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Make a Medic Postgraduate Decks > MRCP Part 2 > Flashcards

MRCP Part 2 Flashcards

1
Q

What is the mainstay of treating anterior uveitis?

A

Steroid and Cycloplegic (mydriatic) Eye Drops

E.g. Cyclopentolate and Corticosteroids

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2
Q

What is a useful effect of COMT inhibitors in patients with Parkinson’s Disease?

A

It is effective at smoothing out on-off fluctuations in patients on L-DOPA/DOPA Decarboxylase Inhibitors

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3
Q

Why should pioglitazone be avoided in patients with congestive cardiac failure?

A

It causes fluid retention

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4
Q

In which patients should donepezil be avoided?

A

Bradycardia

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5
Q

Which type of ovarian tumour produces TSH?

A

Struma ovarii (variant of ovarian teratoma)

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6
Q

Outline the emergency management of acute angle closure glaucoma.

A

Eye Drops (e.g. pilocarpine, timlolol) + IV Acetazolamide

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7
Q

What is the first-line treatment option for trigeminal neuralgia?

A

Carbamazepine

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8
Q

Outline the stages of hypertensive retinopathy.

A 
I	Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
II	Arteriovenous nipping
III	Cotton-wool exudates
Flame and blot haemorrhages
IV	Papilloedema
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9
Q

What is the difference between type 1 and type 2 amiodarone-induced thyrotoxicosis?

A

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

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10
Q

What are the main features of leptospirosis?

A

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

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11
Q

What does capillary wedge pressure represent in terms of cardiac catheterisation?

A

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.

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12
Q

How is p wave asystole managed?

A

External pacing

NOTE: this is when you see only p waves on a rhythm check in a cardiac arrest

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13
Q

What are the indications for carotid endartarectomy?

A

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

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14
Q

How does Q fever manifest?

A

Fevers, headaches, fatigue and muscle aches

Transaminitis on LFTs

Comes from sheep and caused by Coxiella burnetti

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15
Q

Which therapy is effective and reducing morbidity and mortality in toxic epidermal necrolysis?

A

IVIG

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16
Q

How should patients with a superficial vein thrombosis be managed?

A

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

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17
Q

List some poor prognostic factors for CLL.

A 
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
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18
Q

What are the features of local anaesthetic toxicity?

A

CNS: reduced GCS, seizures
Cardiovascular: arrhythmia, hypotension

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19
Q

In which patients can you not give ranolazine?

A

Severely impaired renal function

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20
Q

After calcium channel blockers and beta-blockers, which agents are used in the management of stable angina?

A

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)

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21
Q

What are the main features of acute intermittent porphyria?

A

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

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22
Q

What are the main features of porphyria cutanea tarda?

A

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

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23
Q

What are the main features of variegate porphyria?

A 
autosomal dominant
defect in protoporphyrinogen oxidase
photosensitive blistering rash
abdominal and neurological symptoms
more common in South Africans
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24
Q

What’s the most common chemotherapy regime for small cell lung cancer?

A

Cisplatin and etoposide

NOTE: cisplatin causes hypomagnesemia which leads to muscle cramps, tremor, arrhythmias and confusion

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25
Q

Which UC patients should be considered for drugs that maintain remission (e.g. azathioprine, mercaptopurine)?

A

severe relapse or >=2 exacerbations in the past year they should be given either oral azathioprine or oral mercaptopurine to maintain remission

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26
Q

What are the criteria for LTOT?

A

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

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27
Q

What is one crucial interaction between TB and HIV medications that you should be aware of?

A

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

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28
Q

What is the first-line management option for renal complications of systemic sclerosis?

A

ACE Inhibitors

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29
Q

What clinical features is associated with an increased risk of NSAID-induced asthma exacerabtions?

A

Presence of nasal polyps

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30
Q

How is crusted scabies managed?

A

Isolated and ivermectin

NOTE: crusted scabies is something that happens in people who are significantly immunocompromised

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31
Q

How is cryptococcal meningitis managed?

A

IV Antifungals (e.g. amphotericin B and flucytosine)

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32
Q

How does cryoglobulinaemia present?

A

Raynaud’s only seen in type I
cutaneous: vascular purpura, distal ulceration, ulceration
arthralgia
renal involvement (diffuse glomerulonephritis)

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33
Q

What are the three types of cryoglobulinaemia?

A 
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

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34
Q

Which common cardiac drug should be avoided in patients with cardiac amyloid?

A

Digoxin (higher risk of digoxin toxicity as the drug binds avidly to amyloid fibrils)

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35
Q

How is idiopathic intracranial hypertension managed?

A

Weight Loss

Acetazolamide

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36
Q

Why are SSRIs contraindicated in patients with a background of peptic ulcer disease?

A

Increases the risk of upper GI bleeds by inhibiting platelet aggregation

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37
Q

Which treatment should be considered in addition to a statin in a young patient with familial hypercholesterolaemia?

A

Evolocumab (PCSK9 inhibitor)

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38
Q

Outline the Simon Broome criteria for familial hypercholesterolaemia.

A

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

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39
Q

What is an important acute complication of a ketamine infusion?

A

Raised ICP (monitor for headache, papilloedema and vomiting when administering)

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40
Q

What is the time window for thrombectomy for stroke?

A

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

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41
Q

How should patients with gestational diabetes be followed-up after birth?

A

Postnatal glucose check (fasting blood glucose) 6-13 weeks postpartum

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42
Q

How should patients with COPD who are being worked up for LTOT and have a significant rise in pCO2 with oxygen therapy be managed?

A

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

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43
Q

What is seen on a biopsy of a patient with CMV colitis?

A

Inclusion bodies

NOTE: treated with gancyclovir

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44
Q

Which antibody is specific for drug-induced lupus?

A

Anti-histone

NOTE: common causes include procainamide and hydralazine

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45
Q

Which conditions are associated with SIBO?

A

neonates with congenital gastrointestinal abnormalities
scleroderma
diabetes mellitus

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46
Q

Describe the appearance of cryptosporidium on Ziehl Nielson staining.

A

Red cysts

May be treated with rifaximin but is usually supportive in patients who are immunocompetent

Other treatment: nitazoxanide

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47
Q

What is the drug of choice for lymphatic filariasis?

A

Diethylcarbamazine

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48
Q

How is FSGS treated?

A

Steroids

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49
Q

How does histoplasmosis present?

A

Productive cough
Retrosternal chest pain
Recent travel to USA

Rx: Itraconazole or amphotericin

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50
Q

Which medication enhances the effects of adenosine?

A

Dipyridamole

Leads to prolonged effects

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51
Q

Which TB drug causes arthralgia?

A

Pyrazinamide

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52
Q

What is the purpose of a long synacthen test?

A

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.

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53
Q

Which ECG change is commonly seen in arrhythmogenic right ventricular cardiomyopathy?

A 
TWI in V1-V3
Epsilon wave (terminal notch in QRS complex)
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54
Q

When are platelets and FFP recommended in the context of a gastrointestinal bleed?

A

platelets < 50 and INR/APTT > 1.5 x normal

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55
Q

What are the four types of renal tubular acidosis?

A

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

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56
Q

What are the features of Miller-Fisher Syndrome?

A

Ophthalmoplegia
Areflexia
Ataxia
Usually a DESCENDING paralysis

NOTE: Anti-GQ1b antibodies present in 90% of cases

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57
Q

What is one negative aspect of G6PD level assays?

A

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.

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58
Q

Which four cranial nerve nuclei arise in the medulla?

A

CN 9-12

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59
Q

Which four cranial nerve nuclei arise in the pons?

A

CN 5-8

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60
Q

Which four cranial nerve nuclei arise ABOVE the pons?

A

CN 1-2 (from the cerebrum)

CN 3-4 (from the midbrain)

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61
Q

Which neuroanatomical structures are in the MIDLINE in the brainstem?

A

Motor pathways (corticospinal tract)
Medial lemniscus
Medial longitudinal fasciculus
Motor nuclei of 3, 4, 6 and 12

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62
Q

Which neuroanatomical structures are in the LATERAL aspect of the brainstem?

