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Chempath Flashcards

1
Q

Distinguish between HONK and DKA

A

Anion gap (ketones in DKA increase anion gap)

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2
Q

Thyroid cancers

  • Medullary
  • Papillary
  • Follicular
  • Anaplasitc
A

Features

  • MEN2, Calcitonin, Parafrollicular “C” cells
  • Psammoma bodies
  • Nodules and mets
  • Elderly
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3
Q

Rate limiting haem synthesis

A

AminoLenvulinic Acid synthase

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4
Q

Deficiency of this –> high urea

A

Hypoxanthine-guanine phosphoribosyltransferase (HGPRT)
in e.g. Lesch Nyhan Syndrome
Hyperuricaemia, Gout, PRT (Prutt)

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5
Q

Gynaecomastia + wants viagra

A

Prolactinoma (prolactin will be >6000)

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6
Q

Rounded mass with glands and mucin in Liver

A

Met from pancreatic adenocarcinoma

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7
Q

Histology of acute fatty liver hep

A

Ballooned cells, mallory denk bodies, neutrophils

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8
Q

Alcoholic hepatitis with fibrosis histology

A

Ballooned cells, mallory denk bodies, MEGAMITOCHONDRIA, pericentricular fibrosis

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9
Q

Alpha Fetoprotein raised in?

A

Hepatocellular Carcinoma, pregnancy, testicular Ca

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10
Q

What type of Br can be seen in urine?

A

Unconjugated only (e.g. haemolysis)

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11
Q

High Br, high ALP, high GGT

A

Could be drug induced cholestasis

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12
Q

Corrected calcium

A

measured + 0.02(40-albumin)

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13
Q

Baby with seizures, low Ca, low PTH

A

Primary hypoparathyroidism in e.g. Di George

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14
Q

Low mood after renal transplant for longstnading renal disease (high Ca, high PTH)

A

Tertiary hyperparathyroidism

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15
Q

B12 vs folate deficiency

A

B12: glossitis, jaundice, dementia, other AI conditions, vegans
Folate: diarrhoea, methotrexate

IBD can cause either (methotrexate->folate, loss of terminal ileum absorption->B12)

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16
Q 
Vitamins
B1
B2
B3 (Niacin)
B6
A

B1 - Wernicke’s encephalopathy/Korsakov Syndrome/beri beri –> cardio/neuro (RBC transketeolase)
B2 - Riboflavin (glossitis, RBC glutanthione reductase)
B3 Niacin - Pellagra - dementia, diarrhoea, dermatitis
B6 - Pyridoxine (dermatitis, anaemia, neuropathy)

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17
Q

What does Denosumab target?

A

RANK-L on Osteoclasts (inhibit) for osteoporosis or bony mets

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18
Q

Allopurinol interacts with

A

Azathioprine

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19
Q

Acute intermittent porphyria Ix

A

Urine porphobilinogen (and Urine Aminolevulinic Acid)

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20
Q

In guthrie how do you measure
Hypothyroid
CF
MCADD

A

TSH
Immunoreactive trypsinogen
Acylcarnitine

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21
Q

Normal anion gap

A

18mM

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22
Q

Primary hyperparathyroidism Vit D levels

A

Vit D is low as it is consumed

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23
Q

High Ca + haematuria

A

Renal stone

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24
Q

Band keropathy

A

Long term hyperCa

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25
Q

Addisons + primary hypothyroidism + diabetes

A

Schmidt syndrome (AIPS2)

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26
Q

HTN + Adrenal mass (3 causes)

A

Phaeo, Conns, Cushings

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27
Q

High functioning adrenal (3 causes)

A

Cushings, Conns, CAH

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28
Q

Low functioning adrenal

A

Sepsis, haemorrhage, discontinuation of steroids, Addisons

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29
Q

MI Markers

A

Troponin - rises within 4-6 hours, peaks 12-24 hours, remains high for 3-10 days

CK - rises withing 24 hours (check if double MI)

Myoglobin rises quickly

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30
Q

MEN 1

A

Pituitary, Pancreas, Parathyroid

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31
Q

MEN 2a

A

Parathyroid, Phaeo, Thyroid (med)

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32
Q

Men 2b

A

Phaeo, Thygoid, Ganglioneuroma

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33
Q

Tertiary hyperparathyroidism

A

Often in people with CKD

Longstanding 2° hyperparathyroidism –> gland hyperplasia –> permanent dysregulated high secretions of TSH –> 1° hyperparathyroidism picture

End result: High PTH, high Calcium, variable PO4 levels

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34
Q

T1DM has low Na, everything else is normal. Diagnosis?

