11.Predisposing factors for infective endocarditis include
i) Ventricular septal defect TRUE
ii) Intravenous drug abuse TRUE
iii) Prosthetic valves TRUE
iv) Male sex FALSE
v) Central venous catheterisation TRUE
Explanations
i) Predisposing factors for infective endocarditis include Ventricular septal defect (TRUE)
Antibiotic prophylaxis is recommended for high risk procedures or septic procedures such as dental surgery
ii) Predisposing factors for infective endocarditis include Intravenous drug abuse (TRUE)
Intraveous drug abusers are at greater risk of right-sided valve lesions than the general population. There is often no underlying valve defect.
iii) Predisposing factors for infective endocarditis include Prosthetic valves (TRUE)
Infection may result in a periannular abscess, a regurgitant valve, or an improperly functioning valve. Infection around prosthetic valves is particularly difficult to manage as antibiotics are less effective against bacteria that have colonised a foreign body.
iv) Predisposing factors for infective endocarditis include Male sex (FALSE)
Infective endocarditis has no gender predilection
v) Predisposing factors for infective endocarditis include Central venous catheterisation (TRUE)
This is a potential source of infection
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12 . Features that are indicative of Irritable Bowel Syndrome (IBS) include
i) Altered bowel habit TRUE
ii) Abdominal pain relieved by defaecation TRUE
iii) Mucorrhoea TRUE
iv) Rectal bleeding FALSE
v) Subjective sensation of incomplete evacuation TRUE
Explanations
i) Features that are indicative of Irritable Bowel Syndrome (IBS) include Altered bowel habit (TRUE)
This is a feature of IBS. See also the notes at the bottom of the page.
ii) Features that are indicative of Irritable Bowel Syndrome (IBS) include Abdominal pain relieved by defaecation (TRUE)
See notes at the end of the question
iii) Features that are indicative of Irritable Bowel Syndrome (IBS) include Mucorrhoea (TRUE)
Mucorrhoea is the passage of mucus per rectum and is a recognised feature of IBS
iv) Features that are indicative of Irritable Bowel Syndrome (IBS) include Rectal bleeding (FALSE)
Rectal bleeding is not a feature of IBS and may point to an underlying organic pathology.
v) Features that are indicative of Irritable Bowel Syndrome (IBS) include Subjective sensation of incomplete evacuation (TRUE)
This is a reacognised feature of IBS
Further notes:
Irritable Bowel Syndrome is the name given to a group af abdominal symptoms, for which no organic cause can be found.
Clinical features may include, central/lower abdominal pain, bloating, altered bowel habit (alternating diarrhoea and constipation), tenesmus and abdominal tenderness.
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13.Analgesia:
i) In the WHO analgesic ladder, paracetamol is a step 2 analgesic FALSE
ii) Co-proximol is a combination of paracetamol and codine FALSE
iii) Regular laxatives should be prescribed with morphine TRUE
iv) Diamorphine is five times stronger than morphine FALSE
v) Amitriptyline can be used in neurological pain TRUE
Explanations
i) Analgesia: In the WHO analgesic ladder, paracetamol is a step 2 analgesic (FALSE)
Paracetemol is on step 1 of the WHO analgesic ladder.
ii) Analgesia: Co-proximol is a combination of paracetamol and codine (FALSE)
Co-codamol is the combination of paracetamol and codine. Co-proximal contains dextropropoxyphene.
iii) Analgesia: Regular laxatives should be prescribed with morphine (TRUE)
Constipation is a common side effect of opiates so laxatives should be give prophylactically.
iv) Analgesia: Diamorphine is five times stronger than morphine (FALSE)
It is approximately three time stronger.
v) Analgesia: Amitriptyline can be used in neurological pain (TRUE)
Amitriptyline can be a useful adjuvant in neurological pain.
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14.Gastric cancer:
i) Is approximately ten times more common in Japan and China than in the Western European population TRUE
ii) The risk of gastric malignancy falls in second and third generation Asian immigrants to Western Countries TRUE
iii) Adenocarcinoma of the cardia is seven times more common in men than women TRUE
iv) Sarcomas account for about 30% of cases of gastric malignancy FALSE
v) Gastric malignancy is usually detected at an early stage without nodal involvement in the UK -FALSE
Explanations
i) Gastric cancer: Is approximately ten times more common in Japan and China than in the Western European population (TRUE)
Incidence 3.7 per 100,000 in Western countries
Incidence >30 in Japan, China and Russia
ii) Gastric cancer: The risk of gastric malignancy falls in second and third generation Asian immigrants to Western Countries (TRUE)
The incidence of gastric malignancy in grandchildren and great grand children of Asian immigrants to the West gradually falls to that of the general population
iii) Gastric cancer: Adenocarcinoma of the cardia is seven times more common in men than women (TRUE)
Overall men are twice as likely to develop gastric malignancy, however the subset of cancer of the cardia is rapidly increasing in incidence and affects seven times as many men as women
iv) Gastric cancer: Sarcomas account for about 30% of cases of gastric malignancy (FALSE)
Adenocarcinoma accounts for about 95% of cases
v) Gastric cancer: Gastric malignancy is usually detected at an early stage without nodal involvement in the UK (FALSE)
Gastric malignancy usually presents late and this accounts for some of the dismal survival statistics.
