Passmed 3

Question 1

What are the side effects of thrombolysis?

Answer 1

Hypotension - more common with streptokinase (monitor BP during therapy)

Haemorrhage

allergic reactions may occur with streptokinase

Question 2

How do you differentiate biliary colic, acute cholecystitis and acute cholangitis?

Answer 2

Often students find it difficult to differentiate biliary colic, cholecystitis and cholangitis. This is acute cholecystitis because this woman is systemically unwell and in pain, whereas in biliary colic she won’t be systemically unwell. In acute cholangitis, the woman will most likely be jaundiced, which there is no mention of. Murphy’s positive sign is also a sign typical in acute cholecystitis, and is pain on inspiration during palpation of the right upper quadrant. IV antibiotics and laparoscopic cholecystectomy are the management.

Question 3

What are the 5 steps in anaphylaxis management?

Answer 3

1. ABCDE
2. Adrenaline
   - Can be repeated every 5 mins
3. IV fluid challenge
   - Adult = 500-1000mL
   - Child = 20mL/kg

3. Hydrocortisone
<6 months = 25mg
6 months to 6 years = 50mg
6-12 years = 100mg
over 12 years = 200mg

4. Chloraphenamine
<6 months = 250mcg/kg
6 months to 6 years = 2.5mg
6-12 years = 5mg
over 12 years = 10mg

Question 4

What are the causes of optic atrophy?

Answer 4

Optic atrophy is a descriptive term (its really optic neuropathy)

Acquired

• multiple sclerosis
• papilloedema (longstanding)
• raised intraocular pressure (e.g. glaucoma, tumour)
• retinal damage (e.g. choroiditis, retinitis pigmentosa)
• ischaemia
• toxins: tobacco amblyopia, quinine, methanol, arsenic, lead
• nutritional: vitamin B1, B2, B6 and B12 deficiency

Congenital:
-Friedreich’s ataxia
mitochondrial disorders e.g. Leber’s optic atrophy
-DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram’s syndrome)

Question 5

What are the clinical features of pulmonary arterial hypertension?

Answer 5

Typically females ages 30-50

Present with progressive exertional dyspnoea

Associated with HIV, cocaine and anorexigens (e.g. fenfluramine)

Other possible features include exertional syncope, exertional chest pain and peripheral oedema
cyanosis

Right ventricular heave, loud P2, raised JVP with prominent ‘a’ waves, tricuspid regurgitation

Question 6

What is the treatment of pulmonary

Answer 6

Acute vasodilator testing:
-Significant fall in pulmonary arterial pressure following the administration of vasodilators such as intravenous epoprostenol or inhaled nitric oxide.

If there is a positive response to acute vasodilator testing (a minority of patients)
-oral calcium channel blockers

If there is a negative response to acute vasodilator testing (the vast majority of patients)

• prostacyclin analogues: treprostinil, iloprost
• endothelin receptor antagonists: bosentan, ambrisentan
• phosphodiesterase inhibitors: sildenafil

Patients with progressive symptoms should be considered for a heart-lung transplant.

Question 7

What are the differentials for a cavitating lung lesion on x-ray

Answer 7

Abscess (Staph aureus, Klebsiella and Pseudomonas)
Squamous cell lung cancer
Tuberculosis
Wegener’s granulomatosis
Pulmonary embolism
Rheumatoid arthritis
Aspergillosis, histoplasmosis, coccidioidomycosis

Question 8

What is the medical management of turner’s syndrome?

Answer 8

Growth hormone (to help grow from an early age)

oestrogen is initiated before adolescence for pubertal development and to help prevent osteoporosis.

Question 9

What conditions do NICE recommend growth hormone therapy?

What are the adverse effects?

Answer 9

Proven growth hormone deficiency
Turner’s syndrome
Prader-Willi syndrome
chronic renal insufficiency before puberty

Adverse effects

• headache
• benign intracranial hypertension
• fluid retention

Question 10

What factors play into lithium toxicity?

