Oxford questions Flashcards
1
Q
Wells Score
A
If <2, perform a D-dimer test – if negative, DVT is excluded. Consider alternative diagnoses.
If ≥2, or if the D-dimer is positive, proceed to Doppler and compression ultrasound examination of the venous system.
2
Q
Which patients with a DVT should undergo investigations for an underlying cause
A
Those aged >55yrs with unprovoked DVT, and those with recurrent unprovoked DVT or DVT at an unusual site
3
Q
Ann Arbor classification
A
The Ann Arbor classification is used for lymphoma staging, based on distribution of diseased tissue:
Stage I involves only one lymph node area
II involves 2 or more on one side of the diaphragm
III involves 2 or more on both sides of the diaphragm
IV involves any extra-lymphatic tissue (including bone marrow)
The presence of ‘B symptoms’ is denoted by adding B as a suffix
4
Q
Classic complications of CLL
A
Autoimmune haemolytic anaemia
Hypogammaglobulinaemia
5
Q
Two groups of patients diagnosed with Myasthenia Gravis
A
Young women (20-35)
Tend to present with a generalised, and often acute condition
Older men (60-75)
Who tend to present with prominent oculobulbar involvement
6
Q
Classic presentation of Myasthenia Gravis
A
Patients usually present with fatigueable weakness
Progressively weakness over the course of the day is classic. The weakness improves with rest
Ocular and bulbar involvement is also possible, leading to ptosis, swallowing difficulties and speech disturbance
7
Q
Most common antibodies in Myasthenia Gravis
A
Anti-AChR antibodies
Anti-MUSK antibodies
8
Q
Most important investigation for Myasthenia Gravis
A
Forced vital capacity (FVC) is the key initial investigation in first presentation or flare
If this is low (<1.5l) then make sure ITU are at least aware of the patient, as they can rapidly deteriorate and require intubation and ventilation
Measure this at least 4-hourly in patients with acute/relapsed MG at presentation
9
Q
Genetic disorders associated with colorectal cancer
A
Hereditary non-polyposis colorectal cancer (HNPCC)
Autosomal dominant, due to mutations in various mismatch repair genes and responsible for 3% of colorectal cancers
Familial adenomatous polyposis (FAP)
Autosomal dominant defect in APC gene
MUTYH-associated polyposis
An autosomal recessive condition which may cause polyposis and confers increased colorectal cancer risk
10
Q
How does Hep B present
A
Hep B often presents with a subclinical or flu-like illness but can present with:
Acute hepatitis
Hepatomegaly
Jaundice (only 30-50%)
Dark urine/pale stools due to intrahepatic cholestasis
Serum-sickness-like syndrome
Rash, polyarthritis, fever
Rarely, arteritis or immune-complex-mediated renal failure
Chronic liver disease
11
Q
Hep B medication
A
Pegylated interferon
Good:
No resistance
Finite duration of therapy
Bad:
Less well tolerated due to side-effect profile
Only moderate antiviral activity
Nucleoside (Lamivudine, Entecavir) and Nucleotide (Tenofovir) analogues
Good:
Potent antiviral effects
Few side-effects
Bad:
Risk of resistance to some drugs
12
Q
Where in the spinal column does the spinal cord end?
A
L1
13
Q
For a spinal cord compression why is an MRI of only the spinal cord inadequate
A
Clinical signs are poor at localising the site of the lesion
Metastases are present at more than one site in the spinal canal in 33% of patients with malignant cord compression
Surgical fixation requires good bone texture either side of a lesion, so this area must be imaged too
14
Q
Most malignant causes of spinal cord compression
A
Lung cancer (25%)
Prostate cancer (16%)
Myeloma (11%)
Non-Hodgkin lymphoma (8%)
Breast cancer (7%)
15
Q
Key features to address in a dementia history?
A
Try to establish:
Patient’s (and collateral) view of memory decline
Biographical history
Objective view of memory decline (e.g. knowledge of current affairs)
Impact of memory decline on day-to-day living and hobbies
Social history, including safety and driving
General medical history (especially medications)
16
Q
Micro and Macro pathological of UC
A
Macro:
Inflammation extends proximally from the rectum
Hence inflammation can be classified as proctitis (limited to rectum), left-sided colitis (extending to sigmoid and descending colon), or pan-colitis (when entire colon involved)
Mucosa is reddened, inflamed, and bleeds easily.
