MCQ Davidson4

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					U ö 1000 MCQs FOR DAVIDSON’S PRINCIPLES & P~IACTICE OF MEDICINE
41.
O F  Middle-aged females
O F  May precede jaundice by months or
     years
0T    Vitamin D malabsorption and hepatic osteodystrophy
o F Suggests obstruction of large bile duct
O F High titres of anti-mitochondrial antibody

42
O T  And on elbows, knees and buttocks
O F  Prognosis excellent in the absence of
     symptoms or signs
O T Splenomegaly occurs as portal hypertension develops
0 F Suggests biliary obstruction
O F None proven to be effective

43.
O T Inherited as an autosomal recessive
O T Typically over 40 years
O T ‘Bronzed diabetes’
0 F May be a congestive cardiomyopathy
O F Melanin not iron deposition

44.
O T   Sometimes accompanying an acute
      hepatitis in children
O T   Or fulminant hepatic failure or
      cirrhosis
OT    A variety of extrapyramidal syndromes may be seen
0F    Serum copper falls, hepatic copper is increased
OT    K—F rings are an important diagnostic clue
45.
OT
OT
OT
OT
OT
lntrahepatic parenchymal Intrahepatic presinusoidaf Commonest cause worldwide Leading to portal vein thrombosis
lntrahepatic parenchymal
46.
OT
OT
OT
OF
OT

47.
OT

OT

OF
tDT
OF

48.
OT
OT
OT

OT

49.
OF

OT

OT
GT

OT

50.
OF
OF
OF

OF



51.
OF
OF
OT

GT OF
Most commonly alcoholic cirrhosis
A fungal poison
Occurs in 30% of those with cirrhosis
No chronic hepatic sequelae
And anabolic steroids


Pain in a cirrhotic should be suggestive
Tumours are vascular and spread locally
May be a hepatic bruit Rises in 90% of cases 10% are suitable for surgery


Secondary to biliary obstruction
Secondary to portal pyaemia
Acute pancreatitis
Infection via hepatic artery
Direct local spread


Jaundice is usually mild and uncommonly obstructive Splenomegaly suggests coexistent pathology
May be right shoulder tip pain Single lesions are more common in the right liver
Multiple organisms in one third


Common hepatic duct Normal CBD <8 mm in diameter Distal common bile duct usually joins pancreatic duct
Principally vagal tone controls the gallbladder muscle wall
The converse applies 40% of patients >60 years old But pigment stones are the more common in the developing
countries Usually calcium bilirubinate Hepatic hypersecretion of cholesterol more important
192

                                                                           LIVER, BILIARY       8I
52.
O T     Increased hepatic cholesterol
        secretion
O   T Multiple factors including impaired
           gallbladder motility
O   T Pigment stones
0   T Pigment stones
O   T Impaired gallbladder function

53.
O F    Cystic duct or gallbladder neck are
       obstructed in 90%
O F    50% are infected
O F    May be acalculous
O F    Atropine may reduce choledochal
       sphincter spasm
• F    Most gallstones are radiolucent

54.
O F Jaundice occurs in only 20%
O F Pain typically continuous
O T Murphy’s sign
0F   May follow passage of a gallstone into intestine or biliary surgery
• T May be absent in the elderly
55.
OF

OT
OF
OT
OF


56.
OF

OF OT


GT OF
Associated with gallstones and ulcerative colitis Often with weight loss Suggests hepatocellular carcinoma But not a
specific finding Commonest treatment is palliative stenting


Female preponderance most aged
                       —

>70 years Adenocarcinoma Can also be suspected by the findings on ultrasound scanning Usually diagnosed at
routine cholecystectomy for gallstones Often advanced at diagnosis since presentation is usually late
193
       NUTRITIONAL FACTORS IN
g      DISEASE

1.
O F   2—10~igperday
O T   And riboflavin
O T   Optimally 10% of total calories
o T   Highest level for a specific vitamin
O F   Approximately 1 g

2.
OT    Orl6kJ/g
O F   About 9 kcal (36 kJ)/g
O F   All disaccharides
O T   And arachidonic acid
• T   Arginine is an additional essential
      amino acid in infants

3.
O F   About 2700 kcal (11.3 MJ)
O F   Ketosis occurs below 100 g a day
O T   And niacin and vitamin E
o T   Minimum around 40 g
O F   200 ~ig of folate per day

4.
O T   About 7000 kJ (1750 kcal) per day
O F   Declines with age
O F   Greater in males
o T   But dependent on activity
• T   Overweight 25—30, obese > 30

5.
OF    BMI<16
OT    ‘Famine oedema’
OT    And weakness, amenorrhoea or
      impotence
0 T   Adolescents may maintain hair
      growth
• F   Brain weight is preserved;
      bradycardia is the rule
6.
OF
OT
OT
OT
OT

7.
OF

OF
OF

OT


8.
OT
OT
OT
OF
OT

9.
OT
OT

OF

OF

OT

10.
OT
OT
OT
OF

OF
Increased FFA levels
Plasma glucagon also rises
False-negative Mantoux may occur
And occasionally a metabolic acidosis
Also pancytopenia


Predominantly protein deficiency with a normal total energy intake Protein and energy malnutrition in infancy
BMI is normal or low normal Compromised humoral and cell mediated immunity Exacerbated by diarrhoeal illness


And absence of oedema
Weight < 60% standard for age
With low plasma lipids
Features of kwashiorkor
Contributing to dermatosis


Dehydration and infection Especially hypokalaemia and hypomagnesaemia Isolated calorie replacement may do so
And resolves on re-feeding And growth monitoring (mnemonic
GOBI)


Chiefly as calcium hydroxyapatite 350—550 mg daily for children

Impair absorption e.g. whole grain cereals and spinach Correlates poorly
194
                                                                             NUTRITION        9•
11.
O T   8mg/dayformen
O F   15% is absorbed
O T   E.g. red muscle meat or organ meat
o F   Average loss 2 mg/day due to
      menstruation
O F   Contains 250 mg of iron

12.
O F   Goitre alone or with hypothyroidism
O F   Hard water contains more fluoride
O T   Acrodermatitis enteropathica
O T   And skeletal rarefaction
• F   More likely in breast-fed infants

13.
O T A, D, E, K are the fat-soluble vitamins
O F Occurs as retinol in animal produce
    and as carotene in plants
O T Both conditions are the result of
    vitamin A deficiency and lead to
    blindness
o F Minimum recommended daily intake
    = 1—2mg
O T Present as retinol

14.
OF
OT
Some margarines are fortified
But less efficiently produced in old
age
O F But metabolism partly occurs in the liver
O T 1-alpha hydroxylation occurs in the kidney and 25-hydroxylation in the liver
O T And stimulates osteoclast proliferation
15.
OT
OT
OT
OT
Osteomalacia occurs after fusion Limited diet and sunlight exposure And tendency to infection ‘Rickety rosary
Especially severe if there is coexistent respiratory disease
16.
OT
OT
OT

OT OT


17.
OF
OT
GT
OT

OT


18.
OF

OT
OF
OT
OF


19.
OT
OF
OT


OT OF




20.
OT

OT

OF

OT

OT
With ‘saucer deformity’ Triggered by hypocalcaemia Due to high PTH and low vitamin D respectively
Also kyphosis and cranial ‘bossing Principal form of vitamin D in the circulation


Bone osteoid is increased
And occasionally tetany
Due to proximal myopathy
Pathognomonic radiological features
(Looser’s zones)
Also occurs increased in old age and
malabsorption syndromes


No chronic pain; fractures occur easily but heal
Also inactivity and cigarette smoking Most apparent in vertebral bodies In contrast to osteomalacia Biochemistry is
normal in absence of fracture


And also found in liver Absorbed as vitamin K1 All contain gamma-carboxyglutamic acid
Breast milk contains little vitamin K and placental transfer is poor Warfarin blocks synthesis of vitamin
K-dependent carboxylation of factors
2, 7,9,10


Ascorbic acid deficiency prevents the conversion of proline to hydroxyproline
Recommended intake 30—75 mg Gingivitis only occurs in presence of teeth
Then petechial haemorrhage and ecchymoses
With subperiosteal haemorrhage
195
   XQIUO M1~Qs FOR DAVIDSOWS N~1PL~S & I~RA~T1~ QFMEDI~IN~

21.
O F    Aerobic metabolism of glucose is
       impaired
O F    Wheat, yeast and legumes are rich in
       vitamin B1
O F    Arrhythmia and high output failure
O T    A mixed sensori-motor neuropathy
O T    And confusion

