Wilcoxon signed-rank test
Parametric or non-parametric data
Non-parametric
compares two sets of observations on a single sample
Which drugs can cause cirrhosis (3)
methotrexate
methyldopa
amiodarone
Inheritance of Ocular albinism
X-linked recessive
What is the antibiotic regime of choice for pseudomonas in CF
Ceftazidime and tobramycin
What drug decreases concentration of Li
Acetazolamide & osmotic diuretics
Which GN typically present with nephritic syndrome (2)
Typically presents with nephritic syndrome (haematuria, hypertension)
Rapidly progressive glomerulonephritis - aka crescentic glomerulonephritis
Rapid onset, often presenting as acute kidney injury
causes include Goodpasture’s, ANCA positive vasculitis and SLE
IgA nephropathy - aka Berger’s disease, mesangioproliferative GN
typically young adult with haematuria following an URTI
When are steroids not indicated first line, for GN?
Membranous - tx with BP control and ACEi
Membranoproliferative - steroids are ineffective; can use eculizumab
Diffuse proliferative (post-strep) - self limiting
What are the driving restrictions for syncope (4)
Simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
ANP is mainly secreted by the L or R atrium
Right atrium
Docetaxel
MOA
SE
MOA: antimicrotubule agent; Prevents microtubule depolymerisation and disassembly, decreasing free tubulin
SE: Neutropaenia
Glossopharyngeal nerve (IX) Vagus nerve (X) Accessory nerve (XI)
Posterior meningeal artery Ascending pharyngeal artery Inferior petrosal sinus Sigmoid sinus Internal jugular vein
Which skull foramen
Jugular foramen
Bronchial malignancy is associated with which skin disorder
Erythema gyratum repens
Erythematous scaling rash over the abdomen
Wood grain appearance
Iron-deficiency anaemia - cells seen on microscopy (2)
target cells
‘pencil’ poikilocytes
Which anti TB drug is most likely to cause drug-induced lupus
procainamide
hydralazine
Isoniazid
Vincristine, vinblastine
MOA
SE
MOA: antimicrotubule agents; Inhibits formation of microtubules - act in mitosis phase of cell cycle
SE: Vincristine: Peripheral neuropathy (reversible) , paralytic ileus
Vinblastine: myelosuppression
Paraneoplastic syndromes - Anti-Hu
Associated with (2)
CF (3)
Associations: small cell lung carcinoma and neuroblastomas
CF
sensory neuropathy - may be painful
cerebellar syndrome
encephalomyelitis
Histiocytosis X is a cause of cranial or nephrogenic DI
Cranial
6-mercaptopurine
MOA
SE
MOA: antimetabolite; Purine analogue that is activated by HGPRTase, decreasing purine synthesis
SE: Myelosuppression
IFN-gamma
Function
Indications (2)
Produced by T lymphocytes and NK cells
Weaker antiviral action, more of a role in immunomodulation particularly macrophage activation
Chronic granulomatous disease and osteopetrosis
Secretin
Released by which cells
Stimulus
Effect
S cells
Acidic chyme and fatty acids
Increases pancreatic secretions and hepatic duct cells.
Decreases gastric acid secretion
Trophic effect on pancreatic acinar cells
Inheritance of Lesch-Nyhan syndrome
X-linked recessive
Mann-Whitney U test
What does it test
Parametric or non-parametric data
Non-parametric
Unpaired data
Inheritance of Von Willebrand’s disease (types 1 and 2) type 3
1 and 2 -> AD; 3 -> AR
What is the bug in cat scratch fever
What is the tx
Bartonela hensalae
Immunocompetent - supportive tx
Systemic disease - cipro
What is increased in lead poisoning
Urinary coproporphyrin
What are the features of cubital tunnel syndrome
Which nerve is involved
Ulnar nerve
Tingling in ulnar nerve distribution; weakness is late
Worse when elbow is resting on a surface or the arm is flexed
When are steroids indicated first line, for GN?
Minimal change disease
FSGS
IgA / mesangioproliferative
Rapidly progressive
Causes of a false positive VDRL test (4)
‘SomeTimes Mistakes Happen’ (SLE, TB, malaria, HIV)
commonest SE of nicorandil
ulceration
complication of pcp
pneumothorax
Wilson's disease Gene defect, chromosome and inheritance Effects Serum caeruloplasmin is high/low Serum copper is high/low Urinary Cu excretion is high/low
AR inheritance of ATP7B gene on chr13
Cu deposition in basal ganglia, eyes and liver
Reduced serum caeruloplasmin
Reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
Urinary copper excretion - Increased
When should anticoagulation be started for an ischaemic stroke with AF
2 weeks
What tumour markers is elevated in teratoma / non-seminiferous testicular cancer
AFP & HCG
Indications for IFN-b
Relapsing remitting MS
IL-3
Source:
Effect:
Source: Activated T helper cells
Effect: Stimulates differentiation and proliferation of myeloid progenitor cells
Schizophrenics typically do or do not have insight into their condition
Not
when does the risk of neutropenic sepsis peak
10 days
What is the side effect of zanamivir
Bronchospasm
Tx of HSV (3)
Gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
Cold sores: topical aciclovir although the evidence base for this is modest
Genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir
IFN-alpha
Function
Indications (5)
SE
Produced by leucocytes
Antiviral action
Hepatitis B and C, Kaposi’s sarcoma, metastatic renal cell cancer, hairy cell leukaemia
Flu-like symptoms and depression
Homocystinuria Inheritance Enzyme defect CF Tx
AR
Deficiency of cystathionine beta synthase -> accumulation of homocysteine
CF: Fine, fair hair Marfanoid Learning difficulties, seizures Downwards (inferonasal) dislocation of lens
Pyridoxine (50% respond)
t(11;14) disease and mechanism
Mantle cell lymphoma Cyclin D1 (BCL-1) deregulation
When is omalizumab indicated
Pts with severe allergic asthma who have required >4 courses of steroids in the past month
Drugs which can precipitate myasthenia crisis
Beta-blockers
Penicillamine, Quinidine, procainamide, Li, Phenytoin
Abx: gentamicin, macrolides, quinolones, tetracyclines
Histology of IgA nephropathy
LM - Mesangial cell proliferation
IF - Granular IgA and C3 deposition in the mesangium
How is gestational DM treated
If fasting glucose <7 -> trial diet & exercise; add metformin if not controlled after 1-2wks; add insulin if still not controlled
If glucose >7 at dx or >6 with sx -> insulin
Glibenclamide can be used if metformin is insufficient but insulin refused
Loss of which protein in nephrotic syndrome increases the risk of thrombosis
Antithrombin III
CREST is associated with which antibody
Anti-centromere
Tx for Mycobacteria avium
rifampicin, ethambutol & azithromycin
GFR increases or decreases during pregnancy
Increases
What are the two kinds of serological test in syphilis
cardiolipin tests (not treponeme specific) treponemal specific antibody tests
What antibiotics risk worsening G6PDD
quinolone (cipro) and nitrofurantoin
What is the tx of tapeworm infection (Taenia)
praziquantel or niclosamide
Which gene mutation is likely to exist in essential thrombocythaemia once JAK2 is excluded
Calreticulin
ET in around 20% of JAK-2 negative patients.
Bladder cancer is associated with what industry and what within it
Dyes industry. Rubber and leather industry
Aromatic amines
What does the SeHcat test, test for
Bile acid malabsorption
CCK
Released by which cells
Stimulus
Effect
L cells of upper small intestine
Partially digested proteins and TGs
Increases pancreatic secretions, GB contraction & relaxation of the sphincter of Oddi
Decreases gastric emptying
Trophic effect on pancreatic acinar cells
Induces satiety
What proportion of values lie within 1SD, 2SD and 3SD of the mean
- 3% of values lie within 1 SD of the mean (14)
- 4% of values lie within 2 SD of the mean (14)
- 7% of values lie within 3 SD of the mean (18)
Valproate
MOA and SE
GABA agonist
Weight gain
Nausea
SE of ciclosporin
Everything is increased - fluid, BP, K+, hair, gums, glucose
What is the mode of renal toxicity of gentamicin
Proximal tubule dysfunction
Ix for stable angina: 1, 2 and 3
CT coronary angiography - lumenal flow
Non-functional imaging - MRI, stress echo
Invasive coronary angiography
Which group of antibiotics are associated with exacerbations of myasthenia
Aminoglycosides
When should ciclosporin levels be taken
Trough dose - immediately before the next dose
Amyloidosis
What is the classification
What causes each
AL - primary (AL is alone - 1°)
Myeloma, Waldenstrom’s, MGUS
features include: cardiac and neurological involvement, macroglossia, periorbital eccymoses
AA - secondary - acute phase reactant
seen in chronic infection/inflammation
e.g. TB, bronchiectasis, rheumatoid arthritis
features: renal involvement most common feature
Driving restrictions
AAA
> 6cm -> notify DVLA; will have annual r/v
>6.5cm -> disqualifies patients from driving
Poor prognostic features in AML
> 60 years
20% blasts after first course of chemo
cytogenetics: deletions of chromosome 5 or 7
What is the treatment for schistosomiasis
Praziquantel
What monitoring is required for those on hydroxychloroquine
Annual eye assessment
Hydroxychloroquine can cause a retinopathy
Raltegravir
MOA
Integrase inhibitor
What are the 5 stages of lung changes in sarcoid
Stage 0 - normal CXR
Stage 1 - BHL only
Stage 2 - BHL & pulmonary infiltrates
Stage 3 - Diffuse pulmonary infiltrates only
Stage 4 - widespread fibrosis
Which drug post MI has the best effect on survival / lowers NNT
ACEi
Does a high or low phosphate predispose to pseudogout
Low
Churg Strauss What is it What antibody is positive CF What drug can precipitate an attack
Small/medium vessel vasculitis
pANCA
Asthma, mononeuritis multiplex and eosinophilia
Leukotriene receptor antagonists can worsen the disease (montelukast)
What drug is added 2nd line in those still sx with gout despite maximal allopurinol tx
Benzbromarone
What are the associations of thymoma (5)
Madras: Myasthenia Dermatomyositis Red cell aplasia SLE SIADH
IL-6
Source:
Effect:
Source: Macrophages, Th2 cells
Effect:
Stimulates differentiation of B cells
Induces fever
Polyglandular autoimmune syndrome type 1
Gene defect
Conditions within
Also known as
AR mut AIRE1 gene, chr 21
Addison’s disease; chronic mucocutaenous candidiasis; HypoPTHism
MEDAC - Multiple Endocrine Deficiency Autoimmune Candidiasis
Broca’s area
Where is it
What does it do
What effect does a stroke in this area have
Inferior frontal gyrus - left frontal lobe
Causes expressive dysphasia
Difficulty with fluency - poor repetition
When are steroids not indicated first line, for GN?
