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Question 1

Reversible causes of cardiac arrest

Answer 1

4 Hs
- hypoxia
- hypovolaemic shock
- hyperkalaemia, hypokalaemia, other electrolyte disturbances
- hypothermia

4 Ts
- thrombosis (coronary/pulmonary)
- tension pneumothorax
- tamponade (cardiac)
- toxins

Question 2

Way to classify strokes

Answer 2

Bamford classification system (aka Oxford)

Question 3

Total anterior circulation stroke (TACS) requires the presence of what to be diagnosed?

Answer 3

Unilateral weakness (and/or sensory deficit) of face, arm and leg

Homonymous hemianopia

Higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 4

Which arteries are most likely affected in TACS?

Answer 4

Middle and anterior cerebral arteries
- large cortical stroke

Question 5

Partial anterior circulation stroke (PACS) requires the presence of what to be diagnosed?

Answer 5

Two of the following:
Unilateral weakness (and/or sensory deficit) of face, arm and leg

Homonymous hemianopia

Higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 6

Which arteries are most likely affected in PACS?

Answer 6

Anterior circulation, partly compromised

Question 7

Posterior circulation syndrome (POCS) requires the presence of what to be diagnosed?

Answer 7

One of the following:
Cranial nerve palsy and contralateral motor/sensory deficit

Bilateral motor/sensory deficit

Conjugate eye movement disorder

Cerebellar dysfunction

Isolated homonymous hemianopia

Question 8

Which arteries are most likely affected in POCS?

Answer 8

Posterior circulation
- affects cerebellum and brainstem

Question 9

What sx are seen in cerebellar dysfunction?

Answer 9

Vertigo
Nystagmus
Ataxia

Question 10

Lacunar stroke (LACS) requires the presence of what to be diagnosed?

Answer 10

One of the following:
Pure sensory stroke

Pure motor stroke

Sensori-motor stroke

Ataxic hemiparesis

Question 11

What kind of stroke is a lacunar stroke?

Answer 11

Subcortical
- no loss of higher cerebral functions, i.e. dysphasia
- pccurs secondary to small vessel disease

Question 12

ECG shows:
Broad QRS complex
Tall, tented T waves
Diminished P waves

Answer 12

Hyperkalaemia

Question 13

Which antihypertensive class is associated w hyperkalaemia?

Answer 13

ACE inhibitors
- caution with starting in those with renovascular disease

Question 14

What impact does antiphospholipid syndrome on APTT and why?

Answer 14

Antiphospholipid syndrome causes a paradoxical rise in the APTT

Due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade

Question 15

Pts allergic to sulfasalazine may also be allergic to

Answer 15

Aspirin
- known cross-sensitivity

Question 16

Lupus pernio pertains is pathagnomic for

Answer 16

sarcoidosis
- purple, indurated patches
- frequently affects the nose, cheeks, lips, ears, and digits
- not normally itchy or painful but can be disfiguring

Question 17

Sepsis six

Answer 17

IN:
Give oxygen
Give intravenous antibiotics
Give intravenous fluids
OUT:
Take blood cultures
Check lactate levels
Monitor urine levels

Question 18

Type 1 vs type 2 resp failure

Answer 18

Type 1 respiratory failure
- pO₂ <8, normal pCO₂

Type 2 respiratory failure
- pO₂ <8, high pCO₂

Question 19

Toxoplasmosis vs lymphoma MRI

Answer 19

TOXOPLASMOSIS:
Multiple lesions
Ring or nodular enhancement
Thallium SPECT negative

LYMPHOMA:
Single lesion
Solid (homogenous) enhancement
Thallium SPECT positive

Question 20

Which cancer causes cannonball mets in lungs the most?

Answer 20

Renal cell cancer
- may also occur secondary to choriocarcinoma and prostate cancer

Question 21

Name gram-negative rod/bacilli bacteria

Answer 21

Escherichia coli
Haemophilus influenzae
Pseudomonas aeruginosa
Salmonella sp.
Shigella sp.
Campylobacter jejuni

Question 22

Name gram-positive rod/bacilli bacteria

Answer 22

Actinomyces
Bacillus anthracis (anthrax)
Clostridium
Diphtheria: Corynebacterium diphtheriae
Listeria monocytogenes

Question 23

Gram-positive vs gram-negative cocci

Answer 23

+ve:
Staphylococci + streptococci (including enterococci)

-ve:
Neisseria meningitidis + Neisseria gonorrhoeae, Moraxella catarrhalis

Question 24

Which medication can increase the risk of osteonecrosis post-fracture?

Answer 24

Prednisolone

Question 25

Drugs associated with Steven Johnsons syndrome

Answer 25

Carbamazepine Phenytoin Salicylates Sertraline Imidazole antifungal agents Nevirapine

Question 26

Sudden onset vertigo and vomiting, one-sided facial paralysis and deafness - which artery affected?

Answer 26

Ipsilateral anterior inferior cerebellar artery

Question 27

Which nerve is affected from the following operations? a) posterior triangle lymph node biospy b) Lloyd Davies stirrups c) thyroidectomy d) anterior resection of rectum

Answer 27

a) accessory nerve b) common peroneal nerve c) laryngeal nerve d) hypogastric autonomic nerves

Question 28

Which nerve is affected from the following operations? a) axillary node clearance b) inguinal hernia surgery c) varicose vein surgery d) posterior approach to the hip e) carotid endarterectomy

Answer 28

a) long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve b) ilioinguinal nerve c) sural and saphenous nerves d) sciatic nerve e) hypoglossal nerve

Question 29

Conversions for morphine when: a) oral to subcutaneous b) breakthrough dosing added c) dose increased

Answer 29

a) Oral to subcutaneous: divide oral dose by 2 b) Breakthrough dosing: divide 24-hour requirement by 6 c) Dose increase: increase by 30-50% of the previous dose

Question 30

What could you see on an xray of a bad diabetic foot?

Answer 30

“5Ds” of a Charcot joint: Density change (areas of lucency and sclerosis) Destruction Debris (loose bodies and bone fragments) Distension (joint effusion) Dislocation (e.g. metacarpophalangeal joints).

Question 31

Causes of charcot joint

Answer 31

Diabetes (most common) Syphillis Syringomyelia Spinal cord injury.

Question 32

MAPLE-V for taking a collateral history for cognition includes?

Answer 32

Memory and learning - acute/chronic - duration Attention - any changes in ability to focus on task, i.e. reading/tv Personality - any changes in mood and behaviour noted Language - any difficulty in understanding/communicating Executive function - able to plan and perform complex tasks, i.e. driving, dressing Visuospatial perception - any changes in recognising objects, faces, and hand-eye coordination

Question 33

Hypothermia ECG

Answer 33

‘Osborn’ or ‘J’ waves in majority pts (no correlation to temperature) Arrhythmias at any stage (early: tachy, severe: progressive brady -> asystole)

Question 34

Third nerve palsy

Answer 34

Eye is deviated 'down and out' Ptosis Pupil may be dilated (sometimes called a 'surgical' third nerve palsy)

Question 35

Mesenteric ischaemia features

Answer 35

Typically small bowel Due to embolism Sudden onset, severe sx Ischaemic to lower GI tract Abdo pain Urgent surgery required, high mortality

Question 36

Ischaemic colitis features

Answer 36

Large bowel Multifactorial RFs Transient, less severe sx Bloody diarrhoea Ischaemia to lower GI tract Abdo pain 'Thumbprinting' on Xray Conservative mx

Question 37

What causes 'thumbprinting' in ischaemic colitis?

Answer 37

Seen on abdo xray due to mucosal oedema/haemorrhage

Question 38

When should Bell's palsy sx improve?

Answer 38

Within 3 weeks following treatment If no improvement, must refer urgently to facial nerve specialist (ENT/neurologist) *NICE Guidelines

Question 39

Mx for wound dehiscence

Answer 39

Coverage of the wound with saline impregnated gauze (on the ward) IV broad-spectrum antibiotics Analgesia IV fluids Arrangements made for a return to theatre

Question 40

Best imaging for acoustic neuromas

Answer 40

MRI of the cerebellopontine angle

Question 41

Valgus vs varus knees

Answer 41

Valgus deformity of the knee: the tibia is turned outward in relation to the femur, resulting in the knees ‘knocking’ together Varus deformity of the knee: the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance

Question 42

What does the ACL do?

Answer 42

Prevents tibia sliding out in front of femur

Question 43

What does the PCL do?

Answer 43

Prevents the knee from hyperextending

Question 44

Acronym to remember position of ACL and PCL

Answer 44

LAMP Lateral -> Acl -> medial Medial -> Pcl -> lateral

Question 45

Which tendons are in the pes anserine?

Answer 45

(lateral -> medial) Sartorius Gracilis Semitendinosus

Question 46

Borders of the popliteal fossa

Answer 46

Superomedial border – semimembranosus Superolateral border – biceps femoris Inferomedial border – medial head of the gastrocnemius Inferolateral border – lateral head of the gastrocnemius

Question 47

Contents of the popliteal fossa

Answer 47

(lateral -> medial) Tibial nerve -> branches to common perineal/fibular nerve Popliteal vein Popliteal artery

Question 48

What is the deep peroneal/fibular nerve responsible for?

Answer 48

Dorsiflexion Anterior sensation

Question 49

What is the superficial peroneal/fibular nerve responsible for?

Answer 49

Foot eversion Lateral sensation

Question 50

MCL injury can also result in injury to

Answer 50

Medial meniscus - due to it being firmly attached to tibia/medial collateral ligament

Question 51

Function of meniscus

Answer 51

Shock absorber Allow for increased congruency between joint surfaces Enhanced joint stability Aid in distribution of synovial fluid

Question 52

The Unhappy Triad of the Knee

Answer 52

ACL tear MCL tear Medial meniscus tear *indication for surgery

Question 53

Zones of the meniscus relevance

Answer 53

Red-red: vascular/repairable Red-white: avascular/unrepairable White-white: avascular/unrepairable If unrepairable and sx = meniscectomy indicated

Question 54

Why does the knee pop in a meniscal tear?

Answer 54

Locking/catching sensation due to torn meniscus getting caught between the tibia and femur bone ew ow

Question 55

Feature specific to anterior shoulder dislocation XR

Answer 55

Bankart lesion - as humeral head dislocates it may impact on the anterior (inferior) glenoid rim causing fracture Hill-Sachs lesions - posterolateral humeral fracture occurring when the soft head impacts against hard anterior glenoid

Question 56

Feature specific to anterior shoulder dislocation XR

Answer 56

Bankart lesion - as humeral head dislocates it may impact on the anterior (inferior) glenoid rim causing fracture Hill-Sachs lesions - posterolateral humeral fracture occurring when the soft head impacts against hard anterior glenoid

Question 57

Ddx for erythema nodosum

Answer 57

Wide differential for causes of erythema nodosum including but not limited to: - Sarcoidosis (common association) and TB - Inflammatory bowel disease - Drug reaction – Penicillin, oral contraceptives, phenytoin, sulphonamides - Haemtological malignancy – lymphoma and leukaemia. - Rheumatological conditions – lupus, connective tissue diseases - Infections – fungal, mycobacterial

Question 58

Salter-Harris Classification

Answer 58

Involves growth plates and affects one of these: D - diaphysis M - metaphysis E - epiphysis G - growth plate

Question 59

Risk of infliximab and etanercept (novel anti-cytokine) drugs

Answer 59

Risk of cancers/lymphomas and activation of tuberculosis and other opportunistic infections Drug levels need to be monitored and patients are monitored for development of any side effects such as marrow aplasia

Question 60

Classification of femoral neck fractures

Answer 60

Garden 1 - incomplete fracture of neck (abducted/impacted) 2 - completed without displacement 3 - complete with partial displacement (misaligned femoral trabeculae due to connected fragments) 4 - complete with full displacement (aligned femoral trabeculae due to free fragments)

Question 61

Intracapsular vs extracapsular femur fractures

Answer 61

Intracapsular - greater risk of avascular necrosis

Question 62

Clinical findings of a neck of femur fracture

Answer 62

Shortening of leg External rotation of leg Swelling of hip

Question 63

Role of anterior cruciate ligament

Answer 63

Prevents anterior translocation of tibia at the knee

Question 64

Role of medial collateral ligament

Answer 64

Resist valgus force

Question 65

Name the nerve roots of the following: 1. Ulnar 2. Median 3. Radial

Answer 65

Medial cord brachial plexus C8 – T1 = ulnar nerve Medial and lateral cords, C5 – T1 roots = median nerve Posterior cord of the brachial plexus C5 – T1. = radial nerve

Question 66

+ve Froment’s sign

Answer 66

Ulnar damage - claw deformity Holding a piece of paper between thumb and index finger there is flexion of the terminal phalanx of the thumb on trying to pull paper away

Question 67

+ve Thomas' test

Answer 67

Used to rule out hip flexion contracture and psoas syndrome in straightened leg

Question 68

Reperfusion therapy options for STEMI

Answer 68

1. Primary percutaneous coronary intervention 2. Fibrinolysis

Question 69

CXR signs of pulmonary oedema

Answer 69

Cardiomegaly Prominent upper lobe veins Diffuse interstitial shadowing Classic perihilar ‘bat wings’ shadowing

Question 70

Pt has murmur and pink cheeks as well as describing severe fatigue and SOB Which murmur do you expect to hear?

