Endo + Diabetes, Urinary, Infection + MSK finals flashcards!!!

Question 1

GFR would increase if:

a. There is afferent arteriole constriction
b. There is efferent arteriole constriction
c. There is an increase in tissue pressure in Bowman’s capsule
d. There is an increased release of renin from the JG cells
e. There is an obstruction of the ureters

Answer 1

b. There is efferent arteriole constriction

Question 2

2. How would drinking a large amount of water affect osmolarity and volume of the ECF?

a. Decreased osmolarity and increased volume
b. Both would increase
c. No change in osmolarity and increased volume
d. No change in either
e. Greater increase in ECF volume than ICF volume

Answer 2

a. Decreased osmolarity and increased volume

Question 3

3. Anti-Diuretic Hormone (ADH):

a. Is produced by the anterior pituitary
b. Inserts aquaporins into all parts of the kidney tubule
c. Causes the hypertonic medullary gradient to be established
d. Is released in response to cellular dehydration
e. Is released in response to increased plasma urea

Answer 3

d. Is released in response to cellular dehydration

Question 4

4. If Drug A’s clearance is greater than inulin clearance, then which of the following would be true of Drug A?

a. net reabsorption
b. no reabsorption
c. no secretion
d. net secretion
e. reabsorbed and secreted

Answer 4

d. net secretion

Question 5

5. The following acid/base values were obtained:
   pH = 7.25, [HCO3-] = 12mmoles/l, Pco2 = 3.3kPa (25mmHg)

a. They are indicative of a respiratory acidosis
b. The reduction in Pco2 is a result of under-breathing
c. The subject has probably been taking bicarbonate of soda
d. It could be related to impaired renal function
e. The subject may have been vomiting very badly

Answer 5

d. It could be related to impaired renal function

(ROME: Respiratory = Opposite (pcO2), Metabolic = Equal (HCO3-))

(Normal PCO2 = 35-45mmHg or 4.7-6kPa, Normal HCO3- = 22-29mmol/L)

Question 6

6. The following acid/ base values were obtained:
   pH = 7.45, [HCO3-] = 12mmoles/l, Pco2 = 2.7kPa (20mmHg)

a. The subject is clearly very unwell
b. The subject is likely to have spent a long time at altitude
c. The subject needs bicarbonate
d. The subject is unlikely to be hypoxic
e. This is typical of a metabolic alkalosis

Answer 6

b. The subject is likely to have spent a long time at altitude

(ROME: Respiratory = Opposite (pcO2), Metabolic = Equal (HCO3-))

(Normal PCO2 = 35-45mmHg or 4.7-6kPa, Normal HCO3- = 22-29mmol/L)

Question 7

7. The following acid/base values were obtained:
   pH = 7.28, [HCO3-] = 36mmoles/l, Pco2 = 8kPa (60mmHg)

a. This is typical of an acute respiratory acidosis.
b. The subject will be excreting large amounts of bicarbonate ions
c. The subject will be excreting large amount of ammonium ions
d. The plasma potassium level is likely to be decreased
e. He has a metabolic alkalosis because of the raised bicarbonate

Answer 7

c. The subject will be excreting large amount of ammonium ions

(the lower the pH -> (the more H+ ions present) -> the more NH3 present as NH4+)

(ROME: Respiratory = Opposite (pcO2), Metabolic = Equal (HCO3-))

(Normal PCO2 = 35-45mmHg or 4.7-6kPa, Normal HCO3- = 22-29mmol/L)

Question 8

8. The following acid/base values were obtained:
   pH =7.50, [HCO3-] = 45mmoles/l, Pco2 = 8kPa (60mmHg)

a. This may be the result of bad diarrhoea
b. The subject will be excreting bicarbonate ions
c. The subject will be excreting ammonium ions
d. The plasma potassium level is likely to be increased
e. The subject has a respiratory acidosis because of the raised Pco2

Answer 8

b. The subject will be excreting bicarbonate ions

(the higher the pH -> (the less H+ ions present) -> the more HCO3- is excreted)

(ROME: Respiratory = Opposite (pcO2), Metabolic = Equal (HCO3-))

Question 9

9. The following values were made for an elderly female diabetic patient’s creatinine clearance:
   24hr urine volume 1.44l, serum creatinine concentration 100μmol/L, urine creatinine concentration 6.6mmoles/L.

a. Clinical features of renal impairment would be expected.
b. Serum creatinine alone indicates impaired renal function.
c. Serum potassium should be measured urgently
d. The data suggest there may be renal impairment.
e. There is reason to suspect an incomplete renal collection.

Answer 9

d. The data suggest there may be renal impairment.

(- normal serum creatinine:
Men = 59 - 104 µmol/L
Women = 45 - 84 µmol/L

• normal urine creatinine:
  Men = 7 - 14 mmol/L
  Women = 6 - 13 mmol/L)

Question 10

10. A patient with lung cancer develops the syndrome of inappropriate ADH secretion. Which of the following values for Na+ concentration might be expected to be seen?

a. 140mmol/L
b. 145mmol/L
c. 150mmol/L
d. 138mmol/L
e. 128mmol/L

Answer 10

e. 128mmol/L

normal Na+ = 135-145mmol/L

Question 11

11. Which of the following are classed as loop diuretics?

a. Furosemide
b. Spironolactone
c. Bendroflumethiazide
d. Mannitol
e. Amiloride

Answer 11

a. Furosemide

(Spironolactone = mineralocorticoid receptor antagonist

• Bendroflumethazide = thiazide diuretic
• Mannitol = osmotic diuretic
• Amiloride = eNaC inhibitor)

Question 12

What is the mechanism action of Spironolactone?

Answer 12

• Mineralocorticoid receptor antagonist
• Blocks Na+-K+ exchanger in the DCT
• K+-sparing!!

Question 13

What is the mechanism action of Bendroflumethiazide?

Answer 13

• Thiazide diuretic
• Blocks Na+-Cl- co-transporter in DCT
• Increases Na+ and Cl- secretion
• (NOT K+-SPARING!! - bc blocks a channel proximal in the DCT, therefore increasing the amount of Na+ going to the distal part of the DCT, therefore increasing Na+-K+ exchange and K+ loss…)

Question 14

What is the mechanism action of Mannitol?

Answer 14

• Osmotic diuretic

- PCT + descending limb of LoH

Question 15

What is the mechanism of action of Amiloride?

Answer 15

• Blocks eNaCs (Na+ channels) in DCT
• Prevents reabsorption of Na+ and K+ loss
• K+ sparing!!

Question 16

What is the mechanism of action of Furosemide?

Answer 16

• Blocks Na+-K+-Cl- co-transporter
• in the ascending limb of LoH
• (NOT K+-SPARING)

Question 17

What is the mechanism of action of ADH?

What triggers its release?

Where is it released from?

Answer 17

• Stimulates water reabsorption in the Collecting Duct -> increases the insertion of aquaporins into the membranes of the collecting duct (nephron)
• Triggered during states of increased plasma osmolality (hyperosmolality)
• increased blood osmotic pressure triggers osmoreceptors in the hypothalamus -> (increases thirst response and) stimulates the release of ADH from the posterior pituitary (by nerve impulses through nerve plexus!!)

Question 18

Which diuretics are K+-sparing?

Answer 18

• SEAT*
• Aldosterone antagonists/MRAs = Spironolactone, Eplerenone
• Direct ENaC inhibitors = Amiloride, Triamterene

Question 19

12. A 6 year old child presents with swelling of his face and legs. His serum albumin concentration is 18g/l (normal 37-42) and his mother notices that his urine is frothy. What is the most likely diagnosis?

a. Ig-A glomerulonephritis
b. Minimal change disease
c. Focal and segmental glomerulonephritis
d. Membraneous nephropathy
e. Lupus nephritis

Answer 19

b. Minimal change disease

Question 20

13. A 23 year old woman complains of flank pain, dysuria and frequency of micturition. She has taken ibuprofen for the pain. Her urinalysis shows protein, nitrites and blood. What is the likely diagnosis?

a. Acute pyelonephritis
b. Cystitis
c. Chronic pyelonephritis
d. Reflux nephropathy
e. Analgaesic nephropathy

Answer 20

a. Acute pyelonephritis

Question 21

14. A 40 year old man was found to have asymptomatic proteinuria and microscopic haematuria during routine employment-related examination. His BP was found to be 160/100mmHg and serum creatinine 170micromol/l (normal 86-116). He has no urinary symptoms. What is the next most important investigation?

a. Chest X-ray
b. Echocardiogram
c. Intravenous urogram
d. Ultrasound of the urinary tract
e. Renal biopsy

Answer 21

d. Ultrasound of the urinary tract

(assesses full urinary tract for problems: upper urinary tract = kidneys + ureters, lower urinary tract = bladder + urethra)

Question 22

15. A 60 year old man has stage 5 CKD with a serum creatinine of 500 umol/l, (normal 88-116). Which of the following is likely to be present?

a. High serum calcium
b. Low serum phosphate
c. High serum phosphate
d. Normal serum calcium
e. Normal serum phosphate

Answer 22

c. High serum phosphate
* inability to remove phosphate in CKD*
* nb. hyperphosphataemia causes hypocalcaemia due to increased binding of Ca2+*

Question 23

What are the stages of CKD?

Answer 23

• 5 Stages!!*
• Stage 1: with normal or high GFR -> GFR > 90 mL/min)
• Stage 2: Mild CKD -> GFR = 60-89 mL/min
• Stage 3A: Moderate CKD -> GFR = 45-59 mL/min
• Stage 3B: Moderate CKD -> GFR = 30-44 mL/min
• Stage 4: Severe CKD -> GFR = 15-29 mL/min
• Stage 5: End Stage CKD -> GFR <15 mL/min

Question 24

16. A 60 year old man has stage 5 CKD with a serum creatinine of 500 umol/l, (normal 88-116). Which of the following is likely to be present?

a. Low serum calcium
b. Normal serum calcium
c. Low serum phosphate
d. Normal serum calcium
e. High serum calcium

Answer 24

a. Low serum calcium

• inability to remove phosphate in CKD -> hyperphosphataemia causes hypocalcaemia due to increased binding of Ca2+*
• also: reduction in Calcitriol formation, leads to reduced Ca2+ absorption in the intestines*

Question 25

17. Patients with renal failure are often anaemic. What is the best treatment for their anaemia? a. Oral iron therapy b. Intravenous iron c. Vitamin B12 d. Erythropoietin e. Blood transfusion

Answer 25

d. Erythropoietin | kidneys make erythropoeitin -> increases RBC formation

Question 26

18. For an uncomplicated urinary infection which of the following organism is the most likely cause? a. Staphylococcus aureus b. Klebsiella sp c. Pseudomonas aeruginosa d. Candida albicans e. Escherichia coli

Answer 26

e. Escherichia coli | * MSU + Urinalysis: single organism present in high concentration (≥ 10^5 CFU/ml)*

Question 27

What type of bacteria causes UTI from kidney stones?

Answer 27

Proteus spp.

