QM/BM Flashcards

Question

What impact do macrolides have on the cytochrome P450 system?

Answer 1

Macrolides are potent inhibitors of the cytochrome P450 system and statins should be held while taking the antibiotic.

Answer 2

Statin-induced myopathy. Fatigue and widespread muscle cramps. On examination, she has tenderness of her muscles but no evidence of injury. Blood tests reveal a mildly raised creatinine kinase (CK) (double the upper limit of normal) with normal renal function.

Answer 3

Widen epiphyseal plates and bowed femurs

Answer 4

Onion-skin sign

Answer 5

Sudden onset is a better indicator of good prognosis

Answer 6

Hypomagnesamia, hypokalaemia and hypophosphataemia The metabolism slows during periods of starvation. As the patient begins to receive nutrition again, cells rapidly use up magnesium, potassium and phosphate, to metabolise glucose, proteins and fats.

Answer 7

Valaciclovir

Answer 8

Cardiotoxicity

Answer 9

HER-2-receptor-positive breast cancer

Answer 10

This child's history is consistent with a diagnosis of pertussis (whooping cough). A thorough history may reveal a lack of vaccination and exposure through close contacts. As this child has had a cough for more than 21 days, treatment with a macrolide antibiotic is no longer recommended. She should be managed at home with safety netting advice.

Answer 11

Haematuria, flank pain and mass

Answer 12

This baby is preterm and has presented with signs of necrotising enterocolitis (NEC)(bilious vomiting, bloody stools, absent bowel sounds, systemic compromise with metabolic acidosis). NEC is a common gastrointestinal condition in preterm neonates.

Answer 13

Supine abdo XR which shows dilated asymmetrical bowel loops, bowel wall oedema with 'thumbprinting' and pneumatosis intestinalis (gas within the bowel wall)

Answer 14

It commonly presents with a triad of purpura/petechiae on the buttocks and lower limbs, abdominal pain and arthralgia. Other features include haematuria, proteinuria, pyrexia and hypertension. The majority of HSP cases are self-limiting and resolve completely. Therefore, simple analgesia such as NSAIDs and/or paracetamol can be used. In severe cases, steroids may be indicated.

Answer 15

Risk factors include the 5 F's - female, fat (high BMI), forty, fertile, family history

Answer 16

The complications of amiodarone include an inflammatory pneumonitis followed by a chronic pulmonary fibrosis, which occurs in 5% of patients on amiodarone. Other drugs that can cause pulmonary fibrosis include nitrofurantoin, methotrexate, bleomycin, busulfan and sulfasalazine

Answer 17

Raised, red, painful shin rash. Sarcoidosis

Answer 18

We would expect to see an initial respiratory alkalosis as the high salicylate levels activate the brain's respiratory centres. Later on, metabolic acidosis would develop due to the ingested salicylic acid load.

Answer 19

It usually occurs in immunocompromised patients e.g. with HIV and transplants.

Answer 20

Pneumocystis pneumonia (PCP) is an infection caused by the pneumocystis jiroveci fungus. Patients usually present with fever, non-productive cough and breathlessness on exertion.

Answer 21

Bronchoscopy with bronchoalveolar lavage is the definitive diagnostic investigation, as it allows a sample to be taken, which can then be tested histologically. In practice, sputum samples for polymerase chain reaction (PCR) assays are often taken, which are less invasive and are also diagnostic of the condition.

Answer 22

Co-trimoxazole

Answer 23

P pulmonale (tall, peaked P waves)

Answer 24

Aspergillomas are formed when the aspergillus fungus clumps together in the lung cavity. It usually occurs secondary to an underlying condition - TB in this case. Although there are usually no symptoms, aspergilloma is important differential to consider in patients that present with haemoptysis.

Answer 25

This would indicate an obstructive pattern

Answer 26

In malignant melanoma, the tumour depth is called Breslow thickness and is the most important prognostic factor. The tumour depth has important implications for staging the cancer.

Answer 27

Coeliac's. Dermatitis herpetiformis

Answer 28

The most common type of melanoma is superficial spreading – accounting for up to 70% of cases.

Answer 29

This is an inflammatory skin condition where widespread erythema affects >90% of the skin surface. The history of atopic dermatitis, the fact that the rash has spread to the majority of her body and the image given in the question make a diagnosis of erythroderma likely. Erythroderma should be managed supportively with fluids, emollients and by treating the underlying disease - so in this case, steroids are warranted.

Answer 30

This patient has a diagnosis of Stevens–Johnson syndrome. She has presented with a prodromal flu-like illness, a rash that peels when pressure is applied (Nikolsky's sign) and mucosal ulceration.

Answer 31

The first-line treatment for acne vulgaris is a topical retinoid with or without benzoyl peroxide or a topical antibiotic. Should this treatment be ineffective, then oral lymecycline should be considered.

Answer 32

Scabies is a skin infection caused by the mite Sarcoptes scabiei. It is highly contagious and causes an intensely pruritic rash commonly seen in the inter-web spaces, flexures of the wrist, axillae, abdomen and groin. The first-line treatment of scabies is with topical 5% permethrin. Permethrin should be applied to cool dry skin (ie. not after a hot bath) and should be applied to the whole body (including the face and scalp). It should be left on for 12 h, with the treatment course lasting 7 days.

Answer 33

An elevated gamma-glutamyltransferase can indicate hepatic or biliary tract disease and can aid alongside alkaline phosphatase (ALP) for this purpose as, unlike ALP, it is not elevated in bone disease.

Answer 34

Alpha-fetoprotein (AFP) is a marker of either hepatocellular cancer or testicular/germ-cell cancer. Given the high risk of hepatocellular carcinoma in patients with Hepatitis B cirrhosis, NICE recommend 6-monthly hepatic ultrasound and alpha-fetoprotein levels in these patients if they have significant fibrosis (as determined by METAVIR or Ishak staging)

Answer 35

Trousseau syndrome, also known as migratory thrombophlebitis, is strongly associated with pancreatic cancer.

Answer 36

Metoclopramide enhances gastric emptying and also has a central action for antiemesis.

Answer 37

In liver cirrhosis, an increased oestrogen level induces vascularisation and leads to palmar erythema, a red colouration, particularly in hypothenar and thenar eminences. Other features of increased oestrogen include the development of gynaecomastia and spider naevi.

Answer 38

This is a typical history for a Mallory–Weiss tear, which is a small tear in the mucosa of the lower oesophagus and is usually caused by violent vomiting. The history is typically that of a prolonged period of severe vomiting, followed by an episode of haematemesis. Definitive diagnosis is with oesophagogastroduodenoscopy (OGD).

Answer 39

Salmonella enteritidis is the second most common cause of food poisoning in the UK. The common source of infection includes raw or undercooked eggs.

Answer 40

Bacillus cereus

Answer 41

Campylobacter jejuni is the most common cause of food poisoning in the UK. The most common source of infection is undercooked chicken.

Answer 42

Clinical manifestations of norovirus infection include projectile vomiting and non-bloody diarrhoea. The common sources of norovirus include shellfish, leafy greens, and fresh fruits.

Answer 43

Giardia infection is caused by Giardia lamblia which is transmitted through the faecal-oral route. It is characterised by explosive, non-bloody diarrhoea with an incubation period of one to three weeks.

Answer 44

This is caused by a gastrin secreting neuroendocrine tumour. Excessive gastrin results in acid hypersecretion and recurrent peptic ulcer disease unresponsive to medical therapy. Surgical resection should be considered in localised disease

Answer 45

Lansoprazole, Amoxicillin + Metronidazole for 7 days

Answer 46

Porphyria is a spectrum of disorders caused by defects in haem synthesis due to alterations in enzyme function or structure.

Answer 47

Acute porphyria can manifest with gastrointestinal symptoms, e.g. abdominal pain, vomiting or neuropsychiatric features (peripheral neuropathy, psychosis, and seizure). Due to the overactivity of the sympathetic system, acute porphyria can also result in hypertension and bradycardia.

Answer 48

Urine porphobilinogens are raised during an acute attack. Possible triggers of acute porphyria include antibiotics such as trimethoprim and nitrofurantoin and anaesthetic agents.

Answer 49

Fasting serum gastrin level is used as a screening test for Zollinger-Ellison syndrome. A raised fasting serum gastrin level suggests a diagnosis of Zollinger-Ellison syndrome.

Answer 50

Courvoisier's sign refers to painless jaundice with a palpable gallbladder which is unlikely due to gallstones. It suggests an obstructing pancreatic or biliary neoplasm until proven otherwise.

Answer 51

Cholestyramine is a bile-acid sequestrant, which binds bile salts in the gastrointestinal tract and prevents their reabsorption. This helps improve the itching in patients with PBC. Patients prescribed Cholestyramine should take it 2-4 hours before any other medications, as it can interfere with intestinal absorption. According to the British Society of Gastroenterology guidelines, it is recommended as first-line therapy to manage pruritis in patients with PBC

Answer 52

Type 1 - The commonest type. These patients have raised levels of anti-smooth muscle antibodies (80%), and antinuclear antibodies may also be positive (10%).

