MRCP Part 2 Flashcards
What is the mainstay of treating anterior uveitis?
Steroid and Cycloplegic (mydriatic) Eye Drops
E.g. Cyclopentolate and Corticosteroids
What is a useful effect of COMT inhibitors in patients with Parkinson’s Disease?
It is effective at smoothing out on-off fluctuations in patients on L-DOPA/DOPA Decarboxylase Inhibitors
Why should pioglitazone be avoided in patients with congestive cardiac failure?
It causes fluid retention
In which patients should donepezil be avoided?
Bradycardia
Which type of ovarian tumour produces TSH?
Struma ovarii (variant of ovarian teratoma)
Outline the emergency management of acute angle closure glaucoma.
Eye Drops (e.g. pilocarpine, timlolol) + IV Acetazolamide
What is the first-line treatment option for trigeminal neuralgia?
Carbamazepine
Outline 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 is the difference between type 1 and type 2 amiodarone-induced thyrotoxicosis?
Type 1
- Caused by excess iodine-induced thyroid hormone synthesis
- Goitre present
- Rx: Carbimazole or Potassium Perchlorate
Type 2
- Caused by amiodarone-related destructive thyroiditis
- Goitre absent
- Rx: Corticosteroids
NOTE: these can be distinguished using colour flow Doppler ultrasonography or thyroid uptake scans
What are the main features of leptospirosis?
Acute Phase: fever, malaise, headache, and abdominal pain
Later Phase: severe systemic upset such as renal failure, pulmonary haemorrhage, and hepatic failure.
Ix: Serology
Rx: high-dose benzylpenicillin or doxycycline
What does capillary wedge pressure represent in terms of cardiac catheterisation?
It is equivalent to the left atrial pressure which should equal the left ventricular diastolic pressure
A normal mitral valve would expect less than 5 mm Hg pressure difference (capillary wedge pressure minus left ventricular diastolic pressure). If it is greater than that, there is a degree of mitral stenosis.
How is p wave asystole managed?
External pacing
NOTE: this is when you see only p waves on a rhythm check in a cardiac arrest
What are the indications for carotid endartarectomy?
Recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled
Should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria
How does Q fever manifest?
Fevers, headaches, fatigue and muscle aches
Transaminitis on LFTs
Comes from sheep and caused by Coxiella burnetti
Which therapy is effective and reducing morbidity and mortality in toxic epidermal necrolysis?
IVIG
How should patients with a superficial vein thrombosis be managed?
Ultrasound to check for DVT
Prophylactic dose LMWH for 30 days or fondaparinux for 45 days (if contraindicated, 8-12 days of NSAID)
NOTE: there is a risk of thrombosis extension into the deep veins
List some poor prognostic factors for CLL.
male sex age > 70 years lymphocyte count > 50 prolymphocytes comprising more than 10% of blood lymphocytes lymphocyte doubling time < 12 months raised LDH CD38 expression positive TP53 mutation
What are the features of local anaesthetic toxicity?
CNS: reduced GCS, seizures
Cardiovascular: arrhythmia, hypotension
In which patients can you not give ranolazine?
Severely impaired renal function
After calcium channel blockers and beta-blockers, which agents are used in the management of stable angina?
Long-acting nitrate
Nicorandil (stimulates guanylate cyclase to increase formation of cyclic GMP)
Ranolazine (inward sodium channel inhibitor)
Ivabradine (funny channel inhibitors - reduces HR and workload)
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
What’s the most common chemotherapy regime for small cell lung cancer?
Cisplatin and etoposide
NOTE: cisplatin causes hypomagnesemia which leads to muscle cramps, tremor, arrhythmias and confusion
Which UC patients should be considered for drugs that maintain remission (e.g. azathioprine, mercaptopurine)?
severe relapse or >=2 exacerbations in the past year they should be given either oral azathioprine or oral mercaptopurine to maintain remission
What are the criteria for LTOT?
Offer LTOT to 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
peripheral oedema
pulmonary hypertension
What is one crucial interaction between TB and HIV medications that you should be aware of?
Rifampicin causes reduced absorption and increased metabolism of protease inhibitors
NOTE: in these circumstances, an alternative rifamycin such as rifabutin is recommended as it induced cytochromse p450 less than rifampicin
What is the first-line management option for renal complications of systemic sclerosis?
ACE Inhibitors
What clinical features is associated with an increased risk of NSAID-induced asthma exacerabtions?
Presence of nasal polyps
How is crusted scabies managed?
Isolated and ivermectin
NOTE: crusted scabies is something that happens in people who are significantly immunocompromised
How is cryptococcal meningitis managed?
IV Antifungals (e.g. amphotericin B and flucytosine)
How does cryoglobulinaemia present?
Raynaud’s only seen in type I
cutaneous: vascular purpura, distal ulceration, ulceration
arthralgia
renal involvement (diffuse glomerulonephritis)
What are the three types of cryoglobulinaemia?
Three types type I (25%): monoclonal type II (25%): mixed monoclonal and polyclonal: usually with rheumatoid factor type III (50%): polyclonal: usually with rheumatoid factor
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
Which common cardiac drug should be avoided in patients with cardiac amyloid?
Digoxin (higher risk of digoxin toxicity as the drug binds avidly to amyloid fibrils)
How is idiopathic intracranial hypertension managed?
Weight Loss
Acetazolamide
Why are SSRIs contraindicated in patients with a background of peptic ulcer disease?
Increases the risk of upper GI bleeds by inhibiting platelet aggregation
Which treatment should be considered in addition to a statin in a young patient with familial hypercholesterolaemia?
Evolocumab (PCSK9 inhibitor)
Outline the Simon Broome criteria for familial hypercholesterolaemia.
In adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l or children TC > 6.7 mmol/l and LDL-C > 4.0 mmol/l, plus:
DEFINITE FH: tendon xanthoma in patients or 1st or 2nd degree relatives or DNA-based evidence of FH
POSSIBLE FH: family history of myocardial infarction below age 50 years in 2nd degree relative, below age 60 in 1st degree relative, or a family history of raised cholesterol levels
What is an important acute complication of a ketamine infusion?
Raised ICP (monitor for headache, papilloedema and vomiting when administering)
What is the time window for thrombectomy for stroke?
an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
How should patients with gestational diabetes be followed-up after birth?
Postnatal glucose check (fasting blood glucose) 6-13 weeks postpartum
How should patients with COPD who are being worked up for LTOT and have a significant rise in pCO2 with oxygen therapy be managed?
Patients who develop a respiratory acidosis and/or a rise in PaCO2 of >1 kPa (7.5 mmHg) during an LTOT assessment on two repeated occasions, while apparently clinically stable, should only have domiciliary oxygen ordered in conjunction with nocturnal ventilatory support
What is seen on a biopsy of a patient with CMV colitis?
Inclusion bodies
NOTE: treated with gancyclovir
Which antibody is specific for drug-induced lupus?
Anti-histone
NOTE: common causes include procainamide and hydralazine
Which conditions are associated with SIBO?
neonates with congenital gastrointestinal abnormalities
scleroderma
diabetes mellitus
Describe the appearance of cryptosporidium on Ziehl Nielson staining.
Red cysts
May be treated with rifaximin but is usually supportive in patients who are immunocompetent
Other treatment: nitazoxanide
What is the drug of choice for lymphatic filariasis?
Diethylcarbamazine
How is FSGS treated?
Steroids
How does histoplasmosis present?
Productive cough
Retrosternal chest pain
Recent travel to USA
Rx: Itraconazole or amphotericin
Which medication enhances the effects of adenosine?
Dipyridamole
Leads to prolonged effects
Which TB drug causes arthralgia?
Pyrazinamide
What is the purpose of a long synacthen test?
A long synacthen test (where samples are taken at 1, 4, 8, and 24 hours) can be used to distinguish Addison’s from secondary causes of adrenal insufficiency such as steroid use, panhypopituitarism, and isolated failure of adrenocorticotrophic hormone (ACTH).
RATIONALE: with primary failure, the adrenals will never be able to produce any cortisol. With secondary failure, the exogenous ACTH will eventually be able to produce some cortisol.
Which ECG change is commonly seen in arrhythmogenic right ventricular cardiomyopathy?
TWI in V1-V3 Epsilon wave (terminal notch in QRS complex)
When are platelets and FFP recommended in the context of a gastrointestinal bleed?
platelets < 50 and INR/APTT > 1.5 x normal
What are the four types of renal tubular acidosis?
Type 1 RTA (distal)
inability to generate acid urine (secrete H+) in distal tubule
causes hypokalaemia
complications include nephrocalcinosis and renal stones
causes include idiopathic, rheumatoid arthritis, SLE, Sjogren’s, amphotericin B toxicity, analgesic nephropathy
Type 2 RTA (proximal)
decreased HCO3- reabsorption in proximal tubule
causes hypokalaemia
complications include osteomalacia
causes include idiopathic, as part of Fanconi syndrome, Wilson’s disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate)
Type 3 RTA (mixed)
extremely rare
caused by carbonic anhydrase II deficiency
results in hypokalaemia
Type 4 RTA (hyperkalaemic)
reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion
causes hyperkalaemia
causes include hypoaldosteronism, diabetes
What are the features of Miller-Fisher Syndrome?
