most useful mnemonics for MRCP

most useful mnemonics for MRCP . Osteoporosis risk factors ACCESS: Alcohol Corticosteroid Calcium low Estrogen low Smoking Sedentary lifestyle Ankylosing spondylitis: extra-articular manifestations 6 A's: Atlanto-axial subluxation Anterior uveitis Apical lung fibrosis Aortic incompetence Amyloidosis (kidneys) Autoimmune bowel disease (UC) Causes of Hypercalcemia: MISHAP......... M: Malignancy I: Immobility S: Sarcoidosis H: Hyperparathyroidism A: Addison;s disease P: Paget's disease Pneumonia severity grading: CURB-65 C: Confusion (Higher mental function <8) U: Urea more than 7 R: Respiratory rate >30/min B: B.P less than 90systolic and less than 60 diastolic 65: Age more than 65 years 1 point for each..... If 2plus prognosis is bad and needs admission at hospitalCUSHING: Central obesity/ Cervical fat pads/ Collagen fiber weakness/ Comedones (acne) Urinary free corisol and glucose increase Striae/ Suppressed immunity Hypercortisolism/ Hypertension/ Hyperglycemia/ Hirsutism Iatrogenic (Increased administration of corticosteroids) Noniatrogenic (Neoplasms) Glucose intolerance/ Growth retardation Posted: Wed Nov 22, 2006 3:13 pm Post subject: MRCP MAY 06 RECALLS) in one page For the first question about which drug inhibits purine synthesis...I put methotrexate, is that correct? then there was one with the girl with Turners who had HTNa nd equal BP in both arms so I selected renal artery aplasia, what else can I remember now...2 questions about hyperventilation and 2 about cluster headache.... paradoxical embolus____>transthoracic or transoesophagal echo??? Inferior MI____>Rt coronary artery MOA of cisplatin______??? OA pt with swelling of wrist jt____>OM? Gout? RA? realative risk____>??? 1. Contraindication to Surgery for Lung cancer: Pleural effusion 2. Lung functions shows FEV1/FVC 40% in RA patient: Bronchiltis Obiterans 3. Cisplatin action 4. How to confirm diagnosis of Leigionerre... Urinary antigen?!?! 5. How to confirm Meningococaemia: PCR?!?! 6. erectile dysfunction: Anxiety?? 7. Sildenfil and nicorandil 8. Ciclosporin side effect 9. ABG: Respiratory Alkalosis: PE 10. Paroxitene and unstable angina... 11. UC flare up. next step: possibly azathioprine 12. Knee joint question 13. Cervical spondilysis 14. Two question about RA... psoriatic arthropathy 15. A possibly osteomyelitis!!! 16. metformin and the B12 anaemia 17. metformin and renal impairment?!?!? 18. Sarcoidosis: CXR 19. Overdose of paracetamol and anorexia nervose 20. Overdose of Diazepam and Disulopin: ECG??? there was tachycardia of 140 21. Lateral condyle (tennis elbow) pronation of arm 22. Sensitivity 23. positive Predictive value 24. NNT what does it mean! 25. phase I.. what happens in it? 26. two question about choosing the right test in statistics 27. Lung functions COPD 28. MI then thrombolysed then got red dusky coloration of feet anf eosinophilia.. I just though it could be cholestrol embolism 29. Warfarin and factor VII 30. thalassaemia a.. both parents were traits! 31. APTT prolonged... some 50:50 mix up.. which factor?? 32. patient with some history of back pain: non-specific back pain 33. common peroneal nerve and dorsiflexion of ankle 34. intermittent loss of consciousness.. you know who I am talking about! 35. Benign intracranial hypertension 36. optic neuritis or giant cell arteritis??? swollen pale disc + monoocular visual loss! 37. partial left homonymous hametonpia: which lobe?? 38. cortical thrombophlebitis?!?!? it was complicated question but the CT was very suggestive 39. I guess there was Dengue fever 40. Which malaria..??? It was 6 month period! 41. hypocalcaemia and LOng QT 42. pregnancy and amiodarone for AF 43. HOCM and amiodarone.. there was VT on the treadmill 44. statins caused myalgia.. what not to use with?/ Fibrates 45. Rx for myclonus epilepsy: Valpraote??? 46. There was partial third palsy and six nerve and the ophthalmo section of the fifth.. orbit apex??? 47. What ABG to expect in hyperventilation?? 48. question about P(A-a) O2.. 49. what contains double stranded circular DNA 50. G6PD and trimethoprim for UTI 51. two questions about autoimmune haemolytic anaemia: one of them was about dirst antiglobulin test 52. IgA nephropathy 53. E coli HUS.. question 54. Rhabdomylasis and low dose dopamine??? 55. thiazide action??? 56. ADH action.. where?? 57. patient with past hx of alcohol presents with topheous gout.. he got Alluporinol two days later he got pain in wrist, hands and knees.. one of the option was alcohol binge.. I liked it! 58. question about tuberous sclerosis 59. there was two question I choose colonscopy for.. I can remember them at all 60. HIV and odynophagia! 1. melanoma----- change of colour size of tumor i did change of color i eas not not sure. 2. painless liver enlargment and jaundice. 3. treatment of gonnorhea 4. yratment of cholera. 1.mech.of action aciclovir--dna polymerase inhibition. 2.IgA Nephropathy 3.Antidote for cyanide poisoning-colbat edetate 4.a question about melanoma and carvenous sinus involvement. 5.cluster headcahe 6.villous adenoma--colonoscopy 7.T3 toxicosis 8.Carbimazole 30mg and persistence T4 elevation--propilthyuracil. 9.a case of PE 10.A case of behcet dx -venous thrombosis. 11.Sidenafil and nicorandil 12.sideroblastic anaemia 13.Gullain-barre and vital capacity 14.myotonic dystrophy with cataract and weakness 15.cANCA and wegener granulomatocic 16.APKD and polycystin 17.NNT AND reciprocal of ARR. 18.VIT.K and factor VII 19.OSteomalacia and low calcium and low phosphate but high ALP. 20.CONFUSED and aggressive man --Haloperidol. 21.Prolonged QT and hypocalcemia 22.lithium and drug induced DI 23.CHronic pancreatitis in pregnant lady with loose stool and malabsorptive picture 24CI to surgery lung ca. SVC obstruction 25.Generalized anxiety disorder and IMPOTENCE 26.Major depression and relatives death 27.Scabies and pruritus rash sparing the face 28.Polymorphic light eruption in sun exposed areas. 30.Hep.D super infection 31.Thyroid malignancy common in autoimmune thyroiditis--Lyphoma 32.A case of PCOS 33.A case of BIH 34.A CASE OF WERNICKES ENCEPHALOPATHY. 35.OESOHAGEAL HSV IN HIV 36.A case of cholera -rx--Doxycycline 37.Dog bite infection and FLUCLOX.AND BENZYLPEN. erectile dysfunction was another recurrent topic ... sildenafil contra indications- nifedipine or nicordil? differential dagnosis for ED- perfomance anxiety or an organic cause (clue=normal early morning erections) lump in nose+lump in neck+lung infiltrate 1-lymphoma 2-histocitosis x 3-sarcodosis 4-wegners 1-lateral condylo pain which will increse it -thumb -open fingers.... 2-leg loss reflex what the cause diabetic coronary...neurolog 3-posterior comunicate artery-anterior comunicate artery 4-a trait thalasemia 5-tirdness weakness synaktin short test 6-diabetus insibidus drug indused ..lethium.. 7-erythema on shin ..rash polyuria ..sle..sarcoidosis.. 8-idiopathic parkinson ..assemetry tremor 9-ondansterion for nausia was taking metochlopromide 10-acute loss of vision ..venous thrombosis.. 11-dry eye ..ulcers mouth genital ...sjogren...behcet.. 12-smoking ..coal miner....bladder carcinoma.. 13-methadon .. 14-lethium toxisity ....thiazide or nomal saline... paradoxical embolus definitely for transesophageal echo as u can visualise better oh urinary antigen definitely for legionnaire's and it has to be cholesterol embolus as bld eosinophil is high i opted for giant cell arteritis as the patient very old and giant cell common is old age intermittent loss of concious=ness with quick recovery and no residual neurological defect definitely vasovagal so answer is postural hypotension - its in harrison's 6 months indicate ovale malaria as they have a hypnozoite phase myoclonus best treated with ethosuximide adh acts on collecting duct to increase permeability rosacea best treated with oxytetracycline nicorandil cannot be given with sildenafil too much dilatation too much is not always good hehehe melanoma definitely size look it up in kumar and clarke dog bite...antibiotic complement ,,,SLE WHICH TENDON PREDICTIVE VALUE MEDIAN STUDY PSEUDOMEMBRANEOUS COLITIS ANTIBIOTIC ASSESS OPERATION RISK-MI ?MYOTONIA DYSTROPHICA ESOPHAGEAL ULCER ALEDRONATE MARFAN FIBRILLIN TURNERS-- BP PREGNANT WITH SVT IG HYPERACUTE REACTION ciclosporine mechnism acyclovir mechanism rhabdomylysis mange repeat ?urine for protein cluster headache?/? ?reactive arthritis ?prevent calcium stones A young diagnosed spastic angina best mangement. -fecanide -betablocker -asprine --Asprine is correct. A 17 year old boy with hypertrohpic cardiomyopathy tratment with best prognosis. 1-betablocker. 2-Alcholc aplation of septum. 3-implantable defibrilator automatic. 4-Another antiarthysmic. implantable defibrilator is correct. igm-hyperviscosity behget dvt WHAT WAS THE OLD LADY WITH WRIST SWELLINGa patient with tinnitus, 0.9 cm swelling in pituitary, with no hormones elevated- how do you proceed.... observation?? another choisis for best indicator for tonsilitis abscess is continious fever 1-foramen ovale 2-prick test ...ige . 3- scabis... 4-e coli 5-cholangio carcinoma .. 6-ulcerative cholitis... 7-mody .. 8-liver biopsy...us guided ..mrcp ...ercp.. 9-paroxetin...hypertension.. 10-spinal ..foot depression.. 11-frontal lobe syndrome..parital lesion .. 12-knee replacement ... 13-noctornal dysphasia 14-tachicardia ..diarrhia....anticholinergic...tox.. 15-crticosteroid injection ..joint .. 16-c4..c5..c6..c7....{c4} 17-vertebral prolapse.... 18-3..6...trigemeni........pons 19-aspirin coronary spasm ...metoprolol...propranolol.. 20-genetic...mother brother...father brother..............mother brother...link ressesive 21-hematuria thrombocytopenia..anemia...imunoglobulin..iga.. 22-hemophelia.. 23- 1/2......1/4....1/6...1/8 24-graves disease ....t3...t4... 25-hematuria....hypervescosity..syndrome 26-chronic subdural hematoma 27-eozinophilia....nephrology.... oh yeah wot about the chap with the allergy to seafood and his bp was 170/100 tachy at 110 spo2 98 on air options were iv adrenaline sc adrenalin im adrenaline close observation 1)chap presented with painful shin then malar rash with abdo pain and polyuria.which investiagtion would clinch the diagnosis me think it was chest x ray cuz u can see bilateral hilar lymohadenopathy of sarcoidosis no? 2)lowish ca 2.00 normal po4 1.3 and a sky hi alk phos it's PAGETS innit? cuz excessive bone turnover so hi alk phos and lowish ca from consumption 3)chap on carbamazepine and came to you with agranulocytosis but no fever.free t4 hi wot shud u do? - stop carbamazepine and change to PTU -radioactive iodine -pennicillin V -reduce dose of carbamazepine wots the answer eh? 4)cisplatin goddamit i knew i shud have read it up wots the mode of action? 5)lady with severe hip oa goin for surgery with stable angina how should u assess her? probably thallium scan cuz she can't possibly go for a walk on the treadmill wot with her painful hip and all that 6)chap with an MI who undergoes exercise treadmill and then has paroxysms of short lived vt probably electrophysiological testing and ablation 7)young chap with coronary artery spasm aspirin 8)pregnant lady with SVT? metoprolol? 9)thrid nerve palsy with pupillary sparing and 5th opthalmic branch involvement and 6th nerve involvement probably orbital apex no? 10)chap post renal transplant on cyclosporin and prednisolone and comes to u for an infection twcc 3+ ie low wots wrong b lymphocyte,t lymphocyte,bone marrow suppression?! 11)cant ankle dorsiflex,cant use extensor hallucis longus,medial aspect loss of sensation in the lower limbs.wots wrong with this fella? 12)pregnant again question with background alcohol abuse with small babies,diarrhoea,low folate etc wots wrong -alcohol excess? -chronic pancreatitis -coeliac? 13)20 year old girl with dm on sc insulin keeps getting hypos and hba1c of 5.4. is she anorexic? 14)crazy man hitting wife and claim nobody ain't gonna touch me cuz me got friends high up in the police department hypomonia? paranoid schizophrenic 15)jysus!~human genome project!!! wots the answer issit e)not all dna code for a gene? 16)u are the SHO on call and u have limited isolation beds which of these following organism spreads easiest a)legionella b)mycoplasma c)varicella d)staph e)strep pneumonia issit varicella cuz she's the odd man out 17)someone told me that its pearsons correlation for comparing the median between placebo and statin tell me it aint true! 18)remember the one about the HIV chap with odynophagia etc must be cmv oesophagitis huh? can it possibly be candida? Posted: Fri May 19, 2006 3:30 pm Post subject: -------------------------------------------------------------------------------PSYCHIATRY 1-a lady brought to casualty after the death of her maother sit on chair not resposive :CONVERSION DISORDER this is typical in which there is a stressfull condition(death of mother) dissociated into physical symptoms for the primary gain(alliavation of symptoms an escape phenonmena) 2-a man brought to casulty several time with abdominal pain recently brought with swaeting shivering and said if u dont give me morphine i will commite suicide :MUCHUENSUS SYNDROME (intentional production of symptoms for a primary gain which is MORPHINE its not somatisation disorder .. 