Placement & PassMed Learning Points

Question 1

What are the sick day rules for a diabetic patient who is at risk of suffering from DKA? [2]

Answer 1

When unwell, if a patient is on insulin therapy, insulin therapy should not be stopped due to risk of DKA

Continue same / normal insulin regime

Check blood glucose levels regularly

Question 2

A patient suffers from DKA and has severe seizures. What is the cause of this? [1]

Answer 2

Cerebral oedema

Whilst hypokalaemia is common, does not cause seizures

Question 3

A patient has a water deprivation test for nephrogenic diabetes insipidus.

What is urine osmolality like

• After fluid deprivation [1]
• After desmopression test [1]

Answer 3

• After fluid deprivation: low urine osmolality
• After desmopression test: low urine osmolality

Question 4

How do you distinguish between Graves Disease and toxic multinodular disease using nuclear scintigraphy? [1]

Answer 4

In toxic multinodular goitre:
* nuclear scintigraphy reveals patchy uptake

Graves Disease:
* nuclear scintigraphy reveals diffuse enlargement of both thyroid lobes, with uniform uptake throughout

Question 5

You suspect a patient with pheochromocytoma based off a patients symptoms. What are they symptoms? [3]

What is the most appropriate next test to confirm your diagnosis? [1]

Answer 5

Symptoms:
* recurrent headaches
* sweating
* palpitations
* hypertensive episodes

The most sensitive and specific test for pheochromocytoma is the 24-hour urine collection for fractionated metanephrines.
* Metanephrines are metabolites of catecholamines and their levels in the urine correlate with catecholamine-secreting tumours.

Question 6

Why does cancer increase risk of PE? [1]

Answer 6

Cancer is pro-coagulant state as producing clotting factors
Increase bed-bound state
Damages blood vessel walls

Question 7

For patients with cancer, what is the second leading cause of death after the cancer itself? [1]

Answer 7

PE

Question 8

Why would patient on chemotherapy be referred to a cardiology team? [1]

Answer 8

Multiple chemotherapy drugs (especially doxorubicin) are cardiotoxic; cause damage to (cardiomyocyte mitochondria)

Question 9

Describe the onset of a headache that would indicate it’s from metastasised cancer? [1]

Answer 9

Bad headache that occurs worse in the morning; space occupying lesion that increases ICP

Question 10

Amlodopine can cause what SE? [1]

Answer 10

Pitting oedema

Question 11

Besides excess vitamin D, name and explain which vitamin can cause hypercalcaemia if intake is in excess? [1]

Answer 11

excessive vit A:
- acts on the bone to stimulate osteoclastic resorption, and inhibit osteoblastic formation and in the situations of dehydration or renal failur

Question 12

Which of medications should be withheld while a patient receives DKA treatment? [1]

Answer 12

During DKA, patients are given an aggressive fluid replacement and commenced on a fixed rate of insulin infusion.

While on the insulin infusion, long-acting insulin should continue, but short-acting insulins should be stopped. Once the patient is biochemically stable and able to eat, the short-acting insulin can restart.

Question 13

What is the target clinic blood pressure in adults aged less than 80 with type 2 diabetes mellitus and no other comorbidities? [1]

Answer 13

< 140 / 90

Question 14

What diabetic complication are gliflozins contraindicated in? [1]

Answer 14

It is contraindicated in active foot disease such as skin ulceration with a possible increased risk of toe amputation

Question 15

You suspect the underlying cause may be psychogenic polydipsia and request urine and serum osmolality to confirm.

What results would you expect from a water deprivation test? [2]

Answer 15

urine osmolality after fluid deprivation: high
urine osmolality after desmopressin: high

Question 16

Which type of thyroiditis classically occurs following a viral infection? [1]

Answer 16

De Quervain’s thyroiditis (aka subacute thyroiditis)

Question 17

Describe the 4 phases of subacute thyroiditis [4]

Answer 17

There are typically 4 phases;

phase 1 (lasts 3-6 weeks):
* hyperthyroidism, painful goitre, raised ESR
phase 2 (1-3 weeks):
* euthyroid

phase 3 (weeks - months):
* hypothyroidism

phase 4:
* thyroid structure and function goes back to normal

Question 18

SGLT-2 inhibitors have been linked to which important AE that effects the groin? [1]

Answer 18

SGLT-2 inhibitors have been linked to necrotising fasciitis of the genitalia or perineum (Fournier’s Gangrene)

Question 19

[] is the first-line investigation in suspected primary hyperaldosteronism

Answer 19

A plasma aldosterone/renin ratio is the first-line investigation in suspected primary hyperaldosteronism

Question 20

What is the treatment protocol for a patient with Addison’s if they are vomiting? [1]

Answer 20

A person with Addisons’ who vomits should take IM hydrocortisone until vomiting stops: this prevents an Addisonian crisis

Question 21

Several drugs can cause gynaecomastia but one of the most common causes is []

HINT: cardiac drug

Answer 21

Several drugs can cause gynaecomastia but one of the most common causes is digoxin

Nephrotic syndrome presents with proteinuria without haematuria

Question 22

A man sees his GP for a review of his type 2 diabetes. He is on metformin at the maximum tolerated dose. His latest HbA1c is 64 mmol/mol.

His GP starts him on gliclazide and plans to repeat the HbA1c in 3 months’ time.

What is the patient’s new target HbA1c? [1]

Answer 22

The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol

Question 23

In pregnant woman who develop hyperthyroidism in the first trimester, which treatment is preferred? [1]

Answer 23

In pregnant woman who develop hyperthyroidism in the first trimester, propylthiouracil is preferred over carbimazole due to lower risk of foetal malformation

Question 24

Name 4 antibodies found in DMT1 [4]

Answer 24

Question 25

What is important to note about PTH levels in primary hyperparathyroidism? [1]

Answer 25

The PTH level in primary hyperparathyroidism **may be normal**

Question 26

What is an important SE of prednisolone? [1]

Answer 26

Prednisolone is a corticosteroid that can be used in the treatment of giant cell arteritis. It can cause a **high neutrophil count.**

Question 27

Diabetic ketoacidosis: once blood glucose is < 14 mmol/l due to NaCl and fixed rate insulin has been given. What is the next appropriate step? [1]

Answer 27

Diabetic ketoacidosis: once blood glucose is < 14 mmol/l an infusion of **10% dextrose should be started at 125 mls/hr in addition to the saline regime**

Question 28

What is the common difference between nephrotic syndrome and glomerulonephritis urine samples? [2]

Answer 28

**glomerulonephritis**: which describes inflammation and damage to the glomeruli of the kidneys **causing leakage of protein and/or blood into the urine**

Question 32

[] is the most common cause of peritonitis secondary to peritoneal dialysis

Answer 32

**Coagulase-negative Staphylococcus** is the most common cause of peritonitis secondary to peritoneal dialysis. e.g. **Staphylococcus epidermidis**

Question 33

Severe hyperkalaemia in the context of an AKI requires what treatment? [1]

Answer 33

immediate discussion with critical care/nephrology to **consider haemofiltration/haemodialysis**

Question 34

How can you distinguish between AKI and dehydration? [1]

Answer 34

**Urea:Creatitine Ratio**: In **dehydration**: **urea** that is **proportionally higher than the rise in creatinine** (although both have an increase in urea and creatitine)

Question 35

The risk of which cancers is he most at risk of following renal transplantation? [1]

Answer 35

The **risk of all skin cancers** increases following kidney transplantation, evidence has shown that in particular the risk of squamous cell carcinoma is increased.

Question 36

Which cause of AKI is associated with malignancy? [1]

Answer 36

**Membranous nephropathy** is frequently associated with malignancy

Question 37

Define the term 'acute kidney injury' [3]

Answer 37

- **Rise in serum creatinine** of > or equal to **26 μmol/L within 48 hours** - or **1.5x increase in serum creatinine** known or presumed to have occurred in the **last 7 days** - or **6 hours oliguria** (urine output < 0.5ml/kg/hour)

Question 38

What is the management plan if a patient has reduced urine ouput (< 0.5ml/kg/hr) after an operation?

Answer 38

If a patient has a urine output of < 0.5ml/kg/hr postoperatively the first step is to consider a fluid challenge, if there are no contraindications or signs of haemorrhage etc: **give a STAT fluid bolus of 500ml 0.9% saline.**

Question 39

How do you treat haemolytic uraemic syndrome? [1]

Answer 39

There is no role for antibiotics in the treatment of haemolytic uraemic syndrome unless indicted my preceding diarrhoeal infection - if not preceded by diarrhoeal infection: **treatment is supportive, with fluids, blood transfusions and dialysis as required**

Question 40

Name a drug that is phosphate binder used to treat bone disease of CKD [1]

Answer 40

**Sevelamer** is a non-calcium based phosphate binder that treats hyperphosphataemia in patients with CKD mineral bone disease

Question 41

Which drug is used to treat ascites: - initially [1] - if patient has ascitic protein < 15 g/l [1]

Answer 41

Initially: **spironolactone** if patient has ascitic protein < 15 g/l: **ciprofloxacin**

Question 42

Name a therapeutic drug that induce diabetes insipidus [1]

Answer 42

**Lithium**: desensitises a patient's ability to respond to ADH

Question 43

How do you determine if a patient is suffering from early stages of diabetic nephropathy on US? [1]

Answer 43

**Become enlarged**

Question 44

What type of casts does acute tubular necrosis present with? [1]

Answer 44

**Muddy brown casts** ## Footnote Think of them as dead cells

Question 45

Which form of GN has an overlap with IgA nephropathy? [1] How does this commonly present? [3]

Answer 45

**Henoch-Schonlein purpura:** IgA mediated samlled vessel vasculitis * palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs * abdominal pain * polyarthritis

Question 46

Which cause of AKI presents with **white ceullar casts?** [1]

Answer 46

**Acute interstitial nephritis**: often due to antibiotic therapy

Question 47

When should you perform an A:CR test in diabetic patients? [1]

Answer 47

Early in the monring

Question 48

Which is the most important HLA for donor matching? [1]

Answer 48

HLA-DR

Question 49

# * All patients who are diagnosed with CKD should be prescribed what drug / drug class? [1]

Answer 49

Statins

Question 50

Which drug class is prescribed for diabetes inspidus? [1]

Answer 50

**V2 Receptor agonist**

Question 51

What important cardiac sign does CKD with anaemia cause? [1]

Answer 51

Hyperdynamic circulatory flow murmur due to increased tuburlent flow because of thin blood

Question 52

How can you tell if a cause of AKI is pre-renal? [1]

Answer 52

Responds to fluid challenge

Question 53

Why does Goodpastures syndrome present with haemoptysis? [1]

Answer 53

Type IV collagen is also found in the alveoli, so causes pulmonary haem. Also presents with nose bleeds

Question 54

Describe the pattern and source of the deposits in Goodpastures syndrome [1]

Answer 54

**IgG** deposits in **linear fashion**

Question 55

Which drugs should be stopped in cases of AKI? [5]

Answer 55

**DIANA**: **D**: diuretics **I**: Ionated contrasts **A**: ace inhibitors / ARBs **N**: NSAIDs **A**: aminoglycosides

Question 56

Define the term 'acute kidney injury' [3]

Answer 56

- **Rise in serum creatinine** of > or equal to **26 μmol/L within 48 hours** - or **1.5x increase in serum creatinine** known or presumed to have occurred in the **last 7 days** - or **6 hours oliguria** (urine output < 0.5ml/kg/hour)

Question 57

What is one of the most common causes of acute tubular necrosis? [1]

Answer 57

Haemorrhage

Question 58

How can you prevent contrast induced nephropathy? [1]

Answer 58

Volume expansion with 0.9% saline

Question 59

If prescribing fluids, how much K should be generally given? [1]

Answer 59

**1mmol/kg/day** E.g. if 60kg patient: 6 mmol/kg/day

Question 60

Which type of AKI is associated with malignancy? [1]

Answer 60

Membranous nephropathy

Question 61

Acute interstitial nephritis is associated with which two findings on a FBC? [2]

Answer 61

White cell casts Eisonophil infiltration

Question 62

If a patient presents with symptoms of nephrotic syndrome, & has a history or HIV / heroin abuse / SCA, what is the most likely cause?

Answer 62

Focal sclerosis glomerulosclerosisi

Question 63

Which type of GN is associated with renal transplants? [1]

Answer 63

**Focal sclerosis glomerulosclerosis**

Question 64

What type of anion gap occurs in a patient with severe diarrhoea [1] and vomiting? [1]

Answer 64

**Diarrhoea**: Normal anion gap acidosis **Vomiting**: Normal anion gap alkolosis

Question 65

Why does a patient presenting with nephrotic syndrome have a high risk of VTE? [1]

Answer 65

Loss of anti-thrombin III (which antagonises action of thrombin, so get unopposed action of thrombin)

Question 66

Name three main complications of nephrotic syndrome [3]

Answer 66

Hyperlipidaemia Infection (loss of IgG) VTE

Question 67

Why does alcohol binging lead to polyuria? [1]

Answer 67

**Suppresses ADH release in posterior pituitary** (similar to cranial diabetes)

Question 68

Name a recreational drug that causes SIADH [1]

Answer 68

MDMA

Question 69

What are the NICE guidelines for fluid maintenence? [1]

Answer 69

25-30 ml / kg / day

Question 70

What is the most common cause of haemolytic uraemic syndrome? [1]

Answer 70

E. coli

Question 71

Name an AE of spironolactone [1]

Answer 71

**Gynecosmastia**: inhibits free testosterone from binding to androgen receptors in the breast

Question 72

Rhabdomyolosis causes renal failure via which cause of AKI? [1]

Answer 72

**Tubular cell necrosis**

Question 73

What is the most likely cause of death for someone on haemodialysis with CKD? [1] Explain your answer

Answer 73

**Ischaemic heart disease**: causes dyslipidameia, HTN, anaemia and systemic inflammation

Question 74

What is important to account for when initiating treatment for chronic CKD? [1]

Answer 74

**Iron deficiency** can cause patients to **fail to respond to EPO therapy**

Question 75

A patient presents with CKD and A:CR greater than 30. What drug class should be prescribed? [1]

Answer 75

ACE inhibitor

Question 76

What triad of symptoms indicates renal cell carcinoma? [3]

Answer 76

Flank pain Flank mass Haematuria | only presents in 10%

Question 77

What is a key indicator that a patient is suffering from H.U.S? [2]

Answer 77

**Blood diarrhoea** and **AKI symptoms**

Question 78

What effect does calcium resonium have on K? [1]

Answer 78

**removes K** from the body

Question 79

Which fluid should not be prescribed to patients with hyperkalaemia? [1]

Answer 79

**Hartmanns**: has K in it

Question 80

How does achalasia present on imaging? [1]

Answer 80

**Bird beak sign**

Question 81

What is the name of this sign of a barium swallow? [1] What pathology does it indicate? [the patient presented with dysphagia]

Answer 81

This patient's barium swallowing shows a filling defect of a subsection of the oesophagus with obvious anatomical narrowing. This is sometimes referred to as the '**apple core sign**' with the narrowed oesophagus appearing similar to the core of an apple In the context of **dysphagia**, this barium swallow is highly suggestive of **oesophageal carcinoma**

Question 82

A patient presents with coeliac disease. Which vaccine should they be given every 5 years? [1] Why? [1]

Answer 82

As part of the condition, **hyposplenism is common**, which can **lead** to more **severe infections with pneumococcus**. As such, many groups such as Coeliac UK suggest the administration of the **pneumococcal vaccine every 5 years.** ## Footnote A king wears a CROWN (sounds like Crohn) and drinks from GOBLETs (goblet cell)

Question 83

Name a gastro disease that causes increased goblet cells [1]

Answer 83

**Crohn's disease** - increased goblet cells

Question 84

[] are the investigations of choice in primary sclerosing cholangitis. What sign would indicate a positive result? [1]

Answer 84

**ERCP/MRCP** are the investigations of choice in primary sclerosing cholangitis Multiple biliary strictures giving a '**beaded**' appearance

Question 85

The [] detects the presence of Helicobacter pylori [] is the only test recommended for H. pylori **post-eradication therapy**

Answer 85

The **stool antigen test** detects the presence of Helicobacter pylori **Urea breath test** is the only test recommended for H. pylori post-eradication therapy

Question 86

Investigations discover she has H. pylori. What is the next step? [1]

Answer 86

You need to be off PPIs for two weeks before endoscopy so triple therapy would start afterwards

Question 87

Primary biliary cirrhosis is most characteristically associated with: Anti-nuclear antibodies Anti-ribonuclear protein antibodies Anti-mitochondrial antibodies Rheumatoid factor Anti-neutrophil cytoplasmic antibodies

Answer 87

**Anti-mitochondrial antibodies** **Primary biliary cholangitis - the M rule** **IgM** anti-**M**itochondrial antibodies, M2 subtype **M**iddle aged females

Question 88

[] cancer may present with cholestatic LFTs (**raised yGT & ALP**)

Answer 88

**Pancreatic** cancer may present with cholestatic LFTs

Question 89

Which disease is commonly associated with primary sclerosing cholangitis? [1] Name three raised markers that would indicate PSC [3]

Answer 89

**Ulcerative colitis** **Raised ALP; ANCA; bilirubin**

Question 90

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either oral **[]** or oral **[]** to maintain remission

Answer 90

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either **oral azathioprine** or **oral mercaptopurine** to maintain remission

Question 91

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either oral **[]** or oral **[]** to maintain remission

Answer 91

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either **oral azathioprine** or **oral mercaptopurine** to maintain remission

Question 92

What would indicate that a UC flair up is: - Mild [1] - Moderate [1] - Severe [2]

Answer 92

- **Mild**: Fewer than four stools daily, with or without blood - **Moderate**: Four to six stools a day, with minimal systemic disturbance - **Severe**: More than six stools a day, containing blood & Evidence of systemic disturbance

Question 93

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is [1]

Answer 93

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is **topical (rectal) aminosalicylates**

Question 94

What drug is prescribed for high K if: - ECG changes occur [1] - If K > 6.5 [1]

Answer 94

- ECG changes occur: **calcium gluconate** - If K > 6.5: **insulin dextrose**

Question 95

Name an epileptic drug that causes low Na+? [1] Which pathologies can this lead to? [2]

Answer 95

**Carbamazepine**: can lead to **SIADH** & **seizures**

Question 96

Name two AEs of amlodopine [2]

Answer 96

Headaches Foot swelling

Question 97

Name risks of prescribing testosterone for a patient with low testorone? [3] What follow up would you conduct to ameliorate for this? [1]

Answer 97

Increases the risk of: * **prostate cancer** * **secondary polycythaemia** - increases risk of **DVT and VE** * **Aggression** Conduct a yearly **PSA** for the prostate risk

Question 98

What is the first line treatment for PCOS? [1] What other drug should be considered [1]

Answer 98

1st line: **Weight loss** Consider: **metformin**

Question 99

The [] criteria are used for making a diagnosis of polycystic ovarian syndrome

Answer 99

The **Rotterdam** **criteria** are used for making a diagnosis of polycystic ovarian syndrome

Question 100

The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: [3]

Answer 100

**Oligoovulation** or **anovulation**, presenting with irregular or absent menstrual periods **Hyperandrogenism**, characterised by hirsutism and acne **Polycystic ovaries on ultrasound** (or ovarian volume of more than 10cm3) *It is important to remember that only having one of these three features does not meet the criteria for a diagnosis. As many as 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.*

Question 101

Out of LH & FSH, what is the normal ratio? [1] Which way around is this in PCOS? [1]

Answer 101

Normal: FSH > LH PCOS: **Raised LH to FSH ratio (high LH compared with FSH**

Question 102

Describe what Familial hypocalciuric hypercalcemia (FHH) is [2]

Answer 102

FFH: * is a rare **autosomal** **dominant** condition. * It occurs as a result of mutations in the **calcium-sensing receptor gene (CASR)** that lead to **decreased receptor activity** in parathyroid gland gland * **Can't excrete Ca**

Question 103

How do patients with Familial hypocalciuric hypercalcemia (FHH) present with regards to serum Ca, urine Ca, serum Mg and serum P levles [4]

Answer 103

Patients typically have **mild** **hypercalcemia**, **hypocalciuria**, **hypermagnesemia**, and **hypophosphatemia**.

Question 104

A patient has suspected bleeding varices. What two drugs should you prescribe? [2] Is this before or after endoscopy? [1]

Answer 104

**Terlipressin** & Antibiotics (**Ceftriaxone**) **BEFORE** **endoscopy**

Question 105

What is the management for oesophageal varices if terlipressin and antibiotics does not work? [1]

Answer 105

**Sengstaken-Blakemore** tube if uncontrolled haemorrhage

Question 106

What is the management if Sengstaken-Blakemore tube cannot manage uncontrolled haemorrhage of variceal haem.? [1]

Answer 106

**Transjugular Intrahepatic Portosystemic Shunt (TIPSS):** connects the hepatic vein to the portal vein

Question 107

How do you screening for haemochromatosis: - general population: [1] - family members [1]

Answer 107

Screening for haemochromatosis general population: **transferrin saturation > ferritin** family members: **HFE genetic testing**

Question 108

A patient has moved onto maintence therapy for Crohns. Which one of the following drugs is the most appropriate to prescribe? Azathioprine Budesonide Mesalazine Methotrexate Oral glucocorticoids

Answer 108

A patient has moved onto maintence therapy for Crohns. Which one of the following drugs is the most appropriate to prescribe? **Azathioprine** Budesonide Mesalazine Methotrexate Oral glucocorticoids Mesalazine is used second-line to glucocorticoids to induce remission, but they are not as effective. It appears to act locally on colonic mucosa and reduces inflammation through a variety of anti-inflammatory processes.

