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997 Cards in this Set
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INV for SLE |
Immunology 99% are ANA positive 20% are rheumatoid factor positive anti-dsDNA: highly specific (> 99%), but less sensitive (70%) anti-Smith: most specific (> 99%), sensitivity (30%) also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
Monitoring ESR C4 complement levels anti-dsDNA (nb not in all pxs) |
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STEMI def |
new ST elevation at the J-point in two contiguous leads with the cut-off points: >=0.2 mV in men or >= 0.15 mV in women in leads V2-V3 and/or >= 0.1 mV in other leads |
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Acute MI |
hyperacute T waves are often the first sign of MI but often only persists for a few minutes ST elevation may then develop the T waves typically become inverted within the first 24 hours. The inversion of the T waves can last for days to months pathological Q waves develop after several hours to days. This change usually persists indefinitely |
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Chronic obstructive pulmonary disease requires spirometry to confirm the diagnosis but this chest x-ray is highly suggestive.
Fxs include |
hyperinflation flattened hemidiaphragms hyperlucent lung fields |
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The severity of COPD is categorised using the FEV1*: |
Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity
< 0.7 > 80% Stage 1 - Mild**
< 0.7 50-79% Stage 2 - Moderate
< 0.7 30-49% Stage 3 - Severe
< 0.7 < 30% Stage 4 - Very severe |
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The severity of COPD is categorised using the FEV1*: |
Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity
< 0.7 > 80% Stage 1 - Mild**
< 0.7 50-79% Stage 2 - Moderate
< 0.7 30-49% Stage 3 - Severe
< 0.7 < 30% Stage 4 - Very severe |
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The following investigations are recommended in patients with suspected COPD: |
post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer full blood count: exclude secondary polycythaemia body mass index (BMI) calculation |
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Asthma tx |
Saba Add ICS Add Laba Up ICS +- stop Laba +- add leukotriene antag +- add theothyline Refer to specialist |
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Leukotriene receptor antagonists |
e.g. Montelukast, zafirlukast have both anti-inflammatory and bronchodilatory properties should be used when patients are poorly controlled on high-dose inhaled corticosteroids and a long-acting b2-agonist particularly useful in aspirin-induced asthma associated with the development of Churg-Strauss syndrome |
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Long acting B2-agonists acts as |
bronchodilators but also inhibit mediator release from mast cells.
Recent meta-analysis showed adding salmeterol improved symptoms compared to doubling the inhaled steroid dose |
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A 25-year-old man presents for review. For the past year he has been experiencing headaches. These are now occurring around 5-6 times per month and typically 'last all day' when they occur. They are not associated with any form of aura. A typical headache is described as a severe throbbing on both sides of his head associated with nausea and lethargy. When he gets such a headache he typically goes to bed so he can 'sleep it off'. Before going to bed he typically takes one of his father's diclofenac tablets which seem to help.
Neurological examination is unremarkable.
What is the most likely diagnosis? |
Migraine |
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A 25-year-old man presents for review. For the past year he has been experiencing headaches. These are now occurring around 5-6 times per month and typically 'last all day' when they occur. They are not associated with any form of aura. A typical headache is described as a severe throbbing on both sides of his head associated with nausea and lethargy. When he gets such a headache he typically goes to bed so he can 'sleep it off'. Before going to bed he typically takes one of his father's diclofenac tablets which seem to help.
Neurological examination is unremarkable.
What is the most likely diagnosis? |
Migraine |
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A 65-year-old Asian female presents with generalised bone pain and muscle weakness. Investigations show:
Calcium 2.07 mmol/l Phosphate 0.66 mmol/l ALP 256 U/l
What is the most likely diagnosis? |
Osteomalacia |
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Osteomalacia basics |
normal bony tissue but decreased mineral content
rickets if when growing
osteomalacia if after epiphysis fusion |
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Osteomalacia types |
vitamin D deficiency e.g. malabsorption, lack of sunlight, diet renal failure drug induced e.g. anticonvulsants vitamin D resistant; inherited liver disease, e.g. cirrhosis |
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Osteomalacia vs rickets |
rickets: knock-knee, bow leg, features of hypocalcaemia
osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy |
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Osteomalacia vs rickets |
rickets: knock-knee, bow leg, features of hypocalcaemia
osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy |
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Osteomalacia tx |
calcium with vitamin D tablets |
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Osteomalacia vs rickets |
rickets: knock-knee, bow leg, features of hypocalcaemia
osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy |
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Osteomalacia tx |
calcium with vitamin D tablets |
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Osteomalacia INV |
low calcium, phosphate, 25(OH) vitamin D raised alkaline phosphatase x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures) |
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In a px with aki who is hypotensive n needs IV fluids, why wouldnt you give hartmanns solution? |
Hartmann's solution contains potassium, therefore in the setting of an acute kidney injury, it might be more appropriate to give 0.9% saline, which does not contain any potassium, since hyperkalaemia is a concern in AKI. |
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In a px with aki who is hypotensive n needs IV fluids, why wouldnt you give hartmanns solution? |
Hartmann's solution contains potassium, therefore in the setting of an acute kidney injury, it might be more appropriate to give 0.9% saline, which does not contain any potassium, since hyperkalaemia is a concern in AKI. |
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Most likely orgs causing dis |
Common cold
Rhinovirus
11. A 45-year-old smoker who develops pneumonia
Streptococcus pneumoniae
12. A 6-month-old who is 'chesty', has rhinitis and is off her feeds. Auscultation of her chest reveals bibasal crackles and an expiratory wheeze.
Respiratory syncytial virus |
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Respiratory syncytial virus is associated with |
Bronchiolitis |
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Respiratory syncytial virus is associated with |
Bronchiolitis |
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Orgs n assoc dis |
Parainfluenza virus = Croup Rhinovirus = Common cold Influenza virus = Flu |
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Atypical pneumonia |
Mycoplasma pneumoniae Atypical pneumonia
Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme Legionella pneumophilia Atypical pneumonia
Classically spread by air-conditioning systems, causes dry cough. Lymphopenia, deranged liver function tests and hyponatraemia may be seen Pneumocystis jiroveci |
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Indications for warfarin |
venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5 mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves. |
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Warfarin moa |
Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C. |
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Indications for warfarin |
venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5 mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves. |
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Warfarin moa |
Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C. |
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Which one of the following organisms causes erysipelas? |
Strep pyogenes |
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Alpha haemolytic streptococci (partial haemolysis) |
The most important alpha haemolytic Streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans |
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Indications for warfarin |
venous thromboembolism: target INR = 2.5, if recurrent 3.5 atrial fibrillation, target INR = 2.5 mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves. |
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Warfarin moa |
Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C. |
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Which one of the following organisms causes erysipelas? |
Strep pyogenes |
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Alpha haemolytic streptococci (partial haemolysis) |
The most important alpha haemolytic Streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans |
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Beta haemolytic streptococci (complete haemolysis) |
These can be subdivided into groups A-H. Only groups A, B & D are important in humans. |
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Grp A |
most important organism is Streptococcus pyogenes responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis erythrogenic toxins cause scarlet fever |
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Grp B |
Streptococcus agalactiae may lead to neonatal meningitis and septicaemia |
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Grp D |
Enterococcus |
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Normal creatinine range |
Creatinine 55-120 umol/l |
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Emergency tx with diabetic ketoacidosis |
Emergency treatment with fluids and insulin should be commenced. |
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ABG interpretation |
1. How is the patient?
2. Is the patient hypoxaemic? the Pa02 on air should be >10 kPa
3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)
4. Respiratory component: What has happened to the PaCO2? PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for a metabolic alkalosis) PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for a metabolic acidosis)
5. Metabolic component: What is the bicarbonate level/base excess? bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis) bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory acidosis) |
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ABG interpretation |
1. How is the patient?
2. Is the patient hypoxaemic? the Pa02 on air should be >10 kPa
3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)
4. Respiratory component: What has happened to the PaCO2? PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for a metabolic alkalosis) PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for a metabolic acidosis)
5. Metabolic component: What is the bicarbonate level/base excess? bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis) bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory acidosis) |
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Which one of the following interventions is most likely to increase survival in patients with COPD? |
Smoking cessation |
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COPD mgmt
General management smoking cessation advice annual influenza vaccination one-off pneumococcal vaccination
Plus |
SABA/LAMA
FEV1 > 50% LABA /LAMA
FEV1 < 50% LABA + ICS OR LAMA
LABA + ICS LABA + LAMA + ICS
+- Oral theophylline
+- Mucolytics |
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COPD mgmt (SAMA = muscarinic antag)
General management smoking cessation advice annual influenza vaccination one-off pneumococcal vaccination
Plus |
SABA/SAMA - 1st line
FEV1 > 50% Add LABA /LAMA
FEV1 < 50% Add LABA + ICS OR Add LAMA
Add LABA + ICS OR Add LABA + LAMA + ICS
+- Oral theophylline
+- Mucolytics |
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COPD mgmt (SAMA = muscarinic antag)
General management smoking cessation advice annual influenza vaccination one-off pneumococcal vaccination
Plus |
SABA/SAMA - 1st line
FEV1 > 50% Add LABA /LAMA
FEV1 < 50% Add LABA + ICS OR Add LAMA
Add LABA + ICS OR Add LABA + LAMA + ICS
+- Oral theophylline
+- Mucolytics
+- Cor pulmonale tx |
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COPD mgmt (SAMA = muscarinic antag)
General management smoking cessation advice annual influenza vaccination one-off pneumococcal vaccination
Plus |
SABA/SAMA - 1st line
FEV1 > 50% Add LABA /LAMA
FEV1 < 50% Add LABA + ICS OR Add LAMA
Add LABA + ICS OR Add LABA + LAMA + ICS
+- Oral theophylline
+- Mucolytics
+- Cor pulmonale tx |
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Mgmt of cor pulmonale |
features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2 use a loop diuretic for oedema, consider long-term oxygen therapy ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE |
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Factors which may improve survival in patients with stable COPD |
smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients |
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SIADH - drug causes: |
carbamazepine, sulfonylureas, SSRIs, tricyclics |
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You are asked for advice from a local GP. He has received the following blood results for one of his patients, a 50-year-old non-smoker.
Na+ 130 mmol/l Which drug caused this |
fluoxitine |
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SIADH mgmt |
correction must be done slowly to avoid precipitating central pontine myelinolysis fluid restriction
demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH
ADH (vasopressin) receptor antagonists have been developed |
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SIADH causes |
Malignancy small cell lung cancer also: pancreas, prostate
Neurological stroke subarachnoid haemorrhage subdural haemorrhage meningitis/encephalitis/abscess
Infections tuberculosis pneumonia
Drugs sulfonylureas SSRIs, tricyclics carbamazepine vincristine cyclophosphamide
Other causes positive end-expiratory pressure (PEEP) porphyrias |
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A 25-year-old woman presents for review. She has a history of depression and is currently prescribed citalopram. Despite returning from a recent holiday in Spain she complains of feeling tired all the time. On examination you notice a slightly raised red rash on the bridge of her nose and cheeks. Although she complains of having 'stiff joints' you can find no evidence of arthritis. You order some basic blood tests:
Hb 12.7 g/dl Platelets 130 * 109/l WBC 3.3 * 109/l
Na+ 138 mmol/l K+ 4.0 mmol/l Urea 3.4 mmol/l Creatinine 77 µmol/l
Free T4 12.2 pmol/l TSH 1.25 mu/l CRP 9 mg/l
What is the most likely diagnosis? |
Systemic lupus erythematosus |
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Sle |
The malar rash, arthralgia, lethargy and history of mental health points towards a diagnosis of SLE. Remember that the CRP (in contrast to the ESR) is typically normal in SLE. Rate, discuss and give feedback on this question Next question |
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A 60-year-old woman presents with a tremor. Which one of the following features would suggest a diagnosis of essential tremor rather than Parkinson's disease?
Difficulty in initiating movement Tremor is worse following alcohol Postural instability Unilateral symptoms Tremor is worse when the arms are outstretched |
Tremor is worse when the arms are outstretched |
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Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs
Fxs |
postural tremor: worse if arms outstretched improved by alcohol and rest most common cause of titubation (head tremor) |
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Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs
Fxs |
postural tremor: worse if arms outstretched improved by alcohol and rest most common cause of titubation (head tremor) |
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Tx for essential tremor 1st line |
propranolol is first-line primidone is sometimes used |
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You are clerking a 67-year-old man who has been admitted with chest pain. His past medical history includes hypertension, angina and he continues to smoke 20 cigarettes / day. Blood tests done in the Emergency Department show the following:
Na+ 133 mmol/l K+ 3.3 mmol/l Urea 4.5 mmol/l Creatinine 90 µmol/l
Which one of the following factors is most likely to explain the abnormalities seen in the urea and electrolytes?
Enalapril therapy Felodipine therapy Bendroflumethiazide therapy His smoking history Spironolactone therapy |
Bendroflumethiazide therapy |
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Thiazide diuretics work by |
inhibiting sodium absorption at the beginning of the distal convoluted tubule (DCT)
Potassium is lost as a result of more sodium reaching the collecting ducts |
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Common adverse effects of thiazide diuretics
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dehydration postural hypotension hyponatraemia, hypokalaemia, hypercalcaemia gout impaired glucose tolerance impotence |
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Sxs of hypercalcemia mnemonic |
Stones (renal) Bones (bone pain) Groans (abdominal pain, nausea and vomiting) Thrones (polyuria) Psychiatric overtones (confusion and cognitive dysfunction, depression, anxiety, insomnia, coma) |
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The most common causes of hypercalcaemia are |
malignancy (bone metastases, myeloma, PTHrP from squamous cell lung cancer) and primary hyperparathyroidism |
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The most common causes of hypercalcaemia are |
malignancy (bone metastases, myeloma, PTHrP from squamous cell lung cancer) and primary hyperparathyroidism
Other causes include sarcoidosis* vitamin D intoxication acromegaly thyrotoxicosis Milk-alkali syndrome drugs: thiazides, calcium containing antacids dehydration Addison's disease Paget's disease of the bone** |
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A 60 year old man with a history of hypercholesterolemia, hypertension and type 2 diabetes mellitus reports an episode of right sided facial weakness and dysphasia lasting thirty minutes earlier that same day. His symptoms have since resolved. His blood pressure is recorded at 130/85 mmHg and there is a carotid bruit present on the left side. What is his ABCD2 score?
3 4 5 6 7 |
5
His age (1), history of diabetes (1), facial weakness (2) and duration (1) give him a score of 5. Rate, discuss and give feedback on this question Next question |
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NICE issued updated guidelines relating to stroke and transient ischaemic attack (TIA) in 2008. They advocated the use of the ABCD2 prognostic score for risk stratifying patients who've had a suspected TIA: |
A Age >= 60 years 1 B Blood pressure >= 140/90 mmHg 1 C Clinical features - Unilateral weakness - Speech disturbance, no weakness 2 1 D Duration of symptoms - > 60 minutes - 10-59 minutes 2 1 Patient has diabetes |
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ABCD2 score of 4 or above) should have: |
aspirin (300 mg daily) started immediately specialist assessment and investigation within 24 hours of onset of symptoms measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors |
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the ABCD2 risk score is 3 or below: |
specialist assessment within 1 week of symptom onset, including decision on brain imaging if vascular territory or pathology is uncertain, refer for brain imaging |
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Red flags for lower back pain |
age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever |
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Red flags for lower back pain |
age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever |
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Facet joint pain |
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 |
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A 41-year-old man develops itchy, polygonal, violaceous papules on the flexor aspect of his forearms. Some of these papules have coalesced to form plaques. What is the most likely diagnosis? |
Lichen planus |
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A 41-year-old man develops itchy, polygonal, violaceous papules on the flexor aspect of his forearms. Some of these papules have coalesced to form plaques. What is the most likely diagnosis? |
Lichen planus |
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Lichen |
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common sclerosus: itchy white spots typically seen on the vulva of elderly women |
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A 2-year-old boy is brought in by his mother due to concerns about his hearing and delayed speech. She has noticed problems for the past three months. You can see from the notes that he has had frequent courses of amoxicillin for otitis media in the past. There is no evidence of excessive ear wax on examination. |
Glue ear |
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A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable. |
Threatened miscarriage |
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A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable. |
Threatened miscarriage
The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy. In clinical practice this patient would be referred the same day for an ultrasound scan. |
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A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable. |
Threatened miscarriage
The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy. In clinical practice this patient would be referred the same day for an ultrasound scan. |
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Women who have a urogenital prolapse typically describe a |
'bearing down', 'heaviness' or 'dragging' sensation. |
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A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable. |
Threatened miscarriage
The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy. In clinical practice this patient would be referred the same day for an ultrasound scan. |
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Women who have a urogenital prolapse typically describe a |
'bearing down', 'heaviness' or 'dragging' sensation. |
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A 29-year-old woman presents with suprapubic pain, irregular periods, dysuria and pain during intercourse. There is cervical excitation on examination. |
Pelvic inflammatory disease
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy |
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A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable. |
Threatened miscarriage
The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy. In clinical practice this patient would be referred the same day for an ultrasound scan. |
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Women who have a urogenital prolapse typically describe a |
'bearing down', 'heaviness' or 'dragging' sensation. |
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A 29-year-old woman presents with suprapubic pain, irregular periods, dysuria and pain during intercourse. There is cervical excitation on examination. |
Pelvic inflammatory disease
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy |
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Ectopic pregnancy |
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding Shoulder tip pain and cervical excitation may be seen |
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A 24-year-old woman presents with mild, crampy suprapubic pain and light vaginal bleeding. Her last period was 10 weeks ago. Vaginal examination shows a small amount of blood around the cervix but is otherwise unremarkable. |
Threatened miscarriage
The mild suprapubic pain at 10 weeks gestation is more characteristic of a miscarriage than an ectopic pregnancy. In clinical practice this patient would be referred the same day for an ultrasound scan. |
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Women who have a urogenital prolapse typically describe a |
'bearing down', 'heaviness' or 'dragging' sensation. |
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A 29-year-old woman presents with suprapubic pain, irregular periods, dysuria and pain during intercourse. There is cervical excitation on examination. |
Pelvic inflammatory disease
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy |
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Ectopic pregnancy |
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding Shoulder tip pain and cervical excitation may be seen |
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Ovarian torsion mass key fx |
Tender adnexial mass in abdo |
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Ovarian torsion mass key fx |
Tender adnexial mass in abdo
Nb Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common Unilateral, tender adnexal mass on examination |
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Ovarian torsion mass key fx |
Tender adnexial mass in abdo
Nb Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common Unilateral, tender adnexal mass on examination |
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Endometriosis |
Chronic pelvic pain Dysmenorrhoea - pain often starts days before bleeding Deep dyspareunia Subfertility |
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Ovarian torsion mass key fx |
Tender adnexial mass in abdo
Nb Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common Unilateral, tender adnexal mass on examination |
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Endometriosis |
Chronic pelvic pain Dysmenorrhoea - pain often starts days before bleeding Deep dyspareunia Subfertility |
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Ovarian cyst |
Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain Large cysts may cause abdominal swelling or pressure effects on the bladder |
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A 28-year-old woman is 30 weeks into her first pregnancy. She is found to have a blood pressure of 162/110 mmHg and a urine dipstick shows protein +++. She also has marked oedema of her ankles but feels well in herself. What is the first line therapy to manage her high blood pressure? |
Labetalol |
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overdose of amitriptyline tx |
IV bicarbonate |
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A 28-year-old woman is 30 weeks into her first pregnancy. She is found to have a blood pressure of 162/110 mmHg and a urine dipstick shows protein +++. She also has marked oedema of her ankles but feels well in herself. What is the first line therapy to manage her high blood pressure? |
Labetalol |
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overdose of amitriptyline tx |
IV bicarbonate |
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Salicylate OD TX |
Hemodialysis
Nb rare = urinary alkalinization |
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A 28-year-old woman is 30 weeks into her first pregnancy. She is found to have a blood pressure of 162/110 mmHg and a urine dipstick shows protein +++. She also has marked oedema of her ankles but feels well in herself. What is the first line therapy to manage her high blood pressure? |
Labetalol |
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overdose of amitriptyline tx |
IV bicarbonate |
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Salicylate OD TX |
Hemodialysis
Nb rare = urinary alkalinization |
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Benzodiazepines OD TX
BAZOs |
Flumazenil |
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Tricyclic antidepressants OD TX |
IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
correction of acidosis is the first line in management of tricyclic induced arrhythmias |
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Tricyclic antidepressants OD TX |
IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
correction of acidosis is the first line in management of tricyclic induced arrhythmias |
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Warfar |
Vitamin K, prothrombin complex |
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What does the power of the study equte to? |
Power = 1 - the probability of a type II error |
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Power explanation |
A null hypothesis (H0) states that two treatments are equally effective (and is hence negatively phrased). A significance test uses the sample data to assess how likely the null hypothesis is to be correct.
