1
Q
How does L4 nerve root compression manifest?
A
- Sensory loss anterior aspect of knee
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
2
Q
How does L3 nerve root compression manifest?
A
- Sensory loss over anterior thigh
- Weak quadriceps
- Reduced knee reflex
- Positive femoral stretch test
3
Q
How does L5 nerve root compression manifest?
A
- Sensory loss dorsum of foot
- Weakness in foot and big toe dorsiflexion
- Reflexes intact
- Positive sciatic nerve stretch
4
Q
How does S1 nerve root compression manifest?
A
- Sensory loss posterolateral aspect of leg and lateral aspect of foot
- Weakness in plantar flexion of foot
- Reduced ankle reflex
- Positive sciatic nerve stretch test
5
Q
What urinary marker may be used to diagnose Paget’s disease?
A
Elevated urinary hydroxyproline
6
Q
List some commonly used steroid creams in order of strength.
A
- Mild: Hydrocortisone 0.5-2.5%
- Moderate: Betamethasone valerate 0.025%, Clobetasone butyrate 0.05%
- Potent: Fluticasone propionate 0.05%, Betamethasone valerate 0.1%
- Very potent: Clobetasol propionate 0.05%
7
Q
Which drugs cause liver toxicity with a hepatocellular picture?
A
- Paracetamol
- Sodium valproate, phenytoin
- MAOIs
- Halothane
- Anti-tuberculosis: isoniazid, rifampicin, Pyrazinamide
- Statins
- Alcohol
- Amiodarone
- Methyldopa
- Nitrofurantoin
8
Q
List some Gram-negative rods.
A
- Escherichia coli
- Haemophilus influenzae
- Pseudomonas aeruginosa
- Salmonella sp.
- Shigella sp.
- Campylobacter jejuni
9
Q
What are the BMI cut offs for bariatric surgery recommended by NICE?
A
- With risk factors (T2DM, BP etc): > 35 kg/m^2
- No risk factors: > 40 kg/m^2
10
Q
List some features of Charcot-Marie-Tooth disease.
A
- There may be a history of frequently sprained ankles
- Foot drop
- High-arched feet (pes cavus)
- Hammer toes
- Distal muscle weakness
- Distal muscle atrophy
- Hyporeflexia
- Stork leg deformity
11
Q
Outline the driving rules for people with epilepsy.
A
- First unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months.
- For patients with established epilepsy or those with multiple unprovoked seizures: may qualify for a driving licence if they have been free from any seizure for 12 months. If there have been no seizures for 5 years (with medication if necessary) a ’til 70 licence is usually restored.
Withdrawal of epilepsy medication: should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose.
12
Q
Outline the driving rules after a syncopal episode.
A
- Simple faint: no restriction
- Single episode, explained and treated: 4 weeks off
- Single episode, unexplained: 6 months off
- Two or more episodes: 12 months off
13
Q
Outline driving rules for people with neurological conditions.
(e.g., stroke, TIA)
A
- Stroke/TIA: 1 month off driving; no need to inform DVLA if no residual deficits.
- Multiple TIAs: 3 months off driving; inform DVLA.
- Craniotomy (e.g., meningioma): 1 year off driving.
- Pituitary tumor: 6 months off after craniotomy; can drive when no impairments affect safety.
- Narcolepsy/cataplexy: cease driving on diagnosis; can resume with satisfactory symptom control.
- Chronic neurological disorders (e.g., multiple sclerosis, motor neuron disease): inform DVLA and complete PK1 form.
14
Q
How is Meniere’s disease managed?
A
- Acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
- Prevention: betahistine and vestibular rehabilitation exercises may be of benefit
15
Q
Which Parkinson’s medication can cause pulmonary fibrosis?
A
Pergolide
16
Q
How are oculogyric crises treated?
A
Intravenous antimuscarinic: benztropine or procyclidine
17
Q
Describe the manifestations of a cavernous sinus thrombus.
A
- Ophthalmoplegia: 6th nerve damage occurs before 3rd & 4th.
- Trigeminal nerve involvement may cause hyperaesthesia of the upper face and eye pain.
- Central retinal vein thrombosis
Other causes of cavernous sinus syndrome: local infection (e.g., sinusitis), neoplasia, trauma, periorbital edema.
18
Q
What is the Mann Whitney U test used for?
A
Compares ordinal, interval, or ratio scales of unpaired data.
19
Q
What is the most accurate way of assessing left ventricular function before starting a patient on cardiotoxic drugs?
A
MUGA
(Multi Gated Acquisition Scan)
Also known as radionuclide angiography.
20
Q
How are beta-blocker overdoses managed?
A
If bradycardic, then atropine; in resistant cases glucagon may be used.
