SBA Questions

Question 1

A healthy year old man , 30, progressive severe retrosternal pain improved sitting foreword with a pericardial friction rub what would you see on the ECG?

Answer 1

Saddle shaped ST segment - Pericarditis

Question 2

61 year old has exertion all chest tightness relived by rest - first degree heart block what will the PR interval be like

Answer 2

PR interval is greater than 200ms

Question 3

43 year old African man has hypertension and diabetes mellitus whats the First line treatment

Answer 3

Ramipril - Always with diabetes give an ACE - I

normally African would give CCB - amlodipine

Question 4

Asthma , hypertension, 67, tachycardia and irregularly irregular rhythm ( AF ) , high heart rate . BP and low resp rate how would you treat his hypertension and provide rate control

Answer 4

First line is beta blocker but if they are asthmatic you cant so give Verapamil ( CCB )

Question 5

78 year old has hypertension and - Progressive lengthening of the PR interval with a dropped QRS what is this?

Answer 5

Second degree heart block : Mobitz 1 or wenckerbach pehnomenon

Question 6

50 year old has leg pain on exertion and cramping in right calf when walking , worse if on an incline what is the first line Investigation?

Answer 6

ABPI and Duplex Ultrasound - Intermittent claudication of Periphral vascular disease ! Not DVT can be caused by atherosclerosis and 6 Ps : Pain, Pallor, pulselessnes,s parastehsia, paralysis, cold
First line is lifestyle , second is revascularisation , 3 is amputation

Question 7

78, Fiti, Unwell, dizzy nausea , smoking, T2DM , no chest pain, hypotensive and ST elevation what blood test would you do?

Answer 7

Troponin - Atypical MI

Question 8

35 year old man A and E with palpitations SOB, dizzy, chest pain , narrow complex tachycardia and SVT, valsalva and carotid sinus massage don’t work what do you do

Answer 8

Cardio version with adenosine - In shock straight to cardio version

Question 9

What is a major complication of ACE inhibitors

Answer 9

HyperKalaemia

Question 10

What does hyperkalemia show

Answer 10

Tall Tented T waves

Question 11

Hypokalaemia

Answer 11

U waves, ST depression , T wav inversion

Question 12

Mitral valve prolapse, low grade fever chills , fatigue , purple lesions on hand , dental surgery what investigation would you do ? What organism

Answer 12

Blood culture - Viridans Streptococci ( dental root canal )

Any person - Staph aureus

Question 13

59 year old man comes to A and E with tearing chest pain , High BP. Absent pulse whats the gold standard investigation

Answer 13

CT angiography : Aortic Dissection - false lumen

First like USS may be if your desperate

Question 14

18 feel unconscious swimming, congenital prolonged QT - what abnormal heart rhythm is he at risk of ?

Answer 14

Torsades de pointes - long pause on ECG between QRS and T wave ( long repolarisation time )
TDP is like the AM wave !!

Question 15

65 has SOB acute , left sided chest pain worsened, bed bound , ECG shows regular Raytheon with R wave in V1 and slurred S wave in V 6 what is it showing ?

Answer 15

Right bundle branch block - William and Marrow acronyms
Only look at V1 and V6
Right loos like M =in V1 and W in V 6
William: W in V1 and M in V6

R wave: Bit going up (M) slurred S ( W) - RBBB

Question 16

What is the underlying cause of the RBBB?

Answer 16

Pulmonary Embolism - Acute SOB, pleuritic chest pain, bed bound, recent surgery

Question 17

Infant with Trisomy 31 has a pan-systolic Murmer at the left parasternal border whats the diagnosis

Answer 17

Ventricular septal defect: Downs most commen congential hear is VSD - 30%

TOF - 5%

Question 18

What causes Rheumatic Fever?

Answer 18

Streptococcus Pyogenes - autoimmune condition and antibodies against it targets tissue - molecular mimicry - valvular damage

Question 19

A 79 year old gentlemen has palpitations and lightheaded - go away , 120 bpm but irregular no clear P waves or ischaemia whats first line treatment ?

Answer 19

Metoprolol - haemodynamic ally stable and paroxysmal atrial fibrillation - use beta blocker if contraindicated digoxin or amlodipine, amiodarone is ventricualr tachycardias

Question 20

30 has mild SOB, ejection systolic radiating to carotids what is it ?

Answer 20

Aortic Stenosis - ejection systolic loudest in aortic radiates to carotids
Mitral regurgitation - pan systolic radiating to the axilla

Question 21

65 has chest pain radiation and ST elevation whats the immediate management ?

Answer 21

Morphine, aspirin, oxygen , GTN ( dont give atenolol

MONA : Morphine, oxygen, nitroglycerin, aspirin

Question 22

79 crushing chest pain abnormalities in leads 2,3, and avF which artery is occluded ?

Answer 22

Right coronary artery - inferior leads

1, AVL and V 5 os LCx
V1-V4 is LAD

Question 23

Cyanotic one month baby failure to thrive - TOF includes what defects :

Answer 23

Overriding aorta
Pulmonary valve stenosis
VSD
Right Ventricular hypertrophy

Question 24

SOB worse on lying down , snores, stops breathing at night, peripheral oedema, basal crackles and raised JVP whats the first line to manage fluid overload?

Answer 24

Furosemide ( Loop diuretic ) - Congestive cardiac failure
Thiazide diuretics and aldosterone antagonists are second line
Other first lines are ramipril and bisoprolol

Question 25

66 attends wellness check a GP , 30bpm no SOB, fit and well , hypertension and bronchiectasis , ECG shows 3 degree heart block what should you do?

Answer 25

No associations between P waves and QRS association , regular rate no connection - 3 degree - cardiac emergency - send directly to A and E - pacemaker Escape rytham - bizarre QRS - wider

Question 26

How does apixaban work?

Answer 26

Inhibits Factor Xa - DOAC Warfarin is 1972 via vitamin K Heparin inhabits thrombin

Question 27

28 year old female has palps and dizziness - no medical conditions however drinks 47 units of alcohol and cocaine - saw tooth ECG , no P waves given diagnosis what is the definitive treatment ?

Answer 27

Atrial Flutter is saw tooth - definitive is catheter ablation of the circuit BB are short term

Question 28

81 collapsed , blacked out , light headed on standing , HTN, IHD, BPH and ex smoker, OD, bisoprolol, Ramipril, amlodipine, Bentroflumethiazie, tamsulosin all normal = but low sodium what caused the collpase?

Answer 28

Postural hypertension secondary to medications - tamsulosin and anti hypertensives - postural hypotension

Question 29

Which is considered in CHAD3DS2-VSC ?

