MRCP Deck 1 Apr 2023 Flashcards

Question

A 32 F 2-days post partum has suffered two seizures and has been complaining of a severe headache over the previous 24hrs. She received an epidural during delivery. O/E she is drowsy with a BP of 134/87. She has bilateral papilloedema and a temperature of 37.4. What is the most likely diagnosis? A) Bacterial meningitis B) Cerebral venous thrombosis C) Epidural abscess D) Pre-eclampsia toxaemia E) SAH

Answer 1

Pregnancy and post-partum are both procoagulable states with LP and epidurals also both increasing the risk of cerebral venous thrombosis. The above symptoms are all most consistent with this diagnosis.

Answer 2

Trypanosoma cruzi causes Chagas disease (common in S America) and is spread by reduvid bugs. They are transmitted by scratching infected faeces of the bug into skin abrasions caused by the bug during blood sucking. In acute trypanosomiasis the patient presents with fever, myalgia, hepatosplenomegaly and myocarditis. Chronically, in small proportion there may be delayed ventricular dilatation with heart failure. Unilateral periorbital oedema and swelling of the eyelid can result from a bug bite around the eyes (Romana's sign).

Answer 3

HD is an AD neurodegenerative disorder due to a mutation in CAG trinucleotide in the huntingtin gene on chromosome 4. Normally this triplet sequence contains from about 11-34 repeats - when the number rises >37, HD occurs.

Answer 4

Severe symptomatic hyponatraemia should be treated with IV hypertonic saline (3%) as an initial bolus of 300ml with repeat sodium measurements every 20 mins.

Answer 5

This sample population is very skewed as the mean and median times are so disparate. They are both concentrated towards the lower end of the range which is wide. Hence the best way to summarise this skewed data is to use the median and the range as this is a better way to demonstrate an average and the variance in such an asymmetrical population.

Answer 6

Cisapride is a pro kinetic drug that reduces gastric emptying time and interacts with anticoagulants and increases prothrombin time and bleeding risk. It increases the motility of the entire GI tract. QT abnormalities are reported with therapy and has unfortunately been associated with fatal arrhythmias - leading to restricted use.

Answer 7

Thiazides carry the greatest risk of lithium toxicity when the medications are co-prescribed, leading to a rapid rise in lithium levels due to a decrease in lithium excretion

Answer 8

Docetaxel reversibly binds to microtubules with high affinity, leading to a decrease in the availability of free tubulin, thus preventing mitotic cell activity. Microtubules also accumulate within the cell, increasing the rate of apoptosis.

Answer 9

Cardiomyopathy and skin pigmentation are reversible with treatment. Haemachromatosis is an AR disorder resulting in iron accumulation.

Answer 10

Low caeruloplasmin, low serum copper, increased 24hr urinary copper excretion - the diagnosis is confirmed by genetic analysis of the ATP7B gene

Answer 11

Patients who are allergic to aspirin may also react to sulfasalazine. Aspirin hypersensitivity often co-exists with sensitivity to non-steroidal anti-inflammatories and asthma.

Answer 12

NICE recommends that adding metformin should be considered in type I diabetics with a BMI > 25 - weight loss is likely to be beneficial but there is greater evidence for benefit with the use of metformin. A mixed insulin regime might be used if a multiple injection basal-bolus regime was not suited to the patient's lifestyle but is not usually chosen for better glycaemic control.

Answer 13

Beta-blockers can cause sleep disturbance.

Answer 14

Patients cannot drive for 6 months following a first unprovoked or isolated seizure if brain imaging and EEG normal. The minimum interval for which the patient is unable to drive would be extended to 12 months were there evidence for a structural abnormality (e.g. a space-occupying lesion) on imaging which could have caused his seizure, or if there were evidence for epileptiform activity on his EEG.

Answer 15

Thrombectomy should be offered as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have an acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA).

Answer 16

Age-related macular degeneration is the most common cause of blindness in the UK. It is characterised by degeneration of retinal photoreceptors that results in the formation of drusen (seen on fundoscopy). It is more common with advancing age and is more common in females. Classically there are two forms of macular degeneration - dry/atrophic macular degeneration (90% of cases, characterised by drusen) and wet/exudative/neovascular macular denegeration (choroidal neovascularisation, carries the worst prognosis)

Answer 17

DC cardioversion for a haemodynamically stable, symptomatic patient with paroxysmal AF is an effective treatment provided the patient has been on anticoagulation for at least 4 weeks. The current should be synchronised with the R wave.

Answer 18

Polycythaemia vera is a myeloproliferative disorder caused by clonal proliferation of a marrow stem cell leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets.

Answer 19

Alcohol results in exaggerated insulin secretion causing hypoglycaemia. The mechanism is thought to be due to the effect of alcohol on the pancreatic microcirculation leading to a redistribution of pancreatic blood flow from the exocrine into the endocrine parts and thus increased insulin secretion.

Answer 20

Methotrexate - inhibits dihydrofolate reductase and thymidylate synthesis

Answer 21

In the UK 80% of CF cases are due to delta F508 on the long arm of chromosome 7. It is an AR disorder.

Answer 22

Asbestos is well known to increase the risk of mesothelioma, but also increases the risk of bronchial carcinoma, laryngeal cancer and ovarian cancer.

Answer 23

The rash description is classic for livedo reticularis. SLE has an association with livedo reticularis and fits well with the initial presentation.

Answer 24

The nodules at the PIP and DIP are Bouchards nodes and Heberdens nodes respectively and signify OA of the hands and ankles. The 2W history of dysuria and difficulties passing urine are unrelated.

Answer 25

Nicorandil is an activator of ATP dependent K channels - its pharmacological actions are to relax smooth muscle in veins and increase venous capacitance, leading to reduced ventricular filling pressures and dilatation of the coronary arterioles. Headache is the most common unwanted effect (35%). Other adverse effects include oral ulceration, flushing and GI disturbance.

Answer 26

PMR usually affects elderly white females - symmetrical arthritis with a polyclonal increase in globulins (marker of inflammation). Early morning stiffness, particularly of the hip and shoulder girdle with associated fatigue can last 2-3 hours each morning. Transient synovitis can occur and carpal tunnel may be associated in up to 15% of cases

Answer 27

Klinefelter syndrome occurs due to the presence of an additional X chromosome. It is the most common cause of male hypogonadism and infertility. Affected men tend to be tall and have an increased risk of mild intellectual impairment. They may also have an increased risk of osteoporotic fracture due to low testosterone.

