Questions Flashcards

Question

Features of atrial myxoma?

Answer 1

systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing emboli atrial fibrillation mid-diastolic murmur, 'tumour plop' echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum

Answer 2

selective iliac artery embolisation

Answer 3

Bifascicular block the combination of RBBB with left anterior or posterior hemiblock e.g. RBBB with left axis deviation Trifascicular block features of bifascicular block as above + 1st-degree heart block

Answer 4

Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults. The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role. Features in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection herald patch (usually on trunk) followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a 'fir-tree' appearance Management self-limiting - usually disappears after 6-12 weeks

Answer 5

Primary hyperaldosteronism was previously thought to be most commonly caused by an adrenal adenoma, termed Conn's syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the most common cause. Differentiating between the two is important as this determines treatment. Causes bilateral idiopathic adrenal hyperplasia: the cause of around 60-70% of cases adrenal adenoma: 20-30% of cases unilateral hyperplasia familial hyperaldosteronism adrenal carcinoma Features hypertension increasingly recognised but still underdiagnosed cause of hypertension hypokalaemia e.g. muscle weakness this is a classical feature in exams but studies suggest this is seen in only 10-40% of patients, and is more common with adrenal adenomas metabolic alkalosis Investigations guidelines vary but certain patients should be screened for primary hyperaldosteronism, e.g. hypertension with hypokalemia treatment-resistant hypertension the 2016 Endocrine Society recommend that a plasma aldosterone/renin ratio is the first-line investigation in suspected primary hyperaldosteronism should show high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone) following this a high-resolution CT abdomen and adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess if the CT is normal adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia Management adrenal adenoma: surgery (laparoscopic adrenalectomy) bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

Answer 6

Chylous effusion - often secondary to head or neck surgery including excision of cervical lymph nodes - can result in damage to throacic duct resulting in chylothrox

Answer 7

a rare complication of measles characterised by progressive neurological decline, including memory loss, behabioural changes and seizures often developes within 2-10 years after intial infection

Answer 8

AKA anti-GBM Features pulmonary haemorrhage rapidly progressive glomerulonephritis this typically results in a rapid onset acute kidney injury nephritis → proteinuria + haematuria Investigations renal biopsy: linear IgG deposits along the basement membrane raised transfer factor secondary to pulmonary haemorrhages Management plasma exchange (plasmapheresis) steroids cyclophosphamide One of the main complications is pulmonary haemorrhage. Factors that increase the likelihood of this include: smoking lower respiratory tract infection pulmonary oedema inhalation of hydrocarbons young males

Answer 9

Autoreactive T cell induction

Answer 10

A rare condition that can occur following a period of cerebral hypoxia - onset within days to weks of cardiac arrest. Characterised by intention myoclonus Levetiracetam, clonazepam and valproate are reccomended as first line treatments

Answer 11

It is thought to occur due to the presence of displaced otolithic debris, which leads to abnormal sensations of movement, dizziness and nausea

Answer 12

antithrombin III and plasminogen in the urine

Answer 13

Propionibacterium acnes - a slow growing gram positive bacteria which is porrly virulent. Symptoms may occur many years after original arthoplasty as the bacteria are only identified at the time of revision arthroplasty

Answer 14

red eye acute onset ocular pain and discomfort pupil may be small and irregular photophobia blurred vision tx - urgent review by ophthalmology cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate steroid eye drops

Answer 15

the most common acquired myopathy - more common in men. Wasting and weakness of the quadriceps and the long finger flexors being the most common. Muscles can be affected asymmetrically. CK will be high but not as high as in polymyositis or dermatomyositis

Answer 16

DM1 - DMPK gene on chromosome 19 - Distal weakness more prominent DM2 - ZNF9 gene on chromosome 3 - Proximal weakness more prominent - Severe congenital form not seen General features myotonic facies (long, 'haggard' appearance) frontal balding bilateral ptosis cataracts dysarthria Other features myotonia (tonic spasm of muscle) weakness of arms and legs (distal initially) mild mental impairment diabetes mellitus testicular atrophy cardiac involvement: heart block, cardiomyopathy dysphagia

Answer 17

gram positive anaerobic bacillus produces botulinum toxin, a neurotoxin which irreversibly blocks the release of acetylcholine may result from eating contaminated food (e.g. tinned) or intravenous drug use neurotoxin often affects bulbar muscles and autonomic nervous system Features patient usually fully conscious with no sensory disturbance flaccid paralysis diplopia ataxia bulbar palsy Treatment botulism antitoxin and supportive care antitoxin is only effective if given early - once toxin has bound its actions cannot be reversed ## Footnote the syptoms often begin with blurred vision and ocassionaly D&V . they later manifest as a profound neuromuscular blockade with classical symmetrical descending pattern of paralysis - CN often effected first.

Answer 18

## Footnote Botulism → "B for floppy Baby" (flaccid, descending). Tetanus → "T for Tight" (rigid, spasms, ascending).

Answer 19

Severe staphylcoccal pneumnia post infection with influenza - linezolid should be used

Answer 20

excess cortisol Commonly caused by benign pituitary tumour that secretes ACTH (others causes inlude ectopic production or adrenal adenoma) Causes weight gain, muscle weakness, HTN, diabetes and osteoprosis Hypokalaemic metabolic alkalosis Imparied glucose tolerance To confirm - overnight dexamthasone supression test 24 hour urinary cortisol

Answer 21

T > 42 Rhabdo Kidney disease Liver failure

Answer 22

a neurodegenerative disease which characteristically has its onset in the 6th decade of lide. Initially there are vague changed in personality such as apprehesiveness and fretfulness which suggests an agitated depression patients develop supranuclear ophthalmoplegia, pseudo-bulbar palsy and an axial dystonia Blepharopsam and involuntary eye closure is prominent in some cases Repeated abrupt falling without any evidence of ataxia No resting tremor and patients have poor response to levodopa

Answer 23

AR Disorder of iron absorption and metaolism general population transferrin saturation is considered the most useful marker ferritin should also be measured but is not usually abnormal in the early stages of iron accumulation testing family members genetic testing for HFE mutation These guidelines may change as HFE gene analysis become less expensive Typical iron study profile in patient with haemochromatosis transferrin saturation > 55% in men or > 50% in women raised ferritin (e.g. > 500 ug/l) and iron low TIBC

Answer 24

venesection is the first-line treatment monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l desferrioxamine may be used second-line

Answer 25

primary bilary cholangitis

Answer 26

autoimmune hepatitis

Answer 27

endovascular stenting is often the treatment of choice to provide symptom relief

Answer 28

Pseudo-Cushing's mimics Cushing's often due to alcohol excess or severe depression causes false positive dexamethasone suppression test or 24 hr urinary free cortisol insulin stress test may be used to differentiate Biochemical evidence is that there remains diurnal variation in the cortisol levels

Answer 29

usually presents with malaise and neck pain often tenderness of the thyroid ESR often elevated There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal thyroid scintigraphy: globally reduced uptake of iodine-131 Tx NSAIDs Beta-blockers Steroids in more severe cases

Answer 30

hyperkalaemia hyponatraemia hypoglycaemia metabolic acidosis

Answer 31

Addison's disease, also known as primary adrenal insufficiency, is a rare endocrine disorder characterized by inadequate production of cortisol and aldosterone by the adrenal cortex. Autoimmune destruction is the most common cause, accounting for nearly 80% of cases. Other aetiologies include infections, such as tuberculosis, genetic disorders, and certain medications.

Answer 32

ACTH stimulation yest

Answer 33

shiny, painless areas of yellow/red skin typically on the shin of diabetics often associated with telangiectasia

Answer 34

microscopic haematuria progressive renal failure bilateral sensorineural deafness lenticonus: protrusion of the lens surface into the anterior chamber retinitis pigmentosa renal biopsy: splitting of lamina densa seen on electron microscopy Diagnosis molecular genetic testing renal biopsy electron microscopy: characteristic finding is of the longitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a 'basket-weave' appearance

Answer 35

Blindness, deafness and diaabetes

Answer 36

congnitive impairment, renal failure, hyperphagia, diabetes and obesity

Answer 37

gastroenteritis diarrhoea bacteraemia flu-like illness central nervous system infection meningoencephalitis ataxia seizures typically spread via unpasturised dairy products ## Footnote Pregnancy is a risk factor - pregnant women are almost 20 times more likely to develop Ix blood cultures 'tumbling motility' on wet mounts cerebrospinal fluid findings: pleocytosis, often lymphocytes (nontuberculous bacteria usually cause a rise in neutrophils) raised protein reduced glucose

Answer 38

Listeria is sensitive to amoxicillin/ampicillin (cephalosporins usually inadequate) Listeria meningitis should be treated with IV amoxicillin/ampicillin and gentamicin

Answer 39

Hyperinsulinaemia in the presence of a normal or low c-peptide is suggestive of insulin misuse

Answer 40

a statin and a fibrate along with dietary modification.

Answer 41

the patient may be eu-, hypo- or hyperthyroid at the time of presentation exophthalmos conjunctival oedema optic disc swelling ophthalmoplegia inability to close the eyelids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy

Answer 42

smoking cessation topical lubricants may be needed to help prevent corneal inflammation caused by exposure steroids radiotherapy surgery

Answer 43

Exposure keratopathy this is the most common complication of thyroid eye disease due to eyelid retraction and proptosis (exophthalmos) → cornea becomes excessively exposed, disrupting the normal tear film → dryness, irritation, and corneal ulceration symptoms include foreign body sensation, pain, and photophobia in severe cases, it can lead to corneal scarring and vision impairment. Optic neuropathy one of the most serious complications of thyroid eye disease occurs when enlarged extraocular muscles compress the optic nerve at the apex of the orbit → a reduction in visual acuity, colour vision deficits, and visual field defect it requires urgent medical intervention to prevent permanent vision loss. Strabismus and diplopia fibrosis and enlargement of the extraocular muscles can result in restrictive strabismus → misalignment of the eyes → double vision (diplopia) this not only affects visual function but can also significantly impair the quality of life.

Answer 44

AKA - proximal diabetic neuropathy Typical features include pain is usually in the first symptom, often in the hips or buttocks this is followed by weakness, for example difficulty getting out of a chair Tx - physio and pregabalin or gabapentin ## Footnote the classical picture of proximal pain and weakness in a femoral nerve distribution is suggestive of diabetic amyotrophy - underlying pathology is unclear Often seen with rapid changes in BMs such as thosed started on insulin therapy

Answer 45

profound postpartum blood loss which cases infarction of the pituitary gland

Answer 46

**low ACTH** tiredness postural hypotension **low FSH/LH** amenorrhoea infertility loss of libido **low TSH** feeling cold constipation **low GH** if occurs during childhood then short stature **low prolactin** problems with lactation there may also be features suggestive of the underlying causes pituriary macroadenoma → bitemporal hemianopia pituitary apoplexy → sudden, severe headache

Answer 47

AD **Features** cerebellar haemangiomas: these can cause subarachnoid haemorrhages retinal haemangiomas: vitreous haemorrhage renal cysts (premalignant) phaeochromocytoma extra-renal cysts: epididymal, pancreatic, hepatic endolymphatic sac tumours clear-cell renal cell carcinoma

Answer 48

Management long-acting acetylcholinesterase inhibitors pyridostigmine is first-line immunosuppression is usually not started at diagnosis, but the majority of patients eventually require it in addition to long-acting acetylcholinesterase inhibitors: prednisolone initially azathioprine, cyclosporine, mycophenolate mofetil may also be used thymectomy Management of myasthenic crisis plasmapheresis intravenous immunoglobulins

Answer 49

a collection of CSF within the spinal cord

Answer 50

Features a 'cape-like' (neck, shoulders and arms) loss of sensation to temperature but the preservation of light touch, proprioception and vibration classic examples are of patients who accidentally burn their hands without realising this is due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected spastic weakness (predominantly of the lower limbs) neuropathic pain upgoing plantars autonomic features: Horner's syndrome due to compression of the sympathetic chain, but this is rare bowel and bladder dysfunction scoliosis will occur over a matter of years if the syrinx is not treated

Answer 51

oculomotor dysfunction nystagmus (the most common ocular sign) ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy gait ataxia encephalopathy: confusion, disorientation, indifference, and inattentiveness peripheral sensory neuropathy

Answer 52

Haemophilia A: Characterised by Factor VIII deficiency and accounts for 80-85% of cases. Haemophilia B: Arises due to Factor IX deficiency. ## Footnote PT will be normal APTT will be prolonged They have blleding into deep tissue and joionts

Answer 53

associated with anti factor VIII iGG antibodies Idiopathic in most cases can also be linked to other autoimmune diseases e.g. RA , IBD

Answer 54

sulfonylureas* SSRIs, tricyclics carbamazepine vincristine cyclophosphamide

Answer 55

Urine osmolality: Urine osmolality is inappropriately high (>100 mOsm/kg) in relation to serum osmolality, as the kidneys should normally dilute urine in the setting of low serum osmolality. Urine sodium concentration: Urine sodium concentration is typically high (>40 mmol/L) due to the action of ADH on the renal tubules.

Answer 56

granulomatosis with polyangiitis eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) microscopic polyangiitis ## Footnote there are a number of common findings: renal impairment caused by immune complex glomerulonephritis → raised creatinine, haematuria and proteinuria respiratory symptoms dyspnoea haemoptysiis systemic symptoms fatigue weight loss fever vasculitic rash: present only in a minority of patients ear, nose and throat symptoms sinusitis

Answer 57

Features often patients have fine, fair hair musculoskeletal Marfanoid body habitus: arachnodactyly etc osteoporosis kyphosis neurological: may have learning difficulties, seizures ocular downwards (inferonasal) dislocation of lens severe myopia increased risk of arterial and venous thromboembolism also malar flush, livedo reticularis

Answer 58

retinal haemorrhages and oedema of the optic disc Afferent pupil light defect

Answer 59

Electromyography

Answer 60

General features myotonic facies (long, 'haggard' appearance) frontal balding bilateral ptosis cataracts dysarthria

Answer 61

associated with small cell lung cancer antibody directed against presynaptic voltage-gated calcium channel Features - repeated muscle contractions lead to increased muscle strength (in contrast to myasthenia gravis) - limb-girdle weakness (affects lower limbs first) hyporeflexia autonomic symptoms: dry mouth, impotence, difficulty micturating ophthalmoplegia and ptosis not commonly a feature (unlike in myasthenia gravis)

Answer 62

characteristically affects quadriceps and finger/wrist flexors are usually more severely affected than extensor counterparts Usually late onset and more common in males The CK is modestly raised associated with cytoplasmic inclusions on muscle biopsy

Answer 63

Serological testing for phase I and II antibodies High titres of phase I immunoglobulins G antibodies are diagnostic in the appropriate clinical context C. Burnetti is an obligate intracellular pathogen that cannot be routunely cultures, making serological tests essential for diagnosis.

Answer 64

Usually occurs more than.6 months after transplantation.

Answer 65

familial clusters of malignant melanoma and breast cancer.

Answer 66

autosomal recessive type V glycogen storage disease Muscle pain and stiffness following exercise muscle cramps Lactate does not go up after exercise like it would in normal patients diagnosis confirmed with muscle biopsy ## Footnote second wind phenomenon occurs when patients experience an improvement in exercise tolerance after a brief rest or reduction in intensity due to the body's switch from glycogen-dependent energy metabolism to increased reliance on circulating glucose and fatty acids his adaptation allows for better energy utilisation during prolonged activity despite the underlying myophosphorylase deficiency.

Answer 67

The most useful intial assessment must include nail fold caillary loop examidation. a clos second is ANA testing

Answer 68

Becker muscular dystrophy (BMD) is an X-linked recessive disorder characterised by a gradual, but progressive, skeletal muscle weakness and wasting. It primarily affects males due to its inheritance pattern. Gower's sign - where they used their hands and arms to walk their bodies from a bent over position waddling gait muscles cramps cardiac manifestation

Answer 69

pleural fluid pH A pleural fluid pH of less than 7.2 is highly suggestive of an empyema

Answer 70

a devastating cutaneous dermopathy, seen in patients with CKD who have been exposed to gadolinium based contrast agents seen in MRI - the skin becomes wood-like and hard

Answer 71

caused by protozoan trypanosoma cruzi The vast majority of patients are asymptoatic in the acute phase - although a chagoma (an erythematous nodule at the site of infection) and periorbital oedema. Chronic chagas disease mainly affects the heart and GI tracy.- myocarditis may lead to dilated cardiomyopathy and arhythmias, GI features include megaoesophagus and megacolon causing disphagia and constipation treatment is most effective in the acute phase using azole or nitroderivatives such as benznidazole or nifurtimox chronic disease management involves treating the complications e.g., heart failure

Answer 72

Two forms of African trypanosomiasis, or sleeping sickness, are seen - Trypanosoma gambiense in West Africa and Trypanosoma rhodesiense in East Africa. Both types are spread by the tsetse fly. Trypanosoma rhodesiense tends to follow a more acute course. Clinical features include: Trypanosoma chancre - painless subcutaneous nodule at site of infection intermittent fever enlargement of posterior cervical lymph nodes later: central nervous system involvement e.g. somnolence, headaches, mood changes, meningoencephalitis Management early disease: IV pentamidine or suramin later disease or central nervous system involvement: IV melarsoprol

Answer 73

spread by sandflied cutaneous - topica or mexicana - crusted lesion at the site of the lesion Mucocutaneous - braziliensis - skin lesiona may spread to involve mucosae of nose and pharynx Visceral leishmaniasis - donovani - fevers, sweats, rigors, massive splenomegaly, hepatomegaly, poor appetite, weight loss, grey skin (Kala-azar)

Answer 74

Borrelia burgdorferi

Answer 75

Guillain-Barre syndrome describes an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).

Answer 76

IV immunoglobulins (IVIG) or plasma exchange can be used IVIG is as effective as plasma exchange better tolerated and easier to administer therefore IVIG is generally used first-line for Guillain-Barre syndrome where patients require immunomodulatory therapy no benefit in combining both treatments steroids and immunosuppressants have not been shown to be beneficial FVC regularly to monitor respiratory function

Answer 77

IV ganciclovir

Answer 78

Hep B 1980s Hep C 1990-1992

Answer 79

steroids and azathiorpine

Answer 80

aim for monotherapy there is no indication to monitor antiepileptic drug levels sodium valproate: associated with neural tube defects carbamazepine: often considered the least teratogenic of the older antiepileptics phenytoin: associated with cleft palate lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Answer 81

IV calcium chloride

Answer 82

Mononeuritis multiplex is a disorder causing sensory and motor deficits in at least two separate peripheral nerves, leading to symptoms like pain, numbness, weakness, and paralysis.

Answer 83

Vascultic causes - PAN, GPA, Microscopic polyangitis, EGPA Connective tissue disorder - RA, SLE, Sjorgrens Infective - HIV, Hep B and C, leprosy, lyme disease, syphilis Diabetes lymphoma, leukaemia, sarcoidosis, amyloidosis

Answer 84

coarse tremor (a fine tremor is seen in therapeutic levels) hyperreflexia acute confusion polyuria seizure coma

Answer 85

mild-moderate toxicity may respond to volume resuscitation with normal saline IV fluids with isotonic saline, until euvolemic, then typically twice maintenance rate monitor serum sodium closely (every 4 hours with serial lithium concentrations) if there is a concern about lithium-induced nephrogenic diabetes insipidus haemodialysis may be needed in severe toxicity sodium bicarbonate is sometimes used but there is limited evidence to support this by increasing the alkalinity of the urine it promotes lithium excretion

Answer 86

Increased EPO secretion mainly from renal lesions

Answer 87

Amoebiasis is caused by Entamoeba histolytica May be mild or may cause severe amoebic dysentry (Profuse bloody diaarhoea) May cause lover abcess (fever, RUQ pain, malaise, hepatomegaly) Tx with metronidazole and luminal agent (diloxanide furoate

Answer 88

Rheumatic fever develops following an immunological reaction to a recent (2-4 weeks ago) Streptococcus pyogenes infection.

Answer 89

Management Outline of management antibiotics: oral penicillin V anti-inflammatories: NSAIDs are first-line treatment of any complications that develop e.g. heart failure

Answer 90

**Diagnosis is based on evidence of recent streptococcal infection accompanied by: 2 major criteria 1 major with 2 minor criteria ** Evidence of recent streptococcal infection raised or rising streptococci antibodies, positive throat swab positive rapid group A streptococcal antigen test **Major criteria** erythema marginatum Sydenham's chorea: this is often a late feature polyarthritis carditis and valvulitis (eg, pancarditis) The latest iteration of the Jones criteria (published in 2015) state that rheumatic carditis cannot be based on pericarditis or myocarditis alone and that there must be evidence of endocarditis (the clinical correlate of which is valvulitis which manifests as a regurgitant murmur) subcutaneous nodules **Minor criteria** raised ESR or CRP pyrexia arthralgia (not if arthritis a major criteria) prolonged PR interval

Answer 91

short PR interval wide QRS complexes with a slurred upstroke - 'delta wave' left axis deviation if right-sided accessory pathway in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation right axis deviation if left-sided accessory pathway

Answer 92

Reduces ammonia production by reducing colonies of ammonia forming bacteria

Answer 93

nuclear pleomorphism and absent or late mitoses ## Footnote VS adenocarcinoma of the bronchus - atypical cells showing frequent mitoses and often potentially forming ducts or glands small cell - associated with makred nucleaer pleomorphism and a large number of mitoses

Answer 94

a keratolytic and and an antifungal agent and is used in the forms of shampoos and stay on lotation in the managament of seborrhoeic dermatitis

Answer 95

likely to occur in 5-10% of of woman during the first year - hyperthyroidism is said to occur within the first 4 months of pregnancy, with hypothyroid occuring later 3-7month stage Often symptoms are mild and non-specific. Spontaneous recovery occurs in the majority of patients within 6-12 months

Answer 96

Nausea, vomiting, epigastric pain, sinus tachycardia, tachypnoea, hypotension, tremor, headache, agitation, confusion and hallucinaiton Metabolic features - hypokalaemia, hypomagnesaemia, hypercalcaemia Severe toxicity can cause convulsions and cardiac arrhythmia Activated charcoal can be given, even later after ingestion to redice absorption consider gastric lavage if <1 hour prior to ingestion whole-bowel irrigation can be performed if theophylline is sustained release form If patient has severe hypokalaemia - needs IV potassium replacement

Answer 97

medications used to temporarily stop or delay preterm labour Common tocolytics include magnesium sulfate, nifedipine, indomethacin, and terbutaline

Answer 98

acute pulmonary oedema can occur with adminstraion of B2 agnoists for tocolysis in up to 5-15% of cases. It usually occurs after 24 hours of adminstration of these agents.

