MSRA

Question 1

💊 Statins Monitoring

Answer 1

🧪 Baseline Tests
Lipids, LFTs, HbA1c, U+Es, TSH

🎯 Monitoring
1. Lipid profile - 3months
2. LFTs - 3m + 12m

CK only if muscle symptoms

Question 2

💉 ACE Inhibitors Monitoring

Answer 2

1. 🧪 Baseline
   U+Es + BP
2. ⏱ Titration
   U+Es + BP every 1-2 weeks after dose increase.
3. 📆 Ongoing Monitoring
   U+Es monthly for first 3m -> then every 6months.
4. 🧪 Thresholds
   Creatinine ↑ <30% → acceptable
   Creatinine ↑ >30% → reduce/stop ACEi, consider renal artery stenosis

📋 Sick Day Rules
Stop temporarily during diarrhoea, vomiting, dehydration, acute illness

Question 3

⚡ Amiodarone Monitoring

Answer 3

🧪 Baseline
TFTs, LFTs, U&Es, CXR, ECG

📆 Monitoring
Every 6 months: TFTs, U&Es, LFTs
Yearly: ECG

⚠️ Complications
Pulmonary toxicity (pneumonitis, fibrosis)
Thyroid dysfunction (hypo- or hyper-)
Hepatotoxicity

Question 4

🌡 Levothyroxine

Answer 4

📆 Monitoring
TSH every 3 months until stable (2 similar results)
Then yearly TSH

Question 5

🧠 Sodium Valproate

Answer 5

🧪 Baseline
FBC, LFTs, BMI

📆 Monitoring
After 6 months: FBC, LFTs, BMI
Then yearly
Valproate level only if toxicity or poor adherence suspected

Question 6

🧬 Methotrexate

Answer 6

📅 Prescription
Once weekly, with folic acid 5 mg weekly on separate day

🧪 Monitoring
(same as azathioprine)
1. FBC, U&Es, LFTs
2. Before starting
3. Every 2 weeks until dose stable × 6 weeks
4. Then monthly × 3 months
5. Then at least every 12 weeks
6. More frequent if dose change or toxicity risk

Question 7

🩸 Apixaban

Answer 7

🧪 Baseline
FBC, U&Es, LFTs, clotting screen

📆 Monitoring
Yearly: FBC, U&Es, LFTs
Every 6 months if >75 years or renal impairment

Question 8

💉 Glitazones (e.g. pioglitazone)

Answer 8

❌ Contraindications
1. Heart failure
2. Bladder cancer or macroscopic haematuria
3. Liver disease

🧪 Baseline - LFT

📆 Monitoring
LFTs periodically
Watch for signs of heart failure: oedema, weight gain
Warn about bladder cancer symptoms

Question 9

💔 Trastuzumab (Herceptin)

Answer 9

🧬 Mechanism
Monoclonal antibody against HER2/neu receptor

🎯 Indication
HER2+ breast cancer

⚠️ Adverse Effect
Cardiotoxicity

🧪 Monitoring
Echocardiogram before starting treatment

Question 10

🫁 Granulomatosis with Polyangiitis (GPA)

Answer 10

URT: nasal crusting, epistaxis, saddle nose
(Helps differentiate from Goodpasture’s in MCQs!)

LRT: dyspnoea, haemoptysis

Renal: rapidly progressive GN

Antibody: cANCA / PR3

CXR: cavitating nodules

💊 Steroids + cyclophosphamide ± plasma exchange

Question 11

🧼 Eosinophilic GPA (Churg-Strauss)

Answer 11

Asthma-like (wheezy), eosinophilia, sinusitis

Mononeuritis multiplex

Worsens with montelukast

Antibody: pANCA / MPO

💊 Steroids ± DMARDs

Question 12

🧬 Microscopic Polyangiitis (MPA)

Answer 12

Palpable purpura, fever, weight loss

Renal impairment, mononeuritis multiplex

Antibody: pANCA > cANCA

💊 Steroids + immunosuppression

Question 13

🎨 Henoch-Schönlein Purpura (HSP)

