October #2

Question 1

In Weber’s test if there is a sensorineural problem the sound is localised to the – side

Answer 1

unaffected

Question 2

Samter’s triad =

Answer 2

asthma + aspirin sensitivity + nasal polyposis

Question 3

Immunocompromised patients with poor dentition can develop airway compromise from cellulitis at the floor of the mouth known as –

Answer 3

Ludwig’s angina.

Question 4

A perforated tympanic membrane caused by barotrauma treatment?

Answer 4

A perforated tympanic membrane caused by barotrauma is self-limiting

Question 5

Auricular – occur after direct trauma to the ear and is due to a build up of blood between the– and perichondrium.
This can restrict blood supply and lead to necrosis of the connective tissue.
ENT must therefore assess the patient quickly to decide how to manage it.
Treatment is usually – and – +/- a draining wick depending on the size.

Answer 5

haematomas
cartilage
incision
drainage

Question 6

Nasal polyps

Associations:
a-
a--sensitivity
I--
c--
K--syndrome
C---syndrome

Management
all patients with suspected nasal polyps should be :
topical – shrink polyp size in around 80% of patients

Answer 6

Associations:
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener's syndrome
Churg-Strauss syndrome

Management
all patients with suspected nasal polyps should be referred to ENT for a full examination
topical corticosteroids shrink polyp size in around 80% of patients

Question 7

Topical — with or without – are first line treatment in otitis externa

Answer 7

antibiotics

steroid

Question 8

depression Somatic symptoms can include x3

Answer 8

early morning waking and changes in appetite and weight

Question 9

Pregnant women with a UTI: –is first-line

Answer 9

nitrofurantoin

Question 10

– are contraindicated in patients with asthma when managing atrial fibrillation

Answer 10

Beta-blockers

Question 11

Coeliac UK recommends that everyone with coeliac disease is vaccinated against — infection and has a booster every –years, as there is a potential for people with coeliac disease to develop overwhelming – sepsis due to hyposplenism

Answer 11

pneumococcal
five
pneumococcal

Question 12

– sign: vesicles extending to the tip of the nose. This is strongly associated with ocular involvement in shingles

Answer 12

Hutchinson’s

Question 13

Alpha-1 antitrypsin deficiency is a risk factor for — carcinoma

Answer 13

hepatocellular

Question 14

Pneumatosis intestinalis is a hallmark feature of —- AXR

Answer 14

necrotising enterocolitison

Question 15

Bone protection for patients who are going to take long-term — should start immediately

Answer 15

steroids

Question 16

Phenytoin is a cause of – deficiency

Answer 16

folic acid

Question 17

Hypertrophic obstructive cardiomyopathy - is classically associated with an S–

S- is most commonly caused by heart failure which is the result of a dilated, compliant ventricle. In young people S- can be incidental and bear no clinical significance.

A mid diastolic murmur is classically seen in–

A — is usually made up of one systolic and 2 diastolic sounds which can indicate pericarditis.

Hypertrophic obstructive cardiomyopathy is associated with a – murmur however it classically does not radiate to the carotids.

Answer 17

4

S3 is most commonly caused by heart failure which is the result of a dilated, compliant ventricle. In young people S3 can be incidental and bear no clinical significance.

A mid diastolic murmur is classically seen in mitral stenosis.

A pericardial rub is usually made up of one systolic and 2 diastolic sounds which can indicate pericarditis.

Hypertrophic obstructive cardiomyopathy is associated with a mid-systolic murmur however it classically does not radiate to the carotids.

Therefore S4 is the correct answer which is associated with hypertrophy of the ventricles and always indicates some form of pathology.

Question 18

Aromatase inhibitors (e.g. anastrozole) may cause –

Answer 18

osteoporosis

Question 19

–abuse increases risk of placental abruption

Answer 19

Cocaine

Question 20

Agents used to control rate in patients with atrial fibrillation: x3

Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation x3

Answer 20

Agents used to control rate in patients with atrial fibrillation
beta-blockers
a common contraindication for beta-blockers is asthma
calcium channel blockers
digoxin
not considered first-line anymore as they are less effective at controlling the heart rate during exercise
however, they are the preferred choice if the patient has coexistent heart failure

Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine

Question 21

Factors favouring rate control x2

Factors favouring rhythm control x5

Answer 21

Factors favouring rate control
Older than 65 years
History of ischaemic heart disease

