2
Q
What is the mainstay of treating anterior uveitis?
A
Steroid and cycloplegic (mydriatic) eye drops.
E.g. Cyclopentolate and Corticosteroids
3
Q
What is a useful effect of COMT inhibitors in patients with Parkinson’s Disease?
A
They help smooth out on-off fluctuations in patients on L-DOPA.
4
Q
Why should pioglitazone be avoided in patients with congestive cardiac failure?
A
It causes fluid retention.
5
Q
In which patients should donepezil be avoided?
A
Bradycardia
6
Q
Which type of ovarian tumour produces TSH?
A
Struma ovarii (variant of ovarian teratoma)
7
Q
Outline the emergency management of acute angle closure glaucoma.
A
Eye drops (e.g. pilocarpine, timolol) + IV Acetazolamide
8
Q
What is the first-line treatment option for trigeminal neuralgia?
A
Carbamazepine
9
Q
Outline the stages of hypertensive retinopathy.
A
- I: Arteriolar narrowing; increased light reflex - silver wiring
- II: Arteriovenous nipping
- III: Cotton-wool exudates; flame and blot haemorrhages
- IV: Papilloedema
10
Q
What is the difference between type 1 and type 2 amiodarone-induced thyrotoxicosis?
A
Type 1
- Caused by excess iodine-induced thyroid hormone synthesis
- Goitre present
- Rx: Carbimazole or Potassium Perchlorate
Type 2
- Caused by amiodarone-related destructive thyroiditis
- Goitre absent
- Rx: Corticosteroids
These can be distinguished using colour flow Doppler ultrasonography or thyroid uptake scans.
11
Q
What are the main features of leptospirosis?
A
- Acute Phase: fever, malaise, headache, and abdominal pain
- Later Phase: severe systemic upset such as renal failure, pulmonary haemorrhage, and hepatic failure.
- Investigations: Serology
- Management: high-dose benzylpenicillin or doxycycline
12
Q
What does capillary wedge pressure represent in terms of cardiac catheterisation?
A
It is equivalent to the left atrial pressure which should equal the left ventricular diastolic pressure.
A normal mitral valve would expect less than 5 mm Hg pressure difference (capillary wedge pressure minus left ventricular diastolic pressure). If it is greater than that, there is a degree of mitral stenosis.
13
Q
How is P wave asystole managed?
A
External pacing
This is when you see only p waves on a rhythm check in a cardiac arrest.
14
Q
What are the indications for carotid endarterectomy?
A
Recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled.
Should only be considered if carotid stenosis > 70% according ECST criteria or > 50% according to NASCET criteria.
15
Q
How does Q fever manifest?
A
Fevers, headaches, fatigue and muscle aches, transaminitis on LFTs.
Comes from sheep and caused by Coxiella burnetii.
16
Q
Which therapy is effective at reducing morbidity and mortality in toxic epidermal necrolysis?
A
IVIG
17
Q
How should patients with superficial vein thrombosis be managed?
A
- Perform ultrasound to check for DVT.
- Administer prophylactic dose of LMWH for 30 days or fondaparinux for 45 days. If contraindicated, use NSAIDs for 8-12 days.
There is a risk of thrombosis extension into deep veins.
18
Q
List poor prognostic factors for CLL.
A
- Male
- Age > 70 years
- Lymphocyte count > 50
- Prolymphocytes > 10% of blood lymphocytes
- Lymphocyte doubling time < 12 months
- Raised LDH
- CD38 positive
- TP53 mutation
19
Q
What are the features of local anaesthetic toxicity?
A
CNS: reduced GCS, seizures
Cardiovascular: arrhythmia, hypotension
20
Q
In which patients can you not give ranolazine?
A
Severely impaired renal function
21
Q
After calcium channel blockers and beta-blockers, which agents manage stable angina?
A
- Long-acting nitrates
- Nicorandil (stimulates guanylate cyclase to increase cyclic GMP)
- Ranolazine (inward sodium channel inhibitor)
- Ivabradine (funny channel inhibitors * reduces HR and workload)
22
Q
What are the main features of acute intermittent porphyria?
A
- Autosomal dominant
- Defect in porphobilinogen deaminase
- More common in females aged 20-40
- Presents with abdominal and neuropsychiatric symptoms
- Commonly associated with hypertension and tachycardia
Urine turns deep red on standing.
23
Q
What are the main features of porphyria cutanea tarda?
A
- Most common hepatic porphyria
- Defect in uroporphyrinogen decarboxylase
- Caused by hepatocyte damage (e.g., alcohol)
- Photosensitive rash with bullae and skin fragility on face and hands
Urine shows elevated uroporphyrinogen and pink fluorescence under Wood’s lamp.
Treatment: chloroquine
24
Q
What are the main features of variegate porphyria?
A
- Autosomal dominant
- Defect in protoporphyrinogen oxidase
- Causes photosensitive blistering rash
- Abdominal and neurological symptoms
- More common in South Africans
25
Q
What’s the most common chemotherapy regime for small cell lung cancer?
A
Cisplatin and etoposide
Cisplatin causes hypomagnesemia which leads to muscle cramps, tremor, arrhythmias and confusion.
26
Which **UC patients** should be considered for drugs that maintain remission (e.g. azathioprine, mercaptopurine)?
Severe relapse or ≥ 2 exacerbations in the past year they should be given either **oral azathioprine** or **oral mercaptopurine** to maintain remission.
27
What are the criteria for **LTOT**?
