QM/BM 2 Flashcards

Question

Which vaccines are contraindicated with methotrexate use?

Answer 1

Live vaccines, like the yellow fever vaccine, is contraindicated with Methotrexate due to the level of immunosuppression.

Answer 2

Can be caused by isoniazid. DIL typically presents as a less severe form of SLE which starts while taking an offending medication, and completely resolves after it is discontinued. Positive anti-histone antibody.

Answer 3

The mechanism of action of both trimethoprim and methotrexate is to inhibit folate metabolism. Folate inhibition is responsible for the major side effects of methotrexate, and further inhibition of folate metabolism by trimethoprim can potentiate them.

Answer 4

Sjogren's disease

Answer 5

Reduced tear secretion (keratoconjunctivitis sicca). This causes dry, gritty feeling eyes which may appear red. Superimposed bacterial conjunctivitis often occurs. Dryness of the mouth (xerostomia) which may cause difficulty with swallowing food or talking. Dental caries and oral candidiasis often occur. Intermittent parotid gland swelling.

Answer 6

The DAS-28 score is designed to measure disease activity in rheumatoid arthritis.

Answer 7

Xanthine-oxidase inhibitor

Answer 8

Triad of RA, splenomegaly and neutropenia

Answer 9

Can't pee, can't see, can't climb up a tree The complete triad of urethritis, conjunctivitis and arthritis may occur.

Answer 10

Raised JVP Parasternal heave Loud P2

Answer 11

Bronchiectasis classically causes daily cough with excessive sputum production. This can lead to the patient feeling tired or experiencing shortness of breath. It can be associated with underlying congenital lung disease such as Cystic Fibrosis or Primary Ciliary Dyskinesis (Kartagener's syndrome). It can also occur in otherwise healthy lungs following respiratory tract infections, as appears to be the case here. The infectious agents most commonly responsible for the development of bronchiectasis include: Haemophilus influenzae, Pseudomonas aeruginosa, TB, Bordetella pertussis (otherwise known as whooping cough) and Allergic Bronchopulmonary Aspergillosis (ABPA).

Answer 12

Therefore, would require supplemental oxygen or ventilator support. In order to give the appropriate level of oxygen, arterial blood gas readings are needed to allow titration of a venturi mask accordingly.

Answer 13

Ethambutol can cause a toxic optic neuropathy which develops within a short period of time following its commencement. It tends to start with a loss of colour perception followed by central visual field loss.

Answer 14

Urinary antigen enzyme immunoassay test

Answer 15

Epworth sleepiness scale

Answer 16

This medication causes a dose-related peripheral neuropathy due to the depletion of vitamin B6 and hence it should be taken in combination with Pyridoxine (vitamin B6 replacement). Other side effects include hepatotoxicity, optic neuritis and gout.

Answer 17

COPD patients who have the potential to become carbon dioxide retainers - this can result in them transitioning from being reliant on their hypercapnic drive for respiration, into a hypoxic drive for respiration. This means if they are over-oxygenated this can prompt respiratory arrest as they lose their hypoxia that was previous driving respiration - to reduce this risk it is always best to use a controlled method of oxygen delivery such as a Venturi mask in COPD patients.

Answer 18

Asbestos exposure

Answer 19

The patient has presented with flu-like symptoms and a fever, in addition to a background of contact with birds. This history is indicative of Chlamydophila psittaci.

Answer 20

Coarse inspiratory crepitations and finger clubbing

Answer 21

Low tidal volume mechanical ventilation

Answer 22

The preceding flu-like illness, dry cough, erythema multiforme (target-shaped lesions) and evidence of anaemia (shortness of breath and low haemoglobin) suggest this is mycoplasma which is a common cause of atypical pneumonia.

Answer 23

Peripheral oedema

Answer 24

"Pill in the pocket" Oral flecainide or sotalol

Answer 25

NSAIDS Costochondritis is inflammation of the costal cartilage causing pain on respiration

Answer 26

Cardiac tamponade results from a pericardial effusion that restricts the ability of the heart to fill with blood. Tamponade is associated with Beck's triad which includes distended neck veins, low blood pressure and muffled heart sounds.

Answer 27

Stroke risk in AF

Answer 28

Autosomal dominant

Answer 29

Conns syndrome is an adrenal aldosterone secreting adenoma and these account for up to 80% of all cases of hyperaldosteronism. Such adenomas are usually unilateral and solitary in nature. Due to high levels of aldosterone which work to increase epithelial sodium channel expression (ENaC) on the collecting ducts and increase the Na+/k+ pumps in the distal convoluted tubule. This leads to increased sodium absorption, reduced potassium reabsorption and increased H+ secretion. It is important to remember that that in up to 70% of patients a normal potassium is measured and as such a high index of suspicion is needed. Renin concentrations will be low due to negative feedback. CT/MRI is needed to confirm the presence of the adenoma. Treatment includes aldosterone antagonists such as spironolactone and surgery.

Answer 30

Classic findings of aortic sclerosis are an ejection systolic murmur that does not radiate to the carotids, with a normal S2, pulse character and volume. This woman does not have aortic stenosis as the murmur does not radiate to the carotids. Further, she is asymptomatic. Other differentiating features would be a normal S2 (softer in aortic stenosis), and a normal pulse character and volume (slow rising and narrow pulse pressure in aortic stenosis).

Answer 31

Aortic regurgitation Rheumatic heart disease

Answer 32

Angiography plus percutaneous coronary intervention, as long as it can be delivered within two hours from the time thrombolysis could have been delivered

Answer 33

Rumbling mid-diastolic murmur, loudest at the apex on deep expiration

Answer 34

Start of Q-wave to the end of the T-wave

Answer 35

Rumbling mid-diastolic murmur with an opening snap, malar flush and AF

Answer 36

HOCM typically causes diastolic dysfunction due to impaired relaxation of the thickened left ventricle during diastole. This results in impaired filling of the left ventricle.

Answer 37

Atrial flutter is caused by regular and rapid contraction of the atria which are more frequent than the contractions of the ventricles, usually in a ratio of 2:1. Classically, the heart rate will be around 150, hence 300 atrial contractions, in a sawtooth pattern on ECG.

Answer 38

a rumbling mid-diastolic murmur seen in acute aortic regurg in aortic dissection

Answer 39

If the pt no longer has a pulse

Answer 40

Post infarction pericarditis or Dressler's syndrome can occur in 5-10% of patients after an acute MI and high dose aspirin is the correct first line management of choice

Answer 41

ACE-I, beta-blockers, statin and aspirin

Answer 42

Creatinine Kinase has three isoenzymes.CK-BB (brain), CK-MB (myocardium), and CK-MM (skeletal muscle). The one of clinical value in (re-)infarcts is CK-MB. The one advantage of CK-MB over the troponins is the early clearance that helps in the detection of reinfarct. Troponin levels can be elevated for up to 2 weeks after the initial infarct episode, whilst CK-MB usually clear by 72 hours. A CK-MB level of more than 3 times the upper limit of normal is generally considered to be indicative of one. Previously, before troponins existed as a blood test, CK-MB was the marker used to assist in the diagnosis of myocardial infarcts.

Answer 43

95% of cases are caused by previous rheumatic fever. Atrial fibrillation is a common finding in mitral stenosis due to increases in left atrial pressure and concomitant left atrial dilation.

Answer 44

To do In cor pulmonale you would expect to see right axis deviation and not left axis deviation. This reflects right ventricle hypertrophy as the right side of the heart works harder to pump blood against increased pulmonary resistance.

Answer 45

Hypercalcaemia or intra-cranial bleed

Answer 46

Urine metanephrines

Answer 47

trans thoracic echocardiogram (TTE) Trans-oesophageal echocardiogram - A TOE allows for a better understanding of the make up of this gentleman's heart valves and specifically as to whether any vegetation exists upon his aortic valve given the presenting history. If infective endocarditis is suspected then antibiotics should be commenced given that this patient is unwell, however a TOE would guide management with regards to surgical intervention and prognosis.

Answer 48

CABG has a survival advantage over PCI in patients who: are over 65 years old, have diabetes, or have complex 3 vessel disease.

Answer 49

The A-wave signifies atrial contraction.

Answer 50

Examination findings are suggestive of mitral valve prolapse - a characteristic mid-systolic click, and a systolic murmur suggestive of secondary regurgitation. It can be asymptomatic, or can present with symptoms of dyspnoea and poor exercise tolerance as in this patient, or sometimes chest pain or palpitations secondary to atrial fibrillation. In addition, mitral valve prolapse is also more common in patients with Marfan syndrome - a genetic connective tissue disorder.

Answer 51

The presentation of severe pain, profound vision loss and pus in the anterior chamber within the first week after a cataract surgery is an endophthalmitis until proven otherwise. This is an infection of the vitreous and/or anterior segment and should be treated emergently with intra-vitreal antibiotics.

Answer 52

Lazy eye Strabismus

Answer 53

Leukocoria refers to a white pupillary reflex and can be caused by several conditions, one of which being retinoblastoma.

Answer 54

IV acetazolamide is a carbonic anhydrase inhibitor which causes a reduction in the production of aqueous humour in the ciliary body and therefore a reduction in intra-ocular pressure.

Answer 55

Blurred vision in his right eye. On examination, his right eye is red and watery with a fixed mid-dilated pupil. On palpation of the eye, you note that his right eye is hard compared to his left.

Answer 56

nitial treatment involves admission to hospital for ophthalmology review, reduction of the intraocular pressure (IOP) and providing analgesia to the patient. Pilocarpine is used to reduce the IOP (note that the strength is 4% for brown eyed patients and 2% of blue eyed ones). Other drugs that can be used to reduce the IOP include: oral Acetazolamide, Timolol 0.25% eye drops and Brimonidine 0.1% eye drops

Answer 57

The patient is presenting with a painful red eye with blurred vision and posterior synechiae (the irregular shaped pupil)

Answer 58

'flashes and floaters' with a curtain over his visual field. The curtain he is seeing is his detached retina

Answer 59

He also has high myopia (a prescription of over -6) which is a risk factor for retinal detachments. In myopia, the eye is bigger and therefore the retina is thinner and is more easily torn.

Answer 60

Hyperaemia and haemorrhages are often seen in central retinal vein occlusion, the appearance is sometimes described as a ‘stormy sunset’.

Answer 61

CT sinus and orbits with contrast It is commonly a bacterial infection which is spread via the paranasal sinuses. It is for this reason that CT sinus and orbits is diagnostic of orbital cellulitis.

Answer 62

Wegener's (also known as granulomatosis with polyangiitis or GPA) is an example of a small vessel vasculitis. It is classically cANCA-positive. It classically presents with a triad of upper respiratory tract symptoms, lower respiratory tract symptoms and renal symptoms.

Answer 63

A young patient with a history of active hepatitis B presents with systemic upset, nodular and ulcerating skin lesions and mononeuritis multiplex. Skin biopsy will reveal a non-granulomatous necrotising vasculitis.

Answer 64

Decline in visual acuity and subtle disturbance of colour vision seen with hydroxychloroquine use

Answer 65

Bisphosphonate Can cause oesophageal irritation

Answer 66

a rare diagnosis, the patient describes a history of recurrent bouts of self-limiting high fever and painful serositis associated with a typical lower limb erysipelas-like rash

Answer 67

Pathergy testing and HLA B51 The patient has the classic triad of mouth ulcers, genital ulcers and eye symptoms. He also has erythema nodosum.

Answer 68

A young, male smoker who has been experiencing claudication and has signs of lower limb atherosclerosis with absent pedal pulses.

Answer 69

Hypromellose act as artifical tears and are applied as eye drops to soothe eyes.

Answer 70

Psoriatic arthritis is the only arthritis to be associated with skin and nail changes, including pitting and onycholysis. It can also be associated with a 'rheumatoid-like' symmetrical pattern affecting the small joints of the hands and feet, however, it typically affects the distal interphalangeal joints rather than the metacarpophalangeal joints which are usually affected in rheumatoid arthritis.

Answer 71

Dialysis-induced hypotension is the most common complication of haemodialysis. The mechanism of action is the rapid reduction of blood volume during ultrafiltration and the decrease in extracellular osmolality during dialysis. Patients require accurate fluid assessment and may require cautious replacement of intravascular volume in emergency settings.

Answer 72

The disease is caused by effacement of glomerular podocyte processes, which can only be detected using high resolution electron microscopy.

Answer 73

This patient has presented with clinical features of nephrotic syndrome including significant peripheral oedema and massive proteinuria. most common cause of nephrotic syndrome in children.