What are the features of lithium toxicity?

Answer 10

Toxicity may be precipitated by dehydration, renal failure, diuretics (especially bendroflumethiazide), ACE inhibitors, NSAIDs and metronidazole.

Features:

• coarse tremor (a fine tremor is seen in therapeutic levels)
• hyperreflexia
• acute confusion
• seizure
• coma

Question 11

Which drugs have been shown to reduce mortality in heart failure?

Answer 11

ACE inhibitors (SAVE, SOLVD, CONSENSUS)
spironolactone (RALES)
beta-blockers (CIBIS)
hydralazine with nitrates (VHEFT-1)

Question 12

What is the management of chronic heart failure?

Answer 12

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

*Digoxin is strongly indicated in co-existent heart failure

Question 13

Name the trinucleotide repeat disorders

Answer 13

Examples - note dominance of neurological disorders

• Fragile X (CGG)
• Huntington’s (CAG)
• myotonic dystrophy (CTG)
• Friedreich’s ataxia (GAA)
• spinocerebellar ataxia
• spinobulbar muscular atrophy
• dentatorubral pallidoluysian atrophy

Anticipation means earlier age of onset in successive generations (may also be accompanied by worse symptoms but thats not the definition)

Question 14

When do you refer patients with an established diagnosis of mania?

Answer 14

if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)

if there are features of mania or severe depression then an urgent referral to the CMHT should be made

Question 15

What is Rhinitis medicomentosa

Answer 15

Rhinitis symptoms from using lots of decongestant sprays

Question 16

What are liver cell adenomas?

Answer 16

90% develop in women in their third to fifth decade

Linked to use of oral contraceptive pill

Lesions are usually solitary

They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule

On ultrasound the appearances are of mixed echoity and heterogeneous texture. On CT most lesions are hypodense when imaged prior to administration of IV contrast agents

In patients with haemorrhage or symptoms removal of the adenoma may be required

Question 17

What is the triad of shaken baby syndrome?

Answer 17

Retinal haemorrhages, subdural haematoma and encephalopathy is the triad of the shaken baby syndrome

Question 18

What are the 3 types of non-small cell lung cancer?

How can you differentiate them?

Answer 18

Squamous cell cancer

• typically central
• associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia
• strongly associated with finger clubbing
• hypertrophic pulmonary osteoarthropathy (HPOA)

Adenocarcinoma

• typically peripheral
• most common type of lung cancer in non-smokers, although the majority of patients who develop lung adenocarcinoma are smokers

Large cell lung carcinoma

• typically peripheral
• anaplastic, poorly differentiated tumours with a poor prognosis
• may secrete β-hCG

Question 19

How do you manage balanitis?

Answer 19

Acute infections are managed with saline baths and treatment of the underlying cause. In most cases, topical treatment is recommended:

• Sexually transmitted infection: appropriate treatment of the infection
• Dermatitis: topical hydrocortisone
• Candida: topical clotrimazole or miconazole or nystatin cream
• Bacterial infection: flucloxacillin or erythromycin or metronidazole according to sensitivity

In cases of recurrent balanitis, the most appropriate treatment is circumcision, which will prevent the condition from recurring.

Question 20

What is lung volume reduction surgery?

Answer 20

This question is asking about the late stage treatment of alpha 1-antitrypsin deficiency. For respiratory management, it is similar to that of late stage chronic obstructive pulmonary disease (COPD).

Lung volume reduction surgery removes the worst affected part of the lungs in order to improve airflow and alveolar gas exchange in the remaining portion of the lung.

Question 21

How can crohn’s give you an increased red cell distribution width (RDW)?

Answer 21

Mixed anaemia

Ileal destruction causes B12 deficiency while bleed causes iron deficiency

Both microcytosis and macrocytosis so increased RDW

Question 22

What is the first line management of plantar fasciitis?

Answer 22

Plantar fasciitis is best managed initially with rest, stretching and weight loss if overweight

After can try orthotics and NSAIDs

Question 23

What are the contraindications to lung cancer surgery?

