Wednesday [06/10/2021] Flashcards

Question

CI of quinolones [2]

Answer 1

* Quinolones should generally be avoided in women who are pregnant or breastfeeding * avoid in G6PD

Answer 2

Electric alternanas

Answer 3

Cardiac tamponade signs: * hypotension * raised JVP * soft heart sounds

Answer 4

Electrical alternans is a relatively specific but non-sensitive ECG sign of cardiac tamponade. Electrical alternans is characterised by beat to beat variation in QRS amplitude and morphology. This variability is due to the heart 'swinging' in the pericardial fluid.

Answer 5

QT prolongation is usually caused by electrolyte abnormalities (hypokalemia, hypocalcemia) or medications (antipsychotics). QT prolongation is not associated with cardiac tamponade.

Answer 6

T wave inversion in leads II, III and AVF is highly suggestive of inferior myocardial ischaemia. It is important to remember that cardiac tamponade is a potential complication of a myocardial infarction

Answer 7

* dyspnoea * tachycardia * an absent Y descent on the JVP - this is due to the limited right ventricular filling * pulsus paradoxus - an abnormally large drop in BP during inspiration * Kussmaul's sign - much debate about this * ECG: electrical alternans

Answer 8

**Cardiac tamponade****Constrictive pericarditis****JVP**Absent Y descent**Pulsus paradoxus**Present**Kussmaul's sign**Rare**Characteristic features**

Answer 9

Urgent pericardiocentesis

Answer 10

Folic acid defiency and macroscytic anaemia

Answer 11

Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.

Answer 12

* THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Answer 13

* phenytoin * methotrexate * pregnancy * alcohol excess

Answer 14

Macrocytic, megaloblastic anaemia Neural tube defects

Answer 15

* all women should take 400mcg of folic acid until the 12th week of pregnancy * women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy * women are considered higher risk if any of the following apply: * either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD * the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. * the woman is obese (defined as a body mass index [BMI] of 30 kg/m² or more).

Answer 16

Pulmonary hypertension is a cause of a loud S2 (due to a loud P2)

Answer 17

Diagnosis is clinical and sometimes refers to the American College of Rheumatology classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely

Answer 18

* explanation * aerobic exercise: has the strongest evidence base * cognitive behavioural therapy * medication: pregabalin, duloxetine, amitriptyline

Answer 19

* if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor * if taking an oral anticoagulant: clopidogrel

Answer 20

* anaemia features * lethargy * pallor * dyspnoea * neurological features * peripheral neuropathy: 'pins and needles', numbness. Typically symmetrical and affects the legs more than the arms * subacute combined degeneration of the spinal cord: progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia * neuropsychiatric features: memory loss, poor concentration, confusion, depression, irritabiltiy * other features * mild jaundice: combined with pallor results in a 'lemon tinge' * glossitis → sore tongue

Answer 21

* full blood count * macrocytic anaemia: macrocytosis may be absent in around of 30% of patients * hypersegmented polymorphs on blood film * low WCC and platelets may also be seen * vitamin B12 and folate levels * a vitamin B12 level of \>= 200 nh/L is generally considered to be normal * antibodies * anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%) * anti gastric parietal cell antibodies in 90% but low specificity so often not useful clinically * Schilling test is no longer routinely done * radiolabelled B12 given on two occasions, firstly on its own, secondly with oral IF. Urine B12 levels are then measured

Answer 22

* vitamin B12 replacement * usually given intramuscularly * no neurological features: 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections * more frequent doses are given for patients with neurological features * there is some evidence that oral vitamin B12 may be effective for providing maintenance levels of vitamin B12 but it is not yet common practice * folic acid supplementation may also be required

Answer 23

Risk of urinary retention

Answer 24

* first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin * if the first-line drug treatment does not work try one of the other 3 drugs * tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain * topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia) * pain management clinics may be useful in patients with resistant problems

Answer 25

* *Use a dose of 10 mg prednisolone for children under 2 years of age, 20 mg for children aged 2-5 years and 30-40 mg for children \>5 years. Those already receiving maintenance steroid tablets* * should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.* * *Repeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication.* * *Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days.*

Answer 26

Bronchodilator therapy * give a beta-2 agonist via a spacer (for a child \< 3 years use a close-fitting mask) * give 1 puff every 30-60 seconds up to a maximum of 10 puffs * if symptoms are not controlled repeat beta-2 agonist and refer to hospital Steroid therapy * should be given to all children with an asthma exacerbation * treatment should be given for 3-5 days

Answer 27

Recent studies have identified that thiazolidinediones, in particular, pioglitazone, are associated with an increased risk of bladder cancer. This is a rare, but important, adverse effect to consider in a patient on thiazolidinediones.

Answer 28

1 - SGLT-2 inhibitors - genital infections, diabetic ketoacidosis 2 - Biguanides e.g. metformin - GI upset, lactic acidosis 4 - GLP-1 mimetics - nausea, vomiting, pancreatitis 5 - Insulin - weight gain, hypoglycaemia, lipodystrophy

Answer 29

Thiazolidinediones are a class of agents used in the treatment of type 2 diabetes mellitus. They are agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance. Rosiglitazone was withdrawn in 2010 following concerns about the cardiovascular side-effect profile.

Answer 30

* weight gain * liver impairment: monitor LFTs * fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin * recent studies have indicated an increased risk of fractures * bladder cancer: recent studies have shown an increased risk of bladder cancer in patients taking pioglitazone (hazard ratio 2.64)

Answer 31

* pruritus - may be intense - typical worse palms, soles and abdomen * clinically detectable jaundice occurs in around 20% of patients * raised bilirubin is seen in \> 90% of cases

Answer 32

Nitrofurantoin 7 days course [though should be avoided near term]

Answer 33

* NICE Clinical Knowledge Summaries recommend trimethoprim or nitrofurantoin for 3 days

Answer 34

Aged over 65, visible or non-visible haematuria

Answer 35

* local antibiotic guidelines should be followed if available * NICE Clinical Knowledge Summaries recommend trimethoprim or nitrofurantoin for 3 days * send a urine culture if: * aged \> 65 years * visible or non-visible haematuria

Answer 36

* a urine culture should be sent in all cases * should be treated with an antibiotic for * first-line: nitrofurantoin (should be avoided near term) * second-line: amoxicillin or cefalexin * trimethoprim is teratogenic in the first trimester and should be avoided during pregnancy

Answer 37

Trimethoprim

Answer 38

* a urine culture should be performed routinely at the first antenatal visit * Clinical Knowledge Summaries recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course * the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis * a further urine culture should be sent following completion of treatment as a test of cure

Answer 39

* an immediate antibiotic prescription should be offered for 7 days * as with non-pregnant women, trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected * NICE Clinical Knowledge Summaries state: *'Referral to urology is not routinely required for men who have had one uncomplicated lower urinary tract infection (UTI).'*

Answer 40

* do not treat asymptomatic bacteria in catheterised patients * if the patient is symptomatic they should be treated with an antibiotic * a 7-day, rather than a 3-day course should be given

Answer 41

For patients with sign of acute pyelonephritis hospital admission should be considered * local antibiotic guidelines should be followed if available * the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days

Answer 42

Featifue, erectile dysfunction and arthralgia

Answer 43

Abdominal pain, weight loss, N and V

Answer 44

Wilson's disease normally presents in children and adolescents as neuropsychiatric symptoms as well as the symptoms of liver failure. As said above the fact it typically presents in much younger patients helps to rule this out.