Answer 74

12 week course of pred

Answer 75

If microalbuminuria is detected (>2.5 mg/mmol in men, >3.5 mg/mmol in women), patients should be started on an ACE inhibitor.

Answer 76

It usually presents with microscopic/macroscopic haematuria following an infection affecting the mucosa e.g. upper respiratory tract infection and these are the classical biopsy findings.

Answer 77

Hutchinson’s sign refers to involvement of the nasociliary branch of the trigeminal nerve by herpes zoster virus. This is seen clinically as vesicles on the tip of the nose. This nerve also supplies the globe, making ophthalmic involvement of the virus likely.

Answer 78

Retinal haemorrhages and retinal necrosis describe the classical "pizza pie retinopathy" of CMV retinitis. This is especially likely in an HIV patient with a CD4 count <100. Treatment includes oral Valganciclovir.

Answer 79

A chalazion is a cyst created secondary to obstruction of the Meibomian glands. A chalazion is not an infection and thus is non-tender and non-fluctuant on examination. Rather it is an impairment of Meibomian gland outflow secondary to a previous inflammatory pathology, which may well have been an infection.

Answer 80

Testicular cancer

Answer 81

Bell clapper deformity occurs when the testes is not fixed to the tunica vaginalis and hangs freely leaving it free to rotate. Can increase risk of testicular torsion.

Answer 82

Bladder transitional cell cancer

Answer 83

The history points toward ureteric colic, and a CT KUB is the gold standard investigation for this. This is indicated by loin to groin colicky pain combined with blood and protein present on the urine dip. A CT KUB cannot exclude the presence of infection or obstruction, but may also show features of perinephric stranding or hydronephrosis, which might indicate the need for a ureteric stent. Helical CT KUBs are now performed at a low dose and so radiation exposure is less than previously.

Answer 84

Urinary retention

Answer 85

MRI is now the first-line investigation for prostate cancer. It is reported using the 5 point Likert scale. MRI is the best imaging modality for the prostate since it’s a soft tissue organ. This would show any lesions which could then go on to be targeted by a template biopsy.

Answer 86

A TURP (transurethral resection of the prostate) is a procedure used in benign prostatic hyperplasia (BPH), not prostate cancer.

Answer 87

These can cause obstruction of the gonadal vein leading to left sided varicocele. This should be suspected in older men presenting with varicocele, especially with systemic symptoms such as malaise, lethargy or weight loss.

Answer 88

The patient has had a fall and a significant long lie which is illustrated by the significant CK. Damage to muscle as part of the process will liberate myoglobin which will give the urine a redish appearance, and has sufficiently similar molecular structure to haemaglobin to test positive on a urine dipstick. Myoglobin can also cause an acute tubular necrosis which may further contribute to the reddish appearance.

Answer 89

Wilm’s tumour is the most common renal malignancy in children and presents between the ages of 2 and 5.

Answer 90

Struvite stones, also known as triple phosphate stones, are radiopaque, tend to form staghorn calculi (involving the renal pelvis and at least two calyces) and form in alkaline urine. Certain chronic urinary tract infections predispose to struvite formation by turning the urine alkali. Chronic proteus mirabilis infection predisposes to staghorn renal calculi.

Answer 91

Gradual onset of unilateral pain and swelling suggests a diagnosis of epididymo-orchitis.

Answer 92

PR diclofenac

Answer 93

Poor hygiene and recurrent episodes of balanitis can lead to scarring of preputial orifice and lead to phimosis. This can predispose to UTIs and gives rise to painful erections. The foreskin can't be pulled back (retracted).

Answer 94

IM Ceftriaxone and PO Doxycycline

Answer 95

Reduced venous return to the glans leading to oedema and/or ischaemia of the glans secondary to retracted tight foreskin becoming irreplaceable. This can occur in instances where foreskin is not replaced after catheterization.

Answer 96

Hydroceles typically transilluminate whereas varicoceles do not.

Answer 97

The history of painless retention and preceding nocturnal enuresis is highly suggestive of chronic retention. These patient typically have >1L in their bladders.

Answer 98

Squamous cell carcioma

Answer 99

Transitional cell

Answer 100

Renal clear cell carcinoma

Answer 101

Calcium oxalate

Answer 102

This patient has balanoposthitis which is inflammation of the glans penis. In this case, it is likely associated with atopic eczema and emollients and steroid cream are the treatment of choice.

Answer 103

Squamous cell carcinoma

Answer 104

This patient has a fistula between her vagina and bladder. This accounts for her constant leaking of urine. Risk factors include difficult and prolonged labour in a setting of under developed obstetric services. Damage to both structures can occur and a tract form between them upon healing.

Answer 105

This patient is suffering from TURP syndrome which is a rare but potentially life threatening complication of a TURP. Hyponatraemia due to absorption of irrigation fluids intra-operatively is the common cause.

Answer 106

Nitrofurantoin is avoided at term due to risk of neonatal haemolysis. Amoxicillin is a good alternative.

Answer 107

This is a diagnosis of chronic kidney disease as indexed by the progressive history of symptoms, proteinuria and oedema. His blood tests show anaemia, hyponatraemia and hyperkalaemia. The creatinine is raised more than the urea, suggesting impaired filtration of the kidney. Nephrotoxic drugs, such as naproxen, should be stopped in patients with CKD.

Answer 108

Gradual onset, photophobia and a small pupil are a classic presentation for acute anterior uveitis (AAU). Inflammatory bowel disease is also a significant risk factor for AAU. In AACG you would expect a more acute history, with visual haloes, nausea and vomiting.

Answer 109

It is generally a sign of optic neuropathy. GCA causes ischaemia of the optic nerve head through inflammation of the vessels that supply it.

Answer 110

Exposure keratopathy Bell's palsy is an idiopathic facial nerve palsy. Paralysis of the orbicularis oculi muscle attenuates eyelid closure (lagophthalmos) thus increasing the exposure of the cornea and tear layer to the environment. This increases the risk of damage to the corneal epithelium (exposure keratopathy) which may become infected leading to sight-threatening keratitis.

Answer 111

CRAO does present with acute painless vision loss; however, the fundoscopic picture is different. Occlusion of the retinal artery causes diffuse pallor of the retina. The macula does not receive blood from the retinal artery (as this would obscure light coming into the photoreceptors). Instead it is supplied by the choroidal circulation, which lies behind the macula. This relative hyperaemia of the macula compared to the rest of the retina in CRAO gives it a characteristic 'cherry red spot' appearance. In CRVO, you'd see haemorrhages and cotton wool spots (which shows retinal ischaemia)

Answer 112

Arteriovenous nipping refers to the observation of retinal arteries crossing over and compressing retinal veins, it is seen in hypertensive retinopathy.

Answer 113

Intravitreal vancomycin - usually gram positive

Answer 114

This is a prostaglandin agonist which has the primary action of increasing uveoscleral outflow. A common side effect to warn patients about is eyelash thickening/lengthening.

Answer 115

It presents with symmetric proximal muscle weakness, skin rash, and extramacular manifestations, such as esophageal dysfunction and interstitial lung disease. Anti-Jo1 is associated with the extra muscular features seen in dermatomyositis.

Answer 116

Before starting biologics, TB has to be screened for and treated first before starting biologics.

Answer 117

Eosinophilia, poorly controlled asthma, CXR findings indicative of granulomatous change along with renal involvement make this the most likely diagnosis. Similar to Wegener's but history of asthma and eosinophilia on blood tests are distinguishing features.

Answer 118

ECG with widespread ST elevation demonstrates myocarditis.

Answer 119

Polymyositis occurs in the elderly and causes bilateral, proximal muscle weakness, usually without pain. Muscle bulk is preserved until late in the disease.

Answer 120

Celocoxib is a selective COX-2 inhibitor or coxib (their names usually end in -ib). Coxibs have a lower risk of GI ulceration than regular NSAIDs because they inhibit COX-1 to a far lesser extent. COX-1 is protective for gastric mucosa.

Answer 121

Patients with AAA >4.4cm but <5.5cm found on routine screening should be monitored every 3 months, on top of referral to vascular surgeons within 12 weeks.

Answer 122

Thrombophlebitis is when a blood clot forms in one of your veins and slows the blood flow in the vein. Red, swollen, and irritated skin around the affected area Pain or tenderness that gets worse when you put pressure on the affected area A swollen vein that feels like a tough "cord" under your skin

Answer 123

Pt presenting with a rapidly progressive infection of the deep fascia causing necrosis of the subcutaneous tissue, as signified by the black patch of skin. He is also clinically unwell. All of this points towards Fournier's gangrene as the diagnosis. Fournier's gangrene is essentially necrotizing fasciitis of the perineum and it is a surgical emergency because it can cause rapid and uncontrollable necrosis of tissue and ultimately death by overwhelming sepsis if not treated promptly.

Answer 124

More than 1.2: abnormal thickening of vascular walls (think diabetes) 0.9 - 1.2: Normal 0.8 - 0.9: Mild disease 0.5 - 0.8: Moderate disease Less than 0.5: Severe disease

Answer 125

Femoral hernias are found inferior and lateral to the pubic tubercle. Inguinal hernias are found superior and medial to the pubic tubercle.

Answer 126

Wet gangrene is dry gangrene that has become infected or is secondary to acutely necrotic tissue. Urgently debridement or amputation is needed to save the rest of the limb and the patient form sepsis. Dry gangrene is a complication of critical limb ischaemia. The blood supply to the toe has become so poor that the lack of oxygen and nutrients has led to necrosis of the tissue. There is usually a clear delineation between the dead and living tissue. Dry gangrene is not infected.

Answer 127

Lipodermatosclerosis, varicose veins, and pitting oedema are all signs of chronic venous insufficiency.

Answer 128

Duplex ultrasound shows retrograde venous flow

Answer 129

Haemochromatosis

Answer 130

Allopurinol can acutely raise the level of urate (and precipitate or worsen a flare of gout) before lowering the levels of gout. Therefore covering with an NSAID is important for reducing the risk of another flair while allopurinol therapy is initiated.

Answer 131

Calcium channel blockers like nifedipine is a good first line option for Raynaud's phenomenon following conservative measures such as wearing gloves.

Answer 132

She is presenting with a severe unremitting headache and she is psychotic. She has features of active disease (prominent rash, raised ESR, low complement levels).

Answer 133

Muscle biopsy

Answer 134

It is important to differentiate polymyalgia from myopathies. In a myopathy eg. poly/dermatomyositis, muscle weakness is the main feature, whereas pain is minimal. Also raised CK unlike in PR.

Answer 135

This is the correct answer. This gentleman presents with proximal muscle weakness. The heliotrope rash and shawl sign described indicate dermatomyositis rather than polymyositis as the underlying cause. Polymyositis is another idiopathic inflammatory myopathy, presenting with sub-acute chronic proximal muscle weakness. The skin changes described make dermatomyositis the correct answer here.

Answer 136

This is the correct answer. Methotrexate can cause pneumonitis, and so a baseline chest x-ray should be taken before commencing therapy. If the patient then develops any respiratory symptoms, a repeat chest x-ray can be taken, and the two can be compared.

Answer 137

Takayasu’s is a large vessel arteritis typically affecting the aorta and its main branches, occurring in young women. Symptoms include chest pain and limb claudication on exertion. On examination, radial pulses may be undetectable - Takyasu’s is also known as ‘pulseless arterial disease’, bruits may be audible over the carotids, abdominal aorta or subclavian vessels and unequal blood pressures may be recorded between sides.

Answer 138

Polyarteritis nodosa is a segmental transmural necrotizing vasculitis of medium-sized muscular arteries (does not involve arterioles, capillaries, or venules). Kidney – renal failure Coronary – ischemic heart disease, acute myocardial infarction GI – abdominal pain, nausea, melaena Musculoskeletal – arthritis, myalgia, arthralgia CNS – eye and skin complaints The pulmonary vessels are not affected in PAN (Pulmonary vessels Are NOT affected). Note that polyarteritis nodosa has no association with ANCA antibodies.

Answer 139

Washout methotrexate Hydroxychloroquine and Sulfasalazine with concomitant folate supplementation can be continued throughout pregnancy.

Answer 140

Hep B serology - Hep B is associated with PAN

Answer 141

Osteophytes, also called bone spurs, are bony projections occurring at joint edges in osteoarthritis as new bone is laid down in a disorganised fashion in response to injury.