Question 28

19. A 70 year old man complains of poor stream of urine, nocturia and post-micturition dribbling. Which of the following is the most likely cause? a. Diabetic neuropathy b. Urinary tract infection c. Chronic kidney disease d. Prostatic hypertrophy e. Bladder cancer

Answer 28

d. Prostatic hypertrophy

Question 29

20. A 60 year old man presents with tiredness and malaise. Routine investigations reveal a raised serum creatinine and an estimated GFR of 35ml/min. Which of the following stages of CKD is he in? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Stage 5

Answer 29

c. Stage 3 * - Stage 3A: Moderate CKD -> GFR = 45-59 mL/min - Stage 3B: Moderate CKD -> GFR = 30-44 mL/min*

Question 30

21. The commonest urological malignancy in patients with painless frank haematuria is: a. kidney cancer b. testicular cancer c. bladder cancer d. penile cancer e. prostate cancer

Answer 30

c. bladder cancer

Question 31

What is the most-likely differential of painful frank haematuria?

Answer 31

- UTI | - Urinary calculi (stones)

Question 32

22. What is the commonest type of renal tract stones in adults? a. calcium phosphate b. calcium oxalate c. cystine d. magnesium ammonium phosphate e. uric acid

Answer 32

b. calcium oxalate

Question 33

23. What is the commonest mode of presentation for patients with a renal or ureteric stone? a. loin pain radiating to the flank and/or groin b. frank haematuria c. urinary tract infection d. lower urinary tract symptoms e. acute urinary retention

Answer 33

a. loin pain radiating to the flank and/or groin | * painful frank haematuria = UTI or urinary tract stones!!*

Question 34

24. What are the features of acute urinary retention? a. painful inability to void with a palpable or percussible bladder b. slow stream of micturition with terminal dribbling and frequency c. painless condition with a palpable or percussible bladder d. dysuria with frank haematuria e. bladder pain which is worse when the bladder is full and relieved by voiding

Answer 34

a. painful inability to void with a palpable or percussible bladder ``` (b = LUTS c = chronic urinary retention d = UTI, kidney stone e = interstitial cystitis (inflammation of the bladder)* ```

Question 35

25. The following antibiotics are generally suitable for empirical treatment of complicated urinary traction infections except: a. Vancomycin b. Ciprofloxacin c. Ceftriaxone d. Gentamicin e. Co-amoxiclav

Answer 35

a. Vancomycin * vanc is usually only used for staph aureus, and c. diff -> it is v unusual for staph aureus to cause UTI (it is usually caused by E. coli -> ciprofloxacin!!)*

Question 36

1. A patient with hypothyroidism would demonstrate which of the following symptoms: ``` A. Exopthalmos B. Increased heart rate C. Heat intolerance D. Increased protein catabolism E. Lethargy ```

Answer 36

E. Lethargy *all the rest = hyPERthyroidism*

Question 37

2. Goitre is a common symptom of thyroid dysfunction and can be present in both hypo- and hyper- thyroidism. However it would not be present in which of the following thyroid pathologies? ``` A. Primary hypothyroidism B. Secondary hypothyroidism C. Primary hyperthyroidism D. Secondary hyperthyroidism E. Graves disease ```

Answer 37

B. Secondary hypothyroidism * Goitre is caused by overstimulation of the thyroid gland -> causes hypertrophy - primary hypothyroidism = lack of T3 and T4 -> causes increased TSH from anterior pituitary (ie. due to autoimmunity, iodine-deficiency) - hyperthyroidism = increased activity of the thyroid gland (ie. due to abs mimicking TSH (grave's/primary), adenoma (most common cause of primary hyperthyroidism) or TSH-secreting tumour (secondary) = GOITRE - secondary hypothyroidism = lack of TSH, and therefore a reduction in the stimulation of the thyroid gland = NO goitre!!*

Question 38

3. A decrease in circulating cortisol levels would result in which of the following physiological responses: A. Enhanced gluconeogenesis in the liver. B. Hypotension C. Decreased ACTH secretion from the anterior pituitary D. Elevated fatty acid levels in the plasma E. Suppression the immune system

Answer 38

B. Hypotension *all the others are caused by increased cortisol secretion -> lack of cortisol can be caused by addison's*

Question 39

4. A person with primary hypercortisolism would demonstrate: ``` A. Depressed ACTH correct, due to enhanced negative feedback from cortisol B. Elevated CRH C. Hypotension D. Hypoglycaemia E. Increased bone density ```

Answer 39

A. Depressed ACTH *due to negative feedback* ``` *B = unlikely due to negative feedback from cortisol C = no bc cortisol causes hypertension occurs due to permissive effect of cortisol on noradrenaline α1 adrenoceptors D = no bc hyperglycaemia is an effect of cortisol secretion due to gluconeogenic action on liver E = no bc cortisol stimulates bone resorption so osteoporosis is more likely* ```

Question 40

5. Chronic glucocorticoid therapy is associated with which of the following: A. Enhanced cortisol release from the adrenal glands B. Enhanced ACTH release from the anterior pituitary C. Enhanced CRH release from the hypothalamus D. Adrenal insufficiency E. Adrenal hypertrophy

Answer 40

D. Adrenal insufficiency *excess glucocorticoid therapy (ie. pred, hydrocortisone) on a chronic basis increases negative feedback on CRH and ACTH, which results in hypo-secretion of cortisol when it is suddenly withdrawn, hence why u need to slowly taper off the dose!!*

Question 41

6. Which of the following will elevate free calcium levels in plasma? ``` A. Alkalosis B. Activation of osteoblasts C. Increased phosphate excretion at the kidney D. Calcitonin E. All of the above ```

Answer 41

C. Increased phosphate excretion at the kidney *causes reduced Ca2+ in the blood as there is less being complexed with phosphate in bone -> nb. PTH increases phosphate excretion to increase Ca2+ levels!!* ``` *A = no bc loss of H+ frees up binding sites for Ca++ on plasma proteins B = no bc osteoBlasts Build Bone and use Ca++ in doing so D = calcitonin is a hormone that reduces plasma calcium levels (made by thyroid gland) ```

Question 42

What secretes Calcitonin? What is it's functions of Calcitonin?

Answer 42

- Thyroid gland * It's function is to REDUCE plasma Ca2+!* - inhibits osteoclast activity - inhibits reabsorption of Ca2+ at the renal tubules

Question 43

7. Regarding Growth Hormone which of the following is correct: A. It is also known as somatostatin B. It is also known as somatomedin C. It is a steroid hormone D. Levels in adults are at their highest during REM sleep E. It is relatively insignificant in terms of foetal and neonatal growth

Answer 43

E. It is relatively insignificant in terms of foetal and neonatal growth ``` *A = no bc GH = somatoTROPIN, somatoSTATIN = GHIH B = somatomedin C = IGF-1 C = it is a peptide hormone D = it is highest during delta sleep and lowest during REM sleep E = yep, bc it is more important during the months following birth (thyroid hormone and insulin are more important hormones during foetal + neonatal growth)* ```

Question 44

What stage of sleep is growth hormone highest and lowest in?

Answer 44

- Highest = Delta sleep | - Lowest = REM sleep

Question 45

What structure releases GHRH or GHIH? What is the function of each?

Answer 45

- Hypothalamus!! | - acts on the Anterior Pituitary to increase or decrease GH (respectively)!

Question 46

8. The adrenal zona glomerulosa secretes which hormone: ``` A. Testosterone B. Progesterone C. Aldosterone D. Cortisol E. Epinephrine/adrenaline ```

Answer 46

C. Aldosterone ``` *A = Zona reticularis B = Zona reticularis D = Zona fasiculata E = Adrenal medulla* ```

Question 47

9. Which of the following responses would you expect following insulin release: ``` A. Hepatic gluconeogenesis B. Increased ketone formation C. Increased uptake of glucose by the brain D. Adipose lipolysis E. Stimulation of Na+/K+ ATPase ```

Answer 47

E. Stimulation of Na+/K+ ATPase *function of insulin is to DECREASE BG levels!!* (-> remember, SGLT-1 uses secondary active transport from the sodium gradient created by the Na+-K+-ATPase to bring glucose into cells, so insulin would like that! * C = Brain is an obligatory glucose utiliser so does not require insulin for glucose uptake* * A, B and D are actions of glucagon*

Question 48

10. Which of the following is not a Glucose Counter Regulatory Hormone: ``` A. Thyroid hormone B. Epinephrine (adrenaline) C. Glucagon D. Cortisol E. Growth hormone ```

Answer 48

A. Thyroid hormone * While TH stimulates gluconeogenesis, TH stimulates futile metabolic cycles that consume the glucose as well so blood glucose does not rise significantly.* * all the rest RAISE BG levels*

Question 49

11. A 26 year old man is diagnosed with Type 1 diabetes. He works offshore on a ‘2 week on 3 week off’ rota. He drives a car. He has just got married and his wife is expecting their first child. What information should he receive shortly after diagnosis? A. He should be told he cannot drive. B He may be able to work off-shore depending on his employer and where he is going. C He is likely to pass on his diabetes to his child. D He should be advised to stop drinking any alcohol. E He should be told he is unlikely to ever have any hypos (hypoglycaemic episodes) if he monitors his blood glucose regularly.

Answer 49

B He may be able to work off-shore depending on his employer and where he is going. ``` *A = Important to take lifestyle of pt. on board and consider their employment and home circumstances -> what kind of vehicle does he drive? Does he hold a normal driver's license and what are the DVLA regulations? B = There is not an automatic ban on working off shore if you have Type 1 Diabetes but you need to involve your Occupational Health team/employer C = There is a risk offspring can develop Type 1 DM but not ‘likely’. D = Alcohol within guidance limits but not to stop alcohol at all. Aware of risk of hypoglycaemia and alcohol. E = Patients to achieve good control will experience hypos. ```

Question 50

12. An 80 year old lady who is keen to stay healthy and well comes to see you in clinic. She has been having daily episodes of sweating and palpitations and been feeling hungry. She has had type 2 diabetes for 30 years and is on Metformin 1g bd and Glipizide 5mg bd. Her renal function has deteriorated but her GFR is 50 with a creatinine of 88. Her HbA1c is 51mmol/mol. During one of the episodes she checked her blood glucose and found that it was 3.0mmol/l. What action should be taken initially with regard to her management? ``` A. Stop metformin B. Stop Glipizide C. Check blood glucose more regularly D. Repeat HbA1c E. Request a holter monitor ```

Answer 50

B. Stop Glipizide *Normal GFR = 60 or higher Normal Creatinine = 52-92mmol/l Upper limit of HbA1c = 48 mmol/mol Normal BG = 4 - 5.4 (when fasting) and up to 7.8 (2hrs after meals)* *Glipizide should be stopped as she is having daily hypos and sulphonylureas can cause hypoglycaemia. This is the biggest risk to her safety and her blood glucose levels appear to be reasonably well controlled and the aim of treating her diabetes is to keep her well and safe.*

Question 51

13. 53 year old man diagnosed with T2 Diabetes Mellitus 6 months ago. He has lost 1 stone in weight his BMI is 28 and HbA1c is 75 mmol/mol (9%). What is the next appropriate medication in his management? ``` A. Insulin B. Thiazolidinedione (e.g. pioglitazone) C. Sulphonylurea (e.g. glimepiride) D. Biguanide (e.g. Metformin) E. DPP IV inhibitor (e.g. Sitagliptin) ```

Answer 51

D. Biguanide (e.g. Metformin) * Upper limit of HbA1c = 48 mmol/mol* * Important to be aware of the algorithms for the management of T2 Diabetes -> Sign 154*

Question 52

What is the treatment algorithm for Type 2 DM?