Answer 45

Systemic lupus erythematosus can present with a variety of symptoms such as fatigue, arthralgia and weight loss. While these symptoms could account for his arthralgia and fatigue, erectile dysfunction is not typical. Even if it was, the fact that both his dad and grandfather died of liver conditions points towards another diagnosis.

Answer 46

Budd-Chiari syndrome is due to obstruction of the hepatic vein. It typically presents with right upper quadrant pain and painful ascites. You could also note hepatomegaly, jaundice and it may be associated with an acute kidney injury and so this does not fit his presentation.

Answer 47

Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

Answer 48

It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6\*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia

Answer 49

* 1 in 10 people of European descent carry a mutation in the genes affecting iron metabolism, mainly HFE * prevalence in people of European descent = 1 in 200, making it more common than cystic fibrosis

Answer 50

* early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands) * 'bronze' skin pigmentation * diabetes mellitus * liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition) * cardiac failure (2nd to dilated cardiomyopathy) * hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism) * arthritis (especially of the hands)

Answer 51

* *Reversible complications****Irreversible complications** * Cardiomyopathy * Skin pigmentation * Liver cirrhosis\*\* * Diabetes mellitus * Hypogonadotrophic hypogonadism * Arthropathy

Answer 52

A non-immune host who is exposed to *M. tuberculosis* may develop a primary infection of the lungs. A small lung lesion known as a Ghon focus develops. The Ghon focus is composed of tubercle-laden macrophages. The combination of a Ghon focus and hilar lymph nodes is known as a Ghon complex In immunocompetent people, the initial lesion usually heals by fibrosis. Those who are immunocompromised may develop disseminated disease (miliary tuberculosis).

Answer 53

If the host becomes immunocompromised the initial infection may become reactivated. Reactivation generally occurs in the apex of the lungs and may spread locally or to more distant sites. Possible causes of immunocompromise include: * immunosuppressive drugs including steroids * HIV * malnutrition

Answer 54

The lungs remain the most common site for secondary tuberculosis. Extra-pulmonary infection may occur in the following areas: * central nervous system (tuberculous meningitis - the most serious complication) * vertebral bodies (Pott's disease) * cervical lymph nodes (scrofuloderma) * renal * gastrointestinal tract

Answer 55

* Oral cavity cancers * Cancers of the pharynx (including the oropharynx, hypopharynx and nasopharynx) * Cancers of the larynx

Answer 56

* neck lump * hoarseness * persistent sore throat * persistent mouth ulcer

Answer 57

* Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with: * persistent unexplained hoarseness or * an unexplained lump in the neck

Answer 58

* Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either: * unexplained ulceration in the oral cavity lasting for more than 3 weeks or * a persistent and unexplained lump in the neck. * Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either: * a lump on the lip or in the oral cavity or * a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Answer 59

Thyroid cancer * Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

Answer 60

Nasopharyngeal carcinoma may present as a painless lymphadenopathy because of its tendency for early spread. Nasopharyngeal carcinoma is more common in people of Asian origin, and typically presents with epistaxis, headaches, lymph node metastasis or unilateral hearing loss.

Answer 61

The other remaining options (larynx, buccal mucosa, and tonsillar fossa) would drain to the anterior triangle.

Answer 62

Anterior packing

Answer 63

If anterior packing doesn;t work, then refer for posterior packing

Answer 64

Anterior and posterior bleeds

Answer 65

Bleeding can also indicate platelet function disorders such as thrombocytopenia, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia and ITP. In adolescent males, juvenile angiofibroma is a benign tumour that may bleed as it is highly vascularised. If the nasal septum looks abraded or atrophied, inquire about drug use. This is because inhaled cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum. In the elderly, hereditary haemorrhagic telangiectasia may cause prolonged nasal bleeding. Granulomatosis with polyangiitis and pyogenic granuloma may also present with nosebleeds.

Answer 66

* Asking the patient to sit with their torso forward and their mouth open- avoid lying down unless they feel faint. This decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood. * Pinch the cartilaginous (soft) area of the nose firmly and consistently for at least 20 minutes and ask the patient to breathe through their mouth.

Answer 67

If first aid measures are successful, consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis. Cautions to this include patients that have peanut, soy or neomycin allergies, and Mupirocin is a viable alternative.

Answer 68

If bleeding does not stop after 10-15 minutes of continuous pressure on the nose, consider cautery or packing. Cautery should be used initially if the source of the bleed is visible and cautery is tolerated- it is not so well-tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to hospital for review.

Answer 69

* Ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume. * Use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect * Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation. * Dab the area clean with a cotton bud and apply Naseptin or Muciprocin

Answer 70

* Anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes * Pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions * Pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack. * Examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel. * Patients should be admitted to hospital for observation and review, and to ENT if available

Answer 71

Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre

Answer 72

* progressive cognitive impairment * in contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss * cognition may be fluctuating, in contrast to other forms of dementia * usually develops before parkinsonism * parkinsonism * visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)

Answer 73

* usually clinical * single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT) is used as the radioisotope. The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%

Answer 74

* both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's. NICE have made detailed recommendations about what drugs to use at what stages. Please see the link for more details * neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent

Answer 75

Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)

Answer 76

* small, irregular pupils * no response to light but there is a response to accommodate

Answer 77

* diabetes mellitus * syphilis

Answer 78

* obesity * nulliparity * early menarche * late menopause * unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously * diabetes mellitus * tamoxifen * polycystic ovarian syndrome * hereditary non-polyposis colorectal carcinoma

Answer 79

Endometrial cancer is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection

Answer 80

* postmenopausal bleeding is the classic symptom * premenopausal women may have a change intermenstrual bleeding * pain and discharge are unusual features

Answer 81

* women \>= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway * first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (\< 4 mm) has a high negative predictive value * hysteroscopy with endometrial biopsy

Answer 82

Febrile convulsions are seizures provoked by fever in otherwise normal children. They typically occur between the ages of 6 months and 5 years and are seen in 3% of children.

Answer 83

* usually occur early in a viral infection as the temperature rises rapidly * seizures are usually brief, lasting less than 5 minutes * are most commonly tonic-clonic

Answer 84

Scarlet fever

Answer 85

If the febrile convulsion lasts longer than 5m

Answer 86

SimpleComplexFebrile status epilepticus\< 15 minutes15 - 30 minutes\> 30 minutesGeneralised seizureFocal seizure Typically no recurrence within 24 hoursMay have repeat seizures within 24 hours Should be complete recovery within an hour

Answer 87

* children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics

Answer 88

* the overall risk of further febrile convulsion = 1 in 3. However, this varies widely depending on risk factors for further seizure. These include: age of onset \< 18 months, fever \< 39ºC, shorter duration of fever before seizure and a family history of febrile convulsions * if recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts \> 5 minutes * regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Answer 89

* risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder * children with no risk factors have 2.5% risk of developing epilepsy * if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)

Answer 90

Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the majority of features seen in TS are neurocutaneous.

