1
Q
What is CRP?
A
Acute phase protein produced by the liver in response to increasing levels of IL-6 (produced by macrophages).
CRP binds to damaged and foreign cells, increases complement activation and phagocytosis by macrophages.
2
Q
What does swinging of a chest drain mean?
A
Chest drains should normally swing in response to breathing (inspiration –> fluid level up, expiration –> fluid level down).
Stopping swinging suggests that either the chest drain is blocked or the lung has re-expanded.
3
Q
What is the maximum rate at which you can remove fluid through a chest drain and why?
A
1 L at a time, followed by clamping for 1 hour.
Risk of re-expansion pulmonary oedema.
4
Q
Should a chest drain bubble?
A
Only if it is a chest drain for a pneumothorax.
If it is for a pleural effusion and it is bubbling, it may be suggestive of an air leak.
5
Q
How is digoxin loaded?
A
500 mcg –> 500 mcg (after 6 hours) then OD of:
- 125 mcg if tachycardic
- 62.5 mcg if normocardic
6
Q
When should digoxin be used for rate control?
A
Heart failure patients as it is a negative chronotrope and a positive inotrope.
7
Q
What is a good medical treatment option for SIADH that has not improved with fluid restriction?
A
Demeclocycline
It is a tetracycline antibiotic that is used to treat Lyme disease and acne. It is good in SIADH as it induces a nephrogenic diabetes insipidus.
8
Q
What is hidradenitis suppurativa?
A
Inflammatory skin condition characterised by recurrent painful skin abscesses.
9
Q
Which electrolyte should you be conscious of in patients who are receiving laxido/movicol?
A
Potassium
(laxido/movicol contains potassium)
10
Q
What dose should a nitrate infusion be started at?
A
2 mg/hour (50 mg in 50 mL); max dose 10 mg/hour.
11
Q
Which group of patients with active GI bleeding still require anticoagulation?
A
Inflammatory bowel disease (it is a prothrombotic state).
12
Q
What should you always think about in a patient with normal blood pressure who is tachycardic?
A
Do they need fluids?
CO = SV x HR
(if HR is high and CO is normal, then SV must be low)
Patients can have AF and be tachycardic without the tachycardia being caused by the AF (i.e. physiological tachycardia with AF).
13
Q
What are the main types of renal tubular acidosis?
A
- Type 1: DISTAL tubule dysfunction results in inability to excrete H+.
- Type 2: PROXIMAL tubule dysfunction results in inability to reabsorb bicarbonate.
- Type 4: ALDOSTERONE DEFICIENCY/RESISTANCE results in hyperkalaemia.
Type 1 and type 2 are associated with hypokalaemia.
14
Q
What is May Thurner syndrome?
A
Compression of the left common iliac vein by the overlying right common iliac artery.
Results in stasis of the blood and an increased risk of DVT.
15
Q
Which medication can be used to treat hiccups?
A
Chlorpromazine
(typical antipsychotic)
Not to be confused with prochlorperazine which is a related medication used as an antiemetic.
16
Q
What is short bowel syndrome?
A
Malabsorption caused by a lack of small bowel (leads to diarrhoea, dehydration, malnutrition and weight loss).
Patients are typically given slightly sweet and slightly salty liquids.
17
Q
What dosing should be used for fondaparinux in patients with NSTEMI?
A
2.5 mg SC OD for up to 8 days (or until hospital discharge if sooner).
18
Q
What is the link between magnesium deficiency and potassium deficiency?
A
Magnesium has an inhibitory effect on ROMK channels in the renal tubule, so a lack of magnesium results in increased excretion of potassium.
Magnesium deficiency also causes ineffective Na-K ATPase function.
19
Q
Why is magnesium used in the treatment of AF?
A
It acts as a weak calcium antagonist (blocks calcium at the AV node), resulting in a slower ventricular response.
This is the same way in which magnesium is used in asthma (relaxes the smooth muscle).
20
Q
What are ESBLs?
A
Extended-spectrum beta lactamases - bacteria that are resistant to penicillins and cephalosporins.
21
Q
Why do loop diuretics cause hypocalcaemia?
A
The triple transporter in the ascending limb of the loop of Henle will absorb Na+ /K+/2Cl-.
Na+ and 2CL will be reabsorbed whilst K+ diffuses back into the tubule. This creates an electrochemical gradient (more positive in lumen, more negative in interstitium). Ca2+ will then flow down this gradient.
Blocking the triple transporter with loop diuretics will stop this effect and more calcium will be excreted in the urine.
22
Q
What effect do thiazide diuretics have on calcium?
A
Thiazides promote calcium reabsorption (thereby causing hypercalcaemia).
Loop diuretics cause hypocalcaemia.
23
Q
What is atelectasis and what causes it?
A
Incomplete expansion of the lungs.
It can be caused by anything that can reduce ventilation of airspaces (e.g. obesity, anaesthesia during surgery, mucus plug).
It can cause hypoxia and increased risk of infection.
24
Q
Which bits of the brain are particularly affected by alcohol excess?
A
- Cerebellum
- Frontal lobe
- Limbic System
25
What is **bigeminy**?
Repeated heartbeat pattern (one long then one short) that is most often due to **ectopic beats** occurring so frequently that it happens after each sinus beat.
