Passmed round 2 Flashcards

Question

How do you differentiate lymphogranuloma venereum?

Answer 1

The presence of ulcers and significant rectal symptoms in a sexually active man raises the question of lymphogranuloma venereum, which is caused by a type of Chlamydia trachomatis. Rectal infection with gonorrhoea could cause similar symptoms but would not be expected to cause ulcers.

Answer 2

``` Functional tricuspid regurgitation ---------------------------- Signs are -pan-systolic murmur -prominent/giant V waves in JVP -pulsatile hepatomegaly -left parasternal heave ```

Answer 3

Secretin increases the secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells and it can be used as a test for pancreatic function (secretin stimulation test). ----------------------- Secreted by S cells in upper small intestine Stimulated by Acidic chyme, fatty acids

Answer 4

Fanconi syndrome describes a generalised reabsorptive disorder of renal tubular transport in the proximal convoluted tubule resulting in: - type 2 (proximal) renal tubular acidosis - polyuria - aminoaciduria - glycosuria - phosphaturia - osteomalacia

Answer 5

Sitagliptin is an inhibitor of the enzyme dipeptidyl-peptidase 4 (DPP-4). As such, it prevents DPP-4 from catalysing the breakdown of naturally occurring incretins, potentiating their ability to stimulate insulin release.

Answer 6

A type of thiazolidinediones. Activate peroxisome proliferator-activated receptor gamma (PPAR-γ) to increase insulin sensitivity

Answer 7

Decrease blood glucose by inhibiting renal glucose re-uptake via sodium-glucose co-transporter 2 (SGLT2)

Answer 8

Mimic incretins by binding to GLP-1 receptors and stimulating insulin release

Answer 9

NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

Answer 10

5-HT3 antagonist

Answer 11

Treatment for invasive amoebiasis should be followed by a luminal amoebicide to eradicate the cystic stage which is resistant to metronidazole and tinidazole (which are used against the invasive stage) e.g. 7 days of metronidazole followed by 10 days of diloxanide furoate

Answer 12

Transoesophageal echocardiography (TOE) may be a useful investigation in clinically unstable patients with a suspected aortic dissection

Answer 13

Intravenous dexamethasone should be given prior to or with the first dose of antibiotic to reduce the risk of neurological sequelae by reducing cerebrospinal inflammation. If pneumococcal meningitis is suspected or confirmed from clinical features, cerebrospinal fluid parameters or culture results, then dexamethasone should be continued for 4 days. It should be stopped if another causative organism is strongly suspected or confirmed

Answer 14

Phenoxybenzamine is a non-selective alpha-adrenoceptor antagonist and should be started before a beta-blocker is introduced There is ongoing debate about the optimal medical management of phaeochromocytoma, with the suggestion that antihypertensive treatment regimes other than non specific alpha-blockade are just as effective and safe. There are however no trials to provide an answer to this question yet

Answer 15

Wellens' syndrome is an ECG manifestation of critical proximal left anterior descending (LAD) coronary artery stenosis in patients with unstable angina. It is characterized by symmetrical, often deep (>2 mm), T wave inversions in the anterior precordial leads.

Answer 16

Aortic valve replacement if symptomatic, otherwise cut-off is gradient of 40 mmHg mean Also consider if AS and reduced LVEF

Answer 17

Fabry disease is a rare genetic disorder that prevents the body from making an enzyme called alpha-galactosidase A. Alpha-galactosidase A normally breaks down a fatty substance called globotriaosylceramide. As a result, this fatty substance builds up in the cells of your body particularly cells lining blood vessels in the skin and cells in the kidneys, heart, and nervous system. Characteristic features of Fabry disease include episodes of pain in the hands and feet (acroparesthesia); clusters of small, dark red spots on the skin called angiokeratomas; a decreased ability to sweat (hypohidrosis); cloudiness or streaks in the front part of the eye (corneal opacity or corneal verticillata); problems with the gastrointestinal system; ringing in the ears (tinnitus) and hearing loss. X-linked recessive

Answer 18

Capecitabine is an ORALLY administered prodrug which is enzymatically converted to 5-fluorouracil in the tumour. ------------------------- Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase) Adverse effects: Myelosuppression, mucositis, dermatitis

Answer 19

Sulfasalazine and hydroxychloroquine are considered safe in pregnancy --------------------------- There is some evidence that TNF-a inhibitors may be afe but studies are poor

Answer 20

Verapamil is contraindicated in VT as intravenous administration of a calcium channel blocker can precipitate cardiac arrest.

Answer 21

Insulin binds to tyrosine kinase, a type of enzyme receptor in the cell membrane, resulting in a signal transduction cascade, activating enzymes and transcription factors within the cell that mediates the intracellular effects of insulin. Other tyrosine kinase receptors include insulin-like growth factor (IGF) and epidermal growth factor (EGF).

Answer 22

Given the history of diarrhoea and flushing a diagnosis of carcinoid syndrome should be considered, which would be investigated with urinary 5-HIAA levels. This would not however explain the urticarial skin lesions. In a young person a diagnosis of systemic mastocytosis should be considered. Another factor against carcinoid syndrome is the age of the patient - the average age of a patient with a carcinoid tumour is 61 years

Answer 23

NMDA antagonist

Answer 24

Having multiple sexual partners is the strongest risk factor for the development of cervical carcinoma. This is because having multiple sexual partners greatly increases the chance of being infected with the human papilloma virus. The 16 and 18 viral strain then triggers the carcinogenesis by inhibiting the tumor suppressor gene p53 and RB.

Answer 25

Rasburicase is the preferred treatment choice for patients at high risk of tumour lysis syndrome. Rasburicase is a recombinant form of urate oxidase which catalyzes the oxidation of existing uric acid to allantoin. Allantoin is more soluble than uric acid and is therefore excreted in the kidneys. Allopurinol stops new uric acid being made by blocking the conversion of xanthines to uric acid. If less uric acid is made, this will reduce the substrate available for rasburicase to work. They should not be given together.

Answer 26

Erythromycin is a macrolide, which works by inhibiting the 50S subunit of ribosomes. This prevents the production of proteins from bacteria. Macrolides are commonly confused with tetracyclines, which inhibit the 30S subunit of ribosomes

Answer 27

idiopathic trauma e.g. Excessive manicuring infection: especially fungal skin disease: psoriasis, dermatitis impaired peripheral circulation e.g. Raynaud's systemic disease: hyper- and hypothyroidism

Answer 28

``` deranged clotting (e.g. INR > 1.4) low platelets (e.g. < 60 * 109/l) anaemia extrahepatic biliary obstruction hydatid cyst haemoangioma uncooperative patient ascites ```

Answer 29

CCK is a peptide hormone that increases the digestion of fats and proteins. It is synthesized and released from I cells in the upper small intestine in response to increased detection of partially digested proteins and fats. CCK results in several processes including the secretion of digestion enzymes from the pancreas, contraction of the gallbladder, relaxation of the sphincter of Oddi, decreased gastric emptying, and a trophic effect on pancreatic acinar cells all of which result in fat and protein breakdown as well as hunger suppression.