Answer 91

* depigmented 'ash-leaf' spots which fluoresce under UV light * roughened patches of skin over lumbar spine (Shagreen patches) * adenoma sebaceum (angiofibromas): butterfly distribution over nose * fibromata beneath nails (subungual fibromata) * café-au-lait spots\* may be seen

Answer 92

Cutaneous features * depigmented 'ash-leaf' spots which fluoresce under UV light * roughened patches of skin over lumbar spine (Shagreen patches) * adenoma sebaceum (angiofibromas): butterfly distribution over nose * fibromata beneath nails (subungual fibromata) * café-au-lait spots\* may be seen Neurological features * developmental delay * epilepsy (infantile spasms or partial) * intellectual impairment Also * retinal hamartomas: dense white areas on retina (phakomata) * rhabdomyomas of the heart * gliomatous changes can occur in the brain lesions * polycystic kidneys, renal angiomyolipomata * lymphangioleiomyomatosis: multiple lung cysts *

Answer 93

Little's area in the anterior nasal septum is the site of Kiesselbach's plexus, supplied by 4 arteries. Epistaxis therefore most commonly originates from the anterior of the nose

Answer 94

First-line treatment for neuropathic pain is amitriptyline, duloxetine, gabapentin or pregabalin. If one of these agents don't work next line is to try one of the other remaining three drugs

Answer 95

* diabetic neuropathy * post-herpetic neuralgia * trigeminal neuralgia * prolapsed intervertebral disc

Answer 96

* first-line treatment\*: amitriptyline, duloxetine, gabapentin or pregabalin * if the first-line drug treatment does not work try one of the other 3 drugs * in contrast to standard analgesics, drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added * tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain * topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia) * pain management clinics may be useful in patients with resistant problems

Answer 97

Hepatitis A

Answer 98

* Raised bilirubin * Raised ALT/ AST * Normal or slightly raised ALP

Answer 99

Overview * incubation period: 2-4 weeks * RNA picornavirus * transmission is by faecal-oral spread, often in institutions * doesn't cause chronic disease Features * flu-like prodrome * abdominal pain: typically right upper quadrant * tender hepatomegaly * jaundice * cholestatic liver function tests

Answer 100

* complications are rare and there is no increased risk of hepatocellular cancer

Answer 101

Immunisation * an effective vaccine is available * after the initial dose a booster dose should be given 6-12 months later Who should be vaccinated? (Based on the Green book guidelines) * people travelling to or going to reside in areas of high or intermediate prevalence, if aged \> 1 year old * people with chronic liver disease * patients with haemophilia * men who have sex with men * injecting drug users * individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates

Answer 102

IV loop diuretics e.g. furosemide or bumetanide

Answer 103

Mx of restless leg syndrome

Answer 104

Varicose veins are dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart. They most commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein. Whilst extremely common, the vast majority of patients do not require any intervention.

Answer 105

* increasing age * female gender * pregnancy * the uterus causes compression of the pelvic veins * obesity

Answer 106

For many patients, the cosmetic appearance may prompt presentation. However other patients may complain of symptoms: * aching, throbbing * itching

Answer 107

* a variety of skin changes may be seen: * varicose eczema (also known as venous stasis) * haemosiderin deposition → hyperpigmentation * lipodermatosclerosis → hard/tight skin * atrophie blanche → hypopigmentation * bleeding * superficial thrombophlebitis * venous ulceration * deep vein thrombosis

Answer 108

* the majority of patients with varicose veins do not require surgery. Conservative treatments include: * leg elevation * weight loss * regular exercise * graduated compression stockings * reasons for referral to secondary care include: * significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling * previous bleeding from varicose veins * skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema) * superficial thrombophlebitis * an active or healed venous leg ulcer * possible treatments: * endothermal ablation: using either radiofrequency ablation or endovenous laser treatment * foam sclerotherapy: irritant foam → inflammatory response → closure of the vein * surgery: either ligation or stripping

Answer 109

* anxiety * age less than 50 years old * concurrent use of opioids * the type of chemotherapy used

Answer 110

For patients at low-risk of symptoms then drugs such as metoclopramide may be used first-line. For high-risk patients then 5HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone

Answer 111

Nearly all typical and some atypical antipsychotics like risperidone & amisulpride cause hyperprolactinaemia. Effects of hyperprolactinemia can involve breast tenderness, breast enlargement and lactation.

Answer 112

Aripiprazole is known for its having fewer side effects especially with respect to prolactin elevation.

Answer 113

Atypical antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.

Answer 114

* weight gain * clozapine is associated with agranulocytosis (see below) * hyperprolactinaemia

Answer 115

* increased risk of stroke * increased risk of venous thromboembolism

Answer 116

* clozapine * olanzapine: higher risk of dyslipidemia and obesity * risperidone * quetiapine * amisulpride * aripiprazole: generally good side-effect profile, particularly for prolactin elevation

Answer 117

Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason, clozapine should only be used in patients resistant to other antipsychotic medication. The BNF states: *Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.*

Answer 118

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

Answer 119

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.

Answer 120

Streptococcal infection

Answer 121

Polymorphic eruption of pregnancy is a relatively common skin disorder that can occur in women during pregnancy. It usually presents within the first pregnancy. It appears as an itchy, bumpy rash that starts in the stretch marks of the abdomen in the last 3 months of pregnancy then clears with delivery. This is unlikely to be the case here.

Answer 122

Erythema gyratum repens is a rare paraneoplastic type of annular erythema with a distinctive figurate wood-grain appearance which has a strong association with malignancy.

Answer 123

* inflammation of subcutaneous fat * typically causes tender, erythematous, nodular lesions * usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs) * usually resolves within 6 weeks * lesions heal without scarring

Answer 124

Causes * infection * streptococci * tuberculosis * brucellosis * systemic disease * sarcoidosis * inflammatory bowel disease * Behcet's * malignancy/lymphoma * drugs * penicillins * sulphonamides * combined oral contraceptive pill * pregnancy

Answer 125

* streptococci * tuberculosis * brucellosis

Answer 126

* steatosis - fat in the liver * steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH), see below * progressive disease may cause fibrosis and liver cirrhosis

Answer 127

NAFLD is thought to represent the hepatic manifestation of the metabolic syndrome and hence insulin resistance is thought to be the key mechanism leading to steatosis.

Answer 128

Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse. It is relatively common and thought to affect around 3-4% of the general population.

Answer 129

* _obesity_ * _type 2 diabetes mellitus_ * hyperlipidaemia * jejunoileal bypass * sudden weight loss/starvation

Answer 130

* usually asymptomatic * hepatomegaly * ALT is typically greater than AST * increased echogenicity on ultrasound

Answer 131

* there is no evidence to support screening for NAFLD in adults, even in at risk groups (e.g. type 2 diabetes) * the guidelines are therefore based on the management of the *incidental* finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound * in these patients, NICE recommends the use of the _enhanced liver fibrosis (ELF)_ blood test to check for advanced fibrosis * the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down's syndrome

Answer 132

* the mainstay of treatment is lifestyle changes (particularly _weight loss_) and monitoring * there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Answer 133

IgA nephropathy classically presents as visible haematuria following a recent URTI

Answer 134

It is important to not confuse it with post-streptococcal glomerulonephritis, which is caused by immune complex (IgG, IgM, and C3) deposition in the glomeruli. This happens more slowly, typically 7-14 days following a group A beta-hemolytic Streptococcus infection and causes proteinuria. IgA is a shorter word, fewer days, post-strep longer word so more days

Answer 135

Alport's syndrome is an X-linked dominant disease. It presents with microscopic haematuria, bilateral sensorineural deafness, and lenticonus. This patient does not have any of these characteristics.