## Footnote
It does not require treatment unless it is symptomatic (then use beta-blockers).
26
What is **trigeminy**?
**Ventricular ectopic** occurs every **third** beat.
27
What is a **Premature Ventricular Contraction**?
Premature ventricular complexes are **early beats** originating from an **ectopic focus** within the ventricles rather than from the sinoatrial node.
28
What does **bifascicular block** look like?
RBBB + left or right axis deviation.
29
What does **trifascicular block** look like?
RBBB + left or right axis deviation + PR prolongation.
30
List and give examples for the classes of **antiarrhythmics**.
**Class 1** (Sodium Channel Blocker)
* 1a: Quinidine, Procainamide, Disopyramide, Ajmaline
* 1b: Lidocaine, Mexiletine, Phenytoin
* 1c: Flecainide, Propafenone
**Class 2** (Beta-Blocker): bisoprolol
**Class 3** (Potassium Channel Blocker): amiodarone
**Class 4** (Calcium Channel Blockers): verapamil
31
What are the **AEIOU indications** for haemofiltration?
* Acidosis
* Electrolyte Abnormalities (hyperkalaemia)
* Ingestion of Toxins
* Overload (Fluid)
* Uraemic Symptoms
32
What effect does multiple units of **packed red cells** have on coagulation?
It leads to an **anticoagulant effect** (as the packed red cell samples contain anticoagulant (calcium citrate)).
This means that patients should also receive **FFP** if they have any more than 4 units of packed red cells.
33
How does **mycobacterium avium complex** present in patients who are immunocompromised?
* Similar to lymphoma
* Enlarged lymph nodes
* Fever
* Night sweats
* Weight loss
34
What is an advantage of **RIG** over PEG?
RIG **does not require sedation** and hence is better in patients with respiratory compromise (e.g. MND).
35
What is the main consequence of **heparin-induced thrombocytopaenia**?
Thrombosis
## Footnote
The binding of heparin to platelet factor 4 stimulates the generation of antibodies.
These antibodies then bind to the heparin-platelet factor 4 complex and cause platelet activation resulting in thrombosis formation and depletion of platelets.
36
What does **right ventricular strain** look like on an ECG?
ST depression and T wave inversion in V1-3, I, II and aVF.
37
How do you convert **oral codeine** to **oral morphine**?
10 mg codeine = 1 mg morphine.
## Footnote
Breakthrough pain should be 1/6 of the total daily dose of morphine.
38
Which organism is associated with causing **infective endocarditis** in patients with **colorectal cancer**?
Streptococcus bovis.
39
What is the first-line treatment option for **pericarditis**?
NSAIDs and colchicine.
40
How does **TRALI** present?
* Hypoxia
* Bilateral pulmonary infiltrates
* Fever
* Hypotension
## Footnote
It is caused by the activation of host neutrophils by substances in the blood products. This triggers an inflammatory reaction within the lungs.
41
Which drugs increase the risk of **gout**?
* Alcohol
* Diuretics
* Cytotoxics
* Ciclosporin
* Pyrazinamide
42
List some triggers for **psoriasis**.
* Beta-blockers
* Antimalarials
* Stress
* Streptococcal infection (guttate)
43
What is an **indium labelled white cell study** used for?
* It labels **white cell** and watches where they accumulate (a bit like a PET scan for infection).
* It is good for identifying **occult abscesses**.
44
What pleural fluid results would you expect in a patient with **empyema**?
* pH < 7.2
* Glucose < 3.3 mmol/L
* LDH > 1000
45
How do **aminophyllines** work?
* **Non-selective phosphodiesterase inhibitor** (raises cAMP --> activate PKA --> inhibits TNF-alpha and leukotriene synthesis).
* **Non-selective adenosine receptor antagonist**.
## Footnote
End result is **bronchodilator**.
46
What are the presenting features of **cerebral venous sinus thrombosis**?
* Headache
* Papilloedema
* Tonic Clonic Seizures
## Footnote
MR or CT angiography/venography is required for diagnosis, and it is treated with anticoagulation.
47
How does **Whipple's disease** manifest?
Diarrhoea and arthropathy
## Footnote
It can also cause lymphadenopathy, skin hyperpigmentation, pleurisy and pericarditis.
Duodenal biopsy shows subtotal villous atrophy which is **PAS stain positive** (caused by *Tropheryma whipplei*).
It is treated with oral co-trimoxazole.
48
What is the first-line treatment option for **gout**?
NSAIDs
## Footnote
Colchicine 500 mg QDS can be used if NSAIDs are contraindicated (reduced dose of 500 mg BD can be used in patients with renal impairment).
49
What is **juvenile myoclonic epilepsy**?
Condition characterised by generalised tonic clonic seizures usually provoked by sleep deprivation and excessive alcohol intake.
50
Which common class of medications reduce excretion of **lithium**?
Diuretics
| (in particular, thiazide diuretics)
51
What is the **cardiac index**?
A haemodynamic parameter measured in intensive care which divides **cardiac output** from the left ventricle in one minute by the total body surface area.
## Footnote
Low cardiac index is suggestive of **cardiogenic shock**.
52
What are the typical presenting features of **inclusion body myositis**?
Weakness of **quadriceps** and long muscles of fingers.
## Footnote
CK may be normal.
53
What is **Waldenstrom's macroglobulinaemia**?