For example: 'there is no difference in the prevalence of colorectal cancer in patients taking low-dose aspirin compared to those who are not'
The alternative hypothesis (H1) is the opposite of the null hypothesis, i.e. There is a difference between the two treatments
The p value is the probability of obtaining a result by chance at least as extreme as the one that was actually observed, assuming that the null hypothesis is true. It is therefore equal to the chance of making a type I error (see below).
Two types of errors may occur when testing the null hypothesis type I: the null hypothesis is rejected when it is true - i.e. Showing a difference between two groups when it doesn't exist, a false positive. This is determined against a preset significance level (termed alpha). As the significance level is determined in advance the chance of making a type I error is not affected by sample size. It is however increased if the number of end-points are increased. For example if a study has 20 end-points it is likely one of these will be reached, just by chance. type II: the null hypothesis is accepted when it is false - i.e. Failing to spot a difference when one really exists, a false negative. The probability of making a type II error is termed beta. It is determined by both sample size and alpha
The power of a study is the probability of (correctly) rejecting the null hypothesis when it is false, i.e. the probability of detecting a statistically significant difference power = 1 - the probability of a type II error power can be increased by increasing the sample size
Study accepts H0 Study rejects H0 Reality H0 Type 1 error (alpha) Reality H1 Type 2 error (beta) Power (1 - beta) |
|
|
A 51-year-old woman presents to her GP with abdominal bloating and cramps which have occurred daily for the past 3 weeks. On examination, a small pelvic mass was palpable, What test is the most appropriate next investigation? |
Ca125 |
|
|
A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks she is pregnant. This is confirmed with a positive pregnancy test. She is known to be HIV positive. Which one of the following should NOT be part of the management plan to ensure an optimal outcome? |
Encourage breast feeding |
|
|
A 3-year-old girl is brought in by her mother. Her mother reports that she has been eating less and refusing food for the past few weeks. Despite this her mother has noticed that her abdomen is distended and she has developed a 'beer belly'. For the past year she has opened her bowels around once every other day, passing a stool of 'normal' consistency. There are no urinary symptoms. On examination she is on the 50th centile for height and weight. Her abdomen is soft but slightly distended and a non-tender ballotable mass can be felt on the left side. Her mother has tried lactulose but there has no significant improvement. What is the most appropriate next step in management? |
Local paed referral
Dx is wilms tumor = Wilms' nephroblastoma is one of the most common childhood malignancies. |
|
|
A 27 year old woman is becoming exhausted during labour, and there are new signs on the foetal monitor to suggest foetal distress The midwife elects to attempt a forceps assisted delivery.
Which of the following is more a more likely potential complication associated with this procedure? |
Facial nerve palsy |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical Rate, discuss and give feedback on this question Next question |
True |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical Rate, discuss and give feedback on this question Next question |
True |
|
|
Subacute thyroiditis fxs |
Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical Rate, discuss and give feedback on this question Next question |
True |
|
|
Subacute thyroiditis fxs |
Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism |
|
|
Subacute thyroiditis fxs |
hyperthyroidism painful goitre raised ESR globally reduced uptake on iodine-131 scan |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical Rate, discuss and give feedback on this question Next question |
True |
|
|
Subacute thyroiditis fxs |
Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism |
|
|
Subacute thyroiditis fxs |
hyperthyroidism painful goitre raised ESR globally reduced uptake on iodine-131 scan |
|
|
Subacute thyroiditis mgmt |
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops |
|
|
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first? |
Transvaginal US |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
Endometrial cancer is a common cancer in |
post-menopausal women and it is important to rule this out in all women that present with post-menopausal bleeding. |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical Rate, discuss and give feedback on this question Next question |
True |
|
|
Subacute thyroiditis fxs |
Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism |
|
|
Subacute thyroiditis fxs |
hyperthyroidism painful goitre raised ESR globally reduced uptake on iodine-131 scan |
|
|
Subacute thyroiditis mgmt |
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops |
|
|
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first? |
Transvaginal US |
|
|
indication for assisted delivery. This may be performed using forceps or a ventouse device. During a forceps delivery, the forceps are applied around the face of the foetus and a force is applied by the user in order to aid delivery. As there is compression to the sides of the face, the facial nerve is at risk of being damaged resulting in facial nerve palsy. This may be temporary or permanent. The other optional answers in the question (other than Erb's palsy) are complications that are more associated with ventouse assisted deliveries. Erb's palsy can be a complication of shoulder dystocia. |
True |
|
|
Endometrial cancer is a common cancer in |
post-menopausal women and it is important to rule this out in all women that present with post-menopausal bleeding. |
|
|
Risk factors for endometrial cancer |
HRT Nulliparity Late menopause Early menses Obesity Diabetes Polycystic ovarian syndrome Family history |
|
|
A 38-year-old woman at 37 weeks gestation presents to the Emergency Department with a 12 hour history of nausea and right upper quadrant pain. Her hands and feet are oedematous. Urine dip shows protein 2+. Blood pressure is 160/110 mmHg. Her most recent blood tests are shown below.
Hb 95 g/l Platelets 60 * 109/l WBC 5.5 * 109/l
Bilirubin 88 µmol/l ALP 526 u/l ALT 110 u/l
What is the definitive treatment for this condition?
Seizure prophylaxis Intravenous dexamethasone Platelet transfusion Delivery of the fetus Whole blood transfusion |
Delivery of the fetus
This woman has HELLP syndrome, a severe form of pre-eclampsia. HELLP stands for haemolysis (H), elevated liver enzymes (EL) and low platelets (LP). Additionally, LDH will be raised due to haemolysis. |
|
|
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies |
True |
|
|
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome |
True |
|
|
A 46-year-old woman is referred to endocrine with a tender neck swelling. Blood results are as follows:
TSH <0.1 mU/l T4 188 nmol/l
Hb 14.2 g/dl Plt 377 * 109/l WBC 6.4 * 109/l
ESR 65 mm/hr
Technetium thyroid scan shows decreased uptake globally
What is the most likely diagnosis? |
Subacute thyroiditis |
|
|
Subacute thyroiditis is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical Rate, discuss and give feedback on this question Next question |
True |
|
|
Subacute thyroiditis fxs |
Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism |
|
|
Subacute thyroiditis fxs |
hyperthyroidism painful goitre raised ESR globally reduced uptake on iodine-131 scan |
|
|
Subacute thyroiditis mgmt |
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops |
|
|
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first? |
Transvaginal US |
|
|
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first? |
Transvaginal US
to measure the endometrial thickness.
If the endometrial lining is thickened then a hysteroscopy will be preformed and an endometrial biopsy taken. |
|
|
A 67 year old woman attends your GP surgery complaining of three episodes of post- menopausal bleeding in the past month, which she describes as spotting. She went through the menopause 10 years ago and has had no bleeding until this episode. She took hormone replacement therapy for five years. You perform an abdominal exam, which is unremarkable and a vaginal examination, which is normal apart from some vaginal dryness.
What is the investigation you are going to perform first? |
Transvaginal US
to measure the endometrial thickness.
If the endometrial lining is thickened then a hysteroscopy will be preformed and an endometrial biopsy taken. |
|
|
Mgmt of endometrial cancer |
usually laparoscopic hysterectomy with bilateral salpingo-oophorectomy, with or without radiotherapy |
|
|
A 26 year old pregnant woman is found to be blood group Rhesus (D) negative at booking. Which of the following is an indication for administration of anti-D? |
Amniocentesis |
|
|
A 26 year old pregnant woman is found to be blood group Rhesus (D) negative at booking. Which of the following is an indication for administration of anti-D? |
Amniocentesis
In rhesus negative mothers, mixing of maternal and fetal blood may precipitate isoimmunisation, resulting in immune hydrops for the fetus. Amniocentesis, external cephalic version, blunt abdominal trauma and caesarean section are some of the 'sensitising events' which may do this. In case of rhesus sensitisation, anti-D can be given to the mother to remove any circulating antibodies to fetal red blood cells. |
|
|
A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies |
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks |
|
|
A 61-year-old man presents with a two-week history of a sharp, stabbing pain over his right cheekbone. He describes the pain as 'very severe' and 'coming in spasms'. It typical lasts for around one minute before subsiding. The pain can be triggered by shaving and eating. Examination of his eyes, cranial nerves and mouth is unremarkable. What is the most likely diagnosis? |
Trigeminal neuralgia |
|
|
A 26 year old pregnant woman is found to be blood group Rhesus (D) negative at booking. Which of the following is an indication for administration of anti-D? |
Amniocentesis
In rhesus negative mothers, mixing of maternal and fetal blood may precipitate isoimmunisation, resulting in immune hydrops for the fetus. Amniocentesis, external cephalic version, blunt abdominal trauma and caesarean section are some of the 'sensitising events' which may do this. In case of rhesus sensitisation, anti-D can be given to the mother to remove any circulating antibodies to fetal red blood cells. |
|
|
A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies |
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks |
|
|
A 61-year-old man presents with a two-week history of a sharp, stabbing pain over his right cheekbone. He describes the pain as 'very severe' and 'coming in spasms'. It typical lasts for around one minute before subsiding. The pain can be triggered by shaving and eating. Examination of his eyes, cranial nerves and mouth is unremarkable. What is the most likely diagnosis? |
Trigeminal neuralgia |
|
|
Trigeminal neuralgia tx 1st line |
carbamazepine is first-line
Nb
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology |
|
|
Legionella pnemonia fxs |
There are a number of features here which strongly suggest Legionella: recent foreign travel flu-like symptoms hyponatraemia pleural effusion |
|
|
A 26 year old pregnant woman is found to be blood group Rhesus (D) negative at booking. Which of the following is an indication for administration of anti-D? |
Amniocentesis
In rhesus negative mothers, mixing of maternal and fetal blood may precipitate isoimmunisation, resulting in immune hydrops for the fetus. Amniocentesis, external cephalic version, blunt abdominal trauma and caesarean section are some of the 'sensitising events' which may do this. In case of rhesus sensitisation, anti-D can be given to the mother to remove any circulating antibodies to fetal red blood cells. |
|
|
A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies |
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks |
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A 61-year-old man presents with a two-week history of a sharp, stabbing pain over his right cheekbone. He describes the pain as 'very severe' and 'coming in spasms'. It typical lasts for around one minute before subsiding. The pain can be triggered by shaving and eating. Examination of his eyes, cranial nerves and mouth is unremarkable. What is the most likely diagnosis? |
Trigeminal neuralgia |
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Trigeminal neuralgia tx 1st line |
carbamazepine is first-line
Nb
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology |
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Legionella pnemonia fxs |
There are a number of features here which strongly suggest Legionella: recent foreign travel flu-like symptoms hyponatraemia pleural effusion |
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Legionella bact |
It is typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen |
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A 26 year old pregnant woman is found to be blood group Rhesus (D) negative at booking. Which of the following is an indication for administration of anti-D? |
Amniocentesis
In rhesus negative mothers, mixing of maternal and fetal blood may precipitate isoimmunisation, resulting in immune hydrops for the fetus. Amniocentesis, external cephalic version, blunt abdominal trauma and caesarean section are some of the 'sensitising events' which may do this. In case of rhesus sensitisation, anti-D can be given to the mother to remove any circulating antibodies to fetal red blood cells. |
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A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies |
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks |
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A 61-year-old man presents with a two-week history of a sharp, stabbing pain over his right cheekbone. He describes the pain as 'very severe' and 'coming in spasms'. It typical lasts for around one minute before subsiding. The pain can be triggered by shaving and eating. Examination of his eyes, cranial nerves and mouth is unremarkable. What is the most likely diagnosis? |
Trigeminal neuralgia |
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Trigeminal neuralgia tx 1st line |
carbamazepine is first-line
Nb
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology |
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Legionella pnemonia fxs |
There are a number of features here which strongly suggest Legionella: recent foreign travel flu-like symptoms hyponatraemia pleural effusion |
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Legionella bact |
It is typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen |
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Legionella causes legionnaires dis dx and tx |
Dx urinary antigen
Tx erythromycin |
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Complications of tonsillitis include: |
otitis media quinsy - peritonsillar abscess rheumatic fever and glomerulonephritis very rarely |
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Complications of tonsillitis include: |
otitis media quinsy - peritonsillar abscess rheumatic fever and glomerulonephritis very rarely |
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A 24-year-old woman presents to her GP with lower abdominal pains these have been getting worse over the past 2 days. The pain is in the suprapubic area and slightly to the right. She had some vaginal bleeding this morning which she describes as being like a light period. The patient also describes some shoulder pain which she thinks came on following a game of squash. Her last period was 8 weeks ago and was described as normal. In the past she has been treated for Chlamydia infection and admits to not practicing safer sex.
On examination she is tender in the right iliac fossa. Blood pressure is 100/68mmHg and the pulse is 96/min.
What is the most likely diagnosis? |
Ruptured ectopic pregnancy |
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Complications of tonsillitis include: |
otitis media quinsy - peritonsillar abscess rheumatic fever and glomerulonephritis very rarely |
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A 24-year-old woman presents to her GP with lower abdominal pains these have been getting worse over the past 2 days. The pain is in the suprapubic area and slightly to the right. She had some vaginal bleeding this morning which she describes as being like a light period. The patient also describes some shoulder pain which she thinks came on following a game of squash. Her last period was 8 weeks ago and was described as normal. In the past she has been treated for Chlamydia infection and admits to not practicing safer sex.
On examination she is tender in the right iliac fossa. Blood pressure is 100/68mmHg and the pulse is 96/min.
What is the most likely diagnosis? |
Ruptured ectopic pregnancy |
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classic exam history of ectopic pregnancy - |
amenorrhoea, abdominal pain and vaginal bleeding in combination with shoulder tip pain suggesting peritoneal bleeding. |
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Ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding |
lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm vaginal bleeding: usually less than a normal period, may be dark brown in colour history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination |
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Ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding |
lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm vaginal bleeding: usually less than a normal period, may be dark brown in colour history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination |
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Exam findings ectopic preg |
abdominal tenderness cervical excitation (also known as cervical motion tenderness) adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended |
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A 27-year-old woman comes for review. She is having problems with increasingly frequent migraine attacks. She has tried a combination of paracetamol and ibuprofen to try and control the attacks but this seems to have had a limited effect. Her current medication includes paracetamol and ibuprofen as required and Cerazette (a progestogen-only pill).
What is the most appropriate medication to try and reduce the frequency of her migraine attacks? |
Propanolol
Nb
Propranolol is preferable to topiramate in women of childbearing age (i.e. the majority of women with migraine) |
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A 19 year old with type 1 diabetes presents to the Emergency Department feeling unwell. She states she has had vomiting and diarrhoea for 2 days and has not been taking her full insulin doses as she has been off her food. Her capillary glucose is 37 mmol/l and there are 4+ ketones on urinalysis.
An arterial blood gas is performed and the results are as follows:
pH 7.12 pO2 13 kPa pCO2 3.5 kPa HCO3 13 Na 129 mmol/l K 6.1 mmol/l
Which of the following is the most appropriate initial management?