Answer 53

Deranged LFTs - cholestatic picture Positive anti-smooth muscle and antinuclear antibodies and myeloperoxidase antineutrophil cytoplasmic antibody (ANCA) Multiple beaded biliary strictures are seen on magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). Associated with UC and increased cholangiocarcinoma risk

Answer 54

Carbohydrate antigen 19-9 is a useful initial screening measure of pancreatic cancer.

Answer 55

Creon is a pancreatic enzyme supplement indicated for pancreatic insufficiency in cystic fibrosis.

Answer 56

The most likely diagnosis is primary biliary cholangitis, which typically affects younger females. Positive anti-mitochondrial antibodies are found in more than 90% of individuals. It is also associated with a rise in serum IgM level.

Answer 57

The condition described here is achalasia. This is characterised by a loss of oesophageal peristalsis and a failure of relaxation of the lower oesophageal sphincter in response to swallowing. Oesophageal manometry measures both of these things and is the gold standard test for the diagnosis of achalasia.

Answer 58

Spironolactone - a potassium-sparing diuretic

Answer 59

Typhoid can have an incubation period of anything from a few days to a few weeks, with transmission occurring faeco-orally, and particularly in countries with poor sanitation. Diarrhoea or constipation is common at the outset of the illness, but then often settles; later symptoms include fever, malaise, headache, cough, anorexia, sore throat, and the characteristic maculopapular rose spots, which blanch on pressure,

Answer 60

Salmonella typhi

Answer 61

Whipple's disease

Answer 62

These results are in keeping with someone who has immunity secondary to a vaccine. The hepatitis B vaccine allows the immune system to mount a response against the hepatitis B surface antigen not the hepatitis B core antigen. Hepatitis B surface antigen will be negative, as there is no active infection

Answer 63

These results are in keeping with someone who has immunity secondary to previous infection. HbSAg negative means the infection has been cleared, and the immune system has mounted a response towards both surface and core antigens. The immune system will create antibodies towards the core antigen first (Anti-HbC), however, you are only immune once antibodies have been made against surface antigen (Anti-HbS)

Answer 64

Primary sclerosing cholangitis - associated with UC

Answer 65

Surface inflammation with loss of goblet cells and crypt abscess

Answer 66

Transmural inflammation with non-caseating granulomas

Answer 67

It is characterised by raised IgG, ALT, and positive anti-smooth muscle antibodies.

Answer 68

Stool ova, cysts and parasites

Answer 69

Crohn's disease is an inflammatory bowel disease (IBD) affecting the gastrointestinal tract from mouth to anus. The most commonly affected sites include the terminal ileum and part of the colon. Terminal ileitis affects the absorption of bile salts, increasing the risk of gallstone formation.

Answer 70

In sickle cell disease, a genetic abnormality coding for the beta subunit is responsible for causing the sickle shape of the red blood cells. Fetal haemoglobin does not lead to sickling of red blood cells because there is no beta subunit in the structure.

Answer 71

Hydroxycarbamide can be used to increase the production of fetal haemoglobin (HbF) in patients with sickle cell anaemia. This has a protective effect against sickle cell crises and acute chest syndrome.

Answer 72

Oral lorazepam

Answer 73

This is caused by prolonged conduction of electrical activity through the AV node. It can be identified on ECG by finding a PR interval >200ms.

Answer 74

Atropine is an anticholinergic; it blocks the effects of the parasympathetic nervous system on the heart. This causes an increase in the heart rate and improves atrioventricular conduction. 500 µg intravenous (IV) or intraosseous (IO) can be given and repeated every 3–5 min to a total of 3 mg. It forms part of the resuscitation council algorithm for acute bradycardia.

Answer 75

The ORBIT Bleeding Risk Score for Atrial Fibrillation predicts bleeding risk in patients on anticoagulation for afib, similar to HAS-BLED.

Answer 76

A Type B aortic dissection is a dissection in the descending portion of the aorta, rather than the ascending. This typically causes radial-femoral delay rather than radial-radial delay.

Answer 77

Azithromycin (a macrolide antibiotic) can cause a prolonged QT interval which can lead to Torsades de Pointes, a polymorphic VT. Other medications which can cause a prolonged QT interval include certain antidepressants and antipsychotics, and antiemetics such as ondansetron.

Answer 78

ECG changes that may be seen in myocarditis include sinus tachycardia, ST changes and T wave inversion.

Answer 79

Hypercalcaemia can cause a shortened QT interval and can occur in patients with end-stage renal failure and tertiary hyperparathyroidism.

Answer 80

Digoxin toxicity can also cause a shortened QT interval. However, the classic ECG finding in digoxin toxicity is the reverse tick sign - down-sloping ST depression and inverted T waves. Patients would also likely experience nausea, vomiting and abdominal pain.

Answer 81

Commonly presents with polyarthritis, arthralgia and erythema marginatum.

Answer 82

The patient gives a history of AF, dyspnoea and weight loss, which makes a cardiac tumour more likely. Atrial myxomas are most commonly found in the left atrium.

Answer 83

Mobitz type 1 block (Wenckebach block), is a type of heart block in which the PR interval gradually lengthens before a QRS complex is dropped, resulting in a pattern of progressively longer intervals followed by a skipped beat. It is characterised by a consistent number of skipped beats, as described in the scenario (every 3 or 4 QRS complexes). It is caused by a conduction problem at the atrioventricular (AV) node, which slows the electrical conduction between the atria and ventricles. Mobitz type 1 block is usually benign, but it can progress to more severe forms of heart block if left untreated. Mobitz type 2 block is a type of heart block in which the PR interval remains constant, but QRS complexes are dropped. It is caused by a conduction problem at the level of the His-Purkinje system, which is responsible for conducting the electrical impulse from the AV node to the ventricles. Mobitz type 2 block risks progression to complete heart block and may require pacemaker implantation.

Answer 84

Coxsackievirus B

Answer 85

Hypoglycaemia

Answer 86

De Quervain's thyroiditis is a rare cause of hyperthyroidism, consistent with the patient's symptoms of weight loss, anxiety and sweating. De Quervain's thyroiditis classically presents with a painful smooth goitre.

Answer 87

This is a good screening test for any evidence of Cushing’s syndrome (glucocorticoid excess). However, if this were causing such refractory hypertension, there would be other features of Cushing’s syndrome found on examination, such as central obesity, abdominal striae and skin/muscle atrophy.

Answer 88

In primary hyperaldosteronism, the aldosterone is elevated, which causes sodium, and thus water, retention. This increases renal perfusion pressures and therefore inhibits the secretion of renin, causing renin concentration to drop. Therefore, in Conn's syndrome, the aldosterone to renin ratio will be abnormally high. In secondary hyperaldosteronism, the aldosterone level is elevated due to an elevated renin and activation of the renin-angiotensin-aldosterone pathway. This would result in a normal aldosterone to renin ratio. A high aldosterone to renin ratio should increase suspicion of Conn's syndrome and be followed up with further investigations, such as a saline or fludrocortisone suppression test.

Answer 89

Spironolactone decreases testosterone production and induces peripheral conversion of testosterone to oestradiol, leading to gynaecomastia. Stopping spironolactone normally resolves the adverse effects.

Answer 90

In patients with a thyroid storm, the priorities of management alongside supportive care are threefold: stop thyroid hormone synthesis, block release of further thyroid hormone, inhibit peripheral conversion of T4 to T3. The first priority is to stop thyroid hormone synthesis and both PTU and carbimazole will achieve this. PTU is more rapid onset and also plays a role in blocking the peripheral conversion of T4 to T3, but it has liver toxicity potential. Carbimazole does not block peripheral conversion of T4 to T3 but does block thyroid hormone synthesis and does not have the potential for liver toxicity. In thyrotoxicosis, always avoid salicylates because they are associated with displacement of thyroid hormone from thyroxine-binding globulin (TBG).

Answer 91

Fluid retention, weight gain and worsening heart failure.

Answer 92

Anti-TSH receptor

Answer 93

anti-thyroglobulin antibodies

Answer 94

The RET gene is a proto-oncogene involved in kinase activation. MEN-2a is associated with medullary thyroid cancers, phaeochromocytoma, and parathyroid hyperplasia and adenomas.

Answer 95

Waterhouse-Friderichsen's syndrome is caused by a severe bacterial infection which results in disseminated intravascular coagulation and subsequent adrenal haemorrhage and failure. The adrenal haemorrhage is usually bilateral but can be unilateral.

Answer 96

Classically patients develop a non-specific infection which progresses into a macular, petechial and subsequently purpuric rash along with septic shock.

Answer 97

The first line screening investigations to look for Cushing’s syndrome and excess endogenous glucocorticoid production include a low dose dexamethasone suppression test, 24-hour urinary free cortisol, or midnight and 9am serum/salivary cortisol.

Answer 98

High dose dexamethasone suppression test is carried out after a diagnosis of Cushing’s syndrome has been confirmed. This helps to distinguish whether the excess cortisol secretion is due to excess ACTH secretion from the pituitary gland (where high dose dexamethasone will suppress cortisol secretion) or due to another reason.

