1
Q
Immediate first drug to give for suspected ACS in ED pre-hospital (unless contraindicated)
A
Aspirin 300 mg chewable immediately.
2
Q
STEMI criteria on ECG for immediate reperfusion
A
New ST elevation ≥1 mm in two contiguous limb leads or ≥2 mm in precordial leads, or new LBBB with ischaemic features; urgent reperfusion.
3
Q
Time target for primary PCI in STEMI from first medical contact
A
Ideally within 120 minutes; if not achievable give fibrinolysis if no contraindications.
4
Q
Immediate antiplatelet strategy if patient is going for PCI
A
Give aspirin and a P2Y12 inhibitor (ticagrelor preferred; prasugrel if PCI planned and no contraindications).
5
Q
When is fibrinolysis indicated for STEMI?
A
If PPCI cannot be delivered within guideline timeframes (~120 min) and no contraindications, give fibrinolysis as soon as possible.
6
Q
Initial management difference between NSTEMI and unstable angina
A
NSTEMI has raised troponin → medical therapy and risk stratification for early invasive strategy; unstable angina has normal troponin and managed conservatively unless high risk.
7
Q
High-risk features in NSTEMI prompting early invasive angiography
A
Ongoing chest pain, dynamic ECG changes, hemodynamic instability, heart failure, arrhythmia, GRACE score high.
8
Q
Drug to give for pain and anxiolysis in ACS (unless hypotensive)
A
Give nitrates (sublingual glyceryl trinitrate) for pain unless hypotension or RV infarct suspected; give morphine if severe pain and not hypotensive.
9
Q
When to give high-flow oxygen in suspected ACS?
A
Only if hypoxic (SpO2 <94%) or in respiratory distress; routine high-flow oxygen not recommended.
10
Q
Secondary prevention drugs to start before discharge after MI
A
Dual antiplatelet (aspirin + P2Y12), high-intensity statin, beta-blocker, ACE inhibitor (if indicated), and lifestyle advice.
11
Q
Contraindication to thrombolysis in recent surgery: what to consider?
A
Recent major surgery (within 3 weeks) is a relative/absolute contraindication; assess bleeding risk carefully.
12
Q
Role of cardiac biomarkers in ACS diagnosis
A
Troponin rise and/or fall with clinical context; serial measurements help distinguish NSTEMI from unstable angina.
13
Q
Initial ECG rhythm concerning for posterior MI
A
ST depression in V1–V3 may indicate posterior MI; get posterior leads (V7–V9).
14
Q
Anticoagulation choice in NSTEMI before angiography
A
Consider fondaparinux or unfractionated LMWH per protocol; follow local guidance and invasive plan.
15
Q
When to withhold beta-blockers in ACS
A
Avoid if signs of acute heart failure, bradycardia, hypotension, or risk of cardiogenic shock.
16
Q
Indication for urgent CABG in ACS
A
Left main disease, multi-vessel disease with ongoing ischaemia not amenable to PCI, mechanical complications.
17
Q
Management of ACS in pregnancy initial steps
A
Immediate management as per ACS: aspirin can be given; avoid thrombolysis if possible; liaise with obstetrics and cardiology.
18
Q
Post-MI cardiac rehab recommended timing
A
Offer cardiac rehabilitation and secondary prevention as soon as clinically stable and within weeks after discharge.
19
Q
When to suspect Takotsubo cardiomyopathy instead of ACS
A
Acute chest pain with ECG changes and troponin elevation but non-obstructed coronaries on angiography; often after emotional/physical stress.
20
Q
P2Y12 inhibitor choice if urgent surgery planned
A
If surgery likely soon, consider clopidogrel (longer stop needed) vs ticagrelor (shorter offset than prasugrel); discuss with surgeons and cardiology.
21
Q
Definition of myocardial infarction (biochemical criteria)
A
Rise and/or fall of troponin with at least one value above 99th percentile + clinical evidence of ischaemia (symptoms, ECG changes, imaging).
22
Q
When to consider early invasive strategy for ACS in elderly with comorbidities
A
Balance ischemic vs bleeding risk; consider frailty, comorbidities, and patient’s wishes; discuss MDT and geriatric input.
23
Q
BP threshold for diagnosing hypertension using ambulatory/home measurements
A
Clinic BP ≥140/90 mmHg should be confirmed with ambulatory blood pressure monitoring (ABPM) or home BP monitoring; diagnosis requires average ≥135/85 mmHg daytime ABPM.
24
Q
First-line antihypertensive for adults under 55 (no CVD) per NICE
A
ACE inhibitor (e.g., ramipril) or ARB as first-line in <55 unless contraindicated.
