Part 2 Flashcards

Question 1

Q

Membranous Glomerulonephritis / Nephropathy Pathophysiology / Causes

Answer

A

Primary or Secondary
Immune complexes at basement membrane causing thickening and spiking

This causes Protein leak, hypoalb, oedema and hyperlipid (Nephrotic Syndrome)

Primary: Anti PLA2R Antibodies
Secondary: Infection (hep B, Malaria, Syphilis)
MALIGNANCY: Lung and Lymphoma
Autoimmune, SLE / Rheumatoid

Question 2

Q

Lung Ca that causes paraneoplastic syndromes? Which syndromes?

Answer

A

Small Cell Lung Ca (Central, advanced, smoking)

ACTH secreting -> Cushings Syndrome (hypokalaemia)
ADH secreting -> SIADH and hyponatraemia
Lambert Eaton -> Weakness (Calcium channel)

Question 3

Q

canagliflozin, dapagliflozin and empagliflozin: What are they and how do they work?

Answer

A

SGLT-2 inhibitors
Inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule
reduce glucose reabsorption + increase urinary glucose excretion

Causes normoglycaemic Ketoacidosis
Increased UTIs
Lower limb amputation

Question 4

Q

Left Varicocele?

Answer

A

Consider RCC
- Compression of Left Testicular Vein
RCC: Flank pain, Haematuria and abdominal mass

Seen in older men
Associated with Von Hippel Lindau (VHL mutation autosomal dominant) CNS and eye Haemangiomas

Question 5

Q

Stauffer syndrome

Answer

A

Paraneoplastic Hepatic Dysfunction associated with RCC

Thought to be IL 6 Mediated

Question 6

Q

RCC Paranoeplastic syndrome?

Answer

A

erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH

Stauffer syndrome

Question 7

Q

DDP4 Inhibitors?

Answer

A

Sitagliptin, Vitagliptin.
Work by increasing GLP 1 levels
GLP causes increased insulin, reduced glucagon.

DDP4 inhibitors therefore cause no weightgain or hypoglycaemia as not effecting insulin directly.

Cause Pancreatitis!

Question 8

Q

GPL 1 Mimics:

Answer

A

Exenatide or Liraglitide

Cause increase insulin and decrease glucagon

Nausea and Vomiting
Pancreatitis
Cause Weight Loss

Question 9

Q

Renal Tubular Acidosis Type 1

Answer

A

Due to Reduced H+ Secretion into the urine at the distal convoluted tubule

Leads to a normal anion gap acidosis with hypokalaemia
Associated with hypercalcaemia and kidney stones

HYPOKALAEMIA

Sjrogrens and Rheumatoid Arthritis and Kidney Transpolant are associated with it

Treated with oral sodium bicarbonate

Question 10

Q

Causes of Normal Anion Gap Acidosis

Answer

A

Addison’s
Bicarbonate Losses (Diarrhoea and RTA)
Chloride Excess (IV Fluids NaCl)
Drugs (acetazolamide)

Question 11

Q

Causes of Increased Anion Gap Acidosis

Answer

A

Ketoacidosis (Starvation, DKA)
Uraemia
Lactic acidosis (Metformin, sepsis, Trauma)
Toxins (salicylates, Methanol, Ethylene Glycol)

Question 12

Q

Renal Tubular Acidosis Type 2

Answer

A

Proximal Convoluted Tubule is unable to resorb Bicarbonate leading to increased losses. Is a global problem with PCT leading to reduced resobtion of glucose, phosphate, calcium, protein, potassium etc.

HYPOKALAEMIA

Caused by Drugs and Fanconi Syndrome
Drugs include Acetazolamide, Sulfonamides

Question 13

Q

Renal Tubular Acidosis Type 4

Answer

A

Distal Convoluted Tubule due to reduced Aldosterone action. (Addison’s)
Associated with Hyperkalaemia but normally normal sodium (lower end)

HYPERKALAEMIA

Because aldosterone triggers sodium resorption in exchange for potassium and hydrogen, there is reduced potassium excretion, causing hyperkalemia and reduced acid excretion.

Caused by Diabetes and hypoaldosteronism (steroid use)

Question 14

Q

Alports Syndrome?

Answer

A

Hereditory X linked recessive Disorder of Type IV Collagen leading to Ear, Eye and Kidney problems.
A cause of Renal Failure and may require transplant.

Leads to microscopic haematuria, proteinuria, progressive kidney dysfunction, bilateral sensorineural deafness, retinitis pigmentosa, Lenticonus (protrusion of lens into anterior chamber)

Renal biopsy - splitting of lamina densa.- Basket Weave

Anti GBM antibodies - Therefore if renal transplant fails may be described as Good pastures rather than graft rejection

Question 15

Q

Myasthenia Gravis

Answer

A

Bimodal distrubution 20-30 F, 50-70 M.
Progressive Weakness
Auto anitbodies to Acetyl Choline Post Synaptic Receptors.
Treated with acetylcolinesterase inhibitors like noestigmine.

Can be exacerbated into crisis by Aminoglycosides, Beta Blockers, Lithium, Penacillamine, antibiotics, Gentamicin.

Question 16

Q

ADEM (Acute Disseminated Encephalomylitis)

Answer

A

Autoimmune demylinating disease of the central nervous system. Following bacterial or viral infection 2days - 2 months. Measeles Mumps, Rubella common causes. Multifocal neurological involvement, starting as headache, nausea vomiting, then motor, sensory, ocular motor and brainstem dysfucntion

MRI- supra and infra tentorial demylination
Steroids and IVIG is the management

Question 17

Q

ADEM (Acute Disseminated Encephalomylitis)

Answer

A

Autoimmune demylinating disease of the central nervous system. Following bacterial or viral infection 2days - 2 months. Measeles Mumps, Rubella common causes. Multifocal neurological involvement, starting as headache, nausea vomiting, then motor, sensory, ocular motor and brainstem dysfucntion

MRI- supra and infra tentorial demylination
Steroids and IVIG is the management

Question 18

Q

Typhoid

Answer

A

CAused by Salmonella Typhoid (Para Typhoid - Salmonella Paratyphoid)

Faeco oral route enertic Fever

Features:
RElative Bradycardia
Rose spots (paratyphoid) - rash on trunk
Normally it is Constipation Not Diarrhoea

Complications
Osteomylitis, Meningitis, GI Bleed, Cholecystitis

Treated with Cefotaxime

Question 19

Q

Actinic Keratosis

Answer

A

Multiple, crusty lesions that are pink/brown in sun exposed areas
Topical Florouracil is treatment and sun avoidance
Imiquimod also shows promise
NSAIDS

Treatment:
5 -FU Topical Florouracil cream
NSAIDs
Imiquimod

Cryotherapy and curtarage

Question 20

Q

Serum Ascites Albumin Gradient

SAAG

Answer

A

SAAG is calculated from Ascitic fluid. Ascitic fluid albumin is taken away from the serum albumin value. If < 11 this indicates portal hypertension

If > 11 this is another cause for Ascites

Question 21

Q

Low SAAG < 11 causes of Ascites

Answer

A

Indicates portal hypertension

Cirrhosis
Alcoholic hepatitis
Cardiac ascites
Mixed ascites
Massive liver metastases
Fulminant hepatic failure
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxoedema
Fatty liver of pregnancy

Question 22

Q

High SAAG > 11 Causes of Ascites

Answer

A

Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Bowel obstruction
Biliary ascites
Postoperative lymphatic leak
Serositis in connective tissue diseases

Question 23

Q

Facioscapulohumeral Muscular Dystrophy?

Answer

A

Autosomal Dominant Mysculodystrophy leading to symtpoms in arm and face
Onset around 20 years old

Winging of the scapular is very characteristic

Progressive but good prognosis - mild symptoms

Question 24

Q

Transjugular intrahepatic porto-systemic shunt (TIPPS)

Answer

A

Indications:

Refractory Ascites
Variceal bleeds
hepatic pleural effusions

Is a Bypass of the liver - Portal (hypertensive) blood is stented straight into the hepatic vein (and then IVC) without going through the liver.

This reduces portal hypertension however toxins then no longer are going through the liver

Contraindications:
Severe And Progressive Liver Failure - Child-Pugh Score > 12
Uncontrolled hepatic encephalopathy (exacerbated as toxins now bypassing liver)
Right Sided Heart Failure (this increases venous return therefore exacerbating peripheral oedema)
Uncontrolled sepsis
Unrelieved Biliary Obstruction

Question 25

Q

Transjugular intrahepatic porto-systemic shunt (TIPPS)

Answer

A

Indications:

Refractory Ascites
Variceal bleeds
hepatic pleural effusions

Is a Bypass of the liver - Portal (hypertensive) blood is stented straight into the hepatic vein (and then IVC) without going through the liver.

This reduces portal hypertension however toxins then no longer are going through the liver

Contraindications:
Severe And Progressive Liver Failure - Child-Pugh Score > 12
Uncontrolled hepatic encephalopathy (exacerbated as toxins now bypassing liver)
Right Sided Heart Failure (this increases venous return therefore exacerbating peripheral oedema)
Uncontrolled sepsis
Unrelieved Biliary Obstruction

Question 26

Q

Churg Strauss Syndrome?

Answer

A

Eosphinophilic granulomatosis with polyangiitis EGPA
ANCA (pANCA) associated medium vessel vasculitis
- Asthma (first phase)
- Eosphinophilia (lung and blood) (second stage)
- Sinusitis (polyps)
- Mononeuritis multiplex (vasculitic (3rd) Stage)
- pANCA (60%)

Leukotriene Receptor Antagonist may precipitate Disease

Steroids and immunosupression

Question 27

Q

Granulomatosis with Polyangitis?

Answer

A

Wegener’s Granulomatosis
- Autoimmune necrotising granulomatous vasculitis of the upper and lower airways plus kidneys

Epistaxis, sinusitis, nasal crusting (upper airway)
Dyspnoea, haemoptysis (Lower Airway)
Rapidly Progressive Glomerulonephritis
Saddles-Shape Nose Deformity
Vasculitis Rash

cANCA > 90%

Managed with steroids and cyclophosphamide
Plasma Exchange
`

Question 28

Q

Hypernatraemia

Answer

A

Dehydration
Osmotic Diuresis (Hyperosmolar Non Ketotic Diabetic State)
Diabetes Insipidus
Excess IV saline

Correct with caution - can cause cerebral oedema therefore no greather than 0.5mmol/hour concentration correction

Central pontine Myelinolysis is a neurological disorder caused by rapid correction of HYPOnatraemia
Presents with Paraylsis, dysphagia and dysarthria.

Question 29

Q

Trigeminal Neuralgia?

Answer

A

Electric Shock like pain on light touch of the face. In the Trigeminal region.
First line treatment is Carbemazepine.

Consider diagnosis if:

Opthalmic region only
Optic Neuritis
Bilateral pain
History of MS in family
No response to treatment

Question 30

Q

Primary Biliary Cholangitis

Answer

A

This is an autoimmune disorder effecting liver in middleaged women. Leads to interlobular inflammation of the bile ducts causing cholestasis and leading to cirrhosis

Associated with Connective Tissue Disease:
Sjogren's
RA
Systemic Sclerosis 
Thyroid disease

Anti Mitochondrial Antibodies are 98%
Anti Smooth Muscle is 30%

Increased risk of Cirrohsis
Osteomalacia and Osteoperosis (due to decreased Vitamin D activation by the Liver)

HEPATIC ADENOCARCINOMA risk 20 x

Tx: Cholestyramine, Fat Soluble Vitamin Replacement, Ursodeoxycholic acid, Liver Transplant

Question 31

Q

Methotrexate Myelosuppresion?

Answer

A

Treat with Folinic Acid

Question 32

Q

Cocaine Toxicity Treatment?

Answer

A

Start With Benzos
Then Verapamil for palpitations or tachycardia

AVOID Beta Blocker

Question 33

Q

Dermatitis Herpetiformis?

Answer

A

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.

Itchy blistering on extensor surfaces

Dapsone and Gluten Free Diet is management

IgA deposits seen on immunofluorecence

Question 34

Q

Autoimmune Hepatitis

Answer

A

Autoimmune condition seen in young females associated with HLA B8 and DR3

Three types:
- Type 1 = ANA and or Antismooth Muscle (SMA)

Type 2 = Anti-liver/kidney Microsomal type 1 antibodies (LKM1) ** CHILREN ONLY**
Type 3 = Soluble Liver-Kidney Antigen present
- ONLY MIDDLE AGE**

Treated with Steroids and Liver Transplantation

Question 35

Q

hypertrophic pulmonary osteoarthropathy (HPOA)

Answer

A

Paraneoplastic syndrome with squamous cell and adenocarcinoma Lung cancer which leads to tender and swollen wrists. Associated with clubbing

Bronchogenic carcinoma

Question 36

Q

Thymoma?

Answer

A

Presents in `60-70 year olds. Most common tumour of anterior mediastinum.
Associated with
myasthenia gravis (30-40% of patients with thymoma)
red cell aplasia
dermatomyositis
also : SLE, SIADH

Question 37

Q

Anti Mitochondrial Antibody

Answer

A

Primary Biliary Cirrhosis

Question 38

Q

Anti- Liver/Kidney microsomal Type 1 Antibodies LKM1

Answer

A

Type 2 Autoimmune Hepatitis

Question 39

Q

Severe Cronhs disease treatment?

Answer

A

Steroids and azithromycin
If still agressive go to biological agents quick

Inflixamab is good for severe disease- also rectal / anal disease
Methotrexate for perianal disease

Question 40

Q

Hyperosmolar Hyperglycaemic State?

Answer

A

Medical Emergency and tough to manage
Hyperglycaemia causing osmotic diuresis, severe dehydration and electrolyte deficienceies.
Elderly T2 DM is typical

HSS has higher mortality vs DKA with complications like MI, Stroke, Thrombosis, Seizures, Cerebral oedema and central pontine myelinolysis.

HSS takes days therefore dehydration is more severe

Hyperglycaemia causes osmotic diuresis with associated loss of sodium and potassium
Severe volume depletion causes raised serum osmolarity (> 320mosmol/kg) causing hyperviscosity.
Severe electrolyte losses and volume depletion but hypertonicity causes preservation of intravascular volume

Symtpoms: Fatigue, weakness, lethargy, N+V
Lowered conciousness, headaches, papilloedema
Hyperviscosity
Hypotension, tachycardia, dehydration

Question 41

Q

How to Diagnose HHS

Answer

A

Hypovloaemia
Marked Hyperglycaemia Without Ketonaemia or acidosis
Significan raised serum osmolality (> 320)

Calculate Osmolality with (2 * Na + K) + Glucose + Urea

Question 42

Q

Treatment of Whipple’s Disease?

Answer

A

IV Cefotaxime for 4 weeks
Then co -trimoxazole for 1 year

Biopsy with PAS staining shows positive macrophages in duodenum

Question 43

Q

Calculate the Anion Gap

Answer

A

Na + K - Cl - HCO3

Question 44

Q

Ethylene Glycol Toxicity?

