Medicine

Question 1

name this microbe

Answer 1

plasmodium falciparum

(female anopheles is the vector)

Question 2

management of uncomplicated p.falciparum infection (malaria)

Answer 2

all patients with falciparum malaria should be admitted to hospital for the first 24 hours - even semi-immune patients may worsen quickly

• artemisinin combination therapy (ACT).

or

• quinine with doxycycline

Question 3

management of non-p.falciparum infection

Answer 3

oral artemisinin combination therapy (ACT) or chloroquine (nasty side effects)

Question 4

management of complicated p.falciparum infection

Answer 4

intravenous artesunate

if not available IV quinine (needs to be carefully monitored for hypoglycaemia)

Question 5

gram positive bacteria are

Answer 5

purple

Question 6

gram negative bacteria are

Answer 6

pink

Question 7

name gram positive cocci

Answer 7

Staphyloccocus areus

Staphyloccocus epidermis

Streptococcus pneumonia

Question 8

name gram positive rods

Answer 8

clostridium difficile

listeria monocytogenes

Question 9

name gram negative cocci

Answer 9

neisseria gonorrhoa

neisseria meningiditis

Question 10

name gram negative rods

Answer 10

E.coli

salmonella typhi

klebsiella pneumonia

Question 11

Janet is a 30-year-old woman who has a routine urine culture sent at her midwife appointment. She is asymptomatic but has had a history of post-coital cystitis in the past. Janet is currently 10 weeks pregnant.

The urine culture comes back showing the growth of Escherichia coli .

What is the next step in managing this patient?

Answer 11

treat with 7 days nitrofurantoin

(trimethoprim is teratogenic in first trimester)

Question 12

management of MI

Answer 12

MONA

M-Morphine

Oxygen (<92%)

N-Nitrate

A- Aspirin

BATMAN

B – Beta-blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)

M – Morphine titrated to control pain

A – Anticoagulant: Fondaparinux (unless high bleeding risk)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

Question 13

antiplatelets used in acute MI

Answer 13

Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)

Question 14

name the DOAC

Answer 14

Apixiban- Xa

Dabigatron - IIa

Rivaroxaban- Xa

Edoxaban- Xa

Question 15

when are DOAC used

Answer 15

Stroke prevention in non-valvular atrial fibrillation (NVAF)

Treatment of deep vein thrombosis and pulmonary embolism

Prevention of recurrent deep vein thrombosis and pulmonary embolism

Question 16

needle decompression vs chest drain in pneumothorax

Answer 16

Needle thoracostomy is indicated for emergent decompression of suspected tension pneumothorax.

Drain thoracotomy is indicated after needle thoracostomy, for simple pneumothorax, traumatic hemothorax, or large pleural effusions with evidence of respiratory compromise.

Question 17

during A-E if patient hypoxic (<94%) give

Answer 17

15l of oxygen via a non-rebreathe mask

Question 18

normal urine output

Answer 18

0.5 ml/kg/hr

<0.5 ml/kg/hr defines decreased urine output.

Question 19

what sort of cannula in an emergency situation

Answer 19

2 wide bore cannulas

>bigger than grey

Question 20

which renal drug can cause gynecomastia

Answer 20

spironolactone

Question 21

where do diuretics work on the nephron

Answer 21

Question 22

A 17-year-old female presents to the emergency department feeling generally unwell. The team decides to perform an arterial blood gas (ABG) that shows the following results:

Which of the following could be a cause of the patient’s arterial blood gas results?

Diabetic ketoacidosis

Diarrhoea

Primary hyperaldosteronism

Salicylates poisoning

Vomiting

Answer 22

need to calculate anion gap! (normal is between 10-14mmol/L)

acidosis and the only causes of it from the options is diarrhoea.

The anion gap is calculated by: (sodium + potassium) - (bicarbonate + chloride). A normal anion gap is 10-18 mmol/L. In this case, the anion gap is 13 mmol/L.

