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MRCP Part 1 > Passmed > Flashcards

Passmed Flashcards

1
Q

What is the first line management for primary axillary hyperhidrosis?

A

Topical aluminium hydrochloride

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2
Q

Outline the management options for hyperhidrosis?

A
  • Topical aluminium hydrochloride
  • Iontophoresis - for palmar, plantar and axillary hyperhidrosis
  • Botulimun toxin - for axillary symptoms
  • Surgery - e.g. endoscopic transthoracic sympathectomy - beware risk of compensatory sweating
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3
Q

What is the single most important blood test in restless leg syndrome?

A

Serum ferritin

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4
Q

Causes and associations of restless leg syndrome?

A
  • Family history in 50%
  • Iron deficiency anaemia
  • Uraemia
  • Diabetes mellitus
  • Pregnancy
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5
Q

Aside from conservative management e.g. with walking stretching and massaging the limb, what medical management is there for restless leg syndrome?

A
  • First lie is dopamine agonists e.g. Pramipexole and Ropinirole
  • Treat any iron deficiency
  • Others include benzodiazepines, gabapentin
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6
Q

A 27-year-old man presents to the Emergency Department after a syncopal episode. On inspection of the neck veins he has a prominent ‘a’ wave. On auscultation of the heart, there is a harsh crescendo-decrescendo systolic murmur that is heard best at the apex and lower left sternal border.

What is the diagnosis?

A

HOCM

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7
Q

List some medications to be avoided in HOCM

A
  • Nitrates
  • ACE inhibitors
  • Nifedipine type calcium antagonists / inotropes (note non-dihydropyridines are ok)

Basically things that reduce preload / afterload

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8
Q

Intermittent dysphagia to solids and food impaction in association with asthma and peripheral blood eosinophilia. Did not respond to PPI trial - diagnosis?

A

Eosinophilic oesophagitis

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9
Q

Outline management of eosinophilic oesophagitis?

A
  • Dietary modification - elemental diet, exclude six food groups (common allergy groups like nuts, seafood etc) and targeted exclusion – involve dieticians for advice
  • Topical steroids - if dietary modification fails - e.g. fluticasone and budesonide - 8 week trial
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10
Q

Outline a few complications of eosinophilic oesophagitis?

A
  • Oesophageal strictures
  • Impaction
  • Mallory Weiss tears
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11
Q

At what point do you consider fibrinolysis in STEMI?

A

Within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes

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12
Q

What are the ECG criteria for STEMI?

A

Elevation of 2.5mm in leads V2-V3 in men under 40 or > 2.0mm in men over 40
1.5mm in V2-V3 in women
1mm ST elevation in other leads
New LBBB

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13
Q

In dual antiplatelet therapy prior to PCI in STEMI, which platelet can be added alongside aspirin if there is no other oral anticoagulant that the patient is on or what if they are on one?

A

No oral anticoag - asprin + prasugrel
On oral anticoag - aspirin + clopidogrel

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14
Q

Which other drugs are given during PCI?

A

If there is radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
If there is femoral access: bivaluridin with bailout GPI

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15
Q

What other procedures can be done during PCI excluding the medications you can give?

A
  • Thrombus aspiration
  • Complete revascularisation - considered for patients with multivessel coronary artery disease without cardiogenic shock
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16
Q

Patients undergoing fibrinolysis for STEMI management should also be given what other kind of drug?

What other monitoring should you do when you use a fibrinolytic drug plus this drug?

A

Antithrombin drugs
Repeat ECG after 60-90 minutes to see if ECG changes have resolved - if there is persistent myocardial ischaemia, then PCI should be considered

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17
Q

What is the primary interleukin causing HOTN in sepsis?

A

IL-1 0 stimulates endothelial release of PAF, NO and prostacyclin - causing vasodilation and vacular permeability

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18
Q

List some causes of respiratory alkalosis

A
  • Anxiety leading to hyperventilation
  • PE
  • Salicylate poisoning (N.B causes initial resp alk then later leads to acidosis)
  • CNS disorders: Stroke, subarachnoid haemorrhage, encephalitis
  • Altitude
  • Pregnancy
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19
Q

How to treat isolated systolic HTN?

A

Same treatment formula as standard HTN

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20
Q

Most common cause of traveller’s diarrhoea?

A

E.Coli

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21
Q

In Zolinger Ellison syndrome, what blood marker will be raised, and what secretion test can be used to further investigate Zollinger-Ellison Syndrome?

A

Serum Gastrin
Secretin stimulation test - this will increase secretion of bicarb rich fluid from pancreas and hepatic duct cells - and a positivce test will show markedly raised serum gastrin

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22
Q

What is primary and secondary prevention for hyperlidaemia management and what doses of medication do you give in each?

A

Primary prevention: 10yr cardiovascular risk >/- 10% OR most type 1 diabetics OR CKD if eGFR < 60ml/min/m2 - Atorvastatin 20mg OD

Secondary prevention: known ischaemic heart disease OR cerebrovascular disease or peripheral arterial disease - Arotvastatin 80mg OD

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23
Q

Which antibody can be tested for primary membranous glomerulonephropathy?

A

Anti-PLA2R antibodies

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24
Q

What are the causes of membranous nephropathy?

A

PRIMARY: Primary membranous nephropathy - most commonly associated with PLA2R antibodies
SECONDARY:
* Malignancy e.g. solid tumours (lung, colon, breast, kidney)
* Infections: hep B, C, HIB, malaraia, syphilis, schistosomiasis
* Autoimmune diseases - SLE, sarcoidosis, IBD
* Drugs - NSAIDs, captopril, gold, penicillamine, lithium, clopidogrel

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25
Q

What is the triad with which TTP presents?

A

Fever
Neuro signs
Thrombocytopaenia
Haemolytic anaemia
Renal failure

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26
Q

What investigation can be done to help diagnose TTP? (And therefore also helps differentiate it from HUS)

A

ADAMTS13 assay

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27
Q

When is skin patch test vs skin prick test done?

A
  • Skin patch test - contact hypersensitivity (not IgE mediated - it is a type IV hypersensitivity reaction)
  • Skin prick test - IgE mediated allergies e..g food or pollen allergies
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28
Q

.

A

Ergot derived dopamine agonists including Pergolide, Cabergoline, Bromocroptine for example can cause pulmonary and cardiac fibrosis

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29
Q

What goes wrong in chronic granulomatous deficiency?

A

Primary immunodeficiency caused by a defect in the NADPH oxidase complex, which is integral to function of phagocytic cells e.g. neutrophils. Impairs ability to generate reactive oxygen species necessary to kill certain types of bacteria and fungi

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30
Q

Inheritance pattern of Wiskott-Aldrich syndrome?

