FA Flashcards
which is the cell for acute inflammation
neutrophil
what cell produces collagen in scarring
fibroblast
is leprosy acute inflammation
no. chronic
mycobacteria
is glandular fever acute inflammation
no. it is acute but not not acute inflammation. as it is caused by a virus, lymphocytes (chronic inf) are involved, not neutrophils (acute inf)
what crystals are deposited in gout
urate crystals
monosodium urate
which of the following has granulomatous inflammation
A -chrons
B acute apendicits
C infectious mononucleoisis
D - lobar pneumonia
A- Crohns
- granulomatous inflammation occurs in chronic inflammation only
- granuloma = macrophages (endotheloid cells) surrounded by lymphocytes
- mononucleosis = mono (EBV virus) - lymphocytes only even though acute illness
- acute appendicitis and lobar pneumonia are neutrophils only
name 4 diseases with granulomatos inflammation
TB
Crohns
sarcoidosis
leprosy
what is the name for calcification in diseased (as opposed to normal) tissues
dystrophic calcification
which of the following is a chronic inflammatory process from its start
A appendicitis
B cholecystitis
C infectious mononucleosis
D lobar pneumonia
C - infectious mononucleosis (lymphocyte even though it is an acute illness)
A and D are classic acute inflammation (neutrophils)
B, cholecystitis is acute then chronic
which of the following never metastasises
A malignant melanoma
B small cell carcinoma of the lung
C basal cell carcinoma
D breast cancer
C basal cell carcinoma of skin
excision = cure
which of the following tumours does not commonly metastasise to bone
A breast cancer
B lung cancer
C prostate cancer
D liposarcoma
D liposarcoma
which of the following does not have a screening programme in the UK
A breast cancer
B colorectal cancer
C cervical cancer
D lung cancer
D lung cancer
- colorectal screening for over 60 - faeces smear looking for blood
which of the following is not known to be a carcinogen in humans?
A hepatitis C
B ionising radiation
C aromatic amines
D aspergillus niger
D aspergillus niger
- hep B and C damages liver to increase cell divisions. increases chance of hepatocellular carcinoma
- aromatic amines concentrate in urine and cause bladder cancer
- aspergillus niger = black fungus in shower
what is the name of malignant tumour of glandular epithelium?
A adenocarcinoma
B adenosarcoma
A adenocarcinoma
sarcoma = connective tissue
which of the following is not a feature of malignant tumours
A vascular invasion
B metastasis
C increased cell division
D growth related to overall body growth
D growth related to body growth
a transitional cell carcinoma of the bladder is a malignant tumour
A true
B false
A true
carcinoma = malignant
radon gas is a cause of lung cancer true or false
true
radon = radioactive –> alpha particles damage nearby lung cells
asbestos is a human carcinogen true or false
true
which of the following is most likely to cause cancer
A drinking half a bottle of wine per day
B being obese
C running 20m 2x a week
D smoking 20 cigarettes a day
D smoking
which tumour has the shortest median survival
A basal cell carcinoma of the skin
B malignant melanoma of the skin
C breast cancer
D anaplastic carcinoma of the thyroid
D anaplastic carcinoma of the thyroid
rare
2 months survival
this question is asking about patient survival not cancer survival u dilt
true or false - ovarian cancer commonly spreads in the peritoneum
true
Activation of naïve T cells is bet achieved by which antigen presenting cells?
a) Neutrophils
b) Mast cells
c) Macrophages
d) Dendritic cells
D dendritic cells
What cell type is :located exclusively in tissues, has an important role in both the innate and adaptive immune system, are antigen presenting cells and have phagocytic properties
a) Macrophage
b) Neutrophil
c) Eosinophil
d) Mast cell
e) Fibroblast
A macrophage
Which of the following is not involved in innate immune mechanisms
a) Anatomic barriers
b) Phagocytic
c) Inflammatory mechanisms
d) Antibody production
e) Skin
D antibody production
T cells recognise antigens…
a) In solution in plasma
b) When presented on red blood cells
c) Following presentation on antigen presenting cells
d) In a 3-dimensional form
e) Following presentation on pattern recognition receptors
C
Influenza vaccine is targeted towards ‘at risk’ groups in the UK. Which of the following are classified as ‘at risk’?
a) Over 65 years
b) 16 years old
c) The obese of any age
d) Teenagers
e) Under 2 years old
A and E
Which of the following is administered as a live attenuated vaccine in the UK
a) Hepatitis A
b) Measles, Mumps, Rubella
c) Tetanus
d) Flu
e) Polio
B - MMR
- BCG is also live vaccine
- hep A , polio, flu = inactivated organisms
- tetanus = subunit
Complements are the proteins that are involved in the clearance of antigen/bacteria. Which of the following is not part of the Elimination phase of complement activation?
a) Opsonisation
b) Target cell lysis
c) Chemoattraction of leukocytes
d) Production of interferons
e) Phagocytosis
D
- complements and interferons (antiviral resistance in unaffected cells) are both soluble serum factors but one does not produce the other
- complements do not phagocytose but osponisation directly aids phagocytosis so it is involved
Which of the following is a polysaccharide vaccine
a) anthrax vaccine
b) Hib vaccine (Haemophilus influenza type b)
c) rabies vaccine
d) hepatitis A
B (like subunit type)
- hep A, rabies = inactivated organism. i think anthrax is too (or live)
Which of the following are features of the adaptive immune response
a) Does not require prior contact with the pathogen
b) It works with B and T lymphocytes
c) Lacks specificity
d) Distinguishes “self” from “non-self”
e) Enhanced by complement
B
- complements work in innate system mainly
- autoimmune is lymphocyte and that is unable to distinguish self and non self
What are the two types of immune response in humans?
a) Immunological tolerance
b) Immune surveillance
c) Innate and acquired
d) Intrinsic and extrinisic
e) Overt and covert
C
Which of the following is not an organ-specific auto-immune disease?
a) Ulcerative colitis
b) Type 1 diabetes mellitus
c) Graves disease
d) Hashimoto’s thyroiditis
e) Sjogren’s syndrome
a and E
- UC - rectum and large intestines and lower intestine (gut contains multiple organs)
- both UC and crohns are autoimmune
- E not officially correct but two emails suggest it is
Which of the following is not a classical PAMP?
a) peptidoglycan, found in bacterial cell walls;
b) flagellin, a protein found in bacterial flagella;
c) lipopolysaccharide (LPS) from the outer membrane of gram-negative bacteria;
d) Interleukin 12
e) nucleic acids such as viral DNA or RNA.
D
Infection control: which is false? The five steps of hand hygiene are to wash hands
A Before contact with patient B Before bodily fluid exposure C Before aseptic procedures D After contact with patient surroundings E After patient contact
B
Which of these does NOT feature in the definition of Sepsis?
A Temperature >38.3oC or <36oC B Heart rate >90 C Systolic blood pressure >130 D White Cell count >12 E Hypoxia
C
- hypoxia relates to respiratory rate
- sepsis decreases BP, not raises it
A 21 year old complains of myalgia, sore throat and tiredness. He is febrile and has an enlarged spleen. Which is the best answer?
A He has sepsis and needs broad spectrum antimicrobial therapy with cefotaxime
B A charcoal throat swab will confirm the diagnosis
C Finding atypical lymphocytes on a blood film and a positive EBV IgM in serum would be consistent
D PCR on a viral throat swab will confirm the diagnosis
E This is a viral upper respiratory tract infection and doesn’t warrant investigation or antimicrobial therapy
C
A 34 year old gay man who has had prolonged diarrhoea now presents short of breath with a dry cough and hypoxia. Which is most accurate?
A This is bacterial pneumonia caused by pneumocysitis jirovecii.
B It is too early for a 4th generation HIV test to be positive
C The CD4 T cell count will be between 500 and 750
D Even if the HIV test is negative this man has AIDS
E With appropriate therapy he has a good prognosis
E
- 4th generation HIV test works within 4w. this man has had prolonged symptoms
Which is the incorrect antimicrobial pairing:
A S. pyogenes : can use penicillin B Meropenem : a carbapenem C Glycopeptides : use for MRSA D Co-amoxiclav : contains a Beta-lactamase inhibitor E Cefuroxime : a macrolide
E
- cefuroxime is a cephalosporin
Which is true of antimicrobial resistance?
A it is spread by plasmid mediate gene transfer
B spontaneous gene mutations do not occur
C MRSA refers to vancomycin resistant S. aureus
D Only Mereopenem is effective against all gram negative bacteria
c
i acc think i might now be which is NOT true but this is not confirmed
Which is NOT a feature of mycobacteria?
A Resistance to destaining by acid and alcohol
B Cell wall contains lipoarabinomannan
C They only divide every 20 hours
D They cannot withstand phagolysosomal killing
E May cause meningitis
d
which pair is correct:
A Pityriasis versicolor = bacterium B Ringworm = helminth C Aspergillus fumigatus = mycobacterium D Falciparum malariae = fungal E Giardia lamblia = protozoal
e
- giardia lambia is a flagellate protozoa
- ringworm and aspergillus fumigatus and Pityriasis versicolor = fungus
- falciparum malariae= sporozoa (nonmotile) protozoa
which is correct for what a HIV virus envelope contains?
A RNA + capsid + DNA polymerase
B DNA + capsid + Reverse transcriptase
C DNA + p24 + protease
D RNA + capsid + reverse transcriptase
D
When diagnosing viral infections which is not true?
A The sample must come from a sterile site
B Electron microscopy is rarely used
C Use a green swab not a black swab
D PCR results take 1-2 days
E A detectable IgM in serum may be diagnostic
a
Which of these is NOT a means by which viruses cause disease?
A direct destruction of host cells
B cell proliferation and cell immortalisation
C inducing immune system mediated damage
D Endotoxin production
E modification of host cell structure or function
D
- endotoxin is produced by gram - bacteria
Which site is normally sterile?
A The pharynx B The urethra C Cerebrospinal fluid D The lung E Skin
C
Which is incorrect? Haemophilus influenzae is an important cause of
A meningitis in pre-school children B Otitis media C Pharyngitis D Gastroenteritis E Exacerbations of Chronic Obstructive Pulmonary Disease (COPD)
D
- otitis media are middle ear inflammatory diseases
- gastroenteritis pathogens = camplyobacter, e coli, salmonella, shigella, yersinia, staphylococcus
Which of these is a gram negative bacillus that ferments lactose?
A Shigella sonnei B Listeria monocytogenes C Neisseria meningitidis D Eschericia coli E Streptococcus pyogenes
D
- e.coli/ klebsiella = gram neg bacilli lactose fermenters
- shigella/salmonella, proteus, psuedomonas = gram neg bacilli non-fermenters
- neisseria = gram neg cocci
Chains of purple cocci are seen on a gram film. They show alpha haemolysis when grown on blood agar. They don’t grow near the optochin disc. These are probably
A Streptococcus pneumoniae B Staphylococcus epidermidis C Viridans Streptococci D Group A streptococci (S. pyogenes) E Neisseria meningitidis
A
- not growing near optochin disc = optochin sensitive
Which of the following is not under the control of the pituitary gland?
A Thyroid B Adrenal cortex C Adrenal medulla D Testis E Ovary
c
Which of the following statements is false?
A The pituitary gland lies in the sella turcica
B The weight of the pituitary gland is around 0.5g
C ACTH is secreted from the pituitary during stress
D The pituitary regulates calcium metabolism
E The anterior and posterior pituitary are distinct on an MRI scan
D
- parathyroid controls calcium (not thyroid) and is not related to pituitary
In men all the following are mainly produced in the adrenal cortex except
A DHEAS B Testosterone C Aldosterone D 17-OH progesterone E Androstenedione
B
Which of the following regarding AVP is false?
A AVP levels have a linear relationship with serum osmolality
B is produced in the pituitary gland
C stimulates reabsorption of water in the collecting duct of the nephron
D in hypotension baroreceptors predominantly activate ADH production and secretion
E Further AVP production is no longer effective once urine osmolality has reached a plateau
B
- AVP = arginine vasopressin
Where is growth hormone’s main site of action to stimulate IGF1 release?
A bone B liver C adrenal cortex D muscle E pancreas
b
The following are typical features of excess growth hormone secretion except?
A Polyuria B Joint pains C Sweating D Hypotension E Headaches
D
The following hormones all have a circadian rhythm except?
A Cortisol B Testosterone C DHEA D 17OH progesterone E Thyroxine (T4)
E
Typical features of cortisol deficiency include the following except?
