pts mock 2

Question 1

What is the imaging of choice for diverticulitis

Answer 1

CT ab/pelvis with contrast. Would demonstrate a thickened bowel wall

Question 2

Diverticulitis management

Answer 2

• Mild presentation: oral antibiotics, analgesia, low residue or liquid diet
• Severe presentation:
  
  • Supportive management:NBM, IV fluids and analgesia
  • IV antibiotics:co-amoxiclav is typical but depends on local guidelines
  • Acute PR bleeding: transfuse blood products and arrange angiographic embolisation (blocks blood vessels) if available, otherwise, surgery is required
  • Surgery: if bleeding is not controlled or perforation is present, emergency surgical resection is required e.g. Hartmann’s procedure (removing the affected section of the bowel and creating an alternative path for faeces to be passed).
• Diverticular abscess: radiological drainage or surgery
• Recurrent diverticulitis: elective colonic resection

Question 3

colonoscopy of crohn’s

Answer 3

• Mucosal inflammation, deep ulcers, skip lesions and cobblestone mucosa
• Histology: transmural inflammation, granulomas and goblet cells

Question 4

Maintaining remission of Crohn’s

Answer 4

1st line: Azathioprine or Mercaptopurine

2nd line:Methotrexate, Infliximab, Adalimumab

Post-surgery: consider azathioprine, with or without methotrexate

Question 5

Colonoscopy of UC

Answer 5

• Red and raw mucosa with widespreadshallow ulceration
• No inflammation beyond the submucosa, unless fulminant disease
• Lamina propria inflammatory cell infiltrates
• Pseudopolyps: mucosa adjacent to ulcers is preserved, which has the appearance of polyps
• Crypt abscessesdue to neutrophil migration through gland walls
• Goblet cell depletion, withinfrequent granulomas

Question 6

What is the scoring system for ulcerative colitis

Answer 6

Truelove and Witts’ severity index

Question 7

management for ulcerative colitis

Answer 7

Mild = 1st line aminosalicylate and 2nd line corticosteroids
(if limited to the sigmoid flexure - proctosigmoiditis and left-sided colitis- use a topical aminosalicylate, for extensive - from proximal to the sigmoid - use topical and high dose oral)
Acute severe (any site) = 1st line IV corticosteroid and 2nd line IV ciclosporin
Maintenance = aminosalicylate, azathioprine, mercaptopurine

Question 8

Surgery for people with ulcerative colitis

Answer 8

• Colectomy may be required: leaves patient with J-pouch (can be reversed) or ileostomy.
  
  • J- pouch: ileoanal anastomosis, colon removed and rectum fused to ileum
  • Ileostomy: colon and rectum are removed and the ileum brought out on
    to the abdominal wall as a stoma

Question 9

Tubulo-interstitial causes of AKI

Answer 9

usually due to acute tubular necrosis (ATN). Other tubulointerstitial causes include acute interstitial nephritis that can occur secondary to medications (e.g. NSAIDs, PPI’s, penicillins) and infections. This typically leads to damage to the renal parenchyma that can lead to scarring and fibrosis in the long-term.

Question 10

what levels are assessed before starting azathioprine or mercaptopurine

Answer 10

Thiopurine methyltransferase (TPMT)

Question 11

signs of nephritic syndrome in AKI

Answer 11

Nephritic syndrome: haematuria; proteinuria; oliguria and hypertension

Question 12

signs of tubulo-interstitial disease in AKI

Answer 12

arthralgia, rashes and fever

Question 13

complications of AKI

Answer 13

hyperkalaemia, fluid overload, metabolic acidosis, uraemia, Uraemic complications

Question 14

how do you protect the myocardium with hyperkalaemia

Answer 14

• Protection of the myocardium:10ml of 10% calcium gluconate.
• Reduce extracellular potassium: aim is to drive potassium into the intracellular compartment. Insulin and beta agonists (e.g. 2.5mg nebulised salbutamol) are given.
• Additional: stop or adjust potassium-sparing or potassium-containing medications. Resins can reduce potassium absorption but these takehours/days to have effect.

Question 15

treatment of metabolic acidosis

Answer 15

sodium bicarbonate or dialysis

Question 16

Give examples of nephrotoxic drugs

Answer 16

ACEi, NSAIDs, Spironolactone

Question 17

Prostatitis (acute) medication

Answer 17

• Antibiotics: courses typically 14 days
  
  • First line:Oral ciprofloxacinor ofloxacin
  • Second line:Oral levofloxacin or co-trimoxazole
  • IV antibiotics: for patients with significant infection under microbiology guidance.
• TRUSS guided abscess drainage, if needed

Question 18

reiter’s syndrome triad

Answer 18

Reactive Arthritis
urethritis, arthritis and conjunctivitis (might also get mouth ulcers)
Typically get acute, asymmetrical monoarthritis, typically in the lower leg

Question 19

Budd-Chiari syndrome presentation

Answer 19

presents with abdominal pain, ascites and liver enlargement

Question 20

Saint’s triad

Answer 20

hiatus hernia, cholelithiasis and colonic diverticulosis

Question 21

What is dalteplarin

Answer 21

LMWH

Question 22

prophylaxis for dvt after hip replacement

Answer 22

Patients undergoing an elective hip replacement should be given
thromboprophylaxis with either a low molecular weight heparin administered for 10 days
followed by low-dose aspirin for a further 28 days, or a low molecular weight heparin
administered for 28 days in combination with anti-embolism stockings until discharge,
or rivaroxaban

Question 23

what is apixaban

Answer 23

an anticoagulant

Question 24

what is the target for rituximab

Answer 24

CD20

Question 25

First line for uncomplicated malaria

Answer 25

Artemether with lumefantrine (Riamet)

