MRCP Part 2

Question 1

What is the mainstay of treating anterior uveitis?

Answer 1

Steroid and Cycloplegic (mydriatic) Eye Drops

E.g. Cyclopentolate and Corticosteroids

Question 2

What is a useful effect of COMT inhibitors in patients with Parkinson’s Disease?

Answer 2

It is effective at smoothing out on-off fluctuations in patients on L-DOPA/DOPA Decarboxylase Inhibitors

Question 3

Why should pioglitazone be avoided in patients with congestive cardiac failure?

Answer 3

It causes fluid retention

Question 4

In which patients should donepezil be avoided?

Answer 4

Bradycardia

Question 5

Which type of ovarian tumour produces TSH?

Answer 5

Struma ovarii (variant of ovarian teratoma)

Question 6

Outline the emergency management of acute angle closure glaucoma.

Answer 6

Eye Drops (e.g. pilocarpine, timlolol) + IV Acetazolamide

Question 7

What is the first-line treatment option for trigeminal neuralgia?

Answer 7

Carbamazepine

Question 8

Outline the stages of hypertensive retinopathy.

Answer 8

I	Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
II	Arteriovenous nipping
III	Cotton-wool exudates
Flame and blot haemorrhages
IV	Papilloedema

Question 9

What is the difference between type 1 and type 2 amiodarone-induced thyrotoxicosis?

Answer 9

Type 1

• Caused by excess iodine-induced thyroid hormone synthesis
• Goitre present
• Rx: Carbimazole or Potassium Perchlorate

Type 2

• Caused by amiodarone-related destructive thyroiditis
• Goitre absent
• Rx: Corticosteroids

NOTE: these can be distinguished using colour flow Doppler ultrasonography or thyroid uptake scans

Question 10

What are the main features of leptospirosis?

Answer 10

Acute Phase: fever, malaise, headache, and abdominal pain

Later Phase: severe systemic upset such as renal failure, pulmonary haemorrhage, and hepatic failure.

Ix: Serology

Rx: high-dose benzylpenicillin or doxycycline

Question 11

What does capillary wedge pressure represent in terms of cardiac catheterisation?

Answer 11

It is equivalent to the left atrial pressure which should equal the left ventricular diastolic pressure

A normal mitral valve would expect less than 5 mm Hg pressure difference (capillary wedge pressure minus left ventricular diastolic pressure). If it is greater than that, there is a degree of mitral stenosis.

Question 12

How is p wave asystole managed?

Answer 12

External pacing

NOTE: this is when you see only p waves on a rhythm check in a cardiac arrest

Question 13

What are the indications for carotid endartarectomy?

Answer 13

Recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled

Should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria

Question 14

How does Q fever manifest?

Answer 14

Fevers, headaches, fatigue and muscle aches

Transaminitis on LFTs

Comes from sheep and caused by Coxiella burnetti

Question 15

Which therapy is effective and reducing morbidity and mortality in toxic epidermal necrolysis?

Answer 15

IVIG

Question 16

How should patients with a superficial vein thrombosis be managed?

Answer 16

Ultrasound to check for DVT
Prophylactic dose LMWH for 30 days or fondaparinux for 45 days (if contraindicated, 8-12 days of NSAID)

NOTE: there is a risk of thrombosis extension into the deep veins

Question 17

List some poor prognostic factors for CLL.

Answer 17

male sex
age > 70 years
lymphocyte count > 50
prolymphocytes comprising more than 10% of blood lymphocytes
lymphocyte doubling time < 12 months
raised LDH
CD38 expression positive
TP53 mutation

Question 18

What are the features of local anaesthetic toxicity?

Answer 18

CNS: reduced GCS, seizures
Cardiovascular: arrhythmia, hypotension

Question 19

In which patients can you not give ranolazine?

Answer 19

Severely impaired renal function

Question 20

After calcium channel blockers and beta-blockers, which agents are used in the management of stable angina?

Answer 20

Long-acting nitrate
Nicorandil (stimulates guanylate cyclase to increase formation of cyclic GMP)
Ranolazine (inward sodium channel inhibitor)
Ivabradine (funny channel inhibitors - reduces HR and workload)

Question 21

What are the main features of acute intermittent porphyria?

Answer 21

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

Question 22

What are the main features of porphyria cutanea tarda?

Answer 22

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

Question 23

What are the main features of variegate porphyria?

Answer 23

autosomal dominant
defect in protoporphyrinogen oxidase
photosensitive blistering rash
abdominal and neurological symptoms
more common in South Africans

Question 24

What’s the most common chemotherapy regime for small cell lung cancer?

Answer 24

Cisplatin and etoposide

NOTE: cisplatin causes hypomagnesemia which leads to muscle cramps, tremor, arrhythmias and confusion

Question 25

Which UC patients should be considered for drugs that maintain remission (e.g. azathioprine, mercaptopurine)?

Answer 25

severe relapse or >=2 exacerbations in the past year they should be given either oral azathioprine or oral mercaptopurine to maintain remission

Question 26

What are the criteria for LTOT?

Answer 26

Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following: secondary polycythaemia peripheral oedema pulmonary hypertension

Question 27

What is one crucial interaction between TB and HIV medications that you should be aware of?

Answer 27

Rifampicin causes reduced absorption and increased metabolism of protease inhibitors NOTE: in these circumstances, an alternative rifamycin such as rifabutin is recommended as it induced cytochromse p450 less than rifampicin

Question 28

What is the first-line management option for renal complications of systemic sclerosis?

Answer 28

ACE Inhibitors

Question 29

What clinical features is associated with an increased risk of NSAID-induced asthma exacerabtions?

Answer 29

Presence of nasal polyps

Question 30

How is crusted scabies managed?

Answer 30

Isolated and ivermectin NOTE: crusted scabies is something that happens in people who are significantly immunocompromised

Question 31

How is cryptococcal meningitis managed?

Answer 31

IV Antifungals (e.g. amphotericin B and flucytosine)

Question 32

How does cryoglobulinaemia present?

Answer 32

Raynaud's only seen in type I cutaneous: vascular purpura, distal ulceration, ulceration arthralgia renal involvement (diffuse glomerulonephritis)

Question 33

What are the three types of cryoglobulinaemia?

Answer 33

``` Three types type I (25%): monoclonal type II (25%): mixed monoclonal and polyclonal: usually with rheumatoid factor type III (50%): polyclonal: usually with rheumatoid factor ``` Type I monoclonal - IgG or IgM associations: multiple myeloma, Waldenstrom macroglobulinaemia Type II mixed monoclonal and polyclonal: usually with rheumatoid factor associations: hepatitis C, rheumatoid arthritis, Sjogren's, lymphoma Type III polyclonal: usually with rheumatoid factor associations: rheumatoid arthritis, Sjogren's

Question 34

Which common cardiac drug should be avoided in patients with cardiac amyloid?

Answer 34

Digoxin (higher risk of digoxin toxicity as the drug binds avidly to amyloid fibrils)

Question 35

How is idiopathic intracranial hypertension managed?

Answer 35

Weight Loss | Acetazolamide

Question 36

Why are SSRIs contraindicated in patients with a background of peptic ulcer disease?

Answer 36

Increases the risk of upper GI bleeds by inhibiting platelet aggregation

Question 37

Which treatment should be considered in addition to a statin in a young patient with familial hypercholesterolaemia?

Answer 37

Evolocumab (PCSK9 inhibitor)

Question 38

Outline the Simon Broome criteria for familial hypercholesterolaemia.

Answer 38

In adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l or children TC > 6.7 mmol/l and LDL-C > 4.0 mmol/l, plus: DEFINITE FH: tendon xanthoma in patients or 1st or 2nd degree relatives or DNA-based evidence of FH POSSIBLE FH: family history of myocardial infarction below age 50 years in 2nd degree relative, below age 60 in 1st degree relative, or a family history of raised cholesterol levels

Question 39

What is an important acute complication of a ketamine infusion?

Answer 39

Raised ICP (monitor for headache, papilloedema and vomiting when administering)

Question 40

What is the time window for thrombectomy for stroke?

Answer 40

an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 41

How should patients with gestational diabetes be followed-up after birth?

Answer 41

Postnatal glucose check (fasting blood glucose) 6-13 weeks postpartum

Question 42

How should patients with COPD who are being worked up for LTOT and have a significant rise in pCO2 with oxygen therapy be managed?

Answer 42

Patients who develop a respiratory acidosis and/or a rise in PaCO2 of >1 kPa (7.5 mmHg) during an LTOT assessment on two repeated occasions, while apparently clinically stable, should only have domiciliary oxygen ordered in conjunction with nocturnal ventilatory support

Question 43

What is seen on a biopsy of a patient with CMV colitis?

Answer 43

Inclusion bodies NOTE: treated with gancyclovir

Question 44

Which antibody is specific for drug-induced lupus?

Answer 44

Anti-histone NOTE: common causes include procainamide and hydralazine

Question 45

Which conditions are associated with SIBO?

Answer 45

neonates with congenital gastrointestinal abnormalities scleroderma diabetes mellitus

Question 46

Describe the appearance of cryptosporidium on Ziehl Nielson staining.

Answer 46

Red cysts May be treated with rifaximin but is usually supportive in patients who are immunocompetent Other treatment: nitazoxanide

Question 47

What is the drug of choice for lymphatic filariasis?

Answer 47

Diethylcarbamazine

Question 48

How is FSGS treated?

Answer 48

Steroids

Question 49

How does histoplasmosis present?

Answer 49

Productive cough Retrosternal chest pain Recent travel to USA Rx: Itraconazole or amphotericin

Question 50

Which medication enhances the effects of adenosine?

Answer 50

Dipyridamole Leads to prolonged effects

Question 51

Which TB drug causes arthralgia?

Answer 51

Pyrazinamide

Question 52

What is the purpose of a long synacthen test?

Answer 52

A long synacthen test (where samples are taken at 1, 4, 8, and 24 hours) can be used to distinguish Addison's from secondary causes of adrenal insufficiency such as steroid use, panhypopituitarism, and isolated failure of adrenocorticotrophic hormone (ACTH). RATIONALE: with primary failure, the adrenals will never be able to produce any cortisol. With secondary failure, the exogenous ACTH will eventually be able to produce some cortisol.

Question 53

Which ECG change is commonly seen in arrhythmogenic right ventricular cardiomyopathy?

Answer 53

``` TWI in V1-V3 Epsilon wave (terminal notch in QRS complex) ```

Question 54

When are platelets and FFP recommended in the context of a gastrointestinal bleed?

Answer 54

platelets < 50 and INR/APTT > 1.5 x normal

Question 55

What are the four types of renal tubular acidosis?