Membranous - tx with BP control & ACEi
Membranoproliferative - steroids are ineffective; can use eculizumab
Diffuse proliferative (post-strep) - self limiting
anti dsDNA antibodies are associated with which disease
SLE - specificity 99%; sensitivity 70%
Hyposplenism - cells seen on microscopy (3)
Target cells
Howell-Jolly bodies
Pappenheimer bodies
Histology of minimal change disease
Light microscopy - no change
EM - effacement of podocyte foot processes; thickening of GBM
IF - no immune deposits
Where are antibodies directed against in bullies pemphigoid
Hemidesmosomes BP180 and 230
Which clotting factor in paradoxically increased in liver failure?
FVIII
IL-2
Source:
Effect:
Source: Th1 cells
Effect: Stimulates growth and differentiation of T cell response
Inheritance of Wiskott-Aldrich syndrome
X-linked recessive
Secondary causes of hyper-TGaemia
Hypertriglyceridaemia:
Diabetes mellitus (types 1 and 2) - Disproportionately high VLDL and low HDL
Obesity
Alcohol
Chronic renal failure
Drugs: thiazides, non-selective beta-blockers, unopposed oestrogen, immunosuppressants
Liver disease
Asian diabetics - tend to have low HDL and raised TGs
IFN-beta
Function
Indications
Produced by fibroblasts
Antiviral action
MS - reduces the frequency of exacerbations
Variceal bleed - is banding or sclerotherapy first line
Banding
What is the commonest associated symptom with Waldenstroms macroglobulinaemia
generliased weakness
Other facts:
Raised IgM
Hepatosplenomegaly
Sx of hyperviscosity
Which body part is acne rosecea also associated with
Eyes - blepharitis, keratitis, conjunctivitis
What is the mx of a myasthenic crisis
plasmapheresis or IV Ig
Which drugs can cause hepatocellular damage / hepatitis (10)
Paracetamol Anti-convulsants - sodium valproate, phenytoin anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol nitrofurantoin MAOIs halothane amiodarone methyldopa
Driving restrictions
CABG
CABG - 4 weeks off driving
Association of HLA-A3
haemochromatosis
For how long after a prosthetic valve replacement does staph epidermidis remain the most likely bug in IE, before staph aureus becomes more likely
2 months
Which vaccine should absolutely be avoided in HIV
BCG
What antibodies are present in paraneoplastic pemphigus
Anti-(…)plakins eg envoplakin
Erythema nodosum is a good or bad prognostic feature of sarcoid
Good
Inheritance of Kallman’s syndrome
Presents with undescended testes or not
X-linked recessive
Undescended testes -> much more likely Kallman’s than Klinefelters
What is the treatment for narcolepsy & cataplexy
Modafinil
Which drugs can precipitate acute glaucoma
Amitriptyline and anticholinergics
Which cytokines to Th2 cells secrete (4)
involved in mediating humoral (antibody) immunity
e.g. stimulating production of IgE in asthma
secrete IL-4, IL-5, IL-6, IL-10, IL-13
Second line choice of antibiotic in suspected meningitis when penicillin / cephalosporin contraindicated
Chloramphenicol
BP targets
Age
DM
CKD
<140/90 if <80yrs (clinic) or <135/85 (home);
<150/95 if >80yrs
DM
<130/80 if end organ damage;
Otherwise <140/80
Chronic renal disease
<125/75
IL-4
Source:
Effect:
Source: Th2 cells
Effect: Stimulates proliferation and differentiation of B cells
where are antibodies found in pemphigus vs pemphigoid
pemphigus - within the epidermis
pemphigoid - at the dermo-epidermal junction
Paroxysmal nocturnal haemoglobinuria is associated with what cell markers
what is the classic triad
CD and CD59 negative cells
Haemoglobinuria, pancytopenia, venous thrombosis
Inheritance of Hereditary haemorrhagic telangiectasia
AD
Indications for haemodialysis in methanol poisoning
Low GCS
Visual impairment
Severe poisoning - Level >0.5g/L
Renal impairment
What is the treatment for TTP
Plasma exchange with protein replacement
Which cell surface receptor allows entry of P. vivax, and is absent in West African populations, causing resistance
Duffy
Abciximab
MOA
Glp IIb / IIIA inhibitor
Which GN typically present with nephritic syndrome (2)
Typically presents with nephritic syndrome (haematuria, hypertension)
Rapidly progressive glomerulonephritis - aka crescentic glomerulonephritis
Rapid onset, often presenting as acute kidney injury
causes include Goodpasture’s, ANCA positive vasculitis and SLE
IgA nephropathy - aka Berger’s disease, mesangioproliferative GN
typically young adult with haematuria following an URTI
What factors predispose to pseudogout?
3 electrolytes
4 conditions
Hyper-Ca (hyper-PTHism) Low Mg Low phosphate Hypothyroidism Haemochromatosis, acromegaly, Wilson's disease
Visceral leishmaniasis
species
Tx
L. donovani
Amphotericin B
VHL predisposes to what tumours / sites - 8
What is the commonest cause of death
Which chromosome
Cerebellar, brainstem and spinal haemangioblastomas Retinal angiomas Phaeochromocytomas Paragangliomas Renal cysts and clear cell carcinoma Pancreatic cysts and islet cell tumours Epidydimal tumours Endolymphatic tumours
Renal carcinoma is commonest cause of death
Chr 3
Inheritance of Von Willebrand’s disease (types 1 and 2) and type 3
1 and 2 -> AD; 3 -> AR
Inheritance of Fabry’s disease
X-linked recessive
Test for phaeochromocytoma
urinary vanillylmendelic acid and plasma metanephrines
Which antibody is positive in mixed connective tissue disease
anti RNP
Features of SLE, systemic sclerosis and polymyositis
Which drugs can cause cholestasis (6)
oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
Which kinds of diuretics are associated with hypo-Mg
Thiazide
Loop
K-sparing
Thiazide - yes
Loop - yes
K-sparing - no
What are the transplant criteria for paracetamol OD
pH <7.3
Or all 3 of:
Creatinine >300
PT >100
Grade 3/4 encephalopathy
Doxorubicin
MOA
SE
MOA: Cytotoxic; Stabilizes DNA-topoisomerase II complex inhibits DNA and RNA synthesis
SE: Cardiomyopathy
Lofgren’s syndrome
What is it
Acute sarcoid with: Erythema nodosum Arthralgia Acute anterior uveitis Fever
How are DOACs measured
PT
Inheritance of Hereditary spherocytosis
AD
MODY5
HNF-1b gene mutation
Pancreatic atrophy & renal cysts
x
Features of yellow nail syndrome (5)
Yellow nails Bronchiectasis Congenital lymphedema Pleural effusions Chronic sinusitis
What condition is associated with quadriceps muscle weakness and weakness of finger flexors
Inclusion body myositis
LRTI with what can cause reactivation of HCV cold sores
Strep pneumo
When should Li levels be taken
12hrs post dose
Which cyclins and CDKs are active in G2 phase of cell cycle
Cyclin B and CDK1
Bupropoion
MOA
SE
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Reduces seizure threshold - CI in epilepsy & bipolar
What are the commonest primary malignancies for those presenting with bone mets
Breast & lung - 80%
Remaining 20% - incl kidney, thyroid
Below which LVEF are HGV licences (Group 2) not allowed
40%
IFN-alpha
Function
Indications (5)
SE
Produced by leucocytes
Antiviral action
Hepatitis B & C, Kaposi’s sarcoma, metastatic renal cell cancer, hairy cell leukaemia
Flu-like symptoms and depression
Doxorubicin
Class of drug
MOA
SE
Anthracycline
MOA: Cytotoxic; Stabilizes DNA-topoisomerase II complex inhibits DNA and RNA synthesis
SE: Cardiomyopathy
MODY5
What is the mutation
CF
tx
HNF-1b gene mutation
Pancreatic atrophy & renal cysts
Usually responsive to sulfonylureas - insulin not usually necessary.
