MRCP Part 1 Flashcards
What is CRP?
Acute phase protein produced by the liver in response to increasing levels of IL6 (produced by macrophages)
CRP binds to damaged and foreign cells, increases complement activation and phagocytosis by macrophages
What does singing of a chest drain mean?
Chest drains should normally swing in response to breathing (inspiration –> fluid level up, expiration –> fluid level down)
Stopping swinging suggests that either the chest drain is blocked or the lung has re-expanded
What is the maximum rate at which you can remove fluid through a chest drain and why?
1 L at a time, followed by clamping for 1 hour
Risk of re-expansion pulmonary oedema
Should a chest drain bubble?
Only if it is a chest drain for a pneumothorax
If it is for a pleural effusion and it is bubbling, it may be suggestive of an air leak
How is digoxin loaded?
500 mcg –> 500 mcg (after 6 hours) then OD of:
125 mcg if tachycardic
67.5 mcg if normocardic
When should digoxin be used for rate control?
Heart failure patients as it is a negative chronotrope and a positive inotrope
How should your choice of antihypertensive change dependent on whether it is right or left heart failure with preserve ejection fraction?
RIGHT: choose venodilators (e.g. nitrates)
LEFT: choose arteriodilators (e.g. hydralazine, amlodipine)
What is a good medical treatment option for SIADH that has not improved with fluid restriction?
Demeclocycline
It is a tetracycline antibiotic that is used to treat Lyme disease and acne. It is good in SIADH as it induces a nephrogenic diabetes insipidus.
What is hidradenitis suppurativa?
Inflammatory skin condition characterised by recurrent painful skin abscesses
Which electrolyte should you be conscious of in patients who are receiving laxido/movicol?
Potassium (laxido/movicol contains potassium)
What dose should a nitrate infusion be started at?
2 mg/hour (50 mg in 50 mL)
Max dose 10 mg/hour
Which group of patients with active GI bleeding still require anticoagulation?
Inflammatory bowel disease (it is a prothrombotic state)
What should you always think about in a patient with normal blood pressure who is tachycardic?
Do they need fluids?
CO = SV x HR (if HR is high and CO is normal, then SV must be low)
NOTE: patients can have AF and be tachycardic without the tachycardia being caused by the AF (i.e. physiological tachycardia with AF)
What are the main types of renal tubular acidosis?
Type 1: DISTAL tubule dysfunction results in inability to excrete H+
Type 2: PROXIMAL tubule dysfunction results in inability to reabsorb bicarbonate
Type 4: ALDOSTERONE DEFICIENCY/RESISTANCE results in hyperkalaemia
NOTE: type 1 and type 2 are associated with hypokalaemia
What is May Thurner syndrome?
Compression of the left common iliac vein by the overlying right common iliac artery
Results in stasis of the blood and an increased risk of DVT
Which medication can be used to treat hiccups?
Chlorpromazine (typical antipsychotic)
NOTE: not to be confused with prochlorperazine which is a related medication used as an antiemetic
What is short bowel syndrome?
Malabsorption caused by a lack of small bowel (leads to diarrhoea, dehydration, malnutrition and weight loss)
Patients are typically given slightly sweet and slightly salty liquids
What dosing should be used for fondaparinux in patients with NSTEMI?
2.5 mg SC OD for up to 8 days (or until hospital discharge if sooner)
What is the link between magnesium deficiency and potassium deficiency?
Magnesium has an inhibitory effect on ROMK channels in the renal tubule, so a lack of magnesium results in increased excretion of potassium.
Magnesium deficiency also causes ineffective Na-K ATPase function
Why is magnesium used in the treatment of AF?
It acts as a weak calcium antagonist (blocks calcium at the AV node), resulting in a slower ventricular response
NOTE: this is the same way in which magnesium is used in asthma (relaxes the smooth muscle)
What are ESBLs?
Extended-spectrum beta lactamases - bacteria that are resistance to penicillins and cephalosporins
Why do loop diuretics cause hypocalcaemia?
The triple transporter in the ascending limb of the loop of Henle will absorb Na+ /K+/2Cl-. Na+ and 2CL- will be reabsorbed whilst K+ diffuses back into the tubule. This creates an electrochemical gradient (more positive in lumen, more negative in interstitium). Ca2+ will then flow down this gradient.
Blocking the triple transporter with loop diuretics will stop this effect and more calcium will be excreted in the urine.
What effect do thiazide diuretics have on calcium?
Thiazide promote calcium reabsorption (thereby causing hypercalcaemia).
NOTE: loop diuretics cause hypocalcaemia
What is atelectasis and what causes it?
Incomplete expansion of the lungs
It can be caused by anything that can reduce ventilation of airspaces (e.g. obesity, anaesthesia during surgery, mucus plug)
NOTE: it can cause hypoxia and increased risk of infection
Which bits of the brain are particularly affected by alcohol excess?
Cerebellum
Frontal lobe
Limbic System
What is bigeminy?
Repeated heart beat pattern (one long then one short) that is most often due to ectopic beats occurring so frequently that it happens after each sinus beat.
It does not require treatment unless it is symptomatic (then use beta-blockers)
What is trigeminy?
Ventricular ectopic occurs every third beat
What is a Premature Ventricular Contraction?
Heartbeat is initiated by the Purkinje fibres in the ventricles by the sinoatrial node
What does bifascicular block look like?
RBBB + left or right axis deviation
What does trifascicular block look like?
RBBB + left or right axis deviation + PR prolongation
List and give examples for the classes of antiarrhythmics.
Class 1 (Sodium Channel Blocker) - 1a: Quinidine, Procainamide, Disopyramide, Ajmaline - 1b: Lidocaine, Mexiletine, Phenytoin - 1c: Flecainide, Propafenone Class 2 (Beta-Blocker): bisoprolol Class 3 (Potassium Channel Blocker): amiodarone Class 4 (Calcium Channel Blockers): verapamil
What are the AEIOU indications for haemofiltration?
Acidosis Electrolyte Abnormalities (hyperkalaemia) Ingestion of Toxins Overload (Fluid) Uraemic Symptoms
What effect does multiple units of packed red cells have on coagulation?
It leads to an anticoagulant effect (as the packed red cell samples contain anticoagulant (calcium citrate))
This means that patients should also receive FFP if they have any more than 4 units of packed red cells
How does mycobacterium avium complex present in patients who are immunocompromised?
Similar to lymphoma Enlarged lymph nodes Fever Night sweats Weight loss
What is an advantage of RIG over PEG?
RIG does not require sedation and hence is better in patients with respiratory compromise (e.g. MND).
What is the main consequence of heparin-induced thrombocytopaenia?
Thrombosis
The binding of heparin to platelet factor 4 stimulates the generation of antibodies. These antibodies then bind to the heparin-platelet factor 4 complex and causes platelet activation resulting in thrombosis formation and depletion of platelets.
What does right ventricular strain look like on an ECG?
ST depression and T wave inversion in V1-3, I, II and aVF
How do you convert oral codeine to oral morphine?
10 mg codeine = 1 mg morphine
NOTE: breakthrough pain should be 1/6 of the total daily dose of morphine
Which organism is associated with causing infective endocarditis in patients with colorectal cancer?
Streptococcus bovis
What is the first-line treatment option for pericarditis?
NSAIDs and colchicine
How does TRALI present?
Hypoxia
Bilateral pulmonary infiltrates
Fever
Hypotension
NOTE: it is caused by the activation of host neutrophils by substances in the blood products. This triggers an inflammatory reaction within the lungs.
Which drugs increase the risk of gout?
Alcohol Diuretics Cytotoxics Ciclosporin Pyrazinamide
List some triggers for psoriasis.