Answer 55

Type 1 RTA (distal) inability to generate acid urine (secrete H+) in distal tubule causes hypokalaemia complications include nephrocalcinosis and renal stones causes include idiopathic, rheumatoid arthritis, SLE, Sjogren's, amphotericin B toxicity, analgesic nephropathy Type 2 RTA (proximal) decreased HCO3- reabsorption in proximal tubule causes hypokalaemia complications include osteomalacia causes include idiopathic, as part of Fanconi syndrome, Wilson's disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate) Type 3 RTA (mixed) extremely rare caused by carbonic anhydrase II deficiency results in hypokalaemia Type 4 RTA (hyperkalaemic) reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion causes hyperkalaemia causes include hypoaldosteronism, diabetes

Question 56

What are the features of Miller-Fisher Syndrome?

Answer 56

Ophthalmoplegia Areflexia Ataxia Usually a DESCENDING paralysis NOTE: Anti-GQ1b antibodies present in 90% of cases

Question 57

What is one negative aspect of G6PD level assays?

Answer 57

It may be normal during an acute episode NOTE: this is because cells with the lowest levels of G6PD are destroyed first during an acute episode. Measure again once acute episode has resolved.

Question 58

Which four cranial nerve nuclei arise in the medulla?

Answer 58

CN 9-12

Question 59

Which four cranial nerve nuclei arise in the pons?

Answer 59

CN 5-8

Question 60

Which four cranial nerve nuclei arise ABOVE the pons?

Answer 60

CN 1-2 (from the cerebrum) | CN 3-4 (from the midbrain)

Question 61

Which neuroanatomical structures are in the MIDLINE in the brainstem?

Answer 61

Motor pathways (corticospinal tract) Medial lemniscus Medial longitudinal fasciculus Motor nuclei of 3, 4, 6 and 12

Question 62

Which neuroanatomical structures are in the LATERAL aspect of the brainstem?

Answer 62

Spinothalamic Tract Sympathetic Fibres Sensory Nuclei of CN 5 Spinocerebellar Tract

Question 63

Which rule can be used to remember which motor nuclei are in the midline vs the lateral aspect of the brainstem?

Answer 63

The ones in the midline are all divisible by 12 (12, 6, 4 and 3) (N.B. excludes 1 and 2) The others are found in the lateral aspect (5, 7, 9 and 11)

Question 64

How does an uncal herniation manifest?

Answer 64

``` Ipsilateral 3rd nerve palsy involving the pupil Contralateral paralysis (due to compression of cerebral peduncle) ```

Question 65

What is the recommended treatment option for fatigue associated with MS?

Answer 65

Amantadine NOTE: anaemia, depression and thyroid dysfunction should be ruled out first

Question 66

How is oscillopsia associated with MS treated?

Answer 66

Gabapentin

Question 67

How should bladder dysfunction in MS be investigated and managed?

Answer 67

Ix: US to assess bladder emptying If significant residual volume --> Intermittent self-catheterisation If no significant residual volume --> anticholinergics

Question 68

What are the criteria for beta-interferon use in multiple sclerosis?

Answer 68

Relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided Secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided) Alternatives: glatiramer acetate, diethyl fumarate and teriflunomide NOTE: interferons are contraindicated in liver dysfunction

Question 69

What causes mucosal leishmaniasis and how does it manifest?

Answer 69

Leishmania braziliensis | Skin lesions across mucosa of nose and pharynx (may manifest years after exposure)

Question 70

What causes cutaneous leishmaniasis and how does it manifest?

Answer 70

Leishmania tropica or Leishmania mexicana Crusted lesion at site of bite

Question 71

What causes visceral leishmaniasis and how does it manifest?

Answer 71

Leishmania donovani Fever, sweats and rigors Massive splenomegaly and hepatomegaly Grey skin Pancytopaenia (due to hypersplenism) Ix: bone marrow or splenic aspirate

Question 72

Which vector transmits leishmaniasis?

Answer 72

Sandfly

Question 73

Which blood film abnormalities will be seen in G6PD deficiency?

Answer 73

Heinz bodies Bite cells Blister cells

Question 74

Which stain is used to distinguish primary from metastatic lung cancers when performing cytological analysis of a malignant pleural effusion?

Answer 74

TTF1 (thyroid transcription factor) This is only expressed by cells found in lung and thyroid.

Question 75

How does Kearns-Sayre syndrome manifest?

Answer 75

Onset in patients < 20 years old External ophthalmoplegia, retinitis pigmentosa (causing night blindness). Ptosis may be seen, heart block NOTE: mitochondrial disease

Question 76

What is the most specific ECG feature of acute pericarditis?

Answer 76

PR Depression

Question 77

Which drugs are used in the treatment of ventricular tachycardia (with pulse)?

Answer 77

Procainamide (best option) Amiodarone Lidocaine (caution in left ventricular impairment)

Question 78

What is a major risk of starting ACE inhibitors in someone with bilateral renal artery stenosis?

Answer 78

It can case deteriorating renal function and flash pulmonary oedema

Question 79

What are the features of severe iron toxicity (i.e. overdose)?

Answer 79

``` Abdominal pain and haematemesis (gastrointestinal corrosion) Diarrhoea Raised BM (HALLMARK) Significant sample haemolysis Metabolic acidosis with high anion gap Coagulopathy (particularly APTT) ```

Question 80

What increase in transaminases is allowed after starting a statin?

Answer 80

Up to 3 x upper limit of normal If it appears to be rising but within this limit, the statin can be continued and LFTs repeated in 4-6 weeks

Question 81

How is methotrexate toxicity treated?

Answer 81

Folinic acid NOTE: folic acid is used to prevent methotrexate side-effects

Question 82

Which antibiotics have good Pseudomonas cover?

Answer 82

``` Ciprofloxacin Tazocin Ceftazidime Aztreonam Meropenem ```

Question 83

What is the only absolute contraindication for ECT?

Answer 83

Raised intracranial pressure

Question 84

In which subgroup of patients with stable angina should revascularisation with PCI be offered?

Answer 84

Stable coronary artery disease and ischaemia in > 10 % of the left ventricle

Question 85

What is an osmolar gap?

Answer 85

Measure Osmolality - Calculated Osmolality (2 x Na + Glu + Ur) = <10 If it is high, it means that there is an unmeasured solute in high amounts (e.g. ethylene glycol)

Question 86

Which cause of pneumonia is associated with bulging fissure sign?

Answer 86

Klebsiella pneumonia

Question 87

List some indications for IVIG

Answer 87

primary and secondary immunodeficiency idiopathic thrombocytopenic purpura myasthenia gravis Guillain-Barre syndrome Kawasaki disease toxic epidermal necrolysis pneumonitis induced by CMV following transplantation low serum IgG levels following haematopoietic stem cell transplant for malignancy dermatomyositis chronic inflammatory demyelinating polyradiculopathy NOTE: aseptic meningitis is a classic complication

Question 88

What is the preferred imaging modality for patients with suspected TIA who need brain imaging?

Answer 88

MRI brain with diffusion-weighted imaging

Question 89

What is a gradient record MRI brain used for?

Answer 89

To look for microhaemorrhages

Question 90

How are hiccups managed?

Answer 90

Chlorpromazine Haloperidol and Gabapentin Dexamethasone (used if there are hepatic lesions)

Question 91

What should you do in patients with neutropenic sepsis that has failed to respond to antibiotics after 48 hours?

Answer 91

It may be fungal --> start antifungal therapy

Question 92

What feature can help distinguish dengue from chikungunya?

Answer 92

Chikungunya is more associated with severe joint pains

Question 93

What is the most common GI side-effect of clozapine?

Answer 93

Constipation and intestinal obstruction

Question 94

What are the indication for CRT?

Answer 94

NYHA class three or four symptoms They are in normal sinus rhythm with either → QRS duration of 150 ms or longer estimated by standard electrocardiogram (ECG) → QRS duration of 120-149 ms estimated by ECG and mechanical dyssynchrony that is confirmed by echocardiography. They have a left ventricular ejection fraction of 35% or less. They are receiving optimal pharmacological thera

Question 95

How is Schistosoma haematobium infection treated?

Answer 95

Single dose of praziquantel

Question 96

Which types of porphyria only cause neurovisceral symptoms (i.e. no skin involvement)?

Answer 96

Acute intermittent porphyria | Aminolaevulinic acid dehydrogenase porphyria

Question 97

Which types of porphyria only manifest with photosensitivity?

Answer 97

Porphyria cutanea tarda Congenital erythropoietic porphyria Erythropoietic protoporphyria

Question 98

Which types of porphyria cause both neurovisceral and photosensitive manifestations?

Answer 98

Variegate porphyria | Hereditary coproporphyria

Question 99

How long after CT contrast can a patient have radioiodine therapy?

Answer 99

8 weeks

Question 100

Which criteria are used to diagnose a total anterior circulation stroke?

Answer 100

Unilateral hemiparesis and/or hemisensory loss of face/arm/leg Homonymous hemianopia Higher cognitive dysfunction (e.g. dysphasia) NOTE: partial anterior circulation stroke is if 2 of the 3 above criteria are present

Question 101

Which arteries are affected in a total anterior circulation stroke?

Answer 101

Anterior and Middle Cerebral Arteries

Question 102

What are the main complications of typhoid?

Answer 102

Bowel perforation and haemorrhage | Myocarditis and endocarditis

Question 103

List some contraindications for second line anti-anginal drugs.

Answer 103

Ivabradine - sick sinus syndrome Ranolazine - liver injury Nicorandil - LV failure and cardiogenic shock

Question 104

What are the five types of lupus nephritis?

Answer 104

``` I - Minimal Mesangial II - Mesangial Proliferation III - Focal IV - Diffuse (WORST PROGNOSIS) V - Membranous ```

Question 105

What treatment should be offered to 15-49 year olds with early ADPKD (eGFR > 90)?

Answer 105

ACE inhibitor with target blood pressure of < 110/75 mm Hg NOTE: tolvaptan is recommended for rapidly progressive disease at CKD stage 2-3.

Question 106

What are the indications for starting treatment of CLL?

Answer 106

progressive marrow failure: the development or worsening of anaemia and/or thrombocytopenia massive (>10 cm) or progressive lymphadenopathy massive (>6 cm) or progressive splenomegaly progressive lymphocytosis: > 50% increase over 2 months or lymphocyte doubling time < 6 months systemic symptoms: weight loss > 10% in previous 6 months, fever >38ºC for > 2 weeks, extreme fatigue, night sweats autoimmune cytopaenias e.g. ITP NOTE: FCR is usually the initial treatment of choice, ibrutinib is used afterwards

Question 107

What ABG picture would you see in someone with methaemoglobinaemia?

Answer 107

Mixed respiratory and metabolic acidosis with a relative hypoxia despite the inspired fraction of oxygen.

Question 108

When might ITP be used instead of steroids in a patient with ITP?

Answer 108

If platelets need to rise quickly (e.g. ahead of surgery)

Question 109

What can cause a thunderclap headache with a normal CT head and normal CSF results?

Answer 109

Reversible cerebrovascular vasoconstriction syndrome

Question 110

Why must you exercise caution when thinking about administering blood products to people with selective IgA deficiency?

Answer 110

Associated with anaphylactic reaction to blood products

Question 111

How does benzodiazepine withdrawal manifest?

