis, death, stricture, abscess formation, recurrence, long term stoma, short bowel syndrome after surgery Encourage breastfeeding in premature babies and delayed cord clamping

Question 710

Number features ADHD up to 16 y/o? Over 17?

Answer 710

x6/ x5- inattention, hyperactivity/ impulsivity, sx inattention at least 6 months, hyper/ impuls= 6m extent= disruptive and inappropriate Several before age 12 y/o, in two more settings Presentation= x10 weeks watch and wait period- persist= secondary care referral Drugs>5 y/o Methylphenidate for 6 weeks- dopamine/ norepinephrine reuptake inhibitor--> abdo pain, nausea and dyspepsia, monitor weight and height every 6 months Ind--> lisdexamfetamine- can't tolerate but benefit--> dexamfetamine BASELINE ECG

Question 711

Causes constipation in children?

Answer 711

Idiopathic/ functional Hirschsprung's disease, CF, hypothyroidism <3 stools/ week, retentive posturing, overflow soiling

Question 712

When is encopresis pathological?

Answer 712

4 y/o- rarer causes= spina bifida, cerebral palsy, learning disability, psychosocial stress, abuse

Question 713

Red flags with constipation?

Answer 713

Not passing meconium within 48 hours birth- CF/ Hirsch Neuro signs- lower limbs, vomiting, ribbon stool- anal stenosis, abnormal anus, abnormal lower back/ buttocks, failure to thrive, acute severe abdo pain/ bloating- obstruction, intussusception

Question 714

Tx constipation children?

Answer 714

Correct factors, laxatives- Movicol first line- macrogol, disimpaction regime- high doses at first, scheduling vists, bowel diary and star charts, slowly weaned off- not yet weaned<6m- bottle-fed= extra water between feeds, abdo massage and bicycling infant's legs, breast-fed= consider organic causes High fibre diet

Question 715

Review after Movicol plan?

Answer 715

2 weeks- add stimulant laxative(Senna)- singly or in combination with osmotic e.g. lactulose/ docusate if not tolerated

Question 716

When does coeliac present in children? Genes? Features, Ix and tx?

Answer 716

<3 y/o, HLA-DQ2 & HLA-DQ8 Failure to thrive, diarrhoea, abdominal distension, bruising- vit k deficiency, steatorrhoea, wasted buttocks, short stature, older= anaemia, rare= peripheral neuropathy, cerebellar ataxia, epilepsy Jejunal biopsy--> subtotal villous atrophy, anti-endomysial and anti-gliadin antibodies(anti TTG & anti-EMA,) anti-DGPs screening tests, total IgA, FBC, U&Es, LFTs, vit D, B12, folate, iron levels, STOOL CULTURE FIRST FOR INFECTION- ass w/ T1DM, thyroid disease, AI hepatitis, PBC, PSC, Down's

Question 717

Comps of coeliac disease?

Answer 717

Anaemia, def in iron, B12 & folate, hyposplenism, osteoporosis, EATL, ulcerative jejunitis, small bowel adenocarcinoma

Question 718

Who does benign affect? type of seizures? EEG shows what?

Answer 718

4-12 y/o, seizures= typically@night, partial, secondary may occur, child= otherwise normal Centrotemporal spikes

Question 719

What is Hirschsprung's disease?

Answer 719

Where nerve cells of the myenteric plexus are absent in the distal bowel and rectum- absence PS ganglion cells Entire colon= total colonic aganglionosis--> constricted and proximal= distended and full

Question 720

Cause and ass of Hirschsprung's disease?

Answer 720

Family hx, Down's syndrome, neurofibromatosis, Waadernburg syndrome--> pale blue eyes, hearing loss and patches white skin and hair, MEN 2

Question 721

Sx of Hirschsprung's?

Answer 721

Delay passing meconium > 24 hours, chronic constipation since birth, abdominal pain and distension, vomiting, poor weight gain and failure to thrive

Question 722

What is Hirschsprung- associated enterocolitis?

Answer 722

Within 2-4 weeks birth w/ fever, abdominal distension, diarrhoea and sepsis features(3 Ds- dysmotility, dysbiosis of the gut microbiome, defective intestinal barrier function and mucosal immune response)- can lead to toxic megacolon and perforation of the bowel- needs urgent ABx, fluid resus and decompression of obstructed bowel

Question 723

Tx Hirschsprung's disease?

Answer 723

FBC, sepsis Ix, ABG, serum electrolytes, TFTs- hypothyroidism, AXR, rectal biopsy, enterocolitis= fluid resus and int obstruction, IV ABx in HAEC, barium studies after AXR--> saw-tooth of aganglionic segment, anorectal manometry Def tx= surgical removal aganglionic section of bowel

Question 724

When is a rectal biopsy indicated?

Answer 724

Failure to pass meconium within 48 hours following birth in term infants, constipation since neonatal period, chronic abdominal distension ass w/ vomiting, family hx of Hirschprung's disease, failure to thrive/ growth faltering along with any of above

Question 725

Causes of impetigo?

Answer 725

S.aureus, s.pyogenes- non-bullous or bullous- bullae>5mm in diameter fluid-filled lesions, MRSA= more common

Question 726

Sx non-bullous impetigo? Bullous impetigo?

Answer 726

Usually asymptomatic- may be mildly itchy, thin walled vesicles/ pustules around mouth and nose--> golden crust Flaccid fluid filled vesicles and blisters can persist for 2-3 days- rupture--> thin flat yellow/ brown curst, on flexures, face, trunk and limbs, can be widespread in infants, can have systemic sx, be painful & itchy(more in neonates and children<2y/o,) severe--> staphylococcus scalded skin syndrome

Question 727

Ix impetigo? Tx non-bullous impetigo?

Answer 727

Skin swab for microscopy, culture and sensitivity Hydrogen peroxide 1% cream--> fusidic acid or mupirocin Widespread= topical fusidic acid/ topical ABx for 5 days e.g. flucloxacillin, clari/ erythromycin= alternatives

Question 728

Tx for bullous impetigo?

Answer 728

Oral ABx up to 7 days- flucloxacillin/ clarithromycin Stay away from school/ work until all lesions are crusted over/ until 48 hours after treatment, not touching/ scratching lesions, hand hygiene, avoiding face towels & cutlery

Question 729

Comps of impetigo?

Answer 729

Cellulitis if infection gets deeper in the skin, sepsis, scarring, post- strep GN, staph scalded skin syndrome, scarlet fever

Question 730

Sx chickenpox? Tx?

Answer 730

Fever initially, itchy, rash starting on head/ trunk before spreading, initially macular--> papular--> vesicular Cool, trim nails, calamine lotion, school exclusion- 1-2 days before, until all lesions crusted over Immunocompromised and peripartum exposure= VZIG, develops/ immunocompromised/ adults over 14 y/o presenting within 24 hours, neonates/ at risk of comps= IV aciclovir

Question 731

Comps of chickenpox?

Answer 731

Bacterial superinfection, dehydration, conjunctival lesions, pneumonia, encephalitis--> ataxia, hepatitis and haemorrhagic comps Shingles/ Ramsay Hunt syndrome, Reye's syndrome

Question 732

Causes of Kallman syndrome?

Answer 732

Hypogonadotrophic hypogondadism X-linked= from KAL gene Autosomal dominant and recessive forms--> delayed puberty- less common in females Synkinesia, renal agenesis, visual problems, craniofacial anomalies, expression= highly variable

Question 733

Onset of typical absence seizures (petit mal)? Sx, Ix, tx?

Answer 733

4-8 y/o, 30 seconds long, no warning, quick recovery, often many per day, EEG= 3Hz generalised, symmetrical, sodium valproate, ethosuximide 90%= seizure free in adolescence

Question 734

How does infantile spasms present? Tx?

Answer 734

Aroun 6m age, poor prognosis, clusters full body spasms- Salaam attack EEG= hypsarrhythmia, usually secondary to serious neurological abnormality e.g. tuberous sclerosis, encephalitis, birth asphyxia/ idiopathic Prednisolone, vigabatrin

Question 735

Atonic seizures/ drop attacks may be indicative of what? Tx?

Answer 735

Lennox-Gastaut syndrome- not usually more than 5 minutes, typically begin in childhood Sodium valproate/ ethosuximide, ketogenic diet might help

Question 736

Management of juvenile myoclonic epilepsy?

Answer 736

Often in morning/ following sleep deprivation, daytime absences Sodium valproate, lamotrigine, levetiracetam or topiramate

Question 737

Do an EEG when and MRI brain in epilepsy?

Answer 737

After 2nd simple tonic-clonic seizure First seizure under 2 y/o, focal seizures, no response--> first line anti-epileptics Consider ECG, electrolytes- Na+, K+, Ca+, Mg2+, blood glucose, blood cultures, urine cultures, LP

Question 738

General advice with childhood epilepsy?

Answer 738

Take showers rather than baths, cautious w/ swimming, heights, traffic and heavy, hot or electrical equipment Older= avoid driving unless specific criteria

Question 739

Tests in neonatal jaundice?

Answer 739

Conjugated and unconjugated bilirubin, direct Coombs- direct antiglobulin test, TFTs, FBC, blood film, urine for MC&S & reducing sugars, U&Es, LFTs

Question 740

When should anti-D injections be given?

Answer 740

Test for D antibodies at booking 28w and birth routinely Sensitisation events- APH, amniocentesis, abdominal trauma, miscarriage>12w, termination, ectopic pregnancy, ECV, delivery Rhesus +ve individual GIVEN WITHIN 72 HOURS- after 20 weeks= Kleinhauer test to see how much foetal RBCs--> mother's bloodstream

Question 741

All Rhesus negative have cord blood taken at birth for what? Features affected foetus?

Answer 741

FBC, crossmatch, direct Coombs test Hydrops foetalis, hepatosplenomegaly, foetal anaemia--> pallor, Kernicterus, severe oedema if hydrops fetalis in utero, yellow amniotic fluid LFTs, US for oedema

Question 742

Tx of HDOTN?

Answer 742

Transfusions, UVA phototherapy, Ig to newborn, delivery if severe

Question 743

Sx maternal hyperthyroidism? Sx?

Answer 743

Fetal tachycardia on CT, fetal goitre on USS, neonate= irritable, weight loss, tachycardia, HF, diarrhoea, exophthalmos in first 2 weeks life- eye signs less common Carbimazole/ propylthiouracil, Beta-blockers for sx relief for about 2 years

Question 744

Check what in women planning a pregnancy?

Answer 744

TSH, FT4 and TPOAb, TRAbs if history/ current Graves' disease(CHECK AFTER BIRTH AND AT 6 WEEKS)- delay conception and use contraception until thyroid function normalised Avoid pregnancy for 6 months after radioactive thyroid tx, give leaflet Annual monitoring TFTs hx postpartum thyroiditis

Question 745

RFs for RDS? Sx? DDx?

Answer 745

Maternal diabetes, males, 2nd twin, C-sections Increased WOB shortly after birth>60/min, grunting, nasal flaring, intercostal recession, cyanosis, CXR: diffuse granular patterns- ground glass +/- air bronchograms TTOTN- 1st 4 hours>60, more common after C-sections- CXR= hyperinflation of the lungs and fluid in horizontal fissure--> observation, supportive care, supplementary oxygen, usually within 1-2 days, mec asp, TO fistula

Question 746

Prev RDS?

Answer 746

dex/ betamethasone from 23-35 weeks- high risk--> perinatal centres Delay cord clamping, O2-air blender 21%-85% normal within 5-10 minutes if active baby, increase by 10% every minute until improving CPAP May need endotracheal surfactant, intubation and ventilation, supp O2 91-95% in preterm neonates, gradually step down

Question 747

Comps of RDS?

Answer 747

Pneumothorax, infection, apnoea, IV haemorrhage, pulm haemorrhage, NEC Chronic lung disease of prematurity, retinopathy of prematurity, neuro, hearing and visual impairment

Question 748

Most common type of GI malformation? Sx?

Answer 748

OA + distal TOF Prenatal= polyhydramnios, postnatal= blowing bubbles, salivation + drooling, cyanotic episodes, resp distress + aspiration, distended abdomen, difficulty passing NG tube

Question 749

Ix, tx oesophageal atresia +/- TOF? DDx? Tx?

Answer 749

NG tube= coiled in oesophagus, AXR= no bubbles- isolated OA, renal USS + ECHO Congenital diaphragmatic hernia, duodenal atresia, GORD- VACTERL associations Surgical tx soon after birth to connect- monitor for anastomotic leaks, strictures, or recurrent fistula

Question 750

Sx of bronchopulmonary dysplasia?

Answer 750

Persistent hypoxia +/- difficult ventilator weaning- still needing ventilation at 36w postmens age SaO2<88% in air- from barotrauma and oxygen toxicity, surfactant- related= multifactorial IN PREMATURE BABIES CXR= hyperinflation, rounded radiolucent areas alt w/ thin denser lines Prev= steroids antenatal and postnatal, once born= CPAP, caffeine= stimulates resp effort, not over-oxygenating Formal sleep study- oxygen during sleep- discharge from unit on low dose oxygen, follow- up to wean

Question 751

What do babies with CLDP need monthly injections of?

Answer 751

MAB- palivizumab

Question 752

Sx pulmonary hypoplasia?

Answer 752

Persisting neonatal tachypnoea +/- feeding difficulties- esp if prenatal oligohydramnios e.g. Potter's syndrome, prem rupture of membranes/ congenital diaphragmatic hernia Fetal anomaly US, CXR may be normal

Question 753

Sx persistent pulmonary hypertension of the newborn?

