General Medicine Flashcards
1
Q
Causes of HAGMA (high anion gap metabolic acidosis)
A
KUSSMALL
- Ketoacidosis
- Urea (renal failure)
- Salicylate poisioning
- Methanol
- A
- Lactic acidosis (metformin can cause this)
- Ethylene glycol
2
Q
What disease is caused by C282Y ?
A
Haemochromatosis
3
Q
Positive smooth muscle antibody?
A
Hepatitis
4
Q
Positive AMA?
A
Primary biliary cirrhosis
5
Q
What is Osler-Weber syndrome?
A
Hereditary haemorrhagic telangiectasia. Autosomal dominant disorder which can present as iron deficiency anaemia due to bleeding telangiectases in the bowel or with more urgent GI bleed or haematemesis and melaena.
6
Q
What is Peutz-Jeghers syndrome?
A
Brown melanin-pigmented lesions around the mouth an oral cavity associated with benign small bowel polyps.
7
Q
Does otosclerosis have a relationship with otitis media?
A
Otosclerosis is a common cause of late onset deafness and has no relationship with otitis media.
8
Q
What is the most common cause of a solitary thyroid nodule?
A
Most palpable and apparently solitary thyroid nodules are dominant nodules in a multinodular goitre with the other nodules not being readily palpable.
9
Q
What are the presenting signs/symptoms of Wernicke encephalopathy and what is the pathophysiological cause?
A
Altered level of consciousness, brain stem signs - particularly opthalmoplegia and nystagmus. Due to petechial haemorrhages within the mid-brain and brainstem due to thiamine deficiency (usually associated with alcoholism)
10
Q
What would extensor plantar responses in a patient with Wernicke encephalopathy suggest?
A
Extensor plantar responses would indicate an upper motor neuron lesion. In alcoholics with Wernicke encephalopathy other neurological disorders with upper motor neuron features may co-exist such as central pontine myelinolysis or subdural haematoma.
11
Q
A 65 year old man presents with sudden, persisting monocular visual loss. There is a history of continual ipsilateral headache for the past 12 months. What laboratory test is MOST RELEVANT to the diagnosis and what is the prospect for the return of vision?
A
ESR - temporal arteritis - visual loss will most likely be permanent.
12
Q
When the eyes of a semiconscious accident victim are examined it is found that the right pupil is dilated and does not react to light shone into either eye. The left pupil reacts to light shone directly into the left eye but not to light shone into the right eye. Which nerve(s) are involved?
A
R optic nerve (failure to respond to direct light) and the R third nerve (failure to respond to light in L eye - consensual response).
Involvement of both nerves is not uncommon in a periorbital fracture or tumour.
13
Q
A 50 year old man has a 12 month history of episodes of severe vertigo and vomiting; between episodes he is asymptomatic. He has noticed progressively increasing deafness in his right ear with mild tinnitus. Examination reveals that, except for a nerve deafness in one ear there are no abnormalities in the 3rd, 4th, 5th, 6th or 7th cranial nerves during an acute attack of vertigo. The most likely diagnosis is….
A
Meniere disease (recurrent episodes of vertigo and vomiting with progressive hearing loss).
14
Q
Defining feature of polymyositis?
A
Muscle weakness with no sensory change
15
Q
A 40 year old woman presents complaining of difficulty with swallowing. Examination shows she has a nasal speech, weakness of the facial and neck muscles, receding hairline and a weak and slow hand grip. This patient is most likely to be suffering from…
A
Dystropia myotonica
- Weakness of facial, palatal and neck muscles and dysphagia probably related to weakness of constrictors of the pharynx. Weakness and slowness of hand grip, receeding hairline and testicular atrophy are also features. It is a slowly progressive hereditary disorder and may not become apparent until the age of 40. Later, cataracts and cardiomyopathy may develop.
16
Q
What is bulbar palsy?
A
Lower motor neuron weakness of the cranial nerves originating in the medulla and pons. May present with nasal speech due to involvement of the facial nerves.
17
Q
A 64 year old man complains of 6 months of increasing stiffness in his legs and difficulty with walking. On examination there is wasting of the right biceps brachii with depression of the tendon reflex, spasticity in both legs with weakness of hip flexion and bilateral brisk lower limb tendon reflexes. The most likely cause is…
A
Cervical spondylosis
- Lower limbs - increasing stiffness and difficulty walking with bilateral spasticity, weakness in hip flexion and brisk reflexes - indicates a bilateral pyramidal lesion above the L2 (cord) level.
- Upper limbs - wasting of biceps with depression of tendon jerk - suggesting C6 root lesion.
- Together these symptoms are very suggestive of cervical spondylosis at the C5-C6 level with disc protrusion and osteophytes compressing both the cord (causing cervical myelopathy) and the C6 nerve root. The C5-6 level is the most common level to find cervical disease. The mechanism of the pyramidal involvement is probably ischaemic from compression of the anterior spinal artery.
18
Q
Are reflexes decreased in multiple sclerosis?
A
No - unchanged or increased
19
Q
Is weakness a feature of motor neuron disease?
A
Yes
20
Q
Are reflexes decreased in motor neuron disease?
A
No - they are brisk even when muscles are wasted
21
Q
A 35 year old woman develops weakness of the legs over a period of 7 days. On examination the only abnormalities are generalised weakness of the legs and suppressed reflexes. The MOST LIKELY diagnosis is….
A
Guillain-Barre syndrome
- Rapid onset of motor weakness associated with depressed reflexes
- In the early phases there are relatively few sensory changes
22
Q
What sensorimotor changes occur with spinal cord compression?
