Path

Question 1

A gram negative intracellular diplococcus that causes meningitis

Answer 1

Neisseria or Neisseria Meningitidis

Question 2

A gram positive diplococcus that causes pneumonia

Answer 2

Pneumococcus or streptococcus pneumoniae

Question 3

A gram positive organism that grows in bunches and causes abscesses

Answer 3

Staphylococcus Aureus

Staphylococcus comes from the greek, and means ‘grape-cluster berry’

Question 4

The organism that causes tetanus

Answer 4

Clostridium tetanae

Clostridium species tend to be soil dwelling and form spores. This includes the causative organisms of Botulinum toxin, Gas gangrene and tetanus.

Question 5

A gram negative rod that commonly causes urinary tract infections

Answer 5

E-coli

The most common enteric bacterium that causes pathology.

Question 6

Cystic dilatation of duct during lactation caused by obstruction

• duct ectasia
• mammary duct ectasia
• fibroadenoma
• mastitis
• fibrocystic change
• galactocoele
• galactorrhoea
• gynaecomastia
• intraductal papilloma
• lactating
• adenoma

Answer 6

galactocoele

this is caused by a proteinaceous blockage of the lactiferous duct and the accumulation of milk, producing a cyst.

The milk within the cyst is sterile and there is no point of ingress for bacteria so they don’t become infected. It will resolve when lactation ceases. A simple needle drainage won’t resolve the cyst as the plug remains and milk will continue to be produced.

If management is needed then the cyst should be surgically excised.

Question 7

Infection of the breast that occurs during lactation

• duct ectasia
• mammary duct ectasia
• fibroadenoma
• mastitis
• fibrocystic change
• galactocoele
• galactorrhoea
• gynaecomastia
• intraductal papilloma
• lactating
• adenoma

Answer 7

mastitis

the suffix ‘-itis’ tells you that of the options this is the only infective/inflammatory process.

The symptoms include a red, swollen area of the breast that is often tender. There can also be nipple discharge, sometimes streaked with blood, a firm tender lump, or a burning pain in the breast.

Question 8

Occurs in males with liver disease

• duct ectasia
• mammary duct ectasia
• fibroadenoma
• mastitis
• fibrocystic change
• galactocoele
• galactorrhoea
• gynaecomastia
• intraductal papilloma
• lactating
• adenoma

Answer 8

gynaecomastia

Due to build up of oestrogen seen in liver disease, results in development of breasts.

Question 9

Occurs in the presence of a high prolactin

• duct ectasia
• mammary duct ectasia
• fibroadenoma
• mastitis
• fibrocystic change
• galactocoele
• galactorrhoea
• gynaecomastia
• intraductal papilloma
• lactating
• adenoma

Answer 9

galactorrhoea

Galactorrhoea is the abnormal prodction of milk, as opossed to lactation which is physiological.

It is often seen with pituitary tumours such as prolactinomas.

Question 10

The commonest benign tumour of the female breast

• duct ectasia
• mammary duct ectasia
• fibroadenoma
• mastitis
• fibrocystic change
• galactocoele
• galactorrhoea
• gynaecomastia
• intraductal papilloma
• lactating
• adenoma

Answer 10

fibroadenoma

A fibroadenoma is a benign lump of the female breast, it is colloquially known as a ‘breast mouse’. They are well defined and very mobile within the tissue, this distinguishes them from malignant lumps. They tend to be solitary and found in women of childbearing age.

Question 11

Causes an increased loss of HCO3-

• Diabetic ketoacidosis
• Intestinal fistula
• Metabolic acidosis
• Metabolic alkalosis
• Poor lung perfusion
• Pyloric stenosis
• Renal failure
• Respiratory acidosis
• Respiratory alkalosis

Answer 11

Intestinal fistula

There is an increased loss of bicarbonate if there is an intestianal fistula

Question 12

Causes increased H+ production

• Diabetic ketoacidosis
• Intestinal fistula
• Metabolic acidosis
• Metabolic alkalosis
• Poor lung perfusion
• Pyloric stenosis
• Renal failure
• Respiratory acidosis
• Respiratory alkalosis

Answer 12

Diabetic ketoacidosis

In diabetic ketoacidosis there is an ionic shift due to the accumulation of ketones in the body. this leads to a shift of potassium into the intracellular compartment. THis in turn increases the H+ production to mantain the ionic gap.

Question 13

Causes increased H+ loss

• Diabetic ketoacidosis
• Intestinal fistula
• Metabolic acidosis
• Metabolic alkalosis
• Poor lung perfusion
• Pyloric stenosis
• Renal failure
• Respiratory acidosis
• Respiratory alkalosis

Answer 13

Pyloric stenosis

In pyloric stenosis there is a delay in emptying the stomach contents and there is an increase in vomiting, this is the source of lost H+ ions.

Question 14

Can be compensated by increased renal excretion of H+

• Diabetic ketoacidosis
• Intestinal fistula
• Metabolic acidosis
• Metabolic alkalosis
• Poor lung perfusion
• Pyloric stenosis
• Renal failure
• Respiratory acidosis
• Respiratory alkalosis

Answer 14

Metabolic acidosis

Be aware that compensation for a metabolic acidosis is with hyperventilation. Renal excretion (question 4) of acid is not really compensation, but just correcting the problem.

Question 15

5. Can be compensated by hypoventilation

• Diabetic ketoacidosis
• Intestinal fistula
• Metabolic acidosis
• Metabolic alkalosis
• Poor lung perfusion
• Pyloric stenosis
• Renal failure
• Respiratory acidosis
• Respiratory alkalosis

Answer 15

Metabolic alkalosis

Also although hypoventilation would compensate for a metabolic alkalosis, that effect is minimised in humans by hypoxia.

Question 16

Gain in bicarbonate ions or loss of H+ ions resulting in raised pH.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis with Respiratory Compensation
• Metabolic Alkalosis with Respiratory Compensation
• Respiratory Acidosis with Metabolic Compensation
• Respiratory Alkalosis with Metabolic Compensation

Answer 16

a. Metabolic Alkalosis

This is by definiton a metabolic acidosis.

Question 17

24 year old female presents at A&E with a broken ankle. The interpretation of her blood gas results (pH 7.62, PCO2 3.59, PO2 14.1, HCO3 23, Base Excess 0) demonstrates a ____.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis with Respiratory Compensation
• Metabolic Alkalosis with Respiratory Compensation
• Respiratory Acidosis with Metabolic Compensation
• Respiratory Alkalosis with Metabolic Compensation

Answer 17

a. Respiratory Alkalosis

In true EMQ style this young woman is having a panic attack due to the broken ankle and is hyperventilating. This is resulting in the off-gassing of her CO2 resulting in a respritory alkolosis.

Question 18

3. 22 year old model is admitted to A&E with weakness and tingling sensations in both hands and feet, and “poor balance”. Patient denies pill ingestion but admits she has been on a strict diet regimen to meet her agency’s expectations. Her ABG results (pH 7.55, PCO2 6.67, PO2 12.0, HCO3 45) demonstrate ____.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis with Respiratory Compensation
• Metabolic Alkalosis with Respiratory Compensation
• Respiratory Acidosis with Metabolic Compensation
• Respiratory Alkalosis with Metabolic Compensation

Answer 18

a. Metabolic Alkalosis

The patient has an alkalotic pH with a high bicarbonate. She has a degree of hypercapnia, but not enough to compensate.

In this case we see that this patient is having symptoms of metabolic alkolosis, with the parastesia and poor balance. It is likely that in EMQ land this fashion model has been frequently vomitinf.

Question 19

4. A 40 year old lady with severe chronic back pain (treated aggressively with OTC NSAIDs) for several years was found to have BP 155/95 at her routine GP visit. Her urine dipstick demonstrated ++ protein and increased white blood cells. Her ABG results (pH 7.30, PCO2 4.27, HCO3 15) demonstrate _____.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis with Respiratory Compensation
• Metabolic Alkalosis with Respiratory Compensation
• Respiratory Acidosis with Metabolic Compensation
• Respiratory Alkalosis with Metabolic Compensation

Answer 19

a. Metabolic Acidosis with Respiratory Compensation

This case demonstrates only a partial compensation, she is still acidotic at pH7.30

Question 20

5. A 45 year old man with a history of solvent (inhalant) abuse presents to A&E complaining of dyspnoea (SPO2 99% on room air). He is tachypnoeic on examination and demonstrates Kussmaul breathing. His ABG (pH 6.95, PCO2 1.20, PO2 17.0, HCO3- 2) demonstrates ___.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis with Respiratory Compensation
• Metabolic Alkalosis with Respiratory Compensation
• Respiratory Acidosis with Metabolic Compensation
• Respiratory Alkalosis with Metabolic Compensation

Answer 20

a. Metabolic acidosis with respiratory compensation

He’s been huffing so much glue he’s put himself in metabolic acidosis. This is due to the metabolism of the volitaile compounds leading to increased secretion of sodium and potassium in the urine.

His Kussmaul breathing is a physiologic response to blow off more CO2, but it hasn’t come close to correcting this acidosis.

Question 21

An elderly patient on the ward has RR 16, HR 65, temp 37.5 degrees C. His blood gases are pH 7.35 (7.35-7.45), pCO2 9.0 (4.7-6 kPa), pO2 8.1(10.0-13.3 kPa), HCO3 45 (22-30). Rank the underlying diseases below in order of likelihood, going from most to least likely:

• Pulmonary embolism
• Tension pneumothorax
• COPD
• Hyperventilation
• Pneumonia

Answer 21

Answer: 1. COPD 2. Pneumonia 3. Pulmonary embolism 4. Tension pneumothorax 5. Hyperventilation

This is a picture of respiratory acidosis with metabolic compensation. Hyperventilation would cause alkalosis so is least likely.

A tension pneumothorax would not have time to establish compensation so is next least likely.

The carbon dioxide is high and the oxygen is low so this is type 2 respiratory failure with no v/q mismatch. while a number of small PEs might result in compensation over time they would give a type 1 picture with low oxygen and normal carbon dioxide.

Both pneumonia and COPD might give this blood gas picture but this patient’s vital measurements show no sign of infection so COPD is most likely.

Question 22

1. A 42 year old man with heartburn presents with the following blood gases: pH 7.51, pCO2 5.2kPa, bicarbonate = 30 mmol/l.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Compensated Respiratory Alkalosis
• Compensated Respiratory Acidosis
• Compensated Metabolic Alkalosis
• Compensated Metabolic Acidosis
• Type I Respiratory Failure
• Type II Respiratory Failure

Answer 22

a. Metabolic Alkalosis

He’s been eating antacid tablets like sweeties

We see an alkalotic pH combined with a normal CO2, combined with the history, and we know it’s metabolic with no compensation.

Question 23

2. 65 year old long- term smoker is admitted with drowsiness and confusion. ABG reveals pH 7.36, pO2 7kPa, pCO2 8kPa, bicarbonate 24 mmol/l.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Compensated Respiratory Alkalosis
• Compensated Respiratory Acidosis
• Compensated Metabolic Alkalosis
• Compensated Metabolic Acidosis
• Type I Respiratory Failure
• Type II Respiratory Failure

Answer 23

a. Type II Respiratory Failure

The pH here is normal but there is a low O2 and high CO2, which is a type II respiratory failure, by definition.

Question 24

3. Treat with IV sodium bicarbonate

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
• Compensated Respiratory Alkalosis
• Compensated Respiratory Acidosis
• Compensated Metabolic Alkalosis
• Compensated Metabolic Acidosis
• Type I Respiratory Failure
• Type II Respiratory Failure

Answer 24

a. Metabolic Acidosis

Sodium Bicarbonate is going to make the blood more alkali, as such it could only plausibly be a treatment for acidosis, respiratory acidosi is caused by hypoventialtion, the treatment for which is ventilation support.

Metabolic acidosis is caused by increased H+ ions or increased loss of bicarbonate ions, so it stands to reason that it is treated with IV bicarbonate.

Question 25

4. 24 year old female presents with an aspirin overdose. She appears to be breathing heavily. pH 7.38, pO2 12kPa, pCO2 2.5kPa, bicarbonate 16 mmol/l. * Metabolic Acidosis * Metabolic Alkalosis * Respiratory Acidosis * Respiratory Alkalosis * Compensated Respiratory Alkalosis * Compensated Respiratory Acidosis * Compensated Metabolic Alkalosis * Compensated Metabolic Acidosis * Type I Respiratory Failure * Type II Respiratory Failure

Answer 25

a. Compensated Metabolic Acidosis We know that a Salicylate poisining causes a metabolic acidosis, but in this case the blood gas shows a normal pH and a low CO2, we also have the observation that she is breathing heavily. This is therefore a compensated metabolic acidosis.

Question 26

5. 55 year old male with difficulty breathing is diagnosed with Guillain- Barre syndrome. pH 7.25, pO2 12kPa, pCO2 9kPa, bicarbonate 25 mmol/l. * Metabolic Acidosis * Metabolic Alkalosis * Respiratory Acidosis * Respiratory Alkalosis * Compensated Respiratory Alkalosis * Compensated Respiratory Acidosis * Compensated Metabolic Alkalosis * Compensated Metabolic Acidosis Type I Respiratory Failure Type II Respiratory Failure

Answer 26

a. Respiratory Acidosis We see here an acidic pH with a high CO2. Guillain-Barre can affect the muscles of respiration, as we see here. This has resulted in hypoventilation and an accumulation of CO2.

Question 27

22 year old man presents with a painless, red ulcer on his penis. Microscopy reveals spiral shaped organisms. * Benzylpenicillin * Ceftriaxone * Chloramphenicol * Clarithromycin * Colistin * Gentamicin * Intravenous * Meropenem * Moxifloxacin * Orally * Rifampicin * Trimethoprim * Vancomycin * Rectally

Answer 27

a. Benzylpenicillin What is being described here is the classic chancre ulcer that is the harbinger of primary syphilis infection. The microscopy describes the causative organism of Treponema pallidum. Syphilis is simply treated with a single dose of IM Benzylpenicillin

Question 28

2. On a routine swab for a pre-op patient, the lab is able to culture Staphylococcus aureus. The lab also reports that this particular strain is not sensitive to Penicillins. * Benzylpenicillin * Ceftriaxone * Chloramphenicol * Clarithromycin * Colistin * Gentamicin * Intravenous * Meropenem * Moxifloxacin * Orally * Rifampicin * Trimethoprim * Vancomycin * Rectally

Answer 28

a. Vancomycin Vancomycin is recommended for use on gram-positve bacteria where resistance to penicillins is known or suspected.

Question 29

3. The route of administration when administering Vancomycin to treat serious C.difficile infection. * Benzylpenicillin * Ceftriaxone * Chloramphenicol * Clarithromycin * Colistin * Gentamicin * Intravenous * Meropenem * Moxifloxacin * Orally * Rifampicin * Trimethoprim * Vancomycin * Rectally

Answer 29

a. Orally C.difficile is an infection of the digestive system so the most effective method of administration is into the digestive system. IV administration would be more effective if this were an organism presenting as a bacteraemia.

Question 30

4. This antibiotic which is usually administered as eye drops, can cause grey baby syndrome in neonates, because of an inability to metabolise the drug. * Benzylpenicillin * Ceftriaxone * Chloramphenicol * Clarithromycin * Colistin * Gentamicin * Intravenous * Meropenem * Moxifloxacin * Orally * Rifampicin * Trimethoprim * Vancomycin * Rectally

Answer 30

a. Chloramphenicol Grey baby syndrome occurs due to insufficient enzyme activity and kidney excretion of the drug in neonates. This allows Chloamphenicol to build up to toxic levels, resulting in the life threatening Grey baby syndrome.

Question 31

5. A 21 year old university student presents with meningococcal infection, and he is successfully treated. What prophylaxis might be given to his housemates and closest contacts? * Benzylpenicillin * Ceftriaxone * Chloramphenicol * Clarithromycin * Colistin * Gentamicin * Intravenous * Meropenem * Moxifloxacin * Orally * Rifampicin * Trimethoprim * Vancomycin * Rectally

Answer 31

a. Rifampicin

Question 32

1. 36-year old male presents with hypertension. Lab results: Na+ = 155mmol/L, K+ = 2.9mmol/L, pH = 7.46, low plasma renin activity. * Pituitary dependent Cushing’s disease * Adrenal tumour causing Cushing’s syndrome * Ectopic ACTH causing Cushing’s syndrome * Normal obese person * Cushing’s syndrome of indeterminate cause * Pituitary adenoma * Phaeochromocytoma * Primary adrenal insufficiency * Secondary adrenal insufficiency * Primary hyperaldosteronism * Secondary hyperaldosteronism * Adrenal medulla * Zona glomerulosa * Zona fasciculata * Zona reticularis

Answer 32

a. Primary hyperaldosteronism Here we have a patient with hypernatremia and hypokalemia, these two abnormalities point towards hyperaldosteronism. The only other syndrome in the list of options is Cushing's, which would result in hyperglycaemia but with no other electrolyte disturbances. It is importatnt ot remember that aldosterone is produced in response to the renin-angiotensin system. If there was a tumour secreting renin, or there was excess renin secretion due to renal artery stenosis, then this would be secondary hyperaldosteronism. In this case we are told that the renin levels are appropriately low, so there must be a tumour secreting aldosterone, this is therefore primary hyperaldosteronism.

Question 33

2. 50-year old female with the following lab results: Na+ = 130mmol/L, K+ = 5.9mmol/L, glucose = 3.4mmol/L, urea = 7.2 mmol/L, Ca2+ = 2.8 mmol/L. A short SynACTHen test shows cortisol = 600nmol/L half an hour after administration. * Pituitary dependent Cushing’s disease * Adrenal tumour causing Cushing’s syndrome * Ectopic ACTH causing Cushing’s syndrome * Normal obese person * Cushing’s syndrome of indeterminate cause * Pituitary adenoma * Phaeochromocytoma * Primary adrenal insufficiency * Secondary adrenal insufficiency * Primary hyperaldosteronism * Secondary hyperaldosteronism * Adrenal medulla * Zona glomerulosa * Zona fasciculata * Zona reticularis

Answer 33

a. Secondary adrenal insufficiency Here we have a hyponatremia and a hyperkalemia, which is suggestive of glucocorticoid deficiency. The fact that she has undergone a short synACTHen test just confirms that. The test shows that the adrenals are able to pump out cortisol to a normal level (morning cortisol should be 138–635nmol/l). Therefore the problem is not the adrenal cortex, it must be an issue woth ACTH production at the pituitary, this is therefore a secondarly adrenal insufficiency.

Question 34

3. A 45-year old female patient presents with cushingoid features. A dexamethasone suppression test shows undetectable ACTH, cortisol = 750nmol/L. * Pituitary dependent Cushing’s disease * Adrenal tumour causing Cushing’s syndrome * Ectopic ACTH causing Cushing’s syndrome * Normal obese person * Cushing’s syndrome of indeterminate cause * Pituitary adenoma * Phaeochromocytoma * Primary adrenal insufficiency * Secondary adrenal insufficiency * Primary hyperaldosteronism * Secondary hyperaldosteronism * Adrenal medulla * Zona glomerulosa * Zona fasciculata * Zona reticularis

Answer 34

a. Adrenal tumour causing Cushing’s syndrome Here we have a patient with excess cortisl, following administeration of an exogenous corticosteroid the levels of ACTH are found to be negligible, but in spite of this there is still a high level of cortisol. This tells you that there is a pathological source of cortisol that is outside the phisiological axis. This is an adrenal tumour secreting cortisol.

Question 35

4. A 65-year old male patient presents with cushingoid features. A high dose dexamethasone suppression test shows ACTH 25 pmol/L (high), cortisol = 750nmol/L. * Pituitary dependent Cushing’s disease * Adrenal tumour causing Cushing’s syndrome * Ectopic ACTH causing Cushing’s syndrome * Normal obese person * Cushing’s syndrome of indeterminate cause * Pituitary adenoma * Phaeochromocytoma * Primary adrenal insufficiency * Secondary adrenal insufficiency * Primary hyperaldosteronism * Secondary hyperaldosteronism * Adrenal medulla * Zona glomerulosa * Zona fasciculata * Zona reticularis

Answer 35

a. Ectopic ACTH causing Cushing’s syndrome Here we have a patient with an excess of cortisol, in this case the supression test does not reduce the levels of ACTH. This tells you that there is a pathological source of ACTH that is flogging the adrenals. Hence, this is an ectopic ACTH source causing the Cushing's syndrome.

Question 36

5. A 28-year old man presents with hypertensive episodes. Lab results: Na+ 140mmol/L, K+ = 4.1mmol/L, random cortisol = 200nmol/L. CT shows an adrenal mass, which region is most likely to be affected? * Pituitary dependent Cushing’s disease * Adrenal tumour causing Cushing’s syndrome * Ectopic ACTH causing Cushing’s syndrome * Normal obese person * Cushing’s syndrome of indeterminate cause * Pituitary adenoma * Phaeochromocytoma * Primary adrenal insufficiency * Secondary adrenal insufficiency * Primary hyperaldosteronism * Secondary hyperaldosteronism * Adrenal medulla * Zona glomerulosa * Zona fasciculata * Zona reticularis

Answer 36

a. Adrenal medulla Here we have a patient with entirely normal blood results who is experiencing hypertensive episodes. This is your hint that it is that typical Imperial pathology condition; a phaeochromocytoma. As such is has to be in the adrenal medulla, the site of adrenaline synthesis.

Question 37

1. What is the first line of treatment in phaeochromocytomas? * Conn’s syndrome * Cushing’s syndrome * Alpha blockade * Beta blockade * Surgery * Pituitary MRI * High dose dexamethasone test * Adrenal CT Scan * Spironolactone * Zona glomerulosa * Zona fasciculata * Low dose dexamethasone test * 24 hour ambulatory blood pressure * Aldosterone- renin ratio * Glucose tolerance test *

Answer 37

a. Alpha blockade You need to block the effects of the adrenaline secreting tumour before attempting to remove it. it is likely that the disturbance of the tumour during surgery will cause a huge surge of adrenaline. In terms of alpha and beta blockade, both are needed, but alpha is needed first. I always remember this as alpha being before beta in the greek alphabet! Anyway, if the alpha blockade isn't done first then there is a serious risk that the patient will have an uncontrollable hypertensive episode during surgery. And that, is a bad idea...

Question 38

2. A 25 year old female patient presents with high levels of aldosterone and low levels of renin. On examination the patient is found to be hypertensive. What is the diagnosis? * Phaeochromocytoma * Conn’s syndrome * Cushing’s syndrome * Alpha blockade * Beta blockade * Surgery * Pituitary MRI * High dose dexamethasone test * Adrenal CT Scan * Spironolactone * Zona glomerulosa * Zona fasciculata * Low dose dexamethasone test * 24 hour ambulatory blood pressure * Aldosterone- renin ratio * Glucose tolerance test

Answer 38

a. Conn’s syndrome This is a primary hyperaldosteronism, it is being driven by an aldosterone secreting tumour, and so is known as Conn's syndrome. If this was being driven by excessive renin it would be a secondary hyperaldosteronism.

Question 39

3. A 75 year old lady reports to her GP of very frequent panic attacks. She complains of excessive sweating and following investigations, hypertension is detected and raised levels of catecholamines are found in the urine. * Conn’s syndrome * Phaeochromocytoma * Cushing’s syndrome * Alpha blockade * Beta blockade * Surgery * Pituitary MRI * High dose dexamethasone test * Adrenal CT Scan * Spironolactone * Zona glomerulosa * Zona fasciculata * Low dose dexamethasone test * 24 hour ambulatory blood pressure * Aldosterone- renin ratio * Glucose tolerance test

Answer 39

a. Phaeochromocytoma The episodic nature of these 'panic attacks' combined with the hypertension and high levels of catecholamines tells you that htis is a tumour secreting catecholamines. It is thus, a Phaeo.

Question 40

4. A 53 year old male patient presents with constantly high blood pressure. He is an investment banker and initially the elevation is thought to be related to stress. The patient’s Na, K and urea are all normal. His glucose is however taken randomly and is found to be elevated at 7.9mmol/L. What is the first investigation that needs to be carried out in this patient ? * Conn’s syndrome * Phaeochromocytoma * Cushing’s syndrome * Alpha blockade * Beta blockade * Surgery * Pituitary MRI * High dose dexamethasone test * Adrenal CT Scan * Spironolactone * Zona glomerulosa * Zona fasciculata * Low dose dexamethasone test * 24 hour ambulatory blood pressure * Aldosterone- renin ratio * Glucose tolerance test

Answer 40

a. 24 hour ambulatory blood pressure There doesn't appear to be an endocrine cause for this gentleman's hypertension. The glucose is right on the uper range for a random, it might indicate a glucose tolerance issue, but that doesn't explain the hypertension. As such he really needs further measuring of his BP with ambulatory monitoring.

Question 41

5. Which part of the adrenal cortex produces glucocorticoids in response to the Adrenocorticotrophic hormone ? (ACTH) * Conn’s syndrome * Phaeochromocytoma * Cushing’s syndrome * Alpha blockade * Beta blockade * Surgery * Pituitary MRI * High dose dexamethasone test * Adrenal CT Scan * Spironolactone * Zona glomerulosa * Zona fasciculata * Low dose dexamethasone test * 24 hour ambulatory blood pressure * Aldosterone- renin ratio * Glucose tolerance test

Answer 41

a. Zona fasciculata The adrenal cortex is made up of 3 layers, which moving from superficial to deep are as follows: Zona Glomerulosa - produces mineralcorticoids (aldosterone) Zona Fasiculata - produces glucocorticoids (Steroids) Zona Reticularis - produces androgens (testosterone precursors)

Question 42

1. Distressed parents rush their 7-year-old boy to A&E. He’s experiencing difficulty breathing and facial swelling, which started suddenly during a family picnic. His father mentions there was a dead wasp close to where his son collapsed. * Medication side effect * Acute urticaria * Asthma * C1 inhibitor deficiency * Chronic Granulomatous Disease * Chronic urticaria * Contact dermatitis * Dermatitis herpetiformis * Food intolerance * Hayfever * Hyper IgM * Type I hypersensitivity * Type II hypersensitivity * Type III hypersensitivity * Type IV hypersensitivity

Answer 42

a. Type I hypersensitivity Here you need to recognise that this is an anaphylatic reaction to the wasp sting. This is a hypersensitivity caused by an IgE response leading to a massive mast cell degranulation. This is a type I hypersensitivity.

Question 43

2. A student presents with ‘a lot of sneezing’ and a runny nose. He’s anxious as he cannot concentrate on his upcoming summer exams, and mentions this happened to him the last 2 years. * Medication side effect * Acute urticaria * Asthma * C1 inhibitor deficiency * Chronic Granulomatous Disease * Chronic urticaria * Contact dermatitis * Dermatitis herpetiformis * Food intolerance * Hayfever * Hyper IgM * Type I hypersensitivity * Type II hypersensitivity * Type III hypersensitivity * Type IV hypersensitivity

Answer 43

Hayfever This is pretty basic, this is a reaction to pollen leading to the typical presentation of hayfever we see here.

Question 44

3. A 16-year-old boy has had several bouts of facial swelling and unexplained severe abdominal pain. * Medication side effect * Acute urticaria * Asthma * C1 inhibitor deficiency * Chronic Granulomatous Disease * Chronic urticaria * Contact dermatitis * Dermatitis herpetiformis * Food intolerance * Hayfever * Hyper IgM * Type I hypersensitivity * Type II hypersensitivity * Type III hypersensitivity * Type IV hypersensitivity

Answer 44

a. C1 inhibitor deficiency This deficiency is involved in hereditary angioedema, which results in unchecked activation of the complement system in response to minimul trauma. It causes the facial swelling and reccuring abdominal pain we see here.

Question 45

4. A 10-year-old girl experiences significant weight loss, abdominal pain and diarrhoea. Her parents are particularly worried about a blistering rash on her elbows and knees that she only experienced after they moved from Ireland. * Medication side effect * Acute urticaria * Asthma * C1 inhibitor deficiency * Chronic Granulomatous Disease * Chronic urticaria * Contact dermatitis * Dermatitis herpetiformis * Food intolerance * Hayfever * Hyper IgM * Type I hypersensitivity * Type II hypersensitivity * Type III hypersensitivity * Type IV hypersensitivity

Answer 45

a. Dermatitis herpetiformis Irish girl with weight loss, diarrhoea and abdominal pain basically screams coeliac disease. The blistering rash on the elbows and knees is a complication of coeliac and is termed Dermatitis herpetiformis. The causal mechanism is unknown.