A

Spinothalamic Tract
Sympathetic Fibres
Sensory Nuclei of CN 5
Spinocerebellar Tract

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63
Q

Which rule can be used to remember which motor nuclei are in the midline vs the lateral aspect of the brainstem?

A

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)

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64
Q

How does an uncal herniation manifest?

A 
Ipsilateral 3rd nerve palsy involving the pupil
Contralateral paralysis (due to compression of cerebral peduncle)
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65
Q

What is the recommended treatment option for fatigue associated with MS?

A

Amantadine

NOTE: anaemia, depression and thyroid dysfunction should be ruled out first

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66
Q

How is oscillopsia associated with MS treated?

A

Gabapentin

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67
Q

How should bladder dysfunction in MS be investigated and managed?

A

Ix: US to assess bladder emptying
If significant residual volume –> Intermittent self-catheterisation
If no significant residual volume –> anticholinergics

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68
Q

What are the criteria for beta-interferon use in multiple sclerosis?

A

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

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69
Q

What causes mucosal leishmaniasis and how does it manifest?

A

Leishmania braziliensis

Skin lesions across mucosa of nose and pharynx (may manifest years after exposure)

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70
Q

What causes cutaneous leishmaniasis and how does it manifest?

A

Leishmania tropica or Leishmania mexicana

Crusted lesion at site of bite

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71
Q

What causes visceral leishmaniasis and how does it manifest?

A

Leishmania donovani

Fever, sweats and rigors
Massive splenomegaly and hepatomegaly
Grey skin
Pancytopaenia (due to hypersplenism)

Ix: bone marrow or splenic aspirate

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72
Q

Which vector transmits leishmaniasis?

A

Sandfly

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73
Q

Which blood film abnormalities will be seen in G6PD deficiency?

A

Heinz bodies
Bite cells
Blister cells

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74
Q

Which stain is used to distinguish primary from metastatic lung cancers when performing cytological analysis of a malignant pleural effusion?

A

TTF1 (thyroid transcription factor)

This is only expressed by cells found in lung and thyroid.

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75
Q

How does Kearns-Sayre syndrome manifest?

A

Onset in patients < 20 years old
External ophthalmoplegia, retinitis pigmentosa (causing night blindness). Ptosis may be seen, heart block

NOTE: mitochondrial disease

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76
Q

What is the most specific ECG feature of acute pericarditis?

A

PR Depression

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77
Q

Which drugs are used in the treatment of ventricular tachycardia (with pulse)?

A

Procainamide (best option)
Amiodarone
Lidocaine (caution in left ventricular impairment)

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78
Q

What is a major risk of starting ACE inhibitors in someone with bilateral renal artery stenosis?

A

It can case deteriorating renal function and flash pulmonary oedema

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79
Q

What are the features of severe iron toxicity (i.e. overdose)?

A 
Abdominal pain and haematemesis (gastrointestinal corrosion)
Diarrhoea
Raised BM (HALLMARK)
Significant sample haemolysis 
Metabolic acidosis with high anion gap
Coagulopathy (particularly APTT)
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80
Q

What increase in transaminases is allowed after starting a statin?

A

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

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81
Q

How is methotrexate toxicity treated?

A

Folinic acid

NOTE: folic acid is used to prevent methotrexate side-effects

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82
Q

Which antibiotics have good Pseudomonas cover?

A 
Ciprofloxacin
Tazocin
Ceftazidime
Aztreonam
Meropenem
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83
Q

What is the only absolute contraindication for ECT?

A

Raised intracranial pressure

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84
Q

In which subgroup of patients with stable angina should revascularisation with PCI be offered?

A

Stable coronary artery disease and ischaemia in > 10 % of the left ventricle

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85
Q

What is an osmolar gap?

A

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)

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86
Q

Which cause of pneumonia is associated with bulging fissure sign?

A

Klebsiella pneumonia

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87
Q

List some indications for IVIG

A

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

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88
Q

What is the preferred imaging modality for patients with suspected TIA who need brain imaging?

A

MRI brain with diffusion-weighted imaging

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89
Q

What is a gradient record MRI brain used for?

A

To look for microhaemorrhages

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90
Q

How are hiccups managed?

A

Chlorpromazine
Haloperidol and Gabapentin
Dexamethasone (used if there are hepatic lesions)

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91
Q

What should you do in patients with neutropenic sepsis that has failed to respond to antibiotics after 48 hours?

A

It may be fungal –> start antifungal therapy

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92
Q

What feature can help distinguish dengue from chikungunya?

A

Chikungunya is more associated with severe joint pains

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93
Q

What is the most common GI side-effect of clozapine?

A

Constipation and intestinal obstruction

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94
Q

What are the indication for CRT?

A

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

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95
Q

How is Schistosoma haematobium infection treated?

A

Single dose of praziquantel

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96
Q

Which types of porphyria only cause neurovisceral symptoms (i.e. no skin involvement)?

A

Acute intermittent porphyria

Aminolaevulinic acid dehydrogenase porphyria

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97
Q

Which types of porphyria only manifest with photosensitivity?

A

Porphyria cutanea tarda
Congenital erythropoietic porphyria
Erythropoietic protoporphyria

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98
Q

Which types of porphyria cause both neurovisceral and photosensitive manifestations?

A

Variegate porphyria

Hereditary coproporphyria

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99
Q

How long after CT contrast can a patient have radioiodine therapy?

A

8 weeks

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100
Q

Which criteria are used to diagnose a total anterior circulation stroke?

A

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

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101
Q

Which arteries are affected in a total anterior circulation stroke?

A

Anterior and Middle Cerebral Arteries

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102
Q

What are the main complications of typhoid?

A

Bowel perforation and haemorrhage

Myocarditis and endocarditis

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103
Q

List some contraindications for second line anti-anginal drugs.

A

Ivabradine - sick sinus syndrome
Ranolazine - liver injury
Nicorandil - LV failure and cardiogenic shock

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104
Q

What are the five types of lupus nephritis?

A 
I - Minimal Mesangial
II - Mesangial Proliferation
III - Focal 
IV - Diffuse (WORST PROGNOSIS)
V - Membranous
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105
Q

What treatment should be offered to 15-49 year olds with early ADPKD (eGFR > 90)?

A

ACE inhibitor with target blood pressure of < 110/75 mm Hg

NOTE: tolvaptan is recommended for rapidly progressive disease at CKD stage 2-3.

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106
Q

What are the indications for starting treatment of CLL?

A

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

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107
Q

What ABG picture would you see in someone with methaemoglobinaemia?

A

Mixed respiratory and metabolic acidosis with a relative hypoxia despite the inspired fraction of oxygen.

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108
Q

When might ITP be used instead of steroids in a patient with ITP?

A

If platelets need to rise quickly (e.g. ahead of surgery)

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109
Q

What can cause a thunderclap headache with a normal CT head and normal CSF results?

A

Reversible cerebrovascular vasoconstriction syndrome

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110
Q

Why must you exercise caution when thinking about administering blood products to people with selective IgA deficiency?

A

Associated with anaphylactic reaction to blood products

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111
Q

How does benzodiazepine withdrawal manifest?

A

PHYSICAL: tachycardia, sweating, tremor
NEUROPSYCHIATRIC: nightmares, insomnia, anxiety, seizures, photophobia, derealisation and kinaesthetic hallucinations

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112
Q

Which medications cause false positive 5-HIAA results?

A

Paracetamol
Naproxen
Caffeine
Fluorouracil

FOODS: Banana, Avocado, Aubergine, Pineapple, Plums, Walnuts, Tomatoes

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113
Q

Which medications cause false negative 5-HIAA results?

A

Aspirin
Levodopa
Methyldopa
ACTH

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114
Q

How is a scleroderma renal crisis managed?

A

STAT ACE Inhibitor

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115
Q

What are the first, second and third line treatment options for acute dystonia?

A

1: Procyclidine
2: Benzodiazepine
3: Anticholinergic Antihistamines

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116
Q

List some common drugs that can increase seizure frequency in people with epilepsy?