Answer 52

- Step 1 = lifestyle advice +/- monotherapy (metformin) (consider 3 months lifestyle change first) - > target HbA1c = 53 mmol/mol - > remember pt needs normal renal function for metformin (stop metformin treatment if eGFR is <30ml/min/1.73m2) * if not reaching target, then...* - Stage 2 = add Sulphonylurea (ie. glipizide); or if hypos a concern (ie. due to driving, occupational hazards or falling frequently/risk of falls) thiazolidinedione (ie. pioglitazone -> if no congestive heart failure) or DPP-IV inhibitor (ie. gliptin -> if weight gain was a concern) - Stage 3 = triple therapy: thiazolidinedione or DPP-IV inhibitor or injectable insulin or GLP-1 agonist (ie. semaglutide, if obese, desire to lose weight - it is associated with weight loss)

Question 53

At which eGFR should you stop/not prescribe Metformin for Type 2 DM?

Answer 53

30 ml/minute/ 1.73m2

Question 54

What are the contra-indications for Thiazolidinediones? (ie. pioglitazone)

Answer 54

- Congestive HF | - Obese (BMI >30) (bc it causes weight gain)

Question 55

Which diabetes drug class is associated with weight loss?

Answer 55

GLP-1 agonist (ie. semaglutide) | used in obese (BMI >30) and in those with a desire to lose weight, usually <10yrs from diagnosis

Question 56

14. Which symptom below is NOT typical of hypoglycaemia? ``` A. Headache B. Itch C. Poor concentration D. Sweating E. Irritability ```

Answer 56

B. Itch *other symptoms include: feeling anxious, trembling or shaking, tingling of lips, hunger, going pale, palpitations*

Question 57

15. 32 year old patient with T1 Diabetes Mellitus is reviewed at the diabetes clinic. His blood sugar is 3.2 mmol/l and he tells you he is feeling well. What is the best course of action next? ``` A. Administer IM glucagon B. Send him home for lunch C. Give 200ml fresh orange juice D. Give digestive biscuit E. Administer his lunchtime insulin ```

Answer 57

C. Give 200ml fresh orange juice *mans is having a hypo: Normal BG = 4 - 5.4 (when fasting) and up to 7.8 (2hrs after meals))*

Question 58

16. 25 year old with Type 1 Diabetes Mellitus presents with vomiting and diarrhoea. BP 80/54 and Respiratory Rate is 24 breath/min. Which test is least important for immediate management? ``` A. Blood Glucose B. pH C. Urine/Blood Ketones D. Electrolytes E. Liver function tests ```

Answer 58

E. Liver function tests * DKA protocol: BG, ketones, pH (acid-base balance), U+Es (for electrolytes)* * LFTs are important, but not for acute emergency settings: only used if pt. is jaundiced or self-poisoned with paracetamol (clotting screen in self-poisoning lets u know the synthetic function of the liver in the scenario of self-poisoning*

Question 59

Why are K+ levels high in a DKA?

Answer 59

* NORMAL K+ = 3.6-5.2mmol/L* - Insulin stimulates Na+-K+ pump -> this allows SGLT-1 transporter to work as it uses the sodium gradient created by the Na+-K+ pump to allow the co-transport of sodium and glucose into the body - This is obvs not working in DKA - K+ is not shifted into cells and out of the body, and therefore stays in the interstitial space and causes hyperkalaemia * hence the need to monitor electrolytes (U+Es) in DKA!!*

Question 60

17. 23 year old man diagnosed with hyperthyroidism and has been commenced on carbimazole. What do you need to counsel him regarding? ``` A. Neutropenia B. Fertility C. Metallic taste in mouth D. Renal Function E. Discoloration of Urine ```

Answer 60

A. Neutropenia *Neutropoenia and agranulocytosis -> due to carbimazole-induced bone marrow suppression -> needs to be stopped if pt reports symptoms and signs suggestive of infection (esp. SORE THROAT) -> a WBC count also needs to be performed in the scenario of infection -> carbimazole should be stopped if any clinical or lab evidence of neutropoenia*

Question 61

18. A man with a large prolactinoma complains of impaired vision. What is the most likely pattern of visual field loss to be found on clinical confrontation? ``` A. Homonymous hemianopia B. Bitemporal hemianopia C. Total loss of vision in one eye D. Homonymous quadrantanopia E. Nasal hemianopia ```

Answer 61

B. Bitemporal hemianopia *pituitary adenoma -> impinges on nasal fibres of both optic nerve which cross over just above the pituitary gland -> loss of temporal half of both visual fields!!*

Question 62

19. 38 year old lady presents feeling tired and dizzy. She is tanned and her investigations show Na 123 (low) K 5.6 (high). Thyroid function tests are normal and calcium is normal. Her cortisol 50 (low). What is her diagnosis? ``` A. Hyperparathyroidism B. Addison’s Disease C. Cushing’s Disease D. Grave’s Disease E. Conn’s Syndrome ```

Answer 62

B. Addison’s Disease -> low cortisol and aldosterone * normal Na+ = 135-145mmol/L* * normal K+ = 3.6-5.2mmol/L* ``` *A = Hyperparathyroidism causes hypercalcaemia C = Cushings is an excess of cortisol D = Grave’s disease is autoimmune thyrotoxicosis. E = Conn’s syndrome is excess aldosteronism* ```

Question 63

What are the clinical features of Hyperparathyroidism?

Answer 63

*Hypercalcaemia!* - Bones - Stones - Abdominal moans

Question 64

What are the clinical features of Conn's syndrome

Answer 64

* Excess aldosteronism!!* - Hypokalaemia - Hypernatraemia - Hypertension

Question 65

20. All the conditions below are well recognised causes of secondary diabetes except one. Which condition is not a recognised cause of secondary diabetes? ``` A. Acromegaly B. Haemochromatosis C. Addison’s Disease D. Cushing’s Disease E. Chronic Pancreatitis ```

Answer 65

C. Addison’s Disease - > causes low cortisol and aldosterone, so not associated with hyperglycaemia which u would see in Type 2 DM - > actually causes isseues with hyPOglycaemia *When pt's present with Type 2 DM, always think could this be due to secondary diabetes? A = GH excess -> monitor IGF-1 B = iron deposits in the pancreas -> bronzed diabetes -> deranged LFTs and iron overload (ferritin levels), can require testosterone replacement in men too C = hypercortisolism = body habitus, moon face, buffalo hump, thin arms and legs, central obesity E = has ongoing acute episodes renders the pancreas insufficient -> pain in epigastrium that spreads to the back, malabsorption, steatorrhoea, weight loss -> can require creon too to help absorption of food*

Question 66

What are the typical features of Acromegaly?

Answer 66

* GH excess* - Enlarged hands and feet - change in ring or shoe size - Enlarged facial features - teeth, nose and jaw getting larger (spaced teeth) - Sleep Apnoea (tiredness/difficulty sleeping) - Carpal Tunnel syndrome (compressed nerve causing numbness and weakness in hand)

Question 67

What is the diagnostic test for acromegaly?

Answer 67

- IGF-1 test - OGTT - > (GH causes hyperglycaemia)

Question 68

What are the clinical features of cushing's?

Answer 68

* Hypercortisolism* - Body habitus - Moon face (+ red and puffy) - Buffalo hump - Thin arms and legs - Central obesity - Striae - Easy bruising

Question 69

What is the diagnostic test for Cushing's?

Answer 69

- 24-hr urine cortisol test - > loss of diurnal variation of cushing's - To differentiate between endogenous and ectopic ACTH release - low-dose Dexamethasone suppression test - > should suppress ACTH, if not then probs due to ectopic cause - IPSS (inferior petrosal sinus sampling) - > gold-standard - > differentiates where the source of the ACTH is coming from by sampling the venous blood

Question 70

What primary screening diagnostic test would you do for diabetes?

Answer 70

Random BG test (>11 = diagnostic) *this in conjunction with primary diabetic symptoms will make ur diagnosis of diabetes, may need a fasting BG if pt. if presents w no symptoms to confirm diagnosis*

Question 71

What investigations would you do for a prompt diagnosis of diabetes in an acute presentation?

Answer 71

- Capillary BG test - Urinalysis (glucose and ketones) - Blood ketones * to rule out DKA if presenting w symptoms in the clinic* * if pt. starts vomiting and appears unwell then REFER FOR DKA!!*

Question 72

What is important in the initial management of Type 1 Diabetes?

Answer 72

- Review by the diabetes multi-disciplinary team in the local hospital - Education especially diet (carbohydrate) and lifestyle - Insulin – administration, technique and dose - Home blood sugar and ketone testing - Hypoglycaemia management * if pt. appears well and is not vomiting or anything, if this is the case then REFER ASAP (after taking capillary BG)!!*

Question 73

What are the identifying clinical features of Paget's disease?

Answer 73

- Old man - Bone pain - Raised ALP (alkaline phosphatase)

Question 74

Which ribs are the kidneys behind?

Answer 74

Ribs 11 + 12

Question 75

What is the Mirel scoring system used for and what are its parameters for "high risk"?

Answer 75

- Assesses the need for prophylactic fixation in pts with metastatic bone tumours (due to increased risk of pathological fracture) - High risk of pathological fracture = score of 9 or greater: Peritrochanteric, Lytic, More than 2/3 width of bone involved, Aggravated by function

Question 76

What is the gold-standard for measuring renal plasma flow?

Answer 76

(ie. in renal artery stenosis) PAH clearance

Question 77

What is the gold-standard for measuring GFR?

Answer 77

inulin clearance

Question 78

When should you offer bisphosphonates for prevention of fragility fractures?

Answer 78

- 10-yr fragility fracture risk score (Q-fracture (preferred) or FRAX -> ppl at high risk should be offered DXA scan - >50 w a history of fragility fractures OR <40 with a major risk factor for fragility fractures -> offer DXA scan straight away w no need for risk scoring - If DXA shows BMD T score of < -2.5 SD = offer bisphosphonates (if no C.I) (give HRT if pre-menopausal young woman)

Question 79

Which nerve palsy causes foot drop? Damage to which structure causes this nerve palsy? What dermatome levels is it composed of?

Answer 79

- Common peroneal nerve palsy - Fibular neck fracture - L4-S2

Question 80

Which nerve palsy causes claw hand? Damage to which structure causes this nerve palsy? What dermatome levels is it composed of?

Answer 80

- Ulnar nerve palsy (also causes hyper-extended wrist) - Damage to medial epicondyle - C8, T1

Question 81

Which nerve palsy causes carpal tunnel syndrome? Damage to which structure causes this nerve palsy? What dermatome levels is it composed of?

Answer 81

- Median nerve - Wrist - C6-C8

Question 82

Damage to which dermatomal levels causes Erb's palsy (waiter's tip)? What is the characteristic sign seen in this condition?

Answer 82

- C5-C6 (upper trunk of brachial plexus) | - arm hangs by side, internally rotated, hyper-extended wrist

Question 83

Which nerve palsy causes wrist drop? Damage to which structure causes this nerve palsy? What dermatome levels is it composed of?

Answer 83

- Radial nerve - Humeral mid-shaft fracture - C6 - C8

Question 84

What are the most important hip abductor muscles?

Answer 84

Gluteus medius and minimus

Question 85

What is the action of Gluteus maximus?

Answer 85

- Main hip extensor | - External rotator

Question 86

What does an L1 dermatome radiculopathy present with?

Answer 86

- Reduced sensation across the inguinal area | - Reduced power in hip flexion

Question 87

What does an L2 dermatome radiculopathy present with?

Answer 87

- Loss of sensation across the anterior mid-thigh | - Reduced hip flexion

Question 88

What does an L3 dermatome radiculopathy present with?