A lymphoproliferative disorder characterised by **IgM paraproteinaemia**.
## Footnote
It can result in hyperviscosity and splenomegaly.
54
Which nerve root is responsible for the **biceps reflex**?
C56
## Footnote
Damage to this root will result in **Erb's palsy** (loss of abduction and loss of biceps-mediated supination).
55
What is **Liddle syndrome**?
A secondary cause of hypertension resulting from a **mutated epithelial sodium channel**.
## Footnote
Results in hypertension, alkalosis and hypokalaemia with suppressed renin and aldosterone.
56
What are the main features of **dengue fever**?
* Fever
* Muscle aches
* Headache
* Rash
## Footnote
Lymphopaenia, Thrombocytopaenia and deranged LFTs.
57
Which mutation is most often responsible for **MODY**?
Hepatic Nuclear Factor 1A
| (HNF1A)
## Footnote
MODY presents in early adulthood with insulin-dependent diabetes mellitus (autosomal dominant) * they are very sensitive to sulphonylureas.
58
When should **phenytoin levels** be checked after oral loading?
In roughly **2 weeks** as phenytoin has a long half-life and therefore takes time to reach steady state concentrations.
## Footnote
Aim 10-20 mg/L.
59
What are the main functions of the **proximal convoluted tubule**?
* Reabsorb sodium, amino acids and glucose.
* Exchange **H+ ions for bicarbonate** (reabsorb bicarbonate).
60
What are the symptoms of **Waldenstrom hyperglobulinaemia**?
* Headaches
* Nose bleeds
* Hepatosplenomegaly
* Papilloedema
## Footnote
Resulting from hypercoagulable state (Ix: protein electrophoresis).
61
What is the standard therapy used for **small cell lung cancer**?
Cisplatin and Etoposide
## Footnote
Carboplatin is used for those who cannot tolerate cisplatin.
62
How does **syringomyelia** manifest?
* Weakness in hands then arms (anterior horn cells).
* Loss of pain and temperature in upper limbs (cape-like).
* Followed by loss of fine touch, vibration and proprioception later on.
63
What is the **imidazoline receptor**?
A receptor that can stimulate the **sympathetic nervous system**.
## Footnote
Clonidine and Moxonidine block this receptor to achieve a reduction in blood pressure.
64
What are the main consequences of **hypophosphatemia**?
* Haemolytic anaemia
* Seizures
* Confusion
* Cardiomyopathy
* Skeletal Muscle Weakness
65
List some causes of **hypophosphataemia**.
**Increased Renal Excretion**
* Hyperparathyroidism
* X-Linked Hyperphosphataemia
* Fanconi Syndrome
* Diuretics
**Decreased GI Absorption**
* Reduced intake
* Phosphate binders (sevelamer).
* Alcoholism
**Transcellular Shifts**
* Refeeding syndrome
* Insulin
66
What is the treatment of choice for **TTP**?
Plasma exchange
| (steroids may be used as an adjunct)
67
Damage to which part of the brainstem would result in **upgaze and downgaze palsy**?
Dorsal Midbrain
## Footnote
It may also be associated with convergence nystagmus and impaired pupillary reflexes. Known as Parinaud syndrome.
68
What is the treatment of choice for **cerebral toxoplasmosis**?
Sulfadiazine + Pyrimethamine + Folinic Acid for 6 Weeks.
69
Describe the appearance of the rash in **Darier's disease**.
* Warty brown papules on the chest and back.
* Autosomal dominant inheritance pattern.
70
What are the presenting symptoms of **variant CJD**?
* Rapidly progressive dementia
* Ataxia
* Myoclonus
## Footnote
MRI --> Pulvinar Sign (High intensity in pulvinar region of thalamus) described as 'hockey stick sign'.
71
Which antiemetic is used in the treatment of nausea and vomiting in **hypercalcaemia**?
Haloperidol
## Footnote
This is the most potent D2 antagonist and the mechanism of hypercalcaemia induced nausea is via the D2 receptor.
72
Which foramen do **cranial nerves IX, X and XI** pass through?
Jugular Foramen
73
What is an appropriate fluid regime for someone who is admitted with **DKA**?
* 1 L 0.9% NaCl over 1 Hour
* 1 L 0.9% NaCl + KCl over 2 Hours
* 1 L 0.9% NaCl + KCl over 2 Hours
* 1 L 0.9% NaCl + KCl over 4 Hours
* 1 L 0.9% NaCl + KCl over 6 Hours
## Footnote
ADD 10% Dextrose at 125 mL/hour once BM < 14 mmol/L.
BOLUS: 500 mL NaCl if SBP < 90 mm Hg.
74
How should patients with **DKA** be monitored after commencing treatment?
* **Hourly** capillary ketones and glucose.
* VBG at 1 hour, 2 hours then every 2 hours thereafter.
75
What is **diabetic amyotrophy**?
* Complication of diabetes mellitus that results from damage to the **lumbosacral plexus** (supplying thighs and buttocks).
* Manifests with lower leg pain, weakness, wasting and paraesthesia.
76
List some **CYP inhibitors** that can increase the effect of **warfarin**.
* Ciprofloxacin
* Clarithromycin
* Erythromycin
* Omeprazole
* Metronidazole
* Chloramphenicol
* Cranberry Juice
77
What are the manifestations of **Brucellosis**?