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IV 0.9% NaCl bolus |
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The most common precipitating factors of diabetic ketoacidosis (DKA) are |
Infxn Missed insulin MI |
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A 24-year-old male is admitted to the Emergency Department complaining of severe abdominal pain. On examination he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he will kill himself. This is an example of: |
Malingering |
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Somatisation disorder def |
multiple physical SYMPTOMS present for at least 2 years patient refuses to accept reassurance or negative test results |
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Hypochondrial disorder |
persistent belief in the presence of an underlying serious DISEASE, e.g. cancerpatient again refuses to accept reassurance or negative test results |
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Conversion disorder |
typically involves loss of motor or sensory functionthe patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies |
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Dissociative disorder |
dissociation is a process of 'separating off' certain memories from normal consciousness in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder |
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Munchausen's syndrome |
also known as factitious disorder the intentional production of physical or psychological symptoms making up physical/psych sxs |
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Malingering |
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain |
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Which one of the following is not a risk factor for developing osteoporosis? |
Obesity Low body mass, rather than obesity is associated with an increased risk of developing osteoporosis |
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Advancing age and female sex and significant risk factors for osteoporosis - what are others |
history of glucocorticoid use rheumatoid arthritis alcohol excess history of parental hip fracture low body mass index current smoking nb sedentary lifestyle premature menopause Caucasians and Asians endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus multiple myeloma, lymphoma gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. Coeliac's), gastrectomy, liver disease chronic kidney disease osteogenesis imperfecta, homocystinuria |
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Medications that may worsen osteoporosis (other than glucocorticoids): |
long term heparin therapyproton pump inhibitorsglitazonesaromatase inhibitors e.g. anastrozole |
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A 56 year old gentleman is being treated as an inpatient for a duodenal ulcer. He notices that his first metatarsophalangeal joint is severely inflamed on waking this morning. There is swelling and tenderness of the joint, and fluid is sent for microscopy. He has a past medical history of hypertension. What is the best initial medication to prescribe? |
Colchicine |
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indomethacin is a |
NSAID |
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Erythema ab igne |
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A 65-year-old woman presents with new, ongoing speech disturbance. She is worried that she may have had a stroke. Which one of the following scoring systems is it most appropriate to use to evaluate whether she has had a stroke? CHADS2 scoreABCD2 scoreRCP-RSE scoreROSIER scoreCHADS2-VASC score |
ROSIER score |
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ROSIER score Exclude hypoglycaemia first, then assess the following: |
Loss of consciousness or syncope- 1 point Seizure activity- 1 point New, acute onset of: • asymmetric facial weakness+ 1 point • asymmetric arm weakness+ 1 point • asymmetric leg weakness+ 1 point • speech disturbance+ 1 point • visual field defect+ 1 point |
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A 24-year-old male with no past medical history presents to the Emergency Department with pleuritic chest pain. There is no history of a productive cough and he is not short of breath. Chest x-ray shows a right-sided pneumothorax with a 1 cm rim of air and no mediastinal shift. What is the most appropriate management? |
Discharge with outpatient chest x-ray |
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BTS Primary pneumothorax Recommendations include: |
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men |
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1o pneumothorax mgmt (theres also mgmt for 2o pneumothorax and iatrogenic pneumothorax - not mentioned here) |
rim of air <2cm = tx as outpx with CXR if >2cm = aspiration if aspiration fails = insert chest drain |
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A 6-month-old baby who was born in Bangladesh is brought to surgery. Around one week ago he started with coryzal symptoms. His mother reports he has not been feeding well for the past two days and has started to vomit today. Her main concern is a cough which occurs in bouts and is so severe he often turns red. No inspiratory or expiratory noises are noted. Clinical examination reveals an apyrexial child with a clear chest. What is the most likely diagnosis? |
Pertussis |
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pertussis dx and mgmt |
nasal swab culture PCR and serology mgmt with oral erythromycin |
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A 29-year-old woman who is 14 weeks pregnant presents to the Emergency Department with an exacerbation of asthma. She quickly settles with nebulised salbutamol and you are asked to review her prior to discharge. She currently only uses a salbutamol inhaler (100mcg) as required and thinks that the most common trigger is grass pollen. Her peak flow is now 380 l/min (predicted 440 l/min) and inhaler technique is good. What is the most appropriate course of action? |
Add inhaled beclomethasone 200mcg bd |
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A 62-year-old man presents to his GP with sudden visual loss in his right eye. He is otherwise asymptomatic. Which one of the following conditions is LEAST likely to be responsible? Ischaemic optic neuropathyOcclusion of central retinal veinOcclusion of central retinal arteryOptic neuritisVitreous haemorrhage |
Optic neuritis |
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optic neuritics |
Typically there is a unilateral decrease in visual acuity over hours or days. There may be poor discrimination of colours and eye pain on movement |
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The most common causes of a sudden painless loss of vision are as follows: |
ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) occlusion of central retinal vein occlusion of central retinal artery vitreous haemorrhage retinal detachment |
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Ischaemic optic neuropathymay be due to |
arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient) |
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Ischaemic optic neuropathydue to |
occlusion of the short posterior ciliary arteries, causing damage to the optic nerve |
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Central retinal vein occlusion fxs |
incidence increases with age, more common than arterial occlusion causes: glaucoma, polycythaemia, hypertension severe retinal haemorrhages are usually seen on fundoscopy |
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Central retinal artery occlusion |
due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis) features include afferent pupillary defect, 'cherry red' spot on a pale retina |
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causes of Vitreous haemorrhage |
diabetes, bleeding disorders |
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fxs ofVitreous haemorrhage |
may include sudden visual loss, dark spots |
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Retinal detachment fxs |
preceding fxs include flashes of light or floaters |
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Posterior vitreous detachment |
Flashes of light (photopsia) - in the peripheral field of vision Floaters, often on the temporal side of the central vision |
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Retinal detachment |
Dense shadow that starts peripherally progresses towards the central visionA veil or curtain over the field of visionStraight lines appear curvedCentral visual loss |
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Vitreous haemorrhage |
Large bleeds cause sudden visual loss Moderate bleeds may be described as numerous dark spots Small bleeds may cause floaters |
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You have been asked to investigate the potential benefit of setting up a service to help patients with multiple sclerosis in the local area. What is the most important factor when determining how many resources will be required? |
Prevalence in chronic diseases the prevalence is much greater than the incidencein acute diseases the prevalence and incidence are similar. For conditions such as the common cold the incidence may be greater than the prevalence |
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The incidence is the |
number of new cases per population in a given time period. |
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The prevalence is the |
total number of cases per population at a particular point in time. |
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prevalence = |
incidence * duration of condition |
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Bob, 73, has chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus. He has been experiencing diarrhoea and vomiting for the past 3 days and his family have brought him to the emergency department as they are worried. History, examination and blood tests reveal Bob to be dehydrated and to have developed an acute kidney injury with an estimated glomerular filtration rate (eGFR) of 29ml/min/1.73m². According to NICE guidelines, which one of the following medications should be stopped? |
Metformin |
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Metformin is the drug that needs to be stopped in this case. NICE recommendations on the use of metformin in the treatment of diabetes mellitus specify that: |
A review of the dose of metformin be undertaken if the serum creatinine exceeds 130 micromol/litre or the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73m² Stop Metformin if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30 ml/minute/1.73m² |
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A 2 year old boy presents to the GP with his mother. She is worried that he is not growing at the same rate as the other children at his play group. His mother describes foul smelling diarrhoea about 4-5 times a week, accompanied by abdominal pain.On examination he has a bloated abdomen and wasted buttocks. He has dropped 2 centile lines and now falls on the 10th centile.What is the most appropriate initial investigation? |
IgA TTG antibodies |
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coeliac dis initial inV |
IgA TTG antibodies |
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irritable bowel syndrome or some food intolerances dx |
hydrogen breath test |
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dx of coeliac dis requires |
duo/jejunal biopsy showing subtotal villous atrophy |
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For each one of the following side effects please select the drug that is most characteristically associated with it . Each options may be used once, more than once or not at all. |
gold = proteinuria sulfasalazine = oligospermia infliximab = reactivation of TB |
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Methotrexate AE |
Myelosuppression Liver cirrhosis Pneumonitis |
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Sulfasalazine AE |
Rashes Oligospermia Heinz body anaemia |
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Prednisolone AE |
Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts |
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Etanercept, Infliximab, Adalimumab AE |
Reactivation of tuberculosis |
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An elderly gentleman presents with a three day history of bloody diarrhoea and feverishness. He has no significant travel history. His past medical history is listed as hypertension, osteoarthritis and gout. On examination his temperature is 38.0ºC, heart rate 95/min, blood pressure 120/80 mmHg and his abdomen is soft and non-tender. A stool sample has grown Salmonella. What is the best treatment? |
Ciprofloxacin |
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whats the most common cause of gastroenteritis |
?E.coli |
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Incubation period |
1-6 hrs: Staphylococcus aureus, Bacillus cereus* 12-48 hrs: Salmonella, Escherichia coli 48-72 hrs: Shigella, Campylobacter > 7 days: Giardiasis, Amoebiasis |
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Acute food poisoning is typically caused by |
Staphylococcus aureus,Bacillus cereus or Clostridium perfringens. |
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Escherichia coli |
Common amongst travellers Watery stools Abdominal cramps and nausea |
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Campylobacter |
A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody Complications include Guillain-Barre syndrome |
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Crusted (Norwegian) scabies |
Crusted scabies is seen in patients with suppressed immunity, especially HIV. The crusted skin will be teeming with hundreds of thousands of organisms. |
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Crusted (Norwegian) scabies tx |
Ivermectin is the treatment of choice and isolation is essential |
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At what age would the average child acquire the ability to walk unsupported? |
13-15 months |
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3 months |
Lying on abdomen, good head control Held sitting |
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6 months |
Pulls self to sitting Held sitting, back straight |
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7-8 months |
Sits without support (Refer at 12 months) |
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9 months |
Pulls to standing Crawls nb the majority of children crawl on all fours before walking but some children 'bottom-shuffle'. This is a normal variant and runs in families |
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12 months |
Cruises Walks with one hand held |
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13-15 months |
Walks unsupported |
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18 months |
Squats to pick up a toy |
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2 years |
Runs Walks upstairs and downstairs holding on to rail |
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3 years |
Rides a tricycle using pedals Walks up stairs without holding on to rail |
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4 years |
Hops on one leg |
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What are funnel plots primarily used for? |
Demonstrate the existence of publication bias in meta-analyses |
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A male child from a travelling community is diagnosed with measles. Which one of the following complications is he at risk from in the immediate aftermath of the initial infection? |
Pneumonia |
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For each one of the following scenarios select the vitamin which may cause these features if deficient: |
Bleeding gums = Vitamin C Diarrhoea, confusion and eczematous skin =Niacin Osteomalacia =Vitamin D |
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The table below summarises vitamin deficiency states |
A = Retinoids = Night-blindness (nyctalopia) B1 = Thiamine = Beriberi: polyneuropathy, Wernicke-Korsakoff syndrome, heart failure B3 = Niacin = Pellagra: dermatitis, diarrhoea, dementia B6 = Pyridoxine = Anaemia, irritability, seizures B7 = Biotin = Dermatitis, seborrhoea B9 = Folic acid = Megaloblastic anaemia, deficiency during pregnancy - neural tube defects B12 = Cyanocobalamin = Megaloblastic anaemia, peripheral neuropathy C = Ascorbic acid = Scurvy: gingivitis, bleeding D = Ergocalciferol, cholecalciferol = Rickets, osteomalacia E = Tocopherol, tocotrienol = Mild haemolytic anaemia in newborn infants, ataxia, peripheral neuropathy K = Naphthoquinone = Haemorrhagic disease of the newborn, bleeding diathesis |
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A 60 year old woman presents to the Emergency Department with a three week history of breathlessness and a dry cough. She does not smoke but admits drinks 20 units of alcohol per week. There is a target rash present on both her lower limbs. Her chest x-ray shows reticulo-nodular shadowing of the right lung. A diagnosis of bacterial pneumonia is made, what is the most likely organism causing her symptoms. |
Mycoplasma pneumoniae The dry cough, erythema multiforme (symmetrical target shaped rash with a central blister) and the radiological findings point to a diagnosis of Mycoplasma. nb Klebsiella occurs in alcoholics, and although the woman drinks more than her allowance (for women this is 14 units a week) it is not at the level where it would predispose her to Klebsiella. Furthermore, it typically causes a cavitating pneumonia of the upper lobes. |
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Although pneumococcal pneumonia is the most common pneumonia in the community, you would expect lobar consolidation on x-ray as well as a productive, rather than dry, cough. |
true |
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A newborn baby is noted to have a large swelling on the left-side of the neck. On examination a soft, fluctuant and highly transilluminable lump is noted just beneath the skin. |
Cystic hygroma |
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branchial cyst |
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood |
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Cystic hygroma |
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age |
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A 26-year-old woman presents 3 months after giving birth to her first child. During labour she had a large post-partum haemorrage. She did not breastfeed but has not had a period since. |
Sheehan's syndrome |
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Sheehan's syndrome def |
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock. |
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Sheehan's syndrome fxs |
agalactorrhoea amenorrhoea symptoms of hypothyroidism symptoms of hypoadrenalism |
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A 25-year-old woman presents 5 months after having dilation and curettage for a miscarriage. Since this procedure she has not had a period. A pregnancy test is negative. Hysteroscopy is performed which reveals the diagnosis. |
Asherman's syndrome |
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Asherman's syndrome def |
Asherman's syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would. |
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Amenorrhoea may be divided into |
primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer). |
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Causes of primary amenorrhoea |
Turner's syndrome testicular feminisation congenital adrenal hyperplasia congenital malformations of the genital tract |
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Causes of secondary amenorrhoea (after excluding pregnancy) |
hypothalamic amenorrhoea (e.g. Stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis Sheehan's syndrome Asherman's syndrome (intrauterine adhesions) |
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Amenorrhoea inV |
exclude preg with urinary/serum bhcg others: gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) prolactin androgen levels: raised levels may be seen in PCOS oestradiol thyroid function tests |
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A 34-year-old man with a history of polyarthralgia, back pain and diarrhoea is found to have a 3 cm red lesion on his shin which is starting to ulcerate. What is the most likely diagnosis? |
Pyoderma gangrenosum This patient is likely to have ulcerative colitis, which has a known association with large-joint arthritis, sacroilitis and pyoderma gangrenosum |
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Pyoderma gangrenosum fxs |
typically on the lower limbs initially small red papule later deep, red, necrotic ulcers with a violaceous border may be accompanied systemic symptoms e.g. Fever, myalgia |
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Pyoderma gangrenosumCauses |
idiopathic in 50% inflammatory bowel disease: ulcerative colitis, Crohn's rheumatoid arthritis, SLE myeloproliferative disorders lymphoma, myeloid leukaemias monoclonal gammopathy (IgA) primary biliary cirrhosis |
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Pyoderma gangrenosum mgmt |
the potential for rapid progression is high in most patients and most doctors advocate oral steroids as first-line treatment other immunosuppressive therapy, for example ciclosporin and infliximab, have a role in difficult cases |
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Nephrotic syndrome is classically defined as a triad of |
proteinuria (> 1 g/m^2 per 24 hours) hypoalbuminaemia (< 25 g/l) oedema |
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Minimal change glomerulonephritis tx |
good prognosis with around 90% of cases responding to high-dose oral steroids nb Other features include hyperlipidaemia, a hypercoagulable state (due to loss of antithrombin III) and a predisposition to infection (due to loss of immunoglobulins) |
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What is the name of the system that is used to stage cervical cancer? |
FIGO figo likes to stage the cervix |
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Cervical cancer |
human papilloma virus (HPV) 16,18 & 33 smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status combined oral contraceptive pill* |
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Mechanism of HPV causing cervical cancer |
HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively E6 inhibits the p53 tumour suppressor gene E7 inhibits RB suppressor gene |
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The incidence of cervical cancer peaks around the 6th decade. It may be divided into |
squamous cell cancer (80%) adenocarcinoma (20%) |
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A 36-year-old woman presents for a routine antenatal review. She is now 15 weeks pregnant. Her blood pressure in clinic is 154/94 mmHg. This is confirmed with ambulatory blood pressure monitoring. On reviewing the notes it appears her blood pressure four weeks ago was 146/88 mmHg. A urine dipstick is normal. There is no significant past medical history of note. What is the most likely diagnosis? |
Pre-existing hypertension |
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pre-existing hypertension |
Pregnancy related blood pressure problems (such as pregnancy-induced hypertension or pre-eclampsia) do not occur before 20 weeks. The raised ambulatory blood pressure readings exclude a diagnosis of white-coat hypertension. |
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Bone pain often responds well to NSAIDs |
true Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in managing bony pain but these are not first-line treatments. |
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A 40-year-old man is investigated for back. For the past few months he has been troubled with pain in his lower back which is typically worse in the morning and better by the end of the day. There is some radiation of pain to the right buttock but no leg pains. An x-ray of his lumbar spine is shown below |
Ankylosing spondylitis |
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Ankylosing spondylitis mgmt |
NSAIDs are the first-line treatment encourage physio and regular exercise next meds = DMARDS Anti TNF |
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A 25-year-old woman presents with a 3 year history of dysmenorrhoea and deep dyspareunia. The pain she experiences during her period can be severe and is associated with nausea. She also states that she and her partner have now been trying for a baby for 24 months with no success. What is the likely diagnosis? |
Endometriosis The key signs and symptoms of endometriosis are cyclical abdominal pain and deep dyspareunia. It can be associated with fertility problems. |
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Endometriosis epidem |
Up to 10-15% of women have a degree of endometriosis |
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endometriosis fxs |
chronic pelvic pain dysmenorrhoea - pain often starts days before bleeding deep dyspareunia subfertility |
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gold standard inV for endometriosis |
laparoscopy = definitive dx |
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mgmt of endometriosis |
NSAIDs and other analgesia for symptomatic relief combined oral contraceptive pill progestogens e.g. medroxyprogesterone acetate gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels intrauterine system (Mirena) drug therapy unfortunately does not seem to have a significant impact on fertility rates Surgery some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility |
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A 24-year-old female presents with episodic wheezing and shortness of breath for the past 4 months. She has smoked for the past 8 years and has a history of eczema. Examination of her chest is unremarkable. Spirometry is arranged and is reported as normal. What is the most appropriate management of her symptoms? |
Trial of salbutamol inhaler |
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Asthma diagnosis - if high probability of asthma - start treatment |
true |
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Features which make a diagnosis of asthma more likely |
More than one of the following symptoms: wheeze, breathlessness, chest tightness and cough, particularly if:symptoms worse at night and in the early morningsymptoms in response to exercise, allergen exposure and cold airsymptoms after taking aspirin or beta blockersHistory of atopic disorderFamily history of asthma and/or atopic disorderWidespread wheeze heard on auscultation of the chestOtherwise unexplained low FEV1 or PEF (historical or serial readings)Otherwise unexplained peripheral blood eosinophilia |
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Features which make a diagnosis of asthma less likely |
Prominent dizziness, light-headedness, peripheral tinglingChronic productive cough in the absence of wheeze or breathlessnessRepeatedly normal physical examination of chest when symptomaticVoice disturbanceSymptoms with colds onlySignificant smoking history (ie > 20 pack-years)Cardiac diseaseNormal PEF or spirometry when symptomatic |
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Inhaled steroids should be considered for patients with any of the following asthma-related features: |
exacerbations of asthma in the last two years using inhaled β2 agonists three times a week or more symptomatic three times a week or more waking one night a week |
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A 27-year-old woman presents to her general practitioner with a four day history of pelvic pain and deep dyspareunia. Examination reveals a temperature of 37.9 degrees Celsius, lower abdominal tenderness and cervical motion tenderness. The GP suspects pelvic inflammatory disease may be the cause. What evidence should he or she use to decide whether to initiate antibiotics?Endocervical swab microscopyTransvaginal ultrasoundHigh vaginal swab microscopy and cultureBlood culturesClinical evidence - history and examination |
Clinical evidence - history and examination |
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You see a 28 year old lady who has recently conceived. She has type 1 diabetes which is well controlled, and is otherwise well. Which of the following should she be advised to take during her pregnancy? |
Aspirin |
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Patients with diabetes (type 1 and 2) should take |
aspirin 75mg daily from 12 weeks gestation to reduce the risk of pre-eclampsia They are also at higher risk of neural tube defects, therefore should take the higher dose of folic acid, 5mg daily, whilst trying to conceive until 12 weeks gestation |
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All pregnant and breastfeeding women are advised to take vitamin D 10mcg daily. A vitamin B12 supplement may be advised for pregnant women who eat a vegan diet. |
true |
|
nnt |
25 100/4 = 25 |
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Absolute risk reduction = CER-EER or EER-CER? |
if the outcome of the study is undesirable then ARR = CER - EER if the outcome of the study is desirable then ARR* = EER - CER |
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A 38-year-old woman develops lower back pain radiating down her right leg whilst performing DIY. She describes a severe, sharp, stabbing pain which is worse on movement. Clinical examination reveals a positive straight leg raise test on the right side but otherwise the examination is unremarkable. Appropriate analgesia is prescribed. Of the following, what is the most suitable next-step in management?Check ESRArrange physiotherapyRefer for MRIPerform a vaginal examinationLumbar spine x-ray |
Arrange physiotherapy This patient has symptoms consistent with a prolapsed disc. Even if this is proven by a MRI scan it would not change the initial management as the vast majority of patients improve with conservative treatment such as physiotherapy. |
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This patient has symptoms consistent with a prolapsed disc. Even if this is proven by a MRI scan it would |
not change the initial management as the vast majority of patients improve with conservative treatment such as physiotherapy. 1st = analgesia next = physio nb similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercisesif symptoms persist then referral for consideration of MRI is appropriate |
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Community acquired pneumonia (CAP) may be caused by the following infectious agents: |
Streptococcus pneumoniae (accounts for around 80% of cases) Haemophilus influenzae Staphylococcus aureus: commonly after the 'flu atypical pneumonias (e.g. Due to Mycoplasma pneumoniae) viruses |
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CAP mgmt |
CURB-65 criteria of severe pneumonia if 3 or more Confusion (abbreviated mental test score <= 8/10) Urea > 7 mmol/L Respiratory rate >= 30 / min BP: systolic <= 90 or diastolic <= 60 mmHg age >= 65 years |
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BTS CAP mgmt based on CURB 65 |
low or moderate severity CAP: oral amoxicillin. A macrolide should be added for patients admitted to hospital high severity CAP: intravenous co-amoxiclav + clarithromycin OR cefuroxime + clarithromycin OR cefotaxime + clarithromycin the current BNF has slightly different recommendations for high severity CAP: intravenous benzylpenicillin + clarithromycin OR benzylpenicillin + doxycycline. For 'life-threatening' infections the BNF recommends the same as the BTS guidelines for high-severity CAP |
|
dx |
pneumonectomy |
|
dx |
OA |
|
|
X-ray changes of osteoarthritis |
decrease of joint space subchondral sclerosis subchondral cysts osteophytes forming at joint margins |
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A 32 year old pregnant woman presents to the GP with jaundice, and itchy skin for the past 2 weeks. She claims that is a lot worse during this pregnancy compared to her last one. History reveals that she is currently 30 weeks pregnant with no complications up until presentation. On examination the only notable findings are mild jaundice seen in the sclerae, as well as excoriations around the umbilicus and flanks. She denies any tenderness in her abdomen during the examination. Blood tests show the following:
ALT 206 U/L AST 159 U/L ALP 796 umol/l GGT 397 U/L Bilirubin (direct) 56 umol/L Bile salts 34 umol/L
Bile salts reference range 0 - 14 umol/L
What is the most likely diagnosis? |
Obstetric cholestasis also known as intrahepatic cholestasis of pregnancy |
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Obstetric cholestasis also known as intrahepatic cholestasis of pregnancy description |
is a condition caused by the impaired flow of bile. This in turn causes a build up of bile salts which can then deposit in the skin (causing pruritus) as well as the placenta. It is thought that the aetiology of this condition is a combination of hormonal, genetic and environmental factors.
Although the pruritic symptoms can be distressing for the mother, the build of of bile salts can also be detrimental to foetal wellbeing. The combination of the immature foetal liver's ability to cope with breaking down the excessive bile salt levels as well as the vasoconstricting effect of bile salts on human placental chorionic veins, has been theorised to be the cause of sudden asphyxial events in the foetus leading to anoxia and death |
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|
Obstetric cholestasis also known as intrahepatic cholestasis of pregnancy description |
is a condition caused by the impaired flow of bile. This in turn causes a build up of bile salts which can then deposit in the skin (causing pruritus) as well as the placenta. It is thought that the aetiology of this condition is a combination of hormonal, genetic and environmental factors.
Although the pruritic symptoms can be distressing for the mother, the build of of bile salts can also be detrimental to foetal wellbeing. The combination of the immature foetal liver's ability to cope with breaking down the excessive bile salt levels as well as the vasoconstricting effect of bile salts on human placental chorionic veins, has been theorised to be the cause of sudden asphyxial events in the foetus leading to anoxia and death
Nb mgmt
induction of labour at 37 weeks is common practice but may not be evidence based ursodeoxycholic acid - again widely used but evidence base not clear vitamin K supplementation |
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A 65-year-old woman is admitted to the Emergency department with sepsis and is also found to have an acute kidney injury. Which of the following would be the most likely finding on her arterial blood gas? |
pH 7.12, pCO2 3.1kPa, pO2 11.8kPa, HCO3- 6.2mmol/L. Calculated anion gap is 26mmol/L. |
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A 65-year-old woman is admitted to the Emergency department with sepsis and is also found to have an acute kidney injury. Which of the following would be the most likely finding on her arterial blood gas? |
pH 7.12, pCO2 3.1kPa, pO2 11.8kPa, HCO3- 6.2mmol/L. Calculated anion gap is 26mmol/L. |
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|
Metabolic acidosis |
Patients who have sepsis often have a raised serum lactate due to the hypoperfusion of their peripheries. This gives them a metabolic acidosis with a raised anion gap.
