Third

Question 1

Entamoeba histolytica liver image findings suggestive of an amoebic liver abscess may demonstrate?

Answer 1

‘double-target’ sign, where there is central low attenuation fluid surrounded by an outer ring with high attenuation on the inside of the ring and lower attenuation on the outside

Question 2

Necrotising fasciitis bacteria

Answer 2

Type 1, or polymicrobial

Streptococcus pyogenes , Escherichia coli and Clostridium perfringens

Question 3

Familial Mediterranean Fever features and Mx

Answer 3

presents by the second decade.

common in Turkish, Armenian and Arabic descent.

Features - attacks typically last 1-3 days
pyrexia
abdominal pain (due to peritonitis)
pleurisy
pericarditis
arthritis
erysipeloid rash on lower limbs

Management
colchicine may help

Question 4

Creutzfeldt-Jakob disease

Answer 4

EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus

CSF Findings in CJD is 14-3-3 protein which has a sensitivity of 95% , PPV of around 92% and NPV of around 94%.

Question 5

bulging fissure sign is classical

Answer 5

Klebsiella pneumonia

Question 6

high risk for refeeding syndrome

Answer 6

BMI of <16 kg/m2 and no nutritional intake for >10 days

Unintentional weight loss of more than 15% over 3-6 months

hypophosphataemia and hypokalemia

Question 7

drugs causing pulmonary eosinophilia

Answer 7

drugs: nitrofurantoin, sulphonamides

Question 8

abnormal coag for hemophilia

DIC

HUS / HIT / TTP /ITP

Von willebrand

Answer 8

Both normal in hemophilia

haemophilia ( same as Von willebrand) - prolonged aPTT or normal

haemophilia A (same as Von willebrand) - severely reduced factor VIII levels

Haemophilia occur due to extreme lyonization, homozygosity, mosaicism, or Turner syndrome.
X linked recessive disease as males

haemophilia B - reduced factor 9

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To distinguish between vin willebrand and Hemophilia A -
Von willebrand has prolonged bleeding time and secondly, the platelet aggregation is impaired in response to ristocetin

DIC

DIC
fibrinogen can be normal or elevated in over 50% of cases especially early on (as fibrinogen is an acute phase marker)

PROLONGED PT and APTT

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PT/APTT are usually normal in ITP, TTP, HUS and HIT

Question 9

risk of developing breast and ovarian cancer by age 70 for BRCA1 and BRCA2

Answer 9

breast
55-65% = BRCA1
45% for BRCA2

ovarian
40% for BRCA1 a
15% for BRCA2 mutations.

Question 10

cholestasis (+/- hepatitis) causing drug?

Answer 10

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

Question 11

Cardiac failure of QRS is between 120 and 149ms without evidence of left bundle branch block

Answer 11

cardiac resynchronisation therapy - without defibrillator!!!

Question 12

hyperventilation syndrome (HVS) needs what score in Nijmegen questionnaire

Answer 12

More than 23

HVS - SOB with repeated admission
Rapidly improve in hospital with nebs
And Spirometry is normal

Question 13

Langerhans cell histiocytosis presentation

Answer 13

affects smokers 20-40 years due to proliferation of Langerhans cells (antigen presenting cells containing Birkbeck bodies on electron microscopy).

Presentation of LCH is with exertional dyspnoea and cough, spontaneous pneumothorax, clubbing and manifestation of granuloma infiltration in bones and the hypothalamus

Question 14

Lymphangioleiomyomatosis (LAM) presentation

Answer 14

interstitial lung disease, pneumothorax or chylous pleural effusion. Lung damage is similar to emphysema with pulmonary function tests showing reduced FVC, TLCO

reticulonodular changes in the bases bilaterally

cystic changes in the lung bases with a minimal left sided pleural effusion.

Question 15

immunosuppressant therapy currently being researched for use in non-small cell lung cancer?

Answer 15

Pembrolizumab

Question 16

small cell cancer staging and tx

Answer 16

Early stage (T1-2a,N0,M0) - surgery

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(T1-4,N0-3,M0)
4-6 cycles cisplatin based chemotherapy carboplatin

if poor renal function/poor performance status +/- radiotherapy

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Extensive disease

6 cycles platinum based combination chemotherapy + thoracic radiotherapy if good response

Question 17

how to treat hypertriglyeridemia?

Answer 17

fenofibrate and nicotinic acid

Question 18

how to treate high ldl levels ?

Answer 18

statin and Evolocumab, a PCSK9 inhibitor

Question 19

hiccup mx ?

Answer 19

Hiccup due to gastric distension may be helped by a preparation incorporating an antacid with an antiflatulent.

