1.

Define TIA
- Less than 24hrs + dysfunction of brain/spinal cord/retinal ischaemia without infarction
2. Clinical feature of TIA
- Amaurosis fugax --> blindness in 1 eye
3. Management of TIA
- High risk for stroke/MI --> refer to TIA clinic for 300mg of aspirin
4. Symptoms of bradycardia
- Hypotension, shock, chest pain and syncope
5. Management for initial and unstable bradycardia
- Initial = ABCDE/ECG
- Unstable = atropine/isoprenalin + pacing
6. Bradycardia and risk of asystole
- Risk of asystole = ventricular pause + morbitz type II
7. Screening programme for breast cancer
- ALL women screened between 47-73 years old --> mammograms offered earlier if have
positive family history
8. Describe the criteria for cancer referral for breast cancer?
- Refer within 2 weeks --> 30+ with unexplained breast lump/axilla lump with/without pain,
50+ with nipple discharge/retraction
- Also refer for skin changes = tethering/ peu d'orange
- Non-urgent referral = 30- with breast lump with/without pain
9. Most common lung cancer in NON-smoker
- Adenocarcinoma
10. Types of migraines
- Common migraines = 75% --> migraines without aura
- Classical migraines = 25% --> migraines with aura = visual changes e.g. hemianopia (zigzag
lines) and spreading scotoma
- Hemiplegic migraines = rare --> similar to stroke = hemiplegia (unilateral weakness) and
ataxia
11. Define Breslow’s thickness
- Breslow's thickness = 1mm>, 1-2mm, 2-4mm, 4mm< --> deeper the melanoma = lower rate
of survival
12. TNM staging
- T = tumour --> thickness of melanoma = T0-T4
- N = Node --> cancer cells found in lymph node = N0-N3
- M = metastasis --> cancer cells found in different part of body = M0-M1
13. Causes of large bowel obstruction
- Colorectal cancer (MOST common cause), colonic volvulus (sigmoid volvulus most common,
sigmoid colon twists around sigmoid mesocolon)
14. Presentation of large bowel obstruction
- Abdo pain, bloating, vomiting/nausea, constipation
15. Examination findings of large bowel obstruction
- Abdo distention, high pitch bowel sounds which later disappear
16. Investigation of large bowel obstruction
- CT
17. Management of large bowel obstruction
- Rectal tube and surgery
18. Define Bell’s Palsy
- Acute LMN unilateral facial weakness BUT spares extraocular muscles and mastication
muscles
19. Co-comittant signs of Bell’s Palsy
- Postauricular otalgia, hyperacusis, naevus intermedius symptoms (altered taste, dry
mouth/eyes)
20. Management of Bell’s Palsy
- 50mg predisolone for 10 days + ocular lubrication
21. Causes of acute lower GI bleed
- Diverticular disease (MAIN), colitis, cancer, haemorrhoids and angiodysplasia
22. Investigations for acute lower GI bleed
- Colonscopy/protocscopy/PR/CT
- Recommendations for hospital addmission = 60+, haemodynamic unstable, taking
aspirin/NSAIDs, co-morbidities
23. Types of inguinal hernia
- Direct (through posterior wall of inguinal canal through Hesselbach's triangle = LESS
common and acquired form)
- Indirect (through inguinal canal = MORE common + congenital form)
- Hesselbach's Triangle = inguinal ligament, rectus abdominis and inferior epigastric vessel -->
direct is medial inferior epigastric vessels and indirect is lateral inferior epigastric vessel
24. Inducing remission of ulcerative colitis from mild/moderate and severe
- Mild/moderate (1st line aminosalicylates e.g. mesalazine, 2nd line steroids), severe (1st line
IV steroids, 2nd line IV ciclosporin)
25. Maintaining remission of ulcerative colitis
- 1st line aminosalicylates, then azathioprine/mercaptopurine
26. Surgical management of ulcerative colitis
- Removal of colon/rectum in panprotolectomy and then ileostomy (J pouch for ileo-anal
anastamosis)
27. Causes of acute pancreatitis
- Idiopathic
- Gall stones
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion venom
- Hypertriglyceridaemia/hypercalcaemia/hypothermia
- ERCP
- Drugs (azathioprine/mesalazine)
30. Signs of PE
- Fleischner sign = enlarged pulmonary artery