In patients with a metabolic acidosis, it can be helpful to calculate the anion gap in order to identify the cause of the metabolic acidosis. This is calculated as the difference between plasma cations (Na+ and K+) and anions (Cl- and HCO3-). The normal range is 10-18mmol/L.
If the anion gap is raised, this suggests that there is increased production, or reduced excretion, of fixed/ organic acids e.g. Lactic acid (sepsis, tissue ischaemia) Urate (renal failure) Ketones (diabetic ketoacidosis) Drugs/ toxins (salicylates, methanol, ethylene glycol)
If there is a metabolic acidosis with a normal anion gap, then this is either due to loss of bicarbonate, or accumulation of H+ ions. Causes include: Renal tubular acidosis Diarrhoea Addison's disease Pancreatic fistula |
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|
A 65-year-old woman is admitted to the Emergency department with sepsis and is also found to have an acute kidney injury. Which of the following would be the most likely finding on her arterial blood gas? |
pH 7.12, pCO2 3.1kPa, pO2 11.8kPa, HCO3- 6.2mmol/L. Calculated anion gap is 26mmol/L. |
|
|
Metabolic acidosis |
Patients who have sepsis often have a raised serum lactate due to the hypoperfusion of their peripheries. This gives them a metabolic acidosis with a raised anion gap.
In patients with a metabolic acidosis, it can be helpful to calculate the anion gap in order to identify the cause of the metabolic acidosis. This is calculated as the difference between plasma cations (Na+ and K+) and anions (Cl- and HCO3-). The normal range is 10-18mmol/L.
If the anion gap is raised, this suggests that there is increased production, or reduced excretion, of fixed/ organic acids e.g. Lactic acid (sepsis, tissue ischaemia) Urate (renal failure) Ketones (diabetic ketoacidosis) Drugs/ toxins (salicylates, methanol, ethylene glycol)
If there is a metabolic acidosis with a normal anion gap, then this is either due to loss of bicarbonate, or accumulation of H+ ions. Causes include: Renal tubular acidosis Diarrhoea Addison's disease Pancreatic fistula |
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|
Metabolic acidosis |
Metabolic acidosis is commonly classified according to the anion gap. This can be calculated by: (Na+ + K+) - (Cl- + HCO-3). If a question supplies the chloride level then this is often a clue that the anion gap should be calculated. The normal range = 10-18 mmol/L
Normal anion gap ( = hyperchloraemic metabolic acidosis) gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease
Raised anion gap lactate: shock, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol
Metabolic acidosis secondary to high lactate levels may be subdivided into two types: lactic acidosis type A: shock, hypoxia, burns lactic acidosis type B: metformin
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6 weeks |
6 weeks Smiles (Refer at 10 weeks) 3 months Laughs Enjoys friendly handling 6 months Not shy 9 months Shy Takes everything to mouth |
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Feeding |
May put hand on bottle when being fed 6 months
Drinks from cup + uses spoon, develops over 3 month period 12 -15 months
Competent with spoon, doesn't spill with cup 2 years
Uses spoon and fork 3 years
Uses knife and fork 5 yrs |
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A 7-year-old boy is brought in to the GP surgery with an exacerbation of asthma. On examination he has a bilateral expiratory wheeze but there are no signs of respiratory distress. His respiratory rate is 36 / min and PEF around 60% of normal. What is the most appropriate action with regards to steroid therapy?
|
Oral prednisolone for 3 days |
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Feeding |
May put hand on bottle when being fed 6 months
Drinks from cup + uses spoon, develops over 3 month period 12 -15 months
Competent with spoon, doesn't spill with cup 2 years
Uses spoon and fork 3 years
Uses knife and fork 5 yrs |
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A 7-year-old boy is brought in to the GP surgery with an exacerbation of asthma. On examination he has a bilateral expiratory wheeze but there are no signs of respiratory distress. His respiratory rate is 36 / min and PEF around 60% of normal. What is the most appropriate action with regards to steroid therapy?
|
Oral prednisolone for 3 days |
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All children 2-5 with asthma exas shud get 3 days of |
Oral prednisolone dose |
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All children 2-5 with mild to mod asthma exas shud get 3 days of |
Oral prednisolone dose |
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All children 2-5 with mild to mod asthma exas shud get 3 days of |
Oral prednisolone dose |
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Children with severe or life threatening asthma should be transferred immediately to |
hospital |
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|
Most common benign ovarian tumour in women under the age of 25 years |
Dermoid cyst (teratoma) |
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All children 2-5 with mild to mod asthma exas shud get 3 days of |
Oral prednisolone dose |
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Children with severe or life threatening asthma should be transferred immediately to |
hospital |
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|
Most common benign ovarian tumour in women under the age of 25 years |
Dermoid cyst (teratoma) |
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The most common cause of ovarian enlargement in women of a reproductive age |
Follicular cyst |
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The most common cause of ovarian enlargement in women of a reproductive age
Physiological cysts (functional cysts) |
Follicular cyst |
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Sepsis six has emerged from the surviving sepsis campaign. It is recommended that all patients have the following: |
1. Blood cultures 2. Fluids (0.9% Normal Saline) 3. Urinary Catheter 4. Oxygen 5. Lactate (Venous blood gas or Arterial Blood gas) 6. Antibiotics |
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|
Sepsis six has emerged from the surviving sepsis campaign. It is recommended that all patients have the following: |
1. Blood cultures 2. Fluids (0.9% Normal Saline) 3. Urinary Catheter 4. Oxygen 5. Lactate (Venous blood gas or Arterial Blood gas) 6. Antibiotics |
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|
SIRS DEF |
at least 2 of the following body temperature less than 36°C or greater than 38.3°C heart rate greater than 90/min respiratory rate greater than 20 breaths per minute blood glucose > 7.7mmol/L in the absence of known diabetes white cell count less than 4 or greater than 12 |
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You review a 23-year-old woman who presents with a three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis? |
Allergic rhinitis |
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|
You review a 23-year-old woman who presents with a three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis? |
Allergic rhinitis |
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|
Aspirin can cause |
Nasal polyps |
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|
You review a 23-year-old woman who presents with a three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis? |
Allergic rhinitis |
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|
Aspirin can cause |
Nasal polyps |
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|
What is the most common cause of headaches in children? |
Migraine |
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If there is no structural or histological abnormality causing the heavy menstrual bleeding, the intrauterine system is the first line treatment. |
Yes |
|
|
You review a 23-year-old woman who presents with a three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis? |
Allergic rhinitis |
|
|
Aspirin can cause |
Nasal polyps |
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|
What is the most common cause of headaches in children? |
Migraine |
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If there is no structural or histological abnormality causing the heavy menstrual bleeding, the intrauterine system is the first line treatment. |
Yes |
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A 40-year-old woman is diagnosed as having Addison's disease. What combination of medications is she most likely to be prescribed? |
Hydrocortisone + fludrocortisone
Remember if px sick, just double dose |
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A 34-year-old female presents with vomiting preceded by an occipital headache of acute onset. On examination she was conscious and alert with photophobia but no neck stiffness. CT brain is reported as normal. What is the most appropriate further management? |
CSF examination |
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A 34-year-old female presents with vomiting preceded by an occipital headache of acute onset. On examination she was conscious and alert with photophobia but no neck stiffness. CT brain is reported as normal. What is the most appropriate further management? |
CSF examination
If the CSF examination revealed xanthochromia, or there was still a high level of clinical suspicion, then cerebral angiography would be the next step. Rate, discuss and give feedback on this question Next question
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Main cause of SAH |
85% are due to rupture of berry aneurysms (conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta) |
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Other causes of SAH |
AV malformations trauma tumours |
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Other causes of SAH |
AV malformations trauma tumours |
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3 year old is brought by his Mum to your surgery. He has had a fever and has been refusing to eat. Mum has noticed some spots on his hands and buttocks. On examination the child has a mild vesicular rash to the hands, buttocks, face and a few spots on his ankles. His temperature is 38.1ºC. Your records state that he had chicken pox when he was 9 months old. What is the most likely diagnosis? |
Hand, foot and mouth disease |
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3 year old is brought by his Mum to your surgery. He has had a fever and has been refusing to eat. Mum has noticed some spots on his hands and buttocks. On examination the child has a mild vesicular rash to the hands, buttocks, face and a few spots on his ankles. His temperature is 38.1ºC. Your records state that he had chicken pox when he was 9 months old. What is the most likely diagnosis? |
Hand, foot and mouth disease
Mgmt general advice about hydration and analgesia reassurance no link to disease in cattle children do not need to be excluded from school* |
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A 27-year-old woman complains of recurrent ear discharge. Otoscopy is as follows: |
Cholesteatoma |
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|
Cholesterotoma |
A cholesteatoma consists of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years. |
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|
Cholesteatoma |
A cholesteatoma consists of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years. |
|
|
cholesteatoma |
A cholesteatoma consists of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years.
Main features foul smelling discharge hearing loss
Other features are determined by local invasion: vertigo facial nerve palsy cerebellopontine angle syndrome
Otoscopy 'attic crust' - seen in the uppermost part of the ear drum
Management patients are referred to ENT for consideration of surgical removal |
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screening tools is it most appropriate to detect postnatal depression? |
Edinburgh Scale |
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32 year old lady presents with symmetrical joint pain in her hands and early morning stiffness. She also has some dry, erythematous, inflamed skin mostly in flexor surfaces. An x-ray is ordered and shows loss of joint space, erosions and soft tissue swelling. What is the most likely |
RA |
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|
osteoarthritis and rheumatoid arthritis are LOSS and LESS, respectively. |
X-ray findings of osteoarthritis (LOSS) are: Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
X-ray findings of rheumatoid arthritis (LESS) are: Loss of joint space Erosions Soft tissue Swelling Soft bones - osteopenia |
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32 year old lady presents with symmetrical joint pain in her hands and early morning stiffness. She also has some dry, erythematous, inflamed skin mostly in flexor surfaces. An x-ray is ordered and shows loss of joint space, erosions and soft tissue swelling. What is the most likely |
RA |
|
|
osteoarthritis and rheumatoid arthritis are LOSS and LESS, respectively. |
X-ray findings of osteoarthritis (LOSS) are: Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
X-ray findings of rheumatoid arthritis (LESS) are: Loss of joint space Erosions Soft tissue Swelling Soft bones - osteopenia |
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|
Cervical mgmt |
Borderline or mild dyskaryosis The original sample is tested for HPV* if negative the patient goes back to routine recall if positive the patient is referred for colposcopy
Moderate dyskaryosis Consistent with CIN II. Refer for colposcopy Severe dyskaryosis Consistent with CIN III. Refer for colposcopy Suspected invasive cancer Refer for urgent colposcopy (within 2 weeks) Inadequate Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy |
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A 19 year-old woman attends her GP for a repeat prescription of her combined oral contraceptive pill (COCP). Since starting it, she has been suffering from severe left sided headaches with changes in her vision before the headache begins. Clinical examination is normal. What is the most appropriate step in her management? |
Stop the COCP and start treatment on a progesterone only contraceptive pill. |
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|
if young female px on COC gets severe headaches and vision changes before headache starts most appropriate mgmt |
stop the COC and give progesterone only contraceptive pill |
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|
should u stop an abx if on COCs |
no nb precautions should still be taken with enzyme inducing antibiotics such as rifampicin |
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You are called by the midwife to see a 39-year-old patient who is 37 weeks into her fourth pregnancy who has been complaining of swollen ankles and a headache. Her most recent blood pressure was 163/98 mmHg, she has also been found to have protein on a recent urine dipstick test. When you arrive she is having a tonic-clonic seizure. What is your immediate course of action? |
Put out an obstetric crash call |
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|
mother 39 weeks preg, with preeclampsia has a tonic clonic seizure - mgmt |
call for obstretric help next move her into recovery position = left lateral position = some a/w protection & relief from baby obstrxn of aorto-caval flow next a/w manoevres and high flow O2 tx seizure after 5 min with IV lorazepam or PR diazepam deliver baby +- mg sulphate to prevent recurrrence of seizures) |
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|
whats is preeclampsia + seizure = |
ECLAMPSIA nb if seizure d/p in a px that has preeclampsia = eclampsia |
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|
pre-eclampsia is defined as: |
condition seen after 20 weeks gestationpregnancy-induced hypertensionproteinuria |
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|
what is definitive mgmt of px with eclampsia |
prompt delivery Mg sulphate reduces recurrence of seizures |
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|
Magnesium sulphate is used to both prevent |
seizures in patients with severe pre-eclampsia and treat seizures once they develop |
|
|
guidelines for use of mg sulphate |
given in eclampsia should be given once a decision to deliver has been made monitor urine output, reflexes, respiratory rate and oxygen saturations continue for 24hrs after last seizure/deliver |
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A 22 year-old woman and her male partner present to their GP as they been unsuccessfully trying to conceive for 4 months. Her periods have been regular and there is no obvious cause in her history. What is the most appropriate next step in her management? |
Address how the couple are having sexual intercourse and reassure the patient |
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|
A healthy couple can expect to take up to one year to conceive. Investigations are therefore usually performed after |
one year of regular attempts to conceive. It may however be prudent to address any mechanical reasons that are preventing the couple from conceiving, hence the sexual intercourse history. |
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|
Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years true/false |
true |
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|
infertility causes |
male factor 30% unexplained 20% ovulation failure 20% tubal damage 15% other causes 15% |
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|
Basic investigations for infertility |
semen analysis serum progesterone 7 days prior to expected next period |
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|
key advise/counselling for pxs with infertility |
folic acid aim for BMI 20-25 advise regular sexual intercourse every 2 to 3 days smoking/drinking advice |
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Which one of the following statements regarding maturity-onset diabetes of the young (MODY) is true? |
There is usually a strong family history |
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|
Maturity-onset diabetes of the young (MODY) is characterised by |
d/t of DM2 in patients < 25 yo AD genetic mutations MODY 3 = 60% ketosis is not a GX tx = sulfonylureas |
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A 25-year-old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding. On examination blood pressure is 90 / 60 mmHg |
Placental abruption |
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A 31-year-old woman presents with painless vaginal bleeding at 15 weeks gestation. She has not yet had any antenatal care despite suffering from severe vomiting. On examination the uterus is large for dates |
Hydatidiform mole |
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A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Her last period was 8 weeks ago. On examination her cervix is tender to touch |
Ectopic pregnancy |
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|
Antepartum haemorrhage is defined as |
bleeding after 24 weeks |
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|
Bleeding in pregnancy -1st trimester |
Spontaneous abortion Ectopic pregnancy Hydatidiform mole |
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Bleeding in pregnancy-2nd trimester |
Spontaneous abortion Hydatidiform mole Placental abruption |
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|
3rd trimester bleeding |
Bloody show Placental abruption Placenta praevia Vasa praevia |
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|
Bloody show def |
passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os. |
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bleeding in preg |
Alongside the pregnancy related causes, conditions such as sexually transmitted infections and cervical polyps should be excluded. |
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Spontaneous abortion types |
Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled. Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain. Complete miscarriage - little bleeding |
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|
Ectopic pregnancy |
usu hx 6-8 weeks amen with lower abdo. pain initially and vag. bleeding later +- shoulder tip pain +- cervical excitation |
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|
Hydatidiform mole |
bleeding in 1st/2nd trimester + vomiting +- uterus large for dates high serum bHCG |
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|
placental abruption |
constant lower abdo pain +- shock tender uterus but normal posxn/look +- fetal heart distress |
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|
placental previa |
vag bleeding no pain uterus lie and look abn BUT NOT TENDER |
|
Vasa praevia def |
obstetric complication in which fetal blood vessels cross or run near the external orifice of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue. |
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Vasa praevia |
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen |
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|
vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage |
true |
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A 57-year-old woman presents with an 8 week history of intermittent dizziness. These episodes typically occur when she suddenly moves her head and are characterised by the sensation that the room is 'spinning'. Most attacks last around one minute before dissipating. Neurological examination is unremarkable. What is the most likely diagnosis? |
Benign paroxysmal positional vertigo |
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|
one of the most common causes of vertigo |
BPPV sudden dizziness + vertigo triggered by changes in head position |
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|
BPPV dx |
dix hallpike |
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|
BPPV tx |
Epley manoeuvre (80% successful) teaching the patient exercises they can do themselves at home, for example Brandt-Daroff exercises meds of ltd value |
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|
ABG normal values |
pH 7.35 - 7.45 pCO2 4.5 - 6.0 kPa or 35 - 45mmhg pO2 10 - 14 kPa or 75 - 100mmHg HCO3- 22-26mmol/L |
|
|
Base excess /Base deficit -2 to +2mmol/L |
Represents an increase or decrease in theamount of base compared with the amountof acids present |
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A 69-year-old man with chronic obstructive pulmonary disease (COPD) presents to the Emergency Department with dyspnoea. Three days ago he was started on amoxicillin and prednisolone by his GP. Since arriving in the department he has been given back-to-back nebulised salbutamol and ipratropium bromide. The oxygen concentration has been titrated to 28% to achieve a saturation of 88-92%. Due to his poor response to treatment an aminophyline infusion is started. Thirty minutes later, his arterial blood gases show the following (taken on 28% oxygen):pH7.30pCO27.6 kPapO28.1 kPaWhat is the most appropriate next step in management? |
Non-invasive ventilation |
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COPD px with SOB - on prednisolone + hop salbutamol and ipratropium bromide + aminophyline infusion + 28% O2 (target sats 88-92) has resp acidosis - whats the next mgmt |
Non-invasive ventilation |
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|
Non-invasive ventilation - key indications |
COPD with respiratory acidosis pH 7.25-7.35 type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea cardiogenic pulmonary oedema unresponsive to CPAP weaning from tracheal intubation |
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A 23-year-old woman presents with sweating and tremor. Her thyroid function tests are as follows:TSH<0.05 mU/lFree T425 pmol/l (9-18 pmol/l)What is the most common cause this presentation? |
Graves' disease |
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|
most common cause of thyrotoxicosis |
Graves = 50-60% |
|
|
thyrotoxicosis causes |
Graves' disease toxic nodular goitre subacute (de Quervain's) thyroiditis post-partum thyroiditis acute phase of Hashimoto's thyroiditis (later results in hypothyroidism) toxic adenoma (Plummer's disease) amiodarone therapy |
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InV for thyrotoxicosis |
TFTs thyroid autoantibodies |
|
dx |
greenstick # |
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|
whats the most common salter harris # type |
type 2 Fracture through the physis and metaphysis |
|
salter harris |
I Fracture through the physis only (x-ray often normal) II Fracture through the physis and metaphysis III Fracture through the physis and epiphyisis to include the joint IV Fracture involving the physis, metaphysis and epiphysis V Crush injury involving the physis (x-ray may resemble type I, and appear normal) |
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|
Injuries of Types III, IV and V will usually |
require surgery Type V injuries are often associated with disruption to growth. |
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Osteogenesis imperfecta def |
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. |
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|
Subtype of osteogenesis imperfecta |
Type I - The collagen is normal quality but insufficient quantity. Type II - Poor collagen quantity and quality. Type III - Collagen poorly formed. Normal quantity. Type IV - Sufficient collagen quantity but poor quality. |
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Osteopetrosis |
Bones become harder and more dense. AR common in young |
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when people say they are big boned as a joke, whats the only bone dis where this may actually happen |
osteopetrosis nb lack of differentiation between the cortex and the medulla described as marble bone |
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A 25-year-old man presents with back pain. Which one of the following may suggest a diagnosis of ankylosing spondylitis?Rapid onsetGets worse following exerciseBone tendernessPain at nightImproves with rest |
Pain at night |
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fxs of AS |
young man lower back pain and stiff morning stiffness improves with exercise +- night pain - improves on getting up |
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A 62-year-old woman presents with a one day history of pain around her right eye. She feels nauseous and has vomited once. On examination her right eye is red |
Acute glaucoma |
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A 42-year-old man presents with pain in the posterior and left side of his head. This came on over one minute and is now severe. The pain is worse when he bends his neck. His temperature is 37.3ºC |
