PassMed Notes

Question 1

A patient has heparin-induced thrombocytopenia:
- Describe the pathophysiology of this [2]
- How does this present? [2]
- How do you treat? [1]

Answer 1

Heparin-induced thrombocytopenia occurs due to the production of auto-antibodies against heparin and platelet factor IV

Presentation:
- starts at 5-10 days into treatment
- blood clots forming in the context of recently started heparin and low platelets

Treatment:
- Stop heparin
- Start direct thrombin inhibitor (e.g. argatroban)

Question 2

[] is commonly associated with infective endocarditis amongst IVDU

Answer 2

Staphylococcus aureus is commonly associated with infective endocarditis amongst IVDU

Question 3

Which drug regimens do you use for H. pylori eradication? [2]

Answer 3

H. pylori eradication:
* PPI + amoxicillin + clarithromycin, or
* PPI + metronidazole + clarithromycin

Question 4

A patient presents with cardiac arrest due to hypothermia.

How do you manage this patient accoridng to ALS?

Answer 4

In cases of hypothermia causing cardiac arrest, defibrillation is less effective and only 3 shocks should be administered before the patient is rewarmed to 30 degrees centigrade

NB: IV drugs should be avoided if possible, as the patient is more likely to have a drastic response to the drug

Question 5

Under which conditions would you opt for V/Q over CTPA for a ?PE ? [1]

Answer 5

Pulmonary embolism and renal impairment → V/Q scan is the investigation of choice

Question 6

Describe the MoA of unfractionated heparin [2]

Answer 6

Unfractionated heparin - activates antithrombin III
- Forms a complex that inhibits thrombin, factors Xa, Ixa, Xia and XIIa

Question 7

Describe the ECG findings in pericarditis [2]

Answer 7

Concave ST elevation with PR depression

Question 8

Statins must be temporarily stopped when a [] antibiotic is started
- Why? [1]

Answer 8

Statins must be temporarily stopped when a macrolide antibiotic is started (e.g.clarithromycin)
- Risk of rhabdomyolysis

Question 9

How do you distinguish between an inguinalscrotal hernia and an epididymal cyst? [2]

Answer 9

Scrotal swelling you can’t get above: inguinal hernia

*When trying to work out the cause of a scrotal swelling, there are three important pieces of information which should be sought to help make a diagnosis; if the swelling involves the testicle, if the swelling trans-illuminates when a pen torch is placed below it and if it is possible to palpate above the swelling. *

Question 10

Describe the difference in presentation in:
- oesphageal maligancy
- achalasia
- pharyngeal pouch

Answer 10

oesphageal maligancy
- dysphagia with solid food but progresses with symptoms with soft foods also

achalasia
- with inability to swallow both liquids and solids from the outset.

pharyngeal pouch

Question 11

Which factors can help identify the severity of pancreatitis? [7]

Answer 11

PANCREAS

Pa 02 < 8kPa

Age >55 years

Neutrophilia WBC >15x10^9

Calcium < 2mmol/L

Renal function Urea >16mmol/L

Enzymes LDH >600 ; AST >200

Albumin < 32g/L

Sugar Blood glucose >10mmol/L

Question 12

In pancreatitis - describe the Ca2+ levels that would indicate:
- A cause of pancreatitis
- Severe pancreatitis

Answer 12

A cause of pancreatitis:
- High Ca

Severe pancreatitis
- Indicated by low Ca

Question 13

Which cause of nephrotic syndrome is most asocaited with Ca2+? [1]
Which antibodies is it associated with? [1]

Answer 13

Membranous nephropathy is the most common cause of nephrotic syndrome in adults. It can exist as a primary condition associated with anti-PLA2 antibodies

Question 14

A lean 32-year-old female has recently undergone a colonoscopy to remove some incidental polyps. On inspection of the colon, the doctor also noticed abnormal pigmentation. He send a sample off to be reviewed by the histopathologists and they reported ‘pigment-laden macrophages within the mucosa on PAS staining’.

What condition is being described? [1]
What is the most common cause of the underlying condition? [1]

Answer 14

Melanosis coli is most commonly caused by prolonged laxative use

Question 14

A patient is presenting with ECG: ST-depression in leads I, aVL, V5 and V6.

A decision is made to treat the patient medically instead of with percutaneous coronary intervention.

His BP is 89/58 mmHg.

