Path Flashcards by Ella Robertson

which of thes is the commonest carcinoma in the liver?
liver cell
colangiocarcinoma
metastatic adenocarcinoma

metastatic adenocarcinoma.

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which of these is not associated with fatty change in the liver?
hep b
hep c
alcohol
diabetes

hepatitis B

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which of these is not associated with genetic haemochromatosis
cirrhosis
diabetes
kayser-fleisher rings
myocardial damae

kayser-fleisher rings

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what cell forms outer layer of glomerular filtration barrier?

podocyte.

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to nearest 10% - what % of end stage renal disease is dut to AD PKD?

10% (9.4%)

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what type of amyloid is formed in pt with multiple myeloma?

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commonest cause nephrotic syndrome in children?

minimal change disease

- see child with biopsy, treat them with steroids. if they dont get better then you do a biopsy

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antibodies to phospholipase A2 receptors are associated with what form of glomerulonephritis

membranous glomerulonephritis

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most oeso and gastric cancers arise from pre-existing adeonmas - T/F?

false

gastric and oeso - mainly flat pathway

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coeliac disease on a diet containing gluten following is most likely histological change in due?

villous atrophy no increase in intra-epithelial lymphocytes
villous atrophy, increase in intra-epithelial lymphocytes

villous atrophy - increase in intra-epithelial lymphocytes

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newborn babies, in contrast to adults, have...
1. higher hb
lower WBC
smaller RBC
same percentae of HbF

higher Hb

WBC high too
RBC large by adult size

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complications of sickle cell anaemia that are more common in adults than children include….

Hand-foot syndrome
Hyposplenism
Red cell aplasia
Splenic sequestration
Stroke

-hyosplenism.

everything else - infant or child more common

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Siblings with sickle cell anaemia present simultaneously with severe anaemia and a low reticulocyte count—likely diagnosis?

Splenic sequestration
Parvovirus B19 infection
Folic acid deficiency
Haemolytic crisis
Vitamin B12 deficiency

parvovirus B19.

haemolytic crisis - reticulocytes high.
vit b12 def - uncomon in child.

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A 6-year-old Afro-Caribbean boy presents with chest and abdominal pain; Hb is 63 g/l, MCV 85 fl and blood film shows sickle cells—likely diagnosis?

Sickle cell trait
Sickle cell anaemia
Sickle cell/beta thalassaemia

True answer 2

Cant be sickle trait as anaemia and sickle cells
Not 3 as MCV is normal, would be microcytic if both

trait - hb conc normal and no sickle cell in blood film.
sickle cell/ beta thal - not this as MCV is normal

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7-year-old Afro-Caribbean boy had abdominal pain and urinary tract symptoms and was given an anti-emetic by his G.P. Three days later he was noted to have yellow eyes and was brought to the hospital
(normal) WBC 10.9 × 109/l, (severe anemia) Hb 58 g/l, (upper limit of normal)MCV 100 fl, (norm)platelet count 275 × 109/l

hep a
hep b
sickle cell
G6PD def
heriditary spherocytosis

G6PD deficiency

X linked – therefore mainly males

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bite cells
large cells
rbc with little bit of Hb attached to it
irregularly contracted cells

G6PD deficiency

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A 1-year-old boy presents with joint bleeding, Hb, WBC and platelet count are normal, aPTT is prolonged, PT is normal, bleeding time normal—most likely diagnosis?

Haemophilia A
Haemophilia B
Von Willebrand disease
Thrombotic thrombocytopenia purpura
Has taken mother’s warfarin tablets

haemophilia A

history - b is likely too. but a more common so most likely

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53 year old male with weight loss and abdo discomfort
O/E hepatomegaly and spleen 6 cm below costal margin
Hb 98g/l WBC 20x109/l platelets 60x109/l
BCR-ABL transcripts not detected
JAK2 V617F 20%
BM aspirate dry tap

primary myelofibrosis

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22 year old male
Cyanotic congenital heart disease
Hb 210g/l  and Haematocrit 60%
No splenomegaly 
Select the most likely Lab test results
Serum erythropoietin
JAK2 mutation analysis

JAK2 negative
EPO raised

secondary polycythatmia -

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which is true?

1Immunosuppressive therapy is only used to treat a minority of patients with aplastic anaemia.
1If treated with immunosuppression, then relapse of Aplastic Anaemia occurs in less than 15% of cases
3The cure rate of AA treated by sibling-related allogeneic stem cell transplantation in a patient under 40 years old is > 70%.
4Severe aplastic anaemia is differentiated from non-severe aplastic anaemia on the basis of the acquired cytogenetic abnormalities in the bone marrow.
5Leucodepletion of cellular blood products is only exceptionally undertaken for patients with aplastic anaemia.

3The cure rate of AA treated by sibling-related allogeneic stem cell transplantation in a patient under 40 years old is > 70%.

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which is true?
1Telomeric shortening is a feature of both idiopathic aplastic anaemia and dyskeratosis congenita
2Development of malignancy is an uncommon complication of Fanconi Anaemia
3A single genetic defect has been identified as the underlying cause for Fanconi Anaemia
4Fanconi Anaemia is usually inherited in an autosomal dominant fashion
5Telomeric function is considered to be unimportant in the pathophysiology of Dyskeratosis Congenita.

1Telomeric shortening is a feature of both idiopathic aplastic anaemia and dyskeratosis congenita

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Recurrent infections with high neutrophil count on FBC but no abscess formation

1IFN gamma receptor deficiency

2Leukocyte adhesion deficiency

3Chronic granulomatous disease

4Kostmann syndrome

2Leukocyte adhesion deficiency

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Recurrent infections with hepatosplenomegaly and abnormal dihydrorhodamine test

1IFN gamma receptor deficiency

2Leukocyte adhesion deficiency

3Chronic granulomatous disease

4Kostmann syndrome

3Chronic granulomatous disease

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Recurrent infections with no neutrophils on FBC

1IFN gamma receptor deficiency

2Leukocyte adhesion deficiency

3Chronic granulomatous disease

4Kostmann syndrome

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Infection with atypical mycobacterium. Normal FBC 1IFN gamma receptor deficiency 2Leukocyte adhesion deficiency 3Chronic granulomatous disease 4Kostmann syndrome

1IFN gamma receptor deficiency

Meningococcus meningitis with family history of sibling dying of same condition aged 6 C7 deficiency C3 deficiency with presence of a nephritic factor MBL deficiency C1q deficiency

C7 deficiency. may have some reduction for C3 as well.

Membranoproliferative nephritis and abnormal fat distribution C7 deficiency C3 deficiency with presence of a nephritic factor MBL deficiency C1q deficiency

C3 deficiency with presence of a nephritic factor probs low C3 - acquired.

Severe childhood onset SLE with normal levels of C3 and C4 C7 deficiency C3 deficiency with presence of a nephritic factor MBL deficiency C1q deficiency

C1q deficiency probs get lots of skin disease

Recurrent infections when receiving chemotherapy but previously well C7 deficiency C3 deficiency with presence of a nephritic factor MBL deficiency C1q deficiency

MBL def

Severe recurrent infections from 3 months,CD4 and CD8 T cells absent, NK cells absent, B cell present, Igs low. Normal facial features and cardiac echocardiogram Bare lymphocyte syndrome type II X-linked SCID DiGeorge syndrome IFN gamma receptor deficiency

X-linked SCID bare lymphocytes- you can select CD4 digeorge - more widely abnormalities.

Young adult with chronic infection with Mycobacterium marinum Bare lymphocyte syndrome type II X-linked SCID DiGeorge syndrome IFN gamma receptor deficiency

IFN gamma receptor deficiency

Recurrent infections in childhood, abnormal facial features, congenital heart disease, normal B cells, low T cells, low IgA and IgG Bare lymphocyte syndrome type II X-linked SCID DiGeorge syndrome IFN gamma receptor deficiency

DiGeorge syndrome

6 month baby with two recent serious bacterial infections. T cells present – but only CD8+ population. B cells present. IgM present but IgG low Bare lymphocyte syndrome type II X-linked SCID DiGeorge syndrome IFN gamma receptor deficiency

Bare lymphocyte syndrome type II affects CD4 as type 2. you are not selectign HLA class 2 - so affects cd4

Adult with bronchiectasis, recurrent sinusitis and development of atypical SLE. IgG low. B and T cell normal. IgA deficiency Common variable immunodeficiency Bruton’s X linked hypogammaglobulinaemia X linked hyper IgM syndrome due to CD40ligand mutation

Common variable immunodeficiency in adult - have AI disease as well

Recurrent bacterial infections in a child, episode of pneumocystis pneumonia, high IgM, absent IgA and IgG IgA deficiency Common variable immunodeficiency Bruton’s X linked hypogammaglobulinaemia X linked hyper IgM syndrome due to CD40ligand mutation

X linked hyper IgM syndrome due to CD40ligand mutation cant do germinal centre reaction - cant get Ig isotype switching

1 year old boy. Recurrent bacterial infections. CD4 and CD8 T cells present. B cells absent, IgG, IgA, IgM absent IgA deficiency Common variable immunodeficiency Bruton’s X linked hypogammaglobulinaemia X linked hyper IgM syndrome due to CD40ligand mutation

Bruton’s X linked hypogammaglobulinaemia no b cells defect in b cell maturation pathway. it gets stuck at pre- b cells as lack tyrosine kinase gene.

