61 - Blood Storage Temperature and Shelf Life

Blood Products


whole Blood-2 - 6°C-----28 - 35 days


Red Cells in Additive-----2 - 6°C--42 days


Platelet Concentrate--20 - 24°C under constant agitation--5 days


Frozen Plasma-----Below30°C---365 days


Cryoprecipitate-----Below 30°C------365 days

60 - autosomal dominant disorders

Achondroplasia

Antithrombin III deficiency

C1 esterase inhibitor deficiency

Ehlers-Danlos syndrome

Familial hypercholesterolaemia

Gilbert's disease

hereditary haemorrhagic telangiectasia

hereditary elliptocysis,

hereditary spherocytosis

Huntington's disease

idiopathic hypoparathyroidism

intestinal polyposis

marble bone disease

Marfan's syndrome

neurofibromatosis

Peutz Jegher’s syndrome

polycystic kidney disease (adult)

protein C deficiency

osteogenesis imperfecta

Treacher Collins syndrome

Tuberous sclerosis

Von Willebrand's disease

59 - medicine mcqs - 79 to 89

79 - lupus pernio is seen in?

a- tuberculosis of skin
b- malignancy of skin
c- sarcoidosis
d- HIV

the answer is c . sarcoidosis .

80 - lilac coloured helicotrope , pigmentation over the face is characteristic of ?

a- dermatomyositis
b- polymyositis
c- systemic lupus erythematosus
d- systemic sclerosis

answer is a . dermatomyositis .

81 - caplan's syndrome is seen in ?

a- COPD
b- pneumoconiosis
c- pulmonary edema
d- rheumatoid arthritis

answer is b and d . pneumoconiosis and rheumatoid arthritis .

82 - heberdens nodes are seen in ?

a- rheumatoid arthritis
b- osteoarthritis
c- rheumatic arthritis
d- SLE

the answer is b . osteoarthritis

83 - lordaceous spleen is seen in ?

a- alcoholic hepatitis
b- chronic active hepatitis
c- focal amyloidosis
d- diffuse amyoidosis

answer is d . diffuse amyloidosis .

84 - drug of choice in sarcoidosis ?

a- prednisolone
b- methotrexate
c- cyclophosphamide
d- cyclosporine

answer is a . prednisolone .

85 - keratoderma blenorrhagica is pathognomonic of

a- behcet's disease
b- reiter's disease
c- lyme's disease
d- glucagonoma

answer is b . reiter's disease.

86 - small vessels are involved in ?

a- takayasu arteritis
b- kawasaki's disease
c- PAN
d- temporal arteritis

answer is c . PAN

87 - carotid massage causes ?

a- increases vagal tone
b- decreases sympathetic discharge
c- decreases vagal tone
d- causes tachycardia

answer is c.

88 - anti-platelet action of aspirin is at a dose of ?

a- 50 to 100 mg
b- 100 to 150 mg
c- 150 to 200 mg
d- 200 to 250 mg

answer is a . 50 to 100mg .

89 - the drug which is used in angina that can cause congestive cardiac failure is ?

a- propranolol

b- nifedipine

c- sorbitrate

d- verapamil

answer is a . propranolol .

58 - cardiac tamponade

Q- all of the following features may be seen in cardiac tamponade ,except

a- kussmaul's sign
b- pulsus paradoxus
c- electric alterans
d- right ventricular diastolic collapse on echo

answer is a . kussmaul's sign is seen in constrictive pericarditis , where as it is very rare in cardiac tamponade .

-----------------

Q- all of the following features are seen in cardiac tamponade , except

a- raised JVP
b- kussmaul's sign
c- rapid y descent
d- pulsus paradoxus

answer is c .

this is a tricky question . rapid y descent is a feature of constrictive pericarditis and not the cardiac tamponade . as i have already told u , kussmaul's sign is rare in cardiac tamponade , nonetheless present and so the answer is c.

cardiac tamponade is characterised by AN ABSENT OR DIMUNITIVE Y DESCENT AND A PROMINENT X DESCENT .

-------------

solve the following case

Q- A patient presents with engorged neck veins ,BP 80/50 and pulse rate of 100 following blunt trauma to the chest ,the diagnosis is?

a- pneumothorax
b- right ventricular failure
c- cardiac tamponade
d- hemothorax

answer is c .

the characteristic triad of the cardiac tamponade is

1- raised JVP

2- rising venous pressure and falling arterial pressure

3- distant heart sounds ( quiet heart )

--

when the question says something about prominent both x and y descent on JVP, the answer is constrictive pericarditis . but if the question says there is a prominent X descent and absent or dimunitive Y descent , then the diagnosis is cardiac tamponade .

the points that support the cardiac tamponade are - PULSUS PARADOXICUS , ELECTRICAL ALTERANS AND ABSENT OR DIMUNITIVE Y DESCENT .

the points that favour constrictive pericarditis are - PROMINENT Y DESCENT , KUSSMAUL'S SIGN AND PERICARDIAL KNOCK ( rare in cardiac tamponade )

57 - kussmaul's sign

Q- kussmaul's sign is not seen in?

a- constrictive pericarditis
b- cardiac tamponade
c- Right ventricular infarct
d- restrictive cardiomyopathy

answer is b .

though authors' opinions vary a lot regarding the presence of kussmaul's sign in various conditions ,most of them acknowledge the fact that kussmaul's sign is rare in cardiac tamponade .

rise of JVP during inspiration is called the kussmaul's sign . it is frequently seen in constrictive pericarditis and RVMI .

