Med GEMS Questions Part 2 Flashcards by Verity Loake

A 21 year old woman with transfusion dependent beta thalassaemia normally has a transfusion every two weeks.

She has recently moved into your care and no previous blood results are available.

Pre-Transfusion bloods show a Hb of 76 (low) and a WCC of 23 (Normal Range: <11)

She is clinically well, apyrexial. She denies losing weight or night sweats. Her appetite is good.

What blood test should be ordered to further investigate the raised white cell count given her history?

Reticulocyte count

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A 62 year old man develops palpitations while undergoing chemotherapy for acute myeloid leukaemia.

ECG shows p wave flattening, hyperacute T waves and a broadened QRS compared to an ECG 5 days prior.

What electrolyte abnormality is responsible for the ECG changes?

Hyperkalaemia

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What chromosomal translocation is associated with Mantle Cell Lymphoma?

t(11:14)

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Chromosomal translocation with follicular lymphoma?

t(14:18) [Bcl-2]

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Chromosomal translocation with Burkitt lymphoma?

t(8:14) [c-myc]

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Translocation associated with Acute Promyelocytic leukaemia?

t(15:17)

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A histopathological biopsy of a lymph node is reported as follows:

“Significant infiltrates of homogenous lymphocytes. Macrophages are interspersed between sheets of lymphocytes and clearly contain apoptotic lymphocytes”

What lymphoma is associated with this histopathological description?

Burkitt’s lymphoma

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What is the inheritance pattern of hereditary elliptocytosis?

Autosomal dominant

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What is the most common cause of iron deficiency anaemia in the developing world?

Hookworm

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What blood test is a measure of fibrin degredation products and may reflect activity of the body’s anticoagulant system?

D-dimer

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A patient is investigated for tiredness.

Blood tests show a low haemoglobin.

A peripheral blood smear shows microcytosis, hypochromia and the presence of cigar cells.

What is the likely diagnosis?

Iron deficiency anaemia

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What is the term given to a group of genetic condition which affect the synthesis of the haem molecule, which is vital for the function of haemoglobin, peroxidase and P450 enzymes?

Poryphyria

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What blood film finding may be found in multiple myeloma and is reflective of a paraproteinaemia?

Rouleaux formation

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A 63 year old man is admitted to hospital with severe pain in his right flank which comes and goes in waves. He cannot remain still while the pain is at its worst.

He has had similar episodes in the past which resolved without him seeing a doctor. He has no other past medical history of note.

Blood tests reveal an elevated calcium (3.1, NR 2.2-2.6); a normocytic anaemia (Hb 90, NR >120); and an elevated urea and creatinine.

After further questioning, he reports pain in his back and his legs which has progressively been worsening.

What is the likely underlying diagnosis?

Multiple myeloma

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A 55 year old smoker presents to ED with unilateral left arm swelling which developed over a few days.

A D dimer is elevated. Platelets are elevated. An ultrasound doppler of the left arm does not reveal the presence of a blood clot. Other blood tests are unremarkable.

What is the next most appropriate investigation?

Chest x-ray

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What is the reversal agent for rivaroxaban?

Andexanet alfa

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What is the characteristic lymph node biopsy finding associated with Hodgkin lymphoma?

Reed-sternberg cells

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Multiple myeloma is a lymphoproliferative malignancy of what type of immune cell?

Plasma cells

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What protein is classically mutated in hereditary spherocytosis?

Spectrin

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Secretion of what hormone is responsible for the development of polycythaemia in COPD?

Erythropoietin

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A medical student is unsure about what cell she is looking at under the microscope. She is looking a peripheral blood film.

She describes a cell that looks plentiful on the film and has a multisegmented nucleus. It is approximately twice the size of the red cells she can see on the film.

What cell is she describing?

Neutrophils

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What condition is associated with infiltration of large numbers of megakaryocytes into bone marrow, an elevated platelet count and is associated with increased stroke risk?

Essential thrombocytosis

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What is the most common immunoglobulin produced by plasma cells in multiple myeloma?

IgG

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A 3 year old boy is seen by his GP after his mother noted that his right knee had swollen during the night and become painful to the touch. This has happened multiple times before in the other knee and it has resolved spontaneously. The child appears well and has no fever. He is able to weight bear. He does not appear distressed by it. His brother has had similar symptoms.

His past medical history includes recurrent epistaxis and his mother says he bruises easily.

The GP suspects this may be a clotting disorder and orders a panel of bloods, including inflammatory markers and a clotting screen.

Given the most likely diagnosis, what blood test would you expect to be elevated?

APTT

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A 80 year old man is seen by their GP. His wife is concerned that his gums have grown. He says when he brushes his teeth, they tend to bleed. He has had weight loss (10% in the last 6 months) and now bruises easily. A full blood count shows a low haemoglobin and low platelets. There is an elevated white cell count, with a large number of neutrophils. A blood film shows the presence of myeloid blast cells. What is the diagnosis?

Acute myeloid leukaemia

How can M3 subtype (acute promyelocytic leukaemia) of AML be treated?

all-trans retinoic acid.

What blood test is used clinically to measure the activity of the extrinsic and common clotting pathways?

Prothrombin time

What inherited condition, after cystic fibrosis, is the most common cause of pancreatic exocrine dysfunction in children?