Ophthalmoplegia
Areflexia
Ataxia
Usually a DESCENDING paralysis
NOTE: Anti-GQ1b antibodies present in 90% of cases
What is one negative aspect of G6PD level assays?
It may be normal during an acute episode
NOTE: this is because cells with the lowest levels of G6PD are destroyed first during an acute episode. Measure again once acute episode has resolved.
Which four cranial nerve nuclei arise in the medulla?
CN 9-12
Which four cranial nerve nuclei arise in the pons?
CN 5-8
Which four cranial nerve nuclei arise ABOVE the pons?
CN 1-2 (from the cerebrum)
CN 3-4 (from the midbrain)
Which neuroanatomical structures are in the MIDLINE in the brainstem?
Motor pathways (corticospinal tract)
Medial lemniscus
Medial longitudinal fasciculus
Motor nuclei of 3, 4, 6 and 12
Which neuroanatomical structures are in the LATERAL aspect of the brainstem?
Spinothalamic Tract
Sympathetic Fibres
Sensory Nuclei of CN 5
Spinocerebellar Tract
Which rule can be used to remember which motor nuclei are in the midline vs the lateral aspect of the brainstem?
The ones in the midline are all divisible by 12 (12, 6, 4 and 3) (N.B. excludes 1 and 2)
The others are found in the lateral aspect (5, 7, 9 and 11)
How does an uncal herniation manifest?
Ipsilateral 3rd nerve palsy involving the pupil Contralateral paralysis (due to compression of cerebral peduncle)
What is the recommended treatment option for fatigue associated with MS?
Amantadine
NOTE: anaemia, depression and thyroid dysfunction should be ruled out first
How is oscillopsia associated with MS treated?
Gabapentin
How should bladder dysfunction in MS be investigated and managed?
Ix: US to assess bladder emptying
If significant residual volume –> Intermittent self-catheterisation
If no significant residual volume –> anticholinergics
What are the criteria for beta-interferon use in multiple sclerosis?
Relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
Secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
Alternatives: glatiramer acetate, diethyl fumarate and teriflunomide
NOTE: interferons are contraindicated in liver dysfunction
What causes mucosal leishmaniasis and how does it manifest?
Leishmania braziliensis
Skin lesions across mucosa of nose and pharynx (may manifest years after exposure)
What causes cutaneous leishmaniasis and how does it manifest?
Leishmania tropica or Leishmania mexicana
Crusted lesion at site of bite
What causes visceral leishmaniasis and how does it manifest?
Leishmania donovani
Fever, sweats and rigors
Massive splenomegaly and hepatomegaly
Grey skin
Pancytopaenia (due to hypersplenism)
Ix: bone marrow or splenic aspirate
Which vector transmits leishmaniasis?
Sandfly
Which blood film abnormalities will be seen in G6PD deficiency?
Heinz bodies
Bite cells
Blister cells
Which stain is used to distinguish primary from metastatic lung cancers when performing cytological analysis of a malignant pleural effusion?
TTF1 (thyroid transcription factor)
This is only expressed by cells found in lung and thyroid.
How does Kearns-Sayre syndrome manifest?
Onset in patients < 20 years old
External ophthalmoplegia, retinitis pigmentosa (causing night blindness). Ptosis may be seen, heart block
NOTE: mitochondrial disease
What is the most specific ECG feature of acute pericarditis?
PR Depression
Which drugs are used in the treatment of ventricular tachycardia (with pulse)?
Procainamide (best option)
Amiodarone
Lidocaine (caution in left ventricular impairment)
What is a major risk of starting ACE inhibitors in someone with bilateral renal artery stenosis?
It can case deteriorating renal function and flash pulmonary oedema
What are the features of severe iron toxicity (i.e. overdose)?
Abdominal pain and haematemesis (gastrointestinal corrosion) Diarrhoea Raised BM (HALLMARK) Significant sample haemolysis Metabolic acidosis with high anion gap Coagulopathy (particularly APTT)
What increase in transaminases is allowed after starting a statin?
Up to 3 x upper limit of normal
If it appears to be rising but within this limit, the statin can be continued and LFTs repeated in 4-6 weeks
How is methotrexate toxicity treated?
Folinic acid
NOTE: folic acid is used to prevent methotrexate side-effects
Which antibiotics have good Pseudomonas cover?
Ciprofloxacin Tazocin Ceftazidime Aztreonam Meropenem
What is the only absolute contraindication for ECT?
Raised intracranial pressure
In which subgroup of patients with stable angina should revascularisation with PCI be offered?
Stable coronary artery disease and ischaemia in > 10 % of the left ventricle
What is an osmolar gap?
Measure Osmolality - Calculated Osmolality (2 x Na + Glu + Ur) = <10
If it is high, it means that there is an unmeasured solute in high amounts (e.g. ethylene glycol)
Which cause of pneumonia is associated with bulging fissure sign?
Klebsiella pneumonia
List some indications 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
NOTE: aseptic meningitis is a classic complication
What is the preferred imaging modality for patients with suspected TIA who need brain imaging?
MRI brain with diffusion-weighted imaging
What is a gradient record MRI brain used for?
To look for microhaemorrhages
How are hiccups managed?
Chlorpromazine
Haloperidol and Gabapentin
Dexamethasone (used if there are hepatic lesions)
What should you do in patients with neutropenic sepsis that has failed to respond to antibiotics after 48 hours?
It may be fungal –> start antifungal therapy
What feature can help distinguish dengue from chikungunya?
Chikungunya is more associated with severe joint pains
What is the most common GI side-effect of clozapine?
Constipation and intestinal obstruction
What are the indication for CRT?
NYHA class three or four symptoms
They are in normal sinus rhythm with either
→ QRS duration of 150 ms or longer estimated by standard electrocardiogram (ECG)
→ QRS duration of 120-149 ms estimated by ECG and mechanical dyssynchrony that is confirmed by echocardiography.
They have a left ventricular ejection fraction of 35% or less.
They are receiving optimal pharmacological thera
How is Schistosoma haematobium infection treated?
Single dose of praziquantel
Which types of porphyria only cause neurovisceral symptoms (i.e. no skin involvement)?
Acute intermittent porphyria
Aminolaevulinic acid dehydrogenase porphyria
Which types of porphyria only manifest with photosensitivity?
Porphyria cutanea tarda
Congenital erythropoietic porphyria
Erythropoietic protoporphyria
Which types of porphyria cause both neurovisceral and photosensitive manifestations?
Variegate porphyria
Hereditary coproporphyria
How long after CT contrast can a patient have radioiodine therapy?
8 weeks
Which criteria are used to diagnose a total anterior circulation stroke?
Unilateral hemiparesis and/or hemisensory loss of face/arm/leg
Homonymous hemianopia
Higher cognitive dysfunction (e.g. dysphasia)
NOTE: partial anterior circulation stroke is if 2 of the 3 above criteria are present
Which arteries are affected in a total anterior circulation stroke?
Anterior and Middle Cerebral Arteries
What are the main complications of typhoid?
Bowel perforation and haemorrhage
Myocarditis and endocarditis
List some contraindications for second line anti-anginal drugs.
Ivabradine - sick sinus syndrome
Ranolazine - liver injury
Nicorandil - LV failure and cardiogenic shock
What are the five types of lupus nephritis?
I - Minimal Mesangial II - Mesangial Proliferation III - Focal IV - Diffuse (WORST PROGNOSIS) V - Membranous
What treatment should be offered to 15-49 year olds with early ADPKD (eGFR > 90)?
ACE inhibitor with target blood pressure of < 110/75 mm Hg
NOTE: tolvaptan is recommended for rapidly progressive disease at CKD stage 2-3.
What are the indications for starting treatment of CLL?
progressive marrow failure: the development or worsening of anaemia and/or thrombocytopenia
massive (>10 cm) or progressive lymphadenopathy
massive (>6 cm) or progressive splenomegaly
progressive lymphocytosis: > 50% increase over 2 months or lymphocyte doubling time < 6 months
systemic symptoms: weight loss > 10% in previous 6 months, fever >38ºC for > 2 weeks, extreme fatigue, night sweats
autoimmune cytopaenias e.g. ITP
NOTE: FCR is usually the initial treatment of choice, ibrutinib is used afterwards
What ABG picture would you see in someone with methaemoglobinaemia?
Mixed respiratory and metabolic acidosis with a relative hypoxia despite the inspired fraction of oxygen.
When might ITP be used instead of steroids in a patient with ITP?
If platelets need to rise quickly (e.g. ahead of surgery)
What can cause a thunderclap headache with a normal CT head and normal CSF results?
Reversible cerebrovascular vasoconstriction syndrome
Why must you exercise caution when thinking about administering blood products to people with selective IgA deficiency?
Associated with anaphylactic reaction to blood products
How does benzodiazepine withdrawal manifest?
PHYSICAL: tachycardia, sweating, tremor
NEUROPSYCHIATRIC: nightmares, insomnia, anxiety, seizures, photophobia, derealisation and kinaesthetic hallucinations
Which medications cause false positive 5-HIAA results?
Paracetamol
Naproxen
Caffeine
Fluorouracil
FOODS: Banana, Avocado, Aubergine, Pineapple, Plums, Walnuts, Tomatoes
Which medications cause false negative 5-HIAA results?