Recurrent respiratory tract infections, absent IgA, normal IgM and IgG IgA deficiency Common variable immunodeficiency Bruton’s X linked hypogammaglobulinaemia X linked hyper IgM syndrome due to CD40ligand mutation

IgA deficiency

Which one of the following proteins/cytokines is NOT a drug target for current drugs and/or biologics used to treat allergic disorders? A. IL-13 B. Histamine C. IL-33 D. IgE E. IL-5

C. IL-33

A 60 year old female with hypotension and skin rash under generalanaesthesia What is the most appropriate test to diagnose anaphylaxis? A: Skin prick B. Drug challenge C. Blood histamine D. Serial mast cell tryptase E. Urine prostaglandin D2

D. Serial mast cell tryptase

A 55 year old man who attends A&E with angioedema involving lips and tongue which has developed over previous hours. He has a history of hypertension and is taking an ACE inhibitor and calcium channel blocker. Clinical examination show a pulse of 75bpm, blood pressure 150/90, respiratory rate of 18/min and oxygen saturation 98% on air. What is the most likely diagnosis? A. C1 inhibitor deficiency B. Acute anxiety attack C. Systemic Mastocytosis D. Idiopathic Anaphylaxis E. ACE inhibitor induced angioedema

E. ACE inhibitor induced angioedema A. C1 inhibitor deficiency - under 40

A 35 year old man with tree pollen hayfever and immediate lip tingling and swelling immediately after eating apples. What is the most likely explanation for IgE hypersensitivity ? A. IgG4 subclass deficiency B. Cross reactive IgE sensitisation between hay fever and apple allergens C. Apple-hay fever immune complex disease D. Increased Th17 immune response to apple allergen E. Food aversion disorder

B. Cross reactive IgE sensitisation between hay fever and apple allergens

BCG vaccination A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

B. Reduce risk of TB infection

Bone marrow transplantation A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

D. X linked SCID dont have NK/ or T cell. may have some B cell.

IFN gamma A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

E. Chronic granulomatous disease def in NADPH oxidase - failure in oxidative kiling

EBV-specific CD8 T cells A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

A. Post-transplant lymphoproliferative disorder

Human normal immunoglobulin A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

C. X linked hyper IgM syndrome most important to repleace IgG

Pembrolizumab (anti-PD1) A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

G. Metastatic melanoma enhance t cell response risk of AI side effects though

Varicella zoster immunoglobulin Varicella zoster immunoglobulin A. Post-transplant lymphoproliferative disorder B. Reduce risk of TB infection C. X linked hyper IgM syndrome D. X linked SCID E. Chronic granulomatous disease F. Immunosuppressed VZ seronegative individual after chicken pox exposure G. Metastatic melanoma

F. Immunosuppressed VZ seronegative individual after chicken pox exposure

Cyclophosphamide A. Osteoporosis B. Infertility C. Progressive multifocal leukoencephalopathy D. Neutropenia risk high if TPMT low E. Nephrotoxicity

B. Infertility

Prednisolone A. Osteoporosis B. Infertility C. Progressive multifocal leukoencephalopathy D. Neutropenia risk high if TPMT low E. Nephrotoxicity

A. Osteoporosis

Azathioprine A. Osteoporosis B. Infertility C. Progressive multifocal leukoencephalopathy D. Neutropenia risk high if TPMT low E. Nephrotoxicity

D. Neutropenia risk high if TPMT low small number of people have mutations in TPMT gene.

Tacrolimus A. Osteoporosis B. Infertility C. Progressive multifocal leukoencephalopathy D. Neutropenia risk high if TPMT low E. Nephrotoxicity

E. Nephrotoxicity used for transplantation though

Mycophenolate mofetil A. Osteoporosis B. Infertility C. Progressive multifocal leukoencephalopathy D. Neutropenia risk high if TPMT low E. Nephrotoxicity

C. Progressive multifocal leukoencephalopathy

Basiliximab (Anti-IL2 receptor) A. Inhibits T cell migration but may only be used in highly active remitting/relapsing MS B. Binds to CD80 and CD86 on antigen-presenting cells and inhibits T cell activation and is effective in rheumatoid arthritis C. Depletes B cells and is effective in treatment of B cell lymphomas and rheumatoid arthritis D. Inhibits function of lymphoid and myeloid cells and used in management of rheumatoid arthritis E. Antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection

E. Antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection

Abatacept (CTLA4-Ig fusion protein) A. Inhibits T cell migration but may only be used in highly active remitting/relapsing MS B. Binds to CD80 and CD86 on antigen-presenting cells and inhibits T cell activation and is effective in rheumatoid arthritis C. Depletes B cells and is effective in treatment of B cell lymphomas and rheumatoid arthritis D. Inhibits function of lymphoid and myeloid cells and used in management of rheumatoid arthritis E. Antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection

B. Binds to CD80 and CD86 on antigen-presenting cells and inhibits T cell activation and is effective in rheumatoid arthritis

Rituximab (Anti-CD20) A. Inhibits T cell migration but may only be used in highly active remitting/relapsing MS B. Binds to CD80 and CD86 on antigen-presenting cells and inhibits T cell activation and is effective in rheumatoid arthritis C. Depletes B cells and is effective in treatment of B cell lymphomas and rheumatoid arthritis D. Inhibits function of lymphoid and myeloid cells and used in management of rheumatoid arthritis E. Antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection

C. Depletes B cells and is effective in treatment of B cell lymphomas and rheumatoid arthritis CD20 on B cells but not plasma cells

Natalizumab (Anti-a4 integrin) A. Inhibits T cell migration but may only be used in highly active remitting/relapsing MS B. Binds to CD80 and CD86 on antigen-presenting cells and inhibits T cell activation and is effective in rheumatoid arthritis C. Depletes B cells and is effective in treatment of B cell lymphomas and rheumatoid arthritis D. Inhibits function of lymphoid and myeloid cells and used in management of rheumatoid arthritis E. Antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection

A. Inhibits T cell migration but may only be used in highly active remitting/relapsing MS

Tocilizumab (Anti-IL6 receptor) A. Inhibits T cell migration but may only be used in highly active remitting/relapsing MS B. Binds to CD80 and CD86 on antigen-presenting cells and inhibits T cell activation and is effective in rheumatoid arthritis C. Depletes B cells and is effective in treatment of B cell lymphomas and rheumatoid arthritis D. Inhibits function of lymphoid and myeloid cells and used in management of rheumatoid arthritis E. Antibody specific for CD25 which inhibits T cell activation and is used to prevent rejection

D. Inhibits function of lymphoid and myeloid cells and used in management of rheumatoid arthritis IL6 is on lots of cells but can also be soluble so affects a lot.

Psoriasis A. Treatment options include inhibition of RANK ligand B. Treatment options include inhibition of IL12/23, TNF alpha and IL17A C. Treatment options include inhibition of IL6, TNF alpha and depletion of B cells

B. Treatment options include inhibition of IL12/23, TNF alpha and IL17A

Rheumatoid arthritis A. Treatment options include inhibition of RANK ligand B. Treatment options include inhibition of IL12/23, TNF alpha and IL17A C. Treatment options include inhibition of IL6, TNF alpha and depletion of B cells

C. Treatment options include inhibition of IL6, TNF alpha (TOCILIZUMAB ) and depletion of B cells (RITUXIMAB )

Osteoporosis A. Treatment options include inhibition of RANK ligand B. Treatment options include inhibition of IL12/23, TNF alpha and IL17A C. Treatment options include inhibition of IL6, TNF alpha and depletion of B cells

A. Treatment options include inhibition of RANK ligand Denosumab

18 yr old woman LLL pneumonia Unwell Raised WCC + CRP ``` Pseudomonas aeruginosa Mycobacterium tuberculosis Legionella pneumophilia Streptococcus pneumoniae Staphylococcus aureus ```

Streptococcus pneumoniae

56 yr old man LLL pneumonia Haemoptysis Cavitiation on CXR ``` A) Streptococcus pneumoniae B) Haemophilus influenzae C) Staphylococcus aureus D) Klebsiella pneumoniae E) Any of the above ```

B) Haemophilus influenzae staph a - can give cavitating kleb - cavitating but he is not very unwell

62 yr old smoker Confused Bilateral interstitial change Hyponatraemic ``` Moraxella catarrhalis Mycobacterium tuberculosis Legionella pneumophilia Cytomegalovirus (CMV) Staphylococcus aureus ```

Legionella pneumophilia as he has recent confusion, smoker and hyponatraemic so not common pathogen

21 yr old from Ecuador Cough and weight loss RUZ shadowing on CXR ``` Staphylococcus aureus Aspergillus fumigatus Mycobacterium tuberculosis Haemophilus influenzae Pneumocystis jiroveci ```

TB not PCP as HIV negative. not aspergillus as not immunosuppressed.

64 yr old man Treated for Tb Bilateral ground-glass shadowing ``` A) Aspergillus fumigatus B) H1N1 Swine flu C) Mycoplasma pneumoniae D) Cytomegalovirus (CMV) E) Pneumocystis jiroveci ```

Ground-glass shadowing – PCP. | Recent treatment for TB left him immunosuppressed.

21 yr old man Previously well RUZ pneumonia hypotensive ``` Amoxycillin Tazocin and vancomycin Co-amoxiclav Cefuroxime and clarithromycin Rifater, isoniazid, pyrazinamide and ethambutol ```

Treated with cef and clarithromycin Fluid resuscitation (hypotensive) Supplemental oxygen Senior support requested

20 year old man admitted with a 3 week history of fever and headache. Has been travelling in the Middle East. Has drunk unpasteurised milk. Blood culture has grown a Gram negative coccobacillus Staph. aureus TB Brucellosis Meninigococcal septicaemia

Brucellosis indolent fever

which mec mediates flucloxacillin resistance in s. aureus? 1. impaired uptake of abob 2. enzymatic inactivation of abob 3. alteration of target. 4. enganced efflux of abob

3. alteration of target. alternate PBP no b-lactams work.

which mech is ESBL e.coli resistant to ceftriazone 1. impaired uptake of abob 2. enzymatic inactivation of abob 3. alteration of the target of the abob 4. enhanced efflux of the abob

2. enzymatic inactivation of abob. could use carbopenam, as they are stable to ESBL

3. How common are HAI in UK? A ~8% B ~22% C ~40% D ~55%

most common syndrome of HAI ``` A MRSA bloodstream infections B Norovirus gastroenteritis C Pneumococcal pneumonia D Urinary tract infection E Clostridium difficile ```

E Clostridium difficile then.. | D Urinary tract infection

6. C. difficile is….? ``` Gram positive anaerobe Gram negative aerobe Gram variable coccobacillus Gram positive spore-forming anaerobe Other not listed ```

Gram positive anaerobe

8. What 3 groups of factors influence SSI risk? - Staff, ward category, day of the week - Host defence, host gender, surgeon gender - Host defence, wound environment, pathogens - Virulence of pathogens, antibiotics used, type of suture - Experience of surgeon closing wound, mask use by theatre staff, music played in theatre

-Host defence, wound environment, pathogens, skill of surgeon in closing wound

Admitted in February 2012, with a subarachnoid and subdural haemorrhage after a fall. Decompressive craniectomy April 2012. Cranioplasty with titanium plate. October 2012. Admitted with large subdural collection with midline shift 16.10.12 Abscess evacuation. Titanium plates removed. Underneath there was severe infection with 1-1.5cm thick pus. gram positive cocci... yellow on blood agar, haemolytic. 1. E.coli 2. Enterobacter 3. Neisseria meningitides 4. MRSA

MRSA 16.10.12. Pus grew MRSA. Started on iv linezolid

Age- 70yrs old 1994 Right THR; 1998 Revision of acetabular component X-ray: lysis around distal part of femoral component Diabetic 1. Coagulase negative staphylococci 2. Staph. aureus 3. E.coli 4. Haemophilus influenzae

Samples form 1st stage grew coagulase negative staphylococci in 4 specimens Patient was started on iv vanc and oral rifampicin. 8 weeks later had 2nd stage . No growth from cultures

A 20 year old woman presents with headache and neck stiffness. What is the causative pathogen? Gram positive diplococci alpha haemolysis

strep pneumoniae

A 18 year old man present with headache and neck stiffness. What is the causative pathogen? gram negative cocci lots of neutrophils no haemolysis

meningococus/ neisseria meningitis.