Answer

A

Stage 1: Alcohol intoxication: Confusion, slurred speech dizziness

Stage 2: Metabolic Acidosis with High anion gap and HIGH OSMOLAR GAP
Tachycardia and hypertension

Stage 3: AKI

Question 45

Q

Treatment of local anaesthetic toxicity?

Answer

A

IV lipid emulsion

History of perioral parathesia, followed by tachy cardia and wide QRS interval, followed by cardiac arrest

ALL shortly after a procedure being started

It is due to IV or excess administration. CNS over activity then depression as lidocain blocks inhibitory pathways then blocks both inhib and activating.

Question 46

Q

CF Managemet

Answer

A

REgular Physio and postural Drainage
High Calorie Diet
Vitamin Supplementation
Pancreatic Enzyme Supplements
Heart and Lung Transplant

IF Delta F508 Mutation Orkambi (Lumacaftor and Ivacaftor) combination therapy can be used
Lumacaftor increases the number of CFTR proteins that are transported to the cell surface
Ivacaftor is a potentiator of CFTR that is already on the cell surface, this increased the probability that the defective channel with be open

Question 47

Q

Superior vena Cava Obstruction?

Answer

A

Oncological emergency
Compression of SVC commonly due to lung cancers or lymphoma 
SOB is most common symptom 
Then Swelling of face, neck and arms 
Headache worse in the morning
Dstended neck veins

Small cell Lung Ca, Lymphoma 
Kaposi's Sarcoma, Breast Ca
Aortic Aneurysm
Mediastinal fibrosis
Goitre
Thrombosis

Dexamethasone is management
Acutely Stenting
In the long run, small cell = radio and chemo
Non small cell = radiotherapy

Question 48

Q

Waterhouse Friedrichsen Syndrome?

Answer

A

Adrenal Haemorrhage likely secondary to TB or Minigococcal infection. Adrenal insufficiency with changes seen on CT

Question 49

Q

Raynaud’s Disease

Answer

A

Primary Raynaud’s Disease

Young Women under 30 with bilateral symptoms
No over rashes or abnormal history

Nifedipine 1st line
IV prostacycline 2nd line

Question 50

Q

Strongyloidiasis

Answer

A

Sarvae from soil contaminated with faeces migrates in the blood to the lungs. It enters the bronchial tree, causing irritation, coughed up and swallowed. Then in the duodenum and jej it invades the bowel.

Asymptomatic potentially but can have diarrhoea and abdominal pain and bloating but when immunosuppressed they cause auto infection and disseminated disease

This is a Larva Currens picture
Pruritic, linear, urticarial rash
- Intense Pruritus as worms migrate through the skin
- Asthmatics immunosuppression with steroids causes paradoxical worsening of symptoms

If Larvae Migrate to the lungs pneumonitis similar to Loeffler’s syndrome may be triggered

IverMectin and Albendazole are Treatment

Question 51

Q

Heparin Iduced Thrombocytopenia

Answer

A

HIT
Immune mediated - antibodies form against platelet factor 4 and heparin
These bind to platelets on the surface
Then reduce platelet levels but is a PROTHROMBOTIC state
50% reduction of platelets
Thrombosis
Skin Allergy

Anticoagulants like lepirudin or danaparoid
TAKES A WEEK TO OCCUR!

Question 52

Q

Kearns Sayre Syndrome?

Answer

A

Mitochondrial Disorder presents < 20 with progressive external opthalmoplegia.
Ptosis develops with horizontal gaze issues.
Patients have Pigmentary retinopathy
Patients get tunnel vision and night blindness

Cardiac conduction defects usually develop and can cause sudden cardiac death

Question 53

Q

Retinitis Pigmentosa

Answer

A

Peripheral retina pigmentation leading to tunnel vision

Nightblindness
Tunnel Vision
Fundoscopy shows black bone spicule shaped pigment

Associated with

Refsum Disease: Cerebellar Ataxia, peripheral neuropathy, deafness, ichthyosis
Usher Syndrome
Abetalipoproteinemia
Lawrence-Moon-Biedl Syndrome
Kearns-Sayre Syndrome
Alport’s Syndrome

Question 54

Q

Facioscapulohumeral Muscular Dystrophy?

Answer

A

Autosomal Dominant Mysculodystrophy leading to symtpoms in arm and face
Onset around 20 years old

Question 55

Q

Trientine?

Answer

A

Copper Chelating used to treat Wilsons

Question 56

Q

Low Caeruloplasmin?

Question 57

Q

Kayser-Fleischer Rings?

Answer

A

Green brown deposits at the peripheries of the Iris

Due to deposits in Descement Membrane

Question 58

Q

ATP7B gene defect?

Answer

A

Chromosome 13
Wilson’s disease
Autosomal Recessive

Question 59

Q

Wilson’s Disease?

Answer

A

Copper Accumulation due to defective Liver
Deposits in Liver- causing failure
Deposits all over body causing neurological signs (basal Ganglia), Kidney leading to Fanconi Syndrome and Type 2 RTA, Haemolysis and Blue Nails
Cornea - Kayser-Fleischer Rings

Question 60

Q

Wilson’s Disease Diagnosis?

Answer

A

Low Caeruloplasmin
Low Total Copper (Paradoxical)
High Free Serum Copper
Kayser-Fleischer Rings on Slit Lamp Examination
Increased 24 hour urinary collection

Question 61

Q

Present infection vs Past in Antibodies?

Answer

A

IgM = Ig Mow (NOW)
IgG = Ig Gone (Past)

Question 62

Q

Cocaine Toxicity Treatment?

Answer

A

Start With Benzos
Then Verapamil for palpitations or tachycardia

AVOID Beta Blocker

Question 63

Q

Dermatitis Herpetiformis?

Answer

A

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by deposition of IgA in the dermis.

Itchy blistering on extensor surfaces

Dapsone and Gluten Free Diet is management

IgA deposits seen on immunofluorecence

Question 64

Q

Management of Fibro Myalgia

Answer

A

explanation
aerobic exercise: has the strongest evidence base
cognitive behavioural therapy
medication: pregabalin, duloxetine, amitriptyline

When starting Medication, start a new one for 4 weeks. Then assess response. If no response, stop and trial a different medication.

Answer 64

A

Paraneoplastic syndrome with squamous cell and adenocarcinoma Lung cancer which leads to tender and swollen wrists. Associated with clubbing

Answer 65

A

Presents in `60-70 year olds. Most common tumour of anterior mediastinum.
Associated with
myasthenia gravis (30-40% of patients with thymoma)
red cell aplasia
dermatomyositis
also : SLE, SIADH

Answer 66

A

Caused by infra red radiation (open fire)

Causes squamous cell skin cancer

Answer 67

A

Longer Prodrome than bacterial meningitis
May be a few weeks unwell with behaviour change
Can get cranial nerve palsy (like malignant meningitis)

Lymphocytes seen in CSF
Low Low Glucose < 50%
High Protein > 1
No organisms will be seen

Answer 68

A

Steroids and azithromycin
If still agressive go to biological agents quick

Inflixamab is good for severe disease- also rectal / anal disease
Methotrexate for perianal disease

Answer 69

A

Whipple’s disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men.

Answer 70

A

Features
malabsorption: diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
pleurisy, pericarditis
neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

Answer 71

A

IV Cefotaxime for 4 weeks
Then co -trimoxazole for 1 year

Biopsy with PAS staining shows positive macrophages in duodenum

Answer 72

A

Anticholinergic side effects first:
Dry eyes, blurred vision, sinus tachycardia, nausea, dilated pupils

Then develop:

Cardiovascular instability
ECG: sinus tachy, wide QRS and prolonged QT
Develop Metabolic Acidosis
Seizures / Coma

Widening QRS > 100 = Seizure prone, 160 = Ventricular arrythmias

Answer 73

A

IV bicarbonate
- first line in hypotension and arrythmias
Indications = wider QRS or Ventricular Arrythmia

Avoid class 1 a and class 1 c antiarrythmics 
- Flecanide as prolong depolarisation
Class III drugs like amiodarone avoid due to prolonging the QT interval

IV lipid emulsion can be used
Dialysis is ineffective

Answer 74

A

This termatode (fluke) infection of the lung presents like TB
Prolonged history of productive cough, brown in sputum ? HAemoptysis but not. Then fevers ++

The patients bloods will reveal an eosinophilia and treatment is the Praziquantel

Answer 75

A

Oncological emergency
Compression of SVC commonly due to lung cancers or lymphoma 
SOB is most common symptom 
Then Swelling of face, neck and arms 
Headache worse in the morning
Dstended neck veins

Small cell Lung Ca, Lymphoma 
Kaposi's Sarcoma, Breast Ca
Aortic Aneurysm
Mediastinal fibrosis
Goitre
Thrombosis

Dexamethasone is management
Acutely Stenting
In the long run, small cell = radio and chemo
Non small cell = radiotherapy

Answer 76

A

Unilateral decreased visual activity over hours and days
Poor colour vision - Ischihara plates reduced score
Pain worse on eye movement
Relative Afferent Pupillary Defect
Central Scotoma

IV steroids high dose initially
Recovery is a month

MRI - if > 3 white matter lesions - 50% 5 year risk of developing MS

Causes inclulde
MS
DM
Syphillis

Answer 77

A

Allergy to Aspergillus spores. Often in exam there is a history of bronchiectasis and Eosinophilia

Features:
Bronchoconstriction- wheeze, cough, ? prev diagnosis of asthma ? better with bronchodilators/ asthma treatment
Bronchiectasis

Eosinophillia
Flitting CXR changes
RAST positive test to Aspergillus
Postive IgG precipitins 
Raised IgE

Steroids
Itraconazole is second line

Answer 78

A

Like caffeine is naturally occuring methylxanthines

Bronchodilator used in COPD and Asthma

? phosphodiesterase inhibitor increasing cAMP but not entirely known how it works

Poisoning:

Acidosis
Hypokalaemia
Vomiting
Tachycardia
Arrythmias
Seizures
hyperglycaemia
Increased Myocardial Contractility

Gastric Lavage < 1 hour
Activated Charcoal
Charcoal haemoperfusion > haemodyalisis

Answer 79

A

Direct Coombs Test- used to detec Immunohaemolytic Anaemia

Take Blood of patient and add Coombs Reagent (Anti Auto Antibodies). This causes agglutination if there are auto antibodies present.
Also used in haemolytic disease of the newborn

Indirect Coombs Test
Prenatal Screening of mother for Rhesus Antibodies

Take Mother blood- take out the Rhesus Antibodies
Then add Rhesus positive RBCs (to cause antibodies to attach to antigens) then add Coombs reagent (antiautoantibodies) This causes again RBC agglutination.

Answer 80

A

RBC haemolysis secondary to auto antibodies targeting RBCs causing destruction

Idiopathic
Medication
Underlying Disease Process

RBCs usually 120 day lifetime.

Extrinsic type of haemolytic anaemia
Haemolysis occurs in in liver/spleen therefore extra vascular 
Warm is more common type (> 37 degrees)
Cold Rare (0-10degrees)

Warm = IgG
IgG bind to Rh Antigen on RBC and cause antibody dependent cell mediated cytotoxicity. Macrophages, neuts, t cells and NK cells cause haemolysis

Cold = IgM
IgM bind to L I or P antigens. Then compliment pathway causes breakdown in the liver through Membrane attack complex (MAC). This can also occur in introvascularly causing raynaud’s

Answer 81

A

Increased Reticulocytes 
Normocytic anaemia
Lactate Dehydrogenase levels raised
Hb --> Unconjugated Bilirubin increased
Haptoblobin levels decrease
Haemosiderinuria 
- Damage kidneys and renal insufficiency

Direct Coombs test detects auto antibodies
Warm C3D and IgG positive
Cold C3D only

Answer 82

A

Idiopathic 
Viral infections
SLE
Lymphomas
Leukemia
Penicillin and Cephalosporins

Answer 83

A

Chronic - Leukaemia and Lymphomas

Acute - Viral Pneumonia, Mycoplasma, Infectious Mononucleosis

Answer 84

A

Bounding heart rate
SOB
Multiorgan failure
Jaundice 
Fatigue 
Hepatosplenomegaly

Answer 85

A

Warm - Steroids and splenectomy

Cold - none required

Answer 86

A

Subtype of Diabetes in which patients present with phenotypic features of Type 2 DM whilest displaying the prescence of makrers of autimmunity ( Anti GAD antibodies)

30-40 year olds
Oral hypoglycaemic agents are used
B cell function may decline and may require progressive insulin

Answer 87

A

Nodule < 5mm or clearly benign or unsuitable for treatment - discharge

Nodule 5-6mm CT in 1 year

Nodule > 6-7mm - 3 months CT

Nodule > 8 mm and Low Risk - 3 month CT

Nodule > 8mm and high risk (via Brock Model) - CT PET
IF CT PET shows high uptake - Biopsy

Answer 88

A

If patient > 50 and pneumothorax rim is > 2cm OR PATIENT IS SYMPTOMATIC = Chest Drain

If patient > 50 and pneumothorax rim is 1-2cm
- Aspirate
If fails- still > 1 cm or symptomatic = Chest Drain

If patient > 50 and pneumothorax rim is < 1 cm = admit and oxygen

Answer 89

A

Primary Pneumothorax < 2 cm and not SOB = discharge

If > 2cm or SOB = Aspirate (if fails - chest drain)

Patients should be advised to stop smoking

Answer 90

A

Use when protein 25-30

> 30 is Exudate, < 30 is Transudate. Lights used for inbetween

Lights: if one of the following true then likely Exudate
Pleural fluid protein / Serum protein = >0.5
Pleural fluid LDH / Serum LDH = > 0.6
If Pleural fluid LDH is 66% of normal range of serum LDH

Answer 91

A

Risk Factor is poor Dentition

Answer 92

A

Commonest type of glomerulonephritis
3rd most common cause of ESRF

BM is thickened with subepithelial electron dense deposits. Creating a spike and dome appearance

Idiopathic is due to antiphopholipase A 2 antibodies
Drugs include Penicillamine, NSAIDs and Gold
SLE Thyroiditis and rheumatoid

Management:
ACEi or ARB
These reduce proteinurea and improve prognosis
Then Immunosupression
Steroids + Cyclophosphamides is often used

Consider Anticoagulation

Answer 93

A

1/3 Remission
1/3 Protein urea
1/3 ESRF

Good prognosis :
-females
Young presentation
Asymptomatic

Answer 94

A

Glycogen Storage Disease

Myophosphorylase deficiency or glycogen storage Disease V

Presents in adolescence and presents with exersis in tolerance, cramps and weakness. Unfortunately chronic fatigue is often a mysdiagnosis

Autosomal Recessive

No venous blood lactate rise on exercise
Muscle biopsy shows elevated glycose concentration and muscle phosphorylase deficiency
elevated CK and Myoglobinuria