25
First-line antihypertensive for adults 55 or older or of Black African/Caribbean family origin
Calcium channel blocker (amlodipine) is recommended first-line for people aged ≥55 or of Black African or Caribbean family origin of any age.
26
BP target for most adults with hypertension
Aim for clinic BP <140/90 mmHg; be individualised based on comorbidities and frailty.
27
Initial step-up if BP uncontrolled on monotherapy
Use a two-drug combination: ACEi/ARB + CCB (or add thiazide-like diuretic) depending on age/ethnicity and contraindications.
28
Definition of hypertensive emergency vs urgency
Emergency: severe BP elevation with acute end-organ damage; urgency: severe BP without end-organ damage. Emergency needs immediate inpatient treatment.
29
First-line immediate drug choices for hypertensive emergency
IV agents like labetalol, nitroprusside, or nicardipine per protocol, titrated and in monitored setting.
30
When to suspect secondary hypertension (red flags)
Young age onset, resistant HTN on 3 drugs, abrupt onset, hypokalaemia, abdominal bruit, adrenal features.
31
BP management in type 2 diabetes coexisting with hypertension
Start ACE inhibitor or ARB to reduce diabetic kidney disease risk; individualise targets and monitor renal function.
32
When to measure orthostatic BP in hypertensive patient
If dizziness, syncope, or on multiple agents—measure supine and standing to assess orthostatic hypotension.
33
Choosing antihypertensives in CKD with proteinuria
Prefer ACE inhibitor or ARB titrated to highest tolerated dose for albuminuria; consider adding diuretic if needed.
34
Lifestyle measures recommended for all with hypertension
Weight loss, reduced salt intake (<6 g/day), moderate alcohol reduction, increased activity, smoking cessation.
35
BP target in older frail adults
Individualise; avoid aggressive targets in frail older people—focus on symptom control and fall risk.
36
How to interpret home BP readings vs clinic
Home averages tend to be lower; use ABPM to confirm; home target ~135/85 daytime equivalent.
37
Monitoring after starting/changing antihypertensive therapy
Check renal function, electrolytes (K+), and BP within 1–2 weeks of starting ACEi/ARB or diuretics.
38
Preferred diuretics for hypertension per NICE
Use thiazide-like diuretics (indapamide or chlortalidone) rather than bendroflumethiazide where possible.
39
Pregnancy considerations: which antihypertensives to avoid
Avoid ACE inhibitors and ARBs in pregnancy and breastfeeding; use labetalol, nifedipine MR, or methyldopa.
40
When to initiate antihypertensive treatment in clinic depending on CV risk
Consider earlier treatment if BP high and QRISK2 high; treat based on overall cardiovascular risk and BP level.
41
Resistant hypertension next steps after maxed meds
Check adherence, consider secondary causes, add spironolactone if appropriate, refer to specialist.
42
First-line pharmacological treatment for T2DM
Offer metformin with lifestyle advice unless contraindicated; consider renal function and GI side-effects.
43
When to consider starting insulin in T2DM
If symptomatic hyperglycaemia or very high glucose or A1c despite oral agents, or during acute illness; consider as rescue therapy.
44
GLP-1 receptor agonist roles in T2DM per NICE
Use for people with BMI ≥35 with specific complications or where insulin would otherwise be needed; check current NICE criteria.
45
SGLT2 inhibitor benefits beyond glucose control
Reduce CV and renal outcomes in people with T2DM and established CVD or CKD; consider in appropriate patients.
46
HbA1c target for most non-pregnant adults with T2DM
Aim for individualized targets; commonly around 48 mmol/mol (6.5%) to 58 mmol/mol (7.5%) depending on comorbidities.
47
Foot care red flags in T2DM requiring urgent referral
Ulceration, infection, necrosis, severe peripheral arterial disease, or signs of systemic infection—refer to multidisciplinary foot service.
48
When to offer statin therapy in T2DM
Offer moderate or high-intensity statin for primary prevention depending on age and CV risk; many adults with T2DM qualify.
49
Diabetic nephropathy monitoring frequency
Check urine albumin-to-creatinine ratio (ACR) and eGFR at diagnosis and at least annually.
50
Managing hypoglycaemia risk when adding sulfonylureas
Warn about hypoglycaemia; consider in older adults with caution; advise on recognition and treatment.
51
Perioperative management of T2DM on oral meds
Hold SGLT2 inhibitors 3 days before major surgery; follow trust guidelines for other agents and insulin adjustment.
52
When is metformin contraindicated or needs review?