Answer 753

From birth asphyxia, meconium aspiration, septicaemia/ RDS Cyanosis soon after birth, murmurs/ signs of HF= often ABSENT Pulmonary oligaemia on CXR ECHO- exclude congenital heart disease Mech ventilation & circulatory support, inhaled NO, sildenafil for some, high freq/ oscill ventilation= sometimes helpful ECMO= where placed on heart and lung bypass for several days for severe but reversible cases

Question 754

What can cause congenital diaphragmatic hernias cause? Sx?

Answer 754

Pulmonary hypertension, pulmonary hypoplasia Prenatal US, postnatal CXR Difficult resus at birth, resp distress, bowel sounds in one hemithorax- usually LEFT, displaced apex beat, scaphoid abdomen Most common= posterolateral Bochdalek hernia- only around 50% survive Ass w/ trisomy 18, chromosome deletions, Pierre Robin syndrome

Question 755

Tx of congenital diaphragmatic hernia?

Answer 755

Refer to tertiary fetal medicine centre for fetal surgery- may cause premature birth Large-bore NG tube when Ix suspected- birth= if prenatal Ix- immediately intubate, ventilate and paralyse with minimal pressures, surgery in an appropriate centre

Question 756

Sx inguinal hernia?

Answer 756

Patent processus vaginalis lateral to pubic tubercle- commoner in males e.g. during crying Most= lap repair prevent incarceration 6/2 rule- <6w- operate within 2 days, <6m== within 2 weeks, <6 years= within 2 months Premature infants and neonates= kept overnight as risk of post-operative apnoea, most= day cases

Question 757

Tx umbilical hernia? Ass?

Answer 757

Resolve by 3 y/o Afro-Caribbean infants, Down's, mucopolysaccharide storage diseases

Question 758

Cause of duodenal atresia? Sx?

Answer 758

Other intestinal atresias, VACTERL association Polyhydramnios, post-natally= distended abdomen and vomiting- billious/ non-billious depending on size of atresia Ix= AXR- double bubble sign Tx= duodenoduodenostomy

Question 759

Incubation period for s.aureus, bacillus cereus? Salmonella & E.coli? Shigella, campylobacter? Giardiasis, amoebiasis?

Answer 759

1-6hours 12-48 hours 48-72 hours >7 days

Question 760

Viral causes gastroenteritis? Parasitic?

Answer 760

Rotavirus- infantile, norovirus- all ages, adeno= resp infections- resp infections in children Cryptosporidium, entamoeba histolytica, giardia intestinalis, schistosoma

Question 761

Location of s.aureus, clostridium perfringens? Tx salmonella and shigella? Campylobacter? Cholera? Giardiasis?

Answer 761

Cooked meats and cream products Reheated meat dishes/ cooked meats Ciprofloxacin/ azithromycin- guided by stool sample & sensitivities Macrolide- erythromycin Tetracycline- reduce transmission e.g. doxy/ lymecycline Metronidazole

Question 762

Sx yersinia?

Answer 762

Raw/ undercooked pork- urine/ faeces of mammal Watery/ bloody diarrhoea--> diarrhoea, abdominal pain, fever and lymphadenopathy Can last>3 weeks Older children/ adults= right-sided abdominal pain due to mesenteric lymphadenitis- imp appendicitis Guided by stool culture and sensitivities

Question 763

Tx gastroenteritis? Post gastroenteritis comps?

Answer 763

Barrier nursing, rigorous infection control, stay off school for 48 hour after sx completely resolved Stool sample= microscopy, culture and sensitivities Fluid challenge- record small volume given orally every 5-10 minutes- can tolerate= manage at home Rehydation= dioralyte/ IV fluids Light diet re-introduce Lactose intolerance, IBS, reactive arthritis, GBS

Question 764

Crows NESTS for Crohn's? CLOSEUP for UC?

Answer 764

No blood/ mucus, entire GI tract, skip lesions on endoscopy, terminal ileum most affected & transmural inflammation- full thickness, smoking= RF- wt loss, strictures and fistulas Cont inflammation, limited to colon & rectum, only superficial mucosa, smoking= protective, excrete blood & mucus, use aminosalicylates, PSC

Question 765

Extra-int and ix of IBD?

Answer 765

Finger clubbing, erythema nodosum, pyoderma gangrenosum, episcleritis & iritis, inflammatory iritis, PSC- UC CRP, FBC, TFTs, U&ES, LFTs, faecal calprotectin, coeliac serology, serum ferritin, vitamin B12, folate, vitamin D levels, OGD & colonoscopy w/ biopsy= GOLD, USS, CT & MRI= imaging- comps, AXR/ CT in acute flare for toxic megacolon and/ or perforation Colonoscopy & barium enema= CI due to risk perforation, acute severe UC flare= flexi sig for biopsy MRI- fistulating perianal disease, if needed EUA may be needed, may need CT imaging in acute setting for obstruction/ perforation

Question 766

Score for classifying Crohn's disease? Tx acute flare Crohn's?

Answer 766

Montreal score- age, location, behaviour, "p" if concurrent perianal disease CS therapy- pred/ hydrocortisone--> azathioprine, mercaptopurine, methotrexate, infliximab/ adalimumab >2 exacerbations in 12 months + anti-embolic stockings, low residue diets, fluid resus, proph heparin First presentation/ single ex in 12 months/ CS not tolerate/ CI--> aminosalicylates- sulfasalazine Possible enteral nutrition Impact on daily life, sources information, encourage stop smoking, assess risk osteoporosis, arrange specialist referrals

Question 767

Tx for maintaining remission in Crohn's disease? When surgery?

Answer 767

Azathioprine/ methotrexate/ infliximab/ adalimumab IBD nurses Colonoscopic surveillance >10 years with >1 segment bowel affected Failed medical tx/ severe complications- strictures/ perforation- bowel-sparing approach prevent short gut syndrome Ileocaecal resection, small bowel resection, surgery for peri-anal disease, stricturoplasty- stricture causing obstruction Active severe flare= primary bowel anastomosis should not be performed

Question 768

Tx for inducing remission in UC? Maintaining remission? Surgery?

Answer 768

Aminosalicylate- mesalazine oral/ rectal/ pred Severe= IV hydrocortisone/ ciclosporin Mesalazine, azathioprine, mercaptopurine Panproctocolectomy--> ileostomy or ileo-anal anastomosis J= pouch Emergency= segmental colectomy or subtotal colectomy w/ stoma formation

Question 769

Comps UC?

Answer 769

Toxic megacolon- decompression needed ASAP, colorectal adenocarcinoma, pouchitis- inflam ileal pouch undergone IPAA- metronidazole and ciprofloxacin

Question 770

Severity of UC what score?

Answer 770

Truelove and Witt criteria- bowel movements, blood in stool, pyrexia, pulse>90bpm, anaemia, ESR Montreal score= disease extent, Mayo score= disease severity

Question 771

RFs for premature delivery?

Answer 771

Previous preterm delivery, multiple pregnancy, smoking and illicit drug use, being under or overweight, early pregnancy, issues with cervix, uterus/ placenta, diabetes, HTN, trauma

Question 772

What is apnoea of prematurity? Causes?

Answer 772

Breathing stops spontaneously for>20 seconds/ shorter periods with oxygen desaturation/ bradycardia Often w/ bradycardia- very common in premature Immaturity of autonomic nervous system controlling respiration and HR Infection, anaemia, airway obstruction, CNS pathology- seizures/ haemorrhage, GI reflux, neonatal abstinence syndrome

Question 773

Tx apnoea of prematurity?

Answer 773

Apnoea monitors, tactile stimulation, IV caffeine, settle as baby develops

Question 774

Who should be screened for ROP by ophthalmologist?

Answer 774

Babies born before 32 weeks/ under 1.5kg Starts at 30-31w GESTATIONAL AGE born before 27 weeks 4-5w babies born after 27 weeks Screening= at least every 2 weeks- cease once retinal vessels--> zone 3 at around 36 weeks

Question 775

Examination and screening for ROP?

Answer 775

Monitoring retinal vessels and looking for plus disease Transpupillary laser photocoagulation halt and reverse neovascularisation Cryotherapy & intravitreal VEGF inhibitors Surgery for retinal detachment

Question 776

Sx foetal alcohol syndrome?

Answer 776

1st 3 months--> miscarriage, small for dates, preterm delivery Microcephaly, thin upper lip, smooth flat philtrum, short palpebral fissure, LD, behavioural, hearing and vision, cerebral palsy

Question 777

Zika spread by what?

Answer 777

Aedes mosquito--> congenital Zika syndrome Microcephaly, FGR, ventriculomegaly and cerebellar atrophy Test w/ viral PCR and antibodies to Zika virus- +ve= refer to fetal medicine monitor

Question 778

Withdrawal from most opiates, diazepam, SSRIs and alcohol occurs when? Methadone and benzos? CNS, vasomotor and resp effects, meta and GI effects?

Answer 778

3-72 hours 24 hours- 21 days Irritability, increased tone, not settling, high pitched cry, not settling, tremors, seizures Yawning, sweating, unstable temp and pyrexia, tachypnoea Poor feeding, regurg & vomiting, hypoglycaemia, loose stools with sore nappy area

Question 779

Neonatal abstinence syndrome chart kept for how long? What collected from neonate? Tx opiate and non-opiate withdrawal? Other considerations?

Answer 779

3 days Morphine sulfate Phenobarbitone- slowly weaned off Testing for hep B, C & HIV Safeguarding & social care, safety netting, follow up, support mother, check suitability for breastfeeding

Question 780

RFs for cot death? Measures reduce risk?

Answer 780

Premature, LBW, smoking during pregnancy, male baby Put on back, keep head uncovered, place feet at foot of bed to prevent sliding down and under blanket, keep cot clear of lots of toys and blankets, maintain comfortable room temp, avoid smoking, co-sleeping- part sofa/ chair

Question 781

What are choledochal cysts?

Answer 781

Cystic dilatations of the extrahepatic biliary system May be detected on antenatal scan, present with neonatal jaundice or in older children w/ abdominal pain, palp mass, jaundice or cholangitis USS/ MRCP Surgical excision of cyst with formation of a Roux-en-Y anastomosis to the biliary duct Comps= cholangitis and 2% risk malignancy

Question 782

Sx neonatal hepatitis syndrome?

Answer 782

Prolonged neonatal jaundice and hepatic inflammation- may have LBW and faltering growth Jaundice may be severe and diff from biliary atresia= essential Liver biopsy= often non-specific- shows giant cell hepatitis

Question 783

Sx Alagille syndrome?

Answer 783

Rare autosomal dominant condition with widely varying penetrance within families Triangular facies, skeletal abnormalities- butterfly vertebrae, congenital heart disease- peripheral pulm stenosis, renal tubular disorders, defects in the eye Severe pruritus and faltering growth Nutrition and fat-soluble vitamins Small number= liver transplant, mortality= due to cardiac disease

Question 784

What does progressive familial intrahepatic cholestasis affect? Sx?

Answer 784

Bile salt transport--> jaundice, intense pruritus, faltering growth, rickets and some diarrhoea and hearing loss, older= gallstones Identify mutations in bile salt transport genes Nutritional support & fat soluble vitamins, pruritus can be severe Most= need liver transplant

Question 785

What is acute liver failure?

Answer 785

Development of massive hepatic necrosis with loss liver function with or without hepatic encephalopathy Infection & metabolic conditions Within hours/ weeks with jaundice, encephalopathy, coagulopathy, hypoglycaemia and electrolyte abnormalities Early signs encephalopathy= alternate periods irritability & confusion w/ drowsiness Older may be aggressive Comps= cerebral oedema, haemorrhage from gastritis/ coagulopathy, sepsis and pancreatitis

Question 786

Causes of acute liver failure in children <2 y/o? >2 y/o?

Answer 786

Infection, metabolic disease, seronegative hepatitis, drug induced, neonatal haemochromatosis Seronegative hepatitis, paracetamol overdose, mitochondrial disease, Wilson disease, AI hepatitis

Question 787

Ix and tx acute liver failure in children? EEG & CT findings?

Answer 787

Bilirubin may be normal in early stages- part with metabolic disease Transaminases are greatly increased, ALP is increased, coagulation is very abnormal and plasma ammonia= elevated- monitor acid-base balance, blood glucose and coagulation times Hepatic encephalopathy & cerebral oedema Early referral to national paediatric liver centre

Question 788

Steps to stabilise child before transfer for liver transplant?

Answer 788

Maintain blood glucose>4mmol/L with IV dextrose Broad-spec ABx & antifungal agents prevent sepsis IV vitamin K and H2-blocking drugs or PPIs- prevents haemorrhage from GI tract Fluid restriction and mannitol diuresis if oedema develops

Question 789

Features poor prognosis in liver failure?

Answer 789

Shrinking liver, rising bilirubin w/ falling transaminases a worsening coagulopathy/ progression--> coma Without- 70%--> coma will die

Question 790

What is chignon? When does erythema toxicum neonaturum appear?

Answer 790

Temporary swelling on head seen in newborn infants delivered with Ventouse Day 2-3= white pinpoint papules filled with eosinophils- last 24 hours- MORE COMMON IN FULL TERM BABIES, settles spontaneously

Question 791

When do strawberry naevi grow until?

Answer 791

6-9 months, then regress spontaneously especially in premature babies Can be ass with LBW, prematurity, multiple gestation and CVS sampling Topical propanolol can speed regression MORE THAN 5= USS of the liver

Question 792

Where are Mongolian blue spots seen? Capillary haemangioma/ stork bite/ salmon patch?

Answer 792

Base of the back and on the buttocks- common in dark-skinned parents, can occur in white infants Normally disappear over first year Around eyes, nape of neck- eyes normally disappear in first year and commonly persist if on nape of neck

Question 793

Day of Guthrie heel-prick test?

