Medicine II Flashcards
(82 cards)
1
Q
A 72-year-old man presents to his general practitioner with new-onset constipation. This started about a week ago and coincided with the onset of regular stomach cramps. His wife reports that he has also been increasingly confused in the past few days, and has been very drowsy and lethargic, with weak muscles.
His past medical history is only significant for hypertension, for which he takes regular amlodipine, atenolol, bendroflumethiazide, and ramipril. He has taken over-the-counter macrogol in the past 7 days to try and help with his constipation.
Given the likely cause of his presentation, which medication could have this side effect?
A
Thiazide diuretics can cause hypercalcaemia and hypocalciuria
2
Q
A 56-year-old man has deteriorated rapidly after an ST-elevation myocardial infarction yesterday. During an initial ABCDE assessment, he has a cardiac arrest. The resuscitation team begin cardiopulmonary resuscitation and he is found to be in ventricular fibrillation. Three shocks have been delivered and the team has administered amiodarone along with adrenaline.
How often should adrenaline be given in this scenario?
A
1mg ever 3-5 mins
3
Q
A 23-year-old male is undergoing a medical review at a professional football club when an ejection systolic murmur is found. He is sent for echocardiogram and subsequently diagnosed with hypertrophic obstructive cardiomyopathy (HOCM). Electrocardiogram (ECG) is normal and pulse is regular. Which of the following complications of this condition is most likely to cause sudden death in this athlete?
A
ventricular fibrillation
Hypertrophic obstructive cardiomyopathy - is associated with sudden death in young athletes due to ventricular arrhythmia
4
Q
A 65-year-old man presents to the emergency department with central crushing chest pain 2 hours ago. His ECG on admission showed ST elevation in leads II, III and aVF. Suddenly, the patient develops worsening breathlessness. Upon cardiac auscultation, a new pan-systolic murmur is heard.
What complication is the most likely cause of this patient’s breathlessness?
A
Flash pulmonary oedema can occur after acute mitral valve regurgitation due to myocardial infarction
5
Q
Dressler’s syndrome
A
refers to recurrent pericarditis following a myocardial infarction, with fever, anaemia, raised erythrocyte sedimentation rate (ESR) and pleural effusions. It typically occurs between 2 and 6 weeks following infarction and can be managed with non-steroidal anti-inflammatory drugs (NSAIDs).
6
Q
A 23-year-old man is given intravenous adenosine to treat a supraventricular tachycardia. What is the approximate half-life of adenosine?
A
Adenosine has a very short half-life of about 8-10 seconds
7
Q
A 55-year-old patient presents to the Emergency Department with severe chest pain, chills and high-grade fever. He has no known past medical history. During the examination, poor dental hygiene was noted. On auscultation, a pansystolic murmur was heard in the left lower sternal border. Blood cultures result and echocardiogram are awaited to confirm the diagnosis.
Given the likely diagnosis, what organism is most likely to have caused his condition?
A
streptococcus viridans - poor dental hygiene
8
Q
bacterial causes of endocarditis
A
IV drug user-S. aureus
poor dental hygiene- S. viridans
9
Q
tests for infective endocarditis
A
x3 separate blood culture
Transoesophageal echocardiography (TOE) will detect 95% of vegetations.
- TOE is particularly useful for the detection of mitral valve and prosthetic valve vegetation
- More sensitive at detecting aortic root and septal abscesses and leaflet perforations
10
Q
vitamin k dependent clotting factors
A
2 7 9 10
II, VII, IX and X
11
Q
A 75-year-old gentleman with a past medical history of hypertension only presents with a 3-month history of increasing breathlessness and swollen ankles. You decide to order a BNP test. Which of the following may give him a falsely low BNP result?
A
Aldosterone antagonists
ACE inhibitors,
ARB
beta-blockers
diuretics
obesity.
12
Q
patients with suspected PE should be started on
A
DOAC (even before CTPA)
- some places may say LMWH and then go onto DOAC
13
Q
You are reading the notes of a patient on the coronary care unit. The notes say that the patient suffered a posteriorly situated myocardial infarction. You review the ECG on admission.
Which of the following ECG findings would be most likely in this scenario?