Answer 29

``` Age greater than 75 Female Sex History of CCF Previous stroke / TIA Hypertension DM Stroke/ TIA/ thromboembolism Vascular disease 65-74 Sex ```

Question 30

23 has an ECHO after father passed away on a bike ride - HOCM what can you see on the ECHO?

Answer 30

Diastolic vetnricualar dysfunction ) LVhypertrophy, thickened septum, obstructs aortic valve

Question 31

Exertion also dyspnoea, cough with pink frothy sputum perform a history and examination - heart failure List some clinical signs of heart failure What are the possible X ray findings What blood test would confirm How would you manage it

Answer 31

1. Peripharal oedema, Orthopnea ( increased venous return - more oedema ) Paroxysmal nocturnal dyspnoea , bibasal creptiations 2. Alveolar oedema, kerley B lines, Pleural effusion , cardiomegaly , dilated upper lobe vessel ( upper lobe diversion , ABCDE 3. BNP N-terminal -pro-B Type natureitic peptide ) 4. Bisoprolol, Ramipril and furosemide : ACEI, Beta blocker , aldosterone antagonsit and loop diuretics ABAL

Question 32

What is the difference between essentials and secondary hypertension What Lifestyle advice would you offer a patient to reduce blood pressure Name the most common cause of secondary hypertension What scoring system assess risk of CVD disease What type of medication for a score greater than 10% Name a common side effect of this medication

Answer 32

Essential has no identifiable cause and secondary has one Lifestyle: reduce salt / alcohol / caffeine, healthy balanced diet, regular exercise stop smoking Commonest : Conns or Primary hyperaldosteronsism QRISK score would then give a statin ( myalgia is the side effects ) - 10 years ( N and V)

Question 33

55 Y/O post surgery coughing up blood streaked sputum and sharp unilateral chest pain worse on inspiration : BMI 30 and smokes 20 , high rate and resp rate: What’s the diagnosis What scoring tool would assess risk of her condition List some risk factors What’s the gold standard investigation and management

Answer 33

Pulmonary embolism - blood sputum, unilateral chest pain worse when breathing in Wells score Age, trauma, pregnancy, surgey , obesity, oestrogen,smoking CT pulmonary angiogram and then treat with LMW heparin and warfarin First line is Doppler - dual anticoagulant

Question 34

28, chest pain, aching muscles and joints, sweaty and pale, bruising and track, small main fuel nodules ( Oslers nodes ) high tempurature normal ECG, haemturia What is it ? Which Pathogen ? What is the next investigation Gold standard investigation?

Answer 34

Infective endocarditis - Staphylococcus aureus, blood cultures, transesophageal echo

Question 35

65 year old ongoing tight pain that comes and goes, raised BMI, sat down at rest, 2o smoking an HTN meds: ECG shows prinzmetals How do you distinguish prinzmetals from unstable. Give 2 non modifiable and 3 modifiable risk factors for angina What lifestyle Advice would you give What pharmacological Mangement

Answer 35

ST elevation in prinzmetals - transmural ischaemia in unstable causes ST depression due to subendocardial ischaemia 2 Non modifiable : Age, FH and ethnicity ( Angina is more commen in females MI in males) Modifable: BMI, Smoking , diet , inactivity, stress, HTN, cholesterol and diabetes Weight loss via exercise and diet and smoking cessation First line : CCB e.g. Verapamil all Anginas get GTN

Question 36

A 23 year old lady has unintentionally lost 8kg of weight over the last 8 months and is suffering from episodes of fatigue. She also complains of nausea, headaches, generalised abdominal pain and is feeling terrible overall. How would her cortisol levels react to the Synacthen test if she had secondary adrenal insufficiency?

Answer 36

Short ACTH no change long ACTH increase | -Synacthen stimulates the adrenal glands to secrete corticosteroids in secondary adrenal insufficiency

Question 37

A deficit in which hormone in this patient's condition has caused the development of hyperpigmentation?

Answer 37

ACTH - POMC proopiomelanocortin

Question 38

Where do carcinoid tumours usually metastasise to>

Answer 38

Liver! - neuroendocrine tumours

Question 39

A plasma aldosterone/renin ratio is performed and a diagnosis of primary hyperaldosteronism is made. Which electrolyte imbalances are associated with this condition?

Answer 39

Hypokalemia and hypernatremia To much aldosterone - increases sodium reabsorption and water follows sodium - high sodium and hypertension and potassium is drawn out Hypokalemia@ Weakness, flaccid paralysis and hyporeflexia High aldosterone and low renin

Question 40

With PTH, calcium and phosphate levels would you expect to find with someone with hyperparathyroidism caused by renal disease?

Answer 40

High PTH, low calcium and high phosphate - hypocalcaemia due to decreases 1-25 dihydroxycholecalciferol levels - more PTH and high phosphate as kidneys cant excrete it

Question 41

A 54 year old man with known DMT2 presents into the clinic complaining that his medications are not working. He is still presenting with symptoms despite compliance to medication. However, recently he has developed a loss of appetite and an upset stomach. After taking some investigations the patient is said to have lactic acidosis with severe liver failure. He is currently on triple therapy for his diabetes taking metformin + sulfonylurea + SGLT-2 inhibitor (glifazone), as well as, Ramipril for his hypertension.

Answer 41

Metformin: Increases sensitivity, causes weight loss but GI disturbances, peripheral neuropathy and lactic acidosis Sulphonylureas: Increase insulin secretion in B cells but GI disturbances, hypoglycaemia and weight gain Pioglitazone: Reduces reistance but bone fractures , weight gain and bladder cancer and is contraindicated in HF and bladder cancer DPP-4: Increase DPP-4 to increase insulin and lower glucagon - headache and acute pancreatitis but is cardioprotective SGLT-2 Inhibitors: Inhbit cotransporter to reduce glucose reabsoprtion and increase excretion of glucose but can cause UTI, general pruritis , DKA and back pain - cardioprotective but CI in T2DM

Question 42

A 48 year old lady presents to your surgery complaining of numbness and tingling in her right hand. She also appears to have large hands, rough/tanned skin and a prominent jaw and forehead. None of her clothes fit as she has also gained 10kg in the last year. Which nerve roots are associated with the condition presented above?

Answer 42

Carpal tunnel syndrome: C5/6-T1 median nerve of the medial and lateral brachial plexi cords

Question 43

A 45 year old woman presents to her GP complaining of feeling unsteady. She has mentioned that she has become increasingly more sweaty recently despite it being the winter months. Along with this she is saying that she has begun to eat more than usual. But what's confused her most is that despite this, she is still losing weight. However, what’s been most worrying for her is that she has begun to develop what seems to be waxy discoloration to her lower legs which she describes as orange peel appearance. Which antibody is most likely to be associated with the condition presented above?

Answer 43

Graves - TSH receptor antibodies Hashimotos - Anti TPO Anti DsDNA- SLE Anti thyroglobulin is hashimotos Graves triad: Goitre , orbitopathy, pretibial myxoedema

Question 44

A 15 year old boy with poorly controlled type 1 diabetes comes to A&E with a 2 day history of abdominal pain, vomiting and fruity smelling breath. What is the diagnostic criteria for his suspected condition?

Answer 44

Ketones >= 3 mmol/L, glucose > 11 mmol/L and pH < 7.3

Question 45

A 52 year old male has noticed that his skin is becoming coarser and his shoes no longer fit. Looking over past pictures he has noticed overall enlargement in peripheral limbs. He was initially referred for surgery but is no longer fit enough to undergo the procedure as he is suffering from heart failure as a result of this condition. What is the next best management for him regarding this condition (not heart failure)?

Answer 45

Somatostatin analogue ``` 1st line - transsphenoidal surgery 2nd line - Somatostatin analogue (SSA) octreotide or lanreotide SE: pain at injection site, abdo cramps, flatulance, loose stools, ↑ gallstones, impaired glucose tolerance +/- Dopamine agonist if GH secretions persist 3rd line - GH-receptor antagonist (GHRA) pegvisomant 4th line - Radiotherapy ```

Question 46

An elderly gentleman is difficult to rouse and appears less responsive than usual. He is currently recovering from a chest infection in hospital and has a patent cannula for medications/fluids. Significant PMH includes type 2 diabetes and ischaemic stroke which caused him to become NBM. His blood glucose is currently 2.3 mmol/L. What is the best management for this patient?

Answer 46

IV glucose - NBM so oral glucose is not an option and there is no point giving glucagon because they dont have enough glucose stores

Question 47

A young gentleman presents to the GP practice complaining of sweating more than usual. Under further investigation he tells you that he has also noticed more frequent headaches and a feeling of his heart pounding his chest. He tells you that this has gotten him more anxious recently as this has never happened before. Given the diagnosis, what is the mechanism of action for the first line treatment given to this patient?

Answer 47

Blocks the alpha-adrenergic receptors leading to vasodilation 1st line in hypertensive crisis - phentolamine 2nd line is sodium nitroprusside

Question 48

Hyper / Hypo hypothyroidism What is the difference in symptoms between the two? List 5 for Hyper and 5 for hypothyroidism. How does first line management differ in Hyperthyroidism + Hypothyroidism? What is the most common cause of hypothyroidism in the developing world?

Answer 48

Hyper: Sweating, heat intolerance, weight loss, manic restlessness, palpitations, preorbital myxoedema, erythematous oedematous lesions, thyroid acropachy , diarrhoea, oligomenorrhea , anxiety and tremor First line: Propranolol, carbimazole and iodine Hypo: weight gain , lethargy , dry cold, yellow skin, non pitting oedema, dry coarse scalp, constipation, menorrhagia, carpal tunnel and decreased tendon reflexes 1st line is levothyroxine Developing : iodine deficiency and hashimotos thyroditis

Question 49

What glucose levels are seen in a non diabetic, pre-diabetic and diabetic? Describe the management plan in a patient with newly diagnosed diabetes mellitus type 2 + what would be the follow up management if symptoms progress? What are some complications of DM?

Answer 49

HBA1c less than 42, then 42-47 then 48 and over Lifestyle modifications - Diet, Exercise, Weight loss Monotherapy - Metformin Dual therapy - if HbA1c rises to 58mmol/mol (7.5%) Triple therapy - if HbA1c rises to 58mmol/mol (7.5%) Metformin DPP4 inhibitor SU, Pioglitazone SGLT-2 inhibitor Thiazolidinedione insulin based therapy ONLY WHEN MEDS FAIL Insulin or Glucagon-like peptide (GLP) analogues GLP analogues - incretin mimetics Incretins - gut peptides that work by increasing insulin release. If 58 mmo/L / 7.5% or higher then step up the treatment Acute - DKA, HHS, hypoglycaemia Chronic Microvascular - retinopathy, nephropathy, erectile dysfunction, neuropathy (10-20 years after diagnosis in young patients) Macrovascular - atherosclerosis, ACS, stable angina, PVD, stroke Diabetic foot and ulcers

Question 50

Cushing’s syndrome and Cushing’s disease What is the difference between Cushing’s disease and Cushing’s syndrome? Which investigation can be used to differentiate between the two conditions? How does a patient with Cushing’s syndrome present (5 marks)?

Answer 50

Cushing’s syndrome refers to the state of elevated cortisol levels Cushing’s disease is specifically caused by an ACTH secreting pituitary tumour (pituitary adenoma) Dexamethasone suppression test Overnight Cushing’s syndrome (including disease) is confirmed when there is no suppression 48 hour Cushing’s syndrome (not including disease) = no suppression Obesity, buffalo hump,purpura, abdominal striae, muscle weakness, poor wound healing, hypertension, moon facies, thin skin, amenorrhea,

Question 51

You are an F1 on the endocrine ward and your consultant shows you lots of different ranges of TSH and T3/T4 levels and asks you to interpret the results. Which conditions would most likely cause the following TSH and T3/T4 results? You are an F1 on the endocrine ward and your consultant shows you lots of different ranges of TSH and T3/T4 levels and asks you to interpret the results. TSH: Low T4: High TSH: High T4: Normal TSH: High T4: Low TSH: Low T4: Low

Answer 51

1. Primary hyperthyroidism e.g. graves disease, thyrotoxicosis 2. Poor thyroxine compliance or subclinical hypothyroidism 3. Primary hypothyroidism e.g. hashimotos 2. Secondary hypothyroidism

Question 52

A patient comes into the Hospital with suspected DKA. What are the first line treatments you would offer? What ecg changes are seen in a patient with hyperkalemia (list 4)? What arrhythmia is a consequence of untreated hyperkalaemia?

Answer 52

A patient comes into the Hospital with suspected DKA. What are the first line treatments you would offer? IV Fluids (0.9% Sodium Chloride) IV insulin +/- Potssium ``` What ecg changes are seen in a patient with hyperkalemia (list 4)? Go - Absent p waves Go Long - prolonged PR Go Tall - Tall T waves Go Wide - Wide QRS ‘Sine’ Wave appearance ``` What arrhythmia is a consequence of untreated hyperkalaemia? Ventricular Tachycardia Occurring due to cell membranes becoming partially depolarised resulting in a lower threshold potential -> Ventricles contract quicker

Question 53

Shane is 34yr old male with Down’s syndrome. He has recently been complaining of increasing breathlessness and fatigue over the last 3 or 4 weeks. Upon looking at his medical record, you also notice he has been getting infections much more commonly than normal. On examination you note bruising on his legs but otherwise normal. Which of the following are you most likely to see on a peripheral blood film?

Answer 53

Auer Rods ``` Bone marrow infiltration and failure will lead to: Bruising / bleeding - thrombocytopenia Infections - leukopenia Breathless, fatigue, pale - Anaemia (pancytopenia if all 3 are present) ``` Acute myeloid leukaemia: Age points to AML , ALL is younger and CNS - smudge cells

Question 54

Katie, a 25-year old student has been struggling with tiredness for a few months. She presented to the GP having developed weakness and pins and needles in her hands and feet, and difficulty with balance and walking. She has been following a vegan diet for the past 7 years. What blood tests would you carry out and what would you expect the results to be? (3 marks)

Answer 54

What blood tests would you like to carry out and what would the likely results be? (3 marks) FBC ↓Hb ↑MCV (macrocytic anaemia) Blood film Hypersegmented neutrophils (>5 lobes) and presence of oval macrocytes Serum cobalamin ↓

Question 55

6 month baby A and E high fever and rashes that don’t disappear , unwell in pain what is it

Answer 55

Meningitis - non blanching rashes indicative of meningococcal infection and fever GB: Weakness of legs and arms, campylobacter - cant close eyes Encephalitis: Weakness and sleepiness Pneumonia: Non productive cough and breathing difficulties IE: Fever and new murmer

Question 56

Alice has meningitis causes by a fungus infection what findings on LP

Answer 56

Bacterial : Granulocytes, protien high and glucose low TB and Fungal: Lymphocytes present protien high glucose low Viral lymphocytes , protien high and glucose normal

Question 57

19 and headache that comes and goes , studying for exams around whole forehead but no cough or cold or fever ?

Answer 57

Tension headaches - bilateral pain behind eyes, under stress, low sleep Cluster: Headache is unilateral with pain in episodes, rhinorrhea and tears Migraines: Unilateral puking photo, sound phobia and aura Sinusitis: bilateral hurts in all, fever and sickness Temporal Aura: Sharp unilateral pain that comes for a few seconds that goes away when touching or shaving face

Question 58

23 unilateral headache 3 years comes and goes, weird zig zag lines before getting headaches, father has it to and asthma what is the prophylactic treatment?

Answer 58

Migraine with aura - normally beta blockers but asthmatic so topiramate ( anti epileptics )( not in pregnancy ) - contraceptive Verapamil is used for cluster Sumatriptan is first line for migraines with an NSAID Amitriptyline used if both cant be

Question 59

Mary has severe pain on one side of her head that comes and goes very tender and intermittent jaw claudication ?

Answer 59

It is Giant cell arteritis - jaw claudication and severe pain First line is CRP and ESR Gold standard is Temporal artery biopsy Treat with prednisolone - vessel Inflammation Can causes vision loss, stroke , blindness ( temporal close to optic )

Question 60

Sarah is presenting to A and E with a seizure after collapsing , lost conciousness, 12 weeks pregnant diazepam and lorazepam didn’t help - arms and legs flailing and jaw clenching ?

Answer 60

Generalised tonic clonic seizure - failing and clenching more then 5 minutes its now become status epilepticus Because lorazepam didn’t work your then you give lorazepam again then phenytoin Epilepsy is seizures of unknown cause she is pregnancy so it may be pre eclampsia 2 or more 24 hours apart and Eliminate all causes e.g. electrolyte imbalances If they didn’t have epilepsy lamotrigine - pregnancy

Question 61

Weird jerks, all the time , lost structure -19 year old boy

Answer 61

Focal seizures - Jacksonian march - arms to back - to leg To young for Huntington’s chorea - 40 and no FH and no behavioural change petit mal - absence seizures, staring loss of awareness

Question 62

Jack is 59 - stroke like symptoms - headaches, feeling dizzy, nauseous, homonymous heminapoia , weak , HT, Hcholestroal and diabetes what is first line investigation ?

Answer 62

Order CT scan - positive for Ischaemic stroke - IV alteplase can be given within 4.5 hours so use aspirin and mechanical thrombectomy ( 6-24) Posterior stroke but if it was double vision also posterior circulation - lateral Rectus and superior oblique Amaurosis fugax Check to make sure its not haemorrhagic

Question 63

72 year old man has unusual hemiparesis cant life arm and leg but can feel what is he having:

Answer 63

Lacunar stroke - motor not sensory function - penetrating arteries not main Stroke aetiology: AF, atherothromboembolism of carotid ``` Strokes are either : Total or partial anterior circulation Posterior TIA Lacunar ```

Question 64

Sudden onset headache, soreness around neck and shoulders and photophobia whats the next step in management worst in first 3minutes

Answer 64

Subarachnoid haemorrhage - severest pain in first 3minutes then gets not as bad - CT scan This is Menigism : headache, photophobia and neck stiffness ( SAH and Menigitis , migraines ) LP 12 hours after onset to allow xanthochromia Migraine : Mild to moderate is paracetomal and high is rescuer with sumatriptan What are complications of menigism: - Hydrocephalus and vasospasm - nimodipine - seizures, rebleeding and electrolyte imbalances

Question 65

67 has confusion in A and E with traumatic flow to the head , recovered quickly, past medical history, high cholesterol, crescent shaped haaematoma on the left with midline shift what is the most common cause and 4 risk factors:

Answer 65

Subdural haemorrhage - rupture of the bridging veins - hypertension, trauma, age, alcohol, infant abuse shaken babies, and anticoagulants Acute - younger Chronic in olde r-n atrophy stretches bridging veins - ruptured due to trauma

Question 66

Joe is 59 detained under mental health act, acting strangely , rude comments, addenbrookes normal but atrophy of the right frontal lobe what is the diagnosis ?

Answer 66

Acting weird and histopatholhou of Alzheimer’s: Neurofibrillay tangles, beta amyloid s, atrophy , loss of ACH productions

Question 67

Jane is 30 with acute pain onset in left eye, seeing double cant tell colours apart, more tired, dragging foot, lesions in white matter? How would you manage

Answer 67

Multiple Sclerosis - optic neuritis :2 episodes disseminated in time and space Methylpredisalone - gabapentin is for pain Propranolol

Question 68

Types of MS

Answer 68

Relapsing remitting,progressive primary and secondary progressive

Question 69

4 cardinal brain tumours Sympotyms?

Answer 69

Raised ICP, focal neurological deficit. visual disturbances, seizures, lethargy Lung tumour can metastases to : Brain liver adrenal and bone Lung tumours met from: Bowery, bladder, breast, renal cell carcinoma Name 5 places prostate can golf L prostate, kidney, breast and bone

Question 70

43 year old has progressive difficulty walking and lower back pain, tripping and cant climb stairs, tingling and numbness , food poisoning , what is the most important parameter to moniter?

Answer 70

Guillian Barre syndrome - gastroenteritis , ascending polyneuropathy FVCapacityb - monitor pulmonary function because of ascending neuropathy to diaphragm - failure

Question 71

A 40 year old is referred to a neurology clinic - double and blurred vision more tired no abnormalities which of the following tests is she positive for?

Answer 71

Myasthenia gravis - gets worse towards end of day - antibodies to ACH receptors If its negative to Anti - MUSK Bedside test: ICE PACK test and upgaze Scan - Thymus CT Lambert Eaton - SCC - antibodies to pre synaptic voltage gated calcium channels Not MS no pain

Question 72

A 28 year old construction worker has night numbness and tingling , shaking hands relives symptoyms, no weakness of ahnds - affects thumb , index and middle fingers, no wasting , wore normal, tapping the wrist with a tendon hammer reproduces symptoms - tinnels test

Answer 72

Median neuropathy and carpal tunnel syndrome - construction worker and afects thumb, index and half of middle - median nerve Tinnels positive and phalens test Aetiology: Idiopathic, pregnancy, high BMI, wrist fractures, RA, severe oedema and HF, occupation Electrophysiology - prolongation of action potential - EMG TX: Wrist splints 1st line in mild or pregnancy Corticosteroid injections Surgical related if severe, non pregnant - definitive Median nerve - flexion loss rock Radial - extension loss paper Ulnar - finger abduction and abduction loss scissors

Question 73

69 presents with back pain and dragging right foot, Dorsiflexion weakness, normal inversion and sensory loss of medial aspect whats the cause?

Answer 73

Foot drop - emergency is cauda equine but most common is common peroneal nerve palsy and L5 rediculopathy In spinal nerve compression - lose sphincter and bladder control - high storage gait Common peritoneal never e- lose version and sensory loss due to compression a fibula neck e.g. leg crossings , kneeling bakers cyst and platers casts

Question 74

An 84 year old man has a pill rolling tremor at rest: What imaging would confirm diagnosis and what do your expect to see What lesion in the brain Apart from tremor give 2 other clinical Parkinsons hallmark Name 2 other causes of Parkinsonism Name 3 medications What about if tremor when anxious relived by alcohol

Answer 74

Parkinsons Use DATscan - substantia nigra - degradation and degeneration MRI lesion would be Lewy bodies Tremor, bradykinesia and rigidity Multi - system atrophy, drug inducesd, progressive supranucleur palsy and cortico-basal degeneration Medications: Levodopa ( Dyskinesia , involuntary movement, falls , postural hypertension) Dopamine agonist - bromocriptine , bropinarol ( pulmonary fibrosis, increase gambling and impulsivity )MOA_-B inhibtors Benign or essential listening tremor

Question 75

You are a junior doctor in GP a 70 year old man is struggling to wee whats the first line?

Answer 75

Tamulosin - BPH its an alpha blocker which allows relaxation of the prostate muscle

Question 76

Which arteries supply 80% of the blood to the brain

Answer 76

Internal Carotids - supply 80% with 20% being vertebral

Question 77

A 16-year-old boy presents to A&E with severe pain in his left groin area that started when he was playing football with his friends. On examination, the left side of his scrotum is red and swollen and his cremasteric reflex was absent on the left. What is the diagnosis?

Answer 77

testicular torsion Hydroceles, varicoceles, and epididymal cysts are normally painless. In someone with epididymitis the presentation is similar but, the cremasteric reflex would be present. The cremasteric reflex involves the testis moving upwards when the inner thigh is stroked.

Question 78

What isnt a cause of ischaemic stroke: Vasculitis, embolism, thrombosis, carotid artery dissection, aneurysm rupture

Answer 78

Aneurysm rupture

Question 79

A 52-year-old man presents after having another episode of severe pain down the left side of his abdomen. He previously had an episode a few days ago. He says the episodes don’t last very long but when they happen, he can’t get comfortable and describes the pain as the worst pain he has ever felt in his life. He says he sometimes feels sick when the pain happens. What would be the best investigation to perform?

Answer 79

This presentation is consistent with kidney stones. NCCT-KUB is the gold standard investigation for kidney stones.

Question 80

An 81 year old lady atends your GP practce asking about her risk of having a stroke. She has a past medical history of type 2 diabetes and hypertension and is on warfarin. Which of the following factors does not increase her risk of having a stroke?

Answer 80

Gender NM: Male, older age, FH, ethnciity, APL Modifable: HTN, DM, CVD, PVD, Hyperlipidaemia, excessive alcohol use

Question 81

A 72-year-old man has recently been diagnosed with chronic kidney disease (CKD). Some blood tests have been done which show his glomerular filtration rate (GFR) is 48ml/min/1.73m2. Which stage of CKD is this?

Answer 81