A Hypotension B Muscle aches C Weight loss D Hyperglycaemia E Lethargy
D
A 38 year old lady presented with weight gain, menorrhagia and constipation. She is most likely to be suffering from?
A Cushing’s syndrome B Addison’s disease C Primary hypothyroidism D Graves disease E Acromegaly
C
Which test would you likely want to perform in a patient with proximal muscle weakness, purple striae and thin skin?
A Synacthen test B Overnight dexamethasone suppression test C Insulin tolerance test D Glucagon test E Skin allergy tests
B
- this patient has cushings. the purple striae, thin skin and proximal muscle weakness are a result of protein catabolism. first line = overnight dexamethasone test (corticosteroid injected. serum cortisol measured in morning normal: ACTH/ cortisol suppressed. cushings: no suppression). second line = 48h dexamethoaone (same but steroid taken for longer)
- synachten test differentiates between addisons/ adrenal insufficiency. synACTHen (ACTH analogue = tetracosactide). Addisons: cortisol should be low- not raised by the stimulant. Secondary : cortisol rises
A 24 year old girl presented with hirsutism, oligomenorrhoea and acne. What test would you likely carry out from the ones below?
A Ultra sound adrenals B Ultra sound ovaries C MRI ovaries D CT scan adrenals E Prolactin
B
A 54 year old gentleman presented with hyponatraemia. All the following conditions need excluding before confirming SIADH except?
A Hypothyroidism B Hypervolaemia C Euvolaemia D Adrenal insufficiency E Diuretic use
C
A 66 year old gentleman had a serum sodium of 124 mmol/l, serum osmolality 265 mmol/l and a urine sodium of 52 mmol/l. What would you like to perform first?
A Chest X-ray B CT brain C Skin turgor and jugular venous pressure test D Thyroid function tests E Synacthen test
C
- first thing to decide with hyponatraemia is : euvolemic or not… skin turgor and jugular venous pressure indicate blood volume (decreased turgor and decreased BP = hypovolemia)
- this is SIADH
The following may cause nephrogenic diabetes insipidus except?
A Lithium B Myeloma C Amyloidosis D Hyperkalaemia E Hypercalcaemia
D
- hypokalemia also a cause
The following are most likely causes of SIADH except?
A Multiple sclerosis B Lung abscess C Subdural haemorrhage D Lymphoma E Cerebrovascular accident
A
A 28 year old presented with a microprolactinoma? What is the most unlikely symptom?
A Galactorrhoea B Oligomenorrhoea C Decreased sexual appetite D Headaches E Visual field defects
E
- this does happen but is more severe
The following suppress appetite except:
A Peptide YY B Ghrelin C CCK D GLP1 E Glucose
B
The main adipose signal to the brain is
A CCK B Neuropeptide y C Leptin D Agouti-related peptide E Adiponectin
C
A 65 year old lady is diagnosed with SIADH. Her sodium is 123mmol/l. What is your first line of management?
A If she is symptomatic I will treat with fluid restriction
B If she is asymptomatic I will treat with hypertonic saline
C If she is asymptomatic I will treat with fluid restriction
D If she is asymptomatic I will repeat the sodium level the next day
E If she is asymptomatic I will give normal saline
C
- saline given for severe symptoms if chronic and any symptoms if acute (<48h)
Typical features of hypogonadism in a male include the following except: A Decreased sweating B Joint and muscular aches C Decreased sexual appetite D Decreased hair growth E Asymptomatic
A
What is the next step for a low testosterone sample
repeat at a different time of day
The first line treatment for a patient with a symptomatic prolactinoma is usually:
A Radiotherapy B Transphenoidal surgery C Dopamine agonists D Transfrontal surgery E Somatostatin analogues
C
- E would increase prolactin further
High routine blood glucose. which is NOT a physiological response ti increased blood glucose?
A Decreased breakdown of muscle B Glycogenesis C Increased lipolysis D Increased uptake of glucose by cells E Production of insulin from the pancreas
C
- high glucose causes decrease in breakdown of fats, to prevent further increase in glucose
- a refers to one of the routes of gluconeogenesis
what hormone is produced when blood glucose levels are low
glucagon
whos results do not suggest type 2 diabetes?
Angela= Fasting plasma glucose- 10mmol/L Betty= Fasting plasma glucose- 8mmol/L Cheryl= Oral Glucose Tolerance Test- 25mmol/mol Dianne= HbA1c of 47 Edith= Random plasma glucose of 13mmol/L (with other symptoms of DM)
Dianne.
- 42-47 (6-6.5%) = pre-diabetes
- 48 + (6.5%) =. diabetes
Emily tells you she’s all hot and bothered, she’s recently been snapping , which is out of character for her, eating more, actually lost a bit of weight. Which of the following symptoms would align with your suspected diagnosis?
A dry skin B hair loss C constipation D lethargy e clubbing
E
- dry skin and hair loss are soley hypothyroidism
how does carbimazole affect the thyroid
treats hyperthyroidism (along with radioiodine and surgery) -
Prevents thyroid peroxidase enzyme from iodinating the tyrosine that is in thyroglobulin, so prevents thyroid hormone synthesis Also immunosuppressive (good for graves) Can either titrate dose down slowly, according to thyroid function tests, or do ‘block and replace’ where you give carbimazole and give T4 alongside
Chloe, a 16 year old girl, has had abdominal pain for the past 24hrs. Over the past few weeks she’s been unwell, has lost 12kg and has been drinking excessive quantities of water. She is tachycardic, tachypnoeic, clammy and confused. What is the most likely diagnosis?
A)Cushing’s B) DI C) DKA D) Hyperaldosteronism E) Hyperthyroidism
c
- Cushings: weight gain, nor drinking symptoms, No acute crisis.
- DI : Does cause polydipsia. Not weight loss. Less likely to cause profound dehydration/ shock.
- T1DM- young, weight loss, polydipsia leading to DKA
- hyperaldosteronism: Polydipsia, polyuria, paraesthesia/ paralysis, no weight loss
- hyperthyroidism: Weight loss but no thirst or polydipsia
TRH=
T3=
thyrotropin releasing hormone
triiodothyronine
Deborah, a 68 year old lady, has a tan without being abroad. She’s been feeling tired and tearful. Routine U&E investigations reveal a low sodium, high potassium. What is the most likely diagnosis?
A Addison’s B Conns C Cushings D Depression E T1DM
A
- Addison’s =Tanned, Tired, Tearful.
- Conns= High levels of aldosterone, so Low potassium and high sodium (other way round)
Otto has completely lost his sex drive, has noticed some skin thinning and easy bruising on his lower arms and says he’s been having mood swings. When you check his blood pressure it’s 160/105. What endocrine investigation would you perform?
A Arterial Blood Gas B 24 hour urine cortisol collection. C CT Head D Thyroid Function Tests E Liver Function Tests
B
- looks like cushings
what can taking steroids for a prolonged time cause
secondary adrenal insufficiency
primary = addisons is main cause
drinking tons of milk raises your calcium levels. which of the following is not an effect:
A Bone pain B Constipation C Depression D Hypertension E Kidney Stones
D
- bones, stones groans moans
true or false: bisphosponates are a medical treatment for hypercalcaemia
true. prevent bone resorption/ osteoperosis
Lidocaine is effective in the treatment of ventricular tachycardias because it………..
- slows conduction in healthy heart tissue
- opens sodium channels
- blocks sodium channels at rest
- blocks the activation gate of the sodium channel
- blocks the inactivation gate of the sodium channel
5
It blocks the inactivation gate of the sodium channel. so it prolongs inactivation so it raises the depolarization threshold so the heart is less likely to conduct early action potentials.
Digoxin can be a useful drug in the treatment of supraventricular tachycardias because it……………
- stimulates the release of acetylcholine from sympathetic nerves
- is inotropic
- makes the membrane potential more positive releasing acetylcholine from parasympathetic nerves
- inhibits calcium channels
- stimulates sodium/calcium exchange
3
- Increased vagus (parasympathetic) stimulation - ACh released
- Bradycardia (chonotropic)
- Slows AV node conduction
also:
- Inhibit Na/K pump (blocks Na out and K in action)
- So more Ca in heart
- Increased force of contraction (ionotropic)
Amlodipine and verapamil are both calcium channel blockers, what property makes verapamil the more effective anti-arrhythmic agent ?
- Additional sodium channel blockade
- Once daily treatment
- Lack of effect on the calcium channel at rest
- Blockade of all calcium channel types (L,N & T)
- Additional potassium channel blockade
3
Which additional property makes propranolol the most useful beta blocker to help control the arrhythmias which occur immediately following a heart attack ?
- Calcium channel block
- Potassium channel block
- Heart block
- Sodium channel block
- Parasympathetic activation
4
In the treatment of heart failure, which transport protein or ion channel is inhibited by the loop diuretic, furosemide?
- Na/K ATP-ase
- Epithelial Na channel
- K channel
- Na/K/2Cl transporter
- Na/Cl transporter
4
ACE inhibitors reduce the circulating levels of which adrenal hormone ?
- Aldosterone
- Adrenaline
- Cortisone
- Angiotensin II
- Atrial Natriuretic Peptide
1
- angiotensin 2 is not an adrenal hormone
Which drug exerts a direct inotropic effect (+ force of contraction) on heart muscle?
- Ramipril
- Furosemide
- Losartan
- Digoxin
- Spironolactone
- Glyceryl Trinitrate
4
it does this by: Inhibit Na/K pump (blocks Na out and K in action)
- So more Ca in heart
- Increased force of contraction (ionotropic)
In chronic heart failure beta blockers are…..
- Contra-indicated
- Beneficial by slowing the heart rate
- Beneficial by depressing the myocardium
- Beneficial by increasing oxygen demand
- Effective by blocking reflex sympathetic responses which stress the failing heart
5
For which CVS drug is BRONCHOSPASM a potential side effect?
- Morphine
- Beta blocker
- Calcium Antagonist
- Aspirin
- Nitrate
- ACE inhibitor
2
. For which CVS drug is COUGH a potential side effect ?
- Morphine
- Beta Blockers
- Calcium antagonists
- Aspirin
- Nitrates
- ACE inhibitors
6
- due to build up of bradykinin (ACE function is to metabolise this but unable to do so with ACEi)
- can also occur with CCB (calcium antagonist) but this isnt so common
For which CVS drug is TOLERANCE a potential side effect?
- Bendroflumethazide
- Beta blockers
- Calcium antagonist
- Aspirin
- Nitrate
- ACE inhibitor
5
Which CVS drug is most likely to induce POSTURAL HYPOTENSION as a potential side effect?
- Morphine
- Beta blocker
- Calcium antagonist
- Aspirin
- Nitrate
- ACE inhibitor
3
- calcium antagonist = CCB
- also occur with ACEi, ARB but less so
Doxazosin is an antagonist at which type of peripheral receptor?
- Alpha-1 adrenoceptor
- Purine receptor
- Angiotensin II receptor
- Vasopressin receptor
- Beta-1 adrenoceptor
- Dopamine receptor
1
- doxasosin is an alpha blocker
Atenolol is an antagonist at which type of peripheral receptor?
- Alpha-1 adrenoceptor
- Purine receptor
- Angiotensin II receptor
- Vasopressin receptor
- Beta-1 adrenoceptor
- Dopamine receptor
5
- atenolol = b blocker
The antihypertensive action of lisinopril is due to inhibition of which peripheral enzyme?
- Kininase II
- Renin
- Na/K ATP-ase
- Angiotensin Converting Enzyme (ACE)
- DOPA decarboxylase
4
- pril = ACEi
Which of the following drug side effects is less likely to be seen when treating hypertension with an angiotensin receptor blocker (ARB) rather than an ACE inhibitor?
- Hyperkalaemia
- Cough
- Angioedema
- Renal failure in the presence bilateral renal stenosis
- Cold hands/cold feet
2
- doesnt disturb ACE metabolising bradykinin
How do beta-blockers work to relieve the pain from angina pectoris?
- Reduce O2 demand by slowing the heart rate
- Reduce O2 demand by reducing myocardial contractility
- Improve O2 distribution by slowing the heart rate
- Increase O2 supply by dilating coronary arteries
- Increase O2 supply by stimulating respiration
1, 2, 3
- negatively inotropic and chonotropic so better oxygen distribution
- they do this by : Block reflex sympathetic responses which stress heart in HF eg block adrenaline
- dilate veins, but not arteries. heart is main thing though
What is the major mechanism by which glyceryl trintrate can relieve the pain of angina pectoris?
