MRCP > MRCP Part 2B > Flashcards

MRCP Part 2B Flashcards

Recognize and apply high-yield clinical decision-making in acute presentations, investigations, and management across multisystem conditions, with emphasis on bedside interpretation and guideline-based treatment. (224 cards)

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2
Q

How is the tremor treated in patients with Parkinson’s disease who are already on co-careldopa?

A

Procyclidine

Other anticholinergics include orphenadrine, or trihexyphenidyl.

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3
Q

How is methanol poisoning treated?

A
  • 1st Line: Fomepizole or Ethanol
  • Alternative: Haemodialysis

Folinic acid can reduce ophthalmological complications.

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4
Q

What causes Glanzmann’s thrombasthenia?

A

Ineffective GPIIb/IIIa

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5
Q

What is Foster-Kennedy syndrome?

A

Ipsilateral optic atrophy and contralateral papilloedema.

Caused by frontal lobe mass (e.g. meningioma).

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6
Q

How is a spontaneous carotid artery dissection managed medically?

A

Aspirin

High risk of thromboembolic disease.

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7
Q

How is flexural psoriasis treated?

A

Mild to moderate topical steroids.

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8
Q

Which combination of ECG features are seen in incomplete trifascicular block?

A
  • Right Bundle Branch Block
  • Left Axis Deviation
  • Prolonged PR Interval
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9
Q

At what point should patients with type 1 diabetes mellitus receive a statin?

A
  • Older than 40 years, or
  • Have had diabetes for more than 10 years or
  • Have established nephropathy or
  • Have other CVD risk factors

Do not use QRISK2.

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10
Q

Which medical treatment is used for Parkinson’s dementia?

A

Rivastigmine

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11
Q

Other than anti-acetylcholine receptor antibodies, which antibody is associated with myasthenia gravis?

A

Anti-muscle specific tyrosine kinase (MuSK)

40% of patients have anti-MuSK antibodies and show less response to pyridostigmine.

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12
Q

Which mutation is associated with Hairy Cell Leukaemia?

A

BRAF

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13
Q

List some features of severe malaria.

A
  • Schizonts on a blood film
  • Parasitaemia > 2%
  • Hypoglycaemia
  • Acidosis
  • Temperature > 39 °C
  • Severe anaemia
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14
Q

Which medication is used to prevent acute mountain sickness?

A

Acetazolamide

It works by causing a metabolic acidosis leading to a compensatory respiratory alkalosis (achieved through hyperventilation).

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15
Q

What is roflumilast and when is it recommended in the management of COPD?

A
  • Phosphodiesterase-4 inhibitor
  • Recommended in COPD patients on maximal medical therapy + FEV1 < 50% + 2 or more exacerbations over last year.
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16
Q

Why is sodium bicarbonate used in the treatment of aspirin overdose?

A

It increases the alkalinisation of urine resulting in increased aspirin excretion.

Any aspirin level > 450 mg/L should be treated.
Sodium bicarbonate is also used in the treatment of barbiturate overdose.

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17
Q

What are the indications for dialysis in salicylate overdose?

A
  • Serum concentration > 700mg/L
  • Metabolic acidosis resistant to treatment
  • Acute renal failure
  • Pulmonary oedema
  • Seizures
  • Coma
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18
Q

What to give when three doses of adenosine fail to terminate an SVT in a haemodynamically stable patient?

A

Give verapamil (if no asthma or atrial flutter).

Dose: 2.5-5 mg IV

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19
Q

List some risk factors for refeeding syndrome.

A
  • BMI < 16 kg/m2
  • Unintentional weight loss >15% over 3-6 months
  • Little nutritional intake > 10 days
  • Hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
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20
Q

List some causes of Focal Segmental Glomerulosclerosis.

(FSGS)

A
  • Idiopathic
  • Secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
  • HIV
  • Heroin
  • Alport’s syndrome
  • Sickle-cell
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21
Q

Which HIV drug is associated with the formation of urate stones?

A

Indinavir

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22
Q

What are the three types of long QT syndrome?

A
  • Long QT1: usually associated with exertional syncope, often swimming
  • Long QT2: often associated with syncope occurring following emotional stress, exercise or auditory stimuli
  • Long QT3: events often occur at night or at rest

All three types are associated with an increased risk of sudden cardiac death.

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23
Q

Outline the treatment of idiopathic intracranial hypertension.

A
  • Weight Loss
  • Diuretics
  • Repeated lumbar puncture
  • Surgery (optic nerve sheath decompression and fenestration)
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24
Q

Which drug class is best for treating tics?

A
  • Antipsychotics (e.g. risperidone)
  • Clonidine
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25
Q

During an LTOT assessment, how should you manage a patient whose pCO₂ increases by > 1 kPa after oxygen administration?

A

Medically optimize and reassess in 4 weeks.