How does this alter your mangament? [1]

Answer 14

Avoid Nitrates (GTN) if hypotensive
- Aspirin + ticagrelor + fondaparinux

Question 15

A 65-year-old man presents to the emergency department with a two-hour history of haematemesis. He has a history of ischaemic heart disease and denies any alcohol consumption.

Despite undergoing an endoscopy where a bleeding gastric ulcer is identified and injected with adrenaline, he vomits an additional 20ml of fresh red blood the following day. A further endoscopy is performed where clipping is attempted but unfortunately, it is unsuccessful and he has a reoccurrence of haematemesis an hour later

What is the most appropriate next step?

Answer 15

Refer to general surgery

Question 16

A 75-year-old man is admitted to hospital after experiencing severe non-bloody diarrhoea over the last 3 days. His appetite has been poor and he has been eating and drinking less.

Which is the most likely pattern of results on the arterial blood gas?

Answer 16

Diarrhoea can cause a normal anion gap metabolic acidosis whereas vomiting causes alkalosis

Question 17

A patient has sx that indicate kidney stones.

They have a CTKUB.

What do the arrows point to and what does this indicate? [2]

Answer 17

Periureteric fat stranding may indicate recent stone passage, if a ureteric calculus is not present.

Question 18

When do you use cardioversion to control AF? [2]

How do you treat new onset AF? [3]

How do you treat AF if onset > 48hrs? [3]

AKA: rhythm control for AF

Answer 18

There are two scenarios where cardioversion may be used in atrial fibrillation:
* electrical cardioversion as an emergency if the patient is haemodynamically unstable
* electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred.

Onset < 48 hours
- If the atrial fibrillation (AF) is definitely of less than 48 hours onset patients should be heparinised.

Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation.

Otherwise, patients may be cardioverted using either:
- electrical - ‘DC cardioversion’
- pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease

Onset > 48 hours:
- anticoagulation should be given for at least 3 weeks prior to cardioversion.
- An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus.

NICE recommend electrical cardioversion in this scenario, rather than pharmacological.
- Following electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence

Question 19

What is the ECG finding here? [1]
Which cardiac conditon causes this? [1]

Answer 19

Electrical alternans - caused by cardiac tamponade

Question 20

A patient presents with an AKI.
They have an allergic type picture - with rashes and a fever.

What is the likely cause of this AKI and what might you find on urinanalysis? [3]

Answer 20

Acute interstitial nephritis causes an ‘allergic’ type picture consisting usually of raised urinary WCC and eosinophils, alongside impaired renal function and white cell casts

Question 21

Post-MI, what would indicate a patient is suffering from papillary muscle rupture? [4]

Answer 21

acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema

Question 22

What is the main benefit of prescribing albumin when treating large volume ascites’? [1]

Answer 22

Large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality

Question 23

[] infection (especially [] subtype) is the strongest risk factor for anal cancer

Answer 23

HPV infection (especially HPV 16 subtype) is the strongest risk factor for anal cancer

Question 24

Diabetes insipidus is characterised by a [] plasma osmolality and a [] urine osmolality

Answer 24

Diabetes insipidus is characterised by a **high** **plasma** **osmolality** and a **low** **urine osmolality**

Question 25

Which of the below results is most likely in a patient taking Warfarin? Normal PT, prolonged APTT Prolonged PT, normal APTT Normal PT, normal APTT Prolonged PT, prolonged APTT Normal PT, shortened APTT

Answer 25

Prolonged PT, normal APTT

Question 26

Concurrent use of clopidogrel and [1] can make clopidogrel less effective

Answer 26

Concurrent use of **clopidogrel and omeprazole/esomeprazole** can make clopidogrel less effective

Question 27

Pulmonary stenosis - has what type of murmur? [1]

Answer 27

Pulmonary stenosis - **ejection systolic murmur**

Question 28

**[drug class]** may cause **precipitation of digoxin toxicity**

Answer 28

**Thiazides** may cause precipitation of digoxin toxicity

Question 29

[] is the most common cause of peritonitis secondary to peritoneal dialysis

Answer 29

**Staphylococcus epidermis**

Question 30

[valvular disorder] is associated with Marfan syndrome

Answer 30

**Aortic regurgitation** is associated with Marfan syndrome

Question 31

If a patient with ulcerative colitis has had a severe relapse or **[] exacerbations** in the past year they should be given either [2] to maintain remission

Answer 31

If a patient with ulcerative colitis has had a severe relapse or **>=2 exacerbations** in the past year they should be given either **oral azathioprine or oral mercaptopurine** to maintain remission

