MET LP Flashcards
1
Q
A
2
Q
Besides excess vitamin D, name and explain which vitamin can cause hypercalcaemia if intake is in excess? [1]
A
excessive vit A:
- acts on the bone to stimulate osteoclastic resorption, and inhibit osteoblastic formation and in the situations of dehydration or renal failur
3
Q
What diabetic complication are gliflozins contraindicated in? [1]
A
It is contraindicated in active foot disease such as skin ulceration with a possible increased risk of toe amputation
4
Q
What is the treatment protocol for a patient with Addison’s if they are vomiting? [1]
A
A person with Addisons’ who vomits should take IM hydrocortisone until vomiting stops: this prevents an Addisonian crisis
5
Q
Name 4 antibodies found in DMT1 [4]
A
6
Q
How can you distinguish between AKI and dehydration? [1]
A
Urea:Creatitine Ratio:
In dehydration: urea that is proportionally higher than the rise in creatinine
(although both have an increase in urea and creatitine)
7
Q
How do you treat haemolytic uraemic syndrome? [1]
A
There is no role for antibiotics in the treatment of haemolytic uraemic syndrome unless indicted my preceding diarrhoeal infection
- if not preceded by diarrhoeal infection: treatment is supportive, with fluids, blood transfusions and dialysis as required
8
Q
Name a drug that is phosphate binder used to treat bone disease of CKD [1]
A
Sevelamer is a non-calcium based phosphate binder that treats hyperphosphataemia in patients with CKD mineral bone disease
9
Q
Which drug is used to treat ascites:
- initially [1]
- if patient has ascitic protein < 15 g/l [1]
A
Initially: spironolactone
if patient has ascitic protein < 15 g/l: ciprofloxacin
10
Q
*
All patients who are diagnosed with CKD should be prescribed what drug / drug class? [1]
A
Statins
11
Q
Which drug class is prescribed for diabetes inspidus? [1]
A
V2 Receptor agonist
12
Q
How can you tell if a cause of AKI is pre-renal? [1]
A
Responds to fluid challenge
13
Q
Why does Goodpastures syndrome present with haemoptysis? [1]
A
Type IV collagen is also found in the alveoli, so causes pulmonary haem.
Also presents with nose bleeds
14
Q
Describe the pattern and source of the deposits in Goodpastures syndrome [1]
A
IgG deposits in linear fashion
15
Q
What is one of the most common causes of acute tubular necrosis? [1]
A
Haemorrhage
16
Q
If prescribing fluids, how much K should be generally given? [1]
A
1mmol/kg/day
E.g. if 60kg patient: 6 mmol/kg/day
17
Q
Which type of GN is associated with renal transplants? [1]
A
Focal sclerosis glomerulosclerosis
18
Q
Why does a patient presenting with nephrotic syndrome have a high risk of VTE? [1]
A
Loss of anti-thrombin III (which antagonises action of thrombin, so get unopposed action of thrombin)
19
Q
Name three main complications of nephrotic syndrome [3]
A
Hyperlipidaemia
Infection (loss of IgG)
VTE
20
Q
What is the most common cause of haemolytic uraemic syndrome? [1]
A
E. coli
21
Q
What is important to account for when initiating treatment for chronic CKD? [1]
A
Iron deficiency can cause patients to fail to respond to EPO therapy
22
Q
What is a key indicator that a patient is suffering from H.U.S? [2]
A
Blood diarrhoea and AKI symptoms
23
Q
Investigations discover she has H. pylori.
What is the next step? [1]
A
You need to be off PPIs for two weeks before endoscopy so triple therapy would start afterwards
24
Q
Which disease is commonly associated with primary sclerosing cholangitis? [1]
Name three raised markers that would indicate PSC [3]
A
Ulcerative colitis
Raised ALP; ANCA; bilirubin
25
Name two AEs of amlodopine [2]
Headaches
Foot swelling
26
Name risks of prescribing testosterone for a patient with low testorone? [3]
What follow up would you conduct to ameliorate for this? [1]
Increases the risk of:
* **prostate cancer**
* **secondary polycythaemia** - increases risk of **DVT and VE**
* **Aggression**
Conduct a yearly **PSA** for the prostate risk
27
What is the first line treatment for PCOS? [1]
What other drug should be considered [1]
1st line: **Weight loss**
Consider: **metformin**
28
The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: [3]
**Oligoovulation** or **anovulation**, presenting with irregular or absent menstrual periods
**Hyperandrogenism**, characterised by hirsutism and acne
**Polycystic ovaries on ultrasound** (or ovarian volume of more than 10cm3)
*It is important to remember that only having one of these three features does not meet the criteria for a diagnosis. As many as 20% of reproductive age women have multiple small cysts on their ovaries. Unless they also have anovulation or hyperandrogenism, they do not have polycystic ovarian syndrome.*
29
What is the management for oesophageal varices if terlipressin and antibiotics does not work? [1]
**Sengstaken-Blakemore** tube if uncontrolled haemorrhage
30
What is the management if Sengstaken-Blakemore tube cannot manage uncontrolled haemorrhage of variceal haem.? [1]
**Transjugular Intrahepatic Portosystemic Shunt (TIPSS):**
connects the hepatic vein to the portal vein
31
The Truelove and Witts' severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults. Ulcerative colitis is classified as 'severe' in which instances? [5]
TRUElove and Witt's
when the patient has **blood** in their **stool**, or is passing **more than 6 stools** per **day** plus at least one of the following features:
* T - Temp **> 37.8**
* R - Rate **> 90**
* U - (Uh)naemia **Hb < 105**
* E - ESR **>30**
32
First episode of C. difficile infection:
Oral [] is the first line antibiotic for use in patients with C. difficile infection
second-line therapy: oral []
third-line therapy: oral [] +/- IV []
**Oral vancomycin** is the first line antibiotic for use in patients with C. difficile infection
second-line therapy: **oral fidaxomicin**
third-line therapy: **oral vancomycin +/- IV metronidazole**
33
Which one of the following findings on biopsy would be most consistent with a diagnosis of gastric adenocarcinoma?
Columnar metaplasia
Histiocytic infiltration
Paneth cell metaplasia
Giant cell granulomas
Signet ring cells
Which one of the following findings on biopsy would be most consistent with a diagnosis of gastric adenocarcinoma?
