SAQs

Question 1

What is the default second antiplatelet for everyone after aspirin?

Answer 1

ticagrelor

Unless specific conditions apply, such as anticoagulation or high bleeding risk.

Question 2

When should clopidogrel be used instead of ticagrelor?

Answer 2

• On anticoagulation
• High bleeding risk
• History of intracranial bleed
• Getting thrombolysis (STEMI)
• Can’t tolerate ticagrelor

These conditions dictate the switch from ticagrelor to clopidogrel.

Question 3

What is the default anticoagulant mentioned in the guide?

Answer 3

Fondaparinux

This is the standard choice unless specific conditions necessitate a different anticoagulant.

Question 4

In what situation should LMWH or unfractionated heparin be used instead of fondaparinux?

Answer 4

Going for PCI

This indicates a need for a different anticoagulant during percutaneous coronary intervention.

Question 5

For a STEMI patient receiving thrombolysis, which anticoagulant should be used?

Answer 5

enoxaparin (LMWH)

This is the recommended choice for STEMI patients undergoing thrombolysis.

Question 6

If a patient’s eGFR is less than 20, what anticoagulant should be avoided?

Answer 6

fondaparinux

This is to prevent complications associated with renal impairment.

Question 7

What is the risk and action for a CURB-65 score of 0-1?

Answer 7

Risk: Low
Action: Treat at home

Antibiotics: Oral amoxicillin for 5 days.

Question 8

What is the antibiotic treatment for a CURB-65 score of 2?

Answer 8

Oral amoxicillin + clarithromycin

Consider admission or hospital-supervised care.

Question 9

What is the risk and action for a CURB-65 score of 3-4?

Answer 9

Risk: Severe
Action: Hospital admission (ward)

Antibiotics: IV co-amoxiclav + clarithromycin.

Question 10

What is the risk and action for a CURB-65 score of 5?

Answer 10

Risk: Very severe
Action: Hospital admission (HDU/ITU)

Antibiotics: IV co-amoxiclav + clarithromycin ± review for escalation.

Question 11

If a patient is penicillin allergic, what is the alternative treatment for mild CURB-65 cases?

Answer 11

Doxycycline alone

For severe cases, use levofloxacin.

Question 12

In moderate-severe CURB-65 disease, what should always be added for atypical cover?

Answer 12

A macrolide (clarithromycin)

This covers legionella and mycoplasma.

Question 13

What tests should be sent in severe CURB-65 cases?

Answer 13

Urinary legionella + pneumococcal antigens

These tests help identify specific pathogens.

Question 14

What should be followed according to local practices in CURB-65 management?

Answer 14

Local antibiotic guidelines

These guidelines may vary by hospital.

Question 15

Fill in the blank: For CURB-65 score 0-1, the simple rule is __________.

Answer 15

home + oral

Score 2 → consider admission. Score 3+ → admit + IV antibiotics. Score 5 → ITU involvement.

Question 16

What are the cardinal motor symptoms of Parkinson’s disease?

Answer 16

• Resting tremor
• Rigidity
• Bradykinesia
• Postural instability

These symptoms are the main indicators of Parkinson’s disease.

Question 17

Define resting tremor in the context of Parkinson’s disease.

Answer 17

The ‘pill-rolling’ tremor in the right hand that occurs at rest

This is a characteristic symptom of Parkinson’s disease.

Question 18

What does rigidity refer to in Parkinson’s disease?

Answer 18

‘Cogwheel’ stiffness in both arms

Rigidity is one of the cardinal motor symptoms of Parkinson’s disease.

Question 19

What is bradykinesia?

Answer 19

Slowness, shown by the shuffling gait and difficulty with fine motor tasks

Bradykinesia is a key symptom of Parkinson’s disease.

Question 20

What does postural instability imply in Parkinson’s disease?

Answer 20

Implied by the shuffling, slow gait

This is one of the cardinal motor symptoms of Parkinson’s disease.

Question 21

What is micrographia?

Answer 21

Very small handwriting, a classic PD sign

This symptom is often observed in patients with Parkinson’s disease.

Question 22

Define hypomimia.

Answer 22

Expressionless (‘masked’) face

Hypomimia is a common symptom associated with Parkinson’s disease.

Question 23

What does asymmetric onset refer to in Parkinson’s disease?

