Part 2

Question 1

Membranous Glomerulonephritis / Nephropathy Pathophysiology / Causes

Answer 1

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

Lung Ca that causes paraneoplastic syndromes? Which syndromes?

Answer 2

Small Cell Lung Ca (Central, advanced, smoking)

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

Question 3

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

Answer 3

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

Left Varicocele?

Answer 4

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

Stauffer syndrome

Answer 5

Paraneoplastic Hepatic Dysfunction associated with RCC

Thought to be IL 6 Mediated

Question 6

RCC Paranoeplastic syndrome?

Answer 6

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

Stauffer syndrome

Question 7

DDP4 Inhibitors?

Answer 7

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

GPL 1 Mimics:

Answer 8

Exenatide or Liraglitide

Cause increase insulin and decrease glucagon

Nausea and Vomiting
Pancreatitis
Cause Weight Loss

Question 9

Renal Tubular Acidosis Type 1

Answer 9

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

Causes of Normal Anion Gap Acidosis

Answer 10

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

Question 11

Causes of Increased Anion Gap Acidosis

Answer 11

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

Question 12

Renal Tubular Acidosis Type 2

Answer 12

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

Renal Tubular Acidosis Type 4

Answer 13

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

Alports Syndrome?

Answer 14

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

Myasthenia Gravis

Answer 15

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

ADEM (Acute Disseminated Encephalomylitis)

Answer 16

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

ADEM (Acute Disseminated Encephalomylitis)

Answer 17

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

Typhoid

Answer 18

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

Actinic Keratosis

Answer 19

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

Serum Ascites Albumin Gradient

SAAG

Answer 20

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

Low SAAG < 11 causes of Ascites

Answer 21

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

High SAAG > 11 Causes of Ascites

Answer 22

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

Question 23

Facioscapulohumeral Muscular Dystrophy?

Answer 23

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

Transjugular intrahepatic porto-systemic shunt (TIPPS)

Answer 24

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

Transjugular intrahepatic porto-systemic shunt (TIPPS)

Answer 25

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

Churg Strauss Syndrome?

Answer 26

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

Granulomatosis with Polyangitis?

Answer 27

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

Hypernatraemia

Answer 28

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

Trigeminal Neuralgia?

Answer 29

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

Primary Biliary Cholangitis

Answer 30

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

Methotrexate Myelosuppresion?

Answer 31

Treat with Folinic Acid

Question 32

Cocaine Toxicity Treatment?

Answer 32

Start With Benzos Then Verapamil for palpitations or tachycardia AVOID Beta Blocker

Question 33

Dermatitis Herpetiformis?

Answer 33

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

Autoimmune Hepatitis

Answer 34

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

hypertrophic pulmonary osteoarthropathy (HPOA)

Answer 35

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

Question 36

Thymoma?

Answer 36

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

Anti Mitochondrial Antibody

Answer 37

Primary Biliary Cirrhosis

Question 38

Anti- Liver/Kidney microsomal Type 1 Antibodies LKM1

Answer 38

Type 2 Autoimmune Hepatitis

Question 39

Severe Cronhs disease treatment?

Answer 39

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

Hyperosmolar Hyperglycaemic State?

Answer 40

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

How to Diagnose HHS

Answer 41

Hypovloaemia Marked Hyperglycaemia Without Ketonaemia or acidosis Significan raised serum osmolality (> 320) Calculate Osmolality with (2 * Na + K) + Glucose + Urea

Question 42

Treatment of Whipple's Disease?

Answer 42

IV Cefotaxime for 4 weeks Then co -trimoxazole for 1 year Biopsy with PAS staining shows positive macrophages in duodenum

Question 43

Calculate the Anion Gap

Answer 43

Na + K - Cl - HCO3

Question 44

Ethylene Glycol Toxicity?

Answer 44

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

Treatment of local anaesthetic toxicity?

Answer 45

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

CF Managemet

Answer 46

``` 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

Superior vena Cava Obstruction?

Answer 47

``` 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

Waterhouse Friedrichsen Syndrome?

Answer 48

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

Question 49

Raynaud's Disease

Answer 49

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

Strongyloidiasis

Answer 50

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

Heparin Iduced Thrombocytopenia

Answer 51

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

Kearns Sayre Syndrome?

Answer 52

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

Retinitis Pigmentosa

Answer 53

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

Facioscapulohumeral Muscular Dystrophy?

Answer 54

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

Question 55

Trientine?

Answer 55

Copper Chelating used to treat Wilsons

Question 56

Low Caeruloplasmin?

Answer 56

Wilsons

Question 57

Kayser-Fleischer Rings?

Answer 57

Green brown deposits at the peripheries of the Iris | Due to deposits in Descement Membrane

Question 58

ATP7B gene defect?

Answer 58

Chromosome 13 Wilson's disease Autosomal Recessive

Question 59

Wilson's Disease?

Answer 59

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

Wilson's Disease Diagnosis?

Answer 60

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

Question 61

Present infection vs Past in Antibodies?

Answer 61

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

Question 62

Cocaine Toxicity Treatment?

Answer 62

Start With Benzos Then Verapamil for palpitations or tachycardia AVOID Beta Blocker

Question 63

Dermatitis Herpetiformis?

Answer 63

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

Management of Fibro Myalgia

Answer 64

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.

Question 65

hypertrophic pulmonary osteoarthropathy (HPOA)

Answer 65

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

Question 66

Thymoma?

Answer 66

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 67

Erythema ab igne?

Answer 67

Caused by infra red radiation (open fire) | Causes squamous cell skin cancer

Question 68

Tuberculosis Meningitis?

Answer 68

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

Question 69

Severe Cronhs disease treatment?

Answer 69

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 70

Whipple's Disease?

Answer 70

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.

Question 71

Whipple's Disease Symptoms?

Answer 71

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

Question 72

Treatment of Whipple's Disease?

Answer 72

IV Cefotaxime for 4 weeks Then co -trimoxazole for 1 year Biopsy with PAS staining shows positive macrophages in duodenum

Question 73

TCA overdose?