Answer 99

Lofgren's syndrome is an acute form sarcoidosis characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It typically occurs in young females and carries an excellent prognosis.

Answer 100

anosmia, loss of libido, gonadal deficiency, erectile dysfuncion and absent secondary characteristics Low LH, FSH and testosteroe

Answer 101

Klinefelter's syndrome Klinefelter's syndrome is associated with karyotype 47, XXY. Features often taller than average lack of secondary sexual characteristics small, firm testes infertile gynaecomastia - increased incidence of breast cancer elevated gonadotrophin levels but low testosterone Diagnosis is by karyotype (chromosomal analysis).

Answer 102

Neuromyelitis optica (NMO) is a monophasic or relapsing-remitting demyelinating CNS disorder Although previously thought to be a variant of multiple sclerosis, it is now recognised to be a distinct disease, particularly prevalent in Asian populations. It typically involves the optic nerves and cervical spine, with imaging of the brain frequently normal. Vomiting is also a common presenting complaint. Diagnosis requires bilateral optic neuritis, myelitis and 2 of the following 3 criteria: 1. Spinal cord lesion involving 3 or more spinal levels 2. Initially normal MRI brain 3. Aquaporin 4 positive serum antibody Management treatment of acute attacks high-dose IV methylprednisolone maintenance therapy for attack prevention long-term monoclonal antibody therapy, e.g. eculizumab, ravulizumab (antibody target = complement C5), inebilizumab (antibody target = CD19 on B cells) or satralizumab (antibody target = IL-6 receptor)

Answer 103

characterised by pulmonary infiltrates and pulmonary eosinophilia Idiopathic or secondary to parasites, drugs or systemic diseases such as vasculitis The peripheral eosinophil count is not always raised Presents over months to years CXR - dense bilateral periperal infilrates - often opposite to pulmonary oedema with a distribution in the oiter two thirds of the lungs tx with stroids

Answer 104

Cisplatin based chemoradiotherapy

Answer 105

Hyperkeratosis and scaling of the skin No visual eythema, excorations or inflammatory changes

Answer 106

Flavivirus can progress to viral haemorrhagic fever Symtpoms fever, headache (often retro-orbital), myalgia, bone pain, pleuritic pain, facial flishing, maculopapular rash ## Footnote Severe dengue (dengue haemorrhagic fever) this is a form of disseminated intravascular coagulation (DIC) resulting in: thrombocytopenia spontaneous bleeding around 20-30% of these patients go on to develop dengue shock syndrome (DSS)

Answer 107

age, increased stroke severity (NIHSS), HTN, hyperglycaemia, low plt count, use of antithrombotic drug, poor collateral circulation, recanalisation

Answer 108

Schistosomiasis Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The three main species of schistosome are S. mansoni, S. japonicum and S. haematobium. Acute infections Acute symptoms typically only develop in people who travel to endemic areas, as they don't have any immunity to the worms. Acute manifestations may include: swimmers' itch acute schistosomiasis syndrome (Katayama fever) fever urticaria/angioedema arthralgia/myalgia cough diarrhoea eosinophilia Chronic infections Schistosoma haematobium These worms deposit egg clusters (pseudopapillomas) in the bladder, causing inflammation. The calcification seen on x-ray is actually calcification of the egg clusters, not the bladder itself. Depending on the site of these pseudopapillomas in the bladder, they can cause an obstructive uropathy and kidney damage. This typically presents as a 'swimmer's itch' in patients who have recently returned from Africa. Schistosoma haematobium is a risk factor for squamous cell bladder cancer. Features frequency haematuria bladder calcification Investigation for asymptomatic patients serum schistosome antibodies are generally preferred for symptomatic patients the gold standard for diagnosis is urine or stool microscopy looking for eggs Management single oral dose of praziquantel Schistosoma mansoni and Schistosoma japonicum These worms mature in the liver and then travel through the portal system to inhabit the distal colon. Their presence in the portal system can lead to progressive hepatomegaly and splenomegaly due to portal vein congestion. These species can also lead to complications of liver cirrhosis, variceal disease and cor pulmonale. Schistosoma intercalatum and Schistosoma mekongi These are less prevalent than the other three forms, but are both attributed to intestinal schistosomiasis.

Answer 109

Anterior inferior cerebellar artery (lateral pontine syndrome) Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus Ipsilateral: facial paralysis and deafness

Answer 110

Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus

Answer 111

High grade B cell neoplasm endemic (African) form: typically involves maxilla or mandible sporadic form: abdominal (e.g. ileo-caecal) tumours are the most common form. More common in patients with HIV Burkitt's lymphoma is associated with the c-myc gene translocation, usually t(8:14). The Epstein-Barr virus (EBV) is strongly implicated in the development of the African form of Burkitt's lymphoma and to a lesser extent the sporadic form. Microscopy findings'starry sky' appearance: lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells There is often spontaneous tumour lysis - with very high lactate and uric acid levels ## Footnote management is with chemo - high risk of tumour lysis syndrome - rasburicase is often given before chemo

Answer 112

combined pulmonary fibrosis and emphysema (CPFE). CPFE is characterized by exertional dyspnoea, upper-lobe emphysema and lower-lobe fibrosis, preserved lung volume and severely reduced capacity of gas exchange. The preserved lung volumes are thought to arise because of the counterbalanced effects of hyperinflation from emphysema and the restrictive effects of pulmonary fibrosis. Both mechanisms lead to reduced gas exchange, hence the significantly reduced DLCO.

Answer 113

Plasmodium vivax - most common, with Plasmodium ovale and Plasmodium malariae Plasmodium knowlesi is another non-falciparum species which causes clinical pathology, found predominantly in South East Asia. general features of malaria: fever, headache, splenomegaly Plasmodium vivax/ovale: cyclical fever every 48 hours. Plasmodium malariae: cyclical fever every 72 hours Plasmodium malariae: is associated with nephrotic syndrome. ## Footnote Ovale and vivax malaria have a hypnozoite stage and may therefore relapse following treatment.

Answer 114

in areas which are known to be chloroquine-sensitive then WHO recommend either an artemisinin-based combination therapy (ACT) or chloroquine in areas which are known to be chloroquine-resistant an ACT should be used ACTs should be avoided in pregnant women patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine to destroy liver hypnozoites and prevent relapse

Answer 115

Pseudomonas aeruginosa

Answer 116

Continue low-dose aspirin for secondary prevention of vascular events in patients with upper gastrointestinal bleeding in whom haemostasis has been achieved.

Answer 117

short stereotypes events, abrupt onset and termination of motor syptoms assocated with bizarre vocalisation

Answer 118

Skin: Pruritic maculopapular rash → can become generalized, erythematous, sometimes bullous Often starts on palms, soles, ears, or face Liver: Jaundice, hepatomegaly, right upper quadrant pain Abnormal LFTs (raised bilirubin, ALP, GGT, ALT/AST) GI tract: Profuse watery diarrhea, sometimes bloody Abdominal pain, nausea, vomiting, ileus Anorexia and weight loss ## Footnote if you suspect GVHD it is essential to that infective causes of the patients symptoms are rules out due to the level of immunosupression - test for CMV, HSV 6, adenovirus, parvovirus

Answer 119

EAA: Immune-mediated reaction to repeated inhalation of organic antigens (e.g., moldy hay → farmer’s lung; bird droppings/feathers → bird fancier’s lung). ABPA: Hypersensitivity reaction to colonisation by Aspergillus fumigatus in the airways, usually in patients with asthma or cystic fibrosis.

Answer 120

Extrinsic allergic alveolitis (EAA, also known as hypersensitivity pneumonitis) is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.

Answer 121

It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein Features systemic upset: weight loss, lethargy hyperviscosity syndrome e.g. visual disturbance the pentameric configuration of IgM increases serum viscosity hepatosplenomegaly lymphadenopathy cryoglobulinaemia e.g. Raynaud's Investigations monoclonal IgM paraproteinaemia bone marrow biopsy is diagnostic infiltration of the bone marrow with lymphoplasmacytoid lymphoma cells Management typically rituximab-based combination chemotherapy

Answer 122

ATN is an intrinsic renal injry commonly caused by ischaemia, sepsis or nephrotoxins Brown casts in the urine Due to the intrinsic damage to the renal tubular epithelium, the kidneys are less able to hold onto electrolytes, causing elevated urinary sodium ## Footnote If patients have a prerenal kidney injury they will have concentrated urine with low urinary sodium levels

Answer 123

Sodium nitroprusside IV labetalol

Answer 124

vestibular damage ## Footnote Streptomycin is an aminoglycoside bactericidal antibiotic

Answer 125

rare condition which is sometimes familial with AR inheritance It is associated with the deposition of diffuse calcified microliths in the alveolar space

Answer 126

crusted at the site of bite there may be an underlying ulcer If it is visceral fever, sweats, rigors massive splenomegaly. hepatomegaly poor appetite*, weight loss occasionally patients may report increased appetite with paradoxical weight loss grey skin - 'kala-azar' means black sickness pancytopaenia secondary to hypersplenism

Answer 127

Serum protein electrophoresis (serum immunoglobulins will not confirm the presence of a paraprotein)

Answer 128

omit dose and restart on advice from micro when level < 15

Answer 129

A rare defect in of B cell maturation which produces reduced immunoglobulin production Low antibody levels, specifically in immunoglobulin (Ig) types IgG, IgM and IgA. Recurrent chest infections. May also predispose to autoimmune disorders and lymphona

Answer 130

Many varying causes. Most common (X-linked) due to defect in the common gamma chain, a protein used in the receptors for IL-2 and other interleukins. Other causes include adenosine deaminase deficiency Recurrent infections due to viruses, bacteria and fungi. Reduced T-cell receptor excision circles Stem cell transplantation may be successful Presents in early childhoos with massive infection

Answer 131

Hydatid cysts - slow insidious onset, often asymptomatic, due to a parasitic tapeworm Amoebic liver abscess - protozoan parasite, acurte or subacute, fever RUQ pain, FEVER, HEPATOMEGALY, SWEATS, WEIGHT LOSS ## Footnote Hydatid Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first). Treattment of Echinococcus granulosus is mebadazoles Ameobic - management oral metronidazole a 'luminal agent' (to eliminate intraluminal cysts) is recommended usually as well e.g. diloxanide furoate

Answer 132

Levetiracetam

Answer 133

Features the disease typically has a prolonged and gradual onset flu-like symptoms classically precede a dry cough bilateral consolidation on x-ray complications may occur as below Complications cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia erythema multiforme, erythema nodosum meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases bullous myringitis: painful vesicles on the tympanic membrane pericarditis/myocarditis gastrointestinal: hepatitis, pancreatitis renal: acute glomerulonephritis Investigations diagnosis is generally by Mycoplasma serology positive cold agglutination test → peripheral blood smear may show red blood cell agglutination Management doxycycline or a macrolide (e.g. erythromycin/clarithromycin) ## Footnote Subclinical haemolytic anaemia can present in patients with mycoplasma

Answer 134

mutation in the FBN1 gene Features tall stature with arm span to height ratio > 1.05 high-arched palate arachnodactyly pectus excavatum pes planus scoliosis of > 20 degrees heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation mitral valve prolapse (75%), lungs: repeated pneumothoraces eyes: upwards lens dislocation (superotemporal ectopia lentis) blue sclera myopia dural ectasia (ballooning of the dural sac at the lumbosacral level)

Answer 135

A bezoar is a mass of undigestible material trapped in the gastrointestinal tract, most commonly the stomach, which can cause symptoms like pain, nausea, and obstruction. Types include phytobezoars (from plant matter), trichobezoars (from hair), and pharmacobezoars (from medications).

Answer 136

Associated factors obesity type 2 diabetes mellitus hyperlipidaemia jejunoileal bypass sudden weight loss/starvation Features usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on ultrasound

Answer 137

99% are ANA positive this high sensitivity makes it a useful rule out test, but it has low specificity 20% are rheumatoid factor positive anti-dsDNA: highly specific (> 99%), but less sensitive (70%) anti-Smith: highly specific (> 99%), sensitivity (30%) also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)

Answer 138

relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)

Answer 139

**natalizumab** a recombinant monoclonal antibody that antagonises alpha-4 beta-1-integrin found on the surface of leucocytes inhibit migration of leucocytes across the endothelium across the blood-brain barrier generally considered to have the strongest evidence base for preventing relapse of the disease-modifying and hence is often used first-line given intravenously **ocrelizumab** humanized anti-CD20 monoclonal antibody like natalizumab, it is considered a high-efficacy drug that is often used first-line given intravenously **fingolimod** sphingosine 1-phosphate (S1P) receptor modulator prevents lymphocytes from leaving lymph nodes oral formulations are available **beta-interferon **not considered to be as effective as alternative disease-modifying drugs given subcutaneously/intramuscularly **glatiramer acetate **immunomodulating drug - acts as an 'immune decoy' given subcutaneously along with beta-interferon considered an 'older drug' with less effectiveness compared to monoclonal antibodies and S1P) receptor modulators

Answer 140

large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension absent if in atrial fibrillation

Answer 141

concentric erytheatous bands forming a wood grain appearance believed to be paraneoplastic in origin

Answer 142

caused by atrial contractions against a closed tricuspid valve are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing

Answer 143

caused by defective realease of GnRH, due to failure of development of the olfactory bulb LH and FSH are reduced and patients suffer from anosmia

Answer 144

Klinefelter's syndrome is associated with karyotype 47, XXY. primary hypogonadism (hypergonadotrophic hypogonadism) Features often taller than average lack of secondary sexual characteristics small, firm testes infertile gynaecomastia - increased incidence of breast cancer elevated gonadotrophin levels but low testosterone treatmet is with androgren replacement

Answer 145

a treatment of adrenal cancer when surgery can not be used it acts on adrenal cortex to reduce amounts of steroids produced

Answer 146

controls cortisol synthesis prior to surgery will help control blood sugar and blood pressure

Answer 147

prolactinomas are generally treated first-line with dopamine agonists (e.g., cabergoline or bromocriptine). somatostatin analogues (e.g., octreotide, lanreotide) and GH receptor antagonists (e.g., pegvisomant) are used for GH-secreting adenomas for ACTH-secreting adenomas, medical therapy may include cortisol synthesis inhibitors (e.g., ketoconazole, metyrapone) and neuromodulators like pasireotide

Answer 148

There are 2 predominant types of multiple system atrophy 1) MSA-P - Predominant Parkinsonian features 2) MSA-C - Predominant Cerebellar features Shy-Drager syndrome is a type of multiple system atrophy. Features parkinsonism autonomic disturbance erectile dysfunction: often an early feature postural hypotension atonic bladder cerebellar signs

Answer 149

Overview aka Steele-Richardson-Olszewski syndrome a 'Parkinson Plus' syndrome Features postural instability and falls patients tend to have a stiff, broad-based gait impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs) parkinsonism bradykinesia is prominent cognitive impairment primarily frontal lobe dysfunction Management poor response to L-dopa

Answer 150

**Small cell** ADH ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc Lambert-Eaton syndrome **Squamous cell** parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia clubbing hypertrophic pulmonary osteoarthropathy (HPOA) hyperthyroidism due to ectopic TSH **Adenocarcinoma** gynaecomastia hypertrophic pulmonary osteoarthropathy (HPOA)

Answer 151

proximal tubule

Answer 152

Type 1 RTA (distal) inability to generate acid urine (secrete H+) in distal tubule causes hypokalaemia complications include nephrocalcinosis and renal stones causes include idiopathic, rheumatoid arthritis, SLE, Sjogren's, amphotericin B toxicity, analgesic nephropathy Type 2 RTA (proximal) decreased HCO3- reabsorption in proximal tubule causes hypokalaemia complications include osteomalacia causes include idiopathic, as part of Fanconi syndrome, Wilson's disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate)

Answer 153

Procyclidine

Answer 154

the effectiveness of the COCP and the POP may be reduced by unteraction with carbamazepine and other drugs that induce liver enzyme activity - advice is there for to take a prepation containing at least 50ug of ethinyloestradiol

Answer 155

surgical resection if patients lung function too poor for surgical resection - long term itraconzaole can be effective in reducing symptoms

Answer 156

myocarditis

Answer 157

large numbers of immunocompetent cells in the lamina propria B cell lymphoma comprising large numbers of lymphocytes with irregular nuclear contours and abundant cytoplasm. Treat H.Pylori and tumours shoudl resolve If they don't you can give ritxamab

Answer 158

Creutzfeldt-Jakob disease (CJD) is rapidly progressive neurological condition caused by prion proteins. These proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases. Features dementia (rapid onset) myoclonus Investigation CSF is usually normal EEG: biphasic, high amplitude sharp waves (only in sporadic CJD) MRI: hyperintense signals in the basal ganglia and thalamus

Answer 159

Features acidosis, hypokalaemia vomiting tachycardia, arrhythmias seizures Management consider gastric lavage if <1 hour prior to ingestion activated charcoal whole-bowel irrigation can be performed if theophylline is sustained release form charcoal haemoperfusion is preferable to haemodialysis

Answer 160

adult onset junvenile chronic arthritis arthralgia elevated serum ferritin rash: salmon-pink, maculopapular pyrexia typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash lymphadenopathy rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative they can also get pericaritis

Answer 161

HBsAg positive HBeAG negative indicating that viral replication is at a low level

Answer 162

Gas Gangrene Follows trauma, surgery, or contaminated wounds. Rapidly progressive: severe pain, crepitus, foul-smelling discharge, systemic toxicity. Life-threatening if not managed urgently. Urgent surgical debridement (± amputation). High-dose IV penicillin. Clindamycin often added (to inhibit toxin production). Supportive care: fluids, ICU support. Hyperbaric oxygen therapy (where available).

Answer 163

supportive therapy

Answer 164

When the null hypothesis is incorrectly accepted the best way to minimise this risk is

Answer 165

Type 1 - Rapidly progressive Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks Very poor prognosis Type 2- Slowly progressive Prognosis poor, but patients may live for longer Management - Vasopressin analogues - terlipressin volume expansion with 20% albumin

Answer 166

amox and gent for 4-6 weeks Id allergic to pen - give vanco and gent

Answer 167

quinolones - e.g. cipro

Answer 168

Potential complications of chronic hepatitis C rheumatological problems: arthralgia, arthritis eye problems: Sjogren's syndrome cirrhosis (5-20% of those with chronic disease) hepatocellular cancer cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal) porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse membranoproliferative glomerulonephritis

Answer 169

prodrome, e.g. low-grade fever rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day lymphadenopathy: suboccipital and postauricular

Answer 170

Rare pancreatic endocrine tumours producing vasocactive interstinal peptide - hypokalaemic metabolic acidosis, diarrhoea despite fasting and facial flusing

Answer 171

Raised anion gap metabolic acidosis

Answer 172

Both are neurosurgical emergencies → require urgent MRI spine & decompression. CES = think nerve root compression (disc prolapse, tumour, trauma). CMS = think spinal cord lesion at conus (tumour, trauma, ischaemia). Early sphincter involvement + symmetrical findings → CMS. Radicular pain + asymmetrical weakness → CES. ## Footnote “Sudden onset urinary retention + symmetrical saddle anaesthesia + mixed UMN/LMN signs” → Conus medullaris. “Gradual radicular pain + asymmetrical LMN weakness + late bladder involvement” → Cauda equina.

Answer 173

a movement disorder which manifests as unilater involuntary flinging movements of the proximal upper limbs The lesion is in the ocntralateral subthalamic nucleaus of Luys.

Answer 174

PC is associated with significant alcoholism and obesity

Answer 175

Doxycyline and metronidazole

Answer 176

Overview Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) rare cause of multi-infarct dementia patients often present with migraine 90% of patients will have NOTCH-3 gene mutationz

Answer 177

membranous nephropathy

Answer 178

give platelts with anti-D if plt transfusion can not be delayed

Answer 179

AD inherritance can result in sudden cardiac ECG changes convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave partial right bundle branch block the ECG changes may be more apparent following the administration of flecainide or ajmaline - this is the investigation of choice in suspected cases of Brugada syndrome

Answer 180

visual hallucinations significant sleep disturbance movement disorder (although tremor is often less prevalent that in patients with idiopathic parkinsons.