Answer 136

Membranoproliferative glomerulonephritis can present as nephrotic syndrome, haematuria, or proteinuria. It rarely affects children and it can be caused by multiple factors such as cryoglobulinaemia, hepatitis B or C, and partial lipodystrophy. This patient does not have any of these comorbidities.

Answer 137

Minimal change disease is very common in children, but nearly always presents as nephrotic syndrome. This child's dipstick is negative for proteins but highly positive for blood, indicating a nephritic syndrome.

Answer 138

* _young male, recurrent episodes of macroscopic haematuria_ * _typically associated with a recent respiratory tract infection_ * nephrotic range proteinuria is rare * renal failure is unusual and seen in a minority of patients

Answer 139

* alcoholic cirrhosis * coeliac disease/dermatitis herpetiformis * Henoch-Schonlein purpura

Answer 140

* thought to be caused by _mesangial deposition of IgA immune complexes_ * there is considerable pathological overlap with Henoch-Schonlein purpura (HSP) * histology: mesangial hypercellularity, positive immunofluorescence for IgA & C3

Answer 141

* post-streptococcal glomerulonephritis is associated with low complement levels * main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur) * there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis

Answer 142

* isolated hematuria, no or minimal proteinuria (less than 500 to 1000 mg/day), and a normal glomerular filtration rate (GFR) * no treatment needed, other than follow-up to check renal function * persistent proteinuria (above 500 to 1000 mg/day), a normal or only slightly reduced GFR * initial treatment is with ACE inhibitors * if there is active disease (e.g. falling GFR) or failure to respond to ACE inhibitors * immunosuppression with corticosteroids

Answer 143

* 25% of patients develop ESRF * markers of good prognosis: frank haematuria * markers of poor prognosis: male gender, proteinuria (especially \> 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

Answer 144

* Thoracic pain * Age \<20 or \>55 years * Non-mechanical pain * Pain worse when supine * Night pain * Weight loss * Pain associated with systemic illness * Presence of neurological signs * Past medical history of cancer or HIV * Immunosuppression or steroid use * IV drug use * Structural deformity

Answer 145

Patients with red flags should have blood tests for FBC, ESR, Calcium, Phosphate, Alkaline phosphatase and PSA if appropriate. X-ray imaging should also be arranged.

Answer 146

* *May be acute or chronic** * *Pain worse in the morning and on standing** * *On examination there may be pain over the facets. The pain is typically worse on extension of the back**

Answer 147

**Spinal stenosis**Usually gradual onset Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'. Relieved by sitting down, leaning forwards and crouching down Clinical examination is often normal Requires MRI to confirm diagnosis**Ankylosing spondylitis**Typically a young man who presents with lower back pain and stiffness Stiffness is usually worse in morning and improves with activity Peripheral arthritis (25%, more common if female)**Peripheral arterial disease**Pain on walking, relieved by rest Absent or weak foot pulses and other signs of limb ischaemia Past history may include smoking and other vascular diseases

Answer 148

Suxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Answer 149

**Mechanism of action**Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plateCompetitive antagonist of nicotinic acetylcholine receptors**Examples**Succinylcholine (also known as suxamethonium)Tubcurarine, atracurium, vecuronium, pancuronium**Adverse effects**_Malignant hyperthermia_ _Hyperkalaemia_ (normally transient)Hypotension**Reversal** Acetylcholinesterase inhibitors (e.g. neostigmine)**Notes**_The muscle relaxant of choice for rapid sequence induction for intubation_ May cause f**_asciculations_****Contraindications**Suxamethonium is contraindicated for _patients with penetrating eye injuries or acute_ narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Answer 150

* mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA * potent liver enzyme inducer * hepatitis, orange secretions * flu-like symptoms

Answer 151

* mechanism of action: inhibits mycolic acid synthesis * _peripheral neuropathy_: prevent with pyridoxine (Vitamin B6) * _hepatitis_, agranulocytosis * liver enzyme inhibitor

Answer 152

* mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I * hyperuricaemia causing _gout_ * arthralgia, myalgia * _hepatitis_

Answer 153

* mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan * _optic neuritis: check visual acuity before and during treatment_ * dose needs adjusting in patients with renal impairment

Answer 154

The minority of patients who present within 1 hour may benefit from activated charcoal to reduce absorption of the drug.

Answer 155

* there is a staggered overdose\* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or * the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity

Answer 156

Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects

Answer 157

Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

Answer 158

King's College Hospital criteria for liver transplantation (paracetamol liver failure) Arterial pH \< 7.3, 24 hours after ingestion or all of the following: * prothrombin time \> 100 seconds * creatinine \> 300 µmol/l * grade III or IV encephalopathy

Answer 159

King's College Hospital criteria for liver transplantation (paracetamol liver failure) Arterial pH \< 7.3, 24 hours after ingestion or all of the following: * prothrombin time \> 100 seconds * creatinine \> 300 µmol/l * grade III or IV encephalopathy

Answer 160

If all the tablets are not taken within 1 hour

Answer 161

Standard release isosorbide mononitrate

Answer 162

* all patients should receive aspirin and a statin in the absence of any contraindication * sublingual glyceryl trinitrate to abort angina attacks * NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on 'comorbidities, contraindications and the person's preference' * if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block) * if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od) * if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa * if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine * if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

Answer 163

* many patients who take nitrates develop tolerance and experience reduced efficacy * NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance * this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate

Answer 164

Autoimmune hepatitis is condition of unknown aetiology which is most commonly seen in young females. Recognised associations include other autoimmune disorders, hypergammaglobulinaemia and HLA B8, DR3. Three types of autoimmune hepatitis have been characterised according to the types of circulating antibodies present

Answer 165

**Type I****Type II****Type III**Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA) Affects both adults and children Anti-liver/kidney microsomal type 1 antibodies (LKM1) Affects children only Soluble liver-kidney antigen Affects adults in middle-age

Answer 166

* may present with signs of chronic liver disease * acute hepatitis: fever, jaundice etc (only 25% present in this way) * amenorrhoea (common) * ANA/SMA/LKM1 antibodies, raised IgG levels * liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis

Answer 167

* steroids, other immunosuppressants e.g. azathioprine * liver transplantation

Answer 168

Phenytoin infusion

Answer 169

Carbamazepine is the drug of choice for simple and complex focal seizures and can be used for generalised tonic clinic seizures, but it is not used in the treatment of status epilepticus.

Answer 170

Propofol can be used in intensive care if phenytoin fails to control the seizure at 45minutes.

Answer 171

Sodium valproate is the first-line treatment for newly diagnosed generalised tonic-clonic seizures, but it isn't used in the acute treatment of status epilepticus.

Answer 172

Thiamine should be considered if a seizure is believed to be related to underlying alcohol abuse.