21
Q
Which investigation should be requested in people with suspected restless leg syndrome?
A
Ferritin to exclude iron deficiency anaemia.
22
Q
Outline the driving rules following a cardiac intervention.
A
Elective angioplasty (PCI)
→ No driving for 1 week
Coronary artery bypass graft (CABG)
→ No driving for 4 weeks
Acute coronary syndrome (ACS)
→ No driving for 4 weeks
→ If successfully treated with angioplasty: 1 week
Angina
→ Must stop driving if symptoms occur at rest or while driving
Pacemaker insertion
→ No driving for 1 week
Implantable cardioverter-defibrillator (ICD)
For sustained ventricular arrhythmia
→ No driving for 6 months
Prophylactic insertion
→ No driving for 1 month
Permanent ban for Group 2 drivers
Successful catheter ablation
→ No driving for 2 days
Aortic Aneurysm
≥ 6.0 cm
→ Must notify DVLA
→ Licence allowed with annual review
≥ 6.5 cm
→ Disqualified from driving
Heart transplant
→ No driving for 6 weeks
→ No need to notify DVLA
23
Q
By how much should opioid doses be increased if pain is not controlled in palliative patients?
A
30-50%
24
Q
What is the equation for likelihood ratio?
A
Likelihood ratio for a positive test result = sensitivity / (1 - specificity).
25
How does **mercury poisoning** present?
Visual field defects, hearing loss and paraesthesia.
26
What is the most common cause of **tinea capitis** in the UK?
Trichophyton tonsurans
27
What is **Castleman's disease**?
**Lymphoproliferative disorder** associated in a subset of cases with HIV and HHV-8.
## Footnote
Patients with unicentric Castleman's disease tend to be asymptomatic and lymphadenopathy is constrained to one lymph node group.
28
List common **trinucleotide repeat disorders**.
* **CAG**: Huntington's disease
* **GAA**: Friedrich Ataxia
* **CTG**: Myotonic dystrophy
* **CGG**: Fragile X syndrome
29
What is **pseudohypoparathyroidism**?
* Target cell insensitivity to PTH
* Short fourth and fifth metacarpals
* Short stature
* Cognitive impairment
* Obesity
* Round face
30
Which **antiepileptic** can cause complications in newborn babies?
**Phenytoin** induces vitamin K metabolism, which can cause a relative vitamin K deficiency, creating the potential for haemorrhagic disease of the newborn.
31
How does **ADEM** manifest?
* After a lag time of between a few days to 2 months, there is an acute onset of **multifocal neurological symptoms** with **rapid deterioration**. Non-specific signs such as headache, fever, nausea and vomiting may also accompany the onset of illness.
* **Motor and sensory deficits** are frequent and there may also be brainstem involvement including oculomotor defects.
32
Which **renal disease** is **coeliac disease** associated with?
IgA nephropathy
33
How does **spinal stenosis** present?
Gradual onset **leg and back pain**, **weakness** and **numbness** which is brought on by walking (with a normal clinical examination).
34
Which cells secrete **CCK**?
I cells
35
How does **cystinuria** manifest?
* Recurrent renal stones
* Diagnosed using the cyanide-nitroprusside test
36
What are the **differences** between wet and dry **beri beri**?
* **Wet**: heart failure
* **Dry**: peripheral neuropathy
37
What are the main treatments for **spasticity** in **multiple sclerosis**?
* Baclofen
* Gabapentin
38
List some causes of an abnormal **second heart sound**.
* **Loud**: hypertension
* **Soft**: AS
* **Fixed split**: ASD
* **Reversed split**: LBBB
39
What is **alkaptonuria**?
**Autosomal recessive disorder** that is a result of a deficiency of homogentisic acid dioxygenase leading to elevated levels of homogentisic acid (HGA).
## Footnote
Clinically features include brown/bluish pigment of the ear cartilage or sclera, arthropathy, renal stones, cardiac valve involvement and coronary calcification. Urine turns dark on standing.
40
What is the treatment of choice for **ABPA**?
Oral Steroids
41
Which condition is associated with **anti-NMDA receptor encephalitis**?
Ovarian teratoma
42
What is **Bombesin**?
Tumour marker for small cell lung cancer.
43
What are the features of **Alport syndrome**?
* Microscopic haematuria
* Progressive renal failure
* Bilateral sensorineural deafness
* Lenticonus
* Retinitis pigmentosa
* Renal biopsy: splitting of lamina densa seen on electron microscopy
## Footnote
Caused by **X-linked dominant** mutation in type IV collagen.
44
Which **cardiac changes** may be seen in a patient with **Carcinoid syndrome**?
