MRCP Part 1 Flashcards
What is CRP?
Acute phase protein produced by the liver in response to increasing levels of IL6 (produced by macrophages)
CRP binds to damaged and foreign cells, increases complement activation and phagocytosis by macrophages
What does singing of a chest drain mean?
Chest drains should normally swing in response to breathing (inspiration –> fluid level up, expiration –> fluid level down)
Stopping swinging suggests that either the chest drain is blocked or the lung has re-expanded
What is the maximum rate at which you can remove fluid through a chest drain and why?
1 L at a time, followed by clamping for 1 hour
Risk of re-expansion pulmonary oedema
Should a chest drain bubble?
Only if it is a chest drain for a pneumothorax
If it is for a pleural effusion and it is bubbling, it may be suggestive of an air leak
How is digoxin loaded?
500 mcg –> 500 mcg (after 6 hours) then OD of:
125 mcg if tachycardic
67.5 mcg if normocardic
When should digoxin be used for rate control?
Heart failure patients as it is a negative chronotrope and a positive inotrope
How should your choice of antihypertensive change dependent on whether it is right or left heart failure with preserve ejection fraction?
RIGHT: choose venodilators (e.g. nitrates)
LEFT: choose arteriodilators (e.g. hydralazine, amlodipine)
What is a good medical treatment option for SIADH that has not improved with fluid restriction?
Demeclocycline
It is a tetracycline antibiotic that is used to treat Lyme disease and acne. It is good in SIADH as it induces a nephrogenic diabetes insipidus.
What is hidradenitis suppurativa?
Inflammatory skin condition characterised by recurrent painful skin abscesses
Which electrolyte should you be conscious of in patients who are receiving laxido/movicol?
Potassium (laxido/movicol contains potassium)
What dose should a nitrate infusion be started at?
2 mg/hour (50 mg in 50 mL)
Max dose 10 mg/hour
Which group of patients with active GI bleeding still require anticoagulation?
Inflammatory bowel disease (it is a prothrombotic state)
What should you always think about in a patient with normal blood pressure who is tachycardic?
Do they need fluids?
CO = SV x HR (if HR is high and CO is normal, then SV must be low)
NOTE: patients can have AF and be tachycardic without the tachycardia being caused by the AF (i.e. physiological tachycardia with AF)
What are the main types of renal tubular acidosis?
Type 1: DISTAL tubule dysfunction results in inability to excrete H+
Type 2: PROXIMAL tubule dysfunction results in inability to reabsorb bicarbonate
Type 4: ALDOSTERONE DEFICIENCY/RESISTANCE results in hyperkalaemia
NOTE: type 1 and type 2 are associated with hypokalaemia
What is May Thurner syndrome?
Compression of the left common iliac vein by the overlying right common iliac artery
Results in stasis of the blood and an increased risk of DVT
Which medication can be used to treat hiccups?
Chlorpromazine (typical antipsychotic)
NOTE: not to be confused with prochlorperazine which is a related medication used as an antiemetic
What is short bowel syndrome?
Malabsorption caused by a lack of small bowel (leads to diarrhoea, dehydration, malnutrition and weight loss)
Patients are typically given slightly sweet and slightly salty liquids
What dosing should be used for fondaparinux in patients with NSTEMI?
2.5 mg SC OD for up to 8 days (or until hospital discharge if sooner)
What is the link between magnesium deficiency and potassium deficiency?
Magnesium has an inhibitory effect on ROMK channels in the renal tubule, so a lack of magnesium results in increased excretion of potassium.
Magnesium deficiency also causes ineffective Na-K ATPase function
Why is magnesium used in the treatment of AF?
It acts as a weak calcium antagonist (blocks calcium at the AV node), resulting in a slower ventricular response
NOTE: this is the same way in which magnesium is used in asthma (relaxes the smooth muscle)
What are ESBLs?
Extended-spectrum beta lactamases - bacteria that are resistance to penicillins and cephalosporins
Why do loop diuretics cause hypocalcaemia?
The triple transporter in the ascending limb of the loop of Henle will absorb Na+ /K+/2Cl-. Na+ and 2CL- will be reabsorbed whilst K+ diffuses back into the tubule. This creates an electrochemical gradient (more positive in lumen, more negative in interstitium). Ca2+ will then flow down this gradient.
Blocking the triple transporter with loop diuretics will stop this effect and more calcium will be excreted in the urine.
What effect do thiazide diuretics have on calcium?
Thiazide promote calcium reabsorption (thereby causing hypercalcaemia).
NOTE: loop diuretics cause hypocalcaemia
What is atelectasis and what causes it?
Incomplete expansion of the lungs
It can be caused by anything that can reduce ventilation of airspaces (e.g. obesity, anaesthesia during surgery, mucus plug)
NOTE: it can cause hypoxia and increased risk of infection
Which bits of the brain are particularly affected by alcohol excess?
Cerebellum
Frontal lobe
Limbic System
What is bigeminy?
Repeated heart beat pattern (one long then one short) that is most often due to ectopic beats occurring so frequently that it happens after each sinus beat.
It does not require treatment unless it is symptomatic (then use beta-blockers)
What is trigeminy?
Ventricular ectopic occurs every third beat
What is a Premature Ventricular Contraction?
Heartbeat is initiated by the Purkinje fibres in the ventricles by the sinoatrial node
What does bifascicular block look like?
RBBB + left or right axis deviation
What does trifascicular block look like?
RBBB + left or right axis deviation + PR prolongation
List and give examples for the classes of antiarrhythmics.
Class 1 (Sodium Channel Blocker) - 1a: Quinidine, Procainamide, Disopyramide, Ajmaline - 1b: Lidocaine, Mexiletine, Phenytoin - 1c: Flecainide, Propafenone Class 2 (Beta-Blocker): bisoprolol Class 3 (Potassium Channel Blocker): amiodarone Class 4 (Calcium Channel Blockers): verapamil
What are the AEIOU indications for haemofiltration?
Acidosis Electrolyte Abnormalities (hyperkalaemia) Ingestion of Toxins Overload (Fluid) Uraemic Symptoms
What effect does multiple units of packed red cells have on coagulation?
It leads to an anticoagulant effect (as the packed red cell samples contain anticoagulant (calcium citrate))
This means that patients should also receive FFP if they have any more than 4 units of packed red cells
How does mycobacterium avium complex present in patients who are immunocompromised?
Similar to lymphoma Enlarged lymph nodes Fever Night sweats Weight loss
What is an advantage of RIG over PEG?
RIG does not require sedation and hence is better in patients with respiratory compromise (e.g. MND).
What is the main consequence of heparin-induced thrombocytopaenia?
Thrombosis
The binding of heparin to platelet factor 4 stimulates the generation of antibodies. These antibodies then bind to the heparin-platelet factor 4 complex and causes platelet activation resulting in thrombosis formation and depletion of platelets.
What does right ventricular strain look like on an ECG?
ST depression and T wave inversion in V1-3, I, II and aVF
How do you convert oral codeine to oral morphine?
10 mg codeine = 1 mg morphine
NOTE: breakthrough pain should be 1/6 of the total daily dose of morphine
Which organism is associated with causing infective endocarditis in patients with colorectal cancer?
Streptococcus bovis
What is the first-line treatment option for pericarditis?
NSAIDs and colchicine
How does TRALI present?
Hypoxia
Bilateral pulmonary infiltrates
Fever
Hypotension
NOTE: it is caused by the activation of host neutrophils by substances in the blood products. This triggers an inflammatory reaction within the lungs.
Which drugs increase the risk of gout?
Alcohol Diuretics Cytotoxics Ciclosporin Pyrazinamide
List some triggers for psoriasis.
Beta-blockers
Antimalarials
Stress
Streptococcal infection (guttate)
What is an indium labelled white cell study used for?
It labels white cell and watches where they accumulate (a bit like a PET scan for infection)
It is good for identifying occult abscesses
What pleural fluid results would you expect in a patient with empyema?
pH < 7.2
Glucose < 3.3 mmol/L
LDH > 1000
How do aminophyllines work?
Non-selective phosphodiesterase inhibitor (raises cAMP –> activate PKA –> inhibits TNF-alpha and leukotriene synthesis)
Non-selective adenosine receptor antagonist
NOTE: end result is bronchodilator
What are the presenting features of cerebral venous sinus thrombosis?
Headache
Papilloedema
Tonic Clonic Seizures
NOTE: MR or CT angiography/venography is required for diagnosis, and it is treated with anticoagulation
How does Whipple’s disease manifest?
Diarrhoea and arthropathy
Can also cause lymphadenopathy, skin hyperpigmentation, pleurisy and pericarditis
Duodenal biopsy shows subtotal villous atrophy which is PAS stain positive (caused by Tropheryma whipplei)
It is treated with oral co-trimoxazole
What is the first-line treatment option for gout?
NSAIDs
Colchicine 500 mg QDS can be used if NSAIDs are contraindicated (NOTE: reduced dose of 500 mg BD can be used in patients with renal impairment)
What is juvenile myoclonic epilepsy?
Condition characterised by generalised tonic clonic seizures usually provoked by sleep deprivation and excessive alcohol intake
Which common class of medications reduce excretion of lithium?
Diuretics (in particular, thiazide diuretics)
What is the cardiac index?
A haemodynamic parameter measured in intensive care which divides cardiac output from the left ventricle in one minute by the total body surface area
Low cardiac index is suggestive of cardiogenic shock
What are the typical presenting features of inclusion body myositis?
Weakness of quadriceps and long muscles of fingers
CK may be normal
What is Waldenstrom’s macroglobulinaemia?
A lymphoproliferative disorder characterised by IgM paraproteinaemia
It can result in hyperviscosity and splenomegaly
Which nerve root is responsible for the biceps reflex?
C56
Therefore, damage to this root will result in Erb’s palsy (loss of abduction and loss of biceps-mediated supination)
What is Liddle syndrome?
A secondary cause of hypertension resulting from a mutated epithelial sodium channel
Results in hypertension, alkalosis and hypokalaemia with suppressed renin and aldosterone.
What are the main features of dengue fever?
Fever, muscle aches, headache, rash
Lymphopaenia, Thrombocytopaenia and deranged LFTs
Which mutation is most often responsible for MODY?
Hepatic Nuclear Factor 1A (HNF1A)
NOTE: MODY presents in early adulthood with insulin-dependent diabetes mellitus (autosomal dominant) - they are very sensitive to sulphonylureas
When should phenytoin levels be checked after oral loading?
In roughly 2 weeks as phenytoin has a long half-life and therefore takes time to reach steady state concentrations
Aim 10-20 mg/L
What are the main functions of the proximal convoluted tubule?
Reabsorb sodium, amino acids and glucose
Exchange H+ ions for bicarbonate (reabsorb bicarbonate)
What are the symptoms of Waldenstrom hyperglobulinaemia?
Headaches
Nose bleeds
Hepatosplenomegaly
Papilloedema
NOTE: resulting from hypercoagulable state (Ix: protein electrophoresis)
What is the standard therapy used for small cell lung cancer?
Cisplatin and Etoposide
NOTE: carboplatin is used for those who cannot tolerate cisplatin
How does syringomyelia manifest?
Weakness in hands then arms (anterior horn cells)
Loss of pain and temperature in upper limbs (cape-like)
Followed by loss of fine touch, vibration and proprioception later on
What is the imidazoline receptor?
A receptor that can stimulate the sympathetic nervous system
Clonidine and Moxonidine block this receptor to achieve a reduction in blood pressure
What are the main consequences of hypophosphatemia?
Haemolytic anaemia Seizures Confusion Cardiomyopathy Skeletal Muscle Weakness
List some causes of hypophosphataemia.
Increased Renal Excretion
- Hyperparathyroidism
- X-Linked Hyperphosphataemia
- Fanconi Syndrome
- Diuretics
Decreased GI Absorption
- Reduced intake
- Phosphate binders (sevelamer)
- Alcohlism
Transcellular Shifts
- Refeeding syndrome
- Insulin
What is the treatment of choice for TTP?
Plasma exchange (steroids may be used as an adjunct)
Damage to which part of the brainstem would result in upgaze and downgaze palsy?
Dorsal Midbrain
It may also be associated with convergence nystagmus and impaired pupillary reflexes
NOTE: known as Parinaud syndrome
What is the treatment of choice for cerebral toxoplasmosis?
Sulfadiazine + Pyrimethamine + Folinic Acid for 6 Weeks
Describe the appearance of the rash in Darier’s disease.
Warty brown papules on the chest and back
Autosomal dominant inheritance pattern
What are the presenting symptoms of variant CJD?
Rapidly Progressive Dementia
Ataxia
Myoclonus
MRI –> Pulvinar Sign (High intensity in pulvinar region of thalamus) - described as ‘hockey stick sign’
Which antiemetic is used in the treatment of nausea and vomiting in hypercalcaemia?
Haloperidol
This is the most potent D2 antagonist and the mechanism of hypercalcaemia induced nausea is via the D2 receptor
Which foramen do crainal nerves IX, X and XI pass through?
Jugular Foramen
What is an appropriate fluid regime for someone who is admitted with DKA?
1 L 0.9% NaCl over 1 Hour 1 L 0.9% NaCl + KCl over 2 Hours 1 L 0.9% NaCl + KCl over 2 Hours 1 L 0.9% NaCl + KCl over 4 Hours 1 L 0.9% NaCl + KCl over 6 Hours
ADD 10% Dextrose at 125 mL/hour once BM < 14 mmol/L
BOLUS: 500 mL NaCl if SBP < 90 mm Hg
How should patients with DKA be monitored after commencing treatment?
HOURLY capillary ketones and glucose
VBG at 1 hour, 2 hours then every 2 hours thereafter
What is diabetic amyotrophy?
Complication of diabetes mellitus that results from damage to the lumbosacral plexus (supplying thighs and buttocks)
Manifests with lower leg pain, weakness, wasting and paraesthesia
List some CYP inhibitors that can increase the effect of warfarin.
Ciprofloxacin Clarithromycin Erythromycin Omeprazole Metronidazole Chloramphenicol Cranberry Juice
What are the manifestations of Brucellosis?
Fever Myalgia Weight loss Headache Abdominal pain
Bloods may show deranged LFTs but everything else may be normal
Blood cultures will be positive after 5 days (slow growing)
Caused by exposure to unpasteurised dairy products
What is high take off on an ECG?
Benign early repolarisation (looks like pericarditis) - common feature in < 50 yrs ST elevation in precordials leads Prominent T waves ST segment/T wave ratio < 0.25 Fishhook appearance in V4 ECG changes are stable over time
Which ECG change is seen in hypocalcaemia?
QT prolongation
NOTE: you get QT shortening in hypercalcaemia
Why does metformin cause lactic acidosis?
Mitochondrial toxicity + impaired gluconeogenesis (impairs pyruvate carboxylase which normally converts pyruvate into oxaloacetate)
What can be used as an antidote for excessive beta blockade?
IV glucagon
What are some features of lead poisoning?
Abdominal pain
Motor neuropathy
Basophilic stippling
Why is furosemide not effective in hypoalbuminaemic states?
It is highly protein bound and require protein binding in order to be secreted into the filtrate at the proximal convoluted tubule.
Other causes of reduced protein binding of furosemide include the presence of competing highly protein-bound drugs like phenytoin and warfarin.
What are the presenting features of lateral medullary syndrome?
Ipsilateral facial sensory loss
Contralateral body sensory loss
Cerebellar features (dysphagia, dysarthria, vertigo, nystagmus)
NOTE: due to PICA aneurysm/stroke
What is a major side-effect of ribavirin therapy?
Haemolytic anaemia
Which antibiotic causes a worsening of muscle weakness in Guillain Barre symptoms?
Ciprofloxacin
How is severe lithium overdose treated?
Haemodialysis (especially if level is > 4 mmol/L)
Name a long-acting opioid receptor antagonist used to prevent relapse in people who abuse opioids.
Naltrexone
List some common drugs that can increase serum lithium concentration.
Metronidazole NSAIDs ACE inhibitors and ARBs Thiazide diuretics Steroids
Describe the main features of pseudoxanthoma elasticum.
SKIN: yellow papules over neck, puckered skin
VASCULAR: PVD, mitral valve prolapse, GI bleed, visual loss (retinal angioid streaks)
NOTE: it is a hereditary disorder of elastic tissue
Which HLA types are associated with Coeliac disease?
HLA DQ2 and DQ8
Which type of lupus is ANA negative?
Discoid lupus
What are the two main types of porphyria and what is the difference?
Acute intermittent porphyria (no photosensitivity) Variegate porphyria (photosensitivity)
NOTE: both present with abdominal pain and hypertension
What is oral hairy leukoplakia caused by?
EBV
What are the features of theophylline toxicity?
Severe vomiting Seizures Hyperthermia Hypokalaemia Hyperglycaemia Tachyarrhythmia
How is ITP managed?
Oral Prednisolone –> IVIG
Splenectomy and immunosuppressive drugs (e.g. cyclophosphamide) may also be used
What is Evans syndrome?