Answer 23

Symptoms started on the right side, which is typical of PD

Asymmetric onset is a common characteristic of Parkinson’s disease.

Question 24

What is a common feature of gait in Parkinson’s disease?

Answer 24

Reduced arm swing

This is often observed in patients with Parkinson’s disease.

Question 25

What does a **DaTscan** confirm in the context of Parkinson's disease?

Answer 25

Reduced dopamine transporter activity, supporting degeneration of dopamine-producing nerve cells ## Footnote This finding is consistent with Parkinson's disease.

Question 26

What profile fits a typical Parkinson's disease patient?

Answer 26

* Older age * Gradual onset over weeks * No medications that could explain the symptoms ## Footnote These factors are commonly associated with the diagnosis of Parkinson's disease.

Question 27

How does **ramipril** cause AKI?

Answer 27

Blocks angiotensin II production, preventing efferent arteriolar constriction, reducing glomerular filtration pressure ## Footnote Ramipril is an ACE inhibitor that affects renal blood flow.

Question 28

How does **ibuprofen** cause AKI?

Answer 28

Inhibits prostaglandin synthesis via COX blockade, preventing afferent arteriolar vasodilation, reducing renal blood flow ## Footnote Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can impair kidney function.

Question 29

How does **carbamazepine** cause hyponatraemia?

Answer 29

Causes SIADH — inappropriate ADH secretion causes water retention, diluting serum sodium ## Footnote Carbamazepine is an anticonvulsant that can lead to electrolyte imbalances.

Question 30

What is the mechanism of **fludrocortisone**?

Answer 30

Synthetic mineralocorticoid acting on mineralocorticoid receptors in the distal renal tubule promoting sodium reabsorption and potassium excretion ## Footnote Fludrocortisone is used in conditions like Addison's disease.

Question 31

What is the mechanism of **hydroxycarbamide** in sickle cell disease?

Answer 31

Increases fetal haemoglobin (HbF) production — HbF cannot polymerise so reduces sickling and frequency of crises ## Footnote Hydroxycarbamide is a disease-modifying therapy for sickle cell disease.

Question 32

Oral morphine to subcutaneous morphine conversion?

Answer 32

Divide total daily oral dose by 2 ## Footnote This conversion is important for managing pain in patients requiring different routes of administration.

Question 33

Oral codeine to oral morphine conversion?

Answer 33

Divide total daily codeine dose by 10 ## Footnote Understanding opioid conversions is crucial for effective pain management.

Question 34

Breakthrough morphine dose?

Answer 34

1/6 of total daily oral morphine dose ## Footnote This guideline helps in managing acute pain episodes in patients on chronic opioid therapy.

Question 35

What is the immediate treatment for **Addisonian crisis**?

Answer 35

IV hydrocortisone 100mg stat ## Footnote Prompt treatment is critical to prevent severe complications in adrenal insufficiency.

Question 36

What is first line treatment for **status epilepticus**?

Answer 36

IV lorazepam 4mg — can repeat once after 5 minutes ## Footnote Rapid intervention is necessary to control seizures effectively.

Question 37

What is second line treatment for **status epilepticus**?

Answer 37

IV phenytoin OR IV levetiracetam OR IV sodium valproate ## Footnote These medications are used if seizures persist after initial treatment.

Question 38

Group 1 licence **seizure requirements**?

Answer 38

12 months seizure free — can remain on medication ## Footnote These regulations ensure safety for drivers with a history of seizures.

Question 39

Group 2 licence **seizure requirements**?

Answer 39

5 years seizure free AND off all antiepileptic medication ## Footnote Stricter criteria apply for professional drivers to ensure public safety.

Question 40

Which vehicles require a **Group 2 licence**?

Answer 40

* HGV * Buses * Delivery vans ## Footnote Group 2 licences are necessary for larger vehicles that require additional safety considerations.

Question 41

What organism causes **meningitis** in young university students with purpuric rash?

Answer 41

Neisseria meningitidis ## Footnote This bacterium is a common cause of meningococcal disease in young adults.

Question 42

What organism causes **meningitis** in older adults and immunocompromised patients?

Answer 42

Streptococcus pneumoniae ## Footnote This organism is a leading cause of bacterial meningitis in vulnerable populations.

Question 43

What antibiotic is used to treat **bacterial meningitis**?

Answer 43

IV ceftriaxone 2g ## Footnote Ceftriaxone is a broad-spectrum cephalosporin effective against common pathogens.