``` GFR is how well the kidneys are able to filter blood and is an indication of kidney function. Normal GFR should be at least 90 which is stage 1. Stage 2 -> GFR between 60 and 80 Stage 3a -> GFR of 45-59 Stage 3b -> GFR of 30-44 Stage 4 -> GFR of 15-29 Stage 5 -> GFR of less than 15 ```

Question 82

A 21 year old student presents to A&E with reduced consciousness following a head injury which he sustained afer getng in a fght at the pub several hours ago. You take a history from his friend who has brought his to A&E. His friend tells you that he did not lose consciousness afer hitng his head on the ground but was drowsy and confused. He then improved and was okay for a couple of hours apart from having a headache. He then started vomitng and became unresponsive. What do you think is the most likely diagnosis?

Answer 82

Extradural haemorrhage - lucid interval

Question 83

A 7 year old girl presents to the out of hours GP with fever, headache and a rash. On examinaton she has a stf neck and keeps covering her eyes to avoid looking at the bright lights in the clinic room. What do you expect the rash to look like?

Answer 83

Non Blanching petechial rash

Question 84

A 32 year old gentleman presents to your GP practce complaining that his legs feel weak. On further questoning, the weakness started in his ankles a couple of days ago but is now afectng the whole of his legs. He says that he’s fnding it really hard to walk upstairs and stand up from the sofa. He has no other symptoms. He is normal ft and well and takes no regular medicaton. He had a bit of a cold a few weeks ago but he tells you it wasn’t anything serious. What is the most likely diagnosis?

Answer 84

Guillian Barre syndrome

Question 85

A 78 year old woman atend your memory clinic with her daughter. Her daughter tells you that her memory has been getng worse over the past 12 months. Recently her neighbours have found her wandering around the street late in the evening. She is otherwise well and take no other medicaton apart from a multvitamin. What is the most likely diagnosis?

Answer 85

Alzheimers

Question 86

A 78 year old woman atend your memory clinic with her daughter. Her daughter tells you that her memory has been getng worse over the past 12 months. Recently her neighbours have found her wandering around the street late in the evening. She is otherwise well and take no other medicaton apart from a multvitamin. What is the most likely diagnosis?

Answer 86

``` Cheese Oral contraceptive Caffiene Anxiety Travel Exercise ```

Question 87

a. Defne an ischaemic stroke. (2 marks) b. Give 2 modifable and 2 non-modifable risk factors for a stroke. (4 marks) c. You perform a neurological examinaton. Other than his facial droop, list 2 other signs you may fnd? (2 marks) d. What is the 1st line investgaton? (1 mark) e. Your 1st line investgaton shows no sign of a haemorrhagic stroke, what inital treatment would you give? (1 mark)

Answer 87

jckxbzbzlx

Question 88

) zxxz

Answer 88

List 3 signs of Parkinson’s disease (3 marks) Bradykinesia, rigidity, tremor, postural instability… b. Explain the pathophysiology of Parkinson’s disease (2 marks) Progressive neurodegeneraton of dopaminergic neurons in the substanta nigra resultng in dopamine defciency which results in reduced movement initaton - increased inhibiton of the thalamus c. Name 2 other diferental diagnosis. (2 marks) benign essental tremor, lewy body dementa, drug induced parkinsonism, stroke, PSP, MSA, Wilson’s disease d. Give 1 pharmacological and 1 non-pharmacological aspect of PD management (2 marks) Pharmacological: levodopa, dopamine agonists, MOAB inhibitors Non-pharmacological: physio, OT, SALT, deep brain stmulaton e. Name 1 complicaton of Parkinson’s disease (1 mark) Reduced quality of life, depression, treatment side efects, dementa, constpaton a

Question 89

A 73 year old right-handed man presents with sudden onset weakness of his right arm and leg and slurred speech. He has a history of ischaemic heart disease, diabetes and uncontrolled hypertension. On examinaton, he is alert and is able to provide a history, although his speech is not normal. He has facial asymmetry, and profound weakness of his right arm and leg. Non-contrast CT scan done within 40 minutes of symptom onset shows no obvious acute pathology. Blockage of which artery is likely to be responsible for his syndrome?

Answer 89

Left middle cerebral Anterior - personality and legs

Question 90

21 girl seizures

Answer 90

Lamotrigine Carbamazepine would be if he would

Question 91

A 30 year old man is referred to the clinic with sensory loss on his litle fnger and the lateral half of his ring fnger. He has weakness bending his fngers although he can bring his thumb up vertcally with good resistance. Refexes are preserved. Which nerve has he injured?

Answer 91

Ulnar Radial - base of thumb and back of hand median is indez and middle and half of the ring on palmar sid e

Question 92

A 72 year old woman is reviewed in neurology outpatents for ongoing management of her Parkinson's disease. She was diagnosed 3 years ago when she notced a subtle right side restng tremor and generalised slowness of movement. She takes co-careldopa daily, and last year was started on entacapone to reduce her end-of-dose efect. Recently she has notced the development of slow writhing movements of her upper limbs, most prominent in the morning. What is the underlying cause of the patent's new symptoms?

Answer 92

Long term levodopa - writhing movements of the limsb progression of parkinsons - ridgidty nad trenir

Question 93

A 68 year old man with a history of hypertension obesity and type 2 diabetes presents with fatigue, swollen legs and itchiness GFR is 20 whats the diagnosis

Answer 93

``` Stage 4 - know CKD and AKI - water retintion, fatigue, toxin metabolise build up ( urea ) 1 - above 90 2 - 60 - 89 3A: 45- 59 3b : 30-44 A 15-29 5 less then 15 renal failure ```

Question 94

Lightheadeness and dizziness out of bed or office chair, fainted , what medication is doing this:

Answer 94

Tamulosin- BPH can cause postural hypertension | furosemide can cause it to but they are CI in CKD

Question 95

50 year old man presents to A and E with a 1 hour history of sudden onset left sided flank pain radiating to groin - stabbing 10/10 nauseous and IV tiny

Answer 95

NCCT - KUB ( renal colic ) - sudden onset ipsilateral pain radiating down groin, loin to groin cant sit still Gold standard - NCCT KUB - contrast can damage Renal ultrasound younger and reoccurring Watch and wait. Treat , tamsulosin, anti emetic , surgical innervation KUB - X ray is first line but cant see pure Uric acid

Question 96

76 PMS women has pain urinating and frequancy - has previous epsiodes which are treated with NFT:

Answer 96

E.Coli ( Klebsiella second )

Question 97

Facial oedema - total body swelling, face , abdomen scrotum and fever had a viral illness and fever, heavy protienuria what is it - 5 year old?

Answer 97

Minimal change disease ! IgA is post tonsillitis an dis nephritic - haemturia and mimial protienuria Hoskins - 20 or 75, painful lump after a night alcohol Acute glomerulonephritis post strep adults

Question 98

A 70 year old has puffy legs and fatigue - Periphral oedema but normal - antibiotics for infection which antibiituc causes AKI

Answer 98

Gentamicin

Question 99

What can chloramphenicol do

Answer 99

Bone marrow suppression and amoxicillin can cause hypersensitivity

Question 100

6 year old feels under weather - puffy barely pees, bacterial tonsillitis, protien and blood in the urine

Answer 100

Post streptococcal glomerulonephritis IGA nephropathy = 2 days Post strep is 1-3 weeks Wilma Tumor - mass

Question 101

50 year old - haemorrhagic stroke, well no fever or dysuria, recurrent UTI, FH of CKD and passed away from a stroke at 65

Answer 101

Renal USS- haemorrhagic stroke and CKD, recurrent UTIs, FH, PKD

Question 102

75 year old has difficulty Uric ting and bone pain, prostate is hard and irregular , lost weight which part of the prostate is abnormal?

Answer 102

Peripharal zone becomes cancerous | Transitional zone is BPH

Question 103

A 74 year old male has haemturia and and lethargy with background of schistosomiasis what kind of bladder cancer is it ?

Answer 103

Squamous cell carcinoma - schistosomiasis Normally urethilial carcinoma

Question 104

Which cancers spread to the bone

Answer 104

``` Kidney Thyroid Breast Prostate Lung ```

Question 105

Modes of cancer transport

Answer 105

Haematological Peritoneal translimical Lymph node

Question 106

Worsening left scrotal pain and white urethral discharge, tender erythematosus swollen left scrotum, intact cremasteric reflex and relief with elevation

Answer 106

Epididymo - orhcitis Cysts , hydrocele and tumour - painless lump Testicular torsion is an acute emergency - phrens reflex negative

Question 107

19 has dysuria - unprotected oral and veg animal intercourses , slight white dispatcher no tenderness - chlamydia what is the first line management?

Answer 107

Doxycycline Not good in pregnancy - erythromycin or amoxicillin or axirthyromsyicb

Question 108

34 otherwise healthy fever, haemturia, increased frequancy right sided back OAB, - pyelonephritis whats the classical triad

Answer 108

Nausea and vomiting, fever and loin /flank pain - E.coli , female, vesicles ureteric reflux Cephalaxin Take sample before MSU Broad spectrum then specific

Question 109

66 - urgency’s nd frequancy , 12 times a day and. Times a night she leaks urine occurs as she stands up which nerve contracts the detrusor

Answer 109

Pelvic nerve Symapethic is hypogastric nerves fight and flight - relaxes ( T12 - L2) Parasymapethic Pelvic S2-S4 Pudendal is sphincter somatic ( S2-S4 KNOW BRACHIAL PLEXUS, lower limb innervation ( mononeuropathy s )

Question 110

35 non specific set half discomfort - 2cm by 1cm smooth painful mass, testicular cancer and referred to US what is associated with the diagnosis ?

Answer 110

Increased serum alpha feta protien - all testicular cancers raise AFP Germ cell - raise afp and HCG Gynacomasteia Hyper thyroidsm

Question 111

52 has so we pain down left side of the abdomen - worst pain whats the best investigation ?

Answer 111

Non contrast CT of the kidneys ureter and bladder - kidney stones but if pregnant it was US

Question 112

What is an example of land field group A strep?

Answer 112

Streptococcus pyogenes - clindamycin

Question 113

A 28 year old man attends A and E with a 3 month of history of night sweats , weight loss and a persistent productive cough with red blood what would you do ?

Answer 113

Ziehl Neelson stain on sputum - 1 pink bacilli is positive

Question 114

Man is diagnosed with TB and starts treatment but is worried about red orange urine?

Answer 114

Rifamapicin Isoniazid: Numb and tingly extremeties Ethambutamol : Ocular side effects Rifampicin is orange red urine Pyrazinamide - arthalgia

Question 115

What is coagulase positive

Answer 115

S.aureus

Question 116

Which class of antibiotics target cell wall?

Answer 116

Glycopeptides, cephalosporins, penicillins and carbapenams Macrolides inhibit protien synthesis and are used in cases of penicillin allergy

Question 117

Which two species of malaria can persistent

Answer 117

P.ovale and P.Vivax - 14 day primaquine

Question 118

A man presents for a routine visit with elevated ALT and a history of IVDY want to investigate for HBV what is indicative of active HBC

Answer 118

Hepatitis B surface antigen - HBsAG

Question 119

75 year old man has a history of productive cough, dyspnoea and pleuritic chest pain with a low grade fever whats the most common cause of CAP

Answer 119

S. Pneumoniae ( atypical are mycoplasma , chalmydopjila , legionella - went on holiday stayed in hotel hot country )

Question 120

What do you do first bloods or antibiotics in Sepsis?

Answer 120

Bloods

Question 121

19 year old student has a fever non blanching rash and photo sensitive - lumbar puncture is turbid high opening pressure high WBC and low glucose whats happening

Answer 121

Bacterial mengitis

Question 122

What’s the best way to detect viruses

Answer 122

PCR

Question 123

What cells do HIV infect

Answer 123

CD4

Question 124

What do you give staph infections

Answer 124

Flucloxacillin

Question 125

What should you watch out for in antibiotic questions

Answer 125

Penicillin allergy ( usually give a macrolides

Question 126

Mark is a 63 year old man coming to the clinic with dark stool. He complains of vomiting and occasionally having diarrheal. He has a 30 pack year history and drinks 22 units of alcohol per week. He feels abdominal pain that has been getting worse pver the last few months. He has been on ranitidine for 2 years now. He's lost 9kg in the last few months. He has also been diagnosed with UC in the past. His bloods show anaemia and thrombocytosis whats the diagnosis?

Answer 126

Gastric Adenocarcinoma- melena and weight loss, haemetemesis Colon adenocarcinoma would have fresh red blood mixed with stool SCC are only in the oesophagus - progressive diffculty eating then swallowing UC: Fresh red blood and mucus but no weight loss or constipation, diarrhoea Haemorrhoids - blood when wiping not mixed with stool

Question 127

Patient complains of abdominal pain that has been lasting months. it is localized to the epigastrium. The pain is the worst when he eats. He has been omeprazole and ranitidine but it has not madae the illness go away. He is then given a "test" that shows the patient has H.pylori. What is the necessary treatment and diagnostic test for this?

Answer 127

Omeprazole, amoxicillin and clarithrpmycin Test: Stool antigen test or C-Urea Breath Test

Question 128

John is an avid smoker with a 20 pack history. He has a family history of colon cancer. He has had recent weight loss. He explains that he has difficulty swallowing everything and so he has barely been able to eat, Many times when he tries to eat stuff, they tend to regurgitate. He also explains that he has shortness of breath at exertion and sometimes his fingers tend to get very white and cold. What is the most likely diagnosis?

Answer 128

Systemic sclerosis Differential: Oesophageal Squamous cell Carcinoma but no progression. Fibrosis all over the body. In lungs causes restrictive dyspnoea. In esophagus it stiffens causing no peristalsis. In small peripheral vessels causes raynaud's.

Question 129

Patient comes in with a 3-week history of severe constipation and abdominal pain. At the A+E, he looks very unwell and has vomited a few times since arriving at the hospital. He has T 38.2, HR 111 and RR 24. What is the most likely diagnosis? What is the gold standard investigation for this?

Answer 129

Diverticulitis - almost always with constipation and fever Differential: appendicitis because only causes pain on the right Gold standard: CT (can't colonoscopy because perforation) Diverticular disease: colonoscopy This is caused by constipation causing unwell patient and fever weakness in intestinal wall - poo gets stuck

Question 130

How does volvulus present?

Answer 130

Coffee bean sign | No fever would be present

Question 131

19 year old patient previously diagnosed with borderline personality disorder presents to the hospital extremely unwell. His eyes are barely open and is extremely confused and disoriented. His sclera has yellowed on examination. His mom explains that there was an empty bottle of capsules next to him but is not sure what it was. What is the most likely drug he has overdose on? What treatment does he need to recieve? One of the nurses suspect it is Wilson's disease, the doctor examines the patient's eye and finds no clinical feature of it. What is the doctor looking for?

Answer 131

Paracetamol Jaundice n-acetylcysteine (IV) Charcoal only if it's been within the hour Confused disoriented Kayser fleischer ring

Question 132

Name two features of acute liver failure

Answer 132

