Treating common conditions Flashcards

Question

Sodium valproate monitoring

Answer 1

patients taking nitrates and related drugs such as nicorandil hypotension recent stroke or myocardial infarction non-arteritic anterior ischaemic optic neuropathy

Answer 2

``` visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy nasal congestion flushing gastrointestinal side-effects headache ```

Answer 3

``` antibiotics: ciprofloxacin, erythromycin isoniazid cimetidine, omeprazole amiodarone allopurinol imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir sodium valproate acute alcohol intake quinupristin ```

Answer 4

dyskinesia (involuntary writhing movements), 'on-off' effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness

Answer 5

now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease

Answer 6

probably increases dopamine release and inhibits its uptake at dopaminergic synapses

Answer 7

``` migraine prophylaxis (women of childbearing age) prophylaxis of variceal haemorrhage essential tremor ```

Answer 8

generalised anxiety disorder | depression (post-myocardial infaction)

Answer 9

levodopa | corticosteroids

Answer 10

``` digoxin amantadine amantadine phenytoin metoclopramide ```

Answer 11

Propranolol

Answer 12

bronchospasm cold peripheries fatigue sleep disturbances, including nightmares

Answer 13

uncontrolled heart failure asthma sick sinus syndrome concurrent verapamil use: may precipitate severe bradycardia

Answer 14

``` pioglitazone corticosteroids ciclosporin hydralazine minoxidil ```

Answer 15

Anti-psychotics

Answer 16

dyskinesia, 'on-off' effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness

Answer 17

ataxia, slurred speech, confusion, dizziness and livedo reticularis

Answer 18

oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate) osteonecrosis of the jaw increased risk of atypical stress fractures of the proximal femoral shaft (alendronate)

Answer 19

clarithromycin

Answer 20

After a recent MI - may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration

Answer 21

gastrointestinal upsets are common reduced vitamin B12 absorption lactic acidosis with severe liver disease or renal failure

Answer 22

chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)

Answer 23

After a recent MI

Answer 24

CI'd with iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter

Answer 25

sumatriptan | hydralazine

Answer 26

'triptan sensations' - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure

Answer 27

fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin

Answer 28

``` dehydration & postural hypotension hyponatraemia, hypokalaemia, hypercalcaemia gout impaired glucose tolerance impotence ```

Answer 29

thrombocytopaenia agranulocytosis photosensitivity rash pancreatitis

Answer 30

B-blockers and verapamil

Answer 31

Fludrocortisone

Answer 32

Dexamethasone, Betmethasone

Answer 33

Prednisolone

Answer 34

Hydrocortisone

Answer 35

fluid retention | hypertension

Answer 36

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

Answer 37

impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia

Answer 38

musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head

Answer 39

Increased susceptibility to severe infection, reactivation of tuberculosis

Answer 40

insomnia, mania, depression, psychosis

Answer 41

peptic ulceration, acute pancreatitis

Answer 42

glaucoma, cataracts

Answer 43

suppression of growth in children intracranial hypertension Cushing's syndrome

Answer 44

Impaired glucose tolerance

Answer 45

patients taking nitrates and related drugs such as nicorandil hypotension recent stroke or myocardial infarction non-arteritic anterior ischaemic optic neuropathy

Answer 46

``` visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy nasal congestion flushing gastrointestinal side-effects headache ```

Answer 47

decreases conduction through the AV node which slows the ventricular rate in atrial fibrillation and flutter increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also stimulates vagus nerve

Answer 48

generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision arrhythmias (e.g. AV block, bradycardia)

Answer 49

``` classically: hypokalaemia* increasing age renal failure myocardial ischaemia hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis hypoalbuminaemia hypothermia hypothyroidism ```

Answer 50

amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics

Answer 51

Digibind correct arrhythmias monitor potassium

Answer 52

statins nicotinic acid fenofibrate

Answer 53

ACE inhibitors eg. enalapril

Answer 54

cough angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension (esp in patients taking diuretics)

Answer 55

urea and electrolytes should be checked before treatment is initiated and after increasing the dose a rise in the creatinine and potassium may be expected after starting ACE inhibitors. Acceptable changes are an increase in serum creatinine, up to 30%* from baseline and an increase in potassium up to 5.5 mmol/l*.

Answer 56

pregnancy and breastfeeding - avoid renovascular disease - significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis aortic stenosis - may result in hypotension patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) - significantly increases the risk of hypotension hereditary of idiopathic angioedema

Answer 57

Heart failure, constipation, hypotension, bradycardia, flushing

Answer 58

Angina, hypertension Less negatively inotropic than verapamil but caution should still be exercised when patients have heart failure or are taking beta-blockers

Answer 59

sildenafil

Answer 60

Flushing, headache, ankle swelling

Answer 61

Dihydropiridines eg amlodipine

Answer 62

Hypotension, bradycardia (less than verapamil but caution should still be exercised when patients have heart failure or are taking beta-blockers), heart failure, ankle swelling

Answer 63

thiazides loop diuretics pyrazinamide nicotinic acid

Answer 64

1) yes 2) no 3) yes

Answer 65

spironolactone

Answer 66

``` hypoglycaemic episodes (more common with long acting preparations such as chlorpropamide) weight gain ```

Answer 67

``` syndrome of inappropriate ADH secretion bone marrow suppression liver damage (cholestatic) photosensitivity peripheral neuropathy ```

Answer 68

That the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)

Answer 69

rifampicin

Answer 70

amiodarone lithium carbimazole

Answer 71

Myopathy (esp lipophilic ones): includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase. Liver impairment ?Stroke - there is some evidence that statins may increase the risk of intracerebral haemorrhage in patients who've previously had a stroke (not in primary prevention)

Answer 72

checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range

Answer 73

In patients with a history of intracerebral haemorrhage

Answer 74

all people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease) & NICE recommend anyone with a 10-year cardiovascular risk >= 20% Now diabetic patients > 40-years-old who have no obvious cardiovascular risk (e.g. Non-smoker, not obese, normotensive etc) and have a cardiovascular risk < 20%/10 years do not need to be given a statin.

Answer 75

``` Total cholesterol (mmol/l) LDL cholesterol Joint British Societies < 4.0 < 2.0 ```

Answer 76

glucagon-like peptide-1 mimetic

Answer 77

increases GABA activity

Answer 78

gastrointestinal: nausea, increased appetite and weight gain

Answer 79

hepatitis | pancreatitis

Answer 80

ataxia | tremor

Answer 81

thromobcytopaenia

Answer 82

teratogenic | alopecia: regrowth may be curly

Answer 83

hyponatraemia

Answer 84

Dipeptidyl peptidase-4 inhibitor - also doesn't cause weight gain. Whilst it is well known that insulin resistance and insufficient B-cell compensation occur other effects are also seen in type 2 diabetes mellitus (T2DM). In normal physiology an oral glucose load results in a greater release of insulin than if the same load is given intravenously - this known as the incretin effect. This effect is largely mediated by GLP-1 and is known to be decreased in T2DM. Increasing GLP-1 levels, either by the administration of an analogue (GLP-1 mimetics, e.g. exenatide) or inhibiting its breakdown (dipeptidyl peptidase-4, DPP-4 inhibitors - the gliptins), is therefore the target of two recent classes of drug.

Answer 85

bisphosphonates

Answer 86

amiodarone, quinidine, verapamil, diltiazem, spironolactone, thiazides, loop diuretics

Answer 87

verapamil tricyclic antidepressants opioids antipsychotics

Answer 88

heparin sodium valproate thiazides

Answer 89

azathioprine

Answer 90

brimonidine

Answer 91

sildenafil

Answer 92

corticosteroids sodium valproate thiazides valproic acid

Answer 93

statins | fenofibrate

Answer 94

hyperkalaemia

Answer 95

Octreotide

Answer 96

amiodarone methotrexate bromocriptine

Answer 97

A class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias

Answer 98

``` corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity, 'slate-grey' appearance bradycardia ```

Answer 99

long half-life (20-100 days) should ideally be given into central veins (causes thrombophlebitis) has proarrhythmic effects due to lengthening of the QT interval interacts with drugs commonly used concurrently e.g. Decreases metabolism of warfarin

Answer 100

``` hypotension hyponatraemia hypokalaemia hypochloraemic alkalosis hypocalcaemia ```

Answer 101

ototoxicity renal impairment (from dehydration + direct toxic effect) hyperglycaemia (less common than with thiazides) gout

Answer 102

amiodarone | adenosine

Answer 103

heparin amiloride ciclosporin

Answer 104

hypos and weight gain ``` (less often: syndrome of inappropriate ADH secretion bone marrow suppression liver damage (cholestatic) photosensitivity peripheral neuropathy) ```

Answer 105

lamotrigine | carbamazepine

Answer 106

levodopa digoxin interferon-alpha

Answer 107

chest pain bronchospasm can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)

Answer 108

oxybutynin

Answer 109

``` isotretinoin tricyclic antidepressants levodopa antipsychotics chlorpheniramine ```

Answer 110

5HT3 agonists

Answer 111

ascites: patients with cirrhosis develop a secondary hyperaldosteronism heart failure (NYHA III + IV, patients already taking ACE inhibitor) nephrotic syndrome Conn's syndrome

Answer 112

gout, pre-diabetes, impotence

Answer 113

Blocks the epithelial sodium channel in the distal convoluted tubule

Answer 114

phenytoin | carbamazepine

Answer 115

lithium sodium valproate valproic acid

Answer 116

sodium channel blocker, decreasing the sodium influx into neurons which in turn decreases excitability

Answer 117

``` P450 enzyme inducer dizziness and ataxia drowsiness headache visual disturbances (especially diplopia) Steven-Johnson syndrome leucopenia and agranulocytosis syndrome of inappropriate ADH secretion ```

Answer 118

``` gastrointestinal: nausea increased appetite and weight gain alopecia: regrowth may be curly ataxia tremor hepatitis pancreatitis thromobcytopaenia teratogenic hyponatraemia ```

Answer 119

corticosteroids infliximab etanercept

Answer 120

Oligospermia

Answer 121

Alemtuzumab Treatment of B-cell chronic lymphocytic leukemia (B-CLL) in patients who have been treated with alkylating agents and who have failed fludarabine therapy

Answer 122

patients taking nitrates and related drugs such as nicorandil hypotension recent stroke or myocardial infarction non-arteritic anterior ischaemic optic neuropathy

Answer 123

``` ataxia hepatitis pancreatitis thromobcytopaenia teratogenic ```

Answer 124

Lower them

Answer 125

Sedative (reducing dose of chlordiazepoxide; a benzodiazepine) • Anti-epileptic medication if seizures occur • Vitamin B1 (to prevent Wernicke’s encephalopathy)

Answer 126

1. Infection 2. Heart disease 3. Metabolic disturbance (hypoxia, electrolyte disturbance, hypoglycaemia) 4. Brain disease (stroke) 5. Drugs (night sedation, alcohol withdrawal)

Answer 127

Five questions about person, time and place 1. What is your age? 2. What is your date of birth? (day and month sufficient) 3. What is the time to the nearest hour? 4. What is the year? 5. What is the name of the hospital or number of the residence where the patient is situated? Three questions about factual knowledge 1. Can the patient recognize two persons (the doctor, nurse, home help, etc.)? 2. In what year did World War 1 begin? 3. Name the present monarch/dictator/prime minister/president Two questions about calculation/memory 1. Count backwards from 20 down to 1 2. Give the patient an address, and ask him or her to repeat it at the end of the test

Answer 128

a cholinesterase inhibitor in the CNS to augment cholinergic transmission

Answer 129

Many patients do not respond to the drug; some get worse • GI disturbances are common (20%) • It is reltively expensive

Answer 130

``` SSRIs lower risk of withdrawal low risk of suicide low risk in overdose now mostly generic drugs ```

Answer 131

MAOI reserved for resistant cases and usually only prescribed by psychiatrists

Answer 132

anticholinergic adverse effects cause withdrawal

Answer 133

``` Anticholinergic effects (dry mouth etc) • Postural hypotension (alpha blockade) • Parkinsonism (dopamine antagonism) • Sedation • Cholestasis leading to jaundice ```

Answer 134

a spectrum of extrapyramidal disorders (involuntary movements including athetosis, chorea)

Answer 135

TOLERANCE DEPENDENCE WITHDRAWAL REACTIONS

Answer 136

``` Hypnotics Pre-operative medication • Acutely confused patient • Acute anxiety • Acute epilepsy ```

Answer 137

Heparin and warfarin. If severe: thrombolysis too.

Answer 138

if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.

Answer 139

myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase. liver impairment: the 2008 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range there is some evidence that statins may increase the risk of intracerebral haemorrhage in patients who've previously had a stroke.

Answer 140

antibiotics: tetracycline, nitrofurantoin NSAIDs lithium metformin

Answer 141

``` most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin digoxin, atenolol methotrexate sulphonylureas furosemide opioids ```

Answer 142

Azathioprine is metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.

Answer 143

bone marrow depression nausea/vomiting pancreatitis

Answer 144

``` All patients should be offered the following drugs: ACE inhibitor beta-blocker aspirin statin ``` Clopidogrel since clopidogrel came off patent it is now much more widely used post-MI STEMI: the European Society of Cardiology recommend dual antiplatelets for 12 months. In the UK this means aspirin + clopidogrel

Answer 145

a potassium channel activator which has a vasodilatory effect on the coronary arteries.

Answer 146

headache, flushing | and anal ulceration.

Answer 147

calcaemia | glycaemia (impaired glucose tolerance)

Answer 148

the total daily morphine dose (60 * 2 = 120mg) should be divided by 3 (120 / 3 = 40mg)

Answer 149

``` spironolactone (most common drug cause) cimetidine digoxin cannabis finasteride gonadorelin analogues e.g. Goserelin, buserelin oestrogens, anabolic steroids ```

Answer 150

Phenytoin is associated with a large number of adverse effects. These may be divided into acute, chronic, idiosyncratic and teratogenic

Answer 151

initially: dizziness, diplopia, nystagmus, slurred speech, ataxia later: confusion, seizures

Answer 152

common: gingival hyperplasia (secondary to increased expression of PDGF), hirsutism, coarsening of facial features, drowsiness megaloblastic anaemia (secondary to altered folate metabolism) peripheral neuropathy enhanced vitamin D metabolism causing osteomalacia lymphadenopathy dyskinesia

Answer 153

``` fever rashes, including severe reactions such as toxic epidermal necrolysis hepatitis Dupuytren's contracture* aplastic anaemia drug-induced lupus ```

Answer 154

associated with cleft palate and congenital heart disease

Answer 155

metoclopramide, domperidone phenothiazines haloperidol very rare: SSRIs, opioids

Answer 156

* Syndrome of inappropriate ADH secretion * Hypoglycaemic episodes * Increased appetite and weight gain * Liver dysfunction (cholestatic)

Answer 157

• Weight gain Fluid retention • Liver dysfunction • Fractures

Answer 158

* Gastrointestinal side-effects | * Lactic acidosis

Answer 159

liver disease P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin cranberry juice drugs which displace warfarin from plasma albumin, e.g. NSAIDs inhibit platelet function: NSAIDs

Answer 160

haemorrhage teratogenic, although can be used in breast-feeding mothers skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin. Thrombosis may occur in venules leading to skin necrosis purple toes

Answer 161

dipyridamole enhances effect | aminophylline reduces effect

Answer 162

Agranulocytosis - monitor by FBC

Answer 163

inhibiting the iodination of tyrosyl residues in thyroglobulin competitively inhibit the thyroperoxidase-catalysed oxidation reactions

