1
Q
Describe how someone with venticular ectopics / supraventricular premature beats would present 1[]
A
- Young person
- intermittent palpitations
- heart feels like it stops followed by a pounding sensation
- couple episodes a week for 5-10 mins
- often when falling asleep
2
Q
When would you give surgery for aortic stenosis if asymptomatic? [2]
Describe who gets different types of surgery [2]
A
Aortic stenosis with left ventricular ejection fraction (LVEF) less
than 55% should be referred for consideration of an aortic valve replacement
(AVR)
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
options for aortic valve replacement (AVR) include:
* surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined
* transcatheter AVR (TAVR) is used for patients with a high operative risk
3
Q
A 31-year-old patient visits her GP as she is experiencing bilateral breast pain. Her mother had a mastectomy for breast cancer at the age of 58, and she is anxious that she may have breast cancer.
What are the next two steps [2]
A
Mastalgia, which can be caused by hormonal changes like those in pregnancy or menstruation, should initially be evaluated with a pregnancy test.
If this was negative - then do an ultrasound - mammography is less useful due to denser breasts
4
Q
Describe what / how you determine what sensitivity and specificity are [2]
A
Sensitivity TP / (TP + FN ) Proportion of patients with the condition who have a positive test result
Specificity TN / (TN + FP) Proportion of patients without the condition who have a negative test result
5
Q
A 92 year old woman has severe neck, chest and back pain following a mechanical fall. She has bruising around her right eye.
Investigations:
Full blood count and clotting screen are normal.
Chest X-ray: lung fields clear; left sided 4th rib fracture
CT scan of head: no intracranial injury or bleed, mild small vessel disease; right orbital fracture
Which is the most appropriate next investigation?
Why?
A
CT scan of the cervical spine
Given her severe neck pain after a fall, advanced age, and facial/orbital fracture, a cervical spine injury must be excluded even though the CT head is normal. In elderly patients, c-spine injuries are common and easily missed, and plain films aren’t adequate.
6
Q
Describe when you step up O2 therapy in acute and non-acute COPD [+]
A
Acute COPD:
- If after 60 mins of O2 therapy and pH < 7.35, pCO2 > 6.5 and RR > 23 start NIV
- If after 4 hrs of NIV and pH < 7.25 and RR > 35, GCS < 8, pH < 7.15 or imminent resp. arrest start IMV
Chronic COPD:
- If two measurements of pO2 < 7.3 OR pO2 7.3-8 and secondary polycythemia, pulmonary HTN or pulmonary oedema: start CPAP
7
Q
Describe how you treat epistaxis [2]
A
If visible: cautery
If not visible - anterior packing
8
Q
If in shock, already on fluids and hypotensive - whats the next step in mx? [1]
A
Adrenaline
9
Q
What is the post-op pain management for major abdo / pelvic operations? [1]
A
Spinal epidural
10
Q
A 36 year old man is rescued from a house fire.
He is alert and talking but has a dull headache. His pulse rate is 98 bpm, BP 139/86 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 100% breathing 15 L/min oxygen via a non-rebreather mask.
Which is the most appropriate blood measurement?
Bicarbonate Carboxyhaemoglobin Haemoglobin Lactate Methaemoglobin
A
Carboxyhaemoglobin
11
Q
What is the anti-coagulant used for metal heart valves? [1]
A
Warfarin sodium & aspirin
12
Q
Target INR for metalic heart valves
aortic: [1]
mitral: [1]
A
Target INR
aortic: 3.0
mitral: 3.5
13
Q
What long term anti-coag. is used for prosethetic heart valves? [1]
A
Aspirin
14
Q
- A 62 year old man has acute breathlessness with a weak cough, following a recent viral upper respiratory infection. Over the past 4 months, he has had double vision, limb weakness and slurred speech when tired.
His respiratory rate is 18 breaths per minute and oxygen saturation 96% breathing air. He is sweating and using his accessory muscles of inspiration.
Which is the most appropriate test to monitor his respiratory function?
A
FVC: patient has MG
15
Q
Describe the investigations for ?PE
A
One: Do 2 levels Wells Score:
- If > 4: PE likely; do CTPA. If +ve = treat; if -ve do a leg US for VTE
- If < 4;: do a D-dimer. If D-dimer +ve - do a CTPA; if -ve consider alternative dx
16
Q
- A 23 year old man is diagnosed with appendicitis. He is being prepared for theatre on the acute surgical ward. He has been vomiting intermittently all day, although he has not eaten for 24 hours.
The anaesthetist advises using an airway device to protect the lungs from regurgitated stomach contents.Which airway device is most appropriate?
Guedel (oral) airway i-gel® (supraglottic) airway Laryngeal mask airway Nasopharyngeal airway Tracheal tube
A
Tracheal tube
17
Q
Describe when rapid sequence induction (RSI) with intubation would occur and how this occurs [1]
A
Performed to quickly secure the airway in patients who are at high risk of pulmonary aspiration, such as those with a “full stomach” (not properly fasted), gastroesophageal reflux, or impaired airway reflexes
Laryngoscopes are used to facilitate endotracheal intubation as part of rapid sequence induction (RSI) or modified induction of anaesthesia
Cricoid pressure (pressing down on the cricoid cartilage in the neck) may be used to compress the oesophagus and prevent the stomach contents from refluxing into the pharynx
The larynx is visualised and the
endotracheal tube placed. The stylet, if used, is
then removed and the cuff inflated
Only a cuffed ETT:
* Passes through the vocal cords
* Creates a tracheal seal
* Protects the lungs from regurgitated gastric contents
18
Q
- A 55 year old man has had painful red swelling of his left lower leg for 2 days. He has type 2 diabetes mellitus and takes metformin.