22.
O T    Dermatitis, diarrhoea and dementia
O T    Add to anti-TB regimens using
       isoniazid
O F    Sideroblastic anaemia may respond
O T    Also seen in niacin deficiency
O T    Also seen in niacin deficiency

23.
O T    But deficiency may take years to
       manifest
O T    Vital to tetrahydrofolate metabolism
O T    Mainly in animal foodstuffs
o F    Recommended intake 100 jig daily
• T    And megaloblastic anaemia

24.
O T    If colonic flora are reduced
O F    Use monomeric feeds
O T    1 gglucose=4OkcaI
O F    Use of> 10% dextrose solutions
       causes local phlebitis
O T    Due to elevated insulin levels
25.
OT
OT
OT
OF
Due to hemi-cellulose
But stimulate flatus production
And hence lower the glycaemic index
Only small quantities of fatty acids are
       absorbed after digestion 0 T Typical UK adult consumption
26.
OT
OT
Poor intake Increased metabolic rate and enhanced losses O T Drug-induced vomiting,
       hypercatabolism
O T Or body weight below 80% standard for height
• T Anti-anabolic effect

196
27.
OF

OT
OT
OT
OF

28.
OT
OT
GT
OT



29.
OT
OT

OT
OT
OT

30.
OF
OF


OF OF

OF


31.
OT

OT

OF

OT
Nutritional deficiency should be
suspected in all ill patients
Less if mainly protein loss
But not specific
And macrocytosis
Lymphopenia


Gross obesity >40
Hyperinsulinaemia is common
But no single gene defect identified
But precise endocrine mechanisms
unclear
After correction for total body mass


And clinical gout
And psychosexual and anxiety
disorders
Usually asymptomatic
With insulin resistance
And coronary artery disease


800—1600            kcal daily
0.5—1 kg per week (1000 kcal deficit /day = 7000 kcal /week = 1 kg human tissue)
Reserve for refractory obesity 40 g minimum recommended protein intake
Fat restriction < 50 g/day (calorific values fat = 9 kcal/g, CHO = 4 kcal/g)


Adverse effects are worrying and the long-term results are disappointing Walking expends 5 kcal/min (includes
BMR = 1 kcal/min)
Even a small intake of carbohydrate prevents significant ketosis Calorific value of alcohol = 7 kcal per gram
Effect of anti-obesity drugs plateaus at about 12 weeks

                                                                               NUTRITION     9I
Flat feet
Load-bearing joints
Obese subjects may be less nimble
Not associated with body mass index
Suggests rheumatoid arthritis
33.
OT
OT
OT
OF
Stimulates satiety and can help some patients lose weight Increases insulin secretion
197
32.
OT
GT
OT
OF
OF

                  DISTURBANCES IN WATER,
~g                ELECTROLYTE AND
                  ACID-BASE BALANCE
O   T   Relatively constant in health
O   T   Approx. 28 litres
O   F   25% is intravascular
O   F   Extracellular
O   F   Intracellular
2.
O T   Predominantly from the oxidation of
      glucose
O F   500—1000 mlperday
O T   Depends on solute load
o F   lOOmI
O T   An index of normal renal medullary
      function

3.
O F   Rare in isolation
O T   Usually with water depletion also
O T   An osmotic diuresis
o T   Mineralocorticoid insufficiency
• T   Loss into the ‘third space’

4.
O F   But may be seen in the syndrome of
      inappropriate ADH secretion
O T   Water retention exceeds sodium
      retention
O T   Increased total body water
O F   But seen in adrenocortical
      insuffuciency
O T   Salt loss exceeds water loss

5.
OT
O F Can produce hyponatraemia
O T Monitor pulse, BP and CVP carefully
O T Dependent on cause of deficit
O T The kidneys may be unable to excrete hydrogen ions; monitor the arterial pH
6.
OT
OT
OT
OT
OF

7.
OF
OF
OT

OT



8.

OT

OF

OT

OT
9.
OT
OT

OT OF
Renal tubular insensitivity to ADH
Inadequate intake
Inadequate intake
Renal tubular insensitivity to ADH
Combined salt and water depletion


Urine osmolality> 500 mosm/kg Hypernatraemia
Thirst stimulated by rising plasma osmolality
Signs of volume depletion develop more rapidly in combined salt/water depletion
Also confusion


Unless there is significant peripheral circulatory failure
Too rapid infusions produce cerebral oedema

The use of hypotonic fluids is rarely indicated
Signs develop more rapidly in combined salt/water depletion



Compared with extracellular concentrations of about 4 mmol/L

Increased by bicarbonate and decreased by acidaemia
198

                                                               WATER, ELECTROLYTE   10I
10.
O T    Renal tubular cell K concentration
       increased: excretion increased
O T    Secondary hyperaldosteronism
O T    Mineralocorticoid-Iike effect
o T    Primary or secondary tubular defect;
       also occurs with activation of renin and angiotensin
•F     Causes hyperkalaemia by an effect on the distal convoluted tubules
11.
OT
OT
OT
OT
Tubular response to ADH is impaired
Lethargy and immobility in the elderly
QT interval is prolonged
Painless distension with scanty bowel
sounds
• F Increased sensitivity to digoxin

12.
OT
Insulin promotes movement into the cells
O T Impairment of secretion in the distal
       nephron
O T Increased tissue breakdown
O T Especially if given with ACE inhibitor
O T Avoid concurrent supplementation

13.
O T   Relatively early changes
O T   May be the first manifestation
O T   Such symptoms are commonly
      overlooked
o T   Occur in severe hyperkalaemia
• T   Muscle weakness, loss of tendon
      reflexes and ileus; therefore check the
      plasma electrolytes

14.
O F  But may be necessary to prevent
     recurrence
O F Give parenteral dextrose and insulin
O T Cardioprotective effect
O T Also correct metabolic acidosis if
     present with 1.26% sodium
     bicarbonate i. v.
• T The resin binds potassium in exchange for calcium
15.
OT

OT
OT
OT

OF

16.
OT
OT
OT


OT GT


17.
OT
OF
OT


OF OF




18.
OT

OT
OF
OT


19.
OF

OT

OT OF

OF
Also tremor and choreiform movements
Also from chronic diuretic therapy Excess losses in the urine Including secondary hyperaldosteronism
Very poorly absorbed orally



Two thirds of water absorption occurs here

The absence of AVP renders the collecting ducts impermeable to water



Dilutional hyponatraemia Typically < 250 mosm/kg Occasionally produces generalised seizures
Use small volumes of hypertonic saline very cautiously ECF volume status usually appears normal


Pain and other stressors can induce
ADH release
And many other CNS disorders
Water excretion is however impaired
A rare complication
Also other pneumonias


Diuretic causing sodium and water losses
Inhibition of renal prostaglandin synthesis

But hypothyroidism increases ADH secretion
Inhibits aldosterone production
199
E~ 1 U 1000 MGQs fOR OAVIOS{]WS PR1N(WL~ & PRA~TtC~E (IF MEP1~tt4E
20.
O F    Major action on thick ascending limb
       of loop of Henle
O T    Tubular effect inhibiting urate
       excretion may precipitate gout
O F    Acts on the collecting ducts
o T    Causes hyperkalaemia
O T    Due to relative water excess

21.
OT
OT
OT
The Henderson Hasselbach equation Note nmol/L not mmol/L Unlike plasma CO 2 which is controlled by the
respiratory centre via ventilation
o F Excretion is predominantly renal O F Most is converted to H2CO3 by red
       cell carbonic anhydrase
22.
OF
GT

OT

OT

OF

23.
OF
OT
OF
OF
OF
pH is measured directly Dissociation equilibration formula of a weak acid
                                    -

Useful in distinguishing between causes of metabolic acidosis Hypoventilation causes hypercapnia Normal
bicarbonate 22—28 mmol/L; normal pH = 7.35—7.45


Plasma bicarbonate is reduced
Ketoacidosis
Compensatory hyperventilation
Hyperchloraemic acidosis
Decreased production
200



DISEASES OF THE KIDNEY
AND GENITO-URINARY
SYSTEM
1.
OF
OF
OT
Total number of nephrons = I million
Efferent arterioles
From intralobular branches of renal
artery
O T And arcuate arteries OF lOmmHg
2.
O F 66% of filtered water is reabsorbed
O T And collecting ducts
O T But only 150 mg per day excreted in urine
OF 66%
• F Afferent arterioles

3.
OF
OT
Almost all is passively absorbed
And in ascending limb of loop of
Henle
O F Active reabsorption process
O T Coupled with sodium reabsorption
O F 85% of bicarbonate is reabsorbed