Factors favouring rhythm control
Younger than 65 years
Symptomatic
First presentation
Lone AF or AF secondary to a corrected precipitant (e.g. Alcohol)
Congestive heart failure

Question 22

Causes of folic acid deficiency:
x4

Consequences of folic acid deficiency:
x2

Prevention of neural tube defects (NTD) during pregnancy:
all women should take —mcg of folic acid until the –th week of pregnancy
women at higher risk of conceiving a child with a NTD should take -mg of folic acid from before conception until the –th week of pregnancy
women are considered higher risk if any of the following apply:
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking — drugs or has — disease, d—, or – trait.
→ the woman is–

Answer 22

Causes of folic acid deficiency:
phenytoin
methotrexate
pregnancy
alcohol excess

Consequences of folic acid deficiency:
macrocytic, megaloblastic anaemia
neural tube defects

Prevention of neural tube defects (NTD) during pregnancy:
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
women are considered higher risk if any of the following apply:
→ either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
→ the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
→ the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Question 23

ECG changes in pericarditis
x2

all patients with suspected acute pericarditis should have –

Answer 23

ECG changes
the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography

Question 24

– is used to assess drug sensitivities in TB

Answer 24

Sputum culture

Question 25

The--- test is the main technique used to screen for latent tuberculosis False negative tests may be caused by:

Answer 25

Mantoux ``` miliary TB sarcoidosis HIV lymphoma very young age (e.g. < 6 months) ```

Question 26

Diagnosis of active tuberculosis Chest x-ray --- is the classical finding of reactivated TB bilateral hilar --- Sputum smear 3 specimens are needed rapid and inexpensive test stained for the presence of --- (--- stain) all mycobacteria will stain --- (i.e. nontuberculous mycobacteria) the sensitivity is between 50-80% this is decreased in individuals with HIV to around 20-30% Sputum culture the --- investigation more sensitive than a sputum smear and nucleic acid amplification tests can assess --- can take -- weeks (if using liquid media, longer if solid media) --- (NAAT) allows rapid diagnosis (within 24-48 hours) more sensitive than smear but less sensitive than culture

Answer 26

Chest x-ray upper lobe cavitation is the classical finding of reactivated TB bilateral hilar lymphadenopathy Sputum smear 3 specimens are needed rapid and inexpensive test stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain) all mycobacteria will stain positive (i.e. nontuberculous mycobacteria) the sensitivity is between 50-80% this is decreased in individuals with HIV to around 20-30% Sputum culture the gold standard investigation more sensitive than a sputum smear and nucleic acid amplification tests can assess drug sensitivities can take 1-3 weeks (if using liquid media, longer if solid media) Nucleic acid amplification tests (NAAT) allows rapid diagnosis (within 24-48 hours) more sensitive than smear but less sensitive than culture

Question 27

Haemangioma Should be considered in the differential of a -- in a child Accounts for 90% of --- tumours in children less than 1 year of age ---on imaging Spontaneous regression may occur and malignant transformation is almost unheard of

Answer 27

Haemangioma Should be considered in the differential of a parotid mass in a child Accounts for 90% of parotid tumours in children less than 1 year of age Hypervascular on imaging Spontaneous regression may occur and malignant transformation is almost unheard of

Question 28

Malignant salivary gland tumours Types of malignancy Mucoepidermoid carcinoma 30% of all --malignancies Usually --- potential for local invasiveness and metastasis (depends mainly on grade) Adenoid cystic carcinoma -- growth pattern Tendency for --- spread Nerve growth may display skip lesions resulting in incomplete excision Distant metastasis --- (visceral rather than nodal spread) 5 year survival 35% Mixed tumours Often a malignancy occurring in a previously benign -- lesion ``` Acinic cell carcinoma --- grade malignancy May show -- invasion --- potential for distant metastasis 5 year survival -- ``` Adenocarcinoma Develops from -- portion of gland Risk of regional nodal and distant metastasis 5 year survival depends upon stage at presentation, may be up to -- with small lesions with no nodal involvement Lymphoma Large rubbery lesion, may occur in association with ---tumours Diagnosis should be based on regional nodal biopsy rather than --- Treatment is with --- (and radiotherapy)