If this fails, metoclopramide hydrochloride by mouth or by subcutaneous or intramuscular injection can be added;

if this also fails, baclofen, or nifedipine, or chlorpromazine

haloperidol, gabapentin are also used

dexamethasone is also used, particularly if there are hepatic / cerebral lesions

Question 20

type 1 diabetes BM aim

Answer 20

5-7 waking
4-7- before meals
5-8-after meal

Question 21

Difference between duchenne and Becker

Answer 21

Duchenne - progressive proximal muscle weakness from 5 years

Becker muscular dystrophy- at 10 years

Question 22

High cholesterol MX

Answer 22

Statin

Evolocumab - for high LDL

ezetimibe in cases of primary hypercholesterolaemia

Question 23

What gives eruptive xanthoma?

Answer 23

Familial hypertriglycerdemia

Familial hypercholestrolemia - xanthoma and tendon xanthoma
intermittent claudication

Question 24

sodium / urine osmolality snd plasma osmolality

Answer 24

Plasma osmlarity
Low < 282- true hypotonic hyponatraemia. - check volume status

Normal 282-295 - pseudohyponatraemia and should prompt you to measure proteins and lipids\

High >295- hypertonic hyponatraemia and should prompt you to check for high levels of solutes in the plasma, hyperglycaemia being the most common.

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Low- sodium (<20) in the presence of hyponatraemia suggest that the kidneys are conserving sodium. This should prompt you to consider extra-renal sodium losses (e.g. via GI tract or skin).
secondary hyperaldosteronism: heart failure, liver cirrhosis
nephrotic syndrome
IV dextrose
psychogenic polydipsia

Beer potomania - urine osmolarity to be <100 also serum osmolarity

===========

· High->20 in the presence of hyponatraemia suggests renal sodium loss

Addison’s,
primary polydipsia (urine osmolarity to be <100)
SIADH

diuretics: thiazides, loop diuretics

diuretic stage of renal failure

SIADH (urine osmolality > 500 mmol/kg)
hypothyroidism

euvolaemic hyponatraemia : SIADH , HYPOTHYROIDISM AND Addison

Question 25

drugs known to cause pleural effusion

Answer 25

nitrofurantoin, methotrexate, and amiodarone

Question 26

measure the anticoagulant effect (doac)

Answer 26

aPTT and, if available, the thrombin time (TT)

apt will be prolonged

Question 27

plasma renin for renal artery stenosis ?

Answer 27

high plasma renin - response to the low pressure sensed by the constricted renal artery

Question 28

pathognomonic hallmark of chronic lead poisoning is

Answer 28

radial nerve palsy, or wrist drop, although many peripheral nerve palsies may be seen.

proximal renal tubular failure, particularly with increased excretion of phosphate and glucose and acidification of the urine

lead poisoning with a pronounced anaemia, often with dimorphic picture and reticulocytosis

Basophilia with stippling is seen and bone marrow trephine may show ring sideroblasts.

Abdominal pain, constipation, neuropsychiatric features

Question 29

occupational lead poisoning testing

Answer 29

erythrocyte zinc protoporphyrin (ZPP) levels and delta aminolevulinic acid dehydratase (ALAD)

coupled with skeletal analysis and blood lead levels are used to test for occupational lead poisoning

Question 30

ational choice for chemotherapy or post-operative related nausea

Answer 30

Ondansetron

Question 31

suitable choice where the cause of nausea is unknown and in the last days of life

Answer 31

Levomepromazine is correct. This is a broad-spectrum anti-emetic - a ‘dirty drug’ targeting many receptors

Question 32

what would make you not give doc to an AF patient ?

Answer 32

If this patient had mitral stenosis, weighed over 120kg

Question 33

Angina tx

Answer 33

1st line: PRN GTN
2nd line: BB or CCB
3rd line (if no hypotension after 2nd line) ISMN/nicorandil
3rd line (if hypotension after 2nd line) RANOLAZINE in HR<70, IVABRADINE in HR >70

recommend the use of no more than 2 antianginals prior to consideration of reperfusion therapies
patients with complex anatomy, triple vessel disease or proximal left mainstem disease report better long-term survival and freedom from MI is greater with CABG

Nicorandil is only contraindicated in LV failure and cardiogenic shock

Ranolazine - contra in severe kidney disease liver dysfunction, an absolute contraindication

Question 34

riteria for a treatment break for bone protection ?

Answer 34

her age (< 75 years),
femoral neck/ hip bone mineral density > -2.5
lack of history of fragility fracture
no Previous history of hip or vertebral fracture
not Taking oral glucocorticoids ≥7.5mg prednisolone/day or equivalent

Allpatients on bisphosphonate treatment for ≥10 years should be reviewed

repeat DEXA scan is recommended after two years or in the event of fragility fracture

Tx break after 3-5 years on bisphosoabte of low risk t score more than 2.5

Question 35

MPO and pr3 association antibodies

Answer 35

MPO antibodies - churg

pr3 positive Wegener’s granulomatosis

Microscopic polyangiitis is a small-vessel ANCA vasculitis.
pANCA (against MPO) - positive in 50-75%
cANCA (against PR3) - positive in 40%

Question 36

RAAS system for different disease

Answer 36

High Renin+ Aldosterone= RAS

Low Renin+ HIGH Aldosterone= conn syndrome

Low Renin + low Aldosterone= Liddile syndrome

high aldosterone, high renin, normotension, low K = bartter syndrome

High renin and low aldosterone - gitleman syndrome

Question 37

what can trigger bullous pemphigoid ?

