UK Medical Licensing Assessment (UKMLA) Medicine and Long-Term Conditions Flashcards

24 sample cards from the Medicine and Long-Term Conditions deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. How do the thyroid function test patterns differ in primary hyperthyroidism, primary hypothyroidism, and secondary (pituitary) hypothyroidism?

   Primary hyperthyroidism: low TSH, high T4/T3. Primary hypothyroidism: high TSH, low T4. Secondary hypothyroidism: low/inappropriately normal TSH with low T4 (pituitary failure). TSH is the most sensitive screening test for primary thyroid disease.

2. What is the classic biochemistry and Synacthen response in primary adrenal insufficiency (Addison's disease)?

   Hyponatraemia, hyperkalaemia, hypoglycaemia, and raised ACTH with low cortisol. The short Synacthen (ACTH stimulation) test shows a failure of cortisol to rise. Skin/buccal hyperpigmentation is due to high ACTH. Treat with hydrocortisone and fludrocortisone.

3. Outline the screening and confirmatory tests for Cushing's syndrome.

   Screening: overnight/low-dose dexamethasone suppression test (failure to suppress cortisol), 24-h urinary free cortisol, or late-night salivary cortisol. Then measure ACTH to localise: high-dose dexamethasone suppression and imaging distinguish pituitary (Cushing's disease), ectopic ACTH, and adrenal causes.

4. How do you distinguish cranial (central) from nephrogenic diabetes insipidus using the water deprivation test?

   Both fail to concentrate urine during water deprivation. After giving desmopressin (ADH analogue): cranial DI urine osmolality rises ($> 50\%$ increase) because the kidney responds; nephrogenic DI shows no response because the kidney is resistant to ADH.

5. What are the causes and ECG/clinical features of hypercalcaemia, and the immediate management?

   Commonest causes: primary hyperparathyroidism (outpatients) and malignancy (inpatients). Features ('stones, bones, groans, psychic moans'): renal stones, bone pain, abdominal pain/constipation, confusion, short QT interval. Immediate management: IV 0.9% saline rehydration, then IV bisphosphonate.

6. State the targets and primary-prevention thresholds for statin therapy in lipid management (UK).

   Offer atorvastatin 20 mg for primary prevention if QRISK3 $\geq 10\%$, in CKD, or type 1 diabetes with risk factors. Aim for $> 40\%$ reduction in non-HDL cholesterol. Secondary prevention uses atorvastatin 80 mg. Statins inhibit HMG-CoA reductase.

7. Define obesity by BMI and list the WHO classification categories.

   $BMI = \frac{\text{weight (kg)}}{\text{height (m)}^{2}}$. Underweight $< 18.5$; normal 18.5-24.9; overweight 25-29.9; obese class I 30-34.9; class II 35-39.9; class III (morbid) $\geq 40$ kg/m². Lower thresholds apply for South Asian populations.

8. What is the maximum time window for thrombolysis with alteplase in acute ischaemic stroke, and the key contraindication to exclude first?

   IV alteplase is given within 4.5 hours of symptom onset. A non-contrast CT head must first exclude haemorrhage (the main contraindication). Mechanical thrombectomy can be offered up to 24 hours for large-vessel occlusion in selected patients.

9. State the ABCD2 components used to assess early stroke risk after a TIA.

   Age $\geq 60$ (1), Blood pressure $\geq 140/90$ (1), Clinical features — unilateral weakness (2) or speech disturbance without weakness (1), Duration $\geq 60$ min (2) or 10-59 min (1), Diabetes (1). Higher scores predict greater early stroke risk (though current UK practice treats all TIAs urgently).

10. List the red-flag features of headache that mandate urgent investigation.

    Thunderclap (peak $< 5$ min, ?subarachnoid haemorrhage), new headache age $> 50$ with jaw claudication/scalp tenderness (GCA), morning headache worse on coughing/lying (raised ICP), fever and neck stiffness (meningitis), focal neurology, new headache in immunosuppression/cancer, and progressive headache with personality change.

11. Contrast migraine, tension-type headache, and cluster headache.

    Migraine: unilateral throbbing, 4-72 h, with nausea, photophobia/phonophobia, ± aura. Tension-type: bilateral 'tight band' pressure, no nausea, not aggravated by activity. Cluster: severe unilateral periorbital pain, 15-180 min, in clusters, with ipsilateral lacrimation, rhinorrhoea and ptosis.

12. How are focal and generalised seizures distinguished, and what is the first-line drug for generalised tonic-clonic seizures?

    Focal seizures arise from one hemisphere (may have aura, can become bilateral); generalised seizures involve both hemispheres from onset with loss of awareness. First-line for generalised tonic-clonic: sodium valproate (lamotrigine/levetiracetam in women of childbearing potential as valproate is teratogenic).