Answer 181

Burkholderia pseudomallei - the organism that causes meliodosis is endemic in thailand especially in the wet season and Northern Australia. Infections can present as pneumonia, pulmonary abcesses and pleiral effusions resulting in sepptic shock The history will be similar to that of cavitating lung lesions tx with ceftazidine or meropenenem with co-trimoxazole

Answer 182

increase fluid and fibre A soluble preparation of Ispaghula husk such as fibrogel is one option

Answer 183

Think PTLD in a post-transplant patient with fever + GI mass/bleeding or graft enlargement. EBC is responsible

Answer 184

IV zolendronate

Answer 185

Young woman (<50) + resistant HTN ± abdominal/flank bruit → think renal FMD. One slightly smaller kidney

Answer 186

VZ Immunoglobulins should be given - can be used up to 10 days after exposure to the virus

Answer 187

think bilateral renal artery stenosis

Answer 188

RF: foreign travel swimming/drinking water from a river or lake male-male sexual contact Features non-bloody diarrhoea steatorrhoea bloating, abdominal pain lethargy flatulence weight loss malabsorption and lactose intolerance can occur Tx - metronidazole Don't return to work until symptom free for 48 hours

Answer 189

Doxycycline Borrelia burgdorferi ## Footnote Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy) Ceftriaxone if disseminated dosease

Answer 190

## Footnote SAAG=Serum albumin−Ascitic fluid albumin

Answer 191

**Potential consequences of pre-eclampsia** eclampsia other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata fetal complications intrauterine growth retardation prematurity liver involvement (elevated transaminases) haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure **Features of severe pre-eclampsia** hypertension: typically > 160/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 192

Nice guidance reccomends offering CAPD as an option to patients with end stage renal failure - especially where there is little co-morbidity apart from renal impariment and the patient still has some residual renal function

Answer 193

Pseudoomonas

Answer 194

Topcial salicylic acid

Answer 195

an infection commonest in hte mid-western US states and in the Ohio and Mississippi valleys. Acute infection is characterised by fevers, a cough productive of purulent sputum and bilateral pulmonary infiltrates on CXR Tx with Amphotericin and itraxonazole are both potential treatments

Answer 196

Trastuzumab (HER2) antagonist Can lead to cardiomyopathy

Answer 197

hypothyroid is common in patient on long term lithium therapy. Most important thing is to treat the hypothyroid - lithium does not necessarily need to be discontinued

Answer 198

Possible ECG features include: short PR interval wide QRS complexes with a slurred upstroke - 'delta wave' left axis deviation if right-sided accessory pathway in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation right axis deviation if left-sided accessory pathway Differentiating between type A and type B type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1

Answer 199

ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex

Answer 200

IP vancomycin and switch to CAPD

Answer 201

Give VZ Immunoglobulin ## Footnote ***chicken pox vaccine is a live vaccine and is contraindicated in a patient taking long term immunosuprresion

Answer 202

it manifests as Kimmelstiel-Wilson nodules, diffuse glomerular basement membrane thickening, mesangial expansion, and arteriolar hyalinosis.

Answer 203

Syringomyelia ('syrinx' for short) describes a collection of cerebrospinal fluid within the spinal cord. Causes include: a Chiari malformation: strong association trauma tumours idiopathic Features a 'cape-like' (neck, shoulders and arms) loss of sensation to temperature but the preservation of light touch, proprioception and vibration classic examples are of patients who accidentally burn their hands without realising this is due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected spastic weakness (predominantly of the lower limbs) neuropathic pain upgoing plantars autonomic features: Horner's syndrome due to compression of the sympathetic chain, but this is rare bowel and bladder dysfunction scoliosis will occur over a matter of years if the syrinx is not treated

Answer 204

a rare complication of large volume ascites drainage, and is caused by mesenteric variceal bleeding

Answer 205

Laboratory tumor lysis syndrome: abnormality in two or more of the following, occurring within three days before or seven days after chemotherapy. uric acid > 475umol/l or 25% increase potassium > 6 mmol/l or 25% increase phosphate > 1.125mmol/l or 25% increase calcium < 1.75mmol/l or 25% decrease

Answer 206

left atrial filling pressure

Answer 207

Wernicke's encephalopathy: nystagmus, ophthalmoplegia and ataxia Korsakoff's syndrome: amnesia, confabulation dry beriberi: peripheral neuropathy wet beriberi: dilated cardiomyopathy

Answer 208

Vitamin C (ascorbic acid) deficiency Symptoms and signs include: Follicular hyperkeratosis and perifollicular haemorrhage Ecchymosis, easy bruising Poor wound healing Gingivitis with bleeding and receding gums Sjogren's syndrome Arthralgia Oedema Impaired wound healing Generalised symptoms such as weakness, malaise, anorexia and depression

Answer 209

night blindness is often the initial sign unnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision) fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium

Answer 210

Management high-dose proton pump inhibitor whilst this is commonly used in patients with Barrett's the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited -endoscopic surveillance with biopsies for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years if dysplasia of any grade is identified endoscopic intervention is offered. Options include: radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia endoscopic mucosal resection *radiofrequency ablation is only indicated once a second endoscopy has confired the low grade dysplasia

Answer 211

HLA-B*1502

Answer 212

HLA-DQA1*02:01-HLA-DRB1*07:01

Answer 213

Acetoacetate (AcAc) β-Hydroxybutyrate (β-HB) – predominant in DKA - 75% Acetone (from spontaneous AcAc decarboxylation) ## Footnote Urine nitroprusside detects AcAc (± acetone), not β-HB → can underestimate severity early and appear to “worsen” as β-HB converts back to AcAc during recovery.

Answer 214

smoking drugs: NSAIDs, PPIs and SSRIs

Answer 215

Non-classic CAH presents later in life with symptoms including hirsutism, menstrual irregularities, and infertility.

Answer 216

Morphoea is characterised by an area of inflammation and fibrosis (thickening and hardening) of the skin due to increased collagen deposition. the lesions often begin with a small violaceous/erythematous skin lesions whcih enlarge and progress to hideboung skin with a variable degree of hypo or hyper pigmentation

Answer 217

bilateral idiopathic adrenal hyperplasia: the cause of around 60-70% of cases Conn's syndrome - caused by an adrenal adenoma HTN Hypokalawmia Metabolic alkalosis high aldosterone Low rening levels CT abdomen Adrenal venous sampling

Answer 218

only within 48 hours of onset of symptosms

Answer 219

First Position (Chamber Paced): V - Ventricle A - Atrium D - Dual (both atrium and ventricle) O - None (no pacing) Second Position (Chamber Sensed): V - Ventricle A - Atrium D - Dual (both atrium and ventricle) O - None (no sensing) Third Position (Response to Sensing): I - Inhibited (pacemaker is prevented from pacing if it senses intrinsic cardiac activity) T - Triggered (pacemaker will release a pulse if it senses intrinsic activity, usually used in combination therapies) D - Dual (both inhibited and triggered) O - None (no response to sensing) For pacemakers with more advanced functionalities, there are often fourth and fifth positions: Fourth Position (Rate Modulation): R - Rate modulated (the pacemaker can adjust its pacing rate in response to changes in the patient's activity or other physiological indicators) O - None (no rate modulation) Fifth Position (Multi-Site Pacing): A - Atrium V - Ventricle D - Dual (both atrium and ventricle) O - None (no multi-site pacing) Examples: VVI: A pacemaker that paces the ventricle, senses the ventricle, and will be inhibited if it detects an intrinsic ventricular beat. AAI: A pacemaker that paces the atrium, senses the atrium, and will be inhibited if it detects an intrinsic atrial beat. DDD: A pacemaker that paces and senses in both the atrium and ventricle. It can both inhibit and trigger pacing based on its sensing. VVIR: A ventricular paced, ventricular sensed, inhibited response pacemaker that can adjust its rate based on physiologic demand.

Answer 220

A symptomatic fall in cardiac output due to loss of AV synchrony (and/or suboptimal AV timing) after pacemaker implantation—classically with VVI ventricular pacing in patients who still have intact atrial activity. Pathophysiology (key line) Atria contract against closed AV valves → ↑ venous pressures (neck/head fullness) + ↓ stroke volume. Retrograde VA conduction can make atrial contraction occur during ventricular systole. Can also occur in DDD if AV delay is poorly programmed (timing mismatch). Symptoms & signs Dizziness, fatigue, hypotension, dyspnoea, presyncope/syncope. Neck/occipital pounding, headache, “cannon a waves” in JVP. Worsens when pacing is active (e.g., at low intrinsic rates) and improves when intrinsic AV conduction resumes. Tx - upgrade to a dual chamber pacemaker

Answer 221

Stage I: single lymph node II: 2 or more lymph nodes/regions on the same side of the diaphragm III: nodes on both sides of the diaphragm IV: spread beyond lymph nodes Each stage may be subdivided into A or B A = no systemic symptoms other than pruritus B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis)

Answer 222

Calcium folinate

Answer 223

characterised by the proliferation of Langerhans cells, which are specialised dendritic cells that normally function to present antigen to T lymphocytes. The disease can affect multiple organs, including the bones, skin, lungs, and endocrine system. It is notable for its variable clinical presentation, ranging from isolated bone lesions to multisystem disease.

Answer 224

Features bone pain, typically in the skull or proximal femur cutaneous nodules pituitary involvement: leads to diabetes insipidus due to pituitary stalk involvement pulmonary involvement: More common in adults, presenting with dyspnoea, cough, and chest pain recurrent otitis media/mastoiditis tennis racket-shaped Birbeck granules on electromicroscopy Diagnosis: biopsy: confirmation is through biopsy showing Langerhans cells with characteristic grooved nuclei and positive staining for CD1a and S100 protein imaging: radiographs and MRI for bone lesions; CT may be used for chest and abdominal involvement

Answer 225

Complications Metabolic acidosis Erosion of gastric mucosa → GI bleeding Shock Hepatotoxicity and coagulopathy Treatment: If less than 40mg/kg and asymptomatic - observe at home >40mg/kg or symptomatic - iron levels and AXR Whole bowel irrigation - performed on all patients who have ingested >60mg/kg iron or have undissolved tablets on abdo XR Activated charcoal is ineffective Desferrioxamine is indicated in: Patients with serum iron level > 90umol/l, Patients with serum iron level 60-90umol/l, who are symptomatic or have persistent iron on abdominal x-ray despite whole bowel irrigation Any patient with shock, coma or metabolic acidosis Endoscopy or surgery may be required if whole bowel irrigation is not effective or iron is adhered to the gastric wall.

Answer 226

it is seen in 5% of cases of adenocarcinoma of the breast, lung, GI tract, melanoma and lymphoma. Clinical presentation is variable May present with headache, sciatic pain, causa equina syndrome, multiple craniall nerve palsies, confusional state, seizures, focal neurological deficits or poly-radiculoneuropathy. The diagnosis is establised by identifying tumour cells on CSF using cytopsin millipore filtering flow cytometry - tumour cells are not always seen on the initial csf sampl CSF opening pressures are increased and there is lymphicytic pleocytosis up to 100, elevated protein

Answer 227

Hepatitis A is usually a self-limiting viral illness spread through the faecal-oral route that primarily causes inflammation of the liver. It usually presents with flu-like symptoms, right upper abdominal pain and nausea, diarrhoea and vomiting. Jaundice can later develop. There is normally no specific treatment for hepatitis A but it is a notifiable disease, and immunisation is also recommended if travelling to high-risk countries.

Answer 228

CXR ## Footnote *sputum culture is not always conclusive

Answer 229

Risperidone alone isn’t a classic cause of serotonin syndrome (SS) because it mainly blocks 5-HT2A and D2 receptors; SS is usually due to excess serotonergic activity (e.g., SSRIs/SNRIs, MAOIs, linezolid, MDMA, tramadol)

Answer 230

supportive including IV fluids benzodiazepines more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine

Answer 231

stop antipsychotic patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units IV fluids to prevent renal failure dantrolene may be useful in selected cases thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum bromocriptine, dopamine agonist, may also be used

Answer 232

Leptospirosis is caused by the spirochaete Leptospira interrogans (serogroup L. icterohaemorrhagiae), classically being spread by contact with infected rat urine. Features - fever, flu symptoms, subconjunctival redness Second immune phase - may lead to Weil's disease - AKI, Hepatitis, jaundice, hepatomegaly, aseptic meningitis Ix - Serology - antibodies - PCR - Culture (growth make take several weeks Tx Mild disease - doxycycline or azithromycin Severe disease - IV benpen

Answer 233

Heyde's syndrome - the triad of AS, anemia due to bleeding, and acquired coagulopathy.

Answer 234

Dyspnoea, dry cough, fever Usually has very few chest signs Pneumothroax is a common complication Treat with co-trimoxazole IV pentamidine in severe cases ## Footnote If patients with HIV present with chest signs, productive cough - think is this just normal pneumonia

Answer 235

It can be dificult to distiguish between xanthogranulomatous pyelonephritis and renal cell carcinoma. It typically presents with symptoms of fever, weight loss and loin pain. It is more common in diabetics and immunocopromised patients The most common organism is proteus mirabilis the definitive trearment is nephrectomy as medical tx is insufficient

Answer 236

Thrombotic thrombocytopenic purpura (TTP) is a rare but serious blood disorder that can lead to microvascular thrombosis and organ damage Abnormally large and sticky multimers of von Willebrand's factor cause platelets to clump within vessels In TTP there is a deficiency of ADAMTS13 (a metalloprotease enzyme) which breakdowns ('cleaves') large multimers of von Willebrand's factor Overlaps with haemolytic uraemic syndrome (HUS) fever microangiopathic haemolytic anaemia thrombocytopenia neurological abnormalities kidney disease schistocytes on blood film elevated LDH

Answer 237

AD defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem. The results in the toxic accumulation of delta aminolaevulinic acid and porphobilinogen. It characteristically presents with abdominal and neuropsychiatric symptoms in 20-40-year-olds. AIP is more common in females (5:1) abdominal: abdominal pain, vomiting neurological: motor neuropathy psychiatric: e.g. depression hypertension and tachycardia common Diagnosis classically urine turns deep red on standing raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks) assay of red cells for porphobilinogen deaminase raised serum levels of delta aminolaevulinic acid and porphobilinogen Management avoiding triggers acute attacks IV haematin/haem arginate IV glucose should be used if haematin/haem arginate is not immediately available

Answer 238

thiazides (anti-Ro will be positive) procainamide Isoniazid timolol Phenytoin Hydralazine

Answer 239

prolonged course of azithromycin

Answer 240

Alport's syndrome is usually inherited in an X-linked dominant pattern*. It is due to a defect in the gene which codes for type IV collagen resulting in an abnormal glomerular-basement membrane (GBM). The disease is more severe in males with females rarely developing renal failure. A favourite question is an Alport's patient with a failing renal transplant. This may be caused by the presence of anti-GBM antibodies leading to a Goodpasture's syndrome like picture.

Answer 241

electron microscopy: characteristic finding is of the longitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a 'basket-weave' appearance

Answer 242

Onchocerca volvulus presents as blidness with itchy rash covering large parts of the body

Answer 243

If a pituitary tumour is inoperable or surgery unsuccessful then medication may be indicated: somatostatin analogue directly inhibits the release of growth hormone for example octreotide effective in 50-70% of patients pegvisomant GH receptor antagonist - prevents dimerization of the GH receptor once daily s/c administration very effective - decreases IGF-1 levels in 90% of patients to normal doesn't reduce tumour volume therefore surgery still needed if mass effect dopamine agonists for example bromocriptine the first effective medical treatment for acromegaly, however now superseded by somatostatin analogues effective only in a minority of patients

Answer 244

ora glucose tolerance test patients at risk OGTT should be done at 24-28 weeks If they have had previous gestational diabetes - OGTT AT BOOKING AND ALSO 24-48 WEEKS ## Footnote Risk factors for gestational diabetes BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern) unexplained stillbirth in a previous pregnancy

Answer 245

f the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started if glucose targets are still not met insulin should be added to diet/exercise/metformin gestational diabetes is treated with short-acting, not long-acting, insulin if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered glibenclamide should only be offered for women who cannot tolerate metformin or tho

Answer 246

Myxoedema coma typically presents with confusion and hypothermia. Myxoedema coma is a medical emergency requiring treatment with IV thyroid replacement IV fluid IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded) electrolyte imbalance correction sometimes rewarming

Answer 247

Give Ocreotide - it supresses further insulin release from pancreatic beta cells by inhibiting calcium-mediated exocytosis.

Answer 248

hypovolaemia marked hyperglycaemia (>30 mmol/L) significantly raised serum osmolarity (> 320 mosmol/kg) can be calculated by: 2 * Na+ + glucose + urea no significant hyperketonaemia (<3 mmol/L) no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)

Answer 249

in the majority of cases, symptomatic patients are treated medically with dopamine agonists (e.g. cabergoline, bromocriptine) which inhibit the release of prolactin from the pituitary gland surgery is performed for patients who cannot tolerate or fail to respond to medical therapy. A trans-sphenoidal approach is generally preferred unless there is a significant extra-pituitary extension

Answer 250

symptomatic treatment e.g. paracetamol treatment of underlying precipitating event beta-blockers: typically IV propranolol anti-thyroid drugs: e.g. methimazole or propylthiouracil Lugol's iodine dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3

Answer 251

Non-classical CAH - Adrenal androgens (↑ 17-hydroxyprogesterone → ↑ androstenedione/testosterone) - Early morning 17-hydroxyprogesterone: ↑ (diagnostic) - ACTH stimulation test: exaggerated rise in 17-hydroxyprogesterone PCOS Ovarian androgens (↑ theca cell activity, ↑ testosterone) - LH:FSH ratio >2:1 (though not always) - ↑ Testosterone, ↑ AMH - USS: ≥12 small follicles (“string of pearls”)

Answer 252

Type 4 RTA (hyperkalaemic) reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion causes hyperkalaemia causes include hypoaldosteronism, diabetes

Answer 253

IV Fluis Bisphosphonates - maxial effect seen on day 7 Denosumab is commonly used in malginancy associated hypercalcaemia (can be repeated 2 weekly) Calcitonin - has been found to be most useful when combined with hydration, bisphosphonates and/or denosumab,

Answer 254

The insulin tolerance test can be used to distinguish Cushing's syndrome from pseudo-Cushing's

Answer 255

Iron / calcium carbonate tablets can reduce the absorption of levothyroxine

Answer 256

Endocrine - menstural irregularities, decreased libidi, erectile dysfunction Metabolic abnormalities - hyperglycaemia (resulting from insulin resistance), dyslipidaemia, osteoporosis CV - HTN Low mood, depression, anxiety or psychosis Skin changes - easy bruisng MSK.- muscle weakness resulting from protein catabolism is another common feature.

Answer 257

propylthiouracil has traditionally been the antithyroid drug of choice however, propylthiouracil is associated with an increased risk of severe hepatic injury propylthiouracil is generally used in the first trimester of pregnancy in place of carbimazole, as carbimazole may be associated with an increased risk of congenital abnormalities maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine the risk of neonatal thyroid problems block-and-replace regimes should not be used in pregnancy radioiodine therapy is contraindicated

Answer 258

Radioiodine therapy should be avoided until 8 weeks following CT contrast administration

Answer 259

at least 6 months

Answer 260

a joint which has become badly disrupted and damaged secondary to a loss of sensation. Seen in diabetics or secondary to syphilis The joint appears red, swollen and warm as the condition progresses, the affected joint becomes unstable → abnormal movements and increased risk of fractures and dislocations progressive joint destruction can cause significant deformities common deformities include a collapsed arch in the foot (commonly referred to as 'rocker-bottom' foot) or severe joint misalignment secondary complications such as skin ulceration and infection can occur due to repeated trauma and poor wound healing The investigation - Indium-labelled white cell scan

Answer 261

Unlike in AIH, amiodarone should be stopped if possible in patients who develop AIT ## Footnote The pathophysiology of amiodarone-induced hypothyroidism (AIH) is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect* Amiodarone may be continued if this is desirable

Answer 262

intranuclear inclusions bodies within some of the epithelial cells it is commonly associated with immunosuppression Tx is ganciclovir IV

Answer 263

Carpal tunnel syndrome can result from various factors that increase pressure within the carpal tunnel, leading to compression of the median nerve. These factors include: Anatomical: Congenital narrow carpal tunnel, wrist fracture, or dislocation. Inflammatory: Tenosynovitis, rheumatoid arthritis, or gout. Metabolic: Diabetes, hypothyroidism, or pregnancy (fluid retention). Work-related: Repetitive hand or wrist movements, forceful gripping, or vibration

Answer 264

first-line: PPI + amoxicillin + (clarithromycin OR metronidazole) if ongoing symptoms after first line treatment: PPI + amoxicillin+ (clarithromycin OR metronidazole, whichever was not used first line) if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin

Answer 265

hypokalaemia

Answer 266

Acute Hep B - supportive If have liver failure with acute hep B - give entecavir or tenofivir Chronic hep B Antiviral therapy first line -are entecavir, tenofovir or peginterferon alfa 2a (if no cirrhosis), and entecavir or tenofovir (if cirrhosis present)

Answer 267

urrently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used

Answer 268

Meckel's diverticulum is a congenital diverticulum of the small intestine Symptoms - rectal bleeding abdominal pain intestinal obsruction Investigations Wireless capsule endoscopy Meckel's scan mesenteric arteriography may also be used in more severe cases e.g. transfusion is required

Answer 269

general population transferrin saturation is considered the most useful marker ferritin should also be measured but is not usually abnormal in the early stages of iron accumulation testing family members genetic testing for HFE mutation ## Footnote Typical iron study profile in patient with haemochromatosis transferrin saturation > 55% in men or > 50% in women raised ferritin (e.g. > 500 ug/l) and iron low TIBC

Answer 270

usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on ultrasound Management the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Answer 271

AR disorder characterised by excessive copper liver - hepatitis, cirrhosis Neuro - basal ganglia degeneration, asterixis, chorea, dementia, parkinsonism Kayser Fleischer rings Renal tubular acisosis Hamolysis Ix slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion the diagnosis is confirmed by genetic analysis of the ATP7B gene Tx penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation

Answer 272

Immune-mediated severe thrombocytopenia that occurs 5–10 days after a blood transfusion. Most often due to antibodies against human platelet antigen (HPA-1a). Sudden onset of purpura, bruising, mucosal bleeding about a week post transfusion. Severe thrombocytopenia (platelets often <10 × 10⁹/L). IV immunoglobulin (IVIG) = treatment of choice (rapid platelet recovery). Avoid platelet transfusion unless life-threatening bleeding (they’re usually destroyed). Corticosteroids sometimes used as adjunct. Future transfusions: use antigen-negative or washed blood products.