A
Focal weakness at the site of compression due to involvement of the nerve roots at that level. Weakness distal to the lesion will be pyramidal in nature and associated with increased reflexes.
23
Q
An obese 55 year old man presents with mononeuritis multiplex. He is most likely to also have what condition?
A
Diabetes mellitus
- The primary mechanism of diabetes causing mononeuritis muliplex is thought to be focal ischaemia in individual nerves. Characterised by a polyradiculopathy with usually a symmetrical and predominantly motor deficit.
24
Q
Does lead poisoning cause a motor or sensory neuropathy?
A
Motor - usually proximal
25
What other condition can cause a Guillain-Barre-like syndrome?
Infectious mononucleosis
26
Name some causes of parkinsonism (except Parkinson's disease)...
Manganese intoxication - seen in mineral miners
Phenothiazines - block dopamine receptors - tremor and increased tone - partly reversible
Methyldopa - metabolised to alpha methyldopamine - blocks central dopamine receptors
Carbon monoxide poisoning - extrapyramidal disorder similar to Parkinson disease
Dementia pugilistica - boxers syndrome
27
What does phenytoin intoxication look like?
Cerebellar dysfunction and ataxia (not parkinsonism)
28
What are some treatment drugs for post-herpetic neuralgia?
Usually self-limiting - majority of pts will have no symptoms after 6 months
Amitryptiline - TCA
Pregabalin
Gabapentin
29
Rheumatoid factor - is it sensitive or specific?
Rheumatoid factor will eventually become positive in approximately 2/3 of pts with RA
It is strongly associated (>95%) with the presence of rheumatoid nodules.
It non-specific and can be positive in; SLE, Sjogren's, chronic liver disease, sarcoidosis and others. It is found ing approximately 5% of the healthy population and >10% of those >65.
High titres can be associated with severe disease - but do not indicate activity of disease
30
What is the male to female ratio of anklylosing spondylitis?
M:F 9:1
31
Where are the first radiographic signs of anklylosing spondylitis usually found?
SI joint with blurring of the cortical margins of the subchondral bone followed by erosion and sclerosis.
32
What happens to the intervertebral disc spaces in ankylosing spondylitis?
They are usually maintained, particularly when sclerosis develops in the annulus.
33
Why do patients with ankylosing spondylitis sometimes have breathing issues?
AS reduces the mobility of the spine and the ribs and reduces the lung vital capacity
34
Which of the following is NOT correct? A 3rd heart sound...
1. Is a diastolic filling sound
2. Will disappear if atrial fibrillation occurs
3. Can be normal in young people
4. Is often a sign of left ventricular failure
5. May occur in mitral incompetence
Answer: 2
3rd heart sound is not dependent on atrial contraction and is not influenced by the presence of AF. It is associated with rapid ventricular filling, it is low pitched and best heard with the bell. It may be normal before the age of 30 but should be assumed to be abnormal >40 years of age where it implies ventricular disease. It is commonly heard in acute left ventricular failure, as after MI. It occurs in most cases of severe mitral regurgitation. A rare cause is constrictive pericarditis where the 3rd heart sound represents sudden cessation of ventricular filling.
35
A 28 year old woman presents because of lethargy, dizzy spells and occasional syncope. During a dizzy spell the pulse rate is 32 beats/min and the blood pressure is 85/60mmHg. Which of the following is the MOST LIKELY diagnosis?
1. Addison disease
2. Insulinoma
3. Structural disease of the cardiac conducting system ("sick sinus syndrome")
4. Sinus tachycardia with a 4:1 atrioventricular block
5. Iron deficiency
Sinus tachycardia with a 4:1 atrioventricular block
- Addison disease may be associated with a mild bradycardia but not a pulse of 32/min - strongly suggests a significant degree of heart block.
- Sick sinus syndrome - usually is due to a structural disease of the conducting system - can cause episodic heart block and dizziness but would be very uncommon in a woman of this age (except if had cardiac surgery - uncommon, and usually permanent not transient)
- Insulinomas - syncope but not associated with such a low pulse rate
- Iron deficiency - mild tachycardia
36
A 60 year old man who has enjoyed good health complains of increasing breathlessness, abdominal discomfort and swelling of the feet for 3 weeks. His venous pressure is elevated, the liver is enlarged and there is gross ascites. The resting resp rate is 25/min and there are basal creps. The pulse is 36/min and an ECG shows an atrial rate of 96/min. The BP is 180/80mmHg. The MOST EFFECTIVE IMMEDIATE treatment is....
1. IV frusemide
2. IV frusemide + digoxin
3. IV digoxin
4. Abdominal paracentesis
5. Insertion of a transvenous pacemaker
Answer 5. Insertion of a transvenous pacemaker.
This is heart failure due to complete heart block. The correct treatment is to increase his heart rate immediately with a pacemaker as when his heart rate is increased the signs of cardiac failure will abate. He is at risk of sudden death so the pacemaker is urgent.
- Digoxin may increase risk of asystole
- Reducing plasma volume with frusemide would reduce the filling pressure and further reduce cardiac output - possibly fatally
- Abdominal paracentesis would also reduce the filling pressure and blood volume (as fluid would quickly shift to fill it back again) and reduce the cardiac output also.
37
The MOST COMMON site of a spontaneous rupture of an atherosclerotic aortic aneurysm is...
Abdominal aorta below the renal arteries
38
After a pulmonary embolus which of the following is MOST LIKELY?
1. Low R atrial pressure and low central venous pressure
2. Low systemic arterial pressure and low venous pressures
3. High pulmonary venous pressure and pulmonary oedema
4. High R ventricular pressure and high systemic venous pressure
5. High L atrial pressure and functional mitral valve incompetence
Answer 4: High R ventricular pressure and high systemic venous pressure.