* Fever
* Myalgia
* Weight loss
* Headache
* Abdominal pain
## Footnote
Bloods may show deranged LFTs but everything else may be normal.
Blood cultures will be positive after 5 days (slow growing).
Caused by exposure to unpasteurised dairy products.
78
What is **high take off** on an ECG?
* **Benign early repolarisation** (looks like pericarditis) common feature in < 50 yrs
* ST elevation in precordial leads
* Prominent T waves
* ST segment/T wave ratio < 0.25
* Fishhook appearance in V4
* ECG changes are stable over time
79
Which ECG change is seen in **hypocalcaemia**?
QT prolongation
## Footnote
You get QT shortening in hypercalcaemia.
80
Why does **metformin** cause **lactic acidosis**?
Mitochondrial toxicity + impaired gluconeogenesis (impairs pyruvate carboxylase which normally converts pyruvate into oxaloacetate).
81
What can be used as an antidote for excessive **beta blockade**?
IV glucagon
82
What are some features of **lead poisoning**?
* Abdominal pain
* Motor neuropathy
* Basophilic stippling
83
Why is **furosemide** not effective in **hypoalbuminaemic states**?
It is **highly protein bound** and requires protein binding in order to be secreted into the filtrate at the proximal convoluted tubule.
## Footnote
Other causes of reduced protein binding of furosemide include the presence of competing highly protein-bound drugs like phenytoin and warfarin.
84
What are the presenting features of **lateral medullary syndrome**?
* Ipsilateral facial sensory loss
* Contralateral body sensory loss
* Cerebellar features (dysphagia, dysarthria, vertigo, nystagmus)
## Footnote
Due to PICA aneurysm/stroke.
85
What is a major side-effect of **ribavirin therapy**?
Haemolytic anaemia
86
Which antibiotic causes a worsening of muscle weakness in **Guillain-Barre symptoms**?
Ciprofloxacin
87
How is **severe lithium overdose** treated?
Haemodialysis
| (especially if level is > 4 mmol/L)
88
Name a long-acting **opioid receptor antagonist** used to prevent relapse in people who abuse opioids.
Naltrexone
89
List some common drugs that can increase **serum lithium concentration**.
* Metronidazole
* NSAIDs
* ACE inhibitors and ARBs
* Thiazide diuretics
* Steroids
90
Describe the main features of **pseudoxanthoma elasticum**.
* **SKIN**: yellow papules over neck, puckered skin.
* **VASCULAR**: PVD, mitral valve prolapse, GI bleed, visual loss (retinal angioid streaks).
## Footnote
It is a hereditary disorder of elastic tissue.
91
Which **HLA types** are associated with **Coeliac disease**?
HLA DQ2 and DQ8.
92
Which type of **lupus** is ANA negative?
Discoid lupus
93
What are the two main types of **porphyria** and what is the difference?
* Acute intermittent porphyria (no photosensitivity)
* Variegate porphyria (photosensitivity)
## Footnote
Both present with abdominal pain and hypertension.
94
What is **oral hairy leukoplakia** caused by?
EBV
95
What are the features of **theophylline toxicity**?
* Severe vomiting
* Seizures
* Hyperthermia
* Hypokalaemia
* Hyperglycaemia
* Tachyarrhythmia
96
How is **ITP** managed?
Oral Prednisolone --> IVIG
## Footnote
Splenectomy and immunosuppressive drugs (e.g. cyclophosphamide) may also be used.
97
What is **Evans syndrome**?
AIHA + ITP
## Footnote
It is treated with steroids.
98
What is the issue with using **iodine-containing contrast** in patients with **hyperthyroidism**?
* It can worsen hyperthyroidism caused by toxic multinodular goitre.
* It can improve hyperthyroidism in Graves' disease.
## Footnote
A thyroid uptake scan would be recommended.
99
What are the features of **lithium overdose**?
* Decreased consciousness
* Neuromuscular excitability (tremor)
* Confusion
* Abdominal pain
* Vomiting
* AKI
* ECG Changes (TWI, QT prolongation)
100
How is **tapeworm infection** treated?
Niclosamide 2 g STAT
## Footnote
Tapeworm is caused by *Taenia solium* (pork) or *Taenia saginata* (beef).
101
What is the recommended antibiotic treatment option for **cholera**?
Ciprofloxacin
102
List some manifestations of **temporal lobe epilepsy**.
* Ascending epigastric aura
* Olfactory/gustatory hallucinations
* Ictal fear
* Lip smacking/swallowing
* Limb automatisms (fiddling, tapping)
## Footnote
Caused by hippocampal sclerosis.
103
What is a major complication of **diphtheria**?
Myocarditis
104
Which **chemotherapy agents** are commonly associated with **peripheral neuropathy**?
* Vincristine
* Cisplatin (platinum containing compounds)
* Docetaxel (taxanes)
105
What is the dose conversion between **hydrocortisone** and **prednisolone**?
20 mg IV/PO Hydrocortisone = 5 mg PO Prednisolone
106
Which translocation causes **APML**?
15;17
## Footnote
It is associated with DIC.
107
Which cytokine is a particularly important target in the treatment of **rheumatoid arthritis**?
IL-6 (tocilizumab)
108
What is **Ganser syndrome**?