Columnar metaplasia
Histiocytic infiltration
Paneth cell metaplasia
Giant cell granulomas
**Signet ring cells**
34
If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then **oral []** are added
If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then **oral** **corticosteroids** are added
35
Avoid [] when patient is already on clopidogrel?
for revision: avoid **omeprazole/esomeprazole** when pt already on clopidogrel (use lansoprazole instead)
36
Ciprofloxacin.
Delafloxacin.
Levofloxacin.
Moxifloxacin
These are all examples of quinolones. Treatment for which pathology are they conintradicated in and why? [1]
**Epilepsy**:
**Quinolones may lower the seizure threshold and may trigger seizures.** Levofloxacin is contraindicated in patients with a history of epilepsy and, as with other quinolones, should be used with extreme caution in patients predisposed to seizures, or concomitant treatment with active substances that lower the cerebral seizure threshold, such as theophylline:
37
Name an antibiotic that causes cholestasis [1]
**Co-amoxiclav** is a well recognised cause of cholestasis
38
Co-amoxiclav causing cholestasis would cause which deranged LFTs [3]
Raised ALP
Raised bilirubin
Raised yGT
39
Name a cause of Cushing's symptoms, that is not due to corticosteroid excess [3]
pseudo-Cushing’s syndrome, which has different causes:
- **depression**
- **HIV infection**
- **excess alcohol consumption**.
40
What are the clinic [1] and ABPM [1] BP targets for DMT2 patients? [2]
T2DM blood pressure targets are the same as non-T2DM. If < 80 years:
clinic reading: **< 140 / 90**
ABPM / HBPM:**< 135 / 85**
41
PPIs cause what electrolyte imbalances? [2]
Hyponatraemia
Hypomagnesia
42
Describe a method, that is not looking at specific antibodies, that you can distinguish between DMT1, DMT2 & MODY [1]
**Measuring C-peptide levels** (result of the cleavage of proinsulin into insulin):
**DMT1**: low (there's basically no insulin in type 1 the C-peptide would be low)
**DMT2**: C-peptide remains in the normal range
**MODY**: C-peptide levels will be normal or high, given that insulin is still being produced.
43
A 33-year-old man was admitted to the surgical ward due to an exacerbation of Crohn's disease. He presented with a perianal abscess that has been surgically drained. An MRI confirms a complex perianal fistula.
In addition to an antibiotic and a biologic, what other management would be indicated?
Lidocaine gel
Rectal mesalazine
Seton placement
Surgical resection
Topical glyceryl trinitrate
A 33-year-old man was admitted to the surgical ward due to an exacerbation of Crohn's disease. He presented with a perianal abscess that has been surgically drained. An MRI confirms a complex perianal fistula.
In addition to an antibiotic and a biologic, what other management would be indicated?
**Seton placement**
A seton is a piece of surgical thread that is run through the fistula to allow continuous drainage while the fistula is healing. This ensures that the fistula doesn't heal containing pus within, which would result in further abscess formation.
44
What is the best measure of acute liver failure? [1]
the best measure of acute liver failure is the **international normalised ratio (INR).**
45
If a Crohn's patient has had an ileocacel resection, why may diarrhoea occur? [1]
Name a drug that can treat this [1]
The patient most likely has a **diagnosis of bile acid malabsorption as a complication of the ileocecal resection**.
Treat using: **Cholestyramine** - **bile acid sequestrant** with the potential to control diarrhoea induced by bile acid malabsorption.
46
A 24-year-old man is reviewed in the gastroenterology clinic following a recent admission for a suspected first episode of ulcerative colitis. Colonoscopy during the admission had found moderate proctitis and the patient was started on first-line topical therapy to induce remission. Following review, it is decided to prescribe the patient medication to maintain remission.
What medication should be prescribed?
Intravenous ciclosporin
Oral azathioprine
Oral prednisolone
Topical mesalazine
Topical prednisolone
What medication should be prescribed?
Intravenous ciclosporin
Oral azathioprine
Oral prednisolone
**Topical mesalazine**
Topical prednisolone
A topical (rectal) aminosalicylate +/- an oral aminosalicylate is used first-line in maintain remission in ulcerative colitis patients with proctitis and proctosigmoiditis
47
Whic therapeutic drugs cause cholestasis? [5]
**combined oral contraceptive pill**
antibiotics: **flucloxacillin**, **co-amoxiclav, erythromycin**
**anabolic steroids, testosterones**
phenothiazines: **chlorpromazine**, **prochlorperazine**
**sulphonylureas**
48
Why is prothrombin a better measure of acute liver failure than albumin? [1]
has a shorter half-life than albumin
49
How do you calculate serum osmolality? [1]
2 * Na+ + glucose + urea
50
What are the first line options for diabetic neuropathy? [4]
first-line options include
**amitriptyline** (a tricyclic antidepressant, TCA), **gabapentin** (an anticonvulsant), and **pregabalin** (another anticonvulsant) or **duloxetine**
51
Name a 5 AEs of Pioglitazone [5]
**ELBOW**
E Edema(fluid retention)
L Liver impairment
B Bladder Cancer
O Osteoporosis
W Weight gain
52
Name a haematological side effect of Azathioprine prescription? [1]
**thrombocytopenia**
53
What does this chest x-ray show?
Hiatus hernia
Free gas under the diaphragm
Right basal atelectasis
Right basal consolidation
Right sided pneumothorax
The chest x-ray shows a **hiatus hernia** which can be seen as a retrocardiac air-fluid level.
Hiatus hernia refers to the herniation of a part of the abdominal viscera through the oesophageal aperture of the diaphragm. The vast majority of hiatus hernias involve only the herniation of a part of the gastric cardia through the muscular hiatal aperture of the diaphragm.
54
Blood glucose targets for DMT1 patients are'
[] mmol/l on waking and
[] mmol/l before meals at other times of the day
Blood glucose targets
**5-7** mmol/l on waking and
**4-7** mmol/l before meals at other times of the day
55
What are the serum markers of type 1 auto-immune hepatitis? [3]
Type 1 autoimmune hepatitis:
**Antinuclear antibodies**
**anti-smooth muscle antibodies**
**raised IgG levels**
Additionally, it is more common in young females.