``` nausea vomiting malaise Jaundice - itching ascites pain on right side ``` bleeding coagulopathy confusion encephalopathy

Question 133

Name two features of chronic liver failure

Answer 133

Ascites, gastro-oesophageal varices, peripheral oedema, jaundice triad, clotting dysfunction, malnutrition (bile not produced and liver not storing/processing nutrients).

Question 134

40, pain in his abdomen pain is in epigastrium radiating to the back, vimited, gallstones what investigation?

Answer 134

Serum amylase or lipase - acute pancreatitis Hypercalceamia can cause it alcohol and gallstones

Question 135

Where do you get gaurding?

Answer 135

Perforated appendicts -

Question 136

Jane contrinues drinkinh ahbits - pancreatic calcification?

Answer 136

Chronic pancreatitis, give creaons and ceolaic is a risk factor caused by gallstones and alcohol, risk

Question 137

Max ia a 50 year old gentleman presenting to the A&E with acute pain in his right upper quadrant. This happened after she had a mukbang session eating Fish & Chips. He denies any chest pain, SOB or recent trauma. He had felt nauseous but has not vomited. He bowel movements are normal. He had a past medical history of gallstones. Max leads a sedentary lifestyle and stays at home 100% of the time. His obs is only remarkable for raised temperature. O/E RUQ tenderness, positive murphy's sign What's the definitive treatment of this disease?

Answer 137

Laparoscopic cholecystectomy Jaundice + cholangitis Fever Worse on fatty foods RF for gallstone -> Fat, female, forty, fair

Question 138

Tom is a 55 year old gentleman with a history of sever alcoholic cirrhosis, he is confused and unable to giev a full history. He later comlains dark colouring of his stools. He has a past medical history of liver disease and hypternsion. His obs are temp 36.6, RR 18, PR 113, BP 80/60, mmHg & O2 98% O/E confused hepatomegaly and jaundice His relevant bloods are RBC 78 (90-110), WBC 80 (70-90), Urea 90 (70-80), Creatinine 75 (70-80) Diagnosis?

Answer 138

Rapture of oesophageal varices Blood loss Hyptertension shock Urea -> internal bleeding Mallory-Weiss tear -> self limiting Peptic ulcer disease -> no epigastric pain and history of NSAIDs Anal fissure -> bright red blood and straining down there

Question 139

Max is a healthy 23 yo male who had recently returned from sri lanka on a volunteering trip. He had not had any vaccinations or prophylaxis prior to the trip. HE reported symptoms of fever, nausea and vomiting, and also felt generaly unwell. Blood tests show IgM antibodies in response to the hepatisis A virus. O/E RUQ pain with hepatomoegaly Cause?

Answer 139

Hepatisis A acquire by eating contaminated food Hep A -> dirty food Hep B -> unprotected sex Hep C -> IVDU higher ALT + higher billirubin Dark urine & normal stools

Question 140

Julian comes to the GP complaining of yellowing to his skin. He freuquently gets pain in his RUQ after meals. He has had gallstones in the past and he thinks it might be the same problem again. What wou;d be raised on his LFT? What other symptoms would he have?

Answer 140

GGT and ALP bilirubin Dark urine and pale stools Gillbert causes pre-hipatic jaundice

Question 141

Name 4 risk factors for gallstone formation

Answer 141

dehydration, high cholesterol diet, obesity, Fat, female, forty, fair

Question 142

Name 3 types of gallstones

Answer 142

Cholesterol, black/brown pigmented stones

Question 143

Black gallstone causes

Answer 143

sickle cell, systic fibrosis,

Question 144

25 yo man, GP with 3-month history of diarrhea, abdominal pain and weight loss. He undergoes a biopsy which confirms Cronh's disease List 3 diagnoses Name a blood test an an imaging test to aid with diagnosis List 2 histological features from biopsy List 3 differences between uC and Cronh's Name a lifestyle modification for him How to maintain remission for his condition?

Answer 144

Malignancy, uc, ibs, coeliac diverticular colonoscopy, cobblestone apperance, rosthrone ulcer, skip leisions, blood calprotectin transmural inflamation goblet cell non-caseating lympocytic infiltration ``` UC endoscopy mouth ulcers clubbing apthous pyoderna gangrenosum eryhtmous nodusum uveitis episcleritis anchilosing spondelitis prednicalone acute long line azathiprine second line methotraxate ``` stop smoking

Question 145

A 21-yo female vomits blood after drinking

Answer 145

Mallory weiss tear

Question 146

38 yo man complains of intermittent abdominal pain. It's relieved by eating. C-urea breath test is positive. Diagnosis? Appripriate drug treatment?

Answer 146

Duodenal Ulcer | Omeprazoe, clarithromycin and amoxicillin

Question 147

17 yo abdominal pain, bloating for 6 months, intermittent loose and smelly pale stools with no blood or mucus. Past history of B12 deficiency and mum is on levothyroxine for thyroid disease. She is pale , her abdomen is tender but soft with no guarding. Digital Rectal examination is normal. Which most likely appropriate investigation?

Answer 147

Coeliac of course Total immunoglobulin A + IgA tissue translutaminase - 1st line serology

Question 148

80 to man 1 week ibality to open bowels or pass wind, denies previous episodes and presented due to abdominal distension, discomfort and nausea. Reports that noticed PR beeding several months ago but was painless and infrequent. Denies issues with constipation but notes that over the last 2 months he noticed more frequent loose stools and significant weight loss. An abdominal radiograph revelas dilated loops of large bowel. What is the likely cause of the obstruction?

Answer 148

Rectal cancer

Question 149

Which coronary artery is most commonly occluded in an MI

Answer 149

LAD V1-V4

Question 150

A 32 has lethargy and blurred vision and suspects MS which myelin producing cells are destructed:

Answer 150

Oligodendrocytes not Schwann cells !

Question 151

Which hormone acts on the leydig cells to produce testosterone

Answer 151

Lutenising hormones FSH acts on Sertoli cells GNRH causes release of LH and FSH

Question 152

24 2 month history, 3-4 loose motions with blood - UC is suspected which part of the bowel is affected?

Answer 152

Rectum - starts in rectum then spreads Crohn’s is terminal ileum

Question 153

What sort of hypersensitivity is anaphylaxis?

Answer 153

T1 is within 1 hour IgE mediated and is anaphylaxis 2 is IgG or IgM hours to days e.g. haemolytic anaemia 3 is immune complex mediated 1-3 weeks and causes serum sickness and SLE 4 is T cell mediated days to weeks e.g. SJS and rash

Question 154

56 SCLC male is lethargic and disoriented - low sodium what is the mechanism of action of the hormone being secreted to excess?

Answer 154

Insertion of aquaporin channels- ADH

Question 155

Unilateral tremor, ridgitiy and bradykin ease what is dysfunctioning?

Answer 155

Substantia nigra

Question 156

28 year old female is referred to colposcopy - what time of epithelium lines the endocervix

Answer 156

Endocervix - mucous secreting simple columnar epithelium Ectocervix? Stratified squamous non kertainxed

Question 157

How does testicular torsion present?

Answer 157

Acute onset testicular pain with absent cremasteric reflex

Question 158

A 65 year old male presents to outpatient clinic for his abdominal aortic aneurysm screening. He is found to have a dilation of the abdominal aorta just above the level of the bifurcation of the abdominal aorta into the common lilac arteries. The level of the bifurcation corresponds to which spinal level?

Answer 158

L4

Question 159

CT scan left precentral gyrus what defect what symptoms is it likely to result in?

Answer 159

Weakness of the right side of the body

Question 160

52 year old has a 5 day history of facial pain nasal congestion and headaches worse leading foreward - which sinus is most affected in sinusitis

Answer 160

Maxillary

Question 161

What does beclomethasone do?

Answer 161

Decreases cytokines formation , decreases micro vascular permeability ,reduces bronchiol hyperesponsivness and inhabits eosinophil influx Smooth muscle is relaxed by salbutomal

Question 162

2 week wait colonoscopy - mass in sigmoid colon , mass in sigmoid colon biopsy confirms adenocarcinoma in the sigmoid which lymph nodes has it gone to ?

Answer 162

Inferior mesenteric nodes Para aortic - testes ovaries and adrenal glands ?

Question 163

What is an effect of angiotensin 2?

Answer 163

Release of aldosterone

Question 164

Sudden thunderclap headache + Menigism + PKD history what is it?

Answer 164

SAH

Question 165

Cushings triad

Answer 165

Physiological nervous system : WIdening pulse pressure, bradycardia, irregular respiration’s

Question 166

62 year old female presents to ED with Abdo pain localised to RUQ jaundice what is it most likely to be?

Answer 166

Ascending cholangitis - charcots : Jaundice, RUQ and fever

Question 167

6 month history of weight loss etc etc - CML whats the abnormality?

Answer 167

T(9:22)

Question 168

Teenage boy has an injury from rugby - mid shaft humeral fracture whats at risk?

Answer 168

Radial nerve - Neck - axillary nerve Mid shaft - radial Lower supachorniol - medial nerve and brachial artery in front of

Question 169

What is the mechanism of action of ondansetron?

Answer 169

5-HT3 receptor Antagonsit Beta blocker CVD H1 - antiemetic on histamine - ethinze D2 - dopamine - domperiomde ad methocloparime NK-1 neurokinine -

Question 170

What does the right testicular vein drain into

Answer 170

IVC

Question 171

Process of columnar epithelium into mature sqaumous epithelium is what

Answer 171

Metaplasia

Question 172

38 year old female has a 6 month history of fatigue blood tests below what’s that anaemia cause? Low MCV

Answer 172

Iron deficiency

Question 173

What is the ovarian cancer bio marker?

Answer 173

CA 125 CA 19-9 - pancreatic CEA- colon PSA - prostate HER- 2 breast cancers and BRACA

Question 174

What do penicillins do?

Answer 174

Inhibit cross linking in peptidoglycan cell walls?

Question 175

What epithelium lines the oesophagus?

Answer 175

Stratified sqaumous non keratinised

Question 176

A 47 year old male has an AKI = potassium 6.5 which ECG changes are hyperkalemia

Answer 176

Tall tented T wave

Question 177

What is a node of ranvier?

Answer 177

A junction between two Schwann cells

Question 178

A 71 year old has stiff hands worse in the mrinubg - periarticalr erosions and loss of joint space

Answer 178

Rheumatoid arthritis

Question 179

What do bronchiole walls lack

Answer 179

Hyaline cartilage - Bronchi - bronchiole is Primary, secondary, tertiary - lobar - segmental bronchi ( C shaped hyaline Cartilage ) smaller airways dont need it

Question 180

Obstructuvive v.s. Restrictive

Answer 180

Measure air you can expel Obstructive: FEV1 low FVC normal ratio abnormal Restrictive: FEV1 and FVC low normal ratio

Question 181

Which bacteria usually causes resp symptoms:

Answer 181

Haemophilus influenzae Pseudomonas - skin and wounds UTI -e.coli

Question 182

Which electrolyte do you need to watch in DKA?