Question 109

The NICE guidelines for anaemia-iron deficiency (2013), state the following investigations: [3]

Answer 109

The NICE guidelines for anaemia-iron deficiency (2013), state the following investigations: 1) Check **full blood count**:. 2) If results show a low Hb and low MCV in a non-pregnant person check the **ferritin** **level** 3) It is important to note that **ferritin** levels can be **elevated** when **inflammation** or co-existing conditions such as liver disease, malignancy or hyperthyroidism are present thus giving spurious readings. In this case, as stated by NICE guidelines, a **different measure of iron status should be considered such as iron, total iron binding capacity or transferrin saturation.**

Question 110

Clinical diagnosis of irritable bowel syndrome, supported by relief on defaecation as well as a panel of normal blood tests. The first-line anti-motility agent for this presentation of diarrhoea would be **[]**, as recommended by NICE guidelines

Answer 110

clinical diagnosis of irritable bowel syndrome, supported by relief on defaecation as well as a panel of normal blood tests. The first-line anti-motility agent for this presentation of diarrhoea would be **loperamide**, as recommended by NICE guidelines

Question 111

The Truelove and Witts' severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults. Ulcerative colitis is classified as 'severe' in which instances? [5]

Answer 111

TRUElove and Witt's when the patient has **blood** in their **stool**, or is passing **more than 6 stools** per **day** plus at least one of the following features: * T - Temp **> 37.8** * R - Rate **> 90** * U - (Uh)naemia **Hb < 105** * E - ESR **>30**

Question 112

A patient has positive IgA tissue transglutaminase antibodies (tTGA). What is the most appropriate next step in management? [1]

Answer 112

******Continue gluten-containing diet and refer for intestinal biopsy**: * All cases of suspected coeliac disease with positive serology should have a duodenal biopsy to confirm the diagnosis. Patients will ideally need to consume gluten in their diet for **6 weeks prior to serology testing and biopsy.**

Question 113

Pernicious anaemia is an autoimmune disease that inactivates intrinsic factor and prevents further production. It leads to low vitamin B12 levels and anaemia. The most serious complication that can occur secondary to this condition is []

Answer 113

Pernicious anaemia is an autoimmune disease that inactivates intrinsic factor and prevents further production. It leads to low vitamin B12 levels and anaemia. The most serious complication that can occur secondary to this condition is **gastric carcinoma**

Question 114

First episode of C. difficile infection: Oral [] is the first line antibiotic for use in patients with C. difficile infection second-line therapy: oral [] third-line therapy: oral [] +/- IV []

Answer 114

**Oral vancomycin** is the first line antibiotic for use in patients with C. difficile infection second-line therapy: **oral fidaxomicin** third-line therapy: **oral vancomycin +/- IV metronidazole**

Question 115

IBS is a disease of exclusion. What testing must be done to make a diagnosis? [3]

Answer 115

all patients with suspected IBS should have their: - **full blood count** - **ESR or CRP** - **coeliac disease serology tested**

Question 116

Which one of the following findings on biopsy would be most consistent with a diagnosis of gastric adenocarcinoma? Columnar metaplasia Histiocytic infiltration Paneth cell metaplasia Giant cell granulomas Signet ring cells

Answer 116

Which one of the following findings on biopsy would be most consistent with a diagnosis of gastric adenocarcinoma? Columnar metaplasia Histiocytic infiltration Paneth cell metaplasia Giant cell granulomas **Signet ring cells**

Question 117

If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then **oral []** are added

Answer 117

If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then **oral** **corticosteroids** are added

Question 118

Treatment for Wilson's disease is currently []

Answer 118

Treatment for Wilson's disease is currently **penicillamine** | Copper Penny = Penicillamine

Question 119

What electrolyte imbalance do PPIs cause? [1]

Answer 119

Hyponatraemia

Question 120

What disadvantage of using a proton-pump inhibitor (PPI) long-term? (what pathology can it cause?0

Answer 120

PPIs can increase the risk of **osteoporosis** and **fractures**

Question 121

Dysplasia on biopsy in Barrett's oesophagus requires what management? [1]

Answer 121

Requires an endoscopic intervention: **Endoscopic mucosal resection (EMR)** is a treatment option for Barrett's esophagus with high-grade dysplasia (HGD).

Question 122

Avoid [] when patient is already on clopidogrel?

Answer 122

for revision: avoid **omeprazole/esomeprazole** when pt already on clopidogrel (use lansoprazole instead)

Question 123

Ciprofloxacin. Delafloxacin. Levofloxacin. Moxifloxacin These are all examples of quinolones. Treatment for which pathology are they conintradicated in and why? [1]

Answer 123

**Epilepsy**: **Quinolones may lower the seizure threshold and may trigger seizures.** Levofloxacin is contraindicated in patients with a history of epilepsy and, as with other quinolones, should be used with extreme caution in patients predisposed to seizures, or concomitant treatment with active substances that lower the cerebral seizure threshold, such as theophylline:

Question 124

What are the 4 grades of hepatic encephalopathy? [4]

Answer 124

**Grading of hepatic encephalopathy** **Grade I:** Irritability **Grade II**: Confusion, inappropriate behaviour **Grade III**: Incoherent, restless **Grade IV**: Coma

Question 125

What is the first line treatment for hepatic encephalopathy? [1] What is the secondory prophylaxis of hepatic encephalopathy? [1]

Answer 125

NICE recommend **lactulose first-line** **rifaximin for the secondary prophylaxis of hepatic encephalopathy**

Question 126

If a mild-moderate flare of distal ulcerative colitis doesn't respond to topical (rectal) aminosalicylates then what is the next treatment line? [1]

Answer 126

If a mild-moderate flare of distal ulcerative colitis doesn't respond to **topical (rectal) aminosalicylates** then **oral aminosalicylates should be added**

Question 127

[] is not recommended for the management of UC (in contrast to Crohn's disease)

Answer 127

**methotrexate** is not recommended for the management of UC (in contrast to Crohn's disease)

Question 128

How do you determine the level of C. diff infection? [1]

Answer 128

The WCC count

Question 129

How do you differentiate between moderate and severe C. diff infection? [1]

Answer 129

**A raised WBC count** (but less than 15 * 109 per litre) **is indicative of a moderate C. difficile infection**. If the WBC count is **greater than 15 * 109 per litre**, it is indicative of a **severe** **infection**.

Question 130

What does SAAG stand for? [1]

Answer 130

SAAG = **serum albumin - ascitic fluid albumin**.

Question 131

What SAAG level indicates portal HTN? [1]

Answer 131

Ascites: **a high SAAG gradient (> 11g/L)** indicates portal hypertension

Question 132

A faecal stool sample was sent, and the results this morning are as follows: C. difficile toxin -ve C. difficile antigen +ve What is the next step in the management of this patient? [1] Explain your answer [1]

Answer 132

C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection If the toxin is positive, it means the bacteria is actively replicating and is likely the cause of the diarrhoea. If the antigen is positive in isolation, it merely means the bowel is colonised with C. difficile, and not necessarily causing diarrhoea. Reassure and continue monitoring symptoms

Question 133

Name an antibiotic that causes cholestasis [1]

Answer 133

**Co-amoxiclav** is a well recognised cause of cholestasis

Question 134

Co-amoxiclav causing cholestasis would cause which deranged LFTs [3]

Answer 134

Raised ALP Raised bilirubin Raised yGT

Question 135

A patient has achalasia. The first-line treatment for patients who are young with no comorbidities is []

Answer 135

A patient has achalasia. The first-line treatment for patients who are young with no comorbidities is **pneumatic dilation**

Question 136

Coeliac disease increases the risk of developing which type of cancer? [1]

Answer 136

Coeliac disease increases the risk of developing **enteropathy-associated T cell lymphoma**

Question 137

How does pancreatic cancer lead to steotorrhoea? [1]

Answer 137

**Steatorrhoea** is caused by fat malabsorption and can occur if a **tumour blocks the pancreatic duct** meaning insufficient pancreatic juices are secreted hence, there is a reduction in lipase and bile salts

Question 138

[] is the first line treatment for hereditary haemochromatosis. [] may be used second-line

Answer 138

**Venesection** is the first line treatment for hereditary haemochromatosis. **Desferrioxamine** may be used second-line

Question 139

Primary sclerosing cholangitis is most associated with: Primary biliary cirrhosis Crohn's disease Hepatitis C infection Ulcerative colitis Coeliac disease

Answer 139

Primary sclerosing cholangitis is most associated with: Primary biliary cirrhosis Crohn's disease Hepatitis C infection **Ulcerative colitis** Coeliac disease

Question 140

You suspect a diagnosis of small bowel bacterial overgrowth syndrome (SBBOS). What is the appropriate first-line diagnostic test? Faecal calprotectin Hydrogen breath testing Lower GI endoscopy and biopsy Rifaximin trial Small bowel aspirate and culture

Answer 140

**Hydrogen breath testing** measures the amount of **hydrogen or methane** that you breathe out after **drinking** a mixture of **glucose** and **water**. A rapid rise in exhaled hydrogen or methane may indicate **bacterial overgrowth in your small intestine.**

Question 141

[] is 7 times more common in patients taking mesalazine than sulfasalazine

Answer 141

**pancreatitis** is 7 times more common in patients taking mesalazine than sulfasalazine

Question 142

What would indicate use of LP? [4]

Answer 142

Gives specific information on CNS infection; Can ID blood in the brain: xanthochromia (if SAH hasn't shown up in CT) WCC PCR tests for viral infections

Question 143

Why do you ensure haemostatic parameters such as platelets and coagulation profile are normal prior to undertaking an LP? [1]

Answer 143

the risks of bleeding and brainstem herniation, the two most serious complications of LP

Question 144

What are the symptoms of myeloma? [4]

Answer 144

**CRAB** **C**alcium elevation · **R**enal (kidney) damage · **A**nemia · **B**one disease

Question 145

When are SGLT-2 inhibitors indicated in diabetes patients? [4]

Answer 145

the patient has a** high risk of developing cardiovascular disease** (CVD, e.g. QRISK ≥ 10%) the patient has **established CVD** the patient has **chronic heart failure** SGLT-2 inhibitors should also be started at any point if a **patient develops CVD** (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure | metformin should be established before introducing the SGLT-2 inhibitor

Question 146

If metformin is contraindicated in a diabetic patient, what should a patient be prescribed if: - the patient has a risk of CVD, established CVD or chronic heart failure [1] - if the patient doesn't have a risk of CVD, established CVD or chronic heart failure [2]

Answer 146

if the patient has a risk of CVD, established CVD or chronic heart failure: * **SGLT-2 monotherapy** if the patient doesn't have a risk of CVD, established CVD or chronic heart failure: * **DPP‑4 inhibitor or pioglitazone or a sulfonylurea** * **SGLT-2 may be used if certain NICE criteria are met**

Question 147

If a patient is presenting with Diabetic ketoacidosis: [] should be used initially, even if the patient is severely acidotic [1] What is the following treatment? [3]

Answer 147

Diabetic ketoacidosis: **isotonic saline** should be used initially, even if the patient is severely acidotic an **intravenous insulin infusion** should be started at **0.1 unit/kg/hour** once blood glucose is **< 14 mmol/**l an infusion of **10% dextrose** should be started at **125** **mls/hr in addition** to the 0.9% sodium chloride regime **potassium** may therefore **need** to be added to the **replacement** fluids

Question 148

Name a cause of Cushing's symptoms, that is not due to corticosteroid excess [3]

Answer 148

pseudo-Cushing’s syndrome, which has different causes: - **depression** - **HIV infection** - **excess alcohol consumption**.

Question 149

What is the treatment for hyperacute kidney rejection? [1]

Answer 149

**Removal of the transplanted kidney** is the appropriate management for hyperacute rejection. In hyperacute rejection, there is pre-existing antibody-mediated damage to the transplanted organ, and no treatment is possible. The graft must be removed immediately to prevent further damage.

Question 150

Label A & B [3]

Answer 150

Question 151

Which drug class are a risk factor for C. diff infection? [1]

Answer 151

**PPIs** are a risk factor for C. difficile infection

Question 152

Which type of cancer develops in around 10% of primary sclerosing cholangitis patients? [1] Which disease is PSC commonly found alongside? [1]

Answer 152

**Cholangiocarcinoma** develops in around 10% of primary sclerosing cholangitis patients PSC found in **UC**

Question 153

What are the clinic [1] and ABPM [1] BP targets for DMT2 patients? [2]

Answer 153

T2DM blood pressure targets are the same as non-T2DM. If < 80 years: clinic reading: **< 140 / 90** ABPM / HBPM:**< 135 / 85**

Question 154

How do you confirm that a patient is DMT2 if they are asymptomatic but have a deranged HbA1c? [1]

Answer 154

Asymptomatic patients with an abnormal HbA1c or fasting glucose must be **confirmed** with a **second abnormal reading before a diagnosis of type 2 diabetes is confirmed**

Question 155

How do you adapt a pregnant women's dose of levoythroxine due to their pregnancy? [1] Why? [1]

Answer 155

In pregnancy, anyone already on levothyroxine treatment **should increase their dose**. Thyroid doses should be adjusted in steps of 25-50mcg. In pregnancy, the increase in thyroid replacement is typically 20-50%, **which normally equates to 25mcg-50mcg increase** **low levels of thyroid hormone in the mother may harm her baby or even cause pregnancy loss or miscarriage..**

Question 156

PPIs cause what electrolyte imbalances? [2]

Answer 156

Hyponatraemia Hypomagnesia

Question 157

Describe a method, that is not looking at specific antibodies, that you can distinguish between DMT1, DMT2 & MODY [1]

Answer 157

**Measuring C-peptide levels** (result of the cleavage of proinsulin into insulin): **DMT1**: low (there's basically no insulin in type 1 the C-peptide would be low) **DMT2**: C-peptide remains in the normal range **MODY**: C-peptide levels will be normal or high, given that insulin is still being produced.

Question 158

Which medication is associated with drug-induced cholestasis? [1]

Answer 158

The **oral contraceptive pill** is associated with drug-induced cholestasis

Question 159

Aminosalicylates are associated with a variety of haematological adverse effects, including **[]** What is a key investiation? [1]

Answer 159

Aminosalicylates are associated with a variety of haematological adverse effects, including **agranulocytosis** **FBC** is a key investigation

Question 160

A 33-year-old man was admitted to the surgical ward due to an exacerbation of Crohn's disease. He presented with a perianal abscess that has been surgically drained. An MRI confirms a complex perianal fistula. In addition to an antibiotic and a biologic, what other management would be indicated? Lidocaine gel Rectal mesalazine Seton placement Surgical resection Topical glyceryl trinitrate

Answer 160

A 33-year-old man was admitted to the surgical ward due to an exacerbation of Crohn's disease. He presented with a perianal abscess that has been surgically drained. An MRI confirms a complex perianal fistula. In addition to an antibiotic and a biologic, what other management would be indicated? **Seton placement** A seton is a piece of surgical thread that is run through the fistula to allow continuous drainage while the fistula is healing. This ensures that the fistula doesn't heal containing pus within, which would result in further abscess formation.

Question 161

On histological examination of her bowel, crypt abscesses are seen. What is the most likely diagnosis? Crohn's disease Infectious colitis Irritable bowel syndrome Pseudomembranous colitis Ulcerative colitis

Answer 161

On histological examination of her bowel, **crypt abscesses** are seen. What is the most likely diagnosis? Crohn's disease Infectious colitis Irritable bowel syndrome Pseudomembranous colitis **Ulcerative colitis**

Question 162

Mrs Grey attends the gastroenterology clinic with symptoms of persistent dysphagia, food bolus obstruction and chest pain. She undergoes gastroscopy and a biopsy taken from her oesophagus demonstrates an eosinophilic infiltration. She is diagnosed with eosinophilic oesophagitis. Which of the following interleukins is most likely to have stimulated this cell production and infiltration? Interleukin-5 Interleukin-6 Interleukin-2 Interleukin-8 Interleukin-10

Answer 162

Mrs Grey attends the gastroenterology clinic with symptoms of persistent dysphagia, food bolus obstruction and chest pain. She undergoes gastroscopy and a biopsy taken from her oesophagus demonstrates an eosinophilic infiltration. She is diagnosed with eosinophilic oesophagitis. Which of the following interleukins is most likely to have stimulated this cell production and infiltration? **Interleukin-5** Interleukin-6 Interleukin-2 Interleukin-8 Interleukin-10 Interleukin (IL) 5 is produced by T helper 2 cells and is primarily responsible for stimulating the production of eosinophils. This means that it would likely be responsible for the eosinophilic infiltration found within Mrs Grey's oesophagus.

Question 163

What is the best measure of acute liver failure? [1]

Answer 163

the best measure of acute liver failure is the **international normalised ratio (INR).**

Question 164

If a Crohn's patient has had an ileocacel resection, why may diarrhoea occur? [1] Name a drug that can treat this [1]

Answer 164

The patient most likely has a **diagnosis of bile acid malabsorption as a complication of the ileocecal resection**. Treat using: **Cholestyramine** - **bile acid sequestrant** with the potential to control diarrhoea induced by bile acid malabsorption.

Question 165

Acute, chronic or previous Hep B infection? [1]

Answer 165

acute infection is the correct answer, Positive Anti-HB's' = 'Safe' (Previous vaccination) Positive Anti-HB'c' = Caught (Currently infected)

Question 166

A 24-year-old man is reviewed in the gastroenterology clinic following a recent admission for a suspected first episode of ulcerative colitis. Colonoscopy during the admission had found moderate proctitis and the patient was started on first-line topical therapy to induce remission. Following review, it is decided to prescribe the patient medication to maintain remission. What medication should be prescribed? Intravenous ciclosporin Oral azathioprine Oral prednisolone Topical mesalazine Topical prednisolone

Answer 166

What medication should be prescribed? Intravenous ciclosporin Oral azathioprine Oral prednisolone **Topical mesalazine** Topical prednisolone A topical (rectal) aminosalicylate +/- an oral aminosalicylate is used first-line in maintain remission in ulcerative colitis patients with proctitis and proctosigmoiditis

Question 167

What is the NICE first line treatment for H. pylori? [3]

Answer 167

A **proton pump inhibitor**, plus **amoxicillin**, and either **clarithromycin** or **metronidazole**

Question 168

[] is a severe inflammation of the inner lining of the large intestine, manifests as an antibiotic-associated colonic inflammatory complication. What is the most common cause of this? [1] How does this present? [1]

Answer 168

**Pseudomembranous colitis**, a severe inflammation of the inner lining of the large intestine, manifests as an antibiotic-associated colonic inflammatory complication. The most common cause of this is **clostridium difficile infection**, which can present on sigmoidoscopy with **yellow plaques on the intraluminal wall of the colon**.

Question 169

Whic therapeutic drugs cause cholestasis? [5]

Answer 169

**combined oral contraceptive pill** antibiotics: **flucloxacillin**, **co-amoxiclav, erythromycin** **anabolic steroids, testosterones** phenothiazines: **chlorpromazine**, **prochlorperazine** **sulphonylureas**

Question 170

The [] is key in determining the severity of C. difficile infection

Answer 170

The **white cell count** is key in determining the severity of C. difficile infection

Question 171

Why is prothrombin a better measure of acute liver failure than albumin? [1]

Answer 171

has a shorter half-life than albumin

Question 172

How do you calculate serum osmolality? [1]

Answer 172

2 * Na+ + glucose + urea

Question 173

You suspect an underlying thyroid malignancy and send her for further imaging which confirms a malignancy, likely thyroid in origin. Her case is brought up at the next multi-disciplinary team meeting (MDT) and her prognosis is considered to be excellent. What is the most likely diagnosis? Anaplastic thyroid cancer Follicular lymphoma Follicular thyroid cancer Medullary thyroid cancer Papillary thyroid cancer

Answer 173

You suspect an underlying thyroid malignancy and send her for further imaging which confirms a malignancy, likely thyroid in origin. Her case is brought up at the next multi-disciplinary team meeting (MDT) and her prognosis is considered to be excellent. What is the most likely diagnosis? Anaplastic thyroid cancer Follicular lymphoma Follicular thyroid cancer Medullary thyroid cancer **Papillary thyroid cancer** ## Footnote Papillary Prognosis is Perfect

Question 174

Which of the following often has lymph node metastasis? Anaplastic thyroid cancer Follicular lymphoma Follicular thyroid cancer Medullary thyroid cancer Papillary thyroid cancer

Answer 174

Which of the following often has lymph node metastasis? Anaplastic thyroid cancer Follicular lymphoma Follicular thyroid cancer Medullary thyroid cancer **Papillary thyroid cancer**

Question 175

Which of the following does not respond very well to treatment? Anaplastic thyroid cancer Follicular lymphoma Follicular thyroid cancer Medullary thyroid cancer Papillary thyroid cancer

Answer 175

Which of the following does not respond very well to treatment? **Anaplastic thyroid cancer** Follicular lymphoma Follicular thyroid cancer Medullary thyroid cancer Papillary thyroid cancer ## Footnote Anaplastic is Awful (not treatment responsive usually)

Question 176

How do the following types of thyroid cancer spread? - Papillary [1] - Follicular [1]

Answer 176

**PL** - premier league = **papillary** + **lymphatic** spread FH - **follicular** + **haematogenous spread**

Question 177

What are the first line options for diabetic neuropathy? [4]

Answer 177

first-line options include **amitriptyline** (a tricyclic antidepressant, TCA), **gabapentin** (an anticonvulsant), and **pregabalin** (another anticonvulsant) or **duloxetine**

Question 178

Acromegaly can lead to which cardiac pathology? [1]

Answer 178

**Cardiomyopathy**

Question 179

[] are used in the management of severe alcoholic hepatitis

Answer 179

**Corticosteroids** are used in the management of severe alcoholic hepatitis

Question 180

Name a 5 AEs of Pioglitazone [5]

Answer 180

**ELBOW** E Edema(fluid retention) L Liver impairment B Bladder Cancer O Osteoporosis W Weight gain

Question 181

Name a haematological side effect of Azathioprine prescription? [1]

Answer 181

**thrombocytopenia**

Question 182

What does this chest x-ray show? Hiatus hernia Free gas under the diaphragm Right basal atelectasis Right basal consolidation Right sided pneumothorax

Answer 182

The chest x-ray shows a **hiatus hernia** which can be seen as a retrocardiac air-fluid level. Hiatus hernia refers to the herniation of a part of the abdominal viscera through the oesophageal aperture of the diaphragm. The vast majority of hiatus hernias involve only the herniation of a part of the gastric cardia through the muscular hiatal aperture of the diaphragm.

Question 183

What is Mirizzis syndrome? [1] What is the typical triad of symptoms? [3]

Answer 183

**Mirizzi's syndrome:** - Mirizzi syndrome is defined as **common hepatic duct obstruction** caused by **extrinsic** **compression** from an impacted stone in the cystic duct or infundibulum of the gallbladde It classically presents with **jaundice**, **fever** and **RUQ** pain (also known as Charcot's triad).

Question 184

Mirizzi's syndrome occurs because of extrinsic compression from which locations? [2]

Answer 184

Mirizzi's syndrome is common hepatic duct obstruction caused by extrinsic compression from a large impacted stone in the **cystic** **duct** or **neck of the gallbladder (Hartmann's pouch)**

Question 185

Describe a derm. complication of coeliac disease [1]

Answer 185

**dermatitis herpetiformis**, an itchy papulovesicular rash that affects the extensor surfaces.

Question 186

How often should HbA1c be checked in a DMT1 patient? [1]

Answer 186

Every 3-6 months

Question 187

Blood glucose targets for DMT1 patients are' [] mmol/l on waking and [] mmol/l before meals at other times of the day

Answer 187

Blood glucose targets **5-7** mmol/l on waking and **4-7** mmol/l before meals at other times of the day

Question 188

Pioglitazone is contraindicated in which type of cancer? [1]

Answer 188

Bladder cancer

Question 189

What are the serum markers of type 1 auto-immune hepatitis? [3]

Answer 189

Type 1 autoimmune hepatitis: **Antinuclear antibodies** **anti-smooth muscle antibodies** **raised IgG levels** Additionally, it is more common in young females.