Extensive ulceration, with islands of normal mucosa
Micro:
Superficial inflammation of mucosa (cf. Crohn’s, which is full-thickness)
Chronic inflammatory cell infiltrate in lamina propria (part of mucosa just under epithelium)
Crypt abcesses
Goblet (mucus-making) cell depletion
17
Q
How to classify acute presentation of UC
A
Truelove and Witts’ criteria
18
Q
Extra intestinal manifestations of UC
A
Mouth ulcers (strictly part of the GI tract but often considered separately)
Erythema nodosum
Uveitis/episcleritis
Arthropathy
Pyoderma granulosum
Primary sclerosing cholangitis (75% of this is seen in ulcerative colitis patients)
19
Q
UC complications
A
Acute
Toxic megacolon
Mortality approx. 20%
Primary sclerosing cholangitis
Colorectal carcinoma
Risk increased 10-20 times once patients have had UC for 20 years
5-asa treatment probably reduces risk
Do colonoscopy starting at 10 years
Mucosal dysplasia on rectal biopsy is associated with cancer elsewhere in the bowel.
Then repeat at 1,3,or 5-year intervals depending on risk
Pouchitis after colectomy (with relapsing-remitting course)
Osteoporosis from steroid therapy
Bisphosphonates to over 65s on steroids and DEXA
Then bisphosphonates if T<1.5
20
Q
How does Crohn’s disease present with
A
21
Q
Extra intestinal manifestations of Crohn’s
A
22
Q
Micro/Macro for Crohn’s
A
23
Q
Crohn’s complications
A
24
Q
What’s the differential diagnosis of heart murmurs?
A
25
What are the abnormalities of the heart sounds?
26
What are the different murmur types and clinical findings in different valve lesions?
27
Causes of clubbing
28
Blood test to examine synthetic liver function
The best test of synthetic liver function are PT (prothrombin time [or INR, which is derived from PT]), platelets and albumin
29
Complications of Chronic liver disease
Variceal bleeding
Ascites
Spontaneous bacterial peritonitis
Encephalopathy
Hepatorenal syndrome
HCC
30
Giant Cell Arteritis presentation
31
Staging AKI
Stage 1: Cr ≥1.5-2 times baseline or urine output (UO) <0.5 ml/kg/hours for >6 consecutive hours
Stage 2: Cr ≥2-3 times baseline or UO <0.5 ml/kg/hours for >12 hours
Stage 3: Cr ≥3 times baseline or UO <0.3 ml/kg/h for ≥24 hours or anuria for >12 hours
32
4 types of nephrotoxic drugs you would stop
ACEIs
ARBs
NSAIDs
Aminoglycosides e.g. gentamicin
33
34
How can urine and plasma osmolality and sodium help in the determinig cause of AKI
Pre-renal AKI: kidney is functioning maximally to retain salt and water; urinary osmolality is high (600-900 mosm/L) and urinary sodium is low (<10 mM)
ATN: kidney is functioning inadequately and is unable to retain salt and water; urinary osmolality approaches that of plasma(280 mosm/L) and urinary sodium rises (>30 mM)
35
Complications of AKI
Hyperkalaemia
Hypo/hypernatraemia
Hypercalcaemia
Metabolic acidosis
Pulmonary oedema
Hypertension
Uraemic encephalopathy
Uraemic pericarditis
36
Micropathology of COPD
Hypertrophy and hyperplasia of mucus-secreting goblet cells of bronchial tree
Fibrosis and thickening of bronchial walls
Lymphocytic infiltrate
Emphysema – Dilatation and destruction of lung tissue distal to terminal bronchiole leading to reduced elasticity and gas exchange surface
37
3 main causes of syncope
Reflex/neural
Orthostatic hypotension
Cardiac
38
Define syncope and seizure
Syncope: transient loss of consciousness due to global cerebral hypoperfusion caused by hypotension secondary to a fall in cardiac output (CO) or systemic vascular resistance (SVR)
Seizure: episode of abnormal electrical activity in the brain
39
Reynold's pentad
Primary Sclerosing Cholangitis
Charcot’s triad
PLUS
Septic shock
Confusion
40
Stages of hyperkalaemia
Mild: 5.5-6.0 mM
Moderate: 6.1-6.9 mM
Severe: ≥7.0 mM
41
Causes of hyperkalaemia
Excess intake
Release from intracellular fluid (ICF)
Inadequate excretion
Pseudohyperkalaemia: laboratory artefact typically caused by haemolysis during venepuncture
42
Medications you would give immediately for hyperkalaemia
Calcium chloride or gluconate 10 ml of 10% by slow IV injection
Salbutamol 5 mg nebuliser
Insulin-dextrose infusion: 10 units of actrapid in 50 ml of 50% dextrose over 30 minutes
43
Cushing's triad
Head Injuries
Hypertension
Bradycardia
Irregular respirations
As ICP rises, MAP rises to maintain CPP; excessive MAP may cause a reflex bradycardia.