**Dissociative disorder** characterised by approximate answers, pseudohallucinations, somatic conversion, amnesia and reduced consciousness.
109
What is the first-line treatment option for **cervical dystonia**?
Botulinum toxin injections.
110
List some X-ray features of **osteomyelitis**.
* Regional osteopaenia
* Periosteal reaction
* Focal bone lysis or cortical loss
111
How should exposure to **hepatitis C** be treated?
Monthly hepatitis C PCR.
## Footnote
If it becomes positive, patients should be offered ribavirin and interferon (or daclatasvir).
112
What is **Menetrier disease**?
A rare condition associated with enlarged gastric folds in the fundus and body of the stomach.
## Footnote
It causes epigastric pain, protein loss (hypoalbuminaemia) and hypochlorhydria.
113
What are the features of **Jervell and Lange-Nielsen syndrome**?
Long QT and bilateral sensorineural hearing loss.
114
Why does **urea** increase in dehydration?
**Vasopressin** increases the activity of urea transporter 1 (UT-A1) in the collecting ducts.
## Footnote
The thin ascending limb of the loop of Henle and the inner medullary collecting ducts are permeable to urea. Urea adds to the osmolality of the medullary interstitium, thereby allowing the nephron to concentrate urine.
115
Why do **psoas abscesses** form?
The **iliopsoas** muscle has a very rich blood supply meaning that it is predisposed to **haematogenous spread of infection**.
116
What is **DRESS syndrome**?
**Drug Reaction** with **Eosinophilia** and **Systemic Symptoms**.
## Footnote
**TRIAD**: extensive skin rash + high fever + organ involvement (e.g. liver impairment).
Occurs most commonly with use of anticonvulsants (e.g. carbamazepine), allopurinol and sulphonamide antibiotics.
117
Why do you give a STAT **amikacin** for the treatment of **urosepsis**?
Treat the **ESBLs**.
## Footnote
They will be resistant against co-amoxiclav.
118
Briefly describe **Gitelman**, **Bartter** and **Liddle syndrome**.
* **Gitelman**: dysfunction of Na-Cl cotransporter in distal convoluted tubule (effects similar to thiazide diuretic use), leads to low calcium and low magnesium.
* **Bartter**: dysfunction of Na-K-Cl triple transporter in ascending limb of loop of Henle (effects similar to loop diuretic use).
* **Liddle**: prevention of degradation of ENaC in collecting duct (effects similar to hyperaldosteronism).
119
What is another name for **cANCA**?
Anti-myeloperoxidase antibody.
## Footnote
CANCA target proteinase 3.
120
What is the antibiotics treatment regimen of choice for **cystic fibrosis** patients with **Pseudomonas infection**?
Ceftazidime and tobramycin.
121
What are some features of **chronic lead poisoning**?
* Developmental delay
* Abdominal pain
* Blue line on gums
* Constipation
122
What are some clinical features of **vestibular schwannoma**?
* Unilateral sensorineural hearing loss
* Ipsilateral ataxia
* Facial weakness
* Trigeminal sensory loss
123
How is a **low-dose dexamethasone suppression test** performed?
* 1 mg dexamethasone at midnight.
* Measure serum cortisol at 9 am.
124
What is the difference between **Wells**, **PERC** and **PESI**?
* **Wells**: Determine whether CTPA or D-Dimer would be required.
* **PERC**: Determine whether a PE is even a feasible possibility/requires further investigation.
* **PESI**: Determines mortality in people with a diagnosed PE.
125
Which marker is used as a screening test for **fungal infections**?
Beta-D Glucan
126
At what point do you consider using **negative suction** to resolve a **pneumothorax**?
If a chest drain has **failed to resolve the pneumothorax** and there is a persistent air leak after 48 hours.
127
What causes **TRALI**?
Presence of **anti-HLA antibodies** in the donated blood product.
128
What are the **Truelove and Witts criteria** for a severe **UC flare**?
* Bloody stools > 6 per day
* HR > 90
* Temp > 37.8
* Hb < 10.5
* ESR > 30
* CRP > 30
129
What is an option for the treatment of **severe hand eczema**?
Alitretinoin
130
Name a novel drug that is used to treat **multiple sclerosis**.
Fingolimod
## Footnote
It is a sphingosine-1-phosphate receptor modulator which affects the activity of lymphocytes.
131
What is the most common cause of **line-related sepsis**?
Staphylococcus aureus
132
What are some side-effects of **phenytoin**?
* Ataxia
* Nystagmus
* Agitation
* Drowsiness
| (Cerebellar signs)
133
How is **exercise testing** interpreted according to the **Bruce protocol**?
Patients who cannot undergo two stages of the Bruce protocol (< 6 mins) are at higher risk of adverse cardiovascular events and should be considered for coronary angiography.
134
How do you dose **amiodarone** for cardioversion?
300 mg over 30-60 mins followed by 900 mg over 24 hours.
## Footnote
Needs to be infused through a large cannula into a large peripheral vein or into a central vein as it can cause thrombophlebitis.
135
What should you do with **metformin** in someone who is going to undergo an **angiogram**?
Metformin should be held for 48 hours before and after any procedure involving IV contrast (e.g. CT scan, angiogram).
## Footnote
This is because it could increase the risk of lactic acidosis.
136
How do you manage a relapse of **multiple sclerosis**?