Answer 28

Malignant salivary gland tumours Types of malignancy Mucoepidermoid carcinoma 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) Adenoid cystic carcinoma Unpredictable growth pattern Tendency for perineural spread Nerve growth may display skip lesions resulting in incomplete excision Distant metastasis more common (visceral rather than nodal spread) 5 year survival 35% Mixed tumours Often a malignancy occurring in a previously benign parotid lesion Acinic cell carcinoma Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80% Adenocarcinoma Develops from secretory portion of gland Risk of regional nodal and distant metastasis 5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement Lymphoma Large rubbery lesion, may occur in association with Warthins tumours Diagnosis should be based on regional nodal biopsy rather than parotid resection Treatment is with chemotherapy (and radiotherapy)

Question 29

Patients who have received an organ transplant are at risk of --cancer (particularly --- carcinoma) due to long-term use of --

Answer 29

Patients who have received an organ transplant are at risk of skin cancer (particularly squamous cell carcinoma) due to long-term use of immunosuppressants

Question 30

-- is recommended to start early in the course of COPD, as soon as patients start feeling shortness of breath with regular activity

Answer 30

Pulmonary rehabilitation is recommended to start early in the course of COPD, as soon as patients start feeling shortness of breath with regular activity

Question 31

COPD: stable management General management >--cessation advice: including offering nicotine replacement therapy, -- or --- annual ---vaccination one-off --- vaccination --- to all people who view themselves as functionally disabled by COPD Bronchodilator therapy a --- or --- is first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness' No asthmatic features/features suggesting steroid responsiveness: add a --- + --- if already taking a SA-A, discontinue and switch to a SA-A Asthmatic features/features suggesting steroid responsiveness LA-A + inhaled --- if patients remain breathless or have exacerbations offer triple therapy i.e. LA-A + LA-A + -- if already taking a SA--A, discontinue and switch to a SA--A NICE recommend the use of combined inhalers where possible Oral theophylline NICE only recommends theophylline after trials of --- or to people who cannot used inhaled therapy the dose should be reduced if --- or -- antibiotics are co-prescribed Oral prophylactic antibiotic therapy -- prophylaxis is recommended in select patients patients should not smoke, have optimised standard treatments and continue to have exacerbations other prerequisites include a --- thorax (to exclude bronchiectasis) and ---- (to exclude atypical infections and tuberculosis) LFTs and an ECG to exclude -- prolongation should also be done as --- can prolong the --- interval M--- should be 'considered' in patients with a chronic productive cough and continued if symptoms improve Cor pulmonale features include --- oedema, raised ---, systolic -- heave, loud P- use a --- for oedema, consider long-term oxygen therapy ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE Factors which may improve survival in patients with stable COPD smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients

Answer 31

Next question COPD: stable management NICE updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. General management >smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion annual influenza vaccination one-off pneumococcal vaccination pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above) Bronchodilator therapy a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness' There are a number of criteria NICE suggest to determine whether a patient has asthmatic/steroid responsive features: any previous, secure diagnosis of asthma or of atopy a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up substantial variation in FEV1 over time (at least 400 ml) substantial diurnal variation in peak expiratory flow (at least 20%) Interestingly NICE do not recommend formal reversibility testing as one of the criteria. In the guidelines they state that 'routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading...'. They then go on to discuss why they have reached this conclusion. Please see the guidelines for more details. No asthmatic features/features suggesting steroid responsiveness add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) if already taking a SAMA, discontinue and switch to a SABA Asthmatic features/features suggesting steroid responsiveness LABA + inhaled corticosteroid (ICS) if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS if already taking a SAMA, discontinue and switch to a SABA NICE recommend the use of combined inhalers where possible Oral theophylline NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed Oral prophylactic antibiotic therapy azithromycin prophylaxis is recommended in select patients patients should not smoke, have optimised standard treatments and continue to have exacerbations other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis) LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval Mucolytics should be 'considered' in patients with a chronic productive cough and continued if symptoms improve Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2 use a loop diuretic for oedema, consider long-term oxygen therapy ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE Factors which may improve survival in patients with stable COPD smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients

Question 32

Peri-arrest rhythms: tachycardia If any of the above adverse signs are present then synchronised DC shocks should be given Treatment following this is given according to whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular Broad-complex tachycardia Regular assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block) loading dose of --- followed by 24 hour --- Irregular 1. AF with bundle branch block - treat as for --- 2. Polymorphic VT (e.g. Torsade de pointes) - IV --- Narrow-complex tachycardia Regular --- manoeuvres followed by IV --- if above unsuccessful consider diagnosis of --and control -- (e.g. Beta-blockers) Irregular probable atrial fibrillation if onset < 48 hr consider ---- rate control (e.g. ) and ---