A

XLR

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31
Q

How does Wiskott-Aldrich syndrome present?

A
  • Eczema
  • Thrombocytopaenia
  • Immune deficiency including both T and B lymphocytes
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32
Q

Which anti-epileptic drug is contraindicated in absence seizures?

A

Carbamazepine

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33
Q

What is a Leukaemoid reaction? Plus list some causes

A

Presence of immature cells such as myeloblasts, promyelocytes and nucleated red cells in the peripheral blood. This may be due to infiltration of the bone marrow causing the immature cells to be pushed out or sudden demand for new cells

Causes:
* Severe infection
* Severe haemolysis
* Massive haemorrhage
* Metastatic cancer with bone marrow infiltration

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34
Q

Key differentiator between leukaemoid reaction and CML?

A

Leukaemoid reaction - high leucocyte alkaline phosphatase VS CML - low leucocyte alkaline phosphatase score

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35
Q

Genetic mutations causing nephrogenic diabetes insipidus - more and less common ones - what are they?

A
  • More common - affects the vasopressin (ADH) receptor
  • Less common - affects gene encoding the AQP2 channel
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36
Q

What type of glomerulonephritis is most characteristically associated with Wegener’s granulomatosis (Granulomatosis with Polyangiitis)?

A

Rapidly progressive glomerulonephritis

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37
Q

Deficiencies in which complement increases risk of infection with encapsulated organisms?

A

C5-9 deficiency

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38
Q

Which complement deificiency can cause hereditary angioedema?

A

C1 inhibitor protein deficiency (C1-INH)

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39
Q

C1 inhibitor protein deficiency (C1-INH) is linked to which condition?

A

Hereditary angioedema

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40
Q

Give some key features of leukaemoid reaction?

A
  • High leucocyte alkaline phosphatase score
  • Toxic granulation (Dohle bodies) in the white cells
  • ‘Left shift’ of neutrophils i.e. three or fewer segments of the nucleus
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41
Q

How does retroperitoneal fibrosis present?

A

Lower back / flank pain. Fever and lower limb oedema in some patients

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42
Q

List some associations to retroperitoneal fibrosis

A

Riedel’s thyroiditis
Previous radiotherapy
Sarcoidosis
Inflammatory abdominal aortic aneurysm
Drugs: Methysergide

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43
Q

What is the inheritance pattern of achondroplasia? And which gene is mutated?

A

Autosomal dominant mutation in FGFR-3 gene

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44
Q

How do mutations causing achondroplasia usually arise?

A

70% are sporadic mutations. Once present the mutations are inherited in autosomal dominant fashion in the remaining 30% of cases

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45
Q

What is the most important association with HLA-A3?

A

Haemochromatosis

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46
Q

What is the most important association with HLA-B51?

A

Behcet’s disease

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47
Q

List some of the most important associations with HLA-B27?

A

Ankylosing Spondylitis
Reactive arthritis
Acute anterior uveitis
Psoriatic arthritis

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48
Q

What is the most important association with HLA-DQ2/DQ8?

A

Coeliac disease

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49
Q

What are the most important associations with HLA-DR2?

A

Narcolepsy
Goodpasture’s

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50
Q

List some of the most important associations with HLA-DR3

A

Dermatitis Herpetiformis
Sjogren’s syndrome
PBC

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51
Q

List 2 key associations with HLA-DR4

A

T1DM
Rheumatoid arthritis

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52
Q

How does anthrax present?

A

Painless black eschar, may cause oedema
Can cause axillary lympadenopathy
Can cause GI bleeding

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53
Q

In terms of nephrogenic diabetes insipidus, what are the 2 ones that can occur and which is more common?

A

More common - affects the vasopressin (ADH) receptor
Less common - affects AQP2

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54
Q

What is the management of nephrogenic and then of central diabetes insipidus?

A

Nephrogenic - thiazides, low salt / protein diet
Central - desmopressin

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55
Q

True or false - memantine is indicated in mild dementia

A

False

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56
Q

Which clotting factors are dependent on vitamin K?

A

Clotting factors II, VII, IX and X

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57
Q

What is the pattern of neuro symptoms in Brown-Sequard syndrome?

A

Ipsilateral weakness, loss of proprioception and vibration sensation with contralateral loss of pain and temperature sensation

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58
Q

Between Klinefelter’s and Kallmans which typically causes cryptorchidism and which microorchidism?

A

Kallman’s - cryptorchidism
Klinefelter’s - microorchidism

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59
Q

Which type of allergy test is useful for irritants?

A

Skin patch testing

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60
Q

Thiazides can cause which electrolyte abnormality?

A

Hypercalcaemia

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61
Q

A patient with clear NAFLD based on obesity and prediabetes and a comprehensive liver screen is subsequently performed and found to be normal. A liver ultrasound shows fatty infiltration with no focal lesions, biliary duct dilatation or gallstones. What is the next step investigation?

A

Enhanced liver fibrosis test to aid diagnosis of liver fibrosis

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62
Q

Between cervical and ovarian cancer which presents in younger (<45) more commonly and which is more common in nulliparity and which in parity > 3?

A

Cervical more common in < 45 and in people with para > 3, vs ovarian more likely in nullips

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63
Q

Which strains of HPV cause cervical cancer and by what mechanism?

A

HPV 16+18
HPV 16 - E6 gene inhibits the p53 tumour suppressor gene
HPV 18 - E7 gene inhibits the RB suppressor gene

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64
Q

Initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness

This is all describing which condition?

A

Cubital tunnel syndrome

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65
Q

What is the gold standard method of diagnosing coeliac’s disease?

A

Small bowel biopsy

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66
Q

Chronic diarrhoea with negative anti-TTG and no blood or abdo pain and no extra intestinal manifestations. Takes PPIs long term - likely diagnosis?

A

Microscopic colitis

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67
Q

Give a class of drugs that inhibits bacterial cell wall formation and 2 drug names

A

Glycopeptide antibiotics - teicoplanin and vancomycin

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68
Q

Give some drug classes that inhibit bacterial protein synthesis

A
  1. Macrolides
  2. Aminoglycosides
  3. Tetracyclines
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69
Q

What class of antibiotics inhibit DNA synthesis?

A

Quinolones e.g. ciprofloxacin

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70
Q

Give an example antibiotic that inhibits bacterial RNA synthesis

A

Rifampicin

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71
Q

Name some antibiotics that inhibit bacterial folic acid formation

A

Trimethoprim
Co-trimoxazole
Sulphonamides

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72
Q

Give an antibiotic name that damages DNA

A

Metronidazole

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73
Q

Which chemotherapeutic agent can cause cardiomyopathy?