Answer 273

IV cefotaxime If pen allergic - IV cipro and vancomycin

Answer 274

Small bowel bacterial overgrowth syndrome (SBBOS) is a disorder characterised by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms. Chronic diarrhoe Bloating Flatulence abdo pain Diagnosed - hydrogen breath test, small bowel aspiration and culture Tx - rifaximin

Answer 275

villous atrophy crypt hyperplasia increase in intraepithelial lymphocytes lamina propria infiltration with lymphocytes

Answer 276

INR 6.5 or 3 of: <11 or >40 age bilirubin >300 time from onset of jaundice to the development of come > 7 days INR > 3.5 drug toxicity regardless of whether it was the cause of the acute liver failure

Answer 277

co-trimoxazole IV pentamidine in severe cases aerosolized pentamidine is an alternative treatment for Pneumocystis jiroveci pneumonia but is less effective with a risk of pneumothorax steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

Answer 278

Gram Positive bacillus (rods) May present as meningoencephalitis ataxia seizures symptoms of hemiparesis - mimicking a stroke CSF findings Pleocytosis - often lymphocytes raised protein reduced glucose Management Amox and gent

Answer 279

yaws is caused by trepnema pertenue Non-venereal treponemal disease - similar to syphilis serological testing is indistnguiable from syphilis Presented with one or multiple skin lesions which may ulcerate Transmission - skin to skin Tx with penicillin

Answer 280

an actinomycete infection responsible for pneumonia and cerebreal abscess formation in the immunocpromised Tx - Sulphonamides or co-trimoxazole

Answer 281

AKA african river blindness caused by Onchocerca volvulus second most common cause of blindness world wide spread by blackfly Starts with subcutaneous papules, lymphadenitis and skin depigmentation before the onset of eye disease Tx - Ivermectin

Answer 282

A tick-borne malaria like ilness presents similarly to malaria - fever, chills and rigors The intra-erythrocytic baesia destroy red blood cells causing haemolytic anaemia and haemoglobinuria They get a secondary reactive polyclonal hypergammaglobulinaemia Patients without a spleen have more fulminant and prolonged clinical course Immunocopetent individuals - azithromycin plus atovaquone if severe - IV azithromycin plus oral atovaguone or IV clindamycin plus oral quinine

Answer 283

Coxiella burnetti (a rickettsia) The source of infection is typically an abattoir, cattle/sheep or it may be inhaled from infected dust fever, malaise pyrexia of unknown origin Transaminitis atypical pneumona endocarditis Tx doxy

Answer 284

African trypanosomiasis (sleeping sickness) and American trypanosomiasis (Chagas' disease).

Answer 285

Erythematous swelling or chancre at the site of the fly bite 5-15 days later, fever, headache, myalgia before it progresses to meningoencephalitis A CT head is require in order for an LP to be performed A CT of the brain in the late disease reveal cerebral oedema and whit matter enhancement CSF should always be performed Tx - early disease: IV pentamidine or suramin later disease or central nervous system involvement: IV melarsoprol

Answer 286

American trypanosomiasis, or Chagas' disease, is caused by the protozoan Trypanosoma cruzi. The vast majority of patients (95%) are asymptomatic in the acute phase although a chagoma (an erythematous nodule at site of infection) and periorbital oedema are sometimes seen. Chronic Chagas' disease mainly affects the heart and gastrointestinal tract myocarditis may lead to dilated cardiomyopathy (with apical atophy) and arrhythmias gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation Management treatment is most effective in the acute phase using azole or nitroderivatives such as benznidazole or nifurtimox chronic disease management involves treating the complications e.g., heart failure

Answer 287

Nucleoside analogue reverse transcriptase inhibitors (NRTI) examples: zidovudine (AZT), didanosine, lamivudine, stavudine, zalcitabine Protease inhibitors (PI) inhibits a protease needed to make the virus able to survive outside the cell examples: indinavir, nelfinavir, ritonavir, saquinavir Non-nucleoside reverse transcriptase inhibitors (NNRTI) examples: nevirapine, efavirenz

Answer 288

a human parasitic nematode worm The larvae are present in soil and gain access to the body by penetrating the skin. Features - diarrhoea - Abdominal pain /bloating - papulovesicular lesions where the skin has been penetrated by infective larvae e.g. soles of feet and buttocks - larva currens: pruritic, linear, urticarial rash - if the larvae migrate to the lungs a pneumonitis similar to Loeffler's syndrome may be triggered (high oesinophils) Treatment - Ivermectin

Answer 289

albendazole

Answer 290

30S Subunit Aminoglycosides (gentamicin, amikacin, tobramycin) → misreading of mRNA, bactericidal. Tetracyclines (doxycycline, minocycline, tigecycline) → block tRNA binding to A-site, bacteriostatic. 50S Subunit Chloramphenicol → inhibits peptidyltransferase. Clindamycin → blocks translocation. Macrolides (erythromycin, clarithromycin, azithromycin) → block translocation. Linezolid → inhibits initiation complex formation. Streptogramins (quinupristin/dalfopristin) → inhibit protein elongation.

Answer 291

β-lactams (penicillins, cephalosporins, carbapenems, monobactams) Bind penicillin-binding proteins (PBPs) → inhibit transpeptidation. Glycopeptides (vancomycin, teicoplanin) Bind D-Ala-D-Ala terminus of peptidoglycan → prevent crosslinking. Bacitracin Blocks peptidoglycan transport across membrane.

Answer 292

DNA Gyrase/Topoisomerase inhibitors Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) → inhibit DNA gyrase (topo II) and topo IV. DNA Integrity disruptors Metronidazole, tinidazole → form toxic free radicals → DNA strand breaks. RNA Polymerase inhibitors Rifamycins (rifampicin, rifabutin) → inhibit DNA-dependent RNA polymerase.

Answer 293

Voriconazole - broad spectrum of activity against both yeasts and mooulds

Answer 294

IgA deficiency

Answer 295

denosumab Alendronate is contraindicated if eGFR <35

Answer 296

Toxoplasmosis - usually single or multiple ring enhancing lesions, mass effect may be seen Primary CNS lymphome - CT: single or multiple homogenous enhancing lesions Cryptococcus - CT: meningeal enhancement, cerebral oedema Progressive multifocal leukoencephalopthy - CT: single or multiple lesions, no mass effect, don't usually enhance. MRI is better - high-signal demyelinating white matter lesions are seen

Answer 297

characterised by hardened, sclerotic skin and other connective tissues **Limited cutaneous systemic sclerosis** Raynauds, scleroderma of face and dostal limbs, associated with anti-centeromere AB, a subtype is CREST **Diffuse cutaneous systemic sclerosis** Scleroderma affecs the trunk and proximal limbs, associated with anti scl-70 most common cause of death is respiratory involvement - ILD, PAH Renal disease and HTN. Patients with renal disease should be started on ACEi (captopril) poor prognosis

Answer 298

ANA positive in 90% RF positive in 30% anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis associated with a higher risk of severe interstitial lung disease anti-centromere antibodies associated with limited cutaneous systemic sclerosis

Answer 299

Features miosis (small pupil) ptosis enophthalmos* (sunken eye) anhidrosis (loss of sweating one side)

Answer 300

a myeloproliferative disorder Features e.g. elderly person with symptoms of anaemia e.g. fatigue (the most common presenting symptom) massive splenomegaly hypermetabolic symptoms: weight loss, night sweats etc Lab findings anaemia high WBC and platelet count early in the disease 'tear-drop' poikilocytes on blood film unobtainable bone marrow biopsy - 'dry tap' therefore trephine biopsy needed high urate and LDH (reflect increased cell turnover) Often have JAK2 mutation

Answer 301

Core decompression in early disease Osteotomoy if there is collapse of the femoral head

Answer 302

**Tamoxifen**: Typically used in pre- and peri-menopausal women for a duration of 5 years post-diagnosis. Notable side effects include an increased risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. **Aromatase Inhibitors **(e.g., Anastrozole): Preferred in post-menopausal women, as aromatisation is the primary source of oestrogen production in this group. Aromatase inhibitors are thus employed for ER-positive breast cancer in post-menopausal women

Answer 303

Complement C5-C9

Answer 304

IM ceftriaxone f ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used

Answer 305

Ivabradine is a class of anti-anginal drug which works by reducing the heart rate. Reccomended by nice for the treatment of hear failur on top of BB when the HR is >75 Adverse effects visual effects, particular luminous phenomena, are common headache bradycardia, heart block

Answer 306

Oral vancomycin and IV metronidazole

Answer 307

Nephrotic syndrome Most idiopathic but can be caused by NSAIDs, rifampicin, Hodkin's lymphoma, thymoma, infectious mononucleosis Features Nephrotic syndrome Normotension highly selective proteinuria only intermediate-sized proteins such as albumin and transferrin leak through the glomerulus Renal biopsy normal glomeruli on light microscopy electron microscopy shows fusion of podocytes and effacement of foot processes Management Steroids Cyclophosphamaide is steroid resistant cases

Answer 308

Amox and gent If pregnant - just amoxicillin

Answer 309

cholesterol emboli may break off causing renal disease the majority of cases are secondary to vascular surgery or angiography. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta Features eosinophilia purpura renal failure livedo reticularis

Answer 310

IgG deficiencies - well recognised to present with recurrent resp tract infection and/or sinusitis investigate by doing immunoglbulin substs

Answer 311

simple measures recommend daily application of a high-factor sunscreen camouflage creams may help conceal redness predominant erythema/flushing #link20 topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia brimonidine is a topical alpha-adrenergic agonist this can be used on an 'as required basis' to temporarily reduce redness it typically reduces redness within 30 minutes, reaching peak action at 3-6 hours, after which the redness returns to the baseline mild-to-moderate papules and/or pustules topical ivermectin is first-line alternatives include: topical metronidazole or topical azelaic acid moderate-to-severe papules and/or pustules combination of topical ivermectin + oral doxycycline

Answer 312

Features haemolytic anaemia red blood cells, white blood cells, platelets or stem cells may be affected therefore pancytopaenia may be present haemoglobinuria: classically dark-coloured urine in the morning (although has been shown to occur throughout the day) thrombosis e.g. Budd-Chiari syndrome aplastic anaemia may develop in some patients Diagnosis flow cytometry of blood to detect low levels of CD59 and CD55 has now replaced Ham's test as the gold standard investigation in PNH Ham's test: acid-induced haemolysis (normal red cells would not) Management blood product replacement anticoagulation eculizumab, a monoclonal antibody directed against terminal protein C5, is currently being trialled and is showing promise in reducing intravascular haemolysis stem cell transplantation

Answer 313

AD multiple episodes of muscle weakness Hypokalaemia Avoiding alcohol and low carb diets are the initial intervention of choice

Answer 314

>5.5 cm or a rapidly expanding AAA associated with peripheral arterial aneurysm or PAD

Answer 315

Immunoglobulins which undergo reversible precipitation at 4 deg C, dissolve when warmed to 37 deg C. One-third of cases are idiopathic **Three types** type I (25%): monoclonal - IgG or IgM associations: multiple myeloma, Waldenstrom macroglobulinaemia type II (25%) mixed monoclonal and polyclonal: usually with rheumatoid factor associations: hepatitis C, rheumatoid arthritis, Sjogren's, lymphoma type III (50%) polyclonal: usually with rheumatoid factor associations: rheumatoid arthritis, Sjogren's **Possible features** Raynaud's only seen in type I cutaneous vascular purpura distal ulceration ulceration arthralgia renal involvement diffuse glomerulonephritis **Investigations** low complement (esp. C4) high ESR

Answer 316

**1. Argyll Robertson pupil** Features: small, irregular, bilateral, accommodate but don’t react to light (“prostitute’s pupil”). Causes: neurosyphilis (classically), also diabetes, MS. **2. Holmes–Adie pupil (Adie’s tonic pupil)** Features: dilated, sluggish/absent light reaction, slow (tonic) near response, often unilateral. Associations: idiopathic, post-viral, part of Holmes-Adie syndrome (with absent ankle reflexes). **3. Hutchinson’s pupil** Features: unilateral dilated fixed pupil. Cause: ipsilateral CN III compression (often from uncal herniation due to raised ICP). **4. Horner’s syndrome pupil** Features: miosis (small pupil), ptosis, anhidrosis, apparent enophthalmos. Cause: disruption of sympathetic pathway (e.g. Pancoast tumour, carotid dissection, brainstem stroke). **5. Marcus Gunn pupil (Relative Afferent Pupillary Defect, RAPD)** Features: swinging light test → pupil dilates instead of constricts when light shone in affected eye. Cause: optic nerve lesion (optic neuritis, MS, severe retinal disease).

Answer 317

Methaemoglobinaemia describes haemoglobin which has been oxidised from Fe2+ to Fe3+. This is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin resulting in the reduction of methaemoglobin to haemoglobin. There is tissue hypoxia as Fe3+ cannot bind oxygen, and hence the oxidation dissociation curve is moved to the left Congenital causes haemoglobin chain variants: HbM, HbH NADH methaemoglobin reductase deficiency Acquired causes drugs: sulphonamides, nitrates (including recreational nitrates e.g. amyl nitrite 'poppers'), dapsone, sodium nitroprusside, primaquine chemicals: aniline dyes Features 'chocolate' cyanosis dyspnoea, anxiety, headache severe: acidosis, arrhythmias, seizures, coma normal pO2 but decreased oxygen saturation Management NADH methaemoglobinaemia reductase deficiency: ascorbic acid IV methylthioninium chloride (methylene blue) if acquired

Answer 318

Oral fluconazole

Answer 319

the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer's disease memantine (an NMDA receptor antagonist) is in simple terms the 'second-line' treatment for Alzheimer's, NICE recommend it is used in the following situation reserved for patients with moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's monotherapy in severe Alzheimer's ## Footnote * donepezil is known to cause QT prolongation

Answer 320

Erythema nodosum symmetrical, erythematous, tender, nodules which heal without scarring most common causes are streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill) Pretibial myxoedema symmetrical, erythematous lesions seen in Graves' disease, also seen in autoimmune thyroid disease shiny, orange peel skin Pyoderma gangrenosum initially small red papule later deep, red, necrotic ulcers with a violaceous border idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders Necrobiosis lipoidica diabeticorum shiny, painless areas of yellow/red skin typically on the shin of diabetics often associated with telangiectasia

Answer 321

Cystinuria is an autosomal recessive disorder characterised by the formation of recurrent renal stones. It is due to a defect in the membrane transport of cystine, ornithine, lysine, arginine (mnemonic = COLA) Genetics chromosome 2: SLC3A1 gene, chromosome 19: SLC7A9 Features recurrent renal stones are classically yellow and crystalline, appearing semi-opaque on x-ray Diagnosis cyanide-nitroprusside test Management hydration D-penicillamine urinary alkalinization

Answer 322

furosemide NSAIDs Captopril Penicillamin Abx DPPIV inhibitors

Answer 323

Inhibits IL6

Answer 324

Nicorandil

Answer 325

beta blockers are the mainstay of treatment ICD in high risk patients

Answer 326

Beta blockers

Answer 327

Definitive treatment: radiofrequency ablation medical therapy: sotalol, amiodarone, flecainide sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation

Answer 328

Myotonic dystrophy (also called dystrophia myotonica) is an inherited myopathy with features developing at around 20-30 years old. It affects skeletal, cardiac and smooth muscle General features myotonic facies (long, 'haggard' appearance) frontal balding bilateral ptosis cataracts dysarthria Other features myotonia (tonic spasm of muscle) weakness of arms and legs (distal initially) mild mental impairment diabetes mellitus testicular atrophy cardiac involvement: heart block, cardiomyopathy dysphagia

Answer 329

**Features** ejection systolic murmur, fixed splitting of S2 embolism may pass from venous system to left side of heart causing a stroke **Ostium secundum (70% of ASDs) **associated with Holt-Oram syndrome (tri-phalangeal thumbs) ECG: RBBB with RAD **Ostium primum** present earlier than ostium secundum defects associated with abnormal AV valves ECG: RBBB with LAD, prolonged PR interval

Answer 330

Dual chamber PPM

Answer 331

Antibiotics - tetracycline, fluoroquinolones, sulphonamides NSAIDs Diuretics - furosemide, bumetanide Sulphonylureas Neuroleptics - chlorpromazine Antifungals - e.g. terbinafine, itraconazole Amiodarone Diltiazem

Answer 332

A rare malignant proliferation disorder of B cells Features pancytopenia splenomegaly skin vasculitis in 1/3 patients 'dry tap' despite bone marrow hypercellularity tartrate resistant acid phosphotase (TRAP) stain positive Management chemotherapy is first-line: cladribine, pentostatin immunotherapy is second-line: rituximab, interferon-alpha

Answer 333

chemotherapy is first-line: cladribine, pentostatin

Answer 334

also known as sinusoidal obstruction syndrome a serious complication of allogenic stem cell transplats that can rarely occur within 2 weeks of the transplant Weight gain Oedematous Jaundics Acites Tender hepatomegaly Bloo tests will show a high bilirubin and often a raised ALP and GGT

Answer 335

first-line treatment for ITP is oral prednisolone pooled normal human immunoglobulin (IVIG) may also be used it raises the platelet count quicker than steroids, therefore may be used if active bleeding or an urgent invasive procedure is required splenectomy is now less commonly used

Answer 336

rouleaux formation

Answer 337

acquired factor VIII deficiency

Answer 338

haemolytic anaemia red blood cells, white blood cells, platelets or stem cells may be affected therefore pancytopaenia may be present haemoglobinuria: classically dark-coloured urine in the morning (although has been shown to occur throughout the day) thrombosis e.g. Budd-Chiari syndrome aplastic anaemia may develop in some patients Diagnosis flow cytometry of blood to detect low levels of CD59 and CD55 has now replaced Ham's test as the gold standard investigation in PNH Ham's test: acid-induced haemolysis (normal red cells would not)

Answer 339

Epidemiology: Middle-aged adults. Pathophysiology: Philadelphia chromosome t(9;22) → BCR-ABL fusion → ↑tyrosine kinase activity. Clinical: Often insidious; fatigue, weight loss, sweats. Splenomegaly. May present with hyperviscosity/leukostasis. Investigations: Very high WCC with all stages of myeloid precursors. Low leukocyte alkaline phosphatase. Cytogenetics: BCR-ABL+. Phases: Chronic → Accelerated → Blast crisis. Management: Imatinib (tyrosine kinase inhibitor). Allogeneic SCT if TKI failure.

Answer 340

Epidemiology: Median age ~65 yrs. Clinical: Pancytopenia (anaemia, infections, bleeding), gum hypertrophy, skin infiltration, DIC (esp. APML). Investigations: Blood film: myeloblasts ± Auer rods. BM: >20% blasts. Cytogenetics: t(15;17) = acute promyelocytic leukaemia (APML). Associations: Prior chemo/radiotherapy, myelodysplasia, Down’s. Management: Induction chemo ± allogeneic SCT. APML: ATRA + arsenic trioxide. Complications: Tumour lysis syndrome.

Answer 341

Epidemiology: Elderly, most common leukaemia in adults in the West. Clinical: Often asymptomatic (picked up on FBC). Lymphadenopathy, hepatosplenomegaly. Recurrent infections (hypogammaglobulinaemia). Autoimmune haemolytic anaemia (Coombs +ve). Investigations: FBC: lymphocytosis. Smear: smudge/smear cells. Flow cytometry: clonal B cells (CD5, CD19, CD23). Management: Early: watch and wait. Symptomatic/high stage: chemo-immunotherapy (FCR = fludarabine, cyclophosphamide, rituximab) or newer agents (ibrutinib, venetoclax). Complications: Richter’s transformation → aggressive large B-cell lymphoma.

Answer 342

Epidemiology: Most common childhood leukaemia, bimodal peaks (children + elderly). Clinical: Marrow failure, lymphadenopathy, hepatosplenomegaly, CNS/testicular involvement. Investigations: Blood film: lymphoblasts. BM: >20% blasts. Cytogenetics: Philadelphia chromosome (t(9;22)) = worse prognosis. Management: Combination chemo (induction, consolidation, maintenance). CNS prophylaxis (intrathecal methotrexate). Imatinib/targeted therapy if Ph+. Prognosis: Worse in adults.

Answer 343

Auer rods → AML. Gum hypertrophy + DIC → APML subtype. CNS/testicular relapse risk → ALL. Massive splenomegaly + very high WCC + Philadelphia → CML. Smudge cells + autoimmune haemolysis + elderly → CLL. Treatment triggers in CLL: symptomatic, marrow failure, bulky disease, rapid lymphocyte doubling, AIHA not controlled.

Answer 344

Neuromyelitis optica (NMO), also known as Devic's disease, describes a spectrum of rare autoimmune demyelinating CNS conditions. It is often a differential diagnosis for multiple sclerosis, as it shares many similarities with the neurological condition, including features such as optic neuritis. NMO predominately affects the optic nerve and spinal cord and most cases follow a relapsing pattern (80-90%) compared to a monophasic pattern. It can occur at any age and occurs more frequently in women. Primarily managed in secondary care, treatment focuses on controlling attacks and reducing their frequency. Prognosis is mainly affected by the severity and frequency of attacks, with longterm neurological deficits a potential consequence. Core clinical characteristics include Optic neuritis Area postrema syndrome Myelitis Brainstem syndrome Narcolepsy or acute diencephalic syndrome Present with diencephalic MRI lesions Cerebral syndrome Present with diencephalic MRI lesions ## Footnote LP will show pleocytosis and negative oligoclonal bands thereby differentiating the patients diagnosis from MS.