3-there was a question about post traumatic disorder i cant remember exactly 1-test to confirm haypersensetivity (PLASMA TRYPTASE TEST ACTIVITY),specific for mast cells 2-test to confirm nickle skin sensitivity producing wheals and urticaria (PATCH TEST)this is for skin hypersensitivity ,the prick test is for sytemic hypersensitivity like ASHTMA,ABA. 3-treatment of cholera DOXYCYCLINE 4-The Pt who is hypertensive and developed anaphylaxis with blood pressure 170/100 OBERVE him initially and give hime antihistamin and if BP dros then give him adrenaline 0.5 ml IM 1/1000 and steroids .. 5-test to cnfirm ABA :Apargiluus precipitins 6-HOCM with runs of VT :Automated cadiverter defibrillator 7-SVT WITH 250 RATE :AMIODRONE 7-pt receiving statin developed myalagia drug that should be avoided is:NICOTINIC ACID as both are causes of myositis 8-Pt who was moderate drinker hypertesive brought with gouty attack and given allopurinol came back with an attack the cause is :ALLOPURINOL THERAPY as it was given solely in an alcholic without being covered by NSAIDS which precipitate an attack of gout 9-vellous adenome removed follow up COLONOSCOPY once a year in the first 2 years and then everey 3 years 10-Rt sided effusion,high CA125 :OVARIAN FIBROMA (meigs syndrome) 11-opthalmoplegia+impared sensation in foehead+NO proptosis :CAVERNOUS SINUS THROMBOSIS 12-78 women with acute loss of vision+pale disck:GIANT CELL ARTERITIS 13-lump in nose+lump in neck+pulmonary infiltarte :SARCOIDOSIS the lump in neck is salivary gland swelling ,the lump in nose is lupus perinio (MICULIZ SYNDROME 14-women with +anti RO ,+anti Sm :SLE 16-Women brought with fatige has +anti smooth muscle antibodies what test to perform (LVT its autoimmune hepatitis) 17-dog bit in hand with cellulitis give:B.PEICILLIN+FLUCLOXACILLIN to cover staph,sterpt,pasturella 20-Pt with mody what from history suggest it :STRONG FAMILY HISTORY cuz its AD inhirited Type 2 in young 21-paraplegia with loss of pain and temp and sparing of post colum(ANT. SPINAL ATRTER OCCLUSION 22-DOXORUBUCIN :DILATED CARDIMYOPATHY 23-post transplant taking cyclosporin:NEPHROTOXICITY 24-UC+s2 cm lesion in liver (CHOLANGIOCARCINOMA) 26-carbimazole developed agranulocitosis (START PENICILLIN V ) 28-Needle stick injury from HIV postive :COMMENCE THERAPY IMMEDIATELL with 3 drugs for a month 29-the thalasamia trait family brought anxious about rishk to thier fetus :(THERE IS NO RISK TO THE FETUS) the child HbF will take over ,roblems will appear at 9 months of age when the Gamma chain transform into Beta chain and as they are alfa trait the prognosis is good the child will have a good beta chain a patient with nocturnal cough, BMI- 22, probable diagnosis - asthma, GERD, obstructive sleep apnoea best indicator for peritonsillar abscess- trismus?? 1. The absence of which complement factor predisposes to the development of drug induced lupus. Ans: C4. 2. A young athlete with a family H/o SCD. i episode of ill-sustained VT of 20 beats on exercise testing. Next line of management. a. Holter monitoring b. Amiodarone c. automatic implantable defibrillator d. septal ablation Ans: automatic inplantable defibrillator. 3. In a patient on Warfarin which factor is likely to be reduced ANs: Factor VII. 4. Patient with type 1 DM on insulin presents with 3 episodes of hypoglycemia. There is H/o weight loss from 55-45 kg in 3 months. No significant clinical findings. Possibility a. Anorexia nervosa b. Hyperthyroidism c. Cushings syndrome. Ans: Anorexia nervosa. 5. H/o travel to africa 6 months ago, now presents with fever and chills. a. Brucellosis b. Falciparum malaria c. Ovale malaria Ans: Brucellosis 6. a patient with nocturnal cough and BMI of 22. most likely cause of his cough is a. Asthma. b. GERD. c. OSA. Ans: GERD. 7. Test to confirm nickle skin sensitivity producing wheals and urticaria Ans: Patch test. 8. Treatment of Cholera: Ans: doxycycline. 9. Paraplegia with loss of pain and temp and sparing of post column Ans: Anterior spinal artery occlusion. 10. Cardiotoxicity of Doxorubicin Ans: Dilated cardiomyopathy. 11. Needle stick injury from a HIV positive patient. Ans: commence post exposure prophylaxis with 3 drugs immediately. 12. If you are the SHO on call and u have limited isolation beds which of these following organism spreads easiest a)legionella b)mycoplasma c)varicella d)staph e)strep pneumonia Ans: VZV. 13. HIV positive patient with odynophagia. Ans: Candida albicans. CMV esophagitis is another possibility, but I think candida is the more common one. 14. A patient presented with painful shin lesions with abdominal pain and polyuria. Which investigation would clinch the diagnosis Ans: Chest X-ray to diagnose sarcoidosis 15. Lady with severe hip OA going for surgery with stable angina.How should u assess her? Ans: Thallium scan. 16. Patient with coronary vasospasm. Drug to be avoided. Ans: Aspirin. 17. The following are true regarding the human genome. Ans: Only a small amount of DNA codes for genes. 18. A lady with 3 year H/o joint pains and malaise. Anti smooth muscle antibody is positive. Next line of investigation is a. LFT b. Thyroid function test. Ans: no idea 19. H/o sudden onset of pain in the right eye while hitting nail into the wall. Pain is severe and continuous with occasional exacerbations. Right pupil is small and there is mild ptosis. a. carotid artery dissection. b. facial migraine. c. cluster headache. d. trigeminal neuralgia. Ans: carotid artery dissedction. 20. Right 3 rd nerve palsy with papillary sparing with right 6th nerve palsy and loss of pinprick sensation over the forehead. There is no proptosis. The possible site of lesion is: a. orbital apex b. cavernous sinus. c. interpeduncular fossa. d. midbrain e. pons. Ans: orbital apex/ cavernous sinus thrombosis 21. Patient is on sildenafil. Which drug has to be avoided? Ans: Nicorandil 22. H/o difficulty in closing mouth after chewing for long periods, ptosis and distal muscle weakness. a. MG b. LEMS c. Muscular dystrophy. Ans: MG as there is easy fatigability but what about distal muscle weakness. 23. NNT is calculated as Ans: NNT =1/RRR but this option was not there. I think it is percentage difference between AR and RR because RRR= (1-RR) X 100%. 24. Patient with Pulmonary hypertension and upper GI bleed. The preventive therapy would be. Ans: propranolol. 25. Patient presents with h/o fatigue, lassitude. Investigations reveal thyroid hormones in the lower limit of normal, hyperkalemia and hyponatremia. Next line of investigation is a. Short synacthen test b. TSH c. FT4 Ans: Short synacthen test as it is likely to be Addison’s disease. 26. Lady with amenorrhoea and raised LH and FSH. The likely possibility. a. Primary ovarian failure b. PCOD c. Investigate for pituitary cause. Ans: primary ovarian failure. 27. Throid profile showing increased T3, Low TSH and T4 in the lower limit of normal. The likely possibility is a. T3 toxicosis b. familial dysalbuminemic hypothyroidism c. tertiary hypothyroidism. d. sick euthyroid syndrome Ans: T3 toxicosis 28. a lady presents with 1 year h/o pain in the right hand progressing to involve the entire right upper limb, scapular and pectoral regions. There is decreased pinprick in the hand and absent tendon reflexes, but there is no significant wasting. The possibility is a. brachial plexus infiltration b. cervical sponduylosis c. syringomyelia Ans: Brachial plexus infiltration. 29. H/o vertigo on turning head like while crossing road, also present while turning around in bed. a. BPPV b. Carotid sinus hypersensitivity c. chronic vestibulitis Ans: BPPV 30. H/o sudden falls without loss of consciousness in an elderly lady. She recovers within 1 minute and is able to continue. a. cataplexy b. myoclonic epilepsy c. drop attacks d. carotid sinus hypersensitivity Ans: drop attacks. 31. A person attacks his friend and shows no remorse. Friend says that of late he is very abusive. Wife says that he hasn’t slept for 2 days. On examination he is aggressive. He says he cannot be punished as he has contacts with high level police officials. a. paranoid schizophrenia b. manic episode Ans: manic episode 32. A lady is silent and withdrawn since finding her dead mother in her room. She does not eat, or move from her chair. a. catatonic schizophrenia b. major depression c. conversion disorder. Ans: major depression/ conversion disorder. 33. A patient has frequent nightmares and intrusive thoughts after witnessing the death of 2 colleagues. Wife reports frequent episodes of crying. Ans: post-traumatic stress disorder. 34. Patient presents with h/s/o psychosis. She was started on phenothiazines. She comes 6 months later with h/o joint pains, raynauds phenomenon and dry mouth. a. drug induced lupus b. MCTD Ans: Drug induced lupus. 35. A boy with hemophilia. Which of his relatives is likely to have the disease. Ans: mother’s brother 36. A lady has a brother with hemophilia. Assuming that her husband is normal what is the chance that her daughter will be a carrier. Ans: 1 in 2. 37. Patient with repeated episodes of clostridium difficele diarrhea has come with findings s/o UTI. Treatment Ans: Vancomycin. 38. Pt receiving statin developed myalagia. Drug that should be avoided is Ans: Niacin 39. Antibiotic for dog bite Ans: co-amoxyclav. 40. A man was brought to the casualty with abdominal pain, sweating shivering and said if u dont give me morphine I will commit suicide Ans: Munchausens syndrome 41. A person develops allergy to sea food containing prawns I hour after consuming it and presents 3 hours later with hypertension and tachycardia. Next line of action Ans: close observation. 42. A patient has been detected to have a pituitary tumor of 9 mm without any other abnormalities. A repeat CT few months later does not shoe any increase in size. Next line of action Ans: nothing to be done. 43. a patient with ulcerative colitis has a single hypoechoiec lesion in his liver. What is the possibility a. focal nodular hyperplasia b. cholangiocarcinoma c. hemangioma d. adenoma Ans: cholangiocarcinoma/ adenoma. 44. A patient with ulcerative colitis continues to have rectal bleeding though he is on prednisolone. Next line of management a. iv hydrocortisone b. oral azathioprine c. iv cyclosporine Ans: iv hydrocortisone or oral azathioprine. 45. ABGA in hyperventilation. Ans: decreased pCO2, increased PO2 and pH Q32- THE ANSWER IS CONVERSION DISORDER as there was a stressfull precipitating cause (death of mother) and dissociated into physical symptoms which are being silent and unresposive as an escape phenomena (primary gain) belle indifferent to that thoughts ,,,its definately unlikely to be a major depretion as in major depression there is no obvius cause it could have been right if it was reactive plus from the q there was no SOMATIC feature (wt loss,diurnal variation,constipation....etc q-THE DOG BITE you have a dog bite plus cellulitis so u should cover staph,strept and pasturela so u give benzyl penicillin+flucloxacillin 1-action of cisplatin--cell metaphase arrest 2-in acute renal rejection what is the anti HLA antibodies- IgG, M, E,D,A 3- 4 WEEKS POST RENAL TRANSPLANT REJECTION WHAT IS THE MECAHNISM- DUE TO CYTOTOXIC t-cELLS 4- first action of aciclovir--- Inhibition of thyamidine kinase 5- Treat Of dog bite celliulities+lymphoedema- Fluxo+penicllin 6- ypug pt complaining of abdominal pain and threatens to commit suicide if not given Morphin--- Munchehasen syndrome 7- Calculate Pos. Predective value from Agiven table-- 40/50=80% 8- Def. of NNT to treat the difference between Absoulut and realtive risks. 9- def. of sensetivity 10- calcuation the oral dose of 60 mg Morpgin--180mg 11-case of mania- beating his G/friend and saying he has police connections. 12-case of post traumatic stress syndrome- the guy envolved in accident witnesse his friends death. 13-Preg. lady Hx of alcoholism presented with diarroea in third trimester Foetal USS -IUGR-- chronic pancreatitis 14- Preg. with SVT how to treat-- Verapamil, amiodarone, flecanide, misoprolol 15- which drugs needs dose adjustment in Renal failure-- Temazepam, metformin 16- medication to D/C if wants to start viagra-- Nicorandil 17- Treatment of gonnoreahea--- Amoxcillin 18-pt presented with nech stifness, headach and fever CSF: HIGH PROTIEN, normal gucose, high lymphocytes-- TB meningitis 19-pt with Hx of seafood alargey, presented with tachyponea >35. BP 170/110 what will u do next-- IM adrenalin 20-pt with URTICARIA how would u Tx-- Citizidine 21- Pt had Sx of UMN+LMN what is the diagnosis-- interior spinal artery oclusion 22- Pt presented with face and upper trunk URTICARIA for 6 months recently changed her facial cleanser and take paracentamol for headach what is the Dx-- idiopathic URTICARIA . 23- Which on is Autosomal dom- HMSN1, Lebres Disease, Retinintis pig, 24- Guillan Barre monitoring-- Vital capacity 25- a case (cant remember) Ivx showing cryoglobulin-- Hep. C infection 26- post mi pt recieved thrombolysis, presented with dusky feet--- Chlosterol embolism 27-elderly with frequent fall what inX to R/O reversable cause- brain CT sacn. 28- How to Dx idiopathic parkinsonism--- asymmetrical Bradykinesia 29- pt prested with weakness sfter conversation or eating-- M. Gravis 30-case of joint pain, dactilitis--- Psoriatic arthropathy 31- eczematous pt presented with pustular lesions overe face and trunck how would u mamange? 