Passmedicine Flashcards

Question

What are the ECG findings in Brugada syndrome?

Answer 1

Brugada syndrome is an autosomal dominant inherited cardiovascular disease. It can be asymptomatic and lead to sudden cardiac death. ECG changes consistent with Brugada syndrome include convex ST-segment elevation > 2mm in at least 1 of V1-V3 that is followed by T wave inversion. A partial right bundle branch block may also be seen. Sometimes, a patient may have an appearance of a normal electrocardiogram (ECG). However, following the administration of flecainide, these ST-segment changes may appear.

Answer 2

After 14 days ----------------------------------------- Recent meta-analysis collated the results of seven trials studying early anticoagulation in acute ischaemic strokes. Although the risk of further ischaemic strokes between days 7 and 14 is significantly reduced from 4.9 to 3%, the risk of symptomatic intracerebral haemorrhage was also significantly increased from 0.7% to 2.5%. As a result, early anticoagulation before 14 days is not indicated by NICE or the American Heart and Stroke Associations.

Answer 3

Most (but not all) patients with MG are seropositive for the acetylcholine receptor (AChR) antibody. Antibodies to muscle-specific receptor tyrosine kinase (MuSK), a surface membrane component essential in the development of the neuromuscular junction, have recently been identified and are found in up to 50% of MG patients who are seronegative for AChR antibodies. Emerging data suggests that the patterns of weakness and response to certain treatments may be different from those with AChR positive MG. Anti-striated muscle antibody usually positive in MG patients that have a thymoma.

Answer 4

Streptococcus pneumoniae

Answer 5

NRG-1, a synthetic cathinone, can cause agitation, hyponatraemia and serotonin syndrome. Treatment is with benzodiazepines, cooling and hypertonic saline if hyponatraemic. Patients may require intubation and paralysis to control hyperpyrexia

Answer 6

In normal human physiology, detoxification of cyanide occurs via rhodanese, an enzyme found in many tissues but particularly in the liver and muscle. Rhodanese converts cyanide to thiocyanate, a water-soluble molecule excreted in the urine. In poisoning, rhodanese is saturated and unable to remove the surplus cyanide molecules. Sodium thiosulfate serves as a sulfur donor in the reaction catalyzed by rhodanese. Hence administration of sodium thiosulfate increases cyanide to thiocyanate conversion. Hydroxocobalamin (vitamin B12) has also been approved for the treatment of cyanide poisoning.

Answer 7

NICE advises that all patients suspected to have a diagnosis of myeloma should be offered whole body MRI as first-line imaging, and only consider whole body CT if the patient declines MRI or is unable to have it. Skeletal survey should only be considered if CT and MRI are both not possible. Fluorodeoxyglucose positron emission tomography CT (FDG PET CT) can be considered once a diagnosis is confirmed.

Answer 8

Amphotericin or itraconazole are the pharmacological agents of choice for histoplasmosis Histoplasmosis is due to the fungus Histoplasma capsulatum. It is most commonly encountered in the Mississippi and Ohio River valleys.

Answer 9

Xanthelasma - high lipid levels leading to soft yellow/orange plaques, periorbitally. They are not of clinical concern - except for the underlying lipid profile which should be investigated and treated accordingly. They can be left alone, but if patients are keen for treatment, a commonly used option is topical trichloroacetic acid.

Answer 10

This is a condition that can occur in up to 40% of patients being given chemotherapy with agents such as platinum based drugs (cisplatin and oxaliplatin), vinca alakloids (vincristine and vinblastine), thalidomide and taxanes (paclitaxel and docetaxel). In most cases it is irreversible. The best medication for treatment is gabapentin or pregabalin which should be titrated up to therapeutic levels and used in conjunction with another analgesic agents.

Answer 11

Low risk: one or two adenomas smaller than 10 mm. Intermediate risk: three or four adenomas smaller than 10 mm or one or two adenomas if one is 10 mm or larger. High risk: five or more adenomas smaller than 10 mm or three or more adenomas if one is 10 mm or larger.

Answer 12

Superior Orbital Fissure- Affects CN III, CN IV, CN V(1), CN VI Carvenous sinus syndrome- Affects CN III, CN IV, CN V(1 &2), CNVI Orbital apex syndrome- Affects CN II, CN III, CN IV, CN V(1), CN VI i.e. Orbital apex syndrome is SOF plus visual loss

Answer 13

Inferior leads: II, III and aVF The origin for the right coronary artery is the right coronary sinus which is at the bases of the aorta.

Answer 14

Dexamethasone with ondansetron is effective in refractory chemotherapy-induced vomiting

Answer 15

Amoxcillin, a PPI, and either metronidazole or clarithromycin (decision re: metronidazole or clarithro is taken on the basis of recent exposure to these antibiotics) If patients are Penicillin allergic they get a PPI + Metronidazole and Clarithromycin as this question states. IF they are penicillin allergic and have had previous exposure to clarithromycin then they get PPI + Bismuth + Metronidazole + Tetracycline.

Answer 16

Lower risk 5 year follow up colonoscopy Extensive colitis with no active endoscopic/histological inflammation OR left sided colitis OR Crohn's colitis of <50% colon Intermediate risk ------------------------- 3 year colonoscopy 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 Higher risk -------------------- 1 year follow up colonoscopy Extensive colitis with moderate/severe active endoscopic/histological inflammation OR stricture in past 5 years OR dysplasia in past 5 years declining surgery OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis OR family history of colorectal cancer in first degree relatives aged <50 years

Answer 17

The initial monotherapy of prednisolone is effective at high dose but symptoms return on tapering its dose. An add-on treatment is therefore needed. The next agent to think about is azathioprine or mercaptopurine, in accordance with NICE guidance. Before either is commenced, a TPMT level must be done. If it is deficient, very low or absent, neither azathioprine or mercaptopurine should be offered. Methotrexate is the next most suitable agent to add if the patient cannot tolerate mercaptopurine or azathioprine. Infliximab is used only when patients have failed conventional therapy, including immunosuppressives and corticosteroids.

Answer 18

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

Answer 19

Intravenous albumin treatment has been shown to reduce in-hospital mortality of patients with uncomplicated SBP. Patients with associated renal dysfunction appear to derive the most benefit. Albumin decreases renal insufficiency, probably by increasing the circulatory volume and by binding pro-inflammatory molecules.

Answer 20

Note that a sigmoid volvulus will not retain haustra and typically originate in the left lower quadrant and extend to the right upper quadrant as is the case here. A caecal volvulus will typically originate in the right lower quadrant and extend to the left upper quadrant. Additionally, caecal volvuli retain haustra. As both of these features are not present here, a sigmoid volvulus is a more likely diagnosis.

Answer 21

However, it must be noted that Hep C Antibody testing can throw up false positives (up to 10%). Where Hep C antibodies are positive and RNA viral load is undetected it may be appropriate to repeat the antibody test using a different antibody assay. The false positive rate is thought to be secondary to other similar antibodies in the circulation. If the patient has Hep C antibodies and is Hep C RNA positive for more than 2 months they should be considered for treatment.

Answer 22

Diagnosis is made with small intestinal biopsy showing macrophages containing Periodic acid-Schiff (PAS) granules infiltrating into the lamina propria.

Answer 23

Paracentesis is not contraindicated in patients with an abnormal coagulation profile. The majority of patients with ascites due to cirrhosis have prolongation of the prothrombin time and some degree of thrombocytopenia. There are no data to support the use of fresh frozen plasma before paracentesis although if thrombocytopenia is severe (<40 * 109/l) most clinicians would give pooled platelets to reduce the risk of bleeding.

Answer 24

Antacid solutions, such as peptac, act by coating the stomach with an alkaline solution containing magnesium and calcium, thus improving heartburn symptoms. Unfortunately, this can lead to failed absorption of oral iron replacement. Alternate routes should be considered.

Answer 25

Although the incidence of anaesthetic related hepatitis has decreased over recent years with the introduction of modern agents such as desflurane and sevoflurane, cases are still reported. The rapid rise in transaminases, gamma GT and alkaline phosphatase so soon after surgery fits well with the diagnosis. Supportive therapy is the only option, no therapeutic interventions, (including corticosteroids), have proved effective.

Answer 26

Alcoholic hepatitis almost always presents with clinical jaundice and the presence of a hepatic bruit is particularly suggestive.

Answer 27

Prednisolone has been shown in meta-analyses to confer a significant reduction in 28-day mortality in patients with an MDS >32 or hepatic encephalopathy, however, there was no demonstrable benefit at 90 days or at one year. Combination therapy with prednisolone and pentoxifylline confers no additional benefit over treatment with prednisolone alone, whilst the use of N-acetylcysteine as monotherapy in alcoholic hepatitis is not recommended. In one randomised controlled trial, combination therapy with prednisolone and N-acetylcysteine was shown to be superior to prednisolone monotherapy in reducing mortality at 28 days; largely due to a reduction in the incidence of HRS and superimposed infection.

Answer 28

First episode of Clostridium difficile infection first-line therapy is oral vancomycin for 10 days second-line therapy: oral fidaxomicin third-line therapy: oral vancomycin +/- IV metronidazole

Answer 29

Recurrent episode recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode within 12 weeks of symptom resolution: oral fidaxomicin after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin

Answer 30

Life-threatening Clostridium difficile infection oral vancomycin AND IV metronidazole specialist advice - surgery may be considered

Answer 31

bezlotoxumab is a monoclonal antibody which targets Clostridium difficile toxin B NICE do not currently support its use to prevent recurrences as it is not cost-effective

Answer 32

faecal microbiota transplant may be considered for patients who've had 2 or more previous episodes

Answer 33

A prospective study suggests that continued smoking raises the risk of Crohn's exacerbation by approximately 50%.The study examined 573 Crohn's disease patients for a follow up period of 4 years. In comparison with nonsmokers, continuing smokers relapsed more frequently with an incidence rate ratio of 1.53 (95% confidence interval : 1.102.17). Former smokers and quitters had similar relapse incidences compared with nonsmokers. http://www.nature.com/ajg/journal/v111/n3/full/ajg2015401a.html

Answer 34

Mesalazine in Crohn's disease has debatable efficacy. A meta-analysis conducted in 2004 revealed a statistically significant but probably clinically insignificant effect on disease progression.

Answer 35

Paterson–Brown–Kelly syndrome

Answer 36

Radiographic evidence of colonic distension plus at least three of the following: 1) Fever >38.6°C 2) Heart rate >120 beats per minute (The most reliable sign is the pulse rate) 3) Neutrophilic leucocytosis >10.5 × 109/L, or 4) Anaemia. Plus, at least one of the following: 1- Dehydration 2- Altered mental status 3- Electrolyte disturbances, or 4- Hypotension.

Answer 37

Although well-differentiated carcinoid tumours secrete elevated levels of plasma chromogranin A, it is increasingly recognised that falsely positive elevated levels can be produced by other neuroendocrine tumours, hyperthyroidism, hyperparathyroidism, pituitary tumours, colon carcinoma, IBD, hypertension, COPD, ACS amongst many others. The low specificity of the test means that it is recommended that it is not used on its own as a screening test.

Answer 38

Acroparaesthesia: tingling, burning pain in the hands and feet triggered by stress such as emotion, extreme temperatures, or exercise Angiokeratoma corporis diffusum: lightly verrucous, deep-red to blue-black papules on the trunk (in the bathing trunk distribution) Cardiac: mitral valve prolapse or regurgitation usually, but any valvular heart defect can occur Strokes: including young strokes/TIAs Chronic Kidney Disease: proteinuria usually, can present late in fulminant renal failure Classically death occurred in the 4th decade but this has improved since the availability of dialysis. It would be important to organise urgent renal investigations in this young man amongst your workup.

Answer 39

This is an X-linked recessive lipid storage disorder in which there a deficiency in the fat enzyme alpha-galactosidase. This results in the accumulation of alpha-galactosyl-lactosyl-ceramide in various tissues, including kidney, liver, blood vessels and nerve ganglion cells.

Answer 40

recent guidelines suggest that individuals with an incidental finding of NAFLD should be offered an enhanced liver fibrosis (ELF) blood test. If the ELF result indicates advanced liver fibrosis ( 10.51) then the individual should receive specialist monitoring and intervention. If the ELF result is negative (< 10.51) then the individual is likely to have a benign prognosis from their NAFLD and can be monitored in primary care. For these individuals, a repeat ELF blood test is recommended every 3 years.

Answer 41

The Enhanced Liver Fibrosis (ELF) test is a commercially available algorithm that combines 3 direct serum markers of extracellular matrix remodeling and fibrogenesis: hyal- uronic acid, the N-terminal pro-peptide of collagen type III, and tissue inhibitor of metalloproteinase-1.

Answer 42

LFTs1 Drug induced Peter - paracetamol Had - halothane Epilepsy - sodium valproate/phenytoin And - amiodarone Alcoholic - etoh Tb - anti tb meds He met - methyldopa Norman in - nitro Shadwell - statins

Answer 43

It is sub-divided into type I and type II depending upon the antibodies present: -Type I Anti-smooth muscle antibodies or anti-nuclear antibodies; this constitutes 75% of patients -Type II Anti-LKM-1 or anti-liver cytosolic-1 antibodies

Answer 44

The incidence of vitamin A deficiency has been reported between 5 and 10% after bariatric surgery. Vitamin A deficiency is associated with night blindness, xerophthalmia, and occasionally complete blindness. Night blindness usually manifests as an inability in adjustment to dimmed light and is an early feature of vitamin A deficiency.