Question 190

What is the treatment for auto-immune hepatitis? 2[]

Answer 190

**steroids**: **prednisilone**, other immunosuppressants e.g. **azathioprine** **liver** **transplantation**

Question 191

In general, autoimmune hepatitis affects which population? [1]

Answer 191

Autoimmune hepatitis more frequently affects **women**

Question 192

# 1. Label A-C of the markers that indicate each type of auto-immune hepatitis [3]

Answer 192

Type 1: **ANCA, SMA** Type 2: **Anti-liver/kidney microsomal type 1 antibodies (LKM1)** Type 3: **Soluble liver-kidney antigen**

Question 193

Name 5 drugs that cause gynecomastia [5]

Answer 193

**spironolactone** (most common drug cause) **cimetidine** (H2 antagnosit) **digoxin** **cannabis** **finasteride** GnRH agonists e.g. **goserelin**, buserelin **oestrogens**, **anabolic** **steroids**

Question 194

Describe the MoA of metoclopramide [1]

Answer 194

**metoclopramide**: - **prokinetic**; that increases gastrointestinal motility

Question 195

If a diabetic patient is suffering from gastroparesis induced by diabetic neuropathy, what symptoms might they be suffering from? [3] Which drugs may you prescribe? [3]

Answer 195

symptoms include **erratic blood glucose control, bloating and vomiting** management options include **metoclopramide, domperidone or erythromycin** (prokinetic agents)

Question 196

What is the most likely diagnosis? Colon cancer Perforated duodenal ulcer Ulcerative colitis Infective gastroenteritis Crohn's disease

Answer 196

What is the most likely diagnosis? Colon cancer Perforated duodenal ulcer **Ulcerative colitis** Infective gastroenteritis Crohn's disease The whole colon, without skip lesions, is affected by an irregular mucosa with loss of normal haustral markings.

Question 197

A 32 year old lady with no underlying co-morbidities presents as she has found she is pregnant. You counsel her about pregnancy supplements. She asks if she can just continue her usual multivitamin tablet she buys over the counter. Which vitamin, if taken in high doses, can be teratogenic? Vitamin A Vitamin B1 Vitamin B12 Vitamin C Vitamin D

Answer 197

A 32 year old lady with no underlying co-morbidities presents as she has found she is pregnant. You counsel her about pregnancy supplements. She asks if she can just continue her usual multivitamin tablet she buys over the counter. Which vitamin, if taken in high doses, can be teratogenic? **Vitamin A** Vitamin B1 Vitamin B12 Vitamin C Vitamin D

Question 198

Label the type of IBD for A & B [2]

Answer 198

FIG. 1: Endoscopic features of IBD. A, **UC**: - diffuse erythema - friability, granularity - loss of vascular pattern in the colon. B, **Colonic CD:** - deep fissuring ulcers - “cobblestoned” mucosa are present.

Question 199

Which of the following is UC and CD? [2]

Answer 199

Left: **severe UC** Right : **CD**

Question 200

Label A & B [2]

Answer 200

A: CD B: UC

Question 201

Based on the best evidence from randomized controlled trials, which one of the following treatments is best proven to maintain remission in Crohn disease?
Corticosteroids
Azathioprine
Oral 5-aminosalicylic acid

Answer 201

Based on the best evidence from randomized controlled trials, which one of the following treatments is best proven to maintain remission in Crohn disease?
Corticosteroids
**Azathioprine**
Oral 5-aminosalicylic acid

Question 202

Which part of the body is diverticular disease most likely [95%] to occur? [1]

Answer 202

**Sigmoid colon**

Question 203

Sulphasalazine may be used to treat UC. Name a haematological SE of this treatment [1] and describe how this may present on blood smear [1]

Answer 203

Sulphasalazine may cause **haemolytic anaemia** this can present with**Heinz bodies** | Sulphasala**z**ine **Heinz body**

Question 204

Achalasia is associated with which type of oesophageal cancer? [1] Name a significant risk factor for this cancer [1]

Answer 204

**Squamous cell cancer** **Smoking**

Question 205

How do you determine if a patient is **currently** suffering from a C. diff infection? [1]

Answer 205

**C. difficule toxin positivity shows current infection** C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection

Question 206

How do you determine if a patient is acutely suffering from HBV? [1] How you determine if a patient has immunisation from vaccination? [1] How you determine if a patient has immunisation from previous infection? [1]

Answer 206

How do you determine if a patient is acutely suffering from HBV? [1] - **HBsAg** How you determine if a patient has immunisation from vaccination? [1] - **A vaccine would only lead to anti-HBs antibodies** How you determine if a patient has immunisation from previous infection? [1] - immunity due to natural infection also leads to the **presence of anti-HBc antibodies** & **anti-HBs antibodies** *Anti-HBs = Safe (Have immunity so either immunised or previously exposed, -ve in chronic disease)* *Anti -HBc = Caught (acquired infection at some point rather than immunised)*

Question 207

Coeliac disease patients are likely to suffer from which deficiencies? [3] How does this present in anaemia? [1]

Answer 207

Coeliac disease is associated with **iron, folate and vitamin B12 deficiency** Causes **normocytic anaemia**

Question 208

What is pneumonic for remembering the factors that influence Child-Pugh score? [5]

Answer 208

**ABCDE** A - albumin B - bilirubin C - clotting D - distention (ascites) E - encephalopathy

Question 209

Which LFT is NOT useful in determining severity of liver cirrhosis? [1]

Answer 209

**ALT** (not included in Child-Pugh Score)

Question 210

[] ulcers characteristically cause pain when hungry, and are relieved by eating

Answer 210

**Duodenal** ulcers characteristically cause pain when hungry, and are relieved by eating

Question 211

Which antibiotics are most likely to cause C. difficile infection? [2]

Answer 211

Second and third-generation **cephalosporins** are now the leading cause of C. difficile. **Clindamycin** is historically associated with causing C. difficile but the aetiology has evolved significantly over the past 10 years. **C. difficile: think C!**

Question 212

Explain why patients with coeliac disease require regular immunisations? [1]

Answer 212

**Functional hyposplenism**: - In patients with coeliac disease, there can be a **decrease in splenic function**, which increases their susceptibility to certain infections, especially those caused by encapsulated bacteria such as **Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis.** - The spleen plays a crucial role in the immune system, particularly in **filtering** **bacteria and producing antibodies.**

Question 213

What is the most common cause of acute mesenteric ischaemia? [1] Patients with acute mesenteric ischaemia usually present with which other pathology? [1]

Answer 213

Acute mesenteric ischaemia is typically caused by an **embolism** resulting in occlusion of an artery which supplies the small bowel, for example the **superior mesenteric artery.** Classically patients have a history of **atrial fibrillation.**

Question 214

Which of the following is the location for the obstructing urinary tract stone? ureteropelvic junction mid-ureter ureterovesical junction urethra

Answer 214

ureteropelvic junction mid-ureter **ureterovesical junction** urethra

Question 215

What is the gold standard for diagnosis of renal stones? Ultrasound scan Non-contrast CT scan Plain film radiograph MRI scan

Answer 215

What is the gold standard for diagnosis of renal stones? Ultrasound scan **Non-contrast CT scan** Plain film radiograph MRI scan

Question 216

De Quervain's thyroiditis typically follows which type of pathology? [1]

Answer 216

This presentation of hyperthyroidism and painful goitre following an **upper respiratory tract infection** is typical of De Quervain's thyroiditis.

Question 217

During the first stage of De Quervain's thyroiditis, what is the clinical presentation of a patient? [5]

Answer 217

* **initial** **hyperthyroidism** * **painful goitre** * **globally reduced uptake of iodine-131** * **raised ESR** & **CRP**

Question 218

How do you manage patients with a suspected upper GI bleed? [1]

Answer 218

All patients with suspected upper GI bleed require an **endoscopy within 24 hours of admission** NICE guidelines do not recommend commencing a PPI infusion prior to endoscopy for patients with suspected non-variceal upper gastrointestinal haemorrhage. Rather, it can be commenced post-endoscopy.

Question 219

Thyrotoxicosis can lead to which cardiac pathologies [2]

Answer 219

Thyrotoxicosis can lead to **high output cardiac failure** & **atrial fibrillation**

Question 220

What is the first line treat for hypglycaemia; e..g *if A 25-year-old man is brought to the emergency department by his partner who states that over the past few hours, he has been complaining of nausea and shakiness. The patient explains that he has type 1 diabetes, and his blood glucose reading comes back as 3.4 mmol/L. He has no other past medical history*.

Answer 220

**15g oral glucose gel** Hypoglycaemia treatment - if the patient is conscious and able to swallow the first-line treatment is a fast-acting carbohydrate by mouth i.e.. glucose liquids, tablets or gels

Question 221

When treating dyspepsia, what are the two management options? [2] What happens if one doesn't work/ [1]

Answer 221

NICE guidelines state: 'Offer one of the following strategies to manage uninvestigated dyspepsia symptoms, depending on clinical judgement: - **Prescribe a full-dose proton pump inhibitor (PPI) for 1 month** - **Test for Helicobacter pylori infection if the person's status is not known or uncertain**. If the person tests positive for H. pylori infection, prescribe first-line eradication therapy. If one doesn't work: **swap to other treatment**

Question 222

What is the first line treatment for newly diagnosed DMT1 patients? [1]

Answer 222

In newly diagnosed adults with type 1 diabetes, the first-line insulin regime should be a **basal–bolus using twice‑daily insulin detemir** The basal insulin can be twice‑daily insulin detemir or once-daily insulin glargine or insulin detemir

Question 223

What is the most common congenital male reproductive disorder? Testicular torsion Cryptorchidism Hydrocoele Peyronie disease

Answer 223

What is the most common congenital male reproductive disorder? Testicular torsion **Cryptorchidism** Hydrocoele Peyronie disease

Question 224

What is the classic triad of renal cell carcinoma? [3]

Answer 224

classic triad of renal cell carcinoma: **Haematuria** **Loin pain** **Loin mass**

Question 225

A patient presents with symptoms of an overactive bladder. What is the first choice drug treatment? [1] What treatment is offered if the first choice is contrindicated? [1]

Answer 225

First choice: **Oxybutynin** Second choice: **Mirabegron**

Question 226

What is a positive Prehn's sign? [1] Which two pathologies does it help to distinguish between? [2]

Answer 226

**+ve Prehn's sign**: - the **relief** of **pain** on **elevation** of the **testis** - **Positive**: indicates **epididymo-orchitis** - **Negative** (i.e. the pain is not relieved) in cases of **testicular torsion**.

Question 227

A 45-year-old man presents with symptoms of urinary colic. In the history he has suffered from recurrent episodes of frank haematuria over the past week or so. On examination he has a left loin mass and a varicocele. The most likely diagnosis is: Renal adenocarcinoma Renal cortical adenoma Squamous cell carcinoma of the renal pelvis Retroperitoneal fibrosis Nephroblastoma

Answer 227

A 45-year-old man presents with symptoms of urinary colic. In the history he has suffered from recurrent episodes of frank haematuria over the past week or so. On examination he has a left loin mass and a varicocele. The most likely diagnosis is: **Renal adenocarcinoma** Renal cortical adenoma Squamous cell carcinoma of the renal pelvis Retroperitoneal fibrosis Nephroblastoma

Question 228

Following catheterisation for acute urinary retention secondary to a lower urinary tract infection, the patient's post-void bladder volume is recorded. What is the acceptable upper limit of residual urine in patients < 65 years old? 20ml 50ml 100ml 500ml 800ml

Answer 228

Following catheterisation for acute urinary retention secondary to a lower urinary tract infection, the patient's post-void bladder volume is recorded. What is the acceptable upper limit of residual urine in patients < 65 years old? 20ml **50ml** 100ml 500ml 800ml

Question 229

A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely? Staphylococcus saprophyticus Proteus mirabilis Klebsiella E-Coli Staphylococcus epidermidis

Answer 229

A 48-year-old women presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely? Staphylococcus saprophyticus **Proteus mirabilis** Klebsiella E-Coli Staphylococcus epidermidis Infection with Proteus mirabilis accounts for 90% of all proteus infections. It has a **urease producing enzyme**. This will tend to favor **urinary alkalinisation which is a relative per-requisite for the formation of staghorn calculi.**

Question 230

What ABG result would indicate paracetamol overdose? [1]

Answer 230

**metabolic acidosis**

Question 231

Name three causes of increased erythrocyte lifespan [3]

Answer 231

- **Splenectomy** (think - Coealic Disease) - **B12** and **folate** **deficiences** - **IDA**

Question 232

Name a oesophageal condition caused by long term corticosteroid use [1]

Answer 232

**Oesophageal candidasis**

Question 233

# [](http://) DDescribe the presentation of subacute thyroiditis in the first stage [3]

Answer 233

**PAINFUL goitre** **Raised ESR** (caused by inflammation to thyroid) **Hyperthyroidism features**

Question 234

Subacute thyroiditis occurs after an infection from which type of organism? [1]

Answer 234

Post-**viral** infection

Question 235

Describe the uptake of iodine in subacute thyroiditis [1]

Answer 235

**No increase uptake**: thyroid is inflammed due to infection. Lots of T4 released, but it is acutely damaged and not producing any more during period

Question 236

What is the primary cause of primary hyperaldosteronism? [1]

Answer 236

**Bilateral idiopathic adrenal hyperplasia**

Question 237

What is important to consider about primary hyperaldosteronism?

Answer 237

Textbooks: **hypokalaemic** Life: can be **normokalaemic**

Question 238

What is the order of treatment for: - Acromegaly [2] - Prolactinoma [2]

Answer 238

Acromegaly: - **Surgery 1st line** - **Drugs 2nd line** (octreotide) Prolactinoma: - **Drugs 1st line** (Dopamine agonists: Cabergoline; bromocriptine) - **Surgery 2nd line**

Question 239

What is the name of CKD treatment that stimulates EPO? [1] What checks should occur before this treatment is given? [1

Answer 239

**darbepoetin alfa** Other causes of anaemia (**such as iron deficiency**) should be checked and **corrected prior to therapy with erythropoietin**

Question 240

Which of the following medication classes may be be associated with causing bladder cancer? SGLT-2 inhibitors Biguanides Thiazolidinediones GLP-1 mimetics Insulin

Answer 240

Which of the following medication classes may be be associated with causing bladder cancer? SGLT-2 inhibitors Biguanides **Thiazolidinediones** GLP-1 mimetics Insulin

Question 241

How does IDA present with regards to total iron-binding capacity? [1]

Answer 241

Iron deficient anaemia classically comes as **microcytic**, with a **high total iron-binding capacity**: - because the body still has the **capability to transport iron** around the body since there is **not a high concentration of iron currently**

Question 242

Name three MSK AEs of glucocorticoids [3]

Answer 242

**Osteoporosis** **Proximal myopathy** **Avascular necrosis of the femoral head**

Question 243

What treatment is given for Crohn's patients who develop a perianal fistula? [1]

Answer 243

**Oral metronidazole**

Question 244

# * What pathology is depicted? [1]

Answer 244

**Diverticulosis**: Diverticula are small pouches that bulge outward through weak spots in the colon wall. They often occur in the sigmoid and descending colon but can be found anywhere in the digestive tract. In this case, it is likely causing the patient's left iliac fossa pain due to intermittent inflammation or infection.

Question 245

Which blood vessel is most at risk of a duodenal ulcer? [1]

Answer 245

Gastroduodenal artery

Question 246

A 31-year-old male presents to his GP complaining of a sudden onset 3 day history of fever, shivers and a sore throat. He has a past medical history of ulcerative colitis, for which he is treated with the aminosalicylate, mesalazine. What is the most important investigation in this patient? Blood cultures FBC LFTs U&Es Viral throat swab

Answer 246

A 31-year-old male presents to his GP complaining of a sudden onset 3 day history of fever, shivers and a sore throat. He has a past medical history of ulcerative colitis, for which he is treated with the aminosalicylate, mesalazine. What is the most important investigation in this patient? **FBC** Aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis - FBC is a key investigation

Question 247

Which changes to neurological system do NOT occur due to diabetic neuropathy? [2]

Answer 247

Although this patient has diabetes mellitus, the presentation of **difficulty walking and increased spasticity** is **NOT** explained by diabetic neuropathy.

Question 248

What is the is the characteristic iron study profile in haemochromatosis? [3]

Answer 248

**Raised transferrin saturation** and **ferritin**, with **low TIBC** is the characteristic iron study profile in haemochromatosis

Question 249

Describe the proflie of stool from a Gardia lamblia infection [1] Where is a higher risk of infection? [1]

Answer 249

Giardia causes fat malabsorption, therefore **greasy** **stool** can occur. It is resistant to chlorination, hence **risk of transfer in swimming pools.**

Question 250

State the rules for deciding first line hypertensive drugs [1]

Answer 250

**ACEin / ARB:** - HTN and DM - HTN and under 55 and not Black / Afro C **CCB**: - over 55 - Black / Afro C

Question 251

What is gallstone ileus? [1]

Answer 251

Where a **gall stone** enters the **small** **intestines**; **Lodges** at the **ileocaecal valves; ** Causes **small bowel obstruction** and **air in biliary tree**

Question 252

What is Classic Rigler's Triad of gallstone ileus?

Answer 252

Classic Rigler's Triad - **Air in bile ducts, gallstone visible outside gallbladder and small bowel obstruction :**

Question 253

Long term PPI can cause hypomagnesia. What symptoms would this cause? [1]

Answer 253

**Muscle ache**

Question 254

Long term PPI can lead to which MSK disease? [1] Explain your answer

Answer 254

**Osteoporosis**: PPIs could alter **intestinal calcium absorption**, thus resulting in **increased rates of bone loss**

Question 255

What are the seroligcal markers characteristic of autoimmune hepatitis? [3]

Answer 255

**Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels**

Question 256

In patients with nephrotic syndrome, there is an increased risk of venous thromboembolism due to the loss of which clotting factor? [1]

Answer 256

Anti-thrombin III

Question 257

Which is a key differential when suspect appendicitis (in men)? [1]

Answer 257

**testicular problems** (infection and torsion).

Question 258

Which diabetic drug has an increased risk of leg ulcers and amputation? [1]

Answer 258

**canagliflozin** and the increased risk of leg ulcers and amputation, with a potential class effect across the SGLT-2 inhibitors.

Question 259

What is the 'double duct' sign? [1] Which cancers is it seen in? [2] Which cancer is the most common [1]

Answer 259

The **'double duct**' sign: **combined dilatation of the common bile duct and pancreatic duct** **Pancreatic cancer** & **cholangiocarcinoma** **Pancreatic cancer more common**

Question 260

How do you differentiate between ferritin levels from acute response to liver versus haemochromatosis? [1]

Answer 260

Both get high ferritin levels; **haemochromatosis** normally presents after **fifth decade**

Question 261

Which iron serological marker may be the earliest indictor hereditary haemochromatosis? [1]

Answer 261

**Raised transferrin saturation** may be the earliest indicator of hereditary haemochromatosis.

Question 262

You suspect a patient has autoimmune hepatitis. What is your next step to confirm diagnosis? [1]

Answer 262

**Biopsy** gives definitive diagnosis.

Question 263

You diagnose a patient with **active AIH**. What is the two step treatment regime? [1] How long does treatment for AIH need to occur to prevent relapse? [1]

Answer 263

1st line: **prednisolone** 2nd line: **aziothropine** **Continue treatment for 2 years**

Question 264

How do you check if an NG tube is in the correct location? [2]

Answer 264

1. **Aspirate from tube & pH test**: 1-5.5 2. If aspiration not possible; **CXR**

Question 265

What should you do beforre flushing an NG tube? [1]

Answer 265

CXR to ensure in correct position

Question 266

Describe treatment regime for oesophogeal strictures [2]

Answer 266

PPI **Balloon dilatation following benign biospy**

Question 267

Describe difference in presentation upon catherisation between acute and chronic blader obstruction [2]

Answer 267

Acute: painful Chronic: not painful

Question 268

Describe the pathophysiology of TURP syndrome? [3] How serious is it? [1]

Answer 268

It is caused by **irrigation** with **large volumes of glycine**, which is **hypo**-**osmolar** and is **systemically absorbed** when **prostatic** **venous** **sinuses** are opened up during **prostate resection** This results in **hyponatremia**, and when glycine is broken down by the liver into ammonia, **hyper-ammonia and visual disturbances.** TURP syndrome is a **rare and life-threatening complication**

Question 269

Desribe the early presentation [2] and late presentation [5]of TURP syndrome [2

Answer 269

TURP syndrome typically presents with **CNS, respiratory and systemic symptoms**: **Early features** * mild cases may go **unrecognised** * **restlessness**, **headache**, and **tachypnoea**, or a **burning sensation in the face and hands** **Features of greater severity** * **respiratory** **distress**, **hypoxia**, **pulmonary** **oedema** * **nausea**, **vomiting** * **visual** **disturbance** (e.g. blindness, fixed pupils) * **confusion**, **convulsions**, **and** coma * **haemolysis** * **acute renal failure** * reflex **bradycardia** from fluid absorption

Question 270

Cancer from where is likely causing this symptom? [1]

Answer 270

Renal cell carcinoma

Question 271

# 1. What is acute bacterial prostatis usually caused by? [1]

Answer 271

**E.coli**

Question 272

State risk factors for acute bacterial prostatis [4]

Answer 272

Risk factors for acute bacterial prostatitis include: * **recent urinary tract infection** * **urogenital** **instrumentation** * **intermittent bladder catheterisation** * **recent prostate biopsy.**

Question 273

State the two subclassifications of chronic (3month+) prostatitis [2]

Answer 273

Chronic prostatitis may be sub-divided into: **Chronic prostatitis** or **chronic pelvic pain syndrome** (no infection) **Chronic bacterial prostatitis** (infection)

Question 274

Describe the features of acute bacterial prostatitis [4]

Answer 274

* the **pain** of prostatitis may be referred to a variety of areas including the **perineum, penis, rectum or back** * **obstructive voiding symptoms** may be present * **fever** and **rigors** may be present: features of **systemic infection** * digital rectal examination: tender, **boggy prostate gland** ABS - **Acute pain** - **boggy prostate** - **severe pain** (perineum, penis, rectum, back)

Question 275

How do you treat ABP? [1]

Answer 275

Clinical Knowledge Summaries currently recommend a **14-day course of a quinolone** consider screening for sexually transmitted infections

Question 276

If patient presents with ED. What test should you initially do? [1] If this result is low / borderline, it should be repeated alongside testing for which hormones? [3] If these are then abnormal, what is the next step? [1]

Answer 276

**Free testosterone should also be measured in the morning between 9 and 11am.** If free testosterone is low or borderline, it should be repeated along with f**ollicle-stimulating hormone, luteinizing hormone and prolactin levels**. If any of these are **abnormal refer to endocrinology for further assessment.**

Question 277

Pneumonic for TURP complications? [4]

Answer 277

Complications of Transurethral Resection: **TURP** **T** urp syndrome **U** rethral stricture/UTI **R** etrograde ejaculation **P** erforation of the prostate

Question 278

TURP presents classically as a triad of? [3]

Answer 278

The triad of features are: 1. **Hyponatraemia: dilutional** 2. **Fluid overload** 3. **Glycine toxicity**

Question 279

Name an important AE of prostate cancer radiotherapy [1]

Answer 279

**Proctitis**

Question 280

What is proctitis? [1] Name three causes of proctitis [3]

Answer 280

**Proctitis** is **inflammation** of the **lining** of the **rectum**. Causes: - **radiotherapy** - **inflammatory bowel disease** - **infection**.