AIHA + ITP
NOTE: it is treated with steroids
What is the issue with using iodine-containing contrast in patients with hyperthyroidism?
It can worsen hyperthyroidism caused by toxic multinodular goitre
It can improve hyperthryoidism in Graves’ disease
NOTE: a thyroid uptake scan would be recommended
What are the features of lithium overdose?
Decreased consciousness Neuromuscular excitability (tremor) Confusion Abdominal pain Vomiting AKI ECG Changes (TWI, QT prolongation)
How is tapeworm infection treated?
Niclosamide 2 g STAT
NOTE: tapeworm is caused by Taenia solium (pork) or Taenia saginata (beef)
What is the recommended antibiotic treatment option for cholera?
Ciprofloxacin
List some manifestations of temporal lobe epilepsy.
Ascending epigastric aura Olfactory/gustatory hallucinations Ictal fear Lip smacking/swallowing Limb automatisms (fiddling, tapping)
NOTE: caused by hippocampal sclerosis
What is a major complication of diphtheria?
Myocarditis
Which chemotherapy agents are commonly associated with peripheral neuropathy?
Vincristine
Cisplatin (platinum containing compounds)
Docetaxel (taxanes)
What is the dose conversion between hydrocortisone and prednisolone?
20 mg IV/PO Hydrocortisone = 5 mg PO Prednisolone
Which translocation causes APML?
15;17
NOTE: it is associated with DIC
Which cytokine is a particularly important target in the treatment of rheumatoid arthritis?
IL-6 (tocilizumab)
What is Ganser syndrome?
Dissociative disorder characterised by approximate answers, pseudohallucinations, somatic conversion, amnesia and reduced consciousness
What is the first-line treatment option for cervical dystonia?
Botulinum toxin injections
List some X-ray features of osteomyelitis.
Regional osteopaenia
Periosteal reaction
Focal bone lysis or cortical loss
How should exposure to hepatitis C be treated?
Monthly hepatitis C PCR
If it becomes positive, patients should be offered ribavirin and interferon (or daclatasivir)
What is Menetrier disease?
A rare condition associated with enlarged gastric folds in the fundus and body of the stomach
It causes epigastric pain, protein loss (hypoalbuminaemia) and hypochlorhydria
What are the features of Jervell and Lange-Nielsen syndrome?
Long QT
Bilateral sensorineural hearing loss
Why does urea increase in dehydration?
Vasopressin increases the activity of urea transporter 1 (UT-A1) in the collecting ducts
NOTE: the thin ascending limb of the loop of Henle and the inner medullary collecting ducts are permeable to urea. Urea adds to the osmolality of the medullary interstitium, thereby allowing the nephron to concentrate urine.
Why do psoas abscesses form?
The iliopsoas muscle has a very rich blood supply meaning that it is predisposed to haematogenous spread of infection.
What is DRESS syndrome?
Drug Reaction with Eosinophilia and Systemic Symptoms
TRIAD: extensive skin rash + high fever + organ involvement (e.g. liver impairment)
NOTE: Occurs most commonly with use of anticonvulsants (e.g. carbamazepine), allopurinol and sulphonamide antibiotics.
Why do you give a STAT amikacin for the treatment of urosepsis?
Treat the ESBLs
NOTE: they will be resistant against co-amoxiclav
Briefly describe Gittelman, Bartter and Liddle syndrome.
Gittelman: dysfunction of Na-Cl cotransporter in distal convoluted tubule (effects similar to thiazide diuretic use), leads to low calcium and low magnesium
Bartter: dysfunction of Na-K-Cl triple transporter in ascending limb of loop of Henle (effects similar to loop diuretic use)
Liddle: prevention of degradation of ENaC in collecting duct (effects similar to hyperaldosteronism)
What is another name for pANCA?
Anti-myeloperoxidase antibody
NOTE: cANCA target proteinase 3
What is the antibiotics treatment regimen of choice for cystic fibrosis patients with Pseudomonas infection?
Ceftazidime and tobramycin
What are some features of chronic lead poisoning?
Developmental delay
Abdominal pain
Blue line on gums
Constipation
What are some clinical features of vestibular schwannoma?
Unilateral sensorineural hearing loss
Ipsilateral ataxia
Facial weakness
Trigeminal sensory loss
What are some clinical features of vestibular schwannoma?
Unilateral sensorineural hearing loss
Ipsilateral ataxia
Facial weakness
Trigeminal sensory loss
How is a low-dose dexamethasone suppression test performed?
1 mg dexamethasone at midnight
Measure serum cortisol at 9 am
What is the difference between Wells, PERC and PESI?
Wells: Determine whether CTPA or D-Dimer would be required
PERC: Determine whether a PE is even a feasible possibility/requires further investigation
PESI: Determines mortality in people with a diagnosed PE
Which marker is used as a screening test for fungal infections?
Beta-D Glucan
At what point do you consider using negative suction to resolve a pneumothorax?
If a chest drain has failed to resolve the pneumothorax and there is a persistent air leak after 48 hours
What causes TRALI?
Presence of anti-HLA antibodies in the donated blood product
What are the Truelove and Witts criteria for a severe UC flare?
Bloody stools > 6 per day HR > 90 Temp > 37.8 Hb < 10.5 ESR > 30 CRP > 30
What is an option for the treatment of severe hand eczema?
Alitretinoin
Name a novel drug that is used to treat multiple sclerosis.
Fringolimod
NOTE: it is a sphingosine-1-phosphate receptor modulator which affects the activity of lymphocytes
What is the most common cause of line-related sepsis?
Staphylococcus aureus
What are some side-effects of phenytoin?
Ataxia
Nystagmus
Agitation
Drowsiness
(Cerebellar signs)
How is exercise testing interpreted according to the Bruce protocol?
Patients who cannot undergo two stages of the Bruce protocol (< 6 mins) are at higher risk of adverse cardiovascular events and should be considered for coronary angiography.
How do you dose amiodarone for cardioversion?
300 mg over 30-60 mins followed by 900 mg over 24 hours
Needs to be infused through a large cannula into a large peripheral vein or into a central vein as it can cause thrombophlebitis
What should you do with metformin in someone who is going to undergo an angiogram?
Metformin should be held for 48 hours before and after any procedure involving IV contrast (e.g. CT scan, angiogram)
This is because it could increase the risk of lactic acidosis.
How do you manage a relapse of multiple sclerosis?
Oral Methylprednisolone 0.5 g OD for 5 days
Which medication is used as prophylaxis for patients who suffer cluster headaches?
Verapamil
Alternatives: lithium, sodium valproate, gabapentin
Which type of myocardial infarction and rhythm disturbance would require temporary transvenous pacing?
Second or third degree heart block complicating an acute anterior MI
What is the normal systolic pressure of the pulmonary artery?
25 mm Hg
How can arrhythmias be prevented in patients with long QT syndrome?
Beta-blockers
ICD
Sympathectomy
What are the main presenting symptoms of systemic mastocytosis?
Urticaria pigementosa (with Darier sign)
Abdominal Pain
Flushing
Monocytosis on blood film
Which investigations are used in suspected systemic mastocytosis?
Raised serum tryptase levels
Urinary histamine
What are the main features of benign essential tremor and how is it managed?
Postural tremor that is worse when arms are outstretched
Improves with alcohol
Propranolol is the first-line treatment (primidone is used sometimes)
What is the most commonly isolated organism in animal bites?
Pasteurella multocida
Treated with co-amoxiclav (same with human bites)
List some CYP inducers that decrease the efficacy of warfarin.
Antiepileptics (phenytoin, carbemazepine)
Rifampicin
St. John’s Wort
Alcohol intake
Which beta-blockers are best in the treatment of heart failure?
Bisoprolol
Nebivolol
Carvedilol
What is a hybridoma?
A technique for producing monoclonal antibodies which combines mouse spleen cells with human myeloma cells.
The antibodies generated have a mouse variable region and a human constant region.
At what stage should a patient with rheumatoid arthritis be considered for a trial of a biologic agent?
After 2 DMARDs have been trialled and disease activity remains high (DAS28-CRP or DAS28-ESR > 5.1)
How is Ramsey Hunt syndrome treated?
Oral aciclovir and oral steroids
Which neuronal tracts are affected in subacute combined degeneration of the spinal cord?
Dorsal columns (resulting in loss of vibration and proprioception)
Lateral corticospinal tract (upper motor neurone findings in the legs)
Damage to peripheral nerves results in loss of knee and ankle jerks
How does retinitis pigmentosa manifest?
Night blindness
Tunnel vision
NOTE: it is genetic and associated with Refsum disease, Usher syndrome, abetalipoproteinemia, Laurence-Moon-Biedl syndrome, Kearns-Sayre syndrome and Alport syndrome
What are the first and second-line agents for secondary prevention in patients who have had a stroke or TIA?
Clopidogrel 75 mg OD
If not tolerated –> Aspirin 75 mg OD + Dipyridamole 200 mg BD
What would be a permanent solution to a patient with recurrent atrial flutter?
Radiofrequency ablation to the tricuspid valve isthmus
How is acne rosacea treated?
1st line: topical metronidazole (mild)
2nd line: systemic antibiotics (e.g. oxytetracycline) for severe disease
NOTE: topical brimonidine gel may be used in patients predominantly complaining of flushing
What are the phase I and phase II reactions in drug metabolism?
Phase I: Oxidation, Reduction and Hydrolysis (products are usually more active and may be toxic)
Phase II: Conjugation (products are inactive and excreted in the urine or bile)
How is Cryptosporidium diagnosed?
Modified Ziehl-Neelsen staining of stool to reveal red cysts
What are the two main parametric tests used in medical trials?
Student’s t-test - paired or unpaired*
Pearson’s product-moment coefficient - correlation
What are the main non-parametric tests used in medical trials?
Mann-Whitney U test
compares ordinal, interval, or ratio scales of unpaired data
Wilcoxon signed-rank test
compares two sets of observations on a single sample, e.g. a ‘before’ and ‘after’ test on the same population following an intervention
Chi-squared test
used to compare proportions or percentages e.g. compares the percentage of patients who improved following two different interventions
Spearman, Kendall rank - correlation
What are the features of S1 nerve root compression?
Sensory loss of posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
How long should patients be anticoagulated for if they are to have elective DC cardioversion?
Anticoagulated for at least 3 weeks
After DCCV, the patient should be anticoagulated for at least 4 weeks before decisions about anticoagulation should be made
NOTE: patients can have a TOE and, if negative, be heparinised and receive DCCV then and there. If there is high risk of cardioversion failure (e.g. previous failure or AF recurrence) then patients should also have at least 4 weeks of amiodarone or sotalol before DCCV.
What are the main homozygous genotypes of alpha 1 antitrypsin deficiency?
PiMM = normal PiSS = A1AT 50% of normal PiZZ = A1AT 10% or normal - this is the type that gets lung/liver manifestations
What are the manifestations of a parietal lobe lesion?
Sensory inattention Apraxia Astereognosis Inferior homonymous quadrantanopia Gerstmann syndrome (lesion of dominant parietal lobe): alexia, acalculia, finger agnosia and right-left disorientation
What is an important complication of topiramate treatment?
Acute angle closure glaucoma
Presents with acute myopia, headache and unreactive pupils
Which dermatomes are affected by C6-8 radiculopathies?
C6 - thumb and index finger
C7 - middle finger + palm of hand
C8 - ring + little finger
How is idiopathic pulmonary artery hypertension treated?
Prostacyclin analogues (treprostinil) Endothelin receptor antagonists (bosentan) Phosophodiesterase inhibitors (sildenafil)
NOTE: if good response to acute vasodilator testing - CCBs may be used (minority of patients)
List some NRTIs and NNRTIS.
NRTI: zidovudine, abacavir, emtricitabine, lamivudine, tenofovir
NNRTI: nevirapine, efavirenz
What are the presenting features of porphyria cutanea tarda?
Photosensitive rash with blistering in sun exposed areas (usually hands)
Hypertrichosis
Hyperpigmentation
NOTE: treated with chloroquine and venesection
What is internuclear ophthalmoplegia and which part of the brain is affected?
Inability to adduct the affected eye resulting in nystagmus and diplopia
It is caused by damage to the median longitudinal fasciculus which is found in the paramedian area of the midbrain and pons
How is ethylene glycol poisoning treated?
Fomepizole (inhibitor of alcohol dehydrogenase)
NOTE: ethanol used to be used to treat this k
How does Kearns-Sayre syndrome present?
External ophthalmoplegia Retinitis pigmentosa (night blindness) Ptosis Usually < 20 yrs Diabetes mellitus (insulin-dependent) Complete heart block Cardiomyopathy Recurrent stroke
Maternal inheritance
What is the first-line treatment for severe mitral stenosis?
Percutaneous mitral commisurotomy (balloon valvulotomy)
NOTE: transcatheter mitral valve repair is a second choice
List some medications that can exacerbate myasthenia gravis.
Beta-blockers Antibiotics (gentamicin, macrolides, quinolones, tetracyclines) Phenytoin Lithium Penicillamine Procainamide
Which antigen is the antibody in pemphigus vulgaris and bullous pemphigoid directed against?
Pemphigus Vulgaris: Desmoglein 3
Bullous Pemphigoid: Hemidesmosome
What does the Golgi apparatus add to protein in order to traffic them to lysosomes?
Mannose-6-phosphate
What is the second-line treatment option for angina if beta-blockers and rate-limiting calcium channel blockers are contraindicated?
Nicorandil (potassium channel activator)
NOTE: it is associated with causing gastrointestinal ulceration (ranging from oral ulcers to anal ulcers)
List the commonly used steroids in order of decreasing mineralocorticoid activity.
Hydrocortisone (most mineralocorticoid activity)
Prednisolone
Dexamethasone/Betamethasone
What are the main symptoms of renal vein thrombosis?
Sudden-onset flank pain
Deterioration in renal function
Haematuria
What is chronic granulomatous disease and how does it present?
Neutrophil disorder resulting from a lack of NADPH oxidase, which reduces the ability of the neutrophil to produce ROS
Presents with recurrent pneumonia/abscesses (particularly S. aureus and funguses like Aspergillus)
How is chronic granulomatous disease diagnosed?
Negative nitroblue-tetrazolium test
Abnormal dihydrorhodamine flow cytometry
What is Chediak-Higashi syndrome and how does it present?
Neutrophil disorder resulting from a defect in microtubule polymerisation leading to reduced phagocytosis
Affected children have partial albinism and peripheral neuropathy, recurrent bacterial infections
What is leucocyte adhesion deficiency and how does it present?
Neutrophil disorder caused by defect in LFA-1 integrin on neutrophils
Leads to recurrent bacterial infections, delay in umbilical cord sloughing and absence of neutrophils at site of infection
How does common variable immunodeficiency present?
It is a B cell disorder that results in hypogammaglobulinaemia
It may predispose to lymphoma and autoimmune disorders
What is Bruton’s X-linked agammaglobulinaemia?
B cell disorder characterised by a defect in Bruton’s tyrosine kinase resulting in a severe block in B cell development
Patients develop recurrent bacterial infections, there is an absence of B cells and reduced immunoglobulins of all classes
How might selective IgA deficiency manifest?
Recurrent sinus and respiratory tract infections
Associated with coeliac disease
May develop severe reactions to blood transfusions (due to anti-IgA antibodies)
What is DiGeorge syndrome and how does it manifest?
T cell disorder caused by 22q11.2 deletion resulting in failure to develop the 3rd and 4th pharyngeal pouches
Manifestations include congenital heart disease (e.g. tetralogy of Fallot), learning difficulties, hypocalcaemia, recurrent viral/fungal diseases, cleft palate
List some combined B and T cell disorders.
SCID (multiple causes)
Ataxia Telangiectasia (defect in DNA repair, leads to cerebellar ataxia, telangiectasia, recurrent chest infections and increased risk of malignancy)
Wiskott Aldrich Syndrome (defect in WASP gene, recurrent bacterial infection, eczema, thrombocytopaenia, autoimmune diseases)
Hyper IgM Syndrome (mutation in CD40 gene, hepatitis, diarrhoea, PCP infection)
What are the recommendations for secondary prevention of osteoporotic fractures in postmenopausal women?
1st line: alendronate
2nd line: risedronate or etidronate
3rd line: strontium ranelate or raloxifene
What is myotonic dystrophy and what are its main features?
Inherited myopathy that presents at around 20-30 years
Autosomal dominant trinucleotide repeat disorder (DM1 caused by CTG repeat, DM2 is caused by repeat expansion of ZNF9 gene)
Main features are myotonic facies, frontal balding, bilateral ptosis, cataract and dysarthria
Also associated with dysphagia, diabetes mellitus, mild mental impairment, testicular atrophy, heart block and cardiomyopathy
How should giant cell arteritis be managed?
Uncomplicated (no visual involvement or tongue/jaw claudication) –> PO prednisolone 40-60 mg OD
Complicated (visual involvement and/or tongue/jaw claudication) –> IV methylprednisolone 500-1000 mg for 3 days before starting oral prednisolone
List some features of severe malaria.