A

Doxorubicin can cause dose-dependent cardiotoxicitty - can manifest as CHF

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74
Q

Main side effect of Bleomycin?

A

Pulmonary fibrosis

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74
Q

Main side effects of Paclitaxel and Docetaxel?

A

Peripheral neuropathy, Myelosuppression (and neutropaenia), and Hypersensitivity reactions

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75
Q

Main side effects of Dactinomycin?

A

Myelosuppression
GI toxicity

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76
Q

Why can diagnosis of malaria be difficult in pregnant women?

A

Due to placental sequestration of parasites - so may not be as visible on the blood film

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77
Q

Which anti-malarial is contra-indicate in epilepsy?

A

Mefloquine

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78
Q

What is the most appropriate anti-malarial prophylaxis in South East Asia?

A

Atovaquone + Proguanil (Malarone)
N.B there is high cholroquine resistance in S.E Asia therefore malarone preferable

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79
Q

Which anti-malarials can be used in pregnant women?

A

Chloroquine
Proguanil (but should be alongside folate 5mg OD)

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80
Q

Outline the early and late x-ray changes in rheumatoid arthritis

A

Early - loss of joint space, juxta-articular osteopaenia / osteoporosis and soft tissue swelling
Late - joint subluxation and periarticular erosions

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81
Q

What is likely to be found on renal biopsy in granulomatosis with polyangiitis (Wegener’s)

A

Crescentic glomerulonephritis

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82
Q

How does quinine toxicity present?

A

ECG changes e.g. prolonged QR interval
HOTN
Metabolic acidosis
Hypoglycaemia
Tinnitus
Flushing
Visual disturbance
(Sometimes flash pulmonary oedema)

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83
Q

Tinnitus is typical of overdose to which two substances?

A
  1. Aspirin
  2. Quinine
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84
Q

Lamotrigine can cause which dermatological emergency?

A

Stevens-Johnson syndrome

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85
Q

Blood glucose targets in pregnancy
1) Fasting? (mmol/L)
2) After oral glucose tolerance test?(mmol/L)

A

1) < 5.3 mmol/L
2) < 6.4 mmol/L

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86
Q

In gestational diabetes, if blood glucose targets are not met with diet / metformin - what is the next step?

A

Add on insulin

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87
Q

Is it common for discoid lupus to progress to SLE?

A

No - only in 5-10% of cases

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88
Q

How is discoid lupus managed?

A

Topical steroid cream
Oral antimalarials second line e.g. hydroxychloroquine
Avoid sun exposure

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89
Q

In management of medication overuse headaches we basically withdraw the medication, in which circumstances do we do so abruptly and in which circumstances do we do so gradually?

A

Simple analgaesia + triptans - stop abruptly
Opioid analgaesia - withdraw gradually

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90
Q

What is the most common side effect of ciclosporin?

A

Nephrotoxicity

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91
Q

How is neurogenic bladder managed in MS patients?

A

First do an ultrasound to assess post void residual volume
1. If significant residual volume: intermittent self catheterisation
2. If non-significant residual volume: anticholinergics

Note we do this because anticholinergics can actually worsen neurogenic bladder in those with high residual volume

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92
Q

What is the gold standard investigation of GORD?

A

24hr oesophageal pH monitoring

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93
Q

What is alpha-1 antitrypsin and why does deficiency cause emphysema and cirrhosis?

A

Protease inhibitor of neutrophil elastase

Alpha-1 antitrypsin is produced by the liver and by inhibiting neutrophil elastase it helps protect the lungs and liver against these

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94
Q

What is the best marker of severity in acute pancreatitis?

A

CRP

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95
Q

What investigation is diagnostic for SBOSS?

A

Hydrogen breath test

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96
Q

What is first and second line management of migraines in pregnancy?

A

1st line - paracetamol 1g
2nd line - NSAIDs in first and second trimester

Avoid aspirin and opioids in pregnancy

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97
Q

How does SIGN recommend migraines are managed in menstruation?

A

Mefenamic acid or combination of aspirin, paracetamol and caffeine
Triptans in the acute situation

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98
Q

What is first line management in open angle glaucoma with a raised IOP > 24mmHg?

A

360 degrees selective laser trabeculoplasty

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99
Q

Aside from surgical management with selective laser trabeculoplasty in those with > 24mmHg IOP, what is medical management options for open angle glaucoma - 1st line then some other second line options?

A

First line - Latanoprost

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100
Q

What is a key differentiator in clinical presentation of TRALI vs TACO?

A

TRALI - HOTN
TACO - HTN

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101
Q

How does non-haemolytic febrile reaction to blood transfusion present and what is the management of this?

A

Fever, chills

Rx = Slow or stop the transfusion, paracetamol, monitor

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102
Q

How to manage minor allergic reaction to blood transfusion

A

Rx = temporarily stop the transfusion, antihistamine, monitor

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103
Q

How does acute haemolytic reaction to blood transfusion present and how to manage this?

A

Fever, abdominal pain, HOTN

Rx = stop transfusion, fluid resuscitation
Check the identity of the patient and name on the blood product, send the blood for direct Coomb’s test, repeat typing and cross-matching

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104
Q

How does transfusion-associated circulatory overload (TACO) present and how to manage this?

A

Pulmonary oedema, HTN
Rx = slow or stop transfusion, consider IV diuretic e.g. furosemide and O2

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105
Q

How does TRALI present and how to manage?

A

Hypoxia, pulmonary infiltrates on CXR, fever, HOTN

Rx = stop the transfusion, oxygen and supportive care

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106
Q

Neonatal lupus erythematous is associated with which antibodies? and complications of this include?

A

Anti-SSA / Ro antibodies

Complications: congenital heart block, skin rashes and hepatosplenomegaly

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107
Q

A 27-year-old farmer has been brought to the emergency department after being found unconscious in a barn.

On initial examination he is agitated and combative with hypersalivation with excessive production of respiratory secretions. There is evidence of diaphoresis, urinary and faecal incontinence and miosis along with muscle fasciculations.

What is the likely diagnosis, what happens to the heart rate in this condition and what is the management of this condition?

A

Organophosphate poisoning
Bradycardia

Rx = atropine
? pralidoxime is undergoing research into viability as rx option

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108
Q

How is oscillopsia in multiple sclerosis managed first line?

A

Gabapentin

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109
Q

How is fatigue in multiple sclerosis managed?

