QBANK AUDIT (MLA 1) (CVS, RESP, GI, GERI, NEURO, OPTH., ENDO, RENAL, URO, INFECTION, DERM)

Question 1

COPD MGMT LADDER

Answer 1

1. SABA or SAMA PRN
2. Regular LABA + LAMA or regular LABA + ICS
   (choice depending on asthmatic features/steroid responsiveness)
3. LABA + LAMA + ICS
   After that for severe cases you would think about nebulisers, oral theophylline, mucolytics, prophylactic antibiotics, LTOT etc

• NOTE steroid response likelihood via history

Question 2

Typical iron profile for haemchrom.

Answer 2

If haemochromatosis is the diagnosis to be,
Expect a low TIBC,
Transferrin and Ferritin are oh so high,
Venesection and chelation to say bye bye

Question 3

A 65-year-old male presents to the GP with recurrent mild upper abdominal pain following a meal. He also complained of foul-smelling greasy stools. He has not experienced any weight loss or change in appetite, no nausea or vomiting, and is not clinically jaundiced. He has a past medical history of chronic alcohol abuse - he drinks 80 units per week and has been doing so for the past 10 years.

What is the most appropriate diagnostic test?

Answer 3

CT Abdo

• Chronic Pancreatitis
  => CT
• Alcohol ; CF; Ductal Obstr.
• Pain post meal; Steatorrhea; DM development

> Pancr. enzymes
Analgesia

Question 4

A 76-year-old man presents to hospital with fatigue, confusion and constipation. He has a past medical history of prostate cancer, hypertension and hypercholesterolemia. Bloods reveal a significantly raised calcium.

What is the ECG most likely to show?

Answer 4

Shortening QT

• QT = systole duration - driven by calcium

More calcium on the outside = More calcium moving into the cell and faster (higher potential and electrical pressure gradient) = quicker end of plateu face = shorter systole = short QT

HyperCa Features
* ‘bones, stones, groans and psychic moans’
* corneal calcification
* shortened QT interval on ECG
* hypertension

Question 5

Ileostomy Vs Colostomy in the context of Crohns

Answer 5

This patient has Crohn’s disease which affects the entire gastrointestinal tract, from the mouth to the anus. The most common site of disease is the terminal ileum and thus many patients have ileostomies, however they can also have colostomies.

As a general rule, an ileostomy is spouted to prevent the surrounding skin from coming into contact with the alkaline enzymes in the small intestine, whilst colostomies are flat (1).

Question 6

Mr Jones has recently been diagnosed with bowel cancer.

What is the best marker to use to monitor the progression of the tumour and its response to future treatment?

Answer 6

CEA

Question 6

A 62-year-old man presents to the emergency department with several days of cough and haemoptysis. He also describes reduced urine output for the past two days. He has no significant past medical history.

On examination, bilateral basal crackles are noted on examination of the chest. Haemoptysis is observed. Urinalysis reveals proteinuria and microscopic haematuria. Blood tests are performed:

Na+ 135 mmol/L (135 - 145)
K+ 5.4 mmol/L (3.5 - 5.0)
Urea 14.2 mmol/L (2.0 - 7.0)
Creatinine 254 µmol/L (55 - 120)

What is the most likely diagnosis?

Answer 6

Anti-GBM

-
This patient’s presentation is suspicious of anti-glomerular basement membrane (anti-GBM) disease, formerly known as Goodpasture’s disease. This is a cause of pulmonary-renal syndrome consisting of rapidly progressive renal glomerulonephritis and pulmonary haemorrhage. Patients typically present as seen here, with haemoptysis and reduced urine output. The blood tests show significantly impaired renal function with proteinuria and haematuria. Anti-GBM antibodies in the serum and renal biopsy are used to confirm the diagnosis. Management involves the use of plasma exchange, steroids and cyclophosphamide.

Question 7

A 53-year-old woman presents to the emergency department with a sudden-onset, severe headache, describing it as the worst of her life. She had been sitting at her desk when the headache came on. She has associated nausea and vomiting.

On examination, she has some neck stiffness and photophobia and appears drowsy. A CT scan shows hyperdense across the basal cisterns and sulci.

Which of the following is indicated in managing the complications of this condition?

Answer 7

Nimodipine - prevent vasospasm in SAH

Question 8

Sally is a 29-year-old female who has come to the GP because of a few symptoms she has been experiencing for the past 3 weeks. She first noticed a rash on her thighs which then appeared on her forearms. It is dry, itchy and red. Then she began to have pain in her knees which was worse on movement, the same pain then spread to her left wrist and began to limit her movement. In the last week she has noticed difficulty in moving some of her right fingers from a bent to straight position, it being painful to do so.

The doctor takes blood cultures and sends them off.

What is most likely to been seen on microscopy?

Answer 8

Neisseria gonorrhoea, a gram-negative diplococcus

Disseminated gonococcal infection triad = tenosynovitis, migratory polyarthritis, dermatitis

Question 9

A 23-year-old male medical student presents to the emergency department with severe right upper quadrant abdominal pain. He describes it as sharp and worse on inspiration. He has been feeling tired and short of breath in the last few days and has a cough productive of purulent, bloody sputum. He has a fever, tachycardia and tachypnoea. He has recently come back from a week-long holiday in which he admits to drinking 15 units of alcohol a day.

Dx

Answer 9

Pneumonia - Lower lobe pneumonia may present with upper quadrant abdo pain

thus mimicing a GI hepatic picture!! beware

Question 10

A 61-year-old man presents to his GP with symptoms of fatigue and dizziness. He otherwise describes himself as ‘fit and well’ and has no significant past medical history. He reports no weight loss, no fevers, no changes in bowel habit or problems when passing urine.

The GP arranges blood tests as below:

Hb 100 g/L Male: (135-180)
Female: (115 - 160)
Platelets 170 * 10 9/L (150 - 400)
WBC 5.6 * 10 9/L (4.0 - 11.0)
Iron 9 mmol/L Male: (14-32 μmol/L)
Female: (11-29 μmol/L)
Ferritin 10 ng/mL (20 - 230)
Prothrombin time (PT) 12 secs (10-14 secs)
Activated partial thromboplastin time (APTT) 30 secs (25-35 secs)

What is the most appropriate next step in management?

Answer 10

Urgent CRC referral

Pt 60+ with new Fe-def Anemia

• FIT testing too?

Question 11

A 7-year-old girl is admitted under the paediatric team with a 2-day history of rash, abdominal pain, and blood in her urine. Her notes show a recent course of oral antibiotics for a urinary tract infection from her GP. She has no past medical history and is up to date with immunisations.

On examination, there is a purpuric rash over her buttocks and both lower limbs.

After 4 days on the ward, she is discharged.

Considering her likely diagnosis, what should her parents be counselled to monitor?

Answer 11

BP & dipstick

for HSP to detect progressive renal involvement

Question 12

Myxoedema Coma

Answer 12

Complication of hypothyroidism

Hypothermia and confusion are the most common presenting features of myxoedema crisis, also known as myxoedema coma. The name is a misnomer as it very rarely causes coma or pre-tibial myxoedema (an uncommon manifestation of Graves disease).

Other features include bradycardia, hypotension and hypoventilation.

Question 13

Jeffrey is a 58-year-old man with a past medical history of type 2 diabetes, hypertension and previous bladder cancer. He currently takes metformin at maximum dose and amlodipine.

Routine blood test results have returned showing a HbA1c of 59 mmol/mol. The previous HbA1c result 6 months ago was 51 mmol/mol. Urea and electrolytes are within normal limits.

Jeffrey’s body mass index is 36kg/m². With this in mind, which of the following options is the most appropriate next step in management?

Answer 13

+ emagliflozin
to start dual Rx.
+ benefits in Wt loss in T2DM
* SGLT-2 inhibitors have the beneficial side effect of weight loss in patient with T2DM

with Liraglutide as triple Rx and last resort

Question 14

A 31-year-old woman presents to the Emergency Department complaining of a headache. She has had ‘flu’ like symptoms for the past three days with the headache developing gradually yesterday. The headache is described as being ‘all over’ and is worse on looking at bright light or when bending her neck. On examination her temperature is 38.2º, pulse 96 / min and blood pressure 116/78 mmHg. There is neck stiffness present but no focal neurological signs. On close inspection you notice a number of petechiae on her torso. She has been cannulated and bloods (including cultures) have been taken. What is the most appropriate next step?

Answer 14

> IV CEFOTAXIME

Question 15

A 57-year-old man with a background of hypertension presents to the emergency department with severe chest pain. An ECG shows ST elevation in leads II, III and aVF and the patient is diagnosed with ST-elevation myocardial infarction.

Given the likely location of the coronary occlusion, from which complication is this patient most likely to suffer?

Answer 15

1st Degree AV Block

ST elevation in leads II, III and aVF is in-keeping with an inferior ST-elevation myocardial infarction. Inferior myocardial infarctions are typically due to occlusion of the right coronary artery. The right coronary artery supplies the AV node so a right coronary infarct can cause arrhythmias including sinus bradycardia and atrioventricular block.

Question 16

ECG changes associated with ANTEROSEPTAL and its affected artery

Answer 16

V1-V4

LAD

Compl: RBBBlock; Rupture few weeks after

Question 17

ECG changes associated with LATERAL and its affected artery

Answer 17

I, AVL +/- V5-V6

LCx

Question 18

A 63-year-old man is seen in the clinic with 3 years of worsening shortness of breath on exertion and a dry cough. He has no haemoptysis, has never smoked, and worked in an office for the past 35 years and in a factory for 2 years before. His family with whom he lives recently bought a new pet parrot last week.

His pulse is 85 bpm, his respiratory rate is 16 /min, and he is afebrile. Fine end-inspiratory crackles are heard over both lung bases and finger clubbing is seen. A chest X-ray is unremarkable but a high-resolution CT scan shows a ground glass appearance.