Question 46

5. A 48-year-old man develops and itchy rash on his hands that makes his skin dry and cracked. It’s particularly worse if he’s been gardening. * Medication side effect * Acute urticaria * Asthma * C1 inhibitor deficiency * Chronic Granulomatous Disease * Chronic urticaria * Contact dermatitis * Dermatitis herpetiformis * Food intolerance * Hayfever * Hyper IgM * Type I hypersensitivity * Type II hypersensitivity * Type III hypersensitivity * Type IV hypersensitivity

Answer 46

a. Contact dermatitis The rash apears on the hands after gardening makes it likely that he is being exposed to a chemical or perhaps he is wearing gloves containing latex. Contact dermatitis seems likely here. It is a delayed T-cell mediated reaction.

Question 47

1. A 30-year-old overweight Asian gentleman presents to his GP several hours after noticing that his skin is becoming increasingly itchy and the appearance of hives after admitting to have consumed a ‘cheeky packet of peanuts’ at work. What is the most likely causative factor in mediating his symptoms? * Adrenalineb-Defensin * Complement C3 * Contrast medium * Corticosteroids * Diluent * Filaggrin * Histamine * IgA * IgE * IgG * Mast cell (serum) tryptase * Noradrenaline * Peanuts * Penicillin

Answer 47

a. IgE As tempting as it is to simply answer 'peanuts' here, this is a case of an urticarial reaction to peanuts. This is a type I hypersensitivity reaction and so is mediated by IgE.

Question 48

2. You are a medical student attending an atopy clinic and are observing a doctor administer a skin prick test. The doctor asks you to explain what she is injecting into the patient’s skin as a ‘positive control’. What component makes up the positive control? * Adrenalineb-Defensin * Complement C3 * Contrast medium * Corticosteroids * Diluent * Filaggrin * Histamine * IgA * IgE * IgG * Mast cell (serum) tryptase * Noradrenaline * Peanuts * Penicillin

Answer 48

a. Histamine Your positive control needs to produce a reaction in the skin, as such the only compound you know will produce an urticarial reaction is histamine.

Question 49

3. You are an anaesthetic doctor in surgery and notice that your patient has suddenly developed unexpected widespread rashes and is becoming increasingly hypotensive. You suspect the patient may be having an anaphylactic reaction. What is the best test to determine if the patient is undergoing a systemic allergic reaction in this situation? * Adrenalineb-Defensin * Complement C3 * Contrast medium * Corticosteroids * Diluent * Filaggrin * Histamine * IgA * IgE * IgG * Mast cell (serum) tryptase * Noradrenaline * Peanuts * Penicillin

Answer 49

a. Mast cell (serum) tryptase Tryptase is the most abundant chemical in mast cells, it can be used as a marker for assaying the level of mast cell activation .

Question 50

4. A miserable-looking child of European descent presents to your clinic with a long, troublesome history of atopic dermatitis. Which component is a potential genetic cause of the child’s atopy that should be considered? * Adrenalineb-Defensin * Complement C3 * Contrast medium * Corticosteroids * Diluent * Filaggrin * Histamine * IgA * IgE * IgG * Mast cell (serum) tryptase * Noradrenaline * Peanuts * Penicillin

Answer 50

a. Filaggrin Filaggrin is a component of the lipid membrane that is part of the stratum corneum. Mutations in the gene coding for this protein lead to a loss of integrity of the skin's barrier function. This in turn leads to the drying of the skin seen in eczema.

Question 51

5. A patient with nephrolithiasis is seen by your on-take team at the beginning of a long night shift. You see the patient and refer the patient for appropriate investigations and decide to take a short coffee break. Returning from your break a few hours later, to your dismay, you learn that the patient has developed severe abdominal pain and diarrhoea. The patient also appears to be a little confused. The registrar suggests to you that this may be a non-IgE mediated reaction. What could have happened, and what is the likely cause of the patient’s symptoms? * Adrenalineb-Defensin * Complement C3 * Contrast medium * Corticosteroids * Diluent * Filaggrin * Histamine * IgA * IgE * IgG * Mast cell (serum) tryptase * Noradrenaline * Peanuts * Penicillin

Answer 51

a. Contrast medium I love the line about the several hour long coffee break. This patient has kidney stones so has been sent for contrast imaging to see the number and site of the stones. Knowing this it seems obvious that he is having an adverse reaction to the contrast.

Question 52

1. First line treatment for mild to moderate C. Difficile * Amoxicillin * Ceftriaxone * Chloramphenicol * Ethambutol * Erythromycin * Flucloxacillin * Gentamicin * Isoniazid * Metranidazole * Pyrazinamide * Rifampicin * Vancomycin

Answer 52

a. Metronidazole Just need to memorise this

Question 53

2. Treatment of infections resistant to penicillin e.g. MRSA * Amoxicillin * Ceftriaxone * Chloramphenicol * Ethambutol * Erythromycin * Flucloxacillin * Gentamicin * Isoniazid * Metranidazole * Pyrazinamide * Rifampicin * Vancomycin

Answer 53

a. Vancomycin Vancomycin is the standard treatment for resistant gram-positives

Question 54

3. May cause deafness an unwanted side effect * Amoxicillin * Ceftriaxone * Chloramphenicol * Ethambutol * Erythromycin * Flucloxacillin * Gentamicin * Isoniazid * Metranidazole * Pyrazinamide * Rifampicin * Vancomycin

Answer 54

a. Gentamicin Causes ototoxicity and nephrotoxicity (all of the aminoglycosides do), the sensory-neuro deafness is permanent. Confusingly Erythromycin causes a temporary deafness also.

Question 55

4. 20 year old male, with true resistance to penicillin, presents with a severe headache, neck stiffness, fever and photophobia * Amoxicillin * Ceftriaxone * Chloramphenicol * Ethambutol * Erythromycin * Flucloxacillin * Gentamicin * Isoniazid * Metranidazole * Pyrazinamide * Rifampicin * Vancomycin

Answer 55

a. Chloramphenicol you just have to learn this as the second line treatment for meningitis. Can't give it to baby's though, they go grey and get very sick (grey baby syndrome).

Question 56

5. Treatment of TB but may cause optic neuritis. * Amoxicillin * Ceftriaxone * Chloramphenicol * Ethambutol * Erythromycin * Flucloxacillin * Gentamicin * Isoniazid * Metranidazole * Pyrazinamide * Rifampicin * Vancomycin

Answer 56

Ethambutol The first line treatment for TB uses four drugs, I remember them by the mnemonic RIPE: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol Of these four Ethanbutol is asociated with optic neuritis. Rifampicin - Hepatotoxicity Isoniazid - Hepatotoxicity and peripheral neuropathy Pyrazinamide - Hepatotoxicity and hyperuricaemia

Question 57

1. Which group of antibiotics is not recommended for use in children or pregnant women? * Glycopeptides * Cephalexin * Cefotaxime * Tetracyclines * Macrolides * Cefuroxime * Beta-lactams * Aminoglycosides * 3 days * 7 days * Tazocin * Doxyclycline * Amoxicillin * Flucloxacillin * Ceftriaxone * Trimethoprim

Answer 57

a. Tetracyclines They cause bone and teeth problems in the developing fetus. I always remember by tetra sounds a *little* like terato as in teratogenic...

Question 58

2. Give an example of a second-generation cephalosporin. * Glycopeptides * Cephalexin * Cefotaxime * Tetracyclines * Macrolides * Cefuroxime * Beta-lactams * Aminoglycosides * 3 days * 7 days * Tazocin * Doxyclycline * Amoxicillin * Flucloxacillin * Ceftriaxone * Trimethoprim

Answer 58

Cefuroxime Cephalosporins are a class of beta lactam antibiotic. the second generation includes Cefuroxime

Question 59

3. Which group of antibiotics is bacteriostatic and acts on 50S ribosomes to interfere with mRNA translation? * Glycopeptides * Cephalexin * Cefotaxime * Tetracyclines * Macrolides * Cefuroxime * Beta-lactams * Aminoglycosides * 3 days * 7 days * Tazocin * Doxyclycline * Amoxicillin * Flucloxacillin * Ceftriaxone * Trimethoprim *

Answer 59

Macrolides one to remember

Question 60

4. A 23-year-old intubated male in ITU developes a chest infection 14 days after admission, which antibiotic would you prescribe? * Glycopeptides * Cephalexin * Cefotaxime * Tetracyclines * Macrolides * Cefuroxime * Beta-lactams * Aminoglycosides * 3 days * 7 days * Tazocin * Doxyclycline * Amoxicillin * Flucloxacillin * Ceftriaxone * Trimethoprim *

Answer 60

Tazocin this is a combination of Piperacillin (a penicillin) and Tazobactam (a beta lactamase inhibitor). It is given IV and is used for ITU cases as it is broad spectrum and has good activity against Psudomonas, which is a real sucker for colonising lines.

Question 61

A 28-year-old woman is diagnosed with community-acquired cystitis, what is the recommended duration of antibiotic treatment for this diagnosis? * Glycopeptides * Cephalexin * Cefotaxime * Tetracyclines * Macrolides * Cefuroxime * Beta-lactams * Aminoglycosides * 3 days * 7 days * Tazocin * Doxyclycline * Amoxicillin * Flucloxacillin * Ceftriaxone * Trimethoprim *

Answer 61

a. 3 days nice and quick

Question 62

1. A 3-week old baby presents with a fever, irritability and painful, vesicular lesions on the tongue, buccal mucosa, lips and face. * IV Acyclovir * Oseltamivir * Interferon-beta * Symptomatic treatment and reassurance * IV Gancyclovir * Oral Acyclovir * Ribavarin * Palivizumab * Antiretroviral Therapy * Interferon-alpha and Ribavarin

Answer 62

a. Oral Acyclovir This child is afflicted by the herpes simplex virus, he isn;t massively unwell so IV isn't needed. Oral acyclovir is the drug of choice here.

Question 63

2. On examination of a newborn child you notice that although they are small their head is unusually out of proportion and seems much smaller than the rest of their body, additionally their skin appears slightly yellow, with a petechial rash. * IV Acyclovir * Oseltamivir * Interferon-beta * Symptomatic treatment and reassurance * IV Gancyclovir * Oral Acyclovir * Ribavarin * Palivizumab * Antiretroviral Therapy * Interferon-alpha and Ribavarin

Answer 63

a. IV Gancyclovir This infant is showing signs of congenital cytomegalovirus, this can cause a variety of complications including; low birth weight, microcephaly, seizures, petechial rash moderate hepatosplenomegaly (with jaundice). There can also be complications within the first few years of life that may include hearing loss, vision impairment, and varying degrees of mental retardation. The treatment here is Gancyclovir

Question 64

3. A 2-year old child presents with persistent lymphadenopathy, recurrent fevers and parotid swelling. His adopted parents are unaware of any FH or PMH. * IV Acyclovir * Oseltamivir * Interferon-beta * Symptomatic treatment and reassurance * IV Gancyclovir * Oral Acyclovir * Ribavarin * Palivizumab * Antiretroviral Therapy * Interferon-alpha and Ribavarin

Answer 64

a. Antiretroviral Therapy This child is unfortunately displaying signs of HIV seroconversion, this normally occurs in the first weeks or months after exposure to the HIV virus before going into a latent stage, so I'm not entirely sue why this is happening in a 2 year old. Regardless, he needs antiretrovirals. The evidence now is that if the antiretrovirals are started early there is no reduction in life expectancy due to HIV.

Question 65

4. A primary school teacher brings in her 4-year old child with a fever and an itchy, vesicular rash on his trunk and face. IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin

Answer 65

a. Symptomatic treatment and reassurance This seems to be Chicken pox, there is no need to treat. The risk here is that if the infected child has been around pregnant women (who have never had the virus) thier unborn children are at risk from congenital VZV infection. But there is nothing here to take us down that line of thought.

Question 66

5. An 8-month old child suddenly develops a high fever, headache and a chesty cough. Her mum is concerned as she seems to have lost her appetite over the past 24 hours and is not improving IV Acyclovir Oseltamivir Interferon-beta Symptomatic treatment and reassurance IV Gancyclovir Oral Acyclovir Ribavarin Palivizumab Antiretroviral Therapy Interferon-alpha and Ribavarin

Answer 66

Oseltamivir This is a case of influenza, Oseltamivir (brand name Tamiflu) is a neurominidase inhibitor and so prevents reproduction of the influenza virus. It is given to this patient because of thier young age they are a high risk group for influenza and there is a need to treat.

Question 67

A 70 year man old presented with acute onset of vertigo. On neurological examination he has left-sided loss of pain and temperature sensation with partial right-sided ptosis and miosis as well as right sided diplopia. He has a mild left-sided weakness and an ataxic gait. He reports numbness on the right side of his face. * Acute Extradural Haemorrhage * Acute Subdural Haemorrhage * Chronic Extradural Haemorrhage * Chronic Subdural Haemorrhage * Lacunar Infarction * Left Anterior Cerebral Occlusion * Left Middle Cerebral Occlusion * Left Posterior Cerebral Occlusion * Left Posterior Inferior Cerebellar Artery (PICA) Occlusion * Right Anterior Cerebral Occlusion * Right Middle Cerebral Occlusion * Right Posterior Cerebral Occlusion * Right Posterior Inferior Cerebellar Artery (PICA) Occlusion * Watershed Infarction * Weber’s syndrome * Vascular/Multi-infarct Dementia

Answer 67

Right Posterior Inferior Cerebellar Artery (PICA) Occlusion PICA occlusion is also known as lateral medullary syndrome. This is an infarction of the medulla, part of the brainstem, it causes the typical features we see here; Contralateral sensory deficits of the trunk and extremities combined with ipsilateral sensory deficits affecting the face and cranial nerves. Diagnostically with this syndrome we see loss of nociception and temprature sensation on the contralateral side of the body but ipsilateral side of the face. There is also ataxia if the cerebellum is affected, and a Horner's syndrome if the hypothalamospinal fibers are damaged, as this disrupts sympathetic relay.

Question 68

A 70 year old man with a history of congestive heart failure presents with bilateral visual loss. On examination there is weakness in the proximal limbs that spared both the hands and feet. * Acute Extradural Haemorrhage * Acute Subdural Haemorrhage * Chronic Extradural Haemorrhage * Chronic Subdural Haemorrhage * Lacunar Infarction * Left Anterior Cerebral Occlusion * Left Middle Cerebral Occlusion * Left Posterior Cerebral Occlusion * Left Posterior Inferior Cerebellar Artery (PICA) Occlusion * Right Anterior Cerebral Occlusion * Right Middle Cerebral Occlusion * Right Posterior Cerebral Occlusion * Right Posterior Inferior Cerebellar Artery (PICA) Occlusion * Watershed Infarction * Weber’s syndrome * Vascular/Multi-infarct Dementia

Answer 68

Watershed infarction Watershed infarcts are cortical infarcts caused by prolonged periods of low perfusion, common in patients with a history of cardiovascular disease. This pattern of loss affecting the visual cortex and only the proximal limbs is not consistent with a stroke, the history of cardiovascular risks gives you the clue here.

Question 69

A 70 year lady old collapsed at home and is taken to hospital. She regains consciousness but has a right sided hemiplegia, hemianesthesia and hemianopia with eye deviation towards the left. She also has an expressive aphasia. * Acute Extradural Haemorrhage * Acute Subdural Haemorrhage * Chronic Extradural Haemorrhage * Chronic Subdural Haemorrhage * Lacunar Infarction * Left Anterior Cerebral Occlusion * Left Middle Cerebral Occlusion * Left Posterior Cerebral Occlusion * Left Posterior Inferior Cerebellar Artery (PICA) Occlusion * Right Anterior Cerebral Occlusion * Right Middle Cerebral Occlusion * Right Posterior Cerebral Occlusion * Right Posterior Inferior Cerebellar Artery (PICA) Occlusion * Watershed Infarction * Weber’s syndrome * Vascular/Multi-infarct Dementia

Answer 69

Left Middle Cerebral Occlusion Here we have a right sided loss so the infarct must be in the left hemisphere. The aphasia is due to damage to Broca's (non-fluent aphasia) or Wernicke's (fluent aphasia) area, this confirms this as being a middle cerebral occlusion. of the different territories to be affected, the middle cerebral artery is the most common area. This is a very helpful website for stroke syndromes; http://www.neuroanatomy.ca/stroke\_model/mca\_info.html

Question 70

A 70 year old man is presents with headache, being unable to read the left pages of his book and walking into a lamppost. Neurological examination revealed left sided sensory loss in the head and limbs. * Acute Extradural Haemorrhage * Acute Subdural Haemorrhage * Chronic Extradural Haemorrhage * Chronic Subdural Haemorrhage * Lacunar Infarction * Left Anterior Cerebral Occlusion * Left Middle Cerebral Occlusion * Left Posterior Cerebral Occlusion * Left Posterior Inferior Cerebellar Artery (PICA) Occlusion * Right Anterior Cerebral Occlusion * Right Middle Cerebral Occlusion * Right Posterior Cerebral Occlusion * Right Posterior Inferior Cerebellar Artery (PICA) Occlusion * Watershed Infarction * Weber’s syndrome * Vascular/Multi-infarct Dementia

Answer 70

Right Posterior Cerebral Occlusion The damage to the occipital lobe in this case is causing the left homonymous hemianopsia. This infarct has involved the deeper branch of the posterior artery also, this has damaged the internal capsule and thalamus leading to disruptin of sensory fibres running in this tract, leading to the sensory loss seen here. good website for explaining stroke syndromes; http://www.neuroanatomy.ca/stroke\_model/pca\_info.html

Question 71

A 70 year old lady presented with a headache, mild weakness and drowsiness. She says she can’t remember when it started. On CT the lesion is hypo-dense to the brain parenchyma. * Acute Extradural Haemorrhage * Acute Subdural Haemorrhage * Chronic Extradural Haemorrhage * Chronic Subdural Haemorrhage * Lacunar Infarction * Left Anterior Cerebral Occlusion * Left Middle Cerebral Occlusion * Left Posterior Cerebral Occlusion * Left Posterior Inferior Cerebellar Artery (PICA) Occlusion * Right Anterior Cerebral Occlusion * Right Middle Cerebral Occlusion * Right Posterior Cerebral Occlusion * Right Posterior Inferior Cerebellar Artery (PICA) Occlusion * Watershed Infarction * Weber’s syndrome * Vascular/Multi-infarct Dementia

Answer 71

Chronic subdural haemorrhage Chronic sub-durals are iso-dense or hypo-dense on CT, compared to acute sub-durals which are hyper-dense. the reasoning behind this is that a fresh bleed is, obviously, fresh blood. This contains iron within the haemoglobin and so attenuates the radiation being hyper-dense. As time passes the haemoglobin is broken down and the osmotic draw of the haematoma makes the space closer in density to the brain parenchyma, and eventually similar to water.

Question 72

Number of B cells /μL required to diagnose CLL * 70 * 30 * 50 * 500 * 5000 * 80 * 100 * 1000 * 20 * 40

Answer 72

5000 This question seems a bit pointless

Question 73

% of CLL patients older than 65 years at time of diagnosis * 70 * 30 * 50 * 500 * 5000 * 80 * 100 * 1000 * 20 * 40

Answer 73

70 CLL is a disease that primarily affects the elderly

Question 74

% of cases that present with no anaemia or thrombocytopenia, with three or more areas of lymphoid involvement (Rai Stages I and II, Binet Clinical Stage B) * 70 * 30 * 50 * 500 * 5000 * 80 * 100 * 1000 * 20 * 40

Answer 74

50

Question 75

% of CLL patients in which one or more cytogenetic abnormalities have been found * 70 * 30 * 50 * 500 * 5000 * 80 * 100 * 1000 * 20 * 40

Answer 75

80

Question 76

% of CLL cases which have the most common abnormality: del 13q.14 * 70 * 30 * 50 * 500 * 5000 * 80 * 100 * 1000 * 20 * 40

Answer 76

50

Question 77

A 50 year old man presents with weight loss, fatigue and night sweats. He is diagnosed with chronic myeloid leukaemia and treatment is commenced. Several months later it becomes clear that he is resistant to the main class pharmaceutical agents that were used.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * Allogenic blood transfusion * Allogenic stem cell transplantation * Autologous blood transfusion * Autologous stem cell transplantation * Azathioprine * Daunorubicin infusion * Donor granulocyte infusion * Donor lymphocyte infusion * Dosatinib * Fresh frozen plasma * Golimumab * Hydroxychloroquine * IFN-α infusion * imatinib * Methotrexate * None of the above

Answer 77

Allogenic stem cell transplantation CML treatment if with biologics (such as imatinib) as a first line, here we see our patient as become resistant to those. In that case we need to look at giving this patient the potentially curative option of an allogenic stem cell transplant, the patient is young and there is no reason to think he is anything other than healthy aprart from the CML.

Question 78

A 57 year old woman is known to have chronic myeloid leukaemia. She presents acutely unwell, with 25% myeloblasts on her blood film, and is appropriately treated. 24 months later she relapses.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * Allogenic blood transfusion * Allogenic stem cell transplantation * Autologous blood transfusion * Autologous stem cell transplantation * Azathioprine * Daunorubicin infusion * Donor granulocyte infusion * Donor lymphocyte infusion * Dosatinib * Fresh frozen plasma * Golimumab * Hydroxychloroquine * IFN-α infusion * Imatinib * Methotrexate * None of the above

Answer 78

Donor lymphocyte infusion

Question 79

A 60 year old woman presents with weight loss and lethargy. On examination, she is cachectic with splenomegaly. Her white cell count is 150 x 109/l. Her blood film showed 25% myeloblasts. Cytogenetic analysis showed presence of the Philadelphia chromosome.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * Allogenic blood transfusion * Allogenic stem cell transplantation * Autologous blood transfusion * Autologous stem cell transplantation * Azathioprine * Daunorubicin infusion * Donor granulocyte infusion * Donor lymphocyte infusion * Dosatinib * Fresh frozen plasma * Golimumab * Hydroxychloroquine * IFN-α infusion * Imatinib * Methotrexate * None of the above

Answer 79

Allogenic stem cell transplantation

Question 80

A 55 year old man presents with weight loss and lethargy. On examination, he is cachectic with splenomegaly. His white cell count was 135 x 109/l. Cytogenetic analysis showed presence of the Philadelphia chromosome.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * Allogenic blood transfusion * Allogenic stem cell transplantation * Autologous blood transfusion * Autologous stem cell transplantation * Azathioprine * Daunorubicin infusion * Donor granulocyte infusion * Donor lymphocyte infusion * Dosatinib * Fresh frozen plasma * Golimumab * Hydroxychloroquine * IFN-α infusion * Imatinib * Methotrexate * None of the above

Answer 80

Imatinib Imatinib is the first line treatment for CML, which this is as there is a Philadelphia chromosome.

Question 81

A 57 year old man with a history of chronic myeloid leukaemia presents with night sweats, fatigue and weight loss. He was started on first line therapy 6 months ago but his doctor is concerned that he has relapsed. He wants to try a new treatment option.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * Allogenic blood transfusion * Allogenic stem cell transplantation * Autologous blood transfusion * Autologous stem cell transplantation * Azathioprine * Daunorubicin infusion * Donor granulocyte infusion * Donor lymphocyte infusion * Dosatinib * Fresh frozen plasma * Golimumab * Hydroxychloroquine * IFN-α infusion * Imatinib * Methotrexate * None of the above

Answer 81

Dosatinib Dosatinib is the second line biologic treatment for CML after Imatinib

Question 82

A 50 year old man presented with fatigue, lethargy and weight loss. On examination, he was pale and had gross splenomegaly. His blood film showed an increase in white blood cells (both myelocytes and mature granulocytes). Cytogenetic analysis showed a t(9;22) chromosomal translocation.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * IFN-α * Hydroxycarbamide * Allogeneic stem cell transplantation * Imatinib * Chlorambucil * Cyclosphosphamide * Monitor clinically and give annual influenza vaccine * Radiotherapy and 6-8 cycles of chemotherapy * Dosatinib * Chemotherapy + all-trans-retinoic acid * Chemotherapy (R-CHOP regimen) * Chemotherapy (ABVD regimen) * Chemotherapy (R-CVP regimen) * Donor lymphocyte infusion

Answer 82

Imatinib The translocation here, t(9,22) is the philadelphia chromosome, a translocation closely linked to CML. The first line treatment for CML is imatinib, which gives a normal life expectency in treatment receptive cases, even without the use of chemo or radiotherapy.

Question 83

A 74 year old patient has been diagnosed with chronic myeloid leukaemia and 6 months after starting therapy with the first line drug has shown no improvement in FBC or cytogenetics. His physician switches him to another drug. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * IFN-α * Hydroxycarbamide * Allogeneic stem cell transplantation * Imatinib * Chlorambucil * Cyclosphosphamide * Monitor clinically and give annual influenza vaccine * Radiotherapy and 6-8 cycles of chemotherapy * Dosatinib * Chemotherapy + all-trans-retinoic acid * Chemotherapy (R-CHOP regimen) * Chemotherapy (ABVD regimen) * Chemotherapy (R-CVP regimen) * Donor lymphocyte infusion

Answer 83

Dosatinib Dosatinib is the second line treatment for CML after Imatinib.

Question 84

A 48 year old patient with chronic myeloid leukaemia becomes acutely unwell. A peripheral blood film shows 30% myeloblasts. For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * IFN-α * Hydroxycarbamide * Allogeneic stem cell transplantation * Imatinib * Chlorambucil * Cyclosphosphamide * Monitor clinically and give annual influenza vaccine * Radiotherapy and 6-8 cycles of chemotherapy * Dosatinib * Chemotherapy + all-trans-retinoic acid * Chemotherapy (R-CHOP regimen) * Chemotherapy (ABVD regimen) * Chemotherapy (R-CVP regimen) * Donor lymphocyte infusion

Answer 84

Allogeneic stem cell transplantation Here we have a CML patient who has become very symptomatic, treatment at this stage should be with a SCT as opossed to a biologic.

Question 85

A 59 year old patient with chronic myeloid leukaemia has been found to be positive for the Philadelphia chromosome several years following his stem cell transplantation.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * IFN-α * Hydroxycarbamide * Allogeneic stem cell transplantation * Imatinib * Chlorambucil * Cyclosphosphamide * Monitor clinically and give annual influenza vaccine * Radiotherapy and 6-8 cycles of chemotherapy * Dosatinib * Chemotherapy + all-trans-retinoic acid * Chemotherapy (R-CHOP regimen) * Chemotherapy (ABVD regimen) * Chemotherapy (R-CVP regimen) * Donor lymphocyte infusion

Answer 85

Donor lymphocyte infusion

Question 86

A 61 year old patient with chronic myeloid leukaemia has not responded to different tyrosine kinase inhibitors available.For each scenario, choose the most appropriate treatment option from the list. Each option may be used once, more than once or not at all. * IFN-α * Hydroxycarbamide * Allogeneic stem cell transplantation * Imatinib * Chlorambucil * Cyclosphosphamide * Monitor clinically and give annual influenza vaccine * Radiotherapy and 6-8 cycles of chemotherapy * Dosatinib * Chemotherapy + all-trans-retinoic acid * Chemotherapy (R-CHOP regimen) * Chemotherapy (ABVD regimen) * Chemotherapy (R-CVP regimen) * Donor lymphocyte infusion

Answer 86

Allogeneic stem cell transplantation Imatinib and dosatinib are the tyrosine kinase inhibitors in question here. The next step is to go for an allogenic SCT.