Answer 99

Metformin, like all biguinides, can cause lactic acidosis. This normally occurs in conditions already associated with lactic acidosis, such as hypoxia or heart failure.

Answer 100

De Quervain’s thyroiditis is a subacute thyroiditis caused by granulomatous inflammation and destruction of thyroid cells which is often precipitated by a viral infection. It causes symptoms of hyperthyroidism due to excess release of thyroid hormone. Patients then have a hypothyroid phase. It also presents with a painful neck due to the inflammation. Its presentation is similar to Grave’s disease and a radioisotope scan can differentiate the two. It is self-resolving.

Answer 101

Cholecystitis is acute or chronic inflammation of the gallbladder usually due to cholelithiasis. In acute cholecystitis, obstruction can lead to an infection caused by a number of organisms: E.coli (most common) Klebsiella Enterococcus

Answer 102

Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated) Fever Nausea and vomiting Right upper quadrant tenderness Murphy's sign positive

Answer 103

The most likely diagnosis is oesophageal rupture secondary to forceful vomiting, which is known as Boerhaave syndrome.

Answer 104

The pubic tubercle is an important landmark to distinguish between inguinal and femoral hernias, with the latter being inferior and lateral to it.

Answer 105

A pancreatic pseudocyst is a common complication of chronic pancreatitis with around 25% of patients developing these. They can present asymptomatically depending on size but the most common symptoms are abdominal pain due to obstruction as a result of the mass effect of the cyst. Diagnosis is confirmed on CT as they can be visualised well as well circumscribed collections of fluid with a thick wall. Treatment is usually with surgical drainage although a very small number will spontaneously resolve.

Answer 106

Incision and drainage

Answer 107

Cullen's sign (superficial bruising around the umbilicus) is a rare sign for haemorrhage secondary to acute pancreatitis

Answer 108

This is a typical history of chronic bowel ischaemia with post-prandial pain, diarrhoea and bleeding. The pain occurs after eating as this is when the blood supply demands of the bowel are at their highest (in the same way that angina is brought on by exercise as that is when the heart's blood supply demand is highest). Weight loss is common as the pain stops patients from eating. This patient also has many vascular risk factors pointing towards an ischaemic cause.

Answer 109

This patient most likely has partial collapse of the lungs, known as atelectasis. It is a common cause of post-operative fever around 1-2 days after surgery and can cause shortness of breath. The examination findings of reduced air at the lung bases are typical. It most often occurs due to poor pain control, as this means patients struggle to cough to clear their lungs and have shallow breathing. A chest x-ray would likely show shadowing at the lung bases. Management includes adequate pain control, saline nebulisers and chest physiotherapy.

Answer 110

This is the most likely diagnosis given the clinical features and time period post-surgery. The most common presentations of an anastomotic leak are abdominal pain (sometimes peritonitis) and fever. Leaks usually present 5–7 days postoperatively. The definitive investigation for a suspected anastomotic leak is a CT scan of abdomen and pelvis with contrast. Leaks can be managed conservatively if small; however, in this case, it is likely the patient will need surgical intervention.

Answer 111

This gentleman is symptomatic of iron deficiency anaemia. Combined with systemic features, such as weight loss, this should raise suspicions of a malignancy. Right-sided colonic cancers often present later and in a more insidious manner with occult bleeding and anaemia. Occasionally there is a right-sided mass or vague abdominal pain on examination. The stool in the right-sided colon is semi-liquid, and so, unlike left-sided stools which are more solid, obstructive features are rarely a presenting feature Left-sided colonic cancers present earlier than right-sided neoplasms on the whole. As the stool is more formed this side of the colon, they may also present as a bowel obstruction. Features typical of a left-sided colonic cancer include fresh rectal bleeding, tenesmus, and/or mass in the left iliac fossa or on rectal exam

Answer 112

The psoas sign can be elicited by extending the right hip and, if it is positive, the patient will feel pain in the right iliac fossa. This is caused by an appendix in the retrocaecal position that rests against the iliopsoas muscle and causes irritation. Other signs include the obturator sign, which is elicited by internally rotating a flexed right hip, which again causes pain in the right iliac fossa.

Answer 113

This patient is displaying signs and symptoms of achalasia, failure of the lower oesophageal sphincter to relax due to degeneration of the myenteric plexus. Patients present with difficulty swallowing both liquids and swallows, in contrast to patients with an obstruction who present with difficulty swallowing solids first. The best treatment for this condition is a Heller's cardiomyotomy which is a surgical procedure where the muscle fibers of the lower oesophagus are divided

Answer 114

Ischaemic colitis occurs due hypoperfusion of the large bowel, particularly in the ‘watershed areas’ where collateral blood supply is limited. This results in inflammation and injury to the colon. This patient has cardiovascular risk factors which increases the risk of ischaemic colitis. Thumbprinting on AXR is a sign of large bowel wall thickening, usually due to oedema. Haustra are thickened in regular intervals along the bowel, resembling thumbprints. This may be seen in inflammatory bowel disease, ischaemia, infections and diverticulitis. The patient’s history of presenting complaint fits the clinical picture of the hyperactive phase of ischaemic colitis where patients experience severe pain with frequent passing of loose, bloody stools. The findings on examination suggest that the patient has progressed onto the paralytic phase where the pain becomes more diffuse and constant and the abdomen becomes distended. This patient has yet to progress onto the shock phase, where patients start to display signs of septic shock

Answer 115

This is a Hartmann's procedure, where the sigmoid colon is removed and a colostomy is formed. The stoma can be reversed at a later date if desired. This operation is used in emergencies, particularly in diverticulitis as the sigmoid colon is the most commonly affected site.

Answer 116

Rectal/topical nitro-glycerine is the first-line pharmacological management for anal fissures when lifestyle measures such as increased dietary fibre and simple analgesia has not worked, as recommended by NICE. It works as a vasodilator, which helps the anal sphincter to relax. Treatment of underlying constipation is also important.

Answer 117

20% intralipid infusion Lipids bind to the local anaesthetics and reverse effects of local anaesthetic toxicity.

Answer 118

H1 antagonist

Answer 119

End-tidal CO2

Answer 120

Epidural causes maternal hypotension due to its sympathetic effects, this can result in maternal and foetal distress.

Answer 121

It is commonly due to pulmonary embolism, pneumothorax or tampondade.

Answer 122

Metoclopramide

Answer 123

Suxamethonium and other depolarising muscle relaxants cause the release of potassium from cells. Inducing paralysis during anaesthesia can result in a rise of plasma potassium of up to 1 mmol/l. This is not an issue in this patient, as her potassium is still within the reference range. However, it can become an issue if there is pre-existing hyperkalaemia.

Answer 124

Three classes of antiemetic drugs are used first line: serotonin antagonists (ondansetron, palonosetron), corticosteroids (dexamethasone) and dopamine antagonists (droperidol).

Answer 125

Soft diastolic

Answer 126

The anion gap can be calculated by Na+ K+ – (Cl- + HCO3-)

Answer 127

Patients with moderate or severe hypokalaemia should have an ECG to see if there are any changes. ECG changes in hypokalaemia include flattened or inverted T waves, a prolonged PR interval and U waves.

Answer 128

Acute intermittent porphyria is a rare genetic condition in which the synthesis of haem is affected. Patients can present with many seemingly unrelated symptoms, including abdominal, neurological and psychiatric symptoms. A key feature is red-coloured urine.

Answer 129

The blood results show hypomagnesaemia which can cause a prolonged QT interval. It is one of the causes of Torsades de Pointes.

Answer 130

20 mg ON 80mg in secondary prevention

Answer 131

Trousseau sign is a sign of hypocalcaemia and is elicited by placing a blood pressure cuff over the arm and inflating it. Once inflated, spasms of the hand and forearm indicate a positive Trousseau sign.

Answer 132

Rovsing's sign is a sign of acute appendicitis. A positive finding is when deep palpation of the left iliac fossa causes pain in the right iliac fossa.

Answer 133

Coeliac disease is a T cell-mediated inflammatory autoimmune disease.

Answer 134

Rubella, caused by the rubella togavirus, usually presents with non-specific symptoms and signs such as coryza, arthralgia and a rash, which classically starts on the face and moves down to the trunk, sparing the arms and legs. The child may also have some lymphadenopathy. However, this patient's rash develops from the trunk and spreads towards the limbs, and there is no apparent lymphadenopathy. This makes roseola infantum the more likely diagnosis.

Answer 135

It presents with a painful red eye that is tender on movement and associated with reduced visual acuity and photophobia.

Answer 136

The aetiology of episcleritis is often idiopathic, and it tends to occur in younger patients. It is not painful and does not affect visual acuity.

Answer 137

Lichen sclerosus is most common in postmenopausal women and presents with pale atrophic skin with loss of vulval architecture. It is often associated with urinary incontinence, as in this woman. It increases the risk of vulval malignancy. No loss of architecture in lichen simplex

Answer 138

This question is asking you to think of red flags of headaches which would prompt hospital referral. Headaches triggered by coughing could be indicative of raised intercranial pressure and she would need a CT head scan to identify the cause.