Based on these features, what is the most likely diagnosis?

Answer 18

Fine end-inspiratory crepitations are seen in idiopathic pulmonary fibrosis

Question 19

A 72-year-old man presents to his GP complaining of reduced sensation in his lower limbs that has been progressively worsening over the last 3 months. He feels increasingly unsteady on his feet but is otherwise well.

On examination, vibration and pinprick sensation are reduced symmetrically and he has a wide-based ataxic gait. His ankle reflexes are absent however his knee reflexes are brisk.

His past medical history includes hypertension, managed with ramipril, and gastric cancer, which was treated with a sub-total gastrectomy 4 years ago. He has a body mass index of 29.2kg/m² and drinks 10 units of alcohol per week.

What is the most likely cause of this patient’s symptoms?

Answer 19

Gastrectomy may result in vitamin B12 deficiency
leading to
subacute combined degeneration of the spinal cord

Question 20

A 50-year-old woman presents with right-sided medial thigh pain for the past week. There has been no change in her bowels. On examination you noticed a grape sized lump below and lateral to the right pubic tubercle which is difficult to reduce. What is the most likely diagnosis?

Answer 20

FEMORAL HERNIA

The most likely diagnosis in this case is a Femoral hernia. Femoral hernias are more common in women and typically present as a lump below and lateral to the pubic tubercle, which can be difficult to reduce. They are caused by a defect in the femoral canal, allowing abdominal contents to protrude through the canal. The patient’s age and presentation of right-sided medial thigh pain further support this diagnosis.

Question 21

Most common complication following meningitis

Answer 21

Sensorineural hearing loss

Question 22

Answer 22

Keratoacanthoma

Fast track to exclude SCC

Question 23

A 28-year-old man presents to his GP with a painless ulcer on his penis which has been present for several weeks. He otherwise has no symptoms and is generally well in himself. On examination, he also has non-tender inguinal lymphadenopathy.

The GP prescribes penicillin. Several hours later, the patient presents to the Emergency Department with fever and a new rash. On examination, he appears well but has marked flushing of his torso. There is good air entry on auscultation, with no wheeze. Observations are as follows:

Heart rate: 98 beats/min
Respiratory rate: 18 breaths/min
Blood pressure: 132/72 mmHg
Temperature: 37.9ºC

What is the most appropriate next step in management, given the likely explanation?

Answer 23

> Paracaetamol

The Jarisch-Herxheimer reaction, unlike an anaphylactic reaction, will not present with hypotension and wheeze

He instead presented with the Jarisch-Herxheimer reaction, which is sometimes seen following treatment of syphilis, thought to be due to the release of endotoxins. It presents as fever, rash and tachycardia, but there is crucially no wheeze and no hypotension. No treatment is required except for antipyretics, if needed.

Question 24

A 33-year-old man presents to the emergency department with a 2-hour history of dyspnoea and chest pain. He has no significant past medical history but smokes 20 cigarettes/day. Examination reveals hyperresonance on percussion and reduced breath sounds on the left side. His pulse is 107 bpm and his respiratory rate is 21 breaths/min. A chest X-ray shows a left-sided pneumothorax with a rim of air of 3.3 cm.

Needle aspiration is attempted. Following this, the patient’s breathlessness reduces. A repeat X-ray shows a 2.3 cm rim of air.

What is the most appropriate next step?

Answer 24

> chest drain if needle aspiration unsucessful

Question 25

A 38-year-old woman presents to a rural hospital with left-sided facial paralysis, which she noticed upon waking. She also describes an altered taste sensation in the anterior part of her tongue.

On neurological examination, she exhibits dry eyes and left-sided paralysis of the facial muscles, including the forehead; however, orientation is intact and there are no neurological deficits in the upper or lower limbs.

Where is the pathology most likely located?

Answer 25

CN VII with Bell’s Palsy

Question 26

A 44-year-old man presents with a 3-month history of progressive weakness in the upper and lower limbs. On examination, you note brisk knee reflexes, absent ankle jerks, and extensor plantars. Power is reduced in all muscle groups of the upper (MRC grade 3/5) and lower (MRC grade 3/5) limbs. A neurological examination was otherwise unremarkable.

What is the most likely diagnosis?

Answer 26

ALS / MND

Question 27

A 64-year-old man has had a diagnosis of stable angina from a rapid access chest pain clinic a year ago. He was commenced on glyceryl trinitrate (GTN) spray to be used as and when the chest pain occurred and bisoprolol to be taken every day.

These interventions initially worked until a few weeks ago when after walking 100 yards up the hill to his local shops he noticed the pain came back and was only partially relieved by GTN spray. electrocardiograms, troponin, echocardiography and a myocardial perfusion scan are all unremarkable.

What is the next best step in management?

Answer 27

> Modified release Nifedipine

If angina is not controlled with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be added

Question 28

Angina Pectoris Drug Mgmt

Answer 28

aspirin and a statin in the absence of any contraindication

GTN for reliefof attacks

beta-blocker or a calcium channel blocker first-line based on ‘comorbidities, contraindications and the person’s preference’
- calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used

• if used in combination with a beta-blocker then use a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)
  ! never dual prescribe BB and verapamil

if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

• if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs:
  a long-acting nitrate
  ivabradine
  nicorandil
  ranolazine

*if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

Question 29

TIA presentation in Primary Care and Next Steps

Answer 29

A patient who presents to their GP within 7 days of a clinically suspected TIA should have 300mg aspirin immediately (and be referred for specialist review within 24h)

Question 30

A 35-year-old man is on the acute medical unit with a new diagnosis of hypertrophic obstructive cardiomyopathy. He is on cardiac monitoring, and the emergency buzzer is pulled after he is noted to become very tachycardic. An ECG shows a regular, broad complex tachycardia. The patient has a GCS of 15, blood pressure is 123/81mmHg and he reports feeling well.

What is the most appropriate management?

Answer 30

IV Amiodarone

IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features

Question 31

Abx of chjoice for an animal bite

Answer 31

Co-Amox ofr prophylaxtic Tx

OR

Doxy + Metronidazole if Pen. Allergic

Question 32

Signs in Degenerative Cervical Myelopathy

Answer 32

Pain (affecting the neck, upper or lower limbs)

Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance

Loss of sensory function causing numbness

Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition

Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.

Question 33

A 27-year-old male attends the emergency department with a sudden onset painful left eye and slightly blurred vision. He has no past medical history of note and does not wear glasses or contact lenses. His family history includes type 2 diabetes and Crohn’s disease.

He is wearing sunglasses in the department as he finds the lighting too bright. On removal, you note his left eye is red and his complaint of photophobia is so severe he cannot tolerate ophthalmoscopy. On close inspection, you see a white fluid level visible in the inferior part of the anterior chamber and his pupil appears small and irregular.

Due to these findings, you urgently contact ophthalmology - what is your working diagnosis?

Answer 33

Anterior uveitis presents with acutely painful red eye, photophobia, small pupil, reduced visual acuity. It is often associated with pus in the anterior chamber (a hypopyon)

Question 34

A 34-year-old man presents with an itchy rash on his genitals and palms. He has also noticed the rash around the site of a recent scar on his forearm. Examination reveals papules with a white-lace pattern on the surface. What is the diagnosis?

Answer 34

Lichen Planus

Lichen
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women

Question 35

A 20-year-old man presents with a three-day history of diarrhoea following a holiday to Thailand. He reports opening his bowels up to 15 times per day.

On examination, he has dry mucous membranes, loss of skin turgor and a prolonged capillary refill time. As part of his admission workup, an arterial blood gas is taken.

What would most likely be seen on arterial blood gas?

Answer 35

Prolonged diarrhoea may result in a metabolic acidosis associated with hypokalaemia

Question 36

A 74-year-old woman presents to the emergency department with sudden-onset weakness in her left leg affecting her ability to walk. This started when she woke up this morning.

On examination MRC power was graded as 5/5 in the right limbs, 5/5 in the left upper limb and 3/5 in the left lower limb. Fine touch was also found to be reduced in her left leg compared to the right. Her cranial nerve examination shows no abnormal findings.

A CT scan of her head is ordered.

Based on her presenting symptoms, which artery is most likely to be affected?

Answer 36

Anterior cerebral artery stroke causes leg weakness but not face weakness or speech impairment

Question 37

A 48-year-old woman with a history of asthma presents to the emergency department with shortness of breath, cough, with some specs of brown sputum. The only recent change in her life is moving into her new flat. Chest x-ray appears normal but blood tests later reveal an elevated IgE and IgM to A.fumigatus and so a diagnosis of allergic bronchopulmonary aspergillosis is made.

Which of the following would be considered a major feature seen in this condition?

Answer 37

Eosinophilia is a feature of allergic bronchopulmonary aspergillosis

Question 38

High Risk V Low Risk Pneumothorax and Appropriate Actions

Answer 38

Pneumothorax management: the high-risk characteristics that determine the need for a chest drain are:
Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history
Haemothorax

Needle aspiration is indicated in symptomatic patients who do not have a high-risk characteristic. Patients who have successful needle aspiration will then be followed up in the outpatient department in 2-4 weeks.

Question 39

A 76-year-old gentleman presents to the emergency department. His wife is struggling to cope with him. The wife tells you that he has been getting confused and more forgetful since last month. She is worried as he’s been more unsteady on his feet and has fallen in the last week, she was unable to help him up as he is too heavy. When you examine him you notice that he has been incontinent of urine.

What is the most likely diagnosis?

Answer 39

Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus

Question 40

A 23-year-old woman presents to the general practitioner with a worsening rash on her face and upper back which is causing a significant impact on her self confidence. She is currently five months pregnant and describes experiencing similar lesions during her teenage years. She is otherwise well with no allergies. The rash has not responded to topical benzoyl peroxide.

Examination identifies numerous erythematous papules and pustules distributed across the patient’s face and upper back.

Which of the following management options is most appropriate?