Beta-blockers
Antimalarials
Stress
Streptococcal infection (guttate)
What is an indium labelled white cell study used for?
It labels white cell and watches where they accumulate (a bit like a PET scan for infection)
It is good for identifying occult abscesses
What pleural fluid results would you expect in a patient with empyema?
pH < 7.2
Glucose < 3.3 mmol/L
LDH > 1000
How do aminophyllines work?
Non-selective phosphodiesterase inhibitor (raises cAMP –> activate PKA –> inhibits TNF-alpha and leukotriene synthesis)
Non-selective adenosine receptor antagonist
NOTE: end result is bronchodilator
What are the presenting features of cerebral venous sinus thrombosis?
Headache
Papilloedema
Tonic Clonic Seizures
NOTE: MR or CT angiography/venography is required for diagnosis, and it is treated with anticoagulation
How does Whipple’s disease manifest?
Diarrhoea and arthropathy
Can also cause lymphadenopathy, skin hyperpigmentation, pleurisy and pericarditis
Duodenal biopsy shows subtotal villous atrophy which is PAS stain positive (caused by Tropheryma whipplei)
It is treated with oral co-trimoxazole
What is the first-line treatment option for gout?
NSAIDs
Colchicine 500 mg QDS can be used if NSAIDs are contraindicated (NOTE: reduced dose of 500 mg BD can be used in patients with renal impairment)
What is juvenile myoclonic epilepsy?
Condition characterised by generalised tonic clonic seizures usually provoked by sleep deprivation and excessive alcohol intake
Which common class of medications reduce excretion of lithium?
Diuretics (in particular, thiazide diuretics)
What is the cardiac index?
A haemodynamic parameter measured in intensive care which divides cardiac output from the left ventricle in one minute by the total body surface area
Low cardiac index is suggestive of cardiogenic shock
What are the typical presenting features of inclusion body myositis?
Weakness of quadriceps and long muscles of fingers
CK may be normal
What is Waldenstrom’s macroglobulinaemia?
A lymphoproliferative disorder characterised by IgM paraproteinaemia
It can result in hyperviscosity and splenomegaly
Which nerve root is responsible for the biceps reflex?
C56
Therefore, damage to this root will result in Erb’s palsy (loss of abduction and loss of biceps-mediated supination)
What is Liddle syndrome?
A secondary cause of hypertension resulting from a mutated epithelial sodium channel
Results in hypertension, alkalosis and hypokalaemia with suppressed renin and aldosterone.
What are the main features of dengue fever?
Fever, muscle aches, headache, rash
Lymphopaenia, Thrombocytopaenia and deranged LFTs
Which mutation is most often responsible for MODY?
Hepatic Nuclear Factor 1A (HNF1A)
NOTE: MODY presents in early adulthood with insulin-dependent diabetes mellitus (autosomal dominant) - they are very sensitive to sulphonylureas
When should phenytoin levels be checked after oral loading?
In roughly 2 weeks as phenytoin has a long half-life and therefore takes time to reach steady state concentrations
Aim 10-20 mg/L
What are the main functions of the proximal convoluted tubule?
Reabsorb sodium, amino acids and glucose
Exchange H+ ions for bicarbonate (reabsorb bicarbonate)
What are the symptoms of Waldenstrom hyperglobulinaemia?
Headaches
Nose bleeds
Hepatosplenomegaly
Papilloedema
NOTE: resulting from hypercoagulable state (Ix: protein electrophoresis)
What is the standard therapy used for small cell lung cancer?
Cisplatin and Etoposide
NOTE: carboplatin is used for those who cannot tolerate cisplatin
How does syringomyelia manifest?
Weakness in hands then arms (anterior horn cells)
Loss of pain and temperature in upper limbs (cape-like)
Followed by loss of fine touch, vibration and proprioception later on
What is the imidazoline receptor?
A receptor that can stimulate the sympathetic nervous system
Clonidine and Moxonidine block this receptor to achieve a reduction in blood pressure
What are the main consequences of hypophosphatemia?
Haemolytic anaemia Seizures Confusion Cardiomyopathy Skeletal Muscle Weakness
List some causes of hypophosphataemia.
Increased Renal Excretion
- Hyperparathyroidism
- X-Linked Hyperphosphataemia
- Fanconi Syndrome
- Diuretics
Decreased GI Absorption
- Reduced intake
- Phosphate binders (sevelamer)
- Alcohlism
Transcellular Shifts
- Refeeding syndrome
- Insulin
What is the treatment of choice for TTP?
Plasma exchange (steroids may be used as an adjunct)
Damage to which part of the brainstem would result in upgaze and downgaze palsy?
Dorsal Midbrain
It may also be associated with convergence nystagmus and impaired pupillary reflexes
NOTE: known as Parinaud syndrome
What is the treatment of choice for cerebral toxoplasmosis?
Sulfadiazine + Pyrimethamine + Folinic Acid for 6 Weeks
Describe the appearance of the rash in Darier’s disease.
Warty brown papules on the chest and back
Autosomal dominant inheritance pattern
What are the presenting symptoms of variant CJD?
Rapidly Progressive Dementia
Ataxia
Myoclonus
MRI –> Pulvinar Sign (High intensity in pulvinar region of thalamus) - described as ‘hockey stick sign’
Which antiemetic is used in the treatment of nausea and vomiting in hypercalcaemia?
Haloperidol
This is the most potent D2 antagonist and the mechanism of hypercalcaemia induced nausea is via the D2 receptor
Which foramen do crainal nerves IX, X and XI pass through?
Jugular Foramen
What is an appropriate fluid regime for someone who is admitted with DKA?
1 L 0.9% NaCl over 1 Hour 1 L 0.9% NaCl + KCl over 2 Hours 1 L 0.9% NaCl + KCl over 2 Hours 1 L 0.9% NaCl + KCl over 4 Hours 1 L 0.9% NaCl + KCl over 6 Hours
ADD 10% Dextrose at 125 mL/hour once BM < 14 mmol/L
BOLUS: 500 mL NaCl if SBP < 90 mm Hg
How should patients with DKA be monitored after commencing treatment?
HOURLY capillary ketones and glucose
VBG at 1 hour, 2 hours then every 2 hours thereafter
What is diabetic amyotrophy?
Complication of diabetes mellitus that results from damage to the lumbosacral plexus (supplying thighs and buttocks)
Manifests with lower leg pain, weakness, wasting and paraesthesia
List some CYP inhibitors that can increase the effect of warfarin.
Ciprofloxacin Clarithromycin Erythromycin Omeprazole Metronidazole Chloramphenicol Cranberry Juice
What are the manifestations of Brucellosis?
Fever Myalgia Weight loss Headache Abdominal pain
Bloods may show deranged LFTs but everything else may be normal
Blood cultures will be positive after 5 days (slow growing)
Caused by exposure to unpasteurised dairy products
What is high take off on an ECG?
Benign early repolarisation (looks like pericarditis) - common feature in < 50 yrs ST elevation in precordials leads Prominent T waves ST segment/T wave ratio < 0.25 Fishhook appearance in V4 ECG changes are stable over time
Which ECG change is seen in hypocalcaemia?
QT prolongation
NOTE: you get QT shortening in hypercalcaemia
Why does metformin cause lactic acidosis?
Mitochondrial toxicity + impaired gluconeogenesis (impairs pyruvate carboxylase which normally converts pyruvate into oxaloacetate)
What can be used as an antidote for excessive beta blockade?
IV glucagon
What are some features of lead poisoning?
Abdominal pain
Motor neuropathy
Basophilic stippling
Why is furosemide not effective in hypoalbuminaemic states?
