Senior Medicine Flashcards

Question

A 62 year old woman is brought to A&E after tripping and falling while getting off the Tube. She is in significant pain and cannot weight bear. AP and lateral x-rays reveal a fractured neck of femur (#NOF). She has a background of COPD for which she has been taking oral prednisolone for the past 6 months. The #NOF is fixed with a THR, and she is told to take 10mcg Vitamin D daily and is given a 24 hour ECG halter. Her analgesia and COPD medications have been prescribed. Which additional medication should be prescribed on discharge?

Answer 1

This woman should be prescribed a bisphosphonate e.g. Alendronate Bisphosphonates are usually prescribed after falls resulting in #NOF, and are particularly important in this patient as she is taking long-terms steroids which are a big cause of osteoporosis. Add to this that this woman is post-menopausal and there is no mention of HRT, and she is high risk for osteoporosis. This woman should also have a DEXA scan to quantify her probable osteoporosis. It is worth mentioning that she should probably have been prescribed a bisphosphonate when she started taking long-term steroids.

Answer 2

B. New tricuspid regurgitation with a fever of 38.5 and Janeway lesions and Osler nodes on the hands Although realistically you would strongly suspect infective endocarditis in every one of these cases, the Duke criteria are very specific in terms of what does and does not confirm it. The Duke criteria is as follows: To definitely diagnose infective endocarditis you must have either: Pathological evidence (histology showing vegetations) or Clinical evidence Clinical evidence is divided into major and minor criteria. To confirm the diagnosis you need 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. NB you need criteria from different categories e.g. Roth spots, Osler's nodes, and glomerulonephritis would only count as 1 because they are all immunological phenomena. Major criteria: 1) Evidence of microorganisms in the blood NB: if S. viridans, S. bovis, HACEK group, S. aureus, enterococci, then only two separate cultures are needed. If other organisms are detected, then either two samples >12 hours apart are needed, or all 3 or the majority of 4 samples have to be positive 2) Evidence of endocardial involvement (signs on echocardiogram or new valvular regurgitation) Minor criteria: 1) Predisposing heart condition or IVDU 2) Fever ≥ 38 3) Vascular events e.g. septic pulmonary emboli, Janeway lesions, intracranial haemorrhage 4) Immune events e.g. Roth spots, Osler's nodes, glomerulonephritis 5) Blood cultures or biochemical evidence of active infection that does not meet the major criteria 6) Echo findings indicating infective endocarditis but not sufficient to meet the major criteria NB: Infective endocarditis is considered 'possible' if there is 1 major and 1 minor criterion, or 3 minor criteria

Answer 3

Stage 1: 0-60 minutes: Resuscitate with 500ml boluses of 0.9% saline over 15 minutes each to achieve systolic >90mmHg Then give fluid replacement as standard in DKA (1L over 1 hour, another 1L with K+ over the next 2 hours, another 1L with K+ over the next 2 hours etc.) Give 50 units of fixed rate insulin made up to 50ml with 0.9% saline, at a rate of 0.1units/kg/hour Stage 2: 60 minutes to 6 hours Reassess and monitor (inc. fluid balance and obs) Hourly capillary ketone and glucose measurement Continue fluid replacement Start VTE prophylaxis if appropriate Identify cause or precipitant Add 10% glucose infusion if glucose falls below 14.0mmol/L There are further stages but this is the immediate critical summary. Once the acidosis and ketonaemia have resolved, eating and drinking should be resumed and insulin should be switched to subcutaneous. This website has the full guidelines, condensed management chart, and fluid prescribing guidelines: https://www.diabetes.org.uk/professionals/position-statements-reports/specialist-care-for-children-and-adults-and-complications/the-management-of-diabetic-ketoacidosis-in-adults

Answer 4

Shortened erythrocyte survival is a feature of CKD and may result in an artificially lowered HbA1c

Answer 5

C. His family should be given one 500mg dose of Ciprofloxacin each One element of bacterial meningitis that is often glossed over is the follow-up chemoprophylaxis of contacts. This is mainly for members of the patient's household: healthcare workers don't need prophylaxis unless there has been direct exposure of the mouth or nose to infectious droplets from a patient with meningococcal disease who has received less than 24 hours of antibacterial treatment. Once recovered, there is no need for quarantining or swabbing the patient, and he can return to school when able (though this will depend on recovery and any sequelae).

Answer 6

1. Capillary blood glucose (CBG) of at least 11.0mmol/L or known diabetes 2. Capillary blood ketones>3.0mmol/L or 2+ ketonuria 3. Venous pH<7.3 and/or venous bicarbonate<15mmol/L

Answer 7

Because there is a significant risk of lactic acidosis in these patients if they take metformin

Answer 8

D. Refer urgently to hospital where she should be given co-amoxiclav This is a history suspicious for peri-orbital cellulitis; though the patient is well, the risk of intra-cranial infection is higher than normal and this patient needs admission to hospital and antibiotics. Co-amoxiclav is first line for peri-orbital cellulitis instead of the usual flucloxacillin.

Answer 9

Smoking cessation and home oxygen therapy (if chronically hypoxic) There is growing evidence that other measures may improve survival, but for now these are the only two well-evidenced ones: https://thorax.bmj.com/content/65/4/284 Other measures: A one-off pneumococcal vaccine and annual influenza vaccines Pulmonary rehabilitation (after recent hospitalisation or has breathlessness making them walk slower than contempories on the level, or which makes them stop for breath when walking at their own pace) Optimisation of co-morbitidites Oral mucolytics (e.g. carbocysteine) if patient has trouble bringing up sputum Azithromycin prophylaxis if they do not smoke and have optimised medical and non-medical treatment, but still have 4 or more exacerbations per year

Answer 10

Oral prednisolone 40-50mg daily orally for at least 5 days I.V. hydrocortisone (100mg 6 hourly till converted to prednisolone) or I.M. methylprednisolone are acceptable alternatives if oral medication is unsuitable NB: Regardless of steroids given for an acute exacerbation of asthma, the patient should take their preventer inhaler as normal

Answer 11

Supplementary O2 as needed 5mg oxygen-driven (~6L/min) back-to-back nebulised salbutamol (reserve IV salbutamol for when inhaled is inappropriate) Add 500mcg oxygen-driven nebulised ipratropium bromide if poor initial response OR if severe attack At this point (if not earlier) definitely involve a senior Consider single bolus of IV magnesium sulphate (senior decision) IV aminophylline may be used but is unlikely to work (senior decision) Involve ICU if severe or life-threatening attack that is not responding to treatment - the patient may need intubation and ventilation BTS guidelines download (see p83 for acute asthma in adults): https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-2014/

Answer 12

Measure and record PEF 15–30 minutes after starting treatment, and thereafter according to the response Measure and record PEF before and after nebulised or inhaled β2 agonist Record oxygen saturation by oximetry and maintain arterial SpO2 at 94–98% Repeat measurements of blood gas tensions within one hour of starting treatment if: - the initial PaO2 is <8 kPa unless SpO2 is >92%; OR - the initial PaCO2 is normal or raised; OR - the patient’s condition deteriorates Measure them again if the patient’s condition has not improved by 4–6 hours Measure and record the heart rate Measure serum potassium and blood glucose concentrations

Answer 13

D. Chest pain Chest pain and haemoptysis are two important symptoms to ask about in a history, because they are unlikely to occur in COPD and so suggest there is a different problem.