Answer 40

Acne vulgaris in pregnancy - use oral erythromycin if treatment needed

Question 41

A 41-year-old woman presents with palpitations and heat intolerance. On examination her pulse is 90/min and a small, diffuse goitre is noted which is tender to touch.

Thyroid function tests show the following:
Thyroid stimulating hormone (TSH) < 0.05 mu/l (0.5-5.5 mu/l)
Free T4 24 pmol/l (9-18 pmol/l)

Answer 41

Thyrotoxicosis with tender goitre = subacute (De Quervain’s) thyroiditis

Whilst Grave’s disease is the most common cause of thyrotoxicosis it would not cause a tender goitre. In the context of thyrotoxicosis this finding is only really seen in De Quervain’s thyroiditis.

Question 42

A 27-year-old woman presents to the GP with a 3-month history of weakness that is worse at the end of the day, along with double vision exacerbated by reading. She has a history of type 1 diabetes mellitus that is well-controlled.

The GP makes a routine referral to secondary care, however, today, she presents to the emergency department with worsening dyspnoea and weakness over 2 hours. She is subsequently intubated and ventilated and treatment is being arranged.

What is the most likely immediate treatment for this patient?

Answer 42

Supportive care and IV Ig and Plasma Exchange

Management of myasthenic crisis - intravenous immunoglobulin, plasmapheresis

Question 43

A 65-year-old man with a history of dyspepsia is found to have a gastric MALT lymphoma on biopsy. What treatment should be offered?

Answer 43

Gastric MALT lymphoma - eradicate H. pylori

The correct answer is H. pylori eradication. Gastric MALT (mucosa-associated lymphoid tissue) lymphoma is a type of non-Hodgkin lymphoma that arises from the mucosal lymphoid tissue of the stomach. It has been found to be strongly associated with chronic H. pylori infection, which induces a local inflammatory response and subsequent development of MALT in the gastric mucosa. According to UK guidelines, initial treatment for localised gastric MALT lymphoma should be aimed at eradicating H. pylori, irrespective of the patient’s H. pylori status. This can lead to regression of the tumour in a significant proportion of patients.

Question 44

You are reviewing a 79-year-old man who has a history of hypothyroidism, Parkinson’s disease and depression. These problems are well controlled using levothyroxine, co-careldopa and citalopram. He complains of symptoms consistent with gastro-oesophageal reflux disease. Which one of the following medications is it most important to avoid?

Metoclopramide
Ranitidine
Cyclizine
Lansoprazole
Esomeprazole

Answer 44

Metoclopramide is contraindicated in Parkinsonism

As metoclopramide is a dopamine antagonist it may worsen symptoms in patients with Parkinson’s disease.

Question 45

INR Reducers and Increases

Answer 45

PC BRAS (drugs that reduce INR)
P Phenytoin
C Carbamazepine
B Barbituates
R Rifampicin
A Alcohol (chronic use)
S Sulphonylureas

O-Devices (Drugs that increase INR):
O Omperazole
D Disulfiram
E Erythromycin
V Valproate
I Isoniazid
C Cimetidine + Ciprofloxacin
E Ethanol (Acutely)
S Sulphonamides

Question 46

74-year-old man presents to the emergency department with episodes of haemoptysis, dyspnoea, and palpitations over the past month. On examination, he has an irregularly irregular heartbeat and a mid-diastolic murmur.

Given the likely diagnosis, what would indicate that the leaflets still have some mobility?

Answer 46

In mitral stenosis, an opening snap indicates the leaflets still have some mobility

Question 47

A 19-year-old lady presents to the GP clinic. She has a past medical history of asthma for which she is taking inhaled salbutamol PRN. She was recently started on a new drug which after a few weeks of intake, she has noticed several white patches in her mouth accompanied by a loss of taste. Which of the following medications is most likely to be causing her new symptoms?

inhaled beclometasone
oral montelukast
inhaled pred
oral pred
inhaled tiotropium

Answer 47

inhaled beclometasone

Patients taking inhaled steroids to treat asthma are advised to rinse their mouth straight after intake to prevent development of oral candidiasis

Question 48

A 37-year-old man presents to his general practice as he is due to have a dental procedure the following week. He has a past medical history of hypertrophic cardiomyopathy.

His mother has recently had an inpatient stay for infective endocarditis and he would like to know whether he should take antibiotic prophylaxis before his procedure to prevent him from developing endocarditis.

Given this patient’s risk factors, what antibiotic prophylaxis is recommended to prevent infective endocarditis?

Answer 48

None

Question 49

A 29-year-old woman presents to her GP with several painful, red, raised lesions on her shins. She has also noted a thin, white, odourless vaginal discharge.

Over the last week, she has suffered from feeling increasingly nauseous. She has also been passing urine more frequently but denies dysuria/haematuria.

What is the most appropriate next investigation?

Answer 49

Erythema nodosum may be caused by pregnancyso pregnancy test

Question 50

A 57 year old gentleman has a known history of aortic stenosis. During a routine cardiology clinic appointment he states he has had worsening shortness of breath over the past few months and has had a few fainting episodes. A recent ECHO shows aortic stenosis with a mean gradient of 45mmHg and mild associated aortic regurgitation. An ECG in clinic shows left ventricular hypertrophy, left bundle branch block and a prolonged PR interval.

Which of the following is most likely to indicate the need for valve replacement surgery?

• Age
• Coexistant AR
• 1st degree AV block
• PResence of symptoms
• LBBB

Answer 50

Symptoms

In general, aortic valve replacement is indicated in symptomatic patients with severe aortic stenosis. The presence of symptoms is associated with a mortality of 2-3 years. The triad of symptoms is dyspnoea, chest pain and syncope. Valve replacement in asymptomatic patients is more controversial.

Question 51

An 8-year-old boy with sickle-cell disease presents with a 5-day history of fever, rash, and runny nose. His mother has brought him to the emergency department today, as she is concerned that he seems extremely tired and not himself. His blood tests are shown below.

Answer 51

Parvovirus B19

Parvovirus B19 can cause fever, rash and patients with predisposing haematological conditions, pancytopenia

Patients with a background of haemolytic anaemia, particularly sickle cell disease, are at risk of aplastic anaemia if infected with parvovirus B19 . Also known as ‘fifth disease’, it typically causes a mild illness with a characteristic ‘slapped cheek’ rash.

Question 52

A 40-year-old man with known end-stage renal failure has been on peritoneal dialysis for the past 5 years.

Family screening for a possible donor identified a potential match with his brother and following appropriate counselling a successful renal transplant was performed. On his 3-monthly review, there is no evidence of graft rejection.

What malignancy is this patient most at risk of in the future?

Answer 52

Renal transplant patients - skin cancer (particularly squamous cell) is the most common malignancy secondary to immunosuppression

Question 53

Prior checks starting biologics such as Adalimumab in RheumArth.

Answer 53

CXR
TB skin test
Interferon gamma release assay
Hep B antibodies

Question 54

A 32-year-old woman presents with sudden onset hemiparesis affecting the right face, arm and leg. On examination you note right sided hemiparesis, aphasia, and a right homonymous hemianopia. She has a past medical history of recurrent deep vein thrombosis, pulmonary embolisms and recurrent miscarriages. Blood results reveal a prolonged APTT.

What is the most likely cause of the stroke?

-VWb Disease
- Embolus from paroxysmal AF
- Antiphospholipid syndrome
- SLE
- Factor V Leiden

Answer 54

The clinical features are suggestive of antiphospholipid syndrome. A positive anti-Cardiolipin antibody can assist in making the diagnosis.

It is important to remember that strokes can be caused by hypercoagulable states and hyperviscosity. Antiphospholipid syndrome is a type of thrombophilia disorder resulting in hypercoagulation and increased tendency to form clots - both arterial and venous. This thereby increases the risk of ischaemic strokes.

Question 55

A 20-year-old man is on the post-op recovery unit after a tonsillectomy performed 3 hours ago. He is recovering well and is about to be transferred to an ENT ward. The nurse looking after the patient notices a small amount of new bleeding in the peritonsillar area. The patient is now complaining of pain.

His temperature is 37.2ºC, his heart rate is 97 bpm, his blood pressure is 125/73 mmHg, and his respiratory rate is 13 /min. He has no other past medical history and does not smoke or drink alcohol.

What is the most appropriate next step in his management?

Answer 55

All post-tonsillectomy haemorrhages should be assessed by ENT

Haemorrhage is one of the most important and concerning complications following tonsillectomy, even in small amounts. This patient has a primary haemorrhage as the bleeding has occurred within 6-8 hours of his operation. This requires immediate ENT input

Post-tonsillectomy haemorrhages can have associated risks that can be dire and can be missed as many people, particularly younger patients, can lose a significant amount of blood and compensate before serious problems arise, such as shock.

Question 56

A 16-year-old girl presents to the GP with swollen, red cheeks and a tingling sensation in her mouth, accompanied by small red raised spots across her face. She reports that these symptoms began approximately five hours ago after consuming shrimp. She has no known allergies and has not previously experienced similar symptoms. The patient denies experiencing any difficulty breathing or swallowing; she does not suffer from respiratory compromise.

What is the first-line management for this patient’s presentation?

Answer 56

Non-sedating antihistamines are first-line for acute urticaria

The patient presents with symptoms indicative of acute urticaria, characterised by swelling and wheals confined to the oral region following an allergic reaction to shrimp. There are no indications of respiratory compromise or signs suggestive of complicated or severe urticaria. In such instances, the first-line management involves the use of non-sedating antihistamines like loratadine.

Question 57

Hallmarks of Ovarian Cancer

Answer 57

Older female
Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating

Non-spec syptoms often to later Dx

Question 58

An 85-year-old woman is taken to the emergency department from her care home. She was unable to mobilise this morning and she developed difficulty in her speech.