Answer 142

Lupus anticoagulant, anticardiolipin

Answer 143

Anti Ro and Anti La

Answer 144

PIP (proximal interphalangeal joints) and MCP (metacarpophalangeal joints) of the fingers

Answer 145

Encephalitis, causing seizure, fluctuating consciousness levels, headache and raised inflammatory markers

Answer 146

Churg-Strauss syndrome (now known as eosinophilic granulomatosis with polyangiitis or EGPA) is a rare pANCA-positive vasculitis. It is very strongly associated with asthma and the use of leukotriene receptor antagonists (eg. Montelukast). It tends to present with asthmatic or sinusitis-type symptoms with eosinophilia on the blood results. Patients may also have a background of asthma/sinusitis and then present with vague constitutional symptoms.

Answer 147

The alternating nature of the pain together with the constellation of symptoms suggests ankylosing spondylitis.

Answer 148

This is the most likely diagnosis in this patient who presents with bowel symptoms, and an axial pattern of arthritis, as well as erythema nodosum, a skin manifestation of inflammatory bowel disease (IBD). The dermatological associations are the ulcerative colitis is more likely to feature pyoderma gangrenosum and Crohn's more likely to feature erythema nodosum. Crohn's more often presents with peripheral arthritis but there is, of course, a spectrum. Importantly, joint symptoms may precede bowel symptoms in these patients.

Answer 149

Dry mucosa (especially eye and mouth), fatigue and joint pain

Answer 150

Methotrexate can cause bone marrow suppression, which can result in anaemia, leucopenia, agranulocytosis and thrombocytopenia.

Answer 151

Anti-Scl-70

Answer 152

While NSAIDs (e.g. indomethacin) are the first line option for treatment of gout, they are contra-indicated in many patients. Notably, this patient has CKD 3. Colchicine is an alternative and may have to be dose adjusted in those with renal impairment to avoid accumulation to toxic levels. Its main adverse effect is diarrhoea.

Answer 153

Low dose steroids can be considered in patients on dialysis or end stage renal failure with eGFR less than 10ml/minute/1.73m2 as both NSAIDs and Colchicine should be avoided

Answer 154

The diagnosis of PCOS must fulfil 2 out of 3 for the Rotterdam criteria, which includes: clinical or biochemical hyperandrogenism, polycystic ovary (>12 cysts) on USS, and oligo/anovulation.

Answer 155

ADPKD is the most common hereditary cause of cysts in the kidney and as the name suggests, patients have a strong family history of kidney disease. Abdominal discomfort is due to the increase in the size of the kidneys in an enclosed space. The episode of pain and haematuria is due to cyst rupture. One of the complications of ADPKD is hypertension, which should be managed with angiotensin-converting enzyme inhibitors as the first-line. In this patient's age group (<30), family history, along with 2 or more cysts in one kidney or both kidneys, found on ultrasound is enough to fulfil the diagnostic criteria.

Answer 156

nephrotic syndrome has likely been caused by regular Penicillamine use. Penicillamine is a copper-chelating agent in Wilson's disease, which can result in membranous nephropathy

Answer 157

ATN is a renal cause of acute kidney injury (AKI). It is due to the necrosis and death of tubular epithelial cells. It is classically caused by nephrotoxic agents such as gentamicin, radiocontrast, phenytoin, and cytotoxic agents.Patient present with hypotension which is resistant to fluid challenge. There is a raised urea and creatinine, but normal urea: creatinine ratio and eosinophils can also be raised.Sodium is low due to the urine due to inadequate reabsorption. It is managed by stopping the nephrotoxic agent and providing fluid support or renal replacement therapy.

Answer 158

This patient is presenting with classical features of haemolytic uraemic syndrome - with features of bloody diarrhoea, fever, vomiting, acute kidney injury and haemolysis. Most cases occur following an E.coli O157:H7 diarrhoea. Treatment is supportive with fluid rehydration, haemofiltration, steroids and plasmapheresis. Sometimes schistocytes on blood film.

Answer 159

Carbimazole is an anti-thyroid agent that decreases the uptake and concentration of iodine by the thyroid. It also prevents the thyroid peroxidase enzyme (TPO) from coupling and iodinating the tyrosine residues on thyroglobulin. Thyroglobulin, following the coupling and iodinating process, would normally then be degraded to produce thyroxine (T4) and tri-iodothyronine (T3). Hence, by blocking thyroid peroxidase, Carbimazole reduces the production of the thyroid hormones T3 and T4.

Answer 160

First line medications include duloxetine, gabapentin, pregabalin or amitriptyline

Answer 161

Hashimoto's thyroiditis

Answer 162

Anti-TSH receptor antibodies can be positive in Hashimoto’s but they can also be positive in Grave’s thyroiditis depending on whether the antibody inhibits or activates the receptor.

Answer 163

When a patient is on sufficient prednisolone (10mg and over) and for a long period of time (>3 week) this causes the Hypothalamic-Pituitary- Adrenal axis to switch off ceasing normal endogenous cortisol production. Therefore it is important to increase prednisolone dosages to cover and mirror this normal physiological response and prevent acute hypoadrenalism. Therefore we generally advise in patients with a febrile illness (>37.5 degrees celsius) to double their steroid dose. In this instance where she has not managed to take for 3 days her prednisolone , IV hydrocortisone should be immediately given. Note such sick day rules does not need to be adhered to in patients taking intranasal, inhalation or transdermal steroids given their local and minimal systemic effects.

Answer 164

DVLA guidance states that if a patient has more than one severe episode of hypoglycaemia whilst awake or one episode of severe hypoglycaemia whilst driving then they must stop driving immediately and inform the DVLA. Their license will be revoked but they can reapply after three months.

Answer 165

Lithium toxicity is a recognised cause of nephrogenic diabetes insipidus. This is thought to be due to lithium accumulation in the cells of the collecting duct which prevents water re-absorption.

Answer 166

Sodium- Dependent Glucose Cotransporter 2 inhibitor Dapagliflozin is one of an emerging class of new antihyperglycaemics. This works by binding to SGLT2 receptors which are found within the proximal convoluted tubule and whose inhibition leads to increased glycosuria and reduced reabsorption of glucose. As a result of this osmotic diuresis patients can have reductions in their blood pressure. Dapagliflozin of this class has been found to have very good cardioprotective effects in both patients with and without a previous history of myocardial infarction.

Answer 167

Amiodarone is a routinely used medication and commonly can cause abnormal TFTs. This is because Amiodarone inhibits peripheral conversion of T4 to T3 and has high iodine content and a half-life of around 90 days.

Answer 168

Despite its relative rarity, Haemophilia B should be considered in patients where clinical suspicion of an inherited clotting disorder is high, but the factor VIII assay is normal (thereby excluding Haemophilia A).

Answer 169

Autoimmune therefore Coombs positive Corticosteroids are first line management for primary (idiopathic) autoimmune haemolytic anaemia. They work by suppressing the immune system and hence suppressing production of the autoantibodies directed against the red blood cells that are causing the haemolysis.

Answer 170

Myelofibrosis presents with constitutional symptoms as described and is associated with tear drop cells on the peripheral blood film. It occurs when there is abnormal proliferation of fibroblasts which produce platelet-derived growth factor, leading to significant bone marrow fibrosis. This leads to bone marrow failure which causes anaemia, low platelets and low white cell count. The low white cell count may make the patient more susceptible to infections, as suggested by the multiple URTIs and new onset UTI.

Answer 171

Continuing the transfusion is not dangerous, but febrile reactions can be unpleasant for the patient so it is preferable to slow the rate of transfusion. This is a commonly encountered entity and does not routinely require input from haematology.

Answer 172

This patient is on warfarin and is having a significant arterial bleed and therefore requires reversal of his anticoagulation. Prothrombin complex concentrate provides a concentrate of factors 2,7,9,and 10 (those that are inhibited by the action of warfarin). Therefore replacing these factors will allow the coagulation cascade to proceed normally and clot formation to occur.

Answer 173

Ferritin is an intracellular protein that stores iron. In iron deficiency, there would be low iron stores and hence low ferritin levels.

Answer 174

Haemoglobin electrophoresis

Answer 175

Peripheral blood smear shows mature myeloid cells and multiple basophils

Answer 176

Essential thrombocythaemia occurs due to the clonal proliferation of megakaryocytes leading to persistently elevated platelet levels. Hydroxyurea suppresses the bone production of platelets in the bone marrow. This should reduce her risk of further venous thromboses.

Answer 177

The acute onset of the pain and with no abnormalities on examination and no significant drop in haemoglobin make a vaso-occlusive or "painful" crisis the most likely explanation. Common triggers include the cold (as in this scenario), dehydration, infection and hypoxia. Vaso-occlusive crises may present with pain anywhere in the body and in toddlers under 3 years, hands and feet are commonly affected. Vaso-occlusive crises are caused by micro-occlusion of blood vessels by sickled red blood cells.

Answer 178

Acute chest syndrome is a rare but very serious complication of sickle cell disease. It presents with pain, fever and respiratory symptoms such as tachypnoea, wheeze and cough. It is caused by pulmonary infiltrates, as seen on the chest x-ray, which involves whole lung segments. It should initially be treated with oxygen, analgesia, and empirical antibiotics.

Answer 179

This patient clearly has a thrombophilia and Factor V Leiden is the most common cause of inherited thrombophilia. The mutation is carried in about 5% of the UK population. Although it is autosomal dominant it has incomplete penetrance therefore not all those with the mutation are affected which fits with the history provided.

Answer 180

Beta-thalassaemia major normally presents in the first year of life and is caused by an inherited defect causing a ceasing in beta-chain production and hence no HbA is produced. Fetal haemoglobin (HbF) continues to be produced in order to compensate for this. Normally, we would expect ceasing of HbF production at around 6 months of age. The patient's body produces red blood cells in abnormal locations in the body (extramedullary haematopoeisis) such as the spleen causing splenomegaly and the skull causing frontal bossing, again to attempt to compensate for the lack of HbA. You should suspect thalassaemia when the MCV is disproportionately low compared to the haemoglobin. People of Meditarranean or Far Eastern descent are at highest risk for thalassaemia.

Answer 181

Hydroxycarbamide

Answer 182

Smudge cells are seen in chronic lymphocytic leukaemia (CLL). In CLL lymphocytes are fragile so may be damaged during the slide preparation, resulting in smudge/smear cells. CLL typically presents in male patients over the age of 60, and is often picked up incidentally as a raised white cell count.

Answer 183

The patient’s history, blood count and blood film (showing Cabot rings) is highly suggestive of pernicious anaemia, despite the normal B12 level. In this scenario, testing for methylmalonic acid (a measure of functional B12 status) is reasonable, as is looking for evidence of pernicious anaemia antibodies. Rechecking B12 level at this early stage is unlikely to yield different results. In this scenario it would also be reasonable to start empirical parenteral B12 repletion, given the high index of suspicion for pernicious anaemia.

Answer 184

Hereditary spherocytosis is an autosomal dominant condition which causes defects in the erythrocyte cytoskeleton. Macrophages in the spleen remove abnormal sections of the membrane, resulting in sphere-shaped erythrocytes (spherocytes) instead of the normal biconcave red blood cells. As more of the membrane is removed the erythrocytes prematurely haemolyse.

Answer 185

The patient's symptoms of anaemia, jaundice and splenomegaly are consistent with the diagnosis. Further clues include the patient's Northern European heritage and family history of haemolytic anaemia. The blood tests show a normocytic anaemia, raised reticulocyte count and raised bilirubin, all in keeping with haemolytic anaemia. The findings of spherocytes on the blood film, along with the eosin 5-maleimide (EMA) binding test confirm the diagnosis of hereditary spherocytosis. EMA is a dye which binds to proteins in the erythrocyte cell membrane which are deficient in hereditary spherocytosis. The reduced intensity of the fluorescent stain therefore confirms the diagnosis.

Answer 186

Glucose-6-phosphate deficiency is an X-linked recessive genetic disorder in which a deficiency of the glucose-6-phosphate enzyme results in free radicals destroying erythrocytes in response to oxidative stress.

Answer 187

Features in the history which would be in keeping with this diagnosis include patients of Mediterranean or African ethnicities with a recent trigger for haemolysis (e.g. intercurrent illnesses and infections, medications). The expected diagnostic findings would be Heinz bodies and bite cells on blood film.

Answer 188

Neuroleptic malignant syndrome is an uncommon side effect of anti-psychotic medication, characterised by pyrexia, tachycardia, rigidity and myoclonus. It is an important differential diagnosis for sepsis in patients on anti-psychotics presenting acutely. While it may resemble the acute presentation in these cases, it is not known to cause agranulocytosis.

Answer 189

Myelodysplasia is considered a "premalignant" disease that affects myeloid cells, which has around a 30% chance of developing into AML. Myelodysplasia can present with bone marrow failure, as shown in the blood results, due to ineffective haematopoeisis. Furthermore, bone marrow biopsy may show ring sideroblasts, as described in this patient.