- High right ventricular pressure (blood unable to get into the pulmonary circulation) and a raised systemic venous pressure (backflow from an obstructed right sided circulation).
39
Fibromuscular hyperplasia of the renal arteries as a cause of hypertension is MOST FREQUENT in what gender and age group?
Fibromuscular hyperplasia affecting the renal arteries, is a disease of unknown aetiology most commonly detected in a young woman.
40
In a coal miner aged 50 years, a persistent blood-stained pleural effusion is MOST LIKELY to be due to...
1. Pulmonary tuberculosis
2. Coal miner's pneumoconiosis
3. Carcinoma of the lung
4. Silicosis
5. Mesothelioma
Answer 3: Carcinoma of the lung
- Coal miner's pneumoconiosis and silicosis do not produce blood-stained effusions
- Mesothelioma can produce a blood-stained effusion but usually other signs of asbestosis are apparent and it is far less common than lung Ca
- Pulmonary TB produces an exudative effusion with many lymphocytes but usually not blood stained
41
Which of the following is UNUSUAL in a patient with chronic hypercapnia?
1. Retinal venous distension
2. Drowsiness
3. Cold, clammy skin
4. Headache
5. Muscle twitching
3. Cold clammy skin is not a feature of chronic hypercapnia (pink puffers - not blue bloater)
- Hypercapnia induces peripheral vasodilation resulting in hot, dry skin and retinal distension
- Vasodilation of scalp vessels and intracranial extracerebral vessels are responsible for the headache of hypercapnia
- Drowsiness is due to the direct cerebral effect of the elevated CO2 or acidosis on the reticular formation.
- Muscle twitching is usually due to acidosis, but myoclonic jerks of central origin may also occur
42
Respiratory alkalosis is associated with...
1. Inc PaCO2, Inc plasma bicarb
2. Inc PaCO2, Dec plasma bicarb
3. Dec PaCO2, Inc plasma bicarb
4. Dec PaCO2, Dec plasma bicarb
5. Dec PaCO2, Dec urinary bicarb
Answer 4: Dec PaCO2, Dec plasma bicarb
- In resp alkalosis there is an increased loss of CO2 from hyperventilation. This reduces the PaCO2. The subsequent rise in pH is partly compensated for by an increased urinary excretion of bicarb and causing a decrease in plasma bicarb (hence acidifying the blood to compensate for the alkalosis).
43
A healthy non-smoking 19 yo man is hospitalised for an appendicectomy and mistakenly given an overdose of narcotics. He is found unconscious and on auscultation of his chest he has reduced breath sounds and no added sounds. Chest x-ray is clear. Arterial blood gases (on room air) are MOST LIKELY to show a pH, PaO2 and PaCO2 of...
1. 7.22, 70, 61
2. 7.23, 90, 59
3. 7.23, 86, 30
4. 7.39, 65, 42
5. 7.39, 75, 60
Answer 1: low pH, low O2, high CO2
- Hypoventilation causes a respiratory acidosis with a reduction in PaO2, and increase in PaCO2. One would expect an acidosis not a normal pH as this is acute and not enough time for metabolic compensation.
44
What is the colour of sputum associated with pneumococcal pneumonia?
Rust-coloured
45
What is the colour/consistency of sputum associated with pulmonary oedema?
Pink and frothy
46
What is the colour/consistency of sputum associated with chronic bronchitis?
Clear and mucoid
47
A 24-yo asthmatic presents to ED complaining of SOB. He looks unwell. Pulse rate 130, temp 38. Chest is hyperinflated, breath sounds are vesicular but diminished and there is a soft, generalised expiratory wheeze. Do you take him for an x-ray, do ABGs or peak flow first?
Peak flow - will tell you most about his reserve/severity of this exacerbation.
He sounds too sick to be taken to radiology for a x-ray (unless ofc you are in resus) due to diminished soft breath sounds which are a late sign of life-threatening asthma - but also could be consistent with mild asthma and acute infection.
ABGs will be helpful straight after peak flow to delineate this before a chest x-ray.
48
Dysphagia can be ASSOCIATED with each of the following except...
1. Monilial oesophagitis
2. Myasthenia gravis
3. Iron deficiency anaemia
4. Parkinsonism
5. Oesophageal varices
5. Oesophageal varices - these do not cause dysphagia as they are soft and dilated venous channels easily displaced by food and liquid
49
How is iron deficiency anaemia associated with dysphagia?
Iron deficiency anaemia can be associated with an accompanying hypopharyngeal web in middle-aged women, causing sideropenic dysphagia (Plummer-Vinson syndrome)
50
What is the most significant long-term risk with gluten sensitive enteropathy?
There is a substantial long term risk of developing intestinal lymphoma in patients with gluten-sensitive enteropathy.
51
How long does it take to see a histological change in the intestines of a patient with gluten-sensitive enteropathy when put on a gluten-free diet?
Some patients may take 24-36 months before clinical response is apparent. In some adults there may be little change in the intestinal histological features.
52
What disease is consistent with an inflammatory cell infiltrate with PAS-positive macrophages in the gut?
Whipple disease
53
What magnitude is the increased risk of hepatocellular carcinoma in carriers of hepatitis B?
90-100 fold increased risk
54
What organism is the most common cause of "traveller's diarrhoea"?
Enterotoxigenic E-coli
55
What type of bowel polyp is most likely to produce a cancer?
Villous adenoma
56
A 30 year old woman presents with a 2 week history of bloody diarrhoea. Sigmoidoscopic examination reveals changes compatible with ulcerative colitis. A rectal biopsy is taken. The NEXT STEP should be to...