32-pt had painful nodule on the shin, followed by facial rash, apolyurea, which Invx-- CXR 33- SOME NEW LAW OF CALCULATING ALL LIPID PROFILE. 34- COMPARING POPULATION PERCENTAGE- Chi-squard 35- comparing the cholst. level between male and female-- pearson test 36- calculating the NNT , pts on warfarin risk of stroke 2% on Asprin 4% what is the NNT over five years, 10,20, 30, 40, 100 37- How to Dx menigeaococcemiea-- Blood PCR, CSF microscopy, throat swab, 38- Rx of cholera- Doxycyllin 39-Pt with COPD and LRTI which common organisim- Staph aurus, L. pnemophilla, Mycoplasma.. 40- Pt with cytic fibrosis and LRTI which Tx41- pt with low FEV/FVC low TLCO and High KLCO-- respiratory muscle weaksess 42- Pt hyperventilationg which ABG- High Po2 Low Pco2, High PH low bicarb 43-pt with longstading RA nd 9 years Hx of DM presented with protinurea, kideny USS shows 1.2 difference what is the Dx-- Amylidosis 44- Elderly pt with Iron def anemia, OGD-Gastritis what to do next---colosocopy 45-Pt with bowel adenoma resected how to follow up- Colonoscopy 46- pt with hypothyrodism on replacement presented with normal TSH, low T4, normal T3--- adequate Tx 47-pt presented with lasstitude 6 mths low TSH, high T3, Normal T4---- T3 thyrotoxic 48-Pt with UC +hepatic lesion, high Alk p what Dx- Heaptoma, adenoma, Adencarcinoma, hepato Ca, Cholangiocarcinoma, 49- case with Knee osteoarthritis management --- knee replacement 50- preg lady with Alpha thal trait+ husband trait wants to know the risk to the foetus--- no risk to the feotus 51-pt with G6PD given AB for UTI presented with jaundice whish drug--- trimethoprim 52- x-linked disease which family member will be affected-- mothers brother 53- which organeel contains circular DNA-- Mito 54- t with paradoxical embolus which Invx--- Transoesophageal ECHO 55- pt post MI 6 weeks presnted with SVT which Invx-- ECHO, Electrophiseological testing, 56- elderly lady with freq. LOC weaks up with help after 1 min Dx- drop attacks 57-young lady with diplopiam recent wieght gain Dx----BIH 58- young pt with chronic nocturnal cough, normal CXR Dx-- chronic sinusitis 59- pt present with neck sweeling+ swelling in the nostril Dx--- Sarcoidosis 60- HSP which renal Pathology --- IgA nephropathy 61-AS X-ray Appearance- Dysmophytes 62- Joint pain Xray shoing Osteopenia Dx--- RA 63- Pt with overdose what will increase the toxicity?-----Anorexia nervosa 64- which Diabetic agent will increase insulin senstivity?--- Rosiglitazone 65-Pt with MODY how to confirm it?----- Strong family history 66-action of ADH?----on collecting tubules 67-Pt with liver cirrohsis and ascites which Tx?--------- Aldosterone antagosist 68- Pt with DM presented with proteinurea, High HbA1C and background retinopathy he is on insulin, ramipril what to do next?-------better glycemic control 69-pt presents with ptosis myosis 6 hours after cleaning the ceilling Dx-----Carotid Artery Discetion 70-Pt with sudden severe back pain, Aortic aneuresim confirmed what do next?---- start Labetolol 71-pt with features of Turner syndrome what will casue high BP?--------Coarctation of aorta 72-Pt with features of marfan, which gene defect?---fibrillin 73-Q about human genome project? only few genes code for protien 74-pt with painful third nerve palsy which artery?--Post. Com.Artery 75-Pt with diplopia, third and fifth (opthalmic) nerve palsy where is th lesion? cavernous sinus thrombosis. 76-pt with headache which wakes up with pain hs wife noticed that during these attacks his eye becomes red, 6 weeks ago he had minor head truama with whiplash injury, what is the diagnosis--- I wrote cluster haedache but I think the right answer is cavero-orbital fistula 77- which medication inhibits purin synthesis?-- Azathioprin 78-features of polycythemia, itch, what to expect?--Hyperurecemia 79- Long QT what ppt. it?---- Hypocalcemia 80-pt with high IgM levels, what would be expected?-- Hperviscosity 81-Pt with featurs of Behcets disease prestens with left leg swelling and pain what is the Dx?---- Venous thrombosis 82-Bursa on lateral epicondyle which movement will excerabate the pain?---pronation 82- Pt with mesothelioma and asbestosis exposure which statement is right?--- smoking increase the risk of mesothelioma 83-Pt with urinary retention, loss of senation of medial aspect of thigh--- Lubosacral lesion 84- pt with common peroneal lesion 85- Pt with impotance, dismessed from work Dx?-- Performance anxiety 86-Medication enhancing Lithium Toxicity?---Thiazaide diuretics 87- Pt with recurrent nephrolitheasis, InVx showed Hypercalceuria how to manage?--Thiazaide diuretics 88- Prophylaxis of pt going for dental procedure Hx AS+bicuspid valve?--- 3g Amoxixllin before the procedure 89-case of polysurea pt Hx of bipolar disease Dx?---Drug induced Nephrogenic DI 90-Pt with Occupational asthma how tp confirm the Dx?--- Spirometry at work and after work 91- pt with imtrm. abdominal pain, urin turns dark on standing Dx----- Interm. Porohyria 92-most common cyclosporin complication?---Nephrotoxicity 93-mu r the medical incharge with one isolation room which infection to isolate?-Staph.ausrsu 94-Elderly pt with psychosis Dx as schizophrenia giviv Phenothiazin presented with Raynauds phenomena, dry mouth, and invx low C4, pos Anti Ro and anti Sm Dx?--SLE 95-pT WITH CARBAMAZAPINE INDUCED NEAUTROPENIA WHAT TO DO NEXT?---I wrote radioiodine Tx but I think the right answer is propathyureacyl. 96-Oesaphegeal vareces what prophylaxis?-- Propanolol 97-Pt with 2nd amennoreha high FSH LH Dx?---- PCODs 98-pt with hypopigementation, seizure and subingual fibroma Dx? Tuberous sclerosis 99-pt 24 years with polycyctic kidney grandmother died at 54 of P. kidney which statement is right? PKD1 polycustin gene 100-Regarding lung Physiology ? Av gradient will deacrease with altitude . 101-pt with painfull wrist not relifed by NSAIDS what to do next? cortison injection of the joints 102- Pt with Hep B resistent to interferone presented with sudden hepatic apin, and jaudice, deteriorating LFT Dx?--- Hep D superinfection 103- Pt with celiac dis, on ca, Vit D, and elandoronate, presented with dysphegia Dx?--Drug induced oesophageal ulcer 104- cANCA?--- Pos in wegner dis. 105- pt with Hypercal, high Alk.P Normal phosphate level Dx?---Pagets dis. 106- Autoimmune hemolytic anemia how to confirm the Dx? Pos DAG test 107- Pt with RA on brufen presetned with easy brusing Dx?--I cant remember 107- Pt on chronic warferin Tx which factor will be low?---7 108-young hypertnsive pt presented with optic hemmorahge Dx?-- Hpertensive retinopathy 109-C/I to lung surgery?--- SVC obstruction 110- 55 uears old lady presented with sudden loss of one eye dx? giant cell arteritis. 111- pt presented with tinitis, CT san showed interasellar pit enlargement on .95 cm no hurmonal dist, no increase in size ofter one year what to do next?--- Nothing 112- pt with features of addisons dis, which test to confirm?---Short synthacten test 113-Pt with pain on abduction of arm Dx? Supracapsular lesion 114-most common site for atrial mexoma?--- left atrial 115- Nurse got pricked deeply with HIV post. Pt what to do next?-- Start zudivudin immediately for one month 116-Pt with paradoxical embolus Ivx? transesophagelecho 117- pt with hepatic disesae which Ivx? ERCP 118-PT WITH PROMYELOCYTIC LEUKEMIA Invx? Karyotyping 119- skin lesion, on close inspection there is keratin plaque and skin atrophy Dx? SLE 120- young pt with generalised myoclonus epilepsy Tx? Sodium Valporate 121- a drug in the market pt developed new side effect which study design? case control study 122-pt with joint pain penile lesion Dx? reactive artheritis 123-Pt with HCM+non sustained SVT, HE IS ASYMPTOMATIC Tx? implantabel defibrilator. 124- elderly lady Hx of IHD going for knee surgery how to assess her cardiac Fxn?--Thallium scan 125-ST elevation in lead 2,3, AVF which artery?--RCA 126-Rhabdomylysis renal failure Tx? Iv normal saline 127-Qs about peritonsiller abscess? 128-indcation for melanoma transformation? change in size 129-sile of melanocyte in the skin? stratum basale 130-which malignancy asoo. with thyroiditis? Lymphoma 131- Pt with intracerebral hemorrhage, CT= hemorrahge extending to the cortex, Hx of High BP Dx? Polycystic kidney dis. 132-herpes simplex virus which statement is correct? increase risk of infection befroe the menses 133-pt asking the meaning of anticipation? deacreasing age of presentation with subsequent generation 134-pt presentaed with steroid resistant UC, prsented with diarrohea and 10% wt loss refusing surgery, how to Tx? cyclosporin 135-young eczematous pt presented with itchy postules,esp at nite sparing his head Dx? scabies 136- group of elderly, typical presentation of legionellar dis how to Dx? urinery Ag 137-def of wich complemet leads to-?-?-?- disease?--- C4 138-pt presented with polyurea, urinary Na 10, urinary osmo 295, plasma osmol low Hx of bipolar disorder Dx? Drug induced Nephrogenic DI 139-which medciation causes galactorreah? metclopromide 140-pt with pleural effusion and high CA 125 origin of Tumor? Ovary 141-pt presents with lack of interst, depression and fatigue Dx? Chronic fatigue syndrome 142-S/E of Doxorubucin? Dialated cardiomyopathy 143-drug in phase one tria what dose it mean? I acnt recall my Answer 144-pt present with diarrohe and hematurea( HUS ) which organism? EColi 145- pt presented with abdominal bloatedness and diarrhea fro 2 weeks duration Dx? antamoeba histolitica 146- statin induced myalgia which lipid lowering drug to avoid? I dont know the answer 147-pt preseted with back pain radiating to his shoulder after Hx of trauma for 6 monts past Hx of similar problem resolevd spontanously over 8 mths Dx? non specific back pain 148-pt with left homounymos hemianopia with sensory inattention Dx? parteal lobe lesion 149-confuse and aggitated eldely Tx? Haloperidol 150-some qs about methadone i cant recall 151-Q about normal joint? the suprapetellar bursa is not related to knee joint 152-Rt hypochondrial pain after liver biopsy why? hemetoma collecton 153-pt with typical gout given allopurinal his condition deteriorated why? Allopurinol induced 154- pt already on meclopromide and still nauseated how to Tx? I cant recall the options or my answer CIPROFLOXACIN and not Trimethoprim is contraindicated in G6PD Deficiency!!!WELL trimethoprim is a diaminopyrimidine and in the market is usually combined with sulphamides. It is the sulphamides that cause the haemolysis in G6PD, not trimethoprim. On the contrary CIPRO causes haemolysis in G6PD therefore is contraindicated in such patients. 1—old man with rt knee joint pain &swelling known case of OA on NSAID e out improvement on x-ray d r deformity narow cartiligenous space & cyst in perarticular area management: a-inra- articular steroid b-total joint replacement c-synevectomy d-continou NSAID I put total joint replacement by guess 2—pt in her 32 weeks pregnansy c/o fatigue investigations shows SVT what u will give a-adenosine b-flecanide c-dilti9azem dI don’t know the answer ?? 3—pt e tender erythematous rash on her legs and fatigue joint pain and polyuria o/e there papular rash on her face and nazal pridge invest ANA weekly +ve 1/20 After dilution ?? 1/20 Urine + protein Calcium 3.2 what u will do for her 1- CX ray 2- Ds DNA I put x-ray 4—pt c/o galactorhea known case of gasteritis on treatment what of the following ttt will cause galagtorrhea a- meticulopromide b- omeprazole c- spirinolactone d- I think meticulopromide 5—circular douple strand DNA will be found in a- mitoconderia b- nucleus c- riposome d- golgi apparatus isit mitoconderia?? But I know it is single strand any help?? 6—pt . known case of contact dermatitis what test you will do a—prick test b- patch test I put patch test 7—pt e medial epocondile trauma what action will not able to do a—flexion of forearm b- pronation 8—pt unable to abduct his arm against resistant what m affected : a—infra spinatous b—supra spinatus c—teres minor d—teres major . 9—pt e st segment elevation in lead II & III ,avF, what vesel ocluded a—rt coronary artery 10—old women with recurrent falls with out any precipitating cause and not preceded by any symptoms whats the most common cause a—parkinsonism b—drop attacks c—TIA d— 11—old man admited to ER e severe agitation known on ttt of antidepressant what ttt u will give to him a—oral halopiridol b—I v diazepam c—iv chlorpromazine d—oral diazepam all they select haloiridol but pt severly agitated and u r in ER how u will give oral halopiridol I think its not correct!!??155-painless jaundice in a diabetic pt which drug is the likely cause -SULPHONYLUREAS 156-an obese lady with type 2 diabetes and deranged liver enzymes :NASH 157-DIABETIC with albuminurea 90 mg/24 hour what to do next :ADD ACE INHIBITORS 158-syringomyelia qs For the SVT in pregnancy-the guideline shows Metoprolol,there was no amiodarone therewonder about its safety in pregnancyIf adenosine fails, then IV propranolol or metoprolol are recommended. Intravenous administration of verapamil may be associated with a greater risk of maternal hypotension and subsequent fetal hypoperfusion." Like other autoimmune disorders, there is an increased risk of malignancy, with a B-cell malignant lymphoma, the most common to arise within the gland. A rare association is a sclerosing mucoepidermoid carcinoma which arises with fibrosing Hashimoto's disease. 