Answer 139

Hand, foot and mouth disease

Answer 140

A long-acting GTN - third line in treatment of angina after beta blocker

Answer 141

Beta blockers Then calcium channel blockers like verapamil

Answer 142

Sheehan syndrome is secondary amenorrhoea due to necrosis of the pituitary gland (hypopituitarism). This occurs following massive postpartum haemorrhage – leading to severe hypotension and under-perfusion/ischaemia.

Answer 143

10% calcium gluconate

Answer 144

Serotonin syndrome

Answer 145

Alfentanil

Answer 146

A carcinoid tumour is a type of neuroendocrine tumour which is capable of secreting excessive amounts of serotonin. Common sites include the appendix, ileum or rectum. Carcinoid syndrome typically occurs when liver metastases are present. Symptoms are related to excessive serotonin secretion and include flushing, diarrhoea, bronchospasm and decompensated heart failure secondary (right sided, usually secondary to pulmonary stenosis caused by serotonin-induced fibrosis but can also be due tricuspid regurgitation from degradation of the valve)

Answer 147

Symptoms pointing towards this diagnosis include regurgitation, bulging in the neck on swallowing and halitosis. Iron deficiency anaemia would not be expected in this condition

Answer 148

The history and examination findings are suggestive of iron deficiency anaemia, which, together with the dysphagia, are suggestive of this rare syndrome that is characterised by oesophageal webs, dysphagia and iron deficiency anaemia

Answer 149

This is a typical history of pellagra, which is vitamin B3 deficiency. It is a known side effect of isoniazid when pyridoxine is not given alongside it, especially in developing countries. It presents with a typical triad of dementia, diarrhoea and dermatitis, and can result in death if left untreated.

Answer 150

Type 1 is the most common form of autoimmune hepatitis. Over 80% of affected patients will test positive for anti-smooth muscle antibodies.

Answer 151

Barium swallow x-ray (Upper GI series)

Answer 152

Capsule endoscopy is best used in the diagnosis of disease affecting the small bowel, which is inaccessible using endoscopy, and includes polyps, ulcers, tumours and inflammatory bowel disease.

Answer 153

The presentation above suggests a diagnosis of Henoch-Schonlein purpura (HSP), which is characterised by a tetrad of non-thrombocytopenia palpable purpura, arthralgia, haematuria, and abdominal pain. All children with HSP should be followed up for a year to detect the presence of any persisting haematuria or proteinuria.

Answer 154

E coli and kleb pneumoniae

Answer 155

The presentation is highly suggestive of a diagnosis of hereditary haemochromatosis, one of the most common genetic conditions in Northern Europe. Hereditary haemochromatosis is an autosomal recessive disorder of iron metabolism affecting the heart, liver, joints, pancreas, and skin. Management may include venesection and desferrioxamine. HFE

Answer 156

St Johns Wort - reduces efficacy

Answer 157

Modified Glasgow Criteria

Answer 158

This patient has osteogenesis imperfecta, which is a condition caused by a qualitative defect in collagen type 1 synthesis. Patients typically have a history of multiple fractures in their childhood and may have sclera (blue) and dental abnormalities. Some patients will also have hearing defects as they grow older.

Answer 159

Conversion disorder is the presence of neurological symptoms without any underlying neurological cause. The tests ruled out any medically explained causes such as a tumour or a stroke. Conversion disorder is linked to emotional distress, which this patient could be experiencing through taking his exams.

Answer 160

Histrionic personality disorder is characterised by attention-seeking behaviours. They are willing to be viewed as dependent on others and weak, to gain attention. They use their behaviour/speech and dress to seek attention, such as being over theatrical or flirtatious. However, these patients do not display self-harm or suicidal behaviours/ideas.

Answer 161

Schizotypal personality disorder is characterised by unusual social behaviour, bizarre or magical thinking and distorted perceptions. This is demonstrated by the patient's beliefs around the colour purple. Unlike patients with schizophrenia, those with schizotypal personality disorder are able to maintain a grasp on reality and do not hold their unusual beliefs with such unwavering certainty.

Answer 162

In schizoid personality disorder, patients show a lack of interest in others, apathy and a lack of emotional breadth.

Answer 163

Reassure and observe

Answer 164

Bulimia is characterised by feelings of shame and lack of control around food, which are managed through purging: for example excessive laxative use, or self-induced vomiting. Russell's sign is scarring on fingers from induced vomiting, as seen in bulimia.

Answer 165

First trimester Ebstein's anomaly

Answer 166

Obsessive–compulsive personality disorder does share features of obsessive-compulsive disorder. Patients are preoccupied with extreme perfectionism and may prioritise work to the detriment of other aspects of their lives. However, unlike in obsessive–compulsive disorder, these activities are perceived as pleasurable rather than distressing.

Answer 167

It may be helpful to think of a prion as an 'infectious' protein. They are simply misfolded proteins that can induce other proteins to misfold. An example of diseases they can cause is CJD.

Answer 168

Alzheimer's disease is caused by the misfiling of beta-amyloid proteins, which accumulate to form plaques in the brain. These cause neuronal death leading to loss of cortex which can be seen on an MRI scan.

Answer 169

Gs & Cs raised : Growth hormone, Glucose, salivary Glands, Cortisol, Cholesterol, Carotinaemia

Answer 170

Somatoform disorder describes the presence of physical symptoms that cannot be explained by a physical medical condition. It is an unconscious process, and patients are not fabricating their symptoms. Common presenting symptoms are gastrointestinal symptoms, fatigue, weakness, musculoskeletal symptoms and, as in this patient's case, abdominal pain.

Answer 171

Fine tremor

Answer 172

The most likely diagnosis for this man is neuroleptic malignant syndrome (NMS) secondary to the second-generation antipsychotic he is taking – risperidone. He has the signs and symptoms of NMS – confusion, diaphoresis, rigidity, pyrexia, tachycardia, tachypnoea and high blood pressure. CK will be elevated due to muscle rigidity but may be normal if the rigidity is not profound or if the presentation is early. In severe cases, muscle necrosis and rhabdomyolysis may occur.

Answer 173

Donepezil, an acetylcholinesterase inhibitor, can be used to help improve the cognitive function of those with Alzheimer's disease. They are thought to work by increasing levels of free acetylcholine in the brain. Rivastigmine and galantamine are other acetylcholinesterase inhibitors that can be used for the same purpose.

Answer 174

Pica is the eating of things which are not food or of food items in abnormal quantities.

Answer 175

This man most likely has akathisia secondary to the antipsychotic haloperidol. Akathisia is characterised by the feeling of inner restlessness and tension, an urge to constantly move parts of the body, especially the legs, and difficulty maintaining a posture for a few minutes. First-generation antipsychotics (eg. haloperidol) are more likely to cause akathisia than second-generation antipsychotics (eg. olanzapine). In addition, due to its distressing nature, akathisia is associated with aggression, low mood and suicidal ideations.

Answer 176

Cotard delusion is a rare psychiatric delusion in which the patient believes they are dead or have had organs removed. It is associated with schizophrenia but can be found in patients with depression, brain tumours and migraine headaches.

Answer 177

Fregoli delusion describes where a patient believes that everyone they meet is the same person but with different disguises. It can be associated with injury to the right frontal area, left temporoparietal areas and the fusiform gyrus.

Answer 178

More than six months

Answer 179

Paucity of speech

Answer 180

This is a delusion where a patient believes that someone of a higher status than them (such as a singer, politician or actor) is in love with them.

Answer 181

Thought blocking is when a patient may stop speaking all of a sudden, and this can last for a few minutes. When the patient starts speaking again, they will talk about an entirely different topic. This can be similar to thought withdrawal, but the key to the diagnosis is the change of conversation topic.

Answer 182

This patient has bilateral proximal muscle weakness and Gottron's papules which strongly suggest dermatomyositis. Another characteristic sign of this condition is a heliotrope rash which is a periorbital rash.

Answer 183

Urticaria - antihistamines

Answer 184

A keloid scar is a benign, abnormal, over-proliferation of scar tissue that occurs after an injury to the skin.

Answer 185

The patient is experiencing progressive proximal muscle weakness, along with dermatological features of a heliotrope rash and Gottron's papules. Creatinine kinase is the most sensitive indicator of disease and can give an idea of disease activity.

Answer 186

X-linked - mostly impacts males

Answer 187

The most likely diagnosis here is myelofibrosis, which can occur as a complication of PV and is a cause of massive splenomegaly. Teardrop poikilocytes are the characteristic blood film finding. Diagnosed with bone marrow biopsy

Answer 188

Burkitt lymphoma is a high-grade aggressive Non-Hodgkin's lymphoma, meaning patients are more likely to present with widespread disease and B symptoms at presentation. The starry sky appearance on lymph node biopsy is pathognomonic for Burkitt lymphoma. Previous EBV infection is associated with Burkitt lymphoma. Other risk factors include HIV infection, the t(8:14) c-myc gene translocation, and previous malaria infection. Other EBV-associated malignancies include Hodgkin's lymphoma, nasopharyngeal carcinoma, post-transplant lymphoproliferative disorder and HIV-associated central nervous system lymphomas.