Question 281

What is the most common organic cause of ED? Central neurogenic causes Vascular causes Peripheral neurogenic causes Hormonal causes Structural/anatomical causes

Answer 281

What is the most common organic cause of ED? Central neurogenic causes **Vascular causes** Peripheral neurogenic causes Hormonal causes Structural/anatomical causes | **Penis is an artery**

Question 282

The first-line investigation of a testicular mass is []

Answer 282

The first-line investigation of a testicular mass is **an ultrasound**

Question 283

How long after ejaculation and vigorous exercise should you wait before measuring PSA? [1] How long after protastitis and UTI exercise should you wait before measuring PSA? [1]

Answer 283

ejaculation and vigorous exercise: **wait 48hrs** protastitis and UTI: **wait** **1 month**

Question 284

What is an aide for memorising upper age limit of PSA levels? [1]

Answer 284

(Age-20) / 10

Question 285

What is the purpose of cyproterone acetate? Directly reducing the growth of prostate cancer Increase luteinizing hormone secretion Increase testosterone levels Prevent paradoxical increase in symptoms with GnRH agonists Reduce dose of GnRH agonists required for the intended effect

Answer 285

What is the purpose of cyproterone acetate? Directly reducing the growth of prostate cancer Increase luteinizing hormone secretion Increase testosterone levels **Prevent paradoxical increase in symptoms with GnRH agonists** Reduce dose of GnRH agonists required for the intended effect **Prostate cancer: GnRH agonists may cause 'tumour flare' when started, resulting in bone pain, bladder obstruction and other symptoms**

Question 286

Describe which parameters of varicoceles determine if treatment is given [2]

Answer 286

**Grade II or III varicocoele Management**: * **Asymptomatic** AND **normal** **semen** parameters **Semen analysis every 1-2yrs** * **Symptomatic** OR **abnormal** **semen** parameters: **Surgery**

Question 287

nvestigations for suspected epididymo-orchitis are guided by age: sexually active younger adults: [] older adults with a low-risk sexual history: []

Answer 287

nvestigations for suspected epididymo-orchitis are guided by age: sexually active younger adults: **NAAT for STIs** older adults with a low-risk sexual history: **MSSU**

Question 288

What is the mechanism of action of goserelin in prostate cancer? Androgen receptor antagonist Oestrogen agonist GnRH agonist Luteinising hormone receptor antagonist GnRH antagonist

Answer 288

What is the mechanism of action of goserelin in prostate cancer? Androgen receptor antagonist Oestrogen agonist **GnRH agonist** Luteinising hormone receptor antagonist GnRH antagonist

Question 289

A 60-year-old man presents complaining of an inability to maintain an erection. He had a myocardial infarction (MI) 3 years ago and subsequently suffered from depression. He has a background of poorly controlled hypertension. What medication is most likely to be contributing to his presentation? Amlodipine Bisoprolol Isosorbide mononitrate Mirtazapine Ramipril

Answer 289

A 60-year-old man presents complaining of an inability to maintain an erection. He had a myocardial infarction (MI) 3 years ago and subsequently suffered from depression. He has a background of poorly controlled hypertension. What medication is most likely to be contributing to his presentation? Amlodipine **Bisoprolol**: **B blockers can cause ED** Isosorbide mononitrate Mirtazapine Ramipril

Question 290

How long does finasteride need to be given for results to be seen? [1]

Answer 290

Finasteride treatment of BPH may take **6 months** before results are seen

Question 291

A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment? Tamoxifen Lansoprazole Allopurinol Cyproterone acetate Tamsulosin

Answer 291

A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment? Tamoxifen Lansoprazole Allopurinol **Cyproterone acetate** Tamsulosin Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues **due to the risk of tumour flare**. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels. **The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.**

Question 292

State 3 pieces of evidence from a history / exam that would suggest ED is organic in cause (and not pyscogenic)

Answer 292

Factors favouring an organic cause: * Gradual onset of symptoms * Lack of tumescence * Normal libido

Question 293

What would treatment be for suspected epididymo-orchitis? [2]

Answer 293

IM ceftriaxone Oral doxycycline

Question 294

Name and describe this imaging abnormality in the kidney? [1]

Answer 294

**Periureteric fat stranding**: appearance of oedema within the fat of the perirenal space on CT or MRI.

Question 295

State two causes of **periureteric fat stranding** [2]

Answer 295

Caused by kidney inflammation: * **uteric calculi** * **pyelonephritis**

Question 296

Describe what is meant by Stauffer syndrome

Answer 296

**Stauffer syndrome: RCC paraneoplastic syndrome** **Hepatosplenomegaly** + **Cholestatic LFTs** (elevated bilirubin; ALP and GGT)

Question 297

A 65-year-old man attends an abdominal aortic aneurysm (AAA) screening offered by his GP. On ultrasound, it is revealed that he has a supra-renal aneurysm that is 4.9 cm in diameter. When questioned he says he has no symptoms. How should this patient be managed? 12-monthly ultrasound assessment 3-monthly ultrasound assessment 6-monthly ultrasound assessment Referral to stop smoking services Urgent referral to vascular surgery

Answer 297

A 65-year-old man attends an abdominal aortic aneurysm (AAA) screening offered by his GP. On ultrasound, it is revealed that he has a supra-renal aneurysm that is 4.9 cm in diameter. When questioned he says he has no symptoms. How should this patient be managed? 12-monthly ultrasound assessment **3-monthly ultrasound assessment** 6-monthly ultrasound assessment Referral to stop smoking services Urgent referral to vascular surgery

Question 298

How often do you AAA rescan for 3 - 4.4 cm Small aneurysm [1] 4.5 - 5.4 cm Medium aneurysm [1] ≥ 5.5cm Large aneurysm [1]

Answer 298

3 - 4.4 cm; Small aneurysm: **Rescan every 12 months** 4.5 - 5.4 cm Medium aneurysm: **Rescan every 3 months** ≥ 5.5cm; Large aneurysm; **Refer within 2 weeks to vascular surgery for probable intervention**

Question 299

Describe how you treat superifical thrombophlebitis [3]

Answer 299

**NSAIDs** **Compression socks**: reduces chance of DVT **LMWH**: reduces chance of DVT

Question 300

# ``` ``` How often does AAA screening occur? [1]

Answer 300

**Once**: at 65 in men

Question 301

A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day. Given the likely diagnosis, which one of the following medications should he be prescribed daily for secondary prevention of cardiovascular disease? Clopidogrel 300mg Atorvastatin 40mg Clopidogrel 80mg Simvastatin 20mg Aspirin 300mg

Answer 301

A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day. Given the likely diagnosis, which one of the following medications should he be prescribed daily for secondary prevention of cardiovascular disease? Clopidogrel 300mg Atorvastatin 40mg **Clopidogrel 80mg** Simvastatin 20mg Aspirin 300mg

Question 302

What doses of atorvastatin and clopidogrel should be prescribed for PAD? [2]

Answer 302

**Atorvastatin 80 mg** **Clopidogrel 80 mg**

Question 303

A 55-year-old lady with claudication is assessed and an ABPI is performed. Results show an ABPI value of 1.3. Which of the following conditions may lead to this abnormal result? Hypothyroidism Hypercalcaemia Type 2 diabetes Peripheral arterial disease Previous deep vein thrombosis

Answer 303

A 55-year-old lady with claudication is assessed and an ABPI is performed. Results show an ABPI value of 1.3. Which of the following conditions may lead to this abnormal result? Hypothyroidism Hypercalcaemia **Type 2 diabetes** Peripheral arterial disease Previous deep vein thrombosis

Question 304

[] is the investigation of choice for varicose veins/chronic venous disease?

Answer 304

**Venous duplex ultrasound** is the investigation of choice for varicose veins/chronic venous disease

Question 305

What would a venous duplex ultrasound show in varicose veins? [1]

Answer 305

**retrograde venous flow** due to incompetent venous valves.

Question 306

Name two side effects of tamulosin for treating BPH [2]

Answer 306

Dizziness Postural hypotension

Question 307

Name 4 side effects of finasteride for treating BPH [4]

Answer 307

erectile dysfunction reduced libido ejaculation problems gynaecomastia

Question 308

[] is the first-line imaging in peripheral artery disease

Answer 308

**Duplex ultrasound** is the first-line imaging in peripheral artery disease

Question 309

Which one of the following is most associated with male infertility? Sodium valproate therapy Benign prostatic hyperplasia Varicoceles Epididymal cysts Hydroceles

Answer 309

Which one of the following is most associated with male infertility? Sodium valproate therapy Benign prostatic hyperplasia **Varicoceles** Epididymal cysts Hydroceles

Question 310

What would indicate that urinary retention is chronic? [2]

Answer 310

**Not** painful **more than 1L** in the bladder

Question 311

A 33-year-old is admitted to the Emergency Department with suspected renal colic. He has a ultrasound that shows a probable stone in the left ureter. What is the most appropriate next step with respect to imaging? Non-contrast CT (NCCT) Micturating cystourethrogram Intravenous urography (IVU) Plain radiography KUB MRI

Answer 311

A 33-year-old is admitted to the Emergency Department with suspected renal colic. He has a ultrasound that shows a probable stone in the left ureter. What is the most appropriate next step with respect to imaging? **Non-contrast CT (NCCT)** Micturating cystourethrogram Intravenous urography (IVU) Plain radiography KUB MRI

Question 312

What would indicate that urinary retention is high pressure? [2]

Answer 312

**Hydronephresis** and **impaired renal function** occurs (creatinine increased)

Question 314

A 22-year-old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns. What is the best surgical option? [1]

Answer 314

**Proctectomy**

Question 315

State three indications for surgery for Crohn's? [3]

Answer 315

**fistulae** **abscess formation** **strictures**

Question 316

Define short bowel syndrome [3]

Answer 316

Short bowel syndrome (SBS) refers to a condition wherein **substantial portions of the small intestine are absent, either congenitally or due to resection** Typically, **less than 200 cm** of **residual short bowel is present.** This results in a **loss of surface area for fluid, nutrient, and medication absorption**, causing an **inability to maintain protein-energy, fluid, electrolyte, or micro-nutrient balance** when ingesting a conventionally accepted, normal diet.

Question 317

Describe how to best manage complex perianal fistula? [1]

Answer 317

**long term draining seton sutures,** complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence.

Question 318

Terminal ileal Crohns remains the commonest disease site. How might patients be treated surgically? [1]

Answer 318

Terminal ileal Crohns remains the commonest disease site and these patients may be treated with **limited ileocaecal resections**.

Question 319

What pathology may terminal ileal Crohns lead to? [1]

Answer 319

Terminal ileal Crohns may **affect enterohepatic bile salt recycling** and **increase the risk of gallstones**.

Question 320

What is a proctocolectomy? [1]

Answer 320

the large intestine (the colon) and rectum are removed, leaving the small intestine disconnected from the anus.

Question 321

What is an indication for proctocolectomy in UC patients? [1]

Answer 321

**Dysplastic transformation of the colonic epithelium** with associated **mass lesions** is an absolute indication for a proctocolectomy.

Question 322

What would indicate sub total colectomy in UC patients? [1]

Answer 322

Emergency presentations of poorly controlled colitis that fails to respond to medical therapy

Question 323

Patients with IBD have a high incidence of [] and appropriate [] is mandatory.

Answer 323

Patients with IBD have a high incidence of **DVT** and appropriate **thromboprophylaxis** is mandatory.

Question 324

Name a restorative option in UC [1]

Answer 324

Restorative options in UC include an **ileoanal pouch**. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.

Question 325

Which area in the body is most likely to be affected by ishaemic colitis? [1] Why? [1]

Answer 325

The most common site affected in ischaemic colitis is the **splenic flexure.** This is a **'watershed' area**: it has a dual supply of blood from distal branches of both the superior and inferior mesenteric arteries (the middle colic and left colic arteries, respectively).

Question 326

Name this radiological sign [1] What does it indicate? [1]

Answer 326

**Thumb printing** Indicates **ischaemic colitis**

Question 327

How do you determine if CLI is treated with open surgical revasc or angioplasty & stent? [1]

Answer 327

Multifocal: **open revasc** Focal stenosis or thrombus: **angioplasty and stenting**

Question 328

What pathology is depicted here? [1]

Answer 328

**Lipodermatosclerosis** on the ankle of an older male patient. Note the hyperpigmentation secondary to haemosiderin deposition and the appearance of tight skin

Question 329

# [](http://) You investigate a patient who is demonstrating stenosis in their lower leg.. How do you determine if this patient needs open surgery or endovascular revascularization? [2]

Answer 329

Open surgery: long segments (> 10 cm) Endovascular: short segments ( < 10 cm)

Question 330

What is the first line tx for alcoholic hepatitis? [1]

Answer 330

Prednisolone

Question 331

What copper blood work up would indicate Wilsons? [2] Explain your answer [1]

Answer 331

Low serum copper Low serum ceruloplasmin Caused by a mutation to the enzyme that attached copper to ceruloplasmin at liver; means that isn't transported in serum

Question 332

Explain what you need to check before iniating aziothropine tx? [1]

Answer 332

**Thiopurine methyltransferase (TPMT) levels**: enzyme used in metabolism of aziothropine and mercaptopurine. Some people have mutations, meaning get really bad AEs

Question 333

How long do does it take for finasteride to work? [1]

Answer 333

6 months

Question 334

Under what conditions do you add metformin to insulin treatment for DMT1? [1]

Answer 334

If have DMT1 + BMI over 25

Question 335

What broad symptoms would indicate Wilsons disease? [2]

Answer 335

Liver problems AND neurological problems (Basal ganglia affected)

Question 336

What happens to goblet ells in Crohns? [1]

Answer 336

Increased

Question 337

What bloods should be check before starting NG feeding or TPN in a patient with acutely poor intake? [1] Why these bloods?

Answer 337

Baseline **potassium, phosphate, magnesium & corrcted calcium levels**

Question 338

Explain the pathological consequences of refeeding syndrome [3]

Answer 338

: **Shift from Fat to Carbohydrate Metabolism**: * In refeeding syndrome, the reintroduction of carbohydrates leads to a shift from fat to carbohydrate metabolism. This switch activates insulin secretion, which in turn increases cellular uptake of glucose. **Intracellular Movement of Phosphate**: * Insulin and increased glucose uptake stimulate the intracellular movement of phosphate, which is used in the synthesis of ATP and 2,3-diphosphoglycerate in erythrocytes. This intracellular shift reduces serum phosphate levels. **Decreased Phosphate Stores:** - Patients with chronic malnutrition often have depleted phosphate stores, although their serum phosphate levels may initially be normal. When refeeding starts, the sudden demand for phosphate in anabolic processes exceeds the supply, leading to hypophosphatemia.

Question 339

Describe the clinical consequences of hypophosphatemia (e.g. caused by refeeding syndrome) [5]

Answer 339

**Cardiac Dysfunction**: Hypophosphatemia can impair myocardial contractility, leading to heart failure. It may also cause arrhythmias due to its role in maintaining normal cellular electrophysiology. **Respiratory Failure**: Phosphate is essential for ATP production, necessary for respiratory muscle function. Severe hypophosphatemia can lead to muscle weakness, including the diaphragm and intercostal muscles, potentially resulting in acute respiratory failure. **Neurological Complications:** These can range from confusion and seizures to coma, attributable to disturbed ATP metabolism in the central nervous system. **Haematological Effects:** Reduced 2,3-diphosphoglycerate levels in erythrocytes affect oxygen release from haemoglobin, leading to tissue hypoxia. Hypophosphatemia can also result in hemolysis. **Rhabdomyolysis**: Phosphate depletion impairs ATP production in muscles, which can lead to muscle breakdown and rhabdomyolysis.

Question 340

How is refeeding syndrome prevented?

Answer 340

Determine level of refeeding risk (measure baseline K, Mg, Ca and PO levels). Replete thiamine and electrolytes as per needed Start feeding Repeat checking levels 6-12 hrs after initiating feeding & replace as required Monitor for 3 days

Question 341

How do you manage refeeding syndrome?

Question 342

Patients are considered high-risk of refeeding syndrome if they if one or more of the following..? [4] or two of more the following..? [4]

Answer 342

**One of:** - BMI < 16 kg/m2 - unintentional weight loss >15% over 3-6 months - little nutritional intake > 10 days - hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) **or two of:** * BMI < 18.5 kg/m2 * unintentional weight loss > 10% over 3-6 months * little nutritional intake > 5 days * history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Question 343

How many days of recurrent abdominal pain or discomfort do you need for IBS classification? [1] What are 3 further symptoms needed for IBS diagnosis? [2]

Answer 343

3 days per month in last 3 months Need 2/3 of: - Improvement w defecation - Onset associated with change in frequency of stool - - Onset associated with change in appearance of stool

Question 344

Answer 344

Question 346

# [``](http://) How long should you trial pro-biotics for in patient with IBS? [1]

Answer 346

4 weeks

Question 347

Give the clinical context of why you drain abscesses and give abx? [2]

Answer 347

The general rule is to drain abscesses because **antibiotic penetration is poor** as they are **often isolated from vascular supply.** Thus abx plus draining away the pus is a usual option!

Question 348

Describe the method used most effective calcium resonium in hyperkalaemia [1] Why? [1]

Answer 348

**Calcium resonium enemas** are more **effective** than oral as **potassium is secreted by the rectum**

Question 349

Name a condition that would cause a patient to have falsely low HbA1c readings? [1]

Answer 349

**SCA**: decreased lifespan = decreased HbA1c

Question 350

What are the investigations for acromegaly AFTER serum IGF-1 is measured? [2]

Answer 350

**oral glucose tolerance test (OGTT)** with **serial GH measurements** In patients without acromegaly, **raised blood glucose causes the body to stop producing GH**. If there is a **failure** for serial **GH** readings to **drop** below **1 ng/mL** during the OGTT, this confirms the diagnosis of **acromegaly**.

Question 351

Which class of antihypertensive are contraindicated in end-stage chronic liver disease (Childs score C)? Beta-blockers Calcium-channel blockers ACE inhibitors Diuretics 1 OF 10

Answer 351

Which class of antihypertensive are contraindicated in end-stage chronic liver disease (Childs score C)? Beta-blockers Calcium-channel blockers **ACE inhibitors** Diuretics 1 OF 10

Question 352

Flucloxacillin can cause liver injury with just a single dose. True False

Answer 352

Flucloxacillin can cause liver injury with just a single dose. **True** Usually 1-6 weeks after course

Question 353

Which of the following is NOT a common cause of drug induced liver injury? Ibuprofen Omeprazole Co-amoxiclav Isoniazid

Answer 353

Which of the following is NOT a common cause of drug induced liver injury? Ibuprofen **Omeprazole** Co-amoxiclav Isoniazid 5 OF 10

Question 354

A decrease in first-pass metabolism can: Increase the oral bioavailability of some drugs Decrease the oral bioavailability of some drugs Has no effect on the oral bioavailability of a drug 6 OF 10

Answer 354

A decrease in first-pass metabolism can: **Increase the oral bioavailability of some drugs** Decrease the oral bioavailability of some drugs Has no effect on the oral bioavailability of a drug 6 OF 10

Question 355

Collateral shunts in the liver can lead to: An increase in first-pass metabolism A decrease in first-pass metabolism

Answer 355

Collateral shunts in the liver can lead to: An increase in first-pass metabolism **A decrease in first-pass metabolism**

Question 356

Which ONE of the following is CORRECT regarding the risk factors to be assessed prior to initiating acetylcysteine treatment? Alcoholism Anorexia Taking liver enzyme-inducing drugs None of the above

Answer 356

Which ONE of the following is CORRECT regarding the risk factors to be assessed prior to initiating acetylcysteine treatment? Alcoholism Anorexia Taking liver enzyme-inducing drugs **None of the above**

Question 357

Diclofenac is contraindicated in severe liver dysfunction. Which of the following statements do not apply? It induces cytochrome P450 3A4 It increases the risk of bleeding It increases the risk of renal impairment It has been reported to cause liver injury

Answer 357

Diclofenac is contraindicated in severe liver dysfunction. Which of the following statements do not apply? **It induces cytochrome P450 3A4** Diclofenac does not induce liver enzymes.

Question 358

Should you continue or discontinue NSAIDs in severe liver disease? [1] Expalin your answer

Answer 358

**Discontinue**: can worse **liver and renal function in severe liver disease** **Renal blood flow** is reliant to some extent on **prostacyclins**; there NSAIDs reduce this and deterioate renal function

Question 359

Should you continue or discontinue **spironolactone** in severe liver disease? [1] Expalin your answer

Answer 359

**Discontinue**: causes hyperkalaemia and renal dysfunction. Stop and correct serum potassium

Question 360

Should you continue or discontinue ACEins in severe liver disease? [1] Expalin your answer

Answer 360

**Discontinue**: need RAAS to maintain peripheral vascular resistance in severe liver disease. ACE inhibitors can lead to rapid drop in BP and cause renal failure

Question 361

Which variables are used in the Child-Pugh score? [5]

Answer 361

**Ascites** **Bilirubin** **INR** **Hepatic Enceph** **Serum Albumin**

Question 362

Name two antibiotics that can cause hepatitis and cholestatic jaundice [1] Describe the onset [1]

Answer 362

**Flucoxacillin**: onset may be delayed by up to two months **co-amoxiclav**

Question 363

Explain what is meant by carcinoid syndrome? [1]

Answer 363

Caused by **carcinoid tumours**: causing biologically active **amine and peptides to enter the systemic circulation**: - **serotonin** is most common

Question 364

What are symptoms of carcinoid syndrome? [4]

Answer 364

* Skin flushing * Diarrhoea * Bronchospasm * Hypotension

Question 365

What is the first line test for carcinoid syndrome? [1]

Answer 365

5-1AA blood tests

Question 366

What are the two treatments for carcinoid syndrome? [2]

Answer 366

**Octreatide**: SST analogue **Cyproheptadine**: helps with diarrhoea

Question 367

Define alcoholic ketoacidosis [2]

Answer 367

**Non-diabetiec euglycaemic ketoacidosis**: - If you drink regularly and dont eat, can lead to **starvation** - Produce **ketones** during malnutrition

Question 368

What are the characteristic indicators of alcoholic ketoacidosis? [4]

Answer 368

**Metabolic acidosis** **Raised anion gap** **Increased ketons** **Normal / low glucose**

Question 369

Which one of the following drugs is not a cause of galactorrhoea? Metoclopramide Bromocriptine Chlorpromazine Haloperidol Domperidone

Answer 369

Which one of the following drugs is not a cause of galactorrhoea? Metoclopramide **Bromocriptine** Bromocriptine is a treatment for galactorrhoea, rather than a cause Chlorpromazine Haloperidol Domperidone

Question 370

A 60-year-old man who is known to have Barrett's oesophagus is reviewed with the results of his surveillance biopsies. These show high-grade dysplasia but no evidence of carcinoma. He is asymptomatic apart from his gastro-oesophageal reflux disease symptoms which are well controlled on high dose proton pump inhibitor therapy. What treatment is he most likely to be offered? [2]

Answer 370

**radiofrequency ablation:** preferred first-line treatment, particularly for low-grade dysplasia **endoscopic mucosal resection**

Question 371

What is the triad of hepatorenal syndrome? [3]

Answer 371

**Cirrhosis** **Ascites** **AKI not attributable to any other cause.**

Question 372

How do you treat type 1 HRS? [3]

Answer 372

**terlipressin**, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation ** volume expansion with 20% albumin** **transjugular intrahepatic portosystemic shunt** (still have a v poor prognosis)

Question 373

A 72-year-old man is reviewed in the diabetes clinic. He has a history of heart failure and type 2 diabetes mellitus. His current medications include furosemide 40mg od, ramipril 10mg od and bisoprolol 5mg od. Clinical examination is unremarkable with no evidence of peripheral oedema, a clear chest and blood pressure of 130/76 mmHg. Recent renal and liver function tests are normal. Which one of the following medications is contraindicated? Sitagliptin Pioglitazone Gliclazide Exenatide Metformin

Answer 373

A 72-year-old man is reviewed in the diabetes clinic. He has a history of heart failure and type 2 diabetes mellitus. His current medications include furosemide 40mg od, ramipril 10mg od and bisoprolol 5mg od. Clinical examination is unremarkable with no evidence of peripheral oedema, a clear chest and blood pressure of 130/76 mmHg. Recent renal and liver function tests are normal. Which one of the following medications is contraindicated? Sitagliptin **Pioglitazone**: **contra-indicated in HF because they cause oedema** Gliclazide Exenatide Metformin

Question 374

What is the difference between acute cholecystitis and ascending cholangitis? [2] Give key differentials in how they present

Answer 374

**Acute cholecystitis**: - **Inflammation/infection** of the **gallbladder** **secondary to impacted gallstones** - **Positive Murphys sign** (arrest of inflammation on RUQ palpatation **Ascending cholangitis:** - Ascending cholangitis is a **bacterial infection of the biliary tree**. The most common predisposing factor is gallstones. - Charcot triad: **RUQ pain; fever and jaundice**

Question 375

What history would suggest acute pancreatitis? [3]

Answer 375

Alcohol Watery, non bloody diarrhoea (can be fatty) Colicky abdominal pain

Question 376

Pneumonic for acute pancreatitis?

