Passmed 2 Flashcards
(151 cards)
1
Q
What are the side effects of Rifampicin?
A
Potent liver enzyme inducer
Hepatitis,
Orange secretions
Flu-like symptoms
2
Q
What are the side effects of isoniazid?
A
peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
hepatitis,
agranulocytosis
liver enzyme inhibitor
3
Q
What are the side effects of pyrazinamide?
A
hyperuricaemia causing gout
arthralgia,
myalgia
hepatitis
4
Q
What are the side effects of ethambutol?
A
optic neuritis: check visual acuity before and during treatment
dose needs adjusting in patients with renal impairment
5
Q
How do you manage a thyrotoxic storm?
A
Management:
-symptomatic treatment e.g. paracetamol
-treatment of underlying precipitating event
-beta-blockers: typically IV propranolol
-anti-thyroid drugs: e.g. methimazole or propylthiouracil
(aka thioamides)
-Lugol’s iodine
-dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
6
Q
How do you treat local anaesthetic toxicity?
A
Local anesthetic toxicity can be treated with IV 20% lipid emulsion
It is proposed that lipid infusion creates a lipid phase that extracts the hydrophobic molecules of LA from the aqueous plasma phase and hence reduces serum LA concentration.
7
Q
What is Jarisch-Herxheimer reaction?
A
Jarisch-Herxheimer reaction is sometimes seen after initiating therapy for lymes: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
8
Q
What is a common side effect of colchicine?
A
Diarrhoea
“Colchicine makes you run before you walk”
9
Q
What are the features of granulomatosis with polyangitis?
A
Features
- upper respiratory tract: epistaxis, sinusitis, nasal crusting
- lower respiratory tract: dyspnoea, haemoptysis
- rapidly progressive glomerulonephritis (‘pauci-immune’, 80% of patients)
- saddle-shape nose deformity
- also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions
10
Q
When the cause of acanthosis nigricans is malignancy where can the skin lesion occur?
A
In the mouth
11
Q
What are the features of cyclical vomiting syndrome?
What is it associated with?
A
he main symptoms are severe nausea and vomiting which can last from a few hours to a few days, occurring in discrete episodes. There is also an association with migraine as can be seen in this case. Reduced appetite and weight loss can occur.
Prodromal intense sweating and nausea
12
Q
What form of Pick’s disease (frontotemporal dementia) involves inability to produce speech and loss of literacy skills?
A
Primary progressive aphasia
13
Q
What factors precipitate or worsen psoriasis?
A
trauma
alcohol
drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
withdrawal of systemic steroids
14
Q
Describe the management of HOCM
A
Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*
15
Q
What drugs must you avoid in HOCM?
A
nitrates
ACE-inhibitors
inotropes
(need to maintain cardiac output. Avoid dehydration and fluid restriction too)
16
Q
What ST elevation leads are associated with a higher chance of arrhythmias during MI?
A
II, III, aVF
A right coronary infarct supplies the AV node so can cause arrhythmias after infarction
17
Q
Which opioids are prefered in those with chronic kidney disease?
A
Alfentanil, buprenorphine and fentanyl are the preferred opioids in patients with chronic kidney disease.
18
Q
Which TCAs are particularly dangerous in overdose?
A
Amitriptyline and dosulepin (dothiepin) are particularly dangerous in overdose.
19
Q
What ECG changes in tricyclic antidepressant overdose are associated with seizures and ventricular arrhythmias?
A
ECG changes include:
- sinus tachycardia
- widening of QRS
- prolongation of QT interval
Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias
20
Q
What constitutes a small, medium and large AAA?
When you you need to notify the DVLA?
When do you refer?
A
Small AAA: 3.0-4.4cm
Medium AAA: 4.5-5.4cm
Large AAA: 5.5cm+
DVLA Notified: 6.0-6.4cm
Driving not allowed: 6.5cm+ (until successful treatment)
Small and medium AAA: regular USS to check progress and control of modifiable risk factors (lifestyle, hypertension, smoking…)
Large AAA: see specialist vascular surgeon who will decide on whether surgery is appropriate (eg. endovascular stent)
21
Q
What are the indications for C-section?
A
(apart from CPD/praevia, most are relative) absolute CPD placenta praevia grades 3/4 pre-eclampsia post-maturity IUGR fetal distress in labour/prolapsed cord failure of labour to progress malpresentations: brow placental abruption: only if fetal distress; if dead deliver vaginally vaginal infection e.g. active herpes cervical cancer (disseminates cancer cells)
22
Q
What should be avoided when taking a MAOI?