His temperature is 37.6°C. He has a tender erythematous area extending from the ankle to the proximal calf.
What is the most likely causative organism?
A
Streptococcus pyogenes
19
Q
How to calculate GCS?
A
20
Q
Wafarin reversal?
A
Major bleeding
- stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; give dried prothrombin complex (factors II, VII, IX, and X);
- if dried prothrombin complex unavailable, fresh frozen plasma can be given but is less effective; recombinant factor VIIa is not recommended for emergency anticoagulation reversal
INR >8.0, minor bleeding
- stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours;
- restart warfarin sodium when INR < 5.0
INR >8.0, no bleeding
- stop warfarin sodium; give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use];
- repeat dose of phytomenadione if INR still too high after 24 hours;
- restart warfarin when INR < 5.0
INR 5.0–8.0, minor bleeding
- stop warfarin sodium; give phytomenadione (vitamin K1) by slow intravenous injection; restart warfarin sodium when INR < 5.0
INR 5.0–8.0, no bleeding
- withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose
21
Q
Results for water deprivation test if primary polydipsia? [2]
Which conditions is it associated with? [1]
A
Water deprivation test: primary polydipsia
urine osmolality after fluid deprivation:
- high
urine osmolality after desmopressin:
- high
This is caused by excessive intake of fluids and is associated with psychiatric disorders such as schizophrenia.
22
Q
Water deprivation test: cranial DI?
A
urine osmolality after fluid deprivation: low
urine osmolality after desmopressin: high
This lack of ADH results in an inability to concentrate urine even if a patient is hypovolaemic, therefore producing a low urine osmolality even during water deprivation. However, as the kidneys are unaffected by cranial DI, they will respond to desmopressin (synthetic ADH) to produce concentrated urine.
23
Q
Results for all water deprivation tests? [+]
A
Neurogenic diabetes insipidus
If the diagnosis is neurogenic DI the urine osmolality will be low after fluid deprivation but normalise after desmopressin is given.
- This is because neurogenic DI is caused by the lack of ADH production, therefore, giving a synthetic form of ADH such as desmopressin normalises levels of the hormone resulting in the normalisation of serum and urine osmolality.
Nephrogenic diabetes insipidus
- If the diagnosis is nephrogenic DI then the urine osmolality will remain low throughout regardless of desmopressin. This is because the kidneys are unable to respond to either synthetic or endogenous ADH.
Primary polydipsia
- If the diagnosis is primary polydipsia the urine osmolality will remain high after fluid deprivation as well as after desmopressin is given. This is because the patient’s vasopressin axis is intact and otherwise completely normal.
24
Q
- A 19 year old woman requires an urgent appendicectomy. The anaesthetist explains that the patient will need to breathe oxygen from a face mask before induction of anaesthesia, and that she will feel some pressure on the front of her neck as she goes to sleep. The patient asks why.
What is the purpose of the cricoid pressure?
It facilitates endotracheal intubation It prevents the passage of gastric contents into the airway It reduces the haemodynamic response to endotracheal intubation It reduces the risk of vomiting It stabilises the neck in a neutral position
A
It prevents the passage of gastric contents into the airway
25
23. A 73 year old man has 3 months of increasing weakness of his right hand with
reduced sensation of the forearm.
There is wasting of all the intrinsic muscles of the right hand. There is
weakness of finger abduction and adduction, and thumb adduction. Finger
flexion is normal. There is mild altered light touch sensation along the ulnar
aspect of the forearm. The biceps, supinator and triceps reflexes are normal.
The lower limbs and the left arm are normal.
Where is the most likely site of the lesion causing his symptoms?
A. Median nerve in the forearm
B. Median nerve in the wrist
C. Spinal cord C8 level
D. T1 nerve root
E. Ulnar nerve at the elbow
**D. T1 nerve root**
Justification: The **intrinsic hand muscle wasting suggests** T1. The normal
reflexes and normal other arm are against a cord lesion. The sensory loss on
the forearm excludes median and ulnar nerve lesions. T1 dermatome is often
thought to be higher in the arm medially.
26
Describe how you distinguish between T1 and ulnar nerve lesions
27
85 year old ptx.
A midstream urine culture result 24 hours later shows a mixed growth of
organisms with no leucocytes.
What is the most likely cause ? [1]
**A mixed growth in a urine specimen is usually a result of contamination**
28
How do you differentiate between fat embolism vs PE? [1]
Classic presentation of fat emboli. Multiple fractures followed by early onset (within 24 hours) of hypoxia, dyspnoea, and tachypnoea are the most frequent findings. Neurologic manifestations range from the development of an acute confusional state and altered level of consciousness
to seizures and focal deficits and usually follow respiratory symptoms.