On examination, she looks alert and distressed. A neurological examination reveals the strength of 1/5 in her left upper limb and strength of 3/5 in her left lower limb. The right side of both the upper and lower limb is normal in strength. A sensory examination reveals sensory loss on both the upper and lower limb on the left side. She is unable to visualise objects on her left side in both eyes.

Given the most likely diagnosis, where is the lesion?

Answer 58

Right middle cerebral artery

Contralateral hemiparesis and sensory loss with the upper extremity being more affected than the lower, contralateral homonymous hemianopia and aphasia - middle cerebral artery

Question 59

Microcytic Anemia: A of Chronic Disease V Iron Def.

Answer 59

TIBC is high in IDA, and low/normal in anaemia of chronic disease

Question 60

A 34-year-old financial gains representative presents in a routine surgery with a 2-week history of a droopy left eyelid with forehead weakness. This is confirmed by examination and there are no ocular or ear findings.

What is an important part of treatment?

Answer 60

Eye care is important in Bell’s palsy - drops, lubricants and night time taping should be considered

Question 61

Frankie is a 32-year-old woman who attended for cervical cancer screening 2 years ago. The result was positive for high-risk human papilloma virus (hrHPV) and cervical cytology was normal.

She had repeat testing 12 months later and again tested positive for hrHPV with normal cytology. She was booked in for repeat testing in a further 12 months.

This was carried out 2 weeks ago. The result reveal that Frankie remains hrHPV positive and cytology is normal.

What is the most appropriate next step?

Answer 61

Colposcopy

Cervical cancer screening: if 2nd repeat smear at 24 months is still hrHPV +ve → colposcopy

Question 62

Features of Normal Pressure Hydrocephalus

Answer 62

Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus

Question 63

A 6-month-old baby is brought to the paediatric Emergency Department with suspected bronchiolitis. While awaiting assessment, the infant suddenly becomes unresponsive and Basic Life Support (BLS) is initiated. While observing for signs of life, the doctor decides to quickly assess the pulse.

What pulses are appropriate to check in this scenario?

Answer 63

Paediatric BLS: In an infant, the appropriate places to check for a pulse are the brachial and femoral arteries

Question 64

ou see a 60-year-old woman who recently had urea and electrolytes performed as part of a medication review. You also have previous from 4 months ago to compare with. She has a history of hypertension and takes ramipril. On examination, her blood pressure is 135/80mmHg.

Current blood results:

Na+ 135 mmol/L (135 - 145)
K+ 4.9 mmol/L (3.5 - 5.0)
Urea 6.0 mmol/L (2.0 - 7.0)
Creatinine 125 µmol/L (55 - 120)
eGFR 54 ml/min/1.73m2

Blood results from 4 months ago:

Na+ 136 mmol/L (135 - 145)
K+ 4.0 mmol/L (3.5 - 5.0)
Urea 5.4 mmol/L (2.0 - 7.0)
Creatinine 122 µmol/L (55 - 120)
eGFR 55 ml/min/1.73m2

What additional medication should this woman be prescribed?

• Aspirin
• Atorvastatin
• Clopidogrel
• Losartan
• Metformin

Answer 64

All patients with chronic kidney disease should be started on a statin

According to The National Institute for Health and Care Excellence (NICE) criteria, this patient has chronic kidney disease (CKD) as she has a persistent reduction in her renal function, with an eGFR of <60 on 2 occasions, on blood tests, performed more than 3 months apart. NICE recommend all patients with CKD should be prescribed a statin for the primary or secondary prevention of cardiovascular disease (CVD).

Question 65

A 78-year-old woman presents with a four-hour history of severe dyspnoea. This is present at rest but worse on lying down and with exertion. She was discharged from the coronary care unit three weeks ago following a myocardial infarction.

On examination, she has fine bibasal crepitus and pitting ankle oedema.

Observations:
Pulse: 104 bpm
BP: 126/88 mmHg
Respiratory rate: 28/min
Temperature: 36.8ºC
Oxygen saturations: 92% on room air

Her chest X-ray shows bilateral fluffy opacification with Kerley-B lines.

You make a working diagnosis of acute heart failure and give her 15L high flow oxygen and IV furosemide. A repeat chest X-ray shows no improvement.

What is the next best management step?
- 500ml bolus IV NaCl
- CPAP
- Sodium nitroprusside
- Bisoprolol
- Adenosine

Answer 65

Acute heart failure not responding to treatment - consider CPAP

Question 66

A 45-year-old man has been diagnosed with colorectal cancer. Imaging shows a rectal tumour that is in the mid-rectum, and doesn’t extend past the mid-rectum. What is the most appropriate surgical management for a mid-rectal tumour?

Answer 66

Anterior Resection

Mid/high rectal tumours can be managed with anterior resection. Hartmann’s procedure is generally for sigmoid tumours, and abdominoperineal excision of rectum is for low rectal or anal tumours.

Question 67

Staging of CRC

Answer 67

carcinoembryonic antigen (CEA)

CT of the chest, abdomen and pelvis
their entire colon should have been evaluated with colonoscopy or CT colonography

patients whose tumours lie below the

peritoneal reflection should have their mesorectum evaluated with MRI.

Question 68

Significance of a painful CNIII palsy

Answer 68

Painful third nerve palsy = posterior communicating artery aneurysm

left eye ptosis, and inferior and lateral deviation

The most common cause of surgical third nerve palsy that is associated with a headache and pupil dilation is a posterior communicating artery aneurysm

Question 69

A 26-year-old man attends the emergency department with reduced urinary output, new swelling in his hands and feet, and nausea 3 days after a marathon race. He competes for his university and has been training hard in the months leading up to the event. He has no past medical history and doesn’t take any regular medication. He informs you that he had some tendonitis in the week prior to the event but managed this himself with strapping and simple analgesia. Full blood count, urea and electrolytes, and urine samples are sent to the lab, an initial report returns showing:

Urinary sodium 45 mmol/L (>20)
Urinary osmolality 250 mOsm/kg ( 50-1200)
Fractional sodium excretion 3% ( 1-2)
Urea : creatinine ratio 50:1 (40:1 - 100:1)

What is the likely diagnosis?

Answer 69

Acute tubular necrosis - urine sodium > 40 mmol/L

This patient is attending with signs of an Acute Kidney Injury (AKI) with reduced urinary output and acute peripheral oedema. AKI is defined as stage I, II, or III (see table below for further information). AKI can be caused by many etiologies, including dehydration, physiological stress (such as a hard endurance event), or excessive use of nephrotoxic medications (such as NSAIDs).

The investigation results given in the vignette show a raised urinary sodium - this occurs in acute tubular necrosis (ATN) (the most common renal cause of an AKI).

Question 70

SCLC Vs NSCLC

Answer 70

SCLC accounts for around 15% of cases and generally carries a worse prognosis.

NSCLC can be broken down into
adenocarcinoma
this is now the most common type of lung cancer. The increased in the proportion of lung cancer cases caused by adenocarcinoma is thought to be have been caused by the increased use of low-tar cigarettes
often seen in non-smokers: amongst ‘never’ smokers adenocarcinoma accounts for 62% of cases compared to 18% caused by squamous cell
squamous
cavitating lesions are more common than other types of lung cancer
large cell
alveolar cell carcinoma
not related to smoking
++sputum
bronchial adenoma
mostly carcinoid

Question 71

A 47-year-old woman is referred to the dermatology clinic with a 6-month history of an itchy rash. She describes the rash as feeling constantly dry and is affecting her self-confidence. In the last 2 weeks, she was prescribed a new medication from her general practitioner that seems to have made the rash worse. There is no history of new detergent use and she has no known allergies. Her past medical history includes anxiety, hypertension, gastritis and recurrent urinary tract infections.

On examination, there are well-defined red plaques of dry skin with a silver-coloured scale. The plaques are mostly seen over the elbows, knees and shins.

Which of the following has most likely caused the above presentation?

Answer 71

Beta-blockers are known to exacerbate plaque psoriasis
e.g. propranolol

Question 72

Triggers for Psoriasis

Answer 72

Triggers for Psoriasis - SICKLAB
- Stress/Smoking
- Infection
- hypoCalcaemia
- Koebnerization (trauma)
- Lithium
- Antimalarials/ACEI’s/Acohol
- Beta blockers
Others
- Calcium channel blockers, NSAIDs, TNF-alpha inhibitors

Question 73

Pummer Vinson Syndrome

Answer 73

Plummer Vinson syndrome (oesophageal web) may occur in association with iron deficiency anaemia (although rare).

defined by the classic triad of dysphagia, iron-deficiency anemia and esophageal webs. Even though the syndrome is very rare nowadays, its recognition is important because it identifies a group of patients at increased risk of squamous cell carcinoma of the pharynx and the esophagus.

Question 74

A 35-year-old woman presents to the hospital with severe epigastric pain and profuse vomiting. She has a history of sarcoidosis currently being treated with prednisolone. She drinks 45 units of alcohol per week. Bloods showed a serum amylase of 3150 U/L. The patient is treated with IV fluids and anti-emetics and is admitted under general surgery.

You are asked to review the patient overnight due to concerns she is deteriorating. You send urgent blood tests including an arterial blood gas (ABG).

Which blood result is most concerning and would make you consider an intensive care review?

• Blood glc 3.7
• Hypertriglycerdemia
• HypoCa2+
• Neutropenia
• Serum lipase >3x upper limit of normal

Answer 74

Whilst hypercalcaemia can cause pancreatitis, hypocalcaemia is an indicator of pancreatitis severity

The Glasgow-Imrie criteria are listed below. Each criterion met scores 1 point. 3 or more points indicate a high risk for severe pancreatitis.

Question 75

Gastroparesis Signs

Answer 75

Erratic blood glucose control, bloating and vomiting think gastroparesis

Gastroparesis refers to delayed gastric emptying, which can make it more difficult to deliver insulin timed with meals, leading to delayed digestion and therefore erratic blood sugars

Question 76

A 23-year-old male is brought to the emergency department due to an ongoing seizure. He was at the pub when the seizure started, and witnesses report that the patient had an episode of stiffness before falling to the floor and starting to seize. The seizure has now been going on for 20 minutes. A dose of intravenous lorazepam has been given but not terminated the seizure.