Oral methylprednisolone 0.5 g OD for 5 days.
137
Which medication is used as prophylaxis for patients who suffer **cluster headaches**?
Verapamil
## Footnote
Alternatives: lithium, sodium valproate, gabapentin.
138
Which type of **myocardial infarction** and **rhythm disturbance** would require temporary transvenous pacing?
Second or third degree heart block complicating an acute anterior MI.
139
What is the normal systolic pressure of the **pulmonary artery**?
25 mm Hg
140
How can arrhythmias be prevented in patients with **long QT syndrome**?
* Beta-blockers
* ICD
* Sympathectomy
141
What are the main presenting symptoms of **systemic mastocytosis**?
* Urticaria pigmentosa (with Darier sign)
* Abdominal Pain
* Flushing
* Monocytosis on blood film
142
Which investigations are used in suspected **systemic mastocytosis**?
* Raised serum tryptase levels
* Urinary histamine
143
What are the main features of **benign essential tremor** and how is it managed?
* **Postural tremor** that is worse when arms are outstretched.
* Improves with alcohol.
## Footnote
Propranolol is the first-line treatment (primidone is used sometimes).
144
What is the most commonly isolated organism in **animal bites**?
Pasteurella multocida
## Footnote
Treated with co-amoxiclav (same with human bites).
145
List some **CYP inducers** that decrease the efficacy of **warfarin**.
* Antiepileptics (phenytoin, carbamazepine)
* Rifampicin
* St. John's Wort
* Alcohol intake
146
Which **beta-blockers** are best in the treatment of **heart failure**?
* Bisoprolol
* Nebivolol
* Carvedilol
147
What is a **hybridoma**?
A technique for producing **monoclonal antibodies** which combines mouse spleen cells with human myeloma cells.
## Footnote
The antibodies generated have a mouse variable region and a human constant region.
148
At what stage should a patient with **rheumatoid arthritis** be considered for a trial of a **biologic agent**?
After 2 DMARDs have been trialled and disease activity remains high (DAS28-CRP or DAS28-ESR > 5.1).
149
How is **Ramsay Hunt syndrome** treated?
Oral **aciclovir** and oral **steroids**.
150
Which neuronal tracts are affected in **subacute combined degeneration** of the spinal cord?
**Dorsal columns** (resulting in loss of vibration and proprioception).
**Lateral corticospinal tract** (upper motor neurone findings in the legs).
Damage to peripheral nerves results in loss of knee and ankle jerks.
151
How does **retinitis pigmentosa** manifest?
Night blindness and tunnel vision.
## Footnote
It is genetic and associated with Refsum disease, Usher syndrome, abetalipoproteinemia, Laurence-Moon-Biedl syndrome, Kearns-Sayre syndrome and Alport syndrome.
152
What are the first and second-line agents for secondary prevention in patients who have had a **stroke or TIA**?
* **Clopidogrel** 75 mg OD.
* If not tolerated --> **Aspirin** 75 mg OD + **Dipyridamole** 200 mg BD.
153
What would be a permanent solution to a patient with recurrent **atrial flutter**?
Radiofrequency ablation to the tricuspid valve isthmus.
154
How is **acne rosacea** treated?
**1st line**: topical metronidazole (mild).
**2nd line**: systemic antibiotics (e.g. oxytetracycline) for severe disease.
## Footnote
Topical brimonidine gel may be used in patients predominantly complaining of flushing.
155
What are the **phase I** and **phase II reactions** in **drug metabolism**?
**Phase I**: Oxidation, Reduction and Hydrolysis (products are usually more active and may be toxic).
**Phase II**: Conjugation (products are inactive and excreted in the urine or bile).
156
How is **Cryptosporidium** diagnosed?
Modified **Ziehl-Neelsen** staining of stool to reveal red cysts.
157
What are the two main **parametric tests** used in medical trials?
* Student's t-test (paired or unpaired).
* Pearson's product-moment coefficient correlation.
158
What are the main **non-parametric tests** used in medical trials?
* **Mann-Whitney U test**: compares ordinal, interval, or ratio scales of unpaired data.
* **Wilcoxon signed-rank test**: compares two sets of observations on a single sample, e.g. a 'before' and 'after' test on the same population following an intervention.
* **Chi-squared test**: used to compare proportions or percentages e.g. compares the percentage of patients who improved following two different interventions.
* **Spearman’s or Kendall’s rank correlation**: assesses the association between ranked or non-normally distributed variables.
159
What are the features of **S1 nerve root compression**?
* Sensory loss of posterolateral aspect of leg and lateral aspect of foot.
* Weakness in plantar flexion of foot.
* Reduced ankle reflex.
* Positive sciatic nerve stretch test.
160
How long should patients be anticoagulated for if they are to have elective **DC cardioversion**?
Anticoagulated for **at least 3 weeks**.
## Footnote
After DCCV, the patient should be anticoagulated for at least 4 weeks before decisions about anticoagulation should be made.
Patients can have a TOE and, if negative, be heparinised and receive DCCV then and there. If there is high risk of cardioversion failure (e.g. previous failure or AF recurrence) then patients should also have at least 4 weeks of amiodarone or sotalol before DCCV.
161
What are the main homozygous genotypes of **alpha 1 antitrypsin deficiency**?
