MRCP deck 1 Flashcards
(10 cards)
- 34-year-old woman is admitted to the Emergency Department following a collapse. An ECG shows a polymorphic ventricular tachycardia. Which one of the following is not associated with an increased risk of developing torsade de pointes?
A. Tricyclic antidepressants
B. Subarachnoid haemorrhage
C. Hypercalcaemia
D. Romano-Ward syndrome
E. Hypothermia
Hypocalcaemia, not hypercalcaemia, causes prolongation of the QT interval and hence may predispose to the development of torsade de pointes
Long QT syndrome
Long QT syndrome (LQTS) is an inherited condition associated with delayed repolarization of the ventricles. It is important to recognise as it may lead to ventricular tachycardia and can therefore cause collapse/sudden death.
The most common variants of LQTS (LQT1 & LQT2) are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.
Features
*may be picked up on routine ECG or following family screening
*Long QT1 - usually associated with exertional syncope, often swimming
*Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditorystimuli
*Long QT3 - events often occur at night or at rest
*sudden cardiac death
Management
*avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise)
beta-blockers**
*implantable cardioverter defibrillators in high risk cases
A 27-year-old woman is reviewed in the asthma clinic. She currently uses salbutamol inhaler 100mcg prn combined with beclometasone dipropionate inhaler 400mcg bd. Despite this she is having frequent exacerbations of her asthma and recently required a course of prednisolone. What is the most appropriate next step in management?
A. Add a leukotriene receptor antagonist
B. Add tiotropium
C. Add salmeterol
D. Start to take the salbutamol regularly, 2 puffs qds
E. Switch beclometasone to fluticasone
Long acting B2-agonists acts as bronchodilators but also inhibit mediator release from mast cells. Recent metaanalysis
showed adding salmeterol improved symptoms compared to doubling the inhaled steroid dose
Refer to the lastest GINA guidelines
A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following:
Hb 13.9 g/dl
WBC 6.1 *109/l
Platelets 246 *109/l
Bilirubin 33 μmol/l
ALP 292 u/l
ALT 47 u/l
What is the most likely diagnosis?
A. Systemic lupus erythematous
B. Infectious mononucleosis
C. Primary biliary cirrhosis
D. Autoimmune hepatitis
E. Primary Sjogren’s syndrome
The dry mouth is this patient is due to sicca syndrome, which occurs in 70% of cases of primary biliary cirrhosis.
The raised alkaline phosphatase point towards a diagnosis primary biliary cirrhosis rather than primary Sjogren’s
syndrome.
Which one of the following is a recognised cause of hypokalaemia associated with hypertension?
A. Liddle’s syndrome
B. Bartter’s syndrome
C. Gitelman syndrome
D. Ciclosporin
E. Renal tubular acidosis
Liddle’s syndrome
Hypokalaemia and hypertension
For exams it is useful to be able to classify the causes of hypokalaemia in to those associated with hypertension, and those which are not.
Hypokalaemia with hypertension
Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Liddle’s syndrome
11-beta hydroxylase deficiency*
Carbenoxolone, an anti-ulcer drug, and liquorice excess can potentially cause hypokalaemia associated with
hypertension
Hypokalaemia without hypertension
diuretics
GI loss (e.g. Diarrhoea, vomiting)
renal tubular acidosis (type 1 and 2**)
Bartter’s syndrome
Gitelman syndrome
A 30-year-old man is investigated for enlarged, painless cervical lymph nodes. A biopsy is taken and a diagnosis
of Hodgkin’s lymphoma is made. Which one of the following types of Hodgkin’s lymphoma carries the best
prognosis?
A. Lymphocyte predominant
B. Mixed cellularity
C. Nodular sclerosing
D. Hairy cell
E. Lymphocyte depleted
Hodgkin’s lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-
Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades
Histological classification
nodular sclerosing: most common, good prognosis
mixed cellularity: good prognosis
lymphocyte predominant: best prognosis
lymphocyte depleted: least common, worst prognosis
‘B’ symptoms also imply a poor prognosis
weight loss > 10% in last 6 months
fever > 38ºC
night sweats
Other factors associated with a poor prognosis identified in a 1998 NEJM paper included:
age > 45 years
stage IV disease
haemoglobin < 10.5 g/dl
lymphocyte count < 600/μl or < 8%
male
albumin < 40 g/l
white blood count > 15,000/μl
Reactive arthritis is associated with which one of the following HLA antigens?
A. HLA-B27
B. HLA-A3
C. HLA-DR4
D. HLA-B5
E. HLA-DR3
Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies. It encompasses Reiter’s syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a dysenteric
illness during the Second World War. Later studies identified patients who developed symptoms following a sexually transmitted infection (post-STI, now sometimes referred to as sexually acquired reactive arthritis, SARA).
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint.
A 27-year-old man is investigated for haemoptysis. He is a non-smoker and has no respiratory history of note. Whilst awaiting a bronchoscopy he becomes lethargic and anorexic.
Blood tests show the following:
Na+ 141 mmol/l
K+ 5.3 mmol/l
Urea 16.7 mmol/l
Creatinine 271 μmol/l
A renal biopsy is performed and shows linear IgG deposits along the basement membrane.
What type of antibodies are most likely to cause this type of presentation?
A. cANCA
B. IgA
C. pANCA
D. Anti-nuclear antibodies (ANA)
E. Anti-glomerular basement membrane (anti-GBM) antibodies
Goodpasture’s syndrome
IgG deposits on renal biopsy
anti-GBM antibodies
The combination of haemoptsis, renal failure and linear IgG deposits points to a diagnosis of Goodpasture’s
syndrome.
The ANCA-related nephropathies are associated with crescentic glomerulonephritis.
A 27-year-old man presents to the Emergency Department with 2 day history of severe headache and pyrexia
(38.2ºC).
A CT scan is reported as follows:
CT: Brain Petechial haemorrhages in the temporal and inferior frontal lobes. No mass effect. Brain parenchyma otherwise normal
What is the most likely diagnosis?
A. Brain abscess
B. Meningococcal meningitis
C. Cerebral malaria
D. Herpes simplex encephalitis
E. New variant CJD
CT head showing temporal lobe changes - think herpes simplex encephalitis
A 34-year-old man with a past history of HIV infection presents to the Emergency Department with watery diarrhoea. Cryptosporidium infection is confirmed on ZN staining.
What is the most suitable management?
A. Metronidazole
B. Sulfadiazine + pyrimethamine
C. Supportive therapy
D. Rifampicin + ethambutol + clarithromycin
E. Co-trimoxazole
Supportive therapy is the mainstay of treatment in Cryptosporidium diarrhoea
A 41-year-old man develops itchy, polygonal, violaceous papules on the flexor aspect of his forearms. Some of these papules have coalesced to form plaques.
What is the most likely diagnosis?
A. Lichen planus
B. Scabies
C. Lichen sclerosus
D. Morphea
E. Psoriasis
Lichen planus
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women
