Pastest

Question 1

What is pure red cell aplasia?

Answer 1

Unexplained anaemia and reticulocytopenia with a complete absence of red cell precursors in the bone marrow but with preservation of other cell lines.

It can occur spontaneously, or in association with autoimmune diseases, lymphoproliferative disorders or viral illnesses such as HIV, hepatitis and herpes.

Treatment is supportive, with immunosuppression.

Rarely the condition can occur where recombinant erythropoietin is administered and patients respond to withdrawal of erythropoietin.

Question 2

What is the treatment of serotonin syndrome?

Answer 2

First line: Benzodiazepines,
Second line: Cyproheptadine

Haemodialysis does not directly treat but instead is a supportive measure to treat acute renal failure or to help remove excessive concentrations of myoglobin in rhabdomyolysis.

Question 3

How do you investigate suspected gastinoma?

Answer 3

The best initial screen is a fasting gastrin level on 3 separate days, as the secretion of gastrin is pulsatile. Three samples in the normal range make gastrinoma unlikely.

This is usually followed by basal acid output estimation and a secretin stimulation test. After this, patients usually move on to imaging studies. In the absence of metastases, surgical resection is advised. Ocreotide, interferon and chemotherapy may be useful in non-surgically resectable lesions.

Question 4

What antibodies are associated with diffuse systemic sclerosis?

Answer 4

Different auto-antibody patterns are associated with differing patterns of disease associated with systemic sclerosis. Anti-nuclear antibody (ANA) tests provide in approximately 95% of patients with SSc, and therefore a negative test should prompt consideration of other fibrosing illnesses.

Anti-RNA polymerase III antibodies are found in patients with diffuse disease, and are associated with rapidly progressive skin involvement as well as an increased risk for scleroderma renal crisis. These patients may also be at increased risk for cancer.

Question 5

What are the most common findings on ECG for a hypothermia patient?

Answer 5

J-waves, prolonged QT interval and AV junctional rhythm.

J waves are highly sensitive and specific for hypothermia. Other causes of J-waves include hypercalcaemia and intracranial pathology likely SAH.

Question 6

What are the features of Liddle syndrome?

Answer 6

Hypertension, Hypokalaemia, Alkalosis, Hyporeninaemic hypoaldosteronism and hypertension.

Autosomal dominant

Question 7

What is the referral criteria for specialist transplant unit in paracetamol overdose?

Answer 7

Arterial pH <7.30
Grade III or IV hepatic encephalopathy
Coagulopathy with a PT >100 seconds
Acute renal impairment with a creatinine >300 micromol/l
-Studies have shown up to 80% mortality rate in this case

Question 8

What is the treatment for mesothelioma?

Answer 8

Rarely suitable for surgical resection and is not responsive to chemotherapy.

Palliative radiotherapy after thoracoscopic pleurectomy may be indicated. Only pemetrexed and cisplatin as chemotherapy has demonstrated a positive response. The prognosis is extremely poor, with an average survival of 1-2 years from diagnosis.

Question 9

What are the most effective agents in maintaining remission in Crohn’s disease?

Answer 9

Thiopurines (azathioprine and 6-mercaptopurine) are the most effective agents in maintaining remission in Crohn’d disease long term. They are thought to be particularly effective in patients with fistulating disease.

If not tolerated methotrexate could be used as an alternative.

ASA (5-Aminocalycilic acid) compounds such as balsalazide and sulphasalazine have a role in maintaining remission and are generally well tolerated but are not as effective as thiopurines.

Polymeric diet has most value in reducing the severity of acute flares and their frequency, rather than resolving fistulae.

Question 10

Subacute meningitis (developing over weeks) is more associated with what organisms?

Answer 10

Tuberculous, cryptococcal, histoplasmal, partially treated bacterial, neoplastic or granulomatous infiltration of the meninges.

Question 11

What features are assocaited with TB meningitis?

Answer 11

Subacute onset with confusion
Risk factors (homeless, incarceration, alcohol)
Involvement of the basal meninges (brainstem signs (e.g. cranial nerve palsy))
Associated secondary spinal meningitis,
High protein and very low glucose on CSF
Hyponatraemia secondary to SIADH.

