Things I keep forgetting

Question 1

Acanthrosis nigricans assx

Answer 1

Gastric Ca

Question 2

Acquired icthyosis assx

Answer 2

Lymphoma

Question 3

Acquired hypertrichosis lanuginosa assx

Answer 3

GI + lung Ca

Question 4

Dermatomyositis assx

Answer 4

ovarian + lung ca

Question 5

erythema gyratum repens assx

Answer 5

lung ca

Question 6

erythroderma assx

Answer 6

lymphoma

Question 7

migratory thrombophlebitis assx

Answer 7

pancreatic ca

Question 8

necrolytic migratory erythema assx

Answer 8

glucagonoma

Question 9

pyoderma gangrenosum assx

Answer 9

myeloproliferative disorders
IBD
Rheumatoid arthritis
PBC
Chronic active hepatitis

Question 10

sweet’s syndrome assx

Answer 10

haem malignancy

Question 11

tylosis assx

Answer 11

oesophageal ca

Question 12

Lymphoma skin manifestations

Answer 12

acquired ichthyosis, erythroderma

Question 13

Lung ca skin manifestations

Answer 13

acquired hypertrichosis lanuginosa
dermatomyositis
erythema gyratum repens

Question 14

Vibagatrin key SE

Answer 14

visual field defects - needs monitoring

Question 15

Minimal change GN biopsy findings

Answer 15

normal glomeruli on light microscopy
electron microscopy shows fusion of podocytes and effacement of foot processes

Question 16

Prognosis in minimal change GN

Answer 16

1/3 have just one episode
1/3 have infrequent relapses
1/3 have frequent relapses which stop before adulthood

Question 17

Which pO2s do RBCs sickle at for HbAS?

Answer 17

2.5-4 kPa

Question 18

Which pO2s do RBCs sickle at for HbSS?

Answer 18

5-6 kPa

Question 19

Positively skewed and negatively skewed distributions: mean, median, mode

Answer 19

Normal (Gaussian) distributions: mean = median = mode

Positively skewed distribution: mean > median > mode

Negatively skewed distribution mean < median < mode

think positive going forward with ‘>’, whilst negative going backwards ‘<’

Question 20

Causes of warm AIHA

Answer 20

idiopathic
autoimmune (SLE)
neoplasia (lymphoma, CLL)
drugs (methyldopa)

Question 21

causes of cold AIHA

Answer 21

neoplasia (lymphoma)
infections (mycoplasma, EBV)

Question 22

Likelihood ratio for a +ve test

Answer 22

sensitivity/(1-specificity)

Question 23

Likelihood ratio for a -ve test

Answer 23

(1-sensitivity)/specificity

Question 24

Heberden’s nodes

Answer 24

Osteoarthritis - painless DIPJ swelling

Question 25

Osteoarthritis common joints and symptoms

Answer 25

CMCs, DIPJs, usually bilateral Heberden's, Bouchard's nodes Squaring of thumbs - CMC deformity --> fixed thumb adduction Provoked by movement, relieved by rest Stiffness worsened with ina ctivity

Question 26

Bouchard's nodes

Answer 26

Osteoarthritis - PIPJ swelling

Question 27

Coarctation of aorta murmur

Answer 27

Late systolic

Question 28

From which primaries are lung mets more commonly calcified?

Answer 28

Chondrosaracoma Osteosarcoma

Question 29

What primaries cause cannonball lung mets?

Answer 29

Renal cell ca Choriosarcoma Prostate Ca

Question 30

What primaries cause haemorrhagic pulmonary mets?

Answer 30

Choriosarcoma Angiosarcoma

Question 31

What primaries cause miliary pattern of lung mets?

Answer 31

Renal cell ca Malignant melanoma

Question 32

What primary causes cavitating lung mets?

Answer 32

Squamous cell ca

Question 33

What is the regime of choice when starting insulin in T1DM?

Answer 33

Twice daily insulin detemir

Question 34

When do you start metformin in T1DM?

Answer 34

If BMI>25 - consider it

Question 35

Causes of membranous GN

Answer 35

Idiopathic (anti phospholipase A2 Abs) Infections: HBV, malaria, syphilis Malignancy (5-20%): prostate, lung, lymphoma, leukaemia Drugs: gold, penicillamine, NSAIDs Autoimmune: SLE (class V), thyroiditis, rheumatoid

Question 36

Prognosis in membranous GN

Answer 36

one-third: spontaneous remission one-third: remain proteinuric one-third: develop ESRF

Question 37

Membranous GN Rx

Answer 37

ACE inhibitors/ARBs Severe/progressive - immunosuppression: Steroids + cyclophosphamide Rituximab if moderate risk of progression Anticoagulate for high-risk

Question 38

Good prognosis factors in membranous GN

Answer 38

Female Young age at presentation Asymptomatic proteinuria of modest degree at presentation

Question 39

Discoid lupus Rx

Answer 39

1. topical steroids 2. oral antimalarials eg hydroxychloroquine

Question 40

Drug-induced lupus Abs

Answer 40

ANA 100% Anti-histone 80-90% anti-Ro anti-Smith -ve for dsDNA

Question 41

Occupational asthma chemicals assx:

Answer 41

Isocyanates (most common - spray painting, foam moulding using adhesives) Platinum salts Soldering flux resin Glutaraldehyde Flour Epoxy resins Proteolytic enzymes

Question 42

HHS criteria:

Answer 42

hypovolaemia hyperglycaemia >30 hyperosmolality >320 no ketonaemia/acidosis

Question 43

IL-1 source

Answer 43

macrophages

Question 44

IL-1 function

Answer 44

acute inflammation Induces fever

Question 45

Il-2 source

Answer 45

Th1 cells

Question 46

IL-2 functions

Answer 46

stimulates growth + differentiation of T cell response

Question 47

IL-3 source

Answer 47

activated T helper cells

Question 48

IL-3 functions

Answer 48

Stimulates differentiation + proliferation of myeloid progenitor cells

Question 49

IL-4 source

Answer 49

Th2 cells

Question 50

IL-4 functions

Answer 50

Stimulates proliferation + differentiation of B cells

Question 51

IL-5 source

Answer 51

Th2 cells

Question 52

IL-5 function

Answer 52

eosinophil production stimulation

Question 53

IL-6 source

Answer 53

macrophages Th2 cells

Question 54

Il-6 functions

Answer 54

Stimulates B cell differentiation Fever

Question 55

IL-8 source

Answer 55

Macrophages

Question 56

IL-8 function

Answer 56

neutrophil chemotaxis

Question 57

IL-10 source

Answer 57

Th2 cells

Question 58

IL-10 function

Answer 58

Inhibits Th1 cytokine production (Known as human cytokine synthesis inhibitory factor - anti-inflammatory)

Question 59

IL-12 source

Answer 59

dendritic cells macrophages B cells

Question 60

IL-12 function

Answer 60

Activates NK cells, stimulates differentiation of naive T cells into Th1 cells

Question 61

TNF alpha source

Answer 61

macrophages

Question 62

TNF alpha functions

Answer 62

Fever Neutrophil chemotaxis

Question 63

IFN gamma source

Answer 63

Th1 cells

Question 64

IFN gamma function

Answer 64

activates macrophages

Question 65

Which cytokines do macrophages produce?

Answer 65

(Alpha 1268) IL-1, 6, 8, 12 TNF alpha

Question 66

Which cytokines do Th1 cells produce?

Answer 66

Th 1- 2,3 gamma IL-2, 3 IFN gamma

Question 67

Which cytokines do Th2 cells produce?

Answer 67

IL-4, 5, 6, 10, 13

Question 68

CURB 65

Answer 68

Confusion (AMTS 8 or less) Urea>7 RR>30 BP<90/60 Age >65

Question 69

Enhanced liver fibrosis test composition

Answer 69

Hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1

Question 70

Conditions causing increased KCO with normal or reduced TLCO

Answer 70

Pneumonectomy/lobectomy Scoliosis/kyphosis Neuromuscular weakness Ankylosis of costovertebral joints (eg Ank Spond)

Question 71

Causes of SAAG>11g/L

Answer 71

Portal HTN Liver disorders: cirrhosis, ALD, acute liver failure, liver mets Cardiac: right heart failure, constrictive pericarditis Budd-chiari PVT Veno-occlusive disease Myxoedema

Question 72

Causes of SAAG<11g/L

Answer 72

hypoalbuminaemia: nephrotic syndrome, severe malnutrition Malignancy: peritoneal carcinomatosis Infections: tuberculous peritonitis Others: pancreatitis, bowel obstruction, biliary ascites, postoperative lymphatic leak, serositis

Question 73

What factors increase iron absorption

Answer 73

Vitamin C Gastric acid

Question 74

What reduces iron absorption

Answer 74

PPIs Tetracyclines Gastric achlorhydria Tannin (in tea)

Question 75

Pemphigus vulgaris antibodies

Answer 75

vs desmoglein 3 (a cadherin-type epithelial cell adhesion molecule)

Question 76

Pemphigus vulgaris Sx

Answer 76

Flaccid blisters - easily ruptured vesicles + bullae Mucosal ulceration common (oral 50-70%) Nikolsky's sign +ve (spread of bullae following horizontal, tangential pressure to skin)

Question 77

Bullous pemphigoid Abs

Answer 77

Vs hemidesmosomal proteins BP180, BP230 in basement membrane

Question 78

Bullous pemphigoid sx

Answer 78

Tense blisters - heal without scarring, usually around flexures No mucosal involvement

Question 79

Bullous pemphigoid biopsy

Answer 79

Immunfluorescence: IgG and C3 at dermoepidermal junction

Question 80

Pemphigus vulgaris biopsy

Answer 80

acantholysis

Question 81

Function of Th1 cells

Answer 81

Involved in cell-mediated response and delayed type 4 hypersensitivity

Question 82

Function of Th2 dcells

Answer 82

mediating humoral (Ab) immunity

Question 83

Azoles MOA

Answer 83

inhibits 14 alpha demethylase --> reduces ergosterol production from lanosterol --> reduces plasma membrane structural integrity/stability

Question 84

Azoles SE

Answer 84

CYP450 Inhibitor Hepatotoxic

Question 85

Terbinafine MOA

Answer 85

Inhibits squalene epoxidase --> ultimately reduces ergosterol production --> reduces plasma membrane structural integrity/stability

Question 86

Terbinafine SE

Answer 86

Pancytopenia Agranulocytosis Hepatotoxic

Question 87

Echinocandins (Gaspofungin/any -fungins) MOA:

Answer 87

Beta-glucan synthase inhibition --> prevents beta glucan transport to cell wall to be used for its formation

Question 88

Echinocandin SE

Answer 88

flushing

Question 89

Amphotericin B MOA

Answer 89

binds to ergosterol forming transmembrane channel --> tears in walls (amphoTEARicin) --> leads to monovalent ion (K, Na, H, Cl) leakage + cell death

Question 90

Amphotericin B SE

Answer 90

nephrotoxic, flu-like sx, hypoK, HypoMg, hepatotoxic, phlebitis

Question 91

Nystatin MOA:

Answer 91

binds to ergosterol forming transmembranechannel --> makes little holes --> monovalent ion leakage + cell death

Question 92

Griseofulvin MOA

Answer 92

interacts with microtubules, disrupts mitotic spindle

Question 93

Griseofulvin SE

Answer 93

CYP450 inducer teratogenic

Question 94

Flucytosine MOA

Answer 94

converted by cytosine deaminase to 5-fluorouracil, inhibits thymidylate synthase --> attacks DNA --> disrupts fungal protein synthesis

Question 95

FLucytosine SE

Answer 95

vomiting

Question 96

Aciclovir MOA

Answer 96

guanosine analogue, inhibits viral DNA polymerase

Question 97

Aciclovir SE

Answer 97

crystalline nephropathy - crystalluria

Question 98

Ganciclovir MOA

Answer 98

guanosine analogue, inhibitis DNA polymerase

Question 99

Ganciclovir SE:

Answer 99

myelosuppression/agranulocytosis

Question 100

Foscarnet MOA

Answer 100

pyrophosphate analogue, inhibits DNA polymerase

Question 101

Foscarnet SE

Answer 101

nephrotoxicity, hypoCa, hypoMg, seizures

Question 102

Ribavirin MOA

Answer 102

guanosine analogue, inhibits IMP dehydrogenase, interferes with mRNA capping

Question 103

Ribavirin SE

Answer 103

haemolytic anaemia

Question 104

Amantadine MOA

Answer 104

inhibits M2 protein, uncoating of virus, releases dopamine from nerve endings

Question 105

Amantadine SE

Answer 105

confusion, ataxia, slurred speech

Question 106

Oseltamivir MOA

Answer 106

neuraminidase inhibitor

Question 107

Cidofovir MOA

Answer 107

acyclic nucleoside phosphonate, independent of phosphorylation by viral enzymes

Question 108

Cidofovir SE

Answer 108

nephrotoxicity

Question 109

What is the aim of post-marketing observational studies for new drugs, following clinical trials?

Answer 109

To study profile of adverse effects (esp in pts not studied during clinical trials, such as those with liver, renal disease, pregnant, children)

Question 110

Phases of clinical trials

Answer 110

Phase 0: exploratory, assess drug behaviour in human body, assesses pharmacokinetics, pharmacodynamics Phase I: side-effects, healthy volunteers Phase IIa: optimal dosing. Phase IIb: efficacy Phase III: effectiveness, 100-1000s of people, RCTs Phase IV: postmarketing surveillance, long-term SE, effectiveness

Question 111

A 79-year-old woman was admitted for elective hip-replacement surgery. On examination, she was pale. There was 2-cm splenomegaly and there were small discrete axillary lymph nodes. Investigations: haemoglobin 107 g/L (115–165) white cell count 34.5 × 109/L (4.0–11.0) platelet count 183 × 109/L (150–400) What is the most likely diagnosis?

Answer 111

CLL

Question 112

Livedo reticularis causes

Answer 112

HIP CASE Homocystinuria Idiopathic (most common) PAN Cryoglobulinaemia Antiphospholipid syndrome SLE EDS

Question 113

A 37-year-old woman presented with a history of intermittent lightheadedness. Examination was normal. Investigations: ECG normal 24-hour ambulatory ECG tracing atrial and ventricular premature beats; nocturnal bradycardia and Mobitz type I atrioventricular block, and supraventricular tachycardia Which abnormality on the 24-hour ambulatory ECG is clinically most important?

Answer 113

SVT

Question 114

Wilson's disease - where does the copper often deposit in the brain?

Answer 114

basal ganglia, esp putamen, globus pallidus

Question 115

Wilson's syndrome serum and urinary findings

Answer 115

Reduced serum caeruloplasmin Reduced TOTAL serum copper But increased FREE serum copper Increased 24hr urinary copper excretion

Question 116

Wilson's genetics

Answer 116

Aut Rec Chr 13 ATP7B gene defect

Question 117

Argyll Robertson pupils

Answer 117

ARP Accommodation Reflex Present but Pupillary Reflex Absent Often bilateral, small, irregular pupils Causes: Neurosyphilis, DM

Question 118

Holmes-Adie Pupils

Answer 118

Unilateral, dilated pupil. Once constricted, remains so for abnormally long time, slow reaction to accommodation Holmes Adie syndrom= HA pupil + absent ankle/knee reflexes

Question 119

Prevention of calcum stones

Answer 119

Lifestyle: high fluid intake, add lemon juice to drinking water, avoid carbonated drinks, limit salt intake Drugs: Potassium citrate - reduces urinary supersaturation of ca salts by forming soluble complexes with ca ions and inhibits crystal growth and aggregation. Useful for recurrent stones Thiazides if very high Ca in urine

Question 120

Genotypes in A1AT

Answer 120

PiMM - normal PiMZ - heterozygous carrier PiSS - 50% have normal A1AT levels PiZZ - 10% have normal A1AT levels. Severe phenotype

Question 121

Hypercholesterolaemia causes

Answer 121

Nephrotic syndrome Cholestasis Hypothyroidism

Question 122

Hypertriglyceridaemia causes

Answer 122

DM Obesity CKD Thiazides Non-selective beta blockers Unopposed oestrogen Liver disease ETOH

Question 123

Thyroid cancers from commonest to least common

Answer 123

Papillary Follicular Medullary Anaplastic Lymphoma

Question 124

A 77-year-old man presented with increasing pains around his lower back and lower limb girdle. He had recently presented with symptoms of hesitancy and post-micturition dribbling. Investigations: ESR 28 mm/1st h (<20) serum adjusted calcium 2.34 mmol/L (2.20–2.60) serum phosphate 0.80 mmol/L (0.80–1.45) serum alkaline phosphatase 2985 U/L (45–105) serum prostate-specific antigen 6 μg/L (<4.0) What is the most likely cause of this man's pain?

Answer 124

Paget's

Question 125

A 50-year-old man presented with a 2-day history of multiple painful joints. Two weeks previously, he had been started on treatment with allopurinol for tophaceous gout. His only other medication was paracetamol. He had a history of excess alcohol intake. On examination, his temperature was 37.5°C and there was acute inflammation of the finger joints, wrists, knees and ankles. Investigations: serum gamma glutamyl transferase 90 U/L (<50) serum CRP 180 mg/L (<10) serum urate 0.65 mmol/L (0.23–0.46) What is the most likely cause of his symptoms?