4.
O T   In part regulated by mineralocorticoid
O T   If K~ is low, H~ is secreted
      preferentially
O T   Via renin-angiotensin system
O T   ADH increases tubular permeability to
      water
• T   Permits urinary acidification

5.
O T   Probably in tubular cells
O F   1 ,25-dihydroxycholecalciferol
O T   Vasodilatory actions; produced in
      mesangium
O T   As do many other tissues
• F   Produced in adrenal cortex
6.
OF
OT


OF OT




7.
OF

OF
OT
OT
OF

8.
OF
OT

OF GT


9.
OT
OT

OT
OF
OF
10.
OT
OT
OT
OF

OF
Immunoelectrophoresis required Often with oedema and hypoalbuminaemia
Greater when upright —‘orthostatic proteinuria’
But no red cells on microscopy Microalbuminuria is a sensitive predictor


Moderate 500 mg 2.5 g but rarely
                  —

more
Usually haematuria
Complicating dehydration in infants
Commonest cause in childhood
No glomerular lesion


Proteinuria is typical
Risk factors include diabetes mellitus,
NSAID usage and alcoholism
Typically proteinuria
Immune complex glomerulonephritis’
May be frank haematuria


pH > 8 suggests infection E.g. using urinary and plasma creatinine
Assessed by ultrasound scanning 33% is excreted within the first hour Contraindicated if kidneys are small


More marked in children Often with generalised oedema With RBC casts Non-selective and usually not nephrotic
Suggests Clq esterase inhibitor deficiency
201

             I



11
U 11 1000 MCQs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEOIC1!~
11.
O F    Typically painless
O T    Transudates
O T    Diagnostic prerequisites
o F    May occur in chronic renal failure
• F    Marked sodium retention urinary
                                 —

       sodium < 10 mmol/L
12.
O F   Tubulointerstitial damage only
OT    AndHIV
OT    Usually detectable circulating immune
      complexes
OT    Presents with recurrent macroscopic
      haematuria
O F   Immunoglobulin light chain deposits

13.
O T   With mesangial proliferation and
      inflammatory infiltrate
O F   But precipitating antigen unidentifiable
      in most
O T   Typically in children of school age
o T   And chest X-ray infiltrates
• F   Prognosis better in children


      Hypertension is typical
      Tubular function normal
      Classical’ pathway activation
      Or interstitial fibrosis
      With RBC casts


      But can improve renal function if severely impaired
      Can be of value if nephrotic Often needed in oliguric phase Sodium and water restriction But drug treatment
      may also be necessary


      But can occur at any age
      Usually < 7 days
      Minor proteinuria in the remainder
      20% have hypertension
      Or focal segmental mesangial
      proliferation
17.
OT
OT
OF
OF
OF

18.
OF
OT
OF
OT
OF

19.
OT
OT
OT
OT

OF
20.
OT

OT
OT
OF
OF

21.
OF
OF
OF
OF


22.
OF

OF
OT
GT
OF
More common in females
Or nephrotic presentation
No specific treatment
75% progress to renal failure
Hypocomplementaemia


Acute nephritic or renal failure
Early dialysis is typically required
Occasional association
Epithelial crescent formation occurs
Only in the minority


Removable by plasmapheresis With linear IgG deposition Usually with acute renal failure Antibodies have
pulmonary basement membrane cross-reactivity Limited response given prompt therapy


Uniform basement membrane
thickening
Or asymptomatic proteinuria
Hypertension in 30%
Poor prognosis
No specific treatment


Children aged 3—15 years
Minor or absent
Selective proteinuria
Suggests an alternative cause
And atopy


Diagnosis in children rarely requires
histological confirmation
Useful in management of oedema
Longer term steroids may be helpful
E.g. cyclophosphamide
Rarely, even in relapsing disease
14.
OF
OF
OT
OT


15.
OF

OF
OF
OT



16.
OT
OF
OT
OT
OT
202

                                                  KIDNEY, GENITO-URINARY   11 I
23.
O T   Increases in frequency with time
O T   An immune complex nephritis
O T   20% focal, 15% membranous
o F   Better prognosis
O F   Rare as is CNS involvement

24.
O F Rheumatoid arthritis and
    bronchiectasis
O T Tubular insensitivity to ADH
O T Proximal or distal
o T Treatment does not retard
    progression
• T 50% die in renal failure

25.
O F Suggests acute pyelonephritis
ED  T And urinary frequency
O F Suggests an abnormality of the
    urinary tract
O T E. coil in 75% of UTIs in the community
O F Trimethoprim or co-amoxyclav

26.
O T   But ureteric obstruction may be a
      predisposing factor
O T   With loin or epigastric pain
O F   Typically unilateral but can be bilateral
O F   Commonly found in chilren but not
      adults
• F   Suggests perinephric abscess
27.
OF
OT
OT
OF
OF
28.
OT
5% cf. 40% in elderly females
And ureteric dilatation
40% develop symptoms if untreated
Contraindicated in early pregnancy
Teratogenic risk (a folate antagonist)
       Chronic infection predisposes to
       phosphate stone formation
0. F Usually asymptomatic and presents
       with uraemia or hypertension
O T Recurrent infections can be difficult to
       prevent
o F Usually presents well before the age
       of 40 years
• T ‘Salt-losing nephropathy’
29.
OF
OT

OF

OF

OT


30.
OF
OT
OT


OT OF


31.
OT

OF
OF
OT
OF


32.
OT
OF
OT
OT
OT

33.
OT
OF
OF

OT OF
20% of chronic dialysis patients Other aetiological factors may also be important
Similar to ischaemic or tubulointerstitial nephritis Reflux is often no longer demonstrable in adulthood As a result of
a ‘salt-losing’ nephropathy


Typically normocytic or microcytic Can improve with dialysis Renal osteodystrophy with osteomalacia
Even haemorrhagic pericarditis with tamponade
Metabolic acidosis


Hence polyuria; urinary diluting ability also impaired Hyperphosphataemia Hypocalcaemia Resulting in hyperpnoea
Severe proteinuria diminishes as renal failure progresses


Suggests severe hypertension
May indicate aetiology
Occurs in severe renal failure
Particularly secondary
hyperparathyroidism
Typically progresses from this level on


And in elderly and diabetic patients 2 L instilled four times daily May also be preferable in patients with cardiac
disease
ABO compatibility is essential About 75% graft survival and 90% patient survival
203
EhI I I 1tJUU MUUS IUH UAVIUSUN~~ I-’l-1INUIPLL~ & PFIAUJI~ OF MEDICINE
34.
O F     Remember 20% of acute renal failure
        is non-oliguric
ED      F Blood pressure is often decreased in
        pre-renal ARF
O F     Suggests pre-renal uraemia
o F     Suggests pre-renal uraemia
• F     Haemoglobin is typically near-normal

35.
O T     Unless severe associated illness and
        hypercatabolic state
O   T   And calcium gluconate if severe
O   T   Including estimated insensible loss
O   F   Contraindicated in renal impairment
•   F   An indication for urgent renal dialysis

36.
O T     Removes and replaces one litre of
        filtrate per hour and facilitates TPN
O F     Causes less haemodynamic
      disturbance
O F   Peritoneal dialysis is technically
      easier and less traumatic
O T   But also undertaken intermittently
      over 3—4 hours per day
O F   May be more effective than PD

37.
O F   Creatinine falls even more slowly
O F   Restriction should be relaxed to
      improve nutrition
O T   And often potassium supplementation
      is also necessary
O F   Increase fluid intake in parallel with
      renal losses
O F   Usually resolves in about 4 weeks
38.
OT
OF
OF
OT
E.g. renal calculus
Anuria typically suggests obstruction
Intervention may avoid dialysis
Demonstrates obstruction of the renal
        pelvis or ureter
• F Post-obstructive diuresis occurs
39.
OT
OF
OT
OF


40.
OT
EDT
OF
OT

OF

41.
OT
EDT

OF OT



42.
OT
OF

OF

OF

OF
43.
OF
EDT
OT
OF
OT

44.