A
tall R waves V1-2
14
Q
The most common cause of primary hypothyroidism
A
is Hashimoto’s thyroiditis
- autoimmune destruction of thyroid
15
Q
hyperthyroidism causes
A
- graves- autoimmune
- thyroid
- thyroiditis
16
Q
cause of secondary hypothyroidism
A
- Due to TSH deficiency and usually due to pituitary disease
- Low T3 levels and non-elevated TSH
17
Q
Graves disease
A
- Autoimmune mediated stimulation of TSH receptor on thyroid gland stimulates thyroid hormone synthesis
Effects
- Graves ophthalmopathy
- Pretibial myxoedema (Graves dermopathy)
- Thyroid acropathy
18
Q
causes of thyroiditis
A
Q
thyroiditis
A
- Inflammation of thyroid
- Release of thyroxine into circulation
- Viral infection- de quervains thyroiditis
- After birth- post partum
- Medication- amiodarone
19
Q
limited scleroderma
A
- Diffuse skin tightness below knees and below elbows
- Usually years of raynauds before scleroderma
- Development of Pulmonary arterial (PA) hypertension after a mean of 10 years of symptoms
CREST syndrome
- Calcinosis Cutis
-
Raynaud’s phenomenon
- Ulcers
- White/blue skin
- Oesophageal dysmotility
-
Sclerodactyly
- Very tight skin
- Telangiectasia
20
Q
diffuse sclerodoma
A
- Less common
- High risk of mortality
- Sudden onset of skin involvement and proximal to the elbow sand knees (can effect anywhere)
21
Q
scleroderma treatment
A
Treatment
- No cure
- Psychological support
- Calcium channel blocker- nifedipine for raynauds
- Methotrexate and mycophenolate mofetil may reduce skin thickening
- ACEi prevent hypertensive crisis and reduce mortality from renal failures
- Short courses of prednisolone for flares
- PPI for GI symptoms
22
Q
sjogrens presentation
A
Most pts present with sicca symptoms – xerophthalmia (dry eyes), xerostomia (dry mouth) and fatigue
- Myalgia
- Arthralgia
- Dry mouth
- Fatigue
- Raynauds phenomenon
- Enlarged parotids
- Dry eyes
23
Q
pathophysiology of gout
A
monosodium urate (MSU) crystals that accumulate in joints and soft tissues, result in acute and chronic arthritis, soft-tissue masses called tophi, urate nephropathy, and uric acid nephrolithiasis
- negatively bifringement (monsodium urate)
- needle-shaped and yellow
24
Q
pseudogout
A
- less RF for gout
- positively birefringent crystals (calcium)
- rhomboid shape
25
mnagement of HHS
do not give insulin- central pontime mylenittis
* when you give fluids, dilutes blood and glucose, therefore giving insulin will dilute glucose further→ hypoglycaemia and central pontine myelinolysis
26
method for managing hyperthryoidism
**block and replace**
carbimazole (inhibits thyroid peroxidase TPO) then bring back
can put back on levothryozine (make sure doesnt go into hypo)
to make sure euthyroid
26
method for managing hyperthryoidism
put on B blocker first
**block and replace**
* carbimazole (inhibits thyroid peroxidase TPO, reduces amount of T3/T4) then bring back
* can put back on levothyroxine (make sure doesnt go into hypo)
* to make sure euthyroid
27
A 76-year-old man is reviewed. He was recently admitted after being found to be in atrial fibrillation. This was his second episode of atrial fibrillation. He also takes ramipril for hypertension and has a history of mitral stenosis but has no other history of note. During admission, he was warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review today he is found to be in sinus rhythm. What should happen regarding anticoagulation?
Warfarin should be continued indefinitely as this is his second episode of atrial fibrillation and he has risk factors for stroke (age, hypertension). As he has a history of valvular heart disease, warfarin is still preferred to a direct oral anticoagulant.