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26
Aside from the effects of the infection itself, what other **gastrointestinal complication** can be caused by **Giardia** infection?
Temporary lactose intolerance.
27
What are the main **differences** between American and African **trypanosomiasis**?
* **American**: chagoma (nodule at infection site), myocarditis, dysphagia, megaoesophagus, megarectum (generally chronic). * **African**: chancre, intermittent fever, enlarged posterior cervical lymph nodes, CNS effects.
28
What is the first line treatment for **viral pericarditis**?
NSAID + Colchicine
29
How is **peritoneal dialysis peritonitis** treated?
Intraperitoneal vancomycin + ceftazidime ## Footnote *S. epidermidis* is the most common cause.
30
What are the criteria for **3-yearly colonoscopies** in patients with **ulcerative colitis**?
* Extensive colitis with mild active inflammation * Post-inflammatory polyps * Family history of colorectal cancer in a first-degree relative aged 50 or older
31
Which **genes** are associated with **MEN**?
* **MEN1**: MEN1 gene * **MEN2**: RET oncogene
32
Which common drugs are potent inhibitors of **CYP3A4**?
Macrolides ## Footnote E.g. clarithromycin
33
How is **Anti-GBM** disease treated?
* Plasmapheresis * Steroids * Cyclophosphamide
34
Which drugs treat **Huntington's chorea**?
* **Dopamine depletion**: Reserpine (VMAT), tetrabenazine * **Dopamine antagonists**: antipsychotics (e.g., risperidone)
35
What are the ECG features seen in **dextrocardia**?
* Inverted P wave in lead I * RAD * Loss of R wave progression
36
What are the ECG features of a **posterior MI**?
Changes in V1-3: * Horizontal ST depression * Tall, broad R waves * Upright T waves * Dominant R wave (V2)
37
Which test distinguishes **Conn's syndrome** from adrenal hyperplasia?
Measure **aldosterone** after prolonged standing. Aldosterone increases in adrenal hyperplasia.
38
What are the features of **multiple sclerosis** that are seen on an MRI head scan?
* High signal T2 lesions * Periventricular plaques * Dawson fingers: often seen on FLAIR images - hyperintense lesions perpendicular to the corpus callosum
39
What is the first line treatment option for **scalp psoriasis**?
Topical steroids (daily for 4 weeks)
40
What is the gold standard investigation for **cerebral venous sinus thrombosis**?
MRI Venography ## Footnote Though CT venography is often used for convenience.
41
What is the main indication for placing a **chest drain** in a patient with a pleural effusion?
If the pH on the pleural aspirate is **< 7.2**
42
Outline **Light's criteria** for pleural effusions.
**Exudates** have a protein level of >30 g/L, transudates have a protein level of < 30 g/L If the protein level is between **25-35 g/L**, Light's criteria should be applied. An **exudate** is likely if at least one of the following criteria are met: * pleural fluid protein divided by serum protein >0.5 * pleural fluid LDH divided by serum LDH >0.6 * pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
43
How does chronic inflammatory demyelinating polyneuropathy (**CIDP**) differ from **Guillain-Barré** syndrome (**GBS**)?
* Motor symptoms predominate * Insidious onset (months), like a chronic version of GBS * Treated with steroids and immunosuppressants
44
Which diagnoses are associated with **upgoing plantars and absent ankle jerks**?
* SACD * Motor neurone disease * Friedreich ataxia * Tabes dorsalis * Dual peripheral with central pathology
45
In patients with **stage 1 hypertension**, what is the treatment threshold?
10-year-cardiovascular risk score > 10% or evidence of end organ damage.
46
What is **pacemaker syndrome**?
Occurs when a single lead pacemaker (VVI) is out of sync with atrial activity, leading to reduced **atrioventricular concordance** and worsening breathlessness. ## Footnote This is treated with a DDI pacemaker that senses and paces both atria and ventricles.
47
Which **drug class** is notorious for triggering scleroderma crisis?
Steroids
48
How is **lupus nephritis** treated?
* **Steroids** to induce remission (with or without cyclophosphamide and mycophenolate). * **Mycophenolate** to maintain remission.
49
Which **antibiotics** are good at treating **Legionella**?
Macrolides and Quinolones ## Footnote They have good intracellular penetration.
50
Which class of **Parkinson's medications** is best for off-time reduction?
Dopamine agonists
51
Which class of **Parkinson's medications** is most commonly associated with causing delusions and hallucinations?
Dopamine agonists ## Footnote It also causes impulse control issues.
52
Which additional test is useful in making a diagnosis of **heparin-induced thrombocytopaenia** in someone with a moderate HIT antibody titre?
Serotonin release assay
53
What second line agent is used in the treatment of **familial hypercholesterolaemia**?
Ezetimibe
54
What do **VVI pacemakers** look like on an ECG?
Pacing spikes immediately before the QRS complex
55
What is the most effective screening tool for distinguishing **delirium** from dementia?
Confusion assessment method | (CAM)
56
List some causes of **retroperitoneal fibrosis**.
* Riedel's thyroiditis * previous radiotherapy * sarcoidosis * inflammatory abdominal aortic aneurysm * drugs: methysergide