1-LUMPS BISSNESS IS SARCOID MECKLIC SYNDROME 2- HBV WITH ACUTE DETERURATION WE THINK HEPATIC CA 3- OSTEOARTHRITIS IS ECHO AS SHE CAME FOR KNEE REPLASMENT SHE CAN NOT RUN ON TREDMIL. 4-CATAPLEXY ,AND VASOVEGAL ATTACH BOUT WITH NO LOC AND REGAIN POWER WITH IN MINETES WE DONT KNOW WHAT EXAMINER WANTS . 5- HYPER ACUTE REJECTION THE ANSWER IS IGG ,SURE OF THE ANSWER pregnant SVT---> VERAPAMIL achne with small visicles Rx --->doxytetracycline dog bite Rx ---> augmentine action of acyclovir-->thymidine kinase huscy color legs post procedure--->cholesterol emboli hashimotos thyroiditis ---> lymphoma to avoid what if statin cueses myalgia--->gemfibrosyl if clonic adenoma removed well follow pt wih--->annual colonoscopy drug inc insulin sensitivity ---> poziglitazone lady with severe pain complaining osteoarthritis with stable angina why thallium perfusion to see her cardiac status why not ett ?is there any contraindication for ett in osteoarthritis? one pr fall down and with out conciousnessness and after that he start to walk its cataplexy not like vaso vagal.. A man was brought to the casualty with abdominal pain, sweating shivering and said if u dont give me morphine I will commit suicide .some body is telling Munchausens syndrome ,but i didnt answer this one.any idea? in acute renal rejection what is the anti HLA antibodies...i think ig m preg lady with Alpha thal trait+ husband trait wants to know the risk to the foetus-husband and wife both affected...so answer to check antenatal condition of fetus...the exact stem i cant remember... Pt with Hep B resistent to interferone presented with sudden hepatic apin, and jaudice, deteriorating lft...many people wrote super infection hep d .but patient old i think hepatic ca. can u remember ..one ques from anatomy ...muscles involve in flexion of knee or hip ..i forgot...what was your answer? plz discuss about these questions...latter we will discuss more other question? 22 year old guy goes to gp and claims he has rashes examination reveals no rashes 2 years ago he has seen a gp and was given oitment and it worked but now he could not find any propietary medication that works what is teh diagosis? answer – malingering 1. Theme : Skin tumours A. superficial spreading malignant melanomB. acral lentiginous malignant melanomaC. nodular malignant melanomaD. squamous cell carcinomaE. Bowen's carcinoma in situF. Lentigo maligna melanomaG. Basal cell carcinomaH. ChloasmaI. Melanocytic naevus For each case below, choose the SINGLE most likely skin lesion from the above list of options. Each option may be used once, more than once, or not at all. 1) A 46 year old lady with a pigmented lesion on her legs. It is irregular in shape with brown and blue discolouration. There is peripheral extension with central regression. Mild inflammation is noted and mild nodularity. A. superficial spreading malignant melanom 2) A GP noticed an erythematous plaque on the trunk of a retired builder. Biopsy revealed very large keratinocytes with large nuclei and mitotic figures. E. Bowen's carcinoma in situ 3) A 32 year old lady presents with increasing pigmentation of her skin. She is 4 months pregnant and has no previous medical history. H. Chloasma 4) A 76 year man presents with a skin lesion on his face. It is hyperkeratotic with ulceration. The nodular area on the edge has been noted to be rapidly expanding. D. squamous cell carcinoma 5) A 90 year old lady has noted that she had developed a pearly nodule on her nose. On examination telangiectasia was noted and at the ulcerated margin the edges were rolled upward. G. Basal cell carcinoma 2.: Psychiatric syndromes A. Asperger’s syndromeB. Capgras syndromeC. Cotard’s syndromeD. Ekbom’s syndromeE. Ganser’s syndromeF. Gilles de la Tourette syndromeG. Hurler’s syndromeH. Korasakoff psychosisI. Munchausen’s syndromeJ. Othello syndromeK. Prader-Willi syndrome Select one of the above diagnosis that would be most appropriate for each of the following cases 1) A 24 year old male on remand in prison for murder is referred by the prison doctor. He is noted to be behaving oddly whilst in prison and complains of seeing things. He has a previous history of IV drug abuse. On questioning, he provides inappropriate answers to all questions stating that Bill Clinton is the prime minister of the UK. E. Ganser’s syndrome 2) A couple attend their general practitioner because of marital problems. The wife states that her husband is having affairs although she has no proof of this. The husband states that she has even had him followed by a private detective and this is putting a considerable strain on the marriage. J. Othello syndrome 3) A 62 year old male is brought to the casualty by his daughter because of persistent lying. He is a known alcoholic and has been admitted recently with delirium tremens. On questioning he denies any problem with memory. He knows his name and address and states that he was at the betting shop this morning, but his daughter interjects calling him a liar explaining that he was at her house. H. Korasakoff psychosis 4) A 10 year old boy is taken to his GP by his parents with behavioural problems. He attends a special school due to inappropriate behaviour and during the interview with his parents the boy barks at infrequent episodes and shouts expletives. F. Gilles de la Tourette syndrome 5) A 30 year old schizophrenic female attacks her mother believing that aliens have replaced her with an exact double. B. Capgras syndrome 3. Theme : CAUSES OF HYPOGLYCAEMIA A. Addison's diseaseB. Alcoholic bingeC. Aspirin overdoseD. HypopituitarismE. InsulinomaF. Postprandial hypoglycaemiaG. Quinine therapyH. Retropertionaeal sarcomaI. SepticaemiaJ. Sulphonylurea overdose For each patient below, choose the SINGLE most probable diagnosis from the above list of options. Each option may be used once, more than once or not at all. 1) A 35 year old mother of four, who has recently been depressed, is admitted following a drug overdose. She is now unconscious with signs of cerebral oedema. Results show a plasma glucose of 1.5 mmol/l and INR of 2.0 and Creatinine 400 mmol/L. B. Alcoholic binge C. Aspirin overdose 2) A 54-year-old man is rushed into Casualty semi-conscious with smell of alcohol. His BM glucose is noted to be 2 mmol/l. B. Alcoholic binge 3) A 45 year old type 1 diabetic man. Reports to clinic complaining of recurrent hypoglycaemic episodes and increased skin pigmentation J. Sulphonylurea overdose A. Addison's disease 4) A 57 year old Head master is admitted with a history of recurrent episodes of sweats, confusion and fits. He is admitted for a prolonged 48 hour fast. His symptoms occur when his Blood glucose is 0.8 mmol/L which occurs 14 hours into his fast. E. Insulinoma 5) A 42 year old male expatriate is admitted semi-conscious being feverish with sweats. He is noted to have a temperature of 39.0°C and some neck stiffness. Thick blood film is positive for Falciparum Malaria and he is started on medication. G. Quinine therapy 4 Theme : Investigation of Emergencies A. Arterial blood gases B. Blood Glucose C. Blood Urea electrolytes and creatinineD. CT scan of BrainE. Full blood count and group and cross match F. MRI scan of KneesG. Thyroid function testsH. Toxicology ScreenI. Skull Xray For each patient below, choose the single most essential diagnostic investigation from the above list of options. Eachoption may be used once, more than once or not at all. 1) 21 year old Female found un unconsciousness next to her 22 year old husband, who was found dead. Her ECG shows evidence of Acute MI. I. Skull Xray Note: Severe cases of cocaine intoxication may result in acute myocardial infarction, aortic dissection, myocarditis, ventricular arrhytmias and cardiorespiratory arrest. 2) 24 year old Female, admitted to the Accidents and Emergency department with a Pneumonia is now barely conscious with poor3) respiration despite high flow oxygen therapy. A. Arterial blood gases Note: This patient needs urgent arterial blood gas estimation and should be considered for artificial ventilation. 3) 21 year old rugby player, had suffered from an episode of brief unconsciousness. He is rushed into A&E the next day with unconsciousness. D. CT scan of Brain Note: Extra dural haemorrhage is suggested as complicating a head injury, period of unconsciousness is followed by a period of alertness and the rapid deterioration into unconsciousness. 4) A 72 year old woman is admitted unconscious with a core temperature of 35.6oC. She has a heart rate of 42 beats per minute and slowly relaxing reflexes. G. Thyroid function tests Note: Drowsiness, bradycardia, slowly relaxing reflexes and would suggest the diagnosis of hypothyroid coma. Urgent thyroid function tests will confirm the diagnosis. 5) A 24 year old school teacher who is a very well controlled diabetic is found unconscious by her students after lunch. On her desk is a pile of partly marked papers and an uneaten sandwich B. Blood Glucose Note: Urgent blood glucose estimation by sampling capillary blood would confirm the diagnosis of hypoglycaemic coma. However she requires urgent administration of 50% dextrose or a glucagon injection. 5.Theme : Anaemia in an hypertensive. A. AchlorhydriaB. AngiodysplasiaC. Diverticular diseaseD. Gastric cancerE. Gluten sensitive enteropathyF. Haemolytic anaemiaG. Irritable bowel syndromeH. Inflammatory bowel diseaseI. Mallory-Weiss tearJ. Oesophageal varicesK. Peptic ulceration Choose the SINGLE most likely option from the list. 1) This is the full blood count of a 63 year old male who presents with a recent history of tiredness and indigestion. 3 months ago he was commenced on aspirin 150 mg per day together with atenolol 50 mg per day for hypertension and a strong family history of ischaemic heart disease. Examination reveals a blood pressure of 155/90 and a slight tenderness in the hypochondrium. What is the most likely explanation for this patient's full blood count and symptoms? K. Peptic ulceration Note: This patient has a low haemoglobin concentration on the full blood count accompanied by a low Mean cell volume (MCV) suggesting an iron deficiency anaemia. From the above list, peptic ulceration due to aspirin would be the most likely explanation for this blood picture and the recent symptoms. Upper endoscopy would be the investigation of choice to demonstrate gastric or duodenal lesions and to assess for the presence of H.Pylori infection. 6.Theme : Adverse reactions / interactions of cardiac failure drugs A. warfarinB. aspirinC. frusemideD. bendrofluazideE. amiodaroneF. beta blockersG. spironolactoneH. nitratesI. verapamilJ. ACE inhibitorK. AT II inhibitor For each case below, choose the SINGLE most likely cause from the above list of options. Each option may be used once, more than once, or not at all. 1) A drug that may produce a rapidly progressive pulmonary fibrosis. E. amiodarone Note: Amiodarone can produce pulmonary fibrosis, liver failure, thyroid disturbances, heart block and skin photosensitivity. 2) A drug that is monitored using regular INR measurments. A. warfarin Note: The INR (International Normalized Ratio) is used to monitor therapy with warfarin. 3) A drug that should not be given in combination with betablockers. I. verapamil Note: Verapamil may cause complete heart block when given in conjunction with betablockers. 4) A drug that often causes headache, especially when patients first start the medication. H. nitrates Note: Headache is a common side effect of nitrate therapy because of vasodilation. It is often transient at the start of treatment. Patients should be warned of this possibility to encourage compliance. 5) A drug that may precipitate acute asthma. F. beta blockers Note: Acute asthma due to betablockade may be fatal. 7.Theme : Side effects of psychotrophic medication A. AmitriptylineB. CarbamazepineC. ChlorpromazineD. Clozapine E. DiazepamF. FluoxetineG. HaloperidolH. Lithium I. ParoxetineJ. Sodium valporateK. Thioridazine For each presentation below, choose the SINGLE most likely drug to cause the side-effects from the above list of options. Each option may be used once, more than once, or not at all. 1) Agranulocytosis D. Clozapine Note: Agranulocytosis is a potentially fatal side effect of the atypical antipsychotic, Clozapine. Patients taking Clozapine require mandatory haematological monitoring through the Clozaril patient monitoring System to prevent this serious complication. 2) Thyroid function disturbance H. Lithium Note: Lithium carbonate is used primarily for the prophylactic treatment of bipolar (manicdepressive) illness. Long-term treatment is associated with thyroid hormone abnormalities with 10-15% women over 50 taking lithium developing hypothyroidism. 