Answer 45

whilst metoclopramide is primarily a D2 receptor antagonist, the mechanism of action is quite complicated: it is also a mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist the antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone. At higher doses the 5-HT3 receptor antagonist also has an effect the gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity

Answer 46

70-80 Recent evidence has shown that conservative blood transfusion in the setting of acute upper gastrointestinal bleeding produces better outcomes compared to liberal blood transfusion. An important observation was that there was an improvement in survival rates with the restrictive transfusion strategy. There was a reduction in the risk of further bleeding, the need for rescue therapy, and the rate of complications. In Villanueva et al patients who were transfused when the haemoglobin was below 70g/dL had better outcomes compared to those who received blood transfusion below 100g/dL.

Answer 47

SeHCAT is bile acid analogue which can be detected by a nuclear medicine scan. The SeHCAT test involves a baseline scan, and then a 7 day scan. A 7-day SeHCAT retention value of less than 15% is generally considered indicative of bile salt malabsorption

Answer 48

First line treatment in the UK is procyclidine, a rapid acting anticholinergic, with benzodiazepines and anticholinergic antihistamines 2nd and 3rd line respectively

Answer 49

It's important to remember in diabetes related to pancreatic resection, both alpha cells producing glucagon, and beta cells producing insulin, are removed in the pancreatectomy. This reduces the intensity of any counter regulatory response to hypoglycaemia and thus impacts on prospects of recovery and increases the severity of individual events. For this reason a more lax HbA1c target is instigated for patients who have a history of pancreatectomy, of 53.

Answer 50

Sodium 126-135 mmol/L with normal creatinine - Continue normal diuretic regimen and observe, do not fluid restrict the patient. Sodium 121-125 mmol/L with normal creatinine - International opinion is to continue diuretics, however, the British Society of Gastroenterology recommend a more cautious approach, and suggest either stopping diuretics or reducing the dose. Sodium 121-125 mmol/L with raised creatinine (>150 mmol/L or >120 mmol/L and rising) - Stop diuretics and volume expand with human albumin solution 4.5%, gelofusine, or haemaccel Sodium <121 mmol/L - Incredibly controversial, but the British society of gastroenterology suggest stopping diuretics and volume expanding with human albumin solution 4.5%, gelofusine, or haemaccel (which all contain sodium concentrations similar to that of normal saline).

Answer 51

Drugs such as sulphasalazine, dapsone, ribavirin and poisoning with paraquat ingestion leads to the oxidation of Fe2+ (ferrous) components of haem to Fe3+ (ferric), forming methaemoglobin. When the intrinsic antioxidation mechanism of NADPH and glutathione is overwhelmed, red cell components undergo oxidative damage and cell death, leading to haemolysis, explaining the significantly raised LDH. Methaemoglobin is converted to hemichromes and eventually precipitated to Heinz bodies.

Answer 52

FFP is indicated due to raised INR/APTT > 1.5 x normal. Cryoprecipitate is only required if fibrinogen remains below 1.5 after FFP.

Answer 53

They are caused by the tapeworm parasite Echinococcus granulosus

Answer 54

The 4 main causes for hepatitis with very high ALTs (>1000) = mnemonic 'DIVA' 1. Drug-induced hepatitis 2. Ischaemic hepatitis 3. Viral hepatitis 4. Autoimmune hepatitis

Answer 55

The characteristic pathological findings of carcinoid heart disease are endocardial plaques of fibrous tissue that may involve the tricuspid valve, pulmonary valve, cardiac chambers, venae cavae, pulmonary artery, and coronary sinus.

Answer 56

Hydatid cyst is usually loculated.

Answer 57

The SIGN guidelines for occult bleeding recommend OGD and colonoscopy. If they are both normal they recommend either repeat OGD or capsule endoscopy. If the capsule is negative then either a second capsule or enteroscopy is indicated. CT angiography would be used for acute occult bleeding where the patient is compromised and embolisation of the bleeding vessel is needed

Answer 58

ABSOLUTE Severe and progressive liver failure (Child-Pugh score >12 is associated with a high risk of early death) Uncontrolled hepatic encephalopathy Right-sided heart failure Uncontrolled sepsis Unrelieved biliary obstruction RELATIVE Severe uncorrectable coagulopathy (INR >5) Thrombocytopenia <20 * 109/l Portal and hepatic vein thrombosis Pulmonary hypertension Central hepatoma

Answer 59

Hydrogen breath testing is an appropriate first line test for diagnosis of small bowel overgrowth syndrome

Answer 60

IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females

Answer 61

Deeply inverted T waves in V2-V3 are very suggestive of Wellens’ syndrome which is highly specific for critical stenosis of the left anterior descending artery (LAD). It should be treated as a STEMI with urgent angiography and revascularisation.

Answer 62

First line therapy in the treatment of angina is beta-blockade. Beta-blockers reduce myocardial oxygen consumption by acting as a negative inotrope and also by reducing heart rate. Some patients are unable to take beta-blockers such as asthmatics, or find that side effects such as tiredness, eczema or sexual dysfunction mean they are not tolerable. In these instances, use of calcium channel blockers such as diltiazem are recommended as first-line treatment. Since both of these classes of drug cause a reduction in heart rate and blood pressure their use must be monitored carefully, especially in the elderly. Concomitant use of beta-blockers and calcium channel blockers should be avoided where possible due to the risk of high degree conduction block and cardiac arrest.

Answer 63

Long-acting nitrates, such as isosorbide mononitrate or dinitrate are considered second-line therapy in stable angina. They can be used as monotherapy or as an adjunct to beta-blocker or calcium channel blocker therapy. They work by causing vasodilatation; both drugs possess a nitric oxide moiety which causes endothelial relaxation in blood vessels. This causes coronary vasodilation and improved blood flow to the myocardium with improved symptoms. A consequence of vasodilatation is hypotension and this should be considered when prescribing this drug to patients. Another second-line option drug for stable angina in those patients who cannot tolerate nitrates or they are ineffective is nicorandil. This drug has a similar ultimate effect in that it causes dilatation of peripheral and coronary vessels to reduce symptoms of angina. It works by activating potassium channels on endovascular smooth muscle cells reducing intracellular calcium and hence relaxing the blood vessel. It too can cause profound hypotension and severe headaches.

Answer 64

Ivabradine is a drug which can be used for both angina and heart failure. It works by reducing heart rate to reduce myocardial oxygen demand and improve diastolic function. In this case, the heart rate is adequately controlled so reduction is not necessary. Ivabradine also works by inhibiting the hearts natural pacemaker potential in the sinoatrial node, hence it only works when the patient is in sinus rhythm.

Answer 65

Ranolazine is a viable option in the management of angina where other avenues have been exhausted. It works by inhibiting the delayed sodium influx channel in the myocardium, reducing the intracellular calcium concentrations in the heart muscle. This, in turn, leads to a negative inotropic effect and reduction in symptoms of angina. Ranolazine does not cause a profound hypotensive effect and is the best choice in this scenario.

Answer 66

1st line: PRN GTN 2nd line: BB or CCB (dont mix BB with Diltiazem or Verapamil -> risk of CHB). 3rd line: Add on CCB/BB (whatever was missed in 2nd line) 4th line (if no hypotension after 3rd line) ISMN/nicorandil 5th line (if no hypotension after 4th line) Add on ISMN or nicorandil (wtv was missed) 6th line (if hypotension after 5th line): HR<70: RANOLAZINE (contraindicated in severe renal/liver disease) HR>70: IVABRADINE (contraindicated in Sick sinus syndrome)

Answer 67

liver: cholestasis, hepatitis, fatty liver, neoplasia Paget's osteomalacia bone metastases hyperparathyroidism renal failure physiological: pregnancy, growing children, healing fractures

Answer 68

Transfusions in patients awaiting renal transplants are usually avoided where possible, due to the potential risk of circulating antibodies and thus organ rejection. The transplant team would need to be informed and the patient advised that a transplant will be postponed for at least 3 months, following repeat antibody screening.

Answer 69

GLP-1 antagonists - "glutides"

Answer 70

NSAIDS/ Bisphosphonates Radiotherapy Denosumab (unlicenced)

Answer 71

Osteoporosis and atrial fibrillation

Answer 72

hCG is homologous to TSH in structure and therefore can lead to hyperthyroidism

Answer 73

Valproate-induced hyperammonaemic encephalopathy (VHE) is an unusual complication characterised by a decreasing level of consciousness, focal neurological deficits, cognitive slowing, vomiting, drowsiness, and lethargy. Asymptomatic hyperammonaemia occurs in 15–50% of patients on valproate. Treatment with L-carnitine may be beneficial in reducing ammonia levels.

Answer 74

Widespread T wave inversion in the chest leads can be a normal variant in patients with Afro-Caribbean ethnicity

Answer 75

NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to risedronate or etidronate

Answer 76

Ejection fraction <35% Heart rate >75/min Sinus rhythm NYHA class 2-4 Maximally titrated beta blocker therapy.

Answer 77

Extended spectrum B-lactamase (ESBL) producing organisms are typically resistant to penicillins and cephalosporins and as such the carbapenem class of antibiotics are typically first-line although nitrofurantoin or fosfomycin are also frequently effective. ESBL producers are most commonly Escherichia coli (E. coli) and Klebsiella species.

Answer 78

HLA-B27, although associated with the disease in textbooks, is not particularly useful in making the diagnosis. It is not particularly specific, nor sensitive. 10% of patients with ankylosing spondylitis are HLA-B27 negative, and 10% of the healthy population are HLA-B27 positive.

Answer 79

Superficial vein thrombosis (also referred to as thrombophlebitis) is a common condition and in the majority of cases is self-limiting. Patients presenting with a superficial vein thrombosis are at increased risk of a venous thromboembolic event and up to 20% of patients will already have a deep vein thrombosis (DVT) on presentation. Patients are more likely to have thrombus extension into the deep venous system if they have more than 5cm of thrombus within 10cm of the saphenofemoral junction (i.e. within the proximal long saphenous vein). The evidence for how superficial vein thrombosis should be managed comes from a Cochrane review and is used to support the Scottish intercollegiate guidelines network (SIGN) guidelines on the prevention and management of venous thromboembolism (guide 122). The guidelines recommend that all patients with clinical signs of a superficial vein thrombosis should have an ultrasound scan to exclude a DVT. Patients with a confirmed diagnosis of a superficial vein thrombosis should be considered for treatment with anti-embolism stockings and prophylactic doses of low molecular weight heparin (LMWH) for 30 days or fondaparinux for 45 days. In cases where LMWH is contraindicated, 8-12 days of oral non-steroidal anti-inflammatory drugs should be offered as this has been shown to reduce the risk of thrombus extension.

Answer 80

Cytomegalovirus (CMV) colitis is usually seen in patients who are immunocompromised. It is a member of the herpes virus, for which around 50-80% of the general population are seropositive. The virus lays dormant until the patient is sufficiently immunocompromised. Approximately 30% of all patients with AIDS will develop a gastrointestinal CMV infection. This usually occurs when the CD4+ counts drop to below 100 mm3. CMV can affect the gastrointestinal tract from the oesophagus to the rectum, and symptoms depend on the site of infection. CMV oesophagitis causes odynophagia and retrosternal chest pain. CMV enterocolitis commonly presents with diarrhoea, fever, weight loss and per rectal bleeding. Tenesmus can occur if there is rectal involvement. Cryptosporidiosis is a protozoal infection caused by cryptosporidium parvum. Immunocompromised individuals are particularly susceptible. The incubation period is between 2-10 days (average 7) and symptoms usually last about 1 to 2 weeks, although can occur for longer. The most common symptom is watery diarrhoea. Other symptoms include stomach cramps, dehydration, nausea and vomiting and fever.

Answer 81

chlorpromazine is licensed for the treatment of intractable hiccups haloperidol, gabapentin are also used dexamethasone is also used, particularly if there are hepatic lesions

Answer 82

The optimal drug of choice is an ACE inhibitor, preferably captopril, which has been trialed with the greatest experience, but other ACEi are also likely to be beneficial. In a 15 year prospective cohort, one year survival increased from 15% to 76% with the use of ACEi against other anti-hypertensives1. Steroids should be strictly avoided in SRC, they increase the risk of SRC prior to the event and may exacerbate SRC in the acute setting. Renal dialysis may be required in patients who progress to end-stage renal failure despite ACEi treatments.

Answer 83

female sex age: young age of onset (i.e. 20s or 30s) relapsing-remitting disease sensory symptoms only long interval between first two relapses complete recovery between relapses

Answer 84

Patients who are diagnosed with a pneumothorax should be given high-flow oxygen as it allows the exchange of nitrogen from the air trapped forming the pneumothorax with the additionally inspired oxygen from given to the patient. This exchange increases the oxygen content of the pneumothorax whilst decreasing the nitrogen concentration. Oxygen is more readily absorbed, and therefore the pneumothorax resolves more quickly.

Answer 85

As per NICE guidelines, for patients with chronic kidney disease, investigations for anaemia should be considered if their haemoglobin falls below 110g/L OR they develop symptoms suggestive of anaemia. This should begin with testing for iron deficiency using percentage of hypochromic red cells or reticulocyte haemoglobin content. In patients with anaemia of CKD, do not request transferrin saturation or serum ferritin measurement alone to assess iron deficiency status.

Answer 86

NRTIs - in particular stavudine, didanosine and zidovudine - classically cause mitochondrial toxicity as an unwanted side effect. This can result in nausea, pancreatitis, lactic acidosis and lipoatrophy as demonstrated above.