57
What can be used for **bone protection** in a patient with bone metastases and an eGFR < 30 mL/min?
Denosumab
58
Outline the criteria for **decompressive craniotomy** in the context of malignant MCA syndrome.
* Age ≤ 60 years * Severe stroke: NIHSS > 15 (MCA territory) * Reduced consciousness: NIHSS 1a ≥ 1 * Imaging: infarction ≥ 50% of MCA territory ± ACA/PCA involvement or infarct volume > 145 cm³ (DWI MRI)
59
Outline treatment guidelines for a first episode of **C. difficile**.
* **1st**: Oral Vancomycin (10 days) * **2nd**: Oral Fidaxomicin * **3rd**: Oral Vancomycin + IV Metronidazole ## Footnote For recurrent episodes within 12 weeks: oral Fidaxomicin; if > 12 weeks: oral Fidaxomicin or oral Vancomycin. **If LIFE THREATENING**: oral Vancomycin + IV Metronidazole.
60
Which tests are required to stage **multiple myeloma**?
* Beta-2 microglobulin * Serum albumin
61
Which **drug class** is most effective at treating hypertriglyceridaemia?
Fibrates
62
Summarise the **NICE guidelines** for managing **non-typhoidal salmonella gastroenteritis**.
For patients > 50 years, immunocompromised, or with cardiac valve/endovascular disease: administer **Ciprofloxacin** 500 mg BD.
63
List some pre-ganglionic causes of **Horner syndrome**.
* Pancoast's tumour * Thyroidectomy * Trauma * Cervical rib ## Footnote Causes anhidrosis of the face.
64
List some post-ganglionic causes of **Horner syndrome**.
* Carotid artery dissection * Carotid aneurysm * Cavernous sinus thrombosis * Cluster headache ## Footnote Does NOT cause anhidrosis of the face.
65
Which long-acting insulin is particularly useful in preventing recurrent **DKA** as it has a long half-life?
Degludec | (Tresiba)
66
What can be given in **sulfonylurea overdose** to patients who fail to respond adequately to glucose?
IM Octreotide
67
How is **typhoid fever** managed?
Cefotaxime or Ceftriaxone ## Footnote It is caused by *Salmonella enterica*.
68
How is **arrhythmogenic right ventricular cardiomyopathy** treated?
* Sotalol * Catheter Ablation * ICD
69
What are presenting features of **acute interstitial nephritis**?
* Fever, Rash and Arthralgia * Eosinophilia * Renal Impairment * Hypertension
70
Which common drugs can cause **acute interstitial nephritis**?
* Penicillin * Rifampicin * NSAIDs * Allopurinol * Furosemide
71
Which combination of chemotherapy agents used for **breast cancer** is especially cardiotoxic?
Trastuzumab + anthracyclines ## Footnote E.g. doxorubicin
72
What are the main features of **Langerhans cell histiocytosis**?
* Bone pain (skull and femur) * Cutaneous nodules * Recurrent otitis media/mastoiditis * Spontaneous pneumothorax * Diabetes insipidus * Tennis racket-shaped Birbeck granules on electromicroscopy
73
What are the main treatment options for **eosinophilic oesophagitis**?
* Dietary modification * Topical steroids (e.g. fluticasone, budesonide) * Oesophageal dilatation ## Footnote Diagnosis is confirmed on biopsy.
74
How is **latent tuberculosis** treated?
* 3 months isoniazid and rifampicin * 6 months isoniazid
75
Outline the management of **IgA nephropathy**.
* **No proteinuria, normal GFR**: observe * **Proteinuria**: ACE inhibitor * **Significant fall in GFR/not responding to ACE inhibitor**: corticosteroid
76
How is **tick borne encephalitis** managed?
Supportive management
77
Which **antiemetic** is best for the delayed phase of **chemotherapy-induced nausea**?
Dexamethasone
78
What is **accelerated idioventricular rhythm**?
A benign **ectopic rhythm** of ventricular origin. ## Footnote Usually caused by reperfusion of ischaemic myocardium and has a rate of 50-110 bpm (helps differentiate from ventricular brady or tachycardia).
79
What is the main cause of **frank haematuria** in patients with **sickle cell disease**?
Papillary necrosis
80
What is a key difference between **Gitelman and Bartter syndrome**?
* **Gitelman**: hypocalciuria * **Bartter**: no hypocalciuria ## Footnote Both conditions cause hyponatraemia, hypokalaemia, hypomagnesemia and normotension.
81
What are some contraindications to **testosterone treatment** in men?
* PSA > 4 ng/mL * Male breast cancer * Severe sleep apnoea * Severe LUTS due to BPH
82
How does **loiasis** present?
Filarial infection caused by **loa loa** found in West and Central Africa. * Calabar swellings (transient, non-erythematous, hot swelling of soft tissue around joints) * Pruritus * Urticaria * Eye worm ## Footnote Treatment: Ivermectin
83
How is **pain from shingles** managed?
* Paracetamol and NSAIDs * Neuropathic agents * Oral Corticosteroids
84
List some features and complications of **Ehlers-Danlos syndrome**.
* Elastic, fragile skin * Joint hypermobility: recurrent joint dislocation * easy bruising * Aortic regurgitation, mitral valve prolapse and aortic dissection * Subarachnoid haemorrhage * Angioid retinal streaks
85
What is **Lown–Ganong–Levine syndrome**?
Pre-excitation disorder of the heart due to **abnormal conduction** between **atria and ventricles**. * Short PR interval * Normal QRS complex ## Footnote This differs from Wolff-Parkinson-White syndrome which causes short PR and broad QRS complex.
86