Answer 70

Low-pitched mid-diastolic murmur => mitral stenosis Pink cheeks => mitral facies associated with mitral stenosis

Question 71

Normal PR interval

Answer 71

3-4 squares = 0.12-0.16 seconds

Question 72

Normal QRS duration

Answer 72

Less than 2.5 small squares = 0.10 seconds

Question 73

Normal QT

Answer 73

<440ms men <460ms women

Question 74

Which leads would T wave inversion be normal?

Answer 74

aVR V1

Question 75

Bassett Formula for QTc

Answer 75

QT interval / (square root of resp rate)

Question 76

Atrial fibrillation ECG findings

Answer 76

No discernible P waves Irregularly irregular Tachycardic

Question 77

Drug that causes gingival hypertrophy side effect

Answer 77

Phenytoin

Question 78

Causes of bradycardia

Answer 78

Athlete, vagal stimulation Certain infections including Legionnaire’s disease, typhoid fever and Lyme disease Hypothermia Hypothyroidism Drugs (e.g. beta blockers) Raised intracranial pressure Myocardial infarction

Question 79

Which cardiac conditions would you NOT use digoxin?

Answer 79

WPW syndrome Heart block Hypertrophic obstructive cardiomyopathy CI to digoxin therapy as it will result in worsening of conduction defects

Question 80

What classification do we use for heart failure?

Answer 80

The New York Heart Association (NYHA). Class 1: No limitation of physical activities Class 2: Slight limitation of physical activity in which ordinary physical activity leads to fatigue, palpitation, dyspnea, or anginal pain; the person is comfortable at rest Class 3: Marked limitation of physical activity in which less-than-ordinary activity results in fatigue, palpitation, dyspnea, or anginal pain; the person is comfortable at rest Class 4: Inability to carry on any physical activity without discomfort but also symptoms of heart failure or the anginal syndrome even at rest, with increased discomfort if any physical activity is undertaken

Question 81

Drug used for thrombolysis in stroke

Answer 81

Alteplase

Question 82

Contraindications to thrombolysis

Answer 82

Convulsions post stoke Stroke in the last three months Uncontrolled hypertension (>185 systolic or 110 diastolic) Subarachnoid haemorrhage Neurosurgery in the past 3 months History of intracranial haemorrhage Active internal bleeding Suspected or confirmed endocarditis

Question 83

INR for patients with: a) AF b) DVT/PE vs recurrent DVT/PE c) mechanical heart valves

Answer 83

a) 2.5 (2-3) b) 2.5 (2-3) vs 3.5 (3-4) c) 3.5 (3-4)

Question 84

Test to confirm BPPV

Answer 84

Hallpike test

Question 85

Treatment for BPPV

Answer 85

Epley manoeuvre

Question 86

CHA2DS2-VASc scoring system

Answer 86

Congestive heart failure - 1 Hypertension - 1 Age > 75 - 2 Diabetes - 1 Prior TIA/stroke - 2 Vascular disease - 1 Age 65-74 - 1 Sex female - 1

Question 87

HAS-BLED score

Answer 87

Hypertension - 1 Abnormal renal/liver function - 1/1 Stroke - 1 Bleeding - 1 Labile INRs - 1 Elderly > 65 years - 1 Drugs/alcohol - 1/1

Question 88

Tx based on CHA2DS2-VASc

Answer 88

CHA2DS2-VASc - 2 or more = anticoagulation - consider anticoagulation in men if score 1

Question 89

What is the ORBIT score used for?

Answer 89

Upcoming bleeding scoring tool that will takeover HAS-BLED Considers sex, Hb, hx of bleeding, age, GFR, and antiplatelet treatment to give a score out of 7 Higher the score, the greater the risk of bleeding

Question 90

Drugs that cause fibrotic lung diesase

Answer 90

Methotrexate Bleomycin Nitrofurantoin Amiodarone Sulfasalazine

Question 91

Anti-arrhythmic drug classes

Answer 91

Na+ channel blockers Class Ia - Procainamide Class Ib - Lidocaine Class Ic - Flecainide Class II - Beta blockers K+ channel blockers Class III - amiodaraone, sotolol Clas IV - calcium channel blockers

Question 92

p450 inducers

Answer 92

Carbemazepine Rifampicin Alcohol Phenytoin Griseofluvin Phenobarbitones Smoking

Question 93

Tx for Wolff-Parkinson-White syndrome

Answer 93

Ablation procedure Medications include flecainide and amiodarone - anything that doesn't have AV node blocking ability

Question 94

Digoxin toxicity ECG findings

Answer 94

Down sloping ST-depression in V5 and V6 Flattened, inverted, or biphasic T waves Shortened QT interval

Question 95

What does digoxin toxicity lead to?

Answer 95

Frequent premature ventricular contractions Sinus bradycardia AV block

Question 96

How do calcium channel blockers work?

Answer 96

Decrease cell entry of Ca2+ vai voltage-sensitive channels in smooth muscle Promotes coronary and peripheral vasodilation and reduces myocardial oxygen consumption

Question 97

Dihydropyridine CCBs

Answer 97

Nifedipine Amlodipine - mainly peripheral vasodilators - used in HTN and angina w a beta blocker due to their reflux tachycardia

Question 98

Non-dihydropyridine CCBs

Answer 98

Verapamil Diltiazem - slow conduction at AV and SA nodes - used in HTN, angina and dysrhythmias - DO NOT give w beta blockers => severe bradycardia risk

Question 99

How does digoxin work?

Answer 99

Blocks Na+/K+ pump -> Increases intracellular Ca2+ -> Increases myocardial contractility +ve inotrope

Question 100

What do you do to the dose of digoxin if amiodarone is added?

Answer 100

Halve the dose of digoxin

Question 101

How does amiodarone work?

Answer 101

Prolongs cardiac action potential, reducing potential for tachyarrhythmias

Question 102

What does atropine do?

Answer 102

Antimuscarinic so stops acetylcholine from acting on muscarinic receptors Results in a tachycardia

Question 103

GCS in adults

Answer 103

Question 104

Anterior mediastinal mass on CXR ddx

Answer 104

The four Ts: Thymic mass / thymoma Thyroid mass Teratoma Lymph nodes (‘Terrible’ lymphoma or carcinoma)

Question 105

If elderly female pt placed on steroids for long time, what else should you consider giving them?

Answer 105

Osteoporosis prophylaxis

Question 106

Lumbar puncture findings for: a) Normal b) Bacterial c) Viral d) SAH

Answer 106

Question 107

Damage to what part of the nervous system leads to ptosis?

Answer 107

Midbrain Sympathetic cervical chain Oculomotor nerve

Question 108

When do you perform an LP in a suspected SAH pt and what do you look for?

Answer 108

CT is normal and assuming no contraindications, perform LP to look for xanthochromia (12 hours - 2 weeks post bleed can be detected)

Question 109

LP findings for GBS

Answer 109

Raised protein in CSF Rarely a raised white cell count

Question 110

Which anti-seizure medication makes myoclonus worse?

Answer 110

Carbamazepine

Question 111

Kidney function

Answer 111

Question 112

When would a pt need urgent dialysis?

Answer 112

Presenting with the following signs and sx: Acidosis Electrolyte disturbances (hypokalaemia) Intoxicated (taken drug that needs to be cleared via ) Overload (pulmonary oedema) Uraemia (symptomatic)

Question 113

What you need to consider about a drug when prescribing it?

Answer 113

1. Indication is correct for the presentation of pt 2. Dose 3. Common side effects 4. Know how it's excreted thus confirming dose is correct

Question 114

Drugs that cause AKIs

Answer 114

CANDA - contrast - aminoglycosides - NSAIDs - diuretics - ACEi

Question 115

Why is metformin contraindicated in pts with poor renal function?

Answer 115

Metformin is excreted renally, poor renal function will result in metformin toxicity thus severe lactic acidosis

Question 116

Why can we still use tacrolimus in kidney transplantation despite its nephrotoxicity?

Answer 116

Narrow therapeutic index Constant monitoring Still effective in stopping rejection

Question 117

Which drug is used as chemoprophylaxis for bacterial meningitis?

Answer 117

Rifampicin

Question 118

Complications of mumps

Answer 118

Orchitis – often in males after puberty Meningitis/encephalitis Pancreatitis Hearing loss

Question 119

What do +ve IgM and IgG of infection markers tell you?

Answer 119

A positive IgM reflects an acute infection IgG reflects previous exposure to either natural infection or immunisation

Question 120

Cockcroft and Gault formula

Answer 120

Age in years Weight in kilograms (use ideal body weight where fat is likely to be the major contributor to body mass) Serum creatinine in micromol/litre Constant = 1.23 for men; 1.04 for women

Question 121

Chronic kidney disease categories based on GFR

Answer 121

Question 122

Side effects of long-term steroid use

Answer 122

Cataracts Osteoporosis Diabetes mellitus Weight gain Increased rates of infection, including candida.

Question 123

Most common pathogens for CAP

Answer 123

Streptococcus pneumoniae Haemophilius influenzae Mycoplasma pneumonia

Question 124

What is erythema nodosum associated with?

Answer 124

Infections (streptococcal = commonest infectious cause, TB, Mycoplasma, Salmonella, Yersinia) Sarcoidosis Inflammatory bowel disease (Crohn’s disease and Ulcerative colitis) Neoplasia (leukaemia, Hodgkin’s disease) Drugs especially sulfonamides and oral contraceptives Pregnancy

Question 125

What features are seen in tumour lysis syndrome?

Answer 125

Hyperkalaemia Hyperphosphataemia Hyperuricaemia Hypocalcaemia Renal failure

Question 126

Charcot's Triad

Answer 126

Fever Pain Jaundice = seen in cholangitis

Question 127

Charcot's Triad

Answer 127

Fever Pain Jaundice = seen in cholangitis

Question 128

Reynolds Pentad

Answer 128

Fever Pain Jaundice + Confusion (mental state change) Hypotension

Question 129

Gut derived bacteria most commonly cultured

Answer 129

-ve E coli Klebsiella Enterobacter species +ve Enterococcus species

Question 130

Why is a bladder perforation worse than a ureter perforation?