- Dilatation of veins to reduce the preload on the heart
- Dilatation of arterioles to reduce the after load on the heart
- Dilatation of coronary arteries to increase cardiac perfusion
- Opening of collateral blood vessels to improve cardiac perfusion
- A positive inotropic effect
1
Which of the following drugs is likely to be more suitable for the treatment of variant angina due to coronary artery vasospasm ?
- Bumetanide
- Losartan
- Isosorbide
- Amlodipine
- Glyceryl trintrate
4
- variant angina = coronary spasm = prinzemetals
variant angina = which type
treatment
variant angina = coronary spasm = prinzemetals
amlopidine (CCB)
Which of the following drugs might be used to reduce atheromatous disease, the underlying cause of angina pectoris?
- Atenolol
- Amlodipine
- Simvastatin
- Glyceryl trinitrate
- Enalapril
3
- reduces LDL cholesterol production in the liver
hodgkin lymphoma age group:
A Children
B Teenagers and young adults
C Middle aged (40-60 yrs)
D Older aged (>60yrs)
B, D
two peaks
How is myeloma bone disease usually assessed?
A Plain X-ray
B Clinical assessment
C Isotope bone scan
D PET scan
A
- looks for darker lytic lesions
- PET is better for looking for solid lumps
What is the correct mechanism of action for the anti-emetic drug Ondansetron?
A Peripheral D2 antagonist
B Central D2 antagonist
C Anti-cholinergic
D 5HT3 antagonist
D
most common cause of microcytic anaemia:
A B12 deficiency
B Iron deficiency
C Haematologic malignancy
D Hereditary spherocytosis
B
other causes= thalassemia and chronic disease
In sickle cell anaemia what would you expect to see the reticulocyte count?
Absent
Low
Normal
Raised
Raised
- because shorter life span
Which best outlines the approach to the management of a patient with suspected febrile neutropaenia?
A Encourage fluids and paracetamol
B Perform cultures and wait for results before starting antibiotics
C Perform cultures and start oral antibiotics
D Perform cultures and start broad spectrum iv antibiotics
D
emergency
Malignant spinal cord compression usually presents with?
A Back pain, ataxia and sensory neuropathy
B Back pain, spastic paresis and a sensory level
C Perianal numbness and urinary incontinence
D Weak legs impaired joint position sense
B
How does Aspirin exert its antiplatelet effect?
A ADP receptor antagonist
B Inhibition of Cyclooxygenase enzyme
C Inhibition of Glycoprotein IIb-IIIa
D Inhibition of PAR4 receptor
B
irreversible inhibitor
COX1 enzyme
bacterial infection causes:
Low lymphocytes
Low neutrophils
High lymphocytes
High neutrophils
D high neutrophils
virus –> lymphocytes
chronic myeloid leukaemia
- age
- onset speed
- cause
- findings
- symtpoms
- treatment
- age = 40-60
- onset speed = slow
- cause = philadelphia chromosomes (9, 22) –> new protein tyrosine kinase –> autonomous wbc proliferation
- findings: often incidental: high wbc esp neutrophils, clouddy plasma, splenomegaly
- symtpoms: decrease in appetitie, weight, sweat, itching
- treatment: imatinib - blocks tyrosine kinase activity (specific) (mutations can stop the drug from working)
which of these are which type of what antihypertensive class:
1) verapamil
2) amlodipine,
3) diltiazem
4) nifedipine
- phenylalkylamines
- dihydropiridines
- benzothiazapines
- dihydropiridines
dipine in general = dihydropiridines
verapamil causes what affect to bowel
constipation
which B blockers are selective to heart, and which are non-selective (vascular affects too)
selective to heart = B1
- metoprolol
- bisoprolol
non selective = B1/B2
- propanolol
- nodolol
- carvedilol
atenolol in between there
hypertension step 1
hypertension step 2
hypertension step 3
hypertension step 4
- if under 55 = ACEi/ARB
if over 55 or A-C (any age) = CCB - ACEi/ARB + CCB
- ACEi/ARB +CCB + thiazide diuretic
- = resistant hypertension. consider adding
- spironolactone
- high dose thiazide diuretic
- alpha blocker
- beta blocker
how do thiazide and loop diuretics work?
1 )block sodium and chloride reabsorption - DCT
2) loop diuretics block Na / K/ 2Cl transporter (moving Na, K, 2 Cl into cells from urine via Na movement) - loop of henle. This then reduces water outflow
most common cause of heart failure =
coronary artery disease
heart failure first line treatment
ACEi and B blocker
others = aldosterone antagonist, ARB, nitrate, diuretics for congestions, digoxin
what causes ANP/BNP release
Released by stretching of atrial and ventricular muscle cells
Raised atrial or ventricular pressures
Volume overload
ANP/BNP effect
Increase renal excretion of sodium (natriuresis) and water (diuresis)
Relax vascular smooth muscle (except efferent arterioles of renal glomeruli)
Increased vascular permeability
Inhibit the release or actions of:
Aldosterone, angiotensin II, endothelin, anti-diuretic hormone (ADH)
Counter-regulatory system to the renin-angiotensin system
nitrates dilate arteries or beins
both - reduction or pre and after load
stable angina first line
B blocker or CCB
then combine
then nitrate
also : aspiring, clopidogrel, statins, GTN
what do you give for MI pain releif
GTN spray
opiates - diamorphine
anti arrythmic drugs
- who is the classification system
- name and examples of each class
Class I: Sodium channel blockers (lidocaine)
Class II: Beta adrenceptor antagonists - non/selective (propanolol/bisoprolol)
Class III: Prolong the action potential - (amiodarone)
Class IV: Calcium channel blockers -( verapamil, diltiazem)
Hypothalamic hormones act to mainly stimulate the release of all these hormones except
A ACTH B Growth hormone C TSH D Prolactin E LH
D
- prolactin is inhibited by dopamine (not stimulated)
which of the following is not a sign of hyperthyroidism? A palpitations B Tachycardia C Tremor D Goitre E proximal muscle weakness
A
- this is a symptom, rather than a sign
colonic cancer staging
Duke A - tumour in mucosa/submucosa
Duke B - tumour in wall muscularis layer
Duke C - tumour through muscularis layer and to the lymph nodes
Duke D - metastasis
Which is false regarding colon cancer?
A Bowel cancer screening is offered to people aged 55 or over
B The majority of cancers occur in the proximal colon
C FAP and HNPCC are two inherited causes of colon cancer
D Proximal cancers usually have a worse prognosis
E Patients with PSC and UC have an increased risk of developing colon cancer
B
- majority of cancers in distal colon (descending, sigmoidal, rectum)- sigmoidal is most
- UC increases risk. UC and PSC together increase the risk to a higher degree
A 50 year old man presents with dysphagia. Which one of the following suggests a benign nature of his disease?
A Weight loss
B Dysphagia to solids initially then both solids and liquids
C Dysphagia to solids and liquids occurring from the start
D Anaemia
E Recent onset of symptom
C
- B suggests lumen narrowed - more malignant
- A, D, E are red flags
what is key in histology to diagnose crohns/UC
crohns = granuloma
UC = crypt abscess
A 19 year old girl presents with abdominal pain and loose stool. Which of the features suggest that she has irritable bowel syndrome?
A Anaemia B Nocturnal diarrhoea C Weight loss D Blood in stool E Abdominal pain relieved by defaecation
E
Helicobacter pylori…
A It is a gram positive bacteria
B HP prevalence is similar in developing and developed countries
C 15% of patients with a duodenal ulcer are infected with H. Pylori
D PPIs should be stopped 1 week before a H. Pylori stool antigen test
E It is associated with an increased risk of gastric cancer
E
- gram -
- more prevalent in developing countries
- 50% of duodenal ulcer are infected with H pylori
- PPI should be stopped not 1 but 2 weeks before PPI
H pylori
- test
- treatment
- increases risk of?
stool antigen test
breath test (C urea)
both- no PPIs/antibiotics before
h pylori increases your risk of
- peptic ulcer
- adenocarcinoma
- mucosa-associated lymphoid tissue (MALT) lymphoma
- treatment= 2 antibiotics (amoxicillin and clarithromycin) and PPI for 1week
A 56 year old man presents with abdominal distension and shortness of breath. Examination revealed fever of 38C, a tense distended abdomen with shifting dullness. He also has dullness to percussion in the right lung base. Several spider naevi are seen on his chest. Which is the most important test in the management of this patient?
A CXR
B Ultrasound abdomen
C Echocardiogram
D Ascitic tap
D
- this patient has liver cirrhosis
- ascites
- want to rule out spontaneous bacterial peritonitis as can have high mortality - ascites tap send off asap
other important too, but do later:
- CXR - pneumonia
- US abdomen - look at liver, portal vein (to see if thrombosis)
- echo - heart failure
Which of the following features best distinguishes Ulcerative colitis from Crohn’s disease?
A Ileal involvement B Continuous colonic involvement on endoscopy C Non-caseatinggranuloma D Transmural inflammation E Perianal disease
B
- A,C, D, E = Crohns. UC is colonic, doesnt get that far
. A 68 year old lady presents with abdominal pain and distention. She last opened her bowels 5 days ago. She has a poor appetite and has lost some weight recently. Her PMH includes an abdominal hysterectomy and diverticulosis. She drinks 20 units of alcohol a week and smokes 5 a day. Examination reveals a distended abdomen with tympanic percussion throughout. There is a small left groin lump with a cough impulse. Which one of the following is NOT likely to be the cause of her abdominal pain and distention?
A Colon cancer B Adhesions C Ascites D Diverticulitis E Strangulated hernia
C
- Tympanic = gas rather than fluid. ascites = dull on percussion (fluid)
- diverticulitis can have perforation as a complication (gas, obstruction)
- previous surgery mentioned so maybe adhesions
A patient drinks 4 pints (568ml=1 pint) of beer (4%) a day, and 2 standard (175ml) glasses of red wine (13%) on Saturday and Sunday additionally. How many units of alcohol is he drinking per week? (round up to nearest whole number)
73 units 62 units 94 units 57 units 49 units
A
% x ml / 1000
Beer: 4% x 568ml x 4 x7 ÷ 1000 = 63.6
Wine: 13% x 175ml x 2 x 2 ÷ 1000 = 9.1
Total no. of units per week = 72.7 (73)
A 71 year old man was admitted to hospital with pneumonia after he returned from a cruise holiday in the Mediterranean Sea. He was treated with a week of augmentin (co-amoxiclav) for his pneumonia. On day 7 of his admission, he started having diarrhoea 10 times a day without any blood. He feels unwell and dehydrated. He had a flexible sigmoidoscopy which showed this (yellow bumps all over tube). What is the likely organism responsible for his diarrhoea?
A Norovirus B Escherichia coli C Giardia lamblia D Clostridium difficile E Salmonella enteritidis
D
- yellow =
pseudomembranes - Norovirus: winter vomiting bug. Extremely infectious, via airborne transmission (from vomit) or contaminated food/water.
- E. coli: harmful strains cause UTI, GE, meningitis. E coli 0157 strain can cause HUS (haemolytic uremic syndrome).
- Giardia: protozoa infecting the small bowel causing chronic watery diarrhoea and malabsorption. Transmission via contaminated water/faecal oral route
- Salmonella: from animal faeces. Chicken, eggs, contaminated fruit/veg etc. Can cause bloody diarrhoea.
- C. diff: spore forming bacteria. Causes colitis when C diff replaces the normal gut flora, usually following Abx. Mainly seen in older patients , exposed to hospital environment and antimicrobials
gastroenterisits presentation
GE- severe abdo cramps with bloody diarrhoea.
C diff clinical features
- Abdominal pain
- Watery diarrhoea, no blood
- May develop bloody diarrhoea
- increased WBC
- Complicated by toxic megacolon and perforation
salmonella, C diff, giardia lambia, norovirus:
bloody diarrhea?
salmonella- yes
C diff - no, watery diarrhea
giardia lambia - no, watery diarrhea
norovirus - no, vomitting
A 52 year old lady presents with fatigue and itching. She noticed pale stool and dark urine. She suffers from hypercholesterolaemia and rheumatoid arthritis. She takes simvastatin and cocodamol. Examination revealed jaundice, xanthelasma, spider naevi, and hepatomegaly. Her bloods showed Bili 150 (Raised), ALP 988 (v raised), ALT 80 (slightly raised), positive AMA and a raised IgM. What is the most likely diagnosis?