Answer 73

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

Question 74

Management of TCA overdose?

Answer 74

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

Question 75

Paragonimus westermani?

Answer 75

``` 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

Question 76

Superior vena Cava Obstruction?

Answer 76

``` 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 77

Optic Neuritis

Answer 77

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

Question 78

Allergic Bronchopulmonary Aspergillosis?

Answer 78

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

Question 79

Theophylline?

Answer 79

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

Question 80

Coombs Test?

Answer 80

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.

Question 81

Autoimmune Haemolytic Anaemia?

Answer 81

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

Question 82

Haemolysis signs

Answer 82

``` 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

Question 83

Causes of Warm Haemolytic anaemia?

Answer 83

``` Idiopathic Viral infections SLE Lymphomas Leukemia Penicillin and Cephalosporins ```

Question 84

Cold Haemolytic anaemia causes?

Answer 84

Chronic - Leukaemia and Lymphomas Acute - Viral Pneumonia, Mycoplasma, Infectious Mononucleosis

Question 85

Haemolytic Crisis

Answer 85

``` Bounding heart rate SOB Multiorgan failure Jaundice Fatigue Hepatosplenomegaly ```

Question 86

Treatment of Autoimmune Haemolytic Anaemia?

Answer 86

Warm - Steroids and splenectomy | Cold - none required

Question 87

Latent Autoimmune Diabetes of Adulthood?

Answer 87

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

Question 88

BTS guidelines for lung Nodules?

Answer 88

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

Question 89

Secondary Pneumothorax

Answer 89

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

Question 90

Primary Pneumothorax

Answer 90

Primary Pneumothorax < 2 cm and not SOB = discharge If > 2cm or SOB = Aspirate (if fails - chest drain) Patients should be advised to stop smoking

Question 91

Lights Criteria

Answer 91

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

Question 92

Viridans sterptococcus

Answer 92

Risk Factor is poor Dentition

Question 93

Membranous Glomerulonephritis

Answer 93

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

Question 94

Prognosis of Membranous Glomerulonephritis

Answer 94

1/3 Remission 1/3 Protein urea 1/3 ESRF Good prognosis : -females Young presentation Asymptomatic

Question 95

McArdle Disease?

Answer 95

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

Question 96

Gaucher disease

Answer 96

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

Question 97

Von Girkes Disease

Answer 97

Glycogen Storage Disorder Glucose - 6 - Phosphatase deficiency Hepatic Accumulation of Glycogen Leads to Hypoglcyaemia, Lactic Acidosis and Hepatomegaly

Question 98

Pompe's Disease

Answer 98

Glycogen Storage Disorder Lysosomal Alpha 1, 4 Glucosidase Deficiency Cardiac, Hepatic and Muscle Glycogen accumulation. Features include cardiomegaly

Question 99

Cori Disease

Answer 99

Glycogen Storage Disorder Alpha 1, 6 Glucosidase Deficiency Hepatic and Cardiac Accumulation - leading to muscle hypotonia

Question 100

Dual immunomodulator and biological therapy in Crohns has increased risk compared to biological alone?

Answer 100

Increased risk of non melanoma skin cancer

Question 101

Infliximab risks

Answer 101

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

Question 102

Hypokalaemic Periodic Paralysis

Answer 102

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

Question 103

Indications for Plasma exchange in ANCA associated Vasculitis?

Answer 103

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

Question 104

Indications for plasma exchange?

Answer 104

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

Question 105

Complications of plasma Exchnage?

Answer 105

``` Hypocalcaemia Metabolic Alkalosis Systemic Medication removal Coagulation factor depletion Immunoglobulin depletion ```

Question 106

Cryoglobulinaemia

Answer 106

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

Question 107

Fabry's disease:

Answer 107

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)

Question 108

Chronic inflammatory demyelinating polyradiculoneuropathy CIDP

Answer 108

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

Question 109

Demylinating peripheral neuropathy (slowing of conduction on conduction studies)

Answer 109

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

Question 110

Axonal Pathology

Answer 110

``` Alcohol DM Vasculitis B12 Hereditary sensorimotor neuoropathy type 2 ```

Question 111

C5, 6

Answer 111

Deltoid Biceps Brachioradialis

Question 112

C5, C6, C 7

Answer 112

``` Serratus Anterior (paraylsis - winging of scapula) Triceps ```

Question 113

C8

Answer 113

Finger Flexors

Question 114

Stills Disease

Answer 114

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

Question 115

How to diagnose Still Disease?

Answer 115

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

Question 116

Stills Disease Fever, Rash and other key features

Answer 116

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

Question 117

Stills Disease Treatment?

Answer 117

NSAIDS NSAIDs for fever joint pain and serositis Then Steroids or D MArds

Question 118

Superficial Thrombophlebitis

Answer 118

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

Question 119

C-telopeptide

Answer 119

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

Question 120

Paget's disease

Answer 120

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

Question 121

Complications of pagets

Answer 121

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

Question 122

Acute intermittent porphyria

Answer 122

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

Question 123

Diagnosis of acute intermittent porphyria

Answer 123

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

Question 124

Typhus

Answer 124

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

Question 125

Treatment of Rickettsia disease

Answer 125

Doxycycline | Chloramphenicol

Question 126

Prussian Blue

Answer 126

Used to treat Thallium Poisoning

Question 127

Thallium Poinsoning symptoms?