Question 44

What antibiotic is given for **meningococcal prophylaxis** to close contacts?

Answer 44

Oral ciprofloxacin single dose or rifampicin twice daily for 2 days ## Footnote Prophylaxis is crucial to prevent secondary cases after exposure.

Question 45

What are the four **CSF findings** in bacterial meningitis?

Answer 45

* Cloudy appearance * Raised neutrophils * Raised protein * Low glucose ## Footnote These findings help differentiate bacterial meningitis from viral causes.

Question 46

What is **Waterhouse-Friderichsen syndrome**?

Answer 46

Bilateral adrenal haemorrhage secondary to meningococcal septicaemia causing acute adrenal insufficiency ## Footnote This syndrome is a severe complication of meningococcal infection.

Question 47

What organism commonly causes **wound infections** after abdominal surgery?

Answer 47

Gram-negative enterobacteria — E. coli ## Footnote E. coli is a frequent pathogen in post-surgical infections.

Question 48

What is **acute chest syndrome**?

Answer 48

New pulmonary infiltrates plus any of: chest pain, fever, hypoxia, tachypnoea in a sickle cell patient ## Footnote This condition is a serious complication of sickle cell disease.

Question 49

What are the immediate management steps for **acute chest syndrome**?

Answer 49

* High flow oxygen * IV fluids * IV morphine * Broad spectrum antibiotics * Exchange transfusion if severe * Haematology review ## Footnote Timely management is essential to improve outcomes in acute chest syndrome.

Question 50

What transfusion strategy is used in **severe acute chest syndrome**?

Answer 50

Exchange transfusion — not simple top up transfusion ## Footnote Exchange transfusion helps reduce sickle cell burden and improve oxygenation.

Question 51

Name 4 **long term complications** of sickle cell disease?

Answer 51

* Avascular necrosis * Stroke * Chronic kidney disease * Pulmonary hypertension * Retinopathy * Gallstones * Leg ulcers ## Footnote These complications can significantly affect the quality of life in patients with sickle cell disease.

Question 52

Why is **pethidine contraindicated** in sickle cell disease?

Answer 52

Lowers seizure threshold ## Footnote Pethidine is avoided due to its potential adverse effects in this population.

Question 53

What is **Gillick competence**?

Answer 53

A person under 16 can consent to medical treatment without parental consent if they have sufficient maturity and understanding to fully understand the procedure ## Footnote This principle allows for autonomy in young patients regarding their healthcare.

Question 54

Can a patient with **capacity** be prevented from self-discharging?

Answer 54

No — capacity means the legal right to refuse treatment even if unwise (Mental Capacity Act 2005) ## Footnote Patients have the right to make their own healthcare decisions.

Question 55

Can a **lasting power of attorney** override a valid advance decision?

Answer 55

No — a valid advance decision takes legal precedence over LPA (Mental Capacity Act 2005 s.25) ## Footnote This ensures that patients' wishes are respected even if they lose capacity.

Question 56

When can you breach **confidentiality**?

Answer 56

Risk of serious harm to others, safeguarding concerns, notifiable diseases, court order ## Footnote Confidentiality can be overridden in specific circumstances to protect individuals or the public.

Question 57

Is **euthanasia** legal in the UK?

Answer 57

No — both euthanasia and assisted suicide are illegal ## Footnote The legal framework in the UK prohibits these practices.

Question 58

Why is **vitamin K** not appropriate for a raised INR in liver disease?

Answer 58

The raised INR reflects impaired hepatic synthetic function not vitamin K deficiency — the liver cannot produce clotting factors regardless of vitamin K availability ## Footnote Management of coagulopathy in liver disease requires different approaches.

Question 59

What are the four pillars of **small bowel obstruction management**?

Answer 59

* Nil by mouth * IV fluids * NG tube decompression * Urinary catheter for fluid balance monitoring ## Footnote These steps are essential for managing patients with bowel obstruction.

Question 60

What is the **variceal bleed management** mnemonic?

Answer 60

RANT — Resuscitate, Antibiotics, Narrow portal pressure (terlipressin), Treat varices (endoscopy and band ligation) ## Footnote This mnemonic helps remember the critical steps in managing variceal hemorrhage.

Question 61

Why is oxygen only given if **SpO₂** is below 94% in STEMI?