1. Commence salicylazosulphapyridine
2. Commence IV steroids
3. Order a stool culture
4. Commence rectal steroids
5. Await results of rectal biopsy
3. Order a stool culture
- A history of 2 weeks bloody diarrhoea would be consistent with the first episode of UC but an infective cause must be excluded by stool microscopy and culture. C Jejuni, amoebiasis or CMV enteritis in the immunosuppressed may have a macroscopic appearance indistinguishable from that of UC.
57
A 19 year old female, recently returned from Indonesia, presents with bloody diarrhoea, cramping abdominal pain, tenesmus and fever. Which infection is most likely, how would it be diagnosed and treated?
Shigella infection. Numerous polymorph leucocytes are usually seen in the stool and the infection can be diagnosed by gram stain and stool culture. A quinolone antibiotic is indicated.
58
A 38 year old woman presents with a 2 week history of malaise, feeling hot and feverish, palpitations, sweating, tremor, pain in the neck and weight loss of 2 kg. Her pulse is 120/min and her hands are sweaty with tremor. Her thyroid is palpable, firm, tender and enlarged. Which one of the following results CONFIRMS the MOST LIKELY diagnosis?
1. High serum thyroxine and T3
2. Low thyroid uptake of radioactive iodine
3. Thyroid nuclear scan showing increased uptake
4. Antithyroid antibodies present in high titre
5. Low TSH with flat response to thyrotropin-releasing hormone
2. Low thyroid uptake of radioactive iodine
- Although some of the symptoms in this vignette are those of thyrotoxicosis, the rapid onset with thyroid pain and the palpable tender enlarged thyroid suggest thyroiditis.
- The most reliable test to distinguish between acute thyrotoxicosis and subacute thyroiditis are nuclear uptake tests. Reduced uptake of radioactive iodine is typical of subacute thyroiditis, compared with increased uptake in acute thyrotoxicosis. Subacute thryoiditis is thought to be a response to a viral infection rather than an autoimmune response.
59
All of the following can occur with an ABO-incompatible blood transfusion EXCEPT...
1. Fever, rigors
2. Hypotension
3. Back pain
4. Bilrubinuria
5. Haemoglobinuria
Answer: 4 - Bilirubinuria does not occur with ABO incompatible blood transfusion.
Typically fever, rigors and hypotension followed by back pain and haemoglobinuria causing dark urine. While bilirubin is produced in excess from haemoglobin and the patient may be jaundiced, the bilirubin is in unconjugated form and therefore does not appear in the urine.
60
Macrocytic anaemia is found in all of the following except...
1. Hypothyroidism
2. Anti-epileptic medication
3. Regional ileitis (Crohn disease)
4. Chronic alcoholism
5. Chronic uraemia
5. Chronic uraemia - is normally normochronic and normocytic not macrocytic - it is predominantly due to the inability of the kidneys to produce adequate amounts of EPO
61
Why does phenytoin cause anaemia and what type of anaemia does it cause?
Phenytoin interferes with the absorption of folic acid therefore produces a macrocytic anaemia
62
What are the mechanisms by which alcoholism causes a macrocytic anaemia?
3 mechanisms:
- Liver disease
- Low folate
- Megaloblastic bone marrow
63
which of the following SUPPORTS a diagnosis of glandular fever due to Epstein-Barr virus infection?
1. Splenic infarction
2. Eosinophilia
3. A maculopapular rash following erythromycin
4. The presence of cold agglutinins in the patient's blood
5. Abnormal liver function tests without jaundice
5. Abnormal liver function tests without jaundice
- Splenic infarction is not a frequent complication of EBV infection. Eosinophilia would suggest a parasitic infection. Normally the neutrophils are suppressed and the lymphocytes are elevated with abnormal lymphocytes in EBV infection. A rash may occur with ampicillin in EBV infection but not with erythromycin. Cold agglutinins are typical of mycoplasma infections not EBV
64
Which of the following effects of antidiuretic hormone leads to the production of a concentrated urine?
1. Increase in free water clearance
2. Increase in Na conc in the distal tubule fluid
3. Increase in active transport of water in the distal tubule
4. Increased permeability of water in the distal tubule
5. Increase reabsorption of sodium in the distal tubule
Answer 4
The primary effect of ADH is to increase the permeability of water in the distal tubules. As the distal tubule lies in an area of hyperosmolarity there is a reabsorption of water, leading to more concentrated urine
65
A 60 year old woman is brought to the ED by her relatives who have noticed that she is "unwell" and confused. Initial bloods: Na 139, K 5.4, Cl 113, HCO3 17, urea 11.5 (
3. Metabolic acidosis
- Her lowered PaCO2 and bicarbonate indicate that the acidosis is metabolic rather than respiratory in origin.
- With the raised chloride level, the anion gap has been decreased. In renal metabolic acidosis the anion gap is increased. Adults with profuse vomiting usually develop an alkalosis with elevated bicarbonate and lowered potassium. An infusion of bicarbonate would not contribute to the patient's treatment in that the bicarbonate is lowered secondary to the lowered pH. The primary treatment should be directed towards the cause of the acidosis.
66
Which of the following is the MOST COMMON cause of end-stage renal failure in adults in Australia?
