1
Q
When should we not offer PEP to a patient who has unprotected sex with a patient who is HIV positive?
A
If partner has been on ART > 6 months and has had an undetectable viral load in last 6 months
2
Q
When should PEP be offered routinely (4)
A
If unknown or detectable vial load and:
1. Receptive anal sex
2. Receptive vaginal sex
3. Occupational exposure
4. Needle sharing
3
Q
When should PEP be considered? (2)
A
Unknown or detectable viral and:
1. Insertive vaginal sex
2. Insertive anal sex
4
Q
When is PEP not recommended? (2)
A
- Sex/splash/injection in high risk group but not known HIV
- Human bite in HIV positive
5
Q
What PEP should be offered?
A
Tenovir + emtricitabne (Truvada) combination and raltegravir OD for 28 days
6
Q
When should PEP be started?
A
ASAP (ideally <24hours)
7
Q
After what period is PEP not effective?
A
> 72 hours
8
Q
What is a tetanus prone wound? (5)
A
- Puncture wounds occurring in contaminated enviroment
- Wounds with foreign body
- Compound #s
- Wounds/burns with sepsis
- Certain animal bites
9
Q
What are high risk tetanus prone wounds? (3)
A
- Heavy contamination with soil containing spores
- Wounds/burns with significant devitalised tissues
- Wounds/burns requiring surgery that are delayed over 6 hours
10
Q
What is full tetanus immunisation? (3)
A
- > 11 year priming course and last dose < 10 years ago
- 5-11 years and priming course pre-school booster
- < 5 years and priming course
11
Q
What is partial tetanus immunisation? (2)
A
- Over 11 years, priming course but last dose >10 years
- 5-11 years with priming course but no pre-school booster
12
Q
If fully immunised against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound
A
Nothing
13
Q
If partially immune against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound
A
1.Nil
2. Vaccine dose
3. Vaccine and TIG
14
Q
If no immunisation against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound
A
- Vaccine
- Vaccine and TIG
- Vaccine and TIG
15
Q
What dose of TIG should be given in tetanus? (4)
A
- 250 IU IM
- 500 IU IM if :
- heavy contamination
- burns
- > 24 hours
NB do not given vaccine and TIG at same site
16
Q
What is a clean wound re: tetanus risk?
A
< 6 hours
non-penetrating
17
Q
What values are considered mild/mod/severe hypercalcaemia?
A
- <3
- 3-3.5
- > 3.5
18
Q
What ECG changes do you see in hypercalcaemia? (4)
A
- Short QTc
- Bradycardia
- 1st degree HB
- Broad T waves
19
Q
What is first line treatment for hypercalcaemia?
A
- 4-6 L of IVI over 24 hours
20
Q
What is second line tx for hypercalcaemia?
A
- Zolendronic acid 4mg
- Pomidronate 30-90mg
21
Q
What is third line for hypercalcaemia?
A
- Steroids
- Parathyroidectomy
- Dialysis or diuresis
22
Q
What is pituitary apoplexy?
A
Haemorrhage +/- infarction of a tumour within the pitiutary gland
23
Q
What are the features of pituitary apoplexy? (4)
A
Acute severe headache
Ocular palsy
Bitemporal hemianopia
Meningism
24
Q
What is the management of pituitary apoplexy? (2)
A
- Steroids +/- neurosurgery
25
What clotting factors are in the intrinsic pathway?
IX
X
XI
XII
26
What clotting factors are in the extrinsic pathway?
II, VII, X
27
What is the final pathway of the clotting cascade?
Prothrombin (II) - Thrombin (IIa) - Fibrinogen (I) soluble - Fibrin mesh (insoluble)
28
What are the vitamin K dependent factors?
II
VII
IX
X
Protein C + S
29
What is the mechanism of action of UFH and LMWH?
Indirect thrombin inhibitors
30
What are the factor Xa inhibitors? (4)
Fondaparinox
-bans
Rivoroxaban
Apixiban
Edoxaban
31
What is a direct thromin inhibitor
Dabigatran
32
If minor bleeding how long should UFH be observed for?
6 hours
33
If minor bleeding only how long should LMWH be observed for?