13. Define status epilepticus and outline the emergency drug management.

    A seizure lasting $> 5$ min, or repeated seizures without recovery of consciousness between them. Management: secure airway/oxygen, IV lorazepam (or buccal midazolam/rectal diazepam) repeated once after 5-10 min, then IV phenytoin/levetiracetam, then general anaesthesia if refractory.

14. Compare the cardinal features and pathology of Parkinson's disease.

    Triad: bradykinesia, resting 'pill-rolling' tremor (4-6 Hz), and rigidity (cogwheel/lead-pipe), typically asymmetrical, with postural instability. Pathology: loss of dopaminergic neurons in the substantia nigra pars compacta with Lewy bodies (alpha-synuclein). First-line treatment: levodopa with a decarboxylase inhibitor.

15. Differentiate multiple sclerosis from Guillain-Barré syndrome by site, course and CSF findings.

    MS: CNS demyelination, relapsing-remitting lesions 'disseminated in time and space', CSF oligoclonal bands, MRI plaques. Guillain-Barré: acute ascending peripheral demyelinating polyneuropathy post-infection (e.g. Campylobacter), areflexia, CSF albuminocytological dissociation (high protein, normal cells); monitor FVC for respiratory failure.

16. Describe the pathophysiology and hallmark clinical sign of myasthenia gravis.

    Autoantibodies against postsynaptic acetylcholine receptors (or MuSK) at the neuromuscular junction. Hallmark: fatigable muscle weakness worsening with activity, typically ptosis and diplopia. Associated with thymoma. Tests: anti-AChR antibodies, repetitive nerve stimulation. Treat with pyridostigmine and immunosuppression.

17. What are the classic CSF findings distinguishing bacterial, viral and tuberculous meningitis?

    Bacterial: cloudy, high neutrophils, high protein, low glucose ($< \frac{1}{2}$ serum). Viral: clear, lymphocytes, normal/mildly raised protein, normal glucose. TB: fibrinous, lymphocytes, very high protein, very low glucose. Give empirical IV ceftriaxone immediately for suspected bacterial meningitis.

18. List the signs of raised intracranial pressure and the Cushing's reflex.

    Headache (worse on lying/coughing), vomiting, papilloedema, reduced GCS, and pupillary changes. Cushing's reflex (late, pre-herniation): hypertension (widening pulse pressure), bradycardia, and irregular breathing. Manage by treating the cause, head elevation, and may need mannitol/hypertonic saline.

19. Compare the joint pattern and serology of rheumatoid arthritis versus osteoarthritis.

    Rheumatoid: symmetrical small-joint (MCP/PIP/wrist) inflammatory arthritis, early morning stiffness $> 30$ min, RF and anti-CCP positive, erosions on X-ray. Osteoarthritis: asymmetrical large/weight-bearing and DIP joints, stiffness $< 30$ min, worse with activity; X-ray shows joint-space narrowing, osteophytes, subchondral sclerosis and cysts (LOSS).

20. List the diagnostic autoantibodies associated with SLE and the antiphospholipid syndrome.

    SLE: ANA (sensitive, screening), anti-dsDNA (specific, tracks disease activity), anti-Smith (specific). Antiphospholipid syndrome: lupus anticoagulant, anti-cardiolipin, and anti-beta-2-glycoprotein I antibodies — causing arterial/venous thrombosis and recurrent miscarriage.

21. How is osteoporosis diagnosed by DEXA T-score, and what is the first-line treatment?

    Osteoporosis: T-score $\leq -2.5$; osteopenia: T-score between $-1.0$ and $-2.5$ (standard deviations from young-adult mean). First-line treatment: oral bisphosphonate (e.g. alendronate) with calcium and vitamin D, which inhibits osteoclast-mediated bone resorption.

22. What are the diagnostic features and immediate management of septic arthritis?

    Acutely hot, swollen, painful joint with restricted movement and fever; most commonly Staphylococcus aureus. Investigation: urgent joint aspiration for Gram stain, culture and crystals before antibiotics. Management: joint aspiration/washout and IV antibiotics (e.g. flucloxacillin). It is a surgical emergency to prevent joint destruction.

23. Classify anaemia by mean corpuscular volume (MCV) with examples in each category.

    Microcytic ($MCV < 80$ fL): iron deficiency, thalassaemia, anaemia of chronic disease, sideroblastic. Normocytic (80-100): acute blood loss, haemolysis, chronic disease, renal failure. Macrocytic ($> 100$): B12/folate deficiency (megaloblastic), alcohol, hypothyroidism, liver disease, myelodysplasia.

24. Compare Hodgkin and non-Hodgkin lymphoma and the management of suspected neutropenic sepsis.

    Hodgkin lymphoma: Reed-Sternberg cells, bimodal age, orderly spread, alcohol-induced node pain, generally good prognosis. Non-Hodgkin: heterogeneous (e.g. diffuse large B-cell), often extranodal/widespread. Neutropenic sepsis (neutrophils $< 0.5 \times 10^{9}$/L + temperature $> 38°C$): give empirical IV piperacillin-tazobactam within 1 hour — a medical emergency.

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