Question 12

What are the features of brown-sequard syndrome?

Answer 12

Loss of vibration and proprioception senses on the ipsilateral side.
Associated ipsilateral weakness, hypertonia, hyper-reflexia and extensor plantar reflex, with segmental anaesthesia at the level of the lesion.

Loss of pain and temperature on the contralateral side.

NOTE: complete syndrome picture is rare and many patients may only exhibit some features of the syndrome.

Question 13

What is the most common papilloma virus subtype responsible for causing periungual squamous cell carcinoma?

Answer 13

HPV-16

Other high risk cancer HPV subtypes include 18, 31 and 45.

Question 14

What are the primary cause of plantar warts?

Answer 14

HPV 4

HPV 2 is responsible for common and plantar warts.

Question 15

How do you treat a suspected myxoedema crisis?

Answer 15

Treatment involves IV thyroxine (T3) and slow rewarming. It is also important to take serum for thyroid function and adrenal function. Coexisting hypoadrenalism is suggested by hyponatraemia, hyperkalaemia and raised urea. Patients may also be hypoglycaemia.

Treatment with hydrocortisone is recommended until Addison’s disease is excluded. It is important to provide hydrocortisone until Addison’s is excluded, as just giving thyroid hormone alone may precipitate an adrenal crisis.

Question 16

When do NICE now recommend treatment in patients with Hep B?

Answer 16

Adults aged >30 years with Hepatitis B virus (HBV) DNA >2000 IU/ml and abnormal ALT (>30 IU/ml in men; >19 IU/ml in women) on two consecutive tests, three months apart.

Adults aged <30 years with the above but ALSO evidence of necro-inflammation or fibrosis on liver biopsy or a transient elastography score >6 kPa.

Adults who have HBV DNA > 20,000 IU/ml and abnormal ALT on two consecutive tests conducted 3 months apart, regardless of age or the extent of liver disease.

Patients without a liver biopsy with a transient elastography score > 11kPa

Question 17

What is the treatment for patients with Hepatitis B who meet the criteria?

Answer 17

Pegylated interferon alfa-2a in patients with compensated liver disease for 48 weeks.

Entecavir and tenofovir are offered as second-line treatments where pegylated interferon therapy has failed or is not tolerated.

Question 18

What is the treatment for Hepatitis C?

Answer 18

Pegylated interferon and ribavarin

However, NICE has recently recommended new antivirals for hepatitis C, eg sofosbuvir-velpatasvir (Epclusa) and patients are being selected on clinical need. Therefore, patients may elect to defer treatment with interferon-ribavarin due to its side-effect profile and opt to wait for the newer, better tolerated antivirals.

Question 19

What is the treatment of glioblastoma multiforme post surgical resection?

Answer 19

Gold standard in fit patients is Radiotherapy 60 Gy in 30 fractions with concomitant temozolomide, followed by up to 6 cycles adjuvant temozolomide.
-Temozolomide is an alkylating agent with promotes guanine methylation; this, in turn, causes defective cell replication and triggers cancer death
-The phase III EORTC/NCIC CTG trial showed significant survival improvement in 18-70 year olds who recieved temozolomide and radiotherapy vs radiotherapy alone (2-year survival 26% vs 10%).

In geriatric (>70) patients it is radiotherapy 40 Gy in 15 fractions with concomitant temozolomide, followed by up to 12 cycles adjuvant temozolomide.
-Main concern about a radical course of radiotherapy is potential high incidence of neurotoxity and deterioration in quality of life.
-In addition, some trials have shown longer survival with a hypofractionated, shorter radiotherapy course in the geriatric population.

Question 19

What is the treatment of glioblastoma multiforme post surgical resection?

Answer 19

Gold standard in fit patients is Radiotherapy 60 Gy in 30 fractions with concomitant temozolomide, followed by up to 6 cycles adjuvant temozolomide.
-Temozolomide is an alkylating agent with promotes guanine methylation; this, in turn, causes defective cell replication and triggers cancer death
-The phase III EORTC/NCIC CTG trial showed significant survival improvement in 18-70 year olds who recieved temozolomide and radiotherapy vs radiotherapy alone (2-year survival 26% vs 10%).