44
Define AKI, oilguria, anuria
AKI: sudden deterioration in renal function leading to an inability to maintain fluid, electrolyte and acid-base balance
Oligura: reduced urine output; defined variously as <0.5 ml/kg/hour, <30 ml/hour or <400 ml/day
Anuria: complete absence of urine output
45
Upper/lower causes of fibrosis
46
Organisms most commonly associated with bronchiectasis
Staph aureus
Haemophilus influenza
Pseudomonas
Rarer:
Pneumococcus
Klebsiella
47
Yellow Nail Syndrome
Bronchiectasis + yellow nails + lymphoedema
48
Appearence of Primary Sclerosing cholangitis on ERCP
Onion skin
49
4 characteristic features of asthma
Cough
Dyspnoea
Wheeze
Chest tightness
50
Features that categorise moderate asthma attack
Worsening symptoms
No features of acute severe asthma
PEFR >50% of best/predicted
51
Acute severe asthma attack
Inability to complete sentences in a single breath
PEFR <50% of best/predicted
RR >/= 25
HR >/= 110
52
life threatening asthma
Poor respiratory effort
Cyanosis
Silent chest
Hypotension
Arrhythmia
Exhaustion
Reduced conscious level
PEFR <33% of best/predicted
SpO2 <92%
PaO2 <8 kPa
Normal PaCO2 = 4.6-6.0 kPa
53
Intial treatment for acute asthma
Sit upright.
Salbutamol 5 mg and ipratropium bromide 0.5 mg via oxygen-driven nebuliser
54
Hallmark autoantibody for primary biliary cirrhosis
Antimitochondrial M2 Ab
55
Signs and symptoms of anaphyalxis
Acute onset
Airway and breathing
Dyspnoea, respiratory distress, wheeze, stridor
Cyanosis
Circulation
Tachycardia, hypotension
Skin
Urticaria, angioedema
56
Skin changes in anaphylaxis
Urticaria and/or angioedema (systemic, usually more notable around the face) occurs in 80%
57
Pathophysiology of anaphylatic shock
58
Doses of adrenaline given
59
Anaphylaxis retrospective diagnosis
Measure mast cell tryptase within 6 hours of an anaphylactic reaction.
60
Chlorphenamine (piriton) 10mg IM or IV
Hydrocortisone 200mg IM or IV
61
A previously well 72-year-old man is brought to the emergency department by ambulance after suffering a seizure. He denies any head injury or history of epilepsy. A collateral history from his partner reveals a 7-day history of forgetfulness, with a new and progressively worsening headache. On examination, he is disoriented to time and place and has a temperature of 39.1oC,
What initial antimicrobial treatment would be most appropriate to commence?
Ceftriaxone
Amoxicillin
Aciclovir
62
A 30 year old man goes to see his General Practitioner because of erectile
dysfunction.
Which artery plays an important role in erectile function?
A) Iliolumbar artery
B) Inferior gluteal artery
C) Internal pudendal artery
D) Obturator artery
E) Superior vesical artery
C
63
Question 20
The wife of a right-handed 28 year old man with a three-year history of seizures has
managed to record a typical seizure on video. During the seizure, his eyes and head
initially turn to the left, the left arm extends before the whole body stiffens, goes rigid
and then begins to shake vigorously. The shaking subsides gradually over one
minute.
In which part of the brain is this seizure likely to have started?
A) Left frontal lobe
B) Left mesial temporal lobe
C) Right frontal lobe
D) Right mesial temporal lobe
E) Right parietal lobe
C
64
An 80 year old man mentions some exertional breathlessness whilst consulting his
General Practitioner for another complaint. The GP hears an ejection systolic
murmur that radiates to the neck but notes that mild aortic valve stenosis has been
recorded previously. The GP is not sure whether the patient’s valvular heart disease
has progressed sufficiently to potentially account for the new complaint of
breathlessness.
Which feature of the clinical examination would suggest that the aortic stenosis is
now severe?
A) A collapsing pulse
B) A loud murmur with a palpable thrill over the carotid pulse
C) A small volume and slow rising pulse
D) An accentuated aortic component of the second heart sound
E) Radiation of the murmur through to the back
C) A small volume and slow rising pulse
65
A 66 year old man is referred to the cardiology clinic with episodic chest pain. He
describes the pain as a tightness across the chest, precipitated by exertion. The
chest tightness is associated with shortness of breath and dizziness but the patient
denies having collapsed or lost consciousness. Examination reveals a blood
pressure of 100/80 mmHg and a loud ejection systolic murmur. His second heart
sound is soft. The cardiologist suspects a diagnosis of aortic stenosis.
Which is the most appropriate diagnostic investigation to undertake?
A) Chest X-ray
B) ECG
C) Echocardiogram
D) Exercise tolerance test
E) Myocardial perfusion scan
C
66
A 38 year old woman with known Crohn’s disease is admitted with back pain.
Which one of the following is the commonest dermatological manifestation of
inflammatory bowel disease?
A) Erythema nodosum
B) Oral aphthous stomatitis
C) Psoriasis
D) Pyoderma gangrenosum
E) Sweet syndrome
A
67
A 40 year old man is admitted with jaundice. Urine analysis shows no evidence of
bilirubin in the urine.
Which is the most likely cause of this man’s jaundice?