Diabetic ketoacidosis and salicylates poisoning cause raised anion gap metabolic acidosis. This happens because there is gaining of strong acid.

Primary hyperaldosteronism causes metabolic alkalosis, by retaining more sodium and excreting more potassium. As a consequence, more hydrogen ions will be expelled, causing alkalosis.

Vomiting causes metabolic alkalosis via the loss of hydrogen ions from the stomach contents.

Question 23

A 5-year-old boy presents with puffiness around his eyes and fatigue. His mum also reports that he has developed dark urine, and has been passing urine less frequently than usual. He is otherwise well, however his mum tells you he did have a crusty lesion above his lip a few weeks ago that was treated with antibiotics.

On examination, he appears comfortable. He has mild oedema affecting the feet and hands, and some peri-orbital oedema. His observations are stable, other than a raised blood pressure reading of 130/80 mmHg.

Urinalysis shows:

What is the most likely diagnosis based on this information?

Answer 23

Post-streptococcal glomerulonephritis is the correct answer here. The patient presents with periorbital oedema, oliguria, proteinuria and haematuria after impetigo. This is classical of post-streptococcal glomerulonephritis, which tends to occur 1-3 weeks following an upper respiratory tract infection (URTI), and 3-6 weeks following a skin infection.

Question 24

diabetic retinopathy signs

Answer 24

small vessels are damaged- ischaemia or retina

• Abnormality in microvasculature- dot to blot haemorrhage
• If in macula → maculopathy→ loss of central vision

Question 25

treatment for DKA

Answer 25

Immediate management upon diagnosis: hour 1

• IV 0.9% sodium chloride with potassium added
• fixed rate intravenous insulin infusion (FRIII) 0.1 units per kilogram body weight
• hourly BG monitoring

Question 26

cushings syndrome vs cushings disease

Answer 26

Cushing’s Syndrome is used to refer to the signs and symptoms that develop after prolonged abnormal elevation of cortisol. Cushing’s Disease is used to refer to the specific condition where a pituitary adenoma (tumour) secretes excessive ACTH. Cushing’s Disease causes a Cushing’s syndrome, but Cushing’s Syndrome is not always caused by Cushing’s Disease.

Question 27

hypercalcaemia with low PTH is

Answer 27

• Malignancy must be excluded in all cases of hypercalcaemia where PTH is suppressed. (i.e. homestasis of calcium is still working because PTH is suppressed because calcium is high)
  
  • bone cancer
• Hypercalcaemia with a low PTH may also be seen in benign granulomatous disease such as TB or sarcoidosis.

Question 28

Hypercalcaemia with non-suppressed PTH – primary hyper PTH until proved otherwise

Answer 28

• When PTH is elevated or in the upper part of the normal range, malignancy is unlikely.
• The usual cause is primary hyperparathyroidism which is most commonly due to a single parathyroid adenoma- US
  
  • US
  • SETAMIBI isotope scanning

Question 29

management of hyperkalaemia

Answer 29

• calcium gluconate- stabilises myocardium
• insulin dextrose (draws potassium back into cells)
• calcium resonium- potassium excreted in stool

Question 30

Pheochromocytoma and paraganglioma management

Answer 30

• Alpha blockade- phenoxybenzamine
  
  • Always do alpha-block before b-block
• B blockade- bisoprolol
• Surgical excision
  
  • Perioperative management
    
    • Specialist anaesthetic team
    • Risk of crisis during operation
    • Maximal vasodilation and filling with IV fluids

Question 31

hyperaldosteronism blood tests

Answer 31

hypertension, hypernatraemia, and hypokalemia

Question 32

primary hyperaldosteronism treatment

Answer 32

spironolactone (aldosterone antagonist)

Question 33

A 37-year-old man presents with unexplained weight gain over the last 6 months as well as low energy and irritability over the last 1 month.

On physical examination the patient has significant truncal obesity, a rounded face, a dorso-cervical hump as well as abdominal striation.