1. Diabetes mellitus
2. Polycystic renal disease
3. Analgesic nephropathy
4. Chronic glomerulonephritis
5. Reflux nephropathy
4. Chronic glomerulonephritis
This accounts for 32% of patients presenting for renal replacement therapy. Diabetics count for 20%, Polycystic kidney disease is 10%, analgesic nephropathy is about 5%. Reflux nephropathy due to vesico-ureteric reflux is a common cause of chronic renal failure in childhood but not adults
67
A GP prescribes pencillin V for a sore throat in a 11 yo boy after diagnosing infection with a Group A haemolytic strep. The boy recovers well. Ten days post he develops malaise and mild facial and hand swelling. All of the following statements are correct EXCEPT...
1. Hypertension and pulmonary oedema are commonly associated with this clinical presentation
2. Urinary sediment containing red cells and hyalin casts suggests acute post-strep glomerulonephritis
3. A low antistreptolysin (ASOT) titre excludes post-strep glomerulonephritis
4. Treatment is bed rest, diuretic and antihypertensive medication
5. The boy's family should be screened for Group A haemolytic strep carriers
3. A low ASOT does not exclude post-strep glomerulonephritis
- ASOT may not rise for 2-3 weeks after acute haemolytic strep infection, and indeed, may not rise at all, therefore the presence of a normal or low ASOT does not exclude the diagnosis of post-strep glomerulonephritis
68
The MOST COMMON INITIAL manifestation of HIV infection is...
1. An opportunistic infection
2. Meningitis
3. A GI disorder
4. A mild flu-like illness
5. Not a specific symptomatic pattern
4. A mild flu-like illness
- Opportunistic infections do not occur until later in the disease process when there is profound immune deficiency. Meningitis, GI and other symptoms are again less common as initial manifestations of infection. Although some patients are unable to identify the time of HIV infection from symptomatic assessment, more do have evidence of an initial flu-like febrile illness.
69
An Australian-born patient with AIDS presents with meningitis. The MOST LIKELY pathogen is...
1. Mycobacterium tuberculosis
2. HIV
3. Neisseria meningitidis
4. Cryptococcus neoformans
5. Streptococcus pneumoniae
4. Cryptococcus neoformans
- Meningitis in patients with AIDS is common and is usually due to cryptococcus neoformans. In Australian-born patients the likelihood of TB meningitis is low. HIV can give a mild form of aseptic meningitis, both at the time of initial seroconversion and at any time before the development of AIDS. However, the incidence of aseptic meningitis in patients with established AIDS is low. Bacterial meningitis due to Neisseria and Strep pneumonia are uncommon in AIDS.
70
The major lesion in tabes dorsalis is...
1. Demyelination of posterior columns
2. Isolated degeneration of dorsal nerve roots
3. Isolated degeneration of ventral nerve roots
4. Demyelination of the anterior spino-cerebellar tract
5. Peripheral nerve demyelination
Tabes dorsalis (one of the varieties of tertiary syphilis) is a condition where there is neurological evidence of posterior column demyelination. This is the predominant lesion and results in a loss of vibration and position sense with subsequent damage to a variety of tissues and structures.
71
Metronidazole is active against all of the following organisms EXCEPT....
1. Bacteroides fragilis
2. Giardia lamblia
3. Entamoeba histolytica
4. Toxoplasma gondii
5. Trichomonas vaginalis
4. Toxoplasma gondii is not sensitive to metronidazole
| - Treat it instead with sulfadiazine, clindamycin or pyrimethamine
72
Ceftriaxone is effective therapy for infection caused by which of the following micro-organisms?
1. Mycoplasma pneumoniae
2. Penicillinase-producing Neisseria gonorrhoeae
3. Chlamydia trachomatis
4. Giardia lamblia (intestinalis)
5. Gardnerella vaginalis
2. Ceftriaxone is effective against penicillinase-producing Neisseria gonorrhoeae.
- It is not effective against the others
- Treat Mycoplasma and Chlamydia with tetracycline/erythromycin.
- Treat Giardia and Gardnerella with metronidazole or other azole
73
Tetracycline is the treatment of choice for adults with:
1. Acute bronchitis
2. Tonsilitis in a penicillin-allergic patient
3. Klebsiella UTI
4. Psittacosis
5. Gonorrhoea
4. Tetracycline is specifically effective in treating psittacosis
- Other options for tx include erythromycin or chloramphenicol
- Tetracycline is bacteriostatic - can be effective for treating the others but is not the treatment of choice
74
Cimetidine can reduce the hepatic metabolism of all of the following except:
1. Propranolol
2. Pheytoin
3. Warfarin
4. Digoxin
5. Theophylline
4. Digoxin is not affected by cimetidine
- Cimetidine affects the metabolism of a large number of drugs metabolised in the liver and hence the levels of the other drugs will rise when cimetidine is given.
75
What birth defect is sodium valproate associated with?
Neural tube defects
76
What anti-epileptic drug causes gingival hyperplasia?
Phenytoin
77
What is the preferred treatment for petit-mal seizures?
Sodium valproate (carbamazepine does not work for petit mal seizures)
78
What lab test can help with the diagnosis of allergic rhinitis?
Nasal smears show a large number or eosinophils
79
What is Nystatin used for?
Yeast infections (not fungal infections)
80
Give two examples of antifungal treatments?
Miconazole, clotrimazole
81
What drugs can make psoriasis worse?
Lithium, beta-adrenergic blocking agents, antimalarial drugs, NSAIDs
82
What would be the clinical picture of vertebrobasilar insufficiency?
Altered level of consciousness or loss of memory because of bilateral medial temporal lobe ischaemia
83
Can Parkinson's disease present with a unilateral tremor?
Yes, most commonly in the dominant side, is a typical mode of onset and may occur many years before the development of generalised Parkinson disease
84
List some causes of myoclonic jerks...