Answer 164

fluclox (staph suspected)

Answer 165

Clarithromycin

Answer 166

``` classically: hypokalaemia* increasing age renal failure myocardial ischaemia hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis hypoalbuminaemia hypothermia hypothyroidism drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics ```

Answer 167

Digibind correct arrhythmias monitor potassium

Answer 168

``` rhinorrhoea needle track marks pinpoint pupils drowsiness watering eyes yawning ```

Answer 169

topiramate or propanolol

Answer 170

``` active internal bleeding recent head injury, haemorrhage, trauma or surgery coagulation and bleeding disorders intracranial neoplasm stroke < 3 months ago aortic dissection pregnancy severe hypertension ```

Answer 171

accelerated hypertension (potentially leading to encephalopathy and seizures) bone aches flu-like symptoms skin rashes, urticaria pure red cell aplasia* (due to antibodies against erythropoietin) raised PCV increases risk of thrombosis (e.g. Fistula) iron deficiency 2nd to increased erythropoiesis

Answer 172

Assessment for treatment - patients taking the equivalent of prednisolone 7.5 mg or more each day for 3 months, and one of the following are over the age of 65 years have a history of a fragility fracture have a T-score less than - 1.5 SD

Answer 173

osteonecrosis of the jaw

Answer 174

thyroid dysfunction: both hypothyroidism and hyperthyroidism corneal deposits: present in most patients, rarely interfere with vision, usually reversible on withdrawal of drug pulmonary fibrosis/pneumonitis liver cirrhosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance prolonged QT interval thrombophlebitis and injection site reactions bradycardia

Answer 175

Quinolones

Answer 176

inhibit topoisomeras II (DNA gyrase) and topoisomerase IV

Answer 177

tendon damage (including rupture) - the risk is increased in patients also taking steroids

Answer 178

ethambutol

Answer 179

nitrates and nicorandil (has a nitrate component)

Answer 180

Rifampicin & isoniazid

Answer 181

bronchospasm cold peripheries fatigue sleep disturbances, including nightmares

Answer 182

uncontrolled heart failure asthma sick sinus syndrome concurrent verapamil use

Answer 183

atropine then glucagon if this doesn't work

Answer 184

have both anti-inflammatory and bronchodilatory properties should be used when patients are poorly controlled on high-dose inhaled corticosteroids and a long-acting b2-agonist particularly useful in aspirin-induced asthma associated with the development of Churg-Strauss syndrome

Answer 185

ACE inhibitors.

Answer 186

PACC: phenytoin, AML (leuk), ciclosporin, calcium channel blockers (esp nifedipine)

Answer 187

corneal opacities and optic neuritis

Answer 188

type IV (delayed) These are largely mediated by interferon-γ secreted by Th1 cells which in turn stimulates macrophage activity.

Answer 189

blocks potassium channels (class III antiarrhythmic agent used in the treatment of atrial, nodal and ventricular tachycardias. )

Answer 190

patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease

Answer 191

``` visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy nasal congestion flushing gastrointestinal side-effects headache ```

Answer 192

antiemetics used mainly in the management of chemotherapy related nausea. Examples: ondansetron granisetron

Answer 193

chronic alcohol, HIV, anorexia or P450 inducers

Answer 194

antibiotics: trimethoprim, chloramphenicol

Answer 195

gold, penicillamine

Answer 196

carbamazepine

Answer 197

carbimazole* (also agranulocytosis) | tolbutamide

Answer 198

nephrotoxicity

Answer 199

Both sodium bicarbonate and aminophylline may reduce plasma concentrations of lithium; thiazides increase it

Answer 200

tolterodene, oxybutynin and solifenacin

Answer 201

ipratropium (chronic obstructive pulmonary disease) and procyclidine (Parkinson's disease).

Answer 202

is not associated with polycythaemia. Blood tests typically reveal a raised ferritin and iron, associated with a transferrin saturation of greater than 60% and a low total iron binding capacity

Answer 203

epistaxis and menorrhagia are common whilst haemoarthroses and muscle haematomas are rare

Answer 204

Von Willebrand's disease

Answer 205

tranexamic acid for mild bleeding desmopressin (DDAVP): raises levels of vWF by inducing release of vWF from Weibel-Palade bodies in endothelial cells factor VIII concentrate

Answer 206

rasburicase prophylactically

Answer 207

``` hyperkalaemia hyperphosphataemia hypocalcaemia hyperuricaemia acute renal failure ```

Answer 208

activated protein C resistance

Answer 209

Inherited activated protein C resistance (factor V Leiden) antithrombin III deficiency protein C & S deficiency Acquired antiphospholipid syndrome the Pill

Answer 210

Cytomegalovirus Ganciclovir is the treatment of choice in such patients.

Answer 211

classical triad: haematuria, loin pain, abdominal mass pyrexia of unknown origin left varicocele (due to occlusion of left testicular vein) endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH 25% have metastases at presentation

Answer 212

asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria

Answer 213

nephrotic syndrome normotension - hypertension is rare highly selective proteinuria* renal biopsy: electron microscopy shows fusion of podocytes

Answer 214

majority of cases (80%) are steroid responsive | cyclophosphamide is the next step for steroid resistant cases

Answer 215

Over 50% of renal transplant patients have a significant infection within the first 12 months of having a renal transplant. At the time of transplant the CMV-serological status of the donor and recipient are noted. The highest risk is seen in CMV-seronegative recipients who receive a kidney from a CMV-seropositive donor. These patients are usually given antiviral prophylaxis. Cytomegalovirus tend to be seen after four weeks as before this time the immune system has not been fully affected by the immunosuppressants.

Answer 216

Chronic or intermittent diarrhoea Failure to thrive or faltering growth (in children) Persistent or unexplained gastrointestinal symptoms including nausea and vomiting Prolonged fatigue ('tired all the time') Recurrent abdominal pain, cramping or distension Sudden or unexpected weight loss Unexplained iron-deficiency anaemia

Answer 217

Autoimmune thyroid disease Dermatitis herpetiformis Irritable bowel syndrome Type 1 diabetes

Answer 218

HLA-DQ2 It is strongly associated with HLA-DQ2 (95% of patients) and HLA-B8 (80%) as well as HLA-DR3 and HLA-DR7

Answer 219

AA. Often has a relatively good prognosis

Answer 220

C. B-lineage immunophenotype

Answer 221

an endothelial cell marker - positive in angiosarcoma

Answer 222

Dipeptidyl peptidase-4 inhibitor DPP-4 inhibitors work by blocking the action of DPP-4, an enzyme which destroys the hormone incretin. Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed. These hormones are released throughout the day and levels are increased at meal times.

Answer 223

``` PBC: early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly ``` late: may progress to liver failure PSC: Inflammation and scarring of the bile ducts can lead to liver damage and cirrhosis - a condition where normal liver tissue is replaced by scar tissue (fibrosis). In many cases the symptoms develop gradually over weeks or months. At the beginning of the disease, many people have no symptoms at all. The most common early symptoms include feeling more tired than usual, feeling generally unwell, itchy skin, weight loss and having some discomfort in the right upper tummy (abdomen). Jaundice can develop when the condition worsens. Various complications can occur in some people with PSC: Deficiencies of some vitamins, usually vitamins A, D, E and K infective cholangitis. Cholangiocarcinoma

Answer 224

ursodeoxycholic acid

Answer 225

IBD - most commonly U/C. 4/5 of patients have one or other

Answer 226

malabsorption: osteomalacia, coagulopathy sicca syndrome in 70% of cases portal hypertension hepatocellular cancer (20-fold increased risk)