Subarachnoid haemorrhage |
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|
A 22-year-old woman presents with recurrent headaches around the time of her periods. These are typically on the left-side and severe. When she gets a headache it lasts several hours and she usually goes to bed. |
Migraine |
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|
Migraine |
recurrent, severe headache usu. unilat and throbbing +- aura, nausea, photosensitivity +- exas by ADLs = avoidance of these px goes to bed for relief women +- assoc with menstruction |
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|
Tension headache |
recurrent, non disabling bilateral headache tight band no exas by ADLs |
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|
cluster headache |
episodes 1-2x/day 15min-2hrs with clusters usu. lasting 4-12 weeks intense single eye pain (always same eye) restless during attack +- eye redness, lacrimxn, lid swelling |
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cluster headaches are more common in |
male smokers |
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|
Medication overuse headache |
present >= 15 days/month d/t or worse whilst taking meds px on opioids/triptans are at most risk may be psychiatric comorbidity |
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|
some chronic headaches can be caused by |
chronically raised ICP Paget's disease psychological |
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What is the most appropriate first-line medication to induce remission of UC in the ascending colon |
Oral aminosalicylate disease outside the reach of enemas she should be given an oral aminosalicylate first-line |
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|
The severity of UC is usually classified as being mild, moderate or severe: |
mild: < 4 stools/day, only a small amount of blood moderate: 4-6 stools/day, varying amounts of blood, no systemic upset severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers) |
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|
1st line tx for mild to mod UC to induce remission |
mild to mod proximal large bowel ie ascending colon = oralaminosalicylates distal large bowel = rectal aminosalicylates ( ie messalazine) or steroids nb 2nd line = oral prednisolone |
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|
1st line tx for severe UC to induce remission |
hos IV steroids |
|
|
Maintaining remission for UC |
oral aminosalicylates e.g. mesalazine azathioprine and mercaptopurine |
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|
can you use mnethotraxate in IBD |
NOT FOR UC only for Crohns |
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A 30-year-old woman presents with an offensive 'fishy', thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5. |
Oral metronidazole dx = bact vaginosis |
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|
Amsel's criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present: |
thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH > 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour) |
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A 27-year-old woman complains of an offensive 'musty', frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation. |
Oral metronidazole dx = Trichomonas vaginitis |
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A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram negative diplococcus. |
IM ceftriaxone + oral azithromycin |
|
|
Vaginal discharge is a common presenting symptom and is not always |
pathological |
|
|
Common causes of vaginal discharge |
physiological Candida Trichomonas vaginalis bacterial vaginosis nb less common causes Gonorrhoea Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms ectropion foreign body cervical cancer |
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|
key fxs of candida causing vag. discharge |
'Cottage cheese' discharge Vulvitis Itch |
|
|
key fxs of trichomonas vaginalis |
Offensive, yellow/green, frothy discharge Vulvovaginitis Strawberry cervix |
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|
Which type of motor neuron disease carries the worst prognosis? Relapsing-remittingProgressive bulbar palsyProgressive muscular atrophySpinocerebellar ataxiaAmyotrophic lateral sclerosis |
Progressive bulbar palsy |
|
|
Motor neuron disease def |
neuro. condxn of unknown causes +- upper and lower MN signs usu after 40yo |
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|
most pxs with MND have |
ALS 50% |
|
|
ALS |
usu LMN signs in arms and UMN signs in legs if familial = superoxide dismutase genes mutated |
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|
primary lateral sclerosis |
UMN signs only |
|
|
Progressive muscular atrophy |
LMN signs only affects distle mus's before proximal carries best prog |
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|
Progressive bulbar palsy |
tongue palsy muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei carries worst prognosis |
|
|
bulb/bulbar means |
the medulla oblongata relates to nerves/tracts in the medulla and thus the mus's they innervate |
|
|
Progressive bulbar palsy specifically affects |
CN 9, 10 and 12 nb This disorder should not be confused with pseudobulbar palsy or progressive spinal muscular atrophy. The term Infantile progressive bulbar palsy is used to describe progressive bulbar palsy in children. |
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|
most appropriate initial tx for RA |
Methotrexate + DMARD + oral prednisolone +- paracetamol (pain) |
|
|
newly diagnosed active RA initial tx |
combo of DMARDS = methotrexate + other DMARD + oral steroid |
|
|
DMARDS |
methotrexate sulfaalazine leflunomide hydroxychloroquine |
|
|
when starting methotrexate what should you monitor |
FBC & LFTs due to risk of myelosuppression and liver cirrhosis |
|
|
TNF inhibitors - when should you use for RA |
when inadeq. response to combo DMARD (incl. methotrexate) |
|
|
TNF inhibitors |
etanercept infliximab adalimumab |
|
|
remember mabs are |
monoclonal antibodies |
|
|
for RA what the the different categories of drugs you can use |
DMARDs TNF-inhibitors Rituximab Abatacept |
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|
Rituximab |
anti-CD20 monoclonal antibody, results in B-cell depletion two 1g intravenous infusions are given two weeks apart infusion reactions are common |
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|
Abatacept |
fusion protein that modulates a key signal required for activation of T lymphocytes = leads to decreased T-cell proliferation and cytokine production |
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|
Screening for infections implicated in preterm delivery are not routinely given in preg |
true |
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|
A home visit is requested by the husband of a 71-year-old woman who is 'off her legs'. On arriving the patient states that since mid-morning her left arm has felt weak and a degree of facial asymmetry is noted when she smiles. She is normally fit and well other than a past history of hypertension for which she takes ramipril. What is the most appropriate action? |
Dial 999 for emergency admission |
|
|
should you give aspirin in a suspected stroke |
not until you have excluded hemorrhagic stroke once ruled out - give stat orally/rectally |
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|
in acute mgmt of stroke should you try to lower bp |
not unless there are complications e.g. hypertensive encephalopathy |
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|
mgmt of acute stroke |
optimise b/g, hydration, O2 sats and temp +- lower bp aspirin if not hemorrhagic stroke anticoags if hemorrhagic excluded if cholesteral high = give statins +- thrombolysis if not hemorrhagic |
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|
for acute stroke when should u consider giving thrombolysis |
within 4 hrs of sxs and hemorrhagic stroke EXCLUDED ALTEPASE usu. |
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|
Absolute CI to thrombolysis in stroke |
previous ICH seizure at onset of stroke IC neoplasm SAH suspected stroke/brain trauma injury in last 3/12 LP in preceding 7 dats GI hemorrhage in 3 weeks active bleeding preg eso. varices uncontrolled HTN nb relative CI - Concurrent anticoagulation (INR >1.7) - Haemorrhagic diathesis - Active diabetic haemorrhagic retinopathy - Suspected intracardiac thrombus - Major surgery / trauma in preceding 2 weeks |
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|
2o prevention of acute stroke |
1st line = clopidogrel alternative = aspirin + dipyridamole |
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|
A 24-year-old man presents with a two day history of a red right eye. When he work up this morning his right eye was 'stuck together'. Pupils are equal and reactive and the visual acuity is 6/5 in both eyes when viewing a Snellen chart Of the following management options, which one is the most appropriate? |
Topical chloramphenicol dx = bact conjunctivitis |
|
|
Bacterial conjunctivitis fxs |
red eye purulent discharge +- eyes stuck together in morning |
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|
should contacts be worn during an episode of conjunctivitis |
NO also dont share towels you can still go to school |
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|
Viral conjunctivitis fxs |
serous discharge recent URTI Preauricular lymph nodes |
|
|
Allergic conjunctivitis |
Bilateral symptoms Itch is prominent May be history of atopy May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens) |
|
|
Management of allergic conjunctivitis |
topical or systemic antihistamines topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil |
|
|
ovarian cyst need |
urgent gyn referal cuz it needs inV |
|
|
initial imaging modality for suspected ovarian cysts/tumours is |
US |
|
|
mgmt of ovarian cyst depends on |
age and sxs premenopausal = usu. benign thus repeat US in 8-12/52 postmenopausal = refer to gyn a/t |
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|
A 31-year-old woman with a three year history of ulcerative colitis is started on azathioprine to help prevent relapses. Which one of the following vaccines must be avoided whilst she is on this treatment? |
Yellow fever |
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|
pxs who are immunosuppressed (ie on immunosuppression drugs e.g. azathioprine or who have HIV etc) should not be given |
live (attenuated) vaccines |
|
|
Live attenuated vaccines MOOBY live |
BCG MMR oral polio yellow fever oral typhoid |
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|
Inactivated preparations vaccines |
rabies influenza (intramuscular) |
|
|
Detoxified exotoxins vaccine |
TETANUS |
|
|
Extracts of the organism/virus (sometimes termed fragment) |
diphtheria pertussis ('acellular' vaccine) hepatitis B meningococcus, pneumococcus, haemophilus |
|
|
hepatitis B VACCINE |
contains HBsAg adsorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology |
|
|
influenza vaccine |
different types are available, including whole inactivated virus, split virion (virus particles disrupted by detergent treatment) and sub-unit (mainly haemagglutinin and neuraminidase) |
|
|
Which one of the following defines the standard error of the mean? |
Standard deviation / square root (number of patients) |
|
|
How is the confidence interval calculated? |
The standard error of the mean (SEM) is a measure of the spread expected for the mean of the observations - i.e. how 'accurate' the calculated sample mean is from the true population mean Key point SEM = SD / square root (n) where SD = standard deviation and n = sample size therefore the SEM gets smaller as the sample size (n) increases A 95% confidence interval: lower limit = mean - (1.96 * SEM) upper limit = mean + (1.96 * SEM) nb if a small sample size is used (e.g. n < 100) then it is important to use a 'Student's T critical value' look-up table to replace 1.96 with a different valueif a different confidence level is required, e.g. 90% then 1.96 is replaced by a different value. For 90% this would 1.645 |
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|
Confidence interval def |
a range of values within which the true effect of intervention is likely to lie nb a formal definition may be: a range of values for a variable of interest constructed so that this range has a specified probability of including the true value of the variable. The specified probability is called the confidence level, and the end points of the confidence interval are called the confidence limits The likelihood of the true effect lying within the confidence interval is determined by the confidence level. For example a confidence interval at the 95% confidence level means that the confidence interval should contain the true effect of intervention 95% of the time |
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|
COC pill moa |
Inhibits ovulation |
|
|
implanatable contraceptive(etonogestrel) moa |
Inhibits ovulation |
|
|
Copper intrauterine contraceptive device (used as a standard contraceptive) moa |
Decreases sperm motility and survival |
|
|
Progestogen-only pill (excluding desogestrel) moa |
thickens cervical mucus |
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|
Desogestrel-only pill Injectable contraceptive (medroxyprogesterone acetate) Implantable contraceptive (etonogestrel) these 3 are different contraceptives - whats their moa |
ALL do: Primary: Inhibits ovulation Also: thickens cervical mucus |
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|
Intrauterine system (levonorgestrel) moa |
Primary: Prevents endometrial proliferation Also: Thickens cervical mucus |
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|
Methods of emergency contraception: moa Levonorgestrel Ulipristal |
both inhibit ovulation |
|
|
Which one of the following is an example of a purely secondary accident prevention strategy? |
Cycling helmets |
|
|
Accidents and preventive healthcare strategies Primary prevention |
Stopping smoking Stair guards Speed limits* Teaching road safety Window safety catches |
|
|
Secondary prevention |
Wearing seat belts Cycling helmets Smoke alarms Laminated safety glass |
|
|
Tertiary prevention |
Teaching parents first aid |
|
A 78-year-old man is investigated for headaches. A routine blood screen is normal other than an elevated ALP. A skull x-ray is ordered: dx |
Paget's disease of the bone nb marked thickening of the calvarium. There are also ill-defined sclerotic and lucent areas throughout. These features are consistent with Paget's disease |
|
|
Paget's disease is a disease of |
increased but uncontrolled bone turnover primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity |
|
|
risk factors for pagets dis |
increasing age male sex northern latitude family history |
|
|
pagets dis tx |
bisphosphonate (either oral alendronate/risedronate or IV zoledronate) calcitonin is less commonly used now |
|
|
pagets complications |
deafness (cranial nerve entrapment) bone sarcoma (1% if affected for > 10 years) fractures skull thickening high-output cardiac failure (high Ca2+) |
|
|
A 65-year-old man with a 16 year history of type 2 diabetes mellitus presents complaining of poor eye sight and blurred vision. Visual acuity measured using a Snellen chart is reduced to 6/12 in the right eye and 6/18 in the left eye. Fundoscopy reveals a number of yellow deposits in the left eye consistent with drusen formation. Similar changes but to a lesser extent are seen in the right eye. What is the most likely diagnosis? |
Dry age-related macular degeneration |
|
|
Drusen = Dry macular degeneration |
Fundoscopy showing yellow deposits in the eye = consistent with drusen formation |
|
|
Age related macular degeneration is a common cause of |
blindness |
|
|
Age related macular degeneration |
Degeneration of the central retina (macula) is the key feature with changes usually bilateral |
|
|
Traditionally two forms of macular degeneration are seen: |
dry and wet macular degen |
|
|
dry (geographic atrophy) macular degeneration: |
characterised by drusen - yellow round spots in Bruch's membrane |
|
|
wet (exudative, neovascular) macular degeneration: |
characterised by choroidal neovascularisation. Leakage of serous fluid and blood can subsequently result in a rapid loss of vision. Carries worst prognosis |
|
|
Recently there has been a move to a more updated classification: |
early age related macular degeneration late age related macular degeneration |
|
|
early age related macular degeneration (non-exudative, age related maculopathy): |
drusen and alterations to the retinal pigment epithelium (RPE) |
|
|
late age related macular degeneration |
neovascularisation, exudative |
|
|
Age related macular degeneration risk factors |
age: most patients are over 60yo smoking fhx Caucasians high cumulative sunlight exposure female sex |
|
|
Age related macular degenerationfxs |
reduced visual acuity: 'blurred', 'distorted' vision, central vision is affected first central scotomas fundoscopy: drusen, pigmentary changes |
|
|
Age related macular degeneration Investigation and diagnosis |
optical coherence tomography: provide cross sectional views of the macula if neovascularisation is present fluorescein angiography is performed |
|
|
general mgmt of age related macula degen |
stop smoking high dose beta carotene, vit C and E and zinc (except in smokers) |
|
|
dry mac. degen. tx |
non |
|
|
wet mac. degen. |
photocoagulation photodynamic therapy anti-vascular endothelial growth factor (anti-VEGF) treatments: intravitreal ranibizumab |
|
|
A 75-year-old man presents with a 'sore' on his lip. This has been present for around four months and has been getting slowly worse. His past medical history includes ischaemic heart disease and chronic obstructive pulmonary disease. He still smokes around 20 cigarettes per day. dx |
Squamous cell carcinoma |
|
|
in SCC of skin is METS common |
no rare |
|
|
Squamous cell carcinoma of the skin risk factors |
excessive exposure to sunlight actinic keratoses and Bowen's disease immunosuppression e.g. following renal transplant smoking long-standing leg ulcers (Marjolin's ulcer) |
|
|
A cohort study is being designed to look at the relationship between smoking and breast cancer. What is the usual outcome measure in a cohort study? |
Cohort studies - relative risk |
|
|
case control usu. outcome measure is |
odds ratio nb Inexpensive, produce quick results Useful for studying rare conditions Prone to confounding |
|
|
Cross-sectional survey |
Provide a 'snapshot', sometimes called prevalence studies Provide weak evidence of cause and effect |
|
|
Seborrhoeic keratoses mgmt |
reassurance about the benign nature of the lesion is an option options for removal include curettage, cryosurgery and shave biopsy |
|
|
uk at what age should the child first be offered the influenza vaccine? |
2-3 years |
|
|
anaphylaxis tx |
IM adrenaline |
|
|
You are called to see a lady who has delivered her second child 2 hours ago. The baby was term, weighed 4.1kg, and was healthy. The labour was natural, lasted 6 hours, and she chose to have a physiological third stage. The nurse tells you she thinks she has lost approximately 800ml of blood, but her observations are stable and the bleeding appears to be slowing. What is the most common cause of her blood loss? |
Uterine atony |
|
|
Primary postpartum haemorrhage is defined as |
the loss of 500ml or more from the genital tract within 24 hours of the birth of a baby. This can be further defined as - minor haemorrhage (500-1000ml) or - major haemorrhage (>1000ml), and causes 6 deaths/million deliveries. |
|
|
Primary postpartum haemorrhage causescan be grouped into the 'four T's': |
tone (uterine atony = 90%) tissue (retained placenta) trauma thrombin (coagulation abnormalities) |
|
|
whats the most common cause of 1o post partum hemorrhage |
uterine atony |
|
|
Risk factors for primary PPH include*: |
previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis) |
|
|
Secondary PPH |
occurs between 24 hours - 6 or12 weeks due to retained placental tissue or endometritis |
|
|
mgmt for 1o PPH |
ABC IV syntocinon (oxytocin) or IV ergometrine IM carboprost other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure |
|
|
A study compares the sensitivity of two tests for colorectal cancer. The first test has a sensitivity of 85% whilst the second test has a sensitivity of 91%. What type of significance test should be used for comparing the two results? |
As percentages are being compared the chi-squared test should be used |
|
|
Significance tests: types |
The type of significance test used depends on whether the data is parametric (something which can be measured, usually normally distributed) or non-parametric Non-parametric tests Mann-Whitney U test - unpaired data Wilcoxon signed-rank test - compares two sets of observations on a single sample chi-squared test - used to compare proportions or percentages Spearman, Kendall rank - correlation |
|
|
Which vitamin, if taken in high doses, can be teratogenic? |
Vitamin A nb Pregnant women are also advised to avoid eating liver, as it has high levels of vitamin A. pregnant women should not exceed a daily intake of >10,000IU |
|
|
Vitamin A |
retinol converted into retinal, an important visual pigment important in epithelial cell differentiation antioxidant Consequences of vitamin A deficiency - night blindness |
|
|
ng tubes put into the lung should be removed |
immediately serious consequences for a patient including aspiration pneumonia and death |
|
dx |
Cherry haemangioma (Campbell de Morgan spots) benign skin lesions which contain an abnormal proliferation of capillaries. They are more common with advancing age and affect men and women equally. |
|
|
Cherry haemangioma(aka Campbell de Morgan spots) fxs |
erythematous, papular lesions typically 1-3 mm in size non-blanching not found on the mucous membranes |
|
|
tx for cherry hemangioma |
NOTHING = benign |
|
|
A nurse informs you of a 28 year old woman who is 24 weeks pregnant. He says that she has a blood pressure reading of 155/90 mmHg. Her previous blood pressure 2 days ago was 152/85 mmHg. She was previously healthy prior to becoming pregnant. What is the first line management in this situation? |
Oral labetalol |
|
|
gestational hypertension first line tx |
oral labetalol |
|
|
women who are high risk of d/g preeclampsia should take |
aspirin from 12 weeks until birth of baby |
|
|
high risk grp of preeclampsia |
HTN disease during previous pregnancies chronic kidney disease autoimmune disorders such as SLE or antiphospholipid syndrome type 1 or 2 diabetes mellitus |
|
|
Remember, in normal pregnancy BP CHANGES |
usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks after this time the blood pressure usually increases to pre-pregnancy levels by term |
|
|
Hypertension in pregnancy in usually defined as: |
systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic |
|
|
how do you know if preg. lady has pre existing HTN |
If its before 20 weeks gesation no proteinuria/edema |
|
|
how do you know if preg lady has preg. induced HTN aka gestational HTN |
if it occurs after 20 weeks no proteinuria/edema resolves after birth (usu 1 month) nb these women at increased risk of future preeclampsia/HTN later in life |
|
|
preeclampsia has to occur |
after 20 weeks |
|
whats the lesion |
spider naevi Around 10-15% of healthy people will have one or more of these lesions |
|
|
spider naevi associations |
10-15% in normal peeps liver disease pregnancy combined oral contraceptive pill |
|
|
A 67-year-old man who is a retired builder presents following the development of a number of red, scaly lesions on his forehead. These were initially small and flat but are now erythematous and rough to touch. |
Actinic keratoses |
|
|
Actinic keratoses aka solar keratoses is a |
common premalig. skin lesion that develops as a consequence of chronic sun exposure |
|
|
Actinic keratoses fxs |
small, crusty or scaly, lesions may be pink, red, brown or the same colour as the skin typically on sun-exposed areas e.g. temples of head multiple lesions may be present |
|
|
mgmt of actinic keratosis |
prevention of further risk: e.g. sun avoidance, sun cream fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects topical imiquimod: trials have shown good efficacy cryotherapy curettage and cautery |
|
|
The Gell and Coombs classification divides hypersensitivity reactions into 4 types Type I - Anaphylactic |
antigen reacts with IgE bound to mast cells anaphylaxis, atopy (e.g. asthma, eczema and hayfever) |
|
|
Type II - Cell bound |
IgG or IgM binds to antigen on cell surface autoimmune haemolytic anaemia, ITP, Goodpasture's, pernicious anemia, acute hemolytic transfusion reactions, rheumatic fever, bullous pemphigoid, pemphigus vulgaris |
|
|
Type III - Immune complex |
free antigen and antibody (IgG, IgA) combine serum sickness, systemic lupus erythematosus, post-streptococcal glomerulonephritis, extrinsic allergic alveolitis (especially acute phase) |
|
|
Type IV - Delayed hypersensitivity |
T cell mediated tuberculosis, tuberculin skin reaction, graft versus host disease, allergic contact dermatitis, scabies, extrinsic allergic alveolitis (especially chronic phase), multiple sclerosis, Guillain-Barre syndrome |
|
|
normal pressure hydrocephalus DUG CLASSIC TRIAD |
Urinary incontinence + gait abnormality + dementia |
|
|
Normal pressure hydrocephalus mgmt |
ventriculoperitoneal shunting |
|
|
Normal pressure hydrocephalus pathophys |
thought to be secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis |
|
|
relative risk formula |
EER / CER |
|
|
absolute risk reduction |
CER - EER |
|
|
A 45 year old woman presents with with fever, rigors and left sided loin pain to the emergency department in Manchester. She has polycystic kidney disease (PKD) and 5 months ago she received a renal transplant on the left side for end stage renal failure. She is currently on mycophenolate mofetil 1g twice daily and prednisolone 10 mg once daily.Investigations:White cell count16 x 10^6 / dLUrine MicroscopyWhite cells +++, no organisms seen.Her kidney function tests are as follows:Post-TransplantCurrent AdmissionUrea4.1 mmol/L9.1 mmol/LCreatinine98 µmol/L140 µmol/LPotassium4.9 mmol/L5.3 mmol/LWhat is the most likely diagnosis? |
Acute graft rejection |
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Hyperacute acute rejection |
minutes to hours |
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Acute graft failure |
< 6 months |
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chronic graft failure |
> 6 months |