OT EDT


OT
OF
OF
And fever
Eosinophilia is typical
And neutrophil or monocytic infiltrate
Typically resolves
E.g. penicillin or rifampicin


Urine stasis and infection Or radiotherapy for such cancer Haematuria is common in either ?aberrant vessel or
neuromuscular defect
Typically painful
Typically phosphate stones
Produces osteoporosis and
hypercalciuria
Hyperparathyroidism
Normocalcaemic hypercalciuria Hypercalciuria with or without hypercalcaemia


Suggests total obstruction Acidification with ammonium chloride may benefit
Decreases urinary calcium excretion by 30% in hypercalciuric patients Decreases urinary urate and thereby may
reduce oxalate stone formation Fragmentation by lithotripsy and endoscopic removal is possible


Autosomal dominant
But liver function tests normal
And hypertension and UTI
Typically bilateral
10% will have a subarachnoid
haemorrhage


Anion gap = plasma Na~— (CV +
HCO3)
Increased chloride preserves anion
gap
Even in presence of systemic acidosis
GFR is normal
No features of uraemia
204

                                                            KIDNEY, GENITO4JRINARY                 11 ~
45.
OT    And amphotericin
OT    And vitamin D intoxication
OT    AndSLE
o T   Also causes proximal type 2 RTA
• T   And hydronephrosis

46.
O T   Reduce dose in renal failure
O F   Contraindicated due to catabolic
      effect on protein metabolism
O T   Digoxin toxicity is common given the
      half-life of 35 hours in health
O T   Hepatic metabolism but renal
      excretion of active metabolites
• T   Check plasma levels daily

47.
O T   Occurs in 20% and due to increased
      interleukin release
ED    T Typically osteolytic metastases
O T   Due to blood clot or direct tumour
      obstruction of ureter
o T   Erythropoietin secretion
• F   Suggests hepatoma

48.
O T   An atonic bladder
ED    F Suggests spinal cord damage above
      conus medullaris
O F   Suggests colovesical fistula or
      instrumentation
O F   Suggests pelvic floor muscle
      weakness
O T   An anticholinergic effect
49.
OF
OF
OF
OF



50.
OT
OT
OF

OT OF

51.
OF
EDT
OF


OT OF
52.
OF
EDT

OF OF
Typically transitional cell
Painless haematuria is typical
Radiotherapy is of palliative benefit
Local spread occurs early and
metastases late
And schistosomiasis


As may benign prostatic disease
Or haematuria
Hard with obliteration of median
furrow
And may involve ureters
Osteosclerotic metastases


Aged over 60 years Sometimes precipitated by UTI Associated with diminished androgen secretion
Elevation suggests prostatic carcinoma
Typically symmetrical


Typically painless
Helps in the assessment of treatment
response
Haematogenous spread may occur
Peak incidence aged 25—34 years
Chemotherapy if widespread disease
205

                ENDOCRINE AND
12              METABOLIC DISEASES

1.
O F    Dopamine inhibits prolactin release
ED     F Somatostatin inhibits growth hormone
       release
O T    In vivo significance of effect on
       prolactin is uncertain
O T    Gonadal steroids and inhibin modify
       GnRH effects
O T    Arginine vasopressin also effects
       ACTH release

2.
O T    Prolactin-secreting tumours are the
       most common
O   T   May be visualised on CT scanning
O   F   Usually basophil microadenoma
O   F   Usually acidophil macroadenoma
•   T   Other visual field losses may occur

3.
O T     Perhaps with prognathism and skull
        growth
ED      T Or impaired glucose tolerance
O T     And perhaps hepatomegaly
o F     Growth hormone levels fail to
        suppress
• T     The skin is thickened with increased
        sebum production


        Not usually apparent on plain films
        Impotence in men
        Impaired glucose tolerance
        Plasma cortisol is not suppressed
        Hypertension and hypokalaemia


        Physiological pregnancy
        And metoclopramide, methyldopa
        TRH is elevated
4.
OF
EDT
OT
OF
OF

5.
OT
OT
OT
OT


206
6.
OF

OF
OT
OT
OF

7.
OF
OT
OT
OT
OF

8.
OT
OF
OT
OT
OT

9.
OF
OF

OT OT


10.
OF

EDT



OF
Usually isolated GHRH secretory
failure
Affects the minority
As an isolated abnormality
With consequent short stature
Puberty not affected


May cause gigantism
And other chromosomal abnormalities
And malnutrition
Usually with obesity
Primary hypothyroidism


Pituitary necrosis (Sheehan’s
syndrome)
Usually microadenoma
Usually macroadenoma
Rare
Acquired hypothalamic damage


Aldosterone secretion is maintained
There is secondary adrenal
insufficiency
Impaired LH then FSH secretion
There is increased insulin sensitivity
With hypoglycaemia and hypothermia


Severe hypernatraemia only when water access denied
Glucocorticoid insufficiency may mask diabetes insipidus
O T Or secondary to pituitary tumours or sarcoid
Carbamazepine stimulates ADH release
An effect of long-term overhydration in psychogenic polydipsia

                                                           ENDOCRiNE, META~OL1C   12 1
11.
O T   Used in manic depressive states
O T   Rarely encountered in clinical
      practice
O T   Also inherited in cystinosis
O F   Chlorpropamide increases renal
      sensitivity to vasopressin
O F   Hypokalaemia and hypercalcaemia

12.
OT
EDT
OT
OT
And encephalitis Even apparently minor injury And pulmonary tuberculosis And pancreas, ureter, bladder, prostatic
and other malignancies
•T     As well as carbamazepine, chlorpropamide and others

13.
O T Thyroglobulin is synthesized within
    thyroid cells
O F T4 should be regarded as a pro-
    hormone
O F Bound to thyroxine-binding globulin
    and also to pre-albumin
O T T4 is deiodinated in liver, muscle and
    kidney
• T Production of reverse T3 may increase

14.
O T   With secondary hypothyroidism
ED    F TSH would be elevated
O T   Free T4 is normal
O T   And other acute illness
• F   Total T4 increased

15.
O F   May occur in acute non-thyroidal
      illness
ED    T Suggests primary hyperthyroidism
O F   Suggests secondary hypothyroidism
O T   Suggests autoimmune primary
      hypothyroidism
O F   May be seen in pregnancy
16.
EDT
EDT
OT
EDT
17.
OT

EDT
OF
OT
OF
18.
OF
OF
OF


OF EDT


19.
OF

EDT

OF
OT
OF

20.
OF

OF

OT

OT

OT

21.
OT

EDT OT

OT OF
Or persisting resting sinus
tachycardia
Appetite is maintained
Muscular weakness may occur
Occasionally with ophthalmoplegia
Insulin requirements may increase


Controls ventricular response rate Inhibits the iodination of tyrosine TSH measurement alone should not guide
therapy
But titres correlate poorly with disease activity Especially patients with large goitres


Suggests treatment induced hypothyroidism
                     —

40% in first year long-term follow-up necessary
                 —

Relapse is uncommon In 75% if given a standard dose In 25% if given a standard dose


Radioiodine is better avoided in patients <40 years of age Potassium perchlorate is now avoided high toxicity Beta
                                                                                                 —

blockers are useful for symptomatic treatment Particularly if a recurrent episode Steroids are used in thyroid crisis
and severe eye complications


15% are rendered permanently
hypothyroid at 1 year
producing dysphonia
5—10% develop post-operative
hypocalcaemia
5% at 1 year
No known association
In around 75% of cases
15% multinodular, 5% single nodule
May also cause hypothyroidism
Goitre is therefore usually present
And HLA B8 and DR2
207
U 1 Z 1000 MCQs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEDICINE
23.
EDT
EDT
OT
22.
O F Excessive lacrimation and
       conjunctivitis are more common
ED     F Ophthalmopathy may precede
       hyperthyroidism or even follow treatment
• F No such test available unfortunately 0 T Steroids or surgery may be needed
       other cases
O T Therefore avoid over-treatment of hyperthyroidism if possible


      Both however are non-specific
      And infertility and impotence
      Perhaps due to oedema of the middle
      ear
O T Rarely alopecia, vitiligo and dry hair ED F Reflexes preserved with delayed
      relaxation

24.
O F    Free T3 is an unreliable discriminant
0 T    Rarely causing galactorrhoea
O T    Producing hyponatraemia
O F    Serum lactate dehydrogenase and
       creatine kinase may be elevated
• T    And serum triglyceride levels


       There may be constipation
       But puberty is usually delayed
       May present with short stature
       Epiphyseal closure is delayed
       But a rare occurrence


       Generalised organomegaly can occur
       Usually with hypothyroidism
       Often associated with hypothyroidism
       Usually no treatment required
       With nerve deafness; autosomal
       recessive
25.
OF
EDT
OT
OT
EDT
26.
EDT
EDT
OT
OT
EDT
27.
OF
EDT

OT

     OF
in OF

      28.
OF
EDT
OF

EDT OF

29.

OF

EDT

OF
OT
EDT

30.