Aspirin
Levodopa
Methyldopa
ACTH
How is a scleroderma renal crisis managed?
STAT ACE Inhibitor
What are the first, second and third line treatment options for acute dystonia?
1: Procyclidine
2: Benzodiazepine
3: Anticholinergic Antihistamines
List some common drugs that can increase seizure frequency in people with epilepsy?
Fentanyl Mefenamic Acid Tramadol Amitriptyline Aminophylline Isotretinoin Haloperidol
Outline the differences between the Parkinson’s plus syndromes.
PSP: bilateral symptoms, vertical gaze palsy, nasal voice (due to pseudobulbar palsy)
MSA: significant cerebellar or autonomic dysfunction
CBD: significant higher order dysfunction (e.g. apraxia, aphasia, alien hand syndrome)
What level of LFT derangement would warrant stopping methotrexate?
Doubling of ALT or AST
Which opioids are safe in patients with impaired renal function (eGFR < 30)?
Oxycodone
Fentanyl
Buprenorphine
Methadone
How is lupus nephritis treated?
Focal and Mild: Oral Steroids
Nephrotic Syndrome and Advanced Diffuse Lupus Nephritis: IV Methylprednisolone and IV Cyclophosphamide
When should statins be started after a stroke?
48 hours after the onset of symptoms
In which cases of hyperadrenalism is surgery indicated?
If it is caused by a unilateral adrenal adenoma
Otherwise you manage with spironolactone
When should EPO be started in a patient with CKD?
Once they are iron replete (this can be achieved with IV iron)
List the medical management guidelines for HOCM.
1: Beta-Blocker or Non-Dihydropyridine CCB (e.g. verapamil)
2: Disopyramide (class 1a anti-arrhythmic)
3: Myectomy, DDDR pacemaker, alcohol ablation
How should measles exposure be managed in someone that is vulnerable (e.g. unvaccinated, immunocompromised)?
Immunoglobulin
Why should patients undergoing open surgical valve repair have a coronary angiogram prior to the surgery?
To identify any coronary artery disease that could also be attended to at the same time
What is paragonimiasis and how does it present?
Lung Fluke Infection
Presents very similarly to TB with a chronic history of productive cough, weight loss, night sweats and rashes
Treated with praziquantel
List some side-effects of ciclosporin.
Nephrotoxic Hepatotoxic Fluid retention Hyperkalaemia Hypertrichosis Gingival hyperplasia
What is Fabry disease?
X-linked recessive lipid storage disorder
Caused by deficiency in alpha-galactosidase
Leads to accumulation of lipids in various tissues
Acroparaesthesia (tingling and burning in hands and feet triggered by stress, emotion and temperature) Angiokeratoma corporis diffusum Mitral valve prolapse/regurgitation Young strokes CKD
Which serum measurement is a useful marker of renal function that is less affected by age, sex, race and muscle mass?
Cystatin C
At what serum PTH level should patients with secondary hyperparathyroidism receive calcium and vitamin D supplements?
Twice the upper limit of normal
Supplementing calcium and vitamin D in secondary hyperparathyroidism runs the risk of adynamic bone disease if it is started sooner
How should hoarseness after a total thyroidectomy be investigated?
Laryngoscopy - to assess vocal cord paralysis and evaluate motility
How does strongyloidiasis manifest?
Diarrhoea Abdominal pain and bloating Papulovesicular lesions where skin has been penetrated (e.g. feet) Pruritic rash Pneumonitis (if larvae migrate to lungs)
Rx: Ivermectin
In which groups of patient is CABG considered better than PCI with stent insertion for the management of ischaemic heart disease?
Patients with complex anatomy
Triple vessel disease
Proximal left main stem disease
Which investigation is used for acute intermittent porphyria and how is it treated?
Raised urinary porphobilinogen
Treated with IV haem arginate
Which antibiotics are usually used to manage pyogenic liver abscesses?
amoxicillin + ciprofloxacin + metronidazole
What ECG features do you see in hypocalcaemia?
Prolonged QT Interval
How does histoplasmosis present and how is it treated?
Symptoms of URTI
Retrosternal pain
Rx: amphotericin or itraconazole
Outline the mechanism of hungry bone syndrome.
The mechanism is thought to be thus: high pre-operative levels of parathyroid hormone provide a constant stimulus for osteoclast activity creating the hypercalcaemic state by de-mineralizing the bones. This process can result in x-ray changes very similar to metastatic lytic lesions if left untreated. Upon removal of the parathyroid adenoma the hormone levels fall rapidly (they have a very short half-life) and the osteoclast activity is subsequently diminished and the bones rapidly begin re-mineralisation - ‘hungry bone syndrome’. This process can be uncomfortable and also result in systemic hypocalcaemia.
Which lower limb neurological features do you see in subacute combined degeneration of the spinal cord?
Brisk Knee Reflexes
Absent Ankle Reflexes
Extensor Plantar Reflexes
Describe the manifestations of methoxetamine overdose.
Sympathetic activation (tachycardia, hypertension, mydriasis) Confusion and agitation Cerebellar signs (nystagmus, dysarthria, ataxia)
NOTE: methoxetamine is an analogue of ketamine
What is the most common side effect of checkpoint inhibitors like nivolumab?
Dry itchy skin and rashes
How does anti-NMDA receptor encephalitis present?
Prominent psychiatric symptoms (agitation, hallucinations, delusions) Seizures Insomnia Dyskinesia Autonomic instability
Treated with immunosuppression (steroids, immunoglobulins, rituximab, cyclophosphamide, plasma exchange)
NOTE: it is normally caused by an ovarian teratoma
What is tropical spastic paraparesis?
A condition in which patients with HIV and HTLV1 present with urinary retention and paraparesis
Which antiemetic is best for metabolic causes of nausea and vomiting (e.g. hypercalcaemia, uraemia)?
Central dopamine antagonists (e.g. haloperidol)
What is the first-line antibiotic for ESBL UTIs?
Carbapenems
How does American trypanosomiasis manifest?
ACUTE: asymptomatic, sometimes orbital oedema
CHRONIC: myocarditis (and dilated cardiomyopathy), megaoesophagus (causing dysphagia) and megarectum
Rx: benznidazole or nifurtimox
What is idarucizumab used to reverse?
Dabigatran
What is used to reverse rivaroxaban and apixaban?
Andexanet alpha
What is the DMARD of choice in psoriatic arthritis?
Methotrexate
2nd line: leflunomide
What special feature of carbamazepine must you be aware of when starting patients on the drug?
It causes autoinduction so there may be an increase in seizure prevalence after 3-4 weeks
What forms of smoking cessation treatment are recommended by NICE?
Nicotine replacement therapy (patch and a short-form for acute cravings)
Varenicline (CI in pregnancy)
Bupropion (CI in pregnancy)
Outline the management of non-small cell lung cancer.
Stage 1 and 2: Resection Surgery
Stage 3: Chemotherapy
Stage 4: Palliative
List the contraindications for surgery for non-small cell lung cancer.
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
NOTE: FEV1 > 2 L for pneumonectomy
What special feature of Plasmodium ovale required additional consideration when determining how to treat it?
It has a liver hypnozoite phase that needs to be treated with primaquine
NOTE: primaquine can cause a haemolytic crisis in patients with G6PD deficiency so this should be excluded before starting treatment
Outline the criteria for diagnosing NF2.
Bilateral vestibular schwannomas
A first degree relative with NF2 AND
Unilateral vestibular schwannoma OR
Any two of: meningioma, schwannoma, glioma, neurofibroma, posterior subcapsular lenticular opacities
Unilateral vestibular schwannoma AND
Any two of: meningioma, schwannoma, glioma, neurofibroma, posterior subcapsular lenticular opacities
Multiple meningiomas AND
Unilateral vestibular schwannoma OR
Any two of: schwannoma, glioma, neurofibroma, cataract
What is the threshold for platelet transfusions in an actively bleeding patient?
50
What are the criteria for FFP in patients who are actively bleeding?
Either a fibrinogen level of less than 1 g/litre
or
PT or APTT greater than 1.5 times normal
Which vaccines are contraindicated in adults with HIV?
Cholera CVD103-HgR
Influenza-intranasal
Poliomyelitis-oral (OPV)
Tuberculosis (BCG)
NOTE: if CD4 < 200, then MMR, varicella and yellow fever are also contraindicated
How does relapsing polychondritis present?
Relapsing episodes of chondritis (e.g. auricular chondritis)
Can involve the respiratory tract, heart valves and blood vessels.
List some lead chelators.
dimercaptosuccinic acid (DMSA) - best for chronic exposure
D-penicillamine
EDTA - IV agent used for acute exposure
dimercaprol
How does lead poisoning manifest?
abdominal pain peripheral neuropathy (mainly motor) fatigue constipation blue lines on gum margin (only 20% of adult patients, very rare in children)
How should an HIV viral load of 50-200 in someone on established ART be managed?
Repeat blood test in 1 month
What are the criteria for antibiotic prophylaxis in patients with ascites?
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NOTE: with ciprofloxacin or norfloxacin
What are the criteria for commencing treatment with GLP1 agonists?
- Triple therapy is ineffective/not tolerated/contraindicated
- 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
NOTE: only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
What are the two different types of Wolff-Parkinson-White syndrome?
type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1
How should WPW be managed?