A 65 year old presents with headache and neck stiffness. What is the causative pathogen? Gram positive rod

listeria monocytogenes

A 45 year old presents with headache and neck stiffness. What is the causative pathogen? present 2 weeks Ziehl-Neelsen stain

mycobacterium TB

A 35 year old presents with headache and neck stiffness. What is the causative pathogen? 3 days MSM opening pressure 40ml wter (normal 20cm water). indian ink stains

cryptococcus

Influenza virus infection causes respiratory disease because: 1. The host cell receptor (sialic acid) the virus binds to is only expressed in the lung 2. The influenza virus can only get into the body through the mouth 3. The influenza virus requires activation by host cell proteases that are only expressed in the respiratory tract 4. The influenza virus envelope can only fuse with membranes of cells that secrete mucus.

3. The influenza virus requires activation by host cell proteases that are only expressed in the respiratory tract

The influenza vaccine given to those at greater risk of complications from flu in the UK is 1. A live attenuated virus 2. A purified fraction containing HA and NA of an inactivated virus 3. A purified HA protein expressed in insect cells 4. An immunoglobulin fraction from sera of immune patients.

2. A purified fraction containing HA and NA of an inactivated virus surface proteins cut off and jabbed into people’s arms

A 23 year old male is a close contact of a person with smear positive pulmonary TB, What is his lifetime risk of developing active TB? 0.1% 1% 10% Don’t worry, be happy!

no other illness in life - 10% greatest risk first 6 months

Q1: During acute porphyria, the most useful sample to send is…? ``` Blood CSF Urine Muscle biopsy Stool Skin biopsy ```

urine

Q2 Cutaneous erythema without blisters or bullae, most likely indicates Erythropoietic protoporphyria Congenital erythropoietic porphyria Acute intermittent porphyria

Erythropoietic protoporphyria CEP - blistering AIP - no skin issues

Q3: Hyponatraemia associated with AIP is due to Dehydration SIADH Hypoaldosternism Raised renin

SIADH dehydration - hyperna

Q4 Urine samples taken during an acute attack for diagnosis should be… (porphyria) Taken in an acidified container Protected from light Alkalinised Interpreted with a paired serum sample

Protected from light send unprotected. porphyringoens --> porphyrins and break down

30 year galactorrhoea • A CT scan of her pituitary shows a large (2cm) macroadenoma. • Her prolactin level comes back at 30,000 (normal <600). She has not had sexual intercourse. ``` Cushing’s disease Acromegaly Prolactinoma Non-functioning pituitary adenoma Conn’s syndrome ``` what Ix...?

• Always a prolactinoma if prolactin>6,000 Prolactinoma Ix.. MRI

Which one is URGENT? ``` Fludrocortisone replacement Hydrocortisone replacement Thyroxine replacement Oestrogen replacement GH replacement ```