Answer 793

5 PKU Congenital hypothyroidism-<32w need repeat test at 28 postnatal age SCD CF- immunoreactive trypsinogen MCADD- prevents normal breakdown of fat Homocystinuria MSUD- AR disease mutation in at least 4 genes--> encephalopathy GA1--> movement disorder- dystonia IVA- massive metabolic acidosis rapid death, chronic= ketoacidosis and asymptomatic periods

Question 794

Sx psoriasis in children? Tx?

Answer 794

Guttate= more common often triggered by a throat infection- plaques= likely to be smaller, softer and less prominent Topical steroids, topical vitamin D analogues, topical dithranol Topical calcineurin inhibitors- tacrolimus only in ADULT Phototherapy w/ UVB in extensive Fails--> methotrexate, ciclosporin, retinoids/ biologics Steroid + vit D= Dovobet, Enstilar

Question 795

Cause of molluscum contagiosum?

Answer 795

Poxvirus- small flesh coloured papules w/ central dimple in crops in local area spread through direct contact/ sharing towels/ bedsheets- COMMON IN PRESCHOOL CHILDREN Resolve without tx- up to 18 months Avoid scratching/ picking lesions Topical fusidic acid/ oral flucloxacillin if bacterial superinfection Immunocompromised/ extensive/ problematic areas= specialist- topical K+ hydroxide, benzoyl peroxide, podophyllotoxin, imiquimod or isotretinoin Surgical removal & cryotherapy- leads to scarring

Question 796

Causes of erythema multiforme?

Answer 796

Hypersensitivity- viral infections and medications- HSV, mycoplasma, drugs- penicillins, sulphonamides, carbamazepine, allopurinol, NSAIDs, COCP, nevirapine, SLE, sarcoidosis, malignancy Widespread, itchy, erythematous, target lesions initially back hands/ feet--> torso, upper> lower limbs- can cause stomatitis, fever, muscle & joint aches, headaches, flu-like symptoms Identify cause e.g. CXR- mild usually resolves within one-4 weeks without treatment- may be recurrent May need admission affecting oral mucosa- IV fluids, analgesia, steroids, ABx/ antivirals where infection present

Question 797

Most common type of tinea corporis? Sx?

Answer 797

Trichophyton/ microsporum/ epidermophyton species- spread through infected individuals, animals or soil Erythematous scaly plaques with active, advancing often pruritic border Centre may clear up as it expands--> ring-like

Question 798

Ix and tx tinea corporis?

Answer 798

Clinical, uncertain= KOH preparation of skin scrapings confirm fungal elements under microscopy Cultures for cause Some= Wood's lamp examination- microsporum= fluoresce Topical clotrimazole/ terbinafine to lesion and margin around for at least 2 weeks/ until week after resolution Extensive= systemic= oral terbinafine, itraconazole, fluconazole

Question 799

Fungal nail infections tx? Simple advice for tinea corporis?

Answer 799

Amorolfine nail lacquer for 6-12 months- resistant= oral terbinafine- need LFTs monitored before and while Loose breathable clothing, keep clean & dry, avoid sharing, use separate towel for feet with tinea pedis, avoid scratching and spreading to other areas, wear clean dry socks every day

Question 800

What is tinea incognito?

Answer 800

More extensive and less well recognised fungal skin infection from steroid use to treat initial fungal infection Initial= dermatitis and topical steroid prescribed Less well demarcated border and fewer scales

Question 801

Who does tinea capitis affect in children? Ix? Tx?

Answer 801

6m- 10-12 years- trichophyton, microsporum Scaling & hair loss, inflammation in erythema and pustule formation can occur, 'black dot' might occur Scalp scrapings--> direct microscopy and culture/ sterile brushes Moistened dressings, do not share towels, inspect other children & household contacts Oral antifungal agent- attend school as normal- griseofulvin / oral terbinafine empirically until culture results available

Question 802

Tx tinea capitis in urban area?

Answer 802

Terbinafine for 4 weeks, rural= griseofulvin for 4-8 weeks Tricho= continue--> switch to terbinafine Microsporum= continue/ switch to griseofulvin Griseo not tolerated= consider itraconazole Consider additional topical agent- selenium sulfide/ ketoconazole shampoo twice weekly 2-4 weeks/ imidazole cream daily for one week

Question 803

Persistent tinea capitis tx?

Answer 803

Tx for another month Carriers= topical preparation

Question 804

Cause of scabies?

Answer 804

Sarcoptes scabiei- up to 8 weeks for sx to appear Severe itching 2-6 weeks after infestation= worse in warm conditions and at night Older= burrows, papules and vesicles skin between fingers & toes, axillae, flexors of wrists, belt line and around nipples, penis, and buttocks Young= palms, soles and trunk Clinical Ix/ microscopic examination of skin scrapings from lesions= mite, eggs and faeces

Question 805

Tx and comps of scabies?

Answer 805

Permethrin cream to whole body when skin is cool- left on for 8-12 hours & wash off- repeat week later- difficult to treat/ crusted= oral ivermectin Tx household contacts in same way, wash everything on hot wash Itching can be up to 4 weeks- crotamiton cream and chlorphenamine at night

Question 806

Crusted scabies also known as what?

Answer 806

Norweigan scabies- serious in immuncompromised- patches red skin--> scaly plaques- extremely contagious Misdiagnosed as psoriasis Immuncompromised may not have itch as they don't mount immune response- need admission for tx as inpatient with oral ivermectin and isolation

Question 807

Causes of erythema nodosum? Ix?

Answer 807

HS reaction--> SC layer, No cause- idiopathic, drugs- sulfonamides & dapsone, OCP, sarcoidosis, UC & Crohn's, microorganisms- TB, strep, toxoplasmosis

Question 808

Sx, Ix and tx for erythema nodosum?

Answer 808

Flu-like symptoms, painful nodules on legs last for about 2 weeks, new nodules can last up to 6 weeks- hot & firm--> squashy Clinical Ix/ biopsy- bloods, CXR, strep test, TB Ix, for sarcoidosis, stool sample, bowel Ix NSAIDs, bed rest and legs raised, stockings, cool wet compresses, K iodide, steroids might help inflammation- most resolve within 6 weeks

Question 809

Sx pityriasis rosea? Tx?

Answer 809

Headache, loss of appetite, flu-like sx- herald patch faint red or pink, scaly, oval 2cm or more 2/ more days prior to rest of rash- usually on TORSO Can be arranged in Xmas tree fashion Resolves without tx within 3 months- can leave discolouration- resolve within another few months- continue normal activities, patient education Emollients, topical steroids, sedating antihistamines at night for symptoms

Question 810

Cause of granuloma annulare?

Answer 810

Delayed HS reaction to component of dermis/ numerous triggers, also systemic conditions Any site of body, occasionally widespread, tender when knocked Localised= most common in children- one/ more skin coloured/ red bumps form rings in skin over joints particularly the knuckles, surface smooth and centre= often little depressed, also top foot/ ankle and over one or both elbows SC= rare- mistaken for rheumatoid nodules

Question 811

Ix and tx of granuloma annulare?

Answer 811

Clinically, sometimes= biopsy- necrobiotic degeneration of dermal collagen surrounded by inflam reaction Resolve in few months- sometimes years Consider topical CS ointment under occlusion, steroid injections, cryotherapy/ laser ablation, imiquimod cream topical calcineurin inhibitors Widespread= systemic therapy Can recur even at same sitea

Question 812

Ass w/ alopecia areata? Sx? Ix & tx?

Answer 812

Down's, AI conditions e.g. vitiligo, thyroid disease, family hx- x16 genetic risk loci Exclamation point hairs in 10-40%- pitting & ridging most common Trichoscopy, hair pull test>10% hairs pulled out easily, skin biopsy- bee-swarm pattern Topical/ intralesional corticosteroids- triamcinolone 4-6 weekly, topical minoxidil, phototherapy, dithranol, contact immunotherapy- extensive, systemic corticosteroids for refractory/ severe cases, baricitinib, , support groups, wigs

Question 813

Parasite for headlice? Sx & tx?

Answer 813

Pediculus humanus capitis- spread by close contact Itchy scalp Dimeticone 4% lotion/ wet combing, isopropyl myristate/ cyclomethicone if living lice found - left on for 8 hours then washed off repeated 7 days later Fine combs of wet/ dry hair, detection combing, Bug Buster kit NO EXCLUSION/ TX contacts only if affected

Question 814

What is allergic rhinitis?

Answer 814

A type 1 HS IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitised to allergens--> sneezing, nasal itching, rhinorrhoea and congestion

Question 815

Classification of allergic rhinitis?

Answer 815

Seasonal- same time each year from grass and tree pollen allergens Perennial= throughout the year due to allergens from house dust mites and animal dander Intermittent= <4 days/ week/ <4 consecutive weeks Persistent=> 4 days a week AND >4 consecutive weeks Occupational

Question 816

Ix and tx of allergic rhinitis?

Answer 816

Type, frequency, timing, persistence and location symptoms, severity and impact of sx Housing conditions, pets, occupation Drugs- that may cause aggravate or alleviate sx, family history of atopy, examine for rhinitis and/ or associated conditions Skin prick testing might be useful for pollen, animals and house dust mite allergy Information & support, saline nasal irrigation, avoidance techniques Mild, intermittent or both sx- intranasal antihistamine/ non-sedating oral antihistamine- cetirizine/ loratadine, fexofenadine Moderate- severe persistent sx/ initial ineffective= regular intranasal corticosteroids e.g. fluticasone and mometasone Review after 2-4 weeks if symptoms persist Possible IN decongestant- not prolonged due to hypertrophy nasal mucosa= rhinitis medicamentosa, anticholinergic/ LTRA Oral CS short course, affecting QOL

Question 817

Referral to allergy/ ENT specialist for who w/ allergic rhinitis?

Answer 817

Red flags for alternative, persistent despite optimal tx, avoidance techniques being considered- allergy testing may be needed Would like to consider immunotherapy treatment instead of long-term tx

Question 818

Once anaphylaxis diagnosed, 3x medications?

Answer 818

IM adrenaline repeated after 5 minutes if required Antihistamines e.g. oral chlorphenamine(sedating,)/ cetirizine(non-sedating) Steroids- IV hydrocortisone

Question 819

After anaphylaxis event tx?

Answer 819

Period of assessment and observation due to biphasic reactions Serum mast cell tryptase within 6 hours event Education and follow-up, trained in BLS- training in adrenalin auto-injector

Question 820

Indications for adrenalin auto-injector?

Answer 820

Epipen, Jext and Emerade- all with an reactions, considered in children with generalised allergic reactions w/: asthma needing inhaled steroids, poor access to medical tx, adolescents at higher risk, nut/ insect sting allergies, co-morbidities e.g. CVD Epipen in mid-thigh for 3 seconds, Jext= 10 seconds before removing device- gently massage for 10 seconds Phone emergency ambulance- 2nd dose may be given after 5 minutes if needed

Question 821

What is urticaria and angio-oedema?

Answer 821

Superficial swelling of epidermis and mucous membranes--> red, raised, itchy rash Deeper form swelling in dermis and submucosal/ SC tissues

Question 822

Classification of urticaria? Tx?

Answer 822

Acute<6 weeks Chronic>6weeks on nearly daily basis Chronic spontaneous- no identifiable cause Autoimmune- presence IgG autoantibodies to IgE e.g. SLE Chronic inducible- result to physical stimulus--> aquagenic, cholinergic, solar, cold heat, dermatographism, delayed pressure, vibratory and contact urticaria Non-sedating antihistamine daily for up to 6 weeks- fexofenadine, severe= 7d course oral corticosteroid Sx improve= AH tx daily for 3-6 months/ as required Inadequate response= increasing dose to x4 times licensed dose, alt non-sedating AH, +calamine lotion, sedating antihistamine@night, refer--> dermatologist or immunologist for LTRA, omalizumab, ciclosporin

Question 823

Refer to dermatologist/ immunologist for who w/ urticaria?

Answer 823

Vasculitic urticaria, food/ latex allergy, form of CINDU difficult to manage e.g. solar/ cold Poss referral to clinical psychologist

Question 824

Clinical signs of dehydration in children?

Answer 824

appears unwell/deteriorating, altered responsiveness, sunken eyes, tachycardia, tachypnoea, reduced skin turgor, dry mucous membranes, decreased urine output

Question 825

Signs of clinical shock?

Answer 825

Decreased LOC, pale/ mottled skin, cold extremities, pronounced tachycardia, pronounced tachypnoea, weak peripheral pulses, prolonged CRT, hypotension HYPOTENSION= SIGN OF DECOMPENSATED SHOCK

Question 826

Fluid of choice in Paeds for maintenance fluids? In shock?

Answer 826

NaCl 0.9% + Dextrose 5% + KCl 10mmol (Neonates= 10% +/- dextrose) NaCl 0.9% at 20ml/kg- 10ml/kg <10 minutes in DKA, trauma, primary cardiac pathology e.g. HF Above 3 boluses--> call Paeds ICU support in case child--> pulmonary oedema

Question 827

Fluid in replacement Paeds? U&Es and plasma glucose monitored at least every what?

Answer 827

0.9% NaCl + 5% glucose Losses e.g. diarrhoea, vomiting= w/ potassium e.g. 10mmol/L Every 24 hours

Question 828

Calculating % dehdyration by weight equation? Clinical assessment?

Answer 828

Well weight- current weight/ well weight x 100 No red flags= 5% dehydrated Shocked/ red flags= 10% dehydrated- tx with fluid bolus before replacement fluids

Question 829

How is fluid deficit calculated?

Answer 829

Fluid deficit= % dehydration x weight (kg) x 10 Total= maintenance fluids + fluid deficit

Question 830

What is given for fluid given in shock?

Answer 830

0.9% NaCl no additives IV of 10ml/ kg over<10 minutes, smaller- neoantes, DKA, septic shock, trauma, cardiac pathology After admin= volume status re-assessed- HR, RR, CRT- still shocked= urgent senior advice should be sought- contact Paeds ICU

Question 831

Fluid used in hyponatramia? Signs of dehydration in hypernatraemia, switch to what?

