Meeran Flashcards by Kat Qiao

A gram negative intracellular diplococcus that causes meningitis

Neisseria or Neisseria Meningitides

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A gram positive diplococcus that causes pneumonia

Pneumococcus or streptococcus pneumoniae

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A gram positive organism that grows in bunches and causes abscesses

Staphylococcus Aureus

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The organism that causes tetanus

Clostridium tetanae

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A gram negative rod that commonly causes urinary tract infections

E-coli

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Cystic dilatation of duct during lactation caused by obstruction

duct ectasia

mammary duct ectasia

fibroadenoma

mastitis

fibrocystic change

galactocoele

galactorrhoea

gynaecomastia

intraductal papilloma

lactating adenoma

galactocoele

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Infection of the breast that occurs during lactation

duct ectasia

mammary duct ectasia

fibroadenoma

mastitis

fibrocystic change

galactocoele

galactorrhoea

gynaecomastia

intraductal papilloma

lactating adenoma

mastitis

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Occurs in males with liver disease

duct ectasia

mammary duct ectasia

fibroadenoma

mastitis

fibrocystic change

galactocoele

galactorrhoea

gynaecomastia

intraductal papilloma

lactating adenoma

gynaecomastia

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Occurs in the presence of a high prolactin

duct ectasia

mammary duct ectasia

fibroadenoma

mastitis

fibrocystic change

galactocoele

galactorrhoea

gynaecomastia

intraductal papilloma

lactating adenoma

galactorrhoea

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The commonest benign tumour of the female breast

duct ectasia

mammary duct ectasia

fibroadenoma

mastitis

fibrocystic change

galactocoele

galactorrhoea

gynaecomastia

intraductal papilloma

lactating adenoma

fibroadenoma

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Causes an increased loss of HCO3-

Diabetic ketoacidosis
Intestinal fistula
Metabolic acidosis
Metabolic alkalosis
Poor lung perfusion
Pyloric stenosis
Renal failure
Respiratory acidosis
Respiratory alkalosis

Intestinal fistula

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2. Causes increased H+ production
 Diabetic ketoacidosis
Intestinal fistula
Metabolic acidosis
Metabolic alkalosis
Poor lung perfusion
Pyloric stenosis
Renal failure
Respiratory acidosis
Respiratory alkalosis

Diabetic ketoacidosis

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3. Causes increased H+ loss
 Diabetic ketoacidosis
Intestinal fistula
Metabolic acidosis
Metabolic alkalosis
Poor lung perfusion
Pyloric stenosis
Renal failure
Respiratory acidosis
Respiratory alkalosis

Pyloric stenosis

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4. Can be compensated by increased renal excretion of H+
 Diabetic ketoacidosis
Intestinal fistula
Metabolic acidosis
Metabolic alkalosis
Poor lung perfusion
Pyloric stenosis
Renal failure
Respiratory acidosis
Respiratory alkalosis

Metabolic acidosis

Be aware that compensation for a metabolic acidosis is with hyperventilation. Renal excretion (question 4) of acid is not really compensation, but just correcting the problem.

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5. Can be compensated by hypoventilation
 Diabetic ketoacidosis
Intestinal fistula
Metabolic acidosis
Metabolic alkalosis
Poor lung perfusion
Pyloric stenosis
Renal failure
Respiratory acidosis
Respiratory alkalosis

Metabolic alkalosis

Also although hypoventilation would compensate for a metabolic alkalosis, that effect is minimised in humans by hypoxia.

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Gain in bicarbonate ions or loss of H+ ions resulting in raised pH.

Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis with Respiratory Compensation
Metabolic Alkalosis with Respiratory Compensation
Respiratory Acidosis with Metabolic Compensation
Respiratory Alkalosis with Metabolic Compensation

a. Metabolic Alkalosis

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24 year old female presents at A&E with a broken ankle. The interpretation of her blood gas results (pH 7.62, PCO2 3.59, PO2 14.1, HCO3 23, Base Excess 0) demonstrates a ____.

a. Respiratory Alkalosis

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22 year old model is admitted to A&E with weakness and tingling sensations in both hands and feet, and “poor balance”. Patient denies pill ingestion but admits she has been on a strict diet regimen to meet her agency’s expectations. Her ABG results (pH 7.55, PCO2 6.67, PO2 12.0, HCO3 45) demonstrate ____.

a. Metabolic Alkalosis

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A 40 year old lady with severe chronic back pain (treated aggressively with OTC NSAIDs) for several years was found to have BP 155/95 at her routine GP visit. Her urine dipstick demonstrated ++ protein and increased white blood cells. Her ABG results (pH 7.30, PCO2 4.27, HCO3 15) demonstrate _____.

a. Metabolic Acidosis with Respiratory Compensation

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A 45 year old man with a history of solvent (inhalant) abuse presents to A&E complaining of dyspnoea (SPO2 99% on room air). He is tachypnoeic on examination and demonstrates Kussmaul breathing. His ABG (pH 6.95, PCO2 1.20, PO2 17.0, HCO3- 2) demonstrates ___.

a. Metabolic acidosis with respiratory compensation

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An elderly patient on the ward has RR 16, HR 65, temp 37.5 degrees C. His blood gases are pH 7.35 (7.35-7.45), pCO2 9.0 (4.7-6 kPa), pO2 8.1(10.0-13.3 kPa), HCO3 45 (22-30). Rank the underlying diseases below in order of likelihood, going from most to least likely:

Pulmonary embolism
Tension pneumothorax 
COPD
Hyperventilation
Pneumonia

Answer:

COPD
Pneumonia
Pulmonary embolism
Tension pneumothorax
Hyperventilation

Explanation: this is a picture of respiratory acidosis with metabolic compensation. Hyperventilation would cause alkalosis so is least likely. A tension pneumothorax would not have time to establish compensation so is next least likely. The carbon dioxide is high and the oxygen is low so this is type 2 respiratory failure with no v/q mismatch. while a number of small PEs might result in compensation over time they would give a type 1 picture with low oxygen and normal carbon dioxide. Both pneumonia and COPD might give this blood gas picture but this patient’s vital measurements show no sign of infection so COPD is most likely.

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A 42 year old man with heartburn presents with the following blood gases: pH 7.51, pCO2 5.2kPa, bicarbonate = 30 mmol/l.

Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Compensated Respiratory Alkalosis
Compensated Respiratory Acidosis
Compensated Metabolic Alkalosis
Compensated Metabolic Acidosis
Type I Respiratory Failure
Type II Respiratory Failure

a. Metabolic Alkalosis

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65 year old long- term smoker is admitted with drowsiness and confusion. ABG reveals pH 7.36, pO2 7kPa, pCO2 8kPa, bicarbonate 24 mmol/l.

Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Compensated Respiratory Alkalosis
Compensated Respiratory Acidosis
Compensated Metabolic Alkalosis
Compensated Metabolic Acidosis
Type I Respiratory Failure
Type II Respiratory Failure

a. Type II Respiratory Failure

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Treat with IV sodium bicarbonate

Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Compensated Respiratory Alkalosis
Compensated Respiratory Acidosis
Compensated Metabolic Alkalosis
Compensated Metabolic Acidosis
Type I Respiratory Failure
Type II Respiratory Failure

a. Metabolic Acidosis

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4. 24 year old female presents with an aspirin overdose. She appears to be breathing heavily. pH 7.38, pO2 12kPa, pCO2 2.5kPa, bicarbonate 16 mmol/l. ``` Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Compensated Respiratory Alkalosis Compensated Respiratory Acidosis Compensated Metabolic Alkalosis Compensated Metabolic Acidosis Type I Respiratory Failure Type II Respiratory Failure ```

a. Compensated Metabolic Acidosis

5. 55 year old male with difficulty breathing is diagnosed with Guillain- Barre syndrome. pH 7.25, pO2 12kPa, pCO2 9kPa, bicarbonate 25 mmol/l. ``` Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Compensated Respiratory Alkalosis Compensated Respiratory Acidosis Compensated Metabolic Alkalosis Compensated Metabolic Acidosis Type I Respiratory Failure Type II Respiratory Failure ```

a. Respiratory Acidosis

1. 22 year old man presents with a painless, red ulcer on his penis. Microscopy reveals spiral shaped organisms. ``` Benzylpenicillin Ceftriaxone Chloramphenicol Clarithromycin Colistin Gentamicin Intravenous Meropenem Moxifloxacin Orally Rifampicin Trimethoprim Vancomycin Rectally ```

a. Benzylpenicillin

2. On a routine swab for a pre-op patient, the lab is able to culture Staphylococcus aureus. The lab also reports that this particular strain is not sensitive to Penicillins. ``` Benzylpenicillin Ceftriaxone Chloramphenicol Clarithromycin Colistin Gentamicin Intravenous Meropenem Moxifloxacin Orally Rifampicin Trimethoprim Vancomycin Rectally ```

a. Vancomycin

3. The route of administration when administering Vancomycin to treat serious C.difficile infection. ``` Benzylpenicillin Ceftriaxone Chloramphenicol Clarithromycin Colistin Gentamicin Intravenous Meropenem Moxifloxacin Orally Rifampicin Trimethoprim Vancomycin Rectally ```

a. Orally

4. This antibiotic which is usually administered as eye drops, can cause grey baby syndrome in neonates, because of an inability to metabolise the drug. ``` Benzylpenicillin Ceftriaxone Chloramphenicol Clarithromycin Colistin Gentamicin Intravenous Meropenem Moxifloxacin Orally Rifampicin Trimethoprim Vancomycin Rectally ```

a. Chloramphenicol

5. A 21 year old university student presents with meningococcal infection, and he is successfully treated. What prophylaxis might be given to his housemates and closest contacts? ``` Benzylpenicillin Ceftriaxone Chloramphenicol Clarithromycin Colistin Gentamicin Intravenous Meropenem Moxifloxacin Orally Rifampicin Trimethoprim Vancomycin Rectally ```

a. Rifampicin

1. 36-year old male presents with hypertension. Lab results: Na+ = 155mmol/L, K+ = 2.9mmol/L, pH = 7.46, low plasma renin activity. ``` Pituitary dependent Cushing’s disease Adrenal tumour causing Cushing’s syndrome Ectopic ACTH causing Cushing’s syndrome Normal obese person Cushing’s syndrome of indeterminate cause Pituitary adenoma Phaeochromocytoma Primary adrenal insufficiency Secondary adrenal insufficiency Primary hyperaldosteronism Secondary hyperaldosteronism Adrenal medulla Zona glomerulosa Zona fasciculata Zona reticularis ```

a. Primary hyperaldosteronism

2. 50-year old female with the following lab results: Na+ = 130mmol/L, K+ = 5.9mmol/L, glucose = 3.4mmol/L, urea = 7.2 mmol/L, Ca2+ = 2.8 mmol/L. A short SynACTHen test shows cortisol = 600nmol/L half an hour after administration. ``` Pituitary dependent Cushing’s disease Adrenal tumour causing Cushing’s syndrome Ectopic ACTH causing Cushing’s syndrome Normal obese person Cushing’s syndrome of indeterminate cause Pituitary adenoma Phaeochromocytoma Primary adrenal insufficiency Secondary adrenal insufficiency Primary hyperaldosteronism Secondary hyperaldosteronism Adrenal medulla Zona glomerulosa Zona fasciculata Zona reticularis ```

a. Secondary adrenal insufficiency

3. A 45-year old female patient presents with cushingoid features. A dexamethasone suppression test shows undetectable ACTH, cortisol = 750nmol/L. ``` Pituitary dependent Cushing’s disease Adrenal tumour causing Cushing’s syndrome Ectopic ACTH causing Cushing’s syndrome Normal obese person Cushing’s syndrome of indeterminate cause Pituitary adenoma Phaeochromocytoma Primary adrenal insufficiency Secondary adrenal insufficiency Primary hyperaldosteronism Secondary hyperaldosteronism Adrenal medulla Zona glomerulosa Zona fasciculata Zona reticularis ```

a. Adrenal tumour causing Cushing’s syndrome

4. A 65-year old male patient presents with cushingoid features. A high dose dexamethasone suppression test shows ACTH 25 pmol/L (high), cortisol = 750nmol/L. ``` Pituitary dependent Cushing’s disease Adrenal tumour causing Cushing’s syndrome Ectopic ACTH causing Cushing’s syndrome Normal obese person Cushing’s syndrome of indeterminate cause Pituitary adenoma Phaeochromocytoma Primary adrenal insufficiency Secondary adrenal insufficiency Primary hyperaldosteronism Secondary hyperaldosteronism Adrenal medulla Zona glomerulosa Zona fasciculata Zona reticularis ```

a. Ectopic ACTH causing Cushing’s syndrome

5. A 28-year old man presents with hypertensive episodes. Lab results: Na+ 140mmol/L, K+ = 4.1mmol/L, random cortisol = 200nmol/L. CT shows an adrenal mass, which region is most likely to be affected? ``` Pituitary dependent Cushing’s disease Adrenal tumour causing Cushing’s syndrome Ectopic ACTH causing Cushing’s syndrome Normal obese person Cushing’s syndrome of indeterminate cause Pituitary adenoma Phaeochromocytoma Primary adrenal insufficiency Secondary adrenal insufficiency Primary hyperaldosteronism Secondary hyperaldosteronism Adrenal medulla Zona glomerulosa Zona fasciculata Zona reticularis ```

a. Adrenal medulla

1. What is the first line of treatment in phaeochromocytomas? ``` Phaeochromocytoma Conn’s syndrome Cushing’s syndrome Alpha blockade Beta blockade Surgery Pituitary MRI High dose dexamethasone test Adrenal CT Scan Spironolactone Zona glomerulosa Zona fasciculata Low dose dexamethasone test 24 hour ambulatory blood pressure Aldosterone- renin ratio Glucose tolerance test ```

a. Alpha blockade

2. A 25 year old female patient presents with high levels of aldosterone and low levels of renin. On examination the patient is found to be hypertensive. ``` Phaeochromocytoma Conn’s syndrome Cushing’s syndrome Alpha blockade Beta blockade Surgery Pituitary MRI High dose dexamethasone test Adrenal CT Scan Spironolactone Zona glomerulosa Zona fasciculata Low dose dexamethasone test 24 hour ambulatory blood pressure Aldosterone- renin ratio Glucose tolerance test ```

a. Conn’s syndrome

3. A 75 year old lady reports to her GP of very frequent panic attacks. She complains of excessive sweating and following investigations, hypertension is detected and raised levels of catecholamines are found in the urine. ``` Phaeochromocytoma Conn’s syndrome Cushing’s syndrome Alpha blockade Beta blockade Surgery Pituitary MRI High dose dexamethasone test Adrenal CT Scan Spironolactone Zona glomerulosa Zona fasciculata Low dose dexamethasone test 24 hour ambulatory blood pressure Aldosterone- renin ratio Glucose tolerance test ```

a. Phaeochromocytoma

4. A 53 year old male patient presents with constantly high blood pressure. He is an investment banker and initially the elevation is thought to be related to stress. The patient’s Na, K and urea are all normal. His glucose is however taken randomly and is found to be elevated at 7.9mmol/L. What is the first investigation that needs to be carried out in this patient ? ``` Phaeochromocytoma Conn’s syndrome Cushing’s syndrome Alpha blockade Beta blockade Surgery Pituitary MRI High dose dexamethasone test Adrenal CT Scan Spironolactone Zona glomerulosa Zona fasciculata Low dose dexamethasone test 24 hour ambulatory blood pressure Aldosterone- renin ratio Glucose tolerance test ```

a. 24 hour ambulatory blood pressure

5. Which part of the adrenal cortex produces glucocorticoids in response to the Adrenocorticotrophic hormone ? (ACTH) ``` Phaeochromocytoma Conn’s syndrome Cushing’s syndrome Alpha blockade Beta blockade Surgery Pituitary MRI High dose dexamethasone test Adrenal CT Scan Spironolactone Zona glomerulosa Zona fasciculata Low dose dexamethasone test 24 hour ambulatory blood pressure Aldosterone- renin ratio Glucose tolerance test ```

a. Zona fasciculata

1. Distressed parents rush their 7-year-old boy to A&E. He’s experiencing difficulty breathing and facial swelling, which started suddenly during a family picnic. His father mentions there was a dead wasp close to where his son collapsed. ``` Medication side effect Acute urticaria Asthma C1 inhibitor deficiency Chronic Granulomatous Disease Chronic urticaria Contact dermatitis Dermatitis herpetiformis Food intolerance Hayfever Hyper IgM Type I hypersensitivity Type II hypersensitivity Type III hypersensitivity Type IV hypersensitivity ```

a. Type I hypersensitivity

2. A student presents with ‘a lot of sneezing’ and a runny nose. He’s anxious as he cannot concentrate on his upcoming summer exams, and mentions this happened to him the last 2 years. ``` Medication side effect Acute urticaria Asthma C1 inhibitor deficiency Chronic Granulomatous Disease Chronic urticaria Contact dermatitis Dermatitis herpetiformis Food intolerance Hayfever Hyper IgM Type I hypersensitivity Type II hypersensitivity Type III hypersensitivity Type IV hypersensitivity ```

Hayfever

3. A 16-year-old boy has had several bouts of facial swelling and unexplained severe abdominal pain. ``` Medication side effect Acute urticaria Asthma C1 inhibitor deficiency Chronic Granulomatous Disease Chronic urticaria Contact dermatitis Dermatitis herpetiformis Food intolerance Hayfever Hyper IgM Type I hypersensitivity Type II hypersensitivity Type III hypersensitivity Type IV hypersensitivity ```

a. C1 inhibitor deficiency

4. A 10-year-old girl experiences significant weight loss, abdominal pain and diarrhoea. Her parents are particularly worried about a blistering rash on her elbows and knees that she only experienced after they moved from Ireland. ``` Medication side effect Acute urticaria Asthma C1 inhibitor deficiency Chronic Granulomatous Disease Chronic urticaria Contact dermatitis Dermatitis herpetiformis Food intolerance Hayfever Hyper IgM Type I hypersensitivity Type II hypersensitivity Type III hypersensitivity Type IV hypersensitivity ```

a. Dermatitis herpetiformis

5. A 48-year-old man develops and itchy rash on his hands that makes his skin dry and cracked. It’s particularly worse if he’s been gardening. ``` Medication side effect Acute urticaria Asthma C1 inhibitor deficiency Chronic Granulomatous Disease Chronic urticaria Contact dermatitis Dermatitis herpetiformis Food intolerance Hayfever Hyper IgM Type I hypersensitivity Type II hypersensitivity Type III hypersensitivity Type IV hypersensitivity ```

a. Contact dermatitis

1. A 30-year-old overweight Asian gentleman presents to his GP several hours after noticing that his skin is becoming increasingly itchy and the appearance of hives after admitting to have consumed a ‘cheeky packet of peanuts’ at work. What is the most likely causative factor in mediating his symptoms? ``` Adrenaline b-Defensin Complement C3 Contrast medium Corticosteroids Diluent Filaggrin Histamine IgA IgE IgG Mast cell (serum) tryptase Noradrenaline Peanuts Penicillin ```

a. IgE

2. You are a medical student attending an atopy clinic and are observing a doctor administer a skin prick test. The doctor asks you to explain what she is injecting into the patient’s skin as a ‘positive control’. What component makes up the positive control? ``` Adrenaline b-Defensin Complement C3 Contrast medium Corticosteroids Diluent Filaggrin Histamine IgA IgE IgG Mast cell (serum) tryptase Noradrenaline Peanuts Penicillin ```

a. Histamine

3. You are an anaesthetic doctor in surgery and notice that your patient has suddenly developed unexpected widespread rashes and is becoming increasingly hypotensive. You suspect the patient may be having an anaphylactic reaction. What is the best test to determine if the patient is undergoing a systemic allergic reaction in this situation? ``` Adrenaline b-Defensin Complement C3 Contrast medium Corticosteroids Diluent Filaggrin Histamine IgA IgE IgG Mast cell (serum) tryptase Noradrenaline Peanuts Penicillin ```

a. Mast cell (serum) tryptase

4. A miserable-looking child of European descent presents to your clinic with a long, troublesome history of atopic dermatitis. Which component is a potential genetic cause of the child’s atopy that should be considered? ``` Adrenaline b-Defensin Complement C3 Contrast medium Corticosteroids Diluent Filaggrin Histamine IgA IgE IgG Mast cell (serum) tryptase Noradrenaline Peanuts Penicillin ```

a. Filaggrin

5. A patient with nephrolithiasis is seen by your on-take team at the beginning of a long night shift. You see the patient and refer the patient for appropriate investigations and decide to take a short coffee break. Returning from your break a few hours later, to your dismay, you learn that the patient has developed severe abdominal pain and diarrhoea. The patient also appears to be a little confused. The registrar suggests to you that this may be a non-IgE mediated reaction. What could have happened, and what is the likely cause of the patient’s symptoms? ``` Adrenaline b-Defensin Complement C3 Contrast medium Corticosteroids Diluent Filaggrin Histamine IgA IgE IgG Mast cell (serum) tryptase Noradrenaline Peanuts Penicillin ```

a. Contrast medium

1. First line treatment for mild to moderate C. Difficile ``` Amoxicillin Ceftriaxone Chloramphenicol Ethambutol Erythromycin Flucloxacillin Gentamicin Isoniazid Metronidazole Pyrazinamide Rifampicin Vancomycin ```

a. Metronidazole

2. Treatment of infections resistant to penicillin e.g. MRSA ``` Amoxicillin Ceftriaxone Chloramphenicol Ethambutol Erythromycin Flucloxacillin Gentamicin Isoniazid Metranidazole Pyrazinamide Rifampicin Vancomycin ```

a. Vancomycin

3. May cause deafness an unwanted side effect ``` Amoxicillin Ceftriaxone Chloramphenicol Ethambutol Erythromycin Flucloxacillin Gentamicin Isoniazid Metranidazole Pyrazinamide Rifampicin Vancomycin ```

a. Gentamicin

4. 20 year old male, with true resistance to penicillin, presents with a severe headache, neck stiffness, fever and photophobia ``` Amoxicillin Ceftriaxone Chloramphenicol Ethambutol Erythromycin Flucloxacillin Gentamicin Isoniazid Metranidazole Pyrazinamide Rifampicin Vancomycin ```

a. Chloramphenicol

5. Treatment of TB but may cause optic neuritis. ``` Amoxicillin Ceftriaxone Chloramphenicol Ethambutol Erythromycin Flucloxacillin Gentamicin Isoniazid Metranidazole Pyrazinamide Rifampicin Vancomycin ```

Ethambutol

1. Which group of antibiotics is not recommended for use in children or pregnant women? ``` Glycopeptides Cephalexin Cefotaxime Tetracyclines Macrolides Cefuroxime Beta-lactams Aminoglycosides 3 days 7 days Tazocin Doxyclycline Amoxicillin Flucloxacillin Ceftriaxone Trimethoprim ```

a. Tetracyclines

2. Give an example of a second-generation cephalosporin. ``` Glycopeptides Cephalexin Cefotaxime Tetracyclines Macrolides Cefuroxime Beta-lactams Aminoglycosides 3 days 7 days Tazocin Doxyclycline Amoxicillin Flucloxacillin Ceftriaxone Trimethoprim ```

Cefuroxime

3. Which group of antibiotics is bacteriostatic and acts on 50S ribosomes to interfere with mRNA translation? ``` Glycopeptides Cephalexin Cefotaxime Tetracyclines Macrolides Cefuroxime Beta-lactams Aminoglycosides 3 days 7 days Tazocin Doxyclycline Amoxicillin Flucloxacillin Ceftriaxone Trimethoprim ```

Macrolides

4. A 23-year-old intubated male in ITU developes a chest infection 14 days after admission, which antibiotic would you prescribe? ``` Glycopeptides Cephalexin Cefotaxime Tetracyclines Macrolides Cefuroxime Beta-lactams Aminoglycosides 3 days 7 days Tazocin Doxyclycline Amoxicillin Flucloxacillin Ceftriaxone Trimethoprim ```

Tazocin

A 28-year-old woman is diagnosed with community-acquired cystitis, what is the recommended duration of antibiotic treatment for this diagnosis? ``` Glycopeptides Cephalexin Cefotaxime Tetracyclines Macrolides Cefuroxime Beta-lactams Aminoglycosides 3 days 7 days Tazocin Doxyclycline Amoxicillin Flucloxacillin Ceftriaxone Trimethoprim ```

a. 3 days

1. A 3-week old baby presents with a fever, irritability and painful, vesicular lesions on the tongue, buccal mucosa, lips and face. ``` IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin ```

a. Oral Acyclovir

2. On examination of a newborn child you notice that although they are small their head is unusually out of proportion and seems much smaller than the rest of their body, additionally their skin appears slightly yellow, with a petechial rash. ``` IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin ```

a. IV Gancyclovir

3. A 2-year old child presents with persistent lymphadenopathy, recurrent fevers and parotid swelling. His adopted parents are unaware of any FH or PMH. ``` IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin ```

a. Antiretroviral Therapy

4. A primary school teacher brings in her 4-year old child with a fever and an itchy, vesicular rash on his trunk and face. ``` IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin ```

a. Symptomatic treatment and reassurance

5. An 8-month old child suddenly develops a high fever, headache and a chesty cough. Her mum is concerned as she seems to have lost her appetite over the past 24 hours and is not improving ``` IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin ```

Oseltamivir

A 70 year man old presented with acute onset of vertigo. On neurological examination he has left-sided loss of pain and temperature sensation with partial right-sided ptosis and miosis as well as right sided diplopia. He has a mild left-sided weakness and an ataxic gait. He reports numbness on the right side of his face. ``` Acute Extradural Haemorrhage Acute Subdural Haemorrhage Chronic Extradural Haemorrhage Chronic Subdural Haemorrhage Lacunar Infarction Left Anterior Cerebral Occlusion Left Middle Cerebral Occlusion Left Posterior Cerebral Occlusion Left Posterior Inferior Cerebellar Artery (PICA) Occlusion Right Anterior Cerebral Occlusion Right Middle Cerebral Occlusion Right Posterior Cerebral Occlusion Right Posterior Inferior Cerebellar Artery (PICA) Occlusion Watershed Infarction Weber’s syndrome Vascular/Multi-infarct Dementia ```

Right Posterior Inferior Cerebellar Artery (PICA) Occlusion PICA occlusion is also known as lateral medullary syndrome.

A 70 year old man with a history of congestive heart failure presents with bilateral visual loss. On examination there is weakness in the proximal limbs that spared both the hands and feet. ``` Acute Extradural Haemorrhage Acute Subdural Haemorrhage Chronic Extradural Haemorrhage Chronic Subdural Haemorrhage Lacunar Infarction Left Anterior Cerebral Occlusion Left Middle Cerebral Occlusion Left Posterior Cerebral Occlusion Left Posterior Inferior Cerebellar Artery (PICA) Occlusion Right Anterior Cerebral Occlusion Right Middle Cerebral Occlusion Right Posterior Cerebral Occlusion Right Posterior Inferior Cerebellar Artery (PICA) Occlusion Watershed Infarction Weber’s syndrome Vascular/Multi-infarct Dementia ```

Watershed infarction Watershed infarcts are cortical infarcts caused by prolonged periods of low perfusion, common in patients with a history of cardiovascular disease.