Offer **LTOT** to patients with a pO₂ < **7.3 kPa** or those with pO₂ 7.3 - 8 kPa and one of the following:
* secondary polycythaemia
* peripheral oedema
* pulmonary hypertension
28
What is one crucial interaction between **TB** and **HIV medications**?
**Rifampicin** reduces absorption and increases metabolism of protease inhibitors.
## Footnote
In these cases, an alternative rifamycin, **rifabutin**, is recommended as it induces cytochrome P450 less than rifampicin.
29
What is the first-line management option for renal complications of **systemic sclerosis**?
ACE Inhibitors
30
What clinical feature is associated with an increased risk of **NSAID-induced asthma** exacerbations?
Presence of nasal polyps
31
How is **crusted scabies** managed?
Isolate and ivermectin
## Footnote
Crusted scabies is something that happens in people who are significantly immunocompromised.
32
How is **cryptococcal meningitis** managed?
IV Antifungals
| (e.g. amphotericin B and flucytosine)
33
How does **cryoglobulinaemia** present?
* **Raynaud's**: seen in type I
* **Cutaneous**: vascular purpura, distal ulceration
* **Arthralgia**
* **Renal involvement**: diffuse glomerulonephritis
34
What are the **three types of cryoglobulinaemia**?
* **Type I (25%)**: monoclonal
* **Type II (25%)**: mixed monoclonal and polyclonal (usually with rheumatoid factor)
* **Type III (50%)**: polyclonal (usually with rheumatoid factor)
## Footnote
**Type I**: Monoclonal (IgG or IgM); associations: multiple myeloma, Waldenstrom macroglobulinaemia.
**Type II**: Mixed monoclonal and polyclonal; associations: hepatitis C, rheumatoid arthritis, Sjogren's, lymphoma.
**Type III**: Polyclonal; associations: rheumatoid arthritis, Sjogren's.
35
Which common **cardiac drug** should be avoided in patients with cardiac amyloid?
Digoxin
## Footnote
Higher risk of digoxin toxicity as the drug binds avidly to amyloid fibrils.
36
How is **idiopathic intracranial hypertension** managed?
* Weight loss
* Acetazolamide
37
Why are **SSRIs** contraindicated in patients with a background of peptic ulcer disease?
Increases the risk of **upper GI bleeds** by inhibiting platelet aggregation.
38
Which treatment should be considered in addition to a **statin** in a young patient with familial hypercholesterolaemia?
Evolocumab
| (PCSK9 inhibitor)
39
Outline the **Simon Broome criteria** for **familial hypercholesterolaemia**.
* In adults: TC > 7.5 mmol/L and LDL-C > 4.9 mmol/L
* In children: TC > 6.7 mmol/L and LDL-C > 4.0 mmol/L
**DEFINITE FH**: tendon xanthoma in patients or 1st/2nd degree relatives or DNA evidence of FH.
**POSSIBLE FH**: family history of myocardial infarction below age 50 in 2nd degree relative, below age 60 in 1st degree relative, or family history of raised cholesterol levels.
40
What is an important acute complication of a **ketamine infusion**?
Raised ICP (monitor for headache, papilloedema and vomiting when administering).
41
What is the time window for **thrombectomy** for stroke?
An extended target time of **6-24 hours** may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume.
42
How should patients with **gestational diabetes** be followed-up after birth?
Postnatal glucose check (fasting blood glucose) 6-13 weeks postpartum.
43
How should patients with **COPD** being assessed for LTOT and experiencing a significant rise in pCO₂ with oxygen therapy be managed?
Patients with respiratory acidosis or a rise in PaCO₂ >1 kPa (7.5 mmHg) during LTOT assessment, while clinically stable, should receive **domiciliary oxygen** only with **nocturnal ventilatory support**.
44
What is seen on a biopsy of a patient with **CMV colitis**?
Inclusion bodies
## Footnote
Treated with ganciclovir.
45
Which antibody is specific for **drug-induced lupus**?
Anti-histone
## Footnote
Common causes include procainamide and hydralazine.
46
Which conditions are associated with **SIBO**?
* Neonates with congenital gastrointestinal abnormalities
* Scleroderma
* Diabetes mellitus
47
Describe the appearance of **cryptosporidium** on Ziehl-Neelsen staining.
Red cysts
## Footnote
May be treated with **rifaximin** but is usually supportive in patients who are immunocompetent, other treatment: **nitazoxanide**.
48
What is the drug of choice for **lymphatic filariasis**?
Diethylcarbamazine
49
How is **FSGS** treated?
Steroids
50
How does **histoplasmosis** present?
* Productive cough
* Retrosternal chest pain
* Recent travel to USA
## Footnote
**Treatment**: Itraconazole or amphotericin
51
Which medication enhances the effects of **adenosine**?
Dipyridamole
## Footnote
Leads to prolonged effects.
52
Which **TB drug** causes arthralgia?
Pyrazinamide
53
What is the purpose of a **long synacthen test**?
A long synacthen test (where samples are taken at 1, 4, 8, and 24 hours) can be used to distinguish **Addison's** from secondary causes of **adrenal insufficiency** such as steroid use, panhypopituitarism, and isolated failure of adrenocorticotrophic hormone (ACTH).
## Footnote
With primary failure, the adrenals will never be able to produce any cortisol. With secondary failure, the exogenous ACTH will eventually be able to produce some cortisol.
54
Which **ECG change** is common in **arrhythmogenic right ventricular cardiomyopathy**?
* T-wave inversion (TWI) in V1-V3
* Epsilon wave (notch in QRS complex)
55
When are platelets and FFP recommended in the context of a **gastrointestinal bleed**?