It is highly protein bound and require protein binding in order to be secreted into the filtrate at the proximal convoluted tubule.
Other causes of reduced protein binding of furosemide include the presence of competing highly protein-bound drugs like phenytoin and warfarin.
What are the presenting features of lateral medullary syndrome?
Ipsilateral facial sensory loss
Contralateral body sensory loss
Cerebellar features (dysphagia, dysarthria, vertigo, nystagmus)
NOTE: due to PICA aneurysm/stroke
What is a major side-effect of ribavirin therapy?
Haemolytic anaemia
Which antibiotic causes a worsening of muscle weakness in Guillain Barre symptoms?
Ciprofloxacin
How is severe lithium overdose treated?
Haemodialysis (especially if level is > 4 mmol/L)
Name a long-acting opioid receptor antagonist used to prevent relapse in people who abuse opioids.
Naltrexone
List some common drugs that can increase serum lithium concentration.
Metronidazole NSAIDs ACE inhibitors and ARBs Thiazide diuretics Steroids
Describe the main features of pseudoxanthoma elasticum.
SKIN: yellow papules over neck, puckered skin
VASCULAR: PVD, mitral valve prolapse, GI bleed, visual loss (retinal angioid streaks)
NOTE: it is a hereditary disorder of elastic tissue
Which HLA types are associated with Coeliac disease?
HLA DQ2 and DQ8
Which type of lupus is ANA negative?
Discoid lupus
What are the two main types of porphyria and what is the difference?
Acute intermittent porphyria (no photosensitivity) Variegate porphyria (photosensitivity)
NOTE: both present with abdominal pain and hypertension
What is oral hairy leukoplakia caused by?
EBV
What are the features of theophylline toxicity?
Severe vomiting Seizures Hyperthermia Hypokalaemia Hyperglycaemia Tachyarrhythmia
How is ITP managed?
Oral Prednisolone –> IVIG
Splenectomy and immunosuppressive drugs (e.g. cyclophosphamide) may also be used
What is Evans syndrome?
AIHA + ITP
NOTE: it is treated with steroids
What is the issue with using iodine-containing contrast in patients with hyperthyroidism?
It can worsen hyperthyroidism caused by toxic multinodular goitre
It can improve hyperthryoidism in Graves’ disease
NOTE: a thyroid uptake scan would be recommended
What are the features of lithium overdose?
Decreased consciousness Neuromuscular excitability (tremor) Confusion Abdominal pain Vomiting AKI ECG Changes (TWI, QT prolongation)
How is tapeworm infection treated?
Niclosamide 2 g STAT
NOTE: tapeworm is caused by Taenia solium (pork) or Taenia saginata (beef)
What is the recommended antibiotic treatment option for cholera?
Ciprofloxacin
List some manifestations of temporal lobe epilepsy.
Ascending epigastric aura Olfactory/gustatory hallucinations Ictal fear Lip smacking/swallowing Limb automatisms (fiddling, tapping)
NOTE: caused by hippocampal sclerosis
What is a major complication of diphtheria?
Myocarditis
Which chemotherapy agents are commonly associated with peripheral neuropathy?
Vincristine
Cisplatin (platinum containing compounds)
Docetaxel (taxanes)
What is the dose conversion between hydrocortisone and prednisolone?
20 mg IV/PO Hydrocortisone = 5 mg PO Prednisolone
Which translocation causes APML?
15;17
NOTE: it is associated with DIC
Which cytokine is a particularly important target in the treatment of rheumatoid arthritis?
IL-6 (tocilizumab)
What is Ganser syndrome?
Dissociative disorder characterised by approximate answers, pseudohallucinations, somatic conversion, amnesia and reduced consciousness
What is the first-line treatment option for cervical dystonia?
Botulinum toxin injections
List some X-ray features of osteomyelitis.
Regional osteopaenia
Periosteal reaction
Focal bone lysis or cortical loss
How should exposure to hepatitis C be treated?
Monthly hepatitis C PCR
If it becomes positive, patients should be offered ribavirin and interferon (or daclatasivir)
What is Menetrier disease?
A rare condition associated with enlarged gastric folds in the fundus and body of the stomach
It causes epigastric pain, protein loss (hypoalbuminaemia) and hypochlorhydria
What are the features of Jervell and Lange-Nielsen syndrome?
Long QT
Bilateral sensorineural hearing loss
Why does urea increase in dehydration?
Vasopressin increases the activity of urea transporter 1 (UT-A1) in the collecting ducts
NOTE: the thin ascending limb of the loop of Henle and the inner medullary collecting ducts are permeable to urea. Urea adds to the osmolality of the medullary interstitium, thereby allowing the nephron to concentrate urine.
Why do psoas abscesses form?
The iliopsoas muscle has a very rich blood supply meaning that it is predisposed to haematogenous spread of infection.
What is DRESS syndrome?
Drug Reaction with Eosinophilia and Systemic Symptoms
TRIAD: extensive skin rash + high fever + organ involvement (e.g. liver impairment)
NOTE: Occurs most commonly with use of anticonvulsants (e.g. carbamazepine), allopurinol and sulphonamide antibiotics.
Why do you give a STAT amikacin for the treatment of urosepsis?
Treat the ESBLs
NOTE: they will be resistant against co-amoxiclav
Briefly describe Gittelman, Bartter and Liddle syndrome.
Gittelman: dysfunction of Na-Cl cotransporter in distal convoluted tubule (effects similar to thiazide diuretic use), leads to low calcium and low magnesium
Bartter: dysfunction of Na-K-Cl triple transporter in ascending limb of loop of Henle (effects similar to loop diuretic use)
Liddle: prevention of degradation of ENaC in collecting duct (effects similar to hyperaldosteronism)
What is another name for pANCA?
Anti-myeloperoxidase antibody
NOTE: cANCA target proteinase 3
What is the antibiotics treatment regimen of choice for cystic fibrosis patients with Pseudomonas infection?
Ceftazidime and tobramycin
What are some features of chronic lead poisoning?
Developmental delay
Abdominal pain
Blue line on gums
Constipation
What are some clinical features of vestibular schwannoma?
Unilateral sensorineural hearing loss
Ipsilateral ataxia
Facial weakness
Trigeminal sensory loss
What are some clinical features of vestibular schwannoma?
Unilateral sensorineural hearing loss
Ipsilateral ataxia
Facial weakness
Trigeminal sensory loss
How is a low-dose dexamethasone suppression test performed?
1 mg dexamethasone at midnight
Measure serum cortisol at 9 am
What is the difference between Wells, PERC and PESI?
Wells: Determine whether CTPA or D-Dimer would be required
PERC: Determine whether a PE is even a feasible possibility/requires further investigation
PESI: Determines mortality in people with a diagnosed PE
Which marker is used as a screening test for fungal infections?
Beta-D Glucan
At what point do you consider using negative suction to resolve a pneumothorax?
If a chest drain has failed to resolve the pneumothorax and there is a persistent air leak after 48 hours
What causes TRALI?
Presence of anti-HLA antibodies in the donated blood product
What are the Truelove and Witts criteria for a severe UC flare?
Bloody stools > 6 per day HR > 90 Temp > 37.8 Hb < 10.5 ESR > 30 CRP > 30
What is an option for the treatment of severe hand eczema?
Alitretinoin
Name a novel drug that is used to treat multiple sclerosis.
Fringolimod
NOTE: it is a sphingosine-1-phosphate receptor modulator which affects the activity of lymphocytes
What is the most common cause of line-related sepsis?
Staphylococcus aureus
What are some side-effects of phenytoin?
Ataxia
Nystagmus
Agitation
Drowsiness
(Cerebellar signs)
How is exercise testing interpreted according to the Bruce protocol?