Answer 190

ou should think of sideroblastic anaemia when a microcytic (↓MCV) anaemia (↓Hb) is not responding to iron replacement. Sideroblastic anaemia is a term that encompasses a group of disorders in which there is sufficient iron but ineffective erythropoiesis. It causes a microcytic anaemia and deposition of iron in multiple organs. Examination of the marrow will reveal ring sideroblasts in the nucleus.

Answer 191

Given the patients symptoms and lab results which show high levels of mature myeloid derived cells (neutrophils and platelets). A diagnosis of Chronic Myelogenous Leukaemia (CML) is suspected. This is confirmed by the prescription of imatinib, which is a highly successful treatment for CML. CML is characterised by the t(9;22) Bcr-Abl translocation, forming an unregulated tyrosine kinase which causes excessive proliferation and reduction in apoptosis.

Answer 192

New onset anaemia, jaundice, haemoglobinuria, absent organomegaly EV - inherited red cell abnormalities, abdominal organomegaly, and normal urine.

Answer 193

This patient has massive splenomegaly and a raised white cell count which is suggestive of CML. The Philadelphia chromosome translocation gives rise to the BCR-ABL tyrosine kinase and this can be targeted by Imatinib. This translocation is present in >95% of cases of CML and confers a better prognosis due to the ability to use Imatinib.

Answer 194

Streptococcus pneumonia is the most common cause of community-acquired pneumonia and characteristically presents with rusty-coloured sputum, rapid onset of symptoms and a high fever.

Answer 195

Klebsiella pneumoniae is a common cause of pneumonia in those with depressed immune systems, such as alcoholics, the homeless, and diabetics. Moreover, it can cause cavitating pneumonia which carries a high mortality. The hemoptysis this patient has experienced is likely due to this, and the area of low-enhancement with an air-fluid level is a description of a cavity. TB could present in a similar way, but the history would likely be more subacute with symptoms such as night sweats and weight loss. The finding of gram -ve rods from the sputum sample also goes against this. Gram-negative rods that most commonly cause pneumonia are Klebsiella, Pseudomonas, Haemophilus, and Bordetella pertussis. Out of all these, Klebsiella and Pseudomonas are the only causes of cavitating pneumonia, and Pseudomonas is usually hospital-acquired (e.g. by contaminating ventilators)

Answer 196

Streptococcus pneumoniae is a lobar pneumonia that is also associated with herpes labialis (blisters on lower lip).

Answer 197

Polysomnography

Answer 198

Currently the patient is not retaining carbon dioxide so this would be unnecessary. Tf they were to start to retain carbon dioxide with their home oxygen, the next step would be to use BiPAP. However, many patients do not tolerate this well and it can be very difficult to wean patients off of so it is important to have discussions about whether this is appropriate for the patient early on.

Answer 199

Features suggesting a severe attack include oxygen saturations <90%, peak expiratory flow rate <33% of best, silent chest, bradycardia, hypotension, exhaustion.

Answer 200

Sputum acid-fast bacilli (AFB) smear

Answer 201

Hyponaetraemia

Answer 202

Pituitary apoplexy is a rare emergency and is defined as bleeding into the pituitary gland that occurs in patients who have pituitary tumours. In this question the clues are that there is a history of visual problems in association with sudden headache.

Answer 203

Classic symptoms include sudden onset headache which is usually retro-orbital in nature and nausea or vomiting. A swollen pituitary gland can compress the contents of the cavernous sinus leading to ocular palsies. 80% of patients will have deficiency of hormones, including a lack of ACTH meaning that cortisol levels are low.

Answer 204

Zona glomerulosa

Answer 205

Inorganic iodide in excess of daily doses of 500 to 1000 mcg inhibits organification of iodide, inducing hypothyroidism

Answer 206

MEN I involves: Parathyroid hyperplasia/adenoma in 95% of cases Pituitary prolactinoma or GH secreting tumours (acromegaly) in 70% cases Pancreas endocrine tumours in 70% of cases. These include insulinoma and gastrinoma, which explains peptic ulceration.

Answer 207

This is the correct answer because it is most important to overcome the lack of ACTH by instituting cortisol replacement with steroids. Cortisol is the most important hormone to replace because its defiency can make patients the most unwell and often presents with an 'Addisonian' type clinical picture.

Answer 208

Malaise. Fatigue. Nausea or vomiting. Abdominal pain. Low-grade fever. Muscle pains and cramps. These are followed by dehydration, leading to hypotension and hypovolaemic shock. There may be confusion. Loss of consciousness and coma may occur.

Answer 209

A 75g oral glucose tolerance test ≥11.1 mmol/L (≥200 mg/dL) at 2 hours can be used as a diagnostic test for diabetes. Diabetes should be confirmed on a separate occasion with another diagnostic test

Answer 210

Overnight dexamethasone suppression Test

Answer 211

In hypocalcaemia we have signs of tetany which is of nerve hyperexcitability. Chvostek sign refers to a reaction to percussion of the facial nerve in front of the ear lobe and below the zygomatic process. When present we get ipsilateral contraction of the muscles of the face. While it may be be present it does not suggest the underlying cause of the hypocalcaemia. Other features one might expect in hypocalcaemia include perioral and extremity numbness, laryngospasm and arrhythmia.

Answer 212

Waterhouse-Friderichsen syndrome is adrenal gland failure due to bleeding into the adrenal gland. It is usually caused by severe meningococcal infection or other severe, bacterial infection. Symptoms include acute adrenal gland insufficiency, and profound shock. Waterhouse-Friderichsen syndrome is most often associated with meningococcal disease (accounts for 80% of cases). The syndrome also has been associated with other bacterial pathogens, including Streptococcus pneumoniae, group A beta-hemolytic streptococci, Neisseria gonorrhoeae, Escherichia coli and many others. It may also be associated with a history of splenectomy

Answer 213

Serum C-peptide is a byproduct of insulin production. Therefore, if it is raised this indicates that there is excessive endogenous insulin production. In contrast, if it is not raised then this indicates that the patient has administered herself insulin.

Answer 214

Sulphonylureas work to increase insulin release by closing ATP sensitive potassium channels on the cell membrane of beta cells of the pancreas. This results in the cells to depolarize and calcium channels to open leading to insulin release. Metformin increases peripheral tissue insulin sensitivity but does not cause hypoglycaemia.

Answer 215

Overnight dexamethasone test

Answer 216

Klinefelter's syndrome is a genetic condition where those affected have an extra X-chromosome. Patients often present with minor developmental delay and learning disabilities. Classical description is of tall and slender male with gynaecomastia and small firm testes. In the question we state little facial hair and muscle bulk relating to the lack of circulating testosterone.

Answer 217

Propylthiouracil (doesn't cross the placenta like carbimazole). Works by inhibiting the TPO enzyme.

Answer 218

Propylthiouracil (doesn't cross the placenta like carbimazole). Works by inhibiting the TPO enzyme.

Answer 219

Nelson syndrome is where where in the setting of Cushing’s syndrome a bilateral adrenalectomy has taken place. As a consequence, there is a loss of feedback to the brain and we get increased Corticotrophin-Releasing Hormone from the hypothalamus leading to increased stimulation of the anterior pituitary and enlargement of the pituitary and formation of an adenoma. This leads to symptoms of mass effect with headaches, visual field defects but also hormonal issues with compression of the posterior pituitary. Primary treatment is transphenoidal surgery.

Answer 220

Us eof organic nitrates - can cause significant hypotension

Answer 221

IGF-1 - doesn't fluctuate throughout the day like GH

Answer 222

P. aeruginosa is frequently cultured from samples obtained from a draining sinus tract or deep penetrating ulcers in patients with diabetes. Because Pseudomonas organisms are water-borne, superficial ulcers may be contaminated by bacteria in wet socks or dressings.

Answer 223

P. aeruginosa is frequently cultured from samples obtained from a draining sinus tract or deep penetrating ulcers in patients with diabetes. Because Pseudomonas organisms are water-borne, superficial ulcers may be contaminated by bacteria in wet socks or dressings.

Answer 224

Loss of the lateral third of the eyebrow This is known as Hertoghe sign and classically seen in hypothyroidism although there are a few other conditions where it may also be present (e.g. atopic dermatitis, leprosy).

Answer 225

Primary - one parathyroid gland (or more) produces excess PTH. This may be asymptomatic or can lead to hypercalcaemia. Secondary - there is increased secretion of PTH in response to low calcium because of kidney, liver, or bowel disease. Tertiary - there is autonomous secretion of PTH, usually because of chronic kidney disease (CKD).

Answer 226

Papillary thyroid cancer

Answer 227

This is correct because the results demonstrate a fasting glucose >6mmol/L and <7mmol/L.

Answer 228

Thyroid peroxidase is an enzyme expressed within follicular cells which catalyses the iodination of tyrosine residues in thyroglobulin in order to produce T3 and T4 hormone.

Answer 229

Key side effects of Carbimazole therapy include rash and pruritis. In addition, there is the serious side effect of agranulocytosis with neutropenia. This can occur at any stage of treatment. Therefore, if there are any signs of infection or fever a Full Blood Count (FBC) should be arranged.

Answer 230

According to NICE guidelines, gestational diabetes mellitus is diagnosed if the woman has either: a fasting plasma glucose level of ≥5.6 mmol/L; or a 2-hour post-oral glucose tolerance test plasma glucose level of ≥7.8 mmol/L.

Answer 231

Anaplastic thyroid cancer

Answer 232

These agents eg. octreotide are generally used first line to control excess GH. They work by blocking GH production.

Answer 233

Fluid retention

Answer 234

This is the correct answer as it is the standard medication used to control the manifestations of adrenaline excess. Phenoxybenzamine is a non-specific alpha adrenoceptor blocker. This medication enables the blood pressure to be controlled peri-operatively and avoid spikes of high BP occurring when the tumour is handled.

Answer 235

Parathyroid adenoma

Answer 236

Decreased TSH, normal T3 and T4

Answer 237

Subacute thyroiditis presents with signs and symptoms of hyperthyroidism, a painful neck over the aggravated thyroid gland, malaise and with biochemistry in the early stages consistent with hyperthyroidism. This condition is believed to be related to a viral infection and starts with hyperthyroidism followed by a hypothyroid phase following depletion of thyroid hormone from the thyroid gland. It is often associated with a raised CRP and ESR. The majority of cases return to euthyroidism but some people experience residual hypothyroidism. Most cases respond to NSAID treatment plus beta blockers if required and are self-limiting within 6 months. Anti-thyroid medication is not required.

Answer 238

Basophilic stippling (also known as punctate basophilia) is the blue staining of ribosomal precipitates within the cytoplasm of red blood cells. It is seen in megaloblastic anaemia, thalassaemias (in particular alpha thalassaemia), sideroblastic anaemia and alcohol abuse. A rare cause is the inherited disorder pyrimidine 5'-nucleotidase deficiency.

Answer 239

New onset severe microcytic anaemia at 3-9 months (as levels of foetal haemoglobin fall) is typical of beta-thalassemia major, and frontal bossing may occur as a result of ineffective hematopoiesis (leading to marrow expansion elsewhere in the body). Hepatosplenomegaly may also be detected on abdominal examination (extra-medullary haematopoesis). While thalassaemia is typically detected antenatally, the fact that this child was not born in the UK may explain why this was not detected earlier.

Answer 240

The joint symptoms (focused on the metacarpophalangeal joints) and hyper-pigmented appearance are typical of iron overload, and the patient’s history of repeated transfusions makes this diagnosis likely. It would be sensible to also check liver function tests, oral glucose tolerance tests, and an ECG/echo; and to measure iron status with blood tests and imaging.

Answer 241

The joint symptoms (focused on the metacarpophalangeal joints) and hyper-pigmented appearance are typical of iron overload, and the patient’s history of repeated transfusions makes this diagnosis likely. It would be sensible to also check liver function tests, oral glucose tolerance tests, and an ECG/echo; and to measure iron status with blood tests and imaging.

Answer 242

Acute Myelogenous Leukaemia

Answer 243

ECG, U&E, calcium, uric acid Common metabolic abnormalities include raised uric acid, calcium, and potassium. ECG is important as hyperkalaemia may precipitate arrhythmias.

Answer 244

Epstein-Barr Virus

Answer 245

This is the Cushing's triad, which is the physiological response that can be seen in the context of raised ICP. Increased blood pressure is an attempt to maintain adequate cerebral blood flow, while the bradycardia is a baroreceptor reflex in response to hypertension. The respiratory centre is located in the brainstem. Increased ICP leads to increased pressure on the brainstem, leading to irregular breathing patterns.