Platelets < 50 and INR/APTT > 1.5 x normal
56
What are the four types of **renal tubular acidosis**?
* Type 1 RTA (distal)
* Type 2 RTA (proximal)
* Type 3 RTA (mixed)
* Type 4 RTA (hyperkalaemic)
## Footnote
**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
**Type 3 RTA (mixed)**
* Extremely rare
* Caused by carbonic anhydrase II deficiency
* Results in hypokalaemia
**Type 4 RTA (hyperkalaemic)**
* Reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion
* Causes hyperkalaemia
* Causes include hypoaldosteronism, diabetes
57
What are the features of **Miller-Fisher Syndrome**?
* Ophthalmoplegia
* Areflexia
* Ataxia
* Usually a **descending** paralysis
## Footnote
Anti-GQ1b antibodies present in 90% of cases
58
What is one negative aspect of **G6PD level assays**?
It may be **normal** during an acute episode.
## Footnote
This is because cells with the lowest levels of G6PD are destroyed first during an acute episode. Measure again once acute episode has resolved.
59
Which four **cranial nerve nuclei** arise in the medulla?
CN 9-12
60
Which four **cranial nerve nuclei** arise in the pons?
CN 5-8
61
Which four **cranial nerve nuclei** arise **above** the pons?
* **CN 1-2**: from the cerebrum
* **CN 3-4**: from the midbrain
62
Which **neuroanatomical structures** are in the MIDLINE in the brainstem?
* Motor pathways (corticospinal tract)
* Medial lemniscus
* Medial longitudinal fasciculus
* Motor nuclei of 3, 4, 6 and 12
63
Which **neuroanatomical structures** are in the LATERAL aspect of the brainstem?
* Spinothalamic Tract
* Sympathetic Fibres
* Sensory Nuclei of CN 5
* Spinocerebellar Tract
64
Which **rule** can be used to remember which **motor nuclei** are in the midline vs the lateral aspect of the brainstem?
* The ones in the **midline** are all **divisible by 12** (12, 6, 4 and 3) (N.B. excludes 1 and 2).
* The others are found in the **lateral** aspect (5, 7, 9 and 11).
65
How does an **uncal herniation** manifest?
* **Ipsilateral 3rd nerve palsy** involving the pupil.
* **Contralateral paralysis** (due to compression of cerebral peduncle).
66
What is the recommended treatment option for **fatigue associated with MS**?
Amantadine
## Footnote
Anaemia, depression and thyroid dysfunction should be ruled out first.
67
How is **oscillopsia** associated with MS treated?
Gabapentin
68
How should **bladder dysfunction** in MS be investigated and managed?
Ultrasound to assess bladder emptying.
## Footnote
If significant residual volume --> Intermittent self-catheterisation
If no significant residual volume --> anticholinergics
69
What are the criteria for **beta-interferon** use in multiple sclerosis?
* 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)
## Footnote
Alternatives: glatiramer acetate, diethyl fumarate and teriflunomide.
Interferons are contraindicated in liver dysfunction.
70
What causes **mucosal leishmaniasis** and how does it manifest?
* Leishmania braziliensis
* Skin lesions across mucosa of nose and pharynx (may manifest years after exposure)
71
What causes **cutaneous leishmaniasis** and how does it manifest?
* Leishmania tropica or Leishmania mexicana
* Crusted lesion at site of bite
72
What causes **visceral leishmaniasis** and how does it manifest?
**Leishmania donovani**
* Fever, sweats and rigors
* Massive splenomegaly and hepatomegaly
* Grey skin
* Pancytopaenia (due to hypersplenism)
## Footnote
**Investigations**: bone marrow or splenic aspirate
73
Which **vector** transmits leishmaniasis?
Sandfly
74
Which blood film abnormalities will be seen in **G6PD deficiency**?
* Heinz bodies
* Bite cells
* Blister cells
75
Which **stain** is used to distinguish primary from metastatic lung cancers when performing cytological analysis of a malignant pleural effusion?
TTF1
| (thyroid transcription factor)
## Footnote
This is only expressed by cells found in lung and thyroid.
76
How does **Kearns-Sayre syndrome** manifest?
Onset **before age 20**; symptoms include external ophthalmoplegia, retinitis pigmentosa (night blindness), ptosis, and heart block.
## Footnote
Mitochondrial disease.
77
What is the most specific **ECG feature** of acute pericarditis?
PR depression
78
Which drugs are used in the treatment of **ventricular tachycardia** (with pulse)?
* Procainamide (best option)
* Amiodarone
* Lidocaine (caution in left ventricular impairment)
79
What is a major risk of starting **ACE inhibitors** in someone with bilateral renal artery stenosis?
It can cause **deteriorating renal function** and flash **pulmonary oedema**.
80
What are the features of **severe iron toxicity** (i.e. overdose)?
* Abdominal pain and haematemesis (gastrointestinal corrosion)
* Diarrhoea
* Raised BM (hallmark)
* Significant sample haemolysis
* Metabolic acidosis with high anion gap
* Coagulopathy (particularly APTT)
81
What increase in **transaminases** is acceptable after starting a statin?
* Up to **3 times the upper limit** of normal.
* If rising but within this limit, **continue the statin** and repeat **LFTs** in 4-6 weeks.
82
How is **methotrexate toxicity** treated?
Folinic acid
## Footnote
Folic acid is used to prevent methotrexate side-effects.
83
Which antibiotics have good **Pseudomonas** cover?