56
Name 5 drugs that cause gynecomastia [5]
**spironolactone** (most common drug cause)
**cimetidine** (H2 antagnosit)
**digoxin**
**cannabis**
**finasteride**
GnRH agonists e.g. **goserelin**, buserelin
**oestrogens**, **anabolic** **steroids**
57
Which part of the body is diverticular disease most likely [95%] to occur? [1]
**Sigmoid colon**
58
Sulphasalazine may be used to treat UC.
Name a haematological SE of this treatment [1] and describe how this may present on blood smear [1]
Sulphasalazine may cause **haemolytic anaemia**
this can present with**Heinz bodies**
| Sulphasala**z**ine **Heinz body**
59
Achalasia is associated with which type of oesophageal cancer? [1]
Name a significant risk factor for this cancer [1]
**Squamous cell cancer**
**Smoking**
60
What is pneumonic for remembering the factors that influence Child-Pugh score? [5]
**ABCDE**
A - albumin
B - bilirubin
C - clotting
D - distention (ascites)
E - encephalopathy
61
Which LFT is NOT useful in determining severity of liver cirrhosis? [1]
**ALT**
(not included in Child-Pugh Score)
62
During the first stage of De Quervain's thyroiditis, what is the clinical presentation of a patient? [5]
* **initial** **hyperthyroidism**
* **painful goitre**
* **globally reduced uptake of iodine-131**
* **raised ESR** & **CRP**
63
Thyrotoxicosis can lead to which cardiac pathologies [2]
Thyrotoxicosis can lead to **high output cardiac failure** & **atrial fibrillation**
64
When treating dyspepsia, what are the two management options? [2]
What happens if one doesn't work/ [1]
NICE guidelines state:
'Offer one of the following strategies to manage uninvestigated dyspepsia symptoms, depending on clinical judgement:
- **Prescribe a full-dose proton pump inhibitor (PPI) for 1 month**
- **Test for Helicobacter pylori infection if the person's status is not known or uncertain**. If the person tests positive for H. pylori infection, prescribe first-line eradication therapy.
If one doesn't work: **swap to other treatment**
65
What is the first line treatment for newly diagnosed DMT1 patients? [1]
In newly diagnosed adults with type 1 diabetes, the first-line insulin regime should be a **basal–bolus using twice‑daily insulin detemir**
The basal insulin can be twice‑daily insulin detemir or once-daily insulin glargine or insulin detemir
66
A patient presents with symptoms of an overactive bladder.
What is the first choice drug treatment? [1]
What treatment is offered if the first choice is contrindicated? [1]
First choice: **Oxybutynin**
Second choice: **Mirabegron**
67
Following catheterisation for acute urinary retention secondary to a lower urinary tract infection, the patient's post-void bladder volume is recorded.
What is the acceptable upper limit of residual urine in patients < 65 years old?
20ml
50ml
100ml
500ml
800ml
Following catheterisation for acute urinary retention secondary to a lower urinary tract infection, the patient's post-void bladder volume is recorded.
What is the acceptable upper limit of residual urine in patients < 65 years old?
20ml
**50ml**
100ml
500ml
800ml
68
Name three causes of increased erythrocyte lifespan [3]
- **Splenectomy** (think - Coealic Disease)
- **B12** and **folate** **deficiences**
- **IDA**
69
What is the primary cause of primary hyperaldosteronism? [1]
**Bilateral idiopathic adrenal hyperplasia**
70
What is important to consider about primary hyperaldosteronism?
Textbooks: **hypokalaemic**
Life: can be **normokalaemic**
71
What is the name of CKD treatment that stimulates EPO? [1]
What checks should occur before this treatment is given? [1
**darbepoetin alfa**
Other causes of anaemia (**such as iron deficiency**) should be checked and **corrected prior to therapy with erythropoietin**
72
What treatment is given for Crohn's patients who develop a perianal fistula? [1]
**Oral metronidazole**
73
What is gallstone ileus? [1]
Where a **gall stone** enters the **small** **intestines**;
**Lodges** at the **ileocaecal valves; **
Causes **small bowel obstruction** and **air in biliary tree**
74
What is Classic Rigler's Triad of gallstone ileus?
Classic Rigler's Triad - **Air in bile ducts, gallstone visible outside gallbladder and small bowel obstruction :**
75
Long term PPI can cause hypomagnesia. What symptoms would this cause? [1]
**Muscle ache**
76
Which diabetic drug has an increased risk of leg ulcers and amputation? [1]
**canagliflozin** and the increased risk of leg ulcers and amputation, with a potential class effect across the SGLT-2 inhibitors.
77
You diagnose a patient with **active AIH**.
What is the two step treatment regime? [1]
How long does treatment for AIH need to occur to prevent relapse? [1]
1st line: **prednisolone**
2nd line: **aziothropine**
**Continue treatment for 2 years**
78
Describe treatment regime for oesophogeal strictures [2]
PPI
**Balloon dilatation following benign biospy**
79
State the two subclassifications of chronic (3month+) prostatitis [2]
Chronic prostatitis may be sub-divided into:
**Chronic prostatitis** or **chronic pelvic pain syndrome** (no infection)
**Chronic bacterial prostatitis** (infection)
80
How do you treat acute bacterial prostatis? [1]
Clinical Knowledge Summaries currently recommend a **14-day course of a quinolone**
consider screening for sexually transmitted infections
81
A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment?
Tamoxifen
Lansoprazole
Allopurinol
Cyproterone acetate
Tamsulosin
A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment?
Tamoxifen
Lansoprazole
Allopurinol
**Cyproterone acetate**
Tamsulosin
Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues **due to the risk of tumour flare**. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels.
**The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.**
82
What would treatment be for suspected epididymo-orchitis? [2]
IM ceftriaxone
Oral doxycycline
83
State two causes of **periureteric fat stranding** [2]
Caused by kidney inflammation:
* **uteric calculi**
* **pyelonephritis**
84
[] is the investigation of choice for varicose veins/chronic venous disease?
**Venous duplex ultrasound** is the investigation of choice for varicose veins/chronic venous disease
85
[] is the first-line imaging in peripheral artery disease
**Duplex ultrasound** is the first-line imaging in peripheral artery disease
86
Which one of the following is most associated with male infertility?