Schizonts on a blood film Parasitaemia > 2% Hypoglycaemia Acidosis Temperature > 39 °C Severe anaemia Cerebral malaria (seizures, coma) Acute renal failure ARDS DIC
What is an important contraindication of anticholinergic treatment for urge incontinence?
Previous history of urinary retention
NOTE: it should also be avoided in the elderly as it can worsen confusion
What is the main test used to screen for latent TB?
Mantoux
IGRA is used if Mantoux is positive
What can precipitate pompholyx eczema?
High humidity and heat
What are the main translocations associated with the various types of lymphoma/leukaemia?
Follicular Lymphoma - t(14,18) Burkitt Lymphoma - t(8,14) CML - t(9,22) Mantle Cell Lymphoma - t(11, 14) Ewing Sarcoma - t(11, 22) APML - t(15, 17)
How should wounds at risk of tetanus infection be managed?
Full course of tetanus vaccines (5) with last dose < 10 years –> no vaccine or immunoglobulin
Full course of tetanus vaccines with last dose > 10 years –> if tetanus prone then reinforcing dose of vaccine, if very high-risk give reinforcing dose and tetanus immunoglobulin
If vaccination history unclear –> give reinforcing dose, give tetanus immunoglobulin if tetanus-prone or high-risk wound
What are the main features of acute intermittent porphyria?
autosomal dominant
defect in porphobilinogen deaminase
female and 20-40 year olds more likely to be affected
typically present with abdominal symptoms, neuropsychiatric symptoms
hypertension and tachycardia common
urine turns deep red on standing
What are the main features of porphyria cutanea tarda?
most common hepatic porphyria
defect in uroporphyrinogen decarboxylase
may be caused by hepatocyte damage e.g. alcohol, oestrogens
classically photosensitive rash with bullae, skin fragility on face and dorsal aspect of hands
urine: elevated uroporphyrinogen and pink fluorescence of urine under Wood’s lamp
manage with chloroquine
What are the main features of variegate porphyria?
autosomal dominant defect in protoporphyrinogen oxidase photosensitive blistering rash abdominal and neurological symptoms more common in South Africans
How should you manage someone who has been bitten by someone with Hepatitis B?
If person is known to be a responder to HBV vaccine –> give booster dose
If non-responder or not fully vaccinated –> Give HBIG + Vaccine Booster
NOTE: if unclear whether exposed to HBV, consider giving booster dose and if known non-responder, give booster dose and HBIG
On which chromosomes do you find the PKD genes?
PKD1 –> Chromosome 16
PKD2 –> Chromosome 4
What are the main manifestations of TCA overdose?
Arrhythmias (long QRS - risk of ventricular arrhythmia)
Seizures
Metabolic Acidosis
Coma
How are TCA overdoses managed?
IV Sodium Bicarbonate (first-line for hypotension and arrhythmias)
How is Raynaud’s phenomenon treated?
1st Line: CCBs (e.g. nifedipine)
2nd Line: IV Prostacyclin infusion (e.g. epoprostenol)
Which drug groups could precipitate an attack in patients with a history of acute intermittent porphyria?
Barbiturates Halothane Benzodiazepines Alcohol OCP Sulphonamides
How should patients with suspected HIV seroconversion be investigated?
p24 antigen test (positive from 1 to 3/4 weeks after infection) HIV antibody (most common and accurate test - most will develop antibodies by 4-6 weeks)
NOTE: antibodies may not be detectable yet
What are the main features of MODY?
Develops < 25 yrs
Family history of early-onset diabetes (autosomal dominant)
Ketosis NOT present
Sensitive to sulfonylureas (insulin often not necessary)
NOTE: bit like early-onset type 2 diabetes mellitus
Which class of diabetes medications is associated with causing SIADH?
Sulfonylureas
Which bacterium most commonly causes peritonitis secondary to peritoneal dialysis?
Staphylococcus epidermidis
What is the gold standard diagnostic test for hereditary spherocytosis?
EMA Binding Test
NOTE: it is treated with folate supplementation and splenectomy (in severe cases)
What is Ham’s test used for?
Paroxysmal nocturnal haemoglobinuria
BUT, the gold standard test is now flow cytometry for CD59 and CD55 (these are negative)
How does mycophenolate mofetil work?
Reduces lymphocyte production through inhibition of inosine-5-monophosphate-dehydrogenase (required for purine synthesis)
What causes the majority of cases of primary hyperaldosteronism?
Bilateral adrenal hyperplasia (70%)
NOTE: it used to be thought that most cases were due to adrenal adenomas (Conn’s)
Which layers of the adrenal cortex secrete which hormones?
Glomerulosa –> Aldosterone
Fasciculata –> Glucocorticoids
Reticularis –> Sex Steroids
Medulla –> Catecholamines
What do the x descent and y descent represent on a JVP waveform?
X descent –> fall in atrial pressure during ventricular systole
Y descent –> opening of the tricuspid valve
What does the ulnar nerve supply?
MOTOR: medial two lumbricals, adductor policis, interossei, hypothenar muscles, flexor carpi ulnaris
SENSORY: medial 1.5 fingers
How does damage to the ulnar nerve manifest?
AT WRIST: Claw hand (hyperextension of MCP, flexion of distal and proximal IPJs of 4th/5th digits) + wasting of intrinsic hand muscles + wasting of hypothenar muscles + sensory loss to medial 1.5 fingers
AT ELBOW: Clawing is less severe , radial deviation of wrist
List the manifestations of different complement deficiencies.
C1 inhibitor –> hereditary angioedema
C1, C2, C4 –> immune complex disease (e.g. SLE)
C3 –> recurrent bacterial infections
C5 –> Leiner disease, watery diarrhoea, seborrhoeic dermatitis
C5-C9 –> severe meningococcal infection
Why does trimethoprim cause a slight rise in creatinine?
It competitively inhibits creatinine secretion in the tubule
NOTE: It also blocks ENaC in the distal nephron which causes a hyperkalaemic distal RTA
Which drugs can cause idiopathic intracranial hypertension?
Steroids
COCP
Tetracyclines
Lithium
What is the first-line antibiotic recommended for the treatment of Campylobacter jejuni?
Clarithromycin
What is the first-line antiepileptic drug for the treatment of myoclonic epilepsy?
Sodium valproate
Second line: clonazepam, lamotrigine
NOTE: carbamazepine can worsen myoclonic seizures
What is the first-line antiepileptic used for generalised and focal seizures?
Generalised: sodium valproate
Focal: carbamazepine
Which antiepileptics are used for absence seizures?
Sodium valproate or ethosuximide
How should caustic ingestion be managed?
Asymptomatic - discharge after trial of oral fluids + period of observation
Symptomatic - high dose IV PPI, urgent endoscopy
How is high-altitude pulmonary oedema managed?
Descent
Nifedipine
Others (dexamethasone, acetazolamide, phosphodiesterase type V inhibitors)
How is high-altitude cerebral oedema managed?
Descent
Dexamethasone
Name an alkylating agent and its potential side-effects.
Cyclophosphamide
SE: haemorrhagic cystitis, myelosuppression, transitional cell carcinoma
NOTE: haemorrhagic cystitis can be prevented with mesna
List some cytotoxic antibiotics and their adverse effects.
Bleomycin –> degrades preformed DNA –> lung fibrosis
Anthracyclines (e.g. doxorubicin) –> stabilised DNA topoisomerase II complex inhibits DNA and RNA synthesis –> Cardiomyopathy
Give an example of a topoisomerase inhibitor.
Iriontecan
SE: myelosuppression
What is a notable side-effect of vincristine?
Peripheral Neuropathy
Paralytic Ileus
Which diseases are associated with the following HLA types? HLA-A3 HLA-B51 HLA-B27 HLA-DR2 HLA-DR3 HLA-DR4
HLA-A3 - Hereditary Haemochromatosis
HLA-B51 - Behcet’s Disease
HLA-B27 - Ankylosing Spondylitis, Reactive Arthritis, Anterior Uveitis
HLA-DR2 - Goodpasture’s, Narcolepsy
HLA-DR3 - Dermatitis Herpetiformis, Sjogren Syndrome, PBC
HLA-DR4 - Rheumatoid Arthritis, T1DM (DRB1*04:01)
How does homocystinuria manifest?
Tall stature Long fingers Downward lens dislocation Learning difficulties Unprovoked DVT at early age Malar flush
NOTE: it is an autosomal recessive condition caused by a deficiency of cystathione beta synthase that is screened for in neonatal screening. It is treated with pyridoxine supplements.
Describe the natural history of autosomal recessive polycystic kidney disease.
Diagnosed on prenatal ultrasound scan/early infancy
Newborns have features of Potter sequence due to oligohydramnios
End-stage renal failure in childhood
Which vitamin deficiency causes angular cheilitis?
Riboflavin (Vitamin B2)
Which antibiotic should be used to treat meningococcal meningitis in a patient who has anaphylactic reactions t penicillins?
Chloramphenicol
Which antibiotics may be used as prophylaxis in contacts of people with meningococcal meningitis?
Ciprofloxacin or Rifampicin
Which conditions can cause Charles-Bonnet Syndrome?
Age-related macular degeneration (most common)
Glaucoma
Cataracts
How does ataxia telangiectasia present?
Cerebellar ataxia
Telangiectasia
Recurrent chest infections
Which nerves pass through the following foramina?
Foramen rotundum
Foramen ovale
Jugular foramen
Foramen rotundum - Maxillary Nerve (V2)
Foramen ovale - Mandibular Nerve (V3)
Jugular foramen - IX, X and XI
Which nerves pass through the superior orbital fissure?
III
IV
V1 (Ophthalmic)
VI
What are the main forms of malaria prophylaxis that are currently recommended?
Atovaquone and Proguanil (Malarone)
Doxycycline (risk of photosensitivity)
Which biological therapy may be used to prevent C. difficile recurrence?
Bezlotoxumab
What are some complications of typhoid?
Osteomyelitis
GI bleed/perforation
Meningitis
Cholecystitis
Give some examples of drugs that follow zero-order kinetics?
Alcohol
Phenytoin
Salicylates (aspirin)
What pressures does pulmonary capillary wedge pressure using a Swan-Ganz catheter equate to?
Left atrial pressure
Which patients should be offered prophylactic antibiotics for SBP?
Oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein < 15 g/L until the ascites has resolved
And patients who have had an episode of SBP
What are some features of pseudoxanthoma elasticum?
Autosomal recessive disorder of elastic fibres
Retinal angioid streaks
Plucked chicken skin appearance
Increased risk of ischaemic heart disease
GI haemorrhage
What should splenectomy patients be vaccinated against?
Pneumococcus
Haemophilus type B
Meningococcus type C
Describe the features of Adult-onset Still’s disease.
NOTE: it is a diagnosis of exclusion (ANA and RF negative)
Arthralgia Very high ferritin Salmon-pink maculopapular rash Pyrexia Lymphadenopathy
How would a posterior communicating artery aneurysm present?
3rd Nerve Palsy with Pupil Dilation
Painful + Headache
List some causes of 3rd nerve palsy.
Diabetes Mellitus Vasculitis (e.g. temporal arteritis) Posterior Communicating Artery Aneurysm Cavernous Sinus Thrombosis Weber Syndrome (ipsilateral third nerve palsy with contralateral hemiplegia - caused by midbrain strokes)
Describe steps taken to reduce the risk of contrast-induced nephropathy.
Give IV 0.9% saline at a rate of 1 mL/kg/hour for the 12 hours before and after the CT scan
Metformin should be withheld for a minimum of 48 hours until renal function has been shown to be normal
What are the first-line treatment options for diabetic neuropathy?
Duloxetine
Amitriptyline
Pregabalin
Gabapentin
How should pregnant women at high risk of developing pre-eclampsia be managed?
Aspirin 75 mg OD from 12 weeks until birth
What is calciphylaxis?
Rare complication of end-stage renal disease (vasculopathy of small blood vessels)
Presents with painful necrotic skin lesions containing calcium deposits
What is methaemoglobinaemia?
It is haemoglobin that has been oxidised to the Fe3+ form and can no longer carry oxygen, resulting in global tissue hypoxia
It may be congenital or may occur due to certain medications (e.g. sulphonamides, nitrates, sodium nitroprusside, dapsone, primaquine)
How does methaemoglobinuria present?
Cyanosis
Shortness of breath
Anxiety
Normal pO2 with low SaO2
NOTE: it shifts the oxygen dissociation curve to the left and is treated using methylene blue
What are some causes of cannon a waves?
Complete heart block (irregular)
AVNRT (regular)
Ventricular tachycardia (with 1:1 atrial: ventricular contraction)
How does a VIPoma present?
Large volume diarrhoea Weight loss Dehydration Hypokalaemia Hypochlorhydria
NOTE: 90% are seen in the pancreas (vasoactive intestinal peptide)
Outline the phases of the cardiac action potential and the direction of ion movement.
0 - Rapid Depolarisation - Rapid Na Influx
1 - Early Repolarisation - K Efflux
2 - Plateau - Slow Ca Influx
3 - Final Repolarisation - K Efflux
4 - Restoration of Ionic Concentrations - Na/K ATPase
What is the first-line treatment option for hepatitis B?
Pegylated interferon
Others: tenofovir, entecavir, telbivudine
List some drugs that are commonly overdosed and CAN be removed with dialysis.
Barbiturate Lithium Alcohol (inc methanol, ethylene glycol) Salicylates Theophyllines (charcoal haemoperfusion is preferable)
List some drugs that are commonly overdosed and CANNOT be removed with dialysis.
TCAs benzodiazepines dextropropoxyphene (Co-proxamol) digoxin beta-blockers
List some medications that should be avoided when breastfeeding.
Antibiotics (ciprofloxacin, tetracyclines, chloramphenicol, sulphonamides) Lithium Benzodiazepines Aspirin Carbimazole Methotrexate Sulfonylureas Amiodarone
Which classes of drugs are used to treat glaucoma and how to they work?
Prostaglandin analogues (e.g. latanoprost) - increases uveoscleral outflow
Beta-blockers (e.g. timolol) - reduced aqueous generation
Sympathomimetics (e.g. brimonidine - a2 agonist) - reduces aqueous production and increases outflow
Carbonic anhydrase inhibitors (e.g. dorzolamide) - reduces aqueous production
Miotics (e.g. pilocarpine) - increases uveoscleral outflow
What is the first-line investigation for acute intermittent porphyria?
Raised urinary porphobilinogen
What are the feature of polyarteritis nodosa?
Fever, malaise, arthralgia Low grade fever Haematuria Livedo reticularis Mononeuritis multiplex
NOTE: associated with hep B and ANCA
What is mononeuritis multiplex?
Painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy
Involves isolated damage to at least 2 separate nerve areas
Associated with diabetes mellitus, sarcoidosis, rheumatoid arthritis and polyarteritis nodosa
What is the equation for standard error of the mean?
SEM = SD/sqrt(n)
What change in GFR and creatinine is permissible in patients being started on ACE inhibitors?
Up to 25% decrease in GFR
Up to 30% rise in creatinine
Why do you do U&E before starting someone on amiodarone?
To rule out hypokalaemia
All antiarrhythmics can cause arrhythmias and concomitant hypokalaemia massively increases the risk of that happening
Outline how gestational diabetes should be managed.
If FBG < 7 - diet and exercise
- If targets not met within 1-2 weeks, start metformin (glibenclamide is an alternative)
- If targets still not met, start insulin
If FBG > 7 - start insulin
What is hyperchylomicronaemia?
Disease caused by hereditary lipoprotein lipase deficiency and apolipoprotein C deficiency that predisposes to recurrent attacks of acute pancreatitis.
Which antibiotics work by inhibiting DNA synthesis?
Quinolones
Metronidazole
Sulphonamides
Trimethoprim
Which antibiotics work by inhibiting protein synthesis?
Aminoglycosides Chloramphenicol Macrolides Tetracyclines Fusidic Acid
What are some good prognostic factors for ALL?
French-American-British (FAB) L1 type Common ALL Pre-B phenotype Low initial WBC del(9p) Hyperdiploidy
What is the mechanism of action of the following antivirals? Ribavirin Amantadine Oseltamivir Foscarnet Interferon Alpha Cidofovir
Ribavirin - guanosine analogue, interferes with capping of viral mRNA
Amantadine - M2 inhibitor prevents virus uncoating within cells
Oseltamivir - neuraminidase inhibitor
Foscarnet - inhibits viral DNA polymerase
Interferon Alpha - inhibits mRNA synthesis
Cidofovir - DNA polymerase inhibitor
List the ECG features of digoxin toxicity.
Down-sloping ST depression (reverse tick)
Flattened/inverted T waves
Short QT interval
Arrhythmias (e.g. AV block, bradycardia)
Which gene mutations does testing for hereditary haemochromatosis look for?
C282Y
H63D
What are the two types of mesangiocapillary (membranoproliferative) glomerulonephritis and what are their associations?
Type 1: Cryoglobulinaemia, Hepatitis C
Type 2: Partial Lipodystrophy (associated with low C3)
How is primary open-angle glaucoma treated?