Answer 227

weight gain loose stools thinning hair nausea (feeling sick) and vomiting

Answer 228

UDCA and colestyramine (for itching), steroids if associated with AI hepatitis

Answer 229

``` chronic infection (80-85%) - only 15-20% of patients will clear the virus after an acute infection and hence the majority will develop chronic hepatitis C cirrhosis (20-30% of those with chronic disease) ```

Answer 230

primary hyperaldosteronism

Answer 231

a 40-year-old woman presents with lethargy, weakness and weight loss. On examination her blood pressure is 80/50 mmHg and there is hyperpigmentation of the skin

Answer 232

Primary hyperaldosteronism was previously thought to be most commonly caused by an adrenal adenoma, termed Conn's syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases. Differentiating between the two is important as this determines treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism

Answer 233

adrenal adenoma: surgery bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone Differentiating between the two is important as this determines treatment.

Answer 234

primary hyperaldosteronism

Answer 235

bilateral in 10% malignant in 10% extra-adrenal in 10% (most common site = organ of Zuckerkandl, adjacent to the bifurcation of the aorta)

Answer 236

24 hr urinary collection of metanephrines (sensitivity 97%*) | this has replaced a 24 hr urinary collection of catecholamines (sensitivity 86%)

Answer 237

Surgery is the definitive management. The patient must first however be stabilized with medical management: alpha-blocker (e.g. phenoxybenzamine), given before a beta-blocker (e.g. propranolol)

Answer 238

Hashimoto's thyroiditis

Answer 239

``` dermatitis herpetiformis (a vesicular, pruritic skin eruption) Type 1 diabetes mellitus Autoimmune hepatitis ```

Answer 240

hyposplenism

Answer 241

increase panc. insulin secretion

Answer 242

Investigation ERCP is the standard diagnostic tool, showing multiple biliary strictures giving a 'beaded' appearance ANCA may be positive there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'

Answer 243

Thyroid lymphoma

Answer 244

DM Presenting features early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands) 'bronze' skin pigmentation diabetes mellitus liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition) cardiac failure (2nd to dilated cardiomyopathy) hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism) arthritis (especially of the hands)

Answer 245

Budd-Chiari syndrome

Answer 246

subacute thyroiditis Hashimoto's thyroiditis Riedel's thyroiditis

Answer 247

mild-moderate toxicity may respond to volume resuscitation with normal saline haemodialysis may be needed in severe toxicity sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion

Answer 248

IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias dialysis is ineffective in removing tricyclics

Answer 249

if bradycardic then atropine | in resistant cases glucagon may be used

Answer 250

Self harm common

Answer 251

schizophrenia. Though 2/3 have depression, and >90% of those who present with self harm have at least one psych disorder. Also assoc'd with substance misuse and anxiety disorders. Also personality disorder (eg. borderline/emotionally unstable, histrionic).

Answer 252

lithium in bipolar clozapine in treatment-resistant schizophrenia Controversy around SSRIs - can increase motivation before improving mood/changing mindset (hopelessness, worthlessness, helplessness, pessimism)

Answer 253

``` to communicate distress/seek help escape a situation escape unbearable anguish change behaviour of others to die to escape tension ```

Answer 254

70,000 | 1998 - has reduced paracetamol ODs by 20%

Answer 255

10-15g (20-30 tablets) | 5g in those at high risk

Answer 256

NAPQI (metabolite). This depletes glutathione (antioxidant) Activated charcoal if presents within 2 hours NAC (glutathione precursor) to mitigate effects

Answer 257

50-100 times

Answer 258

Circumstances - when, where, what, how, why, who was around? affairs in order? notes, drunk/sober, disclose it? how did they access care? had they planned it? how feeling now? Obtain a collateral history (family, GP), look at notes. Use of scales not recommended but be aware of actuarial risk factors People are poor at predicting their future behaviour - 20% only decide to 5 mins before the event.

Answer 259

Risk management plan ``` eg. referral to secondary services Counselling or psychological therapy drug/alcohol support services Citizen's advice bureau Homeless charities/council Third sector and voluntary organisations Encourage problem-solving ```

Answer 260

Suicide Open Misadventure Narrative verdict Important for life insurance

Answer 261

``` stability immobilisation (low) denial anger (high) bargaining depression (low) testing acceptance ```

Answer 262

Egoistic - not belonging to society, detachment from community Altruistic - for society eg. soldiers Anomic - moral confusion and lack of direction Fatalistic

Answer 263

hypertension, renal failure and electrolyte imbalances

Answer 264

gamma globulin

Answer 265

corticosteroids, plasmapheresis and intravenous immunoglobulin

Answer 266

Both cyclophosphamide and rituximab are used as induction agents in very active or severe disease. Cyclophosphamide is a chemotherapy drug that is converted in the liver to its active form, phosphoramide mustard, which causes DNA crosslinking and hence apoptosis of rapidly dividing cells, including lymphocytes. Rituximab is a monoclonal antibody directed against CD20, and causes profound B cell depletion but has no direct effect on T cells or granulocytes. Azathioprine and mycophenolate mofetil are usually used as maintenance agents or for their steroid sparing effect. In a patient with mild disease they can be used to induce remission but take three to four weeks to have their maximal effect, and hence are not appropriate in severe or very active disease. Ciclosporin is a calcineurin inhibitor widely used in transplantation to block IL-2 production and hence block proliferation signals to T cells. It is not widely used in the treatment of ANCA vasculitis.

Answer 267

The abdominal x ray shows the classic 'coffee bean' sign. The treatment of uncomplicated sigmoid volvulus is endoscopy and decompression to relieve large bowel obstruction and prevent ischaemia. In the absence of peritonitis decompression of the sigmoid colon with rigid or flexible endoscopy is crucial before ischaemia ensues. This patient has colicky abdominal pain rather than continuous pain and has no localised abdominal tenderness. This indicates obstructed but not ischaemic or perforated bowel (that is, the patient does not have peritonitis) and therefore, laparotomy is not immediately indicated.

Answer 268

Patients with bowel obstruction need Intravenous fluid to replace fluid and electrolyte loss into the lumen of obstructed bowel A nasogastric tube to decompress the small bowel and prevent vomiting and A urinary catheter to guide fluid resuscitation

Answer 269

desquamation of the fingers and toes begins in the periungual region, may involve the palms and soles, and usually is observed one to two weeks after the onset of fever.

Answer 270

the skin rash is associated with streptococcal Group A infection and the skin begins to peel usually around the sixth day of the rash.

Answer 271

The histopathologic pattern in papular urticaria consists of ``` Mild sub-epidermal oedema Extravasation of erythrocytes Interstitial eosinophils Exocytosis of lymphocytes. The reaction is thought to be caused by a haematogenously disseminated antigen deposited by an arthropod bite in a patient who is sensitive. ```

Answer 272

Digitalis/ digoxin, spironolactone, cyproterone acetate, cimetidine, oestrogens, cannabis, testosterone, anabolic steroids.

Answer 273

dementia, urinary incontinence, gait apraxia; usually in the elderly. CSF pressure is normal but brain scans show enlarged ventricles.

Answer 274

B12 deficiency Subacute combined degeneration of the cord due to vitamin B12 deficiency is the most likely cause. Another recognised feature is loss of sphincter control. Treatment with vitamin B12 reverses the peripheral nerve damage but has little effect on the CNS.

Answer 275

papillary muscle rupture This patient presents with features of acute left ventricular failure and has a chest x ray which shows pulmonary oedema as reflected by Kerley B lines and interstitial oedema. The examination findings indicate a harsh systolic murmur at the apex which, in association with acute pulmonary oedema, would be most in keeping with a papillary muscle rupture in association with myocardial infarction. The posteromedial papillary muscle is twice as likely to rupture as is the anterolateral papillary muscle. This is because it is frequently supplied by only one coronary artery (usually the right) system.

Answer 276

This woman has developed a slight fever and breathlessness occurring one day after a procedure which suggests atelectasis.

Answer 277

Hypotension is produced in a tension pneumothorax by compression of the venous component of the mediastinum, reducing the return of blood to the heart and producing the sign of a raised JVP.