A Simvastatin induced liver injury B Primary biliary cirrhosis C Gall stones D Autoimmune hepatitis E Primary sclerosing cholangitis
B
- xanthelasma = yellow eye cholesterol deposits - RA shows other autoimmune condition so maybe autoimmune hepatitis but there are other markers (ANA, SMA)
- A unlikely as she has been on the statin for a while
- PBC has AMA +ve. and raised IgM. is commonly female and middle aged. associated with RA /Sjorgens. xanthalesema common
- PSC is m:f and much younger (10-30), no AMA+ve, only ANCA+ve
- gallstones - do have increased billirubin and raised LFTs but there is no pain/infection
LFTs to determine whether the cause is related ti cholestasis or hepatocellular?
cholestasis (eg gallstones, PBC, PSC) - raised ALP, billirubin
hepatocellular (eg alcohol, infection, autoimmune, drugs)- raised ALT/ AST
PBC vs PSC
- age
- gender
- symptoms
age:
- PBC= 40-60
- PSC = 10-30
gender:
- PBC = f»m
- PSC = f=m
symptoms
- PBC = fatigue, pruritus, xanthelasma (sometimes jaundice)
- PSC = fatigue, pruritus, jaundice
PBC vs PSC
- associated conditions
- increases the risk of what?
associated conditions:
- PBC: RA/ sjorgens
- PSC: IBD
increased risk
- PBC: increased risk of hepatocellular carcinoma
- PSC: increased risk of cholangiocarcinoma
PBC vs PSC
- tests
- where
test
- PBC: AMA +ve, raised IgM
- PSC: ANCA+ve
where
- PBC = intrahepatic bile duct
- PSC= intra and extrahepatic bile duct. inflammation and sclerosis
A 16 year old girl is admitted with vomiting and abdominal pain. She reports taking 20 paracetamol tablets after her boyfriend split up with her. Which one of the following test results would you NOT expect to see?
A Metabolic acidosis B A prolonged prothrombin time C A raised creatinine D Hyperglycaemia E ALT 1000
D
- paracetamol overdose can cause liver failure
- hypoglycaemia (inhibition of gluconeogenesis) and the others are signs of liver injury
- raised creatinine (renal failure) is bad sign- end stage
- paracetemol overdose –> v high ALT, often over 1000
A 68 year old unkempt and malnourished homeless man was brought to the hospital with haematemesis. Endoscopy found bleeding varices. Subsequent USS showed a coarse shrunken liver. On day 2 admission he was found to be ataxic, confused with nystagmus. What is the most likely cause of his neurological presentation?
A Alcohol toxicity B Alcohol withdrawal C Delirium tremens D Wernicke’s encephalopathy E Korsakoff syndrome
D
- shrunken liver = cirrhosis
- if you don’t treat it (IV thiamine), it will go to Korsakoff syndrome (memory impairment, confabulation). this is chronic and irreversible
- alcohol withdrawal looks more like agitation, insomnia, naus/vom, agitation, seizures / delerium tremors (more severe – disorientation, tremors, impaired conciousness, sweating,
visual/ auditory hallucinations). - ask about last drink. withdrawal = 6-24h. delerium tremors = 24-72h
A 23 year old man was brought in at 2am with RIF pain and was diagnosed with acute appendicitis. He was stable and was scheduled for appendicectomy in the morning. During the ward round, he acutely deteriorated. He was immediately brought to theatre for a perforated appendix. What clinical signs would you NOT expect to see?
A Fever B Bowel sounds C Tachycardia D Rebound tenderness E Guarding
B
- peritonitis : rebound tenderness, guarding
- cant hear bowel sounds if severe
- other symptoms : looks unwell, distressed, severe abdominal pain, hypotension, oliguria (shock)
which is typical of OA?
A 60 mins of early morning stiffness
B painful, swelling across metacarpophalangeal joints and proximal interphalangeal joints
C pain in the 1st carpo-metacarpal joints
D mobile, subcutaneous nodules at points of pressure
E alternating buttock pain
C
- A - inflammatory arthritis
- B more typical of RA : several joints, small joints
- C is often how OA presents
- D is RA
- E is spondyloarthritis (sacroilitis)
which of the following is an extra-curricular manifestaltion of RA?
A subcutaneous nodules B episcleritis C peripheral sensory neuropathy D pericardial effusion E all of the above
E
- episcleritis : outer white of eye inflammation. quite painful and red. NSAID eyedrops
- peripheral sensory neuropathy due to nerve compression
- pericardial and plueral effusions are quite common - exudate – protein rich
subcutaneous nodules of RA histology
pastohistopneumonic (specific)
- fibrinoid necrosis in the middle
- ring of pallisading macrophages and fibroblasts
- cuff of lymphocytes and plasma cells in connective tissue
typically back of elbows, heels, back of hands, lungs
painless but mobile
which of the following is classic RA Xray?
A periarticular sclerosis B subchondral cysts C osteopohytes D periarticular erosions E new bone formation
D
- inflammatory cytokines in joint break down bone
- A,B, C, E = OA
- E = spondyloarthritis
mechanical back pain looks like
- short history
- spontaneous - no trauma
- maybe builder- exacerbates it
- maybe bit overweight
- no neurological deficits
- pain not too localised
- fine to give sick note, may need some exercise type thing to strengthen
when is back X ray good/bad
tumour/ discitis
otherwise not very useful
what msk condition is a diet rich in dairy products good for
gout
which of the following is not an autoimmune connective tissue disease?
A SLE B ehler danlos C primary Sjorgrens D systemic sclerosis E dermatomyositis
B
- autoimmune connective tissue diseae: ANA +ve, raynauds, photosensitivity, rashes, arthritis, mouth ulcers
- ehler danlos (stretchy skin, hypermobile joints, cardiac problems eg aortic aneurysm)/ marfans (long limbs, fingers, height, arched palate) are not autoimmune , they are inherited but they are connective tissue diseases
23 y women presents with mouth ulcers, fever, painful white fingers and pleuritic chest pain. she is ANA +ve, with high ESR and leucopenic. which of the following would you not expect to see with her?
A deforming arthritis B photosensitive rash C seizures D pulmonary embolism E thrombocytosis
E
- first step = diagnosis is SLE
- white fingers = raynauds
- leucopenic = low wbc
- can also get sharp abdominal pain - serocytic
- CRP would be normal
- shape change but no erosions, correctable
- seizures due to abnormal blood flow in brain
- lupus associated with anti-phospholipid syndrome - clots (D)
- thrombocytosis = increased platelets. lupus normally - thrombocytopenia
which of the following is used to treat SLE?
A anti TNF B anti malarials C ustekinumab (IL12/23 blocker) D sulfasalzine E allopurinol
B
hydroxychloroquine, chloroquine, mepacrine
- good for arthritis, skin, mucosal membranes
- anti TNF - RA, psoriatic arthirtis, crohns, UC, psoriasis, uveitits
- antiTNF can induce lupus
- ustekinumab (IL12/23 blocker) - spondyloarthritis, IBD
cushings test: once you have established cushings syndrome, how do you determine cause?
assuming youve ruled out drug history etc
- measure serum ACTH
- none = adrenal tumour. so CT/ MRI/ sample to look for it
- detectable = cushings disease (pit) or ectotic tumour. you distnguish between these two by …
a) high dose dexamathasone test
b) CRH test
- CRH given then cortisol measured 2h later
- pit = cortisol rises
- ectopic =
how to confirm cushings in a patient
Overnight dexamethasone suppression test (1st line test)
- This corticosteroid injected at night, blood cortisol measured in the morning
- Normally- ACTH suppression and thus cortisol suppression (neg feedback)
- No suppression in cushings syndrome
48 h dexamethasone suppression test (2nd line test- if no suppression)
- Take dexamethasone 4/day for 2days
- Measure blood cortisol at 0h and 48h
- Cuhsings’s syndrome = no suppression
not sure of the difference
64-year-old male attends a GP practice complaining that this week he’s started experiencing some chest pain when he’s out birdwatching, it’s in the centre of his chest and eases off if he sits down for a few minutes. Which of the following would you expect to see on a stress ECG?
A Saddle shaped ST and PR depression B Tall Tented T waves and pathological Q waves C ST elevation D ST depression E Absent P wave
and what are the others =?
D - angina
A pericarditis
B hyperkalemia
C STEMI
E atrial fibrillation
which heart murmur is mitral regurgitation?
A early diastolic B early systolic click C ejection systolic crescendo decrescendo D end diastolic E pansystolic
and what are the others =?
E
A early diastolic = mitral stenosis
B early systolic click = mitral valve replacement
C ejection systolic crescendo decrescendo = aortic stenosis
Trystan, a 54 year old caucasian gentleman, attends his annual diabetes check with the nurse practitioner. His blood pressure is 143/82. He’s currently on metformin and simvastatin. Which is the appropriate anti-hypertensive to give him?
A Amlopidine B bendroflumethiazide C candesartan D diltiazem E isomorbide mononitrate
C
- ACEi/ ARB first line (current meds are not antiHTN) if under 55 and not A-C
- A would be first line if patient was 55+/ A-C
- D diltiazem = benzothiazapine (non-dihydropyridine CCB) acts on heart, not just vessels so not for HTN
- E- nitrates not for HTN, for angina
- B - diuretics are 4th line
Heparin…
A Increases cGMP and reduces intracellular Ca2+ concentration
B Inhibits cyclooxygenase (COX) reducing production of thromboxane A2
C Inhibits production of vitamin-K dependent clotting factors
D Inhibits thrombin and factor Xa
E Induces vagal nerve stimulation
D
E digoxin
NSAID..
A Increases cGMP and reduces intracellular Ca2+ concentration
B Inhibits cyclooxygenase (COX) reducing production of thromboxane A2
C Inhibits production of vitamin-K dependent clotting factors
D Inhibits thrombin and factor Xa
E Induces vagal nerve stimulation
B
warfarin…
A Increases cGMP and reduces intracellular Ca2+ concentration
B Inhibits cyclooxygenase (COX) reducing production of thromboxane A2
C Inhibits production of vitamin-K dependent clotting factors
D Inhibits thrombin and factor Xa
E Induces vagal nerve stimulation
c
where are the following?
Roth Spots Janeaway lesions Oslar nodes Splinter hemorrhages Clubbing
eyes hands hands hands hands
step 1 and step 2 in DVT investigation
- Wells score
2. d dimer
Diagnostic test for heart failure?
A Troponin I B Atrial natriuretic peptide (ANP) C Brain natriuretic peptide (BNP) D CK-MB E FBC
C
CK-MB =
enzyme found in heart muscles
conc rise when damage to heart muscle eg MI
Elliot presents to you with bloating, stinking stools which float in the pan. He thinks he might be coeliac You organise some blood tests to confirm his diagnosis, which of the following antibodies is associated with coeliac disease?
A Anti-DsDNA B Anti-phospholipid C ANCA D Alpha-gliadin E Rheumatoid factor
D
SLE is associated with…
A Anti-DsDNA B Anti-phospholipid C ANCA D Alpha-gliadin E Rheumatoid factor
A
vasculitis is associated with…
A Anti-DsDNA B Anti-phospholipid C ANCA D Alpha-gliadin E Rheumatoid factor
C
immodium is also called
loperamide
anti motilitic
omeprazole =
PPI
metronidazole=
antibiotic
Jenny’s been non-stop to the loo and has recently been diagnosed with IBS using the Rome III criteria. She’s tried out a low FODMAP diet but her diarrhoea won’t budge. Which of the following drugs is the most appropriate pharmacological intervention for this patient?
- Ferrous sulphate
- Loperamide
- Methotrexate
- Metronidazole
- Omeprazole
loperamide
Which of the symptoms below would indicate that the patient was suffering from Inflammatory Bowel Disease (IBD) and not Irritable Bowel Syndrome?
A Smelly stools B DXA scan revealing decreased bone mineral density C Nocturnal diarrhoea D Abdominal cramps E Feeling fatigued
C
which is false about ascending cholangitis:
A Caused by bacterial infection of biliary tree
B Patients experience epigastric pain
C Patients present with a temperature
D Patients present with yellowing of the skin and sclera
E Murphy’s sign is negatuve
B and E
- RUQ pain
- fever
- jaundice
= charcots triad
murphys sign +ve (RUQ pain not LUQ on inhalation) - gallbladder problem
The gallbladder is supplied blood by the cystic artery. What is the cystic artery a branch of?