- Hampton's hump = peripheral wedge opacity
- Westermark's sign = regional oligaemia
31. Imaging in PE
- VQ scan instead of CTPA = renal impairment, contrast allergy and pregnancy
- Lower limb duplex = 1st line in pregnancy
- Echo = massive PE --> assess suitability for thrombolysis
32. Signs of delirium
- Carphology = picking things out of air / plucking at clothes --> hypoactive delirium
- Positive Oblique sign = lying diagnol
33. Secondary management for MI (6As)
- Aspirin 75mg
- Another antiplatelet
- Atorvastatin 80mg
- ACE inhibitor (10mg of ramipril)
- Atenolol beta blockers
- Aldosterone antagonist for clinical heart failure (epleronone 50mg)
- LIFESTYLE modifications are important
34. Ejection systolic murmur associated with aortic stenosis
35. Avoid antibiotics in E.coli causing gastroenteritis as increases risk of haemolytic uraemic
syndrome
36. E.coli causing gastroenteritis produces shiga toxin --> causes abdo cramp/bloody
diarrhoea/vomiting + breaks RBCs to cause haemolytic uraemic syndrome
37. Grave’s disease most common cause of hyperthyroidism – due to IgG antibodies binding to
TSH receptor which causes excess production of thyroid hormone and also bind to other
areas of the body such as the extraocular muscles leading to gaze abnormalities, the shins
causing raised lesions known as ‘pretibial myxoedema’/painful lesions and rarely the fingers
causing clubbing known as ‘thyroid acropachy
38. De Quervain’s thyroiditis (A) is a transient thyroid state most likely due to a viral infection –
clinical features include fever and painful neck with signs of hyperthyroidism e.g. tachycardia
and raised ESR level. A few weeks later, the patient suffers from transient hypothyroid
symptoms before returning to a euthyroid state.
39. Phaeochromocytoma are malignancies of the sympathetic nervous system, 90 per cent arise
in the adrenal medulla and produce excess catecholamines. The symptoms of a
phaeochromocytoma are often similar to hyperthyroidism and include anxiety, palpitations
and headache. However, these symptoms are usually intermittent and the main risk to
patients is from cardiovascular compromise.
40. Plummer’s disease (E) is a solitary nodule in the thyroid gland producing excess thyroid
hormones. It is usually refractory to antithyroid treatment.
41. Thyroid storm or crisis (B) is a rapid deterioration in patients suffering from hyperthyroidism,
often stimulated by a stressor such as infection. Patients present with acute-onset, severe
tachycardia, distress and hyperpyrexia.
42. CT scan with contrast is the most definitive investigation for aortic dissection vs// CXR, signs
may include a widened mediastinum and irregular aortic contours, while on ECG signs may
mimic findings of an acute ischaemia. ST segments may be elevated or depressed depending
on the location of the dissection.
43. Hemiplegia = paralysis vs// hemiparesis = weakness resulting in pressure sore or decubitus
ulcer due to lack of mobility resulting in decreased perfusion
44. Coeliac disease: T cell mediated autoimmune disease of the small bowel characterised by
intolerance to wheat, barley, rye and oats leading to villous atrophy and malabsorption.
Present with steatorrhoea, diarrhoea, abdominal pain and bloating, nausea and vomiting,
signs of microcytic anaemia (secondary to iron deficiency) or macrocytic anaemia (secondary
to vitamin B12 or folate deficiency), weight loss, failure to thrive in children.
45. Diagnostic test for coeliac disease:
- Testing for antibodies: α-gliadin, tissue transglutaminase (anti-tissue transglutaminase
antibodies) and anti-endomysial (an IgA antibody which is 95 per cent specific for coeliac
disease unless the patient is IgA deficient);
 - Duodenal biopsy which can be performed at upper GI endoscopy.
46. Sodium valproate = enhances GABA BUT is teratogenic
47. Carbamezapine = induces CYP450 SO interacts with other drugs
48. Community based treatment for epilepsy:
- 1st line = Buccal midazolam
- 2nd line = Rectal diazepam