Answer 28

Aortic regurgitation. Endocarditis commonly affects LHS>RHS. IE most commonly affects mitral>aortic>aortic+mitral>tricuspid>pulmonary - if the valve is already abnormal then the likelihood of infection is greater.

Answer 29

LP has 95.8% diagnostic sensitivity and 100% specificity. The gold standard used to be MRI brain but this has been superseded by LP results.

Answer 30

The absolute risk reduction is the difference in risk between the control and the intervention groups - 0.6%

Answer 31

Although the amount of radioiodine during treatment is small, it is recommended to wait approx 2 weeks before having close contact with children and pregnant women. It is recommended to wait at least 6M before attempting to conceive.

Answer 32

Most absorption occurs in the jejunum after degradation in the duodenum by pancreatic proteases.

Answer 33

The pathological changes are symmetrical lesions in the walls of the third ventricle and periaqueductal grey matter, with subsequent atrophy of the mamillary bodies.

Answer 34

Confirmation of H. Pylori eradication occurs 4W post completion of antibiotics and whilst off PPIs for 2W. Non-invasive tests should be used unless the patient has complex peptic ulcer disease or a MALToma. The most specific and sensitive non-invasive test is the 13C urea breath test.

Answer 35

Causes of a reverse split 2nd heart sound include: aortic stenosis, HOCM and IHD with LBB

Answer 36

Fibroblasts are stimulated by anti-TSH receptors and activated T cells and lead to GAG deposition. GAG is hydrophilic so draws in water from surrounding tissues and leads to significant oedema. Visual changes result from pressure being placed on the optic nerve.

Answer 37

Branches of the anterior spinal artery supply the anterior 2/3 of the spinal cord, with the posterior spinal arteries supplying the posterior third. There are segments of the cord in the watershed area between the branches T2-T4 which are vulnerable to ischaemia. It can present with sudden back pain with B/L flaccid weakness and dissociated sensory loss with impaired pinprick and temperature sensation below the level of the infarct. Proprioception and vibration sense are typically spared as they are conducted in the posterior columns. Cauda equina could cause weakness in both legs but the sensory level at T7 localises the lesion to the spinal cord and not the more distal cauda equina.

Answer 38

Significant splenomegaly + mild hepatomegaly, normochromic anaemia and a relatively normal WCC. Blood film shows early WBC and RBC precursors (leukoerythroblastic blood picture). The significantly enlarged spleen and normal WCC strongly suggests myelofibrosis. CML is the other differential for a significantly enlarged spleen but this would have a very elevated WCC.

Answer 39

The features that point towards a pontine haemorrhage are the loss of the dolls eye reflex (confirms a nuclear rather than supranuclear palsy) and B/L pinpoint pupils which are often features of pontine lesions. Lateral medullary syndrome is associated with altered facial sensation ipsilaterally and altered limb sensation contralaterally. Thalamic haemorrhage is associated with contralateral sensory loss and ataxia.

Answer 40

Adynamic bone disease is most prevalent in diabetic patients and those on peritoneal dialysis, and is associated with a higher risk of NOF. There is a tendency towards hypercalcaemia as the bone loses its capacity to buffer serum calcium. It can be caused by overtreatment with alfacalcidol. Histologically it is characterised by a reduction in both bone formation and resorption with thin osteoid seams, little active mineralisation and few osteoclasts.

Answer 41

Zinc deficiency is common in AN patients and causes poor wound healing, hair loss and glossitis. Zinc is common in red meat and shellfish and may be present in some cereals and pulses - it is important to replace as it impairs an individuals ability to gain weight. Vitamin C deficiency can present similarly but is uncommon in AN due to its abundance in fresh fruit and vegetables.

Answer 42

Malignant pleural effusions usually imply widely disseminated disease and any treatment is often palliative.

Answer 43

The gradual onset of dissociated sensory loss in a shawl-like distribution over the shoulders, coupled with distal weakness affecting both hands fits best with syringomyelia. It may also begin after an episode of trauma such as a traffic accident.

Answer 44

Anaerobic pleuropulmonary infections include aspiration pneumonia, necrotising pneumonitis, lung abscess and empyema. It is likely this patient aspirated following his seizure which has led to an anaerobic pneumonia. Patients will often mention a revolting taste and smell of their sputum.

Answer 45

It is a recognised effect that azathioprine causes warfarin resistance but the exact mechanism is unclear ?induction of hepatic enzymes enhancing warfarin clearance.

Answer 46

Niacin (B3) deficiency is characterised by dermatitis, diarrhoea and dementia, a condition known as pellagra.

Answer 47

Glaucoma is a disorder characterised by optic neuropathy as a result of raised IOP. In acute angle-closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow. Features: severe ocular pain, headache, decreased visual acuity, worse with mydriasis hard and red-eye, haloes around lights, semi-dilated non-reacting pupil. Emergency medical treatment is required to lower the IOP with more definitive surgical treatment given once the acute attack has settled. Medical treatment includes IV acetyzolamide and a combination of eye drops - a direct parasynthomimetic (pilocarpine), a b-blocker (timolol), and an alpha-2-agonist (apraclonidine). Definitive treatment is with laser peripheral iridotomy.

Answer 48

Good prognosis features -Female sex -Age: young age of onset (i.e. 20s or 30s) -Relapsing-remitting disease -Sensory symptoms only -Long interval between first two relapses complete recovery between relapses A typical patient carries a better prognosis than an atypical presentation.

Answer 49

Henoch-Schonlein purpura (HSP) is an IgA mediated small vessel vasculitis. There is a degree of overlap with IgA nephropathy (Berger's disease) but is usually seen in children following an infection. It is characterised by mesangial hypercellularity.

Answer 50

Aortic regurgitation can present with symptoms including dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea. He is at risk of aortic regurgitation due to his history of rheumatic fever. Further signs are the wide pulse pressure (114mg) and nail-bed pulsation (Quincke's sign). Aortic regurgitation is associated with an early diastolic murmur, loudest on expiration.