Answer 189

Polycythaemia rubra vera

Answer 190

Schistocytes are fragmented red cells seen in intravascular haemolysis, such as haemolytic anaemia. They are also seen in patients with mechanical heart valves due to mechanical haemolysis of the cells.

Answer 191

Unprovoked - 6 months DOAC Provoked = 3 months

Answer 192

MGUS is a common disease of the elderly, which resembles multiple myeloma, but is usually asymptomatic with a lower level of paraproteins. MGUS can transform into multiple myeloma, and yearly surveillance is recommended

Answer 193

back pain, features of hypercalcaemia (constipation, polyuria, low mood), anaemia (tiredness) and frequent infections

Answer 194

Serum protein electrophoresis identifies the presence of an M protein (excess of a monoclonal antibody). The presence of an M protein along with other results such as bone lesions, hypercalaemia, anaemia, plasma cells on bone biopsy and renal impairment form the diagnostic criteria for myeloma

Answer 195

Von Willebrand disease, which is usually an autosomal dominant condition, results in easy bruising and bleeding from mucous membranes (for example, epistaxis and menorrhagia). It may also cause a mild thrombocytopenia. It is the most common bleeding disorder affecting women.

Answer 196

Beta thalassemia

Answer 197

Pathognomic for CLL

Answer 198

AML is a malignant blood disorder characterised by the proliferation of myeloid precursor (blast) cells.

Answer 199

Patients with sickle cell disease may have reduced splenic function due to repeated splenic infarctions. The spleen plays a very important role in the immune response against infection, particularly against encapsulated organisms which are phagocytosed there. Therefore, patients with sickle cell disease and hyposplenism are at increased risk of severe infections from encapsulated organisms. Examples of such organisms include Streptococcus pneumoniae, Pseudomonas aeruginosa and Haemophilus influenzae.

Answer 200

The FIGO staging system is used to stage endometrial and ovarian cancers. It ranges from stage 0, which refers to carcinoma in situ, to stage 4, which refers to cancer associated with distant metastases.

Answer 201

Co-cyprindiol is a novel combined oral contraceptive pill and is used in patients with hyperandrogenism (such as patients with PCOS). It can help improve the regularity of periods and reduce hirsutism (excessive hair growth).

Answer 202

Oxybutynin for urge incontinence Duloxetine for stress incontinence

Answer 203

Follicular

Answer 204

A-E IV heparin infusion

Answer 205

The key risk factors for varicose veins are obesity, family history, pregnancy, previous leg injury and prolonged standing. Traditional atherosclerotic risk factors such as hypertension, hyperlipideamia and diabetes mellitus are not implicated in the development of varicose veins.

Answer 206

Claudication pain in the buttock and thigh, erectile dysfunction and diminished/absent femoral pulses are hallmark features of aortoiliac artery stenosis, also known as Leriche syndrome.

Answer 207

The external iliac artery becomes the femoral artery after it passes under the inguinal ligament. Patients will have pain that starts just above the inguinal ligament.

Answer 208

To answer this question, it is important to know the blood supplies of the lower limb. This patient presents with an acute onset leg pain with findings consistent with acute limb ischemia. Occlusion at the femoral-popliteal artery is the most likely as the pain starts below the knee. Remember, symptoms of occlusion occurs distal to the site of occlusion.

Answer 209

This patient presents with a painless transient loss of vision, also known as amaurosis fugax. It is caused by temporary blockage of blood flow to the eye.

Answer 210

Critical limb ischaemia is caused by chronic arterial occlusion. It is defined by pain at rest for more than 2 weeks. The pain is gradual in onset instead of acute and the foot should be warm with a pink appearance. It can be associated with nonhealing ulcers and gangrene with an ankle brachial pressure index (ABPI) of less than 0.5. It does not need immediate intervention but an urgent referral to a vascular surgeon should be made.

Answer 211

'Inverted champagne bottle' appearance (tapering of legs above the ankle) and reddish brown discolouration suggest lipodermatosclerosis

Answer 212

Wet gangrene is infectious gangrene, and includes necrotising fasciitis (infection of the subcutaneous fascia and fat), gas gangrene (caused by Clostridium), and gangrenous cellulitis (in the immunocompromised).

Answer 213

Dry gangrene is ischaemic gangrene and occurs secondary to chronically reduced blood flow.

Answer 214

5.5cm or larger

Answer 215

Abdominal US CT angiography can give more detailed view

Answer 216

Naftidrofuryl oxalate is a vasodilator which can alleviate pain in peripheral vascular disease. It should only be prescribed if supervised exercise is ineffective and the patient does not want to be referred for angioplasty or bypass surgery.

Answer 217

The first line management for varicose veins is patient education, which involves advising against prolonged standing and promoting weight loss. According to NICE guidelines, patients should only be referred to a vascular service if the veins are painful, there are associated skin changes such as pigmentation or ulcers, or if there are signs of superficial vein thrombosis.

Answer 218

Nausea and vomiting Tinnitus Fever Confusion Tachycardia Initial respiratory alkalosis (caused by activation of respiratory centres in the brain) Later metabolic acidosis (causes by wasting of bicarbonate ions due to the ingested acid load) - this is often mixed with the respiratory alkalosis

Answer 219

VBG: looking for acid-base imbalance Salicylate levels

Answer 220

Widened QRS complex

Answer 221

Cholecystitis may present with altered stools and urine colour, and occasionally infective symptoms but does not usually cause jaundice, as it is an inflammation of the gallbladder, not blockage of the common bile duct. This patient presents with Charcot's triad (jaundice, fever, right upper quadrant pain), as well as part of Reynolds' pentad (hypovolaemic shock and altered mental status) which is diagnostic for ascending cholangitis.

Answer 222

1:1000 in anaphylaxis 1:10000 in arrest

Answer 223

IV loop diuretic

Answer 224

Whilst IV amiodarone is a treatment option for ventricular tachycardia, this patient is presenting with hypotension and chest pain which are unstable features. She requires immediate synchronised DC cardioversion (up to three attempts) before any amiodarone is given.

Answer 225

This patient is presenting with a spontaneous primary pneumothorax. As he has a pneumothorax which is over 2cm and he is haemodynamically stable, first line management would be needle aspiration followed by a period of observation. Chest drain for secondary above 2cm

Answer 226

First-line treatment in idiopathic or viral pericarditis is ibuprofen and colchicine where there are no contraindications.

Answer 227

In unstable patients with haemodynamic compromise, DC cardioversion can be done. In stable patients, the choice of treatment is IV Magnesium Sulphate 2g over 1 to 2 minutes.

Answer 228

Start intravenous acyclovir and ceftriaxone

Answer 229

Asthma. Use verapamil instead.

Answer 230

This is contraindicated in this case as the patient has been symptomatic for >48 hours. As a result, there is a risk of a thrombus having formed in the left atrial appendage which could be dislodged during cardioversion and migrate to the brain causing a stroke. If this patient was clinically unstable, an urgent echo could be performed to visualise the left atrial appendages for thrombi before performing cardioversion. The most appropriate way to control this patient's abnormal heart rhythm is to anticoagulate them for at least 3 weeks and then cardiovert them.

Answer 231

Osmotic laxative that softens the stool

Answer 232

Midodrine is an alpha-1-adrenergic receptor agonist. Activation of alpha-1-adrenergic receptors leads to an increase in vascular tone and an increase in blood pressure.

Answer 233

Breakthrough pain medication is calculated as a sixth of the total daily dose.

Answer 234

Acetylcholinesterase inhibitors such as donepezil can offer symptomatic benefit and result in an improvement in the activities of daily living, however they do not affect the disease progression. Around half of pts don't benefit from them.

Answer 235

Benserazide is a decarboxylase inhibitor which prevents the peripheral breakdown of levodopa. This means that levodopa is decarboxylated into dopamine in the brain, enabling the full therapeutic dose to take effect.

Answer 236

An Advance Statement also known as a "Statement of Wishes and Care Preferences," allows an individual to make general statements about their wishes, beliefs, feelings and values and how these influence their preferences for their future care and treatment. This includes expressing wishes regarding food preferences, spiritual/religious beliefs, where they would want to be treated and who they would like to have with them during their final days.

Answer 237

Advanced decisions focus upon the refusal of treatments which are life sustaining, including aspects such as providing nutrition through a nasogastric tube if oral intake is no longer feasible.

Answer 238

Midazolam is commonly used to treat restlessness and agitation in end-of-life patients.

Answer 239

A hyperdense, crescent shaped lesion initially; after time hypodense

Answer 240

Used for risk of pressure ulcers

Answer 241

Bowel cancer

Answer 242

The blue and bulging membrane with a mass protruding from behind is a classic finding in an imperforate hymen. This girl has likely started her periods, but the hymen is imperforate. This has caused a backlog of blood through the vagina, causing abdominal pain.