What is the most common endogenous cause of this clinical presentation?

Answer 33

The most common endogenous cause of Cushing’s syndrome is a pituitary adenoma (also known as Cushing’s disease)

exogenous cause- glucocorticoids

Question 34

A 55-year-old man with type 2 diabetes is brought to the practice by his partner for acting strangely and is acutely confused on questioning. He was recently started on insulin therapy for his diabetes. His observations are quickly taken:

• Blood pressure 145/87 mmHg
• Heart rate 110 beats per minute
• Temperature 37.2ºC
• Oxygen saturation 99% on room air
• Respiratory rate 18 breaths per minute
• Capillary blood sugar level 2.1 mmol/L

What is the most appropriate management of this patient?

Answer 34

if the patient is conscious and able to swallow the first-line treatment is a fast-acting carbohydrate by mouth i.e.. glucose liquids, tablets or gels

if unconscious- IV glucose

Question 35

Over-replacement with thyroxine increases the risk for

Answer 35

osteoporosis

Question 36

A 54-year-old woman attends her regular diabetes outpatient appointment. Due to her poor diabetic control despite taking several anti-diabetic medications, the endocrinologist decides to prescribe lifelong regular insulin. The patient drives a regular car for non-commercial purposes.

What advice regarding driving should the endocrinologist provide?

Answer 36

Insulin-dependent diabetics must check their blood glucose every 2 hours whilst driving

Question 37

A 37-year-old presents to the GP for follow-up after a viral asthma exacerbation. He has been prescribed 7 days prednisolone 40mg alongside his salbutamol inhaler. Today is his last day of treatment.

The patient denies any wheeze or chest tightness but does still have a very occasional dry cough. His chest is clear to auscultate, his saturations are 97% and his respiratory rate is 16 breaths per minute.

The patient has no other medical history, takes no other medications and has never required prednisolone before.

What is the next appropriate step once he has taken the last prednisolone dose?

Answer 37

prednisolone can be stopped without weaning

The BNF suggests gradual withdrawal of systemic corticosteroids if patients have:

• received more than 40mg prednisolone daily for more than one week
• received more than 3 weeks of treatment
• recently received repeated courses

Question 38

A 45-year-old woman presents to her GP with 2 weeks history of feeling constantly weak. She has noticed that she now struggles with climbing stairs and combing her hair.

Her past medical history includes poorly controlled type-2 diabetes and a recent admission for severe pneumonia, in which she was started on a reducing course of steroids.

Observations are normal. Examination reveals bilateral reduced power of the shoulders, biceps and hip flexors/extensors. Tone, sensation, reflexes and cranial nerves are normal, with no fatiguability of speech.

What is the most likely cause of her weakness?

Answer 38

proximal myopathy

Proximal myopathy is correct. This patient is complaining of a proximal muscle weakness that matches a proximal myopathy. The prolonged course of steroids could be causing this.

Question 39

A 45-year-old man presents to the emergency department. He describes severe muscle cramps for the past day, alongside muscle weakness and aching. He is currently experiencing homelessness.

On examination, he has central obesity, a round puffy face, and visible striae on his abdomen. He has a heart rate of 82/min, a respiratory rate of 12/min, a blood pressure of 190/85 mmHg, a temperature of 37.2ºC and saturations of 99%.

A diagnosis of Cushing’s syndrome is suspected and a plasma cortisol level is sent off. Along with other blood tests, a venous blood gas is taken.

What would be expected to be seen on his blood gas?

Answer 39

Cushing’s syndrome - hypokalaemic metabolic alkalosis

This man presents with an initially confusing set of symptoms. He has cushingoid features on examination, including central obesity, ‘moon facies’ and abdominal striae. His profound hypertension also is in keeping with a diagnosis of Cushing’s syndrome. The high cortisol levels seen can exhibit mineralocorticoid (aldosterone) activity causing hypertension. Similarly, this mineralocorticoid-like activity involves cortisol binding the Na⁺/K⁺ pump and causing hypokalaemia. This hypokalaemia would explain his symptoms of muscle weakness, tremor and cramping. The mineralocorticoid-like activity also leads to the excretion of hydrogen ions in the renal tubules, with bicarbonate being retained, leading to metabolic alkalosis. Therefore, the correct answer is a hypokalaemic metabolic alkalosis.

