Finals

Question 1

What are some extra-articular manifestations of rheumatoid arthritis?

Answer 1

• Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
• Bronchiolitis obliterans (inflammation causing small airway destruction)
• Felty’s syndrome (RA, neutropenia and splenomegaly)
• Secondary Sjogren’s Syndrome (AKA sicca syndrome)
• Anaemia of chronic disease
• Cardiovascular disease
• Episcleritis and scleritis
• Rheumatoid nodules
• Lymphadenopathy
• Carpel tunnel syndrome
• Amyloidosis

Question 2

How is methotrexate given and what are some side effects?

Answer 2

Methotrexate works by interfering with the metabolism of folate and suppressing certain components of the immune system. Mode of action is via blocking the action of the enzyme dihydrofolate reductase.

It is taken by injection or tablet once a week. Folic acid 5mg is also prescribed once a week to be taken on a different day to the methotrexate. It can be taken once weekly on the day after the methotrexate dose, or it can be taken once daily every day except on the day of the methotrexate dose.

Folic acid reduces the side effects of methotrexate. It can decrease mucosal and gastrointestinal side effects and may prevent liver toxicity. Folic acid should never be taken on the same day as methotrexate as it can impair the efficacy of the medication.

Notable Side Effects:
- Mouth ulcers and mucositis
- Liver toxicity
- Bone marrow suppression and leukopenia (low white blood cells)
- It is teratogenic (harmful to pregnancy) and needs to be avoided prior to conception in mothers and fathers

Common side effects of methotrexate include:
Loss of appetite
Nausea
Indigestion
Diarrhoea
Headaches
Tiredness
Hair loss

Rare but serious side effects of methotrexate include:
Liver toxicity: jaundice
Pulmonary toxicity: persistent cough, chest pain, dyspnoea
Renal toxicity: peripheral oedema, polyuria
Signs of infection: fever, chills, muscle aches, sore throat
Thrombocytopenia: bleeding gums, haematuria, unexplained bruising
Stevens-Johnson syndrome: severe skin rash or blisters on skin, mouth, eyes or genitals

When beginning treatment, full blood count, renal and liver function tests should be carried out every 1-2 weeks until the therapy is stabilised. Thereafter, patients should be monitored every 2-3 months.

Question 3

What are the signs of respiratory distress in children?

Answer 3

Raised respiratory rate
Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises

Question 4

Management of chronic asthma in under-5s

Answer 4

1) Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
2) Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
3) Add the other option from step 2.
4) Refer to a specialist.

Question 5

Management of chronic asthma in 5-12 year olds

Answer 5

1) Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
2) Add a regular low dose corticosteroid inhaler
3) Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
4) Titrate up the corticosteroid inhaler to a medium dose. Consider adding:
- Oral leukotriene receptor antagonist (e.g. montelukast)
- Oral theophylline
5) Increase the dose of the inhaled corticosteroid to a high dose.
6) Referral to a specialist. They may require daily oral steroids.

Question 6

Management of chronic asthma in over 12s

Answer 6

1) Start a short-acting beta 2 agonist inhaler (e.g. salbutamol) as required
2) Add a regular low dose corticosteroid inhaler
3) Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response.
4) Titrate up the corticosteroid inhaler to a medium dose. Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral theophylline or an inhaled LAMA (i.e. tiotropium).
5) Titrate the inhaled corticosteroid up to a high dose. Combine additional treatments from step 4, including the option of an oral beta 2 agonist (i.e. oral salbutamol). Refer to specialist.
6) Add oral steroids at the lowest dose possible to achieve good control under specialist guidance.

Question 7

What antibiotics are given in neonatal sepsis?

Answer 7

Benzylpenicillin and gentamycin

Question 8

What 9 genetic conditions does the newborn heel prick test look for?