How does **dialysis dysequilibrium syndrome** manifest and how is it treated?
High pre-dialysis urea levels cause fluid shifts in the brain. Rapid **urea removal** drops serum osmolality, leading to cerebral edema. Treated with measures to **reduce intracranial pressure** (e.g., hypertonic saline).
87
Which **test** is used to determine whether a patient has **hyperventilation** syndrome?
Nijmegen questionnaire
88
What is the treatment option for **native valve endocarditis** caused by *Staphylococcus*?
Flucloxacillin ## Footnote If penicillin allergic or MRSA --> Vancomycin + Rifampicin
89
What is the treatment option for **prosthetic valve endocarditis** caused by *Staphylococcus*?
Flucloxacillin + Rifampicin + Low Dose Gentamicin ## Footnote If penicillin allergic or MRSA --> switch flucloxacillin for vancomycin
90
What is the treatment option for **native valve endocarditis** caused by fully-sensitive *Streptococci*?
Benzylpenicillin ## Footnote If penicillin allergic --> Vancomycin + Low Dose Gentamicin
91
Why should you aim for a **very low TSH** in patients who have had a **thyroidectomy** for thyroid cancer?
* TSH is a **growth factor** for thyroid cancer. * It should be suppressed with **levothyroxine** to < 0.1 in high risk patients and 0.1-0.5 in low risk patients.
92
Under what circumstance should you seek a **thoracic surgical opinion** in patients with a **chest drain**?
If after 3-5 days there is a persistent **air leak or failure of the lung** to re-expand.
93
What are the two types of **autoimmune polyendocrinopathy syndromes**?
* **APS Type 1**: Chronic mucocutaneous candidiasis + Addison's disease + Primary hypoparathyroidism * **APS Type 2 (Schmidt syndrome)**: Type 1 Diabetes Mellitus + Autoimmune Thyroid Disease
94
In which patients is **plasma exchange** indicated for patients with anti-GBM disease?
* Pulmonary haemorrhage * Renal involvement who do not need renal replacement therapy * Patients who may require dialysis but present acutely and are young and have a proportion of viable glomeruli on renal biopsy
95
List some causes of **membranous glomerulonephritis**.
* **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
96
What is the initial **blind therapy for prosthetic** and **native valve endocarditis** whilst awaiting blood cultures?
* **Prosthetic**: Vancomycin + Rifampicin + Low Dose Gentamicin * **Native**: Amoxicillin +/- Low Dose Gentamicin
97
How is **actinic keratosis** managed?
Topical fluorouracil ## Footnote Alternatives: imiquimod or diclofenac
98
What are the indications for a **surgical opinion** in patients with infective endocarditis?
* Aortic root abscess * Heart failure * Uncontrolled infection * Prevention of embolism (large vegetations with embolic episodes)
99
What are the manifestations of **abetalipoproteinaemia**?
* Failure to thrive + developmental delay * Steatorrhoea * Retinitis pigmentosa * Cerebellar signs * Deep tendon reflexes are absent * Acanthocytosis * Hypocholesterolaemia ## Footnote Management: dietary restriction of fats
100
What initial therapy is given to people with a new diagnosis of **rheumatoid arthritis**?
DMARD monotherapy (e.g. methotrexate) + short course of bridging prednisolone
101
What is **Whipple's triad**?
Used to identify clinically significant hypoglycaemia * borderline low blood sugar * symptoms of hypoglycaemia * improvement of symptoms with sugar
102
What are some main causes of **pacemaker failure**?
* Lead Fracture * Lead Displacement * Twiddler syndrome (patient fiddling with the pacemaker leads to displacement of the wires)
103
How is an **amoebic liver abscess** treated?
Aspirate and metronidazole
104
How is **leprosy** treated?
* Rifampicin * Dapsone * Clofazimine ## Footnote Diagnosed using skin-slit smear
105
Which antibiotics may be recommended as **Traveller's diarrhoea prophylaxis** in immunocompromised patients?
* Ciprofloxacin * Norfloxacin * Rifaximin
106
List some causes of **scarring alopecia**.
* Trauma, burns * Radiotherapy * Lichen planus * Discoid lupus * Tinea capitis (if untreated)
107
What are the indications for **N-acetylcysteine** in paracetamol overdose?
* Staggered overdose or doubt about time of ingestion * Plasma paracetamol level above the normogram line
108
When can **N-acetylcysteine** be stopped in someone with paracetamol overdose?
INR <1.3 and ALT less than **2x upper limit of normal**
109
List the causes of **HIGH anion gap metabolic acidosis**.
* **Lactate**: shock, sepsis, hypoxia * **Ketones**: diabetic ketoacidosis, alcohol * **Urate**: renal failure * **Acid poisoning**: salicylates, methanol
110
List the 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
111
Why should patients with **myasthenia gravis** who have shown no improvement in their symptoms despite 60 mg QDS pyridostigmine need to be admitted to hospital for steroid initiation?
High dose steroids (**60 mg prednisolone**) can cause a paradoxical reaction in up to half of patients, where their symptoms worsen initially.
112
What are the main features of **synthetic cannabinoid toxicity**?