A 70 year lady old collapsed at home and is taken to hospital. She regains consciousness but has a right sided hemiplegia, hemianesthesia and hemianopia with eye deviation towards the left. She also has an expressive aphasia. ``` Acute Extradural Haemorrhage Acute Subdural Haemorrhage Chronic Extradural Haemorrhage Chronic Subdural Haemorrhage Lacunar Infarction Left Anterior Cerebral Occlusion Left Middle Cerebral Occlusion Left Posterior Cerebral Occlusion Left Posterior Inferior Cerebellar Artery (PICA) Occlusion Right Anterior Cerebral Occlusion Right Middle Cerebral Occlusion Right Posterior Cerebral Occlusion Right Posterior Inferior Cerebellar Artery (PICA) Occlusion Watershed Infarction Weber’s syndrome Vascular/Multi-infarct Dementia ```

Left Middle Cerebral Occlusion

A 70 year old man is presents with headache, being unable to read the right pages of his book and walking into a lamppost. Neurological examination revealed left sided sensory loss in the head and limbs. ``` Acute Extradural Haemorrhage Acute Subdural Haemorrhage Chronic Extradural Haemorrhage Chronic Subdural Haemorrhage Lacunar Infarction Left Anterior Cerebral Occlusion Left Middle Cerebral Occlusion Left Posterior Cerebral Occlusion Left Posterior Inferior Cerebellar Artery (PICA) Occlusion Right Anterior Cerebral Occlusion Right Middle Cerebral Occlusion Right Posterior Cerebral Occlusion Right Posterior Inferior Cerebellar Artery (PICA) Occlusion Watershed Infarction Weber’s syndrome Vascular/Multi-infarct Dementia ```

Right Posterior Cerebral Occlusion

A 70 year old lady presented with a headache, mild weakness and drowsiness. She says she can’t remember when it started. On CT the lesion is hypo-dense to the brain parenchyma. ``` Acute Extradural Haemorrhage Acute Subdural Haemorrhage Chronic Extradural Haemorrhage Chronic Subdural Haemorrhage Lacunar Infarction Left Anterior Cerebral Occlusion Left Middle Cerebral Occlusion Left Posterior Cerebral Occlusion Left Posterior Inferior Cerebellar Artery (PICA) Occlusion Right Anterior Cerebral Occlusion Right Middle Cerebral Occlusion Right Posterior Cerebral Occlusion Right Posterior Inferior Cerebellar Artery (PICA) Occlusion Watershed Infarction Weber’s syndrome Vascular/Multi-infarct Dementia ```

Chronic subdural haemorrhage Chronic sub-durals are iso-dense or hypo-dense on CT, compared to acute sub-durals which are hyper-dense.

Number of B cells /μL required to diagnose CLL ``` 70 30 50 500 5000 80 100 1000 20 40 ```

5000

% of CLL patients older than 65 years at time of diagnosis ``` 70 30 50 500 5000 80 100 1000 20 40 ```

% of cases that present with no anaemia or thrombocytopenia, with three or more areas of lymphoid involvement (Rai Stages I and II, Binet Clinical Stage B) ``` 70 30 50 500 5000 80 100 1000 20 40 ```

% of CLL patients in which one or more cytogenetic abnormalities have been found ``` 70 30 50 500 5000 80 100 1000 20 40 ```

A 50 year old man presents with weight loss, fatigue and night sweats. He is diagnosed with chronic myeloid leukaemia and treatment is commenced. Several months later it becomes clear that he is resistant to the main class pharmaceutical agents that were used. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` Allogenic blood transfusion Allogenic stem cell transplantation Autologous blood transfusion Autologous stem cell transplantation Azathioprine Daunorubicin infusion Donor granulocyte infusion Donor lymphocyte infusion Dosatinib Fresh frozen plasma Golimumab Hydroxychloroquine IFN-α infusion Imatinib Methotrexate None of the above ```

Allogenic stem cell transplantation

A 57 year old woman is known to have chronic myeloid leukaemia. She presents acutely unwell, with 25% myeloblasts on her blood film, and is appropriately treated. 24 months later she relapses. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` Allogenic blood transfusion Allogenic stem cell transplantation Autologous blood transfusion Autologous stem cell transplantation Azathioprine Daunorubicin infusion Donor granulocyte infusion Donor lymphocyte infusion Dosatinib Fresh frozen plasma Golimumab Hydroxychloroquine IFN-α infusion Imatinib Methotrexate None of the above ```

Donor lymphocyte infusion

A 60 year old woman presents with weight loss and lethargy. On examination, she is cachectic with splenomegaly. Her white cell count is 150 x 109/l. Her blood film showed 25% myeloblasts. Cytogenetic analysis showed presence of the Philadelphia chromosome. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` Allogenic blood transfusion Allogenic stem cell transplantation Autologous blood transfusion Autologous stem cell transplantation Azathioprine Daunorubicin infusion Donor granulocyte infusion Donor lymphocyte infusion Dosatinib Fresh frozen plasma Golimumab Hydroxychloroquine IFN-α infusion Imatinib Methotrexate None of the above ```

Allogenic stem cell transplantation

A 55 year old man presents with weight loss and lethargy. On examination, he is cachectic with splenomegaly. His white cell count was 135 x 109/l. Cytogenetic analysis showed presence of the Philadelphia chromosome. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` Allogenic blood transfusion Allogenic stem cell transplantation Autologous blood transfusion Autologous stem cell transplantation Azathioprine Daunorubicin infusion Donor granulocyte infusion Donor lymphocyte infusion Dosatinib Fresh frozen plasma Golimumab Hydroxychloroquine IFN-α infusion Imatinib Methotrexate None of the above ```

Imatinib

A 57 year old man with a history of chronic myeloid leukaemia presents with night sweats, fatigue and weight loss. He was started on first line therapy 6 months ago but his doctor is concerned that he has relapsed. He wants to try a new treatment option. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` Allogenic blood transfusion Allogenic stem cell transplantation Autologous blood transfusion Autologous stem cell transplantation Azathioprine Daunorubicin infusion Donor granulocyte infusion Donor lymphocyte infusion Dosatinib Fresh frozen plasma Golimumab Hydroxychloroquine IFN-α infusion Imatinib Methotrexate None of the above ```

Dosatinib

A 50 year old man presented with fatigue, lethargy and weight loss. On examination, he was pale and had gross splenomegaly. His blood film showed an increase in white blood cells (both myelocytes and mature granulocytes). Cytogenetic analysis showed a t(9;22) chromosomal translocation. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` IFN-α Hydroxycarbamide Allogeneic stem cell transplantation Imatinib Chlorambucil Cyclosphosphamide Monitor clinically and give annual influenza vaccine Radiotherapy and 6-8 cycles of chemotherapy Dosatinib Chemotherapy + all-trans-retinoic acid Chemotherapy (R-CHOP regimen) Chemotherapy (ABVD regimen) Chemotherapy (R-CVP regimen) Donor lymphocyte infusion ```

Imatinib

A 74 year old patient has been diagnosed with chronic myeloid leukaemia and 6 months after starting therapy with the first line drug has shown no improvement in FBC or cytogenetics. His physician switches him to another drug. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` IFN-α Hydroxycarbamide Allogeneic stem cell transplantation Imatinib Chlorambucil Cyclosphosphamide Monitor clinically and give annual influenza vaccine Radiotherapy and 6-8 cycles of chemotherapy Dosatinib Chemotherapy + all-trans-retinoic acid Chemotherapy (R-CHOP regimen) Chemotherapy (ABVD regimen) Chemotherapy (R-CVP regimen) Donor lymphocyte infusion ```

Dosatinib

A 48 year old patient with chronic myeloid leukaemia becomes acutely unwell. A peripheral blood film shows 30% myeloblasts. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` IFN-α Hydroxycarbamide Allogeneic stem cell transplantation Imatinib Chlorambucil Cyclosphosphamide Monitor clinically and give annual influenza vaccine Radiotherapy and 6-8 cycles of chemotherapy Dosatinib Chemotherapy + all-trans-retinoic acid Chemotherapy (R-CHOP regimen) Chemotherapy (ABVD regimen) Chemotherapy (R-CVP regimen) Donor lymphocyte infusion ```

Allogeneic stem cell transplantation

A 59 year old patient with chronic myeloid leukaemia has been found to be positive for the Philadelphia chromosome several years following his stem cell transplantation. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` IFN-α Hydroxycarbamide Allogeneic stem cell transplantation Imatinib Chlorambucil Cyclosphosphamide Monitor clinically and give annual influenza vaccine Radiotherapy and 6-8 cycles of chemotherapy Dosatinib Chemotherapy + all-trans-retinoic acid Chemotherapy (R-CHOP regimen) Chemotherapy (ABVD regimen) Chemotherapy (R-CVP regimen) Donor lymphocyte infusion ```

Donor lymphocyte infusion

A 61 year old patient with chronic myeloid leukaemia has not responded to different tyrosine kinase inhibitors available. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. ``` IFN-α Hydroxycarbamide Allogeneic stem cell transplantation Imatinib Chlorambucil Cyclosphosphamide Monitor clinically and give annual influenza vaccine Radiotherapy and 6-8 cycles of chemotherapy Dosatinib Chemotherapy + all-trans-retinoic acid Chemotherapy (R-CHOP regimen) Chemotherapy (ABVD regimen) Chemotherapy (R-CVP regimen) Donor lymphocyte infusion ```

Allogeneic stem cell transplantation

1. A 17 year old was diagnosed with Infectious Mononucleosis (EBV). Confirmatory blood tests also revealed anaemia. Direct Coombs test was positive (but not “strongly positive”). On more detailed analysis, IgM antibodies were eluted from red cells with C3d remaining. ``` A Burns B Cold Autoimmune HA C Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G Hypersplenism H Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA ```

B Cold Autoimmune HA

2. A 4 year old African boy attends your clinic with recurrent pain in the hands. While in the cold waiting room he suddenly grasps his chest in pain and starts breathing rapidly. Investigations reveal hypoxia and new chest X-ray changes that look like consolidation. ``` A Burns B Cold Autoimmune HA C Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G Hypersplenism H Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA ```

N Sickle Cell disease

3. An 18 year old attending a routine check up at her new GP practice is noted to have mild splenomegaly and a leg ulcer. Upon questioning she mentions that she had jaundice as a child, and that one of her parents (and grandparents) suffer from anaemia. Blood results reveal slight anaemia with hyperchromic cells lacking central pallor. Coombs test is negative. ``` A Burns B Cold Autoimmune HA C Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G Hypersplenism H Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA ```

F Hereditary spherocytosis

4. A 58 year old man from South East Asia attends for a clinic feeling anaemic on return from holiday in Africa. On direct questioning he admits that he did start taking the Primaquine and Quinine you prescribed until a couple of days ago. Blood film revealed Heinz bodies and bite cells. ``` A Burns B Cold Autoimmune HA C Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G Hypersplenism H Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA ```

D G6PD deficiency

5. A 31 year old student nurse returns from her elective in Indonesia feeling generally unwell, with rigors and fever. Clinical examination reveals slight splenomegaly and haematuria. ``` A Burns B Cold Autoimmune HA C Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G Hypersplenism H Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA ```

I Malaria

1. A 22 year old woman presents with dark urine and tachycardia. She believes the dark urine is related to some "problems with the water works" she is currently being treated for. Direct antiglobulin test is positive. ``` A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA ```

B Drug induced/Iatrogenic

2. A 72 year old woman presents with haemolytic anaemia. FBC shows Hb 10.7 g/dL, WBC 108x10^3/uL, Platelets 90x10^3/uL. On examination the patient also has splenomegaly. ``` A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA ```

M Warm Type AIHA

3. A 32 year old woman is brought in by her concerned husband. She has a 5 month history or amenorrhea and is grossly distended. Her BP is 154/98. A urine sample is taken and results confirm your suspicion. ``` A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA ```

H Microangiopathic haemolytic anaemia (MAHA)

4. A young boy presents with splenomegaly and jaundice. His blood film shows Howell-Jolly bodies and poikilocytosis. An osmotic fragility test confirms the diagnosis. ``` A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA ```

E Hereditary spherocytosis

5. A teenage boy originally from Lebanon presents with acute haemolytic anaemia after switching to a vegan diet. Blood film shows bite cells and blister cells. ``` A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA ```

C Glucose-6-phosphate deficiency

Innate immune deficiency ``` Recurrent infections with high neutrophil count on FBC but no abscess formation • Lymphocyte adhesion deficiency • Chronic granulomatous disease • Kostmann syndrome • IFN gamma receptor deficiency ```

Lymphocyte adhesion deficiency

Innate immune deficiency ``` Recurrent infections with hepatosplenomegaly and abnormal dihydrorhodamine test • Lymphocyte adhesion deficiency • Chronic granulomatous disease • Kostmann syndrome • IFN gamma receptor deficiency ```

Chronic granulomatous disease

Innate immune deficiency ``` Recurrent infections with no neutrophils on FBC • Lymphocyte adhesion deficiency • Chronic granulomatous disease • Kostmann syndrome • IFN gamma receptor deficiency ```

Kostmann syndrome

Innate immune deficiency ``` Infection with atypical mycobacterium. Normal FBC • Lymphocyte adhesion deficiency • Chronic granulomatous disease • Kostmann syndrome • IFN gamma receptor deficiency ```

IFN gamma receptor deficiency

T-cell deficiency ``` Severe recurrent infections from 3 months,CD4 and CD8 T cells absent, B cell present, IgM present, IgA and IgG absent • X-linked SCID • IFN gamma receptor deficiency • DiGeorge’s syndrome • Bare lymphocyte syndrome type II ```

• X-linked SCID

T-cell deficiency ``` Young adult with chronic infection with Mycobacterium marinum • X-linked SCID • IFN gamma receptor deficiency • DiGeorge’s syndrome • Bare lymphocyte syndrome type II ```

• IFN gamma receptor deficiency

T-cell deficiency ``` Recurrent infections in childhood, abnormal facial features, congenital heart disease, normal B cells, low T cells, low IgA and IgG • X-linked SCID • IFN gamma receptor deficiency • DiGeorge’s syndrome • Bare lymphocyte syndrome type II ```

• DiGeorge’s syndrome

T-cell deficiency ``` 6 month baby with two recent serious bacterial infections. T cells present – but only CD8+ population. B cells present. IgM present but IgG absent • X-linked SCID • IFN gamma receptor deficiency • DiGeorge’s syndrome • Bare lymphocyte syndrome type II ```

• Bare lymphocyte syndrome type II

B-cell deficiency Adult with bronchiectasis, recurrent sinusitis and development of atypical SLE * Common variable immunodeficiency * X linked hyper IgM syndrome due to CD40ligand mutation * Bruton’s X linked hypogammaglobulinaemia * IgA deficiency

• Common variable immunodeficiency

B-cell deficiency Recurrent bacterial infections in a child, episode of pneumocystis pneumonia, high IgM, absent IgA and IgG • Common variable immunodeficiency • X linked hyper IgM syndrome due to CD40ligand mutation • Bruton’s X linked hypogammaglobulinaemia • IgA deficiency

• X linked hyper IgM syndrome due to CD40ligand mutation

B-cell deficiency 1 year old boy. Recurrent bacterial infections. CD4 and CD8 T cells present. B cells absent, IgG, IgA, IgM absent • Common variable immunodeficiency • X linked hyper IgM syndrome due to CD40ligand mutation • Bruton’s X linked hypogammaglobulinaemia • IgA deficiency

• Bruton’s X linked hypogammaglobulinaemia

B-cell deficiency Recurrent respiratory tract infections, absent IgA, normal IgM and IgG • Common variable immunodeficiency • X linked hyper IgM syndrome due to CD40ligand mutation • Bruton’s X linked hypogammaglobulinaemia • IgA deficiency

• IgA deficiency

Complement deficiency Membranoproliferative nephritis and bacterial infections • C3 deficiency with presence of a nephritic factor • C9 deficiency • C1q deficiency • MBL deficiency

• C3 deficiency with presence of a nephritic factor

Complement deficiency Meningococcus meningitis with family history of sibling dying of same condition aged 6 • C3 deficiency with presence of a nephritic factor • C9 deficiency • C1q deficiency • MBL deficiency

• C9 deficiency

Complement deficiency Severe childhood onset SLE with normal levels of C3 and C4 • C3 deficiency with presence of a nephritic factor • C9 deficiency • C1q deficiency • MBL deficiency

• C1q deficiency

Complement deficiency Recurrent infections when receiving chemotherapy but previously well • C3 deficiency with presence of a nephritic factor • C9 deficiency • C1q deficiency • MBL deficiency

• MBL deficiency

Expresses Foxp3 and CD25 and secretes IL-10. Deficient in the monogenic autoimmune disease known as IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome) * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

• 4. T reg cell

In the immature form these cells are adapted for recognition and uptake of pathogens. Maturation is associated with expression of CCR7, migration to lymph nodes and enhanced capacity for antigen presentation. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

• 5. Dendritic cell

These cells can be rapidly mobilised from bone marrow. They express pathogen recognition receptors and Fc receptors and are able to engage in oxidative and non-oxidative killing. They do not express HLA class II molecules and so do not activate CD4 T cells. They are the predominant cell type in synovial fluid taken from patients with gout, * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Neutrophil

These cells may be formed following a germinal centre reaction involving isotype switching and affinity maturation of receptors. They are long-lived and reside in bone marrow. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

• 9. Plasma cell

These cells express CD3 and secrete IL-17 and IL-22. They are thought to be important in some auto-immune conditions including rheumatoid arthritis. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

• 1. Th17 cell

These cells may be resident in peripheral tissues (eg Kupffer cells in liver, microglia in neural tissue) express pathogen recognition receptors and Fc receptors and are able to engage in oxidative and non-oxidative killing. They are an important source of cytokines such as IL-1 and TNF-alpha and are thought to play an important role in some auto-inflammatory and auto-immune diseases. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

• 2. Macrophage

The normal function of these cells is to express cytokines in response to recognition of specific peptides presented by HLA class II molecules. Depletion of these cells during HIV infection is an important factor in development of AIDS. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

• 6. CD4+ T cell

Play a role in protective immunity against HIV infection by killing virus infected cells via perforin and FAS. * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 10. CD8 T cells

Acts as a co-receptor for HIV entry to cells * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 3. CCR5

Serves to generate complementary DNA from RNA, which can then be integrated into host cell genes * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 4. Reverse transcriptase

Directs homing of dendritic cells to lymph nodes * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 8. CCR7

Are often infected by HIV if they express CD4 * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 9. Macrophages

Antibodies against this target are partially protective against HIV infection * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 1. Gp120

Are effective in management of HIV infection if used in combination with other drugs * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

• 7. Protease inhibitors

Mutation in MEFV leads to failure to regulate neutrophil function ``` Rheumatoid arthritis Familial Mediterranean Fever IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) Crohn’s disease Ankylosing Spondylitis ```

Familial Mediterranean Fever

Polygenic auto-inflammatory disease in which NOD-2 (CARD 15) mutations are common ``` Rheumatoid arthritis Familial Mediterranean Fever IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) Crohn’s disease Ankylosing Spondylitis ```

Crohn’s disease

Mixed pattern disease with very high heritability (>90%) and a strong association with HLA-B27 ``` Rheumatoid arthritis Familial Mediterranean Fever IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) Crohn’s disease Ankylosing Spondylitis ```

Ankylosing Spondylitis

Polygenic auto-immune disease associated with polymorphisms in PAD enzymes (which citrullinate proteins). Environmental factors including smoking and gum infection are associated with disease. ``` Rheumatoid arthritis Familial Mediterranean Fever IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) Crohn’s disease Ankylosing Spondylitis ```

Rheumatoid arthritis

Monogenic auto-immune disease due to a mutation in Foxp3 ``` Rheumatoid arthritis Familial Mediterranean Fever IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) Crohn’s disease Ankylosing Spondylitis ```

IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome)

Congenital heart block in infants of mothers with SLE ``` Anti-DNA antibody Anti-RNP antibody Anti-GAD antibody Anti-centromere antibody Anti-Ro antibody ```

Anti-Ro antibody

Lupus nephritis ``` Anti-DNA antibody Anti-RNP antibody Anti-GAD antibody Anti-centromere antibody Anti-Ro antibody ```

Anti-DNA antibody

Mixed connective tissue disease ``` Anti-DNA antibody Anti-RNP antibody Anti-GAD antibody Anti-centromere antibody Anti-Ro antibody ```

Anti-RNP antibody

Limited cutaneous systemic sclerosis ``` Anti-DNA antibody Anti-RNP antibody Anti-GAD antibody Anti-centromere antibody Anti-Ro antibody ```

Anti-centromere antibody

Sjogren’s syndrome ``` Anti-DNA antibody Anti-RNP antibody Anti-GAD antibody Anti-centromere antibody Anti-Ro antibody ```

Anti-Ro antibody

Antibody to gastric parietal cells ``` Autoimmune hepatitis Coeliac disease Pernicious anaemia Dermatitis herpetiformis Primary biliary cirrhosis ```

Pernicious anaemia

Anti-smooth muscle antibody ``` Autoimmune hepatitis Coeliac disease Pernicious anaemia Dermatitis herpetiformis Primary biliary cirrhosis ```

Autoimmune hepatitis

Anti-endomysial antibody ``` Autoimmune hepatitis Coeliac disease Pernicious anaemia Dermatitis herpetiformis Primary biliary cirrhosis ```

Coeliac disease/Dermatitis herpetiformis

Anti-tissue transglutaminase antibody ``` Autoimmune hepatitis Coeliac disease Pernicious anaemia Dermatitis herpetiformis Primary biliary cirrhosis ```

Coeliac disease/Dermatitis herpetiformis

Anti-mitochondrial antibody ``` Autoimmune hepatitis Coeliac disease Pernicious anaemia Dermatitis herpetiformis Primary biliary cirrhosis ```

Primary biliary cirrhosis

Mediated predominantly by antibodies which usually form after the transplantation Hyperacute rejection Acute cellular rejection Acute vascular rejection Chronic allograft rejection

Acute vascular rejection

Both immunological and non-immunological mechanisms contribute Hyperacute rejection Acute cellular rejection Acute vascular rejection Chronic allograft rejection

Chronic allograft rejection

Due to presence of pre-formed antibodies Hyperacute rejection Acute cellular rejection Acute vascular rejection Chronic allograft rejection

Hyperacute rejection

Mediated by activation of CD4 T cells which provide help for a CD8 T cell and B cell response and occurs within 1-4 weeks Hyperacute rejection Acute cellular rejection Acute vascular rejection Chronic allograft rejection

Acute cellular rejection

42 year old lady develops pruritis, rash, hypotension and difficulty breathing. She has received an intra-articular injection of hydrocortisone and lignocaine 10 minutes previously ``` Physical urticaria Type IV hypersensitivity to latex Allergic rhinitis Anaphylaxis C1 inhibitor deficiency ```

Anaphylaxis

16 year old develops itchy red wheals on her skin whenever she goes running. Symptoms tend to be worse in the summer ``` Physical urticaria Type IV hypersensitivity to latex Allergic rhinitis Anaphylaxis C1 inhibitor deficiency ```

Physical urticaria

36 year old lady presents with swelling of face and tongue following dental surgery. There is a family history of similar reactions – both her mother and sister are affected. ``` Physical urticaria Type IV hypersensitivity to latex Allergic rhinitis Anaphylaxis C1 inhibitor deficiency ```

C1 inhibitor deficiency

14 year old presents with nasal irritation and discharge during the summer months. The symptoms are relieved by over the counter anti-histamines ``` Physical urticaria Type IV hypersensitivity to latex Allergic rhinitis Anaphylaxis C1 inhibitor deficiency ```

Allergic rhinitis

25 year old junior doctor develops pruritic/blistering rash on hands within two weeks of starting placement on surgical firm Physical urticaria Type IV hypersensitivity to latex Allergic rhinitis Anaphylaxis C1 inhibitor deficiency

Type IV hypersensitivity to latex

A 58 year old pharmacist presents with a 3 month history of skin itching associated with lethargy and loss of energy. Physical examination is normal, but liver function tests reveal: Total bilirubin = 36umol/l (0-17umol/l) ALT = 28U/l (0-31U/l) Alkaline phosphatase 420U/l (30-130) 1. anti-acetyl choline receptor antibody 2. anti-adrenal cortex antibody 3. antibody to double stranded DNA 4. anti-centromere antibody 5. anti-TTG antibody 6. anti-intrinsic factor antibody 7. anti-mitochondrial antibody 8. anti-neutrophil cytoplasmic antibody 9. anti-RNP antibody 10. anti-smooth muscle antibody

7. anti-mitochondrial antibody

A 56 year old prison officer presents with a history of recurrent nose bleeds, haemoptysis and joint pain associated with profound lethargy. On examination, he has crackles in his upper left lung field, and a cavitating left lung lesion is demonstrated on chest radiography. Urine dipstick is positive for protein and blood. 1. anti-acetyl choline receptor antibody 2. anti-adrenal cortex antibody 3. antibody to double stranded DNA 4. anti-centromere antibody 5. anti-TTG antibody 6. anti-intrinsic factor antibody 7. anti-mitochondrial antibody 8. anti-neutrophil cytoplasmic antibody 9. anti-RNP antibody 10. anti-smooth muscle antibody

8. anti-neutrophil cytoplasmic antibody

A 22 year old woman presents with joint pain and fatigue. She has an intermittent, skin-sensitive rash, and also complains of mouth ulcers. Physical examination is otherwise normal. Urine dipstick is positive ++ protein and ++ blood. Full blood count shows a normocytic normochromic anaemia. 1. anti-acetyl choline receptor antibody 2. anti-adrenal cortex antibody 3. antibody to double stranded DNA 4. anti-centromere antibody 5. anti-TTG antibody 6. anti-intrinsic factor antibody 7. anti-mitochondrial antibody 8. anti-neutrophil cytoplasmic antibody 9. anti-RNP antibody 10. anti-smooth muscle antibody

3. antibody to double stranded DNA

A 30 year old plumber attends his GP complaining of feeling tired all the time. He has type I diabetes, which is currently well controlled, and a history of irritable bowel syndrome. A full blood count shows a microcytic hypochromic anaemia, and iron studies confirm iron deficiency. Vitamin D levels are within the insufficient range. 1. anti-acetyl choline receptor antibody 2. anti-adrenal cortex antibody 3. antibody to double stranded DNA 4. anti-centromere antibody 5. anti-TTG antibody 6. anti-intrinsic factor antibody 7. anti-mitochondrial antibody 8. anti-neutrophil cytoplasmic antibody 9. anti-RNP antibody 10. anti-smooth muscle antibody