A coeliac trunk B Gastoduodenal artery C Left gastro-epiploic artery D Right hepatic artery E Splenic artery
D
R hepatic comes off hepatic artery proper, which comes off common hepatic, which comes of coeliac trunk, along with gastric and splenic.
L gastro epiploic comes off splenic
gastroduodenal comes off common hepatic
which hep has DNA virus
B
haemochromatosis cause
autosomal recessive inheritence
esp n europe
uncontrolled Cu2+ =
sign
wilsons
kaiser fischer rings around pupil
alendronic acid =
bisphosphonate
positive C-urea breath test after epigastric pain following eating. what is the treatment in addition to PPI?
amoxicillin and clarithromycin
this is H pylori peptic ulcer
alendronic acid action….
A Cause increased bone deposition
B Cause reactivation of the metaphysis and epiphysis
C Inhibit osteoclast activity and cause osteoclast apoptosis
D Reduce the signally pathway between osteoblasts and clasts by increasing RANK ligand
E Increase removal of calcium into the haversian canal within bone
C
alendronic acid = bisphosphonate
A 55-year- old painter and decorator comes in to the GP. He describes aching in his hand and arm with pins and needles sensation in his thumb, index and middle fingers. Shaking his hand about in the morning gets rid of this seems to help. The most likely diagnosis is…
A Cervical spine fracture B Compression of median nerve C Compression of radial nerve D C8-T1 nerve lesion E Compression of ulnar nerve
B
- this is carpals syndrome:
median nerve compression
repetitive actions - palm : thumb side = median, pinky side= ulnar
- back: thumb side = radial, pinky side = ulnar
What is the most common cause of osteomyelitis?
A Strep Pneumonia B Staph Aureus C Strep Pyogenes D Mycobaterium tuberculosis E. H. Influenzae
B
Brenda, a 92 year old female, recently had a fall at home and broke her hip. Her DXA scan gave her a T score of -1.6. What does this mean?
osteopenia
Otto, a 21 year-old male presents to your rheumatology clinic complaining of a 3 week history of a stiff and painful knee. On history taking you illicit he also has painful urination (urethritis) and painful eye (conjunctivitis) .Which of the following organisms is the most likely cause?
A Staphylococcus aureus B E.coli 0194 C Streptococcus Pneumonia D Heamophilius influenza E Chlamydia
E
A GP does a joint aspiration of a patient with gout and sends the fluid for microscopy which of the following best describes the results seen
A Tophi
B Needle shaped crystals which are +ve birefringent
C Needle shaped crystals which are -ve birefringent
D Rhomboid shaped/ brick like crystals which are +ve birefringent
ERhomboid shaped/ brick like crystals which are -ve birefringent
C
progressively worsening shortness of breath. He also has digital clubbing, a dry cough and diffuse fine inspiratory crackles are noted on auscultation. Pulmonary nodules are found on the lungs on CT scan.
what is the diagnosis?
what MSK condition is this most likely the cause?
pulmonary fibrosis
RA
gout relief / prevention
relief - a steroids (Colchine if not tolerated)
prevention - xanthine oxidase inhibitors (allopurinol)
A 71 year old lady presents to clinic with ulnar deviation, rheumatoid nodules and squaring of the thumb. She states this has been a progressive change over the last 10 years, but she has ‘just got on with things’. Which blood test would be most specific for this condition?
A Anti-CCP B CRP C ESR D Rheumatoid factor E Alkaline phosphatase
A
- this is RA
- A-D all def present but A most specific (not sure about E- a liver indicator)
septic arthritis. joint aspirate culture grows Staph. Aureus Which antibiotic is most appropriate given that the patient reports she is allergic to penicillin?
A Gentamycin B Clindamycin C Ceftriaxone D flucloxacillin E fluoroquinolone
b clindamycin
- flucoxacillin would have been first choice except for allergy
- erythromycin would also do well
- Cefotaxime for gram neg + gonococcal
- Vancomycin for MRSA
A 53 year old lady is admitted to the acute medical unit with a painful knee. It is hot and swollen. Her observations on admission include oxygen saturations of 96%, blood pressure 99/68mmHg, temperature 38.1 degrees and heart rate 101bpm. On examination there is reduced movement of the joint due to pain. She looks flushed and is concerned because she has rheumatoid arthritis and is worried this is another flare. What is the most likely cause for the above presentation?
A Gout B Osteoartritis C pseudogout D Rheumatoid arthritis flare E Septic Arthritis
E
classic septic arthritis = triad of fever, pain, and impaired range of movement
Mrs Jones gets a diagnosis of osteoarthritis. A few years later she returns to see the doctor for her annual review. She says she is now struggling with her hands, finding it difficult to do buttons up on clothing, and writing with a pen. Which of the following clinical signs are you most likely to identify on examination of this lady’s hands?
1 Bouchard node at the DIPJ 2 Boutonniere’s deformity 3 Heberden’s nodes at the DIPJ 4 Swan neck deformity 5 Ulnar deviation
3
- bouchard = PIPJ
- others (2, 4, 5) = RA
Patient with frequency, urgency and dysuria. Whilst awaiting culture results, treat with …..
A ciproloxacin B co amoxiclav c nitrofurantoin D tazocin E no antibiotic needed
C
e coli pyelonephritis treatment and for how long
co amoxiclav 14 days (7 if normal UTI)
dipstick / mircobiology for catheter bag.
is this able to give indication of infection?
no and no
unable to do diagnosis
urinanalysis of pregnant lady shows leukocytes and protein. this indicates
A nothing, this is normal of pregnancy B pre-eclampsia C UTI D possibility of pre-eclampsia and UTI E obstetric cholestasis
D
- protein - preecclampsia
- leukocytes - UTI
(along with urinary leukocytes and protein) microscopy of a pregnant urine sample shows epithelial cells but no pus cells, suggesting
A definite infection B pyelonephritis C pre eclampsia D sample contamination E none of the above
D
so need repeat before diagnosis/ treatment
the risk of pyelonephritis in untreated asymptomatic bacterirua in pregnancy is
A 5-10% B 20-40% C 50-60% D 60% E 70-75%
B
A 64-year-old man presents to A and E with chest pain that radiates to the left
shoulder, nausea, and sweating. He has no allergies and takes simvastatin for high
cholesterol. Which of the following is the most appropriate initial management?
A. Troponin blood test
B. Full cardiac examination
C. 300mg aspirin
D. High flow oxygen, fluid bolus and GTN spray
E. Referral for percutaneous coronary intervention
C
Which of the following ECG changes is diagnostic in a patient with a myocardial infarction?
A. Absent P waves B. Wide QRS complex C. Tall, tented T waves D. ST depression E. QT prolongation
D
MI - ST elevation/depression, T wave inversion, abnormal Q wave
A = AF
B = bundle block
E = QT syndrome (jervel lange nielson, romano ward, hypoK, hypoCa, drugs, etc)
C = hyperK
John is a 53-year-old Swiss man who attended GP clinic 2 weeks ago for an annual checkup and recorded a blood pressure of 155/100mmHg; consequently, he was given an ambulatory blood pressure monitor for 2 weeks. His results show an average blood pressure of 138/91mmHg. What is the most appropriate management for this result?
A. No management needed, as this result is below 140/90mmHg B. Ramipril C. Amlodipine D. Losartan E. Bendroflumethiazide
B
- A - the cut of for ABMP is 135/85 (not 140/90)
- ACE i is for him as he is under 55 - ramipril (55+/A-C : CCB)
- C = CCB
- D = ARB (if intolerant to ACEi)
- E = diuretic (if ACEi/ARB + CCB not effective
Jane is a 68-year-old woman who has presented to her GP following a diagnosis of hypertension. She is worried that she is at increased risk of having a heart attack and wants to know how likely this is. Which framework should her GP use to calculate
Jane’s risk?
A. CHA2DS2-VASc score B. QRISK2 score C. Wells score D. ABCD2 score E. COVID19 score
B
A. CHA2DS2-VASc score = risk of stroke in AF patient
B. QRISK2 score = MI
C. Wells score = DVT/PE
D. ABCD2 score = stroke after TIA
Which of the following best describes the concept of relative risk in the context of a trial examining the efficacy of statins compared to placebo in reducing heart attacks?
A. The risk of a heart attack in the statin group was 2.67% compared to 1.65% in the
placebo group, therefore statins decrease the risk of heart attack by 1.02%.
B. The risk of a heart attack in the statin group was 2.67% compared to 1.65% in the
placebo group, therefore statins decrease the risk of heart attack by 36%.
C. 98 patients would need to be treated with statins to prevent 1 heart attack.
D. 98 patients would need to be treated with placebo to cause 1 heart attack.
E. If this study was conducted 100 times, these results would occur in 95 of the 100
times
B
- question asks about relative risk!
- A is an absolute risk reduction but sentence phrases it as relative (B)
- C = NNT
- D = NNH
Which of the following is the correct order for the electrical conduction of the heart?
A. AV node -> atria -> SA node -> bundle of His -> Purkinje fibres -> L and R bundle
branches -> ventricles
B. SA node -> ventricle -> AV node -> bundle of His -> Purkinje fibres -> L and R bundle branches -> atria
C. SA node -> bundle of His -> Purkinje fibres -> atria -> AV node -> L and R bundle branches -> ventricles
D. SA node -> atria -> AV node -> bundle of His -> Purkinje fibres -> L and R bundle branches -> ventricles
E. SA node -> atria -> AV node -> L and R bundle branches -> Purkinje fibres -> bundle of His -> ventricles
D
34-y/o Judy presents with symptoms of hypertension despite being on a current regimen of antihypertensive medications. The junior doctor orders appropriate blood tests and the results come back which suggest a diagnosis of Conn’s syndrome. She is scheduled to have an operation for an
adrenalectomy. What medication is prescribed prior to her operation to stabilise her BP and K+ levels?
A. Aspirin B. Furosemide C. Ramipril D. Spironolactone E. Warfarin
D
- Conns = too much aldosterone so hypertension and low K
- spironolactone = K sparing diuretic
- furosemide = loop diuretic (not k) sparing
Which of the following is NOT a cause of hypercalcaemia?
A. Down’s syndrome B. Familial benign hypocalciuric hypercalcaemia C. Malignancy D. Sarcoidosis E. Thyrotoxicosis
A
. Molly has come into GP complaining of diarrhoea, heart palpations and feeling
quite flushed. She has also noticed a change in mood but thinks this can due to her being recently fired from her job. What is the most likely explanation for her symptoms?
A. Carcinoid syndrome B. Depression C. Hypertension D. Hypothyroidism E. Pituitary tumour
A
- carcinoid = Bronchospasm (maybe sob, chest pain, wheeze), Fast heart rate, palpitations, Diarrhea /const, Skin flushing- red face/neck and general cancer symptoms
- looks a bit like hyperT too but that is not an option
pancolitis
UC throughout large bowel
proctitis
UC limited to rectum
left sided collitis
UC : rectum to descending colon
Diffuse inflammation throughout the large bowel, with evidence of granulomas and faecal leukocytes. Crypt architecture is normal.
is this a picture of UC or crohns
– This may seem like an unclear picture of which type of IBD this is. The diffuse nature of the inflammation is not classic of Crohn’s disease, and the presence of granulomas is not classic of Ulcerative colitis. And in both Crohn’s disease and ulcerative colitis you would expect to see some crypt architecture changes. Therefore, it is important to consider other causes of inflammation. In this case, this is a clinical picture of infectious colitis.
halitosis =
v bad breath
A man comes in for a medication review. One of the medications he is on is
tamsulosin to treat his BPH. Which of these is a potential side effect which you need to ask about?
A. Erectile dysfunction B. Haematuria C. Nausea and vomiting D. Postural hypotension E. Weight loss
D
- alpha blocker
- it Relaxes prostate and base of bladder (smooth mucsle) but also alpha 1 adrenoreceptors are in vasculature –> postural hypotension, dizzy, syncope
A patient presents to A&E with left sided loin pain. An abdominal x-ray shows a
stone blocking the ureter on the left side. Monitoring of the patient’s urine output shows it has been less than 0.5ml/kg/hr for over 6 hours and the medical team are worried about an AKI. Which value are they most worried about when monitoring the patient’s U&Es?