Question 40

blood test results of addisons

Answer 40

hyponatraemia

hyperkalaemia

Question 41

A 19-year-old man presents to his GP with some concerns regarding his appearance. He has been going to the gym recently, but despite his efforts has found it very difficult to build muscle and bulk up. He has always been tall and slim and is not yet able to grow facial hair.

His blood results show the following:

FSH11.2 IU/L(1 - 7)LH12.6 IU/L(1 - 8)Serum total testosterone182 nanograms/dL(>300)

Which of the following is the most likely diagnosis?

Answer 41

Klinefelter’s syndrome causes high LH and low testosterone

This scenario describes a case of primary hypogonadism. Hypogonadism is suggested by the lack of secondary sexual characteristics that this patient reports (e.g. slim build; difficulty growing facial hair).

Primary hypogonadism would cause a low testosterone level due to testicular failure, which would, in turn, cause a high FSH and LH due to a lack of negative feedback. Conversely, secondary hypogonadism is caused by decreased levels of the gonadotrophins FSH and LH.

Question 42

rate of fixed insulin infusion for DKA

Answer 42

Diabetic ketoacidosis: the IV insulin infusion should be started at 0.1 unit/kg/hour

Question 43

A 45-year-old male is investigated for polyuria. A water deprivation test is done to ascertain the cause.

Water deprivation started at 8 am.

Based on the presumed diagnosis, what feature is this patient most likely to have in their past medical history?

Answer 43

recent transsphenodal pituitary surgery

Water deprivation test: cranial DI

• urine osmolality after fluid deprivation: low
• urine osmolality after desmopressin: high

Question 44

what is associated with nephrogenic diabetes inspidus

Answer 44

Concurrent lithium use is relevant for nephrogenic diabetes insipidus.

Question 45

You see a 42 year-old gentleman who presents feeling tired all the time. You ask if he has been on holiday because he appears tanned, but he says he has not been in the sun. On examination the palmar creases and buccal mucosa show pigmentation. What underlying condition might cause this presentation?

Answer 45

Addison’s disease is primary adrenocorticoid deficiency. It often presents insidiously with vague symptoms such as tiredness. Hyperpigmentation, characteristically involving the skin creases, buccal mucosa and scars is a common feature.

why?

This occurs because adrenocorticotropic hormone (ACTH), the hormone produced by the pituitary to stimulate the adrenals to produce steroid hormones, has the same precursor molecule as melanocyte-stimulating hormone (MSH), so increased production of ACTH has the side effect of raising MSH levels.

Question 46

A woman presents to her GP with a painful neck, rapid heartbeat, palpitations and feeling warm. A couple of weeks ago, she experienced general malaise and fever and suspected she had influenza - this has since resolved. She is otherwise healthy and takes no regular medications.

On examination, she is tachycardic. A goitre is palpable in the neck and elicits pain when examined. Blood tests are taken:

Answer 46

naproxen

Thyrotoxicosis with tender goitre = subacute (De Quervain’s) thyroiditis

t

The correct answer is naproxen. The diagnosis here is that of subacute (De Quervain’s) thyroiditis, given the history of following a viral illness, raised ESR, tender goitre and initial hyperthyroid phase. Ultimately, this condition is usually self-limiting, and simple analgesia is all that is required.

Question 47

De Quervain’s thyroiditis

Answer 47

a viral illness, raised ESR, tender goitre and initial hyperthyroid phase. Ultimately, this condition is usually self-limiting, and simple analgesia is all that is required.