Answer 88

- Loss of sensation over the distal anterior thigh | - Reduced power in hip flexion, and knee extension

Question 89

What does an L4 dermatome radiculopathy present with?

Answer 89

- Loss of sensation over the medial lower leg - Reduced knee extension + dorsiflexion - Reduced patellar reflex.

Question 90

What does an L5 dermatome radiculopathy present with?

Answer 90

- Weakness of hip abduction - Foot drop - (no specific reflex lost)

Question 91

What does an S1 dermatome radiculopathy present with?

Answer 91

Numbness down the back of the leg into the outside or bottom of the foot.

Question 92

During a hip examination, John, a 68-year-old male, is found to have a positive trendelenburg's sign. When he stands on only his left leg, his right pelvis drops. What muscles and nerve is affected in John?

Answer 92

- LEFT gluteus medius and minimus - Superior gluteal nerve (the LHS is not abducting and able to support the weight of the normal leg so it dips on the normal side (RHS))

Question 93

What are the main side-effects of SGLT-2 inhibitors?

Answer 93

* Dapagliflozin* * works in the PCT to prevent sodium and glucose co-transport + reabsorption* - Urinary and Genital infections (secondary to glycosuria): UTIs, yeast infections, Fournier's gangrene - normoglycaemic Ketoacidosis - hypoglycaemia - hypotension

Question 94

What are the identifying features of Lupus Nephritis?

Answer 94

* urine dipstick = first line for diagnosis! -> shows proteinuria* - Non-specific symptoms: fatigue, arthralgia - more common in Women - Malar rash, Lymphadenopathy, discoid rash - histological appearance = VI different types of GN (WHO classification)

Question 95

What are the identifying features of Acute Interstitial Nephritis ?

Answer 95

* presents w proteinuria -> check bloods for serum creatinine!!* - AKI -> often due to drugs (ie. NSAIDs, allopurinol) - Fever and Arthralgia - histology = marked interstitial oedema and interstitial infiltrate between tubules

Question 96

What are the identifying features of Anti-GBM disease (Goodpasture's syndrome)?

Answer 96

* presents w proteinuria -> check bloods for anti-GBM antibodies* - type of Vasculitis - Pulmonary haemorrhage - rapidly progressing GN - more common in Men - linear IgG deposits in the BM

Question 97

What are the identifying features of Diabetic Nephropathy?

Answer 97

* urine dipstick = first-line (albumin-creatinine ratio) -> raised = problematic* - urinary frequency - peripheral oedema - loss of appetite - may also be asymptomatic and picked up on screening - Histology = thickening of the glomerular basement membrane and mesangial matrix expansion

Question 98

What is the arterial supply to the Adrenal glands? Where do these vessels originate from?

Answer 98

- Superior suprarenal artery -> Inferior Phrenic Artery - Middle suprarenal artery -> Aorta - Inferior suprarenal artery -> Renal Artery

Question 99

Where do the Adrenal veins drain into?

Answer 99

- RHS = IVC | - LHS = Left Renal Vein

Question 100

What are the contents of the Antecubital Fossa from lateral to medial?

Answer 100

* Really Need Beer To Be At My Nicest* - Radial Nerve - Biceps Tendon - Brachial Artery - Median Nerve

Question 101

What are the superficial forearm muscles (from medial to lateral) What do they all attach to?

Answer 101

* F, PL, F, PT* - Flexor Carpi Ulnaris, Palmaris Longus, Flexor Carpi Radialis, Pronator Teres * nb. FDS = INTERMEDIATE forearm flexor, hence not included!* - Medial epicondyle of humerus

Question 102

What nerve innervates superficial forearm flexors?

Answer 102

Median nerve | apart from Flexor Carpi Ulnaris and medial 1/2 of FDP = ulnar nerve!

Question 103

Which enzyme is deficient in Congenital Adrenal Hyperplasia? What are the implications of this?

Answer 103

- 21-Hydroxylase - lack of Aldosterone and Cortisol production (and resultant hypoglycemia, low BP, dehydration), and ambiguous genitalia (due to increased testosterone production) -> lack of this enzyme results in compensatory Adrenal Hyperplasia to increase production of hormones it is unable to make

Question 104

What is first line investigation for suspected Bladder cancer? What is used for staging?

Answer 104

* painless visible (macroscopic) haematuria!!!* - Flexible cystoscopy + biopsy - MRI pelvis (local spread), CT (distant spread)

Question 105

What is the RIFLE Criteria for AKI?

Answer 105

- Risk: increased creatinine 50-100% or U.O <0.5/ml/kg/hr for >6hrs - Injury: increased creatinine 100-200% or U.O <0.5/ml/kg/hr for >12hrs - Failure: increased creatinine >200% or >4mg/dL, or U.O <0.3/ml/kg/hr or anuria for >12hrs - Loss of function: need for Dialysis for >4 weeks - End-Stage Renal disease: Need for Dialysis for >3 months

Question 106

What is the definition of Oliguria and Anuria?

Answer 106

- Oliguria = urine output <400ml/day in adults OR <0.5ml/kg/hr in 24hrs - Anuria = complete lack of urine output

Question 107

What is the Gleason score?

Answer 107

Used for grading Prostate cancer (5 stages)

Question 108

How do you diagnose Prostate cancer? What is used for staging?

Answer 108

- History: Asymptomatic, LUTS (nocturia, hesitancy, poor stream, terminal dribbling, or obstruction), weight loss, +/-bone pain (mets) - DRE: hard, irregular prostate - Bloods: increased PSA (used for monitoring!) - Imaging (gold-standard): TRUS-guided biopsy - Staging: pelvic MRI

Question 109

What is the most common male cancer?

Answer 109

Prostate cancer

Question 110

What is the identifying clinical features of a rotator cuff injury?

Answer 110

- Pain on abduction: (rotator cuff tear = first 60 degrees, shoulder/subacromial impingement = between 60-120 degrees) - Tenderness over anterior acromion

Question 111

Which LNs are implicated in bladder cancer?

Answer 111

External and internal iliac LNs

Question 112

What are the most common infections post-renal transplant?

Answer 112

- CMV (first 4-6 weeks) | - EBV (>6 months)

Question 113

What are the key clinical features of spinal stenosis?

Answer 113

- Pain is worse walking downhill, and better on walking uphill, takes a while to get better w rest - Sciatica - Neck pain (Cervical spine), or back pain (Lumbar spine)

Question 114

What are the clinical features of an inferior gluteal nerve palsy?

Answer 114

* Gluteus maximus denervation* - impaired hip extension + lateral rotation - difficulty in rising from seated to standing position, climbing stairs - lurching gait

Question 115

What are the clinical features of a superior gluteal nerve palsy?

Answer 115

* Gluteus medius, minimus + tensor fasciae latae muscle denervation* - impaired hip abduction - no sensory loss - may be due to: misplaced IM injection, hip surgery, pelvic fracture, posterior hip dislocation - positive Trendelenburg sign (!!!) (hip moves down on the opposite side of the injury)

Question 116

What are the clinical features of an tibial nerve palsy?

Answer 116

* posterior compartment of leg* - impaired foot plantarflexion and inversion - sensory loss to sole of foot - not commonly injured as deep and well protected: popliteral lacerations, posterior knee dislocation

Question 117

What are the clinical features of an obturator nerve palsy?

Answer 117

* medial compartment of the thigh* - impaired hip adduction - sensory loss to medial thigh - may be due to: anterior hip dislocation

Question 118

What are the clinical features of a common peroneal/fibular nerve palsy?

Answer 118

*anterior and lateral compartments of the leg* - impaired foot dorsiflexion and eversion Extensor hallucis longus - sensory loss to dorsum of the foot and the lower lateral part of the leg - injury often occurs at the neck of the fibula, tightly applied lower limb plaster cast - Injury causes Foot drop (!!!)

Question 119

What should you be aware of when prescribing Methotrexate?

Answer 119

- Mucositis: inflamed gut and/or mouth - Myelosuppression - Pneumonitis - Pulmonary fibrosis - Liver fibrosis (hepatotoxic) - C.I during pregnancy!!! (Teratogenic) -> need to avoid pregnancy/use contraception for at least 6 months after treatment

Question 120

What nerve injury causes "sign of benediction" and what muscle is implicated?

Answer 120

- Median nerve | - FDS - flexes the MCPs and PIPs

Question 121

What is the difference in terms of flexion and nerve innervation between FDS + FDP?

Answer 121

- FDS = innervated by median nerve = flexes MCPs and PIPs of fingers 2-5 - FDP = innervated by ulnar (medial 4+5) and median nerve (lateral 2+3) = flexes MCPs and IPs of fingers 2-5

Question 122

What are the boundaries of the adductor canal? What does it contain?

Answer 122

- Anteromedial (Roof): Sartorius - Posterior: Adductor Magnus, Adductor Longus - Lateral: Vastus medialis - Contents = Saphenous vein, artery and nerve

Question 123

Which pts should be assessed using FRAX or QFracture scoring system?

Answer 123

- All men >75, all women >65 - younger pts in the presence of risk factors: prev. fragility fracture, frequent or current use of glucorticoids (ie. pred or hydrocortisone), history of falls, FH of hip fracture, other causes of 2ndary osteoporosis, Low BMI (<18.5), smoking, alcohol intake >14 units/week

Question 124

What is the first-line treatment of scabies?

Answer 124

- Perthmethrin 5% cream | - + clean bedding of affected persons

Question 125

What are the deep 6 lateral rotator muscles? What are they all innervated by?

Answer 125

P-GO-GO-Q (top to bottom) - Piriformis, Gemellus Superior, Obturator Internus, Gemellus Inferior, Obturator Externus (covered), Quadratus Femoris - Sacral Plexus (L4-S2), except obturator externus which is Lumbar plexus

Question 126

What are the key features of Sjögren's syndrome?

Answer 126

- Female - 40-50y/o - dry eyes and mouth, parotid gland enlargement *nb. large cheeks!!*, systemic upset: fatigue, fever, myalgia, arthralgia, dry skin - Diagnosis = blood test: anti-Ro (SSA), anti-La (SSB) antibodies

Question 127

Which structures pass behind the medial malleolus?

Answer 127

Tom, Dick and Very Nervous Harry - Tibialis posterior - flexor Digitorum longus - posterior tibial Artery - posterior tibial Vein - tibial Nerve - flexor Hallucis longus

Question 128

What is the underlying pathology in Graves?

Answer 128

Autoimmune disease whereby antibodies to the thyroid stimulating hormone (TSH) receptor prolong stimulation -> increased thyroid hormone production from the thyroid gland (hyperthyroidism!)

Question 129

What are the key features of Erysipelas?

Answer 129

- Elderly patient with lowered immunity (diabetes mellitus) - with an elevated, well-demarcated, painful rash - caused by S. pyogenes - treated by Flucloxacillin

Question 130

What is the gold-standard imaging for renal colic?

Answer 130

*painful haematuria!! -> sudden onset of flank pain radiating laterally to the abdomen and/or to the groin* CT KUB!!

Question 131

What are the key clinical features of Ankylosing Spondylitis?

Answer 131

- HLA-B27 - Typically males between 20-30y/o -> typically presents w lower back pain and stiffness of insidious onset - diagnosis = x-ray findings (Sacroillitis) + one additional clinical feature: at least 3 months of lower back pain that gets better with exercise and doesn't improve with rest (nocturnal pain, usually worse in the morning), limited movement in your lower back (lumbar spine -> positive Schober's test), limited chest expansion compared with what is expected for age and sex

Question 132

What are the key clinical features of Osteogenesis Imperfecta?

