BPT Trial Exam Questions 3 Flashcards
A 32 year old man presents with 2 months history of lethargy, intermittent fever and weight loss associated with gum bleeding over the last one week. Examination showed petechial haemorrhages and splenomegaly. Her complete blood picture showed: Haemoglobin 90 g/L [120-150] Mean corpuscular volume (MCV) 81 fL [80-100] White cell count 2 X 109 /L [4-10] Differential: Neutrophils 0.4 X 109 /L [1.8-7.5] Lymphocytes 1.2 X 109 /L [1.5-3.5] Monocytes 0.3 X 109 /L [0.2-0.8] Platelet count 18 X 109 /L [150-450] Coagulation profile: Prothrombin time-international normalised ratio (PT-INR) 1.7 [1.0-1.3] Activated partial thromboplastin time (APTT) 42 s [26-38] Fibrinogen 0.9 g/L [2.0-4.0] D-dimer 25mg/L [< 0.2]
A bone marrow aspiration sample shows that 90% of nucleated cells appear as blasts with cytoplasmic rods.
What is the MOST appropriate initial therapy?
A. Daunorubicin and cytarabine
B. Arsenic
C. All-trans-retinoid acid
D. Idrabucin
Answer: C - All-trans-retinoid acid (ATRA)
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This patient has APML, which represents a medical emergency with a high rate of early mortality, often due to haemorrhage from a characteristic coagulopathy. The emergent management would be all-trans retinoid acid.
What is the mechanism of action of digoxin?
A. Inhibition of sympathetic Beta 1 receptors leading to reduced adrenalin mediated calcium release
B. Inhibition of Na/K ATPase resulting in reversal of Na-Ca Exchange
C. Inhibition of cytochrome c oxidase to prevent activation of the AV node
D. Inhibition of Ryanodine receptor calcium channels leading to leading to reduced sarcoplasmic calcium release
Answer: B - Inhibition of Na/K ATPase resulting in reversal of Na-Ca Exchange
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Digoxin inhibits the Na/K ATPase. Dantrolene (used to treat malignant hyperthermia) inhib its the Ryanodine receptor. Beta blockers inhibit the Beta 1. Cyanide inhibits its cytochrome c oxidase, which among other things probably prevents AV node activation?
A 78 year-old gentleman is found to have second-degree atrio-ventricular heart block on ECG. What is the MOST likely pathophysiological cause of his heart block?
A. Cardiomyopathy
B. Hypertension
C. Idiopathic fibrosis
D. Myocardial ischaemia
Answer: C - Idiopathic fibrosis
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Idiopathic fibrosis and sclerosis accounts for approximately 50% of cases of AV block followed by myocardial ischaemia (40%) and other causes including cardiomyopathies, congenital heart disease and familial heart block
ZOOB M, SMITH KS. THE AETIOLOGY OF COMPLETE HEART-BLOCK. British Medical Journal. 1963 Nov 9;2(5366):1149-53.
https://www.uptodate.com/contents/etiology-of-atrioventricularblock?topicRef=910&source=see_link
Hepcidin regulates systemic absorption of iron by:
A. Inhibition of ferroportin leading to reduction in enterocyte basolateral iron release
B. Reducing enterocyte apical iron uptake by ferroportin
C. Iron oxidation by hephaestin
D. Increasing iron binding to transferrin reducing iron availability
Answer: A - Inhibition of ferroportin leading to reduction in enterocyte basolateral iron release
Feedback
The mechanisms by which hepcidin reduces iron absorption in the intestine and releases iron from macrophages is by interacting with and inactivating the iron export protein ferroportin. Inhibition of ferroportin leads to reduction of iron transport across the enterocyte basolateral cell membrane into systemic circulation.
A 20 year old man presents for a check-up with his local primary health care practitioner and is then found to have a random blood glucose of 13.0mmol. This is further investigated with a fasting glucose of 8.0mmol/L and a 2 hour glucose tolerance test of 13.0mmol/L. An HbA1c is 9%. His mother was diagnosed with type 2 diabetes mellitus at the age of 35yrs and his maternal grandmother died of diabetic complications at a young age. He is not particularly overweight. Further testing reveals the absence of islet cell autoantibodies (anti-GAD and anti-IA2). What genetic mutation is MOST likely to be found on further diagnostic testing?