A

Trial of amantadine
Other options: mindfulness training and CBT

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110
Q

Patient with pre-diabetes has lost weight on follow up appt but his HbA1C is still keeping creeping up - what to do?

A) Start metformin
B) Start pioglitazone
C) Review again in 12 months
D) Start orlistat
E) Do an OGTT

A

A) Start metformin

NICE recommend metformin for adults at high risk ‘whose blood glucose measure (fasting plasma glucose or HbA1C) shows they are still progressing towards type 2 diabetes, despite their participation in an intensive lifestyle-change programme’

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111
Q

Summarise the duration of anticoagulant therapy in PE

A

Provoked = 3 months
Provoked but also active cancer with confirmed proximal DVT or PE = up to 6 months
Unprovoked = 6 months
Unprovoked PE or persistent risk factors e.g. antiphospholipid syndrome, active cancer or thrombophilia

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112
Q

What are the management options for motion sickness?

A
  1. Hyoscine - transdermal patches
  2. Cyclizine or cinnarizine (non-sedating anti-histamines)
  3. Promethazine (sedating anti-histamine)
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113
Q

Drug induced liver disease - list some drugs that can cause a hepatocellular picture

A

Paracetamol
Sodium valproate, phenytoin
MAOIs
Halothane
Anti-TB meds - rifampicin, isoniazid, pyrazinamide
Statins
Alcohol
Amiodarone
Methyldopa
Nitrofurantoin

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114
Q

Drug induced liver disease - list some drugs that can cause a cholestatic picture

A

COCP
Abx: flucloxacillin, co-amoxiclav, erythromycin
Anabolic steroids, testosterones
Phenothiazines: chlorpromazine, prochlorperazine
Sulphonylureas
Fibrates
Rare reported causes: Nifedipines

115
Q

List 3 cause of drug induced liver disease that can cause liver cirrhosis

A

Methotrexate, Methyldopa, Amiodarone

116
Q

List the antibiotics that inhibit protein synthesis by acting on
1) 30S ribosomal subunit
2) 50S ribosomal subunit

A

1) Buy AT 30 = aminoglycosides, tetracyclines
2) CCELS at 50 = chloramphenicol, clindamycin, erythromycin / macrolides, linezolid, streptogrammins

117
Q

Which clotting factors are affected by warfarin?

A

Use the mnemonic warfarin 1972
10, 9, 7, 2

118
Q

What is the gold standard test for PNH?

A

Flow cytometry of blood to detect low levels of CD59 and CD55

119
Q

Outline management for PNH

A

Blood product replacement
Anticoagulation
Eculizumab is undergoing research
SCT

120
Q

What is the half life of amiodarone?

A

Approx 20-100 days

121
Q

Outline the steps in medical management of angina pectoris

A

1.

122
Q

Between adenocarcinoma and squamous cell carcinoma which portions of the oesophagus are affected in each?

A

Squamous cell carcinoma - upper and middle portions
Adenocarcinoma - lower portion

123
Q

What is first line then second line then third line management for c.diff infection?

A
  1. First line = oral vancomycin
  2. Second line = oral fidaxomycin
  3. Third line = oral vancomycin +/- IV metronidazole
124
Q

What is the management in the case of recurrent c.diff infection
1) Within 12 weeks of symptom resolution
2) After 12 weeks of symptom resolution

A

1) Oral fidaxomicin
2) Oral vancomycin OR fidaxomycin

125
Q

How is c.diff spread prevented - what are the isolation procedures?

A

Patient should be isolated in side room until no diarrhoea (type 5-7 on bristol stool chart) for at least 48 hours

126
Q

What cardiac abnormalities are associated with carcinoid syndrome?

A

Carcinoid TIPS

Tricuspid insufficiency and pulmonary stenosis

Affects the right side of the heart

127
Q

What is the main management of carcinoid syndrome?
What other drug can be used for management of diarrhoea in carcinoid tumours?

A

Somatostatin analogues e.g. octreotide
Diarrhoea - cyproheptadine may help

128
Q

What is the most useful marker to screen for haemochromatosis?

A

Transferrin saturation

129
Q

What are the management options for haemochromatosis?

A

Venesection is first line - monitoring - transferrin saturation should be kept < 50% and the serum ferritin concentration below 50 ug/L

Desferrioxamine may be used second line

130
Q

What are the triad of symptoms / signs in Budd-Chiari syndrome?

A
  1. Ascites
  2. Abdominal pain
  3. Hepatomegaly
131
Q

What is the initial investigation in Budd-Chiari syndrome?

A

Ultrasound with doppler flow studies

132
Q

List some causes of Budd-Chiari syndrome

A

Polycythaemia rubra vera
Thrombophilia - activated protein C resistance, antithrombin III deficiency, protein C and S deficiencies
Pregnancy
COCP for 20% of cases

133
Q

What type of cells do gastrinomas originate from?

A

G cells

134
Q

What investigation is a test of exocrine function in chronic pancreatitis?

A

Faecal elastase

135
Q

Name the laxative that is only considered in palliative patients due to its carcinogenic potential

A

Co-danthramer

136
Q

What is the management for life threatening c.diff?

A

Oral vancomycin and IV metronidazole

137
Q

What investigation is the most appropriate to assess the effectiveness of treatment in post-eradication therapy?

A

Urea breath test

138
Q

What is first line management of variceal bleeding in patients with medium or large oesophageal varices that have not bled?

A

Propanolol

139
Q

How does propanolol help prevent oesophageal bleeding?

A

Reduces cardiac output and sphlanchnic blood flow

139
Q

How is terlipressin good in controlling variceal bleeding?

A

It is a VP analogue and causes sphlanchnic vasoconstriction thus reducing portal venous inflow

140
Q

Which antibodies are associated with autoimmune hepatitis…?
1) Type 1?
2) Type 2?
3) Type 3?

A

1) Type 1 - anti-ANA and or anti-SMA
2) Type 2 - Anti-LKM1
3) Type 3 Soluble liver kidney antigen

141
Q

What is the management of autoimmune hepatitis?

A

1) Steroids
2) Other immunosuppressants e.g. azathioprine
3) Liver transplant

142
Q

What are two characteristic findings on liver biopsy of autoimmune hepatitis?

A

Inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis

143
Q

What is the gold standard investigation in Whipple’s disease and what is the key finding?

A

Jejunal biopsy and shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules

144
Q

What is the management of Whipple’s disease?

A

Oral co-trimoxazole for 1 year sometimes preceded by course of IV penicillin

145
Q

Whipple’s disease is caused by which organism infection?

A

Tropheryma Whippeli

146
Q

Features of Whipple’s disease?