Renal impairment (eGFR <30 ml/min) is contraindication; use caution and review if eGFR 30–45.
53
Criteria for considering dual therapy early in T2DM
If HbA1c ≥58 mmol/mol on metformin or high baseline HbA1c, consider adding another agent like SGLT2 or DPP4/GLP1 as appropriate.
54
T2DM and empagliflozin: when to consider
In patients with established cardiovascular disease or CKD to reduce CV/renal events (check eGFR thresholds).
55
Vaccination advice for patients with T2DM
Offer annual flu vaccine and pneumococcal vaccine per schedule and consider shingles as indicated.
56
Acute hyperosmolar hyperglycaemic state (HHS) distinguishing feature vs DKA
Very high glucose (often >30 mmol/L) with high osmolality, minimal ketones, and profound dehydration; often in T2DM.
57
When to refer T2DM patients for bariatric surgery consideration
Consider if BMI ≥35 with poor glycaemic control despite optimal therapy and complex management, per local criteria.
58
Monitoring frequency for HbA1c in stable T2DM
Every 3–6 months until stable, then at least every 6 months once at target.
59
Addressing microvascular complications screening in T2DM
Annual retinal screening, annual foot exam, annual ACR/eGFR monitoring.
60
Hypoglycaemia management for someone on insulin or sulfonylurea
Use fast-acting carbohydrate (oral glucose) if conscious; IM glucagon or IV dextrose if unconscious; follow with longer-acting carb.
61
Preferred reliever strategy per 2024 NICE/BTS for adults: what's recommended over SABA-only?
Use ICS/formoterol MART or Anti-Inflammatory Reliever (AIR) strategy for adults where licensed; avoid SABA-only regimen if possible.
62
What to do if an adult asthmatic on MART is using reliever inhaler >2 times/week for symptoms
Review control, inhaler technique, adherence, triggers; consider stepping up treatment and ensure written action plan.
63
Acute severe asthma initial management (oxygen target)
Give oxygen to maintain SpO2 94–98% (unless COPD overlap needing 88–92%), give high-flow bronchodilator therapy and systemic steroids early.
64
When to give oral steroids for an asthma exacerbation in adults
If moderate/severe exacerbation or poor response to bronchodilators, give prednisolone 40–50 mg daily for 5 days (local protocols may vary).
65
Criteria for hospital admission after an asthma exacerbation
Persistent hypoxia, inability to talk, exhaustion, rising CO2, poor response to treatment, or social reasons.
66
Long-term controller options for adult asthma
Low/medium/high dose ICS; add LABA, LAMA or biologics for severe asthma per phenotype and referral to specialist.
67
Peak flow variability significance in asthma monitoring
Diurnal variability >20% suggests poor control; use with symptoms and other measures.
68
Advice regarding exercise-induced bronchoconstriction
Use pre-exercise inhaled SABA or use MART strategy; ensure warm-up and consider controller therapy if frequent.
69
First-line reliever and controller strategy in children under 5
Focus on assessing viral wheeze vs asthma; use SABA for relief; low threshold for specialist referral if recurrent severe episodes.
70
Asthma step up in older children/adolescents
Start low-dose ICS if symptoms >2/week or night symptoms; add LABA or increase ICS dose per guideline; consider MART in adolescents as licensed.
71
Growth monitoring with inhaled steroids in children
Use the lowest effective ICS dose; monitor growth regularly and discuss risk/benefit with parents.
72
When to consider referral to specialist for suspected difficult/severe asthma in children
Poor control despite adherence, frequent exacerbations, need for oral steroids, diagnostic uncertainty, or unusual features.
73
Child with acute wheeze and severe respiratory distress immediate step
Call for senior help, oxygen to target >=94%, high-dose inhaled bronchodilator, consider IV magnesium if life-threatening.
74
Inhaler technique checks frequency in asthma
Check inhaler technique at every review and after exacerbations.
75
Indications for written asthma action plan
Provide to all patients with asthma to guide self-management and when to seek help.
76
Role of FeNO in asthma diagnosis
FeNO may support diagnosis of eosinophilic asthma and steroid responsiveness; interpret in clinical context.
77
Smoking advice for asthma patients
Advise cessation; smoking reduces response to steroids and increases exacerbation risk.
78
Immediate first step on finding an adult unresponsive and not breathing normally
Call for help, shout for assistance, send for AED, start high-quality CPR (30:2) and call emergency services.
79
Compression:ventilation ratio for adult single rescuer CPR
30 compressions : 2 ventilations.