Shwachman Diamond syndrome

What is Diamond–Blackfan syndrome?

typically affects red blood cells only - presents with anaemia

What is the classical inheritance pattern of G6PD deficiency?

X-linked recessive

What first line small molecule inhibitor is used in the treatment of chronic lymphocytic leukaemia?

Ibrutinib

What is Richter's transformation?

Where a low-grade CLL converts to a high grade, aggressive Diffuse Large B Cell Lymphoma.

How does Venetoclax work?

BCL2 inhibitor

A 28 year old woman is 39 weeks pregnant. Her labour is induced. During the delivery she becomes unwell with rigors, sweating and vomiting. Her observations are recorded as: pulse rate 147bpm, blood pressure 92/62mmHg. Bloods reveal an INR of 2.4 (1), APPT 47 seconds (22-42), fibrinogen 0.8 (1.5-4.0g/L), D Dimer 3350 (<250) What condition has been precipitated by her induction of labour?

DIC

What description is given to red blood cells which are typically polychromatic and stain heavily for the presence of RNA?

Reticulocyte

What drug inhibits the fusion protein BCR-ABL and is used in the treatment of Chronic Myeloid Leukaemia?

Imatinib

What abnormality is commonly seen on a full blood count of patients with fanconi anaemia?

Pancytopenia (most common cause of bone marrow failure)

Which haemoglobin chain is mutated in sickle cell disease?

Beta globin

What prothrombotic condition is associated with thrombocytopenia and immune complex formation?

Heparin induced thrombocytopenia

A 61 year old man undergoes the NHS Health check and has a blood test. His cholesterol is high and his WCC is 24 (NR: 4-11) with a neutrophil level of 17 (NR: 1.5-8). On examination, there is fullness in the left upper quadrant of the abdomen but no lymphadenopathy. He denies any recent travel. He denies any fever, night sweats or weight loss. He does not feel unwell. What is the likely diagnosis?

CML

What is the term given to the blood film finding of erythrocytes stacked on top of each other?

Rouleaux formation

A 78 year old woman is suspected to have immune thrombocytopenic purpura. Her platelet count is 115 (NR >150). She reports no bruising, bleeding or rashes. What is the most appropriate treatment?

No treatment

A 55 year old smoker presents to ED with unilateral left arm swelling which developed over a few days. A D dimer is elevated. Platelets are elevated. Other bloods are unremarkable. A Chest X ray is normal, although shows hyperexpanded lung fields. What is the most appropriate next investigation?

USS doppler L arm

What is the classical finding on a full blood count for a patient suspected of dyskeratosis congenita?

Pancytopenia

Findings o FBC in dyskeratosis congenita?

Neutropenia (due to telomere shortening)

What is the most common reaction to transfusion of packed red blood cells?

Fever

A 70 year old man presents with painless cervical lymphadenopathy. Other than an elevated lymphocyte count, his full blood count is normal. Immunophenotyping of lymphocytes taken from that blood sample reveal the cells are positive for CD19 and CD5. What is the most likely diagnosis?

CLL

What can be used to treat CLL?

Ibrutinib

A 70 year old man is seen in clinic. He describes a history of progressive enlargement of a "lump" in his groin. USS reveals it to be a lymph node and a biopsy is taken. What is the likely histopathological type of lymphoma that will be seen on biopsy?

Diffuse large B cell lymphoma

Most common lymphoma in <15 year olds?

Burkitt's lymphoma

In which organ is ferritin typically found in the body?

Liver

What are inclusions of denatured haemoglobin within erythrocytes commonly called when seen in a peripheral blood film?

Heinz bodies

A 18 year old Greek man has just returned from a holiday to Malawi and arranges a GP appointment. He said during the holiday he turned yellow, his urine turned brown and he felt more tired than normal. He has no relevant past medical history, is up to date on her vaccinations and took antimalarial prophylaxis as directed. The doctor suspects an intravascular haemolysis. Blood tests reveal a normocytic anaemia with unconjugated bilirubinemia. Levels of G6PD were normal. DAT negative. What is the most likely reason for the intravascular haemolysis?

G6PD deficiency

A patient has a normocytic anaemia, an elevated unconjugated bilirubin, elevated LDH and low haptoglobin. A peripheral blood film reveals spherocytes. Direct Coomb's test is negative. What investigation will confirm the diagnosis?

Eosin-5-malemide test (to confirm hereditary spherocytosis)

What clotting factor has the shortest half life?

Factor 7

What abnormality on a full blood count would be expected in Shwachman–Bodian–Diamond syndrome?

Neutropenia

A patient with metastatic ovarian cancer is investigated for unilateral lower limb swelling and is confirmed to have a DVT. What is the most appropriate form of anticoagulation?

DOAC

What infectious agent is associated with malignancy of germinal centre B lymphocytes?

Epstein barr virus

A doctor suspects that their patient may be anaemic. The doctor orders a panel of blood tests and a urine dip. The urine dip was positive for blood. A FBC reveals a normocytic anaemia. The results of Iron Studies are below. Serum iron Normal Total Iron Binding Capacity (TIBC) Normal C Reactive Protein 3 (NR 2-8) Ferritin Normal Bilirubin Elevated What type of anaemia does this patient have?

Haemolytic anaemia

Which chemical ion is required to convert Factor IX to Factor X in the intrinsic pathway of the clotting cascade and Factor VII to Factor X in the extrinsic pathway of the clotting disorder?