Answer 243

Epithelial-cell tumour

Answer 244

Left-sided temporal arteritis, which is affecting the blood supply to the optic nerve. Unilateral painless visual symptoms, that have gradually progressed associated with jaw claudication and an elevated CRP/ESR make the diagnosis

Answer 245

Oral pred 40mg if no visual symptoms IV methylpred if visual symptoms

Answer 246

Alport syndrome usually presents in children with haematuria (often microscopic), bilateral sensorineural hearing loss and retinitis pigmentosa. It does not typically cause haemoptysis.

Answer 247

Also called acute calcium pyrophosphate deposition disease (CPPD)

Answer 248

CREST syndrome

Answer 249

Eosinophilic granulomatosis with polyangiitis

Answer 250

Livedo reticularis is a mottled, lace-like rash usually found on the lower limbs and is associated with antiphospholipid syndrome.

Answer 251

Creatine kinease

Answer 252

Steroids Second-line colchicine

Answer 253

Antiphospholipid syndrome (APS)

Answer 254

Low oxygen and high carbon dioxide means that the patient is in type 2 respiratory failure. They have presented with features of polymyositis, the main symptom being bilateral girdle weakness without loss of muscle bulk and elevated serum enzymes. Polymyositis is more prevalent in females and 40-60 year olds. As the condition progresses, it can lead to neuromuscular weakness such as in the respiratory muscles, which leads to poor ventilation and type 2 respiratory failure.

Answer 255

Protein is digested by pepsin, which is secreted by chief cells in the stomach. This patient has severe dementia which can cause patients to stop eating, merely by forgetting to eat or because of changes to the brain that affect the systems that control appetite. He may benefit from nutritional supplements containing protein

Answer 256

Takayasu's arteritis is a large vessel vasculitis that usually affects young women. It typically affects the aorta, causing limb claudication, abnormal or absent pulses and differential blood pressure measurements. Takayasu's arteritis can cause a stroke and should be considered in young women presenting with stroke.

Answer 257

Crescent formation and linear deposition of antibodies along the glomerular basement membrane. It is caused by anti-glomerular basement membrane antibodies, which is why you see deposition of the antibodies along the membrane.

Answer 258

Effacement of podocyte foot processes

Answer 259

Small stones >2cm Above = nephrostomy and remove with forceps

Answer 260

The renal biopsy findings in this case are typical of membranous nephropathy. A tip for remembering the names of the various glomerulonephritides and their biopsy findings is to know that their names often relate to their histological appearances. For example, in membranous nephropathy there is thickening of the glomerular basement membrane. Likewise, minimal change disease gets its name from the fact that there is minimal or no abnormality seen on light microscopy in this condition.

Answer 261

Berry aneurysm --> SAH

Answer 262

Dialysis disequilibrium syndrome is a rare but potentially fatal complication of haemodialysis, particularly in patients who are starting it. Patients may develop cerebral oedema. This is thought to be due to rapid shifts in urea, an osmotically active substance, between different fluid compartments during haemodialysis. In cerebral oedema, there is raised intracranial pressure, which is suggested here by the headache, vomiting and Cushing's triad - low heart rate, raised blood pressure (with wide pulse pressure) and irregular breathing.

Answer 263

In IgA nephropathy, all patients with hypertension or proteinuria should be started on an ACE inhibitor or angiotensin receptor blocker. In addition to lowering blood pressure, ACE inhibitors and angiotensin receptor blockers also help to reduce proteinuria and slow the progression of kidney disease.

Answer 264

Rapidly progressive glomerulonephritis, also called cresenteric glomerulonephritis, is a glomerulonephritis that can occur idiopathically or secondary to other conditions such as systemic lupus erythematosus and Goodpasture syndrome. The biopsy findings would show epithelial crescents (crescent-shaped scars) in most glomeruli.

Answer 265

IgA nephropathy, also called Berger's disease, is caused by IgA deposition in the glomeruli which may complicate an infection, typically an upper respiratory tract infection. The typical presenting features are haematuria and hypertension one to two days after an upper respiratory tract infection.

Answer 266

Fibromuscular dysplasia most commonly occurs in women under the age of 50. It occurs when there is thickening and narrowing within the walls of arteries which can lead to renal artery stenosis. It often presents as treatment-resistant hypertension and deteriorating renal function after the patient is started on an ACE inhibitor.

Answer 267

The most likely diagnosis here is peritoneal dialysis peritonitis. S. epidermidis is a commensal organism of the skin, but it can cause peritonitis and sepsis if it enters the body via the peritoneal dialysis catheter.

Answer 268

All patients with chronic kidney disease should have their eGFR and albumin:creatinine ratio monitored regularly. Proteinuria indicates damage to the glomerular basement membrane and is useful for both diagnosing and monitoring progression of chronic kidney disease.

Answer 269

The characteristic triad of acute interstitial nephritis is rash, fever and eosinophilia (although it is worth noting that this triad is uncommon and occurs in less than 10% of cases). Proton pump inhibitors (such as omeprazole) are a common cause of acute interstitial nephritis.

Answer 270

If the value is >2.5mg/mmol in men or >3.5mg/mmol in women, they should be started on an ACE inhibitor.

Answer 271

The likely diagnosis here is fibromuscular dysplasia, a form of the renovascular disease typically occurring in young women. Often fibromuscular dysplasia involves both renal arteries and usually presents with refractory hypertension and worsening renal impairment after initiation of an angiotensin-converting enzyme inhibitor such as lisinopril. Another clue to diagnosing renal artery stenosis is a renal bruit on examination. The patients are otherwise asymptomatic.

Answer 272

Granulomatosis with polyangiitis is a necrotising small-vessel vasculitis, which often presents with recurrent sinusitis, haemoptysis and rapidly progressive glomerulonephritis. This patient has sinusitis with nephritic syndrome. Further investigation for c-ANCA is required to confirm the diagnosis.

Answer 273

Chromosome 16 Chromosome 4 in ADPKD-2

Answer 274

The abdominal x-ray has failed to pick up any evidence of the stone, shown on the non-contrast CT-KUB, suggesting that the stone is radiolucent. Coupled with a background history of chronic tophaceous gout, this is most likely a uric acid stone.

Answer 275

Tamsulosin is an alpha adrenergic receptor blocker which inhibits the alpha 1 receptors in the bladder neck and prostatic urethra. It results in relaxation of the bladder neck muscle, reduces bladder outlet obstruction and facilitates easier micturition. It works quickly in men with relatively small prostates. However, it should be given in caution in elderly patients as it causes orthostatic hypotension.

Answer 276

Relief of pain on elevation is called a positive Prehn's sign and is a useful discriminator between cases of epididymo-orchitis and testicular torsion. Prehn's sign tends to be negative with testicular torsion (ie. the pain is preserved despite elevation).

Answer 277

This patient has a large retention volume of >1000ml. He should be admitted to monitor for post-obstructive diuresis. Post-obstructive diuresis occurs following rapid decompression of urinary retention. Patients will be at risk for dehydration and should be monitored closely for their urine output in the hospital and if >200ml/hr urine is being produced, they should be replaced with intravenous fluids to avoid acute kidney injury.

Answer 278

Symptoms of a neurogenic bladder would include bladder hyperactivity, which involves bladder spasms, urinary urgency and frequency that can lead to decreased capacity of the bladder and retention over time. This usually occurs with conditions affecting the innervation of the bladder, such as spinal cord injury, multiple sclerosis, stroke, diabetes or Parkinson's disease. This is unlikely here due to the acute onset of symptoms and her lack of risk factors for the condition.

Answer 279

This patient has a diagnosis of shingles. Shingles is a disease caused by the reactivation of the varicella zoster virus, which lies dormant in nerve ganglia following primary infection (chickenpox). Shingles typically occurs in the elderly population; if shingles occurs in young adults (or children in this case), it is important to screen for immunological issues.

Answer 280

Vitiligo is an autoimmune condition in which there is a loss of melanocytes in the epidermis, resulting in loss of pigmentation. Due to the nature of autoimmune conditions often overlapping, it is important to screen for other immune disorders

Answer 281

Anagen effluvium is a type of alopecia which affects the anagen (growth) phase of the hair cycle. Hair stops growing prematurely and starts to shed very quickly. This is commonly due to chemotherapy.

Answer 282

Actinic (or solar) keratosis is a pre-malignant lesion which arises due to alterations in keratinocytes as a consequence of prolonged sun exposure. They can appear as beige, pink or brown patches, usually on areas of skin which have high sun exposure. The lesion may feel sensitive or itchy. Untreated, there is a risk of them progressing to squamous cell carcinoma (SCC).

Answer 283

If they are to be treated, topical podophyllotoxin is commonly used for genital warts. It treats them by preventing cell division and viral replication of infected cells.

Answer 284

Watery nasal discharge after trauma/surgery The current standard in diagnosis of anterior skull base fracture is CT (axial and coronal planes).