* Tricuspid insufficiency
* Pulmonary stenosis
45
Which **antiemetics** are recommended for motion sickness?
Hyoscine > Cyclizine > Promethazine
46
Which **rheumatoid arthritis drugs** are safe to use in pregnancy?
* Hydroxychloroquine
* Sulfasalazine
47
What are the stages of **hypertensive retinopathy**?
* **I** Arteriolar narrowing and tortuosity
* Increased light reflex - silver wiring
* **II** Arteriovenous nipping
* **III** Cotton-wool exudates
* Flame and blot haemorrhages
* **IV** Papilloedema
48
What are some common complications of **seborrhoeic dermatitis**?
* Otitis externa
* Blepharitis
49
Which **pulse abnormality** is seen in severe left ventricular failure?
Pulsus alternans
50
What causes **pulsus bisferiens**?
Mixed aortic valve disease
51
What causes **pityriasis rosea**?
HHV6 and HHV7
52
What underlying condition is associated with **warfarin necrosis**?
Acquired protein C deficiency
53
What is **sideroblastic anaemia** and list some causes.
Red cells fail to completely form **haem**. This leads to deposits of iron in the mitochondria that form a ring around the nucleus called a **ring sideroblast**.
Causes:
* **Congenital**: delta-aminolevulinate synthase-2 deficiency
* **Acquired**: myelodysplasia, alcohol, lead, anti-TB medications
## Footnote
Treated with pyridoxine.
54
How is **schistosomiasis** treated?
Praziquantel
55
List some causes of **normal anion gap metabolic acidosis**.
* Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
* Renal tubular acidosis
* Drugs: e.g. acetazolamide
* Ammonium chloride injection
* Addison's disease
56
List some causes of **raised anion gap metabolic acidosis**.
* **Lactate**: shock, sepsis, hypoxia
* **Ketones**: diabetic ketoacidosis, alcohol
* **Urate**: renal failure
* **Exogenous acids**: salicylates, methanol
57
What are the stages of **diabetic nephropathy**?
1. Hyperfiltration
2. Silent or Latent (GFR remains elevated)
3. Incipient nephropathy (microalbuminuria)
4. Overt nephropathy (persistent proteinuria, hypertension, diffuse glomerulosclerosis with focal glomerulosclerosis (Kimmelstiel-Wilson nodules)
5. ESRF
58
What can reduce the formation of **oxalate stones**?
* Pyridoxine
* Cholestyramine
59
How do **frontal lobe lesions** manifest?
* Expressive (Broca's) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting
* Disinhibition
* Perseveration
* Anosmia
* Inability to plan
60
How is **Meniere's disease** treated?
* **Acute Attack**: Prochlorperazine
* **Prevention**: Betahistine and vestibular rehabilitation exercises
61
What are the most common causes of **viral myocarditis**?
* Parvovirus B19
* HHV6
62
What is **dysbetalipoproteinaemia** and how is it treated?
Mixed **hyperlipidaemia** (raised cholesterol and triglyceride levels). Treated with **fibrates**.
63
List a cause of **upbeat** and **downbeat nystagmus**.
* **Upbeat**: Cerebellar Vermis Lesion
* **Downbeat**: Arnold Chiari Malformation
64
What is the conversion ratio of oral morphine to parenteral **diamorphine**?
3:1
65
List some conditions that are associated with **pseudogout**.
* Haemochromatosis
* Hyperparathyroidism
* Low magnesium, low phosphate
* Acromegaly, Wilson's disease
66
Which chromosomes are the **globin genes** on?
* **Alpha**: 16
* **Beta**: 11
67
Which type of **collagen** is most commonly affected in **Ehlers-Danlos syndrome**?
Type 3
68
List the indications for **parathyroidectomy** in **hyperparathyroidism**.
* Age under 50 years
* Adjusted serum calcium concentration that is 0.25 mmol/L or more above the upper end of the reference range.
* Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 although this threshold depends on other factors, such as age.
* Renal stones or presence of nephrocalcinosis on ultrasound or CT.
* Presence of osteoporosis or osteoporotic fracture.
* Symptomatic disease
69
List some side-effects of **ivabradine**.
* Visual effects (luminous phenomena)
* Headache
* Bradycardia, heart block
## Footnote
It acts on the funny channel and reduces the cardiac pacemaker activity.
70
Outline the management guidelines for **chronic plaque psoriasis**.
* **First line**: potent corticosteroid applied once daily plus vitamin D analogue applied once daily should be applied separately, one in the morning and the other in the evening)
for up to 4 weeks as initial treatment.
* **Second line**: if no improvement after 8 weeks then offer a vitamin D analogue twice daily.