Causes of occupational asthma (7)
I pretend some girls fancy early penetration
isocyanates - commonest cause. Example occupations include spray painting and foam moulding using adhesives platinum salts soldering flux resin glutaraldehyde flour epoxy resins proteolytic enzymes
Neuropathic pain - 1st, 2nd and 3rd line mx
1st - pregabalin, gabapentin, duloxetine, amitriptyline
2 - add one of the other first line agents
3 - tramadol
What tx can be added to a PD pt suffering dyskinesia with L-Dopa & DA agonists
MOA
Amantadine
Antimuscarinic & NMDA-R antagonist
What is the specific effect of metformin
Reduces hepatic glucose output
How does phenytoin cause a macrocytosis
Altered folate metabolism
What is the minimum steroid intake a patient should be taking before they are offered osteoporosis prophylaxis?
7.5mg / day for 3mths
Inheritance of G6PD deficiency
X-linked recessive
Inheritance of Malignant hyperthermia
AD
Inheritance of Di George syndrome
AD - microdeletion of TBX1 on chr 22
Drugs associated with thrombocytopenia (7)
quinine
abciximab
NSAIDS
diuretics: furosemide
antibiotics: penicillins, sulphonamides, rifampicin
anticonvulsants: carbamazepine, valproate
heparin
Churg Strauss What is it What antibody is positive CF What drug can precipitate an attack
Small/medium vessel vasculitis
pANCA
Asthma, mononeuritis multiplex and eosinophilia
Leukotriene receptor antagonists can worsen the disease (montelukast)
What proportion of values lie within 1SD, 2SD & 3SD of the mean
- 3% of values lie within 1 SD of the mean (14)
- 4% of values lie within 2 SD of the mean (14)
- 7% of values lie within 3 SD of the mean (18)
Tx regimes for malaria
Falciparum - complicated
ACT - Riamet & Malarone
Falciparum - uncomplicated
Quinine and doxycycline
Non-falciparum
Chloroquine and primaquine
Arcuate fasciculus
What does it do
What effect does a stroke in this area have
Connects Brocas and Wernickes areas
Stroke causes a fluent dysphasia, mimicking Broca’s
Inheritance of Hunter’s disease
X-linked recessive
How is gestational DM treated
If fasting glucose <7 -> trial diet and exercise; add metformin if not controlled after 1-2wks; add insulin if still not controlled
If glucose >7 at dx or >6 with sx -> insulin
Glibenclamide can be used if metformin is insufficient but insulin refused
Tenofovir
Nucleotide RTI
What are the predominant features of visceral leishmaniasis
fever, widespread lymphadenopathy, hepatosplenomegaly, organ dysfunction
Pancytopaenia
Abnormal LFTs
Inheritance of PKU
AR
Alpha haemolytic strep infective endocarditis tx
Benpen & gent
What effect does bradykinin have on the airways
Bronchoconstriction
von Willebrands disease - bleeding time prolonged or normal
prolonged
Ix of choice for avascular necrosis
MRI
Inheritance of Cystinuria
AR
Myelofibrosis - cells seen on microscopy (1)
‘tear-drop’ poikilocytes
What are the causes of FSGS (6)
1° - idiopathic 2° to other renal pathology e.g. IgA nephropathy, reflux nephropathy HIV heroin Alport's syndrome sickle-cell
Inheritance of ataxia telangiectasia
Autosomal recessive
Which anticonvulsants do not interact with P450
Lamotrignine, Levetiracetam (the Ls are Level)
Which antibody test has the best negative predictive value for SLE
ANA
What are the commonest electrolyte imbalances in reseeding syndrome
hypophosphataemia -> heart failure and skeletal muscle weakness
hypokalaemia
hypomagnesaemia
primarily malabsorptive bariatric procedure
Biliopancreatic diversion with duodenal switch
What are first and second line for the treatment of bipolar disorder
1 - Valproate
2 - Li
what is the first line tx for threadworm
mebendazole
Contraindication to pneumonectomy
FEV1 <2L
Wire looping of capillaries in the glomeruli is seen in which glomerulonephrtis
Diffuse proliferative glomerulonephritis (often due to SLE).
Raltegravir, elvitegravir, dolutegravir
MOA
Integrase inhibitors
Inheritance of Lipid storage disease: Tay-Sach’s, Gaucher, Niemann-Pick
AR
Malignancies cause what kind of GN
Membranous - malignancy
IL-10 (human cytokine synthesis inhibitory factor):
Source:
Effect:
Source: Th2 cells
Effect: Inhibits Th1 cytokine production - anti-inflammatory
What antibiotic can reduce the renal clearance of Li (2)
What other drugs
metronidazole & tetracyclines NSAIDs steroids thiazide & loop diuretics ACEi / ARB
Combining pioglitazone with what, increases the risk of peripheral oedema (CI in HF)
Insulin
What drug is used to treat gastroparesis in T1DM
Domperidone
BPPV
Dix-Hallpike manoeuvre and Epley manoeuvre
Which is therapeutic and which diagnostic
Dix-Hallpike manoeuvre - dx
Epley manoeuvre - therapeutic
Associations of coarctation of the aorta (4)
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
Absorption of which drug is impaired by calcium carbonate
Levothyroxine
What are the acute SE of phenytoin (3-4)
Cerebellar sx - ataxia, slurred speech, dizziness
Diplopia
Nystagmus
+/- confusion and seizures
95% of samples lie within how many SD of the mean
1.96 SD of the mean lie 95% of the sample values
Superior orbital fissure
What leaves via this foramen (6)
Superior ophthalmic vein
Inferior ophthalmic vein
Oculomotor nerve (III) Trochlear nerve (IV) lacrimal, frontal and nasociliary branches of ophthalmic nerve (V1) Abducent nerve (VI)
two main modes of paracetamol metabolism
glucoronic acid conjugation & sulphation
What is the driving restriction post first unprovoked/isolated seizure (2)
6 months - if no structural abnormalities on brain imaging and no definite epileptiform activity on EEG
Otherwise 12 months
IHD and AF - what is the anticoagulation guideline
If stable IHD -> oral anticoagulation only
If recent PCI / ACS -> 6mths of dual anti-plt tx with oral anticoagulation, then single antiplt oral anticoagulation until 12mths
Above what cd4 count in HIV should live vaccines of MMR, yellow fever and chickenpox be given
200
t(15;17) disease and mechanism
Acute promyelocytic leukaemia (M3)
PML and RAR fusion
What are the indications for surgery in primary hyper-PTHism (5)
Age <50 years. Ca > 2.85 gfr <60 Complications of hyper-Ca - stones, nephrocalcinosis, osteoporosis or osteoporotic fracture. Symptomatic disease
Indications for orlistat
BMI >30
BMI >28 if associated complications
>5% weight loss in 3mths
What is first line tx for CMV
ganciclovir
commonest GI problem in SLE
Mouth ulcers
What drugs can be cleared by haemodialysis (5)
What drugs cannot (5)
Drugs that can be cleared with haemodialysis - mnemonic: BLAST
Barbiturate
Lithium
Alcohol (inc methanol, ethylene glycol)
Salicylates
Theophyllines (charcoal haemoperfusion is preferable)
Drugs which cannot be cleared with haemodialysis include tricyclics benzodiazepines dextropropoxyphene (Co-proxamol) digoxin beta-blockers
t(15;17) - disease and mechanism
Acute promyelocytic leukaemia (M3)
PML and RAR fusion
When should an LP be done post headache onset in SAH to exclude a bleed
12hrs
First line tx for SVC obstruction
Stenting esp if solid tumour
Steroids more useful for haematological malignancy
Which factors contribute to the MDRD calculation of gfr
CAGE - serum creatinine, age, gender, ethnicity
What kind of gallstones are most likely to be found in states of raised haemolytic eg HS
Black pigment stones - radiolucent
IL-2
Source:
Effect:
Source: Th1 cells
Effect: Stimulates growth and differentiation of T cell response
What is the prevalence of RA?
1%
What is the conversion ratio between oral MST / morphine sulphate and parenteral (sc, iv, im)
Halve the dose
Associated with breast, colorectal and small cell lung carcinoma
stiff person’s syndrome or diffuse hypertonia
Anti-GAD antibody
Which type of glomerulonephritis is most characteristically associated with partial lipodystrophy?
Mesangiocapillary GN type 2
Mesangiocapillary glomerulonephritis (membranoproliferative) type 1: cryoglobulinaemia, hepatitis C type 2: partial lipodystrophy
Which anti TB drugs should be avoided / reduced in renal impairment (2)
Ethambutol and streptomycin
Bupropoion
x
What is the effect of C5 deficiency
Predisposes to Leiner disease
recurrent diarrhoea, wasting and seborrhoeic dermatitis
IL-10 (human cytokine synthesis inhibitory factor):
Source:
Effect:
Source: Th2 cells
Effect: Inhibits Th1 cytokine production - anti-inflammatory
What drugs increase the risk of idiopathic intracranial htn
Vit A, OCP, steroids, tetracycline, Li
Felty’s syndrome
What is it
Blood
Triad of RA, neutropaenia and splenomegaly
Reticuloendothelial stimulation causes hypersplenism
Normochromic or hypo chromic anaemia
Gardner’s syndrome
CF - 4
Variant of FAP
Osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
Which GN are associated with low complement levels?