Answer 51

Vasodilator testing is the cornerstone test in determining the management of pulmonary artery hypertension (PAH). It usually affects 30-60YO women between and presents with exertional breathlessness and signs of right heart failure (e.g. right axis deviation suggests right ventricular hypertrophy, and peripheral oedema suggests right heart failure). The test involves giving vasodilator agents (e.g. nitric oxide, epoprostenol) and looking for a reduction in pulmonary arterial pressure (usually, a 10mmHg drop is classified as positive). 10-15% of PAH patients will be positive in this test, which suggests a likely benefit from calcium channel blockers in managing the condition. Those with a negative test are treated with prostacyclin analogs, endothelin receptor antagonists or phosphodiesterase inhibitors.

Answer 52

Hungry bone syndrome rare condition that occurs as a result of a sudden drop in previously high parathyroid hormone levels. It is a significant complication of parathyroidectomy's and causes hypocalcaemia.

Answer 53

S2 is caused by the closure of the aortic valve (A2) closely followed by that of the pulmonary valve (P2). Loud S2 -Hypertension: systemic (loud A2) or pulmonary (loud P2) Soft S2 -Aortic stenosis Fixed split S2 -Atrial septal defect Widely split S2 -Deep inspiration -RBBB -Pulmonary stenosis Reversed (paradoxical) split S2 -LBBB -Severe aortic stenosis -WPW type B (causes early P2) -Patent ductus arteriosus

Answer 54

1 Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests* are normal, there is no CKD) 2 60-90 ml/min with some sign of kidney damage (if kidney tests* are normal, there is no CKD) 3a 45-59 ml/min 3b 30-44 ml/min 4 15-29 ml/min 5 Less than 15 ml/min - dialysis or a kidney transplant may be needed

Answer 55

Sacubitril-valsartan would be the most appropriate to commence as the patient has an LVEF <35%, is symptomatic and already established on an ACE-i and beta-blocker. This drug combines the neprilysin-inhibitor sacubitril with the angiotensin receptor blocker (ARB) valsartan. As sacubitril-valsartan contains an ARB it should only be commenced following a wash-out period of any ACEi or ARB a patient is already established on (in this case the patient's ramipril should be stopped). Hydralazine may be considered as an alternative third agent in the management of chronic heart failure. However, it must be used in combination with nitrates. Spironolactone is an aldosterone antagonist used as a second-line agent . This patient has already been established on eplerenone (aldosterone antagonist), and remains symptomatic therefore another class of drug must be commenced. Ivabradine is another third-line agent that can be used, however, the patient must have a resting heart rate of at least 75/min to be commenced on this drug. OVERVIEW (with reduced EF) 1st line - ACEi + b-blocker 2nd line - aldosterone antagonist 3rd line - ivabradine, sacubitril valsartan, hydralazine in combo with nitrate, digoxin, cardiac resynchronisation therapy

Answer 56

Anti-NMDA receptor encephalitis is a paraneoplastic syndrome which presents with prominent psychiatric features.

Answer 57

Coagulase-negative Staphylococcus species e.g. Staphylococcus epidermidis and Staphylococcus capitis peritonitis remains a common complication of peritoneal dialysis. S. Aureus would be the next most common organism.

Answer 58

The patient presents with major bleeding (haematemesis, anaemia, tachycardia, hypotension). The management of major bleeding on warfarin is to stop warfarin and give intravenous vitamin K 5mg and prothrombin complex concentrate. If INR>8 and minor bleeding - stop warfarin and give IV vit K 3mg. If INR>8 and no bleeding - stop warfarin and give PO vitamin K 3mg. If INR 5.0-8.0 and no bleeding - stop warfarin for two doses.

Answer 59

IV metronidazole

Answer 60

The single most important prognostic indicator in paracetamol overdoses is acidosis. Other indicators of reduced prognosis include a creatinine >300, and increased prothrombin time.

Answer 61

Propranolol, salicylates, sodium valproate and severe iron or paracetamol poisoning can cause a modest hypoglycaemia.

Answer 62

Risperidone is a first-line treatment that carries a low risk of T2DM. Olanzapine causes the biggest risk of T2DM. Typical antipsychotics such as chlorpromazine are not recommended for the initial treatment of schizophrenia and also has a significantly increased risk of developing T2DM.

Answer 63

B-blockade may be enough to prevent VT in patients with long QT syndrome. Permanent pacing is first line in patients with LQT2 and LQT3 genotypes since they are at significant risk of sudden cardiac arrest.

Answer 64

Gradual onset diarrhoea with stool ++ for blood and no increase in eosinophils along with ulceration on the flexi sig all indicate amoebiasis. Metronidazole is the treatment of choice.

Answer 65

Metoclopramide is a dopamine antagonist that binds to D2 receptors on pituitary lactotropes, stimulating the release of prolactin by the anterior pituitary, resulting in galactorrhea. Prolactin inhibits GnRH and gonadotropin secretion so oligomenorrhoea and amenorrhoea may occur.

Answer 66

Raloxifene is a SERM that exhibits oestrogen agonist effects on bone and lipid metabolism and oestrogen antagonist effects on uterine endometrium and breast tissue. It causes an increase in hot flushes, leg cramps and an increased risk of clots. It lowers LDL levels, reduces the fracture risk in the spine but has no proven effect in the hips. It has no effect on breast cancer risk.

Answer 67

AVSDs are the most common cardiac complication seen in Down syndrome with VSDs and ASDs being the next most common. The murmur here is typical of that heard in VSD with the possibility of a significant R-L shunt.

Answer 68

Pityriasis versicolor is a yeast infection caused by M. furfur and appears as hypo pigmented, well-demarcated macula's covered in a fine scale. Treatment is often with topical antifungals such as clotrimazole.

Answer 69

Clostridium botulinum blocks the release of ACh from the motor nerve terminal. Botulism can be spread by the ingestion of foods contaminated by inadequate sterilisation/wound contamination in IVDU. Early symptoms are blurred vision, dysphagia and dysarthria, impaired pupillary responses to light, reduced tendon weakness and symmetrical limb weakness. Patients may also have evidence of autonomic disturbances such as dry mouth, constipation and urinary retention.

Answer 70

Hypokalemia is the most important cause of ventricular tachycardia (VT) clinically, followed by hypomagnesaemia.