Question 48

A 23-year-old man is diagnosed as having type 1 diabetes mellitus after presenting with diabetic ketoacidosis. His blood sugars are now stable and he is well. What is the first-line insulin regime he should be offered?

Answer 48

Basal–bolus insulin regimen with twice-daily insulin detemir

In newly diagnosed adults with type 1 diabetes, the first-line insulin regime should be a basal–bolus using twice‑daily insulin detemir

Question 49

A 65-year-old man with type 2 diabetes attends his annual diabetic review. His blood glucose control has been very poor and he is about to be started on insulin. Which of the following should be given to this man when he receives his insulin?

Answer 49

Every person treated with insulin should have a glucagon kit for emergencies

Question 50

A 65-year-old man with type 2 diabetes attends his annual diabetic review. His blood glucose control has been very poor and he is about to be started on insulin. Which of the following should be given to this man when he receives his insulin?

Answer 50

Every person treated with insulin should have a glucagon kit for emergencies

Question 51

A 42-year-old non-binary patient is referred to the endocrinology department after presenting to their urgent care centre with a 3-month history of bilateral lower limb oedema, lethargy, muscle weakness, and pleuritic chest pain. They have a 24-pack-year smoking history, drink 2 bottles of wine per week, and take no recreational drugs. A chest x-ray at the urgent care centre shows a mass lesion in the right hilum. During the follow-up, their endocrinologist ordered a high-dose dexamethasone suppression test.

What would be the likely result of this test, given the patient’s symptoms and primary investigation findings?

Answer 51

High-dose dexamethasone suppression test with an ectopic source of ACTH

• Cortisol: not suppressed
• ACTH: not suppressed

Question 52

management of variceal bleeding

Answer 52

Q

• Initial action: Fluid resuscitation if haemodynamically compromised (followed by blood)
• IV Terlipressin AND IV antibiotics
• Definitive treatment: endoscopic banding

A

Variceal bleeding is a medical emergency and most often presents with fresh

haematemesis +/- melaena.

• Initial action: gain IV access. Fluid resuscitation if haemodynamically compromised (followed by blood) but remember the systolic blood pressure is often low in patients with cirrhosis
• Prescription: IV Terlipressin (if no ischaemic heart disease or peripheral vascular disease) AND IV antibiotics
• Definitive treatment: refer urgently to the GI team for Upper GI endoscopy

Question 53

management of peptic ulcer bleed

Answer 53

• Initial action: . Fluid resuscitation if haemodynamically compromised (followed by blood)
• Prescription: there is no evidence for giving PPI before the endoscopy
• Definitive treatment: If the bleeding cannot be stopped by endoscopy, radiological embolization or surgery may be possible.

The Endoscopist will advise on the need for any medications (such as PPI to treat ulcers) after the endoscopy.

Question 54

Rockall vs blatchford score

Answer 54

Rockall- risk of death and rebleeding from an upper GI bleed

Blatchford- Predicts need for intervention (blood transfusion or therapeutic endoscopy) - requires bloods tests

Question 55

summarise re-feeding syndrome

Answer 55

1. during starvation insulin stops being secreted and electrolytes and thiamine become very deficient
2. when re-feeding starts insulin is produced- this causes ions like phosphate, magnesium, thiamine and potassium to be pumped back into the cell → process uses ATP which further reduces levels of phosphate
3. As a result the phosphate stores become further depleted and the corresponding fluid shift causes oedema and organ dysfunction

• The hypophosphataemia reduces the production of ATP and impairs function of cardiac muscle
• In addition 2,3-DGP is reduced in red cells and this decreases the ability of red cells to deliver oxygen to tissues
• The combined effect of fluid shifts, reduced tissue oxygenation and impaired cardiac function is potentially catastrophic.