Discuss (10)Improve
28
A 56-year-old woman presents to the Emergency Department with central crushing chest pain and ST elevation of 3 mm in leads II, III and aVF. Which one of the following is an absolute contraindication to thrombolysis?
intracranial neoplasm
29
Ankylosing spondylitis - x-ray findings:
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
30
marker of poor prognosis in rheumatoid arthritis
anti-CCP
31
Which of the following is associated with a good prognosis in rheumatoid arthritis?
rheumatoid factor negative
32
treatment of choice for SLE
hydroxychloriquine
33
A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday in Spain. There is no history of trauma and he has had no knee problems previously. On examination he has a swollen, warm left knee with a full range of movement. His ankle joints are also painful to move but there is no swelling. On the soles of both feet you notice a waxy yellow rash. What is the most likely diagnosis?
reactive arthritis
## Footnote
The rash on the soles is keratoderma blenorrhagica. His reactive arthritis may be secondary to either gastrointestinal infection (hotel food) or *Chlamydia (if sexually active)*
Discuss (11)Improve
34
A 42-year-old woman presents to her GP with several months of progressive symmetrical swelling and stiffness of her fingers. Her symptoms are worse in cold weather. She also complains of more frequent 'heartburn' recently. On examination, there are three spider naevi on her face, and her fingers are red, mildly swollen, and shiny. Examination of the heart and lungs was normal.
What is the most likely diagnosis?
**Limited systemic sclerosis (CREST syndrome)** is the correct answer. The patient has Raynaud's phenomenon, oesophageal dysmotility, sclerodactyly and telangiectasia. Calcinosis doesn't always occur. Importantly there is no evidence of any systemic fibrosis, and therefore limited systemic fibrosis is the most likely diagnosis.
35
CREST stands for
calcinosis
raynauds
oesophageal dysmotility,
sclerodactyly,
telangiectasia
36
A 42-year-old man presents to the emergency department with a headache, sweating and palpitations. These symptoms have been ongoing for the last hour and he feels they are worsening.
On examination, his blood pressure is found to be 180/90 mmHg and a fine tremor is noted in both hands. His urine is sampled and shows raised levels of urinary metanephrines
Given this man's presentation, what is the most appropriate first-line treatment?
**PH**aeochromocytoma - give **PH**enoxybenzamine (alpha blocker) before beta-blockers
37
A 43-year-old man is attending today following a referral from his GP. He has a history of poorly controlled hypertension and has come in today to have his aldosterone: renin ratio performed. The results showed high aldosterone and low renin levels. The patient also has a CT scan which shows bilateral hyperplasia of the adrenal glands.
How should this patient be managed?
spironolactone
adrenolectomy if unilateral
38
A 54-year-old woman presents to her general practitioner with a 2 week history of heat intolerance and a sore neck. She underwent menopause four years ago and is adamant that this is different to menopausal hot flushes. She has no relevant past medical or family history. Five weeks ago she had a mild upper respiratory tract infection which resolved in 3 days.
On examination she has a mildly enlarged and tender thyroid gland. There are no discreet nodules. She has a temperature of 38.2ºC and a heart rate of 108/min. She has a fine tremor in bilateral hands and is noticeably diaphoretic. There are no eye, hair, skin or nail changes.
The general practitioner decides to order some blood tests and a thyroid scintigraphy scan.
What blood results would be expected in this patient?
[↑T4, ↑Erythrocyte sedimentation rate, ↓Uptake of iodine-131**38%**](https://www.passmedicine.com/question/questions.php?q=0#)
De Quervain's thyroiditis: initial hyperthyroidism, painful goitre and globally reduced uptake of iodine-131
39
A 19-year-old man presents to the Emergency Department (ED) in the early hours of the morning looking very confused. The on-call doctor tries to take a history from the man however he has trouble speaking. He is unable to walk in a straight line and keeps bumping into other people in the ED. His girlfriend who has accompanied him informs the doctor that he recently contracted malaria for which he was taking quinine sulfate. Which of the following is the most appropriate first-line investigation for this man?
blood glucose measurement- quinine sulfate can cause hypoglycaemia
Hypoglycaemia is commonly mistaken for being ‘drunk’ and so blood glucose measurement should always be part of initial assessment.
40
don't treat HHS with
**insulin**
GIVE IV fluids
* if you give insulin you will further dilute glucose (after being diluted by fluids) and cause hypoglycaemia
Type 2 diabetes
41
A 38-year-old female diabetic patient has called her general practitioner for some advice. She reports having diarrhoea and vomiting for the past 24 hours and has been unable to tolerate solid foods but is drinking without issue.
As she has not been eating, she is concerned about her insulin regime and wants to clarify if she should continue to take it.