A

hyperlipidaemia

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35
Q

High K, low Na, urine osmolality >20

A

CKD/Renin (RAS) cause not aldosterone

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36
Q

Urine osmolality > plasma osmolality

A

SIADH

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37
Q

Low K, alkalosis, hypotension, hypercalciuria

A

Bartter Syndrome

DELETE

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38
Q

Low K and acidosis

A

Renal tubular acidosis

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39
Q

Non-alcoholic fatty liver disease LFTs

A

High ALT and AST ratio 1:1
High GGT

Normal Br and Alb

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40
Q

Low caeruloplasmin

A

Wilsons

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41
Q

Vitamin C deficiency affects what thing to cause bleeding gums and poor dentition?

A

Collagen

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42
Q

Vit E deficiency

A

Haemolytic anaemia, areflexia, ataxia

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43
Q

Vit B6 deficiency

A

AKA Pyroxidine

Dermatitis, peripheral neuropathy, sideroblastic anaemia

Can be caused by isoniazid

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44
Q

Fair skin, brittle hair, developmental delay, intellectual disability

A

Homocystinuria

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45
Q

Glucose-6-phosphate dehydrogenase, hypoglycaemia, big kidneys and liver

A

von Gierke’s syndrome

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46
Q

Toxic encephalopathy causing poor feeding, hypotonia and seizures
Sweet odour and sweaty feet

A

Maple Syrup Urine disease

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47
Q

Cherry-red spot and dymorphia

A

LYsosomal storage disorder (e.g. Fabry’s)

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48
Q

Phenytoin toxicity

A

ataxia and low BP

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49
Q

Lithium SEs

A

tremor and thirst

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50
Q

Gentamicin toxicity

A

Ears and kidneys
Tinnitus - ringing in ear
Gentleman caller ringing

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51
Q

Low vit D, low Ca, high PTH

A

Osteomalacia (not 2° hyperparathyroidism as vit D is the causative problem)

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52
Q

Chronic renal failute, high Ca, high PTH

A

3° hyperparathyroid

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53
Q

Thiamine (B1) test

A

Red cell trasketolase activity

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54
Q

Floppy neonate not feeding

Cataract and conjugated jaundice post milk feed

A

Galactosaemia

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55
Q

Why do you give Calcium gluconate in hyperkalaemia

A

As it is cardioprotective and helps prevent fatal dyrhythmia (does not lower K)

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56
Q

CKMB is useful for what in heart medicine

A

detecting re-infarction as levels rapidly return to normal so would know if was a second one

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57
Q

In an SIADH picture what must you exclude before diagnosing SIADH?

A

Drugs causing it

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58
Q
  1. Causes of pseudo-hyponatraemia

2. what will the osmolality be doing?

A
  1. High lipids or proteins or a spurious sample
  2. The osmolality will be normal (low in true hyponatraemia)

It is caused by dilution

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59
Q

High PTH but high PO4 and low Ca

A

Pseudohyperparathyroidism (Martin-Albright Syndrome)

Generic resistance to PTH
High PTH but Ca and PO4 respond as if low PTH

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60
Q

Anion gap MUDPILES (or KULT)

A 
Metformin
*Uraemia
*DKA (Ketones)
Paraldehyde
Iron
*Lactic acid
Ethanol/methanol
Salicylates
  • Are KUL
    Non* are all the Toxins
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61
Q

Low sodium, all else (K+, CL-?) normal. Glucose before OGTT is 4.9, 2 hours later is 10 ish. Diagnosis?

A

Impaired Glucose Tolerance

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62
Q

A teenager presents with a history of several weeks of increased thirst (polydipsia), increased urination (polyuria) / High urinary output and weight loss - diagnosis?

A

Type 1 diabetes mellitus

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63
Q

High [Na+ / Sodium]
low [K+ / Potassium]
high (Urine osmolality)
diagnosis?

A

Conn’s syndrome

64
Q

pH below 7.35 – Acidosis
K+ - high
Metabolic acidosis present
Diagnosis?

A

Type 1 diabetes mellitus in DKA

65
Q 
High sodium (173), 
high potassium, 
plasma osmolality ~400 (NR 275-290)
urine osmolality ~600 (NR 500-850)
Diagnosis?
A

SIADH

If urine osmolality 2x plasma osmolality, likely to be SIADH

66
Q

What enzyme raised in mumps?