Answer 125

Allopurinol therapy triggering acute flare of gout Due to falling serum urate levels --> uric acid crystals detaching from articular cartilage

Question 126

Burkitt's lymphoma genetics

Answer 126

Overexpression of c-Myc t(8:14) t(8:14) brings c-Myc gene under control of immunoglobulin heavy chain promoter and renders it constitutively active

Question 127

Mantle cell lymphoma genetics

Answer 127

t(11:14) Deregulation of cyclin D1 (BCL-1) gene

Question 128

Follicular lymphoma genetics

Answer 128

t(14:18) Increased BCL-2 transcription

Question 129

Optimal time for vaccination when splenectomy is planned?

Answer 129

1 month pre-surgery

Question 130

Infection prophylaxis in splenectomy

Answer 130

HiB + Men A&C + annual flu + pneumococcal every 5 yrs + lifelong penicillin V

Question 131

Types of Hodgkin's disease (commonest to rarest)

Answer 131

Nodular sclerosing Mixed cellularity Lymphocyte predominant Lymphocyte depleted

Question 132

Poor prognosis factors for Hodgkin's

Answer 132

Age>45 Male Stage IV Hb<105 Lymphocyte<600 WCC>15000 Albumin <40

Question 133

A 17-year-old girl presented with a single, painless, enlarged cervical lymph node. She was asymptomatic. Investigations: chest X-ray enlarged mediastinal lymph nodes What is the most likely diagnosis?

Answer 133

Hodgkin's

Question 134

In severe haemoptysis requiring treatment, where does bleeding originate from?

Answer 134

Bronchial arteries (90%) Pulmonary arteries (5%)

Question 135

Causes of acute interstitial nephritis

Answer 135

Drugs (25%): penicillin, rifampicin, NSAIDs, allopurinol, furosemide Systemic: SLE, sarcoidosis, Sjogren's Infection: Hantavirus, staph

Question 136

Features of acute interstitial nephritis

Answer 136

fever rash arthralgia eosinophilia mild renal impairment HTN Sterile pyuria white cell casts

Question 137

Papillary necrosis causes

Answer 137

POSTCARDS Pyelonephritis Obstructive uropathy Sickle cell TB cirrhosis analgesia/alcohol renal vein thrombosis DM systemic vasculitis

Question 138

Papillary necrosis sx

Answer 138

fever, loin pain, haematuria 'cup and spill' - papillary necrosis with renal scarring on biopsy

Question 139

Lichen planus

Answer 139

violaceous, flat-topped papules, which are often seen on the flexor surfaces of the wrists, lower back and ankles as well as elsewhere on the skin can Koebnerise (lesions arise at area of skin that has been traumatised), resulting in linear pattern from scratching Lacy white pattern on buccal mucosa (Wickham's striae) Can cause non-scarring alopecia if on scalps

Question 140

GI complication of systemic sclerosis

Answer 140

Malabsorption due to SIBO in sclerosed small intestine 40% of patients

Question 141

Causes of foot drop

Answer 141

Common peroneal nerve lesion L5 radiculopathy Sciatic nerve lesion Superficial/deep peroneal nerve lesion CN lesions

Question 142

Common peroneal nerve lesion sx

Answer 142

Foot drop Weakness: foot dorsiflexion, eversion, extensor hallucis longus Sensory loss: over dorsum of foot + lower lateral part of leg Wasting: anterior tibial and peroneal muscles

Question 143

A 47-year-old woman was being treated with lithium for bipolar affective disorder. On examination, her BP was 168/104 mmHg. What is the most appropriate antihypertensive drug for her?

Answer 143

Amlodipine Not ACE inhibitor because of renal risk in light of lithium

Question 144

What antibody mediates hyperacute rejection?

Answer 144

IgG

Question 145

Headache, increasing drowsiness, focal neuro sx + seizures in a woman shortly post partum Dx?

Answer 145

Venous sinus thrombosis

Question 146

Miller Fisher syndrome features

Answer 146

Internal and external ophthalmoplegia Areflexia Ataxia Descending paralysis GBS variant

Question 147

Miller Fisher Abs

Answer 147

GQ1b

Question 148

A 58-year-old man with congestive heart failure remained oedematous despite treatment with furosemide 120 mg daily. Investigations: serum sodium 134 mmol/L (137–144) serum potassium 3.4 mmol/L (3.5–4.9) serum urea 10.6 mmol/L (2.5–7.0) serum creatinine 156 µmol/L (60–110) What other finding is most likely? Options: high plasma aldosterone concentration high serum cortisol concentration low plasma angiotensin II concentration low plasma atrial natriuretic peptide concentration low plasma renin concentration

Answer 148

high plasma aldosterone concentration Pathophysiological activation of RAAS due to reduced renal perfusion pressure in CCF

Question 149

Acromegaly investigations

Answer 149

IGF-1 levels first - not diagostic To diagnose, need OGTT (GH suppressed in normal, but no suppression in acromegaly)

Question 150

Post-exposure prophylaxis of HIV

Answer 150

3 drug ART for 1 month

Question 151

A 21-year-old woman, who was undergoing chemotherapy for non-Hodgkin lymphoma, presented 2 days after being in contact with her nephew, for 2 hours, on the day that he developed a chickenpox rash. Investigations: varicella serology negative What is the most appropriate management?

Answer 151

Give varicella zoster immunoglobulin as she is immunocompromised

Question 152

Diarrhoea within 1 week of travel

Answer 152

E Coli commonest (ETEC)

Question 153

A 36-year-old HIV-positive man presented with a 1-week history of generalised pruritus. He had had unprotected anal sex 2 months previously while on holiday in Spain. He had previously been vaccinated against hepatitis B virus, with an adequate antibody response. On examination, his temperature was 37.8°C and he was jaundiced. Examination was otherwise normal. Investigations: serum total bilirubin 99 µmol/L (1–22) serum aspartate aminotransferase 754 U/L (1–31) serum alkaline phosphatase 173 U/L (45–105) CD4 count 550 × 106/L (430–1690) anti-hepatitis A IgM antibody negative What is the most likely diagnosis? Options: acute hepatitis C acute hepatitis D CMV infection syphilis toxoplasmosis

Answer 153

Acute Hep C

Question 154

Parietal lobe lesion features

Answer 154

Receptive dysphasia, dyslexia, inattention, sensory inattention, apraxia, astereognosis (tactile agnosia), inferior homonymous quadrantanopia Gerstmann syndrome (if dominant parietal angular gyrus lesion) --> alexia, acalculia, finger agnosia, agraphia, left-right limb disorientation

Question 155

A 58-year-old man was seen with progressive breathlessness in the outpatient clinic. He had undergone coronary artery bypass grafting 3 years previously and this had been complicated by a resternotomy for tamponade. He recovered well but had started to feel breathless and fatigued over the past 12 months. He had a history of type 2 diabetes mellitus and hypertension. He was a current smoker. A diagnosis of constrictive pericarditis was made. What is the most common physical finding seen in this group of patients? Options: ascites finger clubbing hepatomegaly pericardial knock pleural effusion

Answer 155

Hepatomegaly - the earliest and most consistent feature of pericardial constriction of the options here. Ascites (a later phenomenon than hepatomegaly) and pericardial knock (recognised in around 50% of cases) are also features of pericardial constriction, making this a true "best-of" question. Finger clubbing is not a feature of constriction, however, and pleural effusion is uncommon.

Question 156

Features of constrictive pericarditis

Answer 156

SOB Right heart failure features: elevated JVP, ascites, oedema, hepatomegaly Prominent X and Y descent Pericardial knock (loud S3) Kussmaul's sign

Question 157

Common cause of myocardial infarction in relation to pregnancy

Answer 157

Coronary artery dissection

Question 158

How to diagnose PBC

Answer 158

AMA M2 subtype diagnostic 98% Other Ix: Raised IgM USS/MRCP - to exclude other causes of extrahepatic obstruction

Question 159

C7 dermatomes

Answer 159

Middle Finger and palm of hand

Question 160

C6 dermatomes

Answer 160

Thumb and index finger

Question 161

T4 dermatomes

Answer 161

nipples T4 at the teatpore

Question 162

T10 dermatomes

Answer 162

Umbilicus

Question 163

L4 dermatome

Answer 163

Knee caps Down on aLL 4s

Question 164

L5 dermatome

Answer 164

big toe, dorsum of foot

Question 165

S1 dermatome

Answer 165

Lateral foot, small toe S1 is the smallest one

Question 166

Triceps reflex nerve roots

Answer 166

C7, 8

Question 167

Biceps reflex nerve roots

Answer 167

C5, 6

Question 168

Ankle jerk reflex nerve roots

Answer 168

S1, 2

Question 169

Knee jerk reflex nerve roots

Answer 169

L3, 4

Question 170

Which skin layer does lipodermatosclerosis affect?

Answer 170

Hypodermis If extensive, papillary dermis

Question 171

Waterlow score parameters

Answer 171

Body weight/BMI Nutritional status Continence Skin type Mobility Age Sex

Question 172

Erythrodermic psoriasis Rx

Answer 172

topical white soft paraffin smeared all over skin

Question 173

A 24-year-old woman presented with shortness of breath of sudden onset. She had been at a nightclub and had been drinking wine but denied taking any illicit substances. She had no relevant medical history. She was a non-smoker. On examination, her temperature was 37.0°C, her pulse was 100 beats/min and her BP was 110/70 mmHg. Her respiratory rate was 32 breaths/min and her oxygen saturation was 98% (94–98) breathing air. Investigations: arterial blood gases, breathing air: PO2 12.9 kPa (11.3–12.6) PCO2 3.8 kPa (4.7–6.0) pH 7.44 (7.35–7.45) H+ 36 nmol/L (35–45) bicarbonate 19 mmol/L (21–29) base excess –2.0 mmol/L (±2.0) chest X-ray normal What is the most likely diagnosis?

Answer 173

Hyperventilation

Question 174

Superior mesenteric artery supply

Answer 174

Small intestine from distal duodenum to 2/3 of transverse colon

Question 175

H pylori strongest association with GI issues

Answer 175

Duodenal ulcers Lesser degree - gastric ulcers and carcinoma

Question 176

Pulsus alternans

Answer 176

severe LVF due to cardiomyopathy, CAD, systemic HTN, AS

Question 177

Pulsus bisferiens

Answer 177

Mod-severe AR Combined AS + AR

Question 178

RF for completed suicide

Answer 178

male Older age Efforts to avoid discovery Planning Leaving written note Final acts Violent method Social isolation

Question 179

Isosorbide mononitrate MOA

Answer 179

nitric oxide donor --> stimulation of guanylate cyclase --> cGMP production --> vasodilation

Question 180

Posterior STEMI ECG

Answer 180

dominant R wave in V1-3 with ST depression

Question 181

Posterior cardiac supply

Answer 181

Posterior descending artery From RCA in 85% of people (right dominant) From LCx in 15% (left dominant)

Question 182

A 42-year-old woman presented complaining of "worms" in the skin of her arms and legs for the past 9 months. She could feel the worms moving, and had tried to get them out of her skin using a needle. She reported that the worms were gradually spreading and she was afraid they would lead to her death. On examination, she was anxious. There were multiple needle marks on the skin of her arms and legs. Examination was otherwise normal. What is the most likely diagnosis? Options: delusional disorder depressive psychosis factitious disorder generalised anxiety disorder somatic symptom disorder

Answer 182

Delusional disorder - delusional parasitosis

Question 183

A 67-year-old woman presented with palpitations and a goitre. Propranolol was started to improve her symptoms. On examination, she had a coarse tremor and sweaty palms, but no thyroid eye signs. Investigations: serum thyroid-stimulating hormone <0.03 mU/L (0.4–5.0) serum free T4 25.0 pmol/L (10.0–22.0) technetium-99m scan of thyroid increased uptake in right upper lobe, with uptake suppressed in rest of thyroid gland What is the most appropriate treatment for her thyroid condition? Answers: carbimazole prednisolone propylthiouracil radioiodine total thyroidectomy

Answer 183

Radioiodine - to treat toxic adenoma - an autonomous nodule causing hyperthyroidism

Question 184

How to calculate osmolality

Answer 184

(2xNa) + (2xK) + glucose + urea

Question 185

Ivabradine MOA

Answer 185

inhibits funny channels

Question 186

Ivabradine criteria

Answer 186

LVEF<35% + sinus rhythm + rate >75bpm (contraix for lower resting rates as blocks cahnnel responsible for cardiac pacing)

Question 187

Hydralazine MOA

Answer 187

elevates cGMP, smooth muscle relaxation in arterioles

Question 188

CHF Rx

Answer 188

1. ACE inhibitors + beta blockers 2. Spiro/eplerenone + SGLT-2 inhibitors 3. Ivabradine, sacubitril-valsartan, digoxin, hydralazine + Nitrates or CRT Offer annual flu vaccine + one-off pneumococcal vaccine (every 5 yrs if splenic dysfunction or CKD)

Question 189

Blood donation contraix

Answer 189

Cancers Heart conditions If you received blood products after 1980 HIV +ve Organ transplant recipient HBV, HCV +ve Injected non-prescription drugs

Question 190

Hemibalism lesion

Answer 190

Basal ganglia's subthalamic nucleus

Question 191

Internuclear ophthalmoplegia lesion

Answer 191

medial longitudinal fasciculus Located in paramedian area of midbrain and pons

Question 192

Where does haloperidol have central anti-emetic action?

Answer 192

D2 antagonism centrally at the area postrema - a medullary structure controlling vomiting

Question 193

A 72-year-old man presented with loss of the lower half of the visual field of his right eye, with no associated pain. He had type 2 diabetes mellitus and was being treated for hypertension. Examination showed normal visual acuity in both eyes, with an inferior altitudinal field defect in his right eye. Fundoscopy of his left eye was normal, and the upper part of the right optic disc showed mild disc swelling. No fundal haemorrhages were seen. His BP was 160/90 mmHg. What is the most likely diagnosis? Options: optic neuritis panuveitis posterior communicating artery aneurysm retinal artery occlusion retinal vein thrombosis

Answer 193

Retinal artery occlusion Visual field deffect makes this more likely Branch retinal vein thrombosis assx with fundal haemorrhages (not seen here) Optic neuritis, panuveitis leads to visual acuity impairment + pain Posterior communicating artery aneurysm typically presents with 3rd nerve palsy with dilation

Question 194

Which muscle is involved with torticollis

Answer 194

contracture of the ipsilateral sternocleidomastoid muscle which leads to the chin being pushed to the opposite side.

Question 195

An 85-year-old woman presented with breathlessness that had developed over the previous 2 years. She complained of a cough that frequently woke her from sleep. She had been treated with radiotherapy for a cervical lymphoma 20 years previously. On examination, she was thin, but had no abnormal physical signs. Her oxygen saturation was 95% (94–98) breathing air. Investigations: high-resolution CT scan of chest basal fibrosis associated with dilated bronchi, but no honeycombing or ground-glass change What is the most likely diagnosis? Answers: bronchiectasis chronic aspiration idiopathic pulmonary fibrosis radiation pneumonitis sarcoidosis

Answer 195

Chronic aspiration The symptoms described are consistent with chronic aspiration occurring in the elderly. The CT findings are radiological bronchiectasis, a sequela of recurrent episodes of aspiration pneumonia. This does not, however, equate to a clinical diagnosis of bronchiectasis. The absence of honeycombing and ground-glass opacities counts against the diagnosis of radiation pneumonitis and idiopathic pulmonary fibrosis.

Question 196

Erythema nodosum causes

Answer 196

Infections: Strep, TB, Brucellosis, Yersinia Systemic: sarcoidosis, IBD, Behcet's Malignancy/lymphoma Drugs: penicillins, sulphonamides, COCPs, pregnancy

Question 197

A 23-year-old man was admitted with a 3-day history of lower cramping abdominal pain and fever. He had mild diarrhoea, but no blood in his stool. He had not travelled recently. On examination, he was tender in his right iliac fossa. There were raised, tender, red nodules on his shins. Investigations: CT scan of abdomen cluster of lymph nodes at appendix suggestive of mesenteric adenitis What is the most likely cause of his symptoms? Answers: Campylobacter jejuni infection Salmonella enteritidis infection tuberculosis ulcerative colitis Yersinia enterocolitica infection

Answer 197

Yersinia enterocolitica infection The history of a non-specific diarrhoeal disease with right iliac fossa pain would most commonly be due to campylobacter. However, the finding of a "cluster of lymph nodes at appendix suggestive of mesenteric adenitis" points more to yersinia infection, which can mimic Crohn's disease and appendicitis (pseudoappendicitis).

Question 198

PNH features

Answer 198

Triad: Intravasc haemolytic anaemia, pancytopenia, venous thrombosis (Budd-Chiari) Haemoglobinuria in morning Aplastic anaemia in some

Question 199

A 78-year-old man presented with a 3-month history of haematuria, increasing tiredness and breathlessness on exertion. On examination, he looked pale. Investigations: haemoglobin 78 g/L (130–180) MCV 108 fL (80–96) white cell count 2.6 × 109/L (4.0–11.0) neutrophil count 0.9 × 109/L (1.5–7.0) platelet count 78 × 109/L (150–400) blood film nucleated red blood cells, myelocytes and metamyelocytes What is the most likely cause of his abnormal blood film? Answers: aplastic anaemia bone marrow metastases hypothyroidism myelodysplasia vitamin B12 deficiency

Answer 199

Bone marrow metastases Pancytopenia with leukoerythroblastic film suggestive of bone marrow infiltration Aplastic anaemia and hypothyroidism generally are associated with a normal blood film, MDS with abnormal blood cell appearances (e.g. poikilocytosis) and vitamin B12 deficiency with the characteristic hypersegmented neutrophils. A further clue in the stem is the haematuria, which indicates an underlying pathology.