* **CNS**: agitation, tremor, anxiety, confusion, somnolence, syncope, hallucinations, changes in perception, acute psychosis, nystagmus, convulsions and coma * **Cardiac**: tachycardia, hypertension, chest pain, palpitations, ECG changes * **Renal**: acute kidney injury * **Muscular**: hypertonia, myoclonus, muscle jerking and myalgia * **Other**: cold extremities, dry mouth, dyspnoea, mydriasis, vomiting and hypokalaemia
113
List some common drugs that cause **peripheral neuropathy**.
* Amiodarone * Isoniazid * Vincristine * Nitrofurantoin * Metronidazole
114
How is **granulomatosis with polyangiitis** treated?
Cyclophosphamide and steroids
115
List some contraindications for using **flecainide**.
* Post myocardial infarction * Structural heart disease: e.g. heart failure * Sinus node dysfunction; second-degree or greater AV block * Atrial flutter
116
How is **atypical haemolytic uraemic syndrome** managed?
* Supportive * Plasma Exchange * Eculizumab
117
What are the symptoms of **systemic mastocytosis**?
* Urticaria pigmentosa - produces a wheal on rubbing (Darier's sign) * Flushing * Abdominal pain * Mastocytosis on the blood film ## Footnote Associated with raised serum tryptase and urinary histamine.
118
What are the physical features of **pseudohypoparathyroidism**?
* Short fourth and fifth metacarpals * Short stature * Cognitive impairment * Obesity * Round face
119
How should **carbapenemase producing organisms** be treated?
* Polymyxins (e.g. colistin) * Tigecycline * Fosfomycin * Aminoglycosides (e.g. gentamicin)
120
Under what circumstance should a **GLP-1 agonist** be continued in a patient at their 6 month review?
If, after 6 months, **HbA1c** reduces by at least 11 mmol/mol.
121
What is the first line imaging modality in **multiple myeloma**?
Whole body MRI
122
Which ECG changes are seen in **Brugada syndrome**?
Convex ST elevation > 2 mm in more than 1 of V1 to V3 followed by a negative T wave Partial RBBB ## Footnote ECG changes may be more evident after administration of flecainide or ajmaline.
123
Which electrolyte abnormalities are associated with **tumour lysis syndrome**?
* HIGH Uric Acid * HIGH Potassium * HIGH Phosphate * LOW Calcium ## Footnote Clinical features: increased serum creatinine, arrhythmia, seizure
124
What **PTH level** would you expect in someone with familial hypocalciuria hypercalcaemia?
There may also be **normal to high parathyroid hormone**, despite the elevated serum calcium levels.
125
List some causes of **pulmonary eosinophilia**.
* Churg-Strauss syndrome * Allergic bronchopulmonary aspergillosis (ABPA) * Loffler's syndrome * Eosinophilic pneumonia * Hypereosinophilic syndrome * Tropical pulmonary eosinophilia * Drugs: nitrofurantoin, sulphonamides
126
What is **Loeffler's syndrome**?
* Transient CXR shadowing and eosinophilia associated with Ascaris lumbricoides * Causes fever, cough and night sweats * Self-limiting
127
Outline the strategies for preventing **tumour lysis syndrome** in patients undergoing chemotherapy.
* **Low risk**: Adequate Hydration * **Medium risk**: IV Fluids + Allopurinol * **High risk**: Rasburicase + IV Fluids
128
List the main contraindications for using **beta-blockers**.
* Uncontrolled heart failure * Asthma * Sick sinus syndrome * Concurrent verapamil use: may precipitate Severe bradycardia
129
How does **acute schistosomiasis** manifest?
* Marked eosinophilia * Cough * Bloody diarrhoea * Splenomegaly
130
What are the manifestations of **quinine toxicity**?
* Arrhythmia * Hypoglycaemia * Flash pulmonary oedema * Tinnitus, deafness and visual defects ## Footnote Treatment is supportive.
131
Outline how you interpret **nerve conduction study** results.
**Axonal** * normal conduction velocity * reduced amplitude * CAUSES: metabolic, toxic or heritable **Demyelinating** * reduced conduction velocity * normal amplitude * CAUSES: autoimmune processes, paraproteinaemia
132
How should a patient with a relapse of **Graves disease** after a trial of anti-thyroid medications be treated?
Definitive treatment with surgery or radioiodine
133
Outline the **BTS guidelines** for investigating **solitary lung nodules**.
* Nodule < 5mm, clear benign features, or unsuitable for treatment: discharge * Nodule ≥ 8mm and high risk: CT-PET; if high uptake, then biopsy * Nodule 5-6mm or ≥ 8mm and low risk: CT surveillance - 5-6mm: 1 year follow-up - ≥ 6mm: 3 months follow-up
134
What should be recommended for patients with **IBS** that is resistant to multiple laxatives at adequate doses?
Linaclotide
135
Which **antiemetic** should be avoided in patients with acute heart failure or ACS?
**Cyclizine**: it is an H1 receptor antagonist and anticholinergic that causes **systemic hypertension** and induces **tachycardia** which can compromise a fragile heart.
136
What is the first-line systemic agent for **psoriasis**?
Methotrexate ## Footnote Offer **ciclosporin** if need rapid control (e.g. psoriasis flare) or palmoplantar pustulosis or considering conception (men and women), next step would be **Acitretin**.
137
How does **heparin** affect thyroid function test results?
Heparin leads to rise in **free fatty acid levels** which inhibit binding of thyroid hormones to plasma-binding proteins causing a rise in T3 and T4
138
What are the **third-line treatment options** for **chronic heart failure**?