Answer 71

Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific. Anti-Jo-1 antibodies are not commonly seen in dermatomyositis - they are more common in polymyositis where they are seen in a pattern of disease associated with lung involvement, Raynaud's and fever

Answer 72

Acute treatment: subcutaneous sumatriptan + 100% O2 Prophylaxis: verapamil

Answer 73

There are two main types of IGR: -Impaired fasting glucose (IFG) (6.1-7.0) - due to hepatic insulin resistance -Impaired glucose tolerance (IGT) (7.8-11.1) - due to muscle insulin resistance Patients with IGT are more likely to develop T2DM and cardiovascular disease than patients with IFG People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes.

Answer 74

Although TCAs primarily increase serotonin and noradrenaline in the brain by slowing re-uptake, they also block histamine, cholinergic and alpha 1 receptors. In overdose, the anti-cholinergic effects give dilated pupils, dry skin, confusion, urinary retention and tachycardia. Divergent pupils are a common finding. TCAs are also cardiotoxic by prolonging the QTc interval and widening the QRS complex. This can potentially lead to ventricular arrhythmias. Other effects of TCAs include seizures and a metabolic acidosis.

Answer 75

This patient has HOCM. Agents that reduce preload/afterload (such as nitrate, ACE inhibitors, nifedipine-type calcium antagonists) are contraindicated with HOCM due to possible aggravation of the outflow tract obstruction. Patients with significant symptoms of heart failure and left ventricular outflow tract (LVOT) obstruction benefit from b-blockers and non-dihydropyridine CCBs. Management of HOCM: Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*

Answer 76

Discoid lupus erythematosus is a benign disorder generally seen in younger females. It very rarely progresses to systemic lupus erythematosus and is characterised by follicular keratin plugs. Features -Erythematous, raised rash, sometimes scaly -May be photosensitive -More common on face, neck, ears and scalp -Lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation

Answer 77

Cubital tunnel syndrome- this is a classical description of ulnar nerve neuropathy. The ulnar nerve supplies sensory innervation to the palmar and dorsal aspects of 1.5 fingers medially. It has a motor component which can result in wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals) and the hypothenar muscles. C8/T1 radiculopathy can mimic ulnar nerve neuropathy. The preserved sensation of the forearm favours cubital tunnel syndrome as the ulnar nerve does not provide sensation to the medial forearm, which is innervated by the medial antebrachial cutaneous nerve (C8 and T1).

Answer 78

Semaglutide is a GLP-1 type drug that promotes weight loss and has no contraindications in renal impairment or inflammatory bowel disease. Pioglitazone promotes fluid retention and hence weight gain and has risks of hypoglycaemia in patients with previous myocardial ischaemia. Sulfonylureas have a tendency to promote weight gain. Insulin is not indicated as a second line treatment. Liraglutide would promote weight loss but is not indicated in inflammatory bowel disease.

Answer 79

The number needed to treat (NNT) is the average number of patients needed to be treated to save one life. NNT = 1 / ARR (absolute risk reduction) ARR = Control event rate - Experimental event rate The mortality in the experimental event arm can be found by multiplying the mortality in the control by the relative risk -- 12.5% x 0.8 = 10% ARR = 12.5 - 10 = 2.5% NNT = 1 / 0.025 = 40

Answer 80

Recurrent laryngeal nerve injury leads to a hoarse voice due to damage to the posterior cricothyroid muscle which is responsible for opening the vocal cords.

Answer 81

It is unwise to increase the lithium level given the level is already at the top of the therapeutic range. The next step would be to use sodium valproate in combination with lithium to treat the condition.

Answer 82

An increasing PR interval suggests an aortic root abscess which has a high mortality. Failure of fever to resolve after 1W also suggests the presence of an intracardiac abscess that requires surgical management.

Answer 83

Bakers cysts (popliteal cysts) may occur in RA following persistent effusion into the knee joint. Telescopic fingers indicate arthritis mutilans.

Answer 84

Hypochloraemic alkalosis is associated with severe hypokalaemia.

Answer 85

ACS in the context of cocaine use is often secondary to coronary artery vasospasm, however can also be thrombotic. Standard ACS pathways should be used, with the addition of IV benzodiazepines.

Answer 86

First-line management of PDA is indomethacin or ibuprofen given to the neonate. Doing nothing is not the correct answer. Although it can happen, PDA does not close spontaneously in most cases. Prostaglandin E1 is incorrect. This can be used if PDA is associated with another congenital heart defect (usually cyanotic) amenable to surgery. It is used to keep the duct open until after surgical repair.

Answer 87

Hypocalcaemia, not hypercalcaemia, causes prolongation of the QT interval and hence may predispose to the development of torsade de pointes

Answer 88

With regards to secondary prevention, clopidogrel is now recommended by NICE ahead of combination use of aspirin plus modified-release (MR) dipyridamole in people who have had an ischaemic stroke following 14 days of aspirin. Aspirin 300mg should be given ASAP if a haemorrhagic stroke has been excluded. If the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Answer 89

Pioglitazone is contraindicated by his history of bladder cancer and may contribute to obesity. A DPP-4 inhibitor such as sitagliptin is therefore the best option. Exenatide generally causes weight loss and is therefore useful in obese diabetics but he does not meet the NICE body mass index criteria of 35 kg/m² Metformin can be titrated up to aim for a HbA1c of 48 mmol/mol (6.5%) if it rises above 51 mmol/mol (6.8%) but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%).

Answer 90

A variable intensity of S1 is consistent with complete heart block. Loud S1 is caused by mitral stenosis and tricuspid stenosis. Soft S1 is caused by mitral regurgitation, severe heart failure, left bundle branch block, and 1st-degree heart block. Loud S2 is caused by systemic hypertension. Soft S2 is caused by severe aortic stenosis.

Answer 91

Homocystinuria is characterized by tall stature, downward lens dislocation (ectopia lentis) and learning difficulties. There is a body habitus that is similar to Marfan's syndrome but key differentiating characteristics are the downward rather than upward lens dislocation and the presence of learning difficulties.

Answer 92

The patient is positive for HLA-DRB1. HLA-DRB1, and its association to HLA-DR4, is a genetic susceptibility locus in rheumatoid arthritis, making this the correct answer. Behcets disease is associated with HLA-B51. Reactive arthritis, as with ankylosing spondylitis, is related to HLA-B27. Sjogren's syndrome is related to HLA-DR3.