A 
Fentanyl
Mefenamic Acid
Tramadol
Amitriptyline 
Aminophylline 
Isotretinoin
Haloperidol
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117
Q

Outline the differences between the Parkinson’s plus syndromes.

A

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)

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118
Q

What level of LFT derangement would warrant stopping methotrexate?

A

Doubling of ALT or AST

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119
Q

Which opioids are safe in patients with impaired renal function (eGFR < 30)?

A

Oxycodone
Fentanyl
Buprenorphine
Methadone

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120
Q

How is lupus nephritis treated?

A

Focal and Mild: Oral Steroids

Nephrotic Syndrome and Advanced Diffuse Lupus Nephritis: IV Methylprednisolone and IV Cyclophosphamide

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121
Q

When should statins be started after a stroke?

A

48 hours after the onset of symptoms

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122
Q

In which cases of hyperadrenalism is surgery indicated?

A

If it is caused by a unilateral adrenal adenoma

Otherwise you manage with spironolactone

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123
Q

When should EPO be started in a patient with CKD?

A

Once they are iron replete (this can be achieved with IV iron)

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124
Q

List the medical management guidelines for HOCM.

A

1: Beta-Blocker or Non-Dihydropyridine CCB (e.g. verapamil)
2: Disopyramide (class 1a anti-arrhythmic)
3: Myectomy, DDDR pacemaker, alcohol ablation

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125
Q

How should measles exposure be managed in someone that is vulnerable (e.g. unvaccinated, immunocompromised)?

A

Immunoglobulin

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126
Q

Why should patients undergoing open surgical valve repair have a coronary angiogram prior to the surgery?

A

To identify any coronary artery disease that could also be attended to at the same time

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127
Q

What is paragonimiasis and how does it present?

A

Lung Fluke Infection
Presents very similarly to TB with a chronic history of productive cough, weight loss, night sweats and rashes

Treated with praziquantel

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128
Q

List some side-effects of ciclosporin.

A 
Nephrotoxic
Hepatotoxic
Fluid retention 
Hyperkalaemia 
Hypertrichosis
Gingival hyperplasia
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129
Q

What is Fabry disease?

A

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
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130
Q

Which serum measurement is a useful marker of renal function that is less affected by age, sex, race and muscle mass?

A

Cystatin C

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131
Q

At what serum PTH level should patients with secondary hyperparathyroidism receive calcium and vitamin D supplements?

A

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

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132
Q

How should hoarseness after a total thyroidectomy be investigated?

A

Laryngoscopy - to assess vocal cord paralysis and evaluate motility

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133
Q

How does strongyloidiasis manifest?

A 
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

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134
Q

In which groups of patient is CABG considered better than PCI with stent insertion for the management of ischaemic heart disease?

A

Patients with complex anatomy
Triple vessel disease
Proximal left main stem disease

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135
Q

Which investigation is used for acute intermittent porphyria and how is it treated?

A

Raised urinary porphobilinogen

Treated with IV haem arginate

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136
Q

Which antibiotics are usually used to manage pyogenic liver abscesses?

A

amoxicillin + ciprofloxacin + metronidazole

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137
Q

What ECG features do you see in hypocalcaemia?

A

Prolonged QT Interval

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138
Q

How does histoplasmosis present and how is it treated?

A

Symptoms of URTI
Retrosternal pain

Rx: amphotericin or itraconazole

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139
Q

Outline the mechanism of hungry bone syndrome.

A

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.

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140
Q

Which lower limb neurological features do you see in subacute combined degeneration of the spinal cord?

A

Brisk Knee Reflexes
Absent Ankle Reflexes
Extensor Plantar Reflexes

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141
Q

Describe the manifestations of methoxetamine overdose.

A 
Sympathetic activation (tachycardia, hypertension, mydriasis)
Confusion and agitation
Cerebellar signs (nystagmus, dysarthria, ataxia)

NOTE: methoxetamine is an analogue of ketamine

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142
Q

What is the most common side effect of checkpoint inhibitors like nivolumab?

A

Dry itchy skin and rashes

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143
Q

How does anti-NMDA receptor encephalitis present?

A 
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

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144
Q

What is tropical spastic paraparesis?

A

A condition in which patients with HIV and HTLV1 present with urinary retention and paraparesis

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145
Q

Which antiemetic is best for metabolic causes of nausea and vomiting (e.g. hypercalcaemia, uraemia)?

A

Central dopamine antagonists (e.g. haloperidol)

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146
Q

What is the first-line antibiotic for ESBL UTIs?

A

Carbapenems

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147
Q

How does American trypanosomiasis manifest?

A

ACUTE: asymptomatic, sometimes orbital oedema
CHRONIC: myocarditis (and dilated cardiomyopathy), megaoesophagus (causing dysphagia) and megarectum

Rx: benznidazole or nifurtimox

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148
Q

What is idarucizumab used to reverse?

A

Dabigatran

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149
Q

What is used to reverse rivaroxaban and apixaban?

A

Andexanet alpha

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150
Q

What is the DMARD of choice in psoriatic arthritis?

A

Methotrexate

2nd line: leflunomide

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151
Q

What special feature of carbamazepine must you be aware of when starting patients on the drug?

A

It causes autoinduction so there may be an increase in seizure prevalence after 3-4 weeks

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152
Q

What forms of smoking cessation treatment are recommended by NICE?

A

Nicotine replacement therapy (patch and a short-form for acute cravings)
Varenicline (CI in pregnancy)
Bupropion (CI in pregnancy)

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153
Q

Outline the management of non-small cell lung cancer.

A

Stage 1 and 2: Resection Surgery
Stage 3: Chemotherapy
Stage 4: Palliative

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154
Q

List the contraindications for surgery for non-small cell lung cancer.

A

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

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155
Q

What special feature of Plasmodium ovale required additional consideration when determining how to treat it?

A

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

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156
Q

Outline the criteria for diagnosing NF2.

A

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

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157
Q

What is the threshold for platelet transfusions in an actively bleeding patient?

A

50

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158
Q

What are the criteria for FFP in patients who are actively bleeding?

A

Either a fibrinogen level of less than 1 g/litre
or
PT or APTT greater than 1.5 times normal

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159
Q

Which vaccines are contraindicated in adults with HIV?

A

Cholera CVD103-HgR
Influenza-intranasal
Poliomyelitis-oral (OPV)
Tuberculosis (BCG)

NOTE: if CD4 < 200, then MMR, varicella and yellow fever are also contraindicated

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160
Q

How does relapsing polychondritis present?

A

Relapsing episodes of chondritis (e.g. auricular chondritis)

Can involve the respiratory tract, heart valves and blood vessels.

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161
Q

List some lead chelators.

A

dimercaptosuccinic acid (DMSA) - best for chronic exposure
D-penicillamine
EDTA - IV agent used for acute exposure
dimercaprol

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162
Q

How does lead poisoning manifest?

A 
abdominal pain
peripheral neuropathy (mainly motor)
fatigue
constipation
blue lines on gum margin (only 20% of adult patients, very rare in children)
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163
Q

How should an HIV viral load of 50-200 in someone on established ART be managed?

A

Repeat blood test in 1 month

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164
Q

What are the criteria for antibiotic prophylaxis in patients with ascites?

A

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

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165
Q

What are the criteria for commencing treatment with GLP1 agonists?

A
  • 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

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166
Q

What are the two different types of Wolff-Parkinson-White syndrome?

A 
type A (left-sided pathway): dominant R wave in V1
type B (right-sided pathway): no dominant R wave in V1
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167
Q

How should WPW be managed?

A

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

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168
Q

List some CYP450 INDUCERS.

A

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

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169
Q

List some CYP450 INHIBITORS.

A 
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

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170
Q

List the manifestations of myotonic dystrophy.

A 
myotonic facies (long, 'haggard' appearance)
frontal balding
bilateral ptosis
cataracts
dysarthria
cardiomyopathy (incl. heart block) 
dysphagia 
diabetes mellitus
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171
Q

Outline the differences between DM1 and DM2.

A

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
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172
Q

How is dermatitis herpetiformis treated?