Answer 278

A needle thoracostomy involves inserting a large bore cannula into the second intercostal space in the mid clavicular line, which should produce a reassuring 'hiss' along with a rapid improvement in the patient's condition.

Answer 279

interferes with bacterial protein synthesis, inhibiting replication.

Answer 280

It is a methylxanthine derivative drug used in the treatment of bronchial asthma. It works by inhibiting phosphodiesterase and thus dampening inflammatory response via modulation of the cytokine cascade. It also has an antagonistic effect at adenosine receptors and it is this pharmacological action which can cause toxicity. Erythromycin is considered the most culpable macrolide in terms of its interaction with aminophylline, although some drugs which are not commonly available in the United Kingdom, such as troleandromycin, seem to inhibit the enzyme system more acutely.

Answer 281

a theoretical risk of increase in QT interval prolongation BT normally only seen when the salbutamol is administered intravenously or when multiple nebulised doses have delivered an excess of the drug.

Answer 282

a subcutaneously delivered monoclonal antibody which binds to IgE and is used in patients with severe asthma with proven IgE mediated sensitivity. It is reserved usually for use only in restricted centres. It causes few drug interactions but it may precipitate an anaphylactic reaction in susceptible individuals at administration.

Answer 283

``` Flushing Agitation Nausea & Vomiting Tachycardia & Arrhythmia including supraventricular tachycardias, Torsades de pointes and Seizures. ```

Answer 284

Acute blood loss Haemolytic anaemia Chronic disorders, and Leucoerythroblastic anaemias

Answer 285

carvedilol (COPERNICUS), bisoprolol (CIBIS) and metoprolol (MERIT-HF)

Answer 286

Primary glomerular disease Glomerulonephritis Anti-GBM disease (Goodpasture's syndrome) Immune complex deposition Inherited conditions such as Alport's syndrome Secondary glomerular disease Diabetes, or other systemic diseases.

Answer 287

``` A Behcet's disease B Drug induced (e.g. OCP, penicillins) C Inflammatory bowel disease D Lymphoma E Mycoplasma pneumonia F Rheumatoid arthritis G Sarcoidosis H Streptococcal infection I Tuberculosis ```

Answer 288

weight gain liver impairment fluid retention (co CI'd in CCF) bladder cancer risk

Answer 289

constipation, | ankle swelling

Answer 290

Carbamazepine - partial seizures | Sodium valproate or ethosuximide - absence seizures

Answer 291

Stage 1 hypertension Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg Stage 2 hypertension Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg Severe hypertension Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

Answer 292

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension) treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension) offer drug treatment regardless of age

Answer 293

``` Measles Mumps Polio (Sabin; Salk is inactivated) Rubella Yellow fever, and BCG Tetanus toxoid is used in this vaccine. ```

Answer 294

Rigors are due to bacteraemia/viraemia and are associated with pyogenic infections. Hodgkin's disease is associated with night sweats but not rigors. Uncomplicated ureteric calculi are associated with the typical renal colic pain without rigors.

Answer 295

The incubation period is 7-14 days during which some patients may have a transient diarrhoea. As bacteraemia develops patients have ``` Chills Diaphoresis Cough Headache Myalgia Delirium Fever. Constipation develops early due to ileocaecal obstruction by swollen Payer patches. Patients may develop rose spots which are salmon-coloured, blanching 1-4 cm maculopapular rash. They appear on the trunk and may resolve in two to five days. ```

Answer 296

Stool cytotoxin tests are used to detect C. difficile infection which may remain positive even after the infection ceases. cephalosporins, amoxicillin and clindamycin.

Answer 297

cyst may cause amoebic colitis or amoebic liver abscess. In colitis the symptoms are of a gradual onset and typically involve abdominal pain, diarrhoea, blood stools and weight loss. Immunosuppressive agents, such as corticosteroids, are a predisposing factor, as are pregnancy, poor nutrition and young children.

Answer 298

A pseudopod-forming non-flagellated protozoa responsible for amoebiasis.

Answer 299

at least 3 sets of cultures, from different sites, are required.

Answer 300

``` Some Escherichia coli isolates produce an ESBL that inactivates second and third generation cephalosporins. The class of drugs that will most reliably treat these infections are the carbapenems e.g. imipenem, meropenem ```

Answer 301

achilles tendonitis | lowers seizure threshold

Answer 302

retinopathy

Answer 303

macrolides and ciprofloxacin.

Answer 304

vanc & teic

Answer 305

aspirin, clopidogrel, a statin, a beta-blocker, and an ACE-inhibitor.

Answer 306

Gingival hypertrophy and tenderness as well as coarse facial features and hirsutism may occur. ataxia, peripheral neuropathy, megaloblastic anaemia, thrombocytopaenia

Answer 307

blurred vision and nystagmus.

Answer 308

``` Cyclophosphamide Chlorambucil Melphalan Nitrosoureas (-mustine) Procarbazine, and Cisplatin. ```

Answer 309

A 2-month-old girl has failure to thrive, polyuria and medullary nephrocalcinosis affecting both kidneys, with alkalosis on ABG. U&E reveals: hypokalaemia, hyponatraemia, and hypochloridaemia. Infantile type includes: fever, dehydration growth retardation, and nephrocalcinosis.

Answer 310

``` Cancer of the breast and genitalia Liver disease History of or current thromboembolism Cardiac abnormalities Congenital hyperlipidaemia Undiagnosed abnormal uterine bleeding. ```

Answer 311

``` Ciclosporin Nifedipine Phenytoin, chronic renal failure, leukaemia. ```

Answer 312

Post-transplant hypertension may be due to ciclosporin toxicity or steroid therapy. Renal artery stenosis may occur in the donor kidney. Hypertension may be a manifestation of chronic rejection. Chronic graft rejection takes months to years and patients develop a slow decline in glomerular filtration rate, interstitial nephritis or glomerulonephritis.

Answer 313

can occur at any time and manifests as graft swelling, fever, abdominal pain and oliguria.

Answer 314

ciprofloxacin

Answer 315

gall stones

Answer 316

acute cholestasis

Answer 317

bacterial eg. E. coli and meningococcal meningitis In cryptococcal meningitis the glucose is usually reduced but there is usually a predominance of lymphocytes. With late tuberculous meningitis, lymphocytes usually predominate except in early disease where there may be 80% polymorphs. Not seen in echo virus meningitis but they are seen in one quarter of cases of mumps and herpes virus meningitis.

Answer 318

20 ml/kg of N. saline

Answer 319

fixed rate initially vs variable rate in HONK/high glucose without urine ketones

Answer 320

Hepatitis A is a picornavirus that is transmitted faeco-orally. It has a positive single-stranded genome. There is a 90% vertical transmission rate in hepatitis B which belongs to the Hepadnaviridae and has an unusual partially double-stranded circular genome. Hep C is a single stranded RNA flavivirus with a 3% vertical transmission rate. It can be transmitted via blood/blood products. It is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis Hepatitis D is an incomplete virus which has a small RNA genome and can only occur in patients already infected with HBV.

Answer 321

Previous tubal surgery Endometriosis Damage Pelvic inflammatory disease.

Answer 322

a traumatic avulsion of the flexor digitorum profundus from its insertion into the distal phalanx.The patient has pain and is unable to actively flex at the DIPJ. A fragment of bone can be avulsed from the distal phalanx during the injury. The photograph demonstrates this. The injury is caused by forced hyperextension of the DIPJ with simultaneous activation of the FDP, classically seen when attempting to grab a jersey during rubgy.

Answer 323

plasma exchange | Then steroids and cyclophosphamide longer- term

Answer 324

antibodies to type IV collagen

Answer 325

large bore venous access to allow rapid removal and return of blood, such as an arterio-venous fistula or central venous access.

Answer 326

low calcium, thought to be transient secondary to the citrate anticoagulant used (which binds calcium), and deranged clotting from removal of clotting factors.

Answer 327

``` TTP ANCA vasculitis MG Guillain-Barre syndrome Cryoglobulinaemia and Hyperviscosity syndromes. ```

Answer 328

The mechanism of action is not fully known, but is likely to involve the following: 1. Increased lipoprotein lipase (LPL) action which causes: Lipolysis of VLDL particles and chylomicrons Removal of triglycerides from the blood, and Storage of triglycerides in adipose, striated muscle and body cells. 2. Increased PPAR- alpha activity: Reduced triglyceride production by the liver Increases oxidation of fatty acids Likely to have anti-inflammatory and anti-atherogenic effects.