Hydrocortisone replacement - maintains cell integrity in shock fludrocortisone - is for adrenal failure.

``` • 31 year old presents with profound tiredness. • Acutely unwell a few days. • Vomiting • Na: 125, K: 6.5, U 10, Glucose 2.9mM. • FT4 < 5nM TSH > 50mU/l • What does this TSH suggest? A. A TSH producing pituitary adenoma B. Graves disease C. A toxic thyroid nodule D. Primary hypothyroidism E. de Quervain’s (viral) thyroiditis. ```

Primary hypothyroidism . Very low T4, make lots of TSH. Not a tumour – as high T4 and TSH

What is the most frequent brain tumour in adults? Glioblastoma, IDH wildtype Meningioma Metastatic carcinoma Astrocytoma, IDH mutant

Metastatic carcinoma 2nd = glioblastoma

What is the most frequent brain tumour in children? Meningioma Pilocytic astrocytoma Medulloblastoma Astrocytoma, IDH mutant

1 - Pilocytic astrocytoma | 2 - medulloblastoma

What is the major change in the last (2016) CNS tumour classification ? Changes in grading system Changes in staging system Incorporation of genetic profile Addition of new histological types

Incorporation of genetic profile

45 year old female History: pulmonary lobectomy 2 days of headache and vomiting Worsening headache CT: right frontoparietal SOL with minimal midline shift to the left Dd: primary tumour, metastasis, abscess Glioblastoma (WHO grade IV) Astrocytoma (WHO grade II) Abscess Metastasis

Metastasis

70 year old male Seizure following 2 weeks of left arm and leg weakness MRI showing heterogeneous enhancing right frontal lesion, started on steroids Partial response to steroids with improved dexterity of the left arm and leg Glioblastoma (WHO grade IV) Meningioma Metastasis Astrocytoma (WHO grade II)

steroids - favours glioma. short hx = high grade tumour, vascular prliferation Glioblastoma (WHO grade IV)

when the integrity of the BBB is disrupted the resultant oedema is...

vasogenic

which of the following types of herniation doesnt involve cerebral cortex?

tonsillar - this bothers cerebellum

What, by consensus, is the best measure of kidney function? - Serum creatinine itself - Serum creatinine and urea - Urine protein:creatinine ratio - Glomerular filtration rate - Cystatin C

-Glomerular filtration rate

Which factor(s) limit(s) the use of serum creatinine as a marker of GFR? ``` It is influenced by intake of fat It is lower in the black population It is related to muscle mass It is reabsorbed by the renal tubules All of the above ```

It is related to muscle mass higher in black population influenced by intake protien - marker of muscle turnover. secreted by renal tubules.

True or false:A spot urine measurement to quantify proteinuria can be done instead of a 24 hour urinary collection?

True Urine protein:creatinine ratio (PCR) Quantitative assessment of amount of proteinuria Measurement of creatinine corrects for urinary concentration

Which of the following is true regarding urine dipstick testing? If the dipstick is negative for blood it reliably excludes haematuria Haematuria is the only cause of a positive dipstick test for blood. You can reliably exclude bacteriuria if the urine dipstick is negative for nitrites The urine dipstick detects Bence Jones proteins - myeloma. Glycosuria detected by the dipstick means the patient has diabetes.

If the dipstick is negative for blood it reliably excludes haematuria b - positive dipstick blood - myoglobin. nitrites - screening tool. gram negative. not goo for BJP blood glu/ HbA1c - diabetes

A 50 year old, known alcoholic, presents generally unwell, seemingly intoxicated, with acute kidney injury. Urine microscopy reveals calcium oxalate crystals, what diagnosis do you suspect?

ethylene glycol posoining. posion with antifreeze (ethylene glycol) metabolised to glycolic acid --> oxalic acid, binds to kineys and causes stones and causes AKI - kills them.

You admit a 28 year old man who you suspect has a renal stone, what is your first choice of imaging? ``` Plain KUB CT Ultrasound KUB IVU MRI ```

CT KUB - 24/7 access

- NSAIDs - decrease afferent arteriolar dilatation - Calcineurin inhibitors - decrease afferent arteriolar dilatation. cyclosporin, immunosuppressants. - ACEi or ARBs - decrease efferent arteriolar constriction - Diuretics

all of them do!

Regarding hyperkalaemia, which of the following is true: -It can lead to ECG changes such as peaked p waves and flattened t waves. -In those with CKD, dietary intake is a major cause and high potassium levels are found in foods such as milk, chocolate, dried fruits and tomatoes. -NSAIDs can lower potassium levels -Hyperaldosteronism is a common - All of the above

-In those with CKD, dietary intake is a major cause and high potassium levels are found in foods such as milk, chocolate, dried fruits and tomatoes. ecg - plat p and peaked t NSAIDS - increase k hyperaldosteonis - low k

gram negative curved rod... toxin affects adenyly cyclase death - shock, meta acidosis, renal failure.

vibrio cholera

affects distal colon - acute mucosal inflamm and eroision spread person to person sx... fevere, pain, d, dysentery

shigella

affects ileum, appendix, colon peyer patch invasion = mesenteric lymph node enlargement, with necrotising granuloams comps... peritonitis, pharyngitis, pericarditis

shigella

Following a trip to Brazil, a patient develops bloody diarrhoea, with a high fever, sweating and on examination the patient is found to have RUQ pain.

entamoeba histolytica

homosexual man develops severe flatulence, accompanied by bloating and explosive diarrhoea.

giardia lamblia | - can be spread unprotected anal sex

Mr C complained of fever and severe (>10 bowel movements/day) diarrhoea after looking after his neighbours dogs for a few days. Laboratory analysis of Mr C’s stools found the causative organism to be a S-shaped microaerophillic bacteria.

Campylobacter pets can have the bacteria and pass it to you, animals normally asx

Mr S became ill with nausea, vomiting and watery diarrhoea about 4 hours after eating some ham at a conference buffet lunch. Mr B’s illness was attributed to a heat stable, preformed toxin in the ham. His symptoms resolved within 24hours.

staphylococcus

A monoclonal immunoglobulin which appears as a dense narrow band (M band) on electrophoresis.

paraprotein

Stimulated by IL-6 secreted by cells in the vicinity of the myeloma cells. Produces radiological changes resembling those of generalized osteoporosis.

osteoclasts

Misfolded protein deposited in myeloma-associated amyloidosis

AL amyloid

Induction chemotherapy regimen with the best evidence pre autologous stem cell transplant in multiple myeloma

Lenalidomide + low dose dexamethasone

Monoclonal immunoglobulin raised in macroglobinaemia

IgM

Proteasome inhibitor active in myeloma

Bortezomib

Monoclonal protein <30 AND BM plasma cells <10% AND no damage

MGUS

Monoclonal protein >30 OR BM plasma cells >10% AND no damage

Asx Myeloma

ANY monoclonal protein level AND BM plasma cells >10% (otherwise it would be plasmacytoma) AND damage

Myeloma

cytokine important growth factor in dev od myeloma?

IL-6

Elevated levels imply a poor prognosis in myeloma patients

beta2 microglobulin for myeloma staging use these levels and albumin levels

A 52 yr old woman who has a 5 yr history of rheumatoid arthritis and has recently been found to have proteinuria. Further examination revealed hepatosplenomegaly. A rectal biopsy stained with Congo Red showed apple green birefringence in polarised light.

Secondary amyloidosis

A 65 yr old man presents to his GP with general malaise, weight loss and visual disturbances that he likens to looking through a watery car windscreen. On examination he has peripheral lymph node enlargement. Protein electrophoresis shows an IgM paraprotein.

Waldenstrom's macroglobulinaemia - a malignant disease of B cells which are lymphoplasmacytoid in appearance. These cells secrete IgM paraprotein which gives rise to clinical manifestations. The disease is commonly seen in elderly men. It is an indolent disease with a median survival of 3 to 5 years, but some patients may survive 10 years or longer. It is regarded as a low grade non-Hodgkin's lymphoma.

A 43 year old man presents to his GP with concerns over a tender lump on the left side of his abdomen. Investigation showed a normal haemoglobin but a mildly raised white-cell count (13.2 x 109/l). On the blood film these cells were mainly small mononuclear cells resembling lymphocytes. These cells stained positively for tartrate-resistant acid phosphatase.

hairy cell leukaemia

Pathological stage IA or IIA disease may be treated with......

ABVD combination chemotherapy + radiotherapy if required

Advanced Hodgkins disease should be treated with…..

Combination Chemotherapy

A patient presents with a lump in his groin and complains of night sweats and an itchy rash. A biopsy is taken and on inspection is shown to include Reed-Sternberg cells.

Hodgkin lymphomaHodgkin lymphoma

what is pel ebstein fever?

hodgkins lymphoma | expereinces fevers, which cyclically increase then decrease over average period of 1/2 weeks

A subtype of Non-Hodgkin lymphoma associated with very aggressive disease.

burkitts

The grade of the Follicular lymphoma NHL subtype.

indolent

Anaemia and neutropenia are more common in which of the above autoimmune disease?

SLE

A 21 year old student recently returning from India complains to his GP of cough, headache and diarrhoea. He is febrile and rose spots are present on his chest. Blood culture reveals salmonella typhi. Which immune cells out of the list are most likely to be raised?

monocytes

A 51 year old man is having work up for palliative surgery due to gastric adenocarcinoma. He is found to be anaemic, with high a reticulocyte count and fragmented red blood cells on blood smear. What is this anaemia known as?

Microangiopathic haemolytic anaemia

An 81 year old man with known prostatic carcinoma presents to his GP with severe bone pain. Blood tests reveal a mild anaemia and peripheral blood film shows nucleated red blood cells and immature myeloid cells. What are these haematological features collectively known as?

leucoerythroblastic anaemia

A peripheral blood smear of a thrombocytopenic patient raised Lactate dehydrogenase and unconjugated bilirubin shows fragmented Red blood cells.

MAHA

Monocytosis but with a normal neutrophil count.

brucella

Neutrophilia with visible toxic granulation and vacuoles on the blood film. The monocyte count is normal.

acute fungal infection

A 22 year old female who has recently undergone surgery presents with difficulties breathing and swelling of the face, hands and feet. She also complains of severe abdominal pains. She has experienced similar problems in the past.

C1 inhibitor deficiency

Differentiation of this is regulated via the RANK gene product. ``` A. Diaphysis B. Cancellous C. Endosteum D. Cortical E. Woven F. Osteocyte G. Osteoclast H. Osteoblast I. Metaphysis J. Periosteum K. Epiphysis L. Lamellar ```

osteoclast

Covers cortical surface of bone and delivers blood supply. ``` A. Diaphysis B. Cancellous C. Endosteum D. Cortical E. Woven F. Osteocyte G. Osteoclast H. Osteoblast I. Metaphysis J. Periosteum K. Epiphysis L. Lamellar ```

periosteum

This type of bone is 80-90% calcified and its function is mainly mechanical and protective. ``` A. Diaphysis B. Cancellous C. Endosteum D. Cortical E. Woven F. Osteocyte G. Osteoclast H. Osteoblast I. Metaphysis J. Periosteum K. Epiphysis L. Lamellar ```

cortical

his type of bone is immature and usually pathological. ``` A. Diaphysis B. Cancellous C. Endosteum D. Cortical E. Woven F. Osteocyte G. Osteoclast H. Osteoblast I. Metaphysis J. Periosteum K. Epiphysis L. Lamellar ```

woven

A 15-year-old male presents with a 2-month history of increasing pain in his right upper arm. Bone biopsy reveals sheets of cells with small, primitive nuclei and scanty cytoplasm. A positive immunoreactivity is seen with the MIC2 (CD99) antibody. ``` A. Primary osteosarcoma B. Ewing's sarcoma C. Osteomalacia D. Osteogenesis imperfecta E. Osteoporosis F. Osteoarthritis G. Chondrosarcoma H. Osteomyelitis I. Osteopetrosis ```

Ewings