1st: Prostaglandin analogue (e.g. latanoprost)
2nd: Beta-blocker (e.g. timolol), sympathomimetic (e.g. brimonidine) or carbonic anhydrase inhibitor
3rd: surgery or laser
What should always be done before starting a patient with COPD on azithromycin?
ECG
Azithromycin can prolong QT interval
What is the difference between the mechanism of action of vincristine and docetaxel?
Vincristine - inhibits microtubule formation
Docetaxel - inhibits microtubule disassembly
Which manoeuvres are used in the diagnosis and treatment of BPPV?
Dix-Hallpike - Diagnostic
Epley - Therapeutic
What are the histological features of diabetic nephropathy?
Kimmelstiel-Wilson lesions (nodular glomerulosclerosis)
Hyaline arteriosclerosis
What are the features of a Holmes-Adie pupil?
Unilateral (80% of cases) benign dilated pupil
Once constricted, the pupil remains small for a long time
Slow reaction to accommodation and none to light
Associated with absent knee/ankle reflexes
What are the main features of NF1 and NF2?
NF1 - Cafe au lait spots - Axillary freckling - Peripheral neurofibromas - Lisch nodules - Scoliosis - Phaeochromocytomas NF2 - Bilateral vestibular schwannomas - Meningiomas and Ependyomas
What are the main features of tuberous sclerosis?
Multiple CNS hamartomas Subependymal giant cell astrocytomas Renal angiomyolipomas Cardiac rhabdomyomas Facial angiofibromas Shagreen patches Retinal astrocytic hamartomas
Which chromosome are HLA antigens encoded on?
Chromosome 6
List some glycogen storage diseases and their manifestations.
Von Gierke disease (type I) - glucose-6-phosphatase - hypoglycaemia, lactic acidosis and hepatomegaly (hepatic glycogen accumulation)
Pompe’s disease (type II) - lysosomal alpha-1,4-glucosidase - cardiac, hepatic and muscle glycogen accumulation, leads to cardiomegaly
Cori disease (type III) - alpha-1,6-glucosidase - hepatic and cardiac glycogen accumulation, leads to muscle hypotonia
McArdle Disease (type V) - glycogen phosphorylase - skeletal muscle glycogen accumulation, leads to myalgia and myoglobinuria with exercise and second wind phenomenon
List some lysosomal storage disorders and their manifestations.
Gaucher - beta-glucocerebrosidase - most common, hepatosplenomegaly and avascular necrosis of femur
Tay-Sachs - Hexosaminidase A - accumulation of G2 ganglioside in lysosomes, leads to developmental delay, cherry red spot on macula, NORMAL liver and spleen
Nieman-Pick - sphingomyelinase - hepatosplenomegaly and cherry spot on macula
Fabry - alpha-galactosidase A - angiokeratomas, renal failure, peripheral neuropathy of extremities
Krabbe - galactocerebrosidase - peripheral neuropathy, optic atrophy and globoid cells
Metachromatic leukodystrophy - arylsulfatase A - demyelination of CNS and PNS
List some mucopolysaccharidoses and their manifestations.
Hurler Syndrome (type I) - leads to gargoylism, hepatosplenomegaly and corneal clouding
Hunter Syndrome (type II) - coarse facial features, behavioural problems, short stature, no corneal clouding
NOTE: both are caused by accumulation of glycosaminoglycans
Damage to which brain structure causes hemibalismus?
Subthalamic nucleus of basal ganglia
What are the ECG features of arrhythmogenic right ventricular cardiomyopathy?
ECG abnormalities in V1-3 (TWI) Epsilon wave (terminal notch in QRS complex)
What is catecholaminergic polymorphic ventricular tachycardia?
Form of inherited (AD) cardiac disease associated with sudden death
Exercise or exertion leads to VT and syncope
Generally presents < 20 years
Which commonly used drugs can cause photosensitivity?
Thiazides Tetracyclines Ciprofloxacin Amiodarone NSAIDs Sulphonylureas
What is the King’s College Hospital criteria for liver transplantation following paracetamol overdose?
Arterial pH < 7.3 more 24 hours after ingestion Or all of the following - PT > 100 seconds - Creatinine > 300 - Grade III or IV Encephalopathy
List the uses of interferon alpha, beta and gamma.
Alpha - hepatitis B/C, Kaposi sarcoma, metastatic renal cell carcinoma, hairy cell leukaemia
Beta - relapsing-remitting MS
Gamma - chronic granulomatous disease, osteopetrosis
What is trihexyphenidyl?
Antimuscarinic used to treat Parkinson’s disease (particularly drug-induced Parkinsonism)
What channel abnormality tends to cause long QT syndrome?
Blockage or loss of function of potassium channels
List some drugs that can cause agranulocytosis.
Antithyroid (carbimazole, propylthiouracil)
Antipsychotics (clozapine)
Antiepileptics (clozapine)
Antibiotics (penicillin, choramphenicol)
Antidepressant (mirtazapine)
What is the Hering-Breuer reflex?
Lung distention is detected by stretch receptors in the lungs which causes slowing of the respiratory rate
NOTE: this prevent the lungs from overexpanding during inspiration
List some common causes of cataracts.
Ageing Smoking Increased alcohol consumption Trauma Diabetes mellitus Long-term corticosteroids Radiation exposure Myotonic dystrophy Metabolic disorders: hypocalcaemia
How is hepatitis C treated?
Combination of protease inhibitors (e.g. sofosbuvir + daclatasvir) with or without ribavirin
TARGET: sustained virologic response (undetectable serum HCV RNA 6 months after ending therapy)
Which chromosomes are the genes responsible for the following diseases found on?
- NF1
- NF2
- von Hippel Lindau
- Tuberous Sclerosis
von Hippel Lindau - 3
Tuberous Sclerosis - 16
NF1 - 17
NF2 - 22
List some causes of mixed upper and lower motor neurone signs.
subacute combined degeneration of the cord motor neuron disease Friedreich's ataxia syringomyelia taboparesis (syphilis) conus medullaris lesion
What are the main features of pemphigus vulgaris?
Mucosal ulceration is common
Blisters are flaccid, easily ruptured bullae
Nikolsky sign positive
Acantholysis on biopsy
What are the main features of macrophage activation syndrome?
Definition; uncontrolled inflammatory state associated with systemic autoimmune diseases (e.g. JIA)
Features: Refractory fever, hepatosplenomegaly
Pathophysiology: caused by abnormal interferon-gamma activity which activates macrophages
Which antibody is primary membranous glomerulonephritis associated with?
Anti-PLA2R
Secondary causes include:
Malignancy such as solid tumours (lung, colon, breast, kidney)
Infections: hepatitis B or C, HIB, malaria, syphilis, schistosomiasis
Autoimmune diseases: SLE, sarcoidosis, IBD
Drugs: NSAID’s, captopril, gold, penicillamine, lithium, clopidogrel
Outline the ECOG score.
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair
5 Dead
Which causes of lung fibrosis classically affect the upper zones?
hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
coal worker’s pneumoconiosis/progressive massive fibrosis
silicosis
sarcoidosis
ankylosing spondylitis (rare)
histiocytosis
tuberculosis
Which causes of lung fibrosis classically affect the lower zones?
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
How does meglitinide work?
Stimulates insulin release
It is good for post-prandial hyperglycaemia and for erratic lifestyles and is less likely to cause hypoglycaemia than sulfonylureas
How does anhydrosis determine the site of the lesion in Horner syndrome?
Head, arm, trunk = central lesion: stroke, syringomyelia
Just face = pre-ganglionic lesion: Pancoast’s, cervical rib
Absent = post-ganglionic lesion: carotid artery
What is Miller Fisher syndrome?
Type of Guillain Barre Syndrome that primarily affects the cranial nerves
Presents with ataxia, ophthalmoplegia, areflexia and descending paralysis. Associated with antiganglioside antibodies GQ1b and GT1a
What is the difference between Hazard Ratio and Risk Ratio?
It is used when risk is not constant to time
It is usually used when assessing survival over time
Describe the CXR stages of sarcoidosis.
1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis
What is Lofgren syndrome?
Presentation of sarcoidosis characterised by the presence of the following symptoms:
- BHL
- Erythema nodosum
- Polyarthritis
- Fever
What are the ECG features of hypokalaemia?
U waves Small or absent T waves (occasionally inverted) Prolonged PR interval ST depression Long QT
Describe the presentation of African trypanosomiasis.
Trypanosoma chancre (painless subcutaneous nodule at site of infection)
Intermittent fever
Enlarged posterior cervical lymph nodes
CNS involvement (somnolence, headache, reversal or sleep-wake cycle)
Treated with IV pentamidine and suramin. IV melarsoprol used for CNS involvement.
What are the main consequences of chronic Chagas disease?
Myocarditis leading to dilated cardiomyopathy GI features (megaoesophagus and megacolon)
Treated with benznidazole or nifurtimox
What are the ECG features of hypothermia?
Bradycardia J wave (hump at end of QRS complex) First degree heart block Long QT Atrial and ventricular arrhythmias
What is the first line treatment option for lichen planus?
Potent topical steroid (e.g. clobetasol)
Description of rash: papular, polygonal, violaceous, flat-topped rash is present on the palms, in her elbow creases and on the soles of her feet
Which type of anaemia can phenytoin cause?
Folate deficiency anaemia
What is the diagnostic criteria for metabolic syndrome?
At least 3 of the following:
elevated waist circumference: men > 102 cm, women > 88 cm
elevated triglycerides: > 1.7 mmol/L
reduced HDL: < 1.03 mmol/L in males and < 1.29 mmol/L in females
raised blood pressure: > 130/85 mmHg, or active treatment of hypertension
raised fasting plasma glucose > 5.6 mmol/L, or previously diagnosed type 2 diabetes
For how long should you monitor a patient undergoing treatment for anaphylaxis?
8 hours (risk of biphasic reaction)
What are the features of Staphylococcal toxic shock syndrome?
Fever > 38.9 Hypotension (SBP < 90 mm Hg) Diffuse erythematous rash Desquamation of skin on palms and soles Involvement of three or more organ systems (e.g. gastrointestinal, renal, hepatitis, thrombocytopaenia, CNS, mucous membrane)
List some associations of retroperitoneal fibrosis.
Riedel's thyroiditis Previous radiotherapy Sarcoidosis Inflammatory abdominal aortic aneurysm Drugs: methysergide
List some drugs that cause lung fibrosis.
Amiodarone
Cytotoxic agents: busulphan, bleomycin
Anti-rheumatoid drugs: methotrexate, sulfasalazine
Nitrofurantoin
Ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide)
What is TLCO?
Rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion.
KCO is adjusted for lung volume
List some causes a high and a low TLCO.
HIGH
- Asthma
- Pulmonary Haemorrhage
- Left-to-Right Shunts
- Polycythaemia
- Hyperkinetic States
- Exercise
LOW
- Pulmonary Fibrosis
- Pneumonia
- PE
- Pulmonary Oedema
- Emphysema
- Anaemia
- Low Cardiac Output
List some drugs that cause hyponatraemia.
sulfonylureas* SSRIs, tricyclics carbamazepine vincristine cyclophosphamide
List some drug classes that can cause haemolysis in G6PD deficient patients.
Dapsone and other sulfones (higher doses for dermatitis herpetiformis more likely to cause problems)
Fluoroquinolones (including ciprofloxacin, moxifloxacin, norfloxacin, and ofloxacin)
Methylthioninium chloride
Niridazole [not on UK market]
Nitrofurantoin
Pamaquin [not on UK market]
Primaquine (30 mg weekly for 8 weeks has been found to be without undue harmful effects in African and Asian people)
Quinolones (such as nalidixic acid [not on UK market])
Rasburicase
Sulfonamides (including co-trimoxazole; some sulfonamides, e.g. sulfadiazine, have been tested and found not to be haemolytic in many G6PD-deficient individuals)
Which gene mutation is associated with MEN?
MEN1 - MEN1 Gene
MEN2 - RET Oncogene
What is the most common histological pattern seen in lupus nephritis?
Diffuse proliferative glomerulonephritis
What are the classical imaging features of silicosis?
Multiple, small, well-rounded nodules particularly in the upper zones
Eggshell calcification may be seen
Describe the presentation of acute schistosomiasis infection.
AKA Katayama Fever
- Fever
- Urticaria
- Arthralgia/Myalgia
- Cough
- Diarrhoea
- Eosinophilia
Describe the presenting features of leptospirosis.
EARLY: fever, subconjunctival suffusion/haemorrhage
LATER (Weil’s Disease)
- AKI (common)
- Hepatitis (jaundice, hepatomegaly)
- Aseptic meningitis
What is leptospirosis caused by and how is it treated?
Caused by Leptospira interrogans (spirochete)
Treated with benzylpenicillin or doxycycline
What are the criteria for considering a patient for GLP1 agonist therapy?
If triple therapy is ineffective, consider combination therapy with metformin, a sulfonylurea and GLP-1 agonist if:
- BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or
- BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
What is a major risk associated with pioglitazone?
Bladder cancer Fluid retention (can't be used in heart failure)
What is the first-line antibiotic for UTI in pregnancy?
Nitrofurantoin
2nd line: amoxicillin, cefalexin
Which specialised form of imaging is used to distinguish between CNS lymphoma and toxoplasmosis?
Thallium SPECT
CNS Lymphoma = positive
Toxoplasmosis = negative
Which statins are associated with a higher risk of statin-induced myopathy?
Higher Risk (Lipophilic): Simvastatin, Atorvastatin Lower Risk (Hydrophilic): Rosuvastatin, Pravastatin, Fluvastatin
How is Giardia treated?
Metronidazole
NOTE: stool microscopy is often negative in giardia
Which type of thyroid cancer is associated with Hashimoto’s thyroiditis?
Thyroid lymphoma (MALT Lymphoma)
List some vaccines of the following types:
- Live Attenuated
- Inactivated
- Toxoid
- Subunit or Conjugate
Live Attenuated
- BCG
- MMR
- Influenza (intranasal)
- Rotavirus
- Polio
- Yellow Fever
- Typhoid
Inactivated
- Rabies
- Hepatitis A
- Influenza (intramuscular)
Toxoid
- DTP
Subunit or Conjugate
- Pneumococcus
- Meningococcus
- Haemophilus
- HPV
- Hepatitis B
What murmur is most commonly associated with an atrial septal defect and ventricular septal defect?
ASD: Ejection systolic murmur loudest on inspiration
VSD: Pansystolic
What is the most common cause of death in scleroderma patients?
Respiratory failure due to interstitial lung disease and pulmonary hypertension
What are some features of cyanide poisoning and how is it treated?
Drowsy, headache, confusion, SOB
Ix: lactic acidosis, high pO2 (incl. venous), normal SaO2
Rx: IV Hydroxocobalamin (others include amylnitrate, sodium nitrite and sodium thiosulfate)
NOTE: cyanide an come from insecticides, photograph development, production of certain metals and burning plastic
Which drug should be avoided at all costs in suspected ventricular tachycardias?
Verapamil (can trigger drop in blood pressure, VF and cardiac arrest)
NOTE: thought a broad complex tachycardia may be caused by SVT with aberrant conduction, verapamil should still not be used
Which of the following drugs are affected by a patient’s acetylator status?
isoniazid procainamide hydralazine dapsone sulfasalazine
NOTE: 50% of the UK population are deficient in hepatic N-acetyltransferase
Which factors shift the oxygen dissociation curve to the LEFT?
Decreased temperature
Decreased 2,3-DPG
Decreased [H+]
Carboxyhaemoglobin
What is the criteria for reversibility on bronchodilator reversibility testing?
> 12% increase in FEV1 which is also at leas a 200 mL increase
List some causes of warm AIHA.
Usually IgG and occurs at body temperature
- Autoimmune diseases (e.g. SLE)
- Malignancy (lymphoma, CLL)
- Drugs (e.g. methyldopa)
List some causes of cold AIHA.
Usually IgM and causes haemolysis at 4 degrees (haemolysis is mediated by complement and is more commonly intravascular)
- Infections (e.g. EBV, mycoplasma)
- Lymphoma
NOTE: symptoms may include Raynaud’s and acrocyanosis (blue colouration of the hands)
Describe the presenting symptoms of Guillain-Barre syndrome.
Ascending weakness
Reduced or absent reflexes
Mild/no sensory symptoms
List some key indications for a permanent pacemaker.
Symptomatic/haemodynamically unstable bradycardia, not responding to atropine
Post-ANTERIOR MI: type 2 or complete heart block*
Trifascicular block prior to surgery
NOTE: post-inferior MI complete heart block is NOT an indication for pacing if the patient is asymptomatic and haemodynamically stable
What type of bacterium is Gardnerella vaginalis?
Gram-positive coccobacilli
NOTE: can occasionally be Gram-negative
NOTE: lactobacillus is responsible for the acidic environment of the vagina
What is an important metabolic consequence of using thiazide diuretics?
Impaired glucose tolerance (can lead to DM)
NOTE: interferon alpha can also impair glucose tolerance
How is small bowel bacterial overgrowth syndrome diagnosed?