Answer 23

assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction

Question 24

What is the management of primary open angle glaucoma?

Answer 24

NICE guidelines:

• first line: prostaglandin analogue (PGA) eyedrop
• second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
• if more advanced: surgery or laser treatment can be tried

Beta blockers act by reducing aqueous secretion by the ciliary body.

Prostaglandin analogues act by increasing aqueous outflow via the uveoscleral route.

Sympathomimetics act by reducing aqueous secretion and increasing aqueous outflow.

Miotics act by opening the aqueous drainage channels in the trabecular meshwork.

Diode laser cycloablation destroys part of the secretory component of the ciliary body, thereby reducing aqueous secretion.

Question 25

What are the copper study results seen in Wilson's disease?

Answer 25

Reduced serum caeruloplasmin Reduced serum copper (counter-intuitive, but 95% of Plasma copper is carried by ceruloplasmin) Increased 24hr urinary copper excretion

Question 26

What is the management of Wilson's disease?

Answer 26

Penicillamine (chelates copper) has been the traditional first-line treatment Trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future Tetrathiomolybdate is a newer agent that is currently under investigation

Question 27

What is the management of GORD in babies?

Answer 27

Advise regarding position during feeds - 30 degree head-up Infants should sleep on their backs as per standard guidance to reduce the risk of cot death Ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum) a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents -NICE do not recommend a proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA), to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply: → unexplained feeding difficulties (for example, refusing feeds, gagging or choking) → distressed behaviour → faltering growth -Prokinetic agents e.g. metoclopramide should only be used with specialist advice

Question 28

What are the complications of acromegaly?

Answer 28

hypertension diabetes (>10%) cardiomyopathy colorectal cancer

Question 29

What are the clinical features of primary syphilis?

Answer 29

Chancre (develops from a single papule) Anogenital, single, painless and indurated with clean base, non-purulent Can be multiple, painful and purulent (usually extra-genital) Resolve over 3-8 weeks

Question 30

What are the clinical features of secondary syphilis?

Answer 30

If primary syphilis is untreated 25% will develop secondary syphilis Occurs 4-10 weeks after initial chancre Multi-system - Rash - ----Widespread mucocutaneous - ----May be itchy - ----Can affect palms and soles - ----Mucous patches (buccal, lingual and genital) - Condylomata lata (higly infectious, mainly affecting perineum and anus) - Hepatitis - Splenomegaly - Glomerulonephritis - Neurological complications - ----Acute meningitis - ----Cranial nerve palsies - ----Uveitis - ----Optic neuropathy - ----Interstitial keratitis and retinal involvement

Question 31

What are the clinical features of tertiary syphilis?

Answer 31

Neurosyphilis - Asymptommatic (abnormal CSF. No signs or symtpoms) - Meningovascular - Parenchymous - ---General Paresis (Cortical neuronal loss -> gradual decline in memory and cognition, emotional lability, psychosis and dementia) - ---Tabes dorsalis (Inflammation of dorsal columns, Argyll-Robertson pupil) Cardiovascular -Aortitis (aortic regurge, heart failure, coronary artery stenosis etc etc) Gummatous -Inflammatory granulomatous destructive lesions (most commonly skin and bone)

Question 32

How can you diagnose syphilis?

Answer 32

Demonstration of T. pallidum from lesions or infected lymph nodes - Dark ground microscopy - Polymerase chain reaction Serological tests for syphilis - Primary screening tests - ---Treponemal EIA/CLIA (preferably that detects both IgG and IgM) or TPPA, which is preferred to TPHA. - ---Request anti-treponemal IgM test if primary syphilis is suspected. - Confirmatory tests - ---Positive screening tests should be confirmed with a different treponemal test. - ---An IgG immunoblot Tests for assessing serological activity of syphilis - A quantitative RPR/VDRL - ---Negative does not rule out need for treatment (base on signs and symptoms not single test) - ---Also used for monitoring response to treatment ***Repeat screening is required at 6 and 12 weeks after a high-risk exposure

Question 33

What is the treatment for syphilis?