Answer 132

- Due to defects in Type 1 collagen - A child with multiple fractures, deafness and blue sclera (+ also dental problems) = osteogenesis imperfecta - adjusted calcium, phosphate, pTH, and ALP results are usually normal

Question 133

What are the key clinical features in Minimal change disease?

Answer 133

- Nephrotic picture: protein (albumin) in the urine, oedema, hypoalbuminaemia - CHILDREN

Question 134

What are the key clinical features of Focal segmental glomerulosclerosis (FSGS)?

Answer 134

- Nephrotic picture: protein (albumin) in the urine, oedema, hypoalbuminaemia - ADULTS

Question 135

What are the key clinical features of IgA nephropathy?

Answer 135

- Nephritic picture: cellular casts, haematuria - during or shortly after URTI - confirmation of diagnosis = Kidney biopsy!!

Question 136

What are the key clinical features of Post-streptococcal GN?

Answer 136

- Nephritic picture: cellular casts, haematuria | - a couple of weeks after a streptococcal infection (ie. pharyngitis)

Question 137

What is the difference between a Monteggia and a Galeazzi fracture?

Answer 137

* GRIMUS -> Galleazzi = Radius, Inferior; Monteggia = Ulna, Superior* - Monteggia fracture = proximal ulnar dislocation -> superior ulnar dislocation (a = proximal in the alphabet, so proximal fracture) - Galeazzi fracture = distal radial dislocation -> inferior dislocation of distal radioulnar joint (z = distal in the alphabet, so distal fracture)

Question 138

What are the key clinical features for Rheumatoid Arthritis?

Answer 138

- Symmetric arthritis in 3+ joints, sparing the DIP joints - Morning stiffness lasting >30 minutes -> symptoms improve with exercise/weight bearing as the day progresses - Can be diagnosed based on clinical features with support from serological testing (positive ACPA or RF) - X-ray may reveal periarticular osteopenia, marginal bony erosions, and joint space narrowing - Biopsy of the rheumatoid nodules showing cholesterol deposits is pathognomonic for RA.

Question 139

What are the key clinical features for Reactive Arthritis?

Answer 139

- Characterised by a triad of conjunctivitis, urethritis, and arthritis, with patients often also having diarrhoea - usually develops 2-4 weeks after a genitourinary (GU) or gastrointestinal (GI) infection - Patients can also develop keratoderma blennorhagicum (hyperkeratotic vesicles on the palms and soles).

Question 140

What are the key clinical features for Septic Arthritis?

Answer 140

- Classically presents as a single red, swollen, and painful joint, with fever - Invasion of the synovial membrane which produces a yellow, turbid synovial fluid with high neutrophils. - This is most commonly found with infection by Staphylococcus aureus - Joint aspiration BEFORE initiating antibiotics!!

Question 141

What are the key clinical features for Osteoarthritis?

Answer 141

- Shorter duration of morning stiffness (<30 minutes), or not there in the mornings - worsens with exercise/weight bearing throughout the day - due to cartilage loss - Features of OA on x-ray include loss of joint space, osteophytes, subchondral sclerosis and subchondral cysts.

Question 142

What are the key clinical features for Psoriatic Arthritis?

Answer 142

- Usually occurs in patients with a history of psoriasis, although joint symptoms may precede skin involvement - Can be symmetric or asymmetric: usually affects the DIP joints (spares MCP joints, unlike RA) - swelling in one or more joints - feels worse when you get up after a rest and lasts longer than 30 minutes. - It is associated with 'sausage' digits (dactylitis) and nail changes (pitting), enthesitis, eye disease (conjunctivitis, anterior uveitis) - seronegative spondyloarthropathy (males): back stiffness, sacroiliitis, atlanto-axial joint involvement - X-ray classically depicts a 'pencil-in-cup' deformity.

Question 143

What are the key clinical features of acute compartment syndrome?

Answer 143

- *severe pain shortly after having a cast applied!! - doesn't respond to morphine* - REMOVE CAST FIRST - then notify the orthopaedic surgeon and theatre team for EMERGENCY FASCIOTOMY - If chronic exertional compartment syndrome: 5 P's (pain, pallor, pulseless, paraesthesia, paralysis -> gold standard for diagnosis is compartment pressure testing (>40mmHg = diagnostic)

Question 144

How to treat a hypoglycaemic episode?

Answer 144

* usually below 4mmol/l* - If alert: quick-acting oral glucose (ie. glucogel, sweeties, orange juice) - If unconscious or unable to swallow: I/M or S/C glucagon

Question 145

What is the first line investigation for Conn's syndrome? What would be the next investigation and why would you do it? Then what would you do and why? What is the treatment?

Answer 145

* Raised BP, hypernatraemia, hypokalaemia* - Renin-Aldosterone ratio -> Aldosterone raised and Renin low bc of negative feedback - To differentiate between a unilateral adenoma and a bilateral adrenal hyperplasion: High resolution CT Abdomen - if that is inconclusive: AVS sampling - Treatment: Unilateral adrenal adenoma: surgery, bilateral adrenal hyperplasia: aldosterone antagonist e.g. spironolactone

Question 146

What is the first line investigation for Conn's syndrome? What would be the next investigation and why would you do it? Then what would you do and why? What is the treatment?

Answer 146

* Raised BP, hypernatraemia, hypokalaemia* - Renin-Aldosterone ratio -> Aldosterone raised and Renin low bc of negative feedback - To differentiate between a unilateral adenoma and a bilateral adrenal hyperplasion: High resolution CT Abdomen - if that is inconclusive: AVS sampling - Treatment: Unilateral adrenal adenoma: surgery, Bilateral adrenal hyperplasia: aldosterone antagonist e.g. spironolactone

Question 147

What is the first line investigation for Conn's syndrome? What would be the next investigation and why would you do it? Then what would you do and why? What is the treatment?

Answer 147

* Raised BP, hypernatraemia, hypokalaemia* - First-line = Renin-Aldosterone ratio -> Aldosterone raised and Renin low bc of negative feedback - To differentiate between a unilateral adenoma and a bilateral adrenal hyperplasia: High resolution CT Abdomen - if that is inconclusive: AVS sampling - Treatment: Unilateral adrenal adenoma: surgery (most common cause), Bilateral adrenal hyperplasia: aldosterone antagonist e.g. spironolactone

Question 148

What are the clinical features of Pseudogout vs. Gout? How do you make a diagnosis of Pseudogout vs. Gout? How are they both treated?

Answer 148

- CLINICAL FEATURES: - > Both: intermittent sudden episodes of painful, warm and red joints with swelling - usually affecting one joint - > Pseudogout: >60, hx of hyperparathyroidism or haemachromatosis, commonly affects knee, then wrist - > Gout: hx of kidney disease, family history, obesity, alcohol intake and certain medications, typically lasts 3-7 days: starts w big toe - DIAGNOSIS (diagnosis is usually clinical, but if in doubt or worry of septic arthritis): Arthrocentesis + Light microscopy - > Pseudogout: calcium pyrophosphate dihydrate crystal deposition -> weakly-positively birefringent rhomboid-shaped crystals - > Gout: uric acid crystal deposition -> negatively-birefringent needle-shaped crystals - TREATMENT: acute = NSAIDs, colchicine, pred; long-term prevention (if severe or repeated attacks) = Allopurinol, Febuxostat

Question 149

Which muscles form the Pes Ansinerus?

Answer 149

* Medial thigh insertion* * STG* - Sartorius - Gracilis - Semitendinosus

Question 150

What are the key features of De Quervain's Tenosynovitis?

Answer 150

- Typically affects females 30-50y/o - Affects Extensor pollicis brevis and abductor pollicis longus tendons - Pain on radial side of wrist - worse on thumb abduction - Positive Finklestein test - Treatment = conservative (heat or ice to affected area, analgesia (NSAIDs), thumb splint)

Question 151

Describe the classification of Growth Plate fractures

Answer 151

* Uses Sam-Harris system* - Type I = Fracture through the physis only (x-ray often normal) - Type II = Fracture through the physis and metaphysis (most common) - Type III = Fracture through the physis and epiphyisis to include the joint - Type IV = Fracture involving the physis, metaphysis and epiphysis - Type V = Crush injury involving the physis (x-ray may resemble type I, and appear normal) (uncommon)

Question 152

Describe the classification of Growth Plate fractures

Answer 152

* Uses Sam-Harris system* - Type I = Fracture through the physis only (x-ray often normal) - Type II = Fracture through the physis and metaphysis (most common) - Type III = Fracture through the physis and epiphyisis to include the joint - Type IV = Fracture involving the physis, metaphysis and epiphysis - Type V = Crush injury involving the physis (x-ray may resemble type I, and appear normal) (uncommon)

Question 153

What are causes of a raised PSA (that is not prostate cancer)?

Answer 153

- BPH - Prostatitis, UTI (NICE recommend to postpone the PSA test for at least 1 month after treatment) - Ejaculation (ideally not in the previous 48 hours) - Vigorous exercise (ideally not in the previous 48 hours) - Urinary retention - Instrumentation of the urinary tract (ie. catheter, cytoscopy, irrigation)

Question 154

What is 1st line treatment of BPH?

Answer 154

Alpha blockers! (Doxazosin)

Question 155

What is the most common cause of hydronephrosis in the newborn?

Answer 155

- Unilateral = PUJ obstruction + VUR | - Bilateral = posterior urethral valves

Question 156

What are the key features of Membranous GN?

Answer 156

- presents with Nephrotic syndrome (proteinuria) - idioptahic: due to antiphospholipase A2 antibodies - Renal Biopsy: thickened basement membrane, sub-epithelial spikes - Treatment: ACEIs or ARBs

Question 157

How do you diagnose Prostate cancer?

Answer 157

- DRE and PSA testing - then TRUS + biopsy - MRI/CT and bone scan for staging

Question 158

What scoring system is used for determining prognosis of prostate cancer?

Answer 158

Gleason score (two grades awarded: 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst - nb. a score of 4 and 3 = 7 has a worse prognosis than 3 + 4 = 7)

Question 159

Which zone of the prostate is most affected by cancer?

Answer 159

Peripheral zone | largest part of prostate gland - causes 80% of cancers

Question 160

Why does inadequate insulin cause hyperkalaemia?

Answer 160

Bc insulin activates the Na+/K+ pump (glucose requires secondary active transport to get into cells) Therefore if there is no insulin, then there is a reduction in the Na+/K+ pump and hyperkalaemia

Question 161

What are the blood test results for primary, secondary and tertiary hyperparathyroidism?

Answer 161

- Primary = high PTH, high Ca2+, low phosphate -> usually due to parathyroid adenoma - Secondary = high PTH, low or normal Ca2+, elevated phosphate, low Vit D -> usually due to chronic renal failure (kidneys cannot excrete phosphate) - Tertiary = normal or high Ca2+, elevated PTH, decreased or normal phosphate, normal or decreased Vit D, raised ALP -> usually occurs due to secondary hyperparathyrodism (due to chronic renal failure) occurring for a long period of time, and parathyroid glands hypertrophy to try to raise Ca2+ levels (leading to chronically elevated PTH)

Question 162

What are the key characteristics of a Colle's Fracture?

Answer 162

- Classically, a fall onto an outstretched hand - XR shows: dinner fork deformity - Fracture of distal radius with posterior displacement of distal fragment

Question 163

What drugs should be stopped in AKI?