27/06/23

1. Malaria
 - Causes infectious splenomegaly and acquired haemolytic anaemia (immune
thrombocytopaenia)
- Associated with Burkitts lymphoma (as well as HIV and EBV)
- Investigate for pyrexia of unknown origin
- Pre-hepatic cause of jaundice
2. Pathogenesis of manifestations of liver failure
- Jaundice: {{c1::due to decreased secretion of conjugated bilirubin}}
- Ecephalopathy: {{c2:: - nitrogenous products e.g. ammonia are absorbed in gut and enter
portal circulation to liver - in liver failure these cannot be extracted and reach brain exerting
their effects}}
- Coagulopathy: {{c3:: reduced synthesis of clotting factors - reduced platelets and platelet
functional abnormalities associated w jaundice or renal failure}}

Acute cholecystitis follows stone or sludge impaction in the neck of the gallbladder, which may cause
continuous epigastric or RUQ pain (referred to right shoulder), vomiting, fever, local peritonism or
GB mass.

Main difference from biliary colic is inflammatory component i.e. local peritonism, fever,
leucocytosis

If stone moves to the common bile duct, obstructive jaundice and cholangitis

Murphy’s sign: pain iliicited when laying 2 fingers over RUQ and asking patient to breathe in
resulting in pain and arrest of inspiration as inflamed GB impinges on fingers – only positive if same
test in LUQ does not illicit pain.