Answer 87

Current NICE guidelines recommend the starting of biologic therapy when the patient has been on at least two DMARDs, including methotrexate, reporting two DAS 28 scores of greater than 5.1 at least one month apart

Answer 88

Helps divide primary and secondary hyperaldosteronism. Primary Renin is low due to something directly making or stimulating aldosterone meaning kidneys well filled so no renin needed Cushing's Conns CAH all examples Secondary think kidney being underfilled despite euvolemia/hypervolemia , leading to high renin >high aldosteronism RAS Heart failure (bp less likely todav htn) Excess diuretics

Answer 89

Hypophosphataemia is the most common electrolyte abnormality during alcohol withdrawal and is a recognised cause of seizures. It is often present at baseline in alcoholic patients and can further decrease in withdrawal. It is thought that this is due to effects on the proximal renal tubule. It can cause muscle pain and disorientation at very low levels (< 0.3 mmol/l).

Answer 90

Tolvaptan is a selective vasopressin receptor 2 antagonist and has been shown to reduce the annual rate of kidney growth and reduce the rate of decline of renal function over a three year period. In England and Wales, tolvaptan is recommended for patients with rapidly progressive disease at CKD stages 2-3. There is no current definition of rapidly progressive disease although an increase in total kidney volume of > 5 % per year is a predictor of rapid disease progression.

Answer 91

Pravastatin was shown to slow disease progression in children with ADPKD, but there is no evidence of benefit in adult patients.

Answer 92

Folinic Acid methotrexate inhibits the enzyme which converts folic acid to folinic acid. So if you have methotrexate toxicity you're unlikely to respond to folic acid as the enzyme is already inhibited, thus you have to give folinic acid.

Answer 93

Digoxin administration is not recommended in cardiac amyloidosis owing to a higher risk of digoxin toxicitiy, as the drug binds avidly to amyloid fibrils.

Answer 94

Continue amiodarone and start levothyroxine.

Answer 95

Continue amiodarone and start carbimazole. This is excess iodine- induced thyroid hormone synthesis. A goitre will be present

Answer 96

Stop amiodarone and start prednisolone This is amiodarone related destructive thyroiditis with an absent goitre.

Answer 97

Combination = long acting patch and short acting formulation (either oral or nasal spray) to help manage acute cravings Combination absolute abstinence rate 32% compared to 25% for non-combination nicotine replacement.

Answer 98

In patients with ischaemic heart disease or seizure where insulin tolerence test will be inappropriate. (risks of hypoglycaemia)

Answer 99

30-40% low IGF-1 may point to diagnosis of GHD but needs to be confirmed with dynamic tests for GH secretion. IGF-1 levels are influenced by age, time of onset of GHD, and degree of hypopituitarism. Insulin tolerance test is considered the gold standard.

Answer 100

Carbamazepine increases risk of toxicity without affecting levels Amiodarone increases risk of VT without increasing lithium levels.

Answer 101

Low serum erythropoietin is suggestive of primary bone marrow disease even in the absence of JAK2 mutation and should prompt testing for the rarer exon 12 mutation of JAK2. This test should be performed before the more invasive bone marrow biopsy.

Answer 102

Both present with hypercalcaemia and low urinary calcium (other causes of hypercalcaemia cause high urinary calcium) FHH has an inappropriately NORMAL PTH due to loss of function mutations in the CASR calcium sensing receptor. This decreases sensitivity to calcium, meaning PTH remains unsuppressed at higher than normal serum calcium levels. Hypocalciuria results from a loss of CASR-mediated negative feedback of tubular reabsorption/excretion of calcium.

Answer 103

Dialysis should be considered in symptomatic lithium toxicity and: -A lithium concentration greater than 5.0 mmol/L in patients with acute lithium overdose and who are not prescribed lithium -A lithium concentration greater than 2.5 mmol/L in patients with chronic poisoning Haemodialysis should be continued until: -All new neurological features have resolved, and -Lithium concentration remains stable at less than 1mmol/L Acute on chronic overdose of lithium can lead to serious toxicity even after a modest overdose, as the extracellular tissues are already saturated with lithium.

Answer 104

Elevated serum levels of hepcidin preventing intestinal absorption of iron.

Answer 105

< 40mg/kg elemental iron and are asymptomatic can be observed at home. > 40mg/kg elemental iron or who are symptomatic need medical assessment with serum iron levels measured 2-4 hours post-ingestion and abdominal x-ray. > 60mg/kg elemental iron or have undissolved tablets on abdominal x-ray within 4 hours who have ingested = Whole bowel irrigation If tablet still present after irrigation give Desferrioxamine. > 90mg/kg elemental iron or in SHOCK= Desferrioxamine. No role for activated charcoal

Answer 106

Capecitabine is the oral analog of 5-flourouraxil, a chemotherapeutic agent which is broken down predominantly, by dihydropyramidine dehydrogenase (DPD). Deficiency is autosomal recessive and can lead to a toxin buildup which in homozygous patients is usually fatal

Answer 107

5-7 mmol/litre on waking 4-7 mmol/litre before meals 5-9 mmol/litre 90 mins after eating.

Answer 108

It is recommended that women conceiving on an effective antiretroviral (ART) regimen should continue this even if it contains efavirenz or does not contain zidovudine. Exceptions are: (1) Protease inhibitor (PI) monotherapy should be intensified to include (depending on tolerability, resistance and prior antiretroviral history) one or more agents that cross the placenta. (2) The combination of stavudine and didanosine should not be prescribed in pregnancy Although there is most evidence and experience in pregnancy with zidovudine plus lamivudine, tenofovir plus emtricitabine or abacavir plus lamivudine are acceptable nucleoside backbones. In the absence of specific contraindications, it is recommended that the third agent in ART should be efavirenz or nevirapine (if the CD4 cell count is less than 250 cells/L) or a boosted PI. No routine dose alterations are recommended for ARVs during pregnancy if used at adult licensed doses. With a viral load <50 at 36 weeks a vaginal delivery is recommended in the absence of any obstetric complications.

Answer 109

Diethylcarbamazine

Answer 110

Formal diagnosis (by Modified Dandy criteria), requires CSF opening pressure greater than 25 cmH2O and normal brain imaging. Imaging is required to exclude venous sinus thrombosis, which could result in the same signs and symptoms and is also more common in women on the oral contraceptive pill. The gold standard imaging for this would be MRI with contrast of the head and orbits and MR venogram.

Answer 111

Supplementing calcium and vitamin D in secondary hyperparathyroidism runs the risk of adynamic bone disease if this is begun at less than twice the upper limit of the normal range for PTH. For this reason levels are usually tracked until they cross this threshold, where upon supplementation is commenced. In the event that patients with PTH levels greater than twice the upper limit of normal are left untreated, there is significant risk of progression to tertiary disease, and increased propensity to complications associated with hyperparathyroidism including bone resorption, fracture and ectopic calcification.

Answer 112

APS type 2 has a polygenic inheritance and is linked to HLA DR3/DR4. Patients have Addison's disease plus either: type 1 diabetes mellitus autoimmune thyroid disease APS type 1 is occasionally referred to as Multiple Endocrine Deficiency Autoimmune Candidiasis (MEDAC). It is a very rare autosomal recessive disorder caused by mutation of AIRE1 gene on chromosome 21 Features of APS type 1 (2 out of 3 needed) chronic mucocutaneous candidiasis (typically first feature as young child) Addison's disease primary hypoparathyroidism Vitiligo can occur in both types

Answer 113

Aldosterone on standing Aldosterone is increased on prolonged standing in adrenal hyperplasia. In Conn's adenoma, the aldosterone would stay the same or drop on standing.

Answer 114

30 minute serum cortisol concetration greater than 420 nmol/L

Answer 115

Once adrenal insufficiency is confirmed with the short synACTHen test the location of the lesion can be achieved by measurement of ACTH or by performing the long Synacthen test. Interpretation of this test is governed by the following: 1. In primary adrenal failure: we would not expect there to be a significant rise in cortisol during the long Synacthen rest since the adrenal glands are intrinsically dysfunctional 2. In secondary adrenal failure: chronically low levels of ACTH due to pituitary failure result in atrophy of the adrenal glands. Prolonged stimulation of the adrenal glands by ACTH in the long Synacthen test results in a degree of recovery by the adrenal glands resulting in a significant rise in cortisol. A response that rises gradually to a peak at 24 hours occurs in secondary adrenal failure. This pattern of results also occurs due to prolonged corticosteroid therapy use. An important point is to remember that in some cases of long-standing adrenal atrophy due to secondary adrenal insufficiency, the adrenal glands will not respond even after 24 hours and will require several daily doses of depot Synacthen before an adrenal response is seen. The majority of these cases should be identifiable by measurement of plasma ACTH, which would be expected to be very low (in contrast to primary adrenal insufficiency where ACTH levels are very high).

Answer 116

Elevated PSA >4ng/ml Male breast Ca Severe sleep apnoea Severe LUTS due to BPH

Answer 117

1st line MTX 2nd line MMF, Azathioprine, cyclophosphamide

Answer 118

Azetozolamide Topiramate RTA Type 1 and Type 2 Diarrhoea Ureterosigmoidostomy Post hypocapnic state

Answer 119

Type 1 RTA can be the first presentation of Sjogren's so these patients should have autoimmune screening (anti-Ro, anti-La, RF and ANA)

Answer 120

Urine pH High in RTA type 1 due to a failure to acidify the urine.

Answer 121

Low glucose Raised protein lymphocytic predominant WCC

Answer 122

Normal or slightly reduced glucose Low protein Monocyte predominant WCC (count usually <500)

Answer 123

All patients with type 1 or type 2 diabetes should have retinal screening during pregnancy as there is an increased risk of developing retinopathy. Patients should be advised to have retinal screening before 13 weeks unless their yearly screening has been done very recently. If any signs of retinopathy are picked up, repeat testing between 16-20 weeks is recommended, otherwise further testing at 28 weeks would suffice.

Answer 124

Initially managed with high dose steroids alongside either mycophenolate or cyclophosphamide. Maintanence 1st line: Mycophenolate Other maintanence options: azathioprine, tacrolimus

Answer 125

Donepezil first line Memantine second line (donepezil is generally avoided in patients with bradycardia and is used with caution in other cardiac abnormalities)

Answer 126

Iodine in IV contrast stays in body for 2 months and limits therapeutic uptake of radio-iodine by the thyroid gland.

Answer 127

The abrupt appearance of multiple seborrhoeic keratoses. Suggests underlying cancer and most associated with gastrointestinal adenocarcinomas and hepatic cancers.

Answer 128

It can worsen the storm by displacing T4 from thyroid binding globulin.

Answer 129

Degludex has a much higher half life than levemore and therefore maintains a basal insulin level when the patient omits or forgets doses. This can prevent DKA.

Answer 130

>50 nmol/L = dietary recommendations 30-50 nmol/L = maintenance dose vitamin D <30 nmol/L = loading dose vitamin D

Answer 131

First line: Nitazoxanide Second line: Rifaximin

Answer 132

DEAR Dipyridamole enhances (large ventricular standstill) Amiphyline reduces (short vent standstill)

Answer 133

The carbapenem - imipenem - is usually combined with cilastatin, a renal dehydropeptidase I inhibitor to decrease the renal degradation of imipenem.

Answer 134

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

Answer 135

Amiophylline is a methylxanthine and acts as a phosphodiesterase inhibitor and adenosine receptor antagonist. It therefore can act oppositely to adenosine in the heart and induce tachyarrhythmias. Therefore, for loading, a cardiac monitor needs to be applied.

Answer 136

In patients who continue to have persistent symptoms despite a long-acting muscarinic antagonist, beta-agonist and inhaled corticosteroid, roflumilast can be tried. Roflumilast is a phosphodiesterase inhibitor recommended by NICE as an option for treating severe chronic obstructive pulmonary disease if the following criteria are met: Severe disease is defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal. AND The person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid.

Answer 137

Causes a characteristic skin rash (mainly at the intertriginous and perioral areas), alopecia, taste impairment, glucose intolerance, and diarrhoea.

Answer 138

First step: pregnancy test Second step: Serum prolactin, TSH and FSH bloods This will help differentiate between the most common causes of secondary amenorrhoes following pregnancy: hyperprolactinaemia, thyroid dysfunction and premature ovarian failure respectively.

Answer 139

Disease caused by the filarial nematode Onchocerca volvulus. The parasite is transmitted by blackflies of the genus Simulium, which deposit the parasites larva onto the skin when biting to extract blood. The adult worm lives in subcutaneous nodules and produces larvae, which become deposited in the skin and eyes. Disease manifests when the parasite dies in tissues and releases Wolbachia endosymbiotic bacteria into tissues, provoking a host immune response. This above patients disease has manifested as river blindness, where the worms die in the cornea and provoke chronic inflammation, eventually leading to clouding of the cornea. Inflammation in subcutaneous tissues leads to a pruritic rash and formation of a leopard-skin appearance over time. The worms can be visualised by microscopy of skin snip biopsy. The treatment of choice is ivermectin; DEC should not be used because rapid death of the worms can exacerbate damage to surround tissues and even cause complete blindness.

Answer 140

SSRIs Linezolid was originally discovered as a psychotropic agent with antidepressant effects through mild reversible nonselective inhibition of monoamine oxidase (MAO), before it was found to have antibiotic efficacy against drug-resistant gram-positive cocci. In combination with serotonin agonists there is a risk of serotonin syndrome. Therefore, when using linezolid it must be considered to discontinue SSRIs.

Answer 141

Tremor-predominant Parkinson's disease can be highly disabling and tremor may persist despite standard treatment with dopaminergic agents, which primarily improve bradykinesia. First-line treatment is such cases is the addition of an anticholinergic drug such as procyclidine, orphenadrine, or trihexyphenidyl. The main side-effect which limits the use of anticholinergics in older patients is cognitive dysfunction, and dementia is a relative contra-indication. Other side effects include blurred vision, urinary retention, nausea, constipation, and dry mouth. Second-line treatments for persistent tremor include amantidine, clozapine, and propranolol. Deep brain stimulation may be used in refractory cases.