Question 200

A 26-year-old woman with a previous history of deep venous thrombosis was treated with low-molecular-weight heparin for a further episode proven by a Doppler ultrasound scan. She also reported that she had had two first-trimester spontaneous miscarriages. She was currently using contraception. Investigations: prothrombin time 13.0 s (11.5–15.5) activated partial thromboplastin time 50 s (30–40) anticardiolipin IgG antibodies 62 U/mL (<10) pregnancy test negative What is the most appropriate treatment? Answers: apixaban aspirin dabigatran low-molecular-weight heparin warfarin

Answer 200

LMWH APLS here - should go for warfarin but it can't be used so LMWH should be used at this time

Question 201

Anti phospholipid syndrome antibodies

Answer 201

anti-beta 2 glycoprotein I Lupus anticoagulant Anticardiolipin

Question 202

APLS Rx

Answer 202

primary thromboprophylaxis with low dose aspirin Secondary thromboprophylaxis with lifelong warfarin (INR 2-3) Recurrent thromboembolic: warfarin (INR 3-4) + low dose aspirin

Question 203

Digoxin half-life

Answer 203

36 hrs

Question 204

Term used to describe an abnormal number of chromosomes but not abnormal numbers of complete chromosome sets

Answer 204

aneuploid

Question 205

Cavernous sinus CN lesions

Answer 205

III, IV, V1, VI

Question 206

Hydatid disease Rx

Answer 206

Albendazole

Question 207

Cysticercosis Rx

Answer 207

niclosamide

Question 208

How to distinguish between irritant vs allergic contact dermatitis

Answer 208

No vesicles, only erythema: irritant Vesicles, weeping eczema: allergic

Question 209

Causes of hypokalaemia with alkalosis

Answer 209

Vomiting Thiazides, loop diuretics Cushing's Conn's Liddle’s

Question 210

ALL Good prognosis

Answer 210

FAB L1 type Common ALL Pre-B phenotype Low initial WBC deletion (9p) Hyperdiploidy

Question 211

ALL poor prognosis

Answer 211

FAB L3 type T or B cell markers present t(9;22) (Philadelphia translocation) age <2 yrs or >10yrs Male sex CNS involvement high initial WBC (>100) non-Caucasian

Question 212

Huntington's genetics

Answer 212

Aut Dom CAG trinucleotide repeat

Question 213

Pseudohypoparathyroidism Dx

Answer 213

Measuring urinary cAMP and PO4 after PTH infusion Increased cAMP and PO4 in hypoPTH, but no change in type 1 pseudohypoPTH In type II psuedohypoPTH cAMP rises, PO4 does not rise

Question 214

Features of psuedohypoPTH

Answer 214

low IQ, short stature, shortened 4th, 5th metacarpals low Ca, high PO4, high PTH

Question 215

Tetanus 1st line abx

Answer 215

IV metronidazole

Question 216

Botulism vs Tetanus

Answer 216

Botulism causes flaccid paralysis vs spastic paralysis in tetanus Botulism toxin blocks ACh release, Tetanus toxin prevents release of inhibitory GABA at NMJ

Question 217

When to refer to nephrology for proteinuria

Answer 217

ACR >70 ACR >30 + persistent haematuria (after UTI excluded) ACR 3-29 + persistent haematuria + RFs (eg declining eGFR, CVS disease)

Question 218

Cyclophosphamide

Answer 218

alkylating agent, causes DNA crosslinking Inhibitory effect on B cells, CD4+ T cells, CD8 + T cells SE: haemorrhagic cystitis, myelosuppression, TCC

Question 219

Bleomycin

Answer 219

Degrades preformed DNA SE: lung fibrosis

Question 220

Anthracyclin

Answer 220

Stabilises DNA topoisomerase II complex, inhibits DNA, RNA synthesis SE: CDM

Question 221

Methotrexate

Answer 221

inhibits dihydrofolate reductase and thymidylate synthesis SE: myelosuppression, mucositis, liver fibrosis, lung fibrosis

Question 222

Fluorouracil

Answer 222

Pyrimidine analogue, blocks thymidylate synthase (during S phase), induces cell cycle arrest + apoptosis SE: myelosuppression, mucositis, dermatitis

Question 223

6-mercaptopurine

Answer 223

Purine analogue activated by HGPRTase, reduces purine synthesis SE: myelosuppression

Question 224

Cytarabine

Answer 224

Pyrimidine antagonist. Interferes with DNA synthesis, esp during S-phase of cell cycle, inhibits DNA polymerase SE: myelosuppression, ataxia

Question 225

Vincristine, vinblastine

Answer 225

Inhibits microtubule formation Vincristine SE: reversible peripheral neuropathy, paralytic ileus Vinblastine SE: myelosuppression

Question 226

Docetaxel

Answer 226

Prevents microtubule depolymerisation & Disassembly, decreases free tubulin SE: neutropenia

Question 227

Irinotecan

Answer 227

Inhibits topoisomerase I, preventing supercoiled DNA relaxation SE: myelosuppression

Question 228

Cisplatin

Answer 228

Causes DNA crosslinking SE: ototoxicity, peripheral neuropathy, hypoMg

Question 229

Hydroxyurea/hydroxycarbamide

Answer 229

Inhibits ribonucleotide reductase, decreases DNA synthesis SE: myelosuppression

Question 230

Which cardiac enzyme is the 1st to rise

Answer 230

Myoglobin

Question 231

Which cardiac enzyme is the last to rise?

Answer 231

LDH

Question 232

Which cardiac enzyme is best to look for reinfarction?

Answer 232

CK-MB (returns to noral after 2-3 days whilst trop-T stays elevated for 7-10 days)

Question 233

Tuberous Sclerosis features

Answer 233

HAMARTOMAS Hamartoma (retinal) Adenoma sebaceum (angiofibromas) Mental retardation Ash leaf spots Rhabdomyoma Tubers Optic haemartomas Mitral regurgitation Astrocytomas, Angiomyolipomata (renal) Seizures, Shagreen patches +cafe au lait spots, polycystic kidneys, subungual fibromata, Can see cafe au lait spots

Question 234

NF1 features

Answer 234

Cafe au lait spots peripheral neurofibromas Lisch nodules (iris hamartomas) Scoliosis Phaeochromocytoma

Question 235

NF2 features

Answer 235

Schwannomas - bilateral vestibular, mutliple intracranial Meningiomas Ependymomas

Question 236

Von Hippel-Lindau syndrome genetics

Answer 236

Aut dom VHL mutation in Chr 3 (3 letters in VHL)

Question 237

Von Hippel Lindau Syndrome features

Answer 237

VHLS Vitreous Haemorrhages Haemangiomas (cerebellar + retinal) Lots of cysts Sadly, cancers (renal clear cell + endolymphatic sac) Phaeochromocytomas

Question 238

Foster-Kennedy syndrome

Answer 238

Frontal lobe tumour causing ipsilateral optic atrophy + contralateral papilloedema

Question 239

Sulphsalazine SE:

Answer 239

rashes oligospermia Heinz body anaemia megaloblastic anaemia lung fibrosis GI upset Headache Agranulocytosis Pancreatitis Interstitial nephritis

Question 240

Subacute (De Quervain's) thyroiditis thyroid scintigraphy findings

Answer 240

Globally reduced uptake of iodine-131

Question 241

Friedrich's ataxia genetics

Answer 241

Aut rec GAA repeat in X25 gene Chr 9

Question 242

Friedrich's ataxia Sx

Answer 242

Similar to SCD of cord: Lateral corticospinal, dorsal column, spinocerebellar lesions: B/l spastic paresis, proprioception, vibration sensation loss, ataxia, LMN sx, cerebellar ataxia, optic atrophy HOCM DM High arched palate

Question 243

Drugs exacerbating Myasthenia gravis

Answer 243

MP Questions LGBT Macrolide Procainamide, Penicillamine, Phenytoin Quinolone, Quinidine Lithium Gentamicin Beta blockers Tetracyclines

Question 244

How long does an AV fistula take to form

Answer 244

6-8 wks

Question 245

Amiodarone induced thyrotoxicosis types

Answer 245

Type 1: excess iodine-induced synthesis. Goitre present. Treat with carbimazole or potassium perchlorate Type 2: Destructive thyroiditis. Goitre absent. Treat with steroids

Question 246

Myotonic dystrophy genetics

Answer 246

Aut Dom Type 1 (DM1): CTG rpt at end of DMPK gene on Chr 19 Type 2 (DM2): rpt expansion of ZNF9 gene on Chr 3

Question 247

Blood film on hyposplenism

Answer 247

Target cells Howell-Jolly bodies Pappenheimer bodies Siderotic granules Acanthocytes

Question 248

IDA blood film

Answer 248

Target cells Pencil pokilocytes

Question 249

Myelofibrosis blood film

Answer 249

Tear drop poikilocytes

Question 250

What is responsible for the plateau phase of a cardiac AP?

Answer 250

Slow Ca influx through L-type Ca channels

Question 251

What is responsible for the rapid depolaration phase of a cardiac AP?

Answer 251

Rapid Na influx

Question 252

What is responsible for repolarisation in a cardiac AP?

Answer 252

K efflux

Question 253

What is responsible for restoration of ionic concentrations in a cardiac AP?

Answer 253

K influx with slow Na efflux, via the Na/K ATP-ase

Question 254

Where are the majority of tumours in Zollinger-Ellison found?

Answer 254

1st part of the duodenum 2nd commonest - pancreas

Question 255

Trastuzumab

Answer 255

Herceptin - HER2/neu receptor mAb for metastatic breast Ca

Question 256

Trastuzumab SE:

Answer 256

flu-like sx, diarrhoea Cardiotoxicity, esp with anthracyclines - needs Echo before treatment

Question 257

Which immunoglobulin type is raised in Alcoholic liver disease?

Answer 257

IgA

Question 258

Which immunoglobulin type is raised in autoimmune hepatitis?

Answer 258

IgG

Question 259

HLA association for autoimmune hepatitis

Answer 259

HLA B8 HLA DR3

Question 260

Type I autoimmune hepatitis antibodies

Answer 260

ANA anti-SMA

Question 261

Type II autoimmune hepatitis antibodies

Answer 261

Anti-LKM1

Question 262

Type III autoimmune hepatitis antibodies

Answer 262

Anti soluble liver kidney antigen ab

Question 263

Complications of plasma exchange

Answer 263

HypoCa (due to citrate used as anticoagulant for extracorporeal system) Metabolic alkalosis Removal of systemic meds Coagulation factor depletion Immunoglobulin depletion

Question 264

Indications for plasma exchange

Answer 264

GBS Myasthenia Goodpasture's ANCA-related vasculitis (if progressive renal failure or pulmonary haemorrhage) TTP/HUS cryoglobulinaemia Hyperviscosity syndrome

Question 265

Extra-articular features in IBD related to disease activity

Answer 265

Pauciarticular, asymmetric arthritis Erythema nodosum Episcleritis (more in Crohn's) Osteoporosis

Question 266

Extra-articular features in IBD un-related to disease activity

Answer 266

Polyarticular symmetric arthritis Uveitis (more in UC) Pyoderma gangrenosum Clubbing PSC (more in UC)

Question 267

Familial Mediterranean Fever inheritance

Answer 267

Aut rec

Question 268

Familial Mediterranean Fever features

Answer 268

Recurrent Pyrexia + Polyserositis (pleuritis, peritonitis, pericarditis, arthritis), erysipeloid rash on lower limbs

Question 269

Familial Mediterranean Fever Rx

Answer 269

Colchicine

Question 270

Hungry bone syndrome

Answer 270

Uncommon complication post thyroidectomy if hyperPTH has been long-standing. Results in hypoCa High pre-op levels of PTH provide constant stimulus for high osteoclast activity. Once parathyroidectomy done, bones rapidly begin re-mineralisation to counter the chronic changes that osteoclasts have done

Question 271

Coarctation of Aorta assx

Answer 271

Turner's Bicuspid aortic valve Berry aneurysms NF

Question 272

Lithium toxicity precipitants

Answer 272

Diuretics (thiazides esp_) ACE inhibitors/ARBs NSAIDs Metronidazole

Question 273

Level at which lithium toxicity occurs and therapeutic level

Answer 273

>1.5 - toxicity 0.4-1 - therapeutic range

Question 274

Lithium toxicity features

Answer 274

CHAPS Coma Coarse tremor Hyperreflexia Acute confusion Polyuria Seizure Coma

Question 275

Tunnel vision causes:

Answer 275

CHO RPG into the tunnel Choroidoretinitis Hysteria Optic atrophy 2ndary to Tabes dorsalis Retinitis pigmentosa Papilloedema Glaucoma

Question 276

Otitis externa Rx

Answer 276

topical steroids + aminoglycoside

Question 277

Anthrax Rx

Answer 277

ciprofloxacin

Question 278

CYP450 inducers

Answer 278

CRAP GPS carbamazepime rifampicin Alcohol (chronic) Phenytoin Griseofulvin Phenobarbiton Sulphonylureas/smoking/St John's Wort

Question 279

CYP450 inhibitors

Answer 279

SICKFACES.COM Sodium valproate Isoniazid Cimetidine Ketoconazole/fluconazole Fluoxetine/sertraline Alcohol (acute)/allopurinol/amiodarone Ciprofloxacin/chloramphenicol Erythromycin/clarithromycin Sulphonamides Cardiac/Liver failure Omeprazole Metronidazole

Question 280

Which is more likely to develop T2DM - IFG or IGT

Answer 280

IGT (IFG due to hepatic insulin resistance while IGT due to muscle insulin resistance)

Question 281

Impaired fasting glucose diagnosis

Answer 281

Fasting glucose 6.1-7.0

Question 282

Impaired glucose tolerance diagnosis

Answer 282

Oral glucose tolerance test (post-2hrs): 7.8-11.1

Question 283

Sulfonylurea SE:

Answer 283

Hypo Weight gain SIADH Cholesterol liver dysfunction Peripheral neuropathy Teratogenic

Question 284

Meglitinides - when to give

Answer 284

basically work like sulfonylureas For erratic lifestyles

Question 285

Sulfonylurea MOA

Answer 285

Binds to ATP-sensitive K channels on beta cells, closing them Increases glucose-INDEPENDENT insulin release

Question 286

Thiazolidinediones SE

Answer 286

weight gain fluid retention (worsened when given with insulin) liver dysfunction fractures Bladder Ca

Question 287

Gliptins SE

Answer 287

pancreatitis

Question 288

GLP-1 mimetics SE

Answer 288

nausea, vomiting Pancreatitis Renal impairment

Question 289

SGLT-2 inhibitors SE

Answer 289

urinary/genital infections Fournier's gangrene Euglycaemic ketoacidosis Lower-limb amputations Weight loss

Question 290

Pendred's syndrome genetics

Answer 290

Aut Rec SLC26A4 mutation in PDS gene Chr 7

Question 291

Pendred's syndrome features

Answer 291

Defect in iodine organification Progressive bilateral sensorineural deafness Delay in academic progression Exacerbated by head trauma Mild hypothyroid/euthryoid with goitre

Question 292

Pendred's syndrome dx

Answer 292

perchlorate discharge test Genetic testing Audiometry MRI (one and a half turns in cochlea instead of two and a half turns)

Question 293

Pendred's syndrome Rx

Answer 293

thyroid hormones Cochlear implants

Question 294

Pelvic inflammatory disease Rx

Answer 294

Oral ofloxacin + oral metronidazole or IM ceftriaxone + oral doxycycline + oral metronidazole

Question 295

Chance of transmission after needlestick for HBV

Answer 295

20-30%

Question 296

Chance of transmission after needlestick for HCV

Answer 296

0.5-2%

Question 297

Chance of transmission after needlestick for HIV

Answer 297

0.3%

Question 298

What stain should you use to diagnose Pneumocystis cariniii pneumonia?

Answer 298

Silver stain

Question 299

Which foramen does the maxillary nerve go through?

Answer 299

Foramen rotundum

Question 300

Which foramen does the mandibular nerve go through?

Answer 300

Foramen ovale

Question 301

Which nerves go through through the jugular foramen?

Answer 301

CNs 9, 10, 11

Question 302

Central causes of Horner's

Answer 302

S's - lesions directly in hypothalamus, brainstem, spinal cord, demyelination, neoplasms, syrinx Stroke Syringomyelia multiple Sclerosis Tumour Encephalitis

Question 303

How to distinguish between different causes of Horner's

Answer 303

Central lesions have anhidrosis of face + arms + trunks Pre-ganglionic have just anhidrosis of face Post-ganglionic have no anhidrosis Hydroxyamphetamine testing can also be done: pupils dilate in central/pre-ganglionic but not in post-ganglionic

Question 304

Pre-ganglionic Horner's causes

Answer 304

T's pancoasT's Tumour Thyroidectomy Trauma Cervical Rib

Question 305

Post-ganglionic Horner's causes

Answer 305

C's Carotid artery dissection Carotid aneurysm Cavernous sinus thrombosis, Cluster headache

Question 306

Pilocarpine action

Answer 306

muscarinic agonist

Question 307

Timolol eye drops MOA

Answer 307

beta blocker --> reduces aqueous production

Question 308

Apraclonidine eye drops MOA

Answer 308

alpha 2 agonist Reduces aqueous production + increases outflow

Question 309

Latanoprost eye drop MOA

Answer 309

prostaglandin analogue Increases uveoscleral outflow

Question 310

Which cells produce pulmonary surfactant

Answer 310

Type 2 pneumocytes

Question 311

What is the main functioning component of pulmonary surfactant?