What is the next appropriate step in management?

Answer 76

status epillepticus!

> second dose of IV loraz A maximum of two doses of IV benzodiazepines can be administered during convulsive status epilepticus

> next phenytoininfusion

> anaesthetic involvement

Question 77

A 45-year-old woman presents to her GP following a review of her recent blood results. She initially presented with complaints of chronic diarrhoea and generalised pains.

Today she reports worsening of her diarrhoea, describing it as “explosive”. She feels relentlessly fatigued. On examination there is mild, generalised tenderness in various joints and her gait is slightly unsteady.

Hb 107 g/L Female: (115 - 160)
Platelets 200 * 109/L (150 - 400)
WBC 9 * 109/L (4.0 - 11.0)
CRP 12 mg/L (< 5)
MCV 76fL (80-100)
Calcium 2.0 mmol/L (2.1-2.6)
Phosphate 0.7 mmol/L (0.8-1.4)
PTH 7.1 pmol/L (1.6-6.9)
Vitamin D 13 ng/mL (20-40 ng/mL)

What is the most likely diagnosis?

Answer 77

Coeliac Disease

Diarrhoea, fatigue, osteomalacia → ?coeliac disease

Question 78

Trousseau’s Sign

Answer 78

Trousseau’s sign: carpal spasm on inflation of BP cuff to pressure above systolic

Trousseau’s sign = hypocalcaemia, often occurs after 2 minutes of cuff inflation above systolic pressure

Question 79

Cranial Diabetes Insipidus

Answer 79

The symptoms of polyuria, nocturia and chronic thirst, combined with preceding head trauma suggest a diagnosis of cranial diabetes insipidus (DI). Cranial DI results from insufficient anti-diuretic hormone (ADH) secretion, preventing the kidneys from concentrating urine.

This lack of ADH results in an inability to concentrate urine even if a patient is hypovolaemic, therefore producing a low urine osmolality even during water deprivation. However, as the kidneys are unaffected by cranial DI, they will respond to desmopressin (synthetic ADH) to produce concentrated urine.

Question 80

Carcinoidn Syndrome

Answer 80

PAraneiplastic syndrome of lung cancer
This presents with hepatomegaly, flushing and diahrroea – Diagnosed using 24 hour urine 5-HIAA tests.

Flushing, diarrhoea, bronchospasm, tricuspid stenosis, pellagra → carcinoid with liver mets - diagnosis: urinary 5-HIAA

This patient’s presentation is suggestive of carcinoid syndrome. This is most commonly due to liver metastases, although can also occur due to neuroendocrine tumours of the gut and bronchi.

Question 81

A 50 year-old man with dialysis dependent chronic kidney disease is awaiting renal transplant. He complains of fatigue. On examination you note heart rate 95 beats per minute, soft ejection systolic murmur that doesn’t radiate and pallor. There were no other abnormal features.

What is the most likely cause of his fatigue?

Answer 81

Anaemia is extremely common in chronic kidney disease. It is often caused by iron deficiency or erythropoietin deficiency. The man in this case has a few signs and symptoms of anaemia - tachycardia, fatigue, pallor and an aortic flow murmur.

Question 82

A 72-year-old man presents to the emergency department with his husband with new onset symptoms. They were having dinner when the man started coughing and having trouble eating. He tried to get up, but he could not walk properly and he was feeling dizzy.

On examination, he has clear ataxia and he is feeling dizzy. Nystagmus is observable in both eyes. He has right-sided facial pain and temperature sensory loss and left-sided upper and lower limb pain and temperature sensory loss, with normal power bilaterally in all muscle groups.

Given the most likely diagnosis, where is the lesion?
- L Anterior Inferior Cerebellar Art
- L Midbrain branches of Post Cerb Art
- L post inf. cerebellar art.
- R ant inf. cerb. art.
- R post. inf. cerb. art.

Answer 82

R Post Inf Cerb Art

Lateral medullary syndrome can be caused by PICA strokes

This patient is presenting with features of lateral medullary syndrome, a neurological disorder causing a range of symptoms due to ischemia in the lateral part of the medulla oblongata in the brainstem. The features are usually ataxia, nystagmus, dysphagia, ipsilateral facial sensory loss and contralateral upper and lower limb sensory loss. Most commonly, this is caused by occlusion of the posterior inferior cerebellar artery.

someone said on a previous thread to remember PICA stroke as ‘PICA can’t chew’ because they present with dysphagia :)

Question 83

Site of lesion:

Contralateral hemiparesis and sensory loss, lower extremity > upper

Answer 83

ACA

Question 84

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia

Answer 84

MCA

Question 85

Contralateral homonymous hemianopia with macular sparing
Visual agnosia

Answer 85

PCA

Question 86

Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

Answer 86

Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain

Question 87

Lacunar Strokes

Answer 87

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
strong association with hypertension
common sites include the basal ganglia, thalamus and internal capsule

Question 88

Markers of Bloods for Alcoholic Hep & Mgmt

Answer 88

LIver Funct.

AST/ALT = 2:1
2 Shots 1 Legend

> 3:1 = acute alcoholic hep

+GGT elevated

> Pred

Question 89

You are bleeped to assess a 66-year-old man with a declining urine output. He was initially admitted with community-acquired pneumonia a week ago and was recovering well until last night. His urine output is 0.2ml/kg/hr for the last 6 hours. The patient reports feeling generally unwell but with no pain.

Urinalysis shows + protein but nil else. His heart rate is 87bpm, respiratory rate 20/min, blood pressure 140/100 mmHg, and temperature 37.8ºC.

Recent bloods show:

Na+ 134 mmol/L (135 - 145)
K+ 4.7 mmol/L (3.5 - 5.0)
Bicarbonate 22 mmol/L (22 - 29)
Urea 8.7. mmol/L (2.0 - 7.0)
Creatinine 131 µmol/L (55 - 120)

What is the most appropriate investigation?

Answer 89

An ultrasound is required in the investigation of all patients presenting with an AKI of unknown aetiology

This patient is presenting with signs and symptoms of acute kidney injury (AKI). This patient has a urine output of <0.5ml/kg/hr which is diagnostic for stage 1 AKI. There are no signs in the history, observations or blood tests that this patient is suffering from a pre-renal aetiology. Therefore it is appropriate to investigate for an intrarenal or post-renal (obstructive) cause using ultrasound. Guidelines state that a renal tract ultrasound should be carried out within 24 hours of diagnosing AKI when the cause is unclear.

Question 90

atelectasis

Answer 90

Post-op complication

Atelectasis is a common post-operative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions. The most effective treatment for atelectasis is deep breathing exercises and chest physiotherapy. This ensures that the airways are opened maximally and coughing can be performed effectively.

Time frames: around 72hours post op or shorter
whereas PE much later end

Question 91

Erythema ab igne

Answer 91

Erythema ab igne is a skin disorder caused by over exposure to infrared radiation. Characteristic features include reticulated, erythematous patches with hyperpigmentation and telangiectasia. A typical history would be an elderly women who always sits next to an open fire.

If the cause is not treated then patients may go on to develop squamous cell skin cancer.

Question 92

A 62-year-old man presents to his general practitioner (GP) with symptoms of exertional breathlessness, wheeze and cough. He has a 30 pack-year smoking history.

As part of the patient’s work-up, spirometry is requested:

FEV1/FVC ratio 0.61

Given the likely diagnosis, which of the following would be an appropriate first-line treatment?

Answer 92

A SABA or SAMA is the first-line pharmacological treatment of COPD

e.g. Ipratropium

Question 93

A 46-year-old woman is reviewed by her GP after suffering a humeral fracture 2 weeks prior. During her hospital admission, she was found to have low vitamin D levels and was diagnosed with osteomalacia.

On questioning, she explains that she has been fatigued for the last 6 months. She reports no other symptoms other than ongoing bloating and non-bloody diarrhoea, which she feels is due to irritable bowel syndrome.

She has a history of Grave’s disease which is treated with carbimazole. Thyroid function during her admission was normal.

What is the most appropriate next step?

• DEXA
• nti-TTG and IgA
• Oral bisphosph
• ORal vit d
• Refer for OGD

Answer 93

anti TTg and IgA

Diarrhoea, fatigue, osteomalacia → ?coeliac disease

AuImm link

• villous atrophy

Question 94

An 18-year-old man is bitten by a frantic dog whilst taking a gap year in Ecuador. He is worried about rabies and phones for advice. He was not immunised against prior to travelling to Ecuador. What is the most appropriate advice after thorough cleansing of the wound?

Answer 94

Rabies - following possible exposure give immunglobulin + vaccination

Abx for dog bite: Co-amox or Doxy

Question 95

Stoma bag, flush to the skin, solid content

Answer 95

COLOSTOMY

Question 96

A 50-year-old man presents to the GP clinic with progressive abdominal swelling and weight gain. He has not experienced abdominal swelling before this episode. He reports slight abdominal discomfort but no pain throughout the day. He mentioned that he gained 2-3 kg over the past 2 weeks and is growing concern about this abnormal weight gain. He consumes approximately 6-7 cans of beer per day and is a non-smoker. His past medical history includes hypertension for which he is currently on enalapril.

On physical examination, he appears in discomfort and there is a visibly enlarged abdomen. He is currently afebrile and vital signs are stable. There is abdominal distention and shifting dullness. There is no tenderness, guarding or rigidity on abdominal palpation. Bowel sounds are normal. The liver is palpated 2-3 cm below the costal margin. There are multiple red arterioles with thin extensions on the upper chest and limbs. There is reddening of the palms bilaterally. The cardiorespiratory examination is unremarkable.