Post strep GN Mesangiocapillary GN Subacute bacterial endocarditis GN Cryoglobulinaemia SLE
A1AT - inheritance and gene
AR or co-dominant inheritance
Chr 14
How often should Li levels be checked
3mthly
6mthly for U&E & TFT
Optic canal
What leaves via this foramen (2)
Optic nerve
Ophthalmic artery
VIP
Released by which cells
Stimulus
Effect
Released by small intestine & pancreas
Stimulus: neural
Stimulates secretion of water & intestinal smooth muscle relaxation
Inhibits acid secretion
What hormone triggers epiphyseal fusion
Oestrogen
Direct contact with left kidney
Left suprarenal gland
Pancreas
Colon
IL-8
Source:
Effect:
Source: Macrophages
Effect: Neutrophil chemotaxis
What are the irreversible features of haemochromatosis
Arthropathy
Diabetes
Liver cirrhosis
Hypergonadotrophic hypogonadism
Histology of FSGS
LM - focal and segmental sclerosis
EM - Thickening of GBM
IF - IgG and C3 deposition
Amphotericin B
MOA
SE
MOA: Binds ergosterol
SE: Nephrotoxicity, flu-like symptoms, electrolytes (hypokalaemia, hypomagnaseamia)
Management (1st and; 2nd line) tx of migraine in pregnancy
Migraine during pregnancy
paracetamol 1g is first-line
aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester
Which viral meningitis is associated with a low CSF glucose
Mumps
Direct contact with right kidney
Right suprarenal gland
Duodenum
Colon
Pearson’s product-moment coefficient
Parametric or non-parametric data
What does it test
Parametric
Tests correlation
Foramen ovale
Mandibular nerve (V3) Accessory meningeal artery
Draw and label the JVP
A - Atria contract C - TV closes (c for close) X - RV contracts V - Atria contact against closed TV Y - TV opens
What are the causes of a decreased TLCO
R->L shunting
Pneumonia
Pulmonary emboli
Problems with the alveolar wall
Fibrosis
pulmonary oedema
Loss of lung tissue
emphysema
No blood
anaemia
low cardiac output
When should digoxin levels be taken
6hrs post dose
MODY2
What is the mutation
CF
tx
Mutation in glucokinase (glucose sensor in pancreatic beta cells)
Controlled with diet alone.
Gold for RA
SE
Peripheral neuropathy
Nephrotic syndrome
Aplastic anaemia
Pulmonary fibrosis
Ehlers Danlos syndrome
Inheritance
Which collagen is most often defective
AD
Collagen 3
Causes of extravascular haemolysis
Haemoglobinopathies: sickle cell, thalassaemia
Hereditary spherocytosis
Haemolytic disease of newborn
Warm autoimmune haemolytic anaemia
Histology of FSGS
LM - focal and segmental sclerosis
EM - Thickening of GBM
IF - IgG and C3 deposition
Second commonest GN cause of nephrotic syndrome in adults after membranous GN
Hep B PEP
What are the 3 classes of responder
Unknown source
Unknown source:
Known responder to the vaccine, non-responder, currently being vaccinated
Known responders - booster dose of HBV vaccine.
Non-responders - HBIG + vaccine
Those in the process of being vaccinated - accelerated course of HBV vaccine
MOA of antipsychotics eg olanzapine (2)
D2 antagonist
5HT-2 antagonist
Dipyradimole
MOA
PDE inhibitor - non-specific
Which drugs may exacerbate HF (5)
thiazolidinediones - pioglitazone - fluid retention
verapamil: negative inotropic effect
NSAIDs & glucocorticoids - fluid retention
class I antiarrhythmics - flecainide (negative inotropic and proarrhythmic effect)
SLE is associated with deficiencies of which complement factors
C3 and 4
A central scotoma points to a defect in which part of the optic pathway
Optic nerve
Inheritance of Hyperlipidaemia type II
AD
Ritonavir
P450 inhibitor or inducer
MOA
Inhibitor
Protease inhibitor
Causes of a raised prolactin (the Ps)
Pregnancy / physiological Prolactinoma polycystic ovarian syndrome primary hypothyroidism Drugs - phenothiazines, metoclopramide, domperidone
MOA of ticagrelor
Plt ADP-R (P2Y12) inhibitor
Does not undergo hepatic activation - not vulnerable to p450 interaction, which clopidogrel is
Reversible allosteric block
Indications for IV Ig (10)
- primary and secondary immunodeficiency
- low serum IgG levels following haematopoietic stem cell transplant for malignancy
- pneumonitis induced by CMV following transplantation
•toxic epidermal necrolysis
idiopathic thrombocytopenic purpura
•Kawasaki disease
•dermatomyositis
- myasthenia gravis
- Guillain-Barre syndrome
- chronic inflammatory demyelinating polyradiculopathy
Which drugs can cause cholestasis (6)
SOAP SF
Steroids
oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
Resistance to ARV drugs tends to be against what class
RTIs
What is the test for hypopituitarism
Combined pituitary function test Including hypoglycaemia (<2.2) to stimulate ACTH and GH
Spearman, Kendall rank
Parametric or non-parametric data
Non-parametric
Tests correlation
SLE is associated with which antibody
anti dsDNA - specificity 99%; sensitivity 70%
Which antibiotic can cause a peripheral neuropathy & optic neuritis
Nitrofurantoin
What is the effect of C1 inhibitor (C1-INH) protein deficiency
Hereditary angioedema
Renal failure in Alports post transplant is typically caused by
Anti GBM antibodies causing a goodpastures like picture
Diffuse systemic sclerosis is associated with which antibody
Scl-70 antibodies
Secretin
Released by which cells
Stimulus
Effect
S cells
Acidic chyme and fatty acids
Increases pancreatic secretions of bicarb from centriacinar cells and hepatic duct cells.
Decreases gastric acid secretion
Indications for IFN-g
Chronic granulomatous disease
Osteopetrosis
Inheritance of Myotonic dystrophy
AD
Associated with small cell lung carcinoma and neuroblastomas
sensory neuropathy - may be painful
cerebellar syndrome
encephalomyelitis
Anti-Hu
Ipilimumab
MOA
CTLA-4 inhibitor
antibiotic of choice for legionnaire’s disease
quinolone
Leukocyte adhesion deficiency Which cell type is affected Defect Effect Test
Neutrophil disorder
Defect of LFA-1 integrin (CD18) protein on neutrophils
Recurrent bacterial infections, Delay in umbilical cord sloughing
Absence of neutrophils/pus at sites of infection
Saquinavir
P450 inhibitor or inducer
MOA
Inhibitor
Protease inhibitor
IFN-gamma
Function
Indications (2)
Produced by T lymphocytes and NK cells
Weaker antiviral action, more of a role in immunomodulation particularly macrophage activation
Chronic granulomatous disease and osteopetrosis
t(8;14) - disease and mechanism
Burkitt’s lymphoma
Myc - Ig
Histology of FSGS
LM - focal and segmental sclerosis
EM - Thickening of GBM
IF - IgG and C3 deposition
Which GN typically present with nephrotic syndrome
Typically presents with nephrotic syndrome (proteinuria, oedema)
Minimal change disease
typically a child with nephrotic syndrome (accounts for 80%)
causes: Hodgkin’s, NSAIDs
good response to steroids
Membranous glomerulonephritis
presentation: proteinuria / nephrotic syndrome / chronic kidney disease
cause: infections, rheumatoid drugs, malignancy
1/3 resolve, 1/3 respond to cytotoxics, 1/3 develop chronic kidney disease
Focal segmental glomerulosclerosis
may be idiopathic or secondary to HIV, heroin
presentation: proteinuria / nephrotic syndrome / chronic kidney disease
What is Weber’s syndrome
What causes it
Ipsilateral third nerve palsy with contralateral hemiplegia -
Midbrain strokes
Drugs causing retinopathy
Hydroxychloroquine
Vigabatrin
What cytokine activates macrophages
What cell release it
IFNg Th1 cells (induced by IL12)
Inheritance of Becker muscular dystrophy
X-linked recessive
What is the inheritance of hypophosphataemic rickets
X-linked dominant
Regimes in multiple myeloma
x
Lamivudine, emtricitabine, epzicom, combivir, trizivir
Zidovudine (AZT)
zalcitabine, stavudine
Abacavir
MOA
SE
Nucleoside RTI
SE - peripheral neuropathy
MODY2
What is the mutation
CF
tx
Mutation in glucokinase (glucose sensor in pancreatic beta cells)
Controlled with diet alone
Association of HLA-DR2 (3)
narcolepsy
Goodpasture’s
SLE
MS
Gastrin
Released by which cells
Stimulus
Effect
G cells in the duodenum & pyloric antrum
Gastric distension, luminal peptides, vagus nerve
Increases acid secretion from parietal cells, pepsinogen and intrinsic factor secretion
Stimulates maturation of parietal cells
Contraindications to lung cancer surgery
SVC obstruction
FEV < 1.5
MALIGNANT pleural effusion
Vocal cord paralysis
Premack principle
Less desired behaviours can be encouraged by use of a more desired reward
Often used in eating disorders
Paroxysmal nocturnal haemoglobinuria is associated with what cell markers
and what is the classic triad
CD and CD59 negative cells
Haemoglobinuria, pancytopenia, venous thrombosis
What are the features of an axonal polyneuropathy
What are the causes (5)
Axonal pathology - conduction speed not lost, but action potential is smaller
Alcohol
Diabetes mellitus (may also cause a demyelinating picture)
Vasculitis
Vitamin B12 deficiency (may also cause a demyelinating picture)
Hereditary sensorimotor neuropathies (HSMN) type II
What is the 1st line DMARD for PsA
Methotrexate
acute intermittent porphyria is due to a defect in which enzyme
Porphobilinogen synthase
CLL causes what kind of autoimmune haemolytic anaemia
Warm AHA
Cutaneous leishmaniasis
Species
Tx
L major/ mexicana / tropicana
Topical sodium stibogluconate
MS - good prognostic factors (5)
Female Young onset Sensory symptoms Long gap between attacks Relapsing remitting disease
Student’s t-test
Parametric or non-parametric data
Parametric
Complications of hepatitis B (6)
Chronic hepatitis Liver failure HCC Glomerulnephritis Polyarteritis nodosa Cryoglobulinaemia
Histology of membranous GN
LM - thickening of GBM and capillaries
EM - Subepithelial deposits
IF - Granular IgG and C3 on outside of GBM
Inheritance of Marfan’s syndromes
AD
Which drugs can cause hepatocellular damage / hepatitis (10)
Paracetamol Anti-convulsants - sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin
Thresholds for dx of DM
Fasting
>7 -> DM
6-7 -> IFG
<6 -> normal
OGTT
>11.1 -> DM
7.8-11.0 -> IFG
<7.8 -> normal
Random >11.1
Which has more effect, R- or S-warfarin
Which p450 metabolises it
Which drug interacts
S-warfarin
2c9
Metronidazole - decreases metabolism of the more efficacious S-warfarin
Goodpasture’s vs Wegener’s - which is more associated with a raised ESR
Goodpastures
Maxillary nerve (V2) Which skull foramen
Foramen rotundum
What are the risk factors for cataracts?