Hydrogen breath test
Small bowel aspiration and culture
What is the first-line treatment option for small bowel bacterial overgrowth syndrome?
Rifaximin
Alternative: co-amoxiclav, metronidazole
How does a Jarishc-Herxheimer reaction manifest?
Fever
Rash
Tachycardia
NOTE: there is NO wheeze or hypotension
How is restless leg syndrome managed?
First-Line: Ropinirole
Alternatives: Benzodiazepines and Gabapentin
What are two main types of cestodes (tapeworms) and how are they treated?
Echinococcus granulosus (dog) Taenia solium (pig)
Treated with bendazoles
List some key types of nematodes (roundworms) and the diseases that they cause.
Strongyloides stercoralis - diarrhoea, abdominal pain, vesicular lesions where skin has been penetrated by infective larvae
Enterobium vermicularis (pinworm) - perianal itching
Ancylostoma duodenale - gastrointestinal upset
Loa Loa - itchy swellings below the skin
Trichinella spiralis - fever, periorbital oedema, myositis
Onchocerca volvulus - river blindness, hyperpigmented skin
Wucheria bancrofti - elephantiasis
Toxocara canis - blindness
Ascaris lumbricoides - intestinal obstruction
List some key types of trematodes (flukes) and the diseases that they cause.
Schistosoma haematobium - haematuria, bladder cancer
Paragonimus westermani - leads to bacterial lung infection
Clonorchis sinensis - biliary tract inflammation
Fasciola hepatica (liver fluke) - biliary obstruction
What is the best prognostic marker for multiple myeloma?
Beta-2 Microglobulin
List some CYP inducers.
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John’s Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline)
List some CYP inhibitors.
antibiotics: ciprofloxacin, erythromycin isoniazid cimetidine,omeprazole amiodarone allopurinol imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir sodium valproate acute alcohol intake quinupristin
What is CADASIL?
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
Genetic condition due to mutation in NOTCH3
Presentation: migraines in middle age, recurrent TIAs/strokes leading to neuro-cognitive decline, psychaitric problems and dementia
MRI shows multiple hyperintense lesions
What is black water fever?
Rare complication of malaria
Results in large intravascular haemolysis leading to haemoglobinuria, anaemia, jaundice and AKI. Urine is dark and hepatosplenomegaly may be noted. Unknown cause.
How does central retinal artery occlusion present?
Sudden painless unilateral visual loss
Afferent pupillary defect and cherry red spot on pale retina
NOTE: can be caused by thromboembolism or arteritis (e.g. GCA)
List some indications for plasma exchange.
GBS Myasthenia Gravis Goodpasture syndrome ANCA positive vasculitis TTP/HUS Cryoglobulinaemia Hyperviscosity syndrome (e.g. due to myeloma)
List some complications of plasma exchange.
Hypocalcaemia (due to binding of calcium to sodium citrate anticoagulant during procedure) Metabolic alkalosis Removal of medications Coagulation factor depletion Ig depletion
What is the main vector for Lassa fever?
Rats
NOTE: it is a viral haemorrhagic fever
Describe the classical presentation of a vestibular schwannoma.
Vertigo
Hearing Loss
Tinnitus
Absent Corneal Reflex
List some conditions that are inherited in an X-linked pattern.
Androgen insensitivity syndrome Becker muscular dystrophy Colour blindness Duchenne muscular dystrophy Fabry's disease G6PD deficiency Haemophilia A,B Hunter's disease Lesch-Nyhan syndrome Nephrogenic diabetes insipidus Ocular albinism Retinitis pigmentosa Wiskott-Aldrich syndrome
What are the four main types of Hodgkin disease?
Nodular Sclerosing
Mixed Cellularity
Lymphocyte Predominant
Lymphocyte Depleted
How is chlamydia managed?
Doxycycline 7 days
If pregnant: azithromycin, erythromycin or amoxicillin
Outline the management of stable angina.
First-Line: Beta-Blocker or Rate-Limiting CCB
Second-Line: Add whichever hasn’t been used so far (e.g. non-rate limiting CCB)
Alternatives: nicorandil, ivabradine, ranolazine, isosorbide mononitrate
How might a parietal lobe seizure manifest?
Paraesthesia
How might a frontal lobe seizure manifest?
Head/leg movements
Posturing
Post-ictal weakness
Jacksonian march
Which cancers are associated with the following familial cancer syndromes? Li Fraumeni Gorlin Lynch Von Hippel Lindau
Li Fraumeni - early onset breast cancer, sarcoma, leukaemia, adrenal tumours (p53 mutation)
Gorlin - multiple BCC, medulloblastoma
Lynch - colorectal cancer, endometrium, ovary, stomach, small intestine, hepatobiliary tract, brain and skin
Von Hippel Lindau - hemangioblastoma, renal cyst, renal cell carcinoma, pancreatic neuroendocrine tumours, phaeochromocytomas and endolymphatic sac tumours
What are the main features of paroxysmal nocturnal haemoglobinuria?
Intravascular haemolytic anaemia Cytopaenia Haemoglobinuria Thrombosis (e.g. Budd-Chiari) Aplastic anaemia (in some patients)
NOTE: treated with blood products and anticoagulation
Which antibodies are associated with the following autoimmune conditions? Dermatomyositis Mixed Connective Tissue Disease Sjogren Syndrome Limited Scleroderma Diffuse Scleroderma
Dermatomyositis - Anti-Mi2
Mixed Connective Tissue Disease - Anti-RNP
Sjogren Syndrome - Anti-Ro
Limited Scleroderma - Anti-Centromere
Diffuse Scleroderma - Anti-Scl70 (topoisomerase II)
What is the difference between the Bohr Effect and the Haldane Effect?
Bohr - increasing acidity means that O2 binds less well to Hb
Haldane - increased pO2 means that CO2 binds less well to haemoglobin
What is Purtscher retinopathy?
Ischaemic retinopathy associated with pancreatitis, head trauma, fat embolisation and vasculitic diseases
What ACR and PCR is roughly equivalent to 1 g proteinuria per 24 hours?
ACR = 70 mg/mmol PCR = 100 mg/mmol
List some drugs that can cause drug-induced cholestasis.
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
List some causes of non-scarring alopecia.
male-pattern baldness
drugs: cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, colchicine
nutritional: iron and zinc deficiency
autoimmune: alopecia areata
telogen effluvium
hair loss following stressful period e.g. surgery
trichotillomania
Outline the management of Guillain Barre syndrome.
IVIG (better than plasma exchange)
Consider steroids and immunosuppressants
FVC monitoring
Which cancers are the MYC oncogenes associated with?
c-Myc - Burkitt’s Lymphoma t(8;14)
n-Myc - Neuroblastoma
What is heart upon auscultation in a patient with complete heart block?
Variable intensity of S1
Other features: heart failure, bradycardia, wide pulse pressure, cannon a waves
Which class of drugs can trigger eosinophilic granulomatosis with polyangiitis?
Leukotriene receptor antagonists
What is an important contraindication for statin therapy?
Pregnancy
Which antibiotics should be avoided in pregnancy?
Tetracyclines
Aminoglycosides
Sulphamides and Trimethoprim
Quinolones
List some causes of hypomagnesemia.
Drug (diuretics, PPI) Diarrhoea Alcohol Hypokalaemia Hypercalcaemia (Ca and Mg compete for transport in the thick ascending limb of loop of Henle) Gitelman/Bartter TPN
What is brachial neuritis?
Acute onset unilateral severe pain followed by shoulder and scapular weakness several days later. Minimal sensory changes.
Triggers include trauma, infection, surgery and vaccination.
Which antibiotics are most strongly associated with C. difficile infection?
- Clindamycin
- Cephalosporins
- Ciprofloxacin
Which receptors does olanzapine block?
5HT2 Receptor
D2 Receptor
Describe the classical presentation of aspirin overdose?
Mixed respiratory alkalosis and metabolic acidosis
Sweaty and confused
Pulmonary oedema is a bad sign (require haemodialysis)
List some drugs that cause peripheral neuropathy.
amiodarone isoniazid vincristine nitrofurantoin metronidazole
Describe how retinal detachment manifests.
Sudden painless loss of vision
Dense shadow starting peripherally and progressing centrally
Which skin disorder is associated with gastric cancer?
Acanthosis nigricans
Which skin disorder is associated with lymphoma?
Acquired icthyosis
Erythroderma
Which skin disorder is associated with gastrointestinal and lung cancer?
Acquired hypertrichosis lanuginosa
Which skin disorder is associated with ovarian and lung cancer?
Dermatomyositis
Lung cancer only: erythema gyratum repens
Which skin disorder is associated with pancreatic cancer?
Migratory thrombophlebitis
Which skin disorder is associated with glucagonoma?
Necrolytic migratory erythema
Which skin disorder is associated with myeloproliferative disorders?
Pyoderma gangrenosum
Which skin disorder is associated with haematological malignancies?
Sweet syndrome - sudden onset of fever and painful rash on the arms, legs, trunk, face, or neck. It’s also known as acute febrile neutrophilic dermatosis
Which skin disorder is associated with oesophageal cancer?
Tylosis
Outline the management of neuropathic pain.
First-Line: amitriptyline, duloxetine, gabapentin or pregabalin (don’t add)
Tramadol rescue therapy
Topical capsaicin for localised neuropathic pain
Which gene mutations are often seen in essential thrombocytosis
JAK2
CALR
Treated with aspirin and hydroxycarbamide
List some causes of chorea.
Huntington's disease, Wilson's disease, ataxic telangiectasia SLE, anti-phospholipid syndrome rheumatic fever: Sydenham's chorea drugs: oral contraceptive pill, L-dopa, antipsychotics neuroacanthocytosis pregnancy: chorea gravidarum thyrotoxicosis polycythaemia rubra vera carbon monoxide poisoning cerebrovascular disease
List the main trinucleotide repeat disorders.
Fragile X (CGG) Huntington's (CAG) myotonic dystrophy (CTG) Friedreich's ataxia* (GAA) spinocerebellar ataxia spinobulbar muscular atrophy dentatorubral pallidoluysian atrophy
What is the mechanism of action of triptans?
Agonist of 5HT1B and 1D
Describe the typical presentation of haemochromatosis.
Lethargy
Arthralgia (with chondrocalcinosis)
Diabetes mellitus
What is the mechanism of action of ondansetron?
5HT3 Antagonist
List some causes of vertigo.
BPPV Viral Labyrinthitis Vestibular Neuronitis Meniere's Disease Vertebrobasilar ischaemia Acoustic neuroma Posterior circulation stroke
What is a major adverse effect of hydroxychloroquine?
Bull’s Eye Retinopathy
Therefore, it requires regular eye checks
Which drugs should be avoided in people with HOCM?
Nitrates
ACE inhibitors
Inotropes
How is TEN managed?
Stop precipitating factor
Supportive care
IVIG (first line)
Alternatives: immunosuppressive medication
What is the difference between MRI FLAIR and STIR?
FLAIR: Suppresses water (does not appear bright). Used for periventricular and cortical lesions in multiple sclerosis.
STIR: Suppresses fat. Shows bright signal in acutely inflamed tissues. Used in flares of thyroid eye disease.
List some classes of drugs that prolong the QT interval.
Antiarrhythmics (amiodarone, sotalol, class 1) TCA Antipsychotics Chloroquine Erythromycin
How does the second-line antihypertensive medication differ for people of Afro-Caribbean origin?
ARB > ACEi
What is bile acid malabsorption and how is it investigated and treated?
Chronic diarrhoea resulting from excessive production of bile acids or reduced reabsorption. May be secondary to Crohn’s disease, coeliac disease, SIBO or cholecystectomy
Ix: SeHCAT
Rx: Cholestyramine
What is the triad of renal cancer?
Hypertension
Hypercalcaemia
Haematuria
What are the features of Gerstmann syndrome?
Acalculia
Right-Left Disorientation
Finger Agnosia
Agraphia
Caused by lesion in the angular and supramarginal gyri between the dominant parietal and temporal lobes
What are troponin I and T bound to?
Troponin I: Binds to actin to hold the troponin-tropomyosin complex in place
Troponin T: Binds to tropomyosin to help position it on the actin
Troponin C: Binds calcium ions
Which antibodies are associated with autoimmune hepatitis?
Type I: ANA, ASMA (Adults and Children)
Type II: Anti-LKM1 (Children Only)
Type III: Soluble Liver Antigen (Adults Only)
Which drugs, if administered together, can reduce the absorption of levothyroxine?
Iron
Calcium Carbonate
NOTE: give at least 4 hours apart
If someone is allergic to sulfasalazine, what other important drug may they be allergic to?
Aspirin or sulphonamides
What clinical feature can help distinguish dengue from chikungunya?
Severe arthralgia
What are some indicators for poor prognosis in acute pancreatitis?
age > 55 years hypocalcaemia < 2 hyperglycaemia > 10 hypoxia (PaO2 < 7.9) neutrophilia (WCC > 15) elevated LDH (> 600) urea > 16 albumin < 32
Who should be offered LTOT?
Patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- nocturnal hypoxaemia
- peripheral oedema
- pulmonary hypertension
What are the main features of brucellosis?
non-specific: fever, malaise
hepatosplenomegaly
sacroiliitis: spinal tenderness may be seen
complications: osteomyelitis, infective endocarditis, meningoencephalitis, orchitis
leukopenia often seen
Ix: Brucella serology
Rx: doxycycline and streptomycin
List some key indication for IVIG.
primary and secondary immunodeficiency
idiopathic thrombocytopenic purpura
myasthenia gravis
Guillain-Barre syndrome
Kawasaki disease
toxic epidermal necrolysis
pneumonitis induced by CMV following transplantation
low serum IgG levels following haematopoietic stem cell transplant for malignancy
dermatomyositis
chronic inflammatory demyelinating polyradiculopathy
What are the main features of background diabetic retinopathy?
microaneurysms (dots) blot haemorrhages (<=3) hard exudates
What are the three stages of LGV infection?
1 - small painless pustule which later forms an ulcer
2 - painful inguinal lymphadenopathy
3 - proctocolitis
How do fibrates work?
Activating PPAR alpha receptors resulting in an increase in LPL activity reducing triglyceride levels
How is actinic keratosis managed?
Avoid sun Topical 5-FU Topical diclofenac Cryotherapy Curettage
Which antibiotics are used to treat cholera?
Doxycycline
Ciprofloxacin
What is Heerfordt syndrome?
Subset of sarcoidosis
Parotid enlargement
Fever
Anterior uveitis
Describe the treatment escalation for mild-moderate proctitis.
- Topical Aminosalicylate
- Oral Aminosalicylate (after 4 weeks)
- Topical or Oral Steroid
How is leprosy treated?
Rifampicin, dapsone and clofazimine for 12 months
How should antiphospholipid syndrome be managed in pregnancy?
- Low-dose aspirin should be commenced once the pregnancy is confirmed on urine testing
- LMWH once a fetal heart is seen on ultrasound. This is usually discontinued at 34 weeks gestation
Describe the presentation of visceral leishmaniasis.
Massive Splenomegaly Fever Weight Loss Pancytopaenia Darkened Skin
NOTE: spread by bites of sand flies
List some causes of hypokalameia with alkalosis.
Vomiting
Thiazide and Loop Diuretics
Cushing Syndrome
Conn Syndrome
How long should patients continue being anticoagulated for after successful DCCV for AF?
4 weeks
If a subsequent echocardiogram shows a structurally abnormal heart, they should be considered for long-term anticoagulation
What is the first-line treatment option for seborrhoeic dermatitis?
Topical Ketoconazole
List some causes of villous atrophy.
coeliac disease tropical sprue hypogammaglobulinaemia gastrointestinal lymphoma Whipple's disease cow's milk intolerance
List the main non-sedating antihistamines.
Loratadine (LEAST sedating)
Cetirizine
How would you treat limited impetigo?
- Hydrogen Peroxide Cream
- Topical Fusidic Acid or Topical Mupirocin
Oral flucloxacillin if severe
What is the anchor drug for maintenance treatment in lupus?
Hydroxychloroquine
What is seen on a biopsy in a biopsy in a patient with rheumatic heart disease?
Aschoff bodies (granuloma with giant cells) Anitschkow cells (enlarged macrophages with wavy rod-like nucleus)
What eye complication can amiodarone cause?
Vortex keratopathy (corneal opacities)
What are the main features of progressive supranuclear palsy?
Impaired vertical gaze
Parkinsonism
Postural instability and falls
Cognitive impairment
What is the most common cause of visceral larve migrans?
Toxocara Canis
What are the three types of type I antiarrhythmic?
They all block sodium channels, but in addition:
Ia - increases action potential (AP) duration (procainamide, disopyramine
Ib - decreases AP duration (lidocaine)
Ic - no effect on AP duration (flecainide, propafenone)
Which mutations cause nephrogenic diabetes mellitus?
V2 receptor mutation (most common)
Aquaporin 2 channel mutation
Which antibiotics can affect skin pigmentation?