A) Acquired haemolytic anaemia
B) Common bile duct stone
C) Hepatocellular carcinoma
D) Pancreatic cancer
E) Viral hepatitis
A) Acquired haemolytic anaemia
68
What does Primary hyperaldosteronism present with
Hypernatraemia
Hypokalaemia
69
An 18 year old man presents with headache, double vision, drowsiness, polydipsia
and polyuria. He is taking no medication and his bloods show him to have a low FT4,
very low 0900h cortisol levels and positive pregnancy test.
Which is the most likely diagnosis?
A) Diabetes mellitus with ketoacidosis
B) Germinoma
C) Pituitary adenoma
D) Testicular seminoma
E) Transgender
B) Germinoma
70
Cause of syncope
Dilatation of venous capacitance vessels
71
Reveresal of warfarin
IV Prothrombin Complex Concentrate and IV vitamin K
72
A 32 year old woman is being treated for sepsis and disseminated intra-vascular
coagulation (DIC). She has a low fibrinogen level.
Which would be the most appropriate blood product to give in this setting?
A) Cryoprecipitate
73
B12 on film
oval macrocytes and
hypersegmented neutrophils.
74
Frameworks for autonomy
A) Deontology
C) Seedhouse’s Ethical Grid
D) The Four Principles
E) The Four Quadrants
75
ipratropium bromide
Is a muscarinic acetylcholine receptor antagonist that acts as a bronchodilator
76
important role in COPD
pathogenesis
Neutrophil proteases
77
A 35 year old woman with a diagnosis of systemic lupus erythematosus (SLE) is
admitted with a flare of her disease.
Which result is in keeping with active SLE?
Low complement C3 & C4
78
patient Sjogrens, most liekely cancer?
Cancer
79
The pathogenesis of cholera in the small intestine results from
C) A toxin that deregulates ion transport in epithelial cells
80
positive 1,3 beta-D-glucan assay
Aspergillus fumigatus and Candida albicans and Pneumocystis jirovecii
81
Briefly explain what diurnal variation is with regards to asthma.
Peak expiratory flow rate (PEFR) and shortness of breath is worse at night and early morning.
82
What is Strep pneumoniae
Streptococcus pneumoniae is a gram-positive, α-hemolytic, lancet-shaped diplococcus
83
Miss X. has now developed a widespread rash across both arms and feels very clammy
. Name the complication she has developed. What is the key feature of the rash?
Meningococcal SEPTICAEMIA
Non-blanching rash
84
What would see with benign prostate hyperplasia
Smooth Enlarged Prostate
85
Symtpoms of UTI
Dysuria
* Frequency
* Urgency
* Cloudy urine
* Haematuria
* Nocturia
* Suprapubic tenderness
86
DEXA scan in full
. Dual X-ray absorptiometry (DEXA) scan
87
Allopurinol mechanism
Allopurinol reduces the production of uric acid (1) by inhibiting the enzyme
xanthine oxidase
88
Total iron binding capacity =
Affinity of iron to bind to protein (transferrin)
89
Part most commonly affected in coeliac
Jejunum
90
Risk Factors for coeliac
Family history of coeliac disease
* Immunoglobulin A deficiency
* Type 1 diabetes
* Autoimmune thyroid disease
* Down’s syndrome
91
Which of the following findings on clinical examination of the left lung would be most consistent with a left-sided pneumothorax?
D) Hyper-resonant percussion note, decreased vocal resonance, reduced expansion
92
A 33 year old lady sees her GP with advice for trying for a baby. She is worried as she is a very fussy eater and worried she will not be able to provide the foetus with enough vitamins to grow. Her sister’s child had spina bifida. You do some blood tests to reassure her and find out she is deficient in folate, B12 and vitamin D. What order do you correct this in?
B12, folate, vitamin D
93
Prevention of UC
= INFLIXIMAB or
AZATHIOPRINE
94
What does pancreatic cancer present with
Normal unconjugated bilirubin, raised conjugated bilirubin, low urine urobilinogen
95
Lhermitte’s sign
electric shock-like sensation that occurs on
flexion of the neck
96
Uhthoff phenomenon
refers to a transient worsening
of neurological symptoms related to a demyelinating disorder such as
multiple sclerosis when the body becomes overheated in hot weather,
exercise, fever, saunas, or hot tubs
97
dormant malaria spore?
Hypnozoites
98
What is meant by a cohort study?
A type of epidemiological study in which a group of people with a common characteristic is followed over time to find how many reach a certain health outcome of interest
99
Define Incidence
B. Number of new cases of disease in a population over a specified period of time
100
A nurse conducting cervical smear tests is interested in finding out how many people who test negative for HPV who truly are negative. What stat is she interested in?
Negative predictive value
101
Some researchers set out to examine the hypothesis that depression causes binge eating disorder. However, they come under criticism because of concerns about the temporal sequence of events. What term are the critiques referring to?