A

Malabsorption - diarrhoea, weight loss
Large joint arthralgia
Lymphadenopathy
Skin - hyperpigmentation and photosensitivity
Pleurisy, pericarditis
Neuro symptoms (rarely) - ophthalmoplegia, dementia, seizures, ataxia, myoclonus

147
Q

What is the management of small bowel overgrowth syndrome?

A

Rifaximin is first line, correct underlying disorder

148
Q

What is the most common cause of HCC
1) Worldwide?
2) In the UK?

A

1) Worldwide - Hep B
2) UK - Hep C

149
Q

What is the management of Gilbert’s syndrome?

A

Nothing really - education and avoidance of triggers only

150
Q

How is Gilbert’s further investigated once suspected (i.e. already know there is isolated unconjugated hyperbilirubinaemia in context of stressors)?

A

Rise in bilirubin following prolonged fasting or IV nicotinic acid

151
Q

Which part of the colon most affected by ischaemic colitis?
Also why not the hepatic flexure as commonly?

A

Splenic flexure - watershed area

Hepatic flexure also well supplied by SMA so less likely affected

152
Q

People with FAP are also at risk of what other type of tumours?

A

Duodenal tumours

153
Q

FAP is what inheritance pattern and which gene on which chromosome

A

Autosomal dominant
APC gene on chromosome 5

154
Q

What is the key management in FAP?

A

Proctocolectomy with ileal pouch anal anastamosis

155
Q

What testing is done in NAFLD to test for enhanced liver fibrosis?

A

ELF blood test - hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1 - combines to create a score - score > 10/5 - enhanced liver fibrosis - refer to liver specialist and likely biopsy

156
Q

First line investigation in ascending cholangitis?

A

Ultrasound

157
Q

What scoring system is used to determine alcoholic hepatitis severity? And at what score do we consider corticosteroids?

A

Maddrey’s discriminant function

Score > 32 usually

158
Q

List some causes of hepatosplenomegaly?

A

Chronic liver disease with portal HTN
Infections - glandular fever, malaria, hepatitis
Lymphoproliferative disorders
Myeloproliferative disorders e.g. CML
Amyloidosis

159
Q

What is first line management for chronic anal fissure?

A

Topical GTN

Note if this is not effective after 8 weeks then secondary care referral should be considered for surgery (sphinchterotomy) or botulinum toxin

160
Q

What is a common cause of diarrhoea following ileal resection in Crohn’s disease?

A

Malabsorption of bile salts

Managed with oral colestyramine

161
Q

Patient with ileal resectio for management of Crohn’s has chronic diarrhoea and you think it is because of malabsorption of bile salts - how is this managed?

A

Oral colestyramine

162
Q

Features of Whipple’s disease?

A

Weight loss, worn out joints (arthralgia)
Hyperpigmentation, hyperactive bowel (diarrhoea)
Inadequate absorption of vitamins, minerals
Pleurisy
Pericarditis
Lymphadenopapthy
Elevated macrophages on biopsy

163
Q

A 67-year-old man is investigated for dyspepsia. A gastroscopy reveals a suspicious lesion which is biopsied. What is the characteristic finding on biopsy would be most consistent with a diagnosis of gastric adenocarcinoma?

A

Signet ring cells

164
Q

Colonoscopy findings of dark brown discolouration in the proximal colon and biopsy findings of pigment laden macrophages in the lamina propria (melanosis coli) in a young woman with diarrhoea and weight loss - diagnosis?

A

Laxative abuse - especially anthroquine compounds such as senna

165
Q

True or false, pellagra (dermatitis, dementia and diarrhoea) can be seen in carcinoid syndrome? Why / why not?

A

True - because tryptophan (which would normally be converted into niacin - vitamin B3) gets diverted into producing excess serotonin. Resulting niacin deficiency leads to pellagra

166
Q

A 28-year-old man undergoes an ileocaecal resection to treat terminal ileal Crohns disease. Post operatively he attends the clinic and complains of diarrhoea. His CRP is within normal limits and small bowel enteroclysis shows no focal changes. What medication would be helpful?

A

Oral cholestyramine - malabsorption of bile salts is common cause of diarrhoea following ileal resection.

167
Q

A 34-year-old female with a history of alcoholic liver disease is admitted with frank haematemesis. She was discharged three months ago following treatment for bleeding oesophageal varices. Following resuscitation, what is the most appropriate treatment whilst awaiting endoscopy?

A

Terlipressin - according to British Society of Gastroenterology guidelines, terlipressin should be administered as soon as variceal bleeding is suspected and continued until an endoscopy can be performed

168
Q

In oesophageal cancer what investigation is used for:
1) Initial staging?
2) Locoregional staging?

A

1) Initial staging - CT
2) Locoregional staging - EUS (endoscopic u/s) - this is helpful in assessing mural invasion

169
Q

What is the most common cause of biliary disease in patients with HIV?

A

Sclerosing cholangitis due to infections e.g. CMV, Cryptospordium and Microsporidia

170
Q

True or false PPIs can increase risk of c.diff - why or why not?

A

True - because less gastric acid production - more facilitative to survival of c.diff

171
Q

What is the inheritance pattern of Peutz-Jegher syndrome?

A

Autosomal dominant

172
Q

What score is used to assess malnutrition?

A

MUST score

173
Q

What investigation is done to monitor response to treatment (venesection) in haemochromatosis?

A

Ferritin and transferrin saturation

174
Q

What vaccination should be given to people with Coeliac’s and how often, and why?

A

Pneumococcal vaccination every 5 years as people with Coeliac’s can have functional hyposplenism increasing susceptibility to encapsulated organisms

175
Q

What investigation is first line for diagnosis of small bowel overgrowth syndrome?

A

Hydrogen breath testing

176
Q

A 45-year-old man is admitted to the Emergency Department with severe abdominal pain. He smokes 20 cigarettes a day and drinks approximately 50 units of alcohol per week. He also complains of sudden deterioration in vision. Fundoscopy reveals shows multiple micro infarcts (cotton wool spots). Your consultant requests amylase as they are considering ?pancreatitis. What is likely going on with the eyes?

A

Purtscher Retinopathy - can be seen following head trauma and in conditions such as acute pancreatitis, fat embolisation, amniotic fluid embolisation and vasculitic diseases

177
Q

What is the inheritance pattern of Dubin Johnson syndrome?

A

Autosomal recessive

178
Q

Does Dubin Johnson syndrome cause unconjugated or conjugated hyperbilirubinaemia? Why?