Forarm muscle exercise testing or genetic testing is diagnositic
Mx: Avoidance of low carb diets and low intensity aerobic exercise

Answer 95

A

Lipid Storage Disease

Genetic Disorder in which glucocerebroside accumulates in cells and organs

Most common lipid storage disorder

Easy Bruising
Fatigue
Anaemia
Thrombocytopenia
Hepatosplenomegaly

ASEPTIC necrosis of the femur

Deficiency of glucocerebrosidase
Leading to glucocerebroside accumulations in macrophages and therefore: spleen, liver, kidneys lungs brain and bone marrow

Commoner in Ashkenazi Jews

Answer 96

A

Glycogen Storage Disorder

Glucose - 6 - Phosphatase deficiency
Hepatic Accumulation of Glycogen

Leads to Hypoglcyaemia, Lactic Acidosis and Hepatomegaly

Answer 97

A

Glycogen Storage Disorder

Lysosomal Alpha 1, 4 Glucosidase Deficiency

Cardiac, Hepatic and Muscle Glycogen accumulation. Features include cardiomegaly

Answer 98

A

Glycogen Storage Disorder

Alpha 1, 6 Glucosidase Deficiency

Hepatic and Cardiac Accumulation - leading to muscle hypotonia

Answer 99

A

Increased risk of non melanoma skin cancer

Answer 100

A

Hypersensitivity
CCF
Aplastic Anaemia
Reactivation of TB
Skin cancer (in combination with azothiaprine)

Answer 101

A

Rare Autosomal Dominant disorder with episodes of paraylsis typically at night

Mutation in muscle voltage gated calcium channels
Can be precipitated by carb meals
History of exercise

Life long Potassium replacement

Answer 102

A

Severe Active Renal disease (Cr > 350)
Pulmonary haemorrhage
Concurrent Anti - GBM Auto Antibody disease

Answer 103

A

Guillain Barre Syndrome
Myasthenia Gravis
Good Pastures syndrome
ANCA positive vasculitis (pulm haem, acute renal failure)
TTP/HUS
Cryoglobulinaemia
Hyperviscosity syndrome (2ndary to myleoma)

Answer 104

A

Hypocalcaemia
Metabolic Alkalosis
Systemic Medication removal
Coagulation factor depletion
Immunoglobulin depletion

Answer 105

A

This is the presence of circulating proteins which precipitate in the cold. Commonly associated with hepatitis C infection.

Three types
1 - monoclonal (25%)
2 - Mixed mono and poly (usually rheumatoid factor) (25%)
3 - Polyclonal (usually rheumatoid factor ) (50%)

Type 1:

IgG or IgM
Multiple Myeloma
Waldenstrom Macroglobulinaemia

Type 2:
mixed monoclonal or polyclonal (usually Rhematoid Factor)
Associated: Hep C, Sjogren’s, Lymphoma and Rehumatoid Arthritis

Type 3:
Polyclonal - usually with Rheumatoid factor
RA and Sjogrens

Symptoms:
- Raynaud’s only seen in type 1
Cutaenous- vascular purpura, distal ulceration and ulceration
- Arthralgia
- Renal involvement (diffuse Glomerulonephritis)

Tests: Low complement (especially c4)
High ESR

Immunosuppression and plasmapheresis

Can cause a peripheral neuropathy from small vessel vasculitis- sensory or sensory motor peripheral neuropathy

Answer 106

A

X-linked lysosomal storage disorder that causes a painful peripheral neuropathy due to deposition of glycosphingolipids within small sensory fibres. (nerve conduction normal as large fibres uneffected)

Answer 107

A

This is prominently motor neuropathy often affecting proximal and distal muscles. There is sensory involvement with vibration and proprioception. Show Conduction slowing reflecting demyelination rather than amplitudes which suggests axonal loss

Answer 108

A

Guillain Barre Syndrome
CIDP (Chornic inflammatory Demyelinating polyradiculoneuropathy)
Amiodarone
Hereditary sensorimotor neuropathies type 1
Paraprotein neuropathy

Answer 109

A

Alcohol
DM
Vasculitis
B12
Hereditary sensorimotor neuoropathy type 2

Answer 110

A

Deltoid
Biceps
Brachioradialis

Answer 111

A

Serratus Anterior (paraylsis - winging of scapula)
Triceps

Answer 112

A

Finger Flexors

Answer 113

A

A Systemic Inflammatory condition of unkown aetiology but often thought to be secondary to an infectious trigger on the background of a genetic predisposition.

Presents in young adults 15-25 yo peak.

Fever and new non pruritic rash

Basically - graham Nash with A rash
Joint pain not swelling
All negative screens

GIVE NSAIDS unlike Graham Nash

Answer 114

A

Yamaguchi criteria
PAtients need all major criteria and 2 minor

Major: Fever 39 degrees > 1 week
Arthralgia > 2 weeks
Non pruritic or maculopapular rash
Lecuocytosis

Minor:
Sore throat, lymphadenopathy, hepatomegaly or splenomegaly, LFT derangement, ANA negative and rheumatoid factor negative

Answer 115

A

Tends to spike daily or twice daily
Rash is salmon coloured on trunk or the soles, palms and face
Knees and wrists are common joint involved
Ferritin rises are characteristic as well

Answer 116

A

NSAIDS

NSAIDs for fever joint pain and serositis

Then Steroids or D MArds

Answer 117

A

Inflammation associated with thrombosis of one of the superficial veins (usually long saphenous vein of the leg.

20% of superficial thrombophlebitis have underlying DVT and 4% will progress to DVT if untreated.

Treatment with oral NSAIDs, stockings and Prophylactic dose Enoxaparin for 30 days as higher risk of DVT

Answer 118

A

Sensitive marker of increased bone turnover observed in Pagets disease and useful in monitoring disease progression or treatment efficacy

Answer 119

A

Increased but uncontrolled bone turnover
Osteoclastic disorter
Increased osteoclastic resorption and then increased osteoblastic activity

UK - 5%

Older man with pone pain and isolated raised ALP
ALP raised
Calcium and phosphate are normal
PINP (procollagen type 1 N-terminal propeptide), serum C telopeptide, urinary N telopeptide and urinary hydroxyproline are raised These are all markers of bone turnover

Indications for treatment:
Bone Pain, Skull or long bone deformity, fracture, periarticular pagets
Treated with bisphosphonates

Answer 120

A

Deafness
Bone Sarcoma 1% of patients
Fractures 
Skull Thickening
High Output Cardiac Failure

Answer 121

A

Rare Autosomal Dominant condition with a defect in porphobilinogen deaminase - biosynthesis of heam.

Toxic accumulation of dela aminolaevulinic acid and porphobillinogen

Abdominal pain with neuropsychaiatric symptoms in a 20-40 year old female (Christie)

Classical presentation is a combination of abdominal, neurological and psychiatric symptoms:

Abdominal pain and vomiting
Motor Neuropathy
Psychiatric - depression / acute agitation
Hypertension and Tachycardia

Answer 122

A

Urine turns red on standing
Raised urinary porphobilinogen
Assay of red cells for pophobilinogen deaminase

Answer 123

A

Rickettsial Disease
Can cause widespread vasculitis

Fever, Headahce
Blakc Eschar at site of inoculation
Maculopapular or vasculitic rash
Deranged clotting, renal failure and DIC, low platelets
Interstitial infiltrates

Answer 124

A

Doxycycline

Chloramphenicol

Answer 125

A

Used to treat Thallium Poisoning

Answer 126

A

Painful peripheral neuropathy
Abdominal pain
Diarrhoea and vomitting
Ataxia 
Sepia tinge to vision
Reduced visual acuity
Cranial nerve palsy
Minimal body hair / alopecia
Glossitis
Mood issues

Occupation: Electroplating

Treated with Prussian Blue

TRIAD: Fluctuant mood, painful distal parasthesia and Alopecia = Pathognomonic

Answer 127

A

pH < 7.2

Purulent aspirate

Answer 128

A

Primary Ciliary Dyskinesia

Bronchiectasis
Recurrent sinusitis
Otitis Media
Subfertility

Dextrocardia / Sinus Invertus

Patients are tested by putting sweet in the nose. If they don’t tase after 20 mins then they have ciliary dyskinesia

Answer 129

A

Infective:

TB
Measles
Purtussis
Pneumonia

CF
Immune Deficiency:
- IgA
- Hypogammaglobulinaemia

Allergic Bronchopulmonary Aspergillosis

Ciliary Dyskinetic Syndromes
Kartageener’s syndrome
Youngs syndrome

Yellow Nail Syndrome

Answer 130

A

Multiple Lesions
Ring or nodular enchancement
Thallium SPECT negative

50% of cerebral lesions in patients with HIV

Treatment is with Sulfadiazinde and pyrimethamine

Answer 131

A

30% of cerebral lesions in patients with HIV
EBV association
Single homogenous enhancing lesion

Treatment with steroids and methotrexate (chemo) and consideration for sugery

Answer 132

A

Toxoplasmosis
CNS lymphoma
Encephalitis: CMV or HIV itself
Can also be HSV
CT shows oedematous brain

- Cryptococcus 
Most common fungal infection of CNS
- Headache, fever, seizures, focal deficit
CSF - high opening pressure
India Ink Test Positive

Progressive Multifocal Leukoencephalopathy
PML
Widespread demyelination
Due to JC virus
behavioural changes, speech, motor, visual impairment
Single or multiple lesions on CT w/o mass effect and don’t usually enhance
MRI shows demylination

Aids Dementia Complex

Caused by HIV virus itself
behavioural changes and motor impairment
CT cortical and subcortical atrophy

Answer 133

A

1 week following resolution of chest x ray

Answer 134

A

II, III and AVF

Right Coronary Artery thrombus

Answer 135

A

V1-V4

Left Anterior Descending

Answer 136

A

V5, 6 and I

Circuflex artery

Answer 137

A

MOST SEVERE Malaria
Causes Cytoadherence to block spleen blood flow and cause ischemic damage

Need to decide if severe or not

Then need to highlight any complications

Severe:

Schizonts (last stage before lysis of RBC and increased viral load)
Parasitaemia > 2%
Hypoglycaemia
Acidosis
Temp 39
Severe Anaemia
Any complications

Complications:

Cerebral Malaria - seizures and coma
Acute Renal failure (blackwater fever)
Acute Respiratory Distress
Hypoglycamia
DIC

SEVERE DISEASE: Treat with IV Artesunate
> 10% parasite = EXCHANGE TRANSFUSION
IF shock - then treat with antibiotics as well

For non severe disease: artemisinin based combo therapys are recommended

Answer 138

A

No duffy antigen

Therefore Plasmodium Vivax cannot enter cells

Answer 139

A

Thalassemia and G6PD increase likelyhood that infected RBC will dye from oxidative stress
This gives a level of immunity

Answer 140

A

Quartan Fever- 72 hours

Answer 141

A

Tertian Fever- 48 hours

Answer 142

A

Fever every 24 hours

Answer 143

A

Fever varies - Malignant Tertian Fever

Answer 144

A

Non Upper Lobe empysema

High Exercise Capacity

Answer 145

A

Occurs in association with PPI use
History of chronic watery diarrhoea with increased frequency
Statins and SSRIs can also cause it
Colonoscopy and biopsy is the way to confirm the diagnosis

Answer 146

A

Non invasive confirmation of coeliac disease

Where negative, but still clinically coeliac, can go onto upper GI endoscopy and biopsy

Answer 147

A

Screening test for active Crohn’s and UC

Answer 148

A

Used to evaluate pancreatic insufficiency

Answer 149

A

Used as Tumor marker for colorectal cancer

Answer 150

A

Cause of Myopathy
Associated with cytoplasmic inclusions on mm biopsy

Older males with proximal and distal muscles
Quads fingers and wrist flexors
Raised CK

Answer 151

A

Anti histone antibody positive
ANA postiive 100%
Anti dsDNA negative

Answer 152

A

Procainamide
Hydralazine
Isoniazid
Micocycline
Phenytoin
Penicillamine

Answer 153

A

Primary infection with varicella zoster virus
Shingles is the reactivation of the dormant virus in dorsal root ganglion

Highly infectious
Respiratory spread
Can be caught of shingles patient
4 days before rash, 5 days after day 1 of rash
10-21 day incubation

Symptoms:
- fever
- itchy rash starting on head/trunk before spreading
- Macular then vesicular 
Systemic upset

Tx: keep cool
Trim nails
5 days off after rash started

IVIG for immunocomprimised or newborns

Common complication is bacterial infection
NSAIDS increase this risk
Can develop cellulitis
Can also develop invasive group a strep infection

This can be Nec Fasc
- out of proportion pain for symptoms of erythematous rash

Other complictions include

pneumonia
Encephalitis
Disseminated haemorrhagic chicken pox
Arthritis

Answer 154

A

Term for rapid loss of renal function assciated with formation of epithelial crescents

Good Pastures Syndrome
Wegener’s Granulomatosis
SLE
Microscopic polyarteritis

PRESENTS AS NEPHRITIC SYNDROME
- red cell casts, proteinuria, hypertension, oliguria

Treated with immunosuppression and plasmapheresis

Anti coagulation

Type 1 - Anti-GBM antibody (Goodpasture Sydrome) - linear on immunofluorecence
Type 2 - Immune complexes (post strep, Lupus, IgA, HSP)
Granular on immunofluorecence
Type 3 - Pauci - Immune (ANCA positive)
No immunofluorecence

Answer 155

A

ECG shows low voltage complexes with poor R wave Progression in the chest leads

This is common in Myeloma

Answer 156

A

is an oppurtunistic infection by the JC virus that only occurs in patients who are immunocomprimised.
Natalizumab has a 2.1 in 1000 risk of developing it.

