Question Bank

A significant rise in creatinine (usually >20-30%) after starting an ACE inhibitor is a classic indicator of bilateral renal artery stenosis. ACE inhibitors reduce efferent arteriolar pressure, which in the presence of stenosis, leads to a drop in glomerular filtration pressure.

The Auspitz sign is the appearance of punctate bleeding points after the removal of a psoriasis scale, reflecting the thinning of the epidermis over elongated dermal papillae. The Koebner phenomenon refers to the development of lesions at sites of trauma, and Wickham striae are seen in Lichen Planus.

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.

First-line management for ankylosing spondylitis (axial spondyloarthritis) is regular NSAIDs and structured exercise/physiotherapy. DMARDs like methotrexate are not effective for purely axial disease. TNF-alpha inhibitors like Etanercept are only used if NSAIDs fail.

Refeeding syndrome occurs when nutrition is reintroduced to a malnourished patient, leading to insulin release. Insulin causes an intracellular shift of potassium, magnesium, and phosphate, which can lead to cardiac arrhythmias and respiratory failure.

NICE guidelines state that the gold standard for diagnosing coeliac disease in adults is an OGD with duodenal biopsies showing villous atrophy. Serology (anti-tTG) is a screening tool, and biopsies must be performed while the patient is still consuming gluten. Colonoscopy is used for IBD, not coeliac disease.

Intravenous acetazolamide is the first-line systemic treatment to rapidly reduce intraocular pressure in acute angle-closure glaucoma (AACG). Pilocarpine is used once the pressure has dropped slightly but is ineffective if the pressure is too high due to iris ischaemia. Latanoprost is used for chronic open-angle glaucoma.

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.

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).

NICE (NG12) guidelines mandate a 2-week wait (2WW) referral for colonoscopy in patients aged 60+ with a change in bowel habit or iron deficiency anaemia. While FIT is used for lower-risk scenarios or primary care screening, this patient meets the criteria for direct urgent referral for suspected colorectal cancer.

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.

In patients under 55 without alarm symptoms, a trial of a full-dose PPI (e.g., Omeprazole 20mg) for 4-8 weeks is the standard first-line management for suspected GORD. OGD is reserved for older patients or those with red flags (dysphagia, weight loss, anaemia).

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.

In phaeochromocytoma, alpha-blockade must be achieved before starting beta-blockers. Failure to do so can lead to unopposed alpha-adrenergic stimulation, causing a hypertensive crisis.

Eczema herpeticum is a dermatological emergency caused by HSV infection on top of eczema, characterized by punched-out erosions. Due to the risk of systemic dissemination and ophthalmic involvement, patients (especially children) should be admitted for IV aciclovir; steroids should be avoided as they can worsen the infection.

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.

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.

The primary treatment for acute pancreatitis is supportive care, with aggressive IV fluid resuscitation (crystalloids) being the most critical step to prevent organ failure and necrosis. Amylase >3x the upper limit of normal is diagnostic. Antibiotics and surgery are not indicated in the initial phase unless infection is proven.

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.

The clinical picture of pain relieved by defecation, bloating, and altered bowel habit in the absence of inflammatory markers (normal CRP/ESR) or weight loss/anaemia is characteristic of Irritable Bowel Syndrome (IBS). Diagnosis is clinical once other conditions (Coeliac, IBD) are excluded.

Severe asthma is defined by any one of: PEF 33-50% predicted, respiratory rate ≥25/min, heart rate ≥110/bpm, or inability to complete sentences in one breath. Life-threatening features would include a silent chest, cyanosis, or PEF <33%.

The patient has cluster headaches. Verapamil is the first-line prophylactic agent (NICE CG150). High-flow oxygen and SC sumatriptan are used for the management of acute attacks, not for prevention. Propranolol and amitriptyline are used for migraine prophylaxis.

A suppressed ACTH in the presence of hypercortisolism indicates ACTH-independent Cushing's Syndrome, most commonly caused by an autonomous adrenal adenoma or exogenous steroids. If exogenous use is ruled out, an adrenal source is most likely.

NICE guidelines recommend referral to a specialist for oral isotretinoin when there is a risk of scarring or if moderate-to-severe acne has failed to respond to two courses of treatment (including an oral antibiotic). This patient has nodules, early scarring, and has failed a standard course of oral lymecycline.