What advice should be given to the patient?
A 38-year-old female diabetic patient has called her general practitioner for some advice. She reports having diarrhoea and vomiting for the past 24 hours and has been unable to tolerate solid foods but is drinking without issue.
As she has not been eating, she is concerned about her insulin regime and wants to clarify if she should continue to take it.
What advice should be given to the patient?
42
A 29-year-old man attends the fertility clinic with his wife after unsuccessfully attempting to conceive for the past 18 months. Prior to organising fertility testing, the consultant performs a physical examination of both patients. On examination, the man has small testicles and pronounced gynaecomastia. He also has truncal obesity, is 188cm tall (UK average = 175cm) and has sparse axillary and pubic hair. The examination is otherwise normal as is the patient's medical history.
Which of the following syndromes is the most likely explanation for this patient's physical characteristics and inability to conceive?
klinefelter
kallmans
kartageners
klinefelter
Klinefelter's syndrome is a chromosomal disorder that affects males and is caused by the presence of an additional X chromosome (i.e. a 47, XXY karyotype). Its characteristic features are small testes, infertility, gynaecomastia, above average height and a lack of secondary sexual characteristics.
Kallmann and Kartagener's syndrome both cause infertility. Kallmann syndrome is due to a failure of GnRH secretion and patients characteristically suffer from anosmia and would not exhibit gynaecomastia. Kartagener's syndrome is associated with dextrocardia and a history of recurrent sinusitis/bronchiectasis.
43
pathophysiology of CKD- mineral bone disease
**Pathophysiology**
***High serum phosphate*** occurs due to reduced phosphate excretion. ***Low active vitamin D*** because the kidney is essential in metabolising vitamin D to its active form. ***Active vitamin D*** is essential in calcium absorption from the intestines and kidneys. Vitamin D also regulates ***bone turnover***.
***Secondary hyperparathyroidism*** occurs because the parathyroid glands react to the low serum calcium and high serum phosphate by excreting more parathyroid hormone. This leads to increased ***osteoclast*** activity. Osteoclast activity lead to the absorption of calcium from bone.
***Osteomalacia*** occurs due to increased turnover of bones without adequate calcium supply.
***Osteosclerosis*** occurs when the osteoblasts respond by increasing their activity to match the osteoclasts by creating new tissue in the bone, however due to the low calcium level this new tissue is not properly mineralised.
***Osteoporosis*** can exist alongside the renal bone disease due to other risk factors such as age and use of steroids.
44
induction treatment in transplantation
Immunosuppressive drugs to create tolerance of the graft
* Methylprednisolone with any of the following:
* Basiliximab
* Thymoglobulin
45
maintenance treatment in transplantation
Prevent acute rejection
* Steroids: prednisolone
* Calcineurin inhibitors (CNI): tacrolimus, cyclosporine, voclosporin
* Antimetabolite medications: mycophenolate, azathioprine
* T cell regulation: belatacept and belimumab
46
A 45-year-old woman is seen by her nephrologist following allogeneic renal transplant for end-stage renal failure. She continues to take prednisolone, azathioprine and ciclosporin. What complication is this patient most at risk of?
Patients on long-term immunosuppression for organ transplantation require regular monitoring as they are at increased risk of skin malignancy. Patients should be educated about minimising sun exposure to reduce the risk of squamous cell carcinomas and basal cell carcinomas.
47
Which one of the following is the most important step in reducing the risk of contrast-induced nephropathy?
[Intravenous 0.9% sodium chloride pre- and post-procedure](https://www.passmedicine.com/question/questions.php?q=0#)
48
A 45-year-old female with nephrotic syndrome develops renal vein thrombosis. What changes in patients with nephrotic syndrome predispose to the development of venous thromboembolism?
loss of antithrombin III
49
You review a 42-year-old woman six weeks following a renal transplant for focal segmental glomerulosclerosis. Following the procedure she was discharged on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On examination her sclera are jaundiced and she has widespread lymphadenopathy with hepatomegaly. What is the most likely diagnosis?
Cytomegalovirus- most common after transpalnt
* anorexia
* fatigue
* arthralgia
50
A 74-year-old female presents to the GP with a history of episodic dizziness, feeling light headed and feeling faint. She has had two falls in past three weeks. On examination she has a heart rate of 64 beats/minute. She is known to have a first degree heart block. You order an ECG.