DEFINITIVE: RFA of accessory pathway
MEDICAL: Sotalol, Amidarone, Flecainide
NOTE: caution with AV blocking drugs especially if broad complex tachycardia because it may lead to increased conduction over accessory pathway leading to 1:1 AV conduction and VF
List some CYP450 INDUCERS.
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John’s Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline
NOTE: these DECREASE INR
List some CYP450 INHIBITORS.
antibiotics: ciprofloxacin, erythromycin isoniazid cimetidine,omeprazole amiodarone allopurinol imidazoles: ketoconazole, fluconazole SSRIs: fluoxetine, sertraline ritonavir sodium valproate acute alcohol intake quinupristin
NOTE: these INCREASE INR
List the manifestations of myotonic dystrophy.
myotonic facies (long, 'haggard' appearance) frontal balding bilateral ptosis cataracts dysarthria cardiomyopathy (incl. heart block) dysphagia diabetes mellitus
Outline the differences between DM1 and DM2.
DM1
- DMPK gene on chromosome 19
- Distal weakness more prominent
DM2
- ZNF9 gene on chromosome 3
- Proximal weakness more prominent
- Severe congenital form not seen
How is dermatitis herpetiformis treated?
Dapsone and a gluten-free diet
Second Line: Sulfapyridine
What causes paroxysmal nocturnal haemoglobinuria?
Acquired intravascular haemolysis due to increased sensitivity of cell membranes to complement due to lack of glycoprotein glycosylphosphatidylinositol (GPI).
How does PNH manifest?
Haemolytic anaemia Cytopaenias Haemoglobinuria Thrombosis Aplastic anaemia
How can PNH be diagnosed?
Flow cytometry of blood to detect low levels of CD59 and CD55
How can PNH be managed?
ACUTE: blood products, anticaogulation, eculizumab
DEFINTIIVE: stem cell transplantation
What is Alport syndrome?
X-linked dominant condition caused by mutation in collagen IV leading to abnormal glomerular basement membrane
How does Alport syndrome manifest?
Microscopic haematuria Progressive renal failure Bilateral sensorineural hearing loss Lenticonus Retinitis pigmentosa Renal Biopsy: split lamina densa (basket weave appearance)
What is a relatively common complication that occurs in patients with Alport syndrome who have received a renal transplant?
Crescentic glomerulonephritis due to de novo anti-GBM disease
Which investigations should be used to screen for haemochromatosis?
general population: transferrin saturation > ferritin
family members: HFE genetic testing
What are the definitive diagnostic tests used for hereditary haemochromatosis?
molecular genetic testing for the C282Y and H63D mutations
liver biopsy: Perl’s stain
Which type of brain tumour is associated with a paraneoplastic phenomenon in which patients develop a high Hb?
Cerebral haemangioblastomas (release erythropoietin)
List some associations of PBC.
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
What is papillary necrosis and what can cause it?
Sloughing of renal papillae which can lead to urinary obstruction, AKI and CKD. It can also cause a salt-losing nephropathy.
CAUSES chronic analgesia use sickle cell disease TB acute pyelonephritis diabetes mellitus
What is the risk of using BRAF inhibitors (e.g. Vemurafenib and dabrafenib) in the treatment of melanoma?
Squamous cell carcinoma
What is the main treatment option for gout in patients with severely impaired renal function?
Steroids (e.g. prednisolone)
Alternative: Canakinumab (anti-IL1 beta)
NOTE: colchicine, NSAIDs and allopurinol are all contraindicated
How does central pontine myelinolysis manifest?
Spastic quadriparesis
Pseudobulbar palsy
Emotional lability
List the indications for an ICD.
long QT syndrome hypertrophic obstructive cardiomyopathy previous cardiac arrest due to VT/VF previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35% Brugada syndrome
What is hypokalaemic periodic paralysis?
Rare autosomal dominant condition characterised by episodes of paralysis (usually at night) that can be precipitated by strenuous exercise, stress or a high carbohydrate meal.
Caused by defect in muscle voltage-gated calcium channels. Requires lifelong potassium replacement.
How should myxoedema coma be managed?
Levothyroxine and liothyronine
How should paroxysmal AF be investigated?
Episodes < 24 hrs apart: 24 hr ambulatory ECG
Episodes > 24 hrs apart: event recorder electrocardiogram
List some causes of erythema multiforme.
viruses: herpes simplex virus (the most common cause), Orf*
idiopathic
bacteria: Mycoplasma, Streptococcus
drugs: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
connective tissue disease e.g. Systemic lupus erythematosus
sarcoidosis
malignancy
How is membranous glomerulonephritis managed?
ACE inhibitor or ARB
Immunosuppression
NOTE: associated with anti-phospholipse A2 antibodies
How is thyroid storm managed?
Beta blockers (e.g. IV propranolol)
Antithyroid drugs (e.g. propylthiouracil)
Lugol’s iodine
Dexamethasone
When should patients undergo a carotid endarterectomy?
Patients with a TIA or small ischaemic stroke with evidence of significant carotid artery stenosis (male patients with a carotid artery stenosis of 50-99% or female patients with a carotid artery stenosis of 70-99%) that corresponds to the same side as the stroke/TIA should be considered for an urgent carotid endarterectomy (CEA) within 14 days
Describe the symptoms of zinc deficiency.
perioral dermatitis: red, crusted lesions acrodermatitis alopecia short stature hypogonadism hepatosplenomegaly geophagia (ingesting clay/soil) cognitive impairment
Describe the clinical manifestations of methanol and ethylene glycol poisoning.
Methanol: retinal injury, visual disturbance
Ethylene Glycol: oliguria, haematuria, flank pain
What is autonomic dysreflexia?
Occurs in individuals with spinal injury at or above T6
Afferent signals triggered by urinary retention/faecal impaction causes sympathetic spinal reflex via thoracolumbar outflow.
Manifests with hypertension, flushing and sweating above the lesion
What is mepolizumab and when is it used?
Anti-IL5 monoclonal antibody
Used for asthma with high eosinophils
What is Weber syndrome?
Form of midbrain stroke characterised by ipsilateral CNIII palsy and contralateral hemiparesis
Caused by a stroke involving a branch of the posterior cerebral artery
List medications that can precipitate myasthenic crises.
penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines
Outline the differences between type 1 and type 2 HRS.
TYPE 1: rapidly progressive, Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
TYPE 2: slowly progressive
How is hepatorenal syndrome managed?
Terlipressin and HAS
NOTE: TIPSS may also be used
What is the first-line treatment option for myelofibrosis?
Hydroxycarbamide
What is the investigation of choice for suspected hydatid cysts?
Serology for Echinococcus granulosus
What is an important side-effect of dapsone to be mindful of?
Haemolytic anaemia
What is Hereditary Neuropathy with Liability to Pressure Palsy?
A condition in which a small amount of pressure on a peripheral nerve results in a mononeuropathy that takes weeks to resolve
Associated with PMP22 gene deletion
What is a common side-effect of efavirenz?
Disturbing dreams and being muddled
What is an alternative to penicillamine for copper chelation?
Trientine
NOTE: people with penicillin allergy cannot receive penicillamine
Which type of meningococcal meningitis is most common across Africa and the Middle East?
Men A
NOTE: B and C are more common in Europe and South America
How should cases of TB with isoniazid resistance be managed?
Continue ethambutol for 6 months
What are the rules for treating subclinical hypothyroidism?
Treat if TSH is > 10 mU/L as long as they are younger than 70 yrs old
Otherwise repeat TFTs in 6 months
What is a major danger of hydatid cyst rupture?
It can cause anaphylaxis
What are the indications for steroid treatment in sarcoidosis?
patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hypercalcaemia
eye, heart or neuro involvement
What ECG changes are seen in hypokalaemia?
U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
Which investigation must be conducted before considering adrenalectomy in a patient with Conn syndrome?
Adrenal venous sampling
This allows you to distinguish between bilateral adrenal hyperplasia and unilateral adrenal adenoma
What is used for bacterial meningitis prophylaxis?
Ciprofloxacin or rifampicin
NOTE: should be offered to everyone that had close contact with the patient within 7 days of symptom onset
What are anti-Hu, anti-Yo and anti-Ri antibodies associated with?
anti-Hu: small cell lung cancer - painful sensory neuropathy, cerebellar syndromes, encephalitis
anti-Yo: ovarian, breast cancer - cerebellar syndrome
anti-Ri: small cell lung cancer - retinal degeneration
Why should aspirin be stopped in thyroid storm?
It can displace T4 from thyroid binding globulin
What is Gardener syndrome?
Autosomal dominant condition characterised by adenomatous intestinal polyps, osteomas and fibromas
NOTE: high risk of colorectal cancer
What triad of features is associated with Still’s disease?
Fever
Joint Pain
Salmon-coloured bumpy rash
NOTE: associated with high ferritin and ESR and treated with NSAIDs
How does cyanide poisoning manifest and how is it treated?
Hypoxia, Hypotension, Headache, Confusion
Rx: IV hydroxocobalamin (alternatives: amyl nitrite (inhaled), IV sodium nitrite, IV sodium thiosulfate)
How is CNS lymphoma treated?