* **Ivabradine**: for sinus rhythm > 75/min and left ventricular fraction < 35% * **Sacubitril-Valsartan**: for left ventricular fraction < 35%, symptomatic on ACE inhibitors or ARBs, after wash-out period * **Digoxin**: improves symptoms, indicated with atrial fibrillation, but does not reduce mortality * **Hydralazine & Nitrate**: particularly for Afro-Caribbean patients * **Cardiac resynchronization therapy**: indicated for widened QRS (e.g., left bundle branch block) on ECG
139
What is the rapid appearance of multiple **seborrhoeic keratoses** suggestive of?
* Underlying malignancy (**known as Leser-Trelat Sign**) * Usually GI or liver cancer
140
What is the **Ki-67 index**?
* **Proliferation index** (marker of cancer cell metabolic rate) * Lymphomas with **LOW Ki-67**: Follicular, Mantle, Marginal Zone, Small Lymphocytic, Lymphoplasmacytic, Skin * Lymphomas with **HIGH Ki-67**: DLBCL, Burkitt, peripheral T-cell lymphoma
141
Which skin conditions exhibit **Koebner phenomenon**?
* Psoriasis * Vitiligo * Warts * Lichen planus * Lichen sclerosus * Molluscum contagiosum
142
How can **non-tuberculous mycobacterial disease** manifest?
* Hypersensitivity-like disease * Cavitating disease * Bronchiectasis with or without nodules ## Footnote Treatment: Rifampicin, clarithromycin and ethambutol
143
What is **POEMS syndrome**?
Rare paraneoplastic syndrome caused by a clone of abnormal plasma cells * **P**olyneuropathy * **O**rganomegaly * **E**ndocrinopathy * **M**-protein band from a plasmacytoma * **S**kin Pigmentation
144
What is an unwanted metabolic side-effect of **NRTIs**?
NRTIs: stavudine, zidovudine, didanosine **Mitochondrial toxicity** --> nausea, pancreatitis, lactic acidosis and lipoatrophy
145
List some consequences of **hypophosphataemia**.
* Red blood cell haemolysis * White blood cell and platelet dysfunction * Muscle weakness and rhabdomyolysis * Central nervous system dysfunction
146
What are the main features of **Friedreich ataxia**?
* Absent ankle jerks/extensor plantars * Cerebellar ataxia * Optic atrophy * Spinocerebellar tract degeneration
147
What pattern of deficits do you see in **anterior spinal artery occlusion**?
1. Bilateral spastic paresis 2. Bilateral loss of pain and temperature sensation
148
What are the main features of **neuromyelitis optica**?
* Quadriparesis or paraparesis within days to weeks * Vision changes * Normal brain MRI * Presence of anti-NMO antibodies (anti-aquaporin 4 antibodies)
149
What metabolic complication is associated with **sodium valproate** use?
Valproate-associated hyperammonaemic encephalopathy
150
Why is **atropine** contraindicated in patients with a heart transplant?
The transplanted hearts are denervated and do not respond to vagal blockade by atropine which might lead to **paradoxical sinus arrest**. ## Footnote IV theophylline should be used instead.
151
How is **cystinuria** treated?
* Hydration * D-penicillamine * Urinary alkalinisation (with potassium citrate)
152
What is the rule regarding **DEXA scans** in patients with fragility fractures?
If > 75 years, they can start a bisphosphonate **without a DEXA scan**
153
When does **renal graft failure** count as acute rather than chronic?
If it is **< 6 months**
154
What is **methaemoglobinaemia**?
Condition where haemoglobin is oxidized from Fe²⁺ to Fe³⁺ (regulated by NADH methaemoglobin reductase). Fe³⁺ **cannot bind oxygen**, causing tissue **hypoxia**.
155
How does **methaemoglobinaemia** present?
* Chocolate cyanosis * Shortness of breath, headache, anxiety * Acidosis, arrhythmia, seizures * Normal pO2 but low saturations
156
How is **methaemoglobinaemia** treated?
* NADH - methaemoglobinaemia reductase deficiency: ascorbic acid * IV methylthioninium chloride (methylene blue) if acquired
157
What is **acute disseminated encephalomyelitis**?
Autoimmune **demyelinating disease** of the CNS, often post-infection (common causes: MMR, varicella). ## Footnote Usually presents with motor and sensory deficits weeks to months after infection.
158
What are the features of a **lacunar stroke**?
* Unilateral weakness * Pure sensory stroke * Ataxic hemiparesis
159
How do you test for **paraquat poisoning**?
Urine dithionate test ## Footnote It can cause GI irritation, liver and kidney failure, and chemical pneumonitis and fibrosis.
160
Which ECG changes are most commonly associated with **HOCM**?
* RAD or LAD * Bundle branch block * PR prolongation * Non-specific T wave abnormalities
161
What are the main features of **von Hippel Lindau syndrome**?
* Haemangioblastomas (cerebellar, spinal and retinal) * Renal cell carcinoma * Phaeochromocytoma * Neuroendocrine tumours of the pancreas
162
How does **phenytoin toxicity** present?
Cerebellar signs (nystagmus, dysdiadochokinesia, broad-based gait)
163
What should you think about when someone on **SSRIs** develops a chronic history of abdominal pain and diarrhoea?
Microscopic colitis
164
What is the threshold for giving **steroids** in **PCP**?
pO₂ < 9.3 kPa ## Footnote Alternative treatments for PCP include clindamycin and primaquine.
165
What are the indications for giving **DigiBind** for digoxin toxicity?
* Haemodynamically unstable or life-threatening rhythm * Hyperkalaemia * Evidence of end-organ hypoperfusion
166