In addition to first degree heart block, there is left axis deviation and right bundle branch block?
What is the most likely diagnosis?
Trifascicular block- important cause of falls in elderly
RBBB +left anterior or posterior hemiblock + 1st-degree heart block = trifasicular block
51
A 24-year-old rugby player is suddenly collapses during a game. After being rushed to hospital it is suspected that he has hypertrophic obstructive cardiomyopathy.
Which of the following signs can be classically elicited on examination of someone with this condition?
Hypertrophic obstructive cardiomyopathy - is classically associated with an S4
52
A 69-year-old man attends his GP for a check-up. Upon his visit, his blood pressure was measured. The first reading was 190/125 mmHg on his left arm, and the second reading was 200/130 mmHg on his left arm. His right arm also produced readings of \>180/120 mmHg. The patient is asymptomatic and was not previously on any medications.
What is the most appropriate next step in his management?
\> 180/120 = GP treat and test for end organ damage
\> 180/120 and retinal haemorrhage/pappilloedema = refer same day
53
The cardiac arrest team is called to the bedside of a 67-year-old male patient, 2 days post-myocardial infarction. Two nurses are currently performing chest compressions and a manual defibrillator has just been attached. Chest compressions are paused briefly so that the rhythm can be analysed: pulseless electrical activity is observed.
Given the above, which of the following should happen in this scenario?
ALS - give adrenaline in non-shockable rhythm as soon as possible
54
most common bacterial cause if endocarditis \<3months after valvular repair
*Staphylococcus epidermidis*
55
A 65-year-old man is found to have an ejection systolic murmur and narrow pulse pressure on examination. He has experienced no chest pain, breathlessness or syncope. An echo confirms aortic stenosis and shows an aortic valve gradient of 30 mmHg. How should this patient be managed?
Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg
56
You have been asked to review the blood pressure of a 65-year-old gentleman. He was recently seen by the practice nurse for his annual health review and his blood pressure measured at the time was 153/88mmHg. There is no history of headache, visual changes or symptoms suggestive of heart failure. His past medical history includes hypertension, asthma and gastro-oesophageal reflux disease. The medications he is currently on include amlodipine, indapamide, lansoprazole, perindopril, salbutamol and a combined long-acting beta-agonist and corticosteroid inhaler.
On examination, his blood pressure is 159/85mmHg. Cardiovascular exam is unremarkable. Fundoscopy shows a normal fundi. The results of the blood test from two days ago are as follow:
## Footnote
Na+141 mmol/L(135 - 145)K+4.9 mmol/L(3.5 - 5.0)Bicarbonate28 mmol/L(22 - 29)Urea6.8 mmol/L(2.0 - 7.0)Creatinine114 µmol/L(55 - 120)
Which of the following is the most appropriate next step management for his blood pressure?
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ \> 4.5mmol/l - add an alpha- or beta-blocker
NICE recommends seeking expert advice if blood pressure remains uncontrolled with the optimal or maximum tolerated doses of **four drugs.**
57
A 62-year-old man presents to the emergency department. He complains of shortness of breath and chest pain. An ECG is performed, and an examination done, both of which rule out a myocardial infarction. There is no sign of a raised jugular venous pulse (JVP). The cardiology registrar states that he believes this is cardiac tamponade due to the abnormally large drop in blood pressure during inspiration.
What is the name given to this abnormally large drop in blood pressure during inspiration?
pulsus paradoxus
In cardiac tamponade, there will be an abnormally large drop in BP during inspiration, known as pulsus paradoxus
58
non cardiac cuase of raised BNP
CKD
59
A 74-year-old obese man with a past medical history of chronic kidney disease, advanced COPD and type 2 diabetes mellitus presents with exertional chest pain and dizziness. On examination, he is found to have a loud ejection systolic murmur with absent S2.
An echocardiogram shows severe aortic stenosis with associated left ventricular hypertrophy.
What is the most suitable definitive management?
Symptomatic aortic stenosis:
* surgical AVR for low/medium operative risk patients
* transcatheter AVR for high operative risk patients
60
A 76-year-old man presents to hospital with fatigue, confusion and constipation. He has a past medical history of prostate cancer, hypertension and hypercholesterolemia. Bloods reveal a significantly raised calcium.