Multifocal demyelination
Presents with sub acute behaviour change, speech, motor and visual impairment

Answer 157

A

Reduce the frequency and duration of relapses - No cure

Acute replase:
High dose steroids - shorten the relapse but not recovery

DMARDS
beta interferon reduces relapse rate by 30%
Criteria for beta interferon:
- Relaps, Remiting disease: 2 r in past 2 years and able to walk 100m
- Secondary progressive disease: 2 r in past 2 years and able to walk 10 m

Glatiramer acetate: Immune decoy
Natalizumab: alpha 4 and beta 1 integrin antagonsit found on leucocytes
Fingolimod

Other issues:
Fatigue: - Exclude anaemia / hypothyroid
Treat with amantadine
mindfullness
CBT

Spasticity: Baclofen and Gabapentin

Bladder Dysfunction

urgency, incontinence and overflow
Guidelines say get US first
If significant residual volume - self catheterise
if no signficant residual volume - anticholinergics

Oscillopsia (visual fields oscillate)
- Gabapentin

Answer 158

A

G6PD deficiency

Primaquine, Cipro and sulphonamides cause haemolysis

Answer 159

A

hyponatraemia
Hypomagnesmia
Osteoperosis
Microscopic colitis
Increased C.Diff
Reduced HIV antiretroviral efficiency (atazanavir, Eviplera)
Reduced Methotrexate clearance (omeprazole and aspirin)

Answer 160

A

Is a cholinesterase inhibitor used to treat mild to moderate dementia

It has vagotonic effects that lead to bradycardia and heart block

Answer 161

A

1st line is acetylcholinesterase inhibitors:
Donepezil, glantamine and rivastigmine (as used in MG)
This is for Mild to moderate Alzheimers

2nd Line is Memantine (NMDA receptor Antagonist)

Add on or monotherapy severe Alzheimers
start if intollerant of first line in moderate disease

Answer 162

A

Primary Hyperaldosteronism
Commonly caused by an adrenal adenoma (CONNS)
However, bilateral adrenal hyperplasia is actually now 70% of cases

Treat conns with surgery but BAH with spironolactone, so differentiating is imporant

Signs and symptoms:

Hypertension (due to high Na)
Hypokalaemia (can present with muscle weakness)
Alkalosis

Aldosterone/renin ratio is the first line investigation
High aldosterone with low renin levels should be seen

Then, high resolution CT with adrenal vein sampling to see if bilateral or unilateral sources of aldosterone excess

If unilateral - surgery
If bilateral adrenocortical hyperplasia - spironolactone

Answer 163

A

Dark Urine, Haemolytic Anaemia and Thrombosis

Due to an acquired genetic mutation in the PIGA gene. This codes for GPI - the anchor protein to CD 55 and CD 59

These are both Complement Regulatory Proteins

This means they help the complement system (alternative pathway that reacts to bacterial endotoxins and forms the MAC) to differentiate from self and non self

CD 55 and CD 59 are found on RBC, Neutrophils and Platelets

Without GPI then there is no CD 55 and CD 59

This causes unregulated complement activation and therefore Intrinsic, intravascular, Haemolysis

There is haemolysis throughout the day
Then at night urine is concentrated so then in the morning it looks like there is increased blood in urine hence the name

Complications are thrombosis (commonest cause of death), Irone Def Anaemia (haemoglobin loss) and AML

Answer 164

A

HAM test positive

Flow Cytometry is gold standard

Answer 165

A

Iron, RBC transfusion
Ecluzimab - binds to C5 and therefore stops MAC formation
Stem cell transplant

Answer 166

A

Due to infection with roundworm Ascaris lumbricoides
Infections begin in gut following ingestion, then penetrate duodenal wall to migrate to lungs, coughed up and swallowed, cycle begins again
Diagnosis is made by identification of worm or eggs within faeces
Treatment is with mebendazole

May have loffler’s syndrome then GI history
Contrast seen in worm on bareum enema

Answer 167

A

Give IV T3 and T4 + Steroids

Presents with hypothermia, low GCS, bradycardia, hypotension
Need to rule out addisons as well

Answer 168

A

The initial management of hypercalcaemia is rehydration with normal saline, typically 3-4 litres/day. Following rehydration bisphosphonates may be used. They typically take 2-3 days to work with maximal effect being seen at 7 days

Other options include:
calcitonin - quicker effect than bisphosphonates
steroids in sarcoidosis

Fluids
Bisphosphonates
CALCITONIN

Steroids for Sarcoidosis
Think about Furosemide in specialist circum

Loop diuretics such as furosemide are sometimes used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.

Answer 169

A

EF < 60%
Left ventricular end systolic diameter > 40mm (LV Dilation or Hypertrophy)
New onset of AF or
Pulmonary Hypertension > 20mmHg

If not 6 monthly ECHO

No need for prophylaxis (only in prostetic repair or replacement)

Answer 170

A

If the patient is symptomatic:
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

This needs to be demonstrated twice in an aysmptomatic patient

HbA1c of > 48mmol/L (6.5%)

Answer 171

A

Prediabetes is split into 2 dependent on the Diagnostic Test used or abnormal

Impaired fasting Glucose: A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

IFG: Fasting Glucose 6.1-7.0 mmol/L

Impaired Glucose Tollerance

OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Answer 172

A

> 48mmol/L = Diabetes (6.5%)

If < 48mmol/L = need fasting glucose or OGTT as this doesn’t exclude diabetes

Answer 173

A

Wait 8 weeks before starting

Answer 174

A

Cause a paraneoplastic syndrome where they release EPO
This leads to a very high Hb

Seen in Von Hipple Lindau syndrome
Have a very good prognosis if they are ameanable to surgical resection

Answer 175

A

CPFE is characterized by exertional dyspnoea, upper-lobe emphysema and lower-lobe fibrosis, preserved lung volume and severely reduced capacity of gas exchange. The preserved lung volumes are thought to arise because of the counterbalanced effects of hyperinflation from emphysema and the restrictive effects of pulmonary fibrosis. Both mechanisms lead to reduced gas exchange, hence the significantly reduced DLCO.

Answer 176

A

Ongoing repair process of having excess collagen / scar tissue in the interstial lung tissue

Type 2 pneumocytes over preliforate and too much collagen is deposited by myofibroblasts
Reduced myofibroblast apopotosis
Reduced blood oxygenation as distance between alveolai and capillary is increased
Excess collagen also causes increased lung stiffness, making ventilation more difficult

This is restrictive lung disease, interstitial lung disease.

Reduced Total Lung Capacity
Reduced Force Vital Capacity
Reduced Force Expitory Volume in first second

Cysts plus thick walls - honeycombing

Progressive therefore symptoms progress overtime
Clubbing
Respiratory failure

Investigation
Chest CT
Spirometry

Treatment is supplimental oxygen and lung transplant

Old age, Male, Tobacco smoker

Life Expectancy from Diagnosis is 3-4 years

Answer 177

A

Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.

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

Don’t offer to smokers who don’t want to give up

Assess risk of falls and fires

Answer 178

A

Protein C deficiency

Protein C deficiency is an autosomal codominant condition which causes an increased risk of thrombosis

Features
venous thromboembolism
skin necrosis following the commencement of warfarin: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis

Answer 179

A

One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase leading to upregulation of nicotinic and muscarinic cholinergic neurotransmission. In warfare, sarin gas is a highly toxic synthetic organophosphorus compound that has similar effects.

Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)
Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
also: small pupils, muscle fasciculation

Management
atropine

Answer 180

A

Restrictive cardiomyopathy

Causes
amyloidosis (e.g. secondary to myeloma) - most common cause in UK
haemochromatosis
post-radiation fibrosis
Loffler’s syndrome: endomyocardial fibrosis with a prominent eosinophilic infiltrate
endocardial fibroelastosis: thick fibroelastic tissue forms in the endocardium; most commonly seen in young children
sarcoidosis
scleroderma

Pathophysiology
primarily characterized by decreased compliance of the ventricular endomyocardium
causes predominately diastolic dysfunction

Features
similar to constrictive pericarditis
low-voltage ECG

Features suggesting restrictive cardiomyopathy rather than constrictive pericarditis
prominent apical pulse
absence of pericardial calcification on CXR
the heart may be enlarged
ECG abnormalities e.g. bundle branch block, Q waves

Investigations
echocardiography
cardiac MRI

Answer 181

A

HHT is autosomal dominant condition - Multiple Telangectasia over skin and mucous membranes

2/ 4 = possible
3/4 = Definite

Epistaxis
Telangiectases
Visceral Lesions (GI tract, or pulm, hepatic, or cerebral AVMs)
Family History (first degree)

Answer 182

A

Autosomal Recessive
Deletion of the Alpha Globin Genes on Chromosome 16
2 pairs of genes
1 defect = silent carrier
2 defect = thalaseamia minor
3 defect = HbH disease - Severe anaemia and hepatosplenomegaly
4 defect -= Bart’s Hydrops Fetalis - incompatabile with life

Answer 183

A

Hemoglobin Electropheresis (increased band at HbH)
Genetic Testing
Fetal Sampling - amniocentesis

Have Haemolysis and Extravascular haemolysis
Get Jaundice
Hypoxia - Increased RBC production
Bones to enlarge and Hepatospenomegaly

Answer 184

A

SEVERE only

Blood TRansfusions
Iron Chelating agents

Fetal : Intrauterine blood transfusions
Bone Marrow Transplants

Answer 185

A

Point Mutation in Beta Globin Gene on Chromosome 11
Causes reduced (B+) or abscent Beta Globin (BO)

Autosomal Recessive therefore can have traight or mild disease if 1 or severe disease if genes from both parents:

1 x B+ = Minor
1 x BO = Minor

2 x B+ = Beta Thalassemia Intermedia

2 x BO = Beta Thalassemia Major

Answer 186

A

HbA x2 and HbB x2

Answer 187

A

HbA x 2 and Hb gamma x 2

Answer 188

A

Minor - Asymptomatic
Beta Thalassemia Major - Start at 6 months as Fetal hb still exists

Symptoms:
Anaemia 
Jaundice
Hepatosplenomegaly
Haemochromatosis 
Growth Retardation

Frontal Bossing
Chipmunck Facies
Hair on End Skull x ray

Answer 189

A

Low Hb
Low MCV (Very Low)
Increased RDW (different sizes due to immature retic)
Film: Microcytic and hypochormic 
Target cells

High Fe
High Ferritin
High Transferritin Sat Level

Haemoglobin Electrophoresis
Low HbA
High HbF
High HbA2 levels

Answer 190

A

Blood Transfusions
Iron Chelating Agents
Splenectomy if hepatosplenomegaly

Answer 191

A

Iron Def
Thalassaemia
Congenital Sideroblastic anaemia
Lead Poisoning

Answer 192

A

weight loss
anaemia
lymphadenopathy

His high dose immunosuppression have precipitated infection with EBV and subsequent B cell proliferation. PTLD incidence is highest in the first year post-transplantation, which is the time when immunosuppression is the most intense. Treatment involves reducing his current immunosuppression therapy and giving additional chemotherapy.

Answer 193

A

azathioprine, 
mesalazine*, 
didanosine, 
bendroflumethiazide, 
furosemide, 
pentamidine, 
steroids, 
sodium valproate

Answer 194

A

Tacrolimus is a macrolide used as an immunosuppressant to prevent transplant rejection. It has a very similar action to ciclosporin:

Action of ciclosporin
decreases clonal proliferation of T cells by reducing IL-2 release
binds to cyclophilin forming a complex which inhibits calcineurin, a phosphotase that activates various transcription factors in T cells

The action of tacrolimus differs in that it binds to a protein called FKBP rather than cyclophilin

Tacrolimus is more potent than ciclosporin and hence the incidence of organ rejection is less. However, nephrotoxicity and impaired glucose tolerance is more common

Answer 195

A

Zinc deficiency causes characteristic skin rash, alopecia, taste impairment, glucose, intolerance and diarrhoea.

Answer 196

A

Night Blindness

Answer 197

A

Spinocerebellar Ataxia
Mypoathy
Anaemia

Answer 198

A

seen in malabsorption and parenteral nutrition

Cardiac necrosis causing congestive cardiomyopathy

Answer 199

A

PEllagra

4 ds

Dermatitis dementia diarrhoea death

Alopecia
Glossitis
Oedema

Answer 200

A

First line is Valproate and Ethosuzimide

Answer 201

A

Medium sized arterial vasculitis with necrotizing inflammation leading to aneurysm formation
jPAN more common in middle aged men with Hep B

Fever
Malaise
Arthralgia
Weight Loss
Mononeuritis multiplex and sensorimotor polyneuropathy
Testicular Pain
Livedo Reticularis
Renal failure
pANCA postiive in 30%
Hep B positive in 30%

Answer 202

A

Homocystinuria
Polyarteritis nodosa
SLE
Amantadine
Cholesterol Embolisation
Antiphospholipid syndrome

Answer 203

A

Rare autosomal recessive def of cystathionine beta synthase
Elevated urine homocystein concentration

Fine Fair Hair
Marfan’s like
Learning Difficulties
Seizures
Lens disolcation
VTE
Livedo reticularis

Treatment is Pyridoxine (Vitamin B 6)

Answer 204

A

Vitamin B 6

Answer 205

A

Cholesterol emboli may break off causing renal disease
Normally after vasc surgery or angiography

Eosinophilia
Purpura
Renal Failure
Livedo reticularis

Answer 206

A

Increases dopamine release and inhibits its uptake at synapses

Causes ataxia, Slurred speech, confusion, dizziness, livedo reticularis
Used in PArkinsons, MS, fam spastic ataxia

Answer 207

A

Occurs when haemopoetic cells lines are replaced by fibroblast. This casues fibrosis and reduced function of the bone marrow

Jak2 gene leads to increased trigger of JAK2 pathway causing increased fibrosis

Then haemopoetic cells migrate to other sites to produce blood - liver spleen lungs
This leads to thromboyctopenia, hepatosplenomegaly and pulmonary hypertension
The patient will be pancytopenic as the extra medullary processes can’t fully compensate for fibrotic marrow

Diagnosis shows
increased platelets
Pancytopenia
Tear shaped and immature blood cells (nucleated rbc etc)

Treatment is with EPO and blood transfusion
Ruxolitinib stops JAK2 pathway and reduces spleen size
BMT

Answer 208

A

B1 deficiency
B1 is Thiamine
Thiamine is a water soluble vitamin of the B complex group
Important in the catabolism of sugars, aminoacids
Clinical consequences are seen in brain and hear (lots of aerobic tissues)

Causes of Thiamine deficiency
Alcohol excess
Malnutrition

Wenicke’s enecphalopathy
- Nystagmus, opthalmoplegia and ataxia

Korsakoff’s Syndrome
- Amnesia and confabulation

Dry beriberi - peripheral neuropathy

Wet Beriberi - dilated cardiomyopathy

Answer 209

A

Dabigatran Reveral in life threatening bleeding

Answer 210

A

Prevention of VTE (PE/DVT)
Prevention of STroke in AF

Contraindicated with Mechanical heart valve replacements

Answer 211

A

Can be used in IgE high Asthma

Answer 212

A

Varicella Zoster Immunoglobulin (VZIG) prophylaxis is recommended for people who fulfill all 3 of:
- Exposure to chicken pox or herpes zoster (shingles)
- Clinical condition that increases risk of severe disease:
This would be Pegnant, neonate or immunosuppresed
- No antibodies

Therefore need an antibody test before going to IVIG

Answer 213

A

Acute presentation of Sarcoidosis

Presents with a classic Triad of erythema nodosum, polyarthralgia and bilateral hilar lymphadenopathy

Answer 214

A

ACE - raised
Calcium Raised
IL 2 receptors Rasied
CRP
Hilar lymphadenopathy 
High Resolution CT - Pulmonary Nodules
PET CT

Histology is gold standard - non caseating granulomas with epitheliod cells

Answer 215

A

6 Months - 60% of people have spontaneous resolution

Can cause pulmonary fibrosis and pulmonary hypertension

Answer 216

A

Sudden loss of conciousness secondary to intermittent complete heart block
Wide inverted T wave
Complete HEart Block