Calcium

A 48 year old female with bilateral hot, swollen and painful wrists presents to her GP. She says she has been feeling under the weather for about a year, however in the last week her joints have become exquisitely painful. She's also felt very tired and thinks she's been losing weight. A full blood count reveals a normocytic anaemia, however there is a decreased total iron binding capacity (TIBC) and elevated serum ferritin. What type of anaemia does this patient have?

Anaemia of chronic disease

Haematology (Bone Marrow Failures) A 14 year old boy is seen by a haematologist. He has been referred due to concerns from his GP about a clotting disorder, as he has had recent unexplained petechiae, nosebleeds, tiredness and fatigue. Bloods from the GP showed a pancytopenia. The haematologist performs a full physical examination and notes the presence of longitudinal ridging in the nails and areas of whitish grey discolouration in the mouth. There are fine, end inspiratory crackles at both lung bases. The haematologist suspects a primary bone marrow disorder. What is the most likely diagnosis?

Dyskeratosis congenita Dyskeratosis congenita is an inherited bone marrow failure which typically presents around age 15. The classical triad is of nail dystrophy (nail loss, longitudinal ridging), oral leukoplakia (white patches in the mouth) and skin pigmentation (lace like hyperpigmentation of skin creases), although this is thought to occur less commonly than previously described. A newer definition involves at least one of the features of the classical triad, with associated bone marrow failure (aplastic anaemia) and two other internal signs (like pulmonary fibrosis). The condition is caused by mutations in genes which protect telomeres. Telomeres protect the ends of chromosomes from damage and are associated with aging. Essentially, this condition reflects abnormal, advanced, cellular aging.

A 6 year old boy is seen by his GP. His dentist said that he should have his blood tested after a recent tooth extraction took a long time to clot. Blood tests show a normal INR, prolonged APTT, normal PT, normal level of platelets, normal levels of Von Willebrand factor, normal factor IX but low Factor VIII. Bleeding time is normal. What is the diagnosis?

Haemophilia A

What scoring system can be used to calculate the probability of developing heparin induced thrombocytopenia?

4T score

A 1 year old has been experiencing excessive sleepiness over the last month. She now sleeps for 18 hours a day and before that her parents noticed her becoming slower and more withdrawn. Her parents are concerned and bring her to see her GP. On examination, there are bruises on her wrist, arms and stomach. There is palpable splenomegaly. The GP makes an urgent safeguarding referral. Blood tests show a low haemoglobin and low platelets. There is an elevated white cell count, reported as neutrophils. A manual differentiation reveals the presence of an abundance of myeloid precursor cells. What is the diagnosis?

Acute myeloid leukaemia

A bone marrow biopsy for a patient suspected of having multiple myeloma shows 15% clonal plasma cells in the bone marrow. She does not have any symptoms of end organ damage. What is the diagnosis?

Smouldering myeloma

Plasma cells in MGUS?

MGUS has <10% plasma cells in the bone marrow on biopsy

After myelodysplastic syndrome, which haematological malignancy does Fanconi anaemia carry an approximate 10% lifetime risk of developing?

AML

Signs of Fanconi anaemia?

The most common type of inherited primary bone marrow failure. It presents between the ages of 5-9 with skeletal abnormalities (abnormal thumbs), short stature, cafe au lait spots and pancytopenia.

A 75 year old woman is seen in A&E with severe, right sided pain. She points to her right PSIS and says the pain is worse there. Palpation does not make the pain worse. Nothing makes the pain better. It is throbbing in nature. She denies trauma and this has worsened over the last two months. In this time, she has lost 5% of her body weight. She is anaemic and has an elevated serum corrected calcium. Serum protein electrophoresis shows the presence of a large, monoclonal band. Urinary bence jones proteins were negative. What is the likely diagnosis?

Multiple myeloma

What is the most common adulthood leukaemia?

CLL

Most common childhood leukaemia?

ALL

A long term alcoholic presents to their GP for a review. The doctor orders a panel of blood tests. A FBC reveals a normocytic anaemia. The results of Iron Studies are below. Serum iron Elevated Total Iron Binding Capacity (TIBC) Normal Ferritin Elevated C Reactive Protein 3 (NR 2-8) A blood film is ordered and reveals the presence of immature red blood cells with inclusions of iron deposits in a ring formation. What type of anaemia does this patient have?

Sideroblastic anaemia

What is the most sensitive biomarker for iron deficiency anaemia?

Serum ferritin

What blood test is used clinically to measure the activity of the instrincit and common clotting pathways?

APTT

A 82 year old man is seen in A+E following 2 weeks of being nonspecifically unwell. Blood tests reveal a profound anaemia (Hb 45 NR >125) and thrombocytopenia (Plts 42 NR >150). Neutrophils are elevated at 4x the upper limit of normal. C reactive protein is normal. Blood cultures are negative. A CXR reveals no consolidation or hilar enlargement. A urine sample reveals protein +1. These haematological abnormalities were not present on a blood test 2 weeks prior. What is the likely diagnosis?

AML

What is the term given to describe spherical erythrocytes which may be congenital or due to autoimmune haemolytic anaemia?

Spherocyte

What clotting factor do the intrinsic and extrinsic clotting pathways converge onto?