A

Dapsone and a gluten-free diet

Second Line: Sulfapyridine

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173
Q

What causes paroxysmal nocturnal haemoglobinuria?

A

Acquired intravascular haemolysis due to increased sensitivity of cell membranes to complement due to lack of glycoprotein glycosylphosphatidylinositol (GPI).

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174
Q

How does PNH manifest?

A 
Haemolytic anaemia 
Cytopaenias
Haemoglobinuria 
Thrombosis 
Aplastic anaemia
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175
Q

How can PNH be diagnosed?

A

Flow cytometry of blood to detect low levels of CD59 and CD55

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176
Q

How can PNH be managed?

A

ACUTE: blood products, anticaogulation, eculizumab
DEFINTIIVE: stem cell transplantation

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177
Q

What is Alport syndrome?

A

X-linked dominant condition caused by mutation in collagen IV leading to abnormal glomerular basement membrane

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178
Q

How does Alport syndrome manifest?

A 
Microscopic haematuria 
Progressive renal failure 
Bilateral sensorineural hearing loss 
Lenticonus
Retinitis pigmentosa 
Renal Biopsy: split lamina densa (basket weave appearance)
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179
Q

What is a relatively common complication that occurs in patients with Alport syndrome who have received a renal transplant?

A

Crescentic glomerulonephritis due to de novo anti-GBM disease

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180
Q

Which investigations should be used to screen for haemochromatosis?

A

general population: transferrin saturation > ferritin

family members: HFE genetic testing

181
Q

What are the definitive diagnostic tests used for hereditary haemochromatosis?

A

molecular genetic testing for the C282Y and H63D mutations

liver biopsy: Perl’s stain

182
Q

Which type of brain tumour is associated with a paraneoplastic phenomenon in which patients develop a high Hb?

A

Cerebral haemangioblastomas (release erythropoietin)

183
Q

List some associations of PBC.

A

Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease

184
Q

What is papillary necrosis and what can cause it?

A

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
185
Q

What is the risk of using BRAF inhibitors (e.g. Vemurafenib and dabrafenib) in the treatment of melanoma?

A

Squamous cell carcinoma

186
Q

What is the main treatment option for gout in patients with severely impaired renal function?

A

Steroids (e.g. prednisolone)
Alternative: Canakinumab (anti-IL1 beta)

NOTE: colchicine, NSAIDs and allopurinol are all contraindicated

187
Q

How does central pontine myelinolysis manifest?

A

Spastic quadriparesis
Pseudobulbar palsy
Emotional lability

188
Q

List the indications for an ICD.

A 
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
189
Q

What is hypokalaemic periodic paralysis?

A

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.

190
Q

How should myxoedema coma be managed?

A

Levothyroxine and liothyronine

191
Q

How should paroxysmal AF be investigated?

A

Episodes < 24 hrs apart: 24 hr ambulatory ECG

Episodes > 24 hrs apart: event recorder electrocardiogram

192
Q

List some causes of erythema multiforme.

A

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

193
Q

How is membranous glomerulonephritis managed?

A

ACE inhibitor or ARB
Immunosuppression

NOTE: associated with anti-phospholipse A2 antibodies

194
Q

How is thyroid storm managed?

A

Beta blockers (e.g. IV propranolol)
Antithyroid drugs (e.g. propylthiouracil)
Lugol’s iodine
Dexamethasone

195
Q

When should patients undergo a carotid endarterectomy?

A

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

196
Q

Describe the symptoms of zinc deficiency.

A 
perioral dermatitis: red, crusted lesions
acrodermatitis
alopecia
short stature
hypogonadism
hepatosplenomegaly
geophagia (ingesting clay/soil)
cognitive impairment
197
Q

Describe the clinical manifestations of methanol and ethylene glycol poisoning.

A

Methanol: retinal injury, visual disturbance

Ethylene Glycol: oliguria, haematuria, flank pain

198
Q

What is autonomic dysreflexia?

A

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

199
Q

What is mepolizumab and when is it used?

A

Anti-IL5 monoclonal antibody

Used for asthma with high eosinophils

200
Q

What is Weber syndrome?

A

Form of midbrain stroke characterised by ipsilateral CNIII palsy and contralateral hemiparesis

Caused by a stroke involving a branch of the posterior cerebral artery

201
Q

List medications that can precipitate myasthenic crises.

A 
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
202
Q

Outline the differences between type 1 and type 2 HRS.

A

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

203
Q

How is hepatorenal syndrome managed?

A

Terlipressin and HAS

NOTE: TIPSS may also be used

204
Q

What is the first-line treatment option for myelofibrosis?

A

Hydroxycarbamide

205
Q

What is the investigation of choice for suspected hydatid cysts?

A

Serology for Echinococcus granulosus

206
Q

What is an important side-effect of dapsone to be mindful of?

A

Haemolytic anaemia

207
Q

What is Hereditary Neuropathy with Liability to Pressure Palsy?

A

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

208
Q

What is a common side-effect of efavirenz?

A

Disturbing dreams and being muddled

209
Q

What is an alternative to penicillamine for copper chelation?

A

Trientine

NOTE: people with penicillin allergy cannot receive penicillamine

210
Q

Which type of meningococcal meningitis is most common across Africa and the Middle East?

A

Men A

NOTE: B and C are more common in Europe and South America

211
Q

How should cases of TB with isoniazid resistance be managed?

A

Continue ethambutol for 6 months

212
Q

What are the rules for treating subclinical hypothyroidism?

A

Treat if TSH is > 10 mU/L as long as they are younger than 70 yrs old

Otherwise repeat TFTs in 6 months

213
Q

What is a major danger of hydatid cyst rupture?

A

It can cause anaphylaxis

214
Q

What are the indications for steroid treatment in sarcoidosis?

A

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

215
Q

What ECG changes are seen in hypokalaemia?

A 
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
216
Q

Which investigation must be conducted before considering adrenalectomy in a patient with Conn syndrome?

A

Adrenal venous sampling

This allows you to distinguish between bilateral adrenal hyperplasia and unilateral adrenal adenoma

217
Q

What is used for bacterial meningitis prophylaxis?

A

Ciprofloxacin or rifampicin

NOTE: should be offered to everyone that had close contact with the patient within 7 days of symptom onset

218
Q

What are anti-Hu, anti-Yo and anti-Ri antibodies associated with?

A

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

219
Q

Why should aspirin be stopped in thyroid storm?

A

It can displace T4 from thyroid binding globulin

220
Q

What is Gardener syndrome?

A

Autosomal dominant condition characterised by adenomatous intestinal polyps, osteomas and fibromas

NOTE: high risk of colorectal cancer

221
Q

What triad of features is associated with Still’s disease?

A

Fever
Joint Pain
Salmon-coloured bumpy rash

NOTE: associated with high ferritin and ESR and treated with NSAIDs

222
Q

How does cyanide poisoning manifest and how is it treated?

A

Hypoxia, Hypotension, Headache, Confusion

Rx: IV hydroxocobalamin (alternatives: amyl nitrite (inhaled), IV sodium nitrite, IV sodium thiosulfate)

223
Q

How is CNS lymphoma treated?

A

Steroids + Methotrexate

224
Q

What effect does smoking have on aminophylline?

A

Required higher doses of aminophylline

225
Q

How is the tremor treated in patients with Parkinson’s disease who are already on co-careldopa?

A

Procyclidine

Other anticholinergics include orphenadrine, or trihexyphenidyl

226
Q

How is methanol poisoning treated?

A

1st Line: Fomepizole or Ethanol
Alt: Haemodialysis

NOTE: folinic acid can reduce ophthalmological complications

227
Q

What causes Glanzmann’s thrombsthenia?

A

Ineffective Glp IIb/IIIa

228
Q

What is Foster-Kennedy syndrome?

A

Ipsilateral optic atrophy and contralateral papilloedema

Caused by frontal lobe mass (e.g. meningioma)

229
Q

How is a spontaneous carotid artery dissection managed medically?

A

Aspirin

NOTE: high risk of thromboembolic disease

230
Q

How is flexural psoriasis treated?