How are they classified (2)
Most are age related
Systemic DM Steroids Infection - congenital rubella Metabolic - hypo-Ca, galactosaemia Conditions - myotonic dystrophy, Down's
Ocular •trauma •uveitis •high myopia •topical steroids
Which cyclins and CDKs are active in G1 phase of cell cycle
Cyclin D and E; CDK 2,4,6
What is the Haldane effect
Increase in pO2 means CO2 binds less well to Hb
How are the causes of cataracts classified (2)
(i) 5
(ii) 4
Most are age related
Systemic DM Steroids Infection - congenital rubella Metabolic - hypo-Ca, galactosaemia Conditions - myotonic dystrophy, Down's
Ocular •trauma •uveitis •high myopia •topical steroids
Association of HLA-B27
ankylosing spondylitis
Reiter’s syndrome
acute anterior uveitis
What are Gram positive rods
ABCD L
Actinomyces Bacillus Clostridium Corynebacterium diphtheria Listeria
Varenicline
MOA
Nicotinic receptor partial agonist
Drugs known to precipitate TEN/SJS (6)
Phenytoin, carbamazepine, penicillin, sulphonamides, NSAIDs, allopurinol
Tx with IVIg +/- immunosuppression (cyclophosphamide, ciclosporin) +/- plasmapheresis
How is hep c confirmed
HCV RNA
Inheritance of Alports disease
X linked dominant
10-15% are autosomal recessive
What are used as prophylaxis in migraine
Topiramate
Propranolol
naftidrofuryl
MOA
5HT2 antagonist
Used for intermittent claudication -> vasodilation
How do you calculate OR
What sort of study generates an OR
Odds of intervention / odds of control
Odds = number with thing / number without thing
Case control - retrospective
Association of HLA-DR3
dermatitis herpetiformis Sjogren's syndrome primary biliary cirrhosis Primary sclerosing cholangitis T1DM
What is the mutation that leads to carbapenem resistance
New Delhi metallo-beta-lactamase 1
IL-8
Source:
Effect:
Source: Macrophages
Effect: Neutrophil chemotaxis
Leprosy
What is the classification
How are they treated
Tuberculoid leprosy (immunocompetent) vs Lepromatous leprosy (immunosuppressed)
Tuberculoid leprosy (immunocompetent) Monthly rifampicin & daily dapsone for 6mths
Lepromatous leprosy (immunosuppressed) Monthly rifampicin; daily dapsone & clofazamine for 24mths
what is the initial step in metabolism of isoniazid
acetylation
Normal range for TSH
0.5 - 2.5
Amiodarone induced thyrotoxicosis I
Pathology
Goitre present or not
Tx
Excess iodine induced thyroxine synthesis -> thyrotoxicosis
Goitre present
Tx: K percolate or carbimazole
TNFa is released from what cell
What is its effect
Macrophages
Fever and neutrophil chemotaxis
Bleomycin
Class
SE
Cytotoxic - Degrades preformed DNA - single DNA strand scission causing inhibition of cell division
(Blows over preformed DNA)
Lung fibrosis
Association of HLA-DR2 (3)
narcolepsy
Goodpasture’s
SLE
Methotrexate
MOA
SE
MOA: Antimetabolite; Inhibits dihydrofolate reductase and thymidylate synthesis
SE: Myelosuppression, mucositis, liver fibrosis, lung fibrosis
Which cyclins and CDKs are active in S phase of cell cycle
Cyclin A and CDK 2
Sleep terrors occur in which stage of sleep
Early stage 4
After 3mths of statin use, what is the target for cholesterol
> 40% reduction in non-HDL cholesterol
What drugs are levels informative in toxicity (8)
Paraquat Paracetamol Salicylate Li Iron Methanol Ethylene glycol Theophylline
SE of isoniazid
Peripheral neuropathy - taken with pyridoxine (B6)
Drug induced lupus
What is Charles Bonnet syndrome
Visual hallucinations, known not to be real, in isolated elderly people, often with impaired vision.
Ribavirin
MOA
SE
MOA:
Guanosine analog which inhibits inosine monophosphate (IMP) dehydrogenase -> interferes with the capping of viral mRNA
SE: haemolytic anaemia
What is the tx for plaque psoriasis
1st, 2nd, 3rd
1 - Potent topical steroid with calcipotroil
Both applied daily for 4wks, one in the morning and one the evening
2 - BD topical vitamin D analogue if no improvement after 8wks
3 - a potent corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation applied once or twice daily
short-acting dithranol can also be used
What is the mode of action of terlipressin in hepatorenal syndrome
Smooth muscle relaxation -> decreased renin secretion
Nivolumab
MOA
PD-1 inhibitor
Cardiolipin tests for syphilis
Examples (2)
Stay positive or negative after tx’d infection
examples VDRL & RPR
becomes negative after treatment
Cushings / Conns causes what kind of metabolic disturbance
Hypochloraemic metabolic alkalosis - low K, high Na
Paraneoplastic syndromes - Anti-GAD antibody
Associations
CF
Associated with breast, colorectal and small cell lung carcinoma
CF: stiff person’s syndrome or diffuse hypertonia
Porphyria cutanea Garda is due to a defect in which enzyme
What accumulates
Uroporphyrilinogen decarboxylase
Inheritance of Retinoblastoma
AD
What is the commonest form / source of partial seizure
Temporal lobe epilepsy
Which spirometry measure is used to monitor the severity & progression of COPD
FEV1
FEV1/FVC <0.7 is for diagnosis only
Inheritance of Fanconi anaemia
AR
Drugs causing erythema nodosum
Hep B vaccine
Omeprazole
Isoretinoin
t(8;21) is associated with which condition
What is likely to be present
AML
Auer rods
Inheritance of AT-III deficiency
AD
IL-5
Source:
Effect:
Source: Th2 cells
Effect: Stimulate production of eosinophils
What is the side effect of GLP1 analogues
When are they CI
Delayed gastric empyting
CI if gastroparesis
Inheritance of Nephrogenic diabetes insipidus
X-linked recessive
Inheritance of Neurofibromatosis and chromosomes
AD
NF1 - chr 17 (neurofibromatosis has 1 letters)
NF2 - chr 22 (all the 2s)
Raltegravir, elvitegravir, dolutegravir
MOA
Integrase inhibitors
Confirmatory test for coeliac disease
Eat gluten for 6wks
Jejunal biopsy
What are the acute SE of phenytoin (3-4)
Cerebellar sx - ataxia, slurred speech, dizziness
Diplopia
Nystagmus
+/- confusion & seizures
What additional SE is present with sulfasalazine over mesalazine
Oligospermia
What is the commonest cause of erythema multiforme
Herpes simplex
How should AF with WPW be managed
Flecainide or DC cardioversion
Didanosine
MOA
SE
Nucleoside RTI
SE: pancreatitis - didanosine makes you die of pancreatitis
enfuvirtide
MOA
Attachment inhibitor - CCR5 antagonist
What are the congenital causes of optic neuropathy
Friedrich’s
Mitochondrial disorders - Leber’s
Retinitis pigmentosa
Wolfram syndrome
Features of a Holmes-Adie pupil
Dilated pupil
Slowly contracts to light and accommodation
Once constricted is very slow to dilate
Associated with decreased ankle reflexes
HSMN type 2 gives what type of peripheral neuropathy
axonal
Othello syndrome
Pt falsely holds wife / partner to be cheating on them, despite no evidence to support it
What are the 5 patterns of psoriatic arthritis
Rheumatoid-like polyarthritis (commonest)
Oligoarthritis - hands and feet; asymmetrical
DIP joint disease
Sacroiliitis
Arthritis mutilans
Causes of macroglossia (5)
Duchenne muscular dystrophy hypothyroidism Acromegaly Amyloidosis Mucopolysaccharidosis (e.g. Hurler syndrome)
Paraneoplastic syndromes - Anti-Yo
Associated with (2)
CF
Associated with ovarian and breast cancer
Cerebellar syndrome
What proportion of primary syphilis cases progress to tertiary
30%
Causes of a false positive syphilis cardiolipin test (5)
pregnancy SLE, anti-phospholipid syndrome TB & leprosy malaria HIV
What does troponin C bind
Calcium
What is the PPV of the faecal occult blood test for detecting colorectal cancer
5-15%
TNFa is mainly secreted by
Macrophages
What is the effect of C3 deficiency
Recurrent bacterial infections
Cadasil
What is it
What are the features
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