Reverse causality
102
Lamotrigine side effect
Large blistering rash throughout the body
103
Huntington’s disease show on an MRI
MRI shows atrophy of the caudate nucleus and putamen
104
How do you diagnose diabetes
Random glucose test
Can be fasting or not
Glycated haemoglobin is only used for monitoring glucose
105
A 28-year-old woman has noticed a change in her appearance; most notably her
clothes do not fit properly and are especially tight around the waist. Her face
appears flushed and more rounded than usual, despite exercising regularly and
eating healthily her weight has steadily increased over the last 3 weeks. On visiting
her GP, he notices her blood pressure has increased since her last visit and she has
bruises on her arm. She is especially worried about a brain tumour. The most
appropriate investigation would be:
A. Low-dose dexamethasone test
B. High-dose dexamethasone test
C. Urinary catecholamines
D. Computed tomography (CT) scan
E. Urinary free cortisol measurement
E. Urinary free cortisol measurement
106
A 16-year-old girl presents to her GP complaining of a swelling in her neck which
she has noticed in the last 2 weeks. She has felt more irritable although this is often
transient. On examination, a diffuse swelling is palpated with no bruit on
auscultation. The most likely diagnosis is:
A. Hyperthyroidism
B. Simple goitre
C. Riedel’s thyroiditis
D. Thyroid carcinoma
E. Thyroid cyst
B A simple goitre (B) is an idiopathic enlargement of the thyroid. Often the
condition is associated with thyroid antibodies, but these do not cause any
symptoms. Riedel’s thyroiditis
(C) is a rare inflammatory disease of the thyroid gland that is characterized by fibrosis of the thyroid gland and other structures in the neck. It is often stony or woody on palpation and patients are usually asymptomatic. The patient does not have any features of hyperthyroidism (A)
in which a thyroid bruit can be present. A thyroid cyst or nodule (E) is usually
harmless and is a fluid-filled swelling often presenting as a single compressible
small lump rather than a diffuse swelling. A full history and examination
should always be conducted with ultrasound and fine needle examination to
exclude malignancy. Thyroid cancer (D) is a rare but important diagnosis,
they often present as irregular thyroid nodules but can metastasize to the
lung, brain, liver and bone. Papillary and follicular cancers usually have good
prognoses compared to medullary and anaplastic cancers
107
A 39-year-old man presents with a three-month history of depression. The patient
recently lost a family member and around the same period began to feel unwell
with constipation and a depressed mood. He has started taking analgesia for a
sharp pain in his right lower back that often radiates towards his front. The most
appropriate investigation is:
A. Serum parathyroid hormone
B. Serum thyroid stimulating hormone
C. Colonoscopy
D. Fasting serum calcium
E. MRI scan
D. Fasting serum calcium
108
The answer is B
Although you may suspect that it's Hyperaldosteronism and therefore but D as the answer you need to exclude primary hypertension and therefore t=need to take a 24-hour ambulatory bp
109
A 29-year-old woman is referred to a diabetic clinic for poor diabetes management.
She was diagnosed with type 1 diabetes at the age of 12 and prescribed actrapid
insulin injections. Recently, the patient has been suffering fluctuations in her
plasma glucose levels and her previously well-controlled glycated haemoglobin has
risen to 8.1 per cent. The patient admits she has recently been avoiding using her
injections. On examination, the patient has a raised, smooth lump that is firm on
palpation at the lower abdomen. The most likely diagnosis is:
A. Worsening of diabetes
B. Lipohypertrophy
C. Injection scarring
D. Lipoma
E. Injection abscess
B Management of diabetes care should always involve explaining the risks
of treatment, especially in young children who are using insulin injections.
Shallow injections should be avoided as they are painful and can lead to
scarring (C). Allergic responses may occasionally occur, but are usually
mild and resolve spontaneously. Importantly, patients should be encouraged
to alternate injection sites between the thighs, abdomen and shoulder to
Answers 147
prevent build up of adipose tissue creating smooth, firm lumps known as
lipohypertrophy (B). This is not dissimilar to a lipoma (D) which are benign
masses consisting of fatty tissue enclosed by a fibrous capsule. They are
usually mobile, painless and soft on palpation. Worsening diabetes (A)
does not cause lipohypertrophy, but would likely worsen symptoms of
diabetes such as weight loss and osmotic diuresis. Patients also increase
their risk of diabetic complications such as retinopathy, neuropathy and
nephropathy. An injection abscess (E) can occur in any situation where
needles are being used in poor sanitary conditions; the presentation,
however, is usually of a pus-filled cavity that is painful and erythematous.