A

Conjugated hyperbilirubinaemia - there is a defect in the canalicular multispecific organic anion transporter (MRP2), which hinders the excretion of conjugated bilirubin into bile. This leads to a buildup of conjugated bilirubin in the liver cells and its subsequent leakage into blood, causing a conjugated hyperbilirubinaemia.

179
Q

What is the prognosis of Dubin Johnson syndrome?

A

Typically has a benign course with patients usually living a normal life span without clinical impairment. Main manifestation is intermittent jaundice which does not cause significant morbidity

180
Q

A 72-year-old woman presents to the emergency department with three months of black stools and shortness of breath. She has a past medical history of knee osteoarthritis. She drinks 10 units of alcohol per week.

On examination, there is an ejection systolic murmur in the aortic area radiating to the carotids. The blood pressure is 110/90 mmHg. The abdominal examination is unremarkable. She has conjunctival pallor.

What is a unifying explanation for the presentation?

A

Angiodysplasia - angiodysplasia is associated with aortic stenosis

181
Q

What heart thing is angiodysplasia associated with?

A

Aortic stenosis

182
Q

Where are most gastrinomas found? And second most common place?

A

Most often in the first part of the duodenum
Second most common - pancreas

183
Q

What does the MELD score test?

A

MELD score assesses the severity of end-stage liver disease

184
Q

What stimulation test can be useful to investigate the cause of pancreatic malabsorption?

A

Secretin stimulation test

185
Q

What are the 2 types of hepatorenal syndrome?

A

Type 1 - rapid onset hepatorenal syndrome
Type 2 - gradual decline in renal function often associated with refractory ascites

186
Q

What has a better prognosis type 1 or type 2 hepatorenal syndrome?

A

Type 2 has a better prognosis but the prognosis is pretty poor in both

187
Q

What are the management options in hepatorenal syndrome?

A

Terlipressin
Volume expansion with 20% HAS
TIPSS
Liver transplantation

188
Q

True or false, lactulose is contraindicated in IBS?

A

True - lactulose can exacerbate IBS

189
Q

Liver pathologies and associated raised immunoglobulin subtypes - which subtype is raised in the following liver pathologies?
1) Alcoholic liver disease
2) Primary biliary cirrhosis
3) Autoimmune hepatitis

A

1) Alcoholic liver disease - IgA
2) Primary biliary cirrhosis - IgM
3) Autoimmune hepatitis - IgG

190
Q

What is the management of autoimmune hepatitis?

A

Steroids, other immunosuppressant drugs e.g. azathioprine
Liver transplantation

191
Q

Which antibodies are associated with the following types of autoimmune hepatitis?
1) Type 1?
2) Type 2?
3) Type 3?

A

1) Type 1 - Anti ANA, Anti-SMA
2) Type 2 - Anti-LKM1
3) Type 3 - Anti-SLKA

192
Q

What percentage of normal energy and protein requirements should you give via enteral feeding to avoid refeeding syndrome in starved patients?

A

50% of normal energy intake in starved patients (< 5 days) to avoid refeeding syndrome

193
Q

What is the management of gastric MALT lymphoma?

A

H.Pylori eradication, regardless of H.Pylori status can lead to regression of the tumuor in a significant proportion of patients

194
Q

What is the management of Barret’s oesophagus?

A

High dose PPIs then endoscopic surveillance with biopsies every 3-5 years - then if any dysplasia is found can then consider things like first line radiofrequency ablation and then endoscopic mucosal resection

195
Q

List some causes of villous atrophy on jejunal biopsy

A

Coeliac’s disease
Tropical sprue
Hypogammaglobulinaemia
Whipple’s disease

196
Q

True or false histologically you would find multiple granulomas in Crohn’s not UC?

A

True - granulomas more suggestive of Crohn’s than UC

197
Q

Inflammation goes to which layer of the gut wall in UC vs in Crohn’s?

A

UC - limited to mucosal layer
Crohn’s - can affect all layers of the bowel wall including the serosa

198
Q

Skip lesions in UC or Crohn’s?

A

Crohn’s

199
Q

Goblet cell depletion in UC or Crohn’s?

A

UC

200
Q

Which of the following features of haemochromatosis are reversible with treament and which are not….

1) Cardiomyopathy
2) Hypogonadotrophic hypogonadism
3) Diabetes mellitus
4) Arthropathy
5) Liver cirrhosis

A

1) Cardiomyopathy - reversible
2) Hypogonadotrophic hypogonadism - irreversible
3) Diabetes mellitus - irreversible
4) Arthropathy - irreversible
5) Liver cirrhosis - irreversible

201
Q

Hyperchylomicronaemia or hypercholesterolaemia associated with acute pancreatitis?

A

Hyperchylomicronaemia (can be caused by hereditary lipoprotein lipase deficiency and apolipoprotein CII deficiency)

202
Q

Which coagulation factor does low molecular weight heparin inhibit the most and how does it do this?

A

Inhibits factor Xa by activating antithrombin III (therefore prevents downstream conversion of prothrombin to thrombin, thereby reducing clotting)

203
Q

List the causes of LBBB

A

MI
HTN
AS
Cardiomyopathy
Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia

204
Q

How long should a patient stop driving for following and elective cardiac angioplasty?

A

1 week

205
Q

Outline the KCH criteria for liver transplant in paracetamol overdose

A
  1. Arterial pH < 7.3, 24 hrs after ingestion
  2. PT > 100s
  3. Creatinine > 300 umol/L
  4. Grade III or IV encephalopathy
206
Q

What is the gold standard investigation for potential CLL?

A

Immunophenotyping (flow cytometry)
Most cases can be identified using a panel of antibodies specific for CD5, CD19, CD20 and CD23

207
Q

Acute angle closure glaucoma vs primary open angle which is associated with hypermetropia and which is associated with myopia?

A

Acute angle closure glaucoma associated with hypermetropia (farsightedness) vs primary open-angle glaucoma is associated with myopia (short-sightedness)

208
Q

What are the features of visceral leishmaniasis?

A
  1. Pyrexia
  2. Splenomegaly
  3. Pancytopaenia due to hypersplenism
  4. Weight loss
  5. Night sweats
209
Q

What are the feature of transfusion associated graft vs host disease?

A

Diarrhoea, liver damage and rash, 2-6 weeks after transfusion

210
Q

3 major risk factors for transfusion associated graft vs host disease?

A
  1. Volume and age of transfused blood
  2. Depressed immune function especially involving T-cells and cell-mediated immunity e.g. Hodgkin’s disease
  3. Similar HLA haplotype sharing
211
Q

Management of transfusion associated graft vs host disease?

A

There is no management :( , just prevention with using gamma irradiated blood products (leucocyte depleted)

212
Q

Which chronic electrolyte disturbance can cause cataracts?