Answer 127

``` 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

Question 128

Indication to leave a chest drain in in infective pleural effusion?

Answer 128

pH < 7.2 | Purulent aspirate

Question 129

Kartagener's Syndrome

Answer 129

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

Question 130

Bronchiectasis Causes:

Answer 130

Infective: - TB - Measles - Purtussis - Pneumonia CF Immune Deficiency: - IgA - Hypogammaglobulinaemia Allergic Bronchopulmonary Aspergillosis Ciliary Dyskinetic Syndromes Kartageener's syndrome Youngs syndrome Yellow Nail Syndrome

Question 131

Toxoplasmosis in HIV

Answer 131

Multiple Lesions Ring or nodular enchancement Thallium SPECT negative 50% of cerebral lesions in patients with HIV Treatment is with Sulfadiazinde and pyrimethamine

Question 132

Primary CNS Lymphoma

Answer 132

30% of cerebral lesions in patients with HIV EBV association Single homogenous enhancing lesion Treatment with steroids and methotrexate (chemo) and consideration for sugery

Question 133

Other Neurological differentials in HIV

Answer 133

- 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

Question 134

Pneumothorax - when can you fly again?

Answer 134

1 week following resolution of chest x ray

Question 135

Inferior MI

Answer 135

II, III and AVF | Right Coronary Artery thrombus

Question 136

Anterior MI

Answer 136

V1-V4 | Left Anterior Descending

Question 137

Lateral MI

Answer 137

V5, 6 and I | Circuflex artery

Question 138

Malaria Falciparum

Answer 138

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

Question 139

Sickle cell immunity to Malaria = how does it work?

Answer 139

No duffy antigen | Therefore Plasmodium Vivax cannot enter cells

Question 140

Other immunity to Malaira?

Answer 140

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

Question 141

P Malariae Fever?

Answer 141

Quartan Fever- 72 hours

Question 142

P vivax and P ovale fever?

Answer 142

Tertian Fever- 48 hours

Question 143

P Knowlesi

Answer 143

Fever every 24 hours

Question 144

P Falciparum

Answer 144

Fever varies - Malignant Tertian Fever

Question 145

Patients that don't benefit from Lung Reduction surgery in COPD?

Answer 145

Non Upper Lobe empysema | High Exercise Capacity

Question 146

Microscopic Colitis

Answer 146

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

Question 147

Anti TTG antibodies

Answer 147

Non invasive confirmation of coeliac disease | Where negative, but still clinically coeliac, can go onto upper GI endoscopy and biopsy

Question 148

Faecal calprotectin

Answer 148

Screening test for active Crohn's and UC

Question 149

Facal Elastase

Answer 149

Used to evaluate pancreatic insufficiency

Question 150

Carcinoembryonic antigen?

Answer 150

Used as Tumor marker for colorectal cancer

Question 151

Inclusion Body Myositis

Answer 151

Cause of Myopathy Associated with cytoplasmic inclusions on mm biopsy Older males with proximal and distal muscles Quads fingers and wrist flexors Raised CK

Question 152

Drug Induced Lupus

Answer 152

Anti histone antibody positive ANA postiive 100% Anti dsDNA negative

Question 153

Drugs that cause Drug Induced Lupus

Answer 153

``` Procainamide Hydralazine Isoniazid Micocycline Phenytoin Penicillamine ```

Question 154

Chickenpox infection in adults

Answer 154

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

Question 155

Rapidly progressive Glomerulonephritis

Answer 155

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

Question 156

Cardiac Amyloidosis

Answer 156

ECG shows low voltage complexes with poor R wave Progression in the chest leads This is common in Myeloma

Question 157

Progressive Multifocal Leukoencephalopathy

Answer 157

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

Question 158

Multiple Slcerosis Treatment:

Answer 158

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

Question 159

If about to treat malaria what should you check?

Answer 159

G6PD deficiency | Primaquine, Cipro and sulphonamides cause haemolysis

Question 160

Lansoprazole interactions

Answer 160

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

Question 161

Donepezil adverse effects

Answer 161

Is a cholinesterase inhibitor used to treat mild to moderate dementia It has vagotonic effects that lead to bradycardia and heart block

Question 162

Pharmacological management of dementia?

Answer 162

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

Question 163

Hyperaldosteronism treatment

Answer 163

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

Question 164

Paraxysmal Noctural Hemoglobinurea

Answer 164

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

Question 165

Diagnosis of PNH

Answer 165

HAM test positive | Flow Cytometry is gold standard

Question 166

Treating PNH

Answer 166

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

Question 167

Ascarasis

Answer 167

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

Question 168

Myoxedmea Coma

Answer 168

Give IV T3 and T4 + Steroids Presents with hypothermia, low GCS, bradycardia, hypotension Need to rule out addisons as well

Question 169

Hypercalcaemia management

Answer 169

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 1. Fluids 2. Bisphosphonates 3. 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.

Question 170

Indication for Mitral Valve Replacement

Answer 170

1. EF < 60% 2. Left ventricular end systolic diameter > 40mm (LV Dilation or Hypertrophy) 3. New onset of AF or 4. Pulmonary Hypertension > 20mmHg If not 6 monthly ECHO No need for prophylaxis (only in prostetic repair or replacement)

Question 171

Diagnosis of Diabetes?

Answer 171

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%)

Question 172

Diagnosis of Prediabetes?

Answer 172

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

Question 173

HbA1c

Answer 173

> 48mmol/L = Diabetes (6.5%) If < 48mmol/L = need fasting glucose or OGTT as this doesn't exclude diabetes

Question 174

Radioiodine therapy following CT Contrast?

Answer 174

Wait 8 weeks before starting

Question 175

Haemangioblastomas

Answer 175

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

Question 176

Combined Pulmonary Fibrosis and Emphysema

Answer 176

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.

Question 177

Idiopathic Pulmonary Fibrosis

Answer 177

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

Question 178

LTOT in COPD

Answer 178

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

Question 179

Protein C deficiency

Answer 179

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

Question 180

Organophosphate insectiside poisoning

Answer 180

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

Question 181

Restrictive Cardiomyopathy?

Answer 181

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

Question 182

Hereditary Haemorrhagic Telangiectasia

Answer 182

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)

Question 183

Alpha Thalassemia Gene Mutation?