Answer 142

treponima pallidum- syphilis: painless ulcer painless lymphnodes (painless painless) herpis simplex and haemophilus ducury (chanchroid) cause painful ulcer painful lymphnodes (painful painful) lymphgranuloma venerum (chlamydia) and granuloma inguinale (Klebsiella granulomatosis) cause painless ulcer painful lymphnodes (painless painful)

Answer 143

B - blood culture in 1st week A - agglutination (widal test) in 2nd wee S - stool culture in 3rd week U - urine culture in 4th week

Answer 144

A. DIABETES (normally): fasting: >7, random(or 2 hour after 75g loading): 11.1 B. gestational diabetes: fasting:>=5.6, 2 hour glucose:>7.8

Answer 145

Loss of consciousness at any point Neurological signs other than headache, Myocardial ischaemia Arrhythmia Pregnancy

Answer 146

INR is 1.3 or less, AND ALT is within the normal range If the ALT is above the normal range (with an INR of 1.3 or less), acetylcysteine may still be stopped if: ALT is less than two times the upper limit of normal AND The increase in ALT value is not more than a doubling of the admission value

Answer 147

The indications for plasma exchange in ANCA-associated vasculitis are: -Severe active renal disease (serum creatinine above 354 micromol/L or who require dialysis), -Pulmonary haemorrhage, -Concurrent anti-GBM autoantibody disease.

Answer 148

If asymptomatic and younger than 65 years then test for latent TB. If Mantoux-negative and unvaccinated then offer vaccination. If at risk of HIV then test for HIV first. If asymptomatic and older than 65 years then assess with a chest X-ray.

Answer 149

Raised intracranial pressure (ICP) is thought to be caused by the yeast cells and fungal polysaccharides forming microscopic plugs and blocking CSF resorption in the subarachnoid villi.

Answer 150

Cross sectional area of <1cm^2

Answer 151

From most recent ESC Heart Failure guidelines (2016): 'A subsequent RCT conducted in self-identified black patients (defined as being of African descent) showed that addition of the combination of hy- dralazine and isosorbide dinitrate to conventional therapy (ACEI, beta-blocker and MRA) reduced mortality and HF hospitalizations in patients with HFrEF and NYHA Classes III IV'

Answer 152

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

Answer 153

Any patient presenting with eye movement weaknesses that cannot be explained by isolated or multiple cranial nerve palsies is called complex ophthalmoplegia. The differentials include myasthenia gravis, mononeuritis multiplex, thyroid eye disease, Kearns-Sayre syndrome, complex progressive external ophthalmoplegia, Miller-Fisher syndrome and botulinum poisoning.

Answer 154

HIV binds to the CD4 cell via the CD4 receptor. This interaction also depends on viral interaction with the CD4 co-receptor. There are two forms of CD4 co-receptor CCR5 and CXCR4. The test for viral tropism determines which of these co-receptors HIV will bind to. Maraviroc blocks HIV binding to the CCR5 receptor, and therefore is an effective drug in a 'CCR5 tropic' virus.

Answer 155

Solitary, solid and non-calcified lung nodules of less than 5mm in size.

Answer 156

Nodule <5mm, or clear benign features, or unsuitable for treatment: can be discharged Nodule =>8mm and high risk*: then CT-PET, and if CT-PET shows high uptake then biopsy Nodule 5-6mm, or =>8mm and low-risk*: then CT surveillance -CT surveillance: if 5-6mm then at 1 year, if =>6 then in three months

Answer 157

It is important to have a basic understanding of two commonly identified groups: Mycobacterium avium complex (MAC) and Mycobacterium kansasii. - MAC: Rifampicin, clarithromycin and ethambutol. Treatment should continue until the patients sputum has remained negative for MAC for 12 months - M.kansasii: Rifampicin, isoniazid and ethambutol. Treatment should continue until the patient has been sputum culture negative for 12 months. It is important that patients with NTM infection should never receive clarithromycin monotherapy due to concerns over development of resistance.

Answer 158

Stalk compression -> non-functioning pituitary adenoma.

Answer 159

For multiple daily dose regimens of gentamicin, if the pre-dose (‘trough’) concentration is high, the interval between doses must be increased. If the post-dose (‘peak’) concentration is high, the dose must be decreased

Answer 160

Rifamycin containing anti-tuberculosis chemotherapy regimes are superior to those which do not contain a rifamycin agent. However, in this scenario the patient is also taking taking a protease inhibitor as part of their antiretroviral therapy. Rifampicin, the common rifamycin agent in anti-tuberculosis regimes, is a potent inducer of liver enzymes, such as cytochrome P450. Furthermore, it up-regulates the expression of P-glycoprotein in the gastrointestinal tract. This leads to reduced absorption and increased metabolism of certain medications, protease inhibitors being one of these (ritonavir booster atazanavir). Co-administration of a protease inhibitor with rifampicin therefore will often lead to subtherapeutic levels of the protease inhibitor. In this scenario, the patient is stable on his current antiretroviral treatment and not keen to switch at present. Therefore, the British HIV Association (BHIVA) suggest the substitution of rifampicin for an alternative rifamycin agent (rifabutin or rifapentine), which has less inducing action of cytochrome P450 and therefore allows the patient to continue their current HIV treatment regime. Regimes containing rifabutin (dose 150mg three times a week) have been shown to have equivocal in outcomes of treatment in the few small observational studies performed in patients with HIV/TB co-infection.

Answer 161

treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater in 2019, NICE made a further recommendation, suggesting that we should 'consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. '. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease

Answer 162

EF <35% and still symptomatic on B-blocker and ACEi Replace ACEi after washout period

Answer 163

Add if EF <35% and HR >75

Answer 164

Calcitonin is used for screening, prognosis and monitoring in medullary thyroid cancer. CEA is often used in conjunction with calcitonin

Answer 165

Tall R waves in V1-V2

Answer 166

Prescribe DAPT (dual anti-platelet therapy). This is aspirin 75 mg daily plus ticagrelor 90 mg twice a day for 12 months. Ticagrelor is the preferred choice (even in those previously treated with clopidogrel) unless the bleeding risk outweighs the benefit. For people at high risk of bleeding, continue DAPT for at least one month. For people with MI at high ischaemic risk who have tolerated DAPT without a bleeding complication, consider treatment with DAPT (ticagrelor 60 mg twice daily) in addition to aspirin for longer than 12 months and up to 36 months. If ticagrelor is not suitable, consider clopidogrel 75 mg daily (as well as aspirin) for longer than 12 months. Aspirin and prasugrel is only recommended for patients undergoing percutaneous intervention and stenting

Answer 167

Before a renal biopsy is performed, patients should have a renal tract ultrasound. The presence of polycystic kidneys, obstruction of the urinary tract, or hydronephrosis are regarded as absolute contraindications to biopsy

Answer 168

Ciprofloxacin Second line: IV Taz, ceftazidime, aztreonam or meropenem

Answer 169

The hypothalamopituitarythyroid axis is well developed at 12 weeks gestation but remains inactive until 1820 weeks. Circulating TSH receptor antibodies (TSH-RAB) in the mother can cross the placenta, and it is these, rather than the thyroid status of the mother, that cause neonatal thyrotoxicosis. The risk of hyperthyroidism to the neonate can be assessed by measuring TSH-RAB in the maternal circulation at the beginning of the third trimester. Antithyroglobulin antibody and thyroid peroxidase antibodies have no effect on the fetus.

Answer 170

Prevention of further risk: e.g. sun avoidance, sun cream fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects topical imiquimod: trials have shown good efficacy cryotherapy curettage and cautery

Answer 171

Theophylline is a methylxanthine derivative drug which is structurally and clinically similar to caffeine. Aminophylline is the name given to theophylline when it is ligand bound to the chemical ethylenediamine which increases water solubility and hence aminophylline tends to be the intravenous form. Methylxanthine derivatives are used clinically for the treatment of bronchoconstriction in asthma, chronic obstructive pulmonary disease and in neonatal apnoea. They work in a two-fold fashion; firstly they inhibit the family of metabolic enzymes, the phosphodiesterases which increase levels of cyclic adenosine monophosphate and dampens the inflammatory cytokine cascade, and secondly they are competitive antagonists at the endogenous adenosine receptors located in the central nervous system, heart and lungs. Inhibition of various phosphodiesterases causes a reduction in the circulating population of inflammatory cytokines and also increases cardiovascular and peripheral blood flow. Due to increased metabolism, hypokalaemia is common and gluconeogenesis and glycogenolysis is stimulated causing a rise in the plasma glucose load. Competitive antagonism at the adenosine receptor causes roughly the opposite effects of adenosine. Whereas this drug is used clinically to slow the heart rate and block transmission at the AV node, theophyllines cause tachycardia and an increase in AV conduction, cardiac automaticity and an increase in myocardial contractility, ultimately leading to an increased cardiac output with hypertension and flushing. Inhibition of adenosine receptors in bronchioles causes relaxation and improved airflow, and in the central nervous system leads to agitation, headache, anxiety, tremor and insomnia. Other symptoms of methylxanthine toxicity include extreme nausea and vomiting, pancreatitis, gastroesophageal irritation, psychiatric symptoms and seizures. Tachyarrhythmias may deteriorate into ventricular rhythms quickly which may be fatal. Competing metabolic acidosis and respiratory alkalosis may cause a mixed arterial blood gas picture and many electrolyte disturbances can occur but an unexplained hyperglycaemia with a hypokalaemia is very suggestive of theophylline toxicity. Theophylline has a narrow window of therapeutic efficacy and patients may become toxic rapidly if drugs which inhibit their metabolism are given concurrently, particularly antibiotics such as macrolides or fluoroquinolones. Management of theophylline toxicity is largely supportive with seizures controlled by benzodiazepines or intubation. Phenytoin is best avoided as it can worsen arrhythmia. Electrolyte abnormalities must be corrected, particularly hypokalaemia and hypomagnesaemia. Hypertension and tachycardia may respond to beta-blockers but beware of making the situation worse in an asthmatic patient. Verapamil is an alternative. Ventricular rhythms should be electrically cardioverted. Theophyllines are one of the few drugs which are highly adsorbed by activated charcoal and this should be considered even beyond an hour after ingestion due to the extended release nature of most preparations and the drugs slowing of gastric emptying

Answer 172

Pulmonary causes -asthma -allergic bronchopulmonary aspergillosis -Churg-Strauss syndrome -Loffler's syndrome -tropical pulmonary eosinophilia -eosinophilic pneumonia -hypereosinophilic syndrome Infective causes -schistosomiasis -nematodes: Toxocara, Ascaris, Strongyloides -cestodes: Echinococcus Other causes -drugs: sulfasalazine, nitrofurantoin -psoriasis/eczema -eosinophilic leukaemia (very rare)

Answer 173

- Recent facial or upper airway surgery or facial injuries. - Recent upper gastrointestinal surgery. - Confusion/agitation. - Bowel obstruction. - Upper airway obstruction. - Excessive upper airway secretions. - Patient actively vomiting.

Answer 174

Increased risk of non-melanoma skin cancer.

Answer 175

Mentzer's Index = MCV/red cell count <13 points towards thalassaemia >13 points towards IDA

Answer 176

The bulging fissure sign is an increasingly rare but classical feature of Klebsiella pneumonia. It is due to large volumes of consolidation (typically in the right upper lobe) causing displacement of the adjacent fissure.

Answer 177

-Progressive marrow failure: the development or worsening of anaemia and/or thrombocytopenia Massive (>10 cm) or progressive lymphadenopathy Massive (>6 cm) or progressive splenomegaly Progressive lymphocytosis: > 50% increase over 2 months or lymphocyte doubling time < 6 months -Only if initial count >30 Systemic symptoms: weight loss > 10% in previous 6 months, fever >38ºC for > 2 weeks, extreme fatigue, night sweats Autoimmune cytopaenias e.g. ITP

Answer 178

acute respiratory illness of less than or equal to 1-month duration pulmonary infiltrates on chest radiography or computed tomography (CT) pulmonary eosinophilia as demonstrated by more than 25% eosinophils in BAL fluid (can be accompanied by variably increased percentages of lymphocytes and neutrophils) or eosinophilic pneumonia on lung biopsy (bronchoscopic or surgical), and the absence of other specific pulmonary eosinophilic diseases e.g. eosinophilic granulomatosis with polyangiitis (previously known as Churg-Strauss syndrome)

Answer 179

Serum eosinophilia in steroid naïve patients and/or no history of recent steroid use Elevated total serum IgE level (>1000 iU/ml), positive serum Aspergillus precipitins (IgM, IgG and IgE antibodies to Aspergillus species) Sputum showing elevated eosinophil count and/or fungal mycelia with healthy cytoplasm (cf. dead mycelia devoid of cytoplasm seen in patients with Aspergilloma) Immediate skin test reactivity to Aspergillus antigens A massive homogeneous shadow without fissure displacement is the most common abnormality seen on a chest radiograph with ABPA The bronchiectasis seen in ABPA is typically central

Answer 180

Membranoproliferative glomerulonephritis (notably type II) reoccurs in 80-100% of cases. This is lower in type I. IgA reoccurs in up to around 60% of patients. FSGS reoccurs in up to around 50% of patients. Polycystic kidney disease and Alport's syndrome do not reoccur in renal transplantation.