Answer 30

``` Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, Sulphonamides Psychiatric drugs: lithium, benzodiazepines Aspirin Carbimazole Methotrexate Sulfonylureas Cytotoxic drugs Amiodarone ```

Answer 31

1 = Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests* are normal, there is no CKD) 2 = 60-90 ml/min with some sign of kidney damage (if kidney tests* are normal, there is no CKD) 3a = 45-59 ml/min, a moderate reduction in kidney function 3b = 30-44 ml/min, a moderate reduction in kidney function 4 = 15-29 ml/min, a severe reduction in kidney function 5 = Less than 15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed

Answer 32

Mentzer index : The index is calculated from the results of a complete blood count. If the quotient of the mean corpuscular volume (MCV, in fL) divided by the red blood cell count (RBC, in Millions per microLiter) is less than 13, thalassemia is said to be more likely. If the result is greater than 13, then iron-deficiency anemia is said to be more likely

Answer 33

a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour)

Answer 34

pelvic floor muscle training -NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months surgical procedures: e.g. retropubic mid-urethral tape procedures duloxetine may be offered to women if they decline surgical procedures - a combined noradrenaline and serotonin reuptake inhibitor - mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Answer 35

Doxycycline (7 day course) if first-line - This is now preferred to azithromycin due to concerns about Mycoplasma genitalium. - This infection is often coexistant in patients with Chlamydia and there is evidence of rising levels of macrolide resistance, hence why doxycycline is preferred If doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used If pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice 'following discussion of the balance of benefits and risks with the patient'

Answer 36

Lofepramine

Answer 37

This disease, also known as juvenile gout, is characterized by hyperuricemia. It is a genetic condition with an X-linked pattern of inheritance. It is caused by a defect in the purine salvage pathway due to the absence of the hypoxanthine-guanine phosphoribosyltransferase (HGPRT) enzyme which catalyzes the conversion of hypoxanthine to inosine monophosphate (IMP) and guanine to guanosine monophosphate (GMP). The consequence is an accumulation of uric acid. The typical findings supporting this diagnosis in this patient is the aggressive behavior, self-mutilation, intellectual impairment as well as laboratory finding of hyperuricemia

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: - for definite FH: tendon xanthoma in patients or 1st or 2nd degree relatives or DNA-based evidence of FH - for 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

Answer 39

A prolonged PR interval is seen in around 20-40% of patients

Answer 40

Peptic ulceration caused by hypercalcaemia which stimulate Gastrin secretion

Answer 41

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

Answer 42

Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis

Answer 43

Most common causes - procainamide - hydralazine Less common causes - isoniazid - minocycline - phenytoin - ------------------------------------ Anti-histone antibodies are in 80-90%

Answer 44

Lithium levels should be checked every 3 months once a stable dose has been achieved

Answer 45

short PR interval wide QRS complexes with a slurred upstroke - 'delta wave' left axis deviation if right-sided accessory pathway* right axis deviation if left-sided accessory pathway*

Answer 46

Patients who develop pseudogout at a younger age (e.g. < 60 years) usually have some underlying risk factor, such as: - haemochromatosis - hyperparathyroidism - low magnesium, low phosphate - acromegaly, Wilson's disease

Answer 47

Discoid lupus erythematous - topical steroids → oral hydroxychloroquine

Answer 48

Botulinum toxin inhibits the release of acetylcholine at synapses

Answer 49

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

Answer 50

Toxic to macrophages

Answer 51

Normal anion gap ( = hyperchloraemic metabolic acidosis) - gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula - renal tubular acidosis - drugs: e.g. acetazolamide - ammonium chloride injection - Addison's disease

Answer 52

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

Answer 53

Methaemaglobinaemia is an underlying problem of EXCESSIVE oxidation of Fe2+ to Fe3+, rendering RBCs unable to bind O2. Methaemaglobin reductase reduces methaemoglobin to haemoglobin (Fe3+ to Fe2+) by transferring electrons from NADH to methaemoglobin. Therefore congenital deficiency will cause methaemoglobinaemia. (OIL RIG - Oxidation is loss, Reduction is gain)

Answer 54

renal stones, asymptomatic hyperbilirubinaemia

Answer 55

The t(14;18) translocation causes increased BCL-2 transcription and causes follicular lymphoma

Answer 56

t(11;22) is a translocation which occurs in Ewing sarcoma. This is a malignant bone tumour which often occurs in individuals under 15 years of age. The disease is known to be very aggressive and is associated with the development of early metastases

Answer 57

t(12;15) is associated with the development of breast cancer, more specifically secretory breast carcinoma. This type of breast cancer is known to be rare and the clinical outcome following is usually good.

Answer 58

Divide by 10

Answer 59

Wpw with Afib: Avoid drugs which prolong av delay | e.g V BAD: Verapamil, B-blocker Adenosine, Digoxin

Answer 60

inhibits the Na+/K+ ATPase pump

Answer 61

Dyspnoea is a common side effect of ticagrelor and is estimated to occur in up to 15% of patients started on this medication. It is hypothesised that the sensation of dyspnoea in ticagrelor-treated patients is triggered by adenosine, because ticagrelor inhibits its clearance (by inhibiting the enzyme adenosine deaminase), thereby increasing its concentration in the circulation. It is important to be aware of this side effect in order to avoid unnecessary treatment and/or investigation, as it is easily remedied by switching the patient to clopidogrel

Answer 62

hyperkalaemia hyponatraemia hypoglycaemia metabolic acidosis

Answer 63

``` Huntington's disease, Wilson's disease, ataxic telangiectasia SLE, anti-phospholipid syndrome rheumatic fever: Sydenham's chorea drugs: oral contraceptive pill, L-dopa, antipsychotics neuroacanthocytosis pregnancy: chorea gravidarum thyrotoxicosis polycythaemia rubra vera carbon monoxide poisoning cerebrovascular disease ```

Answer 64

no antibiotics - may worsen outcome plasma exchange is the treatment of choice steroids, immunosuppressants vincristine

Answer 65

Homocystinuria is caused by a deficiency of cystathionine beta synthase

Answer 66

Hypocalcaemia: Trousseau's sign is more sensitive and specific than Chvostek's sign

Answer 67

Most cases resolve spontaneously within 2-3 months (there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection) Topical agents as per psoriasis UVB phototherapy Tonsillectomy may be necessary with recurrent episodes

Answer 68

- If surgery can wait for 6-8 hours - give 5 mg vitamin K IV | - If surgery can't wait - 25-50 units/kg four-factor prothrombin complex

Answer 69

False positive VDRL/RPR: 'SomeTimes Mistakes Happen' (SLE, TB, malaria, HIV)