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A 62-year-old female with a history of Grave's disease presents with nausea, lethargy and abdominal pain. Examination reveals increased pigmentation of the buccal mucosa. Which one of the following is the best investigation to confirm the suspected diagnosis of Addison's? |
Short ACTH test |
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Addison's disease definite investigation |
ACTH stimulation test (short Synacthen test) if test not available then do morning serum cortisol nb Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated. |
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ACTH stimulation test (short Synacthen test) procedure involves |
Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM |
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If a ACTH stimulation test is not readily available (e.g. in primary care) then sending a 9 am serum cortisol can be useful: |
> 500 nmol/l makes Addison's very unlikely < 100 nmol/l is definitely abnormal 100-500 nmol/l should prompt a ACTH stimulation test to be performed |
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addisons dis Associated electrolyte abnormalities are seen in around one-third of undiagnosed patients: |
hyperkalaemia hyponatraemia hypoglycaemia metabolic acidosis |
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How is premature ovarian failure defined? |
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years |
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Premature ovarian failure causes |
idiopathic - the most common cause chemotherapy autoimmune radiation |
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Features are similar to those of the normal climacteric but the actual presenting problem may differ |
climacteric symptoms: hot flushes, night sweats infertility secondary amenorrhoea raised FSH, LH levels Rate, discuss and give feedback on this question |
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climacteric def |
menopause |
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A 65-year-old man presents with bilateral leg pain that is brought on by walking. His past medical history includes peptic ulcer disease and osteoarthritis. He can typically walk for around 5 minutes before it develops. The pain subsides when he sits down. He has also noticed that leaning forwards or crouching improves the pain. Musculoskeletal and vascular examination of his lower limbs is unremarkable. What is the most likely diagnosis? |
Spinal stenosis |
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Red flags for lower back pain |
age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever |
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A 23-year-old woman presents one week after being prescribed a combined antibiotic and steroid spray for otitis externa. There has been no improvement in her symptoms and the erythema seems to have extended to the ear itself. What is the most appropriate treatment? |
Oral flucloxacillin The spreading erythema is an indication for oral antibiotics. Flucloxacillin is first-line. |
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Causes of otitis externa include: |
infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal seborrhoeic dermatitis contact dermatitis (allergic and irritant) |
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otitis media fxs |
ear pain, itch, discharge otoscopy: red, swollen, or eczematous canal |
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in otitis media with perforated tympanic membrane DONT USE |
AMINOGLYCOSIDES |
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Malignant otitis externa is more common in elderly diabetics. In this condition there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. tx |
IV ABX |
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A 56-year-old man is reviewed in the Cardiology outpatient clinic following a myocardial infarction one year previously. During his admission he was found to be hypertensive and diabetic. He complains that he has put on 5kg in weight in the past 6 months. Which of his medications may be contributing to his weight gain? |
Gliclazide |
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COMMON AE of sulfonylureas |
hypoglycemic episodes WEIGHT GAIN |
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Sulfonylureas are oral hypoglycaemic drugs used in the management of type 2 diabetes mellitus. They work by |
increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present. On a molecular level they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells. |
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sulfonylureas |
1st gen Carbutamide Chlorpropamide 2nd gen Glipizide Gliclazide Glyclopyramide 3rd gen Glimepiride |
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Which one of the following statements best describes a type II statistical error? |
The null hypothesis is accepted when it is false |
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A 39-year-old man comes for review. Six months ago he was started on paroxetine for depression. Around five days ago he stopped taking the medication as he felt that it was having no benefit. His only past medical history of note is asthma. For the past two days he has experienced increased anxiety, sweating, headache and the feeling of a needle like sensation in his head. During the consultation he is pacing around the room. What is the most explanation for his symptoms? |
Selective serotonin reuptake inhibitor`discontinuation syndrome |
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paroxetine is |
an SSRI |
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Paroxetine has a higher incidence of discontinuation symptoms than other |
SSRIs |
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1st line tx for depression |
SSRI = citalopram or fluoxetine fluoxetine 1st line for kids/teens sertraline useful post MI |
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AE of SSRI |
GI sxs most common GI bleed (so give PPI) |
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Citalopram AE |
LONG QT |
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SSRI INTERACTIONS thus avoid it |
NSAID warfarin/heparin aspirin triptans |
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When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms. |
increased mood change restlessness difficulty sleeping
sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia |
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SSRI esp pxs under 30 are at increased risk of |
suicide so if you give it, r/v after 1 week if px good response = continue for 6 months |
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Risk factors for gestational diabetes |
BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes |
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Screening for gestational diabetes |
OGTToral glucose tolerance test measure fasting glucose and then give glucose and measure 2 hrs after |
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Diagnostic thresholds for gestational diabetes |
fasting glucose is >= 5.6 mmol/l 2-hour glucose is >= 7.8 mmol/l |
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Management of gestational diabetes (the mother has DM when preg) |
DM + antenatal clinic within 1 week education for selfmonitoring b/g diet & exercise advice if abn. b/g for 1-2 weeks start metformin if still not controlled add insulin |
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Management of pre-existing diabetes |
weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication ratestreat retinopathy as can worsen during pregnancy |
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Targets for self monitoring of pregnant women (pre-existing and gestational diabetes) |
Fasting 5.3 mmol/l 1 hour after meals7.8 mmol/l, or: 2 hour after meals6.4 mmol/l |
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47 yo px what are themost common causes of bacterial meningitis |
Streptococcus pneumoniae and Neisseria meningitidis |
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Meningitis: causes0 - 3 months |
Group B Streptococcus (most common cause in neonates) = strep. agalactiae E. coli Listeria monocytogenes |
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Meningitis: causes3 months - 6 years |
Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae |
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Meningitis: causes6 years - 60 years |
Neisseria meningitidis Streptococcus pneumoniae |
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Meningitis: causes> 60 years |
Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes |
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Meningitis: causesImmunosuppressed |
Listeria monocytogenes |
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32 year old lady presents with symmetrical joint pain in her hands and early morning stiffness. She also has some dry, erythematous, inflamed skin mostly in flexor surfaces. An x-ray is ordered and shows loss of joint space, erosions and soft tissue swelling. What is the most likely |
RA |
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osteoarthritis and rheumatoid arthritis are LOSS and LESS, respectively. |
X-ray findings of osteoarthritis (LOSS) are: Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
X-ray findings of rheumatoid arthritis (LESS) are: Loss of joint space Erosions Soft tissue Swelling Soft bones - osteopenia |
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Cervical mgmt |
Borderline or mild dyskaryosis The original sample is tested for HPV* if negative the patient goes back to routine recall if positive the patient is referred for colposcopy
Moderate dyskaryosis Consistent with CIN II. Refer for colposcopy Severe dyskaryosis Consistent with CIN III. Refer for colposcopy Suspected invasive cancer Refer for urgent colposcopy (within 2 weeks) Inadequate Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy |
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Addisonian crisis causes |
sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism) adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia) steroid withdrawal |
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Addisonian crisis mgmt |
hydrocortisone 100 mg im or iv 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days |
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PID Causative organisms |
Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis |
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PID complications |
infertility - the risk may be as high as 10-20% after a single episode chronic pelvic pain ectopic pregnancy |
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Acute gout mgmt |
NSAIDs intra-articular steroid injection colchicine* has a slower onset of action. The main side-effect is diarrhoea oral steroids may be considered if NSAIDs and colchicine are contraindicated. A dose of prednisolone 15mg/day is usually used if the patient is already taking allopurinol it should be continued |
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Which one of the following is the most common ocular manifestation of rheumatoid arthritis? |
Keratoconjunctivitis sicca |
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Ocular manifestations of RA |
keratoconjunctivitis sicca (most common)
episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis |
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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.
Nb Fxs auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear other features include vertigo and tinnitus
Mgmt oral aciclovir and corticosteroids are usually given |
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The following ECG is taken from a patient with a significant electrolyte disturbance: |
broad QRS complexes tall tented T waves |
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Foods that are high in potassium: |
salt substitutes (i.e. Contain potassium rather than sodium) bananas, oranges, kiwi fruit, avocado, spinach, tomatoes |
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Foods that are high in potassium: |
salt substitutes (i.e. Contain potassium rather than sodium) bananas, oranges, kiwi fruit, avocado, spinach, tomatoes |
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Causes of hyperkalaemia: |
acute renal failure drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's rhabdomyolysis massive blood transfusion |
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Foods that are high in potassium: |
salt substitutes (i.e. Contain potassium rather than sodium) bananas, oranges, kiwi fruit, avocado, spinach, tomatoes |
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Causes of hyperkalaemia: |
acute renal failure drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's rhabdomyolysis massive blood transfusion |
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A 43-year-old man with a history of Peutz-Jeghers syndrome presents with diarrhoea and rectal bleeding for the past ten days. On examination he has brown pigmented lesions on his lips and palms but abdominal and rectal examination is unremarkable. What is the most likely cause for this presentation? |
Colon cancer |
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Foods that are high in potassium: |
salt substitutes (i.e. Contain potassium rather than sodium) bananas, oranges, kiwi fruit, avocado, spinach, tomatoes |
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Causes of hyperkalaemia: |
acute renal failure drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's rhabdomyolysis massive blood transfusion |
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A 43-year-old man with a history of Peutz-Jeghers syndrome presents with diarrhoea and rectal bleeding for the past ten days. On examination he has brown pigmented lesions on his lips and palms but abdominal and rectal examination is unremarkable. What is the most likely cause for this presentation? |
Colon cancer |
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Colon cancer is the most common type of gastrointestinal cancer that patients with Peutz-Jeghers syndrome develop. |
True |
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Foods that are high in potassium: |
salt substitutes (i.e. Contain potassium rather than sodium) bananas, oranges, kiwi fruit, avocado, spinach, tomatoes |
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Causes of hyperkalaemia: |
acute renal failure drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's rhabdomyolysis massive blood transfusion |
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A 43-year-old man with a history of Peutz-Jeghers syndrome presents with diarrhoea and rectal bleeding for the past ten days. On examination he has brown pigmented lesions on his lips and palms but abdominal and rectal examination is unremarkable. What is the most likely cause for this presentation? |
Colon cancer |
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Colon cancer is the most common type of gastrointestinal cancer that patients with Peutz-Jeghers syndrome develop. |
True |
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A 40-year-old man with a history of psychiatric problems and epilepsy comes for review. He complains that he is drinking excessive amounts of water and having to urinate frequently. He has not lost any weight and states that he is compliant with his current medications. Blood tests show the following:
Na+ 145 mmol/l K+ 4.1 mmol/l Urea 6.3 mmol/l Creatinine 101 µmol/l
Glucose (random) 6.2 mol/l
Which one of the following medications is most likely to be responsible for this presentation? |
Lithium |
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A 40-year-old man with a history of psychiatric problems and epilepsy comes for review. He complains that he is drinking excessive amounts of water and having to urinate frequently. He has not lost any weight and states that he is compliant with his current medications. Blood tests show the following:
Na+ 145 mmol/l K+ 4.1 mmol/l Urea 6.3 mmol/l Creatinine 101 µmol/l
Glucose (random) 6.2 mol/l
Which one of the following medications is most likely to be responsible for this presentation? |
Lithium
This patient has probably developed nephrogenic diabetes insipidus secondary to lithium therapy. Polyuria, polydipsia and a high-normal sodium are pointers towards this. Rate, discuss and give feedback on this question Next question |
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Diabetes insipidus (DI) is a condition characterised by |
either a deficiency of antidiuretic hormone, ADH, (cranial DI) or an insensitivity to antidiuretic hormone (nephrogenic DI). |
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Causes of cranial/central DI |
idiopathic post head injury pituitary surgery craniopharyngiomas histiocytosis X DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome) |
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Causes of nephrogenic DI |
genetic: the more common form affects the vasopression (ADH) receptor, the less common form results from a mutation in the gene that encodes the aquaporin 2 channel electrolytes: hypercalcaemia, hypokalaemia drugs: demeclocycline, lithium tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis |
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InV for DI |
high plasma osmolality, low urine osmolality water deprivation test |
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Classification of diabetic retinopathy |
non-proliferative diabetic retinopathy (NPDR) and those with proliferative retinopathy (PDR): |
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Classification of diabetic retinopathy |
non-proliferative diabetic retinopathy (NPDR) and those with proliferative retinopathy (PDR): |
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NPDR non prolig diabetic retinopathy |
Mild NPDR 1 or more microaneurysm
Moderate NPDR microaneurysms blot haemorrhages hard exudates cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
Severe NPDR blot haemorrhages and microaneurysms in 4 quadrants venous beading in at least 2 quadrants IRMA in at least 1 quadrant |
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Classification of diabetic retinopathy |
non-proliferative diabetic retinopathy (NPDR) and those with proliferative retinopathy (PDR): |
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NPDR non prolig diabetic retinopathy |
Mild NPDR 1 or more microaneurysm
Moderate NPDR microaneurysms blot haemorrhages hard exudates cotton wool spots, venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR
Severe NPDR blot haemorrhages and microaneurysms in 4 quadrants venous beading in at least 2 quadrants IRMA in at least 1 quadrant |
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Proliferative retinopathy |
retinal neovascularisation - may lead to vitrous haemorrhage fibrous tissue forming anterior to retinal disc more common in Type I DM, 50% blind in 5 years |
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Maculopathy |
based on location rather than severity, anything is potentially serious hard exudates and other 'background' changes on macula check visual acuity more common in Type II DM |
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Episodic eye pain, lacrimation, nasal stuffiness occurring daily - cluster headache |
True |
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Episodic eye pain, lacrimation, nasal stuffiness occurring daily - cluster headache |
True |
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A 41-year-old man presents with a two week history of headaches around the left side of his face associated with watery eyes. He describes having about two episodes a day each lasting around 30 minutes. What is the likely diagnosis? |
Cluster headache |
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Cluster headache mgmt |
acute: 100% oxygen, subcutaneous or a nasal triptan prophylaxis: verapamil, prednisolone NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging |
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What is the most significant risk of prescribing an oestrogen-only preparation rather than a combined oestrogen-progestogen preparation? |
Increased risk of endometrial cancer |
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onychomycosis. What treatment should you offer him? |
Oral terbinafine |
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onychomycosis. What treatment should you offer him? |
Oral terbinafine |
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A 35-year-old man attends your surgery two days after being struck on the lateral aspect of his right knee by the bumper of a car travelling at low speed. He is able to walk, all be it with an antalgic gait. However, he is unable to dorsiflex the ankle, evert the foot or extend his toes. There is loss of sensation of the dorsum of the foot. Which structure is he most likely to have damaged? |
Common peroneal nerve |
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Properties of the Normal distribution symmetrical i.e. Mean = mode = median 68.3% of values lie within 1 SD of the mean 95.4% of values lie within 2 SD of the mean 99.7% of values lie within 3 SD of the mean this is often reversed, so that within 1.96 SD of the mean lie 95% of the sample values the range of the mean - (1.96 *SD) to the mean + (1.96 * SD) is called the 95% confidence interval, i.e. If a repeat sample of 100 observations are taken from the same group 95 of them would be expected to lie in that range |
True |
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Properties of the Normal distribution symmetrical i.e. Mean = mode = median 68.3% of values lie within 1 SD of the mean 95.4% of values lie within 2 SD of the mean 99.7% of values lie within 3 SD of the mean this is often reversed, so that within 1.96 SD of the mean lie 95% of the sample values the range of the mean - (1.96 *SD) to the mean + (1.96 * SD) is called the 95% confidence interval, i.e. If a repeat sample of 100 observations are taken from the same group 95 of them would be expected to lie in that range |
True |
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Painful third nerve palsy = posterior communicating artery aneurysm |
True |
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A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present. Which one of the following diagnoses needs to be urgently excluded? |
Posterior communicating artery aneurysm |
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A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present. Which one of the following diagnoses needs to be urgently excluded? |
Posterior communicating artery aneurysm |
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Third nerve palsy |
eye is deviated 'down and out' ptosis pupil may be dilated (sometimes called a 'surgical' third nerve palsy) |
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A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present. Which one of the following diagnoses needs to be urgently excluded? |
Posterior communicating artery aneurysm |
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Third nerve palsy |
eye is deviated 'down and out' ptosis pupil may be dilated (sometimes called a 'surgical' third nerve palsy) |
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A 25-year-old man presents with a pruritic skin rash. This has been present for the past few weeks and has responded poorly to an emollient cream. The pruritus is described as 'intense' and has resulted in him having trouble sleeping. On inspecting the skin you notice a combination of papules and vesicles on his buttocks and the extensor aspect of the knees and elbows. What is the most likely diagnosis? |
Dermatitis herpetiformis |
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Dermatitis herpetifomis |
It is caused by deposition of IgA in the dermis. |
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Dx of Dermatitis herpetiformis |
skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis |
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Mgmt of Dermatitis herpetiformis
|
gluten-free diet dapsone |
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A 30-year-old intravenous drug user is diagnosed as having osteomyelitis of the right tibia. What is the most likely causative organism? |
Staphylococcus aureus |
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Osteomyelitis |
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate. |
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Osteomyelitis dx and mgmt |
MRI
flucloxacillin for 6 weeks clindamycin if penicillin-allergic |
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Osteomyelitis dx and mgmt |
MRI
flucloxacillin for 6 weeks clindamycin if penicillin-allergic |
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The most common causes of bilateral hilar lymphadenopathy are |
sarcoidosis and tuberculosis |
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The most common causes of bilateral hilar lymphadenopathy are |
sarcoidosis and tuberculosis
Other causes include: lymphoma/other malignancy pneumoconiosis e.g. berylliosis fungi e.g. histoplasmosis, coccidioidomycosis |
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Common causes of lobar collapse include: |
lung cancer (the most common cause in older adults) asthma (due to mucous plugging) foreign body |
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The most common causes of bilateral hilar lymphadenopathy are |
sarcoidosis and tuberculosis
Other causes include: lymphoma/other malignancy pneumoconiosis e.g. berylliosis fungi e.g. histoplasmosis, coccidioidomycosis |
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Common causes of lobar collapse include: |
lung cancer (the most common cause in older adults) asthma (due to mucous plugging) foreign body |
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Which one of the following is not a risk factor for primary open-angle glaucoma? |
Hypermetropia |
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Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia |
True |
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Glaucoma is a group disorders characterised by optic neuropathy due, |
in the majority of patients, to raised intraocular pressure (IOP). It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa |
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Glaucoma is a group disorders characterised by optic neuropathy due, |
in the majority of patients, to raised intraocular pressure (IOP).
It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa |
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Glaucoma is a group disorders characterised by optic neuropathy due, |
in the majority of patients, to raised intraocular pressure (IOP).