A

Chronic hypocalcaemia

213
Q

Which is more sensitive Chvostek’s or Trousseau’s for hypocalcaemia?

A

Trousseau’s sign (carpopedal spasm) more sensitive than Chvostek’s sign (facial twitch )

214
Q
A
215
Q

List some causes of respiratory acidosis

A

COPD
Decomposition in other resp conditions e.g. Life threatening asthma / pulmonary oedema
Neuromuscular disease
Obesity hyperventilation syndrome
Sedatives e.g. benzodiazepines, opiate overdose

216
Q

In what scenarios can you consider doing chest drain for pneumothorax management?

A

When there are high risk features present and it is safe to intervene

High risk =
- Haemodynamic compromise
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- >/= 50yrs with significant smoking history
- Haemothorax

Safe to intervene = 2cm apically or laterally or any side on ct which can be safely accessed with radiological support

217
Q

In management of pneumothorax, a needle aspiration was done in a patient without high risk features. However this was unsuccessful. What is the next step?

A

Do a chest drain

218
Q

What is the management considered in patients with recurrent pneumothoraces?

A

VATS for mechanical / chemical pleurodesis +/- bullectomy

219
Q

What are the landmarks for chest drain insertion?

A

Base of axilla, lateral pectoralis major, 5th ICS, anterior latissimus dorsi

220
Q

How does alpha 1 antotrypsin deficiency cause emphysema?

A

Alpha 1 antitrypsin is a protease inhibitor which inhibits neutrophil elastase which would otherwise break down elastin in the lung parenchyma. Therefore deficiency of this causes more breakdown leading to emphysema

221
Q

What is the rough percentage mortality of ARDs?

A

40%

222
Q

Outline the criteria for ARDs

A

Berlin criteria:
Acute onset (within 1 week of risk factors)
Hypoxia with pO2 / FiO2 < 300mmHg (40kPa)
Pulmonary oedema - bilateral infiltrates on CXR not fully explained by effusions, lobar / lung collapse or nodules
Non cardiogenic (pulmonary artery wedge pressures needed if in doubt)

223
Q

Outline the severity classifications for ARDs

A

Based on pO2 / FiO2 ratios:
Mild - 300- 200mmHg
Moderate - 100- 200mmHg
Severe - < 100mmHg

224
Q

List 4 causes of lower zone lung fibrosis

A

R - Rheumatological conditions
A - Asbestos exposure
I - Idiopathic
D - Drug induced

225
Q

What type of hypersensitivity reaction(s) are involved in extrinsic allergic alveolitis?

A

Mainly type III (immune complex mediated)
Partly type IV (delayed hypersensitivity) especially during the chronic phase

226
Q

Does extrinsic allergic alveolitis cause an upper or lower zone fibrosis?

A

Upper / middle

227
Q

What will eosinophils look like in the peripheral blood in extrinsic allergic alveolitis?

A

No eosinophils in peripheral blood film

228
Q

What are the causes of extrinsic allergic alveolitis?

A

Bird fancier’s lung
Farmer’s lung - saccaroohyla rectivirgula
Malt worker’s lung - aspergillus clavatus
Mushroom worker’s lung - thermophiliv actinomycetes

229
Q

List some investigations for extrinsic allergic alveolitis

A

Imaging showing upper / mid zone fibrosis
Bronchoalveolar lavage - lynphocytosis
Serologic assays for specific IgG antibodies
Blood - no eosinophilia

230
Q

Main differential similar to extrinsic allergic alveolitis but with no exposure risk factors that you can consider?

A

Cryptogrenic organising pneumonia

231
Q

What is the most important intervention for long term management of symptoms in non CF bronchiectasis?

A

Postural drainage and inspiration muscle training

232
Q

Silicosis causes upper or lower zone fibrosis?

A

Upper zone fibrosis

233
Q

What are the x-ray features of silicosis?

A

Egg shell calcification of hilar lymph nodes
Upper zone fibrosis

234
Q

Silicosis is a risk factor for development of …. as silica is toxic to ….

A

Silicosis is a risk factor for development of tuberculosis as silica is toxic to macrophages

235
Q

Bronchiectasis and raised IgE, likely diagnosis?

A

ABPA

236
Q

Management options for ABPA?

A

Oral glucocorticoids, antifungal, prophylactic antibiotics, supportive rx
Itraconazole second line agent
Omalizumab (anti-IgE recombinant humanised monoclonal antibody)

237
Q

Key investigation findings in ABPA?

A

Eosinophilia
+ve RAST to aspergillus
+ve IgG precipitins
Raised IgE
Flitting CXR changes

238
Q

What might a gas show in obstructive sleep apnoea?

A

Compensated respiratory acidosis

239
Q

What is the equation for transfer factor?

A

TLCO = KCO x VA

TLCO - transfer factor
KCO - transfer coefficient of carbon monoxide
VA - alveolar volume

240
Q

What will the flow volume loop look like in obstructive lung disease?

A

Concave

241
Q

List some causes of raised TLCO

A
  • Exercise
  • Male
  • Hyperkinetic states
  • Polycythemia
  • Asthma
  • Pulmonary haemorrhage (e.g. GPA, Goodpasture’s)
  • Left-to-right cardiac shunts
242
Q

List some causes of reduced TLCO

A

Pulmonary fibrosis
Pneumonia
PE
Pulmonary oedema
Emphysema
Anaemia
Low cardiac output

243
Q

List some causes of drug induced gynaecomastia

A

Spironolactone
Cimetidine
Digoxin
Cannabis
Finisterre
GnRh agonist e.g. goserelin, buserelin
Oestrogen, anabolic steroids

244
Q

How does Bartter’s syndrome present?

A

Normotensive symptomatic hypokalaemia (weakness) often presenting in childhood as failure to thrive

245
Q

Does Bartter’s syndrome cause a hypertensive or normotensive hyperkalaemia?

A

Normotensive, unlike in Cushings, Conn’s and Liddle’s syndromes

246
Q

Inheritance pattern of MODY?

A

Autosomal dominant

247
Q

Patients with MODY are sensitive to …. therapy

A

Patients with MODY are sensitive to sulfonylurea therapy

248
Q

What is the biggest modifiable risk factor for development of thyroid eye disease?

A

Smoking

249
Q

Management of thyroid eye disease?

A

Smoking cessation
Topical lubricants to prevent corneal ulceration
Steroids
Radiotherapy
Surgery
Referral to ophthalmology see EUGOGO guidelines for referral criteria guidelines

250
Q

How do statins work?