A 20-year-old male complains of a progressively enlarging painful mass on his right upper arm. Radiology demonstrates a lytic lesion of the proximal humerus with an accompanying Codman triangle. Microscopically, pleomorphic mesenchymal cells producing dark-staining osteoid are seen. ``` A. Primary osteosarcoma B. Ewing's sarcoma C. Osteomalacia D. Osteogenesis imperfecta E. Osteoporosis F. Osteoarthritis G. Chondrosarcoma H. Osteomyelitis I. Osteopetrosis ```

A. Primary osteosarcoma Codman triangle (previously referred to as Codman's triangle) is the triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone.

A 24 year old police woman attends the clinic as her GP suspects she may have a parathyroid tumour. She has raised PTH and serum calcium. After a 24hr urinary collection it is noted the patient has a low urine calcium output ``` A. Osteomalacia B. Cushing's syndrome C. Familial hypocalcuric hypercalcaemia D. Primary hypthyroidism (myxoedema) E. Cushing's disease F. Primary hyperparathyroidism G. Paget's disease H. Tertiary hyperparathyroidism I. Osteoporosis J. Secondary hyperparathyroidism with chronic renal osteodystrophy K. Osteitis fibrosa ```

Familial hypocalciuric hypercalcaemia (FHH) a dominantly inherited condition caused by a mutation of the calcium sensing receptor. The result is that the kidney reabsorbes calcium very avidly as a primary problem. This results in hypocalciuria and hypercalcaemia. Because the parathyroid gland calcium receptor also does not work, the parathyroids continue to secrete excess PTH despite the high calcium, so it looks just like primary hyperparathyroidism. However removing the parathyroids does not help the calcium, as the primary cause of trouble is in the kidney.

A 14 year old boy complains to you of a painless lump on his left thigh, just above the knee which is slowly growing. His past medical history reveals that he fractured his femur in the same location several years before. ``` A. Ewing's tumour B. Trauma C. Echondroma D. Osteoarthritis E. Osteitis F. Osteoclastoma G. Osteoid osteoma H. Fibrous dysplasia I. Chondrosarcoma J. Metastases K. Simple bone cyst L. Osteosarcoma M. Rheumatoid arthritis N. Osteoporosis O. Osteochondroma ```

Osteochondroma: 1) Is the commonest bony tumour 2) M:F = 3:1 3) Commonest location is around the knee 4) They are usually painless and slow growing 5) Their aetiology maybe related to previous trauma, such as fracture.

An 18 year old student presents to his GP with focal pain in his left fore-arm which is tender to touch and worsens at night. The pain is relieved with aspirin. An X-ray shows a 1cm are of radio-lucency in the tibia surrounded by dense bone. ``` A. Ewing's tumour B. Trauma C. Echondroma D. Osteoarthritis E. Osteitis F. Osteoclastoma G. Osteoid osteoma H. Fibrous dysplasia I. Chondrosarcoma J. Metastases K. Simple bone cyst L. Osteosarcoma M. Rheumatoid arthritis N. Osteoporosis O. Osteochondroma ```

osteoid osteoma An osteoid osteoma is a benign bone tumor that arises from osteoblasts and was originally thought to be a smaller version of an osteoblastoma. Osteoid osteomas tend to be less than 1.5 cm in size. The tumor can be in any bone in the body but are most common in long bones, such as the femur and tibia.

An 8 year old boy is brought to his GP by his parents with pain in his hips and a fever. Blood results demonstrate a raised ESR and biopsy histology shows droplets of glycogen in the cytoplasm of small round cells in the pelvic bones. ``` A. Ewing's tumour B. Trauma C. Echondroma D. Osteoarthritis E. Osteitis F. Osteoclastoma G. Osteoid osteoma H. Fibrous dysplasia I. Chondrosarcoma J. Metastases K. Simple bone cyst L. Osteosarcoma M. Rheumatoid arthritis N. Osteoporosis O. Osteochondroma ```

ewings tumour

A 15 year old girl shows you a small lump on her upper arm on routine examination. She says the lump has been present for a couple of years and has slowly moved down, away from her shoulder. ``` A. Ewing's tumour B. Trauma C. Echondroma D. Osteoarthritis E. Osteitis F. Osteoclastoma G. Osteoid osteoma H. Fibrous dysplasia I. Chondrosarcoma J. Metastases K. Simple bone cyst L. Osteosarcoma M. Rheumatoid arthritis N. Osteoporosis O. Osteochondroma ```

Simplebone cyst

A 50 year old lady presents with pain in her jaw. She suffers from Paget’s disease. A ‘sunburst’ appearance is seen on X-ray along with a lifted periosteum (Codman’s triangle). ``` A. Ewing's tumour B. Trauma C. Echondroma D. Osteoarthritis E. Osteitis F. Osteoclastoma G. Osteoid osteoma H. Fibrous dysplasia I. Chondrosarcoma J. Metastases K. Simple bone cyst L. Osteosarcoma M. Rheumatoid arthritis N. Osteoporosis O. Osteochondroma ```

osteosarcoma

60 year old life long smoker presents to her GP with a 10 day history of worsening shortness of breath, cough and wheeze. Her cough produces a greenish sputum. On examination she is tachypnoeic and very cyanosed. Auscultation of her chest reveals a harsh polyphonic wheeze and signs of a right lower lobe pneumonia. This lady has developed type II respiratory failure secondary to what pulmonary disease? ``` A. Tuberculosis B. Pulmonary embolism C. Cryptogenic fibrosing alveolitis D. Acute asthma E. Emphysema F. Cystic fibrosis G. Squamous cell carcinoma H. Thymoma I. Pneumococcal pneumonia J. Pulmonary oedema K. Small cell carcinoma L. Chronic bronchitis M. Mycoplasma pneumonia ```

chronic bronchitis It is often very difficulty to distinguish chronic bronchitis and emphysema. The textbook 'blue bloater' and 'pink puffer' may not be clinically manifest to help you. Both are associated with smoking (so that does not distinguish either). However, chronic bronchitis is more likely to be associated with type 2 respiratory failure than emphysema (and also more likely to have polycythaemia). To remember blood gases in each type of respiratory failure: Type 1 = 1 thing is abnormal = low o2 Type 2 = 2 things are abnormal = low o2 and high co2

70 year old man presents to his GP with a four day history of haemoptysis. He has noticed he has been loosing weight over the last 4 months and has felt tired and unwell. On examination he has bilateral ptosis and proximal weakness in the limbs which improves on repeated testing ``` A. Tuberculosis B. Pulmonary embolism C. Cryptogenic fibrosing alveolitis D. Acute asthma E. Emphysema F. Cystic fibrosis G. Squamous cell carcinoma H. Thymoma I. Pneumococcal pneumonia J. Pulmonary oedema K. Small cell carcinoma L. Chronic bronchitis M. Mycoplasma pneumonia ```

small cellcarcinoma This guy has Myasthenic Syndrome Eaton-Lambert syndrome which occurs in ~3% of people with small cell l ung cancer. In contrast with myasthenia gravis, the fatigue gets BETTER with repeated use of the muscle.

45 year old fireman presents to chest clinic with a 1 year history of increasing shortness of breath. On examination you find that he is tachypnoeic and has gross clubbing of the fingers. Auscultation reveals bibasal fine end-inspiratory crackles ``` A. Tuberculosis B. Pulmonary embolism C. Cryptogenic fibrosing alveolitis D. Acute asthma E. Emphysema F. Cystic fibrosis G. Squamous cell carcinoma H. Thymoma I. Pneumococcal pneumonia J. Pulmonary oedema K. Small cell carcinoma L. Chronic bronchitis M. Mycoplasma pneumonia ```

Cryptogenic fibrosing alveolitis

A 29 year old lady presented with painful ulceration of the vulval skin. Histologically, there were intraepithelial blisters, intranuclear viral inclusions and eosinophilic cytoplasmic swelling ``` A. Candida albicans B. Granuloma Inguinale C. Neisseria gonorrheae D. Trichomonas vaginalis E. Cervical Intraepithelial Neoplasia I F. Lymphogranuloma venereum G. Cervical Microglandular Hyperplasia H. Herpes simplex I. Treponema pallidum (syphilis) J. Group B Streptococcus K. Mild dyskaryosis L. Gardnerella vaginalis M. Cervical Intraepithelial Neoplasia III N. Chlamydia O. Severe dyskaryosis ```

Herpes Simplex

A 42 year old lady presented to a clinic for a smear test but explained that due to living abroad she had not had one for 8 years. The smear showed severe dyskaryosis and she was referred for colposcopic examination, which revealed dysplastic changes in the full thickness of the cervical epithelium. ``` A. Candida albicans B. Granuloma Inguinale C. Neisseria gonorrheae D. Trichomonas vaginalis E. Cervical Intraepithelial Neoplasia I F. Lymphogranuloma venereum G. Cervical Microglandular Hyperplasia H. Herpes simplex I. Treponema pallidum (syphilis) J. Group B Streptococcus K. Mild dyskaryosis L. Gardnerella vaginalis M. Cervical Intraepithelial Neoplasia III N. Chlamydia O. Severe dyskaryosis ```

CIN 3

A young lady is found to have chronic irritation and inflammation of the vulva. A pap smear and use of a silver stain reveals fungi within the keratin layer and superficial epithelium. ``` A. Candida albicans B. Granuloma Inguinale C. Neisseria gonorrheae D. Trichomonas vaginalis E. Cervical Intraepithelial Neoplasia I F. Lymphogranuloma venereum G. Cervical Microglandular Hyperplasia H. Herpes simplex I. Treponema pallidum (syphilis) J. Group B Streptococcus K. Mild dyskaryosis L. Gardnerella vaginalis M. Cervical Intraepithelial Neoplasia III N. Chlamydia O. Severe dyskaryosis ```

Candida Albicans

A 22 year old lady presented for her routine smear test. The test showed a slight increase in DNA staining, and also a slightly larger variation in size of nuclei. Further questioning revealed she was a single mother living with her boyfriend, and had had multiple sexual partners since her first sexual contact at age 16. ``` A. Candida albicans B. Granuloma Inguinale C. Neisseria gonorrheae D. Trichomonas vaginalis E. Cervical Intraepithelial Neoplasia I F. Lymphogranuloma venereum G. Cervical Microglandular Hyperplasia H. Herpes simplex I. Treponema pallidum (syphilis) J. Group B Streptococcus K. Mild dyskaryosis L. Gardnerella vaginalis M. Cervical Intraepithelial Neoplasia III N. Chlamydia O. Severe dyskaryosis ```

Mild Dyskaryosis

A pap smear taken from a chronic granulomatous ulcer shows a necrotic centre, periarteritis and endarteritis obliterans and an intense peripheral cellular infiltrate consisting mainly of mononuclear cells and giant cells. ``` A. Candida albicans B. Granuloma Inguinale C. Neisseria gonorrheae D. Trichomonas vaginalis E. Cervical Intraepithelial Neoplasia I F. Lymphogranuloma venereum G. Cervical Microglandular Hyperplasia H. Herpes simplex I. Treponema pallidum (syphilis) J. Group B Streptococcus K. Mild dyskaryosis L. Gardnerella vaginalis M. Cervical Intraepithelial Neoplasia III N. Chlamydia O. Severe dyskaryosis ```

Treponema Pallidum - syphyllis

Bubonic Plague ``` A. Brucella abortus B. Francisella tularensis C. Campylobacter jejuni D. Rickettsia prowazekii E. Yersinia pestis F. Bartonella henselae G. Trypanosoma cruzi H. Cryptosporidium parvum I. Spirillum minus J. Borrelia burgdorferi ```

Yersinia Pestis

A student who presented with two day history of bloody diarrhoea, vomiting, fever, headache and myalgia. He has just returned from camping in the country side near a farm where he had fresh cow’s milk for breakfast everyday. ``` A. Brucella abortus B. Francisella tularensis C. Campylobacter jejuni D. Rickettsia prowazekii E. Yersinia pestis F. Bartonella henselae G. Trypanosoma cruzi H. Cryptosporidium parvum I. Spirillum minus J. Borrelia burgdorferi ```

Campylobacter jejuni

A 2 year old boy living in the slums who has a one day history of profuse watery diarrhoea, fever and abdominal cramps. His family’s main source of water is the river near their squatters. ``` A. Brucella abortus B. Francisella tularensis C. Campylobacter jejuni D. Rickettsia prowazekii E. Yersinia pestis F. Bartonella henselae G. Trypanosoma cruzi H. Cryptosporidium parvum I. Spirillum minus J. Borrelia burgdorferi ```

Cryptosporidium parvum

A man was bitten by a rat in Asia. Ten days later he complains of fever, malaise, headache and myalgia. ``` A. Brucella abortus B. Francisella tularensis C. Campylobacter jejuni D. Rickettsia prowazekii E. Yersinia pestis F. Bartonella henselae G. Trypanosoma cruzi H. Cryptosporidium parvum I. Spirillum minus J. Borrelia burgdorferi ```

Spirillum Minus

Cat Scratch Disease ``` A. Brucella abortus B. Francisella tularensis C. Campylobacter jejuni D. Rickettsia prowazekii E. Yersinia pestis F. Bartonella henselae G. Trypanosoma cruzi H. Cryptosporidium parvum I. Spirillum minus J. Borrelia burgdorferi ```

Bartonella Henselae

