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A 35-year-old man presents to the Emergency department complaining of severe pain in his lower back after lifting a heavy box at work. The pain radiates to his right buttock and thigh. He has had no urinary symptoms.On examination he can straight leg raise to 90 degrees on the left side but only to 30 degrees on the right. Sciatic stretch test is positive.He has difficulty plantarflexing his right ankle and has abnormal sensation on the plantar aspect of the foot. His right ankle reflex is absent but all other reflexes are normal. There is no other sensory disturbance.What is the likely diagnosis?
Disc prolapse at L5\S1
- Sensory loss to the posterior calf and the plantar surface of the foot
- Motor loss to gastrocnemius and soleus and
- Loss of ankle jerk.
Which of the following increase renal blood flow?
the others are agonists of the sympathetic system which causes vasocon of the splanchnic and renal systems and diverts blood flow to the skeletal muscles.
Palsies of the third, fourth and sixth cranial nerves with involvement of the ophthalmic division of the fifth nerve, suggests a lesion of which of the following?
Apex of the orbit
Base of skull
Aswell as these nerves the internal carotid with its sympathetic plexus and the superior and inferior orbital veins also traverse thru it.
One unit of fresh blood raises the haemoglobin concentration by how much?
What is the macula densa and what is its function?
The macula densa is a tissue that is found on the distal convoluted tubule, and sits at the hilum of the Bowman's capsule. Its role is to monitor blood flow into the capsule, and hence is involved in blood pressure control.
On what part of the filtration system of the kidney does aldosterone act?
Distal convoluted tuble, as opposed to ADH which acts mainly on the collecting duct
What is courvoseiers law?
Painless obstructive jaundice with a mass in the RUQ means the patient most probably has cancer.
DO A CT!
What is Faecal elastase a test for?
Pancreatic insufficiency, indicated if the patient presents with steatorrhoea, chronic epigastric pain, wieght loss and anorexia.
If faecal elastase is low then do the exocrine job of the pancreas by giving creon.
which artery Arises from the aorta between the level of L1 and L2 vertebrae, and forms five segmental arteries that do not anastomose.
Drug A has endpoint mortality of 40% and drug B has endpoint mortality of 30%...What is the absoloute risk reduction of drug b compared to A?
10% dont confuse with Relative risk reduction.
How do you stage malignant melanoma?
Following biopsy with Breslow's thickness
What is pagets disease of the bone?
An abnormality in osteoclast activation which leaves them turned on and causes extensive bone resorption. Causes Bowing of the tibia.
What are the layers of the scalp?
- Connective tissue
- Loose connective tissue
What Does secretin do and where is it released from?
Released from the small intestine in respones to acid in the small intestine, stimulates bicarb secretion from pancreas and liver.
Where is Ghrelin released from and what does it do?
Released from the fundus of the stomach, stimulates appetite.
Where is CCK released from? in response to what? what does it do?
- Released from small intestine in response to AA and fats in small intestine.
- Causes pancreatic enzyme secretion, gall bladder contraction and sphincter of oddi relaxation
Where is Glucose-dependent released from? in response to what? what does it do?
What are the 2 main organisms that cause epididymo-orchitis?
What antibiotic(s) would you prescribe to treat this.?
What other aspects would make up your managment plan?
- C.trachomatis and N.gonnorhoea
- Give ciprofloxacin 500mg bd and doxycycline 100mg tds
- Bed rest, NSAIDS and scrotal elevation with an ice pack will aid recovery.
A 28 year old is 8 weeks post partum and develops a flutuant mass in the RUQ of her right breast. The overlying skin in Red and tender.
What is the diagnosis and how is it best managed?
Breast abscess, best managed with USS guided needle aspiration.
- Incision and drainage is contraindcated due to risk of mammary-cutaneous fistula. Only indicated if:
- Abcess is multiloculated
- Repeated aspiration doesnt work
- Overlying skin is necrotic
Hoe does a man with Renal cell carcinoma present?
- Flank mass
- Weight loss
- Could have a varicocoele if renal vein is occluded
What is onychogryphosis?
What is onychocryptosis?
Ingrowing toe nail
What is Hidradentis suppurativa?
Blockage of apocrine glands with antigen antibody complexes, leads to things that look like sebaceous cysts but in the axilla, groin and anywhere that has apocrine glands and hair basically.
What would be the examination findings of Dressler's syndrome?
- Soft systolic murmur in the tricuspid area louder on leaning forward and possibly a pericardial rub.
- They will also have a fever and lethargy.
- ESR is likely to be raised
- Best treated with NSAIDS
A 49-year-old female two days post total thyroidectomy has developed tetany in both hands. Her corrected serum calcium is 1.90 mmol/l (2.2-2.6).