Answer 111

PHYSICAL: tachycardia, sweating, tremor NEUROPSYCHIATRIC: nightmares, insomnia, anxiety, seizures, photophobia, derealisation and kinaesthetic hallucinations

Question 112

Which medications cause false positive 5-HIAA results?

Answer 112

Paracetamol Naproxen Caffeine Fluorouracil FOODS: Banana, Avocado, Aubergine, Pineapple, Plums, Walnuts, Tomatoes

Question 113

Which medications cause false negative 5-HIAA results?

Answer 113

Aspirin Levodopa Methyldopa ACTH

Question 114

How is a scleroderma renal crisis managed?

Answer 114

STAT ACE Inhibitor

Question 115

What are the first, second and third line treatment options for acute dystonia?

Answer 115

1: Procyclidine 2: Benzodiazepine 3: Anticholinergic Antihistamines

Question 116

List some common drugs that can increase seizure frequency in people with epilepsy?

Answer 116

``` Fentanyl Mefenamic Acid Tramadol Amitriptyline Aminophylline Isotretinoin Haloperidol ```

Question 117

Outline the differences between the Parkinson's plus syndromes.

Answer 117

PSP: bilateral symptoms, vertical gaze palsy, nasal voice (due to pseudobulbar palsy) MSA: significant cerebellar or autonomic dysfunction CBD: significant higher order dysfunction (e.g. apraxia, aphasia, alien hand syndrome)

Question 118

What level of LFT derangement would warrant stopping methotrexate?

Answer 118

Doubling of ALT or AST

Question 119

Which opioids are safe in patients with impaired renal function (eGFR < 30)?

Answer 119

Oxycodone Fentanyl Buprenorphine Methadone

Question 120

How is lupus nephritis treated?

Answer 120

Focal and Mild: Oral Steroids | Nephrotic Syndrome and Advanced Diffuse Lupus Nephritis: IV Methylprednisolone and IV Cyclophosphamide

Question 121

When should statins be started after a stroke?

Answer 121

48 hours after the onset of symptoms

Question 122

In which cases of hyperadrenalism is surgery indicated?

Answer 122

If it is caused by a unilateral adrenal adenoma Otherwise you manage with spironolactone

Question 123

When should EPO be started in a patient with CKD?

Answer 123

Once they are iron replete (this can be achieved with IV iron)

Question 124

List the medical management guidelines for HOCM.

Answer 124

1: Beta-Blocker or Non-Dihydropyridine CCB (e.g. verapamil) 2: Disopyramide (class 1a anti-arrhythmic) 3: Myectomy, DDDR pacemaker, alcohol ablation

Question 125

How should measles exposure be managed in someone that is vulnerable (e.g. unvaccinated, immunocompromised)?

Answer 125

Immunoglobulin

Question 126

Why should patients undergoing open surgical valve repair have a coronary angiogram prior to the surgery?

Answer 126

To identify any coronary artery disease that could also be attended to at the same time

Question 127

What is paragonimiasis and how does it present?

Answer 127

Lung Fluke Infection Presents very similarly to TB with a chronic history of productive cough, weight loss, night sweats and rashes Treated with praziquantel

Question 128

List some side-effects of ciclosporin.

Answer 128

``` Nephrotoxic Hepatotoxic Fluid retention Hyperkalaemia Hypertrichosis Gingival hyperplasia ```

Question 129

What is Fabry disease?

Answer 129

X-linked recessive lipid storage disorder Caused by deficiency in alpha-galactosidase Leads to accumulation of lipids in various tissues ``` Acroparaesthesia (tingling and burning in hands and feet triggered by stress, emotion and temperature) Angiokeratoma corporis diffusum Mitral valve prolapse/regurgitation Young strokes CKD ```

Question 130

Which serum measurement is a useful marker of renal function that is less affected by age, sex, race and muscle mass?

Answer 130

Cystatin C

Question 131

At what serum PTH level should patients with secondary hyperparathyroidism receive calcium and vitamin D supplements?

Answer 131

Twice the upper limit of normal Supplementing calcium and vitamin D in secondary hyperparathyroidism runs the risk of adynamic bone disease if it is started sooner

Question 132

How should hoarseness after a total thyroidectomy be investigated?

Answer 132

Laryngoscopy - to assess vocal cord paralysis and evaluate motility

Question 133

How does strongyloidiasis manifest?

Answer 133

``` Diarrhoea Abdominal pain and bloating Papulovesicular lesions where skin has been penetrated (e.g. feet) Pruritic rash Pneumonitis (if larvae migrate to lungs) ``` Rx: Ivermectin

Question 134

In which groups of patient is CABG considered better than PCI with stent insertion for the management of ischaemic heart disease?

Answer 134

Patients with complex anatomy Triple vessel disease Proximal left main stem disease

Question 135

Which investigation is used for acute intermittent porphyria and how is it treated?

Answer 135

Raised urinary porphobilinogen Treated with IV haem arginate

Question 136

Which antibiotics are usually used to manage pyogenic liver abscesses?

Answer 136

amoxicillin + ciprofloxacin + metronidazole

Question 137

What ECG features do you see in hypocalcaemia?

Answer 137

Prolonged QT Interval

Question 138

How does histoplasmosis present and how is it treated?

Answer 138

Symptoms of URTI Retrosternal pain Rx: amphotericin or itraconazole

Question 139

Outline the mechanism of hungry bone syndrome.

Answer 139

The mechanism is thought to be thus: high pre-operative levels of parathyroid hormone provide a constant stimulus for osteoclast activity creating the hypercalcaemic state by de-mineralizing the bones. This process can result in x-ray changes very similar to metastatic lytic lesions if left untreated. Upon removal of the parathyroid adenoma the hormone levels fall rapidly (they have a very short half-life) and the osteoclast activity is subsequently diminished and the bones rapidly begin re-mineralisation - 'hungry bone syndrome'. This process can be uncomfortable and also result in systemic hypocalcaemia.

Question 140

Which lower limb neurological features do you see in subacute combined degeneration of the spinal cord?

Answer 140

Brisk Knee Reflexes Absent Ankle Reflexes Extensor Plantar Reflexes

Question 141

Describe the manifestations of methoxetamine overdose.

Answer 141

``` Sympathetic activation (tachycardia, hypertension, mydriasis) Confusion and agitation Cerebellar signs (nystagmus, dysarthria, ataxia) ``` NOTE: methoxetamine is an analogue of ketamine

Question 142

What is the most common side effect of checkpoint inhibitors like nivolumab?

Answer 142

Dry itchy skin and rashes

Question 143

How does anti-NMDA receptor encephalitis present?

Answer 143

``` Prominent psychiatric symptoms (agitation, hallucinations, delusions) Seizures Insomnia Dyskinesia Autonomic instability ``` Treated with immunosuppression (steroids, immunoglobulins, rituximab, cyclophosphamide, plasma exchange) NOTE: it is normally caused by an ovarian teratoma

Question 144

What is tropical spastic paraparesis?

Answer 144

A condition in which patients with HIV and HTLV1 present with urinary retention and paraparesis

Question 145

Which antiemetic is best for metabolic causes of nausea and vomiting (e.g. hypercalcaemia, uraemia)?

Answer 145

Central dopamine antagonists (e.g. haloperidol)

Question 146

What is the first-line antibiotic for ESBL UTIs?

Answer 146

Carbapenems

Question 147

How does American trypanosomiasis manifest?

Answer 147

ACUTE: asymptomatic, sometimes orbital oedema CHRONIC: myocarditis (and dilated cardiomyopathy), megaoesophagus (causing dysphagia) and megarectum Rx: benznidazole or nifurtimox

Question 148

What is idarucizumab used to reverse?

Answer 148

Dabigatran

Question 149

What is used to reverse rivaroxaban and apixaban?

Answer 149

Andexanet alpha

Question 150

What is the DMARD of choice in psoriatic arthritis?

Answer 150

Methotrexate 2nd line: leflunomide

Question 151

What special feature of carbamazepine must you be aware of when starting patients on the drug?

Answer 151

It causes autoinduction so there may be an increase in seizure prevalence after 3-4 weeks

Question 152

What forms of smoking cessation treatment are recommended by NICE?

Answer 152

Nicotine replacement therapy (patch and a short-form for acute cravings) Varenicline (CI in pregnancy) Bupropion (CI in pregnancy)

Question 153

Outline the management of non-small cell lung cancer.

Answer 153

Stage 1 and 2: Resection Surgery Stage 3: Chemotherapy Stage 4: Palliative

Question 154

List the contraindications for surgery for non-small cell lung cancer.

Answer 154

assess general health stage IIIb or IV (i.e. metastases present) FEV1 < 1.5 litres is considered a general cut-off point* malignant pleural effusion tumour near hilum vocal cord paralysis SVC obstruction NOTE: FEV1 > 2 L for pneumonectomy

Question 155

What special feature of Plasmodium ovale required additional consideration when determining how to treat it?

Answer 155

It has a liver hypnozoite phase that needs to be treated with primaquine NOTE: primaquine can cause a haemolytic crisis in patients with G6PD deficiency so this should be excluded before starting treatment

Question 156

Outline the criteria for diagnosing NF2.

Answer 156

Bilateral vestibular schwannomas A first degree relative with NF2 AND Unilateral vestibular schwannoma OR Any two of: meningioma, schwannoma, glioma, neurofibroma, posterior subcapsular lenticular opacities Unilateral vestibular schwannoma AND Any two of: meningioma, schwannoma, glioma, neurofibroma, posterior subcapsular lenticular opacities Multiple meningiomas AND Unilateral vestibular schwannoma OR Any two of: schwannoma, glioma, neurofibroma, cataract

Question 157

What is the threshold for platelet transfusions in an actively bleeding patient?

Answer 157

50

Question 158

What are the criteria for FFP in patients who are actively bleeding?

Answer 158

Either a fibrinogen level of less than 1 g/litre or PT or APTT greater than 1.5 times normal

Question 159

Which vaccines are contraindicated in adults with HIV?

Answer 159

Cholera CVD103-HgR Influenza-intranasal Poliomyelitis-oral (OPV) Tuberculosis (BCG) NOTE: if CD4 < 200, then MMR, varicella and yellow fever are also contraindicated

Question 160

How does relapsing polychondritis present?

Answer 160

Relapsing episodes of chondritis (e.g. auricular chondritis) | Can involve the respiratory tract, heart valves and blood vessels.

Question 161

List some lead chelators.

Answer 161

dimercaptosuccinic acid (DMSA) - best for chronic exposure D-penicillamine EDTA - IV agent used for acute exposure dimercaprol

Question 162

How does lead poisoning manifest?

Answer 162

``` abdominal pain peripheral neuropathy (mainly motor) fatigue constipation blue lines on gum margin (only 20% of adult patients, very rare in children) ```

Question 163

How should an HIV viral load of 50-200 in someone on established ART be managed?

Answer 163

Repeat blood test in 1 month

Question 164

What are the criteria for antibiotic prophylaxis in patients with ascites?