A

Mild to moderate topical steroids

231
Q

Which combination of ECG features are seen in incomplete trifascicular block?

A

Right Bundle Branch Block
Left Axis Deviation
Prolonged PR Interval

232
Q

At what point should patients with type 1 diabetes mellitus receive a statin?

A

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

233
Q

Which medical treatment is used or Parkinson’s dementia?

A

Rivastigmine

234
Q

Other than anti-acetylcholine receptor antibodies, which other antibody is associated with myasthenia gravis?

A

Anti-muscle specific tyrosine kinase (MuSK)

NOTE: 40% of patients have anti-MuSK antibodies and they have less of a response to pyridostigmine

235
Q

Which mutation is associated with Hairy Cell Leukaemia?

A

BRAF

236
Q

List some features of severe malaria.

A 
schizonts on a blood film
parasitaemia > 2%
hypoglycaemia
acidosis
temperature > 39 °C
severe anaemia
complications as below
237
Q

Which medication is used to prevent acute mountain sickness?

A

Acetazolamide

It works by causing a metabolic acidosis leading to a compensatory respiratory alkalosis (achieved through hyperventilation)

238
Q

What is roflumilast and when is it recommended in the management of COPD?

A

Phosphodiesterase-4 inhibitor

Recommended in COPD patients on maximal medical therapy + FEV1 < 50% + 2 or more exacerbations over last year

239
Q

Why is sodium bicarbonate used in the treatment of aspirin overdose?

A

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

240
Q

What are the indications for dialysis in salicylate overdose?

A 
serum concentration > 700mg/L
metabolic acidosis resistant to treatment
acute renal failure
pulmonary oedema
seizures
coma
241
Q

What should you give when three doses of adenosine fails to terminate an SVT in a haemodynamically stable patient?

A

Verapamil (provided no asthma or atrial flutter)

Dose 2.5-5 mg IV

242
Q

List some risk factors for refeeding syndrome.

A

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)

243
Q

List some causes of FSGS.

A 
idiopathic
secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
HIV
heroin
Alport's syndrome
sickle-cell
244
Q

Which HIV drug is associated with the formation of urate stones?

A

Indinavir

245
Q

What are the three types of long QT syndrome?

A

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

246
Q

Outline the treatment of idiopathic intracranial hypertension.

A

Weight Loss
Diuretics
Repeated lumbar puncture
Surgery (optic nerve sheath decompression and fenestration)

247
Q

Which drug class is best for treating tics?

A

Antipsychotics (e.g. risperidone)

Clonidine

248
Q

During an LTOT assessment, how should you manage a patient whose pCO2 increases by > 1 kPa following oxygen administration?

A

Medically optimise and reassess in 4 weeks

249
Q

Aside from the effects of the infection itself, what other gastrointestinal complication an be caused by Giardia infection?

A

Temporary lactose intolerance

250
Q

What are the main differences between American and African trypanosomiasis?

A

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

251
Q

What is the first line treatment for viral pericarditis?

A

NSAID + Colchicine

252
Q

How is peritoneal dialysis peritonitis treated?

A

Intraperitoneal vancomycin + ceftazidime

NOTE: S. epidermidis is the most common cause

253
Q

What are the criteria for 3 yearly colonoscopies in patients with ulcerative colitis?

A

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

254
Q

Which genes are associated with MEN?

A

MEN1 : MEN1 Gene

MEN2: RET Oncogene

255
Q

Which common drugs are potent inhibitors of CYP3A4?

A

Macrolides (e.g. clarithromycin)

256
Q

How is Anti-GBM disease treated?

A

Plasmapheresis
Steroids
Cyclophosphamide

257
Q

Which drugs are used to treat Huntington’s chorea?

A

DOPAMINE DEPLETION: Reserpine (VMAT), tetrabenazine

DOPAMINE ANTAGONISTS: antipsychotics (e.g. risperidone)

258
Q

What are the ECG features seen in dextrocardia?

A

Inverted P wave in leave I
RAD
Loss of R wave progression

259
Q

What are the ECG features of a posterior MI?

A

Changed in V1-3:

  • Horizontal ST depression
  • Tall, broad R waves
  • Upright T waves
  • Dominant R wave (V2)
260
Q

Which simple test may be used to distinguish Conn’s syndrome from adrenal hyperplasia?

A

Measure aldosterone after prolonged standing

Aldosterone increases after prolonged standing in patients with adrenal hyperplasia

261
Q

What are the features of multiple sclerosis that are seen on an MRI head scan?

A

high signal T2 lesions
periventricular plaques
Dawson fingers: often seen on FLAIR images - hyperintense lesions penpendicular to the corpus callosum

262
Q

What is the first line treatment option for scalp psoriasis?

A

Topics steroids (daily for 4 weeks)

263
Q

What is the gold standard investigation for cerebral venous sinus thrombosis?

A

MRI Venography (though CT venography is often used for convenience)

264
Q

What is the main indication for placing a chest drain in a patient with a pleural effusion?

A

If the pH on the pleural aspirate is < 7.2

265
Q

Outline Light’s criteria for pleural effusions.

A

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
266
Q

How is chronic inflammatory demyelinating polyneuropathy (CIDP) different from GBS?

A 
Motor symptoms predominate
Insidious onset (months) - like a chronic version of GBS 
Treated with steroids and immunosuppressants
267
Q

Which diagnoses are associated with upgoing plantars and absent ankle jerks?

A 
SACD
Motor neurone disease 
Friedrich ataxia
Tabes dorsalis 
Dual peripheral with central pathology
268
Q

In patients with stage 1 hypertension, what is the treatment thershold?

A

10-year-cardiovascular risk score > 10% or evidence of end organ damage

269
Q

What is pacemaker syndrome?

A

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

270
Q

Which drug class is notorious for triggering scleroderma crisis?

A

Steroids

271
Q

How is lupus nephritis treated?

A

Steroids to induce remission (with or without cyclophosphamide and mycophenolate)

Mycophenolate to maintain remission

272
Q

Which antibiotics are good at treating Legionella?

A

Macrolides and Quinolones

NOTE: they have good intracellular penetration

273
Q

Which class of Parkinson’s medications is best for off-time reduction?

A

Dopamine agonists

274
Q

Which class of Parkinson’s medications is most commonly associated with causing delusions and hallucinations?

A

Dopamine agonists

It also causes impulse control issues

275
Q

Which additional test is useful in making a diagnosis of heparin-induced thrombocytopaenia in someone with a moderate HIT antibody titre?

A

Serotonin release assay

276
Q

What second line agent is used in the treatment of familial hypercholesterolaemia?

A

Ezetimibe

277
Q

What do VVI pacemakers look like on an ECG?

A

Pacing spikes immediately before the QRS complex

278
Q

What is the most effective screening tool for distinguishing delirium from dementia?

A

Confusion assessment method (CAM)

279
Q

List some causes of retroperitoneal fibrosis.

A 
Riedel's thyroiditis
previous radiotherapy
sarcoidosis
inflammatory abdominal aortic aneurysm
drugs: methysergide
280
Q

What can be used for bone protection in a patient with bone metastases and an eGFR < 30 mL/min?

A

Denosumab

281
Q

Outline the criteria for decompressive craniotomy in the context of malignant MCA syndrome.

A

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.

282
Q

Outline the treatment guidelines for a first episode of C. difficile.

A

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

283
Q

Which tests are required to stage multiple myeloma?

A

Beta-2 microglobulin

Serum albumin

284
Q

Which drug class is most effective at treating hypertriglyceridaemia?

A

Fibrates

285
Q

Summarise the NICE guidelines for the management of non-typhoidal salmonella gastroenteritis.

A

Anyone > 50 yrs OR immunocompromised OR cardiac valve disease/endovascular abnormalities
Ciprofloxacin 500 mg BD

286
Q

List some pre-ganglionic causes of Horner syndrome.

A

NOTE: causes anhidrosis of the face

Pancoast’s trumour
Thyroidectomy
Trauma
Cervical rib

287
Q

List some post-ganglionic causes of Horner syndrome.