110
A 7-year-old girl presents with red striae which her mother noticed around her
abdomen. The girl also has plethoric cheeks and, on her back, several faint, irregular
brown macules are observed. The mother is particularly concerned about the early
breast development that seems apparent on her daughter. Serum phosphate is
decreased. The most likely diagnosis is:
A. Paget’s disease of the bone
B. McCune–Albright syndrome
C. Cushing’s disease
D. Hypopituitarism
E. Neurofibromatosis
McCune–Albright syndrome (B) is a genetic disorder that causes the
uncontrolled secretion of a number of endocrine glands causing
abnormalities of the skin, bones and hormonal disturbances. It is usually
suspected when the following pathologies occur: precocious puberty,
cushingoid features, hyperpituitarism (acromegaly, gigantism), café-au-lait
spots and hypophasphataemia.
111
An 18-year-old man presents to clinic worried about his scant pubic hair
development. Examination reveals undescended testes and plasma testosterone,
luteinizing hormone and follicle stimulating hormone were found to be low. A
karytotype test was 46, XY. The patient was otherwise well, but during neurological
examination struggled during the olfactory test. The most likely diagnosis is:
A. Hypogonadotropic hypogonadism
B. Klinefelter’s disease
C. Androgen insensitivity syndrome
D. 5-alpha reductase deficiency
E. Kallman’s syndrome
E. Kallman’s syndrome
Kallman
syndrome (E) is differentiated from idiopathic hypogonadotropic
hypogonadism (A) by the additional abnormality of hypo-anosmia.
112
A 45-year-old Asian man is diagnosed with Cushing’s disease in India. He undergoes
a bilateral adrenalectomy and recovers well from the operation. On his return to the
UK one year later, he complains of a constant dull headache, peripheral visual
disturbances and increasing pigmentation of the skin creases of both hands. The
most likely diagnosis is:
A. Ectopic ACTH secreting tumour
B. Prolactinoma
C. Nelson syndrome
D. Addison’s disease
E. Side effects from iatrogenic steroid intake
Nelson syndrome (C) occurs in patients who undergo bilateral
adrenalectomies, the loss of negative feedback over time causes a
macroadenoma to form in the pituitary which secretes adrenocorticotropin
(ACTH)
113
Why is gylcated HB used for diabetes
Glycated haemoglobin (D) reflects the level of blood glucose due to glucose
attachment to red blood cells non-enzymatically
114
115
What is a major complication of anti-phospholipid syndrome?
Pulonary embolism
116
Antibody for drug induced SLE
Anti-histone antibody
117
What is Stills disease?
systemic juvenile idiopathic arthritis and is characterized by swinging
pyrexia, rash and arthritis. Juvenile idiopathic arthritis is the most common
form of persistent arthritis in those under 16 years of age.
118
A 60-year-old man presents with abdominal pain and a cupful of haematemesis.
On examination he is noted to have ascites, hepatomegaly and a very enlarged
spleen extending to the right iliac fossa. His initial blood tests reveal a
leukoerythroblastic picture with a haemoglobin of 8, white cell count (WCC) of 3
and platelets of 120. A diagnosis of myelofibrosis is made. What is most likely to
be seen on the peripheral blood smear?
A. Schistocytosis
B. Sickle cells
C. Spherocytes
D. Dacrocytes
E. Target cells
D. Dacrocytes
119
thrombotic thrombocytopenic purpura is
the pentad of
fever, thrombocytopenia, microangiopathic haemolytic
anaemia, renal failure and neurological symptoms.
120
An 18-year-old African man presents with worries about his general health stating
that hypertension and sickle cell anaemia are present in his family history. The patient
denies any shortness of breath, chest pain, digit or limb changes. Blood pressure is
124/77 mmHg. What test would be appropriate to investigate sickle cell anaemia?
A. Ham’s test
B. Coombs’ test
C. Schilling test
D. Metabisulfite test
E. Osmotic fragility test
Ham’s test (A) is used to diagnose paroxysmal nocturnal
haemoglobinuria.
The Schilling test (C) is used to investigate vitamin B12 deficiency.
The Coomb’s test (direct) (B) is used to investigate causes of autoimmune haemolytic anaemia.
The osmotic fragility test (E) is used to
investigate hereditary spherocytosis.
121
A young patient presents with features of anaemia, neutropenia and
thrombocytopenia. A large number of blasts are present on bone marrow biopsy.
Which investigation would help differentiate between acute myeloid leukaemia
(AML) and acute lymphoblastic leukaemia (ALL)?
A. Myeloperoxidase stain
B. Sudan black B
C. Tartrate-resistant acid phosphatase stain
D. Leukocyte alkaline phosphatase
E. Auramine O stain
A
122
Polycythaemia rubra vera
Low erythropoietin and raised red cell mass
123
A 23-year-old man is stabbed in the neck. Once stabilized, his MRI shows a right
hemisection of the cord at C6. What is the expected result of this injury?
A. Paralysed diaphragm
B. Absent sensation to temperature in the left hand
C. Paralysis of the left hand
D. Absent sensation to light touch in the left hand
E. Brisk right biceps reflex
B. Absent sensation to temperature in the left hand
124
A 17-year-old girl is brought into accident and emergency with generalized tonicclonic seizure. Her mother had found her fitting in her bedroom about 20 minutes
ago. The ambulance crew handover state that her sats are 96 per cent on 15 L of
oxygen and they have given her two doses of rectal diazepam but she has not
stopped fitting. What is the most appropriate management?