Factor 10

A 74 year old woman is seen following blood tests done for monitoring of pernicious anaemia. Her blood tests show a Hb 132 (normal), MCV 92 (normal), Plts 89 (low), WCC 8 (normal). B12 and folate were normal. LFTs were normal. She is tested for HIV (-ve) and Hepatitis B (HbSAg -ve). Her GP sends a blood film and a repeat full blood count, which was normal other than thrombocytopenia. What is the likely cause of her thrombocytopenia?

Immune thrombocytopenia purpura

What is the typical finding on a full blood count for patients with Diamond Blackfan anaemia?

Anaemia

What is the reversal agent for dabigatran?

Idarucizumab

The M3 subtype of Acute Myeloid Leukaemia can be treated effectively with which first line drug?

All Trans Retinoic Acid

The myeloproliferative syndromes, which include essential thrombocytosis, all carry a risk of transformation to what life threatening malignancy?

AML

A 71 year old woman is seen by her GP due to progressive tiredness. She also thinks she has been losing weight. On examination, there was cervical lymphadenopathy. A full blood count showed a low haemoglobin and an elevated white cell count, predominantly lymphocytes. A blood film was performed and did not show any immature cells. What is the likely diagnosis?

CLL

A 70 year old man is admitted to the general medical ward following a paracetamol overdose. He completes treatment for his overdose without complication and is discharged. He is normally fit and well. He received standard venous thromboprophylaxis during his stay with enoxaparin. Blood tests 10 days later at his GP show a severe thrombocytopenia, with normal liver function tests. Other cell lineages are normal. He denies any symptoms of bleeding. He feels well. What is the most likely explanation for his thrombocytopenia?

Heparin induced thrombocytopenia

An 18 year old presents to their GP with a neck lump. It is approximately 3.5cm, mobile and untethered in the posterior triangle of the neck. On further questioning, he reports weight loss and drenching night sweats. A blood film showed the presence of multinucleated and reactive lymphocytes. What is the most likely diagnosis?

Hodgkin's Lymphoma

Give an example of a chemotherapy drug which inhibits BCL2 and hence increases lymphocyte apoptosis in CLL.

Venetoclax

A 68 year old man feels unwell while undergoing his first cycle of chemotherapy for acute myeloid leukaemia. He is known to have primary hyperparathyroidism and takes an inhaled corticosteroid for asthma. A VBG performed by the oncall F1 shows a calcium of 1.6mmol/L. Pre chemotherapy bloods 2 weeks prior show a calcium of 2.71mmol/L What is the diagnosis?

Tumour lysis syndrome

Which cofactor is required for synthesis of the anticoagulant proteins C and S?

Vitamin K

A medical student is unsure about what cell she is looking at under the microscope. She is looking a peripheral blood film. She describes a cell with a bilobed nucleus. The cytoplasm of the cell has stained some areas with a reddish-purple colour. She says there aren't many of these in the blood film. What cell is she describing?

Eosinophil

A medical student is unsure about what cell she is looking at under the microscope. She is looking a peripheral blood film. She describes an odd looking cell that she hasn't seen before in this patient. It has lots of dark blue speckles in the cytoplasm of the cell. It is much larger than the red blood cells. What cell is she describing?

Basophil

What chromosomal translocation is associated with Follicular Lymphoma?

t(14:18)

A 1 month old child is investigated for the cause of a macrocytic anaemia, identified during routine workup for surgery for treatment of her cleft palate. She is noted to be quite underweight. Her brother has suffered from similar issues. Vitamin B12 and folate levels were normal. Haemoglobin electrophoresis showed elevated fetal haemoglobin, but no other abnormalities. Her reticulocyte count was low. What is the most likely underlying diagnosis?

Diamond blackfan syndrome

A medical student is unsure about what cell she is looking at under the microscope. She is looking a peripheral blood film. She describes a cell that is nearly completely dark purple, except for a thin rim of slightly blue stained cytoplasm. It's roughly the same size as red blood cells. What cell is she describing?

Lymphocyte

A 56 year old man is reviewed by his GP after his blood tests suggested a new microcytic anaemia. His ferritin and serum iron is low. His full blood count, CRP, renal function, LFTs, B12 and folate are otherwise normal. A blood film reveals the presence of hypochromic erythrocytes with pencil cells. What is the next most appropriate blood test to request, prior to an OGD and colonoscopy?

Anti Tissue Transglutaminase Antibodies

What clotting disorder is associated with a reduced platelet count, elevated PT, elevated APTT and an elevated bleeding time?

DIC

A 78 year old woman is admitted to hospital following blood tests which showed profound anaemia, leukopenia and thrombocytopenia. Her abdominal exam reveals hepatosplenomegaly. A blood film shows dacrocytes and the presence of immature haematological cells. What investigation would confirm the diagnosis?

Bone marrow biopsy

What chromosomal translocation is associated with a poor prognosis in Acute Lymphoblastic Leukaemia?

t(9:22)

What enzyme is inhibited by warfarin and leads to a reduction in clotting factors II, VII, IX and X?

Vitamin K epoxide reductase

What chromosomal translocation is associated with Chronic Myeloid Leukaemia?

t(9;22)

What molecule, secreted by the liver, inhibits iron absorption from the gut by inhibiting ferroportin?

Hepcidin

What intracellular inclusion may be found in the neutrophils of a patient with acute myeloid leukaemia?