Inherited stroke disorder due to notch 3 mutation on chr19
Presents with migraines, mood disorder & TIA/strokes
Polyglandular autoimmune syndrome type 2
Also known as
Conditions within
HLA relation
Schmidt’s syndrome
HLA-DR3/4
Addison’s disease +/- T1DM or autoimmune thyroid disease
What signs are associated with a cholesterol embolism
Eosinophilia
Livedo reticularis
Purpura
Renal failure
Benserazide
MOA
Indication
Peripheral dopa-decarboxylase inhibitor
PD - reduces peripheral conversion of l-dopa to DA, reducing SE of postural hypotension and N&V
What is seen on histology of rheumatic fever
Achaff bodies (granuloma with giant cells)
How does alcohol cause a diuresis
Cranial DI - decreased release of ADH from the posterior pituitary
Secondary causes of hyper-TGaemia (6)
DM (1 and 2) - high VLDL and low HDL
(Asian diabetics tend to have high TGs and low HDL)
Obesity
Alcohol
Chronic renal failure
Liver disease
Drugs: thiazides, beta-blockers, unopposed oestrogen, immunosuppressants
What is the tx of VTE in cancer
LMWH for 6mths
Leukocyte alkaline phosphatase is: High in (6) Low in (4)
Raised in myelofibrosis leukaemoid reactions polycythaemia rubra vera infections steroids, Cushing's syndrome pregnancy, oral contraceptive pill
Low in chronic myeloid leukaemia pernicious anaemia paroxysmal nocturnal haemoglobinuria infectious mononucleosis
Which antibiotic class can lower the seizure threshold of epilepsy
Example
What is the mode of action
Quinolones
Ciprofloxacin
Inhibit DNA synthesis by interfering with DNA gyrase (topoisomerase II) and topoisomerase IV
Inheritance of leech nyhan syndrome
x-linked recessive
Which immunodeficiencies have defects in B & T cells
SCID Was Ataxic
SCID
Wiskott-Aldrich syndrome
Ataxia Telangiectasia
IL-12
Source:
Effect:
Source: APCs - Dendritic cells, macrophages, B cells
Effect: Activates NK cells and stimulates differentiation of naive T cells (Th0) into Th1 cells
Which SSRI is preferred for breast feeding
sertraline
How can the SE of phenytoin be classified (4)
Acute
Chronic
Idiosyncratic
Teratogenic
A prominent y descent in the JVP is seen in which condition
Constrictive pericarditis
capecitabine is a pro-drug to which chemotherapeutic
5FU
Gitelman vs Bartter syndrome
Which occurs as a child and which as an adult
Which causes stones
Bartter - child
Gitelman - adult
Both hypokalaemia met alkalosis
Bartters causes stones. Gitelman doesn’t
How long should anticoagulation be continued after DC cardioversion of AF
4wks
Association of HLA-DR3
dermatitis herpetiformis
Sjogren’s syndrome
primary biliary cirrhosis
Addisons
Levothyroxine absorption is decreased by taking it with which drugs
Ca or Fe
Inheritance of facioscapulohumeral muscular dystrophy
AD
Superior ophthalmic vein and Inferior ophthalmic vein
Oculomotor nerve (III), Trochlear nerve (IV) lacrimal, frontal and nasociliary branches of ophthalmic nerve (V1) Abducent nerve (VI)
All leave via which foramen
Superior orbital fissure
associated with ovarian and breast cancer
cerebellar syndrome
Anti-Yo
Inheritance of Haemophilia A,B
X-linked recessive
Commonest presentaiton of PsA
Asymmetrical seronegative oligoarthritis
How do you calculate relative risk
What sort of study generates an RR
experimental event rate / control event rate
ER = number with thing happening / TOTAL number in that arm
Cohort - prospective
Hashimotos thyroiditis increases the risk of what thyroid malignancy
Thyroid lymphoma
What is the first line treatment for MRSA UTI
Doxycycline / tetracyclines
Which immunodeficiencies have defects in B and T cells
SCID Was Ataxic
SCID
Wiskott-Aldrich syndrome
Ataxia Telangiectasia
Gaucher’s disease
Defect
CF - 4
Glucocerebrosidase deficiency
Bruising & thrombocytopaenia Fatigue & anaemia Bone lesions / fractures Immunocompromise Hepatosplenomegaly
Chronic granulomatous disease Which cell type is affected Defect Effect Tests
Neutrophil disorder
Lack of NADPH oxidase
Reduced ability of phagocytes to produce reactive oxygen species
Recurrent pneumonias and abscesses, particularly due to catalase-positive bacteria (e.g. Staphylococcus aureus and fungi (e.g. Aspergillus)
Negative nitroblue-tetrazolium test
Abnormal dihydrorhodamine flow cytometry test
What drugs demonstrate zero-order kinetics (3)
Alcohol, phenytoin, salicylates
What are the causes of a decreased TLCO
Fibrosis Pneumonia Right to left shunting - pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output
Chlorambucil
MOA
Indication
Cold autoimmune haemolytic anaemia
Alkylating agent
Erythema gyratum repens is associated with which malignancy
Bronchial
what drugs are metabolised by acetylation
Drugs affected by acetylator status - “I Prefer Dynamic Hip Screws” Isoniazid Procainamide Dapsone Hydralazine Sulfasalazine
Inferior ophthalmic veins
Infraorbital artery
Infraorbital vein
Zygomatic nerve and infraorbital nerve of maxillary nerve (V2)
Orbital branches of pterygopalatine ganglion
Which skull foramen
Inferior orbital fissure
Inheritance of Albinism
AR
Which cytokines to Th1 cells secrete (3)
Involved in the cell mediated response and delayed (type IV) hypersensitivity
IL2, 3
IFNg
Which cytokine triggers differentiation of Th0 cells to TH2 cells
IL5
Cadasil
What is it
What are the features
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
Inherited stroke disorder due to notch 3 mutation on chr19
Presents with migraines, mood disorder and TIA/strokes
IL-12
Source:
Effect:
Source: Dendritic cells, macrophages, B cells
Effect: Activates NK cells and stimulates differentiation of naive T cells into Th1 cells
Cinacalcet
MOA
Indication
MOA: agonsit at the calcium sensing receptor of the parathyroid.
Indication:
Used with tertiary hyper-PTHism to reduced PTH secretion, where surgical parathyroidectomy may not be appropriate
What is the driving restriction post first unprovoked/isolated seizure:
6 months - if no structural abnormalities on brain imaging & no definite epileptiform activity on EEG
Otherwise 12 months
What is fourth line for c. diff infection after oral metro, oral vac, IV metro
Fidaxomycin
What are the features of MEN2A
2Ps
Medullary thyroid cancer
Phaeochromocytoma
Parathyroid
HSMN type 1 gives what type of peripheral neuropathy
demyelinating
What electrophoresis pattern is seen in nephrotic syndrome
Low albumin
Raised a1 and a1 globulins
IHD and AF - what is the anticoagulation guideline
If stable IHD -> oral anticoagulation only
If recent PCI / ACS -> 6mths of dual anti-plt tx with oral anticoagulation, then single antiplt oral anticoagulation until 12mths
What are the SE of quinolone abx
Lower seizure threshold in patients with epilepsy
Tendon damage (including rupture) - the risk is increased in patients also taking steroids
Cartilage damage
Lengthens QT interval
What abx can precipitate theophylline toxicity
Macrolides & quinolone
Atazanavir
P450 inhibitor or inducer
MOA
Inhibitor
Protease inhibitor
Association of HLA-B5
Behcet’s disease
Association of HLA-B5
Behcet’s disease
Can cause both arterial and venous occlusion & venous vasculitis
If all stages of plasmodium are visible in the blood, what is the likely species
O vale
Which gastric diseases cause a lymphoma
Which cells are predominant
H. pylori - B-cell lymphoma
Coeliac - T-cell lymphoma
SE of oxaliplatin
Sensory polyneuropathy
Indications for IFN-a
Hep B&C
Metastatic renal malignancy
Kaposi sarcoma
Inheritance of Androgen insensitivity syndrome
X-linked recessive
What antibiotic causes creatinine to rise
Why
Trimethoprim
Competitively inhibits the tubular secretion of creatinine.