Answer 181

If less than 1 hour after indigestion = gastric lavage If over 1 hour = oral activated charcoal --- If any serious features (seizure, coma, renal failure or pulmonary oedema) = dialysis --- If level 300-600mg/l = rehydrate If level 600-800mg/l = sodium bicarb If level >800 mg/l = dialysis

Answer 182

1) % hypochromic red cells (requires analysis within 6 hours) a value of >6% inidcates iron deficiency. 2) Reticulocyte Hb content where <29pg is diagnostic of iron deficiency anaemia 3) A combination of transferrin saturations (<20%) and ferritin (<100 mcg/l)

Answer 183

There is a significant risk of over-replacement of iron in these patients, and NICE guidelines suggest that a patients ferritin should be kept below 800 ng/ml, and one should consider changing the patient's iron replacement therapy in order to prevent this when their ferritin is higher than 500 ng/ml.

Answer 184

Phlebotomy is the mainstay of treatment in hereditary haemochromatosis and is indicated in all patients with a ferritin level greater than 1,000 microgram / L. Typical initial phlebotomy regimes are 400-500 ml every 1-2 weeks. Once ferritin level falls to the range 50-100 microgram / L, phlebotomy regime can transition to a maintenance schedule every 2-4 months.

Answer 185

Hepatitis B DNA level

Answer 186

1.5.3 Consider levothyroxine for adults with subclinical hypothyroidism who have a TSH of 10 mlU/litre or higher on 2 separate occasions 3 months apart. Follow the recommendations in section 1.4 on follow-up and monitoring of hypothyroidism. 1.5.4 Consider a 6-month trial of levothyroxine for adults under 65 with subclinical hypothyroidism who have: a TSH above the reference range but lower than 10 mlU/litre on 2 separate occasions 3 months apart, and symptoms of hypothyroidism.

Answer 187

NICE recommends the following investigations for all patients: FBC, U&E, LFT, calcium, urinalysis, LDH Chest X-ray CT of chest, abdomen and pelvis AFP and hCG NICE recommends the following investigations for specific patients: Myeloma screen (if lytic bone lesions) Endoscopy (directed towards symptoms) PSA (men) CA 125 (women with peritoneal malignancy or ascites) Testicular US (in men with germ cell tumours) Mammography (in women with clinical or pathological features compatible with breast cancer)

Answer 188

Left atrial pressure Can determine if mitral stenosis is present -> CWP - Left Ventrical pressure should be <5mmHg

Answer 189

HIV, once stable, should be monitored with a viral load every six months and CD4 counts annually at least once virological suppression, defined as sustained viral load less than <50 copies/ml, is established. If the viral load increases to between 50-200 copies/ml on a single sample this is defined as a viral blip and is unlikely to be significant, but a viral load should be re-tested within one month. If a viral load above >200 copies/ml is sustained this is a virological rebound and can imply failure. This can be due to new viral resistance, and, if suspected, would need resistance testing.

Answer 190

ACEi are still first line. -Decrease in eGFR up to 25% or rise in creatinine of up to 30% is acceptable. Furosemide is useful as an anti-hypertensive in patients with CKD and has the added benefit of lowering serum potassium. Thiazides are less useful if renal output is reduced as less urine makes it to the distal tubule.

Answer 191

The plasma leak phase may occur anytime within the first 48 hours after the fever has broken and manifests with leakage into pleural and peritoneal spaces. It may be accompanied by shock and in some cases haemorrhage. Platelets and renal function may be falsely reassuring as they tend to improve after the febrile phase but rising haematocrit is a sensitive sign of plasma leak. It is therefore essential to monitor patients for a full 48 hours after the febrile phase and ensure haematocrit is stable prior to discharge. Platelets should be at least 50 * 109/l and rising prior to discharge.

Answer 192

Abacavir can cause a severe and sometimes fatal hypersensitivity reaction. It is a cell mediated delayed hypersensitivity reaction which occurs around 6 weeks after starting treatment. Symptoms are of fever, rash, malaise and gastrointestinal symptoms. Patients without HLA B*5701 are highly unlikely to develop hypersensitivity. Those with the HLA B*5701 allele have a 50% risk and therefore in these individuals abacavir should be avoided. It is therefore routine to test HLA B*5701 status on all newly diagnosed patients with HIV.

Answer 193

The diagnosis is Hereditary Neuropathy with Liability to Pressure Palsy (HNPP). This is a neurological syndrome in which trivial trauma to a peripheral nerve e.g. sleeping on a limb, results in a mononeuropathy which may take weeks to resolve. It usually presents in second or third decade of life. The condition is most common in families with Dutch or German ancestry. It is caused by a deletion in the peripheral myelin protein 22 gene on chromosome 17. It is an autosomal dominant condition. The patient's presenting mononeuropathy is a common peroneal nerve palsy. Three years ago he had an ulnar nerve palsy and eight years ago he had a radial nerve palsy (also called Saturday night palsy). Nerve conduction studies in HNPP are characteristic of a demyelinating neuropathy: conduction is slow and action potentials are small. Nerve biopsy may show a predominance of smaller fibres and localised thickening of the myelin sheath. These investigations are helpful in supporting the diagnosis although gene testing, if positive, is confirmatory. Management is conservative with e.g. wrist splints, ankle-foot orthoses, and protective padding.

Answer 194

Simple pulmonary eosinophilia, aka Loeffler's syndrome. This is caused by Ascaris lumbricoides, Strongyloides, or Ancylostoma. Infection with these worms is prevalent worldwide, especially in tropical and subtropical countries. Their eggs are passed in the stool of an infected person and then ingestion in food that has had contact with human sewage (they are surprising resilient eggs). The ingested eggs mature into larval worms in the gut and seed into the blood stream via the duodenal walls, from where they circulate around in the blood to eventually enter the lungs were they are coughed up (the pulmonary eosinophilia phase with wheeze and cough for around 2 weeks) and then swallowed back down and settle into mature worms in the small intestine, resulting in a chronic malabsorption condition. The pulmonary condition is self-limmiting although mebendazole given for 3 days can help.

Answer 195

Pathergy test supports the diagnosis of Behcet's (there is no definitive test) This involves pricking the skin with a sterile needle, usually in the forearm. If the lesion becomes indurated within 48 hours, this is supportive of a diagnosis of Behcet's. The test is positive in approximately 60% of patients.

Answer 196

Consider monitoring the person in primary care with no need for specialist referral, depending on clinical judgement, if there is: An adult with a history of a longstanding unchanging thyroid nodule or mass over several years, with no palpable cervical lymphadenopathy and no other red flags or risk factors for malignancy. A non-palpable, asymptomatic thyroid nodule picked up incidentally on an ultrasound scan, CT, or MRI, which is less than 1 cm in diameter, with no associated lymphadenopathy and no other red flags or risk factors for malignancy.

Answer 197

Diarrhoea, epistaxis and high fevers. Splenomegaly and low WCC are common

Answer 198

For people who are not receiving haemodialysis, consider a trial of oral iron before offering intravenous iron therapy. If they are intolerant of oral iron or target Hb levels are not reached within 3 months (see recommendation 1.3.11), offer intravenous iron therapy. For people who are receiving haemodialysis, offer intravenous iron therapy. Offer oral iron therapy to people who are receiving haemodialysis only if: intravenous iron therapy is contraindicated or the person chooses not to have intravenous iron therapy after discussing the relative efficacy and side effects of oral and intravenous iron therapy. [new 2015]

Answer 199

Ferritin >/= 200 (less then give EPO) Transferrin saturation >/= 20%

Answer 200

Vitamin A Supportive Inform public health Need admitted if pregnant of immunocompromised

Answer 201

ciprofloxacin used to be the treatment of choice. However, there is increased resistance to ciprofloxacin (around 36% in the UK) and therefore cephalosporins are now more widely used there was a change in the 2019 British Society for Sexual Health and HIV (BASHH) guidelines. Previously the first-line treatment was IM ceftriaxone + oral azithromycin. The new first-line treatment is a single dose of IM ceftriaxone 1g (i.e. no longer add azithromycin). If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given If ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used

Answer 202

Prednisolone 40mg for 28 days has been shown to increase survival in patients with severe alcoholic hepatitis. However, response to steroid treatment should be re-evaluated at 7 days, as not all patients respond and continuing immunosuppressive treatment in patients who are unlikely to benefit may prove deleterious. As a rule of thumb, an increase in bilirubin over the first 7-days indicates non-response. The Lille score is a more formal method of assessment that takes into account a range of demographic and laboratory values to give a more nuanced evaluation. A Lille score of > 0.45 signifies the failure of prednisolone and justifies its discontinuation. The 6-month survival rate for this group of patients is approximately 25% so supportive treatment should be continued

Answer 203

inflammatory cytokine TNF-α is thought to be key to the pathophysiology of acute alcoholic hepatitis and several studies have investigated the efficacy of anti-TNF-α therapies in this setting. Unfortunately, a number of studies have shown that infliximab and etanercept are associated with higher mortality rates at 2 and 6 months, largely secondary to the development of acute infection. As a result, these agents are not recommended for use in alcoholic hepatitis

Answer 204

accelerated idioventricular rhythm (AIVR). It is associated with atrioventricular dissociation; P waves present but not associated with QRS complexes, wide QRS complexes (>120ms) and a rate between 50-110 beats per minute. AIVR is common post-MI following the reperfusion of an ischaemic myocardium. It is usually self-limiting and therefore treatment is not necessary, especially as the patient is asymptomatic and haemodynamically stable.

Answer 205

1.white cell count <3.5 109/l; 2.mean cell volume >105 fL; 3.neutrophils <1.6 109/l; 4.creatinine increase >30% over 12 months and/or calculated GFR <60 ml/min; 5.unexplained eosinophilia >0.5 109/l; 6.ALT and/or AST >100 U/l; 7.platelet count <140 109/l; 8.unexplained reduction in albumin <30 g/l (GRADE 1C, 99%). 9. If mucositis/oral ulceration occurs. Usually folic acid will be increased to 6 days a week (apart from methotrexate day)

Answer 206

1. EF < 60% 2. Left ventricular end systolic diameter > 40mm 3. New onset of AF or 4. High likelihood of durable repair with low surgical risk and absence of risk factors

Answer 207

Travel to endemic area ( West Africa and Central America ) Fever, with initial resolution Progression to jaundice and renal failure Presence of councilman bodies in liver

Answer 208

Rabies immunoglobulin should be given to provide passive antibodies at the site of exposure prior to the development of an immune response. As far as possible, the dose (20 IU / Kg) should be administered locally around the wound. In addition, post-exposure vaccination should be provided, with the WHO currently recommending a four dose schedule (given on days 0, 3, 7 and 14). If an individual has been previously vaccinated then immunoglobulin is not required and a two dose vaccination schedule (given on days 0 and 3) should be given.

Answer 209

a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism if doesn't respond to COC then topical eflornithine may be tried spironolactone, flutamide and finasteride may be used under specialist supervision.

Answer 210

a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS metformin is also used, either combined with clomifene or alone, particularly in patients who are obese gonadotrophins

Answer 211

This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level. Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow. The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion. The result is an unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke

Answer 212

The suggested first line treatment for cluster headaches is 100% oxygen at a flow rate of at least 12 litres per minute and a subcutaneous or nasal triptan. Evidence from one small study suggests that subcutaneous sumatriptan provides faster relief of symptoms than intranasal sumatriptan. Indometacin is used in paroxysmal hemicrania which has similar characteristics to cluster headaches, but attacks tend to be shorter (2-45 minutes) and more frequent (up to 40/day) and more common in women.

Answer 213

simple measures recommend daily application of a high-factor sunscreen camouflage creams may help conceal redness predominant erythema/flushing CKS -topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia -brimonidine is a topical alpha-adrenergic agonist this can be used on an 'as required basis' to temporarily reduce redness it typically reduces redness within 30 minutes, reaching peak action at 3-6 hours, after which the redness returns to the baseline mild-to-moderate papules and/or pustules CKS -topical ivermectin is first-line alternatives include: topical metronidazole or topical azelaic acid moderate-to-severe papules and/or pustules CKS -combination of topical ivermectin and oral doxycycline

Answer 214

It can be considered in those with paroxysmal AF who: Have no history of left ventricular dysfunction, valvular or ischaemic heart disease Have infrequent episodes Systolic blood pressure >100mmHg and heart rate >70bpm Are able to understand when to take the tablet

Answer 215

There is no consensus on which anti-microbial strategy is best for Pseudomonas aeruginosa eradication. Options include: -Intravenous anti-pseudomonal antibiotic plus inhaled aminoglycoside for 14 days -A prolonged course of oral Ciprofloxacin (e.g. 6 weeks)

Answer 216

Hypercalcaemia

Answer 217

Dialysis disequilibrium syndrome is a rare but serious complication of haemodialysis. It is more likely to occur in patients with very high levels of urea, metabolic acidosis, extremes of age, and central nervous system diseases. High levels of urea result in fluid shifts in the brain. If urea is rapidly decreased, the result is a sudden drop in serum osmolarity, and a fluid shift from interstitial to intracellular compartments. The end result is cerebral oedema. Cerebral oedema can present with headaches, focal neurological deficits, myoclonus, papilloedema and a decreased level of consciousness. Dialysis disequilibrium syndrome can be treated with mannitol or hypertonic saline to increase plasma osmolarity and reduce cerebral oedema.