In geriatric (>70) patients it is radiotherapy 40 Gy in 15 fractions with concomitant temozolomide, followed by up to 12 cycles adjuvant temozolomide.
-Main concern about a radical course of radiotherapy is potential high incidence of neurotoxity and deterioration in quality of life.
-In addition, some trials have shown longer survival with a hypofractionated, shorter radiotherapy course in the geriatric population.

Question 20

How commonly does genitourinary TB develop in those with pulmonary TB?

Answer 20

Genitourinary TB develops in approximately 5% of cases of pulmonary TB and is usually due to haematogenous spread to the renal cortex during the primary phase of infection. The cortical lesion may then ulcerate into the pelvis, ultimately involving the bladder, seminal vesicles and prostate. It tends to present between 20 and 40 years of age. Other clinical features include haematuria, urethral strictures, cold abscesses and chronic epidiymo-orchitis. Kidney disease may occur due to extensive destruction of the kidneys or by obstruction secondary to fibrosis.

Question 21

What ECG changes would you see in dextrocardia (with normal lead placement)?

Answer 21

Inverted P-waves in lead I with a negative major QRS deflection. Upright P-waves with a positive QRS deflection are seen in lead aVR with mirror image findings in lead aVL, and an abnormal precordial progression of R wave from lead V1 to V6.

Question 22

What percentage of patients with sarcoidosis will have neurological complications?

Answer 22

Around 5%.

These include cranial nerve palsies (from basal meningitis), optic neuritis, mononeuritis multiplex, myelopathy, seizures, granulomas causing mass effect and neuropsychiatric manifestations.

Question 23

What is the treatment of cutaneous leprosy?

Answer 23

Dapsone, rifampicin and clofazimine

Question 24

What is the pathogenesis of inclusion body myositis?

Answer 24

CD8 positive T cells and macrophages leading to muscle necrosis.

Question 25

What is the treatment for Typhoid fever?

Answer 25

Options are ciprofloxacin, azithromycin and ceftriaxone Sensitivity testing is important in this case as significant resistance to ciprofloxacin and azithromycin now exist. Where sensitivity does exist to quinolones, these are an option for mild disease. In patients with more significant symptoms or resistance, IV ceftriaxone is the preferred option. Patients are usually retested after 1 week following therapy to rule out chronic carriage or Salmonella

Question 26

What is the criteria for discontinuing trastuzumab

Answer 26

If LVEF drops by 10% AND below 50%, treatment should be suspended and a repeat LVEF performed within 3 weeks. If LVEF has not improved, or declined further trastuzumab should be discontinued unless benefits outweigh the risks. (these patients should be followed up by a cardiologist) The her2 receptor is known to be protective against development of cardiomyopathy.

Question 27

What gastric MALT lymphomas are less likely to respond to eradication therapy?

Answer 27

Response is less likely if cytogenetic abnormalities have been acquired (t11:18 being the most common), or if the muscularis mucosa has been invaded.

Question 28

Maltomas (AKA marginal zone lymphomas) are often associated with chronic inflammation of which 4 types?

Answer 28

In the stomach secondary to chronic H. Pylori gastritis. In the eyes secondary to Sjogren's syndrome. In the thyroid secondary to Hashimoto's thyroiditis. In the intestine secondary to Crohn's or coeliac disease.

Question 29

What is the diagnostic criteria for neurofibromatosis type 1?

Answer 29

Two or more of the following: -6 or more cafe-au-lait macules > 5 mm (prepubertal) or > 15mm (post-pubertal) -two or more neurofibromas of any type or one plexiform -freaking in the axillary or inguinal regions -optic glioma -two or more Lisch nodules on the iris -distinctive Osseous lesion typical of type 1 NF, e.g. sphenoid dysplasia, thickening of the long bone cortex with or without pseudo-arthrosis -a first degree relative with type 1 NF

Question 30

When should a lateral decubitus CXR be used in suspected pneumothorax?