Answer 246

Modified Glasgow criteria

Answer 247

Non-selective adenosine receptor antagonist and phosphodiesterase inhibitor

Answer 248

Try on oral pred, if not then investigate for other differentials

Answer 249

Creatine kinase (compared with creatinine in rhabdomyolysis)

Answer 250

Anti-centromere antibody Scl-70 (anti-topoisomerase 1) Anti-RNA polymerase III

Answer 251

Aspirin 75mg and LMWH

Answer 252

Infliximab is an anti-TNFa biologic treatment. Biologics like infliximab slow the progression of rheumatoid arthritis, improve symptoms and are very effective for certain patients.

Answer 253

Lateral hip pain (worse at night and aggravated by physical activity) Swelling Causes include soft tissue trauma like a fall onto the hip as well as strain injury like hiking, differences in leg length, prolonged sitting and excessive running.

Answer 254

Pulmonary oedema

Answer 255

To control seizures, in the treatment of epilepsy

Answer 256

Oozing from a cannula

Answer 257

Disseminated intravascular coagulation (DIC) is a syndrome characterised by widespread activation of coagulation pathways, and subsequent depletion of platelets and coagulation factors. Causes include sepsis, haematological malignancies, and major organ dysfunction.

Answer 258

This patient has started to become more drowsy, confused and developed a headache about half an hour after being started on 60% oxygen. In the context of a COPD patient, this must be treated as hypercapnia. The oxygen supply should be reduced immediately. You may also need to do an ABG to assess his arterial pH and pCO2, which will allow you to consider further management options such as NIV.

Answer 259

Insert a needle just left to her xiphoid process, aiming towards her left shoulder This describes how pericardiocentesis can be done. Pericardiocentesis involves the insertion of a needle into the pericardial sac to relieve over-accumulation of fluid. This can be done to treat cardiac tamponade, which is what this lady has. SLE is a risk factor for the development of cardiac tamponade.

Answer 260

A serotonin 5HT3 antagonist, it is often used as an adjunct with chemotherapy to reduce nausea. Importantly, it can be given PO/IM/IV making it useful when a patient is unable to keep oral foods down. One should note that ondansetron can increase QT interval and put a patient at risk of torsades de pointes which is what happened in this case.

Answer 261

Clarithromycin

Answer 262

Cyanosis is a feature of life-threatening asthma attack. Other features include PEF < 33% of predicted or best, SpO2 < 92%, PaO2 < 8 kPa, PaCO2 4.6-6.9 kPa, altered conscious level, exhaustion, hypotension, and silent chest. Remember, raised PaCO2 is a feature of near-fatal asthma.

Answer 263

IV Atropine 500 micrograms is given, and can be repeated every 3–5 min to a total of 3 mg.

Answer 264

ST depression with first degree heart block

Answer 265

Glucagon can be given to counteract a beta blocker or calcium channel blocker overdose.

Answer 266

This patient is experiencing severe digoxin toxicity (the presence of arrhythmia and xanthopsia - yellow vision, haemodynamically unstable) following an overdose of digoxin tablets with suicidal intention.

Answer 267

Calcium gluconate is used for acute, severe hyperkalaemia. It is used to stabilise the cardiac myocytes and is usually following by an insulin infusion to slowly shift the potassium into the cells.

Answer 268

Aspirin overdose initially presents with a respiratory alkalosis due to hyperventilation, progressing to a metabolic acidosis. Patients may also experience tinnitus, vomiting and dehydration.

Answer 269

Both the Glasgow-Blatchford score and the Rockall score are used to assess the risk of patients who present with a presentation suggestive of an upper GI bleed. The main difference between being whether endoscopy findings are included. As this patient is yet to have endoscopy, then the Glasgow-Blatchford score is most appropriate.

Answer 270

Naproxen (NSAID) and bed rest

Answer 271

IV sodium bicarbonate

Answer 272

It is spread via sand-flies and the lesions develop at the bite sites , beginning as an itchy papule, crusts develop and then fall off leaving a painless ulcer with a well-defined raised border and a crusted base. This is known as Chiclero's ulcer.

Answer 273

Severe pain on defecation

Answer 274

A long history of halitosis, regurgitation of food and recurrent chest infections

Answer 275

Courvoisier’s sign is a painless palpable gallbladder associated with jaundice. It is associated with a tumour in the head of the pancreas.

Answer 276

Whenever a child presents with an acute abdomen, it must be taken seriously as children can detriorate very quickly. Appendicitis should always be ruled out as mesenteric adenitis is a diagnosis of exclusion. Evidence of mesenteric adenitis in this case, is history of upper respiratory tract infection, no anorexia, afebrile with only minimal guarding indicates a self-limiting disease.

Answer 277

Ultrasound

Answer 278

Under 2y, this boy with inconsolable crying and currant-jelly stool most likely has intussusception.

Answer 279

This is a classical findings in caecal volvulus

Answer 280

The combination of severe chest pain after vomiting, signs of shock, double heart border (a sign of pneumomedistinum) and effusion all fit with Boerhaave syndrome. This is causes by a full thickness rupture of the oesophagus. It is common for patients to not vomit up blood which helps distinguish it from a Mallory-Weiss tear.

Answer 281

This is when palpation of the left lower quadrant of a patient's abdomen increases the pain felt in the right lower quadrant. It is a sign of appendicitis. This occurs as the peritoneal lining has become inflamed around the appendix thus irritating the muscles here; upon palpation of the left side the perineal lining is stretched and will produce pain where the peritoneum is irritating the muscle.

Answer 282

While the symptoms present are classic of bowel obstruction, feature such as nausea and vomiting are more commonly seen in small compared with large bowel obstruction.

Answer 283

CT chest, abdomen and pelvis

Answer 284

A pancreatic pseudocyst is a fluid-filled collection comprising of pancreatic enzymes, blood, and necrotic tissue. They typically appear 4 weeks after an episode of acute pancreatitis and are associated with persistently raised amylase. Up to 50% of pancreatic pseudocysts will self-resolve and can be managed conservatively. Otherwise, pancreatic pseudocysts can be managed by surgical debridement or endoscopic drainage.

Answer 285

Mesenteric angiography is the diagnostic investigation of choice, and will demonstrate a proximal occlusion of mesenteric vessels or vasoconstriction of all mesenteric arcades.

Answer 286

Rubber band ligation

Answer 287

Grade 2 haemorrhoids (i.e. prolapse on straining which spontaneously reduces) Grade 3 haemorrhoids (i.e. prolapse on straining and require manual reduction) Grade 1 haemorrhoids (i.e. no prolapse) can be managed conservatively, ± topical corticosteroids to alleviate pruritus.

Answer 288

The embolic nature of a mesenteric infarction causes a sudden evacuation of the bowels that may contain blood, as the infarction leads to bleeding into the gut wall, lumen and peritoneal cavity.

Answer 289

Carcinoembryonic antigen (CEA)

Answer 290

Hartmann’s procedure is usually performed in an acute setting where it is unsafe to make an anastomosis, usually for perforated diverticular disease or obstructing cancer. It is usually performed as a temporary measure with the aim to reverse it at some point. Hartmann’s procedure involves the resection of the sigmoid colon +/- rectum, resulting in the formation of an end colostomy and a closed rectum. Re-anastomosis is carried out at a later date.

Answer 291

Presents with dysphagia, regurgitation of food (which can be several hours after eating) with a sensation of food being stuck in the throat. Halitosis is often debilitating. A key finding is gurgling sounds being aspirated in the neck which is 'almost' pathognomonic of Zenker diverticulum. Also known as pharyngeal pouch.

Answer 292

Slows HR. Used in SVT.

Answer 293

Symptomatic bradycardia

Answer 294

A tumour marker for HCC, testicular cancer and ovarian cancer.

Answer 295

. Ecchymosis along the flanks of the abdomen represents Gray-Turner’s sign, which represents haemorrhagic pancreatitis.

Answer 296

The development of metastases to the ovary.

Answer 297

The right main bronchus is wider, shorter and more vertical in comparison to the left. Foreign bodies are more likely to be aspirated into this bronchus.

Answer 298

superior and medial to the pubic tubercle.

Answer 299

Physical findings suggest that this patient has a direct inguinal hernia as the hernia reappears despite the occlusion of the deep ring (midpoint of ASIS and pubic tubercle). Direct hernias are more common with age as the abdominal muscle weakens.

Answer 300

Pulmonary atelectasis occurs due to bronchial secretions, which cause airway obstruction and consequently result in lung collapse. It is a common cause of post-operative fever in the first day after surgery. Patients may be tachycardic, tachypnoeic and have a low-grade fever. The physical findings of dull lung bases with reduced fremitus are consistent with pulmonary atelectasis

Answer 301

Hypokalaemia is more likely to present with general weakness, lethargy and cramps than sensory change.

Answer 302

Sigmoid volvulus

Answer 303

This is a syndrome of recurring abdominal pain and reflux symptoms which is not the acute clinical picture described here. The patient would be clinically stable, and it can present months or years after initial surgery.

Answer 304

Place patient nil by mouth (NBM) and insert nasogastric (NG) tube This is known as 'drip and suck' where the patient is resuscitated with fluids and the bowel is decompressed by placing the patient NBM and with the insertion of NG tube.

Answer 305

Pneumobilia (air within the biliary tree)

Answer 306

Pancreatic inflammation leads to release of inflammatory and vasoactive mediators. These in turn cause a combination of vascular injury, microscopic intravascular coagulation and vasoconstriction leading to fluid extravasation into third spaces (e.g. pleural effusions, pseudocyst).

Answer 307

Colorectal cancer

Answer 308

Migratory thrombophlebitis (Trousseau's sign) may occur in pancreatic cancer secondary to the increased risk of venous thrombosis.

Answer 309

Courvoisier's law states that in the presence of a non-tender enlarged gallbladder and jaundice, the cause is unlikely to be gallstones (and is more likely to be pancreatic cancer).

Answer 310

Incision and drainage

Answer 311

More than 90% of anal fissures are located in the posterior midline of the anal canal.

Answer 312

The patient presents with clinical features consistent with Felty's syndrome, an uncommon extra-articular manifestation of rheumatoid arthritis. Felty's syndrome is characterised by the triad of: rheumatoid arthritis with splenomegaly and neutropenia.

Answer 313

A: limited to the bowel wall (i.e. not beyond the muscularis). B: extending through the bowel wall (i.e. beyond the muscularis). C: regional lymph node involvement. D: distant metastases.

Answer 314

Oesophageal manometry which measures the pressure of the sphincter and the surrounding muscles. Manometry will show failure of the lower oesophageal sphincter to relax as well as reduced peristalsis.

Answer 315

To do. Cystoscopy.

Answer 316

"Birds beak" appearance

Answer 317

chest physiotherapy

Answer 318

Longstanding achalasia

Answer 319

The history of ongoing vomiting with a severe ripping chest pain indicates an oesophageal perforation. The crackling sign is the key feature here. It is known as Hamman sign and represents air within the subcutaneous space.

Answer 320

Rigler sign is seen on abdominal x-ray when air is present on both sides of the intestine (on both luminal and peritoneal sides of the bowel wall). It is caused by perforation of a viscus, or recent surgery or instrumentation.

Answer 321

Bile salts are reabsorbed in the terminal ileum; thus its resection increases the risk of gallstone formation.

Answer 322

Septal haematoma is caused by bleeding under the perichondrium lining the septal cartilage, typically due to nasal trauma. Damage to the septal cartilage can occur within 24 hours and if untreated, this can lead to irreversible septal perforation and necrosis, eventually resulting in saddle-nose deformity.

Answer 323

Refer all patients suspected of having a septal haematoma to ENT for emergency incision and drainage.

Answer 324

Anterior rhinoscopy will show a bilateral cherry-red swelling arising from the nasal septum.

Answer 325

Otitis media with effusion

Answer 326

MacConkey agar is used to isolate gram negative bacteria, and test whether they can or cannot ferment lactose, by revealing pink or clear colonies, respectively. Pseudomonas aeruginosa would grow on MacConkey agar.

Answer 327

Quinsy is caused by spread of infection from the tonsils into the peritonsillar space.

Answer 328

Sound therapy

Answer 329

Pain in his forehead and cheeks as well as nasal discharge for >5 days

Answer 330

Initially paracetamol, nasal saline irrigation and decongestants Then consider topical steroids and abx

Answer 331

They tend to be slow growing and can impinge on the vestibulocochlear nerves (giving a sensorineural hearing loss) and the facial nerve (causing a facial droop). The commonest presentations are hearing loss, tinnitus and vertigo.