3) Addiction E. Diazepam Note: All benzodiazepines have the potential for addiction. Use should thus be limited to short term prescription for specific indications. 4) Extra-pyramidal side-effects G. Haloperidol Note: Extrapyramidal side effects include pseudoparkinsonism (rigidity, akinesia and more rarely tremor), dystonia, akathisia (a feeling of subjective restlessness) and, with long-term drug use, tardive dyskinesia. These symptoms are caused by dopamine blockade in the basal ganglia. Haloperidol, a butyrophenone neuroleptic, has a particular propensity for causing EPSE. 5) Polyuria (up to 12 litres/day), polydipsia and nocturia. Serum glucose is normal. F. Fluoxetine H. Lithium Note: The symptoms are suggestive of diabetes insipidus. Lithium is known to cause nephrogenic diabetes insipidus, such that the renal tubules are insensitive to vasopressin. Other drugs causing this condition include demeclocycline and glibenclamide. Selective serotonin reuptake inhibitors (SSRI eg fluoxetine and paroxetine) on the other hand cause inappropriate ADH secretion. 8.Theme : Lung infection A. Aspergillus fumigatusB. Escherischia coliC. Haemophilus influenzaeD. Klebsiella pneumoniaeE. Legionella pneumophilaF. Mycobacterium tuberculosisG. Mycoplasma pneumoniaeH. Pneumocystis cariniiI. Pseudomonas aeruginosaJ. Streptococcus pneumoniaK. Staphylococcus aureus Which of the above organisms is the most likely cause for the following presentations: 1) A 26 year old haemophiliac male presents with fever confusion dyspnoea and weight loss. He has a temperature of 38°C, blood pressure of 126/80 and a pulse of 110 bpm. There are no abnormalities on examination of the chest. H. Pneumocystis carinii 2) An 83 year old male is noted to be pyrexial and dyspnoeic. He has a history of cerebrovascular dementia and has been an inpatient for over 8 weeks awaiting a nursing home placement. Examination reveals a temperature of 39.6°C, a pulse of 120 bpm, a blood pressure of 95/60 mmHg, with widespread crackles and bronchial breath sounds of the right mid zone and base. K. Staphylococcus aureus 3) A 21 year old male with cystic fibrosis presents with fever and breathlessness. He has had a cough productive of a thick green sputum. Examination reveals a temperature of 38.6°C, a pulse of 94 bpm and a blood pressure of 120/80 mmHg, He has widespread coarse crackles with areas of bronchial breathing throughout the lungs. I. Pseudomonas aeruginosa 4) A 55 year old female presents with fever and dyspnoea of three days duration. She has recently started to expectorate a thick, deep red sputum. Examination reveals a temperature of 38.5°C, a pulse of 96 bpm and bronchial breath sounds at the left base. D. Klebsiella pneumoniae 5) A 62 year old female presents with fever and rigors. Three days previously she returned from a holiday in Spain. Examination reveals a temperature of 40°C, a pulse of 120 bpm and a blood pressure of 130/70 mmHg. Chest examination reveals crackles in the right lung base. E. Legionella pneumophila Comments:The first case has typical features of a Pneumocystis carinii pneumonia, with little in the way of chest signs despite often marked hypoxia. For the examination, suspect HIV infection in haemophilias, drug addiction and homosexuals. The second case is a typical presentation of Legionella. The third case has a hospital acquired pneumonia which is most likely to be due to staph aureua. The fourth case has thick red currant jelly like sputum which suggests a diagnosis of Klebsiella. The last patient has cystic fibrosis and is producing a thick green sputum which suggests infection with Pseudomonas aeruginosa. 9.Theme : CNS PROBLEMS A. Bacterial meningitisB. Cryptococcal meningitisC. Guillian-Barre syndromeD. Human immunodeficiency virus (HIV) infectionE. ListeriosisF. Multiple sclerosisG. EncephalitisH. Subarachnoid haemorrhageI. Secondary cancerJ. Viral meningitis All the patients described below have had a lumbar puncture. For each one, choose the single most likely diagnosis from the list of options. Each option may be used once, more than once, or not at all 1) A 32 year old doctor with a family history of polycystic disease of the kidney collapsed suddenly after a sudden persistent occipital headache. A sample of cerebrospinal fluid obtained 12 hours later was reported as xanthochromic. H. Subarachnoid haemorrhage 2) A 28 year old woman presents with urinary incontinence and pain on movement of right eye with rapid deterioration in central vision. On examination she has impaired coordination on heel-shin test. She has nystagmus and an internuclear opthalmoplegia. The cerebrospinal fluid shows a slight increase in lymphocyte count, raised total proteins and raised immunoglobulins F. Multiple sclerosis 3) An 18 year old student presents with headache, neck stiffness and photophobia. The cerebrospinal fluid examination shows 100 lymphocytes, CSF glucose is more than 2/3 blood glucose value and CSF protein is 0.60g/L. Gram stain was negative. J. Viral meningitis 4) A 56 year old woman has a history of headaches for several weeks. More recently she has had several convulsions. She was a heavy smoker until six years ago. There has recently been moderate weight loss. Cerebrospinal fluid shows increased lymphocytes, with clumps of irregular cells which have deeply hyperchromatic nuclei and scanty cytoplasm I. Secondary cancer 5) A 24 year old student has a 24 hour history of an ear infection, with photophobia, neck stiffness and a headache. Cerebrospinal fluid shows a white cell count of 500/mm3, almost all of which are polymorphs. A. Bacterial meningitis Comments:The incidence of subarachnoid haemorrhage is 15/10000. Age range is typically 35-65yrs. Common causes are rapture of congenital berry aneurysms in 70% of patients, and arterovenous malformations in 15%of patients. Recognised associations include polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta. Sudden severe occipital headache is the most striking clinical feature and may be associated with focal neurological signs. CT Brain scan is indicated and if no bleed is identified a Lumbar Puncture may uniformly blood stained fluid or xanthochromia.Multiple sclerosis is a chronic relapsing and remitting disorder characterized by demyelinating plaques within the CNS. Clinical features may be wide ranging including CNS defects such as spastic paraparesis, cerebellar signs, optic atrophy, nystagmus internuclear opthalmoplegia as urinary incontinence. CSF examination shows raised protein and lymphocyte count, oligoclonal bands of IgG on CSF electrophoresis and delayed visual, auditory and somatosensory evoked potentials. MRI is sensitive but not specific for plaque detection.This patient has viral meningitis. Causative viruses include herpes simplex, varicella zoster, coxsackie, echo,mumps and influenza virusesSecondary carcinomas form approximately 25% of all CNS malignancies. These commonly originate from the bronchi, breasts, stomach, prostate, thyroid or kidney.Bacterial meningitis usually has a rapid onset on less than 48 hours. Meningococcus, pnumococcus and Haemophilus are the common causes of pyogenic infection. 10.. Theme : Antihypertensives A. Alpha 1 receptor antagonistB. Alpha methyldopaC. AmoxycillinD. Angiotensin converting enzyme inhibitorE. Angiotensin-II receptor antagonistF. Beta-adrenoreceptor antagonistG. CotrimoxazoleH. HydrallazineI. Isosorbide dinitrateJ. Loop diureticK. SpironolactoneL. Warfarin Which drug do you think would be the most appropriate choice for each patient? 1) A 72-year-old man has heart failure, which has been well controlled for 6 months with a loop diuretic. An ACE inhibitor was started 4 weeks ago. He developed a dry irritating cough. Since discontinuing the ACE inhibitor 1 week ago, the cough has resolved. E. Angiotensin-II receptor antagonist 2) A 20-year-old woman is about to undergo dental treatment. She had no cardiac symptoms but on cardiovascular examination she has a systolic murmur at the left upper chest. C. Amoxycillin 3) A 48-year-old man with type 2 diabetes and asthma develops hypertension with a blood pressure of 160/100 mmHg. He has LV hypertrophy on his ECG but ultrasound scan of his kidneys is normal. D. Angiotensin converting enzyme inhibitor 4) A 70-year-old man with no previous cardiac history has an irregularly irregular pulse of 70 beats per minute. Echocardiography shows that he has normal ventricular function and no heart valve disease, but a moderately enlarged left atrium. L. Warfarin 5) A 63-year-old woman has central chest pain on exertion, which radiated to the left arm. She has never smoked. On exercise, the pain recurs and is associated with 2 mm of STsegment depression in leads II, III and aVF on the ECG, at stage 4 of a standard Bruce protocol. F. Beta-adrenoreceptor antagonist Comments:1. The most appropriate agent in the first case who is intolerant of ACEI due to cough would be a ATII blocker, providing similar therapeutic efficacy but without the cough. 2. The second case requires prophylaxis for dental extraction and the recommended agent is amoxycillin. 3. The third case has LVH with diabetes and the asthma contra-indicates a beta-blocker. Therefore an ACEI would be recommended on the basis of HOPE study. 4. The fourth case requires anticoagulation to minimise the risks of thromboembolism in idiopathic atrial fibrillation. 5. A beta blocker would be the drug of choice for stable angina. 11.Theme : Meningitis A. Candida species B. CryptococcusC. Escherischia coli D. Haemophilus influenzae E. Herpes Simplex F. Listeria Monocytogenes G. Mycobacterium tuberculosisH. Neisseria meningitidisI. Polio virusJ. Staphylococcus aureusK. Streptococcus pneumoniae 1) A 63 year old female presents with headache and confusion. She has photophobia, neck stiffness and a temperature of 39.5°C. CSF examination reveals a turbid fluid, a white cell count of 2500/mm, a glucose of 0.5 mmol/l and a gram positive circular microbes in pairs on gram staining. K. Streptococcus pneumoniae 2) A 5 year old boy presents with fever and headaches. Examination reveals marked nuchal rigidity and photophobia with a temperature of 39°C. CSF examination reveals a turbid fluid, a white cell count of 2000 per mm, a glucose of 0.5 mmol/l although gram stain reveals pleomorphic gram negative organisms. D. Haemophilus influenzae 3) A 25 year old student presents with a fever and headaches. Examination reveals a mild photophobia and a temperature of 40°C. CSF examination shows thick fluid, a white cell count of 3100 per mm, a glucose of 0.3 mmol/l and a gram stain reveals gram negative circular microbes arranged in pairs. H. Neisseria meningitidis 4) A 67 year old male alcoholic presents with increasing confusion and drowsiness. Examination reveals a cachetic appearance, a temperature of 37.3°C with nuchal rigidity and a third nerve palsy. CSF examination reveals a white cell count of 900 per mm, a glucose of 1.1 mmol/l but no organisms on gram staining. G. Mycobacterium tuberculosis 5) A 32 year old female is admitted following a seizure. Examination reveals a temperature of 40°C, some nuchal rigidity and a superior homonymous quadrantanopia. CT scan reveals changes in the right temporal region and lumbar puncture was not attempted. E. Herpes Simplex Comments:Streptococcus pneumoniae is a gram positive coccus grouped in pairs and is the commonest cause of meningitis. Haemophilus is also common in children. The third case has gram negative cocci suggesting meningococcal meningitis. The fourth case is a typical presentation of TB meningitis with cranial nerve defects at presentation. The fourth case with seizures and temporal lobe changes suggest herpes simplex encephalitis. 12. Theme : Antihypertensives A. Alpha 1 receptor antagonistB. Alpha methyldopaC. AmoxycillinD. Angiotensin converting enzyme inhibitorE. Angiotensin-II receptor antagonistF. Beta-adrenoreceptor antagonistG. CotrimoxazoleH. HydrallazineI. Isosorbide dinitrateJ. Loop diureticK. SpironolactoneL. Warfarin Which drug do you think would be the most appropriate choice for each patient? 1) A 72-year-old man has heart failure, which has been well controlled for 6 months with a loop diuretic. An ACE inhibitor was started 4 weeks ago. He developed a dry irritating cough. Since discontinuing the ACE inhibitor 1 week ago, the cough has resolved. E. Angiotensin-II receptor antagonist 2) A 20-year-old woman is about to undergo dental treatment. She had no cardiac symptoms but on cardiovascular examination she has a systolic murmur at the left upper chest. C. Amoxycillin 3) A 48-year-old man with type 2 diabetes and asthma develops hypertension with a blood pressure of 160/100 mmHg. He has LV hypertrophy on his ECG but ultrasound scan of his kidneys is normal. D. Angiotensin converting enzyme inhibitor 4) A 70-year-old man with no previous cardiac history has an irregularly irregular pulse of 70 beats per minute. Echocardiography shows that he has normal ventricular function and no heart valve disease, but a moderately enlarged left atrium. L. Warfarin 5) A 63-year-old woman has central chest pain on exertion, which radiated to the left arm. She has never smoked. On exercise, the pain recurs and is associated with 2 mm of STsegment depression in leads II, III and aVF on the ECG, at stage 4 of a standard Bruce protocol. F. Beta-adrenoreceptor antagonist Comments:1. The most appropriate agent in the first case who is intolerant of ACEI due to cough would be a ATII blocker, providing similar therapeutic efficacy but without the cough. 