Answer 30

If PA CXR is normal and a small pneumothorax is suspected, a lateral decubitus CXR provides added information in up to 14% of cases. For patients in the lateral decubitus position, air rises to the non-dependent lateral location. Only 5ml of pleural air may be needed to detect pneumothorax in this position.

Question 31

When do you add steroids in PCP?

Answer 31

BHIVA guidelines recommend addition of methylprednisolone to IV Co-trimoxazole when paO2 <9.3kPa or SpO2 <92% as this is an indicator of severe disease

Question 32

What are the differentials for absent ankle reflexes and extensor (upgoing) plantars?

Answer 32

Syringimyelia Friedreich’s ataxia Motor neurone disease Conus medularis lesion Subacute degeneration of the cord Taboparesis for of tertiary syphilis

Question 33

Exercise electrocardiology is not useful in patients with what?

Answer 33

Conduction abnormalities Resting ECG abnormalities such as ST-segment depression of > 1mm Wolff-Parkinson-White syndrome Those taking digitalis Those with ventricular paced rhythm

Question 34

What monitoring is required in azathioprine therapy?

Answer 34

FBC, U+Es and LFTs

Question 35

What’s the indication for ivabradine in HFrEF?

Answer 35

Indicated in patients with HFrEF with a heart rate of >70 despite maximal doses of beta blocker.

Question 36

How to you treat organophosphate poisoning?

Answer 36

Atropine and Pralidoxime Atropine is a maid Adonis receptor antagonist; as well as treating bradycardia, it also relieves bronchi spasm and diminishes excess respiratory secretions. Pralidoxime is a cholinesterase activator and can reverse organophosphate- driven inhibition of cholinesterase. It should be given as soon as possible in addition to atropine. Time to adminission if Pralidoxime and atropine is closely linked to chances of survival

Question 37

What are the Kings College Hospital Criteria for non-paracetamol liver failure?

Answer 37

INR >6.5 or 3 of the following -Age <11 or >40 -Serum bilirubin >300 -Time from onset of jaundice to development of coma >7 days -INR >3.5 -drug toxicity, regardless of whether it was the cause of the acute liver failure

Question 38

What antibiotics does cyclosporin interact with?

Answer 38

Macrolides through interaction via CYP3A4 Erythromycin increases levels by 4-7 fold while azithromycin around 20%. This can lead to nephrotoxicity

Question 39

When should ACEi be considered post ACS?

Answer 39

All patients with STEMI (small but significant reduction in 30 day mortality). In NSTEMI if -BP not at recommended target (<120mmHg) -Impaired LVEF <40% -Heart failure in the early phase

Question 40

What are the first line options for medical management of nausea and vomiting in pregnancy?

Answer 40

Antihistamines such as Promethazine or cyclizine

Question 41

What is the treatment for genital herpes?

Answer 41

Oral aciclovir (either 200mg 5x daily or 400mg TDS for 5 days)

Question 42

How does giving shocks and drugs in arrest differ for hypothermic patients?

Answer 42

At core temperature of less than 30 treatment of ventricular arrhythmia with medical therapy is largely ineffective and electrical cardioversion is less effective then in normothermic patients. For this reason a prolonged period of CPR may be required until core temperature is above 30. Defibrillation should be limited to three shocks, and drugs should be withheld at temperatures below 30. Between 30-35 the intervals between drug doses should be doubled when compared with normothermia intervals.

Question 43

What are the indications for surgery in the case of aortic regurgitation?

Answer 43

Significant enlargement of the ascending aorta (regardless of AR severity) Symptomatic severe aortic regurgitation Asymptomatic severe aortic regurgitation with -LVEF 50% or less -LVEDD >70 mm -LVESD >50 mm Surgery should also be considered if significant changes in LV or aortic size occur during follow up.

Question 44

What is the diagnostic criteria for myeloma?