Sodium valproate therapy
Benign prostatic hyperplasia
Varicoceles
Epididymal cysts
Hydroceles
Which one of the following is most associated with male infertility?
Sodium valproate therapy
Benign prostatic hyperplasia
**Varicoceles**
Epididymal cysts
Hydroceles
87
What would indicate that urinary retention is chronic? [2]
**Not** painful
**more than 1L** in the bladder
88
A 33-year-old is admitted to the Emergency Department with suspected renal colic. He has a ultrasound that shows a probable stone in the left ureter. What is the most appropriate next step with respect to imaging?
Non-contrast CT (NCCT)
Micturating cystourethrogram
Intravenous urography (IVU)
Plain radiography KUB
MRI
A 33-year-old is admitted to the Emergency Department with suspected renal colic. He has a ultrasound that shows a probable stone in the left ureter. What is the most appropriate next step with respect to imaging?
**Non-contrast CT (NCCT)**
Micturating cystourethrogram
Intravenous urography (IVU)
Plain radiography KUB
MRI
89
State three indications for surgery for Crohn's? [3]
**fistulae**
**abscess formation**
**strictures**
90
Define short bowel syndrome [3]
Short bowel syndrome (SBS) refers to a condition wherein **substantial portions of the small intestine are absent, either congenitally or due to resection**
Typically, **less than 200 cm** of **residual short bowel is present.**
This results in a **loss of surface area for fluid, nutrient, and medication absorption**, causing an **inability to maintain protein-energy, fluid, electrolyte, or micro-nutrient balance** when ingesting a conventionally accepted, normal diet.
91
What is a proctocolectomy? [1]
the large intestine (the colon) and rectum are removed, leaving the small intestine disconnected from the anus.
92
Name this radiological sign [1]
What does it indicate? [1]
**Thumb printing**
Indicates **ischaemic colitis**
93
How do you determine if CLI is treated with open surgical revasc or angioplasty & stent? [1]
Multifocal: **open revasc**
Focal stenosis or thrombus: **angioplasty and stenting**
94
What is the first line tx for alcoholic hepatitis? [1]
Prednisolone
95
Explain what you need to check before iniating aziothropine tx? [1]
**Thiopurine methyltransferase (TPMT) levels**: enzyme used in metabolism of aziothropine and mercaptopurine. Some people have mutations, meaning get really bad AEs
96
Under what conditions do you add metformin to insulin treatment for DMT1? [1]
If have DMT1 + BMI over 25
97
Explain the pathological consequences of refeeding syndrome [3]
:
**Shift from Fat to Carbohydrate Metabolism**:
* In refeeding syndrome, the reintroduction of carbohydrates leads to a shift from fat to carbohydrate metabolism. This switch activates insulin secretion, which in turn increases cellular uptake of glucose.
**Intracellular Movement of Phosphate**:
* Insulin and increased glucose uptake stimulate the intracellular movement of phosphate, which is used in the synthesis of ATP and 2,3-diphosphoglycerate in erythrocytes. This intracellular shift reduces serum phosphate levels.
**Decreased Phosphate Stores:**
- Patients with chronic malnutrition often have depleted phosphate stores, although their serum phosphate levels may initially be normal. When refeeding starts, the sudden demand for phosphate in anabolic processes exceeds the supply, leading to hypophosphatemia.
98
Describe the clinical consequences of hypophosphatemia (e.g. caused by refeeding syndrome) [5]
**Cardiac Dysfunction**: Hypophosphatemia can impair myocardial contractility, leading to heart failure. It may also cause arrhythmias due to its role in maintaining normal cellular electrophysiology.
**Respiratory Failure**: Phosphate is essential for ATP production, necessary for respiratory muscle function. Severe hypophosphatemia can lead to muscle weakness, including the diaphragm and intercostal muscles, potentially resulting in acute respiratory failure.
**Neurological Complications:** These can range from confusion and seizures to coma, attributable to disturbed ATP metabolism in the central nervous system.
**Haematological Effects:** Reduced 2,3-diphosphoglycerate levels in erythrocytes affect oxygen release from haemoglobin, leading to tissue hypoxia. Hypophosphatemia can also result in hemolysis.
**Rhabdomyolysis**: Phosphate depletion impairs ATP production in muscles, which can lead to muscle breakdown and rhabdomyolysis.
99
Patients are considered high-risk of refeeding syndrome if they if one or more of the following..? [4] or two of more the following..? [4]
**One of:**
- BMI < 16 kg/m2
- unintentional weight loss >15% over 3-6 months
- little nutritional intake > 10 days
- hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
**or two of:**
* BMI < 18.5 kg/m2
* unintentional weight loss > 10% over 3-6 months
* little nutritional intake > 5 days
* history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
100
How many days of recurrent abdominal pain or discomfort do you need for IBS classification? [1]
What are 3 further symptoms needed for IBS diagnosis? [2]
3 days per month in last 3 months
Need 2/3 of:
- Improvement w defecation
- Onset associated with change in frequency of stool
- - Onset associated with change in appearance of stool
101
Describe the method used most effective calcium resonium in hyperkalaemia [1]
Why? [1]
**Calcium resonium enemas** are more **effective** than oral as **potassium is secreted by the rectum**
102
Which class of antihypertensive are contraindicated in end-stage chronic liver disease (Childs score C)?
Beta-blockers
Calcium-channel blockers
ACE inhibitors
Diuretics
1 OF 10
Which class of antihypertensive are contraindicated in end-stage chronic liver disease (Childs score C)?
Beta-blockers
Calcium-channel blockers
**ACE inhibitors**
Diuretics
1 OF 10
103
Diclofenac is contraindicated in severe liver dysfunction. Which of the following statements do not apply?
It induces cytochrome P450 3A4
It increases the risk of bleeding
It increases the risk of renal impairment
It has been reported to cause liver injury
Diclofenac is contraindicated in severe liver dysfunction. Which of the following statements do not apply?
**It induces cytochrome P450 3A4**
Diclofenac does not induce liver enzymes.