Answer 311

Dipalmitoyl phosphatidylcholine (DPPC)

Question 312

Severe AS features

Answer 312

narrow pp slow rising pulse soft/absent S2 S4 thrill delayed ESM longer ESM LVH/failure (displaced apex beat)

Question 313

Causes of Peripheral neuropathy with predominantly sensory loss

Answer 313

VALUE Diabetes Vit B12 def Amyloidosis Leprosy Uraemia ETOH Diabetes

Question 314

Causes of Peripheral neuropathy with predominantly motor loss

Answer 314

GP's CCD GBS Porphyria and lead poisoning (things down the haem biosynthesis pathway) Charcot-Marie-Tooth CIPD (chronic GBS) Diphtheria

Question 315

What is hazard ratio typically used for

Answer 315

analysing survival over time

Question 316

Rheumatoid arthritis XR changes

Answer 316

Loss of joint space Juxta-articular osteoporosis/osteopaenia Soft-tissue swelling Periarticular erosions Subluxation

Question 317

Vaughan Williams class 1a examples

Answer 317

quinidine procainamide disopyramide

Question 318

Vaughan Williams class 1a MOA

Answer 318

blocks Na channels Increases AP duration

Question 319

Vaughan Williams class 1b examples

Answer 319

Lidocaine Mexiletine Tocainide

Question 320

Vaughan Williams class 1b MOA

Answer 320

blocks Na channels Reduces AP duration

Question 321

Vaughan Williams class 1c examples

Answer 321

Flecainide Encainide Propafenodone

Question 322

Vaughan Williams class 1c MOA

Answer 322

blocks Na channels No effect on AP

Question 323

Drug induced lupus causes

Answer 323

Most common: - PH Procainamide Hydralazine Less common: - PIM Isoniaizid Minocycline Phenytoin

Question 324

Ataxic telangiectasia genetics

Answer 324

Aut Rec DNA repair enzyme defect

Question 325

Wiskott-Aldrich syndrome genetics

Answer 325

X recessive WASP gene defect

Question 326

Red flag features when assessing for IBS

Answer 326

Rectal bleed weight loss (unexplained) FHx of bowel/ovarian Ca Onset>60yrs of age

Question 327

Homocystinuria genetics and defect

Answer 327

Aut Rec Cystathionine beta synthase def

Question 328

Homocystinuria features

Answer 328

Hair: Fine, fair hair Body/Bones: Marfanoid, Osteoporotic, Kyphotic Neuropsych: LD, Seizures Eyes: Downwards (inferonasal) lens dislocation, Severe myopia CVS: Arterial + venous thromboembolisms Skin: Malar flush, Livedo reticularis

Question 329

Homocystinuria Ix

Answer 329

plasma, urine homocysteine conc high Cyanide-nitroprusside test +ve

Question 330

Homocystinuria Rx

Answer 330

vit B6 (pyridoxine) supplements

Question 331

Phenylketonuria Genetics + Defect

Answer 331

Aut Rec Chr 12 Phenylalanine hydroxylase def

Question 332

Phenylketonuria features

Answer 332

General: Fair hair, Blue eyes Urin: Musky Neuropsych: LD, Seizures Skin: Eczema

Question 333

Phenylketonuria Ix

Answer 333

Guthrie's test Hyperphenylalaninaemia Urinary phenylpyruvic acid

Question 334

Alkaptonuria genetics + defect

Answer 334

Aut Rec HGD def

Question 335

Alkaptonuria Sx

Answer 335

Eyes: pigmented sclera, corneal deposits Urine: dark urinary homogentisic acid (dark urine on standing), Renal stones Bones: intervertebral disc calcification

Question 336

Alkaptonuria Rx

Answer 336

Vit C restrict phenylalanine and tyrosine

Question 337

Beckwith-Wiedemann syndrome features

Answer 337

Assx: Wilm's Organomegaly Abdo wall defects Neonatal hypoglycaemia

Question 338

Von Gierke's disease defect

Answer 338

Glucose-6-phosphatase defect --> hepatic glycogen accumulation

Question 339

Von Gierke's features

Answer 339

Hypoglycaemia Lactic acidosis Hepatomegaly. (Von Gierke’s got a big liver - due to hepatic glycogen accumulation)

Question 340

Pompe's disease defect

Answer 340

Lysosomal alpha 1,4 glucosidase def

Question 341

Pompe's disease features

Answer 341

Cardiomegaly (Pompey’s got a big heart) Cardiac, hepatic, muscle glycogen accumulation

Question 342

Cori disease defect

Answer 342

Alpha 1,6, glucosidase defect

Question 343

Cori disease features

Answer 343

Muscle dystonia Hepatic, cardiac glycogen acccumulation

Question 344

McArdle's disease defect + features

Answer 344

The Ms Myophosphorylase (glycogen phosphorylase) def, Muscle glycogen accumulation → Myalgia and Myoglobinuria with exercise.

Question 345

Glycogen storage disease types

Answer 345

Type 1 - von Gierke's Type 2 - Pompe's Type 3 - Cori Type 5 - McArdle's

Question 346

Gaucher's disease defect

Answer 346

beta glucocerebrosidase def

Question 347

Gaucher's disease features

Answer 347

hepatosplenomegaly Aseptic necrosis of femur

Question 348

Tay-Sach's features and deficiency

Answer 348

TaY-SaCHs Young presentation (by 6 months) with developmental delay Spleen + liver normal sized Cherry-red spots on macula Hexosaminidase A def → GM2 ganglioside accumulation in lysosomes

Question 349

Niemann-Pick disease

Answer 349

sphingomyelinase def. Hepatosplenomegaly + cherry red spots on macula

Question 350

Fabry's disease inheritance

Answer 350

X recessive

Question 351

Fabry's disease features

Answer 351

FABRY-C Fever Angiokeratomas (bathing trunk distr) Alpha galactosidase A def Burning (peripheral neuropathy) Renal failure Young CVS disease (HF, fibrosis, CAD) Corneal whorls keratopathy/lens opacification (cornea verticillata).

Question 352

Fabry's disease Rx

Answer 352

agalsidase alfa (replacing alpha galactosidase A)

Question 353

Krabbe's disease

Answer 353

Galactocerebrosidase def Peripheral neuropathy optic atrophy globoid cells

Question 354

Metachromatic leukodystrophy

Answer 354

Arylsulfatase A def Demyelination of CNS, PNS

Question 355

Hurler's syndrome

Answer 355

Aut rec alpha-1-iduronidase def → glycosaminoglycan accumulation (heparan, dermatan sulfate). Gargoylism, hepatosplenomegaly corneal clouding

Question 356

Hunter syndrome

Answer 356

X recessive Iduronate sulfatase def → glycosaminoglycan accumulation. Coarse facial feature features, behavioural problems/LD, short stature no corneal clouding.

Question 357

Drugs triggering digoxin toxicity

Answer 357

ACCD Anti-arrhythmics: Amiodarone, Quinidine CCBs (rate limiting - Verapamil, Diltiazem) Ciclosporin Diuretics: Thiazides, Furosemide, Spironolactone (competes for DCT secretion)

Question 358

Post-strep GN - how far is it preceeded by an infection?

Answer 358

7-14 days usually

Question 359

Post-strep GN biopsy features

Answer 359

Acute, diffuse proliferative GN Endothelial proliferation with neutrophils EM: subepithelial 'humps' caused by lumpy immune complex deposits Immunofluorescence: granular or 'starry sky' appearance

Question 360

HyperCa causes other than hyperPTH or malignancy

Answer 360

Endocrine: Acromegaly Thyrotoxicosis Addison's Paget's Drugs: Thiazides Ca-containing antacids Others: Sarcoidosis Vit D intoxication Milk-Alkali syndrome Dehydration

Question 361

Weber's syndrome

Answer 361

Infarction in branches of posterior cerebral artery supplying midbrain Ipsilateral CN III palsy Contralateral weakness of upper + lower extremity

Question 362

PICA infarct

Answer 362

Lateral Medullary syndrome Ipsilateral facial pain and temperature loss Contralateral limb/torso pain and temperature loss Ataxia, nystagmus

Question 363

AICA infarct

Answer 363

Lateral Pontine syndrome Like PICA + ipsilateral facial paralysis + deafness

Question 364

Features of severe falciparum

Answer 364

Blood film features: Schizonts/late stage trophozoites on blood film Parasitaemia >2% Hypoglycaemia Temp>39 Evidence of complications: Cerebral: seizures, coma Blackwater fever: intravascular haemolytic anaemia + AKI, with acidosis ARDS DIC

Question 365

Rx for non-falciparum malaria

Answer 365

Artemisin-based combination therapy (ACT) or Chloroquine (if in sensitive regions)

Question 366

Use of primaquine in non-falciparum malaria

Answer 366

Following acute ACT/chloroquine for ovale/vivax to destroy liver hypnozoites to prevent relapse

Question 367

Causes of Type 1 RTA

Answer 367

Idiopathic Rheumatoid Arthritis SLE Sjogren's Amphotericin B toxicity Analgesic nephropathy

Question 368

Causes of Type 2 RTA

Answer 368

Idiopathic Fanconi syndrome Wilson's Cystinosis Outdated tetracyclines Carbonic anhydrase inhibitors

Question 369

Causes of Type 4 RTA

Answer 369

Hypoaldosteronism Diabetes

Question 370

Focal seizures Rx

Answer 370

1. lamotrigine/levetiracetam 2. carbamazepine, oxcarbazepine, zonisamide

Question 371

Drug induced impaired glucose tolerance

Answer 371

TASTIN Thiazide Antipsychotics Steroids Tacrolimus/ciclosporin IFN alpha Nicotinic acid

Question 372

S4 causes

Answer 372

Atrial contraction vs stiff ventricle (so coincides with p on ECG) AHH! AS HOCM (double apex beat may be felt due to palpable 4) HTN

Question 373

Neuromyelitis optica features

Answer 373

b/l optic neuritis Myelitis Vomiting NMO IgG Abs vs Aquaporin 4 Initially usually normal MRI

Question 374

Neuromyelitis optica Rx

Answer 374

Rituximab

Question 375

Causes of focal segmental glomerulosclerosis/nephritis

Answer 375

Idiopathic Secondary to other renal pathology (eg IgA nephropathy, reflux nephropathy) HIV Heroin Alport's syndrome Sickle cell

Question 376

Focal segmental glomerulosclerosis biopsy features

Answer 376

Focal segmental sclerosis + hyalinosis on light microscopy Effacement of foot processes on EM

Question 377

Gram -ve cocci

Answer 377

Neisseria Moraxella

Question 378

Gram +ve rods

Answer 378

ABCDL Actinomyces Bacillus Clostridium Diphtheria Listeria

Question 379

WPW types with axis deviations

Answer 379

Right sided accessory pathway = LAD Left sided accessory pathway = RAD

Question 380

ASD types and axis deviation

Answer 380

Ostium primum = LAD Ostium secundum = RAD

Question 381

List some oncogenes (7)

Answer 381

erb-B2 (HER2/neu) n-Myc c-Myc ABL RET RAS BCL-2

Question 382

What are the relatie LH and testosterone levels for Klinefelter's vs Kallman's vs Androgen insiensitivity syndrome vs testosterone-secreting tumours

Answer 382

Klinefelter's - primary hypogonadism so high LH, low testosterone Kallman's - hypogonadotrophic hypogonadism so low LH + low testosterone Androgen insensitivity syndrome: high LH with normal/high testosterone Testosterone-secreting tumour: low LH, high testosterone

Question 383

Erb-Duchenne palsy

Answer 383

upper trunk (C5-6) damage eg due to shoulder dystochia during birth Waiter's tip - arm hangs by side, internally rotated, elbow extended

Question 384

Klumpke's palsy

Answer 384

Lower trunk (C8, T1) damage Assx with horner's Claw hand

Question 385

Causes of high-output HF

Answer 385

Anaemia AV malformation Paget's Pregnancy Thyrotoxicosis Thiamine def (wet beri-beri)

Question 386

Congruous vs incongrous homonymous hemianopia - where's the lesion

Answer 386

Congruous - optic radiation or occipital cortex lesion Incongruous - optic tract lesion

Question 387

Macula sparing homonymous hemianopia - where is the lesion?

Answer 387

Occipital cortex (optic radiation would not spare macula)

Question 388

Albinism inheritance

Answer 388

Aut rec

Question 389

Becker vs Duchenne muscular dystrophies

Answer 389

Both due to X rec dystrophin gene mutation on Xp21 Duchenne has frameshift mutation (one or both binding sites of dystrophin being lost) resulting in severe disease, with proximal muscle weakness from 5 yrs, with 30% having intellectual impairment. Picked up with Gower's sign (chid refuses to stand from squatted position) Becker's has non-frameshift mutation, so milder disease, developing from 10yrs

Question 390

Nephrogenic diabetes insipidus genetic causes

Answer 390

X recessive AVPR2 mutation for ADH receptor more common Aquaporin 2 mutation less common

Question 391

Nephrogenic diabetes insipidus non-genetic causes

Answer 391

HyperCa HypoK Lithium Demeclocyclin Tubulo-interstitial disease: obsttruction, sickle cell, pyelonephritis

Question 392

Rx for nephrogenic diabetes insipidus

Answer 392

Thiazides Low salt/protein diet

Question 393

IgA nephropathy Rx

Answer 393

If isolated haematuria/minimal to no haematuria (<500-1000mg/day), normal GFR: f/u for renal function check If persistent proteinuria (500-1000mg/day), normal/slightly reduced GFR: ACE inhibitors Active disease/failure to respond to ACE inhibitors: steroids

Question 394

Achalasia Rx:

Answer 394

1st line - Pneumatic balloon dilation Heller cardiomyotomy if recurrent/persistent symptoms Intra-sphincteric botulinum toxin if high risk

Question 395

Behcet's disease Rx

Answer 395

If eye involvement, oral steroids 2nd line - cyclophosphamide, azathioprine, etanercept

Question 396

Small cell lung ca - which cells are they from?

Answer 396

APUD cells - high amine, high precursor uptake, high enzyme decarboxylase cells

Question 397

Small cell lung ca paraneoplastic features

Answer 397

ADH --> SIADH ACTH --> Cushing's or b/l adrenal hyperplasia VGCC Abs --> Lambert Eaton

Question 398

Squamous cell lung ca paraneoplastic features

Answer 398

PTHrP Clubbing Hypertrophic pulmonary osteoarthropathy Ectopic TSH --> hyperthyroid

Question 399

Adenocarcinoma lung ca paraneoplastic features

Answer 399

Gynaecomastia Hypertrophic pulmonary osteoarthropathy

Question 400

Effect of CO poisoning on ventilation and peripheral chemoreceptors

Answer 400

No impact - peripheral chemoreceptors fail to detect resultant tissue hypoxia

Question 401

What stimulates an increase in ventilatory rate?

Answer 401

Peripheral chemoreceptors detecting hypoxia

Question 402

WHat drives an increased depth of inspiration?

Answer 402

CO2, via stimulation of central chemoreceptors in pons and medulla

Question 403

Rx for erysipelas near nose or eye

Answer 403

Co-amox

Question 404

Erysipelas commonest cause

Answer 404

S pyogenes (beta haemolytic, Group A strep)

Question 405

oromorph to sc morphine

Answer 405

/2

Question 406

oromorph to sc diamorphine

Answer 406

/3

Question 407

oromorph to oxycodone

Answer 407

/1.5-2

Question 408

47F with Rheumatoid arthritis for past 3 years, treated with methotrexate. Suffered pain across her back of her neck over the past year with a recurrent sense of heaviness and muscle weakness affecting both her upper and lower limbs. Symptoms can be reproduced by adopting a flexion posture and there is obvious synovitis affecting the finger joints of both hands and her wrists. Flexion of her cervical spine is reduced by 30% Which of the following is the most important first investigation? - Cervical spine XR in the neutral and flexion position - Lumbar puncture - MRI of cervical spine - nerve conduction studies - Visual evoked potentials

Answer 408

Cervical spine XR in the neutral and flexion position Atlantoaxial sublaxation due to deposition of pannus around dens, leading to instability between C1 and C2 cervical vertebrae

Question 409

Mixed connective tissue disease antibodies

Answer 409

Anti-U1RNP and ANA +ve (-ve for dsDNA, anti-scl70)

Question 410

Endothelin antagonist SE

Answer 410

Teratogenic Hepatotoxicity

Question 411

Haemochromatosis genetics

Answer 411

Aut Rec HFE gene Chr 6 C282Y, H63D mutations

Question 412

Which features of Haemochromatosis are reversible with treatment

Answer 412

Skin pigmentation (bronze) dilated CDM

Question 413

Form of hypogonadism in Haemochromatosis

Answer 413

hypogonadotrophic hypogonadism

Question 414

Iron studies in Haemochromatosis

Answer 414

raised ferritin, transferrin sats, iron low TIBC

Question 415

Rx for haemochromatosis

Answer 415

Venesection 1st line Desferrioxamine 2nd line

Question 416

Evolocumab

Answer 416

binds PCSK9, prevents binding to LDL receptors on liver surface, enhancing ability for liver to bind LDL and remove it Reduces LDL by 60% Recommended when LDL persistently above 4.0 despite maximal lipid-lowering therapy

Question 417

How much does ezetimibe lower cholesterol by?

Answer 417

15-20%

Question 418

Secondary hypothyroidism TFTs

Answer 418

Low T4 + TSH

Question 419

In diabetic retinopathy when to use focal laser therapy vs pan-retinal photocoagulation?