A 6 month old baby is brought to A&E with sudden onset fever, vomiting and diminished conciousness. A widespread haemorrhagic rash is also observed which does not blanch upon application of pressure. ``` A. Meningococcal Septicaemia B. Listeriosis C. Lyme disease D. Leptospirosis E. Brucellosis F. Tularaemia G. Rheumatic fever ```

A. Meningococcal Septicaemia

A 10 year old boy of Middle-Eastern origin presents with general malaise and loss of appetite. He also complains of fever and joint pain. A throat swab is taken, revealing the presence of Group A Streptococci. ``` A. Meningococcal Septicaemia B. Listeriosis C. Lyme disease D. Leptospirosis E. Brucellosis F. Tularaemia G. Rheumatic fever ```

Rheumatic Fever

A zoonosis associated with hepatitis, jaundice, conjunctival injection and renal impairment. Transmission normally occurs by direct contact with either the urine or tissues of an infected animal. ``` A. Meningococcal Septicaemia B. Listeriosis C. Lyme disease D. Leptospirosis E. Brucellosis F. Tularaemia G. Rheumatic fever ```

Leptospirosis

A 22 year old student, who returned from a holiday in the Mediterranean 3 weeks ago, presents with an undulant fever, malaise, weakness and generalized bone pain. Upon examination lymphadenopathy and hepatosplenomegaly are also noted. ``` A. Meningococcal Septicaemia B. Listeriosis C. Lyme disease D. Leptospirosis E. Brucellosis F. Tularaemia G. Rheumatic fever ```

Brucellosis

A 45 year old male farmer presents with a raised, erythematous rash, with clearing in the centre. He also complains of headache, fever, athralgia and malaise. ``` A. Meningococcal Septicaemia B. Listeriosis C. Lyme disease D. Leptospirosis E. Brucellosis F. Tularaemia G. Rheumatic fever ```

Lyme DIsease Erythema chronicum migrans is the classical immune-mediated skin lesion which occurs at the site of the bite in Lyme disease.

A 25 year old Maltese man presented to his GP with lethargy for a month and headaches and fever. On examination, he had a temperature of 39°C and one fingerbreadth splenomegaly. Small Gram-negative coccobacilli were seen on culture in Casteneda’s medium. ``` A. Bacillus anthracis B. Leishmania major. C. Leptospira interrogans D. Borrelia burgdorferi E. Yersina pestis F. Rabies G. Brucella abortus H. Brucella melitensis I. Rickettsia typhi ```

Brucella melitensis The Maltese clue is correct. Abortus comes from cattle, and melitensis comes from goats.

A 30 year man presented with jaundice and conjunctival haemorrhages. He had recently been canoeing in the US and had felt ‘run-down’ upon his return to the UK. ``` A. Bacillus anthracis B. Leishmania major. C. Leptospira interrogans D. Borrelia burgdorferi E. Yersina pestis F. Rabies G. Brucella abortus H. Brucella melitensis I. Rickettsia typhi ```

Leptospira interrogans

A 22 year old student presented to her GP upon return from a biology field trip, with a lesion on her leg which was 3” in diameter and flat, with a red edge and dim centre. She also mentioned feeling tired and suffering from headaches. On examination, the GP noted a fever of 38.0°C and an irregular heartbeat. ``` A. Bacillus anthracis B. Leishmania major. C. Leptospira interrogans D. Borrelia burgdorferi E. Yersina pestis F. Rabies G. Brucella abortus H. Brucella melitensis I. Rickettsia typhi ```

Borrelia burgdorferi

A tanner on holiday from India presented to hospital with an ulcerating papule on his hand. On inspection of the ulcer, the centre was black and necrotic. Gram-positive rods grew on blood agar culture and responded to treatment with large doses of penicillin. ``` A. Bacillus anthracis B. Leishmania major. C. Leptospira interrogans D. Borrelia burgdorferi E. Yersina pestis F. Rabies G. Brucella abortus H. Brucella melitensis I. Rickettsia typhi ```

Bacillus anthracis

A 49 year old man was admitted in A&E with a 3 day history of worsening right arm pain and a 1 day history of dysphagia, hypersalivation, agitation and generalised muscle twitching. Vital signs and blood tests were normal but he became confused. He developed renal failure and died 4 days later. ``` A. Bacillus anthracis B. Leishmania major. C. Leptospira interrogans D. Borrelia burgdorferi E. Yersina pestis F. Rabies G. Brucella abortus H. Brucella melitensis I. Rickettsia typhi ```

Rabies

A 45 year old female whose main hobby was pigeon racing was noted by her GP to an enlarged lymph node in her neck. What is the most likely diagnosis?

Cryptococcis

An 8 year-old boy presents to casualty with a painful and swollen right thigh after being kicked in a football match. On examination a boil is found on the upper part of his right thigh and blood cultures are positive. ``` A. Staphylococcal arthritis B. Brodie's abscess C. Tuberculous arthritis D. Tuberculous osteomyelitis E. Infectious mononucleosis F. Staphylococcal osteomyelitis G. Viral hepatitis H. Rubella I. Candidiasis J. Lyme disease K. Gonococcal arthritis ```

F. Staphylococcal osteomyelitis

A 24 year-old woman presents to A&E a month after a trip to the New Forest with malaise, a migratory erythematous rash, and arthralgia. She also complains of being more forgetful in recent times. ``` A. Staphylococcal arthritis B. Brodie's abscess C. Tuberculous arthritis D. Tuberculous osteomyelitis E. Infectious mononucleosis F. Staphylococcal osteomyelitis G. Viral hepatitis H. Rubella I. Candidiasis J. Lyme disease K. Gonococcal arthritis ```

Lyme

A 19 year-old student presents to her GP with a macular rash and suboccipital lymphadenopathy. She also complains of pain on moving her hands and wrists. ``` A. Staphylococcal arthritis B. Brodie's abscess C. Tuberculous arthritis D. Tuberculous osteomyelitis E. Infectious mononucleosis F. Staphylococcal osteomyelitis G. Viral hepatitis H. Rubella I. Candidiasis J. Lyme disease K. Gonococcal arthritis ```

Rubella

A diabetic 78 year-old man with chronic arthritis presents to A&E with an acutely painful and swollen knee 2 days after he had been given an intra-articular steroid injection. ``` A. Staphylococcal arthritis B. Brodie's abscess C. Tuberculous arthritis D. Tuberculous osteomyelitis E. Infectious mononucleosis F. Staphylococcal osteomyelitis G. Viral hepatitis H. Rubella I. Candidiasis J. Lyme disease K. Gonococcal arthritis ```

A. Staphylococcal arthritis

A 30 year-old man presents to casualty with a painful, swollen and erythematous left forearm one week after sustaining a compound fracture in a motorcycle accident. ``` A. Staphylococcal arthritis B. Brodie's abscess C. Tuberculous arthritis D. Tuberculous osteomyelitis E. Infectious mononucleosis F. Staphylococcal osteomyelitis G. Viral hepatitis H. Rubella I. Candidiasis J. Lyme disease K. Gonococcal arthritis ```

F. Staphylococcal osteomyelitis

Mr PD, a 26 year old musician, arrives in A&E with a warm, painful abscess on his inner upper forearm surrounded by puncture marks, he has a low grade fever. He reports no problem in playing his guitar, but does forget lyrics on stage. ``` A. Tuberculous osteomyelitis B. Painful crisis C. Paget's disease D. Staphylococcus osteomyelitis E. Leukaemia F. Brodie's abscess G. Septic arthritis H. Clutton's joints I. Pott's disease J. Salmonella osteomyelitis K. Lateral epicondylitis L. Osteoporosis ```

D. Staphylococcus osteomyelitis

A 35 year old lady with a history of TB presents with collapsed cervical vertebrae, a marked kyphosis causing difficulty in moving. ``` A. Tuberculous osteomyelitis B. Painful crisis C. Paget's disease D. Staphylococcus osteomyelitis E. Leukaemia F. Brodie's abscess G. Septic arthritis H. Clutton's joints I. Pott's disease J. Salmonella osteomyelitis K. Lateral epicondylitis L. Osteoporosis ```

Potts Disease

Accompanying Mr PD, is a 17 year old female with a larger, redder, painful abscess on her inner upper forearm. She has almost no movement in her elbow. ``` A. Tuberculous osteomyelitis B. Painful crisis C. Paget's disease D. Staphylococcus osteomyelitis E. Leukaemia F. Brodie's abscess G. Septic arthritis H. Clutton's joints I. Pott's disease J. Salmonella osteomyelitis K. Lateral epicondylitis L. Osteoporosis ```

Septic Arthritis

Your Consultant spotlights you to expand on the diagnosis of osteomyelitis in a gentleman with a history of sickle cell crises, presenting with bone pain and excessive sweating. On X-ray he informs you there is “cortical destruction, involucrum and sequestra ``` A. Tuberculous osteomyelitis B. Painful crisis C. Paget's disease D. Staphylococcus osteomyelitis E. Leukaemia F. Brodie's abscess G. Septic arthritis H. Clutton's joints I. Pott's disease J. Salmonella osteomyelitis K. Lateral epicondylitis L. Osteoporosis ```

Salmonella osteomyelitis

A 10 year old boy presents with moderate pain in his lower leg, little redness and swelling, remitting for 6 months. His mother gives you the X-ray report from the previous episode, which showed “a well defined ovoid shape with a surrounding sclerotic margin but little involucrum in his tibia”. ``` A. Tuberculous osteomyelitis B. Painful crisis C. Paget's disease D. Staphylococcus osteomyelitis E. Leukaemia F. Brodie's abscess G. Septic arthritis H. Clutton's joints I. Pott's disease J. Salmonella osteomyelitis K. Lateral epicondylitis L. Osteoporosis ```

Brodies Abscess A Brodie abscess is a subacute osteomyelitis, which may persist for years before converting to a frank osteomyelitis. Classically, this may present after conversion as a draining abscess extending from the tibia out through the shin.

What is a Clutton's Joint?

Manifestation of syphillis at the time of puberty.

A 19 year old student presents with a short history of severe headache and photophobia. O/E he has a non-blanching rash over his abdomen. CSF is performed and shows gram- negative cocci ``` A. Campylobacter jejuni B. Clostridium difficile C. Staphylococcus aureus D. Haemophilus influenzae E. Neisseria meningitides F. Salmonella typhi G. Escherichia coli H. Streptococcus pneumoniae ```

E. Neisseria meningitides

A 30 year old builder develops abdominal pain and diarrhoea 48 hours after having Texa Fried Chicken. Faecal culture shows motile, oxidase-positive colonies and gram stain shows gram-negative rods. ``` A. Campylobacter jejuni B. Clostridium difficile C. Staphylococcus aureus D. Haemophilus influenzae E. Neisseria meningitides F. Salmonella typhi G. Escherichia coli H. Streptococcus pneumoniae ```

A. Campylobacter jejuni

A homeless man presents to St Mary’s A&E with history of cough and shortness of breath. Chest X-Ray was performed and showed consolidation. Sputum cultures were taken and showed gram positive diplocci and neutrophilia. ``` A. Campylobacter jejuni B. Clostridium difficile C. Staphylococcus aureus D. Haemophilus influenzae E. Neisseria meningitides F. Salmonella typhi G. Escherichia coli H. Streptococcus pneumoniae ```

H. Streptococcus pneumoniae

A teenager develops a post-operative wound infection after a road traffic accident. Cultures show coagulase-positive golden yellow colonies and gram positive cocci ``` A. Campylobacter jejuni B. Clostridium difficile C. Staphylococcus aureus D. Haemophilus influenzae E. Neisseria meningitides F. Salmonella typhi G. Escherichia coli H. Streptococcus pneumoniae ```

. Staphylococcus aureus

A 27 year old teacher presents with symptoms of dysuria of 3 days duration. MSU gram stain shows neutrophils, erythrocytes and gram negative bacilli ``` A. Campylobacter jejuni B. Clostridium difficile C. Staphylococcus aureus D. Haemophilus influenzae E. Neisseria meningitides F. Salmonella typhi G. Escherichia coli H. Streptococcus pneumoniae ```

G. Escherichia coli

A 37 year old woman is complaining of pain a tenderness surrounding a recently sutured wound on her forehead. On examination you notice erythema and minimal serous discharge. Which pathogen is the most likely cause of this infection? ``` A. Oral administration of ampicillin B. Escherichia coli C. Staphylococcal aureus D. Heart valve replacement E. Implantation of a prosthetic hip F. Airborne contamination G. Streptococcus pneumoniae H. Oral administration with penicillin G I. Haemophilus influenzae J. Oral administration of flucloxacillin K. I. V. injection of tetanus antitoxin L. Drainage and evacuation of pus M. Removal of a breast carcinoma ```

. Staphylococcal aureus