24 hours
34
In significant bleeding what should be given to reverse UFH?
Protamine
35
What is the reversal agent for fondaparinox?
Recombinant factor VIIa
36
With LWMH (dalteparin/tinzaparin/enoxaparin) and bleeding what needs to done? (2)
1. Anti Xa assays
2. Protamine
37
How effective is protamine with LMWH?
60%
38
What makes a patient on warfarin high risk? (7)
1. > 65
2. HTN
3. Diabetes
4. Renal failure
5. Hepatic failure
6. Anti-plts concurrently
7. Surgery/trauma
39
If there is no bleeding, how should high INR be managed in patients taking warfarin? (2)
INR <8 in low risk or <6 in high risk withold warfarin 24 hours and recheck
INR >8 in low risk of >6 in high risk then 1-2.5mg PO vit K and consider admission
40
When is it acceptable to simply withold warfarin and recheck in 24 hours?
1. No bleeding
2. INR <6 in high risk or < 8 in low risk
41
In minor bleeding on warfarin what tx should be given? (2)
1. 2mg vit k orally
2. 1mg vit K IV
42
In severe bleeding on patients on warfarin what tx should be given? (3)
1. 5-10mg vit K IV
2. PCC 30-50units/kg over 10mins
3. Recheck clotting after 20 mins
43
What is the specific assay for dabigatran?
ECT + HDTI
44
What is the specific assay for factor Xa inhibitors?
CAX
45
What is the antidote for dabigatran?
Idarucizumab
46
What is the antidote for rixoroxaban/apixaban?
Andexanet
47
What is the reversal for edoxaban?
PCC + vit K
48
What assessment tool do NICE recommend for identification of those at risk of alcohol dependence?
AUDIT
49
What assessment tool does NICE recommend for severity of dependnce?
SADQ
50
When should inpatient alcohol detox be considered? (4)
1. SADQ >30
2. Hx of epilepsy
3. Hx of withdrawal seizures or DTs
4. Previous assisted withdrawal programmes
51
If benzos are being used in patients with liver impairment what should be used?
Lorazepam and go slowly
52
What is first line for DTs?
PO lorazepam
53
What is second line for DTs? (3)
1. IV lorazepam
2. IV haloperidol
3. IV clozapine
54
In adrenal crisis what is the initial bolus of hydrocortisone dose?
100mg IV
55
What is the maintenance hydrocortisone give in adrenal crisis?
200mg infusion/24 hours
or
50mg QDS
56
How much IVI should be given over 24 hours to rehydrate a patient with adrenal crisis?
3-4 L
57
What are the severe features of hyponatreamia? (4)
1. Vomiting
2. Arrest
3. Seizures
4. Reduced GCS
58
In presence of severe symptomatic hyponatreamia what is the initial treatment?
1. 150ml 3% normal saline or equivalent over 20mins
2. Repeat twice or until sodium increases by >5mmo/L
59
What is the follow up management of severe hyponatreamia following initial management?
1. Stop hypertonic but continue normal saline
2. Limit sodium increase to 10mmol/l over 24 hours
60
How is osmsolality calculated?
2 (Na + K) + urea + gluc
61
How should we manage HHS?
-Fluids until glucose not dropping by 5units/hour, then fixed rate insulin
-Unless significant ketonuria then start insulin after a period of rehydration, never straight away - can lead to circulatory collapse)
62
What is first and second line for complicated/severe malaria in UK?
IV artesunate first
IV quinine second
63
What is first and second line for uncomplicated malaria in UK?
Artemisinin combination therapy (ACT) first
Atovaquone-praguanil second
64
How does infantile botulism present?
Constipation is often the first sign, along with a dry mouth. Then facial palsy can occur.
Following this, there is a worsening weakness with poor suck, poor head control, hypotonia, hyporeflexia, and a weak cry.
65
Why does botulism infect <1 year olds more than older children
Spores can germinate in stomach and produces toxin, older children would need to ingest the actual toxin
66
How to infants normal contract infantile botulism?