* **Third line**: if no improvement after 8-12 weeks then offer either:
* a potent corticosteroid applied twice daily for up to 4 weeks, or
* a coal tar preparation applied once or twice daily
* short-acting dithranol can also be used.
71
What are the following **antibodies** associated with in the context of **paraneoplastic syndromes**?
* Anti-Hu
* Anti-Yo
* Anti-GAD
* Anti-Ri
* Purkinje Cell Antibody
* **Anti-Hu**: small cell lung cancer and neuroblastomas, sensory neuropathy (may be painful), cerebellar syndrome, encephalomyelitis
* **Anti-Yo**: ovarian and breast cancer, cerebellar syndrome
* **Anti-GAD**: breast, colorectal and small cell lung cancer, stiff person's syndrome or diffuse hypertonia
* **Anti-Ri**: breast and small cell lung cancer, ocular opsoclonus-myoclonus
* **Purkinje Cell Antibody**: peripheral neuropathy in breast cancer
72
How should **listeria meningitis** be treated?
Ceftriaxone + amoxicillin + gentamicin
73
Outline the diagnostic criteria for **neuromyelitis optica**.
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
74
How does **methanol poisoning** present?
Causes both the effects associated with **alcohol** (intoxication, nausea, etc.) and also specific visual problems, including **blindness**.
## Footnote
Treated with fomepizole or ethanol, haemodialysis and cofactor therapy with folinic acid to reduce ophthalmoplegic complications.
75
How should **acute chest syndrome** in **sickle cell disease** be managed?
* Oxygen therapy to maintain saturations > 95%
* Intravenous fluids to ensure euvolaemia
* Adequate pain relief
* Incentive spirometry in all patients presenting with rib or chest pain
* Antibiotics with cover for atypical organisms
* Early consultation with the critical care team and haematology
76
Which cells produce **IL1** and what does it do?
**Macrophages** --> acute inflammation, induced fever.
77
Which cells produce **IL2** and what does it do?
**Th1 cells** --> stimulates growth and differentiation of **T cell** response.
78
Which cells produce **IL3** and what does it do?
**Activated T helper cells** --> stimulates differentiation and proliferation of **myeloid progenitor cells**.
79
Which cells produce **IL4** and what does it do?
**Th2 cells** --> stimulates differentiation and proliferation of **B cells**.
80
Which cells produce **IL5** and what does it do?
**Th2 cells** --> stimulates production of **eosinophils**.
81
Which cells produce **IL6** and what does it do?
**Macrophages, Th2 cells** --> stimulates differentiation of **B cells**, induced **fever**.
82
Which cells produce **IL8** and what does it do?
**Macrophages** --> neutrophil **chemotaxis**.
83
Which cells produce **IL10** and what does it do?
**Th2 cells** --> inhibits **Th1 cytokine** production (anti-inflammatory cytokine).
84
Which cells produce **IL12** and what does it do?
**Dendritic** cells, **macrophages**, **B cells** --> activates **NK cells** and stimulates production of **Th1 cells**.
85
What is an **Argyll-Robertson pupil**?
Features:
* Small, irregular pupils
* No response to light but there is an accommodation reflex
Causes:
* Diabetes mellitus
* Syphilis
86
What are the indications for stopping an **exercise tolerance test**?
* Exhaustion / patient request
* 'Severe', 'limiting' chest pain
* > 3mm ST depression
* > 2mm ST elevation.
Stop if rapid ST elevation and pain
* Systolic blood pressure > 230 mmHg
* Systolic blood pressure falling > 20 mmHg
* Attainment of maximum predicted heart rate
* Heart rate falling > 20% of starting rate
* Arrhythmia develops
87
How is **serotonin syndrome** managed?
* IV fluids
* Benzodiazepines
* Cyproheptadine (in severe cases blocks H1 receptors and serotonin receptors)
88
What is **multifocal atrial tachycardia**?
**Irregular cardiac rhythm** caused by at least three different sites in the atria, which may be demonstrated by morphologically distinctive P waves. It is more common in elderly patients with chronic lung disease, for example COPD.
## Footnote
Management:
* correction of hypoxia and electrolyte disturbances
* rate-limiting calcium channel blockers are often used first-line
* cardioversion and digoxin are not useful in the management of MAT
89
Which causes of **hyperlipidaemia** primarily cause hypercholesterolaemia rather than hypertriglyceridaemia?
* Nephrotic syndrome
* Cholestasis
* Hypothyroidism
90
How is **tetanus** managed?
* IM Tetanus Immunoglobulin
* IV Metronidazole
91
What are some cardiac complications of **donepezil**?
Bradycardia and AV node block
92
Which **cell surface antigen** is found on **Reed-Sternberg cells**?
CD15
93
How does **quinine toxicity** present?