Answer 182

Potassium - in trolled lypoliss- excess ketones

Question 183

72 tear old is hypotensive, tachycardia, abdo pain high lactate, AF, what next?

Answer 183

CT angiogram - thrombus SMA

Question 184

78 year old female stroke ward - right MCA unsafe swallow, pyrexial, tachypnoeic and tachycardia - aspiration pneumonia which lobe is affective?

Answer 184

Right middle lobe

Question 185

Patient and parter - husband has sickle cell and they have a son with it no PMH what is the probability of them having another child with sickle cell?

Answer 185

50

Question 186

72 memory clinic - dementia what screening test?

Answer 186

MOCA

Question 187

40 year old Caucasian - blood pressure over 150/100 whats first line

Answer 187

Ramipril

Question 188

22 female - lethargy ABdo pain, diarrheo and weight loss , IDA

Answer 188

Biopsies are taken duodenum and jejenum

Question 189

Where would you find ciliates columnar epithelium with goblet cells?

Answer 189

Trachea

Question 190

What kind of cartilage makes up the menisci?

Answer 190

Chondrocytes and fibroblasts surrounded by type 1 and type 2 collagen

Question 191

What are the main types of cartilage?

Answer 191

Hyaline - most widespread , avascular , skeleton of the fetus, resp tract up until bronchioles, chondrocytes Elastic: Avascular surrounded by perichondium, 2 collage, more elastic tissue, external ear, epiglottis and auditory tube Fibrocartilage - avascular no perichondium, T 1 collagen , intervertebral disks, mandible, sternocalvicualr and pubic sympshss , aligns along lines of stress

Question 192

What does a vein not contain?

Answer 192

Internal elastic lamina Tunica intima, media and adventitia

Question 193

Which layer do atherosclerotic plaques form

Answer 193

Tunica intima

Question 194

Skin functions?

Answer 194

Protection, water barrier, body tempurature regulation, non specific defence, excretion of salt synthesis of vitamin D, sensory organ Merkel s cells are neural cresct Langerhands are dendritic c- A trap cells

Question 195

What are the agranulocytosis

Answer 195

Lymphocyte and monocytes | Neutrophils, eosphinols and basophils do

Question 196

Where do you find osteocytes

Answer 196

How’s ship lacunae | Haversian down and volkammans across

Question 197

Describe a hepatic sinusoid

Answer 197

Blood in, bile out Triad on edges and porta; vein in the Middle Stellate- stoors nad scars PERIS stain - Kupffer cells blue due to hemosederin

Question 198

What are the symptoms of hypocalcaemia:

Answer 198

Convulsions, arrhythmias, tetany, numbness, chvosteks and trousseaus

Question 199

Myeloma symptoms

Answer 199

C: Hypercalcaemia : Groans ( constipation), stones, bones and moans ( psychic) R: Renal injury ( AKI, creatinine, high urea, low eGFR) Anaemia: Breathlessness, fatigue Bone destruction: Pathological fractures

Question 200

Which type of antibody does warm AIHA involved:

Answer 200

IgG

Question 201

What can you see in G6PD?

Answer 201

Bite cells, Heinz bodies

Question 202

What is a decreased haptoglobin a feature of?

Answer 202

Haemolytic anaemia

Question 203

What do blood tests show in haemolytic anaemia:

Answer 203

Normocytic, increased LDH, increased uncojugated bilirubin, decreased haptoglobin, increased reticulocyte count

Question 204

What’s sickle cell pathology?

Answer 204

Beta globin chains on chromosome 11 misshapen , normally glutamic acid to valine and results in HBs - aggregates with other HBs and RBC polymerises when deoxygenated causing a sickle cell red blood cell Fetal haemoglobin is 2 alpha and 2 gamma - no symptoms until a few motnhs

Question 205

Give signs of Polycythaemia?

Answer 205

High haemoglobin, facial flushing, intermittent itching, worse in the path, alcohol, high altitude, obstructive sleep apnoea, JAK2 mutation

Question 206

What are the two types of Polycythaemia?

Answer 206

Primary: JAK2 mutation - Polycythaemia Vera Secondary: Alcohol, chronic hypoxia , obstructive sleep apnoea, living at altitude , lung disease, smoking, EPO secreting tumours,

Question 207

Sam has a 3 year old bloody diarrhoea for 5 days after eating some dodgy cottage pie at nursery , purpurin rash, fatigue not producing much urine, oliguria,

Answer 207

Haemolytic uraemia syndrome : Microangiopathic haemolytic anaemia, thrombocytopenia and renal impairment DIarrheoa shiga toxin associated FBC: Anaemia and thrombocytopenia, haemolysis , LDH and bilirubin, peripheral blood smear and schistocytes, U and E shows raised creatinine and electrolyte abnormalities , supportive

Question 208

Fever, chills , Diarrhoae , Africa, mosquitos , no prophylaxis, 38 degress and mild jaundice whats the treatment

Answer 208

Oral hydroxychloroquine

Question 209

How do you diagnose malaria:

Answer 209

Giemsa, thin and thick blood films Mild - oral hydrozyquinie Sevre is IV artesunate and priaquine - notify PHE h SLE is also treated with anti malarials

Question 210

What does IDA show on film

Answer 210

Microcytic hypochromic RBC ( anisocytosis and poikilocytosis ) Also TAILS Signs: Koilonychia, angular stomatitis, atrophic glossitis , pallor

Question 211

A 70-year-old male complains of pain in his upper abdomen, with fever, night sweats and weight loss. Examination reveals enlargement of his liver and spleen. A full blood count shows raised basophils, eosinophils and neutrophils. Which of the following would most likely be implicated in this scenario?

Answer 211

Philadelphia chromosome is in 95% of patients with chronic myeloid leukaemia ( CML ) translocation between the long arm of 9:22 resulting in an ABL proto-oncogene ese from chromasone 9 being fused with BCR gene from chromosome 22 - the resulting BCR-ABL codes for a protien with tyrosine kinase activity ``` 50-70 anaemia an dlethargy weight loss and sweating splenomegaly granulocytes increase ```

Question 212

Q.2 A 24-year-old woman with known sickle cell disease presents with sudden onset severe right leg pain and 6 days of fever. She has noticed that her right leg is slightly swollen, and she is unable to weight bear on the affected leg. Which of the following would most likely cause her symptoms?

Answer 212

Osteomyelitis is usually S.Aureus but in sickle cell its salmonella Diffrentials are capilalry infarction secondary to intravascular sickling

Question 213

Q.3 A 68-year-old male presents with exertional fatigue. He is otherwise well with no significant past medical history, and he is not on any medications. His blood results highlight the following abnormal readings:

Answer 213

Multiple myeloma: Bence jones protiens cause RBC to aggregate - rouloux C R A B lethargy, infection, hypercalcaemia, renal failure, carpal tunnel, neuropathy, hyperviscocity Monocolonal invesyogations, bence jones, rain drop skull which is different from primary hyperpaprathyrodism pepper pot

Question 214

Where are smudge cells seen?

Answer 214

Chronic lymphocytic Chronic lymphocytic leukaemia (CLL) is caused by a monoclonal proliferation of well-differentiated lymphocytes which are almost always B-cells (99%). It is the most common form of leukaemia seen in adults. Features often none: may be picked up by an incidental finding of lymphocytosis constitutional: anorexia, weight loss bleeding, infections lymphadenopathy more marked than chronic myeloid leukaemia Investigations full blood count: lymphocytosis, anaemia blood film: smudge cells (also known as smear cells) immunophenotyping is the key investigation (confirms CLL)

Question 215

A 58-year-old man presents to his GP with increasing tiredness, accompanied by bruising on his legs. He also complains of aching bones. He has no previous illnesses. On examination, he is pyrexial and pale, has bony tenderness over the sternum and tibia, and has petechiae on his legs. A bone marrow biopsy was taken and stained, showing the following: Auer rods

Answer 215

AML cute myeloid leukaemia is the more common form of acute leukaemia in adults. It may occur as a primary disease or following a secondary transformation of a myeloproliferative disorder. Features are largely related to bone marrow failure: anaemia: pallor, lethargy, weakness neutropenia: whilst white cell counts may be very high, functioning neutrophil levels may be low leading to frequent infections etc thrombocytopenia: bleeding splenomegaly bone pain Acute promyelocytic leukaemia M3 associated with t(15;17) fusion of PML and RAR-alpha genes presents younger than other types of AML (average = 25 years old) Auer rods (seen with myeloperoxidase stain) DIC or thrombocytopenia often at presentation good prognosis

Question 216

What does Rituximab do?

Answer 216

Binds to CD20 Rituximab is a monoclonal antibody that is used in various conditions including CLL and Non-Hodgkin’s Lymphoma. It acts by binding to the CD20 protein on the cell surface of B-cells and induces lysis. All the other answers are red herrings and are just there to confuse you.

Question 217

Q7: 68F has been admitted to the frailty unit after a fall at home. On examination she has a dislocated hip and lacerations over her body. She has a BMI of 30 and is on HRT for her post-menopausal symptoms. You consider her to have a significant risk for VTE and begin her on prophylactic treatment. What is the mechanism of action for the prescribed medication?

Answer 217

LMWH Patient presents with signs of DVT and this is confirmed using a doppler ultrasound. Prophylactic treatment for DVT is using LMWHs and this is the MOA. LMWH works by binding to ATIII and inhibiting factor Xa. (indirect inhibition) Warfarin works by inhibiting the reduction of Vitamin K and thus inhibiting production of factors 10,9,7,2 (1972) DOACs such as apixaban directly inhibit X 🡪 1st line treatment This is how UH works. This is the MoA of clopidogrel, an antiplatelet. You wouldn’t use this for DVT.

Question 218

Whats in Curb 65?

Answer 218

``` Confusion Urea > 7 mmol/L Respiration rate >30 BP <90 systolic OR <60 diastolic 65 - aged over 65 years ``` 0-1 - Amoxicillin 500mg TDS (Doxycycline 200mg OD then 100mg OD, Clarithromycin 500mg BD) 1-2 - Amoxicillin 500mg TDS PLUS Clarithromycin 500mg BD 3+ - Coamoxiclav 500/125mg 3 TDS orally or 1.2 g TDS IV (levofloxacin) PLUS Clarithromycin 500mg BD

Question 219

How do you treate achalasia

Answer 219

CCB+nitrates you can do balloon diltation and BOTOX

Question 220

What are LFTs in alcohol abuse?

Answer 220

High AST, high ALT, high GGT

Question 221

Q8: A 5 year old female presents to A&E with a widespread purpuric rash and recurrent episodes of epistaxis. Parents report that she has been recently ill with Covid-19 two weeks ago. She complains of headaches and nausea while seated in the A&E department. Bloods show a markedly low platelet count. There is no FHx of bleeding disorders.

Answer 221

Immune thrombocytopenic purpura ITP is most common in ages 2-6 years old and presents with purpura and nosebleeds. It can also cause N+V, headaches, and bleeding gums. It is an autoimmune condition that can present after a viral infection and is self-limiting in nature. It is treated with prednisolone, IVIg and platelet transfusions. TTP presents similarly, however has a different pathophysiology and is more common in adults. TTP is a lack of the VWF cleaving protein and on blood film will show fragmented erythrocytes as well as raised creatinine, bilirubin and reticulocytes. SJS and bullous pemphigoid are dermatological conditions and do not present this way but are just there to confuse you. Haemophilia doesn’t usually present this way and has a massive genetic component as well as being a largely male disease.

Question 222

A 3Y old male patient with Down’s Syndrome presents to clinic with a two week history of shortness of breath and fatigue. On examination you find hepatosplenomegaly, lymphadenopathy and drooping of the right side of his face.

Answer 222

Acute lymphoblastic leukaemia ALL is more common in children aged 2-4 years and has an association with Down’s syndrome. ALL affects the lymphoblasts and therefore presents with symptoms of anaemia, thrombocytopenia and neutropenia. AML presents similarly but is much more common in adults and therefore is unlikely to be the answer in this situation. CML also affects adults and presents with B-symptoms such as weight loss, fatigue, night sweats and bone pain. Hodgkin’s lymphoma has a bi-modal incidence and affects young adults and the elderly and characteristically in exam questions has the patient experiencing pain when drinking alcohol. Kawasaki’s disease is a vasculitis and doesn’t present this way.

Question 223

What do you know about hodgkins?

Answer 223

Hodgkin’s Lymphoma classically presents with the presence of Reed-Sternberg cells. It is also seen with B-symptoms and non-tender rubbery lymph nodes. ABVD is the mnemonic to remember for the chemotherapy drugs that are used to treat Hodgkin’s. A- Adriamycin B- Bleomycin V- Vinblastine D- Dacarbazine

Question 224

A 31 year old obese patient came into A and E complaining of a painful, swollen leg. She has a past medical history of breast cancer (undergoing treatment), antiphospholipid syndrome, and varicose veins. Her current medications include her chemotherapy regimen, vitamin D and an IUD (intrauterine device). The results of her investigations are as follows: D dimer test (positive), Proximal leg vein ultrasound (Confirms DVT). Which of the following is not a risk factor for her DVT:

Answer 224

Contraceptive device ``` Risk factors for DVT: Obesity Recent surgery Long haul flights Active cancer/chemotherapy Immobilization Dehydration Oral contraceptive Hypercoagulability (i.e. Antiphospholipid syndrome) Previous DVT/PE Varicose veins Pregnancy Major trauma ``` D dimer is sensiitve ( true negatives ) not specific ( true positives ) DOACS LMWEH

Question 225

A 62-year-old man has poorly controlled type 2 diabetes. His GP started him on gliclazide treatment in addition to metformin with the aim of improving his glycaemic control. However he presents to the local emergency department 3 days later after feeling tired and very SOB. When asked about any allergies, he remembered when a doctor told him to not take primaquine due to an inherited disease - but he doesn’t remember its name. On examination he appears visibly jaundiced. A blood film reveals the presence of Heinz bodies and bite cells. What investigation would confirm the diagnosis?

Answer 225

G6PD enzyme assay Glucose 6 phosphate dehydrogenase deficiency is a X linked inherited condition which predisposes a patient to haemolytic anaemia due to oxidative stress. The crises in this case was aggravated by gliclazide Jaundice, pallor, SOB, anaemia, dark urine, nausea, splenomegaly

Question 226

A 44 year old man comes into A and E with significant bruising, epistaxis, fever and gingival bleeding. He ends up being diagnosed with DIC. FBC analysis reveals low fibrinogen levels, what blood product can be used to treat this?

Answer 226

Cryoprecipitate PCC usually given for the reversal of warfarin during bleeds, head trauma or prior to surgery FFP can be used to treat clotting abnormalities (PT or APTT elevated) Packed red cells for chronic anaemia Beriplex is a type of PCC. (Note vitamin K can also be given to reverse warfarin) Cryoprecipitate is the correct answer. It is rich in fibrinogen

Question 227

70 Y/O male patient with an advanced, high-grade liver cancer is undergoing an intense chemotherapy regimen. The patient has a past history of CKD and alcohol dependence. Which of the following drugs should be prescribed to the patient during their cancer treatment?

Answer 227

Allopurinol - xanthine oxidase inhibtors

Question 228

What is used in acute alcohol withdrawel?

Answer 228

Chlordiazepoxide is a benzodiazepine used in acute management of alcohol withdrawal. Not suitable here as even though we are told the patient has a PMH of alcohol dependence, we are not told he is currently experiencing alcohol withdrawal

Question 229

A 87 year old patient comes into clinic complaining of lethargy, SOB, weight loss, and left upper quadrant discomfort. On examination, sub conjunctival pallor and splenomegaly are noted. The patient has a number of investigations and is, subsequently, diagnosed with philadelphia chromosome chronic myeloid leukemia. What is the first line management?

Answer 229

Imatinib - tyrosine kinase inhibtor hydroxyurea can be used but is not first line

Question 230

A 33 y/o lady presents with headache, fever, and diarrhoea. She mentions she recently returned from a month-long trip to Djibouti. You order a thick and thin blood film and subsequently diagnose her with malaria. You prescribe her chloroquine as well as primaquine. Which species of malaria require treatment with primaquine (as well as the normal treatment)?

Answer 230

plasmodium vivax and ovale

Question 231

A 17 year old presents to your gp clinic with fatigue, pallor and dyspnea upon exertion.Upon further history, you find that she is a vegetarian and has had heavy periods . Her vital signs are all normal. a ) Name 3 causes of microcytic anaemia [2] b) Name 3 causes of macrocytic anaemia

Answer 231

Microcytic : Thalassemia, IDA, lead deficiency, sideroblastic Macrocytic: B12 and folate deficiency, alcohol use, reticulocytotics

Question 232

give some signs and symptoyms of anaemia

Answer 232