Answer 183

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

Question 184

Alpha Thalassemia Diagnosis

Answer 184

- 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

Question 185

Treatment of Thalassemia

Answer 185

SEVERE only - Blood TRansfusions - Iron Chelating agents Fetal : Intrauterine blood transfusions Bone Marrow Transplants

Question 186

Beta Thalassemia

Answer 186

``` 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

Question 187

Adult Hb

Answer 187

HbA x2 and HbB x2

Question 188

Fetal Hb

Answer 188

HbA x 2 and Hb gamma x 2

Question 189

Beta Thalasemia Symptoms

Answer 189

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

Question 190

Diagnosis

Answer 190

``` 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

Question 191

Beta Thalassemia major Treatment

Answer 191

Blood Transfusions Iron Chelating Agents Splenectomy if hepatosplenomegaly

Question 192

Causes of Microcytic Anaemia?

Answer 192

Iron Def Thalassaemia Congenital Sideroblastic anaemia Lead Poisoning

Question 193

post-transplantation lymphoproliferative disorder (PTLD)

Answer 193

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.

Question 194

Drug induced Pancreatitis

Answer 194

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

Question 195

Tacrolimus

Answer 195

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

Question 196

Zinc Deficiency

Answer 196

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

Question 197

Vitamin A deficiency

Answer 197

Night Blindness

Question 198

Vitamin E deficiency

Answer 198

Spinocerebellar Ataxia Mypoathy Anaemia

Question 199

Selenium deficiency

Answer 199

seen in malabsorption and parenteral nutrition | Cardiac necrosis causing congestive cardiomyopathy

Question 200

``` Niacin deficiency (vitamin b3) ```

Answer 200

PEllagra 4 ds Dermatitis dementia diarrhoea death Alopecia Glossitis Oedema

Question 201

Abscence Seizures?

Answer 201

First line is Valproate and Ethosuzimide

Question 202

Polyarteritis nodosa?

Answer 202

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% ```

Question 203

Livedo reticularis?

Answer 203

``` Homocystinuria Polyarteritis nodosa SLE Amantadine Cholesterol Embolisation Antiphospholipid syndrome ```

Question 204

Homocystinuria

Answer 204

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)

Question 205

Pyridoxine?

Answer 205

Vitamin B 6

Question 206

Cholesterol Embolisation

Answer 206

Cholesterol emboli may break off causing renal disease Normally after vasc surgery or angiography Eosinophilia Purpura Renal Failure Livedo reticularis

Question 207

Amantidine

Answer 207

Increases dopamine release and inhibits its uptake at synapses Causes ataxia, Slurred speech, confusion, dizziness, livedo reticularis Used in PArkinsons, MS, fam spastic ataxia

Question 208

Myelofibrosis?

Answer 208

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

Question 209

Beri Beri

Answer 209

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

Question 210

Idarucizumab

Answer 210

Dabigatran Reveral in life threatening bleeding

Question 211

Dabigatran indications / contraindications

Answer 211

Prevention of VTE (PE/DVT) Prevention of STroke in AF Contraindicated with Mechanical heart valve replacements

Question 212

Omalizumab

Answer 212

Can be used in IgE high Asthma

Question 213

Chicken pox Exposure in Immunocomprimised?

Answer 213

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

Question 214

Lofgren's Syndrome?

Answer 214

Acute presentation of Sarcoidosis | Presents with a classic Triad of erythema nodosum, polyarthralgia and bilateral hilar lymphadenopathy

Question 215

Sarcoidosis investigations

Answer 215

``` 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

Question 216

Sarcoidosis prognosis

Answer 216

6 Months - 60% of people have spontaneous resolution Can cause pulmonary fibrosis and pulmonary hypertension

Question 217

Stoke Adam's syndrome?

Answer 217

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

Question 218

Paraquat poisoning

Answer 218

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

Question 219

MEN | Multiple Endocrine Neoplasia

Answer 219

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 ```

Question 220

Holmes Tremor?

Answer 220

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

Question 221

Vemurafenib and Dabrafenib

Answer 221

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

Question 222

Roflumilast

Answer 222

Recommended in COPD where there are > 2 exacerbations / year and FEV1 < 50% Phosphodiesterase - 4 inhibitor recommeneded

Question 223

CKD bone complications?

Answer 223

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

Question 224

Treatmen of CKD bone disease

Answer 224

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

Question 225

HOCM Treatment?

Answer 225

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

Question 226

HOCM is an autosomal dominant disorder of muscle tissue in 0.2% population

Answer 226

``` Treatment is with Amiodarone Betablockers or verapamil Cardioverter defib Dual Chamber PAcemakers Endocarditis Prophylaxis ``` Avoid NItrates and ACE inhibitors

Question 227

Foster Kennedy Syndrome

Answer 227

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 ```

Question 228

Restless leg syndrome?

Answer 228

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

Question 229

Aortic Stenosis

Answer 229

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

Question 230

Spastic Paraparesis

Answer 230

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 ```

Question 231

Amyloidosis

Answer 231

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

Question 232

Exercise induced wheat angioedema

Answer 232

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.

Question 233

ST elevation without reciprocal depression?

Answer 233

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.

Question 234

tropical spastic paraparesis

Answer 234

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 ```

Question 235

Progressive Supranuclear Palsy

Answer 235

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

Question 236

Cardiac Catheterisation and oxygen saturations

Answer 236

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)

Question 237

DRESS Syndrome

Answer 237

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

Question 238

HELP Syndrome

Answer 238

Haemolysis, Elevated Liver Enzymes and Low Platelets A serious manifestation of Pre Eclampsia HTN, Vomiting and Abdominal Pain

Question 239

Pre Eclampsia? Complications and RF

Answer 239

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 ```

Question 240

Severe Pre Eclampsia?