Answer 173

* a single seizure lasting \>5 minutes, or * \>= 2 seizures within a 5-minute period without the person returning to normal between them

Answer 174

Can lead to irreversible brain damage

Answer 175

* ABC * airway adjunct * oxygen * check blood glucose * First-line drugs are benzodiazepines such as diazepam or lorazepam * in the prehospital setting diazepam may be given rectally * in hospital IV lorazepam is generally used. This may be repeated once after 10-20 minutes * If ongoing (or 'established') status it is appropriate to start a second-line agent such as phenytoin or phenobarbital infusion * If no response ('refractory status') within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.

Answer 176

Travellers' diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common cause is *Escherichia coli*.

Answer 177

Staphylococcus aureus

Answer 178

Campylobacter

Answer 179

bacillus cereus

Answer 180

Amoebiasis

Answer 181

Incubation period * 1-6 hrs: *Staphylococcus aureus*, *Bacillus cereus*\* * 12-48 hrs: *Salmonella*, *Escherichia coli* * 48-72 hrs: *Shigella*, *Campylobacter* * \> 7 days: Giardiasis, Amoebiasis

Answer 182

AdenocarcinomaSquamous cell cancer**Epidemiology**Most common type in the UK/US**Location**Lower third - near the gastroesophageal junction**Risk factors** * GORD * Barrett's oesophagus * smoking * achalasia * obesity

Answer 183

* Upper GI endoscopy is the first line test * Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours * Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary * If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound * Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.

Answer 184

* Operable disease is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy * The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis * In addition to surgical resection many patients will be treated with adjuvant chemotherapy

Answer 185

Cross-match 4-6 units depending on local protocols

Answer 186

Group and save

Answer 187

Cross-match 4-6 units depending on local protocols

Answer 188

Chance of transfusionExample of actionExample of operationsUnlikelyGroup and saveHysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomyLikelyCross-match 2 unitsSalpingectomy for ruptured ectopic pregnancy, total hip replacementDefiniteCross-match 4-6 unitsTotal gastrectomy, oophorectomy, oesophagectomy Elective AAA repair, cystectomy, hepatectomy

Answer 189

Chance of transfusionExample of actionExample of operationsUnlikelyGroup and saveHysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomyLikelyCross-match 2 unitsSalpingectomy for ruptured ectopic pregnancy, total hip replacementDefiniteCross-match 4-6 unitsTotal gastrectomy, oophorectomy, oesophagectomy Elective AAA repair, cystectomy, hepatectomy

Answer 190

Chance of transfusionExample of actionExample of operationsUnlikelyGroup and saveHysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomyLikelyCross-match 2 unitsSalpingectomy for ruptured ectopic pregnancy, total hip replacementDefiniteCross-match 4-6 unitsTotal gastrectomy, oophorectomy, oesophagectomy Elective AAA repair, cystectomy, hepatectomy

Answer 191

The correct answer here is episcleritis. All the other causes of a red eye listed present with pain and either blurring of vision or decreased visual acuity. Episcleritis is classically not painful despite diffuse inflammation although mild tenderness may sometimes be reported. It can be treated with non-steroidal anti-inflammatories or steroids in resistant cases.

Answer 192

* red eye * _classically not painful_ (in comparison to scleritis), but mild pain may be present * watering and mild photophobia may be present * in episcleritis, the _injected vessels are mobile when gentle_ pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move * phenylephrine drops may be used to differentiate between episcleritis and scleritis. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Answer 193

* phenylephrine drops may be used to differentiate between episcleritis and scleritis. Phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels. If the eye redness improves after phenylephrine a diagnosis of episcleritis can be made

Answer 194

* conservative * artificial tears may sometimes be used

Answer 195

If no foetal movements by 24w, referrral to maternal fetal unit

Answer 196

Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

Answer 197

The first onset of recognised fetal movements is known as quickening. This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau. Multiparous women will usually experience fetal movements sooner, from 16-18 weeks gestation. Towards the end of pregnancy, fetal movements should not reduce.

Answer 198

Expectant mothers will usually quickly recognise a pattern to these movements. The nature of the movements themselves can be very variable. There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.

Answer 199

Fetal movements should be established by 24 weeks gestation. Reduced fetal movements is a fairly common presentation, affecting up to 15% of pregnancies. 3-5% of pregnant women will have recurrent presentations with RFM.

Answer 200

* Posture * There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing * Distraction * Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent * Placental position * Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements * Medication * Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements * Fetal position * Anterior fetal position means movements are less noticeable * Body habitus * Obese patients are less likely to feel prominent fetal movements * Amniotic fluid volume * Both oligohydramnios and polyhydramnios can cause reduction in fetal movements * Fetal size * Up to 29% of women presenting with RFM have a SGA fetus

Answer 201

As per RCOG Green-top guidelines, investigations are dependent of gestation at onset of RFM. * If past 28 weeks gestation: * Initially, handheld Doppler should be used to confirm fetal heartbeat. * If no fetal heartbeat detectable, immediate ultrasound should be offered. * If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. * If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement * If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat. * If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used. * If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Answer 202

Fetal movements are usually based solely on maternal perception, though it can also be objectively assessed using handheld Doppler or ultrasonography.

Answer 203

Concern regarding absent or reduced fetal movements stems for the potential for this presentation to represent fetal distress or impending demise. Between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. However, in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication.

Answer 204

Lichen * **p**lanus: **p**urple, **p**ruritic, **p**apular, **p**olygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common * sclerosus: itchy white spots typically seen on the vulva of elderly women

Answer 205

* itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms * rash often polygonal in shape, with a 'white-lines' pattern on the surface (Wickham's striae) * Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma) * oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa * nails: thinning of nail plate, longitudinal ridging

Answer 206

* gold * quinine * thiazides

Answer 207

* potent topical steroids are the mainstay of treatment * benzydamine mouthwash or spray is recommended for oral lichen planus * extensive lichen planus may require oral steroids or immunosuppression

Answer 208

Atorvastatin 80mg OD and Clopidogrel → all patietns with PAD should take these two drugs [he's experiencing intermittent claudication]

Answer 209

Athersclerosis

Answer 210

Exercise training

Answer 211

Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to **quit smoking**. **Comorbidities should be treated**, including * hypertension * diabetes mellitus * obesity As with any patient who has established cardiovascular disease, all patients should be taking a **statin**. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that **clopidogrel** should be used first-line in patients with peripheral arterial disease in preference to aspirin. **Exercise training** has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions.

Answer 212

* angioplasty * stenting * bypass surgery

Answer 213

Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.

Answer 214

* naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life * cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

Answer 215

Hypotension will occur in tension pneumothoraces as a result of cardiac outflow obstruction

Answer 216

* May occur following thoracic trauma when a lung parenchymal flap is created.

Answer 217

* This acts as a one way valve and allows pressure to rise.

Answer 218

* The trachea shifts and hyper-resonance is apparent on the affected side.

Answer 219

* Treatment is with needle decompression and chest tube insertion.

Answer 220

Codeine to morphine divide by 10

Answer 221

divide by 10

Answer 222

divide by 10 [same as codeine]

Answer 223

divide by 1.5-2

Answer 224

* a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily * a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.