104
Should you continue or discontinue **spironolactone** in severe liver disease? [1]
Expalin your answer
**Discontinue**: causes hyperkalaemia and renal dysfunction. Stop and correct serum potassium
105
Should you continue or discontinue ACEins in severe liver disease? [1]
Expalin your answer
**Discontinue**: need RAAS to maintain peripheral vascular resistance in severe liver disease.
ACE inhibitors can lead to rapid drop in BP and cause renal failure
106
Which variables are used in the Child-Pugh score? [5]
**Ascites**
**Bilirubin**
**INR**
**Hepatic Enceph**
**Serum Albumin**
107
What are symptoms of carcinoid syndrome? [4]
* Skin flushing
* Diarrhoea
* Bronchospasm
* Hypotension
108
What are the two treatments for carcinoid syndrome? [2]
**Octreatide**: SST analogue
**Cyproheptadine**: helps with diarrhoea
109
A 60-year-old man who is known to have Barrett's oesophagus is reviewed with the results of his surveillance biopsies. These show high-grade dysplasia but no evidence of carcinoma. He is asymptomatic apart from his gastro-oesophageal reflux disease symptoms which are well controlled on high dose proton pump inhibitor therapy. What treatment is he most likely to be offered?
[2]
**radiofrequency ablation:** preferred first-line treatment, particularly for low-grade dysplasia
**endoscopic mucosal resection**
110
What is the difference between acute cholecystitis and ascending cholangitis? [2]
Give key differentials in how they present
**Acute cholecystitis**:
- **Inflammation/infection** of the **gallbladder** **secondary to impacted gallstones**
- **Positive Murphys sign** (arrest of inflammation on RUQ palpatation
**Ascending cholangitis:**
- Ascending cholangitis is a **bacterial infection of the biliary tree**. The most common predisposing factor is gallstones.
- Charcot triad: **RUQ pain; fever and jaundice**
111
A 60-year-old woman with a history of polycythaemia rubra vera presents with abdominal pain and distension. She is found to have ascites and hepatomegaly on examination
This a steriotypical history of what pathology? [1]
**hepatic vein thrombosis**
112
What is the name for this sign? [1]
Which form of IBD is it most common in? [1]
**Lead pipe / drain pipe colon**: more common in **UC**
*normal mucosal architecture is lost, and scarring shortens and narrows the colon, creating the lead pipe appearance seen on radiographs*
113
What is the name for this sign? [1]
Which form of IBD is it most common in? [1]
**Kantor's string sign**
More common in **Crohns**
*string sign refers to luminal narrowing as the result of inflammatory edema, irritability, spasms and fibrosi*
114
Patient with known Crohn disease. Which of the following features is shown on this selected post-contrast coronal CT image? [1]
**Comb sign**
115
Explain how thyrotoxicosis alters calcium levels? [1]
**The hungry bone syndrome (HBS)** is reported as a well-established thyroidectomy complication of in Graves' disease, especially in the case of severe thyrotoxicosis. **This phenomenon is caused by a rapid increase in the skeletal uptake of blood calcium** leading to persistent symptomatic **hypocalcemia**
116
Which bacteria most commonly causes **post-streptococcal glomerulonephritis?**
Streptococcus pyogenes
117
When does acute graft failure and acute tubular necrosis of graft occur? [2]
**Acute tubular necrosis** of graft is responsible for around 90% acute renal failure episodes in the **first few weeks** after a renal transplant
**acute graft failure** which typically occurs around **6 months post-transplant.**
118
[] is the second most common association of HNPCC after colorectal cancer
**Endometrial cancer** is the second most common association of HNPCC after colorectal cancer
119
What is the inheritance pattern for MODY? [1]
Autosomal dominant
120
A 58-year-old man attends the general practice following a hospital admission for an ankle fracture 4 months ago which has been treated successfully. Whilst he was an inpatient, his HbA1c was found to be 56mmol/mol. His HbA1c is repeated today and has returned as 57mmol/mol.
His only other past medical history includes hip osteoarthritis and a myocardial infarction 7 months ago.
What management should be offered to this patient?
Reinforce lifestyle factors
Start empagliflozin
Start metformin and empagliflozin
Start metformin and up-titrate first
Start sitagliptin
A 58-year-old man attends the general practice following a hospital admission for an ankle fracture 4 months ago which has been treated successfully. Whilst he was an inpatient, his HbA1c was found to be 56mmol/mol. His HbA1c is repeated today and has returned as 57mmol/mol.
His only other past medical history includes hip osteoarthritis and a myocardial infarction 7 months ago.
What management should be offered to this patient?
**Start metformin and up-titrate first**
*If starting an SGLT-2 as initial therapy for T2DM then ensure metformin is titrated up first*
121
What is the treatment for a patient with Crohn's disease and:
- perianal abscess? [1]
- perianal fistula? [1]
- perianal abscess: **incision and drainage**
- perianal fistula: **seton placement**
(The placement of a seton (suitable for high tract disease) though the fistula attempts to bring together and close the tract, passing out at opening of the perianal skin adjacent to the external opening (Fig. 3))
122
Describe the TFT of subclinical hypothyroidism [2]
TSH: **raised**
T4: **normal**
123
During major surgery, the body's stress response causes a decrease in which hormones? [3]
Insulin
Testosterone
Oestrogen
124
What is the first line treatment for symptomatic relief in carcinoid syndrome? [1]
**Octreotide** is a somatostatin analogue used to treat the symptoms of carcinoid syndrome
125
What is meant by Peutz-Jeghers syndrome? [1]
Peutz-Jeghers syndrome is an **autosomal dominant condition** characterised by numerous **hamartomatous polyps** in the **gastrointestinal** **tract**.
126
Describe what is meant by Boerhaave syndrome [1]
**Boerhaave syndrome** is an **oesophageal perforation**, it is differentiated from a Mallory-Weiss tear as it is a **transmural tear rather** than a mucosal tear. It can be associated with haematemesis but this is uncommon.
127
Absorption of levothyroxine is reduced by which drug? [1]
How should you mitigate this? [1]
Absorption of **levothyroxine** is **reduced** by **iron** - advise to **leave 2 hours apart**
128
Describe what is meant by sick euthyroid [1]
How does a patient with sick euthyroid typically present? [3]
euthyroid sick syndrome appears to be a complex mix of **physiologic** **adaptation** and **pathologic response to acute illness**
In the majority of cases however the **TSH level is within the >normal** range with **low t4/3** (inappropriately normal given the low thyroxine and T3).