* Ciprofloxacin
* Tazocin
* Ceftazidime
* Aztreonam
* Meropenem
84
What is the only absolute contraindication for **ECT**?
Raised intracranial pressure.
85
In which subgroup of patients with **stable angina** should revascularization with PCI be offered?
Patients with **stable coronary artery disease** and ischaemia affecting >10% of the left ventricle.
86
What is an **osmolar gap**?
* Measure osmolality − calculated osmolality (2 x Na + Glu + Ur) = **Less than 10**.
* If it is **high**, it means that there is an **unmeasured solute** in high amounts (e.g. ethylene glycol).
87
Which cause of **pneumonia** is associated with bulging fissure sign?
Klebsiella pneumoniae
88
List indications for **IVIG**.
* Primary and secondary immunodeficiency
* ITP
* Myasthenia gravis
* Guillain-Barré syndrome
* Kawasaki disease
* Toxic epidermal necrolysis
* Low serum IgG after haematopoietic stem cell transplant for malignancy
* Dermatomyositis
* Chronic inflammatory demyelinating polyradiculopathy
## Footnote
Aseptic meningitis is a classic complication.
89
What is the preferred imaging modality for patients with suspected **TIA** who need brain imaging?
MRI brain with diffusion-weighted imaging.
90
What is a **gradient record MRI brain** used for?
To look for **microhaemorrhages**.
91
How are **hiccups** managed?
* Chlorpromazine
* Haloperidol and Gabapentin
* Dexamethasone (used if there are hepatic lesions)
92
What should you do in patients with **neutropenic sepsis** that has failed to respond to antibiotics after 48 hours?
It may be fungal --> start **antifungal therapy**.
93
What feature can help distinguish **dengue** from **chikungunya**?
Chikungunya is more associated with **severe joint pains**.
94
What is the most common GI side effect of **clozapine**?
Constipation and intestinal obstruction.
95
What are the indications for **CRT**?
* NYHA class III or IV symptoms
* Normal sinus rhythm with:
- QRS duration of 150 ms or longer by ECG
- QRS duration of 120-149 ms by ECG with confirmed mechanical dyssynchrony
* Left ventricular ejection fraction of 35% or less.
* Receiving optimal pharmacological therapy.
96
How is **Schistosoma haematobium** infection treated?
Single dose of praziquantel
97
Which types of **porphyria** only cause neurovisceral symptoms (i.e. no skin involvement)?
* Acute intermittent porphyria
* Aminolaevulinic acid dehydrogenase porphyria
98
Which types of **porphyria** only manifest with photosensitivity?
* Porphyria cutanea tarda
* Congenital erythropoietic porphyria
* Erythropoietic protoporphyria
99
Which types of **porphyria** cause both neurovisceral and photosensitive manifestations?
* Variegate porphyria
* Hereditary coproporphyria
100
How long after **CT contrast** can a patient have radioiodine therapy?
8 weeks
101
What criteria diagnose a **total anterior circulation stroke**?
* Unilateral hemiparesis and/or hemisensory loss (face/arm/leg)
* Homonymous hemianopia
* Higher cognitive dysfunction (e.g., dysphasia)
## Footnote
A partial anterior circulation stroke is diagnosed if 2 of the 3 criteria are present.
102
Which **arteries** are affected in a total anterior circulation stroke?
Anterior and Middle Cerebral Arteries
103
What are the main complications of **typhoid**?
* Bowel perforation and haemorrhage
* Myocarditis and endocarditis
104
List some contraindications for **second-line anti-anginal drugs**.
* **Ivabradine**: sick sinus syndrome
* **Ranolazine**: liver injury
* **Nicorandil**: LV failure and cardiogenic shock
105
What are the five types of **lupus nephritis**?
* **I**: Minimal Mesangial
* **II**: Mesangial Proliferation
* **III**: Focal
* **IV**: Diffuse (WORST PROGNOSIS)
* **V**: Membranous
106
What treatment should be offered to **15-49 year olds** with early **ADPKD** (eGFR > 90)?
**ACE inhibitor** with target BP < 110/75 mm Hg
## Footnote
Tolvaptan is recommended for rapidly progressive disease at CKD stage 2-3.
107
What are the indications for starting treatment of **CLL**?
* Progressive marrow failure: the development or worsening of anaemia and/or thrombocytopenia
* Massive (>10 cm) or progressive lymphadenopathy
* Massive (>6 cm) or progressive splenomegaly
* Progressive lymphocytosis: > 50% increase over 2 months or lymphocyte doubling time < 6 months
* Systemic symptoms: weight loss > 10% in previous 6 months, fever >38ºC for > 2 weeks, extreme fatigue, night sweats
* Autoimmune cytopaenias e.g. ITP
## Footnote
FCR is usually the initial treatment of choice, ibrutinib is used afterwards
108
What **ABG picture** would you see in someone with methaemoglobinaemia?
Mixed respiratory and metabolic **acidosis** with a relative **hypoxia** despite the inspired fraction of oxygen.
109
When might **IVIG** be used instead of steroids in a patient with ITP?
If platelets need to rise quickly (e.g. ahead of surgery).
110
What can cause a **thunderclap headache** with a normal CT head and normal CSF results?
Reversible cerebrovascular vasoconstriction syndrome.
111
Why must you exercise caution when thinking about administering blood products to people with **selective IgA deficiency**?
Associated with **anaphylactic** reaction to blood products.
112
How does **benzodiazepine withdrawal** manifest?