Auer rods

Which haematological malignancy is most commonly associated with formation of the Philadelphia Chromosome (9;22 translocation)?

CML

What amino acid is glutamate substituted for in sickle cell disease?

Valine

Indications for dialysis:

* Pulmonary oedema * Refractory hyperkalaemia * Metabolic acidosis * Uraemic encephalopathy * Also some drug toxicity (e.g. lithium)

9. What does the number of True positives divided by the total number who have the disease describe?

Sensitivity

10. Which of these ions (K, CL, Na, Mg) is most likely to be outside its normal range in an alkalotic picture (& if person is urinating a lot????)?

Potassium

7. A Girl develops a throat infection. She is given amoxicillin, and a rash develops. It is later found out that she has infectious mononucleosis, and her symptoms persist a. Drug reaction b. Penicillin allergy c. Mastocytosis

Drug reaction

8. Cushing disease person – Which is the best investigation to confirm the suspected diagnosis? a. High dose dexamethasone suppression test b. Low dose dexamethasone suppression test c. Long synacthen test d. Short synacthen test

High or low??

5. pH 7.1, pCO2 low (2.2 or 3 or something) a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

Metabolic acidosis

3. A man has gout and is kept up at night by it. His symptoms are relieved by ibuprofen, but when he stops taking it, the symptoms come back. His neighbour is on allopurinol, and he would like to be on it too. Which of these medications would need to be altered for them to be able to be prescribed allopurinol?

Azathioprine

2. Which of these is a common finding in someone who has portal hypertension? a. Splenomegaly b. Hepatomegaly c. Spider Naevi in distribution of Superior vena cava (SVC) d. Hand flapping e. Jaundice

Splenomegaly

1. Person is discharged after surgery, who had a bilateral hemianopia, with removal of pituitary adenoma. Consultant says it is alright to discharge them. What do you prescribe the patient on discharge? a. DDAVP b. Fludrocortisone c. Testosterone

DDAVP

CAH: what metabolic disturbance?

Hyponatraemia, hyperkalaemia, hypovolaemia

Woman presents worried because she has low glucose when she tests using daughter’s meter (her daughter has T1DM) but denies taking any drugs. Low glucose, high insulin, low C peptide, she has a high BMI

Factitious/ surreptitious insulin (i.e. taking too much external insulin)

Red cell lysis, what ion is raised?

Potassium

Which molecule takes cholesterol and moves it to liver and steroidogenesis organs?

Cholesterol ester transferase? HDL?

Which disease do you see in both MEN1 and MEN2a?

Primary hyperaparathyroidism

High PTH and low Ca, what can this be?

Osteomalacia

What would be high in the most common cause of CAH?

ACTH

Publican with diabetes, fatty stools, weight loss, ‘slate grey skin’ and joint pains. What is the underlying diagnosis causing this?

Haemachromatosis

What enzyme to confirm cardiac failure?

BNP (brain narituretic peptide)

Deficiency of which enzyme leads to hyperuricemia?

HGPRT (Nesch Hyan syndrome)

Which/What enzyme is raised in mumps?

Amylase-5

In Rhabdomyolysis, which biomarker is likely to be raised?

Creatinine kinase

What is a sign that your patient has been taking cocaine?

AST

Low plasma sodium, low urine sodium

Psychogenic polydipsia

Hyperaldosterone picture with raised Na, low K, HTN but raised renin

Renal artery stenosis

Most common brain tumour in children?

Pilocytic astrocytoma (grade 1)

What does brain tumour grade tell us?

Survival

Most common brain tumour in adults?

Metastatic deposits

Which mutation identifies astrocytic tumours with a better prognosis?

IDH mutation

What causes a buruli ulcer?

Mycobacterium ulcerans

Natural reservoir for influenza A virus?

Ducks

A man has gout and is kept up at night by it. His symptoms are relieved by ibuprofen, but when he stops taking it, the symptoms come back. His neighbour is on allopurinol, and he would like to be on it too. Which of these medications would need to be altered for them to be able to be prescribed allopurinol?

Azothioprine

A Girl develops a throat infection. She is given amoxicillin, and a rash develops. It is later found out that she has infectious mononucleosis, and her symptoms persist

Drug reaction

What does the number of True positives divided by the total number who have the disease describe?

Sensitivity

Person is discharged after surgery, who had a bilateral hemianopia, with removal of pituitary adenoma. Consultant says it is alright to discharge them. What do you prescribe the patient

DDAVP

What can cause pleural effusion?

heart failure

Low plasma sodium (124) and urine specific gravity of 1.000 cause?

Psychogenic polydipsia

What would be high in the most common cause of CAH?

ACTH

A patient is found to have a high Na+, low K+, and low renin. What is the likely cause?

Conn's syndrome

What happens to the heart in chronic hypertension?

Left ventricular hypertrophy

What can cause ascites?

Liver failure

A man develops signs of hyperthyroidism. Bloods show low TSH and high thyroxine. A technetium scan shows no uptake. What is the likely diagnosis?

De Quervain's thyroiditis

What does Denosumab target?

RANK ligand (on osteoclasts)

What is associated with mesothelioma?

Asbestos

Old man who fell over, been on floor for days. Severely dehydrated. Dark urine. Not blood on microscopy. What causes the dark urine? And what enzyme would be raised?

