Medicine

Question 1

Grading scale for murmurs

Answer 1

Levine scale
1 slightest possible murmur heard by trained ear
2 soft murmur heard when in optimal condition
3 moderately loud. no thrill
4 loud and associated with a palpable thrill
5 loud with thrill. heard with stethoscope lightly touching chest
6 loud, thrill heard with stethoscope not touching skin

Question 2

Guilliain- Barre syndrome is most likely associated with which organism

Answer 2

Campylobacter jejune

Question 3

Guilliain-barre symptoms are caused by..

Answer 3

loss of myelin

Question 4

GBS definition

Answer 4

acute rapidly evolving demyelinating inflammatory polyradiculoneuropathy that often starts
in the distal lower limbs and ascends

Question 5

signs and symptoms of GBS

Answer 5

■ sensory: distal and symmetric paresthesias, loss of proprioception and vibration sense, neuropathic
pain
■ motor: weakness starting distally in legs, areflexia
■ autonomic: blood pressure dysregulation, arrhythmias, bladder dysfunction

Question 6

investigation for GBS

Answer 6

■ CSF: albuminocytologic dissociation (high protein, normal WBC)
■ EMG/NCS: conduction block, differential or focal (motor > sensory) slowing, decreased F-wave,
sural sparing

Question 7

subtypes of GBS

Answer 7

• subtypes

1. acute inflammatory demyelinating polyneuropathy (AIDP)
2. acute motor-sensory axonal neuropathy (AMSAN)
3. acute motor axonal neuropathy (AMAN)

Question 8

treatments of GBS

Answer 8

• treatment

■ IVIG or plasmapheresis, ± pain management, monitor vitals and vital capacity

Question 9

antidote for nerve gas poisoning

Answer 9

atropine

Question 10

Diabetic retinopathy - clinical features

Answer 10

Non proliferative
pre proliferative
proliferative

Question 11

leading cause of blindness

Answer 11

diabetic retinopathy

Question 12

prevention of diabetic retinopathy

Answer 12

Tight glycemic control

Annual visits to optometrist or ophthalmologist

Question 13

what is diabetic retinopathy

Answer 13

a microvascular complication of poorly controlled diabetes.

Question 14

treatment of diabetic retinopathy

Answer 14

Pan-retinal and focal retinal laser
photocoagulation reduces the risk of visual loss
in patients with macular edema.
intravitreal injection of corticosteroid or anti-VEGF for foveal involved diabetic macular edema

Question 15

how does loss of vision occur in diabetic retinopathy

Answer 15

loss of vision due to
■ progressive microangiopathy leading to macular edema
■ progressive DR → neovascularization → traction → RD and vitreous hemorrhage
■ rubeosis iridis (neovascularization of the iris) leading to neovascular glaucoma (poor prognosis)
■ macular ischemia

Question 16

non- proliferative diabetic retinopathy

Answer 16

increased vascular permeability and retinal ischemia
■ microaneurysms
■ dot and blot hemorrhages
■ hard exudates (lipid deposits), non-specific for DR
■ macular edema

Question 17

pre-proliferative diabetic retinopathy

Answer 17

■ non-proliferative findings plus:
◆ venous beading (in ≥2 of 4 retinal quadrants)
◆ intraretinal microvascular anomalies (IRMA) in 1 of 4 retinal quadrants
– IRMA: dilated, leaky vessels within the retina
◆ cotton wool spots (nerve fibre layer infarcts)

Question 18

proliferative diabetic retinopathy

Answer 18

■ 5% of patients with DM will reach this stage
■ neovascularization of iris, disc, retina to vitreous
◆ neovascularization of iris (rubeosis iridis) can lead to neovascular glaucoma
◆ vitreous hemorrhage, bleeding from fragile new vessels, fibrous tissue can contract causing
tractional RD
■ high risk of severe vision loss secondary to vitreous hemorrhage, RD
soft exudates indicate ischaemia

Question 19

extra ocular muscle palsy associated with diabetic retinopathy

Answer 19

• usually CN III infarct
• pupil usually spared in diabetic CN III palsy, but ptosis is observed
• may involve CN IV and VI
• usually recover within few months

Question 20

peripheral neuropathy facts

Answer 20

• as proprioception reduces it becomes more difficult to walk on uneven surfaces
• many patients are injured yearly by putting their feet on radiators or sitting to close to the fire.
• specific footwear to protect feet
• foot shape changes due to glycosylation of collagen
• charcot Joint

Question 21

microvascular complications of diabetes

Answer 21

Neuropathy, retinopathy, nephropathy, glaucoma and cataracts

Question 22

microvascular complications of diabetes

Answer 22

coronary artery disease, Stroke, peripheral vascular disease (and therefore ulcers and gangrene)