Answer 13

IgA mediated small vessel vasculitis - Most common vasculitis in children

Palpable purpuric rash (legs/buttocks), arthralgia, abdo pain

Nephritis due to IgA nephropathy - AKI, haematuria, proteinuria

Triggered by URTI - history of recent sore throat is exam clue

🧪 IgA deposition in skin/renal biopsy

🩺 Supportive treatment

Question 14

🫁 Goodpasture’s Syndrome

Answer 14

Pulmonary haemorrhage + rapidly progressive GN

Haematuria, oedema, HTN

Antibody: anti-GBM (vs type IV collagen)

Biopsy: linear IgG along BM

💊 Plasma exchange + steroids + cyclophosphamide

Question 15

🚬 Buerger’s Disease (Thromboangiitis Obliterans)

Answer 15

Smoker with limb ischaemia

Raynaud’s + superficial thrombophlebitis

💡 Strongly linked to tobacco use

Question 16

👶 Kawasaki Disease

Answer 16

Child <5, fever ≥5 days

Red eyes/lips/tongue, lymphadenopathy, palm/sole desquamation

Risk of coronary aneurysms → do echo

💊 IVIG + high-dose aspirin

Question 17

🧬 Polyarteritis Nodosa (PAN)

Answer 17

Middle-aged man + Hep B

Mononeuritis multiplex, hypertension, livedo reticularis
Renal: haematuria, failure

🔍 Angiography: microaneurysms

Antibodies: pANCA ±

💊 Steroids + immunosuppression

Question 18

🚫 Takayasu’s Arteritis

Answer 18

Young Asian female

History of intermittent claudication, angina

OE: Unequal BP in arms, difference >10 mmHg

Carotid bruit, AR murmur

💊 Treated with steroids

Question 19

🧓 Polymyalgia Rheumatica

Answer 19

CLINICAL FEATURES
1. Age > 60yrs
2. Pain and stiffness in the shoulders, hips, and neck which develops acutely over a few days to weeks.
3. Stiffness is worse in the mornings
4. Low mood/ depression
5. Night sweats
6. Polyarthralgia

INVESTIGATIONS
1. ESR > 40 (CK, EMG normal)

MANAGEMENT
1. Prednisolone 15-20mg OD for 4 weeks, followed by gradual tapering dose over 12-18 months

2. Co-prescribe PPI
3. Most patients require bone protection - bisphosphonates, adcal D3 etc

Question 20

⏱️ Temporal Arteritis (Giant Cell Arteritis)

Answer 20

1. Age >50
2. 50% associated with PMR - history of proximal muscle weakness/stiffness/fatigue

Clinical feaures:
1. Temporal headache
2. Jaw claudication (chewing)
3Superficial tenderness (e.g. while showering/combing hair)
4. Visual disturbance - due to anterior ischaemic optic neuropathy
Diplopia
Loss of vision
Changes to colour vision

Bloods: Raised ESR/CRP

Diagnosis: Temporal artery biopsy (skip lesions possible)

Histology: granulomatous inflammation with giant cells

Prednisolone 60mg OD + urgent ophthalmology review if eye symptoms

Question 21

🧠 Herpes Simplex Encephalitis

Answer 21

🧬 Cause
1. HSV-1 (most common)
2. Typically affects the temporal and frontal lobes

👀 Clinical Features
1. Fever, headache
2. Confusion
3. Seizures
4. Wernicke’s aphasia (temporal lobe involvement)
5. Features of meningism (photophobia, neck stiffness)
6. Focal neurological signs depending on area affected

🧪 Investigations
1. Lumbar puncture: Lymphocytosis, raised protein, PCR for HSV
2. MRI brain: T2 hyperintensity and oedema in the temporal and frontal lobes