History of sudden intermittent fainting

Answer 217

A

Multi organ damage including lungs, heart liver. Quite deadly
Only real treatment is early use of activated charcoal or fullers earth

Associated with Parkinsons Disese

Answer 218

A

This is a genetic mutation that causes predisposition to development of adenomas in gland tissue
3 main patterns of disease described

MEN 1 - (3 Ps)
Pituitary, parathyroid and Pancreas

Caused by the MEN 1 GENE

MEN 2 is all caused by RET ONCO GENE

MEN 2 a - 2 Ps
Parathyroid
Phaemochromocytoma
Medullary Thyroid Cancer

Men 2 b - 1 P (2 Ms)
Phaeochromocytoma
Medullary Thyroid Cancer 
Neuromas
MARFANS LIKE BODY

Answer 219

A

Lesions in the Red Nucleus
Most commonly due to a stroke in the area

Irregular Low Frequesncy Tremor
At Rest, POSTURAL AND INTENTION

Levodopa or chronic thalamic stimulation

Answer 220

A

Both BRAF inhibitors
Used to increase survival in metastatic Melanoma

Activate the MAPK pathway with keratinocytes and cause increased SCC often within the first three months of therapy

Answer 221

A

Recommended in COPD where there are > 2 exacerbations / year and FEV1 < 50%

Phosphodiesterase - 4 inhibitor recommeneded

Answer 222

A

Low Vitamin D
1 alpha hydroxylation occurs in the Kidny

High Phosphate - Kidneys normally excrete phosphate

High phosphate - drags calcium from bones causing osteomalacia
Low calcium due to lack of Vit D and High phosphate
Secondary hyperparathyroidism

Answer 223

A

Aim is to reduce phosphate and reduce parathyroid hormone levels

Reduce dietary phosphate intake
Phophate Binders
Alfacalcidol and calcitriol (VIT D)
Parathyroidectomy

Phosphate binders:
Calcium Carbonate (issues in hypercalcaemia)

Sevelamer - Non calcium direct binder
Reduces Uric acid and Lipid profile

Answer 224

A

1st line
Start with Betablocker
Verapamil in asthmatics

2nd Line
If failed to tollerate with just monotherapy now start DISOPYRAMIDE (negative ionotropic anti arrhythmic that reduces the LVOT - left ventricular outflow tract gradient and reduces mortality

3rd line
Consider Surgical Myectomy, DDR pacemakers and alcohol ablation.

ACEi should be avoided in HOCM as reducing afterload can worsen the LVOT gradient

Answer 225

A

Treatment is with 
Amiodarone
Betablockers or verapamil
Cardioverter defib
Dual Chamber PAcemakers
Endocarditis Prophylaxis

Avoid NItrates and ACE inhibitors

Answer 226

A

Frontal lobe mass that leads to ipsilateral optic nerve compression and raised intracrainial pressure and secondary optic nerve atrophy

Reduced color vision
Reduced visual acuity
optic atrophy in the ipsilateral eye
papilloedema in the contralateral eye
central scotoma in the ipsilateral eye
anosmia

Answer 227

A

Need to move legs
Relieved by movement
Worse at night

Causing an impact on social or life

Treatment with dopaine agonists or Gabapentin

Second line is SSRI

there is a positive family history in 50% of patients with idiopathic RLS
iron deficiency anaemia
uraemia
diabetes mellitus
pregnancy

pramipexole, ropinirole, bromocriptine, levodopa-carbidopa, and rotigotine

Answer 228

A

Clinical features of symptomatic disease
chest pain
dyspnoea
syncope

An ejection systolic murmur (ESM) is classically seen in aortic stenosis. This is decreased following the Valsalva manoeuvre.

Features of severe aortic stenosis
narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure

Causes of aortic stenosis
degenerative calcification (most commo
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
cardiovascular disease may coexist. For this reason an angiogram is often done prior to surgery so that the procedures can be combined
balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement

Answer 229

A

Spastic paraparesis describes a upper motor neuron pattern of weakness in the lower limbs

Causes
demyelination e.g. multiple sclerosis
cord compression: trauma, tumour
parasagittal meningioma
tropical spastic paraparesis
transverse myelitis e.g. HIV
syringomyelia
hereditary spastic paraplegia
osteoarthritis of the cervical spine

Answer 230

A

amyloidosis is a term which describes the extracellular deposition of an insoluble fibrillar protein termed amyloid
amyloid is derived from many different precursor proteins

the accumulation of amyloid fibrils leads to tissue/organ dysfunction

Classification
systemic or localized
further characterised by precursor protein (e.g. AL in myeloma - A for Amyloid, L for immunoglobulin Light chain fragments)

AA amyloidosis occurs secondary to a poorly controlled chronic inflammatory condition such as ankylosing spondylitis or rheumatoid arthritis. The key to treatment is to address the underlying condition.

AL amyloidosis is not linked to another condition and results from abnormal plasma cells producing excessive amounts of light chains in a process similar to multiple myeloma.

Diagnosis
Congo red staining: apple-green birefringence
serum amyloid precursor (SAP) scan
biopsy of rectal tissue

Can cause carpal tunnel

Answer 231

A

Exercised induced anaphylaxis is now well described and is most associated with wheat ingestion. The clinical manifestations usually occur around 10 minutes after exercise and follow a sequence of pruritus, widespread urticaria and then subsequently respiratory distress and vascular collapse. The condition usually resolves on stopping exercise and is managed in the same manner as anaphylaxis. The patients can usually eat the causative food without problems so long as they do not exercise afterwards. The physiology of the condition remains slightly unknown, but it may be related to endorphin release during exercise. The endocrines cause excessive histamine release from mast cells in susceptible individuals.

Answer 232

A

The presence of ST elevation without reciprocal depression shortly following a myocardial infarction is suggestive of a left ventricle aneurysm. Left ventricle aneurysms predispose to both ventricular arrhythmias and cardiac thrombo-embolisms.

Answer 233

A

HTLV-1 associated Myopathy
HAM

Transmitted through sexual contact / breastfeeding / sharing needles

HTLV-I is a retrovirus endemic in southern Japan, equatorial Africa and South America.

Presents with upper motor neurone signs and symptoms particularly in the LOWER Limb

PAtient with 1/5 Lower limbs
Hyperreflexia
Chronic Urinary Retention
HTLV Antibody positive
Steroids have minimal help but only treatment

Answer 234

A

Progressive supranuclear palsy

Overview
aka Steele-Richardson-Olszewski syndrome
a ‘Parkinson Plus’ syndrome

Features
impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)
parkinsonism
falls
slurring of speech
cognitive impairment

Management
poor response to L-dopa

Answer 235

A

deoxygenated blood returns to the right side of the heart via the superior vena cava (SVC) and inferior vena cava (IVC). It has an oxygen saturation level of around 70%. The right atrium (RA), right ventricle (RV) and pulmonary artery (PA) normally have oxygen saturation levels of around 70%
the lungs oxygenate the blood to a level of around 98-100%. The left atrium (LA), left ventricle (LV) and aorta should all therefore have oxygen saturation levels of 98-100%

Dependent on where the lesion is ASD/VSD/ PDA you can figure out which blood will be mixed

Eisenmenger syndrome is reveral of shunt (from R to left)

PDA attaches the Aorta to the PA (therefore PA will have higher oxygen sats)

Answer 236

A

Unexpected severe reaction to medication
Skin, liver Kidneys Lungs and heart are involved
2 - 8 weeks after starting medication

Skin Rash (MORBILLIFORM) 
Inflammation - looks like sepsis

Eosinophilia
Lymphadenopathy
LFT derrangement

Stop Drug
Piriton/steroids for rash

Supportive Care

Drug Reaction with Eosinophillia and Systemic Symptoms

Answer 237

A

Haemolysis, Elevated Liver Enzymes and Low Platelets

A serious manifestation of Pre Eclampsia

HTN, Vomiting and Abdominal Pain

Answer 238

A

Pre Eclampsia is seen after 20 weeks and characterised by Pregnancy induced Hypertension with proteinuria (0.3g/24 hours)

Pre Eclampsia causes:
- Prematurity IUGR
Eclampsia
Haemorrhage
Cardiac Failure
Multi-organ Failure

RF:
HTN, CKD
Autoimmune
T1/2 Diabetes

OTher softer:
- first preg
> 40 
BMI > 35
Muliple pregnancy
Family history

Answer 239

A

Hypertension > 170 
Proteinuria
HEadache
Visual disturbance
RUQ/Epigastric pain
Hyperreflexia
Platelet count < 100

Essenitally - if you are symptomatic from HTN or have any HELP then it is severe

Answer 240

A

Mod - High Risk Preg= Aspirin from 12 weeks 75mg OD

Treat Blood pressure > 160 (oral labetalol)
Nifedipine if asthmatic

Delivery of the baby is ultimate treatment

Answer 241

A

Need pleuradhesis can’t go until this

Answer 242

A

OSA is transient hypercapnea after sleeping

OHS is chronic hypercapnea in the daytime with increased bicarb (like COPD)

Answer 243

A

Motor loss of thumb,, index and middle finger

No sensory loss( that would be median nerve palsy)

Answer 244

A

Hypersensitivity reaction secondary to infections or drugs

Thought to be spectrum of stevens johnson syndrome

Target LEsions
Back of the hands and feed
Pruritis sometimes seen

HSV - 50% of cases 
ORF
IDiopathic
Mycoplasma Streptococcus
Penicillin, sulphonamides, carbemazepine, allopurinol, NSAIDs, OCP , Nevirapine

SLE
Sarcoidosis
Malignancy

Answer 245

A

MEmbranous Glomerulonephritis

Most common cause of nephrotic sydrome in adults ? maybe because it effects some people twice??

Answer 246

A

Plaques:
Mainly cuased by Asbestos
Previous rib fracture

Thickening: Can be Benign or Malignant

Benign is caused by inflammation essentially:
recent inflam
recurrent pneumothoraces
Pleural empyema
Haemothorax
Asbestosis
Silicosis
Malignant:
Mesothelioma
Primary Pleural Lymphoma
Pleural Mets (Lung and Breast most Commonly)

Answer 247

A

Malignant disease of the pleura. Crocidolite blue asbestos is the most dangerous form

Progressive SOB
Chest Pain
Pleural Effusions
Weight loss
Chest Wall pain
Clubbing
30% present with painless pleural effsion

Malignancy of meothelial cells of the pleura
Mets to contralateral lung and peritoneum
R> L lung

CXR - pleural effusion or thickening
Pleural CT
Biopsy nodules
Send Cytology from pleural fluid

Palliative treatmnet
VERY POOR PROGNOSIS

Asbestos also causes increase risk factor for lung cancers with synergistic (x the rf) effect with cigarrete smoking

Answer 248

A

Upper and Lower Zone
Most common in Lower zones (idiopathic pulmonary fibrosis and drugs)

- Upper:
Hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Coal workers (pneumoconiosis
Silicosis
Sarcoidosis
Ankylosing spondylitis
Histiocytosis
Tuberculosis

lower zones - MORE COMMON
Idiopathic Pulmonary fibrosis
Connective tissue (SLE RA)
Amiodarone, Bleomycin, Methotrexate
Aspestosis

Answer 249

A

Chronic lung disease by progressive fibrosis of the intersitium of the lungs
No underlying cause in idiopathic
Seen in 50-70 year olds
More common in men

Progressive Exertional dyspnoea
Fine End inspiratory crackles
Dry Cough
Clubbing

Restrictive Spirometry
FVC reduced, FEV1 Preserved
FEV1 / FVC = Increased

Impaired Gas Exchange - Reduced TLCO
Interstitial shadowing - ground glass then going to honey combing
ANA positive and RF positive in some cases

Rehab
LTOT and Lung Transplant
Poor Prognosis

Answer 250

A

Abdominal Pain
Painful hepatomegaly
Ascites

Answer 251

A

Blocked hepatic veins (stop blood going into IVC) and cause post hepatic obstruction

Lobular Necrosis in the sinusoids - cause nutmeg liver

Portal hypertension (superior mesenteric and splenic vein) causes splenomegaly

Shunts caused oesoph varices, caput medusa and haemorrhoids

Answer 252

A

El Louise
Mostly associated with hypercoaguability
Polycythemia ruba vera is most common cause
OCP
Pregnancy
Paroxysmal Nocturnal Haemaglobinuria (unkown)
Ca

Other secondary causes (from outside compression)
- Tumour
Think of Evie Jane

Answer 253

A

Receive 7 days cipro / rifampicin
think of adam

This is only for meningococcal disesae
Not for Pneumococcal meningitis

Answer 254

A

Raised Conjugated Bilirubin

Otherwise normal LFTs

Benign autosomal recessive disorder with conjugated hyperbilirubinaemia that is conjugated and therefore in the urine.

CMOAT Protein defect

Answer 255

A

Nitrous Oxide abuse can exacerbate the B12 deficiency especially in at risk groups

Answer 256

A

Think small bowel bacterial overgrowth
RF:
- Noenates with congenital GI abnormalities
- DM
- Scleroderma (? Oeosphageal dysmotility)

Looks like IBS - diarrhoea, bloating, abdo pain

Hydrogen breath test - small bwoel aspiration and culture is used

Correction of the underlying disorder normally fixes the problem
Antibiotics )(Co amox or metronidazole)

B12 is Low, Folate High

Answer 257

A

Rare
Autosomal Dominant condition

Hypertension
Hypokalaemia
Acidosis

Will have picture of hyperaldosteronism
Then renin and aldosterone will be low (negative feedback as kidneys are perfused well - this is normal)

Then diagnosis is Liddles
They alter the sodium channels in the distal tubules causing increased sodium absorption

Treatment is with amiloride or triamterene

potassium sparing diuretic

Answer 258

A

Most common muscular dystrophy

delayed relaxation of muscles
Wasting and weakness
Cardiac conduction deficits
Cataracts
Characteristic FAcies

DM1 and DM2

It is autosomal Dominiant
Trinucleotide repeat
DM1 - CTG at end of DMPK gene on 19
DM2 ZNF9 on Chromosome 3

DM1 - Chromosome 19
Distal weakness more prominent

DM2 - ZNF9 chromosome 3
Proximal weakness more prominent
Severe Congenital form not seen

Long Haggard faces
Frontal Balding
Bilateral Ptosis
Cataracts
Dysarthria

Myotonic - spasms of muscles
Distal weakness
Mild cognitive impairment
DM
Testicular atrophy
Cardiac involvement - myopathy or heart block
Dysphagia

Think of the young guy with cardiac arrest at Mansfield ICU

Answer 259

A

MEn < 3.5 = normal

Women < 2.5 = Normal

Answer 260

A

Larval stage of a tpae Worm Taenia Solium
Neurocysticercosis or Extraneural cysticercosis
NCC causes seizures in endemic areas

Ingestion of eggs in tapeworm carier stool
Eggs hatch in small intestine, invade bowel wall and then disseminate via blood to brain, liver, muscle.
Cysts located in the brain - neurocysticercosis and lead to hydrocephalus. Can be very protracted history

Brain is swiss cheese appearance

Bendazoles is the treatment

Answer 261

A

Most Common cause is fire
Found in insecticides, photograph development and metal

Brick Red Skin
Smell of Almods
Hypoxia, Hypotension, headache, confusion
Brady Cardia
Lactic Acidosis 
Confusion
DILATED PUPILS

100% oxygen

4 threapies

Hydroxocobalamin IV
Sodium Nitrite IV
Sodium Thiosulfate IV
Amyl nitrite

Answer 262

A

Inhibition of acetylcholinesterase leading to increased nicotinic, muscarinic and cholinergic neurotransmittion

SLUD (parasympathetic)
Salivation
Lacrimation
Urination
Defication
Bradycardia
Small Pupils

Atropine
Pralidoxime

Answer 263

A

Children and adolescents
May be precipitated by streptococcal infection 2-4 weeks prior
Tear Drop Papules with scaling on the top

Most resolve on their own within 2-3 months
UVB

Answer 264

A

Children and adolescents
May be precipitated by streptococcal infection 2-4 weeks prior
Tear Drop Papules with scaling on the top

Most resolve on their own within 2-3 months
UVB
Lesions are small round or oval with scaly papules
All over the body
Trunk upper back

Answer 265

A

MIBG Scan uses radioactive Iodine to find phaeochromocytoma tumour cells which is detected with the gamma camera

Answer 266

A

Test for medullary carcinoma of the thyroid (associated with MEN 2)

Answer 267

A

Screening tool for carcinoid

Answer 268

A

Used for Renal Artery stenosis (> CT)

Answer 269

A

test for pancreatic malignancy associated with MEN 1

Answer 270

A

Scan for Phaeochromocytoma.