A. Chlorine B. Creatinine C. Potassium D. Sodium E. Urea
C
- as function decreases, unable to excrete K so hyperK which is a medical emergency
CKD GFR stages
Stage 1 > 90 ml/min with evidence of renal damage
Stage 2 60-89 ml/min with evidence of renal damage
Stage 3a 45-59 ml/min with or without renal damage
Stage 3b 30-44 ml/min with or without renal damage
Stage 4 15-29 ml/min with or without renal damage
Stage 5 <15 ml/min, established renal failure
Loop diuretics act where specifically
ascending limb of loop of henle
na+/k+/2cl- transporter
K+ sparing diuretics act where specifically
DCT inhibiting Na channels so no Na and water reabsoption
thiazide diuretics act where specifically
DCT at Na/Cl transporter
hodgkin lymphoma pain?
painless except on drinking alcohol
difference between non/ hodgekins
hodgkin = assymettrical, young (20s) and old non = symetrical, only old
Myeloma presentation
- Anaemia, neutropenia, thrombocytopenia due to bone marrow infiltration
- Recurrent infection due to monoclonal Igs
- Renal impairment due to the free light chains
- Bone pain, pathological fractures and vertebral collapse due to bone lesions (increases calcium
and Il-6)
auer rods
Auer rods are red staining, needle-like bodies seen in the cytoplasm of myeloblasts, and/or progranulocytes in certain leukemias.
AML
reed sternburg cells
giant cells found with light microscopy in biopsies from individuals with Hodgkin lymphoma
CLL/CML effect in wbc
raised
- CLL = raised lympocytes
- CML = raised myeloid wbc
acute of each = variable
AML /ALL platelets
low
what do all leukamias have the same (fbc)
anaemia
Ann arbor classification
used for what
- Single LN region
- > /= 2 nodal area on the same side of the diaphragm
- Nodes on both sides of the diaphragm
- Disseminate e.g. metastasised to the liver
‘B symptoms’ are constitutional symptoms such as fever, weight loss and night sweats
A/B - B indicates systemic B symptoms (night sweats, weight loss etc)
used for non hodgekins and hodgkins
DVT gold standard investigation
doppler US
- CT/Xray not useful
- D dimer good but no specific (just sensitive)
- venography good too but not as
Which do you not see in iron deficient anaemia?
A. Brittle hair and nails B. Koilonychia C. Pale conjunctivae D. Pale skin E. Splenomegaly
E
- conjunctiva = pull under eye down, that pink bit
- koilonychia = spoon nails
- E can occur but v rare
amitryptilline side effects
blurred vision
confusion
dry mouth
urinary retention
these are due to anticholinergic properties- that decrease the parasympathetic system
macrolides work how?
examples of macrolides
inihbit bacterial protein synthesis
erythomycin
clarithromycin
azithromycin
quinolones work how?
examples of quinolones
Interferes with bacterial DNA replication and transcription
ciprofloxacin lomefloxacin norfloxacin moxifloxacin levofloxacin
Rosie is a 19-year-old female. She has been brought into A&E by her housemates as she has a severe headache and fever. The doctor suspects meningitis. Rosie is known to have suffered from angioedema when previously exposed to amoxicillin. Which of the following drugs does she have
a relative contraindication to receiving?
A. Ceftriaxone B. Chloramphenicol C. Co-amoxiclav D. Paracetamol E. Sodium Chloride 0.9% solution for infusion
C = absolute contraindication A= relative contraindication
?
Which of the following medications are licensed for use in the UK to treat heroin addiction? A. Diclofenac B. Methadone C. Metformin D. Oxycodone E. Tramadol
B
diclofenac =
nsaid
James, a 38-year-old golfer, is diagnosed with a pheochromocytoma and is
scheduled for surgery in several weeks. What is the first drug his endocrinologist will prescribe to him to prepare him for the upcoming surgery?
A. Atenolol B. Atorvastatin C. Carbimazole D. Insulin E. Phenoxybenzamine
E
During the removal of the tumour it is possible for a large amount of catecholamine release to occur – causing refractory hypertension. Therefore, by pre-blocking the
alpha receptors with phenoxybenzamine you prevent this happening.
You do not use beta blockers (A) because blocking B2 mediated vasodilatation could cause uncontrolled A1 mediated vasoconstriction, again causing severe, refractory hypertension. However once alpha blockade is achieved, you may also add beta blockers prior to surgery.
Atorvastatin (B) is used in the management of hypercholesterolaemia, Carbimazole (C) is used in
thyrotoxicosis and Insulin (D) is used in the management of diabetes.
diverticulitis pathogen cause
Diverticulitis is due to colonisation of diverticulae by enteric bacteria such as E.
coli
ischaemic collitis cause
no microbiology
associated with AF
coffee ground vomitus indicates what
upper GI tract bleeding (blood mixes with gastric acid) - black spots in vomit
reduced skin turgor indicates
dehydration eg severe diarrhea
Which of the following organisms does not cause atypical pneumonia?
A. Chlamydia psittaci B. Coxiella burnetii C. Legionella pneumophila D. Mycobacterium avium complex E. Mycoplasma pneumoniae
D
- D = AIDS related illness presenting similarly to pulmonary TB
side effects of TB medication
Rifampicin: Red/orange discolouration of secretions e.g. urine + tears;
Isoniazid: Peripheral
neuropathy;
Pyrazinamide: High uric acid levels → gout;
Ethambutol: Colour blindness + reducedvisual acuity (EYE-thambutol)
Which antibiotic is not indicated in Staphylococcus aureus infection?
A. Ampicillin B. Cefotaxime C. Clarithromycin D. Flucloxacillin E. Vancomycin
A
A: indicated in UTI, respiratory infections and enterococcal infections (endocarditis, wound infection, intra-abdominal infection);
B: used in severe infection eg bacterial meningitis;
C: indicated in Staph infections, strep throat and atypical pneumonias;
D: indicated in Staph aureus and Group A Strep e.g. cellulitis + necrotizing fasciitis;
E: MRSA infection
which heart valve is most commonly affected in IE
tricuspid (R) - first encountered after systemic circulation
Which of the following antibiotics does not inhibit cell wall synthesis? A. Benzylpenicillin B. Cefotaxime C. Erythromycin D. Teicoplanin E. Vancomycin
C
Macrolide abx such as clarithromycin and erythromycin inhibit protein synthesis. Beta lactam abx, including pencillins (BenPen) and cephalosporins (Cefotaxime), and Glycopeptide abx (Vancomycin, teicoplanin) all inhibit cell wall synthesis.
- mycin = not all same
- vancomycin = glycopeptide (Beta lactam, MRSA)
- clarithromycin/erythromycin = macrolides
what score is used for community acquired pneumonia
CURB-65 criteria – score 1 for each of:
Confusion; Urea > 7mmol/L; Resp rate >30/min; Blood pressure - (Sys <90mmHg, Dia <60mmHg); Age >65.
first and second line for osteoperosis
1st = alendronic acid (bisphosphonate) and AdCal (vit D/ calcium supplement)
2nd= denosumab (monoclonal antibody)
bisphosphonates action
Inhibit bone resorption through the inhibition of enzyme (Farnesyl Pyrophosphate synthase) which reduces osteoclast activity
nothing RANK ligand related
denosumab action
Works as a monoclonal antibody for RANK ligand leading to inhibited
osteoclast activity
A 58-year-old male presents with sudden painful inflammation of his big toe.
What is the treatment?
A. Allopurinol B. Colchicine C. Diclofenac D. Febuxostat E. IV antibiotics
B
- reduces inflammation acutely
A and D = preventitive
- allopurinol in flare up can make it worse!!
C no longer prescribed (S/E, CI)
haemorrhage CT appearances
sub arach – star shaped
sub dural – crescent/ sickle
extra dural – lemon/ biconcave
migraine first line treatment
NSAID
topiramate/ amitriptyline are for prophylaxis
. A 41-year-old woman visits her GP complaining of recurrent headaches. She
says that the pain is often just on one side of her head and feels as though her head is throbbing. She has tried to take some paracetamol which helps a little bit but not enough and these headaches are starting to interrupt her daily life. She is worried about driving because she has experienced some really strange feelings for a few minutes before the headaches start. She said these are quite
hard to explain. What would be the 1st line treatment for this patient?
A. Amitriptyline B. Aspirin C. Ibuprofen D. Topiramate E. Withdrawal of current medication
C
- this is migraine
- A/D for prevention
- B for tension headache
Pseudomonas aeruginosa - causes what
infection to patients admitted to hospital 1w+
is strep pneumonia or n. meningitidis more common cause for menigitis
strep pneumoniae
A 19-year-old girl visits her GP because she has started experiencing some unpleasant symptoms. It started with her needing the toilet much more than usual and feeling numb in various parts of her body. She then noticed her hands have started shaking and she feels generally very weak. She is experiencing pain from random things including some pain in her eyes, and whenever she goes in the shower everything feels ten times as worse. This will occur for about a week, and then she will start to feel better again. What is the likely diagnosis based on the clinical history?
A. Creutzfeldt-Jakob disease B. Duchenne Muscular Dystrophy C. Motor Neurone disease D. Multiple Sclerosis E. Myasthenia Gravis
D
.A very rare and usually affects people 55+. Can cause muscle weakness.
B. only affects males – X-linked recessive
C. symtpoms depending on where the lesion is this will present with different symptoms. motor weakness,
D. symptoms depending on the lesion in the CNS. Uhthoff’s phenomenon (symptoms getting worse with heat) is very characteristic of MS, and the patient usually suffers attacks for a period of days -> weeks before remaining symptom free for a short period of time. The symptom free period decreases as the disease progresses.
E. presents with muscle fatigue, but not many of the other symptoms. characteristic order = extraocular, bulbar face, neck, limb girdle and then trunk.
postive babinski reflex in adults
UMN lesion
what medicine is used to treat Huntington’s chorea
risperidone
chorea= random jerky limb movements
what medicine is used to treat huntington’s psychosis
haloperidol
sertalline=
SSRI
depression
gabapentin =
for epileptic seizures and neuropathic pain
What is the treatment for Guillian-Barre syndrome? A. Low dose aspirin B. Dexamethasone C. IV immunoglobulin D. SC Sumatriptan E. Pyridostigmine
C
- prevent harmful antibody damage
other medicines for it =
- plasma exchange
- ventillation if nesc
- LMW heparin and compression stocking to reduce risk of venous thrombosis
A patient is complaining of a recurring headache that lasts about an hour each time and presents as a tight pain going around the head like a band. There is no nausea or vomiting, but some sensitivity to light. Which of these is NOT a cause of tension headaches? A. Depression B. Lack of sleep C. Missed meals D. Dehydration E. Stress
d
A 64-year-old woman goes to A&E because she is really worried about a rash that has developed along the side of her arm. She says it is painful and she also feels quite unwell. A history is taken, and she had recently been in contact with her granddaughter who had chicken pox. Which is the most useful investigation? A. Blood culture B. CT head C. Immunofluorescence D. Lumbar puncture E. Viral PCR
E
- D for meningitis/ encephalitis
- C good but not as good
- A helps but not complete
- B not helpful
when do you treat DVT/PE with thrombolysis?
if big clot (patient not so stable)
otherwise - LMW heparin
warfarin/DOAC long term anticoags
Pyridoxine and TB?
is what you would give to prevent the peripheral neuropathy caused by isoniazid (S/E)
. A 45-year-old man is diagnosed with TB and started on appropriate medication. 2 months into his regime, he starts to experience pins and needles in his legs and muscle weakness. His GP suggests this is likely a side effect of his current TB medication. Which of the following is the likely cause?
A. Rifampicin B. Isoniazid C. Pyridoxine D. Ethambutol E. Pyrazinamide
B
- Rifampicin can present with red/orange discolouration of urine
- Isoniazid with peripheral neuropathy,
- Pyrazinamide with hyperuricaemia causing gout
- Ethambutol affecting the eyes (colour blindness and visual acuity).
- Pyridoxine (B6) is what you would give to prevent the peripheral neuropathy caused by isoniazid.
pneumothorax - when is no treatment needed
no SOB
pneumothorax is <2cm
oxygen/ observation for mildly symptomatic but stable
pneumothorax - when decompress with large bore canula vs chest drain vs needle aspiration
needle aspiration = primary spontaneous pneumothorax
chest drain = patient unstable / secondary pneumothoraxes/ needle aspiration failed x2
large bore canula = this then develops into tension pneumothorax (trachea deviated, shock, resp failure, cardioresp arrest, medical emergency)
talk through ABG interpretation
1) pH- acidic/alkali (low pH= acid)
acidosis )
increase in CO2 = resp
decrease in HCO3 = met
alkalosis)
decrease in CO2 = resp
increase in HCO3 = met
What drug group works as such “works by blocking acetylcholine receptors which when normally activated cause contraction of the bronchial smooth muscle; therefore, when blocked by this class of drug cause bronchodilation”?