Answer 376

**GET SMASHED** **G**allstones **E**thanol **T**rauma **S**teroids **M**umps (other viruses include Coxsackie B) **A**utoimmune (e.g. polyarteritis nodosa), Ascaris infection **S**corpion venom **H**ypertriglyceridaemia, **H**yperchylomicronaemia, **H**ypercalcaemia, **H**ypothermia **E**RCP **D**rugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 377

An obese 55-year-old presents with pain in the RUQ associated with fever. Palpation of the RUQ causes arrest of respiration. What is the most likely pathology? [1]

Answer 377

Acute cholecystitis

Question 378

A 60-year-old woman with a history of polycythaemia rubra vera presents with abdominal pain and distension. She is found to have ascites and hepatomegaly on examination This a steriotypical history of what pathology? [1]

Answer 378

**hepatic vein thrombosis**

Question 379

What is the name for this sign? [1] Which form of IBD is it most common in? [1]

Answer 379

**Lead pipe / drain pipe colon**: more common in **UC** *normal mucosal architecture is lost, and scarring shortens and narrows the colon, creating the lead pipe appearance seen on radiographs*

Question 380

What is the name for this sign? [1] Which form of IBD is it most common in? [1]

Answer 380

**Kantor's string sign** More common in **Crohns** *string sign refers to luminal narrowing as the result of inflammatory edema, irritability, spasms and fibrosi*

Question 381

Patient with known Crohn disease. Which of the following features is shown on this selected post-contrast coronal CT image? [1]

Answer 381

**Comb sign**

Question 382

Which anticoagulant is safe to continue on AKI? [1]

Answer 382

**Warfarin**

Question 383

Which one of the following adverse effects is most characteristically associated with sulfonylureas? Increased risk of fractures Hepatoxicity Mania Cushings syndrome Suppression of growth in childdren

Answer 383

Which one of the following adverse effects is most characteristically associated with sulfonylureas? Increased risk of fractures **Hepatoxicity**: typically cholestatic Mania Cushings syndrome Suppression of growth in childdren

Question 384

What type of cancer is most associated with H.pylori? [1]

Answer 384

**B cell lymphoma of MALT** (classically in the stomach)

Question 385

Explain how thyrotoxicosis alters calcium levels? [1]

Answer 385

**The hungry bone syndrome (HBS)** is reported as a well-established thyroidectomy complication of in Graves' disease, especially in the case of severe thyrotoxicosis. **This phenomenon is caused by a rapid increase in the skeletal uptake of blood calcium** leading to persistent symptomatic **hypocalcemia**

Question 386

When evaluating a patient with acute kidney injury, which one of the following findings is most supportive of acute tubular necrosis?

Answer 386

Poor response to fluid challenge

Question 387

Answer 387

**Arthritis**

Question 388

Patients suffering from haemochromatosis often have which co-morbidity? [1]

Answer 388

DM

Question 389

What are the reversible [2] and irreversible [4] complications of haemochromatosis?

Answer 389

**Reversible complications** * Dilated Cardiomyopathy * Skin pigmentation **Irreversible complications** * Liver cirrhosis * Diabetes mellitus * Hypogonadotrophic hypogonadism * Arthropathy

Question 390

Patients suffering from haemochromatosis have arthritis specifically in which location? [1]

Answer 390

The hands

Question 391

acute interstitial nephritis is associated with what finding that would be identified on a blood film? [1]

Answer 391

**Eosinophilia**

Question 392

Which bacteria most commonly causes **post-streptococcal glomerulonephritis?**

Answer 392

Streptococcus pyogenes

Question 393

Results of high-dose dexamethasone suppression test: ectopic source of ACTH Cortisol suppressed, ACTH suppressed Cortisol suppressed, ACTH not suppressed Cortisol not suppressed, ACTH not suppressed Cortisol not suppressed, ACTH suppressed

Answer 393

Results of high-dose dexamethasone suppression test: ectopic source of ACTH Cortisol suppressed, ACTH suppressed Cortisol suppressed, ACTH not suppressed **Cortisol not suppressed, ACTH not suppressed** Cortisol not suppressed, ACTH suppressed Ectopic ACTH syndrome

Question 394

Name two causes of iatrogenic gynaecomastia [2]

Answer 394

digoxin spironolactone

Question 395

Name 4 iatrogenic causes of pancreatitis [4]

Answer 395

corticosteroids thiazides sodium valproate azathioprine

Question 396

When should you add a second drug for DMT2 treatment? [1]

Answer 396

It's worthwhile thinking of the average patient who is taking metformin for T2DM, you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the **HbA1c rises to 58 mmol/mol (7.5%)**

Question 397

Which type of drugs should be witheld when treating C.diff? [2] Explain your answer [2]

Answer 397

During a Clostridium difficile infection, medications which are **anti-motility and anti-peristaltic should be held**. Anti-peristaltic drugs such as **opioids** can **predispose to toxic megacolon** by **slowing** the **clearance** of the **Clostridium** **difficile** **toxin**. If possible, **antibiotics should also be held** to allow **normal intestine flora to be re-established**, though the antibiotics used to treat the Clostridium difficile should be continued.

Question 398

A lean 32-year-old female has recently undergone a colonoscopy to remove some incidental polyps. On inspection of the colon, the doctor also noticed abnormal pigmentation. He send a sample off to be reviewed by the histopathologists and they reported 'pigment-laden macrophages within the mucosa on PAS staining'. What is the most common cause of the underlying condition? Pre-malignancy C. difficile Antibiotic abuse Laxative abuse Idiopathic

Answer 398

A lean 32-year-old female has recently undergone a colonoscopy to remove some incidental polyps. On inspection of the colon, the doctor also noticed abnormal pigmentation. He send a sample off to be reviewed by the histopathologists and they reported 'pigment-laden macrophages within the mucosa on PAS staining'. What is the most common cause of the underlying condition? Pre-malignancy C. difficile Antibiotic abuse **Laxative abuse** Idiopathic **Melanosis coli** Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages. It is associated with laxative abuse, especially anthraquinone compounds such as senna

Question 399

When does acute graft failure and acute tubular necrosis of graft occur? [2]

Answer 399

**Acute tubular necrosis** of graft is responsible for around 90% acute renal failure episodes in the **first few weeks** after a renal transplant **acute graft failure** which typically occurs around **6 months post-transplant. **

Question 400

How do you determine between achalasia and pharyngeal pouch based off symptoms? [2]

Answer 400

**Achalasia vs pharyngeal pouch:** * Achalasia: **heartburn** * Pharyngeal pouch: **halitosis**

Question 401

[] is the second most common association of HNPCC after colorectal cancer

Answer 401

**Endometrial cancer** is the second most common association of HNPCC after colorectal cancer

Question 402

A 52-year-old man presents to his GP as he is concerned about a discharge from his nipples. Which one of the following drugs is most likely to be responsible? Ranitidine Isoniazid Digoxin Spironolactone Chlorpromazine

Answer 402

A 52-year-old man presents to his GP as he is concerned about a discharge from his nipples. Which one of the following drugs is most likely to be responsible? Ranitidine Isoniazid Digoxin Spironolactone **Chlorpromazine** Each of the other four drugs may be associated with gynaecomastia rather than galactorrhoea

Question 403

HHS has a mortality of 50%. State 5 complications of HHS that cause mortality [5]

Answer 403

* rhabdomyolysis * venous thromboembolism * lactic acidosis * hypertriglyceridaemi * renal failure * stroke * cerebral oedema.

Question 404

What is the inheritance pattern for MODY? [1]

Answer 404

Autosomal dominant

Question 405

A 58-year-old man attends the general practice following a hospital admission for an ankle fracture 4 months ago which has been treated successfully. Whilst he was an inpatient, his HbA1c was found to be 56mmol/mol. His HbA1c is repeated today and has returned as 57mmol/mol. His only other past medical history includes hip osteoarthritis and a myocardial infarction 7 months ago. What management should be offered to this patient? Reinforce lifestyle factors Start empagliflozin Start metformin and empagliflozin Start metformin and up-titrate first Start sitagliptin

Answer 405

A 58-year-old man attends the general practice following a hospital admission for an ankle fracture 4 months ago which has been treated successfully. Whilst he was an inpatient, his HbA1c was found to be 56mmol/mol. His HbA1c is repeated today and has returned as 57mmol/mol. His only other past medical history includes hip osteoarthritis and a myocardial infarction 7 months ago. What management should be offered to this patient? **Start metformin and up-titrate first** *If starting an SGLT-2 as initial therapy for T2DM then ensure metformin is titrated up first*

Question 406

What is the treatment for a patient with Crohn's disease and: - perianal abscess? [1] - perianal fistula? [1]

Answer 406

- perianal abscess: **incision and drainage** - perianal fistula: **seton placement** (The placement of a seton (suitable for high tract disease) though the fistula attempts to bring together and close the tract, passing out at opening of the perianal skin adjacent to the external opening (Fig. 3))

Question 407

Name a liver cause of hypogonadotrophic hypogonadism [1]

Answer 407

**Haemochromatosis** is a cause of hypogonadotrophic hypogonadism

Question 408

Describe the TFT of subclinical hypothyroidism [2]

Answer 408

TSH: **raised** T4: **normal**

Question 409

How do you treat subclinical hypothyroidism if symptoms are present? [1]

Answer 409

**6-month trial of thyroxine**

Question 410

A 53-year-old patient presents to the general practitioner with a 3-year-history of coarse facial features, spade-like hands, large feet. They have been previously managed for the underlying cause of their presentation with trans-sphenoidal surgery, but symptoms have persisted despite this. Which of the following would be considered first-line in this patient? Bromocriptine Dapagliflozin Desmopressin Growth hormone replacement Octreotide

Answer 410

A 53-year-old patient presents to the general practitioner with a 3-year-history of coarse facial features, spade-like hands, large feet. They have been previously managed for the underlying cause of their presentation with trans-sphenoidal surgery, but symptoms have persisted despite this. Which of the following would be considered first-line in this patient? Bromocriptine Dapagliflozin Desmopressin Growth hormone replacement **Octreotide** *Octreotide (somatostatin analogue) is far more effective, bromocriptine (dopamine agonist) was just the first medication they found and is only effective in a small minority*.

Question 411

During major surgery, the body's stress response causes a decrease in which hormones? [3]

Answer 411

Insulin Testosterone Oestrogen

Question 412

What is the first line treatment for symptomatic relief in carcinoid syndrome? [1]

Answer 412

**Octreotide** is a somatostatin analogue used to treat the symptoms of carcinoid syndrome

Question 413

State the treatment plan for a thyroid storm [5]

Answer 413

symptomatic treatment e.g. **paracetamol** treatment of underlying precipitating event beta-blockers: typically **IV propranolol** **anti-thyroid drugs**: e.g. methimazole or **propylthiouracil** **Lugol's iodine** **dexamethasone** - e.g. 4mg IV qds - blocks the conversion of T4 to T3

Question 414

What is meant by Peutz-Jeghers syndrome? [1]

Answer 414

Peutz-Jeghers syndrome is an **autosomal dominant condition** characterised by numerous **hamartomatous polyps** in the **gastrointestinal** **tract**.

Question 415

Describe the presentation of Peutz-Jeghers syndrome [4]

Answer 415

* **hamartomatous polyps** in the gastronintestinal tract (mainly small bowel) * **small bowel obstruction** is a common presenting complaint, often due to **intussusception** * **gastrointestinal bleeding** * **pigmented lesions** on **lips**, **oral** **mucosa**, **face**, **palms** and **soles**

Question 416

**[]** is the investigation of choice for suspected **perianal fistulae** in patients with Crohn's

Answer 416

**MRI** is the investigation of choice for suspected perianal fistulae in patients with Crohn's

Question 417

Describe what is meant by Boerhaave syndrome [1]

Answer 417

**Boerhaave syndrome** is an **oesophageal perforation**, it is differentiated from a Mallory-Weiss tear as it is a **transmural tear rather** than a mucosal tear. It can be associated with haematemesis but this is uncommon.

Question 418

A 53-year-old man with type 2 diabetes attends his GP for his annual diabetic check. He is currently taking Metformin 1g modified release twice daily with no issues. He has no other medical history. On examination he has a pulse rate of 67 bpm, a blood pressure of 141/83 mmHg and his body mass index is 53 kg/m². His most recent HbA1c is shown below: HbA1c 69 mmol/mol (29-42 mmol/mol) Which of the following medications is most suitable to start next to control this man's diabetes? Pioglitazone Sitagliptin Acarbose Insulin Gliclazide

Answer 418

A 53-year-old man with type 2 diabetes attends his GP for his annual diabetic check. He is currently taking Metformin 1g modified release twice daily with no issues. He has no other medical history. On examination he has a pulse rate of 67 bpm, a blood pressure of 141/83 mmHg and his body mass index is 53 kg/m². His most recent HbA1c is shown below: HbA1c 69 mmol/mol (29-42 mmol/mol) Which of the following medications is most suitable to start next to control this man's diabetes? Pioglitazone **Sitagliptin** DPPin useful for weight loss Acarbose Insulin Gliclazide

Question 419

Which score is used to assess upper GI bleeds before [1] and after [1] endoscopy?

Answer 419

Upper GI bleed: - Glasglow-Blatchford = **BEFORE** endoscopy - Rockall score is used **AFTER** endoscopy and provides a percentage risk of rebleeding and mortality

Question 420

The BNF suggests gradual withdrawal of systemic corticosteroids for Crohns Disease patients in which three circumstances? [3]

Answer 420

received more than **40mg prednisolone daily** for **more than one week** received more than **3 weeks of treatment** recently received **repeated courses**

Question 421

Absorption of levothyroxine is reduced by which drug? [1] How should you mitigate this? [1]

Answer 421

Absorption of **levothyroxine** is **reduced** by **iron** - advise to **leave 2 hours apart**

Question 422

Describe what is meant by sick euthyroid [1] How does a patient with sick euthyroid typically present? [3]

Answer 422

euthyroid sick syndrome appears to be a complex mix of **physiologic** **adaptation** and **pathologic response to acute illness** In the majority of cases however the **TSH level is within the >normal** range with **low t4/3** (inappropriately normal given the low thyroxine and T3).

Question 423

How should you treat someone with suspected euthyroid syndrome? [1]

Answer 423

**Changes** are **reversible** upon **recovery from the systemic illness** and hence **no treatment is usually needed.**

Question 424

The lymphatic drainage of the anal canal inferior to the pectinate line is to which lymph nodes? [1] Name two other anatomical areas that drain this area [2]

Answer 424

**Superficial inguinal nodes** **Scrotum** and **thigh** also drain there

Question 425

An autoantibody screen finds raised anti-smooth muscle antibodies (ASMA). What pathology would this indicate? [1] How might this patient present? [1]

Answer 425

**Raised ASMA** indicates **primary sclerosing cholangitis** PSC is strong associated with **UC**; therefore may present on background of **colitis-like symptoms**. **ALP** will also be **raised**

Question 426

An autoantibody screen finds raised anti-mitochondiral antibodies (AMA). What pathology would this indicate? [1] How would this typically present? [3]

Answer 426

**Primary biliary cholangitis**: - **Cholestatic pattern** (jaundice; high bilirubin; raised ALP) - **Itching and lethargy**

Question 427

Desribe the basic pathophysiology of PBC [1] Which patient populations is it most common in? [1]

Answer 427

PBC: - Autoimmune condition causing the **destruction of intrahepatic bile ducts** - Affects **middle aged women**

Question 428

Answer 428

PBC

Question 429

A patient presents with suspected appendicitis. What dermatome level will this pain occur at? [1]

Answer 429

**T10**

Question 430

In which conditions should SIADH **not** be diagnosed? [5]

Answer 430

SIADH should not be diagnosed if: - **Hypovolaemia** - **Hypotension** - **Addisons** - **Fluid overload** - **Hypothyroidism**

Question 431

What investigations should you conduct for SIADH? [2] What results would indicate a diagnosis of SIADH? [4]

Answer 431

Paired **serum** and **urine** **sodium** and **osmalality** measurements Therefore, diagnosis requires: - **Concentrated** **urine** (Na >20) - **Hypersomolality** > 100 mosmol/kg - **Hyponatraemia** (plasma urine Na < 125) - **Abscence of hypvolaemia; oedema or diuretics**

Question 432

What is a gastrointestinal stromal tumour? [1] Where are they most commonly found? [1] What histoligcal finding would indicate a GIST? [1]

Answer 432

Gastrointestinal stromal tumours: - **Tumour in GI tracts** - Most commonly found in **stomach** and also in the small intestine - Mixed **spindle cell tissue** on histology

Question 433

# [](http://) Patients suffering from haemochromatosis have an increased risk of which type of cancer? [1]

Answer 433

**Hepatocellular carcinoma**

Question 434

How do follicular and papillary thyroid carcinomas present histologically? [2]

Answer 434

Follicular: **uniform colloid-filled follicles presenting a normal thyroid** Papillary: **ground-glass** or **orphan-annie nuclei** with **psammoma bodies**

Question 435

Explain what is meant by [1] and causes [6] small intestinal bacterial overgrowth How do patients with SIBO typically present? [5]

Answer 435

SIBO: - Normal mechanisms to control bacteria in the gut fail, due to **decreased gastric acid**; **decreased peristalsis**; **intestinal surgeries**; **autonomic neuropathy in DM**; **fistulae & diverticula**; **SBO** Typical presentation (similar to IBS) - Abdo pain - Bloating - Diarrhoea - Distension - Flatulence

Question 436

Describe an electrolyte change that can occur after UTI has been successfully treated [2]

Answer 436

**Salt losing nephropathy**: - Sometimes after the relief of UTI obstruction, periods of salt-losing nephropathy occurs

Question 437

All patients with acute abdomen should recieve what type of imaging? [1]

Answer 437

**Erect CXR**

Question 438

A patient is acting drunk despite not drinking alcohol for a long period of time. They do however have a long history of drinking in the past. What is the most likely cause of their current symptoms? [1]

Answer 438

Vitamin B1 deficiency: causes W.E

Question 439

What is Plummer-Vinson syndrome caused by? [1] How does it appear under OGD? []1 What is the clinical triad? [3]

Answer 439

PVS: occurs in **long term IDA patients** Disease causing **dysphagia**, **IDA** and **glossitis** Get an **oesophageal web**

Question 440

A patient presents with extreme pain during defecation and passage of fresh blood. What is the most likley diagnosis and treatment? [2]

Answer 440

**Anal fissures** First line treatment is **GTN cream and laxatives**

Question 441

A patient has pruritus, AMA antibodies found and raised ALP. What is the best medication to help the patient in the long term? [1]

Answer 441

She has PBC: so has **accumulation of bile salts and resultant hepatotoxicity** **Ursodeoxycholic acid**: is a synthetic secondary bile acid which reduces the synthesis of cholesterol and bile acids in the liver. Therefore reduces total bile acid secretion **NB:** Tx of choice is liver transplant

Question 442

Describe how hypercortisolism impacts the levels of: Ca2+ PO4- PTH

Answer 442

Ca2+: **reduced** PO4-: **reduced** PTH: **increased** Elevated cortisol leads to **hypocalcaemia** and **secondary** **hyperparathyroidism**

Question 443

Answer 443

Testicular germ cell: pure seminoma

Question 444

Painless jaundice indicates a pathology of which organ? [1]

Answer 444

Pancreas

Question 445

A mass is found in the most distal part of a rectum. It is confirmed as cancer. What is the name of the procedure that should be used to resect this tumour? [1]

Answer 445

Abdominoperineal resection

Question 446

State the first and second line treatment for a patient suffering from constipation secondary to opiate use [2]

Answer 446

First line: **Senna** - stimulant laxative Second line: **Ipsalghula husk**

Question 447

The tail of the pancreas can be found by identifying which ligament? [1]

Answer 447

**Gastrosplenic ligament**

Question 448

Explain why spironolactone is the first line diuretic treatment in ascites [2]

Answer 448

**Inhibits** **aldosterone** so: **Causes Na & fluid excretion** Prevents **hypokalemia**

Question 449

What is the first line management for moderate SIADH? [1]

Answer 449

**Fluid restriction**

Question 450

What cortisol and aldosterone levels would you expect in Sheehans syndrome? [1]

Answer 450

Cortisol: **reduced** Aldosterone: **normal**

Question 451

Name three side effects that occur as a result of tacrolimus treatment for kidney transplant [3] How do you manage this post-transplant? [1]

Answer 451

**Nephrotoxicity** **DM** (NODAT) **Neurotoxicity** Blood tests every two weeks for first three months, then on a monthly basis