It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa |
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Primary open-angle glaucoma (POAG, also referred to as chronic simple glaucoma) is present in around 2% of people older than 40 years.
Other than age, risk factors include: |
family history black patients myopia hypertension diabetes mellitus |
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POAG may present insidiously and for this reason is often detected during routine optometry appointments. Features may include |
peripheral visual field loss - nasal scotomas progressing to 'tunnel vision' decreased visual acuity optic disc cupping |
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A 38-year-old lady presents with a recent episode of renal colic. As part of her investigations the following results are obtained:
Corrected Calcium 3.84 mmol/l PTH 88pg/ml (increased)
Her serum urea and electrolytes are normal.
What is the most likely diagnosis? |
1o hyperPTH |
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1o hyperPTH most commonly due to |
a solitary adenoma |
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1o hyperPTH most commonly due to |
solitary adenoma 80%
Nb
15%: hyperplasia 4%: multiple adenoma 1%: carcinoma |
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1o hyperPTH most commonly due to |
solitary adenoma 80%
Nb
15%: hyperplasia 4%: multiple adenoma 1%: carcinoma |
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Fxs of hyperPTH |
bones, stones, abdominal groans and psychic moans' |
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Fxs of hyperPTH |
bones, stones, abdominal groans and psychic moans'
polydipsia, polyuria peptic ulceration/constipation/pancreatitis bone pain/fracture renal stones depression hypertension |
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1o hyperPTH |
hypertension multiple endocrine neoplasia: MEN I and II |
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1o hyperPTH |
hypertension multiple endocrine neoplasia: MEN I and II |
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1o hyperPTH InV |
raised calcium, low phosphate PTH may be raised or normal technetium-MIBI subtraction scan |
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1o hyperPTH |
hypertension multiple endocrine neoplasia: MEN I and II |
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1o hyperPTH InV |
raised calcium, low phosphate PTH may be raised or normal technetium-MIBI subtraction scan |
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Tx for 1o hyperPTH |
total parathyroidectomy |
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A 25-year-old man presents with a widespread rash over his body. The torso and limbs are covered with multiple erythematous lesions less than 1 cm in diameter which in parts are covered by a fine scale. You note that two weeks earlier he was seen with to a sore throat when it was noted that he had exudative tonsillitis. Other than a history of asthma he is normally fit and well. What is the most likely diagnosis? |
Guttate psoriasis |
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Psoriasis: guttate strep infection e.g. tonsillitis, sore throat and then 2-4 weeks later develop rash (tear drop) |
Guttate psoriasis is more common in children and adolescents. It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing
Features tear drop papules on the trunk and limbs |
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Management of Psoriasis: guttate
|
most cases resolve spontaneously within 2-3 months there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection topical agents as per psoriasis UVB phototherapy tonsillectomy may be necessary with recurrent episodes |
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Management of Psoriasis: guttate
|
most cases resolve spontaneously within 2-3 months there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection topical agents as per psoriasis UVB phototherapy tonsillectomy may be necessary with recurrent episodes |
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Differentiating guttate psoriasis and pityriasis rosea |
guttate psoriasis = strep throat 2-4weeks prior = tear drop, trunk and limbs |
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Differentiating guttate psoriasis and pityriasis rosea |
guttate psoriasis = strep throat 2-4weeks prior = tear drop, scaly papules on the trunk and limbs
pityriasis rosea running parallel to the line of Langer. This may produce a 'fir-tree' appearance
Both usu resolve spontaneously |
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Differentiating guttate psoriasis and pityriasis rosea |
guttate psoriasis = strep throat 2-4weeks prior = tear drop, scaly papules on the trunk and limbs
pityriasis rosea Oval lesion running parallel to the line of Langer. This may produce a 'fir-tree' appearance
Both usu resolve spontaneously |
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Potential complications |
epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome) |
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HTN mgmt |
Step 1 = ACEi
Step 2 = CCB
Step 3 = Diuretic
Step 4 = specialist |
|
|
Blood pressure targets |
Age < 80 years 140/90 mmHg 135/85 mmHg
Age > 80 years 150/90 mmHg 145/85 mmHg |
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A patient of yours has been diagnosed with Horner's syndrome. Which of the following is most likely to be seen? |
Miosis + ptosis + enophthalmos |
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|
A patient of yours has been diagnosed with Horner's syndrome. Which of the following is most likely to be seen? |
miosis + ptosis + enophthalmos +/- anhydrosis |
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a preg women with past mhx of preeclampsia, what medds would you give her at 12-14 weeks gestation to reduce risk of IUGR (intrauterine growth retardation) |
low dose aspirin |
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|
what antiHTN agents can be given in acute mgmt of preeclampsia |
Labetalol and methyldopa |
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|
can labetalol/methyldopa be given prophylactically for preeclampsia to reduce IUGR |
no |
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what agent can be given prophylactically for suspected preeclampsia or px with pmhx of preeclampsia to reduce IUGR |
low dose aspirin = reducing perinatal mortality and reducing the risk of babies being born small for gestational age |
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A 56-year-old woman comes for review. Around 4 weeks ago she had a blistering rash under her right breast which extended around to the back. A diagnosis of shingles was made. Unfortunately since that time she has been experiencing severe 'shooting' pains. The skin is also very tender to touch. Neither paracetamol nor ibuprofen have helped her symptoms. What is the most appropriate next step in management? |
Amitriptyline dx post-herpetic neuralgia |
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|
Neuropathic pain may be defined as |
pain which arises following damage or disruption of the nervous system |
|
|
examples of neuropathic pain |
diabetic neuropathy post-herpetic neuralgia trigeminal neuralgia prolapsed intervertebral disc |
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|
first line tx for neuropathic pain |
amitriptyline, duloxetine, gabapentin or pregabalin nb +- tramadol 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 |
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|
first line tx for trigeminal neuralgia |
? carbamazepine |
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A 35-year-old man presents to his GP surgery as he is having some difficulties with his hearing. He now struggles to follow conversation and often has the TV volume turned up high. Otoscopy is normal. An audiogram is requested: |
What does the audiogram show? Normal hearing |
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|
Audiograms are usually the first-line investigation that is performed when a patient complains of |
hearing difficulties |
|
audiogram explained |
anything above the 20dB line is essentially normal (marked in red on the blank audiogram below) in sensorineural hearing loss both air and bone conduction are impaired in conductive hearing loss only air conduction is impaired in mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone |
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A 77-year-old man on the ward has only produced 120 mL of urine in the past 8 hours. Which metabolic abnormality is the most serious potential complication of his condition? |
Hyperkalaemia |
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|
MAP 2 formulas |
MAP = CO x TPR OR diastolic pressure + 1/3 PP |
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|
normal range for MAP |
70-105mmhg |
|
|
TPR FORMULA |
(MAP - R atrial press.)/CO OR (MAP - CVP)/CO |
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|
normal adult urine output |
.5-1ml/kg/hr |
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|
normal infant urine output |
2ml/kg/hr |
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|
differential diagnosis of shin lesions |
erythema nodosum pretibial myxoedema pyoderma gangrenosum necrobiosis lipoidica diabeticorum |
|
pyoderma gangrenosum |
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|
erythema nodosum |
|
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|
A 64 year old man with known chronic obstructive pulmonary disease (COPD) presents with shortness of breath and productive cough. He is started on antibiotics and controlled oxygen therapy (FiO2 28%) to maintain saturations between 88-92%. An arterial blood gas (ABG) is performed (results below). After 1 hour the ABG is repeated but shows no improvement. pH7.29pO28.4 kpapCO26.7 kpaWhat should be added to his management? |
Biphasic positive airway pressure ventilation (BiPAP) |
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|
mgmt for resp acidosis and type 2 resp failure |
BiPAP |
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|
BiPAP should be considered for all COPD patients with a persisting |
respiratory acidosis (pH <7.35) after a maximum of one hour of standard medical and controlled oxygen therapy. |
|
|
The most common bacterial organisms that cause infective exacerbations of COPD are: |
Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis Respiratory viruses account for around 30% of exacerbations, with the human rhinovirus being the most important pathogen. |
|
|
COPD mgmt NICE GUIDELINES |
up bronchodilator use +- via nebuliser give prednisolone all exacerbation give ABx (not supported by NICE - suggest give only if signs of infxn) BiPAP |
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A 47-year-old man is reviewed in the smoking cessation clinic. Which one of the following conditions would contraindicate the prescription of bupropion? |
Epilepsy |
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|
bupropion can be give to help with |
smoking cessation |
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|
buproprion is CI in smokers with |
EPILEPSY |
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|
nicotine replacement therapy include |
varenicline or bupropion Vareniclinea nicotinic receptor partial agonist Bupropiona norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist |
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|
Neonatal to 3 months - meningitis causes |
Group B Streptococcus: usually acquired from the mother at birth. More common in low birth weight babies and following prolonged rupture of the membranes E. coli and other Gram -ve organisms Listeria monocytogenes |
|
|
1 month to 6 years - meningitis causes |
Neisseria meningitidis (meningococcus) Streptococcus pneumoniae (pneumococcus) Haemophilus influenzae |
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|
Greater than 6 years - meningitis causes |
Neisseria meningitidis (meningococcus) Streptococcus pneumoniae (pneumococcus) |
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A 35-year-old man is investigated for lethargy, arthralgia and deranged liver function tests. He is eventually diagnosed as having hereditary hemochromatosis. His wife has a genetic test which shows she is not a carrier of the disease. What is the chance his child will develop haemochromatosis? |
0% |
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|
hereditary hemochromatosis |
AR |
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|
if one parent affect with HH and the other not a carrier - likelihood infant will develop HH |
0% but 100% of the infants will be carriers BUT NOT AFFECTED |
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|
Haemochromatosis due to |
HFE gene mutation |
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|
Haemochromatosis fxs |
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) |
|
|
which features of haemochromatosis are reversible with treatment: |
Cardiomyopathy Skin pigmentation |
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|
mnemonic for AD |
|
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|
A 71-year-old man presents with sudden painless loss of vision in his left eye: Fundoscopy shows the following: dx |
Retinal detachment |
|
|
Posterior vitreous detachment |
Flashes of light (photopsia) + floaters |
|
|
Retinal detachment |
shadow start outside then in curtain like draping |
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|
vitreous hemorrhage |
small/large bleeds lots of dark spots +- floaters |
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|
The BNF recommends flucloxacillin as first-line treatment for mild/moderate cellulitis what if allergic to penicillin |
Clarithromycin or clindamycin |
|
|
URTI symptoms + amoxicillin → rash |
?glandular fever A rash develops in around 99% of patients who take amoxicillin whilst they have infectious mononucleosis. |
|
|
Infectious mononucleosis dx |
heterophil antibody test (Monospot test) |
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|
Infectious mononucleosis Management is supportive and includes: |
rest during the early stages, drink plenty of fluid, avoid alcohol simple analgesia for any aches or pains consensus guidance in the UK is to avoid playing contact sports for 8 weeks after having glandular fever to reduce the risk of splenic rupture |
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|
There are two main types of IGR (impaired glucose regulation) |
impaired fasting glucose (IFG) - due to hepatic insulin resistance impaired glucose tolerance (IGT) - due to muscle insulin resistance |
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|
which pxs are more likely to d/p DM2 and CVD - IFG/IGT |
IGT pxs |
|
|
IFG def |
6.1 - 7 mmol/l |
|
|
IGT def |
<7mmol/l and OGTT 2hr value 7.8-11mmol/l |
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|
A young mother brings her 5 year old son to the Emergency Department. She mentions her son has had 2 days of swelling on his legs, scrotum and around his eyes. She continues to tell you that he is generally tired and his urine is noted to be frothy. Boys mother has noticed a cough which has persisted. No past medical history except for eczema and asthma. Renal biopsy: no abnormalities can be seen on light microscopy, however, electron microscopy reveals abnormal podocytes (fused).What is the most likely diagnosis? |
Minimal change disease |
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|
when trying to figure out GN - what are the steps |
1st = is it prolif/nonprolif. prolif causes nephritic nonprolif causes nephrotic (MORE O'S) next - look for specific fxs |
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|
Minimal change disease causing GN fxs |
fused podocytes on electron microscopy very young px associated with facial/periorbital swelling and frothy urine association with atopy and Hodgkins lymphoma |
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|
Focal segmental glomerulosclerosis |
podocyte fusion older children and young adults +- hematuria, HTN, i/t renal func. |
|
|
Membranous nephropathy IgA disease |
thickened glomerular BM mostly idiopathic +- assoc with SLE, hep B, malig, gold/penicillamine use |
|
|
Rapidly progressive glomerulonephritis (RPGN) fxs |
crescents on histology usu seen with goodpastures or vasculities (Wegs/microscopic polyangitis) |
|
|
whats the most common cause of glomerulonephritis in adults |
IgA disease |
|
|
Minimal change disease nearly always presents as nephrotic syndrome, accounting for |
75% of cases in children and 25% in adults. |
|
|
Minimal change disease, majority of cases are |
idiopathic but 10-20% have a cause |
|
|
The majority of cases are idiopathic, but in around 10-20% a cause is found: |
drugs: NSAIDs, rifampicin Hodgkin's lymphoma, thymoma infectious mononucleosis |
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|
Pathophysiology of minimal change dis |
T-cell and cytokine mediated damage to the glomerular basement membrane → polyanion loss the resultant reduction of electrostatic charge → increased glomerular permeability to serum albumin |
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|
fxs of MCD |
nephrotic syndrome usu. normotension (rare to get HTN) intermediate sized protinuria (ie albumin and transferrin) fused podocytes |
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|
MCD mgmt |
80% respond to steroids if resistant, next step = cyclophosphamide |
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|
MCD prognosis |
1/3 have just one episode 1/3 have infrequent relapses 1/3 have frequent relapses which stop before adulthood |
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|
This patient has developed side-effects related to his long-term medication: Which drug is most likely to be responsible? |
Prednisolone |
|
|
Cushing's disease (80%) causes |
pituitary tumour secreting ACTH producing adrenal hyperplasia |
|
|
cushings syndrome causes |
iatrogenic: steroids adrenal adenoma (5-10%) adrenal carcinoma (rare) Carney complex: syndrome including cardiac myxoma micronodular adrenal dysplasia (very rare) |
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|
Pseudo-Cushing's fxs |
mimics Cushing's often due to alcohol excess or severe depression causes false positive dexamethasone suppression test or 24 hr urinary free cortisol insulin stress test may be used to differentiate |
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|
A 28-year-old man develops nausea and a severe headache whilst trekking in Nepal. Within the next hour he becomes ataxic and confused. A diagnosis of high altitude cerebral oedema is suspected. Other than descent and oxygen, what is the most important treatment? |
Dexamethasone |
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|
Acetazolamide is used more in the prevention of |
high altitude cerebral oedema. |
|
|
There are three main types of altitude related disorders: |
acute mountain sickness (AMS), which may progress to high altitude pulmonary edema (HAPE) or high altitude cerebral edema (HACE). All three conditions are due to the chronic hypobaric hypoxia which develops at high altitudes |
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|
A 2 year old boy presents to the GP with his mother. She is worried that he is not growing at the same rate as the other children at his play group. His mother describes foul smelling diarrhoea about 4-5 times a week, accompanied by abdominal pain.On examination he has a bloated abdomen and wasted buttocks. He has dropped 2 centile lines and now falls on the 10th centile.What is the most appropriate initial investigation? |
IgA TTG antibodies |
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|
child growth slow, foul smelling diarrhoea 4-5x/week with abdo pain abdo distension and wasted buttocks most appropriate initial inV |
IgA TTG antibodies checking for coeliac dis |
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|
A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder? |
Loss of inhibitions |
|
|
characteristic feature of post-traumatic stress disorder |
Hyperarousal Emotional numbing Nightmares Avoidance nb re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images |
|
|
Post-traumatic stress disorder mgmt |
WAW therapy if top fails = med tx = paroxetine or mirtazapine |
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|
a preg. px with microcytic anaemia how should you mange her |
Prescribe oral ferrous sulphate |
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|
breastfeeding mother with UTI, tx? |
trimethoprim = safe in breastfeeding women |
|
|
Breast feeding: drug contraindications |
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole sulphonylureas cytotoxic drugs amiodarone |
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|
A 54-year-old obese woman presents with shortness of breath. She currently uses HRT and smokes 20 per day. Chest auscultation is unremarkable. Spirometry shows an obstructive pattern with no reversibility to bronchodilators. dx |
COPD |
|
|
The lack of reversibility in response to bronchodilator therapy suggests a diagnosis of ASHTMA OR COPD |
COPD rather than asthma. |
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|
A 62-year-old man who is currently being treated for colorectal cancer presents with progressive shortness of breath over the past 2 months. Respiratory examination is unremarkable other than a respiratory rate of 24 / min. He is also noted to have a raised JVP and a pulse rate of 96 / min. |
Recurrent pulmonary emboli |
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|
A 67-year-old man presents with increasing shortness of breath. His symptoms are worse at night. A third heart sound is noted on examination. |
Heart failure |
|
|
Aortic stenosis |
Chest pain, SOB and syncope ejection systolic murmur radiating to the neck narrow pulse pressure |
|
|
Recurrent pulmonary emboli - you can be predisposed by having a |
MALIGNANCY |
|
|
Recurrent PE fxs |
+- predisposing factors pleuritic CP +- hemoptysis tachycardia and tachypnoea common in acute severe = RHF |
|
|
fxs of lung cancer |
Haemoptysis, chronic cough or unresolving infection are common presentations systemic = weight loss |
|
|
fxs of pul. Fibrosis |
Progressive SOB Fine bibasal crackles Restrictive pattern on spirometry |
|
|
Bronchiectasis fxs |
purulent sputum hx of chest infxns bronchial obstrxn or ciliary dyskinetic syndromes (kartageners synd) |
|
|
Obese patients tend to be more SOB due to |
increased work of activity |
|
|
Which one of the following statements regarding croup is true? Symptoms are typically worse during the dayMost common in children under the age of 6 monthsThroat examination is important prior to making the diagnosisMost commonly caused by parainfluenza virusesMore common in spring |
Most commonly caused by parainfluenza viruses |
|
|
in croup should you do a throat exam |
no, because it might precipitate a/w obstrxn |
|
|
Croup fxs |
peak incidence at 6 months - 3 years more common in autumn stridor barking cough (worse at night) fever coryzal symptoms |
|
|
mgmt of croup |
single dose of dexamethasone in all kids regardless of severity alternative = prednisolone emergency tx = - high flow O2 - nebulised adrenaline |
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|
Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions its mostly caused by |
parainfluenze virus |
|
|
Each one of the following is associated with bronchiectasis, except: Cystic fibrosis Down's syndrome Pertussis Hypogammaglobulinaemia Young's syndrome |
Down's syndrome |
|
|
Bronchiectasis: causes |
post-infective: tuberculosis, measles, pertussis, pneumoniacystic fibrosis bronchial obstruction e.g. lung cancer/foreign body immune deficiency: selective IgA, hypogammaglobulinaemia allergic bronchopulmonary aspergillosis (ABPA) ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome yellow nail syndrome |
|
signet ring sign - can be seen in |
bronchiectasis |
|
|
Bronchiectasis describes a |
permanent dilatation of the airways secondary to chronic infection or inflammation. |
|
dx |
BRONCHIECTASIS |
|
|
Which one of the following statements regarding the link between intrauterine devices (IUDs) and ectopic pregnancies is correct? |
The proportion of pregnancies that are ectopic is increased but the absolute number is decreased |
|
|
Intrauterine contraceptive devices comprise both |
copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena) NB IUS is also used in the management of menorrhagia |
|
|
moa of IUS |
levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening |
|
|
Intrauterine contraceptive devices potential probs |
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception |
|
|
A 76-year-old woman complains of blurred vision. She has not been to the doctors for many years and describes her self as being otherwise fit and well. Fundoscopy reveals the following: Similar changes are seen in both eyes. What is the most likely diagnosis? |
