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A. ACE inhibitor
B. Betablocker
C. Calcium channel blocker
D. Diuretic
A
Autosomal dominant APKD-1 is a relatively common disorder
accounting for approximately 8% of cases of end-stage renal disease
(ESRD).
"The best drugs for this condition are ACE inhibitors (ie, captopril,
enalapril, lisinopril) or angiotensin II receptor antagonist blockers (ie,
telmisartan, losartan, irbesartan, candesartan). Calcium channel
blockers are not encouraged to be used."
However, although widely used and recommended, there is no
evidence that the renin-angiotensin system is affected in the disease.
@ Medicine A 42-year-old female with dysentery has undergone
endoscopy shown in Fig is found to have anti-smooth muscle
antibodies.
Which is the most appropriate next test for this patient?
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A. Abdominal ultrasound
B. Colonoscopy
C. Liver function tests
D. Liver biopsy
Ans C
Ulcerative colitis on endoscopy : The most appropriate investigation for
this woman is LFTs to begin with to assess if there are any features of
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A. Ankylosing spondylitis
B. Crohn's disease
C. Rheumatoid arthritis
D. SLE
C
Scleritis refers to inflammation that occurs throughout the entire
thickness of the sclera, and it is usually more severe than episcleritis. It
typically has a subacute onset, with pain being a dominant feature.
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A. Cimetidine
B. Co-trimoxazole
C. Domperidone
D. Erythromycin
D
Erythromycin has been associated with prolonged QT interval and
torsades de pointes, and is used in diabetic gastropathy, although its
benefits in the condition are not entirely understood. Rarely,
domperidone has been reported to prolong QT.
Prolonged QT is defined as greater than 0.45 s.
Other agents include amitriptyline and phenothiazines yet
metoclopramide and domperidone are not associated.
@ Pathology
A 32-year-old man was prescribed an oral antibiotic for a urinary tract
infection.
Two days later he noticed that his urine was increasingly dark in colour.
Investigations revealed:
Haemoglobin
85 g/L
(130-180)
Reticulocytes
147 109/L (25-85)
Peripheral smear is shown in Fig .
What is the most likely diagnosis?
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A. Acute myeloid leukaemia
B. Autoimmune haemolytic anaemia
C. Paroxysmal cold haemoglobinuria
D. Hereditary spherocytosis
B
Blood film: marked anisopoikilocytosis and bite cells.
Paroxysmal cold haemoglobinuria (PCH) is a rare type of autoimmune
haemolytic anaemia (AIHA) occurring primarily in children.
The classic symptom of PCH is a sudden onset of haemoglobinuria
following exposure to cold, even for a few minutes. Symptoms may
occur minutes to hours following exposure to cold. Haemoglobinuria is
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A. Chlamydia trachomatis
B. Penicillin-resistant Neisseria gonorrhoeae
C. Re-infection with Neisseria gonorrhoeae
D. Ureaplasma urealyticum
A
Fig : Gram's stain of urethral discharge from a male patient with gonorrhea shows gramnegative intracellular monococci and diplococci.
@Medicine
A 49-year-old city worker attends for evaluation of erectile dysfunction.
He has mild hypertension for which he takes amlodipine 5 mg daily, but
no other past medical history of note. He admits to working long hours
and spends a great deal of time entertaining clients.
On examination his BP is 145/82 mmHg, his pulse is 70 and regular and
his BMI is 31.
Investigations show:
Haemoglobin
105 g/L
(135-177)
White cell count 6.8 109/L (4-11)
Platelets 197 109/L (150-400)
Sodium 139 mmol/L (135-146)
Potassium
4.0 mmol/L (3.5-5)
Creatinine
117 mol/L (79-118)
Alkaline phosphatase 130 U/L
(39-117)
Alanine aminotransferase
160 U/L
(5-40)
His physical examination is shown in Fig .
Which of the following is the most likely diagnosis?
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A. Chronic alcoholism
B. Cushing's syndrome
C. Haemochromatosis
D. Klinefelter's syndrome
A
He has obvious bilateral gynaecomastia.
This patient's lifestyle is likely to be associated with heavy alcohol
consumption. This has resulted in abnormal liver function tests and
weight gain. The gynaecomastia may be related purely to obesity or to
increased peripheral production of oestrogens coupled with decreased
hepatic metabolism of sex steroids. Erectile dysfunction is also of
course related to alcohol consumption.
Given the history we are provided with, and the fact this patient only
has mild obesity and controlled hypertension, Cushing's is unlikely.
Haemochromatosis could be considered if when challenged, this
patient denied excess alcohol consumption.
Klinefelter's would not fit well with this phenotype and earlier
presentation would be expected.
Simple obesity should not be associated with other medical conditions.
@ Medicine
A 34-year-old male presents with palpitations. The ECG is shown in Fig
What is the treatment of choice?
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A. Amiodarone
B. Aspirin
C. Diltiazem
D. Radiofrequency ablation
D
The ECG shows a slurred upstroke in the QRS complexes in the chest
leads.
This patient has Wolff-Parkinson-White syndrome as suggested by the
delta wave on ECG.
Anticoagulation is not indicated.
Risk of arrhythmia after ablation is of the order of 7% over five years.
@ Medicine
A 35 year-old woman presented with a five year history of weight gain
associated with a one year history of amenorrhoea.
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A. 24 hour urinary free cortisol (UFC) concentration
B. Combined 9 am ACTH concentration and serum cortisol
concentration
C. Midnight cortisol concentration
D. The 1 mg overnight dexamethasone suppression test (ODST)
A
Of 1 mg ODST or UFC, either test would be appropriate, but UFC is
often recommended and has a 95% specificity (85% specificity in the
obese) and a 98% sensitivity.
It is however important to recognise that these values for specificity
and sensitivity only apply to a high threshold for abnormal urinary free
cortisol, set at 3-4 times the upper limit of the normal range. A number
of patients with Cushings may therefore not fulfil the criteria for
diagnosis of Cushings based on UFC alone.
The ODST has a sensitivity and specificity of 98% and 75-80% in obese
subjects with a cut-off value of 50 nmol/L.
Therefore, purely for convenience sake, a UFC would probably be the
expected response here.
Midnight cortisol is pointless as a screening test expecting the patient
to be fast asleep when blood is taken.
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A. Antiphospholipid antibody syndrome
B. Hypertension
C. Kawasaki syndrome
D. Thrombotic thrombocytopenic purpura
A
This patient has a prothrombotic tendency suggestive of
antiphospholipid syndrome with recurrent abortions, previous DVT and
now she has developed a left hemiparesis suggesting venous sinus
thrombosis.