Answer 70

``` chronic analgesia use sickle cell disease TB acute pyelonephritis diabetes mellitus ```

Answer 71

Nivolumab (PD-1 inhibitor) and ipilimumab (CTLA-4 inhibitor) are checkpoint inhibitors which are used in the treatment of metastatic melanoma. Effects on the endocrine system are being increasingly reported with prolonged therapy (hypophysitis and hypothyroidism) and therefore it is important to assess patients carefully who present with symptoms of hypothyroidism whilst on these drugs. ------------------------- Novel immunotherapy drugs that target checkpoint inhibitors leads to reduced checkpoint inhibition. This keeps the immune system activated and thus potentiating anti-tumour effects. However, it is important to realise, as a consequence, there is reduced self-tolerance and auto-immune side effects occur. Prominently - Thyroiditis - Hypophysitis - Adrenalitis - Brittle diabetes (T1)

Answer 72

X-linked dominant

Answer 73

The anti-Jo-1 antibody is a predictor of the presence of ILD at diagnosis, with up to 70% of patients with the antibody having concurrent ILD. The 5-year survival rate is between 60 and 80%.

Answer 74

Progressive bulbar palsy?

Answer 75

Pseudoxanthoma elasticum is an inherited condition (usually autosomal recessive*) characterised by an abnormality in elastic fibres. - retinal angioid streaks - 'plucked chicken skin' appearance - small yellow -papules on the neck, antecubital fossa and axillae - cardiac: mitral valve prolapse, increased risk of -ischaemic heart disease - gastrointestinal haemorrhage

Answer 76

upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Answer 77

GF works at PEPSI factory and comes home every day with asthma symptoms: -GF— Glutaraldehyede. Flour PEPSi : - Platinum salt - Epoxy resins - Proteiolytic enzymes - Soldering flux resins - Isocynayes

Answer 78

chlorpromazine or haloperidol

Answer 79

Sulphasalazine - A combination of sulphapyridine (a sulphonamide) and 5-ASA - Many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis - Other side-effects are common to 5-ASA drugs (see mesalazine) Mesalazine -A delayed release form of 5-ASA -Sulphapyridine side-effects seen in patients taking sulphasalazine are avoided -------------------------- Common to both 5-ASA -GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis *Pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine

Answer 80

Radial tunnel syndrome presents similarly to lateral epicondylitis however pain is typically distal to the epicondyle and worse on elbow extension/forearm pronation

Answer 81

"5678" Either: - fasting glucose is >= 5.6 mmol/L - 2-hour glucose is >= 7.8 mmol/L

Answer 82

Type 1 - try basal bolus first. 2nd line twice daily 'mixed'. Type 2 - Start with isophane once or twice daily

Answer 83

Hepatorenal syndrome is primarily caused by splanchnic vasodilation

Answer 84

Obesity - NICE bariatric referral cut-offs - with risk factors (T2DM, BP etc): > 35 kg/m^2 - no risk factors: > 40 kg/m^2

Answer 85

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

Answer 86

FSGS | Membranous glomerulosclerosis

Answer 87

Major bleed: stop warfarin. Give prothrombin complex . give vit k Minor bleeding : stop warfarin . Give vitamin k No bleeding : manage according to INR 5:8 .....hold 2 doses &reduce dose 8:12 .... hold warfarin & give vit k 2.5 mg More than 12 .....hold warfarin & give vitk 5 mg

Answer 88

Bradycardia

Answer 89

Although ciprofloxacin is not a beta-lactam antibiotic, its use is strongly linked to the acquisition of MRSA as with all quinolone antibiotics.

Answer 90

The MRI finding of enhancement of the mamillary bodies due to petechial haemorrhages is specific for Wernicke's encephalopathy, although sensitivity is only 50%.

Answer 91

Standard error of the mean = standard deviation / square root (number of patients)

Answer 92

Carbamazepine is contraindicated and can worsen absence seizures (along with phenytoin, vigabatrin and gabapentin)

Answer 93

nitrates ACE-inhibitors inotropes

Answer 94

Urea breath test is the only test recommended for H. pylori post-eradication therapy

Answer 95

``` age > 40 years poor upper extremity muscle strength previous history of a diarrhoeal illness (specifically Campylobacter jejuni) high anti-GM1 antibody titre need for ventilatory support ```

Answer 96

Haemolysis during venipuncture (excessive vacuum of Blood drawing, prolonged tourniquet use or too fine a needle gauge) Delay in the processing of the blood specimen Abnormally high numbers of platelets, leukocytes, or erythrocytes (such as myeloproliferative disorders) Familial causes

Answer 97

Tay-Sachs disease typically presents with developmental delay and cherry red spot on the macula, without hepatomegaly or splenomegaly. This can present after 3 months of age as hypotonia, muscle weakness and myoclonic jerks and then progress to psychomotor retardation and regression, muscle spasticity, recurrent seizures, dementia and eventual death in early childhood. The cherry red spot in the macular is present in 90%.

Answer 98

Dural ectasia affects around 60% of patients with Marfan's syndrome. It may cause lower back pain associated with neurological problems such as bladder and bowel dysfunction.

Answer 99

The blood lead level is usually used for diagnosis. Levels greater than 10 mcg/dl are considered significant Full blood count: microcytic anaemia. Blood film shows red cell abnormalities including basophilic stippling and clover-leaf morphology Raised serum and urine levels of delta aminolaevulinic acid may be seen making it sometimes difficult to differentiate from acute intermittent porphyria Urinary coproporphyrin is also increased (urinary porphobilinogen and uroporphyrin levels are normal to slightly increased)

Answer 100

Clobetasone butyrate 0.05% (moderate) and Clobetasol propionate 0.05% (very potent)

Answer 101

Orlistat works by inhibiting gastric and pancreatic lipase to reduce the digestion of fat

Answer 102

Age under 50 years. Adjusted serum calcium concentration that is 0.25 mmol/L or more above the upper end of the reference range. Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 although this threshold depends on other factors, such as age. Renal stones or presence of nephrocalcinosis on ultrasound or CT. Presence of osteoporosis or osteoporotic fracture. Symptomatic disease

Answer 103

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

Answer 104

Anti-synthetase syndrome is related to dermatomyositis/polymyositis. Findings include relatively acute disease onset, constitutional symptoms (eg, fever and weight loss), myositis, the Raynaud phenomenon, mechanic's hands, arthritis that is generally nonerosive, and interstitial lung disease. Patients have antibodies towards tRNA synthetase. Consider the diagnosis if antisynthetase Ab positive PLUS 2 of the following: ILD, inflammatory myopathy, inflammatory polyarthritis.

Answer 105

early keloids may be treated with intra-lesional steroids e.g. triamcinolone excision is sometimes required

Answer 106

An S4 heart sound occurs in late diastole where there is active left ventricular filling when atrial contraction forces blood into a noncompliant left ventricle. The P wave represents the depolarization of the left and right atrium, which results in atrial contraction. Hence, S4 coincides with the P wave of the ECG.

Answer 107

Variance = square of standard deviation Therefore Standard deviation = square root variance

Answer 108

1) Glucocorticoid/Budesonide to induce remission 1b) 5-ASA (Mesalazine) is second in line to induce remission 2) Azathioprine/Methotrexate/Mercaptopurine can be used as add on to steroid (not monotheraphy) 3) Infliximab finally

Answer 109

Quinine Abciximab NSAIDs Diuretics: furosemide Antibiotics: penicillins, sulphonamides, rifampicin Anticonvulsants: carbamazepine, valproate heparin

Answer 110

It is, as implied by the name, an autosomal dominant condition caused by a NOTCH3 mutation on chromosome 19. ---------------------------------------- CADASIL (also known as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is the most common cause of hereditary cerebral small-vessel disease and vascular cognitive impairment in young adults. Characteristically, this presents with a migraine with aura, and a family history of such, which can ultimately lead to stroke-like features and is a recognised important cause of stroke in the young. Brain imaging will reveal multiple subcortical white matter lesions, particularly in the anterior temporal lobes and basal ganglia, out of keeping with the patient's age.

Answer 111

IV ceftazidime. Melioidosis is a severe, bacterial infection caused by Burkholderia pseudomallei and is common in East Asia and Northern Australia. It can present with localised or septicaemic disease with the lung being the most common site of localised disease. Diabetes is a strong risk factor both for acquiring melioidosis and for developing severe disease. The bacteria is inherently resistant to many antibiotics and for severe disease ceftazidime or a carbapenem should be used. Intravenous treatment should last for at least 10 days and should be followed by an oral maintenance phase of at least 20 weeks to reduce the risk of relapse.

Answer 112

inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl− symporter.