Answer 37

Furosemide
C captopril derivative
P penicillin & penicillamine derivatives
S sulfasalazine

Question 38

primary pulmonary hypertension causes

Answer 38

primary
hiv
apetite suppressant - fenfluramine
connective tissue disease
vasculitis

secondary
thromboembolic

Question 39

Surgery for aortic regurgitation is indicated if

Answer 39

significant enlargement of the ascending aorta

severe regurgitation with symptoms

asymptomatic patients with severe AR who have LV systolic dysfunction ejection fraction of less than 50%

Question 40

surgery in MR indication

Answer 40

EF < 60%
2. Left ventricular end systolic diameter > 40mm
3. New onset of AF or pulmonary hypertension
4. High likelihood of durable repair with low surgical risk and absence of risk factors

Question 41

indication for surgery in parathyridectomy ?

Answer 41

Symptoms of hypercalcaemia
b. Osteoporosis and/or fragility fractures
c. Renal stones or nephrocalcinosis
2. Age <50 years
3. Serum adjusted calcium of 2.85 mmol/L or above
4. Estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m²

Question 42

patients admitted within three days of an acute stroke should have

Answer 42

intermittent pneumatic compression

LMWH - has a high chance of covering to hemorrhagic stroke

Question 43

Evan’s syndrome is

Answer 43

immune thrombocytopenic purpura (ITP) and autoimmune haemolytic anaemia (AIHA).

The body’s immune system mistakenly targets and destroys platelets and red blood cells leading to symptoms of both thrombocytopenia such as easy bruising, petechiae, and bleeding, as well as symptoms of haemolytic anaemia like fatigue, pallor and jaundice.

Diagnosis is typically based on the presence of these two conditions with a positive Direct Coombs Test (DCT) confirming AIHA

Question 44

Glanzmann Thrombasthenia

Answer 44

defective platelet aggregation due to a deficiency or dysfunction of the glycoprotein IIb/IIIa

causing mucocutaneous bleeding such as epistaxis, menorrhagia or gum bleeding.

confirmed by flow cytometry showing GPIIb/IIIa negativity

or Platelet Aggregation Tests using ADP, collagen or adrenaline which show abnormal results

while ristocetin-induced agglutination remains normal.

Question 45

Bernard-Soulier Disease

Answer 45

deficiency or dysfunction in the glycoprotein Ib-IX-V complex

prolonged bleeding time despite having normal platelet count but larger than average size (macrothrombocytes).

Diagnosis can be confirmed by flow cytometry showing GPIb/IX negativity

Platelet Aggregation Test showing decreased agglutination with ristocetin.

Question 46

Paroxysmal nocturnal haemoglobinuria

Answer 46

haemolytic anaemia
pancytopaenia may be present
haemoglobinuria: classically dark-coloured urine in the morning (although has been shown to occur throughout the day)
thrombosis e.g. Budd-Chiari syndrome
aplastic anaemia may develop in some patients

Diagnosis
flow cytometry of blood to detect low levels of CD59 and CD55

tx
blood product replacement
anticoagulation
eculizumab
stem cell transplantation

Question 47

AIP

Answer 47

Acute intermittent porphyria

Acute intermittent porphyria (AIP) defect in porphobilinogen deaminase,

abdominal: abdominal pain, vomiting
neurological: motor neuropathy
psychiatric: e.g. depression
hypertension and tachycardia common
classically urine turns deep red on standing

Diagnosis
raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks)
assay of red cells for porphobilinogen deaminase
raised serum levels of delta aminolaevulinic acid and porphobilinogen

Management
avoiding triggers
acute attacks
IV haematin/haem arginate
IV glucose should be used if haematin/haem arginate is not immediately available

Question 48

chronic demyelinating polyneuropathy

Answer 48

motor and sensory involvement

Question 49

multifocal motor neuropathy with conduction block

Answer 49

immune-mediated disorder, commonly associated with anti-GM1 antibodies

multifocal areas of demyelination and motor block, with f waves and H-reflexes

Anti-GM1b are antibodies typically present

without sensory or bulbar involvement

pure motor peripheral neuropathy

respond well to intravenous immunoglobulin.

Question 50

differentiate MND from multifocal motor neuropathy with conduction block

Answer 50

does not have nerve block ,

typically nerve conduction normal

Question 51

how to differentiate haemophilia A from von willebrand

Answer 51

von willebrand - prolonged bleeding time
platelet aggregation is impaired in response to ristocetin