3. Klinefelter syndrome
- Cause of non-obstructive azoospermia
- Diagnosed by karyotyping reveals extra copy of X-chromosome in affected male
- Clinical feature: tall stature, gynaecomastia, hypogonadism and reduced facial and body hair
- Not associated with resp disease
4. CT thorax and sputum culture useful for bronchiectasis
5. Primary ciliary dyskinesia cause of bronchiectasis and subfertility or infertility in men and can
be diagnosed by nasal biopsy.
6. Testicular biopsy alongside FSH and testosterone levels to investigate azoospermia
7. Vast majority of men with CF unable to conceive naturally due to congenital absence of vas
deferens causing azoospermia. CF = combination of azoospermia and bronchiectasis
8. CF diagnosed by sweat test showing high sweat chloride (>60mmol/l) and 2 copies of disease
causing CFTR mutation on genetic testing
9. Infection occurs in age-related fashion: young children become colonised with S.aureus and
subsequently H.influenzae and in teenage years, infection with pseudomonas aeruginosa
10. Fall + low GCS = urgent CT brain scan but airway from ABCDE via insertion of Guedel airway
- GCS score < 8 indication for referral to critical care or anaesthetist on-call for appropriate
management as patient loses capacity to maintain own airway and require invasive
ventilation
- Trichophyton rubrum responsible for tinea pedis; scaling and erythema are features of
dermatophyte infections but usually not found symmetrically uniform and often only one
foot involved. Edges of lesion would usually be more inflamed and form complete or partial
ring around lesions (ringworm)
- S.aureus causes impetigo lesions surmounted by golden crusts. It can secondarily infect
dermatitis and in, atopic dermatitis can be associated with exacerbation but not likely since
no features such as oozing or crusting
- Contact allergic dermatitis delayed type IV hypersensitivity reaction to topical allergen
1. Acute phase protein produced by liver, in response to IL-6 secreted by macrophages
- CRP is an opsin and complement activator which facilitates phagocytosis
- Bacterial infections are potent stimulators of CRP production
- Raised CRP not specific for bacterial infection so cannot rely solely on CRP:
- High CRP may be associated with other inflammatory conditions such as burns, trauma,
polymyagia rheumatica, giant cell arteritis etc. –
- Patients with severe bacterial infection may have only have a mildly raised (or even normal)
CRP.
- Raised CRP found to be independent risk factor for atherosclerosis (since atherosclerosis is
an inflammatory condition) but not recommended as cardiovascular disease screening test
for average risk adults without symptoms
2. Describe methods of testing for antibodies to ANCA (cANCA vs pANCA vasculitides)
 Indirect immunofluorescence
- c-ANCA recognise Proteinase 3 (PR3) antigen/ produce antibodies to PR3 more often seen in
Granulomatous polyangitis
- p-ANCA recognise Myeloperoxidase (MPO) antigen/ produce antibodies to MPO more often
seen in Microscopic polyangitis and Churg Strauss syndrome
- There may be overlap between Granulomatosis polyangitis (demonstrate pANCA and anti-
MPO) and Microscopic polyangitis/Churg Strauss (demonstrate cANCA and anti-PR3)
 ELISA for anti-myeloperoxidase (MPO) and anti-proteinase3 (PR3) antibodies
- Helps confirm specificity of positive ANCA result by immunofluorescence
- Antibodies to Glomerular basement membrane (GBM) measured by ELISA
 Rheumatoid factor
- Detected by nephelometry/turbidimetry
- Positive results seen in Rheumatoid arthritis, Connective tissue diseases, chronic infections,
healthy individuals
 Anti-CCP (cyclic citrullinated peptide) antibodies
- Detected by ELISA
- Anti-CCP antibodies have high specificity for Rheumatoid arthritis
3. Reflexes and nerve roots:
- Brachioradialis: C5, 6
- Cremasteric reflex: L1, 2
- Ankle jerk: S1,3
- Achilles tendon: S1
- Anal reflex: S4, 5
- Epigastric reflex: T7, 9
- Triceps reflex: C7
- Patellar reflex: L4
- Biceps reflex: C5/6
4. OSHITME – infective exacerbation of COPD give 24% continuous oxygen
5. Sarcoidosis – CXR findings show hilar lymphadenopathy
6. Sleep apnoea syndrome – giving up smoking results in weight gain
7. Uraemia – vomiting, oligoruria (little urine)
8. Fibroadenosis – multiple, painful breast lumps which are painful and tender premenstrually
9. Hodgkin’s disease – young male with multiple hard swelling on left neck with night sweats
and anorexia
10. Paracetemol overdose – IV acetylcystein
11. IV naloxone – needle track marks ?heroine, unrousable, breathing very occasionally and
small pupils
12. Reed-Sternberg cells – Hodgkin’s disease
13. Bell’s palsy – unilateral facial weakness, watering and dribbling; unable to close left eye or
whistle
14. Mycoplasma pneumonia - general malaise, severe cough & breathlessness which has not
improved with a 7 day course of amoxicillin; CXR shows patchy shadowing throughout lung
field and blood film shows clumping of red cells with suggestion of cold agglutinins
15. Diagnosis of scrotal swelling; confusion screen
16. Bruising, tiredness, pale and petechial haemorrhages; blood tests revealed decreased Hb,
raised WCC & a thrombocytopenia. Peripheral blood film showed the presence of blast cells
17. Hyperinflation and diminished breath sounds = COPD
18. Tinea cruris - well demarcated red plaques with arc-like border extending from groin down
his upper thigh, spreading over the last 2 weeks and no salellise lesions
19. Vancomycin – resistant enterococcus: febrile and septic; his blood cultures & wound swabs
grew gram positive cocci in chains, which grew on MacConkey plate & was aesculin-positive.
This isolate was also resistant to the conventional anti-streptococcal antibodies
20. Subarachnoid haemorrhage – sudden onset severe headache, drowsiness and vomiting
21. Donepezil – treatment of cognitive impairment in Alzheimer’s
22. Berry aneurysm – young, worse headache, no history of head trauma and no focal
neurological deficits
23. Sympathomimetics - agitation, tremor, dilated pupils, tachycardia, arrhythmias, convulsions