A

Amylase (Amylase-S from the parotid)

67
Q

What enzyme raised in osteomalacia?

A

Alkaline phosphatase

68
Q

In rhabdomylosis, which biomarker likely to be raised?

A

Creatine kinase

69
Q

Person is discharged after surgery, who had a bilateral hemianopia, with removal of pituitary adenoma. Consultant says it is alright to discharge them. What do you prescribe the patient on discharge?

A
  • Hydrocortisone
  • Levothyroxine
  • Testosterone/Oestrogens (if not preserving fertility)/Gonadotrophins (if preserving fertility)
  • GH
70
Q

A man has gout and is kept up at night by it. His symptoms are relieved by ibuprofen, but when he stops taking it, the symptoms come back. His neighbour is on allopurinol, and he would like to be on it too. Which of these medications would need to be altered for them to be able to be prescribed allopurinol?

a. Azothioprine
b. Cyclophosphamide
c. Aspirin
d. Metformin
e. Amlodipine

A

a. Azothioprine - Apparently, if you give allopurinol with either: Azothioprine or 6-Mercaptopurine it causes overdose of either drug (allopurinol is an enzyme inhibitor, so slows the metabolism of other drugs dependent on the same enzymes, causing their effect to be greatly amplified).

71
Q 
Interpret blood gas: 
pH 7.1, 
PCO2 low (2.2 or 3 or something) (ranges were given)
a.	metabolic acidosis
b.	metabolic alkalosis
c.	respiratory acidosis
d.	respiratory alkalosis
e.	normal
A

a. metabolic acidosis

72
Q

Which of these ions is most likely to be outside it’s normal range in an alkalotic picture with a person who is urinating a lot?

a. Potassium
b. Calcium
c. Sodium
d. Magnesium
e. Chloride

A

c. Sodium

As they are urinating lots, they are starting to dehydrate (I.e. body water volume becomes low).

This dehydration matters, because the concentration of ions in plasma (i.e. plasma osmolality) will be strengthened by virtue of there being less water in the blood diluting the ions found there. However, this is not the only thing you need to keep track of.

When we become dehydrated from peeing lots, our blood volume decreases, thus lowering our BP. The Kidney can detect this drop in BP and becomes concerned that if blood pressure continues to drop, then eventually it won’t get any blood supply at all for itself. So, the kidney produces renin, which triggers the release of aldosterone. (Aldosterone promotes trading of potassium from the blood into the urine, in exchange for both-water-and-sodium to move from the urine into the blood). However, aldosterone also causes a drop in blood H+ levels, and a rise in blood HCO3- levels. Now, at this point you might want to argue that because they are dehydrating, their low H+ levels will appear more concentrated – making them look normal. And the question says this is an alkalotic patient. However, if you take that approach you also need to do the same for the HC03- levels which are now building up in the blood. Therefore, even though H+ might be pushed into the normal range due to overall volume loss, the HC03- levels will be pushed from merely raised to super high, maintaining an overall alkalotic picture.
So from this it seems likely this patient’s problem is taking place in the context of a maintained high level of aldosterone production, without eventual compensation. The only disease which fits that picture to my knowledge is Diabetes insipidus. As Vasopressin/ADH/VP is better at moving water than aldosterone. Therefore despite maintaining a high aldosterone, you net lose water. Therefore the patient is likely to have Diabetes insipidus.
Therefore if aldosterone is high, in the context of low body volume the ion situation plays out as follows:

Volume depletion due to low vasopressin hormone leads to relativistic raise in Na, K, Ca, Mg + other ions.
Production of Aldosterone leads to excretion of H+ and K+.
Therefore H+ and K+ blood ion concentrations are lowered. Making them appear normal, whilst Na, Ca, Mg + other ions remain high. Except Aldosterone only allows trading of potassium from the blood into the urine, in exchange for water and sodium movement into the blood. Therefore, sodium levels which already appear high due to the volume depletion (due to diabeites insipidous), appear even more deranged. Making Sodium the most likely ion to be outside it’s normal range in an alkalotic picture.

The other possibility is that it might just be simple dehydration, which could lead to a higher-than-normal sodium maybe, as explained by Amir Sam.

73
Q

Which enzyme would you expect to be raised in obstructive jaundice/biliary obstruction?

A

Alkaline phosphatase

GGT

74
Q

A man develops signs of hyperthyroidism. Bloods show low TSH and high thyroxine. Does not have good uptake on technetium scan. What is the likely diagnosis?