Answer 130

Urine in bladder more concentrated than ureters so will cause more severe urine peritonitis

Question 131

Dopamine agonist major side effect

Answer 131

Addictive behaviour - gambling - affairs - risky behaviour

Question 132

Three reasons we prescribe fluids

Answer 132

1. Hypovolaemic hypotensive patient - fluid challenge 2. Replacement - patient dehydrated or has lost fluid, but not haemodynamically compromised 3. Maintenance - patient euvolaemic(ish) but not able to take in fluids (or sometimes food too) for short time in the future

Question 133

What rate can you NOT infuse K+ over on the ward?

Answer 133

Do NOT infuse K+ faster than 10mmol/hour on the ward

Question 134

What are the 5 Rs of prescribing IV fluids?

Answer 134

Resuscitation Routine maintenance Replacement Redistribution Reassessment

Question 135

How would you reverse warfarin?

Answer 135

Vitamin K Prothrombin complex concentrate/fresh frozen plasma

Question 136

Recurrent pneumonia in elderly pt, what do you need to consider in mx?

Answer 136

Aspiration pneumonia - SALT review

Question 137

Cardiac output equation

Answer 137

Cardiac output (CO) = heart rate (HR) x stroke volume (SV)

Question 138

What would you expect to see in the MAP/SVR/CO/HR/SV in the following: a) Hypovolaemic shock b) Cardiogenic shock c) Neurogenic shock d) Anaphylactic/septic shock

Answer 138

Question 139

ABCDE for suspicious pigmented lesions

Answer 139

Asymmetry Irregular Border Colour variation Diameter greater than 6mm Evolution

Question 140

Blood transfusion target in bleeding pt

Answer 140

Hb > 70 but if they have previous CVD Hb > 80 to prevent type II MI

Question 141

Role urea plays in upper GI bleeding

Answer 141

Urea reflects the end product of the metabolic breakdown of protein When there is bleeding => protein breakdown & absorption => increase in Urea Good marker of bleed when > 10% of creatinine

Question 142

Score used for upper GI bleed

Answer 142

Blatchford score

Question 143

Role of looking at lactate on ABG

Answer 143

Reflective of how well perfused tissue is

Question 144

Score used post-endoscopy for upper GI bleed

Answer 144

Rockall score

Question 145

2 main causes of duodenal ulcers

Answer 145

H pylori NSAIDs

Question 146

Other diagnostic tests if OGD -ve in pt with melaena

Answer 146

Small bowel capsule Colonoscopy CT angiogram (done by IR) *you choose based on where you think the bleed may be

Question 147

Medication in variceal bleeding

Answer 147

Terlipressin Antibiotics!!! (typically broad spectrum)

Question 148

Post banding for oesophageal varices medication

Answer 148

Nonselective beta blockers to reduce pressure - propanolol - carvedilol

Question 149

Post banding for oesophageal varices medication

Answer 149

Nonselective beta blockers to reduce pressure - propanolol - carvedilol

Question 150

Decompensated cirrhosis with an acute deterioration in liver function presentations

Answer 150

Jaundice Increasing ascites Hepatic encephalopathy Renal impairment GI bleeding Signs of sepsis/hypovolaemia

Question 151

Common precipitants that lead to decompensation of cirrhosis

Answer 151

GI bleeding (variceal and non-variceal) Infection/sepsis (spontaneous bacterial peritonitis, urine, chest, cholangitis etc) Alcoholic hepatitis Acute portal vein thrombosis Development of hepatocellular carcinoma Drugs (Alcohol, opiates, NSAIDs etc) Ischaemic liver injury (sepsis or hypotension) Dehydration Constipation

Question 152

When O/E would there be a succussion splash?

Answer 152

Describes the sound obtained by shaking an individual who has free fluid and air/gas in a hollow organ or body cavity Occurs in intestinal or pyloric obstruction due to pyloric stenosis or gastric carcinoma (gastric stasis and dilatation picture) May be heard with hydropneumothorax, a large hiatal hernia, or over a normal stomach

Question 153

How do you update DKA pt mx based on the blood glucose levels? (Fluids and insulin have been commenced)

Answer 153

Once blood glucose falls to <14.0 mmol/L: 1. Add 10% glucose with normal saline to correct the dehydration 2. Consider reducing intravenous insulin infusion rate to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.

Question 154

Rare side effect of carbimazole and pt advice

Answer 154

Agranulocytosis - if pt sick, stop medication and urgent FBC same day to check WCC

Question 155

Describe a +ve oral glucose tolerance test and which conditions it occurs in

Answer 155

Failure of the normal suppression of GH to less than 2mU/l in response to a glucose load and it occurs in: Acromegaly Anorexia nervosa Poorly controlled diabetes mellitus Hypothyroidism Cushing’s syndrome

Question 156

What is a MIBG scan?

Answer 156

Nuclear medicine scan that uses iodine-123 meta-iodobenzylguanidine (MIBG) Commonly used for detection of neuroendocrine tumours, such as neuroblastoma and phaeochromocytoma Can also aid in the detection of carcinoid and medullary thyroid carcinoma

Question 157

What urine sodium and plasma osmolality would you expect in SIADH?

Answer 157

Urine sodium is increased (>40 mmol/L) Plasma osmolality is decreased (<270 mOsmol/Kg)

Question 158

What medication is used in resistant cases of hyponatraemia associated with SIADH?

Answer 158

Demeclocycline (tetracycline) - acts by directly blocking the renal tubular effect of antidiuretic hormone

Question 159

With a diagnosis of end stage COPD, what three factors are associated with a survival of less than 6 months?

Answer 159

Low BMI Left heart failure Frequent exacerbations

Question 160

Non-pharmacological ways to reduce breathlessness

Answer 160

The use of a hand-held fan Sitting by an open window Breathing out slowly through pursed lips Sitting forward with arms extended on a pillow

Question 161

What should an opioid PRN dose be relative to the 24-hour dose?

Answer 161

Prescribe a PRN dose which is 1/6th of the total 24-hour dose

Question 162

Signs in hypocalcaemia

Answer 162

Chvosteck’s sign: abnormal reaction to stimulation of facial nerve Trousseau’s sign: carpopedal spasm caused by temporary occlusion of arterial flow using a BP cuff

Question 163

Ca most associated with hypercalcaemia

Answer 163

Breast Renal cell Multiple myeloma

Question 164

Causes of a cavitating lung lesion

Answer 164

Cavitating pneumonia Septic emboli (bacterial or fungal) Wegener’s granulomatosis or pulmonary vasculitis Pulmonary infarction Infected bullae or cysts Neoplasia: primary or secondary

Question 165

Which bacteria cause a cavitating lung lesion?

Answer 165

S. aureus Klebsiella Pseudomonas Legionella Anaerobes Mycobacteria

Question 166

Performance status scale

Answer 166

0= no symptoms, fully active, able to perform all pre-disease activity 1= some symptoms but able to carry out light work, able to carry out office work/light house work 2= in bed or resting less than 50% of the day, capable of all self care 3= in bed or resting more than 50% of the day, capable of limited self care 4= in bed/resting all day, cannot carry out any self care 5= patient died

Question 167

Typical blood picture of disseminated intravascular coagulation

Answer 167

↓ platelets ↓ fibrinogen ↑ PT & APTT ↑ fibrinogen degradation products Schistocytes due to microangiopathic haemolytic anaemia

Question 168

What can CLL transform into?

Answer 168

Non-Hodgkin's Lymphoma aka Richter's transformation - pts become very unwell suddenly

Question 169

3rd line mx for heart failure

Answer 169

*can only be started by specialist* Ivabradine Sacubitril-valsartan Digoxin Hydralazine-nitrate combo Cardiac resynchronisation therapy

Question 170

Side effects of thyroxine therapy

Answer 170

Hyperthyroidism: due to over treatment Reduced bone mineral density -> osteoporosis Worsening of angina Atrial fibrillation

Question 171

Syphilis test results in keeping with: a) active syphilis infection b) false-positive result c) successfully treated infection

Answer 171

a) Positive non-treponemal test + positive treponemal test b) Positive non-treponemal test + negative treponemal test c) Negative non-treponemal test + positive treponemal test

Question 172

Describe Valsalva manoeuvre

Answer 172

Question 173

Right vs left murmurs are heard loudest at which point of breathing?

Answer 173

RILE Right-sided murmur → heard best on Inspiration Left-sided murmur → heard best on Expiration

Question 174

Causes of ascites based on the serum-ascites albumin gradient (SAAG)

Answer 174

Question 175

What class of antibiotics cause photosensistivty?

Answer 175

Tetracyclines - doxycycline - tetracycline

Question 176

What types of S2 heart sounds are there and what do they indicate?

Answer 176

Question 177

First line tx for absence seizures

Answer 177

Ethosuximide - effectively raises the seizure threshold and suppresses the spike and wave activity

Question 178

Which anticonvulsant may exacerbate absence seizures?

Answer 178

Carbamazepine

Question 179

Causes of bowel obstruction

Answer 179

Non-mechanical • post-op paralytic ileus • electrolyte abnormalities (hypokalaemia) • anticholinergic medications Mechanical • extraluminal: adhesions, herniae, abscess, neoplasm, volvulus • intraluminal: faecolith, intussusception, gallstone ileus, meconium • mural: atresia, inflammatory bowel disease, diverticulosis, neoplasm

Question 180

Main indications for Hartmann's procedure

Answer 180

Relief of obstruction Perforation of sigmoid colon Refractory sigmoid volvulus

Question 181

Where does the right hemi-colon receive blood supply from?

Answer 181

Ileo-colic, right colic and right branch of the middle colic artery

Question 182

Emergency procedure for toxic megacolon

Answer 182

Subtotal colectomy with ileostomy formation - as the rectum is left intact and a mucous fistula is formed, there is scope for restorative surgery later

Question 183

Possible abdo film signs of acute pancreatitis

Answer 183

Absent psoas shadow - build up of retroperitoneal fluid 'Sentinel loop' of proximal jejunum - gas-filled proximal jejunum *signs don't always show up on film

Question 184

What is a Marjolin’s ulcer?

Answer 184

Refers to a SCC arising in a chronic site of inflammation (e.g. osteomyelitic sinus)

Question 185

What is Bowen's disease?

Answer 185

Refers to an in-situ SCC which presents as flat, red scaly patches on sun-exposed areas

Question 186

Histological features of an SCC

Answer 186

Pleomorphism Dermal invasion by atypical epidermal cells Intraepithelial keratinization Intracellular bridges (at high magnification)

Question 187

What is a ganglion?

Answer 187

Cystic degeneration of fibrous tissue and is usually found around joints, especially the dorsal surface of the wrist joint

Question 188

Histological features of papillary carcinoma of the thyroid

Answer 188

Orphan Annie nuclei - epithelial cells with large clear areas within nuclei Psammoma bodies - spiral rings of calcification

Question 189

Histological features of Hashimoto's disease

Answer 189

Diffuse lymphocytic and plasma cell infiltration with formation of lymphoid follicles and thyroid parenchymal atrophy

Question 190

What other disease may be associated with medullary carcinoma of the thyroid?

Answer 190

Associated with MEN2 so may have had a pheochromocytoma previously

Question 191

Triad seen in cardiac tamponade

Answer 191

Beck’s triad: Muffled heart sounds Hypotension Raised JVP

Question 192

Causes of transudate pleural effusions

Answer 192

Heart failure (most common transudate cause) Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) Hypothyroidism Meigs' syndrome

Question 193

Causes of exudate pleural effusions

Answer 193

Infection: pneumonia (most common exudate cause), TB, subphrenic abscess Connective tissue disease: RA, SLE Neoplasia: lung cancer, mesothelioma, Metastases Pancreatitis Pulmonary embolism Dressler's syndrome Yellow nail syndrome

Question 194

How can we categorise pleural effusions?

Answer 194

Transudate (<30g/L protein) and exudate (>30g/L protein)

Question 195

Side effects of following diabetic drugs: a) Metformin b) Sulfonylureas c) Glitazones d) Gliptins

Answer 195

Question 196

Why is Hartmann's solutions preferred over 0.9% NaCl when large volumes of fluid need to be administered?