Ingesting honey
67
Which type of electrical current causes:
1. Tetany
2. Forceful 'jolt' that can throw a patient a distance from power source
1. AC (usually higher voltage)
2. DC
68
Which type of electrical current causes
1 VT/VF
2. Asytole
1. AC (70ma or higher)
2. DC
69
What 3 things make up a diagnosis of HHS?
1. Hypovolaemia
2. Marked hyperglycaemia without significant ketonaemia or acidosis
3. Osmolality >320 mosmol/kg
70
What makes up the FeverPAIN score?
Fever in last 24hours
Purulent tonsilts
Attends within 3 days
Inflamed tonsils (Severe)
No cough or coryza
71
What is qSOFA made up of?
BP <100mmHg
RR over 22
Altered mental state
1 for each
2 or more suggests greater risk of death
72
What abx do NICE not recommend giving empirically for neutropenic sepsis?
Aminoglycosides
73
What does the road traffic act say about doctors taking blood samples for alcohol and drug testing?
Lawful - regardless of patients consent and has to be given to constable
74
Describe the serious incident framework?
1. Confirm serious incident -report to commissioners (2 days)
2. Confirm level of investigation required (3 days)
3. Investigation - root cause analysis ( 60 days)
4. Final report and action plan (20 days)
75
Describe the serious incident framework?
1. Confirm serious incident -report to commissioners (2 days)
2. Confirm level of investigation required (3 days)
3. Investigation - root cause analysis ( 60 days)
4. Final report and action plan (20 days)
76
What is MHA section 4?
Emergency holding powers (72 hours)
77
What is MHA section 5 (2)
Doctors holding powers (only a ward)
78
What is MHA section 5 (4)
Nurse holding powers
79
What is section 2 MHA?
Nature of illness unclear
80
What is section 3 MHA?
Nature of illness clear
81
What condition is non IgE mediated but can can lead to angio-oedema and GI symtoms?
C1 esterate deficiency
82
What is the treatment for CI esterase deficiency? (3)
1. Berinert (c1 esterase inhibitor)
2. Icatibant (bradykinin receptor blocker)
3. FFP contains C1 esterase
NB: adrenaline/anti-histamines will not work
83
What is the cause of Scromboid?
- histamine poisoning from unrefrigerated fish (esp dark-flesh)
- Cooking does not kill the histamine
84
What are the features of Scromboid poisoning and when do they present/relieve?
- Sx within 10-30 minutes after eating fish + resolved within 12 hours
- Symptoms = pruritis, skin flushing, peppery taste, headache, palpitations, D+V
- Rare to have A/B/C involvement
85
What is the management of Scromboid poisoning? (2)
- Mx = supportive care, antihistamines
-can eat fish in future, inform PHE as case of food poisoning
86
Describe the 4 types of immunological skin reactions?
- Type 1 reaction (IgE mediated) = anaphylaxis
- Type 2 reaction = cytotoxic
- Type 3 reaction = immune complex
- Type 4 reaction = delayed, cell mediated e.g. contact dermatitis
87
What is steven-johnson syndrome?
Severe erythema multiform >10% TBSA.
Vesicles in mucous membranes of eyes and mouth.
-
88
What is toxic epidermal necrolysis (TEN)
Severe erythema multiform >30% TBSA. Painful rash and fever.
Widespread desquamation.
7-14 days after 1st drug exposure
89
What does DRESS stand for?
DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms; also called drug
hypersensitivity syndrome).
90
What are the signs/symptoms of DRESS/drug hypersensitivity syndrome? (5)
2-6 weeks after 1st drug exposure -
Maculopapular rash
Fever
Abnormal LFTs
Lymphadenopathy
Eosinophilia
91
What is erythroderma?
>90% TBSA erythema
92
What is the management for erythroderma?
1. Bed rest
2. IVI
3. Emollients
93
What is erysipelas?
Skin infection distinct from cellulitis
Only superficial dermis so distinct borders
Painful, red and raised
94
What are the causes of a bitemporal hemianopia? (3)
1. Pituitary adenoma
2. Glioma
3. Carotid artery aneurysms
Act on the optic chiasm
95
What is the predominant cause of a homonymous hemianopia?
