General & Geriatrics Flashcards
Which of the following describes the physiological function and regulation of magnesium?
A. Extracellular magnesium accounts for >90% of total body Mg
B. In muscle contraction, magnesium stimulates calcium re-uptake by calcium activated ATPase
C. Magnesium is mainly absorbed in the colon by an active paracellular mechanism
D. Renal reabsorption occurs mainly in the proximal tubule
E. PTH is the major regulator of renal reabsorption
Answer: B - In muscle contraction, magnesium stimulates calcium re-uptake by calcium activated ATPase
Magnesium is integral to function of ATP and has a role in many enzymatic processes, synthesis of DNA and RNA.
99% of Mg is intracellular. It is absorbed in the small intestine by a passive paracellular mechanism.
Which one of the following drugs inhibits reuptake of dopamine, noradrenaline and serotonin and synapses?
A. Alcohol B. Cocaine C. LSD D. Cannabis E. Nicotine
Answer: B - Cocaine
Cocaine blocks reuptake of the 3 neurotransmitters
What is the mechanism of action of Ezetimibe?
A. Modulates lipoprotein synthesis and catabolism by activating PPAR
B. Reduced cholesterol synthesis by inhibiting 3-hydroxy-3-methylglutaryl coenzyme A reductase
C. Inhibits transport of dietary and biliary cholesterol across the intestinal wall
D. Increases demand for cholesterol for bile acid synthesis
E. Suppresses fatty acid release from adipose tissue
Answer: C - Inhibits transport of dietary and biliary cholesterol across the intestinal wall
Note fibrates activate peroxisome proliferator-activated nuclear receptors and module lipoprotein synthesis and catabolism - reduce triglycerides, moderately increase HDL with variable effect on LDL concentration
EMQ
A. Hydroxysteroid dehyrogenase B. Sodium-Chloride cotransporter C. Sympathetic nervous system D. Epithelial sodium channel E. Endothelin F. Aldosterone G. Angiotensin II H. Prostacyclin
- Which of the above has a gene mutation resulting in Liddle syndrome - characterised by hypertension, hypokalaemia and metabolic alkalosis?
- Which of the above has increased expression in Gordon syndrome (pseudohypoladosteronism type IIA) characterised by hypertension, hyperkalaemia and metabolic acidosis?
- Answer: D - Epithelial sodium channel (ENaC)
- Autosomal dominant gain of function
- Low renin and aldosterone - Answer: B - Sodium-Chloride co-transporter
- Gordon syndrome (pseudohypoaldosteronism type IIA) is another autosomal dominant disorder characterised by hyperkalaemia, metabolic acidosis, low plasma renin and normal aldosterone
- The normal aldosterone level is a remarkable feature as hyperkalaemia should stimulate aldosterone secretion
- All of these abnormalities are corrected by giving a thiazide diuretic
- WNK4 mutation leads to increased expression of the thiazide sensitive sodium-chloride co-transporter
Which one of the following features of alcohol withdrawal usually has an onset about 48-72 hours after cessation of alcohol intake?
A. Delirium tremens B. Headache C. Insomnia D. Korsakoff psychosis E. Tremor
Answer: A - Delirium tremens
Early withdrawal include tremor, insomnia, anxiety, palpitations, sweating, agitation, nausea and vomiting - usually within 24-48 hours.
At 48-72 hours, hallucinations, tachycardia, low grade fever, delirium tremens and agitation typically occur - peaking at 5 days.
Technetium-99m bone scan is LEAST useful in evaluating which of the following?
A. Bone viability in avascular necrosis B. Prosthetic joint infection C. Fractures difficult to assess on XR D. Vertebral insufficiency fracture E. Osteolytic lesions in multiple myeloma
Answer: E - Osteolytic lesions in multiple myeloma
Requires osteogenic reaction for uptake which is suppressed in myeloma so low sensitivity.
Which one of the following is true about treatment of patients with metastatic breast cancer?
A. Bone is a rare site of metastasis
B. Denosumab can reduce the incidence of pathological fracture
C. Fluoxetine is a suitable anti-depressant for patients taking tamoxifen
D. Symptomatic hypercalcaemia should be treated with increased oral fluids and oral bisphosphonate
E. Neuropathic pain usually responds quickly to opioids
Answer: B - Denosumab can reduce the incidence of pathological fracture
Fluoxetine, paroxetine and bupropion which are strong CYP2D6 inhibitors should not be taken with tamoxifen.