* **PHYSICAL**: tachycardia, sweating, tremor
* **NEUROPSYCHIATRIC**: nightmares, insomnia, anxiety, seizures, photophobia, derealisation and kinaesthetic hallucinations
113
Which medications cause false positive **5-HIAA** results?
* Paracetamol
* Naproxen
* Caffeine
* Fluorouracil
## Footnote
Foods: Banana, Avocado, Aubergine, Pineapple, Plums, Walnuts, Tomatoes
114
Which medications cause false negative **5-HIAA** results?
* Aspirin
* Levodopa
* Methyldopa
* ACTH
115
How is a **scleroderma renal crisis** managed?
STAT ACE inhibitor
116
What are the first, second and third line treatment options for **acute dystonia**?
* **1**: Procyclidine
* **2**: Benzodiazepine
* **3**: Anticholinergic Antihistamines
117
List some common drugs that can increase seizure frequency in people with **epilepsy**?
* Fentanyl
* Mefenamic Acid
* Tramadol
* Amitriptyline
* Aminophylline
* Isotretinoin
* Haloperidol
118
Outline the differences between the **Parkinson's plus syndromes**.
* **Progressive Supranuclear Palsy**: bilateral symptoms, vertical gaze palsy, nasal voice (due to pseudobulbar palsy)
* **Multiple System Atrophy**: significant cerebellar or autonomic dysfunction
* **Corticobasal Degeneration**: significant higher order dysfunction (e.g. apraxia, aphasia, alien hand syndrome)
119
What level of **LFT derangement** would warrant stopping methotrexate?
Doubling of ALT or AST
120
Which **opioids** are safe in patients with impaired renal function (eGFR < 30)?
* Oxycodone
* Fentanyl
* Buprenorphine
* Methadone
121
How is **lupus nephritis** treated?
* Focal and Mild: Oral Steroids
* Nephrotic Syndrome and Advanced Diffuse Lupus Nephritis: IV Methylprednisolone and IV Cyclophosphamide
122
When should **statins** be started after a stroke?
48 hours after the onset of symptoms
123
In which cases of **hyperadrenalism** is surgery indicated?
* If caused by a **unilateral adrenal adenoma**.
* Otherwise, manage with **spironolactone**.
124
When should **EPO** be started in a patient with CKD?
Once they are **iron replete** (this can be achieved with IV iron).
125
List the medical management guidelines for **HOCM**.
* **1**: Beta-blocker or Non-Dihydropyridine CCB (e.g. verapamil)
* **2**: Disopyramide (class 1a anti-arrhythmic)
* **3**: Myectomy, DDDR pacemaker, alcohol ablation
126
How should **measles exposure** be managed in someone that is vulnerable (e.g. unvaccinated, immunocompromised)?
Immunoglobulin
127
Why should patients undergoing open surgical valve repair have a **coronary angiogram** prior to the surgery?
To identify any **coronary artery disease** that could also be attended to at the same time.
128
What is **paragonimiasis** and how does it present?
* Lung fluke infection
* Presents similarly to TB with chronic productive cough, weight loss, night sweats, and rashes.
## Footnote
Treated with praziquantel.
129
List some side-effects of **ciclosporin**.
* Nephrotoxic
* Hepatotoxic
* Fluid retention
* Hyperkalaemia
* Hypertrichosis
* Gingival hyperplasia
130
What is **Fabry disease**?
* X-linked recessive lipid storage disorder
* Caused by deficiency in alpha-galactosidase
* Leads to accumulation of lipids in various tissues
* Acroparaesthesia (tingling and burning in hands and feet triggered by stress, emotion and temperature)
* Angiokeratoma corporis diffusum
* Mitral valve prolapse/regurgitation
* Young strokes
* CKD
131
Which serum measurement is a useful marker of renal function that is less affected by age, sex, race and muscle mass?
Cystatin C
132
At what serum **PTH level** should patients with secondary hyperparathyroidism receive calcium and vitamin D supplements?
Twice the upper limit of normal.
## Footnote
Supplementing calcium and vitamin D too early in secondary hyperparathyroidism risks adynamic bone disease.
133
How should **hoarseness** after a total thyroidectomy be investigated?
Flexible nasal endoscopy
134
How does **strongyloidiasis** manifest?
* Diarrhoea
* Abdominal pain and bloating
* Papulovesicular lesions where skin has been penetrated (e.g. feet)
* Pruritic rash
* Pneumonitis (if larvae migrate to lungs)
## Footnote
**Treatment**: Ivermectin
135
In which groups of patients is **CABG** considered better than PCI with stent insertion for the management of ischaemic heart disease?
* Patients with complex anatomy
* Triple vessel disease
* Proximal left main stem disease
136
Which investigation is used for **acute intermittent porphyria** and how is it treated?
Raised urinary porphobilinogen
Treated with IV haem arginate
137
Which antibiotics are usually used to manage **pyogenic liver abscesses**?
Amoxicillin + ciprofloxacin + metronidazole
138
What ECG features do you see in **hypocalcaemia**?
Prolonged QT interval
139
How does **histoplasmosis** present and how is it treated?
* Symptoms of URTI
* Retrosternal pain
**Treatment**: amphotericin or itraconazole
140
Outline the mechanism of **hungry bone syndrome**.
1. High pre-operative levels of parathyroid hormone provide a constant stimulus for osteoclast activity creating the **hypercalcaemic state** by de-mineralizing the bones.
2. This process can result in x-ray changes very similar to **metastatic lytic lesions** if left untreated.
3. Upon removal of the parathyroid adenoma the hormone levels fall rapidly (they have a very short half-life) and the osteoclast activity is subsequently diminished and the bones rapidly begin re-mineralisation - '**hungry bone syndrome**'. This process can be uncomfortable and also result in systemic hypocalcaemia.