Answer 225

divide by 2

Answer 226

**From****To****Conversion factor**Oral morphineSubcutaneous morphineDivide by 2Oral morphineSubcutaneous diamorphineDivide by 3Oral oxycodoneSubcutaneous diamorphineDivide by 1.5

Answer 227

**From****To****Conversion factor**Oral morphineSubcutaneous morphineDivide by 2Oral morphineSubcutaneous diamorphineDivide by 3Oral oxycodoneSubcutaneous diamorphineDivide by 1.5

Answer 228

* paracetamol 1g is first-line * NSAIDs can be used second-line in the first and second trimester * avoid aspirin and opioids such as codeine during pregnancy

Answer 229

* if patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)

Answer 230

* many women find that the frequency and severity of migraines increase around the time of menstruation * SIGN recommends that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans are also recommended in the acute situation

Answer 231

* safe to prescribe HRT for patients with a history of migraine but it may make migraines worse

Answer 232

Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually *Streptococcus pyogenes*)

Answer 233

This question is asking about the presentation of an ST-elevated myocardial infarction. The patient has presented 1st-degree heart block following his MI and so we can work out that his MI has most likely affected the inferior leads (right coronary arteries also provide blood supply to the AV node). Therefore the question requires you to know that leads II, III and aVF represent the inferior heart and the right coronary artery.

Answer 234

**ECG changes****Coronary artery****Anteroseptal**V1-V4**Inferior**II, III, aVF**Anterolateral**V4-6, I, aVL**Lateral**I, aVL +/- V5-6**Posterior**Tall R waves V1-2

Answer 235

**ECG changes****Coronary artery****Anteroseptal**V1-V4**Inferior**II, III, aVF**Anterolateral**V4-6, I, aVL**Lateral**I, aVL +/- V5-6**Posterior**Tall R waves V1-2

Answer 236

**ECG changes****Coronary artery****Anteroseptal**V1-V4**Inferior**II, III, aVF**Anterolateral**V4-6, I, aVL**Lateral**I, aVL +/- V5-6**Posterior**Tall R waves V1-2

Answer 237

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

Answer 238

* 2 litres of water * 80mmol potassium

Answer 239

**Na⁺****Cl^-****K⁺****HCO3^-**Glucose**Plasma**135-14598-1053.5-522-28**0.9% saline**154154--**5% glucose**----**0.18% saline with 4% glucose**3030--**Hartmann's solution**131111529

Answer 240

**Na⁺****Cl^-****K⁺****HCO3^-**Glucose**Plasma**135-14598-1053.5-522-28**0.9% saline**154154--**5% glucose**----**0.18% saline with 4% glucose**3030--**Hartmann's solution**131111529

Answer 241

**Na⁺****Cl^-****K⁺****HCO3^-**Glucose**Plasma**135-14598-1053.5-522-28**0.9% saline**154154--**5% glucose**----**0.18% saline with 4% glucose**3030--**Hartmann's solution**131111529

Answer 242

* if large volumes are used there is an increased risk of hyperchloraemic metabolic acidosis

Answer 243

* contains potassium and therefore should not be used in patients with hyperkalaemia

Answer 244

This lesion is characteristic of a seborrhoeic keratosis. Seborrhoeic keratoses are benign skin lesions that are common in people over 50. Note the brown nodule with a fissured greasy surface that is well demarcated against the skin. It has the classic 'stuck on' appearance of seborrhoeic keratoses. Most seborrhoeic keratosis lesions are asymptomatic and therefore no treatment is required.

Answer 245

Actinic keratosis (AK) is incorrect. AK is associated with chronic UV exposure and are typically flesh-coloured, irregularly shaped, small macules or plaques. Actinic keratoses have the potential to progress to squamous cell carcinoma. The lesions are small (typically 1-5mm) and do not have a 'stuck on' appearance as in this case.

Answer 246

Bowen's disease is also known as squamous cell carcinoma (SCC) in situ. Typically these lesions are slow-growing, red, scaly patches.

Answer 247

Malignant melanoma is an important differential to consider. However, a malignant melanoma typically varies more in colour, such as brown/blue/black and red. Furthermore, melanomas do not have a 'stuck on' and greasy appearance as in this case.

Answer 248

Naevus is not the correct answer in this case. Naevi typically develop within the first 20 years of life, whereas seborrhoeic keratosis is more common with advancing age

Answer 249

Seborrhoeic keratoses are benign epidermal skin lesions seen in older people. Features * large variation in colour from flesh to light-brown to black * have a 'stuck-on' appearance * keratotic plugs may be seen on the surface

Answer 250

reassurance about benign nature of the lesion is an option options for removal include crettage, cryosurgery, shave biopsy

Answer 251

Infeciton of the bone

Answer 252

* haematogenous osteomyelitis * results from bacteraemia * is usually monomicrobial * most common form in children * vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults * risk factors include: sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis * non-haematogenous osteomyelitis: * results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone * is often polymicrobial * most common form in adults * risk factors include: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease

Answer 253

* *Staph. aureus* is the most common cause except in patients with sickle-cell anaemia where *Salmonella* species predominate

Answer 254

MRI imaging of choice mdality, sensitivty of 90-100%

Answer 255

* flucloxacillin for 6 weeks * clindamycin if penicillin-allergic

Answer 256

* wheat: bread, pasta, pastry * barley: beer * whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease * rye * oats * some patients with coeliac disease appear able to tolerate oats

Answer 257

rice, potatoes, corn

Answer 258

Tissue transglutaminase

Answer 259

* Patients with coeliac disease often have a degree of **functional hyposplenism** * For this reason, all patients with coeliac disease are offered the pneumococcal vaccine * Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years * Currrent guidelines suggest giving the influenza vaccine on an individual basis.

Answer 260

The Truelove and Witts' severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults.

Answer 261

Any patient with features of severe ulcerative colitis should be admitted to hospital as an emergency. They should be treated with intravenous corticosteroids to induce remission.

Answer 262

* stress * medications * NSAIDs * antibiotics * cessation of smoking

Answer 263

**Mild****Moderate****Severe**Fewer than four stools daily, with or without blood No systemic disturbance Normal erythrocyte sedimentation rate and C-reactive protein valuesFour to six stools a day, with minimal systemic disturbance More than six stools a day, containing blood Evidence of systemic disturbance, e.g. * fever * tachycardia * abdominal tenderness, distension or reduced bowel sounds * anaemia * hypoalbuminaemia

Answer 264

*Haemophilus influenzae***75%** ## Footnote This is an infective exacerbation of COPD, with the fever and basal crackles indicating a bacterial cause. The most common cause in COPD is *Haemophilus influenzae*.

Answer 265

***Haemophilus influenzae type B*****64%** ## Footnote The history indicates acute epiglottitis, and this child would obviously need an ambulance to transfer him to the emergency department urgently. The most common cause of acute epiglottitis in children is *Haemophilus influenzae type B*, and the incidence of acute epiglottitis has fallen since the introduction of the Hib vaccine.

Answer 266

***Pseudomonas aeruginosa*****34%** ## Footnote Bacterial causes of otitis externa are most common, with *Pseudomonas aeruginosa* being most prevalent. Other causes include *Staphylococcus aureus*.