A 47 year old man presents for management of his chronic low back pain starting 4 months ago in his lower back without radiation. He denies weakness or sensory deficit. It is worse when he walks or lifts weight and is interfering with work as a brick-layer.
He has tried over the counter paracetamol and Ibuprofen PRN without relief. MRI lubosacral spine 5 years ago showed disc protrusion at L3-4 with no cord compression. Examination shows diffuse tenderness in his lower back, normal straight leg raise test and normal neurological examination including sphincter tone. How would you manage?
A. Lumbosacral XR
B. Repeat MRI
C. Apply for disability pension for chronic pain
D. Regular paracetamol up to 4g/day, educate around low back pain and recommend physiotherapy
E. Refer to neurosurgeon for discectomy
Answer: D - Regular paracetamol up to 4g/day, educate around low back pain and recommend physiotherapy
Non-specific low back pain without red flags. Imaging spinal changes are frequent in healthy adults and often non-contributory.
Which one of the following treatments is beneficial for producing sustainable sleep improvements in patients with chronic insomnia?
A. Temazepam B. Zolpidem C. Amitriptyline D. CBT E. Psychotherapy
Answer: D - CBT
A 28 year old man sustained bilateral femoral fracture and fractured pelvis following an MVA. 4 days after open reduction and internal fixation of the fractures he becomes acutely dyspnoeic. CXR shows diffuse pulmonary infiltrates and he becomes suddenly disoriented and paranoid. Which of the following is most likely?
A. Pulmonary embolism B. Fat embolism C. Aspiration pneumonia D. Extradural haematoma E. Subarachnoid haemorrhage
Answer: B - Fat embolism
A 50 year old homeless man is found collapsed in the street in winter. When the ambulance crew brought him to an acute medical unit, he was unresponsive with a GCS of 8 and hypothermic - temp 31 degrees. 12 lead ECG was recorded, which would be most consistent with his temperature?
A. 2nd degree heart block B. Prominent P waves C. Short PR interval D. J waves E. U waves
Answer: D - J waves
Seen in hypothermia and hypercalcaemia
The most characteristic and recognisable ECG feature of hypothermia is the J wave. This is the convex positive deflection at the junction of the QRS and the early ST segment.
A 54 year old man has been diagnosed with motor neuron disease. While discussing current management and future palliative care plan, you would advise:
A. Riluzole will relieve symptoms of respiratory failure but not slow disease progression
B. Stem cell transplant is effective
C. Non-invasive ventilation relieves symptoms from respiratory failure and improves survival
D. Benzodiazepines are contraindicated because of concern for respiratory failure
E. Baclofen can be used to relieve fasciculations
Answer: C - Non-invasive ventilation relieves symptoms from respiratory failure and improves survival
Riluzole inhibits glutamate release and has a modest effect, increasing survival by 3-6 months.
NIV benefits symptoms, quality of life and can have survival benefits of up to 12 months (in NON-BULBAR MND).
A 55 year old woman who has diabetic nephropathy and neuropathy involving her lower limbs complains of parasthesiae and chronic ‘electric shocks’ in her feet. The last 6 months, she has been using paracetamol/codeine but her symptoms have persisted. Her pain is limiting her work which requires long periods of standing. Which of the following is the most appropriate option?
A. Add pregabalin
B. Add high dose Ibuprofen TDS
C. Discontinue her meds and refer to physiotherapy
D. Substitute her current meds for Celecoxib
E. Substitute her current meds for oxycodone
Answer: A - Add pregabalin
Which of the following is NOT associated with hypomagnesaemia?
A. Use of aminoglycosides B. Primary hyperaldosteronism C. Hungry bone syndrome D. Chronic alcohol abuse E. Chronic kidney disease
Answer: E - Chronic kidney disease
A 27 year old woman in her 20th week gestation presents with pleuritic chest pain and dyspnoea. CT reveals multiple bilateral pulmonary emboli. Which one of the following is the most appropriate management?
A. LMWH either BD or single daily dosing
B. LMWH should not be stopped with rupture of membranes as risk of VTE is high in this period
C. No need to monitor anti-Xa level if LMWH is used
D. LMWH can be stopped 1 week after delivery provided the patient is mobilising
E. Direct thrombin inhibitors can be used routinely in pregnancy related VTE
Answer: A - LMWH either BD or single daily dosing