Steroids + Methotrexate
What effect does smoking have on aminophylline?
Required higher doses of aminophylline
How is the tremor treated in patients with Parkinson’s disease who are already on co-careldopa?
Procyclidine
Other anticholinergics include orphenadrine, or trihexyphenidyl
How is methanol poisoning treated?
1st Line: Fomepizole or Ethanol
Alt: Haemodialysis
NOTE: folinic acid can reduce ophthalmological complications
What causes Glanzmann’s thrombsthenia?
Ineffective Glp IIb/IIIa
What is Foster-Kennedy syndrome?
Ipsilateral optic atrophy and contralateral papilloedema
Caused by frontal lobe mass (e.g. meningioma)
How is a spontaneous carotid artery dissection managed medically?
Aspirin
NOTE: high risk of thromboembolic disease
How is flexural psoriasis treated?
Mild to moderate topical steroids
Which combination of ECG features are seen in incomplete trifascicular block?
Right Bundle Branch Block
Left Axis Deviation
Prolonged PR Interval
At what point should patients with type 1 diabetes mellitus receive a statin?
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors
NOTE: do not use QRISK2
Which medical treatment is used or Parkinson’s dementia?
Rivastigmine
Other than anti-acetylcholine receptor antibodies, which other antibody is associated with myasthenia gravis?
Anti-muscle specific tyrosine kinase (MuSK)
NOTE: 40% of patients have anti-MuSK antibodies and they have less of a response to pyridostigmine
Which mutation is associated with Hairy Cell Leukaemia?
BRAF
List some features of severe malaria.
schizonts on a blood film parasitaemia > 2% hypoglycaemia acidosis temperature > 39 °C severe anaemia complications as below
Which medication is used to prevent acute mountain sickness?
Acetazolamide
It works by causing a metabolic acidosis leading to a compensatory respiratory alkalosis (achieved through hyperventilation)
What is roflumilast and when is it recommended in the management of COPD?
Phosphodiesterase-4 inhibitor
Recommended in COPD patients on maximal medical therapy + FEV1 < 50% + 2 or more exacerbations over last year
Why is sodium bicarbonate used in the treatment of aspirin overdose?
It increases the alkalinisation of urine resulting in increased aspirin excretion
NOTE: any aspirin level > 450 mg/L should be treated
NOTE: sodium bicarbonate is also used in the treatment of barbiturate overdose
What are the indications for dialysis in salicylate overdose?
serum concentration > 700mg/L metabolic acidosis resistant to treatment acute renal failure pulmonary oedema seizures coma
What should you give when three doses of adenosine fails to terminate an SVT in a haemodynamically stable patient?
Verapamil (provided no asthma or atrial flutter)
Dose 2.5-5 mg IV
List some risk factors for refeeding syndrome.
BMI < 16 kg/m2
unintentional weight loss >15% over 3-6 months
little nutritional intake > 10 days
hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
List some causes of FSGS.
idiopathic secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy HIV heroin Alport's syndrome sickle-cell
Which HIV drug is associated with the formation of urate stones?
Indinavir
What are the three types of long QT syndrome?
Long QT1 - usually associated with exertional syncope, often swimming
Long QT2 - often associated with syncope occurring following emotional stress, exercise or auditory stimuli
Long QT3 - events often occur at night or at rest
sudden cardiac death
Outline the treatment of idiopathic intracranial hypertension.
Weight Loss
Diuretics
Repeated lumbar puncture
Surgery (optic nerve sheath decompression and fenestration)
Which drug class is best for treating tics?
Antipsychotics (e.g. risperidone)
Clonidine
During an LTOT assessment, how should you manage a patient whose pCO2 increases by > 1 kPa following oxygen administration?
Medically optimise and reassess in 4 weeks
Aside from the effects of the infection itself, what other gastrointestinal complication an be caused by Giardia infection?
Temporary lactose intolerance
What are the main differences between American and African trypanosomiasis?
AMERICAN: chagoma (nodule at site of infection), myocarditis, dysphagia, megaoesophagus, megarectum (GENERALLY CHRONIC INFECTION)
AFRICAN: chancre, intermittent fever, enlarged posterior cervical lymph nodes, CNS effects
What is the first line treatment for viral pericarditis?
NSAID + Colchicine
How is peritoneal dialysis peritonitis treated?
Intraperitoneal vancomycin + ceftazidime
NOTE: S. epidermidis is the most common cause
What are the criteria for 3 yearly colonoscopies in patients with ulcerative colitis?
Extensive colitis with mild active endoscopy/histological inflammation
OR post-inflammatory polyps
OR family history of colorectal cancer in a first degree relative aged 50 or over
Which genes are associated with MEN?
MEN1 : MEN1 Gene
MEN2: RET Oncogene
Which common drugs are potent inhibitors of CYP3A4?
Macrolides (e.g. clarithromycin)
How is Anti-GBM disease treated?
Plasmapheresis
Steroids
Cyclophosphamide
Which drugs are used to treat Huntington’s chorea?
DOPAMINE DEPLETION: Reserpine (VMAT), tetrabenazine
DOPAMINE ANTAGONISTS: antipsychotics (e.g. risperidone)
What are the ECG features seen in dextrocardia?
Inverted P wave in leave I
RAD
Loss of R wave progression
What are the ECG features of a posterior MI?
Changed in V1-3:
- Horizontal ST depression
- Tall, broad R waves
- Upright T waves
- Dominant R wave (V2)
Which simple test may be used to distinguish Conn’s syndrome from adrenal hyperplasia?
Measure aldosterone after prolonged standing
Aldosterone increases after prolonged standing in patients with adrenal hyperplasia
What are the features of multiple sclerosis that are seen on an MRI head scan?
high signal T2 lesions
periventricular plaques
Dawson fingers: often seen on FLAIR images - hyperintense lesions penpendicular to the corpus callosum
What is the first line treatment option for scalp psoriasis?
Topics steroids (daily for 4 weeks)
What is the gold standard investigation for cerebral venous sinus thrombosis?
MRI Venography (though CT venography is often used for convenience)
What is the main indication for placing a chest drain in a patient with a pleural effusion?
If the pH on the pleural aspirate is < 7.2
Outline Light’s criteria for pleural effusions.
Exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L
If the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
- pleural fluid protein divided by serum protein >0.5
- pleural fluid LDH divided by serum LDH >0.6
- pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
How is chronic inflammatory demyelinating polyneuropathy (CIDP) different from GBS?
Motor symptoms predominate Insidious onset (months) - like a chronic version of GBS Treated with steroids and immunosuppressants
Which diagnoses are associated with upgoing plantars and absent ankle jerks?
SACD Motor neurone disease Friedrich ataxia Tabes dorsalis Dual peripheral with central pathology
In patients with stage 1 hypertension, what is the treatment thershold?
10-year-cardiovascular risk score > 10% or evidence of end organ damage
What is pacemaker syndrome?
Occurs when a single lead pacemaker (VVI) is out of sync with atrial activity
Although the ventricular rate is guaranteed, this may come at the expense of atrioventricular concordance (reduced diastolic function) leading to worsening of breathlessness
This should be treated with a DDI pacemaker that sense and paces both the atria and the ventricles
Which drug class is notorious for triggering scleroderma crisis?
Steroids
How is lupus nephritis treated?
Steroids to induce remission (with or without cyclophosphamide and mycophenolate)
Mycophenolate to maintain remission
Which antibiotics are good at treating Legionella?
Macrolides and Quinolones
NOTE: they have good intracellular penetration
Which class of Parkinson’s medications is best for off-time reduction?
Dopamine agonists
Which class of Parkinson’s medications is most commonly associated with causing delusions and hallucinations?
Dopamine agonists
It also causes impulse control issues
Which additional test is useful in making a diagnosis of heparin-induced thrombocytopaenia in someone with a moderate HIT antibody titre?
Serotonin release assay
What second line agent is used in the treatment of familial hypercholesterolaemia?
Ezetimibe
What do VVI pacemakers look like on an ECG?
Pacing spikes immediately before the QRS complex
What is the most effective screening tool for distinguishing delirium from dementia?
Confusion assessment method (CAM)
List some causes of retroperitoneal fibrosis.
Riedel's thyroiditis previous radiotherapy sarcoidosis inflammatory abdominal aortic aneurysm drugs: methysergide
What can be used for bone protection in a patient with bone metastases and an eGFR < 30 mL/min?
Denosumab
Outline the criteria for decompressive craniotomy in the context of malignant MCA syndrome.
Aged 60 years or under.
Clinical deficits suggestive of infarction in the territory of the middle cerebral artery, with a score on the National Institutes of Health Stroke Scale (NIHSS) of above 15.
Decrease in the level of consciousness to give a score of 1 or more on item 1a of the NIHSS.
Signs on CT of an infarct of at least 50% of the middle cerebral artery territory, with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side, or infarct volume greater than 145 cm3 as shown on diffusion-weighted MRI.
Outline the treatment guidelines for a first episode of C. difficile.
1st: Oral Vancomycin (10 days)
2nd: Oral Fidaxomicin
3rd: Oral Vancomycin + IV Metronidazole
NOTE: if recurrent episode within 12 weeks –> oral fidaxomicin; if more than 12 weeks –> oral fidaxomicin OR oral vancomycin
If LIFE THREATENING: oral vancomycin + IV metronidazole
Which tests are required to stage multiple myeloma?