Answer 113

AIN is characterised by a triad of rash, fever and eosinophilia. While it is rare for all 3 to be present at the same time, it is important to consider the differential of AIN with any of the three, especially in the setting of arthralgia, sterile pyuria and white cell casts. White cell casts are caused by an acute inflammatory state, either by active infection such as pyelonephritis or an immune nephritic process, which involves cells sloughing in the tubular lumen. ----------------------------- Acute interstitial nephritis (AIN) typically arises following drug therapy in the majority of cases (~75%), with infections and systemic vasculitides forming the rest. The most common drug causes include: non steroidal anti-inflammatories (NSAIDs), penicillins, sulphur-based medications, proton pump inhibitors (PPIs), ciprofloxacin and allopurinol. Definitive diagnosis is done by renal biopsy, which is typically reserved for when the diagnosis is unclear or if another aetiology is suspected to occur concurrently/in equal likelihood. Management involves stopping the offending agent, with severe cases requiring steroids and potentially dialysis.

Answer 114

Subchondral erosions, sclerosis | and squaring of lumbar vertebrae

Answer 115

Increase thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy.

Answer 116

Dihydropyridine calcium channel blocker

Answer 117

Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia

Answer 118

The current BHIVA (British HIV Association) guidelines recommend bictegravir/tenofovir–alafenamide/emtricitabine - 'Biktarvy' - as first-line treatment for HIV in the absence of contraindications and drug-drug interactions. This regimen has a high barrier to resistance and is the optimal choice during the coronavirus pandemic where access to baseline testing for resistance may be less than normal. This patient has normal renal and hepatic function and is not on any other medications. Therefore, this combination is the typical initial choice.

Answer 119

Refer for surgery if primary hyperparathyroidism is confirmed and the patient has: • Polydipsia, polyuria or constipation. • Osteoporosis, fragility fracture or nephrolithiasis. • Albumin-adjusted serum calcium is ≥ 2.85 mmol/L.

Answer 120

Mitochondrial inheritance Onset < 20-years-old External ophthalmoplegia Retinitis pigmentosa

Answer 121

rifampicin + ethambutol + clarithromycin

Answer 122

``` Suprarenal (adrenal glands) Aorta Duodenum Pancreas Ureters Colon Kidneys Esophagus Rectum ```

Answer 123

Neuromyelitis optica which is also known as Devic's disease is an autoimmune disorder in which immune system cells and antibodies attack the optic nerves and the spinal cord. The pathophysiology is still however completely unclear. The diagnosis of neuromyelitis optica is determined as follows: Absolute criteria: - Optic neuritis - Acute myelitis Supportive criteria: - Brain MRI not meeting criteria for MS at disease onset - Spinal cord MRI with contiguous T2-weighted signal abnormality extending over three or more vertebral segments - NMO-IgG seropositive status (The NMO-IgG test checks the existence of antibodies against the aquaporin 4 antigen.) Compared to multiple sclerosis, the acute episodes are not understood to be triggered by the immune system's T cells, but rather by antibodies called NMO-IgG.

Answer 124

Pemphigus Vulgaris: Rare and life threatening IgG Autoantibodies to Desmoglein (Dsg3) Dsg3 is an adhesion molecule between epidermal cells Antibodies disrupt adhesion causing INTRA-epidermal blistering Affects mucosa and skin Bullous Pemphigoid: More common than Pemphigus Vulgaris Less aggressive and generally not life threatening IgG antibodies to BP180 and/or BP 230, components of hemidesmosomes BP180 anchors hemidesmosomes to lamina densa of basement membrane Blistering is SUB-epidermal Investigation for Both: Skin Punch Biopsy ELISA in specialist setting/centres Management: Pemphigoid Vulgaris: Oral Steroids Bullous Pemphigoid: Topical Steroids In both further treatments --> Immunosuppression / Plasmapheresis

Answer 125

Fab region: antigen-binding fragment - the region that binds to antigens Fc region: fragment crystallizable region - the tail region of an antibody that interacts with cell surface receptors

Answer 126

Pulmonary capillary wedge pressure (PCWP) is measured using a balloon tipped Swan-Ganz catheter which is inserted into the pulmonary artery. The pressure measured is similar to that of the left atrium (normally 6-12 mmHg). One of the main uses of measuring the PCWP is determining whether pulmonary oedema is caused by either heart failure or acute respiratory distress syndrome. In many modern ITU departments PCWP measurement has been replaced by non-invasive techniques.

Answer 127

Internuclear ophthalmoplegia is a disorder of conjugate gaze with the failure of adduction seen on the affected eye. This is caused by injury on the medial longitudinal fasciculus, located along the paramedian area of the midbrain and pons. In younger patients, lesions can be caused by multiple sclerosis but older populations can get this due to strokes. Convergence is maintained as this does not involve the medial longitudinal fasciculus. Convergence is mediated by the oculomotor nerve and the Edinger-Westphal nucleus.

Answer 128

Relapsing polychondritis is a rare autoimmune disorder characterised by recurrent episodes of inflammation and destruction of cartilaginous tissues resulting in widespread chondritis of the auricular, nasal, and tracheal cartilages as described in this case. Clinical features can include recurrent chondritis of the laryngotracheobronchitis tree and potentially end up with life-threatening laryngotracheal stenosis.

Answer 129

Bartonella henselae causes cat scratch disease. Patients typically develop low-grade fever, fatigue and malaise and regional ipsilateral lymphadenopathy. Diagnosis can be confirmed by microbiology through serology or culture, or histopathology through visualisation of bacilli in Warthin-Starry staining.

Answer 130

Leber's optic atrophy MELAS syndrome: mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes MERRF syndrome: myoclonus epilepsy with ragged-red fibres Kearns-Sayre syndrome: onset in patients < 20 years old, external ophthalmoplegia, retinitis pigmentosa. Ptosis may be seen sensorineural hearing loss

Answer 131

Klebsiella granulomatis (previously called Calymmatobacterium granulomatis)

Answer 132

NF1: chromosome 17 - as neurofibromatosis has 17 characters NF2: chromosome 22 - all the 2's

Answer 133

Large volume resuscitation with normal saline leads to an overload of chloride ions into the blood. The increased chloride ions, force bicarbonate into the cells and in doing so reduce the available bicarbonate for the pH buffering system. The result is a hyperchloraemic metabolic acidosis.

Answer 134

Predominately motor loss - Guillain-Barre syndrome - porphyria - lead poisoning - hereditary sensorimotor neuropathies (HSMN) (Charcot-Marie-Tooth) - chronic inflammatory demyelinating polyneuropathy (CIDP) - diphtheria Predominately sensory loss - diabetes - uraemia - leprosy - alcoholism - vitamin B12 deficiency - amyloidosis

Answer 135

IV C1-inhibitor concentrate, fresh frozen plasma (FFP) if this is not available prophylaxis: anabolic steroid Danazol may help

Answer 136

Stage 1: Hyperfiltration Stage 2: Silent Stage 3: Microalbuminuria Stage 4: Proteinuria

Answer 137

Doxycycline

Answer 138

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG) Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Answer 139

The typical presentation is that of a younger patient with progressive dementia (less rapid the sporadic CJD) with myoclonus and, in the later stages, mutism and vertical upgaze palsy (found in 50%). An MRI brain reveals a characteristic 'hockey stick sign' where the pulvinar region and dorsomedial thalamus are hyperintense on T2-weighted imaging (or pulvinar sign where the pulvinar region is hyperintense only). CSF protein for 14-3-3 and periodic sharp wave complexes on the EEG are more commonly seen in sporadic CJD.

Answer 140

Criteria (American-European Consensus Conference) - acute onset (within 1 week of a known risk factor) - pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules) - non-cardiogenic (pulmonary artery wedge pressure needed if doubt) - pO2/FiO2 < 40kPa (200 mmHg)

Answer 141

non-specific phosphodiesterase inhibitor and decreases cellular uptake of adenosine ------------------------------- generally described as a non-specific phosphodiesterase (PDE) inhibitor but it is known to be particularly active against PDE5 (like sildenafil) and PDE6.

Answer 142

HOT T-BONE stEAk BiN IT Now. ``` HOT (IL1 - fever) T (IL2 T cell stim) BONE (IL3 stimulates bone marrow) E (IL4 - IgE and B cell stim) A (IL5 - IgA and eosinophils) ``` B (IL6 - B cell stim) N (IL8 - Neutrophil chemotaxis) IT (IL10 - Inhibs Th1 cells) N - (IL12 - NK stim + T0 -> Th1)

Answer 143