Patients with PE may present in the same time frame (i.e., 24 to 72 hours), **but neurologic abnormalities are not explained by this.**
29
What is important to know about petechial rash in fat embolism? [1]
A petechial rash is the last component to appear and only appears in about a
third of cases.
30
The combination of goblet cells and Paneth cells
in the oesophagus is characteristic of what dx? [1]
combination of goblet cells and Paneth cells
is characteristic of **(small) intestinal metaplasia.**
31
Describe blood results between pancreatitis vs cholangitis [2]
Pancreatitis will have ++ amylase
Cholangitis will have +amylase but ++ biliribuin
32
Fit person with short duration of back pain? [1]
Nothing, encourage movement
33
Tx for massive PE x recent bleed (e.g. needed a blood transfusion)?
**IV heparin**
34
Stomach pain x lactic acidosis - think ? [1]
**Mesenteric ischaemia**
35
What do you need for a dx of DIC? [2]
> 1 known causing pathology (e.g. sespsis)
AND
- Low platelets
- Low fibrinogen
- Raised PT
- Raised APTT
36
You suspect UC in a patient
What do you need to do before to rule out other things? [1]
Stool sample
37
What is cataplexy? [1]
Loss of skeletal muscle tone with strong +ve emotions
38
When is charcoal indicated for OD? [2]
## Footnote
§
If < 1hr since taking
Ptx is concious and has protected airway
39
? Adrenal crisis - first line Ix? [1]
Serum plasma cortisol and ACTH
40
'Increasing fatigue, intermittent difficulty swallowing which is worse at end of day, bilateral ptosis' indicates? [1]
**MG**
41
Which antihistamines increase sleep vs not? [2]
**Cetirizine / loratidine**: non sleepy
**Chlorphenamine**: sleepy
42
Describe how you would differentiate between . Chylomicronaemia
Familial combined hyperlipidaemia
Heterozygous familial hypercholesterolaemia
**Chylomicronaemia**
- High triglycerides, often associated with pancreatitis
**Familial combined hyperlipidaemia**
- mixed picture of blood results
**Heterozygous familial hypercholesterolaemia**
- cholesterol ++
- tendon xanthomas
43
Correct Answer: B
Justification: Seeking the awareness that S**NB is diagnostic not therapeutic if 3 nodes are involved**.
- Therefore more **surgery is needed**
44
When investigating sarcoid - what is the best next test after basic bloods? [1]
**CXR**
Serum ACE can have false negatives
45
If **painless** muscle weakness in shoulders / hips what is the most likely dx? [1]
Key blood test? [1]
**Dermatomyositis / myositis**
- Raised **CK**
46
+ve trendelenburg test indicates weakness in which muscle groups? [1]
Hip **abd**uctors
47
tx for cryptosporidium? [1]
None xx
48
49
DIC typical blood picture: [4]
DIC typical blood picture:
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
50
What do you need to check if ?post op. ileus [2]
Current guidance states that patients with paralytic ileus should have **daily U&Es and any abnormalities corrected.**
- look for **potassium, magnesium and phosphate** - most common cause is **hypokalaemia**
51
if 2nd repeat smear at 24 months is still hrHPV +ve → [1]
if 2nd repeat smear at 24 months is still hrHPV +ve → **colposcopy**
52
[2] 'cover' should be used when starting allopurinol
**NSAID or colchicine 'cover'** should be used when starting allopurinol
53
An outbreak of genital herpes should be treated with [1] aciclovir
An outbreak of genital herpes should be treated with **oral** **aciclovir**
54
Which biliary disease is a UKMEC3? [1]
current gallbladder disease
55
You can attempt external cephalic version for a transverse lie if [1]
You can attempt external cephalic version for a transverse lie if the **amniotic sac has not ruptured**
56
What are CI for ECV? [3]
Contraindications include maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormalit
## Footnote
**NB:** can be performed late in pregnancy and even early labour if the membranes have not yet rupture
57
A 32-year-old woman presents to the general practitioner with a lump in her right breast. She has no past medical or family history of note. On examination, there is a small, firm, non-tender lump in the upper left quadrant of the patient right breast. The remainder of the breast examination is unremarkable.
**What is the most appropriate management of this patient?**
**Refer women aged >30** with an unexplained breast lump using a suspected cancer pathway referral
- Routine referral to breast clinic is incorrect as this should only be considered in patients under the age of 30 who present with an unexplained breast lump.
58
Incidence is a measure of [1]
Prevalence is [1]
**Incidence** is a measure of the number of new cases
**prevalence** is a snapshot of existing cases
59
What does MgS do if given in pregnancy [2]
At what dates is it no longer given? [1]
Magnesium sulfate. It is normally given for **neuroprotection of the foetus** and **reduces** the **risk of developing cerebral palsy.** It is not recommended for women > 32 weeks gestation.
60
Volatile liquid anaesthetics
(e.g. x3) may cause **malignant hyperthermia**
What is a key metric that would indicate this is occuring? [1]
Volatile liquid anaesthetics
(**isoflurane, desflurane, sevoflurane**) may cause malignant hyperthermia
**End-tidal CO2 increases** as a result, along with body temperature which causes diaphoresis (excess sweating).
## Footnote
**NB**: MH is a genetic disorder, manifesting due to calcium overload in the skeletal muscle causing sustained muscular contraction and rhabdomyolysis, resulting in excess anaerobic metabolism causing acidosis.