Question 87

1. A 17 year old was diagnosed with Infectious Mononucleosis (EBV). Confirmatory blood tests also revealed anaemia. Direct Coombs test was positive (but not “strongly positive”). On more detailed analysis, IgM antibodies were eluted from red cells with C3d remaining. * A Burns * B Cold Autoimmune HAC Direct membrane damage (drugs) * D G6PD deficiency * E Haemolytic transfusion reaction * F Hereditary spherocytosis * G HypersplenismH Immune (drug induced) * I Malaria * J March haemoglobinuria * K Mechanical haemolysis * L Microangiopathic HA * M Paroxysmal nocturnal haemoglobinuria * N Sickle Cell disease * O Thalassaemia * P Warm Autoimmune HA

Answer 87

B Cold Autoimmune HA The direct coombs test tells us that this is an autoimmune haemolytic anaemia, The prescence of IgM confirms this as the Cold subtype. Conversely the warm typre is mediated by IgG, or rarely IgA.

Question 88

2. A 4 year old African boy attends your clinic with recurrent pain in the hands. While in the cold waiting room he suddenly grasps his chest in pain and starts breathing rapidly. Investigations reveal hypoxia and new chest X-ray changes that look like consolidation. A Burns B Cold Autoimmune HAC Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G HypersplenismH Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA

Answer 88

N Sickle Cell disease this is a case of classic EMQ patterns, the african boy with painful hands is hinting at sickle cell diseae, the disease can be excacerbated by the cold, as we see here. The presentation of dactylitis and a chest crisis is typical of an attack.

Question 89

3. An 18 year old attending a routine check up at her new GP practice is noted to have mild splenomegaly and a leg ulcer. Upon questioning she mentions that she had jaundice as a child, and that one of her parents (and grandparents) suffer from anaemia. Blood results reveal slight anaemia with hyperchromic cells lacking central pallor. Coombs test is negative. A Burns B Cold Autoimmune HAC Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G HypersplenismH Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA

Answer 89

F Hereditary spherocytosis Hereditory spherocytosis causes the symptoms we see here, jaundice as an infant, spenomegaly (due to increased RBC turn over), ulcers (due to occlusions) and anaemia. The family history also helps to establish that this is hereditary. The blood results are also showing us speherocytes, these are spherical red blood cells and not a biconcave disc. This explains why they lack the central pallor (they are thickest in the middle, completely opposite to normal RBCs). they are generally hyperchromic because they are thicker so less light penetrates under microscopy.

Question 90

4. A 58 year old man from South East Asia attends for a clinic feeling anaemic on return from holiday in Africa. On direct questioning he admits that he did start taking the Primaquine and Quinine you prescribed until a couple of days ago. Blood film revealed Heinz bodies and bite cells. A Burns B Cold Autoimmune HAC Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G HypersplenismH Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA

Answer 90

D G6PD deficiency G6PD deficiency is an x-linked recessive condition that causes haemolysis when the affected person is exposed to certain drugs (such as antimalarials), foods (fava beans) or diseases (hepatitis viruses). It is particularly common in mediterranean and african populations. Heinz bodies are inclusions of denatured haemoglobin within red blood cells, the haemoglobin is denatured due to oxidative stress. Bite cells are red blood cells with a missing section of cell mambrane, this is removed in the spleen due to oxidative damage of the membrane. Both of these blood film findings are charachteristic of G6PD deficiency.

Question 91

5. A 31 year old student nurse returns from her elective in Indonesia feeling generally unwell, with rigors and fever. Clinical examination reveals slight splenomegaly and haematuria. A Burns B Cold Autoimmune HAC Direct membrane damage (drugs) D G6PD deficiency E Haemolytic transfusion reaction F Hereditary spherocytosis G HypersplenismH Immune (drug induced) I Malaria J March haemoglobinuria K Mechanical haemolysis L Microangiopathic HA M Paroxysmal nocturnal haemoglobinuria N Sickle Cell disease O Thalassaemia P Warm Autoimmune HA

Answer 91

I Malaria Rigors are caused by malaria (or a profound bacterimia), as a general rule. Generally this history is very sugesstive of malaria.

Question 92

1. A 22 year old woman presents with dark urine and tachycardia. She believes the dark urine is related to some "problems with the water works" she is currently being treated for. Direct antiglobulin test is positive. * A Cold Type AIHA * B Drug induced/Iatrogenic * C Glucose-6-phosphate deficiency * D Hereditary elliptocytosis * E Hereditary spherocytosis * F Isoimmune paroxysmal cold haemoglobin urea * G Malaria * H Microangiopathic haemolytic anaemia (MAHA) * I Paroxysmal nocturnal haemoglobinurea * J Pyruvate kinase deficiency * K Sickle cell disease * L Thalassaemia * M Warm Type AIHA,

Answer 92

B Drug induced/Iatrogenic There's not a lot to go on here, the woman is showing signs of haemolysis, it is autoimmune and she is on medication. So drug induced fits.

Question 93

2. A 72 year old woman presents with haemolytic anaemia. FBC shows Hb 10.7 g/dL, WBC 108x10^3/uL, Platelets 90x10^3/uL. On examination the patient also has splenomegaly. * A Cold Type AIHA * B Drug induced/Iatrogenic * C Glucose-6-phosphate deficiency * D Hereditary elliptocytosis * E Hereditary spherocytosis * F Isoimmune paroxysmal cold haemoglobin urea * G Malaria * H Microangiopathic haemolytic anaemia (MAHA) * I Paroxysmal nocturnal haemoglobinurea * J Pyruvate kinase deficiency * K Sickle cell disease * L Thalassaemia * M Warm Type AIHA

Answer 93

M Warm Type AIHA

Question 94

3. A 32 year old woman is brought in by her concerned husband. She has a 5 month history or amenorrhea and is grossly distended. Her BP is 154/98. A urine sample is taken and results confirm your suspicion. A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA

Answer 94

H Microangiopathic haemolytic anaemia (MAHA) We have a picture of a woman with a pelvic/abdominal mass, given the amenorrhea this is likely a pregnancy... Factor in the hypertension and haemolysis and it looks like HELLP syndrome, which includes a microangiopathic haemolytic anaemia.

Question 95

4. A young boy presents with splenomegaly and jaundice. His blood film shows Howell-Jolly bodies and poikilocytosis. An osmotic fragility test confirms the diagnosis. A Cold Type AIHA B Drug induced/Iatrogenic C Glucose-6-phosphate deficiency D Hereditary elliptocytosis E Hereditary spherocytosis F Isoimmune paroxysmal cold haemoglobin urea G Malaria H Microangiopathic haemolytic anaemia (MAHA) I Paroxysmal nocturnal haemoglobinurea J Pyruvate kinase deficiency K Sickle cell disease L Thalassaemia M Warm Type AIHA

Answer 95

E Hereditary spherocytosis Howell-jolly bodies - inclusions of nuclear remnants in red blood cells Poikilocytosis - any abnormal red cell morphology Both of these are suggestive of sphereocytosis, the osmotic fragility test is diagnostic for hereditary sphereocytosis.

Question 96

5. A teenage boy originally from Lebanon presents with acute haemolytic anaemia after switching to a vegan diet. Blood film shows bite cells and blister cells. * A Cold Type AIHA * B Drug induced/Iatrogenic * C Glucose-6-phosphate deficiency * D Hereditary elliptocytosis * E Hereditary spherocytosis * F Isoimmune paroxysmal cold haemoglobin urea * G Malaria * H Microangiopathic haemolytic anaemia (MAHA) * I Paroxysmal nocturnal haemoglobinurea * J Pyruvate kinase deficiency * K Sickle cell disease * L Thalassaemia * M Warm Type AIHA *

Answer 96

C Glucose-6-phosphate deficiency He's from the right geographical area, and hes just started on a vegatarian diet, presumably heavy on the fava beans.

Question 97

Innate immune deficiency Recurrent infections with high neutrophil count on FBC but no abscess formation * Lymphocyte adhesion deficiency * Chronic granulomatous disease * Kostmann syndrome * IFN gamma receptor deficiency

Answer 97

Lymphocyte adhesion deficiency this is a primary immunodeficiency where the lymphocytes do not correctly adhere to the endothelial wall and then migrate to the site of infection. This leads to the frequent infections seen, but the lack of lymphocyte migration means that there is no formation of pus, hence the lack of abscess formation.

Question 98

Innate immune deficiency Recurrent infections with hepatosplenomegaly and abnormal dihydrorhodamine test * Lymphocyte adhesion deficiency * Chronic granulomatous disease * Kostmann syndrome * IFN gamma receptor deficiency

Answer 98

Chronic granulomatous disease in this (usually) X-linked condition there is a congenital defect with phagocytes, this means that they lack a type of NADPH used to create reactive oxygen species, this reduces the ability to engage in oxidative killing. The dihydrorhodamine test is used to asses the level of reactive oxygen coumpounds, it is abnormal because there is a deficiency.

Question 99

Innate immune deficiency Recurrent infections with no neutrophils on FBC * Lymphocyte adhesion deficiency * Chronic granulomatous disease * Kostmann syndrome * IFN gamma receptor deficiency

Answer 99

Kostmann syndrome This syndrome is a severe congenital neutropenia, it responds well to treatment with granulocyte colony-stimulating factor.

Question 100

Innate immune deficiency Infection with atypical mycobacterium. Normal FBC * Lymphocyte adhesion deficiency * Chronic granulomatous disease * Kostmann syndrome * IFN gamma receptor deficiency

Answer 100

IFN gamma receptor deficiency interferon gamma is an important cytokine in the activation of macrophages and plays a key role in dealing with viruses and mycobacteria. The loss of the receptor makes these patients more prone to mycobacterial infection. It also helps to know that we can test for TB infection with the interferon gamma release assay.

Question 101

T-cell deficiency Severe recurrent infections from 3 months,CD4 and CD8 T cells absent, B cell present, IgM present, IgA and IgG absent * X-linked SCID * IFN gamma receptor deficiency * DiGeorge’s syndrome * Bare lymphocyte syndrome type II

Answer 101

• X-linked SCID Here we have a case of an immunodeficiency affecting both the T cells and the B cells, there is also the loss of two classes of antibody. This is by definition a severe combined immuno deficiency.

Question 102

T-cell deficiency Young adult with chronic infection with Mycobacterium marinum * X-linked SCID * IFN gamma receptor deficiency * DiGeorge’s syndrome * Bare lymphocyte syndrome type II

Answer 102

• IFN gamma receptor deficiency interferon gamma is responsible for activating macrophages to target viruses and bacteria (particularly mycobacteria). This infection with an atypical mycobacterium screams IFN gamma receptor deficiency.

Question 103

T-cell deficiencyRecurrent infections in childhood, abnormal facial features, congenital heart disease, normal B cells, low T cells, low IgA and IgG * X-linked SCID * IFN gamma receptor deficiency * DiGeorge’s syndrome * Bare lymphocyte syndrome type II

Answer 103

• DiGeorge’s syndrome The abnormal facial features combined with cardiac and aortic abnormalities are strongly sugestive of DiGeorges syndrome. it is charecterised by reduced T-cellnumbers due to thymic aplasia

Question 104

T-cell deficiency6 month baby with two recent serious bacterial infections. T cells present – but only CD8+ population. B cells present. IgM present but IgG absent * X-linked SCID * IFN gamma receptor deficiency * DiGeorge’s syndrome * Bare lymphocyte syndrome type II

Answer 104

• Bare lymphocyte syndrome type II In this condition there is a loss of the MHC class II. Without that there can be no antigen presentation to helper T-cells so they are absent. There is also no class switching of antibodies to produce IgG.

Question 105

B-cell deficiency Adult with bronchiectasis, recurrent sinusitis and development of atypical SLE * Common variable immunodeficiency * X linked hyper IgM syndrome due to CD40 ligand mutation * Bruton’s X linked hypogammaglobulinaemia * IgA deficiency

Answer 105

• Common variable immunodeficiency Common variable immunodeficiency is charecterised by hypogammaglobulinemia, this lack of antibodies is why they are particularly prone to bacterial infections. Bronchiectasis often develps due to reccurent respiratory infections, especially when left underttreated. This condition also has links to a host of autoimmune conditions, such as hypothroidism, SLE, psoriasis, vitiligo, rheumatoid arthritis and autoimmune haemolytic anemia.

Question 106

B-cell deficiency Recurrent bacterial infections in a child, episode of pneumocystis pneumonia, high IgM, absent IgA and IgG * Common variable immunodeficiency * X linked hyper IgM syndrome due to CD40 ligand mutation * Bruton’s X linked hypogammaglobulinaemia * IgA deficiency

Answer 106

• X linked hyper IgM syndrome due to CD40ligand mutation The clue here is that this is a hyper IgM condition, the description of the case specifically says high IgM

Question 107

B-cell deficiency 1 year old boy. Recurrent bacterial infections. CD4 and CD8 T cells present. B cells absent, IgG, IgA, IgM absent * Common variable immunodeficiency * X linked hyper IgM syndrome due to CD40 ligand mutation * Bruton’s X linked hypogammaglobulinaemia * IgA deficiency

Answer 107

• Bruton’s X linked hypogammaglobulinaemia Bruton's is a severe congenital agloblinaemia, we see it here presenting in an infant with reccurent respiratory infections.

Question 108

B-cell deficiency Recurrent respiratory tract infections, absent IgA, normal IgM and IgG * Common variable immunodeficiency * X linked hyper IgM syndrome due to CD40 ligand mutation * Bruton’s X linked hypogammaglobulinaemia * IgA deficiency

Answer 108

• IgA deficiency Kind of self-explanatory

Question 109

Complement deficiency Membranoproliferative nephritis and bacterial infections * C3 deficiency with presence of a nephritic factor * C9 deficiency * C1q deficiency * MBL deficiency

Answer 109

• C3 deficiency with presence of a nephritic factor Nephritc factor gives it away here

Question 110

Complement deficiency Meningococcus meningitis with family history of sibling dying of same condition aged 6 * C3 deficiency with presence of a nephritic factor * C9 deficiency * C1q deficiency * MBL deficiency

Answer 110

• C9 deficiency Loss of the late stage complement stages (C5-9) leaves the person very vulnerable to meningococcal infections. The loss of C1, C2, and C4 is associated with autoimmune disease.

Question 111

Complement deficiency Severe childhood onset SLE with normal levels of C3 and C4 * C3 deficiency with presence of a nephritic factor * C9 deficiency * C1q deficiency * MBL deficiency

Answer 111

• C1q deficiency The loss of C1, C2, and C4 is associated with autoimmune disease, such as SLE. Loss of the late stage complement stages (C5-9) leaves the person very vulnerable to meningococcal infections.

Question 112

Complement deficiencyRecurrent infections when receiving chemotherapy but previously well * C3 deficiency with presence of a nephritic factor * C9 deficiency * C1q deficiency * MBL deficiency

Answer 112

• MBL deficiency Deficiencies in the components of the mannose binding lectin pathway are relatively common (around 10% of the population, more in certain ethnicities). most people are asymptomatic, but with immune supression they can be subject to reccurent infections.

Question 113

Expresses Foxp3 and CD25 and secretes IL-10. Deficient in the monogenic autoimmune disease known as IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome) * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 113

• 4. T reg cell

Question 114

In the immature form these cells are adapted for recognition and uptake of pathogens. Maturation is associated with expression of CCR7, migration to lymph nodes and enhanced capacity for antigen presentation. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 114

• 5. Dendritic cell

Question 115

These cells can be rapidly mobilised from bone marrow. They express pathogen recognition receptors and Fc receptors and are able to engage in oxidative and non-oxidative killing. They do not express HLA class II molecules and so do not activate CD4 T cells. They are the predominant cell type in synovial fluid taken from patients with gout, * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 115

Neutrophil

Question 116

These cells may be formed following a germinal centre reaction involving isotype switching and affinity maturation of receptors. They are long-lived and reside in bone marrow. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 116

• 9. Plasma cell

Question 117

These cells express CD3 and secrete IL-17 and IL-22. They are thought to be important in some auto-immune conditions including rheumatoid arthritis. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 117

• 1. Th17 cell TH17 cells secrete IL17, the clue is in the number!

Question 118

These cells may be resident in peripheral tissues (eg Kupffer cells in liver, microglia in neural tissue) express pathogen recognition receptors and Fc receptors and are able to engage in oxidative and non-oxidative killing. They are an important source of cytokines such as IL-1 and TNF-alpha and are thought to play an important role in some auto-inflammatory and auto-immune diseases. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 118

• 2. Macrophage

Question 119

The normal function of these cells is to express cytokines in response to recognition of specific peptides presented by HLA class II molecules. Depletion of these cells during HIV infection is an important factor in development of AIDS. * 1. Th17 cell * 2. Macrophage * 3. Epithelial cell * 4. T reg cell * 5. Dendritic cell * 6. CD4+ T cell * 7. Neutrophil * 8. Th1 cell * 9. Plasma cell * 10. Megakaryocyte * 11. Lymphocyte

Answer 119

• 6. CD4+ T cell

Question 120

Play a role in protective immunity against HIV infection by killing virus infected cells via perforin and FAS. * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 120

• 10. CD8 T cells

Question 121

Acts as a co-receptor for HIV entry to cells * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 121

• 3. CCR5 The viral membrane protein GP120 on HIV binds to CCR5 and uses it as a co-receptor. the 32 amino acid deletion in this protein confers a degree of HIV resistance.

Question 122

Serves to generate complementary DNA from RNA, which can then be integrated into host cell genes * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 122

• 4. Reverse transcriptase Producing DNA from RNA goes against the traditional unidirectional transcription, it is made possible by the viral enzyme reverse transcriptase.

Question 123

Directs homing of dendritic cells to lymph nodes * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 123

• 8. CCR7

Question 124

Are often infected by HIV if they express CD4 * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 124

• 9. Macrophages CD4, along with CCR5 are the cell receptors that guide HIV's site of infection

Question 125

Antibodies against this target are partially protective against HIV infection * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 125

• 1. Gp120 GP120 is the cell membrane binding protein that binds to CCR5 on immune cells.

Question 126

Are effective in management of HIV infection if used in combination with other drugs * 1. Gp120 * 2. Anti-metabolites * 3. CCR5 * 4. Reverse transcriptase * 5. Basophils * 6. Gastric parietal cells * 7. Protease inhibitors * 8. CCR7 * 9. Macrophages * 10. CD8 T cells * 11.IL-8

Answer 126

• 7. Protease inhibitors Protease is an enzyme that cleaves the origional long amino acid chain into the small number of functional proteins in a mature HIV viron.

Question 127

Mutation in MEFV leads to failure to regulate neutrophil function * Rheumatoid arthritis * Familial Mediterranean Fever * IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) * Crohn’s disease * Ankylosing Spondylitis

Answer 127

Familial Mediterranean Fever The gene, MEFV, is an abbreviation of MeditErranean FeVer. Job done

Question 128

Polygenic auto-inflammatory disease in which NOD-2 (CARD 15) mutations are common * Rheumatoid arthritis * Familial Mediterranean Fever * IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) * Crohn’s disease * Ankylosing Spondylitis

Answer 128

Crohn’s disease NOD and CARD15 = Crohn's

Question 129

Mixed pattern disease with very high heritability (\>90%) and a strong association with HLA-B27 * Rheumatoid arthritis * Familial Mediterranean Fever * IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) * Crohn’s disease * Ankylosing Spondylitis

Answer 129

Ankylosing Spondylitis Just need to remember that AnkSpond is a HLA associated condition.

Question 130

Polygenic auto-immune disease associated with polymorphisms in PAD enzymes (which citrullinate proteins). Environmental factors including smoking and gum infection are associated with disease. * Rheumatoid arthritis * Familial Mediterranean Fever * IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) * Crohn’s disease * Ankylosing Spondylitis

Answer 130

Rheumatoid arthritis The immune system often attacks Citrullunated proteins, the role of PAD in autoimmune disease has been seen in rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus and Sjögren's syndrome. It has been found that citrullinated proteins occur after smoking.

Question 131

Monogenic auto-immune disease due to a mutation in Foxp3 * Rheumatoid arthritis * Familial Mediterranean Fever * IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) * Crohn’s disease * Ankylosing Spondylitis

Answer 131

IPEX (immune dysregulation polyendocrinopathy, enteropathy, X linked syndrome) Foxp3 is a key transcription factor for the regulation of regulatory T-cells. In IPEX this mutation leads to dysfunction of the regulatory T-cells and auto-immunity.

Question 132

Congenital heart block in infants of mothers with SLE * Anti-DNA antibody * Anti-RNP antibody * Anti-GAD antibody * Anti-centromere antibody * Anti-Ro antibody

Answer 132

Anti-Ro antibody Anti-Ro and Anti-La are both linked with congenital heart block. Anti double stranded DNA is diagnostic of SLE, but it is not the cuasative antibody for the congenital heart block.

Question 133

Lupus nephritis * Anti-DNA antibody * Anti-RNP antibody * Anti-GAD antibody * Anti-centromere antibody * Anti-Ro antibody

Answer 133

Anti-DNA antibody

Question 134

Mixed connective tissue disease * Anti-DNA antibody * Anti-RNP antibody * Anti-GAD antibody * Anti-centromere antibody * Anti-Ro antibody

Answer 134

Anti-RNP antibody

Question 135

Limited cutaneous systemic sclerosis * Anti-DNA antibody * Anti-RNP antibody * Anti-GAD antibody * Anti-centromere antibody * Anti-Ro antibody

Answer 135

Anti-centromere antibody

Question 136

Sjogren’s syndrome * Anti-DNA antibody * Anti-RNP antibody * Anti-GAD antibody * Anti-centromere antibody * Anti-Ro antibody

Answer 136

Anti-Ro antibody Although anti-Ro is seen in SLE also, it is much more common in Sjogren's.

Question 137

Antibody to gastric parietal cells * Autoimmune hepatitis * Coeliac disease * Pernicious anaemia * Dermatitis herpetiformis * Primary biliary cirrhosis

Answer 137

Pernicious anaemia Gastric parietal cells produce intrinsic factor, which binds B12. If they are destroyed in anauto-immune manner then this leads to pernicious anaemia.

Question 138

Anti-smooth muscle antibody * Autoimmune hepatitis * Coeliac disease * Pernicious anaemia * Dermatitis herpetiformis * Primary biliary cirrhosis

Answer 138

Autoimmune hepatitis both Anti-nuclear and Anti-smoth muscle are classically found

Question 139

Anti-endomysial antibody * Autoimmune hepatitis * Coeliac disease * Pernicious anaemia * Dermatitis herpetiformis * Primary biliary cirrhosis

Answer 139

Coeliac disease/Dermatitis herpetiformis Anti endomysial and Anti-transglutaminase antibodies are the tests of choice for Coeliac and it's assiciated condition, Dermatitis herpetiformis.

Question 140

Anti-tissue transglutaminase antibody * Autoimmune hepatitis * Coeliac disease * Pernicious anaemia * Dermatitis herpetiformis * Primary biliary cirrhosis

Answer 140

Coeliac disease/Dermatitis herpetiformis Anti endomysial and Anti-transglutaminase antibodies are the tests of choice for Coeliac and it's assiciated condition, Dermatitis herpetiformis.

Question 141

Anti-mitochondrial antibody * Autoimmune hepatitis * Coeliac disease * Pernicious anaemia * Dermatitis herpetiformis * Primary biliary cirrhosis

Answer 141

Primary biliary cirrhosis During this disease there is an autoimmune destruction of the small bile ducts, ducts composed of smooth muscle.

Question 142

Mediated predominantly by antibodies which usually form after the transplantation * Hyperacute rejection * Acute cellular rejection * Acute vascular rejection * Chronic allograft rejection

Answer 142

Acute vascular rejection This is clearly an acute reaction so that leaves us two options here. Of the two, cellular rejection involves the cellular immune system (T-cells) and vascular involves the humoral immune system (antibodies).

Question 143

Both immunological and non-immunological mechanisms contribute * Hyperacute rejection * Acute cellular rejection * Acute vascular rejection * Chronic allograft rejection

Answer 143

Chronic allograft rejection for both the rapid immune system and the slower process of fibrosis to be involved it has to be a chronic rejection.

Question 144

Due to presence of pre-formed antibodies * Hyperacute rejection * Acute cellular rejection * Acute vascular rejection * Chronic allograft rejection

Answer 144

Hyperacute rejection If there are already pre-formed antibodies then the reaction is going to be very rapid, this has to be a hyper-acute reaction.

Question 145

Mediated by activation of CD4 T cells which provide help for a CD8 T cell and B cell response and occurs within 1-4 weeks * Hyperacute rejection * Acute cellular rejection * Acute vascular rejection * Chronic allograft rejection

Answer 145

Acute cellular rejection This is clearly an acute reaction so that leaves us two options here. Of the two, cellular rejection involves the cellular immune system (T-cells) and vascular involves the humoral immune system (antibodies).

Question 146

42 year old lady develops pruritis, rash, hypotension and difficulty breathing. She has received an intra-articular injection of hydrocortisone and lignocaine 10 minutes previously * Physical urticaria * Type IV hypersensitivity to latex * Allergic rhinitis * Anaphylaxis * C1 inhibitor deficiency

Answer 146

Anaphylaxis This woman is having a reaction to the lignocaine injection, it is affecting her skin and respiratory system so is anaphylaxis. She is also showing signs of systemic shock, this is an emergency.

Question 147

16 year old develops itchy red wheals on her skin whenever she goes running. Symptoms tend to be worse in the summer * Physical urticaria * Type IV hypersensitivity to latex * Allergic rhinitis * Anaphylaxis * C1 inhibitor deficiency

Answer 147

Physical urticaria This is the medical term for the wheals described here. It is caused by histamine realease in responce to allergens or physical factors, such as heat, and exercise.

Question 148

36 year old lady presents with swelling of face and tongue following dental surgery. There is a family history of similar reactions – both her mother and sister are affected. * Physical urticaria * Type IV hypersensitivity to latex * Allergic rhinitis * Anaphylaxis * C1 inhibitor deficiency

Answer 148

C1 inhibitor deficiency This is an inherited condition where there is angiodema in responce to a minor trauma or enviromental factor.

Question 149

14 year old presents with nasal irritation and discharge during the summer months. The symptoms are relieved by over the counter anti-histamines * Physical urticaria * Type IV hypersensitivity to latex * Allergic rhinitis * Anaphylaxis * C1 inhibitor deficiency

Answer 149

Allergic rhinitis This is hayfever (allergic rhinitis) it is pretty distinctive.

Question 150

25 year old junior doctor develops pruritic/blistering rash on hands within two weeks of starting placement on surgical firm * Physical urticaria * Type IV hypersensitivity to latex * Allergic rhinitis * Anaphylaxis * C1 inhibitor deficiency

Answer 150

Type IV hypersensitivity to latex Type IV is contact dermatitis, they even point out it's to latex. This doctor must have really gotten stuck in as a medical student if they are only just discovering it.

Question 151

A 58 year old pharmacist presents with a 3 month history of skin itching associated with lethargy and loss of energy. Physical examination is normal, but liver function tests reveal: Total bilirubin = 36umol/l (0-17umol/l)ALT = 28U/l (0-31U/l) Alkaline phosphatase 420U/l (30-130) * 1. anti-acetyl choline receptor antibody * 2. anti-adrenal cortex antibody * 3. antibody to double stranded DNA * 4. anti-centromere antibody * 5. anti-TTG antibody * 6. anti-intrinsic factor antibody * 7. anti-mitochondrial antibody * 8. anti-neutrophil cytoplasmic antibody * 9. anti-RNP antibody * 10. anti-smooth muscle antibody

Answer 151

7. anti-mitochondrial antibody Primary biliary cirrhosis is a condition mainly affecting middle-aged women, and those with other autoimmune diseases. The puritis and LFTs suport this diagnosis. Anti-mitochondrial antibody is the test of choice.