``` FABRY'C disease: F - foggy lens A - angiokeratomas B - burning pain R - renal failure Y - youth death C - CV malformation ```

Answer 144

Lassa fever is an arenaviridae virus contracted by direct contact with the excreta of infected African rats (Mastomys rodent) or by person to person spread. It is predominantly seen in West Africa. ------------------------- Ribavarin is used to treat

Answer 145

Reduction in CD4 count Increase B2-microglobulin Decreased IL-2 production Polyclonal B-cell activation Decrease NK cell function Reduced delayed hypersensitivity responses

Answer 146

* Autoimmune haemolytic anaemia * ITP * Goodpasture's syndrome * Pernicious anaemia * Acute haemolytic transfusion reactions * Rheumatic fever * Pemphigus vulgaris / bullous pemphigoid

Answer 147

* Serum sickness * Systemic lupus erythematosus * Post-streptococcal glomerulonephritis * Extrinsic allergic alveolitis (especially acute phase)

Answer 148

* Tuberculosis / tuberculin skin reaction * Graft versus host disease * Allergic contact dermatitis * Scabies * Extrinsic allergic alveolitis (especially chronic phase) * Multiple sclerosis * Guillain-Barre syndrome

Answer 149

* Graves' disease | * Myasthenia gravis

Answer 150

activated by a wide variety of extracellular signals e.g. Peptide hormones, biogenic amines (e.g. adrenaline), lipophilic hormones, light

Answer 151

Produces an exotoxin (tetanospasmin) that prevents the release of glycine from Renshaw cells in the spinal cord causing a spastic paralysis

Answer 152

produces α-toxin, a lecithinase, which causes gas gangrene (myonecrosis) and haemolysis features include tender, oedematous skin with haemorrhagic blebs and bullae. Crepitus may present on palpation

Answer 153

Less likely to prevent stroke and potential impairment of glucose tolerance. This was demonstrated in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).

Answer 154

-Target cells being insensitive to PTH -Due to abnormality in a G protein -Associated with low IQ, short stature, shortened 4th and 5th metacarpals -Low calcium, high phosphate, high PTH diagnosis is made by measuring urinary cAMP and phosphate levels following an infusion of PTH. ---In hypoparathyroidism this will cause an increase in both cAMP and phosphate levels. ---In pseudohypoparathyroidism type I neither cAMP nor phosphate levels are increased whilst in pseudohypoparathyroidism type II only cAMP rises. ----------------------------- Pseudopseudohypoparathyroidism has features of pseudohypoparathyroidism but normal biochemistry

Answer 155

68. 3% of values lie within 1 SD of the mean 95. 4% of values lie within 2 SD of the mean 99. 7% of values lie within 3 SD of the mean

Answer 156

SItS (small t for teres minor) Supraspinatus - aBDucts arm before deltoid Infraspinatus - Rotates arm laterally teres minor - aDDucts & rotates arm laterally Subscapularis - aDDuct & rotates arm medially

Answer 157

Amiloride is a potassium-sparing diuretic. Specifically, it inhibits the epithelial sodium channels found in the distal convoluted tubule

Answer 158

Palatal myoclonus is a specific feature of hypertrophic olivary degeneration. This is caused by a lesion in the triangle of Guillain and Mollaret (triangle linking the inferior olivary nucleus, red nucleus and the contralateral dentate nucleus). An MRI brain is the gold standard imaging for this lesion.

Answer 159

Increases cGMP leading to smooth muscle relaxation. This relaxation occurs to a greater extent in the arterioles rather than the veins

Answer 160

There is some debate as to whether a 24 hour urinary free cortisol or an overnight dexamethasone suppression test should be used to screen patients for Cushing's. The overnight (not high-dose) dexamethasone suppression test has however been shown to be more sensitive and is now much more commonly used in clinical practice.

Answer 161

Loratidine (LORRYtadine for lorry drivers) | Cetirizine is also relatively non sedating but loratadine is best.

Answer 162

This patient has Parinaud syndrome as a result of a lesion at the dorsal midbrain. Rostral interstitial nucleus of medial longitudinal fasciculus lies at the dorsal midbrain and control vertical gaze. They project to the vestibular nuclei. It results in the following symptoms: Upward gaze palsy, often manifesting as diplopia Pupillary light-near dissociation (Pseudo-Argyll Robertson pupils) Convergence-retraction nystagmus It's aetiology include: Brain tumours in the midbrain or pineal gland (pinealoma) Multiple sclerosis Midbrain stroke

Answer 163

The BNF recommends avoiding alpha-blockers for 4 hours after sildenafil

Answer 164

Causes - NSAIDs - bisphosphonates - steroids The following drugs may cause reflux by reducing lower oesophageal sphincter (LOS) pressure - calcium channel blockers* - nitrates* - theophyllines - ------------------------------------ * calcium channel blockers and nitrates are occasionally used in the management of achalasia, itself a cause of dyspepsia, because of their effect on the LOS.

Answer 165

Tolvaptan blocks the action of vasopressin at the V2 receptor. This receptor is found on the basolateral membrane of the principal cells in the collecting ducts of the kidney. This reduces water absorption (through decreased aquaporin 2) and increases aquaresis without sodium loss. Desmopressin is a synthetic analogue of vasopressin that exerts agonism at the V2 receptor.

Answer 166

Has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures Has been shown to increase bone density in the spine and proximal femur May worsen menopausal symptoms Increased risk of thromboembolic events May decrease risk of breast cancer

Answer 167

Human papillomavirus infection (particularly 16, 18 & 33) is by far the most important risk factor

Answer 168

So the most common antibodies are parietal cells antibodies and the most specific antibodies are intrinsic factor antibodies

Answer 169

Carvedilol and labetalol are mixed alpha and beta antagonists

Answer 170

e(AR)ly diastolic -> Aortic Regurgiation (AR) | (M)id Diastolic -> (M)itral stenosis

Answer 171

MODY 3 - 60% of cases - due to a defect in the HNF-1 alpha gene - is associated with an increased risk of HCC MODY 2 - 20% of cases - due to a defect in the glucokinase gene MODY 5 - rare - due to a defect in the HNF-1 beta gene - liver and renal cysts

Answer 172

``` COELIAC DISEASE tropical sprue hypogammaglobulinaemia gastrointestinal lymphoma Whipple's disease cow's milk intolerance ```

Answer 173

``` female sex age: young age of onset (i.e. 20s or 30s) relapsing-remitting disease sensory symptoms only long interval between first two relapses complete recovery between relapses ```