What is the most appropriate management for this patient?
- IV calcium gluconate.
- Hypocalcaemia is the most common complication following total thyroidectomy.
What kind of cardiac abnormality is associated with carcinoid syndrom?
- Excess serotonin and kallkrien leads to fibrosis of the tricuspid and pulmonary valves leading to TIPS:
- Tricuspid insufficiency
- Pulmonary stenosis
What is brucellosis?
- A Zoonosis caused by Brucella abortus found in UNPASTEURISED MILK.
- Presents with Undulant fevers, migrating ARTHRALGIA and myalgia, anaemia, lethargy, and SWEATING.
- Can easily become chronic and is a known cause of depression.
True or false, IgG can cross the placenta irrespective of subclass?
Name 3 autosomal dominant conditions.
- Familial Hypercholesterolaemia
- Adult Polycystic Kidney disease
- MEN 1
- Neurofibromatosis 1 and 2
- Alcohol (chronic) and smoking
- Macrolides and Metronidazole
- Grapefruit juice
- Cimetidine, ciprofloxacin, chloramphenicol
- Alcohol binge
True or false...The primary attack of genital herpes is worse than subsequent episodes.
Incubation period of herpes?
Incubation period of gonorrhoea?
Incubation period of Chlamydia?
In which of the following is bicarb raised?
Chronic renal failure
- Pyloric Stenosis These 2 cause alkalosis
- COPD Co2 retention means more converted to bicarb
- DKA - acidosis, uses up all the bicarb
- CRF - Causes Mild acidosis
How would you manage incontinence of old age?
- Follow regular toilet regime
- Do not use hypnotics to aid sleep
- Treat any constipation or atrophic vaginitis
What are the Duckett-Jones criteria for a diagnosis of Ehumatic fever?
- The Duckett Jones criteria are divided into major and minor:
- Major: Migratory polyarthritis, pancarditis, chorea, erythema marginatum, nodules.
- Minor: Fever, arthralgia, raised inflammatory indices, prolonged PR interval.
What is Reiter's syndrome?
What causes it?
What is the triad of Reiter's syndrome?
- Reactive arthritis, caused by gastroenteritis (salm. or shig.) or non-specific urethritis
- Joint Inflam - Polyarthritis (often sacroiliac, knee and feet (plantar fascitis)
- Eye inflam - uveitis irits etc
- Repro tract inflam - Cervicitis or urethritis
How does Primary HIV infection present?
Glandular fever type illness, Fever, rashes, cranial nerve palsies
What drugs can cause Ataxia?
Lithium and phenytoin. Dose dependent.
Whats the risk of a 35 year old woman having a child with downs?
What is a Gelastic seizure?
- A sudden uncontrolled outburst of energy or laughter.
- ASSOC hypothalamic Hamartomas
What is a hamartoma?
- An abnormal growth that consists of the same tissue from which it is derived.
- Cellular structure may be disorganized.
- Studies seem to indicate that a hamartoma occurs when the tissue in growth did not develop completely. Hamartomas may occur throughout the body, but are often found in the head and neck, particularly around the ears.
If hamartomas occur in multiple sites throughout the body, their presence is called Cowden disease.
By definition there is no metaplasia in hamartomata.
What is Pityriasis Rosea?
- A benign skin rash.
- The initial patch is called as the herald patch/ mother patch. This is followed in crops by smaller daughter patches which have a fine colarette of scales at the periphery. The patches are distributed over the upper trunk along the lines of the ribs and hence termed as having a Christmas tree appearance.
- A viral aetiology is blamed.
- It lasts approximately six to eight weeks and treatment is symptomatic.
What is the classic presentation of an acoustic neuroma?
- Tendency to fall towards the side of the lesion
- Loss of corneal reflex.
What is Kallmann's syndrome?
- Colour blindness
- Congenital Anosmia
- hypogonadotrophic hypogonadism
In what situations do you have to report a death to the coroner?
- These include:
- The cause of death is unknown.
- The deceased was not seen by the certifying doctor either after death or within 14 days before death.
- The death was violent or unnatural.
- The death may be due to an accident.
- The death may be due to self neglect or neglect by others.
- The death may be the result of industrial illness or due to the persons employment
- The death may be due to an abortion.
- The death occurred during an operation or before recovery from anaesthesia.
- The death may be suicide.
- The death occurred during or shortly after being taken into police custody.
What is Exenatide, and what are its metabolic effects?
- Drug used in the treatment of Diabetes.
- A GLP-1 analogue.
- Stimulates insulin release
- Inhibits glucose production by the liver
- Slows gastric emptying
- Suppresses appetite