``` Pallor Beefy red tongue ( b12 deficiency) angular cheilitis(b12) Hyperdynamic circulation if sevre Jaundice (haemolytic anaemia) ``` ``` Fatigue Dyspnoea Faintness Palpitations Headaches Tinnitus ```

Question 233

What differentiates megoblastic and normoblastic on film?

Answer 233

Hypersegmented neutrophils and megoblasts

Question 234

A 5 year-old boy from India presents to your GP practice, his mother complains that he is constantly tired, failing to grow and has gradually been developing a large tummy. On examination, you note chipmunk facies, pallor, hepatosplenomegaly, and jaundice. The mother also states that they have a family history of dysfunctional RBC

Answer 234

Thalassemia Alpha is far east beta is mediterranian, asia, africa ``` FBC: microcytic anaemoa, WBC, platlets Peripheral smear 0 microcytic hypochromic Skull X ray : hair on end Genetic testing Gel elctrophoresis is gold ``` Minor treat: non Intermediate: not transfusion dependent Major: transfusion dependent and chelation to prevent iron overload

Question 235

A 77 y/o male patient presents to A&E with with severe rectal bleeding and vomiting blood. You notice on the drug charts that the patient usually takes warfarin due to recurrent clots in the past. The patient mentions that he recently got back from a 7-day bender in Ibiza and had forgot to take his warfarin during that time. When he got back, he decided to take a weeks worth of tablets to make up for the ones he missed. What would you prescribe to this patient to reverse the effects of warfarin? (Give 2 examples)

Answer 235

Vitamin K or Beriplex Warfarin inhibits hepatic production of vitamin K-dependent coagulation factors and cofactors. Vitamin K must be in its reduced form for synthesis of coagulation factors. It is then oxidised during the synthetic process. An enzyme called vitamin K epoxide reductase reactivates oxidised vitamin K. Warfarin inhibits vitamin K epoxide reductase which prevents reactivation of vitamin K and coagulation factor synthesis.

Question 236

A 58 y/o presents to clinic with fatigue, pallor, and headache. He mentions that his symptoms began a few weeks after undergoing an ileocecal resection to remove a tumour. A blood count and film is carried out and the patient is subsequently diagnosed with pernicious anaemia. Name 5 other signs and/or symptoms of pernicious anaemia:

Answer 236

``` Parasthesia Pallor Fatigue Headache Numbness Peripheral neuropathy Pallor dyspnoea. anorexia, tachycardia, lemon yellow skin , red sore tongue ( glossitis ) angular stomatitis, loss of proprioception, weakness and ataxia ```

Question 237

A 26 year old male presents with haemoptysis, a strong cough, wheeze, chronic nosebleeds and a saddle-nose deformity. A urine dipstick reveals haematuria and proteinuria. Blood test reveals cANCA positive.

Answer 237

Granulomatosis with polyangitis cANCA positive Hearing loss, sinusitis, nose bleeds Saddle shaped nose due to perforated septum Treated with steroids and immunosuppressants

Question 238

2. Mary is a 62y/o lady presenting with dry eyes. She has a PMH of SLE, for which she takes hydroxychloroquine. Mary tells you she has also been more tired than normal lately, and when you ask about her diet she tells you she drinks a lot of water as her mouth gets very dry.

Answer 238

Sjorgens syndrome Secondary as she already has SLE Bloods - anti ro and anti la , ANA,RF , CRP, ESR, FBC Schrimers eye test and the and rose benagl staining Lymphocyte mediated autoimmune disease characterised by destruction of the minor glands, lacrimal glands and joints Symptomatic ce..g eye drops, vaginal lubricants, muscarinic agonists triad of Xerostomia, Xerophthalmia and inflammatory arthritis can lead to NHL an itchiness and dryness in vagina, dysphagia, gastritis MALToma, Pericarditis, CVS

Question 239

What are the complications of SLE?

Answer 239

``` Key features: Photosensitive malar rash - butterfly rash that gets worse with sunlight Arthralgia Myalgia 85% positive for ANA 70% anti-dsDNA positive Cardiovascular disease Infection Anaemia of chronic disease Pericarditis Pleuritis Interstitial lung disease Lupus nephritis Neuropsychiatric SLE Reccurent miscarriage Venous thromboembolism ```

Question 240

An 18 year old male presents to his GP with progressive back pain and stiffness. You decide to send him for a spinal x-ray to investigate which reveals a bamboo spine on the x-ray. What gene would you associate with this disease? Name 3 other findings you would expect to see on the x-ray. Give an example of an Anti-TNF drug that you would prescribe this patient.

Answer 240

Ankylosing spondylitis, HLA b27 Squaring of the vertebral bodies Subchondral sclerosis and erosions, Syndesmophytes Ossification of the ligaments, discs and joints, Fusoion of the facet , sacroiliac and costovertebral joints Etancerpt, adalimubab

Question 241

5. Margaret is a 61-year-old dear who has limped into your GP surgery looking in discomfort. She says she has pain in her left knee, which is worse when she has to walk down to the shops or walk her dog. When you ask about joint stiffness, she says they are stiff for about 25 minutes when she wakes up, and then after that it becomes the pain that limits her. It has gone on for some years but she has had enough. What is your differential diagnosis? What might you see on an X-Ray of her knee? What is the cause of these changes? (think about cartilage physiology) Other than analgesia, what management options does Margaret have?

Answer 241

1, Osteoarthritis 2. Loss of joint space, osteophytes, subchondral sclerosis and subchondral cysts 3. Loss of bone cartilage , weaker - bone on bone surface erosion ) imbalance between cartilage being worn down and chondrocytes repairing it - structural joint issues 4. NSAIDS, sodium hyaluronate injections Intraarticular steroid infection and joint replacement

Question 242

What are S+S of osteoarthritis?

Answer 242

Assymetrical monoarticular arthirits, joint pain, decreased function, stiffness less then 30 minutes, increased with activity

Question 243

What are risk factors of osteoarthritis?

Answer 243

Age, Sex, obesity, joint injurie, stress, genetics, bone deformities, diabetes, hemochromatosis

Question 244

6. A 66 year old patient presents to the GP with bone pain. They have recently had a few fractures which resulted in them going to A+E. You also notice that when they walk in there is some bone deformity in their left leg. You send them for some testing. How would the skull in this patient appear on x-ray? Which LFT would you expect to be raised? What type of drug would you use to treat this patient?

Answer 244

Pagets disease of the bone Cotton wool appearnce due to patches of osteoblast and osteoclast activity- patches of increased and decreased density ALP Bisphosphonates

Question 245

What hand things do you see in RA v.s. Osteoarthirtis?

Answer 245

Osteoarthritis: Boutinerres, swan neck, ulnar deviation and z thumb, nodules Bouchards and heberdens

Question 246

What are some extra-articular manifestations of RA?

Answer 246

Episcleritis, Pericarditis, raynauds, peripheral neuritis, anaemia, raynauds

Question 247

How do you manage RA?

Answer 247

DMARDS: Methotrexate, leflunomide, sulfasalzaine 2 of the above 3: Add in a biologic e..g TNF alpha infliximab, adalinumab, etancaerot 4: Methotrecate and rituximab

Question 248

What are some RA complications?

Answer 248

Feltys syndrome: RA + Splenomegaly+ neutropenia Anaemia of chronic disease Pulmonary fibrosis Amyloidosis

Question 249

What are some diffrential diagnosis of joint pain and stiffness?

Answer 249

``` Osteoarthritis - degenerative arthritis Polymyalgia Rheumatica: Inflmmatoru disorder causing pain, stiffness inflammation in the shoulders, neck muscle nad hips Gout Septic RA ```

Question 250

8. Taylor presents to their GP complaining of muscle pain, fatigue and weakness in both hands and forearms, and their shoulders over the last few weeks. On examination you find Gottron lesions on their knuckles and elbows, a photosensitive rash on their face and some subcutaneous calcinosis. You conduct a blood test and their results show positive for ANA, a creatinine kinase of 1200 U/L, and Anti-Jo-1 antibodies. What is the differential for this patient?

Answer 250

Dermatomyositis Dermatomyositis = chronic inflammation of the skin and muscles Polymyositis = chronic inflammation of the muscles (only) ``` Creatinine Kinase: normally under 300 Also raised: Rhabdomyolysis AKI MI Statins Strenuous exercise ``` ``` Muscle pain, fatigue, weakness Occurs bilaterally Typically affects proximal muscles Shoulder and pelvic girdle Develops over weeks ``` If there is no skin involvement = polymyositis If there is skin involvement = dermatomyositis

Question 251

What are some skin symptoms and antibodiees in dermatomyositis?

Answer 251

``` Skin symptoms: Gottron lesions (erythematous plaques) Photosensitive erythematous rash on back, shoulders and neck Purple rash on face and eyelids Periorbital oedema Subcutaneous calcinosis ``` Antibodies: Anti-Jo-1: poly+derm Anti-Mi-2: derm ANA: derm

Question 252

9a. Vitamin D metabolism is important for the absorption of calcium and phosphate from the intestine, therefore important for bone mineralisation. Which of the following substances is not involved in bone metabolism? ``` Parathyroid Hormone 1-alpha-hydroxylase Antiphospholipid antibody Oestrogen Calcitonin ```

Answer 252

Antiphospholipid antibody - thrombosis and miscarriages Oestrogen regulates bone metabolsism and inhibits remodelling protective against osteoporosis! Calcitonin lowers blood calcium

Question 253

9b. Vitamin D metabolism is important for the absorption of calcium and phosphate from the intestine, therefore important for bone mineralisation. i. What condition might cause an adult to have brittle bones due to insufficient vitamin D? ii. What condition occurs in a child? iii. Why do you not get this condition in adulthood? 9c. i. What does a T-Score of -2 mean? ii. What is the first-line treatment for osteoporosis?

Answer 253

Osteomalacia Rickets Epiphyseal plates fused already Osteopenia Bisphosphonates Osteomalacia & Ricketts Osteomalacia is a disease of defective bone mineralisation, due to Vitamin D deficiency. Presentation: fatigue, bone pain, bone and muscle weakness, and pathological / abnormal fractures. Investigation: serum 25-hydroxyvitamin D low, serum calcium & phosphate low, serum ALP high, PTH high, z-ray may show osteopenia, DEXA may show low bone mineral density Management: vitamin D supplementation (colecalciferol)

Question 254

Give three bisphosphonates?

Answer 254

Alendronate, risendronate and zolendronic acid

Question 255

How does the T score work?

Answer 255

More then -1 is normal -1 to 2.5 is osteopenia -2 to -2.5 osteoporosis Add a fracture and its sevre

Question 256

10. Susan is a 55 year old female who has presented to you with a severe unilateral headache in her forehead. She has also had some blurred vision and tenderness of the scalp. Her blood test results in an ESR of 73.

Answer 256

Do a temporal artery biopsy if it shows multinucleated giant cells - GCA Raised ESR Give 40-60mg pred

Question 257

1. Which of the following is not a true regarding gout? Negatively birefringent on polarised light microscopy Monosodium urate crystals Allopurinol is first-line treatment during acute flare Tophi may deposit within the ear Needle-shaped crystals

Answer 257

Allopurinol is not first line in an acute flare ! - colchine + NSAIDS are is

Question 258

Where does pseudogout usually present?

Answer 258

Knee - chondrocalcinosis is pathognmonic

Question 259

Sharon is a 54 year old female who presents to your GP practice with a main complaint of chronic widespread pain and tenderness. She complains that her muscles feel stiff in the morning. She also has had difficulty sleeping, and therefore is tired and has low mood and concentration. You determine that the pain is musculoskeletal, not arthritic. What is your diagnosis?