A

Viral De Quervain’s thyroiditis

Good uptake bilaterally = Grave’s Disease, and is due to auto-immune attack on the thyroid by
the body.

Poor uptake = Viral De Quervain’s as the virus causes all of the stored thyroxine to be released
and so new technetium markers are unable to be taken up.

75
Q

What can be used to measure the turnover of bone, and is raised in people who have Paget’s, Osteomalacia / Rickets?

A

Alkaline Phosphatase (ALP)

76
Q

Sodium balance

  • Renal artery stenosis
  • SIADH secondary to small cell lung carcinoma
  • Cranial diabetes insipidus
  • Primary/psychogenic polydipsia
  • Hypovolaemic hyponatraemia

A. Man with cough, SoB and weight loss. Hyponatraemia, low serum osmolality, urine Na and osmolality were inappropriately normal
B. Elderly woman with C. diff colitis and profuse diarrhoea
C. Low plasma sodium, low urine sodium
D. Man who has been in a car accident, raised sodium and plasma osmolality, low urine osmolality
E. Raised Na, low K, HTN but raised renin

A 
A.	SIADH secondary to small cell lung cancer
B.	Hypovolaemic hyponatraemia
C.	Primary/psychogenic polydipsia
D.	Cranial DI
E.	Renal artery stenosis
77
Q

Enzymes

  • ESR
  • Ca2+
  • K+
  • ALT
  • ALP
  • AST
  • CRP

A. What enzyme is raised in Paget’s?
B. What would be raised in obstructive jaundice due to gallstones?
C. What would be raised in obstructive jaundice due to pancreatic adenocarcinoma?
D. What is a sign that your patient has been taking cocaine?
E. Refractory, elevated levels of this are an indication for dialysis?
F. Temporal arteritis test which will help with diagnosis?

A 
A.	ALP
B.	ALP
C.	ALP
D.	AST
E.	K+
F.	ESR
78
Q

Increased calcitonin suggests what type of cancer?

A

Medullary thyroid carcinoma

79
Q

Both mother and grandmother had medullary thyroid carcinoma and have tested positive for MEN2. What biomarker would be raised in the blood to confirm medullary thyroid cancer?

A

Calcitonin

80
Q

Congenital adrenal hyperplasia, which enzyme deficiency is most common?

A

21-alpha hydroxylase

81
Q

Low TSH, raised T3/4 following viral infection. Diagnosis?

A

Viral thyroiditis/De Quervain’s thyroiditis

82
Q 
72 y/o Afro-Caribbean woman is admitted with acute SOB. PMHx includes hypertension and T2DM. She takes Metformin, Atorvastatin, and Amlodipine. O/E BP is 148/96. Auscultation reveals a 3rd heart sound and bibasal crackles, but no murmurs.
Investigations:
Sodium 142
Potassium 3.5
Urea 12.4
Creatinine 126
Rank the following diagnoses from most to least likely:
a.	Essential hypertension
b.	Cushing’s syndrome
c.	Conn’s syndrome
d.	Phaeochromocytoma
e.	Addison’s disease
A

a. Essential hypertension
c. Conn’s syndrome
b. Cushing’s syndrome
d. Phaeochromocytoma
e. Addison’s disease

83
Q

Rank the following in order of efficacy at reducing LDL:

a. Atorvastatin
b. Bezafibrate
c. Evolocumab
d. Prednisolone
e. Simvastatin

A

c. Evolocumab
e. Simvastatin
a. Atorvastatin
b. Bezafibrate
d. Prednisolone

84
Q

What is the most common cause of hypocalcaemia in the community?

A

Vitamin D deficiency

85
Q

What is the most common cause of hypercalcaemia in the community?

A

Primary hyperparathyroidism

86
Q

Which blood test may confirm a diagnosis of acute pancreatitis?

A

Serum amylase

87
Q

Deficiency of which plasma protein occurs in patients with movement disorder and liver disease?

A

Caeruloplasmin

88
Q

Name a hormone that increases urinary phosphate excretion

A

Parathyroid hormone

89
Q

Which liver enzyme is associated with obstructive jaundice?

A

Alkaline phosphatase

90
Q

Which condition occurs in MEN 1 and 2a?

A

Parathyroid hyperplasia

91
Q

A patient presents in Addisonian crisis with a systolic BP of 90, which fluid should be given?

A

I.V. 0.9% saline

92
Q

Which enzyme is inhibited by Allopurinol?

A

Xanthine oxidase

93
Q

What adrenal gland zone makes Cortisol?