Answer 831

2.7% sodium NaCl- hypertonic boluses 0.45% NaCl- CORRECT SLOWLY OVER 48 HOURS FOR HYPOVOLAEMIC HYPERNATRAEMIA NO MORE THAN 12MMOL/L RISE/ FALL IN SERUM SODIUM OVER 24 HOUR PERIOD--> central pontine myelinolysis and cerebral oedema

Question 832

Primitive reflexes persist until when usually?

Answer 832

4-6m- past= sign of CNS dysfunction Moro Grasp/ palmar reflex Sucking Rooting Stepping Asymmetrical tonic neck reflex --> POSTURAL: Labyrinthine righting Postural support Lateral propping Parachute

Question 833

What is common following an inferior MI? What is common in the 48 hours following an transmural MI? When does left ventricular free wall rupture occur? What occurs in 1st week? What is acute mitral regurgitation more common?

Answer 833

AV block Pericarditis 1-2 weeks after- acute HF secondary to cardiac tamponade Ventricular septal defect- acute HF w/ pansystolic murmur- ECHO exclude mitral regurgitation- urgent surgical correction Infero-posterior infarction due to ischaemia/ rupture of papillary muscle- acute hypotension and pulm oedema may occur- early to mid systolic murmur- vasodilator, often require emergency surgical repair

Question 834

Red flags for developmental milestones?

Answer 834

Lost developmental milestones, not able to hold an object at 5m Not sitting unsupported at 12m Not standing independently by 18m Not walking independently at 2y Not running at 2.5y No words/ interest in others at 18m

Question 835

Who gets parvovirus B19 and months? Incubation and sx?

Answer 835

3-15 y/o- April & May= peak 7-10 days Infectious 4-20 days before rash- once rash= not infectious Mild fever, coryza and non-specific viral sx e.g. myalgia & lethargy- after 2-5 days= rash rapidly as diffuse bright red rash on both cheeks Few days later= reticular mildly reticular erythematous rash affecting trunk and limbs appears can be raised and itchy Rash fades over 1-2 weeks

Question 836

Ix and tx slapped cheek syndrome? At risk require what? Comps?

Answer 836

Sx relief, avoid increased risk comps- immunocompromised/ haem disorders/ pregnant women Serology testing- high titre viral DNA for parvovirus to confirm Ix and checking of FBC and reticulocyte count for aplastic anaemia Aplastic anaemia, encephalitis/ meningitis, pregnancy comps including hydrops foetalis, mirror syndrome- ass w/ severe pre-eclampsia, fetal death, rarely= hepatitis, myocarditis or nephritis

Question 837

How is mumps spread? Incubation period? Sx?

Answer 837

Respiratory droplets of Paramyxovirus 14-25 days- 7 days before and 9 days after parotid swelling starts prodromal flu sx few days before parotid swelling- uni/ bilateral, trismus fever- 3-4 days, muscle aches, reduced appetite, headache, dry mouth, abdominal pain, testicular pain & swelling-within week, confusion, neck stiffness & headache, pancreatitis, sensorineural hearing loss

Question 838

Tx mumps?

Answer 838

Rest, paracetamol for high fever/ discomfort, notifiable disease, stay off school/ work for 5 days for initial development Admit for meningitis, encephalitis, epididymo-orchitis

Question 839

Cause of SSSS? Sx, Ix and tx?

Answer 839

S.aureus--> TSST-1 superantigen toxin- splits stratum granulosum <5 y/o affected Generalised patches erythema--> bullae--> burst--> scalding, hypotension systolic<90mmHg, desquam of rash especially palms and soles Involve 3/more organ systems= D&V, mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, confusion Nikolsky positive, ORAL MUCOSA UNAFFECTED Skin biopsy can diff from TEN, blood cultures Systemic sx- can lead to sepsis Admission- IV flucloxacillin

Question 840

Cause of toxic shock syndrome? Sx?

Answer 840

Sever systemic reaction--> staph exotoxin--> T cell activation- IL-1 and TNF-alpha, group A strep, MRSA- tampons, breaks in skin, nasal packing Non-specific flu-like sx--> high fever and eruption widespread macular rash becomes erythrodermic with >90% body surface involved including mucosal membranes Multi-organ= hypotension, confusion- encephalopathy

Question 841

Ix and tx of toxic shock syndrome?

Answer 841

Sepsis 6, throat swabs, wound swabs DRABCDE, central venous pressure monitoring for shock Clindamycin + cephalosporin/ meropenem/ vancomycin for broad spectrum + IV IG Debridement, drainage/ amputation, corticosteroids

Question 842

Cause and sx diphtheria infection? Ix & tx?

Answer 842

Corynbacterium diphtheriae Necrosis of myocardial, neural and renal tissue Sore throat- grey pseudomembrane on posterior pharyngeal wall Bulky cervical lymphadenopathy--> bull neck membrane Neuritis Heart block Throat swab uses tellurite agar or Loeffler's media IM penicillin, diphtheria antitoxin

Question 843

How is polio spread and in who? Incubation? Sx? Ix? Tx?

Answer 843

Stools/ droplets 3-21 days, infectious 1 day before and up to 2 weeks after paralytic polio Most no sx, 2-5 days of fever, tiredness, headache, sore throat, stomach pain, N/vomiting, neck stiffness, pain in arms and legs Sx relief, physio, ventilators, meds for muscle spasms, mobility Can lead to meningitis and paralysis 2x types vaccine

Question 844

Types of immunodeficiency?

Answer 844

Primary- genetically determined- X-linked/ autosomal recessive, may be family hx of parental consanguinity & unexplained death especially in boys Secondary- another disease/ tx Suspect in Severe Prolonged Unusual / Recurrent Infections

Question 845

E.g. of T cell defects in immunodeficiency?

Answer 845

SCID HIV infection Wiskott-Aldrich syndrome Di George syndrome Duncan disease Ataxia telangiectasia PNP deficiency

Question 846

E.g. of B-cell disorders? Neutrophil disorders? Leucocyte function defects? Complement defects?

Answer 846

Common variable immunodeficiency Hyper IgM syndrome Selective IgA deficiency Chronic granulomatous disease Leucocyte adhesion deficiency- LAD Early complement component deficiency Terminal complement component deficiency Mannose-binding lectin MBL deficiency

Question 847

Cause of SCID? Sx?

Answer 847

>50% = common gamma chain mutation on X chromosome for interleukin receptors on T & B cells= X-linked recessive JAC3 gene mutations, adenosine deaminase deficiency Persistent severe diarrhoea, FTT, opportunistic infections more frequent & severe, pneumocystis jiroveci pneumonia and CMV, unwell after live vaccinations, Omenn syndrome

Question 848

Mutation for Omenn syndrome (rare cause SCID)?

Answer 848

RAG 1/ 2 proteins in T & B cells= autosomal recessive Erythroderma, alopecia, diarrhoea, FTT, lymphadenopathy, hepatosplenomegaly IG therapy, sterile environment, avoiding live vaccines, haematopoietic stem cell transplantation

Question 849

Cause and sx of Wiskott-Aldrich syndrome?

Answer 849

WASP gene= X-linked recessive Eczema, thrombocytopenia, neutropenia, recurrent infections, chronic bloody diarrhoea Low IGM levels Increased risk AI disorders and malignancy

Question 850

Cause of Di George syndrome? Sx?

Answer 850

Abnormal dev 3 & 4th branchial cleft- deletion section chromosome 22; 22q11-->incomplete thymus gland--> CATCH-22: Congenital HD, abnormal facies, thymus gland, cleft palate, hypoparathyroidism & resulting hypocalcaemia, 22nd chromosome affected

Question 851

What is Duncan disease/ X-linked lymphoproliferative disorder? Sx, tx?

Answer 851

Xq25- EBV infection Fatal infectious mononucleosis--> acquired hypogammaglobulinaemia, red cell aplasia/ lymphomatoid granulomatosis Pharyngitis, hepatosplenomegaly, liver failure, lymphocytosis, thrombocytopenia/ BM failure, hepatic encephalopathy BM transplant, genetic testinf EBV-- hepatic necrosis/ BM failure

Question 852

Cause of ataxia telangiectasia? Sx?

Answer 852

AR condition affecting ATM serine/ threonine kinase protein on Ch 11 for DNA coding Low T-cell and Igs, ataxia, telangiectasia, predisp to cancers, slow growth and delayed puberty, accelerate ageing, liver failure

Question 853

Type of condition PNP deficiency?

Answer 853

AR PNPase breaks down purines--> dGTP builds up

Question 854

Cause of Bruton's agammaglobulinaemia? Sx? Tx?

Answer 854

X-linked tyrosine kinase--> lack B cell development Recurrent bacterial infections, absence B cells with reduced Iggs IV immunoglobulin, high dosage ABx therapy, inhaled bronchodilators and steroids usually needed Nasal steroids for sinusitis in older Tx eczema Can cause bronchiectasis

Question 855

What is common variable immunodeficiency caused by? Sx?

Answer 855

Many causes- low IgG, IgM and IgA Recurrent chest infections & chronic lung disease over time Prone to RA, Hodgkin's lymphoma Ig infusions Later onset than Bruton's

Question 856

What is hyper IgM syndrome?

Answer 856

B cells produce IgM but prevented switching to IgG and IgA Pneumocystis pneumonia, hepatitis, diarrhoea

Question 857

Most common primary immune defect? Sx?

Answer 857

Selective IgA deficiency Recurrent sinus and resp infections Ass w/ coeliac disease Severe reactions to blood transfusions OFTEN ASYMPTOMATIC

Question 858

Cause of Leucocyte adhesion deficiency? sx?

Answer 858

Def of neutrophil surface adhesion molecules CD18, CD11B- inability neutrophils migrate to sites of infection/ inflammation Delay in umbilical cord sloughing, absence of neutrophils/ pus at sites of infection

Question 859

Complement used for dealing with what? Examples?

Answer 859

HIB, S.pneumoniae, n.meningitidis Early complement component deficiency Terminal complement component deficiency Mannose-binding lectin MBL deficiency

Question 860

Sx of complement deficiency? Tx hereditary angiodema?

Answer 860

Recurrent bacterial infections, SLE-like illness, recurrent meningococcal, pneumococcal and HIB infections C1 esterase inhibitor before dental/ surgical procedures

Question 861

Ix for T cell def? B cells? Combined? Neutrophil? Complement?

Answer 861

FBC, lymphocytes, Immunoglobulins, IgG subclasses in children>2 years, antibody responses, lymph subsets Ix above, genetics for SCID FBC, NBT test, CD11b/ CD18 for LAD, neutrophil mobility - chemotaxis CH50, AP50, complement proteins, MBL levels

Question 862

Causes of global developmental delay? Gross motor delay(isolated= CK test)? Fine motor delay? Language? Social & personal?

Answer 862

Down's- hypotonia, Fragile X, fetal alcohol, Rett syndrome, metabolic disorders- first 2 years of life CP- hypertonia, ataxia, myopathy, spina bifida, visual impairment- 3m- 2 y/o Dyspraxia- handwriting, dressing, cutting up food, poorly est laterality, copying and drawing, messy eating, saliva dribbling, CP, muscular dystrophy- 4-6 y/o, visual impairment, congenital ataxia- rare Specific social circumstances, hearing impairment, global delay, learning disability, neglect, autism, cerebral palsy- refer to S&L, audiology and health visitor, neglect concern= safeguarding- Symbolic Toy and Reynell test Autism, emotional and social neglect, parenting issues- 2-4 y/o

Question 863

1st-line Ix for global developmental delay?

Answer 863

FBC & haematinics- iron def & folate/ B12 deficiency U&e- renal failure and hyponatraemia CK- duchenne muscular dystrophy TFTs- Congenital hypothyroidism LFTs- Metabolic disorders Vitamin D- motor delay Hearing test- isolated speech and language delay 2nd line= karyotyping/ DNA analysis, more detailed metabolic screens, MRI and EEG

Question 864

Tx dev delay?

Answer 864

Comm Paediatrician= detailed dev assessment & holistic assessment e.g. Griffiths scales of child development/ schedule growing skills MDT- S&L, OT, portage practitioners and orthoptists

Question 865

Sx ADHD? Ix & tx?

Answer 865

Hyperactivity, inattention and or/ impulsivity since childhood Short attention span, quickly moving from one activity to another, quickly losing interest, constantly moving/ fidgeting, impulsive behaviour, disruptive/ rule breaking Healthy diet and exercise- food dirary Conser tx failed/ severe= medications- methylphenidate- 6w trial basis--> GI upset, dexamfetamine, atomoxetine PERFORM BASELINE ECG

Question 866

Necessary for ADHD ix?

Answer 866

3-7y/o- may not be recognised until after 7 y/o- esp if hyperactivity not present Sx for at least 6 months At least 2 settings Other causes excluded Before 12 y/o Parent education/ support programmes & watchful waiting for up to 10 weeks, group CBT, individual psych tx, drug tx only above 5 y/o

Question 867

Monitor what every 3m in children older than 10 y/o in ADHD? Specialist advice when?

Answer 867

Weight- 3 & 6 months after tx has started Height every 6 months BP & HR before and after each dose change & every 6 months >120bpm, arrhythmia, sys BP>95th percentile on x2 occasions/ other adverse effects

Question 868

When are autistic features usually observable? Sx?

Answer 868

Before 3 y/o Social: lack eye contact, avoids physical contact, delay in smiling, unable to read non-verbal cues, difficulty establishing friendships, not displaying desire to share attention Communication: delay/ absence/ regression in language development, lack app non-verbal comm, diff w/ imaginative/ imitative behaviour, repetitive use of words/ phrases Behaviour= greater interest in objects/ numbers/ patterns than people, repetitive movements- may be self-stimulating like hand-flapping/ rocking, intensive and deep interests persistent and rigid, fixed routines, anxiety outside this, restricted food preferences

Question 869

Tx autism?