OF

OF

OF

OT

OF


31.
OF



OF GT


OF EDT
Goitre may occur at any age The most common cause of goitrous hypothyroidism
Typically deficiency of intrathyroidal peroxidase
Should suppress the serum TSH May be seen in Hashimoto’s disease


The thyroid is typically painful Virus-induced thyroid inflammation But biochemical evidence of hyperthyroidism is
common Antibodies in low titre transiently Transient hypothyroidism with thyroidal recovery usually


May cause painful thyroiditis with transient hypothyroidism Hypothyroidism if iodine deficiency is severe
No association Secondary hypothyroidism E.g. cassava root


‘Hot’ nodules are almost always benign
Radiotherapy provides brief symptomatic relief only Total thyroidectomy, radioiodine and long-term thyroxine
Papillary tumours are the most common cell type Rare despite high calcitonin levels; carcinoid syndrome can occur


40% of calcium is protein-bound; normal after correction for serum albumin
But metabolic alkalosis increases the level of ion ised calcium Due to bone metastases (often microscopic)
Decreases serum calcium levels Increases vitamin D level production with low PTH levels
208

                                                            ENDOCRINE, METABOLIC                 121
But 50% are asymptomatic
Solitary parathyroid adenoma in 90%
A relatively late feature
And peptic ulceration and myopathy
With characteristic polyuria


Phosphate is usually low
Increased 1,25 D levels
Predisposing to stone formation
Indicating osteoblastic activity
Chloride is usually elevated


Feature of idiopathic hypoparathyroidism
ED     T Secondary to hyperphosphataemia,
       hypocalcaemia and low vitamin D
       levels
O F Diffuse hypertrophy of small glands
O T Tertiary hyperparathyroidism
O T Failure of vitamin D absorption

35.
O F Autosomal dominant
EDT
OF TypelI
OF TypeII
EDT

36.
O T    Often via production of osteoclast
       activating factors
O T    Undetectable using standard PTH
       assays
O T    Increased vitamin D level production
       with low PTH levels
O F    Hyperthyroidism is a rare cause
• T    Increased vitamin D level production
       with low PTH levels
37.
EDT
EDT
OF
OT
EDT
Features of tetany
And mouth and oesophagus
Features of hypercalcaemia
Basal ganglia calcification is typical
In prolonged hypocalcaemia
38.
EDT
EDT
OT
OF

OF

39.
EDT
OF

OF
OT
OF

40.
OF
OF
OF
OT

EDT

41.
EDT
OF

OF

OT

OF

42.
OF

EDT

OF

OF
EDT
Adrenal, thyroid and ovary
Presents in infancy
Occurs in 1%
Calcitonin elevation occasionally
causes hypocalcaemia



Producing tissue resistance to PTH
PTH concentrations rise cf. true
hypoparathyroidism
Serum phosphate is high
And occasionally mental retardation
Alfacalcidol treatment


Alkalosis reduces the ionised calcium
Alkalosis reduces the ionised calcium
Alkalosis reduces the ionised calcium
Due to sequestration in areas of
pancreatic and fat necrosis
Vitamin D malabsorption


Usually 20 ml of a 10% solution Rendered ineffective by antibody formation
Calcitonin may worsen hypocalcaemia
But serum calcium must be monitored But indicated in tetany due to hyperventilation alkafos,s


Principally under control of angiotensin II
In the zona reticularis and zona fasciculata respectively Cortisol levels fall to a nadir at around midnight
Hypoglycaemia stimulates cortisol release
Anti-insulin effects
209
32.
EDT
OF
OF
OT
EDT

33.
OF
OF
OT
EDT
EDT

34.
OF
U 1 Z 1000 MCQs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEDICINE
43.
O T    ‘Pseudo-Cushing’s’ syndrome due to
       stress responses
ED     F Pituitary microadenoma or hyperplasia
O F    Weight loss, pigmentation and
       metabolic alkalosis
o T    Non-ACTH-dependent Cushing’s
O F    Mineralocorticoid effects

44.
O T    Protein catabolism in bone
ED     F Hypertension may occur
O T    Impotence in men
O T    Muscle protein catabolism
O F    Impaired glucose tolerance

45.
O F    Diurnal pattern of secretion is lost
ED     F Plasma cortisol fails to suppress with
       dexamethasone
• T    Sometimes used as a screening test
O T    Particularly in virilising tumours
ED     F ACTH is undetectable at all times
46.
EDT
EDT
OT
Decreases mucosal resistance
       Increased renal sodium reabsorption Particularly likely to affect the femoral heads
O F Sometimes used to treat severe pseudo-gout
O T Typical; causes day-night reversal of biorhythms
47.
OF
Cf. oedema in patients with secondary
       hyperaldosteronism
ED T Rarely hypokalaemic paralysis
O T Hypertension and hypokalaemia are characteristic
ED F NIDDM is however associated with primary hypoadrenalism
ED F Associated with renin suppression
48.
EDT
EDT
OF


EDT 210
49.
EDT

OF
OT
OF

EDT

50.
EDT

EDT

OF

OF
OF

51.
EDT

OF

OF

OT

OF

52.

EDT

EDT

OT


OT EDT
All features of glucocorticoid insufficiency
Only new scars become pigmented Vitiligo is seen in 10—20% Increased insulin sensitivity with hypoglycaemia
Loss of adrenal androgen


Especially if caused by an expanding pituitary lesion
ACTH stimulation cannot distinguish primary from secondary failure ACTH levels are not elevated and no
autoimmune association No mineralocorticoid deficiency Replacement therapy should mimic the diurnal rhythm


Cortisol acetate requires initial hepatic metabolism
Mineralocorticoid is invariably required
Patients must increase dose with intercurrent illness
Pay attention to the underlying precipitant
30—40 mg per day usually


With defective cortisol production; 20% are due to 11 -hydroxylase deficiency
But mineralocorticoids preserved in two thirds
Unlike females, appear normally virilised and recognition can be delayed
High levels of androgens Increased ACTH secretion
Rare cause
Commonest cause
                                                        Rare
Both may cause hypercalcaemia
Now a rare cause

                                                           ENDOCRINE, METABOLIC             121
53.
ED F Measurement of plasma ACTH and an ACTH stimulation test often suffice
ED T Or if severe hypoglycaemic symptoms develop
O T Serious risk of hypoglycaemiainduced complications
ED T Plasma cortisol at 0800 hrs < 180 nmol/L
ED F Test of hypothalamic-pituitary-adrenal axis

54.
O F   Noradrenaline is a precursor of
      adrenaline
ED    T Catecholamine secretion
O F   90% are benign
O T   Occurs in MEN type II syndrome
ED    F Symptoms worsen due to unopposed
      alpha-adrenoceptor activity

55.
O T   Hyperprolactinaemia and testicular
      dysfunction
ED    T Psychogenic impotence
O T   Involving internal pudendal artery
O T   Vascular disease and autonomic
      neuropathy
O T   Spinal cord demyelination

                                                   56.
ED    T E.g. following severe orchitis
O F   Maldescended testes in an adult
      should be removed
O T   Antisperm antibodies may
      subsequently destroy sperm
ED    F No treatment is widely effective
O F   Suggests pituitary/hypothalamic
      cause
                                                   57.
                                                   OF
                                                   OF
                                                   OT
                                                   OF
Serum LH is elevated
Serum FSH is elevated
Associated with anosmia
Testicular damage —

       hypergonadotrophic
ED F Altered metabolism of testosterone hypergonadotrophic
                                           —

                                                   58.

                                                   OF

                                                   OF

                                                   OT
                                                   EDT
                                                   EDT

                                                    59.
                                                   EDT

                                                   EDT
                                                   OT
                                                        EDT
                                                        EDT


                                                         60.
                                                        EDT
                                                        EDT
                                                         OF
                                                        OT

                                                         OF

                                                         61.
                                                         OF
                                                        EDT
                                                        OT
                                                        OT
                                                        EDT


                                                         62.
                                                        EDT
                                                        EDT
                                                        OT
                                                        EDT
                                                        EDT

                                                         63.
                                                         OF
                                                         OF
                                                         OF
                                                        EDT
                                                         OF
Adrenal androgen production is spared
Height is excessive due to failure of epiphyseal fusion Testicular atrophy in particular Androgen deficiency
Testosterone withdrawal


Usually 47,XXY chromosomal composition
Usually 45,X May present with secondary amenorrhoea or premature menopause
Affects 15% of males with leprosy May also be associated with reduced serum gonadotrophins


Chromosomal abnormalities are rare
Occurs in the minority
Sterility follows if bilateral
Secondary sexual characteristics are
preserved
Testicular descent ensues in 40%


May cause dysmenorrhoea
Elevated adrenal androgens
Distinctive morphological features
Or other severe systemic disease
Or other hypothalamic or pituitary
                                                      problem
Suppression of GnRH
Failure of gonadotrophin secretion
Impotence in men
Or other severe systemic disease
Polycystic ovary disease