Answer 218

Uncontrolled hypertension Active malignancy Chronic infection Overt proteinuria Bilateral renal artery atherosclerosis Sickle cell disease

Answer 219

Rivastigmine

Answer 220

Endomysial CD8 positive T-cell mediated lymphocytic infiltrates that invade nonnecrotic muscle fibres = polymyositis - Perimysial inflammation by CD4 positive T-lymphocytes and parafascicular atrophy = dermatomyositis - Inflammatory infiltrates and inclusions within muscle fibres = inclusion body myositis

Answer 221

Offer systemic non-biological therapy to people with any type of psoriasis if: It cannot be controlled with topical therapy and It has a significant impact on physical, psychological or social wellbeing and one or more of the following apply: psoriasis is extensive (for example, more than 10% of body surface area affected or a PASI score of more than 10) or psoriasis is localised and associated with significant functional impairment and/or high levels of distress (for example severe nail disease or involvement at high-impact sites) or phototherapy has been ineffective, cannot be used or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months). Choice of drugs: Offer methotrexate as the first choice of systemic agent for people with psoriasis who fulfil the criteria for systemic therapy (above) Offer ciclosporin as the first choice of systemic agent for people who fulfil the criteria for systemic therapy (above) and who: need rapid or short-term disease control (for example a psoriasis flare) or have palmoplantar pustulosis or are considering conception (both men and women) and systemic therapy cannot be avoided. Consider changing from methotrexate to ciclosporin (or vice-versa) when response to the first-choice systemic treatment is inadequate. Consider acitretin for adults, and in exceptional cases only for children and young people, in the following circumstances: if methotrexate and ciclosporin are not appropriate or have failed or for people with pustular forms of psoriasis.

Answer 222

Furosemide Captopril Penicillin derivatives Penicilliamine

Answer 223

Patients are considered high-risk if one or more of the following: -BMI < 16 kg/m2 -unintentional weight loss >15% over 3-6 months -little nutritional intake > 10 days -hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) If two or more of the following: -BMI < 18.5 kg/m2 -unintentional weight loss > 10% over 3-6 months -little nutritional intake > 5 days -history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Answer 224

Weight loss of 4 kg or more Livedo reticularis Testicular pain/tenderness Myalgia or leg weakness/tenderness Mononeuropathy or polyneuropathy Diastolic blood pressure greater than 90 mm/Hg Elevated blood urea nitrogen (BUN) or creatinine level unrelated to dehydration or obstruction Presence of hepatitis B surface antigen or antibody in serum Arteriogram demonstrating aneurysms or occlusions of the visceral arteries Presence of polymorphonuclear neutrophils in a biopsy specimen from a small- or medium-sized artery Three Out of 10 needed for the Dianosis of PAN.

Answer 225

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension) -treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater in 2019, NICE made a further recommendation, suggesting that we should 'consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. '. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease

Answer 226

pH < 7 Blood ketone > 6 mmol/L Bicarbonate < 5 mmol/L Anion gap >16 mmol/l Potassium < 3.5 mmol/L on admission Tachycardia or bradycardia Systolic blood pressure <90 mmHg Oxygen saturation <92% on air GCS < 12

Answer 227

leaD -Dmsa -D penicillamine -eDta -Dimercaprol EDta = used in ED (acute poisoning) Others used in chronic poisoning.

Answer 228

Lyme disease Systemic lupus erythematosus Neurosarcoidosis Subacute sclerosing panencephalitis Subarachnoid hemorrhage Syphilis Primary central nervous system lymphoma Sjögren's syndrome Guillain-Barre syndrome Meningeal carcinomatosis Neuromyelitis optica

Answer 229

Long QT1: adrenergic surge due to intense physical activity such as swimming Long QT2: adrenergic surge due to intense emotion such as excitement or fear Long QT3: death during sleep

Answer 230

For those presenting after 14 days of exposure we recommend treatment only following a positive test for gonorrhoea. For those presenting within 14 days of exposure we recommend considering epidemiological treatment based on a clinical risk assessment and following a discussion with the patient. In asymptomatic individuals, it may be appropriate to not give epidemiological treatment, and to repeat testing 2 weeks after exposure.

Answer 231

- Separate levodopa from meals or take on empty stomach - Increase Levodopa dose or increase frequency or switch to extended release formulation - Add 2nd line agent - Consider rescue Mx for severe/unpredictable/Debilitating Off periods : S/C Apomorphine

Answer 232

Glanzmann's thrombasthenia is rare autosomal recessive platelet disorder caused by qualitative or quantitative deficiencies in GpIIb/IIIa, the receptor for fibrinogen. Note the contrast to ITP, where antibodies are formed against GpIIb/IIIa. The PFA-100 assay shows that platelets are not aggregating and this may be due to platelet glycoproteins or their interaction with von willebrand factor. The ristocetin effectively allows aggregation of von willebrand factor to GPIb and does not require GPIIb/IIIa. Therefore Glanzmann thrombasthenia will have normal platelet aggregation once ristocetin is added.

Answer 233

Accelerated idioventricular rhythm does NOT require treatment. But in real life, potassium would be supplemented to 4.5 and magnesium to 1.0, whether having ectopic activity or not. Atropine can be given if symptomatic

Answer 234

'Ruxolitinib' (JAK inhibitor) as first line for: 1. Symptomatic splenomegaly. (evidence grade 1A) 2. Myelofibrosis?related symptoms that are impinging upon quality of life. (evidence grade 1B) 3. Hepatomegaly and portal hypertension due to myelofibrosis are reduced by ruxolitinib (Verstovsek et al, 2010) and it can be considered for these indications. (evidence grade 2B). Hydroxycarbamide can also be used first line but Ruxolitinib now preferred. Thalidomide and prednisolone (in presence of cytopenias) consider lenalidomide (if anaemic with platelet count >100 9 109/l).

Answer 235

Class I Minimal mesangial lupus nephritis Class II Mesangial proliferative lupus nephritis Class III Focal lupus nephritis (active and chronic; proliferative and sclerosing) Class IV Diffuse lupus nephritis (active and chronic; proliferative and sclerosing; segmental and global) -Worst prognosis Class V Membranous lupus nephritis Class VI Advanced sclerosis lupus nephritis

Answer 236

Multifocal Motor Neuropathy with Conduction Block For exam purposes, the key difference between these two conditions is the nerve conduction studies. MMNCB shows conduction block. MND does not. MMNCB is a demyelinating condition, much in the same way Guillain Barré or chronic inflammatory demyelinating polyneuropathy (CIDP) are. However, in MMNCB this demyelination is in segments of a nerve rather than affecting the whole nerve. Therefore, the action potentials (as well as being slowed because of demyelination) actually don't get past the areas of conduction block. The importance of doing nerve conduction studies is to decide whether a motor neuropathy is axonal (i.e. the axon itself getting damaged) or demyelinating. The demyelinating ones tend to be more easily and similarly treatable. MMNCB, Guillain Barré, and CIDP are all good examples of demyelinating neuropathies, all of which therefore respond to intravenous immunoglobulin (IVIG).

Answer 237

1.6.1 In adults with CKD and an ACR under 70 mg/mmol, aim for a clinic systolic blood pressure below 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure below 90 mmHg. [2021] 1.6.2 In adults with CKD and an ACR of 70 mg/mmol or more, aim for a clinic systolic blood pressure below 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure below 80 mmHg. [2021] 1.6.3 In children and young people with CKD and an ACR of 70 mg/mol or more, aim for a clinic systolic blood pressure below the 50th percentile for height. [2021]

Answer 238

I pulmonary arterial hypertension II pulmonary hypertension secondary to left heart disease III pulmonary hypertension secondary to lung disease IV pulmonary hypertension secondary to chronic thromboembolic disease V pulmonary hypertension with unclear causes

Answer 239

FBC, ESR, U&E, calcium, albumin, uric acid Serum protein electrophoresis Urine protein electrophoresis Immunoglobulin levels Plain X-ray of symptomatic areas

Answer 240

Ivermectin

Answer 241

Methanol Uraemia (renal failure) Diabetic ketoacidosis Paracetamol use (chronic - caused by 5-oxoproline) Isoniazid Lactate Ethanol or propylene glycol Salicylates

Answer 242

Visual distubrance including the phenomenon of phosphenes, or "flashing lights". Other visual symptoms described include green discolouration of visual fields, blurring of vision and scintillating scotomata. Thes visual symptoms are usually transient and mild. They arise due to inhibition of similar ionic channels in the retina to the sinoatrial If channels. Approximately 20%of patients taking the drug develop some form of visual disturbance but only 1% need to discontinue therapy because of it.

Answer 243

It can be difficult to differentiate early in the disease. Two significant differences may help to distinguish between them: 1) In chikungunya, rashes appear on the torso and the arms while in dengue, they appear on the arms and the face. 2) Joint pain in chikungunya is experienced in the hands, wrists, feet and legs, while in dengue it is experienced in the shoulders and the knees.

Answer 244

Seborrhoeic dermatitis does not cross the hair line while psoriasis will.

Answer 245

First line is topical potent steroids for 4 weeks Second line is either a different formulation (e.g. shampoo or mousse) and/or a topical agent to remove adherent scale (e.g. salicylic acid) before application of the potent steroid.

Answer 246

SICKFACES.COM Sodium Valproate Isoniazid Cimetidine Ketoconazole (and other azoles) Fluoxetine (and other SSRIs) Alcohol (acute) and grapefruit juice, amiodarone, allopurinol Chloramphenicol Erythromycin Sulfonamides Ciprofloxacin Omeprazole Metronidazole

Answer 247

Largely supportive for immunocompetent patients If the patient has HIV and is not on antiretroviral therapy then this should be started and often will be enough to resolve the infection Nitazoxanide may be used for immunocompromised patients. Rifaximin is sometimes used for immunocompromised patients/ patients with severe disease.

Answer 248

NICE recommend parathyroidectomy for most patients with diagnosed primary hyperparathyroidism due to the high cure rates (up to 98%) and reduced risk of drug side effects. Conservative therapies are available and effective for some patients, however. Surgery is indicated for those with one or more of: 1. Symptomatic disease 1a. Symptoms of hypercalcaemia 1b. Osteoporosis and/or fragility fractures 1c. Renal stones or nephrocalcinosis 2. Age <50 years 3. Serum adjusted calcium of 2.85 mmol/L or above 4. Estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m

Answer 249

Ciclosporin is metabolised by CYP3A4, and clarithromycin and erythromycin are both potent CYP3A4 inhbitors, leading to a potential elevation in ciclosporin levels, and subsequent nephrotoxicity.

Answer 250

Nujmegen questionnaire

Answer 251

Fentanyl, mefanimic acid, tramadol, aminophylline, isotretinoin, haloperidol, amitriptyline

Answer 252

Must have all the following: NYHA III or IV heart failure Ejection fraction of <35% The heart is beating regularly with evidence of electrical conduction disease They are medication that is most effective for them

Answer 253

EBCD (rather than usual ABCD) - Eumovate, Betnovate & Cutivate, Dermovate.

Answer 254

15% The rate increases with the severity of original bleed. These patients need repeat endoscopy as an absolute indication

Answer 255

1 year = 90%, 10 years = 60% for cadaveric transplants 1 year = 95%, 10 years = 70% for living-donor transplants

Answer 256

NICE guidance would recommend the patient underwent a further renal function test in 2 weeks (to exclude causes of acute deterioration in eGFR), and then a further renal function test at 90 days after the original test. Should the patient's eGFR remain in the same range as the initial test (45-59 ml / min / 1.73 m2) and if there continues to be no evidence of markers of kidney damage, then NICE guidance would recommend using measuring cystatin-C levels to confirm or rule out CKD.

Answer 257

No clinical neurological signs have been shown to correlate reliably with poor outcomes when measured less than 24 hours after cardiac arrest. Work by Rittenberger and colleagues (2010) looked at patients who suffered ventricular tachycardia or ventricular fibrillation cardiac arrests. They found that GCS motor score did not correlate with cardiac arrest outcome when measured at 24 or 72 hours. However, lack of pupillary light or corneal reflex at 72 hours was a reliable predictor of death. Vestibulo-ocular reflexes are also used but are less reliable. No biochemical, imaging or neurophysiological studies are currently recommended for the assessment of prognosis.

Answer 258

clinical deficits that suggest infarction in the territory of the middle cerebral artery, with a score above 15 on the NIHSS decreased level of consciousness, with a score of 1 or more on item 1a of the NIHSS signs on CT of an infarct of at least 50% of the middle cerebral artery territory: with or without additional infarction in the territory of the anterior or posterior cerebral artery on the same side or with infarct volume greater than 145 cm3, as shown on diffusion-weighted MRI scan.

Answer 259

Approx 2.4 12.5 mcg = 30 mg oramorph 50 = 120 75 = 180 100 = 240

Answer 260

NICE guidelines recommends first line pharmacological treatment for mixed incontinence or overactive bladder syndrome alone is either tolterodine, oxybutynin or darifenacin. Duloxetine should only be used if the patient does not tolerate first line therapy and is not a candidate for surgery.

Answer 261

Venous thromboembolic event (VTE) is an important cause of maternal death in the UK. Pregnant women are 10x more likely to have a VTE than non-pregnant women of the same age. Where there is suspicion of a pulmonary embolism (PE) , a chest x-ray should be performed initially. If this does not explain the patient's symptoms, compression duplex dopplers should be performed. A diagnosis of deep vein thrombosis (DVT) can indirectly confirm a PE, reducing radiation doses for the mother. If both tests are negative, and the clinical suspicion of PE remains high, further imaging should be organised; either CTPA or ventilation-perfusion scan (V/Q scan). British thoracic society guidelines (BTS) recommend a CTPA in non-pregnant women. The decision as to which scan to perform should be ideally taken with the input from the patient. V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA but carries a lower risk of maternal breast cancer. The ventilation component of the V/Q scan may be able to be omited, reducing the radiation dose. A D Dimer would not assist in the diagnosis, as it may be raised anyway in pregnancy due to disturbances in the coagulation system.