* ECG changes
* Hypotension
* Metabolic acidosis
* Hypoglycaemia
* Tinnitus
* Flushing
* Visual disturbances
* Flash pulmonary oedema may occur
94
What is the first-line treatment option for **Lyme disease** with **CNS involvement** (e.g. Bell's palsy)?
IV Ceftriaxone
95
What are the main features of **Langerhans cell histiocytosis**?
* Bone pain (usually skull or proximal femur)
* Cutaneous nodules
* Recurrent otitis media/mastoiditis
* Tennis racket-shaped Birbeck granules on electron microscopy
96
What ECG feature is seen in **aortic root abscesses**?
Prolonged PR interval
97
How is **Adult-onset Still's disease** treated?
* NSAIDs (first-line for fever, joint pain and serositis)
* Steroids
* Methotrexate, IL-1 (anakinra) or anti-TNF
98
What is **Foster-Kennedy syndrome**?
When a **frontal lobe tumour** leads to **ipsilateral optic atrophy** and **contralateral papilloedema**
99
What advice should you provide to someone who is on **metformin** for diabetes and is planning on fasting for Ramadan?
* **One-third** of normal dose **before sunrise**
* **Two-thirds** of normal dose **after sunset**
100
What is the main pharmacological effect of **ketamine**?
NMDA receptor antagonist
101
What investigation findings might you see in **lead poisoning**?
* Raised serum lead concentration
* Microcytic anaemia with basophilic stippling
* Raised serum and urine delta aminolaevulinic acid
* Raised urinary coproporphyrin
102
What immunofluorescence **pattern** is seen in **bullous pemphigoid**?
Immunofluorescence shows IgG and C3 at the **dermoepidermal junction**.
103
What are the main features of **Yellow Nail Syndrome**?
* Congenital lymphoedema
* Bronchiectasis
* Chronic sinusitis
* Pleural effusions
104
List some causes of **left axis deviation**.
* Left anterior hemiblock
* Left bundle branch block
* Inferior myocardial infarction
* Wolff-Parkinson-White syndrome- right-sided accessory pathway
* Hyperkalaemia
* Congenital: ostium primum ASD, tricuspid atresia
* Minor LAD in obese people
105
List some causes of **right axis deviation**.
* Right ventricular hypertrophy
* Left posterior hemiblock
* Lateral myocardial infarction
* Chronic lung disease → cor pulmonale
* Pulmonary embolism
* Ostium secundum ASD
* Wolff-Parkinson-White syndrome- left-sided accessory pathway
* Normal in infant < 1 years old
* Minor RAD in tall people
106
Which two **tests** are used to assess **correlation** in data?
1. **Parametric** (normally distributed): Pearson's coefficient
2. **Non-parametric**: Spearman's coefficient
107
What is **Beckwith-Wiedemann syndrome**?
**Inherited condition** associated with organomegaly, macroglossia, abdominal wall defects, Wilms' tumour and neonatal hypoglycaemia.
108
How is **thyroid storm** managed?
* Symptomatic treatment (e.g. paracetamol)
* Treatment of underlying precipitating event
* Beta-blockers: typically IV propranolol
* Anti-thyroid drugs (e.g. propylthiouracil)
* Lugol's iodine
* Dexamethasone (blocks the conversion of T4 to T3)
109
At what **dose and duration** of prednisolone is the risk of osteoporosis thought to significantly increase, warranting bisphosphonate treatment?
Equivalent of **prednisolone** 7.5mg a day for 3 or more months.
110
Which group of patients with **type 1 diabetes mellitus** should be offered atorvastatin 20 mg OD?
* Older than 40 years, or
* have had diabetes for more than 10 years or
* have established nephropathy or
* have other CVD risk factors
111
What **target** should be achieved at follow-up for a patient on statins?
Repeat a **full lipid profile**. If non-HDL cholesterol hasn't decreased by at least **40%**, discuss concordance and lifestyle changes. NICE recommends considering **atorvastatin** dose increase to **80 mg**.
112
How do you check if **thrombolysis** for a STEMI is effective?
Perform an ECG **90 minutes** post-thrombolysis to assess for > **50%** ST elevation resolution:
* If inadequate, rescue PCI is superior to **repeat thrombolysis**.
* For patients successfully treated, **thrombolysis PCI** is beneficial; optimal timing is under investigation.
113
What is **anti-synthetase syndrome**?
Combination of **proximal myopathy** and **mechanic's hands**.
114
How does **terbinafine** work?
Inhibits **squalene epoxidase** thereby inhibiting the production of ergosterol.
115
How do **azoles** (e.g. fluconazole) work?
Inhibits **14a-demethylase** which produces **ergosterol**.