Answer 93

The LFTs demonstrate a cholestatic picture with a raised ALP/GGT and associated hyperbilirubinemia. This is a classical presentation of drug-induced cholestasis. Co-amoxiclav is a well-recognised and common cause of cholestasis. All the other drugs tend to cause a hepatitis-type picture.

Answer 94

Smoking increases risk of lung ca by a factor of 10 Other factors -Asbestos - increases risk of lung ca by a factor of 5 -Arsenic -Radon -Nickel -Chromate -Aromatic hydrocarbon -Cryptogenic fibrosing alveolitis

Answer 95

Because the patient is asymptomatic but has the criteria for multiple myeloma, the underlying diagnosis of this stem is smoldering multiple myeloma. The treatment of smoldering multiple myeloma is typically to watch and wait

Answer 96

Sildenafil is a PO drug approved for the treatment of erectile dysfunction. It selectively inhibits type-V phosphodiesterase that is found in human penile erectile tissue. It may interact with nitrates to cause hypotension and syncope; adverse effects include flushing, headache, dyspepsia and nasal congestion.

Answer 97

Carcinoid syndrome is a paraneoplastic syndrome that occurs as a result of carcinoid tumours. It leads to symptoms including flushing and diarrhoea and less frequently heart failure and bronchoconstriction.

Answer 98

This woman has had an arterial embolic event despite heparin anticoagulation. Therefore this is suspicious for HIT and a low platelet count would be supportive of this.

Answer 99

28 days of Truvada + raltegravir should be used for all PEP.

Answer 100

IV carbonic anhydrase inhibitor will quickly lower intraocular pressure, before optic nerve damage or even retinal artery compression and occlusion occur. Hyphaemia occurs when blood from iris vessels fills the anterior chamber and can be quantified in terms of its % filling. If large, they are at risk of causing a raised IOP as blood cells block the trabecular meshwork and impairs the drainage of aqueous humour. One sign of raised IOP is corneal oedema and hence corneal haziness.

Answer 101

Nifedipine should be prescribed to a patient over the age of 30 with uncontrolled hypertension. CCBs however may delay the onset of labour. ACEi should not be used in pregnant women due to the adverse risks to the foetus.

Answer 102

The presence of bloody diarrhoea suggests a GI infection by an enteroinvasive organism. The most common are Salmonella spp, Shigella spp. and Enterohaemorrhagic E Coli. Entomoeba histolytica can also cause bloody diarrhoea but these symptoms progress more slowly.

Answer 103

Renal tubular acidosis 4 results from a deficiency of mineralocorticoids - e.g. through medications (NSAIDs, ACEi), Addisons disease or congenital enzyme defects. The aldosterone deficiency means there is less sodium resorption and hence less potassium excretion, leading to hyperkalaemia. Acidosis is uncommon in RTA4. RTA1 is seen in many renal disorders - e.g. AI disease, rejection of transplanted kidney, chronic pyelonephritis or medications such as lithium. It leads to the reduced excretion of hydrogen ions, causing a metabolic acidosis and hence hypokalaemia. RTA2 is much less common than RTA1 and occurs due to a defect in bicarbonate resorption leading to metabolic acidosis and hence hypokalaemia.

Answer 104

Causes of upper lobe fibrosis on CXR: -Ankylosing sponylitis -Sarcoidosis -Tb -EAA -Silicosis -ABPA -Post-radiotherapy

Answer 105

The INR should be >2 on the day of the procedure and the preceding 3-4 weeks due to risk of dislodging a clot.

Answer 106

This patient is likely to have ulcerative colitis, which has a known association with large-joint arthritis, sacroilitis and pyoderma gangrenosum

Answer 107

Blood pressure: systolic increases, diastolic decreases which leads to an increased pulse pressure - in healthy young people the increase in MABP is only slight.

Answer 108

The key clue here is chondrocalcinosis, the finding of calcification of the articular cartilage. Although not specific, this is suggestive of pseudogout. In the knee, this often manifests as calcification of the menisci.

Answer 109

-Alcohol withdrawal symptoms: 6-12 hours -Seizures: 36 hours -Delirium tremens: 72 hours

Answer 110

Appropriate first-line treatment would be oral prednisolone. Corticosteroids help suppress the immune-mediated destruction of platelets in severe/critical bleeding. IVIG is a second-line therapy for minor bleeding, or first-line (along with other agents) for severe bleeding. Observation only is reserved for asymptomatic adults with a platelet count >=30 * 109/L. Platelet transfusions are reserved for those with life- or organ-threatening bleeding and may be used to control active bleeding for surgery; however, they are ineffective as a treatment for ITP due to continued immune-mediated platelet destruction.

Answer 111

The following drugs tend to cause a hepatocellular picture: -paracetamol -sodium valproate, phenytoin -MAOIs -halothane -anti-tuberculosis: isoniazid, rifampicin, -pyrazinamide -statins -alcohol -amiodarone -methyldopa -nitrofurantoin The following drugs tend to cause cholestasis (+/- hepatitis): -COCP -antibiotics: flucloxacillin, co-amoxiclav, erythromycin -anabolic steroids, testosterones -phenothiazines: chlorpromazine, -prochlorperazine -sulphonylureas -fibrates Liver cirrhosis: -methotrexate -methyldopa -amiodarone

Answer 112

Genital warts are caused by human papillomavirus HPV, especially types 6 & 11. It is well established that HPV (types 16,18 & 33) predisposes to cervical cancer. Topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion: -multiple, non-keratinised warts are best treated with topical agents -solitary, keratinised warts respond better to cryotherapy Imiquimod is a topical cream that is generally used second line.