Myoglobin, creatinine kinase

What liver enzyme is raised in MI?

Aspartate aminotransferase

What enzyme to confirm cardiac failure?

Brain nariuretic peptide

5yr old, tetany, bone pain. Widened epiphyses + ‘Cupping’ of metaphysis shown on x-ray. What is the cause?

Rickets

Publican with diabetes, fatty stools, weight loss, ‘slate grey skin’ and joint pains. What is the underlying diagnosis causing this?

Haemachromatosis

Swollen joint, needle-shaped aspirate with negative birefringence, which enzyme manufactures the material that makes up the crystals?

Xanthine oxidase

T1DM with hypoglycaemia, what is the management option if no IV access?

IM glucagon

Which cancer typically causes an increase in calcitonin?

Medullary carcinoma of the thyroid

Patient with High PTH vitamin deficiency?

Calcium

Patient with Pellagra vitamin deficiency?

Niacin (B3 deficiency)

Baby with seizures: low Ca, low PT

Hypopoarathyroidism

10 year old with seizures: low Ca, high PO4, high PTH

Renal osteodystrophy

In Rhabdomyolysis, which biomarker is likely to be raised?

Creatinine kinase

Deficiency of which enzyme leads to hyperuricemia?

HGPRT

Which enzyme regulates the rate limiting step in the haem biosynthesis pathway?

ALA synthase

Which/What enzyme is raised in mumps?

Amylase-S

Woman with colicky abdominal pain, markedly raised ALP, other LFTs also deranged?

Acute cholestasis

Mechanism of death due to raised ICP?

Coning

22 year old student with two weeks anorexia, fever and malaise – ALT was most elevated, raised ALP + GGT?

Viral hepatitis

A 57 year old man presents following hematemesis and is found to have high ALT + GGT, slightly raised ALP, and low Albumin

Cirrhosis

Patient can’t fit in her shoes or put on her wedding ring and has prognathism, what test do you need to do to confirm?

serum IGF then oral glucose tolerance test

BP 190/100, thin skin, overweight, high-normal sodium, low normal potassium, OGTT done (glucose high normal)

Low dose dexamethasone suppression test then inferior petrosal sinus sampling

Pt with low Na, High K + postural hypotension

SynACTHten test

Diabetic visiting his GP for a routine appointment

HbA1c

Lichen sclerosis has what type of inflammatory pattern?

Lichenoid reaction

Calcium high, PTH low?

Bone metastasis

Calcium low, PTH low?

Hypoparathyroidism

Temporal arteritis test which will help with diagnosis?

ESR

Hyperaldosterone picture with raised Na, low K, HTN but raised renin

Renal artery stenosis

Low plasma sodium, low urine sodium?

Psychogenic polydipsia

Man who has been in a car accident, raised sodium and plasma osmolality, low urine osmolality?

Cranial DI

Which is the most common cytogenic abnormality in myeloma?

Hyperdiploid karyotype

ST elevation in leads V2,3,4 indicates coronary artery?

Left

ST elevation in leads V2,3,4 indicates coronary artery?

Left

First choice for imaging of kidney stone?

Measures to define AKI?

Urine output and urea

What would make you want to start antimicrobials immediately?

Low BP

Biggest prognostic indicator for graft vs host disease?

Prior acute GvHD

What prothrombotic condition is associated with thrombocytopenia and immune complex formation?

Heparin induced thrombocytopenia

CML

What is the classical finding on a full blood count for a patient suspected of dyskeratosis congenita?

Pancytopenia

Diffuse large B cell

A bone marrow biopsy for a patient suspected of having multiple myeloma shows 15% clonal plasma cells in the bone marrow. She does not have any symptoms of end organ damage. What is the diagnosis?

Smouldering myeloma

MGUS has what percentage of plasma cells in the bone marrow on biopsy?

<10%

After myelodysplastic syndrome, which haematological malignancy does Fanconi anaemia carry an approximate 10% lifetime risk of developing?

AML

What is the most sensitive biomarker for iron deficiency anaemia?

Serum ferritin

What clotting factor do the intrinsic and extrinsic clotting pathways converge onto?

Factor 10

What is the typical finding on a full blood count for patients with Diamond Blackfan anaemia?

Anaemia

What is the reversal agent for dabigatran?

Idarucizumab

What drug should be given urgently to a patient on LMWH therapy who has significant, life threatening bleeding?

Protamine sulfate

Diamond-blackfan

What enzyme is inhibited by warfarin and leads to a reduction in clotting factors II, VII, IX and X?

Vitamin K epoxide reductase

A 74 year old man is seen in the haematological outpatients clinic following a routine GP blood test which showed a lymphocytosis. His medication includes intramuscular hydroxocobalamin for pernicious anaemia. The patient feels well. Haemoglobin and platelets are normal. The patient has an elevated serum B12 at 3x the upper limit of normal. Lymphocytes >10x the upper limit of normal. An abdominal examination is normal. Neurologically he has reduced fine touch sensation bilaterally to his ankles. A blood film is pending. What is the likely explanation for his abnormal blood tests?

CLL

What oncogene is typically found in Burkitt's lymphoma and is created by a translocation between chromosome 8 and 14?

C-myc

What are inclusions of clusters of nuclear DNA within erythrocytes commonly called when seen in a peripheral blood film? This finding is often associated with Sickle Cell Disease in adults.