Answer 196

Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis

Question 197

Contraindications to sulfasalazine

Answer 197

G6PD deficiency Allergy to aspirin or sulphonamides (cross-sensitivity)

Question 198

Which drugs cause hypomagnesium?

Answer 198

Diuretics PPIs

Question 199

What next steps are needed following a diagnosis of dermatomyositis?

Answer 199

CT chest/abdo/pelvis to rule out malignancy (one of the causes of this presentation)

Question 200

Causes of hydronephrosis

Answer 200

Question 201

Mx of torsades de pointes

Answer 201

IV magnesium sulfate

Question 202

Which pts with ascites would you offer which prophylactic abx?

Answer 202

Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved

Question 203

Most common cause of hyperaldosteronism

Answer 203

Bilateral idiopathic adrenal hyperplasia

Question 204

Which gene is impacted in Wilson's disease?

Answer 204

ATP7B gene - leads to copper excess (low serum copper due to build up in tissues)

Question 205

Anticholinergic toxidrome presentation

Answer 205

Question 206

Cholinergic toxidrome presentation

Answer 206

Question 207

Hallucinogenic toxidrome presentation

Answer 207

Question 208

Sedative toxidrome presentation

Answer 208

Question 209

Sympathomimetic toxidrome presentation

Answer 209

Question 210

Laboratory tumor lysis syndrome findings

Answer 210

Abnormality in two or more of the following, occurring within three days before or seven days after chemotherapy: - Uric acid > 475umol/l or 25% increase - Potassium > 6 mmol/l or 25% increase - Phosphate > 1.125mmol/l or 25% increase - Calcium < 1.75mmol/l or 25% decrease

Question 211

Clinical tumor lysis syndrome findings

Answer 211

Laboratory tumour lysis syndrome plus one or more of the following: 1. Increased serum creatinine (1.5 times upper limit of normal) 2. Cardiac arrhythmia or sudden death 3. Seizure

Question 212

When is CKD diagnosed?

Answer 212

When there is a persistent reduction in renal function, with an eGFR of <60 on 2 occasions, on blood tests, performed more than 3 months apart

Question 213

What should all CKD pts be prescribed?

Answer 213

Statin for primary/secondary prevention of CVD

Question 214

Blood film shows large cells with a bilobed nucleus and prominent eosinophilic inclusion-like nucleoli What this?

Answer 214

Reed-Sternberg cell Dx: Hodgkin's lymphoma

Question 215

Drugs that induce lupus

Answer 215

‘It’s not HIPP to have Lupus’ (Hydralazine, Isoniazid, Procainamide, Phenytoin) Most common causes - procainamide - hydralazine Less common causes - isoniazid - minocycline - phenytoin

Question 216

Antibody present in drug-induced lupus

Answer 216

Anti-histone antibody in 80-90% pts

Question 217

Requirements for maintenance fluids

Answer 217

25-30 ml/kg/day of water Approximately 1 mmol/kg/day of potassium, sodium and chloride Approximately 50-100 g/day of glucose to limit starvation ketosis

Question 218

Reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve Mx?

Answer 218

Ramsay Hunt syndrome Mx: oral aciclovir and corticosteroids

Question 219

Fundoscopic appearance in patients with anterior ischaemic optic neuropathy

Answer 219

Swollen pale optic disc with blurred margins

Question 220

Ankylosing spondylitis other features

Answer 220

THE 'A's: Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)

Question 221

Which is the most highly negatively inotropic calcium channel blocker?

Answer 221

Verapamil - precipitates pulmonary oedema in chronic HF pts

Question 222

Contraindication to triptan use

Answer 222

History/significant risk factors for ischaemic heart disease or cerebrovascular disease

Question 223

Which artery is affected in locked-in syndrome?

Answer 223

Basilar artery - supplies the cerebellum, thalamus, occipital lobe, and brainstem - infarct leads to suddenly reduced GCS, advanced motor sx, can be associated w headache and visual changes

Question 224

Most common cause of large bowel obstruction

Answer 224

Tumour/malignancy - more distal colonic and rectal tumours commonly

Question 225

High rupture risk features of AAA

Answer 225

Symptomatic (abdo pain Aortic diameter >=5.5cm Rapidly enlarging (>1cm/year) *therefore referral for endovascular repair (EVAR)

Question 226

Which illicit substance increases the risk of serotonin syndrome?

Answer 226

MDMA (go mandy/molly) guys just don't mix

Question 227

Notable gluten-free carbs

Answer 227

Rice, potatoes, and corn (maize)

Question 228

Which vasculitis involves ENT, respiratory and kidneys?

Answer 228

Granulomatosis with polyangiitis (aka Wegener's #nazi)

Question 229

What chemotherapy do you have for non-Hodgkin's lymphoma?

Answer 229

ICE - ifosfamide - carboplatin - etoposide

Question 230

Locations of hip fractures

Answer 230

Location intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line)

Question 231

Hip fracture system used

Answer 231

The Garden system: Type I: Stable fracture with impaction in valgus Type II: Complete fracture but undisplaced Type III: Displaced fracture, usually rotated and angulated, but still has boney contact Type IV: Complete boney disruption

Question 232

Which abx do you prescribe in acute bronchitis and when?

Answer 232

Doxycycline - delayed prescription when CRP 20-100mg/L - immediate CRP when CRP >100mg/L

Question 233

Prophylaxis of cluster headaches

Answer 233

Verapamil

Question 234

What this and what caused it?

Answer 234

Colles fracture - extraarticular fracture of distal radius - occurs due to falling on an outstretched hand - treated with closed reduction and cast immobilisation

Question 235

Most common bacterial pneumonia in bronchiectasis

Answer 235

Haemophilus influenzae

Question 236

Felty's syndrome features

Answer 236

Rheumatoid arthritis Splenomegaly Low white cell count

Question 237

Which abx drug class increases risk of tendinopathy?

Answer 237

Quinolones - ciprofloxacin

Question 238

Common factors indicating severe pancreatitis

Answer 238

Age > 55 years Hypocalcaemia Hyperglycaemia Hypoxia Neutrophilia Elevated LDH and AST *note: actual amylase level is not of prognostic value

Question 239

On top of routine blood investigations, what other bloods should you order in a 'Confusion Screen'?

Answer 239

B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion TFTs: confusion is more commonly seen in hypothyroidism Glucose: hypoglycaemia can commonly cause confusion Bone Profile (Calcium): hypercalcaemia can cause confusion

Question 240

1st line tx of thyroid storm

Answer 240

IV beta-blockers

Question 241

What is the nutcracker phenomenon? (fun fact it rare)

Answer 241

Compression of the left renal vein, most commonly between the aorta and the superior mesenteric artery, with impaired blood outflow often accompanied by distention of the distal portion of the vein Sx may include haematuria, orthostatic proteinuria, flank pain and/or abdominal pain

Question 242

What is TURP syndrome?

Answer 242

Complication of TURP - presents w CNS, resp, systemic sx - result of absorption of irrigation fluid glycine via prostatic venous sinuses - glycine is hypo-osmolar thus causes hyponatraemia and also broken down by the liver into ammonia & hyper-ammonia *Use three-way irrigation in post-TURP pts to reduce risk of this syndrome

Question 243

What is a staghorn calculus compoed of?

Answer 243

Calcium magnesium ammonium phosphate - triple phosphate stone - genuinely sounds like fake news there u go

Question 244

Rovsing's sign

Answer 244

Question 245

What would you see on CT/MRI of an Alzheimer' pt?

Answer 245

Widespread cerebral atrophy mainly involving the cortex and hippocampus (responsible for memory)

Question 246

In which pt groups is diclofenac contraindicated?

Answer 246

Ischaemic heart disease Peripheral arterial disease Cerebrovascular disease Congestive heart failure (New York Heart Association classification II-IV) *MRHA June 2013, significantly increased risk of CV events compared to other NSAIDs

Question 247

Which malignancy is associated with Hashimoto's thyroditis?

Answer 247

Thyroid lymphoma

Question 248

Behcet's syndrome triad

Answer 248

Oral ulcers Genital ulcers Anterior uveitis *note: it is complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins

Question 249

1st line imaging for suspected multiple myeloma

Answer 249

Whole body MRI

Question 250

What is 1st next step when a postmenopausal woman has a fracture?

Answer 250

Slap her (on bisphosphonates) - don't need to bother w DEXA scan to confirm osteoporosis clearly has it

Question 251

Acute severe colitis criteria/features

Answer 251

Truelove and Witts: 1. Frequency of stool >6 2. Overtly bloody stool 3. Fever (>37.5) 4. Tachycardia (>90) 5. Anaemia (Hb<105) 6. Raised ESR (>30)

Question 252

Why should you avoid colonoscopy in acute IBD presentations?

Answer 252

Increased risk of perforation so stick to sigmoidscopy

Question 253

Bird's peak appearance on barium swallow, what this?

Answer 253

Achalasia - smooth muscle layer of the oesophagus has impaired peristalsis and failure of the sphincter to relax causing a functional stenosis or functional oesophageal stricture

Question 254

Which type of volvulus as an association with large bowel malignancy?

Answer 254

Caecal

Question 255

What's a Krukenberg tumour?

Answer 255

Ovarian mass as a result of metastasis from a gastric tumour - signet ring cells #path

Question 256

What is pseudo-obstruction?

Answer 256

Disorder characterised by acute dilatation of the colon in the absence of a mechanical obstruction - causes include electrolyte imbalance, medication, recent surgery

Question 257

Difference between large and small bowel on AXR

Answer 257

Small bowel = valvulae conniventes, bands which go around the bowel circumferentially Large bowel = haustra, lines which do not quite go all the way around

Question 258

Functional vs mechanical obstruction bowel sounds

Answer 258

Functional/ileus = quiet/absent Mechanical = present/increased ('tinkling')

Question 259

Most common causes of small bowel obstruction in the UK

Answer 259

Intra-abdominal adhesions Obstructed herniae

Question 260

Initial mx of small bowel obstruction

Answer 260

Nil by mouth IV fluids NG tube Analgesia *Laparotomy reserved if failure to respond

Question 261

AXR with contrast enema, what is seen at the splenic flexure region?

Answer 261

Applecore stricture - pathognomic of carcinoma

Question 262

Most common causes of pneumoperitoneum

Answer 262

Perforated diverticulum Perforated duodenal ulcer

Question 263

Which three structures cause gas accumulation in the retroperitoneum when they perforate?

Answer 263

3rd part of the duodenum (distal part) Ascending colon Descending colon

Question 264

Which conditions are associated with toxic megacolon?

Answer 264

Ulcerative colitis Infective colitis (especially C. difficile) RARELY in Crohn's disease

Question 265

Which drugs worsen pseudomembranous colitis?

Answer 265

Opiates Anti-diarrhoeal

Question 266

When can a pt weight bear after hip surgery?

Answer 266

British Orthopaedic Association (BOA) state: - aim of hip fracture surgery to allow pt to fully weight bear, unrestricted, immediately following surgery - reduces the length of stay and complications associated with immobility (chest infection, VTE, pressures sores)

Question 267

Criteria for discharge post acute asthma attack

Answer 267

1. Stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours 2. Inhaler technique checked and recorded 3. PEF >75% of best or predicted

Question 268

What is Weber's syndrome?

Answer 268

Midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis - branches of the posterior cerebral artery affected

Question 269

Posterior hip dislocation - what does affected leg look like?

Answer 269

Shortened Adducted Internally rotated *90% of hip dislocations

Question 270

Anterior hip dislocation - what does affected leg look like?

Answer 270

Abducted Externally rotated NO leg shortening.

Question 271

When do you use primaquine for malaria treatment?