Diagnostic paracentesis is performed which appears clear. A protein concentration of 2g/dL and a high serum-ascites albumin gradient (SAAG) of > 1.1g/dL was found. Normal levels of white cell count were found. Serum electrolytes were normal.

Apart from alcohol cessation, what is the most appropriate long-term management plan?

• IV Ceftriaxone
• Propranolol
• Restrict Diet Na
• Rest fluid
• Therapeuti LArge-Volume PAracentesis

Answer 96

Reducing dietary sodium is a key intervention in patients with ascites

Question 97

OMeprazole & Upper GI Endoscopy

Answer 97

Proton pump inhibitors should be stopped 2 weeks before an upper GI endoscopy

The patient has presented with concerning symptoms that are indicative of gastric cancer, such as weight loss, dyspepsia, and the presence of Virchow’s node (an enlarged left supraclavicular lymph node). Proton pump inhibitors such as omeprazole can mask the features of gastro-oesophageal malignancy during endoscopic examination. NICE guidelines recommend discontinuation of these agents 2 weeks before an endoscopy.

Question 98

A 45-year-old woman presents to her general practitioner (GP) with an infected wound for which she was prescribed flucloxacillin. Five days after initiation of treatment, a swab culture grows S. aureus sensitive to clindamycin, prompting the GP to switch her antibiotic therapy accordingly.

One week later, she revisits the GP complaining of profuse watery diarrhoea and abdominal cramping. A stool culture reveals a gram-positive anaerobic bacterium.

What medication targets the toxin produced by this microorganism?

Answer 98

Bezlotoxumab is a monoclonal antibody which targets C. difficile toxin B

Whereas
Vanc. + Metr. = C diff

Question 99

Imm Compromised patients with Toxoplasmosis

Answer 99

Pyrimethamine and sulphadiazine are management options for immunocompromised patients.

Question 100

A 45-year-old female presents to the outpatient clinic with pain and swelling in her right leg for two days. She has a past medical history of type 2 diabetes. Her diabetes is well controlled. She is allergic to penicillin. On examination, there is warmth, erythema, tenderness, and swelling visible on her right shin. The margin of erythema in not clearly defined. Cellulitis is diagnosed.

Which of the following is the best treatment option for this patient?

Answer 100

Patients with cellulitis who are penicillin allergic can be given clarithromycin, erythromycin (in pregnancy) or doxycyline

Question 101

Urine findings for Acute Tubular NEcr

Answer 101

The presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis.

Question 102

A 45-year-old man presents with palpitations that began around 40 minutes ago. Other than having a stressful day at work there appears to have been no obvious trigger. He denies any chest pain or dyspnoea. An ECG shows a regular tachycardia of 180 bpm with a QRS duration of 0.10s. Blood pressure is 106/70 mmHg and oxygen saturations are 98% on room air. You ask him to perform the Valsava manoeuvre but this has no effect on the rhythm. What is the most appropriate next course of action?

Answer 102

SVT

Patients with SVT who are haemodynamically stable and who do not respond to vagal manoeuvres, the next step is treating with adenosine

> Valsalva / Sinus massage
IV Adenosine 6mg rapid bolus then titrate to 12mg then to 18mg if no response
/ verapamil IF ASTHMATIC
ELECTRICAL CARDIOVERSION

Prophylaxis
> BB
> Radiofreq ablation

Question 103

A 75-year-old gentleman presents with painful itchy white spots on his penis. These lesions are hyperkeratotic and have been placed in multiple locations on his foreskin and glans. This has been associated with dysuria and a reduction of sensation in the glans. You believe he has Balanitis Xerotica Obliterans. What can be associated with this condition?

Answer 103

Balanitis xerotica obliterans is a cause of phimosis

alanitis Xerotica Obliterans is a cause of phimosis. This is the male equivalent to lichen sclerosis in women. In an uncircumcised male, it can cause phimosis which is when the foreskin is too tight and can not be pulled back past the glans. This is due to the scarring that occurs from BXO.

It increases your risk for squamous cell cancer.

It predisposes you to infection.

It does not cause prostate hyperplasia.

It does not cause basal cell carcinoma but squamous cell carcinoma instead.

Question 104

Mesothelioma Definitive Dx Mode

Answer 104

Diagnosis of a mesothelioma is made on histology, following a thoracoscopy

Question 105

AF Mgmt

Answer 105

Stable:
> Rate or rythm control <48hr
> Rate control >48hr
> Or LT rythm control delay cardioversion until maintained 3w of anticoag.

Question 106

UC: Mode of investigation to assess disease acivity and therapeutic response

Answer 106

> Sigmoidoscopy

Colonosocopy = risk of perf.

Question 107

A 75-year-old female was admitted to the geriatric ward 1 week ago after developing a community acquired pneumonia. She was treated with co-amoxiclav and clarithromycin as per local guidelines. She also takes regular omeprazole and movicol. Yesterday, she complained of her stool being a bit softer than usual, and a nurse recorded ‘1x type 5 ; 2x type 4’ motions over the last 24 hours on the stool chart.

A faecal stool sample was sent, and the results this morning are as follows:

C. difficile toxin -ve
C. difficile antigen +ve

What is the next step in the management of this patient?

Answer 107

No Abx needed just reassure and monitor bowel motions

C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection

Question 108

A 65-year-old man attends a stroke clinic following a transient ischaemic attack.

On examination, he has a diastolic murmur loudest over the apex. His pulse rate is 90 bpm and irregular, blood pressure is 130/90 mmHg, and respiratory rate is 20 breaths per minute. An ECG shows an irregular ventricular rate and absent P waves.

What is the most likely cause of the murmur?

Answer 108

Diastolic murmur + AF → ?mitral stenosis

Mitral stenosis is associated with a mid-diastolic murmur loudest over the apex and accentuated with the patient in a left lateral position. It commonly causes atrial fibrillation (secondary to left atrial enlargement) which may result in embolic sequelae (e.g. stroke, TIA, mesenteric ischaemia).

Question 109

A 27-year-old man presents to the emergency department with a 2-day history of fever, tiredness, and a tingling sensation in the lateral aspect of his right thigh. He has found the tingling was initially bearable but has become painful in the past 24 hours. On examination, the area described is erythematous with a macular rash appearing. His only past medical history is HIV for which he takes anti-retroviral therapy and has an undetectable viral load. He denies any cough, coryzal symptoms, focal neurological signs, or trauma to the site.

Considering the likely diagnosis, what is the appropriate management for the patient out of the options listed?

Answer 109

Shingles

> Aciclovir

The majority of patients with suspected shingles should be treated with antivirals within 72 hours of onset

Question 110

A patient is seen in the follow-up clinic several weeks after an emergency open appendicectomy. Although the patient has had no further abdominal issues or pain, they report that the scar at the site of the incision has grown very large and has extended beyond the dimension of the original wound.

On examination, there is an overgrowth of granulation tissue at the otherwise healed incision site which is non-tender on palpitation but itchy.

As the condition is still in its early stages of development an intra-lesion steroid injection is advised.

What group is this condition most common in?

Answer 110

Keloid: more common in young black male adults

Keloid scars are benign, fibrotic overgrowth of granulated tissue that develops at a site of skin trauma, typically following injury or surgical incision. The tissue overgrowth is normally comprised of atypical fibroblast with deposition of several excessive extracellular matrix components including collagen, elastin and fibronectin.

Question 111

A 29-year-old woman presents to the GP complaining of being tired for several months. She occasionally gets headaches and neck tenderness and feels light-headed. She has noticed that she does not perform as well as she used to when exercising and that her arms and legs feel fatigued even when doing daily activities. She especially notices pain in her arms when cooking.

On examination, her heart rate is 82 bpm, BP is 129/56 mmHg, and oxygen sats are 98%. Her left radial pulse is weak and difficult to find on the right. An early diastolic murmur is heard on the left sternal border.

What is the most likely diagnosis?

Answer 111

Intermittent limb claudication, absent or weak peripheral pulses in a young woman, → ?Takayasu’s arteritis

This is a large-vessel vasculitis. It is the most likely diagnosis considering the patient’s age and features of malaise, headache, carotid tenderness, weak pulses and limb claudication on exercise. It is also associated with aortic regurgitation, which could explain the murmur heard and the wide pulse pressure on examination.

Question 112

A 28-year-old woman presents with a one-week history of grey/white vaginal discharge associated with a ‘fishy’ odour. There are no itching symptoms. She had a similar episode previously and was treated with metronidazole. She requests treatment but reports that metronidazole previously gave her vulvovaginal irritation.

What is the best treatment option?

Answer 112

Topical clindamycin is an alternative to metronidazole for patients with bacterial vaginosis

Question 113

A 54-year-old man presents to the endocrinology clinic. His GP referred him following a suspicious thyroid lump. The patient has undergone a US-guided FNAC which has demonstrated medullary thyroid cancer. A CT scan of the chest and neck reveals no further spread. The patient has a history of asthma and hypertension. as well as intermittent headaches which he finds difficult to control. He normally has ramipril, amlodipine, bendroflumethiazide and atenolol, but still has found it difficult to control his hypertension. On examination, there is a palpable neck mass, but otherwise, there are no abnormalities. What is the most likely explanation for the intermittent headaches?

Answer 113

Phaeochromocytoma

Medullary thyroid cancer is associated with MEN-2

This patient has a medullary carcinoma of the thyroid and poorly controlled hypertension despite intense pharmacological therapy. Medullary carcinoma is associated with MEN-2, which in turn is associated with phaeochromocytoma, which can explain the poorly controlled hypertension. Insulinoma is associated with MEN-1 and presents with hypoglycaemia, typically in the morning, as well as weight gain. Cushing’s syndrome would cause persistent hypertension with electrolyte abnormalities as well as Cushingoid signs. His normal appearance makes both Cushing’s syndrome and disease less likely.

Question 114

A 22-year-male presents to the emergency department complaining of testicular pain. The pain is localised in the right testicle and has come up gradually over the last 24 hours.