A. Lorazepam
B. Phenobarbital
C. Intubation
D. Call ITU
E. Phenytoin loading
E Status epilepticus is a serious condition of continuous seizure activity
lasting more than 30 minutes. The mortality rate is one in five. This girl
has been fitting for at least 20 minutes despite two doses of diazepam so
must urgently be loaded with phenytoin (E) and monitored closely. ITU (D)
should be alerted in case phenytoin does not stop the seizure in which case
phenobarbital (B) can be considered, but the phenytoin should be given
first. Ultimately, general anaesthetic and intubation (C) may be required.
There is increasing evidence that lorazepam (A) is more effective than
diazepam, but in this case the patient has already had two doses of
benzodiazipine so the next step is phenytoin infusion.
125
Dermatomes
126
A neurologist is examining a patient. She takes the patient's middle finger and flicks
the distal phalanx, her thumb contracts in response. What sign has been elicited?
A. Chvostek’s
B. Glabellar
C. Hoffman’s
D. Tinel’s
E. Babinksi’s
C The neurologist has elicited a positive Hoffman’s reflex (C) suggestive of
upper motor neurone disease. It would have been negative if the thumb
had not contracted in response to flicking the patient’s distal phalanx.
Chvostek’s sign (A) is contraction of the face on stimulation of the facial
nerve over the masseter. This is seen in hypocalcaemia. The glabellar tap
(B) is an insensitive test for parkinsonism where the doctor taps above the
bridge of the nose and the patient continues to blink. A normal response
is to desensitize to the stimulus and stop blinking. Tinel’s sign (D) can be
elicited by tapping a nerve such as the ulnar nerve at the elbow, resulting
in a tingling sensation in the distribution of the nerve. This is a sign of nerve compression. It is also useful in carpal tunnel syndrome by tapping
over the median nerve at the wrist. Babinski’s reflex (E) is extension and
outward fanning of the toes in response to a firm stimulus of the outer
soles. It is suggestive of upper motor neurone disease.
127
A 36-year-old woman presents to clinic with neurological symptoms. On
examination, she is able to stand with her feet together. Upon closing her eyes,
however, she is unable to keep her balance. What is the diagnosis?
A. Diabetes
B. Cerebellar problem
C. Alcohol abuse
D. Proprioceptive problem
E. Visual problem
D
The test performed is Romberg’s test.
128
What two medications are licensed for the treatment of IPF to prolong life (but not cure it)? State the mechanism of action for both.
● Pirfenidone - TGFβ Inhibitor; reduces fibroblast activity
● Nintedanib – monoclonal antibody against tyrosine kinase; interferes with fibroblast proliferation, migration and differentiation
129
Hypocalcaemia signs
CATS go numb:
● C - convulsions
● A - Arrhythmias
● T - Tetany (intermittent involuntary muscle contractions)
● S - spasms
● Numb - numbness
130
Action of aldosterone
Stimulates Na+/K+ pump (1 mark) - so increases sodium reabsorption into the blood and increase potassium secretion into the urine
131
marker of Addison’s
Anti 21 hydroxylase
132
Medication for diabetes
133
Antibiotics
134
How to diagnose malaria
Thick and thin blood films
135
Test for infectious mononucleosis
Paul Bunnell test
136
Diif between Primary and Post-primary TB
Primary is asymptpomatic
Pst primary presets with fever night sweats and weight loss
137
Treatment for C.difficile toxin
Oral metronidazole
138
Primary syphilis is treated with
procaine
penicillin
139
A 42-year-old man presents to accident and emergency with a 3-week history of
retrosternal discomfort after swallowing. He mentions that he has been unable to
keep any food down at all. He has been HIV positive for ten years. He is admitted
and endoscopy shows areas of ulceration throughout the oesophagus. What is the
most likely causative organism?
A. Staphylococcus aureus
B. Crytosporidium parvus
C. Candida albicans
D. Pneumocystis jiroveci
E. Cryptococcus neoformans
C. Candida albicans
Candida albicans (C) is a fungal infection that may colonize the oesophagus
of patients with HIV, causing dysphagia and retrosternal discomfort. It is
treated with fluconazole or ketoconazole
140
A 42-year-old man presents to his GP with ‘blotches’ over his legs. He has been HIV
positive for ten years. On examination, there are multiple purple and brown papules
over his legs and his gums. A diagnosis of Kaposi’s sarcoma is suspected. What is
the most likely causative organism?