Beta-2 microglobulin
Serum albumin
Which drug class is most effective at treating hypertriglyceridaemia?
Fibrates
Summarise the NICE guidelines for the management of non-typhoidal salmonella gastroenteritis.
Anyone > 50 yrs OR immunocompromised OR cardiac valve disease/endovascular abnormalities
Ciprofloxacin 500 mg BD
List some pre-ganglionic causes of Horner syndrome.
NOTE: causes anhidrosis of the face
Pancoast’s trumour
Thyroidectomy
Trauma
Cervical rib
List some post-ganglionic causes of Horner syndrome.
NOTE: does NOT cause anhidrosis of the face
Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache
Which long-acting insulin is particularly useful in preventing recurrent DKA as it has a long half-life?
Degludec (Tresiba)
What can be given in sulfonylurea overdose to patients who fail to respond adequately to glucose?
IM Octreotide
How is typhoid fever managed?
Cefotaxime or Ceftriaxone
NOTE: it is caused by Salmonella enterica
How is arrhythmogenic right ventricular cardiomyopathy treated?
Sotalol
Catheter Ablation
ICD
What are presenting features of acute interstitial nephritis?
Fever, Rash and Arthralgia
Eosinophilia
Renal Impairment
Hypertension
Which common drugs can cause acute interstitial nephritis?
penicillin rifampicin NSAIDs allopurinol furosemide
Which combination of chemotherapy agents used for breast cancer is especially cardiotoxic?
Trastazumab + anthracyclines (e.g. doxorubicin)
What are the main features of Langerhans cell histiocytosis?
Bone pain (skull and femer) Cutaneous nodules Decurrent otitis media/mastoiditis Spontaneous peumothorax Diabetes insipidus Tennis racket-shaped Birbeck granules on electromicroscopy
What are the main treatment options for eosinophilic oesophagitis?
Dietary modification
Topical steroids (e.g. fluticasone, budesonide)
Oesophageal dilatation
NOTE: diagnosis is confirmed on biopsy
How is latent tuberculosis treated?
3 months isoniazid and rifamipicin
6 months isoniazid
Outline the management of IgA nephropathy.
no proteinuria, normal GFR: observe
proteinuria: ACE inhibitor
signifcant fall in GFR/not responding to ACE inhibitor: corticosteroid
How is tick borne encephalitis managed?
Supportive management
Which antiemetic is best for the delayed phase of chemotherapy-induced nausea?
Dexamethasone
What is accelerated idioventricular rhythm?
A benign ectopic rhythm of ventricular origin
Usually caused by reperfusion of ischaemic myocardium and has a rate of 50-110 bpm (helps differentiate from ventricular brady or tachycardia)
What is the main cause of frank haematuria in patients with sickle cell disease?
Papillary necrosis
What is a key difference between Gitelman and Bartter syndrome?
Gitelman: Hypocalciuria
Bartter: NO hypocalciuria
NOTE: both conditions cause hyponatraemia, hypokalaemia, hypomagnesemia and normotension
What are some contraindications to testosterone treatment in men?
PSA > 4 ng/mL
Male breast cancer
Severe sleep apnoea
Severe LUTS due to BPH
How does loiasis present?
Filarial infection caused by loa loa found in West and Central Africa
Calabar swellings (transient, non-erythematous, hot swelling of soft tissue around joints)
Pruritus
Urticaria
Eye worm
Rx: Ivermectin
How is pain from shingles managed?
1: Paracetamol and NSAIDs
2: Neuropathic agents
3. Oral Corticosteroids
List some features and complications of Ehlers-Danlos syndrome.
elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks
What is Lown–Ganong–Levine syndrome?
Pre-excitation disorder of the heart due to abnormal conduction between atria and ventricles
SHORT PR interval
Normal QRS complex
This differs from Wolff-Parkinson-White syndrome which causes short PR and broad QRS complex.
How does dialysis dysequilibrium syndrome manifest and how is it treated?
High levels of urea pre-dialysis leads to fluid shifts in teh brain. The sudden removal of urea leads to a drop in serum osmolality and a shift of fluid into the intracellular compartment leading to cerebral oedema.
Treated with measures to reduce intracranial pressure (e.g. hypertonic saline)
Which test is used to determine whether a patient has hyperventilation syndrome?
Nijmegen questionnaire
What is the treatment option for native valve endocarditis caused by Staphylococcus?
Flucloxacillin
If penicillin allergic or MRSA –> Vancomycin + Rifampicin
What is the treatment option for prosthetic valve endocarditis caused by Staphylococcus?
Flucloxacillin + Rifampicin + Low Dose Gentamicin
If penicillin allergic or MRSA –> switch flucloxacillin for vancomycin
What is the treatment option for native valve endocarditis caused by fully-sensitive Streptococci?
Benzylpenicillin
If penicillin allergic –> Vancomycin + Low Dose Gentamicin
Why should you aim for a very low TSH in patients who have had a thyroidectomy for thyroid cancer?
TSH is a growth factor for thyroid cancer
It should be suppressed with levothyroxine to < 0.1 in high risk patients and 0.1-0.5 in low risk patients
Under what circumstance should you seek a thoracic surgical opinion in patients with a chest drain?
If after 3-5 days there is a persistent air leak or failure of the lung to re-expand
What are the two types of autoimmune polyendocrinopathy syndromes?
APS Type 1: Chronic mucocutaneous candidasis + Addison’s disease + Primary hypoparathyroidism
APS Type 2 (Schmidt syndrome): Type 1 Diabetes Mellitus + Autoimmune Thyroid Disease
In which patients is plasma exchange indicated for patients with anti-GBM disease?
Pulmonary haemorrhage
Renal involvement who do not need renal replacement therapy
Patients who may require dialysis but present acutely and are young and have a proportion of viable glomeruli on renal biopsy
List some causes of membranous glomerulonephritis.
infections: hepatitis B, malaria, syphilis
malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia
drugs: gold, penicillamine, NSAIDs
autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
What is the initial blind therapy for prosthetic and native valve endocarditis whilst awaiting blood cultures?
Prosthetic: Vancomycin + Rifampicin + Low Dose Gentamicin
Native: Amoxicillin +/- Low Dose Gentamicin
How is actinic keratosis managed?
Topical fluorouracil
Alternatives: imiquimob or diclofenac
What are the indications for a surgical opinion in patients with infective endocarditis?
Aortic root abscess
Heart failure
Uncontrolled infection
Prevention of embolism (large vegetations with embolic episodes)
What are the manifestations of abetalipoproteinaemia?
failure to thrive + developmental delay steatorrhoea retinitis pigmentosa cerebellar signs deep tendon reflexes are absent acanthocytosis hypocholesterolaemia
Rx: dietary restriction of fats
What initial therapy is given to people with a new diagnosis of rheumatoid arthritis?
DMARD monotherapy (e.g. methotrexate) + short course of bridging prednisolone
What is Whipple’s triad?
Used to identify clinically significant hypoglycaemia
- borderline low blood sugar
- symptoms of hypoglycaemia
- improvement of symptoms with sugar
What are some main causes of pacemaker failure?
Lead Fracture
Lead Displacement
Twiddler syndrome (patient fiddling with the pacemaker leads to displacement of the wires)
How is an amoebic liver abscess treated?
Aspirate and metronidazole
How is leprosy treated?
Rifampicin
Dapsone
Clofazimine
Diagnosed using skin-slit smear
Which antibiotics may be recommended as Traveller’s diarrhoea prophylaxis in immunocompromised patients?
ciprofloxacin, norfloxacin or rifaximin.
List some causes of scarring alopecia.
trauma, burns radiotherapy lichen planus discoid lupus tinea capitis (if untreated)
What are the indications for N-acetylcysteine in paracetamol overdose?
Staggered overdose or doubt about time of ingestion
Plasma paracetamol level above the normogram line
When can N-acetylcysteine be stopped in someone with paracetamol overdose?
INR <1.3 and ALT less than 2x upper limit of normal
List the causes of HIGH anion gap metabolic acidosis.
lactate: shock, sepsis, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
List the 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
Why should patients with myasthenia gravis who have shown no improvement in their symptoms despite 60 mg QDS pyridostigmine need to be admitted to hospital for steroid initiation?
High dose steroids (60 mg prednisolone) can cause a paradoxical reaction in up to half of patients, where there symptoms worsen initially
What are the main features of synthetic cannabinoid toxicity?
CNS: agitation, tremor, anxiety, confusion, somnolence, syncope, hallucinations, changes in perception, acute psychosis, nystagmus, convulsions and coma.
Cardiac: tachycardia, hypertension, chest pain, palpitations, ECG changes.
Renal: acute kidney injury.
Muscular: hypertonia, myoclonus, muscle jerking and myalgia.
Other: cold extremities, dry mouth, dyspnoea, mydriasis, vomiting and hypokalaemia
List some common drugs that cause peripheral neuropathy.
amiodarone isoniazid vincristine nitrofurantoin metronidazole
How is granulomatosis with polyangiitis treated?
Cyclophosphamide and steroids
List some contraindications for using flecainide.
post myocardial infarction
structural heart disease: e.g. heart failure
sinus node dysfunction; second-degree or greater AV block
atrial flutter
How is atypical haemolytic uraemic syndrome managed?