Question 452

A surgeon suspects gastric cancer. Where is the cancer most likely to be? Cardia Fundus Body Antrum Pylorus

Answer 452

A surgeon suspects gastric cancer. Where is the cancer most likely to be? **Cardia** Fundus Body Antrum Pylorus

Question 453

How do you manage: Nephrogenic DI [1] Cranial DI [1]

Answer 453

Nephrogenic DI: **treat cause; bendroflumethiazide** Cranial DI: **Desmopressin** (is a synthetic analog of vasopressin)

Question 454

Coeliac Crohns Graves SLE DMT1

Answer 454

**Crohns**

Question 455

What does this imaging indicate? [1] Describe the usual clinical presentation [1]

Answer 455

**Medullary sponge kidney**: bunch of grapes / flower appearance Clinically: **asymptomatic haematuria**; usually picked up indicidentally. Benign condition

Question 456

Which part of the ureters is the most narrow? [1]

Answer 456

**Vesicoureteric junction**: area where the ureter joins the bladder.

Question 457

Give five causes of bilateral carpal tunnel sydnrome [5]

Answer 457

**Pregnancy** (normally resolves post-partum) **Acromegaly** **Obesity** **Hypothyrodisim** **RA**

Question 458

Achalasia and alcohol are associated with which type of oesphageal cancer? [1]

Answer 458

**Squamous cell cancer**

Question 459

Which type of oesophageal cancers are located: - At the upper and middle third? [1] - Lower third? [1]

Answer 459

Upper and middle: **Squamous cell carcinoma** Lower: **adenocarcinoma**

Question 460

Which method for unblocking urinary calculi is best used in an urological emergency? [1]

Answer 460

**Percutaneous nephrostomy**

Question 461

How clinically significant is haematospermia in under 40s ? [1] Give three reasons why it may occur? [4]

Answer 461

**Haemtospermia** is **rarely associated with significant underlying medical condition** Due to: - **UTI** - **Trauma** - **STI** - **Cancer** - should exclude with an appropriate physical exam

Question 462

What are the indications for RRT in AKI? [5]

Answer 462

**Hyperkalaemia** **Metabolic acidosis** Symptoms or complications of **uraemia**: **pericarditis** or **encephalopathy** **Fluid overload** **Pulmonary oedema**

Question 463

How would you investigate Boerhaave syndrome? [1] Where in the oesophagus does a tear usually occur? [1] Why is this clinically significant? [1]

Answer 463

**CXR** Tear usually occurs at **posterior** - can lead to **pneumothorax**

Question 464

Explain which excess consumption of which vitamin can lead to kidney stones? [1]

Answer 464

**Vitamin C**: excess can be converted to oxalic acid in the body, leading to subsequent hyperoxaluria and kidney stones

Question 465

A patient presents with mild / moderate UC. Under which conditions would you give oral as well as rectal aminosalicylates? [1]

Answer 465

**When ascending colon has UC.** Rectal aminosalicylates (given as an enema) simply can't reach the ascending colon so if there's inflammatory changes there, you'd also need oral to cover that (whilst the rectal aminosalicylates take care of the transverse and descending colon inflammation)

Question 466

What is the typical presentation for a pharyngeal pouch? [4] What is the treatment for a pharyngeal pouch [1]

Answer 466

**Presentation**: - **Dysphagia** - **aspiration pneumonia** - **halitosis** - **neck swelling which gurgles on palpitation** - **regurgitation** **Treatment**: - **surgical repair and resection**

Question 467

How do you investigate for a pharyngeal pouch? [1]

Answer 467

**barium swallow combined with dynamic video fluoroscopy**

Question 468

Based off this imaging, what is the suspected diagnosis? [1]

Answer 468

Pharnygeal pouch

Question 469

State which medications and how long for before OGD (1-4): [4]

Answer 469

**1 day** = gaviscon **2 weeks** = PPIs **3 days** = ranitidine **4 weeks** = antibiotics

Question 470

Which anti-emetic can cause galactorrhoea? [1]

Answer 470

**Metoclopramide** is a dopamine antagonist, used to reduce nausea and vomiting. It can cross the blood-brain barrier and affect dopamine receptors which inhibit prolactin release. As a result, more prolactin is released, leading to galactorrhoea.

Question 471

[] is the most common cause of primary hyperaldosteronism

Answer 471

**Bilateral idiopathic adrenal hyperplasia** is the most common cause of primary hyperaldosteronism

Question 472

In pancreatic cancer, which 3 different abdominal masses may be present? [3]

Answer 472

* **hepatomegaly** (metastases) * **gallbladder** (Courvoisier's law) * **epigastric mass** (primary) NB **painless jaundice is suggestive of pancreatic cancer**

Question 473

A 23-year-old man presents to the endocrinology clinic complaining of difficulty obtaining and maintaining erections. The issue started three months ago and seems to be getting worse, accompanied by fatigue. He has no past medical history and his parents both reached puberty at a normal age. On examination, he has normal genitalia and he has appropriate secondary sexual characteristics for his age. Blood tests show the following: FSH Low LH Low Oestrogen Low Progesterone Low Testosterone Low What is the most likely diagnosis? 5-α reductase deficiency Androgen insensitivity syndrome Congenital adrenal hyperplasia Haemochromatosis Klinefelter's syndrome

Answer 473

A 23-year-old man presents to the endocrinology clinic complaining of difficulty obtaining and maintaining erections. The issue started three months ago and seems to be getting worse, accompanied by fatigue. He has no past medical history and his parents both reached puberty at a normal age. On examination, he has normal genitalia and he has appropriate secondary sexual characteristics for his age. Blood tests show the following: FSH Low LH Low Oestrogen Low Progesterone Low Testosterone Low What is the most likely diagnosis? 5-α reductase deficiency Androgen insensitivity syndrome Congenital adrenal hyperplasia **Haemochromatosis** Klinefelter's syndrome **Haemochromatosis is a cause of hypogonadotrophic hypogonadism**

Question 474

# 1. A 28-year-old female presents to the gastroenterology clinic with a history of irritable bowel symptoms and weight loss. She undergoes upper endoscopy and colonoscopy. A terminal ileal biopsy shows transmural inflammation, non-caseating granulomas and skip-lesions. As a result, she is started on a short course of steroids to induce remission of her underlying condition. Which medication would be most appropriate to maintain remission? Ciclosporin Low dose prednisone Mercaptopurine Mesalazine Tacrolimus

Answer 474

A 28-year-old female presents to the gastroenterology clinic with a history of irritable bowel symptoms and weight loss. She undergoes upper endoscopy and colonoscopy. A terminal ileal biopsy shows transmural inflammation, non-caseating granulomas and skip-lesions. As a result, she is started on a short course of steroids to induce remission of her underlying condition. Which medication would be most appropriate to maintain remission? Ciclosporin Low dose prednisone **Mercaptopurine** Mesalazine Tacrolimus

Question 475

[] is the first-line medication for primary biliary cholangitis

Answer 475

**Ursodeoxycholic acid** is the first-line medication for primary biliary cholangitis

Question 476

[] is the investigation of choice for suspected perianal fistulae in patients with Crohn's

Answer 476

**MRI** is the investigation of choice for suspected perianal fistulae in patients with Crohn's

Question 477

How do you distinguish between IDA and anaemia of chronic disease from an iron study? [2]

Answer 477

**TIBC** is **high** in **IDA** **TIBC** is **low/normal** in **anaemia of chronic disease**

Question 478

By which mechanism does loperamide act through to slow down bowel movements? Reduction in gastric motility through stimulation of alpha receptors Reduction in gastric motility through inhibition of dopamine receptors Reduction in gastric motility through simulation of GABA receptors Reduction in gastric motility through stimulation of opioid receptors Reduction in gastric motility through inhibition of somatostatin receptors

Answer 478

By which mechanism does loperamide act through to slow down bowel movements? **Reduction in gastric motility through stimulation of opioid receptors** Loperamide is a μ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut

Question 479

A transjugular intrahepatic portosystemic shunt procedure connects which two vessels? Internal jugular vein and hepatic vein Internal jugular vein and portal vein Hepatic artery and hepatic vein Hepatic artery and portal vein Hepatic vein and portal vein

Answer 479

A transjugular intrahepatic portosystemic shunt procedure connects which two vessels? Internal jugular vein and hepatic vein Internal jugular vein and portal vein Hepatic artery and hepatic vein Hepatic artery and portal vein **Hepatic vein and portal vein**

Question 480

How do you manage: adrenal adenoma: [1] bilateral adrenocortical hyperplasia [1]

Answer 480

adrenal adenoma: surgery - **laparoscopic adrenalectomy** bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. **spironolactone**

Question 481

What effect does hypercalcaemia have on QT interval? [1]

Answer 481

Shortens QT interval

Question 482

Sheep farmers are at a higher risk of which disease? [1] Caused by which organsim? [1] Which organ is impacted? [1]

Answer 482

**Hydatid disease** occurs because of **chronic tapeworm infection** ( worm: *Echinococcus granulosus*) Patients may suffer from **progressive liver symptoms over several years**

Question 483

How do you treat Hydatid disease? [2]

Answer 483

**Surgical excision of large cysts**, coupled with **albendazole** in repeated **1-month** or **3-6-month** **course** of **albendazole**.

Question 484

Which of the following compounds in the vitamin D synthesis pathway binds to the vitamin D receptor to exert its role in calcium homeostasis? Calcidiol Colecalciferol Calcitriol Previtamin D3 24, 25-dihydroxycolecalciferol

Answer 484

Which of the following compounds in the vitamin D synthesis pathway binds to the vitamin D receptor to exert its role in calcium homeostasis? Calcidiol Colecalciferol **Calcitriol** Previtamin D3 24, 25-dihydroxycolecalciferol

Question 485

What is Budd-Chiari syndrome? [1] What is Budd-Chiari syndrome associated with? [2]

Answer 485

Budd–Chiari syndrome of **hepatic vein thrombosis** Associated with **pregnancy** and **being postpartum**

Question 486

Name two symptoms that Budd-Chiaria syndrome causes [2]

Answer 486

hepatosplenomegaly and ascites

Question 487

Name an iatrogenic risk factor for Budd-Chiaria syndrome [1]

Answer 487

The oral contraceptive pill

Question 488

Individuals with Peutz–Jeghers have a 15-fold increased risk of **[] cancer** compared to the general population

Answer 488

Individuals with Peutz–Jeghers have a 15-fold increased risk of **intestinal cancer** compared to the general population

Question 489

A 28-year-old female presents with jaundice. The following results are available: HBsAg +ve, HBeAg +ve, HBeAb −ve, HBc IgM +ve Which of the following interpretations is most accurate? Susceptible to hepatitis B Chronic hepatitis B with low infectivity Chronic hepatitis B with high infectivity Previous immunisation against hepatitis B Natural immunity against hepatitis B

Answer 489

A 28-year-old female presents with jaundice. The following results are available: HBsAg +ve, HBeAg +ve, HBeAb −ve, HBc IgM +ve Which of the following interpretations is most accurate? Susceptible to hepatitis B Chronic hepatitis B with low infectivity **Chronic hepatitis B with high infectivity** Previous immunisation against hepatitis B Natural immunity against hepatitis B The presence of HBsAg (surface antigen) indicates current infection. The presence of HBeAg (HBV ‘e’ antigen) also indicates current infection, either acute hepatitis B or a chronic carrier state of high infectivity (suggests highly active HBV). IgM antibodies may remain positive in the patient for up to 900 days post-acute phase of hep B infection.

Question 490

A 40-year-old female presents to the Surgical Admissions Unit with right upper quadrant colicky abdominal pain and vomiting. It came on while eating but is starting to subside. On examination, she is restless and sweaty with a heart rate of 100 bpm and a blood pressure of 125/86 mmHg. Abdominal ultrasound confirms the presence of gallstones. What is the most common composition of gallstones? Cholesterol Uric acid Palmitate Bilirubin Calcium

Answer 490

A 40-year-old female presents to the Surgical Admissions Unit with right upper quadrant colicky abdominal pain and vomiting. It came on while eating but is starting to subside. On examination, she is restless and sweaty with a heart rate of 100 bpm and a blood pressure of 125/86 mmHg. Abdominal ultrasound confirms the presence of gallstones. What is the most common composition of gallstones? **Cholesterol** Uric acid Palmitate Bilirubin Calcium

Question 491

A middle-aged man presented to his General Practitioner (GP) with a three-month history of epigastric pain and weight loss. He mentions that he tried over-the-counter antacids, which initially provided some relief, but the pain has worsened. He decided to see his GP after realising he had lost about 5 kg. He denies any vomiting or loose stools. He has never had problems with his stomach before and has no significant family history. Endoscopy and biopsy are performed; histology shows active inflammation. What is the most likely diagnosis? Helicobacter pylori gastritis Invasive carcinoma Duodenal ulcer Crohn's disease Gastrointestinal stromal tumour

Answer 491

A middle-aged man presented to his General Practitioner (GP) with a three-month history of epigastric pain and weight loss. He mentions that he tried over-the-counter antacids, which initially provided some relief, but the pain has worsened. He decided to see his GP after realising he had lost about 5 kg. He denies any vomiting or loose stools. He has never had problems with his stomach before and has no significant family history. Endoscopy and biopsy are performed; histology shows active inflammation. What is the most likely diagnosis? **Helicobacter pylori gastritis** Helicobacter pylori gastritis is a very common diagnosis in adults suffering from symptoms of dyspepsia. H. pylori is a Gram-negative bacterium and, although harmless in most people, can cause gastritis and peptic ulcer formation in some people. The infection increases the risk of gastric adenocarcinoma, so eradication therapy with antibiotics is necessary.

Question 492

Which of the following is an extra-intestinal clinical feature associated with inflammatory bowel disease? Aortic aneurysm Bilateral symmetrical deforming arthropathy of the hands Heberden’s nodes Prostatitis Sacroiliitis

Answer 492

Which of the following is an extra-intestinal clinical feature associated with inflammatory bowel disease? Aortic aneurysm Bilateral symmetrical deforming arthropathy of the hands Heberden’s nodes Prostatitis **Sacroiliitis**

Question 493

A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis. What is the most appropriate treatment? Put it into the scrotum surgically (orchidopexy) Remove it (orchidectomy) Remove it along with the opposite testis (bilateral orchidectomy) Start the patient on testosterone Perform a chromosome analysis

Answer 493

A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis. What is the most appropriate treatment? **Remove it (orchidectomy)** Orchidectomy of the undescended testis is the most appropriate option since it eliminates the risk of subsequent development of seminoma

Question 494

What blood results would indicate small intestinal bacterial overgrowth (SIBO)? [3]

Answer 494

High folate Low B12 General malabsorption

Question 495

What is SIBO associated with? [3] What causes SIBO? [1]

Answer 495

**failure of normal bacterial growth control** in the small gut and can be **associated** with **decreased gastric acid secretion, slowed gut motility, and immunodeficiency syndromes**

Question 496

Renal biopsy, or trauma, is a risk factor for subsequent development of a **[]** Name two presentations that the above answer may present with [2]

Answer 496

Renal biopsy may cause **renal arteriovenous malformations (AVMs)** most common presentation is with **hypertension and haematuria**

Question 497

A 25-year-old male has presented to the Emergency Department with fever, jaundice and malaise for the past three days. Initial laboratory studies show raised liver enzymes and a low platelet count. He has no recent travel history. A diagnosis of autoimmune hepatitis is being considered. Which of the following antibodies are most specific for this condition? Anti-smooth muscle antibodies Anti-mitochondrial antibodies Hepatitis A Immunoglobulin M (IgM) antibodies Anti-nuclear antibody Anti-Smith antibodies

Answer 497

A 25-year-old male has presented to the Emergency Department with fever, jaundice and malaise for the past three days. Initial laboratory studies show raised liver enzymes and a low platelet count. He has no recent travel history. A diagnosis of autoimmune hepatitis is being considered. Which of the following antibodies are most specific for this condition? **Anti-smooth muscle antibodies**

Question 498

Which of the following is the most appropriate antibiotic for this patient’s infected pressure ulcer? Ceftriaxone Ciprofloxacin Clarithromycin Flucloxacillin Nitrofurantoin

Answer 498

Which of the following is the most appropriate antibiotic for this patient’s infected pressure ulcer? **Flucloxacillin** The patient has an infected sacral pressure sore. The infection is likely to be superficial with no extension to the underlying bone (which would be concerning for osteomyelitis). Along with cleaning and dressing the wound, culture swabs of the fluid should be taken so antibiotics can be tailored according to microbial sensitivities. Superficial infections are typically treated with oral antibiotics such as flucloxacillin as this is likely to provide coverage for gram-positive bacteria that reside on the skin surface, such as **Staphylococcus aureus**. As the patient is bed-bound, he should also be assessed for an air mattress.

Question 499

A 37-year-old female patient presents with a swollen neck, and an abnormal neck mass raises suspicion of thyroid malignancy. Fine-needle aspiration (FNA) is arranged, and subsequent histology from a thyroid lobectomy reveals chromatin clearing, nuclear shape changes, and irregularity of the nuclear membrane. No evidence of C cell differentiation is observed, and the patient does not report any family history of cancer. What is the most likely diagnosis? Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Answer 499

A 37-year-old female patient presents with a swollen neck, and an abnormal neck mass raises suspicion of thyroid malignancy. Fine-needle aspiration (FNA) is arranged, and subsequent histology from a thyroid lobectomy reveals chromatin clearing, nuclear shape changes, and irregularity of the nuclear membrane. No evidence of C cell differentiation is observed, and the patient does not report any family history of cancer. What is the most likely diagnosis? **Papillary carcinoma of the thyroid** **Histological features are changes in nuclear shape and size and nuclear membrane irregularity**

Question 500

Which is the most common? Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Answer 500

Which is the most common? **Papillary carcinoma of the thyroid** Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Question 501

Which form of thyroid cancer shows vascular invasion and capsule invasion, and both can only be seen accurately on a full histological specimen? Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Answer 501

Which form of thyroid cancer shows vascular invasion and capsule invasion, and both can only be seen accurately on a full histological specimen? Papillary carcinoma of the thyroid **Follicular carcinoma of the thyroid** Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Question 502

Which form of thyroid cancer peak incidence is between 60 and 70 years of age, Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Answer 502

Which form of thyroid cancer peak incidence is between 60 and 70 years of age, Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid **Anaplastic carcinoma of the thyroid** Lymphoma of the thyroid

Question 503

Which form of thyroid cancer often associated with Hashimoto’s thyroiditis? Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid Lymphoma of the thyroid

Answer 503

Which form of thyroid cancer often associated with Hashimoto’s thyroiditis? Papillary carcinoma of the thyroid Follicular carcinoma of the thyroid Medullary carcinoma of the thyroid Anaplastic carcinoma of the thyroid **Lymphoma of the thyroid**

Question 504

Define Gilbert's syndrome [1]

Answer 504

Gilbert’s syndrome is an **autosomal recessive condition** associated with **intermittent raised unconjugated bilirubinaemia**, resulting from a **defective glucuronyl transferase**. This is the **enzyme** involved in **conjugation** of **bilirubin**, and so the **ability** of **patients** to **conjugate bilirubin is significantly reduced.**

Question 505

Gilbert's syndrome is defined by which four characteristics? [4]

Answer 505

The condition is defined by the four following characteristics, necessary for diagnosis: * **unconjugated hyperbilirubinaemia** * **normal liver function** * **no haemolysis** * **no evidence of liver disease**

Question 506

Expalin why in Gilbert’s syndrome, there is absence of bilirubin in the urine?

Answer 506

*In unaffected individuals following conjugation, conjugated bilirubin is released into the bile and is either excreted in the faeces as stercobilin or reabsorbed in the circulation and excreted by the kidneys in the urine in the form of urobilinogen* In Gilberts: there is a defective glucuronyl transferase. This is the enzyme involved in conjugation of bilirubin, and so the ability of patients to conjugate bilirubin is significantly reduced. **Unconjugated bilirubin is non-water-soluble; therefore, it cannot be excreted in the urine.**

Question 507

Which age group and sex does Gilbert's syndrome normally effect? [1] What is the treatment? [1]

Answer 507

Usually presents during adolescent years No treatment is required for Gilbert’s syndrome.

Question 508

Describe the clinical presentation of Gilbert's syndrome [2]

Answer 508

**Asymptomatic** between episodes **Jaundice** triggered by stress / infection / dieting, fasting, an operation, dehydration, intermittent illnes

Question 509

A 55-year-old male alcoholic with known cirrhotic liver disease is admitted to the Gastroenterology Ward with a distended abdomen, jaundice and confusion. On examination, he is clinically jaundiced and has a massively distended abdomen with evidence of a fluid level on percussion. An aspirate of fluid is taken from his abdomen and sent for analysis. Results indicate the fluid is an exudate. Which of the following is an exudative cause of ascites? Portal hypertension Cardiac failure Fulminant hepatic failure Budd–Chiari syndrome Malignancy

Answer 509

A 55-year-old male alcoholic with known cirrhotic liver disease is admitted to the Gastroenterology Ward with a distended abdomen, jaundice and confusion. On examination, he is clinically jaundiced and has a massively distended abdomen with evidence of a fluid level on percussion. An aspirate of fluid is taken from his abdomen and sent for analysis. Results indicate the fluid is an exudate. Which of the following is an exudative cause of ascites? **Malignancy** Ascites is defined as an accumulation of fluid within the peritoneal cavity. The causes can be classified according to the **protein content of the fluid: < 30 g/l transudate, >30 g/l exudate**. The most common causes of an exudative ascites are infection or malignancy. The above patient scenario would be more in keeping with a malignant cause.