Answer 14

D. Take a sputum sample and switch her to doxycycline This patient's infection has not resolved on her initial antibiotic, but there is also no indication yet that she is sick enough to warrant hospital admission. In this scenario you should switch antibiotic. If this fails, then you would consider admission and/or specialist input.

Answer 15

Increase dose or frequency of SABA/SAMA bronchodilators 5 days of oral amoxicillin, clarithromycin, or doxycycline 5 days of oral prednisolone (probably no need for bone protection unless needing frequent courses e.g. 3/4 times per year)

Answer 16

D. Rectal involvement Differentiating UC from Crohn's is tricky, and can only be done definitively on biopsy. However there are some features than can be more suggestive of one over the other. Lower right quadrant pain and fistula formation are both classically features of Crohn's. The pain results from involvement of the ileum - common in Crohn's but uncommon in UC. Fistula formation is associated with Crohn's because it affects the full thickness of the bowel, whereas UC affects only the mucosa and submucosa and so is unlikely to cause a fistula. Clubbing and aphthous ulcers are features of both UC and Crohn's and are not a helpful way to differentiate. Similarly arthritis and erythema nodosum occur in both diseases. Extraintestinal manifestations are a little more common in Crohn's than UC, but this is not reliable in clinically differentiating them. Papers on extraintestinal manifestations of IBD: https: //academic.oup.com/ibdjournal/article/21/8/1982/4602969 https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3127025/

Answer 17

B. NAAT Nucleic acid amplification testing is the test of choice for chlamydia and gonorrhoea. This history could be either, thought the bleeding is more suggestive of chlamydia. Endocervical swabs can be used to get a sample for NAAT, but would probably be uncomfortable or painful in this patient particularly given the cervical inflammation. Furthermore they are no longer necessary because they are no more diagnostically useful than a lower vaginal swab with NAAT. A urinary b-hCG should always be considered in a woman of child-bearing age presenting in most settings, but is not going to diagnose the issue here.

Answer 18

C. Transmural inflammation Anti ttg antibodies are a very sensitive and specific test for coeliac disease. Fetal calprotectin is a useful test for detecting IBD, but does not differentiate between Crohn's and UC. If nothing else, remember that Crohn's affects the full thickness of bowel in non-continuous 'skip lesions', whereas UC causes severe mucosal and submucosal inflammation in a continuous fashion from the rectum proximally. Summary: Crohn's: Skip lesions present anywhere along the GI tract, most commonly in the terminal ileum. Causes transmural inflammation leading to strictures and fistulas. Features granuloma formation. UC: Continuous lesions begin at the rectum and move proximally. Causes inflammation of the mucosa and submucosa, and features mucosal ulcers, depletion of goblet cells, and crypt abscesses.

Answer 19

A. High resolution CT scan This is a history of bronchiectasis - a chronic condition involving dilatation and thickening of central and medium-sized bronchi due to a cycle of infection and inflammatory mediator release. 50% of cases in adults are idiopathic but a significant proportion are tied to cystic fibrosis or previous infection, e.g. with measles, tuberculosis, and whooping cough. More niche causes are disease such as Kartagener's syndrome, primary ciliary dyskinesis, congenital immune deficiency, and yellow nail syndrome. Once bronchiestasis is established, the patient is more vulnerable to unusual lung infections e.g. with Haemophilus influenzae and Pseudomonas aeruginosa. The key features of a bronchiectasis history are: persistent productive cough, haemoptysis, and recurrent chest infections. The infection with an unusual organism (Pseudomonas) is a clue, and the CXR can be misleadingly normal in bronchiectasis (though the tram-track sign indicative of airway thickening may be seen), hence a high-resolution CT is needed to visualise the airways (will show signet-ring sign). An HIV test would be a good idea in this patient (and is in many) but HIV is not the main problem here. The sweat test is unlikely to be useful because this would be a very late age to present with cystic fibrosis (especially given the average life expectancy is mid 40s). Spirometry would be useful for COPD, but the haemoptysis and Pseudomonas make this unlikely. An ECG may be indicated here, but not as the main diagnostic investigation.

Answer 20

C. Calculate an ELF score This is a history suspicious of non-alcoholic fatty liver disease (NAFLD) which usually presents as an incidental finding of a raised ALT and AST (ALT>AST) along with a raised GGT and occasionally a raised ALP. NAFLD is now the commonest cause of abnormal LFTs in the UK. NAFLD may lead to non-alcoholic steatohepatitis (NASH) where the fatty liver causes inflammation and this carries a risk of inflammation, fibrosis, and eventual cirrhosis. Patients with suspected NAFLD should have blood tests to look for concomitant metabolic disease (lipids, Hba1c). Their risk of progression to advanced liver disease/ fibrosis is the most important factor here, and should be assessed using a score like the Enhanced Liver Fibrosis score (ELF). Imaging such as a liver USS may be helpful as increased echogenicity supports a diagnosis of NAFLD when interpreted in the context of being otherwise well with raised LFTs. Management is conservative with risk factor modification, follow-up, and a target of 10% weight loss over 6 months. The main cause of death in NAFLD patients is cardiac disease, so risk factors such as diabetes, hypertension, and hypercholesterolaemia should be assessed for and managed. Patients at high risk of fibrosis are referred to specialists who may use vitamin E or pioglitazone. 30-40% of patients with cirrhosis from NAFLD require transplantation. 'A' is a biomarker for hepatocellular carcinoma, which there are no features of in this history. 'B' is not necessary here as the patient is a mild drinker (though alcohol excess should be curbed in NAFLD to avoid exacerbating it). 'D' is not necessary here, and 'E' is negligent as you have not investigated or treated the patient.

Answer 21

C. Caput Medusa This is a 2 part question: 1. Identify the cause of the ascites 2. Recall the associated clinical sign A SAAG > 11g/L is the threshold and is very useful for differentiating 'transudative' from 'exudative' ascites (though these terms are falling out of use). SAAG> 11 is a good indicator that the cause is portal hypertension. Inflammatory conditions cause a lower SAAG because the inflammation leads to production of protein which then sits in the ascites. Inflammatory causes include tuberculosis, penumonia, pancreatitis, abdominal malignancy and ovarian inflammation. Nephrotic syndrome will also cause a low SAAG (as well as frothy urine - sign of proteinuria) because protein is lost through the kidneys. This results in a low gradient because though the ascitic protein is low, so is the serum protein.