A

NOTE: does NOT cause anhidrosis of the face

Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache

288
Q

Which long-acting insulin is particularly useful in preventing recurrent DKA as it has a long half-life?

A

Degludec (Tresiba)

289
Q

What can be given in sulfonylurea overdose to patients who fail to respond adequately to glucose?

A

IM Octreotide

290
Q

How is typhoid fever managed?

A

Cefotaxime or Ceftriaxone

NOTE: it is caused by Salmonella enterica

291
Q

How is arrhythmogenic right ventricular cardiomyopathy treated?

A

Sotalol
Catheter Ablation
ICD

292
Q

What are presenting features of acute interstitial nephritis?

A

Fever, Rash and Arthralgia
Eosinophilia
Renal Impairment
Hypertension

293
Q

Which common drugs can cause acute interstitial nephritis?

A 
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
294
Q

Which combination of chemotherapy agents used for breast cancer is especially cardiotoxic?

A

Trastazumab + anthracyclines (e.g. doxorubicin)

295
Q

What are the main features of Langerhans cell histiocytosis?

A 
Bone pain (skull and femer) 
Cutaneous nodules
Decurrent otitis media/mastoiditis
Spontaneous peumothorax
Diabetes insipidus
Tennis racket-shaped Birbeck granules on electromicroscopy
296
Q

What are the main treatment options for eosinophilic oesophagitis?

A

Dietary modification
Topical steroids (e.g. fluticasone, budesonide)
Oesophageal dilatation

NOTE: diagnosis is confirmed on biopsy

297
Q

How is latent tuberculosis treated?

A

3 months isoniazid and rifamipicin

6 months isoniazid

298
Q

Outline the management of IgA nephropathy.

A

no proteinuria, normal GFR: observe
proteinuria: ACE inhibitor
signifcant fall in GFR/not responding to ACE inhibitor: corticosteroid

299
Q

How is tick borne encephalitis managed?

A

Supportive management

300
Q

Which antiemetic is best for the delayed phase of chemotherapy-induced nausea?

A

Dexamethasone

301
Q

What is accelerated idioventricular rhythm?

A

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)

302
Q

What is the main cause of frank haematuria in patients with sickle cell disease?

A

Papillary necrosis

303
Q

What is a key difference between Gitelman and Bartter syndrome?

A

Gitelman: Hypocalciuria
Bartter: NO hypocalciuria

NOTE: both conditions cause hyponatraemia, hypokalaemia, hypomagnesemia and normotension

304
Q

What are some contraindications to testosterone treatment in men?

A

PSA > 4 ng/mL
Male breast cancer
Severe sleep apnoea
Severe LUTS due to BPH

305
Q

How does loiasis present?

A

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

306
Q

How is pain from shingles managed?

A

1: Paracetamol and NSAIDs
2: Neuropathic agents
3. Oral Corticosteroids

307
Q

List some features and complications of Ehlers-Danlos syndrome.

A

elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks

308
Q

What is Lown–Ganong–Levine syndrome?

A

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.

309
Q

How does dialysis dysequilibrium syndrome manifest and how is it treated?

A

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)

310
Q

Which test is used to determine whether a patient has hyperventilation syndrome?

A

Nijmegen questionnaire

311
Q

What is the treatment option for native valve endocarditis caused by Staphylococcus?

A

Flucloxacillin

If penicillin allergic or MRSA –> Vancomycin + Rifampicin

312
Q

What is the treatment option for prosthetic valve endocarditis caused by Staphylococcus?

A

Flucloxacillin + Rifampicin + Low Dose Gentamicin

If penicillin allergic or MRSA –> switch flucloxacillin for vancomycin

313
Q

What is the treatment option for native valve endocarditis caused by fully-sensitive Streptococci?

A

Benzylpenicillin

If penicillin allergic –> Vancomycin + Low Dose Gentamicin

314
Q

Why should you aim for a very low TSH in patients who have had a thyroidectomy for thyroid cancer?

A

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

315
Q

Under what circumstance should you seek a thoracic surgical opinion in patients with a chest drain?

A

If after 3-5 days there is a persistent air leak or failure of the lung to re-expand

316
Q

What are the two types of autoimmune polyendocrinopathy syndromes?

A

APS Type 1: Chronic mucocutaneous candidasis + Addison’s disease + Primary hypoparathyroidism

APS Type 2 (Schmidt syndrome): Type 1 Diabetes Mellitus + Autoimmune Thyroid Disease

317
Q

In which patients is plasma exchange indicated for patients with anti-GBM disease?

A

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

318
Q

List some causes of membranous glomerulonephritis.

A

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

319
Q

What is the initial blind therapy for prosthetic and native valve endocarditis whilst awaiting blood cultures?

A

Prosthetic: Vancomycin + Rifampicin + Low Dose Gentamicin

Native: Amoxicillin +/- Low Dose Gentamicin

320
Q

How is actinic keratosis managed?

A

Topical fluorouracil

Alternatives: imiquimob or diclofenac

321
Q

What are the indications for a surgical opinion in patients with infective endocarditis?

A

Aortic root abscess
Heart failure
Uncontrolled infection
Prevention of embolism (large vegetations with embolic episodes)

322
Q

What are the manifestations of abetalipoproteinaemia?

A 
failure to thrive + developmental delay
steatorrhoea
retinitis pigmentosa
cerebellar signs
deep tendon reflexes are absent
acanthocytosis
hypocholesterolaemia

Rx: dietary restriction of fats

323
Q

What initial therapy is given to people with a new diagnosis of rheumatoid arthritis?

A

DMARD monotherapy (e.g. methotrexate) + short course of bridging prednisolone

324
Q

What is Whipple’s triad?

A

Used to identify clinically significant hypoglycaemia

  • borderline low blood sugar
  • symptoms of hypoglycaemia
  • improvement of symptoms with sugar
325
Q

What are some main causes of pacemaker failure?

A

Lead Fracture
Lead Displacement
Twiddler syndrome (patient fiddling with the pacemaker leads to displacement of the wires)

326
Q

How is an amoebic liver abscess treated?

A

Aspirate and metronidazole

327
Q

How is leprosy treated?

A

Rifampicin
Dapsone
Clofazimine

Diagnosed using skin-slit smear

328
Q

Which antibiotics may be recommended as Traveller’s diarrhoea prophylaxis in immunocompromised patients?

A

ciprofloxacin, norfloxacin or rifaximin.

329
Q

List some causes of scarring alopecia.

A 
trauma, burns
radiotherapy
lichen planus
discoid lupus
tinea capitis (if untreated)
330
Q

What are the indications for N-acetylcysteine in paracetamol overdose?

A

Staggered overdose or doubt about time of ingestion

Plasma paracetamol level above the normogram line

331
Q

When can N-acetylcysteine be stopped in someone with paracetamol overdose?

A

INR <1.3 and ALT less than 2x upper limit of normal

332
Q

List the causes of HIGH anion gap metabolic acidosis.

A

lactate: shock, sepsis, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol

333
Q

List the causes of NORMAL anion gap metabolic acidosis.

A 
gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
renal tubular acidosis
drugs: e.g. acetazolamide
ammonium chloride injection
Addison's disease
334
Q

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?

A

High dose steroids (60 mg prednisolone) can cause a paradoxical reaction in up to half of patients, where there symptoms worsen initially

335
Q

What are the main features of synthetic cannabinoid toxicity?

A

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

336
Q

List some common drugs that cause peripheral neuropathy.

A 
amiodarone
isoniazid
vincristine
nitrofurantoin
metronidazole
337
Q

How is granulomatosis with polyangiitis treated?

A

Cyclophosphamide and steroids

338
Q

List some contraindications for using flecainide.

A

post myocardial infarction
structural heart disease: e.g. heart failure
sinus node dysfunction; second-degree or greater AV block
atrial flutter

339
Q

How is atypical haemolytic uraemic syndrome managed?

A

Supportive
Plasma Exchange
Eculizumab

340
Q

What are the symptoms of systemic mastocytosis?

A

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

341
Q

What are the physical features of pseudohypoparathyroidism?