Gonadotrophins elevated
Features of androgen excess
Osteoporosis develops prematurely
Due to oestrogen deficiency
Normal menopause occurs at this age
                                                   211
U 1 ~ 1000 MCOs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEDICINE
                                                   64.
O T   But 50% if NIDDM undetected
ED    F Converse applies particularly if obese
O F   Inheritance is polygenic
O T   70%agedover5oyearsinUK
ED    F 90% of islet cell mass must be
      destroyed

                                                   65.
O T   Patchy distribution in pancreas
ED    T Cross-reactivity of antibodies to
      bovine serum albumin
O T   And anti-insulin antibodies
O T   Schmidt’s syndrome
ED    T Coded on the short arm of
      chromosome 6

                                                   66.
O T   Hypokalaemic alkalosis impairs
      insulin secretion
ED    T Pancreatic fibrosis
O T   Conn’s syndrome produces an
      hypokalaemic alkalosis
O T   Islet cell destruction
ED    T Excessive counter-regulatory
      hormones

                                                   67.
ED F In contrast to IDDM
ED T Cf. 60% concordance in monozygotic twins with IDDM
O F Variable insulin resistance
O T Especially if combined with underactivity
ED T In contrast to IDDM

                                                   68.
O T   Due to osmotic diuresis
ED    F Catabolism, including glycogenolysis,
      is increased
O F   Increased lipolysis and enhanced
      ketogenesis
O T   Primarily hepatic
O T   Intracellular to extracellular fluid shift
                                                        69.
                                                       EDT
                                                       EDT
                                                       OT

                                                       EDT

                                                        OF


                                                        70.
                                                        OF
                                                        OF
                                                        OT

                                                        OF

                                                       EDT

                                                        71.
                                                       EDT

                                                       EDT

                                                        OT
                                                        OF
                                                        OF

                                                        72.
                                                       EDT
                                                       EDT
                                                        OF

                                                        OT
                                                        OF


                                                        73.
                                                        OF

                                                       EDT

                                                     OF
                                                     OT
                                                     OF
And increased plasma osmolality Compensatory respiratory alkalosis Thirst and hence intake may be impaired
More profound ketogenesis occurs in
                                                   IDDM
Insulin deficiency increases their production only


Too insensitive to detect all cases Renal threshold may be high But it should never be assumed to be so
10—20% have serious vascular disease
Red cells contain less glucose
IDDM or NIDDM may subsequently develop
Predisposition to arterial disease remains
Or thiazide diuretic therapy Risk of IDDM >6% Risk of IDDM 36%


Or plasma glucose> 11.1 mmol/L Or plasma glucose > 7.8 mmol/L Prolonged restriction impairs glucose tolerance
WHO standard test (1985)
High levels occur within 120 minutes if gastric emptying is rapid


Plasma values are higher than whole blood
But specific type of stick used should be checked
Positive if> 0.5—1.0 mmol/L Normally distributed about this mean Unrelated to the later development of
                                                   NIDDM
                                                     212

                                                               ENDOCRINE, METABOLIC               12I
                                                         74.
ED T Catabolism and osmotic diuresis
ED T Predisposition to infection
O T Particularly in ketosis
O T Small vessel disease and neuropathy
ED T Often detected on routine urine testing

                                                         75.
ED F 50% of new diabetics can be controlled on diet alone
ED T Higher than that in average UK diet
• F Consume within diet guidelines ED T UK national diet tends to higher
       proportion of fat
ED F Severe calorie restriction cannot be sustained for long

                                                         76.
ED     F Combined treatment may limit weight
       gain
ED     F Insulin secretion is stimulated
O F    Such an action would produce insulin
       resistance
O T    Thus limiting hyperglycaemia
O T    Disulfiram-like reaction

                                                         77.
                                                        EDT

                                                        EDT
                                                         OF
                                                        EDT
                                                         OF


                                                         78.
                                                        EDT
Onset of effect = 30 minutes after injection
Variably delayed onset of action Often relative insulin resistance But varies in other countries Conversion to human
insulin may cause hypoglycaemia
Causes and effects of hypoglycaemia
should be familiar to patients
ED T Insulin resistance may decline
O F Unlikely to achieve good glycaemic
       control
O F Check every 2—3 months
O F Patients need to check blood glucose
       levels regularly
                                                      79.
                                                     EDT

                                                     EDT

                                                      OT
                                                      OF

                                                     EDT


                                                      80.
                                                     EDT
                                                     EDT

                                                      OT

                                                      OF

                                                      OF

                                                      81.
                                                      OF
                                                     EDT
                                                      OF
                                                     OT
                                                      OF


                                                      82.
                                                     EDT
                                                     EDT
                                                      OF
                                                     OT
                                                      OF

                                                      83.
                                                     EDT
                                                     EDT
                                                      OF

                                                       OF
                                                      EDT
But 50% of long term IDDM patients have no symptoms Sympathetic nervous system activation
Neuroglycopenia
But plasma glucose may not parallel CSF glucose levels Nocturnal hypoglycaemia may be difficult to recognise
25 g of glucose
Because glucagon increases insulin secretion
Hypoglycaemia does not occur with biguanides
Can recur following initial treatment Long-acting hypoglycaemics cause prolonged hypoglycaemia


Volume depletion in ketoacidosis Diminished in ketoacidosis
Suggests metabolic acidosis
Dehydration in ketoacidosis
An insensitive indicator of
ketoacidosis
Due to ketoacidosis
Due to dehydration
Skin is typically dry
Due to ketosis and dehydration
Suggests severe hypoglycaemia


50% intracellular + 50% extracellular
Chloride deficit similar
Picture should be that of an acute
metabolic not respiratory acidosis
Typically normal or high
Even in absence of infection
                                                      213
U 1 ~ 1000 MCQs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEDICINE
                                                        84.
O F Best replaced by 5—10% dextrose when blood glucose is near normal
ED F Give none if K~ > 5.5 mmol/L
O T Or in severe acidosis pH <7.0
                          —

ED F Dextrose is used to correct CF depletion and if blood glucose
      <15 mmol/L
ED T Central venous pressure monitoring may be necessary

                                                      85.
O F    Photocoagulation is indicated
ED     F Often the first sign of retinopathy
       detectable by ophthalmoscopy
• F    Regular examination is mandatory
O F    Suggests glomerular dysfunction and
       is a sensitive indicator of
       microangiopathy
ED     T Due to cardiac autonomic neuropathy

                                                      86.
O T    Due to intrauterine death, prematurity
       and congenital malformation
O F    Typically larger than expected
• F    Defer delivery to 38—39 weeks or later
       if possible
O F    Insulin is necessary to achieve
       optimal control
O F    Requirements increase in second
       trimester
                                                 87.
O T   Minimise risk of intraoperative
      hypoglycaemia
O F   Usual s.c. insulin should be
      substituted with GKI infusion
O T   Observation alone in minor surgery
ED    F Often higher
O T   With 2—4 hourly BM strip measurement

                                                 88.
O T   Risk of pancreatitis, no atherogenic
      risk
ED    T Triglycerides variably abnormal in all
      except type Ia
O T   May be slightly elevated in type V
o T   And premature coronary
      atherosclerosis
ED    T Rare in comparison to type II

                                                 214
                                                 89.

                                                 EDT

                                                 OF

                                                 OT

                                                 OF
                                                 OF

                                                  90.
                                                 EDT

                                                 EDT

                                                 OF

                                                 OT

                                                 EDT

                                                  91.
                                                 EDT

                                                 EDT
                                                  OF
                                                  OF
                                                 EDT

                                                  92.
                                                  OF
                                                 EDT

                                                 OT
                                                 EDT
                                                  OF
And aim for weight reduction to body mass index <25 Particularly in patients with coronary artery disease
Especially if refractory to dietary measures
Suggests better risk profile Statins have such an effect


By definition, blood glucose < 2.5 mmol/L
Often overlooked as cause of cerebral symptoms
An overnight or 12-hour fast is usually sufficient
Early dumping is due to the release of vasoactive amines/hormones Symptoms then relieved by eating


Rate-limiting step in biosynthesis of
                                                       haem
Porphobilinogen accumulates
Typical of acute porphyria
Typical of the non-acute porphyrias
Both are hepatic porphyrias


Decreased PD enzyme activity levels Until precipitated by drugs or alcohol in some
Pain may mimic acute abdomen Marked systemic upset Barbiturates and oral contraceptives typically induce
exacerbations