Answer 33

Benzathine penicillin G Neurosyphilis (at any stage) or congenital syphilis -Benzylpenicillin or Procaine penicillin * **If penicillin allergic use Doxycycline * **Steroids given with antibiotics for cardiovascular syphilis

Question 34

What reactions may occur during syphilis treatment?

Answer 34

(i) Jarisch-Herxheimer reaction: An acute febrile illness with headache, myalgia, chills and rigours which resolves within 24 hours (ii) Procaine reaction (procaine psychosis, procainemania, Hoigne’s syndrome) - Due to inadvertent intravenous injection of procaine penicillin. - Characterised by fear of impending death and may cause hallucinations or fits immediately after injection and lasts less than 20minutes (iii) Anaphylactic shock (iv) Allergy: penicillin desensitisation should be considered for patients reporting a history of penicillin allergy

Question 35

You've found someone with dermatomyositis? What do you look for now?

Answer 35

Underlying malignancy typically ovarian, breast and lung cancer, found in 20-25% - more if patient older

Question 36

What are the causes of haemolytic uraemic syndrome?

Answer 36

classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7 ('verotoxigenic', 'enterohaemorrhagic'). This is the most common cause in children, accounting for over 90% of cases pneumococcal infection HIV rare: systemic lupus erythematosus, drugs, cancer

Question 37

What is the management of blepharitis?

Answer 37

- softening of the lid margin using hot compresses twice a day - mechanical removal of the debris from lid margins - cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used* - artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film

Question 38

After you discover liver cysts/lesions on ultrasound what should you do next?

Answer 38

CT to visualise better and see if cancer or not

Question 39

How do you manage aortic dissections?

Answer 39

Type A -ASS Aortic root replacement and Surgery Type B - BooBs Bed rest and Beta blockers

Question 40

What is the lymphatic drainage of anal cancer?

Answer 40

The lymphatic drainage, and therefore, tumour spread, varies in different parts of the canal: anal margin tumours spread to the inguinal lymph nodes and those which are more proximal spread to the pelvic lymph nodes

Question 41

What is the T staging in anal cancer?

Answer 41

TX primary tumour cannot be assessed T0 no evidence of primary tumour Tis carcinoma in situ T1 tumour 2 cm or less in greatest dimension T2 tumour more than 2 cm but not more than 5 cm in greatest dimension T3 tumour more than 5 cm in greatest dimension T4 tumour of any size that invades adjacent organ(s) - for example, vagina, urethra, bladder (direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) - is not classified as T4)

Question 42

What is Samter's triad?

Answer 42

The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter's triad

Question 43

When do you use cement in a hip fracture?

Answer 43

NON-cement for NON mobilisers

Question 44

What is the chemotherapy regimen for Hodgekin's lymphoma?

Answer 44

ABVD A – doxorubicin (Adriamycin®) B – bleomycin V – vinblastine (Velbe®) D – dacarbazine (DTIC).

Question 45

What is the treatment for neutropenic sepsis?

Answer 45

Piperacillin and Tazobactam (Tacoxin)

Question 46

What clinical features point to a diagnosis of MND?

Answer 46

- fasciculations - the absence of sensory signs/symptoms* - the mixture of lower motor neuron and upper motor -neuron signs - wasting of the small hand muscles/tibialis anterior is common Other features - doesn't affect external ocular muscles - no cerebellar signs - abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature

Question 47

What are the mechanisms for how multiple myeloma causes renal failure?