A

Zona fasiculata

94
Q

Which vitamin deficiency causes pellagra?

A

Niacin (B3)

95
Q

Which enzyme causes hypercalcaemia in sarcoidosis?

A

Alpha 1 hydroxylase

96
Q

A patient is found to have a high Na+, low K+, and low renin. What is the likely cause?

A

Conn’s syndrome

97
Q

Which hormone released from fat cells has hypothalamic receptors?

98
Q

A 35 y/o woman presents with neck pain worse on swallowing, she had an URTI 2 weeks prior. Investigations show low TSH, and high T3 and T4. Technetium scanning shows low thyroid uptake. What is the likely diagnosis?

A

Viral thyroiditis/ de Quervain’s thyroiditis

99
Q

28 y/o woman with IDA has IgA antibodies for tissue transglutaminase. What is the likely diagnosis?

A

Coeliac disease

100
Q

Which enzyme level or activity should be measured before giving azathioprine?

A

Thiopurine methyltransferase

101
Q

40 y/o woman presents with headache, but normal visual fields. MRI shows a 4mm pituitary adenoma. Investigations:

Cortisol 400 (high end of normal)
ACTH 30 (normal)
Prolactin 1400 (high)
TSH 3.3 (normal)
Free T4 17 (normal)
What is the most likely diagnosis?
a.	Acromegaly
b.	Hypopituitarism
c.	Non-functioning pituitary macroadenoma
d.	Prolactinoma
e.	TSHoma
A

d. Prolactinoma

102
Q

Which of the following is found in haemolytic jaundice?

a. Raised AST
b. Raised CK
c. Normal bilirubin
d. Pale stools
e. High urobilinogen in urine

A

e. High urobilinogen in urine

103
Q

60 y/o man with BMI of 28 is referred with abdo pain. Investigations:

ALP 650 (most raised result)
ALT 145 (high)
AST 100 (high)
GGT 171 (high)
CK 254 (high)
What is the most likely diagnosis?
a.	Acute pancreatitis
b.	Alcoholic cirrhosis
c.	Haemolytic jaundice
d.	Gallstones
e.	Alcoholic hepatitis
A

d. Gallstones

104
Q

Increased insulin sensitivity causes low plasma glucose, and features in which of the following?

a. Acromegaly
b. ACTH deficiency
c. Cushing’s disease
d. Phaeochromocytoma
e. PCOS

A

b. ACTH deficiency

105
Q

40 y/o woman presents with headache and a bitemporal hemianopia. MRI shows a 2cm pituitary adenoma. Investigations:

Cortisol 400 (high end of normal)
ACTH 30 (normal)
Prolactin 1400 (high)
TSH 3.3 (normal)
Free T4 17 (normal)
What is the most likely diagnosis?
a.	Acromegaly
b.	Hypopituitarism
c.	Non-functioning pituitary macroadenoma
d.	Prolactinoma
e.	TSHoma
A

c. Non-functioning pituitary macroadenoma

106
Q

25 y/o man brought to A&E with abdominal pain followed by collapse. His blood pressure shows he is in shock and his blood gas results are:

Na+ 120 (low)
K+ 6.2 (high)
HCO3 10.1 (low)
Urea 9.4 (high)
Creatinine 146 (high)
Glucose 2.5 (low)
pH 7.2 (low)
pCO2 3.0 (low)
What is the most likely diagnosis?
a.	Acute abdomen
b.	Addison’s disease
c.	Conn’s syndrome
d.	Cushing’s syndrome
e.	Diabetic ketoacidosis
A

b. Addison’s disease

107
Q

Which of the following stimulates receptors in the adrenals and leads to aldosterone release?

a. ACTH
b. Angiotensin 2
c. Calcium
d. Renin
e. Sodium

A

b. Angiotensin 2

108
Q

25 y/o man brought to A&E with abdominal pain followed by collapse. His blood pressure shows he is in shock and his blood gas results are:

Na+ 120 (low)
K+ 6.2 (high)
HCO3 10.1 (low)
Urea 9.4 (high)
Creatinine 146 (high)
Glucose 2.5 (low)
pH 7.2 (low)
pCO2 3.0 (low)
Which of the following does the blood gas show?
a.	Metabolic alkalosis
b.	Metabolic acidosis
c.	Respiratory alkalosis
d.	Respiratory acidosis
e.	Mixed metabolic alkalosis and respiratory acidosis
A

b. Metabolic acidosis

109
Q

Which of the following can cause hypoglycaemia?