141
Which lower limb neurological features do you see in **subacute combined degeneration** of the spinal cord?
* Brisk Knee Reflexes
* Absent Ankle Reflexes
* Extensor Plantar Reflexes
142
Describe the manifestations of **methoxetamine overdose**.
* **Sympathetic activation**: tachycardia, hypertension, mydriasis
* **Cognitive effects**: confusion, agitation
* **Cerebellar signs**: nystagmus, dysarthria, ataxia
## Footnote
Methoxetamine is an analogue of ketamine.
143
What is the most common side effect of **checkpoint inhibitors** like nivolumab?
Dry itchy skin and rashes
144
How does **anti-NMDA receptor encephalitis** present?
* Prominent psychiatric symptoms (agitation, hallucinations, delusions)
* Seizures
* Insomnia
* Dyskinesia
* Autonomic instability
* Treated with immunosuppression (steroids, immunoglobulins, rituximab, cyclophosphamide, plasma exchange)
## Footnote
It is normally caused by an ovarian teratoma.
145
What is **tropical spastic paraparesis**?
A condition in which patients with **HIV** and **HTLV1** present with urinary retention and paraparesis.
146
Which **antiemetic** is best for metabolic causes of nausea and vomiting (e.g. hypercalcaemia, uraemia)?
Central dopamine antagonists
| (e.g. haloperidol)
147
What is the first-line antibiotic for **ESBL UTIs**?
Carbapenems
148
How does **American trypanosomiasis** manifest?
* **Acute**: asymptomatic, sometimes orbital oedema
* **Chronic**: myocarditis (and dilated cardiomyopathy), megaoesophagus (causing dysphagia) and megarectum
## Footnote
Treatment: benznidazole or nifurtimox
149
What is **idarucizumab** used to reverse?
Dabigatran
150
What is used to reverse **rivaroxaban and apixaban**?
Andexanet alpha
151
What is the **DMARD of choice** in psoriatic arthritis?
Methotrexate
## Footnote
2nd line: leflunomide
152
What special feature of **carbamazepine** must you be aware of when starting patients on the drug?
It causes **autoinduction** so there may be an increase in seizure prevalence after 3-4 weeks.
153
What forms of **smoking cessation treatment** are recommended by NICE?
* Nicotine replacement therapy (patch and a short-form for acute cravings)
* Varenicline (CI in pregnancy)
* Bupropion (CI in pregnancy)
154
Outline the management of **non-small cell lung cancer**.
* **Stage 1 and 2**: Resection Surgery
* **Stage 3**: Chemotherapy
* **Stage 4**: Palliative
155
List the contraindications for surgery for **non-small cell lung cancer**.
* 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
## Footnote
FEV1 > 2 L for pneumonectomy
156
What special feature of **Plasmodium ovale** required additional consideration when determining how to treat it?
It has a liver hypnozoite phase that needs to be treated with primaquine.
## Footnote
Primaquine can cause a haemolytic crisis in patients with G6PD deficiency so this should be excluded before starting treatment.
157
Outline the criteria for diagnosing **NF2**.
* Bilateral vestibular schwannomas
* A first degree relative with NF2 AND
* Unilateral vestibular schwannoma OR
* Any two of: meningioma, schwannoma, glioma, neurofibroma, posterior subcapsular lenticular opacities
* Unilateral vestibular schwannoma AND
* Any two of: meningioma, schwannoma, glioma, neurofibroma, posterior subcapsular lenticular opacities
* Multiple meningiomas AND
* Unilateral vestibular schwannoma OR
* Any two of: schwannoma, glioma, neurofibroma, cataract
158
What is the threshold for **platelet transfusions** in an actively bleeding patient?
50
159
What are the criteria for **FFP** in actively bleeding patients?
Fibrinogen level < 1 g/L or PT/APTT > 1.5 times normal.
160
Which vaccines are contraindicated in adults with **HIV**?
* Cholera CVD103-HgR
* Influenza-intranasal
* Poliomyelitis-oral (OPV)
* Tuberculosis (BCG)
## Footnote
If CD4 < 200, then MMR, varicella and yellow fever are also contraindicated.
161
How does **relapsing polychondritis** present?
* Relapsing episodes of chondritis (e.g., auricular chondritis)
* May involve respiratory tract, heart valves, and blood vessels.
162
List some **lead chelators**.
* Dimercaptosuccinic acid (DMSA): best for chronic exposure
* D-penicillamine
* EDTA: IV agent used for acute exposure
* dimercaprol
163
How does **lead poisoning** manifest?
* Abdominal pain
* Peripheral neuropathy (mainly motor)
* Fatigue
* Constipation
* Blue lines on gum margin (only 20% of adult patients, very rare in children)
164
How should an **HIV viral load** of 50-200 in someone on established ART be managed?
Repeat blood test in 1 month
165
What are the criteria for **antibiotic prophylaxis** in patients with ascites?
* Patients who have had an episode of SBP
* Patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
## Footnote
with ciprofloxacin or norfloxacin
166
What are the criteria for commencing treatment with **GLP1 agonists**?
* Triple therapy is ineffective/not tolerated/contraindicated
* BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or
* BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
## Footnote
Only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months.
167
What are the two different types of **Wolff-Parkinson-White syndrome**?
* **Type A (left-sided pathway)**: dominant R wave in V1
* **Type B (right-sided pathway)**: no dominant R wave in V1
168
How should **WPW** be managed?