129
An autoantibody screen finds raised anti-smooth muscle antibodies (ASMA). What pathology would this indicate? [1]
How might this patient present? [1]
**Raised ASMA** indicates **primary sclerosing cholangitis**
PSC is strong associated with **UC**; therefore may present on background of **colitis-like symptoms**. **ALP** will also be **raised**
130
An autoantibody screen finds raised anti-mitochondiral antibodies (AMA). What pathology would this indicate? [1]
How would this typically present? [3]
**Primary biliary cholangitis**:
- **Cholestatic pattern** (jaundice; high bilirubin; raised ALP)
- **Itching and lethargy**
131
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Patients suffering from haemochromatosis have an increased risk of which type of cancer? [1]
**Hepatocellular carcinoma**
132
How do follicular and papillary thyroid carcinomas present histologically? [2]
Follicular: **uniform colloid-filled follicles presenting a normal thyroid**
Papillary: **ground-glass** or **orphan-annie nuclei** with **psammoma bodies**
133
A patient is acting drunk despite not drinking alcohol for a long period of time. They do however have a long history of drinking in the past. What is the most likely cause of their current symptoms? [1]
Vitamin B1 deficiency: causes W.E
134
What is Plummer-Vinson syndrome caused by? [1]
How does it appear under OGD? []1
What is the clinical triad? [3]
PVS: occurs in **long term IDA patients**
Disease causing **dysphagia**, **IDA** and **glossitis**
Get an **oesophageal web**
135
A patient presents with extreme pain during defecation and passage of fresh blood. What is the most likley diagnosis and treatment? [2]
**Anal fissures**
First line treatment is **GTN cream and laxatives**
136
A mass is found in the most distal part of a rectum. It is confirmed as cancer. What is the name of the procedure that should be used to resect this tumour? [1]
Abdominoperineal resection
137
State the first and second line treatment for a patient suffering from constipation secondary to opiate use [2]
First line: **Senna** - stimulant laxative
Second line: **Ipsalghula husk**
138
The tail of the pancreas can be found by identifying which ligament? [1]
**Gastrosplenic ligament**
139
What is the first line management for moderate SIADH? [1]
**Fluid restriction**
140
What cortisol and aldosterone levels would you expect in Sheehans syndrome? [1]
Cortisol: **reduced**
Aldosterone: **normal**
141
Name three side effects that occur as a result of tacrolimus treatment for kidney transplant [3]
How do you manage this post-transplant? [1]
**Nephrotoxicity**
**DM** (NODAT)
**Neurotoxicity**
Blood tests every two weeks for first three months, then on a monthly basis
142
How do you manage:
Nephrogenic DI [1]
Cranial DI [1]
Nephrogenic DI: **treat cause; bendroflumethiazide**
Cranial DI: **Desmopressin** (is a synthetic analog of vasopressin)
143
Achalasia and alcohol are associated with which type of oesphageal cancer? [1]
**Squamous cell cancer**
144
Which method for unblocking urinary calculi is best used in an urological emergency? [1]
**Percutaneous nephrostomy**
145
How clinically significant is haematospermia in under 40s ? [1]
Give three reasons why it may occur? [4]
**Haemtospermia** is **rarely associated with significant underlying medical condition**
Due to:
- **UTI**
- **Trauma**
- **STI**
- **Cancer** - should exclude with an appropriate physical exam
146
How would you investigate Boerhaave syndrome? [1]
Where in the oesophagus does a tear usually occur? [1]
Why is this clinically significant? [1]
**CXR**
Tear usually occurs at **posterior** - can lead to **pneumothorax**
147
[] is the first-line medication for primary biliary cholangitis
**Ursodeoxycholic acid** is the first-line medication for primary biliary cholangitis
148
How do you investigate haemorrhoids if:
- low risk colorectal cancer? [1]
- high risk colorectal cancer? [1]
- low risk colorectal cancer: **flexible sigmoidoscopy**
- high risk colorectal cancer: **Colonoscopy**
149
A six-year-old child is brought to the paediatrician by his parents for a follow-up examination after diagnosis of a genetically inherited disease. On examination, the paediatrician notes a yellow-brown coloration right around the iris.
Which type of renal dysfunction is the first-line treatment for this child’s condition most associated?
Membranous nephropathy
Minimal change disease
Focal segmental glomerulosclerosis
Type II membranoproliferative glomerulonephritis
Diffuse proliferative glomerulonephritis
A six-year-old child is brought to the paediatrician by his parents for a follow-up examination after diagnosis of a genetically inherited disease. On examination, the paediatrician notes a yellow-brown coloration right around the iris.
Which type of renal dysfunction is the first-line treatment for this child’s condition most associated?
**Membranous nephropathy**
Minimal change disease
Focal segmental glomerulosclerosis
Type II membranoproliferative glomerulonephritis
Diffuse proliferative glomerulonephritis
**This child has Wilson’s disease, an inherited disorder of copper metabolism, in which there is an inability to secrete copper into bile and transfer copper into caeruloplasmin. A mutation in the ATP7B gene causes Wilson’s disease. Treatment for Wilson’s disease is penicillamine, a copper-chelating agent. It is associated with membranous nephropathy.**
150
Which type of bacteria mostly cause SBP? [1]
Which treatment should you therefore use? [2]
Gram negative bacteria
Piperacillin and tazobactuam common choice
151
SIADH can occur from which type of brain injury? [1]
**Sub Arach Haem**: causes dilutional hyponatraemia
152
Which antispasmodic is used for diverticula disease? [1]
**Dicycloverine**
153
What is the name of this sign? [1]
What pathology does it indicate? [1]
**Cullens sign**
Cullen's sign is described as superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region. This is also known as peri-umbilical ecchymosis. It is most often recognised as a result of **haemorrhagic pancreatitis.**
154
What is the name of this sign? [1]
What pathology does it indicate? [1]
**Grey-Turner's sign**
Classically it correlates with **severe acute necrotizing pancreatitis**
155
What is the most common fistula that occurs in diverticula disease [1]
**Colovescial fistula**
156
What electrolyte disturbance does Fanconi syndrome present with? [2]
Which other disease state is Fanconi syndrome associated with? [1]
**Hypophosphatemia**, and **hypokalemia**
Associated with **Wilson's disease**
157
A 32-year-old man presented complaining of headaches and sweating, and was found to be hypertensive. Investigations confirmed the diagnosis of a phaeochromocytoma. He was treated with phenoxybenzamine before surgery.