Answer 419

Focal laser therapy for diabetic maculopathy with risk of permanent sight loss Pan-retinal photocoagulation when severe peripheral retinal ishaemia +/- neovascularisation

Question 420

Which cells are primarily responsible for immune memory?

Answer 420

T cells

Question 421

When are additional atrial leads necessary for dual-chamber pacemakers?

Answer 421

When there are risks of pAF as well

Question 422

Kallman's inheritance

Answer 422

X recessive

Question 423

Kallman's form of hypogonadism

Answer 423

Hypogonadotrophic hypogonadism

Question 424

Klinefelter's hypogonadism form

Answer 424

hypergonadotrophic hypogonadism (Klinefelter- tall - hypergonadotrophic)

Question 425

Type 1 autoimmune polyendocrinopathy syndrome

Answer 425

MEDAC (multiple endocrine deficiency autoimmune candidiasis) chronic mucocutaneous candidiasis in children Addison's primary hypoPTH

Question 426

Type 2 autoimmune polyendocrinopathy syndrome

Answer 426

Schmidt's syndrome Addison's T1DM Autoimmune thyroid disease (hyper or hypo)

Question 427

Type 2 Autoimmune polyendocrinopathy syndrome genetics

Answer 427

Polygenic HLA DR3/4 association

Question 428

Type 1 Autoimmune polyendocrinopathy syndrome genetics

Answer 428

Aut rec AIRE1 mutation Chr 21

Question 429

MEN 1

Answer 429

MEN1 gene 3 Ps: hyperPTH, Pituitary tumours, pancreatic tumours + adrenal, thyroid tumours

Question 430

MEN 2a

Answer 430

RET oncogene 1M, 2Ps: Medullary thyroid ca (70%) (+ papillary thyroid Ca) HyperPTH Phaeochromocytoma

Question 431

MEN 2b

Answer 431

RET oncogene 2Ms, 1P: Medullary thyroid ca Marfanoid Phaeochromocytoma

Question 432

Strongyloidiasis Rx

Answer 432

Ivermectin 1st line Albendazole 2nd line

Question 433

Venous drainage for the upper two-thirds of the oesophagus

Answer 433

Via oesophageal veins into azygous veins into SVC

Question 434

Venous drainage for lower third of oesophagus

Answer 434

via superficial veins into left gastric vein into portal vein

Question 435

Rx for restless leg syndrome

Answer 435

Treat IDA if present Dopamine agonists 1st line (ropinirole, pramipexole) Gabapentin also effective Benzos can be tried

Question 436

Cyanide poisoning enzyme inhibition

Answer 436

inhibition of cytochrome c oxidase --> cessation of mitochondrial electron transfer chain

Question 437

Rx for cyanide poisoning

Answer 437

100% oxygen IV hydroxycobalamin Inhaled amyl nitritie IV sodium nitrite IV sodium thiosulfate

Question 438

Salicylate overdose Rx

Answer 438

IV bicarbonate - urinary alkalisation Haemodialysis (if acidosis resistant to treatment, AKI, pulm oedema, seizures, coma, conc>700)

Question 439

Haemodialysis for overdoses

Answer 439

BLAST Barbiturates Lithium Alcohool (including methanol) Salicylates Theophylline (charcoal haemoperfusion preferred)

Question 440

Dermatomyositis Rx

Answer 440

1. Prednisolone 2. Azathioprine 3. If co-existing lung disease, more aggressive immunotherapy - ciclosporin, cyclophosphamide

Question 441

Baclofen MOA

Answer 441

GABA derivative GABA-B agonist

Question 442

Artery lying close to recurrent laryngeal nerve

Answer 442

Right INFERIOR thyroid artery bifurcation

Question 443

Ankylosing Spondylitis Rx

Answer 443

Regular exercise Physiotherapy 1. NSAIDs 2. Anti-TNF (eg adalimumab) if persistently high disease activity - after trialling two NSAIDs If peripheral joint activity, DMARDs

Question 444

Rx to reduce phosphate in CKD

Answer 444

Phosphate binders eg calcium acetate

Question 445

Indication for teriparatide in osteoporosis

Answer 445

Two or more osteoporotic fractures T score -3.5 or worse

Question 446

Bell's palsy Rx

Answer 446

High dose steroids (eg 60mg OD)

Question 447

Wegener's new name

Answer 447

GPA

Question 448

cANCA target

Answer 448

PR3

Question 449

pANCA target

Answer 449

MPO

Question 450

Churg Strauss new name

Answer 450

eGPA

Question 451

Ezetimibe MOA

Answer 451

NPC1L1 sterol transporter inhibitor

Question 452

Fibrates MOA

Answer 452

PPAR alpha upregulation --> lipoprotein lipase upregulation, increases apoprotein A-I, A-II synthesis

Question 453

Sideroblastic anaemia causes

Answer 453

D MELT Delta-aminolevulinate synthase 2 deficiency MDS ETOH Lead TB meds

Question 454

Sideroblastic anaemia Ix

Answer 454

microcytic anaemia high ferritin, iron, transferrin sats Basophilic stippling Prussian blue/Perl's staining for bone marrow film, with sideroblasts

Question 455

Sideroblasti anaemia rx

Answer 455

supportive pyridoxine

Question 456

Lead poisoning cause

Answer 456

Ferrochetalase + ALA dehydrogenase defect

Question 457

Oral features in lead poisoning

Answer 457

blue gum lines

Question 458

Lead poisoning ix

Answer 458

high lead level in blood >10mcg/dl microcytic anaemia blood film: basophilic stippling clover leaf morphology High serum + urine delta aminolaevulinic acid high urinary coproporphyrin

Question 459

Lead poisoning Rx

Answer 459

DMSA D-penicillamine EDTA Dimercaprol

Question 460

Acute Intermittent Porphyria Genetics

Answer 460

Aut Dom porphobilinogen deaminase defect

Question 461

Acute Intermittent Porphyria Ix

Answer 461

Raised urinary porphobilinogen Red cell assay for porphobilinogen deaminase Raised serum delta aminolaevulinic acid and porphobilinogen

Question 462

Drugs precipitating AIT

Answer 462

BOBAHS Barbiturates Oral contraceptives Benzos Alcohol, Azithromycin Halothane Sulphonamides

Question 463

Rx for AIT

Answer 463

IV haematin/haem arginate IV glucose if not available

Question 464

Porphyria cutanea tarda defect

Answer 464

uroporphyrinogen decarboxylase

Question 465

Porphyria cutanea tarda ix

Answer 465

high urinary uroporphyrinogen Pink fluorescence of urine under Wood's lamp

Question 466

Porphyria cutanea tarda Rx

Answer 466

chloroquine Venesection if ferritin>600

Question 467

Variegate porphyria genetics

Answer 467

Aut Dom Protoporphyrinogen oxidase def

Question 468

How to investigate for IDA in CKD

Answer 468

Percentage of hypochromic red cells >6% If not available within 6 hrs, reticulocyte Hb content Ferritin not recommended as it can be elevated due to chronic inflammation in CKD

Question 469

Antibodies involved in type I hypersensitivity

Answer 469

IgE (bound to mast cells)

Question 470

Type I hypersensitivity examples

Answer 470

Anaphylaxis Atopy (eg asthma, eczema, hayfever)

Question 471

Type II hypersensitivity examples

Answer 471

AIHA ITP Goodpasture's Pernicious anaemia Acute haemolytic transfusion reactions Rheumatic fever Pemphigus vulgaris Bullous pemphigoid

Question 472

Type III hypersensitivity reaction examples

Answer 472

Serum sickness SLE Post-strep GN Extrinsic allergic alveolitis (acute phase)

Question 473

Type IV hypersensitivity reaction examples

Answer 473

TB/Tuberculin skin reactions Graft vs host disease Allergic contact dermatitis Scabies Extrinsic allergic alveolitis (chronic phase) MS GBS

Question 474

HLA B27 assx

Answer 474

Ank spond reactive arthritis acute anterior uveitis psoriatic arthritis

Question 475

HLA DQ2/8 assx

Answer 475

coeliac

Question 476

HLA DR2 assx

Answer 476

Narcolepsy Goodpasture's

Question 477

HLA DR 3 assx

Answer 477

Dermatitis herpetiformis Sjogren's PBC

Question 478

HLA DR 4 assx

Answer 478

T1DM Rheumatoid arthritis

Question 479

Rheumatoid arthritis specific HLA assx

Answer 479

DRB1 gene DRB1*04:01 DRB1*04:04

Question 480

Stevens Johnson syndrome HLA Assx

Answer 480

HLA B*1502 - carbamazepine induced SJS + TEN in Han Chinese

Question 481

Causes of Stevens Johnson syndrome

Answer 481

Abs: (symptoms within 1 wk) Penicillin Sulphonamides AEDs: (within 2 months) Lamotrigine Carbamazepine Phenytoin Allopurinol NSAIDs Oral contraceptives

Question 482

ASD murmur

Answer 482

ESM louder on inspiration

Question 483

Truner's hypogonadism type

Answer 483

hypergonadotrophic hypogonadism

Question 484

Polymyositis Abs

Answer 484

Anti Jo-1

Question 485

Prophylaxis of variceal haemorrhage

Answer 485

Propanolol (or carvedilol)

Question 486

Electrolytes in Rhabdomyolysis

Answer 486

HypoCa HyperPO4 HyperK

Question 487

Soft S1 causes

Answer 487

long PR MR

Question 488

Loud S1

Answer 488

MS

Question 489

Soft S2

Answer 489

severe AS

Question 490

S3 causes

Answer 490

diastolic filling of ventricle LVF dilated CDM constrictive pericarditis (pericardial knock) MR

Question 491

Microscopic polyangiitis Abs

Answer 491

pANCA > cANCA

Question 492

First pass metabolism drugs

Answer 492

Love at FIRST sight - Heart related meds Aspirin Isosorbide dinitrate GTN lignocaine Propanolol Verapamil isoprenaline Steroids + Testosterone

Question 493

Zero order kinetics drugs

Answer 493

When you lose the girl (drink, heart attack, seziures) Ethanol Aspirin Heparin Seizures

Question 494

Acetylator status drugs

Answer 494

HIgh SPeeD Hydralazine Isoniazid Sulfasalazine Procainamide Dapsone

Question 495

Causes for lower than expected HbA1c levels

Answer 495

(Basically reasons that would reduce RBC lifespan) Sickle-cell anaemia G6PD def Hereditary spherocytosis Haemodialysis

Question 496

Higher than expected HbA1c levels

Answer 496

Vit B12, folate def IDA splenectomy

Question 497

HbA1c 6% corresponds to what mmol/mol?

Answer 497

42

Question 498

What does HbA1c of 6^ correspond to the average plasma glucose over last 3 months?

Answer 498

7.5

Question 499

Formula for average plasma glucose from HbA1c by %

Answer 499

2*HbA1c - 4.5

Question 500

PMR initial Rx

Answer 500

prednisolone 15mg OD for 3 wks with tapering Increase to 25mg OD if uncontrolled High dose steroids if evidence of teporal arteritis

Question 501

Peutz Jeghers genetics

Answer 501

Aut Dom LKB1 or STK11 gene mutations (encoding serine threonine kinase)

Question 502

Where doess addition of mannose-6-phosphate happen and what is its purpose?

Answer 502

In the Golgi apparatus To designate it for transport to lysosomes

Question 503

Where does RNA splicing happen?

Answer 503

Nucleus

Question 504

Where does RNA transcription happen?

Answer 504

Nucleus

Question 505

What happens in the nucleolus?

Answer 505

Ribosome production

Question 506

What does the lysosome do?

Answer 506

break down large molecules

Question 507

What do peroxisomes do?

Answer 507

Very long chain fatty acid, amino acid catabolism Forms hydrogen peroxide

Question 508

What do proteasomes do?

Answer 508

Degrades protein molecules tagged with ubiquitin

Question 509

What kind of iron does methaemoglobinaemia have?

Answer 509

Fe3+ instead of Fe2+, which cannot bind oxygen as well Dissociation curve shifts left

Question 510

Acquired causes of methaemoglobinaemia

Answer 510

Sulphonamides Dapsones Nitrates Sodium nitroprusside Primaquine Aniline dyes

Question 511

Rx for methaemoglobinaemia

Answer 511

If aquired, IV methylthioninium chloride (methylene blue) If congenital, ascorbic acid

Question 512

What immunoglobulin deficiency is commonest in cases of anaphylaxis to blood transfusions?

Answer 512

IgA deficiency

Question 513

Immunodeficiencies - neutrophil disorders

Answer 513

Chronic granulomatous disease Chediak-Higashi syndrome Leukocyte Adhesion Deficiency

Question 514

Chronic granulomatous disease defect

Answer 514

NADPH oxidase deficiency Reduces ability of phagocytes to produce reactive oxygen species

Question 515

Chronic granulomatous disease features

Answer 515

pneumonias abscesses (esp catalase +ve -S aureus, fungi)

Question 516

Chronic granulomatous disease ix

Answer 516

-ve nitroblue-tetrazolium test abnormal dihydrorhodamine flow cytometry test

Question 517

Chediak-Higashi syndrome defect

Answer 517

Microtubule polymerisation defect Reduced phagocytosis

Question 518

Chediak-Higashi syndrome features

Answer 518

Partial albinism in children Peripheral neuropathy Recurrent bacterial infection

Question 519

Chediak-Higashi syndrome ix

Answer 519

Giant granules in neutrophils + platelets

Question 520

Leukocyte adhesion deficiency defect

Answer 520

LFA-1 integrin (CD18) defect on neutrophils

Question 521

Leukocyte adhesion deficiency features

Answer 521

Recurrent bacterial infections Delay in umbilical cord sloughing Absence of neutrophils/pus at sites of infection

Question 522

Immunodeficiencies - B-cell disorders

Answer 522

CVID Bruton's X-linked congenital agamaglobulinaemia Selective IgA deficiency

Question 523

CVID features

Answer 523

Low Ab levels, esp IgG, IgM, IgA Recurrent pneumias Autoimmune disorders, lymphoma

Question 524

Bruton's X linked congenital agammaglobulinaemia defect

Answer 524

X rec Bruton's tyrosine kinase gene (BTK) Severe block in B cell development

Question 525

Bruton's agammaglobulinaemia features

Answer 525

Recurrent bacterial infections Absence of B-cells with reduced immunoglobulins of all classes

Question 526

Selective IgA deficiency defect

Answer 526

B cell maturation defect

Question 527

Which is the most common primary antibody deficiency

Answer 527

Selective IgA def

Question 528

Selective IgA def features

Answer 528

Recurrent sinus and resp infections Assx: coeliac - false -ve screen Severe reactions to blood transfusions (anaphylaxis)

Question 529

T-cell disorders

Answer 529

Di George's syndrome

Question 530

DiGeorge syndrome defect

Answer 530

Aut Dom 22q11.2 microdeletion

Question 531

Di George syndrome features

Answer 531

CATCH 22 Cardiac abnormalities - Tetralogy of Fallot, Truncus arteriosus Abnormal facies Thymic aplasia Cleft Palate HypoCa/hypoPTH 22q11.2 microdeletion Also: Failure to develop 3rd, 4th pharyngeal pouches LD Recurrent viral/fungal infections

Question 532

Immunodeficiencies - combined B and T cell disorders

Answer 532

SCID WAS Ataxic and Hyper SCID Wiskott-Aldrich Syndrome Ataxic Telangiectasia Hyper-IgM syndrome

Question 533

SCID defect

Answer 533

X- linked - most often recessive Defect in common gamma chain (protein used for IL-2 and other ILs) Can also be due to adenosine deaminase def

Question 534

SCID features

Answer 534

Recurrent infections (viral, bacterial, fungal) Reduced T-cell receptor excision circles

Question 535

SCID Rx

Answer 535

Stem cell transplantation

Question 536

Wiskott-Aldrich Syndrome defect

Answer 536

X rec WASP gene defect

Question 537

Wiskott-Aldrich syndrome features

Answer 537

Recurrent bacterial infections Eczema Low platelets Autoimmune + malignancy risk Low IgM

Question 538

Ataxic telangiectasia defect

Answer 538

Aut rec DNA repair enzyme defect

Question 539

Ataxic telangiectasia features

Answer 539

Cerebellar ataxia Telangiectasia (spider angiomas) Recurrent chest infections 10% riskof lymphoma/leukaemias

Question 540

Hyper IgM syndrome defect

Answer 540

CD40 mutations

Question 541

Hyper IgM syndrome features

Answer 541

infection/pneumocystis pneumonia Hepatitis Diarrhoea

Question 542

Vitamin D actions

Answer 542

(Steroid hormone, fat-soluble) Increases Ca + PO4 Increases gut Ca + PO4 absorption Increases renal Ca + PO4 reabsorption Regulates osteoblast activity Suppresses PTH release Facilitates PTH-induced osteoclast activation and bone resorption Immuno-inflammation - maintains balance between Th1 and Th2 activity - reduces Th1 response to mitigate inflammation and tissue damage, upregulates Th2 response - anti-inflammatory

Question 543

Where does vit D enhance PO4 reabsorption in the nephron?

Answer 543

PCT

Question 544

PTH actions

Answer 544

Increases Ca Reduces PO4 Increases renal Ca reabsorption Reduces renal PO4 reabsorption Increases osteoclast activity (indirectly) Renal 1 alpha hydroxylation of 25 hydroxycholecalciferol

Question 545

Calcitonin

Answer 545

From Thyroid C cells Inhibits osteoclast activity Inhibits renal tubular Ca reabsorption

Question 546

Inferior MI - which artery is affected?