* **Definitive**: radiofrequency ablation of accessory pathway
* **Medical**: Sotalol, Amiodarone, Flecainide
## Footnote
Caution with AV blocking drugs especially if broad complex tachycardia because it may lead to increased conduction over accessory pathway leading to 1:1 AV conduction and VF.
169
List some **CYP450 inducers**.
* Antiepileptics: **phenytoin**, **carbamazepine**
* Barbiturates: **phenobarbitone**
* **Rifampicin**
* **St John's Wort**
* Chronic **alcohol** intake
* **Griseofulvin**
## Footnote
These **decrease** INR.
170
List some **CYP450 inhibitors**.
* Antibiotics: **ciprofloxacin**, **erythromycin**
* **Isoniazid**
* **Cimetidine**, **omeprazole**
* **Amiodarone**
* **Allopurinol**
* Imidazoles: **ketoconazole**, **fluconazole**
* SSRIs: **fluoxetine**, **sertraline**
* **Ritonavir**
* **Sodium valproate**
* Acute **alcohol** intake
## Footnote
These **increase** INR.
171
List the manifestations of **myotonic dystrophy**.
* Myotonic facies (long, 'haggard' appearance)
* Frontal balding
* Bilateral ptosis
* Cataracts
* Dysarthria
* Cardiomyopathy (incl. heart block)
* Dysphagia
* Diabetes mellitus
172
Outline the differences between **DM1 and DM2**.
**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
173
How is **dermatitis herpetiformis** treated?
Dapsone and a gluten-free diet
## Footnote
Second Line: Sulfapyridine
174
What causes **paroxysmal nocturnal haemoglobinuria**?
Acquired **intravascular haemolysis** due to increased sensitivity of cell membranes to complement due to lack of **glycoprotein glycosylphosphatidylinositol** (GPI).
175
How does **PNH** manifest?
* Haemolytic anaemia
* Cytopaenias
* Haemoglobinuria
* Thrombosis
* Aplastic anaemia
176
How can **PNH** be diagnosed?
Flow cytometry of blood to detect low levels of **CD59** and **CD55**.
177
How can **PNH** be managed?
* **Acute**: blood products, anticoagulation, eculizumab
* **Definitive**: stem cell transplantation
178
What is **Alport syndrome**?
**X-linked dominant** condition caused by mutation in collagen IV leading to abnormal glomerular basement membrane.
179
How does **Alport syndrome** manifest?
* Microscopic haematuria
* Progressive renal failure
* Bilateral sensorineural hearing loss
* Lenticonus
* Retinitis pigmentosa
* Renal Biopsy: split lamina densa (basket weave appearance)
180
What is a relatively common complication that occurs in patients with **Alport syndrome** who have received a renal transplant?
Crescentic glomerulonephritis due to de novo anti-GBM disease.
181
Which investigations should be used to screen for **haemochromatosis**?
* **General population**: transferrin saturation > ferritin
* **Family members**: HFE genetic testing
182
What are the definitive diagnostic tests used for **hereditary haemochromatosis**?
* Molecular genetic testing for the C282Y and H63D mutations
* Liver biopsy: Perl's stain
183
Which type of **brain tumour** is associated with a paraneoplastic phenomenon in which patients develop a high Hb?
Cerebral haemangioblastomas (release erythropoietin)
184
List some associations of **primary biliary cholangitis**.
* Sjogren's syndrome (seen in up to 80% of patients)
* Rheumatoid arthritis
* Systemic sclerosis
* Thyroid disease
185
What is **papillary necrosis** and what can cause it?
Sloughing of **renal papillae** which can lead to urinary obstruction, AKI and CKD. It can also cause a salt-losing nephropathy.
**Causes**:
* chronic analgesia use
* sickle cell disease
* TB
* acute pyelonephritis
* diabetes mellitus
186
What is the risk of using **BRAF inhibitors** (e.g. Vemurafenib and dabrafenib) in the treatment of melanoma?
Squamous cell carcinoma
187
What is the main treatment option for **gout** in patients with severely impaired renal function?
Steroids
| (e.g. prednisolone)
## Footnote
Alternative: Canakinumab (anti-IL1 beta)
Colchicine, NSAIDs and allopurinol are all contraindicated.
188
How does **central pontine myelinolysis** manifest?
* Spastic quadriparesis
* Pseudobulbar palsy
* Emotional lability
189
List the indications for an **ICD**.
* Long QT syndrome
* Hypertrophic obstructive cardiomyopathy
* Previous cardiac arrest due to VT/VF
* Previous myocardial infarction with non-Sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35%
* Brugada syndrome
190
What is **hypokalaemic periodic paralysis**?
* Rare autosomal dominant condition with episodes of paralysis (often at night) triggered by strenuous exercise, stress, or high carbohydrate meals.
* Caused by a defect in muscle voltage-gated calcium channels. Requires lifelong potassium replacement.
191
How should **myxoedema coma** be managed?
Levothyroxine and liothyronine
192
How should **paroxysmal AF** be investigated?
* Episodes < 24 hrs apart: 24 hr ambulatory ECG
* Episodes > 24 hrs apart: event recorder electrocardiogram
193
List causes of **erythema multiforme**.
* **Viruses**: herpes simplex (most common)
* Idiopathic
* **Bacteria**: Mycoplasma, Streptococcus
* **Drugs**: penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine
* **Connective tissue disease**: e.g. systemic lupus erythematosus
* Sarcoidosis
* Malignancy
194
How is **membranous glomerulonephritis** managed?