Answer 345

Causes drugs: the most common cause, particularly antibiotics penicillin rifampicin NSAIDs allopurinol furosemide proton pump inhibitors systemic disease: SLE, sarcoidosis, and Sjogren's syndrome infection: Hanta virus , staphylococci Pathophysiology histology: marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules Features fever, rash, arthralgia eosinophilia mild renal impairment hypertension Investigations sterile pyuria white cell casts

Answer 346

Cyanide may be used in insecticides, photograph development and the production of certain metals. Cyanide inhibits the enzyme cytochrome c oxidase, resulting in cessation of the mitochondrial electron transfer chain. Presentation 'classical' features: brick-red skin, smell of bitter almonds acute: hypoxia, hypotension, headache, confusion chronic: ataxia, peripheral neuropathy, dermatitis Management supportive measures: 100% oxygen definitive: hydroxocobalamin (intravenously), also combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously)

Answer 347

clinical manifestations may be classified into muscarinic, nicotinic and CNS effects ## Footnote Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD) Salivation Lacrimation Urination Defecation/diarrhoea cardiovascular: hypotension, bradycardia also: small pupils, muscle fasciculation

Answer 348

atropine the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

Answer 349

Felty's syndrome (RA + splenomegaly + low white cell count) Tx is with pulsed corticosteroid and/or cyclophosphamide

Answer 350

aka temporal arteritis typically patient > 60 years old usually rapid onset (e.g. < 1 month) headache (found in 85%) jaw claudication (65%) vision testing is a key investigation in all patients - anterior ischaemic optic neuropthy accounts for the majority of ocular complication Ix ESR and CRP Temporal artery biopsy Tx High dose glucocortcoids should be given urgent ophthalmology review

Answer 351

TNF alpha antagonist

Answer 352

Features pain on the radial side of the wrist tenderness over the radial styloid process abduction of the thumb against resistance is painful Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation Management analgesia steroid injection immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required

Answer 353

vasodilator therapy: Calcium channel blockers, phosphodiesterase-5 inhibitors, and prostacyclin analogues can help manage Raynaud's phenomenon and digital ulcers, as well as pulmonary arterial hypertension. Immunosuppressive therapy: Corticosteroids, methotrexate, mycophenolate mofetil, and cyclophosphamide can be used to reduce inflammation and slow the progression of fibrosis, particularly in cases of interstitial lung disease and rapidly progressive skin involvement. Gastrointestinal management: Proton pump inhibitors and prokinetic agents can help manage gastroesophageal reflux and motility disorders, while dietary modifications may be necessary for malabsorption or constipation. Renal management: Prompt treatment with angiotensin-converting enzyme inhibitors (ACEIs) is crucial in the management of scleroderma renal crisis. Physical therapy and occupational therapy: These interventions can help maintain joint mobility, improve muscle strength, and address functional limitations. Psychological support: Providing counselling and support for patients with SSc is essential, as the disease can have a significant impact on mental health and quality of life.

Answer 354

inflammatory disorder causing symmetrical, proximal muscle weakness Associated with malignancy dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids Features proximal muscle weakness +/- tenderness Raynaud's respiratory muscle weakness interstitial lung disease e.g. fibrosing alveolitis or organising pneumonia seen in around 20% of patients and indicates a poor prognosis dysphagia, dysphonia Investigations elevated creatine kinase other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT) are also elevated in 85-95% of patients EMG muscle biopsy anti-synthetase antibodies anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud's and fever Management high-dose corticosteroids tapered as symptoms improve azathioprine may be used as a steroid-sparing agent

Answer 355

Skin features photosensitive macular rash over back and shoulder heliotrope rash in the periorbital region Gottron's papules - roughened red papules over extensor surfaces of fingers 'mechanic's hands': extremely dry and scaly hands with linear 'cracks' on the palmar and lateral aspects of the fingers nail fold capillary dilatation Other features proximal muscle weakness +/- tenderness Raynaud's respiratory muscle weakness interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia dysphagia, dysphonia Investigations the majority of patients (around 80%) are ANA positive around 30% of patients have antibodies to aminoacyl-tRNA synthetases (anti-synthetase antibodies), including: antibodies against histidine-tRNA ligase (also called Jo-1) antibodies to signal recognition particle (SRP) anti-Mi-2 antibodies

Answer 356

Myocolonus and dementia (rapid onset) Investigation CSF is usually normal EEG: biphasic, high amplitude sharp waves (only in sporadic CJD) MRI: hyperintense signals in the basal ganglia and thalamus

Answer 357

cerebral autosomal dominant arteriopathy wiht subcortical infarcts and leucoencephalopathy often patients have migraines with aura, strole like episodes and have a positive family history foe migraine and early demential in the absence of vascular RF.

Answer 358

Guillain-Barre syndrome describes an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni) nitial symptoms around 65% of patients experience back/leg pain in the initial stages of the illness The characteristic features of Guillain-Barre syndrome is progressive, symmetrical weakness of all the limbs. the weakness is classically ascending i.e. the legs are affected first reflexes are reduced or absent sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs Investigations lumbar puncture rise in protein with a normal white blood cell count (albuminocytologic dissociation) - found in 66% nerve conduction studies may be performed decreased motor nerve conduction velocity (due to demyelination) prolonged distal motor latency increased F wave latency

Answer 359

Miller Fisher syndrome variant of Guillain-Barre syndrome associated with ophthalmoplegia, areflexia and ataxia. The eye muscles are typically affected first usually presents as a descending paralysis rather than ascending as seen in other forms of Guillain-Barre syndrome anti-GQ1b antibodies are present in 90% of cases

Answer 360

The main treatment for SMA is medicines that target the altered genes that cause SMA, including: nusinersen (Spinraza) risdiplam (Evrysdi) onasemnogene abeparvovec (Zolgensma)

Answer 361

small and medium vasculitis Typically presents with a history of asthma, atomy and recurrent nasal polyps mononeuritis multiplex renal involvmenet less commonly seen pANCA high eosinophils features Resp - asthma, allergic rhinitis, paranasal sinusitis, nasal polyps, cough, haemoptysis Cardiac - pericarditis or myocarditis, heart failure renal - HTN, CKD, glomerulonephritis GI - bowel ischaemia, perforation, PR bleeding, appendicitis, pancreatitis Skin - urticaria, purpura, livedo reticularis, necrotic bullae, digital ischaemia Tx - steroids with or withot additional therapy with methotrexate, azathioprine or cyclophosphamide

Answer 362

axillary nerve - C5,C6 can be injured with humeral neck fracture/disolcation

Answer 363

Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3 Features cerebellar haemangiomas: these can cause subarachnoid haemorrhages retinal haemangiomas: vitreous haemorrhage renal cysts (premalignant) phaeochromocytoma extra-renal cysts: epididymal, pancreatic, hepatic endolymphatic sac tumours clear-cell renal cell carcinoma

Answer 364

Features oculomotor dysfunction nystagmus (the most common ocular sign) ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy gait ataxia encephalopathy: confusion, disorientation, indifference, and inattentiveness peripheral sensory neuropathy ## Footnote Korsakoff syndrome - amnesia and confabulation

Answer 365

Acute initially: dizziness, diplopia, nystagmus, slurred speech, ataxia later: confusion, seizures Chronic common: gingival hyperplasia (secondary to increased expression of platelet derived growth factor, PDGF), hirsutism, coarsening of facial features, drowsiness megaloblastic anaemia (secondary to altered folate metabolism) peripheral neuropathy enhanced vitamin D metabolism causing osteomalacia lymphadenopathy dyskinesia

Answer 366

Brachial neuritis is characterized by acute onset of unilateral (occasionally bilateral) severe pain, followed by shoulder and scapular weakness several days later. Sensory changes are usually minimal. There may be subsequent rapid wasting of the arm muscles in accordance to which nerve is involved. Precipitating factors include recent trauma, infection, surgery, or even vaccination.

Answer 367

due to vitamin B12 deficiency resulting in impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts.. Recreational nitrous oxide inhalation may also result in vitamin B12 deficiency → subacute combined degeneration of the spinal cord. Features **dorsal column involvement** distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms impaired proprioception and vibration sense l**ateral corticospinal tract involvement** muscle weakness, hyperreflexia, and spasticity upper motor neuron signs typically develop in the legs first brisk knee reflexes absent ankle jerks extensor plantars **spinocerebellar tract involvement** sensory ataxia → gait abnormalities positive Romberg's sign

Answer 368

**Features** parkinsonism autonomic disturbance erectile dysfunction: often an early feature postural hypotension atonic bladder cerebellar signs

Answer 369

Overview aka Steele-Richardson-Olszewski syndrome a 'Parkinson Plus' syndrome **Features** postural instability and falls patients tend to have a stiff, broad-based gait impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs) parkinsonism bradykinesia is prominent cognitive impairment primarily frontal lobe dysfunction **Management** poor response to L-dopa

Answer 370

Muscarinic (SLUDGE/DUMBELS): Salivation Lacrimation Urination Defecation Gastrointestinal upset Emesis DUMBELS: Diarrhoea, Urination, Miosis, Bradycardia/Bronchorrhoea/Bronchospasm, Emesis, Lacrimation, Salivation Nicotinic: Fasciculations, muscle weakness, paralysis (respiratory failure risk). CNS: Confusion, seizures, coma. ## Footnote Causes Organophosphate poisoning (insecticides). Carbamate poisoning. Excess acetylcholinesterase inhibitors (e.g., pyridostigmine, donepezil)

Answer 371

Causes Tricyclic antidepressants (amitriptyline). Antihistamines (chlorphenamine, diphenhydramine). Antipsychotics (chlorpromazine). Atropine, scopolamine. Symptoms Peripheral: Dry mouth, dry skin (↓ secretions). Flushing (vasodilation). Hyperthermia (↓ sweating). Urinary retention, constipation. Mydriasis → blurred vision, photophobia. Tachycardia. CNS: Agitation, confusion, hallucinations, delirium. Seizures, coma (in severe cases). Management Supportive. Physostigmine (AChE inhibitor) in severe/life-threatening cases — but risky (can cause seizures, bradycardia).

Answer 372

The typical clinical features involve distal and proximal weakness with sensory deficits developing over at least 8 weeks, but pure motor and pure sensory variants also exist. Tx - Corticosteroids 60mg OD oral prednisolone for 6 weeks recommended as first line Plasma exchange Effective for quick relief of symptoms, but requires combining with other treatments to demonstrate longer term benefits. Intravenous immunoglobulin (IVIG) A Cochrane systematic review concluded that IVIG improves symptoms for at least 2-6 weeks compared with placebo, with one trial demonstrating benefits up to 48 weeks. Analgesia for neuropathic pain Some patients may require analgesia e.g. gabapentin, pregabalin for neuropathic pain if this contributes a significant part of their symptoms.

Answer 373

waking with generalised weakness and paralysis that is transient in nature. attacks most frequently occur in the morning and are often triggered by strenuous exercise the night before or a high carb meal acetazolamide can be used to redcue attacks other agents include potassium sparing diurtics

Answer 374

can occur secondary to nephrotic syndrome they will have normal plasma osmolity with hyponatraemia explaiend by the electroylte exclusion effect

Answer 375

alcoholic cirrhosis coeliac disease/dermatitis herpetiformis Henoch-Schonlein purpura

Answer 376

presentations young male, recurrent episodes of macroscopic haematuria typically associated with a recent respiratory tract infection nephrotic range proteinuria is rare renal failure is unusual and seen in a minority of patients Differentiating between IgA nephropathy and post-streptococcal glomerulonephritis post-streptococcal glomerulonephritis is associated with low complement levels main symptom in post-streptococcal glomerulonephritis is proteinuria (although haematuria can occur) there is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis

Answer 377

Management isolated hematuria, no or minimal proteinuria (less than 500 to 1000 mg/day), and a normal glomerular filtration rate (GFR) no treatment needed, other than follow-up to check renal function persistent proteinuria (above 500 to 1000 mg/day), a normal or only slightly reduced GFR initial treatment is with ACE inhibitors if there is active disease (e.g. falling GFR) or failure to respond to ACE inhibitors immunosuppression with corticosteroids

Answer 378

switch to high flux dialysis membanes

Answer 379

the basement membrane is thickened with subepithelial electron dense deposits. This creates a 'spike and dome' appearance

Answer 380

idiopathic: due to anti-phospholipase A2 antibodies infections: hepatitis B, malaria, syphilis malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia drugs: gold, penicillamine, NSAIDs autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid

Answer 381

all patients should receive an ACE inhibitor or an angiotensin II receptor blocker (ARB): these have been shown to reduce proteinuria and improve prognosis immunosuppression as many patients spontaneously improve only patient with severe or progressive disease require immunosuppression corticosteroids alone have not been shown to be effective. A combination of corticosteroid + another agent such as cyclophosphamide is often used consider anticoagulation for high-risk patients

Answer 382

Raised asthma pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise Low TLCO pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output KCO also tends to increase with age. Some conditions may cause an increased KCO with a normal or reduced TLCO pneumonectomy/lobectomy scoliosis/kyphosis neuromuscular weakness ankylosis of costovertebral joints e.g. ankylosing spondylitis ## Footnote The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer coefficient, KCO)

Answer 383

uniform blood staining and a protein level > 30 there would also be a low pH

Answer 384

U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT ## Footnote In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

Answer 385

Anti-centromere → Limited (CREST), assoc. with PAH Anti-Scl-70 (topoisomerase I) → Diffuse, assoc. with ILD Anti-RNA polymerase III → Diffuse, ↑ risk renal crisis

Answer 386

prolactinoma - prolactin will typically be greater than 2000 where as non-functioning pituitary adenoma would not usually be that elevated

Answer 387

Management treat any underlying precipitating cause **NICE recommend lactulose first-line, with the addition of rifaximin for the secondary** prophylaxis of hepatic encephalopathy lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production other options include embolisation of portosystemic shunts and liver transplantation in selected patients

Answer 388

Grading of hepatic encephalopathy Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma

Answer 389

GTN antihypertensives alpha-blockers TCAs Diuretics Levodopa Alcohol

Answer 390

flow cytometry of blood to detect low levels of CD59 and CD55 eculizumab

Answer 391

daily spiking fevers, sore throat, arthralgia, evanescent salmon pink rash and a very high ferritin

Answer 392

Management co-trimoxazole IV pentamidine in severe cases aerosolized pentamidine is an alternative treatment for Pneumocystis jiroveci pneumonia but is less effective with a risk of pneumothorax steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

Answer 393

type I (25%): monoclonal - IgG or IgM associations: multiple myeloma, Waldenstrom macroglobulinaemia type II (25%) mixed monoclonal and polyclonal: usually with rheumatoid factor associations: hepatitis C, rheumatoid arthritis, Sjogren's, lymphoma type III (50%) polyclonal: usually with rheumatoid factor associations: rheumatoid arthritis, Sjogren's

Answer 394

Possible features Raynaud's only seen in type I cutaneous vascular purpura distal ulceration ulceration arthralgia renal involvement diffuse glomerulonephritis Investigations low complement (esp. C4) high ESR Management treatment of underlying condition e.g. hepatitis C immunosuppression plasmapheresis

Answer 395

rrhythmogenic right ventricular cardiomyopathy Investigation ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex echo changes are often subtle in the early stages but may show an enlarged, hypokinetic right ventricle with a thin free wall magnetic resonance imaging is useful to show fibrofatty tissue

Answer 396

dexamethasone

Answer 397

benzodiazapines

Answer 398

temporary PM If atropine does not work it suggests the block is below the AV node

Answer 399

a recognised complication of upper GI surgery It results from rapid transit of hyperosmolar gastric contents into the the small intestine, causing and exaggerated insulin response, postprandial hypyglycaemia. symptoms usually occur 1-2 hours post meal and imporve with glucose intake

Answer 400

Key feature: Reed–Sternberg cells (large, bilobed, “owl-eye” nuclei). Age distribution: Bimodal (young adults + elderly). Spread: Contiguous lymph node groups.

Answer 401

usually a clinical diagnosis but an MRI brain is usually done to suport the diagnosis shows midbrain atrophy with preserved pons - the classic hummingbird sign on sagital MRI

Answer 402

Lamotrigine

Answer 403

IV Diltiazem or Verapamil

Answer 404

Urine osmolality: Urine osmolality is inappropriately high (>100 mOsm/kg) in relation to serum osmolality, as the kidneys should normally dilute urine in the setting of low serum osmolality. Urine sodium concentration: Urine sodium concentration is typically high (>40 mmol/L) due to the action of ADH on the renal tubules.

Answer 405

Sterpods and then hydroxychloriquine long term steroids are first line tx for moderate to severe cytopenias in an haematological flare of SLE

Answer 406

for individuals with one first degree relative diagnosed with colorectal cancer before the age of 65 - colonoscopic surveillance from the age of 45-50 is recommended.

Answer 407

Anticholinergic effects: Dry mouth Constipation Blurred vision Urinary retention

Answer 408

A monoclonal proliferation of well-differentiated lymphocytes which are almost always B-cells (99%). It is the most common form of leukaemia seen in adults. Often picked up as an incidental finding Will have high lyphocyte count Smudge/smear cells Diagnosis - immunophenotyping is the key investigation

Answer 409

iatrogenic: corticosteroid therapy ACTH-dependent causes Cushing's disease (a pituitary adenoma → ACTH secretion) ectopic ACTH secretion secondary to a malignancy ACTH-independent causes adrenal adenoma

Answer 410

acute bacterial prostatitis

Answer 411

haemodialysis (if the pH < 7.25, visual symptoms and methanol levels > 50)

Answer 412

infected rat urine sewage worker, farmers, abattoir workers, returning traveller Features fever, flu like ilness, fever, **subconjunctival effusions** second immune phase - AKI Hepatitis - jaundice, hepatomegaly aseptic meningitis Serology - AB to leptospira may develop after 7 days PCR Cultures - may take weeks to grow Mx - mild disease - doxy Severe disease IV ben pen ## Footnote Weil's disease should always be considered in high-risk patients with hepatorenal failure

Answer 413

DMARD monotherapy +/- a short course of bridhing prednisolone. Methotrexate is the most widely used Sulfasalazine

Answer 414

serum osmolality is the first step - this will help determine true hypo-osmolality or is an artefact (pseudohyponatraenia)

Answer 415

ABPI between 05. and 0.8 indicates that moderate arterial impairment is too low for full compression and yet adequate for moderate cmpression

Answer 416

Often in the returning traveller Prolonged non-bloody diarrhoea Treatment with metronidazole

Answer 417

AD group of protein aggregate myopathies characteristed by distal lower limb weakness, foot drom and slowly progressive hand involvemen There will be desmin-positive sarcoplasmic inclusions and myofibrillar disorganisation on biopsy are diagnostic hallmarks

Answer 418

Stop sulfonylureas and metformin Give a markedly reduced basal dose of long acting insulinm (about one third to one quarter of the original dose)

Answer 419

Etanecrecpt a TNF alpha inhibitor ## Footnote ****The disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement

Answer 420

needs sedationn with IV diazepam - this decreases endogenous heat production and improves haemodynamic stability

Answer 421

Features malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus Investigation jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules Management guidelines vary: oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin

Answer 422

Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O

Answer 423

Features fever, malaise, arthralgia weight loss hypertension mononeuritis multiplex, sensorimotor polyneuropathy testicular pain livedo reticularis haematuria, renal failure perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with 'classic' PAN hepatitis B serology positive in 30% of patients ## Footnote middle aged men Associated with hep B

Answer 424

NICE recommend either cognitive behavioural therapy or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Answer 425

The following drugs tend to cause a hepatocellular picture: paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin The following drugs tend to cause cholestasis (+/- hepatitis): combined oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine

Answer 426

↑ Indirect (unconjugated) bilirubin → jaundice. ↑ LDH (released from lysed RBCs). ↓ Haptoglobin (binds free Hb → depleted in haemolysis). ↑ Plasma free haemoglobin (esp. intravascular haemolysis). ↑ Urobilinogen in urine.

Answer 427

Methaemoglobinaemia describes haemoglobin which has been oxidised from Fe2+ to Fe3+. Congenital causes haemoglobin chain variants: HbM, HbH NADH methaemoglobin reductase deficiency Acquired causes drugs: sulphonamides, nitrates (including recreational nitrates e.g. amyl nitrite 'poppers'), dapsone, sodium nitroprusside, primaquine chemicals: aniline dyes Features 'chocolate' cyanosis dyspnoea, anxiety, headache severe: acidosis, arrhythmias, seizures, coma normal pO2 but decreased oxygen saturation Management NADH methaemoglobinaemia reductase deficiency: ascorbic acid IV methylthioninium chloride (methylene blue) if acquired

Answer 428

for oral to subcut morphine - divide by 2 For oral morphine to subcut diamorphine - devide by 3

Answer 429

eye care Prednisolone for patients who present within 72 hours of symptoms onset

Answer 430

Breast Ca screening Thyroid cancer screening - thyroid exam and TSH Lung cancer - consider CT if high risk Skin cancer checks Baseline echo PFTs if sympotmatc

Answer 431

propranolol topiramate: should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives amitriptyline ## Footnote for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'

Answer 432

seminomas: seminomas: hCG may be elevated in around 20% non-seminomas: AFP and/or beta-hCG are elevated in 80-85% LDH is elevated in around 40% of germ cell tumours

Answer 433

possible enteropathy associated T cell lymphoma

Answer 434

Sporadic CJD accounts for 85% of cases 10-15% of cases are familial mean age of onset is 65 years New variant CJD younger patients (average age of onset = 25 years) psychological symptoms such as anxiety, withdrawal and dysphonia are the most common presenting features the 'prion protein' is encoded on chromosome 20 - it's role is not yet understood methionine homozygosity at codon 129 of the prion protein is a risk factor for developing CJD - all patients who have so far died have had this median survival = 13 months Investigation CSF is usually normal EEG: biphasic, high amplitude sharp waves (only in sporadic CJD) MRI: hyperintense signals in the basal ganglia and thalamus * MRI brain is first line ix

Answer 435

caused by HHV-8 (human herpes virus 8) presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract) skin lesions may later ulcerate respiratory involvement may cause massive haemoptysis and pleural effusion radiotherapy + resection ## Footnote common in patients with HIV

Answer 436

Management stop antipsychotic patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units IV fluids to prevent renal failure dantrolene may be useful in selected cases thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum bromocriptine, dopamine agonist, may also be used

Answer 437

humanized anti-CD20 monoclonal antibody

Answer 438

sphingosine 1-phosphate (S1P) receptor modulator

Answer 439

a recombinant monoclonal antibody that antagonises alpha-4 beta-1-integrin found on the surface of leucocytes

Answer 440

Corticosteroids topically or intralesional

Answer 441

supportive measures: 100% oxygen definitive: hydroxocobalamin (intravenously), also combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously) ## Footnote Fire is the most common source of cyanide exposure in industrialised countries. Mouth-to-mouth resuscitation is contraindicated in cyanide poisoning because of risk to the provider of CPR.