Answer 271

In non-falciparum malaria to destroy liver hypnozoites and prevent relapse - Plasmodium vivax - Plasmodium ovale - Used post-acute/initial therapy

Question 272

Ankylosing spondylitis - x-ray findings

Answer 272

Subchondral erosions Sclerosis Squaring of lumbar vertebrae

Question 273

IgA nephropathy vs post-streptococcal glomerulonephritis

Answer 273

Question 274

3 features of a Colles' fracture

Answer 274

1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation

Question 275

What's a Smith's fracture?

Answer 275

Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed *Reverse Colles' fracture

Question 276

What's a Bennett's fracture?

Answer 276

Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal

Question 277

What's a Monteggia's fracture?

Answer 277

Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability

Question 278

What's a Galeazzi fracture?

Answer 278

Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow

Question 279

What's a Pott's fracture?

Answer 279

Bimalleolar ankle fracture Forced foot eversion

Question 280

What's a Barton's fracture?

Answer 280

Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist

Question 281

Tx for benzodiazepine overdose

Answer 281

Flumazenil

Question 282

Which drug at what dose should be given to the following patients: a) < 6 months b) 6 months - 6 years c) 6-12 years d) Adult and child > 12 years

Answer 282

Repeat every 5 minutes if necessary

Question 283

When is amiodarone given during resuscitation?

Answer 283

Amiodarone 300 mg given in VF/pulseless VT after 3 shocks Further dose amiodarone 150 mg given in VF/pulseless VT after 5 shocks

Question 284

Ann-Arbor staging of Hodgkin's lymphoma

Answer 284

I: single lymph node II: 2 or more lymph nodes/regions on same side of the diaphragm III: nodes on both sides of the diaphragm IV: spread beyond lymph nodes Each stage may be subdivided into A or B A = no systemic symptoms other than pruritus B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis)

Question 285

What is an Argyll-Robertson pupil?

Answer 285

Small, irregular pupils No response to light but there is a response to accommodate *Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Question 286

Causes of Argyll-Robertson Pupil

Answer 286

Diabetes mellitus Syphilis

Question 287

Initial management of suspected or confirmed scaphoid fracture

Answer 287

Immobilisation with a Futuro splint or standard below-elbow backslab Referral to orthopaedics - clinical review with further imaging should be arranged for 7-10 days later when initial radiographs are inconclusive

Question 288

Four main sx addressed in palliative care, and include an example of a drug that address it

Answer 288

Agitation - midazolam Pain - morphine sulfate Nausea/vomiting - cyclizine Respiratory secretions - glycopyrronium

Question 289

Alendronate contraindications

Answer 289

Hx of peptic ulceration Significant swallowing difficulties

Question 290

What and where are fragility fractures?

Answer 290

Fractures that result from mechanical forces that would not ordinarily result in fracture - spine (vertebrae), hip (proximal femur) and wrist (distal radius)

Question 291

Digoxin side effects include

Answer 291

Nausea Vomiting Complete heart block Xanthopsia

Question 292

Common side effect of n-acetylcysteine tx

Answer 292

Rash - can be treated w chlorpheniramine - carry on w treatment, if unsure ask poisons unit

Question 293

When do you start COPD pts on LTOT?

Answer 293

2 measurements of pO2 < 7.3 kPa

Question 294

2% strength liquid medicine means how much of the drug is dissolved in 100ml?

Answer 294

2% = 2g in 100ml

Question 295

1st line tx for trigeminal neuralgia

Answer 295

Carbamazepine - don't forget to safety net for agranulocytosis

Question 296

Myxoedema coma sx

Answer 296

Confusion Bradycardia Hypothermia Hypothyroid (profound)

Question 297

Myxoedema coma tx

Answer 297

IV thyroid hormone replacement IV fluid IV hydrocortisone (to avoid precipitating an Addisonian crisis) Electroyte imbalance correction Rewarming if needed

Question 298

Which TB drugs cause optic neuritis?

Answer 298

Ethambutol Isoniazid (not as common)

Question 299

TB drug tx

Answer 299

Rifampicin Isoniazid Pyrazinamide Ethambutol

Question 300

What marker is raised post-anaphylaxis?

Answer 300

Serum tryptase levels - raised up to 12 hours post acute case

Question 301

Which nerve is prone to damage during axillary dissection?

Answer 301

Intercostobrachial - traverse the axilla and supply cutaneous sensation

Question 302

Extra-renal features of ADPKD

Answer 302

Hepatic cysts which manifest as hepatomegaly Diverticulosis Intracranial aneurysms Ovarian cysts

Question 303

Syndrome that causes tingling/numbness of the 4th and 5th finger

Answer 303

Cubital tunnel syndrome due to compression of the ulnar nerve

Question 304

What is tennis elbow?

Answer 304

Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow extended

Question 305

How can post-tonsillectomy haemorrhages be categorised?

Answer 305

Primary (or reactionary) - within the first 6-8 hours following surgery Secondary - between 5-10 days following surgery

Question 306

Which Hodgkin's lymphoma type has the best prognosis?

Answer 306

Lymphocyte predominant - around 5% of cases

Question 307

Triangle of safety for chest drain insertion

Answer 307

Base of the axilla Lateral edge pectoralis major 5th intercostal space Anterior border of latissimus dorsi

Question 308

Pleural plagues noted on CT as a result of asbestos changes What is prognosis?

Answer 308

Commonest form of asbestos-related lung changes however they do not undergo any form of malignant progression and therefore are considered benign, no need for follow-up

Question 309

Glasgow-Imrie parameters needed to score for severity of acute pancreatitis

Answer 309

PaO2 WCC Serum calcium Urea LDH Albumin Glucose

Question 310

Pyogenic liver abscess features

Answer 310

Liver enlargement Resemble acute cholecystitis/ascending cholangitis/gallbladder empyema: - chills - vomiting - fever - RUQ pain - sudden dramatic weight loss - clay-coloured stool

Question 311

Which infections can mimic ileo-caecal Crohn’s disease?

Answer 311

Tuberculosis Yersinia

Question 312

Five things that need regular monitoring on total parenteral feeding

Answer 312

4 hourly obs (focus on temperature) Daily electrolytes Daily inspection of line and dressing Accurate fluid balance recording Blood glucose

Question 313

Where does an inguinal hernia pass through?

Answer 313

Passes superior and medial to the pubic tubercle, following the line of the inguinal canal

Question 314

Where does a femoral hernia lie?

Answer 314

Lies inferior and lateral to the pubic tubercle

Question 315

Where do direct and indirect inguinal hernia lie in relation to the inferior epigastric vessels?

Answer 315

Direct = medial Indirect = lateral

Question 316

Contents of spermatic cord/inguinal canal

Answer 316

3 arteries: testicular, cremasteric and artery to the vas deferens 3 nerves: genitofemoral nerve, sympathetics (and ilioinguinal – not actually in cord, but in canal) 3 other structures: vas deferens, veins (pampiniform plexus) and lymphatics

Question 317

Tx for achalasia

Answer 317

Balloon dilatation Surgical cardiomyotomy (aka laparoscopic Heller procedure) Botox injections Per-oral endoscopic myotomy (POEM)

Question 318

ECHO findings in HOCM

Answer 318

Asymmetric septal hypertrophy Systolic anterior movement (SAM) of the anterior mitral valve leaflet Mitral regurgitation

Question 319

Sickle cell crisis mx

Answer 319

analgesia e.g. opiates Rehydrate Oxygen Antibiotics if evidence of infection Blood transfusion Exchange transfusion

Question 320

What indications would make you pick blood transfusion over an exchange transfusion and vice versa during a sickle cell crisis?

Answer 320

Blood transfusion - severe or symptomatic anaemia, pregnancy, pre-operative - does not rapidly reduce the percentage of Hb S containing cells Exchange transfusion - acute vaso-occlusive crisis: stroke, acute chest syndrome, multiorgan failure, splenic sequestration crisis - does rapidly reduce the percentage of Hb S containing cells

Question 321

Chronic myeloid leukaemia tx

Answer 321

Imatinib = tyrosine kinase inhibitor

Question 322

How is acute graft failure picked up?

Answer 322

Usually asymptomatic Picked up by a rising creatinine, pyuria, and proteinuria Occurs around 6 months post-op

Question 323

What happens when you combine beta-blockers and verapamil?

Answer 323

Potentially cause profound bradycardia and asystole

Question 324

1st line tx for acute angle closure glaucoma

Answer 324

Pilocarpine = direct muscarinic agonist - disease causes decreased aqueous production and uveoscleral outflow - pilocarpine causes pupillary constriction which opens the angle by pulling the peripheral iris away from the trabeculum

Question 325

Proliferative diabetic retinopathy on fundoscopy

Answer 325

Dot and blot haemorrhages Cotton wool spots Neovascularisation at optic disc

Question 326

Which drugs may have to be stopped in AKI as increased risk of toxicity but doesn't usually worsen AKI itself?

Answer 326

• Metformin • Lithium • Digoxin

Question 327

Which cancer risk is increased in achalasia?

Answer 327

Squamous cell carcinoma of the oesophagus

Question 328

What is malignant hyperthermia?

Answer 328

Autosominal dominant condition resulting in a defective ryanodine receptor Leads to calcium efflux channel in the sarcoplasmic reticulum when suxamethonium given Sx include muscle rigidity and increased metabolism + an unexplained increase in heart rate and rising end tidal CO2

Question 329

Where are meningiomas typically located?

Answer 329

Falx cerebri Superior sagittal sinus Convexity Skull base

Question 330

Chlamydia investigation

Answer 330

Nuclear acid amplification tests (NAATs) - for women: the vulvovaginal swab - for men: the urine test

Question 331

What causes Marfan's syndrome?

Answer 331

Mutation in a protein called fibrillin-1

Question 332

Syphilis organism

Answer 332

Treponema pallidum

Question 333

Iron study profile in haemochromatosis

Answer 333

Transferrin saturation: high Ferritin: high Total iron binding capacity: low

Question 334

Herpes simplex keratitis - presentation - diagnosis - mx

Answer 334

PC: painful red eye with photophobia and epiphora Abnormal fluorescein staining: linear branching corneal ulcer Management: topical aciclovir

Question 335

Which drug is given to treat neuroleptic malignant syndrome?

Answer 335

Bromocriptine - dopamine agonist

Question 336

Serotonin syndrome vs neuroleptic malignant syndrome

Answer 336

Question 337

What are thymomas associated with?

Answer 337

Myasthenia gravis - 10-15% of MG have thymomas

Question 338

1st line tx of hypertension in diabetics

Answer 338

ACE inhibitors/A2RBs are first-line regardless of age

Question 339

Which hormones are produced by which testicular tumours?

Answer 339

Alkaline phosphatase (ALP) = seminoma Alpha fetoprotein (AFP) = teratoma, yolk sac carcinoma Human chorionic gonadotrophin (hCG) = teratomas with choriocarcinomatous (trophoblastic) differentiation Lactate dehydrogenase (LDH) = non-specifically raised with bulky tumours of both main tumour types

Question 340

Most common parotid malignancy in adults

Answer 340

Mucoepidermoid tumours - presence of a mass in the parotid with concurrent facial nerve paralysis suggests direct invasion of facial nerve from tumour

Question 341

Which artery is most likely affected when patients present with significant posterior nose bleeds?

Answer 341

The sphenopalatine artery (SPA) - branch of internal maxillary artery

Question 342

Which vessels supply Little's area/Kiesselbach's plexus?