Answer 332

This is a remnant of the second branchial cleft, which first presents if it becomes filled with fluid. Usually it first fills with fluid in childhood after an upper respiratory tract infection, after which time it persists.

Answer 333

An increased risk of oral, pharyngeal and laryngeal cancer.

Answer 334

Ultrasound

Answer 335

Tympanosclerosis is a condition characterised by chronic inflammation and scarring of the tympanic membrane leading to subsequent calcification of the tympanic membrane and associated structures.

Answer 336

The aetiology of tympanosclerosis is not well understood, but there appear to be a number of factors associated with the condition; including long term otitis media and tympanostomy (grommet) insertion. Patients will normally present with significant hearing loss and on examination will present with chalky white patches on the tympanic membrane.

Answer 337

This should be suspected in any adult that presents with chronic (>12 weeks) rhinosinusitis for the first time. Additional alarm symptoms include blood-stained nasal discharge and swelling overlying the sinus

Answer 338

Asymmetric neck mass in an adult patient is malignant until proven otherwise. hard and fixed nature on examination

Answer 339

Hereditary haemmorhagic telangiectasia (or Osler Weber Rendu disease) is an autosomal dominant (AD) disorder characterised by telangiectasia on skin and mucous membranes. These malformations can occur within the nasal mucosa and are prone to bleeding.

Answer 340

Pleomorphic adenoma

Answer 341

Urgent referral to rule out cancer

Answer 342

It is a serious and rare complication of chronic otitis media and commonly occurs in younger patients (aged 5-15 years old). It is caused by the abnormal accumulation of skin, squamous epithelium within the middle eat cleft and mastoid air cells.

Answer 343

When there's debris in the ear canal, so the abx can reach the mucosa and penetrate the site of infection

Answer 344

Clarithromycin or erythromycin

Answer 345

Reinke’s oedema or vocal cord oedema is a progressive problem caused by thickening of the vocal cords. It is commonly linked to hypothyroidism.

Answer 346

ENT emergency - urgent same-day referral to ENT

Answer 347

Nasal obstruction, clear nasal discharge and a background of atopic asthma

Answer 348

Conductive deafness

Answer 349

a pink tinge to the tympanic membrane, which is known as Schwarze sign or Flamingo flush, which only occurs in 10% otosclerosis cases but is highly specific.

Answer 350

Chronic plaque psoriasis is the commonest type of psoriasis and presents with symmetrical, erythematous, scaly plaques usually seen on the extensor surfaces of the limbs (knees + elbows), scalp and lower back. It is usually well-demarcated and discoid (coin-shaped) and is often associated with nail changes.

Answer 351

Auspitz sign - pinpoint bleeding on removal of a layer of scale- is a classical finding.

Answer 352

Ann Arbor Staging is used to stage Non-Hodgkin Lymphoma and includes location of the malignancy and symptoms it is causing.

Answer 353

Breslow thickness measures the depth of the Melanoma from the top of the granular layer of the epidermis to the deepest cancerous cell. Breslow thickness at the time of surgical removal is used to predict the likelihood of recurrence. Melanomas less than 0.75mm have a very low risk, 0.75 to 1.5mm have a medium risk and those larger than 1.5mm have a high risk of recurrence.

Answer 354

Folliculitis presents as an itchy red rash of pustules in an area around hair follicles. This can be anywhere on the body (except the soles or palms), but is most common on the neck, armpit or groin.

Answer 355

Erythroderma, also known as "red man syndrome", is defined as erythema (reddening) of more than 90% of the skin surface.

Answer 356

Commonly, those affected have an underlying skin condition, for example Atopic Eczema (as in this case) or Psoriasis. Other causes include drug reactions or malignancies such a Lymphoma.

Answer 357

Comedones are dilated sebaceous follicles in the skin (also called pores). They can be open (blackheads) or closed (whiteheads) due to the accumulation of bacterial and cellular debris. Both open and closed comedones are non-inflammatory lesions associated with mild Acne Vulgaris.

Answer 358

In moderate and severe Acne Vulgaris, papules, nodules and pustules can be seen. A papule is solid, raised lesion less than 0.5 cm in diameter. A nodule is also a solid, raised lesion less than 0.5 cm in diameter but with a deeper component. A pustule is a lesion less than 0.5 cm in diameter that contains pus.

Answer 359

This is the only option that causes a scarring alopecia. Folliculitis decalvans causes a scarring alopecia with peri-follicular pustules and multiple hairs originating from a single follicle.

Answer 360

Necrotising Fasciitis is a serious bacterial infection of the soft tissue and fascia. Cellulitis is a bacterial infection of the skin involving deep subcutaneous tissue.

Answer 361

Secondary syphilis develops as a maculopapular rash covering the torso and limbs as well as the palms and soles. Patients generally feel very unwell and have lymphadenopathy.

Answer 362

Pityriasis rosea is found to present most commonly in individuals between the ages of 10 and 35. They are often found to have had a viral respiratory illness in the few weeks preceding the rash. It begins with a single large red patch (herald patch) which is followed by a generalised pink rash.

Answer 363

Guttate Psoriasis is a type of Psoriasis that is typically triggered by a Streptococcal infection. The rash has a sudden onset 2-4 weeks post infection. It most commonly occurs in children and young adults. 'Gutta' translates as 'drop' from Latin, describing the characteristic appearance of the rash. Guttate Psoriasis usually resolves in a few months but can persist as Plaque Psoriasis.

Answer 364

The fragile, superficial blisters in pemphigus vulgaris are caused by deposition of IgG auto-antibodies within the epidermis. Specifically, IgG binds to the desmosomes between keratinocytes and cleaves them, allowing cells to separate and blisters to form. This results in the characteristic ‘chicken-wire’ or ‘crazy-paving’ appearance.

Answer 365

Bullous pemphigoid results in deep, tense blisters due to deposition of IgG auto-antibodies to the basement membrane.

Answer 366

These lesions typically resolve by themselves, and no single treatment has been found to be better than the natural resolution of this condition.

Answer 367

Lichen planus is a cutaneous disorder with itchy, flat topped papules usually seen on the lower legs, flexor aspects of the wrist, and the genitalia. The aetiology is not fully understood, but it is thought to be related to anxiety, stress, viral infection and drug reactions.

Answer 368

The image shown demonstrates Urticaria (also known as Hives) which characteristically presents with pruritic wheals. A wheal is a transient, raised lesion due to underlying dermal oedema.

Answer 369

If haemodynamically stable - amiodarone If unstable - cardioversion

Answer 370

Conditions for severe asthma

Answer 371

One-third of the distance from the anterior superior iliac spine to the umbilicus on the right side. Indicates acute appendicitis

Answer 372

Therefore, the most appropriate first step is to attempt vagal maneuvers such as carotid massage or valsalva maneuver (asking the patient to blow into a syringe) which is an attempt to transiently block the atrioventricular node. If this is unsuccessful, IV Adenosine can be given.

Answer 373

Go over ABG interpretation

Answer 374

Carbon monoxide poisoning

Answer 375

When CT head after brain injury

Answer 376

As this patient does not have any underlying lung disease, this can be considered a primary pneumothorax. Patients with a primary pneumothorax who are asymptomatic and have a pneumothorax measuring <1cm from the chest rim, as in this case, can be discharged and followed up in 2 to 4 weeks in the outpatient department.

Answer 377

Obstructive shock

Answer 378

Cardiogenic shock is when the heart fails to pump effectively. It is most commonly caused after a myocardial infarction. Other causes include ventricular arrythmias and atrial fibrillation.

Answer 379

Vasodilatory action and they also increase fluid excretion to decrease the hydrostatic pressure in the pulmonary circulation and allow fluid to move out of the lungs back into the circulation.

Answer 380

Exophthalmos is specific to Grave’s disease because it is a consequence of antibody infiltration and oedema of the periorbital tissues and muscles.

Answer 381

Klinefelter’s syndrome results from an extra X chromosome in males and presents with the classical features of tall stature, hypogonadism, gynaecomastia and delayed puberty (failure to develop signs of puberty by age of 15 years in boys).

Answer 382

Smoking is the main risk factor for thyroid eye disease in patients with Graves' disease.

Answer 383

The classic electrolyte disturbances occurring in Addison's are hyponatraemia and hyperkalaemia (most severe in an Addisonian crisis). This is to the fact that as well as cortisol deficiency, there will be some mineralocorticoid deficiency related electrolyte imbalance as well resulting in loss of sodium and retention of potassium. Other things to look out for include a raised urea, normocytic anaemia, raised ESR and an eosinophilia.

Answer 384

Management of gestational diabetes

Answer 385

Finding lack of suppression of growth hormone (GH) during OGTT (with 75 g glucose load) is the standard method to confirm the diagnosis of acromegaly.

Answer 386

Hyperparathyroidism, primary, secondary and pseudohypoparathyroidism

Answer 387

Macrosomia (birthweight >4kg) and neonatal seizures are both complications of poorly controlled maternal diabetes during pregnancy and thus this is the most likely diagnosis. Macrosomia is a result of excess maternal blood glucose crossing the placenta and inducing increased insulin production in the baby. Hypoglycaemic episodes due to sustained high fetal insulin levels after birth can lead to seizures when severe.

Answer 388

Sore throat - This may be a presentation of bone marrow suppression causing agranulocytosis (a reduction in white blood cells) which is rare (0.03%) but can can lead to life-threatening sepsis. It may present with a sore throat, fever or throat/mouth ulcers. If it is suspected, warn the patient to stop the drug and get an urgent full blood count (FBC).

Answer 389

Weaning down and discontinuing the dopamine agonist after a year's worth of treatment, in the context of a pituitary microprolactinoma (less than 10mm) is a safe and appropriate thing to do. Monitoring of the serum prolactin should take place but in the majority of cases the hyperprolactinaemia will resolve. If the prolactin levels are resurgent then restarting the medication and considering definitive surgery are the next steps.

Answer 390

Phenoxybenzamine, a non-selective alpha blocker, is the most common medication used to alpha block patients prior to pheochromocytoma resection. A major disadvantage of Phenoxybenzamine is that it blocks presynaptic alpha-2 receptors enhancing the release of noradrenaline, resulting in a reflex tachycardia.

Answer 391

Caused by a severe bacterial infection which results in disseminated intravascular coagulation and subsequent adrenal haemorrhage and failure. Waterhouse-Friderichsen's syndrome is characterised by adrenal haemorrhage and consequent adrenal failure.

Answer 392

Water deprivation test. Patients are deprived of fluids for 8 hours or until 3% loss of their body weight is reached. Serum osmolality, urine volume, and urine osmolality are measured hourly. The test is said to be positive if there is a suboptimal response in urinary concentration to dehydration (normal response equates to a rise in urine osmolality to >700 mOsm/kg); the level of concentration in urine osmolality will give an indication of renal concentrating capacity, and thus the severity of diabetic insipidus (partial versus complete).

Answer 393

First line treatment for acromegaly is trans-sphenoidal surgery. If surgery cannot or is not performed, patients should be managed with SRLs 9somatostatin receptor ligands).

Answer 394

When there is steroid induced hyperglycaemia it is important to elicit whether there is a background history of diabetes before a HbA1c test is performed. As stated this was normal and as such this hyperglycaemia is due to the steroids. In this instance starting Sulphonyulrea therapy, such as Gliclazide is the first agent to use

Answer 395

A painless palpable gallbladder and jaundice. Seen in pancreatic cancer

Answer 396

Migrator thrombophlebitis. Seen in pancreatic cancer.

Answer 397

Zollinger Ellison Syndrome is a condition whereby there is excess acid production leading to peptic ulcers. It is caused by a gastrinoma which is a neuroendocrine tumour secreting the hormone gastrin. Gastrin is a peptide hormone that is released by parietal G-cells of the antrum of the stomach. It functions by increasing the insertion of H+/K+-ATPase pumps into the apical membrane of parietal cells thus releasing more H+ into the stomach lumen thereby decreasing the pH.

Answer 398

Amoxicillin, clarithromycin and omeprazole for 7 days

Answer 399

Hereditary haemochromatosis (HH) is a genetic condition of increased intestinal iron absorption that results in joint pains (especially in 2nd & 3rd MCP joints), erectile dysfunction, slate-grey skin pigmentation, cirrhosis, dilated cardiomyopathy and osteoporosis. It usually presents in men in middle age. This patient has acute-on-chronic liver failure. A ferritin level of over 1mg/L and transferrin saturation of over 45% are highly suggestive of HH – the diagnosis can be confirmed through genetic studies. Treatment is with regular venesection

Answer 400

This patient has presented with symptoms that may suggest COPD; however, he has no smoking history and bronchodilators are ineffective. He has also presented with jaundice suggesting liver disease. The unifying diagnosis in this case would be alpha-1 antitrypsin deficiency. Therefore a serum level would be low

Answer 401

Octreotide is a somatostatin analogue, which blocks the release of serotonin and counters its peripheral effects.