A. Glucokinase gene
B. Insulin VNTR gene
C. Hepatocyte nuclear factor-4-alpha gene
D. PDS Gene
Answer: C - Hepatocyte nuclear factor-4-alpha gene
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This is maturity onset diabetes of the young (MODY) which is characterised by the following:
Typically development of type 2 diabetes in patients aged <25 years old.
Typically inherited as an autosomal dominant condition
Family history of early onset diabetes is often present
Ketosis is not a feature of presentation
Patients with the most common form (MODY3) tend to be very sensitive to sulfonylureas and insulin is not usually necessary in looking at each of the possible answers:
Mutation in the glucokinase (GCK) gene result in MODY 2 which accounts for 20% of MODY cases.
Mutation in the insulin VNTR gene on Chromosome 11 is associated with type 1 diabetes.
Mutation in the PDS gene which is the causal gene in Pendred Syndrome associated with congenital bilateral sensorineural hearing loss, goitre with hypothyroidism.
Mutation in the HNF-alpha gene results in MODY 3 which accounts for 60%
of all MODY cases.
A young couple are both affected by achondroplasia and present for genetic counselling as they wish to have a child. Patients who are heterozygous for this condition manifest dwarfism, while homozygosity results in early neonatal death. What are the different chances of outcome for their future child?
Options: 1. Achondroplasia, 2. Early neonatal death, 3 no abnormality
A. 1. 25%, 2. 50%, 3. 25%
B. 1. 50%, 2. 25%, 3. 25%
C. 1. 33%, 2. 33%, 3. 33%
D. 1. 25%, 2. 50%, 3. 50%
Answer: B
Which of the following conditions has NOT demonstrated mortality benefit associated with the use of beta blocker therapy?
A. Catecholaminergic polymorphic VT
B. Stable angina
C. Myocardial infarction
D. Heart failure with reduced ejection fraction
Answer: B - stable angina
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Beta blockers are effective at relieving symptoms of angina but do not have proven mortality benefit for those with stable angina without prior infarction. The other conditions have mortality benefit with the use of beta blockers along with Congenital Long QT Syndrome
Abiraterone is an oral agent used in combination with prednisolone for treatment of castrate resistant metastatic prostate cancer. What is its mechanism of action?
A. Gonadotropin-releasing hormone (GnRH) agonist
B. Gonadotropin-releasing hormone (GnRH) antagonist
C. Irreversibly inhibits product of CYP17, blocking the synthesis of androgens in the tumour, testes, and adrenal glands.
D. Androgen receptor inhibitor - acts at multiple sites in androgen receptor signalling pathway
Answer: C - Irreversibly inhibits product of CYP17, blocking the synthesis of androgens in the tumour, testes, and adrenal glands.
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Abiraterone — Androgens produced in the testes, adrenals, and the tumor cells themselves can cause ““autocrine/paracrine”” signaling, which results in tumor progression. Abiraterone is an orally administered small molecule that irreversibly inhibits the products of the cytochrome P450, family 17 (CYP17) gene (including both 17,20-lyase and 17-alpha-hydroxylase). In doing so, abiraterone blocks the synthesis of androgens in the tumor as well as in the testes and adrenal glands. However, inhibition of 17-alpha-hydroxylase also decreases cortisol, and there is a compensatory rise in adrenocorticotropic hormone (ACTH), which is mediated by a hypothalamic response to partial adrenal inhibition.
The increased ACTH release can cause increased adrenal mineralocorticoid production, which can lead to hypertension and hypokalemia. When abiraterone is given without concomitant glucocorticoids, patients typically do not experience clinical adrenal insufficiency since cortisol production is preserved. The effects of mineralocorticoid excess can be attenuated by coadministration with prednisolone, which reduces ACTH-mediated stimulation of the adrenal glands.
https://www.uptodate.com/contents/overview-of-the-treatment-of-castration-resistant-prostate-cancer-crpc?search=abiraterone&source=search_result&selectedTitle=2~21&usage_type=default&display_rank=3#H606478460
Which of the following complications of aortic stenosis is associated with the WORST prognosis?