What are the first-line drugs for treating **diabetic neuropathy**?
* Pregabalin * Gabapentin * Duloxetine * Amitriptyline
167
What are the main features of **McArdle disease**?
* Muscle pain and stiffness following exercise * Muscle cramps * Myoglobinuria * Low lactate levels during exercise * Second wind phenomenon ## Footnote it is an **autosomal recessive** type V glycogen storage disease that leads to decreased muscle glycogenolysis.
168
What lipid profile results are expected in **dysbetalipoproteinaemia**?
* High cholesterol * High triglycerides * Normal HDL * Low LDL ## Footnote Caused by a defect in apo E; usually requires a second risk factor for issues. Palmar xanthomas are pathognomonic.
169
How does **beta-2 microglobulin amyloidosis** manifest?
* Manifests 5 or more years after starting **haemodialysis** * Affects the **axial skeleton** and is associated with tenosynovitis, carpal tunnel syndrome and shoulder pain.
170
What stimulant is best to manage symptoms of **cataplexy**?
Oxybate
171
In which types of **porphyria** are faecal porphyrins elevated?
* Hereditary coproporphyria * Variegate porphyria ## Footnote These two and acute intermittent porphyria present very similarly and are difficult to distinguish clinically.
172
How does **Chediak-Higashi syndrome** manifest?
* Oculocutaneous albinism * Bleeding diathesis * Recurrent infections * Peripheral neuropathy * Giant granules on leukocytes
173
What is **alkaptonuria**?
* Autosomal recessive disorder affecting phenylalanine and tyrosine metabolism. * Features include pigmented sclerae, urine turning black on air exposure, intervertebral disc calcification, and renal stones. * Treated with high-dose **vitamin C**.
174
How is **hepatotoxicity or hyperammonaemic encephalopathy** in sodium valproate overdose treated?
L-carnitine
175
List some causes of **Fanconi syndrome**.
* Cystinosis (most common cause in children) * Sjögren’s syndrome * Multiple myeloma * Nephrotic syndrome * Wilson's disease
176
List some absolute contraindications for **thrombolysis for stroke**.
* Previous intracranial haemorrhage * Seizure at onset of stroke * Intracranial neoplasm * Suspected subarachnoid haemorrhage * Stroke or traumatic brain injury in preceding 3 months * Lumbar puncture in preceding 7 days * Gastrointestinal haemorrhage in preceding 3 weeks * Active bleeding * Pregnancy * Oesophageal varices * Uncontrolled hypertension >200/120mmHg
177
Which antibodies are associated with the two different types of **autoimmune hepatitis**?
* **Type 1**: ASMA or ANA * **Type 2**: Anti-LKM or anti-liver-cytosolic 1
178
What is a **Holmes tremor**?
* Irregular low frequency tremor (combination of resting, postural and action) * Occurs due to lesion of red nucleus (e.g. due to previous stroke, tumour, MS)
179
Outline the NICE guidelines for **chronic plaque psoriasis**.
1. Potent topical steroid AND vitamin D analogue 2. Vitamin D analogue twice daily 3. Potent topical steroid twice daily OR coal tar preparation ## Footnote Alternative: Dithranol Specialist: Methotrexate, ciclosporin and phototherapy Last Line: Adalimumab
180
How is **hepatocellular carcinoma** in cirrhosis managed?
Liver transplantation if: * cirrhosis and single small HCC (< 5 cm) * up to three lesions < 3 cm
181
What is **multicentric reticulohistiocytosis**?
Non-Langerhans cell histiocytosis with skin and joint involvement (associated with cancer in 25% of cases)
182
List some causes of **chronic urticaria**.
* Autoimmune diseases * Lymphoma * Drug reactions (NSAIDs, opiates)
183
What is **homocystinuria**?
* Autosomal recessive disorder of methionine metabolism * Tall * Kyphoscoliosis * Livedo reticularis * Malar flush * Downward lens dislocation * Young strokes * Light brittle hair
184
Which **CDs** are usually associated with lymphoma?
* CD19 * CD20 * CD22 * CD79a * CD45
185
How is **Nocardia infection** treated?
Sulphonamide ## Footnote E.g. co-trimoxazole
186
How should **renal tubular acidosis** be treated?
Oral sodium bicarbonate, sodium citrate or potassium citrate.
187
How can **hemicrania continua and paroxysmal hemicrania** be distinguished from cluster headaches and SUNCT?
They are responsive to **indomethacin**.
188
How is **paraquat poisoning** treated?
Activated charcoal and fuller's earth
189
Which conditions recur in **renal transplant** patients?
* IgA nephropathy * Membranoproliferative glomerulonephritis (highest rate of recurrence) * Focal segmental glomerulosclerosis * Membranous glomerulonephritis
190
What is a very sensitive marker of **bone turnover** that is used in Paget's disease?
Serum non-isomerised C-telopeptide (CTx)
191
How does **thallium poisoning** present?
* Fluctuating mood (with or without confusion) * Painful distal paraesthesia * Alopecia ## Footnote Treatment: Oral Prussian Blue
192
What is the first-line oral therapy for **pyelonephritis**?
Oral cefalexin
193
Which other type of cancer is the **APC gene** associated with?
Thyroid cancer
194
What should you do with regular **TNF blockers** before major surgery?
Stop TNF blockers 2-4 weeks prior to surgery. Can restart once there's no infection and wound healing is satisfactory.
195
Which groups of patients benefit from **lung volume reduction surgery** for emphysema?