Answer 442

Haemolytic uraemic syndrome is generally seen in young children and produces a triad of: acute kidney injury microangiopathic haemolytic anaemia (MAHA) thrombocytopenia **Investigations** a blood film is the most useful initial diagnostic test remember that in HUS there is a ΜΑНΑ (i.e. Coombs-negative haemolysis) resulting from intravascular red blood cell fragmentation → formation of ѕϲhiѕtοϲytеs anaemia: a haemoglobin level < than 8 g/dL thrombocytopenia U&E: acute kidney injury stool culture looking for evidence of STEC infection PCR for Shiga toxins **Management** treatment is supportive e.g. Fluids, blood transfusion and dialysis if required there is no role for antibiotics, despite the preceding diarrhoeal illness in many patients the indications for plasma exchange in HUS are complicated as a general rule plasma exchange is reserved for severe cases of HUS not associated with diarrhoea eculizumab (a C5 inhibitor monoclonal antibody) has evidence of greater efficiency than plasma exchange alone in the treatment of adult atypical HUS **** treatment is supportive e.g. Fluids, blood transfusion and dialysis if required there is no role for antibiotics, despite the preceding diarrhoeal illness in many patients the indications for plasma exchange in HUS are complicated as a general rule plasma exchange is reserved for severe cases of HUS not associated with diarrhoea eculizumab (a C5 inhibitor monoclonal antibody) has evidence of greater efficiency than plasma exchange alone in the treatment of adult atypical HUS

Answer 443

Phlebotomy is the mainstay of treatment in hereditary haemochromatosis and is indicated in all patients with a ferritin level greater than 1,000 microgram / L. Typical initial phlebotomy regimes are 400-500 ml every 1-2 weeks. Once ferritin level falls to the range 50-100 microgram / L, phlebotomy regime can transition to a maintenance schedule every 2-4 months.

Answer 444

ACE levels CXR Spirometry

Answer 445

**Risk factors for SBBOS** neonates with congenital gastrointestinal abnormalities scleroderma diabetes mellitus It should be noted that many of the features overlap with irritable bowel syndrome: chronic diarrhoea bloating, flatulence abdominal pain **Diagnosis** hydrogen breath test small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce clinicians may sometimes give a course of antibiotics as a diagnostic trial **Management **correction of the underlying disorder antibiotic therapy:rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.

Answer 446

Bisphosphonates (first-line): Zoledronic acid (IV) – most commonly used, given every 3–4 weeks. Pamidronate (IV) – alternative if zoledronic acid is contraindicated. Denosumab (SC injection): A monoclonal antibody against RANKL, useful especially if there is renal impairment, where bisphosphonates may not be safe.

Answer 447

Vancomycin red man syndrome is thought to occur because of histamine release related to too rapid infusion of the abx It can be managed by stopping the infusion temporarily, administer hydrocortisone and chlorphenamide and then restart it at 50% of the previous rate.

Answer 448

Features: bone pain, typically in the skull or proximal femur cutaneous nodules pituitary involvement: leads to diabetes insipidus due to pituitary stalk involvement pulmonary involvement: More common in adults, presenting with dyspnoea, cough, and chest pain recurrent otitis media/mastoiditis tennis racket-shaped Birbeck granules on electromicroscopy

Answer 449

Single organ disease: Bone lesion: Surgical curettage the mainstay of treatment for a solitary lesion. Radiotherapy, bisphosphonates and chemotherapy can be considered if the site of the solitary lesion is inaccesable or multiple lesions are present. Skin: Topical steroids. PUVA therapy. Lymph nodes: Surgical excision of a single node. Systemic steroids for multiple nodes. Chemotherapy for nodes resistant to treatment. Pulmonary involvement: Smoking cessation is key and often the only intervention required. Multi-system disease: A combination of cytotoxic medications and systemic steroids are used in multi-system disease and refractory single organ disease. Children: prednisolone and vinblastine with 6-mercaptopurine added after the first six weeks for a total duration of 6-12 months. Adults: cladribine or cytarabine is recommended for 6-12 months.

Answer 450

Amifampridine (3,4-diaminopyridine, 3,4-DAP) First-line therapy. Blocks potassium channels → prolongs presynaptic action potential → increases calcium influx → more acetylcholine release. Markedly improves strength. Pyridostigmine (AChE inhibitor) May provide additional benefit but generally less effective than in myasthenia gravis. Guanidine (rarely used due to toxicity, only if others unavailable).

Answer 451

APML is associated with the t(15;17) translocation which causes fusion of the PML and RAR-alpha genes. Features presents younger than other types of AML (average = 25 years old) DIC or thrombocytopenia often at presentation good prognosis APML is treated with all-trans retinoic acid (ATRA) to force immature granulocytes into maturation to resolve a blast crisis prior to more definitive chemotherapy.

Answer 452

Strongyloides stercoralis is a human parasitic nematode worm. The larvae are present in soil and gain access to the body by penetrating the skin. Infection with Strongyloides stercoralis causes strongyloidiasis. Features diarrhoea abdominal pain/bloating papulovesicular lesions where the skin has been penetrated by infective larvae e.g. soles of feet and buttocks larva currens: pruritic, linear, urticarial rash if the larvae migrate to the lungs a pneumonitis similar to Loeffler's syndrome may be triggered Treatment ivermectin and albendazole are used

Answer 453

Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The three main species of schistosome are S. mansoni, S. japonicum and S. haematobium. Acute symptoms typically only develop in people who travel to endemic areas, as they don't have any immunity to the worms. Acute manifestations may include: swimmers' itch acute schistosomiasis syndrome (Katayama fever) fever urticaria/angioedema arthralgia/myalgia cough diarrhoea eosinophilia Schistosoma haematobium frequency haematuria bladder calcification Tx single oral dose of praziquantel

Answer 454

Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia. Features bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma bronchiectasis (proximal) Investigations eosinophilia flitting CXR changes positive radioallergosorbent (RAST) test to Aspergillus positive IgG precipitins (not as positive as in aspergilloma) raised IgE Management oral glucocorticoids itraconazole is sometimes introduced as a second-line agent

Answer 455

patients with renal disease should be started on an ACE inhibitor - captopril is typically used due to its rapid onset and short half-life, allowing for dose titration ACE inhibitors target the underlying mechanism by reducing efferent arteriolar vasoconstriction and limiting renin-angiotensin system activation

Answer 456

Diagnosis requires a range of clinical, radiological and microbiological characteristics to be fulfilled as described below: Clinical: Pulmonary symptoms (e.g. cough, sputum, or constitutional) and exclusion of alternative diagnosis Radiological: Chest X-ray or HRCT demonstrating cavities, bronchiectasis and or nodules Microbiological: Two or more positive sputum samples for an NTM species taken on separate days (or one of more positive sample from bronco-alveolar lavage or tissue biopsy) Once a diagnosis of NTM is reached, it is important to know the basic treatment for common pulmonary NTM infections. It is important to have a basic understanding of two commonly identified groups: Mycobacterium avium complex (MAC) and Mycobacterium kansasii. - MAC: Rifampicin, clarithromycin and ethambutol. Treatment should continue until the patients sputum has remained negative for MAC for 12 months - M.kansasii: Rifampicin, isoniazid and ethambutol. Treatment should continue until the patient has been sputum culture negative for 12 months.

Answer 457

NSAIDs (ibuprofen, diclofenac, naproxen) Proton pump inhibitors (PPIs) – e.g. omeprazole, lansoprazole SSRIs – especially sertraline, paroxetine Aspirin Statins – simvastatin, atorvastatin Beta-blockers Carbamazepine ACE inhibitors / ARBs (less common reports) ## Footnote Drug-induced lymphocytic colitis often presents with chronic watery diarrhoea (no blood, no weight loss), usually in older women. Colonoscopy looks normal → diagnosis by biopsy (intraepithelial lymphocytes, surface epithelial damage). Symptoms can improve after withdrawal of culprit drug.

Answer 458

Anti-PLA2R antibody (Medicine/Nephrology) PLA2R = Phospholipase A2 receptor (on podocytes). Anti-PLA2R antibody is the most specific biomarker for primary membranous nephropathy (MN). Positive in ~70–80% of cases of primary MN. Useful for: Diagnosis (helps distinguish primary from secondary MN). Monitoring disease activity (titres often correlate with proteinuria and disease course). Prognosis (persistent high titres = more likely relapse/progression).

Answer 459

Rituximab is considered a first-line immunosuppressive therapy for patients with primary membranous nephropathy (MN)

Answer 460

Features flu-like symptoms including fever (present in > 95% of patients) dry cough relative bradycardia confusion lymphopaenia hyponatraemia deranged liver function tests pleural effusion: seen in around 30% of patients Management Erythromycin or clarithromycin If allergic can be given levofloxacin (quinolones)

Answer 461

Anti-U1 RNP → think Mixed Connective Tissue Disease (MCTD). ## Footnote Mixed connective tissue disease (MCTD, Sharp's syndrome) is a rare, heterogeneous, multi-system autoimmune disorder. It is a distinct clinical entity, but features of systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and myositis may all be present. It is associated with anti-U1 ribonucleoprotein (RNP) antibodies.* It is not to be confused with 'undifferentiated connective tissue disease'.** *Note that anti-U1 RNP antibodies are not completely specific and may also be seen in definite SSc and SLE **Undifferentiated connective tissue disease refers to syndromes in which features of one or more 'classical' connective tissue disease may be present, but do not meet diagnostic criteria. Anti-U1 RNP is absent.

Answer 462

Dermatological: photosensitive rash, scleroderma-like changes, alopecia Oesophageal dysfunction Respiratory: pleuritis, pulmonary hypertension, interstitial lung disease Haematological: anaemia, lymphadenopathy, splenomegaly, rarely TTP Cardiac: pericarditis, pericardial effusion, accelerated coronary artery disease Renal: glomerulonephritis (tends to be milder than SLE) Neuropsychiatric: seizures, mood disturbance

Answer 463

AKA American trypanosomiasis Tx - treatment is most effective in the acute phase using azole or nitroderivatives such as benznidazole or nifurtimox

Answer 464

Subacute combined degeneration of the spinal cord is due to vitamin B12 deficiency resulting in impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts.. Recreational nitrous oxide inhalation may also result in vitamin B12 deficiency → subacute combined degeneration of the spinal cord. Features dorsal column involvement distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms impaired proprioception and vibration sense lateral corticospinal tract involvement muscle weakness, hyperreflexia, and spasticity upper motor neuron signs typically develop in the legs first brisk knee reflexes absent ankle jerks extensor plantars spinocerebellar tract involvement sensory ataxia → gait abnormalities positive Romberg's sign

Answer 465

calcium phosphate

Answer 466

IV access → take bloods and blood cultures lumbar puncture if this cannot be done within the first hour, IV antibiotics should be given after blood cultures have been taken IV antibiotics 3 months - 60 years: BNF recommends ceftriaxone ≥60 years: BNF recommends ceftriaxone + amoxicillin (or ampicillin) for adults add IV vancomycin if recent prolonged/multiple antibiotic use or travel to areas with highly resistant pneumococci IV dexamethasone the BNF recommend to 'consider adjunctive treatment with dexamethasone (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery' CT scan is not normally indicated

Answer 467

nephrogenic diabetes insipidus thiazides low salt/protein diet central diabetes insipidus can be treated with desmopressin

Answer 468

Integrin antagonist

Answer 469

in the majority of cases, symptomatic patients are treated medically with dopamine agonists (e.g. cabergoline, bromocriptine) which inhibit the release of prolactin from the pituitary gland surgery is performed for patients who cannot tolerate or fail to respond to medical therapy. A trans-sphenoidal approach is generally preferred unless there is a significant extra-pituitary extension

Answer 470

a cause of aplastic crisis in patients who have chronic haemolysis such as sickle cell disease and hereditary spherocytosis

Answer 471

The risk of calcium oxalate stone is significantly increased in patients who have short bowel syndrome. SHort bowel syndrome drives increased distal absorption of oxalate in the colon, the excretion of which then leads to a significantly increased risk of oxalate stone formation

Answer 472

a shockable rhythm

Answer 473

Trans-sphenoidal surgery is the first-line treatment for acromegaly in the majority of patients. If a pituitary tumour is inoperable or surgery unsuccessful then medication may be indicated: **somatostatin analogue** directly inhibits the release of growth hormone for example octreotide effective in 50-70% of patients **pegvisomant** GH receptor antagonist - prevents dimerization of the GH receptor once daily s/c administration very effective - decreases IGF-1 levels in 90% of patients to normal doesn't reduce tumour volume therefore surgery still needed if mass effect

Answer 474

Lymphangioleiomyomatosis (LAM) is a rare, progressive disease categorised by lung cysts, kidney tumours and lymphatic abnormalities. LAM can occur in isolation or as part of the genetic disease tuberous sclerosis (TSC). Patients have repeated lung collapse and respiratory impairment leading to death or lung transplantation and they can also suffer complications from kidney tumours.

Answer 475

There is trifascicular block with syncope or presyncope not explained by another cause.

Answer 476

clozapine is the most effective agent to use in parkinsons psychosis

Answer 477

Necrolytic migratory erythema is a characteristic rash usually occurring in the glucagonoma syndrome. Glucagonoma syndrome is due to a slow-growing cancerous tumour located in the alpha cells of the pancreas. Glucagonoma is very rare and affects adults over the age of 50. The tumour secretes excessive amounts of the hormone glucagon. Diagnosis : do a serum glucagon level

Answer 478

Glucagonomas are small tumours, almost always found in the pancreas, and frequently malignant. The tumours arise from the alpha cells of the pancreas. They present with diabetes mellitus, venous thrombo-embolism and the classical rash of necrolytic migratory erythema - a red, blistering rash. A serum level of glucagon >1000pg/ml usually suggests the diagnosis, imaging with CT scanning is also required. Treatment options include surgical resection and octreotide.

Answer 479

carpal tunnel syndrome

Answer 480

AKA meralgia paraesthetica

Answer 481

Anthropometry - mid arm miscule circmfrance and skin fold thickness allows for an assessment of body composition and a number of anthropometric measurements

Answer 482

Prednisolone to induce remession followed by azathiorprine

Answer 483

most common form of fungal infection of CNS headache, fever, malaise, nausea/vomiting, seizures, focal neurological deficit CSF high opening pressure elevated protein reduced glucose normally a lymphocyte predominance but in HIV white cell count many be normal India ink test positive CT: meningeal enhancement, cerebral oedema Tx - dual antifungal therapy - amphotericin B and flucytosine

Answer 484

a mitochindrial disorder mainly seen in men visual field loss occurs rapidly over 3-4 months with onset in young adulthood and usually begins in one eye there is incomplete penetrance

Answer 485

may present as SOB lying flat Restrictive pattern on spirometry assess using supine and erect spirometry CT would be required to investigate underlying cause

Answer 486

laser ablation

Answer 487

overnight dexamethsone supression test 24 hour urinary cortisol bedtime salivary cortisol

Answer 488

autoimmune destruciton of red blood cells and plts there will be decreased haotoglobin level and low plts can also cause neutropeania initial treatment is with corticosteroids

Answer 489

Raw freshwater fish → tapeworm (Diphyllobothrium latum) → B12 deficiency. tx - praziquantel + B12 replacement

Answer 490

dialysis disequilibrium syndrome - which is attributed to cerebral oedema and agressive dialysis protocols to remove solutes that promote a reserve osmotic shift when the process is first instigated Sodium modelling, which is a part of the dialysis protocol on modern machines, alters the dialysis regimen to reduce these solute shifts and is the intiial intervention of choice for DDS. If patients do not respond then other interventions such as stopping dialysis and giving mannitol may be required

Answer 491

Initially there is a respiratory alkalosis with hyperventilation, tinnitus and N&V After a few hours a metabolic acidosis develops accompanied by hypoventilation resulting in a mixed respiratory and metabolic acidosis Activated charcoal should be given as early as possible following diagnosis

Answer 492

Treatment general (ABC, charcoal) urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine haemodialysis Indications for haemodialysis in salicylate overdose serum concentration > 700mg/L metabolic acidosis resistant to treatment acute renal failure pulmonary oedema seizures coma

Answer 493

The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum. Symptoms include: chills, shivering, sweating, anxiety and coughing. Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

Answer 494

Hepatitis A Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation HNIG is typically reserved for those who cannot receive the vaccine or where rapid protection is required (e.g. immunosuppressed individuals) In most cases, hepatitis A vaccine is preferred for post-exposure prophylaxis

Answer 495

HBsAg positive source If the person exposed is a known responder (anti-HBs ≥10 mIU/mL following full vaccination), a booster dose should be given If they are a non-responder (anti-HBs <10 mIU/mL 1–2 months after completing the full course), they should receive hepatitis B immunoglobulin (HBIG) and a booster vaccine Unknown source For known responders, a booster dose may be considered depending on the risk assessment For non-responders, HBIG and a booster vaccine should be given Individuals undergoing a primary course of vaccination should complete an accelerated schedule and may be offered HBIG if the risk of exposure is considered high

Answer 496

There is no effective post-exposure prophylaxis for hepatitis C Initial testing should include baseline HCV serology and HCV RNA (PCR) Repeat HCV RNA at 6 and 12 weeks post-exposure, and HCV antibody at 3 and 6 months If seroconversion occurs, early referral to hepatology for consideration of direct-acting antiviral therapy is advised

Answer 497

The risk of HIV transmission depends on the nature of the exposure (e.g. needlestick, type of sexual contact, human bite) and the viral load of the source individual Low-risk incidents such as human bites generally do not require post-exposure prophylaxis (PEP), unless blood is present or other risk factors apply First-line PEP regimen is oral antiretroviral therapy: tenofovir disoproxil/emtricitabine (Truvada®) + raltegravir PEP should be started as soon as possible (ideally within 1–2 hours, and no later than 72 hours post-exposure) Treatment course lasts 4 weeks HIV serological testing is required at 12 weeks after completing PEP PEP reduces the risk of HIV transmission by approximately 80%

Answer 498

Varicella zoster immunoglobulin (VZIG) should be given to IgG-negative pregnant women or immunosuppressed individuals after significant exposure If VZIG is unavailable or >10 days post-exposure, oral aciclovir may be considered (based on risk assessment)

Answer 499

total thyroidectomy followed by radioiodine (I-131) to kill residual cells monitoring: neck ultrasound papillary/follicular carcinoma: yearly thyroglobulin levels to detect early recurrent disease medullary carcinoma: calcitonin + carcinoembryonic antigen

Answer 500

Intermittent vomiting and difficulty dosing mealtime insulin - suggests variable nutrient absorption barium swallow can confirm delayed gastic emptying tx - prokinetic antiemetics such as domperiodne

Answer 501

Use the mnemonic CRABBI: **Calcium** hypercalcaemia primary factor: due primarily to increased osteoclastic bone resorption caused by local cytokines (e.g. IL-1, tumour necrosis factor) released by the myeloma cells much less common contributing factors: impaired renal function, increased renal tubular calcium reabsorption and elevated PTH-rP levels this leads to constipation, nausea, anorexia and confusion **Renal** monoclonal production of immunoglobulins results in light chain deposition within the renal tubules this causes renal damage which presents as dehydration and increasing thirst other causes of renal impairment in myeloma include amyloidosis, nephrocalcinosis, nephrolithiasis **Anaemia** bone marrow crowding suppresses erythropoiesis leading to anaemia this causes fatigue and pallor **Bleeding** bone marrow crowding also results in thrombocytopenia which puts patients at increased risk of bleeding and bruising **Bones** bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity creates lytic bone lesions this may present as pain (especially in the back) and increases the risk of pathological fractures **Infection** a reduction in the production of normal immunoglobulins results in increased susceptibility to infection

Answer 502

commence a long actinging inuslin

Answer 503

vancomycin teicoplanin linezolid

Answer 504

tilt table test

Answer 505

Safe: diuretics, beta-blockers, hydralazine, nitrates, digoxin.

Answer 506

🔥 CYP450 Inducers 👉 "CRAP GPS" Carbamazepine Rifampicin Alcohol (chronic use) Phenytoin Griseofulvin Phenobarbital Sulphonylureas 💡 Think: inducers rev up the engine → drug burns up faster → ↓ levels. ❄️ CYP450 Inhibitors 👉 "SICKFACES.COM" (sometimes with "GP") Sodium valproate Isoniazid Cimetidine Ketoconazole Fluconazole Amiodarone Ciprofloxacin Erythromycin / clarithromycin Sulfonamides Chloramphenicol Omeprazole Metronidazole 💡 Think: inhibitors put the brakes on metabolism → drug builds up → toxicity risk.