A
Tyramine rich foods Cheese (particularly mature e.g. stilton) Degraded protein (e.g. pickled herring, smoked fish, chicken liver, hung game) Yeast and protein extract (e.g. Bovril, Oxo and Marmite) Chianti wine, beer Broad bean pods Soya bean extract Overripe or unfresh food Amfetamines Cocaine L-dopa/ dopamine Local anaesthetics containing adrenaline
23
Q
Under what 3 terms can you detain someone under the mental health act?
How long do they last?
Who has to approve it?
A
Compulsory Treatment Order, for long term treatment, can only be granted by the Mental Health Tribunal
Short Term Detention Certificate (STDC) that can last for up to 28 days and must be granted by an Approved Medical Practitioner
Emergency Detention Certificate (EDC) that can be granted by any medical practitioner and lasts for up to 72 hours
24
Q
How does someone qualify for an Emergency Detention Certificate?
A
Must be CONSIDERED LIKELY that:
- They have a mental health disorder
- The patients decision making ability with regard to medical treatment for that mental disorder significantly impaired
Must also be satisfied that:
- You have to detain this patient for treatment (have you exhausted all other possibilities?
- If they were not detained this person would be a danger to themself or others
- Is it not possible for you to apply for a short term detention certificate
25
How does someone qualify for a Short Term Detention Certificate?
- does this patient have a mental health disorder?
- Because of this disorder is the patients decision making ability with regard to medical treatment for this disorder significantly impaired?
- Do you HAVE to detain this patient to determine medical treatment for them or to give them medical treatment?
- If you didn’t detain the patient they would be a risk to themselves or others
- granting a short term detention certificate is necessary
26
Newly diagnosed patients who presented with DKA should be offered which insulin regimen first line?
basal–bolus using twice‑daily insulin detemir
offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
NICE recommend adding metformin if the BMI is 25 or more
27
What spinal cord structure is affected in syringomyelia?
Spinothalamic tract / anterior white commissure
28
Anastomotic leak tends to present when?
5-7 days post abdominal surgery
29
What should you advise methotrexate patients planning children?
Patients using methotrexate require effective contraception during and for at least 3 months after treatment in MEN or WOMEN
30
A raised PSA with an enlarged, nodular, and hard prostate should be referred for which investigation?
TRUS biopsy of the prostate
31
What are the culture negative causes of infective endocarditis?
Culture negative causes:
- Prior antibiotic therapy
- Coxiella burnetii
- Bartonella
- Brucella
- HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
32
When do you target an INR of 3 or more?
Treatment of recurrent DVT, PE (long term)
-target of 3·5 is also recommended for patients who suffer recurrence of VTE whilst on warfarin with an INR between 2·0 and 3·0
Prosthetic heart valves (long-term)
- for patients in whom valve type and location are known specific target INRs are recommended (1)
- --bileaflet valve (aortic) 2·5
- --tilting disk valve (aortic) 3·0
- --bileaflet valve (mitral) 3·0
- --tilting disk (mitral) 3·0
- --caged ball or caged disk (aortic or mitral) 3·5
- otherwise a target INR of 3·0 is recommended for valves in the aortic position and 3·5 in the mitral position (1)
33
How do you diagnose hyperemesis gravidarum?
Hyperemesis gravidarum, diagnostic criteria triad:
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
34
What is the first line treatment for PE?
The initial management for a PE is either low molecular weight heparin (LMWH), or thrombolysis depending on the patients blood pressure.
If the patient is hypotensive, thrombolysis is used. If the patient is normotensive, as in this case, LMWH is used initially.
After 5 days this may be bridged to warfarin, but this is not the initial treatment.
An inferior vena cava filter is rare, but may be used for recurrent PEs.
Compression stockings will reduce this risk of a further PE, but will not treat the current one.
35
What is the diagnostic test for Wilson's disease?
Copper studies (including serum copper, serum caeruloplasmin, and urine copper)
36
What bloods are increased in CML?
The blood work shows raised neutrophils and thrombocytosis. All of which are of myeloid lineage. Coupled with anaemia this would make CML highly likely. CML patients present with thrombocytosis in some cases.
37
What is a FAST scan?
While CT imaging is useful in the assessment of free fluid in the abdomen and chest of trauma patients, the most appropriate initial investigation to conduct is a focused assessment with sonography for trauma (FAST) scan. In the hands of a skilled practitioner, this can detect free fluid surrounding the kidneys, the spleen, the liver, bladder and pericardium. It is also possible to visualise all four chambers of the heart and to assess the hepatic vasculature. An extended focused assessment with sonography for trauma (eFAST) can be conducted, which also assesses for pneumothorax. The sensitivity of a FAST detecting a pneumothorax is 40%, however is considered more sensitive than a supine chest radiograph at detecting pneumothoraces.