DISEASES OF THE BLOOD
       Bone marrow functional by 11—22 weeks gestation
ED T Some migrate to the thymus
O T At birth most of the bone marrow is haemopoietically active
O T Proerythroblast is earliest identifiable red cell precursor
ED F Produced by cells in tubules
                                                          2.
                                                         OF
                                                         OF
                                                         OT
Membrane antigens
Reticulocytes stain in this way
Required to maintain biconcave
       morphology
O T Shorter (25—35 days) if measured by chromium labelling
ED T By conversion to carbonic acid which then dissociates

                                                     3.
ED F Two alpha and two gamma
ED F Two alpha and two delta
O T Methaemoglobin contains a ferric ion
ED T W generated in dissociation buffered by deoxyhaemoglobin
ED F Decreased

                                                       4.
ED T Ranges from 40—70%
ED T Around 8 hours in circulation before margination
O F Less nuclear segmentation a shift to the left in the nuclear segmentation count (Arneth count)
                                   —

ED F Both derive from granulocytemacrophage colony forming cells
ED T Hence high serum vitamin B12 levels in chronic myeloid Ieukaemia
                                                       5.
                                                       OF
                                                       EDT
                                                        OF
                                                        OF
                                                       EDT

                                                       6.
                                                       OF


                                                       EDT

                                                       OT
                                                       OT
                                                       EDT

                                                        7.
                                                       EDT

                                                       OF

                                                       OT

                                                       OF

                                                       EDT

                                                        8.
                                                       EDT
                                                       EDT
                                                        OF

                                                        OF
                                                       EDT
10 day lifespan
By the megakaryocytes
Found in red blood cells
May increase
And coagulation factors


Seen in other disorders of haemoglobin synthesis e.g. thalassaemia
Residual ribosomal material is stained faintly
Sign of dyserythropoiesis And lead poisoning And haemoglobinopathies


Average menstrual loss is 30 mg per month
Males lose 1 mg per day, females lose 2 mg per day 60—70% resides in the haemoglobin molecule
Stored as ferritin Normally about 15% of which is absorbed


Microcytosis is the first sign Sometimes poikilocytosis Only in severe anaemia; hypochromia is due to microcytosis
Suggests hyposplenism Thrombocytosis suggests active bleeding
                                                         215

              I
13    1000 MOOs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEDICINE

                                                      10.
                                                      OF
                                                     EDT
9.
O F    Only if coexistent deficiency
       demonstrated
0 F    Continue for 3 months to replenish
       stores
O F    Unless malabsorption, bleeding or
       poor compliance
ED     T Rising counts also occur in response
       to bleeding
ED     F Oral iron is usually effective


      Macrocytic with polychromasia Typically a dimorphic red cell population
O F Typically macrocytic
O T And other haemoglobinopathies
ED T Or a normochromic normocytic picture


       Typically macrocytic
       Erythropoietin deficiency
       Typically macrocytic
       Protein energy malnutrition
       Rarely may produce vitamin B12
       deficiency and megaloblastosis


       With megaloblastic marrow
       With polychromasia
       With or without cirrhosis
       Dimorphic, with microcytic population
       But variable red cell morphology


      Commonly due to vitamin B12
      deficiency
ED T Shift to the right in the Arneth count
O T And red cell fragmentation
ED F Features of bleeding or haemolysis
O F Bilirubinuria is not a feature of any anaemia
                                                      11.
                                                      OF
                                                     EDT
 OF
EDT
 OF


 12.
EDT
EDT
OT
 OF
EDT

 13.
EDT
 14.
 OF
EDT


 OF
EDT


 15.
 OF
EDT
OT
OT
EDT


 16.
 OF
EDT

OT

OT

EDT

 17.
EDT
EDT

EDT

EDT


18.
OF
OF
OT

OF
                                                        EDT
Feature of vitamin B12 deficiency only Glossitis less common in folate deficiency
Mild haemolysis Features of vitamin B12 deficiency Partially dependent on underlying cause


Typically 45—65 years
Found in 90% and <50% respectively
Mild haemolysis occurs
Associated gastric atrophy
Failure to correct suggests terminal
ileal disease


Typically elderly patients Usually with hypercellular dysplastic marrow
Normoblasts with interrupted perinuclear iron ring Particularly of chromosomes 5 and 7 Risk is dependent on the
precise type of myelodysplastic syndrome


Sometimes haemolytic anaemia alone Or penicillamine
And other viral infections Especially due to vitamin B 12 deficiency
Sometimes with sideroblastic marrow change


Peaks about 30 years of age Thrombocytopenia Diagnosis cannot be made on peripheral blood film alone
Splenomegaly occurs in under 10% Often with a chronic low-grade haemolysis

                                                                             BLOOD      131
                                                       19.
ED F Bilirubin is unconjugated therefore not found in urine
ED T The latter always indicating intravascular haemolysis
O F Decreased serum haptoglobin
ED T Most is bound to serum haptoglobin
ED T Often with reticulocytosis

                                                         20.
O T    Red cells are rich in LDH
ED     T But no bilirubinuria
• T    Specific red cell abnormalities may be
       present e.g. spherocytes
ED     T Reflects reticulocytosis
O T    With megaloblastic change if folate
       deficiency ensues

                                                         21.
O T    Mechanical intravascular haemolysis
ED     T Associated with cold agg:utinins
O T    Low-grade haemolysis
O T    Severe in blackwater fever
ED     T In G6PD deficiency

                                                         22.
ED     T For 5 years at least
ED     F In children, defer as long as possible
O F    They represent an indication
O T    Pneumoccal immunisation is advised
O F    Indicated if severe or recurrent
       symptoms

                                                          23.
O T Pigment gallstones
ED F RBC destruction occurs in the spleen
O F Osmotic fragility is increased
ED T Often in association with parvovirus infection
ED F Suggests warm autoimmune haemolysis
                                                          24.
                                                         EDT
                                                          OF

                                                          OT

                                                          OF

                                                         EDT


                                                          25.
                                                         EDT
                                                         EDT
                                                         OT
                                                         EDT

                                                         EDT

                                                          26.
                                                          OF
                                                         EDT
                                                         OT

                                                          OF
                                                         EDT


                                                          27.
                                                         EDT

                                                         EDT
                                                         OT
                                                         OT
                                                         EDT

                                                          28.
                                                          OF
                                                          OF

                                                          OT

                                                          OF

                                                         EDT
Often precipitated by viral infection Not until HbF levels faIl after the age of 3 months
And bones and spleen with acute severe pain
Splenic atrophy and functional hyposplenism Pneumococcal septicaemia also a feature
Decreased P~O2
May precipitate infarction crises

Local tissue hypoxia in the bloodless field



Typically hypochromic microcytic
In the ‘major’ (homozygous) form
Due to bone marrow hyperplasia in
early life
Not until HbF synthesis declines
Particularly in the ‘minor’
(heterozygous) form


Not features of increased erythrocyte
production
Suggesting intravascular haemolysis
With warm or cold antibody
Warm usually IgG, cold usually 1gM
CLL and Iymphoma


ABO is commoner but milder Placental clearance of bilirubin occurs prenatally
With a marked reticulocytosis
(10—50%)
Rhesus incompatibility is rare in the first pregnancy
Must be given within 72 hours of delivery if there is a Rhesus incompatibility
                                                         217
      1000 MCOs FOR DAVIDSON’S PRINCIPLES & PRACTICE OF MEDICINE

                                                       29.
                                                       OF
                                                      EDT
                                                      OT
                                                       OF
Males over 40 years
And elevated red cell mass
But may be asymptomatic
A feature of chronic myeloid
leukaemia
ED T E.g. increased risk of stroke
                                                       30.
                                                      EDT
                                                      EDT
                                                       OF
And vitamin B12 deficiency
And sulphonamide therapy
Only if secondary folate deficiency
develops
O F Atypical lymphocytosis
ED T And propylthiouracil therapy
                                                     31.
ED T Often with neutropenia
ED F Polymorphonuclear leucocytosis
O T Non-specific feature of many viral infections
ED F Non-Hodgkin’s Iymphoma
O T Predominantly small lymphocytes

                                                     32.
O T Or may be neutropenia in SEE
ED T And lithium therapy
O T Variable, increases at delivery
ED F Typically lymphocytosis
ED T And myocardial infarction

                                                     33.
ED T Usually with demonstrable marrow infiltration
ED T An ominous finding
•T    And tear-drop poikilocytosis of the RBCs
O F Lymphocytosis
ED T Rare after acute bleeding

                                                    34.
ED T Fever even without underlying infection
ED T Infection and infiltration contribute
O T Particularly purpura
ED F Normocytic or macrocytic anaemia, with primitive white cells
O F Hypercellular with leukaemic blast cells
                                                    35.
                                                    OF
                                                    OF
                                                    OT