1. Normal sleep
2. Epilepsy
3. Creutzfeldt Jacob disease
4. Subacute encephalitis
5. Uraemia (and will respond to treatment for uraemia)
85
Typical symptoms of a MCA area stroke?
1. Dysphasia (temporal lobe)
| 2. Constructional apraxia (parietal lobe)
86
What is the tremor that is associated with multiple sclerosis?
Red nucleus tremor - gross flapping tremor occuring while maintaining a posture
Or also an "intention tremor" due to cerebellar involvement
87
Classical presentation of optic neuritis?
Central scotoma in the affected eye (lesion is anterior to the optic chiasm)
88
What affect does papilloedema have on the visual field?
Enlarges the blind spot, as when the nerve head swells the blind spot enlarges
89
What visual disturbance does glaucoma cause?
Peripheral field loss, constricted visual fields due to decreased peripheral perfusion because of the raised pressure and damage to nerve fibres in the optic cup (therefore increased cup disc ratio)
90
What visual symptoms would be produced by an optic glioma?
Field defect or scotoma in one eye
91
Where is the lesion in spastic paraparesis?
Bilateral involvement of the pyramidal tracts eg in cervical spondylosis where the backward pressure on the dura (due to disc or osteophytes) compromises the anterior spinal artery and produces an ischaemic lesion of the corticospinal tracts.
92
Drug causes of peripheral neuritis?
Nitrofuratoin - can cause severe sensorimotor neuropathy particularly if there is renal failure
Isoniazid - can produce peripheral neuropathy which is common in pts treated for TB - small doses of pyridoxine can help this
Vincristine - produces a mild degree of neuropathy in most patients in whom it is used, in some it may be severe and require cessation of the drug
93
Causes of mononeuritis multiplex?
Polyarteritis nodosa - multiple infarcts in nerves
Diabetes - scattered vascular lesions
Sarcoidosis - invasion of individual nerves with granulomatous tissue
94
Causes of wasting of the small muscle of the hand?
T1 nerve root lesion (Klumpke paralysis)
Cervical rib (angulation of the lower trunk of the brachial plexus over the rib, affects T1 predominantly)
Apical carcinoma of the lung (Pancoast syndrome)
95
Nerve lesion responsible for foot drop?
L5 - common peroneal nerve - tibialis anterior weakness
96
What symptoms would compression of the first sacral nerve root cause?
Loss of the ankle jerk - and if weakness associated it will be of plantar flexion of the foot
97
What nerve is responsible for the knee jerk?
L4
98
What conditions does Carbamazepine treat?
Complex partial seizures
Generalised tonic clonic seizures
Trigeminal neuralgia
99
What haematological conditions predispose to gout?
Polycythemia vera
| Myelofibrosis
100
Biochemical disturbance found in rickett's?
Increase in serum alk phos
| Decreased serum calcium
101
What happens to JVP and BP in cardiac tamponade?
BP falls during inspiration due to increased intrathoracic pressure reducing filling of the right ventricle. JVP increases in cardiac tamponade.
102
Is mitral valve prolapse more common in men or women?
Women
103
Complications of mitral valve prolapse?
Infective endocarditis
| Systemic emboli
104
Why are ACE inhibitors useful in congestive heart failure?
They lower the blood pressure and reduce sodium and water retention.
105
What antihypertensive drugs can increase insulin resistance and elevate the cholesterol level?
Thiazide diuretics
106
When does the non-productive cough from an ACE inhibitor start?
At any time, not commonly within the first few weeks
107
What is Budd-Chiari syndrome?
Complication of hypercoagulable states with hepatic vein occlusion resulting in hepatosplenomegaly, ascites, jaundice and portal hypertension
108
What is Leriche syndrome?
Thrombus or plaque at the aortic bifurcation with symptoms of bilateral ischaemic buttock claudication and impotence
109
What is meralgia paraesthetica?
Dysaesthesia (tingling and numbness) in the distribution of the lateral cutaneous nerve of the thigh as a result of tense ascites pinching the nerve as it passes through the fibrous tunnel beneath the inguinal ligament just medal to the ASIS. Can also occur due to obesity or strenuous physical training.
110
A radial nerve lesion in the spiral groove of the humerus would cause what clinical signs?
Wrist drop and sensory loss in the anatomical snuff box
111
Buerger sign?
Dependency rubor and elevational pallor indicating arterial insufficiency
112
Describe the features of neurofibromatosis type I (Von Recklinghausen disease)
Cafe au lait spots
Pedunculated and sessile skin lesions (molluscum fibrosum)
Subcutaneous swellings (firm consistency) overlying peripheral nerves
113
Treatment of pilonidal sinus?
Formal excision and drainage, including secondary and primary sinuses, underlying cavity and contained hairs using an advancement flap
114
In Amaurosis fugax which artery is often involved and from where does the pathology most frequently arise?
Ophthalmic artery platelet embolisation from an ipsilateral carotid artery plaque
115
If a patient has a right sided embolus to the cerebral cortex involving the motor area of an upper limb, besides UMN signs of that limb what is an associated clinical sign you may detect?
Descending upper motor neurones cross in the pyramids to supply the contralateral lower motor neurone hand musculature, giving a contralateral left-sided hand weakness
116
Name the types of thryoid malignancy from most to least common.
Papillary - most common in young adults, rarely spread beyond head and neck
Follicular - less common and difficult to differentiate from a benign adenoma, haematogenous spread, sometimes to bone
Medullary - least common and usually part of the MEN spectrum
117
What is Brown-Sequard syndrome?