Answer 174

Hypokalaemia with hypertension - Cushing's syndrome - Conn's syndrome (primary hyperaldosteronism) - Liddle's syndrome - 11-beta hydroxylase deficiency* Carbenoxolone, an anti-ulcer drug, and liquorice excess can potentially cause hypokalaemia associated with hypertension *21-hydroxylase deficiency, which accounts for 90% of congenital adrenal hyperplasia cases, is not associated with hypertension

Answer 175

PCT= Fanconi Ascending loop= Barter DCT= Gitlmn Collecting tubule= Liddle

Answer 176

Acute onset (within 1 week of a known risk factor) Pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules) Non-cardiogenic (pulmonary artery wedge pressure needed if doubt) pO2/FiO2 < 40kPa (200 mmHg)

Answer 177

methyldopa: used in the management of hypertension during pregnancy moxonidine: used in the management of essential hypertension when conventional antihypertensives have failed to control blood pressure clonidine: the antihypertensive effect is mediated through stimulating alpha-2 adrenoceptors in the vasomotor centre

Answer 178

SGLT-2 inhibitors are recognised to increased total cholesterol, (both HDL and LDL), although cardiovascular outcome studies as yet do not suggest this translates into increased risk of MACE events. In fact, the EMPA-reg study with empagliflozin demonstrated a reduction in overall mortality. SGLT-2 inhibitors like dapagliflozin promote increased glucose excretion because they inhibit glucose reabsorption in the kidney. This corresponds to a calorie load of 200-400 kcal per day. In some patients, this results in dramatic weight loss, although on average this equates to 1-2% reduction in weight over 6 months.

Answer 179

Pendred is an autosomal recessive genetic disorder that is characterised by bilateral sensorineural deafness, with mild hypothyroidism and a goitre. The patients tend to present with progressive hearing loss and delay in academic progression. Often head trauma tends to make the sensorineural deafness worse, leading to patients having to avoid contact sports. In Pendred syndrome there is a defect in the organification of iodine, leading to dyshormonogenesis. However thyroid symptoms in pendred syndrome are often mild and patients are often clinically euthyroid, presenting only with a goitre. Thyroid function tests are also often normal, requiring the perchlorate discharge test to aid diagnosis. The syndrome can be diagnosed via genetic testing (Pendred syndrome (PDS) gene, chromosome 7), audiometry and MRI imaging to look for characteristic one and a half turns in the cochlea, compared to the normal two and a half turns. Treatment is with thyroid hormone replacement and cochlear implants.

Answer 180

Full course 5 vaccines, last within 10 years: No Ig or booster (regardless of wound) Full course 5 vaccines, last >10 years: - Tetanus-prone wound: Booster dose + further doses to complete - High risk wound: Booster dose + Tetanus Ig Incompletely immunised/not known: Booster dose regardless of clean, if tetanus prone/high risk: booster + Ig

Answer 181

Come lets go sun bathe Stratum corneum - Flat, dead, scale-like cells filled with keratin. Continually shed Stratum lucidum - Clear layer - present in thick skin only Stratum granulosum - Cells form links with neighbours Stratum spinosum - Squamous cells begin keratin synthesis. Thickest layer of epidermis Stratum (basale) germinativum - The basement membrane - single layer of columnar epithelial cells - Gives rise to keratinocytes - Contains melanocytes

Answer 182

For pregnant lady with SVT prophylaxis - Metoprolol | otherwise - flecainide given there is no structural heart disease .

Answer 183

Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III via the kidneys

Answer 184

if asymptomatic then observe the patient is a general rule if symptomatic then valve replacement if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

Answer 185

Paraneoplastic Hepatic dysfunction syndrome = Stauffer's syndrome Stauffer's syndrome is a group of signs/symptoms indicative of liver dysfunction arising due to underlying renal cell carcinoma. Biochemically, there is can be an elevated alkaline phosphatase (ALP), γ-glutamyl transferase (GGT), platelets; prolonged prothrombin time (PT) with hepatosplenomegaly without hepatic metastasis or jaundice. Paraneoplastic syndromes commonly occurring with renal cell carcinoma can be constitutional symptoms such as fever, cachexia, and weight loss, ranging to more specific metabolic and biochemical disturbances like hypercalcemia, non-metastatic liver dysfunction, amyloidosis etc.

Answer 186

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)

Answer 187

a recombinant monoclonal antibody that antagonises Alpha-4 Beta-1-integrin found on the surface of leucocytes, thus inhibiting migration of leucocytes across the endothelium across the blood-brain barrier

Answer 188

sphingosine 1-phosphate receptor modulator, prevents lymphocytes from leaving lymph nodes. An oral formulation is available

Answer 189

NICE currently advises 5 different monoclonal antibodies in the treatment of uncontrolled severe asthma. These target various aspects of the underlying inflammatory pathway and the choice of antibody depends on whether or not there is a strong association with allergy. The choice for the specialist clinician is whether or not to target IgE (in the allergic phenotype) or to target eosinophil maturation via IL-4/5/13 (in the eosinophilic phenotype). There is a clear overlap between IgE and eosinophilia, therefore classifying the asthma phenotype is complex and requires measurement of serum IgE and serum eosinophil counts. In this scenario, the patient is stated to have severe allergic asthma. NICE, therefore, recommends IgE monoclonal antibody therapy after 4 or more trials of oral corticosteroids have been completed in the previous year with optimised standard therapy. This is in the form of omalizumab (Xolair). In the instance of uncontrolled severe eosinophilic asthma, NICE recommends various IL-5 antibody therapies in the form of mepolizumab, reslizumab and benralizumab or IL-4/13 antibody therapy in the form of dupilumab. Plasma cells are responsible for producing IgE. After IgE is released, it binds to the Fc domain on the IgE receptor found on mast cells and basophils. In response to an allergen, this receptor-bound IgE causes degranulation and release of allergic mediators including histamine that form the allergy cascade. Omalizumab is a monoclonal antibody that selectively binds to the domain at which IgE normally does, preventing interaction with its receptor.

Answer 190

The most common cause of biliary disease in patients with HIV is sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia

Answer 191

Quinolones (levofloxacin, ciprofloxacin)

Answer 192

Lactulose (worsens bloating symptoms)

Answer 193

One of the commonest adverse effects of this treatment process is hypocalcaemia which occurs as calcium is chelated by sodium citrate, the agent used as an anticoagulant during the procedure. Patients undergoing plasma exchange are therefore required to have their blood tests monitored closely.

Answer 194

loud: hypertension soft: AS fixed split: ASD reversed split: LBBB

Answer 195

There are two main types of IGR: impaired fasting glucose (IFG) - due to hepatic insulin resistance impaired glucose tolerance (IGT) - due to muscle insulin resistance patients with IGT are more likely to develop T2DM and cardiovascular disease than patients with IFG

Answer 196

Long-term therapy with metformin is known to reduce intestinal absorption of vitamin B12, specifically on calcium-dependent membrane action responsible for vitamin B12-intrinsic factor absorption in the terminal ileum. One study reports a highly significant inverse correlation between the dose and duration of metformin treatment and reduced serum levels of vitamin B12, with 33% of study participants affected.

Answer 197

Ethanol reduces the calcium-dependent secretion of anti-diuretic hormone (ADH) by blocking channels in the neurohypophyseal nerve terminal.