A. Herpes simplex virus type 1
B. Herpes simplex virus type 2
C. Human herpes virus type 3
D. Human herpes virus type 8
E. Pneumocystis jiroveci
D. Human herpes virus type 8
141
A 30-year-old man is brought to accident and emergency by his wife in a confused
state. After an argument at home, the wife had left the patient and on returning
found him unconscious. She suspects he may have made a suicide attempt but had
not thought to look for any pills or bottles close to the patient. While waiting to be
seen, the patient suffers a seizure. On recovery, an examination shows the patient’s
temperature is 39°C, pulse is irregular, respiratory rate is 20 and the patient’s pupils
are dilated. An ECG recording reveals tachycardia and widened QRS complexes,
while a blood gas is normal. The most likely substance ingested is:
A. Carbamazepine
B. Gabapentin
C. Aspirin
D. Sodium valproate
E. Amitryptiline
E. Amitryptiline
This patient has most likely ingested excess tricyclic antidepressants such
as amitryptiline (E). Toxicity results in elevated anticholinergic effects such
as pupil dilation, skin flushing, seizures, hypotension and muscle twitching.
Cardiac complications typically include prolonged QRS complexes and
tachyarrhythmia. Aspirin (C) breaks down into salicylic acid by the action
of hydrolases, mostly by the liver. In an overdose, elevated plasma salicylate
levels cause several systemic effects: most importantly, renal impairment
causing a metabolic acidosis, while respiratory centres are stimulated
causing hyperventilation. Carbamazepine (A) is an anticonvulsant and in
overdose can cause a dry mouth, convulsions, opthalmopathy, pupil
dilation and hallucinations. Muscle twitching is not a usual feature.
Gabapentin (B) is a GABA agonist, and in excess causes malaise, slurring
of speech and gastrointestinal abnormalities. Sodium valproate (D) is often
characterized in excess by drowsiness, respiratory depression and seizures.
The patient’s respiratory movements have not been affected.
142
Causes of haemopytosis
Pulmonary tuberculosis (A), Bronchiectasis (B), Aspergilloma (C) and
Wegener’s granulomatosis (D) cause haemoptysis. Other causes include:
* bronchogenic carcinoma;
* pulmonary abscess;
* farmer’s lung;
* pulmonary embolus;
* Goodpasture’s syndrome.
143
You are told that a patient has been admitted to accident and emergency with
jaundice and right upper quadrant pain. What levels of plasma bilirubin would this
patient have in order for jaundice to be clinically visible:
A. >30µmol/L
B. >25µmol/L
C. >35µmol/L
D. >15µmol/L
E. >20µmol/L
C
144
Mechanism of aspirin
It irreversibly inhibits the Cox enzyme, preventing arachidonic acid from being
broken down into prostaglandin H2
145
What is a like to renal cell carcinoma
Von Hippel Lindau
146
1)
A 64 year old gentleman who works as a customer service advisor presents to his
GP with a week history of left eyelid drooping and sharp left shoulder pain. Aside
from asthma, for which he is prescribed salbutamol and beclomethasone inhalers, he
is usually fit and healthy. He has smoked 15 cigarettes a day since he was a
teenager and drinks approximately 6 units of alcohol per week. On questioning from
the GP, the man also recounts a 3 month history of worsening cough and dyspnoea
(which he had previously put down to his asthma) as well as anorexia and noticeable
weight loss. On examination, there is drooping of his left eyelid and his left pupil
appears constricted.
Given the most likely diagnosis, where is the location of the pathology?
A) Left lung, apex
B) Left lung, lower lobe
C) Left bronchus
D) Right lung, apex
E) Right lung, middle lobe
A!!!!
147
What type of reaction is hypersesntibity pneumonitics
3
148
Malignant vs benign cancer
149
Necrosis vs apoptosis
150
Neutrophil action in acute inflammation
Margination
Adhesion
Emigration
Diapedesis
Chemotaxis
151
Metastasis
1. Detachment
2. Invasion of other tissue
3. Invasion of BV
4. Evasion of host defence, adherence to BV wall
5. Extravasation to distant site
152
Unlicesed medication for venous ulcer
Pentoxifylline
153
How to distinguihs between direct and indirect hernia
Indirect remans reduced with pressure at the deep ring
154
Durgs used for Interstital cystits or bladde rpain syndroe
Solifenacin: Antivholinergic
Mirebegron: Beta 3 receptor agonist
Cimitedine: Histamine 2 receptor antagonist
155
Regarding Leriche syndrome
Area of occlusion:
Features
Distal aorta/proximal common iliac artery
Thigh/buttock claudication
Absent femoral pulses
Male impotence
156
Medications for persisting sciatica
Amitryptyline
Duloxetine
157
Surgical options for voluls
Sigmoid: Hartmann's procedure
Caecal: Ileocaecal resection
right hemicolectomy
158
mechanism of β-lactam antibiotics
Inhibits transpeptidation reactions needed to cross-link peptidoglycans in the cell
wall
159
Hypokalaemia ECG findings
Flat T-wave, prolonged QT interval, ST depression