Answer 262

The definitive treatment for NPH is VP shunting. Symptoms of NPH including dementia are reversed with successful VP shunting in 60-90 % of the patients. 10% develop complications like postural headache, subdural effusion, shunt infection, and bacterial meningitis.

Answer 263

Anti-GBM is not possible since the patient's don't possess the antigenic target (disruption of basement membrane). Anti-GBM can only occur in an Alport's patient post transplant when they acquire the antigen within the normal basement membrane of the donor kidney.

Answer 264

Latent tuberculosis treatment options: 3 months of isoniazid (with pyridoxine) and rifampicin, or 6 months of isoniazid (with pyridoxine)

Answer 265

PPIs They reduce the absorption of rilpivirine which can cause viral blips, with subsequent virological failure and resistance

Answer 266

consider gastric lavage if <1 hour prior to ingestion activated charcoal whole-bowel irrigation can be performed if theophylline is sustained release form charcoal haemoperfusion is preferable to haemodialysis

Answer 267

Type A - Arabia, Africa Type B,C - Europe, South America

Answer 268

The mainstay of treatment of polycythaemia vera is aspirin and venesection. A target PCV < 0.45 has been shown to have a significantly lower rate of death from cardiovascular disease and major thrombosis than target PCV 0.45-0.50. Treatment with aspirin reduces the risk of non-fatal myocardial infarction, non-fatal stroke, pulmonary embolus, major venous thrombosis or death from cardiovascular cause compared to placebo. Aspirin does not increase the incidence of major bleeding episodes compared to placebo. Cytoreductive treatments such as hydroxyurea are used to treat high-risk polycythaemia Vera.

Answer 269

Any of the following risk factors: -BMI >30 -Previous delivery of a baby over 4.5kg -Previous gestational diabetes -FHx of diabetes (1st degree relative) -Minority ethnic family origin with a high prevalence of diabetes.

Answer 270

24-28 weeks. If the patient has had gestational diabetes in a previous pregnancy then early-self monitoring of blood glucose of OGTT as soon as possible after booking could also be used for diagnosis. A diagnosis of gestational diabetes is made if the patient has either: -Fasting glucose of 5.6 mmol/L or above OR a 2hr plasma glucose of 7.8 mmol/L or above

Answer 271

15 mg pred OD (taper over 2 years) Pts should have a dramatic improvement in symptoms. If not then stop pred and consider alternative diagnosis.

Answer 272

- demyelinating pathology (reduced conduction velocity, normal amplitude) = GBS, chronic inflammatory demyelinating polyneuropathy, amiodarone, hereditary sensorimotor neuropathies (HSMN) type I, paraprotein neuropathy, multiple myeloma - axonal pathology (normal conduction velocity, reduced amplitude) = alcohol, DM, vasculitis, B12 deficiency, hereditary sensorimotor neuropathies (HSMN) type II

Answer 273

There are diagnostic criteria for NF1 that require at least two of seven criteria. Some of these do not appear until later childhood or adolescence, and so confirmation of the diagnosis may be delayed and children should be followed up: At least six café-au-lait spots or hyperpigmented macules. They must be at least 5 mm wide in children younger than 10 years and 15 mm in adults. Axillary or inguinal freckles. Two or more typical neurofibromas or one plexiform neurofibroma. Optic nerve glioma. Two or more iris hamartomas. They are called Lisch nodules and are seen by slit-lamp examination. Sphenoid dysplasia or typical long-bone abnormalities such as arthrosis. Having a first-degree relative with NF1.

Answer 274

At least one of the following three is required for diagnosis of NF2: Bilateral 8th nerve masses on MRI scan. A first-degree relative with NF2 for a unilateral 8th nerve mass. A first-degree relative with NF2 for an individual with at least two of the following: Meningioma Glioma Schwannoma Juvenile cataracts

Answer 275

Surface antigen - detects whether a person is currently infected with hepatitis B

Answer 276

Indicates whether immunity to the virus is present. Is therefore present in people with either previous immunisation or infection.

Answer 277

Indicates previous and/or ongoing infection with hepatitis B. It can be further subdivided into IgG and IgM which indicates a timeframe for infection. IgM is present in infection of <6 months IgG is present in infections of >6 months

Answer 278

A prolonged course of a quinolone (e.g. 4 week course of ciprofloxacin)

Answer 279

Oral treatment of brucellosis is possible with a 6-week course of doxycycline and rifampicin. An alternative treatment regime combines 6 weeks of oral doxycycline with 3 weeks of either intramuscular streptomycin or intravenous gentamicin. Treatment involving parenteral antibiotics has a lower failure rate but is less convenient for the patient.

Answer 280

The main difference in the management of membranous glomerulonephritis and the other glomerulopathies is that high dose steroids and azathioprine are not associated with any significant benefits in the former. The main treatment strategy involves control of blood pressure with ACE inhibitors and immunosuppression with either cyclophosphamide, chlorambucil, ciclosporin or mycophenolate mofetil along with prednisolone. Rituximab has also been shown to have a benefit in the short term.

Answer 281

idiopathic: due to anti-phospholipase A2 antibodies infections: hepatitis B, malaria, syphilis malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia drugs: gold, penicillamine, NSAIDs autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid

Answer 282

Broadly: Nodules < 5 mm require no further surveillance. Nodules 5-6mm require CT at 1 year Nodules 6-8 mm require CT at 3 months Nodules > 8 mm require malignancy risk calculation using the Brock model and should then have CT or PET according to whether this risk is > 10%. The Brock model (see McWilliams et al) takes into account age, gender, family history and features of the nodule

Answer 283

Once other problems (e.g. aneamia, thyroid or depression) have been excluded NICE recommend a trial of amantadine Other options include mindfulness training and CBT

Answer 284

Baclofen and gabapentin are first line. Other options include diazepam, dantrolene and tizanidine. Physiotherapy is important Cannabis and botox are undergoing evaluation

Answer 285

may take the form of urgency, incontinence, overflow etc guidelines stress the importance of getting an ultrasound first to assess bladder emptying - anticholinergics may worsen symptoms in some patients -if significant residual volume → intermittent self-catheterisation -if no significant residual volume → anticholinergics may improve urinary frequency

Answer 286

Gabapentin is first line

Answer 287

Thunderstorm asthma is a rare event in which the pressure changes in a thunderstorm causes the release of pollen and spores which trigger asthma exacerbation, which can occur in people not previously known to have asthma. The wet conditions at the beginning of a thunderstorm can cause pollen grains to rupture leading to increased amounts of allergen as well.

Answer 288

Endomysial lymphocytic infiltrates that invade nonnecrotic muscle fibres

Answer 289

Perimysial inflammation of lymphocytes and parafascicular atrophy

Answer 290

Inflammatory infiltrates and inclusions within muscle fibres

Answer 291

thymoma lymphoma thyroid and parathyroid malignancies germ cell tumours e.g. teratomas thoracic aortic aneurysm

Answer 292

The most common primary antibody deficiency Affected patients may develop recurrent chest infections, bronchitis, sinusitis or even otitis media. Associated with atopic disorders such as asthma and atopic dermatitis. Some patients may also be at risk of severe transfusion reactions.

Answer 293

Characterised by a triad of recurrent chest infections/recurrent sinus infections Atopic dermatitis Thrombocytopenia and platelet dysfunction Inherited as an X linked recessive condition.

Answer 294

In staggered overdoses, clinically significant hepatotoxicity is unlikely and the patient is not considered to be at risk if all of the following criteria are fulfilled: at least 4 hours or more since the last paracetamol ingestion the patient has no symptoms suggesting liver damage the paracetamol concentration is less than 10 mg/L the ALT is within the normal range, and their INR is 1.3 or less. Acetylcysteine can be discontinued in patients not considered to be at risk of clinically significant liver damage e.g. if all the criteria are met

Answer 295

Myositis-specific antibodies are targeted against three types of proteins: Transfer ribonucleic acid (tRNA) synthetases: whilst a number of antibodies have been described, the main one is the Anti-Jo-1 antibody. Patients who are Anti-Jo-1 positive tend to have interstitial lung disease, arthritis (non-deforming) and fevers. Nuclear Mi-2 protein: these are seen in approximately 20% of patients with myositis, and are more specific for dermatomyositis. Signal recognition peptide (SRP): anti-SRP antibodies are seen in approximately 5% of patients with polymyositis, and are associated with poor response to treatment and a poor prognosis.

Answer 296

Anti-IgE Omalizumab is an anti-IgE monoclonal antibody recommended by NICE for patients with severe allergic asthma which is refractory to other treatments including multiple courses of oral corticosteroids per year. The manufacturer recommends that the drug is only used in patients who have a positive skin test to a recognised respiratory allergen.

Answer 297

In an individual of 15-39 years of age with a family history of ADPKD, a renal ultrasound with a total of three or more cysts is considered to be diagnostic of the disease. The HALT-PKD trial demonstrated that individuals aged 15-49 years with early ADPKD (eGFR > 90), treatment with an ACE inhibitor that successfully achieved a blood pressure target of < 110 / 75 mmHg benefited from a reduction in the annual increase in total kidney volume and other outcomes compared to higher blood pressure targets. (Younger age group because obviously low blood pressure in older group may be unrealistic) In England and Wales, tolvaptan is recommended for patients with rapidly progressive disease at chronic kidney disease stage 2-3.

Answer 298

1 - HSV1 2 - HSV2 3-5 are in reverse alphabetical order: 3 - VZV 4 - EBV 5 - CMV 6 - sixth disease 7 - similar to sixth disease, often asymptomatic 8 - risk for Kaposi and Castleman's

Answer 299

Zieve syndrome is a triad of symptoms: haemolytic anemia, cholestatic jaundice, and transient hyperlipidemia

Answer 300

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: Denosumab- given weekly calcitonin - quicker effect than bisphosphonates steroids in sarcoidosis Loop diuretics such as furosemide are sometimes used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.

Answer 301

Risk of vertical transmission with hepatitis C is generally low and up to 6%. The risk of transmission appears to be high in women with HIV co-infection or high viral load.

Answer 302

Mnemonic : 1 in front- HTN. 1 at back- virilisation 21- hydroxylase: 1 at back only so: no HTN, only virilisation 11-hydroxylase: 1 in both front and back- so both HTN and virilisation 17- only 1 in front- so only HTN,no virilisation

Answer 303

1. 21 hydroxylase mutation (90% of CAH). This mediates conversion of 17OH-progesterone to 11-deoxycortisol and progesterone to deoxycorticosterone. Loss of function results in reduced cortisol and aldosterone and subsequent elevation in ACTH. This causes overstimulation of the adrenal cortex (hyperplasia). The steroid precursors are forced down the sex hormone pathway leading to androgen excess (ambiguous genitalia, salt wasting, hypovolaemia and shock i.e classic type). Presentation of 21 hydroxylase deficiency can also be asymptomatic with androgen excess become a problem in late childhood i.e. non-classic (premature pubarche, accelerated bone age, acne, hirsutism, oligomenorrhoea and this mimics polycystic ovarian syndrome). 2. 11-beta hydroxylase mutation (5% of CAH). Raised BP as 11-deoxycortisol has some aldosterone activity. Also raised androgens. 3. 17-alpha hydroxylase deficiency Raised aldosterone but low androgens. 4. 3-beta steroid dehydrogenase Low aldosterone and low androgens. The short synacthen test is helpful when 17OH-progesterone is only modestly elevated (if 17OH-progesterone is very high then it is diagnostic). Measuring 17OH-progesterone at 0 and 60 mins after ACTH causes elevated responses in patients with CAH (>35 nmol/L

Answer 304

Argatroban (hepatic excretion) Bivaludin contraindicated eGFR <30

Answer 305

1. EF < 60% 2. Left ventricular end systolic diameter > 40mm 3. New onset of AF or 4. High likelihood of durable repair with low surgical risk and absence of risk factors

Answer 306

azathioprine must not be given in conjunction with allopurinol as the 2 drugs cause an increased risk in haematological toxicity, such as that seen in this patient.

Answer 307

Immune checkpoint inhibitors are a type of immunotherapy that are increasingly being used to treat certain types of cancer, as an alternative to cytotoxic chemotherapy. They are currently only used to treat solid tumours. They work by enhancing the bodies own T-cell population to destroy the cancer cells. Their side effect profile reflects their mechanism of action and are, therefore, inflammatory and autoimmune in nature. They include: Dry, itchy skin and rashes (most commonly) Nausea and vomiting Decreased appetite Diarrhoea Tiredness and fatigue Shortness of breath and a dry cough.

Answer 308

People aged between 70-79 years old are eligible for shingles vaccine Even if had chickenpox as immunity will have worn of

Answer 309

Corrigan pulse – A 'water hammer' or 'collapsing' pulse is characterised by a rapidly rising and falling arterial pulse during late systole and diastole with wide pulse pressure. This finding is best appreciated by palpation of the radial or brachial arteries (exaggerated by raising the arm) or the carotid pulses. De Musset's sign – A head bob occurring with each heartbeat. Traube's sign – A pistol shot pulse (systolic and diastolic sounds) heard over the femoral arteries. Duroziez's sign – A systolic and diastolic bruit heard when the femoral artery is partially compressed. Quincke's pulses – capillary pulsations in the fingertips or lips. Mueller's sign – systolic pulsations of the uvula

Answer 310

RomaNO Ward = NO deafness

Answer 311

Absolute Patient or carer unable to train adequately in the technique. Inguinal, umbilical, or diaphragmatic hernias (esp. pleuroperitoneal leak). Ileostomy or colostomy. Abdominal wall infections or intra-abdominal sepsis, e.g. active diverticular disease. Relative Abdominal surgeries (adhesions). The more extensive the surgery, the more likely PD will be unsuccessful. Morbid obesity (inadequate clearance). Huge polycystic kidneys (insufficient intraperitoneal space). Severe gastroparesis (worsening vomiting). Severe lung disease (diaphragmatic

Answer 312

Methotrexate is very effective at improving psoriatic arthritis but in addition to this it also has a dramatic effect on skin disease to a much greater extent than the other disease modifying anti-rheumatic drugs (DMARDs) listed. Therefore it is the DMARD of choice in psoriatic arthritis. If there was a contraindication to methotrexate leflunomide would be used second line for peripheral psoriatic arthritis. You would only use infliximab or another anti-TNF drugs first line if the patient had a predominantly axial spondyloarthropathy.