a. Atorvastatin
b. Bendrofluazide
c. Glucagon
d. Prednisolone
e. Quinine

A

a. Atorvastatin

110
Q

Which of the following findings is consistent with moderate alcohol intake?

a. Reduced albumin
b. Elevated HDL
c. Nearly normal AST
d. Normal GGT
e. Normal triglycerides

A

b. Elevated HDL

111
Q 
40 y/o woman has post-partum haemorrhage and is then unable to breastfeed. Investigations:
Cortisol <50 (very low)
ACTH <10 (very low)
Prolactin <50 (very low)
TSH 0.9 (normal)
Free T4 12 (normal)
What is the most likely diagnosis?
a.	Acromegaly
b.	Hypopituitarism
c.	Non-functioning macrodenoma
d.	Prolactinoma
e.	TSHoma
A

b. Hypopituitarism

112
Q

Which of the following would be consistent with obstructive jaundice?

a. Normal ALP
b. Normal AST
c. Normal GGT
d. Dark stools
e. Increased bilirubin in the urine

A

e. Increased bilirubin in the urine

113
Q 
Pituitary
•	TSHoma
•	Non-functional macroadenoma
•	Prolactinoma
•	Hypothyroidism

A. Woman comes in with bitemporal hemianopia, 2cm mass, and a raised prolactin 1400
B. Woman comes in with no visual change, 4mm mass, and raised prolactin 1400
C. Raised prolactin, raised TSH, raised T4
D. High TSH low T4

A

A. Non-functional macroadenoma
B. Prolactinoma
C. TSHoma
D. Hypothyroidism

114
Q 
Calcium homeostasis
•	Hypoparathyroidism
•	Bone metastases
•	Osteoporosis
•	Osteomalacia
•	Hyperparathyroidism
A.	Calcium low, PTH high
B.	Calcium high, PTH low
C.	Calcium high, PTH high
D.	Calcium low, PTH low
E.	Calcium normal, PTH normal
A 
A.	Osteomalacia
B.	Bone metastases
C.	Hyperparathyroidism
D.	Hypoparathyroidism
E.	Osteoporosis
115
Q 
Investigations
•	Oral glucose tolerance test
•	HbA1c
•	Inferior petrosal sinus sampling
•	Synacthen test
•	Fluid deprivation test

A. Patient can’t fit in her shoes or put on her wedding ring and has prognathism, what test do you need to do to confirm?
B. BP 190/100, thin skin, overweight, high-normal sodium, low normal potassium, OGTT done (glucose high normal)
C. Pt with low Na, High K + postural hypotension
D. Diabetic visiting his GP for a routine appointment
E. Patient with low sodium, potassium normal, low plasma osmolality and urine osmolality was 70

A 
A.	Oral glucose tolerance test
B.	Inferior petrosal sinus sampling		
C.	Synacthen test
D.	HbA1c	
E.	Fluid deprivation test
116
Q 
LFTs
•	Gilbert’s
•	Paget’s
•	Viral hepatitis
•	Cirrhosis
•	Alcoholic hepatitis
•	Acute cholestasis

A. 24 year old asymptomatic man with isolated rise in unconjugated bilirubin (all other results (ALT, ALP etc normal)
B. 22 year old student with two weeks anorexia, fever and malaise – ALT was most elevated, raised ALP + GGT
C. Woman with colicky abdominal pain, markedly raised ALP, other LFTs also deranged
D. A 57 year old man presents following hematemesis and is found to have high ALT + GGT, slightly raised ALP, and low Albumin
E. An elderly gentleman has massively elevated ALP on its own, and the other results are normal. He also reports a history of headaches.

A 
A.	Gilbert’s
B.	Viral hepatitis
C.	Acute cholestasis
D.	Cirrhosis
E.	Paget’s
117
Q 
Biochem
•	2
•	3
•	4.5
•	6.1
•	10
•	11.5
•	35
•	284
•	304
•	334

A. Bicarbonate in a pyloric stenosis patient
B. What is the likely K+ value in a patient with DKA
C. Man with impaired glucose tolerance, their fasting value
D. Anion gap calculation
E. Osmolarity calculation

A 
A.	35
B.	3
C.	6.1
D.	Na + K - HCO3 - Cl
E.	2(Na + K) + U + G
118
Q 
Enzymes
•	Amylase-S
•	Amylase-P
•	Alkaline Phosphatase
•	Glucose 6 phosphate dehydrogenate
•	Creatinine Kinase
•	ALA Synthase 
•	HGPRT

A. Deficiency of which enzyme leads to hyperuricemia?
B. Which enzyme regulates the rate limiting step in the haem biosynthesis pathway?
C. Which enzyme is raised in osteomalacia?
D. Which/What enzyme is raised in mumps?
E. In Rhabdomyolysis, which biomarker is likely to be raised?