Patients who cannot undergo two stages of the Bruce protocol (< 6 mins) are at higher risk of adverse cardiovascular events and should be considered for coronary angiography.
How do you dose amiodarone for cardioversion?
300 mg over 30-60 mins followed by 900 mg over 24 hours
Needs to be infused through a large cannula into a large peripheral vein or into a central vein as it can cause thrombophlebitis
What should you do with metformin in someone who is going to undergo an angiogram?
Metformin should be held for 48 hours before and after any procedure involving IV contrast (e.g. CT scan, angiogram)
This is because it could increase the risk of lactic acidosis.
How do you manage a relapse of multiple sclerosis?
Oral Methylprednisolone 0.5 g OD for 5 days
Which medication is used as prophylaxis for patients who suffer cluster headaches?
Verapamil
Alternatives: lithium, sodium valproate, gabapentin
Which type of myocardial infarction and rhythm disturbance would require temporary transvenous pacing?
Second or third degree heart block complicating an acute anterior MI
What is the normal systolic pressure of the pulmonary artery?
25 mm Hg
How can arrhythmias be prevented in patients with long QT syndrome?
Beta-blockers
ICD
Sympathectomy
What are the main presenting symptoms of systemic mastocytosis?
Urticaria pigementosa (with Darier sign)
Abdominal Pain
Flushing
Monocytosis on blood film
Which investigations are used in suspected systemic mastocytosis?
Raised serum tryptase levels
Urinary histamine
What are the main features of benign essential tremor and how is it managed?
Postural tremor that is worse when arms are outstretched
Improves with alcohol
Propranolol is the first-line treatment (primidone is used sometimes)
What is the most commonly isolated organism in animal bites?
Pasteurella multocida
Treated with co-amoxiclav (same with human bites)
List some CYP inducers that decrease the efficacy of warfarin.
Antiepileptics (phenytoin, carbemazepine)
Rifampicin
St. John’s Wort
Alcohol intake
Which beta-blockers are best in the treatment of heart failure?
Bisoprolol
Nebivolol
Carvedilol
What is a hybridoma?
A technique for producing monoclonal antibodies which combines mouse spleen cells with human myeloma cells.
The antibodies generated have a mouse variable region and a human constant region.
At what stage should a patient with rheumatoid arthritis be considered for a trial of a biologic agent?
After 2 DMARDs have been trialled and disease activity remains high (DAS28-CRP or DAS28-ESR > 5.1)
How is Ramsey Hunt syndrome treated?
Oral aciclovir and oral steroids
Which neuronal tracts are affected in subacute combined degeneration of the spinal cord?
Dorsal columns (resulting in loss of vibration and proprioception)
Lateral corticospinal tract (upper motor neurone findings in the legs)
Damage to peripheral nerves results in loss of knee and ankle jerks
How does retinitis pigmentosa manifest?
Night blindness
Tunnel vision
NOTE: it is genetic and associated with Refsum disease, Usher syndrome, abetalipoproteinemia, Laurence-Moon-Biedl syndrome, Kearns-Sayre syndrome and Alport syndrome
What are the first and second-line agents for secondary prevention in patients who have had a stroke or TIA?
Clopidogrel 75 mg OD
If not tolerated –> Aspirin 75 mg OD + Dipyridamole 200 mg BD
What would be a permanent solution to a patient with recurrent atrial flutter?
Radiofrequency ablation to the tricuspid valve isthmus
How is acne rosacea treated?
1st line: topical metronidazole (mild)
2nd line: systemic antibiotics (e.g. oxytetracycline) for severe disease
NOTE: topical brimonidine gel may be used in patients predominantly complaining of flushing
What are the phase I and phase II reactions in drug metabolism?
Phase I: Oxidation, Reduction and Hydrolysis (products are usually more active and may be toxic)
Phase II: Conjugation (products are inactive and excreted in the urine or bile)
How is Cryptosporidium diagnosed?
Modified Ziehl-Neelsen staining of stool to reveal red cysts
What are the two main parametric tests used in medical trials?
Student’s t-test - paired or unpaired*
Pearson’s product-moment coefficient - correlation
What are the main non-parametric tests used in medical trials?
Mann-Whitney U test
compares ordinal, interval, or ratio scales of unpaired data
Wilcoxon signed-rank test
compares two sets of observations on a single sample, e.g. a ‘before’ and ‘after’ test on the same population following an intervention
Chi-squared test
used to compare proportions or percentages e.g. compares the percentage of patients who improved following two different interventions
Spearman, Kendall rank - correlation
What are the features of S1 nerve root compression?
Sensory loss of posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
How long should patients be anticoagulated for if they are to have elective DC cardioversion?
Anticoagulated for at least 3 weeks
After DCCV, the patient should be anticoagulated for at least 4 weeks before decisions about anticoagulation should be made
NOTE: patients can have a TOE and, if negative, be heparinised and receive DCCV then and there. If there is high risk of cardioversion failure (e.g. previous failure or AF recurrence) then patients should also have at least 4 weeks of amiodarone or sotalol before DCCV.
What are the main homozygous genotypes of alpha 1 antitrypsin deficiency?
PiMM = normal PiSS = A1AT 50% of normal PiZZ = A1AT 10% or normal - this is the type that gets lung/liver manifestations
What are the manifestations of a parietal lobe lesion?
Sensory inattention Apraxia Astereognosis Inferior homonymous quadrantanopia Gerstmann syndrome (lesion of dominant parietal lobe): alexia, acalculia, finger agnosia and right-left disorientation
What is an important complication of topiramate treatment?
Acute angle closure glaucoma
Presents with acute myopia, headache and unreactive pupils
Which dermatomes are affected by C6-8 radiculopathies?
C6 - thumb and index finger
C7 - middle finger + palm of hand
C8 - ring + little finger
How is idiopathic pulmonary artery hypertension treated?
Prostacyclin analogues (treprostinil) Endothelin receptor antagonists (bosentan) Phosophodiesterase inhibitors (sildenafil)
NOTE: if good response to acute vasodilator testing - CCBs may be used (minority of patients)
List some NRTIs and NNRTIS.
NRTI: zidovudine, abacavir, emtricitabine, lamivudine, tenofovir
NNRTI: nevirapine, efavirenz
What are the presenting features of porphyria cutanea tarda?
Photosensitive rash with blistering in sun exposed areas (usually hands)
Hypertrichosis
Hyperpigmentation
NOTE: treated with chloroquine and venesection
What is internuclear ophthalmoplegia and which part of the brain is affected?
Inability to adduct the affected eye resulting in nystagmus and diplopia
It is caused by damage to the median longitudinal fasciculus which is found in the paramedian area of the midbrain and pons
How is ethylene glycol poisoning treated?
Fomepizole (inhibitor of alcohol dehydrogenase)
NOTE: ethanol used to be used to treat this k
How does Kearns-Sayre syndrome present?
External ophthalmoplegia Retinitis pigmentosa (night blindness) Ptosis Usually < 20 yrs Diabetes mellitus (insulin-dependent) Complete heart block Cardiomyopathy Recurrent stroke
Maternal inheritance
What is the first-line treatment for severe mitral stenosis?
Percutaneous mitral commisurotomy (balloon valvulotomy)
NOTE: transcatheter mitral valve repair is a second choice
List some medications that can exacerbate myasthenia gravis.
Beta-blockers Antibiotics (gentamicin, macrolides, quinolones, tetracyclines) Phenytoin Lithium Penicillamine Procainamide
Which antigen is the antibody in pemphigus vulgaris and bullous pemphigoid directed against?