Answer 313

Cyclopentolate is a muscarinic antagonist, and cycloplegic. It relieves the pain associated with uveitis as it dilates the pupil and prevents iridospasm. Atropine is another cycloplegic medication that can be used in anterior uveitis. Used alone it is less appropriate than the combination of cyclopentolate drops and steroids

Answer 314

dyspnoea ↑ left atrial pressure → pulmonary venous hypertension haemoptysis due to pulmonary pressures and vascular congestion may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins mid-late diastolic murmur (best heard in expiration) loud S1 opening snap indicates mitral valve leaflets are still mobile low volume pulse malar flush atrial fibrillation secondary to ↑ left atrial pressure → left atrial enlargement

Answer 315

Trivalent antitoxin

Answer 316

First line pharmacological treatment aims to prevent copper absorption by using chelating agents. Penicillamine is a potential first line treatment however, in this case, there is a high risk of a hypersensitivity reaction given this patients history of penicillin allergy. Trientine is now a popular first line treatment of neurological and hepatic disease in Wilsons as it has a better side-effect profile than penicillamine. In this patient with a penicillin allergy it would certainly be the treatment of choice.

Answer 317

1. Check TSH 2. TSH suppressed → Thyroid uptake scan → Cold/iso nodule → FNA cytology 2. TSH suppressed → Thyroid uptake scan →Hot nodule → No FNA required 2. TSH normal/elevated → Thyroid USS → Suspicious features → FNA cytology 3. FNA cytology is then graded using the Royal College of Pathologist classification on a spectrum from benign → malignant.

Answer 318

Patients with a TIA or small ischaemic stroke with evidence of significant carotid artery stenosis (male patients with a carotid artery stenosis of 50-99% or female patients with a carotid artery stenosis of 70-99%) that corresponds to the same side as the stroke/TIA should be considered for an urgent carotid endarterectomy (CEA) within 14 days.

Answer 319

FEV1<1.5 Litres Vocal cord paralysis Malignant effusion SVCO Stage IIIb or IV (mets)

Answer 320

Transfuse as per local massive bleeding protocol, recognising that over transfusion is as damaging as under transfusion and that a restrictive transfusion policy (aiming for 70-80 g/L is suggested in haemodynamically stable patients.

Answer 321

Do not offer platelets to patients who are actively bleeding and are haemodynamically stable. To those still actively bleeding, offer platelets if count is <50 x 109/L. This patient does not need platelets as his platelet count is above the threshold at which it would be beneficial.

Answer 322

Acid-fast stain which shows partially acid fast branching rods organism in contrast to mycobacterium which does fully stain.

Answer 323

In approximately 1-2% of myeloma cases, the myeloma cells produce very low amounts of paraprotein, which can only be detected using the serum free light chain test. This is called oligosecretory myeloma

Answer 324

Repeat serological testing is the best method of confirming Strongyloides stercoralis eradication following treatment. A post-treatment to pre-treatment titre ratio of < 0.6 is taken to represent a good indicator of treatment success

Answer 325

Medical treatment of HOCM consists of starting either a beta blocker, typically propranolol (but contraindicated in this case due to asthma) or a non-dihydropyridine calcium channel blocker, typically verapamil. In the case of persistent symptoms despite monotherapy, American Heart Association and European Society of Cardiology recommend consideration of disopyramide, a negative inotropic 1a anti-arrhythmic that demonstrated a significant decrease of LVOT gradients and mortality when compared to placebo. However, its significant cholinergic side effects and concerns of pro-arrhythmias, restricts its use to a second line agent. Surgical myectomy, DDDR pacemakers and alcohol ablation should be considered in patients who continue to be symptomatic despite 2 agents.

Answer 326

First 2 months: Rifampicin, pyrazinamide and ethambutol Continue: rifampicin and ethambutol for 7 months (up to 10 months for extensive disease) In MDR TB you add a quinolone or aminoglycoside.

Answer 327

Dapsone, rifampicin and clofazimine for a two year period.

Answer 328

Recent changes in NICE guidelines suggested that when a patient with IBS has resistant constipation despite using multiple laxatives with proper doses, linaclotide (which is a guanylate cyclase-C receptor agonist) should be used as the next step in management. It works by increasing intestinal fluid secretion and transit and decreases visceral pain. Lactulose is not advised by NICE to be given in patients with IBS. Adding a TCA or SSRI is the next step after linaclotide if it is found to be of no benefit.

Answer 329

POEMS Polyneuropathy Organomegaly Endocrinopathy M-protein band from a plasmocytoma Skin pigmentation

Answer 330

The recent optic neuritis treatment trial (ONTT) compared the use of oral prednisolone and intravenous methylprednisolone in acute optic neuritis1. Intravenous methylprednisolone increased the speed of visual recovery and reduced the risk of conversion to multiple sclerosis at 2 years while oral prednisolone demonstrated neither benefits. Intravenous steroids do not improve visual function at 2 years compared to placebo however. Intravenous immunoglobulin has no proven benefit.

Answer 331

the HRCT findings of basal predominance fibrosis and honeycombing is consistent with a usual interstitial pneumonia (UIP) pattern. Traction bronchiectasis may or may not be present in UIP. Non-specific interstitial pneumonia (NSIP) is radiologically characterized by symmetric bilateral areas of ground-glass opacity with superimposed fine reticular opacities but with no or only minimal

Answer 332

Atropine is usually the first line treatment for bradycardia and if that fails then consider transcutaneous or transvenous pacing. However, in patients with heart transplant atropine is contraindicated. The hearts of these patients are denervated and do not respond to vagal blockade by atropine, which might precipitate paradoxical sinus arrest of high-grade block. In these cases, theophyline intravenousely is indicated.

Answer 333

Hydrochlorothiazide and indometacin are used in the management of nephrogenic DI, however, indometacin is contraindicated in patients with recurrent gastrointestinal bleeding, therefore hydrochlorothiazide is the correct

Answer 334

A C1-esterase inhibitor can be used for short-term prophylaxis before procedures or to terminate acute attacks of hereditary angioedema. Conestat alfa and icatibant are licensed for the treatment of acute attacks of hereditary angioedema in adults with C1-esterase inhibitor deficiency. Tranexamic acid and danazol are used for short-term and long-term prophylaxis

Answer 335

Thymectomy is a well recognised treatment for myasthenia gravis and should also be considered in non-thymomatous generalised myasthenia in patients with antibodies to acetylcholine receptor who are aged under 50. Biopsy is not generally required prior to surgery. However, thymectomy is not generally carried out in myasthenia gravis when patients have antibodies to MUSK, late onset disease or purely ocular disease

Answer 336

Surgery for aortic regurgitation is indicated if there is significant enlargement of the ascending aorta, severe regurgitation with symptoms or if severe with an ejection fraction of less than 50%. ACE inhibitors can be useful when there is hypertension, when surgery is contraindicated or when ventricular dysfunction persist following surgery

Answer 337

Whilst in most cases, oseltamivir (a neuraminidase inhibitor) is first line treatment for influenza, the BNF advises that for severely immunocompromised individuals zanamivir should be first line treatment. This can help reduce the length of symptoms and prevent complications from developing during the course of the infection.

Answer 338

Post transplant lymphoproliferstive disorder (PTLD): -weight loss -anaemia -lymphadenopathy Immunosuppression precipitates infection with EBV and subsequent B cell proliferation. PTLD incidence is highest in the first year post transplantation, Wbu CV is the time when immunosuppression is the most intense. Treatment involves reducing current immunosuppression therapy and giving additional chemotherapy.

Answer 339

Graft dysfunction and ureteric stenosis

Answer 340

Irregular low frequency tremor which is a combination of RESTING (unlike cerebellar), postural and action tremor. Lesion in the red nucleus. Most commonly previous stroke but may also be structural disorders like MS, tumour etc. Treatment includes medical therapy such as levodopa however thalamotomy or Groningen thalamus stimulation have also shown to play a role in managing this condition.

Answer 341

Hyperglycaemia. Not many drugs in overdose cause this at all.

Answer 342

Close contacts within 7 days. Ciprofloxacin is the drug of choice with rifampicin second line.

Answer 343

Flecainide

Answer 344

Brisk knee, absent ankle and extensor plantar reflexes.

Answer 345

POEMS syndrome is a rare paraneoplastic syndrome caused by a clone of abnormal plasma cells. It is associated with polyneuropathy, organomegaly, endocrinopathy, M-protein band from a plasmocytoma, and skin pigmentation

Answer 346

Radio-iodine therapy

Answer 347

1st line: B-Blocker (verapamil if asthma) 2nd line: Disopyramide 3rd line: Myectomy, DDDR pacemaker, alcohol ablation

Answer 348

Mild: <4 stools per day, only a small amount of blood Moderate: 4-6 stools per day, varying amounts of blood, no systemic upset. Severe: >6 bloody stools per day and features of systemic upset (pyrexia, tachy, inflammatory markers)

Answer 349

Topical (rectal aminosalicylate) -If extensive also add an oral aminosalicylate If remission not achieved within 4 weeks then add oral aminosalicylate If remission still not achieved add topical or oral corticosteroid

Answer 350

IV steroids (ciclosporin may be used if steroids contraindicated) If after 72 hours there is no improvement, consider adding IV ciclosporin to IV steroid or consider surgery

Answer 351

Oral azathioprine or oral mercaptopurine

Answer 352

Triad is virtually pathognomic: -Fluctuating mood, with or without confusion -Painful distal parasthesia -Alopecia In massive exposure, death from neuromuscular respiratory failure is rapid, but in more prolonged exposure insidious symptoms of neuropathy, abdominal pain, gastrointestinal bleeding, optic neuritis, confusion and weakness occur. Skin changes such as palm and sole scaling, stomatitis, glossitis, keratitis, eczema and classical alopecia and Mee's lines on the nails typically occur within two weeks of continual exposure. Treatment is with Prussian Blue which is administered orally at a dose of 250-300mg/kg/day (approximately 10g twice daily for an adult) and this complexes with thallium and is excreted in the faeces. Thallium poisoning is often diagnosed late or not at all due to a low index of suspicion; indeed it is often misdiagnosed as Guillain-Barre syndrome due to the glove and stocking distribution of sensory symptoms and patients may receive intravenous steroids or immunoglobulins unnecessarily. In Guillain-Barre syndrome (GBS), classically there is ascending paralysis that is not seen in thallium poisoning and typically sensory symptoms in GBS are of numbness not hyperalgesia.

Answer 353

Avoid stat insulin to correct hyperglycaemia unless symptomatic or ketones >0.6. It is safer to increase the 'usual' insulin if patient is persistently hyperglycaemic.

Answer 354

Strongly suggest acute promyelocytic leukaemia

Answer 355

Classically low HOWEVER Fibrinogen is an acute phase marker. Therefore in DIC fibrinogen levels can be normal or elevated in over 50% of cases especially early on.

Answer 356

AA occurs due to chronic inflammation AL occurs due to light chain disease (where cardiac manifestations are very common)

Answer 357

First 2 months: -rifampicin, isoniazid (with pyridoxine) and ethambutol Continue: -rifampicin and isoniazid for 7 months

Answer 358

First 2 months: -rifampicin, isoniazid (with pyridoxine) and pyrazinamide Continue: -rifampicin and isoniazid (with pyridoxine) for 4 months

Answer 359

Habit reversal therapy (HRT) Atypical Antipsychotics (risperidone) or clonidine

Answer 360

Inverted P wave in lead I Right axis deviation Loss of R wave progression

Answer 361

Magnesium Penicillamine Quinidine Procainamide Beta-blockers Lithium Phenytoin Antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Answer 362

Lupus nephritis is initially managed with high dose steroids alongside either mycophenolate or cyclophosphamide. The preferred treatment for maintenance is mycophenolate.

Answer 363

IV Haem arginate

Answer 364

LH and FSH low-normal and testosterone is low

Answer 365

ECG changes Hypotension Metabolic acidosis Hypoglycaemia Tinnitus Flushing Visual disturbances Flash pulmonary oedema

Answer 366

Vivax - India Ovale - Africa

Answer 367

No Varices - Repeat endoscopy 2-3 years Grade 1 - Repeat endoscopy in 1 year Grade 2-3 or signs of bleeding - Non-cardio selective beta blocker

Answer 368

Elevated estradiol and progesterone Slight rise in LH Mild rise prolactin

Answer 369

Struvite stones are formed in the presence of increased urinary ammonia and alkaline urine (>7.2)

Answer 370

Caused by the gram-negative bacterium Yersinia pestis. It is transmitted by fleas and is endemic to the Democratic Republic of the Congo, Madagascar, and Peru. Symptoms typically include flu-like symptoms from 3-7 days post-exposure followed by the eruption of inflamed, tense and painful lymph nodes. The disease carries a significantly high mortality rate if not treated and prompt recognition and antibiotic administration (i.e. Streptomycin) can reduce the mortality from 60% to 15%.