                                                     OF
                                                     OF

                                                      36.
                                                     EDT
                                                     EDT

                                                      OF
                                                     EDT
                                                      OF

                                                      37.
                                                     EDT

                                                     EDT
                                                     OT
                                                      OF
                                                     EDT


                                                      38.
                                                      OF
                                                     EDT
                                                      OF
                                          EDT
                                           OF

                                          39.
                                          OF

                                          EDT
                                          OT
                                          EDT
                                           OF

                                           40.
                                           OF
                                          EDT

                                          OF

                                          EDT
                                           OF
Peaks in childhood
Acute myeloid Ieukaemia
About 100% respond cf. 70% with
AME; but relapse can be problematic
Acute myeloid leukaemia
May complicate myelofibrosis


Splenomegaly in 90%
Hyperuricaemia is often
asymptomatic
Atypical feature
Variable platelet dysfunction
Median survival 3 years


On blast transformation, platelet count
may fall
Mean total WCC is 220 x 1 09/L
Philadelphia chromosome
Usually decreased LAP score
Occurs in 30% in ALL and 70% in
AML


Peak age 65 years
Typically warm antibody
Mild organomegaly only
Bacterial more than viral
Overall median survival 6 years


Mild thrombocytopenia with usually
normal urate
Associated paraproteinaemia in 5%
Total WCC typically 50—200 x 1 09/L
May be associated with haemolysis
Transformation is rare
Neither is characteristic Mild splenomegaly, generalised Iymphadenopathy
Moderate to massive splenomegaly, no lymphadenopathy Usually both mild Splenomegaly without
lymphadenopathy
                                                         218

                                                                        BLOOD     13 1
41.
ED F Massive splenomegaly can occur
ED T Characteristic finding
O T In contrast to CML
ED T Increased cell turnover
ED F Excess of megakaryocytes

42.
O T   In males more than females
O T   60% have urinary light chain
O T   Better in younger patients
ED    T Reduction of normal plasma cells
      causes immunodeficiency
O T   All of which may be asymptomatic

43.
ED F Myeloma produces suppression of the other serum immunoglobulins
O T A diagnostic preretluisite
O T Amyloidosis occurs in 10%
ED T But the serum paraprotein may be undetectable
ED T Malignant plasma cell infiltration

44.
ED    T Suggests renal amyloidosis
ED    F High concentration suggests poor
      prognosis
O T   And thrombocytopenia
O F   No prognostic significance
O T   ADLs are useful indicators
                                                    45.
                                                   EDT
                                                   EDT
                                                   OT
                                                    OF
A pathological hallmark
Variable in degree
Characterises 70% of cases
In contrast to non-Hodgkin’s
       lymphoma
ED F Usually involved though without palpable splenomegaly

                                                    46.
ED T Usually painless
ED F Suggests haemolysis
O T Lymphopenia suggests poor prognosis
ED T And fever
ED T Dependent on staging at presentation
                                                    47.
                                       EDT
                                       EDT
                                       OT
                                        OF
                                        OF


                                       48.
                                       OF

                                       EDT
                                       OT
                                       OT
                                       EDT

                                        49.
                                       EDT

                                       OF
                                       OT

                                        OF
                                       EDT

                                        50.
                                       EDT
                                       EDT
                                       OT
                                       OT
                                       EDT

                                        51.
                                       EDT
                                       EDT
                                        OF
                                        OF
                                       EDT

                                       52.
                                       OF

                                       EDT
                                        OF
                                        OF
                                       EDT
Also termed ‘nodular’
Typically extra-nodal at diagnosis
Involves any organ
85% are B cell tumours
The converse is true; prognosis also
stage and age dependent


Measure the fibrinogen level if
deficiency is suspected
The Stuart—Prower factor
First factor in extrinsic pathway
Also affects the PTT
Prothrombin


May not detect minor fibrinogen
(Factor 1) deficiency
Detected by prothrombin time
Factor X also influences prothrombin
time
Specific assay to measure
Initial factors in the intrinsic system


Initiated by thromboplastin
An unusual complication
Endothelial injury
Exogenous endotoxins
Commonly bronchial carcinoma


Microangiopathic platelet destruction
May be absent in mild cases
Increased
Both are prolonged
Factor 5, 7 and fibrinogen deficiency


BT is normal but petechial
haemorrhages may occur
Irrespective of its cause
No vessel wall or platelet defect

Secondary decrease in factor 8 level with a qualitative platelet defect
                                                          219
El 1 ~I 1OU~ MCQS FOR OAVIDSO~S PRINCiPLES & PRACTICE OF MEDICINE
53.
ED F A primary vascular defect
ED T Factor 9 deficiency
• F Reduced cutaneous capillary integrity
o F Vasculitis without thrombocytopenia
ED T Factor 8 deficiency

54.
ED T Prenatal diagnosis is possible
ED T Usually at age over 6 months
• F Only the PTT is prolonged
ED F Half-life = 12 hours
O T DDAVP therapy is useful in some patients

55.
ED     T Endothelial failure to synthesize vWF
ED     T Impaired collagen synthesis impairs
       capillary support
O T    Endothelial damage
O F    Factor 9 deficiency
O T    Platelet dysfunction may also develop
          E.g. myelofibrosis
       Even in absence of blood loss
       Thrombocytopenia
       With marrow infiltration
       Non-specific inflammatory response
                                                       56.
                                                      EDT
                                                      EDT
                                                       OF
                                                      EDT
                                                      EDT
                                                       57
                                                      EDT
                                                      EDT

                                                       OT

                                                       OF
                                                      EDT

                                                       58.
                                                      EDT

                                                       OF

                                                       OF

                                                      EDT

                                                       59.
                                                      EDT

                                                      EDT

                                                        OT
                                                      EDT
                                                      EDT
Often with leucopenia Primary, or secondary to superimposed infections
Increased peripheral consumption of platelets
The platelet count is normal Also many cytotoxic agents


Can therefore be transmitted transplacentally
Usually young females Other clotting tests normal Suggests another cause of thrombocytopenia Particularly in
children


May present with recurrent spontaneous abortion Suspect if resistance to anticoagulation with heparin And
congestive heart failure Associated thrombocytosis And myelofibrosis
                                                       220



ONCOLOGY
14
                                                      1.
ED    F Ultraviolet light exposure
ED    F Linked to herpes simplex type II
      infection
• T   In Africa and in Europe
O T   And Ieukaemia and breast cancer
O T   And lung cancer

                                                      2.
ED F Testicular germ cell tumours
ED T And testicular germ cell tumours
O F Colorectal carcinoma
O F As yet, no marker for cervical carcinoma
ED F Ovarian carcinoma

                                                      3.
O T   Expresses the value of a positive test
      i.e. the sensitivity
O T   Expresses the value of a negative
      test i.e. the specificity
O T   A limitation in all screening
ED    F Sensitivity
ED    F Specificity

                                                    4.
ED F Small cell carcinoma
ED T And renal and ovarian carcinoma
O T And ovarian and nasopharyngeal carcinoma
O T Eaton Lambert syndrome ED T And other gastrointestinal malignancy


      Also records the presence or absence of lymph node involvement
      TO = excised tumour And permits assessment of treatment Without new lesions appearing Indicates disease
      on just one side of the diaphragm
                                                      5.
                                                      OF

                                                     OF
                                                    OT
                                                    OT
                                                     OF
                                                     6.
                                                    EDT

                                                     OF
                                                        OT

                                                        OF
                                                       EDT

                                                        7.
                                                        ED
                                                        ED

                                                        OT

                                                        OF
                                                       EDT

                                                        8.
                                                       EDT
                                                        OF
                                                        OF
                                                        OF
                                                        OF


                                                        9.
                                                       EDT
                                                        OF
                                                        OF

                                                        OT
                                                       EDT
And stage lIE if there was also extra-lymphatic involvement Disease would be classified as stage lIE
Or other diffuse extra-lymphatic involvement
Classified as stage IISE A = asymptomatic


T TX,NO,MO = occult carcinoma T Or extension to visceral pleura/partial
    atelectasis
Or spread to heart, great vessels, mediastinum
Peribronchial or ipsilateral hilar Ml = metastases present


Impairing cell reproduction
1 Joule per kilogram
Sealed sources implanted internally
Low energy radiation (50—100 kVp)
Hypoxia renders tissue less sensitive
to irradiation


An anti-metabolite
A plant alkaloid
An antibiotic anticancer drug
(doxorubicin)
Also BCNU and CCNU
And transcription
                                                        221

                                                         I

				
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