``` A 55 year old man comes into A&E complaining of a increasing difficulty in opening is mouth and that the muscles on his face occasionally spasm. On examination you observe that his eyes are partially closed and that the angles of his mouth are stretched outwards and slightly downwards. You also note that he has a very rigid abdomen. Which treatment option should be carried out first for this patient? A. Oral administration of ampicillin B. Escherichia coli C. Staphylococcal aureus D. Heart valve replacement E. Implantation of a prosthetic hip F. Airborne contamination G. Streptococcus pneumoniae H. Oral administration with penicillin G I. Haemophilus influenzae J. Oral administration of flucloxacillin K. I. V. injection of tetanus antitoxin L. Drainage and evacuation of pus M. Removal of a breast carcinoma ```

K. I. V. injection of tetanus antitoxin

``` Which of the above is an example where prophylactic systemic antibiotic therapy should not be used. A. Oral administration of ampicillin B. Escherichia coli C. Staphylococcal aureus D. Heart valve replacement E. Implantation of a prosthetic hip F. Airborne contamination G. Streptococcus pneumoniae H. Oral administration with penicillin G I. Haemophilus influenzae J. Oral administration of flucloxacillin K. I. V. injection of tetanus antitoxin L. Drainage and evacuation of pus M. Removal of a breast carcinoma ```

M. Removal of a breast carcinoma

``` Postoperative inspection of a wound in the left axilla reveals the presence of an abscess. What is the appropriate treatment to resolve the abcess A. Oral administration of ampicillin B. Escherichia coli C. Staphylococcal aureus D. Heart valve replacement E. Implantation of a prosthetic hip F. Airborne contamination G. Streptococcus pneumoniae H. Oral administration with penicillin G I. Haemophilus influenzae J. Oral administration of flucloxacillin K. I. V. injection of tetanus antitoxin L. Drainage and evacuation of pus M. Removal of a breast carcinoma ```