Answer 22

B. Take another vaginal swab and give 1g IM ceftriaxone The extra swab should be taken for sensitivity testing in case the gonorrhoea is resistant. Ceftriaxone 1g IM is first-line if sensitivities are unknown. If the gonorrhoea is known to be sensitive to ciprofloxacin, then a one-off dose of 500mg can be given. 'E' is the first-line treatment for chlamydia. Erythromycin or azithromycin can be used in pregnant women, in whom doxycycline is contra-indicated.

Answer 23

B. Repeat U&Es in 2 weeks Up to a 30% rise in creatinine is ok after starting or increasing the dose of ACEi, but does require re-checking the U&Es after 2 weeks if it is greater than 20%. K+ is allowed to rise up to 5.5 without being concerning.

Answer 24

D. Spirometry +/- reversibility testing NICE says that spirometry should be offered to all symptomatic patients with a suspicion of asthma over the age of 5 years. Testing for revesriblity by giving a SABA and repeating the spirometry may be helpful, especially in cases like this one where the child is symptomatic. Fractional exhaled nitric oxide testing is a relatively new test which should ideally be offered to all patients aged 17 or older with query asthma. It can be considered where there is diagnostic uncertainty in younger patients, but the results may be disrupted if the patient is already taking inhaled corticosteroids.

Answer 25

A. Give oral dexamethasone This is a case of superior vena cava obstruction: one of the oncological emergencies (though there are non-malignant causes). SVC obstruction causes oedema and distension of the veins distal to the obstruction. The oedema causes breathlessness, cough, hoarseness and stridor (laryngeal oedema), and facial plethora. Confusion, stridor, and blurred vision are less common signs that occur only in severe obstruction. Oral dexamethasone is given to reduce the swelling around the tumour to help alleviate the obstruction. Radiotherapy, chemotherapy, and stenting may all be used to relieve the obstruction more definitively. Acutely steroids will be given if there is airway obstruction, but there is some debate about whether they should be given initially in the absence of airway obstruction as they interfere with histpathological diagnosis. ``` BMJ Best Practice Guideline: https://bestpractice.bmj.com/topics/en-gb/848 Scottish guidelines (referenced on official Finals mock): http://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/Superior-Vena-Cava-Obstruction.aspx ```

Answer 26

135/85mmHg 145/85 for the over 80s The targets are 5mmHg higher for clinic readings

Answer 27

C. Offer ambulatory blood pressure monitoring Hypertension can be diagnosed on the basis of: Clinic blood pressure of 140/90 mmHg or higher AND ABPM daytime average or HBPM average of 135/85 mmHg or higher Both have to be present Home blood pressure monitoring is an acceptable alternative to ambulatory

Answer 28

Obstructive: Reduced FVC More reduced FEV1 Thus reduced FEV1/FVC ratio Restrictive: Reduced FVC Equally or less reduced FEV1 Thus normal or high FEV1/FVC ratio

Answer 29

25-30 ml/kg/day of water 1 mmol/kg/day of potassium, sodium, and chloride 50-100 g/day of glucose to limit starvation ketosis NB: remember to not give too much saline to a patient as they will be at risk of hyperchloraemic acidosis. Alternate with bags of 5% dextrose. Think of it as a 'sweet and salted' approach https://www.nice.org.uk/guidance/cg174/chapter/1-Recommendations

Answer 30

He can read the line at 6m, but someone with normal visual acuity could read the line at 12m

Answer 31

REVIEW 1/2 https://thorax.bmj.com/content/64/12/1090

Answer 32

D. Klebsiella pneumoniae infection K. pneumoniae is a major cause of hospital acquired pneumonia (HAP) and particularly affects patients with chronic diseases e.g. diabetes, alcoholism, COPD. The major clues in this history are the diabetes and alcoholism, the upper lobe cavitation, and the bloody 'jelly' sputum.

Answer 33

D. Insert a chest drain There are two main questions when making decisions about managing pneumothoraces: 1st: Is the patient over 50, a smoker, or is there any evidence of underlying disease? 2nd: How large is the pneumothorax at the level of the hilum/ is the patient breathless? This patient has underlying disease (asthma) and is breathless, and has an air rim of >2cm. Accordingly they need a chest drain. Full BTS guidelines: https://thorax.bmj.com/content/65/Suppl_2/ii18

Answer 34

C. Double the hydrocortisone, don't change the fludrocortisone During periods of illness endogenous steroid production rises, and this needs to be mimicked in those taking supplementary steroids to avoid Addisonian crisis. NB: Hydrocortisone for Addison's disease is split into morning and evening doses, with the morning dose being higher. This is to mimic the natural dirunal variation of cortisol.

Answer 35

E. Discharge with safety netting and follow-up There are two main questions when making decisions about managing pneumothoraces: 1st: Is the patient over 50, a smoker, or is there any evidence of underlying disease? 2nd: How large is the pneumothorax at the hilum/ is the patient breathless? This patient has no underlying disease and is not breathless, and has an air rim of <2cm. Accordingly ths doctor can discharge them with safety-netting and a follow up in 2-4 weeks. Full BTS guidelines: https://thorax.bmj.com/content/65/Suppl_2/ii18

Answer 36

C. 20mg oral morphine sulphate immediate release Opiate analgesia for breakthrough pain is generally 1/6th the dose of the standard pain relief for that day.

Answer 37

D. Streptococcus viridans This is a case of subacute bacterial endocarditis, as evidenced by the splenomegaly and clubbing. Both of these features take time to develop and so would not occur in an acute presentation. Given the presence of these signs, and the more chronic subtle history, this infection is most likely caused by Streptococcus viridans. S. viridans is the causative agent in subacute bactwerial endocarditis and is a commensal organism found at the gums (hence previous dental procedures are a risk factor).

Answer 38

B. Losartan An ACEi, ARB, or aldosterone antagonist should be started in diabetic patients with CKD (as indicated by the 2 fasting glucose measurements ≥7.0mmol/L). Statins are started for the same indications in CKD patients as in any other patients. EPO can be used in patients with CKD and normocytic anaemia, who have had iron studies to demonstrate sufficient iron reserves, but there is no mention of anaemia here. Cholecalciferol and other vitamin D supplements are not used routinely - only if there is a deficiency. Apixaban may be used if there is concurrent non-valvular AF.

Answer 39

E. Start an ACEi Normally stage 1 hypertension does not need treatment. With a clinic BP of <160/100, and an ambulatory BP of <150/95, she does have stage 1 hypertension but her diabetes mean she should be treated. Though she is above 55, the presence of diabetes means she should be given an ACEi. Criteria for starting treatment in stage 1 hypertension are: ``` Target organ damage Established cardiovascular disease Renal disease Diabetes An estimated 10-year risk of cardiovascular disease (QRISK) of 10% or more Age under 60 - you would consider it ```

Answer 40

REVIEW* D. Anti-ttG antibodies Anti-ttG antibodies are a sensitive and specific test for coeliac disease - an important differential to rule out in IDA (microcytic anaemia picture). Whilst malignancy is also important to consider she does not meet the criteria for a 2 week wait, so a reasonable next step may be a FIT test (replacement of faecal occult blood test but essentially the same) rather than proceeding straight to endoscopy. Faecal calprotectin (inflammatory bowel disease) is a good answer and may well be done, though coeliac disease is a better differential for this presentation.