A 
A.	HGPRT
B.	ALA Synthase 
C.	Alkaline Phosphatase
D.	Amylase-S
E.	Creatinine Kinase
119
Q 
Calcium and Bone Handling
•	Hypoparathyroidism
•	Renal osteodystrophy
•	Tertiary hyperparathyroidism
•	Paget’s disease
•	Metastatic disease

A. High calcium, normal phosphate, low PTH, high ALP, patient feels tired
B. 72 year old with headache: high CA, normal phosphate, normal PTH, high ALP
C. Baby with seizures: low Ca, low PTH
D. Pt presents with low mood after renal transplant following longstanding renal disease: high Ca, high PTH
E. 10 year old with seizures: low Ca, high PO4, high PTH

A 
A.	Metastatic disease
B.	Paget’s disease
C.	Hypoparathyroidism
D.	Tertiary hyperparathyroidism
E.	Renal osteodystrophy
120
Q 
Vitamin Deficiencies
•	B3 deficiency
•	B12 deficiency
•	Folate deficiency
•	Calcium deficiency
•	Vitamin D deficiency
A.	Vegan with megaloblastic anaemia
B.	Person with Crohn’s with megaloblastic anaemia
C.	Patient with Pellagra
D.	Young patient with bowed legs
E.	Patient with High PTH
A 
A.	B12 deficiency
B.	Folate deficiency
C.	B3 deficiency
D.	Vitamin D deficiency
E.	Calcium deficiency
121
Q

What is the most common cause of acute pancreatitis?

A

Gallstones

122
Q

Which cancer typically causes an increase in calcitonin?

A

Medullary carcinoma of the thyroid

123
Q

Low TSH and high T4 following viral infection, what is the diagnosis?

A

Viral thyroiditis/ De Quervain’s thyroiditis

124
Q

Which thyroid cancer most commonly metastasises to the lymph nodes?

125
Q

Which enzyme is raised in Paget’s, Osteomalacia etc. and is caused by osteoblast activation?

A

Alkaline phosphatase

126
Q

Patient with GI conditions, lack of which substance leads to B12 being malabsorbed?

A

Intrinsic factor

127
Q

T1DM with hypoglycaemia, what is the management option if no IV access?

A

IM Glucagon

128
Q

Swollen joint, needle-shaped aspirate with negative birefringence, which enzyme manufactures the material that makes up the crystals?

A

Xanthine Oxidase

129
Q

Treatment for gout, specifically one you should use acutely (i.e. not allopurinol)

A

Colchicine or an NSAID

130
Q

Publican with diabetes, fatty stools, weight loss, ‘slate grey skin’ and joint pains. What is the underlying diagnosis causing this?

A

Haemochromatosis (joint pain, skin changes, pancreatitis, liver deposition)

131
Q

5yr old, tetany, bone pain. Widened epiphyses + ‘Cupping’ of metaphysis shown on x-ray. What is the cause?

132
Q

A girl comes, overweight, irregular periods, flare of acne and hirsutism. Diagnosis?

A

Polycystic ovarian syndrome

133
Q

What enzyme to confirm cardiac failure?

A

Brain Natriuretic Peptide

134
Q

What liver enzyme is raised in MI?

A

Aspartate aminotransferase (AST)

135
Q

Old man who fell over, been on floor for days. Severely dehydrated. Dark urine. Not blood on microscopy. What causes the dark urine?

136
Q

Old man who fell over, been on floor for days. Severely dehydrated. Dark urine. What enzyme will be high (>5x upper limit of normal)?

A

Creatine Kinase

137
Q

PCSK9 inhibitor - evolucumab, what does it halve?

A

LDL levels

138
Q

Which molecule takes cholesterol and moves it to liver and steroidogenesis organs?

A

high-density lipoprotein

HDL

139
Q

Which disease do you see in both MEN1 and MEN2a?

A

Primary hyperparathyroidism

140
Q

Vitamin deficiency that causes megaloblastic anaemia & neural tube defects?

141
Q

High PTH, high vit D and low Ca, what can this be?