Pemphigus Vulgaris: Desmoglein 3
Bullous Pemphigoid: Hemidesmosome
What does the Golgi apparatus add to protein in order to traffic them to lysosomes?
Mannose-6-phosphate
What is the second-line treatment option for angina if beta-blockers and rate-limiting calcium channel blockers are contraindicated?
Nicorandil (potassium channel activator)
NOTE: it is associated with causing gastrointestinal ulceration (ranging from oral ulcers to anal ulcers)
List the commonly used steroids in order of decreasing mineralocorticoid activity.
Hydrocortisone (most mineralocorticoid activity)
Prednisolone
Dexamethasone/Betamethasone
What are the main symptoms of renal vein thrombosis?
Sudden-onset flank pain
Deterioration in renal function
Haematuria
What is chronic granulomatous disease and how does it present?
Neutrophil disorder resulting from a lack of NADPH oxidase, which reduces the ability of the neutrophil to produce ROS
Presents with recurrent pneumonia/abscesses (particularly S. aureus and funguses like Aspergillus)
How is chronic granulomatous disease diagnosed?
Negative nitroblue-tetrazolium test
Abnormal dihydrorhodamine flow cytometry
What is Chediak-Higashi syndrome and how does it present?
Neutrophil disorder resulting from a defect in microtubule polymerisation leading to reduced phagocytosis
Affected children have partial albinism and peripheral neuropathy, recurrent bacterial infections
What is leucocyte adhesion deficiency and how does it present?
Neutrophil disorder caused by defect in LFA-1 integrin on neutrophils
Leads to recurrent bacterial infections, delay in umbilical cord sloughing and absence of neutrophils at site of infection
How does common variable immunodeficiency present?
It is a B cell disorder that results in hypogammaglobulinaemia
It may predispose to lymphoma and autoimmune disorders
What is Bruton’s X-linked agammaglobulinaemia?
B cell disorder characterised by a defect in Bruton’s tyrosine kinase resulting in a severe block in B cell development
Patients develop recurrent bacterial infections, there is an absence of B cells and reduced immunoglobulins of all classes
How might selective IgA deficiency manifest?
Recurrent sinus and respiratory tract infections
Associated with coeliac disease
May develop severe reactions to blood transfusions (due to anti-IgA antibodies)
What is DiGeorge syndrome and how does it manifest?
T cell disorder caused by 22q11.2 deletion resulting in failure to develop the 3rd and 4th pharyngeal pouches
Manifestations include congenital heart disease (e.g. tetralogy of Fallot), learning difficulties, hypocalcaemia, recurrent viral/fungal diseases, cleft palate
List some combined B and T cell disorders.
SCID (multiple causes)
Ataxia Telangiectasia (defect in DNA repair, leads to cerebellar ataxia, telangiectasia, recurrent chest infections and increased risk of malignancy)
Wiskott Aldrich Syndrome (defect in WASP gene, recurrent bacterial infection, eczema, thrombocytopaenia, autoimmune diseases)
Hyper IgM Syndrome (mutation in CD40 gene, hepatitis, diarrhoea, PCP infection)
What are the recommendations for secondary prevention of osteoporotic fractures in postmenopausal women?
1st line: alendronate
2nd line: risedronate or etidronate
3rd line: strontium ranelate or raloxifene
What is myotonic dystrophy and what are its main features?
Inherited myopathy that presents at around 20-30 years
Autosomal dominant trinucleotide repeat disorder (DM1 caused by CTG repeat, DM2 is caused by repeat expansion of ZNF9 gene)
Main features are myotonic facies, frontal balding, bilateral ptosis, cataract and dysarthria
Also associated with dysphagia, diabetes mellitus, mild mental impairment, testicular atrophy, heart block and cardiomyopathy
How should giant cell arteritis be managed?
Uncomplicated (no visual involvement or tongue/jaw claudication) –> PO prednisolone 40-60 mg OD
Complicated (visual involvement and/or tongue/jaw claudication) –> IV methylprednisolone 500-1000 mg for 3 days before starting oral prednisolone
List some features of severe malaria.
Schizonts on a blood film Parasitaemia > 2% Hypoglycaemia Acidosis Temperature > 39 °C Severe anaemia Cerebral malaria (seizures, coma) Acute renal failure ARDS DIC
What is an important contraindication of anticholinergic treatment for urge incontinence?
Previous history of urinary retention
NOTE: it should also be avoided in the elderly as it can worsen confusion
What is the main test used to screen for latent TB?
Mantoux
IGRA is used if Mantoux is positive
What can precipitate pompholyx eczema?
High humidity and heat
What are the main translocations associated with the various types of lymphoma/leukaemia?
Follicular Lymphoma - t(14,18) Burkitt Lymphoma - t(8,14) CML - t(9,22) Mantle Cell Lymphoma - t(11, 14) Ewing Sarcoma - t(11, 22) APML - t(15, 17)
How should wounds at risk of tetanus infection be managed?
Full course of tetanus vaccines (5) with last dose < 10 years –> no vaccine or immunoglobulin
Full course of tetanus vaccines with last dose > 10 years –> if tetanus prone then reinforcing dose of vaccine, if very high-risk give reinforcing dose and tetanus immunoglobulin
If vaccination history unclear –> give reinforcing dose, give tetanus immunoglobulin if tetanus-prone or high-risk wound
What are the main features of acute intermittent porphyria?
autosomal dominant
defect in porphobilinogen deaminase
female and 20-40 year olds more likely to be affected
typically present with abdominal symptoms, neuropsychiatric symptoms
hypertension and tachycardia common
urine turns deep red on standing
What are the main features of porphyria cutanea tarda?
most common hepatic porphyria
defect in uroporphyrinogen decarboxylase
may be caused by hepatocyte damage e.g. alcohol, oestrogens
classically photosensitive rash with bullae, skin fragility on face and dorsal aspect of hands
urine: elevated uroporphyrinogen and pink fluorescence of urine under Wood’s lamp
manage with chloroquine
What are the main features of variegate porphyria?
autosomal dominant defect in protoporphyrinogen oxidase photosensitive blistering rash abdominal and neurological symptoms more common in South Africans
How should you manage someone who has been bitten by someone with Hepatitis B?
If person is known to be a responder to HBV vaccine –> give booster dose
If non-responder or not fully vaccinated –> Give HBIG + Vaccine Booster
NOTE: if unclear whether exposed to HBV, consider giving booster dose and if known non-responder, give booster dose and HBIG
On which chromosomes do you find the PKD genes?
PKD1 –> Chromosome 16
PKD2 –> Chromosome 4
What are the main manifestations of TCA overdose?
Arrhythmias (long QRS - risk of ventricular arrhythmia)
Seizures
Metabolic Acidosis
Coma
How are TCA overdoses managed?
IV Sodium Bicarbonate (first-line for hypotension and arrhythmias)
How is Raynaud’s phenomenon treated?
1st Line: CCBs (e.g. nifedipine)
2nd Line: IV Prostacyclin infusion (e.g. epoprostenol)
Which drug groups could precipitate an attack in patients with a history of acute intermittent porphyria?
Barbiturates Halothane Benzodiazepines Alcohol OCP Sulphonamides
How should patients with suspected HIV seroconversion be investigated?
p24 antigen test (positive from 1 to 3/4 weeks after infection) HIV antibody (most common and accurate test - most will develop antibodies by 4-6 weeks)
NOTE: antibodies may not be detectable yet
What are the main features of MODY?
Develops < 25 yrs
Family history of early-onset diabetes (autosomal dominant)
Ketosis NOT present
Sensitive to sulfonylureas (insulin often not necessary)
NOTE: bit like early-onset type 2 diabetes mellitus
Which class of diabetes medications is associated with causing SIADH?