Answer 342

Superior labial Anterior ethmoidal Posterior ethmoidal Greater palatine Sphenopalatine

Question 343

Causes of cataracts

Answer 343

Senile cataracts (age-related) = vast majority Pre senile cataract - steroids - uveitis (for which steroids are given) - diabetes mellitus - high myopia - significant trauma - Down’s syndrome - Retinitis pigmentosa

Question 344

Features are present on fundoscopy for retinitis pigmentosa

Answer 344

Arteriolar attenuation Bone-spicule pigmentation of retina (black lines in retinal periphery) Temporal optic disc pallor/waxy optic disc pallor Remember to work through 'colour, contour, and cupping' for the optic disc

Question 345

Features of retinitis pigmentosa

Answer 345

Nyctalopia (night blindness) Loss of peripheral vision Both eyes affected Inherited by either AR/AD or X-linked R

Question 346

If hypopyon on eye examination, what is dx until proven otherwise?

Answer 346

Endophthalmitis - forms an exudate rich in white cells as a result of infection; hypopyon

Question 347

Tx for retinal neovascularisation and why it is done

Answer 347

Pan retinal laser photocoagulation - induce regression of new vessels to stop them bleeding and causing vitreous haemorrhage

Question 348

Tx for diabetic macular oedema

Answer 348

Intravitreal injections of anti-VEGFs/dexamethasone

Question 349

Most common cause of unilateral or bilateral proptosis

Answer 349

Thyroid eye disease - typically hyperthyroidism/Grave's

Question 350

O/E - Mydriasis - General corneal haze - Eye hard when gently palpated Tx plan?

Answer 350

Acute angle closure glaucoma - opthalamic emergency - IV acetazolamide to drop intraocular pressure - Topical eyedrops: prostaglandin analogues and if no CI beta-blockers to drop IOP - Topical steroids to reduce inflammation - Pilocarpine to cause miosis to unblock closed drainage angle - Laser peripheral iridotomy to prevent further attacks

Question 351

Define mydriasis

Answer 351

Fixed mid dilated pupil

Question 352

Three causes of an abnormally large pupil

Answer 352

Pharmacological Third nerve palsy Acute glaucoma *you can only say ‘Holmes Adie’ having named these first three causes

Question 353

Cause of an abnormally small pupil

Answer 353

Horner's syndrome

Question 354

Resp drugs that can cause hypokalaemia

Answer 354

Theophylline Prednisolone Salbutamol *K+ should be monitored during therapy

Question 355

Four conditions you would consider using IV magnesium sulfate

Answer 355

Acute severe asthma Pre-eclampsia Torsades de pointes ventricular tachycardia Severe diarrhoeas with hypokalaemia *Use with caution in hepatic failure as metabolised via liver

Question 356

10% of true penicillin-sensitive patients are also allergic to which abx class?

Answer 356

Cephalosporins - cefurozime - cefalexin

Question 357

Pharmacodynamic vs pharmacokinetic interactions

Answer 357

Pharmacodynamic interactions occur when drugs compete at the same receptor site or on the same physiological system Pharmacokinetic interactions occur when one drug alters the absorption, distribution, metabolism or excretion of another

Question 358

Which NSAID carries the lowest risk of GI side effects?

Answer 358

Ibuprofen

Question 359

Name 5 NSAIDs

Answer 359

Diclofenac Ibuprofen Piroxicam Naproxen Indomethacin

Question 360

Name 5 drugs used for neuropathic pain

Answer 360

Amitriptyline Carbamazepine Gabapentin Pregabalin Venlafaxine

Question 361

Which anti emetic should you not used in GI obstruction/perforation/haemorrhage?

Answer 361

Metoclopramide - few anti emetic that directly acts on GI tract - increases gut motility thus can increase risk of perforation

Question 362

When is ondansetron most effective as an anti-emetic?

Answer 362

N&V post-op N&V secondary to cytotocic therapy *5HT3 antagonist

Question 363

Anti emetics first line in early pregnancy

Answer 363

Prochlorperazine Cyclizine

Question 364

Give examples of the following laxative types: a) Bulk-forming b) Stimulant c) Faecal softeners d) Osmotic laxatives

Answer 364

a) Fybogel (ispaghula husk), methylcellulose b) Senna, sodium picosulfate, bisacodyl, docusate sodium c) Docusate sodium, methylcellulose, enemas containing arachis oil d) Lactulose, macrogol (Movicol), phosphate enemas

Question 365

Why is lactulose used in hepatic encephalopathy?

Answer 365

With lactulose, the gut contents have a lower pH than normal This decreases the activity of ammonium-producing organisms

Question 366

Bowel prep prior to ix or colorectal surgery

Answer 366

Magnesium citrate with sodium picosulfate aka Picolax

Question 367

Immediate mx of tension pneumothorax

Answer 367

Insertion of a cannula into the second intercostal space mid-clavicular line until a functioning intercostal tube can be inserted NO CXR - life threatening, don't delay tx

Question 368

Mx of acute diverticulosis

Answer 368

Question 369

Common features of melanoma (A-E)

Answer 369

• Asymmetrical outline • Border irregularity • Colour variegation • Diameter >6 mm • Elevation

Question 370

Which type of melanoma occurs in palms, soles, and subungual areas?

Answer 370

Acral lentiginous melanoma

Question 371

X ray signs of osteoarthritis

Answer 371

Loss of joint space (due to cartilage loss) Osteophyte formation Subchondral cysts Subchondral sclerosis (laying down of new bone)

Question 372

Most common cause of stroke

Answer 372

Carotid artery stenosis - atherosclerosis is common at the carotid bifurcation

Question 373

Triad of aortic stenosis

Answer 373

Dyspnoea Chest pain Syncope

Question 374

Indications for an ECHO in a pre-op patient

Answer 374

New heart murmur Sx of heart failure Known valvular heart disease with last ECHO >2 years ago

Question 375

Which conditions is primary biliary cirrhosis associated with?

Answer 375

Rheumatoid arthritis Sjögren’s syndrome Thyroid disease Keratoconjunctivitis sicca Renal tubular acidosis Membranous glomerulonephritis

Question 376

Signs of liver disease

Answer 376

Clubbing Flapping tremor Dupuytren’s contracture Palmar erythema* Gynaecomastia Spider naevi* *denotes signs that also occur in acute liver disease

Question 377

Features of following upper limb nerve injuries: a) Median b) Ulnar c) Radial d) Axillary e) Long thoracic

Answer 377

Question 378

Klumpke's palsy features

Answer 378

Paralysis of intrinsic muscles of the hand Loss of sensation in ulnar distribution Horner’s syndrome sometimes present

Question 379

Erb's palsy features

Answer 379

Loss of shoulder abduction and elbow flexion Arm held internally rotated ‘Waiter’s tip’ sign if arm adducted behind back

Question 380

Features of following lower limb nerve injuries: a) Common peroneal b) Tibial c) Sciatic

Answer 380

Question 381

Which hormone treatment do you use if breast carcinoma is ER +ve?

Answer 381

Pre/perimenopausal = oestrogen receptor modulator, i.e. tamoxifen - as oestrogen mainly produced by ovaries Postmenopausal = aromatase inhibitors, i.e. anastrazole - as oestrogen mainly produced by peripheral aromatisation

Question 382

Tx for acute episode of optic neuritis

Answer 382

3-day pulse dose regime of METHYLPREDNISOLONE be given prior to the initiation of prednisolone for a further 7-11 days *BMJ Best Practice

Question 383

Mirror image nuclei = ?

Answer 383

Reed-Sternberg cells

Question 384

Gold standard diagnosis for Addison's disease

Answer 384

ACTH stimulation test (short Synacthen test)

Question 385

Tx for long-term psoriasis

Answer 385

Topical calcipotriol - vitamin D analogue reduces epidermal proliferation - reduced scale and thickness of psoriatic plaques, but not associated erythema

Question 386

How do you calculate the fluid requirements for a burns patient in the first 24 hours?

Answer 386

Parkland Formula (1st 24 hours) 4ml x pt wt (kg) x % burn = [x]ml - all patients with burns >15% TBSA should receive this

Question 387

Features of superficial burns

Answer 387

Dry Sometimes minor blistering and erythema Painful Often due to sunburn or minor scalds

Question 388

Features of partial thickness burns

Answer 388

Moist and red Broken blisters Normal capillary refill Usually painful unless deep dermal

Question 389

Features of full thickness burns

Answer 389

Dry, charred Often white Painless Absent capillary return

Question 390

Which part of the skin is affected in the following? a) superficial burns b) partial thickness burns c) full thickness burns

Answer 390

a) Epidermis b) Dermis c) Epidermis and dermis destroyed, starting to damage subcutaneous tissue

Question 391

How many years does neurosyphilis occur after primary infection?

Answer 391

10-20 years (damn)

Question 392

How long after exposure is HIV seroconversion illness likely to develop?

Answer 392

2 weeks to 12 weeks - most individuals show sx 2-4 weeks later

Question 393

How long after exposure is secondary syphilis likely to occur?

Answer 393

6 weeks-6 months

Question 394

Lateral knee pain in runners w tenderness 2-3cm above the lateral joint line

Answer 394

Iliotibial band syndrome

Question 395

Common bacterial cause of chronic wound infections

Answer 395

Pseudomonas aeruginosa

Question 396

First-line investigation in suspected prostate cancer

Answer 396

Multiparametric MRI

Question 397

Which airway device provides protection for the lungs from regurgitated stomach contents?

Answer 397

Tracheal tube

Question 398

Drugs that commonly cause urinary retention

Answer 398

Opioid analgesics (esp early postop) Anticholinergics General anaesthetics Alpha-adrenoreceptor agonists Benzodiazepines NSAIDs Calcium-channel blockers Antihistamines Alcohol

Question 399

Adult adrenaline dose for anaphylaxis

Answer 399

IM 0.5ml of a 1:1000 (500 micrograms)

Question 400

What monitoring is done for patients on statins and why?

Answer 400

LFTs before tx Repeat at 3 months Repeat at 12 months If serum transaminases raised by x3 upper limit of reference range, discontinue tx

Question 401

What dose should you titrate about levothyroxine?

Answer 401

25micrograms every 4 weeks

Question 402

Which conditions would you expect a raised total gas transfer (TLCO)?

Answer 402

Asthma Pulmonary haemorrhage (Wegener's, Goodpasture's) Left-to-right cardiac shunts Polycythaemia Hyperkinetic states Male gender, exercise

Question 403

Which conditions would you expect a lowered total gas transfer (TLCO)?

Answer 403

Pulmonary fibrosis Pneumonia Pulmonary emboli Pulmonary oedema Emphysema Anaemia Low cardiac output

Question 404

Which should you replace first: folate or vit B12?

Answer 404

Vitamin B12 first due to the risk of precipitating subacute combined degeneration of the cord Think BeFore: B before F to help you remember

Question 405

Factor V Leiden mutation results in ?

Answer 405

Activated protein C resistance

Question 406

Second-line antibiotic for a first episode of mild, moderate or severe C. difficile infection if vancomycin is ineffective

Answer 406

Fidaxomicin: 200 mg orally twice a day for 10 days

Question 407

First-line antibiotic for a first episode of mild, moderate or severe C. difficile infection

Answer 407

Vancomycin: 125 mg orally four times a day for 10 days

Question 408

Antibiotics for life-threatening C. difficile infection

Answer 408

Vancomycin: 500 mg orally four times a day for 10 days AND Metronidazole: 500 mg intravenously three times a day for 10 days

Question 409

Breast cacner screening programme in UK

Answer 409

50-70 years old, every 3 years

Question 410

Sx of low K+ and why

Answer 410

Low extracellular potassium reduces cell excitability and thus impedes muscle fibre conduction (smooth and skeletal): Absent reflexes Constipation Cramps Weakness Tiredness

Question 411

What rate of IV K+ is max?

Answer 411

No more than 10 mmol/hr and a maximum of 40 mmol should be administered via peripheral IV (risk of phlebitis)

Question 412

Bulbar vs pseudobulbar palsy

Answer 412

Pseudobulbar = UMN of CN 9-12 Bulbar = LMN of CN 9-12

Question 413

Mechanism of aciclovir

Answer 413

Nucleoside analogue that inhibits viral DNA synthesis

Question 414

What scoring system is used to predict a patient’s preoperative morbidity irrespective of the surgery they are about to undergo?