Answer 61

Hyperoxia causes vasoconstriction and worsens myocardial injury ## Footnote Oxygen therapy should be carefully managed in acute coronary syndromes.

Question 62

What is the classic triad of **right ventricular infarction**?

Answer 62

* Hypotension * Raised JVP * Clear lung fields ## Footnote Recognizing this triad is crucial for diagnosing right ventricular involvement in myocardial infarction.

Question 63

What are the three **sick day rules** for Addison's disease?

Answer 63

* Double oral hydrocortisone dose * Carry emergency IM hydrocortisone kit * Seek urgent medical help if unable to keep tablets down ## Footnote These rules help manage adrenal insufficiency during illness.

Question 64

What is the difference between **group and save** and **crossmatch**?

Answer 64

Group and save identifies blood group and saves sample. Crossmatch physically tests compatibility with donor blood — used when transfusion is certain ## Footnote Understanding these processes is vital for safe blood transfusion practices.

Question 65

What mnemonic can be used to remember the **8 criteria for severe pancreatitis**?

Answer 65

PANCREAS ## Footnote Each letter corresponds to a specific criterion for assessing the severity of acute pancreatitis.

Question 66

What does the **P** in the PANCREAS mnemonic stand for?

Answer 66

$pO_{2} < 8$ kPa ## Footnote This indicates a low partial pressure of oxygen, which is a criterion for severe pancreatitis.

Question 67

What does the **A** in the PANCREAS mnemonic represent?

Answer 67

Age $> 55$ years ## Footnote Older age is a risk factor for severe pancreatitis.

Question 68

What does the **N** in the PANCREAS mnemonic refer to?

Answer 68

Neutrophils (WCC) $> 15 \times 10^{9}/L$ ## Footnote Elevated white cell count indicates inflammation and severity.

Question 69

What does the **C** in the PANCREAS mnemonic indicate?

Answer 69

Calcium $< 2.0$ mmol/L ## Footnote Low calcium levels can signify severe pancreatitis.

Question 70

What does the **R** in the PANCREAS mnemonic stand for?

Answer 70

Renal (Urea) $> 16$ mmol/L ## Footnote Elevated urea levels indicate renal impairment, which is a criterion for severity.

Question 71

What does the **E** in the PANCREAS mnemonic signify?

Answer 71

Enzymes (LDH $> 600$ U/L or AST/ALT $> 200$ U/L) ## Footnote High enzyme levels are indicative of severe pancreatitis.

Question 72

What does the **A** in the PANCREAS mnemonic refer to?

Answer 72

Albumin $< 32$ g/L ## Footnote Low albumin levels can indicate poor nutritional status and severity.

Question 73

What does the **S** in the PANCREAS mnemonic stand for?

Answer 73

Sugar (Glucose) $> 10$ mmol/L ## Footnote Elevated glucose levels can be a sign of stress response in severe pancreatitis.

Question 74

What is the **key rule** regarding the score for severe pancreatitis?

Answer 74

A score of 3 or more within 48 hours indicates severe pancreatitis ## Footnote This scoring system helps in the early identification of severe cases.

Question 75

What is the management approach for **intracapsular (displaced) neck of femur fractures**?

Answer 75

Requires replacing the head ## Footnote This is necessary due to likely disruption of the blood supply.

Question 76

What surgical option is used for **extracapsular neck of femur fractures**?

Answer 76

Dynamic Hip Screw (DHS) ## Footnote This method is typically used for fixation of extracapsular fractures.

Question 77

What is the recommended **surgery time** for hip fractures?

Answer 77

Within 36 hours of admission ## Footnote Timely surgery is crucial for better outcomes in hip fracture management.

Question 78

What should be monitored for **delirium** in hip fracture patients?

Answer 78

Acute drops in mental test scores ## Footnote For example, a drop from 7 to 4 in the AMT test indicates potential delirium.

Question 79

What should patients be started on before discharge to prevent future fractures?

Answer 79

* Alendronate (bisphosphonates) * Vitamin D * Calcium ## Footnote These are essential for bone protection after a hip fracture.

Question 80

What are the **King's College Criteria** for liver transplant after a paracetamol overdose?

Answer 80

Arterial pH $< 7.3$ or all three of the following: * INR $> 6.5$ * Creatinine $> 300 \mu$mol/L * Grade III/IV Encephalopathy ## Footnote Lactate $> 3.5$ is also a major red flag.