38
Urinary hyaline casts are seen in the urine of which patients?
Those taking loop diuretics like furosemide
39
When is mirtazapine useful?
Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
It is generally taken in the evening as it can be sedative.
40
What is the diagnostic test in suspected spinal epidural abscess?
In suspected spinal epidural abscess, a full spine MRI is required to search for skip lesions
41
What are the side effects of zopiclone?
Its side effects include: agitation, bitter taste in mouth, constipation, decreased muscle tone, dizziness, dry mouth, and increased risk of falls (especially in the elderly).
42
What must be done before starting hydroxychloroquine treatment?
Patients that will be taking hydroxychloroquine long-term now require baseline ophthalmologic examination at the outset of treatment
43
What are the 5 main principles of the mental capacity act of 2005? (england)
The Act contains 5 key principles:
-A person must be assumed to have capacity unless it is established that he lacks capacity
- A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
- A person is not to be treated as unable to make a decision merely because he makes an unwise decision
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
- Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action
44
How do you assess capacity?
An adult can only be considered unable to make a particular decision if:
1. He or she has an 'impairment of, or disturbance in, the functioning of the mind or
brain' whether permanent or temporary AND
2. He or she is unable to undertake any of the following
a. understand the information relevant to the decision
b. retain that information
c. use or weigh that information as part of the process of making the decision
d. communicate the decision made by talking, sign language or other means
No individual can be labelled 'incapable' simply as a result of a particular medical condition. Section 2 of the Act makes it clear that a lack of capacity cannot be assumed by a person's age, appearance, or any condition or aspect of a person's behaviour
45
When is hand preference (seeming right or left handed) worrying?
Hand preference before 12 months is abnormal - it could be an indicator of cerebral palsy
46
What are the clinical features of HOCM on ECHO?
MR SAM ASH
Mitral Regurgitation
Systolic Anterior Movement (of the mitral anterior valve leaflet)
Asymmetrical Septal Hypertrophy
47
What is the first line treatment for anorexia nervosa?
For adults with anorexia nervosa, NICE recommend we consider one of:
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM).
In children and young people, NICE recommend 'anorexia focused family therapy' as the first-line treatment. The second-line treatment is cognitive behavioural therapy.
48
What imaging investigations are used in Budd-Chiari syndrome?
Ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation.
Hepatic vein venography could help identify the thrombus and further demonstrate a web as a cause of the obstruction. It would also be able to distinctly visualise intrahepatic collaterals.
49
What do you monitor on methylphenidate (ritalin)?
Height and weight every 6 months
50
What is post thrombotic syndrome?
It is increasingly recognised that patients may develop complications following a DVT. Venous outflow obstruction and venous insufficiency result in chronic venous hypertension. The resulting clinical syndrome is known as post-thrombotic syndrome. The following features maybe seen:
- painful, heavy calves
- pruritus
- swelling
- varicose veins
- venous ulceration
While compression bandages are not recommended for prophylaxis they can be used for treatment along with elevation of the affected leg.
51
What are the normal levels of PSA?
{Age} {PSA level (ng/ml)}
50-59 years 3.0
60-69 years 4.0
> 70 years 5.0
In general: (age-20)/10
52
What raises the level of the PSA test?
benign prostatic hyperplasia (BPH)
prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract
53
What is the long term treatment for someone with ascites and spontaneous bacterial peritonitis?
Antibiotic prophylaxis should be given to patients with ascites if:
- patients who have had an episode of SBP
- patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: 'Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved'
54
What parkinson's drugs should you never stop acutely in parkinson's patients?
Levodopa
Risks triggering neuroleptic malignant syndrome
If a patient with Parkinson's disease cannot take levodopa orally, they can be given a dopamine agonist patch as rescue medication to prevent acute dystonia
55
What monitoring is required for dopamine agonist therapy in parkinsons?
Dopamine receptor agonists
e.g. bromocriptine, ropinirole, cabergoline, apomorphine
ergot-derived dopamine receptor agonists (bromocriptine, cabergoline) have been associated with pulmonary, retroperitoneal and cardiac fibrosis. The Committee on Safety of Medicines advice that an echocardiogram, ESR, creatinine and chest x-ray should be obtained prior to treatment and patients should be closely monitored
Patients should be warned about the potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence
more likely than levodopa to cause hallucinations in older patients. Nasal congestion and postural hypotension are also seen in some patients
56
What is the treatment for long QT?
Avoid medications which may worsen
Beta-blockers (not sotalol as this will worsen QT)
Implantable cardioverter defibrilator if high risk
-QTc >500ms or previous episodes of cardiac arrest.