Answer 267

* Gram-positive cocci = staphylococci + streptococci (including enterococci) * Gram-negative cocci = *Neisseria meningitidis* + *Neisseria gonorrhoeae*, also *Moraxella catarrhalis*

Answer 268

Therefore, only a small list of Gram-positive rods (bacilli) need to be memorised to categorise all bacteria - mnemonic = ABCD L * *Actinomyces* * *Bacillus anthracis* (anthrax) * *Clostridium* * Diphtheria: *Corynebacterium diphtheriae* * *Listeria monocytogenes*

Answer 269

Remaining organisms are Gram-negative rods, e.g.: * *Escherichia coli* * *Haemophilus influenzae* * *Pseudomonas aeruginosa* * *Salmonella sp.* * *Shigella sp.* * *Campylobacter jejuni*

Answer 270

Phayngeal pouch: During swallowing an outpouching of the posterior hypopharyngeal wall is visualised at the level C5-C6, right above the upper oesophageal sphincter. A pharyngeal pouch is a posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men

Answer 271

* dysphagia * regurgitation * aspiration * neck swelling which gurgles on palpation * halitosis

Answer 272

Acute glaucoma

Answer 273

Cluster headache

Answer 274

Temporal artery

Answer 275

Medicaiton overuse headache

Answer 276

* meningitis * encephalitis * subarachnoid haemorrhage * head injury * sinusitis * glaucoma (acute closed-angle) * tropical illness e.g. Malaria

Answer 277

* chronically raised ICP * Paget's disease * psychological

Answer 278

Ramsey Hunt syndreom: Oral aciclovir and oral prednisolone for 5d

Answer 279

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

Answer 280

* auricular pain is often the first feature * facial nerve palsy * vesicular rash around the ear * other features include vertigo and tinnitus

Answer 281

Emergency surgical exploration as this is presentation of testicular torsion!

Answer 282

Men aged 20-30 y/o

Answer 283

Around 95% are germ-cell tumours

Answer 284

* *Tumour type****Key features****Tumour markers****Pathology**Seminoma * Commonest subtype (50%) * Average age at diagnosis = 40 * Even advanced disease associated with 5 year survival of 73% * AFP usually normal * HCG elevated in 10% seminomas * Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions) Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Answer 285

Non seminomatous germ cell tumours (42%) * Teratoma * Yolk sac tumour * Choriocarcinoma * Mixed germ cell tumours (10%) * Younger age at presentation =20-30 years * Advanced disease carries worse prognosis (48% at 5 years) * Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy * AFP elevated in up to 70% of cases * HCG elevated in up to 40% of cases * Other markers rarely helpful Heterogenous texture with occasional ectopic tissue such as hair

Answer 286

* Cryptorchidism * Infertility * Family history * Klinefelter's syndrome * Mumps orchitis

Answer 287

* A painless lump is the most common presenting symptom * Pain may also be present in a minority of men * Other possible features include hydrocele, gynaecomastia

Answer 288

* Ultrasound is first-line * CT scanning of the chest/ abdomen and pelvis is used for staging * Tumour markers (see above) should be measured

Answer 289

* Orchidectomy (Inguinal approach) * Chemotherapy and radiotherapy may be given depending on staging * Abdominal lesions \>1cm following chemotherapy may require retroperitoneal lymph node dissection.

Answer 290

* 5 year survival for seminomas is around 95% if Stage I * 5 year survival for teratomas is around 85% if Stage I

Answer 291

Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection. * Infection spreads from the urethra or bladder. In men \<35 years, gonorrhoea or chlamydia are the usual infections. * Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug. * Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.

Answer 292

* Twist of the spermatic cord resulting in testicular ischaemia and necrosis. * Most common in males aged between 10 and 30 (peak incidence 13-15 years) * Pain is usually severe and of sudden onset. * Cremasteric reflex is lost and elevation of the testis does not ease the pain. * Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Answer 293

* Presents as a mass that transilluminates, usually possible to 'get above' it on examination. * In younger men it should be investigated with USS to exclude tumour. * In children it may occur as a result of a patent processus vaginalis. * Treatment in adults is with a Lords or Jabouley procedure. * Treatment in children is with trans inguinal ligation of PPV.

Answer 294

The correct answer is: **Breast abscess****70%** ## Footnote This lady is likely to be breast feeding and is at risk of mastitis. This may lead to an abscess if not treated. *Staphylococcus aureus* is usually the causative organism.

Answer 295

**Duct ectasia****55%** ## Footnote Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts

Answer 296

**Intraductal papilloma****65%** ## Footnote Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained. If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.

Answer 297

Periductal mastitis

Answer 298

Intraductal papilloma

Answer 299

* Mammary duct ectasia may be seen in up to 25% of normal female breasts * Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age \>50 years) * The discharge is often thick and green * Duct ectasia is a normal varient of breast involution and is not the same condition as periductal mastitis

Answer 300

* Lactational mastitis is common * Infection is usually with *Staphylococcus aureus* * On examination there is usually a tender fluctuant mass * Treatment is with antibiotics and ultrasound guided aspiration * Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

Answer 301

* Rare in western countries, usually secondary TB * Affects women later in child bearing period * Chronic breast or axillary sinus is present in up to 50% cases * Diagnosis is by biopsy culture and histology

Answer 302

Ampulla fallopian tube

Answer 303

tubal ectopic: 93-97% * ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics * isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics * fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics

Answer 304

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy

Answer 305

* incidence = c. 0.5% of all pregnancies

Answer 306

* damage to tubes (pelvic inflammatory disease, surgery) * previous ectopic * endometriosis * IUCD * progesterone only pill * IVF (3% of pregnancies are ectopic)

Answer 307

Kartagener's syndrome (also known as primary ciliary dyskinesia) was first described in 1933 and most frequently occurs in examinations due to its association with dextrocardia (e.g. 'quiet heart sounds', 'small volume complexes in lateral leads')

Answer 308

Pathogenesis * dynein arm defect results in immotile cilia Features * dextrocardia or complete situs inversus * bronchiectasis * recurrent sinusitis * subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)

Answer 309

Minimal change disease would have been the most likely differential of nephrotic syndrome were the patient a child.

Answer 310

Mesangiocapillary glomerulonephritis causes a nephritic syndrome with at least a small amount of blood being present in the urine, which is absent in this patient.

Answer 311

Granulomatosis with polyangiitis is associated with a more nephritic picture.

Answer 312

Goodpasture's is associated with haematuria and concurrent pulmonary disease in which haemoptysis is a feature, neither of which this patient has.

Answer 313

Focal segmental glomerulosclerosis (FSGS) is a cause of nephrotic syndrome and chronic kidney disease. It generally presents in young adults.