2. The second case requires prophylaxis for dental extraction and the recommended agent is amoxycillin. 3. The third case has LVH with diabetes and the asthma contra-indicates a beta-blocker. Therefore an ACEI would be recommended on the basis of HOPE study. 4. The fourth case requires anticoagulation to minimise the risks of thromboembolism in idiopathic atrial fibrillation. 5. A beta blocker would be the drug of choice for stable angina. 13.Theme : Thyroid swelling. A. Anaplastic cancerB. Hashimoto thyroiditisC. Drug induced thyrotoxicosisD. Follicular cancerE. Papillary cancerF. Reiters thyroiditisG. Simple goitreH. Subacute thyroiditisI. Thyroid adenomaJ. Thyrotoxic goitre For each patient below choose from the list above the single most likely diagnosis. Each option may be chosen more than once or not at all. 1) A woman presents with goitre, constipation and bradycardia. She also has megaloblastic anaemia. B. Hashimoto thyroiditis Note: Associated with other autoimmune conditions. 2) A 40 year old woman gives a history of sore throat, a painful neck swelling and fever. Her thyroid hormone levels are elevated and ESR is markedly raised. H. Subacute thyroiditis Note: Subacute thyroiditis is associated with viral infections. It is characterized by transient hyperthyroidism and high ESR. 3) A 40 year old woman complains of a rapidly growing hard swelling. She also has a history of dysphagia and hoarseness. A. Anaplastic cancer Note: A very tricky question. The diagnosis probably lies with the very rapid growth. Anaplastic tumours are only seen in about 10% of women below 40 years of age. 4) A 50 year old man with a history of heart disease complains of night glare and tinge while driving. His FT3 and FT4 levels are raised and TSH is decreased. C. Drug induced thyrotoxicosis Note: The drug in question is amiodarone which can cause almost any type of thryoid hormone abnormality. The visual symptoms are the result of corneal deposits. 5) A 25 year old woman pesents with sweating, palpitation and heat intolerance. On examination, a soft thyroid swelling and a bruit is revealed. J. Thyrotoxic goitre Note: Thyrotoxicosis with a bruit is most certainly Graves’ disease. 14.Theme : Antihypertensive mode of action A. Alpha-methyldopaB. BendrofluazideC. CarvedilolD. DoxazosinE. HydrallazineF. LosartanG. MinoxidilH. MoxonidineI. NebivololJ. NifedipineK. Quinapril For each mode of drug action below select the SINGLE antihypertensive drug that matches from the list of options above. 1) A combined alpha- and beta- receptor antagonist C. Carvedilol 2) A selective beta-1 receptor antagonist I. Nebivolol 3) Blocks the angiotensin II receptor K. Quinapril F. Losartan 4) Acts on central imidazoline receptors H. Moxonidine 5) A specific alpha1-receptor antagonist D. Doxazosin Comments:Carvedilol has combined alpha and beta blocking effects whereas nebivolol is a selective beta-1 antagonist and hence has reduced beta-2 mediated side effects such as cold peripheries. Losartan, Eprosartan and Irbesartan are all angiotensin II receptor antagonists. Moxonidine is an Imidazoline agonist, acting on the sympathetic nuclei within the medulla reducing sympathetic activity. Both Prazosin and Doxazosin are alpha1adrenoreceptor antagonists. 15.Theme : Overdose A. Acetylcysteine B. DesferrioxamineC. Dimercaprol D. Ethanol E. FlumazenilF. GlucagonG. NaloxoneH. Observation I. PralidoximeJ. Penicillamine K. Sodium nitrite 1) A 70 year old farmer is admitted acutely after ingesting an unknown overdose. Examination reveals a particularly anxious male who is sweaty and salivating. His temperature is 40°C and he has a blood pressure of 90/60 mmHg with a pulse of 65 beats per minute. I. Pralidoxime Note: The first case has features of organophosphate poisoning as suggested by the hypersalivation, sweating and relative bradycardia indicating increased cholinergic activity. This should be treated with Pralidoxime. 2) A 16 year old girl is admitted after taking a paracetamol overdose with alcohol 4 hours previously. Her plasma paracetamol concentration is just below the nonagram concentration that would suggest treatment. Her plasma alcohol concentration is 120 mg/l A. Acetylcysteine Note: The second case has paracetamol poisoning and although the paracetamol concentration is below the level to treat on the nonagram this person has consumed large amounts of alcohol and so should be treated with acetylcysteine. 3) A 52 year old vagrant attends casualty with hyperventilation and vomiting. He confesses to having drunk methanol. D. Ethanol Note: The third case has consumed methanol which may cause blindness, lactic acidosis and liver failure. Problems are a result of the build up of toxic metabolites of methanol which may be inhibited by the administration of ethanol. 4) A 6 year old child is admitted after consuming her mothers ferrous sulphate tablets. She has had one haemetemesis and the iron concentration is excessive. B. Desferrioxamine Note: The fourth case has consumed a large amount of ferrous sulphate which needs to be treated with desferrioxamine. 5) A 50 year old female is admitted unconscious after taking an overdose of an unknown substance. The only history is from her husband who states that she has been depressed and anxious of late and has been prescribed some medication by the GP. Examination reveals a Galsgow Coma Scale of 10/15 and she responds and opens her eyes to pain. She has a pulse of 62 beats per minute regular, a blood pressure of 130/80 mmHg and a respiratory rate of 20/minute with a saturation of 96 per cent. The pupils are of normal size. H. Observation Note: The final case has a benzodiazepine overdose overdose with stable observations. She does not require any Flumazenil and can be observed. 16.Theme : Childhood respiratory diseases A. AsthmaB. BronchiolitisC. CroupD. Cystic fibrosisE. DiphtheriaF. EpiglottisG. PneumoniaH. InfluenzaI. Retropharyngeal abscessJ. Whooping cough 1) A six month old baby presents with high fever, breathlessness, cough and feeding difficulties. Chest examination reveals dull percussion note over the right base posteriorly with bronchial breath sounds on auscultation. G. Pneumonia Note: Pneumonia may occur at any age. Patients present with fever, tachypnoea, feeding difficulties and cyanosis. Examination reveals bronchial breath sounds and crepitations. Chest X ray may show consolidation. Common organisms are pneumococcus, haemophilus, staphylococcus, mycoplasma, TB and viruses. 2) A 1 year old baby boy is wheezy, coughing, cyanosed and breathless with intercostal recession. B. Bronchiolitis Note: Acute bronchiolitis is very common in infancy. In winter epidemics of respiratory syncytial virus infection are the commonest cause. wheeze, cough, fever and respiratory distress are common. Chest X ray shows hyperinflation. 3) A 4 year old non immunized boy presents with bouts of coughing ending in vomiting. He has an absolute lymphocytosis. J. Whooping cough Note: Whooping cough is caused by Bordetella pertussis infection. bouts of coughing ending in vomiting, especially at night and after feeding suggest the diagnosis. The characteristic whoop, forced inspiration through a closed glottis may or may not be present. Absolute lymphocytosis is common. Complications include CNS haemorrhages, rectal prolapse and bronchiectasis. 4) A nine month old baby girl is upset and has stridor. Her voice is hoarse and has a barking cough. She has a low grade fever. C. Croup Note: Croup usually occurs in epidemics in autumn or spring. Causative viruses are Parainfluenza (types 1,2,or 3), respiratory syncytial viruses and measles virus. Onset is over a few days, stridor is harsh and occurs only when child is upset. A barking cough, harsh voice and ability to swallow secretions are typical. 5) A 2 year old boy is very unwell. His temperature is 39°C and he is unable to swallow his secretions. F. Epiglottis Note: Acute epiglottis is due to Haemophilus influenza type B infection. It is characterised by sudden onset, high fever, continuous stridor and drooling of secretions. Intravenous antibiotics, anaesthetic support are usually indicated. 17.Theme : Ingestion disorders A. Anorexia nervosaB. Amphetamine abuseC. Bulimia nervosaD. Diabetes insipidusE. Food faddismF. Laxative abuseG. PicaH. Primary polydipsiaI. Prader-Willi syndromeJ. SchizophreniaK. Simple obesity Select the single most appropriate diagnosis from the above list to explain the following cases: 1) A 20 year old student attends the clinic worried about excessive thirst. Whilst sitting an exam he became aware of a sudden desire to drink and over the last three weeks he has drunk approximately 5 litres offluid each day. He is aware of polyuria but denies any nocturia or nocturnal drinking. H. Primary polydipsia 2) A 24 year old jockey attends the clinic requesting advice regarding diet. He is in training for a race meeting and is aware of persistent diarrhoea over the last six weeks. He has a BMI of 23. F. Laxative abuse 3) A worried mother attends the clinic with her 15 year old daughter. She is concerned that her daughter is refusing food. The daughter states that she will not eat fast food nor any microwaved food. She has a BMI of 24.5. E. Food faddism 4) A 10 year old boy is presented by his parents with problems with weight gain. He attends a special school for learning disabilities and is noted to complain of constantly feeling hungry. He has a BMI of 34.8. I. Prader-Willi syndrome 5) A 23 year old female with Down’s syndrome is referred by her carers who have noticed that recently she is eating paper and chews her teddy. G. Pica Comments:The first case has Prader-Willi syndrome a genetic condition associated with obesity due to compulsive food consumption and mental retardation. The next case of a jockey in training who is trying to lose weight with diarrhoea suggests laxative abuse. The third case of a young girl with a normal BMI yet refusing to eat certain foods suggests food faddism. The fourth case of Down’s syndrome and eating different material is Pica which is usually a promlem in infants but can occur with mental retardation. The final case has anxiety and primary polydipsia – distinguished from diabetes insipidus by the lack of water consumption in the night or indeed any nocturia. 18.A 35 year old woman presents with episodic sweats associated with hunger. She was otherwise well, and had gained some weight recently. Investigations reveal normal urea and electrolytes, liver function tests and full blood count. An overnight fasting plasma glucose is 3.8 mmol/l ( NR 3-6). Available marks are shown in brackets 1 ) 24 hour ECG recording 2 ) 48 hr fast 3 ) fasting insulin and C-peptide concentrations 4 ) MR scan of pancreas 5 ) Short synacthen test Comments:This patient presents with features suggestive of spontaneous hypoglycaemia often due to an insulinoma. She requires confirmation of the suspected diagnosis and this should be undertaken with a 48 hr fast. If the patient develops symptoms then a plasma glucose is measured and if low, insulin and c-peptide is then collected and the fast terminated. We have been provided with a fasting plasma glucose on this patient which is normal. Measuring insulin and c-peptides with this normal glucose would provide no meaningful information. First we have to see whether she actually becomes hypoglycaemic. 19.Theme : CAUSES OF WEIGHT GAIN A. AcromegalyB. Addison' s diseaseC. Cushing's syndromeD. CraniopharyngiomaE. HypothyroidismF. HypopituitarismG. Klinefelter' s syndromeH. Polycystic ovary syndromeI. Type 2 diabetesJ. Pregnancy In each of the following situations, a patient presents with a complaint of weight gain. For each one, select the most likely diagnosis from the list of options. Each option may be used once, more than once, or not at all. BMI = Body Mass Index 1) A 28 year old mother of one, presents with a weight gain 10 kg over the last three months. She is has had no periods for the past three months and her prolactin level is 5,000. J. Pregnancy Note: Pregnancy is the commonest cause of hyperprolactinaemia and amenorrhoea. 2) A 40 year old woman complains of marked lethargy and weight gain of 6kg over the past year. Her periods have become heavy and her face has become puffy. E. Hypothyroidism Note: Weight gain is a recognised feature of hypothyroidism. 3) A 28 year old woman has been overweight since her teens, and is worried about further weight gain of 5kg in the past year. She has no periods for the last nine months. Pregnancy test is negative. She has had some facial hair over the moustache area for years, but now needs to shave often. She has been trying to get pregnant for the past 18 months. Her BMI is 30 H. Polycystic ovary syndrome Note: Polycystic ovary syndrome is characterised by amenorrhoea or oligomenorrhoea, obesity and hyperandrogenism which may present as hirsutism and increased testosterone. 