* PiMM = normal.
* PiSS = A1AT 50% of normal.
* PiZZ = A1AT 10% of normal.
## Footnote
This is the type that gets lung/liver manifestations.
162
What are the manifestations of a **parietal lobe lesion**?
* Sensory inattention
* Apraxia
* Astereognosis
* Inferior homonymous quadrantanopia
* Gerstmann syndrome (lesion of dominant parietal lobe): alexia, acalculia, finger agnosia and right-left disorientation
163
What is an important complication of **topiramate treatment**?
Acute angle closure glaucoma
## Footnote
Presents with acute myopia, headache and unreactive pupils.
164
Which dermatomes are affected by **C6-8 radiculopathies**?
* C6 - thumb and index finger.
* C7 - middle finger + palm of hand.
* C8 - ring + little finger.
165
How is **idiopathic pulmonary artery hypertension** treated?
* Prostacyclin analogues (treprostinil)
* Endothelin receptor antagonists (bosentan)
* Phosphodiesterase inhibitors (sildenafil)
## Footnote
If good response to acute vasodilator testing CCBs may be used (minority of patients).
166
List some **NRTIs** and **NNRTIs**.
* **NRTI**: zidovudine, abacavir, emtricitabine, lamivudine, tenofovir.
* **NNRTI**: nevirapine, efavirenz.
167
What are the presenting features of **porphyria cutanea tarda**?
* Photosensitive rash with blistering in sun-exposed areas (usually hands)
* Hypertrichosis
* Hyperpigmentation
## Footnote
Treated with chloroquine and venesection.
168
What is **internuclear ophthalmoplegia** and which part of the brain is affected?
* Inability to adduct the affected eye resulting in **nystagmus** and **diplopia**.
* It is caused by damage to the **median longitudinal fasciculus** which is found in the paramedian area of the midbrain and pons.
169
How is **ethylene glycol poisoning** treated?
**Fomepizole** (inhibitor of alcohol dehydrogenase).
## Footnote
Ethanol used to be used to treat this.
170
How does **Kearns-Sayre syndrome** present?
* External ophthalmoplegia
* Retinitis pigmentosa (night blindness)
* Ptosis
* Usually < 20 yrs
* Diabetes mellitus (insulin-dependent)
* Complete heart block
* Cardiomyopathy
* Recurrent stroke
* Maternal inheritance
171
What is the first-line treatment for **severe mitral stenosis**?
Percutaneous mitral commissurotomy (balloon valvulotomy).
## Footnote
Transcatheter mitral valve repair is a second choice.
172
List some medications that can exacerbate **myasthenia gravis**.
* Beta-blockers
* Antibiotics (gentamicin, macrolides, quinolones, tetracyclines)
* Phenytoin
* Lithium
* Penicillamine
* Procainamide
173
Which antigen is the antibody in **pemphigus vulgaris** and **bullous pemphigoid** directed against?
* **Pemphigus Vulgaris**: Desmoglein 3
* **Bullous Pemphigoid**: Hemidesmosome
174
What does the **Golgi apparatus** add to protein in order to traffic them to lysosomes?
Mannose-6-phosphate
175
What is the second-line treatment option for **angina** if beta-blockers and rate-limiting calcium channel blockers are contraindicated?
Nicorandil (potassium channel activator).
## Footnote
It is associated with causing gastrointestinal ulceration (ranging from oral ulcers to anal ulcers).
176
List the commonly used steroids in order of decreasing **mineralocorticoid activity**.
* Hydrocortisone (most mineralocorticoid activity)
* Prednisolone
* Dexamethasone/Betamethasone
177
What are the main symptoms of **renal vein thrombosis**?
* Sudden-onset flank pain
* Deterioration in renal function
* Haematuria
178
What is **chronic granulomatous disease** and how does it present?
* Neutrophil disorder resulting from a lack of **NADPH oxidase**, which reduces the ability of the neutrophil to produce ROS.
* Presents with recurrent pneumonia/abscesses (particularly *S. aureus* and fungi like *Aspergillus*).
179
How is **chronic granulomatous disease** diagnosed?
Negative **nitroblue-tetrazolium test** and abnormal **dihydrorhodamine** flow.
180
What is **Chediak-Higashi syndrome** and how does it present?
* Neutrophil disorder resulting from a defect in **microtubule polymerisation** leading to reduced phagocytosis.
* Affected children have **partial albinism** and **peripheral neuropathy**, **recurrent bacterial infections**.
181
What is **leucocyte adhesion deficiency** and how does it present?
* Neutrophil disorder caused by defect in **LFA-1 integrin** on neutrophils.
* Leads to recurrent bacterial infections, delay in umbilical cord sloughing and absence of neutrophils at site of infection.
182
How does **common variable immunodeficiency** present?
* It is a B cell disorder that results in **hypogammaglobulinaemia**.
* It may predispose to lymphoma and autoimmune disorders.
183
What is **Bruton's X-linked agammaglobulinaemia**?
* B cell disorder characterised by a defect in **Bruton's tyrosine kinase** resulting in a severe block in B cell development.
* Patients develop recurrent bacterial infections, there is an absence of B cells and reduced immunoglobulins of all classes.
184
How might **selective IgA deficiency** manifest?
* Recurrent sinus and respiratory tract infections.
* Associated with coeliac disease.