Answer 41

1. Hyperkalaemia - B. Spironolactone 2. Cough - E. ACE inhibitors 3. Constipation - C. Oxybutynin 4. Ankle swelling - D. Amlodipine 5. Hyponatraemia - A. Indapamide/ bendroflumathiazide The STOPP toolkit is a list of times when you should consider stopping certain drugs (p17): https://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty-1.pdf

Answer 42

D. Urine dip This is a bit of a trick question, but illustrates a useful principle: do the simple tests and rule out the common things first. A UTI is a common cause of urinary incontinence, and anyone presenting in this way should have a urine dip before any more in depth investigations.

Answer 43

D. Plasma aldosterone:renin ratio Hypertension with hypokalaemia is suggestive of Conn's syndrome - primary hyperaldosteronism. The family history is also suggestive, though other causes of hypertension may also be familial. An elevated aldosterone:renin ratio may be used to diagnose Conn's syndrome. Treatment depends on whether the adrenal hyperplasia is unilateral or bilateral, which is assessed using adrenal vein sampling to try and lateralise the aldosterone production. Treatment may be either with unilateral laparoscopic adrenalectomy or aldosterone antagonist therapy. Unilateral Conn's is usually an indication for surgery, whereas bilateral Conn's generally favours medical management (unless there is a large tumour which should be removed due to malignant potential).

Answer 44

D. 500mcg of 1 in 1000 adrenaline IM

Answer 45

D. I.V. 20% glucose Management of hypoglycaemia in a diabetic patient depends on their level of consciousness: Awake: Give a 15-20g quick-acting carbohydrate e.g. orange juice, 4 heaped tsp sugar in water, 5-7 dextrose tablets Confused, aggressive, or uncooperative but can swallow: Give 2 tubes glucose gel squeezed into mouth or cheek OR give glucagon 1mg I.M. Unconscious, very aggressive, or seizing: 1st line give I.V. glucose (75-100ml 20% OR 150-200ml 10%) 2nd line give 1mg I.M. glucagon (less likely to work after starvation, in liver disease, in patients taking sulphonylureas, or alcohol intoxication) Hypoglycaemia guidelines: http://www.diabetologists-abcd.org.uk/JBDS/JBDS_HypoGuideline_FINAL_280218.pdf

Answer 46

C. Prothrombin complex

Answer 47

C. MRCP This is a history of primary sclerosing cholangitis (PSC) - inflammation of the bile duct which is very strongly associated with ulcerative colitis. MRCP is the best investigation to diagnose PSC as it is non-invasive but detailed enough. AN USS of the biliary tree may well be done in someone with biliary obstruction, but is not the best investigation in this case.

Answer 48

Blatchford before endocsopy | Rockall after

Answer 49

Background - microaneurysms, haemorrhages Pre-proliferative - hard exudates, haemorrhages, cotton wool spots Proliferative - new vessels present REVIEW* Add new staging

Answer 50

C. Pleural effusion Whiteout of the hemithorax has a few different causes, and an important way to distinguish between them is the position of the trachea (and, if visible, the mediastinum). The main causes of total lung whiteout classified by trachea position are: Trachea pulled towards whiteout: Pneumonectomy Total lung collapse Pulmonary agenesis/ hypoplasia ``` Trachea central: ARDS/ pulmonary oedema (bilateral) Massive consolidation Askin tumour (chest wall tumour) Being on ECMO Pleural mass (e.g. mesothelioma) ``` Trachea pushed away from whiteout: Pleural effusion/ haemothorax Huge pulmonary mass (obstructs the bronchus causing distal total lung collapse, but the mass of the tumour still pushes the trachea away) Diaphragmatic hernia/ rupture

Answer 51

1. Worsening cognitive impairment in a patient already impaired - D. Amitryptilline 2. May mask symptoms of hypoglycaemia - E. Carvedilol 3. Worsening of constipation - A. Diltiazem 4. Worsening of symptoms in Parkinson's - B. Haloperidol 5. Toxic megacolon is used in ulcerative colitis - C. Loperamide The STOPP toolkit is a list of times when you should consider stopping certain drugs (p17): https://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty-1.pdf

Answer 52

Stage 1: General arterial narrowing and silver wiring Stage 2: AV nipping Stage 3: flame haemorrhages, cotton wool spots, hard exudates Stage 4: Papilloedema

Answer 53

D. Order a proximal leg vein USS, take bloods, and start apixiban in the meantime For a ?DVT, a 2-level DVT Wells score should be calculated. If the score is 1 or less, a DVT is unlikely and should be ruled out using a d-dimer. If the result takes more than 4 hours, interim anti-coagulation should be given as a precaution. For a score of 2 or more, a proximal leg vein USS should be arranged within 4 hours and interim anticoagulation with apixaban or rivaroxaban should be given. If the scan can't be done within 4 hours, take a d-dimer, give interim anti-coagulation, and get a scan within 24 hours. Before starting anticoagulation you should take an FBC, LFTs, U&Es, and a clotting but do not wait for the results before starting treatment.

Answer 54

D. Oral vancomycin and I.V. metronidazole In life-threatening c. diff infection (shocked, radiographic evidence of toxic megacolon, ileus) the patient should receive oral vancomycin and I.V. metronidazole. It is also important to stop the precipitating antibiotics.

Answer 55

Clinical evidence of a LRTI in combination with x-ray changes

Answer 56

1. Fishy-smelling, thin, grey vaginal discharge but not itching or soreness. Vaginal pH is 5.6 - C. Oral metronidazole 400mg BD for 7 days 2. Vulval itching and soreness, and pain when urinating. Her discharge is yellow-green and frothy with a fishy odour. Vaginal pH is 5.6 - C. Oral metronidazole 400mg BD for 7 days 3. Fever, dysuria, and a painful blistering vulval rash with bilateral inguinal lymphaednopathy - A. Oral aciclovir 400mg TDS for 10 days 4. Purulent vaginal discharge, painful sex, and post-coital bleeding - B. Oral doxyclycline 100mg BD for 7 days

Answer 57

Oxycodone is mostly metabolised in the liver and so is preferred for mild-moderate impairment. Fentanyl, alfentanil, and buprenorphine can be used in severe renal impairment.