Question 23

other complications of diabetes

Answer 23

increased risk of infections
pregnancy complications
metabolic difficulties
impotence
autonomic neuropathy

Question 24

causes of sudden loss of vision in diabetic patients

Answer 24

central retinal artery occlusion
retinal detachment
vitreous haemorrhage

Question 25

eye assessments for diabetic patients include

Answer 25

opthalmoscopy through dilated pupils retinal photography fluorecein angiography slit lamp examination

Question 26

what is peripheral neuropathy

Answer 26

a symmetrical sensory polyneuropathy, initially affecting distal lower extremities. decreased or loss of ankle reflexes occurs early in disease. progressive loss increases the risk of ulcer formation

Question 27

large fibre loss - peripheral neuropathy

Answer 27

loss of vibration | loss of proprioception

Question 28

Small fiber loss peripheral neuropathy

Answer 28

loss of light touch loss of temperature impairment of pain

Question 29

drugs approved by Health Canada for peripheral neuropathy

Answer 29

duloxetine | pregabalin

Question 30

Dengue fever

Answer 30

Common Arboviral infection

Question 31

clinical incubation period dengue fever

Answer 31

5-10 days

Question 32

vector for dengue fever including breeding areas

Answer 32

Aedes aegypti mosquito which prefers to breed in clean water and common in urban areas with higher incidences in the Welter months

Question 33

symptoms of dengue fever

Answer 33

lethargy biphasic fever (present for 2 days which resolves and is then followed by a second fever) headache - especially retro orbital pain arthralgia myalgia rash - usually with second fever. maculopapular starting on trunk and spreading to limbs

Question 34

Severe cases/complications of Dengue

Answer 34

Dengue shock syndrome Dengue haemorrhage fever these have immunological basis - if previous immunity to dengue serotypes --> increases risk

Question 35

dengue antibodies

Answer 35

IgG usually remains positive for life | antibodies do not give protection against dengue as more than one serotype but is not at increased risk of complication

Question 36

pre renal causes of AKI

Answer 36

Drugs Hypercalcaemia Hypovolaemia (absolute and effect)

Question 37

Drugs causing AKI

Answer 37

ACE/ARB NSAIDS cyclosporin Tacrolimus

Question 38

diagnosing Zollinger -Ellison syndrome

Answer 38

fasting serum gastrin level

Question 39

Anti-Saccharomyces cerevisiae antibodies

Answer 39

A group of antibodies directed at components of the cell wall of the yeast Saccharomyces cerevisiae. Associated with chronic inflammatory bowel disease (particularly Crohn disease).

Question 40

Schilling test

Answer 40

A test to determine the cause of B12 deficiency. Patients ingest radiolabelled B12 and then its urinary excretion is measured. Excretion will be normal if the cause is a dietary deficiency. If excretion is low (suggesting malabsorption), the test is repeated with orally administered intrinsic factor (IF). If excretion normalizes, the cause is IF deficiency. If excretion still remains low, the test is repeated with antibiotics, and then pancreatic enzymes to rule out bacterial overgrowth and pancreatic insufficiency, respectively.

Question 41

p-ANCA

Answer 41

An autoantibody against myeloperoxidase granules (present in the perinuclear region of cytoplasm). p-ANCA levels are increased in patients with ulcerative colitis, autoimmune systemic vasculitis (especially Churg-Strauss syndrome and microscopic polyangiitis) and primary sclerosing cholangitis.

Question 42

fecal lactoferrin

Answer 42

A marker of intestinal inflammation used to assess for, e.g., inflammatory bowel disease (IBD)

Question 43

Whipple disease

Answer 43

An infectious disease caused by the bacteria Tropheryma whipplei. It is notoriously difficult to diagnose because of its variable presentation. Findings often include chronic malabsorptive diarrhea, weight loss, migratory non-deforming arthritis, lymphadenopathy, and a low-grade fever.

Question 44

Tropical Sprue

Answer 44

A bacterial infection that is associated with a stay in the tropics or subtropics and leads to structural damage of the intestinal mucosa. Characterized by chronic diarrhea with subsequent malabsorption, abdominal cramps, progressive weight loss, and fatigue.

Question 45

Hepatitis C

Answer 45

A viral infection that causes acute or chronic inflammation of the liver after an incubation period of 2 weeks to 6 months. Usually transmitted parenterally but can be transmitted sexually or perinatally. Inflammation is usually mild or not present at all and resolves within a few weeks or months. Can rarely cause acute liver failure. Often leads to chronic hepatitis.