4) A 35 year old woman was well till three years ago, when she started to gain weight. She has gained over 12kg in weight since then, especially around her abdomen and back. She has pink abdominal striae and proximal muscle weakness. Her blood pressure is 170/90mmHg, having previously been normal, and she has developed diabetes. Her periods stopped 4 months ago. Her BMI is 28. C. Cushing's syndrome Note: The clinical features of cushing's syndrome include obesity, hirustism, proximal muscle weakness, easy bruising, hypertension and diabetes 5) A 40 year old woman has always been has gradually gained 16kg over the past 2 years. Her periods are regular, and on examination she has generalised obesity, with a BMI of 33. she complains of thirst and polyuria. I. Type 2 diabetes Note: The clinical features of type 2 diabetes mellitus include obesity and osmotic symptoms. 20.Theme : Ovarian Neoplasia A. Serous CystadenomaB. Serous MucinousadenomaC. ArrehnoblastomaD. Krukenbergberg TumourE. Granulosa Cell TumourF. Cystic TeratomaG. FibromaH. EndometriomaI. Clear Cell Tumour For each case of suspected Ovarian Neoplasia below choose the Single most likely lesion from the list of options. 1) Anterior cystic lesion noted on ultrasound and x-ray to contain bone and ?teeth found in a 21 year-old girl. F. Cystic Teratoma Note: Cystic teratoma otherwise known as a benign tumour. This accounts for 12-15% of ovarian neoplasia and the give away is that they contain numerous tissue like hair, teeth and bone and they are particularly common in young women. They are the only kind of ovarian neoplasia that you are not protected against from oral contraceptive pill usage. 2) A 45 year-old lady complaining of breathlessness and who was noted to have pleural effusions and bilateral ovarian masses. G. Fibroma Note: The syndrome described is Meig's syndrome and this is commonly associated with ovarian fibromas be they benign or malignant. In this case benign Pathology is probably sequestration of fluid to the ovary secondary to hypoproteinaemia in general leading to third spacing, other ascites and/or pleural effusions but the syndrome refers particularly to pleural effusions and ovarian masses. 3) A 75 year-old Japanese lady noted to have haematemesis and also bilateral ovarian swellings. D. Krukenbergberg Tumour Note: Krukenberg tumour refers to secondary tumour in the ovary from a gastro-intestinal primary particularly stomach. The haematomas in Japanese women were meant to give a clue to the primary source and the fact that this was most likely to be the primary source and the ovarian swellings were likely to be secondary. Comments:There are numerous histological sub classifications of ovarian tumours which can be complicated to learn. Essentially they go along the axis of benign or malignant then versus the histological cell type. The commonest group being of epithelial cell origin but there are also sex core tumours and embryonic tumours. Again these need to be learnt as they make good material for questions. 21.Theme : WEAKNESS IN THE LOWER LIMBS A. Guillain-Barre syndromeB. Transverse MyelitisC. Juvenile Multiple sclerosis D. Chronic fatigue syndromeE. Spinal tumour F. DermatomyositisG. Congenital myopathyH. Duchenne muscular dystrophy I. Fascioscapulohumeral dystrophyJ. Spinal abscess For these children with lower limb weakness select the most likely diagnosis. 1) A 15 year old boy started walking at 18 months of age. He has mild ptosis, absence of facial expression and neck weakness. His mother has similar symptoms I. Fascioscapulohumeral dystrophy Note: This is a description of fascioscapularhumeral dystrophy which typically presents in the teenage years. The family history does not suggest an X-linked disorder rather autosomal dominant. 2) A 6 year old child presents with acute onset symmetrical flaccid paralysis initially affecting the legs then involving the trunk, and now some mild weakness in the arms. 2 weeks prior to this he had been unwell with URTI and fever. On examination there is minimal movement with gravity eliminated in all muscle groups in the lower limbs, deep tendon reflexes are absent, plantar responses are up-going. Distal sensory losses are demonstrable. The CSF shows raised protein but no pleocytosis. A. Guillain-Barre syndrome Note: The description is of Guillain-Barre syndrome which may be preceded by an URTI. There are lower motor neurone signs but also with absent reflexes due to progressive distal demyelination. Sometimes there is cranial nerve involvement (Miller Fisher syndrome) 3) A 9 year old boy has a gradual onset of proximal weakness in the pelvic girdle and to a lesser extent in the shoulder girdle also. There is a faint violaceous rash over the eyelids and some telangiecasia over the finger knuckles. He has a low grade fever and the thigh and buttock muscles are notably tender on examination. F. Dermatomyositis Note: Proximal myopathy, heliotrope rash over eyelids and the description of Gotrens papules over the knuckles indicate dermatomyositis 22.Theme : Diagnosis of conditions in labour. A. Atonic uterusB. Cord prolapseC. Deep transverse arrestD. Delay in the 1st stage of labourE. Delay in the 2nd stage of labourF. Delay in the 3rd stage of labourG. Obstructed labourH. Secondary arrest of cervical dilatationI. Shoulder dystociaJ. Tertiary arrest of cervical dilatationK. Uterine hypertonicity 1) A woman has been fully dilated for the last 2 .5 hours. She has been actively pushing for the last hour. E. Delay in the 2nd stage of labour Note: The 2nd stage of labour commences at full dilatation and should be complete by 2 hours in a primigravid woman. 2) Following the delivery of the placenta, the midwife notes that the uterus is soft and not contracting despite oxytocin. This is followed by a small post partum haemorrhage. A. Atonic uterus Note: This is typical of an atonic or poorly contracted uterus. 3) A 32-year-old woman has been commenced on intravenous oxytocin regime because of failure to progress in the first stage of labour. After 15 minutes, the uterine contractions were occurring once every 90 seconds. K. Uterine hypertonicity Note: Maximum uterine contractions in labour are once every two minutes. Anything more frequent that that or the equivalent of more than 15 contractions in 30 minutes is termed uterine hypertonicity. 4) A 21-year-old primigravid woman is examined at 3 hourly intervals and her partogram shows the cervix to be dilating at the rate of 1cm/hour. However, over the last two vaginal examinations the cervix is noted to be 9cms dilated and the presenting part is at the ischial spines with 1+ of caput and minimal moulding. H. Secondary arrest of cervical dilatation Note: This common in the latter stages of the first stage. Although it can also be called delay in the first stage of labour, secondary arrest is more appropriate. 5) A 25-year-old woman has been fully dilated for the last two hours. Prior to this the time taken to reach full dilatation was prolonged. An attempt at instrumental delivery was unsuccessful and at caesarean section there was a marked amount of free fluid in the abdominal cavity and there was 3+ of caput and moulding of the foetal head at delivery. G. Obstructed labour Note: The findings of free fluid at caesarean section and marked caput and moulding are all indicative of obstructed labour. 23.Theme : Arrhythmias A. Atrial ectopic beats B. Atrial fibrillation C. Complete heart blockD. Idioventricular rhythmE. Sinus arrhythmiaF. Sinus bradycardia G. Supraventricular tachycardia H. Ventricular ectopic beats I. Ventricular fibrillation J. Ventricular tachycardia Select the arrhythmia which you think would be most likely to cause each patient’s symptoms: 1) A 19-year-old student reports the sudden onset of a regular tachycardia at 160 beats/min, while she is playing hockey. Her symptoms usually stop within 30 minutes of finishing exercise, and she has no other symptoms. G. Supraventricular tachycardia 2) A 55-year-old man reports that he has had several episodes of palpitations at weekends, lasting several hours. He is unable to describe the frequency or rhythm of his heartbeat. He is a non-smoker, who drinks at least 25 pints of beer per weekend. B. Atrial fibrillation 3) A 37-year-old woman has a family history of coronary artery disease. She has noticed palpitations especially during the night. She describes a sensation of her heartbeat momentarily stopping, and then racing. She taps her pulse during these times at about 110 beats/minute. H. Ventricular ectopic beats 4) An 84-year-old man is brought to the Casualty Department having fainted while walking home from the post office. He is now well. He has a regular heartbeat of C. Complete heart block 5) A 34-year-old man competes in triathlons and goes mountain cycling in his spare time. He is referred after a routine medical examination because his heart rate is 40 beats/minute. F. Sinus bradycardia Comments:The first case has an SVT suggested by the rate of 160 and appears to be precipitated by exercise. The next case probably has atrial fibrillation as he is unable to describe the rhythm. The third case is a young female who is otherwise well but describes ventricular ectopics followed by the transient pause. The fourth case with a rate of only 40 bpm is suggestive of complete heart block. The final case however is a fit young man whose low heart rate is a reflection of his fitness. 24.Theme : Investigation of Emergencies A. Arterial blood gasesB. Blood GlucoseC. Blood Urea electrolytes and creatinineD. CT scan of BrainE. Full blood count and group and cross matchF. MRI scan of KneesG. Thyroid function testsH. Toxicology ScreenI. Skull Xray For each patient below, choose the single most essential diagnostic investigation from the above list of options. Each option may be used once, more than once or not at all. 1) 21 year old Female found unconsciousness next to her 22 year old husband, who was found dead. Her ECG shows evidence of Acute MI. H. Toxicology Screen Note: Severe cases of cocaine intoxication may result in acute myocardial infarction, aortic dissection, myocarditis, ventricular arrhytmias and cardiorespiratory arrest. 2) 24 year old Female, admitted to the Accidents and Emergency department with a Pneumonia is now barely conscious with poor respiration despite high flow oxygen therapy. A. Arterial blood gases Note: This patient needs urgent arterial blood gas estimation and should be considered for artificial ventilation. 3) 21 year old rugby player, had suffered from an episode of brief unconsciousness. He is rushed into A&E the next day with unconsciousness. D. CT scan of Brain Note: Extra dural haemorrhage is suggested as complicating a head injury, period of unconsciousness is followed by a period of alertness and the rapid deterioration into unconsciousness. 4) A 72 year old woman is admitted unconscious with a core temperature of 35.6oC. She has a heart rate of 42 beats per minute and slowly relaxing reflexes. G. Thyroid function tests Note: Drowsiness, bradycardia, slowly relaxing reflexes and would suggest the diagnosis of hypothyroid coma. Urgent thyroid function tests will confirm the diagnosis. 5) A 24 year old school teacher who is a very well controlled diabetic is found unconscious by her students after lunch. On her desk is a pile of partly marked papers and an uneaten sandwich B. Blood Glucose Note: Urgent blood glucose estimation by sampling capillary blood would confirm the diagnosis of hypoglycaemic coma. However she requires urgent administration of 50% dextrose or a glucagon injection. 25.Theme : Investigation of the weight loss A. barium enemaB. barium mealC. bronchoscopyD. faecal occult bloodE. gastroscopyF. lateral chest X-rayG. prostate specific antigenH. serum glucoseI. thyroid function testsJ. ultrasound abdomenK. ZN stain sputum for acid fast bacilli 1) A 76 year old woman complains of a 6 month history of dysphagia and weight loss. It has been gradual in onset and mainly affects solids, which seem to stick retrosternally. E. gastroscopy Note: A gastroscopy is probably the best investigation because it is possible to visulaise lesions, perform biopsies and also laser/stenting/dilatation of stricture as necessary. 2) A 78 year old woman complains of being restless and losing weight, despite having a good appetite. Examination reveals atrial fibrillation. I. thyroid function tests Note: She has features of thyrotoxicosis ie being restless and fidgety, and development of AF. Classic features include weight loss, tremor, palpitations and hyperactivity. Apathy, weight loss and depression may be the main symptoms in the elderly. The commonest cause of thyrotoxicosis is Graves' disease, followed by toxic nodular goiter (often in older people with goiter). 