A

Inhibit HMG-CoA reductive - the rate limiting enzyme in hepatic cholesterol synthesis

251
Q

When to check LFTs in patients commencing statin therapy? And at what level do you consider stopping statins?

A

At baseline, at 3 months then at 12 months
Stop if serum transaminases raised 3x the upper limit of normal

252
Q

What is one key important drug interaction in which you should avoid statins?

A

Macrolides e.g. erythromycin, clarithromycin

253
Q

Give 2 key absolute contraindications to statin therapy and one recommended contraindication

A

Pregnancy and macrolide antibiotics

History of intracerebral haemorrhage

254
Q

Who should take statins?

A

Anyone who scores with ten year cardiovascular risk > 10% on QRISK2 score or
Any type 1 Diabetic who were diagnosed > 10 years ago OR age > 40 OR established nephropathy

255
Q

What dose or atorvastatin is used in
1) Primary prevention?
2) Secondary prevention?

A

1) 20mg NOCTE
2) 80mg NOCTE

256
Q

Mode of action of dabigatran?

A

Direct thrombin inhibitor

257
Q

What is the reversal agent for dabigatran?

A

Idarucizumab

258
Q

Contraindications for dabigatran?

A

Creatinine clearance <30ml/min
Recent mechanical heart valve replacement

259
Q

Mechanism of action of thiamine diuretics?

A

Inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide sensitive Na-Cl symporter

260
Q

How can methadone cause sudden cardiac death?

A

Methadone - prolonged QT - torsades de pointes - sudden cardiac death

261
Q

What is a normal corrected QT interval in males? Females?

A

Males = 430ms
Females = 450ms

262
Q

Management of long QT?

A

Avoid drugs which prolong the QT interval and other precipitants e.g. strenuous exercise
Beta blockers (but beware sotalol can exacerbate)
ICD in high risk cases

263
Q

What is the key investigation for Addison’s disease?
What is an alternative when it is not possible to do this e.g in primary care?

A

Key investigation is short synACThen test (aka ACTH stimulation test) - give synthetic ACTH then measure cortisol at baseline, at 30 mins and 60 mins and see response- if no or v small increase in cortisol this suggests primary adrenal insufficiency aka addison’s disease

An alternative is measuring the 9am cortisol - a level > 500 nmol/L makes Addison’s unlikely
100-500 warrants investigation
< 100 is definitely abnormal

264
Q

What is Eisenmenger’s syndrome / how does it come about?

A

Reversal of left right shunt due to pulmonary hypertension
Uncorrected left right shunt e.g. in VSD, ASD, PDA leads to remodelling of pulmonary vasculature causing obstruction to pulmonary blood and pulmonary hypertension

Presents with cyanosis, clubbing, rv failure, haemoptysis / embolism, loud s2, raised jvp large a waves

265
Q

Give some signs / symptoms of Eisenmenger’s syndrome

A

Presents with cyanosis, clubbing, rv failure, haemoptysis / embolism, loud s2, raised jvp large a waves

266
Q

Management of Eisenmenger’s syndrome?

A

Heart-lung transplantation

267
Q

What is the target INR in mechanical heart valve anticoagulation?
1) Aortic
2) Mitral

A

1) 3
2) 3.5

268
Q

What are the only two anticoagulants indicated in anticoagulation in mechanical heart valves?

A

Warfarin
LMWH

269
Q

Most common form of thyroid cancer?

A

Papillary

270
Q

Best prognosis subtype of thyroid cancer?

A

Papillary

271
Q

Anaplastic thyroid cancer is associated with…. whereas lymphoma of the thyroid gland is associated with…..

A

Anaplastic thyroid cancer is associated with toxic multipolar goitre, whereas lymphoma of the thyroid gland is associated with hashimoto’s thyroiditis

272
Q

What is the management of papillary and follicular thyroid cancer?

A

Total thyroidectomy
Followed by radioiodene to kill residual cells
Yearly thryoglobulin levels to determine early recurrent disease

273
Q

Management in anaplastic carcinoma of the thyroid gland?

A

Resection, palliation through isthmusectomy and radiotherapy.
N.b chemotherapy is ineffective

274
Q

Define pulsus paradoxus then give 2 conditions it may occur in?

A

Greater than normal (>10mmHg) fall in systolic blood pressure during inspiration
Severe asthma, cardiac tamponade

275
Q

Give a condition that can cause a slow rising / plateau pulse

A

Aortic stenosis

276
Q

Give 3 conditions which can cause a collapsing pulse

A

Aortic regurgitation
PDA
Hyperkinetic states (anaemia, thyrotoxic, fever, exercise / pregnancy)

277
Q

Give a condition in which you might see pulses alternans

A

Severe LVF

278
Q

What is bisferiens pulse?
Give the main condition you might see it, then name another less common

A

Double pulse - two systolic pulses

Mixed aortic valve disease mainly
Sometimes HOCM

279
Q

Give a condition in which there may be a jerky pulse

A

HOCM

280
Q

Outline the guidelines for management of subclinical hypothyroidism

A

TSH > 10 mU/L and free thyroxine within normal range THEN consider starting levothyroxine if TSH level is > 10 mU/L on 2 separate occasions 3 months apart

TSH 5.5-10 mU/L and free thyroxine within normal range
If < 65 years consider offering 6 month trial of levothyroxine if TSH level is 5.5-10 mU/L on 2 separate occasions 3 months apart and there are symptoms of hypothyroidism

In older people watch and wait

If asymptomatic observe and repeat TFTs in 6 months

281
Q

Broad complex tachycardia but not VF / torsades what two other possibilities could it be and how do you differentiate?

A

VT or SVT with aberrant conduction

Brugada algorithm -
- Absence of RS complexes (I.e either monophasoc R or S waves in all precordial or an R to S interval is > 100ms in one precordial lead is suggestive of VT
- AV dissociation suggests VT

Other suggesting VT
- Fusion or capture beats
- Positive QRS concordance in chest leads
- Marked LAD
- History of IHD
- Lack of response to adenosine or carotid sinus massage
- QRS > 160ms

282
Q

What medication should you absolutely not give to patients with VT as it can lead to VF?

A

Verapamil

283
Q

List some causes of hypophosphataemia

A

Alcohol excess
Acute liver failure
DKA
Refeeding syndrome
Primary hyperPTH
Osteomalacia

284
Q

Give some consequences of hypophosphataemia

A

Red blood cell haemolysis
White blood cell and platelet dysfunction
Muscle weak ess ans rhabdomyolysis
CNS dysfunction

285
Q

What is the investigation of choice for upper airway compression?

A

Flow volume loop

MRCP Part 1 (1 decks)

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