61
Breast fibroadenoma: surgical excision is usual if >[]cm
Breast fibroadenoma: surgical excision is usual if **>3cm**
## Footnote
Small firm anf mobile - 'breast mouse'
62
Which pathologies / indications make something an ASA II / III / IV / V
**ASA II: A patient with mild systemic disease**
- current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension, mild lung disease
**ASA III: A patient with severe systemic disease**
- poorly controlled Diabetes Mellitus/Hypertension, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history (>3 months) of Myocardial infarction, Cerebrovascular accidents
**ASA IV A patient with severe systemic disease that is a constant threat to life**
- recent (< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
**ASA V A moribund patient who is not expected to survive without the operation**
- ruptured abdominal/thoracic aneurysm, massive trauma, intra-cranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
63
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are [2]
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are **venlafaxine or a SSRI**
64
TRALI vs TACO vs acute haemolytic reaction? [3]
**TACO**:
- Pulmonary oedema, hypertension
**Transfusion-related acute lung injury (TRALI)**
- Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension
**Acute haemolytic transfusion reaction results from a mismatch of blood group (ABO) which causes massive intravascular haemolysis.** This is usually the result of red blood cell destruction by IgM-type antibodies.
- Symptoms begin minutes after the transfusion is started and include a fever, abdominal and chest pain, agitation and hypotension.
65
[1] should be used first-line for **acute stress disorders**
**Trauma-focused cognitive-behavioural therapy (CBT)** should be used first-line for acute stress disorders
**benzodiazepines**
* sometimes used for acute symptoms e.g. agitation, sleep disturbance
Eye movement desensitisation and reprocessing therapy is not appropriate for an acute stress disorder
- This is the first-line treatment for **post-traumatic stress disorder**
66
This patient has borderline low blood pressure, and therefore, in the context of his trauma, is at risk of low blood pressure intra-operatively. [1] that increases blood pressure and is, therefore, **useful for general anaesthetic in patients with trauma.**
This patient has borderline low blood pressure, and therefore, in the context of his trauma, is at risk of low blood pressure intra-operatively. **Ketamine** is an NMDA receptor antagonist that increases blood pressure and is, therefore, useful for general anaesthetic in patients with trauma.
67
Hiccups in palliative care - [2]
Hiccups in palliative care - **chlorpromazine or haloperidol**
68
On an x-ray, what would indicate prolonged inflammation of the supraspinatous tendon? [1]
**Calcification**
69
NNT = [1]
NNT = **1 / Absolute Risk Reduction**
Experimental (drug A) event rate = 300 / 500 = 0.6
Control (placebo) event rate = 225 / 450 = 0.5
Absolute risk reduction = 0.6 - 0.5 = 0.1
Number needed to treat = 1 / 0.1 = 10
70
Dropping sats following intubation → ? [1]
Dropping sats following intubation → ? **oesophageal intubation**
71
If a pregnant woman reports reduced fetal movements then [1] should be used to confirm fetal heartbeat as a first step
What are the next steps? [1]
**If past 28 weeks gestation:**
If a pregnant woman reports reduced fetal movements then **handheld Doppler** should be used to confirm fetal heartbeat as a first step
- If no fetal heartbeat detectable, **immediate ultrasound should be offered.**
- If **fetal heartbeat present**, **CTG** should be used for at **least 20 minutes** to monitor fetal heart rate which can assist in excluding fetal compromise. If concern remains, despite normal CTG, urgent (within 24 hours) **ultrasound can be used**. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
72
Long term mechanical ventilation in trauma patients can result in [1] formation
Long term mechanical ventilation in trauma patients can result in **tracheo-oesophageal fistula formation**
73
The mean ± 2 standard deviations contains [1]
The mean ± 2 standard deviations contains **95.4% of the values**
74
Patients with schizophrenia must not drive and must notify the DVLA, until stable and well for [1] months and following a suitable psychiatristy report
Patients with schizophrenia must not drive and must notify the DVLA, until stable and well for **3 months** and following a **suitable psychiatristy report**
75
76
. Nucleic acid amplification testing (NAAT) confirms that his condition is caused by an **obligate intracellular bacterium**
Dx? [1]
Chlamydia
77
How does neonatal syphilus present? +]
**sensorineural** **deafness** and a **desquamating rash**. Other features include **Hutchinson's teeth, interstitial keratitis, and ostrochondritis visible on x-ray.**
78
How does iron overload present? [+]
This causes symptoms similar to hereditary haemochromatosis, such as cardiac failure, liver impairment, and endocrine issues like diabetes.
79
[1] is commonly used in emergency scenarios for rapid sequence induction as in this scenario.
**Suxamethanoium** is commonly used in emergency scenarios for rapid sequence induction as in this scenario.
80
Describe / explain how you can reduce cerebral perfusion in a patient [2]
A lower PaCO2 is usually achieved through **hyperventilation**. A lower PaCO2 causes **vasoconstriction** in the **cerebral** **arterioles**, moderately reducing cerebral perfusion, and thus ICP.