3) A 38 year old Indian presents with a troublesome productive cough, with weight loss and night sweats. His chest X-ray shows some shadowing in the left upper zone. K. ZN stain sputum for acid fast bacilli Note: Tiredness, anorexia, weight loss, fever and cough are features of pulmonary tuberculosis. In UK, the incidence of TB in immigrants form Asian subcontinent is 40 times higher than the local Caucasian population. Pulmonary TB is unlikely with a normal CXR. (normally shows shadow/ loss of volume/fibrosis in the upper zones). Bronchoscopy with bronchial lavage may be needed if sputum is not available. 4) A 30 year old man presents with a 4 week history of weight loss, polyuria and polydipsia. H. serum glucose Note: Diabetes mellitus, hypercalcaemia and and hypokalaemia are causes of polyuria and polydipsia. In DM, there is osmotic diuresis due to glycosuria resulting in dehydration and thirst (hypertonic extracellular fluid). Weight loss may be due to dehydration and accelerated breakdown of fat and muscle due to insulin deficiency. Diabetic ketoacidosis may be the presenting feature if early symptoms are missed. 5) A 67 year old man complains of tiredness and weight loss. He has iron deficiency anaemia ( Hb 7.2g/dl). His recent gastrocopy reveals gastric erosions. A. barium enema Note: The gastric erosions found may not account for the weight loss ie red herring. It is important to exclude pathology of the large bowel, with either a colonoscopy or barium enema. Blood loss of > 20ml/day will result in iron deficiency anaemia ( 0.5-1.2ml/day in normal person). If investigations do not provide diagnosis (exclude haematuria) in presence of persistent bleeding, consider barium meal and follow through to study small bowel. Also consider coeliac or superior mesenteric angiography. 26.Theme : Substance abuse A. Aspirin B. BarbituratesC. BenzodiazepinesD. CannabisE. CocaineF. Ecstasy G. Hallucinogenic Mushrooms H. Methanol I. OpiatesJ. Solvent abuse K. Tricyclic antidepressants 1) A 33 year old female is brought to casualty unconscious. Examination reveals a Glasgow Coma Scale of 6, a blood pressure of 120/70, a pulse of 52 beats per minute a respiratory rate of 10 per minute with saturations of 85 percent. She has small pupils. I. Opiates 2) A 26 year old female presents to casualty in distress. She is agitated and has had a haemetemesis. Examination reveals a temperature of 40°C, a pulse of 120 beats per minute and a blood pressure of 110/80 mmHg. She has a respiratory rate of 38/minute and has saturations of 100%. Her pupils are normal in size. A. Aspirin 3) A 42 year old female presents unconscious. She has a Glasgow Coma Scale of 7, a temperature of 37.5°C, a pulse of 134 beats per minute, a blood pressure of 130/60 mmHg and a respiratory rate of 22 with saturations of 95%. Examination of the pupils reveals dilated pupils. A bladder is palpable on examination of the abdomen. K. Tricyclic antidepressants 4) An 18 year old female is brought to casualty after collapsing in a night club. Her friends state that she has taken unknown substances during the night and has been hyperactive. She is hallucinating and has a Glasgow Coma Scale of 15. Her temperature is 38.5°C, ahe appears dehydrated, she has a pulse of 110 beats per minute and a blood pressure of 110/70 mmHg. Respiratory rate is 22/minute and she has saturations of 99%. F. Ecstasy 5) A 17 year old male is brought to casualty after being found collapsed in the street. Examination reveals a Glasgow Coma Scale of 7, a temperature of 36.5°C, a blood pressure of 145/85 mmHg with a pulse of 70 beats per minute. His pupil size is normal and he has a respiratory rate of 15 with saturations of 96%. C. Benzodiazepines Comments:The first case has respiratory depression and pin-point pupils suggestive of opiates. The second case has hyperventialtion, a pyrexia and has had a haemetemesis suggestive of a gastirc irritant - aspirin. This causes a metabolic acidosis with hyperpyrexia in overdose. Haemetemsis due to gastirc irritation is a feature and coagulation may be deranged. The third case has reduced concious level, irritability a tacchycarida, urinary retention and dilated pupils. These features suggest an anticholinergic toxicity and from the above list, tricyclic antidepressants fit. Fits and ventricular arrhythmias are a another feature. The fourth case of a young girl out clubbing with hyperactvity, dehydration together with generally non-specific signs but slight hypertension suggest amphetamine use. This is most likely to be ecstasy - MDMA. Ecstasy may also cause arrhythmias and seizures and has been connected with some fatalities associated with water intoxication and acute hyponatraemia. The final case to all intents and purposes is unrouseable and asleep. This is most likely to be due to benzodiazepines. 27.Theme : Diagnosis of vitamin and mineral deficiencies A. copperB. niacinC. riboflavinD. seleniumE. thiamine (Vitamin B1)F. vitamin AG. vitamin B12H. vitamin CI. vitamin DJ. vitamin KK. zinc 1) A 1 year old boy presents with severe diarrhoea, alopecia, failure to thrive and a rash over the mucocutaneous junctions. He became unwell soon after breast feeding was stopped. K. zinc Note: Acrodermatitis enteropathica is a rare genetic disorder leading to impaired zinc metabolism. Zinc is an essential trace element for RNA and DNA synthesis, and function of metalloenzymes. Severe deficiency can produce skin changes (bullous/pustular dermatitis over mucocutaneous junctions and pressure areas), alopecia, diarrhoea, weigt loss, emotional disorder and increased infections (Candida and bacterial). Without zinc supplement, it can be fatal. Acquired cases may be related to crohn's disease, liver disease and other malabsorption syndromes 2) A 45 year old alcoholic is admitted with confusion, ataxia and opthalmoplegia. He is thin and wasted. E. thiamine (Vitamin B1) Note: This patient has Wernicke's encephalopathy (acute confusion, nystagmus, ataxia, variable opthalmoplegia) from thiamine deficiency. There are haemorrhages in mammillary bodies, thalamus and hypothalamus. If untreated, it will lead to irreversible condition called Korsakov's syndrome, characterized by grossly impaired short-term memory and disorientation. Patients compensate for this by confabulation. 3) A 70 year old widower presents with confusion, diarrhoea and dermatitis. He lives alone and has little social contact. B. niacin Note: This man has the classical triad (3Ds - dementia, diarrhoea and dermatitis) of pellagra (niacin deficiency). This is rare and has been described in those whose diet is virtually based on maize (niacin in form of niacytin and not bioavailable). It can also occur in treatment with isoniazid, malabsorption, starvation and carcinoid syndrome/phaeochromocytoma. 4) A 40 year old alcoholic presents with breathlessness for the last 4 months with orthopnoea and leg oedema. He also complains of pains and tenderness of his feet and calves. Chest X-ray shows cardiomegaly and small bilateral pleural effusions. E. thiamine (Vitamin B1) Note: Thiamine deficiency can produce wet beri-beri (cardiomyopathy), with peripheral oedema, pleural effusion/ascites. There is impaired glucose metabolism with accumulation of lactate and pyruvate resulting in vasodilatation and oedema. Cardiac muscle is also affected with development of heart failure. There may be co-existing dry beri-beri (distal motor-sensory neuropathy), with aching in extremities, cutaneous hyperaesthesia, tenderness of soles of feet and eventually, peripheral neuropathy. Thiamine deficiency is confirmed by reduced erythrocyte transketolase activity, which needs thiamine as a cofactor 5) A 80 year old nursing home resident is admitted with bony and muscular pain, with proximal myopathy. X-rays of her pelvis reveals Looser's zones. I. vitamin D Note: Osteomalacia is caused by defect in Vitamin D metabolism or availability, resulting in inadequate mineralisation of osteoid. Hence bone is soft and prone to subclinical fractures. There is often proximal myopathy and characteristic 'waddling gait'. In this case, there may be inadequate sunlight exposure due to poor mobility ie stuck indoors. Alkaline phosphotase is elevated, with low serum phosphate and low/low normal corrected plasma calcium. Xrays show defective bone mineralisation - loss of bone density, thinning of trabeculae and cortex, and Looser's zones (pseudofractures consisting of short lucent bands running through cortex at right angles). Childhood rickets usually presents with bone deformity and impaired growth 28.Theme : Hypertension A. Conn’s syndromeB. Cushing’s syndromeC. Diastolic hypertensionD. Drug-induced hypertensionE. Essential hypertensionF. GlomerulonephritisG. Hypertensive encephalopathyH. Isolated systolic hypertensionI. Malignant hypertensionJ. PhaeochromocytomaK. Renal artery stenosisL. White coat hypertension What is the most likely cause of hypertension in each patient? 1) A 35-year-old woman is referred with hypertension. She is overweight has a blood pressure of 168/100 mmHg and her potassium is 3.0 mmol/L. A. Conn’s syndrome 2) A 48-year-old man is seen in hospital with general malaise. He is known to be hypertensive, and a month previously he was started on an ACE inhibitor by his GP, at which time his renal function was normal. Now his serum urea is 30.0 mmol/L and the creatinine is 250 µmol/L. F. Glomerulonephritis K. Renal artery stenosis 3) .An 80-year-old woman consults her GP due to headaches. The GP measures her blood pressure as 180/70 mmHg on at least 3 separate occasions. H. Isolated systolic hypertension 4) A 58-year-old man is admitted to hospital unconscious. His blood pressure is 220/130 mmHg, he has papilloedema, and his ECG shows marked LV hypertrophy. I. Malignant hypertension G. Hypertensive encephalopathy 5) A 55-year-old overweight woman is seen in the outpatient clinic having been diagnosed as hypertensive by her GP. Both her parents were hypertensive and she has a blood pressure of 160/104 mmHg. B. Cushing’s syndrome E. Essential hypertension Comments:The hypokalaemic hypertension in the first case suggests Conn’s syndrome. The second case with deteriorating renal function precipitated by an ACEI suggests renal artery stenosis. The third case has isolated systolic hypertension defined as a systolic above 160 and a diastolic below 90 mmHg. This is the commonest type of hypertension in the elderly. The fourth case has hypertensive retinopathy rather than malignant hypertension as he is unconcious. Finally, the strong family history and obesity suggests a diagnosis of essential hypertension – i.e no specific cause but often the hypertension is familial and multifactorial. 29.Theme : CHILDHOOD VIRAL INFECTIONS A. AdenovirusB. CoxsackieC. CytomegalovirusD. Epstein barr E. MeaslesF. Molluscum contagiosum G. MumpsH. RotavirusI. RubellaJ. Varicella For each patient with the group of symptoms listed below, choose the SINGLE most probable causative agent from the above list of options. Each option may be used once, more than once or not at all. 1) A two year old infant boy is admitted to hospital with vomiting, non bloody watery diarrhoea and is dehydrated. It emerges other children from his play group have developed a similar illness. H. Rotavirus Note: Rotavirus is the most common cause of severe viral gastroenteritis worldwide. Infection is via the faeco-oral route and often occurs in children aged between six months to six years. This RNA virus replicates in the intestinal mucosal cells damages transport mechanisms leading to salt and water depletion which results in diarrhorea and vomiting. Diagnosis is made from clinical features and culture of virus from stools and also by Polymerase chain reaction techniques. Treatment is mainly re-hydration and correction of any electrolyte imbalance. 2) A two year old boy is mildly unwell. His mother has noticed vesicles in his mouth, palms and soles of his feet. B. Coxsackie Note: Coxsackie A16 virus is the cause of hand, foot and mouth disease characterized by fever, sore throat and ulcerating vesicles in palms, orophaynx and on soles. Incubation period is 5-7 days and these heal without crusting. Treatment is symptomatic. 3) A Three-year baby girl presents with a macular confluent rash which appeared initially behind the ears and is spreading. Over the previous five days she has had a low grade fever, catarrh and conjunctivitis. Her mother is vague about her immunization history. E. Measles Note: Measles is caused by and RNA paramyxovirus and occurs worldwide. Outbreaks are common in areas with high numbers of non immunized children. Infection is transmitted via respiratory droplets and incubation period is 10-21 days. The prodromal stage fever conjunctivitis, runny nose and coughing lasts for five days. Koplik’s spots are bright red lesions with a central white dot which appear on the buccal mucosa. These are virtually diagnostic. The typical macular confluent rash appears on the face from day 3-5 and spreads to the rest of the body. Diagnosis is made from clinical features, viral culture from lesions and a grater than 4-fold rise in antibody titres. Otitis media, pneumonia, meningitis and very rarely several years after primary infection subacute sclerosing panencephalitis (SSPE).