Answer 47

``` Tubular precipitation of protein Direct infiltration Hypercalcaemia Hyperuricaemia Dehydration Amyloid ```

Question 48

How do you manage ADHD?

Answer 48

At presentation ask parents to come back after 10 weeks to see if it's not a transient thing Start lifestyle stuff first (medication last resort and only available to children >5) Methylphenidate first line -Monitor height and weight every 6 months If there is inadequate response, switch to lisdexamfetamine; -Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can't tolerate its side effects. All drugs cardiotoxic so ECG before treatment

Question 49

What murmur does anaemia cause?

Answer 49

Aortic flow murmur -soft ejection systolic murmur which doesn't radiate Common in dialysis patients

Question 50

What are the clinical features of cocaine use?

Answer 50

Cardiovascular effects - myocardial infarction - both tachycardia and bradycardia may occur - hypertension - QRS widening and QT prolongation - aortic dissection Neurological effects - seizures - mydriasis - hypertonia - hyperreflexia Psychiatric effects - agitation - psychosis - hallucinations Others - ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if patients complain of abdominal pain or rectal bleeding - hyperthermia - metabolic acidosis - rhabdomyolysis

Question 51

What drug should you consider starting in Afro-Caribbean patients with chronic heart failure who aren't controlled on ACEi and B-blocker?

Answer 51

Hydralazine and nitrate

Question 52

What is the dose of adrenaline given in cardiac arrest?

Answer 52

10ml of 1:10,000

Question 53

What is the centor criteria?

Answer 53

presence of tonsillar exudate tender anterior cervical lymphadenopathy or lymphadenitis history of fever absence of cough 3 or more = 40-60% chance of strep = PenV for 7-10 days

Question 54

What are the complications of SAH?

Answer 54

Re-bleeding (in around 30%) Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset -Nimodipine Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) -Monitor U+Es closly Seizures Hydrocephalus -May need external ventricular drain or longer-term ventrico-peritoneal shunt Death

Question 55

Which ducts commonly get stones in the salivary glands?

Answer 55

Wharton's duct = submandibular | Stensens duct = parotid

Question 56

What is a venous hum?

Answer 56

Due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles

Question 57

When do you consider NOAC over warfarin in prevention of stroke in AF?

Answer 57

Non-valvular AF and one of the following: - Prior stroke or transient ischaemic attack - Age 75 years or older - Hypertension - Diabetes mellitus - Heart failure

Question 58

Dabigatran is contraindicated in which patiens?

Answer 58

Renal failure (its renaly secreted)

Question 59

Which margins of excision relate to breslow thickness?

Answer 59

Lesions 0-1mm thick = 1cm Lesions 1-2mm thick = 1- 2cm (Depending upon site and pathological features) Lesions 2-4mm thick = 2-3 cm (Depending upon site and pathological features) Lesions >4 mm thick = 3cm

Question 60

What are the investigations for Myasthenia gravis?

Answer 60

Single fibre electromyography: high sensitivity (92-100%) CT thorax to exclude thymoma CK normal Autoantibodies: around 85-90% of patients have antibodies to acetylcholine receptors. In the remaining patients, about about 40% are positive for anti-muscle-specific tyrosine kinase antibodies Tensilon test: IV edrophonium reduces muscle weakness temporarily - not commonly used anymore due to the risk of cardiac arrhythmia

Question 61

What are the risk factors for orofacial clefts?

Answer 61

Orofacial clefts are a common malformation with many associated risk factors which can be split into those due to events in pregnancy (smoking, benzodiazepine use, anti-epileptic use, rubella infection) and syndromic disorders affecting the baby (trisomies 18, 13 and 15).

Question 62

What are the causes of post-coital bleeding?

Answer 62

no identifiable pathology is found in around 50% of cases cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill cervicitis e.g. secondary to Chlamydia cervical cancer polyps trauma

Question 63

What is the management of an overactive bladder?

Answer 63