Sulfonylureas
Which bacterium most commonly causes peritonitis secondary to peritoneal dialysis?
Staphylococcus epidermidis
What is the gold standard diagnostic test for hereditary spherocytosis?
EMA Binding Test
NOTE: it is treated with folate supplementation and splenectomy (in severe cases)
What is Ham’s test used for?
Paroxysmal nocturnal haemoglobinuria
BUT, the gold standard test is now flow cytometry for CD59 and CD55 (these are negative)
How does mycophenolate mofetil work?
Reduces lymphocyte production through inhibition of inosine-5-monophosphate-dehydrogenase (required for purine synthesis)
What causes the majority of cases of primary hyperaldosteronism?
Bilateral adrenal hyperplasia (70%)
NOTE: it used to be thought that most cases were due to adrenal adenomas (Conn’s)
Which layers of the adrenal cortex secrete which hormones?
Glomerulosa –> Aldosterone
Fasciculata –> Glucocorticoids
Reticularis –> Sex Steroids
Medulla –> Catecholamines
What do the x descent and y descent represent on a JVP waveform?
X descent –> fall in atrial pressure during ventricular systole
Y descent –> opening of the tricuspid valve
What does the ulnar nerve supply?
MOTOR: medial two lumbricals, adductor policis, interossei, hypothenar muscles, flexor carpi ulnaris
SENSORY: medial 1.5 fingers
How does damage to the ulnar nerve manifest?
AT WRIST: Claw hand (hyperextension of MCP, flexion of distal and proximal IPJs of 4th/5th digits) + wasting of intrinsic hand muscles + wasting of hypothenar muscles + sensory loss to medial 1.5 fingers
AT ELBOW: Clawing is less severe , radial deviation of wrist
List the manifestations of different complement deficiencies.
C1 inhibitor –> hereditary angioedema
C1, C2, C4 –> immune complex disease (e.g. SLE)
C3 –> recurrent bacterial infections
C5 –> Leiner disease, watery diarrhoea, seborrhoeic dermatitis
C5-C9 –> severe meningococcal infection
Why does trimethoprim cause a slight rise in creatinine?
It competitively inhibits creatinine secretion in the tubule
NOTE: It also blocks ENaC in the distal nephron which causes a hyperkalaemic distal RTA
Which drugs can cause idiopathic intracranial hypertension?
Steroids
COCP
Tetracyclines
Lithium
What is the first-line antibiotic recommended for the treatment of Campylobacter jejuni?
Clarithromycin
What is the first-line antiepileptic drug for the treatment of myoclonic epilepsy?
Sodium valproate
Second line: clonazepam, lamotrigine
NOTE: carbamazepine can worsen myoclonic seizures
What is the first-line antiepileptic used for generalised and focal seizures?
Generalised: sodium valproate
Focal: carbamazepine
Which antiepileptics are used for absence seizures?
Sodium valproate or ethosuximide
How should caustic ingestion be managed?
Asymptomatic - discharge after trial of oral fluids + period of observation
Symptomatic - high dose IV PPI, urgent endoscopy
How is high-altitude pulmonary oedema managed?
Descent
Nifedipine
Others (dexamethasone, acetazolamide, phosphodiesterase type V inhibitors)
How is high-altitude cerebral oedema managed?
Descent
Dexamethasone
Name an alkylating agent and its potential side-effects.
Cyclophosphamide
SE: haemorrhagic cystitis, myelosuppression, transitional cell carcinoma
NOTE: haemorrhagic cystitis can be prevented with mesna
List some cytotoxic antibiotics and their adverse effects.
Bleomycin –> degrades preformed DNA –> lung fibrosis
Anthracyclines (e.g. doxorubicin) –> stabilised DNA topoisomerase II complex inhibits DNA and RNA synthesis –> Cardiomyopathy
Give an example of a topoisomerase inhibitor.
Iriontecan
SE: myelosuppression
What is a notable side-effect of vincristine?
Peripheral Neuropathy
Paralytic Ileus
Which diseases are associated with the following HLA types? HLA-A3 HLA-B51 HLA-B27 HLA-DR2 HLA-DR3 HLA-DR4
HLA-A3 - Hereditary Haemochromatosis
HLA-B51 - Behcet’s Disease
HLA-B27 - Ankylosing Spondylitis, Reactive Arthritis, Anterior Uveitis
HLA-DR2 - Goodpasture’s, Narcolepsy
HLA-DR3 - Dermatitis Herpetiformis, Sjogren Syndrome, PBC
HLA-DR4 - Rheumatoid Arthritis, T1DM (DRB1*04:01)
How does homocystinuria manifest?
Tall stature Long fingers Downward lens dislocation Learning difficulties Unprovoked DVT at early age Malar flush
NOTE: it is an autosomal recessive condition caused by a deficiency of cystathione beta synthase that is screened for in neonatal screening. It is treated with pyridoxine supplements.
Describe the natural history of autosomal recessive polycystic kidney disease.
Diagnosed on prenatal ultrasound scan/early infancy
Newborns have features of Potter sequence due to oligohydramnios
End-stage renal failure in childhood
Which vitamin deficiency causes angular cheilitis?
Riboflavin (Vitamin B2)
Which antibiotic should be used to treat meningococcal meningitis in a patient who has anaphylactic reactions t penicillins?
Chloramphenicol
Which antibiotics may be used as prophylaxis in contacts of people with meningococcal meningitis?
Ciprofloxacin or Rifampicin
Which conditions can cause Charles-Bonnet Syndrome?
Age-related macular degeneration (most common)
Glaucoma
Cataracts
How does ataxia telangiectasia present?
Cerebellar ataxia
Telangiectasia
Recurrent chest infections
Which nerves pass through the following foramina?
Foramen rotundum
Foramen ovale
Jugular foramen
Foramen rotundum - Maxillary Nerve (V2)
Foramen ovale - Mandibular Nerve (V3)
Jugular foramen - IX, X and XI
Which nerves pass through the superior orbital fissure?
III
IV
V1 (Ophthalmic)
VI
What are the main forms of malaria prophylaxis that are currently recommended?
Atovaquone and Proguanil (Malarone)
Doxycycline (risk of photosensitivity)
Which biological therapy may be used to prevent C. difficile recurrence?
Bezlotoxumab
What are some complications of typhoid?
Osteomyelitis
GI bleed/perforation
Meningitis
Cholecystitis
Give some examples of drugs that follow zero-order kinetics?
Alcohol
Phenytoin
Salicylates (aspirin)
What pressures does pulmonary capillary wedge pressure using a Swan-Ganz catheter equate to?
Left atrial pressure
Which patients should be offered prophylactic antibiotics for SBP?
Oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein < 15 g/L until the ascites has resolved
And patients who have had an episode of SBP
What are some features of pseudoxanthoma elasticum?
Autosomal recessive disorder of elastic fibres
Retinal angioid streaks
Plucked chicken skin appearance
Increased risk of ischaemic heart disease
GI haemorrhage
What should splenectomy patients be vaccinated against?
Pneumococcus
Haemophilus type B
Meningococcus type C
Describe the features of Adult-onset Still’s disease.
NOTE: it is a diagnosis of exclusion (ANA and RF negative)
Arthralgia Very high ferritin Salmon-pink maculopapular rash Pyrexia Lymphadenopathy
How would a posterior communicating artery aneurysm present?
3rd Nerve Palsy with Pupil Dilation
Painful + Headache
List some causes of 3rd nerve palsy.
Diabetes Mellitus Vasculitis (e.g. temporal arteritis) Posterior Communicating Artery Aneurysm Cavernous Sinus Thrombosis Weber Syndrome (ipsilateral third nerve palsy with contralateral hemiplegia - caused by midbrain strokes)
Describe steps taken to reduce the risk of contrast-induced nephropathy.