Question 152

A 56 year old prison officer presents with a history of recurrent nose bleeds, haemoptysis and joint pain associated with profound lethargy. On examination, he has crackles in his upper left lung field, and a cavitating left lung lesion is demonstrated on chest radiography. Urine dipstick is positive for protein and blood. * 1. anti-acetyl choline receptor antibody * 2. anti-adrenal cortex antibody * 3. antibody to double stranded DNA * 4. anti-centromere antibody * 5. anti-TTG antibody * 6. anti-intrinsic factor antibody * 7. anti-mitochondrial antibody * 8. anti-neutrophil cytoplasmic antibody * 9. anti-RNP antibody * 10. anti-smooth muscle antibody

Answer 152

8. anti-neutrophil cytoplasmic antibody The symptoms theis gentleman is displaying are classic for Granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis). cANCA is the test of choice here

Question 153

A 22 year old woman presents with joint pain and fatigue. She has an intermittent, skin-sensitive rash, and also complains of mouth ulcers. Physical examination is otherwise normal. Urine dipstick is positive ++ protein and ++ blood. Full blood count shows a normocytic normochromic anaemia. * 1. anti-acetyl choline receptor antibody * 2. anti-adrenal cortex antibody * 3. antibody to double stranded DNA * 4. anti-centromere antibody * 5. anti-TTG antibody * 6. anti-intrinsic factor antibody * 7. anti-mitochondrial antibody * 8. anti-neutrophil cytoplasmic antibody * 9. anti-RNP antibody * 10. anti-smooth muscle antibody

Answer 153

3. antibody to double stranded DNA This is SLE, the test of choice here is anti-dsDNA

Question 154

A 30 year old plumber attends his GP complaining of feeling tired all the time. He has type I diabetes, which is currently well controlled, and a history of irritable bowel syndrome. A full blood count shows a microcytic hypochromic anaemia, and iron studies confirm iron deficiency. Vitamin D levels are within the insufficient range. * 1. anti-acetyl choline receptor antibody * 2. anti-adrenal cortex antibody * 3. antibody to double stranded DNA * 4. anti-centromere antibody * 5. anti-TTG antibody * 6. anti-intrinsic factor antibody * 7. anti-mitochondrial antibody * 8. anti-neutrophil cytoplasmic antibody * 9. anti-RNP antibody * 10. anti-smooth muscle antibody

Answer 154

5. anti-TTG antibody Coeliac disease, anti-endomysial or anti-TTG are the tests used for diagniosis.

Question 155

A 44 year old builder presents with a history of fingers intermittently becoming very cold and white with recent development of a gangrenous tip of his finger. The skin over his fingers feels ‘tight’ and you note telangectasia on his hands. * 1. anti-acetyl choline receptor antibody * 2. anti-adrenal cortex antibody * 3. antibody to double stranded DNA * 4. anti-centromere antibody * 5. anti-TTG antibody * 6. anti-intrinsic factor antibody * 7. anti-mitochondrial antibody * 8. anti-neutrophil cytoplasmic antibody * 9. anti-RNP antibody * 10. anti-smooth muscle antibody

Answer 155

4. anti-centromere antibody This is limited cutaneous scleroderma (previously CREST syndrome), he is demonstrating the classic signs of Reynauds, sclerodactyly and Telangiectasia. The test for this condition is ant-centromere antibody.

Question 156

A 19 year old student presents with a chronic, extremely itchy rash consisting of papules and vesicles which is distributed symmetrically over the extensor surfaces of her elbows, legs and buttocks. You suspect dermatitis herpetiformis. * 1. anti-acetyl choline receptor antibody * 2. anti-adrenal cortex antibody * 3. antibody to double stranded DNA * 4. anti-centromere antibody * 5. anti-TTG antibody * 6. anti-intrinsic factor antibody * 7. anti-mitochondrial antibody * 8. anti-neutrophil cytoplasmic antibody * 9. anti-RNP antibody * 10. anti-smooth muscle antibody

Answer 156

6. anti-intrinsic factor antibody You've got me here, this sounds like Coeliac which should be anti-TTG. I have no idea why this is pernicious anaemia.

Question 157

* A. Is mediated by Toll like receptors which recognise pathogen associated molecular patterns * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Answer 157

Pathogen recognition It's basically given in the question

Question 158

* B. May be mediated by antibodies, complement components or acute phase proteins and facilitates phagocytosis * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Answer 158

Opsonisation The process of proteins such as C3b attaching to microbial walls allows phagocytotic cells to attach and engulf the pathogenic organisms.

Question 159

* C. Describes killing mediated by reactive oxygen species generated by action of the NADPH oxidase complex * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Answer 159

Oxidative killing its given to you in the question!

Question 160

* D. May be mediated by bacteriocidal enzymes such as lysozyme * Oxidative killing * Pathogen recognition * Opsonisation * Non-oxidative killing

Answer 160

Non-oxidative killing enzymatic methods of patogen killing are obviously of the non-oxidative variety.

Question 161

- Derived from monocytes and resident in peripheral tissues * Neutrophils * Natural Killer Cells * Dendritic cells * Macrophages

Answer 161

Macrophages

Question 162

- Polymorphonuclear cells capable of phagocytosing pathogens and killing by oxidative and non-oxidative mechanisms * Neutrophils * Natural Killer Cells * Dendritic cells * Macrophages

Answer 162

Neutrophils

Question 163

- Lymphocytes that express inhibitory receptors capable of recognising HLA class I molecules and have cytotoxic capacity * Neutrophils * Natural Killer Cells * Dendritic cells * Macrophages

Answer 163

Natural Killer Cells

Question 164

- Immature cells are adapted for pathogen recognition and uptake whilst mature cells are adapted for antigen presentation to prime T cells * Neutrophils * Natural Killer Cells * Dendritic cells * Macrophages

Answer 164

Dendritic cells

Question 165

Express receptors that recognise peptides usually derived from intracellular proteins and expressed on HLA class I molecules * Th1 cells * CD8 T cells * T follicular helper (Tfh) cells * T regulatory cells

Answer 165

CD8 T cells CD8 T-cells are heavily involved in triggering apoptosis of cells infected with intracellular pathogens. The MHC class I is expressed on all cells and presents intracellular peptides for recognition by CD8 T-cells. Those cells that have been hijacked and are producing pathogenic proteins are recognised and given apoptotic signals.

Question 166

Subset of lymphocytes that express Foxp3 and CD25 * Th1 cells * CD8 T cells * T follicular helper (Tfh) cells * T regulatory cells

Answer 166

T regulatory cells Fop3 is a master regulator for T-cells and is therefore found on T-regulatory cells.

Question 167

Subset of cells that express CD4 and secrete IFN gamma and IL-2 * Th1 cells * CD8 T cells * T follicular helper (Tfh) cells * T regulatory cells

Answer 167

Th1 cells T-helper cells are CD4 positive, that is why HIV (which targets CD4 cells) is so devastating to the immne system

Question 168

Play an important role in promoting germinal centre reactions and differentiation of B cells into IgG and IgA secreting plasma cells Th1 cells CD8 T cells T follicular helper (Tfh) cells T regulatory cells

Answer 168

T follicular helper (Tfh) cells The follicular cells reside in the lymphoid tissue and are crucial to the selection and survival of B cells that are producing high-affinity antibodies to encountered pathogens. Follicular cells start life as T-helper cells and then migrate to the lymphoid tissue after exposure to an antigen.

Question 169

Exist within the bone marrow and develop from haematopoietic stem cells * Pre-B cells * IgA * IgG secreting plasma cells * IgM secreting plasma cells

Answer 169

Pre-B cells The starting point of plasma cells

Question 170

Cell dependent on the presence of CD4 T cell help for generation. * Pre-B cells * IgA * IgG secreting plasma cells * IgM secreting plasma cells

Answer 170

IgG secreting plasma cells IgG is the high affinity antibody that is produced after helper T-cells encounter a specific pathogen, and then migrate to the lymphoid tissue where they become follicular helper T-cells. Once in the lymphoid tissue these T-cells promote B-cells into class switching to produce high-affinity antibodies.

Question 171

Are generated rapidly following antigen recognition and are not dependent on CD4 T cell help * Pre-B cells * IgA * IgG secreting plasma cells * IgM secreting plasma cells

Answer 171

IgM secreting plasma cells IgM is the low affinity antibody and is produced without specific encounters with the antigen and follicular T-cell class switiching of B-cells.

Question 172

Divalent antibody present within mucous which helps provide a constitutive barrier to infection * Pre-B cells * IgA * IgG secreting plasma cells * IgM secreting plasma cells

Answer 172

IgA IgA is a dimer, think two y-shaped antibodies end to end. It is the only antibody that can cross the mucus membranes. Loss of function or abcense of this antibody leads to reccurent respiratory or GI infections.

Question 173

Area within secondary lymphoid tissue where B cells proliferate and undergo affinity maturation and isotope switching * Primary lymphoid organs * Thoracic duct * Thymus * Germinal centre

Answer 173

Germinal centre Here T-helper cells that have been exposed to an antigen and have become follicular helper T-cells reside. They facilitate the affinity maturation and class switching of B-cells to produce the high affinity IgG. It's a bit like a boot camp.

Question 174

Include both the bone marrow and thymus; sites of B and T cell development * Primary lymphoid organs * Thoracic duct * Thymus * Germinal centre

Answer 174

Primary lymphoid organs self explanatory really.

Question 175

Carries lymphocytes from lymph nodes back to the blood circulation * Primary lymphoid organs * Thoracic duct * Thymus * Germinal centre

Answer 175

Thoracic duct

Question 176

Site of deletion of T cells with inappropriately high or low affinity for HLA molecules and of maturation of T cells into CD4+ or CD8+ cells * Primary lymphoid organs * Thoracic duct * Thymus * Germinal centre

Answer 176

Thymus The thymus is the site of T-cell development and the elimination of self-targeting T-cells. The agenesis of the Thymus in DiGeorges syndrome is why there are extremely low levels of T-cells in that condition.

Question 177

Binding of immune complexes to this protein triggers the classical pathway of complement activation * C3 * C1 * C9 * MBL

Answer 177

C1 There are three complement pathways, There are three complement pathways, 1. The 'classical' pathway starts with C1 and antigen-antibody complexes on bacterial surfaces. 2. The 'Alternative' pathway starts with C3 binding to bacteria 3. The mannose binding - Lectin pathway starts with MBL (mannose binding lectin) attaching to bacterial sugars such as manose. All of these pathways then arrive at the point were C3 is cleaved into C3a and C3b

Question 178

Cleavage of this protein may be triggered via the classical, MBL or alternative pathways * C3 * C1 * C9 * MBL

Answer 178

C3 There are three complement pathways, 1. The 'classical' pathway starts with C1 and antigen-antibody complexes on bacterial surfaces. 2. The 'Alternative' pathway starts with C3 binding to bacteria 3. The mannose binding - Lectin pathway starts with MBL (mannose binding lectin) attaching to bacterial sugars such as manose. All of these pathways then arrive at the point were C3 is cleaved into C3a and C3b

Question 179

Binds to microbial surface carbohydrates to activate the complement cascade in an immune complex independent manner C3 C1 C9 MBL

Answer 179

MBL There are three complement pathways, 1. The 'classical' pathway starts with C1 and antigen-antibody complexes on bacterial surfaces. 2. The 'Alternative' pathway starts with C3 binding to bacteria 3. The mannose binding - Lectin pathway starts with MBL (mannose binding lectin) attaching to bacterial sugars such as manose. All of these pathways then arrive at the point were C3 is cleaved into C3a and C3b

Question 180

Part of the final common pathway resulting in the generation of the membrane attack complex * C3 * C1 * C9 * MBL

Answer 180

C9 C5 to C9 are all involved in forming the membrane attack complex

Question 181

Polymorphonuclear cell capable of phagocytosing pathogens

Answer 181

Neutrophil

Question 182

Type of cell derived from monocytes and are resident in peripheral tissues

Answer 182

Macrophage

Question 183

Type of lymphocyte that expresses FOXP3 and CD25

Answer 183

TH1

Question 184

Divalent antibody present in mucus; provides constitutive barrier to infection

Answer 184

IgA

Question 185

Binding of immune complexes to this protein triggers the classical pathway of complement

Answer 185

C1

Question 186

Monoclonal antibody that prevents osteoporosis by inhibiting RANKL. Can be used in pts on long-term steroids

Answer 186

Denosumab

Question 187

Mycophenolate

Answer 187

Reversibly inhibits guanine synthesis (de novo pathway of purine synthesis)Used to prevent transplant rejection, esp renalCan also be a steroid sparing agent in authoimmune diseases

Question 188

CTLA4-immunoglobulin fusion protein sometimes used in RA when anti-TNF doesn't work

Answer 188

Abatacept

Question 189

Drug used in autoimmune disorders (e.g. SLE) when body develops end-organ resistance to corticosteroids and DMARDS fail

Answer 189

Cyclophosphamide

Question 190

TNF alpha inhibitor for severe RA, when DMARDS fail

Answer 190

Infliximab

Question 191

Patients in this immune modulating drug require regular monitoring of retina

Answer 191

Hydroxychloroquine

Question 192

First-line DMARD for RA

Answer 192

Methotrexate

Question 193

What drug would you prescribe for RA pt who has recently developed vasculitis and requires a strong immunosuppressant

Answer 193

Cyclophoshamide

Question 194

Immunosuppressive drug for RA that requires washout before a woman can conceive

Answer 194

Leflunomide

Question 195

Biological DMARD in RA treatment

Answer 195

Infliximab

Question 196

t(9;22)

Answer 196

Phildelphia chromosome.Seen in 95% CML, 25-30% ALL

Question 197

Diagnosis--Fatigue, anemia, lymphocytosis, painless LAD, smudge cells on blood film.

Answer 197

CLL smudge cells are remnants of leukocytes with no identifiable structres. they look like pink/purple smudges funnily enough

Question 198

Diagnosis--Fatigue, night sweats, weight loss, anemia, leukocytosis, splenomegaly, Philedelphia chromosome.

Answer 198

CML

Question 199

Diagnosis--Anemia, fever, weight loss, splenomegaly, pancytopenia, irregularly-shaped cels with filament-like cytoplasmic projections on blood film

Answer 199

Hairy cell leukemia The irregularly shaped cells with the filliments are the hairy cells mentioned.

Question 200

Pallor, HSM, anemia, leukocytosis, thrombocytopenia. Blast cells and Auer rods on blood film

Answer 200

AML

Question 201

Most likely diagnosis-young boy with Down's, pallor, tachycardia, petechiae, testicular enlargement. Anemia, thrombocytopenia, leukocytosis, blast cells.

Answer 201

ALL

Question 202

Pt with this disease possesses homozygous isoform of ApoE, ApoE2/E2

Answer 202

Familial dysbetalipoproteinemia (type III)

Question 203

Type of primary hypercholesterolemia which involves mutation of ATP-binding cassette transporters G5, G8

Answer 203

Phytosterolemia

Question 204

AD form of primary hypercholesterolemia which can be caused by gain of function mutation of proprotein convertase subtilisi/kexin type 9 (PCSK9) gene

Answer 204

Familial hypercholesterolemia (type I)

Question 205

AD mutation of ApoB gene could lead to this condition

Answer 205

Hypobetalipoproteinemia

Question 206

A condition which results from dysregulated lipoprotein metabolism leading to cholesterol deposition in arterial wall

Answer 206

Atherosclerosis

Question 207

Lipoprotein found in VLDL and chylomicrons; activates lipoprotein lipase in capillaries

Answer 207

ApoC

Question 208

Main lipoprotein of LDL and chylomicrons. Leads to heart disease if deficient

Answer 208

ApoB

Question 209

Binds to LDL receptor to promote degradation. Loss of function leads to low LDL levels

Answer 209

PCSK9

Question 210

Class of apolipoprotein produced by astrocytes in CNS. Polymorphisms of this are associated with Parkinson's and Alzheimer's.

Answer 210

ApoE

Question 211

Major lipoprotein in HDL. Mutation can lead to paradoxical drop in HDL concentration and reduction in atheroma in animal models

Answer 211

ApoA1

Question 212

Dx: 25 year old man presents with jaundice, fever, RUQ pain

Answer 212

Ascending cholangitis

Question 213

Dx: 25 yr old man presents with 3 yr hx occasional episodes mild jaundice, worse with chest infection. Mild unconjugated hyperbilirubinemia, normal liver biopsy

Answer 213

Gilberts. This is a condition chaerecterised by isolated elevated levels of unconjugated billirubin. It is episodic and worse in time sof infection.

Question 214

Dx: 45 year old lady with mildly elevated serum bili, normal ALP and AST, anemia. No urinary bili present

Answer 214

Hemolytic jaundice

Question 215

60 year old diabetic pt presents with localized back pain, fever, malaise, swelling at site of pain. CRP raised. * Septic Arthritis * Prosthetic joint infection * Hematogenous osteomyelitis * Brodie's abscess * Vertebral osteomyelitis * Cellulitis * Spinal cord neoplasm * Gout * Acute osteomyelitis * Chronic osteomyelitis

Answer 215

Vertebral osteomyelitis this is an infection of the bone within the vertebral body. The history suports this

Question 216

29 year old pt presents with 1 wk painful, red, swollen, restricted knee join. Raised CRP, WCC \>50,000/mm3. Causative agent S aureus. Pt is an IV drug abuser * Septic Arthritis * Prosthetic joint infection * Hematogenous osteomyelitis * Brodie's abscess * Vertebral osteomyelitis * Cellulitis * Spinal cord neoplasm * Gout * Acute osteomyelitis * Chronic osteomyelitis

Answer 216

Septic arthritis S.aureus is commonly introduced to the blood stream i in IV drug users, where it cause several pathologies. It is also the most likely organism for infective endocarditis in IV drug users.

Question 217

Young pt presents with sudden fever, bone pain, swelling, restricted movement in elbow joint three weeks after injury * Septic Arthritis * Prosthetic joint infection * Hematogenous osteomyelitis * Brodie's abscess * Vertebral osteomyelitis * Cellulitis * Spinal cord neoplasm * Gout * Acute osteomyelitis * Chronic osteomyelitis

Answer 217

Acute osteomyelitis

Question 218

Pt presents 1/12 after bilateral arthroplasty. Claims joints "haven't felt right:. Fever, leaking wounds, pain. S aureus isolated * Septic Arthritis * Prosthetic joint infection * Hematogenous osteomyelitis * Brodie's abscess * Vertebral osteomyelitis * Cellulitis * Spinal cord neoplasm * Gout * Acute osteomyelitis * Chronic osteomyelitis

Answer 218

Prosthetic joint infection This one is clear enough

Question 219

Suddent onset excruciating pain in left MTP joint, Swelling and highly inflammed. * Septic Arthritis * Prosthetic joint infection * Hematogenous osteomyelitis * Brodie's abscess * Vertebral osteomyelitis * Cellulitis * Spinal cord neoplasm * Gout * Acute osteomyelitis * Chronic osteomyelitis

Answer 219

Gout Classic site for teh first presentation of gout is the first meta-tarsal phalangeal joint, the big toe.

Question 220

48 yr old woman, BMI 28, presents with 3/52 history of painful L knee and lethargy. O/E, joint is edematous and hot. She is pyrexial, has reduced range of movement.Further questioning-has had intra-articular steroid injections for her RA a month previously.

Answer 220

Septic arthritis

Question 221

Investigations- septic arthritis of joint

Answer 221

Blood culture and synovial fluid aspirate

Question 222

69 year old man recovering in ward following sx for L2/3 disc herniation and spinal canal compression. Op went well, but pt now has a temperature and complaining of bad back and a pain in his leg. What diagnostic test is most sensitive in helping your dx? Blood culture and synovial fluid aspirate CT MRI Open biopsy Plain XR

Answer 222

MRI The neurological syptoms here dictate that your first step is a spinal MRI.

Question 223

What causative organism do you suspect in previous pt (L2/3 herniation man)

Answer 223

S. aureus Commonest post operative infective agent.

Question 224

81 year old woman with type I DM presents in A&E 4/52 post-bilateral hip replacement sx. She is in pain, not mobilizing, complaining that hips never felt right after sx. WCC 20x10^9/LCRP 156Pelvic XR shows areas of lysis around acetabular component of both joints and joint aspirate reveals 6700 WC/mL. What do you suspect?

Answer 224

Prosthetic joint infection

Question 225

Most common causative organism in septic arthritis

Answer 225

S. Aureus

Question 226

Causes arthritis mainly in young children * S. aureus * E. coli * P. aeruginosa * Kingella * Coag negative staph * H. influenza * N. gon * Salmonella * Borrelia burgdoferi * Brucells * Mycobacterium tuberculosis * S. pyogenes * Proteus miribalis * Candida albicans * Bartonelle henselae * Toxoplasma gondii

Answer 226

H. influenza

Question 227

Most common cause of infectious arthritis in teenagers and young adults

Answer 227

N. gonorrhoeae

Question 228

Bug that most commonly involves vertebral column in adults. Associated with wedging and/or collapse of vertebrae.

Answer 228

Mycobacterium tuberculosis

Question 229

Most common cause of prosthetic joint infection

Answer 229

Coag negative staph (e.g.staph epidermidis)

Question 230

Organism classically causing infective endocarditis in drug users

Answer 230

S. aureus

Question 231

40 year old man recently returns from travel in North America, presenting with fever, flu-like symptoms, and a bulls-eye rash

Answer 231

Lyme disease This bulls-eye rash is erythema migrans, which just screems Lyme disease (Borrelia burgdorferi), a tick bourne bacteria.

Question 232

35 year old man recently returns from south Asia and presents to his GP with undulant fever, malaise, rigors, and arthralgias. Admits to drinking unpasteurized milk.

Answer 232

Brucellosis Unpasturised milk or contact with cattle in asia/middle east/ africa, think Brucellosis (named after an army doctor, Maj.Gen Sir David Bruce, no less).

Question 233

20 year old woman returns from southern France where she spent time on a farm. She presents with fever, dry cough, and diarrhea

Answer 233

Q fever another zoonosis, nothing massively specific about it's presentation in the initial period. It can have GI and upper respiratory tract symptoms. It can progress to an atypical pneumonia, and rarely after many months, years or even decades of chronic infection it can cause a endocarditis that is usually fatal if untreated.

Question 234

An ornithologist presents to his GP with fever, arthralgia, cough, dyspnea. Levathar-cole-lillie bodies can be seen on BAL

Answer 234

Psittacosis Bird keeper is either going to have Psittacosis or cryptococcus, the Leventhal-Cole-Lillie bodies are key to identifying this as psittacosis.

Question 235

30 year old sewage worker presents with 1 week hx flu-like symptoms with diarrhea. Diagnosis confirmed with microscopic agglutination test

Answer 235

Leptospirosis sewage or mucky river water = leptospirosis (weil's disease)

Question 236

Pigeon fancier presents with cough, low-grade fever, and chest pain. India ink CSF stain was positive.

Answer 236

Cryptococcus the india ink stain is the giveaway here

Question 237

40 year old man presents with abdo pain. O/E, he has hepatomegaly. Abdo USS reveals well-defined round lesion in liver. He has two dogs.

Answer 237

Hyatid disease this si a cystic disease caused by the parasitic tapeworm Echinococcus, humans are not the definitive hosts for this pathogen so it forms cysts within the muscle, organs and brain. Really nasty stuff, check ut videos of the cysts being removed, they can be the size of melons. There is a serious risk of a massive IgE reaction if these cysts rupture

Question 238

Eastern European vet presents wit fever and sweating and one month history of malaise, weight loss, and myalgia. Rose Bengal test was positive and blood cultures reveal gram negative bacilli

Answer 238

Brucellosis The rose Bengal stain is the key element here. Unpasturised milk or contact with cattle in asia/middle east/ africa, think Brucellosis (named after an army doctor, Maj.Gen Sir David Bruce, no less). This guy has been in contact with cattle in eastern eurpe, Brucellosis is less common there but still possible.

Question 239

21 year old med student presents with sore throat, fever, headache, and myalgia. She recently returned from volunteering at a hospital in Nigeria, where she helped deliver babies. She is treated with a slow IV infusion of ribavirin

Answer 239

Lassa fever This is damn rare, the only chance you have is if you know what ribavarin is used to treat. It is used as an oral preparation for Hep C, the use here as an IV infusion means it is for a viral haemorraghic fever. I'm not really sure how you could narrow it down from there!

Question 240

12 year old boy presents with a fever, headache, malaise, and a non-specific rash. He has had several tick bites while on holiday in the US. FBC shows leukopenia and thrombocytopenia; LFTs show raised AST

Answer 240

Ehrlichiosis Another obscure one! Erlichosis is a bacterial infection carried by ticks, it classically destroys white blood cells and supresses TNF-alpha. It also causes the liver damage we see here.

Question 241

Bullet shaped virus,incubation 1-3 months

Answer 241

Rabies You dont get many clues here!

Question 242

Major cause of death in children in endemic areas. Can be hard to dx as protean manifestations, but often presents with erythema migrans

Answer 242

Borreliosis This is lyme disease, it presents with the classic bulls-eye rash of erythema migrans.

Question 243

Dogs, cats, and other animals are primary hosts. Larval form can cause red pruritic eruption confined to dermis. Wearing shos is an effective prevention method in infected areas.

Answer 243

Cutaneous larva migrans This is a cutaneous infection casued by the larvae o parastic nematode worms shed in animal faeces.

Question 244

PUO/undulant fever. Can cause meningoencephalitis but rarely life threatening.Not currently present in UK

Answer 244

Brucellosis Unpasturised milk or contact with cattle in asia/middle east/ africa, think Brucellosis (named after an army doctor, Maj.Gen Sir David Bruce, no less).

Question 245

Bacillus with reservoir in rodents

Answer 245

Yersinia pestis The black death ladies and gentlemen, likey to be a common presenting complaint during your foundation years.

Question 246

33 year old woman presents with sudden onset fever, headache, and myalgia, She spent most of summer outside and recals getting bitten by multiple mosquitoes. O/E she is pyrexial, has maculopapular rash on trunk and extremities. CSF shoes elevated protein and cell count with PMN predominance and decreased glucose.Doctor tells you that most pts with this disease are asymptomatic and finding specific IgM would establish dx.

Answer 246

West Nile virus This question is a bit bogus as there is no mention of travel, and the WN virus doesn't exist in n.europe.

Question 247

20 year old man presents with sudden onset fever, myalgia, headache. Just before feeling unwell, he had noticed intensely painful swelling in L groin. He just returned from a field trip to New Mexico and mentioned there were some small bites on his legs that were very itchy. O/E his leg is held flexed and in eternal rotation and the lump is 5cm long and tender to touch, with local edema. Blood culture reveals gram neg coccobacillus

Answer 247

Bubonic plague the gram-negative coccobacillus here is yersinia pestis The massive tender inguinal lymph node following tick bites is rather diagnostic of this condition.

Question 248

16 year old woman presents with 3 days constantly high fevers and aches and pains in lower back. Predominantly frontal headache and retro-orbital pain worse on eye movement. Temp 38.4 BP 110/80, pulse 92. generalized flushing of skin. Bloods-thrombocytopenia nd leukopenia

Answer 248

Dengue fever

Question 249

56 year old woman presents with fever and headache, chills and rigors, feels heart racing during these episodes. Mentions fever seems to come and go every 72 hours (how convenient). Flew to New Zealand but stopped over in Nigeria. GP says influena. Two days later, she goes to A&E with similar sxs and vomiting. Now mildly jaundiced

Answer 249

P. malariae the rigors and the classic 72 hour fever are the massive clues here. The stop over in nigeria is her opportuunity for exposure, although in reality you don't expect malaria transmission in urban areas, so unless her stopover included a trip to a rural area it's an unlikely scenario.

Question 250

The antiviral which is given to untreated pregnant women with HIV to prevent vertical transmission of the virus during childbirth .• Zidovudine * Ribavirin * Neuraminidase inhibitor * Foscarnet * Ganciclovir * Nevirapine * Cidofovir * Oseltamivir * Interferon-g (gamma) * Aciclovir triphosphate * Interferon-α (alpha) * Aciclovir• Interferon-b (beta) * Entecevir * Aciclovir monophosphate

Answer 250

Correct F. NevirapineResponse Feedback: In 1999, the HIVNET 012 team reported exciting preliminary results that single-dose nevirapine prophylaxis for mother and baby significantly lowered HIV-1 infection risk at 14–16 weeks compared with controls who received short-course zidovudine prophylaxis.