What is the pharmacological property of phenoxybenzamine that makes it the most suitable treatment for a phaeochromocytoma?
Irreversible α-adrenoceptor antagonist
Irreversible α- and β-adrenoceptor antagonist
Reversible α-adrenoceptor agonist
Reversible α-adrenoceptor antagonist
Reversible β-adrenoceptor antagonist
A 32-year-old man presented complaining of headaches and sweating, and was found to be hypertensive. Investigations confirmed the diagnosis of a phaeochromocytoma. He was treated with phenoxybenzamine before surgery.
What is the pharmacological property of phenoxybenzamine that makes it the most suitable treatment for a phaeochromocytoma?
**Irreversible α-adrenoceptor antagonist**
Irreversible α- and β-adrenoceptor antagonist
Reversible α-adrenoceptor agonist
Reversible α-adrenoceptor antagonist
Reversible β-adrenoceptor antagonist
158
Describe the difference in symptoms that you would consider when prescribing Loperamide, Mebeverine & Fybogel for IBS? [3]
**Mebeverine**: is an antispasmodic which can help relieve colicky abdominal pain in these patients.
**Loperamide**: useful adjunct for patients with diarrhoea-predominant IBS (IBS-D).
**Fybogel**: For patients with constipation-predominant IBS (IBS-C),
159
Describe what effect **severe** pancreatitis have on calcium levels? [2]
**Hypocalcaemia**: causes deposition of calcium in stomach. Only in severe pancreatitis
160
If there is found to br a cystic mass in the pancreas, what is the most likely diagnosis? [1]
**Pseudocyst**: areas of local necrotic haemorrhage rich in pancreatic enzymes. 75% of cysts in pancreas are pseudocysts
161
What is the usual cause of pseudocysts of pancreas?[1]
Acute on chronic pancreatitis
162
*A 70-year-old woman presented with difficulty swallowing, chronic cough associated with occasional swellings in the neck. She had a recent admission where she was treated with intravenous antibiotics for aspiration pneumonia*
This is a typical presentation of which pathology? [1]
Dysphagia, aspiration pneumonia, halitosis → **pharyngeal pouch**
163
Describe the typical presentation of Peutz-Jeghers syndrome [2]
**Pigmented lips, hands, soles of feet and face**
Leads to **SBO** & **GI bleeds**
164
If a patient is having an upper GI bleed, when would the following be indicated?
platelet transfusion [1]
fresh frozen plasma [3]
prothrombin complex concentrate [1]
**platelet transfusion**
- if actively bleeding **platelet count** of **less than 50 x 10^9/litre**
**fresh frozen plasma**
- **fibrinogen** level of **less than 1 g/litre**
- **a prothrombin time** (international normalised ratio) or **activated partial thromboplastin time** **greater than 1.5 times normal**
**prothrombin complex concentrate:**
- to patients who are taking **warfarin** and **actively bleeding**
165
What are first and second line laxative treatments for constipation patients? [2]
**first-line laxative:**
- bulk-forming laxative first-line, such as **ispaghula husk**
**second-line**:
- osmotic laxative, such as a **macrogol**
166
What associated symptom is an indicator of a severe UC flare-up? [1]
**Fever** is an indicator of a severe UC flare-up
167
What are the three cause of ALT / AST > 1000? [3]
The 3 causes of ALT/AST >1000:
* **Ischaemia**
* **Paracetamol OD**
* **Viral hepatitis**
168
What is the most appropriate management concerning the risk of spontaneous bacterial peritonitis?
Oral penicillin
Oral ciprofloxacin
Oral azithromycin
Oral doxycycline
intravenous cefotaxime
**Oral ciprofloxacin** - used to PREVENT SBP
**T**reat - Cefo**t**axime
**P**revent - Ci**p**rofloxacin
169
What is the most common complication of thyroid eye disease? [1]
**Exposure keratopathy**
- damage to the cornea that occurs primarily from prolonged exposure of the ocular surface to the outside environment.
170
What is the most appropriate investigation for patients with an increased urinary cortisol level and low plasma ACTH? [1]
**CT adrenal glands**:
171
A patient presents with symptoms that cause moans, groand and pain in bones. What is the underlying likely pathophysiology? [1]
**Hypercalcaemia**
172
Chronic depression in the context of calcium changes indicates which pathology? [1]
**Chronic secondary hypoparathyroidism**
173
When is metformin contraindicated in a diabetic patient? [1]
**If eGFR < 30**
174
What effect on insluin and c-peptide levels would occur if gave a patient a sulfonyurea like glicazide? [1]
Explain your answer [1]
**Insulin and C-peptide levels increase**
- Pro-insulin is broken down into insulin and c-peptide
- Sulfonyureas increase the secretion of insulin from B cells
175
Name 4 pathologies that cause a **falsely high** HbA1c [4]
**Increase** the **lifespan** of RBC:
- **Vit B12 deficiency**
- **Folate deficiency**
- **IDA**
- **Splenectomy**
176
Name 4 pathologies that cause a **false low** HbA1c [4]
**Decrease** the **lifespan** of RBC:
- **G6PD**
- **SCA**
- **Haemodialysis**
- **Hered. spherocytosis**
177
A patient presents with symptoms of thyrotoxicosis with a tender goitre.
What is the most likely diagnosis?
Follicular carcinoma
Grave's disease
Hashimoto's disease
Papillary carcinoma
Subacute (De Quervain's) thyroiditis
A patient presents with symptoms of thyrotoxicosis with a tender goitre.
What is the most likely diagnosis?