Answer 869

CAMHS, S&L, dietician, Paediatrician, social workers, special school environments, charitis

Question 870

What forms largest group of eating disorders? Also?

Answer 870

Atypical eating disorders- sx for eating disorder, not specific diagnostic criteria- over-concern with body weight and shape- many have had anorexia or bulimia previously Anorexia nervosa, bulimia nervosa, binge eating disorder

Question 871

Sx anorexia nervosa?

Answer 871

BMI<18.5/ <5th percentile on growth chart, intense fear gaining weight, behaviour interfering with weight gain, psych disturbance, denial seriousness of malnutrition- may be secrecy, hormonal disturbance, physical signs Hypokalaemia, raised cortisol & GH, hypotension, hypothermia, bradycardia, arrhythmias, cardiac atrophy, sudden cardiac death

Question 872

Sx bulimia nervosa?

Answer 872

Recurrent episodes binge eating at least once a week for 3 months Recurrent inappropriate comp behaviour to prevent weight gain at 1/week for 3m- vomiting, purging, fasting, excessive exercise, laxative, diuretic/ diet pill use, weight often within normal limits/ above weight range for age, psych sx, physical- Russell's sign(knuckles,) alkalosis, hypokalaemia, swollen salivary glands, mouth ulcers, erosion teeth

Question 873

Sx binge eating disorder?

Answer 873

Planned binge involving binge foods- excessive amount food in discreet time followed by feeling loss control cannot stop eating/ control amount food eat, may eat more rapidly/ until uncomfortably full BW may be normal, overweight/ obese

Question 874

Ix and tx eating disorders?

Answer 874

SCOFF questionnaire- two or more positive answers 'Do you ever make yourself sick because you feel uncomfortably full?' 'Do you worry that you have lost control over how much you eat?' 'Have you recently lost more than one stone in a 3-month period?' 'Do you believe yourself to be fat when others say you are too thin?' 'Would you say that food dominates your life?' Score of 2/ less on Sit up- Squat-Stand test(SUSS) Consider FBC, ESR, U&Es, LFTs, blood glucose, creatinine, urinalysis, ECG Ca2+, Mg2+, phosphate, B12, folate, ferritin, TFTs, FSH, LH, oestradiol, prolactin, urinalysis, pregnancy test, coeliac screening

Question 875

Tx eating disorders? Admit who?

Answer 875

Refer to CMHT/ CAMHS, Paeds referral, arrange regular review, poss comps, vomiting- dental and medical review regular, gradually reduce and stop laxatives, contraception advice, bone scanning possibly Wt loss>1kg/ week, bradycardia 40 bpm/ less, CV instability, hypothermia, reduced muscle power on SUSS, concurrent infection, overall ill health/ rapid deterioration, abnormal blood tests- electrolytes/ hypoglycaemia, risk refeeding syndrome, acute mental health risk, lack home support

Question 876

Risk of refeeding syndrome increased by what? Sx & tx?

Answer 876

Rapid weight loss, fasting for over 5 days, BMI<16, comp behaviours, dehydrations, use diet pills/ diuretics, water loading or excessive exercise Hypomagnesaemia, hypokalaemia, hypophosphataemia, hyperglycaemia, risk of arrhythmias, HF & fluid overload Slowly reintroduce food w/ restricted calories Mg2+, K+, phosphate and glucose monitoring, fluid balance monitoring, ECG monitoring in severe, vit B and thiamine supplementation

Question 877

Specialist tx for anorexia?

Answer 877

CBT-ED 40 sessions over 40 weeks twice-weekly in first 2/ 3 weeks MANTRA SSCM- specialist supportive clinical management--> psychodynamic therapy if effective FT-AN in children--> CBT-ED/ adolescent focussed psychotherapy(AFP-AN)

Question 878

Specialist tx for bulimia? Binge-eating?

Answer 878

Self-help programmes--> after 4 weeks= CBT-ED Children= FT-BN--> CBT-ED Self-help--> group CBT-ED after 4 weeks/ individual CBT-ED

Question 879

Sx of Tourette's syndrome? Sx and complex tics? Tx?

Answer 879

Tics for over a year- involuntary movements or sounds- overwhelming urge= premonitory sensations Often around/ after 5 y/o- ass w/ OCD & ADHD Clearing throat, blinking, head jerking, sniffing, grunting, eye rolling Twirling on spot/ touching objects, copropraxia= obscene gestures, coprolalia= obscene words, echolalia= repeating other people's words Mild= reassurance and monitoring, reduce stresses, severe= habit reversal training, exposure with response prevention, medications= antipsychotics

Question 880

Types atrial septal defect from most--> least common? Comps?

Answer 880

Ostium secundum- septum secundum fails to close- Treacher-Collins syndrome, TAR syndrome Patient foramen ovale Ostium primum--> complete/ partial AVSD, present earlier than secundum Stroke, AF/ atrial flutter, pulm HTN & right-sided HF, Eisenmenger syndrome(R-->L shunt)

Question 881

Sx ASD? DDx and tx?

Answer 881

Often asymptomatic- incidental finding of ejection systolic murmur on auscultation 2nd ICS, split S2 May--> HF- SOB, fatigue, oedema, rapid HR in adulthood Migraine w/ aura ass w/ PFO VSD/ PDA/ pulmonary stenosis Transthoracic echocardiogram, ECG= RBBB with RAD/ primum= RBBB w/ LAD & prolonged PR interval Most cons tx- most close within 12m birth, surgical may be needed for larger defects/ sx- transvenous catheter closure via femoral vein/ open heart surgery, anticoagulants, routine echocardiograms every 2-3y Comps= HF, paradoxical embolisms- clot from right side--> left, arrhythmias, cyanosis, peripheral oedema, TIA/ stroke

Question 882

Most common and RF for VSDs? Sx and examination?

Answer 882

Maternal DM, rubella, foetal alcohol syndrome, uncontrolled maternal PKU, family hx VSD, Down's, trisomy 18, trisomy 13, Holt-Oram syndrome Asymptomatic until later- poor feeding, dyspnoea, tachypnoea, FTT, sx HF Pansystolic murmur lower sternal border in 3rd and 4th IC spaces- systolic thrill, tachypnoea- 1st sign left-sided HF, can lead to cyanosis & haemoptysis, Eisenmenger's syndrome

Question 883

Ix, DDx and tx VSD?

Answer 883

ECG- LVG, P pulmonale/ BVH, septic screen, U&E before starting meds, microarray for genetics Transthoracic echo, CXR= cardiomegaly, cardiac CT angiography, cardiac catheterisation Mitral regurg, tricuspid regurg- Carvalho's sign increase in intensity with inspiration ASD, PDA, pulmonary stenosis, TOF

Question 884

Medical and surgical tx VSD? Comps?

Answer 884

Adequate weight gain, diuretics, ACE-i, digoxin, dentral hygiene for IE Surgical repair- open heart via median sternotomy, catheter procedure less common, hybrid approach Pulm artery banding palliative surgery CHF, growth failure, aortic valve regurg, pulm HTN- CI in pregnancy, frequent chest infections, IE, arrhythmias, most spont close by 10 y/o

Question 885

Strong ass w/ AVSD?

Answer 885

Down's syndrome, complete= in Heterotaxy syndromes Failure closure superior and inferior endocardial cushions--> single common AV valve L--> R shunt, HF sx, increased distance between aorta and apex of heart, aortic valve= displaced anterosuperior

Question 886

Sx of AVSD?

Answer 886

Tachycardia, tachypnoea, poor feeding, sweating, FTT All w/ complete AVSD= sx by year one, systolic heave & ejection systolic murmur along left sternal border, accentuated S1 in complete/ wide split S2 in partial AVSD, partial= wide and fixed splitting of S2, apical thrill, ES murmur left upper sternal border/ mid-diastolic murmur along left lower sternal border, pansystolic left lower sternal border Complete= not usually associated with separate murmur

Question 887

Ix, ddx and tx of AVSD?

Answer 887

ECG= superior QRS axis between -40- 150 degrees, prolonged PR interval, RVH CXR= cardiomegaly Karyotyping ECHO Gooseneck sign on lateral left ventricular angiogram MRI ASD, VSD, PDA, HF, sepsis Diuretics, ACE-i, digoxin, caloric intake Complete= need corrective surgery usually around 3-6 months age, Down's may need earlier Pulm artery banding palliative surgery Median sternotomy under CP bypass- single/ double/ modified single patch repair COMPS= FTT, recurrent LRTIs, CHF, pulm vascular disease, Eisenmenger's syndrome

Question 888

What increases the risk of PDA? Sx?

Answer 888

Females, preterm, LBW Post-partum if beyond 3 months in preterm infants/ 1 year in term infants Small= asymptomatic, large= FTT, feeding difficulties, LRTI, pulm oedema and resp failure can occur HF Pulm HTN Tachypnoea, resp distress, episodes apnoea, tachycardia, wide pulse pressure>30mmHg Hyperactive precordium, forceful apex beat, bounding pulse Continuous machinery murmur

Question 889

DDx, Ix and tx of PDA?

Answer 889

VSD & AVSD, truncus arteriosus, venous hum, aortopulmonary window, TOF, ruptured aneurysm of Valsalva in Marfans Increases creatinine- reduced renal hypoperfusion, unexplained metabolic acidosis, decreased urine output ECHO short axis view, + Doppler flow studies,- monitored until 1 y/o left heart volume overload with dilated LA and LV in HD significant PDA CXR= plethoric lung fields- pulm oedema

Question 890

Tx PDA?

Answer 890

Cons- high calorie formula, fluid restriction, monitor urine output, PEEP for pulmonary oedema, monitor for NEC- usually 7d closure Pharm= indomethacin, ibuprofen, diuretics Surgical ligation- cannot ween from ventilation--> injury to descending aorta and recurrent laryngeal nerve Trans-catheter PDA device closure via key-hole- device embolisation, haemolysis COMPS= NEC, RDS, RHF, pulm HTN, Eisenmenger syndrome

Question 891

What is coarctation of the aorta? Ass? Sx?

Answer 891

Congenital narrowing of descending aorta Turner's, NF, bicuspid aortic valve, berry aneurysms Mild= asymptomatic, HF in infancy, HTN in adults, RF delay, systolic murmur below left clavicle and scapula Tachypnoea, poor feeding, grey and floppy baby, LV heave due to LVH, underdeveloped left arm & legs

Question 892

Ddx, Ix and tx of coarctation of the aorta?

Answer 892

Aortic stenosis- sx of decreased CO, PDA, HTN ECHO + Doppler studies Mild= monitored w/ echo & anti-hypertensives if needed Severe= angioplasty & stent insertion Prostaglandin presenting w/ shock to keep patent until defect correct

Question 893

RFs for TOF? Ix? Sx? Tx for tet spells?

Answer 893

Rubella, increased age of mother, alcohol consumption in pregnancy, diabetic mother, 1-2m CXR= boot shaped heart ECHO, cardiac catheterisation ES murmur from pulmonary stenosis on newborn check, HF before age of 1 Cyanosis- determined by degree of RV OUTFLOW OBSTRUCTION, poor feeding, clubbing, poor weight, gain, tet spells Older= squat, younger= knees to chest

Question 894

Tx TOF?

Answer 894

Cyanotic episodes= beta-blockers reduce infundibular spasm, surgical repair in 2 parts- correction RV outflow tract obstruction, closure of VSD Supp O2, IV fluids, morphine- more effective breathing, NaCO3- buffers met acidosis, phenyl-epinephrine infusion- increased systemic vascular resistance Neonates= prostaglandin maintain ductus arteriosus

Question 895

Sx tricuspid atresia?

Answer 895

Poor feeding, general= progressive cyanosis, hepatomegaly, single S2 with pan-systolic murmur due to VSD at left lower sternal edge, continuous mechanical murmur, signs of HF

Question 896

Ix, tx and comps of tricuspid atresia?

Answer 896

Superior QRS axis, LVH, RAH and bi-atrial hypertrophy all common CXR- reduced/ increased pulm vascular markings depending on relation of great vessels ECHO- small RV, enlarged RA, LA and LV IV PGE1, Rashkind balloon atrial septostomy Stage 1 at birth= BT shunt, DKS, PDA stenting Stage 2@3-6m= BGS, hemi-Fontan procedure Stage 3@3-4y= Fontan procedure Palliative= Fontan circulation--> anticoagulation Post - Fontan comps= low CO and HF, pleural effusion and chylothorax, thrombus formation Late= SV arrhythmias, protein losing enteropathy, progressive drop in arterial saturations

Question 897

TGA associated with what?

Answer 897

VSD, coarctation of the aorta, pulmonary stenosis Most= aorta anterior and to right of pulmonary artery, M>F

Question 898

Aetiology and RFs for tricuspid atresia?

Answer 898

Dextroposition of the aorta/ no rotation of the aorto-pulmonary septum at the infundibular level. This causes the fourth aortic arch, which will later become the aorta, to interact with the anterior conus on the right ventricle Age>40 y/o, maternal diabetes, rubella, poor nutrition, alcohol consumption Cyanosis first 24h, signs CHF, may become evident over 3-6 weeks if large VSD RVH, single second heart sound, systolic murmur if VSD present, no signs resp distress Tricuspid- ECG= LAD

Question 899

Ix and tx of TGA?

Answer 899

Pulse ox= cyanosis, meta acidosis w/ decreased PaO2, echo, CXR- egg on string PGE1 infusion, correct met acidosis, emergency atrial balloon septostomy- mixing, def surg= arterial switch operation (ASO) before 4w, follow-up for HF & arrhythmias COMPS= neopulmonary stenosis, neoaortic regurgitation, neoaortic root dilatation

Question 900

What is pulm stenosis ass w/? Sx?