Answer 198

Around 1 in 10 people who are diagnosed with a renal angiomyolipoma have underlying tuberous sclerosis. Conversely, most patients with tuberous sclerosis will have several renal angiomyolipomata affecting both kidneys.

Answer 199

The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.

Answer 200

Hypertension is present in essentially 100 percent of patients with preeclampsia, 85 percent of patients with HELLP, and up to about 50 percent of patients with AFLP. Severe symptoms and signs of hepatic insufficiency such as hypoglycemia, encephalopathy, ascites and coagulopathy are more consistent with AFLP than HELLP or severe preeclampsia. Multi-organ involvement is also more common with AFLP, especially renal failure. Hypertension and proteinuria are often more severe in HELLP and severe preeclampsia

Answer 201

Bisphosphonate infusions can lead to hypocalcaemia although it is more common when using larger doses in malignancy induced hypercalcaemia as oppose to the smaller dose used in osteoporosis.

Answer 202

Severe valvular incompetence Aortic abscess (often indicated by a lengthening PR interval) Infections resistant to antibiotics/fungal infections Cardiac failure refractory to standard medical treatment Recurrent emboli after antibiotic therapy

Answer 203

``` sulfonylureas* SSRIs, tricyclics carbamazepine vincristine cyclophosphamide ```

Answer 204

``` viral meningitis/encephalitis TB meningitis partially treated bacterial meningitis Lyme disease Behcet's, SLE lymphoma, leukaemia ```

Answer 205

Toxocara canis ----------------------- commonly acquired by ingesting eggs from soil contaminated by dog faeces commonest cause of visceral larva migrans other features: eye granulomas, liver/lung involvement

Answer 206

Acute angle closure glaucoma= Hypermetropia (hyper and acute both crazy) priMarY OPen-angle glaucoma= MYOPia

Answer 207

1) Ex“opathalmo”s+“ Opthalmo”plegia [ NOT lid lag] 2) Pretibial myxedema 3) Thyroid acropachy (clubbing)

Answer 208

Polymerase chain reactions are used to detect mutated oncogenes

Answer 209

Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart

Answer 210

1st-line: tetracyclines e.g. doxycycline | 2nd-line: macrolides e.g. erythromycin

Answer 211

The early diastolic murmur is caused by aortic regurgitation, which is seen in around 20% of patients with Takayasu's arteritis.

Answer 212

It is a catecholaminergic polymorphic VT. This basically means that the arrhythmia is catecholamine i.e. adrenaline driven. So more the adrenaline release/ emotional stress/exercise, higher chances of VT or other life threatening arrhythmias. Why do we get arrhythmia with adrenaline in CPVT? Dysfunctional calcium regulation within cells resulting in calcium sparks during cardiac muscle contraction due to a genetic defect in Ryanodine receptor. These calcium sparks are triggered by adrenaline hence leading to excessive action potentials and contraction of cardiac muscles resulting in bidirectional adrenaline triggered VTs. Diagnosis? Challenging! Symptoms of syncope in young. ECG is mostly normal and routine cardiac investigations are also normal. Stress test ECG however picks ventricular ectopics due to adrenaline release. Treatment options are beta blockers, flecainide, sympathetic denervation, ICD. Research ongoing.

Answer 213

Rifampicin is an RNA synthesis inhibitor. It specifically inhibits bacterial DNA-dependent RNA polymerase. In doing so, elongation is physically blocked and so, without adequate RNA, bacteria cannot translate proteins.

Answer 214

Head pops (headache), breasts pop (breast tenderness), Tummy pops (weight gain) and skin pops (acne), endometrium pops (irregular periods)

Answer 215

heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation

Answer 216

31mmol is 5%. add 11mmol for every 1% thereon

Answer 217

APTT measures intrinsic pathway (appointments happen inside) PT measures extrinsic pathway (playtime happens outside) ----------------------------- And APTT evaluates factors VIII to XII While PT evaluates factor VII And both evaluate the common pathway (factors X --> V --> II --> I) To narrow down where the problem is!

Answer 218

Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel) Romano-Ward syndrome (no deafness)

Answer 219

Bardet-Biedl syndrome is a rare autosomal recessive condition that gives retinitis pigmentosa, but also presents with obesity, polydactyly and frequently mental retardation.

Answer 220

Metformin acts by activation of the AMP-activated protein kinase (AMPK)

Answer 221

The hazard ratio (HR) is similar to relative risk but is used when risk is not constant to time. It is typically used when analysing survival over time

Answer 222

A large body of evidence from the use of azathioprine in pregnancy for the treatment of both rheumatological conditions and inflammatory bowel disease, supports its use. Although it is less effective in the management of SLE with renal disease versus other options, balance of benefit risk makes it the preferred intervention.

Answer 223

Minimal glucocorticoid activity, very high mineralocorticoid activity, -Fludrocortisone Glucocorticoid activity, high mineralocorticoid activity, -Hydrocortisone Predominant glucocorticoid activity, low mineralocorticoid activity -Prednisolone Very high glucocorticoid activity, minimal mineralocorticoid activity -Dexamethasone/ Betamethasone --------------------------------- This is clinically relevant as there are some situations where it is important to combine high glucocorticoid (anti-inflammatory) activity with minimal mineralocorticoid (fluid-retention) effects. A good example is the use of dexamethsone for patients with raised intracranial pressure secondary to brain tumours.

Answer 224

The key diagnostic tests used to identify patients likely to benefit from cardiac resynchronization therapy is the transthoracic echocardiogram and ECG. Those with left ventricular ejection fractions of <35% and a LBBB (QRS duration greater than 120 ms) on ECG are excellent candidates for CRT (biventricular pacing). The echo will show asynchronous contraction of the LV and RV and subsequently reduced ejection fraction. A transoesophageal echo is not required. Biventricular pacing improves quality of life and exercise tolerance amongst other endpoints, and does so by ensuring that the ventricles contract at the same time (resynchronization) due to asynchronous stimulation (LBBB causing asynchronous activation) via the conduction system.

Answer 225

Froin syndrome is characterized by xanthochromia and hypercoagulability of the cerebrospinal fluid (CSF) due to elevated protein levels. This entity results from blockage of the spinal canal by a mass lesion leading to an isolated caudal CSF space.

Answer 226

0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours 3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours 4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair 5 Dead

Answer 227

increase pancreatic insulin secretion like sulfonylureas they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells often used for patients with an erratic lifestyle adverse effects include weight gain and hypoglycaemia (less so than sulfonylureas)

Answer 228

Polymorphic eruption of pregnancy - Pruritic condition associated with last trimester - Lesions often first appear in abdominal striae - Management depends on severity: emollients, mild potency topical steroids and oral steroids may be used Pemphigoid gestationis - Pruritic blistering lesions - Often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms - Usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy - Oral corticosteroids are usually required

Answer 229

Drugs which may precipitate acute glaucoma include anticholinergics and tricyclic antidepressants (any drugs which dilate the pupil)

Answer 230

Basics -used in investigation of hypopituitarism -IV insulin given, GH and cortisol levels measured with normal pituitary function GH and cortisol should rise Contraindications - epilepsy - ischaemic heart disease - adrenal insufficiency

Answer 231

VALPROATE ``` Vomiting Alopecia Liver toxicity Pancreatitis/ Pancytopenia Retention of fats (weight gain) Oedema (peripheral oedema) Anorexia Tremor Enzyme inhibition ```

Answer 232

N1 → N2 → N3 → REM Theta → Sleep spindles/K-complexes → Delta → Beta The Sleep Doctor's Brain