A. Angina
B. Heart failure
C. Atrial fibrillation
D. Syncope
Answer: B - heart failure
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Asymptomatic AS holds a relatively good prognosis, however the onset of symptoms can herald a sharp decline in survival unless semi-urgent intervention is undertaken. Heart failure, typically manifesting as exertional dyspnoea, is associated with the worst outcomes followed by syncope and Angina with median survival being 1, 2 and 3 years, respectively.
Mirabegron treats detrusor muscle over-activity via which mechanism?
A. Alpha-2 adrenergic receptor blockade
B. Beta-1 adrenergic receptor activation
C. Beta-2 adrenergic receptor blockade
D. Beta-3 adrenergic receptor activation
Answer: D - Beta-3 adrenergic receptor activation
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Mirabegron activates the β3 adrenergic receptor in the detrusor muscle in the
bladder, which leads to muscle relaxation and an increase in bladder capacity.
Mirabegron was shown to relax in vitro human and rabbit prostatic smooth muscle through activation of β3 adrenoceptor. The same group also showed that mirabegron promotes smooth muscle relaxation by α1 adrenergic receptor blockade Alexandre, E C; Kiguti, L R; Calmasini, F B; Silva, F H; da Silva, K P; Ferreira, R; Ribeiro, C A; Mónica, F Z; Pupo, A S (2015-10-01). “Mirabegron relaxes urethral smooth muscle by a dual mechanism involving β3-adrenoceptor activation and α1-adrenoceptor blockade”. British Journal of Pharmacology. 173: 415–428
What is the most sensitive test for Tuberculosis diagnosis?
A. Bronchial washings
B. Pleural biopsy (Abrams needle) histology and AFB stain
C. Bronchoscopy histology and AFB stain
D. Pleural fluid culture
Answer: C - Bronchoscopy histology and AFB stain
Note: Pleural TB most sensitive test = pleural biopsy
A 39 year old woman presents to her GP with symptoms of dysuria and increased urinary frequency for the past three days. She also complains of lower abdominal pain but has no overt signs of systemic sepsis. Examination is entirely normal aside from mild suprapubic pain. Urine dip correlateswith a diagnosis of urinary tract infection with positive nitrites, leukocytes, blood and protein. The sample is sent for culture. The patient’s medical history is significant only for rheumatoid arthritis for which she takes methotrexate, folic acid, ibuprofen and omeprazole. Which one of the following antibiotics is CONTRAINDICATED in this patient?
A. Trimethoprim
B. Nitrofurantoin
C. Ciprofloxacin
D. Amoxicillin/clavulanic acid
Answer: A - Trimethoprim
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The concurrent use of methotrexate and trimethoprim may cause bone marrow suppression and pancytopenia
What is the most commonly isolated organism from sputum in adults with cystic fibrosis?
A. Burkholderia cepacia complex
B. Methicillin sensitive Staphylococcus aureus (MSSA)
C. Methicillin resistant Staphylococcus aureus (MRSA)
D. Pseudomonas aeruginosa
Answer: D - pseudomonas aeruginosa
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- all of the above are associated with a decline in lung function
- Burkholderia cepacia is the famous one because in some centres it is a contraindication for transplant
- when MRSA and Pseudomonas aeruginosa are isolated for the first time the patient undergoes eradication therapy
- MSSA is not eradicated but there have been studies looking at outcomes differing between community-acquired MSSA and hospital-MSSA but we don’t routinely type these on our isolates in SA
Pseudomonas is the most common organism in adults
MSSA the most common in children (declines over time)
For pre-operative staging of oesophageal cancer, which one of the following provides the MOST accurate information on the T stage?
A. MRI
B. PET scan
C. Endoscopic ultrasound
D. Quadruple phase CT
Answer: C - EUS
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EUS provides information on depth of tumour invasion and node stage
Which of the following is the MOST common complication of endoscopic biliary sphincterotomy?
A. Pancreatitis
B. Haemorrhage
C. Cholangitis
D. Perforation
Answer: A - pancreatitis
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Pancreatitis rate is approx. 1 in every 20 ERCP
A 37 year old man is admitted under the acute surgical unit with a perianal abscess. He has a history of type 2 diabetes and is on metformin 1g BD, dapagliflozin 10mg daily, sitagliptin 100mg daily and insulin glargine 30 units daily. He omitted his lantus due to nausea and decreased oral intake for the two days prior to presenting to the emergency department with his perianal abscess. He had continued on his other medications. Below are selected results from his post-operative biochemistry. Which medication is the most likely cause of his biochemical abnormality?