Answer 402

A bisphosphonate

Answer 403

Prednisolone

Answer 404

Whipple's disease is a rare disorder caused by Tropheryma whipplei infection. This infection causes a systemic disease characterised by several features.

Answer 405

It often starts insidiously with large-joint polyarthralgia. Gastrointestinal features include malabsorption, diarrhoea and weight loss. Patients can have skin manifestations: hyperpigmentation and photosensitivity. Cardiac involvement can lead to endocarditis. Neurological symptoms include dementia, ophthalmoplegia and facial myoclonus, as well as insomnia. Gold standard for diagnosis is a jejunal biopsy, which shows stunted villi and deposition of macrophages in the lamina propria, which stain positive for period acid-Schiff (PAS). Treatment is with antibiotics; current guidance is Co-Trimoxazole

Answer 406

This patient is presenting with features of Typhoid fever. Typhoid fever is a bacterial infection cause by Salmonella typhi. Features include systemic upset such as fever and malaise, abdominal pain, relative bradycardia and rose spots (macular rash across the trunk). Diarrhoea is uncommon. Patients may also have hepatosplenomegaly on examination, and their blood tests tend to show a leukopaenia. Incubation period ranges from 6 to 30 days. Mainstay treatment for Typhoid fever is intravenous fluids and a short course of antibiotics, most commonly a quinolone such as Ciprofloxacin

Answer 407

Lactulose is catabolised by colonic bacteria to form short-chain fatty acids. These decrease colonic pH and hold ammonia (NH3) in the large intestine as NH4+. As raised serum ammonia is the cause of hepatic encephalopathy, lactulose reduces the risk of developing this condition

Answer 408

Total IgA and IgA tissue transglutaminase (tTG).

Answer 409

Aminosalicylate agents. Used to maintain remission in UC

Answer 410

The yellowish pigmentation of the sclera, which is the normally white area of the eye

Answer 411

Sliding hiatal hernia (80%): The gastro-oesophageal junction slides up into the chest. A less competent sphincter results in acid reflux. Treatment is similar as for GORD. Rolling hiatal hernia (20%): The gastro-oesophageal junction remains in the abdomen but part of the stomach protrude into the chest alongside the oesophagus. This type needs more urgent treatment as volvulus can result in ischemia and necrosis.

Answer 412

Anterior uveitis is inflammation of the anterior portion of the uvea, which includes the iris and ciliary body. Patients typically present with a red and painful eye. Other features include photophobia, blurred vision, lacrimation and a hypopyon (inflammatory cells in the anterior chamber).

Answer 413

It is associated with HLA-B27 and seen in several autoimmune conditions including inflammatory bowel disease (both UC and Crohn's disease), ankylosing spondylitis, reactive arthritis and Behcet's disease

Answer 414

This scenario is very suggestive of cholera, caused by a strain of Vibrio cholerae, probably from a roadside stall. The illness is characterized by an abrupt onset of voluminous watery diarrhoea, which – in the absence of appropriate hydration- is associated with a rapid descent into hypovolaemic, acidosis and death

Answer 415

Reading liver test results

Answer 416

Metronidazole is unpalatable and can cause a metallic taste in the mouth.

Answer 417

Schistosomiasis is an infection from a trematode (fluke) of the genus Schistosoma. It is an endemic in many countries, particularly those in sub-Saharan Africa. In these areas it is the leading cause of portal hypertension - which this patient is presenting with (ascites, caput medusae). As well as the liver, chronic disease can cause genitourinary (frequency, haematuria, urinary tract obstruction), and other gastrointestinal symptoms (GI bleed, diarrhoea, abdominal pain)

Answer 418

Dermatitis herpetiformis is an autoimmune skin disorder strongly associated with coeliac disease. The features are an intensely itchy papulovesicular rash, which has a symmetrical distribution on extensor surfaces. The mainstay of treatment is adhering to a gluten-free diet, and Dapsone can be given to alleviate the itch. This patient is likely to have had gluten on his weekend away, which precipitated the rash

Answer 419

Transferrin saturation measures the volume of iron that is bound to protein, or transferrin, in your blood. Transferrin saturation > 45% is abnormal and highly suggestive of a diagnosis of haemochromatosi

Answer 420

Azathioprine or mercaptopurine

Answer 421

Metronidazole interacts with alcohol causing very unpleasant side effects, such as nausea, vomiting, skin flushing, headaches, abdominal pain and tachycardia. This advice should be given to all patients prescribed metronidazole as it takes 48 hours for the body to clear the drug

Answer 422

Vancomycin PO

Answer 423

Metformin can cause bile acid malabsorption and thus leads to chronic diarrhoea in patients taking this agen

Answer 424

A tumour marker is a biomarker found in either blood, urine or other body tissues, which when elevated, can suggest the presence of cancer. There are different tumour markers associated with different types of cancer. Tumour markers can be used for cancer screening, diagnosis, disease monitoring, staging and prognosis. AFP is a tumour marker for HCC and germ cell tumours, such as testicular cancer

Answer 425

Wilson's disease is an autosomal recessive disorder where there is accumulation of copper in the liver causing oxidative stress and leading to the destruction of hepatocytes. Children typically present with features of liver disease, such as hepatitis, cirrhosis and acute liver failure. Adults present with neurological features such as psychiatric changes, tremor, dyskinesia or dystonia. A low caeruloplasmin level is diagnostic of Wilson's disease. The genetic abnormality affects a membrane-bound, copper-transporting ATPase, which normally works to incorporate copper with caeruloplasmin. In Wilson's, this ATPase is defective leading to inadequate incorporation of copper and caeruloplasmin

Answer 426

Correct. The symptoms described are the classic triad of pellagra: dermatitis, dementia and diarrhoea. This is caused by deficiency in niacin (vitamin B3), and is managed by supplementation with nicotinamide

Answer 427

Anti-smooth muscle antibodies are positive in 70% of patients with autoimmune hepatitis (AIH). They are usually associated with type I AIH, which is the commonest type

Answer 428

Non-selective beta blockers are given to reduce re-bleeding and help with hepatic decompression. They reduce azygos blood flow, and also variceal pressure. This is achieved by causing splanchnic vasoconstriction and reducing cardiac output

Answer 429

Spironolactone is an aldosterone antagonist which is a first line treatment for ascites. If resolution of ascites fails with spironolactone alone, furosemide may be added

Answer 430

A peri-anal fistula is an abnormal tract between the anal canal and surface of the skin. It is the most common type of fistula and often appears following an abscess.

Answer 431

Terlipressin is a vasopressin analogue, which causes vasoconstriction of dilated splanchnic blood vessels. This causes a reduction in portal venous pressure and thus pressure in the bleeding varices. Patients presenting with variceal bleeds should be adequately fluid resuscitated, started on broad spectrum antibiotics (typically Piperacillin/Tazobactam) and Terlipressin

Answer 432

This patient has presented with Charcot's triad (fever, RUQ pain and jaundice) which is in keeping with ascending cholangitis. Definitive treatment would be with an ERCP, to remove the obstruction from the common bile duct

Answer 433

Mirrizi's syndrome causes an obstructive jaundice due to compression of the common bile duct secondary to the present of gallstones in the cystic duct. The symptoms described by the patient suggest an obstructive cause for her jaundice, producing a conjugated hyperbilirubinaemia

Answer 434

Human tetanus Ig should be given for immediate protection, and in patients who have received the full five-dose course of tetanus vaccine at the correct times (or is up to date with their schedule), no other doses are needed. This patient is unsure of his status and so needs a booster dose - if it is found he has never had the vaccine, then the full course should be arranged subsequently

Answer 435

Bilateral swelling of his cheeks. After this, painful swollen testicles.

Answer 436

Erythromycin 500mg QDS

Answer 437

This is a classical description of Dengue fever, which presents similarly to malaria, Chikungunya and Zika virus. It is transmitted via mosquitos, particularly the day biting Aedes mosquito. It can be a very severe infection and can lead to haemorrhagic signs. The positive tourniquet test is recommended by the WHO to differentiate the infection from acute gastroenteritis. The test involves inflating a blood pressure cuff to midway between systolic and diastolic for 5 minutes. You then look to see if there are ten or more petechiae per inch squared. If there are, it is a positive test and dengue is suspected

Answer 438

Teicoplanin

Answer 439

A cephalosporin abx used to treat meningitis

Answer 440

Topical terbinafine - an antifungal

Answer 441

Neisseria meningitidis

Answer 442

Coagulase negative staphylococcus e.g. staph. epidermidis

Answer 443

Symptoms come on gradually with pain on or around the affected area, the patient is feverish and systemically unwell. Intravenous drug users are at high risk for atypical infections and they can often occur in unusual places

Answer 444

Entamoeba histolytica infection, which is a cause of sexually acquired amoebic colitis and hepatic amoebic abscesses

Answer 445

Despite this being an emerging infectious disease globally, hydatid disease (caused by parasitic tapeworms of the Echinococcus species) is still less likely here. He has no history of working with cattle, who act as the intermediate host for the parasite. Dogs, wolves or foxes are the definitive hosts once they ingest the eggs in faecally contaminated soil or food.

Answer 446

It is known as the 100-day cough as it can last a significant period of time. Caused by bordetella pertussis.

Answer 447

If meningitis is suspected and there is evidence of a non-blanching rash or meningococcal septicaemia, treatment must be initiated with IM Benzylpenicillin 1.2 g before the patient is admitted to hospital

Answer 448

Streptococcus pneumoniae

Answer 449

The patient has presented with two major (arthritis and erythema marginatum) and two minor (heart block on ECG and fever) criteria for acute rheumatic fever. Although there has been no mention of a group A strep infection, the combination of these symptoms in a patient between 5-15 years old point strongly towards this diagnosis. Some strep infections may not be noticed by patients (particularly if a mild skin infection), or may not be identified when taking the history from the patient or their parents. This can lead to clinicians overlooking rheumatic fever as a diagnosis

Answer 450

The pupil is constricted and does not react to light but does react to the accommodation reflex. This is a severe form of Syphilis and only occurs when left untreated. This patient may have had treatment, but it may not have been sufficient to clear the infection. It is crucial to retest people who have tested positive for Syphilis after treatment to check the treatment has worked

Answer 451

The rash develops as a result of Amoxicillin treatment in the presence of EBV. Initiially presents with a viral hepatitis.

Answer 452

Nasal mupirocin and chlorhexidine wash

Answer 453

Patients with acute bacterial meningitis (the most likely diagnosis in this case) tend to have cloudy or frankly purulent CSF with a high opening pressure, low glucose and high protein

Answer 454

Secondary usually appears 4-6 weeks after an episode of primary Syphilis which is when there is one painless ulcer (a chancre) typically with central slough and a rolled edge. This is a progression of Primary syphilis and is treated the same way, with intramuscular Penicillin Tertiary is This is when the Syphilis infection has spread to other organs.

Answer 455

Co-trimoxazole. The causative pathogen is a fungus known as pneumocystis jirovecii, an opportunistic infection in immunocompromised patients. Examination of the chest is often normal. It is treated with co-trimoxazole (a combination of trimethoprim and sulfamethoxazole).

Answer 456

Two doses of Praziquantel

Answer 457

The Interferon gamma release assay is used to identify patients who may have latent TB infection. It can detect latent TB in patients who have already been vaccinated with a BCG (as opposed to a Tuberculin Skin test which can be less accurate in patients who have previously been vaccinated). In practice, both Interferon gamma release assays and the Tuberculin skin test are used in screening, regardless of immunisation status.

Answer 458

The presence of relative afferent pupillary defect, colour blindness and optic disc oedema localises the pathology to the optic nerve.

Answer 459

Peripheral laser iridotomy is a procedure using lasers to create a small hole in the iris to prevent angle-closure occurring. It is performed bilaterally as the other eye is at risk

Answer 460

Topical chloramphenicol

Answer 461

Ceftriaxone IV, bacitracin ointment and hourly saline lavage

Answer 462

Photopsia, described by patients as ‘flashes of light’ is a feature that some patients with posterior vitreous detachment repor

Answer 463

Glaucoma is defined as an optic neuropathy with characteristic features of the optic nerve on examination which differentiates it from other causes of optic neuropathy. It is thus a clinical diagnosis based on examining the optic disc. Where as most non-glaucomatous optic neuropathies present either with optic disc swelling (blurred margins) or optic disc atrophy (pale optic nerve), glaucoma presents with a raised cup: disc ratio of >0.8.