10% of phaeochromocytoma is in the sympathetic chain (similar to neuroblastoma).

Answer 271

A

Mycobacterium Marinum

3-4 week incubation and lesions are painful or painless
Break in the skin then you get lumps
Treatment with tetracyclines, fluoroquinolones, sulfonamides and macrolides

Answer 272

A

Opthalmoplegia, ataxia and areflexia = think miller fisher

Vairant of Guillain Barre Syndrome
Anti GQ1b Antibodies in 90 %

Eye Muscles are typically first effected
Descending paralysis normally
Anti GQ1b

Answer 273

A

Immune mediated demyelination of peripheral nervous system often triggered by infection (Campylobacter classically)

Cross reaction of antibodies with gangliosides in the peripheral nervous system

AntiGanglioside antibodies found in 25% of patients

Anti GM1 Antibodies (25%)

Answer 274

A

Guillain Barre Syndrome

Answer 275

A

Miller-Fisher Syndrome

Answer 276

A

Polymyositis

Answer 277

A

Myasthenia Gravis

Answer 278

A

If resistant disease requires 5 drugs for 18-24 months

If LFTs 5 x the normal limit then stop the medication

Answer 279

A

These are low down in the septum

Answer 280

A

These are high up in the septum

Answer 281

A

These are high up in the septum

Answer 282

A

Stop Interferon Beta

Pregnancy improves rate of relapse during pregnancy, then increases for 6 months post partum, then goes back to normal
There is no risk of progression to progressive disease

Answer 283

A

This is a tool used to gague impact of MS on patients life and measure severity of diease/ relapses

Answer 284

A

Commonest cause of Glomerulonephritis worldwise
Macroscopic Haematuria in young person with an URTI

Associated conditions: 
Alcoholic cirrhosis
Coeliac Disease
Dermatitis Herpitformis
HSP

Mesangial Deposition of IgA immune complexes
Considerable overlap with HSP
Positive immunofluorescence for igA and C 3

Typical patient:
Young male with recurrent episodes
URTI
Very rare progression to renal failure

Answer 285

A

Post Strep
Low Complement levels
Proteinuria > Haematuria
An interval between URTI and renal problems in post strep

Berger’s
- Haematuria
- 2 days post URTI
‘Young males

Answer 286

A

Steroids have no help

Endstage renal failure in 25%

Good Prognosis is Frank Haematuira
Bad is Male and Protein ++

Answer 287

A

Inheritted condition with delayed repolarization of the ventrilces. Can lead to VT/ Torsade de pointes and sudden death.

LQTS1 + 2 are commonest and are from slow rectifier potassium channel defects.

Long QT1 - USually with exertional syncope, oten swimming

Long QT2 - Emotional stress causes syncope

Long QT3 - Events occur at night or at rest

Answer 288

A

Amiodarone, Sotalol

TCA/ SSRIs (citalopram)

Methadone

Chloroquine

Erythromcyin

Haloperidol

Ondanestron

Answer 289

A

Amiodarone, Sotalol

TCA/ SSRIs (citalopram)

Methadone

Chloroquine

Erythromcyin

Haloperidol

Ondanestron

Answer 290

A

Long QT + Deafness

Answer 291

A

Long QT no Deafness

Answer 292

A

Hypocalcaemia, kalaemia, magnesaemia

Also Acute MI, myocarditis, hypothermia and SAH

Answer 293

A

Primarcy Biliary Cirrhosis
IgM
M2 Subtype
Middle Age Females

Answer 294

A

Primarcy Biliary Cholangitis
IgM
M2 Subtype
Middle Age Females

Sjogren’s Syndrome
Rheumatoid Arthritis
Systemic Slcerosis
Thyroid Disease

Answer 295

A

Calcitonin - This is the marker for medullary thyroid cancer

Answer 296

A

Neuroendocrine tumours and Carcinoid Tumours respectively

Answer 297

A

Autoimmune thyroid conditions like hashimotos and Graves

Answer 298

A

Marker for papillary and follicular thyroid carcinoma

Answer 299

A

Inflammatory condition that usually affects the genitalia and is more common in elderly females.

Leads to atrophy of the epidermis
White Plaques
Very itchy
Steroids and emolients

Answer 300

A

Inflammatory condition that usually affects the genitalia and is more common in elderly females.

Leads to atrophy of the epidermis
White Plaques
Very itchy
Steroids and emolients

Answer 301

A

Pruiritic blistering lesions
Larger and peri umbilical
2nd - 3rd trimester
Oral Steroids

Answer 302

A

Pruritic condition of the last trimester
Abdominal striae
Topical steroids - oral

Answer 303

A

Acute encephalitis
Agitation
Hypersalivation
Hydrophobia

Dog or animal bit in foreign country
Need irrigation of the wound
Need IVIG x 2 doses
If immunised need 2 further doses of the vaccine
If un immunised

Answer 304

A

Acute encephalitis
Agitation
Hypersalivation
Hydrophobia

Dog or animal bit in foreign country
Need irrigation of the wound

If immunised need 2 further doses of the vaccine

If un immunised
Need IVIG doses in first 7 days
Then need full vaccination course
Use newer vaccinations over nerve based ones

Answer 305

A

Acute encephalitis
Agitation
Hypersalivation
Hydrophobia

Dog or animal bit in foreign country
Need irrigation of the wound

If immunised need 2 further doses of the vaccine

If un immunised
Need IVIG doses in first 7 days
Then need full vaccination course
Use newer vaccinations over nerve based ones

Answer 306

A

Ciliary dysmotility

Answer 307

A

Think Bronchiectasis

IgA immuno deficiency and hypogammaglobulinaemia cause Bronchiectasis

Answer 308

A

Think Bronchiectasis

IgA immuno deficiency and hypogammaglobulinaemia cause Bronchiectasis

Answer 309

A

Deficiency of a Protease inhibitor produced by the liver
This is protective against neutrophil elactase

Non smoking COPD - think alpha 1 antitrypsin
Linked on 14 chromosome

Allells are looked at on electropheresis
Allells - M= normal, S= slow, Z = very slow
PiMM is normal
PiSS is 50% of normal alpha 1 anti tripsin speed
PiZZ is 10% of normal alpha 1 antitripsin speed

PiZZ normally manifest disease

Mainly emphysema in lower lobes
Also Liver cirrhosis in 1%

Spirometry shows obstructive picture!

Answer 310

A

FIrst-line treatment over seven days:
If no allergies: PPI, amoxicillin and clarithromycin or metronidazole
If penicillin allergic: PPI, clarithromycin and metronidazole
If penicillin allergic and previous clarithromycin exposure: PP, bismuth, metronidazole and tetracycline

Answer 311

A

Actinomyces israelii

chronic, progressive granulomatous disease caused by filamentous Gram-positive anaerobic bacteria

Actinomycetaceae family.

typically causes oral/facial abscesses with sulphur granules in sinus tracts
may also cause an abdominal mass e.g. in the right iliac fossa

The mass forms multiple sinus tracts

Histological: Gram-positive organisms and sulphur granules.

Answer 312

A

Actinomyces israelii

chronic, progressive granulomatous disease caused by filamentous Gram-positive anaerobic bacteria

Actinomycetaceae family.

typically causes oral/facial abscesses with sulphur granules in sinus tracts
may also cause an abdominal mass e.g. in the right iliac fossa

The mass forms multiple sinus tracts

Histological: Gram-positive organisms and sulphur granules.

Long-term antibiotic therapy usually with penicillin

May require surgery in necrosis or abscess formation

Answer 313

A

Actinomyces israelii

chronic, progressive granulomatous disease caused by filamentous Gram-positive anaerobic bacteria

Actinomycetaceae family.

typically causes oral/facial abscesses with sulphur granules in sinus tracts
may also cause an abdominal mass e.g. in the right iliac fossa

The mass forms multiple sinus tracts

Histological: Gram-positive organisms and sulphur granules.

Long-term antibiotic therapy usually with penicillin

May require surgery in necrosis or abscess formation

Answer 314

A

Nocardia

Basics
typically causes pneumonia in immunocompromised patients
may also cause brain abscesses

Answer 315

A

Nocardia

Basics
typically causes pneumonia in immunocompromised patients
may also cause brain abscesses

Sulphur granules seen

Answer 316

A

Hypoglycaemia

Causes
insulinoma - increased ratio of proinsulin to insulin
self-administration of insulin/sulphonylureas
liver failure
Addison’s disease
alcohol

Other possible causes in children
nesidioblastosis - beta cell hyperplasia

Answer 317

A

Is a mraker of endogenous insulin secretion
Can be used to investigat insulinoma
Fasted Insulin and C peptide levels (supervised) will be normal if no insulinoma

These will be raised in insulinoma causing the hypoglycaemia

Answer 318

A

Is a mraker of endogenous insulin secretion
Can be used to investigat insulinoma
Fasted Insulin and C peptide levels (supervised) will be normal if no insulinoma

These will be raised in insulinoma or sulphonyl urea poisoning causing the hypoglycaemia

Answer 319

A

Foods causing false positive 5-HIAA urinary collection results:
Banana
Avocado
Aubergine
Pineapple
Plums
Walnuts
Tomatoes

Drug
Flouracil
Caffeine
Naproxen 
Paracetamol

Answer 320

A

Aspirin, Levodopa, Methyldopa, ACTH

Answer 321

A

Correct Iron
Ferritin < 100 or Transferrin sats > 20% then give iron infusion

Folowing this - give the EPO

Answer 322

A

Small BActerial Overgrowth Syndrome

RF: DM, Scleroderma and Neonates with GI abnormalities
Rifamixin
Co amoxiclav
Metronidazole

High FOLATE
Low B12

Answer 323

A

H. Pylori

Answer 324

A

New treatment for osteoperosis
Human MAB
Stops RNAKL osteoclasts
Can be given to prevent path fractures if boney mets are present

If low eGFR - this is the preferred treatment of osteoperosis

Answer 325

A

Less than 20mmHg

Answer 326

A

Intraepidermal SCC
Elderly Ladies get it
Red Scaly Patches
Sun Exposed Areas like lower limb

Answer 327

A

Gram positive cocci
Associated with close contact with animals and unpasturised milk
Treatment is Doxycycline and Rifampicin for 8 weeks

Features
non-specific: fever, malaise
hepatosplenomegaly
sacroilitis: spinal tenderness may be seen
complications: osteomyelitis, infective endocarditis, meningoencephalitis, orchitis
leukopenia often seen

Diagnosis
the Rose Bengal plate test can be used for screening but other tests are required to confirm the diagnosis
Brucella serology is the best test for diagnosis
blood and bone marrow cultures may be suitable in certain patients, but these tests are often negative

Answer 328

A

Autosomal recessive disesae of HDG deficiency
Tyrosine metabolism therefore not possible
then toxic build up of homogenistic acid
Urine is black
Pigmented sclera
Then the acid builds up in cartilage and tissue
Causes calcification of intervertabral discs- causing back pain
Renal Stones

Change of Diet
High Dose Vitamin C

Looks like bamboo spine

Answer 329

A

25% of all Drug induced AKI
Causes
drugs: the most common cause, particularly antibiotics
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
systemic disease: SLE, sarcoidosis, and Sjögren's syndrome
infection: Hanta virus , staphylococci

Features
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension

Answer 330

A

2 or more attacks per month
Topiramate or propanolol

Propanolol in child bearing women (Topiramate is teratogenic)

Toperamte in asthma

2nd line is acupuncture

Answer 331

A

eGFR in high muscle mass or low muscle mass

Answer 332

A

Post Bronchodilator FEV1/FVC = < 0.7

+

Stages:
FEV1 <80% predicted = 1 
FEV1 50-80% of Predicted = 2 
FEV1 30-50% of PRedicted = 3 
FEV1 <30% of PRedicted = 4

Answer 333

A

Can have metformin to reduce the insulin side effects and improve glycaemic control

Answer 334

A

Progressive marrow failure
Massive >10cm or progressive lymphadenopathy
Massive > 6cm or progressive splenomegaly
Progressive Lymphocytosis (>50% increase in 2 months)
Systemic symptoms
Autoimmune cytopaenia

Answer 335

A

? For Treatment - ? indicated

If not indicated - regular blood test

Fludarabine, Cyclophosphamide and rituximab is initial treatment FCR

Ibrutinib for those who failed prev FCR

Answer 336

A

Chemo for those who fail initial Fludarabine, Cyclophosphamide and rituximab treatment for CLL

Answer 337

A

Fludarabine, Cyclophosphamide and rituximab for CLL

Answer 338

A

DEVIC’s Disease
Demyelinating condition associated with anti NMO antibodies - Aquaporin 4 antibodies. This presents with demyelination of the optic nerve and spinal cord.