Answer 58

E. Give a tetanus booster plus tetanus immunoglobulin If the patient is fully vaccinated and the vaccine is in date (last booster within 10 years) then nothing further is needed regardless of how high risk the injury is. Risk of tetanus is divided into 3 categories: clean, tetanus-prone, and high risk. If their immunisation is out of date: do nothing if the wound is clean, but give a booster if it is tetanus-prone or high risk, and immunoglobulin if the wound is high risk (e.g. contaminated with soil or manure, or wounds requiring surgical intervention that was delayed for 6 hours or more) If they were never fully vaccinated or don't know their vaccination status: give a tetanus booster for any wound, and immunoglobulin for a tetanus-prone or high risk wound. Green book of immunisation guidelines (p10): https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859519/Greenbook_chapter_30_Tetanus_January_2020.pdf

Answer 59

Flare: Glucocorticoids e.g. prednisolone or hydrocortisone Budesonide may be given - it is less effective but has less severe side-effects Mesalazine may be given as 2nd line if steroids are unsuitable and the flare is mild Severe flares may require azathioprine, infliximab, methotrextae, or adalimumab Maintaining remission: 1st azathioprine or mercaptopurine 2nd methotrexate Consider surgical resection for patients with refractory disease and children whose growth may be stunted by the disease

Answer 60

Mild-moderate flare: Rectal mesalazine, with added oral mesalazine if patient continues to flare Add topical or oral steroids if symptoms persist ``` Severe flare: 1st line I.V. steroids 2nd line add I.V. ciclosporin 3rd line Infliximab Assess need for surgery (symptoms, blood results, x-ray findings) ``` Maintaining remission: Mesalazine for mild-moderate disease Azathioprine/ mercaptopurine for severe/ refractory cases ``` NB: severity is decided using the Truelove-Witts' severity index (accounts for temperature, WCC, no. bowel movements per day etc.) All of the following would make a flare severe: Pulse >90bpm Pyrexic Anaemic ≥6 bowel movements per day ESR >30mm/hr Significant blood in stool ```

Answer 61

1. Significant overdose of propranolol - D. Supportive treatment inc. lorazepam for seizures 2. Overdose of 40 paracetamol tablets taken over the course of an hour, the last was taken 90 minutes ago - C. Start intravenous N-acetyl-cysteine 3. Overdose of 35 aspirin tablets taken 30 minutes ago - A. Oral activated charcoal 4. Overdose of 10 paracetamol tablets in a 70kg man 2 hours ago - B. Observation 5. Student brought to A&E after a carbon monoxide leak was detected in the building, pulse oximeter shows sats of 99% on room air - E. High flow oxygen +/- I.V. mannitol RE paracetamol poisoning: If the overdose is staggered and significant, then start acetylcysteine If the overdose is less than 75mg/kg it is very unlikely to be toxic, and even up to 150mg/kg it is unlikely

Answer 62

Fludrocortisone 1st line | Midodrine 2nd line alone or in combination with fludrocortisone

Answer 63

1. Abdominal pain, transient diarrhoea, nausea, vomiting, lactic acidosis in renal failure - B. Metformin 2. Increased risk of bone fractures and bladder cancer - D. Thiazolidinediones (pioglitazone) 3. Increased risk of UTIs, hypoglycaemia, dehydration - A. SGLT2 inhibitors (empagliflozin) 4. Fairly mild side-effect profile: headache, constipation, dizziness - C. DPP4 inhibitors (sitagliptin) 5. Abdominal pain, diarrhoea, nausea, vomiting, hypoglycaemia, agraunlocytosis - E. Sulphonylureas (gliclazide)

Answer 64

Initiate lifestyle changes and reassess Hba1c (this may be skipped and metformin started) If above 48mmol/L then intensify - start Metformin and aim for 48mmol/L ``` If still above 58mmol/L then intensify again - add: Pioglitazone A sulphonylurea A DPPG-4 inhibitor Or an SLGT-2 inhibitor Aim for 53mmol/L ``` If still above 58mmol/L then intensify again: Try triple therapy Or add insulin Aim for 53mmol/L Triple therapy with metformin, GLP-1 agonist (e.g. exenatide), and a sulphonylurea is used if normal triple therapy doesn't work/ isn't tolerated and insulin can't be used NICE visual summary: https://www.nice.org.uk/guidance/ng28/resources/algorithm-for-blood-glucose-lowering-therapy-in-adults-with-type-2-diabetes-pdf-2185604173

Answer 65

REVIEW* Refer them to GUM clinic for partner notification, or get their consent to share their details for partner notification. Generally if the infection is asymptomatic, partners from the last few months should be informed, if symptomatic then it can be the last few weeks. Current partner should be tested but treated before results are back Test of cure 3-6 months later for chlamydia, >2 weeks after treatment completion for gonorrhoea

Answer 66

1. Patient fell at home and hit his head, now has left-sided weakness, is taking warfarin for AF - D. Prothrombin complex concentrate 2. Patient with known cirrhosis has a bleeding varix, clotting test shows an INR of 2.6 - A. Fresh frozen plasma 3. Patient with DIC is bleeding - B. Cryoprecipitate 4. Patient due to have surgery with platelet count of 40 - F. Transfusion 5. Patient in ED whose blood tests show a platelet count of 20 - E. No transfusion needed 6. Patient on the ward with a Hb of 60 - C. Transfusion Anaemia: Transfuse if below 70g/L or 80g/L in ACS Give oral iron if IDA before and after surgery Thrombocytopenia transfusion thresholds: <10x10^9/L even if not bleeding <30x10^9/L if bleeding significantly <50-75x10^9 if having surgery (depending on type of surgery) <100x10^9 if severe bleeding/ bleeding in critical sights (CNS or eyes) <100x10^9 if having surgery in critical sights (CNS or eyes) FFP contains all clotting factors and fibrinogen, and can be given in major bleeding with deranged clotting times Cryoprecipitate contains fibrinogen, von Willebrand factor, factor VIII, factor XIII and fibronectin. It is used in cases where fibrinogen is low NICE transfusion guidelines: https://www.nice.org.uk/guidance/ng24/chapter/Recommendations

Answer 67

B. Start 15L O2 through a non-rebreathable mask Although this patient has COPD, the most important issue in the vignette is the profound hypoxia. This should be addressed quickly as it will kill the patient before the complications of giving high flow oxygen will. Even in CO2 retainers, it is acceptable to give high flow oxygen for short intervals to correct hypoxia, before weaning the oxygen down. NB: Do not assume all COPD patients are CO2 retainers: this is a feature of more advanced disease that is indicated by a raised bicarbonate on blood gases. Retainers have the lower target range for oxygen saturations (88% - 92%), but non-retainers do not, so this is an important distinction.