Question 56

Prevention of refeeding

Answer 56

• Reintroduction of diet should be very slow
  
  • 5-10kcal/kg/day
• IV Phosphate infusion
• Parenteral multivitamins
• Phosphate magnesium and potassium levels monitored

Question 57

assessing the severity of a patient with liver cirrhosis

Answer 57

Child-Pugh classification

A - albumin
B - bilirubin
C - clotting
D - distention (ascites)
E - encephalopathy

Question 58

A 25-year-old man presents to his GP with a history of watery diarrhoea for several days. Last week the patient had taken IM ceftriaxone for gonorrhoea. There has been no recent travel and his diet has remained unchanged. This is the first time the patient has experienced diarrhoea in his lifetime. The GP carried out some investigations which revealed the following:

positive for C.difficile

What is the most appropriate course of action?

Answer 58

oral vancomycin

Question 59

prophylaxis for high risk oesophageal varices

Answer 59

B-blockers- propanolol

Question 60

A 44-year-old man presents to the emergency department with a 24 hour history of haematemesis and haematochezia. The patient has known alcohol-related liver cirrhosis.

The patient is alert, pale and clammy. His observations show a heart rate of 132/min, blood pressure of 85/45 mmHg, oxygen saturation of 97% on room air and a respiratory rate of 17/min. Physical examination shows hepatomegaly and no other significant findings are noted.

Once the patient is haemodynamically stable, the patient is sent for endoscopy as you suspect variceal haemorrhage.

What must be administered before endoscopy?

Answer 60

terlipressin +- IV antibiotics

Question 61

markers for autoimmune hepatitis

Answer 61

anti-nuclear antibodies

smooth muscle antibodies

treatment: steroids

Question 62

A 19-year-old man is referred to the general medical clinic. For the past six months his family have noted increasing behavioural and speech problems. He himself has noticed that he is more clumsy than normal and reports excessive salivation. His older brother died of liver disease. Given the likely underlying condition what is the most appropriate therapy?

Answer 62

Treatment for Wilson’s disease is currently penicillamine (chelates copper)

Question 63

A 45-year-old woman was commenced on treatment for a tuberculosis infection, 3 months ago. She has since developed a burning sensation at the base of her feet.

Which of the following medications may have caused this new ‘burning sensation’?

Answer 63

Isoniazid therapy can cause a vitamin B6 deficiency causing peripheral neuropathy

Question 64

In life-threatening Clostridium difficile infection treatment is

Answer 64

with ORAL vancomycin and IV metronidazole

Question 65

A 40-year-old female presents to her GP with a 6-week history of epigastric pain. This is described as a sharp pain associated with nausea and typically comes on within minutes of eating. Her bowel habit and stools were normal. Physical examination was unremarkable.

Which of the following is the most likely diagnosis?

Answer 65

Gastric ulcers cause pain when, or shortly after, eating

Hydrochloric acid secretion in the stomach is triggered by receptors in the gustatory centre in the brain and mouth when food is detected. The acid only reaches the duodenum and causes irritation later on when the digested food travels there.

Question 66

Primary biliary cirrhosis is most characteristically associated with which antibodies

Answer 66

anti-mitochondrial antibodies

Question 67

Primary biliary cirrhosis is most characteristically associated with which disease

Answer 67

ulcerative colitis

Question 68

The AST/ALT ratio in alcoholic hepatitis is

Answer 68

2:1

Question 69

A 15-year-old boy presents to his general practitioner with a 4-month history of a growing lump on the posterior aspect of his right thigh, which has become extremely painful over the last two weeks. A radiograph is ordered, which identifies a lytic lesion in the diaphysis of the right femur with an ‘onion skin’ appearance.

What is the most likely diagnosis?

Answer 69

Ewings sarcoma

malignant tumour that occurs most frequently in the diaphysis of the pelvis and long bones

Question 70

A 70-year-old woman has had jaw pain and trouble chewing for the last 2 months. She feels like her ‘jaw is heavy’. There is no clicking or locking of her jaw and there is no scalp tenderness or changes to her vision. Her past medical history consists of well-controlled polymyalgia rheumatica and depression. She remembers a medical student explaining that this could be a side effect of one of her drugs. She takes vitamin D supplements, calcium supplements, prednisolone, alendronic acid, and sertraline.