Answer 8

• Sickle cell
• Cystic fibrosis
• Congenital hypothyroidism
• Phenylketonuria (PKU)
• Medium-chain acyl-coA dehydrogenase deficiency (MCADD)
• Maple syrup urine disease (MSUD)
  Isovaleric acideaemia (IVA)
• Glutaric acuduria type 1 (GA1)
• Homocysteinuria (HCU)
• Severe combined immunodeficiency (SCID)

Question 9

What are the paediatric causes of a pan-systolic murmur?

Answer 9

VSD
Mitral regurg
Tricuspid regurgitate

Question 10

What are the features of Tetralogy of Fallot?

Answer 10

-VSD
- Overriding aorta
- Pulmonary valve stenosis
- Right ventricular hypertrophy

Question 11

What are some causes of clubbing in children?

Answer 11

• Hereditary clubbing
• Cyanotic heart disease
• Infective endocarditis
• Cystic fibrosis
• Tuberculosis
• Inflammatory bowel disease
• Liver cirrhosis

Question 12

What are the features of Down’s syndrome?

Answer 12

• Hypotonia (reduced muscle tone)
• Brachycephaly (small head with a flat back)
• Short neck
• Short stature
• Flattened face and nose
• Prominent epicanthic folds
• Upward sloping palpebral fissures
• Single palmar crease

Question 13

What are some complications of Down’s?

Answer 13

• Learning disability
• Recurrent otitis media
• Deafness. Eustachian tube abnormalities lead to glue ear and conductive hearing loss.
• Visual problems such myopia, strabismus and cataracts
• Hypothyroidism occurs in 10 – 20%
• Cardiac defects affect 1 in 3, particularly ASD, VSD, patent ductus arteriosus and tetralogy of Fallot
• Atlantoaxial instability
• Leukaemia is more common in children with Down’s
• Dementia is more common in adults with Down’s

Question 14

What are the side effects of sodium valproate?

Answer 14

• Teratogenic, so patients need careful advice about contraception
• Liver damage and hepatitis
• Hair loss
• Tremor

Question 15

What are the side effects of carbamazepine?

Answer 15

• Agranulocytosis
• Aplastic anaemia
• Induces the P450 system so there are many drug interactions

Question 16

What are the side effects of phenytoin?

Answer 16

• Folate and vitamin D deficiency
• Megaloblastic anaemia (folate deficiency)
• Osteomalacia (vitamin D deficiency)

Question 17

What are the side effects of ethosuximide?

Answer 17

• Night terrors
• Rashes

Question 18

What are the side effects of lamotrigine?

Answer 18

• Stevens-Johnson syndrome or DRESS syndrome. These are life threatening skin rashes.
• Leukopenia

Question 19

What is the inheritance pattern of Duchenne’s muscular dystrophy?

Answer 19

X-linked recessive

Question 20

What are the side-effects of metformin?

Answer 20

• GI disturbances
• Lactic acidosis

Question 21

What are the side-effects of sulfonylureas?

Answer 21

• Hypoglycaemic episodes
• Increased appetite and weight gain
• Syndrome of inappropriate ADH secretion
• Liver dysfunction (cholestatic)

Question 22

What are the side-effects of glitazones?

Answer 22

• Weight gain
• Fluid retention
• Liver dysfunction
• Fractures

Question 23

What are the side-effects of gliptins?

Answer 23

Pancreatitis

Question 24

In an OGTT, what are the values for impaired fasting glucose?

Answer 24

6.1 - 6.9 mmol/L

Question 25

In an OGTT, what are the values for impaired glucose tolerance?

Answer 25

Plasma glucose at 2 hours of 7.8 - 11.1 mmol/L

Question 26

In an OGTT, what are the values for diabetes?

Answer 26

Plasma glucose at 2 hours above 11.1 mmol/L

Question 27

What is Meig's syndrome?

Answer 27

A triad of: - Ovarian fibroma (a type of benign ovarian tumour) - Pleural effusion - Ascites Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.