Answer 163

- NSAIDs (ie. aspirin, ibruprofen, naproxen) - Aminoglycosides (ie. gentamicin) - ACEIs - Diuretics - Metformin - Lithium - Digoxin

Question 164

What are the diagnostic tests for suspected AKI?

Answer 164

- U+Es: (creatinine (!!!), Na+, K+, urea) - Clinical Features: - > a rise in serum creatinine of 26 micromol/litre or greater within 48 hours - > a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days - > a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults - Urinalysis - Renal US (if no cause for deterioration is found and pt. is at risk of urinary tract obstruction)

Question 165

What are the pre-renal, intrinsic, and post-renal causes of AKI?

Answer 165

- Pre-renal: *loss of blood flow to kidneys* - > Hypovolaemia secondary to D+V - > Renal artery stenosis - Intrinsic: - > GN - > ATN - > AIN - > Rhabdomyolysis - > TLS - Post-renal: - > kidney stone in ureter or bladder - > BPH - > external compression of ureter

Question 166

What is the treatment of AKI?

Answer 166

* Involves fluid resuscitation, avoidance of nephrotoxic medications and contrast media exposure, and correction of electrolyte imbalances* - Stop precipitating drugs!!: NSAIDs (ie. aspirin, ibruprofen, naproxen), Aminoglycosides (ie. gentamicin), ACEIs, Diuretics, Metformin, Lithium, Digoxin - Stabilisation of the cardiac membrane: IV calcium gluconate - Short-term shift in K+ from extracellular to intracellular fluid compartment: - > combined insulin/dextrose infusion - > nebulised salbutamol - Removal of K+ from the body: Calcium resonium (orally or enema), Loop diuretics, Dialysis

Question 167

Key Features of Thyroid cancer: - Papillary? - Follicular? - Medullary? - Anaplastic? - Lymphoma?

Answer 167

- Papillary 70% (MOST COMMON) Often young females - excellent prognosis - Follicular 20% - Medullary 5% Cancer of parafollicular (C) cells, secrete calcitonin, part of MEN-2 - Anaplastic 1% Not responsive to treatment, can cause pressure symptoms - Lymphoma Rare Associated with Hashimoto's thyroiditis

Question 168

Why does Addison's cause metabolic acidosis?

Answer 168

- Bc Addisons causes a decrease in Na+ (low bp) and increase in K+ - Hyperkalaemia and high H+ levels seem to go hand-in-hand with each other -> (bc Na+ is exchanged with both K+ and H++ out of the body, so if it is low, then both K+ and H+ would be high bc they're not being exhanged) -> metabolic acidosis

Question 169

What splits up the Sciatic foramen? What are the contents of the Greater and the Lesser Sciatic foramen?

Answer 169

- Piriformis - Greater Sciatic foramen = Superior Gluteal Vein, Artery and Nerve - Lesser Sciatic foramen = Inferior Gluteal Artery and Vein, Sciatic Nerve

Question 170

How to differentiate between OA and RA?

Answer 170

- OA = morning stiffness <30 mins, gets worse w activity, unilateral symptoms, affecting mainly weight-bearing joints, PIP + DIP joints, more common in the elderly, equal incidence between the sexes - RA = morning stiffness >30 mins, improves w activity, bilateral symmetric symptoms in 3+ joints, affects MCP + PIP joints (spares the DIP joints!!), possible systemic features (ie. raynaud's), occurs in adults of all ages, incidence mainly in females

Question 171

Which cancers are implicated in the hereditary condition MEN2?

Answer 171

* Multiple Endocrine Neoplasia 2* - Medullary thyroid cancer - Parathyroid tumour - Phaeochromocytoma

Question 172

Which test is used to assess the rupture of the collateral ligaments of the knee?

Answer 172

Drawer test

Question 173

Where do gonadal (testicular and ovarian) veins drain into?

Answer 173

- Left = Left renal vein | - Right = IVC

Question 174

Which is the most sensitive diagnostic test for diagnosing SLE?

Answer 174

ANA test (blood test)

Question 175

What type of Hypersensitivity reaction is SLE?

Answer 175

Type 3 HS | Immune-Complex mediated

Question 176

Where is the majority of filtered water re-absorbed in the nephron?

Answer 176

PCT (70%)

Question 177

What is the first line treatment of DKA?

Answer 177

- IV fluid replacement - followed by IV insulin - patients who normally take long-acting insulin should continue their usual dose(s) throughout treatment.

Question 178

What is the first line treatment of DKA?

Answer 178

- IV fluid replacement (!!!) - followed by IV insulin (!!!) - patients who normally take long-acting insulin should continue their usual dose(s) throughout treatment.

Question 179

What is the first line treatment of DKA?

Answer 179

- IV fluid replacement (!!!) - followed by IV insulin (!!!) - patients who normally take long-acting insulin should continue their usual dose(s) throughout treatment.

Question 180

What is the difference between MEN type I and type II?

Answer 180

- Type I = 3 Ps: Parathyroid (hyperparathyroidism), Pituitary, Pancreas - Type II = 2 Ps: Medullary thyroid cancer, Parathyroid, Phaeochromocytoma

Question 181

What is the difference between MEN type I and type II?

Answer 181

- Type I = 3 Ps: Parathyroid (hyperparathyroidism), Pituitary, Pancreas - Type II = 2 Ps: Medullary thyroid cancer, Parathyroid, Phaeochromocytoma

Question 182

When would u give meds for HT? What would u give first line?

Answer 182

- BP of >140/90 on 2 occasions (double-check BP if it is >140/90 in clinic) - <55 of any family origin or Type 2 diabetic: ACEIs or ARBs - >55 or Black: CCBs

Question 183

Which ligament is most likely damaged in ankle sprains?

Answer 183

- Anterior Talofibular ligament (ATFL) -> "Always Tears First" - resists inversion, so therefore pt. presents with inversion injuries

Question 184

What effect do NSAIDs have on the Kidneys?

Answer 184

- inhibit COX-1 and COX-2 enzymes -> reducing prostaglandin production - prostaglandins are responsible for afferent arteriole vasodilation and increasing GFR - therefore, NSAIDs block afferent arteriole vasodilation and decrease renal blood flow and GFR

Question 185

What is the most common causative organism in Osteomyelitis? What about in sickle-cell anaemia?

Answer 185

- Staph Aureus | - Salmonella

Question 186

What is the first line management of Osteomyelitis?

Answer 186

- Bone aspiration/biopsy THEN | - IV abx

Question 187

What type of HS reactions are responsible for renal graft failure? - hyperacute (early acute)? (minutes to hours) - acute graft failure (<6 months) (late acute)?

Answer 187

- Type 2 HS: antibodies against graft | - Type 4 HS: cytotoxic T-cell mediated (or CMV-mediated)

Question 188

Muscles of the Foot: Muscle, Origin, Insertion, Nerve supply, Action

Answer 188

- Abductor hallucis: - Medial side of the calcaneus, flexor retinaculum, plantar aponeurosis - Medial side of the base of the proximal phalanx Medial plantar nerve - Abducts the great toe - Flexor digitorum brevis: - Medial process of the calcaneus, plantar aponeurosis - Via 4 tendons into the middle phalanges of the lateral 4 toes. - Medial plantar nerve - Flexes all the joints of the lateral 4 toes except for the interphalangeal joint. - Abductor digit minimi: - From the tubercle of the calcaneus and from the plantar aponeurosis - Together with flexor digit minimi brevis into the lateral side of the base of the proximal phalanx of the little toe - Lateral plantar nerve - Abducts the little toe at the metatarsophalangeal joint - Flexor hallucis brevis: - From the medial side of the plantar surface of the cuboid bone, from the adjacent part of the lateral cuneiform bone and from the tendon of tibialis posterior. - Into the proximal phalanx of the great toe, the tendon contains a sesamoid bone - Medial plantar nerve - Flexes the metatarsophalangeal joint of the great toe. - Adductor hallucis: - Arises from two heads. - The oblique head arises from the sheath of the peroneus longus tendon, and from the plantar surfaces of the bases of the 2nd, 3rd and 4th metatarsal bones. - The transverse head arises from the plantar surface of the lateral 4 metatarsophalangeal joints and from the deep transverse metatarsal ligament. Lateral side of the base of the proximal phalanx of the great toe. - Lateral plantar nerve - Adducts the great toe towards the second toe. Helps maintain the transverse arch of the foot. - Extensor digitorum brevis - On the dorsal surface of the foot from the upper surface of the calcaneus and its associated fascia - Via four thin tendons which run forward and medially to be inserted into the medial four toes. The lateral three tendons join with hoods of extensor digitorum longus. - Deep peroneal - Extend the metatarsophalangeal joint of the medial four toes. It is unable to extend the interphalangeal joint without the assistance of the lumbrical muscles.

Question 189

Arches of the Foot

Answer 189

2 longitudinal arches, 1 transverse arch: - Longitudinal arches: - > Medial: longitudinal arch is higher on the medial than on the lateral side. The posterior part of the calcaneum forms a posterior pillar to support the arch. The anterior pillar of the medial arch is composed of the navicular bone, the three cuneiforms and the medial three metatarsal bones. - > Lateral: The lateral part of this structure passes via the cuboid bone and the lateral two metatarsal bones. The medial part of this structure is more important. The head of the talus marks the summit of this arch, located between the sustentaculum tali and the navicular bone. - Transverse arch: The transverse arch is situated on the anterior part of the tarsus and the posterior part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly, which contributes to the shape of the arch.

Question 190

What would a patient's water deprivation test show before and after being given Desmopressin if they had a ... - Cranial DI? - Nephrogenic DI?

Answer 190

- Cranial DI: low urine osmolality before desmopressin, high urine osmolality after desmopressin - Nephrogenic DI: low plasma osmolality before and after desmopressin

Question 191

What is the clearance of a substance at the Kidneys dependent on?

Answer 191

It's diffusivity across the basement membrane and it's tubular secretion/reabsorption

Question 192

What are the key clinical features of Frozen shoulder/Adhesive Capsuliits?

Answer 192

- Most common in middle-aged females, diabetics - Features typically develop over days - External rotation is affected more than internal rotation or abduction - Both active and passive movement is affected - Patients typically have a painful freezing phase, an adhesive phase and a recovery phase - Bilateral in up to 20% of patient - The episode typically lasts between 6 months and 2 years - Treatment = conservative (NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids)

Question 193

What is Sheehan's syndrome?

Answer 193

Global Hypopituitarism present after childbirth (agalactorrhoea (prolactin), amenorrhoea (lack of FSH, LH (gonadotropins), cold intolerance, constipation, (thyroid hormones) weight loss (steroid hormones)

Question 194

What is the first line treatment for Carpal Tunnel syndrome?

Answer 194

*Conservative treatment* Wrist splints (at night), physical therapy, and/or corticosteroid injections

Question 195

What are the clinical features of Carpal Tunnel syndrome?