57
What are the clinical features of Takayasu's arteritis?
Takayasu's arteritis most commonly affects young Asian females.
Pulseless peripheries are a classical finding.
Very high BP
Systolic murmur
Patients present with features of mild systemic illness, followed by pulseless phase with symptoms of vascular insufficiency
58
What condition should you always rule out in suspected acute pancreatitis?
Peptic ulcer perforation by getting an erect chest x-ray
59
In which patients should cyclizine be avoided?
Cyclizine is a H1-receptor antagonist that acts by blocking histamine receptors in the CTZ. It is safe to use in pregnancy. However, cyclizine can cause a drop in cardiac output and an increase in heart rate. For this reason, caution should be employed in patients with severe heart failure.
60
When do you use surgical decompression for renal colic?
Patients with obstructive urinary calculi and signs of infection require urgent renal decompression and IV antibiotics due to the risk of sepsis
61
What are the two tests for strabismus?
Detection of a squint may be made by the corneal light reflection test - holding a light source 30cm from the child's face to see if the light reflects symmetrically on the pupils
```
The cover test is used to identify the nature of the squint
ask the child to focus on a object
cover one eye
observe movement of uncovered eye
cover other eye and repeat test
```
62
Describe the treatment for heart failure
NICE issued updated guidelines on management in 2010, key points include:
-first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker*. Generally, one drug should be started at a time
-
second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
- if symptoms persist cardiac resynchronisation therapy or digoxin** should be considered.
- An alternative supported by NICE in 2012 is ivabradine. The criteria for ivabradine include that the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), has a heart rate > 75/min and a left ventricular fraction < 35%
- diuretics should be given for fluid overload
- offer annual influenza vaccine
- offer one-off*** pneumococcal vaccine
63
What are the post splenectomy blood film features?
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
64
What do you do with patients who require surgery but cannot take oral iron because of side effects?
IV iron should be used in patients who are found to have iron deficiency anaemia prior to surgery where oral iron either can't be tolerated or the time interval is too short.
65
Give 3 causes of placental abruption
Cocaine abuse, pre-eclampsia and HELLP syndrome are known causes of placental abruption, which typically presents with hyperreflexia
66
Describe the treatment for IBS
First-line pharmacological treatment - according to predominant symptom
- Pain: antispasmodic agents
- Constipation: laxatives but avoid lactulose
- Diarrhoea: loperamide is first-line
For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:
optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
they have had constipation for at least 12 months
Second-line pharmacological treatment
-low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Other management options
-Psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy
complementary and alternative medicines: 'do not encourage use of acupuncture or reflexology for the treatment of IBS'
67
Whats the treatment of primary syphilis?
intramuscular benzathine penicillin is the first-line management
alternatives: doxycycline
the Jarisch-Herxheimer reaction is sometimes seen following treatment. Fever, rash, tachycardia after first dose of antibiotic. It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment. No treatment is needed other than antipyretics if required
68
What drugs are used to treat MRSA?
The following antibiotics are commonly used in the treatment of MRSA infections:
- vancomycin
- teicoplanin
- linezolid
69
What is the triad of gastric volvulus?
Gastric volvulus- triad of vomiting, pain and failed attempts to pass an NG tube
70
What is the initial management of spinal compression?
8mg of oral dexamethasone twice daily should be given and urgent assessment by oncology.
71
Tonsilar SCC is associated with what?
HPV
Human papilloma virus, specifically HPV-16, has been linked to the development of tonsillar SCC. HPV lives as part of the normal oral and vaginal flora in some people, and it's worth remembering that HPV-6 and 11 are the common genital wart-causing subtypes, while 16, 18 and 45 cause up to 95% of cervical cancers. Some studies have shown a trend linking number of sexual partners and oral sex in men, however the level of risk is likely low.
72
What is the treatment for gastric MALT lymphoma?
H. Pylori eradication
This usually causes regression of the tumour.
73
Describe the weber classification of ankle fractures
Weber classification
Related to the level of the fibular fracture.
-Type A is below the syndesmosis
-Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
-Type C is above the syndesmosis which may itself be damaged
A subtype known as a Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.
74
What is the diagnostic criteria for hereditary haemorrhagic telangectasia?
There are 4 main diagnostic criteria. If the patient has 2 then they are said to have a possible diagnosis of HHT. If they meet 3 or more of the criteria they are said to have a definite diagnosis of HHT:
- epistaxis : spontaneous, recurrent nosebleeds
- telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
- visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM
- family history: a first-degree relative with HHT
75
Describe the operative treatment of oesophageal carcinoma
Treatment
-Operable disease is best managed by surgical resection.