Follicular carcinoma
Grave's disease
Hashimoto's disease
Papillary carcinoma
**Subacute (De Quervain's) thyroiditis**
178
Describe the glucose levels in alcoholic ketoacidosis [1]
**Low or normal**
179
State 4 adverse effects of metclopramide use
- extrapyramidal effects: **acute dystonia** - eyes can get stuck in one position (**oculogyric crisis**)
- **diarrhoea**
- **hyperprolactinaemia**
- **tardive** **dyskinesia** - irregular movements which you cannot control
- **parkinsonism**
180
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State a neuro / psychotic side effect of pred use? [1]
**Steroid psychosis**: *can occur shortly after administering high doses of glucocorticoids.*
181
What is the earliest clinical manifestation of diabetic kidney disease? [1]
**Microalbuminaemia**
182
What would indicate that diabetic kidney disease needs treatment? [1]
What treatment would you provide? [1]
**ACR > 3**
**Start ACEin or ARB** (but not together)
183
How do you differentiate between acute cholecystitis and acute pancreatitis? [3]
**Acute pancreatitis:**
- **Gall** **stones** and **alcohol** most common causes
- **Apyrexial**
- **Epigastric** **pain** (sometimes radiates to the back)
**Acute cholecystitis**
- Similar pain to **biliary** **colic** but more **sustained**
- Radiates to back / **shoulder tip**
- **Murphy sign positive**
184
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Describe an endocrine implication of HIV infection [1]
**HIV** can lead to **adrenal insufficiency** (typically due to CMB related **necrotising adrenalitis**)
185
What is Budd-Chiari syndrome? [1]
Name 4 factors that can contribute to this syndrome [1]
**Hepatic vein thrombosis**
* Polycythemia rubra vera
* Protein C/S resistance; anti-thrombin III d. protein C&S deficiency
* Pill
* Antiphosphoipid syndrome
186
State the typical triad with regards to the presentation of hepatic vein thrombosis / Budd-Chiari syndrome [3]
- **Abdomen pain**
- **Ascites**
- **Tender hepatomegaly**
187
Which treatment for hyperthyroidism can exacerbate thyroid eye disease? [1]
**Radiotherapy**
188
Describe what the Amsterdam criteria is with regards to HNPCC [3]
The Amsterdam criteria are used in the diagnosis hereditary non polyposis colorectal cancer:
- **3+ family members have HNPCC**
- **Cases span 2 generations**
- **One family member dies before 50**
189
If someone is suffering from a pituitary ademona, what would their ACTH and cortisol levels be post high dose dexamethason test be? [2]
ACTH & Cortisol **low**
190
What is the first line management of acute [4] and chronic [3] anal fissures
**Acute**:
- Soften stool
- Lubricants (topical jelly)
- Topical anasethetics
- Analgesia
**Chronic:**
- Acute measures
- Topical GTN (1st line for chronic)
- sphincterotomy or botox
## Footnote
*sphincterotomy releases the painful spasm of torn sphincter and accelerates healing*
191
What is the treatment for colonic cancer
- Chemotherapy [1]
- Radiotherapy - what is the indication? [1]
- Target therapies [2]
**Chemotherapy**:
- **FOLFOX or FOLFIRI**
- Neo / adjuvant or for met.
**Radiotherapy**:
- Rectal cancer; neo or adjuvant treatment
**Target therapies**
- **Bevacizumab** (anti-VEGF)
- **Cetuximab** (anti-EGFR)
192
Which type of surgery is indicated for rectal tumours? [1]
**Anterior resection**: unless in lower rectal
193
A tumour is found in the rectum that is in close relation to the anus. What is the name of the surgery used to treat this tumour? [1]
**abdominoperineal resection** for anal verge rectal cancer
194
A patient has bowel perforation secondary to a colonic tumour. What is treatment aim? Via which type of surgery? [1]
**End colostomy** via a **Hartmans procedure**
195
What impact does cirrhosis have on ALT/AST levels? [1]
Why? [1]
Normal / slightly raised
Hepatocytes are damaged, so less ALT/AST can be released
196
Small bowel overgrowth is diagnosed with what investigational technique? [1
**Hydrogen breath test**
197
What are the risk factors for SBOS? [3]
- Neonates with GI abnormalities
- DM
- Scleroderma
198
RLS is often caused by which type of lymphoma? [1]
Burkitt lymphoma
199
What is the before breakfast / waking DMT1 glucose goal? [1]
5-7mmol/l
200
What is the DMT1 glucose goal for times of the day not prior to breakfast? [1]
4-7mmol/l
201
A patient is on long-term steroids for their existing illness.
They become acutely unwell. How should you alter their dose of their steroid? [1]
**Double dose during intercurrent illness**
202
What treatment should you give for severe colitis from UC if IV steroids haven't worked? [1]
**IV ciclosporin**
203
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Following a severe relapse or > =2 exacerbations in a year for a UC patient, which medication is advised? [2]
**Oral aziothropine** or **oral mercaptopurine**
204
Haemophilus influenzae
205
**Acanthosis nigricans**
206
**Achalasia**
207
Plummer-Vinson syndrome
208
**Plummer-Vinson**
209
Describe how a liver biopsy might show autoimmune hepatitis [2]
liver biopsy: inflammation extending beyond limiting plate **'piecemeal necrosis', bridging necrosis**
210
You have placed an NG tube and test the aspirate's pH. It comes back as 6.2.
What is the next appropriate step? [1]
If aspirate >5.5, **request a chest x-ray to confirm the position of the NG tube.**
211
Which of the following is not considered a complication of HHS?
Deep vein thrombosis
Cerebrovascular event
Cerebral oedema
Foot ulceration
Transverse myelitis
Which of the following is not considered a complication of HHS?
Deep vein thrombosis
Cerebrovascular event
Cerebral oedema
Foot ulceration
**Transverse myelitis**
212
Which is the predominant ketone body in Diabetic Ketoacidosis (DKA)?
A Acetone
B Acetoacetate
C Beta-hydroxybutyrate
D Vaccenic acid
E Palmitoleic acid
Which is the predominant ketone body in Diabetic Ketoacidosis (DKA)?
A Acetone
B Acetoacetate
**C Beta-hydroxybutyrate**
D Vaccenic acid
E Palmitoleic acid
213
Which of the following auto-antibodies is associated with type 1 diabetes mellitus?
A Anti-centromere
B Anti-glutamic acid decarboxylase
C Anti-21-hydroxylase
D Thyroid peroxidase antibody
E Anti-mitochondrial antibody
Which of the following auto-antibodies is associated with type 1 diabetes mellitus?
A Anti-centromere
**B Anti-glutamic acid decarboxylase**
C Anti-21-hydroxylase
D Thyroid peroxidase antibody
E Anti-mitochondrial antibody
214