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.

A pan-systolic murmur at the apex radiating to the axilla indicates mitral regurgitation. Chronic mitral regurgitation leads to volume overload of the left atrium and left ventricle, causing left atrial enlargement.

Stanford Type B dissections (descending aorta) are usually managed medically with aggressive blood pressure control (e.g., IV labetalol). Type A dissections (ascending aorta) require urgent surgery.

A pleural protein level >30 g/L is classified as an exudate. Bronchial carcinoma is a common cause of exudative effusions. Heart failure, cirrhosis, and nephrotic syndrome typically cause transudates (protein <30 g/L).

NICE recommends 5 days of oral prednisolone (30mg) for COPD exacerbations and a course of antibiotics if sputum is purulent. Current guidelines have moved away from longer 10-14 day courses of steroids to reduce side effects.

According to the Resuscitation Council UK tachycardia algorithm, the first-line drug for stable narrow-complex SVT after failed vagal manoeuvres is adenosine (6mg, then 12mg, then 12mg). DC cardioversion is for hemodynamically unstable patients.

A Wells score >4 indicates that a pulmonary embolism is likely. In this clinical scenario, the patient should proceed directly to definitive imaging (CTPA) rather than a D-dimer, which is only used to rule out PE in 'unlikely' cases.

The clinical picture describes Murphy's sign, suggestive of acute cholecystitis. Transabdominal ultrasound is the first-line imaging modality for suspected biliary disease as it can identify gallstones, gallbladder wall thickening, and pericholecystic fluid. CT is less sensitive for gallstones, and MRCP is used if choledocholithiasis is suspected.

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.

Squamous cell carcinoma is often centrally located and is classically associated with paraneoplastic hypercalcaemia due to the secretion of parathyroid hormone-related protein (PTHrP).

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.

The patient has signs of severe aortic stenosis (syncope, slow-rising pulse, ESM radiating to carotids). Longstanding aortic stenosis leads to increased afterload and subsequent left ventricular hypertrophy (LVH).

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.

The Short Synacthen test (ACTH stimulation test) is the gold standard for diagnosing primary adrenal insufficiency (Addison's). A failure of cortisol to rise above 425-500 nmol/L (depending on the assay) 30 minutes after synthetic ACTH administration is diagnostic.

In cranial DI, the kidneys can concentrate urine when exogenous ADH (Desmopressin) is provided. In nephrogenic DI, the kidneys fail to respond to Desmopressin, and in primary polydipsia, the urine should concentrate during the deprivation phase.

The clinical picture of fluid loss (vomiting/diarrhoea) combined with hypotension and tachycardia suggests dehydration. The high urea-to-creatinine ratio and negative urinalysis further support a pre-renal cause rather than intrinsic or post-renal damage.

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.

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.

The clinical triad of tremor, bradykinesia, and rigidity is characteristic of Parkinson's Disease. The pathological hallmark is the presence of Lewy bodies (alpha-synuclein aggregates) and the loss of dopaminergic neurons in the substantia nigra pars compacta. Atrophy of the caudate is seen in Huntington's disease.

Rifampicin causes orange/red discoloration of urine, tears, and sweat. Optic neuritis is associated with ethambutol; peripheral neuropathy with isoniazid; and hyperuricaemia with pyrazinamide.

Metamorphopsia (distortion of straight lines) and loss of central vision are hallmark symptoms of age-related macular degeneration (AMD). Glaucoma typically causes peripheral vision loss first. Cataracts cause generalized blurring and glare without specific distortion.

Bullous pemphigoid is an autoimmune blistering disease common in the elderly; the bullae are tense because they are subepidermal. High-potency topical steroids (e.g., clobetasol propionate) are first-line for localized or moderate disease and are associated with fewer side effects than oral steroids in this age group.

Idiopathic Pulmonary Fibrosis typically presents with clubbing and bi-basal fine crackles. HRCT characteristically shows a 'usual interstitial pneumonia' (UIP) pattern, featuring subpleural honeycombing and traction bronchiectasis.

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.

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.

NICE recommends an ACE inhibitor and a beta-blocker as first-line treatment for all patients with heart failure with reduced ejection fraction (HFrEF). While furosemide treats symptoms of congestion, it does not improve mortality like beta-blockers do.