Answer 113

The oxygen dissociation curve describes the relationship between the percentage of saturated haemoglobin and partial pressure of oxygen in the blood. -Shifts to left = for given oxygen pressure, there is increased saturation of Hb with oxygen i.e. decreased oxygen delivery to tissues -Shifts to right = for given oxygen pressure, there is reduced saturation of Hb with oxygen i.e. enhanced oxygen delivery to tissues Shifts to Left = Lower oxygen delivery -HbF, methaemoglobin, carboxyhaemoglobin -Low [H+] (alkali) -Low pCO2 -Low 2,3-DPG -Low temperature Raised [H+] (acidic) Shifts to Right = Raised oxygen delivery -Raised pCO2 -Raised 2,3-DPG* -Raised temperature

Answer 114

Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific Ix -elevated creatine kinase -EMG -muscle biopsy -ANA positive in 60% -anti-Mi-2 antibodies are highly specific for dermatomyositis, but are only seen in around 25% of patients -anti-Jo-1 antibodies are more common in polymyositis. Management -prednisolone

Answer 115

All of the answer options can cause a metabolic acidosis. As this man is homeless and there is no further information given, the most likely causes for his presentation are alcohol, methanol and ethylene glycol (anti-freeze). Reduced vision and poorly reactive pupils are common complications of methanol poisoning. A metabolite of methanol, formic acid, accumulates in the optic nerve causing visual disturbance and eventually blindness.

Answer 116

Otosclerosis is characterised by conductive hearing loss, tinnitus and positive family history. It is a form of hearing loss that occurs due to abnormal bone growth in your middle ear (due to fixation of the stapes at the oval window). In 10% of cases of otosclerosis, there is a redness of the promontory of the cochlea seen through the tympanic membrane due to prominent vascularity known as the Schwartz sign, which is seen in this case. Meniere's disease produces a classic triad of symptoms (episodic vertigo, tinnitus, and hearing loss), likely caused by endolymphatic hydrops of the labyrinthine system of the inner ear. The absence of recurrent rotatory vertigo makes this diagnosis unlikely.

Answer 117

The left circumflex artery supplies the lateral and posterior left ventricular walls. It is likely to be critical stenosis rather than complete occlusion due to the presence of T-wave inversion rather than ST-elevation.

Answer 118

Potassium depletion enhances the binding of digoxin to the Na+/K+ pump which increases the extent of inhibition of sodium transport, which in turn, causes digoxin toxicity.

Answer 119

A course of ECT is sometimes used as treatment for severe depression if there is a risk to a persons life and urgent treatment is required, or for moderate or severe depression when all other treatments have not helped. Indications for ECT in depression include: -Depressive stupor or catatonia -Psychotic depression -Refusal of food or drink -When the patient is dangerously suicidal -Situations where a delay in the effects of the anti-depressants will result in serious health risk

Answer 120

Eosinophilic pneumonia often needs treatment with corticosteroid medications - treatment may need to be >6M in patients with chronic forms of the disease. It is also vital to remove any possible causal factors.

Answer 121

Propylthiouracil is the intervention of choice in pregnant women and should be used to maintain thyroid levels in the upper third of the normal range. It should not be sued late in pregnancy due to the risk of maternal liver toxicity.

Answer 122

When there are symptoms of bone pain and stiffness, coupled with a raised ALP, bisphosphonates are the treatment of choice. If there is a history of gastric issues then IV would be indicated over PO.

Answer 123

Adults presenting with chickenpox within 72 hours of the rash should be treated with PO aciclovir IF: they are immunocompromised/rash on non-truncal areas/moderate or severe pain and moderate or severe rash as these patients are at an increased risk of complications.

Answer 124

Progression of TB during first line treatment indicates the possibility of MDR TB which should mean that this patient should be escalated to a 5-drug regime therapy, the specific choices depend on the drugs the strain is resistant to.

Answer 125

Following the HTN treatment ladder, this patient is over the age of 55 and does not have diabetes - hence should be started on a CCB first-line. Amlodipine is the drug of choice for isolated systolic hypertension in the elderly.

Answer 126

Tremor is a common adverse effect of calcineurin inhibitors

Answer 127

Ciprofloxacin lowers the seizure threshold. Quinolones should be used with caution in patients with a history of epilepsy, or conditions that predispose to seizures

Answer 128

Lateral medullary syndrome, also known as Wallenberg's syndrome, occurs following occlusion of the posterior inferior cerebellar artery. It presents with: cerebellar signs, contralateral sensory loss & ipsilateral Horner's

Answer 129

Dialysis is not indicated in severe toxicity. Early features relate to anticholinergic properties: dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision. Features of severe poisoning include: -arrhythmias -seizures -metabolic acidosis -coma ECG changes include: -sinus tachycardia -widening of QRS -prolongation of QT interval Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias Management includes the use of IV sodium bicarbonate.

Answer 130

Topical steroids is the first-line NICE recommendation for treatment of flexural psoriasis. Mild to moderate topical steroids are prescribed for no longer than 2 weeks at a time. NICE recommend a step-wise approach for chronic plaque psoriasis: -regular emollients may help to reduce scale loss and reduce pruritus -first-line: A potent corticosteroid applied once daily plus vitamin D analogue applied once daily for up to 4 weeks as initial treatment -second-line: if no improvement after 8 weeks then offer a vitamin D analogue twice daily -third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily -short-acting dithranol can also be used

Answer 131

Carbamazepine is an inducer of CYP enzymes and hence acts to increase the conversion of paracetamol to its toxic metabolite, NAPQI. This has been demonstrated to worsen the prognosis of patients who take a paracetamol overdose. The following groups are at an increased risk of developing hepatotoxicity following a paracetamol overdose: -patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John's Wort) -malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days

Answer 132

Unless the blood pressure is extremely high and requires immediate treatment, NICE now recommends ambulatory or home blood pressure monitoring (ABPM/HBPM), as this provides more reliable readings and avoid white-coat hypertension.

Answer 133

Protein C deficiency is an autosomal codominant condition which causes an increased risk of thrombosis. It increases the risk of venous thromboembolism and of skin necrosis following the commencement of warfarin

Answer 134

Schistosomiasis is the most common cause of bladder calcification worldwide. Schistosoma haematobium causes haematuria and the eggs can appear as calcification in the bladder. This typically presents as a 'swimmer's itch' in patients who have recently returned from Africa. Schistosoma haematobium is a risk factor for squamous cell bladder cancer.

Answer 135

Diffuse proliferative glomerulonephritis, causes: -post-streptococcal -SLE

Answer 136

The patient has a mild flare-up of UC with demonstrable disease extending past the left-sided colon, oral aminosalicylates are the agent of choice as enemas only reach the splenic flexure. Intravenous steroids are usually given first-line for severe colitis. Features of severe disease include >6 bowel movements per day with systemic upset, visible blood, pyrexia, tachycardia (>90 beats per minute), anaemia, and an ESR >30mm/hour.