* May develop severe reactions to blood transfusions (due to anti-IgA antibodies).
185
What is **DiGeorge syndrome** and how does it manifest?
* T cell disorder caused by **22q11.2 deletion** resulting in failure to develop the 3rd and 4th pharyngeal pouches.
* Manifestations include congenital heart disease (e.g. tetralogy of Fallot), learning difficulties, hypocalcaemia, recurrent viral/fungal diseases, cleft palate.
186
List some combined **B and T cell disorders**.
* **SCID** (multiple causes).
* **Ataxia Telangiectasia** (defect in DNA repair, leads to cerebellar ataxia, telangiectasia, recurrent chest infections and increased risk of malignancy).
* **Wiskott Aldrich Syndrome** (defect in WASP gene, recurrent bacterial infection, eczema, thrombocytopaenia, autoimmune diseases).
* **Hyper IgM Syndrome** (mutation in CD40 gene, hepatitis, diarrhoea, PCP infection).
187
What are the recommendations for **secondary prevention** of **osteoporotic fractures** in postmenopausal women?
**1st line**: alendronate.
**2nd line**: risedronate or etidronate.
**3rd line**: strontium ranelate or raloxifene.
188
What is **myotonic dystrophy** and what are its main features?
* Inherited myopathy that presents at around 20-30 years.
* **Autosomal dominant** trinucleotide repeat disorder (DM1 caused by CTG repeat, DM2 is caused by repeat expansion of ZNF9 gene).
* Main features are myotonic facies, frontal balding, bilateral ptosis, cataract and dysarthria.
## Footnote
Also associated with dysphagia, diabetes mellitus, mild mental impairment, testicular atrophy, heart block and cardiomyopathy.
189
How should **giant cell arteritis** be managed?
* **Uncomplicated**: (no visual involvement or tongue/jaw claudication) --> PO prednisolone 40-60 mg OD.
* **Complicated**: (visual involvement and/or tongue/jaw claudication) --> IV methylprednisolone 500-1000 mg for 3 days before starting oral prednisolone.
190
List some features of **severe malaria**.
* Schizonts on a blood film
* Parasitaemia > 2%
* Hypoglycaemia
* Acidosis
* Temperature > 39 °C
* Severe anaemia
* Cerebral malaria (seizures, coma)
* Acute renal failure
* ARDS
* DIC
191
What is an important contraindication of **anticholinergic treatment** for **urge incontinence**?
Previous history of urinary retention.
## Footnote
It should also be avoided in the elderly as it can worsen confusion.
192
What is the main test used to screen for **latent TB**?
Mantoux
## Footnote
IGRA is used if Mantoux is positive.
193
What can precipitate **pompholyx eczema**?
High humidity and heat.
194
What are the main translocations associated with the various types of **lymphoma/leukaemia**?
* Follicular Lymphoma: t(14,18)
* Burkitt Lymphoma: t(8,14)
* CML: t(9,22)
* Mantle Cell Lymphoma: t(11, 14)
* Ewing Sarcoma: t(11, 22)
* APML - t(15, 17)
195
How should wounds at risk of **tetanus infection** be managed?
* Full course of tetanus vaccines (5) with last dose < 10 years --> no vaccine or immunoglobulin.
* Full course of tetanus vaccines with last dose > 10 years --> if tetanus prone then reinforcing dose of vaccine, if very high-risk give reinforcing dose and tetanus immunoglobulin.
* If vaccination history unclear --> give reinforcing dose, give tetanus immunoglobulin if tetanus-prone or high-risk wound.
196
What are the main features of **acute intermittent porphyria**?
* **Autosomal dominant** defect in porphobilinogen deaminase. Female and 20-40 year olds more likely to be affected typically present with abdominal symptoms, neuropsychiatric symptoms, hypertension and tachycardia.
* Urine turns **deep red** on standing.
197
What are the main features of **porphyria cutanea tarda**?
* Most common hepatic porphyria defect in **uroporphyrinogen decarboxylase** that may be caused by hepatocyte damage e.g. alcohol, oestrogens.
* Classically **photosensitive rash** with bullae, skin fragility on face and dorsal aspect of hands.
* Urine: **elevated uroporphyrinogen** and **pink fluorescence** of urine under Wood's lamp. Manage with chloroquine.
198
What are the main features of **variegate porphyria**?
* **Autosomal dominant** defect in protoporphyrinogen oxidase.
* Photosensitive blistering rash, abdominal and neurological symptoms.
## Footnote
More common in South Africans.
199
How should you manage someone who has been bitten by someone with **Hepatitis B**?
If person is known to be a responder to HBV vaccine --> give booster dose.
If non-responder or not fully vaccinated --> Give HBIG + Vaccine Booster.
## Footnote
If unclear whether exposed to HBV, consider giving booster dose and if known non-responder, give booster dose and HBIG.
200
On which chromosomes do you find the **PKD genes**?
* PKD1 --> Chromosome 16
* PKD2 --> Chromosome 4
201
What are the main manifestations of **TCA overdose**?
* Arrhythmias (long QRS - risk of ventricular arrhythmia)
* Seizures
* Metabolic Acidosis
* Coma
202
How are **TCA overdoses** managed?
IV Sodium Bicarbonate (first-line for hypotension and arrhythmias).
MRCP
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