Answer 32

Broad-complex tachycardia Regular assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block) loading dose of amiodarone followed by 24 hour infusion Irregular 1. AF with bundle branch block - treat as for narrow complex tachycardia 2. Polymorphic VT (e.g. Torsade de pointes) - IV magnesium Narrow-complex tachycardia Regular vagal manoeuvres followed by IV adenosine if above unsuccessful consider diagnosis of atrial flutter and control rate (e.g. Beta-blockers) Irregular probable atrial fibrillation if onset < 48 hr consider electrical or chemical cardioversion rate control (e.g. Beta-blocker or digoxin) and anticoagulation

Question 33

Klebsiella pneumonia-> commonly due to-- Klebsiella pneumonia is more common in -- and patients with a history of ----. It is also frequently caused by ---. Klebsiella commonly affects the --- lobes of the lungs. Haemophilus influenzae is common in--- patients with --- and can present as a --- pneumonia. It does not cause 'red-currant jelly' sputum. Mycoplasma is an --- pneumonia which classically presents with a gradual onset dry cough and occasionally other features, such as --- and erythema multiforme. Staphylococcus aureus pneumonia commonly occurs after influenza and can also be a complication of ---infection. On chest x-ray, --- consolidation, c--- or a p---- might be seen. Streptococcus pneumoniae is the most common cause of pneumonia and characteristically presents with a --- and --- chest pain.

Answer 33

aspiration Klebsiella pneumonia is more common in diabetics and patients with a history of alcohol excess. It is also frequently caused by aspiration. In this scenario, the recent stroke has caused problematic dysphagia. Klebsiella commonly affects the upper lobes of the lungs. Haemophilus influenzae is common in older patients with chronic obstructive pulmonary disease (COPD) and can present as a hospital-acquired pneumonia. It does not cause 'red-currant jelly' sputum. Mycoplasma is an atypical pneumonia which classically presents with a gradual onset dry cough and occasionally other features, such as autoimmune haemolytic anaemia and erythema multiforme. Staphylococcus aureus pneumonia commonly occurs after influenza and can also be a complication of measles infection. On chest x-ray, multi-lobar consolidation, cavitation or a pneumothorax might be seen. Streptococcus pneumoniae is the most common cause of pneumonia and characteristically presents with a high fever and pleuritic chest pain.

Question 34

Blisters/bullae no mucosal involvement (in exams at least*): ---- mucosal involvement: ---

Answer 34

Blisters/bullae no mucosal involvement (in exams at least*): bullous pemphigoid mucosal involvement: pemphigus vulgaris

Question 35

``` ECG features of hypokalaemia -- waves small or absent -- waves (occasionally inversion) prolong --- interval -- depression long --- ```

Answer 35

``` ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT ``` One registered user suggests the following rhyme In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

Question 36

To convert from oral morphine to diamorphine the total daily morphine dose should be divided by -- (120 / -- = ---mg)

Answer 36

To convert from oral morphine to diamorphine the total daily morphine dose should be divided by 3 (120 / 3 = 40mg)

Question 37

Palliative care prescribing: pain. NICE guidelines Starting treatment when starting treatment, offer patients with advanced and progressive disease regular --- (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain if no comorbidities use ---mg of MR a day with --mg morphine for breakthrough pain. For example, --mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required --- morphine should be used in preference to transdermal patches --- should be prescribed for all patients initiating strong opioids patients should be advised that nausea is often transient. If it persists then an --- should be offered drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered

Answer 37

Starting treatment when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required oral modified-release morphine should be used in preference to transdermal patches laxatives should be prescribed for all patients initiating strong opioids patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered

Question 38

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points the breakthrough dose of morphine is one--- the daily dose of morphine all patients who receive opioids should be prescribed a --- opioids should be used with caution in patients with chronic kidney disease ---e is preferred to morphine in palliative patients with mild-moderate renal impairment if renal impairment is more severe, --, -- and ---are preferred metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that--- are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy

Answer 38

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points the breakthrough dose of morphine is one-sixth the daily dose of morphine all patients who receive opioids should be prescribed a laxative opioids should be used with caution in patients with chronic kidney disease oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy

Question 39

Conversion between opioids From To Conversion factor Oral codeine Oral morphine Divide by -- Oral tramadol Oral morphine Divide by --- Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation. From To Conversion factor Oral morphine Oral oxycodone Divide by --- transdermal perparations a transdermal fentanyl 12 microgram patch equates to approximately -- mg oral morphine daily a transdermal buprenorphine 10 microgram patch equates to approximately -- mg oral morphine daily. From To Conversion factor Oral morphine--Subcutaneous morphineDivide by Oral morphine--Subcutaneous diamorphineDivide by Oral oxycodone--Subcutaneous diamorphineDivide by --