Answer 900

TOF, Noonan syndrome & Williams, rubella, due to carcinoid syndrome Often asymptomatic Signs of right HF- dyspnoea, fatigue, peripheral oedema, ascites ES murmur at pulm area, thrill, RVH due to RVH, raised JVP with giant a waves

Question 901

Ix and tx of pulmonary stenosis?

Answer 901

ECHO ECG= P pulmonale, RAD, RVH CXR= prominent pulm arteries Mild= watch and wait, surg= valvotomy and balloon angioplasty for supravalvular lesions- consider with transvalvular pressure gradients>50mmHg COMPS= right HF & IE

Question 902

What is Ebstein's anomaly?

Answer 902

Tricuspid set lower in right side heart- ass w/ ASD, patent foramen ovale & WPW syndrome May be caused by lithium in-utero Cyanosis, prominent A wave in distended jugular venous pulse, hepatomegaly, tricuspid regurgitation- pansystolic murmur worse on inspiration, RBBB- widely split S1 & S2, ass/ASD often present few days after birth when DA closes--> cyanotic and symptomatic ECHO Tx arrhythmias & HF, proph ABx for IE

Question 903

What is Eisenmenger's syndrome? 3x conditions causing?

Answer 903

R--> L heart bypassing lungs ASD, VSD & PDA Can develop after 1-2 years with large shunts/ adulthood with small shunts

Question 904

Sx Eisenmenger's syndrome? Ix and tx?

Answer 904

Late teens= cyanosis- might develop RVF, haemoptysis, embolism, RV heave, loud P2, raised JVP, peripheral oedema, plethoric complexion- ECHO, pulm function tests, cardiac catheterisation= GOLD- identify and degree of pulm HTN Identify and prompt tx- heart-lung transplant- not possible= palliative care Medical = O2, tx pulm HTN- sildenafil, arrhythmias, polycythaemia w/ venesection, thrombosis= anticoagulation, IE= proph ABx

Question 905

Sx aortic valve stenosis? Ix and tx?

Answer 905

SOB, fatigue, dizziness, fainting, worse on EXERTION, severe= HF within months birth ES murmur cre-decr- radiates to carotids Ejection click, thrill during systole, slow rising pulse and narrow pulse pressure ECHO, ECGs & exercise testing, more sig= restrict exercise Perc balloon aortic valvoplasty, surgical aortic valvotomy, valve replacement COMPS= LV outflow tract obstruction, HF, vent arrhythmia, bacterial endocarditis, sudden death often on exertion

Question 906

Sx HF in infants?

Answer 906

Poor feeding/faltering growth Sweating Tachypnoea Tachycardia Gallop rhythm Cardiomegaly Hepatomegaly

Question 907

Common underlying causes of IE in Paeds?

Answer 907

VSD, PDA, aortic valve abnormalities- bicuspid and TOF- can be pre/ post-repair

Question 908

Causes of IE in Paeds?

Answer 908

S.aureus , viridans- after dental procedures, s.pneumoniae, HACEK organisms, enterococci after GU/ GI surgery

Question 909

Sx IE? Ix?

Answer 909

Low-grade fever, change in heart murmur= concerning Splenomegaly, petechiae, Osler's nodes- painful fingers/ toes, Janeway lesions- palms/ soles, splinter haemorrhages- haemorrhagic streaks in nail bed, splinter haemorrhages, haematuria, PE, seizures/ hemiparesis/ Roth spots Non-specific symptoms- myalgia Blood cultures from different sites + anaemia, leucocytosis and raised ESR, microscopic haematuria + Modified Duke's criteria Major= + BC, evidence endocardial involvement Minor= pre-disposing heart condition/ IV drug user, temp>38 degrees, vascular phenomenoa, immunologic phenomena, micro/ ECHO +ve doesn't meet major criteria 2 major/ one major and 3 minor/ x5 minor

Question 910

Tx IE? Methicillin-susceptible, resistant? Enterococcus? HACEK?

Answer 910

Proph abx IV penicillin or ceftriaxone for 4w/ 2w above w/ gentamicin B-lac res penicillin for 6 weeks with/ without gentamicin for 3-5 days Vancomycin for 6w w or without gentamicin for first 3-5 days 4-6w IV penicillin w/gentamicin, allergic penicillin= 6w vancomycin and gentamicin Ceftriaxone w/ gentamicin for 4w, fungal= amphotericin B

Question 911

PPx of rheumatic fever?

Answer 911

2-4w after Beta-haemolytic strep--> auto-antibodies cross react with the endocardium= molecular mimicry- mitral valve disease= commonly in years after

Question 912

Major and minor Jones' criteria for rheumatic fever?

Answer 912

Evidence recent strep infection plus 2 major or one major and two minor criteria: Major= arthritis- knees, ankles, elbows, wrists, pancarditis--> new tachycardia/ murmur/ conduction defect, Sydenham's chorea- abrupt non rhythmic involuntary movements + muscular weakness + emotional disturbance more on one side and cease during sleep, often late feature Erythema marginatum- trunk, thighs and arms raised sharp outer edges w/ diffuse clear centre SC nodules over extensor surfaces and bony prominences Minor: fever, arthralgia, raised ESR & CRP, prolonged PR on ECG

Question 913

Ix and tx rheumatic fever?

Answer 913

ESR, CRP, FBC, cultures, RAD test, throat culture, anti-strep serology, ECG, CXR, ECHO Benzylpenicillin, aspirin/ NSAIDs, assess for emergency valve replacement, severe= glucocorticoids and diuretics may be needed Proph w/ IM benzylpenicillin every 3-4 weeks, oral phenoxy BD 10d following BP, oral sulfadiazine daily/ oral azithromycin- allergy Haloperidol/ diazepam for chorea 40% require surgery

Question 914

Most common arrhythmia Paeds? Tx?

Answer 914

SVT- HR 250-300 bpm, pulm oedema, hydrops foetalis & IU death Complete heart block- presyncope/ syncope, often those undergone surgery- endocardial pacemaker Long QT syndrome- sudden LOC during exercise, stress/ emotion ECHO, correct acidosis, PEEP, vagal manoeuvres, IV adenosine, electrical cardioversion w/ synchronised direct current shock if adenosine fails Maintenance w/ flecainide/ sotalol, no delta wave= digoxin, is= propanolol Relapse= RF ablation/ cryoablation of accessory pathway

Question 915

What is asthenopenia?

Answer 915

Eye strain/ fatigue/ pain- particularly in afternoon or at end of day

Question 916

Examples of innocent murmurs?

Answer 916

Still's murmur, venous hum, turbulent flow in pulm artery bifurcation 10 Ss- soft, systolic, short, S1 & S2 normal, symptomless, special test- XR & ECG normal, standing/ sitting vary with position, sternal depression

Question 917

What is aniso vs isometropia?

Answer 917

Difference in refractive error vs same reduction in RE in both eyes

Question 918

RFs for cryptochordism? Tx?

Answer 918

Family hx, LBW, SGA, prematurity, maternal smoking during pregnancy W&W- most descended in first 3-6 months- not desc by 6m= seen by Paediatric urologist Orchidopexy between 6 and 12m age

Question 919

Peak age for test torsion? Tx?

Answer 919

12 y/o Bell-clapper deformity- absent fixation between testicle and tunica vaginalis--> horizontal position Firm swollen testicle, unilateral pain, elevated testicle- elevated, absent cremasteric reflex, abnormal test lie, rotation- epididymis not in normal posterior position NBM, analgesia, Immediate scrotal exploration- orchidopexy- orchidectomy if surgery delayed or necrosis USS can show whirlpool sign

Question 920

Sx androgen insensitivity syndrome?

Answer 920

Genetically male, female phenotype- normal female external genitalia Testes in abdomen/ inguinal canal- anti-Mullerian hormone, no uterus/ upper vagina/ cervix/ Fallopian tubes/ ovaries Primary amenorrhoea@puberty, little/ no axillary and pubic hair, undescended testes--> groin swellings, taller than female average, infertile, increased risk testicular cancer unless removed Partial= ambiguous features Infancy= inguinal hernias containing testes Raised LH, normal/ riased FSH, normal/ raised testosterone levels, raised oestrogen levels for male

Question 921

Ix and tx AIS?

Answer 921

Buccal semar/ chromosomal analysis Counselling- raise child as female, bilateral orchidectomy, oestrogen therapy, vaginal dilators/ surgery

Question 922

Causes congenital hypothyroidism? Sx? Ix, tx and comps?

Answer 922

Thyroid dysgenesis- usually sporadic--> aplasia/ hypoplasia, ectopic- lingual/ sublingual, cong TSH deficiency, Pendred's syndrome, iodine deficiency, congenital TSH deficiency Umbilical hernia, prolonged jaundice, constipation, hypotonia, hoarse cry, poor feeding, excessive sleepiness, dry skin, coarse facies, delayed ND Guthrie card- TSH high and/ or FT4 low- levothyroxine Comps= ND delay & mental retardation, poor motor coordination, hypotonia, ataxia, poor growth and short stature

Question 923

Time for 1st, 2nd and 3rd trimesters? Feel movements?

Answer 923

0-12 weeks, 12-26w, 27+ weeks 10 midwife appointments in nulliparous and 7 in second pregnancy From 20 weeks

Question 924

Things covered in antenatal appointments?

Answer 924

Discuss plans for the remainder of the pregnancy and delivery Symphysis–fundal height measurement from 24 weeks onwards Fetal presentation assessment from 36 weeks onwards Urine dipstick for protein for pre-eclampsia Blood pressure for pre-eclampsia Urine for microscopy and culture for asymptomatic bacteriuria

Question 925

When is pertussis vaccine offered in pregnant women?

Answer 925

From 16 weeks, influenza when available in Autumn/ Winter

Question 926

Systems for estimating degree liver fibrosis in nAFLD?

Answer 926

NAFLD Fibrosis Score(NFS,) fibrosis 4 (FIB-4) score

Question 927

What is Knight's move thinking also known as? Flight of ideas is what? Tangentiality?

Answer 927

Loosening of association- ideas may appear loosely connected Rapid speech often without pauses- pressured speech, meaningful connections often maintained Jump from one topic to another without clear connection- immediate response to question

Question 928

Qs in an abbreviated mental test?

Answer 928

Recall an address, age and DOB, time, year, dates of WW2, name present monarch, count backwards from 20

Question 929

How should citalopram, escitalopram, sertraline or paroxetine be switched to another SSRI? To venlafaxine? Fluoxetine to another SSRI? Venlafaxine? SSRI--> TCA?

Answer 929

First withdrawn before alternative started Cross-taper cautiously- start 37.5mg daily and increase very slowly Leave of 4-7 days before starting low-dose alternative SSRI Withdraw and start at 37.5mg each day and increase very slowly Cross-tapering- current dose reduced slowly, whilst dose new drug increased slowly- fluoxetine withdrawn prior to TCAs starting

Question 930

Ix for schizophrenia? Poor prognosis factors? Tx?

Answer 930

FBC & LFT, U&Es- baseline before medication, serological testing for syphilis Strong family hx, gradual onset, low IQ, prodromal phase of social withdrawal, lack of obvious precipitant Oral atypical antipsychotics= first line- resistant= clozapine- good for positive and negative sx Depot if suits patient Psychotherapy- CBT Acute= lorazepam, promethazine/ haloperidol CBT to all CV RF modification due to high rates CVD in patients

Question 931

Drugs causing psychosis?

Answer 931

Anticonvulsants, high-dose corticosteroids, levodopa and dopamine agonists or opioids

Question 932

E.g. typical and atypical antipsychotics? SEs?

Answer 932

Haloperidol, chlorpromazine= D2 receptor antagonists Olanzapine, quetiapine, risperidone, aripiprazole- D2/ D3 and 5-HT2A antagonists EP SEs, hyperprolactinaemia, drowsiness, orthostatic hypotension, anticholinergic SEs As effective as typical- reduced EP SEs & sedation & seizures & anticholinergic SEs, some = orthostatic hypotension Increased metabolic SEs, weight gain, dyslipidaemia and glucose met, INCREASED STROKE AND VTE IN ELDERLY

Question 933

Monitoring for antipsychotics?

Answer 933

Weight at start, then weekly for first 6 weeks, then at at 12 weeks , at 1 year and then yearly Fasting blood glucose, HbA1C, blood lipid concs@baseline, 12 weeks, at 1 year and then yearly Prolactin@baseline ECG may be needed- part if CV RFs/ personal hx/ admitted as inpatient, BP before@12 weeks, 1 year and then yearly during treatment & dose titration

Question 934

Action, CI and SEs of SNRIs?

Answer 934

Increases serotonin and norepinephrine levels- venlafaxine and duloxetine, Hx heart disease and high BP Nausea, insomnia, increased HR, agitation

Question 935

Action of noradrenergic and specific serotonergic antidepressants(NASSAS?) SEs?

Answer 935

Mirtazapine- modulating norepinephrine and serotonin levels, blocks alpha receptors to increase monoamines Sedation, increased appetite and weight gain, constipation and diarrhoea

Question 936

Action, cautions and SEs of tricyclic antidepressants?

Answer 936

Blocks re-uptake of serotonin and NAD e.g. amitriptyline, clomipramine and imipramine Also antimuscarinic Previous HD, can ex schizophrenia, ex long QT syndrome, preg & BF, blood sugar in T1 & T2DM, may prec urinary ret- avoid in men with enlarged prostates, those on other CP450 meds Anti-cholinergic SEs- drowsy, confusion, arrhythmias, seizures, vomiting, flushing, dilated pupils- FBC, U&Es, CRP, LFTs, VBG, ECG

Question 937

Action, e.g., cautions and SEs of MAO-is?