80
When to use defibrillation and what are shockable rhythms
Shockable rhythms: VF and pulseless VT — deliver immediate defibrillation (unsynchronised shock) and resume CPR.
81
Adrenaline dosing during cardiac arrest (adult)
Adrenaline 1 mg IV/IO every 3–5 minutes during cardiac arrest.
82
Amiodarone dosing for shockable cardiac arrest
Amiodarone 300 mg IV bolus after 3rd shock; 150 mg further bolus if required.
83
When to consider reversible causes (4 Hs and 4 Ts)
Always consider hypoxia, hypovolaemia, hypo/hyperkalaemia/metabolic, hypothermia; and tension pneumothorax, tamponade, toxins, thrombosis (PE/MI).
84
Post-ROSC target blood pressure and initial care
Aim MAP ≥65 mmHg, treat reversible causes, consider targeted temperature management per local protocol and urgent coronary angiography if indicated.
85
When to stop resuscitation (general considerations)
Consider duration, reversible causes treated, ROSC unlikely despite good quality CPR and escalating measures; discuss with team and follow local guidance.
86
CPR ratio and differences for paediatric cardiac arrest (single rescuer)
15 compressions : 2 ventilations for children if single rescuer trained in paediatric CPR (infants/children).
87
When to give calcium during cardiac arrest
Give calcium if hypocalcaemia, calcium channel blocker overdose, or hyperkalaemia suspected; not routinely.
88
Use of mechanical chest compression devices in prolonged arrest
Consider mechanical devices if sustained high-quality manual compressions not possible, e.g., during transport.
89
Shock sequence during resuscitation for VF/VT
Shock — CPR 2 min — rhythm check — repeat shocks as per algorithm; give adrenaline and amiodarone as indicated.
90
Recognising PEA and immediate management
Pulseless electrical activity: continue CPR, give adrenaline, search/treat reversible causes (Hs and Ts).
91
Ventilation rate during advanced life support with advanced airway
One breath every 6 seconds (~10 breaths/min) without interrupting chest compressions.
92
Role of targeted temperature management post-cardiac arrest
Consider targeted temperature management for comatose adults after ROSC per local protocol; discuss benefits/risks.
93
When to perform immediate coronary angiography after ROSC
Suspected cardiac cause (e.g., STEMI) or ongoing instability—consider urgent angiography in discussion with cardiology.
94
First-line reliever strategy for newly diagnosed adult asthma (2024 NICE/BTS/SIGN): what is recommended?
Use an anti-inflammatory reliever (AIR) strategy or MART (maintenance and reliever therapy) with an ICS/formoterol; avoid SABA-only reliever where possible.
95
What inhaler type is contraindicated as sole reliever therapy under the new guidance?
Short-acting beta2-agonist (SABA)-only regimens (e.g., salbutamol) are discouraged as sole reliever therapy due to risk of overuse and poor outcomes.
96
Which inhalers are licensed for reliever use in MART/AIR?
Only certain low-dose ICS/formoterol combinations that are licensed for reliever use (check product SPC). Always check licence before MART/AIR.
97
Acute severe asthma initial immediate steps (first 5 minutes) in ED/ambulance
High-flow oxygen to maintain SpO2 94-98% (or 88-92% if COPD overlap), rapid-acting bronchodilator (nebulised/MDI with spacer), send arterial blood gas if cyanosed/very unwell; call senior/respiratory. Consider IV steroids if not already given.
98
Adult asthma exacerbation: when to give oral corticosteroids?
If not responding rapidly to bronchodilator therapy or moderate/severe exacerbation — give oral prednisolone 40-50 mg once daily (or equivalent) for 5 days (local protocols may vary).
99
When should you consider hospital admission for asthma exacerbation?
Persistent hypoxia, inability to complete sentences, exhaustion, rising PaCO2, poor response to initial therapy, or social factors that limit home care.
100
Wells score for PE: what are the key components used to stratify pre-test probability?
Clinical signs of DVT, alternative dx less likely than PE, HR>100, immobilisation/surgery in last 4 weeks, previous DVT/PE, haemoptysis, active cancer. Use score to guide D-dimer vs imaging.
101
Initial investigation for suspected PE in a low/moderate probability patient
D-dimer test first; if raised (age-adjusted), proceed to CTPA (or V/Q if CTPA contraindicated).
102
Immediate anticoagulation decision in suspected PE before imaging
If high clinical suspicion and delay to imaging, start therapeutic anticoagulation unless contraindicated (typically LMWH/DOAC per local guidance).
103
Thrombolysis indication in PE
Massive PE with haemodynamic instability (shock, persistent hypotension) is an indication for systemic thrombolysis, after weighing bleeding risk.