CVA
96
What acts on the optic nerve directly causing loss of vision?(2)
1. MS
2. Ethylene glycol
97
What does a complete 3rd nerve palsy looks like? (3)
1. Down and out pupil
2. Proptosis
3. Dilated pupil
98
What does on differentiate between compressive and medical causes of third nerve palsy?
Pupillary involvement - compressive/surgical (bleed/aneurysm/SOL) usually cause pupillary dilatation as the parasympathetic fibres are on the outside of the nerve and are compressed.
99
What do patients with a CN IV (trochlear) present with?
1. Weakness of downward gaze - difficulty walking downstairs or reading
2. Vertical diplopia
100
Which muscle does CN IV (trochlear) innervate?
Superior oblique
101
What muscle does CN VI (abducens) innvervate?
Lateral rectus
102
What will patients suffering from CN VI palsy present with?
1. Convergent squint at rest (pupil moves towards nose)
2. If complete palsy will be unable to abduct eye past midline
3. Horizontal diplopia on affected eye
103
What does vitreous haemorrhage present like?
Painless visual changes - from floaters/black spots to light perception only
104
What is the hx for CRAO and CRVO?
Sudden, painless visual loss
105
What does this suggest and describe the findings?
1. CRAO
2. Pale optic disc / retina with 'cherry red spot' of the macula
106
What does this finding suggest?
CRVO
107
What is the ED management for CRAO?(2)
Digital massage of eye in supine position (patient should do to themselves)
IV acetazolamide
108
What laboratory criteria are needed to confirm tumour lysis syndrome? (4)
2 or more of:
1. Hyperkalaemia
2. Hyperphosphataemia
3. Hyperuricaemia
4. Hypocalcaemia
109
How long after a dive do the bends normally present?
< 6 hours (90%)
110
What increases your risk of the bends? (7)
1.Deep dive, long dive, missed decompression stops, multiple dives
2. Age
3. Exercise during or after a dive
4. Flying/ ascending to altitude after diving
5. Obesity
6. Dehydration
7. Alcohol use prior to dive
111
What are is mainstay of treatment for the bends?
1. High flow oxygen
2. Rehydration
Decompression chamber gold standard - obvious practical issues
112
What should be avoided in in the bends? (2)
Analgesia - oxygen normally enough and risks with opiates and NSAIDs
No entonox!
113
What distinguishes keratitis/keratoconjunctivitis from conjunctivities?
1. Pain worse
2. Photophobia
3. Worsening visual acuity
More likely if contact lens wearer
114
How does acute angle glaucoma present in terms of the eye?
1. Painful + red
2. Decreased visual acuity
3. Mid-dilated pupil
4. Non-responsive pupil
115
How should acute closed angle glaucoma be managed? (3)
1. 500mg IV acetazolamide
2. Opiates/analgesia
3. After one hour of treatment topical miotic such a pilocarpine every 5 mins (pupil unlikely to respond until this point)
116
What is episcleritis? (3)
1.Engorgement of the superficial episcleral plexus
2. More irritating than painful
3.Self limiting
117
Describe the features of scleritis?
1. Either localised of generalised blue-ish/violet discolouration
2. Deep, dull ocular pain
3. Pain worse on movement of eye
Associated with rheumatological diseases
118
What serotype is anterior uveitis associated with?
HLA-B27
119
How does anterior uveitis present? (4)
1. Painful red eye, worse on accomodation
2. Photophobia, can be consensual
3. Pupil maybe an unusual shape
4. Can have keratitic precipitates
120
Which commonly used drugs can precipitate acute closed angle glaucoma?
1. Anticholinergics
2. Chlorphenamine (has some anticholinergic propertis)
3. Salbutamol
4. SSRIs
121
Who is more prone to getting acute closed angle glaucoma?
Elderly and far sighted
122
What is the difference between monocular and binocular diplopia?
Mononuclear diplopia does not resolve when one eye closed, binocular is present with both eyes open and resolves when either eye is closed.
Binocular suggests concerning pathology, monocular suggests issue with eye
123
How does acetazolamide help treat acute closed angle glaucoma?
It decreases the production of aqueous humour