Answer 240

``` 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

Question 241

Treatment of Pre Eclampsia?

Answer 241

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

Question 242

Pneumothorax diving?

Answer 242

Need pleuradhesis can't go until this

Question 243

Difference between osa and ohs

Answer 243

OSA is transient hypercapnea after sleeping | OHS is chronic hypercapnea in the daytime with increased bicarb (like COPD)

Question 244

Anteriror Interosseous Syndrome

Answer 244

Motor loss of thumb,, index and middle finger | No sensory loss( that would be median nerve palsy)

Question 245

Erythema Multiforme

Answer 245

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

Question 246

WHich pathology recurrs in renal transplant the most?

Answer 246

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

Question 247

Poor Prognosis in aspestosis?

Answer 247

Clubbing

Question 248

Pleural Thickening/ Plaques

Answer 248

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)

Question 249

Mesothlioma

Answer 249

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

Question 250

Lung Fibrosis

Answer 250

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 ```

Question 251

Idiopathic pulmonary fibrosis

Answer 251

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

Question 252

Budd Chiari Syndrome Triad?

Answer 252

Abdominal Pain Painful hepatomegaly Ascites

Question 253

Budd Chiari Pathophysiology

Answer 253

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

Question 254

Causes of budd chiari

Answer 254

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

Question 255

Confirmed Meningococcal meningitis contacts?

Answer 255

Receive 7 days cipro / rifampicin think of adam This is only for meningococcal disesae Not for Pneumococcal meningitis

Question 256

Dubin Johnson Syndrome

Answer 256

Raised Conjugated Bilirubin Otherwise normal LFTs Benign autosomal recessive disorder with conjugated hyperbilirubinaemia that is conjugated and therefore in the urine. CMOAT Protein defect

Question 257

Nitrous Oxide and B12 Deficiency?

Answer 257

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

Question 258

B12 low, Folate high?

Answer 258

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

Question 259

Liddle's syndrome

Answer 259

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

Question 260

Myotonic Dystrophy

Answer 260

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

Question 261

Albumin Creatinine Ratio?

Answer 261

MEn < 3.5 = normal | Women < 2.5 = Normal

Question 262

Cysticercosis

Answer 262

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

Question 263

Cyanide Poisoning

Answer 263

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

Question 264

Organophosphate poisoning

Answer 264

Inhibition of acetylcholinesterase leading to increased nicotinic, muscarinic and cholinergic neurotransmittion ``` SLUD (parasympathetic) Salivation Lacrimation Urination Defication Bradycardia Small Pupils ``` Atropine Pralidoxime

Question 265

Guttate Psoriasis

Answer 265

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

Question 266

Guttate Psoriasis

Answer 266

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

Question 267

Aminophylline

Answer 267

...

Question 268

Scan for Phaeochromcytoma?

Answer 268

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

Question 269

Pentagastrin Stimulation test?

Answer 269

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

Question 270

24 hr urinary HIAA

Answer 270

Screening tool for carcinoid

Question 271

MRI renal angiography

Answer 271

Used for Renal Artery stenosis (> CT)

Question 272

GH, IGF1 and Gut hormones-

Answer 272

test for pancreatic malignancy associated with MEN 1

Question 273

MIBG

Answer 273

Scan for Phaeochromocytoma. | 10% of phaeochromocytoma is in the sympathetic chain (similar to neuroblastoma).

Question 274

Fish tank granuloma

Answer 274

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

Question 275

Miller - Fisher Syndrome?

Answer 275

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

Question 276

guillain Barre Syndrome

Answer 276

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%)

Question 277

Anti GM1 Antibodies

Answer 277

Guillain Barre Syndrome

Question 278

Anti GQ1b Antibodies

Answer 278

Miller-Fisher Syndrome

Question 279

Anti Jo Antibodies

Answer 279

Polymyositis

Question 280

Anti Cholinesterase antibodies

Answer 280

Myasthenia Gravis

Question 281

Tuberculosis Management in resistant disesae

Answer 281

If resistant disease requires 5 drugs for 18-24 months If LFTs 5 x the normal limit then stop the medication

Question 282

Atrial Septal Primum Defect osition?

Answer 282

These are low down in the septum

Question 283

Atrial Septal Secundum Defect position?

Answer 283

These are high up in the septum

Question 284

Atrial Septal Secundum Defect position?

Answer 284

These are high up in the septum

Question 285

MS in pregnancy

Answer 285

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

Question 286

Expanded Disability Status Scale

Answer 286

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

Question 287

Bergers disease Causes? Associated diseases?

Answer 287

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

Question 288

How to differentiate between post strep and IgA nephropathy

Answer 288

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

Question 289

Treatment of IgA

Answer 289

Steroids have no help Endstage renal failure in 25% Good Prognosis is Frank Haematuira Bad is Male and Protein ++

Question 290

Long QT Syndrome

Answer 290

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

Question 291

Drugs that cause prolonged QT

Answer 291

Amiodarone, Sotalol TCA/ SSRIs (citalopram) Methadone Chloroquine Erythromcyin Haloperidol Ondanestron

Question 292

Drugs that cause prolonged QT

Answer 292

Amiodarone, Sotalol TCA/ SSRIs (citalopram) Methadone Chloroquine Erythromcyin Haloperidol Ondanestron

Question 293

Jervell Lange Nielsen

Answer 293

Long QT + Deafness

Question 294

Ramano-Ward Syndrome

Answer 294

Long QT no Deafness

Question 295

Electrolyte causes of Long QT

Answer 295

Hypocalcaemia, kalaemia, magnesaemia Also Acute MI, myocarditis, hypothermia and SAH

Question 296

Anti Mictochondrial Antibodies?

Answer 296

Primarcy Biliary Cirrhosis IgM M2 Subtype Middle Age Females

Question 297

Anti Mictochondrial Antibodies?

Answer 297

Primarcy Biliary Cholangitis IgM M2 Subtype Middle Age Females Sjogren's Syndrome Rheumatoid Arthritis Systemic Slcerosis Thyroid Disease

Question 298

MEN 2a/b Thyroid cancer monitoring?

Answer 298

Calcitonin - This is the marker for medullary thyroid cancer

Question 299

Chromogranin A and 5-HIAA?

Answer 299

Neuroendocrine tumours and Carcinoid Tumours respectively

Question 300

Thyroid peroxidase antibody titre ?

Answer 300

Autoimmune thyroid conditions like hashimotos and Graves

Question 301

Thyroglobulin

Answer 301

Marker for papillary and follicular thyroid carcinoma

Question 302

Lichen Sclerosus

Answer 302

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

Question 303

Lichen Sclerosus

Answer 303

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

Question 304

Pemphigoid Gestationis

Answer 304

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

Question 305

Polymorphic eruption of pregnancy

Answer 305

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

Question 306

Rabies?

Answer 306

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 ```

Question 307

Rabies?

Answer 307

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

Question 308

Rabies?

Answer 308

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

Question 309

Saccharin test?

Answer 309

Ciliary dysmotility

Question 310

Low Immunoglobulins in respiratory case?

Answer 310

Think Bronchiectasis | IgA immuno deficiency and hypogammaglobulinaemia cause Bronchiectasis

Question 311

Low Immunoglobulins in respiratory case?

Answer 311

Think Bronchiectasis | IgA immuno deficiency and hypogammaglobulinaemia cause Bronchiectasis

Question 312

Alpha 1 antitripsin

Answer 312

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!

Question 313

Treatment of H Pylori

Answer 313

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

Question 314

Acintomyces?

Answer 314

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.

Question 315

Acintomyces?

Answer 315

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

Question 316

Acintomyces?

Answer 316

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

Question 317

Norcardia?

Answer 317

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

Question 318

Norcardia?

Answer 318

Nocardia Basics typically causes pneumonia in immunocompromised patients may also cause brain abscesses Sulphur granules seen

Question 319

Causes of Hypoglycaemia

Answer 319

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

Question 320

C peptide

Answer 320

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

Question 321

C peptide

Answer 321

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

Question 322

False Positive 5-HIAA urinary collection

Answer 322