Howell jolly bodies

A 60 year old woman is seen in the emergency department. She is known to have Immune thrombocytopenic purpura and a previous cholecystectomy. A contrast enhanced CT Abdomen Pelvis shows the presence of a small amount of free fluid in the abdomen and fat stranding around the ileocecal area in the right iliac fossa. The surgeons wish to take her to theatre, however, her platelets are 14 (NR >150). What is an appropriate treatment to raise her platelet count quickly preoperatively?

IVIG

What dysfunctional gene is common to myelofibrosis, essential thrombocytosis and polycythaemia rubra vera?

JAK2

A medical student is unsure about what cell she is looking at under the microscope. She is looking a peripheral blood film. She says she has seen a number of these cells in this sample, but that they are not too common. This cell is very large and has a bilobed nucleus. She says at least 4 red blood cells could fit inside this cell. What cell is she describing?

Monocyte

What blood test should be monitored regularly on a patient treated with unfractionated heparin?

APTT

A 60 year old man is diagnosed with Immune thrombocytopenic purpura. He reports nosebleeds quite frequently, usually every 2-3 days. His platelet count is 34. What is an appropriate treatment to improve his platelet count?

Prednisolone

What coagulation factor decreases after starting warfarin therapy and causes an initial prothrombotic state?

Protein C and Protein S

How is the influeza virus comprised?

A purified fraction containing HA and NA of an inactivated virus

Tau staining in the peristriate but not the striate cortex is consistent with which brakk grading?

Five

Which herniation does not involve the cortex?

Tonsillar

Frontal lesion tumour?

Glioblastoma multiforme (Grade 4)

What is raised in true secondary polycythaemia?

EPO

Name a narrow spectrum agent?

Amoxicillin

Risk of thrombosis is increased by?

Reduced protein S

IPEX syndrome is what?

Monogenic autoimmune disease

What is dermatomyositis associated with?

Anti-jo1, high CK, positive ANA

Which part of the female reproductive track most likely gets metastatic deposits?

Ovaries

Signs of typhoid?

Fever, rose spots, Faget's sign, constipation, relative bradycardia, epistaxis, hepatosplenomegaly, malaise, headache

What drug causes hypokalaemia?

furosemide

Which interleukin is

Which benign breast condition can mimic breast cancer on radiology?

Radical scar

Histopathological myeloma marker?

CD138

Major toxic effect of cocaine?

cardiotoxic

Organism causing intercranial abscess?

MRSA

Organsim causing prosthetic joint infection?

Coagulase negative staphylococci

Resistance to aciclovir mechanism?

Thymidine kinase mutations

Treatment for monkey pox?

Tecoviromat

Treatment for BK virus?

Cidofovir

Treatment for BK virus?

Cidofovir

Complications of CMV in neonates?

Colitis, pneumonitis, hepatitis, retinitis, bone marrow suppression

2nd line anti-viral treatment?

Foscarnet

Treatment for non-falciparum malaria?

Chloroquine and primaquine

Toxoid vaccines:

Tetanus and diptheria

Viral vector vaccine

Astra Zeneca

Types of immunosuppression: FROM MOST TO LEAST SEVERE

Allogenic stem cell transplant Advanced HIV infection (CD4 dep) Solid organ transplant Various monoclonal antibody therapies Cytotoxic chemotherapy DMARDs and steroids

Disseminated catch stratch disease treatment?

Mx: Erythromycin/doxycycline PLUS rifampicin

Brucellosis

Predilection to the testis/orchitis Fever Back pain Focal abscesses (psoas, liver etc.)

What causes rabies?

Lyssa virus

Rat bite fever?

streptobacillus monoiliformis or spirillum minus Fevers Polyarthralgia Maculopapular progressing to purpuric rash Endocarditis Managed with penicillins

When is CMV most risky for fetus?

Third trimester

Anaphylaxis definition:

Severe, life-threatening allergic reaction that has an AB or C problem and urticaria. Don’t need a blood pressure drop to diagnose anaphylaxis.

Aetiology of anaphylaxis?

Antibodies (IgE) activate mast cells Release mediators including histamine, proteases, proteoglycans and cytokines.

How does adrenaline work?

Adrenaline causes bronchodilation, vasoconstriction. Acts on beta 2 receptors and stops cells from emptying their cell contents.

Hughes syndrome

Some patients with SLE can also have anti-phospholipid antibody syndrome

Something elevated in multiple myeloma?

ESR! ALP is not

Gene in Bruton's ?

BTK gene

What goes up in T cell mediated graft rejection?

Creatinine

Antibody-mediated rejection takes place where?

Intravascularly Glomerulitis

Which type of rejection is easier to treat?

T cells

Treatment for e antigen positive Hep B in pregnancy?

Vaccine at birth + HBIG within 48 hours

Treatment for e antigen negative Hep B in pregnancy?

Vaccine at birth + routine vaccination schedule

Is Hep B+D co-infection or superinfection worse?

Superinfection - high risk of severe liver disease

HEP E infection route?

G1+2 = fecal-oral G3+4 = zoonotic

Hepatitis extra-hepatic manifestations?

Encephalitis, ataxia, IgA nephropathy, Guillian barré syndrome. red cell aplasia, thrombocytopenia

Antibodies in coeliac disease?