Conservative measures include moderating fluid intake bladder retraining should be offered Antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) Mirabegron may be considered if first-line drugs fail

Question 64

What is Boas' sign?

Answer 64

In acute cholecystitis there is hyperaesthesia beneath the right scapula It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level.

Question 65

How do you manage hepatitis B?

Answer 65

pegylated interferon-alpha used to be the only treatment available. It reduces viral replication in up to 30% of chronic carriers. A better response is predicted by being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy whilst NICE still advocate the use of pegylated interferon first-line other antiviral medications are increasingly used with an aim to suppress viral replication (not in a dissimilar way to treating HIV patients) -examples include tenofovir and entecavir

Question 66

How do you differentiate between superficial epidermal, partial thickness, and full thickness burns?

Answer 66

Superficial epidermal = Red and painful Partial-thickness (superficial dermal) = Pale pink, painful, blistered Partial-thickness (deep dermal) = Typically white but may have patches of non-blanching erythema. Reduced sensation Full-thickness = White/brown/black in colour, no blisters, no pain

Question 67

What 3 syndromes are associated with sarcoidosis?

Answer 67

Lofgren's syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

Question 68

When can you consider 3 shocks followed by CPR rather than just 1 shock and CPR?

Answer 68

If a patient has a monitored and witnessed cardiac arrest in the catheter laboratory, coronary care unit, a critical care area or whilst monitored after cardiac surgery, and a manual defibrillator is rapidly available: - Confirm cardiac arrest and shout for help. - If the initial rhythm is VF/pVT, give up to three quick successive (stacked) shocks. - Rapidly check for a rhythm change and, if appropriate, ROSC after each defibrillation attempt. - Start chest compressions and continue CPR for 2 min if the third shock is unsuccessful. This three-shock strategy may also be considered for an initial, witnessed VF/pVT cardiac arrest if the patient is already connected to a manual defibrillator – these circumstances are rare.

Question 69

What is the criteria for liver transplantation following paracetamol overdose?

Answer 69

Arterial pH < 7.3, 24 hours after ingestion or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy

Question 70

How can you use ABPI to determine the severity of claudication?

Answer 70

Intermittent claudication symptoms are likely to start at an ABPI of less than 0.9-0.8. Rest pain suggests a likely ABPI of <0.5 but the absence of skin changes, and intact pedal pulses suggests there is still some perfusion to the peripheries. An ABPI <0.3 would usually result in gangrene and ulcerative changes - at least for exam question purposes. An ABPI of >1 is often seen in diabetic patients with calcified vessel disease.

Question 71

What is the first line analgesic for patients with a NOF?

Answer 71

iliofascial nerve block The Fascia iliaca compartment is an area of potential space that lies between the posterior surface of the fascia iliaca and the anterior surface of the iliacus and posts major muscles. Local anaesthetic injected into this potential space affects the femoral, obturator and lateral femoral cutaneous nerves. The aim of this is to reduce the use of opioids analgesics e.g. morphine, which is particularly helpful in elderly patients who are often more susceptible to their side effects. As the vast majority of patients with neck of femur fractures are elderly, an iliofascial nerve block is now the recommended first line method of analgesia in most UK hospitals.

Question 72

What is the treatment of sinusitis?

Answer 72

NICE guidelines only recommend treatment with intra-nasal corticosteroids if the symptoms of sinusitis are severe or have lasted for a period of 10 days or more. Antibiotics are only advised if individuals are systemically unwell or have significant co-morbidities that pre-dispose them complications (for example chronic severe COPD).

Question 73

What is the treatment for acne with scarring?

Answer 73

oral irotretinoin

Question 74

What are the restrictive lung disorders?

Answer 74

``` Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis Neuromuscular disorders ```

Question 75

What is the treatment for B-blocker overdose?

Answer 75

if bradycardic then atropine | in resistant cases glucagon may be used

Question 76

When do you ELISA for HIV?

Answer 76

3-12 weeks for seroconversion If negative ELISA before 12 weeks you need to repeat at 12 weeks or later to be sure

Question 77

What must you test for in every patient starting thiopurines (azathioprine/ mercaptopurine)?

Answer 77

TPMT

Question 78

How do you manage pancreatic pseudocyst post pancreatitis?

Answer 78

>6cm or remains after 12 weeks then you drain

Question 79

What is a Grawit'z tumour?

Answer 79

Renal adenocarcinoma (RCC)

Question 80

What is the management of a renal cell carcinoma?

Answer 80

T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological results to total radical nephrectomy. Partial nephrectomy may also be performed when there is inadequate reserve in the remaining kidney. For T2 lesions and above a radical nephrectomy is standard practice and this may be performed via a laparoscopic or open approach. Preoperative embolisation is not indicated nor is resection of uninvolved adrenal glands. During surgery early venous control is mandatory to avoid shedding of tumour cells into the circulation. Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or biological agents. These should not be administered outside the setting of clinical trials. Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the bladder.

Question 81

What is plagiocephaly?

Answer 81

Plagiocephaly is more common since there have been campaigns to encourage babies to sleep on their back to reduce the risk of sudden infant death syndrome (SIDS). Plagiocephaly is a skull deformity producing unilateral occipital flattening, which pushes the ipsilateral forehead ear forwards producing a 'parrallelogram' appearance. The vast majority improve by age 3-5 due to the adoption of a more upright posture.

Question 82

What are the negative prognostic factors for Hodgekin lymphoma?

Answer 82

The presence of B symptoms (night sweats, weight loss and fever) Male gender Being aged >45 years old at diagnosis High WCC, low Hb, high ESR or low blood albumin

Question 83

What serology can be carried out in coeliac disease?

Answer 83

tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE endomyseal antibody (IgA) anti-casein antibodies are also found in some patients

Question 84

What dose of levothyroxine do you start hypothyroid patients?

Answer 84

initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. The BNF recommends that for patients with cardiac disease, severe hypothyroidism or patients over 50 years the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100mcg od

Question 85

How do you manage missed clozapine doses in schizophrenic patients?

Answer 85

If doses are missed for more than 2 consecutive days (48 hours), you will need to restart their clozapine slowly (like when they first started on it). This restart of treatment needs to be under the direction of a Psychiatrist. This is because when you start Clozapine after a break of >48 hours, it can make side effects worse, such as blood pressure changes, drowsiness and dizziness. If there is a gap in treatment of 3 days (72 hours) then you may also require more frequent blood tests for a short period.

Question 86

How long does a pityriasis rosea rash usually last?

Answer 86

6-12 weeks

Question 87

What is normal weight gain in babies?

Answer 87

200g/week at 0-3 months 150g/week at 3-6 months 100g/week at 6-9 months 75-50g at 9-12 months.

Question 88

When are nutrient-dense formulas used in paediatrics?

Answer 88

``` prescribable 0-18 months for: – Disease related malnutrition – Growth failure – Malabsorption – per 100ml ``` • SMA High Energy 91kcal 250ml cartons • Infatrini (Nutrica) 100kcal 200ml cartons

Question 89

What kind of thickened feeds can you get in paediatrics?

Answer 89

``` Gaviscon sachets (not an antacid) • Carobel (carob based) adds 5kcal/100ml • Thick and Easy (maize based) adds 10-15kcal/100ml • Pre thickened formula – Enfamil AR – SMA Stay Down ```

Question 90

What feeds can be used for milk intolerance in paediatrics?

Answer 90

``` Soya Formula eg Wysoy, Infasoy • NOT feed of choice < 12 months • Hydrolysed protein feeds are recommended – Nutramigen ,Pepdite, Pepti-junior, – Neocate LCP: amino acid based – Aptamil Pepti - not lactose free – palatability a problem in older babies ```

Question 91

What can be used for secondary lactose intolerance after gastroenteritis in paeds?

Answer 91

``` Lactose free milks • short lived condition eg post gastro-enteritis • often confused with cow’s milk protein intolerance • CHO as glucose polymer – SMA LF, Enfamil Lactofree ```

Question 92

What is the school exclusion advice for Scarlet fever?

Answer 92

24 hours after commencing antibiotics

Question 93

What is the school exclusion advice for measles and rubella?

Answer 93

4 days from onset of rash

Question 94

What is the school exclusion advice for mumps?

Answer 94

5 days from onset of swollen glands

Question 95

What is the school exclusion advice for scabies?

