Question Bank

In Minimal Change Disease (MCD), light microscopy typically appears normal. The diagnosis is confirmed via electron microscopy showing effacement of podocyte foot processes. MCD is the most common cause of nephrotic syndrome in children and is highly steroid-responsive.

NICE recommends adding a low-dose ICS if a patient has symptoms ≥3 times a week or is waking at night. If symptoms are uncontrolled on SABA + ICS, the next step would be adding an LTRA.

While the Epworth scale and oximetry are screening tools, multi-channel polysomnography (in a sleep lab) is the gold standard for diagnosing Obstructive Sleep Apnoea (OSA). It monitors EEG, airflow, and respiratory effort.

Goodpasture's syndrome (Anti-GBM disease) presents with the combination of pulmonary haemorrhage and rapidly progressive glomerulonephritis. It is characterised by anti-GBM antibodies and a linear pattern of IgG deposition.

Primary hyperaldosteronism (Conn's Syndrome) presents with hypertension, hypokalaemia, and a high ARR. The first-line imaging to differentiate between an adrenal adenoma and bilateral adrenal hyperplasia is a CT Adrenal scan.

The clinical picture is consistent with Immune Thrombocytopenic Purpura (ITP). First-line treatment for patients with a platelet count <30 x 10^9/L or significant bleeding is oral corticosteroids (prednisolone). IVIg is typically reserved for patients requiring a rapid rise in platelets or those refractory to steroids. Platelet transfusions are ineffective as the antibodies will destroy the donor platelets immediately.

For a patient with hypoglycaemia who is conscious but cannot safely swallow (no safe swallow or uncooperative), IM Glucagon is the treatment of choice in the community. Oral options are unsafe due to aspiration risk, and IV access is rarely available outside a hospital setting.

Acute Tubular Necrosis (ATN) is often caused by prolonged ischaemia (e.g., hypotension/shock during surgery). The presence of 'muddy brown' casts in the urine is highly pathognomonic for ATN compared to simple pre-renal azotaemia.

Unilateral sensorineural hearing loss and tinnitus are red flags for a vestibular schwannoma (acoustic neuroma). Gadolinium-enhanced MRI of the internal auditory meatus is the gold-standard investigation. CT is less sensitive for small lesions in the cerebellopontine angle.

Orbital cellulitis (infection posterior to the orbital septum) is distinguished from preseptal cellulitis by signs of orbital involvement: proptosis, painful eye movements (ophthalmoplegia), and reduced visual acuity. Both conditions may present with eyelid swelling, redness, and fever.

IgA nephropathy typically presents with 'synpharyngitic' haematuria (occurring during or shortly after an upper respiratory tract infection). Post-streptococcal glomerulonephritis usually has a longer lag period (1-3 weeks) between infection and renal symptoms.

Low pH (<7.35) and high pCO2 (>6.0 kPa) indicate respiratory acidosis (Type 2 failure). The elevated bicarbonate (29 mmol/L) suggests the body has begun to compensate (chronic/partially compensated), but the pH remains acidotic.

If a bleeding point is clearly visualized in anterior epistaxis (Little's area) and simple pressure fails, silver nitrate cautery is the treatment of choice after applying local anaesthetic. Nasal packing is reserved for cases where the bleeding point cannot be identified or cautery is unsuccessful.

MND (specifically Amyotrophic Lateral Sclerosis) typically presents with a combination of upper motor neurone signs (brisk reflexes, increased tone) and lower motor neurone signs (wasting, fasciculations) in the absence of sensory loss. Tongue fasciculations (bulbar involvement) are a specific sign of MND.

The 2023 BTS Pleural Disease Guidelines updated the management of primary spontaneous pneumothorax (PSP). For a symptomatic PSP with a rim >2 cm (or >3 cm at the hilum), ambulatory management using a small-bore drain with a Heimlich valve is now the preferred first-line approach. This allows the patient to be managed as an outpatient or with a short admission, with the valve permitting one-way airflow. Needle aspiration is no longer recommended as standard first-line intervention. Conservative (watch-and-wait) management is appropriate for small (<2 cm) or asymptomatic PSP. Intercostal chest drains are reserved for failed ambulatory management or haemodynamic compromise. Pleurodesis is used for recurrent pneumothorax.