IgA anti-tissue transglutaminase, anti-gliadin, anti-endosymial antibodies

How many species of schistomiasis?

4. Eggs migrate through the bladder/bowel and cause damage.

Strongyloides treatment?

Ivermectin Are capable of autoinfection

Signs of filiariasis?

Dance sign, loa loa migration

Fibroadenoma

benign, mobile lump, multinodular composed of expanded intralobular stroma, compressed ‘slit like’ ducts, branching sheets of epithelium

Radical scar

‘benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue’ ○ Stellate mass on mammogram (resembles carcinoma), central elastotic nidus surrounded by proliferative corona

loss of E-cadherin?

Lobular carcinoma in situ

, H pylori can cause what?

MALT lymphoma

● Variant CJD

- Depression then CNS symptoms in young person

● Tuberous sclerosis

epileptic with patch on back and lumps in brain

associated with focal glomerulonephritis?

Heroin use

- oncogene, poor prognosis, squamous and small cell

K-ras

● Squamous cell Carcinoma of the lung

prickles, keratinisation, PTHrp secretion, smokers, central but not so much anymore

Honeycomb lung?

Fibrosing lung disease (idiopathic pulmonary fibrosis)

Stages of lobular pneumonia?

Stages: 1.Consolidation; 2. Red Hepatisation (neutrophilia); 3. Grey Hepatisation (Fibrosis); 4. Resolution

● Polyarteritis nodosa association?

Associated with Hep B/C

Cryoglobulinaemia

● Cryoglobulinaemia (in Meeran’s book) - Igs precipitate at low temps (secondary to connective tissue diseases, lymphoproliferative disease) leading to complement activation, neutrophil recruitment and vascular damage

>20% blasts =?

AML

What else can cause MALT apart from H pylori?

Sjorgen's syndrome

● Acute promyelocytic leukaemia presents as?

DIC

● Pelger Huet cells ?

MDS

Another name for diabetes insipidus?

Vasopressin deficiency

HHS full name?

Hyperosomolar hyperglycaemic state

● Beri beri syndrome?

B1 deficiency

● Dementia/dermatitis/Casal’s necklace/diarrhoea deficiency?

Niacin/B3 deficiency

dexamethasone suppression test ○ If it suppresses with high dose

Cushing's disease (ACTH-producting pituitary tumour)

● Polyuria, polydipsia, hyponatraemia and high ish serum osmolality - test?

blood glucose, as high lipids can cause pseudohyponatraemia

● Hypoglycaemia - test C peptide (which is secreted in equimolar amounts to insulin) results with different conditions?

○ C peptide levels are high in insulinoma, normal or low with exogenous insulin, and elevated with oral sulfonylureas

● Impaired glucose tolerance

2 hours post glucose ≥7.8 and <11.1

● Deficiency resulting in urate overproduction

HGPRT = lesch nyhan syndrome

● Hypoglycaemic neonate, which condition do you want to rule out first?

Galactosaemia

○ Tay Sachs

cell membrane components (gangliosides - kind of sphingolipid) accumulate in nerve cells ■ Months after birth: deterioration of mental and physical abilities, cherry red spot on retina, death before the age of 4 ■ Can also present in older children with skill deterioration or as adults when effects can stop progressing

○ Lysosomal

Substrate accumulation within the organelles leading to organomegaly (connective tissue, solid organs, cartilage, bone, above all - nervous tissue) ■ Urine mucopolysaccharides, oligosaccharides, leucocyte enzyme activities ● Urea cycle

Maple syrup urine disease?

Sweaty feet, : sweet smelling urine, also smell of ear wax, seem healthy at birth but quickly deteriorate with severe brain damage during times of metabolic crisis & can die of cerebral oedema

● Marker of antibody mediated rejection

C4d

Treatment for GvHD?

Steroids Prophylaxis: Methotrexate, cyclosporine

○ Antigen for non-neutralising antibodies HIV

p24 gag IgG

● Tocilizumab

○ Antibody against IL6 receptor ○ Used in caslteman’s, RA if not responding to methotrexate, sulfasalazine ○ IV every 4 weeks: reduces macrophage/T cell/B cell/neutrophil activation

● Ustekinumab

○ Antibody to p40 subunit of IL12 and IL23 ○ Psoriasis, psoriatic arthritis, subcut every 12 weeks

● Routine but not given to immunocompromised children

MMR

Hep B is what type of vaccine?

Conjugate

○ Haemophilus ducreyi

Chcolate agar

Tests for syphillus

VDRL tells you if ever syphilis, can also do RPR

silver stain

PCP

● Moroxella catarrhalis

○ Smoking, gram negative coccus

○ Recent viral infection, cavitation on CXR, gram positive cocci in grape bunch clusters

Staph aureus

● Giardia treatment?

Metronidazole

○ Gram negatives abx treatment?

Ciprofloxacin

● RUQ abscess/cyst, flask shaped cysts in liver

Entamoeba histolytica

● Mucor indicus

○ Opportunistic, really bad, rapidly spreads, brain, lungs, black discharge from nose ○ Needs amphotericin B

○ Chemokine that inhibits HIV entry into cells?

MIP-1a

● Haemorrhagic cystitis, virus in kids?

Adenovirus

Antidote: 10 ml 10% calcium gluconate (slow IV infusion)