Answer 414

The American Society of Anesthesiologists (ASA) grading system

Question 415

Most common caues of a posterior dislocation of the shoulder

Answer 415

Epileptic seizures Electric shocks Direct trauma to the front of the shoulder

Question 416

X-ray features of osteosarcoma

Answer 416

Cortical destruction Periosteal elevation (Codman’s triangle) Calcification within the tumour but outside of the bone (sunray spicules)

Question 417

X-ray shows lytic lesion with a laminated periosteal reaction in left leg What bone tumour is this?

Answer 417

Ewing sarcoma - X-ray sign: 'onion skinning'

Question 418

Hesselbach’s triangle

Answer 418

Rectus muscle medially Inferior epigastric vessels laterally Inguinal ligament inferiorly

Question 419

Lesion in Wernicke's aphasia

Answer 419

Superior temporal gyrus - typically supplied by the inferior division of the left MCA - 'receptive' aphasia

Question 420

Lesion in Broca's aphasia

Answer 420

Inferior frontal gyrus - typically supplied by the superior division of the left MCA - 'expressive' aphasia

Question 421

Ottawa ankle rules

Answer 421

X-rays are only necessary if there is pain in the malleolar zone and: 1. Inability to weight bear for 4 steps 2. Tenderness over the distal tibia 3. Bone tenderness over the distal fibula

Question 422

Which structure is divided in surgical management of carpal tunnel syndrome?

Answer 422

Flexor retinaculum to decompress the median nerve

Question 423

PE with haemodynamic instability tx

Answer 423

Thrombolysis

Question 424

Where does the aorta bifurcate in relation to spine level?

Answer 424

Level of L4 which correlates to the level of the UMBILICUS

Question 425

Most commonly affected valve in IVDU pts

Answer 425

Tricuspid valve - most exposed through repeated injection of foreign material (and infection entering) into the venous circulation

Question 426

Goodpasture's syndrome triad

Answer 426

Pulmonary haemorrhage Acute renal failure anti-GBM antibody

Question 427

Buerger's disease

Answer 427

Raynaud's syndrome Intermittent claudication Finger ulcerations *thromboangiitis obliterans

Question 428

With which abx class do you also need to stop prescribing statins and why?

Answer 428

When prescribing a macrolide antibiotic due to the increased risk of rhabdomyolysis

Question 429

Treatment for dermatitis herpetiformis and its side effects

Answer 429

Oral dapsone - widespread rash - haemolytic anaemia - agranulocytosis

Question 430

Describe a +ve Simmons test

Answer 430

No plantar flexion on squeezing the affected calf => ruptured Achilles tendon

Question 431

Define sensitivity

Answer 431

Number of disease and test positive (true positive) divided by the number of all the people with the disease

Question 432

Characteristic signs of a cerebellar lesion

Answer 432

DANISH-P(eople) D: dysdiadochokinesis A: ataxia N: nystagmus I: intention tremor S: slurred speech H: hypotonia P: past pointing

Question 433

Anteroseptal MI ECG features and artery

Answer 433

V1-V4 Left anterior descending

Question 434

Inferior MI ECG leads and artery

Answer 434

II, III, aVF Right coronary

Question 435

Lateral MI ECG leads and artery

Answer 435

I, aVL +/- V5-6 Left circumflex

Question 436

Posterior MI ECG leads and artery

Answer 436

Changes in V1-3 - confirmed by ST elevation and Q waves in posterior leads (V7-9) - usually left circumflex, also right coronary

Question 437

Anterolateral MI ECG leads and artery

Answer 437

V1-6, I, aVL / Proximal left anterior descending

Question 438

Reciprocal changes of STEMI are typically seen in posterior MI ECG

Answer 438

Horizontal ST depression Tall, broad R waves Upright T waves Dominant R wave in V2

Question 439

Preferred DOAC for patients with renal impairment

Answer 439

Apixaban - minimal renal drug clearance

Question 440

Cushing reflex

Answer 440

Physiological nervous system response to increased intracranial pressure (ICP) that results in hypertension and bradycardia Reason: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure If intracranial pressure is high, only way the body can compensate to increase CPP is by increasing MAP A sympathetic reflex therefore results in hypertension, leading to a counter parasympathetic reflex by stimulation of the baroreceptors resulting in bradycardia

Question 441

First-line for acute bronchitis when CRP > 100

Answer 441

Doxycycline (unless pregnant/child)

Question 442

Which cranial nerves are affected with vestibular schwannomas?

Answer 442

V, VII, VIII - in cerebellopontine junction

Question 443

Maximum atropine dose for bradycardia tx

Answer 443

Start with 500mcg Maximum is 3mg

Question 444

Which drug increases risk of azathioprine toxicity?

Answer 444

Allopurinol - inhibits xanthine oxidase which is needed for breakdown of azathioprine

Question 445

Drug that reverses heparin

Answer 445

Protamine sulphate

Question 446

Cushing's triad as a result of raised ICP

Answer 446

Widening pulse pressure Bradycardia Irregular breathing *suggests impending brain herniation!!!

Question 447

Signs of right-sided heart failure

Answer 447

Raised JVP Ankle oedema Hepatomegaly

Question 448

Elderly patient dizzy on extending neck, dx?

Answer 448

Vertebrobasilar ischaemia

Question 449

Kings College Criteria for liver transplantation following Paracetamol overdose

Answer 449

One of the following: - Arterial pH < 7.3 - Arterial lactate > 3.0 mmol/l after adequate fluid resuscitation - Arterial lactate > 3.5 mmol/l at 4 hours OR if all three of the following occur in a 24 hr period: - Creatinine > 300 micromol/l - PT > 100 (INR >6) - Grade III/IV encephalopathy

Question 450

Classical sign of a mandibular fracture

Answer 450

Bite malalignment

Question 451

Which nerve is found within the parotid gland?

Answer 451

Facial nerve - courses within the middle ear cavity and temporal bone - emerges from the skull base via the stylomastoid foramen and then within the substance of the parotid gland

Question 452

Chilaiditi’s syndrome

Answer 452

Epigastric pain (need this to make it syndrome) CXR shows loop of large bowel lying between liver and diaphragm (otherwise if only this, just a sign) *Normal human variation

Question 453

Common points where stones can get stuck in transiting the ureter

Answer 453

1. Pelvi-ureteric junction (“PUJ”)/proximal ureter 2. Where the ureter crosses the iliac vessels in the upper pelvis (the “pelvic brim”) 3. Intramural ureter/vesicoureteric junction (“VUJ”)

Question 454

Most common cause of diarrhoea in patients with HIV infection

Answer 454

Cryptosporidium - intracellular protozoa - incubation period of 7 days

Question 455

When do we give prophylactic IV antibiotics in upper GI bleeds and which abx class?

Answer 455

Patients w liver cirrhosis - shown to reduce mortality, NICE 2016 guideline - typically quinolones used

Question 456

Most common cause of peritonitis secondary to peritoneal dialysis

Answer 456

Coagulase-negative Staphylococcus

Question 457

Empirical antibiotic of choice for neutropenic sepsis

Answer 457

IV piperacillin with tazobactam (Tazocin)

Question 458

6 signs of ischaemic limb

Answer 458

• Pallor • Pulseless • Paraesthesiae • Painful • Paralysis • Perishingly cold

Question 459

ECG features of hypomagnesaemia and which pt demographic commonly affected by it

Answer 459

Prolonged QT interval U waves Seen in alcoholics due to malnutrition

Question 460

Gonorrhoea vs chlamydia organism findings

Answer 460

G: gram-negative intracellular diplococci C: obligate intracellular bacterium

Question 461

State drug used for sinus/atrial/nodal bradycardias as well as when PEA and < 60bpm

Answer 461

Atropine - causes blockade of parasympathetic activity at both the sinoatrial node and the atrioventricular node - it may increase sinus automaticity and facilitate AV node conduction

Question 462

State drug used in mx of torsades de pointes and ventricular tachyarrhythmias AND another indication for using this drug

Answer 462

Magnesium sulfate - acute asthma - digoxin toxicity

Question 463

State drug used in ventricular fibrillation or pulseless ventricular tachycardia

Answer 463

Amiodarone

Question 464

State drug used in paroxysmal supraventricular tachycardia and narrow complex tachycardia

Answer 464

Adenosine - slows conduction across the atrioventricular node but has limited effect on myocardial cells - makes it very effective for terminating paroxysmal supraventricular tachycardias associated with re-entrant circuits thus revealing underlying atrial rhythms

Question 465

Features of lichen planus

Answer 465

Purple Pruritic Papular Polygonal rash on flexor surfaces Wickham's striae over surface Oral involvement common

Question 466

Anterior compartment in the lower limb (muscle-nerve-action)

Answer 466

Question 467

Peroneal compartment in the lower limb (muscle-nerve-action)

Answer 467

Question 468

Superficial posterior compartment in lower limb (muscle-nerve-action)

Answer 468

Question 469

Deep posterior compartment in lower limb (muscle-nerve-action)

Answer 469

Question 470

Drug given for all cases of sudden-onset sensorineural hearing loss

Answer 470

High-dose oral corticosteroids - risk of permanent hearing impairment so rapid intervention required - theorised inflammation is the main driver in this hearing loss

Question 471

Causes of erythema nodosum

Answer 471

NO-DOSUM NO: idiopathic D: drugs (penicillin and sulphonamides) O: oral Contraceptives/ pregnancy S: sarcoidosis/ TB U: UC, Crohn's, Behcet's M: microbiology (Strep, Myco, EBV etc.)

Question 472

Modalities for confirming syphilis infection

Answer 472

Dark ground microscopy of chancre Syphilis specific serology CSF analysis (tertiary/neuro/eye sx)

Question 473

Which HPV strains cause anogenital warts and cervical intracellular neoplasia (CIN)?

Answer 473

HPV 6 and 11 - anogenital warts HPV 16 and 18 - CIN

Question 474

ECG features of hypertrophic cardiomyopathy

Answer 474

Ventricular hypertrophy - generalised hypertrophic changes suggested by increased amplitudes of R waves in the inferior limb leads and increased amplitude of both R and S waves in the septal and anterior precordial leads Non-specific T wave inversions - note T wave in V3 appears biphasic Deep Q waves in leads II and III Atrial fibrillation occasionally seen

Question 475

Which drug is contraindicated in ventricular tachycardia?

Answer 475

Verapamil - precipitates cardiac arrest in VT

Question 476

Limited cutaneous systemic sclerosis antibody

Answer 476

Anti-centromere antibodies *C for Central Sx

Question 477

Diffuse cutaneous systemic sclerosis antibody

Answer 477

Anti-scl-70 antibodies

Question 478

Which organism is associated with gas gangrene?

Answer 478

Clostridium perfringens

Question 479

Complications of enteral feeding

Answer 479

Diarrhoea - occurs in around 1 in 6 patients - mechanism is unknown Aspiration Metabolic - hyperglycaemia - refeeding syndrome

Question 480

Appearances on plain radiograph in psoriatic arthritis

Answer 480

Unusual combination of coexistence of erosive changes and new bone formation Periostitis 'Pencil-in-cup' appearance

Question 481

Auscultation findings of bronchiectasis

Answer 481

Coarse crackles and high-pitched inspiratory squeaks

Question 482

Subphrenic abscess features

Answer 482

Localised collection of pus beneath the diaphragm develops 2-3 weeks after peritonitic event Gradual sx: pain, tenderness, swinging fevers, generalised weakness, diaphragmatic irritation (shoulder tip pain, hiccups), respiratory difficulty (pulmonary collapse/effusions)

Question 483

Diabetic pt presents w small reddish papules arranged in a ring on the back of their hands and feet - which condition?