Question 26

First line for complicated malaria

Answer 26

1. Artesunate- this is the most effective treatment but is not licensed. 2. Quinine dihydrochloride

Question 27

What is the name for a malignant tumour of smooth muscle

Answer 27

Leiomyosarcoma

Question 28

What is the medication for paracetamol overdose

Answer 28

N-acetyl cystine

Question 29

What enzyme degrades trypsin

Answer 29

chymotrypsin C

Question 30

What are the causes of acute pancreatitis

Answer 30

I GET SMASHED, pregnancy, neoplasia

Question 31

Genetic link to pancreatitis

Answer 31

PRSS1

Question 32

Signs of Pancreatitis

Answer 32

Should be suspected in any person with: - Acute upper or generalised abdominal pain, particularly if they have a history or clinical features of gallstones or alcohol misuse - Abdominal tenderness and guarding - Abdominal distension - Jaundice - Cullen's sign - periumbilical bleeding, secondary to intraperitoneal haemorrhage - Grey Turner's syndrome - flank bleeding secondary to retroperitoneal haemorrhage - Fox’s sign: bleeding over the inguinal ligament secondary to retroperitoneal haemorrhage

Question 33

symptom of pancreatitis

Answer 33

Poor urinary output: due to insensible fluid losses, third-spacing (movement of fluid from intravascular to interstitial spaces) - Nausea, vomiting and anorexia - Severe upper abdominal pain - Steatorrhoea

Question 34

the scoring of pancreatitis

Answer 34

Modified glasgow scoring

Question 35

Primary investigation of pancreatitis

Answer 35

- Serum amylase: amylase rises faster than lipase but also levels fall faster within 24-48hrs; less specific than lipase; is not of prognostic value. Serum amylase may be raised in other conditions such as renal failure, so is non-specific - Serum lipase: more specific for acute pancreatitis; levels rise slower than amylase but have a longer half-life. Amylase is tested more frequently in the UK

Question 36

Acute pancreatitis treatment

Answer 36

IV Fluid resuscitation... - ERCP - Cholecystectomy - Alcohol cessation and withdrawal management

Question 37

PBC key presentation

Answer 37

The classic presentation of PBC is with significant itching in a middle-aged female. (I think its just jaundice really from charcot's triad)

Question 38

Signs of PBC

Answer 38

- Skin hyperpigmentation: due to increased melanin - Clubbing - Mild hepatosplenomegaly - Xanthelasma and xanthomata (late sign) - due to leakage of cholesterol - Scleral icterus (late sign)

Question 39

Symptoms of PBC

Answer 39

- Pruritis (itchy skin) - leakage of bile salts - Fatigue and weight loss - Dry eyes and dry mouth - Sjögren's syndrome - Obstructive jaundice (late sign)

Question 40

Management of PBC

Answer 40

- Ursodeoxycholic acid (A bile acid analogue which dampens the inflammatory response, acts as an anti-apoptotic agent, and improves cholestasis) - Fat-soluble vitamin supplementation: cholestasis impairs fat absorption - Cholestyramine - Codeine phosphate: for diarrhoea - Biphosphonates: for osteoporosis

Question 41

Gold standard investigation for acute cholecystitis

Answer 41

Abdominal ultrasound - - Pericholecystic fluid - Distended gallbladder - Thickened gallbladder wall (>3 mm) - Gallstones - Positive sonographic Murphy's sign

Question 42

Gold standard for PSC

Answer 42

ERCP - but has been replaced by MRCP as MRCP is less invasive.

Question 43

empirical first line treatment for septic arthritis

Answer 43

flucloxacillin

Question 44

First line treatment for withdrawal seizures

Answer 44

chlordiazepoxide

Question 45

What is sjorgrens syndrome

Answer 45

Sjogren’s syndrome is the immune destruction of exocrine glands and often presents with arthritis, dry eyes and dry mouth. The Schirmer test involves placing a small strip of paper in the eye to measure tear production and is used in the diagnosis of Sjogren’s, alongside lacrimal gland biopsy and antibody testing.

Question 46

treatment for ankylosing spondylitis (in order)

Answer 46

- NSAID e.g. ibuprofen or naproxen (2-4 weeks. If no improvement, switch to another NSAID) - Steroid - used during flares (oral, IM or directly into joints) - Anti-TNF e.g. etanercept or monoclonal antibodies against TNF e.g. infliximab, adalimumab - Monoclonal antibodies targeting IL-7 - e.g. secukinumab

Question 47

What is pseudogout

Answer 47

Pseudogout is a form of inflammatory arthritis caused by deposition of calcium pyrophosphate crystals in the synovium.

Question 48

The greatest risk factor for pseudogout

Answer 48

- increasing age (the greatest) - - Previous joint trauma - Hyperparathyroidism - Haemochromatosis

Question 49

What is Reiter's triad

Answer 49

Reactive arthritis secondary to a Chlamydia infection. This can cause Reiter’s triad of conjunctivitis, urethritis and arthritis (can’t see, can’t pee, can’t climb tree) as well as keratoderma blennorrhagium (the rash on his feet) and mouth ulcers

Question 50

Explain Amaurosis Fugax

Answer 50

Often described as a black curtain coming across the vision. A classical syndrome of painless short-lived monocular blindness. It is a term usually reserved for transient visual loss of ischaemic origin. - Occurs due to the temporary reduction in the retinal, ophthalmic or ciliary blood flow leading to temporary retinal hypoxia. - The principle cause of amaurosis fugax is transient obstruction e.g. due to emboli, of the ophthalmic artery, which is a branch of the internal carotid artery. - However, other ischaemic causes to consider include giant cell arteritis (i.e. temporal arteritis) and central retinal artery occlusion.

Question 51

What is Polymyalgia rheumatica

Answer 51

is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.