Answer 195

- Pain + parasthesia in the distribution of the median nerve - Thenar eminence muscle wasting - Difficulty in performing tasks (ie. buttoning shirt, opening jars) - Pain relieved by hanging arm over the side of the bed - Phalen test + Tinel's test positive

Question 196

Causes of Hypercalcaemia

Answer 196

*CHIMPANZEES* ``` C alcium supplementation H yperparathyroidism I atrogentic (Drugs: Thiazides -> remember, decreasing Na+ causes increased Ca2+ and vice-versa!) M ilk Alkali syndrome P aget disease of the bone A cromegaly and Addison's Disease N eoplasia Z olinger-Ellison Syndrome (MEN Type I) E xcessive Vitamin D E xcessive Vitamin A S arcoidosis ```

Question 197

Physiological actions of commonly used diuretics: Site of action, Diuretic, Carrier or Channel inhibited, % of filtered Na+ excreted

Answer 197

- Ascending limb of LoH -> Frusemide -> Na+/K+ 2Cl - carrier -> Up to 25% - DCT -> Thiazides -> Na+Cl- carrier -> Between 3 and 5% - > Cortical collecting tubule -> Spironolactone -> Na+/K+ ATP ase pump -> Between 1 and 2%

Question 198

What should you suspect if you see: 1. red cell casts 2. needle-shaped crystals 3. rhomboid-shaped crystals ... on urine microscopy?

Answer 198

1. Nephritic syndrome 2. Gout 3. Pseudogout

Question 199

THIS IS UR DAILY REMINDER TO REMEMBER THE DIFFERENCE BETWEEN CARPAL TUNNEL + CUBITAL TUNNEL SYNDROME!!!!

Answer 199

- Carpal Tunnel = Median Nerve palsy | - CUBITAL Tunnel = Ulnar Nerve palsy (nb. CLAW HAND as well!!)

Question 200

What scoring system is used for?

Answer 200

- BPH | - If it is =/>8 -> give alpha blockers!! (ie. tamsulosin, alfuzosin)

Question 201

What are the clinical features of SLE?

Answer 201

- anti-ds DNA antibodies (ANA antibodies) - Photosensitivity - Malar or discoid rash - Pancytopenia, - Pleuritis - Nephritis

Question 202

What are the clinical features of Limited Systemic Sclerosis?

Answer 202

- Anti-centromere antibodies (ANA antibodies) * CREST* - Calcinosis -> Ca2+ deposits in the skin - Raynaud's - Esophageal dysfunction - Sclerodactyly - Telangiectasias

Question 203

What are the clinical features of autoimmune vaculitis? (Granulomatosis with polyangiitis (wegener's), eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), microscopic polyangiitis)

Answer 203

* proteinuria + red cell casts on urinalysis...* - ANCA antibodies: cANCA (wegener's), pANCA (churg-strauss, microscopic polyangiitis) (!!!) - Renal impairment: caused by immune complex glomerulonephritis → raised creatinine, haematuria and proteinuria - Respiratory symptoms: dyspnoea haemoptysiis - Systemic symptoms: fatigue weight loss fever - Vasculitic (purpuric) rash - ENT symptoms: sinusitis

Question 204

Paediatric Orthopaedics Diagnosis Mode of presentation Treatment Radiology

Answer 204

Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Question 205

Which type of collagen is primarily affected by Osteogenesis Imperfecta?

Answer 205

Type 1 collagen

Question 206

What are the commonest causes of hypercalcaemia in hospitalised and non-hospitalised pts?

Answer 206

- Hospitalised: primary hyperparathyroidism - Non-hospitalised: metastatic malignancy (PTHrP ie. squamous cell carcinoma of the Lung, Breast, Renal, and Multiple Myeloma)

Question 207

What are the commonest causes of hypercalcaemia in hospitalised and non-hospitalised pts?

Answer 207

- Hospitalised: primary hyperparathyroidism - Non-hospitalised: metastatic malignancy (PTHrP ie. squamous cell carcinoma of the Lung, Breast, Renal, and Multiple Myeloma)

Question 208

Which cancers commonly metastasise to the bone?

Answer 208

- Breast - Prostate - Lung - Kidney - Thyroid

Question 209

What is the primary ketone body found in DKA?

Answer 209

Acetoacetate

Question 210

An 8-year-old boy presents to the GP following 7 days of diarrhoea which his mother mentions has been bloody since yesterday. He has abdominal pain and he is passing scant urine. His mother mentions that she has noticed several bruises but doesn't recall any trauma. What is the most like causative organism?

Answer 210

E. Coli!!! This is Haemolytic Uraemic Syndrome (HUS) -> produces a triad of haemolytic anaemia, thrombocytopaenia and AKI that may lead to renal failure.

Question 211

What is the first line treatment for Acromegaly?

Answer 211

Trans-sphenoidal surgery

Question 212

What are the key clinical features of Fibromyalgia?

Answer 212

- Woman - between 30-50 y/o - Chronic pain in multiple sites - (11/18 sites) - lethargy, cognitive impairment: 'fibro fog', sleep disturbance, headaches, dizziness

Question 213

What diagnosis causes muddy brown casts on urine microscopy?

Answer 213

Acute tubular necrosis

Question 214

Which hormones drive growth through 1. infancy? (birth-2 y/o) 2. childhood? (3-11 y/o) 3. puberty? (12-18)

Answer 214

1. insulin and nutrition (nb. poorly-controlled diabetes during pregnancy will result in over-production of insulin by the foetus and therefore the child will be large (macrocosmic) when it comes out) 2. GH and Thyroid hormones (lake of maternal thyroid hormones results in infantile features (+ developmental delay of foetus), and suppressed growth regardless of GH status) 3. GH + Sex steroids

Question 215

What is the role of the Macula Densa?

Answer 215

- Present at the point where the thick ascending limb of the Loop of Henle meets the DCT - Acts as chemoreceptors -> detects the conc. of NaCl (which reflects BP) and adjusts GFR accordingly - > afferent arteriole vasoconstriction (ATP, adenosine) to reduce GFR in low BP states, - > or afferent arteriole vasodilation (NO) to increase GFR in high BP states

Question 216

What is the role of the Juxtaglomerular cells?

Answer 216

- Found in the walls of the afferent arteriole | - Acts as baroreceptors to detect changes in BP and can secrete Renin

Question 217

What does increased specific gravity mean?

Answer 217

Conc. of the urine is high

Question 218

Where are the receptors for thyroid hormones?

Answer 218

In the nucleus | even though they are peptide hormones lmao -> they ACT as a steroid!

Question 219

Which muscles does the axillary nerve innervate?

Answer 219

Teres minor + Deltoid

Question 220

Which fascia contains the thyroid gland?

Answer 220

Pretracheal fascia

Question 221

Key clinical features: | hand disease

Answer 221

Dupuytren's contracture, more common in older male, affects palmar fascia mainly of 4th and 5th finger. As it progresses, nodules and cord develop in the palmar fascia resulting in flexion at MCP + PIP joints - most commonly affects ring finger, little finger - manual labourers, Men Trigger finger causes stiffness, pain and locking sensation when flexing or therefore difficulty extending it. Ganglion cyst also known as bible cyst is usually found in the dorsal and volar aspect of the wrist and is usually soft in nature. Many cysts disappear on its own. Flexor tendon rupture is usually due to trauma to the flexor tendon such as sports injury. It is usually acute in nature and results in acute loss of flexion in the affected finger. It usually requires surgery.

Question 222

What are the most common complications of RA?

Answer 222

- Carpal Tunnel syndrome * due to widespread inflammation* - Lungs: pleurisy, pulmonary fibrosis - Heart – Pericarditis - Eyes – Scleritis, Sjögren's syndrome - Blood vessels – Vasculitis - permanent joint damage, joint deformities - CVD - Cervical myelopathy

Question 223

What is the most common cause of death in RA?

Answer 223

CVD (Atherosclerosis)

Question 224

Which cancer is associated with Paget's?

Answer 224

Osteosarcoma

Question 225

MSK - Paeds

Answer 225

- Development dysplasia of the hip Often picked up on newborn examination Barlow's test, Ortolani's test are positive Unequal skin folds/leg length - Transient synovitis (irritable hip Typical age group = 2-10 years Acute hip pain associated with viral infection Commonest cause of hip pain in children - Perthes disease Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral Features hip pain: develops progressively over a few weeks limp stiffness and reduced range of hip movement x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening - Slipped upper femoral epiphysis Typical age group = 10-15 years More common in obese children and boys Displacement of the femoral head epiphysis postero-inferiorly Bilateral slip in 20% of cases May present acutely following trauma or more commonly with chronic, persistent symptoms Features knee or distal thigh pain is common loss of internal rotation of the leg in flexion - Juvenile idiopathic arthritis (JIA) Preferred to the older term juvenile chronic arthritis, describes arthritis occurring in someone who is less than 16 years old that lasts for more than three months. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA Features of pauciarticular JIA joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows limp ANA may be positive in JIA - associated with anterior uveitis - Septic arthritis Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint

Question 226

Which test is the gold-standard for directly measuring renal function?

Answer 226

inulin clearance | estimates creatinine clearance/GFR

Question 227

Key clinical features of cystinuria

Answer 227

- Recurrent kidney stones from childhood - Positive family history for nephrolithiasis - Sodium nitroprusside test positive

Question 228

What is the difference between GLUT2 and GLUT4 transporters?

Answer 228

- GLUT 2 = insulin-independent -> found in Pancreatic beta-islet cells, Liver, Brain, Kidneys - GLUT 4 = insulin dependent -> adipose tissue and skeletal muscle

Question 229

What are the effects of strenuous exercise on blood glucose levels?

Answer 229

- Early drop: due to increased glucose uptake in the muscle via GLUT-2 (which is independent of insulin) - Occasional rise: high-intensity sport causes release of adrenaline and cortisol which can cause blood glucose to rise temporarily, particularly during competitive sport - Late drop: uses muscle and liver glycogen which then is replaced over the next few hours

Question 230

What are the effects of Angiotensin II on GFR?

Answer 230

- it maintains GFR (by increasing it) -> increases filtration fraction (even if plasma blood flow is low) - by vasoconstricting the efferent arteriole of the glomerulus

Question 231

Why does alcohol cause increased urinary frequency?

Answer 231

Because it suppresses ADH release from the posterior pituitary

Question 232

What are the common neoplastic syndromes of RCC?

Answer 232

- Polycythaemia (due to erythropoeitin release) | - Hypercalcaemia (due to PTH release)

Question 233

What are anti-TPO antibodies associated with?

Answer 233

Hashimoto's thyroiditis

Question 234

What is the principal side-effects of SGLT-2 inhibitors?

Answer 234

The gliflozins, such as empagliflozin or dapagliflozin Recurrent UTIs (they inhibit renal re-absorption of glucose)

Question 235

What histological finding is present in Minimal Change disease?

Answer 235

Fusion of podocytes and effacement of foot processes

Question 236

What are the key characteristics of Adhesive Capsulitis?

Answer 236

- Reduced shoulder movements - both actively and passively | - External rotation is affected more than internal rotation or abduction.

Question 237

What are they key clinical features of Heberden's nodes? How do you differentiate them between Rheumatoid nodules?

Answer 237

- OA - On the DIP joints (outer Hebrides -> Heberden's nodes) - Asymmetrical - Mono or pauci-articular - RA = symmetrical and polyarticular

Question 238

What is the difference between Seminomas and Teratomas?

Answer 238

- Seminomas = >40 y/o | - Teratomas = <40 y/o

Question 239

What is the normal passage of blood through the Glomerulus?

Answer 239

Afferent arteriole -> glomerular capillary bed -> efferent arteriole -> peritubular capillaries and medullary vasa recta

Question 240

What cells secrete Glucagon? What is the function of Glucagon? What increases and decreases its secretion?