5. anti-TTG antibody

A 44 year old builder presents with a history of fingers intermittently becoming very cold and white with recent development of a gangrenous tip of his finger. The skin over his fingers feels ‘tight’ and you note telangectasia on his hands. 1. anti-acetyl choline receptor antibody 2. anti-adrenal cortex antibody 3. antibody to double stranded DNA 4. anti-centromere antibody 5. anti-TTG antibody 6. anti-intrinsic factor antibody 7. anti-mitochondrial antibody 8. anti-neutrophil cytoplasmic antibody 9. anti-RNP antibody 10. anti-smooth muscle antibody

4. anti-centromere antibody

A 19 year old student presents with a chronic, extremely itchy rash consisting of papules and vesicles which is distributed symmetrically over the extensor surfaces of her elbows, legs and buttocks. You suspect dermatitis herpetiformis. 1. anti-acetyl choline receptor antibody 2. anti-adrenal cortex antibody 3. antibody to double stranded DNA 4. anti-centromere antibody 5. anti-TTG antibody 6. anti-intrinsic factor antibody 7. anti-mitochondrial antibody 8. anti-neutrophil cytoplasmic antibody 9. anti-RNP antibody 10. anti-smooth muscle antibody

6. anti-intrinsic factor antibody

* A. Is mediated by Toll like receptors which recognise pathogen associated molecular patterns * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Pathogen recognition

* B. May be mediated by antibodies, complement components or acute phase proteins and facilitates phagocytosis * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Opsonisation

* C. Describes killing mediated by reactive oxygen species generated by action of the NADPH oxidase complex * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Oxidative killing

* D. May be mediated by bacteriocidal enzymes such as lysozyme * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Non-oxidative killing

- Derived from monocytes and resident in peripheral tissues Neutrophils Natural Killer Cells Dendritic cells Macrophages

Macrophages

- Polymorphonuclear cells capable of phagocytosing pathogens and killing by oxidative and non-oxidative mechanisms Neutrophils Natural Killer Cells Dendritic cells Macrophages

Neutrophils

- Lymphocytes that express inhibitory receptors capable of recognising HLA class I molecules and have cytotoxic capacity Neutrophils Natural Killer Cells Dendritic cells Macrophages

Natural Killer Cells

- Immature cells are adapted for pathogen recognition and uptake whilst mature cells are adapted for antigen presentation to prime T cells Neutrophils Natural Killer Cells Dendritic cells Macrophages

Dendritic cells

Express receptors that recognise peptides usually derived from intracellular proteins and expressed on HLA class I molecules Th1 cells CD8 T cells T follicular helper (Tfh) cells T regulatory cells

CD8 T cells

Subset of lymphocytes that express Foxp3 and CD25 Th1 cells CD8 T cells T follicular helper (Tfh) cells T regulatory cells

T regulatory cells

Subset of cells that express CD4 and secrete IFN gamma and IL-2 Th1 cells CD8 T cells T follicular helper (Tfh) cells T regulatory cells

Th1 cells

Play an important role in promoting germinal centre reactions and differentiation of B cells into IgG and IgA secreting plasma cells Th1 cells CD8 T cells T follicular helper (Tfh) cells T regulatory cells

T follicular helper (Tfh) cells

Exist within the bone marrow and develop from haematopoietic stem cells Pre-B cells IgA IgG secreting plasma cells IgM secreting plasma cells

Pre-B cells

Cell dependent on the presence of CD4 T cell help for generation. Pre-B cells IgA IgG secreting plasma cells IgM secreting plasma cells

IgG secreting plasma cells

Are generated rapidly following antigen recognition and are not dependent on CD4 T cell help Pre-B cells IgA IgG secreting plasma cells IgM secreting plasma cells

IgM secreting plasma cells

Divalent antibody present within mucous which helps provide a constitutive barrier to infection Pre-B cells IgA IgG secreting plasma cells IgM secreting plasma cells

IgA

Area within secondary lymphoid tissue where B cells proliferate and undergo affinity maturation and isotope switching Primary lymphoid organs Thoracic duct Thymus Germinal centre

Germinal centre

Include both the bone marrow and thymus; sites of B and T cell development Primary lymphoid organs Thoracic duct Thymus Germinal centre

Primary lymphoid organs

Carries lymphocytes from lymph nodes back to the blood circulation Primary lymphoid organs Thoracic duct Thymus Germinal centre

Thoracic duct

Site of deletion of T cells with inappropriately high or low affinity for HLA molecules and of maturation of T cells into CD4+ or CD8+ cells Primary lymphoid organs Thoracic duct Thymus Germinal centre

Thymus

Binding of immune complexes to this protein triggers the classical pathway of complement activation C3 C1 C9 MBL

Cleavage of this protein may be triggered via the classical, MBL or alternative pathways C3 C1 C9 MBL

Binds to microbial surface carbohydrates to activate the complement cascade in an immune complex independent manner C3 C1 C9 MBL

MBL

Part of the final common pathway resulting in the generation of the membrane attack complex C3 C1 C9 MBL

Polymorphonuclear cell capable of phagocytosing pathogens

Neutrophil

Type of cell derived from monocytes and are resident in peripheral tissues

Macrophage

Type of lymphocyte that expresses FOXP3 and CD25

TH1

Divalent antibody present in mucus; provides constitutive barrier to infection

IgA

Binding of immune complexes to this protein triggers the classical pathway of complement

Monoclonal antibody that prevents osteoporosis by inhibiting RANKL. Can be used in pts on long-term steroids

Denosumab

Mycophenolate

Reversibly inhibits guanine synthesis (de novo pathway of purine synthesis) Used to prevent transplant rejection, esp renal Can also be a steroid sparing agent in authoimmune diseases

CTLA4-immunoglobulin fusion protein sometimes used in RA when anti-TNF doesn't work

Abatacept

Drug used in autoimmune disorders (e.g. SLE) when body develops end-organ resistance to corticosteroids and DMARDS fail

Cyclophosphamide

TNF alpha inhibitor for severe RA, when DMARDS fail

Infliximab

Patients in this immune modulating drug require regular monitoring of retina

Hydroxychloroquine

First-line DMARD for RA

Methotrexate

What drug would you prescribe for RA pt who has recently developed vasculitis and requires a strong immunosuppressant

Cyclophoshamide

Immunosuppressive drug for RA that requires washout before a woman can conceive

Leflunomide

Biological DMARD in RA treatment

Infliximab

t(9;22)

Phildelphia chromosome. | Seen in 95% CML, 25-30% ALL

Diagnosis--Fatigue, anemia, lymphocytosis, painless LAD, smudge cells on blood film.

CLL

Diagnosis--Fatigue, night sweats, weight loss, anemia, leukocytosis, splenomegaly, Philedelphia chromosome.

CML

Diagnosis--Anemia, fever, weight loss, splenomegaly, pancytopenia, irregularly-shaped cels with filament-like cytoplasmic projections on blood film

Hairy cell leukemia

Pallor, HSM, anemia, leukocytosis, thrombocytopenia. Blast cells and Auer rods on blood film

AML

Most likely diagnosis-young boy with Down's, pallor, tachycardia, petechiae, testicular enlargement. Anemia, thrombocytopenia, leukocytosis, blast cells.

ALL

Pt with this disease possesses homozygous isoform of ApoE, ApoE2/E2

Familial dysbetalipoproteinemia (type III)

Type of primary hypercholesterolemia which involves mutation of ATP-binding cassette transporters G5, G8

Phytosterolemia

AD form of primary hypercholesterolemia which can be caused by gain of function mutation of proprotein convertase subtilisi/kexin type 9 (PCSK9) gene

Familial hypercholesterolemia (type I)

AD mutation of ApoB gene could lead to this condition

Hypobetalipoproteinemia

A condition which results from dysregulated lipoprotein metabolism leading to cholesterol deposition in arterial wall

Atherosclerosis

Lipoprotein found in VLDL and chylomicrons; activates lipoprotein lipase in capillaries

ApoC

Main lipoprotein of LDL and chylomicrons. Leads to heart disease if deficient

ApoB

Binds to LDL receptor to promote degradation. Loss of function leads to low LDL levels

PCSK9

Class of apolipoprotein produced by astrocytes in CNS. Polymorphisms of this are associated with Parkinson's and Alzheimer's.

ApoE

Major lipoprotein in HDL. Mutation can lead to paradoxical drop in HDL concentration and reduction in atheroma in animal models

ApoA1

Dx: 25 year old man presents with jaundice, fever, RUQ pain

Ascennding cholangitis

Dx: 25 yr old man presents with 3 yr hx occasional episodes mild jaundice, worse with chest infection. Mild unconjugated hyperbilirubinemia, normal liver biopsy

Gilberts.

Dx: 45 year old lady with mildly elevated serum bili, normal ALP and AST, anemia. No urinary bili present

Hemolytic jaundice

60 year old diabetic pt presents with localized back pain, fever, malaise, swelling at site of pain. CRP raised. ``` Septic Arthritis Prosthetic joint infection Hematogenous osteomyelitis Brodie's abscess Vertebral osteomyelitis Cellulitis Spinal cord neoplasm Gout Acute osteomyelitis Chronic osteomyelitis ```

Vertebral osteomyelitis

29 year old pt presents with 1 wk painful, red, swollen, restricted knee join. Raised CRP, WCC >50,000/mm3. Causative agent S aureus. Pt is an IV drug abuser ``` Septic Arthritis Prosthetic joint infection Hematogenous osteomyelitis Brodie's abscess Vertebral osteomyelitis Cellulitis Spinal cord neoplasm Gout Acute osteomyelitis Chronic osteomyelitis ```

Septic arthritis

Young pt presents with sudden fever, bone pain, swelling, restricted movement in elbow joint three weeks after injury ``` Septic Arthritis Prosthetic joint infection Hematogenous osteomyelitis Brodie's abscess Vertebral osteomyelitis Cellulitis Spinal cord neoplasm Gout Acute osteomyelitis Chronic osteomyelitis ```

Acute osteomyelitis

Pt presents 1/12 after bilateral arthroplasty. Claims joints "haven't felt right:. Fever, leaking wounds, pain. S aureus isolated ``` Septic Arthritis Prosthetic joint infection Hematogenous osteomyelitis Brodie's abscess Vertebral osteomyelitis Cellulitis Spinal cord neoplasm Gout Acute osteomyelitis Chronic osteomyelitis ```

Prosthetic joint infection

Suddent onset excruciating pain in left MTP joint, Swelling and high inflamm. ``` Septic Arthritis Prosthetic joint infection Hematogenous osteomyelitis Brodie's abscess Vertebral osteomyelitis Cellulitis Spinal cord neoplasm Gout Acute osteomyelitis Chronic osteomyelitis ```

Gout

48 yr old woman, BMI 28, presents with 3/52 history of painful L knee and lethargy. O/E, joint is edematous and hot. She is pyrexial, has reduced range of movement. Further questioning-has had intra-articular steroid injections for her RA a month previously.

Septic arthritis

Investigations- septic arthritis of joint

Blood culture and synovial fluid aspirate

69 year old man recovering in ward following sx for L2/3 disc herniation and spinal canal compression. Op went well, but pt now has a temperature and complaining of bad back and a pain in his leg. What diagnostic test is most sensitive in helping your dx? ``` Blood culture and synovial fluid aspirate CT MRI Open biopsy Plain XR ```

MRI

Whta causative organism do you suspect in previous pt (L2/3 herniation man)

S. aureus

81 year old woman with type I DM presents in A&E 4/52 post-bilateral hip replacement sx. She is in pain, not mobilizing, complaining that hips never felt right after sx. WCC 20x10^9/L CRP 156 Pelvic XR shows areas of lysis around acetabular component of both joints and joint aspirate reveals 6700 WC/mL. What do you suspect?

Prosthetic joint infection

Most common causative organism in septic arthritis

S. Aureus

Causes arthritis mainly in young children ``` S. aureus E. coli P. aeruginosa Kingella Coag negative staph H. influenza N. gon Salmonella Borrelia burgdoferi Brucells Mycobacterium tuberculosis S. pyogenes Proteus miribalis Candida albicans Bartonelle henselae Toxoplasma gondii ```

H. influenza

Most common cause of infectious arthritis in teenagers and young adults

N. gonorrhoeae

Bug that most commonly involves vertebral column in adults. Associated with wedging and/or collapse of vertebrae.

Mycobacterium tuberculosis

Most common cause of prosthetic joint infection

Coag negative staph (e.g.staph epidermidis)

Organism classically causing infective endocarditis in drug users

S. aureus

40 year old man recently returns from travel in North America, presenting with fever, flu-like symptoms, and a bulls-eye rash

Lyme disease

35 year old man recently returns from south Asia and presents to his GP with undulant fever, malaise, rigors, and arthralgias. Admits to drinking unpasteurized milk.

Brucellosis

20 year old woman returns from southern France where she spent time on a farm. She presents with fever, dry cough, and diarrhea

Q fever

An ornithologist presents to his GP with fever, arthralgia, cough, dyspnea. Levathar-cole-lillie bodies can be seen on BAL

Psittacosis

30 year old sewage worker presents with 1 week hx flu-like symptoms with diarrhea. Diagnosis confirmed with microscopic agglutination test

Leptospirosis

Pigeon fancier presents with cough, low-grade fever, and chest pain. India ink CSF stain was positive.

Cryptococcus

40 year old man presents with abdo pain. O/E, he has hepatomegaly. Abdo USS reveals well-defined round lesion in liver. He has two dogs.

Hyatid disease

Eastern European vet presents wit fever and sweating and one month history of malaise, weight loss, and myalgia. Rose Bengal test was positive and blood cultures reveal gram negative bacilli

Brucellosis

21 year old med student presents with sore throat, fever, headache, and myalgia. She recently returned from volunteering at a hospital in Nigeria, where she helped deliver babies. She is treated with a slow IV infusion of ribavirin

Lassa fever

12 year old boy presents with a fever, headache, malaise, and a non-specific rash. He has had several tick bites while on holiday in the US. FBC shows leukopenia and thrombocytopenia; LFTs show raised AST

Ehrlichiosis

Bullet shaped virus,incubation 1-3 months

Rabies

Major cause of death in children in endemic areas. Can be hard to dx as protean manifestations, but often presents with erythema migrans

Borreliosis

Dogs, cats, and other animals are primary hosts. Larval form can cause red pruritic eruption confined to dermis. Wearing shos is an effective prevention method in infected areas.

Cutaneous larva migrans

PUO/undulant fever. Can cause meningoencephalitis but rarely life threatening. Not currently present in UK

Brucellosis

Bacillus with reservoir in rodents

Yersinia pestis

33 year old woman presents with sudden onset fever, headache, and myalgia, She spent most of summer outside and recals getting bitten by multiple mosquitoes. O/E she is pyrexial, has maculopapular rash on trunk and extremities. CSF shoes elevated protein and cell count with PMN predominance and decreased glucose. Doctor tells you that most pts with this disease are asymptomatic and finding specific IgM would establish dx.

West Nile

20 year old man presents with sudden onset fever, myalgia, headache. Just before feeling unwell, he had noticed intensely painful swelling in L groin. He just returned from a field trip to New Mexico and mentioned there were some small bites on his legs that were very itchy. O/E his leg is held flexed and in eternal rotation and the lump is 5cm long and tender to touch, with local edema. Blood culture reveals gram neg coccobacillus

Bubonic plague

16 year old woman presents with 3 days constantly high fevers and aches and pains in lower back. Predominantly frontal headache and retro-orbital pain worse on eye movement. Temp 38.4 BP 110/80, pulse 92. generalized flushing of skin. Bloods-thrombocytopenia nd leukopenia

Dengue fever

56 year old woman presents with fever and headache, chills and rigors, feels heart racing during these episodes. Mentions fever seems to come and go every 72 hours (how convenient). Flew to New Zealand but stopped over in Nigeria. GP says influena. Two days later, she goes to A&E ith similar sxs and vomiting. Now mildly jaundices

P. malariae

``` The antiviral which is given to untreated pregnant women with HIV to prevent vertical transmission of the virus during childbirth. • Zidovudine • Ribavirin • Neuraminidase inhibitor • Foscarnet • Ganciclovir • Nevirapine • Cidofovir • Oseltamivir • Interferon-g (gamma) • Aciclovir triphosphate • Interferon-α (alpha) • Aciclovir • Interferon-b (beta) • Entecevir • Aciclovir monophosphate ```

Correct F. Nevirapine Response Feedback: In 1999, the HIVNET 012 team reported exciting preliminary results that single-dose nevirapine prophylaxis for mother and baby significantly lowered HIV-1 infection risk at 14–16 weeks compared with controls who received short-course zidovudine prophylaxis.

``` An immunomodulatory therapy used in the treatment of hepatitis B. • Zidovudine • Ribavirin • Neuraminidase inhibitor • Foscarnet • Ganciclovir • Nevirapine • Cidofovir • Oseltamivir • Interferon-g (gamma) • Aciclovir triphosphate • Interferon-α (alpha) • Aciclovir • Interferon-b (beta) • Entecevir • Aciclovir monophosphate ```

Correct K. Interferon-α (alpha)

``` An antiviral currently used to prevent and treat Influenza in the elderly and which has the potential to be used to prevent Avian influenza. • Zidovudine • Ribavirin • Neuraminidase inhibitor • Foscarnet • Ganciclovir • Nevirapine • Cidofovir • Oseltamivir • Interferon-g (gamma) • Aciclovir triphosphate • Interferon-α (alpha) • Aciclovir • Interferon-b (beta) • Entecevir • Aciclovir monophosphate ```

Correct H. Oseltamivir

``` The final metabolite of the antiviral used to treat Herpes Simplex • Zidovudine • Ribavirin • Neuraminidase inhibitor • Foscarnet • Ganciclovir • Nevirapine • Cidofovir • Oseltamivir • Interferon-g (gamma) • Aciclovir triphosphate • Interferon-α (alpha) • Aciclovir • Interferon-b (beta) • Entecevir • Aciclovir monophosphate ```

Correct J. Aciclovir triphosphate

``` An antiviral which can be used in aerosol form to prevent respiratory syncytial virus in children with heart and lung disease • Zidovudine • Ribavirin • Neuraminidase inhibitor • Foscarnet • Ganciclovir • Nevirapine • Cidofovir • Oseltamivir • Interferon-g (gamma) • Aciclovir triphosphate • Interferon-α (alpha) • Aciclovir • Interferon-b (beta) • Entecevir • Aciclovir monophosphate ```

Correct B. Ribavirin

``` Which option is the product of the action of viral tyrosine kinase on aciclovir? • Cytomegalovirus • Guanosine • Aciclovir monophosphate • Aciclovir diphosphate • Influenza • Ribavarin • AIDS • Famciclovir • Thymidine • Varicella-zoster virus • Aciclovir triphosphate ```

Correct C. Aciclovir monophosphate Response Feedback: Aciclovir diphosphate and triphosphate are the product of cellular tyrosine kinase, whereas aciclovir monophosphate is the product of viral tyrosine kinase.

``` Which option inhibits the action of viral DNA polymerase? • Cytomegalovirus • Guanosine • Aciclovir monophosphate • Aciclovir diphosphate • Influenza • Ribavarin • AIDS • Famciclovir • Thymidine • Varicella-zoster virus • Aciclovir triphosphate ```

Correct K. Aciclovir triphosphate Response Feedback: Aciclovir diphosphate and triphosphate are the product of cellular tyrosine kinase, whereas aciclovir monophosphate is the product of viral tyrosine kinase.

``` The synthetic nucleoside analogue ganciclovir is the drug of choice against which infective virus? • Cytomegalovirus • Guanosine • Aciclovir monophosphate • Aciclovir diphosphate • Influenza • Ribavarin • AIDS • Famciclovir • Thymidine • Varicella-zoster virus • Aciclovir triphosphate ```

Correct A. Cytomegalovirus

``` Ribavirin, a synthetic nucleoside that acts as an RNA polymerase inhibitor, is similar in structure to which of the options given above? • Cytomegalovirus • Guanosine • Aciclovir monophosphate • Aciclovir diphosphate • Influenza • Ribavarin • AIDS • Famciclovir • Thymidine • Varicella-zoster virus • Aciclovir triphosphate ```

Correct B. Guanosine

``` Valaciclovir, a prodrug of aciclovir, is used to treat patients with which viral disease in the list, above? • Cytomegalovirus • Guanosine • Aciclovir monophosphate • Aciclovir diphosphate • Influenza • Ribavarin • AIDS • Famciclovir • Thymidine • Varicella-zoster virus • Aciclovir triphosphate ```

Correct J. Varicella-zoster virus

``` An immunomodulator effective in HBV infection • Doxacyclin • Ribavarin • Amantadine • Abacavir • Adefovir • Interferon • Gancyclovir • Ibuprofen • Citalapram • Loviride • Foscarnet • Zidovudine • Aciclovir ```

Correct F. Interferon

``` Used for the treatment of severe, resistant herpes infections • Doxacyclin • Ribavarin • Amantadine • Abacavir • Adefovir • Interferon • Gancyclovir • Ibuprofen • Citalapram • Loviride • Foscarnet • Zidovudine • Aciclovir ```

Correct K. Foscarnet

``` The treatment of choice for CMV-induced hepatitis • Doxacyclin • Ribavarin • Amantadine • Abacavir • Adefovir • Interferon • Gancyclovir • Ibuprofen • Citalapram • Loviride • Foscarnet • Zidovudine • Aciclovir ```

Correct G. Gancyclovir

``` A drug that is effective against influenza A but not influenza B • Doxacyclin • Ribavarin • Amantadine • Abacavir • Adefovir • Interferon • Gancyclovir • Ibuprofen • Citalapram • Loviride • Foscarnet • Zidovudine • Aciclovir ```

Correct C. Amantadine

``` A purine nucleoside analogue that selects specifically for thymidine kinase • Doxacyclin • Ribavarin • Amantadine • Abacavir • Adefovir • Interferon • Gancyclovir • Ibuprofen • Citalapram • Loviride • Foscarnet • Zidovudine • Aciclovir ```

Correct M. Aciclovir

``` A nucleoside analogue which inhibits reverse transcriptase • Human normal immunoglobulin • Indinavir • Amantadine • Enfuvirtide • Ganciclovir • Ribavarin • Efavirenz • Interferon • Zanamivir • Aciclovir • Nevirapine • Zidovudine • Human specific immunoglobulin ```

Correct L. Zidovudine

``` The drug mechanisms which acts by stopping post-translational cleaving of polyproteins by inhibiting proteases • Human normal immunoglobulin • Indinavir • Amantadine • Enfuvirtide • Ganciclovir • Ribavarin • Efavirenz • Interferon • Zanamivir • Aciclovir • Nevirapine • Zidovudine • Human specific immunoglobulin ```

Correct B. Indinavir

``` The drug that is selectively toxic to virally infected cells through its selective phosphorylation using viral thymidine kinase • Human normal immunoglobulin • Indinavir • Amantadine • Enfuvirtide • Ganciclovir • Ribavarin • Efavirenz • Interferon • Zanamivir • Aciclovir • Nevirapine • Zidovudine • Human specific immunoglobulin ```

Correct J. Aciclovir

``` The drug which can be delivered by inhalation to treat both influenza A and B. • Human normal immunoglobulin • Indinavir • Amantadine • Enfuvirtide • Ganciclovir • Ribavarin • Efavirenz • Interferon • Zanamivir • Aciclovir • Nevirapine • Zidovudine • Human specific immunoglobulin ```

Correct I. Zanamivir

``` The drug which works by attenuating or preventing rabies or hepatitis, following a known exposure but before the onset of signs and symptoms. • Human normal immunoglobulin • Indinavir • Amantadine • Enfuvirtide • Ganciclovir • Ribavarin • Efavirenz • Interferon • Zanamivir • Aciclovir • Nevirapine • Zidovudine • Human specific immunoglobulin ```

Correct M. Human specific immunoglobulin

``` A 40yr old female non-smoker presents with a one week history of fever, shortness of breath and a cough productive of rusty coloured sputum. She complains of a sharp chest pain which “catches” her on inspiration. On examination she has increased vocal resonance in the right middle zone on auscultation. The x-ray shows right middle lobe consolidation. • P. aeuruginosa • C. psittaci • S. pneumoniae • L. pneumophila • M. pneumoniae • K. pneumoniae • S. aureus • C. neoformans • M. tuberculosis • B. pertussis ```

Correct C. S. pneumoniae

``` A 37yr old American business man staying in a hotel presents with a headache, myalgia and a dry cough. He is also suffering with nausea, diarrhoea and abdominal pain. On examination he is tachypnoeic and has a pyrexia of 39ºC. Blood tests reveal lymphopenia and hyponatraemia. • P. aeuruginosa • C. psittaci • S. pneumoniae • L. pneumophila • M. pneumoniae • K. pneumoniae • S. aureus • C. neoformans • M. tuberculosis • B. pertussis ```

Correct D. L. pneumophila

``` A 19yr old medical student who lives in residential halls presents with a one week history of headache, malaise, shortness of breath and a cough. Her WBC is not raised but tests reveal the presence of cold agglutinins. • P. aeuruginosa • C. psittaci • S. pneumoniae • L. pneumophila • M. pneumoniae • K. pneumoniae • S. aureus • C. neoformans • M. tuberculosis • B. pertussis ```

Correct E. M. pneumoniae

``` A 30yr old lady presents with a three week history of tiredness, malaise, cough and weight loss. She feels her condition has worsened in the past week and she now also suffers from a fever and haemoptysis. In addition she complains of a “tender lump” in her supraclavicular region. Chest x-ray demonstrates nodular shadowing of the right upper zone. • P. aeuruginosa • C. psittaci • S. pneumoniae • L. pneumophila • M. pneumoniae • K. pneumoniae • S. aureus • C. neoformans • M. tuberculosis • B. pertussis ```

Correct J. M. tuberculosis

``` A forty year old ornithologist presents with malaise, muscular pains and a cough. On examination he has a fever and several distinctive rose spots on his abdomen. Chest x-ray reveals a diffuse pneumonia. • P. aeuruginosa • C. psittaci • S. pneumoniae • L. pneumophila • M. pneumoniae • K. pneumoniae • S. aureus • C. neoformans • M. tuberculosis • B. pertussis ```

Correct B. C. psittaci

``` Dry cough, new infiltrates on CXR, dyspnoea and target shaped lesions on the palms. No recent history of herpes. • P. aeuruginosa • C. psittaci • S. pneumoniae • L. pneumophila • M. pneumoniae • K. pneumoniae • S. aureus • C. neoformans • M. tuberculosis • B. pertussis ```

Correct E. M. pneumoniae

``` An 80 year old clown appears at the GP having been discharged from hospital for a complicated bowel resection with a stint in the ITU. He has a cough and fever and is prescribed a macrolide antibiotic because he is penicillin allergic. • Anaerobic infection • Legionella pneumophila • MSSA • Chlamydia psittaci • M. Catarrhalis • H. influenzae • S. pneumoniae • Burkholderia cepacia • PCP/ P jiroveci • MRSA • M tuberculosis • MSSA or MRSA • Chlamydia pneumoniae ```

Correct C. MSSA

``` A 55 year old female clown, recovering from a cold, is found to have a cavitating lesion on CXR and a productive cough. • Anaerobic infection • Legionella pneumophila • MSSA • Chlamydia psittaci • M. Catarrhalis • H. influenzae • S. pneumoniae • Burkholderia cepacia • PCP/ P jiroveci • MRSA • M tuberculosis • MSSA or MRSA • Chlamydia pneumoniae ```

Correct L. MSSA or MRSA Response Feedback: Q2: influenza is a classic precedent of S. aureus pneumonia. This is because there is transient postviral hypofunction of airway clearance mechanisms e.g. cilia.

``` An 18 year old trainee clown is being seen in the cystic fibrosis clinic and is found to be colonised with a particularly persistent organism. • Anaerobic infection • Legionella pneumophila • MSSA • Chlamydia psittaci • M. Catarrhalis • H. influenzae • S. pneumoniae • Burkholderia cepacia • PCP/ P jiroveci • MRSA • M tuberculosis • MSSA or MRSA • Chlamydia pneumoniae ```

Correct H. Burkholderia cepacia

A 40 year old clown specialist is found to have a lobar pneumonia which on culture grew Gram +ve diplococci. * Anaerobic infection * Legionella pneumophila * MSSA * Chlamydia psittaci * M. Catarrhalis * H. influenzae * S. pneumoniae * Burkholderia cepacia * PCP/ P jiroveci * MRSA * M tuberculosis * MSSA or MRSA * Chlamydia pneumoniae

Correct G. S. pneumoniae

``` A 35 year old clown who is a specialist in bird/clown comedy is found to have an atypical pneumonia which is treated with Augmentin and Clarythromicin • Anaerobic infection • Legionella pneumophila • MSSA • Chlamydia psittaci • M. Catarrhalis • H. influenzae • S. pneumoniae • Burkholderia cepacia • PCP/ P jiroveci • MRSA • M tuberculosis • MSSA or MRSA • Chlamydia pneumoniae ```

Correct D. Chlamydia psittaci

``` 19 year old male presents to A&E with severe respiratory difficulty, light-headedness and a red itchy rash. On examination he has laryngeal oedema, bilateral wheezing across the lung fields and is hypotensive. He has recently been taking antibiotics for a chest infection. • Contact dermatitis • Anaphylaxis • Acute Urticaria • Food allergy • Chronic Urticaria • Angioedema • Allergic bronchopulmonary Aspergillosis • Allergic asthma • Drug allergy • Allergic Rhinitis ```

Correct B. Anaphylaxis Response Feedback: With regards to the first question, whilst the anaphylaxis is most likely due to a drug allergy, it is important to note that this is an anaphylactic reaction. The answer 'drug allergy' does not emphasise the type of reaction occuring. Note that ambiguous questions will NOT appear on your exam - these questions have been written by students. For a discussion about anaphylaxis vs anaphylactoid reactions see attached file.