Answer 137

The NICE guidelines suggest that if a patient has a normal CT brain within 6 hours of the onset of the headache then SAH is unlikely and you should consider an alternative diagnosis. If the CT is performed greater than 6 hours after the onset of the headache and shows no evidence of SAH then you should consider a lumbar puncture, which should be performed at least 12 hours after onset. If the CT shows a subarachnoid haemorrhage, the next investigation is usually a CT angiogram.

Answer 138

S. Aureus food poisoning leads to profuse vomiting that occurs 2-4 hours after eating food (often pre-made salads, meat or dairy products) that is contaminated by an enterotoxin. Diarrhoea occurs a few hours later that is profuse and watery.

Answer 139

The finding of a urine osmolality higher than plasma implies defective water excretion and is characteristic of SIADH. The plasma osmolality is likely to be low (2Na + U + G) and the low plasma osmolality could just be due to fluid overload rather than SIADH.

Answer 140

Although current diagnostic criteria for MS rely on MRI scanning, visual evoked potentials (VEP) and LP may be performed in addition. VEPs are averaged evoked potentials evoked by visual stimuli and detected by scalp electrodes placed over the occiput. It is sensitive for detecting demyelination of the optic nerve and central visual pathways. Nerve conduction studies are not helpful in the diagnosis of MS as it is a purely central nerve disorder.

Answer 141

Patients with severe hypothyroidism are at risk of developing pericardial effusions, cardiomegaly and heart failure. Hypothyroidism may cause nerve entrapment syndrome but do not cause length-dependent neuropathy. Gynaecomastia, optic neuropathy and pre-tibial myxoedema are all complications of hyperthyroidism.

Answer 142

Chloramphenicol, ciprofloxacin, erythromycin, metronidazole and omeprazole are all hepatic enzyme inhibitors. Phenobarbital, rifampicin and carbamazepine are all hepatic enzyme inducers.

Answer 143

The first choice treatments for primary generalised epilepsy are lamotrigine and valproate. In women of child-bearing age, valproate is avoided.

Answer 144

Klebsiella pneumonia is more common in diabetics and patients with a history of alcohol excess. It is also frequently caused by aspiration. Here, the recent stroke has caused problematic dysphagia. Klebsiella commonly affects the upper lobes of the lungs.

Answer 145

The investigation of CLL includes a full blood count, blood film which may show the presence of smudge or smear cells and a bone marrow aspiration to demonstrate infiltration with lymphocytes. Immunophenotyping is an important investigation for diagnosing CLL and has a role in predicting prognosis. Most cases can be identified using a panel of antibodies specific for CD5, CD19, CD20 and CD23

Answer 146

Bullous pemphigoid is an AI condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230. Bullous pemphigoid is more common in elderly patients. Features include -itchy, tense blisters typically around flexures -the blisters usually heal without scarring -there is stereotypically no mucosal involvement (i.e. the mouth is spared)

Answer 147

Research shows Hashimoto's thyroiditis is amongst the autoimmune diseases found to be associated with the development of MALT lymphomas. Current theories suggest that lymphoma develops in response to areas of localised autoimmune stimulation.

Answer 148

The most common organism causing infective exacerbations of COPD is Haemophilus influenzae. Other bacterial causes include Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses account for around 30% of exacerbations, with the human rhinovirus being the most common.

Answer 149

Juxta-articular osteopenia, along with loss of joint spae and soft-tissue swelling, is a common early X-ray feature of rheumatoid arthritis whilst joint subluxation and peri-articular erosions often occur in the context of progressive disease.

Answer 150

CT is the most sensitive method to detect the characteristic pancreatic calcification which is associated with the condition. Functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive

Answer 151

If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend individual eating-disorder-focused cognitive behavioural therapy (CBT-ED). Children should be offered bulimia-nervosa-focused family therapy (FT-BN). Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking.

Answer 152

Expressivity refers to the extent to which a particular genotype is expressed in the phenotype of an individual. Marfan's disease has a very varied expressivity, meaning different people affected by it can be affected very differently. Anticipation is the phenomenon in which the age of onset of a condition lowers with each successive generation. Classically this is seen in trinucleotide repeat disorders such as Huntington's disease (CAG expansion), myotonic dystrophy (CTG), and fragile X-syndrome (CGG). Methylation is a process by which genes can be silenced by the addition of methyl groups. Penetrance refers to the proportion of the population who have a particular mutation also having the associated disease. An example would be BRCA-1, a mutation of which causes breast cancer in 80% of those affected, giving it a penetrance of 80%.

Answer 153

IL-1, IL-6, and TNF-a are involved in the complex cytokine cascade during sepsis. Sepsis triggers the release of IL-1 causing vasodilation → hypotension.

Answer 154

She may have consumed 25g of paracetamol which is a life-threatening overdose. N-acetyl cysteine needs to be commenced immediately. NAC should be given immediately if there is a staggered overdose, uncertainty regarding the timing of the overdose or if a patient presents within 8-24hrs after an overdose of more than 150mg/kg.

Answer 155

Patients with haematuria and unexplained or unusual sites of thrombosis, or with a raised LDH (indicating haemolysis), abnormal cell counts or aplastic anaemia, should be screened for PNH. PNH is a rare acquired disorder characterised by intravascular haemolysis due to deficiency of decay-accelerating factor, a protein normally present on red blood cells. Flow cytometry of blood to detect low levels of CD59 and CD55 has now replaced Ham's test as the gold standard investigation in PNH.

Answer 156

Odds are a ratio of the number of people who incur a particular outcome to the number of people who do not incur the outcome. 40 of the 80 patients received significant pain relief It can therefore be inferred that 40 of the 80 patients did not receive significant pain relief. Therefore the odds are 40 / 40 = 1

Answer 157

During Ramadan, one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after sunset.