A

Osteomalacia

142
Q

Low plasma sodium (124) and urine specific gravity of 1.000 cause?

A

Psychogenic polydipsia

143
Q

What would be high in the most common cause of CAH?

A

Sex steroid hormones & ACTH

144
Q

Which hormone leads to release of prolactin?

145
Q

Red cell lysis, what ion is raised:

a. Potassium
b. Sodium
c. Calcium
d. Bicarbonate

A

a. Potassium

146
Q

Woman presents worried because she has low glucose when she tests using daughter’s meter (her daughter has T1DM) but denies taking any drugs. Low glucose, high insulin, low C peptide, she has a high BMI?

a. Factitious/ surreptitious insulin
b. Surreptitious gliclazide
c. Type 1 diabetes mellitus
d. Anorexia nervosa
e. Insulinoma

A

a. Factitious/ surreptitious insulin

147
Q

Person is discharged after surgery, who had a bilateral hemianopia, with removal of pituitary adenoma. Consultant says it is alright to discharge them. What do you prescribe the patient on discharge?

a. DDAVP
b. Fludrocortisone
c. Testosterone

A

a. DDAVP (hydrocortisone if an option)

148
Q

Which of these is a common finding in someone who has portal hypertension?

a. Splenomegaly
b. Hepatomegaly
c. Spider Naevi in distribution of Superior vena cava (SVC)
d. Hand flapping
e. Jaundice

A

a. Splenomegaly

149
Q

A man has gout and is kept up at night by it. His symptoms are relieved by ibuprofen, but when he stops taking it, the symptoms come back. His neighbour is on allopurinol, and he would like to be on it too. Which of these medications would need to be altered for them to be able to be prescribed allopurinol?

A

Azathioprine

150
Q

pH 7.1, pCO2 low (2.2 or 3 or something)

a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis

A

a. metabolic acidosis

151
Q

A Girl develops a throat infection. She is given amoxicillin, and a rash develops. It is later found out that she has infectious mononucleosis, and her symptoms persist

a. Drug reaction
b. Penicillin allergy
c. Mastocytosis

A

a. Drug reaction

152
Q

Cushing disease person – Which is the best investigation to confirm the suspected diagnosis?

a. High dose dexamethasone suppression test
b. Low dose dexamethasone suppression test
c. Long synacthen test
d. Short synacthen test
e. Inferior petrosal sinus sampling

A

e. Inferior petrosal sinus sampling

Previously, high dose dexamethasone suppression test

153
Q

What does the number of True positives divided by the total number who have the disease describe?

a. Positive predictive value
b. Negative predictive value
c. Sensitivity
d. Specificity
e. Z score

A

c. Sensitivity

154
Q

Which of these ions is most likely to be outside its normal range in an alkalotic picture (& if person is urinating a lot????)?

a. Potassium
b. Calcium
c. Sodium
d. Magnesium

A

a. Potassium

155
Q

Shows you a Blood gas and a couple of biomarker values (e.g. urea I think), which demonstrates hypoxia, then asks you which part of it would indicate that the patient requires immediate dialysis

A

Hyperuricaemia

156
Q 
Rank the following diagnoses in order of expected measured serum potassium, with (1) being the highest potassium and (5) being the lowest.
A. Phaeochromocytoma
B. Conn's syndrome
C. Pneumonia
D. Addison's disease
E. Cushing's disease
A 
D. Addison's disease
C. Pneumonia
E. Cushing's disease
A. Phaeochromocytoma
B. Conn's syndrome
157
Q

Five patients (Patient A to E) each have a blood gas sample sent to the laboratory. The clinical details of the cases are detailed below. Rank these cases on the expected pH from (1) lowest pH (acidosis) to (5) highest pH (alkalosis)
Patient A, a 59 year old with with very long standing COPD who has an acute exacerbation and is feeling breathless.
Patient B, is having a panic attack, is hyperventilating and complains of tetany
Patient C, a 17 year old with type 1 diabetes who omits his insulin.
Patient D, a 58 year old with very long standing COPD who is currently quite well
Patient E, has a cardiac arrest and has blood gases show a low p02 and a high pC02

A

Patient D, a 58 year old with very long standing COPD who is currently quite well
Patient A, a 59 year old with with very long standing COPD who has an acute exacerbation and is feeling breathless.
Patient B, is having a panic attack, is hyperventilating and complains of tetany
Patient E, has a cardiac arrest and has blood gases show a low p02 and a high pC02
Patient C, a 17 year old with type 1 diabetes who omits his insulin.

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