Question Bank

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.

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.

In suspected variceal haemorrhage (cirrhosis history + bleeding), NICE recommends Terlipressin and prophylactic antibiotics (e.g., Ceftriaxone) before endoscopy. PPIs are used for non-variceal bleeds but have no role in acute variceal management prior to endoscopy. Propranolol is used for secondary prevention, not acute bleeds.

The patient likely has Autosomal Dominant Polycystic Kidney Disease (ADPKD). There is a significant association between ADPKD and intracranial berry aneurysms, which can lead to subarachnoid haemorrhage (explaining her father's early death).

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.

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.

In the UK, patients with cirrhosis are screened for HCC every 6 months using liver ultrasound and often serum alpha-fetoprotein (AFP). CEA is for colorectal cancer, and CA19-9 is for pancreatic/biliary cancer.

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.

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

NICE NG100 recommends offering first-line conventional DMARDS (cDMARDs) monotherapy, with methotrexate being the standard first choice. Steroids are used as 'bridging therapy' but do not replace DMARDs. Biologics like Infliximab are reserved for patients failing dual cDMARD therapy.

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.

Septic arthritis is a surgical emergency; joint aspiration for synovial fluid analysis (Gram stain and culture) is the gold standard for diagnosis. Imaging and bloods are supportive but cannot definitively rule in or out infection as quickly or accurately as aspiration.

NICE guidelines recommend an ACE inhibitor (like Ramipril) or an ARB as first-line therapy for patients with CKD and diabetes, or for those with an ACR >30 mg/mmol (or >3 if they have diabetes), due to their renoprotective effects.

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.

ACE inhibitors (like ramipril) should be withheld during an AKI as they can impair autoregulation of glomerular blood flow and exacerbate hyperkalaemia, which is already present here. Bisoprolol and statins are generally continued unless there is severe hypotension or rhabdomyolysis.

Staphylococcus aureus is the most common cause of acute infective endocarditis, particularly in IV drug users. The murmur described is tricuspid regurgitation (right-sided), which is characteristic of endocarditis in this patient group.

Oesophageal manometry is the gold standard for diagnosing achalasia, classically showing a failure of the lower oesophageal sphincter to relax and lacked peristalsis in the distal oesophagus. Barium swallow provides characteristic signs but is not confirmatory. OGD is necessary to rule out pseudoachalasia/malignancy.

Primary hyperparathyroidism is characterized by elevated calcium and inappropriately elevated (or high-normal) PTH, often due to a solitary adenoma. Secondary hyperparathyroidism features high PTH but low/normal calcium (usually renal failure). Malignancy typically causes suppressed PTH due to PTHrP production.

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.

PMR typically shows a rapid and dramatic response to low-dose steroids. NICE and BSR guidelines suggest reviewing response within 1 week; failure to see significant improvement in symptoms (usually >70% within 1 week) should prompt reconsideration of the diagnosis.

For patients with ischaemic stroke presenting within 4.5 hours of symptom onset, thrombolysis with Alteplase is the first-line treatment if haemorrhage is excluded and no contraindications exist. Aspirin 300mg should be given 24 hours after thrombolysis. BP should only be lowered aggressively if >220/120 mmHg unless thrombolysis is planned (where the limit is <185/110 mmHg).

According to UK national DKA guidelines, resolution is defined by pH >7.3, bicarbonate >18 mmol/L, and ketones <0.6 mmol/L. Glucose often normalizes before the metabolic acidosis resolves; therefore, glucose monitoring alone is insufficient for stopping the insulin infusion.

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.

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.

According to the Resus Council and NICE, the first-line treatment for status epilepticus (seizure > 5 mins) in a hospital setting with IV access is IV lorazepam 4mg, which can be repeated once after 10-20 mins. IM midazolam is preferred if IV access is not available. Phenytoin or levetiracetam are second-line agents.

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.

NICE recommends NSAIDs (like naproxen) or colchicine as first-line for acute gout. While colchicine is an option, NSAIDs are often preferred if there are no contraindications; Allopurinol and Febuxostat are urate-lowering therapies (ULT) and should not be initiated during an acute flare.

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).

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 guidelines recommend an antipsychotic (e.g., haloperidol, olanzapine, risperidone, or quetiapine) as first-line treatment for an acute manic episode. Lithium alone may not be sufficient for acute control, and antidepressants like amitriptyline are contraindicated as they can worsen mania.

The classic ECG findings (short PR interval and delta wave) describe Wolff-Parkinson-White (WPW) syndrome, which is caused by the presence of an accessory conduction pathway known as the Bundle of Kent, bypassing the AV node.

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.

In elderly patients or those with underlying ischaemic heart disease, Levothyroxine should be started at 12.5–25 micrograms to avoid precipitating a myocardial infarction or angina through sudden increases in metabolic demand.

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.

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.

NICE NG89 recommends that for elective total hip replacement, pharmacological VTE prophylaxis should be offered for 35 days. Options include oral anticoagulants like rivaroxaban or apixaban, or LMWH for 10 days followed by aspirin for 28 days. Aspirin alone for 14 days is insufficient duration and not first-line.

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.

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.

For patients of Black African or African Caribbean family origin of any age, or patients over 55 who are not of Black African/Caribbean origin, the first-line treatment for hypertension is a Calcium Channel Blocker (CCB) such as amlodipine.

In shockable rhythms (VF/Pulseless VT), Resus Council UK guidelines recommend 1mg adrenaline and 300mg amiodarone after the 3rd shock. For non-shockable rhythms, adrenaline is given immediately.

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%.

His CHA2DS2-VASc score is 3 (Age >=75 = 2 points, Diabetes = 1 point). Anticoagulation (DOAC like apixaban) is indicated for men with a score of 1 or more, and recommended for a score of 2 or more; aspirin is no longer used for stroke prevention in AF.

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.

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.

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.

Myasthenia Gravis is an autoimmune condition characterized by fatiguable muscle weakness due to autoantibodies against the postsynaptic nicotinic acetylcholine receptors at the neuromuscular junction. Antibodies against voltage-gated calcium channels are seen in Lambert-Eaton Myasthenic Syndrome.

Agranulocytosis is a rare but life-threatening side effect of thionamides like Carbimazole. Patients must be warned to have an urgent Full Blood Count if they develop signs of infection, such as a sore throat or fever.

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.

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.