Give IV 0.9% saline at a rate of 1 mL/kg/hour for the 12 hours before and after the CT scan
Metformin should be withheld for a minimum of 48 hours until renal function has been shown to be normal
What are the first-line treatment options for diabetic neuropathy?
Duloxetine
Amitriptyline
Pregabalin
Gabapentin
How should pregnant women at high risk of developing pre-eclampsia be managed?
Aspirin 75 mg OD from 12 weeks until birth
What is calciphylaxis?
Rare complication of end-stage renal disease (vasculopathy of small blood vessels)
Presents with painful necrotic skin lesions containing calcium deposits
What is methaemoglobinaemia?
It is haemoglobin that has been oxidised to the Fe3+ form and can no longer carry oxygen, resulting in global tissue hypoxia
It may be congenital or may occur due to certain medications (e.g. sulphonamides, nitrates, sodium nitroprusside, dapsone, primaquine)
How does methaemoglobinuria present?
Cyanosis
Shortness of breath
Anxiety
Normal pO2 with low SaO2
NOTE: it shifts the oxygen dissociation curve to the left and is treated using methylene blue
What are some causes of cannon a waves?
Complete heart block (irregular)
AVNRT (regular)
Ventricular tachycardia (with 1:1 atrial: ventricular contraction)
How does a VIPoma present?
Large volume diarrhoea Weight loss Dehydration Hypokalaemia Hypochlorhydria
NOTE: 90% are seen in the pancreas (vasoactive intestinal peptide)
Outline the phases of the cardiac action potential and the direction of ion movement.
0 - Rapid Depolarisation - Rapid Na Influx
1 - Early Repolarisation - K Efflux
2 - Plateau - Slow Ca Influx
3 - Final Repolarisation - K Efflux
4 - Restoration of Ionic Concentrations - Na/K ATPase
What is the first-line treatment option for hepatitis B?
Pegylated interferon
Others: tenofovir, entecavir, telbivudine
List some drugs that are commonly overdosed and CAN be removed with dialysis.
Barbiturate Lithium Alcohol (inc methanol, ethylene glycol) Salicylates Theophyllines (charcoal haemoperfusion is preferable)
List some drugs that are commonly overdosed and CANNOT be removed with dialysis.
TCAs benzodiazepines dextropropoxyphene (Co-proxamol) digoxin beta-blockers
List some medications that should be avoided when breastfeeding.
Antibiotics (ciprofloxacin, tetracyclines, chloramphenicol, sulphonamides) Lithium Benzodiazepines Aspirin Carbimazole Methotrexate Sulfonylureas Amiodarone
Which classes of drugs are used to treat glaucoma and how to they work?
Prostaglandin analogues (e.g. latanoprost) - increases uveoscleral outflow
Beta-blockers (e.g. timolol) - reduced aqueous generation
Sympathomimetics (e.g. brimonidine - a2 agonist) - reduces aqueous production and increases outflow
Carbonic anhydrase inhibitors (e.g. dorzolamide) - reduces aqueous production
Miotics (e.g. pilocarpine) - increases uveoscleral outflow
What is the first-line investigation for acute intermittent porphyria?
Raised urinary porphobilinogen
What are the feature of polyarteritis nodosa?
Fever, malaise, arthralgia Low grade fever Haematuria Livedo reticularis Mononeuritis multiplex
NOTE: associated with hep B and ANCA
What is mononeuritis multiplex?
Painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy
Involves isolated damage to at least 2 separate nerve areas
Associated with diabetes mellitus, sarcoidosis, rheumatoid arthritis and polyarteritis nodosa
What is the equation for standard error of the mean?
SEM = SD/sqrt(n)
What change in GFR and creatinine is permissible in patients being started on ACE inhibitors?
Up to 25% decrease in GFR
Up to 30% rise in creatinine
Why do you do U&E before starting someone on amiodarone?
To rule out hypokalaemia
All antiarrhythmics can cause arrhythmias and concomitant hypokalaemia massively increases the risk of that happening
Outline how gestational diabetes should be managed.
If FBG < 7 - diet and exercise
- If targets not met within 1-2 weeks, start metformin (glibenclamide is an alternative)
- If targets still not met, start insulin
If FBG > 7 - start insulin
What is hyperchylomicronaemia?
Disease caused by hereditary lipoprotein lipase deficiency and apolipoprotein C deficiency that predisposes to recurrent attacks of acute pancreatitis.
Which antibiotics work by inhibiting DNA synthesis?
Quinolones
Metronidazole
Sulphonamides
Trimethoprim
Which antibiotics work by inhibiting protein synthesis?
Aminoglycosides Chloramphenicol Macrolides Tetracyclines Fusidic Acid
What are some good prognostic factors for ALL?
French-American-British (FAB) L1 type Common ALL Pre-B phenotype Low initial WBC del(9p) Hyperdiploidy
What is the mechanism of action of the following antivirals? Ribavirin Amantadine Oseltamivir Foscarnet Interferon Alpha Cidofovir
Ribavirin - guanosine analogue, interferes with capping of viral mRNA
Amantadine - M2 inhibitor prevents virus uncoating within cells
Oseltamivir - neuraminidase inhibitor
Foscarnet - inhibits viral DNA polymerase
Interferon Alpha - inhibits mRNA synthesis
Cidofovir - DNA polymerase inhibitor
List the ECG features of digoxin toxicity.
Down-sloping ST depression (reverse tick)
Flattened/inverted T waves
Short QT interval
Arrhythmias (e.g. AV block, bradycardia)
Which gene mutations does testing for hereditary haemochromatosis look for?
C282Y
H63D
What are the two types of mesangiocapillary (membranoproliferative) glomerulonephritis and what are their associations?
Type 1: Cryoglobulinaemia, Hepatitis C
Type 2: Partial Lipodystrophy (associated with low C3)
How is primary open-angle glaucoma treated?
1st: Prostaglandin analogue (e.g. latanoprost)
2nd: Beta-blocker (e.g. timolol), sympathomimetic (e.g. brimonidine) or carbonic anhydrase inhibitor
3rd: surgery or laser
What should always be done before starting a patient with COPD on azithromycin?
ECG
Azithromycin can prolong QT interval
What is the difference between the mechanism of action of vincristine and docetaxel?
Vincristine - inhibits microtubule formation
Docetaxel - inhibits microtubule disassembly
Which manoeuvres are used in the diagnosis and treatment of BPPV?
Dix-Hallpike - Diagnostic
Epley - Therapeutic
What are the histological features of diabetic nephropathy?
Kimmelstiel-Wilson lesions (nodular glomerulosclerosis)
Hyaline arteriosclerosis
What are the features of a Holmes-Adie pupil?
Unilateral (80% of cases) benign dilated pupil
Once constricted, the pupil remains small for a long time
Slow reaction to accommodation and none to light
Associated with absent knee/ankle reflexes
What are the main features of NF1 and NF2?
NF1 - Cafe au lait spots - Axillary freckling - Peripheral neurofibromas - Lisch nodules - Scoliosis - Phaeochromocytomas NF2 - Bilateral vestibular schwannomas - Meningiomas and Ependyomas
What are the main features of tuberous sclerosis?
Multiple CNS hamartomas Subependymal giant cell astrocytomas Renal angiomyolipomas Cardiac rhabdomyomas Facial angiofibromas Shagreen patches Retinal astrocytic hamartomas
Which chromosome are HLA antigens encoded on?
Chromosome 6
List some glycogen storage diseases and their manifestations.