81
TACO vs TRALI? [2]
82
Do you give abx for centor score of 2? [1]
No xoxoxox
83
Dx of pityriasis rosea.
NICE guidelines recommend [1] for symptomatic relief of itching.
NICE guidelines recommend **topical corticosteroids** for symptomatic relief of itching.
84
[1] is a specific sign for opioid withdrawal
**Yawning** is a specific sign for opioid withdrawal
85
Normal ECG x Raised Trops X chest pain = ? [1]
NSTEMI
- If not raised troponin would be unstable angina
86
Crescentic dense shape on CT = ? [1] Causes? [1]
SDH - chronic alcohol use
87
*Poorly controlled DMT2 x sudden onset loss of vision*
**Tx? [1]**
**Vitreoctomy**
88
Anky Spond X eye pain - tx? [1]
**Topical steroids** - for anterior uveitis tx
89
Post-MI: raised ST x fatigue = ?
**Ventricular aneursym**
90
Post-surgery: bibasal areas of dullness. Raised RR. Dx? [1] Tx? [1]
**Atelectasis** - tx with chest physio
91
Mycoplasma dx? [1]
Serology
92
Hiatus hernia - tx [2]
**First line**: PPI
**Second line**: Nissen fundiplication
93
Remember you cant presribe sildenafil with.. [1]
Nitrates
94
What criteria would ensure that a stroke is a TACS? [3]
Hemiparesis
HH
Focal neurological deficit
95
Aortic dissection - would other presentations would help this dx? [2]
New focal neurology
New early diastolic murmur (AR)
96
How do you calculate alcohol consumption? [1]
**Vol X ABV / 1000**
97
CNIII palsy - how do you differentiate between a medical and surgical cause? [2]
Surgical involves the pupil. examples include stroke
Medical does not - e.g. diabetic microvascular changes
98
How do you tell the difference between pituitary and adrenal adenoma based off sx? [1]
Pit will have hyperpigmentation but adrenal wont
99
How do you treat hypernatraemia? [2]
5% dextrose with water
OR
0.9% NaCl slowly
100
Which is the most common cause of encephalitis? [1]
What would an MRI show of this? [1]
HSV - preferance for medial temporal lobes
101
If a ptx has ascites with low SAAG - what does this mean the cause of the ascites is? [1]
due to hypoalbuminaemia OR peritoneal disease, not increase hydrostatic pressure
102
What's the difference between TENS and SJS? [1]
TENS > 30%
SJS < 10%
103
Describe what choroidal detachment looks / present like
Fundoscopy reveals an elevated, dome-shaped retinal area with smooth, bullous elevation. The lesion is reddish-brown and does not extend to the optic disc.
104
1st and 2nd line for constipation? [2]
**first-line laxative**: bulk-forming laxative first-line, such as ispaghula
**second-line**: osmotic laxative, such as a macrogol
105
Typical patient for Budd-Chiari? [3]
Young female, otherwise well, no liver damage with ascites
106
A patient has RHF secondary to COPD. What it is the likely murmur? [1]
Tricuspid regurg
107
Minimum time for blood transfusion once its out of the fridge? lol
4hrs
108
WPW has an accessory via the ..
Bundle of Kent lol
109
Describe the presentation of a carotid artery dissection [2]
Partial Horners
neck pain
headache
110
HOCM imaging? [2]
Echo
cMRI
111
Describe the shape of Perthes on xray [1]
Looks like a mushroom
112
Which inhaler increases the risk of acute angle glaucoma? [1] Why? [1]
Tiotropium - anticholinergics cause mydriasis - which closes the angle
113
Which is the most common type of renal ca? [1]
Clear cell
114
Which muscle controls which part / angles of shoulder movement
1st 15 degrees - supraspinatous
30-90 - deltoid
## Footnote
NB: Painful arc of motion is supraspinatous
115
# ND
Difference between NMS and SS with regards to timing and muscle invovlement? [2]
And reflexes?
NMS - causes muscle rigidity - increased CK, hyporeflexia
SS - causes myclonus, hyperreflexia
116
Which anaesthetic would you use for rapid sequence induction? [1]
Suxamethonium
117
How do you tell the difference between cavernous sinus thrombosis and PCA? [1]
**C**ST - has absent **c**orneal reflex
Posterior C.A - 3rd nerve palsy but pupil stays dilated
118
Case control study uses which results? [1]
Odds ratio lol
119
If a patient is snoring which type of airway should you put in ? [1]
Oropharyngeal
120
apixaban can be tolerated to which egfr? [1]
15
121
How do you tx phantom limb pain? [1]
Duloxetine / preg / amitry / gabapentin
122
Inheritance of DMD? [1]
X-linked
123
How do you treat catatonia? [2]
BDZ
ECT
124
How can you prevent further nose bleeds? [1]
Naseptin - chlorhexidine and neomycin
125
What is the difference between strabismus and amblyopia?