Spinal cord hemisection
Clinical features include - Ipsilateral lower motor neuron lesion
Crossed sensory loss below the lesion
Ipsilateral loss of position sense
Contralateral pain and temperature sense loss
Ipsilateral UMN signs below the lesion
118
What are the signs of a second cranial nerve palsy?
Unilateral blindness with failure of the direct but not consensual responses to light and no change in pupillary size
119
What are the signs of a third cranial nerve palsy?
Pupillary dilatation and failure of the direct and consensual responses to light. "Down and out" eye (as all but two ocular muscles are paralysed).
120
Lymphadenopathy with biopsy proven metastatic SCC in the posterior triangle of the neck would indicate a likely primary site of....
Nasopharynx
121
Where do lymphatic mets usually arise in laryngeal neoplasia?
Anterior triangle, deep cervical nodes
122
SCCs of the lips are usually secondary to ....
```
Four S's
Smoking
Spirits
Spices (betel nut, pan)
Syphilis
```
123
What cranial nerve supplies sensation to the tongue?
Trigeminal nerve via the lingual nerve
124
A thyrotoxic patient was subjected to a subtotal thyroidectomy after she had been made euthyroid by medical treatment. The day after the operation her temperature is 39o and her pulse rate is 110/min and regular. She is most likely to have what operative complication?
Pulmonary atelectasis
125
Signs and symptoms of raised intracranial pressure?
Worsening headache, often associated with vomiting, progressing to drowsiness and papilloedema. Bradycardia and hypertension are late signs of tentorial herniation.
126
30 yo T1DM with one month history of diplopia on vertical gaze, worse on reading or descending stairs, greatest when looking down and to the left. She tilts her head to obtain better vision. On examination there is no ptosis, PEARLA, no previous head or eye trauma.
What is the most likely diagnosis?
Binocular vertical diplopia indicating a 4th cranial nerve lesion due to diabetic ocular neuropathy.
CN IV supplies the superior oblique which rotates the eye down and in and intorts it. A third nerve palsy can also cause vertical diplopia but is usually associated with ptosis and change in pupil size and reactions.
127
What are the signs of a sixth cranial nerve palsy?
Sixth cranial nerve supplies the lateral rectus which causes horizontal diplopia on lateral gaze to the affected side with failure of abduction of the eye.
The nerve is long from the lower pons to the superior orbital fissure so often complicates a head injury but is non-specific for the type or severity of the head injury
128
Signs and symptoms of Bell's palsy
Unilateral weakness of all of the muscles of facial expression (including frontalis) and the eyelid will not close.
Taste may be lost to the anterior two-thirds of the tongue
Hyperacusis (loud distortion of noise) may result because of paralysis of the stapedius muscle (which is supplied by a branch of the facial nerve)
129
What is Charcot-Marie-Tooth disease?
Hereditary sensorimotor neuropathy affecting both motor and sensory nerves. Signs and symptoms relate to distal muscle weakness in feet and later hands, pain and sensory disturbance are unusual. Transmission is autosomal dominant usually and frequency is around 1:2500 people.
130
What is vestibular neuronitis and it's signs and symptoms?
Sudden and near-complete loss of vestibular function due to a self-limiting viral infection of the vestibular nerve which becomes swollen and painful. Patients experience severe vertigo, nystagmus towards the affected side but no hearing deficit. Treatment is expectant and the severe vertigo usually subsides over a few days, but positional vertigo on head movement may persist for several weeks.
131
Signs and symptoms of an cerebellopontine angle tumour?
Cerebellopontine angle tumours such as acoustic neuromas (schwannoma) of the 8th cranial nerve often cause unilateral sensorineural hearing loss associated with tinnitus, episodic vertigo and gait instability. Other cranial nerves can become affected, 7th nerve paresis, 5th nerve and sometimes 9,10 and 11 causing dysarthria or dysphagia
132
How is the pons significant in determining sensory neurological lesions?
Sensory fibres decussate in the pons therefore:
Suprapontine lesions cause involvement in all sensory modalities as at this level up all sensory fibres run together and affect the contralateral side.
Pontine/Infrapontine lesions affect the ipsilateral posterior column (touch, postural and vibration) or contralaterally the anterior and lateral column spinothalamic fibres (pain and temperature).
133
Signs and symptoms of PICA (posterior inferior cerebellar artery) syndrome?
```
Vertigo and nystagmus (cerebellar lesion)
Horner syndrome (lower brain stem)
Pons and cerebellum = distribution of the PICA
```
134
What nerve when injured would cause you to not be able to extend your fingers or thumb (but wrist extension preserved)?
Posterior interosseous nerve
| - Supplies the long extensors of the fingers and thumbs and runs in the posterior forearm compartment
135
4 symptoms of Meniere disease?
1. Periodic episodes of rotatory vertigo or dizziness
2. Fluctuating, progressive, low-frequency perceptive hearing loss (with loudness recruitment - hearing is better with background noise)
3. Tinnitus
4. A sensation of "fullness" or pressure in the ear
136
Which antibiotic used for TB can cause profound hearing loss?
Streptomycin
137
What is the presentation and pathophysiology of benign paroxysmal positional vertigo?
Presents with dizziness particularly related to head movements, light-headedness and nausea.
Considered to be due to debris (otoconia) in the canal system with crystals of calcium carbonate originating in the utricle of the ear
138
Typical presentation of motor neurone disease
Wasting of the small muscles of the hand with UMN lesions in the lower limbs caused by degeneration of spinal and cranial motor neurons and pyramidal neurons in the motor cortex.
139
What is Ekbom syndrome?
Restless legs syndrome
140
What drug is used for chronic recurrent gout?