Answer 937

Inhibits monoamine oxidase--> elevation in brain levels of catecholamines and serotonin Moclobemide- B inhibitor, phenelzine- A inhibitor Cerebrovascular disease, manic phase of bipolar, phaeochromocytoma, severe CVD Hypertensive reactions with tyramine- containing foods, avoid broad bean pods- contain dopa, anticholinergic effects

Question 938

Action of benzos?

Answer 938

Increase GABA- increases frequency of chloride channels & barbiturates increase duration of Cl- channel opening- used for sedation, hypnotic, anxiolytic, anticonvulsant, muscle relaxant

Question 939

E.g. of anxiolytics? Issue? Withdrawal sx?

Answer 939

Antidepressants, buspirone, benzos, pregabalin, hydroxyzine Long-term dependence- short time 2-4 weeks- withdraw in steps about 1/8 of daily dose every fortnight, SEs= drowsy, confusion, hypoventilation, lack coordination- part elderly Up to 3 weeks after stopping= seizures, tinnitus, tremor, loss of appetite, anxiety and irritability, risk falls in elderly

Question 940

Antidote to benzos? Cautions/ CIs? Sx overdose?

Answer 940

Flumazenil- comp at GABAA receptor- can induce seizure- overdose prolonged sleep usually without serious dep respiration Acute pulm insuff, NM resp weakness, obsessional states, phobia states, sleep apnoea, unstable MG Drowsy, dysarthria, ataxia, nystagmus, resp depression and coma

Question 941

E.g. of hypnotics(Z-drugs)?

Answer 941

Benzos and barbiturates- risk of resp depression

Question 942

CI lithium? Monitoring for lithium?

Answer 942

Addison's disease, cardiac ass w/ rhythm disorder, personal/ family hx Brugada syndrome, low Na+ diets and untreated hypothyroidism Severe renal impairment- narrow index 0.4-1 Before= U&Es, ECG, TFTs, BMI and FBC, monitor BMI, serum electrolytes, eGFR and TFT every 6 months during tx Check lithium 12 hours post-dose- weekly and after each dose change until concs stable, then 3 monthly Info booklet, alert card and record book

Question 943

E.g. stimulants? Action?

Answer 943

Methylphenidate, dexamfetamine sulfate, lisdexamfetamine mesilate Taken up into presynaptic nerves w/ two Na+ ions and one chloride ion via monoamine reuptake transporters Displace other monoamines to be stored by VMAT2 which releases neurotransmitters into the synapse via retro-transport. They also weakly inhibit dopamine and serotonin reuptake and moderately inhibit noradrenaline reuptake. Furthermore, they inhibit the mitochondrial-bound enzyme mono-amine oxidase (MAO) which is the catalytic enzyme in charge of degrading all the excess of neurotransmitter

Question 944

SEs, cautions/ CIs and monitoring for stimulants?

Answer 944

Upper abdo pain, decreased appetite, tachy, tremor, hyperhidrosis, insomnia, movement disorders, nausea--> wakefulness, excessive activity, paranoia, hallucinations and HTN--> exhaustion, convulsions, hyperthermia and coma Advanced arteriosclerosis, agitated states, hyperthyroidism, moderate and severe HTN, sx CVD Pulse, BP and psych sx before start, following dose adjustment & every 6 months, weight in adults and weight/ height in children every 6m

Question 945

Indications, mechanism and SEs of ECT?

Answer 945

Severe dep refractory to medication e.g. catatonia those with psych sx ABSOLUTE CI= RAISED ICP Electric current through brain causing surge of electrical activity, usually 6-12 sessions (2/wk) Headache, nausea, short memory impairment, memory loss of events prior to ECT, cardiac arrhythmia Impaired mem= long-term memory

Question 946

Types and aim of psych therapies?

Answer 946

Psychotherapy: talking CBT: hot cross bun model (thoughts, emotions, behaviour, bodily sensations.) Depression, GAD, phobias, OCD, PTSD, bulimia Behavioural therapy: relaxation, densensitisation Dynamic psychotherapy: patient narrates and Dr makes links Family therapy Counselling: recent events Group psychotherapy: forming, storming, norming, performing. Personality disorders, addiction Cognitive analytical therapy: Dr writes letter at beginning and end. Depression, personality disorders Interpersonal therapy DBT: manage emotions by experiencing, recognising and accepting them- EUPD

Question 947

Causes of a raised ferritin?

Answer 947

Haemochromatosis- raised transferrin and low TIBC, infection, chronic alcohol consumption, NAFLD, hepatitis C, cancer

Question 948

Causes of a painful and painless red eye?

Answer 948

Acute angle-closure glaucoma, anterior uveitis, scleritis, corneal abrasions/ ulceration, keratitis, foreign body, traumatic/ chemical injury Conjunctivitis, episcleritis, subconjunctival haemorrhage

Question 949

Causes of sudden loss of vision?

Answer 949

Ischaemic/ vascular- ischaemic optic neuropathy/ central vein/ artery occlusion, vitreous haemorrhage, retinal detachment, retinal migraine

Question 950

Causes of ptosis?

Answer 950

3rd nerve palsy, Horner's syndrome, myaesthenia gravis, carotid artery dissection, cluster headache, myotonic dystrophy, LES syndrome, paroxysmal hemicrania

Question 951

Causes of relative afferent pupillary defect?

Answer 951

Lesion anterior to optic chiasm Optic neuritis, glaucoma, retinal detachment, severe retinal ischaemia/ optic nerve compression due to tumours or inflammation

Question 952

Treatment for a brain abscess?

Answer 952

CT, MRI for abscess vs cerebral metastases Craniotomy and cavity debrided, may reform IV 3rd generation cephalosporin + metronidazole 6-8 weeks ICP tx e.g. dexamethasone

Question 953

Cause of folliculitis? Tx?

Answer 953

S.aureus- eosinophilic= immunosuppression like in HIV- not infectious cause- needs skin biopsy--> eosinophils in skin surface Papules and pustules except palms and soles of feet Topical antibiotics, antibacterial soaps, oral in severe cases, gram negative/ hot tub= different approach

Question 954

Cause gangrene? Sx? Ix and tx?

Answer 954

C. perfringens Acute severe localised pain, minimal local inflammation, skin darkening and spreading erythema, fever, gas production in affected area, potent smell Radiographic, WCC and inflammatory markers, tissue cultures Surgical debridement, ABx administration, amputation, hyperbaric oxygen therapy

Question 955

Causes of wet and dry gangrene?

Answer 955

Wet= s.pyogenes, gas= c.perfringens, dry= chronically reduced blood flow- atherosclerosis and PAD, thrombosis- vasculitis, vasospasm Wet= poorly demarcated from surrounding tissue, fever & septic symptoms Dry= well demarcated necrotic area without signs of infection, auto-amputation

Question 956

Ix and tx of wet and dry gangrene?

Answer 956

FBC, CRP/ ESR, blood cultures, lactic acid levels, imaging, tissue biopsy '', Dopper USS/ angiography, tissue biopsy Surgical debridement or amputation and broad-spec IV ABx Surgical debridement/ amputation

Question 957

Eligible GBMSM under 25 y/o receive what HPV vaccination? 25-45 y/o? Who gets a 3 dose- schedule?

Answer 957

1-dose through SH clinics 2-dose schedule through SH clinics Immunocompromised/ HIV positive

Question 958

Investigations in returning traveller?

Answer 958

FBC, U&Es, LFTs, 2x blood cultures, malaria blood film and rapid diagnostic test, CXR, urine MC&S- also PCR Ricksettsia serology, viral haemorrhagic fever testing, leptospirosis serology, cross-sectional imaging, LP

Question 959

Mnemonic for upper vs lower lobe predominance?

Answer 959

CASSET HPP= CF, AS, silicosis, sarcoidosis, eosinophilic granuloma, TB, hypersensitivity pneumonitis, pleuroparenchymal fibroelastosis, pneumocystis pneumonia SET CAP- silicosis/ sarcoidosis, EG/ extrinsic allergic alveolitis, TB/ fungal, cystic fibrosis, ankylosing spondylitis, PCP BAD RASH: bronchiectasis, aspiration, DIP, RA, asbestosis, scleroderma, Hamman- Rich syndrome/ acute interstitial pneumonitis

Question 960

Ottawa rules for ankle injury? Knee? Foot?

Answer 960

Pain in malleolar zone and any one of: bony tender at lateral malleolar zone/ medial malleolus, inability to walk x4 weight-bearing steps Age>55, isolated patellar tenderness without other bone tenderness, tenderness of fibular head, inability to flex 90 degrees, inability to weight bear after injury and in A&E 4 steps regardless of limping Bone tenderness at navicular bone, at base 5th metatarsal, inability to weight bear both immediately and in A&E department

Question 961

2WW referral for laryngeal cancer? Oral cancer?

Answer 961

Aged 45 and over= persistent unexplained hoarseness or unexplained lump in neck Unexplained ulceration in oral cavity for more than 3 weeks/ persistent and unexplained lump in neck Assessment by dentist= lump on lip or in oral cavity or red or red and white patch in oral cavity consistent with erythroplakia or erythroleukoplakia

Question 962

Tx for inguinal hernias?

Answer 962

Medically fit even if they are asymptomatic, truss for fit for surgery, mesh repair= lowest recurrence rate- unilateral= open approach/ bilateral or recurrent repaired laparoscopically Open repair--> non-manual work after 2-3 weeks and laparoscopic repair after 1-2 weeks Comps= early- bruising, wound infection, late= chronic, recurrence

Question 963

Inheritance and ass of VHL syndrome?

Answer 963

VHL autosomal dominant inheritance, haemangioblastomas in brain/ spinal cord--> ataxia, retinal angiomas--> vision loss Cysts in kidneys, increased clear cell RCC risk, pancreatic neuroendocrine tumour, phaeochromocytomas, inner ear tumours, liver/ lungs

Question 964

Presentation of Stauffer syndrome?

Answer 964

Paraneoplastic disorder ass/w RCC--> cholestasis/ hepatosplenomegaly, secondary to increased levels of IL-6

Question 965

Cause of malignant hyperthermia? S&S, Ix and tx?

Answer 965

AD mutation in ryanodine receptor 1 gene--> abnormality in Ca2+ regulation within muscle cells--> increased Ca2+ levels in sarcoplasmic reticulum and cons increased in met rate Rapid increase in body temp, muscle rigidity, met acidosis, tachycardia, increased exhaled CO2 Bloods for met acidosis and CK raised, ABG for resp and met acidosis, core temp Immediate discontinue agent, IV Dantrolene, cooling techniques- ice packs/ IV fluids and cooling blankets, correct acidosis and cooling blankets, supportive- oxygen, ventilation and HD support

Question 966

Tx for central vs peripheral vertigo?

Answer 966

HINTs: head impulse, nystagmus, test of skew Head impulse normal= eyes fixed on examiner nose--> no sx/ central cause VN/ labyrinthitis= eyes will saccade Nystagmus: few beats normal, unilateral horizontal peripheral, bilateral/ vertical nystagmus= central Test of skew(alternate cover test): covers one eye at a time- should remain fixed on examiner's nose with no deviation, if vertical correction= central cause

Question 967

How is vestibular migraine treated?

Answer 967

Avoiding triggers, lifestyle, medical= triptans, propanolol, topiramate, amitriptyline prevent DON'T DRIVE AND INFORM DVLA IF LIABLE TO SUDDEN/ UNPROVOKED/ UNPREC EPISODES DISABLING DIZZINESS

Question 968

Red flags for neck lumps?

Answer 968

Hard, painful & fixed lump Associated otalgia, dysphagia, stridor, or hoarse voice, unilateral nasal sx, unexplained wt loss, night sweats/ fever/ rigors, CN palsies >40 y/o generally Child= + Supraclavicular mass, lumps>2cm & previous hx malignancy

Question 969

4x classes of anti-arrhythmic drugs?

Answer 969

Class I= sodium-channel blockers e.g. quinidine, procainamide, lidocaine, flecainide- suppression of atrial/ ventricular premature beats II= beta-blockers e.g. bisoprolol, carvedilol, timolol, atropine III= potassium channel blockers e.g. amiodarone IV= CCBs e.g. amlodipine, nifedipine, verapamil, diltiazem, adenosine, digoxin

Question 970

What do you get with flail chest? Ass with what?

Answer 970

Chest wall disconnects from thoracic cage, multiple rib fractures, ass w/ pulm contusion- ABGs and pulse oximetry important, significant hypoxia= early intubation, abnormal chest motion, avoid over hydration and fluid overload

Question 971

Trimodal death distribution following trauma? Presence of mediastinal haematoma indicates what?

Answer 971

Immediately- brain/ high spinal injuries, cardiac/ great vessel damage, salvage rate= low Early hours= splenic rupture, SDH, haemopneumothoraces, days following= sepsis of multi organ failure Great vessel injury--> CT angio and oesophageal contrast swallow

Question 972

Haemothorax caused by what? Tx and indications for thoracotomy?

Answer 972

Laceration of lung vessel or internal mammary artery by rib fracture Wide bore 36F chest drain Loss of more than 1.5L blood initially / ongoing losses of >200ml/ per hour for > 2 hours

Question 973

Ix for cardiac contusions? Commonest cause death after RTA/ falls? Tx pulmonary contusion?

Answer 973

ECHO for pericardial effusions and tamponade, risk arrhythmias after 24 hours, diaphragmatic injury= usually left sided Traumatic aortic disruption- incomplete laceration near ligamentum arteriosum- all will have contained haematoma Early intubation and ventilation

Question 974

In blunt trauma needing laparotomy, what is most commonly injured? Ix for abdominal trauma?