Question 510

How do you investigate haemorrhoids if: - low risk colorectal cancer? [1] - high risk colorectal cancer? [1]

Answer 510

- low risk colorectal cancer: **flexible sigmoidoscopy** - high risk colorectal cancer: **Colonoscopy**

Question 511

# [](http://) A 50-year-old male with severe ureteric colic has an impacted 8 mm stone at the pelvi-ureteric junction (PUJ). He has an unremarkable past medical history and his laboratory investigations are normal. Which of the following is the most appropriate management strategy for this patient? Extracorporeal shock wave lithotripsy Endoscopic retrograde basket extraction Endoscopic retrograde laser vaporisation of the stone Open surgical removal Waiting for the spontaneous passage of stone

Answer 511

A 50-year-old male with severe ureteric colic has an impacted 8 mm stone at the pelvi-ureteric junction (PUJ). He has an unremarkable past medical history and his laboratory investigations are normal. Which of the following is the most appropriate management strategy for this patient? **Extracorporeal shock wave lithotripsy** Endoscopic retrograde basket extraction Endoscopic retrograde laser vaporisation of the stone Open surgical removal Waiting for the spontaneous passage of stone

Question 512

Namet two contraindications for shockwave lithotripsy? [2]

Answer 512

**Pregnancy** and **coagulopathy**

Question 513

A six-year-old child is brought to the paediatrician by his parents for a follow-up examination after diagnosis of a genetically inherited disease. On examination, the paediatrician notes a yellow-brown coloration right around the iris. Which type of renal dysfunction is the first-line treatment for this child’s condition most associated? Membranous nephropathy Minimal change disease Focal segmental glomerulosclerosis Type II membranoproliferative glomerulonephritis Diffuse proliferative glomerulonephritis

Answer 513

A six-year-old child is brought to the paediatrician by his parents for a follow-up examination after diagnosis of a genetically inherited disease. On examination, the paediatrician notes a yellow-brown coloration right around the iris. Which type of renal dysfunction is the first-line treatment for this child’s condition most associated? **Membranous nephropathy** Minimal change disease Focal segmental glomerulosclerosis Type II membranoproliferative glomerulonephritis Diffuse proliferative glomerulonephritis **This child has Wilson’s disease, an inherited disorder of copper metabolism, in which there is an inability to secrete copper into bile and transfer copper into caeruloplasmin. A mutation in the ATP7B gene causes Wilson’s disease. Treatment for Wilson’s disease is penicillamine, a copper-chelating agent. It is associated with membranous nephropathy.**

Question 515

Where exactly are loop colostomies located? 1[]

Answer 515

usually in the **right transverse colon**, **proximal to the middle colic artery**

Question 516

Ileostomies can be low or highoutput: Low output tends to output **[]** ml/day for a **low output ileostomy**, and **[]** ml/day for a **high output ileostomy**

Answer 516

tends to output **500 ml/day for a low output ileostomy**, and **1000 ml/day for a high output ileostomy**

Question 517

How do you know if stoma retraction has occurred? [2]

Answer 517

Stoma retraction presents with **persistent leakage** and **peristomal irritant dermatitis.**

Question 518

When is stoma ischaemia most likely to occur? [1]

Answer 518

24hrs post op

Question 519

Define what is meant by a parasternal hernia [1]

Answer 519

Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma, i.e. **a condition wherein abdominal contents, typically the bowel or greater omentum, protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma**

Question 520

How do you determine if a stoma has a parasternal hernia?

Answer 520

**Positive cough impulse** and and **lump at the hernia site**

Question 521

How can you confirm if a patient has achalasia? [1] What would this investigation show? [1]

Answer 521

**Conventional manometry**: tracings in patients with achalasia show the **absence of esophageal peristalsis**

Question 522

What is the surgical procedure to treat achalasia called? [1] What are therapeutic treatments for achalasia? [4]

Answer 522

Surgical: **pneumatic dilation** Medical: **Botox injection; CCBs; long acting nitrates; sildenafil**

Question 523

What is the first line imaging investigation used for renal hypertension? [1] Which pathologies are you investigating for? [2]

Answer 523

**Abdominal duplex US** Investigating for: **renal artery stenosis; PCKD**

Question 524

Which type of bacteria mostly cause SBP? [1] Which treatment should you therefore use? [2]

Answer 524

Gram negative bacteria Piperacillin and tazobactuam common choice

Question 525

SIADH can occur from which type of brain injury? [1]

Answer 525

**Sub Arach Haem**: causes dilutional hyponatraemia

Question 526

Which antispasmodic is used for diverticula disease? [1]

Answer 526

**Dicycloverine**

Question 528

What is the name of this sign? [1] What pathology does it indicate? [1]

Answer 528

**Cullens sign** Cullen's sign is described as superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region. This is also known as peri-umbilical ecchymosis. It is most often recognised as a result of **haemorrhagic pancreatitis.**

Question 529

What is the name of this sign? [1] What pathology does it indicate? [1]

Answer 529

**Grey-Turner's sign** Classically it correlates with **severe acute necrotizing pancreatitis**

Question 530

Name four complications of diverticula disease [4]

Answer 530

**abscess formation**, **perforation**, **obstruction**, formation of **adhesions**, **fistulae** and **strictures**

Question 531

What is the most common fistula that occurs in diverticula disease [1]

Answer 531

**Colovescial fistula**

Question 532

What are the common presentations of colovesical fistulas? [3]

Answer 532

**pneumaturia** (passage of gas mixed with urine), **faecaluria**, **recurrent urinary tract infections**, or **passage of urine rectally**

Question 533

National Institute for Health and Care Excellence (NICE) guidelines recommend a surveillance colonoscopy for patients with UC how often for low, medium and high risk patients? [3]

Answer 533

aLow: **every 5 years** Medium: **every 3 years** High: **annually**

Question 534

What is the Rockall score used for? [1] What two factors does it consider when creating a score? [2]

Answer 534

The Rockall score, used in **acute upper GI bleeds**, considers **shock**, defined by **systolic blood pressure** and **pulse rate**

Question 535

What is Fanconi syndrome and why does it occur? [1]

Answer 535

Fanconi syndrome arises from an **underlying dysfunction in the proximal convoluted tubule (PCT)**, resulting in a **broad impairment of reabsorption.**

Question 536

What electrolyte disturbance does Fanconi syndrome present with? [2] Which other disease state is Fanconi syndrome associated with? [1]

Answer 536

**Hypophosphatemia**, and **hypokalemia** Associated with **Wilson's disease**

Question 537

What are the NICE guidelines on what makes patients with colorectals adenomas low, intermediate and high risk? [3] How often should low, intermediate and high risk colorectal adenoma patients be offered colonoscopies? [3]

Answer 537

Classification of risk and advised management in patients with colorectal adenomas are as follows: **Low risk** - **one** or **two** **adenomas** **smaller** than **10** **mm** - should be considered for **colonoscopy at five years** **Intermediate risk** - **three/four adenomas smaller than 10 mm** or - **one/two adenomas if one is 10 mm or larger** - should be offered a **colonoscopy at three years** **High risk** - **five** or **more** **adenomas** **smaller** than **10** **mm** or - **three or more adenomas if one is 10 mm** or **larger** - offered a **colonoscopy at one year**.

Question 538

Thumbprinting can occur in ulcerative colitis and which other pathology? [1]

Answer 538

**Ischaemic colitis**

Question 539

A 32-year-old man presented complaining of headaches and sweating, and was found to be hypertensive. Investigations confirmed the diagnosis of a phaeochromocytoma. He was treated with phenoxybenzamine before surgery. What is the pharmacological property of phenoxybenzamine that makes it the most suitable treatment for a phaeochromocytoma? Irreversible α-adrenoceptor antagonist Irreversible α- and β-adrenoceptor antagonist Reversible α-adrenoceptor agonist Reversible α-adrenoceptor antagonist Reversible β-adrenoceptor antagonist

Answer 539

A 32-year-old man presented complaining of headaches and sweating, and was found to be hypertensive. Investigations confirmed the diagnosis of a phaeochromocytoma. He was treated with phenoxybenzamine before surgery. What is the pharmacological property of phenoxybenzamine that makes it the most suitable treatment for a phaeochromocytoma? **Irreversible α-adrenoceptor antagonist** Irreversible α- and β-adrenoceptor antagonist Reversible α-adrenoceptor agonist Reversible α-adrenoceptor antagonist Reversible β-adrenoceptor antagonist

Question 540

Describe the difference in symptoms that you would consider when prescribing Loperamide, Mebeverine & Fybogel for IBS? [3]

Answer 540

**Mebeverine**: is an antispasmodic which can help relieve colicky abdominal pain in these patients. **Loperamide**: useful adjunct for patients with diarrhoea-predominant IBS (IBS-D). **Fybogel**: For patients with constipation-predominant IBS (IBS-C),

Question 542

Describe what effect **severe** pancreatitis have on calcium levels? [2]

Answer 542

**Hypocalcaemia**: causes deposition of calcium in stomach. Only in severe pancreatitis

Question 543

If there is found to br a cystic mass in the pancreas, what is the most likely diagnosis? [1]

Answer 543

**Pseudocyst**: areas of local necrotic haemorrhage rich in pancreatic enzymes. 75% of cysts in pancreas are pseudocysts

Question 544

What is the usual cause of pseudocysts of pancreas?[1]

Answer 544

Acute on chronic pancreatitis

Question 545

Which part of the pancreas do 60% of pancreatitic tumours occur? Tail Head Islet of langerhans Body

Answer 545

Head

Question 546

How do you determine if raised cortisols level are from Cushings Disease or ectopic ACTH source in a high dose dexamethasone suppression test? [2]

Answer 546

In Cushing’s disease, the pituitary remains partially responsive to the glucocorticoid feedback. In ectopic sources of ACTH there is none, so cortisol remains high despite dexamethasone

Question 547

*A 70-year-old woman presented with difficulty swallowing, chronic cough associated with occasional swellings in the neck. She had a recent admission where she was treated with intravenous antibiotics for aspiration pneumonia* This is a typical presentation of which pathology? [1]

Answer 547

Dysphagia, aspiration pneumonia, halitosis → **pharyngeal pouch**

Question 548

What pathology are the yellow arrows pointing to in this barium enema? Sigmoid carcinoma Crohn's disease Coeliac disease Constipation with overflow diarrhoea Ulcerative coltiis

Answer 548

What pathology are the yellow arrows pointing to in this barium enema? Sigmoid carcinoma Crohn's disease Coeliac disease Constipation with overflow diarrhoea **Ulcerative coltiis** - loss of haustral markings - **lead pipe colon**

Question 549

What pathology is indicated in this imaging? Sigmoid carcinoma Crohn's disease Coeliac disease Constipation with overflow diarrhoea Ulcerative coltiis

Answer 549

What pathology is indicated in this imaging? Sigmoid carcinoma Crohn's disease Coeliac disease Constipation with overflow diarrhoea **Ulcerative coltiis** - lead pipe colon

Question 550

Granulomas are more commonly associated with Sigmoid carcinoma Crohn's disease Coeliac disease Constipation with overflow diarrhoea Ulcerative coltiis

Answer 550

**Crohn's disease**

Question 551

Blood diarrhoea is most commonly associated with Sigmoid carcinoma Crohn's disease Coeliac disease Constipation with overflow diarrhoea Ulcerative coltiis

Answer 551

**Ulcerative coltis**

Question 552

What is first and second line treatment for haemochromatosis? [2]

Answer 552

1st: - **Venesection** 2nd - **Desferrioxamine**

Question 553

Name a therapeutic drug that is a risk factor for cholestasis [1]

Answer 553

**Co-amoxiclav**

Question 554

What is this patient likely suffering from? [1]

Answer 554

**Peutz-Jeghers syndrome**

Question 555

Describe the pathophysiology of **Peutz-Jeghers syndrome** [3]

Answer 555

**Hamartomatous polyps** in the **gastronintestinal** **tract** (mainly small bowel) * **small bowel obstruction** (tinkling bowels) is a common presenting complaint, often due to **intussusception** * **gastrointestinal bleeding**

Question 556

Describe the typical presentation of Peutz-Jeghers syndrome [2]

Answer 556

**Pigmented lips, hands, soles of feet and face** Leads to **SBO** & **GI bleeds**

Question 557

Which scores for upper GI bleeeds are used: - to help clinicians decide whether patient patients can be managed as outpatients or not [1] - provides a percentage risk of rebleeding and mortality, includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage [1]

Answer 557

- to help clinicians decide whether patient patients can be managed as outpatients or not: **Glasgow-Blatchford** - provides a percentage risk of rebleeding and mortality, includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage: **Rockall**

Question 558

If a patient is having an upper GI bleed, when would the following be indicated? platelet transfusion [1] fresh frozen plasma [3] prothrombin complex concentrate [1]

Answer 558

**platelet transfusion** - if actively bleeding **platelet count** of **less than 50 x 10^9/litre** **fresh frozen plasma** - **fibrinogen** level of **less than 1 g/litre** - **a prothrombin time** (international normalised ratio) or **activated partial thromboplastin time** **greater than 1.5 times normal** **prothrombin complex concentrate:** - to patients who are taking **warfarin** and **actively bleeding**

Question 559

Which numbers on the Bristol Stool Chart indicate diarrhoea? [2]

Answer 559

**6 & 7**

Question 560

Which numbers on the Bristol Stool Chart indicate constipation? [2]

Answer 560

**1 & 2**

Question 561

What are first and second line laxative treatments for constipation patients? [2]

Answer 561

**first-line laxative:** - bulk-forming laxative first-line, such as **ispaghula husk** **second-line**: - osmotic laxative, such as a **macrogol**

Question 562

What associated symptom is an indicator of a severe UC flare-up? [1]

Answer 562

**Fever** is an indicator of a severe UC flare-up

Question 563

Describe what is meant by the pathology ischaemic hepatitis [1] What pathologies are associated with ischaemic hepatitis? [1] What LFTs would indicate ischaemic hepatiis? [1]

Answer 563

Ischaemic hepatitis is a diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as '**shock liver**'). It is **not** an **inflammatory process.** It is diagnosed in the **presence of an inciting event** (e.g. a cardiac arrest) and **marked increases in aminotransferase levels** (exceeding 1000 international unit/L or 50 times the upper limit of normal). **Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction.**

Question 564

What are the three cause of ALT / AST > 1000? [3]

Answer 564

The 3 causes of ALT/AST >1000: * **Ischaemia** * **Paracetamol OD** * **Viral hepatitis**

Question 565

Acute liver failure typically presents with a triad of which three symptoms? [3]

Answer 565

* **encephalopathy** * **jaundice** * **coagulopathy**

Question 566

Name a clinical situation in an acute flare up of UC where you presribe an oral aminosalicylate alongside a rectal one? [1]

Answer 566

In a mild-moderate flare of **ulcerative colitis extending past the left-sided colon**, oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far e.g. *Diffuse superficial ulceration from the rectum to the hepatic flexure*

Question 567

What is the most appropriate management concerning the risk of spontaneous bacterial peritonitis? Oral penicillin Oral ciprofloxacin Oral azithromycin Oral doxycycline intravenous cefotaxime

Answer 567

**Oral ciprofloxacin** - used to PREVENT SBP **T**reat - Cefo**t**axime **P**revent - Ci**p**rofloxacin

Question 568

What is the most appropriate management concerning the treatment of spontaneous bacterial peritonitis? Oral penicillin Oral ciprofloxacin Oral azithromycin Oral doxycycline intravenous cefotaxime

Answer 568

**intravenous cefotaxime** **T**reat - Cefo**t**axime **P**revent - Ci**p**rofloxacin

Question 569

Name 5 causes of raised ferritin (that are not related to iron overload) [5]

Answer 569

**Inflammation** (due to ferritin being an acute phase reactant) **Alcohol excess** **Liver disease** **Chronic kidney disease** **Malignancy** *The liver is a major storage site for iron, therefore it has a lot of ferritin. Damage to the hepatocytes will result in leaking of the ferritin = high serum ferritin*

Question 570

Describe what is meant by the pathology of exposure keratopathy in Graves disease? [1]

Answer 570

**Proptosis** of the **eyeballs** and **eyelid** **retraction** causes the **corneas to be more exposed to the environment** so they become more **exposed** and **irritated**

Question 571

What is the most common complication of thyroid eye disease? [1]

Answer 571

Exposure keratopathy

Question 572

Describe the key changes to the eye that occurs in thyroid eye disease [4]

Answer 572

**Corneal damage**: - Due to continous exposure and dryness **Reduced tear film**: - Inability to close eyelids fully - Potential inflammation in the tear ducts reduces the protective tear film that coats the cornea **Proptosis**: - Eye muscles push forward - Fat swells - Prevents the eyeball closing properly **Eyelid retraction**: - Causes increased exposure of the cornea

Question 573

Describe the effect of pred on glucose levels [1]

Answer 573

**Increases** glucose by **blocking the action of insulin**

Question 574

What is the most appropriate investigation for patients with an increased urinary cortisol level and low plasma ACTH? [1]

Answer 574

**CT adrenal glands**:

Question 575

Which of the following is most likely to trigger a G6PD episode? Bisoprolol Clindamycin Gliptazide Infliximab Sitgagliptin

Answer 575

**Gliptazide** G6PD deficiency impacted by **sulph** drugs and causing haemolysis: - **Sulphnonadmides** - **Sulphasalazine** - **Sulphonureas**

Question 576

If a DMT2 patient needs hypertensive treatment, what is the preferred first line treatment? [1]

Answer 576

**ARB** ( > ACEin): cause less side effects like cough

Question 577

A patient presents with symptoms that cause moans, groand and pain in bones. What is the underlying likely pathophysiology? [1]

Answer 577

**Hypercalcaemia**

Question 578

Chronic depression in the context of calcium changes indicates which pathology? [1]

Answer 578

**Chronic secondary hypoparathyroidism**

Question 579

When is metformin contraindicated in a diabetic patient? [1]

Answer 579

**If eGFR < 30**

Question 580

Glicazide is what class of drug? [1]

Answer 580

Sulfonyurea

Question 581

Liraglutide is what class of drug? [1]

Answer 581

GLP-1 agonist

Question 582

Linagliptin is what class of drug? [1]

Answer 582

DPP-4 inhibitor

Question 583

What effect on insluin and c-peptide levels would occur if gave a patient a sulfonyurea like glicazide? [1] Explain your answer [1]

Answer 583

**Insulin and C-peptide levels increase** - Pro-insulin is broken down into insulin and c-peptide - Sulfonyureas increase the secretion of insulin from B cells

Question 584

Name 4 pathologies that cause a **falsely high** HbA1c [4]

Answer 584

**Increase** the **lifespan** of RBC: - **Vit B12 deficiency** - **Folate deficiency** - **IDA** - **Splenectomy**

Question 585

Name 4 pathologies that cause a **false low** HbA1c [4]

Answer 585

**Decrease** the **lifespan** of RBC: - **G6PD** - **SCA** - **Haemodialysis** - **Hered. spherocytosis**

Question 586

A patient presents with symptoms of thyrotoxicosis with a tender goitre. What is the most likely diagnosis? Follicular carcinoma Grave's disease Hashimoto's disease Papillary carcinoma Subacute (De Quervain's) thyroiditis

Answer 586

A patient presents with symptoms of thyrotoxicosis with a tender goitre. What is the most likely diagnosis? Follicular carcinoma Grave's disease Hashimoto's disease Papillary carcinoma **Subacute (De Quervain's) thyroiditis**

Question 587

How can you differentiate between subacute thyroiditis (in the period of hyperthyroid) from other causes of thyrotoxicosis? [1]

Answer 587

Patients will present with a **tender goitre**

Question 588

Describe the glucose levels in alcoholic ketoacidosis [1]

Answer 588

**Low or normal**

Question 589

When is metclopramide contra-indicated? [1]

Answer 589

Metoclopramide should be avoided in **bowel** **obstruction**

Question 590

State three indications of metoclopramide [3]

Answer 590

* **gastro-oesophageal reflux disease** * prokinetic action is useful in **gastroparesis** secondary to **diabetic neuropathy** * often combined with analgesics for the treatment of **migraine** (migraine attacks result in gastroparesis, slowing the absorption of analgesics)

Question 591

State 4 adverse effects of metclopramide use

Answer 591

- extrapyramidal effects: **acute dystonia** - eyes can get stuck in one position (**oculogyric crisis**) - **diarrhoea** - **hyperprolactinaemia** - **tardive** **dyskinesia** - irregular movements which you cannot control - **parkinsonism**

Question 592

What are the five needs for renal replacement therapy [5]

Answer 592

**AKI** + - **Hyperkalaemia** - **Pulmonary oedema** - **Uraemia** (e.g. pericarditis; encephalopathy) - **Acidaemia** - **Refractory** **hypertension**

Question 593

What would indicate a step up to aziothropine / mercaptopurine treatment in UC? [1]

Answer 593

2+ (severe?) exacerbations in the past year

Question 594

Name a drug that causes gallactorrhoea [1]

Answer 594

**Metoclopromide** ## Footnote *Met: millky* *Spiro: sexy*

Question 595

# [](http://) State a neuro / psychotic side effect of pred use? [1]

Answer 595

**Steroid psychosis**: *can occur shortly after administering high doses of glucocorticoids.*

Question 596

What is the earliest clinical manifestation of diabetic kidney disease? [1]

Answer 596

**Microalbuminaemia**

Question 597

Describe the investigations would conduct to assess if a patient has diabetic kidney disease [2]

Answer 597

1. **ACR screen** - spot sample 2. If abnormal; **repeat as first past**

Question 598

What would indicate that diabetic kidney disease needs treatment? [1] What treatment would you provide? [1]

Answer 598

**ACR > 3** **Start ACEin or ARB** (but not together)

Question 599

Describe what is meant by euthyroid sick syndrome [3]

Answer 599

**euthyroid sick syndrome** is a state where the thyroid gland is functioning normally, but the thyroid hormones are at **abnormal levels.** Common causes of ESS include **starvation** or a **serious illness** **TSH**: - **Normal / low** **T3/T4:** - **Low**

Question 600

How do you differentiate between acute cholecystitis and acute pancreatitis? [3]

Answer 600

**Acute pancreatitis:** - **Gall** **stones** and **alcohol** most common causes - **Apyrexial** - **Epigastric** **pain** (sometimes radiates to the back) **Acute cholecystitis** - Similar pain to **biliary** **colic** but more **sustained** - Radiates to back / **shoulder tip** - **Murphy sign positive**

Question 601

# [](http://) Describe an endocrine implication of HIV infection [1]

Answer 601

**HIV** can lead to **adrenal insufficiency** (typically due to CMB related **necrotising adrenalitis**)

Question 602

Name a cancer associated with Hashimotos [1]

Answer 602

**MALT**

Question 603

Describe the specific vision change that can occur with a prolactinoma [1]

Answer 603

**bitemporal superior quadrantanopia**

Question 604

What is Budd-Chiari syndrome? [1] Name 4 factors that can contribute to this syndrome [1]

Answer 604

**Hepatic vein thrombosis** * Polycythemia rubra vera * Protein C/S resistance; anti-thrombin III d. protein C&S deficiency * Pill * Antiphosphoipid syndrome

Question 605

State the typical triad with regards to the presentation of hepatic vein thrombosis / Budd-Chiari syndrome [3]

Answer 605

- **Abdomen pain** - **Ascites** - **Tender hepatomegaly**

Question 606

Explain the acid/base implication of Addison's disease [1]

Answer 606

**Metabolic acidosis with hyperkalaemia** Deficiency of aldosterone causes wasting of sodium, with retention of positively charged ions (K+ and H+). This leads to hyperkalemia and non-anion-gap metabolic acidosis (NAGMA).

Question 607

Describe how long term steroid treatment can impact a patient with Addisons, particularly when they get ill? [1]

Answer 607

**Steroids** **suppress** **adrenal** **output** When the body needs a higher dose (due to infection), **cant make extra steroids** Causes an **Addisonian crisis**

Question 608

Which treatment for hyperthyroidism can exacerbate thyroid eye disease? [1]

Answer 608

**Radiotherapy**

Question 609

Upon further investigation, the patient is found to have the most common type of thyroid cancer. What is the most likely complication of this type of malignancy? Hashimoto's thyroiditis Hyperthyroidism Raised calcitonin Spread to cervical lymph nodes Vascular invasion

Answer 609

Upon further investigation, the patient is found to have the most common type of thyroid cancer. What is the most likely complication of this type of malignancy? Hashimoto's thyroiditis Hyperthyroidism Raised calcitonin **Spread to cervical lymph nodes** Vascular invasion ## Footnote Papillary thyroid cancer is well-differentiated, therefore, has a good prognosis. However, it tends to spread to local lymph nodes early.