Answer 285

Tympanosclerosis occurs as a result of calcium phosphate plaques forming in the lamina propria of the tympanic membrane after increased fibroblast activity depositing collagen. This leaves white patches that are visible on the membrane. Hearing aids can help with hearing loss, and surgery can be considered to remove the sclerotic parts.

Answer 286

The Parkland formula indicated how much fluid a burns patient should receive within the first 24hrs of admission and is given by 4 x weight(kg) x total burn surface area (%). The surface area of the burn can be approximated by the 'rule of 9s', with each arm counting as 9%, each leg 18%, the head 9% and the front and back of the torso 36%.

Answer 287

Saphena varix is dilation of the saphenofemoral junction, and can often be mistaken for a femoral hernia as it also exhibits positive cough impulse. However, in this case it is unlikely as it would be lateral and inferior to the pubic tubercle, just like a femoral hernia.

Answer 288

CT angiogram

Answer 289

Crucially for this question, they are also associated with hypokalemia. This is thought to be due to the polyp secreting insulin.

Answer 290

Pancreatic cancer

Answer 291

This typically effects children and adolescents, but can effect adults. Typically is presents like appendicitis, following a bacterial or viral illness (e.g. Yersina, Campylobacter or Salmonella). The appendix is normal on ultrasound (or CT in older patients) and there are pronounced lymph nodes

Answer 292

Bowel ca, not colorectal cancer

Answer 293

hypocalcaemia. HypERcalcaemia can cause pancreatitis, whilst hypOcalcaemia is an indicator for severity of pancreatitis. This is because calcium gets trapped in the tissue surrounding the necrosing tissue around the pancreas. This process is called saponification

Answer 294

This is patient has presented with pain indicating he has a gastric ulcer (epigastric pain worsened by eating). The rebound tenderness points towards possible peritonitis, which could be caused by the perforation of the ulcer. An erect chest x-ray is the best initial investigation to look for air under the diaphragm.

Answer 295

Chancroid is an infection of the genital skin and typically presents as a painful lesion that bleeds on contact. There may also be associated lymphadenopathy. It is most commonly contracted in tropical areas.

Answer 296

Trichomonas

Answer 297

Lymphogranuloma venereum (LGV) is an sexually transmitted infection (STI) caused by certain strains of Chlamydia trachomatis. LGV usually causes a painless genital ulcer at the site of inoculation and a subsequent inflammatory reaction of the inguinal nodes (buboes). LGV can also cause systemic symptoms of fever, fatigue and malaise. Given the patient's history of unprotected sexual activity and the presence of these specific symptoms, LGV is the most likely diagnosis.

Answer 298

It is a tetracycline antibiotic that blocks translation by binding the bacterial 30S ribosomal subunit.

Answer 299

Treponema pallidum

Answer 300

Don't kiss any babies! Neonatal herpes infection.

Answer 301

If one pill has been missed, and it has been less than 72 hours since that missing dose, patients should be advised to take the missed pill as soon as possible, alongside their normal medication. This means they may need to take two pills on the same day. No extra contraception should be required as long as no more doses are omitted.

Answer 302

Trachoma is chronic conjunctivitis caused by Chlamydia trachomatis, which usually presents before three months of age. Initial symptoms are conjunctival hyperaemia, eyelid oedema, photophobia, and watery to purulent discharge. Infants may develop symptoms of pneumonia by the age of eight weeks.

Answer 303

Kaposi sarcoma (KS) is a multicentric vascular tumour caused by human herpesvirus-8. It is common in immunosuppressed persons such as those with AIDS or organ transplants. The risk increases in patients with low CD4 counts of less than 200, which is likely in this case as he has been non-compliant with his therapy. Cutaneous lesions are asymptomatic purple macules that coalesce into violet to black-coloured plaques and nodules. LANA1 (latent nuclear antigen 1) is usually expressed by Kaposi's sarcoma-associated herpesvirus (KSHV), also known as human herpesvirus 8 (HHV-8).

Answer 304

Intravaginal metronidazole gel is used to treat bacterial vaginosis, which typically presents with a grey-white watery discharge with a characteristic fishy smell.

Answer 305

HPV = genital warts HSV = genital herpes

Answer 306

The initial symptoms include gastrointestinal upset, headache and fever, which may then progress to abdominal pain and neurological symptoms including delirium and coma. Hepatosplenomegaly and rose-coloured spots may be seen in affected individuals. Gastrointestinal ulceration with bleeding and perforation is a major complication of typhoid fever and requires prompt operative treatment and antimicrobial therapy.

Answer 307

This patient with acute-onset joint pain and systemic illness most likely has septic arthritis. This patient was previously treated for a sexually transmitted infection. N. gonorrhoeae is the commonest cause of septic arthritis in young, sexually active patients. Reactive with chlamydia - Urinary and ocular symptoms may also be seen.

Answer 308

Macrolide e.g. azithromycin

Answer 309

Praziquantel should be given now and again in 2 months to destroy the flukes responsible. Of note, corticosteroids would also be indicated if she presented with Katayama fever, a hypersensitivity reaction.

Answer 310

Brucellosis is a zoonotic infection, and high-risk occupations include farmers and vets. The symptoms are often vague, and complications include subacute and infective endocarditis, which is likely in this case. This form of infective endocarditis is often culture-negative.

Answer 311

This patient has presented with Pott's disease, or tubercular spondylitis, one of the commonest extrapulmonary manifestations of tuberculosis. Risk factors for infection with tuberculosis include prolonged exposure to poor living conditions and being immunocompromised. Clinical features include localised back pain, neurological deficits and radiographic findings indicative of vertebral body involvement. A biopsy demonstrating granuloma formation is highly suggestive of a tubercular process.

Answer 312

Erythema migrans is a classic finding in the early localised phase of Lyme disease (although not every patient will have or remember it). Tick-bourne disease

Answer 313

C. jejuni is a common cause of gastroenteritis, with transmission classically resulting from ingesting undercooked or contaminated poultry. C. jejuni typically presents with diarrhoea, which may be bloody, and rarely with vomiting.

Answer 314

Hepatitis A is most commonly transmitted via the faecal-oral route, and typically has a shorter incubation period of 2-4 weeks.

Answer 315

Oral vancomycin and intravenous metronidazole are recommended for severe Clostridium difficile. Severe infection is associated with a rise in white cell count and creatinine, pyrexia and evidence of severe colitis.

Answer 316

Topical clotrimazole (anti-fungal)

Answer 317

Vitamin B6 (pyridoxine) should be co-prescribed to reduce the risk of drug-induced vitamin depletion.

Answer 318

Carbapenems e.g. meropenem

Answer 319

Ethambutol may cause disturbances in vision, in particular red-green colour detection. Ethambutol can cause ocular toxicity, particularly if there is impairment of renal function. Patients should be warned of this side effect before initiating treatment and need immediate evaluation for possible optic neuritis.

Answer 320

Doxycycline

Answer 321

Viral pneumonia

Answer 322

This patient most likely has Katayama fever, an acute presentation of schistosomiasis infection. Katayama fever tends to present with a broad spectrum of symptoms around a month after initial exposure. A characteristic 'swimmer's itch' may be seen following exposure to fresh water in an endemic area. Eosinophilia is a common laboratory finding.

Answer 323

EBV (glandular fever)

Answer 324

This man has presented with acute otitis media, a common complication of measles. Incomplete vaccination status, alongside a history of high fever and a maculopapular rash, makes this the most likely diagnosis.

Answer 325

Hepatitis A infection typically presents with the symptoms described above, and a 2-6 week incubation period following exposure is typical. Poor food hygiene in an endemic country such as India is the likely source of infection in this case. The majority of hepatitis A infections will resolve within 2-3 weeks of symptoms onset.

Answer 326

Erysipelas describes a more superficial infection of the epidermis and dermis. While it presents very similarly to cellulitis, its borders tend to be more clearly demarcated.

Answer 327

Avoid triggers; prophylaxis with Verapamil; managing an acute attack with 100% oxygen via non-rebreathable mask (CI: COPD) with a subcutaneous or nasal Triptan (CI: ischaemic heart disease).

Answer 328

This patient has presented with features of progressive supranuclear palsy - balance issues leading to recurrent falls and vertical gaze palsy. It is classified as a Parkinson's plus syndrome as it presents with parkinsonism with additional features.

Answer 329

This is another Parkinson's plus syndrome which presents with parkinsonism in addition to autonomic features such as postural hypotension, impotence and incontinence.

Answer 330

Parkinisonism and involves spontaneous activity by an affected limb, or akinetic rigidity of that limb.

Answer 331

The involuntary, sudden movements the patient is describing are known as choreoathetosis. Tetrabenazine is useful for managing choreoathetosis. It works by reducing the uptake of monoamines such as dopamine which have been found to cause these movements.

Answer 332

This is a muscle relaxant commonly given to patients with multiple sclerosis or palliative patients experiencing muscle spasms. However, it would not help to suppress choreoathetosis.