Answer 546

Distal RCA if right sided dominant If left dominant, left circumflex

Question 547

Rx for acne rosacea for flushing/erythema sx

Answer 547

Topical brimonidine (alpha agonist)

Question 548

Mild/mod acne rosacea Rx

Answer 548

1. topical ivermectin Alternatives - (eg if pregnant) topical metronidazole azelaic acid (beware hypersensitivity)

Question 549

Mod/severe acne rosacea rx

Answer 549

Topical ivermectin + oral doxycycline

Question 550

When to refer for acne rosacea

Answer 550

If rhinophyma or refractory To consider laser therapy if prominent telangiectasia

Question 551

If suspicious of Brugada, what can you give to unmask ECG changes to make a diagnosis?

Answer 551

Ajmaline infusion or Flecainide

Question 552

Brugada vs HOCM or Long QTc features

Answer 552

Episodes of VF much more often seen at night, when asleep in Brugada In HOCM, long QTc, disturbances often related to exercise (except with inherited type III long QT syndrome)

Question 553

WPW associations

Answer 553

HOCM MVP Ebstein's Thyrotoxicosis ASD secundum PRKAG2 gene mutation

Question 554

Which drugs to avoid in HOCM

Answer 554

ACE inhibitors Nitrates Ionotropes

Question 555

When comparing means across different populations/groups, which statistical test should be used?

Answer 555

Tukey's range test

Question 556

Upper zone fibrosis causes

Answer 556

CHARTS Coal worker's pneumoconiosis Histiocytosis/Hypersensitivity pneumonitis Ankylosing Spondylitis Radiation TB Silicosis

Question 557

Lower zone fibrosis causes

Answer 557

CIMBAA Connective tissue disorders (Rheumatoid, SLE) Idiopathic pulmonary fibrosis Methotrexate Bleomycin Amiodarone Asbestosis

Question 558

Do diuretics affect preload or afterload?

Answer 558

Preload

Question 559

58M with known right lower lobe bronchiectasis presents to ED with 200ml of haemoptysis. He states small amounts of haemoptysis over the last 3 months, with gradual increase in frequency. He was admitted with RLL pneumonia one year ago. Temperature 36.7, Pulse 105bpm, regular, BP 110/80, RR 23. Reduced breath sounds at right base. Sats 90% on air. Hb 99 WCC 6.9 plt 303 Na 143 K 4.7 Cr 92 CXR: right basal patchy opacification Which of the following is the most important intervention? - CT angiography - IV abx - LMWH - Routine bronchoscopy - Tranexamic acid

Answer 559

CT angiography Has had large haemoptysis withsteady increase of haemoptysis over last few months. Potentially life threatening bleed evidenced and it is likely that the bronchiectasis with inflammation/erosion is compromising a pulmonary vessel. Currently, he is stable so CT angiography can be performed with the option to embolise a bleeding vessel with the help of IR Bronchoscopy can also be considered on an urgent/emergency basis to achieve haemostasis, by bedside (not routine) TXA can be used but more urgently, needs to find the cause of the bleed

Question 560

Dx of catch scratch disease

Answer 560

Warthin-Starry staining for Bartonella

Question 561

Brucellosis features

Answer 561

fever malaise hepatosplenomegaly sacroiliitis Hyperhidrosis - wet hay smell Erythema nodosum

Question 562

Compl of brucellosis

Answer 562

Osteomyelitis Infective endocarditis Meningoencephalitis Orchitis Leukopenia

Question 563

Ix and dx for brucellosis

Answer 563

Rose Bengal plate test - screening Serology - dx

Question 564

Rx for brucellosis

Answer 564

Doxy + streptomycin or Doxy + rifampicin 6 weeks

Question 565

Leptospirosis features:

Answer 565

Early: Flu-like Subconjunctival suffusion/haemorrhage 2nd phase - Weil's disease: AKI 50% Hepatitis Hepatomegaly Aseptic meningitis Cardiac

Question 566

Leptospirosis ix

Answer 566

Serology - Abs present after 7 days Microscopic agglutination test - paired acute + convalescent plasma samples 2 wks apart PCR Cultures (takes several weeks, urine culture +ve during 2nd wk of illness)

Question 567

Rx for leptospirosis

Answer 567

High-dose benzylpenicillin or Doxycycline

Question 568

Achondroplasia genetics

Answer 568

Aut Dom FGFR-3

Question 569

L3 sensory + motor

Answer 569

Sensory: anterior portion of thigh down to medial epicondyle of femur Motor: Knee extension

Question 570

How do NSAIDs cause renal damage over time?

Answer 570

COX inhibition --> reduced Prostaglandin E2 and I2, which are crucial for adequate renal perfusion via arteriolar dilatation

Question 571

Gilbert's syndrome genetics

Answer 571

Aut Rec mild deficiency in bilirubin Uridine diphosphate glucuronosyltransferase (UDP-glucuronyl transferase)

Question 572

What is the direct precursor to bilirubin?

Answer 572

Biliverdin

Question 573

Gilbert's Ix

Answer 573

IV nicotinic acid --> causes rise in bilirubin

Question 574

Inherited Causes of unconjugated bilirubinaemia

Answer 574

Gilbert's Crigler Najjar

Question 575

Crigler najjar:

Answer 575

Type 1: Aut Rec Absolute UDP-glucuronosyl transferase deficiency No survival beyond adulthood Type 2: More common and less severe than type 1

Question 576

Inherited Causes of conjugated bilirubinaemia

Answer 576

Dubin-Johnson syndrome Rotor syndrome

Question 577

Dubin-Johnson syndrome

Answer 577

Aut Rec Defect in cannalicular multispecific organ anion transporter (cMOAT) protein Defective hepatic bilirubin excretion due to multidrug resistance protein 2 (MRP2) Grossly black liver

Question 578

Rotor syndrome

Answer 578

Aut rec Defect in hepatic uptake and bilirubin storage Benign

Question 579

Investigations for sulfonylurea abuse

Answer 579

Has raised insulin and C-peptide Requires urinary analysis for sulfonylureas

Question 580

What kind of stuff's on the Barthel index?

Answer 580

Feeding Bathing Grooming (incl dressing) Bowel control Bladder control Toilet use Mobility on a level surface Ability to climb stairs

Question 581

Sjogren's Abs

Answer 581

ANA 70% Rh Factor 50% Anti-Ro 70% anti-La 30%

Question 582

Freiberg's disease

Answer 582

Avascular necrosis of the second metatarsal Seen in young women May be related to stress or trauma Blood supply to second metatarsal slightly tenuous and easily interrupted XR: sclerotic, flattened metatarsal

Question 583

Gene mutation responsible for rapidly progressive focal segmental glomerulosclerois in West African population

Answer 583

APOL1

Question 584

Alport's genetics

Answer 584

X dominant Type 4 collagen defect COL4A4 mutation

Question 585

Impetigo Rx

Answer 585

hydrogen peroxide 1% or topical fusidic acid or topical mupirocin if resistance suspected or MRSA or Flucloxacillin (or erythromycin if pen allergic) if extensive School exclusion 48hrs post abx start or until lesions have crusted over + healed

Question 586

Alport's syndrome features

Answer 586

Goodpasture's-like Renal: Microscopic haematuria Progressive renal failure Ears: B/l sensorineural deafness Eyes: Lenticonus Retinitis pigmentosa Leiomyoma Aortic dissection

Question 587

Fat soluble vitamins

Answer 587

ADEK

Question 588

Sleep stages

Answer 588

The Sleep Doctor's Brain N1: Theta waves, light sleep, hypnic jerks N2: Sleep spindles + K complexes, Deeper sleep, 50% of total sleep N3: Delta waves, deep sleep, parasomnias (night terrors, nocturnal enuresis, sleepwalking) REM: Beta waves, dreaming, atonia, erections

Question 589

45M to be discharged following intentional paracetamol OD with 30 tablets, with symptoms of severe depression. What is the most appropriate next step? - 28 days amitriptyline 100mg OD + CBT - 7 days citalopram 20mg OD + CBT - 7 days diazepam 5mg BD + CBT - 28 days duloxetine 60mg OD + CBT - CBT without medications

Answer 589

7 days citalopram 20mg OD + CBT Should minimise access to harmful agents so only prescribe 7 days worth of meds. SSRIs are also safer than TCAs in OD Prescription should be combined with CBT

Question 590

MRI/CT showing leptomeningeal and pachymeningeal enhancement with dilated perivascular spaces HIV +ve 35M presented with grand mal seizure, drowsy, confused, GCS 13, temp 38, bp 105/70, pulse 94, regular Fundoscopy with b/l papilloedema Cause?

Answer 590

Cryptococcal infection

Question 591

Progressive multifocal leukoencephalopathy MRI and CT findings

Answer 591

CT - single/multiple lesions, no mass effect, no enhancement MRI - high-signal demyelinating white matter lesion

Question 592

Herpes simplex encephalitis CT/MRI findings

Answer 592

MR better Medial temporal, inferior frontal changes (eg petechial haemorrhages)

Question 593

Procyclidine MOA

Answer 593

anticholinergic

Question 594

ADPKD genetics

Answer 594

Aut Dom PKD1 in Chr 16 PKD 2 in Chr 4

Question 595

IgA nephropathy biopsy

Answer 595

Mesangial hypercellularity Immunofluorescence +ve for IgA, C3

Question 596

Poor Prognosis factors for IgA nephropathy

Answer 596

Proteinuria Male HTN ACE genotype DD Smoking High cholesterol

Question 597

Good prognosis factors for IgA nephropathy

Answer 597

Frank haematuria

Question 598

Alexia without agraphia - which brain lesion causes this?

Answer 598

Left posterior cerebral artery perfusing splenium of corpus callosum and left visual (occipital) cortex

Question 599

CLL poor prognosis

Answer 599

Male Age>70 Lymphocytes >50 Prolymphocytes >10% Lymphocytes doubling in <12 months Raised LDH CD38 +ve TP53 mutation Deletion of short arm of Chr 17

Question 600

Good prognosis factors in CLL

Answer 600

Deletion of long arm of Chr 13

Question 601

Crypt abscesses in IBD

Answer 601

UC

Question 602

Granulomas in IBD

Answer 602

Crohn's

Question 603

Rose thorn ulcers in IBD

Answer 603

Crohn's

Question 604

Patau syndrome

Answer 604

Trisomy 13 Microcephaly Small eyes Cleft lip/palate Polydactyly Scalp lesions

Question 605

Edward's syndrome

Answer 605

Trisomy 18 Micrognathia Low-set ears Rocker bottom feet Overlapping fingers

Question 606

Fragile X

Answer 606

LD Macrocephaly Long face Large ears Macro-orchidism

Question 607

Noonan syndrome

Answer 607

Aut dom Chr 12 (noon's at 120 Webbed neck Pectus excavatum Short stature Pulmonary stenosis Cryptorchidism

Question 608

Pierre-Robin syndrome

Answer 608

Micrognathia Posterior displacement of tongue (can result in airway obstruction) Cleft palate

Question 609

Prader-Willi syndrome

Answer 609

Hypotonia Hypogonadism Obesity

Question 610

William's syndrome

Answer 610

Short stature LD Friendly, extrovert personality Transient neonatal hyperCa Supravalvular AS

Question 611

Cri du chat syndrome

Answer 611

Chr 5p deletion Characteristic cry (hence the name) Larynx and neurological problems Feeding difficulties and poor weight gain LD Microcephaly and micrognathism Hypertelorism

Question 612

Where is VIP secreted from

Answer 612

Small intestine Pancreas

Question 613

What does VIP do?

Answer 613

Stimulates pancreas and intestinal secretion Inhibits acid secretion

Question 614

Where is CCK released from

Answer 614

I cells in small intestine

Question 615

5 main causes of massive splenomegaly

Answer 615

Myelofibrosis CML Visceral Leishmaniasis (kala-azar) Malaria Gaucher's syndrome

Question 616

Addison's and calcium

Answer 616

HypoCa

Question 617

Causes of high prolactin

Answer 617

Pregnancy Prolactinoma Oestrogens Physiological (Stress, exercise, sleep) Acromegaly PCOS Primary hypothyroidism Dopamine antagonists Antipsychotics SSRIs Opioids

Question 618

Doxazosin SE

Answer 618

Pitting oedema of lower limb Cardiac failure

Question 619

Contraction of which muscle does clonus involve?

Answer 619

Gastrocnemius

Question 620

Where is the insulin receptor located?

Answer 620

On the cell membrane - it is a tyrosine kinase transmembrane receptor

Question 621

Types of aortic dissection

Answer 621

Type A - ascending aorta Type B - descending aorta DeBakey classification: Type I - from ascending aorta --> aortic arch --> possibly more distal Type II - just in ascending aorta Type III - starts in descending aorta --> extends distally

Question 622

Aortic dissection - what agent to lower bp with?

Answer 622

IV labetalol - for close titration Beta blockers preferred as it reduces force of ventricular contraction

Question 623

What is used for CMV prophylaxis?

Answer 623

Valganciclovir 450mg OD (better than ganciclovir)

Question 624

Pyoderma gangrenosum features

Answer 624

Nodule developing rapidly to inflamed ulcerated lesion

Question 625

Red-brown plaques over pre-tibial area, gradually extending and developing central atrophic skin with yellow discolouration

Answer 625

Necrobiosis lipoidica

Question 626

What factor leads to high level of clearance via haemodialysis?

Answer 626

High water solubility Low molecular size

Question 627

Where does the PICA branch from?

Answer 627

Vertebral artery

Question 628

Where does the AICA branch from?

Answer 628

Basilar artery

Question 629

Most appropriate rx for unconscious hypoglycaemic?

Answer 629

IM glucagon 1mg

Question 630

Diabetic nephropathy biopsy features

Answer 630

Basement membrane thickening Capillary obliteration Mesangial widening Nodular hyaline areas (Kimmesltiel-Wilson nodule)

Question 631

Endothelin actions

Answer 631

Natriuresis + Diuresis Vasodilation (driven by NO release) Bronchoconstriction

Question 632

Where does the parietal lobe receive blood supply from?

Answer 632

Middle + anterior + posterior cerebral arteries

Question 633

What should surfaces on wards be cleaned with to reduce sprea of C Diff?

Answer 633

Dilute bleach solution

Question 634

Amlodipine SE

Answer 634

Flushing Headache Ankle swelling

Question 635

Verapamil SE

Answer 635

HF Constipation Hypotension Bradycardia Flushing Avoid in VT

Question 636

Diltiazem SE

Answer 636

Hypotension Bradycardia HF Ankle Swelling

Question 637

Diphtheria Rx

Answer 637

IM penicillin Diphtheria antitoxin

Question 638

Diabetic nephropathy Rx

Answer 638

ACE inhibitors

Question 639

What do you need to give for patients with primary pulmonary HTN who get pregnant and why?

Answer 639

LMWH due to risk of PE

Question 640

What happens to pulse pressure with age?

Answer 640

Widens over time - SBP increases, DBP falls or stays the same Due to arterial stiffness increasing over time

Question 641

Markers in testicular cancer - seminomas

Answer 641

beta hCG 20% LDH (more sensitive, much less specific)

Question 642

Markers in testicular cancer - non-seminomas and teratomas

Answer 642

AFP +/- beta hCG in 80%

Question 643

ARDS Causes

Answer 643

Infection - sepsis, pneumonia, COVID Massive blood transfusion Trauma Smoke inhalation Acute pancreatitis Cardio-pulmonary bypass

Question 644

Diagnosis of ARDS

Answer 644

Acute <1wk B/l opacities on radiography/ b/l B lines and/or consolidations on USS not fully explained by effusions, atelectasis or nodules/masses PaO2/FiO2<40

Question 645

ARDS rx

Answer 645

Oxygenation +/- ventilation

Question 646

19F, microcytic anaemia, normal menstrual cycle, suffers intermittent diarrhoea and abdo bloating, putting it down to her diet. BMI 23. IDA noted on bloods What is the likely underlying diagnosis?

Answer 646

Coeliac disease

Question 647

Normal range of FEV1/FVC ratio

Answer 647

0.75-0.85

Question 648

Rx for SBP

Answer 648

IV cefotaxime

Question 649

SBP diagnosis

Answer 649

Ascitic tap neutrophils> 250 cells/ul

Question 650

When to give Abx prophylaxis for SBP and what is the abx

Answer 650

If fluid protein <15g/l If Child-Pugh >9 If hepatorenal Give oral cipro/norfloxacin

Question 651

Renin aldosterone ratio in Conn's and RAS

Answer 651

Conn's - low RAR RAS - high RAR

Question 652

HELLP syndrome Rx

Answer 652

4g MgSO4 Then, assess whether delivery possible/appropriate

Question 653

Impaired near vision, impaired dark adaptation, optic-nerve drusen

Answer 653

Macular degeneration

Question 654

LTOT in COPD criteria

Answer 654

PaO2<7.3 kPa or PaO2 7.3-8 kPa + secondary polycythaemia, peripheral oedema, pulm HTN

Question 655

24F, RIF pain, Fever, Joint pain over last 10 days with mild diarrhoea. Returned from holiday in Thailand shortly before symptoms. Temp 38.2, bp 105/72, HR 95, regular. Tender in RIF and BS normal Hb 131 WCC 13.3 Platelets 209 Na 142 K 4.5 Cr 82 CRP 175 Stool culture G -ve rod Most likely organism

Answer 655

Yersinia enterocolitica

Question 656

Yersinia enterocolitica Rx

Answer 656

aminoglycosides

Question 657

Typical Antipsychotics Examples

Answer 657

Haloperidol Chlorpromazine

Question 658

Atypical antipsychotic examples

Answer 658

Clozapine Risperidone Olanzapine Apiprazole

Question 659

Creutzfeld-Jakob disease (CJD) MRI findings

Answer 659

hyperintense signals in basal ganglia, thalamus Hockey stick sign in pulvinar region

Question 660

What should be used with caution in AS

Answer 660

Bisoprolol Nitrates

Question 661

Cortical blindness lesion

Answer 661

Occipital lobes

Question 662

Lithium action on nephrons

Answer 662

Nephrogenic diabetes insipidus Reduced aquaporin 2 expression

Question 663

Complications of SAH

Answer 663

Re-bleed Hydrocephalus Vasospasm Hyponatraemia (SIADH) Seizures

Question 664

Gradual deterioration with headache and confusion after SAH

Answer 664

Hydrocephalus

Question 665

When are re-bleeds most common post SAH

Answer 665

in 1st 12 hrs

Question 666

Acutely painful red eye with cloudy anterior chamber

Answer 666

Anterior uveitis

Question 667

Large A waves causes

Answer 667

Anything increasing right ventricular resistance when right atrium contracts so: Right ventricular hypertrophy Tricuspid stenosis Pulmonary stenosis (due to RVH with pulm stenosis) Pulm HTN

Question 668

How to manage psychotic sx in Parkinson's disease?