- The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus.
- The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed.
- Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis.
- The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.
76
How do you distinguish transient tachypnoea of the newborn and neonatal respiratory distress syndrome?
It is important to be aware of risk factors when answering questions like these. Prematurity is the major risk factor for NRDS. Caesarean section is the major risk factor for tachypnoea of the newborn (TTN). Meconium staining is the major risk factor for aspiration pneumonia.
Neonates with NRDS usually present with respiratory distress shortly after birth which usually worsens over the next few days. In contrast, TTN usually presents with tachypnoea shortly after birth and often fully resolves within the first day of life. A chest radiograph can be useful. In NRDS the characteristic features are a diffuse ground glass lungs with low volumes and a bell-shaped thorax. In TTN the CXR depicts a heart failure type pattern (e.g. interstitial oedema and pleural effusions) but key distinguishing features from congenital heart disease are a normal heart size and rapid resolution of the failure type pattern within days.
77
When do you refer children with bronchiolitis to hospital?
NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air.
NICE recommend that clinicians 'consider' referring to hospital if any of the following apply:
- a respiratory rate of over 60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume 'taking account of risk factors and using clinical judgement')
- clinical dehydration.
78
When do you refer unilateral undescended testes?
At birth — arrange review at 6–8 weeks of age.
At 6–8 weeks of age:
- If both testes are normally descended, no further action is required.
- If there is a unilateral undescended testis, re-examine at 3 months of age.
At 3 months of age:
- If both testes are normally descended, no further action is required.
- If the testes are both in the scrotum, but one or both are retractile, advise the parents that annual follow up is needed throughout childhood as there is a significant risk of ascending testes.
- If the testis is still undescended, refer the child to be seen by an appropriate paediatric surgeon, ideally before 6 months of age.
79
Give some causes of oligohydramnios
```
Premature rupture of membranes
Fetal renal problems e.g. renal agenesis
Intrauterine growth restriction
Post-term gestation
Pre-eclampsia
```
80
What are the features of renal cell carcinoma?
```
Classical triad: haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Left varicocele (due to occlusion of left testicular vein)
Endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
```
25% have metastases at presentation
81
What are the ECG changes that are an indication for thrombolysis or percutaneous intervention?
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6)
OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL)
OR
New Left bundle branch block
82
What is the classic feature of typhoid fever?
Rose spots on abdomen
| salmon have spots on their belly -> salmonella typhi
(malaria doesn't present with a rash)
83
When do you need to refer bow legs in children?
Under 3 it is a normal variant and should resolve by 4 years
84
What can nephrotic syndrome do to TFTs?
Low total T4 due to loss of thyroid binding globulins in urine
85
What are the first, second and third line treatments for osteoporosis?
Alendronate is first-line
Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate
Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates
86
Otosclerosis can be precipitated by what in those genetically predisposed?
Pregnancy
87
What is the most common long term side effect of meningitis?
Sensorineural hearing loss
88
What are the complications of mycoplasma pneumonia?
Complications
-cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia
- erythema multiforme, erythema nodosum
- meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases
- bullous myringitis: painful vesicles on the tympanic membrane
- pericarditis/myocarditis
- gastrointestinal: hepatitis, pancreatitis
- renal: acute glomerulonephritis
89
What are the criteria for an endometrial biopsy?
Persistent intermenstrual bleeding and in women aged 45 and over treatment failure or ineffective treatment.
women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
-This isnt reliable in pre-menopausal women as the endometrium changes during the month
90
What are the risks associated with SSRIs in pregnancy?
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
91
Describe the drug level monitoring for lithium, ciclosporin, digoxin and phenytoin
Lithium
range = 0.4 - 1.0 mmol/l
take 12 hrs post-dose
Ciclosporin
trough levels immediately before dose
Digoxin
at least 6 hrs post-dose
Phenytoin levels do not need to be monitored routinely but trough levels, immediately before dose should be checked if:
- adjustment of phenytoin dose
- suspected toxicity
- detection of non-adherence to the prescribed medication
92
What is the characteristic iron study profile seen in haemochromatosis?
Raised transferrin saturation and ferritin, with low TIBC is the characteristic iron study profile in haemochromatosis
93
What is the first line investigation in suspected heart failure?
All patients with suspected chronic heart failure should have an NT‑proBNP test first-line
All patient with suspected heart failure should have a 12-lead ECG in all people
94
What patients are at risk of refeeding syndrome?