Answer 314

* idiopathic * secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy * HIV * heroin * Alport's syndrome * sickle-cell

Answer 315

* renal biopsy * focal and segmental sclerosis and hyalinosis on light microscopy * effacement of foot processes on electron microscopy

Answer 316

Management * steroids +/- immunosuppressants Prognosis * untreated FSGS has a \< 10% chance of spontaneous remission

Answer 317

This patient has features of congestive heart failure. While loop diuretics (furosemide, bumetanide) and nitrates are important in the management of acute or decompensated cardiac failure, they have no effect on long-term survival. The following drugs have all been shown to reduce mortality in patients with left ventricular failure: * ACE-inhibitors * Beta-blockers * Angiotensin receptor blockers * Aldosterone antagonists * Hydralazine and nitrates

Answer 318

Digoxin has been shown to reduce hospital admissions but not mortality. It is generally used in patients with worsening heart failure despite first or second line treatments, or in patients with co-existant atrial fibrillation

Answer 319

The first-line treatment for all patients is both an **ACE-inhibitor** and a **beta-blocker** * generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first * beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol. * ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with *preserved* ejection fraction

Answer 320

Second-line treatment is an **aldosterone antagonist** * these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone * it should be remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored

Answer 321

Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy * ivabradine * criteria: sinus rhythm \> 75/min and a left ventricular fraction \< 35% * sacubitril-valsartan * criteria: left ventricular fraction \< 35% * is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs * should be initiated following ACEi or ARB wash-out period * digoxin * digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties * it is strongly indicated if there is coexistent atrial fibrillation * hydralazine in combination with nitrate * this may be particularly indicated in Afro-Caribbean patients * cardiac resynchronisation therapy * indications include a widened QRS (e.g. left bundle branch block) complex on ECG

Answer 322

* offer **annual influenza vaccine** * offer one-off **pneumococcal vaccine** * adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years

Answer 323

Allergic bronchopulmonary aspergillosis results from an allergy to *Aspergillus spores*. In the exam questions often give a history of bronchiectasis and eosinophilia.

Answer 324

* bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma * bronchiectasis (proximal)

Answer 325

* eosinophilia * flitting CXR changes * positive radioallergosorbent (RAST) test to Aspergillus * positive IgG precipitins (not as positive as in aspergilloma) * raised IgE

Answer 326

* oral glucocorticoids * itraconazole is sometimes introduced as a second-line agent

Answer 327

The diagnosis of type 2 diabetes mellitus can be made by either a plasma glucose or a HbA1c sample. Diagnostic criteria vary according to whether the patient is symptomatic (polyuria, polydipsia etc) or not.

Answer 328

If the patient is symptomatic: * fasting glucose greater than or equal to 7.0 mmol/l * random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test) If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions.

Answer 329

* a HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus * a HbAlc value of less than 48 mmol/mol (6.5%) does not exclude diabetes (i.e. it is not as sensitive as fasting samples for detecting diabetes) * in patients without symptoms, the test must be repeated to confirm the diagnosis * it should be remembered that misleading HbA1c results can be caused by increased red cell turnover (see below)

Answer 330

* haemoglobinopathies * haemolytic anaemia * untreated iron deficiency anaemia * suspected gestational diabetes * children * HIV * chronic kidney disease * people taking medication that may cause hyperglycaemia (for example corticosteroids)

Answer 331

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG) Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l Diabetes UK suggests: * 'People with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn't have diabetes but does have IGT.'

Answer 332

Whole breast radiotherapy

Answer 333

* erythematous plaques covered with a silvery-white scale * typically on the extensor surfaces such as the elbows and knees. Also common on the scalp, trunk, buttocks and periumbilical area * clear delineation between normal and affected skin * plaques typically range from 1 to 10 cm in size * if the scale is removed, a red membrane with pinpoint bleeding points may be seen (Auspitz's sign)

Answer 334

Chronic plaque psoriasis is the most common form of psoriasis seen in clinical practice, accounting for around 80% of presentations.

Answer 335

Exacerbations of chronic bronchitisAmoxicillin or tetracycline or clarithromycinUncomplicated community-acquired pneumoniaAmoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)Pneumonia possibly caused by atypical pathogensClarithromycinHospital-acquired pneumoniaWithin 5 days of admission: co-amoxiclav or cefuroxime More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)

Answer 336

Lower urinary tract infectionTrimethoprim or nitrofurantoin. Alternative: amoxicillin or cephalosporinAcute pyelonephritisBroad-spectrum cephalosporin or quinoloneAcute prostatitisQuinolone or trimethoprim

Answer 337

**Condition****Recommended treatment**ImpetigoTopical hydrogen peroxide, oral flucloxacillin or erythromycin if widespreadCellulitisFlucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)Cellulitis (near the eyes or nose)Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)ErysipelasFlucloxacillin\* (clarithromycin, erythromycin or doxycycline if penicillin-allergic)Animal or human biteCo-amoxiclav (doxycycline + metronidazole if penicillin-allergic)Mastitis during breast-feedingFlucloxacillin

Answer 338

Throat infectionsPhenoxymethylpenicillin (erythromycin alone if penicillin-allergic)SinusitisPhenoxymethylpenicillinOtitis mediaAmoxicillin (erythromycin if penicillin-allergic)Otitis externa\*\*Flucloxacillin (erythromycin if penicillin-allergic)Periapical or periodontal abscessAmoxicillinGingivitis: acute necrotising ulcerativeMetronidazole

Answer 339

**Condition****Recommended treatment**GonorrhoeaIntramuscular ceftriaxone*Chlamydia*Doxycycline or azithromycinPelvic inflammatory diseaseOral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazoleSyphilisBenzathine benzylpenicillin or doxycycline or erythromycinBacterial vaginosisOral or topical metronidazole or topical clindamycin

Answer 340

*Clostridium difficile*First episode: metronidazole Second or subsequent episode of infection: vancomycinCampylobacter enteritisClarithromycinSalmonella (non-typhoid)CiprofloxacinShigellosisCiprofloxacin

Answer 341

Laughter → fall/collapse ? cataplexy

Answer 342

Laughter → fall/collapse ? cataplexy

Answer 343

Cataplexy describes the sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Around two-thirds of patients with narcolepsy have cataplexy. Features range from buckling knees to collapse.

Answer 344

Undercooked pork

Answer 345

Hepatitis E and A

Answer 346

Hepatitis D requires co-infection with hepatitis B.

Answer 347

* RNA hepevirus * spread by the faecal-oral route * incubation period: 3-8 weeks * common in Central and South-East Asia, North and West Africa, and in Mexico * causes a similar disease to hepatitis A, but carries a significant mortality (about 20%) during pregnancy * does not cause chronic disease or an increased risk of hepatocellular cancer * a vaccine is currently in development, but is not yet in widespread use

Answer 348

Hep B I think

Answer 349

This patient has developed pulmonary fibrosis secondary to long term amiodarone use. It typically occurs with doses that exceed 400mg daily after two or more months of therapy. Estimates range from 1 to 5% in the patients who are on long term amiodarone. The mechanism is not entirely understood however, current hypotheses include direct toxic injury to the lung or an indirect immunological reaction.

Answer 350

Acronym for causes of upper zone fibrosis: CHARTS * C - Coal worker's pneumoconiosis * H - Histiocytosis/ hypersensitivity pneumonitis * A - Ankylosing spondylitis * R - Radiation * T - Tuberculosis * S - Silicosis/sarcoidosis

Answer 351

* diopathic pulmonary fibrosis * most connective tissue disorders (except ankylosing spondylitis) e.g. SLE * drug-induced: amiodarone, bleomycin, methotrexate * asbestosis

Answer 352

Liver disease

Answer 353

iron defieincy anaemia

Answer 354

Colonscopy to r/o colorectal Ca

Answer 355

Fungal infection

Answer 356

* tinea capitis - scalp * tinea corporis - trunk, legs or arms * tinea pedis - feet

Wednesday [06/10/2021] Flashcards

(403 cards)