116
How does **griseofulvin** work?
Interacts with microtubules to disrupt the **mitotic spindle**.
117
How does **flucytosine** work?
Converted by cytosine deaminase to **5-fluorouracil**, which inhibits **thymidylate synthase** and disrupts fungal protein synthesis.
118
How does **caspofungin** work?
Inhibits synthesis of **beta-glucan**, a major fungal cell wall component.
119
How does **nystatin** work?
Binds with **ergosterol** forming a transmembrane channel that leads to monovalent ion (K+, Na+, H+ and Cl) leakage.
120
What does **alemtuzumab** target and what is its use?
* Targets **CD52**
* Used for **chronic lymphocytic leukaemia** (CLL)
121
What does **OKT3** target and what is its use?
* Targets **CD3**
* Used to prevent organ rejection
122
What is a **leukaemoid reaction**?
Presence of **immature cells** like myeloblasts, promyelocytes, and nucleated red cells in peripheral blood. This may result from **bone marrow infiltration** or sudden demand for new cells.
## Footnote
Causes include severe infection, hemolysis, massive hemorrhage, and metastatic cancer with bone marrow infiltration.
123
How can a **leukaemoid reaction** be differentiated from **chronic myeloid leukaemia**?
* High leucocyte alkaline phosphatase score
* Toxic granulation (Dohle bodies) in white cells
* 'Left shift' of neutrophils (3 or fewer nuclear segments)
124
What is used to treat **adrenaline-induced ischaemia**?
Phentolamine
125
A lesion in which part of the **brain** would cause alexia without agraphia?
Corpus callosum
126
How is **eosinophilic oesophagitis** managed?
* Dietary modification (e.g. elemental diet)
* Topical steroids (e.g. fluticasone)
* Oesophageal dilatation
127
What is the mechanism of action of **5-FU**?
**Pyrimidine analogue** inducing cell cycle arrest and apoptosis by blocking **thymidylate synthase** (works during **S phase**).
128
What is the mechanism of action of **6-mercaptopurine**?
**Purine analogue** that is activated by **HGPRTase**, decreasing purine synthesis.
129
What is the mechanism of action of **cytarabine**?
Pyrimidine antagonist. Interferes with DNA synthesis specifically at the **S-phase** of the cell cycle and inhibits **DNA polymerase**.
130
What is the mechanism of action of **cisplatin**?
Causes **DNA cross-linking**, inhibiting replication.
131
What is the mechanism of action of **hydroxyurea**?
Inhibits **ribonucleotide reductase**, decreasing DNA synthesis.
132
What can be used to accelerate clearance of **guttate psoriasis**?
UV B
133
What is **Loeffler syndrome**?
Transient CXR shadowing and eosinophilia due to parasites like **Ascaris lumbricoides** causing an alveolar reaction.
## Footnote
Presents with fever, cough, and night sweats lasting less than 2 weeks.
Generally self-limiting.
134
Which **investigations** are used for **age-related macular degeneration**?
**First-Line**: Slit lamp microscopy
* Fluorescein angiography if neovascular ARMD suspected
* Optical coherence tomography
135
Outline the latest **NICE guidelines** for **thrombolysis** and **thrombectomy**.
Offer **thrombectomy with thrombolysis** for patients with confirmed **proximal anterior circulation occlusion** on imaging.
NICE recommends a modified Rankin score of **less than 3** and a National Institutes of Health Stroke Scale (NIHSS) score **greater than 5** for selecting patients for **mechanical thrombectomy**.
136
How is **acute angle closure glaucoma** treated?
* **Eye drops** (e.g., pilocarpine, timolol, apraclonidine)
* **IV acetazolamide**
137
What is **Leiner disease**?
Rare and serious syndrome of **infantile erythroderma** of severe and progressive generalized seborrheic-like dermatitis, recalcitrant diarrhea, malabsorption and wasting, and recurrent local and systemic infections.
## Footnote
Associated with C5 deficiency.
138
Which **cytokines** do **Th1 cells** produce?
* IFN-gamma
* IL-2
* IL-3
139
Which **cytokines** do **Th2 cells** produce?
* IL-4
* IL-5
* IL-6
* IL-10
* IL-13
140
What are the indications for starting **antiepileptic medication** after the first seizure?
* Neurological deficit
* Brain imaging shows a structural abnormality
* EEG shows unequivocal epileptic activity
* Patient or their family or carers consider the risk of having a further seizure unacceptable
141
What change in **ion channel activity** leads to a **long QT interval**?
Loss of function or blockade of **potassium channels**
This leads to the myocardial cells being overloaded with positively charged ions.
142
Outline the management guidelines for **COPD**.