Answer 329

Only once a week Take the tablet first thing in the morning, at least 30 minutes before other medications or food Take with a glass of water - not juice, tea or coffee After taking the tablet, remain upright for at least 30 minutes to allow the tablet to pass safely into the stomach.

Answer 330

Gastrointestinal disturbance is common but usually mild Alendronate can cause oesophagitis which can be severe Risedronate is better tolerated Some can cause bone pain. Risk of osteonecrosis of the jaw and of AF (matrix metalloproteinase?)

Answer 331

should stop their treatment and should be considered either for an intravenous or intramuscular bisphosphonate, or for another agent.

Answer 332

Loops Furosemide is a loop diuretic which promotes calcium excretion. It is used in the management of severe hypercalcaemia, usually with IV fluid replacement to prevent dehydration, known to further elevate calcium levels.

Answer 333

One year mortality has dropped from >90% to 10-20%. In survivors, 60% will reach end stage renal failure and require long term renal replacement therapy. Any patient presenting already anuric has a lower chance of renal recovery than one who is oliguric.

Answer 334

Alemtuzumab, or Campath,

Answer 335

B cells are the first subset to recover, beginning to return by three to six months, and reaching levels within the normal range by six to 24 months. CD8 T cell recovery follows shortly after, beginning at six to nine months and reaching the normal range by nine to 24 months. CD4 T cell recovery is much slower, for reasons which are not fully understood. CD4 counts can remain suppressed for many years following a single treatment, although many patients show recovery of cells to low levels by 12 months.

Answer 336

Little or no haematuria Caused by glomerular pathology Hyperlipidaemia can be marked and leads to increased cardiovascular risk Reduced immunoglobulins can predispose to infection Loss of certain proteins can predispose to thrombosis - renal vein thrombosis is a recognised complication Creatinine can be normal or elevated.

Answer 337

Glomerulonephritis, such as minimal change disease, membraneous glomerulonephritis, etc Focal segmental glomerulosclerosis Diabetic nephropathy Amyloid (AL form) Connective tissue disease such as systemic lupus erythematosus.

Answer 338

MAOIs- there is a real risk of precipitating a catecholamine crisis. Extent of symptoms varies from patient to patient depending on dose of both MAOI and type of topical anaesthesia used. Dental surgeries often ask patients taking MAOIs to disclose this so that local anaesthetics not containing adrenaline derivatives can be used.

Answer 339

This patient should initially receive calcium gluconate (10 ml of 10%) to protect the myocardium, and this can be repeated if worrying ECG features persist. A venous blood gas would be a quick way of getting a potassium level, and this should be confirmed with a laboratory sample. It is important to repeat after treatment to ensure the potassium level is decreasing. Refractory hyperkalaemia (>6.5 mmol/L) is an indication for urgent renal replacement therapy, and certainly needs discussion with a nephrologist. Salbutamol is an effective treatment at quickly lowering potassium levels, and is useful if IV access is proving difficult, and thus an insulin/dextrose infusion cannot be started quickly. Large doses (10-20 mg) are needed to provide a sufficient effect. Calcium resonium is used to bind potassium in the gut, and helps to reduce total body potassium. However, it takes a number of hours to have its effect and thus would not be a priority in the acute management of hyperkalaemia.

Answer 340

Status epilepticus is a medical emergency, where two or more seizures follow each other without regaining consciousness or when one seizure lasts for 30 minutes or longer. There is a risk of cardiorespiratory failure and death if grand mal seizures are involved.

Answer 341

In known epileptics several factors such as abrupt withdrawal of treatment, alcohol abuse or poor compliance may precipitate status epilepticus. However more than half of cases occur in people with no history of epilepsy. Of these many are due to eclampsia in pregnant women.

Answer 342

Angina Exertional syncope, and Exertional shortness of breath.

Answer 343

The diagnosis may be confirmed with Echo demonstrating a gradient across the aortic valve. Gradients above 50 mmHg suggest moderate severity stenosis. Valve replacement is prognostically beneficial in severe stenosis. Ventricular arrhythmias may cause sudden death.

Answer 344

Shock, continued or rebleeding, chronic liver disease and old age are all associated with a poor prognosis.

Answer 345

AKI often causes a marked elevation in urea compared to creatinine and hypocalcaemia would be unusual. However, hypocalcaemia is common in CKD4-5.

Answer 346

Monoamine oxidase inhibitors have many drug and dietary interactions; dentists should be warned of their use to avoid catecholamine crises when using adrenaline in local anaesthesia.

Answer 347

the glucose is usually reduced but there is usually a predominance of lymphocytes.

Answer 348

subtotal or total villous atrophy, with crypt hyperplasia. | http://www.nature.com/nri/journal/v2/n9/fig_tab/nri885_F1.html

Answer 349

A high potassium level causes tall peaked T waves with disappearance of the ST segment. A low potassium causes flattened T waves with the appearance of a U wave. High and low magnesium levels produce the same patterns as potassium.

Answer 350

ST segment elevation may be caused by acute myocardial infarction (MI) or Prinzmetal's angina or pericarditis. To differentiate the two, acute MI has upwardly convex ST segments and is present in only a few leads with reciprocal changes in others, and in pericarditis the ST segments are upwardly concave and are usually present in all leads.

Answer 351

congenitally acquired cytomegalovirus (CMV) and toxoplasmosis infection

Answer 352

The jaundice usually starts at the age of about 3 months because haemoglobin F is still the predominant haemoglobin in neonates.

Answer 353

It supplies the hamstrings and all the muscles of the lower leg and foot via the tibial and common peroneal nerve, additionally it also is responsible for the sensation of the lateral side of the leg below the knee.

Answer 354

Foot drop Loss of power below the knee and loss of knee flexion Loss of ankle jerk and plantar response (not knee jerk), and Loss of sensation below the knee on the lateral side.

Answer 355

Prochlorperazine and droperidol are both dopamine antagonists. Cyclizine is an anticholinergic drug. Granisetron is a 5HT3 receptor antagonist, is of the same class of drug as ondansetron. Both granisetron and dexamethasone are useful antiemetics in the management of nausea and vomiting secondary to cytotoxic chemotherapy.

Answer 356

in those taking anticonvulsants, rifampicin, erythromycin, grapefruit juice and antiretroviral medications.

Answer 357

increase the risk of ventricular arrhythmias due to prolongation of QTc interval. eg. erythromycin and cisapride, cimetidine, isoniazid

Answer 358

carbamazepine, phenytoin, primidone and phenobarbitone

Answer 359

Gentamicin is nephrotoxic, causing acute tubular necrosis. It is also associated with ototoxicity.

Answer 360

Methysergide, rosiglitazone

Answer 361

when there is a poorly compliant right ventricle (or tricuspid stenosis) increasing the impedence against which the right atrium has to eject blood.

Answer 362

high with an abrupt fall in systole (x descent) and may rise with inspiration (Kussmaul's sign).

Answer 363

Usually it is associated with a bicuspid aortic valve and hypoplastic aortic arch. ``` It is seen in: Turner's syndrome Cerebral "berry" aneurysms Neurofibromatosis I Williams syndrome (congenital hypercalcaemia) Sturge-Weber. ```

Answer 364

Often presents in childhood with heart failure The condition involves collateral flow around the scapulae, through the subclavian vessels and upper intercostal arteries.

Answer 365

myxoedema, rheumatoid arthritis, diabetes, acromegaly and pregnancy.