Answer 68

B. 28% Venturi mask This patient is only a little below their target saturations of 88-92%. Their target is lower because their blood gas shows they are a CO2 retainer (high bicarbonate indicates metabolic compensation of chronic respiratory acidosis). Giving this patient high flow oxygen would be acceptable if they were more profoundly hypoxic, but given their sats are only a little below the target range, they should be brought up more cautiously to avoid causing acidosis. BNF summary on oxygen in COPD: https://bnf.nice.org.uk/treatment-summary/oxygen.html

Answer 69

They are comparable apart from for PO2 and PCO2 pH is consistently 0.02-0.04 lower in VBg HCO3 is consistently 1-2meq/L higher in VBG Lactate correlates well but starts to diverge >2mmol/L More info: https: //www.oxfordmedicaleducation.com/abgs/venous-blood-gas-vbg-interpretation/ https: //litfl.com/vbg-versus-abg/ NB: be cautious of intepreting electrolyte results on blood gases, but there is some evidence they correlate resonably well: https://pubmed.ncbi.nlm.nih.gov/26658635/

Answer 70

1. Low aPTT and PT - D. Warfarin 2. Low aPTT, normal PT - B. Von Willebrand disease 3. Low aPTT, normal PT - C. Haemophilia 4. Low aPTT, low PT, low fibrinogen - A. DIC NB: The clotting casacade is easier to remember than you think: Extrsinsic pathway is measured by PT/ INR and just involves factor 7 Intrinsic pathway is measured by aPTT and involves 8, 9, 11, and 12 Common pathway involves everything downstream of factor 10 (1, 2, 5)

Answer 71

D. A significantly raised serum urea This is a bit of a trick question, but makes a point: it makes sense that passing bright fresh-looking blood should be a symptom of lower GI bleed, but 1/3 of massive upper GI bleeds will also feature this. That is because blood accelerates thepassage of gut contents and so blood from the upper Gi tract can be accelerated through the bowel and still look reasonably fresh. Raised serum urea is an established feature of an upper GI bleed, and is included in the Blatchford scoring system (predicts the need for endoscopy). This is becase when blood reaches the stomach, it is partially digested. This essentially constitutes a large protein meal and so will elevate the level of urea in the blood as that protein is broken down.

Answer 72

A. Propranolol and Omeprazole PPIs are given for 6-8 weeks after all upper GI bleeds whether variceal or not. Low dose Propranolol is started in patients who've had a variceal bleed to control portal hypertension and reduce the risk of re-bleeding (this is titrated to a resting heart rate of 60bpm).

Answer 73

A-E assessment: give nasal oxygen, attach monitoring, and keep NBM Order urgent blood products, transfuse 1-2L crystalloid in the meantime if shocked Follow major haemorrhage protocol (MHP) for transfusion If bleeding does not require MHP: Give RBCs if Hb <10, platelets if PLT count is below 50x10^9, and reverse any coagulopathies Stop any NSAIDs (consult with cardiology for low dose clopidogrel or aspirin) If suspected variceal bleed: give terlipressin and ciprofloxacin If severe bleed - take immediately for endoscopy once stablisied If non-severe bleed - arrange endoscopy within 24 hours Endoscopy: Adrenaline + clips/ thermal coagulation/ fibrin injection for arterial bleed Band ligation for variceal bleed Post-endoscopy and follow-up: Give 6-8 weeks PPI for arterial and variceal bleeds Arterial bleeds should have a follow-up endoscopy after 6-8 weeks to confirm healing and look for underlying malignancy For a variceal bleed, repeat endoscopy at 1-2 week intervals is required for total variceal obliteration, and until then the patient should remain on an endoscopic surveillance program RCP guidelines: https://www.rcpjournals.org/content/clinmedicine/12/6/589 British society of Gastrology guidelines: https://www.bsg.org.uk/wp-content/uploads/2019/12/UK-guidelines-on-the-management-of-variceal-haemorrhage-in-cirrhotic-patients.pdf NICE guidelines: https://www.nice.org.uk/guidance/CG141/chapter/1-Guidance#management-of-non-variceal-bleeding

Answer 74

E. Ultrasound scan This is a history of PCOS: the most common endocrine condition affecting women of reproductive age. The aetiology of PCOS is unclear, but there is a well-established pattern of raised LH and testosterone. The 'cysts' are actually ovarian follicles which have grown but then neither ovulated nor undergone atresia. PCOS is diagnosed using the Rotterdam criteria - 2/3 must be met to diagnose PCOS: 1. Oligo/anovulation 2. Clinical (hirsutism or less commonly male pattern alopecia) or biochemical signs of hyperandrogenism (raised FAI or free testosterone) 3. Polycystic ovaries on ultrasound

Answer 75

A. 100mg I.V. hydrocortisone This is a history of pituitary apoplexy: infarction of - or a bleed into - the pituitary gland. This usually occurs on a background of a pituitary tumour, but the tumour has also usually not been detected prior to this, as many pituitary tumours never are. Pituitary apoplexy presents as sudden onset frontal headache plus the effects of bleeding into the cavernous sinus. The optic nerve becomes compressed, often at the chiasm leading to a bitemporal hemianopia. The occulomotor nerve is often compressed leading to reduced upwards gaze and dilated pupils. The trochlear nerve, abducens nerve, and internal carotid arteries may also be affected. The management of apoplexy is not well agreed-upon, but there is consensus that it is important to quickly give glucocorticoid replacement (hydrocortisone or dexamethasone). This is becaus epituitary damage decreases ACTH release, which normally functions to stimulate cortisol production. Therefore apoplexy runs the risk of Addisonian crisis which must be protected against with glucocorticoids. Depending on whether there are signs of increased ICP/ local structure compression, the neurosurgeons may decide to operate.

Answer 76

C. SIADH Though it may seem niche, SIADH is actually common in hospital inpatients and is particularly associated with pneumonia. It is the most common cause of hyponatraemia in hospitalised patients. SIADH results from increased secretion of ADH (vasopressin) fom the posterior pituitary (neurohypophysis) in response to a variety of stimuli including: drugs, brain injury, infection, and malignancy. ADH results in increased reabsorption of water in the collecting ducts of the kidney. This increases blood volume which is dteetcted by the atria of the heart as increased stretch. They release atrial natruiretic peptide (ANP) which causes excretion of sodium and with it water. In this way the patient will be euvolemic, but hyponatraemic. Treatment is with hypertonic saline for sodium replacement and fluid restriction. Vaptans are ADH receptor blockers which effectively treat the condition but are often not used unless the case is chronic. The definitive treatment is to treat the underlying cause. NB: It is important not to raise the serum sodium by more than 10mmol over 24 hours, as beyond this there is a risk of central pontine myelinolysis. The rapid change in osmolality causes cell lysis in the pons of the brianstem and leads to quadriplegia, dysarthria, dysphgia, seizures, coma, and death.

Answer 77

C. Nephrogenic diabetes insipidus Water deprivation tests are simpler to interpret then they look. In a healthy subject we would expect their serum osmolality to rise a little after 8 hours of fluid depreivation. However we would expect to see a much greater rise in their urine osmolality as their kidneys worked to retain water and concentrate the urine. If the urine does not concentrate sufficiently, the next consideration is the effect of desmopressin. Desmopressin is an ADH analogue which should increase urine osmolality and decrease serum osmolality if there is a deficiency in ADH production (cranial diabetes insipidus). However if the kidneys are resistant to ADH (nephrogenic diabetes insipidus) then administering desmopression will have no effect; the serum osmolality will still be high and the urine will be innappropriately dilute. Some important causes of nephrogenic diabetes insipidus include: lithium, hyperclacaemia, and most diseases affecting the kidneys (CKD, PKD, infarction, autoimmue, multiple myeloma).