Answer 164

patients who have had an episode of SBP patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome NOTE: with ciprofloxacin or norfloxacin

Question 165

What are the criteria for commencing treatment with GLP1 agonists?

Answer 165

- Triple therapy is ineffective/not tolerated/contraindicated - BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or - BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities NOTE: only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months

Question 166

What are the two different types of Wolff-Parkinson-White syndrome?

Answer 166

``` type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1 ```

Question 167

How should WPW be managed?

Answer 167

DEFINITIVE: RFA of accessory pathway MEDICAL: Sotalol, Amidarone, Flecainide NOTE: caution with AV blocking drugs especially if broad complex tachycardia because it may lead to increased conduction over accessory pathway leading to 1:1 AV conduction and VF

Question 168

List some CYP450 INDUCERS.

Answer 168

antiepileptics: phenytoin, carbamazepine barbiturates: phenobarbitone rifampicin St John's Wort chronic alcohol intake griseofulvin smoking (affects CYP1A2, reason why smokers require more aminophylline NOTE: these DECREASE INR

Question 169

List some CYP450 INHIBITORS.

Answer 169

``` antibiotics: ciprofloxacin, erythromycin isoniazid cimetidine,omeprazole amiodarone allopurinol imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir sodium valproate acute alcohol intake quinupristin ``` NOTE: these INCREASE INR

Question 170

List the manifestations of myotonic dystrophy.

Answer 170

``` myotonic facies (long, 'haggard' appearance) frontal balding bilateral ptosis cataracts dysarthria cardiomyopathy (incl. heart block) dysphagia diabetes mellitus ```

Question 171

Outline the differences between DM1 and DM2.

Answer 171

DM1 - DMPK gene on chromosome 19 - Distal weakness more prominent DM2 - ZNF9 gene on chromosome 3 - Proximal weakness more prominent - Severe congenital form not seen

Question 172

How is dermatitis herpetiformis treated?

Answer 172

Dapsone and a gluten-free diet Second Line: Sulfapyridine

Question 173

What causes paroxysmal nocturnal haemoglobinuria?

Answer 173

Acquired intravascular haemolysis due to increased sensitivity of cell membranes to complement due to lack of glycoprotein glycosylphosphatidylinositol (GPI).

Question 174

How does PNH manifest?

Answer 174

``` Haemolytic anaemia Cytopaenias Haemoglobinuria Thrombosis Aplastic anaemia ```

Question 175

How can PNH be diagnosed?

Answer 175

Flow cytometry of blood to detect low levels of CD59 and CD55

Question 176

How can PNH be managed?

Answer 176

ACUTE: blood products, anticaogulation, eculizumab DEFINTIIVE: stem cell transplantation

Question 177

What is Alport syndrome?

Answer 177

X-linked dominant condition caused by mutation in collagen IV leading to abnormal glomerular basement membrane

Question 178

How does Alport syndrome manifest?

Answer 178

``` Microscopic haematuria Progressive renal failure Bilateral sensorineural hearing loss Lenticonus Retinitis pigmentosa Renal Biopsy: split lamina densa (basket weave appearance) ```

Question 179

What is a relatively common complication that occurs in patients with Alport syndrome who have received a renal transplant?

Answer 179

Crescentic glomerulonephritis due to de novo anti-GBM disease

Question 180

Which investigations should be used to screen for haemochromatosis?

Answer 180

general population: transferrin saturation > ferritin | family members: HFE genetic testing

Question 181

What are the definitive diagnostic tests used for hereditary haemochromatosis?

Answer 181

molecular genetic testing for the C282Y and H63D mutations | liver biopsy: Perl's stain

Question 182

Which type of brain tumour is associated with a paraneoplastic phenomenon in which patients develop a high Hb?

Answer 182

Cerebral haemangioblastomas (release erythropoietin)

Question 183

List some associations of PBC.

Answer 183

Sjogren's syndrome (seen in up to 80% of patients) rheumatoid arthritis systemic sclerosis thyroid disease

Question 184

What is papillary necrosis and what can cause it?

Answer 184

Sloughing of renal papillae which can lead to urinary obstruction, AKI and CKD. It can also cause a salt-losing nephropathy. ``` CAUSES chronic analgesia use sickle cell disease TB acute pyelonephritis diabetes mellitus ```

Question 185

What is the risk of using BRAF inhibitors (e.g. Vemurafenib and dabrafenib) in the treatment of melanoma?

Answer 185

Squamous cell carcinoma

Question 186

What is the main treatment option for gout in patients with severely impaired renal function?

Answer 186

Steroids (e.g. prednisolone) Alternative: Canakinumab (anti-IL1 beta) NOTE: colchicine, NSAIDs and allopurinol are all contraindicated

Question 187

How does central pontine myelinolysis manifest?

Answer 187

Spastic quadriparesis Pseudobulbar palsy Emotional lability

Question 188

List the indications for an ICD.

Answer 188

``` long QT syndrome hypertrophic obstructive cardiomyopathy previous cardiac arrest due to VT/VF previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35% Brugada syndrome ```

Question 189

What is hypokalaemic periodic paralysis?

Answer 189

Rare autosomal dominant condition characterised by episodes of paralysis (usually at night) that can be precipitated by strenuous exercise, stress or a high carbohydrate meal. Caused by defect in muscle voltage-gated calcium channels. Requires lifelong potassium replacement.

Question 190

How should myxoedema coma be managed?

Answer 190

Levothyroxine and liothyronine

Question 191

How should paroxysmal AF be investigated?

Answer 191

Episodes < 24 hrs apart: 24 hr ambulatory ECG | Episodes > 24 hrs apart: event recorder electrocardiogram

Question 192

List some causes of erythema multiforme.

Answer 192

viruses: herpes simplex virus (the most common cause), Orf* idiopathic bacteria: Mycoplasma, Streptococcus drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine connective tissue disease e.g. Systemic lupus erythematosus sarcoidosis malignancy

Question 193

How is membranous glomerulonephritis managed?

Answer 193

ACE inhibitor or ARB Immunosuppression NOTE: associated with anti-phospholipse A2 antibodies

Question 194

How is thyroid storm managed?

Answer 194

Beta blockers (e.g. IV propranolol) Antithyroid drugs (e.g. propylthiouracil) Lugol's iodine Dexamethasone

Question 195

When should patients undergo a carotid endarterectomy?

Answer 195

Patients with a TIA or small ischaemic stroke with evidence of significant carotid artery stenosis (male patients with a carotid artery stenosis of 50-99% or female patients with a carotid artery stenosis of 70-99%) that corresponds to the same side as the stroke/TIA should be considered for an urgent carotid endarterectomy (CEA) within 14 days

Question 196

Describe the symptoms of zinc deficiency.

Answer 196

``` perioral dermatitis: red, crusted lesions acrodermatitis alopecia short stature hypogonadism hepatosplenomegaly geophagia (ingesting clay/soil) cognitive impairment ```

Question 197

Describe the clinical manifestations of methanol and ethylene glycol poisoning.

Answer 197

Methanol: retinal injury, visual disturbance | Ethylene Glycol: oliguria, haematuria, flank pain

Question 198

What is autonomic dysreflexia?

Answer 198

Occurs in individuals with spinal injury at or above T6 Afferent signals triggered by urinary retention/faecal impaction causes sympathetic spinal reflex via thoracolumbar outflow. Manifests with hypertension, flushing and sweating above the lesion

Question 199

What is mepolizumab and when is it used?

Answer 199

Anti-IL5 monoclonal antibody | Used for asthma with high eosinophils

Question 200

What is Weber syndrome?

Answer 200

Form of midbrain stroke characterised by ipsilateral CNIII palsy and contralateral hemiparesis Caused by a stroke involving a branch of the posterior cerebral artery

Question 201

List medications that can precipitate myasthenic crises.

Answer 201

``` penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines ```

Question 202

Outline the differences between type 1 and type 2 HRS.

Answer 202

TYPE 1: rapidly progressive, Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks TYPE 2: slowly progressive

Question 203

How is hepatorenal syndrome managed?

Answer 203

Terlipressin and HAS NOTE: TIPSS may also be used

Question 204

What is the first-line treatment option for myelofibrosis?

Answer 204

Hydroxycarbamide

Question 205

What is the investigation of choice for suspected hydatid cysts?

Answer 205

Serology for Echinococcus granulosus

Question 206

What is an important side-effect of dapsone to be mindful of?

Answer 206

Haemolytic anaemia

Question 207

What is Hereditary Neuropathy with Liability to Pressure Palsy?

Answer 207

A condition in which a small amount of pressure on a peripheral nerve results in a mononeuropathy that takes weeks to resolve Associated with PMP22 gene deletion

Question 208

What is a common side-effect of efavirenz?

Answer 208

Disturbing dreams and being muddled

Question 209

What is an alternative to penicillamine for copper chelation?

Answer 209

Trientine NOTE: people with penicillin allergy cannot receive penicillamine

Question 210

Which type of meningococcal meningitis is most common across Africa and the Middle East?

Answer 210

Men A NOTE: B and C are more common in Europe and South America

Question 211

How should cases of TB with isoniazid resistance be managed?

Answer 211

Continue ethambutol for 6 months

Question 212

What are the rules for treating subclinical hypothyroidism?

Answer 212

Treat if TSH is > 10 mU/L as long as they are younger than 70 yrs old Otherwise repeat TFTs in 6 months

Question 213

What is a major danger of hydatid cyst rupture?

Answer 213

It can cause anaphylaxis

Question 214

What are the indications for steroid treatment in sarcoidosis?

Answer 214

patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment hypercalcaemia eye, heart or neuro involvement

Question 215

What ECG changes are seen in hypokalaemia?