``` Foods causing false positive 5-HIAA urinary collection results: Banana Avocado Aubergine Pineapple Plums Walnuts Tomatoes ``` ``` Drug Flouracil Caffeine Naproxen Paracetamol ```

Question 323

Drugs causing false negative 5-HIAA urinary collection

Answer 323

Aspirin, Levodopa, Methyldopa, ACTH

Question 324

Anaemia in CKD patients?`

Answer 324

Correct Iron Ferritin < 100 or Transferrin sats > 20% then give iron infusion Folowing this - give the EPO

Question 325

Hydrogen breath test?

Answer 325

Small BActerial Overgrowth Syndrome RF: DM, Scleroderma and Neonates with GI abnormalities Rifamixin Co amoxiclav Metronidazole High FOLATE Low B12

Question 326

Urea Breath Test

Answer 326

H. Pylori

Question 327

Denosumab

Answer 327

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

Question 328

Pulmonary arterial pressure

Answer 328

Less than 20mmHg

Question 329

Bowen's disease

Answer 329

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

Question 330

Brucellosis?

Answer 330

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

Question 331

Alkaptonuria

Answer 331

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

Question 332

Acute Interstitial Nephritis

Answer 332

``` 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 ```

Question 333

Migraine prophylaxis?

Answer 333

2 or more attacks per month Topiramate or propanolol Propanolol in child bearing women (Topiramate is teratogenic) Toperamte in asthma 2nd line is acupuncture

Question 334

serum cystatin C

Answer 334

eGFR in high muscle mass or low muscle mass

Question 335

COPD severity?

Answer 335

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 ```

Question 336

Poorly controlled DM1 with high BMI and south indian?

Answer 336

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

Question 337

CLL indications for treatment

Answer 337

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

Question 338

Management of CLL

Answer 338

? For Treatment - ? indicated If not indicated - regular blood test Fludarabine, Cyclophosphamide and rituximab is initial treatment FCR Ibrutinib for those who failed prev FCR

Question 339

Ibrutinib

Answer 339

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

Question 340

FCR?

Answer 340

Fludarabine, Cyclophosphamide and rituximab for CLL

Question 341

Neuromyelitis optica

Answer 341

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

Question 342

Uhthoff's phenomenon

Answer 342

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

Question 343

Hypertriglycerideaemia?

Answer 343

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

Question 344

Calciphylaxis

Answer 344

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.

Question 345

Treatment of pulmonary fibrosis?

Answer 345

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

Question 346

Inferior MI and heart block

Answer 346

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

Question 347

Anterior MI and heart block

Answer 347

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

Question 348

TTP

Answer 348

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

Question 349

Upshaw - Schulman Syndrome

Answer 349

Autosomal recessive Deficiency of ADAMTS13 Enzyme causing TTP

Question 350

Causes of Acquired TTP

Answer 350

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

Question 351

Colonoscopy screening in IBD patients for Colorectal cancer

Answer 351

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

Question 352

``` Guillian Barre syndrome: weakness? Tone? Reflexes? Sensory symptoms? Pain? CSF? ```

Answer 352

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

Question 353

Bile Acid Malabsorption

Answer 353

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

Question 354

SeHCAT scan ?

Answer 354

Selenium scan for Bile Acid Malabsorption

Question 355

Which antibiotic causes tendinopathy/ Rupture?

Answer 355

Ciprofloxacin | Levofloxacin

Question 356

Staghorn / Struvite stones

Answer 356

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

Question 357

Numbers in SIADH

Answer 357

Na < 135 Serum Osm < 271 Urine Osm > 100 Euvolaemic patient

Question 358

SIADH Causes

Answer 358

Malignancy (Small cell lung CA/ Prost/ Panc) Neuro (Stroke, SAH, Subdural, Infection) Infection (TB, Pneumonia) Drugs: Sulfonylurea, SSRI, Carbamazepine, Cyclophosphamide, Vincristine PEEP Porphyrias

Question 359

Treatment of SIADH

Answer 359

Slow correction to avoid central pontine Myelinolysis Fluid REstriction Demeclocycline ADH (Vasopressin) antagonist

Question 360

Multifocal motor Neuropathy with conduction Block

Answer 360

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

Question 361

TRALI - Transfusion related acute lung injury

Answer 361

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

Question 362

TB screening?

Answer 362

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

Question 363

Ziehl Neelson Stain?

Answer 363

TB - stain

Question 364

TB meningitis?