Drainage and evacuation of pus

``` A man is recovering from surgery and inspection of the wound reveals that it has become infected. A swab is taken and the laboratory results show Staphylococcal aureus infection. What is appropriate treatment for this man? A. Oral administration of ampicillin B. Escherichia coli C. Staphylococcal aureus D. Heart valve replacement E. Implantation of a prosthetic hip F. Airborne contamination G. Streptococcus pneumoniae H. Oral administration with penicillin G I. Haemophilus influenzae J. Oral administration of flucloxacillin K. I. V. injection of tetanus antitoxin L. Drainage and evacuation of pus M. Removal of a breast carcinoma ```

Oral administration of flucloxacillin

A 15 year old girl consults her GP after experiencing a high temperature and several headaches over the last three weeks. She has no medical history of note and has recently begun a weekend job helping at a local farm. ``` A. Sarcoidosis B. Mycobacterium tuberculosis C. Hepatitis B D. Drug induced fever E. Hepatitis A F. Mycobacterium avium complex G. Brucellosis H. Plasmodium malariae I. Escherichia coli J. Hepatitis C K. Epstein-Barr virus L. SLE M. Hodgkin’s lymphoma ```

Brucellosis Brucellosis is an infection you can catch from unpasteurised milk and cheese

A 55 year old female school teacher presents at A&E with a high fever three days after her return from India. On admission, her temperature chart shows an intermittent pyrexia every 72 hours (quartan fever) ``` A. Sarcoidosis B. Mycobacterium tuberculosis C. Hepatitis B D. Drug induced fever E. Hepatitis A F. Mycobacterium avium complex G. Brucellosis H. Plasmodium malariae I. Escherichia coli J. Hepatitis C K. Epstein-Barr virus L. SLE M. Hodgkin’s lymphoma ```

H. Plasmodium malariae

An 80 year old man returns to his GP two weeks after being prescribed co-trimoxazole for a UTI. His urinary symptoms have now eased, but he is still experiencing a fever. His blood count shows eosinophilia. ``` A. Sarcoidosis B. Mycobacterium tuberculosis C. Hepatitis B D. Drug induced fever E. Hepatitis A F. Mycobacterium avium complex G. Brucellosis H. Plasmodium malariae I. Escherichia coli J. Hepatitis C K. Epstein-Barr virus L. SLE M. Hodgkin’s lymphoma ```

. Drug induced fever

A 40 year old female intravenous drug user presents at A&E with a mild ongoing fever, nausea and vomiting. Her partner mentions that she is a bit yellow. ``` A. Sarcoidosis B. Mycobacterium tuberculosis C. Hepatitis B D. Drug induced fever E. Hepatitis A F. Mycobacterium avium complex G. Brucellosis H. Plasmodium malariae I. Escherichia coli J. Hepatitis C K. Epstein-Barr virus L. SLE M. Hodgkin’s lymphoma ```

Hep B

A female infant presents to A&E with symptoms of hypoxia. It is noted that she has dactylitis. ``` A. Haemophilia A B. Autoimmune Haemolytic Anaemia C. Acute Lymphoblastic Leukaemia D. Sickle Cell Disease E. Haemolytic Uraemic Syndrome F. Parvovirus B19 Infection G. Iron Deficiency Anaemia H. Vitamin K Deficiency I. Autoimmune Thrombocytopenic Purpura J. Normal Neonate ```

Sickle Cell

A 4 year old male presents to A&E with pallor, bruising and bone pain. O/E: hepatosplenomegaly is noted. Blood analysis reveals a reduced Hb and a raised WCC. Blast cells are noted on the blood film ``` A. Haemophilia A B. Autoimmune Haemolytic Anaemia C. Acute Lymphoblastic Leukaemia D. Sickle Cell Disease E. Haemolytic Uraemic Syndrome F. Parvovirus B19 Infection G. Iron Deficiency Anaemia H. Vitamin K Deficiency I. Autoimmune Thrombocytopenic Purpura J. Normal Neonate ```

ALL

A child is known to have a blood disorder and seems to have suffered from a stroke. What is the blood disorder that this child is most likely to have? ``` A. Haemophilia A B. Autoimmune Haemolytic Anaemia C. Acute Lymphoblastic Leukaemia D. Sickle Cell Disease E. Haemolytic Uraemic Syndrome F. Parvovirus B19 Infection G. Iron Deficiency Anaemia H. Vitamin K Deficiency I. Autoimmune Thrombocytopenic Purpura J. Normal Neonate ```

Sickle Cell

A routine blood sample is taken from an asymptomatic neonate. Results reveal a raised Hb, a raised WCC and a raised MCV. Both Hb A and F are present. ``` A. Haemophilia A B. Autoimmune Haemolytic Anaemia C. Acute Lymphoblastic Leukaemia D. Sickle Cell Disease E. Haemolytic Uraemic Syndrome F. Parvovirus B19 Infection G. Iron Deficiency Anaemia H. Vitamin K Deficiency I. Autoimmune Thrombocytopenic Purpura J. Normal Neonate ```

Normal Neonate

A male infant is admitted to hospital for a routine circumcision. During the operation haemostasis seems to be impaired. His mother failed to mention in the family history that her father had some sort of blood disorder. ``` A. Haemophilia A B. Autoimmune Haemolytic Anaemia C. Acute Lymphoblastic Leukaemia D. Sickle Cell Disease E. Haemolytic Uraemic Syndrome F. Parvovirus B19 Infection G. Iron Deficiency Anaemia H. Vitamin K Deficiency I. Autoimmune Thrombocytopenic Purpura J. Normal Neonate ```

Haemophilia A

A 3 month old boy, of Greek origin is brought to A&E by his mother straight from his christening. On examination, he is crying and appears jaundiced. Mild splenomegaly is felt in his abdomen. His mother says he has a fever and she notes that his urine was very dark when she changed his nappy. Investigation of his blood film reveals polychromatic macrocytes and irregularly shaped red blood cells. You also note his “special christening clothes” that his mother proudly tells you have been in the family for generations, they smell strongly of moth balls. Assay for G6PD reveals a normal level. ``` A. Sickle Cell Anaemia B. Von Willebrand’s Disease C. Hereditary Spherocytosis D. Haemolytic Disease of the Newborn E. Thalassaemia Major F. Hereditary Eliptocytosis G. G6PD deficiency H. Transient Abnormal Myelopoiesis I. Haemophillia B J. Haemolytic Uraemic Syndrome K. Thalassaemia Minor L. Haemophilia A M. Sickle Cell Trait ```

G6PD Why can G6PD levels be normal in G6PD deficiency? In an acute haemolytic crisis we would mount a reticulocyte response (young red cells) which have a high level of G6PD, therefore this may elevate the measured G6PD level. Therefore you would have to measure the G6PD level after the acute haemolytic episode has resolved, to see if the patient is truly G6PD deficient. ps polychromatic macrocytes = reticulocytes (polychromasia due to ribosomal RNA)

A 6 month old girl is brought to her GP by her Greek Cypriot parents. They complain that she looks small compared to their neighbour’s baby of the same age. They also think her face looks funny. On examination, you note pallor and jaundice, the baby’s skull appears bossed and there is maxillary prominence. There is also marked hepatosplenomegaly. Her blood film shows a microcytosis and haemoglobin analysis shows high levels of HbF and HbA2. ``` A. Sickle Cell Anaemia B. Von Willebrand’s Disease C. Hereditary Spherocytosis D. Haemolytic Disease of the Newborn E. Thalassaemia Major F. Hereditary Eliptocytosis G. G6PD deficiency H. Transient Abnormal Myelopoiesis I. Haemophillia B J. Haemolytic Uraemic Syndrome K. Thalassaemia Minor L. Haemophilia A M. Sickle Cell Trait ```

THal Major

A young boy is referred to you because of prolonged bleeding following circumcision. You also note some bleeding of the gums. Coagulation tests reveal a normal PT but a raised APTT and an increased Bleeding Time. Analysis of clotting factors reveals a low Factor VIII. ``` A. Sickle Cell Anaemia B. Von Willebrand’s Disease C. Hereditary Spherocytosis D. Haemolytic Disease of the Newborn E. Thalassaemia Major F. Hereditary Eliptocytosis G. G6PD deficiency H. Transient Abnormal Myelopoiesis I. Haemophillia B J. Haemolytic Uraemic Syndrome K. Thalassaemia Minor L. Haemophilia A M. Sickle Cell Trait ```

Von Willebrands Disease Von Willebrand's Disease is autosomal dominant. - Remember that Haemophilia causes prolonged APTT, normal PT and normal bleeding time, with normal VWF level whereas von willebrand's disease (VWD) causes prolonged APTT AND prolonged bleeding time (very impt to remember!), with low VWF level (but normal level in VWD type 2, which is functionally abnormal) - Both Haemophilia and VWD have normal platelet count. - Remember that FVIII levels may also be low in von willebrand's disease, as von willebrand's factor (VWF) is the carrier molecule for FVIII, preventing its premature degredation in the circulation, so if VWF is low, FVIII is vulnerable to degredation and is therefore also low.

A baby is noted to be jaundiced a few days after birth, with marked anaemia. Examination reveals an enlarged spleen. The blood film shows numerous spherocytes. On questioning the parents, the father says his mother told him he was a “bit yellow” as a child. ``` A. Sickle Cell Anaemia B. Von Willebrand’s Disease C. Hereditary Spherocytosis D. Haemolytic Disease of the Newborn E. Thalassaemia Major F. Hereditary Eliptocytosis G. G6PD deficiency H. Transient Abnormal Myelopoiesis I. Haemophillia B J. Haemolytic Uraemic Syndrome K. Thalassaemia Minor L. Haemophilia A M. Sickle Cell Trait ```

Hereditary Spherocytosis

A baby with Down’s syndrome is noted, on routine blood testing, to have large numbers of circulating megakaryocyte blast cells and nucleated red blood cells. A repeat blood film 2 months later is normal. ``` A. Sickle Cell Anaemia B. Von Willebrand’s Disease C. Hereditary Spherocytosis D. Haemolytic Disease of the Newborn E. Thalassaemia Major F. Hereditary Eliptocytosis G. G6PD deficiency H. Transient Abnormal Myelopoiesis I. Haemophillia B J. Haemolytic Uraemic Syndrome K. Thalassaemia Minor L. Haemophilia A M. Sickle Cell Trait ```

Transient Abnormal Myelopoiesis

A 6 year old boy from Greece presents to paediatric outpatients with severe anaemia. On examination he is anaemic and has enlarged maxilla and prominent frontal and parietal bones and hepatosplenomegaly. A skull X-ray reveals expansion of the medullary cavity giving rise to a ‘hair on end’ appearance. What is the likely diagnosis?

Beta Thal

A 2 year old girl presents to his GP following a viral illness with purpuric rash, ecchymoses and epistaxis. Normal haemoglobin and white cell count and platelets 19x109/L. Bone marrow show increased numbers of megakaryocytes. What is the likely diagnosis?

AI Thrombocytopenia

A 35 year old woman was brought to A&E with a severe headache. She was lucid and mentioned that she suffered from frequent headaches but that this one felt like a hammer-blow. She was photophobic and nauseous with slight neck stiffness. Her pulse rate was 75bpm, and BP was 130/80. ``` A. Opiate overdose B. Vascular dementia C. Alzheimer’s disease D. Subdural haemorrhage E. Transient hypotension F. Meningitis G. Brain stem infarction H. Subarachnoid haemorrhage I. Cerebral embolus J. Raised intracranial pressure K. Extradural haemorrhage L. Temporal arteritis M. Panic attack N. Pontine haemorrhage O. Transient Ischaemic attack P. Cerebellar stroke ```

Subarachnoid Haemorrhage

A 70 year old woman goes to her GP accompanied by her daughter who looks after her. She has started undressing and wandering the streets in the night and she is aggressive and argumentative. She had a stroke 3 years ago and recovered well with only some transient ischaemic attacks recorded since. A CT scan has since shown areas of scattering of low density in the white matter. ``` A. Opiate overdose B. Vascular dementia C. Alzheimer’s disease D. Subdural haemorrhage E. Transient hypotension F. Meningitis G. Brain stem infarction H. Subarachnoid haemorrhage I. Cerebral embolus J. Raised intracranial pressure K. Extradural haemorrhage L. Temporal arteritis M. Panic attack N. Pontine haemorrhage O. Transient Ischaemic attack P. Cerebellar stroke ```

Vascular Dementia

An 86 year old man is admitted to A&E having collapsed at his home. He is unconscious and a couple of days later he is still deeply unconscious. His pupils are pin-point and their reaction to light is difficult to see clearly. ``` A. Opiate overdose B. Vascular dementia C. Alzheimer’s disease D. Subdural haemorrhage E. Transient hypotension F. Meningitis G. Brain stem infarction H. Subarachnoid haemorrhage I. Cerebral embolus J. Raised intracranial pressure K. Extradural haemorrhage L. Temporal arteritis M. Panic attack N. Pontine haemorrhage O. Transient Ischaemic attack P. Cerebellar stroke ```

Brain Stem Infarction

A 20 year old man was taken to A&E after a pub brawl where he was stamped on whilst trying to break up a fight. He remained lucid for approximately 3 hours after the incident and then slipped in and out of consciousness with hemiparesis afterwards. He had a deep laceration on the side of his head. A CT scan showed high attenuation adjacent to the skull and a midline shift. ``` A. Opiate overdose B. Vascular dementia C. Alzheimer’s disease D. Subdural haemorrhage E. Transient hypotension F. Meningitis G. Brain stem infarction H. Subarachnoid haemorrhage I. Cerebral embolus J. Raised intracranial pressure K. Extradural haemorrhage L. Temporal arteritis M. Panic attack N. Pontine haemorrhage O. Transient Ischaemic attack P. Cerebellar stroke ```

Extradural Haemorrhage

A 42 year old lady went to her GP in a frightened, agitated and still dazed state as the previous day she had what she described as a ‘strange migraine’ but without the headache when, she said, she suddenly could not see the TV. She said she thought it affected just the one eye and that she felt disorientated and unable to speak what she wanted to say. This lasted approximately 2-3 hours and then slowly started to clear. She was tachycardic with hot, sweaty palms. ``` A. Opiate overdose B. Vascular dementia C. Alzheimer’s disease D. Subdural haemorrhage E. Transient hypotension F. Meningitis G. Brain stem infarction H. Subarachnoid haemorrhage I. Cerebral embolus J. Raised intracranial pressure K. Extradural haemorrhage L. Temporal arteritis M. Panic attack N. Pontine haemorrhage O. Transient Ischaemic attack P. Cerebellar stroke ```

TIA

Occlusion of this cerebral vessel can cause weakness and numbness in the contralateral lower limb and similar but milder symptoms in the contralateral upper limb. ``` A. Extradural haemorrhage B. Posterior cerebral artery C. Lacunar infarcts D. Middle cerebral artery E. Subarachnoid haemorrhage F. Anterior cerebral artery G. Transient ischaemic attack (TIA) H. Bacterial meningitis I. Stroke J. Amyloidosis K. Berry's aneurysm L. Vertebrobasilar circulation M. Viral meningitis N. Hydrocephalus ```

F. anterior cerebral artery

A 35-year old patient presented to A&E complaining of severe headache and vomiting. On examination, there is neck stiffness; fundoscopy reveals preretinal (subhyaloid) haemorrhages; CSF is spun down and shows xanthochromia. You notice the patient has palpable kidneys bilaterally. ``` A. Extradural haemorrhage B. Posterior cerebral artery C. Lacunar infarcts D. Middle cerebral artery E. Subarachnoid haemorrhage F. Anterior cerebral artery G. Transient ischaemic attack (TIA) H. Bacterial meningitis I. Stroke J. Amyloidosis K. Berry's aneurysm L. Vertebrobasilar circulation M. Viral meningitis N. Hydrocephalus ```

E. Subarachnoid haemorrhage

This group of ischaemic brain lesions typically affect the basal ganglia, internal capsule, thalamus and pons and are smaller than 1cm. ``` A. Extradural haemorrhage B. Posterior cerebral artery C. Lacunar infarcts D. Middle cerebral artery E. Subarachnoid haemorrhage F. Anterior cerebral artery G. Transient ischaemic attack (TIA) H. Bacterial meningitis I. Stroke J. Amyloidosis K. Berry's aneurysm L. Vertebrobasilar circulation M. Viral meningitis N. Hydrocephalus ```

Lacunar Infarcts

This structural abnormality of cerebral vessels usually affects the branching points of the circle or Willis and is a risk of regional infarcts in young patients. ``` A. Extradural haemorrhage B. Posterior cerebral artery C. Lacunar infarcts D. Middle cerebral artery E. Subarachnoid haemorrhage F. Anterior cerebral artery G. Transient ischaemic attack (TIA) H. Bacterial meningitis I. Stroke J. Amyloidosis K. Berry's aneurysm L. Vertebrobasilar circulation M. Viral meningitis N. Hydrocephalus ```

Berry's Aneurysm

Transtentorial herniations can potentially compromise the sufficiency this particular part of the cerebral circulation and cause occipital lobe infarction. ``` A. Extradural haemorrhage B. Posterior cerebral artery C. Lacunar infarcts D. Middle cerebral artery E. Subarachnoid haemorrhage F. Anterior cerebral artery G. Transient ischaemic attack (TIA) H. Bacterial meningitis I. Stroke J. Amyloidosis K. Berry's aneurysm L. Vertebrobasilar circulation M. Viral meningitis N. Hydrocephalus ```

Posterior Cerebral Artery

A back-office secretary in investment banking complains to her GP of intermittent attacks of tightness and pressure at the front of her head which sometimes radiates to the back and her neck. There is no associated vomiting or visual disturbance. She admits to feeling over-worked even though she got 6 months paid maternity leave. ``` A. Subdural haemorrhage B. Tension headache C. Benign intracranial hypertension D. Berry aneurysm E. Subarachnoid haemorrhage F. Sinusitis G. Glaucoma H. Migraine I. Trigeminal neuralgia ```

Tension Headache

A public school teacher is sitting at work eating a plougman’s when she starts to feel unwell and is unable to see properly, which lasts for 10 mins. Then one side of her head starts to throb and she begins to feel nauseous. Both bright lights and loud noises make her feel worse. 4 hours later it stops and she goes to sleep. ``` A. Subdural haemorrhage B. Tension headache C. Benign intracranial hypertension D. Berry aneurysm E. Subarachnoid haemorrhage F. Sinusitis G. Glaucoma H. Migraine I. Trigeminal neuralgia ```

Migraine

25 year old obese woman goes to GP about worsening headaches. They are especially bad in the mornings and she also feels nauseous with some visual disturbances. ``` A. Subdural haemorrhage B. Tension headache C. Benign intracranial hypertension D. Berry aneurysm E. Subarachnoid haemorrhage F. Sinusitis G. Glaucoma H. Migraine I. Trigeminal neuralgia ```

Benign Intracranial HT

This condition is considered a medical emergency, but can lie undetected for years. Treatment is by micro-vascular clipping or occlusion. ``` A. Subdural haemorrhage B. Tension headache C. Benign intracranial hypertension D. Berry aneurysm E. Subarachnoid haemorrhage F. Sinusitis G. Glaucoma H. Migraine I. Trigeminal neuralgia ```

Berry ANeurysm

An elderly diabetic lady with an acute headache and associated blurred vision and vomiting. Pain is localised to the upper anterior region of her head. ``` A. Subdural haemorrhage B. Tension headache C. Benign intracranial hypertension D. Berry aneurysm E. Subarachnoid haemorrhage F. Sinusitis G. Glaucoma H. Migraine I. Trigeminal neuralgia ```

Glaucoma

Gonorrhoea is?

Gram negative diplococci were found in smears of the discharge and culture of the causative agent confirmed the presumed diagnosis.

31 year old man presents to a GUM clinic complaining of pain on passing urine and a penile discharge. His history reveals that he had travelled to Bangkok 10 days earlier “on a business trip”. On examination he had a purulent urethral discharge and a swollen tender prostate. Gram negative diplococci were found in smears of the discharge and culture of the causative agent confirmed the presumed diagnosis.

Gonorrhoea

Disseminated infection can be found in people with deficiencies in late complement components

Gonorrhoea

Gram-negative diplococci

Neisseria gonorrhoeae

Chlamydia

is a genus of pathogenic bacteria that are obligate intracellular parasites.

A prematurely born 1 week old infant presented with microcephaly, chorioretinitis and vesicular skin lesions. He also had non-specific features of fever, irritability and failure to feed. ``` A. Group B streptococci B. E. coli C. Bacterial meningitis D. Congenital rubella syndrome E. Neonatal HSV infection F. Chlamydial ophthalmia G. Hepatitis B H. Listeria I. Bordetella pertussis J. Congenital toxoplasmosis K. Chickenpoc (VZV) L. Viral meningitis ```

E. Neonatal HSV infection

A 2 week old female had an enlarged liver and spleen and her skin was tinged yellow. She was not eating much nor was she vomiting. She also suffered from regular seizures. Investigation revealed intra-cranial calcification. ``` A. Group B streptococci B. E. coli C. Bacterial meningitis D. Congenital rubella syndrome E. Neonatal HSV infection F. Chlamydial ophthalmia G. Hepatitis B H. Listeria I. Bordetella pertussis J. Congenital toxoplasmosis K. Chickenpoc (VZV) L. Viral meningitis ```

J. Congenital toxoplasmosis

A French mother brings her 2 month old daughter with fever to hospital. The infant is shown to have elevated hepatic enzymes and is treated with pyrimethamine, sulphadiazine and folic acid for a year after appropriate investigations are performed. ``` A. Neonatal Respiratory Tract Infection B. Conjunctivitis caused by a blocked tear duct C. Congenital Rubella Syndrome D. Neonatal HIV infection E. Chlamydial conjunctivitis in the newborn F. E.Coli infection G. Neonatal Meningitis H. Neonatal Herpes Simplex Infection I. Congenital Toxoplasmosis J. Group B Streptococci Syndrome K. EBV-related infectious mononucleosis ```

I. Congenital Toxoplasmosis