Supportive
Plasma Exchange
Eculizumab
What are the symptoms of systemic mastocytosis?
urticaria pigmentosa - produces a wheal on rubbing (Darier’s sign)
flushing
abdominal pain
monocytosis on the blood film
NOTE: associated with raised serum tryptase and urinary histamine
What are the physical features of pseudohypoparathyroidism?
short fourth and fifth metacarpals short stature cognitive impairment obesity round face
How should carbapenemase producing organisms be treated?
Polymyxins (e.g. colistin)
Tigecycline
Fosfomycin
Aminoglycosides (e.g. gentamicin)
Under what circumstance should a GLP-1 agonist be continued in a patient at their 6 month review?
If, after 6 months, HbA1c reduces by at least 11 mmol/mol
What is the first line imaging modality in multiple myeloma?
Whole body MRI
Which ECG changes are seen in Brugada syndrome?
Convex ST elevation > 2 mm in more than 1 of V1 to V3 followed by a negative T wave
Partial RBBB
NOTE: ECG changes may be more evident after administration of flecainide or ajmaline
Which electrolyte abnormalities are associated with tumour lysis syndrome?
HIGH Uric Acid
HIGH Potassium
HIGH Phosphate
LOW Calcium
Clinical features: increased serum creatinine, arrhythmia, seizure
What PTH level would you expect in someone with familial hypocalciuria hypercalcaemia?
There may also be normal to high parathyroid hormone, despite the elevated serum calcium levels.
List some causes of pulmonary eosinophilia.
Churg-Strauss syndrome allergic bronchopulmonary aspergillosis (ABPA) Loffler's syndrome eosinophilic pneumonia hypereosinophilic syndrome tropical pulmonary eosinophilia drugs: nitrofurantoin, sulphonamides less common: Wegener's granulomatosis
What is Loeffler’s syndrome?
Transient CXR shadowing and eosinophilia associated with Ascaris lumbricoides
Causes fever, cough and night sweats
Self-limiting
Outline the strategies for preventing tumour lysis syndrome in patients undergoing chemotherapy.
LOW RISK: Adequate Hydration
MEDIUM RISK: IV Fluids + Allopurinol
HIGH RISK: Rasburicase + IV Fluids
List the main contraindications for using beta-blockers.
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
How does acute schistosomiasis manifest?
marked eosinophilia
cough
bloody diarrhoea
splenomegaly
What are the manifestations of quinine toxicity?
Arrhythmia
Hypoglycaemia
Flash pulmonary oedema
Tinnitus, deafness and visual defects
NOTE: treatment is supportive
Outline how you interpret nerve conduction study results.
Axonal
- normal conduction velocity
- reduced amplitude
- CAUSES: metabolic, toxic or heritable
Demyelinating
- reduced conduction velocity
- normal amplitude
- CAUSES: autoimmune processes, paraproteinaemia
How should a patient with a relapse of Graves disease after a trial of anti-thyroid medications be treated?
Definitive treatment with surgery or radioiodine
Outline the BTS guidelines on the investigation of solitary lung nodules.
Nodule <5mm, or clear benign features, or unsuitable for treatment: can be discharged
Nodule =>8mm and high risk: then CT-PET, and if CT-PET shows high uptake then biopsy
Nodule 5-6mm, or =>8mm and low-risk: then CT surveillance
CT surveillance: if 5-6mm then at 1 year, if =>6 then in three months
What should be recommended for patients with IBS that is resistant to multiple laxatives at adequate doses?
Linaclotide
Which antiemetic should be avoided in patients with acute heart failure or ACS?
Cyclizine - it is an H1 receptor antagonist and anticholinergic that causes systemic hypertension and induces tachycardia which can compromise a fragile heart
What is the first-line systemic agent for psoriasis?
Methotrexate
Offer ciclosporin if need rapid control (e.g. psoriasis flare) or palmoplantar pustulosis or considering conception (men and women)
NOTE: next step would be Acitretin
How does heparin affect thyroid function test results?
Heparin leads to rise in free fatty acid levels which inhibit binding of thyroid hormones to plasma-binding proteins causing a rise in T3 and T4
What are the third line treatment options for chronic heart failure?
ivabradine
- criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
sacubitril-valsartan
- criteria: left ventricular fraction < 35%
- is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
- should be initiated following ACEi or ARB wash-out period
digoxin
- digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
- it is strongly indicated if there is coexistent atrial fibrillation
hydralazine in combination with nitrate
- this may be particularly indicated in Afro-Caribbean patients
- cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
What is the rapid appearance of multiple seborrhoeic keratoses suggestive of?
Underlying malignancy (known as Leser-Trelat Sign)
Usually GI or liver cancer
What is the Ki-67 index?
Proliferation index (marker of metabolic rate of cancer cells)
Lymphoma with LOW Ki67: Follicular, Mantle, Marginal Zone, Small Lymphocytic, Lymphoplasmacytic, Skin
Lymphome with HIGH Ki67: DLBCL, Burkitt, peripheral T cell lymphoma
Which skin conditions exhibit Koebner phenomenon?
psoriasis vitiligo warts lichen planus lichen sclerosus molluscum contagiosum
How can non-tuberculous mycobacterial disease manifest?
Hypersensitive-like disease
Cavitating disease
Bronchiectasis with or without nodules
Treatment: Rifampicin, clarithromycin and ethambutol
What is POEMS syndrome?
Rare paraneoplastic syndrome caused by a clone of abnormal plasma cells
Polyneuropathy Organomegaly Endocrinopathy M-protein band from a plasmacytoma Skin Pigmentation
What is an unwanted metabolic side-effect of NRTIs?
NRTIs: stavudine, zidovudine, didanosine
Mitochondrial toxicity –> nausea, pancreatitis, lactic acidosis and lipoatrophy
List some consequences of hypophosphataemia.
red blood cell haemolysis
white blood cell and platelet dysfunction
muscle weakness and rhabdomyolysis
central nervous system dysfunction
What are the main features of Friedreich ataxia?
absent ankle jerks/extensor plantars
cerebellar ataxia
optic atrophy
spinocerebellar tract degeneration
Other: HOCM, DM, high arched palate
What pattern of deficits do you see in anterior spinal artery occlusion?
- Bilateral spastic paresis
2. Bilateral loss of pain and temperature sensation
What are the main features of neuromyelitis optica?
quadriparesis or paraparesis within days to weeks
vision changes
normal brain MRI
presence of anti-NMO antibodies (anti-aquaporin 4 antibodies)
responsive to immunosuppressants
What metabolic complication is associated with sodium valproate use?
Valproate-associated hyperammonaemic encephalopathy
Why is atropine contraindicated in patients with a heart transplant?
The transplanted hearts are denervated and do not respond to vagal blockade by atropine which might lead to paradoxical sinus arrest
IV theophylline should be used instead.
How is cystinuria treated?
Hydration
D-penicillamine
Urinary alkalinisation (with potassium citrate)
What is the rule regarding DEXA scans in patients with fragility fractures?
If > 75 years, they can start a bisphosphonate without a DEXA scan
When does renal graft failure count as acute rather than chronic?
If it is < 6 months
What is methaemoglobinaemia?
Haemoglobin that has been oxidised from Fe2+ to Fe3+ (usually regulated by NADH methaemoglobin reductase)
Fe3+ CANNOT bind oxygen, resulting in tissue hypoxia
How does methaemoglobinaemia present?
Chocolate cyanosis
Shortness of breath, headache, anxiety
Acidosis, arrhythmia, seizures
Normal pO2 but low saturations
How is methaemoglobinaemia treated?
NADH - methaemoglobinaemia reductase deficiency: ascorbic acid
IV methylthioninium chloride (methylene blue) if acquired
What is acute disseminated encephalomyelitis?
Also known as post-infectious encephalomyelitis - it is an autoimmune demyelinating disease of the CNS.
It can occur following infection (common culprits include MMR and varicella).
Usually presents with motor and sensory deficits weeks to months after the initial infection.
What are the features of a lacunar stroke?
Unilateral weakness
Pure sensory stroke
Ataxic hemiparesis
How do you test for paraquat poisoning?
Urine dithionate test
It can cause GI irritation, liver and kidney failure, and chemical pneumonitis and fibrosis
Which ECG changes are most commonly associated with HOCM?
RAD or LAD
Bundle branch block
PR prolongation
Non-specific T wave abnormalities
What are the main features of von Hippel Lindau syndrome?
Haemangioblastomas (cerebellar, spinal and retinal)
Renal cell carcinoma
Phaeochromocytoma
Neuroendocrine tumours of the pancreas
How does phenytoin toxicity present?
Cerebellar signs (nystagmus, dysdiadochokinesia, broad-based gait)
What should you think about when someone on SSRIs develops a chronic history of abdominal pain and diarrhoea?
Microscopic colitis
What is the threshold for giving steroids in PCP?
pO2 < 9.3 kPa
NOTE: alternative treatment options for PCP include clindamycin and primaquine
What are the indications for giving DigiBind for digoxin toxicity?
Haemodynamically unstable or life-threatening rhythm
Hyperkalaemia
Evidence of end-order hypoperfusion
What are the first-line drugs for treating diabetic neuropathy?