What is the most likely cause of her symptoms?

Answer 70

Bisphosphonates can cause osteonecrosis of the jaw

Question 71

A 45-year-old woman presents to the rheumatology clinic because of poorly controlled rheumatoid arthritis. She has a five-year history of swollen, painful joints in her hands and feet, especially her metacarpophalangeal joints. They are stiff and painful in the morning and the pain improves with usage throughout the day.

She already tried methotrexate and sulfasalazine and they both have been unsuccessful treatments. The doctor decides to put her on a trial of TNF-inhibitors.

Which one of the following would you perform before the commencement of treatment?

Answer 71

X-ray to look for latent TB

biologics can cause reactivation

Question 72

A 48-year-old male presents to his GP with bone pain for the past few weeks. He has also had a reduction in his hearing recently. His blood results show an isolated rise in alkaline phosphate.

Given the likely diagnosis, which bone is most likely to be in pain?

Answer 72

Paget’s disease of the bone generally affects the skull, spine/pelvis, and long bones of the lower extremities

It is easy to remember which bones are most commonly affected by Paget’s disease by drawing an imaginary line down the centre of a patient. The bones covered are the skull, vertebral bones and pelvis. Along with the femur and tibia, these are the most commonly affected bones by Paget’s disease.

Question 73

blood test for renal pathology

Answer 73

FBC

U and E

LFTs - esp albumin

Bone profile (calcium and phosphate)

HbA1c

eGFR

Anion gap

Question 74

urine test for renal pathology

Answer 74

• Urine dipstick: WCC, blood, protein, nitrayr
  
  • infection/ malignancy
• Urine MSU
• albumin: creatinine ratio

Question 75

A 42-year-old man with polyuria undergoes investigation. His results are as follows:

Urine Osmolality before tests285 mOsm/kg * 10⁹/lAfter water deprivation test283 mOsm/kg * 10⁹/lAfter exogenous anti-diuretic hormone (ADH)290 mOsm/kg * 10⁹/l

Which of the following medications may cause this picture?

Answer 75

Lithium is a recognised cause of nephrogenic diabetes insipidus

Question 76

diabetes inspidius investigation findings

Answer 76

• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
• water deprivation test

cranial: urine osmolality will increase after desmopressin
nephrogenic: urine osmolality will not change

Question 77

treatment of cranial diabetes insipidus

Answer 77

desmopressin

Question 78

treatment of nephrogenic diabetes insipidus

Answer 78

thiazides, low salt/protein diet

Question 79

You see a 60-year-old woman who recently had urea and electrolytes performed as part of a medication review. You also have previous from 4 months ago to compare with. She has a history of hypertension and takes ramipril. On examination, her blood pressure is 135/80mmHg.

Answer 79

All patients with chronic kidney disease should be started on a statin

Question 80

A 40-year-old woman presents to her GP, anxious to be ‘checked out’ because her older brother recently passed away from a haemorrhagic stroke. She was told that his autopsy showed cerebral aneurysmal rupture. The patient is well currently, with no fever, weight loss, headache or dysuria but has been treated for recurrent urinary tract infections (UTIs) over the past 3 years. Her father had a history of chronic kidney disease (CKD) and passed away from a stroke at age 65.

What is the most appropriate investigation for diagnosis of this patient’s condition?

Answer 80

renal USS best diagnosis for adult polycystic kidney disease

Question 81

how can CKD cause mineral bone disease

Answer 81

The high phosphate levels in chronic kidney disease (CKD) patients ‘drags’ calcium from the bones, resulting in osteomalacia.

Alendronic acid is a bisphosphonate that reduces the rate of bone turnover and strengthens the bone.

remember: CKD patients usually have low levels of calcium due to lack of vitamin D and high phosphate.