Answer 215

``` U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT ```

Question 216

Which investigation must be conducted before considering adrenalectomy in a patient with Conn syndrome?

Answer 216

Adrenal venous sampling This allows you to distinguish between bilateral adrenal hyperplasia and unilateral adrenal adenoma

Question 217

What is used for bacterial meningitis prophylaxis?

Answer 217

Ciprofloxacin or rifampicin NOTE: should be offered to everyone that had close contact with the patient within 7 days of symptom onset

Question 218

What are anti-Hu, anti-Yo and anti-Ri antibodies associated with?

Answer 218

anti-Hu: small cell lung cancer - painful sensory neuropathy, cerebellar syndromes, encephalitis anti-Yo: ovarian, breast cancer - cerebellar syndrome anti-Ri: small cell lung cancer - retinal degeneration

Question 219

Why should aspirin be stopped in thyroid storm?

Answer 219

It can displace T4 from thyroid binding globulin

Question 220

What is Gardener syndrome?

Answer 220

Autosomal dominant condition characterised by adenomatous intestinal polyps, osteomas and fibromas NOTE: high risk of colorectal cancer

Question 221

What triad of features is associated with Still's disease?

Answer 221

Fever Joint Pain Salmon-coloured bumpy rash NOTE: associated with high ferritin and ESR and treated with NSAIDs

Question 222

How does cyanide poisoning manifest and how is it treated?

Answer 222

Hypoxia, Hypotension, Headache, Confusion Rx: IV hydroxocobalamin (alternatives: amyl nitrite (inhaled), IV sodium nitrite, IV sodium thiosulfate)

Question 223

How is CNS lymphoma treated?

Answer 223

Steroids + Methotrexate

Question 224

What effect does smoking have on aminophylline?

Answer 224

Required higher doses of aminophylline

Question 225

How is the tremor treated in patients with Parkinson's disease who are already on co-careldopa?

Answer 225

Procyclidine Other anticholinergics include orphenadrine, or trihexyphenidyl

Question 226

How is methanol poisoning treated?

Answer 226

1st Line: Fomepizole or Ethanol Alt: Haemodialysis NOTE: folinic acid can reduce ophthalmological complications

Question 227

What causes Glanzmann's thrombsthenia?

Answer 227

Ineffective Glp IIb/IIIa

Question 228

What is Foster-Kennedy syndrome?

Answer 228

Ipsilateral optic atrophy and contralateral papilloedema Caused by frontal lobe mass (e.g. meningioma)

Question 229

How is a spontaneous carotid artery dissection managed medically?

Answer 229

Aspirin NOTE: high risk of thromboembolic disease

Question 230

How is flexural psoriasis treated?

Answer 230

Mild to moderate topical steroids

Question 231

Which combination of ECG features are seen in incomplete trifascicular block?

Answer 231

Right Bundle Branch Block Left Axis Deviation Prolonged PR Interval

Question 232

At what point should patients with type 1 diabetes mellitus receive a statin?

Answer 232

older than 40 years, or have had diabetes for more than 10 years or have established nephropathy or have other CVD risk factors NOTE: do not use QRISK2

Question 233

Which medical treatment is used or Parkinson's dementia?

Answer 233

Rivastigmine

Question 234

Other than anti-acetylcholine receptor antibodies, which other antibody is associated with myasthenia gravis?

Answer 234

Anti-muscle specific tyrosine kinase (MuSK) NOTE: 40% of patients have anti-MuSK antibodies and they have less of a response to pyridostigmine

Question 235

Which mutation is associated with Hairy Cell Leukaemia?

Answer 235

BRAF

Question 236

List some features of severe malaria.

Answer 236

``` schizonts on a blood film parasitaemia > 2% hypoglycaemia acidosis temperature > 39 °C severe anaemia complications as below ```

Question 237

Which medication is used to prevent acute mountain sickness?

Answer 237

Acetazolamide It works by causing a metabolic acidosis leading to a compensatory respiratory alkalosis (achieved through hyperventilation)

Question 238

What is roflumilast and when is it recommended in the management of COPD?

Answer 238

Phosphodiesterase-4 inhibitor Recommended in COPD patients on maximal medical therapy + FEV1 < 50% + 2 or more exacerbations over last year

Question 239

Why is sodium bicarbonate used in the treatment of aspirin overdose?

Answer 239

It increases the alkalinisation of urine resulting in increased aspirin excretion NOTE: any aspirin level > 450 mg/L should be treated NOTE: sodium bicarbonate is also used in the treatment of barbiturate overdose

Question 240

What are the indications for dialysis in salicylate overdose?

Answer 240

``` serum concentration > 700mg/L metabolic acidosis resistant to treatment acute renal failure pulmonary oedema seizures coma ```

Question 241

What should you give when three doses of adenosine fails to terminate an SVT in a haemodynamically stable patient?

Answer 241

Verapamil (provided no asthma or atrial flutter) Dose 2.5-5 mg IV

Question 242

List some risk factors for refeeding syndrome.

Answer 242

BMI < 16 kg/m2 unintentional weight loss >15% over 3-6 months little nutritional intake > 10 days hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

Question 243

List some causes of FSGS.

Answer 243

``` idiopathic secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy HIV heroin Alport's syndrome sickle-cell ```

Question 244

Which HIV drug is associated with the formation of urate stones?

Answer 244

Indinavir

Question 245

What are the three types of long QT syndrome?

Answer 245

Long QT1 - usually associated with exertional syncope, often swimming Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli Long QT3 - events often occur at night or at rest sudden cardiac death

Question 246

Outline the treatment of idiopathic intracranial hypertension.

Answer 246

Weight Loss Diuretics Repeated lumbar puncture Surgery (optic nerve sheath decompression and fenestration)

Question 247

Which drug class is best for treating tics?

Answer 247

Antipsychotics (e.g. risperidone) | Clonidine

Question 248

During an LTOT assessment, how should you manage a patient whose pCO2 increases by > 1 kPa following oxygen administration?

Answer 248

Medically optimise and reassess in 4 weeks

Question 249

Aside from the effects of the infection itself, what other gastrointestinal complication an be caused by Giardia infection?

Answer 249

Temporary lactose intolerance

Question 250

What are the main differences between American and African trypanosomiasis?

Answer 250

AMERICAN: chagoma (nodule at site of infection), myocarditis, dysphagia, megaoesophagus, megarectum (GENERALLY CHRONIC INFECTION) AFRICAN: chancre, intermittent fever, enlarged posterior cervical lymph nodes, CNS effects

Question 251

What is the first line treatment for viral pericarditis?

Answer 251

NSAID + Colchicine

Question 252

How is peritoneal dialysis peritonitis treated?

Answer 252

Intraperitoneal vancomycin + ceftazidime NOTE: S. epidermidis is the most common cause

Question 253

What are the criteria for 3 yearly colonoscopies in patients with ulcerative colitis?

Answer 253

Extensive colitis with mild active endoscopy/histological inflammation OR post-inflammatory polyps OR family history of colorectal cancer in a first degree relative aged 50 or over

Question 254

Which genes are associated with MEN?

Answer 254

MEN1 : MEN1 Gene | MEN2: RET Oncogene

Question 255

Which common drugs are potent inhibitors of CYP3A4?

Answer 255

Macrolides (e.g. clarithromycin)

Question 256

How is Anti-GBM disease treated?

Answer 256

Plasmapheresis Steroids Cyclophosphamide

Question 257

Which drugs are used to treat Huntington's chorea?

Answer 257

DOPAMINE DEPLETION: Reserpine (VMAT), tetrabenazine DOPAMINE ANTAGONISTS: antipsychotics (e.g. risperidone)

Question 258

What are the ECG features seen in dextrocardia?

Answer 258

Inverted P wave in leave I RAD Loss of R wave progression

Question 259

What are the ECG features of a posterior MI?

Answer 259

Changed in V1-3: - Horizontal ST depression - Tall, broad R waves - Upright T waves - Dominant R wave (V2)

Question 260

Which simple test may be used to distinguish Conn's syndrome from adrenal hyperplasia?

Answer 260

Measure aldosterone after prolonged standing | Aldosterone increases after prolonged standing in patients with adrenal hyperplasia

Question 261

What are the features of multiple sclerosis that are seen on an MRI head scan?

Answer 261

high signal T2 lesions periventricular plaques Dawson fingers: often seen on FLAIR images - hyperintense lesions penpendicular to the corpus callosum

Question 262

What is the first line treatment option for scalp psoriasis?

Answer 262

Topics steroids (daily for 4 weeks)

Question 263

What is the gold standard investigation for cerebral venous sinus thrombosis?

Answer 263

MRI Venography (though CT venography is often used for convenience)

Question 264

What is the main indication for placing a chest drain in a patient with a pleural effusion?

Answer 264

If the pH on the pleural aspirate is < 7.2

Question 265

Outline Light's criteria for pleural effusions.

Answer 265

Exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L If the protein level is between 25-35 g/L, Light's criteria should be applied. An exudate is likely if at least one of the following criteria are met: - pleural fluid protein divided by serum protein >0.5 - pleural fluid LDH divided by serum LDH >0.6 - pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Question 266

How is chronic inflammatory demyelinating polyneuropathy (CIDP) different from GBS?

Answer 266

``` Motor symptoms predominate Insidious onset (months) - like a chronic version of GBS Treated with steroids and immunosuppressants ```

Question 267

Which diagnoses are associated with upgoing plantars and absent ankle jerks?

Answer 267

``` SACD Motor neurone disease Friedrich ataxia Tabes dorsalis Dual peripheral with central pathology ```

Question 268

In patients with stage 1 hypertension, what is the treatment thershold?

Answer 268

10-year-cardiovascular risk score > 10% or evidence of end organ damage

Question 269

What is pacemaker syndrome?

Answer 269

Occurs when a single lead pacemaker (VVI) is out of sync with atrial activity Although the ventricular rate is guaranteed, this may come at the expense of atrioventricular concordance (reduced diastolic function) leading to worsening of breathlessness This should be treated with a DDI pacemaker that sense and paces both the atria and the ventricles

Question 270

Which drug class is notorious for triggering scleroderma crisis?

Answer 270

Steroids

Question 271

How is lupus nephritis treated?

Answer 271

Steroids to induce remission (with or without cyclophosphamide and mycophenolate) Mycophenolate to maintain remission

Question 272

Which antibiotics are good at treating Legionella?

Answer 272

Macrolides and Quinolones NOTE: they have good intracellular penetration

Question 273

Which class of Parkinson's medications is best for off-time reduction?

Answer 273

Dopamine agonists

Question 274

Which class of Parkinson's medications is most commonly associated with causing delusions and hallucinations?

Answer 274

Dopamine agonists It also causes impulse control issues

Question 275

Which additional test is useful in making a diagnosis of heparin-induced thrombocytopaenia in someone with a moderate HIT antibody titre?

Answer 275

Serotonin release assay

Question 276

What second line agent is used in the treatment of familial hypercholesterolaemia?

Answer 276

Ezetimibe

Question 277

What do VVI pacemakers look like on an ECG?

Answer 277

Pacing spikes immediately before the QRS complex

Question 278

What is the most effective screening tool for distinguishing delirium from dementia?

Answer 278

Confusion assessment method (CAM)

Question 279

List some causes of retroperitoneal fibrosis.