Answer 974

Spleen Stab wounds= liver Gunshot= small bowel Ix peritoneal lavage- bleeding if hypotensive- 98% effective- may miss RP and diaphragmatic injury Abdominal CT= organ injury if normotensive- time for reporting, need for contrast USS= document fluid if hypotensive- non invasive and repeatable, operator dependent, may miss RP injury Urethrography if suspected urethral injury

Question 975

Sx post-op ileus?

Answer 975

Green bilious vomiting, abdominal distension, diffuse abdominal pain, constipation and lack of flatulence, absent bowel sounds CHECK POTASSIUM, MAGNESIUM AND PHOSPHATE- NBM, NG tube, IV fluids mobilisation, TPN

Question 976

Causes of post-op N&V? Tx?

Answer 976

Infection, hypovolaemia, pain, paralytic ileus, drugs Minimise patient movement, analgesia, IV fluids Ondansetron- risk QT prolong and constipation Cyclizine- avoid in severe HF Prochlorperazine- risk EP SEs

Question 977

Drugs given before GA? 7 Ps of RSI?

Answer 977

Benzos for muscle relaxation, fentanyl/ alfentanyl for pain and HTN response to laryngoscope, alpha-2-adrenergic agonists Prep, preoxygenation 5 minutes prior, pretreatment- opiate analgesia or fluid bolus, pretreatment, paralysis- propofol or sodium thiopental and sux/ rocoronium, protection and positioning- intubation with laryngoscopy- direct vision, end-tidal CO2 and bilateral auscultation, placement and proof, post-intubation management- taping/ tying ETT, mechanical ventilation and sedation agents Cricoid pressure= reduces risk of gastric aspiration

Question 978

What can reduce NM blocking agents? Non-depolarising e.g. rocoronium? Where is nerve stimulator used to test muscle relaxant has worn off?

Answer 978

Neostigmine Sugammadex Ulnar nerve- watch thumb to twitch/ facial nerve- watch orbiculares oculi at eye- train of four stimulation TOF needed- stimulated x4 times, once worn off= inhaled anaesthetic stopped

Question 979

Where is spinal anaesthetic injected? What is normally used as epidural anaesthetic?

Answer 979

Subarachnoid space- into L3/L4 or L4/L5, cold spray used to see if it's worked, takes 1-3 hours to wear off Levobupivacaine with or without fentanyl--> headache, hypotension, motor weakness in legs, nerve damage, meningitis, haematoma Increased risk instrumental delivery and prolonged second stage

Question 980

Cause of sux apnoea? S&Sx, Ix and tx?

Answer 980

Rare genetic defect in plasma cholinesterase Prolonged period paralysis following administration, little effort to breathe or cough spont at end Check levels Intubate and ventilate until spont breathe- avoid in future procedures

Question 981

Cuff pressure for ETT can be checked using what? Extra hole in case opening at tip of ETT--> occluded? Laryngoscope with camera? What helps with intubation? ETT when patient awake? Check what?

Answer 981

Manometer Murphy's eye McGrath Bougie/ stylet Awake fibre-optic intubation- restricted mouth opening/ difficult anatomy e.g. trismus End-tidal CO2- capnography

Question 982

Supraglottic airways with an inflatable? When are tracheostomies used?

Answer 982

Laryngeal mask airways e.g. LMA, non-inflatable= I-gel After a laryngectomy procedure- resp failure with long-term ventilation required, prolonged weaning from mechanical ventilation, upper airway obstruction, tx resp secretions, reducing risk aspiration

Question 983

Plan A-D for difficult airways? What is a type of central venous catheter used for haemodialysis? When are PICC lines used? Where does a Hickman line go? Pulm artery catheter?

Answer 983

Laryngoscopy with tracheal intubation, supraglottic airway device, face mask ventilation, cricothyroidotomy Vas cath- has 2/3 lumens Low risk infection- medium term IV access Through SC tissue--> SC/ jugular vein with tip sits in SVC- cuff surrounds for chemo/ haemodialysis Swan- Ganz= into internal jugular vein into RA, RV and into pulmonary artery, pressure distal to wedged balloon can be measured= pressures in LA- specialist cardiac centres

Question 984

Portacath?

Answer 984

Port under skin top chest through SC tissue and into SC vein- tip sits in SVC or RA- bump on skin- for chemo

Question 985

Tx heat burns? Chemical burns? Wallace's rule of 9s? Chart most accurate?

Answer 985

Within 20 minutes= irrigate burn with cool water for between 10-30 minutes- cover w/ cling film, layered Irrigate with water for about hour Each arm, head & neck, each anterior leg, each posterior leg, anterior, posterior chest, anterior, posterior abdomen= 9%, palm= 1%- not accurate for burns>15% TBSA Lund and Browder

Question 986

Degree of burn for superficial epidermal, superficial derma, deep dermal and full thickness burns? Initial tx for superficial epidermal? Dermal burns? When should early intubation be considered? Parkland formula?

Answer 986

1st degree 2nd degree for dermal 3rd degree First aid, analgesia/ emollients Clean wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours Deep burns to face or neck, blisters or oedema of oropharynx, stridor IV fluids for children burns>10% TBSA/ adults>15% Weight kg x 4 x % burn- half in first 8 hours

Question 987

Refer who to secondary for burns? Tx more severe burns?

Answer 987

All deep dermal and full thickness Superficial>3% in adults/ 2% in children Superficial dermal involving face, hands, perineum, genitalia/ flexure/ circumferential burns of limbs, torso/ neck, any inhalation injury, any electrical/ chemical burn injury/ suspicion NAI

Question 988

Tx more severe burns?

Answer 988

Cons early intubation, IV fluids, urinary catheter, analgesia, burns>10% adults/ 5% children--> burns unit Circumferential burns affecting limb/ severe torso burns impeding respiration may need escharotomy Complex may need excision and skin grafting

Question 989

Dressing for burns?

Answer 989

Paraffin gauze, silicone- coated nylon dressing, polyurethane film/ hydrocolloid dressing. Secondary non-fibrous absorbent dressing such as dressing pad and secured with conforming bandage/ tubular gauze bandage Consider tetanus vaccination Empirical ABx for infection, consider different after 7 days

Question 990

Tx local anaesthetic toxicity?

Answer 990

20% intralipid emulsion- A-E approach and ECG monitoring

Question 991

Modes of ventilation for mechnical ventilation?

Answer 991

Volume controlled ventilation- specific tidal volume, pressure controlled ventilation- specific pressure per breath, assist control- breaths are triggered by the patient, CPAP

Question 992

What is the most extreme or respiratory support?

Answer 992

ECMO- where respiratory failure is not adequately managed by intubation and ventilation- similar to haemodialysis Short-term, potentially reversible cause of resp failure- in specialist ECMO centres- not available in most ICUs- need to be transferred

Question 993

What is peritoneal dialysis usually used in? Haemodialysis?

Answer 993

Acute renal failure- limited to CKD, not usually AKI Vas cath in acute setting- anticoagulation with citrate or heparin is needed to prevent clotting in machine and during process- for continuous RRT- CRRT- 24 hours a day, intermittent haemodialysis 3-12 hours before taking a break

Question 994

Tx anaemia before surgery?

Answer 994

<6 weeks= IV iron >6 weeks= oral iron B12/ folate replacement, ESA therapy, transfusion if profound anaemia and can't be delayed

Question 995

Peri-op tx on steroids?

Answer 995

Oral--> 50-100mg IV hydrocortisone, hypotension= add fludrocortisone Minor= oral pred can be restarted immediately post-operatively, major= IV hydrocortisone up to 72 hours post-op

Question 996

Post-op fluid management?

Answer 996

Hartman's to prevent hyperchloraemic acidosis, restart asap if HD stable and euvolaemic, review if urinary sodium <20, if oedematous- tx hypovolaemic first, monitor urinary Na

Question 997

Early causes pyrexia post-op?

Answer 997

Blood transfusion, cellulitis, UTI, physiological systemic inflam reaction, pulm atelectasis Late= VTE= pneumonia, wound infection, anastomotic leak- 4Ws and iatrogenic

Question 998

Special tests for surgical comps?

Answer 998

CT scanning for intra-abdominal abscesses, air and if luminal contrast used an leak Gastrograffin enema for rectal an leaks Doppler USS leg veins Peritoneal fluid for U&Es, ECHO

Question 999

What does thermoregulation refer to in periop period?

Answer 999

1 hour prior to until 24 hours after surgery completed Prevent hypothermia mainly Risks= ASA grade 2 or above, major surgery, low body weight, large volumes unwarmed IV infusions, unwarmed blood transfusions If <36 before- start warming 30 mins prior to anaesthetic Bair hugger from onset anaesthesia any >30 minutes/ for patients at high risk periop hypothermia regardless duration Fluid volumes>500ml warmed prior to admin as all blood products- won't correct existing hypothermia

Question 1000

Post-op temp monitoring?

Answer 1000

Initially then every 15 minutes until transfer to ward Not to ward if temp is below 36 degrees Comps= coagulopathy, prolonged recovery from anaesthesia, reduced wound healing, infection, shivering--> myocardial ischaemia

Question 1001

Stages wound healing?

Answer 1001

Haemostasis- minutes to hours following injury- minutes to hours, vasospasm in adjacent vessels- platelet plug formation and generation fibrin rich clot Inflammation= days 1-5, neutrophils to wound Growth factors released- FGF & VEGF, fibroblasts, macrophages Regeneration- days 7-56, platelet derived growth factor and transformation growth factors- stim fibroblasts and epithelial cells, fibroblasts= collagen network, angiogenesis Remodelling- 6w to 1 years, fibroblasts differentiate, collagen fibres remodelled, microvessels regress--> pale scar Hypertrophic, keloid scars

Question 1002

x4 types of fistulae?

Answer 1002

Enterocutaneous- intestine to skin- high/ low output depending on source, enteroenteric or enterocolic- large/ small intestine may malabsorption syndromes in IBD serious, enterovaginal- as above, enterovesicular- to bladder may result in frequent UTIs/ passage gas from urethra during urination

Question 1003

Tx fistulae?

Answer 1003

Well-fitted stoma bag, high output= use of ocreotide reduce volume pancreatic secretions High fistulae--> nutritional comps Secondary to Crohn's= drain acute sepsis Barium and CT show track for abscesses and fistulae Perianal= Goodsall's rule

Question 1004

How to measure leg swelling in DVT? THROMBOSIS causes? Refer who?

Answer 1004

Measure circumference of calf 10cm below tibial tuberosity- more than 3cm difference= significant Trauma/ thrombophilia, hormonal- COCP, pregnancy, HRT/ relatives- family history, recent surgery/ old age>60 y/o/ obesity, malignancy, bone fractures, obesity, smoking, immobilisation, sicknessPregnant/ has given birth within the past 6 weeks >2 Wells score= Doppler USS proximal leg veins within 4 hours <1= D-dimer- positive--> proximal leg vein USS within 4 hours -ve= stop interim AC, consider alternatives Non-modifiable RFs= lifelong anticoagulation

Question 1005

Signs of hypothermia on an ECG?

Answer 1005

Osborne waves/ J waves- small hump at end of QRS complex, long QT interval, 1st degree heart block, atrial and ventricular arrhythmias, bradycardia

Question 1006

Causes of sick sinus syndrome? ECG abnormalities? Tx?

Answer 1006

Idiopathic degenerative fibrosis, ischaemia, cardiomyopathies, drugs- digoxin, Beta-blockers, calcium channel blockers Sinus bradycardia, sinus arrhythmia, sinoatrial exit block, sinus arrest>3 seconds, bradycardia- tachycardia syndrome Correction extrinsic causes, pacemaker insertion

Question 1007

High-risk characteristics for pneumothorax?

Answer 1007

HD compromise, significant hypoxia, bilateral pneumothorax, underlying lung disease, >/=50 y/o age significant smoking history, haemothorax

Question 1008

Triangle of safety for chest drain insertion?

Answer 1008

Base of axilla, lateral edge pec major, 5th IC space and anterior border of lat dorsi

Question 1009

Causes of ARDS? Criteria?

Answer 1009

Infection- sepsis, pneumonia, massive blood transfusion, trauma, smoke inhalation, acute pancreatitis, COVID-19, CP bypass Acute onset within 1 week RF Pulm oedema- bil infil on CXR, non-cardiogenic- pulm artery wedge pressure not raised, pO2/FiO2<40kPa Tx= ITU, oxygenation/ ventilation to treat hypoxaemia, vasopressors, ABx for sepsis, prone positioning and muscle relaxation

Question 1010

5 As of ankylosing spondylitis?

Answer 1010

Apical fibrosis, anterior uveitis, aortic regurgitation, achilles tendonitis, AV node block, amyloidosis

Question 1011

Sx of amyloidosis?

Answer 1011

Feeling very tired or weak, losing weight without trying to, SOB, swollen feet/ legs, bruising around the eyes Fast/ slow HB/ chest pain if heart affected Loss of appetite, feeling or being sick, diarrhoea/ constipation if digestive system affected Frothy urine if kidneys affected Pain, numbness/ tingling in hands and feet if nerves affected

Question 1012

Causes of main types of amyloidosis?

Answer 1012

AL= issue with bone marrow- sometimes linked with multiple myeloma AA= long-term RA, Crohn's/ UC/ TB Hereditary ATTR= inherited genetic condition Wild-type- develops as you get older usually in men> 75 y/o Beta-2 microglobulin= having long-term dialysis

PHASE 3B (11 decks)

• Public Health Learning(ECP)
• Trauma and Orthopaedics
• ENT
• Notes from MCQs
• Ophthalmology
• Dermatology
• Infectious Diseases
• Data Interpretation + Radiology
• Palliative Care/ Oncology
• Acute Medicine/ Anaesthetics
• Intro Lectures