What is the ECG most likely to show?
shortening of QT interval
61
A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After discussing treatment options he elects not to be cardioverted. Examination of the cardiovascular system is otherwise unremarkable with a blood pressure of 118/76 mmHg. According to the latest NICE guidelines, if the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer?
no treatment- do CHADVASC
Anticoagulation should be considered for the following:
* Men: CHA2DS2-VASC \>= 1
* Women CHA2DS2-VASC \>= 2
62
A 68-year-old with a history of ischaemic heart disease is seen in the hypertension clinic. Despite four antihypertensives his blood pressure is 172/94 mmHg. An abdominal ultrasound shows asymmetrical kidneys
renal artery stenosis
63
A 45-year-old man presents to his general practitioner concerned about his sex life. He is unable to get and maintain an erection and feel it is affecting him mentally.
He has a past medical history of atrial fibrillation and hypertension.
Which one of the following may be the underlying cause of erectile dysfunction in this patient?
beta blocker
64
if patient on warfarin nad has major bleed
stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
65
investigations for prostate cancer
* **Multiparametric MRI**
* **Prostate biopsy**
* isotope bone scan
66
A 24-year-old man is seen in the Acute Assessment Unit with a 4-day history of diarrhoea. He has been opening his bowels 15 times per day, passing fresh blood mixed with the stools, and feeling that he still needs to void even when his bowels are empty.
On examination, his abdomen is generally tender with voluntary guarding but no peritonism. There is a painful, nodular, erythematous eruption on the extensor aspects of his lower legs.
What is the most likely diagnosis?
ulcerative colitis
**Ulcerative colitis** is the most likely diagnosis here. This young man presents classically with bloody diarrhoea and tenesmus which is more commonly seen in ulcerative colitis compared to Crohn's. The painful, nodular, erythematous eruption refers to erythema nodosum, a feature frequently associated with autoimmune conditions such as ulcerative colitis. Ulcerative colitis can be diagnosed on flexible sigmoidoscopy with histology showing acute and chronic inflammation within the lamina propria and crypts.
**Crohn's disease** is a differential here (with erythema nodosum being more common in Crohn's patients), but bloody diarrhoea and tenesmus are more commonly associated with ulcerative colitis. Crohn's disease can be diagnosed on flexible sigmoidoscopy with histology showing patchy transmural inflammation with chronic inflammatory infiltrate and granuloma formation.
67
A 22-year-old man presents with crampy abdominal pain diarrhoea and bloating. He has just returned from a holiday in Egypt. He had been swimming in the local pool three weeks ago. He reports that he is opening his bowels 5 times a day. The stool floats in the toilet water, but there is no blood. What is the most likely cause?
Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.
68
A 67-year-old man is investigated for dyspepsia. A gastroscopy reveals a suspicious lesion which is biopsied. Which one of the following findings on biopsy would be most consistent with a diagnosis of gastric adenocarcinoma?
signet ring cells
69
A 12-year-old girl has recently been diagnosed as having coeliac disease. Along with a gluten free diet, she has been asked to receive some extra vaccinations, including the pneumococcal vaccine. Her mother has come to see her GP, asking why she needs to receive this vaccine.
Which of the following is the reason she needs the pneumococcal vaccine?
people with coeliac have hyposplenism
70
management of severe alcoholic hepatitis
prednisolone
71
A 48-year-old woman presents to gastroenterology clinic for follow up. She required treatment in hospital four weeks ago for an acute flare of ulcerative colitis. Currently she appears well and does not report symptoms suggesting another flare. This was the second time she has been admitted to hospital in the last year due to an exacerbation of ulcerative colitis.
What is the most appropriate maintenance treatment option for this woman?
Following a mild-to-moderate ulcerative colitis flare
* proctitis and proctosigmoiditis
* topical (rectal) aminosalicylate alone (daily or intermittent) or
* an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
* an oral aminosalicylate by itself: this may not be effective as the other two options
* left-sided and extensive ulcerative colitis
* low maintenance dose of an oral aminosalicylate
Following a severe relapse or \>=2 exacerbations in the past year
* oral azathioprine or oral mercaptopurine
72
what is not recommended in UC
methotrexate
it is in crohns
73
Fernando is a 56-year-old man who presents to the emergency department as he has noticed a gradual increase in swelling around his abdomen over the last few months. He has not noticed any other symptoms over this time.