**strabismus**: misalignment of eyes. often hereditary. **decreaed ability to abduct eye**
**amblyopia**: lazy eye - often follows strabismus. **poor vision without squint**
126
Ix for inhaled foreign body? [1]
**Rigid bronchoscopy**
127
What is the treatment for PTSD depending on timings? [2]
watchful waiting may be used for mild symptoms lasting less than 4 weeks
**1st line for those presenting within 1-3 months** = Trauma focused CBT
**1st line for those presenting after 3 months** = EMDR
128
Which types of lymphoma has CD20 +ve? [2]
Which infections are each of the above associated with? [2]
large cell diffuse - hep c and BL - EBV
129
Dx for narcolepsy? [1]
Multple sleep latency EEG
130
Laughter x collapse = ?
Cataplexy
131
Which organism is most likely to cause viral meninigitis vs encephalitis? [2]
Encephalitis - HSV
Menigitis - Coxsackie
132
'green slough' in DMT2 foot ulcer. What is the most likely organism? [1]
**Pseudomonas**
133
How do you treat lithium OD? [1]
IV NaCl
134
Bitemporal hem. - if superior vs inferior fields first, what are the likely causes? [2]
Superior: pit tumour
Inferior: craniopharyngimona
135
Thyroid eye disease can cause **optic nerve compression**, which may lead to vision impairment; [**tx**] is often required when visual disturbances or threat to vision become significant.
Thyroid eye disease can cause optic nerve compression, which may lead to vision impairment; **surgical decompression** is often required when visual disturbances or threat to vision become significant.
136
Thyroid eye disease mx:
Conservative = [1]
Medical = [1]
Surgical = [1]
Conservative = **Smoking Cessation**
Medical = **Steroids or immunosuppressants**
Surgical = **Orbital Decompression if sight threatening complications**
137
*A 58-year-old male presents to the Emergency Department with painless visual loss that he describes as a curtain coming down over his vision. He has never had this happen before. His only past medical history is well-controlled diabetes, and he is short-sighted.*
This is a classic history suggestive of [x]
**Retinal detachment**
-
138
When do you give PPI vs EMR for oesophageal cell changes? [2]
**Oesophageal dysplasia**
- The major risk factor of Barretts's is oesophageal adenocarcinoma. Treatment is with **high dose PPI and regular endoscopies** to screen for the development of dysplasia and adenocarcinoma
**Oesophageal metaplasia**
- EMR is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer
139
What is a common medical cause of CNIII palsy? [1]
How do you differentiate between a surgical cause? [1]
This patient has an oculomotor nerve palsy (cranial nerve III), and one of the common medical causes of this presentation is due to **vasculopathic ischaemia to the third nerve**. Note that this is a **medical third nerve palsy** which is **pupillary sparing** rather than a '**surgical**' third nerve palsy where aneurysms, tumours and raised intracranial pressure can **push on the outer autonomic fibres of the nerve, causing the pupil to dilate**. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared
140
Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. The most common encapsulated bacteria are [3]
Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. The most common encapsulated bacteria are **Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis**
141
Describe the difference in presentation between PICA and Webers [2]
**Weber syndrome** presents as **ipsilateral oculomotor nerve palsy and contralateral weakness**
Sudden onset vertigo, nystagmus, and ipsilateral dysphagia, reduced facial sensation, and Horner's syndrome suggests a central cause, particularly dysfunction of the lateral part of the medulla. This is commonly caused by a **posterior inferior cerebellar artery** or vertebral artery ischaemia.
142
A 19-year-old man presents to the GP clinic with redness in both eyes that developed over the past week. He also complains of tearing and an itchy sensation around his eyes. He has never experienced these symptoms before. He has a past medical history of eczema as a child and takes over-the-counter antihistamines for hay fever. In the last week he has also tried cold compresses, artificial tears and taking frequent showers.
Given the most likely diagnosis, what is the most appropriate next step in management?
The most likely diagnosis in this scenario is allergic conjunctivitis given the patient's symptoms of red eye, watery discharge and itching
According to NICE guidelines, the **1st line treatment is a topical mast cell stabilizer (sodium cromoglycate) and topical antihistamine (antazoline).**
143
This patient has metastatic spinal cord compression (MSCC) and cauda equina syndrome secondary to a metastatic deposit in the lumbar spine which is impinging on the spinal cord. High dose dexamethasone is given to reduce inflammation around the tumour.
What is the next immediate mx? [1]
Given this patient's new neurology findings, however, he should have **urgent radiotherapy within 24hrs to prevent permanent neurological damage. **
144
A 54-year-old woman presents to A&E with sudden, painless loss of vision. This has not happened to her before. There was no obvious trigger, since she was sitting at home when this happened. She has a past medical history of severe left temporal lobe epilepsy and recently underwent surgery for this. When asked to point out the numbers on a clock face, she cannot see from number 12 to 3 in both eyes. Fundoscopic examination is unremarkable.
What is responsible for this patient's visual field defect?
**Lesion of the inferior optic radiation**
This patient has a right superior homonymous quadrantanopia visual field defect caused by damage to the left inferior optic radiation. This is likely due to her recent temporal lobe surgery. the left temporal lobe. Damage to the temporal optic radiation fibres (Meyer's loop) causes superior contralateral quadrantanopias. Damage to the parietal optic radiation fibres result in inferior contralateral quadrantanopias.