Answer 366

minor trauma, post-vaccination or drugs and infections, such as: Gastrointestinal Urinary tract, or Respiratory tract.

Answer 367

CA125 AFP CEA

Answer 368

Irritability Fits Cardiovascular instability Haematuria (due to ATN)

Answer 369

Erythema marginatum

Answer 370

commonly associated with lymphomas, leukaemias, and renal cell carcinoma. Not associated with carcinoma of the head of the pancreas.

Answer 371

inflammatory bowel diseases (Crohn's and ulcerative colitis). It may also be seen in rheumatoid arthritis. Less common associations include chronic active hepatitis, myelodysplasia and solid tumours.

Answer 372

anticholinergic - so reduce secretions, gut motility etc

Answer 373

arterial pH 3.0 mmol/L after fluid rehydration, or if all three of the following occur in a 24 hour period: PT >100 seconds Creatinine >300 µmol/L Grade III/IV encephalopathy.

Answer 374

Decrease of serum complement is recognised. Also anti-streptococcal exoenzymes, such as anti-streptolysin (ASO), etc.

Answer 375

Dyspnoea is recognised; fluid overload and hyponatraemia.

Answer 376

Diffuse endocapillary proliferative glomerulonephritis is typical; focal glomerular lesions would suggest an alternative diagnosis.

Answer 377

affects function of DNA gyrase

Answer 378

A palpable thyroid nodule should be investigated with fine needle aspiration (FNA) which should be carried out under the auspices of a thyroid clinic. If the nodule is palpable, neither a thyroid ultrasound nor an uptake scan is indicated prior to FNA.

Answer 379

Neisseria meningitidis is the causative agent and the features are divided into meningitic and septic. Meningitic features include: ``` Vomiting Neck stiffness Photophobia Kernig sign Brudzinski sign Focal neurology Opisthotonus. Septic features include: ``` ``` Systemically unwell Pyrexia Anorexia Reduced tone. Purpura result from increased capillary permeability. ```

Answer 380

Measles - the white oral lesions are Koplik spots - a pathognomic feature of the infection.

Answer 381

Stimulates insulin release Inhibits glucose production by the liver Slows gastric emptying Suppresses appetite.

Answer 382

amiodarone sotalol Type 1a antiarrhythmic drugs. ``` Medications that more commonly cause Torsades Bepridil Disopyramide Procainamide Quinidine Sotalol ``` ``` Medications that less frequently cause Torsades Amiodarone Chlorpromazine & haloperidol & droperidol Cisapride Clarithromycin Domperidone Erythromycin Lidoflazine Mesoridazine Methadone Sparfloxacin Thioridazine ```

Answer 383

Hypocalcaemia | Hypokalaemia

Answer 384

Bacterial infection - Left shift, Toxic granulation, Vacuolation Stress: trauma, surgery, burns, haemorrhage Steroids Inflammation: MI, PAN Myeloproliferative disorders: e.g. CML

Answer 385

chemo, cytotoxics, carbimazole, sulphonamides

Answer 386

BM infiltration

Answer 387

in HIV/AIDS Demyelinating inflammation of brain white matter caused by JC virus.

Answer 388

cryptococcal

Answer 389

Amphotericin B + flucytosine for 2wks then fluconazole for for 6mo / until CD4 >200

Answer 390

Methotrexate, amiodarone, isoniazid

Answer 391

Afebrile Descending symmetric flaccid paralysis No sensory signs Autonomic: dry mouth, fixed dilated pupils

Answer 392

Watery diarrhoea, cramps, flu-like Pneumonia Meningoencephalitis Miscarriage

Answer 393

Dysentery, wind, tenesmus Wt. loss if chronic Liver abscess - RUQ pain, swinging fever, sweats - Mass in R lobe Flask-shaped ulcer on histo

Answer 394

Abdo pain, fever, diarrhoea Mesenteric adenitis Reactive arthritis, pharyngitis, pericarditis Erythema Nodosum

Answer 395

ciprofloxacin

Answer 396

Typhoidal salmonella, Yersinia enterocolitica, Brucella

Answer 397

6wks -6mo wks after chancre

Answer 398

Cardiolipin antibody

Answer 399

Bartonella henselae | Treat w/ azithromyin

Answer 400

``` Early localised: - Erythema migrans (target lesions) Early disseminated: - Malaise, LN, migratory arthritis, hepatitis Late persistent : - Arthritis, focal neuro (Bell’s palsy), heart block, myocarditis - Lymphocytoma: blue/red ear lobe ```

Answer 401

High fever, headache, myalgia / myositis Cough, chest pain ± haemoptysis ± hepatitis ̄c jaundice ± meningitis

Answer 402

histologically due to interstitial nephritis and may be accompanied by an eosinophilia, rash and non-specific symptoms such as lethargy and fatigue.

Answer 403

Addison's disease is a cause of hyperkalaemia as hypocortisolism reduces renal potassium excretion due to reduced activation of the sodium/potassium pump in the distal convoluted tubule. The biochemical picture is therefore one of: ``` Hyponatraemia Elevated urea Hypoglycaemia, and Hyperkalaemia. Hyperkalaemia initially causes membrane excitability due to partial membrane depolarisation then, as levels of serum potassium increase, it may cause muscle weakness, arrhythmias, and eventually cardiac arrest. ``` As the hyperkalaemia progresses, the ECG changes deteriorate: peaked T waves, decreased P waves and QRS widening.

Answer 404

``` colon cancer fistulae and fissures abscess formation stricture formation, and toxic dilatation of the colon with the risk of perforation. ```

Answer 405

Hepatotoxicity Myelosuppression such as neutropenia and thrombocytopenia (not iron deficiency anaemia) Azoospermia (like sulfasalazine) in males Alopecia Nausea and vomiting Hepatitis, and Increased susceptibility to infection. There is also an increased risk of cancer associated with its long term use - lymphoma and skin cancer.

Answer 406

rebound anxiety, insomnia and depression which can last for weeks or months.

Answer 407

Sepsis Pernicious anaemia, and Systemic lupus erythematosus. It is frequently due to drug therapy such as carbimazole or cytotoxics.

Answer 408

Lesch-Nyhan syndrome is due to deficiency of HPRT (hypoxanthine-guanine phosphoribosyl transferase), which is associated with purine overproduction, hyperuricaemia and gout. There is also a neurological syndrome characterised by choreoathetosis, spasticity, mental deficiency and behavioural disturbance (particularly self-mutilation). It is an X linked recessive disorder.

Answer 409

Acute sarcoidosis Streptococcal infection Rheumatic fever Primary tuberculosis Drugs, for example, sulfonamides, penicillin, oral contraceptive pill, codeine, salicylates, barbiturates Others - pregnancy, ulcerative colitis (UC), Crohn's disease, malignancy, Behcet's syndrome. Co-trimoxazole is the combination of trimethoprim and the sulfonamide, sulfamethoxazole.