Question 251

An immunomodulatory therapy used in the treatment of hepatitis B.• Zidovudine• Ribavirin• Neuraminidase inhibitor• Foscarnet• Ganciclovir• Nevirapine• Cidofovir• Oseltamivir• Interferon-g (gamma)• Aciclovir triphosphate• Interferon-α (alpha)• Aciclovir• Interferon-b (beta)• Entecevir• Aciclovir monophosphate

Answer 251

Correct K. Interferon-α (alpha)

Question 252

An antiviral currently used to prevent and treat Influenza in the elderly and which has the potential to be used to prevent Avian influenza.• Zidovudine• Ribavirin• Neuraminidase inhibitor• Foscarnet• Ganciclovir• Nevirapine• Cidofovir• Oseltamivir• Interferon-g (gamma)• Aciclovir triphosphate• Interferon-α (alpha)• Aciclovir• Interferon-b (beta)• Entecevir• Aciclovir monophosphate

Answer 252

Correct H. Oseltamivir

Question 253

The final metabolite of the antiviral used to treat Herpes Simplex• Zidovudine• Ribavirin• Neuraminidase inhibitor• Foscarnet• Ganciclovir• Nevirapine• Cidofovir• Oseltamivir• Interferon-g (gamma)• Aciclovir triphosphate• Interferon-α (alpha)• Aciclovir• Interferon-b (beta)• Entecevir• Aciclovir monophosphate

Answer 253

Correct J. Aciclovir triphosphate

Question 254

An antiviral which can be used in aerosol form to prevent respiratory syncytial virus in children with heart and lung disease• Zidovudine• Ribavirin• Neuraminidase inhibitor• Foscarnet• Ganciclovir• Nevirapine• Cidofovir• Oseltamivir• Interferon-g (gamma)• Aciclovir triphosphate• Interferon-α (alpha)• Aciclovir• Interferon-b (beta)• Entecevir• Aciclovir monophosphate

Answer 254

Correct B. Ribavirin

Question 255

Which option is the product of the action of viral tyrosine kinase on aciclovir?• Cytomegalovirus• Guanosine• Aciclovir monophosphate• Aciclovir diphosphate• Influenza• Ribavarin• AIDS• Famciclovir• Thymidine• Varicella-zoster virus• Aciclovir triphosphate

Answer 255

Correct C. Aciclovir monophosphateResponse Feedback: Aciclovir diphosphate and triphosphate are the product of cellular tyrosine kinase, whereas aciclovir monophosphate is the product of viral tyrosine kinase.

Question 256

Which option inhibits the action of viral DNA polymerase?• Cytomegalovirus• Guanosine• Aciclovir monophosphate• Aciclovir diphosphate• Influenza• Ribavarin• AIDS• Famciclovir• Thymidine• Varicella-zoster virus• Aciclovir triphosphate

Answer 256

Correct K. Aciclovir triphosphateResponse Feedback: Aciclovir diphosphate and triphosphate are the product of cellular tyrosine kinase, whereas aciclovir monophosphate is the product of viral tyrosine kinase.

Question 257

The synthetic nucleoside analogue ganciclovir is the drug of choice against which infective virus?• Cytomegalovirus• Guanosine• Aciclovir monophosphate• Aciclovir diphosphate• Influenza• Ribavarin• AIDS• Famciclovir• Thymidine• Varicella-zoster virus• Aciclovir triphosphate

Answer 257

Correct A. Cytomegalovirus

Question 258

Ribavirin, a synthetic nucleoside that acts as an RNA polymerase inhibitor, is similar in structure to which of the options given above?• Cytomegalovirus• Guanosine• Aciclovir monophosphate• Aciclovir diphosphate• Influenza• Ribavarin• AIDS• Famciclovir• Thymidine• Varicella-zoster virus• Aciclovir triphosphate

Answer 258

Correct B. Guanosine

Question 259

Valaciclovir, a prodrug of aciclovir, is used to treat patients with which viral disease in the list, above?• Cytomegalovirus• Guanosine• Aciclovir monophosphate• Aciclovir diphosphate• Influenza• Ribavarin• AIDS• Famciclovir• Thymidine• Varicella-zoster virus• Aciclovir triphosphate

Answer 259

Correct J. Varicella-zoster virus

Question 260

An immunomodulator effective in HBV infection• Doxacyclin• Ribavarin• Amantadine• Abacavir• Adefovir• Interferon• Gancyclovir• Ibuprofen• Citalapram• Loviride• Foscarnet• Zidovudine• Aciclovir

Answer 260

Correct F. Interferon

Question 261

Used for the treatment of severe, resistant herpes infections• Doxacyclin• Ribavarin• Amantadine• Abacavir• Adefovir• Interferon• Gancyclovir• Ibuprofen• Citalapram• Loviride• Foscarnet• Zidovudine• Aciclovir

Answer 261

Correct K. Foscarnet

Question 262

The treatment of choice for CMV-induced hepatitis• Doxacyclin• Ribavarin• Amantadine• Abacavir• Adefovir• Interferon• Gancyclovir• Ibuprofen• Citalapram• Loviride• Foscarnet• Zidovudine• Aciclovir

Answer 262

Correct G. Gancyclovir

Question 263

A drug that is effective against influenza A but not influenza B• Doxacyclin• Ribavarin• Amantadine• Abacavir• Adefovir• Interferon• Gancyclovir• Ibuprofen• Citalapram• Loviride• Foscarnet• Zidovudine• Aciclovir

Answer 263

Correct C. Amantadine

Question 264

A purine nucleoside analogue that selects specifically for thymidine kinase• Doxacyclin• Ribavarin• Amantadine• Abacavir• Adefovir• Interferon• Gancyclovir• Ibuprofen• Citalapram• Loviride• Foscarnet• Zidovudine• Aciclovir

Answer 264

Correct M. Aciclovir

Question 265

A nucleoside analogue which inhibits reverse transcriptase• Human normal immunoglobulin• Indinavir• Amantadine• Enfuvirtide• Ganciclovir• Ribavarin• Efavirenz• Interferon• Zanamivir• Aciclovir• Nevirapine• Zidovudine• Human specific immunoglobulin

Answer 265

Correct L. Zidovudine

Question 266

The drug mechanisms which acts by stopping post-translational cleaving of polyproteins by inhibiting proteases• Human normal immunoglobulin• Indinavir• Amantadine• Enfuvirtide• Ganciclovir• Ribavarin• Efavirenz• Interferon• Zanamivir• Aciclovir• Nevirapine• Zidovudine• Human specific immunoglobulin

Answer 266

Correct B. Indinavir

Question 267

The drug that is selectively toxic to virally infected cells through its selective phosphorylation using viral thymidine kinase• Human normal immunoglobulin• Indinavir• Amantadine• Enfuvirtide• Ganciclovir• Ribavarin• Efavirenz• Interferon• Zanamivir• Aciclovir• Nevirapine• Zidovudine• Human specific immunoglobulin

Answer 267

Correct J. Aciclovir

Question 268

The drug which can be delivered by inhalation to treat both influenza A and B.• Human normal immunoglobulin• Indinavir• Amantadine• Enfuvirtide• Ganciclovir• Ribavarin• Efavirenz• Interferon• Zanamivir• Aciclovir• Nevirapine• Zidovudine• Human specific immunoglobulin

Answer 268

Correct I. Zanamivir

Question 269

The drug which works by attenuating or preventing rabies or hepatitis, following a known exposure but before the onset of signs and symptoms.• Human normal immunoglobulin• Indinavir• Amantadine• Enfuvirtide• Ganciclovir• Ribavarin• Efavirenz• Interferon• Zanamivir• Aciclovir• Nevirapine• Zidovudine• Human specific immunoglobulin

Answer 269

Correct M. Human specific immunoglobulin

Question 270

A 40yr old female non-smoker presents with a one week history of fever, shortness of breath and a cough productive of rusty coloured sputum. She complains of a sharp chest pain which “catches” her on inspiration. On examination she has increased vocal resonance in the right middle zone on auscultation. The x-ray shows right middle lobe consolidation.• P. aeuruginosa• C. psittaci• S. pneumoniae• L. pneumophila• M. pneumoniae• K. pneumoniae• S. aureus• C. neoformans• M. tuberculosis• B. pertussis

Answer 270

Correct C. S. pneumoniae

Question 271

A 37yr old American business man staying in a hotel presents with a headache, myalgia and a dry cough. He is also suffering with nausea, diarrhoea and abdominal pain. On examination he is tachypnoeic and has a pyrexia of 39ºC. Blood tests reveal lymphopenia and hyponatraemia.• P. aeuruginosa• C. psittaci• S. pneumoniae• L. pneumophila• M. pneumoniae• K. pneumoniae• S. aureus• C. neoformans• M. tuberculosis• B. pertussis

Answer 271

Correct D. L. pneumophila

Question 272

A 19yr old medical student who lives in residential halls presents with a one week history of headache, malaise, shortness of breath and a cough. Her WBC is not raised but tests reveal the presence of cold agglutinins.• P. aeuruginosa• C. psittaci• S. pneumoniae• L. pneumophila• M. pneumoniae• K. pneumoniae• S. aureus• C. neoformans• M. tuberculosis• B. pertussis

Answer 272

Correct E. M. pneumoniae

Question 273

A 30yr old lady presents with a three week history of tiredness, malaise, cough and weight loss. She feels her condition has worsened in the past week and she now also suffers from a fever and haemoptysis. In addition she complains of a “tender lump” in her supraclavicular region. Chest x-ray demonstrates nodular shadowing of the right upper zone.• P. aeuruginosa• C. psittaci• S. pneumoniae• L. pneumophila• M. pneumoniae• K. pneumoniae• S. aureus• C. neoformans• M. tuberculosis• B. pertussis

Answer 273

Correct J. M. tuberculosis

Question 274

A forty year old ornithologist presents with malaise, muscular pains and a cough. On examination he has a fever and several distinctive rose spots on his abdomen. Chest x-ray reveals a diffuse pneumonia.• P. aeuruginosa• C. psittaci• S. pneumoniae• L. pneumophila• M. pneumoniae• K. pneumoniae• S. aureus• C. neoformans• M. tuberculosis• B. pertussis

Answer 274

Correct B. C. psittaci

Question 275

Dry cough, new infiltrates on CXR, dyspnoea and target shaped lesions on the palms. No recent history of herpes.• P. aeuruginosa• C. psittaci• S. pneumoniae• L. pneumophila• M. pneumoniae• K. pneumoniae• S. aureus• C. neoformans• M. tuberculosis• B. pertussis

Answer 275

Correct E. M. pneumoniae

Question 276

An 80 year old clown appears at the GP having been discharged from hospital for a complicated bowel resection with a stint in the ITU. He has a cough and fever and is prescribed a macrolide antibiotic because he is penicillin allergic.• Anaerobic infection• Legionella pneumophila• MSSA• Chlamydia psittaci• M. Catarrhalis• H. influenzae• S. pneumoniae• Burkholderia cepacia• PCP/ P jiroveci• MRSA• M tuberculosis• MSSA or MRSA• Chlamydia pneumoniae

Answer 276

Correct C. MSSA

Question 277

A 55 year old female clown, recovering from a cold, is found to have a cavitating lesion on CXR and a productive cough.• Anaerobic infection• Legionella pneumophila• MSSA• Chlamydia psittaci• M. Catarrhalis• H. influenzae• S. pneumoniae• Burkholderia cepacia• PCP/ P jiroveci• MRSA• M tuberculosis• MSSA or MRSA• Chlamydia pneumoniae

Answer 277

Correct L. MSSA or MRSAResponse Feedback: Q2: influenza is a classic precedent of S. aureus pneumonia. This is because there is transient postviral hypofunction of airway clearance mechanisms e.g. cilia.

Question 278

An 18 year old trainee clown is being seen in the cystic fibrosis clinic and is found to be colonised with a particularly persistent organism.• Anaerobic infection• Legionella pneumophila• MSSA• Chlamydia psittaci• M. Catarrhalis• H. influenzae• S. pneumoniae• Burkholderia cepacia• PCP/ P jiroveci• MRSA• M tuberculosis• MSSA or MRSA• Chlamydia pneumoniae

Answer 278

Correct H. Burkholderia cepacia

Question 279

A 40 year old clown specialist is found to have a lobar pneumonia which on culture grew Gram +ve diplococci.• Anaerobic infection• Legionella pneumophila• MSSA• Chlamydia psittaci• M. Catarrhalis• H. influenzae• S. pneumoniae• Burkholderia cepacia• PCP/ P jiroveci• MRSA• M tuberculosis• MSSA or MRSA• Chlamydia pneumoniae

Answer 279

Correct G. S. pneumoniae

Question 280

A 35 year old clown who is a specialist in bird/clown comedy is found to have an atypical pneumonia which is treated with Augmentin and Clarythromicin• Anaerobic infection• Legionella pneumophila• MSSA• Chlamydia psittaci• M. Catarrhalis• H. influenzae• S. pneumoniae• Burkholderia cepacia• PCP/ P jiroveci• MRSA• M tuberculosis• MSSA or MRSA• Chlamydia pneumoniae

Answer 280

Correct D. Chlamydia psittaci

Question 281

19 year old male presents to A&E with severe respiratory difficulty, light-headedness and a red itchy rash. On examination he has laryngeal oedema, bilateral wheezing across the lung fields and is hypotensive. He has recently been taking antibiotics for a chest infection.• Contact dermatitis• Anaphylaxis• Acute Urticaria• Food allergy• Chronic Urticaria• Angioedema• Allergic bronchopulmonary Aspergillosis• Allergic asthma• Drug allergy• Allergic Rhinitis

Answer 281

Correct B. AnaphylaxisResponse Feedback: With regards to the first question, whilst the anaphylaxis is most likely due to a drug allergy, it is important to note that this is an anaphylactic reaction. The answer 'drug allergy' does not emphasise the type of reaction occuring. Note that ambiguous questions will NOT appear on your exam - these questions have been written by students. For a discussion about anaphylaxis vs anaphylactoid reactions see attached file.

Question 282

A 3 year old girl is brought into A&E by her parents. She has had vomiting and diarrhoea since early yesterday evening when she was at a birthday party. On examination she has urticaria.• Contact dermatitis• Anaphylaxis• Acute Urticaria• Food allergy• Chronic Urticaria• Angioedema• Allergic bronchopulmonary Aspergillosis• Allergic asthma• Drug allergy• Allergic Rhinitis

Answer 282

Correct D. Food allergy

Question 283

A 40 year old man presents to his GP complaining of loss smell and nasal itching and discharge. On examination his nasal mucosa are swollen and have a bluish tinge. His symptoms improve with a corticosteroid spray• Contact dermatitis• Anaphylaxis• Acute Urticaria• Food allergy• Chronic Urticaria• Angioedema• Allergic bronchopulmonary Aspergillosis• Allergic asthma• Drug allergy• Allergic Rhinitis

Answer 283

Correct J. Allergic Rhinitis

Question 284

A 25 year old woman presents to her GP complaining of itchy, red wheals on her torso which have been present for 7 weeks. She can not remember how they started but has noticed they are worse in the heat and when she exercises.• Contact dermatitis• Anaphylaxis• Acute Urticaria• Food allergy• Chronic Urticaria• Angioedema• Allergic bronchopulmonary Aspergillosis• Allergic asthma• Drug allergy• Allergic Rhinitis

Answer 284

Correct E. Chronic Urticaria

Question 285

A 30 year old women presents to her GP with a red, itchy, oozing rash around her neck and fingers• Contact dermatitis• Anaphylaxis• Acute Urticaria• Food allergy• Chronic Urticaria• Angioedema• Allergic bronchopulmonary Aspergillosis• Allergic asthma• Drug allergy• Allergic Rhinitis

Answer 285

Correct A. Contact dermatitis

Question 286

A 55 year old man with history of angina was advised to take a tablet before a long flight. After taking the pill, he suddenly finds that he has difficulty breathing, feels nauseous and is itching.• Allergic asthma• Urticarial vasculitis• Chronic urticaria• Panic attack• Acute urticaria• C1 inhibitor deficiency• IgE mediated anaphylaxis• Mast cell degranulation• Extrinsic allergic alveolitis• Coeliac disease• Idiopathic angioedema

Answer 286

Correct H. Mast cell degranulationMast cell degranulation is not IgE mediated.

Question 287

A 24 year old medical student develops worsening swelling of the hands and feet and abdominal pain before her final year medical exams. She says that similar milder episodes have occurred preciously.• Allergic asthma• Urticarial vasculitis• Chronic urticaria• Panic attack• Acute urticaria• C1 inhibitor deficiency• IgE mediated anaphylaxis• Mast cell degranulation• Extrinsic allergic alveolitis• Coeliac disease• Idiopathic angioedema

Answer 287

Correct F. C1 inhibitor deficiency

Question 288

A 50 year old Irish woman presents to her GP with episodes of diarrhoea, which is difficult to flush, abdominal pain, weight loss and fatigue. She also describes a blistering itchy rash on her knees.• Allergic asthma• Urticarial vasculitis• Chronic urticaria• Panic attack• Acute urticaria• C1 inhibitor deficiency• IgE mediated anaphylaxis• Mast cell degranulation• Extrinsic allergic alveolitis• Coeliac disease• Idiopathic angioedema

Answer 288

Correct J. Coeliac diseaseCoeliac disease is associated with a superficial, blistering skin rash 'dermatitis herpetiformis', which is intensely itchy!

Question 289

A 26 year old male who has been suffering from ‘flu-like’ symptoms with fever presents to the GP after developing skin rash in the last few days.• Allergic asthma• Urticarial vasculitis• Chronic urticaria• Panic attack• Acute urticaria• C1 inhibitor deficiency• IgE mediated anaphylaxis• Mast cell degranulation• Extrinsic allergic alveolitis• Coeliac disease• Idiopathic angioedema

Answer 289

Correct E. Acute urticaria

Question 290

A 35 year old woman presents with persistent itchy wheels for the last 2 months. She noticed that when this is at its worst, she also has a fever and feels generally unwell. After an acute attack, she has bruising and post-inflammatory residual pigmentation at the site of the itching.• Allergic asthma• Urticarial vasculitis• Chronic urticaria• Panic attack• Acute urticaria• C1 inhibitor deficiency• IgE mediated anaphylaxis• Mast cell degranulation• Extrinsic allergic alveolitis• Coeliac disease• Idiopathic angioedema

Answer 290

Correct B. Urticarial vasculitis

Question 291

A 19 year old male presents to A&E with increasing breathlessness. On examination his blood pressure is 90/55 mmHg and his respiratory rate is 28/min. He shows you a generalised red itchy skin rash, and examination of his chest reveals bilateral inspiratory and expiratory wheezes throughout.• Acute urticaria• Allergic conjunctivitis• Acute angioedema• Anaphylaxis• Chronic urticaria• Contact hypersensitivity• Allergic asthma• Hereditary angioedema• Allergic rhinitis• Allergic bronchopulmonary aspergillosis

Answer 291

Correct D. AnaphylaxisThe combination of hypotension, respiratory distress, urticaria and bronchoconstriction is very suggestive of anaphylaxis

Question 292

A 35 year old woman presents with a two day history of a red itchy skin rash which started soon after her first scuba-diving lesson. She is otherwise well.• Acute urticaria• Allergic conjunctivitis• Acute angioedema• Anaphylaxis• Chronic urticaria• Contact hypersensitivity• Allergic asthma• Hereditary angioedema• Allergic rhinitis• Allergic bronchopulmonary aspergillosis

Answer 292

Correct A. Acute urticariaThis rash is very suggestive of acute urticaria. The temporal association with scuba diving may indicate an allergy to latex (in wet suits).

Question 293

A 22 year old woman presents with an intermittently itchy and desquamating skin rash on her abdomen which is unresponsive to antihistamines• Acute urticaria• Allergic conjunctivitis• Acute angioedema• Anaphylaxis• Chronic urticaria• Contact hypersensitivity• Allergic asthma• Hereditary angioedema• Allergic rhinitis• Allergic bronchopulmonary aspergillosis

Answer 293

Correct F. Contact hypersensitivityThis rash is typical of contact hypersensitivity. The distribution of the rash suggests that the specific agent is nickel, which used to be a component of the studs of jeans and is commonly found in the metal used in belts.

Question 294

A 40 year old man complains of loss of smell with nasal itching and discharge over 4 weeks. He also describes morning sneezing. He is otherwise in good health. On examination his nasal mucosa are swollen and hyperaemic.• Acute urticaria• Allergic conjunctivitis• Acute angioedema• Anaphylaxis• Chronic urticaria• Contact hypersensitivity• Allergic asthma• Hereditary angioedema• Allergic rhinitis• Allergic bronchopulmonary aspergillosis

Answer 294

Correct I. Allergic rhinitisThe combination of sneezing, rhinorrhea and loss of smell is very suggestive of allergic rhinitis

Question 295

This 45 year old woman presents to A&E with tongue swelling and acute respiratory tract obstruction. She has longstanding hypertension and received a renal transplant two years previously. She has no history of allergic disease. On examination her blood pressure is stable, and examination of her lung fields reveal normal breath sounds. Her current medication includes cyclosporine, azathioprine, captopril and nifedipine.• Acute urticaria• Allergic conjunctivitis• Acute angioedema• Anaphylaxis• Chronic urticaria• Contact hypersensitivity• Allergic asthma• Hereditary angioedema• Allergic rhinitis• Allergic bronchopulmonary aspergillosis

Answer 295

Correct C. Acute angioedemaThis woman has angioedema of the tongue, without symptoms suggestive of a generalised allergic reaction. Isolated angioedema may be allergic in origin, but 94% of cases angioedema presenting to A&E are drug induced and the majority of these are associated with ACE inhibitors (eg captopril).

Question 296

A 19 year old male presents to A&E with increasing breathlessness. On examination his blood pressure is 90/55 mmHg and his respiratory rate is 28/min. He shows you a generalised red itchy skin rash, and examination of his chest reveals bilateral inspiratory and expiratory wheezes throughout.• IM adrenaline 1mL of 1:1000• Venom immunotherapy• IV adrenaline 0.3mL of 1:1000• IM adrenaline 0.5 mL of 1:1000• Intranasal antihistamines• None of the above• PO antihistamines• IV antihistamines• Intraarticular corticosteroids• IM adrenaline 1mL of 1:10000• Inhaled antihistamines• Intracardiac adrenaline• Inhaled corticosteroids

Answer 296

Correct A. IM adrenaline 1mL of 1:1000The most important treatment of anaphylaxis is adrenaline, which should be given intramuscularly. (Note for final year pharm: 1:1000 means 1mg/mL; 1:10000 means 0.1mg/mL ; 1% means 1g/dL)

Question 297

A 35 year old woman presents with a two day history of a red itchy skin rash which started soon after her first scuba-diving lesson. She is otherwise well.• IM adrenaline 1mL of 1:1000• Venom immunotherapy• IV adrenaline 0.3mL of 1:1000• IM adrenaline 0.5 mL of 1:1000• Intranasal antihistamines• None of the above• PO antihistamines• IV antihistamines• Intraarticular corticosteroids• IM adrenaline 1mL of 1:10000• Inhaled antihistamines• Intracardiac adrenaline• Inhaled corticosteroids

Answer 297

Correct G. PO antihistaminesSevere acute urticaria is effectively treated with a short course of oral anti-histamines

Question 298

A 22 year old woman is presents with this intermittently itchy and desquamating skin rash which is unresponsive to antihistamines• IM adrenaline 1mL of 1:1000• Venom immunotherapy• IV adrenaline 0.3mL of 1:1000• IM adrenaline 0.5 mL of 1:1000• Intranasal antihistamines• None of the above• PO antihistamines• IV antihistamines• Intraarticular corticosteroids• IM adrenaline 1mL of 1:10000• Inhaled antihistamines• Intracardiac adrenaline• Inhaled corticosteroids

Answer 298

Correct F. None of the aboveContact hypersensitivity should be treated by avoidance of the sensitising agent, in this case nickel

Question 299

A 40 year old man complains of loss of smell with nasal itching and discharge over 4 weeks. He also describes morning sneezing. He is otherwise in good health. On examination his nasal mucosa are swollen and hyperaemic.• IM adrenaline 1mL of 1:1000• Venom immunotherapy• IV adrenaline 0.3mL of 1:1000• IM adrenaline 0.5 mL of 1:1000• Intranasal antihistamines• None of the above• PO antihistamines• IV antihistamines• Intraarticular corticosteroids• IM adrenaline 1mL of 1:10000• Inhaled antihistamines• Intracardiac adrenaline• Inhaled corticosteroids

Answer 299

Correct G. PO antihistaminesOral antihistamines and intranasal corticosteroids are the mainstay of treatment of mild allergic rhinitis. (As intranasal corticosteroid is not an option available, the “single best” answer here is oral antihistamines.)

Question 300

This 45 year old woman presents to A&E with tongue swelling and acute respiratory tract obstruction. She has longstanding hypertension and received a renal transplant two years previously. She has no history of allergic disease. On examination her blood pressure is stable, and examination of her lung fields reveal normal breath sounds. Her current medication includes cyclosporine, azathioprine, captopril and nifedipine.• IM adrenaline 1mL of 1:1000• Venom immunotherapy• IV adrenaline 0.3mL of 1:1000• IM adrenaline 0.5 mL of 1:1000• Intranasal antihistamines• None of the above• PO antihistamines• IV antihistamines• Intraarticular corticosteroids• IM adrenaline 1mL of 1:10000• Inhaled antihistamines• Intracardiac adrenaline• Inhaled corticosteroids

Answer 300

Correct D. IM adrenaline 0.5 mL of 1:1000Intramuscular adrenalin should be used in patients with severe local angioedema with secondary acute respiratory tract obstruction. However this is not always effective in ACE inhibitor-induced angioedema, and some patients will require intubation. Always stop the causative agent!

Question 301

Cytokines exerting an anti-viral effect• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 301

Correct J. Interferons

Question 302

Immunoglobulin dimer• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 302

Correct E. IgA

Question 303

MHC associated with Th1 cells• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 303

Correct M. Major histocompatability complex class 2

Question 304

Acts on hepatocytes to induce synthesis of acute phase proteins in response to bacterial infection• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 304

Correct K. IL6

Question 305

Arise in the first few days after infection and are important in defence against viruses and tumours• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 305

Correct I. Natural Killer cells

Question 306

MHC associated with Th2 cells• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 306

Correct M. Major histocompatability complex class 2T helper cells are CD4+ and bind MHC class II ; cytotoxic T cells are CD8+ and bind MHC class I.

Question 307

MHC associated with cytotoxic T cells• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 307

Correct G. Major histocompatability complex class 1T helper cells are CD4+ and bind MHC class II ; cytotoxic T cells are CD8+ and bind MHC class I.