Answer 279

``` Riedel's thyroiditis previous radiotherapy sarcoidosis inflammatory abdominal aortic aneurysm drugs: methysergide ```

Question 280

What can be used for bone protection in a patient with bone metastases and an eGFR < 30 mL/min?

Answer 280

Denosumab

Question 281

Outline the criteria for decompressive craniotomy in the context of malignant MCA syndrome.

Answer 281

Aged 60 years or under. Clinical deficits suggestive of infarction in the territory of the middle cerebral artery, with a score on the National Institutes of Health Stroke Scale (NIHSS) of above 15. Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS. Signs on CT of an infarct of at least 50% of the middle cerebral artery territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 cm3 as shown on diffusion-weighted MRI.

Question 282

Outline the treatment guidelines for a first episode of C. difficile.

Answer 282

1st: Oral Vancomycin (10 days) 2nd: Oral Fidaxomicin 3rd: Oral Vancomycin + IV Metronidazole NOTE: if recurrent episode within 12 weeks --> oral fidaxomicin; if more than 12 weeks --> oral fidaxomicin OR oral vancomycin If LIFE THREATENING: oral vancomycin + IV metronidazole

Question 283

Which tests are required to stage multiple myeloma?

Answer 283

Beta-2 microglobulin | Serum albumin

Question 284

Which drug class is most effective at treating hypertriglyceridaemia?

Answer 284

Fibrates

Question 285

Summarise the NICE guidelines for the management of non-typhoidal salmonella gastroenteritis.

Answer 285

Anyone > 50 yrs OR immunocompromised OR cardiac valve disease/endovascular abnormalities Ciprofloxacin 500 mg BD

Question 286

List some pre-ganglionic causes of Horner syndrome.

Answer 286

NOTE: causes anhidrosis of the face Pancoast's trumour Thyroidectomy Trauma Cervical rib

Question 287

List some post-ganglionic causes of Horner syndrome.

Answer 287

NOTE: does NOT cause anhidrosis of the face Carotid artery dissection Carotid aneurysm Cavernous sinus thrombosis Cluster headache

Question 288

Which long-acting insulin is particularly useful in preventing recurrent DKA as it has a long half-life?

Answer 288

Degludec (Tresiba)

Question 289

What can be given in sulfonylurea overdose to patients who fail to respond adequately to glucose?

Answer 289

IM Octreotide

Question 290

How is typhoid fever managed?

Answer 290

Cefotaxime or Ceftriaxone NOTE: it is caused by Salmonella enterica

Question 291

How is arrhythmogenic right ventricular cardiomyopathy treated?

Answer 291

Sotalol Catheter Ablation ICD

Question 292

What are presenting features of acute interstitial nephritis?

Answer 292

Fever, Rash and Arthralgia Eosinophilia Renal Impairment Hypertension

Question 293

Which common drugs can cause acute interstitial nephritis?

Answer 293

``` penicillin rifampicin NSAIDs allopurinol furosemide ```

Question 294

Which combination of chemotherapy agents used for breast cancer is especially cardiotoxic?

Answer 294

Trastazumab + anthracyclines (e.g. doxorubicin)

Question 295

What are the main features of Langerhans cell histiocytosis?

Answer 295

``` Bone pain (skull and femer) Cutaneous nodules Decurrent otitis media/mastoiditis Spontaneous peumothorax Diabetes insipidus Tennis racket-shaped Birbeck granules on electromicroscopy ```

Question 296

What are the main treatment options for eosinophilic oesophagitis?

Answer 296

Dietary modification Topical steroids (e.g. fluticasone, budesonide) Oesophageal dilatation NOTE: diagnosis is confirmed on biopsy

Question 297

How is latent tuberculosis treated?

Answer 297

3 months isoniazid and rifamipicin | 6 months isoniazid

Question 298

Outline the management of IgA nephropathy.

Answer 298

no proteinuria, normal GFR: observe proteinuria: ACE inhibitor signifcant fall in GFR/not responding to ACE inhibitor: corticosteroid

Question 299

How is tick borne encephalitis managed?

Answer 299

Supportive management

Question 300

Which antiemetic is best for the delayed phase of chemotherapy-induced nausea?

Answer 300

Dexamethasone

Question 301

What is accelerated idioventricular rhythm?

Answer 301

A benign ectopic rhythm of ventricular origin Usually caused by reperfusion of ischaemic myocardium and has a rate of 50-110 bpm (helps differentiate from ventricular brady or tachycardia)

Question 302

What is the main cause of frank haematuria in patients with sickle cell disease?

Answer 302

Papillary necrosis

Question 303

What is a key difference between Gitelman and Bartter syndrome?

Answer 303

Gitelman: Hypocalciuria Bartter: NO hypocalciuria NOTE: both conditions cause hyponatraemia, hypokalaemia, hypomagnesemia and normotension

Question 304

What are some contraindications to testosterone treatment in men?

Answer 304

PSA > 4 ng/mL Male breast cancer Severe sleep apnoea Severe LUTS due to BPH

Question 305

How does loiasis present?

Answer 305

Filarial infection caused by loa loa found in West and Central Africa Calabar swellings (transient, non-erythematous, hot swelling of soft tissue around joints) Pruritus Urticaria Eye worm Rx: Ivermectin

Question 306

How is pain from shingles managed?

Answer 306

1: Paracetamol and NSAIDs 2: Neuropathic agents 3. Oral Corticosteroids

Question 307

List some features and complications of Ehlers-Danlos syndrome.

Answer 307

elastic, fragile skin joint hypermobility: recurrent joint dislocation easy bruising aortic regurgitation, mitral valve prolapse and aortic dissection subarachnoid haemorrhage angioid retinal streaks

Question 308

What is Lown–Ganong–Levine syndrome?

Answer 308

Pre-excitation disorder of the heart due to abnormal conduction between atria and ventricles SHORT PR interval Normal QRS complex This differs from Wolff-Parkinson-White syndrome which causes short PR and broad QRS complex.

Question 309

How does dialysis dysequilibrium syndrome manifest and how is it treated?

Answer 309

High levels of urea pre-dialysis leads to fluid shifts in teh brain. The sudden removal of urea leads to a drop in serum osmolality and a shift of fluid into the intracellular compartment leading to cerebral oedema. Treated with measures to reduce intracranial pressure (e.g. hypertonic saline)

Question 310

Which test is used to determine whether a patient has hyperventilation syndrome?

Answer 310

Nijmegen questionnaire

Question 311

What is the treatment option for native valve endocarditis caused by Staphylococcus?

Answer 311

Flucloxacillin If penicillin allergic or MRSA --> Vancomycin + Rifampicin

Question 312

What is the treatment option for prosthetic valve endocarditis caused by Staphylococcus?

Answer 312

Flucloxacillin + Rifampicin + Low Dose Gentamicin If penicillin allergic or MRSA --> switch flucloxacillin for vancomycin

Question 313

What is the treatment option for native valve endocarditis caused by fully-sensitive Streptococci?

Answer 313

Benzylpenicillin If penicillin allergic --> Vancomycin + Low Dose Gentamicin

Question 314

Why should you aim for a very low TSH in patients who have had a thyroidectomy for thyroid cancer?

Answer 314

TSH is a growth factor for thyroid cancer | It should be suppressed with levothyroxine to < 0.1 in high risk patients and 0.1-0.5 in low risk patients

Question 315

Under what circumstance should you seek a thoracic surgical opinion in patients with a chest drain?

Answer 315

If after 3-5 days there is a persistent air leak or failure of the lung to re-expand

Question 316

What are the two types of autoimmune polyendocrinopathy syndromes?

Answer 316

APS Type 1: Chronic mucocutaneous candidasis + Addison's disease + Primary hypoparathyroidism APS Type 2 (Schmidt syndrome): Type 1 Diabetes Mellitus + Autoimmune Thyroid Disease

Question 317

In which patients is plasma exchange indicated for patients with anti-GBM disease?

Answer 317

Pulmonary haemorrhage Renal involvement who do not need renal replacement therapy Patients who may require dialysis but present acutely and are young and have a proportion of viable glomeruli on renal biopsy

Question 318

List some causes of membranous glomerulonephritis.

Answer 318

infections: hepatitis B, malaria, syphilis malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia drugs: gold, penicillamine, NSAIDs autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid

Question 319

What is the initial blind therapy for prosthetic and native valve endocarditis whilst awaiting blood cultures?

Answer 319

Prosthetic: Vancomycin + Rifampicin + Low Dose Gentamicin Native: Amoxicillin +/- Low Dose Gentamicin

Question 320

How is actinic keratosis managed?

Answer 320

Topical fluorouracil Alternatives: imiquimob or diclofenac

Question 321

What are the indications for a surgical opinion in patients with infective endocarditis?

Answer 321

Aortic root abscess Heart failure Uncontrolled infection Prevention of embolism (large vegetations with embolic episodes)

Question 322

What are the manifestations of abetalipoproteinaemia?

Answer 322

``` failure to thrive + developmental delay steatorrhoea retinitis pigmentosa cerebellar signs deep tendon reflexes are absent acanthocytosis hypocholesterolaemia ``` Rx: dietary restriction of fats

Question 323

What initial therapy is given to people with a new diagnosis of rheumatoid arthritis?

Answer 323

DMARD monotherapy (e.g. methotrexate) + short course of bridging prednisolone

Question 324

What is Whipple's triad?

Answer 324

Used to identify clinically significant hypoglycaemia - borderline low blood sugar - symptoms of hypoglycaemia - improvement of symptoms with sugar

Question 325

What are some main causes of pacemaker failure?

Answer 325

Lead Fracture Lead Displacement Twiddler syndrome (patient fiddling with the pacemaker leads to displacement of the wires)

Question 326

How is an amoebic liver abscess treated?

Answer 326

Aspirate and metronidazole

Question 327

How is leprosy treated?

Answer 327

Rifampicin Dapsone Clofazimine Diagnosed using skin-slit smear

Question 328

Which antibiotics may be recommended as Traveller's diarrhoea prophylaxis in immunocompromised patients?

Answer 328

ciprofloxacin, norfloxacin or rifaximin.

Question 329

List some causes of scarring alopecia.

Answer 329

``` trauma, burns radiotherapy lichen planus discoid lupus tinea capitis (if untreated) ```

Question 330

What are the indications for N-acetylcysteine in paracetamol overdose?

Answer 330

Staggered overdose or doubt about time of ingestion | Plasma paracetamol level above the normogram line

Question 331

When can N-acetylcysteine be stopped in someone with paracetamol overdose?

Answer 331

INR <1.3 and ALT less than 2x upper limit of normal

Question 332

List the causes of HIGH anion gap metabolic acidosis.

Answer 332

lactate: shock, sepsis, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol

Question 333

List the causes of NORMAL anion gap metabolic acidosis.

Answer 333

``` gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease ```

Question 334

Why should patients with myasthenia gravis who have shown no improvement in their symptoms despite 60 mg QDS pyridostigmine need to be admitted to hospital for steroid initiation?

Answer 334

High dose steroids (60 mg prednisolone) can cause a paradoxical reaction in up to half of patients, where there symptoms worsen initially

Question 335

What are the main features of synthetic cannabinoid toxicity?

Answer 335

CNS: agitation, tremor, anxiety, confusion, somnolence, syncope, hallucinations, changes in perception, acute psychosis, nystagmus, convulsions and coma. Cardiac: tachycardia, hypertension, chest pain, palpitations, ECG changes. Renal: acute kidney injury. Muscular: hypertonia, myoclonus, muscle jerking and myalgia. Other: cold extremities, dry mouth, dyspnoea, mydriasis, vomiting and hypokalaemia

Question 336

List some common drugs that cause peripheral neuropathy.