Answer 410

Carbamazepine 100-400mg, 8 hourly

Answer 411

corticosteroids infliximab etanercept

Answer 412

isosorbide mononitrate minoxidil hydralazine

Answer 413

nasal congestion blue vision & non-arteritic anterior ischaemic neuropathy flushing GI upset headaches don't give with nitrates, or with other PDE inhibitors

Answer 414

``` gastrointestinal: nausea appetite increased + weight gain alopecia: regrowth may be curly ataxia &tremor hepatitis & pancreatitis thrombocytopaenia teratogenic hyponatraemia ```

Answer 415

sodium valproate phenytoin carbamazepine amantadine

Answer 416

P450 enzyme inducer dizziness and ataxia drowsiness, headache visual disturbances (especially diplopia) Steven-Johnson syndrome leucopenia and agranulocytosis syndrome of inappropriate ADH secretion (-> hyponatraemia

Answer 417

Na channel blocker

Answer 418

inhibits sodium absorption at the beginning of the distal convoluted tubule

Answer 419

``` carbimazole azathioprine phenytoin carbamazepine methotrexate thiazides chloramphenicol antipsychotics ganciclovir interferon-alpha ```

Answer 420

``` ciclosporin aminoglycosides eg. gentamycin amphotericin B foscarnet vancomycin loop diuretics NSAIDs ```

Answer 421

in the treatment of patients with hyperlipidaemia, although its use is limited by side-effects. As well as lowering cholesterol and triglyceride concentrations it also raises HDL levels

Answer 422

flushing impaired glucose tolerance myositis

Answer 423

long half-life (20-100 days) should ideally be given into central veins (causes thrombophlebitis) has proarrhythmic effects due to lengthening of the QT interval interacts with drugs commonly used concurrently e.g. decreases metabolism of warfarin numerous long-term adverse effects

Answer 424

TFT, LFT, U&E, CXR prior to treatment | TFT, LFT every 6 months

Answer 425

``` thyroid dysfunction corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia ```

Answer 426

Age over 50 New onset of new type of localised headache ESR >50 mm/hr by the Westergreen method Temporal artery tenderness to palpation or decreased pulsation Arterial biopsy showing granulomatous inflammation or mononuclear cell infiltration usually with multinucleated giant cells.

Answer 427

levodopa, corticosteroids

Answer 428

``` spironolactone anti-psychotics? Ace inhibitors quinidine thiazides loop diuretics Ca channel blockers ciclosporin beta blockers ```

Answer 429

pyrophosphate analogues, inhibit osteoclast activity

Answer 430

``` carbamazepine valproate chlorpropramide, selective serotonin reuptake inhibitor (SSRIs) and TCAs lithium, MDMA/ecstasy, tramadol, haloperidol, vincristine, desmopressin ```

Answer 431

``` pioglitazone amiodarone sulfonylureas ciclosporin sodium valproate methotrexate phenytoin rifampicin pyrazinamide statins valproic acid halothane ```

Answer 432

rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia Mesalazine: side-effects seen in patients taking sulphasalazine are avoided mesalazine is still associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis

Answer 433

pioglitazone heparin bisphosphonates

Answer 434

TPMT (as it is a prodrug of thipurine)

Answer 435

digoxin amantadine phenytoin metoclopramide

Answer 436

``` iron-deficiency anaemia thalassaemia* congenital sideroblastic anaemia anaemia of chronic disease (more commonly a normocytic, normochromic picture) lead poisoning ```

Answer 437

Steroids or colchicine

Answer 438

oral ulcers genital ulcers iritis Other associations: venous + arterial thrombosis, pericarditis, episcleritis, polyarteritis, abdo pain/diarrhoea

Answer 439

Normal: Suppurative diseases – CF, empyema, bronchiectasis, non-small cell carcinoma, CFA – cryptogenic fibrosing alveoli tis Rare: Lung abcess, mesothelioma, empyema, asbestosis

Answer 440

Colchicine, strong NSAIDs e.g. indomethacin or steroids. | Allopurinol only later.

Answer 441

``` reduced 1 hydroxylation of vitamin D, which leads to: Reduced absorption of calcium Increased phosphate concentrations Hyperparathyroidism, and Osteomalacia. ```

Answer 442

No P waves, fast but regular rhythm. The inferior leads may suggest the "saw-toothed" P wave pattern typical of atrial flutter.

Answer 443

Hydralazine Methyldopa Nifedipine, and Labetalol.

Answer 444

Diuretics ACE inhibitors - AT and antagonists Reserpine, and Sodium nitroprusside.

Answer 445

``` Hypothyroidism Hypokalaemia Diabetes Uraemia, and Hypocalcaemia, etc. ```

Answer 446

Dapsone | Gluten free diet.

Answer 447

Amiodarone increases the refractory period in the accessory path Although orthodromic tachycardia is the commonest it frequently has phasic aberrant conduction making it broad. Verapamil is NOT the treatment of choice for an associated SVT. Verapamil may exacerbate the rhythm disturbance associated with WPW and atrial fibrillation (AF) may result in ventricular fibrillation (VF).

Answer 448

``` Cerebral cortical and cerebellar hypoplasia Microcephaly Convulsions Limb hypoplasia Rudimentary digits. ```

Answer 449

cataracts, cardiac abnormalities, thrombocytopenia and cerebral calcification The fetus is most vulnerable in the first 16 weeks of pregnancy. Cataracts are associated with infections in weeks 8-9, deafness at 5-7 weeks and cardiac lesions from 5-10 weeks. Diagnosis is based on rising antibody titres in blood taken 10 days apart and the presence of IGM antibodies at 4-5 weeks from incubation period.

Answer 450

usually multi-organ and granulomata may be found on the skin and the pharynx. Treatment is with ampicillin and gentamicin.

Answer 451

ampicillin and gentamicin

Answer 452

In the above question both subdural effusions and tuberculous meningitis result in raised ICP. Dehydration often presents with a sunken fontanelle. An enlarged posterior fontanelle is often found in babies born with congenital hypothyroidism. Delayed closure of the fontanelle may be seen in cases of hypercalcaemia.

Answer 453

The diagnosis of beta thalassaemia is usually suggested by The presence of an isolated, mild microcytic anaemia Target cells on the peripheral blood smear and A normal red blood cell count. An elevation of Hb A2 (2 alpha-globin chains complexed with 2 delta-globin chains) demonstrated by electrophoresis confirms the diagnosis of beta thalassaemia. The Hb A2 level in these patients usually is approximately 4-6%. In rare cases of concurrent severe iron deficiency the increased Hb A2 level may not be observed although it becomes evident with iron repletion.

Answer 454

in any patient where the defect has persisted beyond 6 months of age.

Answer 455

opposite the premolars two days prior to the development of the rash in measles

Answer 456

night blindness, dry skin, dry conjunctiva and cornea (xerophthalmia), Bitot's spots (white plaques of keratinised epithelial cells. Deficiency is common in young children from developing countries.

Answer 457

is with oral retinal palmitate 50,000 units on two successive days.

Answer 458

The history is suggestive of a viral bronchiolitis. There are clinical signs of both upper and lower respiratory disease. Babies are often obligate nasal breathers in the first few months of life. Normal saline nose drops may assist feeds by thinning nasal secretions.

Answer 459

often showing hyponatraemia, hypokalaemia and a profound hypochloraemic metabolic alkalosis. As the alkalosis worsens, the increasing bicarbonate may combine with calcium ions and so reduce ionised serum calcium. Rarely, tetany may result.

Answer 460

Roseola infantum The 18-month-old has the classical description of roseola, caused by human herpes virus 6. A similar picture is caused by HHV7, though it has a peak presentation between 3-4 years.

Answer 461

Enterovirus In the 2-year-old, although fever with petechiae may be due to meningococcal disease, they are usually caused by viruses, with Enterovirus being most common. The blanching lesions would argue against meningococcus here.

Answer 462

Enlarged Peyer's patches Meckel's diverticula Tumours and Haematomas complicating Henoch-Schonlein purpura.

Answer 463

It is an inherited autosomal recessive disorder of lipid metabolism. It is due to a beta-glucosidase deficiency. This causes an accumulation of glycolipids (especially glucosylceramide) principally in the phagocytic cells of the body but also (less commonly) in the cells of the central nervous system. Clinical features include Hepatosplenomegaly (splenomegaly can be massive which can cause a pancytopenia) Neurological dysfunction Bone erosions particularly of the long bones and fractures Pingueculae - orange wedge-shaped deposits in the subconjunctiva and a yellow/brown discolouration of the skin particularly those areas exposed to sunlight. Gaucher cells (look like wrinkled paper) are characteristically seen in reticuloendothelial cells. Bone erosions may occur near areas of excessive bone growth and lead to fractures. However, the commonest bone condition in adults with Gaucher's is avascular necrosis.

Treating common conditions Flashcards

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