Answer 44

Clonal bone marrow plasma cells >10% or biopsy-proven bony or extramedullary plasmacytoma and any one or more of the following features and myeloma-defining events: -Evidence of end organ damage that can be attributed to the underlying plasma cell proliferative disorder, specifically --Hypercalcaemia: serum calcium >0.25 higher than upper limit of normal or >2.75 --Renal insufficiency: creatinine clearance <40ml per minute or serum creatinine >177 --Anaemia: haemoglobin value of >20g/l below the lowest limit of normal, or a haemoglobin value <100 g/l --Bone lesions: one or more osteolytic lesion on skeletal radiography, CT or PET/CT -Any one or more of the following biomarkers of malignancy --60% or greater clonal plasma cells on bone marrow examination --Serum involved/uninvolved free light chain ratio of 100 or greater, provided the absolute level of the involved light chain is at least 100mg/l -More than one focal lesion on MRI that is at least 5mm or greater in size.

Question 45

What is the timeline in cardiac markers?

Answer 45

Myoglobin earliest -As early as 1 hour, peaks 6-7, normal 24 Creatine Kinase -Rises after 3-12 hours, peak 18-24 Troponin I and Troponin T (Trop I most specific) -3-12 hours, remains elevated up to 10 days post so good in delayed presentation LDH -6-12 hours

Question 46

What limited cutaneous systemic sclerosis autoantibodies are associated with which complications?

Answer 46

Anti-centromere antibodies are most strongly associated with CREST (specificity >90%) and PULMONARY HYPERTENION. Anti-topoisomerase 1 antibodies are assocaited with interstitial lung disease. Anti-RNA polymerase III antibodies are associated with renal and cardiac involvement, including scleroderma renal crisis.

Question 47

What are the common GBS causing infections?

Answer 47

Campylobacter jejuni (25%) CMV, EBM, Influenza Mycoplasma pneumoniae HIV Haemophilus influenzae Other infections that can mimic GBS, include diptheria and Lyme's disease

Question 48

What distribution of psoriatic type rash is suggestive of acrokeratosis paraneoplastica and what is it associated with.

Answer 48

Widespread psoriatic type rash involving the EARS Associated with squamous cell carcinoma of the upper one third of the respiratory or GI tract, i.e. the oropharynx, larynx, lungs or oesophagus.

Question 49

How are transplants generally classified?

Answer 49

Autografts: in which the same individual acts as both the donor and recipient. Isografts: in which the donor and recipient are genetically identical Allografts: where the donor and recipient are genetically dissimilar but belong to the same species: Xenografts: in which the donor and recipient belong to different species. In orthotopic transplants the transplanted part is placed in its normal anatomical location, while in heterotopic transplants it is placed in a different anatomical location.

Question 50

What is the crossover between penicillin and cephalosporin allergy?

Answer 50

20%

Question 51

Cabergoline or bromocriptine in microprolactinoma?

Answer 51

Meta-analysis suggests that cabergoline is more efficacious than bromocriptine in normalising prolactin, with a better side effect profile, and it is therefore the treatment of choice in this patient. Bromocriptine has a slightly less favourable adverse event profile versus cabergoline, but greater evidence exists for safe use in early pregnancy.

Question 52

What drugs are metabolised by CYP3A4?

Answer 52

Fentanyl, Buprenorphine, Oxycodone, Methadone, Diazepam, Midazolam, Alprazolam, Metoprolol, Losartan, Amlodipine, Rivaroxaban, Dabigatran, Apixaban, Tacrolimus

Question 53

What drugs are CYP3A4 inhibitors?

Answer 53

Amiodarone, Cimetidine, Conazoles, Diltiazem, Verapamil, Macrolides (erythromycin/ clarithromycin), Fluoxetine, Isoniazid, protease inhibitors, grapefruit, black pepper, inflammation

Question 54

What is the diagnostic criteria for obesity hypoventilation syndrome?

Answer 54

BMI >30 Daytime paCo2 >6 Absence of other causes of hypoventilation (e.g. opioid overdose)

Question 55

What is the indication for screening patients with ADPKD for intracerebral aneurysm?

Answer 55

Family history of intracerebral aneurysm (ICA) or subarachnoid haemorrhage Personal history of previous ICA rupture Patients with a high risk profession (e.g. pilot) Patient anxiety despite being given adequate information regarding risk.

Question 56

Ipilimumab has what mechanism of action?