💊 Management
IV aciclovir – initiate immediately if suspected

Question 22

🧠 Brain Abscess

Answer 22

🧬 Pathophysiology
Localised infection with pus formation in the brain parenchyma

May follow otitis media, sinusitis, dental infections or bacteraemia

Causative organisms vary – often polymicrobial

👀 Clinical Features
1. Headache, fever
2. Focal neurological signs
3. Seizures
4. Features of raised ICP (vomiting, papilloedema)

Clues in MCQs: History of sinusitis, followed by worsening headache, confusion

🧪 Investigations
CT Head with contrast: Ring-enhancing lesion
Blood cultures

💊 Management
IV ceftriaxone + metronidazole
Surgical drainage or craniotomy with debridement if indicated

Question 23

🎯 Lyme Disease

Answer 23

Caused by Borrelia burgdorferi, a spirochete bacterium transmitted by Ixodes ticks.

Classical presentation: Erythema migrans (‘target lesion’) + flu-like illness after hiking or woodland exposure.

🧪 Investigations

1st-line investigation (if no rash): ELISA → immunoblot.

1st-line treatment: Doxycycline 100 mg BD for 21 days.

Question 24

🌊 Duodenal Atresia

Answer 24

👀 Clinical Features
1. Bilious vomiting within 48h of birth, begins following first oral feed
2. Polyhydramnios antenatally

🧪 Investigations
AXR: Double bubble sign

💊 Management
Duodenoduodenostomy

Question 25

🥣 Infantile Hypertrophic Pyloric Stenosis

Answer 25

🧬 Pathophysiology Hypertrophy of the circular muscle of the pylorus causes gastric outlet obstruction. 👀 Clinical Features 1. Age: 3–8 weeks 2. Projectile, non-bilious vomiting within minutes of feeding 3. Constipation, FTT 4. Palpable ‘olive’ mass in RUQ 5. Visible gastric peristalsis 🧪 Investigations 1st line: Abdominal USS: thickened pyloric muscle Biochemistry: Hypochloraemic, hypokalaemic metabolic alkalosis 💊 Management Ramstedt pyloromyotomy

Question 26

🎯 Intussusception

Answer 26

🧬 Pathophysiology Telescoping of proximal bowel into distal segment → obstruction, ischaemia Majority of cases occur in association with or following viral gastroenteritis/URTI 👀 Clinical Features Peak: 3–18 months 1. Colicky episodic pain, drawing up legs 2. Redcurrant jelly stool 3. Palpable sausage-shaped mass (RUQ) 4. Bilious vomiting, distension if progressed. 🧪 Investigations 1. USS: Target sign 2. Contrast enema (diagnostic & therapeutic): Coiled spring appearance - gold standard. 💊 Management 1st Line: Therapeutic enema - air/water/contrast pumped into the colon, in an attempt to reduce the invagination, and restore the bowel to its normal position Surgery if unsuccessful or peritonitic

Question 27

🥦 Toddler’s Diarrhoea (Chronic Non-Specific)

Answer 27

👀 Clinical Features 1. non-specific, chronic diarrhoea which most commonly affects children between 6 months and 5 years of age. 2. Loose stools with undigested food (e.g. ‘peas and carrot stools’) 3. Colicky pain, increased flatus 4. Otherwise well and thriving with good development/growth. 💊 Management 1. Reassurance 2. Dietary: Reduce juice/milk, increase fat 3. Loperamide rarely needed

Question 28

🚫 Hirschsprung’s Disease

Answer 28

🧬 Pathophysiology Absence of ganglion cells in bowel (usually rectosigmoid) → functional obstruction 👀 Clinical Features Neonates: 1. Delayed meconium (>48 hrs), abdominal distension, bilious vomiting Older children: Chronic constipation since birth Poor response to laxatives FTT 🧪 Investigations AXR: Obstruction Rectal biopsy: Absence of ganglia 💊 Management Surgical resection of aganglionic segment

Question 29

Neurofibromatosis type 1

Answer 29

Mutation in NF1 gene chromosome 17 Usually diagnosed as baby/early childhood 👀 CFs: 1. > 6 cafe au lait spots 2. Axillary freckling 3. Neurofibroma 4. Lisch nodules, optic glioma.