Age-related macular degeneration |
|
|
A 62-year-old woman presents with painful 'bruises' on her shins and forearms. She cannot remember knocking herself. What is the most likely diagnosis? |
Erythema nodosum |
|
|
Erythema nodosum def |
inflammation of subcutaneous fat tender, erythematous, nodular lesions usually occurs over shins, may +- forearms, thighs usually resolves within 6 weeks lesions heal without scarring |
|
|
Erythema nodosum causes |
infection: streptococci, TB, brucellosis systemic disease: sarcoidosis, inflammatory bowel disease, Behcet's malignancy/lymphoma drugs: penicillins, sulphonamides, combined oral contraceptive pill pregnancy |
|
dx |
Congenital diaphramatic hernia |
|
|
A 49-year-old female consults her GP asking about hormone replacement therapy (HRT). What is the most compelling indication for starting HRT? |
Control of vasomotor symptoms such as flushing |
|
|
Main indication for HRT |
control of vasomotor symptoms |
|
|
why is HRT given in premature menopause |
to prevent d/t of osteoporosis |
|
|
does HRT reduce the incidence of colorectal cancer |
yes |
|
|
A 78 year old lady is incidentally found to have a serum sodium level of 128 mmol/L at her annual review. She is asymptomatic and feeling well in herself. Which of the following medications could be a cause of her hyponatraemia? |
Sertraline |
|
|
Many drugs can cause hyponatraemia by increasing the production of, or potentiating the action of antidiuretic hormone (ADH). The most commonly implicated drugs include |
diuretics (especially thiazides), selective serotonin reuptake inhibitors (SSRIs), antipsychotics such as haloperidol, nonsteroidal anti-inflammatories and carbamazepine. |
|
|
SSRIs can increase the release of |
ADH causing hyponatremia usu. within a few weeks of tx, resolves within 2 weeks of stopping |
|
|
Hyponatraemia may be caused by |
water excess or sodium depletion |
|
|
Causes of pseudohyponatraemia include |
hyperlipidaemia (increase in serum volume) or a taking blood from a drip arm. |
|
|
Hyponatraemia inV |
Urinary sodium and osmolarity |
|
|
hyponatremia with Urinary sodium > 20 mmol/l |
Sodium depletion, renal loss (patient often hypovolaemic) - e.g. diuretics, Addisons, RF or Patient often euvolaemic e.g. SIADH (urine osmolality > 500mmol/kg), hypothyroidism |
|
|
HyponatraemiaUrinary sodium < 20 mmol/l |
Sodium depletion, extra-renal loss e.g. - diarrhoea, vomiting, sweating - burns, adenoma of rectum or Water excess (patient often hypervolaemic and oedematous) - secondary hyperaldosteronism: heart failure, cirrhosis - reduced GFR: renal failure - IV dextrose, psychogenic polydipsia |
|
|
A 4-year-old boy presents with fever and a sore throat. Examination reveals tonsillitis and a furred tongue with enlarged papillae. There is a blanching punctate rash sparing the face |
Scarlet fever |
|
|
A 3-year-old girl with a two day history of fever and malaise. Developed a pink maculopapular rash initially on the face before spreading. Suboccipital lymph nodes are also noted |
Rubella |
|
|
A 4-year-old boy presents with fever, malaise and a 'slapped-cheek' appearance |
Parvovirus B19 |
|
|
slapped cheek with PALM of hand |
PALMOVIRUS aka PARVOVIRUS B19 |
|
|
chickenpox fxs |
fever first starts head/trunk then spreads itchy papular then vesicular |
|
|
measles |
Prodrome: irritable, conjunctivitis, fever koplip spots = white spots on mouth starts behind ears then spreads maculopapular |
|
mumps fxs |
fever, mus. pain parotitis (earache, pain on eating) starts unilat then bilat in 70% PARROTS GET MUMPS |
|
|
rubella |
starts at face then to body maculopapular pink rash usu. fades by 3-5 days lymphadenopathy |
|
|
Scarlet fever IMAGINE SCARLET ALL light RED EXCEPT HER FACE with STRAWBERRY ON HER TONGUE |
rxn to toxins from grp A hemolytic strep strawberry tongue fever, tonsilitis fine punctate red rash NOT ON FACE |
|
|
neonates = BABY cause of meninigitis in this grp |
grp B strep = grp BABY strep |
|
|
Erythema infectiosum aka |
fifth disease or 'slapped-cheek syndrome' |
|
|
Erythema infectiosum aka fifth disease or 'slapped-cheek syndrome' caused by |
parvovirus B19 |
|
|
Hand, foot and mouth disease caused by |
coxsackie A16 virus |
|
Hand, foot and mouth disease fxs |
sore throat, fever vesicles on mouth, palms and soles of feet |
|
|
A 35-year-old woman presents with a variety of symptoms including generalised skin tingling and headache. She is concerned she may have multiple sclerosis. What is the most common presentation of multiple sclerosis? |
Optic neuritis |
|
|
What is the most common presentation of multiple sclerosis? |
Optic neuritis |
|
|
Which of the following foods should be avoided in pregnancy? |
Cooked liver |
|
|
Select the side-effect most characteristically associated with the following antibiotics: |
Amoxicillin = Rash with infectious mononucleosis Metronidazole = Reaction following alcohol ingestion Doxycycline = Photosensitivity |
|
|
Amoxicillin unique AE |
Rash with infectious mononucleosis |
|
|
Co-amoxiclav aka augmentum unique AE |
cholestasis |
|
|
flucloxacillin unique AE |
cholestasis |
|
|
erythromycin unique AE |
• Gastrointestinal upset • Prolongs QT interval |
|
|
Ciprofloxacin unique AE |
• Lowers seizure threshold • Tendonitis |
|
|
Metronidazole unique AE |
Reaction following alcohol ingestion |
|
|
Doxycycline unique AE |
Photosensitivity |
|
|
Trimethoprim unique AE |
• Rashes, including photosensitivity • Pruritus • Suppression of haematopoiesis |
|
|
Which one of the following is responsible for causing scarlet fever? |
Group A haemolytic streptococci usu strep pyogenes |
|
|
scarlet fever more common in kids aged |
2-6yo |
|
|
scarlet fever dx |
throat swab but abx should be done stat rather than wait for results |
|
|
mgmt of scarlet fever |
oral penicillin V allergy = AZI |
|
|
complications of scarlet fever |
otitis media (most common) rheumatic fever: usu. 20 days postinfxn acute GN: usu. 10 days postinfxn |
|
|
A 54-year-old woman who is currently receiving chemotherapy for breast cancer presents for advice. Her granddaughter has developed chickenpox, with the pox first appearing yesterday whilst she was looking after her. The patient has never had chickenpox herself and is concerned about developing it, although she is asymptomatic at the current time. What is the most appropriate management? |
Arrange varicella zoster immunoglobulin |
|
|
if an elderly px is immunocompromisd and therefore at risk of severe varicella infxn what is the mgmt |
give varicella zoster immunoglobulin |
|
|
Chickenpox is caused by |
primary infection with varicella zoster virus |
|
|
Shingles is |
reactivation of dormant virus in dorsal root ganglion |
|
|
Chickenpox is highly infectious |
true spread via the respiratory route can be caught from someone with shingles infectivity = 4 days before rash, until 5 days after the rash first appeared* A common complication is secondary bacterial infection of the lesions incubation period = 10-21 days |
|
|
chickenpox mgmt |
keep cool, trim nails calamine lotion |
|
|
chickenpox mgmt for immunocompromised pxs and newborns with peripartum exposure |
varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered |
|
|
A 74-year-old man presents to surgery after seeing his optician. They have noticed raised intra-ocular pressure and decreased peripheral vision. His past medical history includes asthma and type 2 diabetes mellitus. You refer him on to ophthalmology. What treatment is he most likely to be started on given the likely diagnosis? |
Latanoprost |
|
|
Primary open-angle glaucoma: management eye drops. These aim to lower intra-ocular pressure which in turn has been shown to prevent progressive loss of visual field |
Prostaglandin analogues (e.g. Latanoprost) Beta-blockers (e.g. Timolol) Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist) Carbonic anhydrase inhibitors (e.g. Dorzolamide) Miotics (e.g. pilocarpine, a muscarinic receptor agonist) |
|
|
Prostaglandin analogues (e.g. Latanoprost) moa |
Increases uveoscleral outflow |
|
|
Beta-blockers (e.g. Timolol) |
Reduces aqueous production |
|
|
Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist) moa |
Reduces aqueous production and increases outflow |
|
|
Carbonic anhydrase inhibitors (e.g. Dorzolamide) |
Reduces aqueous production |
|
|
Miotics (e.g. pilocarpine, a muscarinic receptor agonist) |
Increases uveoscleral outflow |
|
|
Beta-blockers (e.g. Timolol) Should be avoided in |
asthmatics and patients with heart block |
|
|
Vitiligo is associated with other autoimmune conditions such as |
Addison's disease, type 1 diabetes mellitus and autoimmune thyroid disorders. pernicious anemia, alopecia areata |
|
|
Autosomal recessive conditions are |
'metabolic' - exceptions: inherited ataxias |
|
|
Autosomal dominant conditions are |
'structural' - exceptions: Gilbert's, hyperlipidaemia type II |
|
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The following conditions are autosomal recessive: |
Albinism Ataxia telangiectasia Congenital adrenal hyperplasia Cystic fibrosisCystinuria Familial Mediterranean Fever Fanconi anaemia Friedreich's ataxia Gilbert's syndrome*Glycogen storage disease Haemochromatosis Homocystinuria Lipid storage disease: Tay-Sach's, Gaucher, Niemann-Pick Mucopolysaccharidoses: Hurler's PKU Sickle cell anaemia Thalassaemias Wilson's disease |
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is repetitive behavior assoc. with ADHD |
no |
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Attention Deficit Hyperactivity Disorder (ADHD) is characterised by |
extreme restlessness poor concentration uncontrolled activity impulsiveness |
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A 61-year-old man presents with a chronic cough. His past medical history includes hypertension and gout. He is due to retire shortly from his job as a sewage worker. He drinks around 50 units of alcohol a week and smokes 20 cigarettes per day. A chest x-ray is ordered: dx |
Lung cancer squamous: c. 35% adenocarcinoma: c. 30% small (oat) cell: c. 15% large cell: c. 10%other c. 5% |
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A 85-year-old lady presents to her GP complaining of itchy white plaques affecting her vulva. There is no history of vaginal discharge or bleeding. A similar plaque is also seen on her inner thigh. What is the likely diagnosis? |
Lichen sclerosus |
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Lichen planus vs lichen sclerosus |
Lichen planus : purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham's striae over surface. Oral involvement common lich |
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Lichen sclerosus mgmt |
topical steroids and emollients increased risk of vulval cancer |
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What is the normal heart rate of a 3-year-old? |
90 - 140 bpm |
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For each patient below choose from the list above the single most likely diagnosis from the list above. Each option may be chosen more than once or not at all |
A 2-week-old infant with a small chin, posterior displacement of the tongue and cleft palate =Pierre-Robin syndrome Supravalvular aortic stenosis is found in a 3-year-old boy with learning difficulties =William's syndrome A 9-week-old is noted to have a small chin and rocker-bottom feet = Edward's syndrome |
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rocker bottom feet is assoc with |
edwards syndrome |
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small chin, posterior displacement of the tongue and cleft palate is assoc with |
Pierre-Robin syndrome |
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aortic stenosis is found in a 3-year-old boy with learning difficulties is assoc with |
williams syndrome |
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Prader-Willi syndrome key fxs |
Hypotonia Hypogonadism Obesity |
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Noonan syndrome key fxs |
Webbed neck Pectus excavatum Short stature Pulmonary stenosis |
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A 32 year old lady presents with hair-loss which she thinks started after the birth of her second child 7 months ago. She is normally fit and well and is not on any regular or over the counter medication. On examination you notice patches of hair loss around her occiput. The skin looks normal and a few short broken hairs are obvious at the edges of two of the patches. What condition is most likely? |
Alopecia areata |
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can women get hair loss aka alopecia areata |
yes |
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Alopecia areata mgmt |
usu. nothing 50% regrow in 1 yr, 80-90% eventually other options topical/intralesional corticvosteroids topical minoxidil phototherapy dithranol contact immunotherapy wigs |
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Which one of the following statements regarding migraine is true? |
It is 3 times more common in women |
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Common triggers for a migraine attack |
tiredness, stress alcohol combined oral contraceptive pill lack of food or dehydration cheese, chocolate, red wines, citrus fruits menstruation bright lights |
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Which of the following infections usually has the longest incubation period? |
HIV |
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Incubation periods Questions may either ask directly about incubation periods or they may be used to provide a clue in a differential diagnosis |
Less than 1 week meningococcus diphtheria influenza scarlet fever 1 - 2 weeks malaria dengue fever typhoid measles 2 - 3 weeks mumps rubella chickenpox Longer than 3 weeks infectious mononucleosis cytomegalovirus viral hepatitis HIV |
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You are asked to attend a meeting at a local nursing home. There is currently an increased incidence of MRSA in the patients and a strategy is being drawn up to tackle this. What is the most effective single step to reduce the incidence of MRSA? |
Hand hygiene |
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What is the most effective single step to reduce the incidence of MRSA? |
Hand hygiene |
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You are asked to interpret the post-bronchodilator spirometry results of a 56-year-old woman who has been complaining of progressive shortness-of-breath.FEV1/FVC0.60FEV1% predicted60%Using the most recent NICE guidelines, what is the most appropriate interpretation of these results? |
COPD (stage 2 - moderate) |
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the perineum is the diamond shaped area that includes the |
anus and in females the vag |
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A 45-year-old man presents to the Emergency Department due to severe pain in the perineal area over the past 6 hours. On examination the skin is cellulitic, extremely tender and haemorrhagic bullae are seen. What is the most appropriate management? |
Surgical debridement |
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mgmt of nec fasc |
urgent surgical referral for debridement IV abx nb mortality hasnt changed much with nec fasc, even with the advent of abx, hence need for surgical debridement |
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is nec fasc a medical emergency |
yes |
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nec fasc fxs |
acute painful red lesion tender over infected area |
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A 26-year-old woman presents with a four month history of back pain. The pain is located around the lower lumbar vertebrae and spreads to both buttocks. Ibuprofen and walking seem to improve the pain. A lumbar spine film is requested: What is the most likely cause of this patients back pain? |
Ankylosing spondylitis you can seesyndesmophytes |
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RA typical XR findings |
oss of joint space juxta-articular osteoporosis soft-tissue swelling periarticular erosions subluxation |
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InV for ank spond |
ESR, CRP HLA-B27 spine XR = MOST USEFUL |
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A 34-year-old female with a history of alcoholic liver disease is admitted with frank haematemesis. She was discharged three months ago following treatment for bleeding oesophageal varices. Following resuscitation, what is the most appropriate treatment whilst awaiting endoscopy? |
Terlipressin Terlipressin is the only licensed vasoactive agent for variceal haemorrhage in the UK reduces mortality more than octreotide |
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Acute mgmt of variceal haemorrhage |
ABC FFP, vit K terlipressin (allergy = octreotide) prophylactic abx (reduces mort in liver cirr. pxs) endoscopy Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail |
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Prophylaxis of variceal haemorrhage |
propranolol banding |
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A 69-year-old man who is known to have Alzheimer's disease is reviewed in clinic. His latest Mini Mental State Examination(MMSE) score is 18 out of 30. According to NICE guidelines, what further action should be taken? |
Supportive care + donepezil |
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Alz dis |
most cases are sporadic/random 5% = AD - mutxn in amyloid precursor protein, presenilin 1 and presenilin 2 |
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pathological changes in alz dis |
brain atrophy A-beta amyloid protein and intraneuronal neurofibrillary tangles caused by abn aggregation of tau protein = low Ach due to damage to brain by these plaques |
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mgmt of Alz dis |
mild-moder =acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) mod - severe = memantine (NMDA receptor antag) |
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A 19-year-old student presents with a 1 cm golden, crusted lesion on the border of her left lower lip. What is the most suitable management? |
topical fusidic acid → oral flucloxacillin / topical retapamulin |
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A 19-year-old student presents with a 1 cm golden, crusted lesion on the border of her left lower lip. dx |
Impetigo |
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dx |
impetigo |
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Impetigo def |
superficial bacterial skin infection usually caused by either Staphylcoccus aureus or Streptococcus pyogenes. |
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impetigo fxs |
'golden', crusted skin lesions typically found around the mouth very contagious |
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impetigo localised dis mgmt |
topical fusidic acid is first-line topical retapamulin 2nd line if top no good if MRSA = give topical mupirocin (Bactroban) |
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impetigo extensive dis mgmt |
oral flucloxacillin oral erythromycin if penicillin allergic |
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APGAR SCORE for peds pxs stands for |
Appearance, Pulse, Grimace, Activity, Respiration The Apgar score is used to assess the health of a newborn baby |
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You have just helped deliver a 2 week premature baby and are asked to do a quick assessment of the current APGAR score. The baby has a slow irregular cry, is pink all over, a slight grimace, with a heart rate of 140 BPM and flexed arms and legs. The current APGAR score is? |
A - Pink all over no cyanosis - 2 points P - Pulse rate over 100 - 2 points G - Grimace - 1 point A - Activity flexed arms and legs - 2 points R - Respiration slow irregular cry - 1 point |
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APGAR score - what score considered normal |
any score over 7 = normal |
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The Apgar score is used to assess the health of a newborn baby scores b/d |
Score = 2 for any Pulse > 100 Respiratory effort = Strong, crying Colour = PInk Muscle tone = active mvmt Reflex irritability = sneezes, coughs Score = 1 for any Pulse <100 Respiratory effort = weak, irregular Colour = blue limbs Muscle tone = limb flexion Reflex irritability = grimace Score = 0 for any Pulse = Absent Respiratory effort = Nil Colour = Blue all over Muscle tone = Flaccid Reflex irritability = Nil |
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apgar score summary |
0 score for APGAR points if nil, absent, blue all over and flaccid 2 score if high pulse, and all normal incl, sneezing and coughing and active mvmt 1 score if b/w 0 and 2 for the APGAR points |
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A 46 year old lady had some bloods done as she was feeling tired all the time. All blood tests were normal except for her thyroid function test (TFT) which showed:TSH12.5 mU/lFree T47.5 pmol/lWhat is the most appropriate management? |
Levothyroxine |
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hypothyroidism tx |
levothyroxine increase dose in preg. |
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hyperthyroidism tx |
carbimazole |
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goal of hypothyroidism tx is |
normal TSH levels |
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AE of hypothyroidism tx or thyroxine therapy |
hyperthyroidism: due to over treatment reduced bone mineral density worsening of angina atrial fibrillation |
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A 2-year-old boy is seen in the Emergency Department with watery diarrhoea for the past two day. What is the most likely causative agent? |
Rotavirus in UK |
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most common cause of gastroenteritis in NZ |
CAMPYLOBACTER next salmonella and giardia |
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Clinical dehydration signs |
malaise Decreased urine output Skin colour unchanged Warm extremities Altered responsiveness (for example, irritable, lethargic) Sunken eyes Dry mucous membranes Tachycardia Tachypnoea Normal peripheral pulses Normal capillary refill time Reduced skin turgor Normal blood pressure |
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Clinical shock signs |
Decreased level of consciousness Cold extremities Pale or mottled skin Tachycardia Tachypnoea Weak peripheral pulses Prolonged capillary refill time Hypotension |
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gastroenteritis inV |
stool culture |
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gastroenteritis mgmt |
if shock = IV rehydration dont stop breastfeeding if dehydration is suspected |
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Recommend Adult Life Support (ALS) adrenaline doses |
anaphylaxis: 0.5ml 1:1,000 IM cardiac arrest: 10ml 1:10,000 IV or 1ml of 1:1000 IV |
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adrenaline indications |
anaphylaxis cardiac arrest |
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Which one of the following is most associated with the syndrome of inappropriate ADH secretion? Colorectal adenocarcinomaSmall cell lung cancerMalignant melanomaGastric adenocarcinomaSquamous cell lung cancer |
Small cell lung cancer |
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Causes of SIADH |
Malignancy = SCLC, pancreas, prostate Neuro: - stroke, SAH, SDH, meningitis/encephalitis/abscess Infxns: - TB - pneumonia Drugs - sulfonylureas - SSRI, tricyclics - carbamazepine - vincristine - cyclophosphamide other causes - PEEP - porphyrias |
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mgmt of SIADH |
correct slow to avoid central pontine myelinolysis fluid restrict demeclocycline: reduces renal sensitivity to ADH vasopressin antagonists |
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You review a patient in the respiratory clinic who has a history of recurrent pulmonary embolism despite anticoagulation with warfarin. Which one of the following physiological changes would be expected? |
Reduced TLCO |
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TLCO |
The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer coefficient, KCO) |
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Causes of a raised TLCO |
asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise |
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Causes of a lower TLCO |
pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output |
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Strep species |
Alpha hemolysis (partial hemolysis) = step pneumoniae, viridans
Beta hemolysis (full hemolysis) - has 3 main grps - Grp A, B, D - grp A = strep pyogenes - grp B = strep agalactiae - grp D = enterococci |