A 
short fourth and fifth metacarpals
short stature
cognitive impairment
obesity
round face
342
Q

How should carbapenemase producing organisms be treated?

A

Polymyxins (e.g. colistin)
Tigecycline
Fosfomycin
Aminoglycosides (e.g. gentamicin)

343
Q

Under what circumstance should a GLP-1 agonist be continued in a patient at their 6 month review?

A

If, after 6 months, HbA1c reduces by at least 11 mmol/mol

344
Q

What is the first line imaging modality in multiple myeloma?

A

Whole body MRI

345
Q

Which ECG changes are seen in Brugada syndrome?

A

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

346
Q

Which electrolyte abnormalities are associated with tumour lysis syndrome?

A

HIGH Uric Acid
HIGH Potassium
HIGH Phosphate
LOW Calcium

Clinical features: increased serum creatinine, arrhythmia, seizure

347
Q

What PTH level would you expect in someone with familial hypocalciuria hypercalcaemia?

A

There may also be normal to high parathyroid hormone, despite the elevated serum calcium levels.

348
Q

List some causes of pulmonary eosinophilia.

A 
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
349
Q

What is Loeffler’s syndrome?

A

Transient CXR shadowing and eosinophilia associated with Ascaris lumbricoides
Causes fever, cough and night sweats
Self-limiting

350
Q

Outline the strategies for preventing tumour lysis syndrome in patients undergoing chemotherapy.

A

LOW RISK: Adequate Hydration
MEDIUM RISK: IV Fluids + Allopurinol
HIGH RISK: Rasburicase + IV Fluids

351
Q

List the main contraindications for using beta-blockers.

A

uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia

352
Q

How does acute schistosomiasis manifest?

A

marked eosinophilia
cough
bloody diarrhoea
splenomegaly

353
Q

What are the manifestations of quinine toxicity?

A

Arrhythmia
Hypoglycaemia
Flash pulmonary oedema
Tinnitus, deafness and visual defects

NOTE: treatment is supportive

354
Q

Outline how you interpret nerve conduction study results.

A

Axonal

  • normal conduction velocity
  • reduced amplitude
  • CAUSES: metabolic, toxic or heritable

Demyelinating

  • reduced conduction velocity
  • normal amplitude
  • CAUSES: autoimmune processes, paraproteinaemia
355
Q

How should a patient with a relapse of Graves disease after a trial of anti-thyroid medications be treated?

A

Definitive treatment with surgery or radioiodine

356
Q

Outline the BTS guidelines on the investigation of solitary lung nodules.

A

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

357
Q

What should be recommended for patients with IBS that is resistant to multiple laxatives at adequate doses?

A

Linaclotide

358
Q

Which antiemetic should be avoided in patients with acute heart failure or ACS?

A

Cyclizine - it is an H1 receptor antagonist and anticholinergic that causes systemic hypertension and induces tachycardia which can compromise a fragile heart

359
Q

What is the first-line systemic agent for psoriasis?

A

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

360
Q

How does heparin affect thyroid function test results?

A

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

361
Q

What are the third line treatment options for chronic heart failure?

A

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

362
Q

What is the rapid appearance of multiple seborrhoeic keratoses suggestive of?

A

Underlying malignancy (known as Leser-Trelat Sign)

Usually GI or liver cancer

363
Q

What is the Ki-67 index?

A

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

364
Q

Which skin conditions exhibit Koebner phenomenon?

A 
psoriasis
vitiligo
warts
lichen planus
lichen sclerosus
molluscum contagiosum
365
Q

How can non-tuberculous mycobacterial disease manifest?

A

Hypersensitive-like disease
Cavitating disease
Bronchiectasis with or without nodules

Treatment: Rifampicin, clarithromycin and ethambutol

366
Q

What is POEMS syndrome?

A

Rare paraneoplastic syndrome caused by a clone of abnormal plasma cells

Polyneuropathy
Organomegaly
Endocrinopathy
M-protein band from a plasmacytoma
Skin Pigmentation
367
Q

What is an unwanted metabolic side-effect of NRTIs?

A

NRTIs: stavudine, zidovudine, didanosine

Mitochondrial toxicity –> nausea, pancreatitis, lactic acidosis and lipoatrophy

368
Q

List some consequences of hypophosphataemia.

A

red blood cell haemolysis
white blood cell and platelet dysfunction
muscle weakness and rhabdomyolysis
central nervous system dysfunction

369
Q

What are the main features of Friedreich ataxia?

A

absent ankle jerks/extensor plantars
cerebellar ataxia
optic atrophy
spinocerebellar tract degeneration

Other: HOCM, DM, high arched palate

370
Q

What pattern of deficits do you see in anterior spinal artery occlusion?

A
  1. Bilateral spastic paresis

2. Bilateral loss of pain and temperature sensation

371
Q

What are the main features of neuromyelitis optica?

A

quadriparesis or paraparesis within days to weeks
vision changes
normal brain MRI
presence of anti-NMO antibodies (anti-aquaporin 4 antibodies)
responsive to immunosuppressants

372
Q

What metabolic complication is associated with sodium valproate use?

A

Valproate-associated hyperammonaemic encephalopathy

373
Q

Why is atropine contraindicated in patients with a heart transplant?

A

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.

374
Q

How is cystinuria treated?

A

Hydration
D-penicillamine
Urinary alkalinisation (with potassium citrate)

375
Q

What is the rule regarding DEXA scans in patients with fragility fractures?

A

If > 75 years, they can start a bisphosphonate without a DEXA scan

376
Q

When does renal graft failure count as acute rather than chronic?

A

If it is < 6 months

377
Q

What is methaemoglobinaemia?

A

Haemoglobin that has been oxidised from Fe2+ to Fe3+ (usually regulated by NADH methaemoglobin reductase)

Fe3+ CANNOT bind oxygen, resulting in tissue hypoxia

378
Q

How does methaemoglobinaemia present?

A

Chocolate cyanosis
Shortness of breath, headache, anxiety
Acidosis, arrhythmia, seizures
Normal pO2 but low saturations

379
Q

How is methaemoglobinaemia treated?

A

NADH - methaemoglobinaemia reductase deficiency: ascorbic acid
IV methylthioninium chloride (methylene blue) if acquired

380
Q

What is acute disseminated encephalomyelitis?

A

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.

381
Q

What are the features of a lacunar stroke?

A

Unilateral weakness
Pure sensory stroke
Ataxic hemiparesis

382
Q

How do you test for paraquat poisoning?

A

Urine dithionate test

It can cause GI irritation, liver and kidney failure, and chemical pneumonitis and fibrosis

383
Q

Which ECG changes are most commonly associated with HOCM?

A

RAD or LAD
Bundle branch block
PR prolongation
Non-specific T wave abnormalities

384
Q

What are the main features of von Hippel Lindau syndrome?

A

Haemangioblastomas (cerebellar, spinal and retinal)
Renal cell carcinoma
Phaeochromocytoma
Neuroendocrine tumours of the pancreas

385
Q

How does phenytoin toxicity present?

A

Cerebellar signs (nystagmus, dysdiadochokinesia, broad-based gait)

386
Q

What should you think about when someone on SSRIs develops a chronic history of abdominal pain and diarrhoea?

A

Microscopic colitis

387
Q

What is the threshold for giving steroids in PCP?

A

pO2 < 9.3 kPa

NOTE: alternative treatment options for PCP include clindamycin and primaquine

388
Q

What are the indications for giving DigiBind for digoxin toxicity?

A

Haemodynamically unstable or life-threatening rhythm
Hyperkalaemia
Evidence of end-order hypoperfusion

389
Q

What are the first-line drugs for treating diabetic neuropathy?

A

Pregabalin
Gabapentin
Duloxetine
Amitriptyline

390
Q

What are the main features of McArdle disease?

A 
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

391
Q

What lipid profile results would you expect to see in a patient with dysbetalipoproteinaemia?

A

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

392
Q

How does beta-2 microglobulin amyloidosis manifest?