Minocycline - darkening of skin
Doxycycline/Tetracycline - photosensitivity
List some causes of hypertrichosis.
drugs: minoxidil, ciclosporin, diazoxide
congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis
porphyria cutanea tarda
anorexia nervos
NOTE: hypertrichosis is when hair grows anywhere, whereas hirsutism is when women develop male pattern facial hair
What are the features of Meig syndrome?
Ovarian fibroma
Ascites
Pleural effusion
List some drugs that cause impaired glucose tolerance.
thiazides, furosemide (less common) steroids tacrolimus, ciclosporin interferon-alpha nicotinic acid antipsychotics
How is Prinzmetal angina treated?
Dihydropyridine CCB (e.g. felodipine)
Which organisms are normally isolated from human bites?
Streptococci spp. Staphylococcus aureus Eikenella Fusobacterium Prevotella
What kind of drug is naftidrofudryl?
5-HT2 Receptor Antagonist
It is used in peripheral vascular disease as it increases blood flow to the peripheries
Which antibody is associated with idiopathic membranous glomerulonephritis?
Anti-phospholipase A2
Describe the electron microscopy appearance of membranous glomerulonephritis.
Basement membrane is thickened with subepithelial electron dense deposits (creating spike and dome appearance)
What kind of drug is aprepitant?
Neurokinin 1 receptor blocker
Used as an anti-emetic
Which antibiotics are used to treat brain abscesses?
IV 3rd generation cephalosporin and metronidazole
Which diagnostic test is useful for investigating hereditary angioedema in between attacks?
C4 (low)
NOTE: C1-INH is low during an attack
What is the best test for chronic pancreatitis?
Secretin stimulation test
What are the main side-effects of ciclosporin?
Fluid retention Hypertension Hyperkalaemia Hypertrichosis Gingival Hyperplasia Tremor Impaired Glucose Tolerance Nephro/Hepatotoxic
Which nerve root is damaged in Klumpke’s palsy and how does it manifest?
damage to T1
loss of intrinsic hand muscles
due to traction
Which nerve root is damaged in Erb’s palsy and how does it manifest?
damage to C5,6 roots
winged scapula
may be caused by a breech presentation
What is a neonatal complication of systemic lupus erythematosus and which antibody is it associated with?
Congenital heart block, rash and hepatosplenomegaly
Associated with Anti-Ro
What causes the following syndromes? Benedikt syndrome Millard-Gubler syndrome Nothnagel syndrome Weber syndrome
Benedikt: occlusion of the posterior cerebral artery is a possible cause. It causes 3rd nerve palsy, cerebellar ataxia and movement disorders (including tremor and chorea).
Millard-Gubler: ipsilateral 6th and 7th nerve palsies and contralateral hemiparesis.
Nothnagel: ipsilateral 3rd nerve palsy and limb ataxia
Weber: contralateral hemiparesis and a 3rd nerve palsy
How does rasburicase work?
Converts uric acid to allantoin
Which drug that is commonly used in patients with ischaemic heart disease is associated with causing shortness of breath as a side-effect?
Ticagrelor
NOTE: if patients experience this side-effect, it can be switched for clopidogrel
How does congenital toxoplasmosis manifest?
Cerebral calcification
Chorioretinitis
NOTE: patients may present later in life
How is pneumocystis pneumonia managed?
Co-trimoxazole
Steroids if pO2 < 9.3 kPa
NOTE: IV pentamidine in severe cases (risk of pneumothorax)
What causes granuloma inguinale?
Klebsiella granulomatis
Gram-negative bacillus that causes painless ulcer. Swab reveals mononuclar cells containing Donovan bodies
Which investigation should be considered for patients with suspected aortic dissection who are too unstable to go for a CT?
Transoesophageal echocardiogram
What are some common side-effects of sodium valproate?
Tremor
Alopecia
Hepatotoxicity
How does amoebiasis present?
Profuse, bloody diarrhoea after a long incubation period
Ix: hot stool sent for microscopy
Rx: Metronidazole
Which mutation normally causes HOCM?
Mutation affecting beta-myosin heavy chain protein
Describe the course of yellow fever.
Flu-like illness –> brief remission –> jaundice and haematemesis
Describe the two different types of amiodarone-induced thyrotoxicosis.
Type 1: Goitre + Treated with Carbimazole or Potassium Perchlorate
Type 2: NO Goitre + Treated with Steroids
Which conditions are associated with thymomas?
myasthenia gravis (30-40% of patients with thymoma)
red cell aplasia
dermatomyositis
also : SLE, SIADH
How does zinc deficiency manifest?
perioral dermatitis: red, crusted lesions acrodermatitis enteropathica alopecia short stature hypogonadism hepatosplenomegaly geophagia (ingesting clay/soil) cognitive impairment
How does a vitreous haemorhage present?
Dark spots (scotomas) in the vision initially followed by painless loss of vision
Associated with diabetic retinopathy
How does tularaemia present?
Erythematous papulo-ulcerative lesion at site of bite with reactive and ulcerating regional lymphadenopathy
Transmitted by rabbits, hares, pikas, beavers and ticks
Treated with doxycycline (F. tularensis)
List some precipitants for digoxin toxicity.
Hypokalaemia Hypomagnesemia Hypercalcaemia Hypernatraemia Acidosis Renal impairment Hypoalbuminaemia
List some causes of rapidly progressive glomerulonephritis.
Goodpasture’s syndrome
ANCA positive vasculitis (e.g. Wegener’s)
List the indications for surgical intervention in patients with infective endocarditis.
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
Which types of glomerulonephritis have low complement levels?
post-streptococcal glomerulonephritis
subacute bacterial endocarditis
systemic lupus erythematosus
mesangiocapillary glomerulonephritis
What advice should you give a patient on warfarin undergoing a dental extraction?
Check INR 72 hours before the procedure, and proceed if it is less than 4.0
Which primary cancers cause calcified lung metastases?
Chondrosarcoma and Osteosarcoma
Describe the presentation of a cholesterol embolism.
Livedo reticularis
Eosinophilia
Purpura
Renal failure
NOTE: it tends to occur after a precipitating event such as AAA repair
Which medications may be used for anticoagulation in patients with HIT?
Direct thrombin inhibitor (e.g. argatroban)
Danaparoid
What is the first-line imaging modality for stable angina?
CTCA
Which tumour marker is used for primary peritoneal cancer?
CA125
How is membranous glomerulonephritis managed?
All patients should receive an ACEi or ARB
Immunosuppression may be considered in some
List some indiciations for steroids in sarcoidosis.
parenchymal lung disease
uveitis
hypercalcaemia
neurological or cardiac involvement
Describe the different types of cryoglobulinaemia.
Type I
monoclonal - IgG or IgM
associations: multiple myeloma, Waldenstrom macroglobulinaemia
Type II
mixed monoclonal and polyclonal: usually with rheumatoid factor
associations: hepatitis C, rheumatoid arthritis, Sjogren’s, lymphoma
Type III
polyclonal: usually with rheumatoid factor
associations: rheumatoid arthritis, Sjogren’s
What is the first-line investigation for Budd-Chiari syndrome?
Ultrasound with Doppler flow studies
What are the main causes of biliary disease in patients with HIV?
Sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia
Why is adenosine contraindicated in Wolff-Parkinson-White syndrome?
Blocking the AV node may enhance the rate of conduction through the accessory pathway
Use flecainide instead
What are the main clinical features of Ebstein’s anomaly?
Tricuspid regurgitation Pansystolic murmur (louder on inspiration)
ECG changed include RBBB and WPW syndrome
List some causes of a false positive VDRL/RPR?
SLE
TB
Malaria
HIV
How is pneumocystis pneumonia diagnosed?
Bronchial alveolar lavage with silver staining
What are the X-ray findings in ankylosing spondylitis?
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
Which gynaecological conditions is associated with secondary polycythaemia?
Uterine fibroids (ectopic production of erythropoietin)
Which nerve supplies the deltoid muscle?
Axillary nerve
How should you manage the glycaemic control of a patient with diabetes who has been admitted with a myocardial infarction?
Stop metformin and other oral agents
Start IV insulin infusion
What are the first-line treatments for spasticity in multiple sclerosis?
Balcofen
Gabapentin
Which class of drugs will reduce the effect of adenosine?
Aminophyllines
NOTE: dipyridamole increases the effect of adenosine
Which cells mediate hyperacute graft rejection?
B cells
What are the features of Pendred syndrome?
Mild hypothyroidism
Goitre
Bilateral sensorineural deafness
NOTE: it is autosomal recessive
How does Friedreich ataxia manifest?
Cerebellar signs Mixed upper and lower motor neurone signs Pes cavus Optic atrophy Normal IQ
NOTE: it is an autosomal recessive trinucleotide repeat disorder
How does central retinal vein occlusion present?
Sudden painless loss of vision
Fundoscopy finding of retinal haemorrhages in the affected eye
List some causes of painful genital ulcers.
Herpes simplex
Chancroid
List some causes of painless genital ulcers.
Syphilis
LGV
Damage to which brain structure results in chorea?
Caudate nucleus of the basal ganglia
Describe the histological appearance of discoid lupus.
Follicular keratin plugs
NOTE: it also causes scarring alopecia, is photosensitive and usually presents between 20-40 years
What is the most common cause of endocarditis?
Staphylococcus aureus Staphylococcus epidermidis (if within 2 months of valve replacement)
How does amphotericin B work?
Binds with ergosterol, a component of fungal cell membranes, forming pores that cause lysis of the cell wall and subsequent fungal cell death
How does caspofungin work?
inhibits synthesis of beta-glucan, a major fungal cell wall component.
What is the most common cardiac defect in Marfan syndrome?
Dilation of the aortic sinuses (predisposes to dissection)
What is the recommended empirical antibiotic therapy for infective endocarditis?
Native valve: Amoxicillin (consider low-dose gentamicin)
Native valve but penicillin allergic: vancomycin + gentamicin
Prosthetic valve: vancomycin + rifampicin + gentamicin
What are the main treatment options for hiccups in palliative care?
Chlorpromazine
Haloperidol
What causes Farmer’s lung?
Saccharopolyspora rectivirgula
Which drug classes are contraindicated in someone who is going to start a phosphodiesterase inhibitor?
Nitrates
Nicorandil
What are the main indications for a chest drain in pleural infection?
Frankly purulent or turbid/cloudy pleural fluid
Identification of organisms upon staining
pH < 7.2
Which vitamin can improve iron absorption in the intestines?
Vitamin C
Which type of collagen is affected in Ehlers-Danlos syndrome?
Type V
What is ocular opsoclonus-myoclonus?
Paraneoplastic condition associated with breast cancer characterised by rapid eye movements, myoclonus and ataxia
NOTE: associated with anti-Ri antibody
How is anthrax treated?
Oral ciprofloxacin
What is the first-line investigation for chroinc pancreatitis?
CT Pancreas
How should Plasmodium vivax be treated?
Chloroquine or ACT
Primaquine should also be given following acute treatment to destroy liver hypnozoites
Which cytogenetic findings are associated with poor outcomes in AML?
Deletion of chromosome 5 or 7
How soon after starting new diabetes medications should the HbA1c be checked?
3-6 months until stable then 6 monthly
Describe the ECG findings seen in ostium primum and ostium secundum defects.
Ostium primum: RBBB with LAD, long PR
Ostium secundum: RBBB with RAD
How is otitis externa managed?
Topical antibiotic (e.g. gentamicin) or topical antibiotic with a topical steroid
NOTE: oral antibiotics (e.g. flucloxacillin) may be considered if the infection appears to be spreading
How does posterior vitreous detachment manifest?
Flashes and floaters
How is Mycobacterium avium complex infection managed?
Rifampicin + ethambutol + clarithromycin
Which antiepileptic drug is most associated with weight gain?
Sodium valproate
List some Gram-positive bacilli.
Corynebacterium
Clostridia
Listeria
Bacillus
What LVEF bars people from driving?
< 40% LVEF
List some causes of predominantly MOTOR neuropathy.
Guillain-Barre syndrome
porphyria
lead poisoning
hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth
chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
List some causes of predominantly SENSORY neuropathy.
diabetes uraemia leprosy alcoholism vitamin B12 deficiency amyloidosis
What is Lemierre syndrome?
When a peritonsillar abscess leads to thrombophlebitis of the internal jugular vein
It can result in septic pulmonary emboli
Presents with neck pain
List some treatment options for patients with alopecia areata.
Hair will regrow in 50% of patients within 1 year topical or intralesional corticosteroids topical minoxidil phototherapy dithranol contact immunotherapy wigs
Describe the WHO classification of lupus nephritis.
class I: normal kidney class II: mesangial glomerulonephritis class III: focal (and segmental) proliferative glomerulonephritis class IV: diffuse proliferative glomerulonephritis class V: diffuse membranous glomerulonephritis class VI: sclerosing glomerulonephritis
What is the mechanism of action of rifampicin?
Inhibits bacterial DNA-dependent RNA polymerase (thereby inhibiting RNA synthesis)
What is the main physiological function of interferon alpha, beta and gamma?
Alpha - produced by leukocytes, antiviral action
Beta - produced by fibroblasts, antiviral action
Gamma - produced by NK cells and T helper cells, important in macrophage activation
Which monoclonal antibody may be used in HUS?
Eculizumab (mAb against C5 inhibitor)
List some causes of raised leukocyte ALP.
myelofibrosis leukaemoid reactions polycythaemia rubra vera infections steroids, Cushing's syndrome pregnancy, oral contraceptive pill
List some causes of low leukocyte ALP.
chronic myeloid leukaemia
pernicious anaemia
paroxysmal nocturnal haemoglobinuria
infectious mononucleosis
Which electrolyte deficiency is associated with cisplatin?
Hypomagnesemia
What is the cut-off for offering bisphosphonates in steroid-induced osteoporosis?
T score of less than -1.5
NOTE: if T score is 0 to -1.5 then repeat DEXA in 1-3 years
Describe the features of SSRI discontinuation.
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
NOTE: paroxetine is associated with a higher risk of discontinuation symptoms
Outline the levels of scientific evidence.
Ia - meta-analysis of randomised controlled trials
Ib - at least one randomised controlled trial
IIa - at least one well designed controlled trial which is not randomised
IIb - at least one well designed experimental trial
III - case, correlation and comparative studies
IV - panel of experts
Describe the presentation of American trypanosomiasis.
Myocarditis may lead to dilated cardiomyopathy (with apical atophy) and arrhythmias
Gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation
NOTE: treated with benznidazole
When is plasma exchange recommended for HUS?
Severe HUS that is NOT associated with diarrhoea
List some causes of optic atrophy.
Acquired causes
multiple sclerosis
papilloedema (longstanding)
raised intraocular pressure (e.g. glaucoma, tumour)
retinal damage (e.g. choroiditis, retinitis pigmentosa)
ischaemia
toxins: tobacco amblyopia, quinine, methanol, arsenic, lead
nutritional: vitamin B1, B2, B6 and B12 deficiency
Congenital causes
Friedreich’s ataxia
mitochondrial disorders e.g. Leber’s optic atrophy
DIDMOAD - the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram’s syndrome)
What are the consequences of Fanconi syndrome?
type 2 (proximal) renal tubular acidosis polyuria aminoaciduria glycosuria phosphaturia osteomalacia
List some causes of Fanconi syndrome.
cystinosis (most common cause in children) Sjogren's syndrome multiple myeloma nephrotic syndrome Wilson's disease
How does complex regional pain syndrome manifest?
progressive, disproportionate symptoms to the original injury/surgery allodynia temperature and skin colour changes oedema and sweating motor dysfunction
What are the two types of complex regional pain syndrome?
type I (most common): there is no demonstrable lesion to a major nerve type II: there is a lesion to a major nerve
List some causes of onycholysis.
idiopathic
trauma e.g. Excessive manicuring
infection: especially fungal
skin disease: psoriasis, dermatitis
impaired peripheral circulation e.g. Raynaud’s
systemic disease: hyper- and hypothyroidism
What additional medications should be part of the treatment plan for a patient with a cocaine-induced MI?
IV benzodiazepines
Describe the presentation of Clostridium botulinum infection.
Afebrile, descending, flaccid paralysis.
Presenting features typically include difficulty speaking or slurred speech, blurred or double vision, and/or dysphagia.
Other features include ptosis and facial muscle weakness.
What LFT results are considered the cut off for stopping statin therapy?
LFTs more than 3 x upper limit or normal
NOTE: LFTs should be checked at baseline, 3 months and 12 months
What are the CBG targets for pregnant women with gestational diabetes mellitus?
Fasting: 5.3mmol/L
1 hour postprandial: 7.8 mmol/L
2 hours postprandial: 6.4 mmol/L
When should you check lithium levels for monitoring?
12 hours after last dose
List some mixed alpha and beta antagonists.
Carvedilol
Labetalol
Which parameters can be used to distinguish prerenal AKI from acute tubular necrosis?
Urine sodium: less than 20 in pre-renal, more than 40 in ATN
Fractional sodium excretion: <1% in pre-renal, >1% in ATN
Fractional Urea excretion: <35% in pre-renal, >35% in ATN
Describe the manifestations of anterior, posterior and central cord syndromes.