Answer 336

``` amiodarone isoniazid vincristine nitrofurantoin metronidazole ```

Question 337

How is granulomatosis with polyangiitis treated?

Answer 337

Cyclophosphamide and steroids

Question 338

List some contraindications for using flecainide.

Answer 338

post myocardial infarction structural heart disease: e.g. heart failure sinus node dysfunction; second-degree or greater AV block atrial flutter

Question 339

How is atypical haemolytic uraemic syndrome managed?

Answer 339

Supportive Plasma Exchange Eculizumab

Question 340

What are the symptoms of systemic mastocytosis?

Answer 340

urticaria pigmentosa - produces a wheal on rubbing (Darier's sign) flushing abdominal pain monocytosis on the blood film NOTE: associated with raised serum tryptase and urinary histamine

Question 341

What are the physical features of pseudohypoparathyroidism?

Answer 341

``` short fourth and fifth metacarpals short stature cognitive impairment obesity round face ```

Question 342

How should carbapenemase producing organisms be treated?

Answer 342

Polymyxins (e.g. colistin) Tigecycline Fosfomycin Aminoglycosides (e.g. gentamicin)

Question 343

Under what circumstance should a GLP-1 agonist be continued in a patient at their 6 month review?

Answer 343

If, after 6 months, HbA1c reduces by at least 11 mmol/mol

Question 344

What is the first line imaging modality in multiple myeloma?

Answer 344

Whole body MRI

Question 345

Which ECG changes are seen in Brugada syndrome?

Answer 345

Convex ST elevation > 2 mm in more than 1 of V1 to V3 followed by a negative T wave Partial RBBB NOTE: ECG changes may be more evident after administration of flecainide or ajmaline

Question 346

Which electrolyte abnormalities are associated with tumour lysis syndrome?

Answer 346

HIGH Uric Acid HIGH Potassium HIGH Phosphate LOW Calcium Clinical features: increased serum creatinine, arrhythmia, seizure

Question 347

What PTH level would you expect in someone with familial hypocalciuria hypercalcaemia?

Answer 347

There may also be normal to high parathyroid hormone, despite the elevated serum calcium levels.

Question 348

List some causes of pulmonary eosinophilia.

Answer 348

``` Churg-Strauss syndrome allergic bronchopulmonary aspergillosis (ABPA) Loffler's syndrome eosinophilic pneumonia hypereosinophilic syndrome tropical pulmonary eosinophilia drugs: nitrofurantoin, sulphonamides less common: Wegener's granulomatosis ```

Question 349

What is Loeffler's syndrome?

Answer 349

Transient CXR shadowing and eosinophilia associated with Ascaris lumbricoides Causes fever, cough and night sweats Self-limiting

Question 350

Outline the strategies for preventing tumour lysis syndrome in patients undergoing chemotherapy.

Answer 350

LOW RISK: Adequate Hydration MEDIUM RISK: IV Fluids + Allopurinol HIGH RISK: Rasburicase + IV Fluids

Question 351

List the main contraindications for using beta-blockers.

Answer 351

uncontrolled heart failure asthma sick sinus syndrome concurrent verapamil use: may precipitate severe bradycardia

Question 352

How does acute schistosomiasis manifest?

Answer 352

marked eosinophilia cough bloody diarrhoea splenomegaly

Question 353

What are the manifestations of quinine toxicity?

Answer 353

Arrhythmia Hypoglycaemia Flash pulmonary oedema Tinnitus, deafness and visual defects NOTE: treatment is supportive

Question 354

Outline how you interpret nerve conduction study results.

Answer 354

Axonal - normal conduction velocity - reduced amplitude - CAUSES: metabolic, toxic or heritable Demyelinating - reduced conduction velocity - normal amplitude - CAUSES: autoimmune processes, paraproteinaemia

Question 355

How should a patient with a relapse of Graves disease after a trial of anti-thyroid medications be treated?

Answer 355

Definitive treatment with surgery or radioiodine

Question 356

Outline the BTS guidelines on the investigation of solitary lung nodules.

Answer 356

Nodule <5mm, or clear benign features, or unsuitable for treatment: can be discharged Nodule =>8mm and high risk*: then CT-PET, and if CT-PET shows high uptake then biopsy Nodule 5-6mm, or =>8mm and low-risk*: then CT surveillance CT surveillance: if 5-6mm then at 1 year, if =>6 then in three months

Question 357

What should be recommended for patients with IBS that is resistant to multiple laxatives at adequate doses?

Answer 357

Linaclotide

Question 358

Which antiemetic should be avoided in patients with acute heart failure or ACS?

Answer 358

Cyclizine - it is an H1 receptor antagonist and anticholinergic that causes systemic hypertension and induces tachycardia which can compromise a fragile heart

Question 359

What is the first-line systemic agent for psoriasis?

Answer 359

Methotrexate Offer ciclosporin if need rapid control (e.g. psoriasis flare) or palmoplantar pustulosis or considering conception (men and women) NOTE: next step would be Acitretin

Question 360

How does heparin affect thyroid function test results?

Answer 360

Heparin leads to rise in free fatty acid levels which inhibit binding of thyroid hormones to plasma-binding proteins causing a rise in T3 and T4

Question 361

What are the third line treatment options for chronic heart failure?

Answer 361

ivabradine - criteria: sinus rhythm > 75/min and a left ventricular fraction < 35% sacubitril-valsartan - criteria: left ventricular fraction < 35% - is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs - should be initiated following ACEi or ARB wash-out period digoxin - digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties - it is strongly indicated if there is coexistent atrial fibrillation hydralazine in combination with nitrate - this may be particularly indicated in Afro-Caribbean patients - cardiac resynchronisation therapy indications include a widened QRS (e.g. left bundle branch block) complex on ECG

Question 362

What is the rapid appearance of multiple seborrhoeic keratoses suggestive of?

Answer 362

Underlying malignancy (known as Leser-Trelat Sign) Usually GI or liver cancer

Question 363

What is the Ki-67 index?

Answer 363

Proliferation index (marker of metabolic rate of cancer cells) Lymphoma with LOW Ki67: Follicular, Mantle, Marginal Zone, Small Lymphocytic, Lymphoplasmacytic, Skin Lymphome with HIGH Ki67: DLBCL, Burkitt, peripheral T cell lymphoma

Question 364

Which skin conditions exhibit Koebner phenomenon?

Answer 364

``` psoriasis vitiligo warts lichen planus lichen sclerosus molluscum contagiosum ```

Question 365

How can non-tuberculous mycobacterial disease manifest?

Answer 365

Hypersensitive-like disease Cavitating disease Bronchiectasis with or without nodules Treatment: Rifampicin, clarithromycin and ethambutol

Question 366

What is POEMS syndrome?

Answer 366

Rare paraneoplastic syndrome caused by a clone of abnormal plasma cells ``` Polyneuropathy Organomegaly Endocrinopathy M-protein band from a plasmacytoma Skin Pigmentation ```

Question 367

What is an unwanted metabolic side-effect of NRTIs?

Answer 367

NRTIs: stavudine, zidovudine, didanosine Mitochondrial toxicity --> nausea, pancreatitis, lactic acidosis and lipoatrophy

Question 368

List some consequences of hypophosphataemia.

Answer 368

red blood cell haemolysis white blood cell and platelet dysfunction muscle weakness and rhabdomyolysis central nervous system dysfunction

Question 369

What are the main features of Friedreich ataxia?

Answer 369

absent ankle jerks/extensor plantars cerebellar ataxia optic atrophy spinocerebellar tract degeneration Other: HOCM, DM, high arched palate

Question 370

What pattern of deficits do you see in anterior spinal artery occlusion?

Answer 370

1. Bilateral spastic paresis | 2. Bilateral loss of pain and temperature sensation

Question 371

What are the main features of neuromyelitis optica?

Answer 371

quadriparesis or paraparesis within days to weeks vision changes normal brain MRI presence of anti-NMO antibodies (anti-aquaporin 4 antibodies) responsive to immunosuppressants

Question 372

What metabolic complication is associated with sodium valproate use?

Answer 372

Valproate-associated hyperammonaemic encephalopathy

Question 373

Why is atropine contraindicated in patients with a heart transplant?

Answer 373

The transplanted hearts are denervated and do not respond to vagal blockade by atropine which might lead to paradoxical sinus arrest IV theophylline should be used instead.

Question 374

How is cystinuria treated?

Answer 374

Hydration D-penicillamine Urinary alkalinisation (with potassium citrate)

Question 375

What is the rule regarding DEXA scans in patients with fragility fractures?

Answer 375

If > 75 years, they can start a bisphosphonate without a DEXA scan

Question 376

When does renal graft failure count as acute rather than chronic?

Answer 376

If it is < 6 months

Question 377

What is methaemoglobinaemia?

Answer 377

Haemoglobin that has been oxidised from Fe2+ to Fe3+ (usually regulated by NADH methaemoglobin reductase) Fe3+ CANNOT bind oxygen, resulting in tissue hypoxia

Question 378

How does methaemoglobinaemia present?

Answer 378

Chocolate cyanosis Shortness of breath, headache, anxiety Acidosis, arrhythmia, seizures Normal pO2 but low saturations

Question 379

How is methaemoglobinaemia treated?

Answer 379

NADH - methaemoglobinaemia reductase deficiency: ascorbic acid IV methylthioninium chloride (methylene blue) if acquired

Question 380

What is acute disseminated encephalomyelitis?

Answer 380

Also known as post-infectious encephalomyelitis - it is an autoimmune demyelinating disease of the CNS. It can occur following infection (common culprits include MMR and varicella). Usually presents with motor and sensory deficits weeks to months after the initial infection.

Question 381

What are the features of a lacunar stroke?

Answer 381

Unilateral weakness Pure sensory stroke Ataxic hemiparesis

Question 382

How do you test for paraquat poisoning?

Answer 382

Urine dithionate test It can cause GI irritation, liver and kidney failure, and chemical pneumonitis and fibrosis

Question 383

Which ECG changes are most commonly associated with HOCM?

Answer 383

RAD or LAD Bundle branch block PR prolongation Non-specific T wave abnormalities

Question 384

What are the main features of von Hippel Lindau syndrome?

Answer 384

Haemangioblastomas (cerebellar, spinal and retinal) Renal cell carcinoma Phaeochromocytoma Neuroendocrine tumours of the pancreas

Question 385

How does phenytoin toxicity present?

Answer 385

Cerebellar signs (nystagmus, dysdiadochokinesia, broad-based gait)

Question 386

What should you think about when someone on SSRIs develops a chronic history of abdominal pain and diarrhoea?

Answer 386

Microscopic colitis

Question 387

What is the threshold for giving steroids in PCP?

Answer 387

pO2 < 9.3 kPa NOTE: alternative treatment options for PCP include clindamycin and primaquine

Question 388

What are the indications for giving DigiBind for digoxin toxicity?

Answer 388

Haemodynamically unstable or life-threatening rhythm Hyperkalaemia Evidence of end-order hypoperfusion

Question 389

What are the first-line drugs for treating diabetic neuropathy?

Answer 389

Pregabalin Gabapentin Duloxetine Amitriptyline

Question 390

What are the main features of McArdle disease?