A

Manifests 5 or more years after starting haemodialysis

Affects the axial skeleton and is associated with tenosynovitis, carpal tunnel syndrome and shoulder pain.

393
Q

What stimulant is best to manage symptoms of cataplexy?

A

Oxybate

394
Q

In which types of porphyria are faecal porphyrins elevated?

A

Hereditary coproporphyria
Variegate porphyria

NOTE: these two and acute intermittent porphyria present very similarly and are difficult to distinguish clinically

395
Q

How does Chediak-Higashi syndrome manifest?

A 
Oculocutaneous albinism
Bleeding diathesis
Recurrent infections 
Peripheral neuropathy
Giant granules on leukocytes
396
Q

What is alkaptonuria?

A

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

397
Q

How is hepatotoxicity or hyperammonaemic encephalopathy in sodium valproate overdose treated?

A

L-carnitine

398
Q

List some causes of Fanconi syndrome.

A 
cystinosis (most common cause in children)
Sjogren's syndrome
multiple myeloma
nephrotic syndrome
Wilson's disease
399
Q

List some absolute contraindications for thrombolysis for stroke.

A
  • 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
400
Q

Which antibodies are associated with the two different types of autoimmune hepatitis?

A

Type 1: ASMA or ANA

Type 2: Anti-LKM or anti-liver-cytosolic 1

401
Q

What is a Holmes tremor?

A

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)

402
Q

Outline the NICE guidelines for chronic plaque psoriasis.

A
  1. Potent topical steroid AND vitamin D analogue
  2. Vitamin D analogue twice daily
  3. Potent topical steroid twice daily OR coal tar preparation

Alternative: Dithranol

Specialist: Methotrexate, ciclosporin and phototherapy
Last Line: Adalimumab

403
Q

How is hepatocellular carcinoma in cirrhosis managed?

A

Liver transplantation if:

  • cirrhosis and single small HCC (< 5 cm)
  • up to three lesions < 3 cm
404
Q

What is multicentric reticulohistiocytosis?

A

Non-Langerhans cell histiocytosis with skin and joint involvement (associated with cancer in 25% of cases)

405
Q

List some causes of chronic urticaria.

A

Autoimmune diseases
Lymphoma
Drug reactions (NSAIDs, opiates)

406
Q

What is homocystinuria?

A

Autosomal recessive disorder of methionine metabolism

Tall 
Kyphoscoliosis 
Livedo reticularis 
Malar flush 
Downward lens dislocation
Young strokes
Light brittle hair
407
Q

Which CDs are usually associated with lymphoma?

A 
CD19
CD20
CD22 
CD79a
CD45
408
Q

How is Nocardia infection treated?

A

Sulphonamide (e.g. co-trimoxazole)

409
Q

How should renal tubular acidosis be treated?

A

oral sodium bicarbonate, sodium citrate or potassium citrate.

410
Q

How can hemicrania continua and paroxysmal hemicrania be distinguished from cluster headaches and SUNCT?

A

They are responsive to indomethacin

411
Q

How is paraquat poisoning treated?

A

activated charcoal and fuller’s earth

412
Q

Which conditions recur in renal transplant patients?

A

IgA nephropathy
Membranoproliferative glomerulonephritis (highest rate of recurrence)
Focal segmental glomerulosclerosis
Membranous glomerulonephritis

413
Q

What is a very sensitive marker of bone turnover that is used in Paget’s disease?

A

Serum non-isomerised C-telopeptide (CTx)

414
Q

How does thallium poisoning present?

A

Fluctuating mood (with or without confusion)
Painful distal paraesthesia
Alopecia

Rx: Oral Prussian Blue

415
Q

What is the first-line oral therapy for pyelonephritis?

A

Oral cefalexin

416
Q

Which other type of cancer is the APC gene associated with?

A

Thyroid cancer

417
Q

What should you do with regular TNF blockers in patients who are due to undergo major surgery?

A

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

418
Q

Which groups of patients benefit from lung volume reduction surgery for emphysema?

A

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

419
Q

Which group of patients with mitral regurgitation need to be referred for surgery despite being asymptomatic?

A

LVEF < 60%

420
Q

How is brucellosis treated?

A

ORAL: 6 weeks of doxycycline and rifampicin

ORAL + IV: 6 weeks of oral doxycycline + 3 weeks of IM streptomycin or IV gentamicin

421
Q

Which common drugs cause drug-induced cholestasis?

A 
Flucloxacillin
Erythromycin
Chlorpromazine
Oral contraceptives
Anabolic steroids
422
Q

How is polycythaemia vera management?

A

Aspirin and venesection aiming for PCV of < 0.45

423
Q

Which test can be done in patients with suspected growth hormone deficiency in whom an insulin-tolerance test would be inappropriate?

A

Arginine-GHRH stimulation test

424
Q

Which antibody is more likely to be positive in Crohn’s disease than ulcerative colitis?

A

Anti-Saccharomyces cerevisiae antibodies

425
Q

What can precipitate lithium toxicity?

A

dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

426
Q

What is a common side-effect of minocycline?

A

Skin pigmentation with blue/black/grey discoloration

Minocycline is a tetracycline used for rosacea

427
Q

How long after taking acitretin must you avoid getting pregnant?

A

3 years

428
Q

What is Zieve syndrome?

A

Haemolysis, severe hyperlipidaemia and cholestatic jaundice in people with heavy alcohol abuse

429
Q

Which antipsychotic is best in patients with Parkinson’s disease?

A

Quetiapine

430
Q

What are the features of McCune-Albright syndrome?

A

Precocious puberty
Cafe-au-lait pigmentation
Polyostotic fibrous dysplasia (multiple pathological fractures)
Hyperthyroidism

431
Q

What measure is good to determine whether a patient is at risk of tumour lysis syndrome before commencing chemotherapy?

A

LDH

432
Q

Which type of ureteric calculus commonly occurs in people with short bowel?

A

Oxalate

433
Q

What are the main features of a somatostatinoma?

A

Diabetes mellitus
Diarrhoea
Gallstones

434
Q

Which investigation findings support a diagnosis of Wilson’s disease?

A

reduced serum caeruloplasmin
reduced total serum copper
increased 24hr urinary copper excretion
ATP7B gene mutation

435
Q

How is paroxysmal nocturnal hemicrania treated?

A

Indomethacin

436
Q

What are the features of theophylline toxicity?

A

Hypokalaemia
Hyperglycaemia
Tachycardia
Increased myocardial contractility

437
Q

What are early and late dumping syndromes?

A

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

438
Q

What are the two main associations of pseudo-Cushing’s syndrome?

A

Alcoholism

Depression

439
Q

How is pemphigus vulgaris diagnosed?

A

Direct immunofluorescence of skin biopsy

440
Q

What are the features of myoclonic epilepsy with ragged red fibres (MERRF)?

A 
myopathy
peripheral neuropathy
ataxia
Wolff-Parkinson-White syndrome
bilateral deafness
441
Q

Which patients on bisphosphonates would be eligible for a treatment break?

A

< 75 years
Femoral neck bone mineral density > -2.5
Lack of history of fragility fracture

NOTE: repeat DEXA in 2 years

442
Q

What is multifocal motor neuropathy with conduction block?

A

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

443
Q

What is Lymphangioleiomyomatosis?

A

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

444
Q

What are the main features of Cowden syndrome?

A

Inherited cancer syndrome associated with PTEN mutation

Multiple hamartomas
Breast cancer (most common)
Endometrial cancer 
Colorectal cancer 
Thyroid cancer 
Melanoma
445
Q

Outline the guidelines on the surgical management of aortic regurgitation.

A

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

446
Q

What type of COCP should people taking carbamazepine take?

A

Any containing at least 50 micrograms of ethinyloestradiol

447
Q

What is babesiosis?

A

Tick-borne malaria-like illness caused by Babesia

Causes fever, chills, rigors and red cell destructions (leading to haemolytic anaemia and haemoglobinuria)

448
Q

How does chancroid manifest?

A

Single PAINFUL genital ulcer with painful inguinal lymphadenopathy

Caused by H. ducreyi and treated with macrolides or quinolones

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