``` A 3 year old girl is brought into A&E by her parents. She has had vomiting and diarrhoea since early yesterday evening when she was at a birthday party. On examination she has urticaria. • Contact dermatitis • Anaphylaxis • Acute Urticaria • Food allergy • Chronic Urticaria • Angioedema • Allergic bronchopulmonary Aspergillosis • Allergic asthma • Drug allergy • Allergic Rhinitis ```

Correct D. Food allergy

``` A 40 year old man presents to his GP complaining of loss smell and nasal itching and discharge. On examination his nasal mucosa are swollen and have a bluish tinge. His symptoms improve with a corticosteroid spray • Contact dermatitis • Anaphylaxis • Acute Urticaria • Food allergy • Chronic Urticaria • Angioedema • Allergic bronchopulmonary Aspergillosis • Allergic asthma • Drug allergy • Allergic Rhinitis ```

Correct J. Allergic Rhinitis

``` A 25 year old woman presents to her GP complaining of itchy, red wheals on her torso which have been present for 7 weeks. She can not remember how they started but has noticed they are worse in the heat and when she exercises. • Contact dermatitis • Anaphylaxis • Acute Urticaria • Food allergy • Chronic Urticaria • Angioedema • Allergic bronchopulmonary Aspergillosis • Allergic asthma • Drug allergy • Allergic Rhinitis ```

Correct E. Chronic Urticaria

``` A 30 year old women presents to her GP with a red, itchy, oozing rash around her neck and fingers • Contact dermatitis • Anaphylaxis • Acute Urticaria • Food allergy • Chronic Urticaria • Angioedema • Allergic bronchopulmonary Aspergillosis • Allergic asthma • Drug allergy • Allergic Rhinitis ```

Correct A. Contact dermatitis

``` A 55 year old man with history of angina was advised to take a tablet before a long flight. After taking the pill, he suddenly finds that he has difficulty breathing, feels nauseous and is itching. • Allergic asthma • Urticarial vasculitis • Chronic urticaria • Panic attack • Acute urticaria • C1 inhibitor deficiency • IgE mediated anaphylaxis • Mast cell degranulation • Extrinsic allergic alveolitis • Coeliac disease • Idiopathic angioedema ```

Correct H. Mast cell degranulation | Mast cell degranulation is not IgE mediated.

``` A 24 year old medical student develops worsening swelling of the hands and feet and abdominal pain before her final year medical exams. She says that similar milder episodes have occurred preciously. • Allergic asthma • Urticarial vasculitis • Chronic urticaria • Panic attack • Acute urticaria • C1 inhibitor deficiency • IgE mediated anaphylaxis • Mast cell degranulation • Extrinsic allergic alveolitis • Coeliac disease • Idiopathic angioedema ```

Correct F. C1 inhibitor deficiency

``` A 50 year old Irish woman presents to her GP with episodes of diarrhoea, which is difficult to flush, abdominal pain, weight loss and fatigue. She also describes a blistering itchy rash on her knees. • Allergic asthma • Urticarial vasculitis • Chronic urticaria • Panic attack • Acute urticaria • C1 inhibitor deficiency • IgE mediated anaphylaxis • Mast cell degranulation • Extrinsic allergic alveolitis • Coeliac disease • Idiopathic angioedema ```

Correct J. Coeliac disease Coeliac disease is associated with a superficial, blistering skin rash 'dermatitis herpetiformis', which is intensely itchy!

``` A 26 year old male who has been suffering from ‘flu-like’ symptoms with fever presents to the GP after developing skin rash in the last few days. • Allergic asthma • Urticarial vasculitis • Chronic urticaria • Panic attack • Acute urticaria • C1 inhibitor deficiency • IgE mediated anaphylaxis • Mast cell degranulation • Extrinsic allergic alveolitis • Coeliac disease • Idiopathic angioedema ```

Correct E. Acute urticaria

``` A 35 year old woman presents with persistent itchy wheels for the last 2 months. She noticed that when this is at its worst, she also has a fever and feels generally unwell. After an acute attack, she has bruising and post-inflammatory residual pigmentation at the site of the itching. • Allergic asthma • Urticarial vasculitis • Chronic urticaria • Panic attack • Acute urticaria • C1 inhibitor deficiency • IgE mediated anaphylaxis • Mast cell degranulation • Extrinsic allergic alveolitis • Coeliac disease • Idiopathic angioedema ```

Correct B. Urticarial vasculitis

``` A 19 year old male presents to A&E with increasing breathlessness. On examination his blood pressure is 90/55 mmHg and his respiratory rate is 28/min. He shows you a generalised red itchy skin rash, and examination of his chest reveals bilateral inspiratory and expiratory wheezes throughout. • Acute urticaria • Allergic conjunctivitis • Acute angioedema • Anaphylaxis • Chronic urticaria • Contact hypersensitivity • Allergic asthma • Hereditary angioedema • Allergic rhinitis • Allergic bronchopulmonary aspergillosis ```

Correct D. Anaphylaxis The combination of hypotension, respiratory distress, urticaria and bronchoconstriction is very suggestive of anaphylaxis

``` A 35 year old woman presents with a two day history of a red itchy skin rash which started soon after her first scuba-diving lesson. She is otherwise well. • Acute urticaria • Allergic conjunctivitis • Acute angioedema • Anaphylaxis • Chronic urticaria • Contact hypersensitivity • Allergic asthma • Hereditary angioedema • Allergic rhinitis • Allergic bronchopulmonary aspergillosis ```

Correct A. Acute urticaria This rash is very suggestive of acute urticaria. The temporal association with scuba diving may indicate an allergy to latex (in wet suits).

``` A 22 year old woman presents with an intermittently itchy and desquamating skin rash on her abdomen which is unresponsive to antihistamines • Acute urticaria • Allergic conjunctivitis • Acute angioedema • Anaphylaxis • Chronic urticaria • Contact hypersensitivity • Allergic asthma • Hereditary angioedema • Allergic rhinitis • Allergic bronchopulmonary aspergillosis ```

Correct F. Contact hypersensitivity This rash is typical of contact hypersensitivity. The distribution of the rash suggests that the specific agent is nickel, which used to be a component of the studs of jeans and is commonly found in the metal used in belts.

``` A 40 year old man complains of loss of smell with nasal itching and discharge over 4 weeks. He also describes morning sneezing. He is otherwise in good health. On examination his nasal mucosa are swollen and hyperaemic. • Acute urticaria • Allergic conjunctivitis • Acute angioedema • Anaphylaxis • Chronic urticaria • Contact hypersensitivity • Allergic asthma • Hereditary angioedema • Allergic rhinitis • Allergic bronchopulmonary aspergillosis ```

Correct I. Allergic rhinitis | The combination of sneezing, rhinorrhea and loss of smell is very suggestive of allergic rhinitis

``` This 45 year old woman presents to A&E with tongue swelling and acute respiratory tract obstruction. She has longstanding hypertension and received a renal transplant two years previously. She has no history of allergic disease. On examination her blood pressure is stable, and examination of her lung fields reveal normal breath sounds. Her current medication includes cyclosporine, azathioprine, captopril and nifedipine. • Acute urticaria • Allergic conjunctivitis • Acute angioedema • Anaphylaxis • Chronic urticaria • Contact hypersensitivity • Allergic asthma • Hereditary angioedema • Allergic rhinitis • Allergic bronchopulmonary aspergillosis ```

Correct C. Acute angioedema This woman has angioedema of the tongue, without symptoms suggestive of a generalised allergic reaction. Isolated angioedema may be allergic in origin, but 94% of cases angioedema presenting to A&E are drug induced and the majority of these are associated with ACE inhibitors (eg captopril).

``` A 19 year old male presents to A&E with increasing breathlessness. On examination his blood pressure is 90/55 mmHg and his respiratory rate is 28/min. He shows you a generalised red itchy skin rash, and examination of his chest reveals bilateral inspiratory and expiratory wheezes throughout. • IM adrenaline 1mL of 1:1000 • Venom immunotherapy • IV adrenaline 0.3mL of 1:1000 • IM adrenaline 0.5 mL of 1:1000 • Intranasal antihistamines • None of the above • PO antihistamines • IV antihistamines • Intraarticular corticosteroids • IM adrenaline 1mL of 1:10000 • Inhaled antihistamines • Intracardiac adrenaline • Inhaled corticosteroids ```

Correct A. IM adrenaline 1mL of 1:1000 The most important treatment of anaphylaxis is adrenaline, which should be given intramuscularly. (Note for final year pharm: 1:1000 means 1mg/mL; 1:10000 means 0.1mg/mL ; 1% means 1g/dL)

``` A 35 year old woman presents with a two day history of a red itchy skin rash which started soon after her first scuba-diving lesson. She is otherwise well. • IM adrenaline 1mL of 1:1000 • Venom immunotherapy • IV adrenaline 0.3mL of 1:1000 • IM adrenaline 0.5 mL of 1:1000 • Intranasal antihistamines • None of the above • PO antihistamines • IV antihistamines • Intraarticular corticosteroids • IM adrenaline 1mL of 1:10000 • Inhaled antihistamines • Intracardiac adrenaline • Inhaled corticosteroids ```

Correct G. PO antihistamines | Severe acute urticaria is effectively treated with a short course of oral anti-histamines

``` A 22 year old woman is presents with this intermittently itchy and desquamating skin rash which is unresponsive to antihistamines • IM adrenaline 1mL of 1:1000 • Venom immunotherapy • IV adrenaline 0.3mL of 1:1000 • IM adrenaline 0.5 mL of 1:1000 • Intranasal antihistamines • None of the above • PO antihistamines • IV antihistamines • Intraarticular corticosteroids • IM adrenaline 1mL of 1:10000 • Inhaled antihistamines • Intracardiac adrenaline • Inhaled corticosteroids ```

Correct F. None of the above | Contact hypersensitivity should be treated by avoidance of the sensitising agent, in this case nickel

``` A 40 year old man complains of loss of smell with nasal itching and discharge over 4 weeks. He also describes morning sneezing. He is otherwise in good health. On examination his nasal mucosa are swollen and hyperaemic. • IM adrenaline 1mL of 1:1000 • Venom immunotherapy • IV adrenaline 0.3mL of 1:1000 • IM adrenaline 0.5 mL of 1:1000 • Intranasal antihistamines • None of the above • PO antihistamines • IV antihistamines • Intraarticular corticosteroids • IM adrenaline 1mL of 1:10000 • Inhaled antihistamines • Intracardiac adrenaline • Inhaled corticosteroids ```

Correct G. PO antihistamines Oral antihistamines and intranasal corticosteroids are the mainstay of treatment of mild allergic rhinitis. (As intranasal corticosteroid is not an option available, the “single best” answer here is oral antihistamines.)

``` This 45 year old woman presents to A&E with tongue swelling and acute respiratory tract obstruction. She has longstanding hypertension and received a renal transplant two years previously. She has no history of allergic disease. On examination her blood pressure is stable, and examination of her lung fields reveal normal breath sounds. Her current medication includes cyclosporine, azathioprine, captopril and nifedipine. • IM adrenaline 1mL of 1:1000 • Venom immunotherapy • IV adrenaline 0.3mL of 1:1000 • IM adrenaline 0.5 mL of 1:1000 • Intranasal antihistamines • None of the above • PO antihistamines • IV antihistamines • Intraarticular corticosteroids • IM adrenaline 1mL of 1:10000 • Inhaled antihistamines • Intracardiac adrenaline • Inhaled corticosteroids ```

Correct D. IM adrenaline 0.5 mL of 1:1000 Intramuscular adrenalin should be used in patients with severe local angioedema with secondary acute respiratory tract obstruction. However this is not always effective in ACE inhibitor-induced angioedema, and some patients will require intubation. Always stop the causative agent!

``` Cytokines exerting an anti-viral effect • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct J. Interferons

``` Immunoglobulin dimer • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct E. IgA

``` MHC associated with Th1 cells • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct M. Major histocompatability complex class 2

``` Acts on hepatocytes to induce synthesis of acute phase proteins in response to bacterial infection • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct K. IL6

``` Arise in the first few days after infection and are important in defence against viruses and tumours • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct I. Natural Killer cells

``` MHC associated with Th2 cells • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

``` Correct M. Major histocompatability complex class 2 T helper cells are CD4+ and bind MHC class II ; cytotoxic T cells are CD8+ and bind MHC class I. ```

``` MHC associated with cytotoxic T cells • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

``` Correct G. Major histocompatability complex class 1 T helper cells are CD4+ and bind MHC class II ; cytotoxic T cells are CD8+ and bind MHC class I. ```

``` Along with IgD, is one of the first immunoglobulins expressed on B cells before they undergo antibody class switching • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct H. IgM

``` The most abundant (in terms of g/L) immunoglobulin in normal plasma • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct L. IgG

``` Deficiencies in this predispose to SLE • Alternative complement pathway • CD8+ • IgE • Classical complement pathway • IgA • Innate immune system • Major histocompatability complex class 1 • IgM • Natural Killer cells • Interferons • IL6 • IgG • Major histocompatability complex class 2 ```

Correct D. Classical complement pathway

``` Kostmanns syndrome is a congenital deficiency of which component of the immune system? • T lymphocyte • Mast cell • Complement • Fungal • Neutrophil • MHC Class I • MHC Class II • B lymphocyte • Parasitic • Viral • Bacterial ```

Correct E. Neutrophil

``` Which component of the innate immune system is usually one of the first to respond to infection through a cut? • T lymphocyte • Mast cell • Complement • Fungal • Neutrophil • MHC Class I • MHC Class II • B lymphocyte • Parasitic • Viral • Bacterial ```

Correct E. Neutrophil

``` Which infection is most common as a consequence of B cell deficiency? • T lymphocyte • Mast cell • Complement • Fungal • Neutrophil • MHC Class I • MHC Class II • B lymphocyte • Parasitic • Viral • Bacterial ```

Correct K. Bacterial

``` Meningococcal infections are quite common as a result of which deficiency of the component of the immune system? • T lymphocyte • Mast cell • Complement • Fungal • Neutrophil • MHC Class I • MHC Class II • B lymphocyte • Parasitic • Viral • Bacterial ```

Correct C. Complemental

``` Produced by the liver, when triggered, enzymatically activate other proteins in a biological cascade and are important in innate and antibody mediated immune response? • T lymphocyte • Mast cell • Complement • Fungal • Neutrophil • MHC Class I • MHC Class II • B lymphocyte • Parasitic • Viral • Bacterial ```

Correct C. Complement

``` A complete deficiency in this molecule is associated with recurrent respiratory and gastrointestinal infections. • C3b • MAC • Neutrophils • AP50 • C1 • C3a • IgM • IgA • Myeloperoxidase • Macrophages • IgG • NADPH oxidoase • CH50 ```

Correct H. IgA

``` Leukocyte Adhesion Deficiency is characterised by a very high count in which of the above? • C3b • MAC • Neutrophils • AP50 • C1 • C3a • IgM • IgA • Myeloperoxidase • Macrophages • IgG • NADPH oxidoase • CH50 ```

Correct C. Neutrophils

``` Which crucial enzyme is vital for the oxidative killing of intracellular micro-organisms? • C3b • MAC • Neutrophils • AP50 • C1 • C3a • IgM • IgA • Myeloperoxidase • Macrophages • IgG • NADPH oxidoase • CH50 ```

Correct L. NADPH oxidoase

``` Which complement factor is an important chemotaxic agent? • C3b • MAC • Neutrophils • AP50 • C1 • C3a • IgM • IgA • Myeloperoxidase • Macrophages • IgG • NADPH oxidoase • CH50 ```

Correct F. C3a

``` What is the functional complement test used to investigate the classical pathway? • C3b • MAC • Neutrophils • AP50 • C1 • C3a • IgM • IgA • Myeloperoxidase • Macrophages • IgG • NADPH oxidoase • CH50 ```

Correct M. CH50

``` Graves Disease • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct A. Type II – Antibody mediated

``` SLE • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct H. Type III – Immune complex mediated

``` Rheumatoid arthritis • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct D. Type IV – T-cell mediated

``` Asthma • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct E. Not an autoimmune disease

``` Type 1 diabetes • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct D. Type IV – T-cell mediated

``` Immune thrombocytopaenic purpura • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct A. Type II – Antibody mediated

``` ABO hemolytic transfusion reaction • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct A. Type II – Antibody mediated

``` Hepatitis C associated membranoproliferative glomerulonephritis type I • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct H. Type III – Immune complex mediated

``` Goodpasture's syndrome • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct A. Type II – Antibody mediated

``` Myaesthenia gravis • Type II – Antibody mediated • Type II – Antigen mediated • Type III – complement mediated • Type IV – T-cell mediated • Not an autoimmune disease • Type III – T-cell mediated • Type IV – Complement mediated • Type III – Immune complex mediated ```

Correct A. Type II – Antibody mediated

``` Systemic lupus erythematosis • Anti-GAD antibody • c-ANCA • p-ANCA • Anti-nuclear antibody • Anti-mitochondrial antibody • Anti-CCP antibody • Anti-DNA antibody • Coomb's test • Anti-cardiolipin antibody • Anti-centromere antibody • Rheumatoid factor ```

Correct G. Anti-DNA antibody The rationale for the answer for SLE being anti-DNA antibody rather than ANA is that whilst ANA is very sensitive for SLE, it is not specific. Anti-DNA, in contrast, is highly specific to SLE (~95%).

``` Wegener's granulomatosis • Anti-GAD antibody • c-ANCA • p-ANCA • Anti-nuclear antibody • Anti-mitochondrial antibody • Anti-CCP antibody • Anti-DNA antibody • Coomb's test • Anti-cardiolipin antibody • Anti-centromere antibody • Rheumatoid factor ```

Correct B. c-ANCA | Remember that c-ANCA matches with Wegener's Granulomatosis, whilst p-ANCA would match with polyarteritis nodosa

``` Rheumatoid arthritis • Anti-GAD antibody • c-ANCA • p-ANCA • Anti-nuclear antibody • Anti-mitochondrial antibody • Anti-CCP antibody • Anti-DNA antibody • Coomb's test • Anti-cardiolipin antibody • Anti-centromere antibody • Rheumatoid factor ```

Correct F. Anti-CCP antibody Rheumatoid factor is not specific or sensitive to rheumatoid arthritis and is common in the elderly. Anti-CCP is a more specific test for rheumatoid arthritis and a better predictor of an aggressive course.

``` Auto-immune haemolytic anaemia • Anti-GAD antibody • c-ANCA • p-ANCA • Anti-nuclear antibody • Anti-mitochondrial antibody • Anti-CCP antibody • Anti-DNA antibody • Coomb's test • Anti-cardiolipin antibody • Anti-centromere antibody • Rheumatoid factor ```

Correct H. Coomb's test

``` Primary biliary cirrhosis • Anti-GAD antibody • c-ANCA • p-ANCA • Anti-nuclear antibody • Anti-mitochondrial antibody • Anti-CCP antibody • Anti-DNA antibody • Coomb's test • Anti-cardiolipin antibody • Anti-centromere antibody • Rheumatoid factor ```

Correct E. Anti-mitochondrial antibody

``` What is the specific auto-antigen that is the target of the immune system in Goodpasture's syndrome? • Blood vessels • Smooth linear pattern • Type II Hypersentivity • Prednisolone • Lumpy-bumpy pattern • Ciclosporin • Glomerular basement membrane • Anti-neutrophil cytoplasmic antibodies • Lung • Skin • Type II collagen • Type IV collagen • Mesangium • Plasmapheresis ```

Correct L. Type IV collagen poorly written question...

``` The pattern of the antibody deposition in the glomerular basement membrane in Goodpasture's syndrome is typically described as what? • Blood vessels • Smooth linear pattern • Type II Hypersentivity • Prednisolone • Lumpy-bumpy pattern • Ciclosporin • Glomerular basement membrane • Anti-neutrophil cytoplasmic antibodies • Lung • Skin • Type II collagen • Type IV collagen • Mesangium • Plasmapheresis ```

Correct B. Smooth linear pattern

``` Name the drug most likely to be used in the treatment of Goodpasture's syndrome. • Blood vessels • Smooth linear pattern • Type II Hypersentivity • Prednisolone • Lumpy-bumpy pattern • Ciclosporin • Glomerular basement membrane • Anti-neutrophil cytoplasmic antibodies • Lung • Skin • Type II collagen • Type IV collagen • Mesangium • Plasmapheresis ```