Patients are considered high-risk if one or more of the following:
- BMI < 16 kg/m2
- unintentional weight loss >15% over 3-6 months
- little nutritional intake > 10 days
- hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
If two or more of the following:
- BMI < 18.5 kg/m2
- unintentional weight loss > 10% over 3-6 months
- little nutritional intake > 5 days
- history of: alcohol abuse, drug therapy including insulin, -chemotherapy, diuretics and antacids
95
What are the diagnostic criteria for multiple myeloma?
Monoclonal protein band in serum or urine electrophoresis
Increased plasma cells on marrow biopsy
Evidence of end-organ damage from myeloma:
- Hypercalcaemia
- Renal insufficiency
- Anaemia
Bone lesions:
-skeletal survey after diagnosis
96
What is the treatment of status epilepticus in paeds?
1 Buccal midazolam/ IV lorazepam
2 IV lorazepam
3 IV phenytoin (phenobarbital if already on regular phenytoin)
4 Rapid sequence induction of anaesthesia using thiopental sodium
97
Describe vaccination and antibiotic prophylaxis following splenectomy
Following a splenectomy patients are particularly at risk from pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus* infections
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Vaccination
if elective, should be done 2 weeks prior to operation
-Hib, meningitis A & C
-annual influenza vaccination
-pneumococcal vaccine every 5 years
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Antibiotic prophylaxis
penicillin V: unfortunately clear guidelines do not exist of how long antibiotic prophylaxis should be continued. It is generally accepted though that penicillin should be continued for at least 2 years and at least until the patient is 16 years of age, although the majority of patients are usually put on antibiotic prophylaxis for life
98
What percentage of patients with diabetes mellitus will have at least one episode of adhesive capsulitis (frozen shoulder)?
20%
99
Bell's palsy is more common in which group of patients?
Pregnancy
3 times more likely to get it
(baby spice had it when she was pregnant)
100
Which steroid is used for preterm prelabour rupture of membranes to prevent respiratory distress syndrome?
Dexamethasone
In addition the following should be carried out:
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
-delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
101
What are the paraneoplastic features of Small cell lung cancer?
ADH
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
Lambert-Eaton syndrome
102
What are the paraneoplastic syndromes of squamous cell lung cancer?
Parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Hyperthyroidism due to ectopic TSH
103
What are the paraneoplastic syndromes of adenocarcinoma?
gynaecomastia
hypertrophic pulmonary osteoarthropathy (HPOA)
104
What eye problems can amiodarone cause?
Can result in both corneal opacities and optic neuritis
105
What investigation can differentiate essential tremor and parkinson's
Diagnosis is usually clinical. However, if there is difficulty differentiating between essential tremor and Parkinson's disease NICE recommend considering 123I‑FP‑CIT single photon emission computed tomography (SPECT)
106
Describe the treatment of hypophosphataemia
Hypophosphatemia is recognised by a serum phosphate level <0.80 mmol/L. It is further classified as mild (∼0.64–0.80 mmol/L), moderate (∼0.32–0.64 mmol/L) and severe (<0.32 mmol/L).
In mild to moderate hypophosphataemia where patients are asymptomatic, enteral replacement is required using Phosphate Sandoz® effervescent tablets. Each tablet contains 16.1mmol of phosphate, 20.4mmol of sodium and 3.1mmol of potassium. An adult dose is usually up to 6 tablets daily in divided doses, which is dissolved in water to produce a solution that can safely be administered via feeding tubes. Dose adjustments to be made according to response.
Intravenous phosphate replacement is required for patients with severe hypophosphataemia or when symptomatic. Phosphate Polyfusor® is a commonly used 500ml solution which contains 50mmol of phosphate, 81mmol of sodium and 9.5mmol of potassium. The maximum dose is 500ml Polyfusor® per infusion and maximum infusion rate is 150ml Polyfusor® per hour.
107
What clotting investigation results are seen in vWF deficiency?
Prolonged bleeding time
APTT may be prolonged
Factor VIII levels may be moderately reduced
Defective platelet aggregation with ristocetin
108
What are the ECG features of Wolf-Parkinson-White syndrome?
Short PR interval
Wide QRS complexes with a slurred upstroke - 'delta wave'
Left axis deviation if right-sided accessory pathway*
Right axis deviation if left-sided accessory pathway
109
Describe the medical management of pre-eclampsia
Labetalol first line
(if asthmatic then nifedipine is first line)
Methyldopa and hydralazine are other options
110
What are the contraindications to a planned vaginal birth after caesarean (VBAC)?
Classical caesarean scar
Previous episodes of uterine rupture
Any other contraindications to vaginal birth (e.g. stage 3-4 placenta praevia etc)
111
What is the first line treatment for extrinsic allergic alveolitis?