Von Gierke disease (type I) - glucose-6-phosphatase - hypoglycaemia, lactic acidosis and hepatomegaly (hepatic glycogen accumulation)
Pompe’s disease (type II) - lysosomal alpha-1,4-glucosidase - cardiac, hepatic and muscle glycogen accumulation, leads to cardiomegaly
Cori disease (type III) - alpha-1,6-glucosidase - hepatic and cardiac glycogen accumulation, leads to muscle hypotonia
McArdle Disease (type V) - glycogen phosphorylase - skeletal muscle glycogen accumulation, leads to myalgia and myoglobinuria with exercise and second wind phenomenon
List some lysosomal storage disorders and their manifestations.
Gaucher - beta-glucocerebrosidase - most common, hepatosplenomegaly and avascular necrosis of femur
Tay-Sachs - Hexosaminidase A - accumulation of G2 ganglioside in lysosomes, leads to developmental delay, cherry red spot on macula, NORMAL liver and spleen
Nieman-Pick - sphingomyelinase - hepatosplenomegaly and cherry spot on macula
Fabry - alpha-galactosidase A - angiokeratomas, renal failure, peripheral neuropathy of extremities
Krabbe - galactocerebrosidase - peripheral neuropathy, optic atrophy and globoid cells
Metachromatic leukodystrophy - arylsulfatase A - demyelination of CNS and PNS
List some mucopolysaccharidoses and their manifestations.
Hurler Syndrome (type I) - leads to gargoylism, hepatosplenomegaly and corneal clouding
Hunter Syndrome (type II) - coarse facial features, behavioural problems, short stature, no corneal clouding
NOTE: both are caused by accumulation of glycosaminoglycans
Damage to which brain structure causes hemibalismus?
Subthalamic nucleus of basal ganglia
What are the ECG features of arrhythmogenic right ventricular cardiomyopathy?
ECG abnormalities in V1-3 (TWI) Epsilon wave (terminal notch in QRS complex)
What is catecholaminergic polymorphic ventricular tachycardia?
Form of inherited (AD) cardiac disease associated with sudden death
Exercise or exertion leads to VT and syncope
Generally presents < 20 years
Which commonly used drugs can cause photosensitivity?
Thiazides Tetracyclines Ciprofloxacin Amiodarone NSAIDs Sulphonylureas
What is the King’s College Hospital criteria for liver transplantation following paracetamol overdose?
Arterial pH < 7.3 more 24 hours after ingestion Or all of the following - PT > 100 seconds - Creatinine > 300 - Grade III or IV Encephalopathy
List the uses of interferon alpha, beta and gamma.
Alpha - hepatitis B/C, Kaposi sarcoma, metastatic renal cell carcinoma, hairy cell leukaemia
Beta - relapsing-remitting MS
Gamma - chronic granulomatous disease, osteopetrosis
What is trihexyphenidyl?
Antimuscarinic used to treat Parkinson’s disease (particularly drug-induced Parkinsonism)
What channel abnormality tends to cause long QT syndrome?
Blockage or loss of function of potassium channels
List some drugs that can cause agranulocytosis.
Antithyroid (carbimazole, propylthiouracil)
Antipsychotics (clozapine)
Antiepileptics (clozapine)
Antibiotics (penicillin, choramphenicol)
Antidepressant (mirtazapine)
What is the Hering-Breuer reflex?
Lung distention is detected by stretch receptors in the lungs which causes slowing of the respiratory rate
NOTE: this prevent the lungs from overexpanding during inspiration
List some common causes of cataracts.
Ageing Smoking Increased alcohol consumption Trauma Diabetes mellitus Long-term corticosteroids Radiation exposure Myotonic dystrophy Metabolic disorders: hypocalcaemia
How is hepatitis C treated?
Combination of protease inhibitors (e.g. sofosbuvir + daclatasvir) with or without ribavirin
TARGET: sustained virologic response (undetectable serum HCV RNA 6 months after ending therapy)
Which chromosomes are the genes responsible for the following diseases found on?
- NF1
- NF2
- von Hippel Lindau
- Tuberous Sclerosis
von Hippel Lindau - 3
Tuberous Sclerosis - 16
NF1 - 17
NF2 - 22
List some causes of mixed upper and lower motor neurone signs.
subacute combined degeneration of the cord motor neuron disease Friedreich's ataxia syringomyelia taboparesis (syphilis) conus medullaris lesion
What are the main features of pemphigus vulgaris?
Mucosal ulceration is common
Blisters are flaccid, easily ruptured bullae
Nikolsky sign positive
Acantholysis on biopsy
What are the main features of macrophage activation syndrome?
Definition; uncontrolled inflammatory state associated with systemic autoimmune diseases (e.g. JIA)
Features: Refractory fever, hepatosplenomegaly
Pathophysiology: caused by abnormal interferon-gamma activity which activates macrophages
Which antibody is primary membranous glomerulonephritis associated with?
Anti-PLA2R
Secondary causes include:
Malignancy such as solid tumours (lung, colon, breast, kidney)
Infections: hepatitis B or C, HIB, malaria, syphilis, schistosomiasis
Autoimmune diseases: SLE, sarcoidosis, IBD
Drugs: NSAID’s, captopril, gold, penicillamine, lithium, clopidogrel
Outline the ECOG score.
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair
5 Dead
Which causes of lung fibrosis classically affect the upper zones?
hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
coal worker’s pneumoconiosis/progressive massive fibrosis
silicosis
sarcoidosis
ankylosing spondylitis (rare)
histiocytosis
tuberculosis
Which causes of lung fibrosis classically affect the lower zones?
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
How does meglitinide work?
Stimulates insulin release
It is good for post-prandial hyperglycaemia and for erratic lifestyles and is less likely to cause hypoglycaemia than sulfonylureas
How does anhydrosis determine the site of the lesion in Horner syndrome?
Head, arm, trunk = central lesion: stroke, syringomyelia
Just face = pre-ganglionic lesion: Pancoast’s, cervical rib
Absent = post-ganglionic lesion: carotid artery
What is Miller Fisher syndrome?
Type of Guillain Barre Syndrome that primarily affects the cranial nerves
Presents with ataxia, ophthalmoplegia, areflexia and descending paralysis. Associated with antiganglioside antibodies GQ1b and GT1a
What is the difference between Hazard Ratio and Risk Ratio?
It is used when risk is not constant to time
It is usually used when assessing survival over time
Describe the CXR stages of sarcoidosis.
1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis
What is Lofgren syndrome?
Presentation of sarcoidosis characterised by the presence of the following symptoms:
- BHL
- Erythema nodosum
- Polyarthritis
- Fever
What are the ECG features of hypokalaemia?
U waves Small or absent T waves (occasionally inverted) Prolonged PR interval ST depression Long QT
Describe the presentation of African trypanosomiasis.
Trypanosoma chancre (painless subcutaneous nodule at site of infection)
Intermittent fever
Enlarged posterior cervical lymph nodes
CNS involvement (somnolence, headache, reversal or sleep-wake cycle)
Treated with IV pentamidine and suramin. IV melarsoprol used for CNS involvement.
What are the main consequences of chronic Chagas disease?
Myocarditis leading to dilated cardiomyopathy GI features (megaoesophagus and megacolon)
Treated with benznidazole or nifurtimox
What are the ECG features of hypothermia?
Bradycardia J wave (hump at end of QRS complex) First degree heart block Long QT Atrial and ventricular arrhythmias
What is the first line treatment option for lichen planus?
Potent topical steroid (e.g. clobetasol)
Description of rash: papular, polygonal, violaceous, flat-topped rash is present on the palms, in her elbow creases and on the soles of her feet
Which type of anaemia can phenytoin cause?
Folate deficiency anaemia