Anterior: affects motor function, pain and temperature sensation. Proprioception is usually spared.
Posterior: affects proprioception.
Central: bilateral motor weakness.
List some features that can help distinguish VT from SVT with aberrant conduction.
AV dissociation fusion or capture beats positive QRS concordance in chest leads marked left axis deviation history of IHD lack of response to adenosine or carotid sinus massage QRS > 160 ms
What is the most common cause of of occupational asthma?
Isocyanates (e.g. spray paints, foam moulding)
What is the target range for TSH in hypothyroidism?
0.5-2.5
List some causes of type 1 renal tubular acidosis.
idiopathic, rheumatoid arthritis SLE Sjogren's amphotericin B toxicity analgesic nephropathy
List some causes of type 2 renal tubular acidosis.
idiopathic as part of Fanconi syndrome Wilson's disease, cystinosis outdated tetracyclines carbonic anhydrase inhibitors (acetazolamide, topiramate)
List some causes of type 4 renal tubular acidosis.
Hypoaldosteronism
Diabetes mellitus
Which type of bacterium is most commonly implicated in neutropaenic sepsis?
Gram-positive cocci (usually S. epidermidis)
What is nesidioblastosis?
Beta cell hyperplasia
What is palatal myoclonus a feature of?
Hypertrophic olivary degeneration
Part of the triangle of Mollaret: inferior olivary nucleus + red nucleus + contralateral dentate nucleus
How is Cryptosporidium diarrhoea managed in an immunocompromised patient?
Supportive therapy
What is cubital tunnel syndrome?
Compression of the ulnar nerve and can present with tingling/numbness of the 4th and 5th finger
Which antibody is associate with PBC and what is the first-line treatment option?
Anti-Mitochondrial Antibody (M2)
Rx: Ursodeoxycholic acid
What is Melioidosis caused by and how does it present?
Cause: Burkholderia pseudomallei (soil and fresh water)
Usually presents with acute pulmonary infection
May also be localised to skin (ulcer, nodule, abscess)
Visceral abscesses (prostate, spleen, kidney, liver)
Disseminated infection resulting in fever and septic shock
Rx: IV Ceftazidime, imipenem or meropenem
Describe the treatment of invasive amoebiasis.
Metronidazole 7 days (target the invasive stage)
Diloxanide furoate for 10 days afterwards (eradicate the cystic stage)
What is the most common genetic abnormality seen in Brugada Syndrome?
SCN5A gene (which encode the myocardial sodium ion channel protein)
What is the best investigation for insulinoma?
Prolonged (72-h) fasting glucose levels
+/- CT Pancreas
List some key differences between wet and dry age related macular degeneration.
Dry - more common, drusen (yellow spots)
Wet - characterised by choroidal neovascularisation, worse prognosis
How is age related macular degeneration treated?
Zinc with anti-oxidant vitamins
Anti-VEGF for wet AMD (e.g. bevacizuimab)
Laser photocoagulation
What kind of pulse abnormality is noted with patent ductus arteriosus?
Large volume, bounding, collapsing pulse
List some contraindications for lung cancer surgery.
SVC Obstruction
FEV < 1.5 L
Malignant pleural effusion
Vocal cord paralysis
Which tumour markers are associated with which testicular tumours?
Seminomas - hCG
Non-Seminomas - AFP and/or hCG in 80%
Germ Cell - LDH elevated in 40%
What is dacrocystitis?
Infection of the lacrimal sac
Causes eye watering and swelling and erythema at the inner canthus of the eye
Treated with antibiotics
List some risk factors for allopurinol sensitivity.
Diuretic use
CKD
Chinese, Korean and Thai
NOTE: patients at high risk of allopurinol sensitivity should be tested for the HLA-B*5801 allele
How is strongyloides treated?
Ivermectin
Second-Line: Albendazole
Which parameters are used to monitor treatment in hereditary haemochromatosis?
Ferritin
Transferrin saturation
Which medications should be avoided in Wolff-Parkinson-White syndrome?
Verapamil and digoxin
It may precipitate VF or VT
What are the two main causes of eruptive xanthoma?
Familial hypertriglyceridaemia
Lipoprotein lipase deficiency
Waht is relapsing polychondritis?
Characterised by episodes of inflammation and deterioration of cartilage, most commonly affecting the ears
Ears: auricular chondritis, hearing loss, vertigo
Nasal: nasal chondritis → saddle-nose deformity
Respiratory tract: e.g. hoarseness, aphonia, wheezing, inspiratory stridor
Ocular: episcleritis, scleritis, iritis, and keratoconjunctivitis sicca
Joints: arthralgia
Less commonly: cardiac valcular regurgitation, cranial nerve palsies, peripheral neuropathies, renal dysfunction
Which spinal cord abnormality are people with Marfan syndrome at increased risk of?
Dural ectasia - ballooning of the dural sac at the lumbosacral level. It may cause lower back pain and consequences such as bladder and bowel dysfunction.
How does L4 nerve root copmression manifest?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
How does L3 nerve root compression manifest?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
How does L5 nerve root compression manifest?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch
How does S1 nerve root copmression manifest?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
What urinary marker may be used to diagnose Paget’s disease?
Urinary hydroxyproline (raised)
List some commonly used steroid creams in order of strength.
Mild - Hydrocortisone 0.5-2.5%
Moderate - Betamethasone valerate 0.025%, Clobetasone butyrate 0.05%
Potent - Fluticasone propionate 0.05%, Betamethasone valerate 0.1%
Very potent - Clobetasol propionate 0.05%
Which drugs cause liver toxicity with a hepatocellular picture?
paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin
List some Gram-negative rods.
Escherichia coli Haemophilus influenzae Pseudomonas aeruginosa Salmonella sp. Shigella sp. Campylobacter jejuni
What are the BMI cut offs for bariatric surgery recommended by NICE?
with risk factors (T2DM, BP etc): > 35 kg/m^2
no risk factors: > 40 kg/m^2
List some features of Charcot-Marie-Tooth disease.
There may be a history of frequently sprained ankles Foot drop High-arched feet (pes cavus) Hammer toes Distal muscle weakness Distal muscle atrophy Hyporeflexia Stork leg deformity
Epilepsy driving rules.
first unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months
for patients with established epilepsy or those with multiple unprovoked seizures:
may qualify for a driving licence if they have been free from any seizure for 12 months
if there have been no seizures for 5 years (with medication if necessary) a ’til 70 licence is usually restored
withdrawawl of epilepsy medication: should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose
Syncope driving rules.
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
Neurological condition driving rules.
stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit
multiple TIAs over short period of times: 3 months off driving and inform DVLA
craniotomy e.g. For meningioma: 1 year off driving*
pituitary tumour: craniotomy: 6 months; trans-sphenoidal surgery ‘can drive when there is no debarring residual impairment likely to affect safe driving’
narcolepsy/cataplexy: cease driving on diagnosis, can restart once ‘satisfactory control of symptoms’
chronic neurological disorders e.g. multiple sclerosis, motor neuron disease: DVLA should be informed, complete PK1 form (application for driving licence holders state of health)
How is Meniere’s disease managed?
acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
prevention: betahistine and vestibular rehabilitation exercises may be of benefit
Which Parkinson’s medication can cause pulmonary fibrosis?
Pergolide
How are oculogyric crises treated?
intravenous antimuscarinic: benztropine or procyclidine
Describe the manifestations of a cavernous sinus thrombus.
other causes of cavernous sinus syndrome: local infection (e.g. sinusitis), neoplasia, trauma
periorbital oedema
ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th
trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain
central retinal vein thrombosis
What is the Mann Whitney U test used for?
compares ordinal, interval, or ratio scales of unpaired data
What is the most accurate way of assessing left ventricular function before starting a patient on cardiotoxic drugs?
MUGA (Multi Gated Acquisition Scan, also known as radionuclide angiography)
How are beta-blocker overdoses managed?
if bradycardic then atropine
in resistant cases glucagon may be use
Which investigation should be requested in people with suspected restless leg syndrome?
Ferritin to exclude iron deficiency anaemia
Cardiac conditions and driving.
angioplasty (elective) - 1 week off driving
CABG - 4 weeks off driving
acute coronary syndrome- 4 weeks off driving
1 week if successfully treated by angioplasty
angina - driving must cease if symptoms occur at rest/at the wheel
pacemaker insertion - 1 week off driving
implantable cardioverter-defibrillator (ICD)
if implanted for sustained ventricular arrhythmia: cease driving for 6 months
if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
successful catheter ablation for an arrhythmia- 2 days off driving
aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review.
an aortic diameter of 6.5 cm or more disqualifies patients from driving
heart transplant: do not drive for 6 weeks, no need to notify DVLA
By how much should opioid doses be increased if pain is not controlled in palliative patients?
By 30-50%
What is the equation for likelihood ratio?
Likelihood ratio for a positive test result = sensitivity / (1 - specificity)
How does mercury poisoning present?
Visual field defects, hearing loss and paraesthesia
What is the most common cause of tinea capitis in the UK?
Trichophyton tonsurans
What is Castleman’s disease?
Lymphoproliferative disorder associated in a subset of cases with HIV and HHV-8. Patient’s with unicentric Castleman’s disease tend to be asymptomatic and lymphadenopathy is constrained to one lymph node group.
List common trinucleotide repeat disorders.
CAG: Huntington’s disease
GAA: Friedrich Ataxia
CTG: Myotonic dystrophy
CGG: Fragile X syndrome
Waht is pseudohypoparathyroidism?
target cell insensitivity to PTH short fourth and fifth metacarpals short stature cognitive impairment obesity round face
Which antiepileptic can cause complications in newborn babies?
Phenytoin induces vitamin K metabolism, which can cause a relative vitamin K deficiency, creating the potential for heamorrhagic disease of the newborn
How does ADEM manifest?
After a lag time of between a few days to 2 months, there is an acute onset of multifocal neurological symptoms with rapid deterioration. Non-specific signs such as headache, fever, nausea and vomiting may also accompany the onset of illness. Motor and sensory deficits are frequent and there may also be brainstem involvement including oculomotor defects.
Which renal disease is coeliac disease associated with?
IgA nephropathy
How does spinal stenosis present?
gradual onset leg and back pain, weakness and numbness which is brought on by walking (with a normal clinical examination)
Which cells secrete CCK?
I cells
How does cystinuria manifest?
Recurrent renal stones
Diagnosed using the cyanide-nitroprusside test
What are the differences between wet and dry beri beri?
Wet - heart failure
Dry - peripheral neuropathy
What are the main treatments for spasticity in multiple sclerosis?
Baclofen
Gabapentin
List some causes of an abnormal second heart sound.
loud: hypertension
soft: AS
fixed split: ASD
reversed split: LBBB
What is alkaptonuria?
autosomal recessive disorder that is a result of a deficiency of homogentisic acid dioxygenase leading to elevated levels of homogentisic acid (HGA).
Clinically features include brown/bluish pigment of the ear cartilage or sclera, arthropathy, renal stones, cardiac valve involvement and coronary calcification. Urine turns dark on standing.
What is the treatment of choice for ABPA?
Oral Steroids
Which condition is associated with anti-NMDA receptor encephalitis?
Ovarian teratoma
What is Bombesin?
Tumour marker for small cell lung cancer
What are the features of Alport syndrome?
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus: protrusion of the lens surface into the anterior chamber
retinitis pigmentosa
renal biopsy: splitting of lamina densa seen on electron microscopy
NOTE: caused by X-linked dominant mutation in type IV collagen
Which cardiac changes may be seen in a patient with Carcinoid syndrome?
tricuspid insufficiency and pulmonary stenosis
Which antiemetics are recommended for motion sickness?
hyoscine > cyclizine > promethazine
Which rheumatoid arthritis drugs are safe to use in pregnancy?
hydroxychloroquine
sulfasalazine
What are the stages of hypertensive retinopathy?
I Arteriolar narrowing and tortuosity Increased light reflex - silver wiring II Arteriovenous nipping III Cotton-wool exudates Flame and blot haemorrhages IV Papilloedema
What are some common complications of seborrhoeic dermatitis?
Otitis externa
Blepharitis
Which pulse abnormality is seen in severe left ventricular failure?
Pulsus alternans
What causes pulsus bisferiens?
Mixed aortic valve disease
What causes pityriasis rosea?
HHV6 and HHV7
What underlying condition is associated with warfarin necrosis?
Acquired protein C deficiency
What is sideroblastic anaemia and list some causes.
Red cells fail to completely form haem. This leads to deposits of iron in the mitochondria that form a ring around the nucleus called a ring sideroblast.
CONGENITAL: delta-aminolevulinate synthase-2 deficiency
ACQUIRED: myelodysplasia, alcohol, lead, anti-TB medications
Treated with pyridoxine
How is schistosomiasis treated?
Praziquantel
List some causes of normal anion gap metabolic acidosis.
gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease
List some causes of raised anion gap metabolic acidosis.
lactate: shock, sepsis, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
What are the stages of diabetic nephropathy?
1: Hyperfiltration
2: Silent or Latent (GFR remains elevated)
3: Incipient nephropathy (microalbuminuria)
4: Over nephropathy (persistent proteinuria, hypertension, diffuse glomerulosclerosis with focal glomerulosclerosis (Kimmelstiel-Wilson nodules)
5: ESRF
What can reduce the formation of oxalate stones?
Pyridoxine
Cholestyramine
How do frontal lobe lesions manifest?
expressive (Broca's) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting disinhibition perseveration anosmia inability to generate a list
How is Meniere’s disease treated?
Acute Attack: Prochlorperazine
Prevention: Betahistine and vestibular rehabilitation exercises
What are the most common causes of viral myocarditis?
Parvovirus B19
HHV6
What is dysbetalipoproteinaemia and how is it treated?
mixed hyperlipidaemia (raised cholesterol and triglyceride levels)
Treated with fibrates
List a cause of upbeat and downbeat nystagmus.
Upbeat - Cerebellar Vermis Lesion
Downbeat - Arnold Chiari Malformation
What is the conversion ratio of oral morphine to parenteral diamorphine?
3:1
List some conditions that are associated with pseudogout.
haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly, Wilson’s disease
Which chromosomes are the globin genes on?
Alpha - 16
Beta - 11
Which type of collagen is most commonly affected in Ehlers-Danlos syndrome?
Type 3
List the indications for parathyroidectomy in hyperparathyroidism.
Age under 50 years.
Adjusted serum calcium concentration that is 0.25 mmol/L or more above the upper end of the reference range.
Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 although this threshold depends on other factors, such as age.
Renal stones or presence of nephrocalcinosis on ultrasound or CT.
Presence of osteoporosis or osteoporotic fracture.
Symptomatic disease
List some side-effects of ivabradine.
visual effects, particular luminous phenomena, are common
headache
bradycardia, heart block
NOTE: it acts on the funny channel and reduces the cardiac pacemaker activity
Outline the management guidelines for chronic plaque psoriasis.
FIRST LINE : potent corticosteroid applied once daily plus vitamin D analogue applied once daily
should be applied separately, one in the morning and the other in the evening)
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
What are the following antibodies associated with in the context of paraneoplastic syndromes? Anti-Hu Anti-Yo Anti-GAD Anti-Ri Purkinje Cell Antibody
Anti-Hu: small cell lung cancer and neuroblastomas, sensory neuropathy (may be painful), cerebellar syndrome, encephalomyelitis
Anti-Yo: ovarian and breast cancer, cerebellar syndrome
Anti-GAD: breast, colorectal and small cell lung cancer, stiff person’s syndrome or diffuse hypertonia
Anti-Ri: breast and small cell lung cancer, ocular opsoclonus-myoclonus
Purkinje Cell Antibody: peripheral neuropathy in breast cancer
How should listeria meningitis be treated?
Ceftriaxone + amoxicillin + gentamicin
Outline the diagnostic criteria for neuromyelitis optica.
Diagnosis is requires bilateral optic neuritis, myelitis and 2 of the follow 3 criteria:
- Spinal cord lesion involving 3 or more spinal levels
- Initially normal MRI brain
- Aquaporin 4 positive serum antibody
How does methanol poisoning present?
Causes both the effects associated with alcohol (intoxication, nausea etc) and also specific visual problems, including blindness.
NOTE: treated with fomepizole or ethanol, haemodialysis and cofactor therapy with folinic acid to reduce ophthalmoplegic complications
How should acute chest syndrome in sickle cell disease be managed?
Oxygen therapy to maintain saturations > 95%
Intravenous fluids to ensure euvolaemia
Adequate pain relief
Incentive spirometry in all patients presenting with rib or chest pain
Antibiotics with cover for atypical organisms
Early consultation with the critical care team and haematology
Which cells produce IL1 and what does it do?
Macrophages –> acute inflammation, induced fever
Which cells produce IL2 and what does it do?
Th1 cells –> stimultes growth and differentiation of T cell response
Which cells produce IL3 and what does it do?
Activated T helper cells –> stimulates differentiation and proliferation of myeloid progenitor cells
Which cells produce IL4 and what does it do?
Th2 cells –> stimulates differentiation and proliferation of B cells
Which cells produce IL5 and what does it do?