104
Diagnostic criteria for DKA (adults): key biochemical features
Hyperglycaemia (usually glucose >11 mmol/L), ketonaemia/ketonuria (blood ketones >3 mmol/L or significant urine ketones), metabolic acidosis (venous pH <7.3 or bicarbonate <15 mmol/L).
105
Initial fluid management in DKA
Start with 0.9% saline bolus (e.g., 1 L over first hour) unless contraindicated, then reassess; follow local DKA protocol for further fluid replacement and potassium management.
106
Insulin therapy in DKA after initial fluids
Give fixed-rate IV insulin infusion (e.g., 0.1 units/kg/hr) after initial fluid resuscitation and ensure serum potassium is >3.5 mmol/L before starting; transition to subcutaneous insulin when ketones resolved and patient eating.
107
Potassium replacement rules in DKA
If K+ <3.5 mmol/L: replace and do NOT start insulin until K+ corrected; if 3.5–5.5 give replacement on protocol; if >5.5 withhold K+ replacement.
108
'Sepsis 6' initial bundle actions
Deliver high-flow oxygen, take blood cultures, give IV antibiotics, give IV fluids, measure lactate and urine output; begin within 1 hour for suspected sepsis/septic shock.
109
Blood pressure target and vasopressors in septic shock
Target MAP ≥65 mmHg; start noradrenaline if hypotension persists after fluid resuscitation.
110
Empirical antibiotics for community-acquired sepsis in previously well adult (within 1 hour)
Administer broad-spectrum IV antibiotics according to local guideline and likely source (e.g., ceftriaxone + metronidazole for intra-abdominal; check local trust empiric sepsis guidelines).
111
BP thresholds defining hypertension in pregnancy
BP ≥140/90 mmHg on two occasions defines hypertension; severe hypertension is ≥160/110 mmHg.
112
First-line antihypertensive choices in pregnancy and exception
First-line: labetalol or nifedipine MR; methyldopa is alternative. Avoid ACE inhibitors and ARBs. If patient has asthma, avoid labetalol—use nifedipine.
113
Acute severe hypertension in pregnancy immediate management
Aim to lower BP promptly using IV labetalol, IV hydralazine or oral nifedipine per local protocol; target reduction to <160/110 first, avoid precipitous drops.
114
Immediate management difference between STEMI and NSTEMI
STEMI: urgent reperfusion (primary PCI within 120 minutes or fibrinolysis if delay) + dual antiplatelet; NSTEMI: risk stratify and medical therapy, consider early invasive strategy depending on risk.
115
Initial antiplatelet therapy for suspected ACS pre-PCI
Give aspirin 300 mg chewable immediately; give P2Y12 inhibitor (ticagrelor/prasugrel) guided by planned PCI and bleeding risk.
116
When is fibrinolysis appropriate in STEMI?
If PPCI cannot be delivered within recommended timeframes (eg >120 minutes from first medical contact) and no contraindications, give fibrinolysis.
117
Time window for IV alteplase in ischaemic stroke (standard)
Up to 4.5 hours from onset in eligible patients (earlier is better). Selection criteria apply; follow local stroke protocol.
118
BP threshold for giving thrombolysis in ischaemic stroke
Systolic BP should be <185 mmHg and diastolic <110 mmHg before thrombolysis; if higher, lower BP cautiously prior to thrombolysis.
119
Indication for mechanical thrombectomy in stroke
Large vessel occlusion within a longer time window (up to 24 hours in selected patients based on imaging/perfusion) may be eligible for thrombectomy.
120
First-line drug and dose for adult anaphylaxis
Intramuscular adrenaline (epinephrine) 500 micrograms (0.5 mg) into mid-anterolateral thigh; repeat every 5 minutes as needed.
121
Positioning and immediate supportive measures in anaphylaxis
Lay patient flat with legs elevated (unless vomiting/respiratory distress), call for help, oxygen, high-flow, secure airway, IV fluids for hypotension.
122
Immediate management if bacterial meningitis is suspected and LP will be delayed
Give immediate empirical IV antibiotics (e.g., ceftriaxone ± ampicillin depending on age/immune status) and steroids (dexamethasone) where indicated before imaging/LP.
123
When to defer lumbar puncture prior to neuroimaging
If focal neurological signs, papilloedema, seizures, or reduced consciousness—perform CT head before LP.
124
When to stop or adjust ACE inhibitors/ARBs in AKI or rising creatinine
If creatinine rises >30% after starting ACEi/ARB or potassium >5.5 mmol/L, review and consider stopping; manage cause and re-evaluate.