Correct D. Prednisolone bad question

``` Immune damage may be associated with the kidney and commonly which other tissue in Goodpasture's syndrome? • Blood vessels • Smooth linear pattern • Type II Hypersentivity • Prednisolone • Lumpy-bumpy pattern • Ciclosporin • Glomerular basement membrane • Anti-neutrophil cytoplasmic antibodies • Lung • Skin • Type II collagen • Type IV collagen • Mesangium • Plasmapheresis ```

Correct I. Lung

Which of the following demonstrates proteinaceous material and inflammatory cells only? * Acute mastitis * Breast abscess * Duct ectasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Fibrocystic disease * Intraductal papilloma * Invasive cancer * Paget's disease * Peau d'orange * Phyllodes tumour

Duct ectasia

Which of the following is a fibroepithelial tumour, most common in women >40 years of age? * Acute mastitis * Breast abscess * Duct ectasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Fibrocystic disease * Intraductal papilloma * Invasive cancer * Paget's disease * Peau d'orange * Phyllodes tumour

Phyllodes tumour

Which of the following is the most common non-invasive breast neoplasm? * Acute mastitis * Breast abscess * Duct ectasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Fibrocystic disease * Intraductal papilloma * Invasive cancer * Paget's disease * Peau d'orange * Phyllodes tumour

Ductal carcinoma in situ

Which of the following describes a benign breast change associated with hormonal changes/menstruation? * Acute mastitis * Breast abscess * Duct ectasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Fibrocystic disease * Intraductal papilloma * Invasive cancer * Paget's disease * Peau d'orange * Phyllodes tumour

Fibrocystic disease (now called fibrocystic breast changes...)

Which of the following best describes a common infection in lactating women, most commonly within the first 6 weeks postpartum? * Acute mastitis * Breast abscess * Duct ectasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Fibrocystic disease * Intraductal papilloma * Invasive cancer * Paget's disease * Peau d'orange * Phyllodes tumour

Acute mastitis

A younger patient presents with a solid, well-defined lump in her breast. FNAC shows benign cells. * Acute pyogenic mastitis * Ductal carcinoma in situ * Duct ectasia * Fat necrosis * Fibroadenoma * Fibrocystic changes * Intraductal papilloma * Invasive ductal carcinoma * Lipoma * Lobular carcinoma in situ * Mucinous carcinoma * Phyllodes tumour * Radial scar

Fibroadenoma

FNAC is performed on a tender lump in the breast of a woman who gave birth 5 weeks ago. Neutrophils and inflammatory debris are seen but no malignant cells. * Acute pyogenic mastitis * Ductal carcinoma in situ * Duct ectasia * Fat necrosis * Fibroadenoma * Fibrocystic changes * Intraductal papilloma * Invasive ductal carcinoma * Lipoma * Lobular carcinoma in situ * Mucinous carcinoma * Phyllodes tumour * Radial scar

Duct ectasia

Mammography of a hard lump shows a stellate mass with microcalcification. As well as the primary lump, enlarged axillary lymph nodes are present in the patient. * Acute pyogenic mastitis * Ductal carcinoma in situ * Duct ectasia * Fat necrosis * Fibroadenoma * Fibrocystic changes * Intraductal papilloma * Invasive ductal carcinoma * Lipoma * Lobular carcinoma in situ * Mucinous carcinoma * Phyllodes tumour * Radial scar

Invasive ductal carcinoma

Women with this condition present with thick, creamy discharge with an underlying mass. Cytology shows no epithelial cells, but macrophages and debris are present * Acute pyogenic mastitis * Ductal carcinoma in situ * Duct ectasia * Fat necrosis * Fibroadenoma * Fibrocystic changes * Intraductal papilloma * Invasive ductal carcinoma * Lipoma * Lobular carcinoma in situ * Mucinous carcinoma * Phyllodes tumour * Radial scar

Acute pyogenic mastitis

This is an acute, inflammatory condition, characterised commonly by the presence of Staph. aureus in breastfeeding women. * Atypical ductal hyperplasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Invasive papillary adenoma * Lipoma * Lobular carcinoma in situ * Mammary duct ectasia * Mastitis * Mucinous carcinoma * Pyllodes tumour * Sclerosing adenosis

Mastitis

This is a condition which may present as a painless, palpable mass, skin thickening/retraction, mammographic density or mammographic calcifications. Most affected women have a history of breast trauma or surgery. * Atypical ductal hyperplasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Invasive papillary adenoma * Lipoma * Lobular carcinoma in situ * Mammary duct ectasia * Mastitis * Mucinous carcinoma * Pyllodes tumour * Sclerosing adenosis

Fat necrosis

Histologically, the acini are compressed and distorted by dense stroma. The acini are arranged in a swirling pattern and the outer border is well circumscribed. * Atypical ductal hyperplasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Invasive papillary adenoma * Lipoma * Lobular carcinoma in situ * Mammary duct ectasia * Mastitis * Mucinous carcinoma * Pyllodes tumour * Sclerosing adenosis

Sclerosing adenosis

An incidental biopsy finding, not associated with calcifications or stromal reactions and does not produce mammographic densities. More common in pre-menopausal women. * Atypical ductal hyperplasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Invasive papillary adenoma * Lipoma * Lobular carcinoma in situ * Mammary duct ectasia * Mastitis * Mucinous carcinoma * Pyllodes tumour * Sclerosing adenosis

Lobular carcinoma in situ

A radiographically well circumscribed mass which is grossly rubbery, white, mobile and clearly demarcated from the surrounding yellow adipose tissue. The epithelium of this mass is hormonally responsive and an increase in size may occur during pregnancy. In older women, the stroma typically becomes densely hyalinised and the epithelium atrophic. * Atypical ductal hyperplasia * Ductal carcinoma in situ * Fat necrosis * Fibroadenoma * Invasive papillary adenoma * Lipoma * Lobular carcinoma in situ * Mammary duct ectasia * Mastitis * Mucinous carcinoma * Pyllodes tumour * Sclerosing adenosis

Fibroadenoma

A 25 year old woman presents 2 weeks after the birth of her child with pain in her left breast. O/E she has a tender, 5cm swelling adjacent to her nipple.

Breast abscess

50yo woman presents with discharge of thick, creamy fluid from her R nipple. O/E there is a poorly defined sub-areolar mass. Cytology shows macrophages and debris while an ultrasound identifies dilated sub-areolar ducts.

Duct ectasia

47yo woman presents with 4 week history of blood stained discharge from her L nipple. Examination is unremarkable and no lumps are palpable.

Duct papilloma

21yo woman presents with a 2cm mobile lump. Ultrasound identifies a solid, well-defined mass. FNAC shows benign cells.

Fibroadenoma

36yo woman presents with an ill-defined lump in the R breast. She reports that it enlarges and becomes tender in the second phase of her menstrual cycle.

Fibrocystic changes

Rank these complications in the chronological order (from most immediate to late) that are likely to happen after a myocardial infarction. ``` A Pericarditis B Dressler Syndrome C Myocardial Rupture D Ventricular Aneurysm E Ventricular Fibrillation ```

EACBD from immediate to late. E – Serious/life threatening arrhythmias (such as ventricular fibrillation) are mostly likely to happen within the first hour after a MI. This is often a cause of sudden death A – Pericarditis – Transmural MIs can cause fibrinohemorrhagic pericarditis (due to myocardial inflammation) and usually appears 2-3 days after an infarction. C – Myocardial rupture are caused by the lysis of myocardial connective tissue which reaches maximum stage during day 3-7. This causes the infarcted muscles to become soft, friable granulation tissue. B – Dressler syndrome specifically refers to pericarditis that occurs from week 2 to months afterwards which is believed to be caused by autoimmune inflammation of the infarct. D – Ventricular aneurysm is a late complication after a MI (months) caused by the thin wall of the scar tissue of the MI

``` A 65-year-old chronic alcoholic presents to the A&E Department with a minor head injury. On examination he is found to be pale. Blood tests show a high MCV. What is the likeliest result of MCV (fl) in a normal person? A. 30 B. 290 C. 2.2 D. 90 E. 130 F. 15 G. 4 ```

Correct D. 90

``` A 40-year-old woman presents with a two month history of tiredness, intermittent pyrexia and abdominal pain. On examination she has an enlarged palpable spleen. Blood tests show anaemia with a raised white cell count. What is the likeliest result of a white cell count (x 109 per l) in a normal person? A. 30 B. 290 C. 2.2 D. 90 E. 130 F. 15 G. 4 ```

Correct G. 4

``` A 5-year-old boy presents with a purpuric rash and petechiae following a recent viral infection. Blood tests showed thrombocytopenia. What is the likeliest result of a platelet count (x109/l) in a normal adult? A. 30 B. 290 C. 2.2 D. 90 E. 130 F. 15 G. 4 ```

Correct B. 290

``` A 35-year-old man presents with hypertension. Blood tests show normal sodium, urea and glucose and a raised potassium. What is the likeliest result of potassium (mmol/l) in a normal person? A. 30 B. 290 C. 2.2 D. 90 E. 130 F. 15 G. 4 ```

Correct G. 4

``` A 70-year-old woman presents in a coma with a long history of polyuria and polydipsia. Investigations show that her plasma osmolarity is raised. What is the likeliest result of plasma osmolarity (mmol/l) in a normal person? A. 30 B. 290 C. 2.2 D. 90 E. 130 F. 15 G. 4 ```

Correct B. 290

``` A 14-year-old boy presents with symptoms of chronic liver failure. LFTs display abnormally high levels of transaminases with normal alk phos & bilirubin levels. There’s marked accumulation of copper-associated protein in hepatocytes obtained from a biopsy. His serum copper levels and caeruloplasmin are abnormally low. A. Chronic hepatitis C B. Chronic hepatitis B C. Budd-Chiari syndrome D. Wilson's disease E. Primary biliary cirrhosis F. Primary hepatocellular carcinoma G. Hepatitis A H. Crigler Najjar syndrome ```

Correct D. Wilson's disease

``` A 30-year-old Thai male presents to a day surgery unit for a cholecystectomy. His LFTs reveal very elevated transaminases with normal bilirubin & alk phos levels. Microscopy of a liver biopsy identifies antigens from a dsDNA virus in the cytosol of hepatocytes. A. Chronic hepatitis C B. Chronic hepatitis B C. Budd-Chiari syndrome D. Wilson's disease E. Primary biliary cirrhosis F. Primary hepatocellular carcinoma G. Hepatitis A H. Crigler Najjar syndrome ```

Correct B. Chronic hepatitis B

``` A 58-year-old woman presents with recent onset of Jaundice. LFTs reveal increased bilirubin & markedly elevated alk phos & normal transaminases. Further investigations uncovered raised IgM and serum cholesterol. Anti mitochondrial antibodies are also detected. A liver biopsy shows enlargement of the portal tracts by white blood cells and granulomas. Bile ducts are also less than normal. A. Chronic hepatitis C B. Chronic hepatitis B C. Budd-Chiari syndrome D. Wilson's disease E. Primary biliary cirrhosis F. Primary hepatocellular carcinoma G. Hepatitis A H. Crigler Najjar syndrome ```

Correct E. Primary biliary cirrhosis

``` A 48-year-old male returning from a 6mths round the world trip presents with a recent Hx of nausea, anorexia & distaste for cigarettes. He developed jaundice; his urine became dark and his stools pale. His spleen was palpable. Investigations showed bilirubinuria, increased urinary urobilinogen & a raised serum AST & ALT. Within 4 weeks his symptoms had completely subsided. A. Chronic hepatitis C B. Chronic hepatitis B C. Budd-Chiari syndrome D. Wilson's disease E. Primary biliary cirrhosis F. Primary hepatocellular carcinoma G. Hepatitis A H. Crigler Najjar syndrome ```

Correct G. Hepatitis A

``` A 55-year-old woman presents with a short Hx of nausea and abdominal pain; tender hepatomegaly and ascities. LFTs show mildly raised transaminases, bilirubin and normal alk phos. The woman also had polycythaemia rubra vera. Liver biopsy suggests venous outflow obstruction. A. Chronic hepatitis C B. Chronic hepatitis B C. Budd-Chiari syndrome D. Wilson's disease E. Primary biliary cirrhosis F. Primary hepatocellular carcinoma G. Hepatitis A H. Crigler Najjar syndrome ```

Correct C. Budd-Chiari syndrome

``` A liver enzyme raised after a myocardial infarction A. Direct bilirubin B. Activated partial thromboplastin time C. Prothrombin time D. Alkaline phosphatase E. Albumin F. Gamma glutamyl transpeptidase G. Alanine transaminase H. Aspartate transaminase I. Gamma globulin J. Total bilirubin ```

Correct H. Aspartate transaminase

``` A test of the integrity of the extrinsic pathway A. Direct bilirubin B. Activated partial thromboplastin time C. Prothrombin time D. Alkaline phosphatase E. Albumin F. Gamma glutamyl transpeptidase G. Alanine transaminase H. Aspartate transaminase I. Gamma globulin J. Total bilirubin ```

Correct C. Prothrombin time The intrinsic pathway is initiated by the activation of the 'contact factor' of plasma and can be measured by the APTT test. The extrinsic pathway is initiated by the release of tissue factor and can be measured by the PT test.

``` An enzyme markedly raised in obstructive jaundice along with direct bilirubin A. Direct bilirubin B. Activated partial thromboplastin time C. Prothrombin time D. Alkaline phosphatase E. Albumin F. Gamma glutamyl transpeptidase G. Alanine transaminase H. Aspartate transaminase I. Gamma globulin J. Total bilirubin ```

Correct D. Alkaline phosphatase

``` Raised in alcohol abuse A. Direct bilirubin B. Activated partial thromboplastin time C. Prothrombin time D. Alkaline phosphatase E. Albumin F. Gamma glutamyl transpeptidase G. Alanine transaminase H. Aspartate transaminase I. Gamma globulin J. Total bilirubin ```

Correct F. Gamma glutamyl transpeptidase

``` Levels can be affected by diet A. Direct bilirubin B. Activated partial thromboplastin time C. Prothrombin time D. Alkaline phosphatase E. Albumin F. Gamma glutamyl transpeptidase G. Alanine transaminase H. Aspartate transaminase I. Gamma globulin J. Total bilirubin ```

Correct E. Albumin

``` A 26-year-old receptionist presents to her GP with a history steatorrhoea, abdominal pain and weight loss, as well as feeling tired all the time. Initial blood tests reveal a microcytic anaemia. A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct F. Anti-endomysial antibodies | (1) Coeliac disease: Anti-endomysial antibodies/ Tissue-transglutaminase antibodies

``` A 60-year-old woman with hypothyroidism presents with progressive dyspnoea and tiredness. FBC reveals macrocytic anaemia. A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct K. Anti-gastric parietal cell antibodies | (2) Pernicious anaemia: Anti-intrinsic factor antibodies, and gastric parietal antibodies.

``` A 40-year-old plumber presents to his GP with a history of wheezing and lethargy, along with recurrent nose bleeds. On examination he has crackles in his upper left lung field. Urine dipstick is positive for blood and protein. A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct G. c-ANCA | (3) Wegener's : Antibody to Proteinase-3 : 3 is the 3rd letter of the alphabet; c-ANCA.

``` A 30-year-old market trader presents with tiredness and jaundice, and further history reveals he suffered from a chest infection one week previously. On examination mild splenomegaly is noted, and blood tests show reticulocytosis, hyperbilirubinaemia, and spherocytosis. A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct M. Osmotic fragility test | Spherocytosis: Osmotic fragility test.

``` An 80-year-old retired clerk presents with a 2-month history of skin itching and lethargy. Examination is normal. LFTs are: bilirubin 6umol/l (reference range 0-17umol/l); ALT 24U/l (reference range 0-31U/l); Alk Phos 500U/l (reference range 30-130U/l). A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct B. Anti-mitochondrial antibody | (5) PBC - AMA E2 subtype of pyruvate dehydrogenase complex

``` A 10-year-old girl presents with weight loss, polyuria, tachypnoea, vomiting. Looks very dehydrated. Beta hydroxybutyrate is raised in the blood. A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct I. Anti-GAD | 7) Type 1 diabetes: Anti-Glutamic acid decarboxylase antibodies (Anti-GAD

``` A 55-year-old woman is warned of future risk of AML given her recent diagnosis of PNH following a spontaneous cerebral venous sinus thrombosis. A. p-ANCA B. Anti-mitochondrial antibody C. Anti-DsDNA D. Anti-scl70 E. ANA F. Anti-endomysial antibodies G. c-ANCA H. Anti-smooth muscle antibody I. Anti-GAD J. Anti-acetylcholine receptor antibody K. Anti-gastric parietal cell antibodies L. Ham's test M. Osmotic fragility test ```

Correct L. Ham's test | (6) Paroxysmal nocturnal haemoglobinuria (PNH): Ham's test.

``` A 40-year-old woman presents with polyuria and polydipsia. She has a fasting glucose 5.1mmol/L and an oral glucose tolerance test value of 5.0mmol/L. She has a corrected calcium of 2.80mmol/L and a PTH of 7.2pmol/L. A. Sarcoidosis B. Crohn’s disease C. Gestational diabetes D. Impaired fasting glucose E. Vitamin D deficiency F. Malignancy G. Primary hyperparathyroidism H. Tuberculosis I. Psychogenic polydipsia J. Impaired glucose tolerance K. Secondary hyperthyroidism L. Diabetes mellitus type 1 M. Diabetes mellitus type 2 N. Lung cancer O. Hypocalcaemia ```

Correct G. Primary hyperparathyroidism

A 35-year-old Afro-Caribbean woman presents with polyuria and polydipsia. She also complains of a dry cough. She has a fasting glucose of 5.8mmol/L and an oral glucose tolerance test value of 6.5mmol/L. She has a corrected calcium of 2.7mmol/L and a PTH of

Correct A. Sarcoidosis

``` A 15-year-old girl presents with weight loss, polyuria and polydipsia. Over the last few months she reports feeling increasingly tired and complains of perianal itching. On examination you notice a small perianal abscess. Her fasting glucose is 22.3mmol/L. His corrected calcium is 2.5mmol/L and his PTH is 7.0pmol/L. A. Sarcoidosis B. Crohn’s disease C. Gestational diabetes D. Impaired fasting glucose E. Vitamin D deficiency F. Malignancy G. Primary hyperparathyroidism H. Tuberculosis I. Psychogenic polydipsia J. Impaired glucose tolerance K. Secondary hyperthyroidism L. Diabetes mellitus type 1 M. Diabetes mellitus type 2 N. Lung cancer O. Hypocalcaemia ```

Correct L. Diabetes mellitus type 1

``` A 56-year-old obese woman presents with polyuria and polydipsia. She complains of tiredness and depression. Her fasting glucose is 4.9mmol/L and her OGTT is 4.5mmol/L. She has a corrected calcium of 2.4mmol/L and a PTH of 7.1mmol/L. A. Sarcoidosis B. Crohn’s disease C. Gestational diabetes D. Impaired fasting glucose E. Vitamin D deficiency F. Malignancy G. Primary hyperparathyroidism H. Tuberculosis I. Psychogenic polydipsia J. Impaired glucose tolerance K. Secondary hyperthyroidism L. Diabetes mellitus type 1 M. Diabetes mellitus type 2 N. Lung cancer O. Hypocalcaemia ```

Correct I. Psychogenic polydipsia

``` A 58-year-old Afro-Caribbean gentleman presents with polyuria, polydipsia and weight loss. He has an oral glucose tolerance test of 10.1mmol/L. His corrected calcium is 2.5mmol/L and his PTH is 7.0pmol/L. A. Sarcoidosis B. Crohn’s disease C. Gestational diabetes D. Impaired fasting glucose E. Vitamin D deficiency F. Malignancy G. Primary hyperparathyroidism H. Tuberculosis I. Psychogenic polydipsia J. Impaired glucose tolerance K. Secondary hyperthyroidism L. Diabetes mellitus type 1 M. Diabetes mellitus type 2 N. Lung cancer O. Hypocalcaemia ```

Correct J. Impaired glucose tolerance

``` Varies with posture when sample is taken. A. ALT B. Potassium C. Glucose D. Albumin E. Triglycerides F. ALP G. Creatinine Kinase H. Cortisol I. Urea ```

Correct D. Albumin Plasma renin activity also varies with posture - it rises in the upright position. Some people have so-called benign postural and/or exercise-induced albuminuria.

``` Varies with exercise A. ALT B. Potassium C. Glucose D. Albumin E. Triglycerides F. ALP G. Creatinine Kinase H. Cortisol I. Urea ```

Correct G. Creatinine Kinase

``` Increases during pregnancy A. ALT B. Potassium C. Glucose D. Albumin E. Triglycerides F. ALP G. Creatinine Kinase H. Cortisol I. Urea ```

Correct F. ALP

``` Varies with race A. ALT B. Potassium C. Glucose D. Albumin E. Triglycerides F. ALP G. Creatinine Kinase H. Cortisol I. Urea ```

``` Correct G. Creatinine Kinase There are 3 main iso-forms of CK. CK-MM: present in muscles. CK-BB: Present in Brain. CK-MB: Present in cardiac muscle. ```

``` Most likely to vary with time of sampling A. ALT B. Potassium C. Glucose D. Albumin E. Triglycerides F. ALP G. Creatinine Kinase H. Cortisol I. Urea ```

Correct H. Cortisol

``` A 19-year-old woman admitted to hospital with acute asthma suffered a cardiac arrest after treatment. She was already taking several medications for her respiratory condition. What drug excess is likely to have caused this problem? A. Oxidation by cytochrome P450 B. Poor compliance C. Gentamicin D. Kidneys E. Liver F. GI system G. Theophylline H. Warfarin I. Lungs J. Rosiglitazone K. Digoxin L. Low therapeutic index M. Conjugation by sulphate/gluconaride N. High therapeutic index ```

Correct G. Theophylline

``` Failure to respond to drug therapy is commonly caused by what? A. Oxidation by cytochrome P450 B. Poor compliance C. Gentamicin D. Kidneys E. Liver F. GI system G. Theophylline H. Warfarin I. Lungs J. Rosiglitazone K. Digoxin L. Low therapeutic index M. Conjugation by sulphate/gluconaride N. High therapeutic index ```

Correct B. Poor compliance

``` Lipid soluble drugs require metabolism by the liver in two phases. What is Phase I? A. Oxidation by cytochrome P450 B. Poor compliance C. Gentamicin D. Kidneys E. Liver F. GI system G. Theophylline H. Warfarin I. Lungs J. Rosiglitazone K. Digoxin L. Low therapeutic index M. Conjugation by sulphate/gluconaride N. High therapeutic index ```

Correct A. Oxidation by cytochrome P450

``` Drugs are mainly excreted by which organ? A. Oxidation by cytochrome P450 B. Poor compliance C. Gentamicin D. Kidneys E. Liver F. GI system G. Theophylline H. Warfarin I. Lungs J. Rosiglitazone K. Digoxin L. Low therapeutic index M. Conjugation by sulphate/gluconaride N. High therapeutic index ```

Correct D. Kidneys

``` The effect of which drug can be measured by the surrogate marker HbA1C A. Oxidation by cytochrome P450 B. Poor compliance C. Gentamicin D. Kidneys E. Liver F. GI system G. Theophylline H. Warfarin I. Lungs J. Rosiglitazone K. Digoxin L. Low therapeutic index M. Conjugation by sulphate/gluconaride N. High therapeutic index ```

Correct J. Rosiglitazone

``` A 58-year-old man presents to your A&E complaining of chest pain and palpitations. He says he takes several drugs for his 'heart problems' and admits to being diabetic. What drug could be causing his problems? A. Oxidation by cytochrome P450 B. Poor compliance C. Gentamicin D. Kidneys E. Liver F. GI system G. Theophylline H. Warfarin I. Lungs J. Rosiglitazone K. Digoxin L. Low therapeutic index M. Conjugation by sulphate/gluconaride N. High therapeutic index ```

Correct K. Digoxin Possible features of DIGOXIN TOXICITY include: • arrhythmia: the most common arrhythmias are ventricular extrasystoles, ventricular bigeminy / trigeminy and atrial tachycardia with complete heart block • anorexia, nausea and vomiting and occasionally, diarrhoea • confusion especially in the elderly • yellow vision (xanthopsia), blurred vision and photophobia

``` Peak and trough levels of this drug should be taken A. Ethosuximide B. Gentamicin C. Heparin - Low molecular weight D. Phenytoin E. Phenobarbitone F. Ciclosporin G. Warfarin H. Lithium I. Heparin - unfractionated J. Carbamazepine K. Aspirin L. Clonazepam M. Theophylline N. Digoxin ```

Correct B. Gentamicin

``` Symptoms of under-treatment and toxicity may be similar A. Ethosuximide B. Gentamicin C. Heparin - Low molecular weight D. Phenytoin E. Phenobarbitone F. Ciclosporin G. Warfarin H. Lithium I. Heparin - unfractionated J. Carbamazepine K. Aspirin L. Clonazepam M. Theophylline N. Digoxin ```

Correct N. Digoxin

``` Decreased excretion, increased plasma concentration and increased risk of toxicity may occur when this taken in conjunction with thiazide diuretics A. Ethosuximide B. Gentamicin C. Heparin - Low molecular weight D. Phenytoin E. Phenobarbitone F. Ciclosporin G. Warfarin H. Lithium I. Heparin - unfractionated J. Carbamazepine K. Aspirin L. Clonazepam M. Theophylline N. Digoxin ```

Correct H. Lithium

``` Is ototoxic and nephrotoxic A. Ethosuximide B. Gentamicin C. Heparin - Low molecular weight D. Phenytoin E. Phenobarbitone F. Ciclosporin G. Warfarin H. Lithium I. Heparin - unfractionated J. Carbamazepine K. Aspirin L. Clonazepam M. Theophylline N. Digoxin ```

Correct B. Gentamicin

``` Requires regular monitoring of APTT A. Ethosuximide B. Gentamicin C. Heparin - Low molecular weight D. Phenytoin E. Phenobarbitone F. Ciclosporin G. Warfarin H. Lithium I. Heparin - unfractionated J. Carbamazepine K. Aspirin L. Clonazepam M. Theophylline N. Digoxin ```

Correct I. Heparin - unfractionated

``` A man was put into custody after driving under the influence of drugs. On arrest he was reported as acting extremely aggressive and paranoid. He also claimed his heart was racing. One hour later he was found dead. There was suspicion of police brutality. A. Cyanide B. Methadone C. Amphetamines D. Strychnine E. Organophosphate F. Paracetamol G. Benzodiazepines H. Ethanol I. Cocaine J. Police brutality K. Carbon monoxide L. Aspirin M. Methanol N. Cannabis O. Ecstasy P. Heroin ```

Correct I. Cocaine ‘In the lectures slides it mentiones EBE and BE as breakdown products of cocaine: what are these?’ EME = ecgonine methyl ester BE = benzoylecgonine They are the two degredation products of cocaine produced by pseudocholinesterases and hydrolysis respectively.