* Upper emphysema and low exercise capacity * Patients with predominantly upper lobe emphysema and high exercise capacity * Patients with non-upper lobe emphysema and low exercise capacity
196
Which group of patients with **mitral regurgitation** need to be referred for surgery despite being asymptomatic?
LVEF < 60%
197
How is **brucellosis** treated?
* ORAL: 6 weeks of doxycycline and rifampicin * ORAL + IV: 6 weeks of oral doxycycline + 3 weeks of IM streptomycin or IV gentamicin
198
Which common drugs cause **drug-induced cholestasis**?
* Flucloxacillin * Erythromycin * Chlorpromazine * Oral contraceptives * Anabolic steroids
199
How is **polycythaemia vera** management?
Aspirin and venesection aiming for PCV of < 0.45
200
Which test can be done in patients with suspected **growth hormone deficiency** in whom an insulin-tolerance test would be inappropriate?
Arginine-GHRH stimulation test
201
Which antibody is more likely to be positive in **Crohn's disease** than ulcerative colitis?
Anti-Saccharomyces cerevisiae antibodies
202
What can precipitate **lithium toxicity**?
* Dehydration * Renal failure * Drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
203
What is a common side-effect of **minocycline**?
Skin pigmentation with blue/black/grey discoloration ## Footnote Minocycline is a tetracycline used for rosacea.
204
How long after taking **acitretin** must you avoid getting pregnant?
3 years
205
What is **Zieve syndrome**?
Haemolysis, severe hyperlipidaemia and cholestatic jaundice in people with heavy alcohol abuse.
206
Which antipsychotic is best in patients with **Parkinson's disease**?
Quetiapine
207
What are the features of **McCune-Albright syndrome**?
* Precocious puberty * Cafe-au-lait pigmentation * Polyostotic fibrous dysplasia (multiple pathological fractures) * Hyperthyroidism
208
What measure is good to determine whether a patient is at risk of **tumour lysis syndrome** before commencing chemotherapy?
LDH
209
Which type of **ureteric calculus** commonly occurs in people with short bowel?
Oxalate
210
What are the main features of a **somatostatinoma**?
* Diabetes mellitus * Diarrhoea * Gallstones
211
Which investigation findings support a diagnosis of **Wilson's disease**?
* Reduced serum caeruloplasmin * Reduced total serum copper * Increased 24hr urinary copper excretion * ATP7B gene mutation
212
How is **paroxysmal nocturnal hemicrania** treated?
Indomethacin
213
What are the features of **theophylline toxicity**?
* Hypokalaemia * Hyperglycaemia * Tachycardia * Increased myocardial contractility
214
What are **early and late dumping syndromes**?
Both are complications of bariatric surgery. **Early**: rapid emptying of food into the small bowel causing colicky abdominal pain, diarrhoea and nausea **Late**: post-prandial hypoglycaemia due to hyperinsulinaemia
215
What are the two main associations of **pseudo-Cushing's syndrome**?
* Alcoholism * Depression
216
How is **pemphigus vulgaris** diagnosed?
Direct immunofluorescence of skin biopsy
217
What are the features of **myoclonic epilepsy with ragged red fibres (MERRF)**?
* Myopathy * Peripheral neuropathy * Ataxia * Wolff-Parkinson-White syndrome * Bilateral deafness
218
Which patients on bisphosphonates would be eligible for a **treatment break**?
* < 75 years * Femoral neck bone mineral density > -2.5 * Lack of history of fragility fracture ## Footnote Repeat DEXA in 2 years.
219
What is **multifocal motor neuropathy with conduction block**?
**Acquired autoimmune demyelinating motor neuropathy**. Presents with acute motor function loss in specific nerve distributions. As more nerves are involved, it resembles **motor neuron disease (MND)**. **MMNCB** shows a conduction block on nerve conduction studies, unlike MND. Treated with **IVIG**.
220
What is **lymphangioleiomyomatosis**?
Proliferation of atypical smooth muscle cells in the lungs, lymphatics, and uterus, likely caused by **estrogens**. ## Footnote Presents with progressive interstitial lung disease, pneumothorax, or chylous pleural effusion.
221
What are the main features of **Cowden syndrome**?
* Inherited cancer syndrome with **PTEN** mutation * Multiple hamartomas * Breast cancer (most common) * Endometrial cancer * Colorectal cancer * Thyroid cancer * Melanoma
222
Outline the guidelines for surgical management of **aortic regurgitation**.
Consider surgery for asymptomatic patients with resting ejection fraction < 50% and severe LV dilatation (LVESD > 50 mm or LVESD > 25 mm/m² in small body size). Surgery is indicated for all symptomatic patients, regardless of EF and LV dimensions.
223
What type of **COCP** should people taking carbamazepine take?
Any containing at least 50 micrograms of ethinylestradiol.
224
What is **babesiosis**?
**Tick-borne malaria-like** illness caused by *Babesia*. ## Footnote Causes fever, chills, rigors and red cell destruction (leading to haemolytic anaemia and haemoglobinuria).
225
How does **chancroid** manifest?
Single **painful genital ulcer** with painful inguinal **lymphadenopathy**. ## Footnote Caused by *H. ducreyi* and treated with macrolides or quinolones.
MRCP
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