A. H1 receptor antagonists B. Inhaled corticosteroids C. Leukotriene receptor antagonists D. Long-acting muscarinic antagonists E. Short acting beta-adrenergic receptor agonists
D
- muscarinic = ACh
- E acts on beta 2 receptors
- A = antihistamine
A 28-year-old woman presents with a dry cough and shortness of breath for the last 8 months. She also has a persistent rash on her shins. A chest X ray shows bilateral hilar lymphadenopathy. A biopsy is done to confirm diagnosis. Which shows non-caseating granulomas with epithelioid cells. Which of the following electrolyte disturbance is most indicative of the above diagnosis?
A. Hyperkalaemia B. Hypercalcaemia C. Hyponatraemia D. Hypocalcaemia E. Hypokalaemia
B
- this is sarcoidosis
- E - heavy GI loss (d/v, laxatives), burns, drugs
- C - small cell cancer (ADH secretion –> SIADH)
- D - CKD, hypoPTH, pancreatitis
goodpastures effects where
glomerulus and pulmonary basement membranes
anti smooth muscle seen in what pathology
autoimmune hepatitis
PBC
6in1 vaccine contains?
diphtheria, tetanus, pertussis, polio, Hib and Hepatitis B
well’s score interpretation
DVT
2 or more = likely
PE
2-6 = moderately likely
7 or more = highly likely
normal temp/ RR/ HR
temp: 36.4-37.2 (37.8+- fever)
RR: 12-20
HR: 60-100
AVPU stands for
alert verbal pain unresponsive
bit like glasgow coma scale, assess conciousness
CHA2DS2VASc factors
Risk of stroke for AF
- Congestive Heart Failure
- Hypertension
- Age (75+=2)
- Diabetes
- Stroke/ TIA/ Thromboembolism (2 points)
- Vascular disease (prioir MI, plaque, PAD)
- Age (65-74, 75+)
- Sex category (female=1)
abcd2 score factors
risk of stroke for TIA
- age
- BP
- Clinical features of TIA (weakness unilateral =2, speech disturbance =1 ,other =0)
- duration of symptoms (<10, 10-60, 60+)
- diabetes
wells score factors
DVT
- active cancer
- bedridden / surgery
- calf swelling unilateral
- superficial veins
- entire leg swollen
- locally tender
- pitting oedema unilateral
- paralysis/paresis
- previous DVT
- other diagnoses
PE
- DVT
- other diagnoses
- HR
- immobilisation/ surgery
- previous PE/DVT
- hemoptysis
- malignancy
qrisk2 score factors
risk of heart attack/stroke in next 10 years
- age
- sex
- ethnicity
- postcode
- BMI
- smoking
- diabetes
- FH of angina/heart attack (first degree relative)
- CKD
- AF
- blood pressure treatment
- blood pressure
- RA
- cholesterol (total:HDL)
hasbled factors
risk of bleeding with AF (on anticoagulation)
- hypertension
- alcohol
- stroke
- renal disease
- liver disease
- prior major bleeding/ predisposition
- unstable/high INR
- age
- medication the predisposes to bleeding (Aspirin, clopidogrel, NSAIDs)
collapsing pulse =
aortic regurgitation
pulsus paradox =
BP drops during inspiration
severe asthma
COPD
blood loss
cardiac
radio-radial delay=
pulse stronger in one arm
coarctation of the aorta (narrow)
An ejection systolic murmur heard loudest on inspiration would be suggestive of
which valvular pathology?
A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis E. Pulmonary stenosis
E
aortic stenosis murmur=
loudest when=
ejection systolic crescendo decrescendo murmur
+slow rising narrow pulse pressure
loudest on expiration
aortic regurgitation murmur/ pulse =
early diastolic descrescendo murmur
collapsing pulse
mitral stenosis murmur=
apical mid diastolic rumble
3 cardinal signs of heart failure =
shortness of breath, fatigue, ankle oedema
\+ often orthnopnea, paroxysmal nocturnal breathing, cold peripheries, raised JVP cyanosis hypotension increased weight 3/4th heart sounds, displaced apex beat, murmurs
Which of the following signs on ECG would be most indicative of a diagnosis of Right Bundle Branch Block?
A. R wave in V1, and Slurred S wave in V1 B. R wave in V1 and Slurred S wave in V6 C. R wave in V6 and Slurred S wave in V1 D. R wave in V6 and Slurred S wave in V6 E. Wide QRS and abnormal pattern.
B
- R wave - resembles m.
- Slurred S wave- resembles W.
- MaRRoW. M in V1 = R wave (resembles M), W in V6 = slurred S wave (resembles W)
- E = complete heart block
Which of these isn’t a feature of tetralogy of Fallot?
A. Atrial septal defect B. Hypertrophy of the right ventricle C. Overriding aorta D. Pulmonary stenosis E. Ventricular septal defect
A
tetralogy of fallot contains
treatment
congenital
- ventricular septal defect
- pulmonary stenosis
- R ventricle hypertrophy (higher pressure in R side that left, so R–> L shunt)
- overriding aorta (aorta right over septal defect- think it says more about the septal defect than the aorta)
surgery
- patch ventricular septal defect
- rebore pulmonary artery
- maybe new pulmonary valve if regurgitated
eisenmengers =
hypertrophy of arterioles (irreversible)- restrict high lung pressure
can be due to VSD
VSD / ASD direction of blood flow
both L to R
so not blue
tetralogy of fallot = R to L due to pulmonary artery flow obstructed by shunt
AVSD=
associated with?
hole in centre where atria and ventricles meet
trisomy, Downs
repair is tricky
patent ductus arteriosus=
from aorta to pulmonary artery, doesnt close
machinery murmur, big heart, breathless
can cause eisnenmengers
achalasia =
cause
peristalsis reduced in oesophagus and lower oesophageal sphincter does not relax to open when swallowing so food/drink does not pass to stomach and is often vomitted back up (no blood)
rarely genetic, mainly nerve issues maybe virus but not sure
mallory weiss tear
causes
where
presentation
treatment
increase in intra abdominal pressure (coughin, retching, dry heaves (alcoholic)). risk factors = alcoholism, eating disorder, male, NSAIDs
tear is in oesophagogastic junction
results in vomitting, with blood, retching
most heal spontaneously, sometimes surgery
A 42-year-old female presents to the gastro clinic complaining of chest pain. She says that it feels like a burning sensation in the middle of her chest that
gets worse when is lying or bending down. She also says that she wakes up in the evening feeling breathless. She hasn’t been vomiting any blood, had any difficulty swallowing food and drink or lost any weight. What medication would
you give first to try treat this patient?
A. Sulfasalazine B. Omeprazole C. Amoxicillin D. Prednisolone E. Ranitidine
B
- this is GORD
- B = PPI
- A is for UC
- C = antibiotic
- D = corticosteroid
- E ranitidine = H2 antagonist . can be used in GORD but not the 1st line
GORD pain presents how
middle of chest
burning
worse when lying/ bending down
may wake up in evening feeling breathless
no blood in vomit
sulfasalzine
5 aminosalicyclic acid (like mesalazine)
for UC (not crohns) along with prednisolone and fluids (depending on severity)
also DMARD- MSK
A patient comes in with abdominal pain, bloating, constipation. You examine
the abdomen and discover a hard mass in the left iliac fossa and carry out a digital rectal examination which shows an empty rectum. What is the first line investigation in this case?
A. Abdominal X-ray B. Abdominal CT C. Abdominal ultrasound D. Abdominal MRI E. Full blood count
A
- obstruction first line investigation = Xray
- large bowel obstruction here
Which of these is correct regarding duodenal ulcers?
A. They cause pain when eating and it is relieved several hours after eating
B. They cause pain several hours after eating and the pain gets better when eating
C. They cause pain when the patient is hungry, and it is relieved by eating
D. They cause pain when eating and are relieved by drinking
E. They cause pain when the patient drinks and is relieved by eating
B
- pain is due to acid in the duodenum so is several hours after eating (stomach empty). Relieved by eating (acid dissolves food, used up, stomach full)
does UC or crohns have a stronger genetic link
whats the deal with gender
crohns (higher proportion with first degree relative)
crohns f>m. UC f=m
dermatitis herpetiformis
rash - immunological response to gluten on skin, commonly extensor surfaces
coeliac
A 60-year-old male presents with blood and mucus in his stools for the past 3 weeks, he has had on off diarrhoea and constipation during this time. He has lost 2 stone over the 3 weeks. He smokes and reveals his father died of rectal cancer. Which is the most appropriate investigation?
A. Blood test: FBC, U+E, Tumour Markers etc B. Colonoscopy C. Double contrast barium enema D. CT Colonoscopy E. MRI
B
- A useful for monitoring but not diagnostic
- C - avoids risk of perforation but misses small lesions (Second line)
- D good for older patients, esp for excluding cancer
appendicitis pain migration
umbilical to right iliac fossa
+ fever
+ naus/vom
often young (10-20)
Which of these is not a cause of diverticulum?
A. Alcohol B. Low fibre diet C. Obesity D. NSAIDs E. Smoking
A
others are
pANCA test for what
UC - specific, but not sensitive
PSC
RA
other things - polyangitis, glomerulonephritis
Which of the following organisms is the most common cause of pyelonephritis?
A. Coagulate negative staphylococcus B. Enterococcus C. Escherichia coli D. Klebsiella E. Proteus
C
prostatitis/ cystitis presentation
prostatitis
- pelvic/perineal pain (3m+)
- trauma involving nerve damage (Eg fall)
- dysuria
- frequency
- ejaculatory pain
cystitis
- dysuria
- frequency
- urgency
- urine that smells/ cloudy/ dark/ blood
Lucy is a 30-year-old woman who is 2 months pregnant, as her GP you find that she has a lower urinary tract infection and are considering which antibiotic to prescribe her. Which of the following medications would you definitely avoid prescribing?
A. Amoxicillin B. Cephalexin C. Fosfomycin D. Nitrofurantoin E. Trimethoprim
E
- D only contraindicated in third trimester
- E is teratogenic in 1st trimester
budd chiari
triad
occlusion of hepatic veins
rare
triad = abdominal pain, ascites, liver enlargement
Which of the following is not a complication of polycystic kidney disease?
A. Cardiovascular disease B. Kidney stones C. Nephrotic syndrome D. Polycystic liver disease E. Subarachnoid haemorrhage
C
- A : PKD –> hypertension
- B : PKD –> slower urine, stasis
- C: nephrotic syndrome causes = autoimmune, DM, infection, neoplasia, gold, NSAIDs, atopy, SLE
- D : polycystic liver/ pancreas disease yes
- E: PKD –> berry aneurysms –> SAH
How is Hodgkin lymphoma (HL) clinically differentiated from Non-Hodgkin lymphoma (NHL)?
A. Clinical presence of B symptoms in HL and its absence in NHL
B. Disease is limited to lymph nodes in HL whilst in NHL disease can spread beyond lymph nodes
C. Presence of Reed-Sternberg cells in HL on histological observation and absence of such cells in NHL
D. Presence of Auer rods in HL on histological observation and absence of such cells in NHL
E. Physical examination reveals lymphadenopathy in HL whilst this is not the case in NHL
C
- A - B symptoms = systemic symptoms. they are less common in nonhodgkin but not absent
- B - not true of either, can spread beyond
- D = AML
- E - true of both non and Hodg
A patient presents to A&E with a fever and confusion. Upon further investigation, you find that she has AKI and her FBC reveals thrombocytopenia and anaemia. You recognise this as Thrombotic Thrombocytopenic Purpura and realise it is a medical emergency and you need to treat her immediately without waiting for diagnostic confirmation. What is the urgent gold standard treatment for someone with TTP?