The triad of erythema nodosum (tender nodules on shins), bilateral hilar lymphadenopathy (BHL), and dry cough/arthralgia is highly suggestive of acute sarcoidosis (Löfgren's syndrome).

The presentation is classic for Guillain-Barré Syndrome (GBS), often preceded by Campylobacter jejuni infections. Treatment is IVIG or plasma exchange. Corticosteroids are not effective in GBS. Monitoring FVC is crucial as respiratory failure is a major complication requiring ICU admission.

For peripheral arterial disease (PAD), NICE recommends clopidogrel 75mg daily as the first-line antiplatelet agent for the prevention of cardiovascular events. Aspirin is used for coronary artery disease secondary prevention.

In severe hyperkalaemia (>6.5 mmol/L) or with ECG changes, the priority is to stabilise the cardiac membrane using 10% IV calcium gluconate. Insulin/dextrose and salbutamol shift potassium into cells but do not stabilise the myocardium.

In the UK, 6-monthly liver ultrasound is the recommended primary surveillance modality for HCC in patients with cirrhosis, as per NICE (TA474) and EASL guidelines. Serum AFP is not recommended as a routine standalone screening tool by NICE due to its limited sensitivity and specificity; it may be used adjunctively at the clinician's discretion but is not mandated. CEA is a marker for colorectal cancer; CA19-9 is used in biliary and pancreatic malignancy; liver biopsy is not a surveillance tool. All patients with compensated cirrhosis, regardless of aetiology, should be enrolled in a 6-monthly ultrasound surveillance programme.

His CHA₂DS₂-VASc score is 4: Age ≥75 scores 2 points; Hypertension (BP 135/82 mmHg qualifies as hypertension or treated hypertension) scores 1 point; Type 2 Diabetes scores 1 point. For male patients with a score of 2 or more, anticoagulation with a DOAC (such as apixaban) is recommended by NICE and the 2020 ESC AF guidelines. Aspirin is no longer recommended for stroke prevention in AF. Warfarin with a target INR of 3.5 is not indicated; standard INR target for AF is 2.0–3.0, and DOACs are preferred over warfarin for non-valvular AF.

NICE NG89 recommends pharmacological VTE prophylaxis for 35 days following elective total hip replacement. Recommended options include rivaroxaban 10 mg once daily for 35 days, or apixaban 2.5 mg twice daily for 35 days (not 14 days — the 14-day duration applies to total knee replacement). LMWH for 10 days followed by aspirin for 28 days is an alternative per NICE NG89. Aspirin monotherapy for 14 days is inadequate in duration and not recommended as the sole agent. Fondaparinux for 14 days is insufficient duration for hip replacement prophylaxis.

This patient's CURB-65 score is 5, as all five criteria are met: Confusion ✓ (present), Urea ≳7 mmol/L ✓ (8.2 mmol/L), Respiratory rate ≥30/min ✓ (32/min), Blood pressure ≤90 systolic or ≤60 diastolic ✓ (85/55 mmHg), Age ≥65 ✓ (82 years). A score of 3 or more indicates severe pneumonia with high mortality risk, mandating urgent hospital admission. A score of 4 or 5 should prompt consideration of ITU-level care. Intravenous antibiotics per local CAP protocol (typically co-amoxiclav + clarithromycin) should be commenced promptly after blood cultures are taken.

In accordance with NICE and British Society of Gastroenterology guidelines, any male or post-menopausal female with unexplained iron deficiency anaemia must be referred for urgent (2-week wait) GI investigation to exclude malignancy. While iron supplementation is needed, it must not delay diagnostic investigations. Bone marrow biopsy is not indicated for simple microcytic anaemia.

NICE guidelines (CG150) recommend combination therapy with an oral triptan and an NSAID (or paracetamol) for the acute treatment of migraine. Propranolol and amitriptyline are used for prophylaxis, not acute treatment. Subcutaneous triptans are usually reserved for patients with severe vomiting or those who fail oral therapy.