Answer 56

Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor. Licensed for a range of advanced cancers, including malignant melanoma and renal cell carcinoma. Autoimmune disease such as thyroid disease and T1DM are seen as adverse events in association with CTLA-4 inhibition.

Question 57

What is the pathophysiology of pseudohypoparathyroidism?

Answer 57

The G-protein-coupled receptor for PTH becomes unresponsive to the hormone, hence patients become hypocalcaemic in the face of normal or elevated PTH levels. Variable degrees of resistance involving other G-protein-mediated receptors, such as those linked or TSH, LH and FSH activity may also be seen. Calcium and vitamin D is the intervention of choice. Calcium levels should be monitored frequently during treatment as rapid rises may occur. Clinical features include short stature, short metacarpals, subcutaneous calcification and variable intellectual impairment.

Question 58

What is the treatment for latent TB in HIV positive individuals?

Answer 58

Monotherapy with isoniazid for 6-9 months. Monotherapy for 6 months can be associated with poor compliance but it is the regimen of choice for those on HAART as it avoids the dangerous drug interactions if rifampicin were used. Normally rifampicin and isoniazid for 3 months is fine in those not on HAART.

Question 59

What are the risk factors for Torsades de pointes?

Answer 59

Hypocalcaemia, Hypokalaemia, hypomagnesaemia Congestive heart failure, Digitalis therapy Subclinical long-QT syndrome Baseline QT prolongation Severe alkalosis Recent conversion from AF Drugs that prolong QT interval (e.g. sotalol, macrolides) Female sex is a powerful predictor of the risk of TdP in patients with congenital and acquired long QT syndrome

Question 60

What does cranberry juice inhibit to increase effects of warfarin?

Answer 60

CYP2C9

Question 61

How does diet interfere with levodopa transport?

Answer 61

Levodopa is absorbed in the duodenum and its transport across the blood brain barrier is facilitated by a large neutral amino acid transporter protein. Dietary protein can therefore compete with levodopa transport in both the gastrointestinal system and across the blood brain barrier, reducing its effect. Some patients find it beneficial to have medications on an "empty stomach" (i.e. 60 minutes before or after a meal)

Question 62

What is the treatment for chronic hepatitis B and C?

Answer 62

Hepatitis B -No decompensation with E-antigen positivity: Interferon -Decompensated liver disease: Tenofovir or entecavir. Hepatitis C: -Interferon and ribavirin

Question 63

what is the first second and third line prophylactic treatment for co-trimoxazole in HIV?

Answer 63

Co-trimoxazole Oral dapsone (remember avoid in G6PD) Nebulised pentamidine

Question 64

What are the organism names of hookworm (commonest cause of iron deficiency anaemia worldwide)?

Answer 64

Necator Americanus and ancylostoma duodenale

Question 65

How does metformin cause GI upset?

Answer 65

Interferes with enterohepatic circulation of bile salts causing bile salt malabsorption.

Question 66

What rate control should not be used in cocaine overdose?

Answer 66

B-blockers may lead to worsening of myocardial ischaemia. Use Verapamil instead.

Question 67

What is the histology of a sarcoid granuloma?

Answer 67

Granuloma with prominent epithelioid cells with sparse lymphocytic infiltrate at the margins.

Question 68

What HLA serotype is associated with erythema nodosum?

Answer 68

HLA-B27

Question 69

What is the treatment escalation for dermatitis herpetiformis?

Answer 69

Gluten free diet Dapsone Oral sulfapyridine

Question 70

What stain is positive in hairy cell leukaemia?

Answer 70

Tartrate-resistant acid phosphatase stain (TRAP) This is a B-lymphocyte disorder. The abnormal cell has hair like cytoplasmic projections. Infiltration of the bone marrow leads to pancytopenia and patients have hepatosplenomegaly. Infiltration of bone marrow leads to a dry tap on attempted aspiration, and a bone marrow biopsy reveals cells that are said to have the characteristic 'fried egg' appearance. Purine analogues and interferon have been used for treatment, and occasionally splenectomy has been required.

Question 71

What stain is positive in AML?