Allopurinol - contraindicated in the setting of acute gout, but introduced 4 weeks after the resolution of an acute attack, must be started low (50-100mg) and adjusted slowly
141
Treatment for aspirate-proven acute gout?
Indomethacin 50mg tds
| Colchicine - less effective and more difficult to get dose right to avoid diarrhoea
142
45 yo woman with proximal muscle weakness, maculopapular rash on chest and back and raised CK 570 (range: 30-125)?
Dermatomyositis
143
CREST syndrome
```
Calcinosis of subcutaneous tissue in the hands
Raynaud phenomenon
Oesophageal reflux
Sclerodactyly
Telangiectasia of the hands and mouth
```
144
36 yo M with joint pains and fevers for 8 months. BP is 180/118. There is a left foot drop and digital infarcts. What diagnosis do you suspect and what would be the investigation to confirm it?
Polyarteritis nodosa
- Joint, neurological and skin manifestations with fever and hypertension.
- Muscle biopsy would show necrotising vasculitis affecting small arteries
- Renal biopsy would also be important
145
First line treatment for SVT
| & Second line treatment
First line: Adenosine or verapamil intravenously
with/without vagal stimulation
Second line: B-blocker or flecainide
146
Thromboangilits obliterans (Buerger disease) - what is it?
Nonatherosclerotic segmental inflammatory disease of small and medium sized arteries, veins and nerves of the extremities. It is more common with home-made cigarettes with raw tobacco. It usually starts with distal ischaemia and ulceration in the digits then moves more proximally.
147
Best antibiotic currently empiral cover for atypical organisms in pneumonia?
Azithromycin
- Covers legionella, mycoplasma, chlamydia and strep pneumo and is well tolerated
- Erythromycin is less expensive but associated with more GI side effects
148
Treatment of flail chest
Controlled positive pressure ventilation after intubation with intercostal catheter insertion to prevent tension pneumothorax while on positive pressure. Controlled ventilation continues until flailing no longer occurs on spontaneous ventilation.
149
Which malignancy does Crohn disease increase the risk of 100-fold?
Adenocarcinoma of the distal ileum
150
Which malignancy does Peutz-Jeghers syndrome predispose for?
Harmartomas which may undergo malignant transformation into adenocarcinoma?
151
Which malignancy does coeliac disease predispose for?
Primary jejunal lymphoma
152
What can Budd-Chiari syndrome sometimes be secondary to?
Polycythaemia
| - Causes thrombosis of the hepatic veins or IVC causing hepatic congestion, ascites and cirrhosis and failure
153
Signs and symptoms of transient global amnesia
Memory loss with no other symptoms & full recovery. Typically in men >55 years following exercise.
154
Signs of zinc deficiency?
Exanthematous dermatitis (acrodermatitis enteropathica)
155
What is the cause of hypercalcaemia due to lung cancer?
Production of parathyroid hormone-related peptide (PTHrP) caused by SCC
156
Symptoms of hypercalcaemia?
Fatigue, constipation, polyuria
| Later neural confusion & coma
157
How do you diagnose Q fever?
Serum testing for antibodies
| - Rickettsia does not grow in standard media
158
List some AIDS-defining illnesses?
Cytomegalovirus retinitis
PCP
Candida oesophagitis
Cryptosporidial enteritis
159
An obese 55 yo presents with sudden onset of cramping and abdo pain for 12 hours with vomiting. Exam shows irregular pulse 120/min BP 100/60 and laboured respiration. Peripheral cyanosis is noted & abdo distended, with diffuse tenderness. Bowel sounds are absent. Rectal exam reveals dark blood stained material.
Mesenteric vascular occlusion is most likely cause
160
Key serum finding in haemolytic anaemia?
Decreased Haptoglobin level
- Haptoglobin molecules capture the haemoglobin spilled into the plasma during haemolysis and carry it to the liver, therefore the amount of circulating haptoglobin falls
161
ITP and bleeding treatment
Corticosteroids
| Splenectomy if thrombocytopenia persists despite steroid therapy
162
Causes of secondary polycythaemia
Chronic pulmonary disease and hypoxia or from excessive renal production from tumour or excessive EPO production
163
Which nodes does prostate cancer spread to?
Pelvic nodes
164
64 yo M with 3 months of frequency, nocturia, dysuria undergoes a cystoscopy. Instrumentation is difficult and 6 hours post procedure he has a rigor and develops a 40 degree fever. What is the most likely cause?
Gram-negative bacteraemia
165
80 yo M with controlled congestive cardiac failure presents with backache and is discovered to have spinal mets from prostate carcinoma. What is the best initial treatment?
Orchidectomy
166
Where does the spinal cord end?
Lower border of the L1 vertebra
167
Why cant you get UMN signs in disc prolapse below L1?
Because it would impinge on cauda equina not cord, therefore no UMN signs
168
How to select antibiotics for epididymo-orchitis?
Urine m/c/s
| Bladder infections of residual urine can cause secondary infection of epididymis via the vas deferens
169
Clinical picture of schistosomiasis?
UTI with cystitis and terminal haematuria in a male from Egypt
Subclinical infection is common and up to 60% of adult males from endemic areas
170
Kimmelsteil-Wilson Lesions
Classic histopathological appearance of nodular glomerulosclerosis in diabetes associated with proteinuria and hypertension. Late complication >20 years after diabetes onset.
171
Extrahepatic effects of Wilson's disease?
Renal - proximal renal tubular dysfunction
Cardiac
Bone - arthritis, Rickets
Eye - Kayser Fleischer rings
CNS - dystonia, dysarthria, excessive salivation, Mask-like facies, dysphagia, incoordination, handwriting deteriorates, behavioural changes
Haemolysis