More severe corse than MS

Particularly prevalent in asian populations
Optic nerve and cervical spine
2/3 of the following

Spinal Cord Lesion involving 3 or more levels
2 Initially normal MRI brain
Aquaporin 4 positive serum antibody

Answer 339

A

Seen in MS - Worsening of symptoms associated with heat. This could be hot weather, exercise, hot bath or tubs or saunas

Answer 340

A

Causes pancreatitis
Treated with Fibrates
Statins do reduce triglyceride levels but they are manly indicated in mixed hyperlipidaemia

Answer 341

A

Rare complication of endstage renal failure. Depsoitions of calcium within arterioles causing microvascular occlusion and necrosis. This causes painful necrotic skin lesions.

Hypercalcaemia, hyperphosphataemia and hyperparathyroidism

Warfarin causes / exacerbates / is contra indicated in Calciphylaxis

Treatment is trying to control cal phosph and pth levels and avoid calcium and warfarin.

Answer 342

A

Get a restrictive lung picture
FEV1 normal, FVC decreased, FEV1/FVC increased

Pulmonary rehab

Pirfenidone (antifibrotic agent) is used in selected patients

Nintendanib Also in certain circumstances

Answer 343

A

Inferior portions of ventricles supplied by the Right Coronary artery

Also supplies the SAN and AVN Therefore heart block followin inferior MI is failry common and transient after PCI

Escape rhythm comes from high up in conductive system so narrow QRS as goes down bundle of his

Answer 344

A

Heart block is uncommon but shows significant damage to ventricular myocardium and conductive system

Escape rhythm therefore starts distally resulting in a broad complex ventricular escape rhythm - wide QRS

Answer 345

A

Pentad

Microangiopathic haemolytic anaeia
Thrombocytopenia
Fever
Neurological fluctuation
Renal Failure

Microangiopathic haemolytic shown by schistocytes

TTP is inherited or acquired

Inhertied - Deficiency of ADAMTS13 Gene
Therefore Deficient of the enzyme

Acquired - Much more common
An Inhibitor of ADAMTS13 Enzye - redcued activity

ADAMTS13 normal function
- Cleave vWF multimers into vWF monomers

In TTP this is reduced therefore increased vWF multimers - Causing platelet microthrombi and decreased platelets
- Microthrombi

In acquired TTP it is IgG inhibition

Coombes test negative

MCV normal 
Intravascular haemolysis:
- LDH high 
- Haptoglobin low
- Hemosiderin urea 
- Hyperbilirubinaemia
- Platelets low

Treatment is with Plasma Exchange - new plasma to increase ADAMST13 Enzymes

Answer 346

A

Autosomal recessive Deficiency of ADAMTS13 Enzyme causing TTP

Answer 347

A

post-infection e.g. urinary, gastrointestinal
pregnancy
drugs: ciclosporin, oral contraceptive pill, penicillin, clopidogrel, aciclovir
tumours
SLE
HIV

Answer 348

A

Increased risk
Surveillance is done on mild, mod, severe risk

Mild (EVERY 5 YEARS)
Extensive colitis with no active endoscopic/histological inflammation
OR left sided colitis
OR Crohn’s colitis of <50% colon

Mod (EVERY 3 YEARS)

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

Severe (EVERY YEAR)

Extensive colitis with moderate/severe active endoscopic/histological inflammation
OR stricture in past 5 years
OR dysplasia in past 5 years declining surgery
OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
OR family history of colorectal cancer in first degree relatives aged <50 years

Answer 349

A

Guillain-Barre syndrome describes an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni)

Weakness in the lower extremities are affected first, however it tends to affect proximal muscles earlier than the distal ones

reflexes are reduced or absent

sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs
around 65% of patients experience back/leg pain in the initial stages of the illness

Slightly raised protein on CSF

Answer 350

A

Common in Crohns post terminal ileal resection
Terminal ilium absorbs bile acids
Without this can have chronic diarrhea
Secondary causes are often seen in patients with ileal disease, such as with Crohn’s. Other secondary causes include:
cholecystectomy
coeliac disease
small intestinal bacterial overgrowth

the test of choice is SeHCAT
nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT)
scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT

Management
bile acid sequestrants e.g. cholestyramine

Answer 351

A

Selenium scan for Bile Acid Malabsorption

Answer 352

A

Ciprofloxacin

Levofloxacin

Answer 353

A

Magnesium, ammonium phophate stones are formed in urinary amonnia high levels and alkaline urine > 7.2.

Urea-releaseing bacteria hydrolyze the ammonium (Proteius, Klebsiella and Mycoplasma)

Occurs in women more commonly

Hypercalaemia is another risk factor

Answer 354

A

Na < 135
Serum Osm < 271
Urine Osm > 100

Euvolaemic patient

Answer 355

A

Malignancy (Small cell lung CA/ Prost/ Panc)

Neuro (Stroke, SAH, Subdural, Infection)

Infection (TB, Pneumonia)

Drugs: Sulfonylurea, SSRI, Carbamazepine, Cyclophosphamide, Vincristine

PEEP
Porphyrias

Answer 356

A

Slow correction to avoid central pontine Myelinolysis

Fluid REstriction

Demeclocycline

ADH (Vasopressin) antagonist

Answer 357

A

An Acquired immune mediated demylinating neuropathy
MND like symptoms but responds to IVIG

Typically it presents with aseymmetric bi brachial motor weakness wihtouth sensory or bulbar involvement

Treatmnet is IVIG

Answer 358

A

Seen in plasma transfusions and cause of most morbidity in trasnfusions.

Human Luecocyte antibodies / Neutrophil antibodies in the donor plasma lead to non cardiogenic pulmonary oedema due to increased vascular permeability.

Hypoxia, Pulmonary infiltrates on Chest X ray, Fever, Hypotension

Stop Transfuision
Oxygen
Supportive care

Answer 359

A

Performed with the Mantoux test
Type 4 Hypersensitivity Reaction
Interferon gamma blood test then used

Mantoux test:
0.1ml of 1:1000 purified protein derivative is injected intradermally
Read 3 days later

If induation < 6mm - Negatvie - no significant hypersensitivity to tuberculin protein - PREVIOUSLY UNVACCINATED

If Induration 6-15mm - Postivie- hypersensitive to tuberculin protein. NOT FOR BCG - PREVIOUS TB or PREVIOUS BCG

15 mm + = Strongly positive hypersensitive to tuberculin protine - SUGGESTIVE OF TB INFECTION

Answer 360

A

TB - stain

Answer 361

A

STart 4 x Antibiotics for TB

Then start CEF and Vanc and Dex as well to treat for Bacterial Meningitis too

Answer 362

A

Lithium
Beta Blockers
Antimalarials
Non Steroidal anti inflammatory
Ace I
Tetracyclines and Penicillins

TRauma and Alcohol

Strep = Guttate Psoriasis

Answer 363

A

FSH and LH
If LH and FSH are High then it would suggest a Primary cause of hypogonadism

If LH and FSH are low then suggests secondary

If Primary:

Klinefelter’s
Kallman
Childhood Mumps
Testosterone levels declining with age

IF Secondary needs:

Prolactin
Morning Cortisol
MRI of Pituitary

Answer 364

A

Loss of libido
Erectile Dysfunction
Lethargy
Decreased Muscle mass and Strength
Reduced facial hair growth
Impaired Glucose Tolerance

Answer 365

A

Late Consequence of NEurosyphillis
Slow degeneration (demyelination) of neural tracts of the dorsal root ganglia of the spinal cord

Trep Palladium

20 years after infection
Radicular parethesia
Thunder bold pain in limbs, back and face
Broad based foot slapping gait - senosry ataxia
Loss of reflexes in lower limbs
Argyll Roberson Pupils - small pupil, loss of light reaction but preserved accomodation

Answer 366

A

Done with B2 - microglobulin and albumin

Answer 367

A

Sniffing Glue

Increases Dopamine- euphoria

Irritation of the eyes, nose and respiratory tract from inhalation. 
Ataxia
Confusion 
Headache 
Euophoria

Answer 368

A

Condition of hyperpigmented macules in sun exposed areas.

Found in women on Hormone therapy Pill or Pregnant

Answer 369

A

Gastric Malt Lymphoma
H Pylori infection in 95% of cases
Good Prognosis
If low grade then 80% respond to H Pylori Eradication

Answer 370

A

Urine Na < 20
Urine Osm > 500
Serum urea: Creatinie ration Increased
Urine: Plasma Urea > 10

Answer 371

A

Give IVIG Whatever the time between the exposer
then the 5 dose schedule of Rabies Vaccination
0, 3, 7, 14, 28 days

Answer 372

A

5-HT2 Receptor Antagonist

USed in Seretonin Syndrome Resistant to initial control with oral diazepam

Following this with respiratory failure, coma, rigidity or severe hyperthermia - Intubate and Ventilate with Chlorpromazine

Answer 373

A

Reduced GCS, Paralysis, Bilateral Pin Point Pupils

First ORder Sympathetic tracts - bilateral horners syndrome

Answer 374

A

Fixed, Mid point pupils

Answer 375

A

Ipsilateral hornders syndrome and pin point pupil

Answer 376

A

Lateral medullary syndrome:
Medulla is supplied by vertibral artery and PICA
Stroke leads to:
- Spinothalamic damage- contralateral pain and temperature loss
- Hypothalamic spinal damage - Ispilateral horners
- Ipsilateral Ataxia (spinocerebellar tracts)

Cranial nerve involvement:
- Hoarse voice and dysphagia (cranial nerves IX - XII
Vertigo (VIII)
Facial parathesia - Cranial nerve V root is here too

Answer 377

A

Anti Nuclear Antigens
Antigen Antibody Complex then leads to build up in organs and damage

Fever Joint Pain Rash in Woman
Multi organ
therefore hard to diagnose:

4 of these 11

Malar Butterfly rash
Discoid Rash
Photosensitivity
Ulcers

Pleuritis / Pericarditis

Arthritis

Kidney Involvement

Neurological Disorders

Anaemia, Thrombocytopenia, Leukopenia

Antibodies:

ANA positive (very sensitive)
Anti Smith - Anti dsDNA - Anti Phopspholipid

Trigger 
UV radiation
Estrogen
Virus
Bacteria
Drugs

Answer 378

A

Sjogren’s syndrome

Anti Ro can cross placenta and cause congenital heart block which can reuquire pacing at birth

Answer 379

A

Rhuematoid

Answer 380

A

Available for people 70-79
Live Attenuated
Immunosuppression therefore a contra indication

Management of acute shingles is with oral acyclovir

Answer 381

A

Take insulin before bed and wake up with high blood sugar levels (rebound high)
Paradoxically you should lower the insulin before bed

Too low overnight then get a rebound secretion of glucagon etc to increase blood sugars

Answer 382

A

Treat Precipitating Cause
Lactulose
Rifamixin (used in bacterial overgrowth too)
Lactulose promotes excretion of ammonia causing gut bacteria to metabolise it
Antibiotics like rifamixin modulate gut flore so reduced ammonia production

Answer 383

A

Treatment with radiofrequency ablation is usually well tollerated and successful

Surveillance should be done endocsopically every 6 months for first year then annually after that

If High grade dysplasia or intra mucosal carinoma, then every 3 months for first year, 6 months for sedond year and then annually

Answer 384

A

Autosomal recessive disorder with defect in the ATM gene

Causes one of the inherited combined immunodeficiency disorders presenting with abnormal movements in childhood at age 2 years old

Cerebellar Ataxia
Telangectasia
IgA deficiency
Increased risk of Lymphoma na dluekaemia

Hypogammaglobulinaemia

Answer 385

A

Trypanosoma Cruzi from South America

2 forms of Trypanosomiasis - African (sleeping sickness) and Chaga’s

American Trypanosomiasis is caused by T Cruzi

Chagoma (erythematous nodule at site of infection)
Perioorbital swelling (romana sign)
Heart and GI tract effect chronically

Myocarditis with dilated cardiomyopathy
Gastointestinal is mega oesophagus and mega colon that causes constipation and dysphagia

AZOLE for Treatment
First line is Benznidazole

Answer 386

A

Trypanosoa rhodesiense is by the Tsetse fly.
More acute
Chancre - nodule at site of infection
Posterior cervical lympho nodes

Then CNS involvement - Sleepyness, headaches, mood changes, meningo ecnephalitis

IV pentamidine
IV melarsoprol
`

Answer 387

A

Amiodarone
Bleomycin, Bromocryptine
Cabergoline
DMARDS - Methotrexate, Sulfasalazine
Nitrofurantoin

`

Answer 388

A

R Wave TALL in V1 and V2

Answer 389

A

Interstitial lung disease in coal miners with RA. Muliple nodules on CXR

Answer 390

A

Maturity onset Diabetes of the Young

Esentially this is T2 DM in < 25 year old person
Autosomal dominant so there is lots of family history

MODY 3 = 60%
HNF1 alpha gene defect
Increased risk of HCC

MODY 2 = 20% of cases
Due to glucokinase gene defect

Treatment is with sulfonylureas

C peptide is good marker of insulin production and can reule out Type 1 DM
If C Peptide is high, then is T 2 as there is insulin production just not enough

Answer 391

A

1/6 people on amiodarone get thyroid problems

Amiodarone induced hypothyroidism

Amiodarone induced thyrotoxicosis is in 2 types
Type 1 - Excess iodine causes excess hormone production. This has a Goitre and is treated with Carbimazole

Type 2 - Amiodarone causes destructive thyroiditis. Destruction on US, no goitre and treated with STeroids

Answer 392

A

Cause of Thunderclap headhache (max intensity within minute 10/10) with normal CT and LP (aka not SAH)

Vasoconstriction after Cannabis, post partum or seretonin
Throbbing headhace and seizures
Beading on CT A

Can cause bleeds and strokes

Answer 393

A

Cause of Thunderclap headahce with normal CT and LP (AKA Not SAH)

Swelling of brain usually as a result of underlying cause.

Headhace, changes in vision and seizures.

High BP, CKD, Infection, Autoimmune disease and Pre Eclampsia are the usual causes

Answer 394

A

SAH
Cerebral Venous Sinus Thrombosis
Artery Dissection
Pituitary apoplexy
Reversible Cerebral Vasoconstriction
Posterior Reversible Leucoencephalopathy syndrome
Hypertensive crisis

Answer 395

A

Caused by tumor most commonly but 80% not diagnosed previously
Sudden headache, visual field defect
MRI imaging
May have normal CT

Answer 396

A

Best Treatment for Lupus Nephritis is Mycophenolate Mofetil

Start by treating with steroids and cyclophosphamide then switch to mycophenolate long term

Answer 397

A

BAsically Scabies if treated properly should not have any burrow markes or tract marks. There may be pruritis up to 6 weeks after due to allergic reaction.