Question 30

👶 Down Syndrome

Answer 30

👀 Clinical features: 1. Generalised hypotonia and head lag at birth 2. Facial features: up-slanting eyes, low-set ears, flat nasal bridge, epicanthic folds, protruding tongue 3/ Brushfield spots (white specks in the iris) 4. Short neck, brachycephaly (flat occiput) 5. Single palmar crease, wide sandal gap between toes 6. Learning disability, short stature. ⚠️Complications: 1. Congenital heart disease (50%) – AVSD most common 2. Duodenal atresia 3. Early-onset Alzheimer’s disease

Question 31

♀️ Turner Syndrome

Answer 31

Genetics: 45,X (monosomy X) 👀 Clinical features: 1. Female with short stature (growth falters after age 3–5) 2. Webbed neck, low posterior hairline, widely spaced nipples (‘shield chest’) 3. Neonatal lymphoedema – puffy hands and feet 4. Cubitus valgus 5. Primary amenorrhoea, infertility (streak ovaries) ⚠️Complications: 1. Coarctation of the aorta Horseshoe kidney 🧪Diagnosis: Karyotyping

Question 32

😊 William’s Syndrome

Answer 32

Cause: Microdeletion on chromosome 7q11.23 (includes elastin gene) 👀 Clinical features: 1. Elfin facial appearance: full cheeks, wide mouth, full lips, periorbital fullness 2. Overfriendly behaviour, anxiety, poor concentration 3. Mild to moderate learning disability 4. Hypercalcaemia in infancy (15%) ⚠️Complications: Supravalvular aortic stenosis 🧪Diagnosis: FISH or chromosomal microarray

Question 33

🧠 Patau Syndrome

Answer 33

Genetics: Trisomy 13 (usually maternal nondisjunction) 👀 Clinical features: 1. Small for gestational age 2. Microcephaly, holoprosencephaly 3. Cleft lip and palate, microphthalmia 4. Polydactyly 5. Fused kidneys ⚠️Prognosis: Very poor – most die within days to weeks 🧪Diagnosis: Antenatal US and confirmed by karyotype

Question 34

🧠 Edward’s Syndrome

Answer 34

Genetics: Trisomy 18 👀Clinical features: 1. Females > males 2. Small size, micrognathia 3. Overlapping fingers, clenched hands 4. Rocker-bottom feet ⚠️Prognosis: Very poor – median lifespan 4 days

Question 35

🍽 Prader-Willi Syndrome

Answer 35

Genetics: Deletion on paternal chromosome 15 (15q11-q13) 👀Clinical features: 1. Neonatal hypotonia, poor feeding, failure to thrive 2. Rapid weight gain from 1 year 3. Truncal obesity, short stature 4. Food foraging, insatiable appetite 5. Mild learning difficulties

Question 36

♂️ Klinefelter Syndrome

Answer 36

Prevalence: 1/500 males Genetics: 47,XXY (nondisjunction) 👀Clinical features: 1. Tall stature, reduced facial/body hair 2. Pubertal testicular involution – small, firm testes 3. Gynaecomastia 4. Infertility (azoospermia) 5. Mild learning difficulties 🧪Diagnosis: Karyotype Endocrine profile: Hypergonadotrophic hypogonadism – high LH/FSH, low testos

Question 37

🕷 Marfan Syndrome

Answer 37

Prevalence: 1/5000 Genetics: Autosomal dominant – FBN1 gene mutation (chr15q21) 👀Clinical features: 1. Tall, slim, long limbs – arachnodactyly 2. High arched palate, scoliosis, joint hypermobility 3. Positive wrist/thumb signs 4. Pectus excavatum or carinatum 5. Mitral valve prolapse (mid-systolic click), aortic root dilatation – risk of dissection Management: Regular echo, beta-blockers or ARBs, avoid contact sport