## Footnote
Inferior radiation does superior vision
145
herpes zoster ophthalmicus - what happens to most patients? [1]
Ocular involvement occurs in approximately 50% of patients and some of these can
experience a range of complications. **However, in the majority of cases there is
complete resolution with no sequelae**.
146
chronic inflammatory demyelinating polyneuropathy presents with UMN or LMN signs? [1]
**LMN**
147
How do you rule out arterial vs neuropathic ulcers? [1]
Neuropathic will not have normal sensation alongside the ulcer
148
: Serum osmolality is ?
: Serum osmolality is 2 x(Na) + Urea + glucose
149
Severe bleed x warfarin use.
Which the best to reverse and why? [1]
**Prothrombin complex concentrate (PCC)**
* PCC is a concentrated source of clotting factors that can be used to rapidly reverse the
anticoagulant effect of warfarin and restore haemostasis. It is more effective
than fresh frozen plasma or cryoprecipitate and has a lower risk of
complications
150
When is duloxetine CI? [1]
Although duloxetine can be used in this
condition it **is not recommended with an eGFR < 30 mL/min**
151
A 28 year old woman has pain on swallowing. She has asthma that is well
controlled using metered dose salbutamol and beclometasone dipropionate
(800 micrograms/day) inhalers.
She has white plaques in her mouth.
An anti-fungal oral suspension is prescribed.
What is the most appropriate management with regard to her beclometasone?
**Correct answer: D) Take beclometasone dipropionate using a large volume
spacer**
Justification: This patient has developed oral candidiasis and this is most
likely due to local deposition of the inhaled steroid (beclometasone
dipropionate). The risk of this happening again can be reduced by using a
large volume spacer as there will be less local deposition of the drug in her
mouth. Changing to a dry powder or a different steroid inhaler is unlikely to
help and may make things worse.
152
[1] is a common pathogen in intravenous drug
users and can cause endocarditis, pneumonia, and sepsis
**Staphylococcus aureus** is a common pathogen in intravenous drug
users and can cause endocarditis, pneumonia, and sepsis
153
A ptx is dx w a teratoma.
Which tissue might be involved? [2]
Justification: The most likely diagnosis in this case is teratoma, as it is a type
of germ cell tumour that often **contains different types of tissue, including
cartilage and epithelium**.
154
A patient has an MI.
They have a new murmur 2 weeks after.
What is the cause and what murmur would this be? [1]
What else would you see on presentation? [2]
The presence of a
**pansystolic murmur** at the apex suggests **mitral regurgitation,** which can occur
due to the rupture of one of the **papillary muscles that anchors the valve
leaflets**
The bibasal inspiratory crackles suggest **pulmonary oedema**, which
can occur as a result of the increased pressure in the left atrium and
pulmonary veins due to the mitral regurgitation
155
The description of the eruption fits best with bullous impetigo,
although this usually occurs in children. [1], is the most
common causative organism
The description of the eruption fits best with bullous impetigo,
although this usually occurs in children. **Staphylococcus aureus**, is the most
common causative organism
156
When is bariatric surgery indicated/ [2]
Bariatric
surgery is an effective treatment option for **obesity in patients with BMI > 40
kg/m2, or BMI > 35 kg/m2 with comorbidities such as diabetes and
hypertension**
157
Microscopy of a meningeal swab shows Gram-positive cocci arranged in
pairs
Dx? [1]
**Streptococcus pneumoniae**
158
The most appropriate management in this case of a patient with a
neuropathic bladder would be ... ?
Why not alternatives? [2]
The most appropriate management in this case of a patient with a
neuropathic bladder due to multiple sclerosis would be **intermittent selfcatheterization**. Drug interventions are unlikely to be of benefit. Indwelling
urethral catheter or suprapubic catheter are to be avoided due to increase
infection risk.
159
160
161
Describe what an artefact health inequality is [1]
Artefact
would be proposing that the observed differences are due to differences in
measurement
162
What is idealist re social inequality? [1]
Idealist would be
suggesting that individuals’s construction of health is different in different
groups, so they might define health differently
163
What does materiliasm mean re social inequality? [1]
**Materialist**, emphasises the
role of economic and social factors, such as income, education, and
employment, in shaping health outcomes
164
Spondylolisthesis - define, examination findings [2] and symptoms? [2]
Spondylolisthesis is a condition where one
vertebra slips out of line with the one above it, most commonly in the lumbar
spine
exaggerated lumbar lordosis and the palpable depression
Symptoms include lower back
pain that worsens with activity and improves with rest. Neurological
examination is typically normal
165
When would you refer someone to a urogynaeclinic with pelvic organ prolapse? [1]
Referral to urogynaecology clinic is usually needed if
there is a severe prolapse e.g. 3rd degree or severe urinary bowel incontinence
or failed PFEs when management may include more invasive options such as
surgical repair
166
How would you differentiate Behcets and SLE? [1]
Patients with Behcet’s
syndrome experience ulceration and joint pain but renal involvement and
haematological changes are less likely
167
Adenocarcinomas of the lung often metastasise
to the liver through the []
Adenocarcinomas of the lung often metastasise
to the liver through the **bloodstream**, making haematogenous spread the most
likely route.
168
How do you differentiate if a cancer spreads via lymph or blood?