Na 134 K 2.9 Cl 102 Bicarb 10 Creatinine 90 Urea 8.0 Lactate 1.4 Glucose 7.5
A. Metformin
B. Dapagliflozin
C. Insulin glargine
D. Sitagliptin
Answer: B - dapagliflozin
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This man has a high anion gap acidosis based on his biochemistry. The anion gap can be calculated by (Na + K) – (Cl + bicarb) and in this biochemistry there is a high anion gap of 25.
Some causes of a high anion gap include ketoacidosis, lactic acidosis and uraemic acidosis. In this the setting of normal renal function and normal lactate then ketoacidosis should be suspected, especially with the omission of insulin and prolonged fasting. This is a case of SGLT2 inhibitor related euglycaemic diabetic ketoacidosis which is a well described phenomenon most commonly encountered in the setting of acute illness or prolonged fasting
A female who is a known carrier of the BRCA1 gene mutation wants to know the risk of transmitting the mutation to her son. The best approximation is:
A. 0%
B. 25%
C. 50%
D. 100%
Answer: C = 50%
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Both BRCA1 and BRCA2 are autosomal dominant mutations. The chance of inheriting the BRCA2 mutation is the same for both sons and daughters. The chance of developing breast cancer is distinctly different for the two genders
Which of the following antibodies is associated with multifocal motor neuropathy with conduction block?
A. Anti-GQ1b
B. Anti-GM1
C. Anti-GD1a
D. Anti-GT1a
Answer: B - anti-GM1
Feedback MMN-CB Investigations Anti-GM1 (polyclonal IgM) Ab in 60-80% CSF usually normal NCS - Sensory studies normal - Small CMAPS - Conduction block outside usual entrapment sites, reduced MCV in segments with CB - Want >2 conduction blocks on motor NCS outside of normal entrapment sites
Which of the following agents is most likely to significantly REDUCE dabigatran drug levels?
A. Amiodarone
B. Verapamil
C. Rifampicin
D. Itraconazole
Answer: C - Rifampicin
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P-glycoprotein inducers, such as phenytoin and rifampicin, significantly reduces dabigatran level and is not recommended to be used concurrently with dabigatran. P-glycoprotein inhibitors, such as amiodarone, verapamil and quinidine causes variable increase in dabigatran levels.
What is the purpose of a phase III clinical trial in advanced cancer?
A. Compare response rate of study treatment to standard therapy
B. To ascertain the effect of a treatment on overall survival
C. To determine whether a new treatment is effective in treatment of a cancer
D. To identify an optimal treatment regimen for a study drug
Answer: A - Compare response rate of study treatment to standard therapy
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“Phase 1
To find a safe dose
To decide how the new treatment should be given (by mouth, in a vein, etc.)
To see how the new treatment affects the human body and fights cancer
Number of people taking part: 15–30
Phase 2
To determine if the new treatment has an effect on a certain cancer
To see how the new treatment affects the body and fights cancer
Number of people taking part: Less than 100
Phase 3
To compare the new treatment (or new use of a treatment) with the current
standard treatment”
Sixty eight year old man, day 25 post allogeneic stem cell transplant develops develops febrile neutropenia. He has been on appropriate post-transplantation prophylaxis with posaconazole, famciclovir and inhaled pentamidine. He is commenced on empirical piperacillin and tazobactam, gentamicin and vancomycin. Peripherally inserted central catheter is removed. Routine cultures (blood, sputum, urine, CMV and nasopharyngeal viral swab) after 3 days remains negative. Fevers persist and on day 5 a CT chest is performed showing a cavitating right upper lobe lesion with halo-sign. What is the likely pathogen?
A. Mucormycosis
B. Invasive Aspergillosis
C. Tuberculosis
D. Aspergilloma
Answer: A - Aspergillosis
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“Knowledge of invasive fungal disease is important. Most common Pathogen causing invasive fungal disease is aspergillus followed by mucormycosis. Halo sign is indicative of angioinvasive fungal disease.