Question 82

While working on a paediatrics ward as a junior doctor you are looking after 2-year-old boy with X-linked nephrogenic diabetes insipidus. He was recently diagnosed after his parents noticed that he was experiencing excessive polydipsia and polyuria. What is the pharmacological treatment of choice in this condition from the list below?

Answer 82

chlorthiazide

Question 83

A 3-year-old, originally presented with persistent haematuria, undergoes a renal biopsy showing splitting on the lamina densa resulting in an abnormal glomerular-basement membrane.

Whilst under investigation, the child develops swallowing issues and a recurrent cough. CT chest showed the presence of oesophagus and tracheobronchial leiomyomatosis.

A potential genetic cause is suspect and testing identifies an X-linked dominant inherited protein defect, confirming the syndrome responsible for the child issues.

What other feature is most associated with this child’s likely syndrome?

Answer 83

Alports syndrome- sensinoneural hearing loss

progressive renal failure secondary to glomerular-basement membrane abnormality and sensorineural hearing loss. Other features of the syndrome include ocular issues, smooth muscle tumours (leiomyomas) and rarely aortic dissection.

Question 84

A 76-year-old woman with a history of stage 3 chronic kidney disease presents with worsening anaemia. As a result, she is started on erythropoietin.

Which of the following side effects is she most likely to experience?

Answer 84

skin rash

bone ache

flu like symptoms

Question 85

A 25-year-old woman with a history of end-stage renal disease secondary to focal segmental glomerulosclerosis presents to the Emergency Department. For the past 12 months she has used Continuous Ambulatory Peritoneal Dialysis (CAPD). She feels generally unwell with abdominal pain and a fever. She also describes her last bag as being ‘cloudy’. Which organism is most likely to be responsible for this presentation?

Answer 85

staphylococcus epidermis

Question 86

most common cause of surgical wound infection

Answer 86

staphylococcus epidermis

Question 87

most common cause of haemolytic uraemic syndrome

Answer 87

E.coli

example presentation: A 14-year-old girl is referred to the paediatric unit with reduced urine output and lethargy. She has been passing bloody diarrhoea for the past four days.

Question 88

Causes of transient or spurious non-visible haematuria

Answer 88

• urinary tract infection
• menstruation
• vigorous exercise (this normally settles after around 3 days)
• sexual intercourse

Question 89

A 54-year-old man presents with a 1-month history of a painful lesion on his forehead. He feels the lesion has grown in size over the past month. His past medical history includes a renal transplant six years ago due to autosomal dominant polycystic kidney disease (ADPCKD). He is currently taking tacrolimus, mycophenolate mofetil, and prednisolone. On examination, there is a two-cm, firm, keratotic nodule on the right side of his forehead.

What is the most appropriate management of the lesion?

Answer 89

surgical excision and biopsy

Patients who have received an organ transplant are at risk of skin cancer (particularly squamous cell carcinoma) due to long-term use of immunosuppressants

Question 90

You are a doctor on the acute medical ward. One of your patients is a 25-year-old man who is being treated for paracetamol poisoning. Your senior asks you to order some blood tests to assess the severity of his condition, particularly if there is any evidence of acute liver failure.

Which one of the following results would most support this diagnosis?

Answer 90

Prothrombin has a shorter half-life than albumin, making it a better measure of acute liver failure

Question 91

A 45-year-old man presents to the Emergency Department with a 3 week history of increasing abdominal pain and diarrhoea. The pain is described as diffuse and is 6/10 in severity. He is now passing around 5 loose, non-bloody stools per day.

His past medical history includes lower back pain for which he takes regular ibuprofen.

An abdominal film is requested:

Answer 91

The abdominal x-ray is consistent a diagnosis of ulcerative colitis showing lead pipe appearance of the colon (red arrows).

Question 92

How many units of alcohol are in a 750ml bottle of red wine with an alcohol by volume of 12%?

Answer 92

9 units

Alcohol units = volume (ml) x ABV (%) / 1,000