Gastric malignancy is detected much earlier in Japan as a result of a national screening program.
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15 . Upper gastrointestinal (GI) bleeding
i) Is commonly due to systemic hypertension FALSE
ii) Usually result in dark brown stools FALSE
iii) In >35% of cases, is due to gastric carcinoma FALSE
iv) Proton pump inhibitors should not be prescribed for alcoholics with upper GI bleeds FALSE
v) Due to ruptured varices, should always be managed with a Sengstaken-Blackmore tube FALSE
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15. i) Upper gastrointestinal (GI) bleeding Is commonly due to systemic hypertension (FALSE)
Portal hypertension may be a cause, but systemic hypertension is not causative of upper GI bleeding.
ii) Upper gastrointestinal (GI) bleeding Usually result in dark brown stools (FALSE)
The coulour of melaena is is described as tarry black and NOT dark brown.
iii) Upper gastrointestinal (GI) bleeding In >35% of cases, is due to gastric carcinoma (FALSE)
Gastric carcinoma is one of the rare causes of upper GI bleeding. The commonest causes include GU/DU, gastritis, gastric erosion and oesophageal varicies
iv) Upper gastrointestinal (GI) bleeding Proton pump inhibitors should not be prescribed for alcoholics with upper GI bleeds (FALSE)
Proton pump inhibitors are very useful drugs that protect the gastric mucosa, they have few side effects and are generally very safe. An IV proton pump inhibitor should be prescribed in almost all cases of upper GI bleeding.
v) Upper gastrointestinal (GI) bleeding Due to ruptured varices, should always be managed with a Sengstaken-Blackmore tube (FALSE)
This question was designed to catch you. Everyone has heard of Sengstaken-Blackmore tubes, but in practice they are rarely used! Injection sclerotherpy is commonly used.
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16. Risk factors for aortic dissection include:
i) Hypertension TRUE
ii) Marfan's syndrome TRUE
iii) Hypothyroidism FALSE
iv) Bicuspid aortic valve TRUE
v) Pregnancy TRUE
Explanations
i) Risk factors for aortic dissection include: Hypertension (TRUE)
This is an important risk factor
ii) Risk factors for aortic dissection include: Marfan's syndrome (TRUE)
This is an important risk factor
iii) Risk factors for aortic dissection include: Hypothyroidism (FALSE)
Hypothyroidism is not a recognised risk factor
iv) Risk factors for aortic dissection include: Bicuspid aortic valve (TRUE)
This is an important risk factor
v) Risk factors for aortic dissection include: Pregnancy (TRUE)
This is an important risk factor: half of all dissections in women under 40 occur during pregnancy, usually in the third trimester
Further notes:
The other important cause that is not listed here is atherosclerosis.
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17. Keloid scarring is more common in:
i) Young patients TRUE
ii) Women FALSE
iii) Dark skinned people TRUE
iv) Sternal incisions TRUE
v) Wounds under tension TRUE
Explanations
i) Keloid scarring is more common in: Young patients (TRUE)
See notes at the bottom of the page
ii) Keloid scarring is more common in: Women (FALSE)----check
See notes at the bottom of the page
iii) Keloid scarring is more common in: Dark skinned people (TRUE)
See notes at the bottom of the page
iv) Keloid scarring is more common in: Sternal incisions (TRUE)
See notes at the bottom of the pagE
v) Keloid scarring is more common in: Wounds under tension ( TRUE )
Further notes:
Keloid scarring is more common in:
- Young people
- Men
- Dark skinned individuals
- Those with a genetic predisposition
- Where there is undue tension on the wound
- Where there is delatyed wound healing
- Specific sites: face, neck, sternum, shoulders.
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18.Fluid and electrolyte balance
i) Daily potassium requirements are approximately 60-80mmol TRUE
ii) 1 litre of normal saline provides approximately double the daily sodium requirements of a normal individual TRUE
iii) Normal saline has a pH of 5.0 TRUE
iv) Potassium can be administered as a bolus of 20mmol in 10ml 5% dextrose over 5 minutes in severe, symptomatic hypokalaemia FALSE
v) Lactate containing solutions should be avoided in diabetics TRUE
Explanations
i) Fluid and electrolyte balance Daily potassium requirements are approximately 60-80mmol (TRUE)
Daily requirements for potassium equates to approximately 1mmol /kg. However lower doses are often provided in clinical situations as potassium levels are affected by renal function, surgery, trauma and others.
ii) Fluid and electrolyte balance 1 litre of normal saline provides approximately double the daily sodium requirements of a normal individual (TRUE)
Daily sodium requirements approximate to between 1 and 1.5mmol per kg of body weight. Thus a 70kg person will require between 70 and 105mmol of sodium per day. 1 litre of 0.9%saline provides 150mmol of sodium... Over and above daily sodium requirements for a normal individual.