Pregabalin
Gabapentin
Duloxetine
Amitriptyline
What are the main features of McArdle disease?
muscle pain and stiffness following exercise muscle cramps myoglobinuria low lactate levels during exercise second wind phenomenon
NOTE: it is an autosomal recessive type V glycogen storage disease that leads to decreased muscle glycogenolysis
What lipid profile results would you expect to see in a patient with dysbetalipoproteinaemia?
High Cholesterol
High Triglycerides
Normal HDL
Low LDL
NOTE: it is caused by a defect in apo E and usually requires a second risk factors to cause issues
Palmar xanthomas are pathognomonic
How does beta-2 microglobulin amyloidosis manifest?
Manifests 5 or more years after starting haemodialysis
Affects the axial skeleton and is associated with tenosynovitis, carpal tunnel syndrome and shoulder pain.
What stimulant is best to manage symptoms of cataplexy?
Oxybate
In which types of porphyria are faecal porphyrins elevated?
Hereditary coproporphyria
Variegate porphyria
NOTE: these two and acute intermittent porphyria present very similarly and are difficult to distinguish clinically
How does Chediak-Higashi syndrome manifest?
Oculocutaneous albinism Bleeding diathesis Recurrent infections Peripheral neuropathy Giant granules on leukocytes
What is alkaptonuria?
Autosomal recessive disorder of phenylalanine and tyrosine metabolism.
Features include pigmented sclerae, urine turning black if exposed to air, intervertebral disc calcification and renal stones
Treated with high dose vitamin C
How is hepatotoxicity or hyperammonaemic encephalopathy in sodium valproate overdose treated?
L-carnitine
List some causes of Fanconi syndrome.
cystinosis (most common cause in children) Sjogren's syndrome multiple myeloma nephrotic syndrome Wilson's disease
List some absolute contraindications for thrombolysis for stroke.
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
Which antibodies are associated with the two different types of autoimmune hepatitis?
Type 1: ASMA or ANA
Type 2: Anti-LKM or anti-liver-cytosolic 1
What is a Holmes tremor?
Irregular low frequency tremor (combination of resting, postural and action)
Occurs due to lesion of red nucleus (e.g. due to previous stroke, tumour, MS)
Outline the NICE guidelines for chronic plaque psoriasis.
- Potent topical steroid AND vitamin D analogue
- Vitamin D analogue twice daily
- Potent topical steroid twice daily OR coal tar preparation
Alternative: Dithranol
Specialist: Methotrexate, ciclosporin and phototherapy
Last Line: Adalimumab
How is hepatocellular carcinoma in cirrhosis managed?
Liver transplantation if:
- cirrhosis and single small HCC (< 5 cm)
- up to three lesions < 3 cm
What is multicentric reticulohistiocytosis?
Non-Langerhans cell histiocytosis with skin and joint involvement (associated with cancer in 25% of cases)
List some causes of chronic urticaria.
Autoimmune diseases
Lymphoma
Drug reactions (NSAIDs, opiates)
What is homocystinuria?
Autosomal recessive disorder of methionine metabolism
Tall Kyphoscoliosis Livedo reticularis Malar flush Downward lens dislocation Young strokes Light brittle hair
Which CDs are usually associated with lymphoma?
CD19 CD20 CD22 CD79a CD45
How is Nocardia infection treated?
Sulphonamide (e.g. co-trimoxazole)
How should renal tubular acidosis be treated?
oral sodium bicarbonate, sodium citrate or potassium citrate.
How can hemicrania continua and paroxysmal hemicrania be distinguished from cluster headaches and SUNCT?
They are responsive to indomethacin
How is paraquat poisoning treated?
activated charcoal and fuller’s earth
Which conditions recur in renal transplant patients?
IgA nephropathy
Membranoproliferative glomerulonephritis (highest rate of recurrence)
Focal segmental glomerulosclerosis
Membranous glomerulonephritis
What is a very sensitive marker of bone turnover that is used in Paget’s disease?
Serum non-isomerised C-telopeptide (CTx)
How does thallium poisoning present?
Fluctuating mood (with or without confusion)
Painful distal paraesthesia
Alopecia
Rx: Oral Prussian Blue
What is the first-line oral therapy for pyelonephritis?
Oral cefalexin
Which other type of cancer is the APC gene associated with?
Thyroid cancer
What should you do with regular TNF blockers in patients who are due to undergo major surgery?
Stop TNF blockers 2-4 weeks before a major surgical procedure
Can be restarted once there is no evidence of infection and wound healing is satisfactory
Which groups of patients benefit from lung volume reduction surgery for emphysema?
Upper p emphysema and low exercise capacity
Patients with predominantly upper lobe emphysema and high exercise capacity
Patients with non-upper lobe emphysema and low exercise capacity
Which group of patients with mitral regurgitation need to be referred for surgery despite being asymptomatic?
LVEF < 60%
How is brucellosis treated?
ORAL: 6 weeks of doxycycline and rifampicin
ORAL + IV: 6 weeks of oral doxycycline + 3 weeks of IM streptomycin or IV gentamicin
Which common drugs cause drug-induced cholestasis?
Flucloxacillin Erythromycin Chlorpromazine Oral contraceptives Anabolic steroids
How is polycythaemia vera management?
Aspirin and venesection aiming for PCV of < 0.45
Which test can be done in patients with suspected growth hormone deficiency in whom an insulin-tolerance test would be inappropriate?
Arginine-GHRH stimulation test
Which antibody is more likely to be positive in Crohn’s disease than ulcerative colitis?
Anti-Saccharomyces cerevisiae antibodies
What can precipitate lithium toxicity?
dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
What is a common side-effect of minocycline?
Skin pigmentation with blue/black/grey discoloration
Minocycline is a tetracycline used for rosacea
How long after taking acitretin must you avoid getting pregnant?
3 years
What is Zieve syndrome?
Haemolysis, severe hyperlipidaemia and cholestatic jaundice in people with heavy alcohol abuse
Which antipsychotic is best in patients with Parkinson’s disease?
Quetiapine
What are the features of McCune-Albright syndrome?
Precocious puberty
Cafe-au-lait pigmentation
Polyostotic fibrous dysplasia (multiple pathological fractures)
Hyperthyroidism
What measure is good to determine whether a patient is at risk of tumour lysis syndrome before commencing chemotherapy?
LDH
Which type of ureteric calculus commonly occurs in people with short bowel?
Oxalate
What are the main features of a somatostatinoma?
Diabetes mellitus
Diarrhoea
Gallstones
Which investigation findings support a diagnosis of Wilson’s disease?
reduced serum caeruloplasmin
reduced total serum copper
increased 24hr urinary copper excretion
ATP7B gene mutation
How is paroxysmal nocturnal hemicrania treated?
Indomethacin
What are the features of theophylline toxicity?
Hypokalaemia
Hyperglycaemia
Tachycardia
Increased myocardial contractility
What are early and late dumping syndromes?
Both are complications of bariatric surgery
Early: rapid emptying of food into the small bowel causing colicky abdominal pain, diarrhoea and nausea
Late: post-prandial hypoglycaemia due to hyperinsulinaemia
What are the two main associations of pseudo-Cushing’s syndrome?
Alcoholism
Depression
How is pemphigus vulgaris diagnosed?
Direct immunofluorescence of skin biopsy
What are the features of myoclonic epilepsy with ragged red fibres (MERRF)?
myopathy peripheral neuropathy ataxia Wolff-Parkinson-White syndrome bilateral deafness
Which patients on bisphosphonates would be eligible for a treatment break?
< 75 years
Femoral neck bone mineral density > -2.5
Lack of history of fragility fracture
NOTE: repeat DEXA in 2 years
What is multifocal motor neuropathy with conduction block?
Acquired autoimmune demyelinating motor neuropathy
Presents with relatively acute onset loss of motor function in a specific nerve distribution
As more nerves get involved, it looks more and more like MND
MMNCB shows a conduction block on nerve conduction studies, whereas MND does not
Treated with IVIG
What is Lymphangioleiomyomatosis?
Proliferation of atypical smooth muscle cells in the lungs, lymphatics and uterus, most likely caused by oestrogens.
Presents with progressive interstitial lung disease, pneumothorax or chylous pleural effusion
What are the main features of Cowden syndrome?
Inherited cancer syndrome associated with PTEN mutation
Multiple hamartomas Breast cancer (most common) Endometrial cancer Colorectal cancer Thyroid cancer Melanoma
Outline the guidelines on the surgical management of aortic regurgitation.
Surgery should be considered in asymptomatic patients with resting ejection fraction < 50% with severe LV dilatation (LVESD > 50 mm (or LVESD > 25 mm/m2 body surface area in those with small body size)).
Surgery should be considered in ALL symptomatic patients regardless of EF and LV dimensions
What type of COCP should people taking carbamazepine take?
Any containing at least 50 micrograms of ethinyloestradiol
What is babesiosis?
Tick-borne malaria-like illness caused by Babesia
Causes fever, chills, rigors and red cell destructions (leading to haemolytic anaemia and haemoglobinuria)
How does chancroid manifest?
Single PAINFUL genital ulcer with painful inguinal lymphadenopathy
Caused by H. ducreyi and treated with macrolides or quinolones