Invasive aspergillosis
- Halo sign (lesion surrounded by ground glass infiltrate)
- Galactomannan is a major constituent in aspergillus cell walls - can be positive
Classic features of Mucormycosis are pleural effusion, destructive lesions and “reverse halo” sign (ground-glass lesion surrounded by ring of consolidation)
- 1,3-beta-D-glucan assay and the Aspergillus galactomannan assay negative
- Treatment: IV Amphotericin B (isavuconazole / posaconazole step-down - voriconazole no activity)
A 22 year old right handed woman reports at least six occurrences over the past year of episodes of feeling like she’s on a roller-coaster with her stomach rising within her, on several of these occasions she has subsequently been noticed by her boyfriend to stare fixedly into the distance and not answer him when he tries to get her attention. This period of staring lasts for about a minute each time. On the two most recent occasions she her boyfriend noticed her right eye kept blinking repeatedly. She is usually slightly disorientated for about 10 minutes. The last episode happened two weeks ago. Her interictal EEG is normal. She undergoes a brain MRI. What is the most likely diagnosis?
A. Autosomal dominant lateral temporal epilepsy (ADLTE)
B. Right temporal lobe epilepsy related to mesial temporal sclerosis
C. Left temporal lobe epilepsy related to vascular malformation
D. Left temporal lobe epilepsy related to mesial temporal sclerosis
Answer: B - Right temporal lobe epilepsy related to mesial temporal sclerosis
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Localising seizures has featured several times in past college MCQs. The classical history of an aura with either psychic phenomenon (ie: déjà vu, jamais vu) or epigastric sensations are common and can precede focal seizures with altered consciousness. There are commonly associated automatisms as well as autonomic features such as heart rate changes.
Previous MCQ questions will often give a very classical history and then provide distracting information such as MRI or EEG waveforms whilst the majority of the information needed to come to the diagnosis is in the history provided.
The history in this woman is reflective of a focal impaired awareness seizure of temporal lobe epilepsy (see MJA article referenced below regarding newer
classifications, this previously would have been called a complex partial seizure).
Temporal lobe epilepsy is most commonly due to mesial temporal sclerosis (the mesial temporal lobe comprising of the hippocampus, amygdala and
parahippocampal gyrus). Localising features can include unilateral automatisms (in this case the repetitive eye blinking) that are usually ipsilateral to the site of seizure focus. In contrast if the question had contained unilateral dystonic posturing then this is usually the
contralateral side. These are not always 100% accurate in localising the seizure site in the case of bilateral seizure foci.
In looking at the other answers, ADLTE is an uncommon familial form of temporal lobe epilepsy with prominent auditory hallucinations and focal seizures that evolve into bilateral convulsive seizures. In this case the right sided eye blinking suggests a right sided seizure focus and thus C and D are incorrect. Furthermore, mesial temporal sclerosis would be a much more common underlying aetiology than a vascular malformation.
With regards to the circle of Willis, which two arteries does the posterior communicating artery connect in conventional anatomy?
A. Posterior cerebral artery and middle cerebral artery
B. Posterior cerebral artery and internal carotid artery
C. Posterior cerebral artery and external carotid artery
D. Superior cerebellar artery and middle cerebral artery
Answer: B - Posterior cerebral artery and internal carotid artery
Which of the following treatments for multiple sclerosis are CORRECTLY matched to their mechanism of action?
A. Glatiramer acetate: DNA topoisomerase inhibitor
B. Alemtuzumab: Anti-CD52 monoclonal antibody
C. Mitoxantrone: Modulates nuclear factor-like-2 transcriptional pathway
D. Natalizumab: Anti-CD25 antibody
Answer: B - Alemtuzumab: anti-CD52 monoclonal body
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Glatiramer acetate is a synthetic peptide containing myelin protein which alters macrophages and shifts the immune response from T helper 1 cells to T helper 2 regulatory cells.
Mitoxantrone is a DNA topoisomerase II inhibitor
Alemtuzumab is an anti-CD52 monoclonal antibody
Natalizumab is a monoclonal antibody that targets the alpha-4 subunit of integrin molecules which are important to the adhesion and migration of cells from the vasculature to the inflamed tissue.