On examination, he looks distressed. His heart rate is 64/min, blood pressure 120/96 mmHg, respiratory rate 16/min and temperature 38.2 ºC. The right testicle is erythematous and swollen. Elevation of the scrotal skin eases the pain. He denies any discharge.

Given the most likely diagnosis, what is the most appropriate next step?

Answer 114

> MSU and NAATs

Investigations for suspected epididymo-orchitis are guided by age:
sexually active younger adults: NAAT for STIs
older adults with a low-risk sexual history: MSSU

Question 115

A 56-year-old man presents to the GUM clinic with a soft granuloma to the forehead. You make a clinical diagnosis of a syphilitic gumma and take bloods for syphilis serology. What stage of syphilis does he have?

Answer 115

Tertiary

This stage is characterised by the presence of granulomas (gummas) in various organs, including skin, bone, and liver. These lesions are a result of chronic inflammation caused by the spirochete Treponema pallidum and can occur years or even decades after the initial infection. The gummas are typically non-cancerous but can cause significant tissue damage.

NOT Secondary as . Although secondary syphilis can present with skin lesions, they are usually symmetrical rash over the trunk and extremities, mucous patches or condylomata lata rather than solitary gummas.

Question 116

According to NICE, management of chronic plaque prosirasis consits of:

Answer 116

regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend:
a potent corticosteroid applied once daily plus vitamin D analogue applied once daily
should be applied separately, one in the morning and the other in the evening)
for up to 4 weeks as initial treatment

second-line: if no improvement after 8 weeks then offer:
a vitamin D analogue twice daily

third-line: if no improvement after 8-12 weeks then offer either:
a potent corticosteroid applied twice daily for up to 4 weeks, or
a coal tar preparation applied once or twice daily
short-acting dithranol can also be used

Question 117

TB Management

Answer 117

Rifampicin, isoniazid, pyrazinamide and ethambutol.

This regimen should be taken for two months (intensive phase), followed by a continuation phase with rifampicin and isoniazid for an additional four months.

The treatment for latent tuberculosis is 3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid (with pyridoxine)

Question 118

Complications of TB Tx

Answer 118

rifampicin
potent liver enzyme inducer
hepatitis, orange secretions
flu-like symptoms

isoniazid
peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
hepatitis, agranulocytosis
liver enzyme inhibitor

pyrazinamide
hyperuricaemia causing gout
arthralgia, myalgia
hepatitis

ethambutol
optic neuritis: check visual acuity before and during treatment

Question 119

A 77-year-old man admitted with a small bowel obstruction has become markedly withdrawn and quiet. Although the obstruction has been resolved, he cannot state his location, name, address, or date of birth. At night, he becomes physically aggressive and restless but does not exhibit any signs of infection or sensory impairment. Attempts by the nursing staff to verbally de-escalate the situation and optimise his environment have not reduced his combativeness towards staff.

What is the most appropriate pharmacological management for this patient?

Answer 119

Acute confusional state: if treating the underlying cause and environmental modification not working then haloperidol sometimes used

According to NICE guidelines, haloperidol or olanzapine is the preferred pharmacological management of acute confusional states if medication is indicated. Administration is preferably oral, which has an onset of action of about 1-2 hours. NICE recommends a low-dose and short-term treatment lasting a week. Alternative administrations include IV, which has an onset of seconds, or IM, which has an onset of about 20 minutes. It is important to note that typical antipsychotics such as haloperidol are contraindicated in Parkinson’s disease or Lewy body dementia as dopamine antagonism can worsen motor symptoms.

Question 120

A 77-year-old man with heart failure presents with acute dyspnoea and chest pain. His regular medications ramipril and bisoprolol. Vital signs are BP 89/66 mmHg, oxygen saturation 95% on room air, heart rate 49 beats per minute, temperature 37.4°C, and respiratory rate 19 breaths per minute.

Examination reveals bibasal crackles are heard on auscultation.

Blood tests show:

Hb 140 g/L (135-180)
Platelets 209 * 10 9/L (150 - 400)
WBC 10.7 * 10 9/L (4.0 - 11.0)
Na+ 141 mmol/L (135 - 145)
K+ 4.2 mmol/L (3.5 - 5.0)
BNP 144 pg/mL (< 100)

A chest X-ray shows cardiomegaly, pleural effusion, and alveolar oedema.

What is the most appropriate initial management plan?

Answer 120

Sit Up & IV loop diuretic is the treatment for acute pulmonary oedema

+ Supplemental oxygen could be an additional intervention according to British Thoracic Society Guidelines which recommend targeting an oxygen saturation between 94-98%. In this scenario though, supplemental oxygen isn’t warranted since the patient’s oxygen saturation levels are already adequate.

Question 121

A 55-year-old lady is found in cardiac arrest with the following blood result:

Sodium 130mmol/l (135-145)
Potassium 7.3mmol/l (3.5-5.0)
Urea 9.1mmol/l (2.5-7.0)
Creatinine 167mmol/l (60-110)

She is initially given IV calcium gluconate.

What does this medication do to the electrolyte levels?

Answer 121

Hyperkalaemia + ECG changes: IV calcium gluconate is given for stabilisation of the cardiac membrane

Initially the calcium gluconate is given to stabilise the membrane so the level of potassium doesn’t increase.

It is the combination of insulin and dextrose or the use of nebulised salbutamol that causes the removal of potassium from the extracellular space to the intracellular space.

Potassium is then excreted from the body via calcium resonium.

Question 122

Surgery for inflammatory bowel disease

A 22-year-old man presents with his first presentation of ulcerative colitis. Despite aggressive medical management with steroids, azathioprine and infliximab his symptoms remain unchanged and he has developed a megacolon.

Answer 122

> Sub Tot Colectomy

In patients with fulminant UC a sub total colectomy is the safest treatment option. The rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications.

Question 123

Surgery for inflammatory bowel disease

A 22-year-old man has a long history of ulcerative colitis. His symptoms are well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma.

Answer 123

Panproctocolectomy and ileoanal pouch

In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.

Question 124

Significance of swinginglight test

Answer 124

Marcus Gunn Pupil

During the ‘swinging light test’ the right and left pupils dilate when shining light into the right eye. This indicates a problem with the right-sided afferent pathway (e.g. right-sided retina or optic nerve).

Question 125

A 43-year-old woman comes to see you for support in losing weight. She has tried a variety of strategies including limiting calories, regular exercise, calorie counting and group classes. She has been taking orlistat for 3 months which reduced her weight from 90kg to 88kg. Her BMI is 36kg/m² and her latest HbA1c is 44 mmol/mol.

What is the next most appropriate step in her management?

• CBT
• Continue orlistat
• Levothyroxine
• Liraglutide
• Refer for bariatric surgery

Answer 125

Liraglutide should be considered as an adjunct for weight loss in obese class II patients who are prediabetic

Liraglutide is licensed as an adjunct to a reduced-calorie diet and increased physical activity for weight management in obese adults. This patient is obese and prediabetic and has already trialled the first step of medical management. Recent NICE guidance [CG189] has extended this to patients with a BMI 27+ in the presence of at least one weight-related comorbidity, such as dysglycaemia (prediabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia, or obstructive sleep apnoea.

Question 126

Signs of Hypokalemia in ECG

Answer 126

Alongside U waves, the following ECG features may be seen in hypokalaemia:
ECG features of hypokalaemia
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT

In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

Question 127

Hoffman’s Sign and Significance

Answer 127

is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick

Question 128

A 45-year-old Scottish man presents to the GP with erectile dysfunction. He also reports feeling tired all of the time and has been troubled recently with pain in the joints of both hands. On further evaluation, you note that the joint pain is worse across the second and third metacarpophalangeal joints bilaterally.

What is the most likely diagnosis?

Answer 128

Early signs of haemochromatosis are fatigue, erectile dysfunction and arthralgia

Haemochromatosis typically presents in individuals aged between 30 and 60 years and predominantly affects those of white Northern European descent. The condition is especially prevalent among populations with Celtic ancestry, including individuals from Ireland, Scotland, and Wales.

Question 129

A 41-year-old man presents to the GP accompanied by his partner, who has noticed that he has become increasingly irritable and forgetful over the past six months. The GP notes that the patient appears restless and demonstrates fidgety hand movements, which are affecting his ability to unbutton his coat and use his mobile phone.

The patient does not have a significant medical history and is not on any regular medications. His family history is unknown as he was adopted as an infant.

Physical examination reveals no additional abnormalities.

What is the most important diagnosis to consider

Answer 129

Middle-aged, personality changes, involuntary movements → ?Huntington’s disease

Question 130

A 6-year-old girl presents with her grandmother to her GP with multiple painless, smooth, dome-shaped papules on her abdomen, arms, and legs. The lesions have a pearly, flesh-coloured appearance, and some show central depressions. The grandmother randomly noticed them, as there is no associated fever or itching. On examination, no surrounding erythema is noted. She is otherwise healthy with no significant past medical history.

To what family does the most likely virus causing this patient’s presentation belong?

Answer 130

Poxviridae

Molluscum contagiosum is caused by a pox virus

Question 131

A 61-year-old man attends an outpatient urology clinic after experiencing visible haematuria and left-sided loin discomfort, with a palpable loin mass. He undergoes kidney biopsy and positron-emission tomography. A diagnosis of T2N0M0 clear cell carcinoma is made, with an 11cm tumour that extensively involves the left kidney. He is fit and well otherwise and works as a postman.

What treatment is most likely to be offered?

Answer 131

Totalnephrectomy

Radical nephrectomy is the most effective management option in renal cell carcinoma - RCC is usually resistant to radiotherapy or chemotherapy

A partial nephrectomy may be appropriate for T1 disease less than 7cm, or in some cases of T2 disease where the entire tumour may be safely resected without the need to remove the entire kidney.