Answer 259

Fibromyalgia - risk factors are psychosocial Fibromyalgia = Disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues Poor diet can increase fibromyalgia pain, but isn’t a risk factor. Repeated nerve stimulation results in the sensitization of the brain’s pain receptors, causing them to overreact to stimuli Severe pain in 3-6 different areas, or milder pain in ≥7

Question 260

What are some risk factors for fibromyalgia

Answer 260

``` Neurosis: depression, anxiety, stress Dissatisfaction at work Overprotective family or lack of support Middle age Low income Divorced Low educational status ```

Question 261

13. Colin is a 78-year-old man who has a long history of osteoarthritis. He underwent a knee replacement 3 days ago, and now has an acutely swollen knee that is hot to the touch, stiff, and he can’t move it due to severe pain. He has a fever of 38.1 and is lethargic.

Answer 261

Septic arthirits- S.aureus joint aspiration and culture Flucloxacillin + rifampcin

Question 262

Jules is a 14 year old who has presented to you with a complaint of bone pain with swelling around their knee. The swelling hasn’t gone down despite ibuprofen use over the last week. Jules has a PMHx of hereditary retinoblastoma. Based on their symptoms and PMHx:

Answer 262

Osteosarcoma X ray. MRI , biopsy Surgery

Question 263

Mary is a 37 y.o lady presenting to her GP with a 2-week history of difficulties swallowing. She has no problem drinking but solid food tends to get stucked somewhere around her sternum. There is no pain on swallowing and she has not regurgitated food back out. She denies any weight loss, fever or recent trauma. Past medical history of GORD. Her mum had a disease which she could not recall but affected her skin badly. O/E: Patches of shiny skin bilaterally on her arms up to her shoulder. Limited ROM of fingers. White discoloration over her knuckles Based on the most likely diagnosis, which would be most useful for diagnosis of the pathology? (+++)

Answer 263

Serum nucleur antigens - Limited - anticentromere Diffuse - Antitopoisomeras, Anti scl70 and anti RNA polymerase 3

Question 264

Chimdi is a 1 year-old boy who had recently moved from Nigeria to the United Kingdom. During his 1st week here, he started having fever and felt generally unwell. When you examined him, he was tender to touch over his left hip. His vitals are temp: 38, RR: 40, 120bpm, 95 O2%. Later, you had found out from his parents that he had sickle cell disease. Further investigations were ordered and it was confirmed that Chimdi had osteomyelitis of his left hip and was given antibiotics for it. Based on the history above, what is the most likely causative organism? (++)

Answer 264

Salmonella

Question 265

Malcolm is a 25 y.o gentleman presenting to his GP with pain in his lower back for 3 months. He also gets stiffness in the back in the morning, however that improves with exercise. He has a family history of arthritis. He has Crohn’s for which is well controlled with medications. His obs are normal. On examination, he has redness in both eyes. Based on the above, what is the most likely diagnosis? (+)

Answer 265

Ankylosing spondylitis Psoriatic : psoriasis, nail pitting and sausage RA: females Reactive: Cant see, cant pee cant climb, recent infection Osteoarthritis : Worse with ifnection

Question 266

What are some key signs of seronegative spondyloarthropathy?

Answer 266

``` Sausage digits Psoriasis Inflammatory back pain NSAIDS Enthesitis ( heel ) Arthritis crohns and colitis / elevated CRP but can be normal HLA - B27 Uveitis ```

Question 267

``` A 82 y.o gentleman presents to the GP with a 2 month history of back pain. The pain is localised and does not radiate at all. He has also been feeling very tired recently and you notice that he seem to look really pale. Over the past 2 months, Jim been constantly getting pneumonia. Jim used to work in the petrol industry. His obs are normal. His relevant blood results are: Hb: 97 (110-130) Creatinine: 260 (<176) Urea: 49 (<30) CRP 63 (<40) Based on the history, which is the best investigation to confirm the diagnosis. (++) ```

Answer 267

Multiple myeloma: CRAB and serum electrophoresis ( IGG A or light protien chains _ Clonal bone marrow greater than 10% + CRAB + serum electrophoresis, prognostic is CRP an dLDH

Question 268

Malcolm has a red hot swollen joint. He also has a fever and is systemically unwell. His blood pressure is low. How would you manage this patient? (2) Name 3 risk factors for septic arthritis? (1) Malcolm is sexually active, what is the most likely causative organism for his septic joint? (1)

Answer 268

Sepsis 6 and joint fluid aspiration Immunosuppresents diabtes , HIV old age, IVDU Neisseria gonorrhoea

Question 269

63 y.o. Patient comes in with left sided knee pain. She says she’s had it for a few months now and hurts whenever she tries to move it. She also thinks she’s been having hearing difficulties on her right ear as of late. She is given a bone isotope test thats shows areas of abnormal bone turnover with decreased osteoclast action. The main areas found affected were the right side of skull and left knee. What is the most likely diagnosis: What is the first line treatment for her:

Answer 269

Pagets Zolendronate

Question 270

John 42 y.o. Man comes to clinic with freaking out as he is afraid that he has lung cancer. He screams that he has recently had a cough and has been coughing out blood. He says he has hd weight loss recently too. His father had lung cancer while his mother had an autoimmune disease that he can’t remember the name of. He says recently he has been peeing less and the color is usually very dark reddish brown but he just thought it was because he had been drinking too much alcohol. When investigated, his blood showed that he was positive for Anti glomerular basement membrane antibodies. Urine dipstick showed: Blood +++ Protein + Nitrites What is the most likely cause of his symptoms:

Answer 270

GOODPASTURES - affects lungs and glomerulus - anti GBM

Question 271

Mary 33 y.o. Woman comes into clinic complaining of pain and swelling of joints all over. Her fingers, wrist and knees hurt the most on both sides. She says that the pain and stiffness is worse in the morning but thankfully gets better as the day goes by. What is the best biochemical blood marker to test for to diagnose her: Name two clinical features/ deformities commonly found on the arms/hands of patients: Name one sign of this illness seen on xrays: What is the one joint never affected by this illness: What marker is used to monitor progression of this illness:

Answer 271

``` Anti - CCP ulnar deviation, boutonnieres, swan , X Loss of joint space, soft tissue swelling, bony erosions DIPJ CRP ```

Question 272

Mary is 34 y.o. Woman who has been trying to conceive for the last 10 years. However she is always unsuccessful as the last four times she was pregnant, she ended up having a miscarriage. She and her partner have had fertility consultation. Her ovaries, fallopian tube and uterus were all normal and she has no history of STD. His sperm count was also normal. When further questioned, Mary rememebered that her mom did also tend to have miscarriages a lot and so the doctor believes this could be autoimmune caused. What is the most likely diagnosis?

Answer 272

Antiphospholipid syndrome - stops the egg implanting and inhibts grow of foetal cells also thrombosis

Question 273

Patient has been diagnosed with systemic lupus erythematosus (SLE). List one risk factor for this illness: List two clinical manifestations of this illness: What are two gold standard biochemical marker used to diagnose this illness: Describe the ESR and CRP changes caused by this illness: What is the first line management for this illness:

Answer 273

FH, idiopathic, Epstien barr, hydralazine, isoniazid Malar rash , symmetrical small joint arthralgia, renal glomerulonephritis, lungs pleural effusion, heart pericarditis , cns seizures and psychosis anti dsDNA - specific anti ANA - sensitive low speecific Normal CRP high ESR Oral corticosteroids ( pred ) and high dose corticosteorids ( methylpred)

Question 274

Risks for gout?

Answer 274

Thiazides, s, stopping an d starting allopurinonal surgeyr, trauma, red meats and seafood, alcohol ( beer), dehydration

Question 275

What do you see in X rays for osteoarthritis ?

Answer 275

Loss of joint space Osteophytes Subchodnral sclerois Subchondral cysts

Question 276

What do you see in RE?

Answer 276

Loss of joint space Erosions of bone Soft bones - osteopenia Soft tissue swelling

Question 277

What are risk factors for back pain and management?

Answer 277

``` Trauma and thoracic pain Unexplained weight loss Neurological findings/ nocturnal pain Age over 55 or under 25 Fever Immunocomporsed Steroid History of cancer or TB ``` E.g. mets causing spinal cord compression Nsaids are 1 codeine second exercsie and physio thirst

Question 278

What do you prescribe for osteoporosis?

Answer 278

Bisphosphonates ( flu like symptoms, hypocalcamiea ) and V.D and calcium

Question 279

8 year old boy has waddling gait, underweight malnourshied, wrist bony swellings,

Answer 279

Rickets - excessive non mineralised osteoid

Question 280

What is black water fever ?

Answer 280

A rare complication of anaemia where RBC haemolysis leads to dark urine

Question 281

What chromosomal abnormality is associated with multiple myeloma?

Answer 281

t11:14

Question 282

9. You see a 50-year-old male in A&E who has presented with breathlessness, bone pain and a severe infection. His temperature is 39.1, his heart rate is 110 and his blood pressure is 130/85. He tells you this is the 3rd severe infection he has had in 6 months and thinks they are causing him to lose weight. On examination, you note hepatosplenomegaly and see some gum hypertrophy. a) What is the most likely diagnosis for this man? (1 mark) b) What would you expect to see on a bone marrow biopsy? (1 mark) c) What 2 things are associated with this cancer? (2 marks) d) Give 3 treatments this man is likely to receive (3 marks)

Answer 282

AML Auer rods Downs syndrome and radiatoin treat: Transfuse, allopurinal, IV antibiocts, chemotherpay, steroidfs, transplant

Question 283

10. You are a medical student on placement where you see a patient with diagnosed chronic lymphoblastic leukaemia. You have the opportunity to speak with him and examine him. a) What age would you expect this man to be? (1 mark) b) What would you expect to find on examination? (2 marks) c) What would you expect to see on a blood film? (1 mark) d) What treatment would this man be receiving? (2 marks) e) What is a complication of CLL that you should be aware of? (1 mark)

Answer 283

Over 60 Lymphadenopathy, - enlarged rubbery non tender, sweating, anorexia splenomehaly Smudge cells Rituximab, and bruton kinase inhibtors e.g. ibrutinib chemotherpay, allopurinaol Richters transformatoin to aggressive lymphoma

Question 284

11. You see a 17-year-old male with fever and night sweats. He admits to sometimes drinking with his friends and tells you that over the last 2 months he gets painful lumps in his neck and armpits when he drinks. He has no significant family history, does not smoke or take any recreational drugs. a) What investigations would you want to order before making a diagnosis and what signs would you expect to see reported in the results? (6 marks) b) What is the most likely diagnosis for this patient? (1 mark) c) What would you be the treatment plan for this patient? (3 marks)

Answer 284

FBC: Anaemia, thrombocytopenia high ESR CXR- wide mediastinum Blood film : Reed sternberg cells !! Hodkins Chemotherpay ABVD Marrow transplant

Question 285

. A 35-year-old male presents with increased urinary frequency, pain on urination and mild back pain. He is pyrexic, tachycardic and tachypnoeic. You send a urine sample which returns positive for a UTI. You explain the diagnosis to the man, and tell him that he will need antibiotics to get rid of the infection. At this point, he tells you that he has G6PD deficiency. a) What is the function of G6PD? (2 marks) b) What are 3 of the common symptoms of G6PD deficiency? (3 marks) c) What would you see on a blood film for this man? (2 marks) d) What antibiotic is now contraindicated for his UTI? (1 mark)

Answer 285

Protects RBC against oxidative stress Fatigue, SOB< pallor and palpatations Bite cells and reticulocytes Cant give nitrofurantoin

Question 286

An 80-year-old man recently had a fall which resulted in a fracture neck of femur. He successfully underwent a total hip replacement and is currently being warded in the NGH. During the ward rounds, being a good F1 doctor, you assess and examine him. It is noted that he has a swell in his left calf only. It appears slightly pale and it is painful when you squeeze it. a) What is the most likely diagnosis? (1 mark) b) Pain and pallor are 2 out of the 6 symptoms for acute limb ischaemia. What are the 4 other symptoms? (4 marks) (HINT 6 P’s) c) Name 1 possible complication. (1 mark) d) What is the first line investigation? (1 mark) e) What is the name of the Scoring system used in making a diagnosis? (1 mark) f) List 4 factors in the scoring system. (4 marks

Answer 286

DVT Pulselessness, pallor, paresthesia , , paralysis, pershingly cold PE D- Dimer if positive do a gold standard US ``` Wells score - Clinical features - HR -Immobilization -Previous PE or DVT Hemoptysis Malignancy over 4 likley ```

Question 287

You took some bloods as part of SEPSIS 6, and the results are shown below. • Platelet Count: Low • Prothrombin Time: Elevated • APTT: Elevated • Bleeding Time: Elevated • Fibrin Degradation Products: High D-Dimer: Elevated • Fibrinogen levels: Low Coagulation Factor Levels: Low a) What haematological condition does this patient have? (1 mark) b) Explain its pathophysiology (3 marks) c) What does a sepsis 6 involve? (6 marks) (HINT – Give 3, take 3) d) Which antibiotic is to be prescribed for the complicated UTI caused by E. coli? (1 mark)

Answer 287

Disseminated intravascular coagulation Platlets are acitvated leading to microthrombi NO Tissue damage causes the release and and activation of tissue factor this leads to widespread clot formation and platlet consumption and coagulation factors - increased plasminogen leads to more fibronlysis clotting and breathing Tissue factor release coagulation - intrisnic and extrinsicn thrombosis which are fibrinolysed causing bleeding Give flood, antibiocts, oxygeb, take urine output , cultures and LDH Trimethoprim or NFT

Question 288

What do you see JAK -2 mutation in?

Answer 288

Polycythaemia ruby vera | Acute dehydartion, obesity, HTN . alcohol

Question 289

. Psoriasis is a systemic, immune-mediated, inflammatory skin disease that can be associated with arthritis (psoriatic arthritis). Name 2 ‘hidden’ places where psoriasis can be found on the body. (2 marks)

Answer 289

Behind the ear, inside the ear, nails, onokylysis, scalp, umbilicus, genitals, soles of the feet

Question 290

A patient presents to A&E with a hot, swollen, tender, and restricted knee joint and a high fever. They are diagnosed with septic arthritis and their knee joint is urgently aspirated List 5 risk factors for septic arthritis. (5 marks)

Answer 290