24. Strep pneumonia, Neisseria meningitides cause acute bacterial meningitis in adults. Nisseria
meningitides results in meningococcal meningitis with presence of non-blanching, petechial
rash vs// VZV causes viral meningitis vs// Neisseria gonorrhoea causes gonorrhoea and
listeria monocytogenes results in neonatal meningitis
- Typical features on presentation include signs of meningism, such as neck stiffness and
photophobia, deceased consciousness and a non-blanching petechial rash over the trunk
and lower limbs
- The best management is administration of 1.2mg of IM or IV benzylpenicillin
- Blood cultures and lumbar puncture
25. 5fs = gallstones – conjugated hyperbilirubinaemia with symptoms of jaundice, dark urine and
pale stools; LTFs indicate cholestasis with unparalleled rise in ALP, AST and ALT mildly
elevated in comparison
26. Viral, alcoholic hepatitis and autoimmune hepatitis expect elevation in ALT and AST enzymes
due to hepatocellular damage
27. HTN, radiofemoral delay, mid-systolic murmur maximal at aortic area and radiating to the
back. ECG shows left ventricular hypertrophy = coarctation of the aorta
28. Bruits over the intercostal spaces with notching of the lower margins of the ribs may also be
apparent.
29. First degree heart block where PR interval >200 ms vs// shortened PR results from fast AV
conduction, usually down an accessory pathway seen in Wolff– Parkinson–White syndrome.
30. Mesothelioma associated with asbestos occupational exposure and can present with weight
loss, cough, dyspnoea, finger clubbing and pleural effusions (recurrent). With secondary
metastases, lymphadenopathy, hepatomegaly, bony pain and tenderness, abdominal pain
 and bowel obstruction with peritoneal malignant mesothelioma can occur. Diagnosis is
usually histological (pleural biopsy with Abrams’ needle or during thoracoscopy) and
cytological analysis can be performed via pleural aspiration.
31. Pancoast’s tumour (tumour arising from lung apex) = hoarse voice, miosis, anhydrosis,
ptosis; as it grows can compress structures such as brachiocephalic vein, subclavian artery,
recurrent laryngeal nerve (causing voice hoarseness (A)), vagus nerve, phrenic nerve or
compression of the sympathetic ganglion resulting in a group of symptoms known as
Horner’s syndrome (miosis (B) – pupil constriction, enopthalmos – sunken eye, ptosis (E) –
drooping eyelid and ipsilateral anhydrosis (C) – loss of sweating due to compression of
sympathetic supply (thoracic outlet) to the face). Exopthalmos (D) is defined as the
appearance of protruding eye and is seen in patients with Grave’s disease.
32. GI causes of finger clubbing = IBD, liver cirrhosis, primary biliary cirrhosis, coeliac, achalasia
33. Spherocytes commonly seen in haemolytic anaemia vs// target cells indicative of obstructive
jaundice, liver disease, haemoglobinopathies and hyposplenism
34. Aplastic anaemia – failure of the bone marrow causing pancytopaenia and hypocellular bone
marrow with increasing proportion of fatty tissue
35. Patent foramen ovale increases risk of (ischaemic) stroke due to emboli originating in the
venous circulation
36. Investigations for iron deficiency anaemia: increased total iron binding capacity (serum Fe /
transferrin saturation), ferritin increases in cancer/infection due to inflammatory response
and may be norm/low in iron deficiency, FBC shows hypochromic microcytic anaemia and
blood films anisopoikolocytosis (change in size of RBCs) and pencil poikilocytosis (change in
shape of RBCs)
37. Myelofibrosis = teat drop cells
38. Schistocytes fragmented RBCs seen in haemolytic anaemia or DIC
39. ALL bone marrow analysis shows >20% lymphoblasts
40. Examination findings of iron deficiency anaemia are: koilonychia and angular stomatitis
41. Addisonian crisis
42. Extraintestinal signs of UC are finger clubbing, erythema nodosum, iritis and sacroilitis
43. Non-insulin dependent DM – granuloma annulare characterized as benign chronic skin
condition with dermal papules and annular plaques
44. Sodium nitroprusside for rapid lowering of BP
45. Skull based fracture causes pituitary trauma resulting in hypopituitarism
46. Acute coronary syndrome is a spectrum of cardiac ischaemia-infarction determined by the
presence of two out of three factors: chest pain, ECG changes and cardiac enzyme rise.
Depending on these results, patients will fall into one of the following categories: unstable
angina, NSTEMI or STEMI.
- Inverted T waves (A) and ST depression (B) are signs of ischaemia.
- ST elevation, Q waves and raised troponin are indicative of infarction – central crushing
chest pain
- Initially, ‘ST elevation’ or ‘non ST elevation’ ECG changes are used to stratify each patient’s
risk as the results of blood tests for troponin levels (E) (which should be carried out 12 hours
after the pain started) are not known and Q waves have not had time to develop.
- ST elevation (C) is a very good predictor of imminent infarction (positive troponin). However,
if this patient is treated quickly enough with thrombolysis or primary PCI, infarction can be
avoided. A patient with STEMI who goes on to have negative troponin is termed to have had
an ‘aborted MI’. Q waves (D) (indicating full-thickness MI) take time to develop, so ‘Q wave’
or ‘non Q wave’ MI is a diagnosis given on discharge.
 - Proximal myopathy ddx: osteomalacia, Cushing’s, thyrotoxicosis, hypothyroidism, ethanol,
myasthesia gravis, connective tissue diseases (DMD, SLE, RA, vasculitis), infection, cancer,
illicit drug use
- Sarcoidosis - presence of non-caseating granulomas with multinucleated giant cells in the
centre. CD4 lymphocytes are spread out through the granuloma, and CD8 cells cluster
around the periphery
- Genital herpes caused by HSV1/2 treated with anitvirals e.g. acyclovir or ganciclovir
- Define dementia: The significant impairment of memory and one or more other domain of
cognition (language, visuospacial skills and praxis) in a setting of clear consciousness and
interfering with work, social activities or relationships.
- Marfan’s syndrome