Answer 39

Conversion between opioids From To Conversion factor Oral codeine Oral morphine Divide by 10 Oral tramadol Oral morphine Divide by 10** Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation. From To Conversion factor Oral morphine Oral oxycodone Divide by 1.5-2*** The current BNF gives the following conversion factors for transdermal perparations a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily. From To Conversion factor Oral morphine Subcutaneous morphine Divide by 2 Oral morphine Subcutaneous diamorphine Divide by 3 Oral oxycodone Subcutaneous diamorphine Divide by 1.5

Question 40

Small bowel bacterial overgrowth syndrome (SBBOS) Risk factors for SBBOS --- with congenital gastrointestinal abnormalities s--- d--- Diagnosis --- --aspiration and culture: clinicians may sometimes give a course of -- as a diagnostic trial Management correction of underlying disorder antibiotic therapy: --- is now the treatment of choice due to relatively low resistance. ---or --- are also effective in the majority of patients.

Answer 40

Risk factors for SBBOS neonates with congenital gastrointestinal abnormalities scleroderma diabetes mellitus It should be noted that many of the features overlap with irritable bowel syndrome: chronic diarrhoea bloating, flatulence abdominal pain Diagnosis hydrogen breath test small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce clinicians may sometimes give a course of antibiotics as a diagnostic trial Management correction of underlying disorder antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.

Question 41

Peptic ulcer disease (uncomplicated) Risk factors drugs:x4 -- syndrome: rare cause characterised by excessive levels of --, usually from a --- secreting tumour the role of alcohol and smoking is not clear

Answer 41

Peptic ulcer disease (uncomplicated) Risk factors Helicobacter pylori is associated with the majority of peptic ulcers: 95% of duodenal ulcers 75% of gastric ulcers drugs: NSAIDs SSRIs corticosteroids bisphosphonates Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from a gastrin secreting tumour the role of alcohol and smoking is not clear

Question 42

Non-invasive ventilation - key indications COPD with --- type -- respiratory failure secondary to -- cardiogenic pulmonary oedema unresponsive to --- weaning from tracheal intubation

Answer 42

Non-invasive ventilation - key indications COPD with respiratory acidosis pH 7.25-7.35* type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea cardiogenic pulmonary oedema unresponsive to CPAP weaning from tracheal intubation

Question 43

Gestation Purpose of visit 8 - 12 weeks (ideally < 10 weeks) x5 10 - 13+6 weeks 11 - 13+6 weeks 16 weeks x2 18 - 20+6 weeks 25 weeks (only if primip) x3 28 weeks x2 ``` 31 weeks (only if primip) Routine care as above 34 weeks Routine care as above Second dose of --- ``` Information on labour and birth plan 36 weeks Routine care as above Check presentation - offer external cephalic version if indicated Information on breast feeding, vitamin K, 'baby-blues' 38 weeks Routine care as above 40 weeks (only if primip) Routine care as above Discussion about options for prolonged pregnancy 41 weeks Routine care as above Discuss labour plans and possibility of induction

Answer 43

Gestation Purpose of visit 8 - 12 weeks (ideally < 10 weeks) Booking visit general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes BP, urine dipstick, check BMI Booking bloods/urine FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies hepatitis B, syphilis HIV test is offered to all women urine culture to detect asymptomatic bacteriuria 10 - 13+6 weeks Early scan to confirm dates, exclude multiple pregnancy 11 - 13+6 weeks Down's syndrome screening including nuchal scan 16 weeks Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron Routine care: BP and urine dipstick 18 - 20+6 weeks Anomaly scan 25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH) 28 weeks Routine care: BP, urine dipstick, SFH Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron First dose of anti-D prophylaxis to rhesus negative women 31 weeks (only if primip) Routine care as above 34 weeks Routine care as above Second dose of anti-D prophylaxis to rhesus negative women* Information on labour and birth plan 36 weeks Routine care as above Check presentation - offer external cephalic version if indicated Information on breast feeding, vitamin K, 'baby-blues' 38 weeks Routine care as above 40 weeks (only if primip) Routine care as above Discussion about options for prolonged pregnancy 41 weeks Routine care as above Discuss labour plans and possibility of induction