Answer 364

STart 4 x Antibiotics for TB | Then start CEF and Vanc and Dex as well to treat for Bacterial Meningitis too

Question 365

Psoriasis triggered by which drugs?

Answer 365

``` Lithium Beta Blockers Antimalarials Non Steroidal anti inflammatory Ace I Tetracyclines and Penicillins ``` TRauma and Alcohol Strep = Guttate Psoriasis

Question 366

Low Testosterone next test

Answer 366

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

Question 367

Hypogonadism symptoms

Answer 367

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

Question 368

Tabes Dorsalis

Answer 368

``` 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

Question 369

Myeloma Staging

Answer 369

Done with B2 - microglobulin and albumin

Question 370

Toulene Toxicity

Answer 370

Sniffing Glue Increases Dopamine- euphoria ``` Irritation of the eyes, nose and respiratory tract from inhalation. Ataxia Confusion Headache Euophoria ```

Question 371

Melasma

Answer 371

Condition of hyperpigmented macules in sun exposed areas. | Found in women on Hormone therapy Pill or Pregnant

Question 372

Malt Lymphoma

Answer 372

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

Question 373

Pre Renal Azotemia

Answer 373

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

Question 374

Rabies Exposure?

Answer 374

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

Question 375

Cyproheptadine?

Answer 375

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

Question 376

Pontine Haemorrhage

Answer 376

Reduced GCS, Paralysis, Bilateral Pin Point Pupils | First ORder Sympathetic tracts - bilateral horners syndrome

Question 377

Midbrain haemorrhage/ Lesions

Answer 377

Fixed, Mid point pupils

Question 378

Lateral medulla

Answer 378

Ipsilateral hornders syndrome and pin point pupil

Question 379

Wallenberg Syndrome?

Answer 379

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

Question 380

Lupus

Answer 380

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 ```

Question 381

Anti Ro/ Anti La

Answer 381

Sjogren's syndrome | Anti Ro can cross placenta and cause congenital heart block which can reuquire pacing at birth

Question 382

Anti CCP

Answer 382

Rhuematoid

Question 383

Shingles Vaccine?

Answer 383

Available for people 70-79 Live Attenuated Immunosuppression therefore a contra indication Management of acute shingles is with oral acyclovir

Question 384

Somogyi Effect

Answer 384

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

Question 385

Hepatic Encephalopathy

Answer 385

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

Question 386

Barrets oesophagus with low grade dysplasia

Answer 386

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

Question 387

Ataxia Telangectasia

Answer 387

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

Question 388

Chaga's disease

Answer 388

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

Question 389

African sleeping sickness

Answer 389

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 `

Question 390

Drugs that cause lung fibrosis

Answer 390

``` Amiodarone Bleomycin, Bromocryptine Cabergoline DMARDS - Methotrexate, Sulfasalazine Nitrofurantoin ``` `

Question 391

Posterior MI

Answer 391

R Wave TALL in V1 and V2

Question 392

Caplan's Syndrome?

Answer 392

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

Question 393

MODY

Answer 393

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

Question 394

Amiodarone and Thyroid Gland

Answer 394

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

Question 395

Reversible cerebrovascular vasoconstriction syndrome

Answer 395

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

Question 396

Posterior Reversible Encephalopathy syndrome

Answer 396

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

Question 397

Thunderclap headache

Answer 397

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

Question 398

Pituitary apoplexy is bleeding into or impair blood supply to the pituitary

Answer 398

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

Question 399

Lupus Nephritis?

Answer 399

Best Treatment for Lupus Nephritis is Mycophenolate Mofetil Start by treating with steroids and cyclophosphamide then switch to mycophenolate long term

Question 400

Scabies failure of treatment

Answer 400

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%

Question 401

Achalasia

Answer 401

Management: - Nifedipine Heller Cariomyotomy Botox Baloon Dilation

Question 402

Crohn's Disease

Answer 402

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

Question 403

Haemochromatosis screening?

Answer 403

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

Question 404

Lung Cancer Associated with Paraneoplastic syndromes?

Answer 404

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

Question 405

Anti Yo

Answer 405

Associated wtih ovarian and breast cancer | Cerebellar syndrome

Question 406

Anti GAD

Answer 406

Breast, colorectal and small cell lung cancer | Stiff person's syndrome or diffuse hypertonia

Question 407

Anti Ri

Answer 407

Ocular opsoclonus myoclonus | Breast and small cell lung cancer

Question 408

Ritonavir

Answer 408

Anti HIV drug inhibits P450 system | May increase seretide levels or fluticasone therefore make you more likely to have adrenal insufficiency

Question 409

p450 inducers

Answer 409

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

Question 410

p450 inhibitors

Answer 410

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

Question 411

Gottron's papulses?

Answer 411

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

Question 412

Erythema Gyratum Repens

Answer 412

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

Question 413

Dermatomyositis

Answer 413

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

Question 414

Cystinuria

Answer 414

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)

Question 415

Intrahepatic cholestasis of pregnancy

Answer 415

``` 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

Question 416

Acute Fatty liver of Pregnancy

Answer 416

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

Question 417

If New drug added in DM?

Answer 417

Aim for Reduction in HbA1c by 11% Aiming for HbA1c < 48 (6.5%) Add another drug is > 58mmol (7.5%)

Question 418

Anti CCP?

Answer 418

Rheumatoid Arthritis

Question 419

Amytrophic Lateral Sclerosis

Answer 419

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

Question 420

Efavirenz toxicity

Answer 420

Neuropsychiatric toxicity Psychosis Is cp450 drug

Question 421

Ethambutol Toxicity

Answer 421

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

Question 422

Rifamipicin

Answer 422

Causes red secretions

Question 423

Isoniazid

Answer 423

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

Question 424

Nephrogenic Diabetes insipidus? Treatment? Diagnosis

Answer 424

Water Deprivation test - urine osm stays exactly the same throughout Treatment with Thiazides and Low Salt/ Protein Diet

Question 425

Paraquat Overdose Testing

Answer 425

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

Question 426

Dukes Cancer Staging?

Answer 426

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

Question 427

Efaverinz side effects?