Answer 158

MODY is autosomal dominant diabetes mellitus which presents for the first time in young slim individuals without symptoms of polyuria and polydipsia. Many patients with MODY including those with the HNF-1 alpha form of the disease, can be managed with sulphonylureas for years before needing to start insulin therapy. Evaluation of family history and testing for antibodies for type 1 diabetes can help to differentiate MODY from other forms of diabetes mellitus. MODY is characterised by the development of type 2 diabetes mellitus in patients < 25 years old. Type 1 diabetes isn't associated with such strong heritability and given this patient's body habitus, type 2 diabetes is very unlikely. LADA is associated with a body habitus similar to the overweight / obese picture seen in type 2 diabetes for many patients, although progression to insulin therapy occurs more quickly.

Answer 159

Goodpasture's syndrome -IgG deposits on renal biopsy -Anti-GBM antibodies ANCA vasculitis can cause a pulmonary-renal syndrome that is indistinguishable clinically from anti-GBM disease. However, the renal biopsy in ANCA vasculitis would demonstrate vasculitis rather than the deposition of IgG antibodies. c-ANCA is most likely to be associated with proteinase-3 antibodies and clinically may also have ear, nose and throat (ENT) disease.

Answer 160

Deficiencies of the membrane attack complex, (C5-C9) are particularly associated with meningococcal infection. Deficiencies of the C1 complex are recognised to be closely associated with the development of systemic lupus erythematosus. C3 deficiency is associated with a predisposition to infection with capsulated bacterial infections such as pneumococcus and Haemophilus which begins quite soon after birth. C4 deficiency is rare and is associated with early onset systemic lupus erythematosus. CD59 deficiency is involved in the pathogenesis of paroxysmal nocturnal haemoglobinuria.

Answer 161

This man has expressive aphasia due to a lesion in Broca's area, located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech here would be non-fluent, laboured and halting. Temporal lobe lesion may lead to Wernicke's aphasia: this area 'forms' the speech before 'sending it' to Brocas area. Lesions result in word substituion, neologisms but speech remains fluent.

Answer 162

By blocking the DPP-4 enzyme, sitagliptin reduces the peripheral breakdown of GLP-1 and GIP. This potentiates the incretin effect which is typically reduced in diabetes. Exenatide and liraglutide are examples of GLP-1 mimetics. They increase insulin secretion and inhibit glucagon secretion. One of the major advances of GLP-1 mimetics is that they typically result in weight loss, in contrast to insulin, sulfonylureas and thiazolidinediones. They are sometimes used in combination with insulin in T2DM to minimise weight gain.

Answer 163

Topiramate is also recommended by NICE as first-line prophylaxis against migraine. However, given that she is female and of child-bearing age a beta-blocker (such as propranolol) is a better choice.

Answer 164

Following the NICE 2017 guidelines, it is now recommended to use new generation dopamine receptor agonist for motor symptoms that are not affecting a patient's quality of life. For first-line treatment: -If the motor symptoms are affecting the patient's quality of life: levodopa -If the motor symptoms are not affecting the patient's quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor

Answer 165

Medication overuse headache -simple analgesia + triptans: stop abruptly -opioid analgesia: withdraw gradually

Answer 166

Prevention of acute mountain sickness includes limiting gain of altitude to 500m/day, increasing physical fitness and acetazolamide, a carbonic anhydrase inhibitor that causes metabolic acidosis and a compensatory respiratory alkalosis to increase respiratory rate and tissue oxygenation.

Answer 167

Bronchiectasis: most common organism = Haemophilus influenzae

Answer 168

In G6PD deficiency, blood film may show bite cells, blister cells, and Heinz bodies. Schistocytes are seen in MAHA (e.g., DIC, HUS). DIC can cause bleeding from various sites, while HUS, along with haemolytic anaemia, presents with thrombocytopenia and renal failure.

Answer 169

Calcineurin inhibitors inhibit calcineurin - the activity of which induces IL-2. Reduction of IL-2 leads to less T-cell mediated transplant rejection.

Answer 170

Salicylates directly stimulate the respiratory centre to produce an increase in depth and rate of breathing, thereby causing a respiratory alkalosis. Metabolic acidosis is a characteristic feature as the toxicity progresses and is not solely a compensatory mechanism.

Answer 171

The most sensitive test for SLE is ANA with 100% sensitivity. However, there are other tests for SLE with better specificity. The most specific tests are anti-dsDNA antibody and an anti-Smith antibody with 99% specificity. Anti-histone antibodies are present in more than 95% of patients with drug-induced lupus, especially among those taking procainamide, hydralazine, chlorpromazine, and quinidine.

Answer 172

In Goodpastures disease, B/L diffuse infiltrates in the lower zones are characteristic and represent pulmonary haemorrhages.

Answer 173

Ileocolic artery - supplies blood to terminal artery and appendix - it is the most inferior branch of the SMA

Answer 174

Yellow fever vaccine contains significant amounts of egg protein.

Answer 175

Gastric juice is normally at a pH range between 1.5 and 3.5

Answer 176

50% of patients are responsive to pyridoxine supplementation. Phenylalanine exclusion is the treatment of choice for phenylketonuria.

Answer 177

IV 20% dextrose should be given to correct the hypoglycaemia prior to treatment with IV thiamine.

Answer 178

The extensive back pressure from pulmonary hypertension can lead to TR which, in time, can lead to left atrial dilatation.

Answer 179

Posterior cerebral - ipsilateral third nerve palsy and contralateral hemiplegia is characteristic of Weber syndrome.

Answer 180

SOB, tachycardia and a raised JVP are often seen in cardiac tamponade.

Answer 181

Rasburicase is recombinant urate oxidase that drives the metabolism of uric acid.

Answer 182

4W - NICE guidelines currently state to avoid contact sport for 4W following EBV diagnosis

Answer 183

Artemether and lumefantrine is the initial intervention of choice for non-falciparum malaria. Primaquine should also overlap with this initial therapy to prevent relapse. Artesunate is the intervention of choice for patients with severe falciparum malaria.

Answer 184

Minimal glucocorticoid activity, very high mineralocorticoid activity - Fludrocortisone Glucocorticoid activity, high mineralocorticoid activity - Hydrocortisone Predominant glucocorticoid activity, low mineralocorticoid activity - Prednisolone Very high glucocorticoid activity, minimal mineralocorticoid activity - Dexamethasone, Betamethasone

Answer 185

Clostridioides difficile: spreads via the faecal-oral route by ingestion of spores

Answer 186

A recognised side effect of this drug is 'bull's eye retinopathy', which may result in severe and permanent visual loss.