However, it is important to remember that many surgical patients may be experiencing excess sodium losses - ileostomy contents and diarrhoea are both rich in sodium and thus sodium should be replaced accordingly.
iii) Fluid and electrolyte balance Normal saline has a pH of 5.0 (TRUE)
Normal saline has a pH of 5.0!
Administration of large volumes of normal saline can lead to a hyperchloraemic metabolic acidosis
iv) Fluid and electrolyte balance Potassium can be administered as a bolus of 20mmol in 10ml 5% dextrose over 5 minutes in severe, symptomatic hypokalaemia (FALSE)
Potassium is very arhythmiogenic if given too rapidly. Potassium should be infused at a maximal rate of 20mmol per hour in a monitored ICU environment.
v) Fluid and electrolyte balance Lactate containing solutions should be avoided in diabetics (TRUE)
Studies have shown that diabetic patients given lactate develop elevated blood glucose levels and lactate containing solutions should therefore be avoided.
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19.The following conditions will often cause acute visual disturbance:
i) Open angle glaucoma FALSE
ii) Migraine TRUE
iii) Occlusion of the internal carotid artery TRUE
iv) Cataract FALSE
v) Optic neuritis TRUE
Explanations
i) The following conditions will often cause acute visual disturbance: Open angle glaucoma (FALSE)
This is false: open angle glaucoma will cause a gradual loss of vision. In contrast acute angle CLOSURE glaucoma is associated with a sudden loss of vision, painful, red eye, corneal clouding and patients may complain of haloes around lights
ii) The following conditions will often cause acute visual disturbance: Migraine (TRUE)
Migraines are often associated with visual disturbances such as flashing lights and zigzag lines.
iii) The following conditions will often cause acute visual disturbance: Occlusion of the internal carotid artery (TRUE)
Occlusion of the internal carotid artery will usually cause Total Anterior Circulation Syndrome characterised, in part, by visual disturbance because the orbit and optic nerves derive at least part of their arterial supply from the internal carotid artery.
iv) The following conditions will often cause acute visual disturbance: Cataract (FALSE)
This is false as cataracts present with a gradual loss of vision.
v) The following conditions will often cause acute visual disturbance: Optic neuritis (TRUE)
Optic neuritis will usually cause a sudden loss in vision: often with a central scotoma, red desaturation (the colour red appears faded) and a painful eye that is worse on movement.
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20. A 24 year old woman is sent a letter following an abnormal pap smear result. The smear showed moderate dyskaryosis. The following is now true of her management:
i) She should be referred for colposcopy TRUE
ii) If colposcopy were undertaken it would reveal CIN in 50-75% cases. TRUE
iii) She should be advised to refrain from sexual intercourse until further investigations. FALSE
iv) Treatment with LLETZ (large loop excision of transformation zone) will increase her risk of miscarriage in subsequent pregnancies FALSE
v) If CIN III is subsequently found and excisional treatment successfully undertaken, her risk of developing CIN III in the future is the same as that of the general population FALSE
Explanations
i) A 24 year old woman is sent a letter following an abnormal pap smear result. The smear showed moderate dyskaryosis. The following is now true of her management: She should be referred for colposcopy (TRUE)
All cases of moderate or severe dyskaryosis should be referred for colposcopy and cervical biopsy as they are predictive of CIN (Cervical Intraepithelial Neoplasia)
ii) A 24 year old woman is sent a letter following an abnormal pap smear result. The smear showed moderate dyskaryosis. The following is now true of her management: If colposcopy were undertaken it would reveal CIN in 50-75% cases. (TRUE)
CIN II or CIN III is present in 50-75% of cases where an abnormal smear revealed moderate dyskaryosis. This risk rises to 80-90% in cases of severe dyskaryosis.
iii) A 24 year old woman is sent a letter following an abnormal pap smear result. The smear showed moderate dyskaryosis. The following is now true of her management: She should be advised to refrain from sexual intercourse until further investigations. (FALSE)
There is no indication for this. If she were to subsequently undergo ablative treatment she should refrain from intercourse for ~4 weeks after this to allow healing.
iv) A 24 year old woman is sent a letter following an abnormal pap smear result. The smear showed moderate dyskaryosis. The following is now true of her management: Treatment with LLETZ (large loop excision of transformation zone) will increase her risk of miscarriage in subsequent pregnancies (FALSE)
There is no conclusive evidence to say this is the case. Knife cone biopsy is however associated with increased risk of misscarriage in subsequent pregnancies as cervical incompetence is a known complication.
v) A 24 year old woman is sent a letter following an abnormal pap smear result. The smear showed moderate dyskaryosis. The following is now true of her management: If CIN III is subsequently found and excisional treatment successfully undertaken, her risk of developing CIN III in the future is the same as that of the general population (FALSE)
Her risk of subsequently developing CIN III is now ~5 x greater than the general population.
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