Answer 427

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

Question 428

In Thyrotoxicosis which drugs should you stop?

Answer 428

Amiodarone | Aspirin- can make it owrse

Question 429

Leprosy Treatment?

Answer 429

Management WHO-recommended triple therapy: rifampicin, dapsone and clofazimine RDC Rif, Dap, Clof Think hypopigment and sensation loss Alopecia Foreign travel Slow growing

Question 430

Medullary Thyroid Cancer Tumour Marker?

Answer 430

Calcitonin

Question 431

MElanoma Tumour marker?

Answer 431

s100 | `

Question 432

Upgoing plantars and absent ankle jerks?

Answer 432

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

Question 433

Rheumatoid Arthritis Management?

Answer 433

``` 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

Question 434

Lung Cancer Management:

Answer 434

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

Question 435

Rotterdam Criteria for Diagnosis of PCOS?

Answer 435

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

Question 436

Management of PCOS

Answer 436

Weight Reduction COCP Acne/ Hirsutism COCP Spironolactone Infertility Weight loss Clomifene Consider Metformin too

Question 437

Thrombus visualised on Stroke but on going haemorrhagic transformation>

Answer 437

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

Question 438

Alcoholic Hallucinosis

Answer 438

Alcoholic Hallucinosis is a rare condition that occurs in intoxication or withdrawal of alcohol. Consciousness in tact Auditory Hallucinations heared Resolve in 6 months

Question 439

Treatment of Glioblastoma?

Answer 439

Chemo-Radiotherapy | Surgical

Question 440

Treatment of Infertility in Kallmann's syndrome?

Answer 440

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

Question 441

Treatment of Abscence Seizures?

Answer 441

Valproate and Ethosuximide Avoid CarbeMAZEapine Makes Abscence and Juvenille myoclonic epilespy worse.

Question 442

Keratoacanthoma

Answer 442

Benign epithelial tumour Advancing age Smooth Dome Volcano

Question 443

Anterior Uveitis

Answer 443

``` 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

Question 444

Aortic Stenosis Clinical Findings

Answer 444

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

Question 445

Autoimmune Haemolytic Anaemia

Answer 445

Direct Coombs Test Warm - IgG positive SLE, CLL, Lymphoma, Methyldopa Cold- IgM positive Lymphoma, Mycoplasma, EBV

Question 446

Waldenstrom's Macroglobulinaemia

Answer 446

``` Older MEn IgM Paraproteinaemia Weight loss Lethargy Hyperviscous Heptamosplenomegaly Lymphadenopathy Raynauds ```

Question 447

AML

Answer 447

``` 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 ```

Question 448

Thiazides electrolyte distrubance?

Answer 448

Hypercalcaemina

Question 449

Inferior Quadrantanopia - homonymous hemianopia and bi temporal hemianopia?

Answer 449

PITS - homonoymous Parietal is Inferior Temporal is Superior Craniopharyngioma is inferior homonymous quadrantanopia

Question 450

Superior Quadrantanopia- unilateral and bilateral?

Answer 450

Unilateral = Temporal lesion Bilateral = Pituitary

Question 451

Hereditary Spherocytosis

Answer 451

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

Question 452

Gilteman's Syndrome

Answer 452

Hypokalaemia and Normotension

Question 453

Liddl'es Syndrome

Answer 453

Hpokalaemia and Hypertension

Question 454

Bartter's Syndrome

Answer 454

Hypokalaemia and Normotension

Question 455

Causes of Hypokcalaemia and Normotension

Answer 455

``` Diuretics Gilteman Bartter's RTA 1 + 2 Diarrhoea ```

Question 456

Hypokalamiea and Hypertension

Answer 456

Cushings Liddle's Primary Hyperaldosteronism 11 beta hydroxlase deficiency

Question 457

Hashimotos Thyroiditis

Answer 457

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

Question 458

Vitamin B 1?

Answer 458

Thiamine

Question 459

Ropinirole?

Answer 459

Restless legs dsyndrome and Parkinsons

Question 460

Riluzole

Answer 460

MND

Question 461

Writer's Cramp/ Focal dystonia?

Answer 461

Flexion/Extension/rotation of Muscles of the hand. Suddenly | Relieved by stimulating another body part

Question 462

Alendronate upper GI side effects?

Answer 462

Swap to Risedronate or Etidronate

Question 463

Scleroderma Antibodies

Answer 463

scl 70 = Diffuse | Anti Centromere Antibodies = Limited

Question 464

Enzyme Inhibitors

Answer 464

SICKFACES. COM ``` Sodium Valproate Isoniazid Cemetidine Ketaconazole Fluconazole Alochol Chloramphenicol Erythromycin Sulphonamides Ciprofloxacin Omeprazole Metronidazole ```

Question 465

Scleroderma Antibodies

Answer 465

scl 70 = Diffuse | Anti Centromere Antibodies = Limited

Question 466

Loiasis:

Answer 466

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

Question 467

PPAR Gamma Agonist?

Answer 467

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

Question 468

Non Alcoholic Fatty liver Disease

Answer 468

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

Question 469

Deferiprone

Answer 469

Iron Chelating agent used in haemochromatosis treatment

Question 470

In pregnancy management of Haemochromatosis?

Answer 470

Monitor Cardiac and liver function ``` Pregnancy will lower iron Monitor Ferritin If normal, observe If low treated iron deficiency If high phlebotomy ```

Question 471

Polychondritis

Answer 471

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

Question 472

HIT confirm diagnosis

Answer 472

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

Question 473

Carcinoid syndrome?

Answer 473

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

Question 474

HHV 5 treatment post kidney transplant?

Answer 474

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

Question 475

Zanamavir

Answer 475

Treatment of Influenza in Immuno comprimised | Oseltamivir is in Immunocompetant

Question 476

HHV 5 treatment post kidney transplant?

Answer 476

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

Question 477

Zollinger Ellison Syndrome

Answer 477

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

Question 478

Colonoscopy Risk Criteria

Answer 478

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