Question 46

test to confirm acute hepatitis A

Answer 46

Anti-HAV IgM

Question 47

primary sclerosing cholangitis

Answer 47

Primary sclerosing cholangitis (PSC) is a progressive chronic inflammation of both the intrahepatic and extrahepatic bile ducts. While the exact etiology is unknown, there is a strong association with autoimmune diseases, particularly ulcerative colitis (UC). In the early stages, PSC is usually asymptomatic. Later in the course of the disease, patients present with symptoms of cholestasis (e.g., pruritus, jaundice). Laboratory abnormalities include elevated liver function tests and autoantibodies (pANCA in up to 80% of cases). Magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) is performed to confirm the diagnosis. Management is primarily symptomatic, with liver transplantation reserved for end-stage liver disease.

Question 48

hydatid cyst disease

Answer 48

A helminthic infection caused by cestodes of the genus Echinococcus (e.g., E. granulosus, E. multilocularis). Infection is typically acquired by accidental ingestion of Echinococcus eggs, which are shed in the feces of infected dogs. Infection results in cystic lesions in the liver (75% of cases), lung (15% of cases), and, rarely, other organs.

Question 49

albendazole

Answer 49

An orally administered, broad-spectrum antihelminthic drug that is used to treat echinococcosis, cysticercosis, pinworm infection (enterobiasis), hookworm infection (ancylostomiasis, necatoriasis), ascariasis, trichuriasis, and strongyloidiasis. Mechanism of action: inhibition of microtubule synthesis.

Question 50

HBsAg

Answer 50

Surface antigen Protein on the surface of HBV; first evidence of infection Anti‑HBs Indicates immunity to HBV due to vaccination or resolved infection Usually appears 1–3 months after infection.

Question 51

HBcAg

Answer 51

Core antigen Protein of the nucleocapsid Anti‑HBc Anti-HBC IgM indicates recent infection with HBV (≤ 6 months) Anti-HBc IgG indicates resolved or chronic infections

Question 52

HBeAg

Answer 52

Envelope antigen Protein secreted by the virus that indicates viral replication and infectivity Anti‑HBe Indicates long-term clearance of HBV

Question 53

Hepatitis A virus (HAV)

Answer 53

``` Picornavirus Non-enveloped virus Positive sense, single-stranded, linear RNA Fecal-oral 15–50 Acute hepatitis: fever, malaise, loss of appetite, nausea, abdominal pain, jaundice, ↑ AST/ALT Children < 6 years often have no symptoms Anti-HAV IgM Supportive Food and water hygiene Immunization Full recovery within ∼ 3 months Does not become chronic ```

Question 54

IE - staphylococcus aureus

Answer 54

Most common cause of acute IE for all groups (including IV drug users and patients with prosthetic valves or pacemakers/ICDs) Affects previously healthy valves Usually fatal within 6 weeks (if left untreated)

Question 55

IE - Viridans streptococci

Answer 55

Most common cause of subacute IE, especially in predamaged native valves (mainly the mitral valve) and in prosthetic valves (≥ 60 days after surgery) Common cause of IE following dental procedures Produce dextrans that facilitate binding fibrin-platelet aggregates on damaged heart valves

Question 56

IE - Viridans streptococci

Answer 56

Most common cause of subacute IE, especially in predamaged native valves (mainly the mitral valve) and in prosthetic valves (≥ 60 days after surgery) Common cause of IE following dental procedures Produce dextrans that facilitate binding fibrin-platelet aggregates on damaged heart valves

Question 57

Risk factors for chronic venous disease

Answer 57

Higher age and female sex (see “Epidemiology” above) Family history of venous disease Ligamentous laxity Sedentary lifestyle and prolonged standing Obesity Pregnancy Smoking Prior thrombosis (postthrombotic syndrome) Prior extremity trauma Congenital abnormalities

Question 58

primary prevention rheumatic fever

Answer 58

prompt antibiotic treatment (e.g., penicillin V) of GAS tonsillopharyngitis diagnosed by throat culture or rapid strep test

Question 59

secondary prevention rheumatic fever

Answer 59

Antibiotic prophylaxis to prevent recurrence Drug of choice: IM penicillin G benzathine In patients with a penicillin allergy: oral macrolides Usually administered every 28 days Immediately follows antibiotic treatment of acute rheumatic fever (see “Treatment” above) Duration depends on risk and severity of original episode Rheumatic fever without carditis: 5 years or until the patient is age 21 (whichever is longer) Rheumatic fever with carditis: 10 years or until the patient is age 21 (whichever is longer) Rheumatic fever with carditis and permanent valvular heart defects: 10 years or until age 40 (whichever is longer)