The treatment of extrinsic allergic alveolitis is mainly avoidance of triggers
Get rid of your parrot
Corticosteroids
112
What are the management options for actinic keratosis?
Prevention of further risk: e.g. sun avoidance, sun cream
Fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
Topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects
Topical imiquimod: trials have shown good efficacy
Cryotherapy
Curettage and cautery
113
What are the signs of cerebellar dysfunction?
Useful and well-known mnemonic to remember symptoms of cerebellar disease is DANISH:
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk'
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
114
What is hand-foot syndrome?
Hand-foot syndrome is caused by the sickling of red blood cells interfering with circulation to the hands and feet. This results in swelling, pain and erythema with a sudden onset.
The syndrome normally lasts for 1-2 weeks with treatment only being supportive. It is not seen in children older than five as hematopoiesis in the small bones of the hands and feet ceases at this age.
115
Which patients should be assessed for osteoporosis using either FRAX or QFracture?
They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
- previous fragility fracture
- current use or frequent recent use of oral or systemic glucocorticoid
- history of falls
- family history of hip fracture
- other causes of secondary osteoporosis
- low body mass index (BMI) (less than 18.5 kg/m²)
- smoking
- alcohol intake of more than 14 units per week for women and more than 14 units per week for men.
116
When do you get an immediate DEXA scan rather than carry out a FRAX/ QFracture?
There are some situations where NICE recommend arranging BMD assessment (i.e. a DEXA scan) rather than using one of the clinical prediction tools:
-before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).
117
In someone with a DVT how long does their warfarin treatment last if it is:
Provoked or unprovoked?
Provoked = 3 months
Unprovoked = 6 months
118
What are the features of vasa praevia?
The classic triad of vasa praevia is rupture of membranes followed by painless vaginal bleeding and fetal bradycardia. Unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant. The two conditions may be difficult to distinguish in acute clinical situations, but for examination purposes a preceding rupture of membranes will usually be emphasised. Although ultrasound scans can detect vasa praevia, many cases are undetectable antenatally.
119
What are the guidelines for managing primary pneumothorax?
Recommendations include:
-if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
- otherwise aspiration should be attempted
- if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
- patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
120
What are the guidelines for managing secondary pneumothorax?
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
regarding scuba diving, the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'
121
What contraceptive methods are unaffected by liver enzyme inducing drugs (EIDs)?
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Examples of contraceptives that are unaffected by EIDs are:
Copper intrauterine device
Progesterone injection (Depo-provera)
Mirena intrauterine system
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The copper intra-uterine device is usually the preferred option, as it is a non-hormonal method.
122
What are the diagnostic criteria for anorexia nervosa?
1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
123
What is the treatment for anorexia nervosa?
For adults with anorexia nervosa, NICE recommend we consider one of:
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM).
In children and young people, NICE recommend 'anorexia focused family therapy' as the first-line treatment. The second-line treatment is cognitive behavioural therapy.
The prognosis of patients with anorexia nervosa remains poor. Up to 10% of patients will eventually die because of the disorder.
124
What are the 5 year survival rates for dukes stage?
Dukes' A Tumour confined to the mucosa 95%
Dukes' B Tumour invading bowel wall 80%
Dukes' C Lymph node metastases 65%
Dukes' D Distant metastases 5%
125
In cord prolapse what position should women be in while waiting for C section?
This is an example of cord prolapse, the majority of which occur after artificial rupture of membranes. The correct position for a woman to be in while being prepared for caesarean is on all fours (on knees and elbows), while someone pushes the presenting part of the fetus up.
126
What is the treatment for necrotising acute gingivitis?
refer the patient to a dentist, meanwhile the following is recommended:
- oral metronidazole* for 3 days
- chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
- simple analgesia
127
What is total gas transfer on spirometry?
What conditions would show a raised TLCO?
The total gas transfer (TLCO) is an overall measure of gas transfer for the lungs from the alveoli into the capillaries and reflects how much oxygen is taken up into the red cells.
You would only expect to find a raised TLCO in asthma or a left-to-right cardiac shunt. This is because in these conditions, the problem is not affecting the alveoli directly or gas exchange and so the lungs try to compensate for the problem by improving gas exchange.
The other conditions are all associated with a lower TLCO.
128
Pigmented gallstones are associated with what?
Sickle cell anaemia
129
What tumour markers are raised in cholangiocarcinoma?
CA19-9 (in up to 85%)
CA-125 (in up to 65%)
CEA
130
What is lochia?
When should it be investigated?
Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium*. This should be expected to cease after 4-6 weeks. Continue vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.
INVESTIGATE AFTER 6 WEEKS
* Puerperium is the period of approximately six weeks after childbirth during which time the woman's reproductive organs return to normal. Lochia is a normal part of this process.
