Theory Examination Questions

1. (a) In a pt. with MS with incompetence, list six clinical findings that you would find if they
develop infective endocarditis.
Clnical finding
 fever,
 complains of unusual tiredness
 night sweats
 weight loss
 low back pain
 petechiae

(b) How would you advise a pt. on SBE prophylaxis who wants to have a tooth extraction?
Prophylaxis = they don’t need it.

2. (a) Describe the common clinical findings of Ulcerative Colitis (UC). Include extracolonic
manifestations.
 bloody diarrhea
 tenesmus
 lower abdominal discomfort
 malaise
 lethargy
 anorexa
 weight loss
 apthous ulcer
 proctitis with blood mix wth stool, urgency and tenesmus
 diarrhea at night with urgency and incontinence
 In severe cases anorexia, malaise, weight loss and abdominal pain occur, and the patient
is toxic with fever, tachycardia and signs of peritoneal inflammation
Extraintestinal
  Uveitis
 Pyoderma gangrenosum
 Pleuritis
 Erythema nodosum
 Spondyloarthropathy
 Ankylosing spondylitis
 Primary sclerosing cholangitis
(b) State the liver complications in a pt. with UC.
 Primary sclerosing cholangitis causing jaundice
 Fatty liver disease
 Chronic active hepatitis
 Drug induced liver toxicity- eg azathioprine
 Liver cirrhosis
 cholangiocarcinoma

3. Describe the mgt of toxic megacolon.

Investigation
 Cbc
 Biochemistry
 Coagulation
 Esr and crp
 Histopathology
 Plan abdominal radiograph- dlated transverse colon, loss of haustra, ntraluminal
soft tsse masses, perforation could lead to pneumoperitoneum, segmentsl psrietsl
thinning.
 Avoid barium
Treatment
1. NG tube, npo
2. fluids and electrolytes to help prevent dehydration and shock
3. Cyclosporine
4. Antibiotics to prevent sepsis- ampicillin, gentamicin, metronidazole
5. Causes should be treated
6. Avoid meds to increase gi motility
7. Surgery if perforation occur- colectomy.
8. If antibiotic fail- do lecocytopheresis or steroid
4. (a) What is renal osteodystrophy: metabolic bone disease which accompanies CKD consists of a
mixture of osteomalacia, hyperparathyroid bone disease (osteitis fibrosa), osteoporosis and
osteosclerosis.

(b) Sate the biochemical changes in the blood.

 Decreased 1,25(OH)2D(diminished conversion of 25(OH)D to 1,25(OH)2D)
  ↓ Plasma [Ca2+]
 Decrease PTH
 Increase Plasma [PO4]
5. Compare the [Ca2+] and [PO4] in CRF versus malabsorption.
CRF Malabsorption
Ca low, phosphate high Both low
Trigleceride malabsorption binding to calcium

6. (a) How would a 75 yrs old female with complete heart block present?
Third-degree atrioventricular (AV) block (ie, complete heart block) has a wide range of clinical
presentations. Occasionally, patients are asymptomatic or have only minimal symptoms related
to hypoperfusion. In these situations, symptoms include the following:

 Stokes adam attack- patent fall to the ground, develop a near death appearance, patient
become cyanose then patient recover suddenly.
 Fatigue
 Dizziness
 Impaired exercise tolerance
 Chest pain
More commonly, however, patients are profoundly symptomatic, especially if a wide-complex
escape rhythm is present, indicating that the origin of the pacemaker is below the His bundle. In
such cases, symptoms can include the following:

 Confusion
 Dyspnea
 Severe chest pain
 Sudden death

(b) what clinical findings would you find in this pt.?

 Varying intensity of the first heart sound
 Cannon waves in neck

Signs of congestive heart failure as a result of decreased cardiac outputmay be present and
may include the following:

 Tachypnea or respiratory distress

 Rales
 Jugular venous distention

Patients may have signs of hypoperfusion, including the following:

 Altered mental status

 Hypotension
 Lethargy
 (c) How would you mgt this pt?
1. pacemaker is definitve
2. temporary- atropine, tanscutaneous and transvenous pacing
Activity restriction
Prevent renal failure, dehydration and electrolyte disturbances.

7. (a) What is the differential diagnosis in a pt. with sickle cell anemia with acute onset of knee
pain?
1. gout
2. avn
3. septic arthritis
4. osteomyelitis
5. trauma
(b) What would be the indication to do exchange transfusion in this pt.?
1. priapism
2. stroke
3. Acute chest syndrome
4. Multiorgan failure syndrome
8. (a) What are the features of nephrotic syndrome= check paper before.

Swelling (edema) is the most common symptom. It may occur:

 In the face and around the eyes (facial swelling)

 In the arms and legs, especially in the feet and ankles
 In the belly area (swollen abdomen)

Other symptoms include:

 Foamy appearance of the urine

 Poor appetite
 Weight gain (unintentional) from fluid retention

(b) What complications would you anticipate in a pt. with minimal change type of nephrotic
syndrome?
Malnutrition
Infection
Edema
Complication of steroid-

9. (a) List nine causes of hypertension. – pass paper

(b) What non-pharmacologic advice would you give for the mgt. of hypertension?
 The 2010 American Heart Association-American Stroke Association (AHA-ASA) guidelines for
the primary prevention of stroke makes the following recommendations:

 Hypertension: the AHA-ASA guidelines recommend regular blood pressure screening,

lifestyle modification, and drug therapy; lower risk of stroke and cardiovascular events are
seen when systolic blood pressure levels are lower than 140 mm Hg and diastolic blood
pressure levels are less than 90 mm Hg
 In patients who have hypertension with diabetes or renal disease, the BP goal is lower than
130/80 mm Hg
 Diet and nutrition: a diet that is low in sodium and high in potassium is recommended to
reduce BP; diets that promote the consumption of fruits, vegetables, and low-fat dairy
products, such as the DASH-style diet, help lower BP and may lower the risk of stroke
 Physical inactivity: increasing physical activity is associated with a reduction in the risk of
stroke; the goal is to engage in 30 minutes or more of moderate intensity activity on a daily
basis
 Obesity and body fat distribution: weight reduction in overweight and obese persons is
recommended to reduce BP and the risk of stroke

10. (a) How would you establish the diagnosis of autoimmune hepatitis in a pt.?