Answer 333

This patient has presented with features of a surgical third nerve palsy. The main features are ptosis and a dilated pupil in a down-and-out position. The most common cause of a surgical third nerve palsy is a posterior communicating artery aneurysm, which can cause a severe headache.

Answer 334

Same as bacterial but with lymphocytes

Answer 335

The classic triad of features is urinary incontinence, dementia and gait abnormality which develops over several months, all of which are seen in this patient. In patients who are fit for surgery, ventriculo-peritoneal shunting can be used. Otherwise conservative management with repeated CSF taps is an alternative treatment option.

Answer 336

Avoid triggers; prophylaxis with Propranolol (CI: asthma), Topiramate (teratogenic) or Amitriptyline; managing an acute attack with an oral triptan such as Sumatriptan (CI: ischaemic heart disease), in addition to Paracetamol or an NSAID. Ensure that female patients are not taking combined oral contraceptive pills as it increases their risk of ischaemic stroke.

Answer 337

Anosmia - lack of sense of smell

Answer 338

Mononeuritis multiplex, occasionally termed polyneuritis multiplex, is a type of peripheral neuropathy which is characterized by simultaneous or sequential involvement of individual non-contiguous nerve trunks, either partially or completely, evolving over days to years and typically presenting with acute or subacute loss of sensory and motor function of individual nerves. The pattern of involvement is asymmetric. However, as the disease progresses, deficits becomes more confluent and symmetrical, making it difficult to differentiate from polyneuropathy. Therefore, attention to the pattern of early symptoms is important. Mononeuritis multiplex may also cause pain, which is characterized as deep, aching pain that is worse at night and frequently in the lower back, hip, or leg. In people with diabetes mellitus, mononeuritis multiplex is typically encountered as acute, unilateral, and severe thigh pain followed by anterior muscle weakness and loss of knee reflex.

Answer 339

This is caused by compression of the lateral femoral cutaneous nerve and would present with abnormal sensations on the lateral aspect of the thigh. This does not correspond with this patient's presenting complaint.

Answer 340

Very high protein, nil else

Answer 341

High urinary copper

Answer 342

Patients present with an ipsilateral (left side in this case) loss of light touch, vibration sensation and motor function in addition to the loss of contralateral pain and temperature sensation (right side in this patient) below the level of the lesion. This is due to the tracts in the spinal cord decussating at different levels. The fibres of the corticospinal tract (motor function) and the dorsal column (responsible for light touch and proprioception) both decussate in the medulla, leading to the ipsilateral side being affected. On the other hand, the fibres of the spinothalamic tract (responsible for pain and temperature sensation) decussate within the spinal cord itself which leads to the contralateral side being affected.

Answer 343

Thymic hyperplasia

Answer 344

This patient's symptoms are suggestive of hereditary spastic paraparesis which causes degeneration of mainly the corticospinal tracts and, in some patients, the dorsal column. Patients present with spasticity, hyperreflexia and gait disturbance. The scissor gait is seen due to increased muscle tone in the adductor muscles.

Answer 345

This patient most likely has signs of idiopathic intracranial hypertension. The main features of this are diffuse headaches which are worse when lying down or bending, visual disturbances and a high BMI. The fundoscopy findings indicate bilateral papilloedema which is also a common sign in these patients. The most appropriate management initially is to encourage weight loss as this is one of the strongest risk factors for developing idiopathic intracranial hypertension.

Answer 346

Selegiline is a monoamine oxidase type B inhibitor and is used as a treatment for Parkinson's disease. It is imperative that this patient receives his Parkinson's medication as soon as possible, as any delay from the usual time of administration may have a serious impact on his symptoms. Parkinson's medications are time critical, meaning that the patient may come to harm if they are not given at the usual time.

Answer 347

Bruising over the mastoid process is known as Battle sign. It is caused by a subcutaneous haematoma behind the ear and is suggestive of a skull fracture.

Answer 348

This refers to bruising around the umbilical area and is suggestive of an intraperitoneal haemorrhage.

Answer 349

All pregnant women who are Rhesus negative blood group should receive anti-D injections at 28 and 34 weeks gestation as part of routine antenatal care. In some areas, a single larger dose of anti-D is given at 34 weeks only. Haemolytic disease of the newborn occurs when a Rhesus negative woman becomes pregnant with a Rhesus positive foetus. This is usually not a problem during the first pregnancy. However, during subsequent pregnancies, the maternal anti-D antibodies can cross the placenta and lead to haemolysis of foetal red blood cells. Anti-D is given during pregnancy to neutralise maternal anti-D antibodies and reduce the risk of haemolytic disease of the newborn.

Answer 350

An Actim-PROM vaginal swab detects insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid. The concentration of IGFBP-1 is much higher in the amniotic fluid than in the maternal blood. Therefore, a positive Actim-PROM suggests pre-labour rupture of membranes.

Answer 351

Downs, Edward and Patau

Answer 352

Uterine atony is the most common cause of primary postpartum haemorrhage and occurs when the uterus does not contract sufficiently following delivery. This can be managed by applying pressure to the uterus, giving medications to induce uterine contractions or by surgical techniques, including inserting an intrauterine balloon, placing a haemostatic suture around the uterus, arterial ligation or a hysterectomy.

Answer 353

Eclampsia is the occurrence of one or more seizures in a woman with pre-eclampsia. There is no mention of seizure activity in this patient.

Answer 354

Cisplatin can cause nephrotoxicity and ototoxicity, it is important to monitor kidney function.

Answer 355

Tamoxifen is a oestrogen antagonist, commonly indicated for ER+ positive breast cancers. However, it also works as an agonist on endometrial tissue which can result in endometrial proliferation and cause abnormal vaginal bleeding.

Answer 356

IV bisphosphonates and fluids

Answer 357

Papillary is by far the most common type, accounting for up to 70% of all thyroid cancers.

Answer 358

This boy has orbital cellulitis, a sight-threatening soft tissue infection posterior to the orbital septum. This is often a result of nearby infections such as sinusitis. A CT orbits, brain and sinus should be done to rule out local extension of the infection, which can lead to an intracranial abscess

Answer 359

Blepharitis describes the inflammation of the eyelid. It presents as sore, itchy eyelid margins with a crusty appearance at the base of the eyelashes. It does not present with vision loss, as described in the vignette above

Answer 360

Used in primary open-angle closure glaucoma. LATE-NIGHT-PROS(titute) - eye lashes get longer (mascara) - change in iris colour (contact lenses)

Answer 361

The family history combined with the history of night blindness and possible reduced visual fields (she bumps into things) makes this the most likely diagnosis

Answer 362

Parainfluenza virus

Answer 363

Conduct disorder is a paediatric condition characterised by young people presenting with antisocial behaviours, such as skipping school, stealing and physically harming other people or animals. Antisocial PD diagnosed after 18

Answer 364

In paediatric BLS, if the patient is not breathing, you must give rescue breaths first. This is because cardiac arrest in children is more likely to be caused by respiratory pathology than cardiac.

Answer 365

The most appropriate next investigation is a cranial ultrasound as this baby is only a week old; therefore, the anterior fontanelle is still open. Will be open for first few months of life Other risk factors for hydrocephalus include spina bifida and meningitis.

Answer 366

3:1 15:2 in children

Answer 367

13-15 months

Answer 368

Duodenal obstruction (most commonly atresia)

Answer 369

Boys usually start to develop secondary sexual characteristics between the ages of 9-14. This includes testicular growth and growth of pubic hair. Precocious puberty in boys is when these changes occur before the age of 9 and this should be investigated.

Answer 370

After full work-up, GnRH analogues

Answer 371

Genetic karyotyping

Answer 372

1:10000 1:1000 in anaphylaxis

Answer 373

NICE recommends a bilirubin level using a transcutaneous bilirubinometer in babies over 24 hours old

Answer 374

H influenza B

Answer 375

The first-line antibiotic for bacterial tonsillitis is phenoxymethylpenicillin, however in a patient who is allergic to penicillin, macrolides are used e.g. azithromycin

Answer 376

At 12 months, a child should have developed a pincer grip, i.e., bringing the thumb and index finger close together to hold an object, such as a pencil. It is important to remember that a delay in reaching fine motor developmental milestones may indicate a problem with vision rather than a neurological or muscular problem.

Answer 377

Glandular fever, also known as infectious mononucleosis, is an infection most commonly caused by the Epstein-Barr virus (EBV). It is most common in people aged between 15–24 years. It commonly presents with fever, lymphadenopathy and sore throat. The lymphadenopathy is usually of the posterior cervical lymph nodes. Other features include splenomegaly and hepatomegaly. There may also be a non-specific rash if the patient has been treated with amoxicillin.

Answer 378

By 6 months

Answer 379

Babies start saying 'mama' or 'dada', also known as '2 syllable babble', at about 10 months. 6-month-old babies should be turning their head towards loud sounds and starting to babble, coo and laugh. They should also start understanding 'bye-bye'.

Answer 380

Palmar grasp is a fine motor skill which is usually expected by 4-6 months of age – the lack of this at 9 months would be concerning, but the question asks specifically about gross motor skills, not fine motor.