However, if failed treatment with permethrin 5% and everything done properly - then treat with different insecticide. Like Malthion 0.5%

Answer 398

A

Management:
- Nifedipine

Heller Cariomyotomy
Botox
Baloon Dilation

Answer 399

A

Start with steroids

Induce remission
Then start Azothiprine or Metocaptopurine
Before starting this check TPMT

If TPMT low then need to not give above and give Methotrexate instead

If early severe disease or resistant disease consider infliximab

Metrionidazole for peri anal disesae

Mesalazine should be considered in previous surgery

Answer 400

A

Transferrin Saturation
NOT FERRITIN - Acute phase reactant

Trans ferritin Sats > 55%
Raised ferritin and Iron
Low TIBC

Venesection is the first line treatment
Following this
Desferrioxamine is second line
Aim Transsferrin sats < 50% and Serum ferritin below 50

Answer 401

A

Small Cell Lung Cancer
- Lamber-Eaton Myasthenic Syndorome
Antibody against pre synaptic voltage gated calcium channel
Causes weakness that gets better with repeated movements

Anti Hu Syndrome- Sensory neuo[athy and cerebellar syndrome
anti GAD
Still persons syndrome

Anti Ri
Ocular opsoclonus- myoclonus

Answer 402

A

Associated wtih ovarian and breast cancer

Cerebellar syndrome

Answer 403

A

Breast, colorectal and small cell lung cancer

Stiff person’s syndrome or diffuse hypertonia

Answer 404

A

Ocular opsoclonus myoclonus

Breast and small cell lung cancer

Answer 405

A

Anti HIV drug inhibits P450 system

May increase seretide levels or fluticasone therefore make you more likely to have adrenal insufficiency

Answer 406

A

PC BRAS - induce (Fits, TB, DM, Alcohol)

Phenytoin
Carbamazepine
Barbiturates
Rifampicin
Alcohol (long term)
Sulphonylureas (gliclazide)/ St John's Wart

These reduce the other drugs concentration metabolised by cyctocrome P450 aka Warfarin, Steroids, COCP

Answer 407

A

O DEVICES

Omeprazole
Disulfiram
Erythromycin
Valpropate
Isoniazid
Ciprofloxacin
Ethanol (acutely)
Sulfonamides (Sulfasalazine)

These increase the other drugs concentration metabolised by cytocrome p450 aka warfarin, steroids, cocp

Answer 408

A

Rough patches seen in dermatomyositis. They are seen on start of the extensor aspect of fingers. (MCP and PIP Joint)

These are accompanied by heliotrope rash around the eyes

This is either idiopathic dermatomyositis or secondary to malignancy- this is common

Answer 409

A

Annular erthema
Looks like dried red larva ‘wood grain’
Seen in malignancy
Lung Cancer

Answer 410

A

Symmetrical proximal mm weakness with skin lesions
Inflammatory process
Idiopathic or malignancy

Ovarian, breast and lung cancer

Polymositis is without skin involvement

Skin:
Photosensitive
Gottrons
Heliotrope rash periorbitally
Macular rash - back and shoulder
Nail fold capillary dilatation

Proximal mm weakness
Resp mm weakness
ILD
Raynauds
Dysphagia/ Dysphonia

ANA positive
Anti Jo 1 Antibodies
Anti Mi - 2 Antibodies
Anti SRP antibodies

Answer 411

A

Autosomal Recessive Disorder by the formation of recrrent renal stones
COLA defect
Semi opaque on x ray
Need a cyanide nitroprusside test to diagnose

Treatment with
Hydration
D pinicillamine
Urinary Alkalinization (Bicarb)

Answer 412

A

Seen in 2nd Trimester - 3rd trimester
Itchy feet
ALT < 3 x normal
Bile Acids +++ (10-100x)
Ursodeoxycholic acid and delivery (Induce at 37 weeks)

No Rash
No Jaundice but raised bilirubin

Answer 413

A

3rd Trimester or post partum

Abdominal Pain
N +V 
Headache
Jaundice
HYPO Glycaemia 
Pre Eclampsia

ALT very raised
Supportive treatment and delivery of the child

Answer 414

A

Aim for Reduction in HbA1c by 11%

Aiming for HbA1c < 48 (6.5%)

Add another drug is > 58mmol (7.5%)

Answer 415

A

Rheumatoid Arthritis

Answer 416

A

Mixture of upper motor neurone and lower motor neurone features
PSeudo-Bulbar ‘ Donald Duck ‘ speech - nasal, high pitch
Tongue Fasciculations

Treatment of MND:
NEurological condition that can present with both upper and lower motor neuron signs. Resents > 40
Amyotrophic lateral sclerosis, progresive muscular atrophy and bulbar palsy

Treatment
Riluzole - stimulates glutamate receptors
Prolongs life by 3 months

Non invasive Ventilation BIPAP at night
7 months added on

Answer 417

A

Neuropsychiatric toxicity
Psychosis
Is cp450 drug

Answer 418

A

Ethambutol - E - Eye
Optic neuritis
Colour vision loss first sign

Answer 419

A

Causes red secretions

Answer 420

A

Peripheral neuropathy
Pyridoxine Hydrochloride Vitamin B6
Used to prevent this and sideroblastic anaemia

Also used with penicilamine D for prevention of neuropathy in wilsons patients

Answer 421

A

Water Deprivation test - urine osm stays exactly the same throughout

Treatment with Thiazides and Low Salt/ Protein Diet

Answer 422

A

Urine Dithionate Testing
Try to confirm or exclude exposure to paraquat
Positive within 6 hours and remains for a few days
Administer Fullers Eart before result is back

Answer 423

A

Dukes’ classification and 5-year survival rates
Stage 5-year survival

A - confined to mucosa and submucosa
95% in men and 100% in women

B - extends through the muscularis propria
> 80% in men and 90% in women

C - regional lymph nodes involved
65% in men and 65% in women

D - distant spread
> 5% in men and 10% in women

Answer 424

A

Anti HIV med thtat causes cognitive/neuro sypmtoms when starting in 50% of patient sin the first month

Answer 425

A

Amiodarone

Aspirin- can make it owrse

Answer 426

A

Management
WHO-recommended triple therapy: rifampicin, dapsone and clofazimine

RDC Rif, Dap, Clof

Think hypopigment and sensation loss
Alopecia
Foreign travel
Slow growing

Answer 427

A

Calcitonin

Answer 428

A

subacute combined degeration of the cord SCDC 
Montor Neurone Disease
Friedrich's Ataxia
Tabes Dorsalis
Dual Peripheral with central pathology

Answer 429

A

Monotherapy
Monitor CRP and DAS28 score to see response
Flares - steroids
Methotrexate is most widely used 
Sulfasalazine 
Hydroxychloroquine

If there is an inadequate response to 2 DMARDs (including Methotrexate) then start TNF alpha inhibitor:

Entanercept (can cause demyelination and reactivation of TB)

Infliximab (Reactivation of TB)

Also can give Rituximab - Anti CD20 monoclonal antibody resulting in B cell depletion

Answer 430

A

Non Small Cell
- Radio therapy mainly

20% are suitable for surgery

? Fit for surgery 
- Peripheral tumour
No malignant effusion, vocal cord involvement, SVC obstruction
FEV1 > 1.5 L for Lobectomy
FEV1 > 2 L for pneumonectomy

Small Cell

Poor Prognosis
Treatment offered for 1 - 2 disease
Chemo and Radiotherapy usually

10 % 5 year survival from Lung Ca

Answer 431

A

Clinical or biochemical evidence of hyperadrogenism
Evidence of oligo or an ovulation
Presence of polycstic ovaries

Answer 432

A

Weight Reduction
COCP

Acne/ Hirsutism
COCP
Spironolactone

Infertility
Weight loss
Clomifene
Consider Metformin too

Answer 433

A

Start Heparin infusion
This is quickest to reverse
Neuro obs
Stop if further deterioration ie re bleeds

Answer 434

A

Alcoholic Hallucinosis is a rare condition that occurs in intoxication or withdrawal of alcohol.

Consciousness in tact
Auditory Hallucinations heared
Resolve in 6 months

Answer 435

A

Chemo-Radiotherapy

Surgical

Answer 436

A

HCG - stimulate the gonads
FSH- Stimulate ovulation
Then once ovulated- Harvest the Eggs and Start IVF

Answer 437

A

Valproate and Ethosuximide

Avoid CarbeMAZEapine
Makes Abscence and Juvenille myoclonic epilespy worse.

Answer 438

A

Benign epithelial tumour
Advancing age
Smooth Dome
Volcano

Answer 439

A

Acute onset
Pain
Pupil small and irregular
Photophobia
Blurred Vision
Red Eye
Hypopyon

Ankylosing Spondylitis
Reactive Arthritis
Ulcerative Colitis
Becet's Disease
sarcoidosis

Atropine
Steroids

Answer 440

A

Narrow pulse pressure
Slow Rising Pulse
Delayed ESM
Absent S2
S4 
ESM decreased following valsava

Answer 441

A

Direct Coombs Test
Warm - IgG positive
SLE, CLL, Lymphoma, Methyldopa

Cold- IgM positive
Lymphoma, Mycoplasma, EBV

Answer 442

A

Older MEn
IgM Paraproteinaemia
Weight loss
Lethargy
Hyperviscous
Heptamosplenomegaly
Lymphadenopathy
Raynauds

Answer 443

A

Myeloid failure
RBCs, Platelets and Neutrophils low
Plenomegaly
Splenomegaly
Infections
Fatigue

Acute Promyelocytic Leukaemia M3
t(15:17)
PML and RAR alpha gene fusion
Young people < 25
Good Probnosis

Answer 444

A

Hypercalcaemina

Answer 445

A

PITS - homonoymous
Parietal is Inferior
Temporal is Superior

Craniopharyngioma is inferior homonymous quadrantanopia

Answer 446

A

Unilateral = Temporal lesion

Bilateral = Pituitary

Answer 447

A

Most common haemolytic anaemia
Autosomal Dominant
Biconcave disc is now sphere

Failure to thrive
Jaunic,e Glalstones
Splenomegaly

APLASTIC CRISIS precipitated by PArvovirsu infection
Osmotic fragility test previously recommended but no longer

Patients with FH, Typical features and lab tests don’t require any other tests
Cryoheaeolysis and EMA binding if needed

Acute Hammolytic crisis - suporitve
Transfusion

Folate replacement and Splenectomy in the long run

Answer 448

A

Hypokalaemia and Normotension

Answer 449

A

Hpokalaemia and Hypertension

Answer 450

A

Hypokalaemia and Normotension

Answer 451

A

Diuretics
Gilteman
Bartter's
RTA 1 + 2 
Diarrhoea

Answer 452

A

Cushings
Liddle’s
Primary Hyperaldosteronism
11 beta hydroxlase deficiency

Answer 453

A

Chronic Autoimmune Thyroiditis
Hypothyroidism after transiet hyperthyroidism

Female
Hypothyroid
Goitre- firm non tender

Anti thyroid peroxidase and anti thryoglobulin antibodies present

Development of MALT lymphoma
Other Autoimmune conditions common

Answer 454

A

Restless legs dsyndrome and Parkinsons

Answer 455

A

Flexion/Extension/rotation of Muscles of the hand. Suddenly

Relieved by stimulating another body part

Answer 456

A

Swap to Risedronate or Etidronate

Answer 457

A

scl 70 = Diffuse

Anti Centromere Antibodies = Limited

Answer 458

A

SICKFACES. COM

Sodium Valproate
Isoniazid
Cemetidine
Ketaconazole
Fluconazole
Alochol
Chloramphenicol
Erythromycin
Sulphonamides
Ciprofloxacin
Omeprazole
Metronidazole

Answer 459

A

scl 70 = Diffuse

Anti Centromere Antibodies = Limited

Answer 460

A

African Eye worm

2 symptms
Calabar Swellings around hands and arms that move - angio edema

Eye worm moving across the eye ball

Treatment:
Removal
DEC - diethylcarbamazine
or Albendazole

Answer 461

A

Pioglitazone

USed in severe NAFLD with cirrhosis even in the abscene of diabetes

Answer 462

A

Steatosis - Fat in liver
Steatohepatitis - Fat in liver with associated inflammation (ALT up)
Progressive disease to fibrosis and cirrhosis

Hepatic Manifestation of metabolic syndrome - Insulin resistence

Non Alcoholic Steatohepatitis NASH is used to show changes similar to alcoholic hepatitis in the absence of alcohol abuse.

4% population have NASH
- Obesity
T2DM
High Cholesterol
Sudden Weight loss

Increased echogenicity on ultrasound and ALT greater than AST

Enhanced liver Fibrosis blood test to check. > 10.5 is suggestive of Advanced cirrhosis

if ELF not avaialbe FIbroScan - Liver stiffness on US

Biopsy is the next stage

Weightlos and lifestyle measurements
Pioglitazone

Answer 463

A

Iron Chelating agent used in haemochromatosis treatment

Answer 464

A

Monitor Cardiac and liver function

Pregnancy will lower iron
Monitor Ferritin
If normal, observe
If low treated iron deficiency
If high phlebotomy

Answer 465

A

Inflammatory process of cartilage
Effects the ears and nose commonly with pain and inflammation

No specific antibodies

Can have scleritis, episcleritis and arthropathy as well

Answer 466

A

If > 50% in 7 days but another alternative diagnosis (sepsis)
Then do Anti Platelet 4 antibodies

if moderate or low positive

Then final test is Seretonin release assay - this is highly specific

Answer 467

A

From a neurendocrine tumour that then secretes neurotransmitters

Needs to be in the liver to have carcinoid syndrome

Seretonin is one of the neurotransmitters secreted

Diarrhoea (increased motility)
Tricuspid Regurgitation (mid diastolic murmur) - due to fibrosis of the heart
Bronchoconstriction

Histamine and bradykinin also released
This leads to flushing (red Face) and Itching
There is reduced trptophan and therefore Vitamin b3 levels drop
This can cause Pellagra

(diarrhoea, dermatitis, dementia

Octreotide scan and CT can show the tumour site

Urinary 5 hydroxyureindoleacetic acid 5HIAA

Somatostatin analogls like ocretotide

Answer 468

A

HHV 5 is CMV
Can be from latent activation, infection via transplanted organ or new infection

IV ganciclovir is needed
Withouth this Renal function likely to deteriorate

Answer 469

A

Treatment of Influenza in Immuno comprimised

Oseltamivir is in Immunocompetant

Answer 470

A

HHV 5 is CMV
Can be from latent activation, infection via transplanted organ or new infection

IV ganciclovir is needed
Withouth this Renal function likely to deteriorate

Answer 471

A

Excess Gastrin
Likley due to duodenal or gastic tumour secreting gastrin (can be pancreas)
30% from MEN 1

Multiple Ulcers
Diahrroea
Malabsorption

Need Gastrin Level
Then need to do a secretin stimulation test
This will cause the gastrin to go up

Answer 472

A

Low Risk - 5 years colonsocopy
1 or 2 adenomas < 10mm

Intermediate risk - 3 years (x 2 )
3 - 4 adenomas < 10mm
or
1-2 Adenomas > 10mm

High Risk - 1 year (then 3 years x 2)
5 + < 10mm
3 + > 10mm

Brainscape's Knowledge GenomeTM

Part 2 Flashcards

Brainscape's Knowledge Genome^TM