A. Platelets B. Hydroxycarbamide C. Immunosuppressants D. Plasma exchange E. Broad spectrum antibiotics
D
- this is an emergency, do not wait for confirmation
- plasma exchange replenishes ADAMTS13 (what is deficient in TTP, degrades vWF)
- A would increase thrombosis! bad news
- B this is for polycythaemia rubra vera, sickle cell
- C this is a treatment but not urgent
- E there is no infection
frax score factors
risk of fracture in next 10 years
age gender BMI previous fracture parent fractured hip smoker glucocorticoids RA secondary osteoperosis alcohol
alteplase =
fibrinolytic drug
used mainly MI, PE, ischaemic stroke
artesunate=
first line treatment for severe /complicated malaraia
quinine/doxycycline are alternatives (contraindication etc)
complicated/ uncomplicated malaria treatment
complicated
- first line treatment for severe /complicated malaraia = artesunate
- quinine/doxycycline are alternatives (contraindication etc)
uncomplicated
- cholorquine
- artemisnin combination therapy for mixed infection
primaquine for hypnozoites
A 24-year-old male presents to General Practice complaining of a painful elbow. Upon examination the GP suspects a diagnosis of olecranon bursitis. The patient asks the GP about the pathological process that occurs in this condition. The GP explains the process of inflammation. Which of the following is not a clinical feature of acute inflammation?
A. Rubor B. Dolor C. Suppuration D. Tumor E. Loss of function
C
also dolor (pain)
suppurration (pus formation) is a potential outcome of acute inflammation
Which of the following pathologies would result in resolution?
A. Acute cholecystitis B. Cerebral infarction C. Full nephrectomy D. Myocardial infarction E. Partial lobectomy
A
all others are permanent - repair
paracetomol overdose 1st line treatment
N -acetyl cystine
Which of the following is not characteristic of an upper Gi bleed?
A. Coffee ground vomit (haematemesis) B. Diarrhoea C. Hypotension D. Melaena (black stools) E. Tachycardia
B
Mr Jones, a 57-year-old man, presents to his GP with an intermittent pain in the right upper quadrant (RUQ), made worse when he eats, especially fatty meals. He has a BMI of 35 and on examination has yellowish sclera. Last night he had a fever and rigors (convulsive sweating and shivering). What is the likely diagnosis?
A. Acute pancreatitis B. Ascending Cholangitis C. Biliary colic D. Primary Biliary cholangitis E. Vincent’s angina
B
- biliary colic and ascending cholangitis both have RUQ, worse with fatty food, and jaundice. ascending cholangitis also has fever +rigors.
- PBC - more like lethargy, itch. not related to fatty foods
- vincent’s angina = ulceration of mouth and gum inflammation. commonly smokers.
Mr Gascoigne, a 52-year-old male, is brought to the emergency department by
the police after wandering confused in the street. He is a known alcoholic but from what history you can gather, it seems that he has not had a drink in the last 48 hours. Which of the following would be the most appropriate immediate pharmaceutical treatment for this patient?
A. Adrenaline B. Amlodipine C. Chlordiazepoxide D. Methadone E. Morphine
C
chlordiazepoxide = 1st line treatment for alcohol withdrawal (We are within 72h)
- adrenaline is only helpful is cardiac insufficiency
- amlopidine = last resort cardioversion
- methadone = opioid addiction treatment
- morphine is pain killer, not appropriate for this case
korsakoff syndrome cause
wernickes syndrome
so also B1/ thiamine deficiency commonly in alcoholics
Which of the following side effects is most likely to occur with Alendronic Acid use?
A. Cough B. Gout C. Haemolytic anaemia D. Oesophagitis E. Urinary frequency
D
- this is why it is recommended to take bisphosphonates first thing in morning and remain upright for 30mins
- C = side effect of sulphasalazine (DMARD), RA
EMG is used in diagnosis of what?
polymyositis (idiopathic symmetrical proximal muscle weakness) - shows fibrillation
EMG= electromyography
pencil in cup deformity=
bone end eroded into sharpened pencil
– psoriatic arthritis - arthritis mutilans
Which of the following X ray signs is mostly likely to be found a patient with psoriatic arthritis?
A. Bamboo spine B. Pencil in cup C. Periarticular erosions D. Osteophytes E. Rhomboid crystals
B
bone end eroded into sharpened pencil
– psoriatic arthritis - arthritis mutilans
A - ankylosing spondylitis
B - gout, RA
C - OA
D - pseudogout
A 23-year-old student comes to your GP clinic complaining of back pain. He describes an aching pain that has come on over a few months and now wakes him at night. He denies weight loss, fevers or change in appetite. He has found gentle exercise to be helpful but struggles to keep up with his usual yoga class, finding the stretches difficult. Given the likely diagnosis, what is the most appropriate first line management?
A. Chemotherapy B. Ibuprofen C. Infliximab D. Paracetamol E. Watch and wait
b
this is ankylosing spondylitis
- NSAID should be used in the meantime whilst confirming with other tests (Xray, bloods)
- paracetemol is not an NSAID (used if ibuprofen contraindicated)
- infliximab (a monoclonal antibody, a DMARD), along with antiTNF used for severe AS (local pain relief steroid injections, surgery too)
Beryl is an 83-year-old lady presenting to A&E with a hip fracture after falling from her chair in her care home. On examination Beryl looks frail and underweight. She suffered a stroke 4 years ago and has been left with right sided weakness and has fallen several times. Last year she broke her wrist. You are concerned about her bone health and order a DEXA scan. The T score
comes back as -2.2. Which of the following is the most likely cause underlying Beryl’s fractures?
A. Osteoarthritis B. Osteomalacia C. Osteopenia D. Osteoporosis E. Osteosarcoma
C
- not greater than -2.5 (then would be D)
E more common in younger patients
A 52-year-old man complains of an incident occurring a few hours ago ‘a black curtain suddenly coming down’ in his right eye. He says that the episode was painless and only lasted a few minutes and that his vision was back to normal
after. You check his observations and note the following: RR 14, HR 70, T
36.5oC, SPO2 98% room air, BP 165/95. On listening to his neck, you can hear a bruit. He has no other past medical history other than having type 2 diabetes
which is controlled with medication. What is the most likely diagnosis?
A. Amaurosis fugax B. Glaucoma C. Optic neuritis D. Papilledema E. Retinal vein thrombosis
A
- retinal artery occlusion
B = painful, blurry (DM) C = painful, blurry (MS) D = headaches E = painless but resulting vision loss is prolonged
A 23-year-old investment banker is admitted to A&E after having a generalised tonic-clonic seizure that was witnessed by his brother. The brother states that
the patient was ironing his shirt when they seemed to gasp and fall to the floor, with their limbs then jerking for about a minute. After being unresponsive for a
few minutes, the patient recovered and noticed that their tongue was bleeding.The
brother claims that the patient has never had a seizure before, although when working late the patient would sometimes twitch his head or arm. There
is no other significant past medical, family or medication histories. Cardiovascular and neurological examinations were normal, blood tests were
normal and ECG was normal as well. What pharmacological treatment should be offered to the patient before their discharge from hospital?
A. Clonazepam B. Gabapentin C. Rivastigmine D. No treatment needed E. Sodium valproate
E
A ?
B 2nd line focal seizure
C Alzheimers
D unprovoked seizure needs prevention of further episodes
. Which of the following clinical features is NOT commonly found in patients with Parkinson’s disease?
A. Blank facial expressions except when told to smile
B. Extremely small handwriting
C. Hands shaking when trying to reach for something
D. Rigid limbs and difficulty getting out of bed
E. Slow walking
C
A , hypomimia - common B, micrographia - common C - implies intention tremor whereas PD has resting tremor, (which stabilises on active movement) D - rigidity - common E - bradykinesia - common
A 48-year-old woman presents with a daily headache and blurred vision that has worsened over the past several months. You are worried that she could have a space-occupying lesion. Which of the following clinical features is least likely to occur in patients with brain tumours?
A. Ascending paralysis from the lower limbs B. Coma C. Dysdiadochokinesis D. Nausea and vomiting E. Seizures
A
- A- looks like guillain barre (autoimmune and not brain tumour related)
- B - late stage due to raised ICP
- D- naus/vom due to raised ICP
A 69-year-old woman presents in A&E with extreme right-sided head pain and trouble seeing things with her right-eye. She struggles to dictate her history to you, claiming that she also has jaw pain too. She claims she is normally healthy but in the recent months has become more and more drained, with
aches all over her body. She also mentions weak shoulders and hips. When you examine her, her right-side scalp is very painful to the touch. Her blood
tests also came back and reveal a markedly raised ESR. What is the most appropriate next step in the management of this lady?
A. IM benzylpenicillin
B. Oral prednisolone
C. Prescribe codeine and advise plenty of bed rest at home
D. Refer to ophthalmology for their input
E. Urgent CT head
b
- this is giant cell temporal arteritis (related to polymyalgia rheumatica- weakness, aches)
- steroids advised esp with vision loss
A - meningitis
C- painrelief but not underlying cause
D stabilise asap
A 48-year-old man attends A&E with back pain. He works as a delivery driver and says that the pain started after loading a pallet into his truck. On
presentation, he is in visible discomfort and is unable to walk. He also says that he has been unable to go to the toilet since the pain started. A neurological examination of his lower limbs reveals intact sensation throughout, except his perineum. Power in both his legs is also reduced throughout. A digital rectal examination reveals poor anal tone. Which of the following diagnoses is the most likely?
A. Cauda equina syndrome B. Compression of the spinal cord C. Musculoskeletal injury D. Nerve root compression E. Vertebral fracture
A
- inability to open bowels/ urinate
- reduced anal tone
- saddle anaesthesia (numbness in saddle area)
- prolapsed disc compresses nerves in cauda equina
B - would have sensation loss below lesion, and UMN below lesion
D- would have shooting pain and decreased sensation
Which of the following best describes the mechanism of action of the drugs neostigmine and pyridostigmine that are used to treat myasthenia gravis?
F. Blocks active site of acetylcholinesterase, increasing the amount of Ach
available to the post-synaptic membrane
A. Crosses the blood-brain barrier and is converted into dopamine which acts to
reduce the neurological symptoms
B. Inhibits the conversion of angiotensin I to angiotensin II
C. Inhibits the conversion of arachidonic acid to prostaglandins
D. Reduces intracranial pressure by setting up an osmotic gradient between the CSF and subarachnoid space
F
A = Levodopa B= ACEi C = inbuprofen , COXi D = mannitol
Which of the following is least likely to be a risk factor for developing peripheral neuropathies?
F. Diabetes Mellitus A. Immunocompromised status B. Lymphoedema C. Systemic lupus erythematosus D. Thiamine (Vit B1) deficiency
B
least involvement with nerve damage
all others can be causes
ischaemic stroke should recieve altepase in what length of time
<4.5h ideally
CT needs to exclude haemorrhage first
What is the commonest cause of an infective exacerbation of COPD?
A. Haemophilus Influenzae B. Parainfluenza Viruses C. Rhinovirus D. Staphylococcus Aureus E. Streptococcus Pneumoniae
A
e also common but a more common
COPD exacerbation. immediate investigation?
ABG - establish need for respiratory support / ventilation
later: assess peak flow, send urine/sputum cultures
life threatening asthma attack signs
SpO2 <92% (oxygen saturation) Pa02 <8kPa normal PaCO2 PEF <33% best/predicted altered conciousness exhaustion arrythmia hypotension cyanosis silent chest poor respiratory effort
Sp02 =
oxygen saturation
Jess, a 21-year-old asthmatic has come to see her GP after she noticed that she feels shaky and her heart races after she takes one of her new medications for asthma. Which medication below is most commonly associated with a fine tremor?
A. Beclametasone inhaler B. Montelukast oral medication C. Proprionate inhaler D. Prednisolone oral medication E. Salbutamol inhaler
E
- relaxes airway smooth muscle but also acts on sympathetic heart receptors, causing tachycardia, and sympathetic receptors in skeletal muscle, causing tremor
A,C = inhaled steroids - oral candida, stunted growth B = leukotriene receptor antagonist
. Which type of lung cancer is most commonly seen in non-smokers?
A. Adenocarcinoma B. Carcinoid tumour C. Large cell and differentiated carcinoma D. Small cell lung cancer E. Squamous cell carcinoma
A
- still commonly smokers though too
D next
Which lung cancer is strongly associated with asbestos exposure?
A. Adenocarcinoma B. Large cell and differentiated carcinoma C. Mesothelioma D. Squamous carcinoma E. Small cell carcinoma
C
- can get compensation
- must go to coroner
- asbestos also associated with fibrosis, pleural thickening, pleural plaques
factor V leiden =
type of thrombophilia (inherited)