Rise reverses upon stopping the drug
Rise in creatinine does not represent a decrease in grr
patients with suspected idiopathic intracranial htn - should a dx LP take place or OCP stopped first
LP
For how long after a prosthetic valve replacement does staph epidermidis remain the most likely bug in IE, before staph aureus becomes more likely
2 months
Strep viridans becomes more likely long term
What is the standard error of the mean
= sd / root (number of patients)
Management (1st and 2nd line) tx of migraine in pregnancy
Migraine during pregnancy
paracetamol 1g is first-line
aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester
Commonest cause of HCC in the Uk
hep C (hep B worldwide)
Inheritance of Hereditary non-polyposis colorectal carcinoma (+genes -2)
Peutz-Jeghers syndrome
Inheritance of Familial adenomatous polyposis (+chr)
AD
HNPCC - MSH2 / MLH1
FAP - APC on chr 5
What needs to be monitored with leflunomide therapy
BP - can cause hypertension
Absorption of which drug is impaired by calcium carbonate or iron
Levothyroxine
IL-12
Source:
Effect:
Source: APCs - Dendritic cells, macrophages, B cells
Effect: Activates NK cells and stimulates differentiation of naive T cells (Th0) into Th1 cells
IL-5
Source:
Effect:
Source: Th2 cells
Effect: Stimulate production of eosinophils
Causes of a LBBB (7)
ischaemic heart disease hypertension aortic stenosis cardiomyopathy rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
Fluorouracil (5-FU)
MOA
SE
MOA: Antimetabolite; Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase)
SE: Myelosuppression, mucositis, dermatitis
What is common variable immunodeficiency (CVID)
Commonest clinically significant immunodeficiency
Defined as:
The presence of hypogammaglobulinaemia of two or more immunoglobulin isotypes (low IgG, IgA, or IgM)
Recurrent sinopulmonary infections
Impaired functional antibody responses
IgG is more likely to be deficient than IgM
What are the features of a demyelinating polyneuropathy
What are the causes (5)
Demyelinating pathology - slowed conduction due to loss of myelin
Guillain-Barre syndrome
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Amiodarone
Hereditary sensorimotor neuropathies (HSMN) type I
Paraprotein neuropathy
Inheritance of Hypokalaemic periodic paralysis
AD
On which chromosome are the alpha chains of Hb found (a-thal)
Chr 16
Which spirometry measure is used to monitor the severity and progression of COPD
FEV1
FEV1/FVC <0.7 is for diagnosis only
Inheritance of Von Hippel-Lindau syndrome
AD
HLA Cw6 is associated with
psoriasis
Associated with breast and small cell lung carcinoma
CF: ocular opsoclonus-myoclonus
Anti Ri
What drug is used in myeloma when thalidomide is not tolerated
bortezomib
What does troponin I bind
Actin
Inheritance of Noonan syndrome
AD
Steroids boost levels of which white cell
Neutrophils
What is familial dis-b-lipoproteinaemia
How is it treated
ApeE2/2 genotype causing raised TGs
Tx’d with omega 3 acids or fibrates
What are the thresholds for diagnosing DM in pregnancy
Fasting glucose >5.6
OGTT >7.8
What are the SE of topiramate (3)
Weight loss, renal stones, cognitive and behavioural changes
What is the tx of lichen planus
Topical steroids +/- oral steroids or immunosuppression if
extensive
Wilson's disease Gene defect, chromosome & inheritance Effects Serum caeruloplasmin is high/low Serum copper is high/low Urinary Cu excretion is high/low
AR inheritance of ATP7B gene on chr13
Cu deposition in basal ganglia, eyes and liver
Reduced serum caeruloplasmin
Reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
Urinary copper excretion - Increased
What is the preferred access for dialysis
AV fistula
What are the idiosyncratic SE of phenytoin (7)
2 blood - Megaloblastic anaemia, aplastic anaemia
2 skin / systemic - fever, rash (TEN)
2 liver - Dupytren’s contracture, hepatitis
SLE
Which cytokines to Th2 cells secrete (4)
involved in mediating humoral (antibody) immunity
e.g. stimulating production of IgE in asthma
secrete IL-4, IL-5, IL-6, IL-10, IL-13
Which drugs can precipitate acute glaucoma
Amitriptyline and anticholinergics
CCK
Released by which cells
Stimulus
Effect
I cells of upper small intestine
Partially digested proteins and TGs
Increases pancreatic secretions, GB contraction & relaxation of the sphincter of Oddi
Decreases gastric emptying
Trophic effect on pancreatic acinar cells
Induces satiety
Which cytokine triggers differentiation of Th0 cells to TH1 cells
IL12
Antibody associations of drug induced lupus
dsDNA -ve; anti ANA in 100%
Anti histone in 80-90%
anti-Ro, anti-Smith positive in around 5%
Maraviroc
MOA
Attachment inhibitor - CCR5 antagonist
t(11;14) - disease and mechanism
Mantle cell lymphoma Cyclin D1 (BCL-1) deregulation
Management of a secondary pneumothorax
If >50yrs & >2cm -> chest drain
1-2cm -> aspirate and if fails, chest drain
If <1cm -> oxygen only
What are the treatments for pseudo gout
NSAIDs
Colchicine if NSAIDs contraindicated
Optic nerve and Ophthalmic artery leave via which foramen
Optic canal
ECG changes associated with hypokalaemia
P wave flattening PR interval lengthening ST depression T wave flattening or inversion U waves Long QT interval
t(9;22) - disease and mechanism
Philadelphia chromosome - CML
Ondansetron
MOA
SE
5HT3 antagonist
Acts at the chemoreceptorvtrigger zone of the medulla oblongata
Constipation is main side effect
What are the chronic SE of phenytoin (7)
Peripheral neuropathy, gingival hyperplasia, coarsening of facial features, lymphadenopathy, hirsutism, osteomalacia, dyskinesia
Inheritance of Romano-Ward syndrome
AD
What does troponin T bind
Tropomyosin
SLE is associated with deficiencies of which complement factors
C3 and 4
What are the reversible complications of haemochromatosis
Cardiomyopathy
Skin pigmentation
Benzbromarone
MOA
Indication
Benzbromarone
MOA: URAT-1 inhibitor - increases excretion of uric acid
Indications:
For those who fail to achieve sufficient uric acid target or who are still sx despite maximal allopurinol therapy
What hormones are potentially secreted from a rental cell carcinoma
ACTH
Pth
Epo
Renin
Tuberous sclerosis
What is it
What is the gene defect
What are the features
AD inherited neurocutanoues syndrome
TSC1 on chr9 - hamartin
TSC2 on chr16 - tuberin
Features:
Cutaneous - ash leaf macules; shagreen patch; adenoma sebaceum; subungual fibromas;
Neurological - epilepsy, developmental delay
Abdo - polycystic kidneys, angiomyolipomas
Retinal - hamartomas
Cardiac rhabdomyomas
Churg Strauss is associated with which kind of GN
FSGS
A 30-year-old female is diagnosed with having Grave’s disease. What is her chance of developing thyroid eye disease?
25-50%
VIP
Released by which cells
Stimulus
Effect
Released by small intestine & pancreas
Stimulus: neural
Stimulates secretion by pancreas and intestines
Inhibits acid secretion
Inheritance of FAP
Gene
AD defect in APC gene - chr 5
Which drugs cause haemolysis in G6PDD (4)
Ciprofloxacin
Primaquire
Sulph-drugs - sulphonamides, sulphasalazine, sulfonylureas
What are the causes of a raised TLCO
Pulmonary haemorrhage Left to right shunts Hyperkinetic states Asthma Polycythaemia male gender, exercise
Which cytokines to Th1 cells secrete (3)
Involved in the cell mediated response and delayed (type IV) hypersensitivity
IL2, 3
IFNg
What are the tx options for hiccoughs in palliative care
Chlorpromazine or haloperidol
Associations of mesangiocapillary GN
Mesangiocapillary glomerulonephritis (membranoproliferative) type 1: cryoglobulinaemia, hepatitis C type 2: partial lipodystrophy
Terbinafine
MOA
Inhibits squalene oxidase
Prognostic markers in ALL - good or bad?