Answer 240

- Source: Alpha cells of the Pancreas - Function: Glycogenolysis, Gluconeogenesis, Lipolysis - Increases = hypoglycaemia, stresses, increased catecholamines + SNS stimulation, increased plasma AAs - Decreases = hyperglycaemia, insulin, somatostatin, increased FFAs and keto acids

Question 241

Which zone of the prostate is affected by BPH? What about prostate cancer?

Answer 241

- BPH = Transitional zone | - Prostate cancer = Peripheral zone

Question 242

Which serum electrolyte should you check in hypocalcaemia which is refractory to treatment with calcium and vitamin D supplementation?

Answer 242

Magnesium | Hypomagnesaemia may cause hypocalcaemia which will not be corrected until you correct the magnesium levels!

Question 243

What causes Rickets?

Answer 243

- Reduced Vit D (nb. malnourished pts) - causes excessive non-mineralised osteoid (need Ca2+ for mineralisation)

Question 244

What type of joint is the wrist joint?

Answer 244

Synovial condyloid

Question 245

Treatment of hip fractures

Answer 245

-> Intracapsular hip fracture - Undisplaced Fracture: internal fixation, or hemiarthroplasty if unfit. - Displaced Fracture: NICE recommend replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture total hip replacement is favoured to hemiarthroplasty if patients: were able to walk independently out of doors with no more than the use of a stick and are not cognitively impaired and are medically fit for anaesthesia and the procedure. -> Extracapsular hip fracture: Management stable intertrochanteric fractures: dynamic hip screw if reverse oblique, transverse or subtrochanteric fractures: intramedullary device

Question 246

MOA Diabetes drugs

Answer 246

Sitagliptin is an inhibitor of the enzyme dipeptidyl-peptidase 4 (DPP-4). As such, it prevents DPP-4 from catalysing the breakdown of naturally occurring incretins, potentiating their ability to stimulate insulin release. Activate peroxisome proliferator-activated receptor gamma (PPAR-γ) to increase insulin sensitivity is incorrect. This is the mechanism by which thiazolidinediones such as pioglitazone reduce blood glucose. Decrease blood glucose by inhibiting renal glucose re-uptake via sodium-glucose co-transporter 2( SGLT2) is incorrect. This describes the mechanism of action of SGLT2 inhibitors such as dapagliflozin. Mimic incretins by binding to GLP-1 receptors and stimulating insulin release is incorrect. This is how GLP-1 receptor agonists such as exenatide promote insulin release and lower blood glucose. Trigger the closure of ATP-sensitive K+ channels, stimulating insulin exocytosis is incorrect as this is the mechanism of action of sulfonylureas such as glibenclamide, rather than DPP-4 inhibitors.

Question 247

Which bone is affected in a Boxer fracture?

Answer 247

5th Metacarpal | occurs after punching a wall/hard surface

Question 248

Flexor tendon injury common cause

Answer 248

Prying apart frozen hamburgers

Question 249

Thyroid disease

Answer 249

This patient presented with a one-month history of the signs and symptoms the most consistent with a clinical diagnosis of hypothyroidism. She had low mood, weight gain, round puffy face and a low heart rate and blood pressure. The most common cause of clinical hypothyroidism in the developed world is Hashimoto's thyroiditis. 1: This characterizes Hashimoto's thyroiditis. This is an autoimmune condition more common women and is certain populations (Japanese). It usually presents in the elderly and is associated with HLA-DR3, 4 and 5 polymorphisms. 2: This will be present in subacute thyroiditis (De Quervain's thyroiditis). This is usually a painful condition, often occurs following a viral infection and is more common in women. It can also be accompanied by a sore throat. The patient can present with hyperthyroidism in the early phase of the disease and then progress to hypothyroidism. 3: This describes a thyroid condition known as Riedel's thyroiditis. Patients with this condition present with hypothyroidism and on examination have a hard, non-tender, asymmetric mass fixed to the underlying tissue in the thyroid region. Patients are often investigation for a possible thyroid malignancy due to the characteristics of the mass. 4: This will be present in multinodular goitres. These can be nontoxic or toxic. A toxic multinodular goitre functions autonomously in producing thyroid hormones and therefore produces signs and symptoms of hyperthyroidism. 5: This pathology is characteristic of papillary carcinoma of the thyroid. It is the most common carcinoma of the thyroid and has the best prognosis compared to the other types which are follicular, medullary and anaplastic.

Question 250

What percentage of patients with a raised PSA level (relative to their age) do not have prostate cancer?

Answer 250

75%

Question 251

Body fluid volumes: Compartment -> Volume in litres -> Percentage of total volume

Answer 251

* 70 Kg male = 42 L water (60% of total body weight)* - Intracellular -> 28 L -> 60-65% - Extracellular -> 14 L -> 35-40% - Plasma -> 3 L -> 5% - Interstitial -> 10 L -> 24% - Transcellular -> 1 L -> 3%

Question 252

What is the normal angle between the femoral neck and the femoral shaft?

Answer 252

130 degrees *any changes to this angle may occur due to a disease or pathology and should be investigated*

Question 253

What humeral structure articulates with the head of the radius and the head of the ulna?

Answer 253

- Radius = Capitulum | - Ulna = Trochlea

Question 254

What are anti-Jo-1 antibodies associated with?

Answer 254

Dermatomyositosis - (also seen: muscle weakness, muscle pains and a skin rash (heliotropic: purple))

Question 255

What position would the leg be in a posterior dislocation? What about an anterior dislocation?

Answer 255

- Leg is INTERNALLY ROTATED with posterior hip dislocation | - but EXTERNALLY ROTATED with anterior hip dislocations

Question 256

Risk factors for Rheumatoid Arthritis

Answer 256

- Peak onset 30-50 yrs (but can occur in all ages) - More common in Females (3:1) - Native American - Associated with HLA-DR4

Question 257

Which blood vessel mainly supplies the femoral head?

Answer 257

Medial and lateral femoral circumflex arteries | branches of profunda femoris

Question 258

Which virus is most implicated in viral warts?

Answer 258

HPV

Question 259

What are the different Type 2DM medications?

Answer 259

``` sulphonylureas metformin alpha-glucosidase inhibitors (acarbose) glitazones insulin ```

Question 260

Which bacteria causes staghorn calculi?

Answer 260

Proteus Miribalis

Question 261

What is the Z score? How do u interpret results?

Answer 261

- The Z score is a comparison of a person's bone density with that of an average person of the same age, sex, and ethnic background - > -1.0 = normal -1.0 to -2.5 = osteopaenia < -2.5 = osteoporosis

Question 262

What is the first line treatment of scabies

Answer 262

*excoriation marks, burrows, ink test* Permethrin 5%

Question 263

Histological findings kidney disease

Answer 263

1. Glomerular hypertrophy will be seen in acute post-streptococcal glomerulonephritis. 2. In IgA nephropathy, there is a proliferation of the mesangial cells. 3. Deposits of immune complex in the mesangial cells are present in IgA nephropathy but can only be seen with electron microscopy. 4. Thickening of the glomerular basement membrane occurs in diabetic nephropathy or membranous nephropathy, which are both types of nephrotic syndrome. 5. In diabetic nephropathy, there is an expansion of the mesangial matrix.

Question 264

What are the characteristic radiological findings for Calcium Oxalate stones?

Answer 264

Envelope-shaped crystals

Question 265

How do you prevent lipodystrophy (as a side-effect of Insulin)?

Answer 265

- typically presents as atrophy/lumps of subcutaneous fat - can be prevented by rotating the injection site - may cause eractic insulin absorption

Question 266

Where is Renin, ACE and Angiotensinogen released from?

Answer 266

- Renin = JG cells of Kidneys - ACE = Lungs - Angiotensinogen = Liver

Question 267

What are the associations with Hashimoto's?

Answer 267

- anti-TPO antibodies - firm, non-tender goiter - other autoimmune conditions e.g. coeliac disease, type 1 diabetes mellitus, vitiligo - MALT lymphoma

Question 268

Which test is used to confirm the diagnosis of Addison's?

Answer 268

A short synacthen test | synthetic ACTH

Question 269

Which tests confirm a diagnosis of Cushing's?

Answer 269

- 24-hour urinary free-cortisol test (!!) | - Low-dose dexamethasone suppression test

Question 270

What are the effects of PTH on Vit D to increase Ca2+ levels?

Answer 270

PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin D (at the Kidneys) -> increases Ca2+ absorption in the intestines

Question 271

What are the histological findings for diabetic nephropathy?

Answer 271

Kimmelstiel-Wilson lesions (!!!) nodular glomerulosclerosis

Question 272

What percentage of men with a raised PSA have prostate cancer?

Answer 272

25% (1 in 4)

Question 273

What condition is associated with Giant Cell Arteritis?

Answer 273

Polymyalgia Rheumatica

Question 274

Anti-diabetic drugs mechanisms of action

Answer 274

- Biguanides e. g. Metformin - Increase peripheral insulin sensitivity and hepatic glucose uptake. Sulfonylureas e.g. Gliclazide - Depolarise islet cells in the pancreas increasing insulin release. Thiazolidinediones e.g. Pioglitazone - Increase peripheral insulin sensitivity. SGLT2 Inhibitors e.g. Dapgliflozin - Increase urinary glucose loss. DPP4-Inhibitors e.g. Sitagliptin - Inhibit GLP1 breakdown. GLP1 Analogues e.g. Exenatide Increase insulin secretion and sensitivity. - Intestinal Alpha-Glucosidase Inhibitors e.g. Acarbose Delay intestinal carbohydrate absorption

Question 275

What is the treatment for Cellulitis and Erysipelas?

Answer 275

IV benzylpenicillin and fluclox | clindamycin if penicillin allergy

Question 276

What is the treatment of Minimal Change disease?

Answer 276

Give steroids!!

Question 277

Clinical features of Nephrotic syndrome

Answer 277

- Systemic Disease: Diabetes Mellitus (Glomerulosclerosis) Systemic Lupus Erythematosus (Membranous) Amyloidosis - Minimal Change Glomerulonephritis Associated with upper respiratory tract infection Biopsy: normal light microscopy, fusion of podocytes on electron microscope Treat with steroids 1% go on to have end-stage renal failure - Membranous nephropathy Associated with cancers (Lung, Colon Breast), inflammatory conditions (SLE, thyroid disease), infections (Hepatitis B) and drugs (Penicillamine and Gold) Biopsy: subepithelial immune complex deposits 40% have spontaneous remission - Focal segmental glomerulosclerosis More common in Afro-caribbean population Associated with Berger's disease, sickle cell, HIV Biopsy: focal scarring, IgM deposition Treat with steroids or cylophosphamide/ciclosporin 30-50% progress to end stage renal failure -Membranoproliferative/Mesangiocapillary Less common May present as both nephrotic or nephritic Associated with Hepatitis B, Hepatitis C and Endocarditis 50% progress to End-Stage Renal Failure

Question 278

How does Macula Densa control GFR in times of high Renal Blood Flow (RBF)?

Answer 278

- Increased RBF (due to increased BP) means there is an increase in water and Na+ coming to the Macula Densa and increased GFR is happening - Therefore, to prevent this excess GFR from happening, the Macula Densa will vasoconstrict the afferent arterioles so that GFR will decrease and return back to normal * it's role is to essentially maintain GFR within normal limits, independent of BP (it works even in an isolated kidney!*

Question 279

What are the indications for surgery and surgical management of Dupuytren's contractures?

Answer 279

Indications for surgery: - Functional impairment - MCP joint contracture > 30 degrees - Any PIP contracture - Rapidly progressive disease Surgical management: - Fasciectomy with Z-shaped scar