Daclizumab is an anti-CD25 antibody acting on IL-2 receptors on T cells
Dimethyl fumarate modulates nuclear factor-like-2 transcriptional pathway
A 64-year-old female with a history of rheumatoid arthritis presents with increased difficulty in walking. On examination there is weakness of ankle dorsiflexion and of the extensor hallucis longus associated with loss of sensation on the lateral aspect of the lower leg. What is the MOST likely diagnosis?
A. Common peroneal nerve palsy
B. Tibia nerve palsy
C. Lateral cutaneous nerve palsy
D. Femoral nerve palsy
Answer: A - common peroneal nerve palsy
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The sciatic nerve divides into the tibial and common peroneal nerves. Injury often occurs at the neck of the fibula. The most characteristic feature of a common peroneal nerve lesion is foot drop. Other features include:
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
Which of the following is the MOST CORRECT statement regarding clindamycin use in toxic shock syndrome:
A. Clindamycin inhibits toxin synthesis
B. Clindamycin provides MRSA cover in toxic shock syndrome
C. Clindamycin adds bactericidal effect in toxic shock syndrome
D. Clindamycin has good soft tissue penetration and therefore improves outcome in toxic shock syndrome
Answer: A - Clindamcyin inhibits toxin synthesis
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Clindamycin and lincomycin are used in toxic shock syndrome to reduce toxin
production
32-year-old man presented to the neurosurgery clinic with mild balance difficulties and hearing loss in the left ear. Evaluation of the patient’s hearing revealed profound sensorineural loss on the leftside and normal hearing on the right side. Magnetic resonance imaging of the brain performed after the administration of contrast material revealed tumors in both internal acoustic canals (33 by 26 by31 mm on the left side and 32 by 28 by 30 mm on the right side), with extension in the cerebellopontine angles and brainstem compression, representing bilateral vestibular schwannomas. What hereditary condition is associated with this presentation?
A. Von Hippel Landau syndrome
B. Li Fraumeni Syndrome
C. Neurofibromatosis 1
D. Neurofibromatosis 2
Answer: D - NF2
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Bilateral vestibular schwannomas are a hallmark of neurofibromatosis type 2. In affected persons, there may be development of schwannomas on other cranial and peripheral nerves, meningiomas, ependymomas, and astrocytomas. Patients may have a parent affected with neurofibromatosis type 2, which is caused by mutations in NF2. These abnormalities are inherited in an autosomal-dominant manner, although de novo mutations may also occur
Which one of the following types of glomerulonephritis is MOST characteristically associated with Wegener’s granulomatosis?
A. Mesangiocapillary glomerulonephritis
B. Rapidly progressing glomerulonephritis
C. Membranous glomerulonephritis
D. Focal segmental glomerulonephritis
Answer: B - RPGN
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Typically presents with nephritic syndrome (haematuria, hypertension)
Rapidly progressive glomerulonephritis - aka crescentic glomerulonephritis
Rapid onset, often presenting as acute kidney injury
Causes include Goodpasture’s, ANCA positive vasculitis
IgA nephropathy - aka Berger’s disease, mesangioproliferative GN
- typically young adult with haematuria following an URTI
A 48 year old man just migrated from China to Australia 1 year ago. He has been diagnosed with HIV as well as toxoplasma gondii encephalitis with associated seizures. He was started on sulfadiazine, pyrimethamine and leucovorin. He was also started on carbamazepine for seizures, and dolutegravir, abacavir and lamivudine combination tablet (Triumeq) for HIV. A few days later, he develops fever, nausea, diarrhoea, shortness of breath and rash suggestive of drug reaction. His HLA-B1502 is negative. His HLA-B5701 is positive. What is the MOST likely cause of his drug reaction?
A. Carbamazepine
B. Abacavir
C. Sulfadiazine
D. Dolutegravir
Answer: B - Abacavir
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Hypersensitivity reaction associated with abacavir is strongly associated with the presence of HLA-B5701 allele. HLA-B1502 allele is associated with SJS/TEN in Han Chinese
A 65-year-old man who is known to have colorectal cancer is referred to the renal clinic. His GP performed a protein-creatinine ratio as he had been complaining of ‘frothy’ urine. The results suggest nephrotic range proteinuria which is confirmed on a 24-hour urinary collection. Assuming the proteinuria is related to his colorectal cancer what is the renal histology MOST LIKELY to show?