Question 308

Along with IgD, is one of the first immunoglobulins expressed on B cells before they undergo antibody class switching• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 308

Correct H. IgM

Question 309

The most abundant (in terms of g/L) immunoglobulin in normal plasma• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 309

Correct L. IgG

Question 310

Deficiencies in this predispose to SLE• Alternative complement pathway• CD8+• IgE• Classical complement pathway• IgA• Innate immune system• Major histocompatability complex class 1• IgM• Natural Killer cells• Interferons• IL6• IgG• Major histocompatability complex class 2

Answer 310

Correct D. Classical complement pathway

Question 311

Kostmanns syndrome is a congenital deficiency of which component of the immune system?• T lymphocyte• Mast cell• Complement• Fungal• Neutrophil• MHC Class I• MHC Class II• B lymphocyte• Parasitic• Viral• Bacterial

Answer 311

Correct E. Neutrophil

Question 312

Which component of the innate immune system is usually one of the first to respond to infection through a cut?• T lymphocyte• Mast cell• Complement• Fungal• Neutrophil• MHC Class I• MHC Class II• B lymphocyte• Parasitic• Viral• Bacterial

Answer 312

Correct E. Neutrophil

Question 313

Which infection is most common as a consequence of B cell deficiency?• T lymphocyte• Mast cell• Complement• Fungal• Neutrophil• MHC Class I• MHC Class II• B lymphocyte• Parasitic• Viral• Bacterial

Answer 313

Correct K. Bacterial

Question 314

Meningococcal infections are quite common as a result of which deficiency of the component of the immune system?• T lymphocyte• Mast cell• Complement• Fungal• Neutrophil• MHC Class I• MHC Class II• B lymphocyte• Parasitic• Viral• Bacterial

Answer 314

Correct C. Complemental

Question 315

Produced by the liver, when triggered, enzymatically activate other proteins in a biological cascade and are important in innate and antibody mediated immune response?• T lymphocyte• Mast cell• Complement• Fungal• Neutrophil• MHC Class I• MHC Class II• B lymphocyte• Parasitic• Viral• Bacterial

Answer 315

Correct C. Complement

Question 316

A complete deficiency in this molecule is associated with recurrent respiratory and gastrointestinal infections.• C3b• MAC• Neutrophils• AP50• C1• C3a• IgM• IgA• Myeloperoxidase• Macrophages• IgG• NADPH oxidoase• CH50

Answer 316

Correct H. IgA

Question 317

Leukocyte Adhesion Deficiency is characterised by a very high count in which of the above?• C3b• MAC• Neutrophils• AP50• C1• C3a• IgM• IgA• Myeloperoxidase• Macrophages• IgG• NADPH oxidoase• CH50

Answer 317

Correct C. Neutrophils

Question 318

Which crucial enzyme is vital for the oxidative killing of intracellular micro-organisms?• C3b• MAC• Neutrophils• AP50• C1• C3a• IgM• IgA• Myeloperoxidase• Macrophages• IgG• NADPH oxidoase• CH50

Answer 318

Correct L. NADPH oxidoase

Question 319

Which complement factor is an important chemotaxic agent?• C3b• MAC• Neutrophils• AP50• C1• C3a• IgM• IgA• Myeloperoxidase• Macrophages• IgG• NADPH oxidoase• CH50

Answer 319

Correct F. C3a

Question 320

What is the functional complement test used to investigate the classical pathway?• C3b• MAC• Neutrophils• AP50• C1• C3a• IgM• IgA• Myeloperoxidase• Macrophages• IgG• NADPH oxidoase• CH50

Answer 320

Correct M. CH50

Question 321

Graves Disease• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 321

Correct A. Type II – Antibody mediated

Question 322

SLE• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 322

Correct H. Type III – Immune complex mediated

Question 323

Rheumatoid arthritis• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 323

Correct D. Type IV – T-cell mediated

Question 324

Asthma• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 324

Correct E. Not an autoimmune disease

Question 325

Type 1 diabetes• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 325

Correct D. Type IV – T-cell mediated

Question 326

Immune thrombocytopaenic purpura• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 326

Correct A. Type II – Antibody mediated

Question 327

ABO hemolytic transfusion reaction• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 327

Correct A. Type II – Antibody mediated

Question 328

Hepatitis C associated membranoproliferative glomerulonephritis type I• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 328

Correct H. Type III – Immune complex mediated

Question 329

Goodpasture's syndrome• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 329

Correct A. Type II – Antibody mediated

Question 330

Myaesthenia gravis• Type II – Antibody mediated• Type II – Antigen mediated• Type III – complement mediated• Type IV – T-cell mediated• Not an autoimmune disease• Type III – T-cell mediated• Type IV – Complement mediated• Type III – Immune complex mediated

Answer 330

Correct A. Type II – Antibody mediated

Question 331

Systemic lupus erythematosis• Anti-GAD antibody• c-ANCA• p-ANCA• Anti-nuclear antibody• Anti-mitochondrial antibody• Anti-CCP antibody• Anti-DNA antibody• Coomb's test• Anti-cardiolipin antibody• Anti-centromere antibody• Rheumatoid factor

Answer 331

Correct G. Anti-DNA antibodyThe rationale for the answer for SLE being anti-DNA antibody rather than ANA is that whilst ANA is very sensitive for SLE, it is not specific. Anti-DNA, in contrast, is highly specific to SLE (~95%).

Question 332

Wegener's granulomatosis• Anti-GAD antibody• c-ANCA• p-ANCA• Anti-nuclear antibody• Anti-mitochondrial antibody• Anti-CCP antibody• Anti-DNA antibody• Coomb's test• Anti-cardiolipin antibody• Anti-centromere antibody• Rheumatoid factor

Answer 332

Correct B. c-ANCARemember that c-ANCA matches with Wegener's Granulomatosis, whilst p-ANCA would match with polyarteritis nodosa

Question 333

Rheumatoid arthritis• Anti-GAD antibody• c-ANCA• p-ANCA• Anti-nuclear antibody• Anti-mitochondrial antibody• Anti-CCP antibody• Anti-DNA antibody• Coomb's test• Anti-cardiolipin antibody• Anti-centromere antibody• Rheumatoid factor

Answer 333

Correct F. Anti-CCP antibodyRheumatoid factor is not specific or sensitive to rheumatoid arthritis and is common in the elderly. Anti-CCP is a more specific test for rheumatoid arthritis and a better predictor of an aggressive course.

Question 334

Auto-immune haemolytic anaemia• Anti-GAD antibody• c-ANCA• p-ANCA• Anti-nuclear antibody• Anti-mitochondrial antibody• Anti-CCP antibody• Anti-DNA antibody• Coomb's test• Anti-cardiolipin antibody• Anti-centromere antibody• Rheumatoid factor

Answer 334

Correct H. Coomb's test

Question 335

Primary biliary cirrhosis• Anti-GAD antibody• c-ANCA• p-ANCA• Anti-nuclear antibody• Anti-mitochondrial antibody• Anti-CCP antibody• Anti-DNA antibody• Coomb's test• Anti-cardiolipin antibody• Anti-centromere antibody• Rheumatoid factor

Answer 335

Correct E. Anti-mitochondrial antibody

Question 336

What is the specific auto-antigen that is the target of the immune system in Goodpasture's syndrome?• Blood vessels• Smooth linear pattern• Type II Hypersentivity• Prednisolone• Lumpy-bumpy pattern• Ciclosporin• Glomerular basement membrane• Anti-neutrophil cytoplasmic antibodies• Lung• Skin• Type II collagen• Type IV collagen• Mesangium• Plasmapheresis

Answer 336

Correct L. Type IV collagenpoorly written question...

Question 337

The pattern of the antibody deposition in the glomerular basement membrane in Goodpasture's syndrome is typically described as what?• Blood vessels• Smooth linear pattern• Type II Hypersentivity• Prednisolone• Lumpy-bumpy pattern• Ciclosporin• Glomerular basement membrane• Anti-neutrophil cytoplasmic antibodies• Lung• Skin• Type II collagen• Type IV collagen• Mesangium• Plasmapheresis

Answer 337

Correct B. Smooth linear pattern

Question 338

Name the drug most likely to be used in the treatment of Goodpasture's syndrome.• Blood vessels• Smooth linear pattern• Type II Hypersentivity• Prednisolone• Lumpy-bumpy pattern• Ciclosporin• Glomerular basement membrane• Anti-neutrophil cytoplasmic antibodies• Lung• Skin• Type II collagen• Type IV collagen• Mesangium• Plasmapheresis

Answer 338

Correct D. Prednisolonebad question

Question 339

Immune damage may be associated with the kidney and commonly which other tissue in Goodpasture's syndrome?• Blood vessels• Smooth linear pattern• Type II Hypersentivity• Prednisolone• Lumpy-bumpy pattern• Ciclosporin• Glomerular basement membrane• Anti-neutrophil cytoplasmic antibodies• Lung• Skin• Type II collagen• Type IV collagen• Mesangium• Plasmapheresis

Answer 339

Correct I. Lung

Question 340

Which of the following demonstrates proteinaceous material and inflammatory cells only?• Acute mastitis• Breast abscess• Duct ectasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Fibrocystic disease• Intraductal papilloma• Invasive cancer• Paget's disease• Peau d'orange• Phyllodes tumour

Answer 340

Duct ectasia

Question 341

Which of the following is a fibroepithelial tumour, most common in women \>40 years of age?• Acute mastitis• Breast abscess• Duct ectasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Fibrocystic disease• Intraductal papilloma• Invasive cancer• Paget's disease• Peau d'orange• Phyllodes tumour

Answer 341

Phyllodes tumour

Question 342

Which of the following is the most common non-invasive breast neoplasm?• Acute mastitis• Breast abscess• Duct ectasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Fibrocystic disease• Intraductal papilloma• Invasive cancer• Paget's disease• Peau d'orange• Phyllodes tumour

Answer 342

Ductal carcinoma in situ

Question 343

Which of the following describes a benign breast change associated with hormonal changes/menstruation?• Acute mastitis• Breast abscess• Duct ectasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Fibrocystic disease• Intraductal papilloma• Invasive cancer• Paget's disease• Peau d'orange• Phyllodes tumour

Answer 343

Fibrocystic disease (now called fibrocystic breast changes...)

Question 344

Which of the following best describes a common infection in lactating women, most commonly within the first 6 weeks postpartum?• Acute mastitis• Breast abscess• Duct ectasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Fibrocystic disease• Intraductal papilloma• Invasive cancer• Paget's disease• Peau d'orange• Phyllodes tumour

Answer 344

Acute mastitis

Question 345

A younger patient presents with a solid, well-defined lump in her breast. FNAC shows benign cells.• Acute pyogenic mastitis• Ductal carcinoma in situ• Duct ectasia• Fat necrosis• Fibroadenoma• Fibrocystic changes• Intraductal papilloma• Invasive ductal carcinoma• Lipoma• Lobular carcinoma in situ• Mucinous carcinoma• Phyllodes tumour• Radial scar

Answer 345

Fibroadenoma

Question 346

FNAC is performed on a tender lump in the breast of a woman who gave birth 5 weeks ago. Neutrophils and inflammatory debris are seen but no malignant cells.• Acute pyogenic mastitis• Ductal carcinoma in situ• Duct ectasia• Fat necrosis• Fibroadenoma• Fibrocystic changes• Intraductal papilloma• Invasive ductal carcinoma• Lipoma• Lobular carcinoma in situ• Mucinous carcinoma• Phyllodes tumour• Radial scar

Answer 346

Duct ectasia

Question 347

Mammography of a hard lump shows a stellate mass with microcalcification. As well as the primary lump, enlarged axillary lymph nodes are present in the patient.• Acute pyogenic mastitis• Ductal carcinoma in situ• Duct ectasia• Fat necrosis• Fibroadenoma• Fibrocystic changes• Intraductal papilloma• Invasive ductal carcinoma• Lipoma• Lobular carcinoma in situ• Mucinous carcinoma• Phyllodes tumour• Radial scar

Answer 347

Invasive ductal carcinoma

Question 348

Women with this condition present with thick, creamy discharge with an underlying mass. Cytology shows no epithelial cells, but macrophages and debris are present• Acute pyogenic mastitis• Ductal carcinoma in situ• Duct ectasia• Fat necrosis• Fibroadenoma• Fibrocystic changes• Intraductal papilloma• Invasive ductal carcinoma• Lipoma• Lobular carcinoma in situ• Mucinous carcinoma• Phyllodes tumour• Radial scar

Answer 348

Acute pyogenic mastitis

Question 349

This is an acute, inflammatory condition, characterised commonly by the presence of Staph. aureus in breastfeeding women.• Atypical ductal hyperplasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Invasive papillary adenoma• Lipoma• Lobular carcinoma in situ• Mammary duct ectasia• Mastitis• Mucinous carcinoma• Pyllodes tumour• Sclerosing adenosis

Answer 349

Mastitis

Question 350

This is a condition which may present as a painless, palpable mass, skin thickening/retraction, mammographic density or mammographic calcifications. Most affected women have a history of breast trauma or surgery.• Atypical ductal hyperplasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Invasive papillary adenoma• Lipoma• Lobular carcinoma in situ• Mammary duct ectasia• Mastitis• Mucinous carcinoma• Pyllodes tumour• Sclerosing adenosis

Answer 350

Fat necrosis

Question 351

Histologically, the acini are compressed and distorted by dense stroma. The acini are arranged in a swirling pattern and the outer border is well circumscribed.• Atypical ductal hyperplasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Invasive papillary adenoma• Lipoma• Lobular carcinoma in situ• Mammary duct ectasia• Mastitis• Mucinous carcinoma• Pyllodes tumour• Sclerosing adenosis

Answer 351

Sclerosing adenosis

Question 352

An incidental biopsy finding, not associated with calcifications or stromal reactions and does not produce mammographic densities. More common in pre-menopausal women.• Atypical ductal hyperplasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Invasive papillary adenoma• Lipoma• Lobular carcinoma in situ• Mammary duct ectasia• Mastitis• Mucinous carcinoma• Pyllodes tumour• Sclerosing adenosis

Answer 352

Lobular carcinoma in situ

Question 353

A radiographically well circumscribed mass which is grossly rubbery, white, mobile and clearly demarcated from the surrounding yellow adipose tissue. The epithelium of this mass is hormonally responsive and an increase in size may occur during pregnancy. In older women, the stroma typically becomes densely hyalinised and the epithelium atrophic.• Atypical ductal hyperplasia• Ductal carcinoma in situ• Fat necrosis• Fibroadenoma• Invasive papillary adenoma• Lipoma• Lobular carcinoma in situ• Mammary duct ectasia• Mastitis• Mucinous carcinoma• Pyllodes tumour• Sclerosing adenosis

Answer 353

Fibroadenoma

Question 354

A 25 year old woman presents 2 weeks after the birth of her child with pain in her left breast. O/E she has a tender, 5cm swelling adjacent to her nipple.

Answer 354

Breast abscess

Question 355

50yo woman presents with discharge of thick, creamy fluid from her R nipple. O/E there is a poorly defined sub-areolar mass. Cytology shows macrophages and debris while an ultrasound identifies dilated sub-areolar ducts.

Answer 355

Duct ectasia

Question 356

47yo woman presents with 4 week history of blood stained discharge from her L nipple. Examination is unremarkable and no lumps are palpable.

Answer 356

Duct papilloma

Question 357

21yo woman presents with a 2cm mobile lump. Ultrasound identifies a solid, well-defined mass. FNAC shows benign cells.

Answer 357

Fibroadenoma

Question 358

36yo woman presents with an ill-defined lump in the R breast. She reports that it enlarges and becomes tender in the second phase of her menstrual cycle.

Answer 358

Fibrocystic changes

Question 359

Rank these complications in the chronological order (from most immediate to late) that are likely to happen after a myocardial infarction. A PericarditisB Dressler SyndromeC Myocardial RuptureD Ventricular AneurysmE Ventricular Fibrillation

Answer 359

EACBD from immediate to late.E – Serious/life threatening arrhythmias (such as ventricular fibrillation) are mostly likely to happen within the first hour after a MI. This is often a cause of sudden deathA – Pericarditis – Transmural MIs can cause fibrinohemorrhagic pericarditis (due to myocardial inflammation) and usually appears 2-3 days after an infarction.C – Myocardial rupture are caused by the lysis of myocardial connective tissue which reaches maximum stage during day 3-7. This causes the infarcted muscles to become soft, friable granulation tissue.B – Dressler syndrome specifically refers to pericarditis that occurs from week 2 to months afterwards which is believed to be caused by autoimmune inflammation of the infarct.D – Ventricular aneurysm is a late complication after a MI (months) caused by the thin wall of the scar tissue of the MI

Question 360

A 65-year-old chronic alcoholic presents to the A&E Department with a minor head injury. On examination he is found to be pale. Blood tests show a high MCV. What is the likeliest result of MCV (fl) in a normal person?A. 30B. 290C. 2.2D. 90E. 130F. 15G. 4

Answer 360

Correct D. 90

Question 361

A 40-year-old woman presents with a two month history of tiredness, intermittent pyrexia and abdominal pain. On examination she has an enlarged palpable spleen. Blood tests show anaemia with a raised white cell count. What is the likeliest result of a white cell count (x 109 per l) in a normal person?A. 30B. 290C. 2.2D. 90E. 130F. 15G. 4

Answer 361

Correct G. 4

Question 362

A 5-year-old boy presents with a purpuric rash and petechiae following a recent viral infection. Blood tests showed thrombocytopenia. What is the likeliest result of a platelet count (x109/l) in a normal adult?A. 30B. 290C. 2.2D. 90E. 130F. 15G. 4

Answer 362

Correct B. 290

Question 363

A 35-year-old man presents with hypertension. Blood tests show normal sodium, urea and glucose and a raised potassium. What is the likeliest result of potassium (mmol/l) in a normal person?A. 30B. 290C. 2.2D. 90E. 130F. 15G. 4

Answer 363

Correct G. 4

Question 364

A 70-year-old woman presents in a coma with a long history of polyuria and polydipsia. Investigations show that her plasma osmolarity is raised. What is the likeliest result of plasma osmolarity (mmol/l) in a normal person?A. 30B. 290C. 2.2D. 90E. 130F. 15G. 4

Answer 364

Correct B. 290

Question 365

A 14-year-old boy presents with symptoms of chronic liver failure. LFTs display abnormally high levels of transaminases with normal alk phos & bilirubin levels. There’s marked accumulation of copper-associated protein in hepatocytes obtained from a biopsy. His serum copper levels and caeruloplasmin are abnormally low.A. Chronic hepatitis CB. Chronic hepatitis BC. Budd-Chiari syndromeD. Wilson's diseaseE. Primary biliary cirrhosisF. Primary hepatocellular carcinomaG. Hepatitis AH. Crigler Najjar syndrome

Answer 365

Correct D. Wilson's disease

Question 366

A 30-year-old Thai male presents to a day surgery unit for a cholecystectomy. His LFTs reveal very elevated transaminases with normal bilirubin & alk phos levels. Microscopy of a liver biopsy identifies antigens from a dsDNA virus in the cytosol of hepatocytes.A. Chronic hepatitis CB. Chronic hepatitis BC. Budd-Chiari syndromeD. Wilson's diseaseE. Primary biliary cirrhosisF. Primary hepatocellular carcinomaG. Hepatitis AH. Crigler Najjar syndrome

Answer 366

Correct B. Chronic hepatitis B

Question 367

A 58-year-old woman presents with recent onset of Jaundice. LFTs reveal increased bilirubin & markedly elevated alk phos & normal transaminases. Further investigations uncovered raised IgM and serum cholesterol. Anti mitochondrial antibodies are also detected. A liver biopsy shows enlargement of the portal tracts by white blood cells and granulomas. Bile ducts are also less than normal.A. Chronic hepatitis CB. Chronic hepatitis BC. Budd-Chiari syndromeD. Wilson's diseaseE. Primary biliary cirrhosisF. Primary hepatocellular carcinomaG. Hepatitis AH. Crigler Najjar syndrome

Answer 367

Correct E. Primary biliary cirrhosis

Question 368

A 48-year-old male returning from a 6mths round the world trip presents with a recent Hx of nausea, anorexia & distaste for cigarettes. He developed jaundice; his urine became dark and his stools pale. His spleen was palpable. Investigations showed bilirubinuria, increased urinary urobilinogen & a raised serum AST & ALT. Within 4 weeks his symptoms had completely subsided.A. Chronic hepatitis CB. Chronic hepatitis BC. Budd-Chiari syndromeD. Wilson's diseaseE. Primary biliary cirrhosisF. Primary hepatocellular carcinomaG. Hepatitis AH. Crigler Najjar syndrome

Answer 368

Correct G. Hepatitis A

Question 369

A 55-year-old woman presents with a short Hx of nausea and abdominal pain; tender hepatomegaly and ascities. LFTs show mildly raised transaminases, bilirubin and normal alk phos. The woman also had polycythaemia rubra vera. Liver biopsy suggests venous outflow obstruction.A. Chronic hepatitis CB. Chronic hepatitis BC. Budd-Chiari syndromeD. Wilson's diseaseE. Primary biliary cirrhosisF. Primary hepatocellular carcinomaG. Hepatitis AH. Crigler Najjar syndrome

Answer 369

Correct C. Budd-Chiari syndrome

Question 370

A liver enzyme raised after a myocardial infarctionA. Direct bilirubinB. Activated partial thromboplastin timeC. Prothrombin timeD. Alkaline phosphataseE. AlbuminF. Gamma glutamyl transpeptidaseG. Alanine transaminaseH. Aspartate transaminaseI. Gamma globulinJ. Total bilirubin

Answer 370

Correct H. Aspartate transaminase

Question 371

A test of the integrity of the extrinsic pathwayA. Direct bilirubinB. Activated partial thromboplastin timeC. Prothrombin timeD. Alkaline phosphataseE. AlbuminF. Gamma glutamyl transpeptidaseG. Alanine transaminaseH. Aspartate transaminaseI. Gamma globulinJ. Total bilirubin

Answer 371

Correct C. Prothrombin timeThe intrinsic pathway is initiated by the activation of the 'contact factor' of plasma and can be measured by the APTT test. The extrinsic pathway is initiated by the release of tissue factor and can be measured by the PT test.

Question 372

An enzyme markedly raised in obstructive jaundice along with direct bilirubinA. Direct bilirubinB. Activated partial thromboplastin timeC. Prothrombin timeD. Alkaline phosphataseE. AlbuminF. Gamma glutamyl transpeptidaseG. Alanine transaminaseH. Aspartate transaminaseI. Gamma globulinJ. Total bilirubin

Answer 372

Correct D. Alkaline phosphatase

Question 373

Raised in alcohol abuseA. Direct bilirubinB. Activated partial thromboplastin timeC. Prothrombin timeD. Alkaline phosphataseE. AlbuminF. Gamma glutamyl transpeptidaseG. Alanine transaminaseH. Aspartate transaminaseI. Gamma globulinJ. Total bilirubin

Answer 373

Correct F. Gamma glutamyl transpeptidase

Question 374

Levels can be affected by dietA. Direct bilirubinB. Activated partial thromboplastin timeC. Prothrombin timeD. Alkaline phosphataseE. AlbuminF. Gamma glutamyl transpeptidaseG. Alanine transaminaseH. Aspartate transaminaseI. Gamma globulinJ. Total bilirubin

Answer 374

Correct E. Albumin

Question 375

A 26-year-old receptionist presents to her GP with a history steatorrhoea, abdominal pain and weight loss, as well as feeling tired all the time. Initial blood tests reveal a microcytic anaemia.A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 375

Correct F. Anti-endomysial antibodies(1) Coeliac disease: Anti-endomysial antibodies/ Tissue-transglutaminase antibodies

Question 376

A 60-year-old woman with hypothyroidism presents with progressive dyspnoea and tiredness. FBC reveals macrocytic anaemia.A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 376

Correct K. Anti-gastric parietal cell antibodies(2) Pernicious anaemia: Anti-intrinsic factor antibodies, and gastric parietal antibodies.

Question 377

A 40-year-old plumber presents to his GP with a history of wheezing and lethargy, along with recurrent nose bleeds. On examination he has crackles in his upper left lung field. Urine dipstick is positive for blood and protein.A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 377

Correct G. c-ANCA(3) Wegener's : Antibody to Proteinase-3 : 3 is the 3rd letter of the alphabet; c-ANCA.

Question 378

A 30-year-old market trader presents with tiredness and jaundice, and further history reveals he suffered from a chest infection one week previously. On examination mild splenomegaly is noted, and blood tests show reticulocytosis, hyperbilirubinaemia, and spherocytosis.A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 378

Correct M. Osmotic fragility test Spherocytosis: Osmotic fragility test.

Question 379

An 80-year-old retired clerk presents with a 2-month history of skin itching and lethargy. Examination is normal. LFTs are: bilirubin 6umol/l (reference range 0-17umol/l); ALT 24U/l (reference range 0-31U/l); Alk Phos 500U/l (reference range 30-130U/l).A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 379

Correct B. Anti-mitochondrial antibody(5) PBC - AMA E2 subtype of pyruvate dehydrogenase complex

Question 380

A 10-year-old girl presents with weight loss, polyuria, tachypnoea, vomiting. Looks very dehydrated. Beta hydroxybutyrate is raised in the blood.A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 380

Correct I. Anti-GAD(7) Type 1 diabetes: Anti-Glutamic acid decarboxylase antibodies (Anti-GAD).

Question 381

A 55-year-old woman is warned of future risk of AML given her recent diagnosis of PNH following a spontaneous cerebral venous sinus thrombosis.A. p-ANCAB. Anti-mitochondrial antibodyC. Anti-DsDNAD. Anti-scl70E. ANAF. Anti-endomysial antibodiesG. c-ANCAH. Anti-smooth muscle antibodyI. Anti-GADJ. Anti-acetylcholine receptor antibodyK. Anti-gastric parietal cell antibodiesL. Ham's testM. Osmotic fragility test

Answer 381

Correct L. Ham's test(6) Paroxysmal nocturnal haemoglobinuria (PNH): Ham's test.

Question 382

A 40-year-old woman presents with polyuria and polydipsia. She has a fasting glucose 5.1mmol/L and an oral glucose tolerance test value of 5.0mmol/L. She has a corrected calcium of 2.80mmol/L and a PTH of 7.2pmol/L.A. SarcoidosisB. Crohn’s diseaseC. Gestational diabetesD. Impaired fasting glucoseE. Vitamin D deficiencyF. MalignancyG. Primary hyperparathyroidismH. TuberculosisI. Psychogenic polydipsiaJ. Impaired glucose toleranceK. Secondary hyperthyroidismL. Diabetes mellitus type 1M. Diabetes mellitus type 2N. Lung cancerO. Hypocalcaemia

Answer 382

Correct G. Primary hyperparathyroidism

Question 383

A 35-year-old Afro-Caribbean woman presents with polyuria and polydipsia. She also complains of a dry cough. She has a fasting glucose of 5.8mmol/L and an oral glucose tolerance test value of 6.5mmol/L. She has a corrected calcium of 2.7mmol/L and a PTH of

Answer 383

Correct A. Sarcoidosis

Question 384

A 15-year-old girl presents with weight loss, polyuria and polydipsia. Over the last few months she reports feeling increasingly tired and complains of perianal itching. On examination you notice a small perianal abscess. Her fasting glucose is 22.3mmol/L. His corrected calcium is 2.5mmol/L and his PTH is 7.0pmol/L.A. SarcoidosisB. Crohn’s diseaseC. Gestational diabetesD. Impaired fasting glucoseE. Vitamin D deficiencyF. MalignancyG. Primary hyperparathyroidismH. TuberculosisI. Psychogenic polydipsiaJ. Impaired glucose toleranceK. Secondary hyperthyroidismL. Diabetes mellitus type 1M. Diabetes mellitus type 2N. Lung cancerO. Hypocalcaemia

Answer 384

Correct L. Diabetes mellitus type 1

Question 385

A 56-year-old obese woman presents with polyuria and polydipsia. She complains of tiredness and depression. Her fasting glucose is 4.9mmol/L and her OGTT is 4.5mmol/L. She has a corrected calcium of 2.4mmol/L and a PTH of 7.1mmol/L.A. SarcoidosisB. Crohn’s diseaseC. Gestational diabetesD. Impaired fasting glucoseE. Vitamin D deficiencyF. MalignancyG. Primary hyperparathyroidismH. TuberculosisI. Psychogenic polydipsiaJ. Impaired glucose toleranceK. Secondary hyperthyroidismL. Diabetes mellitus type 1M. Diabetes mellitus type 2N. Lung cancerO. Hypocalcaemia

Answer 385

Correct I. Psychogenic polydipsia

Question 386

A 58-year-old Afro-Caribbean gentleman presents with polyuria, polydipsia and weight loss. He has an oral glucose tolerance test of 10.1mmol/L. His corrected calcium is 2.5mmol/L and his PTH is 7.0pmol/L.A. SarcoidosisB. Crohn’s diseaseC. Gestational diabetesD. Impaired fasting glucoseE. Vitamin D deficiencyF. MalignancyG. Primary hyperparathyroidismH. TuberculosisI. Psychogenic polydipsiaJ. Impaired glucose toleranceK. Secondary hyperthyroidismL. Diabetes mellitus type 1M. Diabetes mellitus type 2N. Lung cancerO. Hypocalcaemia

Answer 386

Correct J. Impaired glucose tolerance

Question 387

Varies with posture when sample is taken.A. ALTB. PotassiumC. GlucoseD. AlbuminE. TriglyceridesF. ALPG. Creatinine KinaseH. CortisolI. Urea

Answer 387

Correct D. AlbuminPlasma renin activity also varies with posture - it rises in the upright position. Some people have so-called benign postural and/or exercise-induced albuminuria.