Th2 cells –> stimulates production of eosinophils
Which cells produce IL6 and what does it do?
Macrophages, Th2 cells –> stimulates differentiation of B cells, induced fever
Which cells produce IL8 and what does it do?
Macrophages –> neutrophil chemotaxis
Which cells produce IL10 and what does it do?
Th2 –> inhibits Th1 cytokine production (anti-inflammatory cytokine)
Which cells produce IL12 and what does it do?
Dendritic cells, macrophages, B cells –> activates NK cells and stimulates production of Th1 cells
What is an Argyll-Roberton pupil?
Features
small, irregular pupils
no response to light but there is a response to accommodate
Causes
diabetes mellitus
syphilis
What are the indications for stopping an exercise tolerance test?
exhaustion / patient request
‘severe’, ‘limiting’ chest pain
> 3mm ST depression
> 2mm ST elevation.Stop if rapid ST elevation and pain
systolic blood pressure > 230 mmHg
systolic blood pressure falling > 20 mmHg
attainment of maximum predicted heart rate
heart rate falling > 20% of starting rate
arrhythmia develops
How is serotonin syndrome managed?
IV fluids
Benzodiazepines
Cyproheptadine (in severe cases - blocks H1 receptors and serotonin receptors)
What is multifocal atrial tachycardia?
Irregular cardiac rhythm caused by at least three different sites in the atria, which may be demonstrated by morphologically distinctive P waves. It is more common in elderly patients with chronic lung disease, for example COPD
Management
- correction of hypoxia and electrolyte disturbances
- rate-limiting calcium channel blockers are often used first-line
- cardioversion and digoxin are not useful in the management of MAT
Which causes of hyperlipidaemia primarily cause hypercholesterolaemia rather than hypertriglyceridaemia?
Nephrotic syndrome
Cholestasis
Hypothyroidism
How is tetanus managed?
IM Tetanus Immunoglobulin
IV Metronidazole
What are some cardiac complications of donepezil?
Bradycardia and AV node block
Which cell surface antigen is found on Reed-Sternberg cells?
CD15
How does quinine toxicity present?
ECG changes, hypotension, metabolic acidosis, hypoglycaemia and classically tinnitus, flushing and visual disturbances. Flash pulmonary oedema may occur
What is the first-line treatment option for Lyme disease with CNS involvement (e.g. Bell’s palsy)?
IV Ceftriaxone
What are the main features of Langerhans cell histiocytosis?
Bone pain (usually skull or proximal femur)
Cutaneous nodules
Recurrent otitis media/mastoiditis
Tennis racket-shaped Birbeck granules on electron microscopy
What ECG feature is seen in aortic root abscesses?
Prolonged PR interval
How is Adult-onset Still’s disease treated?
NSAIDs (first-line for fever, joint pain and serositis)
Steroids
Methotrexate, IL-1 (anakinra) or anti-TNF
What is Foster-Kennedy syndrome?
When a frontal lobe tumour leads to ipsilateral optic atrophy and contralateral papilloedema
What advice should you provide to someone who is on metformin for diabetes and is planning on fasting for Ramadan?
One-third of normal dose before sunrise
Two-thirds of normal dose after sunset
What is the main pharmacological effect of ketamine?
NMDA Receptor Antagonist
What investigation findings might you see in lead poisoning?
Raised serum lead concentration
Microcytic anaemia with basophilic stippling
Raised serum and urine delta aminolaevulinic acid
Raised urinary coproporphyrin
What immunofluorescence pattern is seen in bullous pemphigoid?
immunofluorescence shows IgG and C3 at the dermoepidermal junction
What are the main features of Yellow Nail Syndrome?
Congenital lymphoedema
Bronchiectasis
Chronic sinusitis
Pleural effusions
List some causes of left axis deviation.
left anterior hemiblock
left bundle branch block
inferior myocardial infarction
Wolff-Parkinson-White syndrome* - right-sided accessory pathway
hyperkalaemia
congenital: ostium primum ASD, tricuspid atresia
minor LAD in obese people
List some causes of right axis deviation.
right ventricular hypertrophy left posterior hemiblock lateral myocardial infarction chronic lung disease → cor pulmonale pulmonary embolism ostium secundum ASD Wolff-Parkinson-White syndrome* - left-sided accessory pathway normal in infant < 1 years old minor RAD in tall people
Which two tests are used to assess correlation in data?
parametric (normally distributed): Pearson’s coefficient
non-parametric: Spearman’s coefficient
What is Beckwith-Wiedemann syndrome?
Inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia
How is thyroid storm managed?
symptomatic treatment e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil
Lugol’s iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
At what dose and duration of prednisolone is the risk of osteoporosis thought to significantly increase, warranting bisphosphonate treatment?
equivalent of prednisolone 7.5mg a day for 3 or more months
Which group of patients with type 1 diabetes mellitus should be offered atorvastatin 20 mg OD?
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors
What target are you aiming for at follow-up in a patient who has been started on statins?
repeat a full lipid profile
if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes should be discussed with the patient
NICE recommend we consider increasing the dose of atorvastatin up to 80mg
How do you check whether thrombolysis for a STEMI has been effective?
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation
- if there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
- for patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation
What is anti-synthetase syndrome?
Combination of proximal myopathy and mechanic’s hands
How does terbinafine work?
Inhibits squalene epoxidase thereby inhibiting the production of ergosterol
How do azoles (e.g. fluconazole) work?
Inhibits 14a-demethylase which produces ergosterol
How does griseofulvin work?
Interacts with microtubules to disrupt the mitotic spindle
How does flucytosine work?
Converted by cytosine deaminase to 5-fluorouracil, which inhibits thymidylate synthase and disrupts fungal protein synthesis
How does caspofungin work?
Inhibits synthesis of beta-glucan, a major fungal cell wall component
How does nystatin work?
Binds with ergosterol forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage
What does alemtuzumab target and what is it used for?
Anti-CD52
Used in CLL
What does OKT3 target and what is it used for?
Anti-CD3
Used to prevent organ rejection
What is a leukaemoid reaction?
presence of immature cells such as myeloblasts, promyelocytes and nucleated red cells in the peripheral blood. This may be due to infiltration of the bone marrow causing the immature cells to be ‘pushed out’ or sudden demand for new cells
Causes include severe infection, severe haemolysis, massive haemorrhage and metastatic cancer with bone marrow infiltration
How can a leukaemoid reaction be differentiated from chronic myeloid leukaemia?
High leucocyte alkaline phosphatase score
Toxic granulation (Dohle bodies) in the white cells
‘Left shift’ of neutrophils i.e. three or fewer segments of the nucleus
What is used to treat adrenaline-induced ischaemia?
Phentolamine
A lesion in which part of the brain would cause alexia without agraphia?
Corpus callosum
How is eosinophilic oesophagitis managed?
Dietary modification (e.g. elemental diet) Topical steroids (e.g. fluticasone) Oesophageal dilatation
What is the mechanism of action of 5-FU?
Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase)
What is the mechanism of action of 6-mercaptopurine?
Purine analogue that is activated by HGPRTase, decreasing purine synthesis
What is the mechanism of action of cytarabine?
Pyrimidine antagonist. Interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase
What is the mechanism of action of cisplatin?
Causes cross-linking in DNA
What is the mechanism of action of hydroxyurea?
Inhibits ribonucleotide reductase, decreasing DNA synthesis
What can be used to accelerate clearance of guttate psoriasis?
UV B
What is Loeffler syndrome?
transient CXR shadowing and blood eosinophilia
thought to be due to parasites such as Ascaris lumbricoides causing an alveolar reaction
presents with a fever, cough and night sweats which often last for less than 2 weeks.
generally a self-limiting disease
Which investigations are used for age-related macular degeneration?
First-Line: Slit lamp microscopy
Fluorescein angiography if neovascular ARMD is suspected
Ocular coherence tomography
Outline the latest NICE guidelines regarding thrombolysis and thrombectomy.
Offer thrombectomy, together with thrombolysis, for patients who have a confirmed occlusion of the proximal anterior circulation on imaging.
NICE have also made recommendations to use a modified Rankin score of less than 3 and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5 when considering the selection of patients for mechanical thrombectomy.
How is acute angle closure glaucoma treated?
Eye drops (e.g. pilocarpine, timolol or apraclonidine) and IV acetazolamide
What is Leiner disease?
Rare and serious syndrome of infantile erythroderma of severe and progressive generalized seborrheic-like dermatitis, recalcitrant diarrhea, malabsorption and wasting, and recurrent local and systemic infections.
Associated with C5 deficiency
Which cytokines do Th1 cells produce?
IFN-gamma
IL-2
IL-3
NOTE: involved in cell-mediated immunity and delayed (type IV) hypersensitivity
Which cytokines do Th2 cells produce?
IL-4 IL-5 IL-6 IL-10 IL-13
NOTE: involved in humoral immunity
What are the indications for starting antiepileptic medication after the first seizure?
the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable
What change in ion channel activity leads to a long QT interval?
Loss of function or blockade of potassium channels
This leads to the myocardial cells being overloaded with positively charged ions
Outline the management guidelines for COPD.
1: SABA
2A (+ Asthmatic Features): LABA + ICS
3A: LAMA + LABA + ICS
2B (- Asthmatic Features): LABA + LAMA
According to NICE, how should the daily fluid and electrolyte requirements of a patient be calculated?
Fluid - 25-30 mL/kg Sodium - 1mmol/kg Potassium - 1 mmol/kg Water - 30ml/Kg Glucose - 50-100g
What regime is used for post-exposure prophylaxis for HIV?
Combination antiretrovirals (tenofovir, emtricitabine, lopinavir/ritonavir) + repeat HIV test in 12 weeks
Which drugs can cause acute pancreatitis?
azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
What type of pulse do you see in patent ductus arteriosus?
Collapsing
What does gastrin do?
Causes acid secretion, mucosal growth and smooth muscle contraction
What does pancreatic polypeptide do?
Inhibits pancreatic enzyme secretion
What is multifocal motor neuropathy?
Disease that causes progressive asymmetrical, distal upper limb weakness
Associated with anti-GM1 antibodies
Which antibiotics is usually included in the treatment of toxic shock syndrome?
Clindamycin
What is Tolosa-Hunt syndrome?
Granulomatous inflammatory process involving the cavernous sinus/superior orbital fissure
Leads to III, IV, VI and V(I) palsy
Which fruit allergy is associated with latex allergy?
Bananas
Which artery is most commonly affected in lateral medullary syndrome?
Vertebral artery
What are palmar crease xanthomata pathognomonic of?
Type III Hyperlipidaemia (Broad Beta Disease)
What is Sezary syndrome?
Type of cutaneous T cell lymphoma (like mycosis fungoides)
Presents with erythroderma
What are the main features of a pontine stroke?
Contralateral limb weakness with bulbar involvement
Ipsilateral 6th and 7th nerve palsies
Which intervention can be used to treat refractory pain in pancreatic cancer?
Coeliac plexus block
What is MacLeod syndrome?
Unilateral emphysema following childhood bronchiolitis
What are some major adverse effects of d-Penicillamine?
Pancytopenia and acute tubulointerstitial nephritis
What is adynamic bone disease?
The bone loses its capacity to buffer calcium and can be associated with over treatment with alfacalcidol
It leads to reduced active mineralisation and increased risk of fractures (especially NOF)
It is more common in diabetic patients and those on peritoneal dialysis
What must you do before thrombolysing a patient with a PE?
Bedside echocardiogram to confirm right heart strain
What is the main purpose of post-marketing observations studies?
To identify rare adverse events
What are the features of anti-phospholipid syndrome?
Recurrent miscarriage
Thrombocytopaenia
VTE
Livedo reticularis
Other: renal vein thrombosis, progressive cognitive impairment
What does lactose break down into?
Glucose and Galactose
What dose maltose break down into?
2 x glucose
What does sucrose break down into?
Glucose and Fructose
What treatment is used in patients with recurrent urinary tract calculi and how does it work?
Potassium citrate
It reduces urinary supersaturation of calcium salts by forming soluble complexes with calcium ions, and by inhibiting crystal growth and aggregation
What is the most common type of thyroid cancer?
Papillary (80%) - associated with spread to lymph nodes
Others: follicular, medullary, anaplastic
Which gene is associated with B-cell non-Hodgkin lymphoma?
BCL2
When should a patient undergoing an elective splenectomy receive the pneumococcal vaccine?
2-4 weeks before surgery
What is the classical presentation of Hodgkin lymphoma?
Neck and mediastinal lymphadenopathy in adolescents
Which artery is most commonly responsible for haemoptysis?
Bronchial (95%)
What is the mechanism by which NSAIDs call renal injury?
Acute tubulointerstitial nephritis
What feature can help distinguish ATN from AIN?
ATN has bland urinalysis
AIN will feature blood/protein/leucocytes
What is the difference in the way that haemoglobinuria and haemosiderinuria is interpreted?
Haemoglobinuria = acute haemolysis Haemosiderinuria = chronic haemolysis
What is the first step in the management of a suspected septic arthritis?
Blood cultures
Then antibiotics and joint fluid aspiration
What is the most common gastrointestinal complication of systemic sclerosis?
SIBO
What can be used to get an accurate measurement of oxygen saturation in a patient with carbon monoxide poisoning?
Four-wavelength spectrophotometer
How is erythroderma managed in a patient with psoriasis?
Topical white soft paraffin all over the body
What pulse abnormality is seen in cardiac tamponade?
Pulsus paradoxus
Which ECG features would you expect to see in a posterior STEMI?
In V1-V3
- horizontal ST depression
- tall, broad R waves
- upright T waves
- dominant R wave (R/S ratio > 1 in V2)
Which part of the brain controls vomiting?
Area postrema
What is the first-line treatment option for discoid lupus?
Hydroxychloroquine
How does aciclovir cause AKI?
In the presence of dehydration, aciclovir can precipitate as crystals in the kidney tubules
What is the role of the inferior laryngeal nerve?
Sensory innervation to larynx inferior to the vocal cords
What is a poor prognostic marker seen in the karyotype of a patient with acute myeloid leukaemia?
Chromosome 7 Abnormalities
What is the sniff test used for and what does it show?
Unilateral paralysis of the diaphragm
During force inspiratory movement (sniff) the unaffected hemidiaphragm moves down forcefully and increases the intra-abdominal pressure, thereby pushing the affected hemidiaphragm up (paradoxical movement)
This can be confirmed using X-ray and fluoroscopy
Which antiemetics can cause QT prolongation?
Metoclopramide
Ondansetron
Prochlorperazine
What is the best early indicator of prognosis in paracetamol-induced liver injury?
INR at 48 hours
NOTE: a doubling of the INR in 24 hours warrants referral to a specialist liver unit
Where are the different GLUT channels found?
GLUT1: erythrocytes and endothelial barrier cells
GLUT2: from intestinal cells into portal circulation
GLUT3: neurones
GLUT4: striated muscle and adipose tissue
List some drugs that cause torsades de pointes.
Antiarrhythmics (sotalol, procainamide, flecainide)
Antibiotics (erythromycin, levofloxacin)
Antifungals (ketoconazole)
Antipsychotics (risperidone, haloperidol)
TCA
Lithium
How does ezetimibe work?
Reduces intestinal cholesterol absorption
What is a key difference between Bartter and Gitelman syndrome?
Gitelman causes low urinary calcium excretion whereas Bartter does not
Describe how pacemaker terminology work?
Position I - Paced Chamber (Atrium, Ventricle or Dual)
Position II - Sensed Chamber (Atrium, Ventricle or Dual)
Position III - How It Will Respond to Sensed Chamber (Inhibit, Trigger output pulse, Dual modes of response, nO response to sensed input)
Position IV - Rate Modulation (Rate modulation active, rate modulation nOt active)
Position V - location or absence of multisite pacing (rarely used)
How are acute attacks of acute intermittent porphyria treated?
IV Haem Arginate
Which of the following is a marker of bronchial carcinoid?
Chromogranin A
Neuron-specific enolase is less sensitive
Which myocardial enzyme is released soonest after myonecrosis?
Glycogen phosphorylase BB
What is a leukoerythroblastic blood film?
Immature white and red cells on peripheral blood film - this is caused by bone marrow infiltration
What is the best test for invasive aspergillosis?
Serum Galactomannan
What is the treatment of choice for multifocal atrial tachycardia in a patient with pulmonary hypertension?
Verapamil
NOTE: multifocal atrial tachycardia is a rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria. Most commonly seen in patients with severe COPD or congestive heart failure.
Which antibodies are seen in autoimmune encephalitis?
Anti-LGI1
NMDA
How are urinary cystine stones diagnosed?
Positive urine cyanide nitroprusside test
What is Kennedy syndrome and how does is present?
Spinal bulbar muscular atrophy
Proximal weakness and cramps, wasting, fasciculations, weakness and hyporeflexia
Associated with androgen insensitivity
Other than opioids, what treatment may be effective in the management of liver capsule pain in a patient with oedema secondary to hepatic metastases?
Corticosteroids