125
CKD and drug dosing principle
Many drugs require dose adjustment in reduced eGFR (e.g., NOACs, antibiotics); always check renal function and local guidance for dosing.
126
When is warfarin preferred over DOACs?
Warfarin preferred in mechanical heart valves, moderate–severe mitral stenosis, pregnancy, or when monitoring/interaction management is needed.
127
Immediate reversal for major bleeding on warfarin vs apixaban
Warfarin: give prothrombin complex concentrate (PCC) + vitamin K; DOACs: specific reversal agents (e.g., idarucizumab for dabigatran) or PCC depending on agent and availability.
128
Management of severe hypoglycaemia (unable to swallow) in the community
Give IM glucagon (1 mg adult) or IV 50% dextrose (20 ml) if IV access; once conscious, give long-acting carbohydrate and review insulin regimen.
129
Immediate glucose target after treating hypoglycaemia
Aim to raise blood glucose to >4 mmol/L and ensure sustained by giving oral carbohydrate when able.
130
Which valvular lesion typically produces a crescendo-decrescendo ejection systolic murmur at the right 2nd intercostal space radiating to the carotids?
Aortic stenosis — crescendo-decrescendo ejection systolic murmur at R 2nd ICS, radiates to carotids; accentuated by sitting forward and expiration; quieter with Valsalva.
131
Describe the murmur of aortic stenosis: timing, best heard where, radiation and maneuvers that accentuate it.
Ejection systolic crescendo‑decrescendo murmur, best at R 2nd ICS (aortic area), radiates to carotids, increases with sitting forward/expiration, decreases with Valsalva.
132
Which valvular lesion causes a pansystolic (holosystolic) murmur best heard at the apex and radiating to the axilla?
Mitral regurgitation — pansystolic murmur at apex radiating to axilla; louder with handgrip and squatting; quieter with Valsalva.
133
Describe the murmur of mitral regurgitation: timing, best heard where, radiation and maneuvers that accentuate it.
Pansystolic (holosystolic) murmur throughout systole, best at apex (5th ICS MCL), radiates to axilla. Louder with increased afterload (handgrip) and squatting; quieter with Valsalva.
134
Which murmur is a low-pitched diastolic rumble with an opening snap best heard at the apex in the left lateral position?
Mitral stenosis — low-pitched diastolic rumble with opening snap after S2, best at apex in left lateral position; louder with expiration.
135
Describe the murmur of mitral stenosis and which maneuvers accentuate it.
Low-pitched diastolic rumble with opening snap after S2, best at apex in left lateral; louder with expiration and increased flow states.
136
Which murmur produces an early diastolic decrescendo (blowing) murmur heard best at the left sternal edge when leaning forward?
Aortic regurgitation — early diastolic decrescendo 'blowing' murmur best at left sternal edge when sitting/leaning forward; wide pulse pressure may be present.
137
Describe the murmur of aortic regurgitation and maneuvers that accentuate it.
Early diastolic high-pitched 'blowing' decrescendo murmur at left sternal edge; accentuated by sitting forward and expiration; increased with handgrip in chronic AR.
138
Which lesion causes a holosystolic murmur that increases with inspiration and is heard best at the left lower sternal border?
Tricuspid regurgitation — holosystolic murmur at LLSB, increases with inspiration (Carvallo's sign).
139
Describe the murmur of tricuspid regurgitation and how to differentiate clinically from MR.
Pansystolic murmur best at LLSB; increases with inspiration (right-sided); MR radiates to axilla and increases with handgrip instead.
140
Which murmur is a systolic ejection murmur heard at the left upper sternal border with a wide split S2, often in congenital disease?
Pulmonary stenosis — systolic ejection murmur at L 2nd/3rd ICS with ejection click and wide split S2; louder on inspiration.
141
Describe a murmur that increases on inspiration and is heard at the left upper sternal border — what is likely?
Right-sided lesions (pulmonary stenosis or increased flow). Inspiratory accentuation suggests right-sided origin.
142
Which lesion causes a loud pansystolic murmur at the left lower sternal border often heard in childhood?
Ventricular septal defect (VSD) — loud pansystolic murmur at LLSB; small VSDs louder, large VSDs may have signs of heart failure.
143
If you hear a loud pansystolic murmur at the left lower sternal border in a child, what is a likely cause?
Small VSD — loud pansystolic murmur at LLSB in children.
144
Which condition produces a harsh systolic murmur that increases with Valsalva and decreases with handgrip?
Hypertrophic obstructive cardiomyopathy (HOCM) — murmur increases with Valsalva/standing (reduced preload) and decreases with handgrip/squatting.