Answer 668

1. Quetiapine 2. Clozapine

Question 669

Reverse split S2 causes

Answer 669

P2 before A2 LBBB Severe AS RV pacing WPW type B PDA

Question 670

Widely split S2

Answer 670

Deep inspiration RBBB Pulm stenosis Severe MR

Question 671

Carney syndrome

Answer 671

Left atrial myxoma Pituitary adenoma

Question 672

25F, aquarium worker, with rash on dorsum of right hand that has been there for weeks. Ring of papules around 2cm across the dorsum of the hand. Each papule 1-2mm in diameter. Rash non-itchy. Diagnosis? Granuloma annulare Mycobacterium marinum Pityriasis rosea Sarcoidosis Tinea corporis

Answer 672

Granuloma annulare. Mycobacterium marinum is a single erythematous nodular lesion rather than an arc of small papules

Question 673

Mebendazole MOA

Answer 673

inhibiting the production of microtubules via binding to colchicine binding-site of β-tubulin and thereby blocking polymerization of tubulin dimer

Question 674

Antibiotic for women with UTI who have eGFR <45

Answer 674

Pivmecillinam 400mg STAT + 200mg TDS 3 days

Question 675

Carcinoid syndrome Rx

Answer 675

1. Octreotide 2. Telotristat - tryptophan hydroxylase inhibitor (blocks tryptophan to serotonin conversion)

Question 676

What causes hepatorenal syndrome

Answer 676

Splanchnic VASODILATION --> RAAS activation --> renal vasoconstriction

Question 677

32M worsening asthma despite taking high dose salmeterol fluticasone inhaler. He is obese and takes omeprazole for reflux symptoms which happens most evenings. His chest is clear on auscultation. His BMI is 31. Hb 140 WCC 7.1 PLT 181 Na 142 K 3.9 Cr 80 Which of the following is the most useful next investigation? - Bronchoscopy - CT thorax - Oesophageal pH monitoring - Resp function test - Serial peak- flow measurement

Answer 677

Oesophageal pH monitoring GORD can lead to increase in vagal tone that can contribute to bronchial hyperreactivity. Micro-aspiration of acid into the bronchial tree also though to occur at night.

Question 678

In immunocompetent Hep B infections, what is the treatment?

Answer 678

Observation - it is self-limiting in more than 90%

Question 679

Drug causes of peripheral neuropathy

Answer 679

MAIN Venom Metronidazole Amiodarone Isoniazid Nitrofurantoin Vincristine

Question 680

Drugs causing lung fibrosis

Answer 680

CRANE Cytotoxics (bleomycin, busulphan) Rheumatoid rx (methotrexate, sulfasalazine) Amiodarone Nitrofurantoin Ergot-derived dopaminergics (bromocriptine, cabergoline, pergolide)

Question 681

Most common GI manifestations of CMV infection in HIV

Answer 681

Colitis (most common) Oesophagitis

Question 682

Monitoring requirements in myotonic dystrophy

Answer 682

ECGs - due to risk of atrial arrhythmias and heart blocks Every 1-5 yrs LV dysfunction also possible

Question 683

Diffuse proliferative GN biopsy

Answer 683

Glomeruli showing endothelial and mesangial proliferation, 'wire-loop' appearance EM: subendothelial immune complex deposits Immunofluorescence: granular appearance If severe: thickened capillary wall due to immune complex deposits

Question 684

Hydralazine SE

Answer 684

tachycardia palpitations flushing fluid retention headache drug-induced lupus

Question 685

Median nerve injury

Answer 685

LOAF muscles: Lateral 2 lumbricals Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis Injury at wrist --> thenar wasting + opponens pollicis weakness Injury at elbow --> loss of pronation of forearm and weak wrist flexion Sensory loss to palmar aspect of lateral 3.5 fingers

Question 686

Membranoproliferative GN Biopsy

Answer 686

Type 1: EM shows 'tram-track' appearance with subendothelial and mesangium immune deposits of electron-dense material Type 2: EM shows intramembranous immune complex deposits with 'dense deposits'

Question 687

Where is ghrelin secreted from?

Answer 687

P/D1 cells in stomach fundus and epsilon cells of pancreas

Question 688

Sezary syndrome

Answer 688

T cell cutaneous lymphoma Sx: pruritis, erythroderma, atypical t cells, lymphadenopathy, hepatosplenomegaly

Question 689

How much does 1L of 0.9% saline increase intravascular volume?

Answer 689

200-250ml

Question 690

Chronic Heart Failure 1st line Rx

Answer 690

ACEi + Beta blockers If HR>75, beta blockers first If HR<75, ACEi first

Question 691

Normal gastric pH

Answer 691

1.5-3.5

Question 692

Which schistosomiasis species causes bladder issues?

Answer 692

S haematobium Causes pseudopapillomas in bladder causing inflammation and calcified egg clusters on XR, causing haematuria, obstructive uropathy, AKI, SCC

Question 693

Which schistosomiasis causes Katayama fever most commonly and what is Katayama fever?

Answer 693

Schistosomiasis japonicum Fever, urticaria/angioedema, cough, diarrhoea, eosinophilia

Question 694

Threadworms species

Answer 694

Enterobius vermicularis

Question 695

Threadworms rx

Answer 695

bendazoles

Question 696

Commonest causes of visceral larva migrans

Answer 696

Toxocara canis - dog roundworm

Question 697

How to treat dog roundworms?

Answer 697

Diethylcarbamazine

Question 698

Commonest cause of cutaneous larva migrans?

Answer 698

Ancylostoma braziliense - dog hookworm

Question 699

Dog hookworm rx

Answer 699

topical/oral thiabendazole

Question 700

Elephantiasis cause and rx

Answer 700

Wuchereria bancrofti Ditehylcarbamazine

Question 701

Cystercosis/neurocystercosis cause and rx

Answer 701

Taenia solium - undercooked pork Rx - bendazoles

Question 702

Culture -ve Infective endocarditis

Answer 702

Prior abx therapy Coxiella burnetii Bartonella Brucella HACEK Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella

Question 703

Poor prognosis factors in sarcoidosis

Answer 703

Insidious onset Features>6 months Absence of erythema nodosum Extrapulmonary manifestations CXR stage 3/4 features (interstitial infiltrates/fibrosis) Black African/Afro-Caribbean

Question 704

CRT in HF management

Answer 704

LVEF<35% QRS >150

Question 705

18F working in a nursery presents with sudden onset watery diarrhoea with mucus and blood over the past 6 hrs. Several staff and children have had the same symptoms over the last week. She has a 15mmHg postural drop in blood pressure moving from lying to standing and her heartrate is 95bpm and regular. She has a left sided abdominal tenderness. Most likely diagnosis

Answer 705

Shigella sonnei infection Acute watery diarrhoea with mucus or blood with significant postural hypotension when fluid loss significant. Lasts for 3 days and resolves spontaneously. If very severe or immunocompromised, can consider azithromycin

Question 706

Amyloidosis AL assx

Answer 706

MM Waldenstrom's MGUS Macroglossia

Question 707

Amyloidosis AA assx

Answer 707

Adult Still's Rheumatoid TB Bronchiectasis

Question 708

Amyloidosis B-2 microglobulin assx

Answer 708

renal dialysis

Question 709

AA amyloidosis features

Answer 709

Nephrotic syndrome Renal dysfunction Can lead to ESRF

Question 710

AL amyloidosis features

Answer 710

variable - SOB, weakness, proteinuria, nephrotic syndrome, impaired renal function, cardiomyopathy, heart failure

Question 711

ATTR amyloidosis

Answer 711

aut dom variant

Question 712

Which cells are increased in men vs in women in airways for CF

Answer 712

Men - neutrophils Women - eosinophils, mast cells, T cells

Question 713

Gitelman's syndrome genetics

Answer 713

Aut Rec SLC12A3 mutation Defect in thiazide-sensitive NaCl transporter in DCT

Question 714

Bartter's genetics

Answer 714

Aut Rec SLC12A1 mutation Defective Cl absorption at Na/K/Cl co-transporter in ascending loop of Henle

Question 715

Liddle's syndrome genetics

Answer 715

Aut Dom SCNN1B mutation Epithelial Na channel defect in DCT

Question 716

Time taken for keratinocyte turnover in normal vs in Psoriasis

Answer 716

28-30 days normal 3 days in psoriasis

Question 717

Alopecia areata

Answer 717

Well demarcated alopecia Small, broken 'exclamation mark' hairs

Question 718

Scarring alopecia causes:

Answer 718

Trauma Burns Radiotherapy Lichen planus Discoid lupus Tinea capitis

Question 719

Non-scarring alopecia causes:

Answer 719

Male-pattern baldness Drugs: cytotoxics, carbimazole, heparin, contraceptives, colchicine Deficiencies: iron, zinc Alopecia areata Telogen effluvium (post-stressful period) Trichotillomania

Question 720

Most sensitive way to differentiate between acute and chronic renal failure

Answer 720

Serum PTH - lower in AKI

Question 721

1st line rx in any prolactinomas

Answer 721

Cabergoline

Question 722

Low T4 and normal TSH

Answer 722

Secondary hypothyroidism (TSH should be high but is inappropriately normal) or Sick euthyroid syndrome (can either have low or normal TSH)

Question 723

Commonest congenital adrenal hyperplasia forms

Answer 723

21 hydroxylase deficiency (90%) 11 beta hydroxylase 5% 17 hydroxylase (rare)

Question 724

Aplastic anaemia ix

Answer 724

Bone marrow aspirate and trephine biopsy - hypocellular bone marrow, absence of abnormal infiltrate or marrow fibrosis

Question 725

Cutaneous Leishmaniasis

Answer 725

Leishmania tropica/mexicana Crusted lesion at site of ulcer, may have underlying ulcer Dx: punch biopsy - histology + culture Miltefosine - Systemic rx if from South/Central America due to mucocutaneous risk, or if multiple (>4) or large (>5cm) lesions or involving face, hands, genitals, or immunocompromised, or if local rx fails

Question 726

Mucocutaneous leishmaniasis

Answer 726

Leishmania braziliensis, guyanensis - from South/Central America Lesions spread from ulcer to involve mucosae of nose, pharynx etc

Question 727

Visceral leishmaniasis

Answer 727

Kala Azar Leishmania donovani (mediterranean, Asia, South America, Africa) Fevers, sweats, rigors, massive splenomegaly with pancytopenia, hepatomegaly, anorexia, weight loss, grey skin Dx by bone marrow or splenic aspirate - shows amastigotes

Question 728

Visceral Leishmaniasis rx

Answer 728

Miltefosine (Inhibits phosphatidylcholine synthesis) or Liposomal Amphotericin B

Question 729

Chagas disease

Answer 729

American trypanosomiasis T Cruzi Triatomine bug Chagomas, periorbital oedema Myocarditis, dilated CDM with apical atrophy, arrhythmias Mega GI - oesophagus, colon Rx: azoles (benznidazole) or nitroderivateves (nifurtimox)

Question 730

Sleeping sickness

Answer 730

African trypanosomiasis T rhodiense (east) or gambiense (west) Tsetse flies Chancres, fevers, posterior cervical lymphadenopathy, later neuro sx Rx: IV pentamidine/suramin, IV melarsoprol (later disease)

Question 731

King's college criteria for liver transplant

Answer 731

pH<7.3 or INR>6.5 + Creat >300 + G3/4 encephalopathy

Question 732

Aortic regurgitation murmur

Answer 732

Diastolic murmur over left sternal border (3/4th intercostal space)

Question 733

Mechanism behind acute transplant rejection

Answer 733

Lymphocytes activated against donor antigens are present, with donor dendritic cells functioning as antigen-presenting cells T-cell mediated - esp cytotoxic T cells

Question 734

Types of Von Hippel Lindau disease

Answer 734

Type 1 - low risk of phaeo Type 2 - have phaeo 2A - low risk of renal cell ca 2B - high risk of renal cell ca 2C - only have phaeo

Question 735

What mediates hepatotoxicity with sodium valproate?

Answer 735

Mitochondrial dysfunction

Question 736

Abs in systemic sclerosis with ILD

Answer 736

anti-topoisomerase 1 (anti-scl70) Also, anti-Th/To, anti-Ro52/TRIM21, anti-U11/U12

Question 737

HIV testing at 4 weeks since exposure

Answer 737

HIV-1 RNA testing - becomes +ve 1.5-2 wks post infection P24 Ag testing reaches max sensitivity at 3.5 weeks so chance it might be falsely -ve at this time

Question 738

Child-Pugh

Answer 738

Bilirubin: <34.2 - 1. 34.2-51.3 - 2. >51.3 - 3. Ascites: absent - 1. Slight -2. Moderate - 3. PT: <4 - 1. 4-6 - 2. >6 - 3. Albumin: >35 -1. 28 -35 -2. <28 -3. Encephalopathy: none - 1. 1-2 - 2. 3-4 - 3.

Question 739

UC inducing remission in severe

Answer 739

1. IV steroids 2. IV ciclosporin or surgery if no improvement after 72hrs

Question 740

Which type of Hb is increased in beta thalassaemia trate?

Answer 740

Hb A2

Question 741

Carbimazole MOA

Answer 741

thyroid peroxidase inhibitor - stops it from coupling and iodinating tyrosine residues on thyroglobulin

Question 742

Tinea capitis Rx

Answer 742

oral terbinafine for tricophyton tonsurans (commonest) oral griseofulvin for microsporum canis (dogs/cats) and, Topical ketoconazole shampoo for 2wks to reduce transmission

Question 743

HCC risk factors

Answer 743

Aflatoxin Hep B more (more worldwide) than Hep C (more in Europe) Cirrhosis ETOH HH PBC A1AT hereditary tyrosinosis Glyc storage disease Contraceptives Anabolic steroids PCT Males DM Metabolic syndrome

Question 744

Rapid onset, painless loss of vision with flame haemorrhages

Answer 744

Central retinal vein occlusion

Question 745

How does alcohol cause hypoglycaemia?

Answer 745

Exaggerated insulin secretion Effect on pancreatic microcirculation Redistribution of pancreatic blood flow from exocrine into endocrine parts

Question 746

BRCA2

Answer 746

Chr 13 Breast Ovarian Prostate Pancreas

Question 747

BRCA1

Answer 747

Chr 17 Breast Ovarian

Question 748

When to stop anti-TB meds in context of deranged LFTs

Answer 748

Stop all TB meds if more than 5 x upper limit of normal

Question 749

Long QT syndrome genetic defect

Answer 749

K channel ALPHA subunit defect Chr 11 Jervell-Lange-Nielsen: aut rec (deaf) KCNQ1 Romano-Ward: aut dom

Question 750

How to treat Barrett's oesophagus with low grade dysplasia?

Answer 750

High dose PPIs first If no improvement/refractory, radiofrequency ablation

Question 751

How to manage diabetes secondary to CF

Answer 751

Insulin Progressive beta cell loss and defective insulin release occurs in CF

Question 752

Evinacumab

Answer 752

anti-ANGPTL3 for familial hypercholesterolaemia

Question 753

Evolocumab

Answer 753

PCSK9 inhibitor prevents PCSK9-mediated LDLr degradation

Question 754

Chancroid

Answer 754

Haemophilus ducreyi (Painful ulcer + painful inguinal LN) Painful genital ulcers Unilateral, painful inguinal lymphadenopathy Ulcers have sharply defined, ragged, undermined border

Question 755

Lymphogranuloma venereum

Answer 755

Chlamydia trachomatis (Painless ulcer, painful inguinal LN) Stage 1: small PAINLESS pustule, later forms ulcer 3-12 days later Stage 2: PAINFUL unilateral inguinal lymphadenopathy ‘buboes’. Groove sign - separation of inguinal nodes by inguinal ligament Stage 3: proctocolitis

Question 756

Granuloma inguinale

Answer 756

Donovanosis - Klebsiella granulomatis Painless ulcer Painless genital ulcers, can progress to significant tissue destruction if untreated

Question 757

SIBO Dx

Answer 757

Hydrogen breath test 14-C D-xylose breath test 14-C-glychocolic acid breath test

Question 758

Medial pontine syndrome

Answer 758

Occlusion of paramedian branches of basilar artery Corticospinal - contralateral spastic hemiparesis Medial lemniscus - controlateral loss of fine touch, vibration, position sense Ipsilateral abducens

Question 759

Medial medullary syndrome

Answer 759

Deviation of tongue to side of infarct Contralateral limb weakness, fine touch, proprioception, vibration loss

Question 760

Where are thyroid hormone receptors located?