Answer 483

Granuloma annulare - asx and lesions fade gradually - theory T cell mediated reaction

Question 484

Ankle brachial pressure index - equation - normal range

Answer 484

Question 485

Where is the metaphysis and epiphysis?

Answer 485

Children have growth plates: - Metaphysis is the area of bone on the inside of the physis (growth plate) - Epiphysis is the outermost part of the bone

Question 486

Tx for scabies

Answer 486

5% permethrin cream - can use in pregnancy

Question 487

What is Osler–Weber–Rendu syndrome?

Answer 487

Hereditary haemorrhagic telangiectasia (AD inheritance) Presents w recurrent epistaxis and gastrointestinal bleeds although stroke and cerebral abscess also possible in young pts

Question 488

Surgical signs associated with pancreatitis

Answer 488

Grey-Turner’s sign = bruising discolouration in the flanks Cullen’s sign = bruising discolouration around the umbilicus

Question 489

Which movement is pain the worst for lateral epicondylitis?

Answer 489

Worse on resisted wrist extension/supination whilst elbow extended

Question 490

Which diabetes drug class is CI in heart failure?

Answer 490

Thiazolidinediones (i.e. pioglitazone) as they increase fluid retention, and at greater risk of retention if also on insulin

Question 491

What percentage of gallstones and renal stones are radio-opaque?

Answer 491

10% of gallstones and 90% of renal calculi are radio-opaque

Question 492

Which conditions should you take care/not give thiazides in?

Answer 492

Question 493

Which conditions should you take care/not give beta-blockers in?

Answer 493

Question 494

Which conditions should you take care/not give ACEi in?

Answer 494

Question 495

Which conditions should you take care/not give CCBs in?

Answer 495

Question 496

Myelodysplasia can progress to which cancer?

Answer 496

Acute myeloid leukaemia

Question 497

Churg-Strauss syndrome serology

Answer 497

+ve pANCA

Question 498

Wellen's syndrome

Answer 498

Resolved chest pain in patient with deeply inverted T waves in V2-3 suggestive of critical stenosis of the left anterior descending artery (LAD)

Question 499

Mackler triad for Boerhaave syndrome

Answer 499

Vomiting Thoracic pain Subcutaneous emphysema (feel crepitus)

Question 500

Which tablets can reduce the absorption of levothyroxine?

Answer 500

Iron Calcium carbonate *advise to take 4 hours apart

Question 501

How do glucocorticoids impact neutrophils?

Answer 501

Cause neutrophilia

Question 502

How long does it take an arteriovenous fistula to develop for dialysis?

Answer 502

6 to 8 weeks

Question 503

Which organism causing pneumonia is common post influenza infection?

Answer 503

Staph aureus

Question 504

Prescription for cellulitis (including if penicillin allergic)

Answer 504

Flucloxacillin 500–1000 mg four times daily for 5–7 days Clarithromycin 500 mg twice daily for 5–7 day

Question 505

Most common causes of isolated right heart failure

Answer 505

Cor pulmonale (secondary to severe lung disease) Tricuspid/pulmonary valve disease Primary pulmonary arterial hypertension Chronic pulmonary thromboembolic disease Obstructive sleep apnoea

Question 506

Chronic open angle glaucoma tx

Answer 506

1. Prostaglandin eyedrops (side effect: make eyelashes longer and darker) 2. Beta-blocker eyedrops (must exclude any systemic contraindications to beta-blockers before prescribing beta-blocker eyedrops, as with topical treatment, there is a small amount of systemic absorption)

Question 507

Four causes of optic disc swelling

Answer 507

Papilloedema Severely raised blood pressure Optic neuritis (i.e. multiple sclerosis) Anterior ischaemic optic neuropathy (incl. temporal or giant cell arteritis)

Question 508

Most affected portions of bowel in coeliac disease

Answer 508

Duodenum Jejunum *Jejunal biopsy ideal

Question 509

Lipodermatosclerosis features

Answer 509

Hard and tight skin Hyperpigmentation due to haemosiderin deposition

Question 510

What does a transjugular intrahepatic portosystemic shunt (TIPS) procedure connect?

Answer 510

The hepatic vein to the portal vein

Question 511

Drugs that may exacerbate myasthenia gravis

Answer 511

Penicillamine Quinidine, procainamide Beta-blockers Lithium Phenytoin Antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Question 512

Triad of insulinoma sx

Answer 512

Whipple’s triad 1. Episodic hypoglycaemia 2. Central nervous system dysfunction (anxiety, confusion) 3. Symptomatic relief by the administration of glucose

Question 513

Monteggia vs Galeazzi fracture - bones affected - dislocation - mechanism of injury

Answer 513

Question 514

Colles vs Smith fracture - bones affected - mechanism of injury

Answer 514

Question 515

What are struvite stones made up of and associated with?

Answer 515

Magnesium ammonium phosphate Associated with chronic UTIs caused by Gram-negative rods that split urea into ammonium (Pseudomonas, Proteus)

Question 516

Hypersensitivity reaction classifications

Answer 516

Question 517

X-ray changes in rheumatoid arthritis

Answer 517

1. Narrowing of joint space 2. Soft tissue swelling 3. Juxta-articular erosions 4. Joint subluxation

Question 518

Modified Dukes staging for colorectal cancer classification

Answer 518

Question 519

Which brain lobes are involved in which quadrantopia?

Answer 519

armPITS Parietal = Inferior quadrantopia Temporal = Superior quadranatopia

Question 520

Complications of proliferative diabetic neuropathy

Answer 520

Vitreous haemorrhage Retinal detachment As proliferation of new blood vessels on the retina increases their risk

Question 521

Causes of gingival hyperplasia

Answer 521

Phenytoin Ciclosporin Calcium channel blockers AML

Question 522

Terlipressin action

Answer 522

Vasopressin analogue causing splanchnic vasoconstriction, thereby causing a reduction in portal pressure and variceal bleeding

Question 523

What would you see on a coeliac blood film?

Answer 523

Hyposplenism features - Target cells - Howell-Jolly bodies

Question 524

Why is nephrotic syndrome associated with a hypercoagulable state?

Answer 524

Due to loss of antithrombin III via the kidneys resulting in an acquired deficiency

Question 525

Fitz Hugh Curtis syndrome

Answer 525

Pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions

Question 526

Primary biliary cholangitis features

Answer 526

IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females

Question 527

Classification for ankle fracture and its resultant mx plan

Answer 527

Weber A (below) = conservative Weber B (through) = conservative/surgical Weber C (above) = surgical

Question 528

What does an absent psoas shadow suggest on AXR?

Answer 528

Retroperitoneal pathology - i.e. pancreatitis, ruptured AAA - aka +ve Psoas sign

Question 529

Drugs that cause gynaecomastia

Answer 529

‘Some Drugs Cause Awesome Knockers’ - Spironolactone - Digoxin - Cimetidine - Alcohol - Ketoconazole

Question 530

Presentation of porphyrias

Answer 530

Abdo pain, skin involvement, dark piss AND ‘The four H’s, P’s and S’s’: • Hypotonia, Hypotension, Hyponatraemia, Hypokalaemia • Proteinuria, Psychosis, Paralysis, Peripheral neuritis • Seizures, Shock, Sensory impairment, viSual abnormalities

Question 531

Potential complications of total parenteral nutrition (TPN)

Answer 531

Derangement of liver enzymes as a result of cholestasis leading to frank liver damage Sepsis Thrombosis Hyponatraemia

Question 532

What is meralgia paraesthetica?

Answer 532

Lateral femoral cutaneous nerve entrapment - characterized by tingling, numbness and burning pain in your outer thigh - can be relieved by lying down w hip flexed - still able to weight bear and walk

Question 533

Virus associated with tonsil cancer

Answer 533

HPV - who fuckin knew - causes squamous cell carcinoma

Question 534

Anticholinergic intoxication antidote

Answer 534

glucocorticoids

Question 535

Allergic bronchopulmonary aspergillosis tx

Answer 535

Oral glucocorticoids

Question 536

Which pts is pioglitazone contraindicated?

Answer 536

Bladder cancer Unexplained macroscopic haematuria Heart failure

Question 537

First line test for acromegaly

Answer 537

Serum IGF-1 levels

Question 538

Normal pressure hydrocephalus features

Answer 538

Urinary incontinence Gait abnormality Dementia

Question 539

When are nitrates contraindicated in ACS?

Answer 539

Hypotension (<90mmHg systolic)

Question 540

Pt is folate and B12 deficient - what are they at risk of when supplementing them?

Answer 540

Subacute combined degeneration of the cord can be precipitate by administration of folate without B12 THEREFORE folate should be given at the same time or started after B12 replacement

Question 541

Name gram positive cocci

Answer 541

Streptococcus pyogenes MRSA (methicillin resistant Staphylococcus aureus)

Question 542

Name gram negative rods

Answer 542

Escherichia coli Pseudomonas aeruginosa Haemophilus influenza

Question 543

Name a gram negative cocci

Answer 543

Neisseria meningitidis

Question 544

Most common reason for hip replacement revisions

Answer 544

Aseptic loosening of the joint - lead to pain, stiffness, and loss of range of motion in the hip - often caused by wear and tear on the hip joint - can also be caused by infection

Question 545

Causes of sudden vision loss (Overview card - good to keep repeating this)

Answer 545

*https://www.racgp.org.au/download/Documents/AFP/2009/October/200910examination.pdf

Question 546

Right iliac fossa mass ddx

Answer 546

Crohn’s disease Appendix mass or abscess Caecal carcinoma, Ovarian or renal mass, TB, Actinomycosis or amoebic abscess

Question 547

Which diuretic class increase and decreases calcium levels respectively?

Answer 547

Loop diuretics EXCRETE CALCIUM - inhibit the Na/K/2Cl ATPase in the luminal membrane of the loop of Henle, causing excretion of sodium - cause an increase in excretion of calcium and magnesium because of increased potassium secretion thus changed potential difference favours excretion of calcium Thiazide diuretics REABSORB CALCIUM - increasing calcium reabsorption from the luminal membrane into the interstitium in exchange for sodium

Question 548

What could cause a lobar collapse in an asthmatic?

Answer 548

Mucus plugs are common in asthmatics and can occlude the bronchus causing collapse distally

Question 549

Mx of pneumothorax, repeat and go over the following multiple times: a) Primary pneumothorax b) Secondary pneumothorax

Answer 549

Question 550

In which CKD cases would you expect pts to initially present with enlarged kidneys isntead?

Answer 550

Diabetic nephropathy Polycystic kidney disease HIV-associated nephropathy Amyloidosis

Question 551

Which valvular abnormality is associated with polycystic kidney disease?

Answer 551

Mitral valve prolapse

Question 552

Difference in urine osmolality and sodium in pre-renal vs renal AKIs

Answer 552

Pre-renal Kidneys act to concentrate urine and retain sodium => urine osmolality high, urine sodium low Renal Kidneys can no longer concentrate urine or retain sodium => urine osmolality low, urine sodium high

Question 553

Drug to reverse dabigatran action

Answer 553

Idarucizumab - licensed for life-threatening bleeds

Question 554

Which colonic adenomas are associated with an increased risk of developing cancer?

Answer 554

Tubular Villous Tubulovillous

Question 555

Tx of proximal scaphoid pole fractures

Answer 555

Surgical fixation - high risk of avascular necrosis

Question 556

Which medication can be prescribed to reduce complications following subarachnoid haemorrhage?

Answer 556

Nimodipine is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages

Question 557

Where would you expect pain if there was an occlusion/stenosis in the following: a) external iliac artery, b) internal iliac artery, c) common femoral artery, d) superficial femoral artery?

Answer 557

External iliac artery: upper thigh Internal iliac artery: buttocks Common femoral artery: lower thigh Superficial femoral artery: calf

Question 558

Otitis externa tx in diabetics

Answer 558

Ciprofloxacin to cover Pseudomona which causes necrotizing otitis externa