A. Minimal change glomerulonephritis
B. Membranous glomerulonephritis
C. Membranoproliferative glomerulonephritis
D. Focal segmental glomerulonephritis
Answer: B - Membranous GN
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Membranous glomerulonephritis
Malignancy causes membranous glomerulonephritis. Patients with underlying
malignancies such as lung, colon and gastric cancer may develop nephrotic syndrome as a paraneoplastic complication. There appears to be an association with HLA-DR3.
Which of the following is useful in preventing predominantly calcium containing renal stones?
A. High fluid intake
B. Allopurinol
C. Sodium bi carbonate
D. Pyridoxine
Answer: A - high fluid intake
Feedback
Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
Preventive measures:
high fluid intake
low animal protein, low salt diet (a low calcium diet has not been shown to be
superior to a normocalcaemic diet)
thiazides diuretics (increase distal tubular calcium resorption)
Oxalate stones:
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
Uric acid stones:
allopurinol
urinary alkalinization e.g. oral bicarbonate
A 27 year-old non-smoker female of asian background presented to the Emergency Department with sudden-onset left pleuritic chest pain and shortness of breath. Her only medication is the Combined oral contraceptive pill She explained that she has suffered from gradual deterioration in her exercise tolerance over the last year. Chest X-ray demonstrated a large pneumothorax. This was treated successfully with needle aspiration. Repeat chest X-ray showed resolution of the pneumothorax but uncovered reticulo-nodular changes in both lung bases. Computed tomography (CT) of her chest showed cystic changes in the lung bases with a minimal left sided pleural effusion. Which of the following is the most disease to accound for this patients symptoms?
A. Neurofibromatosis
B. Alveolar proteinosis
C. Histiocytosis x
D. Lymphangioleiomyomatosis
AnswerL D - Lymphangioleiomyomatosis
Feedback Lymphangioleiomyomatosis (LAM) affects premenopausal women causing proliferation of atypical smooth muscle cells in the lungs, lymphatics and uterus, most likely caused by oestrogens. There is association with tuberous sclerosis and renal angiomyolipomas. Presentation is with dyspnoea due to progressive interstitial lung disease is common. Many patients will develop pneumothoracies. Other manifestations include chylous pleural effusions along with lymphedema and chylous ascites . Pulmonary function tests showing reduced FVC, TLCO and KCO with increased TLC. The disease is associated with mTOR pathway hyperactivity and treatment is with mTOR inhibitors.
Increasing adverse effects of morphine toxicity in renal failure is primarily explained by:
A. Uremic toxins inhibit transport of morphine metabolites out of the CNS
B. Impaired elimination of morphine - 3-glucoronide
C. Impaired elimination of morphine -6-glucoronide
D. Impaired metabolism of morphine into inactive metabolites
Answer: C - impaired elimination of M-6G
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Renal failure impairs elimination of M6G, M3G and normorphine + parent compound, which are all renally excreted. M6G is the main metabolite of morphine. It is analgesic and has some antagonism of respiratory centres and likely is the main driver of increasing toxicity of morphine in renal failure. M3G is about 10% of the metabolism and has no analgesic properties but can cause some neuromuscular side effects.
A 56 year old man with Child-Pugh B liver cirrhosis due to chronic Hepatitis B infection was noted on routine ultrasound of the liver for surveillance to have a liver lesion. His alpha-fetoprotein (AFP) is normal. A triple-phase computed tomography (CT) of the liver showed a 5 cm lesion in segment VII of the liver exhibiting early arterial enhancement with early venous washout. What is the MOST appropriate management for this patient (after discussion at an MDT)?
A. Perform a CT-guided biopsy of the liver lesion
B. Initiate therapy for hepatocellular carcinoma
C. Antibiotic therapy for liver abscess
D. Repeat CT in 6 months
Answer: B - initiate therapy for HCC
Feedback
HCC can be diagnosed on contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound (US). In high-risk patients, HCC can frequently be diagnosed on imaging alone, obviating the need for biopsy, such as the patient in this case. Therefore, he should be referred for treatment. AFP has a sensitivity of only 60% for HCC.