* **1**: SABA
* **2A** (+ Asthmatic Features): LABA + ICS
* **3A**: LAMA + LABA + ICS
* **2B** (- Asthmatic Features): LABA + LAMA
143
According to **NICE**, how should the daily **fluid and electrolyte requirements** of a patient be calculated?
* **Fluid**: 25-30 mL/kg
* **Sodium**: 1 mmol/kg
* **Potassium**: 1 mmol/kg
* **Water**: 30 ml/Kg
* **Glucose**: 50-100g
144
What regime is used for **post-exposure prophylaxis** for HIV?
Combination **antiretrovirals** (tenofovir, emtricitabine, lopinavir/ritonavir) + repeat **HIV test** in 12 weeks.
145
Which drugs can cause **acute pancreatitis**?
* Azathioprine
* Mesalazine
* Didanosine
* Bendroflumethiazide
* Furosemide
* Pentamidine
* Steroids
* Sodium valproate
146
What type of **pulse** do you see in patent ductus arteriosus?
Collapsing
147
What does **gastrin** do?
Causes acid secretion, mucosal growth and smooth muscle contraction.
148
What does **pancreatic polypeptide** do?
Inhibits pancreatic enzyme secretion.
149
What is **multifocal motor neuropathy**?
A disease causing progressive, asymmetrical weakness in **distal upper limbs**. It is associated with **anti-GM1** antibodies.
150
Which **antibiotic** is usually included in the treatment of **toxic shock** syndrome?
Clindamycin
151
What is **Tolosa-Hunt syndrome**?
**Granulomatous** inflammatory process involving the cavernous sinus/superior orbital fissure, leads to **III, IV, VI and V(I) palsy**.
152
Which **fruit allergy** is associated with **latex allergy**?
Bananas
153
Which **artery** is most commonly affected in **lateral medullary syndrome**?
Vertebral artery
154
What are palmar crease **xanthomata** pathognomonic of?
Type III Hyperlipidaemia
| (Broad Beta Disease)
155
What is **Sezary syndrome**?
Type of **cutaneous T cell lymphoma** (like mycosis fungoides). Presents with **erythroderma**.
156
What are the main features of a **pontine stroke**?
* Contralateral limb weakness with bulbar involvement
* Ipsilateral 6th and 7th nerve palsies
157
Which **intervention** can be used to treat refractory pain in pancreatic cancer?
Coeliac plexus block
158
What is **MacLeod syndrome**?
Unilateral **emphysema** following childhood **bronchiolitis**.
159
What are some major adverse effects of **d-Penicillamine**?
Pancytopenia and acute tubulointerstitial nephritis.
160
What is **adynamic bone disease**?
* Condition where bone loses capacity to **buffer calcium**, often due to over-treatment with **alfacalcidol**.
* Leads to **reduced mineralization** and increased fracture risk (especially NOF).
* More common in **diabetic** patients and those on **peritoneal dialysis**.
161
What must you do before **thrombolysing** a patient with a PE?
Bedside **echocardiogram** to confirm right heart strain.
162
What is the main purpose of **post-marketing observational studies**?
To identify rare adverse events.
163
What are the features of **anti-phospholipid syndrome**?
* Recurrent miscarriage
* Thrombocytopaenia
* VTE
* Livedo reticularis
## Footnote
Other: renal vein thrombosis, progressive cognitive impairment
164
What does **lactose** break down into?
Glucose and Galactose
165
What does **maltose** break down into?
2 x glucose
166
What does **sucrose** break down into?
Glucose and Fructose
167
What treatment is used for recurrent **urinary tract calculi** and how does it work?
**Potassium citrate**
Reduces urinary supersaturation of calcium salts by forming soluble complexes with calcium ions and inhibiting crystal growth and aggregation.
168
What is the most common type of **thyroid cancer**?
**Papillary** (80%): associated with spread to lymph nodes
## Footnote
Others: follicular, medullary, anaplastic
169
Which **gene** is associated with **B-cell non-Hodgkin lymphoma**?
BCL2
170
When should a patient undergoing an elective **splenectomy** receive the pneumococcal vaccine?
2-4 weeks before surgery
171
What is the classical presentation of **Hodgkin lymphoma**?
Neck and mediastinal lymphadenopathy in adolescents
172
Which **artery** is most commonly responsible for **haemoptysis**?
Bronchial (95%)
173
What is the mechanism by which **NSAIDs** cause renal injury?
Acute tubulointerstitial nephritis
174
What feature can help distinguish **ATN** from **AIN**?
* ATN has bland urinalysis
* AIN will feature blood/protein/leucocytes
175
What is the difference in the way that **haemoglobinuria** and **haemosiderinuria** is interpreted?