Falls

Fall is defined as an event which causes a person to, unintentionally, rest on the ground or other
lower level. A simple fall is defined as one occurring as a result of a chronic impairment of cognition,
vision, balance, or mobility. It is distinguished from a collapse caused by an acute medical problem,
such as an acute arrhythmia, transient ischaemic attack, or vertigo.

Falls multifactorial risk assessment: gait, balance, muscle strength, osteoporosis risk, perceived
functional ability, fear of falls, vision, cognition, neuro exam, continence, home and hazards, CVD
exam, medication review

Falls risk assessment - ?Performance-Orientated Assessment of Mobility

Benzodiazepines. Psychoactive drugs such as benzodiazepines are most commonly reported as

increasing the risk of falls in older people. Choice A: Aminoglycosides can also contribute to falls in
older people because of the risk of direct vestibular damage. Choice C: Diuretics can contribute to
falls by impairing cerebral perfusion, especially when patients are dehydrated. Choice D:
Antihypertensives such as vasodilators can impair cerebral perfusion as well and cause falls in older
people.

Get-Up-and-Go Test. This is a basic test that is done after an older patient reports one fall over the
past year. If a patient has difficulty with the Get-Up-and-Go Test, then further evaluation is
necessary, possibly using choices A, C, and D. These tests can identify problems with balance and
stability during walking and other movements that may indicate that the patient is at risk for future
falls.

Falls History!

5Ws + H:

Who --> who saw you fall? --> consider taking a collateral history

When --> when did you fall? --> time of day / what were you doing (getting out of bed/looking
upwards)

Where --> where did you fall? --> outside/home

What:

- Before = warning/dizziness/ chest pain and palpitation

- During = loss of consciousness (how long/first thing remember), incontinence/tongue bitting

(seizures)/ pale/flushing (vasovagal syncope), injury/part of body which hit floor

- After = how did you get up, continue back to normal activity? was there any confusion (head
injury), weakness/speech difficulty (stroke/TIAs)

Why = why do you think it happened? --> ICE + meds/mechanical trip over rug

How = how many times have you fallen in last 6 months?

Systems enquiry + PMH (JADE TAB MARCH)

DH = SIDE effects of drugs

FH

SH = smoking/alcohol, support at home (friends/family/carers) and mobility aids (frames/stairs)