Question 388

Varies with exerciseA. ALTB. PotassiumC. GlucoseD. AlbuminE. TriglyceridesF. ALPG. Creatinine KinaseH. CortisolI. Urea

Answer 388

Correct G. Creatinine Kinase

Question 389

Increases during pregnancyA. ALTB. PotassiumC. GlucoseD. AlbuminE. TriglyceridesF. ALPG. Creatinine KinaseH. CortisolI. Urea

Answer 389

Correct F. ALP

Question 390

Varies with raceA. ALTB. PotassiumC. GlucoseD. AlbuminE. TriglyceridesF. ALPG. Creatinine KinaseH. CortisolI. Urea

Answer 390

Correct G. Creatinine KinaseThere are 3 main iso-forms of CK.CK-MM: present in muscles.CK-BB: Present in Brain.CK-MB: Present in cardiac muscle.

Question 391

Most likely to vary with time of samplingA. ALTB. PotassiumC. GlucoseD. AlbuminE. TriglyceridesF. ALPG. Creatinine KinaseH. CortisolI. Urea

Answer 391

Correct H. Cortisol

Question 392

A 19-year-old woman admitted to hospital with acute asthma suffered a cardiac arrest after treatment. She was already taking several medications for her respiratory condition. What drug excess is likely to have caused this problem?A. Oxidation by cytochrome P450B. Poor complianceC. GentamicinD. KidneysE. LiverF. GI systemG. TheophyllineH. WarfarinI. LungsJ. RosiglitazoneK. DigoxinL. Low therapeutic indexM. Conjugation by sulphate/gluconarideN. High therapeutic index

Answer 392

Correct G. Theophylline

Question 393

Failure to respond to drug therapy is commonly caused by what?A. Oxidation by cytochrome P450B. Poor complianceC. GentamicinD. KidneysE. LiverF. GI systemG. TheophyllineH. WarfarinI. LungsJ. RosiglitazoneK. DigoxinL. Low therapeutic indexM. Conjugation by sulphate/gluconarideN. High therapeutic index

Answer 393

Correct B. Poor compliance

Question 394

Lipid soluble drugs require metabolism by the liver in two phases. What is Phase I?A. Oxidation by cytochrome P450B. Poor complianceC. GentamicinD. KidneysE. LiverF. GI systemG. TheophyllineH. WarfarinI. LungsJ. RosiglitazoneK. DigoxinL. Low therapeutic indexM. Conjugation by sulphate/gluconarideN. High therapeutic index

Answer 394

Correct A. Oxidation by cytochrome P450

Question 395

Drugs are mainly excreted by which organ?A. Oxidation by cytochrome P450B. Poor complianceC. GentamicinD. KidneysE. LiverF. GI systemG. TheophyllineH. WarfarinI. LungsJ. RosiglitazoneK. DigoxinL. Low therapeutic indexM. Conjugation by sulphate/gluconarideN. High therapeutic index

Answer 395

Correct D. Kidneys

Question 396

The effect of which drug can be measured by the surrogate marker HbA1CA. Oxidation by cytochrome P450B. Poor complianceC. GentamicinD. KidneysE. LiverF. GI systemG. TheophyllineH. WarfarinI. LungsJ. RosiglitazoneK. DigoxinL. Low therapeutic indexM. Conjugation by sulphate/gluconarideN. High therapeutic index

Answer 396

Correct J. Rosiglitazone

Question 397

A 58-year-old man presents to your A&E complaining of chest pain and palpitations. He says he takes several drugs for his 'heart problems' and admits to being diabetic. What drug could be causing his problems?A. Oxidation by cytochrome P450B. Poor complianceC. GentamicinD. KidneysE. LiverF. GI systemG. TheophyllineH. WarfarinI. LungsJ. RosiglitazoneK. DigoxinL. Low therapeutic indexM. Conjugation by sulphate/gluconarideN. High therapeutic index

Answer 397

Correct K. DigoxinPossible features of DIGOXIN TOXICITY include:• arrhythmia: the most common arrhythmias are ventricular extrasystoles, ventricular bigeminy / trigeminy and atrial tachycardia with complete heart block• anorexia, nausea and vomiting and occasionally, diarrhoea• confusion especially in the elderly• yellow vision (xanthopsia), blurred vision and photophobia

Question 398

Peak and trough levels of this drug should be takenA. EthosuximideB. GentamicinC. Heparin - Low molecular weightD. PhenytoinE. PhenobarbitoneF. CiclosporinG. WarfarinH. LithiumI. Heparin - unfractionatedJ. CarbamazepineK. AspirinL. ClonazepamM. TheophyllineN. Digoxin

Answer 398

Correct B. Gentamicin

Question 399

Symptoms of under-treatment and toxicity may be similarA. EthosuximideB. GentamicinC. Heparin - Low molecular weightD. PhenytoinE. PhenobarbitoneF. CiclosporinG. WarfarinH. LithiumI. Heparin - unfractionatedJ. CarbamazepineK. AspirinL. ClonazepamM. TheophyllineN. Digoxin

Answer 399

Correct N. Digoxin 

Question 400

Decreased excretion, increased plasma concentration and increased risk of toxicity may occur when this taken in conjunction with thiazide diureticsA. EthosuximideB. GentamicinC. Heparin - Low molecular weightD. PhenytoinE. PhenobarbitoneF. CiclosporinG. WarfarinH. LithiumI. Heparin - unfractionatedJ. CarbamazepineK. AspirinL. ClonazepamM. TheophyllineN. Digoxin

Answer 400

Correct H. Lithium

Question 401

Is ototoxic and nephrotoxicA. EthosuximideB. GentamicinC. Heparin - Low molecular weightD. PhenytoinE. PhenobarbitoneF. CiclosporinG. WarfarinH. LithiumI. Heparin - unfractionatedJ. CarbamazepineK. AspirinL. ClonazepamM. TheophyllineN. Digoxin

Answer 401

Correct B. Gentamicin

Question 402

Requires regular monitoring of APTTA. EthosuximideB. GentamicinC. Heparin - Low molecular weightD. PhenytoinE. PhenobarbitoneF. CiclosporinG. WarfarinH. LithiumI. Heparin - unfractionatedJ. CarbamazepineK. AspirinL. ClonazepamM. TheophyllineN. Digoxin

Answer 402

Correct I. Heparin - unfractionated

Question 403

A man was put into custody after driving under the influence of drugs. On arrest he was reported as acting extremely aggressive and paranoid. He also claimed his heart was racing. One hour later he was found dead. There was suspicion of police brutality.A. CyanideB. MethadoneC. AmphetaminesD. StrychnineE. OrganophosphateF. ParacetamolG. BenzodiazepinesH. EthanolI. CocaineJ. Police brutalityK. Carbon monoxideL. AspirinM. MethanolN. CannabisO. EcstasyP. Heroin

Answer 403

Correct I. Cocaine‘In the lectures slides it mentiones EBE and BE as breakdown products of cocaine: what are these?’EME = ecgonine methyl esterBE = benzoylecgonineThey are the two degredation products of cocaine produced by pseudocholinesterases and hydrolysis respectively.

Question 404

A 24-year-old woman goes to a party where she has some pills. She subsequently becomes feverish and confused. She was found to be hyperthermic and blood results showed a raised urea and creatinine, her myoglobin was also found to be high.A. CyanideB. MethadoneC. AmphetaminesD. StrychnineE. OrganophosphateF. ParacetamolG. BenzodiazepinesH. EthanolI. CocaineJ. Police brutalityK. Carbon monoxideL. AspirinM. MethanolN. CannabisO. EcstasyP. Heroin

Answer 404

Correct O. Ecstasy

Question 405

James Pond comes to A&E claiming he’s been poisoned. Minutes later he dies. His skin was brick red and there was a faint odour of almonds.A. CyanideB. MethadoneC. AmphetaminesD. StrychnineE. OrganophosphateF. ParacetamolG. BenzodiazepinesH. EthanolI. CocaineJ. Police brutalityK. Carbon monoxideL. AspirinM. MethanolN. CannabisO. EcstasyP. Heroin

Answer 405

Correct A. Cyanide

Question 406

Following a death in the family, a young woman is brought into the hospital with confusion. On inspection she appears jaundiced. Her friend reports that she had been vomiting earlier and that she had found an empty medicine bottle in her room.A. CyanideB. MethadoneC. AmphetaminesD. StrychnineE. OrganophosphateF. ParacetamolG. BenzodiazepinesH. EthanolI. CocaineJ. Police brutalityK. Carbon monoxideL. AspirinM. MethanolN. CannabisO. EcstasyP. Heroin

Answer 406

Correct F. Paracetamol

Question 407

A man was found collapsed on the floor of his room and his breathing was found to be severely depressed. A urine test was found to be positive for 6-MAM.A. CyanideB. MethadoneC. AmphetaminesD. StrychnineE. OrganophosphateF. ParacetamolG. BenzodiazepinesH. EthanolI. CocaineJ. Police brutalityK. Carbon monoxideL. AspirinM. MethanolN. CannabisO. EcstasyP. Heroin

Answer 407

Correct P. Heroin

Question 408

A 30-year-old farmer presents to casualty complaining of diarrhoea and painful mouth ulcers. On questioning he admitted accidentally ingesting liquid paraquatA. NaloxoneB. DesferrioxamineC. Hyperbaric oxygenD. GlucagonE. Gastric lavageF. Activated charcoalG. N-acetylcysteineH. AtropineI. HaemodialysisJ. Symptomatic and Supportive treatmentK. Dicobalt edentate

Answer 408

Correct F. Activated charcoalRemember activated charcoal is NOT helpful in poisoning with: cyanide, iron, ethanol, lithium, acid or alkali, pesticides.

Question 409

A 15-year-old girl presents with sweats and hyperventilation indicative of a severe metabolic acidosis; after taking a large number of salicylate tabletsA. NaloxoneB. DesferrioxamineC. Hyperbaric oxygenD. GlucagonE. Gastric lavageF. Activated charcoalG. N-acetylcysteineH. AtropineI. HaemodialysisJ. Symptomatic and Supportive treatmentK. Dicobalt edentate

Answer 409

Correct I. Haemodialysis

Question 410

A 26-year-old woman collapses after a massive overdose of atenolol. She remains in cardogenic shock despite initial treatment with IV atropineA. NaloxoneB. DesferrioxamineC. Hyperbaric oxygenD. GlucagonE. Gastric lavageF. Activated charcoalG. N-acetylcysteineH. AtropineI. HaemodialysisJ. Symptomatic and Supportive treatmentK. Dicobalt edentate

Answer 410

Correct D. Glucagon

Question 411

A pregnant 30-year-old woman is found drowsy in her rented flat. She complains of severe nausea for the last 3 hours. Her carboxyhaemoglobin level is 41%.A. NaloxoneB. DesferrioxamineC. Hyperbaric oxygenD. GlucagonE. Gastric lavageF. Activated charcoalG. N-acetylcysteineH. AtropineI. HaemodialysisJ. Symptomatic and Supportive treatmentK. Dicobalt edentate

Answer 411

Correct C. Hyperbaric oxygen

Question 412

A 25-year-old man is delirious and hyperpyrexial after taking a pill in a club. He is hyperreflexic and is hyponatraemicA. NaloxoneB. DesferrioxamineC. Hyperbaric oxygenD. GlucagonE. Gastric lavageF. Activated charcoalG. N-acetylcysteineH. AtropineI. HaemodialysisJ. Symptomatic and Supportive treatmentK. Dicobalt edentate

Answer 412

Correct J. Symptomatic and Supportive treatment

Question 413

An 18 year old female is brought in to A&E from a rave in the early hours of the morning. On initial examination she is agitated with a heart rate of 120 bpm. She is very sweaty and has wide dilated pupilsA. AcetylcysteineB. LithiumC. SalicylatesD. Carbon MonoxideE. ParacetamolF. OrganophosphatesG. MethanolH. Tricyclic antidepressantsI. EcstasyJ. DesferrioxamineK. Naloxone

Answer 413

Correct I. EcstasyBoth TCA od's and ecstasy od's can cause wide dilated pupils.Ecstasy is more likely to lead to agitation and TCA drowsiness.ps...the other question in the stem , points very clearly to TCA overdose (reflexes and widened QRS complexes). Also....remember that ecstasy may induce vasopressin secretion and an SIADH, with hyponatraemia

Question 414

A 25 year old male is admitted with hyperventilation. He is sweating and appears nauseous. He says that he has ringing in his ears. Blood gases show that he has mixed acid-base disturbanceA. AcetylcysteineB. LithiumC. SalicylatesD. Carbon MonoxideE. ParacetamolF. OrganophosphatesG. MethanolH. Tricyclic antidepressantsI. EcstasyJ. DesferrioxamineK. Naloxone

Answer 414

Correct C. Salicylates

Question 415

An 80 year old man and his 79 year old wife were brought in after a neighbour found them collapsed in their home. On questioning the neighbour it was found that the couple had not been feeling well for a few weeks and had been complaining of nausea, headaches and dizzinessA. AcetylcysteineB. LithiumC. SalicylatesD. Carbon MonoxideE. ParacetamolF. OrganophosphatesG. MethanolH. Tricyclic antidepressantsI. EcstasyJ. DesferrioxamineK. Naloxone

Answer 415

Correct D. Carbon Monoxide

Question 416

A depressed 30 year old woman was brought into A&E after being found by a friend. On examination she appears very drowsy with sinus tachycardia and wide dilated pupils. She has marked reflexes and extensor plantar responses. ECG shows a wide QRS intervalA. AcetylcysteineB. LithiumC. SalicylatesD. Carbon MonoxideE. ParacetamolF. OrganophosphatesG. MethanolH. Tricyclic antidepressantsI. EcstasyJ. DesferrioxamineK. Naloxone

Answer 416

Correct H. Tricyclic antidepressantsBoth TCA od's and ecstasy od's can cause wide dilated pupils.Ecstasy is more likely to lead to agitation and TCA drowsiness.ps...the other question in the stem , points very clearly to TCA overdose (reflexes and widened QRS complexes). Also....remember that ecstasy may induce vasopressin secretion and an SIADH, with hyponatraemia

Question 417

A 45 year old farm worker is admitted complaining primarily of nausea and vomiting. On further questioning it is revealed that he also has a headache, hypersalivation and he is finding it hard to breathe. On examination the patient appears sweaty and has flaccid paresis of his limb musclesA. AcetylcysteineB. LithiumC. SalicylatesD. Carbon MonoxideE. ParacetamolF. OrganophosphatesG. MethanolH. Tricyclic antidepressantsI. EcstasyJ. DesferrioxamineK. Naloxone

Answer 417

Correct F. Organophosphates

Question 418

Which of the above techniques can be used to test for all classes of drugs of abuse (DOA)?A. Urine sampleB. BarbituatesC. Blood sampleD. ParacetamolE. BenzodiazepinesF. Drugs of abuse (DOA)G. Stool sampleH. Liquid chromotographyI. ImmunoassayJ. Liver sampleK. Thin layer chromotography

Answer 418

Correct I. Immunoassay

Question 419

What sample is required for use with gas chromatography mass spectroscopy?A. Urine sampleB. BarbituatesC. Blood sampleD. ParacetamolE. BenzodiazepinesF. Drugs of abuse (DOA)G. Stool sampleH. Liquid chromotographyI. ImmunoassayJ. Liver sampleK. Thin layer chromotography

Answer 419

Correct C. Blood sample

Question 420

Colorimetric can be used to test for which drug commonly taken in overdose?A. Urine sampleB. BarbituatesC. Blood sampleD. ParacetamolE. BenzodiazepinesF. Drugs of abuse (DOA)G. Stool sampleH. Liquid chromotographyI. ImmunoassayJ. Liver sampleK. Thin layer chromotography

Answer 420

Correct D. Paracetamol

Question 421

Which of the above techniques can be used to test for benzodiazepines and various antipsychotic drugs?A. Urine sampleB. BarbituatesC. Blood sampleD. ParacetamolE. BenzodiazepinesF. Drugs of abuse (DOA)G. Stool sampleH. Liquid chromotographyI. ImmunoassayJ. Liver sampleK. Thin layer chromotography

Answer 421

Correct H. Liquid chromotography

Question 422

Which of the above techniques can be used to analyse samples of stool, liver and also urine?A. Urine sampleB. BarbituatesC. Blood sampleD. ParacetamolE. BenzodiazepinesF. Drugs of abuse (DOA)G. Stool sampleH. Liquid chromotographyI. ImmunoassayJ. Liver sampleK. Thin layer chromotography

Answer 422

Correct K. Thin layer chromotography

Question 423

Which option is the best specimen for assessing long-term drug use?A. THCB. MorphineC. MDMAD. HairE. ToxicologyF. ForensicsG. ParacetamolH. CocaineI. SalivaJ. BloodK. Urine

Answer 423

Correct D. Hair

Question 424

Which drug is found in the most addict related deaths?A. THCB. MorphineC. MDMAD. HairE. ToxicologyF. ForensicsG. ParacetamolH. CocaineI. SalivaJ. BloodK. Urine

Answer 424

Correct B. Morphine

Question 425

Which option is responsible for the analysis of samples for drugs and poisons?A. THCB. MorphineC. MDMAD. HairE. ToxicologyF. ForensicsG. ParacetamolH. CocaineI. SalivaJ. BloodK. Urine

Answer 425

Correct E. Toxicology

Question 426

Which option is the best example of a quick, cheap, easy and non-invasive specimen which is likely to be adulterated for forensic drug analysis? Disadvantages include a small window of detection.A. THCB. MorphineC. MDMAD. HairE. ToxicologyF. ForensicsG. ParacetamolH. CocaineI. SalivaJ. BloodK. Urine

Answer 426

Correct I. Saliva

Question 427

Which drug is not excreted into saliva?A. THCB. MorphineC. MDMAD. HairE. ToxicologyF. ForensicsG. ParacetamolH. CocaineI. SalivaJ. BloodK. Urine

Answer 427

Correct A. THC

Question 428

The most important cell in the initiation of normal haemostasis.A. PlasminB. Thromboxane A2C. FibrinogenD. a2 macroglobulinE. ErythrocyteF. MegakaryocyteG. Antithrombin IIIH. Endothelial cellI. FibrinJ. PlateletK. CycloxygenaseL. Protein CM. Tissue plasminogen-activator (t-PA)

Answer 428

Correct H. Endothelial cell

Question 429

The main component involved in stabilising the primary haemostatic plug.A. PlasminB. Thromboxane A2C. FibrinogenD. a2 macroglobulinE. ErythrocyteF. MegakaryocyteG. Antithrombin IIIH. Endothelial cellI. FibrinJ. PlateletK. CycloxygenaseL. Protein CM. Tissue plasminogen-activator (t-PA)

Answer 429

Correct I. Fibrin

Question 430

A serine protease which assists in the break down of blood clots by binding to the clot and localising agents which break it down.A. PlasminB. Thromboxane A2C. FibrinogenD. a2 macroglobulinE. ErythrocyteF. MegakaryocyteG. Antithrombin IIIH. Endothelial cellI. FibrinJ. PlateletK. CycloxygenaseL. Protein CM. Tissue plasminogen-activator (t-PA)

Answer 430

Correct M. Tissue plasminogen-activator (t-PA)

Question 431

A potent inhibitor of plasmin in the blood.A. PlasminB. Thromboxane A2C. FibrinogenD. a2 macroglobulinE. ErythrocyteF. MegakaryocyteG. Antithrombin IIIH. Endothelial cellI. FibrinJ. PlateletK. CycloxygenaseL. Protein CM. Tissue plasminogen-activator (t-PA)

Answer 431

Correct D. a2 macroglobulin

Question 432

A single chain glycoprotein, synthesised by the liver and endothelium, which has strongly anticoagulant action and is important in the mode of action of heparin.A. PlasminB. Thromboxane A2C. FibrinogenD. a2 macroglobulinE. ErythrocyteF. MegakaryocyteG. Antithrombin IIIH. Endothelial cellI. FibrinJ. PlateletK. CycloxygenaseL. Protein CM. Tissue plasminogen-activator (t-PA)

Answer 432

Correct G. Antithrombin III

Question 433

This product of the cyclic endoperoxides induces platelet aggregationA. Ehlers-Danlos syndromeB. Christmas diseaseC. Prostacyclin PGI2D. HaemophiliaE. MegakaryocyteF. von Willebrand deficiencyG. Thromboxane A2H. Sensitised plateletI. Factor VIII deficiencyJ. Marfan syndromeK. Vitamin K deficiencyL. Factor XII deficiencyM. Autoimmune thrombocytopenic purpura

Answer 433

Correct G. Thromboxane A2

Question 434

A 6 foot 7 inch rower presents to his GP complaining of easy skin bruising. On further examination he is found to have pectus excavatum, lax joints and a high-arched palate.A. Ehlers-Danlos syndromeB. Christmas diseaseC. Prostacyclin PGI2D. HaemophiliaE. MegakaryocyteF. von Willebrand deficiencyG. Thromboxane A2H. Sensitised plateletI. Factor VIII deficiencyJ. Marfan syndromeK. Vitamin K deficiencyL. Factor XII deficiencyM. Autoimmune thrombocytopenic purpura

Answer 434

Correct A. Ehlers-Danlos syndrome

Question 435

A 62 year old overweight woman presents to the Emergency Department following a Road Traffic Accident. A full set of investigations is carried out – which shows an increased Activated Partial Thromboplastin Time (APTT) and Prothrombin Time (PT)A. Ehlers-Danlos syndromeB. Christmas diseaseC. Prostacyclin PGI2D. HaemophiliaE. MegakaryocyteF. von Willebrand deficiencyG. Thromboxane A2H. Sensitised plateletI. Factor VIII deficiencyJ. Marfan syndromeK. Vitamin K deficiencyL. Factor XII deficiencyM. Autoimmune thrombocytopenic purpura

Answer 435

Correct K. Vitamin K deficiency

Question 436

A 25 year old man presents to the Emergency Department a day after attending his dentist for a routine check-up. After treatment at the dentists the previous day, his gums had not stopped bleeding. On investigation, his APTT and bleeding time are prolonged but a normal PT.A. Ehlers-Danlos syndromeB. Christmas diseaseC. Prostacyclin PGI2D. HaemophiliaE. MegakaryocyteF. von Willebrand deficiencyG. Thromboxane A2H. Sensitised plateletI. Factor VIII deficiencyJ. Marfan syndromeK. Vitamin K deficiencyL. Factor XII deficiencyM. Autoimmune thrombocytopenic purpura

Answer 436

Correct F. von Willebrand deficiency

Question 437

A 16 year old girl presents to the Haematology Outpatients clinic describing a fluctuating history of easy bruising, epistaxis and menorrhagia. On investigation there is a thrombocytopaenia with increased megakaryocytes on BM examination.A. Ehlers-Danlos syndromeB. Christmas diseaseC. Prostacyclin PGI2D. HaemophiliaE. MegakaryocyteF. von Willebrand deficiencyG. Thromboxane A2H. Sensitised plateletI. Factor VIII deficiencyJ. Marfan syndromeK. Vitamin K deficiencyL. Factor XII deficiencyM. Autoimmune thrombocytopenic purpura

Answer 437

Correct M. Autoimmune thrombocytopenic purpura

Question 438

Which protein, important in haemostasis, is vitamin K dependent but is not a serine protease?A. Tissue factorB. Protein CC. Factor VIID. CyclooxygenaseE. Arichidonic acidF. Tissue factor pathway inhibitorG. Activated factor XH. Protein SI. Vascular endotheliumJ. ThrombinK. Vascular subendotheliumL. Platelets

Answer 438

Correct H. Protein S

Question 439

Which option is required as a cofactor for protein C activity?A. Tissue factorB. Protein CC. Factor VIID. CyclooxygenaseE. Arichidonic acidF. Tissue factor pathway inhibitorG. Activated factor XH. Protein SI. Vascular endotheliumJ. ThrombinK. Vascular subendotheliumL. Platelets

Answer 439

Correct H. Protein S

Question 440

Which option synthesises tissue factor, vWF, prostacyclin, plasminogen activator, antithrombin III and thrombomodulin?A. Tissue factorB. Protein CC. Factor VIID. CyclooxygenaseE. Arichidonic acidF. Tissue factor pathway inhibitorG. Activated factor XH. Protein SI. Vascular endotheliumJ. ThrombinK. Vascular subendotheliumL. Platelets

Answer 440

Correct I. Vascular endothelium

Question 441

Which enzyme, important for platelet aggregation, is irreversibly inhibited by aspirin?A. Tissue factorB. Protein CC. Factor VIID. CyclooxygenaseE. Arichidonic acidF. Tissue factor pathway inhibitorG. Activated factor XH. Protein SI. Vascular endotheliumJ. ThrombinK. Vascular subendotheliumL. Platelets

Answer 441

Correct D. Cyclooxygenase

Question 442

Which key clotting factor activates both factors V and VIII, and also activates protein C?A. Tissue factorB. Protein CC. Factor VIID. CyclooxygenaseE. Arichidonic acidF. Tissue factor pathway inhibitorG. Activated factor XH. Protein SI. Vascular endotheliumJ. ThrombinK. Vascular subendotheliumL. Platelets

Answer 442

Correct J. Thrombin

Question 443

A 37 year old mother of 4 children, presents to her GP because of recurrent nose bleeds and feeling tired all the time and heavy periods.A. Disseminated intravascular coagulationB. Antiphospholipid antibody syndromeC. Sickle cell anaemiaD. Christmas DiseaseE. Osler-Weber-Rendu SyndromeF. B-ThalassaemiaG. Vitamin K DeficiencyH. Bile acid malabsorptionI. Warfarin overdoseJ. Von Willebrand’s DiseaseK. Haemophilia AL. MalignancyM. Henoch – Schönlein PurpuraN. Factor V Leiden

Answer 443

Correct E. Osler-Weber-Rendu SyndromeA rare autosomal dominant disorder. Alternative name = hereditary haemorrhagic telangiectasia. There is a structural abnormality of the blood vessels, resulting in telangiectases, which are thin walled so are likely to bleed. This leads to haemorrhage and anaemia. It is more common in females, and may not present until later in life. Epistaxis is the commonest presenting symptom. This patient is feeling tired, not just because of her 4 children, but because she also has iron deficiency anaemia.

Question 444

A 3 year old boy is brought to see his GP by his mother. A fortnight ago he had been brought along because of cold-like symptoms, unsurprising since it was the middle of winter and he attends nursery. He was therefore sent home with some Calpol, and as expected his symptoms soon resolved. However this morning his mother noticed a rash on his bottom, and he said his tummy ached.A. Disseminated intravascular coagulationB. Antiphospholipid antibody syndromeC. Sickle cell anaemiaD. Christmas DiseaseE. Osler-Weber-Rendu SyndromeF. B-ThalassaemiaG. Vitamin K DeficiencyH. Bile acid malabsorptionI. Warfarin overdoseJ. Von Willebrand’s DiseaseK. Haemophilia AL. MalignancyM. Henoch – Schönlein PurpuraN. Factor V Leiden

Answer 444

Correct M. Henoch – Schönlein PurpuraAffects children between 2-8yrs old. More common in winter. Usually presents following an upper respiratory tract infection. Rapid onset, with a palpable purpuric rash over the buttocks and legs, as well as symmetrical urticarial plaques, and haemorrhagic bullae. Arthritis of the knee and ankle. Abdominal pain – perhaps due to mesenteric vasculitis. Can have renal involvement – with haematuria/proteinuria. (not idiopathic thrombocytopenic purpura – because it’s not an option here)

Question 445

22 year old Saharawi refugee presents with anaemia, weight loss, loose stools and blood tests reveal an increased PT and slightly increased APTT, with normal thrombin time and platelet count.A. Disseminated intravascular coagulationB. Antiphospholipid antibody syndromeC. Sickle cell anaemiaD. Christmas DiseaseE. Osler-Weber-Rendu SyndromeF. B-ThalassaemiaG. Vitamin K DeficiencyH. Bile acid malabsorptionI. Warfarin overdoseJ. Von Willebrand’s DiseaseK. Haemophilia AL. MalignancyM. Henoch – Schönlein PurpuraN. Factor V Leiden

Answer 445

Correct G. Vitamin K DeficiencyPrevalence of coeliac disease is highest in Saharawi refugees. This patient has coeliac disease, and as a result of malabsorption is losing weight and has loose stools (steatorrhoea), and vitamin K deficiency. The blood results related to vitamin K deficiency.