Answer 71

Sudan black B stain and myeloperoxidase

Question 72

What stain is positive in ALL?

Answer 72

Terminal deoxynucleotidyl transferase stain (TDT)

Question 73

What stain is positive in polycythemia rubra vera and myelofibrosis

Answer 73

LAP This tends to be low in CML.

Question 74

What toxin causes vomiting in bacillus cereus food poisoning?

Answer 74

Cereulide

Question 75

What is the difference between classical CAH and non-classical CAH?

Answer 75

Classical has virilisation and salt wasting while non-classical CAH has virilisation without salt wasting.

Question 76

What is your target ferritin in CKD?

Answer 76

Anything lower than 100 then you need to iron replace.

Question 77

What is the most common mechanism for anaphylaxis in blood transfusions?

Answer 77

IgA deficiency. Common deficiency in humans. Pack red cells can contain small amounts of IgA and if recipient has anti-IgA antibodies you can get anaphylactic transfusion reaction.

Question 78

Summarise the treatment for syphilis

Answer 78

Treatment is generally with benzathine penicillin IM with dose and need for repeat of treatment dependent on the stage of syphilis and if the patient is pregnant. For early syphilis, including primary, secondary and early latent, a single dose of 2.4MU is needed. For latent, cardiovascular and gummatous syphilis three doses over 3 weeks are needed. Note that for cardiovascular syphilis, steroids should be given as well, starting the day before antibiotics. For neurosyphilis, procaine penicillin and probenecid is needed for 2 weeks. In pregnancy, treatment for early syphilis is one dose up to 27 weeks of pregnancy and two doses from week 28 to term

Question 79

How is coal worker's pneumoconiosis (CWP) subdivided?

Answer 79

Simple CWP generally leads to multiple small, round opacities, typically 1-10mm in diameter, mostly in the upper lobes. Complicated CWP shows much larger opacities in the upper lobes, with associated fibrosis, particularly when there is coexisting smoking.

Question 80

What is the most common cancer in Cowden's syndrome?

Answer 80

Breast cancer (lifetime risk in affected women is up to 50%)

Question 81

What is the gold standard investigation for sarcoidosis?

Answer 81

Bronchoscopy with transbronchial biopsy -90% of people with pulmonary sarcoidosis will have positive results

Question 82

What drugs are the more common causes of drug-induced autoimmune haemolytic anaemia?

Answer 82

Penicillin and Penicillin derivatives Cephalosporins Levodopa Methyldopa, Quinidine NSAIDs Discontinuing the causative agent usually leads to rapid improvement in the condition and a short course of oral prednisolone may accelerate recovery.

Question 83

What are the CT and renal biopsy findings in Xanthogranulomatous pyelonephritis?

Answer 83

CT shows heterogenous non-enhancing mass Renal biopsy shows lipid-laden macrophages with lymphocytes and polymorphonuclear leukocytes. Xanthogranulomatous pyelonephritis can be difficult to distinguish from a renal cell carcinoma. It typically presents with symptoms of fever, weight loss and loin pain. It is more common in idabetics, the immunocompromised and patients with obstructive uropathy. The most common organism is Proteus mirabilis. Histology combined with clinical and radiological evidence confirms the diagnosis. The definitive treatment is nephrectomy, as medical therapy is insufficient.

Question 84

When do you commence treatment in chronic hepatitis B?

Answer 84

Adults aged >30 years with HBV DNA >2000 and abnormal ALT (>30 IU/ml in men; >19 IU/ml) on two consecutive tests, three months apart Adults aged <30 years with above criteria IF there is evidence of necro-inflammation or fibrosis on liver biopsy or a transient elastography score >6kPa Adults who have HBV DNA >20000 IU/ml and abnormal ALT (as above) on tow consecutive tests, three months apart, regardless of age or the extent of disease Patients without a liver biopsy with a transient elastography score >11 kPa

Question 85

What is the treatment for chronic hepatitis B?

Answer 85

First line treatment with pegylated interferon alfa-2a in patients with compensated liver disease for 48 weeks. Entecavir and tenofovir are offered as second line treatments where pegylated interferon therapy has failed or is not tolerated.