Answer 464

Plasma free copper is paradoxically low in Wilson's disease because it quickly accumulates in the liver and the central nervous system (particularly the basal ganglia and the limbic system, giving rise to features like parkinsonism, psychosis and dementia)

Answer 465

Haemoglobin electrophoresis. Haemoglobin electrophoresis will show an increase in HbF or HbA2.

Answer 466

This is correct. ITP causes an isolated reduction in platelets due to a transient production of anti-platelet antibodies. This may present as a purpuric rash and is often preceded by a viral illness. It is a self-limiting condition and rarely requires intervention

Answer 467

Imatinib is a BCL-ABR tyrosine kinase inhibitor which works to inhibit the tyrosine kinase activity induced by the Philadelphia chromosome. The Philadelphia chromosome is a hybrid chromosome of chromosome 9 and 22 - t(9;22) - forming the fusion gene BCR/ABL. This fusion gene, through its tyrosine kinase activity, potentiates uncontrolled proliferation of the myeloid cells, leading to CML

Answer 468

JAK2 (V617F) mutation

Answer 469

Metallic aortic valves are known to cause non-immune haemolytic anaemia in some cases (probably due to shear stress against the foreign material of the valve)

Answer 470

Hereditary spherocytosis is an autosomal dominant disease, treated (in severe cases) with childhood splenectomy. It is also more common in patients from northern Europe

Answer 471

She is concerned as the baby has persistent watery eyes. The baby is otherwise healthy. On examination the eye is white. Applying pressure over the lacrimal sac produces a yellow discharge.

Answer 472

Goldman’s tonometry is the gold standard test for measuring intra-ocular pressure, which will be significantly raised in acute angle closure glaucoma (>30mmHg)

Answer 473

Chemosis refers to oedema of the conjunctiva. Inflammation of the conjunctiva in ophthalmia neonatorum (also known as neonatal conjunctivitis)

Answer 474

Chronic open angle glaucoma. Latanoprost is a prostaglandin analogue, it increases uveoscleral outflow by increasing the sclera’s permeability to aqueous humour

Answer 475

Haemolytic anaemia

Answer 476

The diagnosis of amyloidosis requires tissue biopsy and apple-green birefringence when stained with Congo red and viewed under polarised light

Answer 477

A 60 year old male presents to the general practitioner with a 4 week history of new epigastric discomfort. He is referred for urgent oesophagogastroduodenoscopy (OGD) which reveals a mass in the antrum. There is no extra-gastric disease. Histopathological assessment of the antrum biopsy reveals inflammatory changes consistent with chronic gastritis and CLO (Campylobacter-like organism test) positivity. There are also marked infiltrates of small to medium-sized lymphoid cells.

Answer 478

The patient presents with localised gastric MALT lymphoma. The accepted initial management is with triple therapy with a proton-pump inhibitor (such as omeprazole) plus two antibiotics (for example amoxicillin and clarithromycin)

Answer 479

Haematinics include ferritin, folate, vitamin B12, iron, and iron binding capacity.

Answer 480

Bone marrow biopsy. Aplastic anaemia occurs when the bone marrow fails to produce blood cells of all lineages, leading to reduced production of red blood cells, white blood cells, and platelets, as shown by the pancytopenia. In aplastic anaemia, a bone marrow biopsy will show that the bone marrow contains fewer blood cells than normal

Answer 481

This is a description of Taeniasis or tapeworm. It can be contracted by eating uncooked pork or beef as the eggs are laid in meat. The patient describes seeing grapefruit seeds in his stool, these are proglottids which are tapeworm segments. It can be treated with anti-parasitic therapy: praziquantel and niclosamide

Answer 482

A history of rapidly enlarging lymph nodes on a background of CLL is suggestive of Richter Transformation (the development of an aggressive high grade B cell lymphoma)

Answer 483

The release of immature red cells from the marrow which are larger, and contain higher levels of ribosomal RNA which stains the blood film blue (known as polychromasia)

Answer 484

TRALI causes respiratory symptoms such as dyspnoea and cough and causes a "white out" on a chest x-ray, as described above. It causes acute respiratory distress syndrome (ARDS) and is usually due to anti-leucocyte antibodies in the donor plasma

Answer 485

Hyperviscosity syndrome is a condition that occurs when your blood becomes so thick that your body's overall blood flow decreases Chest pain, myalgia, weakness, headache, blurred vision, loss of concentration

Answer 486

Children. Serum creatinine

Answer 487

Long QT interval

Answer 488

Osmotic diuresis occurs when certain substances (e.g. glucose, mannitol) are found in high concentrations in the renal tubules preventing water from reabsorbed. This results in hypovolaemic hypernatraemia and can be secondary to pathological states such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS). This patient is a known diabetic, is clinically hypovolaemic and has a very high glucose level. Therefore, even without formally calculating serum osmolality it very likely that he fits a diagnosis of HHS

Answer 489

Potassium-sparing diuretic

Answer 490

Extremes of muscle mass leads to a high serum creatinine. Given that creatinine is an important variable in the calculation of eGFR by the MDRD equation and is essentially inversely proportional to eGFR, this may underestimate the eGFR

Answer 491

[Na+ + K+] – [Cl- + HCO3]. The normal range is 10-18mmol/L.

Answer 492

. This patient's ABG shows a metabolic acidosis with partial respiratory compensation, with a raised anion gap (28.6). Salicylate overdose is a cause of metabolic acidosis with raised anion gap.

Answer 493

Metformin is a well known causes of lactic acidosis, particularly in the context of renal dysfunction. This is because lactic is normally metabolised by the liver with a secondary clearance from the kidneys. Metformin impairs the livers' ability to metabolise lactic and when the kidneys are also not fully able to clear lactate it leads to a build up

Answer 494

Acute porphyrias are a group of rare inherited diseases of metabolism which affect the biosynthesis of haem. Acute Intermittent Porphyria is a rare metabolic disorder that is characterised by deficiency of the enzyme as hydroxymethylbilane synthase (also known as porphobilinogen deaminase).

Answer 495

Generalised abdo pain,vomiting, tachycardia, urine that turns red on exposure to light

Answer 496

However IV replacement needs to be careful because of the risk of arrhythmia. The maximum safe rate of potassium replacement is 10mmol/hour (though some resources suggest 20mmol/hour is safe)

Answer 497

Almost all cells universally have a hydrogen/potassium antiporter ion channel in their membranes. Hydrogen ions are increased in metabolic acidosis extracellularly, and will equilibrate such that they enter cells in exchange for potassium ions exiting. This leads to a rise in potassium levels extracellularly. The extracellular concentration of ions is what's measured in blood tests

Answer 498

Hypokalaemia

Answer 499

Thiazide diuretics, like bendroflumethiazide

Answer 500

severe prolonged vomiting causes a metabolic alkalosis (as a by-product of increased acid secretion in the stomach), hypokalaemia (due to increased potassium wasting in the kidneys in exchange for proton retention to combat the alkalosis) and hypochloraemia (due to loss of chloride in the vomit). Furthermore, this diagnosis explains why the patient is hypovolaemic

Answer 501

High-potency bisphosphonates are considered first-line therapy for malignant hypercalcaemia and reduce bone resorption by inhibiting the recruitment, activity, adhesion and survival of osteoclasts.

Answer 502

The patient has the features of SIADH (euvolaemic hyponatreamia with low serums osmolality, high urine osmolality and high urine sodium). The first-line treatment for SIADH is fluid restriction

Answer 503

Total cholesterol/HDL ratio

Answer 504

high calcium, low phosphate, mildly raised ALP Can present with recurrent renal stones

Answer 505

Lynch syndrome is an autosomal dominant inherited genetic condition that is associated with an increased risk of colorectal cancer. It is associated with an increased risk of other cancers such as ovarian, endometrial, renal, stomach and brain cancers. Patients with Lynch syndrome have an estimated 20-80% risk of developing colorectal cancer in their lifetime, compared with an average lifetime risk of 6-7%

Answer 506

The left sided supraclavicular lymph node described above is a Virchow's node, which is a lymph node supplied by the intra-abdominal lymph system. An enlarged node here is known as Troisier's sign, which suggests the presence of a gastric malignancy

Answer 507

The clinical triad of acute mesenteric ischaemia is severe abdominal pain, unremarkable abdominal examination, and shock.

Answer 508

Colorectal carcinoma

Answer 509

Abscesses and empyemas

Answer 510

Computed tomography colonography (CT) (Virtual colonoscopy)

Answer 511

Gastric adenocarcinoma

Answer 512

Peritonitis. A major indication for urgent surgical intervention.

Answer 513

Hypovolaemia

Answer 514

Adequate magnesium intake is required for maintaining normal potassium levels, because hypomagnesaemia results in excess urinary excretion of potassium. In other words, simply replacing potassium when the magnesium is also low is like adding water in a bath without plugging the hole. It is therefore important to check magnesium levels in hypokalaemia

Answer 515

Urinary Bence-Jones protein testing involves the detection of light chain (which are seen in myeloma) in the urine. It is the first line screening test for myeloma although it can neither fully confirm nor exclude the diagnosis

Answer 516

In cases of acute hyponatraemia (< 48 hours), or chronic hyponatraemia (> 48 hours) that is symptomatic or severe, aggressive therapy with hypertonic saline is indicated as above. This is needed to raise the serum sodium by 4-6 mmol/L above baseline up to a maximum of 10-12 mmol/L in the first 24 hours. Aggressive therapy is required in order to avoid brain herniation.

Answer 517

IgA nephropathy typically occurs in young males (9-15 years old) soon after they develop a sore throat. At the milder end of the spectrum, they can present with haematuria without must disruption to the renal function or their blood pressure

Answer 518

Indications for haemodialysis AEIOU = Acidosis, Electrolytes (hyperK+), Intoxication (Drug OD), Oedema, Uraemic symptoms (encephalopathy)

Answer 519

Renal biopsy

Answer 520

Muddy brown casts in the urine represent collections of dead renal tubule epithelial cells and are pathognomonic for acute tubular necrosis (ATN).

Answer 521

Anti-streptolysin O antibodies will be raised after infection with streptococci.

Answer 522

Staphlococcus epidermidis

Answer 523

Subcutaneous Erythropoietin injection. his is likely caused by her underlying chronic kidney disease (CKD). The kidneys produce erythropoietin, which stimulates the production of red blood cells. In CKD, reduced levels of erythropoietin result in a normocytic, normochromic anaemia. The first-line management of anaemia in CKD is to replace erythropoietin with regular subcutaneous injections. However, EPO should not be given if there is iron deficiency anaemia as it can exacerbate this.

Answer 524

Chronic kidney disease (CKD) can be differentiated from acute kidney injury (AKI) using a renal ultrasound, which would show bilateral shrunken kidneys in end-stage renal disease (ESRD).

Answer 525

This patient has features of pulmonary (SOB, haemoptysis, consolidation on chest x-ray) and renal (dark urine, swollen legs, hypertension and a probable AKI on his blood tests) disease.

Answer 526

Early recognition and treatment with high dose, corticosteroids, cyclophosphamide and plasmapheresis can prevent further irreversible loss of renal function. Any delay in treating the condition is associated with adverse clinical outcomes. Plasmapheresis is thought to be efficacious as it removes circulating anti-basement membrane antibodies as well as other immunological mediators of injury

Answer 527

The classic presentation of acute interstitial nephritis is a patient with non-oliguric acute renal failure associated with the hypersensitivity triad (rash, fever and eosinophilia) triggered by medication.

Answer 528

5P's - Pee (diuretics) - Pain (NSAIDs) - Penicillins (and cephalosporins) - PPIs - rifamPicin

Answer 529

Renal biopsy

Answer 530

The CKD affects calcium regulation in 2 ways:phosphate is not removed from the blood, causing hypocalcaemia in the blood as more calcium binds to the excess phosphate. This triggers an appropriate response from the parathyroid hormone.vitamin D is no longer converted to its active form causing inadequate calcium absorption from the gut, levels of calcium in the blood falls triggering the release of parathyroid hormone

Answer 531

Denosumab - a monoclonal anitbody that acts against RANK ligand on osteoclasts thereby reducing their activity. Used in stage 4 CKD.

Answer 532

Blocks the aldosterone pathway thereby leading to a retention of potassium