``` A 24-year-old woman goes to a party where she has some pills. She subsequently becomes feverish and confused. She was found to be hyperthermic and blood results showed a raised urea and creatinine, her myoglobin was also found to be high. A. Cyanide B. Methadone C. Amphetamines D. Strychnine E. Organophosphate F. Paracetamol G. Benzodiazepines H. Ethanol I. Cocaine J. Police brutality K. Carbon monoxide L. Aspirin M. Methanol N. Cannabis O. Ecstasy P. Heroin ```

Correct O. Ecstasy

``` James Pond comes to A&E claiming he’s been poisoned. Minutes later he dies. His skin was brick red and there was a faint odour of almonds. A. Cyanide B. Methadone C. Amphetamines D. Strychnine E. Organophosphate F. Paracetamol G. Benzodiazepines H. Ethanol I. Cocaine J. Police brutality K. Carbon monoxide L. Aspirin M. Methanol N. Cannabis O. Ecstasy P. Heroin ```

Correct A. Cyanide

``` Following a death in the family, a young woman is brought into the hospital with confusion. On inspection she appears jaundiced. Her friend reports that she had been vomiting earlier and that she had found an empty medicine bottle in her room. A. Cyanide B. Methadone C. Amphetamines D. Strychnine E. Organophosphate F. Paracetamol G. Benzodiazepines H. Ethanol I. Cocaine J. Police brutality K. Carbon monoxide L. Aspirin M. Methanol N. Cannabis O. Ecstasy P. Heroin ```

Correct F. Paracetamol

``` A man was found collapsed on the floor of his room and his breathing was found to be severely depressed. A urine test was found to be positive for 6-MAM. A. Cyanide B. Methadone C. Amphetamines D. Strychnine E. Organophosphate F. Paracetamol G. Benzodiazepines H. Ethanol I. Cocaine J. Police brutality K. Carbon monoxide L. Aspirin M. Methanol N. Cannabis O. Ecstasy P. Heroin ```

Correct P. Heroin

``` A 30-year-old farmer presents to casualty complaining of diarrhoea and painful mouth ulcers. On questioning he admitted accidentally ingesting liquid paraquat A. Naloxone B. Desferrioxamine C. Hyperbaric oxygen D. Glucagon E. Gastric lavage F. Activated charcoal G. N-acetylcysteine H. Atropine I. Haemodialysis J. Symptomatic and Supportive treatment K. Dicobalt edentate ```

Correct F. Activated charcoal Remember activated charcoal is NOT helpful in poisoning with: cyanide, iron, ethanol, lithium, acid or alkali, pesticides.

``` A 15-year-old girl presents with sweats and hyperventilation indicative of a severe metabolic acidosis; after taking a large number of salicylate tablets A. Naloxone B. Desferrioxamine C. Hyperbaric oxygen D. Glucagon E. Gastric lavage F. Activated charcoal G. N-acetylcysteine H. Atropine I. Haemodialysis J. Symptomatic and Supportive treatment K. Dicobalt edentate ```

Correct I. Haemodialysis

``` A 26-year-old woman collapses after a massive overdose of atenolol. She remains in cardogenic shock despite initial treatment with IV atropine A. Naloxone B. Desferrioxamine C. Hyperbaric oxygen D. Glucagon E. Gastric lavage F. Activated charcoal G. N-acetylcysteine H. Atropine I. Haemodialysis J. Symptomatic and Supportive treatment K. Dicobalt edentate ```

Correct D. Glucagon

``` A pregnant 30-year-old woman is found drowsy in her rented flat. She complains of severe nausea for the last 3 hours. Her carboxyhaemoglobin level is 41%. A. Naloxone B. Desferrioxamine C. Hyperbaric oxygen D. Glucagon E. Gastric lavage F. Activated charcoal G. N-acetylcysteine H. Atropine I. Haemodialysis J. Symptomatic and Supportive treatment K. Dicobalt edentate ```

Correct C. Hyperbaric oxygen

``` A 25-year-old man is delirious and hyperpyrexial after taking a pill in a club. He is hyperreflexic and is hyponatraemic A. Naloxone B. Desferrioxamine C. Hyperbaric oxygen D. Glucagon E. Gastric lavage F. Activated charcoal G. N-acetylcysteine H. Atropine I. Haemodialysis J. Symptomatic and Supportive treatment K. Dicobalt edentate ```

Correct J. Symptomatic and Supportive treatment

An 18 year old female is brought in to A&E from a rave in the early hours of the morning. On initial examination she is agitated with a heart rate of 120 bpm. She is very sweaty and has wide dilated pupils ``` A. Acetylcysteine B. Lithium C. Salicylates D. Carbon Monoxide E. Paracetamol F. Organophosphates G. Methanol H. Tricyclic antidepressants I. Ecstasy J. Desferrioxamine K. Naloxone ```

Correct I. Ecstasy Both TCA od's and ecstasy od's can cause wide dilated pupils. Ecstasy is more likely to lead to agitation and TCA drowsiness. ps...the other question in the stem , points very clearly to TCA overdose (reflexes and widened QRS complexes). Also....remember that ecstasy may induce vasopressin secretion and an SIADH, with hyponatraemia

``` A 25 year old male is admitted with hyperventilation. He is sweating and appears nauseous. He says that he has ringing in his ears. Blood gases show that he has mixed acid-base disturbance A. Acetylcysteine B. Lithium C. Salicylates D. Carbon Monoxide E. Paracetamol F. Organophosphates G. Methanol H. Tricyclic antidepressants I. Ecstasy J. Desferrioxamine K. Naloxone ```

Correct C. Salicylates

``` An 80 year old man and his 79 year old wife were brought in after a neighbour found them collapsed in their home. On questioning the neighbour it was found that the couple had not been feeling well for a few weeks and had been complaining of nausea, headaches and dizziness A. Acetylcysteine B. Lithium C. Salicylates D. Carbon Monoxide E. Paracetamol F. Organophosphates G. Methanol H. Tricyclic antidepressants I. Ecstasy J. Desferrioxamine K. Naloxone ```

Correct D. Carbon Monoxide

``` A depressed 30 year old woman was brought into A&E after being found by a friend. On examination she appears very drowsy with sinus tachycardia and wide dilated pupils. She has marked reflexes and extensor plantar responses. ECG shows a wide QRS interval A. Acetylcysteine B. Lithium C. Salicylates D. Carbon Monoxide E. Paracetamol F. Organophosphates G. Methanol H. Tricyclic antidepressants I. Ecstasy J. Desferrioxamine K. Naloxone ```

Correct H. Tricyclic antidepressants Both TCA od's and ecstasy od's can cause wide dilated pupils. Ecstasy is more likely to lead to agitation and TCA drowsiness. ps...the other question in the stem , points very clearly to TCA overdose (reflexes and widened QRS complexes). Also....remember that ecstasy may induce vasopressin secretion and an SIADH, with hyponatraemia

``` A 45 year old farm worker is admitted complaining primarily of nausea and vomiting. On further questioning it is revealed that he also has a headache, hypersalivation and he is finding it hard to breathe. On examination the patient appears sweaty and has flaccid paresis of his limb muscles A. Acetylcysteine B. Lithium C. Salicylates D. Carbon Monoxide E. Paracetamol F. Organophosphates G. Methanol H. Tricyclic antidepressants I. Ecstasy J. Desferrioxamine K. Naloxone ```

Correct F. Organophosphates

``` Which of the above techniques can be used to test for all classes of drugs of abuse (DOA)? A. Urine sample B. Barbituates C. Blood sample D. Paracetamol E. Benzodiazepines F. Drugs of abuse (DOA) G. Stool sample H. Liquid chromotography I. Immunoassay J. Liver sample K. Thin layer chromotography ```

Correct I. Immunoassay

``` What sample is required for use with gas chromatography mass spectroscopy? A. Urine sample B. Barbituates C. Blood sample D. Paracetamol E. Benzodiazepines F. Drugs of abuse (DOA) G. Stool sample H. Liquid chromotography I. Immunoassay J. Liver sample K. Thin layer chromotography ```

Correct C. Blood sample

``` Colorimetric can be used to test for which drug commonly taken in overdose? A. Urine sample B. Barbituates C. Blood sample D. Paracetamol E. Benzodiazepines F. Drugs of abuse (DOA) G. Stool sample H. Liquid chromotography I. Immunoassay J. Liver sample K. Thin layer chromotography ```

Correct D. Paracetamol

``` Which of the above techniques can be used to test for benzodiazepines and various antipsychotic drugs? A. Urine sample B. Barbituates C. Blood sample D. Paracetamol E. Benzodiazepines F. Drugs of abuse (DOA) G. Stool sample H. Liquid chromotography I. Immunoassay J. Liver sample K. Thin layer chromotography ```

Correct H. Liquid chromotography

``` Which of the above techniques can be used to analyse samples of stool, liver and also urine? A. Urine sample B. Barbituates C. Blood sample D. Paracetamol E. Benzodiazepines F. Drugs of abuse (DOA) G. Stool sample H. Liquid chromotography I. Immunoassay J. Liver sample K. Thin layer chromotography ```

Correct K. Thin layer chromotography

``` Which option is the best specimen for assessing long-term drug use? A. THC B. Morphine C. MDMA D. Hair E. Toxicology F. Forensics G. Paracetamol H. Cocaine I. Saliva J. Blood K. Urine ```

Correct D. Hair

``` Which drug is found in the most addict related deaths? A. THC B. Morphine C. MDMA D. Hair E. Toxicology F. Forensics G. Paracetamol H. Cocaine I. Saliva J. Blood K. Urine ```

Correct B. Morphine

``` Which option is responsible for the analysis of samples for drugs and poisons? A. THC B. Morphine C. MDMA D. Hair E. Toxicology F. Forensics G. Paracetamol H. Cocaine I. Saliva J. Blood K. Urine ```

Correct E. Toxicology

``` Which option is the best example of a quick, cheap, easy and non-invasive specimen which is likely to be adulterated for forensic drug analysis? Disadvantages include a small window of detection. A. THC B. Morphine C. MDMA D. Hair E. Toxicology F. Forensics G. Paracetamol H. Cocaine I. Saliva J. Blood K. Urine ```

Correct I. Saliva

``` Which drug is not excreted into saliva? A. THC B. Morphine C. MDMA D. Hair E. Toxicology F. Forensics G. Paracetamol H. Cocaine I. Saliva J. Blood K. Urine ```

Correct A. THC

``` The most important cell in the initiation of normal haemostasis. A. Plasmin B. Thromboxane A2 C. Fibrinogen D. a2 macroglobulin E. Erythrocyte F. Megakaryocyte G. Antithrombin III H. Endothelial cell I. Fibrin J. Platelet K. Cycloxygenase L. Protein C M. Tissue plasminogen-activator (t-PA) ```

Correct H. Endothelial cell

``` The main component involved in stabilising the primary haemostatic plug. A. Plasmin B. Thromboxane A2 C. Fibrinogen D. a2 macroglobulin E. Erythrocyte F. Megakaryocyte G. Antithrombin III H. Endothelial cell I. Fibrin J. Platelet K. Cycloxygenase L. Protein C M. Tissue plasminogen-activator (t-PA) ```

Correct I. Fibrin

``` A serine protease which assists in the break down of blood clots by binding to the clot and localising agents which break it down. A. Plasmin B. Thromboxane A2 C. Fibrinogen D. a2 macroglobulin E. Erythrocyte F. Megakaryocyte G. Antithrombin III H. Endothelial cell I. Fibrin J. Platelet K. Cycloxygenase L. Protein C M. Tissue plasminogen-activator (t-PA) ```

Correct M. Tissue plasminogen-activator (t-PA)

``` A potent inhibitor of plasmin in the blood. A. Plasmin B. Thromboxane A2 C. Fibrinogen D. a2 macroglobulin E. Erythrocyte F. Megakaryocyte G. Antithrombin III H. Endothelial cell I. Fibrin J. Platelet K. Cycloxygenase L. Protein C M. Tissue plasminogen-activator (t-PA) ```

Correct D. a2 macroglobulin

``` A single chain glycoprotein, synthesised by the liver and endothelium, which has strongly anticoagulant action and is important in the mode of action of heparin. A. Plasmin B. Thromboxane A2 C. Fibrinogen D. a2 macroglobulin E. Erythrocyte F. Megakaryocyte G. Antithrombin III H. Endothelial cell I. Fibrin J. Platelet K. Cycloxygenase L. Protein C M. Tissue plasminogen-activator (t-PA) ```

Correct G. Antithrombin III

``` This product of the cyclic endoperoxides induces platelet aggregation A. Ehlers-Danlos syndrome B. Christmas disease C. Prostacyclin PGI2 D. Haemophilia E. Megakaryocyte F. von Willebrand deficiency G. Thromboxane A2 H. Sensitised platelet I. Factor VIII deficiency J. Marfan syndrome K. Vitamin K deficiency L. Factor XII deficiency M. Autoimmune thrombocytopenic purpura ```

Correct G. Thromboxane A2

``` A 6 foot 7 inch rower presents to his GP complaining of easy skin bruising. On further examination he is found to have pectus excavatum, lax joints and a high-arched palate. A. Ehlers-Danlos syndrome B. Christmas disease C. Prostacyclin PGI2 D. Haemophilia E. Megakaryocyte F. von Willebrand deficiency G. Thromboxane A2 H. Sensitised platelet I. Factor VIII deficiency J. Marfan syndrome K. Vitamin K deficiency L. Factor XII deficiency M. Autoimmune thrombocytopenic purpura ```

Correct A. Ehlers-Danlos syndrome

``` A 62 year old overweight woman presents to the Emergency Department following a Road Traffic Accident. A full set of investigations is carried out – which shows an increased Activated Partial Thromboplastin Time (APTT) and Prothrombin Time (PT) A. Ehlers-Danlos syndrome B. Christmas disease C. Prostacyclin PGI2 D. Haemophilia E. Megakaryocyte F. von Willebrand deficiency G. Thromboxane A2 H. Sensitised platelet I. Factor VIII deficiency J. Marfan syndrome K. Vitamin K deficiency L. Factor XII deficiency M. Autoimmune thrombocytopenic purpura ```

Correct K. Vitamin K deficiency

``` A 25 year old man presents to the Emergency Department a day after attending his dentist for a routine check-up. After treatment at the dentists the previous day, his gums had not stopped bleeding. On investigation, his APTT and bleeding time are prolonged but a normal PT. A. Ehlers-Danlos syndrome B. Christmas disease C. Prostacyclin PGI2 D. Haemophilia E. Megakaryocyte F. von Willebrand deficiency G. Thromboxane A2 H. Sensitised platelet I. Factor VIII deficiency J. Marfan syndrome K. Vitamin K deficiency L. Factor XII deficiency M. Autoimmune thrombocytopenic purpura ```

Correct F. von Willebrand deficiency

``` A 16 year old girl presents to the Haematology Outpatients clinic describing a fluctuating history of easy bruising, epistaxis and menorrhagia. On investigation there is a thrombocytopaenia with increased megakaryocytes on BM examination. A. Ehlers-Danlos syndrome B. Christmas disease C. Prostacyclin PGI2 D. Haemophilia E. Megakaryocyte F. von Willebrand deficiency G. Thromboxane A2 H. Sensitised platelet I. Factor VIII deficiency J. Marfan syndrome K. Vitamin K deficiency L. Factor XII deficiency M. Autoimmune thrombocytopenic purpura ```

Correct M. Autoimmune thrombocytopenic purpura

``` Which protein, important in haemostasis, is vitamin K dependent but is not a serine protease? A. Tissue factor B. Protein C C. Factor VII D. Cyclooxygenase E. Arichidonic acid F. Tissue factor pathway inhibitor G. Activated factor X H. Protein S I. Vascular endothelium J. Thrombin K. Vascular subendothelium L. Platelets ```

Correct H. Protein S

``` Which option is required as a cofactor for protein C activity? A. Tissue factor B. Protein C C. Factor VII D. Cyclooxygenase E. Arichidonic acid F. Tissue factor pathway inhibitor G. Activated factor X H. Protein S I. Vascular endothelium J. Thrombin K. Vascular subendothelium L. Platelets ```

Correct H. Protein S

``` Which option synthesises tissue factor, vWF, prostacyclin, plasminogen activator, antithrombin III and thrombomodulin? A. Tissue factor B. Protein C C. Factor VII D. Cyclooxygenase E. Arichidonic acid F. Tissue factor pathway inhibitor G. Activated factor X H. Protein S I. Vascular endothelium J. Thrombin K. Vascular subendothelium L. Platelets ```

Correct I. Vascular endothelium

``` Which enzyme, important for platelet aggregation, is irreversibly inhibited by aspirin? A. Tissue factor B. Protein C C. Factor VII D. Cyclooxygenase E. Arichidonic acid F. Tissue factor pathway inhibitor G. Activated factor X H. Protein S I. Vascular endothelium J. Thrombin K. Vascular subendothelium L. Platelets ```

Correct D. Cyclooxygenase

``` Which key clotting factor activates both factors V and VIII, and also activates protein C? A. Tissue factor B. Protein C C. Factor VII D. Cyclooxygenase E. Arichidonic acid F. Tissue factor pathway inhibitor G. Activated factor X H. Protein S I. Vascular endothelium J. Thrombin K. Vascular subendothelium L. Platelets ```

Correct J. Thrombin

``` A 37 year old mother of 4 children, presents to her GP because of recurrent nose bleeds and feeling tired all the time and heavy periods. A. Disseminated intravascular coagulation B. Antiphospholipid antibody syndrome C. Sickle cell anaemia D. Christmas Disease E. Osler-Weber-Rendu Syndrome F. B-Thalassaemia G. Vitamin K Deficiency H. Bile acid malabsorption I. Warfarin overdose J. Von Willebrand’s Disease K. Haemophilia A L. Malignancy M. Henoch – Schönlein Purpura N. Factor V Leiden ```

Correct E. Osler-Weber-Rendu Syndrome A rare autosomal dominant disorder. Alternative name = hereditary haemorrhagic telangiectasia. There is a structural abnormality of the blood vessels, resulting in telangiectases, which are thin walled so are likely to bleed. This leads to haemorrhage and anaemia. It is more common in females, and may not present until later in life. Epistaxis is the commonest presenting symptom. This patient is feeling tired, not just because of her 4 children, but because she also has iron deficiency anaemia.

``` A 3 year old boy is brought to see his GP by his mother. A fortnight ago he had been brought along because of cold-like symptoms, unsurprising since it was the middle of winter and he attends nursery. He was therefore sent home with some Calpol, and as expected his symptoms soon resolved. However this morning his mother noticed a rash on his bottom, and he said his tummy ached. A. Disseminated intravascular coagulation B. Antiphospholipid antibody syndrome C. Sickle cell anaemia D. Christmas Disease E. Osler-Weber-Rendu Syndrome F. B-Thalassaemia G. Vitamin K Deficiency H. Bile acid malabsorption I. Warfarin overdose J. Von Willebrand’s Disease K. Haemophilia A L. Malignancy M. Henoch – Schönlein Purpura N. Factor V Leiden ```

Correct M. Henoch – Schönlein Purpura Affects children between 2-8yrs old. More common in winter. Usually presents following an upper respiratory tract infection. Rapid onset, with a palpable purpuric rash over the buttocks and legs, as well as symmetrical urticarial plaques, and haemorrhagic bullae. Arthritis of the knee and ankle. Abdominal pain – perhaps due to mesenteric vasculitis. Can have renal involvement – with haematuria/proteinuria. (not idiopathic thrombocytopenic purpura – because it’s not an option here)

``` 22 year old Saharawi refugee presents with anaemia, weight loss, loose stools and blood tests reveal an increased PT and slightly increased APTT, with normal thrombin time and platelet count. A. Disseminated intravascular coagulation B. Antiphospholipid antibody syndrome C. Sickle cell anaemia D. Christmas Disease E. Osler-Weber-Rendu Syndrome F. B-Thalassaemia G. Vitamin K Deficiency H. Bile acid malabsorption I. Warfarin overdose J. Von Willebrand’s Disease K. Haemophilia A L. Malignancy M. Henoch – Schönlein Purpura N. Factor V Leiden ```

Correct G. Vitamin K Deficiency Prevalence of coeliac disease is highest in Saharawi refugees. This patient has coeliac disease, and as a result of malabsorption is losing weight and has loose stools (steatorrhoea), and vitamin K deficiency. The blood results related to vitamin K deficiency.

``` A 5 year old boy has the following blood results: normal PT, increased APTT, normal platelet count, decreased VIII:C and decreased vWF. A. Disseminated intravascular coagulation B. Antiphospholipid antibody syndrome C. Sickle cell anaemia D. Christmas Disease E. Osler-Weber-Rendu Syndrome F. B-Thalassaemia G. Vitamin K Deficiency H. Bile acid malabsorption I. Warfarin overdose J. Von Willebrand’s Disease K. Haemophilia A L. Malignancy M. Henoch – Schönlein Purpura N. Factor V Leiden ```

Correct J. Von Willebrand’s Disease The most common hereditary bleeding disorder, affect 1% of the population. vWF is a carrier protein for factor VIII and stabilises it. Mutation is in chromosome 12

``` A 32 week pregnant lady who has gestational diabetes and is epileptic has a caesarean section while on holiday in rural China. Her newborn baby is suffering from bleeding from the umbilical stump, as well as nose and gums. What is wrong with the baby? A. Disseminated intravascular coagulation B. Antiphospholipid antibody syndrome C. Sickle cell anaemia D. Christmas Disease E. Osler-Weber-Rendu Syndrome F. B-Thalassaemia G. Vitamin K Deficiency H. Bile acid malabsorption I. Warfarin overdose J. Von Willebrand’s Disease K. Haemophilia A L. Malignancy M. Henoch – Schönlein Purpura N. Factor V Leiden ```

Correct G. Vitamin K Deficiency Drugs, such as anticonvulsants, which the mother is likely to be taking as she suffers from epilepsy, as well as isoniazid, rifampicin and anticoagulants, are risk factors for haemorrhagic disease of the newborn – which is what this baby has. This is due to vitamin K deficiency – although rare now in the UK as prophylactic vitamin K is given to newborns.

``` A fit 48-year-old investment banker presents to A&E with a painful R arm that was present when he woke up that morning. He is otherwise well and there is no history of trauma or abnormalities of any system. On examination there is marked tenderness and mild erythema along the anterolateral aspect of the forearm and cubital fossa, with no abnormality of the upper arm or axilla. A. Superficial venous thrombosis B. Pulmonary embolism C. Superior vena caval obstruction D. Thrombophlebitis E. Inferior vena caval obstruction F. Deep vein thrombosis G. Axillary vein thrombosis H. DIC I. Varicose veins J. Postphlebitic syndrome ```

Correct A. Superficial venous thrombosis Thrombophlebitis refers to the inflammation of a vein which is thrombosed - you get all the normal signs of inflammation. It can be migratory - migratory thrombophelbitis. Superfical venous thrombosis is what it says on the tin - thrombosis of a superficial vein. This may be associated with thrombophlebitis - ie there is associated inflammation.

``` A 45-year-old lady, known heavy smoker with chronic respiratory problems, presents to her GP with increasing dyspnoea and swelling of her R arm and face. On examination of her chest there is no asymmetry or tracheal deviation, but there are added sounds over the R upper lobe and on bending forward her face becomes congested. A. Superficial venous thrombosis B. Pulmonary embolism C. Superior vena caval obstruction D. Thrombophlebitis E. Inferior vena caval obstruction F. Deep vein thrombosis G. Axillary vein thrombosis H. DIC I. Varicose veins J. Postphlebitic syndrome ```

Correct C. Superior vena caval obstruction

``` A 56-year-old woman returns to the Vascular Clinic with recurrence of her L leg ulcer after the area has been knocked by a shopping trolley. On examination the ulcer is situated above the medial malleolus, its dimensions being 6cm x 5cm. The base is filled with yellowish slough and the surrounding area is erythematous, with prominent oedema. A. Superficial venous thrombosis B. Pulmonary embolism C. Superior vena caval obstruction D. Thrombophlebitis E. Inferior vena caval obstruction F. Deep vein thrombosis G. Axillary vein thrombosis H. DIC I. Varicose veins J. Postphlebitic syndrome ```

Correct J. Postphlebitic syndrome

``` A 48-year-old man develops R-sided pleuritic chest pain and coughs up a trace of bloodstained sputum 8 days after a R hemicolectomy. He has mild dyspnoea but chest examination and chest radiography are normal. A. Superficial venous thrombosis B. Pulmonary embolism C. Superior vena caval obstruction D. Thrombophlebitis E. Inferior vena caval obstruction F. Deep vein thrombosis G. Axillary vein thrombosis H. DIC I. Varicose veins J. Postphlebitic syndrome ```

Correct B. Pulmonary embolism

``` A 32-year-old lady develops acute swelling of her L leg 2 days post-partum. She had bilateral leg swelling during the pregnancy but the delivery was normal. On examination there is tense swelling of the leg and thigh and some deep tenderness over the calf and medial aspect of the thigh. A. Superficial venous thrombosis B. Pulmonary embolism C. Superior vena caval obstruction D. Thrombophlebitis E. Inferior vena caval obstruction F. Deep vein thrombosis G. Axillary vein thrombosis H. DIC I. Varicose veins J. Postphlebitic syndrome ```

Correct F. Deep vein thrombosis

``` A drug that is administered intravenously and has a rapid effect by potentiating the action of antithrombin. Action can be reversed quickly which is of relevance in myocardial infarction patients who may require early invasive treatment (ie PTCA). A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct L. Unfractionated heparin (UFH)

``` Potentiates antithrombin III. Usually given subcutaneously. Can cause osteoporosis and hyperkalaemia. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct D. Dalteparin (LMWH)

``` Used to monitor patients undergoing warfarin therapy. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct K. Prothrombin time (PT)

``` Used to monitor patients undergoing unfractionated heparin therapy. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct J. APTT

``` This anticoagulant drug is directly contraindicated in pregnancy, especially the first 16 and last 4 weeks of a 40 week gestation. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct A. Warfarin

``` Reflects the amount and activity of fibrinogen. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct B. Thrombin time (TT)

``` Antiplatelet action. Indicated for primary prophylaxis of stroke in a patient experiencing recurrent retinal TIAs (amaurosis fugax). Ineffective for DVT prophylaxis. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct N. Aspirin

``` Antiplatelet action. Licensed for secondary prophylaxis of stroke. More effective than aspirin alone. Cheap. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct E. Dipyridamole modified release (MR) and aspirin

``` Antiplatelet action. Licensed for primary prevention of stroke in aspirin allergic patients, secondary prevention of stroke (but expensive) and in acute myocardial infarction in addition to aspirin. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct O. Clopidogrel

``` Dangerous combination with no added efficacy and increased GI bleed. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct H. Clopidogrel and aspirin

``` Old model of starting warfarin A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days

``` New (recommended, Tait) model of starting warfarin A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days

``` In patients with metallic heart valves, this drug is the most effective anticoagulant A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct A. Warfarin

``` In patients with cancer and acute venous thromboembolism, the most effective drug at reducing the risk of recurrent VTE is __? A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct D. Dalteparin (LMWH)

``` This drug when given alone initially increases the clotting risk A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct A. Warfarin

``` Side effects include cutaneous necrosis A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct A. Warfarin

``` The drug most likely to cause thrombocytopaenia with paradoxical thrombosis A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct L. Unfractionated heparin (UFH)

``` Indicated as thrombotic prophylaxis in DIC A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct D. Dalteparin (LMWH)

``` Contra-indicated if recent sore throat, if ever used before, or in the presence of proliferative retinopathy. A. Warfarin B. Thrombin time (TT) C. LMWH and aspirin D. Dalteparin (LMWH) E. Dipyridamole modified release (MR) and aspirin F. Pentapolysaccharide G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days H. Clopidogrel and aspirin I. Calciparone J. APTT K. Prothrombin time (PT) L. Unfractionated heparin (UFH) M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days N. Aspirin O. Clopidogrel P. Streptokinase ```

Correct P. Streptokinase

A 65 year old patient presents with hepatosplenomegaly. He is mildly anaemic and thrombocytompenic. A blood monocyte count of 1.2 x 109/l is observed. Bone marrow aspirate reveals ring sideroblasts at 15% of total blasts. Auer rods are observed. A. Aplastic Anaemia B. Refractory Anaemia with excess of Blasts II C. Refractory Anaemia with excess of Blasts I D. Acute Myeloid Leukaemia E. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome) F. Refractory Cytopaenia with Multilineage Dysplasia G. Refractory anaemia H. Myelodysplastic syndrome,unclassifiable I. Chronic Myelomonocytic Anaemia J. Refractory Anaemia with Ring Sideroblasts K. Secondary Sideroblastic Anaemia

Correct I. Chronic Myelomonocytic Anaemia | We agree that the case for CMML is nonspecific. The main positive feature is the monocyte count.

An alcoholic presents to your clinic with anaemia. Sideroblasts are observed on morphological examination. A. Aplastic Anaemia B. Refractory Anaemia with excess of Blasts II C. Refractory Anaemia with excess of Blasts I D. Acute Myeloid Leukaemia E. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome) F. Refractory Cytopaenia with Multilineage Dysplasia G. Refractory anaemia H. Myelodysplastic syndrome,unclassifiable I. Chronic Myelomonocytic Anaemia J. Refractory Anaemia with Ring Sideroblasts K. Secondary Sideroblastic Anaemia

Correct K. Secondary Sideroblastic Anaemia

A 58 year old lady complains of lethargy and “easy bruising”. She presents with purpura. Her FBC reveals Hb 10.5g/dl; WBCs 2.3x109/l and platelets 8x109/l. Blood film reveals

Correct F. Refractory Cytopaenia with Multilineage Dysplasia To count as significant, dysplasia must involve at least 10% of cells in a lineage. To count as RCMD, at least 2 MYELOID lineages must be dysplastic, and there must be bi or pancytopenia in the peripheral blood. (This can include anaemia!)