Answer 507

Ivabradine is a class of anti-anginal drug which works by reducing the heart rate. It acts on the If ('funny') ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity. Adverse effects visual effects, particular luminous phenomena, are common headache bradycardia, heart block ## Footnote Use in HF if HR above 75 can be used if not able to have BB or if HR remains high even with BB

Answer 508

The treatment for MODY depends on the specific genetic subtype. For example, MODY2 often does not require specific treatment, as the hyperglycemia is mild and usually does not lead to complications. In contrast, MODY associated with HNF1A often respond well to treatment with low-dose sulfonylureas. Insulin therapy may be necessary in some cases, especially during pregnancy or if sulfonylureas are contraindicated or ineffective.

Answer 509

strongly associated with pneumococcal pneumonia (Streptococcus pneumoniae).

Answer 510

Prothrombin complex concentrate

Answer 511

Relapsing polychondritis is a multi-systemic condition characterised by repeated episodes of inflammation and deterioration of cartilage. This most commonly affects the ears, however, can affect other parts of the body such as the nose and joints. Key features: Ears: auricular chondritis, hearing loss, vertigo Nasal: nasal chondritis → saddle-nose deformity Respiratory tract: e.g. hoarseness, aphonia, wheezing, inspiratory stridor Ocular: episcleritis, scleritis, iritis, and keratoconjunctivitis sicca Joints: arthralgia Less commonly: cardiac valcular regurgitation, cranial nerve palsies, peripheral neuropathies, renal dysfunction Diagnosis: Various scoring systems based on clinical, pathological, and radiological criteria Treatment Induce remission: steroids Maintenance: azathioprine, methotrexate, cyclosporin, cyclophosphamide

Answer 512

hronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1) Associations Sjogren's syndrome (seen in up to 80% of patients) rheumatoid arthritis systemic sclerosis thyroid disease Clinical features early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure Diagnosis immunology anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific smooth muscle antibodies in 30% of patients raised serum IgM imaging required before diagnosis to exclude an extrahepatic biliary obstruction (typically a right upper quadrant ultrasound or magnetic resonance cholangiopancreatography (MRCP) Management first-line: ursodeoxycholic acid slows disease progression and improves symptoms pruritus: cholestyramine fat-soluble vitamin supplementation liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) recurrence in graft can occur but is not usually a problem

Answer 513

Gentamicin IM and azithromycin PO single dose

Answer 514

In late pregnancy there is a physiological rise in total cholesterol and triglyceride levels No need for intervention

Answer 515

Methanol poisoning causes both the effects associated with alcohol (intoxication, nausea etc) and also specific visual problems, including blindness. These effects are thought to be secondary to the accumulation of formic acid. The actual pathophysiology of methanol-associated visual loss is not fully understood but it is thought to be caused by a form of optic neuropathy Management fomepizole (competitive inhibitor of alcohol dehydrogenase) or ethanol haemodialysis cofactor therapy with folinic acid to reduce ophthalmological complications

Answer 516

**Non-proliferative diabetic retinopathy ** Mild NPDR 1 or more microaneurysm Moderate NPDR microaneurysms blot haemorrhages hard exudates cotton wool spots ('soft exudates' - represent areas of retinal infarction), venous beading/looping and intraretinal microvascular abnormalities (IRMA) less severe than in severe NPDR Severe NPDR blot haemorrhages and microaneurysms in 4 quadrants venous beading in at least 2 quadrants IRMA in at least 1 quadrant **Proliferative diabetic retinopathy** Key features retinal neovascularisation - may lead to vitrous haemorrhage fibrous tissue forming anterior to retinal disc more common in Type I DM, 50% blind in 5 years **Maculopathy** Key features based on location rather than severity, anything is potentially serious hard exudates and other 'background' changes on macula check visual acuity more common in Type II DM

Answer 517

Maculopathy if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors Non-proliferative retinopathy regular observation if severe/very severe consider panretinal laser photocoagulation Proliferative retinopathy panretinal laser photocoagulation intravitreal VEGF inhibitors often now used in combination with panretinal laser photocoagulation examples include **ranibizumab** strong evidence base suggests they both slow progression of proliferative diabetic retinopathy and improve visual acuity if severe or vitreous haemorrhage: vitreoretinal surgery

Answer 518

Ranibizumab

Answer 519

Occupations at risk of silicosis mining slate works foundries potteries Features upper zone fibrosing lung disease 'egg-shell' calcification of the hilar lymph nodes

Answer 520

Step pneumoniae

Answer 521

A rare cystic lung disease caused by abnormal proliferation of smooth muscle–like cells in lungs, lymphatics, and kidneys. Leads to progressive cystic destruction of the lungs. Strongly affects women of childbearing age (oestrogen-sensitive). Progressive exertional dyspnoea. Recurrent pneumothoraces (often bilateral, recurrent). Chylous pleural effusions (milky, due to lymphatic obstruction). Chronic cough, haemoptysis. May have renal angiomyolipomas (association with tuberous sclerosis complex, TSC1/TSC2 mutations). Sirolimus (mTOR inhibitor): slows decline in lung function, first-line in progressive disease. Supportive: Bronchodilators (if airflow obstruction). Oxygen therapy if hypoxic. Pneumothorax management: pleurodesis (high recurrence risk). Lung transplant: for advanced respiratory failure. Avoid oestrogen therapy (may worsen disease).

Answer 522

insulin promotes salt and water retention - wich can worsen HF and fluid overload

Answer 523

this is a late effect of intracranial radiation which presents with migraine like episodes with focal neurological deficits Some patients get associated seizures Characterized by reversible neurological symptoms such as: Stroke-like deficits (hemiparesis, aphasia, visual loss) Migraine-like headaches Seizures MRI shows reversible, unilateral cortical abnormalities (often T2/FLAIR hyperintensity, gyral enhancement). You would just monitor with interval MRI scan

Answer 524

Features muscle pain and stiffness following exercise muscle cramps second wind phenomenon occurs when patients experience an improvement in exercise tolerance after a brief rest or reduction in intensity due to the body's switch from glycogen-dependent energy metabolism to increased reliance on circulating glucose and fatty acids his adaptation allows for better energy utilisation during prolonged activity despite the underlying myophosphorylase deficiency. rhabdomyolysis & myoglobinuria low lactate levels during exercise

Answer 525

Deficiency of α-galactosidase A → accumulation of globotriaosylceramide (Gb3) in vascular endothelium, kidneys, heart, nerves. Inheritance X-linked recessive Males severely affected, females variably affected (lyonization). Clinical Features 🔹 Neurological / Pain Acroparaesthesia: burning pain in hands/feet, often episodic “pain crises” Hypohidrosis/anhidrosis (↓ sweating) Heat/cold intolerance 🔹 Skin Angiokeratomas: small dark red–purple papules, typically in a “bathing trunk” distribution (buttocks, groin, umbilicus). 🔹 Eye Corneal verticillata (whorled corneal opacity) – slit lamp finding, vision usually normal. 🔹 Renal Proteinuria, progressive renal impairment → ESRD. 🔹 Cardiac LV hypertrophy, arrhythmias, heart failure. 🔹 Cerebrovascular Premature strokes, TIA, vertigo. ## Footnote Pain is evoked by vigerous exercise, hot weather or febrile ilness A diffuse vascular involvement leads to HTN, cardiomegaly, kidney disease and thrombotic infarction occurs in various viscera

Answer 526

can occu in young hypertensive patients with renal artery stenosis which in young adults is commonly caused by fibromuscular dysplasia.

Answer 527

ollowing a splenectomy patients are particularly at risk from pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus* infections Vaccination if elective, should be done 2 weeks prior to operation Hib, meningitis A & C annual influenza vaccination pneumococcal vaccine every 5 years

Answer 528

1️⃣ Reduced renal perfusion Stenosed renal arteries → kidneys sense low perfusion (even though systemic BP may be high). Kidneys interpret this as hypotension. 2️⃣ Activation of the Renin–Angiotensin–Aldosterone System (RAAS) ↓ Renal perfusion → ↑ renin release → ↑ angiotensin II → systemic vasoconstriction → ↑ afterload. ↑ aldosterone → Na⁺ and water retention → ↑ circulating volume → ↑ preload. 3️⃣ Hypertension + Volume Overload Marked salt and water retention increases intravascular volume rapidly. The non-stenosed kidney (if unilateral) cannot excrete sodium effectively because systemic pressure rises above its autoregulatory range. Result → sudden rise in LV filling pressure. 4️⃣ Flash Pulmonary Oedema The heart (especially if there is any diastolic dysfunction or LV hypertrophy) cannot accommodate the sudden rise in preload. This causes acute pulmonary venous congestion → pulmonary oedema — the “flash” onset.

Answer 529

acute interstitial nephritis

Answer 530

scattered large atypical mononuclear and binucleate cells with prominent oesinophilic nucleio and abundant cytoplasm

Answer 531

chemotherapy is the mainstay of treatment. Two combinations may be used ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine): considered the standard regime BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone): alternative regime with better remission rates but higher toxicity radiotherapy combined modality therapy (CMT) chemotherapy followed by radiotherapy hematopoietic cell transplantation may be used for relapsed or refractory classic Hodgkin lymphoma

Answer 532

Features may cause mild flu-like illness lasting less than one week classic description involves sudden onset of high fever, rigors, nausea & vomiting. Bradycardia may develop. A brief remission is followed by jaundice, haematemesis, oliguria if severe jaundice, haematemesis may occur Councilman bodies (inclusion bodies) may be seen in the hepatocytes

Answer 533

Supplementing calcium and vitamin D in secondary hyperparathyroidism runs the risk of adynamic bone disease if this is begun at less than twice the upper limit of the normal range for PTH.

Answer 534

Strongly associated with polymysoitis

Answer 535

characterisitic of dermatomyositis

Answer 536

prolonged non-bloody diarrhoea Bloating, abdo pain, flatulene, steatorrhoea Risk factors foreign travel swimming/drinking water from a river or lake male-male sexual contact Tx metronidazole

Answer 537

Bloody diarrhoea Vomiting and abdominal pain Tenesmus Common in nurseries Supportive management Can give cipro

Answer 538

A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody May mimic appendicitis Complications include Guillain-Barre syndrome

Answer 539

**medical therapy: **prolactinomas are generally treated first-line with dopamine agonists (e.g., cabergoline or bromocriptine). somatostatin analogues (e.g., octreotide, lanreotide) and GH receptor antagonists (e.g., pegvisomant) are used for GH-secreting adenomas for ACTH-secreting adenomas, medical therapy may include cortisol synthesis inhibitors (e.g., ketoconazole, metyrapone) and neuromodulators like pasireotide **transsphenoidal surgery** the primary treatment for most pituitary adenomas is transsphenoidal surgery, especially for non-functioning and ACTH- or GH-secreting adenomas non-functioning adenomas are generally diagnosed due to their compressive symptoms (e.g. visual problems) or hormone deficiencies - surgery is therefore the first-line treatment

Answer 540

X-linked dominant

Answer 541

Hypoxic challenge test

Answer 542

Rheumatoid arthritis Splenomegaly

Answer 543

Familial Mediterranean Fever (FMF, also known as recurrent polyserositis) is an autosomal recessive disorder which typically presents by the second decade. It is more common in people of Turkish, Armenian and Arabic descent. Features - attacks typically last 1-3 days pyrexia abdominal pain (due to peritonitis) pleurisy pericarditis arthritis erysipeloid rash on lower limbs Management colchicine may help

Answer 544

Methaemoglobinaemia There will be a significant differnece in sats on ABG and peripheral oxygen

Answer 545

Indications for steroids patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment hypercalcaemia eye, heart or neuro involvement

Answer 546

**Risk factors for SBBOS** neonates with congenital gastrointestinal abnormalities scleroderma diabetes mellitus It should be noted that many of the features overlap with irritable bowel syndrome: chronic diarrhoea bloating, flatulence abdominal pain **Diagnosis** hydrogen breath test small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce clinicians may sometimes give a course of antibiotics as a diagnostic trial **Management** correction of the underlying disorder antibiotic therapy:rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.

Answer 547

**Bullous pemphigoid** = subepidermal blister (below the epidermis) Linear deposition of IgG and C3 along basement membrane zone **Pemphigus vulgaris **= intraepidermal blister (within the epidermis) Fish-net / lace-like pattern of IgG between keratinocytes

Answer 548

Cinacalcet

Answer 549

Domperidone

Answer 550

Type 1 - associated with sudden cardiac arrest - often during sleep. Coved ST elevation Type 2 - associated with saddle back ST elevation also associated with caridac arrest during sleep

Answer 551

numerous hamartomatous polyps in the gastrointestinal tract It is also associated with pigmented freckles on the lips, face, palms and soles AD

Answer 552

Genital herpes is most often caused by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1). Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site. There is typically multiple painful ulcers. Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days. Chancroid is a tropical disease caused by **Haemophilus ducrey**i. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border. Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of three stages stage 1: small painless pustule which later forms an ulcer stage 2: painful inguinal lymphadenopathy stage 3: proctocolitis

Answer 553

Duchenne = Deadly (complete dystrophin loss, early onset) Becker = Better (some dystrophin, later onset)

Answer 554

Management oral glucocorticoids itraconazole is sometimes introduced as a second-line agent ## Footnote Features bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma bronchiectasis (proximal) Investigations eosinophilia flitting CXR changes positive radioallergosorbent (RAST) test to Aspergillus positive IgG precipitins (not as positive as in aspergilloma) raised IgE

Answer 555

A lytic lesion surrounded by soft tissue swelling against a background or marked ESR elevation, anaemia and low plt count Can be in patients with myeloma

Answer 556

Acute raditation colitis occurs within 60 days of exposure Vs chemo related colitis - more likely to be seen at the time of tx or a few days after

Answer 557

Isoniazid Hydralazine Procainamide Tumour necrosis factor alpha inhibitors Minocyline Quinidine

Answer 558

Single paingul penile ulcer and mekred inguinal lymphadeopathy which may ulcerate H. Ducreyi causes it Tx - signle dose ceftriaxone IM or azithromycin

Answer 559

Macrolide - e.g. erythromycin Safe in pregnancy

Answer 560

Nifedipine

Answer 561

multiple physical SYMPTOMS present for at least 2 years patient refuses to accept reassurance or negative test results

Answer 562

Functional neurological disorder (conversion disorder) typically involves loss of motor or sensory function the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Answer 563

Dissociative disorder dissociation is a process of 'separating off' certain memories from normal consciousness in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

Answer 564

Factitious disorder also known as Munchausen's syndrome the intentional production of physical or psychological symptoms

Answer 565

Malingering fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Answer 566

Cisplatin based chemo

Answer 567

Argatroban

Answer 568

Argatroban

Answer 569

Protamine sulphate

Answer 570

Polycystic kidney disease obstruction of the urianry tract Hydronephrosis

Answer 571

whole body MRI

Answer 572

Usually a transient phenomenon in patients with inferior MI and resolves in minutes and hours after reperfusion intervention This is in contrast to extensive anterior MI where heart block is often permanent.

Answer 573

To prevent re-bound hyperglycaemia on ceasing the IV infusion

Answer 574

Management treatment is supportive e.g. Fluids, blood transfusion and dialysis if required there is no role for antibiotics, despite the preceding diarrhoeal illness in many patients the indications for plasma exchange in HUS are complicated as a general rule plasma exchange is reserved for severe cases of HUS not associated with diarrhoea eculizumab (a C5 inhibitor monoclonal antibody) has evidence of greater efficiency than plasma exchange alone in the treatment of adult atypical HUS ## Footnote If there is neurological deficit plasma exchange

Answer 575

NIV Hyperbaric oxygen should be avoided in patient with COPD

Answer 576

Immunophenothyping

Answer 577

Complete AIS (CAIS) normal female external genitalia short, blind-ending vagina absent uterus and fallopian tubes (due to AMH secretion from Sertoli cells) 'primary amenorrhoea' (typical presentation in adolescence) little or no axillary and pubic hair (androgen-dependent) breast development at puberty (due to aromatisation of testosterone to oestradiol) inguinal/abdominal testes: may present as inguinal hernia in childhood

Answer 578

**Management** high-dose proton pump inhibitor whilst this is commonly used in patients with Barrett's the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited -endoscopic surveillance with biopsies for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years if dysplasia of any grade is identified endoscopic intervention is offered. Options include: radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia endoscopic mucosal resection

Answer 579

Caspofungin 1st line 2nd line -amphotericin

Answer 580

Increases production of thyroid binding globulin and increases the activity of uridine diphosphate glucuronosyltransferase which catalyses the breakdown of thyroid hormone.

Answer 581

a hypoxia inducible factor 1 activator which is a PO treament used for anaemia associated with CKD where iron is replete. It can be used as an alternative to EPO analogues

Answer 582

doxy BD 14 days

Answer 583

Management simple measures: walking, stretching, massaging affected limbs treat any iron deficiency alpha-2-delta ligands (pregabalin or gabapentin) are first-line dopamine agonists (e.g. Pramipexole, ropinirole) were once first-line for RLS, but due to high rates of augmentation and impulse control disorders, gabapentinoids are now preferred.

Answer 584

live attenuated influenza vaccination

Answer 585

pancreatic endocrine tumour which produces vasoactive intestinal peptide There is significant bicarb loss which leads to acidosis somatostatin analogues are of value in managing diarrhoea

Answer 586

excision biospy of lypmh node

Answer 587

can often be seen after PCI Observation only of otherwise stable

Answer 588

α-blockers such as tamsulosin to reduce smooth muscle tone to improve urine flow (for mild-moderate IPSS score) These medications act immediately If unfortunate side effects are experienced, patients may choose to switch to a different drug The next option would be a 5α-reductase inhibitor such as finasteride. These drugs reduce the conversion of testosterone to DHT These medications may take 6-12 months before a therapeutic effect is noted For patients with a severe IPSS score, it may be appropriate to begin combined treatment with both an α-blocker and a 5α-reductase inhibitor

Answer 589

## Footnote Type I: Mild, early, non-immune → continue heparin. Type II: Immune-mediated, delayed, causes thrombosis → stop heparin and switch anticoagulant.

Answer 590

mebendazole

Answer 591

Staph Epidermidis

Answer 592

Uncomplicated falciparum malaria strains resistant to chloroquine are prevalent in certain areas of Asia and Africa the 2010 WHO guidelines recommend artemisinin-based combination therapies (ACTs) as first-line therapy examples include artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine Severe falciparum malaria a parasite counts of more than 2% will usually need parenteral treatment irrespective of clinical state intravenous artesunate is now recommended by WHO in preference to intravenous quinine if parasite count > 10% then exchange transfusion should be considered shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse

Answer 593

Weil's disease should always be considered in high-risk patients with hepatorenal failure Leptospirosis is a blood infection caused by bacteria of the genus Leptospira that can infect humans, dogs, rodents, and many other wild and domesticated animals. Signs and symptoms can range from none to mild to severe.

Answer 594

mild-moderate disease: doxycycline or azithormycin severe disease: IV benzylpencillin

Answer 595

The recommended initial management of otitis externa is: topical antibiotic or a combined topical antibiotic with a steroid if the tympanic membrane is perforated aminoglycosides are traditionally not used* if there is canal debris then consider removal if the canal is extensively swollen then an ear wick is sometimes inserted Second-line options include consider contact dermatitis secondary to neomycin oral antibiotics (flucloxacillin) if the infection is spreading taking a swab inside the ear canal empirical use of an antifungal agent

Answer 596

Use atraumatic LP needles

Answer 597

Causative agent: Borrelia burgdorferi (spread by Ixodes ticks) Pathogenesis: Spirochaete infection triggers immune-mediated inflammation in the nervous system. Timing: Usually develops weeks to months after initial erythema migrans rash. 1️⃣ Peripheral nervous system involvement Cranial nerve palsies, especially bilateral facial (VII) nerve palsy — classic feature Radiculitis / radiculopathy — severe shooting pains, paresthesia, limb weakness Peripheral neuropathy — distal sensory loss or pain 2️⃣ Central nervous system involvement Meningitis (lymphocytic meningitis) Headache, neck stiffness, photophobia Encephalitis or myelitis (rare) Confusion, seizures, ataxia, limb weakness

Answer 598

Anti-NMDA receptor encephalitis is a paraneoplastic syndrome, presenting as prominent psychiatric features including agitation, hallucinations, delusions and disordered thinking; seizures, insomnia, dyskinesias and autonomic instability. Ovarian teratomas are detected in up to half of all female adult patients, particularly prevalent in Afro-Caribbean patients. MRI head can be normal but abnormalities can be visualised on FLAIR sequences in the deep subcortical limbic structures. CSF may demonstrate pleocytosis but can be normal initially. Anti-MuSK is an autoantibody specific to muscle kinase in myasthenia gravis with no evidence of a thymoma and without antibodies to acetylcholine receptors. Anti-GM1 is an autoantibody specific to acute inflammatory demyelinating polyneuropathy (AIDP) variant of Guillain-Barre syndrome. Treatment of anti-NMDA encephalitis is based of immunosuppression with intravenous steroids, immunoglobulins, rituximab, cyclophosphamide or plasma exchange, alone or in combination. Resection of teratoma is also therapeutic.

Answer 599

progressive apoptosis, primarily of rod receptors.