Hypodiploidy
Hyperdiploidy
Trisomy 4, 10 and 17
t(12;21) translocation
t(1:19) translocation
t(9:22) translocation
Precursor B-ALL
Hypodiploidy - bad
Hyperdiploidy - good
Trisomy 4, 10 and 17 - good
t(12;21) translocation - good
t(1:19) translocation - good
t(9:22) translocation - bad
Precursor B-ALL - good; more responsive to chemotherapy
Secondary causes of hypercholesterolaemia (3 - organs)
Hypercholesterolaemia:
Kidneys - Nephrotic syndrome, Chronic renal failure, dialysis or post-transplant
Liver - Cholestasis
Thyroid - Hypothyroidism
Which drugs can worsen gout
Ciclosporin, alcohol, nicotinic acid, thiazides, loops, ethambutol, aspirin, pyrazinimade
What are the 5 stages of lung changes in sarcoid
Stage 0 - normal CXR Stage 1 - BHL only Stage 2 - BHL and pulmonary infiltrates Stage 3 - Diffuse pulmonary infiltrates only Stage 4 - widespread fibrosis
Febuxostat
MOA
Indication
CI
Xanthine oxidase inhibitor
Gout
CI with azathioprine - causes toxic accumulation
What is added to standard RIPE therapy for tx of TB meningitis
Steroids
t(9;22) - disease and mechanism
Philadelphia chromosome - CML
Histology of IgA nephropathy
LM - Mesangial cell proliferation
IF - Granular IgA and C3 deposition in the mesangium
Nevirapine
Delavirdine
Efavirenz
Non-nucleotide RTI
Which TCAs are best and worst in OD
Best (least bad) - lofeprimine
Worst - amitryptiline or dosulepin
What is the treatment for mall and syndrome
bHCG
Hydroxyurea
MOA
SE
MOA: cytotoxic; Inhibits ribonucleotide reductase, decreasing DNA synthesis
SE: Myelosuppression
Contraindication to lobectomy
FEV1 <1.5L
Inheritance of Duchenne muscular dystrophy
X-linked recessive
What are pts with Di George syndrome most at risk of
T-cell defect - viral and fungus infections
Eg cryptococcus
What does the galactomannan test test for
ELISA - Invasive aspergillosis
What are parameters of the CURB65 score
Confusion Urea >8 RR >30 BP <90 syst or <60 dias Age >65
What is the tx for bacillus anthracis infection
Ciprofloxacin or doxycycline
Test of choice for giardia
Stool culture / antigen testing
Causes of membranous GN
Classification (5)
idiopathic
infections: hepatitis B, malaria, syphilis
malignancy: lung cancer, lymphoma, leukaemia
drugs: gold, penicillamine, NSAIDs
autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
Association of HLA-DR4
T1DM (associated with DR4>DR3) rheumatoid arthritis Pemphigus Drug induced SLE PMR IgA nephropathy
What is the role of IL-1
What is it secreted by
It is secreted mainly by macrophages and monocytes and acts as a costimulator of T cell and B cell proliferation.
Increases the expression of adhesion molecules on the endothelium.
Stimulates the release by the endothelium of vasoactive factors such as PAF, nitric oxide and prostacyclin
Causes vasodilation and increases vascular permeability.
Which is painful, scleritis or episcleritis
Scleritis because it stings
What tx is used for Tourette’s syndrome
Atypical antipyschotic eg risperidone
TNFa is released from what cell
What is its effect
Macrophages
Fever and neutrophil chemotaxis
MODY3 - 60%
What is the mutation
CF
tx
HNF-1a gene mutation
Higher glucose levels to be required to elicit insulin secretion.
Usually responsive to sulfonylureas - insulin not usually necessary
Inheritance of Colour blindness
X-linked recessive
Which antibody is most likely to be positive in dermatomyositis
ANA - commonest (positive in 60%)
25% are anti-Mi-2 positive - most specific
Driving restrictions
Angioplasty (elective)
Angioplasty (elective) - 1 week off driving
What is the driving restriction for someone experiencing multiple TIAs over a short time period
3mths
c3 nephritic factor is what
Anti-C3bBb
Chediak-Higashi syndrome Which cell type is affected Defect Effect CF
Neutrophil disorder
Microtubule polymerization defect
Decrease in phagocytosis
Partial albinism, peripheral neuropathy, recurrent bacterial infections
Which kind of melanoma is normally seen on the palms and soles
Acral lentiginous
IL-4
Source:
Effect:
Source: Th2 cells
Effect: Stimulates proliferation and differentiation of B cells
Driving restrictions
Successful catheter ablation for an arrhythmia
successful catheter ablation for an arrhythmia- 2 days off driving
Paroxysmal nocturnal haemoglobinuria is associated with what cell markers
& what is the classic triad
CD55 & CD59 negative cells
Haemoglobinuria, pancytopenia & venous thrombosis
Mucocutaneous leishmaniasis
Species
Tx
L. braziliensis
amphotericin B
HLA DR1 is associated with what
Bronchiectasis
Wernicke’s area
Where is it
What does it do
What effect does a stroke in this area have
Superior temporal gyrus - left temporal lobe
Responsible for recognising and analysing spoken language.
Causes a receptive dysphasia - poor repetition, poor comprehension
Amiodarone induced thyrotoxicosis II
Pathology
Goitre present or not
Tx
Amiodarone related destruction of the thyroid
No goitre
Steroids
What cytokine activates macrophages
What cell release it
IFNg Th1 cells (induced by IL12)
pH 7.4 corresponds to what H+ conc
pH 7.0 corresponds to what H+ conc
- 4 = H+ of 40
7. 0 = H+ of 100
Irradiated blood is given to prevent what
Graft vs host disease
Mandibular nerve (V3)
Accessory meningeal artery
Which skull foramen
Foramen ovale
Features of lateral medullary syndrome
Cerebellar features
ataxia
nystagmus
Brainstem features
ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
5 stages of diabetic glomerular nephropathy
Stage 1 - hyperfiltration: increase in GFR
Stage 2 (silent or latent phase) - pre-microalbuminuria
Stage 3 (incipient nephropathy) - microalbuminuria
Stage 4 (overt nephropathy) - persistent proteinuria
Stage 5 - end-stage renal disease
Commonest SE of ticagrelor
Dyspnoea
What is the best prognostic marker in multiple myeloma
B2 microglobulin
Features of Alports syndrome
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus: protrusion of the lens surface into the anterior chamber
retinitis pigmentosa
renal biopsy: splitting of lamina densa seen on electron microscopy
Causes of a raised anion gap
Raised anion gap lactate: shock, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol
chi-squared test
Parametric or non-parametric data
Non-parametric
Used to compare proportions or percentages
Causes of a normal anion gap metabolic acidosis
Normal anion gap ( = hyperchloraemic metabolic acidosis) GRAD GI bicarbonate loss: diarrhoea, fistula Renal - renal tubular acidosis Drugs: e.g. acetazolamide Addison's disease
At what level of falciparum parasitaemia should exchange transfusion be considered
10% parasitaemia on blood film
What is the commonest malignancy associated with dermatomyositis
Lung
What is the treatment for leptospirosis (Weil’s disease)
Penicillin or doxycycline
What ophthalmic condition is most commonly associated with Charles Bonnet syndrome
AMD
Which drug class is used first line to tx glaucoma in those with asthma
Prostaglandin analogue - latanoprost
What are Gram negative cocci (2)
Neisseria & moroxella
What is the MOA of mycophenylate
Inhibits inosine monophosphate dehydrogenase
IL-6
Source:
Effect:
Source: Macrophages, Th2 cells
Effect:
Stimulates differentiation of B cells
Induces fever
Foramen rotundum
Maxillary nerve (V2)
What are the features of MEN2B
1P Phaeo Medullary thyroid Marfanoid Neurofibromatosis / neuromas
4 features of tetralogy of fallot
Overriding aorta
Pulmonary atresia
Right ventricular hypertrophy
VSD
What is the screening test for hereditary angiooedema
C4
What is the most common ocular manifestation of RA
Keratoconjunctivitis sick - dryness of the eyes
What factor is the strongest predictor of the risk of progression to cirrhosis in hep B
Viral load
Drugs causing a raised ICP (7)
Steroids Tetracyclines OCP Isoretinoin Levothyroxine Lithium Antihistamine - cimetidine
Treponemal specific tests for syphilis
Examples (2)
Stay positive or negative after tx’d infection
THPA
Stay positive
IL-3
Source:
Effect:
Source: Activated T helper cells
Effect: Stimulates differentiation and proliferation of myeloid progenitor cells
What is the urinary test for phaeochromocytoma
24hr metnephrins
Inheritance of Neurofibromatosis and chromosomes
AD
NF1 - chr 17 (neurofibromatosis has 1 letters)
NF2 - chr 22 (all the 2s)
Drugs which can precipitate myasthenia crisis
Beta-blockers
Penicillamine, Quinidine, procainamide, Li, Phenytoin
Abx: aminoglycosides (gentamicin), macrolides, quinolones, tetracyclines
What is the role of IL-1
What is it secreted by
It is secreted mainly by macrophages and monocytes and acts as a costimulator of T cell and B cell proliferation.
Increases the expression of adhesion molecules on the endothelium.
Stimulates the release by the endothelium of vasoactive factors such as PAF, nitric oxide and prostacyclin
Causes vasodilation and increases vascular permeability.
MODY5
What is the mutation
CF
tx
HNF-1b gene mutation
Pancreatic atrophy & renal cysts
Usually responsive to sulfonylureas - insulin not usually necessary
Which is more common - ostium primum or ostium secundrum ASD
Ostium secundum
Commonest complication of ERCP
Acute pancreatitis