 Serum antinuclear antibody (ANA)

 Anti–smooth muscle antibody (ASMA)
 Liver-kidney microsomal type 1 (LKM-1) antibody
 Serum protein electrophoresis (SPEP)
 Quantitative immunoglobulins
 Cbc
 LFT

Urgent liver biopsy, transjugular if appropriate, may help to confirm the clinical suspicion of acute
autoimmune hepatitis- Biopsies may show evidence for interface hepatitis (ie, piecemeal
necrosis), bridging necrosis, and fibrosis.

Laboratory findings in autoimmune hepatitis include the following:

 Elevated serum aminotransferase levels (1.5-50 times reference values)

 Elevated serum immunoglobulin levels, primarily immunoglobulin G (IgG)
 Seropositive results for ANAs, SMAs, or LKM-1 or anti–liver cytosol 1 (anti-LC1) antibodies

(b) List two drugs used in the mgt. of this pt.

a. prednisolone
b. azathioprine
c. cyclosporine
11. (a) Which is the first joint to be affected in ankylosing spondylitis? = sacroliac
(b) Which other inflammatory disease would affect this joint?
1. osteoarthritis
2. Psoriatic
3. Traumatic
 4. Ibd

List four extraskeletal manifestations of ankylosing spondylitis.

12. Give six causes of acute onset of chest pain.

a. MI
b. Oesophageal rupture
c. Angina
d. Pulmonary embolism
e. Trauma
f. Dissecting aortic aneurysm
g. Mallory Weiss tear
13. Give five causes of ataxia.
a. Vitamin b 12 deficiency
b. Hypothyroidism
c. Inherited- Friedreich's ataxia, Spinocerebellar ataxia
d. Non-inherited ataxia
Brain surgery. Head injury. Alcohol abuse. brain tumor. Multiple sclerosis
14. How would you conclusively diagnose iron deficiency anemia in a pt.?
1. Cbc with ddx and indices
2. Plasma ferritin is a measure of iron stores in tissues and is the best single test to confirm
iron deficiency
3. Blood smear
4. Plasma iron
5. total iron binding capacity (TIBC)
6. Trabnsferrin
7. Bone marrow biopsy that stain- prussian blue- definitive
 15. How would you mgt. a pt. with malaria who developed ATN?
a. Antimalarial
b. Exclude pre-renal cause
c. Check fluid balance, urinary sodium
d. Replace fluid
e. Monitor BP
f. Monitor urine output
g. If urine output is inadequate despite fluid replacement, give diuretic/dopamine
h. BUN and creatine- check ratio
i. Peritoneal dialysis

16. Outline the mgt. of a delirious elderly pt. with a serum [Ca2+] of 16 mg/dL?

Treatment depends on the severity of symptoms and the underlying cause.[7]

 Volume expansion and saline diuresis

 o Volume depletion results from uncontrolled symptoms leading to decreased intake and enhanced
renal sodium loss. This tends to exacerbate or perpetuate the hypercalcemia by increasing Na+
reabsorption in the thick ascending limb of the loop of Henle (TALH). Thus, appropriate volume
repletion with isotonic sodium chloride solution is an effective short-term treatment for
hypercalcemia.
o Once volume is restored, simultaneous administration of loop diuretics blocks Na+ and calcium
reabsorption in the TALH.
o Replacing ongoing sodium, potassium, chloride, and magnesium losses is important if prolonged
sodium chloride and loop diuretic therapy is contemplated.
 Mobilization
o Immobilization aggravates hypercalcemia.
o Whenever possible, weightbearing mobilization should be encouraged.
 Reduction of gastrointestinal calcium absorption
o Reduction of dietary calcium and vitamin D intake is effective for treating hypercalcemia due to
increased intestinal calcium absorption (eg, in idiopathic infantile hypercalcemia, ie, Williams
syndrome).
o In vitamin D toxicity or extrarenal synthesis of 1,25(OH) D3 (eg, in sarcoidosis), prednisone may help
reduce plasma calcium levels by reducing intestinal calcium absorption.
o Oral phosphate also can be used to form insoluble calcium phosphate in the gut.
 Inhibition of bone resorption
o Bisphosphonates inhibit osteoclastic bone resorption and are effective in the treatment of
hypercalcemia due to conditions causing increased bone resorption and malignancy-related
hypercalcemia.
o Pamidronate and etidronate can be given intravenously, while risedronate and alendronate may be
effective as oral therapy.
o Calcitonin can be given intramuscularly or subcutaneously, but it becomes less effective after several
days of use.
o Mithramycin blocks osteoclastic function and can be given for severe malignancy-related
hypercalcemia. It has significant hepatic, renal, and marrow toxicity.
 Dialysis: Peritoneal or hemodialysis against calcium-free or lower calcium concentration dialysate
solution is highly effective in lowering plasma calcium levels.