Answer 78

1. The most common cause of hyperthyroidism - C. Graves' disease 2. May present with a painful goitre - E. DeQuervain's/ viral thyroiditis 3. Associated with anti-myeloperoxidase antibodies - A. Hashimoto's thyroiditis 4. The most common cause of hypothyroidism worldwide - B. Iodine deficiency 5. Common in hospital inpatients and self-resolves - D. Sick euthyroid syndrome

Answer 79

The two main causes of hyperthyroidism are Graves' disease and toxic nodular disease. Graves' disease acocunts for ~80% of cases in iodine-replete areas, and toxic nodular disease accounts for ~50% of cases in iodine-deficient areas Graves' disase medica|: Monotherapy - propylthiouracil or carbimazole for 12-18 months titrated up Block and replace - totally block thyroid with thionamides and replace with levothyroxine. Useful for patients whose thyroxine fluctuates Both regimes have a 35% chance of achieving long-term remission If relapse - radioiodine or surgery Toxic nodular disease medical: Radioiodine is first line Takes weeks-months to work so interim therapy is needed Most people will need thyroxine replacement lifelong afterwards Beta blockers provide symptom relief Surgical: Considered for large goitre, compressive symptoms e.g. dysphagia or dyspnoea, opthalmopathy with Graves', or planned pregnancy Patient is made euthyroid with Lugol's iodine (potassium iodide) given for 10 days before surgery Total thyroidectomy with replacement levothyroxine RCP Summary of hyperthyroidism: https://www.rcpjournals.org/content/clinmedicine/17/3/274

Answer 80

Classified by volume status: ``` Hypovolaemic (losses): Vomiting Diarrhoea Salt-wasting nepropathy High output stoma Diuretics ``` Euvolaemic (endocrine): SIADH Hypothyroidism Addison's disease Hypervolaemic (failures): Cardiac failure Liver failure Nephrotic syndrome

Answer 81

D. Prolactinoma; dopamine antagonist This a history of a prolactinoma, the most common type of pituitary tumour (closely followed by non-functioning macroadenoma). The prevalence is thought to be ~1 in 1600 and predominantly affects women in their second or third decade of life. This presentation is mostly vague, with the nipple discharge (galactorrhoea) giving a bit more of a clue. The tests listed are a reasonable investigation of the presentation. The diagnostic result is a prolactin of 20,000: though hyperprolactinaemia may be caused by a maceoadenoma which compresses the pituitary stalk to remove inhibition of lactotrophs by dopamine from the posteior pituitary (neurohypophysis), this will not generally cause a rise above 6000mcg/L. A result of 20,000 is diagnostic of a prolactinoma. Prolactinomas are managed with observation if asymptomatic and small, but if larger than 1cm (macroadenoma) or symptomatic then they need treating. First line is dopamine agonists (cabergoline or bromocriptine) which are usually very effective. However if they fail or are unsuitable, trans-sphenoidal surgical resection is indicated.

Answer 82

REVIEW* Raised anion gap acidosis: M - methanol U - uraemia (renal failure, not the uraemia itself) D - diabetic ketoacidosis P - paracetamol I - infection, iron, isoniazid, inborn errors of metabolism L - lactic acidosis E - ethylene glycol (antifreeze) (ethanol is also included, but only causes acidosis through increased lactic acid in the blood, as does metformin in overdose) S - salicylatyes (aspirin) ``` Normal gap acidosis: U - ureteric-intestinal diversion S - sigmoid fistula E - excess saline D - diarrhoea C - carbonic anhydrase inhibitors e.g. Acetazolamide A - Addison's R - renal tubular acidosis P - pancreatic fistula ``` ``` Alkalosis: H+ loss (e.g. vomiting) Long standing hypokalaemia Excess bicarbonate intake Hyperventilation ```

Answer 83

COCP: 7 days of cover provides 7 days of cover Take missed pill asap and next scheduled pill even if that is 2 in one day After the pill-free week, have to competely miss two pills (>72 hours) to need emergency contraception and barrier Use barrier until there is 7 days of coverage POP: Traditional POP - within 3 hours Desogestrel POP - within 12 hours Take missed pill asap and next scheduled pill even if that is 2 in one day Use barrier contraception till there is 48 hours of cover

Answer 84

Oral or transdermal: Oral oestrogen is standard but transdermal is useful for where oral is not tolerated or contraindicated (e.g. VTE risk, migraines, cardiac risk factors, GI disturbance that would decrease absorption, enzyme-inducing drugs, lactose intolerance) Progestogen may be given orally but can be given as a Mirena coil - particularly useful where contraception is still needed, withdrawal bleeds are heavy, or other adverse effects are not tolerated Preparation: Usually need to add progestogen for protection against endometrial cancer (though increases risk of breast cancer) Oestrogen only HRT if no uterus Cyclical vs non-cyclical: Progestogen is given at the end of cycle to induce bleed, or continuously to avoid bleed Cyclical is for women still having periods but the only reason is so they know when they stop (1 month cycles for regular periods and 3 month cycles for irregular periods) Risks: There is an increased risk of breast cancer for non-cyclical (1 extra case in 50 women instead of 1 in 70) Increased risk of breast cancer even with oestrogen only (1 extra case per 200 treatments) However there is little to no risk if taken for less than 1 year Small increase in risk of stroke for oestrogen-only but no others No increased risk of heart disease for any preparations PE risk higher for oral HRT but still very low (0.14-0.18% up from 0.10% based on WHI trials) No increased risk of VTE for transdermal HRT Women's Health Initative Trial: https://jamanetwork.com/journals/jama/fullarticle/1745676

Answer 85

B. Switch her to a variable-rate infusion with hourly capillary blood glucose tests Variable rate insulin infusions (VRII) are indicated in: severe non-dka vomiting, patients who are NBM before surgery, and severe illness requiring tight glycaemic control e.g. sepsis. They may also be used in: corticosteroid use, pregnant patients, ACS, and TPN/ enteral feeding. Though it allows for tight glycaemic control, VRII is labour intensive as it requires hourly capillary blood glucose monitoring, and may do more harm than good if done incorrectly. For these reasons it is seldom used except for specific indications. For diabetic of either type taking insulin, VRII should not be started if they will only miss one meal. If they will miss more then it should be started. https://www.diabetes.org.uk/resources-s3/2017-09/Use%20of%20variable%20rate%20intravenous%20insulin%20infusion%20in%20medical%20inpatients_0.pdf