If it ends in **-sarcoma** → think lungs via **blood**
If it’s a **carcinoma** → think **lymph** nodes first.
Except: - Some **carcinomas** prefer **blood** spread:
* **Renal cell carcinoma**
* **Hepatocellular carcinoma**
* **Follicular thyroid carcinoma**
* **Choriocarcinoma**
169
How do you calculate NNT? [1]
Justification for correct answer: The absolute risk reduction (ARR) can be
calculated as the difference in the risk of death between the treatment and
control groups:
ARR = risk in control group - risk in treatment group
ARR = 48/240 - 12/120
ARR = 0.2 - 0.1
ARR = 0.1
The number needed to treat (NNT) can be calculated as the reciprocal of the
ARR:
NNT = 1 / ARR
NNT = 1 / 0.1
NNT = 10
Therefore, the NNT to avoid one death within 2 years is 10.
170
Where do osteosarcomas typically present? [1]
In which age groups [1]
occurs most frequently in the **metaphyseal** **region** of long bones prior to epiphyseal closure, with 40% occuring in the femur, 20% in the tibia, and 10% in the humerus
**seen mainly in children and adolescents**
171
If a cancer of cartilage - what name / age group? [1]
**Chondrosarcoma** more common in middle-age
172
Discrete variables are
. Discrete variables
are those that can only take certain values, usually integers (e.g. number of
children).
173
Nominal variables are
Nominal variables are those that have no intrinsic order or ranking
(e.g. hair colour, occupation)
174
Hodgkin/Reed-Sternberg (HRS) cells admixed with a
polymorphous inflammatory infiltrate = ? [1]
HL
175
Describe social phobia [1]
The patient’s fear of public speaking,
avoidance behaviour, and recognition that his fears are irrational are
consistent with a diagnosis of social phobia. Social phobia is a type of anxiety
disorder characterised by an excessive and persistent fear of social situations,
including public speaking. It can cause significant distress and interfere with
daily activities. Treatment options may include cognitive-behavioural therapy
and/or medication.
176
A 62 year old man is brought to the operating theatre recovery room after a
laryngoscopy and vocal cord biopsy.
He appears to be conscious, but his breathing is shallow and respiratory rate
28 breaths per minute. His voice is weak and, when the recovery nurse asks
him to squeeze her fingers with his hand, the grip is not sustained.
Which drug will reverse these signs?
**Neostigmine** is a
cholinesterase inhibitor and is the most appropriate agent to administer to
reverse the effects of neuromuscular blockade.
- Administration would increase grip strength, respiratory
muscular strength and may improve vocal chord movement and speech.
177
The histological description of duct-like
structures lined by regular, low columnar cells separated by loose fibrous
tissue, with well-defined margins is consistent with a [1]
The histological description of duct-like
structures lined by regular, low columnar cells separated by loose fibrous
tissue, with well-defined margins is consistent with a **fibroadenoma**
178
How do you account for prematurity when working out dev. delay? [1]
The fact that she was born
at 30 weeks’s gestation i.e. 10 weeks premature, should be taken into
consideration when assessing her development
179
Difference between avoidant and dependent? [+]
**Avoidant → “I want relationships but I avoid them because I feel inadequate and fear criticism.”**
* Avoids social situations due to fear of embarrassment
* Extremely sensitive to rejection
* Few friends despite wanting relationships
* Low self-esteem
* Sees self as socially inept or inferior
* Anxiety-driven physical symptoms in social settings
**Dependent → “I need someone to take care of me because I can’t cope alone.”**
* Difficulty making everyday decisions without reassurance
* Needs others to assume responsibility for major areas of life
* Difficulty expressing disagreement (fear of losing support)
* Goes to excessive lengths to obtain support
* Feels helpless when alone
* Urgently seeks another relationship when one ends
180
When can't you give misoprostol for a miscarriage? [1]
If patient has infection
181
What can you give to treat bowel colic in palliative med? [1]
HH / GP
182
How do you check if you have intubated the oesophagus c.f the trachea? [1]
Check capnography
183
Even when the tube is visualized passing the cords, confirmation of effective ventilation is vital. The key modalities to confirm placement are a combination of:
[3]
Even when the tube is visualized passing the cords, confirmation of effective ventilation is vital. The key modalities to confirm placement are a combination of:
chest rise,
breath sounds, and
end-tidal CO2 via capnography.
184
MoA of anastrozole? [1]
Peripheral oestrogen synthesis inhibitor
## Footnote
NB: tamixofen - partial OR antagonism
185
Mastoiditis most likely caused by? [1]
Strep. pneumoniae
186
Ovarian cancer is spread via ..
Lymph
187
CLL undergoes Richter transformation to..
NHL
188
Which line do you give TPN via? [1]
Central
189
What would blood film show for DIC? [1]
Schistocytes
190
A patient with a high anterior resection will most likely have which type of stoma? [1]
Loop ileostomy
191
A patient with a low anterior resection will most likely have which type of stoma? [1]
What distance would indicate this tx? [1]
End colostomy
< 5 cm from anus
192
Describe what successful treatment of syphilis would be on RPR tests [1]
1/16 --> 1/4
Year 5 Revision
flashcards
Decks in class (19)
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