Answer 233

All pregnant women are offered screening for hepatitis B babies born to mothers who are chronically infected with hepatitis B or to mothers who've had acute hepatitis B During pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin Studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy There is little evidence to suggest caesarean section reduces vertical transmission rates Hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 234

Amoxicillin + Ciprofloxacin + Metronidazole

Answer 235

MRI with contrast enhancement

Answer 236

Varenicline is a nicotinic receptor partial agonist Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist

Answer 237

larva migrans: there are two disease entities: cutaneous (caused by Ancylostoma) and visceral (cause by toxocara). - cutaneous larva migrans: IVERMECTIN or THIABENDAZOLE. - visceral larva migrants: self limited. steroids if severe. ALEBENDAZOLE for eradication

Answer 238

Silver Stain

Answer 239

Treponema pallidum haemagglutination test (TPHA)

Answer 240

ABCD = Achey balls? cef and doxy ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days

Answer 241

Contraindicated - Cholera CVD103-HgR - Influenza-intranasal - Poliomyelitis-oral (OPV) - Tuberculosis (BCG) Can be used if CD4 >200 - MMR - Varicella - Yellow fever

Answer 242

sodium valproate second line: lamotrigine, carbamazepine

Answer 243

sodium valproate or ethosuximide --------------------------- sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy *carbamazepine may exacerbate absence seizures

Answer 244

sodium valproate second line: clonazepam, lamotrigine ------------------------- carbamazepine may exacerbate myoclonic seizures

Answer 245

carbamazepine or lamotrigine second line: levetiracetam, oxcarbazepine or sodium valproate

Answer 246

Unfractionated heparin activates antithrombin III which in turn inhibits thrombin and factors Xa, Ixa, XIa and XIIa. This stops fibrin formation and thrombin from activating factors V, VIII, and XI. This process can be reversed with protamine sulphate.

Answer 247

New Delhi metallo-beta-lactamase 1 is the mutation that leads to carbapenem resistance. Typically found in Klebsiella pneumoniae, Escherichia Coli (E. Coli), Enterobacter cloacae and others. First line of management is the old antibiotic colistin and second line may be tigecycline.

Answer 248

D-alanyl-D-lactate variation leading to loss of affinity to antibiotics is the mechanism of VRE (vancomycin resistant enterococci). Vancomycin binds D-ala-D-ala.

Answer 249

The presence of MexAB-OprM efflux pumps is one of the mechanisms by which pseudomonas aeruginosa is resistant to -lactams, chloramphenicol, fluoroquinolones, macrolides, novobiocin, sulfonamides, tetracycline, and trimethoprim.

Answer 250

Alteration to the penicillin binding protein 2 is the mechanism behind methicillin-resistant staphylococcus aureus. Mutations in the MEC gene which codes the penicillin binding proteins give staphylococcus aureus its resistance.

Answer 251

The commonest side effect caused by ivabradine is transient luminous phenomenon (reported by up to 15% of patients), such as bright spots appearing in their field of vision. Less commonly blurred vision is reported. Patients should be informed of this common side effect before starting the medication. The visual side effects of ivabradine are likely to be mediated by inhibition of a channel similar to the If channel found in the retina called the Ih channel. The h = hyperpolarisation-activated, these channels were formerly called IQ channels, Q = queer, again for their unusual characteristics.

Answer 252

Competitively inhibits the tubular secretion of creatinine

Answer 253

ACEi, ARBs, thiazides, aldosterone antagonists, and dihydropyridine CCBs all cause falsely negative aldosterone renin ratio, whereas BBlockers cause ARR to be falsely positive. He distinctly said that stopping BBlockers was most important for screening for primary aldosteronism

Answer 254

``` Gitelman's syndrome is due to a reabsorptive defect of the NaCl symporter in the DCT ---------------- NORMOTENSION hypokalaemia hypocalciuria hypomagnesaemia metabolic alkalosis --------------------------- Gitelman Na-Cl symporter not working Bartter Na-K-Cl co-transporter; you can Barter with 3 things better than 2 ```

Answer 255

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

Answer 256

troponin C: binds to calcium ions -Calcium ions are bound to by troponin C, playing the main role in Ca2+-dependent regulation of muscle contraction troponin T: binds to tropomyosin, forming a troponin-tropomyosin complex troponin I: binds to actin -Actin holds the troponin-tropomyosin complex in place which regulates muscle contraction

Answer 257

faecal elastase

Answer 258

Equivalent of 7.5 mg oral prednisolone each day for 3 months.

Answer 259

Herpes simplex

Answer 260

- Unexplained deterioration in vision - Awareness of change in intensity or quality of colour vision in one or both eyes - History of eye suddenly 'popping out' (globe subluxation) - Obvious corneal opacity - Cornea still visible when the eyelids are closed - Disc swelling

Answer 261

Pregnancy/ Post natal = Paroxetine -Less secreted in milk ----------------------------------- Highest incidence of discontinuation syndrome

Answer 262

Monoclonal Gammopathy of Uncertain Significance (MGUS): ▪︎M protein <30 g/l ▪︎BM plasma cells <10% ▪︎No CRAB features ``` Smoldering Multiple Myeloma: ▪︎M protein > 30 g/l ▪︎BM plasma cells 10-60% ▪︎No CRAB features ▪︎Rx: Observe + monitor ``` Multiple myeloma: ▪︎M protein >30g/l ▪︎BM plasma cells >10% ▪︎CRAB features

Answer 263

rise in bilirubin following prolonged fasting or IV nicotinic acid

Answer 264

Can be considered if seizure free for >2 years, with AEDs being stopped over 2-3 months.

Answer 265

``` Antiepileptics: phenytoin, carbamazepine Barbiturates: phenobarbitone Rifampicin St John's Wort Chronic alcohol intake Griseofulvin Smoking (affects CYP1A2, reason why smokers require more aminophylline) ```

Answer 266

Generally: Rats = Leptospirosis while Rabbits = Tularaemia --------------------------- Tularaemia is a zoonotic infection involving the microorganism F. tularensis commonly transmitted through lagomorphs such as rabbits, hares and pikas but also in aquatic rodents - beavers and muskrat - and ticks. It can present in a variety of forms. Commonly, it produces an erythematous papulo-ulcerative lesion at the site of the bite with reactive and ulcerating regional lymphadenopathy. It is treated with antibiotics such as doxycycline.

Answer 267

``` THE MASCOTS: • Terfenadine • Haloperidol • Erythromycin • Methadone • Amiodarone • Sotalol • Chloroquine • Ondansetron • TCAs • SSRIs ```

Answer 268

Taxanes such as docetaxel - prevents microtubule depolymerisation & disassembly, decreasing free tubulin

Answer 269

- TACO usually occurs in elderly patients with a decreased cardiovascular reserve and ability to compensate for an increase in fluid volume. - TACO is more likely in rapid/substantial transfusions, whereby receiving more units increase the likelihood of overload. - TACO presents with hypertension due to volume excess, whereas TRALI presents with hypotension due to ARDS and the resultant hypovolaemic shock. - TRALI is likely to be associated with fever and leukopenia, whereas TACO usually has neither.

Answer 270

Ehlers-Danlos syndrome is primarily caused by a genetic defect in collagen type III. Collagen Type V is affected in a less common variant of Ehlers-Danlos syndrome.

Answer 271

Erythromycin

Answer 272

Live vaccines can be given on the same day. If not given on the same day, then there must be a 4 week interval between further live vaccinations to prevent the risk of immunological interference.

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