131
What is the most appropriate time to take blood samples for therapeutic monitoring of digoxin levels?
At least 6 hours after last dose
132
What are the most common visual hallucinations in Charles-Bonnet syndrome?
Faces, children and wild animals
Charles-Bonnet syndrome is characterised by visual hallucinations associated with eye disease.
It occurs in patients of increasing age; equally amongst males and females; and with no known increased risk with family history.
133
Myelofibrosis shows what on blood film?
Tear drop poikilocytosis
It's tear-drop shaped because the bone marrow is fibrosed. So the RBC's are being 'pushed' out through a solid, unforgiving gap, and as such become squeezed like a tear drop.
134
When should patients be suspected of laryngeal cancer and referred to ENT urgently?
What do you need to order beforehand?
A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 and over with:
- persistent unexplained hoarseness or
- An unexplained lump in the neck.
Any patient presenting with hoarseness who are being referred down the suspected cancer pathway should have a chest x-ray to exclude an apical lung lesion.
135
What blood pressure targets are you aiming for in hypertension?
Age <80 years:
- Clinic BP = <140/90
- Home BP = <135/85
Age >80 years:
- Clinic BP = <150/90
- Home BP = <145/85
136
What should you advise patients taking bisphosphonates?
Take at least 30 mins before breakfast with plenty of water and sit up for a further 30 mins
137
What is Loeffler endocarditis?
Löeffler endocarditis is endocarditis due to eosinophil proliferation in the heart. It is associated with helminthic infections
138
What cardiac defects are associated with carcinoid syndrome?
Carcinoid syndrome can affect the right side of the heart.
The valvular effects are tricuspid insufficiency and pulmonary stenosis
TIPS
- Tricuspid insufficiency
- Pulmonary stenosis
139
What are the indications for packed red blood cells?
Hb <100 and high risk of myocardial ischemia
severe anemia (e.g. Hb<70)
major active bleeding and Hb<100
140
What are the indications for platelets?
<10
<20 and high risk (fever, neutropenia, antibiotics, risk of intracranial haemorrhage)
<50 and active bleeding or requires invasive procedure
<80 and requires neurosurgery or ophthalmic surgery
platelet function defects and bleeding (regardless of platelet count)
141
What are the indications for fresh frozen plasma?
INR >1.5 and needs invasive procedure
INR >1.5 and actively bleeding (e.g. massive transfusion protocol, post-bypass surgery)
142
What are the indications for cryprecipitate?
fibrinogen <1.0 and actively bleeding (e.g. massive transfusion protocol)
DIC
hereditary hypofibrinogenemia, haemophilia, von Willebrand disease
143
When do you use granulocyte concentrate?
neutropenic sepsis
144
What is the immediate management of patients with airway problems post head and neck surgery?
Cut the sutures from surgery and call for senior help
Each patient undergoing head and neck surgery is returned to the ward with a suture blade. In the event of a post operative bleed. If a bleed occurs, the pressure behind the suture line increases and the trachea becomes compressed resulting in stridor. Therefore 3 is the answer becuase immediate removal of the pressure will relieve the stridor. Senior assistance will be required as this patient will require further surgery for haemostasis.
145
Most physiological systems are low in anorexia nervosa. Which things are raised?
Anorexia features
- most things low
- G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
146
A woman presents to hospital with chest pain.
On the ECG there is deep ST depression in I-III, aVF, and V3-V6. aVR also has ST elevation
What is the diagnosis?
Deep and widespread ST depression is associated with very high mortality because it signifies severe ischemia usually of LAD or left main origin.
147
What factors determine if an IV glycoprotein Iib/IIIa receptor antagonist is to be given in MI?
High GRACE score and whether PCI is to be performed
148
What is the treatment for renal cell carcinoma?
Radical nephrectomy usually first line
chemo and radiotherapy usually isnt effective in this type of cancer but may be used
149
What are the causes of cerebellar injury?
Ataxic gaits typically occur following cerebellar injury, the causes of which can be remembered by the mnemonic 'pastries'
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P - Posterior fossa tumour
A - Alcohol
S - Multiple sclerosis
T - Trauma
R - Rare causes
I - Inherited (e.g. Friedreich's ataxia)
E - Epilepsy treatments
S - Stroke
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150
What investigation must be done before treating a venous ulcer?
Ankle-brachial pressure index
Need to check arterial supply before compression stockings
151
If a patient is taking allopurinol and has an attack of gout what do you do to the allopurinol dose?
Keep it going
You dont need to stop allopurinol already started as your not risking any massive crystal shifts