Answer 760

Nucleus (nuclear receptors)

Question 761

Morphine metabolites that accumulate in renal failure

Answer 761

Morphine-6-glucuronide Normorphine Morphine-3-glucuronide

Question 762

Where does gentamicin toxicity occur in the nephron?

Answer 762

PCT

Question 763

Where does rhabdomyolysis primarily damage in the nephron

Answer 763

DCT

Question 764

Right kidney anterior surface relations

Answer 764

Partly covered by peritoneum Liver 2nd part of duodenum Hepatic flexure of colon Small intestine

Question 765

Right kidney lateral border relations

Answer 765

Right lobe of liver Hepatic flexure of colon

Question 766

Left kidney anterior surface relations

Answer 766

Partly covered by peritoneum Spleen Stomach Pancreas Splenic vessels Jejunum Splenic flexure Descending colon

Question 767

Left kidney lateral border relations

Answer 767

spleen descending colon

Question 768

Alzheimer's genetics

Answer 768

5% aut dom amyloid precursor protein - chr 21 Presenilin 1 - chr 14 Presenilin 2 - chr 1 Apoprotein E allele E4 - cholesterol transport protein

Question 769

Amoebiasis

Answer 769

Entaemoeba histolytica Inc period >7 days Amoebic dysentery - long incubation period, abdo pain. Trophozoites on stool microscopy (hot stool required) Amoebic liver abscess - RUQ pain, 'anchovy sauce' liver contents, hepatomegaly Rx: oral metronidazole + luminal agent (eg diloxanide furoate)

Question 770

Steroid replacement in Addison's

Answer 770

15-25mg/day in two divided doses of oral hydrocortisone That's 4mg/day prednisolone

Question 771

29F with flu-like illness a few days post C-section, which involved a 3 unit blood transfusion. Pharyngitis and cervical lymphadenopathy seen Likely cause: Coxsackie B virus CMV EBV HHV7 Parvovirus B19

Answer 771

CMV Esp in light of 3U RBC transfusion - can mimick EBV. In adults, most have already been exposed to EBV, making it less likely in this age.

Question 772

When should metformin be stopped in renal failure?

Answer 772

GFR<30 Dose reduction if GFR 30-45

Question 773

Leber's hereditary optic neuropathy

Answer 773

Mitochondrial 9:1 M:F Progressive unilateral optic neuropathy, other eye affected months/yrs afterwards Some also have proximal myopathy, with hypertonia Fundoscopy - telangiectasias, pseudo-oedema of optic disc

Question 774

Gynaecomastia drug causes

Answer 774

DISCO + FC Digoxin Isoniazid Spironolactone Cimetidine Oestrogen Finasteride Cannabis

Question 775

Pneumococcal meningitis Rx

Answer 775

Ceftriaxone + Vancomycin

Question 776

CPM mechanism

Answer 776

Astrocyte apoptosis before oligodendrocyte apoptosis and degeneration as well as myelinolysis

Question 777

42F, BG of Sjogren's syndrome with left sided swelling of face - 2cm smooth swelling at angle of left jaw. Most likely dx?

Answer 777

Parotid gland stone

Question 778

Compl of pan-retinal photocoagulation

Answer 778

Loss of night, peripheral, colour vision

Question 779

Pelger-Huet anomaly

Answer 779

Aut Dom Defect in lamin B receptor gene Bilobed dumb-bell shaped nuclei Homozygotes have dysfunctional neutrophils - may have increased bacterial inf risk + skeletal abnormalities

Question 780

What causes haemoptysis in bronchiectasis?

Answer 780

Erosion and rupture of pulmonary capillaries or adjacent bronchial arteries May require embolisation if massive

Question 781

Strongest RFs for osteonecrosis of jaw when on bisphosphonates

Answer 781

Dental caries - greatest risk Smoking Age>65 long-term steroid use

Question 782

What contributes to IDA in CKD

Answer 782

Increased hepcidin - reduce oral iron absorption from duodenum by degrading ferroportin (may benefit better from ferinject)

Question 783

Accidental Adrenaline injection into digits Rx

Answer 783

Topical nitroglycerin initially Then consider phentolamine injection

Question 784

ECG feature signifying highest risk of cardiac arrest in hyperK

Answer 784

long QT

Question 785

Poor prognosis in AML

Answer 785

Age >60yrs >20% blasts post 1st chemo Chr 5 or 7 deletion

Question 786

Most likely abnormality on Lung function tests for obesity

Answer 786

Reduced expiratory reserve volume In severe obesity, reduced total lung capacity and FVC (but most likely to be normal in regular obesity)

Question 787

Avascular necrosis of hip features

Answer 787

Deep pain, worsened with exercise and when lying on affected side. Radiates to groin

Question 788

Nintedanib

Answer 788

Tyrosine kinase inhibitor for IPF

Question 789

Lewy Body Dementia Rx

Answer 789

ACh-esterase inhibitors - donepezil, rivastigmine NMDAr antagonists - memantine Avoid neuroleptics and dopamine antagonists (can develop irreversible parkinsonism)

Question 790

24M with neutropenic sepsis c/o blurred vision in his left eye. Fundoscopy shows yellow-white ball-like lesions affecting retina with blurred edges. Likely cause?

Answer 790

Candida albicans chorioretinitis Haematogenous spread in neutropenic pts. Systemic antifungals needed eg voriconazole

Question 791

Growth hormone in pregnancy

Answer 791

Rise initially Fall from wk 15-17 (due to -ve feedback loop from IGF1 that placental growth hormone initially drives increase of)

Question 792

ACTH hormone in pregnancy

Answer 792

Rise progressively

Question 793

Oxytocin in pregnancy

Answer 793

Rise from T1-T3, then fall from post-partum period

Question 794

Prolactin during pregnancy

Answer 794

Rise

Question 795

TSH in pregancy

Answer 795

Rise and peak at wk 24-28

Question 796

Most prominent Waldenstrom's Macroglobulinaemia features

Answer 796

Hyperviscosity - headache, blurred vision, dizziness

Question 797

62F reviewed in renal clinic with acidosis, hypoNa, hypoK. Recently completed chemo for breast Ca Where is the most likely site of her renal injury?

Answer 797

PCT - 70% of solutes including Na, K, HCO3, glucose reabsorbed in PCT. Chemo agents like ofosamide, oxaplatin can result in proximal RTA

Question 798

Which CD is present on mantle cells

Answer 798

CD5

Question 799

Which CD is on macrophages

Answer 799

CD14

Question 800

Which CD is on Reed Sternberg cells

Answer 800

CD15

Question 801

Which CD is the Fc of IgG

Answer 801

CD16

Question 802

Which CD is on EBV receptors

Answer 802

CD21

Question 803

Which CD acts as a co-stimulatory receptor on T cells

Answer 803

CD28

Question 804

Which CD is present on leucocytes

Answer 804

CD45

Question 805

Which CD is uniquely present on T killer cells

Answer 805

CD56

Question 806

Which CD is the FAS receptor?

Answer 806

CD95

Question 807

What molecular role does Vit B12 play?

Answer 807

Cofactor for methionine synthase function - prevents homocysteine rise, generating tetrahydrofolate and methionine Also cofactor forL-methylmalonyl-coenzyme A mutase function

Question 808

Actinic keratosis Rx

Answer 808

0.5% fluorouracil for 6-12wks Alternative: salicylic acid, imiquimod, diclofenac

Question 809

Rx choice when VT persists, failed chemical cardioversion with focal structural source of arrhythmia found?

Answer 809

Radiofrequency ablation

Question 810

18M of West African heritage, anaemic, no symptoms with moderate splenomegaly Hb 130 Blood film: target cells MCV 101 WCC 8.1 Plt 209 Na 143 K 4.9 Cr 90 Most likely cause of his anaemia

Answer 810

Haemoglobin C trait Common in West Africa, with MCV at top end of normal suggesting reticulocyte count. Target cells present with this

Question 811

Anti-NMDA paraneoplastic

Answer 811

Encephalitis 50% ovarian teratomas assx

Question 812

Anti-Hu paraneoplastic

Answer 812

Assx: small cell lung ca neuroblastomas Sx: sensory neuropathy (painful) cerebellar syndrome encephalomyelitis (Hu kicked my chair (pain) and then fell over (ataxia))

Question 813

Anti-Yo paraneoplastic

Answer 813

Assx: ovarian, breast ca (Yo lady (ovarian, breast ca) give me back my DANISH) Sx: cerebellar syndrome

Question 814

Anti-GAD paraneoplastic

Answer 814

Assx: breast, colorectal, small cell lung ca Sx: stiff person’s syndrome, diffuse hypertonia (GAD I’m stiff)

Question 815

Anti-Ri paraneoplastic

Answer 815

Small breasts Ri-eally blurry vision Assx: breast, small cell lung ca Sx: ocular opsoclonus-myoclonus (Ri-elly blurry vision)

Question 816

Purkinje cell Ab paraneoplastic

Answer 816

Assx: breast ca Sx: peripheral neuropathy

Question 817

MODYs commonest to least commonest

Answer 817

MODYs (aut dom): Dx with genetic testing. Rx: sulfonylureas 3-2-1, 45. MODY 3 (60%): HNF1A, progressive, higher risk for complications, Rx: low-dose sulfonylureas MODY 2 (20%): GCK, stable, fasting hyperglycaemia. Rx: none required MODY1: HNF4A, progressive, reduced endogenous insulin secretion, higher risk for complications MODY4: PDX1 MODY5: HNF1B

Question 818

Psoriatic arthritis Rx

Answer 818

Mild: NSAIDs Mod/severe: - methotrexate - mAbs: ustekinumab (IL12 + IL23) secukinumab (IL17) - apremilast (PDE4 inh, anti-inflammatory) Prognosis: better than Rh Arth

Question 819

57M with nausea, diarrhoea, facial flushing, SOB, palpitations 15-30mins post meal, after a partial gastrectomy for peptic ulcer disease 3/12 ago Most appropriate intervention?

Answer 819

Frequent, small, high-fibre, high-protein meals Pt has gastric dumping - change in eating patterns recommended. This likely developed post-op due to pyloric sphincter loss of function Can consider octreotide

Question 820

Carotid artery dissection ix

Answer 820

MR angiography most sensitive

Question 821

In MS with spasticity in a pt who is independent and high functioning, what is the recommended Rx?

Answer 821

Local therapy with botulinum toxin initially Baclofen usually 1st line for spasticity but if it is localised then botulinum toxin may be preferred

Question 822

27F, 29wks pregnant, with pain in left calf and left sided pleuritic chest pain. Calf mildly tender and 4cm greater in diameter than right calf. BP 122/72, HR 95bpm at rest. Chest clear on auscultation Most appropriate investigation?

Answer 822

Duplex ultrasound left leg V/Q scan has risks of baby cancer CTPA has risks of breast cancer So avoid these if possible by doing a duplex USS if high suspicion of DVT and treat if +ve for DVT

Question 823

Silicosis CXR

Answer 823

Upper zone fibrosis Reticulonodular shadowing Eggshell LN calcification

Question 824

34F with kidney-pancreas transplant for T1DM presents with deteriorating renal function. She received a 5-day course of 50mg Fluconazole for oral candidiasis 2 weeks ago. Her immunosuppressive regimen includes tacrolimus, prednisolone, mycophenolate mofetil. She feels well and has no symptoms. Hb 112 WCC 3.9 CRP 9 Plt 221 Na 143 K 4.9 Cr 220 What is the most likely cause of this patient's symptoms?

Answer 824

Tacrolimus toxicity Due to CYP450 inhibition by fluconazole resulting in increased tacrolimus levels, resulting in renal failure

Question 825

Conduction aphasia

Answer 825

Subcortical lesion near left superior temporal gyrus - in arcuate fasciculus in dominant hemisphere

Question 826

Lambert-Eaton Rx

Answer 826

Amifampridine - 3,4-diaminopyridine (increases ACh conc at NMJ, selectively inhibits presynaptic fast voltage gated K channels) Immunosuppression with prednisolone, azathioprine IVIG Plasma exchange

Question 827

Cellulitis related to DM - rx?

Answer 827

Co-amoxiclav - broad spectrum coverage

Question 828

What investigations to perform for achalasia?

Answer 828

Needs upper GI endoscopy first as 1/3 have malignancy Then Oesophageal manometry, barium swallow to diagnose

Question 829

Medullary sponge kidney

Answer 829

Predisposes to recurrent renal stones Can be aut dom CT urography to dx Potassium citrate to improve bone density

Question 830

Infective endocarditis blind therapy

Answer 830

Native valve: amox + gent Prosthetic valve: vanc + rifampicin + gent Pen allergic: vanc + gent

Question 831

Infective endocarditis Staphylococci rx

Answer 831

Native valve: fluclox Pen allergic/MRSA: vanc + rifampicin Prosthetic valve: fluclox + rifampicin + gent Pen allergic/MRSA: vanc + rifampicin + gent

Question 832

Streptococci infective endocarditis rx

Answer 832

Fully-sensitive: benzylpenicillin Pen allergic: vanc + gent Less sensitive: benzylpenicillin + gent Pen allergic: vanc + gent

Question 833

CSF production

Answer 833

Choroid plexus

Question 834

CSF absorption

Answer 834

Arachnoid granulations

Question 835

Menstrual migraines with highly predictable attacks - rx option when acute episodes are not responding adequately to intervention?

Answer 835

Zolmitriptan or frovatriptan as prophylaxis on days when headaches expected

Question 836

Down's cardiac assx

Answer 836

endocardial cushion defects Combined AVSD VSD Secundum ASD Tetralogy of Fallot (VSD, overriding aorta, pulm sten, rvh) Isolated PDA

Question 837

35M with abdo bloating, cramps, watery diarrhoea. Returned a short time ago from a luxury hotel in Tunisia. 5 of his relatives and friends who stayed at the same hotel and used the swimming pool are also unwell. Hb 125 WCC 7.2 CRP 65 Plt 185 Na 142 K 3.4 Cr 112 Cause?

Answer 837

Giardia lamblia Swimming pools can easily spread giardia rx with metronidazole

Question 838

Couple aged 25 and 27 referred to genetics clinic after having a 2nd child with trisomy 21. Planning for 3rd child Next step?

Answer 838

Karyotyping of both parents Robertsonian translocation likely cause in this case

Question 839

Commonest cause of trisomy 21

Answer 839

Non-disjunction (maternal) Risk at 40 1/100

Question 840

Severe asthma, eosinophilic, taking high-dose ICS + LABA + LTRA Most appropriate next intervention?

Answer 840

Mepolizumab Anti-IL5 mAb - lowers eosiniophil count

Question 841

Where are Beta 3 adrenergic receptors found?

Answer 841

Adipose tissue Bladder smooth muscle

Question 842

Severe COPD patient with 2 or more exacerbations in last 12 months despite triple therapy FEV1<50% of normal post-bronchodilator therapy Treatment option

Answer 842

Roflumilast PDE4 inhibitor

Question 843

COPD stages by FEV1

Answer 843

1- FEV1>80% 2- FEV1 50-79 3 - FEV1 30-49 4 - <30

Question 844

Syphilis Rx

Answer 844

IM benzathine penicillin Alt: doxy 14 days

Question 845

Causes of false +ve non-treponemal (VDRL, RPR) tests

Answer 845

Pregnancy Systemic: SLE, APLS Infections: TB Leprosy Malaria HIV

Question 846

SVT prophylaxis/prevention

Answer 846

Beta blockers - metoprolol Radio-frequency ablation

Question 847

UTI rx in pregnant

Answer 847

1. Nitrofurantoin 2. Amoxicillin or cephalosporins

Question 848

Pregabalin MOA

Answer 848

Voltage gated Ca channel inhibitor Specifically on alpha 2 delta subunit Although GABA analogue, no direct agonist acitvity on GABA A or B receptors - but does lead to increase in L-glutamic acid decarboxylase responsible for GABA synthesis

Question 849

Most common type of bladder caner

Answer 849

Urothelial/Transitional cell

Question 850

Anti-emetic option in terminal care when there is bowel obstruction

Answer 850

Haloperidol

Question 851

Is azathioprine teratogenic?

Answer 851

No

Question 852

Is mycophenolate mofetil teratogenic?

Answer 852

Yes

Question 853

Is tacrolimus teratogenic?

Answer 853

Yes - preterm birth increased

Question 854

Inciting pathological event in T2DM

Answer 854

Ectopic fat deposition - ie in visceral places next to liver and muscle

Question 855

What deficiencies do you commonly see post gastric bypass

Answer 855

Zinc ADEK vitamins

Question 856

Goserelin MOA

Answer 856

GnRH AGONIST

Question 857

Cowden's syndrome

Answer 857

Aut Dom PTEN mutation (tumour suppressor gene) Breast Colon Thyroid Endometrial Haemartomas Mucocutaneous neuromas acral keratosis

Question 858

How to monitor papillary thyroid cancer

Answer 858

Thyroglobulin levels yearly

Question 859

Familial hypocalciuric hypercalcaemia

Answer 859

No sx of hyperCa Aut Dom Urine Ca:creatinine clearance ratio <0.01 PTH norma Reduced 24hr urine ca