* Haemoglobinuria = acute haemolysis
* Haemosiderinuria = chronic haemolysis
176
What is the first step in the management of a suspected **septic arthritis**?
Blood cultures
## Footnote
Then antibiotics and joint fluid aspiration.
177
What is the most common gastrointestinal complication of **systemic sclerosis**?
SIBO
178
What can be used to get an accurate measurement of **oxygen saturation** in a patient with carbon monoxide poisoning?
Four-wavelength spectrophotometer
179
How is **erythroderma** managed in a patient with psoriasis?
Topical white soft paraffin all over the body
180
What pulse abnormality is seen in **cardiac tamponade**?
Pulsus paradoxus
181
Which **ECG features** would you expect to see in a **posterior STEMI**?
In V1-V3
* horizontal ST depression
* tall, broad R waves
* upright T waves
* dominant R wave (R/S ratio > 1 in V2)
182
Which part of the **brain** controls vomiting?
Area postrema
183
What is the first-line treatment option for **discoid lupus**?
Hydroxychloroquine
184
How does **aciclovir** cause AKI?
In the presence of dehydration, aciclovir can precipitate as crystals in the kidney tubules
185
What is the role of the **inferior laryngeal nerve**?
Sensory innervation to larynx inferior to the vocal cords
186
What is a poor prognostic marker seen in the **karyotype** of a patient with acute myeloid leukaemia?
Chromosome 7 Abnormalities
187
What is the **sniff test** and what does it indicate?
Test for **unilateral diaphragm paralysis**. During a sniff, the unaffected hemidiaphragm moves down, pushing the affected hemidiaphragm up (paradoxical movement). Confirm with **X-ray** or **fluoroscopy**.
188
Which **antiemetics** can cause QT prolongation?
* Metoclopramide
* Ondansetron
* Prochlorperazine
189
What is the best early indicator of prognosis in **paracetamol-induced liver injury**?
INR at 48 hours
## Footnote
A doubling of the INR in 24 hours warrants referral to a specialist liver unit.
190
Where are the different **GLUT channels** found?
* **GLUT1**: erythrocytes and endothelial barrier cells
* **GLUT2**: from intestinal cells into portal circulation
* **GLUT3**: neurones
* **GLUT4**: striated muscle and adipose tissue
191
List some drugs that cause **torsades de pointes**.
* Antiarrhythmics (sotalol, procainamide, flecainide)
* Antibiotics (erythromycin, levofloxacin)
* Antifungals (ketoconazole)
* Antipsychotics (risperidone, haloperidol)
* TCA
* Lithium
192
How does **ezetimibe** work?
Reduces intestinal cholesterol absorption.
193
What is a key difference between **Bartter** and **Gitelman syndrome**?
Gitelman causes **low urinary calcium excretion** whereas Bartter does not.
194
Describe how **pacemaker terminology** work?
* **Position I**: Paced Chamber (Atrium, Ventricle or Dual)
* **Position II**: Sensed Chamber (Atrium, Ventricle or Dual)
* **Position III**: How It Will Respond to Sensed Chamber (Inhibit, Trigger output pulse, Dual modes of response, nO response to sensed input)
* **Position IV**: Rate Modulation (Rate modulation active, rate modulation nOt active)
* **Position V**: location or absence of multisite pacing (rarely used)
195
How are acute attacks of **acute intermittent porphyria** treated?
IV Haem Arginate
196
Which of the following is a **marker** of **bronchial carcinoid**?
Chromogranin A
Neuron-specific enolase is less sensitive
197
Which **myocardial enzyme** is released soonest after myonecrosis?
Glycogen phosphorylase BB
198
What is a **leukoerythroblastic blood film**?
Immature white and red cells on peripheral blood film - this is caused by bone marrow infiltration.
199
What is the best test for **invasive aspergillosis**?
Serum Galactomannan
200
What is the treatment of choice for **multifocal atrial tachycardia** in a patient with pulmonary hypertension?
Verapamil
## Footnote
Multifocal atrial tachycardia is a rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria. Most commonly seen in patients with severe COPD or congestive heart failure.
201
Which **antibodies** are seen in **autoimmune encephalitis**?
* Anti-LGI1
* NMDA
202
How are urinary **cystine stones** diagnosed?
Positive **urine cyanide nitroprusside** test.
203
What is **Kennedy syndrome** and how does it present?
**Spinal bulbar muscular atrophy**
Proximal weakness and cramps, wasting, fasciculations, weakness and hyporeflexia
Associated with androgen insensitivity.
204
Other than **opioids**, what treatment may be effective in the management of liver capsule pain in a patient with oedema secondary to hepatic metastases?
Corticosteroids
MRCP
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