145
Describe the murmur of HOCM and the manoeuvres that change its intensity.
Harsh midsystolic murmur at left sternal border; increases with Valsalva/standing; decreases with squatting/handgrip.
146
Continuous 'machinery' murmur best heard in left infraclavicular area — what's the lesion?
Patent ductus arteriosus (PDA) — continuous machine-like murmur best heard left infraclavicular area.
147
If you hear a continuous machine-like murmur beneath the left clavicle, which lesion should you suspect?
Patent ductus arteriosus (PDA).
148
Soft, early to mid-systolic flow murmur in children that decreases when sitting or with Valsalva — what is this likely?
Innocent (Still's) murmur — musical/vibratory mid-systolic murmur common in children.
149
Describe features that suggest an innocent flow murmur rather than pathological murmur.
Soft, short systolic murmur, varies with position, no other signs (no thrill, normal ECG/CXR), common in children/young adults.
150
Name the drug class of metformin and give one key mechanism of action.
Biguanide — Metformin: reduces hepatic gluconeogenesis and increases peripheral insulin sensitivity.
151
Give an example drug from the biguanide class used in T2DM.
Metformin.
152
Name the class and an example of a drug that stimulates insulin secretion by binding to K-ATP channels in beta-cells.
Sulfonylureas — example: Gliclazide (also glimepiride, glibenclamide).
153
Give an example of a meglitinide and its clinical use.
Repaglinide — short-acting secretagogue used for post-prandial glucose control.
154
Which antidiabetic class includes sitagliptin and what is its mechanism?
DPP-4 inhibitors (gliptins) — inhibit DPP-4 to increase endogenous incretins (GLP-1/GIP) leading to glucose-dependent insulin release.
155
Name a GLP-1 receptor agonist and one extra-glycaemic benefit.
Liraglutide (semaglutide) — benefits include weight loss and reduced CV risk in select populations.
156
Give an example of an SGLT2 inhibitor and two non-glycaemic benefits.
Dapagliflozin, empagliflozin — reduce HF hospitalisations and slow CKD progression.
157
Which class does pioglitazone belong to and what is its mechanism?
Thiazolidinediones (TZDs) — PPAR-gamma agonists that increase insulin sensitivity.
158
Name rapid-acting insulin analogues and their timing of use.
Insulin aspart, lispro, glulisine — given at mealtimes for post-prandial control.
159
Name long-acting basal insulin analogues.
Insulin glargine, detemir, degludec — used for background basal insulin.
160
List common side effects of metformin and a rare but serious adverse effect to monitor for.
Common: GI upset (diarrhoea, nausea). Rare but serious: lactic acidosis (risk increased in severe renal impairment).
161
Metformin major contraindications and monitoring requirements.
Contraindications: eGFR <30 mL/min/1.73 m2. Cautions if eGFR 30–45; withhold for contrast/acute illness. Monitoring: baseline and annual eGFR, consider B12 if symptomatic.
162
Key adverse effect of sulfonylureas and a main contraindication.
Adverse effect: hypoglycaemia, weight gain. Caution/avoid in frail elderly and those at risk of severe hypoglycaemia.
163
Monitoring and patient advice for someone started on gliclazide.
Advise on hypoglycaemia recognition, carry glucose; monitor capillary glucose where indicated; review renal function and interactions.
164
Main advantage and side effect of meglitinides (repaglinide).
Short-acting → lower prolonged hypoglycaemia risk; side effect = hypoglycaemia, weight gain.
165
Main benefits and adverse effects of DPP-4 inhibitors (sitagliptin).
Weight neutral, low hypoglycaemia risk; rare reports of pancreatitis, joint pain.
166
DPP-4 inhibitors monitoring and cautions.
Adjust dose in renal impairment as required (e.g., sitagliptin); caution in history of pancreatitis.
167
List common side effects and a key contraindication for GLP-1 receptor agonists.
Side effects: nausea, vomiting, decreased appetite, weight loss. Contraindications: personal/family history of medullary thyroid carcinoma or MEN2 (agent-specific warnings).
168
GLP-1 receptor agonists monitoring and patient counselling points.
Monitor for persistent severe abdominal pain (pancreatitis); counsel on GI side effects and gradual dose titration to reduce nausea.
169
Common side effects and serious cautions for SGLT2 inhibitors.
Genital mycotic infections, polyuria, volume depletion; rare but serious euglycaemic DKA; caution in low eGFR, frail/elderly, and perioperative periods.
170
SGLT2 inhibitors monitoring essentials.