Question 32

What is Charcot's triad? [3] What does it indicate? [1]

Answer 32

**Charcot's cholangitis triad:** - **fever, jaundice and right upper quadrant pain** - This is caused by bacterial infection of the biliary tree as a result of biliary stasis from obstruction

Question 33

[3] following diarrhoeal illness - consider HUS

Answer 33

**Normocytic anaemia, thrombocytopaenia and AKI** following diarrhoeal illness - consider **HUS**

Question 34

A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the [] vein to the [] vein

Answer 34

A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the **hepatic vein to the portal vein**

Question 35

What sign that could be found by smelling breath would indicate acute liver failure? [1]

Answer 35

**Fetor hepaticus, sweet and fecal breath**, is a sign of liver failure

Question 36

A patient is dx with familial adenomatous polyposis. What management is given? [1]

Answer 36

Familial adenomatous polyposis - once diagnosed patients typically have a **total proctocolectomy with ileal pouch anal anastomosis** due to the extremely high risk of developing colorectal cancer

Question 37

[] casts may be seen in the urine of patients taking **loop diuretics**

Answer 37

**Hyaline casts** may be seen in the urine of patients taking loop diuretics

Question 38

Which one of the following statements regarding amiodarone is correct? Has a half-life of 7-14 days Should not be given to asthmatics Is a class II antiarrhythmic agent Is a common cause of hypokalaemia Is a common cause of thrombophlebitis

Answer 38

Is a common cause of **thrombophlebitis**

Question 39

Adrenaline induced ischaemia - give [1]

Answer 39

Adrenaline induced ischaemia - **phentolamine**

Question 40

A ptx with CKD. ECG report: Prolonged QT interval and evidence of ST segment depression and flat T waves in leads I, II and III. What is the most appropriate management? [1]

Answer 40

**Hypocalcaemia: prolonged QT interval** is an indication for **urgent IV calcium gluconate**

Question 41

Magnesium 0.4 mmol/L (0.7 - 1.05) Potassium 2.8 mmol/L (3.5 - 5.0) What is the most appropriate initial treatment option for this patient?

Answer 41

**Replace magnesium before correcting hypokalaemia.** Hypomagnesemia prevents potassium absorption

Question 42

What is the most appropriate dose of adrenaline to give during a cardiac arrest? [1]

Answer 42

Recommend Adult Life Support (ALS) adrenaline doses * anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM * **cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV**

Question 43

A patient has an AKI picture. You trial a fluid challenge and there is no response. What is the most likely cause? [1]

Answer 43

**Acute tubular necrosis** - poor response to fluid challenge

Question 44

Which of the following may precipitate digoxin toxicity? Her current medications include: Adcal D3 2 tablets once daily Amiodarone 200mg twice daily Bisoprolol 5mg once daily Digoxin 125mcg once daily Losartan 12.5mg once daily Paracetamol 1g four times daily

Answer 44

**Amiodarone** may cause precipitation of digoxin toxicity - if starting amiodarone on a patient taking digoxin the dose should be reduced

Question 45

[] is the intervention of choice for severe mitral stenosis

Answer 45

**Percutaneous mitral commissurotomy** is the intervention of choice for severe mitral stenosis

Question 46

Bleeding on dabigatran? Can use [1] to reverse

Answer 46

Bleeding on dabigatran? Can use **idarucizumab** to reverse - **dab = mab** *Andexanet alfa is a recombinant form of factor Xa, used for reversing bleeding in patients taking rivaroxaban or apixaban.*

Question 47

A patient is cANCA +ve. Given the likely diagnosis, what findings would be expected on renal biopsy?

Answer 47

The correct answer is **crescentic glomerulonephritis**. This patient has a history of chronic sinusitis and haemoptysis, along with persistent microscopic haematuria and elevated inflammatory markers (ESR and CRP). The positive cANCA (PR3) test result suggests the **diagnosis of granulomatosis with polyangiitis (GPA)**, formerly known as Wegener's granulomatosis. GPA is a small-vessel vasculitis that often involves the kidneys, causing rapidly progressive glomerulonephritis. On renal biopsy, crescentic glomerulonephritis would be expected in this case, which is characterized by the presence of cellular crescents in more than half of the glomeruli.