* ACE inhibitor or ARB
* Immunosuppression
## Footnote
Associated with anti-phospholipase A2 antibodies.
195
How is **thyroid storm** managed?
* Beta blockers (e.g. IV propranolol)
* Antithyroid drugs (e.g. propylthiouracil)
* Lugol's iodine
* Dexamethasone
196
When should patients undergo **carotid endarterectomy**?
Patients with TIA or small ischaemic stroke and significant carotid artery stenosis (50-99% in males, 70-99% in females) on the same side as the event should be considered for urgent **carotid endarterectomy (CEA)** within 14 days.
197
Describe the symptoms of **zinc deficiency**.
* Perioral dermatitis: red, crusted lesions
* Acrodermatitis
* Alopecia
* Short stature
* Hypogonadism
* Hepatosplenomegaly
* Geophagia (ingesting clay/soil)
* Cognitive impairment
198
Describe the clinical manifestations of **methanol and ethylene glycol poisoning**.
* **Methanol**: retinal injury, visual disturbance
* **Ethylene Glycol**: oliguria, haematuria, flank pain
199
What is **autonomic dysreflexia**?
* Occurs in individuals with spinal injury **at or above T6**.
* Afferent signals triggered by urinary retention/faecal impaction causes sympathetic spinal reflex via thoracolumbar outflow.
* Manifests with hypertension, flushing and sweating above the lesion.
200
What is **mepolizumab** and when is it used?
* Anti-IL5 monoclonal antibody
* Used for asthma with high eosinophils
201
What is **Weber syndrome**?
Form of midbrain stroke characterised by ipsilateral CNIII palsy and contralateral hemiparesis.
## Footnote
Caused by a stroke involving a branch of the posterior cerebral artery.
202
List medications that can precipitate **myasthenic crises**.
* Penicillamine
* Quinidine, procainamide
* Beta-blockers
* Lithium
* Phenytoin
* Antibiotics: gentamicin, macrolides, quinolones, tetracyclines
203
Outline the differences between **type 1 and type 2 HRS**.
* **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
* **TYPE 2**: slowly progressive
204
How is **hepatorenal syndrome** managed?
Terlipressin and HAS
## Footnote
TIPSS may also be used
205
What is the first-line treatment option for **myelofibrosis**?
Hydroxycarbamide
206
What is the investigation of choice for suspected **hydatid cysts**?
Serology for Echinococcus granulosus
207
What is an important side-effect of **dapsone** to be mindful of?
Haemolytic anaemia
208
What is **Hereditary Neuropathy with Liability to Pressure Palsy**?
* A condition in which a small amount of pressure on a peripheral nerve results in a mononeuropathy that takes weeks to resolve.
* Associated with PMP22 gene deletion.
209
What is a common side-effect of **efavirenz**?
Disturbing dreams and being muddled.
210
What is an alternative to **penicillamine** for copper chelation?
Trientine
## Footnote
People with penicillin allergy cannot receive penicillamine.
211
Which type of **meningococcal meningitis** is most common across Africa and the Middle East?
Men A
## Footnote
B and C are more common in Europe and South America.
212
How should cases of **TB with isoniazid resistance** be managed?
Continue ethambutol for 6 months
213
What are the rules for treating **subclinical hypothyroidism**?
Treat if TSH is > 10 mU/L as long as they are younger than 70 yrs old
Otherwise repeat TFTs in 6 months
214
What is a major danger of **hydatid cyst rupture**?
It can cause anaphylaxis.
215
What are the indications for **steroid treatment in sarcoidosis**?
* 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.
## Footnote
Eye, heart or neuro involvement
216
What ECG changes are seen in **hypokalaemia**?
* U waves
* Small or absent T waves (occasionally inversion)
* Prolonged PR interval
* ST depression
* Long QT
217
Which investigation must be conducted before considering **adrenalectomy** in a patient with Conn syndrome?
* Adrenal venous sampling
* This allows you to distinguish between **bilateral adrenal hyperplasia** and **unilateral adrenal adenoma**.
218
What is used for **bacterial meningitis prophylaxis**?
Ciprofloxacin or rifampicin
## Footnote
Should be offered to everyone that had close contact with the patient within 7 days of symptom onset.
219
What are anti-Hu, anti-Yo and anti-Ri antibodies associated with?
* **Anti-Hu**: small cell lung cancer - painful sensory neuropathy, cerebellar syndromes, encephalitis
* **Anti-Yo**: ovarian, breast cancer - cerebellar syndrome
* **Anti-Ri**: small cell lung cancer - retinal degeneration
220
Why should **aspirin** be stopped in thyroid storm?
It can displace T4 from thyroid binding globulin.
221
What is **Gardner syndrome**?
Autosomal dominant condition characterised by adenomatous intestinal polyps, osteomas and fibromas.
## Footnote
high risk of colorectal cancer
222
What triad of features is associated with **Still's disease**?
* Fever
* Joint Pain
* Salmon-coloured bumpy rash
## Footnote
Associated with high ferritin and ESR and treated with NSAIDs.
223
How does **cyanide poisoning** manifest and how is it treated?
Hypoxia, Hypotension, Headache, Confusion
**Treatment**: IV hydroxocobalamin (alternatives: amyl nitrite (inhaled), IV sodium nitrite, IV sodium thiosulfate).
224
How is **CNS lymphoma** treated?
Steroids + Methotrexate
225
What effect does **smoking** have on aminophylline?
Requires higher doses of aminophylline.
MRCP
flashcards
Decks in class (8)
# Cards