``` Over 80 Pre existing RA DM Immunosuppresion Joint surgery Prosthetic joiny Recent intraarticualr injections Trauma ```

Question 291

A 73-year-old lady with previously diagnosed cancer starts to experience unremitting bone pain, which has begun to wake her up at night. CT scans reveal bone metastases in her spine, rib, and pelvis. What primary cancer might this patient have? Suggest two. (2 marks)

Answer 291

``` Breast Lung Kidney Thyroid Prostate ```

Question 292

SLE: Multisystem inflammator disorder name two autoantibodeis

Answer 292

ANA and antidsDNA and antismith

Question 293

Stat drug classes for osteoporsis ?

Answer 293

Bisphosphonates e.g. alendronic acid, zolendronate taken once a week on an empty stomach must be taken standing up for hald na hour

Question 294

Where do heberdens and bouchards occur?

Answer 294

Heberdens at the distal interphalnageal joint | Bouchards at the proximal interphalangeal joint

Question 295

What’s a volvulus

Answer 295

Torsion of the colon on its mesenteric axis which contains vasculature , lymphatics and nervous supply to the bowel Results in comprised blood flow and closed loop obstruction Coffee bean sign Significant sigmoidoscopy and rectal tube Colicky pain, Abdomianl pain and absolute constipation

Question 296

What’s the portal triad?

Answer 296

Hepatic artery, portal vein and bile duct

Question 297

What’s the functional unit of the liver?

Answer 297

Sinusoid - Kupffer and stellate cells ( scarring )

Question 298

Hep B serology

Answer 298

HBsAg : Found in acute infection prescience of 6 months implies chornic HbeAG: Found in acute infection persistence implies viral active replication and can be used to distinguish between active and inactive chronic infections HBV- DNA: Implies viral replication in acute and chronic Anti HBS: Immunity through immunisation or cleared infection Anti HBC - previous or current infection Anti IgM: Infection within 6 months IgG : Long term Anti HbE; Seroconversion for life

Question 299

Where do you see lead pipe?

Answer 299

UC - pseudopolyps | C

Question 300

Digestion and lipid absorption?

Answer 300

Orlistat is a lipase inhibitor | Small novel disease - bile salt malabsorption

Question 301

Itchy skin, dark urine , pale stool?

Answer 301

Cholangiocarcinoma of the pancreatic head Pre hepatic is haemolysis e.g. malaria or H.anaemia or sepsis, red cell breakdown produces biliribun faster then the liver can take to up but its unconjugated - normal urine Hepatic: Gilberts, viral hep, paracetomal - dark urine Post hepatic: Obstruction e.g. gallstones , cholangiocarcinoma etc Dark urine and pale stool

Question 302

52 year old female abdo pain and vomiting gallstones and asthma, icteric sclera and tender in RUQ>

Answer 302

Ascending cholangitis - bile synthesised in liver and stored in the gall bladder Gallstones: Cholesterol or pigment stones in gallbladder Biliary colic: temporary obstruction of the cystic duct: intermittent epigastric /RUQ pain after pain Acute cholecystitis: Obstruction of the gallbladder - inflammation - persistent pain and murphys sign ( can have an a calculus cholecystitis) Ascending cholangitis: Infection of the biliary tract - gallstones, ERCP. Cholangiocarcinoma : Charcots triad of jaundice , fever, pain and RUQ Acute pancreatitis: GET SMASHED , sever epigastric pain, vomiting, low grade fever, cullens and grey turners sign

Question 303

Severe generalised abdomianl pain, N and V, irregularly irregular pulse, ABG shows lactate and acidosis

Answer 303

Acute mesenteric ischaemia Causes by thrombus , embolism , non occlusive ( Shock0, venous or artieral embolism CT with contrast Coeliac Trunk SMA- midgut ( halfway duodenum to 2/3 across transverse colon ) - ileocolic, right colic , midcolic, IMA: to superior 1/3 of rectum - left colic, marginal artery , sigmoid , superior rectal and mid ad inferior are from internal iliac !

Question 304

What do you find on coeliac disease?

Answer 304

Biopsy: Crypt hyperplasia Villus atrophy Increased intraepithelial lymphocytes Lamina propria lymphocyte infiltration

Question 305

DIverticulitis

Answer 305

Risks: Diverticular disease , smoking , obese Sigmoid colon usually and sometimes ascending ``` Signs: Abdo pain N and V Fever Change in bowel habit Blood is rare ``` CT ABx+ Fluids + analgesics Surgery !

Question 306

Upper GI bleed?

Answer 306

Varicose - vomit red blood Mallory wise -LOS Ulcer - duodenal to gastro duodenal and gastric - left gastric Haematemesis Melena Long capillary refil ``` Regular IBS,IV acces take blood - g + s and cross match, rests Blatchford Stop NSAIDS> aspirin, warfarin Arrange upper GI Endosocpy,y NBM Rockfall score post endosocpy ```

Question 307

Bile Physiology?

Answer 307

Bile primary salts is formed from cholesterol using 7 alpha hydroxylation - colic acid and chenodeoxycholic acid which are secreted to gut where they are converted to deoxycolic and lithocholic acid via bacteria conjugated by glycine and taurine - so you get 8 conjugated bile salts , CCK contracts gall bladder - 95% reabsorbed

Question 308

Which cranial nerves are involved in swallowing

Answer 308

Vagus Soft palatable blocks nasophyranic Epiglottis blocks await Red: Weigjt loss, anorexia, anaemia, rapidly progression -palpable mass Achalasia, benign stricture, malignancy, pharyngeal pouch, MG

Question 309

LFTs?

Answer 309

ALT: Liver specific ALP: Bile duct specific , raise in bone e.g. mets and pagets AST: Alcohol specific GGT: Differentiates between bone and liver Albumin PT/INR

Question 310

Portal hTN?

Answer 310

Hypersplenism - moderate anaemia, neutropenia, thrombocytopenia Marked ascites, capital Medusa OEsophegeal varicose

Question 311

B12 absorption

Answer 311

Cobalamin is water soluble- DNA synthesis, myelin synthesis and RBC synthesis Intrinsic factor is needed and produced by gastric parietal cells Most common is pernicious anaemia - gloss it’s, leatherargy and meagolobastic Macrocytic IM b12 - hypersegement neurtrophls Progressive symmetrical poly neuropathy

Question 312

Which signs are associated with acute appendicitis?

Answer 312

Rosvigs - press on LIF and you feel pain on the right Psoas - hand on thigh and push it up against resistance - flex psoas - pain Obturator - medial appendix - flex hip and knee and internally rotate - uses obturatro- pain Mcburney’s: pressing on mc Burney rebound exhibits pain Murphys: Cholecytitis Pain in umbilicus migrating Low grade fever, constipation/ diarrhoea N and V WCC+ CRP raised Pregnancy in girls - ectopic USS/CT Mitselshemrt pain When your symptoyms get better - perforated appendix !

Question 313

Which acts on parietal cells to control stomach acid secretion ?

Answer 313

Histamine - ECL ACH - PNS acts by vagus receptors and ECL cells for histamine Gastrin - g cells increases calcium and stimulates ECL Somatostatin - delta cells , inhibits histamine and gastrin Gastric acid is stimulated by gastrin, ACH, histamine and is inhibited by somatostatin CCK is released from enteroendocrine in response to fatty chyme and binds to delta cells to release somatastin and reduce acid

Question 314

Distended abdomen, vomiting, constipation and colicky abdominal pain which imaging technique would you do?

Answer 314

CT abdomen Small bowel obstruction

Question 315

What is the lateral border of the antecubital fossa?

Answer 315

Brachioradialis Blood is taken from antecubital vein ! Lateral border: Brachioradialis ( extensor ) Medial ( flexors of medial epicondyle ) e.g. pronator there’s Superior border is epicondyle line Biceps tendon is inside Brachial artery and vein Median and radial nerve Ulnar is around medial epicondyle

Question 316

What does the long thoracic nerve innervated?

Answer 316

Serratus anterior - winged scapula C5,C6,C7 Main deep: Latissamus Doris and trapezius Then deep t this: Rhomboid - retraction of scapula Roatation cuff: Supraspiantus, infraspinatus, teres minor, teres major isn’t ! Sub scapularis is the 4 Deltoid is on top

Question 317

What does the head of the radius Articular with

Answer 317

Capitulum of the humerus: Head and ridge - anatomical neck but the surgical neck is below - higher fracture chance Greater tubercle - attaches rotator cuffs Biceptial groove between greater and lesser tubuercule for the long head of the biceps Deltoid tuberosity for deltoid Posterior radial/ spiral groove for radial nerve Condyles and lateral is capitulum and the lumps are the trochleor Head of the radius articulates with capitulum Ulnar arituckakr with the trochleor - olecranon porcess articulates into olecranono fossa , head of ulnar is near the wrists Epicondyles medialandlateral

Question 318

What do you find in the popliteal fossa?

Answer 318

``` Popliteal nerve Poliptal artery Popliteal vein Tibial nerve Common perineal ( fibulae nerve ) ``` Superiomedial border - semimembranous muscle Superior lateral border - biceps femurs Infromedial border - medial head of gastrocnemius Medial lateral: Lateral head of gastrocnemius and plantar is Popliteal artery , popliteal vein, tibial nerve and common perineal nerve ( branches of sciatic) Short saphenous vein passes between heads of gastoneaemus Can get bakers cysts

Question 319

What does cutaeous innervation to the index finger?

Answer 319

Median and radial nerve Ulnar does pinkie and half of the ring finger Median does - From middle of the ring finger - anterior is median nerve and nail beds Radial does posterior part of muffle of ring finger and hand of other 3 fingers

Question 320

Hand muscles

Answer 320

Superficial: Pronator teres, Flexor carpi radialias,palmaris longus, flexor carpi ulnaris deep: flexor digitorrium profundus, flexor polllicus longus and pronator quadrate s

Question 321

Numbness over right shoulder and restricted movement, cant abduct beyond 15 degrees, loss inferior deltoid

Answer 321

Axillary: Semsory regimental badge and does teres minor and deltoid Exits at subscalaris at quandarangular space - compression risk and posterior circumflaex -lateral cutanus nerve

Question 322

What’s the medial border of the femoral triangle ?

Answer 322

Top: Inguinal ligament, lateral is sartorius Adductor longus ! Sartorius is lateral contains femoral nerve , common femoral artery, femoral vein gives of great saphinous Flood : Ileopsoa is floor NAVI

Question 323

A 31 year old female has tingling in her thumb index and middle fingers which gets worse at night, Sympotyms get worse when she holds her wrist in flexion whats been affected?

Answer 323

Median nerve - CTS Compression of the median nerve within the carpal tunnel - pain numbness and parastehsia in the lateral 3 digits Female, increasing age, pregnancy and obesity , DM, RA, hypothyroidism , repetitive movements Tinels and phalens Clinical diagnosis or nerve conduction studies Management - splint and corticosteroid injections Shake arm Carpal tunnel decompression Palm is spared

Question 324

Mid shaft humeral fracture what would present?

Answer 324

Wrist drop Surgical neck - nerve axillary gets damaged - deltoid and rotator cuff weakness of shoulder abduction Shaft: Spiral radial nerve groove - wrist drop - triceps and extensors Claw Hand: ulnar nerve - change extend Sign of benediction: median nerve Musculocutanus: Weakness of elbow flexion: Biceps brachii, brachialis and Cora o brachialis Ok sign Spread fingers

Question 325

Swelling and when knee is flexed at 90 degrees you get significant tibial excursion when force is applied in the anterior direction

Answer 325

Anterior crucial efforts ligament Patellar ligament is a continuation of the quadriceps femoris Lateral and medial collateral - Prevnts excessive medial or lateral movement Medial : Medial epicondyle of femur and medial condole of the tibia LCL: Lateral epicondyle and depression on the fibula head Cruciate ligaments connect femur and Tibia - anterior cruciate attaches at anterior intercondyle region Blends with medial meniscus and ascends posterior Ely to attach to the femur at the intercondyle fossa and prevents anterior dislocation Posterior cruciate: Posterior intercondyle to anterior medial femoral condole ( prevents posterior dislocation of the tibia onto the femur: AC injury: Twisting knee whilst weight baring no contact Rapid joint swelling , pain and instability Lachmans test and anterior draw test X ray excludes bony injuries and MRI Manages: RICE and Rehab Tendon or graft Can get bony emulsion of the lateral proximal tibia - segulds fracture MRI is gold

Question 326

A tree surgeon falls with his harm in a full abducted position above the head what would you see?

Answer 326

Claw hand Long thoracic is adherent to wall of the thorax Klumpers palsy - claw hand ulnar nerve

Question 327

Brachial Plexus?

Answer 327

Upper part : Erbs palsy e.g. traumatic birth waiters tip - pronated internally rotate cant flex elbow C5-T1 RTDCB Musculocutaneus : Biceps brachii, brachialis an coracobrachialis and skin overlying median and ulnar supply below elbow Median - most of anterior foramen and ulnar is hand but median does LOAF

Question 328

Pain in elbow after painting worse carrying heavy objects improves on rest its recreated with wrist extension and forearm supination with an extended elbow and maximal pain is never the insertion of the common extensor tendon whats caused it ?

Answer 328

Lateral Epicondylitis and medial epicondylitis Repetitive overused - microtears -fibrosis - tendinosis Pain affecting elbow radiating down forearm Examination: Local tenderness, cozens and mikes CLinical or USS and MRI Modify activity analgesia, corticosteroid injection

Question 329

Pain in right hip, leg is shortened and internally rotated which artery’s branches supply the had of the femur?

Answer 329

Femoral - Profundus femoris ! | Fetus is obtruator artery - obdurate ligament

Question 330

Breaking of femur neck?

Answer 330

High risk of avascular necrosis

Question 331

Fell on wrist and pain on movement and tender in anatomical snuff box what has je fracture?

Answer 331

Scaphoid - retrograde blood supply Blood supply Snuffbox: Radial arter, nerve and cephalic vein floor is the scaphoid X ray may need to do 2 10 days apart Immobilise MRI is most definitive

Question 332

What do you see on X ray for osteoarthritis

Answer 332

Loss of joint space Osteophytea t joint margins Subchondral cysts Subchondral sclerosis RA: Lojs, periaticualr erosions, osteopenia and soft tissue swelling