On examination, his blood pressure is 120/80mmHg, heart rate 65/minute and regular, respiratory rate 15/minute, and he is afebrile. Fernando appears generally well although his abdomen appears distended and tense. Shifting dullness is present on percussion of the abdomen.
Fernando is sent for an ascitic tap and the fluid is sent for analysis. The serum ascitic albumin gradient (SAAG) returns as 13g/L. The white cell count is \<250 neutrophils/mm³.
Which of the following conditions would be a plausible cause of Fernando's ascites?
normal SAAG is \<11 g/l
liver cirrhosis
74
A 50-year-old man presents to the GP with general aches in his joints. After further enquiry, you note he has been a bit run down recently and feeling quite fatigued. After some time he also notes that he is having a problem achieving an erection and this has all been ongoing for the last year. He has no other medical conditions however both his father and grandfather died of a liver condition.
Given this man's presentation, what is the most likely diagnosis?
early signs of haematomachrosis: ED and arthralgia
75
A 60-year-old man attended his routine hepatology clinic review today. His medical issues include liver cirrhosis, type 2 diabetes, and hypertension.
On examination, he has scleral icterus and a distended abdomen suggestive of ascites. He looks alert and comfortable. This presentation could be caused by complications from one of his medical conditions.
Which of the following blood test would be helpful in assessing the severity of his complication?
albumin
76
A 23-year-old man presents to the outpatient department with recent onset of fatigue and a tremor in his right hand. He also reports that recently he has been ‘stumbling into things’ as he is walking. On examination, he has some yellowish discoloration as well as dark rings around the iris of both eyes.
What is the most appropriate first-line treatment for this patient?
Pencillamine
Kayser-Fleischer rings are seen in the eyes of patients with Wilson’s disease
77
The barium enema shown below was performed on a 28-year-old man who presented with persistent diarrhoea.
UC
This image demonstrates the complete loss of haustral markings in the distal part of the bowel ('lead pipe colon'), consistent with ulcerative colitis.
78
You see a 4-year-old boy in clinic with his parents. His parents are concerned that he is having difficulty growing.
On examination of his growth chart he has slipped from the 80th percentile for height and weight to the 20th percentile in the last six months. They also mention that their son has been very lethargic in the last month. On examination you note some abdominal distention.
You suspect that this child may have coeliac disease. Which blood test from the list below is the most appropriate to aid a diagnosis coeliac disease at this time?
IgA and IgA tTG antibody testing is the first line test of choice.
79
An 82-year-old female presents to the emergency department having suffered from diarrhoea and abdominal pain for the past week. She has a past medical history of type 2 diabetes mellitus and recently required treatment with co-amoxiclav and clarithromycin for severe community-acquired pneumonia. Her observations show:
* Respiratory rate: 25/min
* Heart rate: 131 bpm
* Temperature: 38.7ºC
* Blood pressure: 86/68mmHg
* Oxygen saturation: 96% on room air
Key investigation findings include an abdominal radiograph which shows large bowel distension (diameter \>6cm) and later, a stool sample which is positive for *Clostridium difficile* toxin (CDT).
Which of the following is the most appropriate prescribing strategy for this patient?
In life-threatening *Clostridium difficile* infection treatment is with ORAL vancomycin and IV metronidazole
80
Which one of the following extra-intestinal manifestations of inflammatory bowel disease is much more common in ulcerative colitis than in Crohn's disease?
primary sclerosing cholangitis
81
A 56-year-old man presents with a 3-month history of fatigue, global weakness and weight loss. On systems review, he also states that he has been having some pains in his fingers, mainly his second and third fingers, for the past month or so and has been having increasing difficulties with erectile dysfunction. You suspect that he may have hereditary haemochromatosis and as such arrange for him to have blood tests.
Which of the below results would be most in keeping with your suspected diagnosis?
[Ferritin - high; serum iron - high; total iron binding capacity - low; transferrin saturation - high**65%**](https://www.passmedicine.com/question/questions.php?q=0#)