Question 48

[] is the most common and important viral infection in solid organ transplant recipients

Answer 48

**Cytomegalovirus** is the most common and important viral infection in solid organ transplant recipients

Question 49

Hypertrophic obstructive cardiomyopathy - is classically associated with an which extra heart sound? [1]

Answer 49

Hypertrophic obstructive cardiomyopathy - is classically associated with an **S4** *Therefore S4 is the correct answer which is associated with hypertrophy of the ventricles and always indicates some form of pathology.*

Question 50

**HOCM** may present with **ejection systolic murmur**, [louder / quieter] on performing Valsalva and [louder / quieter] on squatting

Answer 50

**HOCM** may present with ejection systolic murmur, louder on performing Valsalva and quieter on squatting

Question 51

Describe the difference in a bleeding and perforated peptic ulcer [2]

Answer 51

**Hypotension + melaena** → bleeding peptic ulcer **A perforated peptic ulcer** - would present with **signs and symptoms of peritonitis** as contents from the gastrointestinal system will enter the peritoneal cavity. The signs and symptoms that would be seen include diffuse abdominal pain, abdominal distension, rigidity, and guarding. This patient does have a soft and mostly non-tender abdomen, therefore this is unlikely.

Question 52

A 55-year-old man who has a history of ischaemic heart disease presents with myalgia. His long-term medications include aspirin, simvastatin and atenolol. Given his statin use a creatine kinase is measured and reported as follows: Creatine kinase 1,420 u/l (< 190 u/l) His problems seem to have followed the prescription of a new medication. Which one of the following is most likely to have caused the elevation in creatine kinase? Rifampicin Felodipine Clarithromycin Isosorbide mononitrate Amitriptyline

Answer 52

**Statins + erythromycin/clarithromycin - an important and common interaction**

Question 53

Describe the maximum rate of IV K infusion [1]

Answer 53

The maximum rate of IV potassium infusion that can be conducted without monitoring is 10mmol/hour So if 80mmol needed - must go over 8hrs

Question 54

A 65-year-old man presents to the emergency department with acute abdominal pain and vomiting. He points to his xiphisternum and states the pain started there, before becoming generalised. He noticed ground coffee-like material in his vomit but has not passed any bloody stools. His past medical history includes atrial fibrillation, peptic ulcer disease, and osteoarthritis. His pulse is 112 bpm, his blood pressure is 134/75 mmHg, and his temperature is 37.8ºC. His abdomen is distended with generalised tenderness. Guarding and rebound tenderness are also present. What is the most appropriate **initial** step?

Answer 54

An **erect chest x-ray** is a key investigation for a suspected perforated peptic ulcer - then OGD

Question 55

According to DVLA UK guidance, how long should the patient be advised to refrain from driving after the acute MI? [1]

Answer 55

**1 week**

Question 56

A 62 year old female presents to the Emergency Department with intermittent central chest pain. These episodes typically occurs at rest and has her symptoms have resolved by the time she reaches the Emergency Department. An ECG is performed on arrival and demonstrates deeply inverted T-waves in precordial leads V2-V4. What is the likely diagnosis? [1]

Answer 56

**Wellens syndrome** - Wellens syndrome is caused by severe proximal LAD stenosis and characterized by deeply inverted or biphasic T-waves in leads V2-V3. This patient's ECG findings and history of chest pain primarily at rest are consistent with Wellens syndro

Question 57

What is the most comon cause of acute bronchitis? [1] What are the features? [3]

Answer 57

**Rhinovirus** is the most common viral cause of **acute bronchitis**, characterised by a **non-productive cough, fatigue**, and signs such as **wheeze** or **rhonchi** that improve with coughing

Question 58

In **nephrotic patients**, **sudden onset abdominal pain, haematuria, worsening renal function, and oedema** may indicate **[]**. **How would you dx this? [1]**

Answer 58

In nephrotic patients, sudden onset abdominal pain, haematuria, worsening renal function, and oedema may indicate **renal vein thrombosis;** a **renal Doppler ultrasound** is crucial for timely diagnosis and management.

Question 59

A 21-year-old man presents to the emergency department with a painful, persistent erection lasting over 4 hours without sexual stimulation. He has no history of sickle cell disease or recent genital trauma. Aspiration and irrigation are attempted unsuccessfully, **what is the next most appropriate step in managing this patient**? [1]

Answer 59

**Phenylephrine** - Intracavernosal injection of alpha agonists such as **Adrenaline** or Phenylephrine can be used in the management of priapism where aspiration and irrigation have not been successful.