Answer 86

Stop any fast or rapid-acting insulin Continue their basal long-acting insulin Add 50 units rapid-acting insulin as a fixed rate infusion made up to 50ml with 5% dextrose, at a rate of 0.1U/kg/hr

Answer 87

▸ Patients with stable chronic obstructive pulmonary disease (COPD) and a resting PaO2 ≤7.3 kPa ▸ Patients with stable COPD with a resting PaO2 ≤8 kPa with evidence of peripheral oedema, polycythaemia (haematocrit ≥55%) or pulmonary hypertension ▸ Patients with resting hypercapnia if they fulfil all other criteria for LTOT BTS long term oxygen therapy guidelines: file:///C:/Users/luke/Downloads/BTS%20Guidelines%20for%20Home%20Oxygen%20Use%20in%20Adults.pdf

Answer 88

D. Autosomal dominant polycystic kidney disease Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease with a prevalence of ~1 in 2000. It is caused by a mutation in the genes for either polycystin 1 or 2, which leads to abnormal cell growth and fluid excretion in the kidneys, causing cysts in the kidneys and liver. It generally presents between 30-40 years of age and may cause painless haematuria, hypertension, flank pain, recurrent utis, and kidney stones. Diagnosis is with an USS or CT. Management centres on treating the complications and eventually often involves dialysis and transplantation. Tolvaptan may be given in some ADPKD patients as it slows disease progression. Autosomal recessive polycystic kidney disease is significantly rarer and causes disease in utero and shortly after birth, with patients generally in end-stage renal failure by their mid-teens.

Answer 89

C. Urea breath test For non-concerning dyspepsia, either offer a urea breath test (and then H pylori eradication triple therapy) or start a PPI for 4 weeks depending on clinical judgement. If one approach doesn't work, try the other.

Answer 90

One-off pneumococcal and seasonal influenza vaccinations Use QRISK score to determine need for antiplatelet prophylaxis against CVD Prescribe Atorvastatin 20mg for primary CVD prevention Prescribe an ACEi depending an urinary albumin:creatinine ratio and comorbidities: >3mg/mmol + diabetes >30mg/mmol + hypertension >70mg/mmol

Answer 91

D. Metoclopramide Metoclopramide is a dopamine antagonist anti-emetic and is particularly useful for gastrointestinal causes of nausea because it has a prokinetic effect. As a result it will improve both the constipation and the nausea in this case. Haloperidol is generally used for metabolic causes of nausea e.g. uraemia, eletrolyte imbalance Cyclizine is particularly useful for nausea from raised ICP, motion sickness, and mechanical bowel obstruction Dexamethasone is often given because it reduces inflammaiton and swelling which often alleviates symptoms, and has additional anti-emetic activity Hyoscine is used for motion sickness, but in palliative care is more useful for reducing symptoms of colic and secretions in end of life patients NB: Pro-kinetic should not be used where there is a mechanical bowel obstruction, only where there is functional obstruction/ dysmotility

Answer 92

Never stop or skip an insulin dose The doses may need to be adjusted based on blood glucose Check blood glucose at least every 4 hours, even through the night Maybe check urinary or blood ketones regularly too Fluid intake of ~3L per day is encouraged NICE CKS: https://cks.nice.org.uk/topics/diabetes-type-1/management/management-adults/#sick-day-rules

Answer 93

REVIEW* Failure to respond to conservative management Severe symptoms Large 3rd or 4th degree haemorrhoids

Answer 94

Prostate - lung, liver, bone Breast - lung, liver, bone, brain Lung - liver, bone, brain, adrenals Ovary and colorectal - liver, peritoneum, lung It's a good idea to have an idea of common metastasis sites for the main cancers, and as you can see here there is a common trend towards lung, liver, bone, and brain.

Answer 95

C. Organise CT coronary angiography Whilst a calcium channel blocker or beta blocker is the first line preventative treatment for angina, the diagnosis of angina is not purely clinical and so further testing is needed before prophylactic treatment. That said, aspirin can be started as a preventative measure if angina is likely. Isosorbide nitrate is a preventative rather than a reliever therapy and is not first line for angina - it should only be tried after CCB and a beta blocker have failed or are contraindicated. CT angiography is the first line investigation for diagnosing angina. If this is inconclusive functional imaging (stress echo, MRI perfusion scan etc.) may be used. If this is not an option, invasive coronary angiography may be tried. If there is pre-existing ischaemic damage to the heart, functional imaging or a stress ECG may be used.

Answer 96

E. Prescribe oral doxycycline This is a history of bronchitis - a clinically mild chest infection. This can be distinguished form community-acquired pneumonia by the lack of severe features such as being generally unwell, low blood pressure, fevers/ rigors, chets pain, hypoxia. Some of these features may be present in bronchitis but will be much less severe. Treatment for bronchitis is usually conservative: advise they increase fluid intake and take OTC analgesia. If a CRP measurement has been taken (it shouldn't be routinely) then a CRP >100 is an indication for antibiotics, and a CRP of 20-100 may be an indication to give an 'in case' prescription for if symptoms worsen. Treatment is also indicated if they have comorbidities or recent hospital admissions, especially if they are >65. Oral doxycyline is first line for people >17, and oral amoxicillin is first line for people <17. CURB-65 is a hospital scoring system for severity of pneumonia and can't be done in GP because there is generally not quick access to serum urea tests. The equivalent in GP practice is the CRB-65, but again this is for pneumonia rather than bronchitis.

Answer 97

E. Drug reaction This picture is indicative of interstitial nephritis - inflammation of the kidney which is usually due to medications (e.g. antibiotics, NSAIDs). This leads to blood in the urine and a sterile pyuria (WCC in urine without organisms) as well as a certain amount of proteinuria. There may also be findings of an 'allergic' picture with eosionphilia, eosinophils in the urine, and white cell casts. The negative nitrites make this less likely to be pyelonephritis, though admittedly do not exclude it. Interstitial nephritis will generally cause a fever, rash, and arthralgia.

Answer 98

D. Acute tubular necrosis A major clue here is the urinary sodium - in acute tubular necrosis the kidney fails to retain sodium as it should and so the urinary sodium will usually be elevated above 40mmol/L. Pre-renal and post-renal causes will not cause this urinary sodium increase. ACE inhibitors essentially cause a pre-renal AKI because they decrease perfusion of the kidney.

Answer 99

Multilayer compression bandaging (assuming normal ABPI) - strongest tolerable Pentoxyfylline adjunct to help healing Cleaning and wound dressing advice Emollient +/- steroids for venous eczema Elevate legs at night and at rest for oedema

Answer 100

``` Conservative: Lose weight Exercise Elevate legs Compression stockings (check ABPI first) Refer to vascular if: symptomatic, thrombosed, there are skin changes of chronic venous insufficiency, there is a venous ulcer ``` Surgical: 1st line: Endothermal ablation 2nd line: Foam sclerotherapy 3rd line: Ligation/ stripping

Senior Medicine Flashcards

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