Answer 600

anti-Hu: small cell lung cancer - painful sensory neuropathy, cerebellar syndromes, encephalitis

Answer 601

anti-Yo: ovarian, breast cancer - cerebellar syndrome

Answer 602

anti-Ri: small cell lung cancer - retinal degeneration

Answer 603

Paraneoplastic limbic encephalitis Triggered by tumours, especially: Small-cell lung carcinoma (SCLC) → anti-Hu (ANNA-1) Testicular tumours → anti-Ma2 Thymoma → anti-AMPA receptor Breast or ovarian cancer → anti-Yo or anti-Ri

Answer 604

CSF: lymphocytosis, elevated protein

Answer 605

Renal biopsy demonstrates: electron microscopy: the basement membrane is thickened with subepithelial electron dense deposits. This creates a 'spike and dome' appearance Management all patients should receive an ACE inhibitor or an angiotensin II receptor blocker (ARB): these have been shown to reduce proteinuria and improve prognosis immunosuppression as many patients spontaneously improve only patient with severe or progressive disease require immunosuppression corticosteroids alone have not been shown to be effective. A combination of corticosteroid + another agent such as cyclophosphamide is often used consider anticoagulation for high-risk patients

Answer 606

Causes idiopathic: due to anti-phospholipase A2 antibodies infections: hepatitis B, malaria, syphilis malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia drugs: gold, penicillamine, NSAIDs autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid

Answer 607

GBS - anti-GM1 antibodies in 25% of patients MFS -anti-GQ1b antibodies are present in 90% of cases

Answer 608

Ethylene glycol is a type of alcohol used as a coolant or antifreeze Features of toxicity are divided into 3 stages: Stage 1: symptoms similar to alcohol intoxication: confusion, slurred speech, dizziness Stage 2: metabolic acidosis with high anion gap and high osmolar gap. Also tachycardia, hypertension Stage 3: acute kidney injury ## Footnote tx- - fomepizole

Answer 609

Amantadine

Answer 610

baclofen and gabapentin are first-line. Other options include diazepam, dantrolene and tizanidine physiotherapy is important cannabis and botox are undergoing evaluation

Answer 611

Familial Mediterranean fever Tx with colchicine ## Footnote Features - attacks typically last 1-3 days pyrexia abdominal pain (due to peritonitis) pleurisy pericarditis arthritis erysipeloid rash on lower limbs

Answer 612

There are no precise diagnostic criteria but the following are typically seen hypovolaemia marked hyperglycaemia (>30 mmol/L) significantly raised serum osmolarity (> 320 mosmol/kg) can be calculated by: 2 * Na+ + glucose + urea no significant hyperketonaemia (<3 mmol/L) no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)

Answer 613

Thoracic Society recommending the patient to demonstrate FEV1 >2l/s for pneumonectomy and 1.5l/s for lobectomy. TLCO is similarly recommended to be greater than 40% of predicted for resective surgery1. Forced vital capacity is not demonstrated to be a significant predictor of post-operative outcomes. ## Footnote **Surgery contraindications** assess general health stage IIIb or IV (i.e. metastases present) FEV1 < 1.5 litres is considered a general cut-off point* malignant pleural effusion tumour near hilum vocal cord paralysis SVC obstruction

Answer 614

Latent tuberculosis treatment options: 3 months of isoniazid (with pyridoxine) and rifampicin, or 6 months of isoniazid (with pyridoxine)

Answer 615

Management treat hypertension initial therapy for focal (class III) or diffuse (class IV) lupus nephritis glucocorticoids with either mycophenolate or cyclophosphamide subsequent therapy mycophenolate is generally preferred to azathioprine to decrease the risk of developing end-stage renal disease

Answer 616

This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level. Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow. The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion. Features the result is an unbalanced physiological response, characterised by extreme hypertension flushing and sweating above the level of the cord lesion agitation in untreated cases, severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke. Management of autonomic dysreflexia involves removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia.

Answer 617

methotrexate if this fails - can trial ciclosporin

Answer 618

Posterior reversible encephalopathy syndrome - form uncontrolled HTN

Answer 619

metabolic acidosis with raised anion gap

Answer 620

Heterozygous. LDL >7.5 Homozygous.- LDL >13

Answer 621

raised LDL and triglycerides

Answer 622

cholesterol and triglycerides equally elevated palmar xanthomata and tuberous xanthomata

Answer 623

Azathioprine or mercaptopurine

Answer 624

A gram negative coccobacillus transmitted via undercooked meat it leads to fever muscle pain, abdo pain and diarrhoea Tx - spetrin , gent, 3rd gen cephalosporins

Answer 625

Brucellosis is a zoonosis more common in the Middle East and in farmers, vets and abattoir workers **Notifiable diseae ** **Features** non-specific: fever (often undulant), malaise, night sweats, fatigue hepatosplenomegaly musculoskeletal: arthralgia, sacroiliitis, spondylodiscitis (spinal tenderness may be seen) complications: osteomyelitis, infective endocarditis, meningoencephalitis, orchitis leukopenia and anaemia may be seen **Tx** - first-line: doxycycline (6 weeks) + rifampicin (6 weeks) alternative: doxycycline (6 weeks) + streptomycin (for first 2–3 weeks) in cases where rifampicin is unsuitable prolonged or triple therapy (e.g. with gentamicin) may be required for complicated or focal disease such as spondylitis or endocarditis

Answer 626

likely SCLC

Answer 627

sglt 2 inhinbitors

Answer 628

patients with spinal arthritis are more likely to get peg fracrues to investigate you need anteroposterior, lateral and open mouth neck xrays

Answer 629

Bacillus cereus

Answer 630

Transverse myelitis is a rare neuro-immune condition that causes focal inflammation of the spinal cord. A typical patient presents with acute or subacute symptoms below the level of the lesion, including sensory impairment, motor weakness and bladder or bowel dysfunction Investigations - MR Spine first line LP to confirm the inflammation

Answer 631

azithromycin

Answer 632

25% (Cr can go down 30%)

Answer 633

Features venous/arterial thrombosis recurrent miscarriages livedo reticularis other features: pre-eclampsia, pulmonary hypertension Investigations antibodies anticardiolipin antibodies anti-beta2 glycoprotein I (anti-beta2GPI) antibodies lupus anticoagulant thrombocytopenia prolonged APTT

Answer 634

Basiliximab 2 hours before and 4 days fter surgery

Answer 635

1. - idopathic, heritable, drugs 2. Pulmonary HTN due to left heart disease 3. Pulomanry HTN due to lung disease +/- hypoxia 4. chronic PE 5. unclear cause or multifactorial

Answer 636

Exfoliative toxin A

Answer 637

insulin producing beta cells there will be high cpeptide and high insulin

Answer 638

**Three types** **type I (25%):** monoclonal - IgG or IgM associations: multiple myeloma, Waldenstrom macroglobulinaemia **type II (25%)** mixed monoclonal and polyclonal: usually with rheumatoid factor associations: hepatitis C, rheumatoid arthritis, Sjogren's, lymphoma **type III (50%)** polyclonal: usually with rheumatoid factor associations: rheumatoid arthritis, Sjogren's **Possible features** Raynaud's only seen in type I cutaneous vascular purpura distal ulceration ulceration arthralgia renal involvement diffuse glomerulonephritis **Investigations** low complement (esp. C4) high ESR **Management **treatment of underlying condition e.g. hepatitis C immunosuppression plasmapheresis

Answer 639

Type 1 accounts for 90% of cases cause: cryoglobulinaemia, hepatitis C renal biopsy electron microscopy: subendothelial and mesangium immune deposits of electron-dense material resulting in a 'tram-track' appearance Type 2 - 'dense deposit disease' causes: partial lipodystrophy (patients classically have a loss of subcutaneous tissue from their face), factor H deficiency caused by persistent activation of the alternative complement pathway low circulating levels of C3 C3b nephritic factor is found in 70% an antibody to alternative-pathway C3 convertase (C3bBb) stabilizes C3 convertase renal biopsy electron microscopy: intramembranous immune complex deposits with 'dense deposits'

Answer 640

**Causes**idiopathic: due to anti-phospholipase A2 antibodies infections: hepatitis B, malaria, syphilis malignancy (in 5-20%): prostate, lung, lymphoma, leukaemia drugs: gold, penicillamine, NSAIDs autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid

Answer 641

young patient non smoker recurrent respiratory tract infections and haemoptysis Diarhoea, flushing, palpitaitons

Answer 642

Staph aureus Stap Viridans (poor dental hygiene) Staph epidermidis (indwelling lines) Strep bovis/gallolyticus (colon Ca)

Answer 643

increased risk of bleeding following relatively minor surgical procedures such as tooth extractions and occurs in association wiht autoimmune diseases such as RA

Answer 644

Features vaginal discharge: offensive, yellow/green, frothy vulvovaginitis strawberry cervix pH > 4.5 in men is usually asymptomatic but may cause urethritis Investigation microscopy of a wet mount shows motile trophozoites Management oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

Answer 645

urine and plasma osmolalities followed by water deprivation tesr

Answer 646

Nivolumab (also risk of myocarditis, colitis, hepatitis, pneumonitis)

Answer 647

arthralgia, skin rash and photosensitivity

Answer 648

IV methylpred

Answer 649

raises the posibility of small bowel lymphome MRI of the abdomen should be performed

Answer 650

Myeloproliferative neoplasm with clonal proliferation of myeloid stem cells → bone marrow fibrosis due to cytokines from megakaryocytes (TGF-β, PDGF) Fibrosis and extramedullary haematopoiesis → cytopenias and splenomegaly Fatigue, night sweats, weight loss, bone pain,** massive splenomegaly** Blood film. - teardrop cells Bone morrow biopsy - dry tap JAK2 V617F (50–60%), CALR, MPL mutations Supportive (transfusions, hydroxycarbamide), JAK2 inhibitor (ruxolitinib), splenectomy if severe, allogeneic stem cell transplant = only curative

Answer 651

Ineffective marrow production → cytopenias (esp. anemia) Fatigue, infections, bleeding (due to cytopenias), no splenomegaly (usually) Pallor, petechiae, bruising, infection signs

Answer 652

AL - most common, due to myeloma, waldenstrom's MGUS. features include nephrotic syndorme, cardiac and neurolgical, macroglossia AA amyloid - A for precursor serum amyloid A protein. seen in chronic infection/inflammation - TB, RA ATTR - wild type - elderly ATTR - mutant. familial Heart and peripheral nerves, HFpEF Ab2M - associated with dialysis

Answer 653

Siberian tick typhus From mediterranea spanish coast and in portugal fever and macular rash tc - doxycycline

Answer 654

Erythema chronicum migrans

Answer 655

even though eosinophils are seen in the blood - the biopsy mainly has t lymphocytes and monocytes

Answer 656

They present with diabetes mellitus, venous thrombo-embolism and the classical rash of necrolytic migratory erythema - a red, blistering rash A serum level of glucagon >1000pg/ml usually suggests the diagnosis, imaging with CT scanning is also required. Tx - surgery and ocreotide .

Answer 657

Topical paromomycin

Answer 658

Doxycycline and rifampicin If there is discitis. doxycycline and streptomycin

Answer 659

increased risk of endometrial, ovarian, stomach, small intestine, gall badder and upper urinary tract Cancer , colon.

Answer 660

spiro firstly then add loop diuretic

Answer 661

TB significantly more likely as a cause of the ascites

Answer 662

Levetiracetam

Answer 663

Myc activation

Answer 664

Cutaneous features depigmented 'ash-leaf' spots which fluoresce under UV light roughened patches of skin over lumbar spine (Shagreen patches) adenoma sebaceum (angiofibromas): butterfly distribution over nose fibromata beneath nails (subungual fibromata) cafe-au-lait spots* may be seen Neurological features developmental delay epilepsy (infantile spasms or partial) intellectual impairment Also retinal hamartomas: dense white areas on retina (phakomata) rhabdomyomas of the heart gliomatous changes can occur in the brain lesions polycystic kidneys, renal angiomyolipomata lymphangioleiomyomatosis: multiple lung cysts

Answer 665

potassium channel inhibition

Answer 666

This syndrome represents a specific form of pneumoconiosis that occurs in individuals with rheumatoid arthritis who have been exposed to coal dust or silica. The key features are the presence of multiple, well-defined nodules (typically 0.5-5 cm in diameter) that may cavitate, predominantly affecting the upper and middle lung zones.

Answer 667

Clinical features pruritus urticaria Calabar swellings: transient, non-erythematous, hot swelling of soft-tissue around joints 'eye worm' - the dramatic presentation of subconjunctival migration of the adult worm.

Answer 668

EMA binding test

Answer 669

yes it is not an absolute contraindication and should be considered where the benefits outweigh the risks

Answer 670

Ciclosporin Tacrolimus Sirolimus Phenytoin Sodium valproatee CCB (nifedipine and amlidpine)

Answer 671

Epithelial sodium channel mutation

Answer 672

SNRI and SSRI

Answer 673

predominant efferent glomerular arteriolar dilation. this leads to reduced glomerular pressure which is thought to be renoprotective

Answer 674

macrolide. Erythromycin

Answer 675

Doxycycline and hydroxychloroquine

Answer 676

Bats are the correct answer. This man has evidence of viral haemorrhagic fever (VHF) with hypotension and multi-organ dysfunction. He has returned from a region where Marburg virus has previously been found. Additionally, he has been taking photos of neolithic wall paintings, which are typically found in caves. Exposure to bats and caves are risk factors for Marburg virus.

Answer 677

Gram positive bacilli

Answer 678

ever, sweats, rigors massive splenomegaly. hepatomegaly poor appetite*, weight loss occasionally patients may report increased appetite with paradoxical weight loss grey skin - 'kala-azar' means black sickness pancytopaenia secondary to hypersplenism

Answer 679

nephrogenic diabetes insipidus thiazides low salt/protein diet central diabetes insipidus can be treated with desmopressin

Answer 680

Nephrogenic

Answer 681

induction of labour at 37-38 weeks is common practice but may not be evidence based ursodeoxycholic acid - again widely used but evidence base not clear vitamin K supplementation

Answer 682

From thyroid C cells; ↓ osteoclast activity, ↓ renal Ca reabsorption Decreases serum calcium Decreases bone resorption

Answer 683

Calcimimetic; increases sensitivity of Ca-sensing receptor on parathyroid → ↓ PTH secretion ↓ serum Ca & ↓ PTH ↓ bone resorption secondary to ↓ PTHman ## Footnote Used to treat terttiary hyperparathyroidism

Answer 684

patient thinks they are dead

Answer 685

When people think a random person is someone they know

Answer 686

a patient thinks someone they know has been relpaced by an imposter

Answer 687

Trimethorprim ## Footnote Nitro should not be used at an eGFR of 15-30

Answer 688

Treatment general (ABC, charcoal) urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine haemodialysis Indications for haemodialysis in salicylate overdose serum concentration > 700mg/L metabolic acidosis resistant to treatment acute renal failure pulmonary oedema seizures coma

Answer 689

spinal cord hemisection Ipsilateral spastic paresis, loss of proprioception and vibration contralateral loss of pain an temp

Answer 690

b12 and Vit E deficiency 1. Bilateral spastic paresis 2. Bilateral loss of proprioception and vibration sensation 3. Bilateral limb ataxia

Answer 691

1. Bilateral spastic paresis 2. Bilateral loss of pain and temperature sensation

Answer 692

Pramipexole, Ropinirole, Rotigotine patch, Apomorphine injection/infusion) Can be used in younger patients to delay levodopa initiation, or added when “wearing-off.” Apomorphine: rescue therapy for “off” periods. Side effects: Nausea, somnolence Impulse control disorders (gambling, hypersexuality, binge eating) Hallucinations, confusion Peripheral oedema

Answer 693

(e.g. Selegiline, Rasagiline, Safinamide) Inhibit dopamine breakdown → prolong effect. Useful in early disease or as adjunct to levodopa. May delay need for levodopa start. Side effects: Insomnia, confusion Hypertensive crisis if combined with tyramine (rare) Serotonin syndrome risk with SSRIs

Answer 694

(e.g. Entacapone, Opicapone, Tolcapone) Prolong levodopa half-life — used in “end-of-dose” wearing-off. Always given with levodopa. Side effects: Diarrhoea Orange urine Hepatotoxicity (Tolcapone)

Answer 695

Mild symptomatic benefit (↑ dopamine release, ↓ reuptake). Can reduce levodopa-induced dyskinesia. Side effects: Livedo reticularis Ankle oedema Confusion, hallucinationsp

Answer 696

⚖️ 1️⃣ Trachea PULLED TOWARDS the lesion → Due to volume loss or negative intrathoracic pressure on that side. Causes: Lung collapse (atelectasis) Fibrosis Pneumonectomy (post-surgical) Upper lobe collapse (especially from tumour or mucus plug) 🩻 Mechanism: loss of lung volume → vacuum effect → trachea shifts toward affected side. 💨 2️⃣ Trachea PUSHED AWAY from the lesion → Due to increased pressure or volume on one side. Causes: Tension pneumothorax 🚨 (most important emergency cause) Massive pleural effusion Large thoracic mass / tumour Empyema (if large) 🩻 Mechanism: pressure buildup pushes trachea away from the affected side.

Answer 697

Viral infections (HIV, hepatitis, mononucleosis) Lupus (SLE, antiphospholipid) Autoimmune disease Pregnancy Senescence (old age)

Answer 698

🧫 Syphilis Serology – Key Points 🧠 Two main categories of tests: Type Examples What they detect Use 1️⃣ Non-treponemal tests **VDRL, RPR ** Screening, monitoring response to treatment 2️⃣ Treponemal tests **TPHA, FTA-ABS, EIA/TPPA ** Antibodies against Treponema pallidum Confirm diagnosis (specific) ## Footnote 🧮 Monitoring after treatment Use VDRL/RPR titres (not TPHA) — these fall with successful therapy. A fourfold drop (e.g. 1:32 → 1:8) = adequate response Persistently high or rising = treatment failure or reinfection

Answer 699

**Generalised tonic-clonic seizures** lamotrigine or levetiracetam **Focal seizures** first line: lamotrigine or levetiracetam second line: carbamazepine, oxcarbazepine or zonisamide **Absence seizures (Petit mal)** first line: ethosuximide second line: lamotrigine or levetiracetam carbamazepine may exacerbate absence seizures **Myoclonic seizures** first-line: levetiracetam second line: lamotrigine **Tonic or atonic seizures** first-line: lamotrigine second line: clobazam, rufinamide, or topiramate

Answer 700

Alkaptonuria (ochronosis) is a rare autosomal recessive disorder of phenylalanine and tyrosine metabolism caused by a lack of the enzyme homogentisic dioxygenase (HGD) which results in a build-up of toxic homogentisic acid. The kidneys filter the homogentisic acid (hence black urine) but eventually it accumulates in cartilage and other tissues. Alkaptonuria is generally a benign and often asymptomatic condition. Possible features include: pigmented sclera urine turns black if left exposed to the air intervertebral disc calcification may result in back pain renal stones

Answer 701

think lymes disease

Answer 702

Zidovudine

Answer 703

FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG) are useful investigations raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis prolactin may be normal or mildly elevated testosterone may be normal or mildly elevated - however, if markedly raised consider other causes SHBG is normal to low in women with PCOS

Answer 704

Classically onion skin

Answer 705

(na + k) - (bicarb + chloride) Normal gap between 8 and 16

Answer 706

drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

Answer 707

Frontal – Fencing posture Temporal – Taste/smell aura, automatisms Occipital – Ocular (visual) symptoms Parietal – Pins & needles (sensory)

Answer 708

Candesartan

Answer 709

Short RBC life (haemolysis, blood loss, transfusion, dialysis ) → false low Long RBC life (iron/B12/folate deficiency) → false high ## Footnote anything that prolongs RBC life or interferes with the assay → false ↑ HbA1c. anything that reduces RBC lifespan or introduces new RBCs → false ↓ HbA1c.

Answer 710

happens follwoing haematopoietic stem cell transplant usually within 12 days of transplant weight gain, painful hepatomegaly, ascites and jaundice Diagnoiss : liver biopsy

Answer 711

Sarcoidosis

Answer 712

Histoplasmosis is due to the fungus Histoplasma capsulatum. It is most commonly encountered in the Mississippi and Ohio River valleys. Features URTI symptoms retrosternal pain Management amphotericin or itraconazole are the pharmacological agents of choice for histoplasmosis

Answer 713

medications that inhibits the p450 system

Answer 714

Caplan syndrome, also known as rheumatoid pneumoconiosis, is a condition caused by occupational exposure to dust like coal, silica, or asbestos, which leads to both lung nodules and rheumatoid arthritis.

Answer 715

chest drain

Answer 716

t is an autosomal recessive, trinucleotide repeat disorder characterised by a GAA repeat in the X25 gene on chromosome 9 (frataxin).

Answer 717

Ataxia telangiectasia is an autosomal recessive disorder caused by a defect in the ATM gene which encodes for DNA repair enzymes.

Answer 718

continue aspirin stop clopi

Answer 719

Cystinuria is an autosomal recessive disorder characterised by the formation of recurrent renal stones. It is due to a defect in the membrane transport of cystine, ornithine, lysine, arginine (mnemonic = COLA) Genetics chromosome 2: SLC3A1 gene, chromosome 19: SLC7A9 Features recurrent renal stones are classically yellow and crystalline, appearing semi-opaque on x-ray Diagnosis cyanide-nitroprusside test Management hydration D-penicillamine urinary alkalinization

Answer 720

Macrolide (erythromycin) If allerigc can have a quinolone - ciprofloxacin

Answer 721

Libman–Sacks endocarditis is a form of non-bacterial endocarditis that is seen in association with systemic lupus erythematosus, antiphospholipid syndrome, and malignancies.

Answer 722

High calorie and high fat

Answer 723

The following drugs may exacerbate myasthenia: penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Answer 724

middle meningeal artery

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