Question 610

Upon further investigation, the patient is found to have follicular thyroid cancer. What is the most likely complication of this type of malignancy? Hashimoto's thyroiditis Hyperthyroidism Raised calcitonin Spread to cervical lymph nodes Vascular invasion

Answer 610

Upon further investigation, the patient is found to have follicular thyroid cancer. What is the most likely complication of this type of malignancy? Hashimoto's thyroiditis Hyperthyroidism Raised calcitonin Spread to cervical lymph nodes **Vascular invasion**

Question 611

What is Lynch syndrome aka? [1]

Answer 611

**hereditary nonpolyposis colorectal cancer syndrome**

Question 612

Describe what the Amsterdam criteria is with regards to HNPCC [3]

Answer 612

The Amsterdam criteria are used in the diagnosis hereditary non polyposis colorectal cancer: - **3+ family members have HNPCC** - **Cases span 2 generations** - **One family member dies before 50**

Question 613

Which genes are implicated in HNPCC? [2] Cancer in which organs does HNPCC typically present? [2]

Answer 613

Genes: - MSH2 - MSH1 Typically presents as **colorectal** or **ovarian cancer**

Question 614

How would a patient typically present who has had surgery for their familial adenomatous polyposis? [1]

Answer 614

Post-surgery (total protocolectomy) have an **ileal pouch with anal anastomosis**

Question 615

State the surgery that is usually given to patients who have FAP [1]

Answer 615

**total** **protocolectomy** with an **ileal pouch with anal anastomosis**

Question 616

Familial adenomatous polyposis has a risk of causing a tumour to which part of the body? [1]

Answer 616

**Duodenal tumour**

Question 617

Goitre that is tender upon palpitation indicates..? [1]

Answer 617

**de quervain thyroiditis**

Question 618

Which is the most common type of thyroid cancer? [1]

Answer 618

Follicular

Question 619

Hep A has increased risk due to eating what type of food? [1]

Answer 619

Shellfish

Question 620

If someone is suffering from a pituitary ademona, what would their ACTH and cortisol levels be post high dose dexamethason test be? [2]

Answer 620

ACTH & Cortisol **low**

Question 621

A three-year-old child is brought to their General Practitioner (GP) with failure to thrive. His parents complain that he drinks a lot of water, urinates frequently, and is not growing well. The GP does blood and urine tests and diagnoses Fanconi syndrome. Which of the following features would you most likely see in Fanconi syndrome? Oliguria Hyperphosphatemia Alkalosis Hypokalaemia Hyperkalaemia

Answer 621

A three-year-old child is brought to their General Practitioner (GP) with failure to thrive. His parents complain that he drinks a lot of water, urinates frequently, and is not growing well. The GP does blood and urine tests and diagnoses Fanconi syndrome. Which of the following features would you most likely see in Fanconi syndrome? Oliguria Hyperphosphatemia Alkalosis **Hypokalaemia** Hyperkalaemia

Question 622

A 63-year-old man who consumes over-the-counter multivitamins on a daily basis presents with sudden-onset right flank pain with radiation to the groin. He has nausea and vomiting. Urinalysis shows microscopic haematuria. There are square, envelope-shaped crystals in the urine. Excessive intake of which of the following vitamins may result in this condition? Vitamin B1 Vitamin B6 Vitamin B12 Vitamin C Vitamin E

Answer 622

A 63-year-old man who consumes over-the-counter multivitamins on a daily basis presents with sudden-onset right flank pain with radiation to the groin. He has nausea and vomiting. Urinalysis shows microscopic haematuria. There are square, envelope-shaped crystals in the urine. Excessive intake of which of the following vitamins may result in this condition? Your answer was incorrect Vitamin B1 Vitamin B6 Vitamin B12 **Vitamin C** Vitamin E

Question 623

What is the first line management of acute [4] and chronic [3] anal fissures

Answer 623

**Acute**: - Soften stool - Lubricants (topical jelly) - Topical anasethetics - Analgesia **Chronic:** - Acute measures - Topical GTN (1st line for chronic) - sphincterotomy or botox ## Footnote *sphincterotomy releases the painful spasm of torn sphincter and accelerates healing*

Question 624

What is the treatment for an anal fistuale? [1]

Answer 624

The placement of a seton are used in **anal** **fistulae** to keep them open and allow proper drainage before definitive repair.

Question 625

Diverticula disease is most likely to impact which part of the colon? Rectum Descending colon Ascending colon Sigmoid colon Transverse colon

Answer 625

Diverticula disease is most likely to impact which part of the colon? Rectum Descending colon Ascending colon **Sigmoid colon** Transverse colon

Question 626

What is the investigational technqqiue used to assess the rectum to see if anastamosis of surgery have succesfully joined? [1]

Answer 626

**Barium enema**

Question 627

What is the treatment for colonic cancer - Chemotherapy [1] - Radiotherapy - what is the indication? [1] - Target therapies [2]

Answer 627

**Chemotherapy**: - **FOLFOX or FOLFIRI** - Neo / adjuvant or for met. **Radiotherapy**: - Rectal cancer; neo or adjuvant treatment **Target therapies** - **Bevacizumab** (anti-VEGF) - **Cetuximab** (anti-EGFR)

Question 628

Which type of surgery is indicated for rectal tumours? [1]

Answer 628

**Anterior resection**: unless in lower rectal

Question 629

A tumour is found in the rectum that is in close relation to the anus. What is the name of the surgery used to treat this tumour? [1]

Answer 629

**abdominoperineal resection** for anal verge rectal cancer

Question 630

A patient has bowel perforation secondary to a colonic tumour. What is treatment aim? Via which type of surgery? [1]

Answer 630

**End colostomy** via a **Hartmans procedure**

Question 631

Why is there no need for a loop ileostomy in a Hartmans procedure? [1]

Answer 631

No anastomosis is occurring (& wrong place)

Question 632

Which of the following indicates bowel cancer? CEA AFP C19 CA-125

Answer 632

WHich of the following indicates bowel cancer? **CEA** AFP C19 CA-125

Question 633

Which of the following indicates pancreatic cancer? CEA AFP C19 CA-125

Answer 633

Which of the following indicates pancreatic cancer? CEA AFP **C19** CA-125

Question 634

Which of the following indicates ovarian cancer? CEA AFP C19 CA-125

Answer 634

Which of the following indicates ovarian cancer? CEA AFP C19 **CA-125**

Question 635

Which of the following indicates hepatocellular cancer? CEA AFP C19 CA-125

Answer 635

Which of the following indicates hepatocellular cancer? CEA **AFP** C19 CA-125

Question 636

What lifestyle advice would you give someone who has diverticulosis? [1]

Answer 636

Eat lots of fibre and increase fluid intake

Question 637

What is the name for the fistula that can occur as a result of diverticulosis and pneumaturia or faecaluria presentations?

Answer 637

**Colovesical fistula**

Question 638

In Guillan-Barre syndrome, which limbs are impacted first? [1]

Answer 638

Legs and feet become weak before arms

Question 639

What impact does cirrhosis have on ALT/AST levels? [1] Why? [1]

Answer 639

Normal / slightly raised Hepatocytes are damaged, so less ALT/AST can be released

Question 639

What are the four differentials for ALT/ASTs in the 1000s? [4]

Answer 639

- Autoimmune hepatitis - Toxin induced injury - Viral hep (HAV, HBV - NOT HCV) - Ischaemic hepatitis

Question 640

Questions regarding ischaemic hepatitis will often have which clue in the vignette? [1]

Answer 640

Low BP

Question 641

What are indications for an **urgent endoscopy?** [3]

Answer 641

- dysphagia - upper abdominal mass (consistent with stomach cancer) - > 55 & WL

Question 642

What is meant by myelodysplastic syndrome?

Answer 642

Dysfunctional blood cell production in B.M: causes **pancytopenia**

Question 643

Small bowel overgrowth is diagnosed with what investigational technique? [1

Answer 643

**Hydrogen breath test**

Question 644

What are the risk factors for SBOS? [3]

Answer 644

- Neonates with GI abnormalities - DM - Scleroderma

Question 645

How do you treat SBOS? [1]

Answer 645

Treat underlying cause Abx with **rifaximin**

Question 646

A patient with a Cushings background would cause what type of electrolyte changes? [1]

Answer 646

**Hypokalemic metabolic acidosis** Excess cortisol activates aldosterone receptors

Question 647

RLS is often caused by which type of lymphoma? [1]

Answer 647

Burkitt lymphoma

Question 648

What is the before breakfast / waking DMT1 glucose goal? [1]

Answer 648

5-7mmol/l

Question 649

What is the DMT1 glucose goal for times of the day not prior to breakfast? [1]

Answer 649

4-7mmol/l

Question 650

What is the surgical treatment of: - Achalasia [1] - GORD [1]

Answer 650

Achalasia: **Heller cardiomyotomy**: lengthwise cut is made in the muscle layer of the lower oesophagus to relieve pressure GORD: **Nissen fundiplication**: The surgery tightens the junction between the esophagus and the stomach to prevent acid reflux.

Question 651

What would indicate LTOT in COPD patients if all other management is met? [1]

Answer 651

pO2 < 7.3kPa on 2 measurements

Question 652

Which disease are cholestyramine and ursodeoxycholic acid used to treat? [1] Describe the difference in indications for each of the above [2]

Answer 652

**Primary biliary cholangitis** **Cholestyramine**: - symptomatic relief of pruritis **ursodeoxycholic acid**: - first line to improve liver function & slow disease

Question 653

Which drug is used to treat cerebral oedema? [1]

Answer 653

Dexamethasone

Question 654

A patient is on long-term steroids for their existing illness. They become acutely unwell. How should you alter their dose of their steroid? [1]

Answer 654

**Double dose during intercurrent illness**

Question 655

What treatment should you give for severe colitis from UC if IV steroids haven't worked? [1]

Answer 655

**IV ciclosporin**

Question 656

Which of the following are used in a mild-moderate flair of UC? Corticosteroids Mesalamine Oral mercaptopurine Topical Sulfasalazine Topical aziothropine

Answer 656

Which of the following are used in a mild-moderate flair of UC? Corticosteroids Mesalamine Oral mercaptopurine **Topical Sulfasalazine** Topical aziothropine

Question 657

# [](http://) Following a severe relapse or > =2 exacerbations in a year for a UC patient, which medication is advised? [2]

Answer 657

**Oral aziothropine** or **oral mercaptopurine**

Question 658

If an alcoholic is vomiting blood severely, what are the two main differentials (not including varices) [2]

Answer 658

**Mallory-Weis syndrome**: - a tear of the tissue of your lower esophagus **Boerhavve syndrome** - spontaneous **oesophageal rupture** resulting from sudden increased intra-oesophageal pressure - **transmural tear** Alcoholic --> vomiting --> mallory weis tear --> boerhave (oes. perforation, emergency, wide mediastinum)

Question 659

Which is more associated with gallstones: UC Crohns **Explain your answer** [1]

Answer 659

Which is more associated with gallstones: UC **Crohns** due to loss of bile salts due to terminal ileitis; so less bile reabsorbed | Crohns gives you stones

Question 661

Pain when swallowing +/- history of heartburn XS alcohol or smoking No weight loss, systematically well

Answer 661

**Oesophagitis**

Question 662

Dysphagia + there may be a history of HIV or other risk factors such as steroid inhaler use

Answer 662

**Oesophageal candidiasis**

Question 663

Dysphagia of **both** **liquids** AND **solids** from the **start** Heartburn Regurgitation of food - may lead to cough, aspiration pneumonia etc

Answer 663

**Achalasia**

Question 664

Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen

Answer 664

**Pharyngeal pouch**

Question 665

Dysphagia with liquids as well as solids May present with extraocular muscle weakness or ptosis

Answer 665

**Myasthenia gravis**

Question 666

There may be a history of anxiety Symptoms are often intermittent and relieved by swallowing Usually painless - the presence of pain should warrant further investigation for organic causes

Answer 666

Globus hystericus

Question 667

Answer 667

**Oesphagitis**

Question 668

Answer 668

Haemophilus influenzae

Question 669

Answer 669

myasthenia gravis

Question 670

Answer 670

**Acanthosis nigricans**

Question 671

Answer 671

**Achalasia**

Question 672

Answer 672

Plummer-Vinson syndrome

Question 673

Answer 673

**Plummer-Vinson**

Question 674

What are the fluid requirements for adults for: - water [1] - K [1] - Glucose [1]

Answer 674

**Water**: - **25-30ml/kg/day** **K:** - **1mmol/kg/day** **Glucose**: - **50-100g/day**

Question 675

How do you calculate fluid maintenance in children? [1]

Answer 675

**100ml/kg for the first 10kg, 50ml/kg for the next 10kg and 20ml/kg for every subsequent kg.**

Question 676

Which antibodies are raised in type 1 autoimmine hepatitis? [2] Which Ig? [1]

Answer 676

**ANA/SMA/LKM1 antibodies, raised IgG levels**

Question 677

*liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis* This would suggest which pathology? [1]

Answer 677

Autoimmune hepatitis

Question 678

Describe how a liver biopsy might show autoimmune hepatitis [2]

Answer 678

liver biopsy: inflammation extending beyond limiting plate **'piecemeal necrosis', bridging necrosis**

Question 679

Describe the acid/base picture of Cushings disease [1]

Answer 679

**hypokalaemic metabolic alkalosis**: - Cortisol at high levels can simulate the effects of aldosterone. There is increased sodium and subsequently water retention and increased potassium excretion, resulting in hypokalaemia. Bicarbonate resorption is increased in the tubules with potassium depletion causing metabolic alkalosis.

Question 680

What would the HBV serology for a vaccine responder look like? [1]

Answer 680

**Anti-HBsAg +ve only**

Question 681

What would the HBV serology for someone suffering from an acute infection look like? [2]

Answer 681

HBsAg +ve Anti-HBcAg IgM +ve

Question 682

What would the HBV serology for someone suffering from a chronic infection look like? [2]

Answer 682

HBsAg +ve Anti-HBcAg IgG +ve

Question 683

What would be the serology for HBV for someone who previously was infected but is now immune? [2]

Answer 683

Anti-HBcAg IgG +ve Anti-HBsAg +ve ## Footnote NB: vaccine = **Anti-HBsAg +ve only**

Question 684

A patient is diagnosed with DMT1 after an admission for DKA. What is the insulin regime you should start them on post-admission? [1]

Answer 684

Twice-daily basal insulin detemir (long acting), insulin aspart (short acting) bolus with meals

Question 685

What are the treatment options for uinlateral and bilateral primary hyperaldosteronism? [2]

Answer 685

**adrenal adenoma:** - surgery (laparoscopic adrenalectomy) **bilateral adrenocortical hyperplasia** - aldosterone antagonist e.g. spironolactone

Question 686

What is the pH that is safe to use for an NG tube? [1]

Answer 686

**< 5.5**

Question 687

You have placed an NG tube and test the aspirate's pH. It comes back as 6.2. What is the next appropriate step? [1]

Answer 687

If aspirate >5.5, **request a chest x-ray to confirm the position of the NG tube.**

Question 688

What should you do if you place an NG but can't get any aspirate? [4]

Answer 688

* Turn the patient on to their left side * Inject 10-20ml air * Offer a drink (if safe swallow) or mouth care (if nil by mouth) and re-check aspirate in 15-20 minutes * Advance or withdraw the NG tube by 10-20 cm

Question 689

Which of the following is not considered a complication of HHS? Deep vein thrombosis Cerebrovascular event Cerebral oedema Foot ulceration Transverse myelitis

Answer 689

Which of the following is not considered a complication of HHS? Deep vein thrombosis Cerebrovascular event Cerebral oedema Foot ulceration **Transverse myelitis**

Question 690

Which of the following is the most common precipitant of hyperglycaemic hyperosmolar state (HHS)? A Infection B Non-compliance C Inappropriate dose alteration D New diagnosis of diabetes E Myocardial infarction

Answer 690

Which of the following is the most common precipitant of hyperglycaemic hyperosmolar state (HHS)? A Infection B Non-compliance C Inappropriate dose alteration **D New diagnosis of diabetes** E Myocardial infarction

Question 691

Which of the following human leucocyte antigens is strongly associated with type 1 diabetes mellitus? A HLA-DR4 B HLA-B27 C HLA-A3 D HLA-B5 E HLA-DQ2

Answer 691

Which of the following human leucocyte antigens is strongly associated with type 1 diabetes mellitus? **A HLA-DR4** B HLA-B27 C HLA-A3 D HLA-B5 E HLA-DQ2

Question 692

Which is the predominant ketone body in Diabetic Ketoacidosis (DKA)? A Acetone B Acetoacetate C Beta-hydroxybutyrate D Vaccenic acid E Palmitoleic acid

Answer 692

Which is the predominant ketone body in Diabetic Ketoacidosis (DKA)? A Acetone B Acetoacetate **C Beta-hydroxybutyrate** D Vaccenic acid E Palmitoleic acid

Question 693

He is started on a treatment protocol for **hyperglycaemic hyperosmolar** state and blood glucose is monitored hourly. After two hours his plasma glucose was still 33 mmol/L. A decision is made to start on a fixed rate intravenous insulin infusion (FRIII). What is the most appropriate starting rate for the insulin infusion in this patient? A 0.01 unit/kg/hr B 0.05 unit/kg/hr C 0.1 unit/kg/hr D 0.5 unit/kg/hr E 1.0 unit/kg/hr

Answer 693

He is started on a treatment protocol for **hyperglycaemic hyperosmolar** state and blood glucose is monitored hourly. After two hours his plasma glucose was still 33 mmol/L. A decision is made to start on a fixed rate intravenous insulin infusion (FRIII). What is the most appropriate starting rate for the insulin infusion in this patient? A 0.01 unit/kg/hr **B 0.05 unit/kg/hr** C 0.1 unit/kg/hr D 0.5 unit/kg/hr E 1.0 unit/kg/hr

Question 694

Which of the following is not considered a complication of diabetic ketoacidosis? A Cerebral oedema B Hyponatraemia C Hypokalaemia D Hypoglycaemia E Adult-respiratory distress syndrome

Answer 694

Which of the following is not considered a complication of diabetic ketoacidosis? A Cerebral oedema **B Hyponatraemia** C Hypokalaemia D Hypoglycaemia E Adult-respiratory distress syndrome

Question 695

Which of the following is not considered a electrolyte disturbance associated with HHS? A Hypophosphataemia B Hypokalaemia C Hypermagnesaemia D Hyperkalaemia E Hyponatraemia

Answer 695

Which of the following is not considered a electrolyte disturbance associated with HHS? A Hypophosphataemia B Hypokalaemia **C Hypermagnesaemia** D Hyperkalaemia E Hyponatraemia

Question 696

Which of the following best describes the mechanism of action of the antidiabetic agent, gliclazide? A Potentiates insulin release from pancreatic alpha-cells B Inhibition of potassium efflux from pancreatic beta-cells C Inhibition of calcium influx from pancreatic beta-cells D Inhibition of hepatic gluconeogensis E Enhanced peripheral uptake of blood glucose

Answer 696

Which of the following best describes the mechanism of action of the antidiabetic agent, gliclazide? A Potentiates insulin release from pancreatic alpha-cells **B Inhibition of potassium efflux from pancreatic beta-cells** C Inhibition of calcium influx from pancreatic beta-cells D Inhibition of hepatic gluconeogensis E Enhanced peripheral uptake of blood glucose

Question 697

Which of the following is considered a rapid-acting exogenous insulin? A Glargine B Humulin N C Humulin 70/30 D Determir E Aspart

Answer 697

Which of the following is considered a rapid-acting exogenous insulin? A Glargine B Humulin N C Humulin 70/30 D Determir **E Aspart**

Question 698

Which of the following albumin:creatinine ratio (ACR) is indicative of moderately increased albuminuria? A < 3 mg/mmol B 3 - 20mg/mmol C 3 - 30 mg/mmol D 30 - 50 mg/mmol E 50 - 70 mg/mmol

Answer 698

Which of the following albumin:creatinine ratio (ACR) is indicative of moderately increased albuminuria? A < 3 mg/mmol B 3 - 20mg/mmol **C 3 - 30 mg/mmol** D 30 - 50 mg/mmol E 50 - 70 mg/mmol **A1: < 3 mg/mmol** **A2: 3 - 30 mg/mmol** **A3: > 30 mg/mmol**

Question 699

What would be the most appropriate investigation to assess for early signs of diabetic nephropathy in this patient? A Glomerular filtration rate (GFR) B Urinalysis C Serum creatinine D Serum urea E Albumin:creatinine ratio (ACR)

Answer 699

What would be the most appropriate investigation to assess for early signs of diabetic nephropathy in this patient? A Glomerular filtration rate (GFR) B Urinalysis C Serum creatinine D Serum urea **E Albumin:creatinine ratio (ACR)** - **An ACR > 3 mg/mmol and < 30 mg/mmol is suggestive of microalbuminuria**

Question 700

Which of the following auto-antibodies is associated with type 1 diabetes mellitus? A Anti-centromere B Anti-glutamic acid decarboxylase C Anti-21-hydroxylase D Thyroid peroxidase antibody E Anti-mitochondrial antibody

Answer 700

Which of the following auto-antibodies is associated with type 1 diabetes mellitus? A Anti-centromere **B Anti-glutamic acid decarboxylase** C Anti-21-hydroxylase D Thyroid peroxidase antibody E Anti-mitochondrial antibody

Question 701

In DKA, which of the following parameters would warrant referral to high-dependency care (HDU)? A GCS < 14 B Bicarbonate level > 18 mmol/L C Diastolic BP < 90 mmHg D Blood ketones > 6 mmol/L E pH < 7.35

Answer 701

In DKA, which of the following parameters would warrant referral to high-dependency care (HDU)? A GCS < 14 B Bicarbonate level > 18 mmol/L C Diastolic BP < 90 mmHg **D Blood ketones > 6 mmol/L** E pH < 7.35

Question 702

One or more of which parameters would warrant referral to a high-dependency unit (level 2 care)? [7]

Answer 702

- Blood ketone > 6 mmol/L - Bicarbonate level < 5 mmol/L - pH < 7.0 - GCS ≤ 12 - Systolic BP < 90 mmHg - Hypokalaemia on admission < 3.5 mmol/L

Question 703

What is the minimum recommended time to check potassium during treatment of DKA? 30 minutes 1 hourly 2 hourly 4 hourly 12 hourly

Answer 703

What is the minimum recommended time to check potassium during treatment of DKA? 30 minutes 1 hourly 2 hourly **4 hourly** 12 hourly

Question 704

A patient with known UC presents with a biliary picture. What is the most likely result and why? [1]

Answer 704

**Sclerosing cholangitis**: - Condition of inflammation, fibrosis, and strictures of bile ducts - Leads to cholestasis and eventually cirrhosis