A 78 year old male patient with recurring infections of the face and maxillary sinuses associated with neutropenia. His bloods are: Hb 9.8 g/dl; WBC 1.3x109/l; Neutrophils 0.3x109/l; platelets 38x109/l.The lab informs you that there are Blasts approximately compromise 17% of bone marrow aspirate. A. Aplastic Anaemia B. Refractory Anaemia with excess of Blasts II C. Refractory Anaemia with excess of Blasts I D. Acute Myeloid Leukaemia E. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome) F. Refractory Cytopaenia with Multilineage Dysplasia G. Refractory anaemia H. Myelodysplastic syndrome,unclassifiable I. Chronic Myelomonocytic Anaemia J. Refractory Anaemia with Ring Sideroblasts K. Secondary Sideroblastic Anaemia

Correct B. Refractory Anaemia with excess of Blasts II

You are called to A&E to see a 65 year old man. He is complaining of fever, shortness of breath, and has lost 5Kg in the last few months. His notes say he was previously diagnosed with “Refractory Anaemia with excess Blasts in Transformation” (RAEB-t). His blast cell count is approximately 30% of all nucleated cells. A. Aplastic Anaemia B. Refractory Anaemia with excess of Blasts II C. Refractory Anaemia with excess of Blasts I D. Acute Myeloid Leukaemia E. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome) F. Refractory Cytopaenia with Multilineage Dysplasia G. Refractory anaemia H. Myelodysplastic syndrome,unclassifiable I. Chronic Myelomonocytic Anaemia J. Refractory Anaemia with Ring Sideroblasts K. Secondary Sideroblastic Anaemia

Correct D. Acute Myeloid Leukaemia

A 34 year old man with peripheral cytopenia suffers from bleeding gums. Peripheral blood shows 5% blast cells and bone marrow 42% blast cells. A. Juvenile myelomonocytic leukaemia B. Refractory cytopenia with multilineage dysplasia C. Refractory anaemia D. Inherited aplastic anaemia E. Secondary aplastic anaemia F. 5q syndrome G. Idiopathic aplastic anaemia H. Acute myeloid leukaemia I. Refractory anaemia with an excess of blasts J. Myelofibrosis

Correct H. Acute myeloid leukaemia

A 74 year old woman with high-normal platelet count. Bone marrow aspirate shows hyperplasia of hypolobulated micromegakaryocytes. Responds well to lenalidomide. A. Juvenile myelomonocytic leukaemia B. Refractory cytopenia with multilineage dysplasia C. Refractory anaemia D. Inherited aplastic anaemia E. Secondary aplastic anaemia F. 5q syndrome G. Idiopathic aplastic anaemia H. Acute myeloid leukaemia I. Refractory anaemia with an excess of blasts J. Myelofibrosis

Correct F. 5q syndrome

A 20 year old man with hepatitis C complains of fatigue and breathlessness and bruises very easily. A. Juvenile myelomonocytic leukaemia B. Refractory cytopenia with multilineage dysplasia C. Refractory anaemia D. Inherited aplastic anaemia E. Secondary aplastic anaemia F. 5q syndrome G. Idiopathic aplastic anaemia H. Acute myeloid leukaemia I. Refractory anaemia with an excess of blasts J. Myelofibrosis

Correct E. Secondary aplastic anaemia

This patients blood film shows classic Pelger-Huet neutrophils and bone marrow blasts make up 15% of cells. A. Juvenile myelomonocytic leukaemia B. Refractory cytopenia with multilineage dysplasia C. Refractory anaemia D. Inherited aplastic anaemia E. Secondary aplastic anaemia F. 5q syndrome G. Idiopathic aplastic anaemia H. Acute myeloid leukaemia I. Refractory anaemia with an excess of blasts J. Myelofibrosis

Correct I. Refractory anaemia with an excess of blasts

In this case haemoglobin is normal but there is a reduction in platelets and neutrophils A. Juvenile myelomonocytic leukaemia B. Refractory cytopenia with multilineage dysplasia C. Refractory anaemia D. Inherited aplastic anaemia E. Secondary aplastic anaemia F. 5q syndrome G. Idiopathic aplastic anaemia H. Acute myeloid leukaemia I. Refractory anaemia with an excess of blasts J. Myelofibrosis

Correct B. Refractory cytopenia with multilineage dysplasia

``` A 64 year old man complains of headaches, fatigue and itchy skin, particularly evident after a hot bath. He has a long-standing history of alcohol abuse and drug history reveals that he taking thiazide diuretics. On examination, you note that he is thin with sunken eyes. A. Chronic myeloid leukaemia B. Acute myeloid leukaemia C. Venesection D. Splenomegaly E. Pseudopolycythaemia F. Chlorambucil G. Tear drop poikilocytes H. Imitanib I. Haematocrit J. Melphalan K. Idiopathic myelofibrosis L. Erythropoeitin M. Hydroxycarbamide N. Essential thrombocythaemia O. Microcytosis P. Polycythaemia vera ```

Correct E. Pseudopolycythaemia

``` A 55 year old female has a past medical history of deep vein thrombosis. She also complains of easy bruising. Her platelet count is 770 x109/L, CRP is 4mg/L. You prescribe aspirin. A. Chronic myeloid leukaemia B. Acute myeloid leukaemia C. Venesection D. Splenomegaly E. Pseudopolycythaemia F. Chlorambucil G. Tear drop poikilocytes H. Imitanib I. Haematocrit J. Melphalan K. Idiopathic myelofibrosis L. Erythropoeitin M. Hydroxycarbamide N. Essential thrombocythaemia O. Microcytosis P. Polycythaemia vera ```

Correct N. Essential thrombocythaemia

``` A 53 year old man goes to see his doctor about an embarrassing problem. It seems that his friends have nicknamed him ‘Rudolph’. You seem quite confused, but all becomes apparent when he points to his nose, which appears red. After further questioning, he describes a ‘burning’ sensation on his nose, hands and feet and visual disturbances. You send him for ‘blood tests’. What do you expect to be raised? A. Chronic myeloid leukaemia B. Acute myeloid leukaemia C. Venesection D. Splenomegaly E. Pseudopolycythaemia F. Chlorambucil G. Tear drop poikilocytes H. Imitanib I. Haematocrit J. Melphalan K. Idiopathic myelofibrosis L. Erythropoeitin M. Hydroxycarbamide N. Essential thrombocythaemia O. Microcytosis P. Polycythaemia vera ```

Correct I. Haematocrit | Burning sensation of the hands and feet is denoted by the term 'erythromelalgia'.

``` A consultant grills you on a ward round: there is a patient with a WBC of 140 x109/L, Hb 12 g/dL, Platelet count 320 x109/L. She complains of tiredness, night sweats, fever and abdominal pain. Her spleen is markedly enlarged. Blood film shows blasts, neutrophils, basophils. How would you treat her? A. Chronic myeloid leukaemia B. Acute myeloid leukaemia C. Venesection D. Splenomegaly E. Pseudopolycythaemia F. Chlorambucil G. Tear drop poikilocytes H. Imitanib I. Haematocrit J. Melphalan K. Idiopathic myelofibrosis L. Erythropoeitin M. Hydroxycarbamide N. Essential thrombocythaemia O. Microcytosis P. Polycythaemia vera ```

Correct H. Imitanib

``` You are asked to see a 76 year old man on the wards, who presented with fatigue, dyspnoea, bleeding gums and nightsweats. His abdomen is massively enlarged. You read his notes and find ‘bone marrow aspirate: ‘dry tap’. What would you expect to see on the blood film? A. Chronic myeloid leukaemia B. Acute myeloid leukaemia C. Venesection D. Splenomegaly E. Pseudopolycythaemia F. Chlorambucil G. Tear drop poikilocytes H. Imitanib I. Haematocrit J. Melphalan K. Idiopathic myelofibrosis L. Erythropoeitin M. Hydroxycarbamide N. Essential thrombocythaemia O. Microcytosis P. Polycythaemia vera ```

Correct G. Tear drop poikilocytes

``` A 64-year old woman receiving long-term chemotherapy for lymphoma presents with worsening bone pain, recurrent fever and night sweats. Blood film shows blast cells with Auer rods. A. Chronic lymphocytic leukaemia B. Richter's syndrome C. Hypothyroidism D. Chronic myeloid leukaemia E. Tumour-lysis syndrome F. Hairy cell leukaemia G. Vincristine poisoning H. Bronchial carcinoma I. Acute myeloid leukaemia J. DIC K. Septicaemia L. Lung fibrosis M. Acute promyelocytic leukaemia N. Acute lymphoblastic leukaemia ```

Correct I. Acute myeloid leukaemia

``` A 61-year-old man with CLL presents with recurrent pneumonia and haemoptysis. On fibreoptic bronchoscopy, the patient is found to have an endobronchial mass. The biopsy shows anaplastic, large cell lymphoma. A. Chronic lymphocytic leukaemia B. Richter's syndrome C. Hypothyroidism D. Chronic myeloid leukaemia E. Tumour-lysis syndrome F. Hairy cell leukaemia G. Vincristine poisoning H. Bronchial carcinoma I. Acute myeloid leukaemia J. DIC K. Septicaemia L. Lung fibrosis M. Acute promyelocytic leukaemia N. Acute lymphoblastic leukaemia ```

Correct B. Richter's syndrome

``` A newly diagnosed ALL patient complains of tiredness, polyuria, polydipsia, abdominal pain and vomiting on receiving chemotherapy. On examination, BP: 160/100mmHg, temp: 39ºC, and ECG shows tented T waves. Blood test shows serum K+: 6.9mmol/L and phosphate: 7.1 mmol/L. The patient later dies of cardiac arrest. A. Chronic lymphocytic leukaemia B. Richter's syndrome C. Hypothyroidism D. Chronic myeloid leukaemia E. Tumour-lysis syndrome F. Hairy cell leukaemia G. Vincristine poisoning H. Bronchial carcinoma I. Acute myeloid leukaemia J. DIC K. Septicaemia L. Lung fibrosis M. Acute promyelocytic leukaemia N. Acute lymphoblastic leukaemia ```

Correct E. Tumour-lysis syndrome

``` A routine medical of 33-year-old footballer reveals: Hb = 9.9g/dl and WCC = 130 x 109/L. His blood film shows whole spectrum of myeloid precursors, including a few blast cells. He admits to having frequent night sweats and blurred vision. There is a presence of Ph chromosome t(9;22) on cytogenetic analysis. A. Chronic lymphocytic leukaemia B. Richter's syndrome C. Hypothyroidism D. Chronic myeloid leukaemia E. Tumour-lysis syndrome F. Hairy cell leukaemia G. Vincristine poisoning H. Bronchial carcinoma I. Acute myeloid leukaemia J. DIC K. Septicaemia L. Lung fibrosis M. Acute promyelocytic leukaemia N. Acute lymphoblastic leukaemia ```

Correct D. Chronic myeloid leukaemia

``` A 5-year-old girl presents with failure to thrive, recurrent fever and bruising. Immunotyping reveals the presence of CD10. A. Chronic lymphocytic leukaemia B. Richter's syndrome C. Hypothyroidism D. Chronic myeloid leukaemia E. Tumour-lysis syndrome F. Hairy cell leukaemia G. Vincristine poisoning H. Bronchial carcinoma I. Acute myeloid leukaemia J. DIC K. Septicaemia L. Lung fibrosis M. Acute promyelocytic leukaemia N. Acute lymphoblastic leukaemia ```

Correct N. Acute lymphoblastic leukaemia

``` A 6-year-old boy presents with bone pain. On examination you notice he looks pale and has many bruises. What is his diagnosis? A. Magnesium exposure B. Acute myeloid leukaemia C. Marfan’s syndrome D. Neutrophils E. Thalassaemia F. Chronic lymphocytic leukaemia G. Blast cells H. Ionising radiation I. Sickle cell disease J. Lymphocytes K. Chronic myeloid leukaemia L. Down’s syndrome M. Acute lymphocytic leukaemia ```

Correct M. Acute lymphocytic leukaemia

``` A patient has acute lymphoblastic leukaemia. A bone marrow biopsy will show infiltration by which cells? A. Magnesium exposure B. Acute myeloid leukaemia C. Marfan’s syndrome D. Neutrophils E. Thalassaemia F. Chronic lymphocytic leukaemia G. Blast cells H. Ionising radiation I. Sickle cell disease J. Lymphocytes K. Chronic myeloid leukaemia L. Down’s syndrome M. Acute lymphocytic leukaemia ```

Correct G. Blast cells

``` Patients with this inherited disorder have an increased risk of developing acute leukaemia. A. Magnesium exposure B. Acute myeloid leukaemia C. Marfan’s syndrome D. Neutrophils E. Thalassaemia F. Chronic lymphocytic leukaemia G. Blast cells H. Ionising radiation I. Sickle cell disease J. Lymphocytes K. Chronic myeloid leukaemia L. Down’s syndrome M. Acute lymphocytic leukaemia ```

Correct L. Down’s syndrome

``` An environmental factor associated with acute leukaemia. A. Magnesium exposure B. Acute myeloid leukaemia C. Marfan’s syndrome D. Neutrophils E. Thalassaemia F. Chronic lymphocytic leukaemia G. Blast cells H. Ionising radiation I. Sickle cell disease J. Lymphocytes K. Chronic myeloid leukaemia L. Down’s syndrome M. Acute lymphocytic leukaemia ```

Correct H. Ionising radiation

``` The commonest adult leukaemia. A. Magnesium exposure B. Acute myeloid leukaemia C. Marfan’s syndrome D. Neutrophils E. Thalassaemia F. Chronic lymphocytic leukaemia G. Blast cells H. Ionising radiation I. Sickle cell disease J. Lymphocytes K. Chronic myeloid leukaemia L. Down’s syndrome M. Acute lymphocytic leukaemia ```

Correct F. Chronic lymphocytic leukaemia

``` A 50yr old man presents to his GP complaining of weight loss, tiredness, easy bruising and a painful big toe. On examination his spleen is massively enlarged. Investigation shows a raised serum urate. The peripheral blood film is abnormal, showing proliferation of which type of cell? A. Blast cells B. Auer rods C. Spherocytes D. Neutrophils E. Clonal B lymphocytes F. Chromosome 11q23 deletion G. Chromosome 9;22 translocation H. Pelger-Huet cells I. Reticulocytes J. Platelets K. Eosinophils ```

Correct D. Neutrophils CML. Increased mass of turning-over cells generates urate. Q2. CML, blast phase. Transformation tends to be into AML but in 20% is lymphoblastic (ALL). Q3. CLL. Only two chronic B cell leukaemia/lymphomas are CD5+: CLL (CD5+ CD23+) and Mantle Cell Lymphoma (CD5+ CD23-). CLL may be assoc. with Coombs positive AIHA and ITP. The combination is called Evans syndrome. Q4. CML del(11q23): poor prognostic sign in CLL. Tip: Neutrophil alkaline phosphatase is LOW in CML and raised in myeloproliferative disorders and infections. Pelger Huet cells: bilobed neutrophils. Autosomal dominant or AML or MDS (myelodysplastic syndrome)

``` A 65yr old lady is seen in the haematology clinic where she has been treated for 7 years with Imantinib for chronic myeloid leukaemia. Having been previously well, she is now complaining of shortness of breath and general weakness. Examination reveals splenomegally. Her peripheral blood film has changed from previous appointments and reflects the progression of her disease. Which type of cell is now proliferating? A. Blast cells B. Auer rods C. Spherocytes D. Neutrophils E. Clonal B lymphocytes F. Chromosome 11q23 deletion G. Chromosome 9;22 translocation H. Pelger-Huet cells I. Reticulocytes J. Platelets K. Eosinophils ```

Correct A. Blast cells

``` A 70yr old man complains of a year’s history of fatigue, weight loss and recurrent sinusitis. His white cell count is raised with a lymphocytosis of 283x109 /L. Blood film shows features of haemolysis and Coomb’s test is positive. Further investigation show the bone marrow, blood and lymph nodes are infiltrated with which cell population? A. Blast cells B. Auer rods C. Spherocytes D. Neutrophils E. Clonal B lymphocytes F. Chromosome 11q23 deletion G. Chromosome 9;22 translocation H. Pelger-Huet cells I. Reticulocytes J. Platelets K. Eosinophils ```

Correct E. Clonal B lymphocytes

``` A routine full blood count on a 62yr old gardener reveals a high white cell count of 154x109 /L, and the differential shows this to be a neutrophilia. The haemoglobin and platelet count are normal. Biopsy shows a hypercellular “packed” bone marrow, and cells show the presence of which chromosomal abnormality? A. Blast cells B. Auer rods C. Spherocytes D. Neutrophils E. Clonal B lymphocytes F. Chromosome 11q23 deletion G. Chromosome 9;22 translocation H. Pelger-Huet cells I. Reticulocytes J. Platelets K. Eosinophils ```

Correct G. Chromosome 9;22 translocation

``` A 70 year old lady presents to her GP complaining of tight chest pain, which radiated to her left arm and was relieved by rest. Her ECG revealed some st depression A. Decubitus Angina B. Acute Myocardial Infarction C. Ventricular Tachycardia D. Restrictive cardiomyopathy E. Acute Coronary Syndrome F. Aortic Dissection G. Stable Angina H. Pulmonary embolus I. Transient Ischaemic Attack J. Dressler’s Syndrome K. Coarctation of the Aorta L. Mitral Stenosis M. Aortic Stenosis N. Cerebrovascular Accident O. Pericarditis ```

Correct G. Stable Angina Decubitus angina occurs when the patient lies down. It is usually a complication of cardiac failure due to the strain on the heart resulting from increased intravascular volume.

``` A 50 year old male smoker, with a history of hypertension presents to the A and E department with continuous, central, crushing chest pain radiating to the left arm. The ECG showed st elevation. A. Decubitus Angina B. Acute Myocardial Infarction C. Ventricular Tachycardia D. Restrictive cardiomyopathy E. Acute Coronary Syndrome F. Aortic Dissection G. Stable Angina H. Pulmonary embolus I. Transient Ischaemic Attack J. Dressler’s Syndrome K. Coarctation of the Aorta L. Mitral Stenosis M. Aortic Stenosis N. Cerebrovascular Accident O. Pericarditis ```

Correct B. Acute Myocardial Infarction

``` A 63 year old obese, diabetic male presents to A and E with tight chest pain at rest, which radiated to the left arm and lasted for less than 20 minutes. The CK was not raised. A. Decubitus Angina B. Acute Myocardial Infarction C. Ventricular Tachycardia D. Restrictive cardiomyopathy E. Acute Coronary Syndrome F. Aortic Dissection G. Stable Angina H. Pulmonary embolus I. Transient Ischaemic Attack J. Dressler’s Syndrome K. Coarctation of the Aorta L. Mitral Stenosis M. Aortic Stenosis N. Cerebrovascular Accident O. Pericarditis ```

Correct E. Acute Coronary Syndrome Acute coronary syndrome (unstable angina) is defined as recurrent episodes of angina on minimal effort or at rest and persists for longer than stable angina.

``` A 68 year old man presents with sudden onset chest pain, which radiated to the back. On examination the patient was shocked, with a hemiplegia and the chest X-ray showed mediastinal enlargement. A. Decubitus Angina B. Acute Myocardial Infarction C. Ventricular Tachycardia D. Restrictive cardiomyopathy E. Acute Coronary Syndrome F. Aortic Dissection G. Stable Angina H. Pulmonary embolus I. Transient Ischaemic Attack J. Dressler’s Syndrome K. Coarctation of the Aorta L. Mitral Stenosis M. Aortic Stenosis N. Cerebrovascular Accident O. Pericarditis ```

Correct F. Aortic Dissection

``` A 73 year old man with a known history of peripheral vascular disease presents to the A and E department with a sudden onset hemiplegia which resolved within 24 hours. A. Decubitus Angina B. Acute Myocardial Infarction C. Ventricular Tachycardia D. Restrictive cardiomyopathy E. Acute Coronary Syndrome F. Aortic Dissection G. Stable Angina H. Pulmonary embolus I. Transient Ischaemic Attack J. Dressler’s Syndrome K. Coarctation of the Aorta L. Mitral Stenosis M. Aortic Stenosis N. Cerebrovascular Accident O. Pericarditis ```

Correct I. Transient Ischaemic Attack

``` A 65 year old man is in hospital after suffering an acute myocardial infarction. The house officer hears a pansystolic murmur on auscultation. A. Pericardial effusion B. Pericarditis C. Aortic regurgitation D. Aortic stenosis E. Mitral regurgitation F. Congenital septal defect G. Myomalacia cordis H. Rheumatic fever I. Myxomatous mitral valve J. Dilated cardiomyopathy K. Hypertrophic cardiomyopathy L. Infective endocarditis ```

Correct G. Myomalacia cordis

``` A 28 year old sportsman presents to A&E with severe chest pain and breathlessness. He has a history of asthma. There is a systolic murmur on examination. A. Pericardial effusion B. Pericarditis C. Aortic regurgitation D. Aortic stenosis E. Mitral regurgitation F. Congenital septal defect G. Myomalacia cordis H. Rheumatic fever I. Myxomatous mitral valve J. Dilated cardiomyopathy K. Hypertrophic cardiomyopathy L. Infective endocarditis ```

Correct K. Hypertrophic cardiomyopathy

``` 39 year old lady suffers a sharp retrosternal chest pain which is worse on inspiration. The finding on auscultation is typical of this presentation. A. Pericardial effusion B. Pericarditis C. Aortic regurgitation D. Aortic stenosis E. Mitral regurgitation F. Congenital septal defect G. Myomalacia cordis H. Rheumatic fever I. Myxomatous mitral valve J. Dilated cardiomyopathy K. Hypertrophic cardiomyopathy L. Infective endocarditis ```

Correct B. Pericarditis

``` middle aged women is in hospital after fainting at the gym. She has a severe headache and feels generally unwell. There is a systolic ejection murmur on examination A. Pericardial effusion B. Pericarditis C. Aortic regurgitation D. Aortic stenosis E. Mitral regurgitation F. Congenital septal defect G. Myomalacia cordis H. Rheumatic fever I. Myxomatous mitral valve J. Dilated cardiomyopathy K. Hypertrophic cardiomyopathy L. Infective endocarditis ```

Correct D. Aortic stenosis

``` A 46 year old women presents to A&E out of breath and with severe chest pain. On examination a mid systolic click late systolic murmur is revealed. A. Pericardial effusion B. Pericarditis C. Aortic regurgitation D. Aortic stenosis E. Mitral regurgitation F. Congenital septal defect G. Myomalacia cordis H. Rheumatic fever I. Myxomatous mitral valve J. Dilated cardiomyopathy K. Hypertrophic cardiomyopathy L. Infective endocarditis ```

Correct I. Myxomatous mitral valve

``` A 10 year old boy presents with skin rash and joint pain in his elbows and knees. His mother tells you that he recently had a sore throat. On examination he is found to have an ejection systolic murmur and a friction rub. A. Cardiac Failure B. Acute rheumatic fever C. Aortic stenosis – acquired D. Chronic rheumatic valvular disease E. Pericarditis F. Aortic stenosis - Degenerative G. Non infective endocarditis H. Cardiomyopathy (Obliterative) I. Subacute bacterial endocarditis J. Cardiomyopathy (Restrictive K. Cardiomyopathy (Hypertrophic) L. Acute bacterial endocarditis M. Cardiomyopathy (Dilated) ```

Correct B. Acute rheumatic fever

``` A 69 year old woman is suffering from sudden onset fever and malaise. There is no previous history of heart disease. Auscultation reveals a heart murmur. She later develops sepsis. A. Cardiac Failure B. Acute rheumatic fever C. Aortic stenosis – acquired D. Chronic rheumatic valvular disease E. Pericarditis F. Aortic stenosis - Degenerative G. Non infective endocarditis H. Cardiomyopathy (Obliterative) I. Subacute bacterial endocarditis J. Cardiomyopathy (Restrictive K. Cardiomyopathy (Hypertrophic) L. Acute bacterial endocarditis M. Cardiomyopathy (Dilated) ```

Correct L. Acute bacterial endocarditis

``` A 40 year old man presents with a sharp chest pain. He has a pericardial friction rub, diminished heart sounds and a raised JVP. A. Cardiac Failure B. Acute rheumatic fever C. Aortic stenosis – acquired D. Chronic rheumatic valvular disease E. Pericarditis F. Aortic stenosis - Degenerative G. Non infective endocarditis H. Cardiomyopathy (Obliterative) I. Subacute bacterial endocarditis J. Cardiomyopathy (Restrictive K. Cardiomyopathy (Hypertrophic) L. Acute bacterial endocarditis M. Cardiomyopathy (Dilated) ```

Correct E. Pericarditis

``` A 25 year old man presents with palpitations. Chest X-ray shows an enlarged heart and echocardiogram shows thickening of the septum. A. Cardiac Failure B. Acute rheumatic fever C. Aortic stenosis – acquired D. Chronic rheumatic valvular disease E. Pericarditis F. Aortic stenosis - Degenerative G. Non infective endocarditis H. Cardiomyopathy (Obliterative) I. Subacute bacterial endocarditis J. Cardiomyopathy (Restrictive K. Cardiomyopathy (Hypertrophic) L. Acute bacterial endocarditis M. Cardiomyopathy (Dilated) ```

Correct K. Cardiomyopathy (Hypertrophic)

``` A 75 year old diabetic female with a history of 4 myocardial infarctions presents with shortness of breath and ankle swelling. She was found to have an enlarged liver and echocardiogram demonstrated a dilated heart. A. Cardiac Failure B. Acute rheumatic fever C. Aortic stenosis – acquired D. Chronic rheumatic valvular disease E. Pericarditis F. Aortic stenosis - Degenerative G. Non infective endocarditis H. Cardiomyopathy (Obliterative) I. Subacute bacterial endocarditis J. Cardiomyopathy (Restrictive K. Cardiomyopathy (Hypertrophic) L. Acute bacterial endocarditis M. Cardiomyopathy (Dilated) ```

Correct A. Cardiac Failure

``` A 19 year old American student with bronchiectasis is on inhaled tobramycin for chronic Pseudomonal infection. The mutation delta F508 is identified. A. Gallstones B. Gallstone pancreatitis C. Cystic fibrosis D. Hypercalcaemia E. Pseudocysts F. Vibrio cholerae infection G. Insulinoma H. Renal tubular acidosis I. Haemochromatosis J. Carcinoma tail of the pancreas K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Carcinoma head of the pancreas N. Iatrogenic pancreatitis ```

Correct C. Cystic fibrosis

``` A 68 year old smoker presents with jaundice and worsening abdominal and back pain. Scratch marks are seen on his arms and legs. He has lost 5kg in 2 months. Ultrasound shows dilated intrahepatic bile ducts. A. Gallstones B. Gallstone pancreatitis C. Cystic fibrosis D. Hypercalcaemia E. Pseudocysts F. Vibrio cholerae infection G. Insulinoma H. Renal tubular acidosis I. Haemochromatosis J. Carcinoma tail of the pancreas K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Carcinoma head of the pancreas N. Iatrogenic pancreatitis ```

Correct M. Carcinoma head of the pancreas

``` A 39 year old Nepalese man presents with severe watery diarrhoea. He is found to have hypokalaemia and, surprisingly, a metabolic acidosis. A RUQ mass is detected by contrast-enhanced spiral CT scanning. Stool bicarb is high and urine anion gap is negative. A. Gallstones B. Gallstone pancreatitis C. Cystic fibrosis D. Hypercalcaemia E. Pseudocysts F. Vibrio cholerae infection G. Insulinoma H. Renal tubular acidosis I. Haemochromatosis J. Carcinoma tail of the pancreas K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Carcinoma head of the pancreas N. Iatrogenic pancreatitis ```

Correct K. VIPoma (Werner Morrison syndrome)