Question 132

A 58-year-old man attends the emergency department with palpitations, reporting a ‘racing heart’ for four days, but denies any pre-syncope or chest pain. Usually, he is fit and well. On assessment, his ECG reveals an irregularly irregular pulse, with a ventricular rate of 105 bpm. He is haemodynamically stable. He is given oral bisoprolol, and his heart rate drops to 68 bpm. He is not keen to take medications long-term.

What is the most appropriate management strategy?

Answer 132

If a patient has been in AF for more than 48 hours then anticoagulation + BBlockade should be given for at least 3 weeks prior to cardioversion.

An alternative strategy is to perform a transoesophageal echo (TOE) for UNSTABLE PATIENTS to exclude a left atrial appendage (LAA) thrombus

Question 133

A 17-year-old boy from Bangladesh has recently moved to the UK. He has a background of tuberculosis infection as a child and went on to develop a hormone insufficiency disorder following this. This was diagnosed when he developed a chest infection and subsequently needed hospitalisation for hypovolaemic shock.

Given the likely diagnosis based on the information above, which medicine should he be prescribed in case of a crisis?

Answer 133

Patients with Addison’s should be given a hydrocortisone injection kit for adrenal crises

This patient has Addison’s disease on a background of tuberculosis, which is a significant infective cause of primary adrenal insufficiency. It is important to be mindful of this in patients presenting from countries where tuberculosis is endemic.

Question 134

You are seeing John, a 50-year-old man who is complaining of central constricting chest pain. Walking up the stairs triggers the pain. The pain goes away with resting. He experiences some shortness of breath but denies any syncope or palpitations. He suffers from hypertension and diabetes. He takes verapamil for migraine prophylaxis. His other medications include GTN spray, aspirin, atorvastatin, Ramipril and metformin. On examination, his rhythm seems to be irregular. There is no murmur on auscultation of the heart. There is no tenderness on chest wall palpation.

He is asking for a medication that would be helpful to prevent the chest pain from occurring. What is the most appropriate treatment?

Answer 134

This is a typical angina history. Beta-blocker is a first line Angina prophylaxis.

However, this man is taking verapamil for his migraine. Verapamil should not be used with beta blocker due to the risk of bradycardia, heart block or even congestive cardiac failure.

Therefore, bisoprolol and metoprolol are incorrect answers. Ibuprofen and digoxin do not reduce the frequency of angina.

Therefore, the next line for prophylaxis of angina is Nicorandil.

Question 135

A 32-year-old man presents to the medical assessment unit with a dry cough for 1-week. His oxygen saturations are 92% on room air. He has bilateral coarse crackles on auscultation and a chest X-ray shows bilateral consolidation.

A peripheral blood smear shows red blood cell agglutination.

What bacteria is most likely to cause this presentation?

Answer 135

Pneumonia, peripheral blood smear showing red blood cell agglutination → Mycoplasma pneumonia

Question 136

An 83-year-old man presents to the emergency department with acute-onset abdominal pain that began earlier in the day. He describes the pain as severe and cramping and reports the presence of blood mixed with his stool. His medical history includes type 2 diabetes mellitus, atrial fibrillation, and peripheral vascular disease.

A computed tomography (CT) scan reveals segmental thickening of the large bowel wall accompanied by pericolic fat stranding. Portal venous gas is also observed.

Considering the most likely diagnosis, which site is most likely affected?

Answer 136

The splenic flexure is the most commonly affected site in ischaemic colitis

Ischaemic colitis frequently occurs in ‘watershed’ areas, which are zones where arterial supply overlaps. The splenic flexure receives blood from both the superior mesenteric artery and the inferior mesenteric artery.

Question 137

An 8-year-old girl is brought to the emergency department with worsening redness and swelling around her right eye for the past 2 days.

On examination of the child, there is tenderness and erythema over the right eyelid and during the assessment of her eye movements, she complains of pain and ‘seeing double’. Her temperature is 38°C.

Given the likely diagnosis, what is the most appropriate treatment?

Answer 137

> IV Cefotaxime

Orbital cellulitis differentiated from preseptal cellulitis by presence of: reduced visual acuity, proptosis and pain with eye movements

Question 138

A 65-year-old woman presents for a review of her type 2 diabetes mellitus. She has been taking metformin and sitagliptin, but this has been ineffective. It is mutually decided that she will start taking insulin. She is concerned about how this is going to affect her driving, as her father who also had type 2 diabetes stopped driving early due to problems with hypoglycaemia.

What is the most appropriate advice to give her regarding checking her blood glucose?

Answer 138

Insulin-dependent diabetics must check their blood glucose every 2 hours whilst driving

Question 139

A 65-year-old man attends the respiratory clinic with shortness of breath and increased secretions. On examination, he has a bilateral expiratory wheeze. Observations are as follows: heart rate 82 beats per minute, blood pressure 125/80 mmHg, SpO2 95% on air, temperature 37.1ºC, and respiratory rate 14 breaths per minute.

A CT scan is performed:

CT chest Intralobular, small, rounded and branching opacities; thickened interlobular septa; pleural plaques

What is the most important aspect of treatment?

• Carbocisteine
• LT O2 Rx
• Pulm Rehab
• Salbutamol Inhaler
• Smoking Cessation

Answer 139

ASBESTOSIS

> SMOKING CESSATION

Smoking cessation is very important in patients with asbestos-related lung disease as the risk of lung cancer in smokers is very high

Question 140

Signifiance of PSA Testing Timings for different things

Answer 140

6 weeks of a prostate biopsy
4 weeks following a proven urinary infection
1 week of digital rectal examination
48 hours of vigorous exercise
48 hours of ejaculation

Question 141

A 50-year-old woman presents to the emergency department with severe left eye pain over the last 4 hours. She has no changes in her vision, nausea, or vomiting and has a past medical history of systemic lupus erythematosus and takes hydroxychloroquine. She has myopia and wears glasses.

Her pulse is 92 bpm, her blood pressure is 123/75 mmHg, and she is afebrile. The left eye is deep red and injected throughout. When palpating the eye, the injected vessels are immobile and her eye is tender. The right eye is normal and visual fields and acuity are intact.

What is the most likely diagnosis?

Answer 141

Scleritis

classically painful and may be associated with reduced visual acuity and blurred vision

An extremely painful and deep red injected eye in a patient with a systemic connective tissue disease such as systemic lupus erythematosus (SLE) should raise suspicion of scleritis. Pain on palpating the eye is often present and visual acuity and pupillary responses may be abnormal depending on which parts of the globe are affected and how severe the symptoms are.

Question 142

A 25-year-old farmer presents with a contaminated puncture wound after catching his arm on farming machinery that is heavily contaminated with soil. After cleaning the wound thoroughly, you wonder about his requirement for protection against tetanus and see that he completed 5 doses of tetanus vaccine previously with his last dose 8 years ago.

What is the recommended treatment regarding tetanus for this man?

Answer 142

No need for booster or Ig

If a patient has had 5 doses of tetanus vaccine, with the last dose < 10 years ago, they don’t require a booster vaccine nor immunoglobulins, regardless of how severe the wound is

Question 143

A 40-year-old woman presents to her GP with a 1-day history of dysuria which is associated with urinary frequency and offensive-smelling urine. She feels well in herself and denies nausea, vomiting or flank pain. She has not had these symptoms before.

On examination, the patient has a temperature of 36.6ºC. There is no renal angle tenderness but mild suprapubic tenderness is present.

A urine dip is as below:

Beta hCG -
Blood -
Leucocytes ++
Nitrites +++

The patient has a history of rheumatoid arthritis for which she takes methotrexate. She has no allergies.

What is the most appropriate management of her symptoms?

Answer 143

> Nitrofurantoin

NEVER PRESCRIBE TWO METHS TOGETHER (TRIMETHOPRIM) DT BM SUPPRESSION RISK

Question 144

Genetic phenomenon assoc with HD

Answer 144

Anticipation.

CAG rpts increase = severity

Question 145

A 56-year-old woman presents with an intensely itchy rash affecting her right hand. She tells you she’s had this for three weeks and over-the-counter anti-itch creams have failed to help. She wonders if this could be scabies as she works in a primary school.

On examination, the patient has multiple pink/purple papules over the volar right wrist. These measure roughly 1-2mm in diameter. There are no lesions elsewhere on her body and she has no skin changes in her web spaces. You cannot detect any burrow lesions.

What is the most appropriate treatment option for this patient?

Answer 145

LICHEN PLANUS

> Betamethasone valerate 0.1% (Betnovate)
Potent topical steroids are the first-line treatment for lichen planus

This is an inflammatory condition affecting the skin and mucosal surfaces. On the skin, it presents as pink-purple papules and plaques which are shiny, flat-topped, and firm on palpation. The plaques may be crossed by fine white lines known as Wickham striae. Symptoms can range from none (which is uncommon) to an intense itch.

Question 146

A 24-year-old male presents to the emergency department with an acutely painful red eye, which is associated with photophobia, lacrimation and reduced visual acuity. He has a past medical history of ankylosing spondylitis. Examination identifies a small, irregularly shaped pupil.

Which is the most appropriate management of this patient’s presenting condition?

• acetazolamide and mydriatic drops
• acetazolamide and pilocarpine drops
• chloramphenicol drops
• oral steroids and pilocarpine drops
• steroid and mydriatic drops

Answer 146

ant uve.

Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops

This patient is presenting with an acutely painful red eye associated with photophobia, lacrimation and reduced visual acuity. This, along with his past medical history of ankylosing spondylitis (associated with HLA B27) and examination findings of a small, irregularly shaped pupil suggests a diagnosis of anterior uveitis, a condition characterised by inflammation of the anterior portion of the uvea (middle layer of the eye). Management of anterior uveitis is with steroid and cycloplegic (mydriatic) eye drops.

Question 147

Prophylaxis for contacts of patients with meningococcal meningitis

Answer 147

> Ciprofloxacin
or Rifampicin