Answer 95

Until treated

Question 96

When do you perform stool microbiological investigations?

Answer 96

You suspect septicaemia There is blood and/or mucus in the stool The child is immunocompromised

Question 97

In eclampsia when can magnesium infusion be stopped?

Answer 97

Should continue for 24 hours after delivery OR after last seizure (whichever comes later)

Question 98

What is Palivizumab?

Answer 98

Palivizumab is a monoclonal antibody which is used to prevent respiratory syncytial virus (RSV) in children who are at increased risk of severe disease. Those at risk of developing RSV include Premature infants Infants with lung or heart abnormalities Immunocompromised infants

Question 99

What is the chemo treatment for Ewing sarcoma?

Answer 99

VDC/IE Vincristine Doxorubicin Cyclophosphamide Ifosfamide Etoposide

Question 100

What drugs cause serotonin syndrome?

Answer 100

Serotonergic drugs that are associated with serotonin syndrome include tramadol, selective serotonin reuptake inhibitors (SSRI), monoamine oxidase inhibitors (MAOI), triptans and St Johns wort.

Question 101

What is the treatment of hyperhydrosis?

Answer 101

The first line management of this condition is aluminium chloride which can be given in the form of roll-ons applied at nighttime. Underlying anxiety should also be treated. This is basically excess sweating

Question 102

What are the clinical features of thrombotic thrombocytopenic purpura?

Answer 102

1. Fever 2. Neurological (seizures, hemiparesis, reduced consciousness) 3. Renal dysfunction (AKI) 4. Anaemia (MAHA with jaundice) 5. Platelets (reduced)

Question 103

What is endometrial hyperplasia?

Answer 103

``` Taking oestrogen unopposed by progesterone Obesity Late menopause Early menarche Aged over 35-years-old Being a current smoker Nulliparity Tamoxifen ```

Question 104

What are the side effects of clozapine?

Answer 104

agranulocytosis (1%), neutropaenia (3%) reduced seizure threshold - can induce seizures in up to 3% of patients constipation (more people die of obstruction and perforation than agranulocytosis) myocarditis: a baseline ECG should be taken before starting treatment hypersalivation

Question 105

What foods should be avoided in pregnancy?

Answer 105

Liver (high in Vit A -> teratogenic) Alcohol listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat salmonella: avoid raw or partially cooked eggs and meat, especially poultry

Question 106

What are the features of fetal alcohol syndrome?

Answer 106

``` Microcephaly (small head) Short palpebral fissures (small eye opening) Hypoplastic upper lip (thin) Absent philtrum Reduced IQ Variable cardiac abnormalities. ```

Question 107

In bronchiolitis when should you consider another diagnosis?

Answer 107

Consider a diagnosis of pneumonia if the child has: - high fever (over 39°C) and/or - persistently focal crackles.

Question 108

What chemotherapy is used in breast cancer?

Answer 108

FEC = Node -ve breast cancer 5-FU Epirubicin Cyclophosphamide FEC-D = Node +ve breast cancer -as above plus docetaxel

Question 109

When is radiotherapy offered in breast cancer?

Answer 109

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who've had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

Question 110

Paget's disease of the nipple is associated with which breast lesion?

Answer 110

Invasive carcinoma In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

Question 111

What are the signs of hyposplenism on blood film?

Answer 111

``` Target cells Howell Jolly bodies Pappenheimer cells acanthocytes siderotic granules ```

Question 112

What is the management of hepatorenal syndrome?

Answer 112

Terlipressin Albumin infusion Transcutaneous intrahepatic portosystemic shunt (TIPS)

Question 113

What are the 5 features of the Colle's deformity?

Answer 113

``` Dorsal angulation Dorsal displacement Shortening Radial deviation Supination ```

Question 114

Which muscles are divided on a posterior approach to a hip replacement?

Answer 114

During the posterior approach to the hip the short external rotators of the hip are divided to expose the capsule. These are: - piriformis - obturator internus, and - the gemelli.