Question 446

A 5 year old boy has the following blood results: normal PT, increased APTT, normal platelet count, decreased VIII:C and decreased vWF.A. Disseminated intravascular coagulationB. Antiphospholipid antibody syndromeC. Sickle cell anaemiaD. Christmas DiseaseE. Osler-Weber-Rendu SyndromeF. B-ThalassaemiaG. Vitamin K DeficiencyH. Bile acid malabsorptionI. Warfarin overdoseJ. Von Willebrand’s DiseaseK. Haemophilia AL. MalignancyM. Henoch – Schönlein PurpuraN. Factor V Leiden

Answer 446

Correct J. Von Willebrand’s DiseaseThe most common hereditary bleeding disorder, affect 1% of the population. vWF is a carrier protein for factor VIII and stabilises it. Mutation is in chromosome 12

Question 447

A 32 week pregnant lady who has gestational diabetes and is epileptic has a caesarean section while on holiday in rural China. Her newborn baby is suffering from bleeding from the umbilical stump, as well as nose and gums. What is wrong with the baby?A. Disseminated intravascular coagulationB. Antiphospholipid antibody syndromeC. Sickle cell anaemiaD. Christmas DiseaseE. Osler-Weber-Rendu SyndromeF. B-ThalassaemiaG. Vitamin K DeficiencyH. Bile acid malabsorptionI. Warfarin overdoseJ. Von Willebrand’s DiseaseK. Haemophilia AL. MalignancyM. Henoch – Schönlein PurpuraN. Factor V Leiden

Answer 447

Correct G. Vitamin K DeficiencyDrugs, such as anticonvulsants, which the mother is likely to be taking as she suffers from epilepsy, as well as isoniazid, rifampicin and anticoagulants, are risk factors for haemorrhagic disease of the newborn – which is what this baby has. This is due to vitamin K deficiency – although rare now in the UK as prophylactic vitamin K is given to newborns.

Question 448

A fit 48-year-old investment banker presents to A&E with a painful R arm that was present when he woke up that morning. He is otherwise well and there is no history of trauma or abnormalities of any system. On examination there is marked tenderness and mild erythema along the anterolateral aspect of the forearm and cubital fossa, with no abnormality of the upper arm or axilla.A. Superficial venous thrombosisB. Pulmonary embolismC. Superior vena caval obstructionD. ThrombophlebitisE. Inferior vena caval obstructionF. Deep vein thrombosisG. Axillary vein thrombosisH. DICI. Varicose veinsJ. Postphlebitic syndrome

Answer 448

Correct A. Superficial venous thrombosisThrombophlebitis refers to the inflammation of a vein which is thrombosed - you get all the normal signs of inflammation. It can be migratory - migratory thrombophelbitis. Superfical venous thrombosis is what it says on the tin - thrombosis of a superficial vein. This may be associated with thrombophlebitis - ie there is associated inflammation.

Question 449

A 45-year-old lady, known heavy smoker with chronic respiratory problems, presents to her GP with increasing dyspnoea and swelling of her R arm and face. On examination of her chest there is no asymmetry or tracheal deviation, but there are added sounds over the R upper lobe and on bending forward her face becomes congested.A. Superficial venous thrombosisB. Pulmonary embolismC. Superior vena caval obstructionD. ThrombophlebitisE. Inferior vena caval obstructionF. Deep vein thrombosisG. Axillary vein thrombosisH. DICI. Varicose veinsJ. Postphlebitic syndrome

Answer 449

Correct C. Superior vena caval obstruction

Question 450

A 56-year-old woman returns to the Vascular Clinic with recurrence of her L leg ulcer after the area has been knocked by a shopping trolley. On examination the ulcer is situated above the medial malleolus, its dimensions being 6cm x 5cm. The base is filled with yellowish slough and the surrounding area is erythematous, with prominent oedema.A. Superficial venous thrombosisB. Pulmonary embolismC. Superior vena caval obstructionD. ThrombophlebitisE. Inferior vena caval obstructionF. Deep vein thrombosisG. Axillary vein thrombosisH. DICI. Varicose veinsJ. Postphlebitic syndrome

Answer 450

Correct J. Postphlebitic syndrome

Question 451

A 48-year-old man develops R-sided pleuritic chest pain and coughs up a trace of bloodstained sputum 8 days after a R hemicolectomy. He has mild dyspnoea but chest examination and chest radiography are normal.A. Superficial venous thrombosisB. Pulmonary embolismC. Superior vena caval obstructionD. ThrombophlebitisE. Inferior vena caval obstructionF. Deep vein thrombosisG. Axillary vein thrombosisH. DICI. Varicose veinsJ. Postphlebitic syndrome

Answer 451

Correct B. Pulmonary embolism

Question 452

A 32-year-old lady develops acute swelling of her L leg 2 days post-partum. She had bilateral leg swelling during the pregnancy but the delivery was normal. On examination there is tense swelling of the leg and thigh and some deep tenderness over the calf and medial aspect of the thigh.A. Superficial venous thrombosisB. Pulmonary embolismC. Superior vena caval obstructionD. ThrombophlebitisE. Inferior vena caval obstructionF. Deep vein thrombosisG. Axillary vein thrombosisH. DICI. Varicose veinsJ. Postphlebitic syndrome

Answer 452

Correct F. Deep vein thrombosis

Question 453

A drug that is administered intravenously and has a rapid effect by potentiating the action of antithrombin. Action can be reversed quickly which is of relevance in myocardial infarction patients who may require early invasive treatment (ie PTCA).A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 453

Correct L. Unfractionated heparin (UFH)

Question 454

Potentiates antithrombin III. Usually given subcutaneously. Can cause osteoporosis and hyperkalaemia.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 454

Correct D. Dalteparin (LMWH)

Question 455

Used to monitor patients undergoing warfarin therapy.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 455

Correct K. Prothrombin time (PT)

Question 456

Used to monitor patients undergoing unfractionated heparin therapy.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 456

Correct J. APTT

Question 457

This anticoagulant drug is directly contraindicated in pregnancy, especially the first 16 and last 4 weeks of a 40 week gestation.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 457

Correct A. Warfarin

Question 458

Reflects the amount and activity of fibrinogen.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 458

Correct B. Thrombin time (TT)

Question 459

Antiplatelet action. Indicated for primary prophylaxis of stroke in a patient experiencing recurrent retinal TIAs (amaurosis fugax). Ineffective for DVT prophylaxis.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 459

Correct N. Aspirin

Question 460

Antiplatelet action. Licensed for secondary prophylaxis of stroke. More effective than aspirin alone. Cheap.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 460

Correct E. Dipyridamole modified release (MR) and aspirin

Question 461

Antiplatelet action. Licensed for primary prevention of stroke in aspirin allergic patients, secondary prevention of stroke (but expensive) and in acute myocardial infarction in addition to aspirin.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 461

Correct O. Clopidogrel

Question 462

Dangerous combination with no added efficacy and increased GI bleed.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 462

Correct H. Clopidogrel and aspirin

Question 463

Old model of starting warfarinA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 463

Correct M. 10mg, 10mg, 5mg, measure on 4th day then every 2 days

Question 464

New (recommended, Tait) model of starting warfarinA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 464

Correct G. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 days

Question 465

In patients with metallic heart valves, this drug is the most effective anticoagulantA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 465

Correct A. Warfarin

Question 466

In patients with cancer and acute venous thromboembolism, the most effective drug at reducing the risk of recurrent VTE is \_\_?A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 466

Correct D. Dalteparin (LMWH)

Question 467

This drug when given alone initially increases the clotting riskA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 467

Correct A. Warfarin

Question 468

Side effects include cutaneous necrosisA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 468

Correct A. Warfarin

Question 469

The drug most likely to cause thrombocytopaenia with paradoxical thrombosisA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 469

Correct L. Unfractionated heparin (UFH)

Question 470

Indicated as thrombotic prophylaxis in DICA. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 470

Correct D. Dalteparin (LMWH)

Question 471

Contra-indicated if recent sore throat, if ever used before, or in the presence of proliferative retinopathy.A. WarfarinB. Thrombin time (TT)C. LMWH and aspirinD. Dalteparin (LMWH)E. Dipyridamole modified release (MR) and aspirinF. PentapolysaccharideG. 5mg, 5mg, 5mg, 5mg, measure on 5th day, 8th day and then every 4 daysH. Clopidogrel and aspirinI. CalciparoneJ. APTTK. Prothrombin time (PT)L. Unfractionated heparin (UFH)M. 10mg, 10mg, 5mg, measure on 4th day then every 2 daysN. AspirinO. ClopidogrelP. Streptokinase

Answer 471

Correct P. Streptokinase

Question 472

A 65 year old patient presents with hepatosplenomegaly. He is mildly anaemic and thrombocytompenic. A blood monocyte count of 1.2 x 109/l is observed. Bone marrow aspirate reveals ring sideroblasts at 15% of total blasts. Auer rods are observed.A. Aplastic AnaemiaB. Refractory Anaemia with excess of Blasts IIC. Refractory Anaemia with excess of Blasts ID. Acute Myeloid LeukaemiaE. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome)F. Refractory Cytopaenia with Multilineage DysplasiaG. Refractory anaemiaH. Myelodysplastic syndrome,unclassifiableI. Chronic Myelomonocytic AnaemiaJ. Refractory Anaemia with Ring SideroblastsK. Secondary Sideroblastic Anaemia

Answer 472

Correct I. Chronic Myelomonocytic AnaemiaWe agree that the case for CMML is nonspecific. The main positive feature is the monocyte count.

Question 473

An alcoholic presents to your clinic with anaemia. Sideroblasts are observed on morphological examination.A. Aplastic AnaemiaB. Refractory Anaemia with excess of Blasts IIC. Refractory Anaemia with excess of Blasts ID. Acute Myeloid LeukaemiaE. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome)F. Refractory Cytopaenia with Multilineage DysplasiaG. Refractory anaemiaH. Myelodysplastic syndrome,unclassifiableI. Chronic Myelomonocytic AnaemiaJ. Refractory Anaemia with Ring SideroblastsK. Secondary Sideroblastic Anaemia

Answer 473

Correct K. Secondary Sideroblastic Anaemia

Question 474

A 58 year old lady complains of lethargy and “easy bruising”. She presents with purpura. Her FBC reveals Hb 10.5g/dl; WBCs 2.3x109/l and platelets 8x109/l. Blood film reveals

Answer 474

Correct F. Refractory Cytopaenia with Multilineage DysplasiaTo count as significant, dysplasia must involve at least 10% of cells in a lineage. To count as RCMD, at least 2 MYELOID lineages must be dysplastic, and there must be bi or pancytopenia in the peripheral blood. (This can include anaemia!)

Question 475

A 78 year old male patient with recurring infections of the face and maxillary sinuses associated with neutropenia. His bloods are: Hb 9.8 g/dl; WBC 1.3x109/l; Neutrophils 0.3x109/l; platelets 38x109/l.The lab informs you that there are Blasts approximately compromise 17% of bone marrow aspirate.A. Aplastic AnaemiaB. Refractory Anaemia with excess of Blasts IIC. Refractory Anaemia with excess of Blasts ID. Acute Myeloid LeukaemiaE. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome)F. Refractory Cytopaenia with Multilineage DysplasiaG. Refractory anaemiaH. Myelodysplastic syndrome,unclassifiableI. Chronic Myelomonocytic AnaemiaJ. Refractory Anaemia with Ring SideroblastsK. Secondary Sideroblastic Anaemia

Answer 475

Correct B. Refractory Anaemia with excess of Blasts II

Question 476

You are called to A&E to see a 65 year old man. He is complaining of fever, shortness of breath, and has lost 5Kg in the last few months. His notes say he was previously diagnosed with “Refractory Anaemia with excess Blasts in Transformation” (RAEB-t). His blast cell count is approximately 30% of all nucleated cells.A. Aplastic AnaemiaB. Refractory Anaemia with excess of Blasts IIC. Refractory Anaemia with excess of Blasts ID. Acute Myeloid LeukaemiaE. Myelodysplastic syndrome associated with isolated del(5q) chromosome abnormality (5q syndrome)F. Refractory Cytopaenia with Multilineage DysplasiaG. Refractory anaemiaH. Myelodysplastic syndrome,unclassifiableI. Chronic Myelomonocytic AnaemiaJ. Refractory Anaemia with Ring SideroblastsK. Secondary Sideroblastic Anaemia

Answer 476

Correct D. Acute Myeloid Leukaemia

Question 477

A 34 year old man with peripheral cytopenia suffers from bleeding gums. Peripheral blood shows 5% blast cells and bone marrow 42% blast cells.A. Juvenile myelomonocytic leukaemiaB. Refractory cytopenia with multilineage dysplasiaC. Refractory anaemiaD. Inherited aplastic anaemiaE. Secondary aplastic anaemiaF. 5q syndromeG. Idiopathic aplastic anaemiaH. Acute myeloid leukaemiaI. Refractory anaemia with an excess of blastsJ. Myelofibrosis

Answer 477

Correct H. Acute myeloid leukaemia

Question 478

A 74 year old woman with high-normal platelet count. Bone marrow aspirate shows hyperplasia of hypolobulated micromegakaryocytes. Responds well to lenalidomide.A. Juvenile myelomonocytic leukaemiaB. Refractory cytopenia with multilineage dysplasiaC. Refractory anaemiaD. Inherited aplastic anaemiaE. Secondary aplastic anaemiaF. 5q syndromeG. Idiopathic aplastic anaemiaH. Acute myeloid leukaemiaI. Refractory anaemia with an excess of blastsJ. Myelofibrosis

Answer 478

Correct F. 5q syndrome

Question 479

A 20 year old man with hepatitis C complains of fatigue and breathlessness and bruises very easily.A. Juvenile myelomonocytic leukaemiaB. Refractory cytopenia with multilineage dysplasiaC. Refractory anaemiaD. Inherited aplastic anaemiaE. Secondary aplastic anaemiaF. 5q syndromeG. Idiopathic aplastic anaemiaH. Acute myeloid leukaemiaI. Refractory anaemia with an excess of blastsJ. Myelofibrosis

Answer 479

Correct E. Secondary aplastic anaemia

Question 480

This patients blood film shows classic Pelger-Huet neutrophils and bone marrow blasts make up 15% of cells.A. Juvenile myelomonocytic leukaemiaB. Refractory cytopenia with multilineage dysplasiaC. Refractory anaemiaD. Inherited aplastic anaemiaE. Secondary aplastic anaemiaF. 5q syndromeG. Idiopathic aplastic anaemiaH. Acute myeloid leukaemiaI. Refractory anaemia with an excess of blastsJ. Myelofibrosis

Answer 480

Correct I. Refractory anaemia with an excess of blasts

Question 481

In this case haemoglobin is normal but there is a reduction in platelets and neutrophilsA. Juvenile myelomonocytic leukaemiaB. Refractory cytopenia with multilineage dysplasiaC. Refractory anaemiaD. Inherited aplastic anaemiaE. Secondary aplastic anaemiaF. 5q syndromeG. Idiopathic aplastic anaemiaH. Acute myeloid leukaemiaI. Refractory anaemia with an excess of blastsJ. Myelofibrosis

Answer 481

Correct B. Refractory cytopenia with multilineage dysplasia

Question 482

A 64 year old man complains of headaches, fatigue and itchy skin, particularly evident after a hot bath. He has a long-standing history of alcohol abuse and drug history reveals that he taking thiazide diuretics. On examination, you note that he is thin with sunken eyes.A. Chronic myeloid leukaemiaB. Acute myeloid leukaemiaC. VenesectionD. SplenomegalyE. PseudopolycythaemiaF. ChlorambucilG. Tear drop poikilocytesH. ImitanibI. HaematocritJ. MelphalanK. Idiopathic myelofibrosisL. ErythropoeitinM. HydroxycarbamideN. Essential thrombocythaemiaO. MicrocytosisP. Polycythaemia vera

Answer 482

Correct E. Pseudopolycythaemia

Question 483

A 55 year old female has a past medical history of deep vein thrombosis. She also complains of easy bruising. Her platelet count is 770 x109/L, CRP is 4mg/L. You prescribe aspirin.A. Chronic myeloid leukaemiaB. Acute myeloid leukaemiaC. VenesectionD. SplenomegalyE. PseudopolycythaemiaF. ChlorambucilG. Tear drop poikilocytesH. ImitanibI. HaematocritJ. MelphalanK. Idiopathic myelofibrosisL. ErythropoeitinM. HydroxycarbamideN. Essential thrombocythaemiaO. MicrocytosisP. Polycythaemia vera

Answer 483

Correct N. Essential thrombocythaemia

Question 484

A 53 year old man goes to see his doctor about an embarrassing problem. It seems that his friends have nicknamed him ‘Rudolph’. You seem quite confused, but all becomes apparent when he points to his nose, which appears red. After further questioning, he describes a ‘burning’ sensation on his nose, hands and feet and visual disturbances. You send him for ‘blood tests’. What do you expect to be raised?A. Chronic myeloid leukaemiaB. Acute myeloid leukaemiaC. VenesectionD. SplenomegalyE. PseudopolycythaemiaF. ChlorambucilG. Tear drop poikilocytesH. ImitanibI. HaematocritJ. MelphalanK. Idiopathic myelofibrosisL. ErythropoeitinM. HydroxycarbamideN. Essential thrombocythaemiaO. MicrocytosisP. Polycythaemia vera

Answer 484

Correct I. HaematocritBurning sensation of the hands and feet is denoted by the term 'erythromelalgia'.

Question 485

A consultant grills you on a ward round: there is a patient with a WBC of 140 x109/L, Hb 12 g/dL, Platelet count 320 x109/L. She complains of tiredness, night sweats, fever and abdominal pain. Her spleen is markedly enlarged. Blood film shows blasts, neutrophils, basophils. How would you treat her?A. Chronic myeloid leukaemiaB. Acute myeloid leukaemiaC. VenesectionD. SplenomegalyE. PseudopolycythaemiaF. ChlorambucilG. Tear drop poikilocytesH. ImitanibI. HaematocritJ. MelphalanK. Idiopathic myelofibrosisL. ErythropoeitinM. HydroxycarbamideN. Essential thrombocythaemiaO. MicrocytosisP. Polycythaemia vera

Answer 485

Correct H. Imitanib

Question 486

You are asked to see a 76 year old man on the wards, who presented with fatigue, dyspnoea, bleeding gums and nightsweats. His abdomen is massively enlarged. You read his notes and find ‘bone marrow aspirate: ‘dry tap’. What would you expect to see on the blood film?A. Chronic myeloid leukaemiaB. Acute myeloid leukaemiaC. VenesectionD. SplenomegalyE. PseudopolycythaemiaF. ChlorambucilG. Tear drop poikilocytesH. ImitanibI. HaematocritJ. MelphalanK. Idiopathic myelofibrosisL. ErythropoeitinM. HydroxycarbamideN. Essential thrombocythaemiaO. MicrocytosisP. Polycythaemia vera

Answer 486

Correct G. Tear drop poikilocytes

Question 487

A 64-year old woman receiving long-term chemotherapy for lymphoma presents with worsening bone pain, recurrent fever and night sweats. Blood film shows blast cells with Auer rods.A. Chronic lymphocytic leukaemiaB. Richter's syndromeC. HypothyroidismD. Chronic myeloid leukaemiaE. Tumour-lysis syndromeF. Hairy cell leukaemiaG. Vincristine poisoningH. Bronchial carcinomaI. Acute myeloid leukaemiaJ. DICK. SepticaemiaL. Lung fibrosisM. Acute promyelocytic leukaemiaN. Acute lymphoblastic leukaemia

Answer 487

Correct I. Acute myeloid leukaemia

Question 488

A 61-year-old man with CLL presents with recurrent pneumonia and haemoptysis. On fibreoptic bronchoscopy, the patient is found to have an endobronchial mass. The biopsy shows anaplastic, large cell lymphoma.A. Chronic lymphocytic leukaemiaB. Richter's syndromeC. HypothyroidismD. Chronic myeloid leukaemiaE. Tumour-lysis syndromeF. Hairy cell leukaemiaG. Vincristine poisoningH. Bronchial carcinomaI. Acute myeloid leukaemiaJ. DICK. SepticaemiaL. Lung fibrosisM. Acute promyelocytic leukaemiaN. Acute lymphoblastic leukaemia

Answer 488

Correct B. Richter's syndrome

Question 489

A newly diagnosed ALL patient complains of tiredness, polyuria, polydipsia, abdominal pain and vomiting on receiving chemotherapy. On examination, BP: 160/100mmHg, temp: 39ºC, and ECG shows tented T waves. Blood test shows serum K+: 6.9mmol/L and phosphate: 7.1 mmol/L. The patient later dies of cardiac arrest.A. Chronic lymphocytic leukaemiaB. Richter's syndromeC. HypothyroidismD. Chronic myeloid leukaemiaE. Tumour-lysis syndromeF. Hairy cell leukaemiaG. Vincristine poisoningH. Bronchial carcinomaI. Acute myeloid leukaemiaJ. DICK. SepticaemiaL. Lung fibrosisM. Acute promyelocytic leukaemiaN. Acute lymphoblastic leukaemia

Answer 489

Correct E. Tumour-lysis syndrome

Question 490

A routine medical of 33-year-old footballer reveals: Hb = 9.9g/dl and WCC = 130 x 109/L. His blood film shows whole spectrum of myeloid precursors, including a few blast cells. He admits to having frequent night sweats and blurred vision. There is a presence of Ph chromosome t(9;22) on cytogenetic analysis.A. Chronic lymphocytic leukaemiaB. Richter's syndromeC. HypothyroidismD. Chronic myeloid leukaemiaE. Tumour-lysis syndromeF. Hairy cell leukaemiaG. Vincristine poisoningH. Bronchial carcinomaI. Acute myeloid leukaemiaJ. DICK. SepticaemiaL. Lung fibrosisM. Acute promyelocytic leukaemiaN. Acute lymphoblastic leukaemia

Answer 490

Correct D. Chronic myeloid leukaemia

Question 491

A 5-year-old girl presents with failure to thrive, recurrent fever and bruising. Immunotyping reveals the presence of CD10.A. Chronic lymphocytic leukaemiaB. Richter's syndromeC. HypothyroidismD. Chronic myeloid leukaemiaE. Tumour-lysis syndromeF. Hairy cell leukaemiaG. Vincristine poisoningH. Bronchial carcinomaI. Acute myeloid leukaemiaJ. DICK. SepticaemiaL. Lung fibrosisM. Acute promyelocytic leukaemiaN. Acute lymphoblastic leukaemia

Answer 491

Correct N. Acute lymphoblastic leukaemia

Question 492

A 6-year-old boy presents with bone pain. On examination you notice he looks pale and has many bruises. What is his diagnosis?A. Magnesium exposureB. Acute myeloid leukaemiaC. Marfan’s syndromeD. NeutrophilsE. ThalassaemiaF. Chronic lymphocytic leukaemiaG. Blast cellsH. Ionising radiationI. Sickle cell diseaseJ. LymphocytesK. Chronic myeloid leukaemiaL. Down’s syndromeM. Acute lymphocytic leukaemia

Answer 492

Correct M. Acute lymphocytic leukaemia

Question 493

A patient has acute lymphoblastic leukaemia. A bone marrow biopsy will show infiltration by which cells?A. Magnesium exposureB. Acute myeloid leukaemiaC. Marfan’s syndromeD. NeutrophilsE. ThalassaemiaF. Chronic lymphocytic leukaemiaG. Blast cellsH. Ionising radiationI. Sickle cell diseaseJ. LymphocytesK. Chronic myeloid leukaemiaL. Down’s syndromeM. Acute lymphocytic leukaemia

Answer 493

Correct G. Blast cells

Question 494

Patients with this inherited disorder have an increased risk of developing acute leukaemia.A. Magnesium exposureB. Acute myeloid leukaemiaC. Marfan’s syndromeD. NeutrophilsE. ThalassaemiaF. Chronic lymphocytic leukaemiaG. Blast cellsH. Ionising radiationI. Sickle cell diseaseJ. LymphocytesK. Chronic myeloid leukaemiaL. Down’s syndromeM. Acute lymphocytic leukaemia

Answer 494

Correct L. Down’s syndrome

Question 495

An environmental factor associated with acute leukaemia.A. Magnesium exposureB. Acute myeloid leukaemiaC. Marfan’s syndromeD. NeutrophilsE. ThalassaemiaF. Chronic lymphocytic leukaemiaG. Blast cellsH. Ionising radiationI. Sickle cell diseaseJ. LymphocytesK. Chronic myeloid leukaemiaL. Down’s syndromeM. Acute lymphocytic leukaemia

Answer 495

Correct H. Ionising radiation

Question 496

The commonest adult leukaemia.A. Magnesium exposureB. Acute myeloid leukaemiaC. Marfan’s syndromeD. NeutrophilsE. ThalassaemiaF. Chronic lymphocytic leukaemiaG. Blast cellsH. Ionising radiationI. Sickle cell diseaseJ. LymphocytesK. Chronic myeloid leukaemiaL. Down’s syndromeM. Acute lymphocytic leukaemia

Answer 496

Correct F. Chronic lymphocytic leukaemia

Question 497

A 50yr old man presents to his GP complaining of weight loss, tiredness, easy bruising and a painful big toe. On examination his spleen is massively enlarged. Investigation shows a raised serum urate. The peripheral blood film is abnormal, showing proliferation of which type of cell?A. Blast cellsB. Auer rodsC. SpherocytesD. NeutrophilsE. Clonal B lymphocytesF. Chromosome 11q23 deletionG. Chromosome 9;22 translocationH. Pelger-Huet cellsI. ReticulocytesJ. PlateletsK. Eosinophils

Answer 497

Correct D. NeutrophilsCML. Increased mass of turning-over cells generates urate. Q2. CML, blast phase. Transformation tends to be into AML but in 20% is lymphoblastic (ALL). Q3. CLL. Only two chronic B cell leukaemia/lymphomas are CD5+: CLL (CD5+ CD23+) and Mantle Cell Lymphoma (CD5+ CD23-). CLL may be assoc. with Coombs positive AIHA and ITP. The combination is called Evans syndrome. Q4. CML del(11q23): poor prognostic sign in CLL. Tip: Neutrophil alkaline phosphatase is LOW in CML and raised in myeloproliferative disorders and infections. Pelger Huet cells: bilobed neutrophils. Autosomal dominant or AML or MDS (myelodysplastic syndrome)

Question 498

A 65yr old lady is seen in the haematology clinic where she has been treated for 7 years with Imantinib for chronic myeloid leukaemia. Having been previously well, she is now complaining of shortness of breath and general weakness. Examination reveals splenomegally. Her peripheral blood film has changed from previous appointments and reflects the progression of her disease. Which type of cell is now proliferating?A. Blast cellsB. Auer rodsC. SpherocytesD. NeutrophilsE. Clonal B lymphocytesF. Chromosome 11q23 deletionG. Chromosome 9;22 translocationH. Pelger-Huet cellsI. ReticulocytesJ. PlateletsK. Eosinophils

Answer 498

Correct A. Blast cells

Question 499

A 70yr old man complains of a year’s history of fatigue, weight loss and recurrent sinusitis. His white cell count is raised with a lymphocytosis of 283x109 /L. Blood film shows features of haemolysis and Coomb’s test is positive. Further investigation show the bone marrow, blood and lymph nodes are infiltrated with which cell population?A. Blast cellsB. Auer rodsC. SpherocytesD. NeutrophilsE. Clonal B lymphocytesF. Chromosome 11q23 deletionG. Chromosome 9;22 translocationH. Pelger-Huet cellsI. ReticulocytesJ. PlateletsK. Eosinophils

Answer 499

Correct E. Clonal B lymphocytes

Question 500

A routine full blood count on a 62yr old gardener reveals a high white cell count of 154x109 /L, and the differential shows this to be a neutrophilia. The haemoglobin and platelet count are normal. Biopsy shows a hypercellular “packed” bone marrow, and cells show the presence of which chromosomal abnormality?A. Blast cellsB. Auer rodsC. SpherocytesD. NeutrophilsE. Clonal B lymphocytesF. Chromosome 11q23 deletionG. Chromosome 9;22 translocationH. Pelger-Huet cellsI. ReticulocytesJ. PlateletsK. Eosinophils

Answer 500

Correct G. Chromosome 9;22 translocation