Baseline eGFR, periodic renal monitoring, advise to stop before major surgery (~48–72 hrs), monitor for signs of DKA and genital infections.
171
Major adverse effects and contraindications of pioglitazone (TZD).
Adverse effects: fluid retention, weight gain, risk heart failure exacerbation; avoid in symptomatic heart failure; liver impairment caution.
172
TZD monitoring recommendations.
Monitor weight, signs of heart failure, and LFTs at baseline; avoid in active hepatic disease.
173
Key risks and monitoring for insulin therapy.
Risks: hypoglycaemia, weight gain. Monitor capillary glucose, HbA1c, adjust doses for renal impairment, and educate on hypoglycaemia management.
174
Which patients require caution with insulin dose adjustments (renal/hepatic disease)?
Renal impairment reduces insulin clearance → increased hypoglycaemia risk; reduce doses and monitor closely. Hepatic impairment may reduce insulin needs.
175
What monitoring is required after initiating an ACE inhibitor or ARB?
Check BP, serum creatinine and electrolytes (K+) within 1–2 weeks after initiation or dose change; stop/adjust if creatinine rises >30% or K+ >5.5 mmol/L.
176
Baseline and ongoing monitoring recommended for statin therapy.
Baseline LFTs; routine repeat LFTs not required unless symptomatic. Monitor for muscle symptoms; check CK if myopathy suspected.
177
Monitoring required for warfarin therapy.
INR monitoring regularly; adjust dosing to target INR; monitor for bleeding and interactions.
178
Monitoring for lithium therapy.
Baseline renal function, thyroid function; monitor serum lithium levels (steady state, after dose changes), renal and thyroid periodically.
179
Monitoring for aminoglycoside antibiotics (gentamicin).
Therapeutic drug monitoring with trough/peak levels per local protocol; monitor renal function and hearing.
180
Monitoring for vancomycin therapy.
AUC-guided or trough monitoring per local protocol; monitor renal function and ototoxicity risk.
181
Monitoring for amiodarone therapy.
Baseline TFTs, LFTs, CXR if indicated; monitor TFTs and LFTs periodically (e.g., every 3–6 months); watch for pulmonary, thyroid, hepatic toxicity.
182
Monitoring for methotrexate (low-dose) therapy.
Baseline FBC, LFTs, renal function; regular FBC and LFT monitoring during treatment; counsel on contraception.
183
Monitoring for carbamazepine therapy.
Baseline and periodic LFTs, FBC (risk of agranulocytosis), drug levels as indicated; counsel re: interactions and teratogenicity.
184
Monitoring and counselling for patients starting systemic corticosteroids long-term.
Monitor blood glucose, BP, weight, lipids, bone health; consider bone protection; counsel on infection risk and steroid withdrawal.
185
Monitoring for patients started on metformin relating to rare adverse effect.
Baseline and periodic eGFR monitoring; advise withholding metformin during acute illness/contrast; consider B12 if neuropathy or macrocytic anaemia.
186
Neonatal Pan-systolic
VSD
187
Neonatal Systolic and Diastolic
PDA
188
Neonatal Ejection Systolic
ASD
189
Neonatal Early Diastolic
Pulmonary or Aortic regurg
190
Neonatal Late Systolic
Coarctation of aorta or mitral prolapse
191
Gram-positive cocci?
Staphylococci (clusters), Streptococci (chains), Enterococci.
192
Gram-positive rods?
Listeria, Bacillus, Clostridium, Corynebacterium.
193
Gram-negative cocci?
Neisseria meningitidis, Neisseria gonorrhoeae.
194
Gram-negative rods?
Enterobacteriaceae, Klebsiella, E. coli, Pseudomonas.
195
Cavitating pneumonia post-stroke?
Klebsiella (aspiration risk ↑).
196
Bacterial cause of rusty sputum?
Streptococcus pneumoniae.
197
Cause of bullous myringitis?
Mycoplasma pneumoniae.
198
Rapidly progressive necrotising fasciitis?
Group A Strep (S. pyogenes).
199
Pseudomembranous colitis organism?
C. difficile.
200
Who gets Pseudomonas infections?
CF patients, burns, ventilated patients.
201
When to use Mann–Whitney U test?
Comparing medians of two independent non‑parametric groups.
202
When to use unpaired t‑test?
Comparing means of two independent parametric groups.
203
When to use paired t‑test?
Comparing means of paired/related parametric samples.
204
When to use chi‑square test?
Comparing proportions between categorical groups.
205
When to use ANOVA?
Comparing means across >2 parametric groups.
NICE guideline
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