Answer 390

``` muscle pain and stiffness following exercise muscle cramps myoglobinuria low lactate levels during exercise second wind phenomenon ``` NOTE: it is an autosomal recessive type V glycogen storage disease that leads to decreased muscle glycogenolysis

Question 391

What lipid profile results would you expect to see in a patient with dysbetalipoproteinaemia?

Answer 391

High Cholesterol High Triglycerides Normal HDL Low LDL NOTE: it is caused by a defect in apo E and usually requires a second risk factors to cause issues Palmar xanthomas are pathognomonic

Question 392

How does beta-2 microglobulin amyloidosis manifest?

Answer 392

Manifests 5 or more years after starting haemodialysis | Affects the axial skeleton and is associated with tenosynovitis, carpal tunnel syndrome and shoulder pain.

Question 393

What stimulant is best to manage symptoms of cataplexy?

Answer 393

Oxybate

Question 394

In which types of porphyria are faecal porphyrins elevated?

Answer 394

Hereditary coproporphyria Variegate porphyria NOTE: these two and acute intermittent porphyria present very similarly and are difficult to distinguish clinically

Question 395

How does Chediak-Higashi syndrome manifest?

Answer 395

``` Oculocutaneous albinism Bleeding diathesis Recurrent infections Peripheral neuropathy Giant granules on leukocytes ```

Question 396

What is alkaptonuria?

Answer 396

Autosomal recessive disorder of phenylalanine and tyrosine metabolism. Features include pigmented sclerae, urine turning black if exposed to air, intervertebral disc calcification and renal stones Treated with high dose vitamin C

Question 397

How is hepatotoxicity or hyperammonaemic encephalopathy in sodium valproate overdose treated?

Answer 397

L-carnitine

Question 398

List some causes of Fanconi syndrome.

Answer 398

``` cystinosis (most common cause in children) Sjogren's syndrome multiple myeloma nephrotic syndrome Wilson's disease ```

Question 399

List some absolute contraindications for thrombolysis for stroke.

Answer 399

- Previous intracranial haemorrhage - Seizure at onset of stroke - Intracranial neoplasm - Suspected subarachnoid haemorrhage - Stroke or traumatic brain injury in preceding 3 months - Lumbar puncture in preceding 7 days - Gastrointestinal haemorrhage in preceding 3 weeks - Active bleeding - Pregnancy - Oesophageal varices - Uncontrolled hypertension >200/120mmHg

Question 400

Which antibodies are associated with the two different types of autoimmune hepatitis?

Answer 400

Type 1: ASMA or ANA | Type 2: Anti-LKM or anti-liver-cytosolic 1

Question 401

What is a Holmes tremor?

Answer 401

Irregular low frequency tremor (combination of resting, postural and action) Occurs due to lesion of red nucleus (e.g. due to previous stroke, tumour, MS)

Question 402

Outline the NICE guidelines for chronic plaque psoriasis.

Answer 402

1. Potent topical steroid AND vitamin D analogue 2. Vitamin D analogue twice daily 3. Potent topical steroid twice daily OR coal tar preparation Alternative: Dithranol Specialist: Methotrexate, ciclosporin and phototherapy Last Line: Adalimumab

Question 403

How is hepatocellular carcinoma in cirrhosis managed?

Answer 403

Liver transplantation if: - cirrhosis and single small HCC (< 5 cm) - up to three lesions < 3 cm

Question 404

What is multicentric reticulohistiocytosis?

Answer 404

Non-Langerhans cell histiocytosis with skin and joint involvement (associated with cancer in 25% of cases)

Question 405

List some causes of chronic urticaria.

Answer 405

Autoimmune diseases Lymphoma Drug reactions (NSAIDs, opiates)

Question 406

What is homocystinuria?

Answer 406

Autosomal recessive disorder of methionine metabolism ``` Tall Kyphoscoliosis Livedo reticularis Malar flush Downward lens dislocation Young strokes Light brittle hair ```

Question 407

Which CDs are usually associated with lymphoma?

Answer 407

``` CD19 CD20 CD22 CD79a CD45 ```

Question 408

How is Nocardia infection treated?

Answer 408

Sulphonamide (e.g. co-trimoxazole)

Question 409

How should renal tubular acidosis be treated?

Answer 409

oral sodium bicarbonate, sodium citrate or potassium citrate.

Question 410

How can hemicrania continua and paroxysmal hemicrania be distinguished from cluster headaches and SUNCT?

Answer 410

They are responsive to indomethacin

Question 411

How is paraquat poisoning treated?

Answer 411

activated charcoal and fuller's earth

Question 412

Which conditions recur in renal transplant patients?

Answer 412

IgA nephropathy Membranoproliferative glomerulonephritis (highest rate of recurrence) Focal segmental glomerulosclerosis Membranous glomerulonephritis

Question 413

What is a very sensitive marker of bone turnover that is used in Paget's disease?

Answer 413

Serum non-isomerised C-telopeptide (CTx)

Question 414

How does thallium poisoning present?

Answer 414

Fluctuating mood (with or without confusion) Painful distal paraesthesia Alopecia Rx: Oral Prussian Blue

Question 415

What is the first-line oral therapy for pyelonephritis?

Answer 415

Oral cefalexin

Question 416

Which other type of cancer is the APC gene associated with?

Answer 416

Thyroid cancer

Question 417

What should you do with regular TNF blockers in patients who are due to undergo major surgery?

Answer 417

Stop TNF blockers 2-4 weeks before a major surgical procedure Can be restarted once there is no evidence of infection and wound healing is satisfactory

Question 418

Which groups of patients benefit from lung volume reduction surgery for emphysema?

Answer 418

Upper p emphysema and low exercise capacity Patients with predominantly upper lobe emphysema and high exercise capacity Patients with non-upper lobe emphysema and low exercise capacity

Question 419

Which group of patients with mitral regurgitation need to be referred for surgery despite being asymptomatic?

Answer 419

LVEF < 60%

Question 420

How is brucellosis treated?

Answer 420

ORAL: 6 weeks of doxycycline and rifampicin | ORAL + IV: 6 weeks of oral doxycycline + 3 weeks of IM streptomycin or IV gentamicin

Question 421

Which common drugs cause drug-induced cholestasis?

Answer 421

``` Flucloxacillin Erythromycin Chlorpromazine Oral contraceptives Anabolic steroids ```

Question 422

How is polycythaemia vera management?

Answer 422

Aspirin and venesection aiming for PCV of < 0.45

Question 423

Which test can be done in patients with suspected growth hormone deficiency in whom an insulin-tolerance test would be inappropriate?

Answer 423

Arginine-GHRH stimulation test

Question 424

Which antibody is more likely to be positive in Crohn's disease than ulcerative colitis?

Answer 424

Anti-Saccharomyces cerevisiae antibodies

Question 425

What can precipitate lithium toxicity?

Answer 425

dehydration renal failure drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

Question 426

What is a common side-effect of minocycline?

Answer 426

Skin pigmentation with blue/black/grey discoloration Minocycline is a tetracycline used for rosacea

Question 427

How long after taking acitretin must you avoid getting pregnant?

Answer 427

3 years

Question 428

What is Zieve syndrome?

Answer 428

Haemolysis, severe hyperlipidaemia and cholestatic jaundice in people with heavy alcohol abuse

Question 429

Which antipsychotic is best in patients with Parkinson's disease?

Answer 429

Quetiapine

Question 430

What are the features of McCune-Albright syndrome?

Answer 430

Precocious puberty Cafe-au-lait pigmentation Polyostotic fibrous dysplasia (multiple pathological fractures) Hyperthyroidism

Question 431

What measure is good to determine whether a patient is at risk of tumour lysis syndrome before commencing chemotherapy?

Answer 431

LDH

Question 432

Which type of ureteric calculus commonly occurs in people with short bowel?

Answer 432

Oxalate

Question 433

What are the main features of a somatostatinoma?

Answer 433

Diabetes mellitus Diarrhoea Gallstones

Question 434

Which investigation findings support a diagnosis of Wilson's disease?

Answer 434

reduced serum caeruloplasmin reduced total serum copper increased 24hr urinary copper excretion ATP7B gene mutation

Question 435

How is paroxysmal nocturnal hemicrania treated?

Answer 435

Indomethacin

Question 436

What are the features of theophylline toxicity?

Answer 436

Hypokalaemia Hyperglycaemia Tachycardia Increased myocardial contractility

Question 437

What are early and late dumping syndromes?

Answer 437

Both are complications of bariatric surgery Early: rapid emptying of food into the small bowel causing colicky abdominal pain, diarrhoea and nausea Late: post-prandial hypoglycaemia due to hyperinsulinaemia

Question 438

What are the two main associations of pseudo-Cushing's syndrome?

Answer 438

Alcoholism | Depression

Question 439

How is pemphigus vulgaris diagnosed?

Answer 439

Direct immunofluorescence of skin biopsy

Question 440

What are the features of myoclonic epilepsy with ragged red fibres (MERRF)?

Answer 440

``` myopathy peripheral neuropathy ataxia Wolff-Parkinson-White syndrome bilateral deafness ```

Question 441

Which patients on bisphosphonates would be eligible for a treatment break?

Answer 441

< 75 years Femoral neck bone mineral density > -2.5 Lack of history of fragility fracture NOTE: repeat DEXA in 2 years

Question 442

What is multifocal motor neuropathy with conduction block?

Answer 442

Acquired autoimmune demyelinating motor neuropathy Presents with relatively acute onset loss of motor function in a specific nerve distribution As more nerves get involved, it looks more and more like MND MMNCB shows a conduction block on nerve conduction studies, whereas MND does not Treated with IVIG

Question 443

What is Lymphangioleiomyomatosis?

Answer 443

Proliferation of atypical smooth muscle cells in the lungs, lymphatics and uterus, most likely caused by oestrogens. Presents with progressive interstitial lung disease, pneumothorax or chylous pleural effusion

Question 444

What are the main features of Cowden syndrome?

Answer 444

Inherited cancer syndrome associated with PTEN mutation ``` Multiple hamartomas Breast cancer (most common) Endometrial cancer Colorectal cancer Thyroid cancer Melanoma ```

Question 445

Outline the guidelines on the surgical management of aortic regurgitation.

Answer 445

Surgery should be considered in asymptomatic patients with resting ejection fraction < 50% with severe LV dilatation (LVESD > 50 mm (or LVESD > 25 mm/m2 body surface area in those with small body size)). Surgery should be considered in ALL symptomatic patients regardless of EF and LV dimensions

Question 446

What type of COCP should people taking carbamazepine take?

Answer 446

Any containing at least 50 micrograms of ethinyloestradiol

Question 447

What is babesiosis?

Answer 447

Tick-borne malaria-like illness caused by Babesia Causes fever, chills, rigors and red cell destructions (leading to haemolytic anaemia and haemoglobinuria)

Question 448

How does chancroid manifest?

Answer 448

Single PAINFUL genital ulcer with painful inguinal lymphadenopathy Caused by H. ducreyi and treated with macrolides or quinolones