``` A 59 year old widow complains of persistent back pain, loss of appetite and that she has dropped from dress size 18 to a size 14 in just 2 months. She was recently diagnosed with diabetes. A large central mass is palpable as well hepatosplenomegaly. A. Gallstones B. Gallstone pancreatitis C. Cystic fibrosis D. Hypercalcaemia E. Pseudocysts F. Vibrio cholerae infection G. Insulinoma H. Renal tubular acidosis I. Haemochromatosis J. Carcinoma tail of the pancreas K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Carcinoma head of the pancreas N. Iatrogenic pancreatitis ```

Correct J. Carcinoma tail of the pancreas | Carcinoma of the head of the pancreas causes obstructive jaundice, whereas that of the tail does not.

``` A 47 year old lecturer is referred to hospital clinic from his GP with worsening abdominal pain. He has a poor diet and weight loss. He has previously been prescribed Thiamine. A. Gallstones B. Gallstone pancreatitis C. Cystic fibrosis D. Hypercalcaemia E. Pseudocysts F. Vibrio cholerae infection G. Insulinoma H. Renal tubular acidosis I. Haemochromatosis J. Carcinoma tail of the pancreas K. VIPoma (Werner Morrison syndrome) L. Chronic alcoholic pancreatitis M. Carcinoma head of the pancreas N. Iatrogenic pancreatitis ```

Correct L. Chronic alcoholic pancreatitis

``` 65 year old female with a large, cystic mass on tail of pancreas imaged using computed tomography. Further cytology reported the presence of epithelium A. Scorpion Sting B. Pseudocyst C. Trousseau’s Syndrome D. Pancreas Divisum E. Jaundice F. Whipples' resection G. Cystic Fibrosis H. Thrombophlebitis I. Pancreatitis J. Hyperlipidaemia K. Alcoholism L. Gall Bladder M. Cystadenoma N. Agenesis O. Type 1 Diabetes P. Carcinoma of the Pancreas ```

Correct M. Cystadenoma Pancreatic pseudocyst is a fluid filled collection contained within a well-defined capsule of fibrous or granulation tissue or a combination of both. It does not possess an epithelial lining. A cystadenoma has an epithelial wall or capsule that contains a fluid collection.

``` 55 year old, diabetic, afro-Caribbean male presents with weight loss, poor diet and a gnawing pain in his back, which is sometimes felt ‘under his chest’ A. Scorpion Sting B. Pseudocyst C. Trousseau’s Syndrome D. Pancreas Divisum E. Jaundice F. Whipples' resection G. Cystic Fibrosis H. Thrombophlebitis I. Pancreatitis J. Hyperlipidaemia K. Alcoholism L. Gall Bladder M. Cystadenoma N. Agenesis O. Type 1 Diabetes P. Carcinoma of the Pancreas ```

Correct P. Carcinoma of the Pancreas

``` The commonest cause of acute pancreatitis in the UK. A. Scorpion Sting B. Pseudocyst C. Trousseau’s Syndrome D. Pancreas Divisum E. Jaundice F. Whipples' resection G. Cystic Fibrosis H. Thrombophlebitis I. Pancreatitis J. Hyperlipidaemia K. Alcoholism L. Gall Bladder M. Cystadenoma N. Agenesis O. Type 1 Diabetes P. Carcinoma of the Pancreas ```

Correct K. Alcoholism

``` Inflammatory condition of the exocrine pancreas that results in injury to acinar cells. A. Scorpion Sting B. Pseudocyst C. Trousseau’s Syndrome D. Pancreas Divisum E. Jaundice F. Whipples' resection G. Cystic Fibrosis H. Thrombophlebitis I. Pancreatitis J. Hyperlipidaemia K. Alcoholism L. Gall Bladder M. Cystadenoma N. Agenesis O. Type 1 Diabetes P. Carcinoma of the Pancreas ```

Correct I. Pancreatitis

``` ERCP finding due to incomplete fusing of pancreatic buds. A. Scorpion Sting B. Pseudocyst C. Trousseau’s Syndrome D. Pancreas Divisum E. Jaundice F. Whipples' resection G. Cystic Fibrosis H. Thrombophlebitis I. Pancreatitis J. Hyperlipidaemia K. Alcoholism L. Gall Bladder M. Cystadenoma N. Agenesis O. Type 1 Diabetes P. Carcinoma of the Pancreas ```

Correct D. Pancreas Divisum

``` A condition in which the normal squamous epithelial lining of the oesophagus is replaced by columnar epithelium because of damage caused by gastro –oesophageal reflux or oesophagitis. The condition may be associated with an ulcer, and the epithelium has an abnormally high likelihood of undergoing malignant change. A. Gastric cancer B. Gastric ulcer C. Intestinal metaplasia D. Campylobacter jejuni E. Adenocarcinoma F. Barrett’s oesophagus G. Squamous carcinoma H. Helicobacter pylori I. Oesophageal varices J. Pernicious anaemia K. Duodenal ulceration L. Reflux oesophagitis ```

Correct F. Barrett’s oesophagus

``` Caused by the action of acid and pepsin on the duodenal mucosa. Associated with increased output of stomach acid. Symptoms include pain in the upper abdomen, especially when the stomach is empty. A. Gastric cancer B. Gastric ulcer C. Intestinal metaplasia D. Campylobacter jejuni E. Adenocarcinoma F. Barrett’s oesophagus G. Squamous carcinoma H. Helicobacter pylori I. Oesophageal varices J. Pernicious anaemia K. Duodenal ulceration L. Reflux oesophagitis ```

Correct K. Duodenal ulceration

``` The result of failure to produce intrinsic factor, and the subsequent reduction in the absorption of B12 from the bowel. Characterised by the defective production of red blood cells and the presence of megaloblasts in the bone marrow. A. Gastric cancer B. Gastric ulcer C. Intestinal metaplasia D. Campylobacter jejuni E. Adenocarcinoma F. Barrett’s oesophagus G. Squamous carcinoma H. Helicobacter pylori I. Oesophageal varices J. Pernicious anaemia K. Duodenal ulceration L. Reflux oesophagitis ```

Correct J. Pernicious anaemia

``` Dilated veins in the lower oesophagus due to portal hypertension. These may rupture, leading to life threatening haematemesis. Bleeding may be stopped by a compression balloon, sclerotherapy, or applying elastic bands via an endoscope. A. Gastric cancer B. Gastric ulcer C. Intestinal metaplasia D. Campylobacter jejuni E. Adenocarcinoma F. Barrett’s oesophagus G. Squamous carcinoma H. Helicobacter pylori I. Oesophageal varices J. Pernicious anaemia K. Duodenal ulceration L. Reflux oesophagitis ```

Correct I. Oesophageal varices

``` A genus of spiral flagellated Gram negative bacteria. Found in the stomach within the mucosa layer. It occurs in the majority of middle-aged people and causes progressive gastritis. Invariably present in duodenal ulceration and usually in gastric ulceration A. Gastric cancer B. Gastric ulcer C. Intestinal metaplasia D. Campylobacter jejuni E. Adenocarcinoma F. Barrett’s oesophagus G. Squamous carcinoma H. Helicobacter pylori I. Oesophageal varices J. Pernicious anaemia K. Duodenal ulceration L. Reflux oesophagitis ```

Correct H. Helicobacter pylori

``` A breach in mucosa which extends through muscularis mucosa into submucosa or deeper A. Peptic ulcer B. Pernicious anaemia C. Partial villus atrophy D. Coeliac disease E. Normal stomach F. GORD G. H. pylori infection H. Chronic gastritis I. Barrett’s oesophagus J. Intestinal metaplasia K. Normal oesophagus ```

Correct A. Peptic ulcer

``` Present in almost all patients with duodenal ulcer and 70 % with gastric ulcer. A. Peptic ulcer B. Pernicious anaemia C. Partial villus atrophy D. Coeliac disease E. Normal stomach F. GORD G. H. pylori infection H. Chronic gastritis I. Barrett’s oesophagus J. Intestinal metaplasia K. Normal oesophagus ```

Correct G. H. pylori infection

``` Around 10 % eventually get primary lymphoma (less often, carcinoma) of the gut if not properly treated. HLA B8 is linked with this. A. Peptic ulcer B. Pernicious anaemia C. Partial villus atrophy D. Coeliac disease E. Normal stomach F. GORD G. H. pylori infection H. Chronic gastritis I. Barrett’s oesophagus J. Intestinal metaplasia K. Normal oesophagus ```

Correct D. Coeliac disease

``` The commonest cause of oesophagitis. A. Peptic ulcer B. Pernicious anaemia C. Partial villus atrophy D. Coeliac disease E. Normal stomach F. GORD G. H. pylori infection H. Chronic gastritis I. Barrett’s oesophagus J. Intestinal metaplasia K. Normal oesophagus ```

Correct F. GORD

``` Re-epithelialisation by metaplastic columnar epithelium with goblet cells A. Peptic ulcer B. Pernicious anaemia C. Partial villus atrophy D. Coeliac disease E. Normal stomach F. GORD G. H. pylori infection H. Chronic gastritis I. Barrett’s oesophagus J. Intestinal metaplasia K. Normal oesophagus ```

Correct I. Barrett’s oesophagus

``` A 40 year old male complaining of a long history of burning epigastric pain, worse on lying flat. Endoscopy and biopsy reveals inflamed squamous lining and increased basal cell proliferation. A. Active Chronic Gastritis B. Acute Gastritis C. Coeliac Disease D. Duodenal Ulcer E. Barretts Oesophagus F. Oesophageal Varices G. Pernicious Anaemia H. GORD I. Gastric Carcinoma J. Oesophageal Adenocarcinoma ```

Correct H. GORD

``` A 38 year old female with Rheumatoid Arthritis presents with a single episode of malaena. Investigations reveal erosions through out the stomach and a neutrophilic infiltrate in the superficial mucosa A. Active Chronic Gastritis B. Acute Gastritis C. Coeliac Disease D. Duodenal Ulcer E. Barretts Oesophagus F. Oesophageal Varices G. Pernicious Anaemia H. GORD I. Gastric Carcinoma J. Oesophageal Adenocarcinoma ```

Correct B. Acute Gastritis

``` A 30 year old female complaining of diarhorrea and weight loss. Biopsy of duodenum shows increased intraepithelial cytotoxic T cells. A. Active Chronic Gastritis B. Acute Gastritis C. Coeliac Disease D. Duodenal Ulcer E. Barretts Oesophagus F. Oesophageal Varices G. Pernicious Anaemia H. GORD I. Gastric Carcinoma J. Oesophageal Adenocarcinoma ```

Correct C. Coeliac Disease

``` A 60 year old male complaining of epigastric pain relieved by antacids and meals. He has a positive CLO test. A. Active Chronic Gastritis B. Acute Gastritis C. Coeliac Disease D. Duodenal Ulcer E. Barretts Oesophagus F. Oesophageal Varices G. Pernicious Anaemia H. GORD I. Gastric Carcinoma J. Oesophageal Adenocarcinoma ```

Correct D. Duodenal Ulcer

``` A 65 year old male with a long history of epigastric pain. Endoscopy reveals 3.2cm of columnar metaplasia in the lower oesophagus. Goblet cells are seen. A. Active Chronic Gastritis B. Acute Gastritis C. Coeliac Disease D. Duodenal Ulcer E. Barretts Oesophagus F. Oesophageal Varices G. Pernicious Anaemia H. GORD I. Gastric Carcinoma J. Oesophageal Adenocarcinoma ```

Correct E. Barretts Oesophagus

``` A 63 year old man presents with epigastric pain associated with dyspepsia. The pain gets worse at night and when he is hungry. He complains of nausea and flatulence. This patient is on NSAIDs. A. Helicobacter pylori B. Hiatus hernia C. Tropical sprue D. Mucosal associated lymphoid tumour E. Gastric ulcer F. Lymphoma G. Pernicious anaemia H. Barrett's oesophagus I. Gastro-oesophageal disease J. Coeliac disease K. Partial villous atrophy L. Cryptosporidiosis M. Whipple's disease N. Carcinoma of the oesophagus O. Duodenal ulcer P. Microsporidiosis ```

Correct O. Duodenal ulcer

``` A 70 year old woman has progressive low retrosternal dysphagia, initially to solids and now also to liquids. She complains of chest pain and weight loss over the last 3 months. A social history reveals that she has been a heavy smoker for many years and drinks around 20 units of alcohol a week. A. Helicobacter pylori B. Hiatus hernia C. Tropical sprue D. Mucosal associated lymphoid tumour E. Gastric ulcer F. Lymphoma G. Pernicious anaemia H. Barrett's oesophagus I. Gastro-oesophageal disease J. Coeliac disease K. Partial villous atrophy L. Cryptosporidiosis M. Whipple's disease N. Carcinoma of the oesophagus O. Duodenal ulcer P. Microsporidiosis ```

Correct N. Carcinoma of the oesophagus

``` A 26 year old man presents with watery diarrhoea, abdominal cramps, nausea, vomiting and a low grade fever. It started 3 days after eating some undercooked meat at a barbecue. A. Helicobacter pylori B. Hiatus hernia C. Tropical sprue D. Mucosal associated lymphoid tumour E. Gastric ulcer F. Lymphoma G. Pernicious anaemia H. Barrett's oesophagus I. Gastro-oesophageal disease J. Coeliac disease K. Partial villous atrophy L. Cryptosporidiosis M. Whipple's disease N. Carcinoma of the oesophagus O. Duodenal ulcer P. Microsporidiosis ```

Correct L. Cryptosporidiosis

``` A 66 year old man complaining of epigastric pain undergoes an endoscopy. The mucosa appears reddened in the antrum of the stomach. 13C is detected on a urea breath test. A. Helicobacter pylori B. Hiatus hernia C. Tropical sprue D. Mucosal associated lymphoid tumour E. Gastric ulcer F. Lymphoma G. Pernicious anaemia H. Barrett's oesophagus I. Gastro-oesophageal disease J. Coeliac disease K. Partial villous atrophy L. Cryptosporidiosis M. Whipple's disease N. Carcinoma of the oesophagus O. Duodenal ulcer P. Microsporidiosis ```

Correct A. Helicobacter pylori

``` A 58 year old female presents with malnutrition. She complains of abdominal pain, weight loss and arthritis. She has steatorrhoea. A jejunal biopsy showed periodic acid-Schiff (PAS)-positive macrophages A. Helicobacter pylori B. Hiatus hernia C. Tropical sprue D. Mucosal associated lymphoid tumour E. Gastric ulcer F. Lymphoma G. Pernicious anaemia H. Barrett's oesophagus I. Gastro-oesophageal disease J. Coeliac disease K. Partial villous atrophy L. Cryptosporidiosis M. Whipple's disease N. Carcinoma of the oesophagus O. Duodenal ulcer P. Microsporidiosis ```

Correct M. Whipple's disease

``` A 35-year-old man presents with a long history of epigastric burning pain, made worse at night and when drinking hot liquids. Recently he has had difficulty swallowing solids. Endoscopy shows lower oesophageal erosions and strictures and pH demonstrates acidity. A. Gastroenteritis (Salmonella) B. Zollinger-Ellison syndrome C. Gastric ulcer D. Haemorrhagic gastritis E. Pyloric stenosis F. Mallory-Weiss tear G. Adenocarcinoma H. Mucosal-associated lymphoid tumour I. Barrett's oesophagus J. Gastroenteritis (Staphylococcus aureus) K. Achalasia L. Duodenal ulcer M. Bulbar palsy N. Gastro-oesophageal reflux disease ```

Correct N. Gastro-oesophageal reflux disease

``` A 20-year-old student gives an 8 hour history of very frequent vomiting and epigastric cramping. O/E she is pale and shivering. Her serum WBC is normal. A. Gastroenteritis (Salmonella) B. Zollinger-Ellison syndrome C. Gastric ulcer D. Haemorrhagic gastritis E. Pyloric stenosis F. Mallory-Weiss tear G. Adenocarcinoma H. Mucosal-associated lymphoid tumour I. Barrett's oesophagus J. Gastroenteritis (Staphylococcus aureus) K. Achalasia L. Duodenal ulcer M. Bulbar palsy N. Gastro-oesophageal reflux disease ```

Correct J. Gastroenteritis (Staphylococcus aureus)

``` A 30-year-old woman presents with haematemesis and diarrhoea. She has recurrent peptic ulceration and is taking omeprazole. Despite this, she has persistently high serum gastrin levels. Endoscopy shows a large 3cm actively bleeding ulcer in the duodenum. A. Gastroenteritis (Salmonella) B. Zollinger-Ellison syndrome C. Gastric ulcer D. Haemorrhagic gastritis E. Pyloric stenosis F. Mallory-Weiss tear G. Adenocarcinoma H. Mucosal-associated lymphoid tumour I. Barrett's oesophagus J. Gastroenteritis (Staphylococcus aureus) K. Achalasia L. Duodenal ulcer M. Bulbar palsy N. Gastro-oesophageal reflux disease ```

Correct B. Zollinger-Ellison syndrome

``` A 50-year-old women presents with chest pain associated with regurgitation of solids and liquids equally, both occurring after swallowing. Diagnosis is confirmed by a characteristic ‘beak like’ tapering of the lower oesophagus on barium swallow and manometry shows failure of relaxation of the LOS. A. Gastroenteritis (Salmonella) B. Zollinger-Ellison syndrome C. Gastric ulcer D. Haemorrhagic gastritis E. Pyloric stenosis F. Mallory-Weiss tear G. Adenocarcinoma H. Mucosal-associated lymphoid tumour I. Barrett's oesophagus J. Gastroenteritis (Staphylococcus aureus) K. Achalasia L. Duodenal ulcer M. Bulbar palsy N. Gastro-oesophageal reflux disease ```

Correct K. Achalasia

``` A 65-year-old woman presents with a 3 month history of anorexia, weight loss and epigastric pain. Blood tests reveal an iron deficiency anaemia. Endoscopy shows a thickened rigid gastric wall known as ‘leather bottle stomach’ indicating infiltration into all layers of the gastric wall. Numerous signet ring cells on biopsy diffusely infiltrate the mucosa. A. Gastroenteritis (Salmonella) B. Zollinger-Ellison syndrome C. Gastric ulcer D. Haemorrhagic gastritis E. Pyloric stenosis F. Mallory-Weiss tear G. Adenocarcinoma H. Mucosal-associated lymphoid tumour I. Barrett's oesophagus J. Gastroenteritis (Staphylococcus aureus) K. Achalasia L. Duodenal ulcer M. Bulbar palsy N. Gastro-oesophageal reflux disease ```

Correct G. Adenocarcinoma

``` A 45 year old woman presents with large tongue and swelling of the legs. She has a high BP and urine dipstick reveals protein +++.The tissue from renal biopsy stains with Congo red dye and shows apple green birefringence under polarised light A. Renal amyloidosis B. Sarcoidosis C. Mixed connective tissue disease D. Polyarteritis nodosa E. Temporal arteritis F. Kawasaki's disease G. Scleroderma H. Systemic lupus erythematous I. Sjorgen's syndrome ```

Correct A. Renal amyloidosis

``` A 28 year old woman presents with malaise, weight loss, an erythematous rash on the face and joint pains. Both antinuclear antibodies (ANA) and double-stranded DNA (dsDNA) antibodies were found in the serum. A. Renal amyloidosis B. Sarcoidosis C. Mixed connective tissue disease D. Polyarteritis nodosa E. Temporal arteritis F. Kawasaki's disease G. Scleroderma H. Systemic lupus erythematous I. Sjorgen's syndrome ```

Correct H. Systemic lupus erythematous

``` A 55 year old woman presents with severe, unremitting headache with scalp tenderness. Her ESR and CRP are raised. A biopsy reveals giant cells. A. Renal amyloidosis B. Sarcoidosis C. Mixed connective tissue disease D. Polyarteritis nodosa E. Temporal arteritis F. Kawasaki's disease G. Scleroderma H. Systemic lupus erythematous I. Sjorgen's syndrome ```

Correct E. Temporal arteritis

``` A 40 year old man with previous hepatitis B infection presents with weight loss, muscle aches and abdominal pain. On examination he has high BP and urine dipstick reveals blood + and protein + A. Renal amyloidosis B. Sarcoidosis C. Mixed connective tissue disease D. Polyarteritis nodosa E. Temporal arteritis F. Kawasaki's disease G. Scleroderma H. Systemic lupus erythematous I. Sjorgen's syndrome ```

Correct D. Polyarteritis nodosa

``` A 30 year old Afrocaribbean woman presents with tender red nodules on the shins and legs. She also has joint pains in her feet and hands. Her blood test reveals a raised angiotensin converting enzyme (ACE) and Ca2+ level. A. Renal amyloidosis B. Sarcoidosis C. Mixed connective tissue disease D. Polyarteritis nodosa E. Temporal arteritis F. Kawasaki's disease G. Scleroderma H. Systemic lupus erythematous I. Sjorgen's syndrome ```

Correct B. Sarcoidosis

``` A 35 year old female presents to her GP with unsightly, red, tender lesions on her shins. A subsequent CT scan shows evidence of enlarged glands in the lung hilar region, and nodular shadowing in the right middle lobe. A. Haemodialysis associated amyloidosis B. Hereditary amyloidosis C. Senile amyloidosis D. Hogkin’s Lymphoma E. Bronchial carcinoma F. Sarcoidosis G. Myeloma associated amyloidosis H. Reactive amyloidosis I. Waldenström’s macroglobulinaemia ```

Correct F. Sarcoidosis

``` A 60 year old man, currently undergoing treatment for long-standing chronic renal failure, complaining of tingling in his wrist & hand when he wakes in the morning. A. Haemodialysis associated amyloidosis B. Hereditary amyloidosis C. Senile amyloidosis D. Hogkin’s Lymphoma E. Bronchial carcinoma F. Sarcoidosis G. Myeloma associated amyloidosis H. Reactive amyloidosis I. Waldenström’s macroglobulinaemia ```

Correct A. Haemodialysis associated amyloidosis Beta -2-microglobulin amyloidosis is associated with haemodialysis. This is a secondary amyloidosis due to impaired clearance of b2m across dialysis membranes that causes carpal tunnel syndrome. The term "amyloidosis" refers to deposition of insoluble abnormally folded protein fibrils. It is an umbrella term that encompasses several precursor proteins and, alone, DOES NOT imply a specific cause.

``` A 70 year old woman is referred to hospital with signs of peripheral oedema and hepatosplenomegaly. Hospital investigations demonstrate a degree of bone erosion and high levels of circulating kappa uniform light chain A. Haemodialysis associated amyloidosis B. Hereditary amyloidosis C. Senile amyloidosis D. Hogkin’s Lymphoma E. Bronchial carcinoma F. Sarcoidosis G. Myeloma associated amyloidosis H. Reactive amyloidosis I. Waldenström’s macroglobulinaemia ```

Correct G. Myeloma associated amyloidosis AL amyloidosis may be idiopathic/primary or "secondary to having multiple myeloma" or other monoclonal B-cell proliferative disorders. Myeloma is NOT a type of amyloidosis!! It is a type of lymphoproliferative disorder; specifically, it is a monoclonal expansion of plasma cells which MAY OR MAY NOT BE ASSOCIATED WITH AL type amyloidosis depending on whether the precursor proteins, immunoglobulin light chains, happen to be amyloidogenic or not. The term "amyloidosis" refers to deposition of insoluble abnormally folded protein fibrils. It is an umbrella term that encompasses several precursor proteins and, alone, DOES NOT imply a specific cause.

``` A 32 year old man presents with a painless, enlarged axillary lymph node. Slight hepatosplenomegaly is noted on examination. Whilst the patient denies experiencing any night sweats, weight loss or fevers, bloods on admission show a raised ESR and abnormal liver biochemistry. A. Haemodialysis associated amyloidosis B. Hereditary amyloidosis C. Senile amyloidosis D. Hogkin’s Lymphoma E. Bronchial carcinoma F. Sarcoidosis G. Myeloma associated amyloidosis H. Reactive amyloidosis I. Waldenström’s macroglobulinaemia ```

Correct D. Hogkin’s Lymphoma KM: I thought a list of causes of splenomegaly might be useful. Whenever someone asks you for a list of causes, always try to classify your answers, instead of listing causes in a random manner (this is especially important for finals next year). Classification is always very individual...so develop your own system early on. One such classification for splenomegaly could depend on the size of the spleen ie massive, moderate, mild • Massive splenomegaly: o common in the UK -- CML, myelofibrosis (ie haematological) o common worldwide -- malaria, kala-azar (ie infectious) • Moderate splenomegaly: o Portal hypertension, lymphoma, CLL, thalassaemia and metabolic diseases e.g Gaucher's • Mild splenomegaly: o Infection (viral e.g. EBV, hepatitis or bacterial e.g infective endocarditis, miliary TB) o Connective Tissue Diseases (e..g RA, PAN, SLE, Felty's syndrome) o Infiltrative disorders (amyloidosis, sarcoidosis)

``` A 64 year old woman with a history of chronic rheumatological disease presents to her GP complaining of abdominal discomfort – which is found to be due to hepatosplenomegaly. An ensuing liver biopsy stains positive with Congo Red stain. A. Haemodialysis associated amyloidosis B. Hereditary amyloidosis C. Senile amyloidosis D. Hogkin’s Lymphoma E. Bronchial carcinoma F. Sarcoidosis G. Myeloma associated amyloidosis H. Reactive amyloidosis I. Waldenström’s macroglobulinaemia ```

Correct H. Reactive amyloidosis Secondary or reactive amyloidosis (AA) is secondary to inflammatory conditions including rheumatoid arthritis, crohn's disease etc. The term "amyloidosis" refers to deposition of insoluble abnormally folded protein fibrils. It is an umbrella term that encompasses several precursor proteins and, alone, DOES NOT imply a specific cause. KM: I thought a list of causes of splenomegaly might be useful. Whenever someone asks you for a list of causes, always try to classify your answers, instead of listing causes in a random manner (this is especially important for finals next year). Classification is always very individual...so develop your own system early on. One such classification for splenomegaly could depend on the size of the spleen ie massive, moderate, mild • Massive splenomegaly: o common in the UK -- CML, myelofibrosis (ie haematological) o common worldwide -- malaria, kala-azar (ie infectious) • Moderate splenomegaly: o Portal hypertension, lymphoma, CLL, thalassaemia and metabolic diseases e.g Gaucher's • Mild splenomegaly: o Infection (viral e.g. EBV, hepatitis or bacterial e.g infective endocarditis, miliary TB) o Connective Tissue Diseases (e..g RA, PAN, SLE, Felty's syndrome) o Infiltrative disorders (amyloidosis, sarcoidosis)

% of cases which have the most common abnormality: del 13q.14 ``` 70 30 50 500 5000 80 100 1000 20 40 ```

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