56 - continuous murmurs

Q- continuous murmurs are seen in all of the following except

a- coarcation of aorta
b- patent ductus arteriosus
c- aortic sinus of valsalva rupture
d- AV malformations
e- peripheral pulmonary stenosis

the answer is e .

---

continuous murmurs result from continuous flow between a high pressure and low pressure area that persists through the end of systole and beginning of diastole .

the causes of continuous murmurs are :

1- systemic arteriovenous fistula( congenital or acquired )

2-coronary arteriovenous fistula

3- anomalous origin of left coronary artery from pulmonary artery

4- ruptured sinus of valsalva into right side of heart

5- coarctation of aorta ( continuous murmur in the back )

6- patent ductus arteriosus ( PDA )

7- surgically created shunts ( eg: blalock tausig shunt )

55 - carey coombs murmur

Q- which is false with regard to the carey coombs murmur ?



a- delayed diastolic murmur

b- seen in rheumatic fever

c- associated with AR

d- low pitched murmur



the answer is c .



the characteristics of the carey coombs murmur are :

1- delayed diastolic ( or mid diastolic )


2- mitral murmur


3- low pitched ( soft )


4- associated with acute rheumatic carditis


5- attributed to inflammation of the mitral valve cusps.


6- excessive left atrial blood flow as a consequence of mitral regurgitation


-----


the low pitched delayed diastolic mitral murmur associated with acute rheumatic fever ( with MR ) is the CAREY COOMBS MURMUR .


the low pitched delayed diastolic mitral murmur associated with severe chronic AORTIC REGURGITATION is AUSTIN FLINT MURMUR .

54 - first heart sound - S1

Q- first heart sound is soft in all of the following conditions , except

a- short PR interval
b- ventricular septal defect
c- mitral regurgitation
d- calcified valve

the answer is a . short PR interval .

the first heart sound also called S1 is loud only in two conditions , one is the short PR interval and the other is the AORTIC STENOSIS .

the first heart sound is soft in the following conditions :

1- LONG PR INTERVAL

2- VENTRICULAR SEPTAL DEFECT

3- MITRAL REGURGITATION

4- CALCIFICATION IN MITRAL STENOSIS .

the first heart sound is normally produced due to the closure of the AV valves .

53 - pulsus paradoxus

Q- pulsus paradoxus is seen in all except ?

a- IPPV
b- cardiac tamponade
c- constrictive pericarditis
d- C O P D

the answer is a . intermittent positive pressure ventilation .

normally during inspiration there is decrease in the systolic blood pressure and arterial pulse volume , but in pulsus paradoxus this decrease is greatly accentuated .

the paradox here is that in conditions like cardiac tamponade , airway obstruction and constrictive pericarditis the decrease in systolic blood pressure is so much that the pulse cannot be felt but on auscultation we can hear the heart sounds . thats the paradox here .

the conditions in which pulsus paradoxus is seen are

CARDIAC TAMPONADE

CONSTRICTIVE PERICARDITIS

C . O . P. D /ACUTE SEVERE ASTHMA

SUPERIOR VENACAVAL OBSTRUCTION .

refer harrisons book of medicine - page 1255 - 15 th edition and page 1305 - 16 th edition .

----

PULSUS PARADOXUS CLINICALLY , ELECTRICAL ALTERANS ON ECG AND RVDC(right ventricular diastolic collapse) ON

ECHOCARDIOGRAPHY ARE CHARACTERISTIC FEATURES OF CARDIAC TAMPONADE .

Q- electric alterans is seen in ?

a- cardiac tamponade
b- restrictive cardiomyopathy
c- right ventricular infarct
d- constrictive pericarditis

answer is a .

52 - pulsus bisferiens

Q- pulsus bisferiens is best felt in ?

a- carotid arteries
b- brachial arteries
c- radial artery
d- femoral artery

the answer is c .

normally the central arteries like the carotid and the brachial give much information about the left ventricular function or aortic valve function ,but pulses like pulsus bisferiens and pulsus alterans are best felt in the peripheral arteries .

pulsus bisferiens is a pulse with 2 systolic peaks and it is seen in conditions like

AORTIC REGURGITATION

and

HYPERTROPHIC CARDIOMYOPATHY .

REFER HARRISONS BOOK OF MEDICINE - 15 th edition -PAGE 1255 AND 1305 - 16 th edition.

51 - food poisoning

Thirty-eight children consumed eatables procured from a single source at a picnic party. Twenty children developed abdominal cramps followed by vomiting and watery diarrhea 6-10 hours after the party. The most likely etiology for the outbreak is:

1. Rotavirus infection.
2. Entero-toxigenic E.Coli infection
3. Staphylococcol toxin.
4. Claustridium perfringens infection.



Answer

4. Claustridium perfringens infection.

Reference

Nelson is the book referred because we have 38 children going to the picnic
Nelson's Text book of Paediatrics. 15^th Edition Chapter 194 Anaerobic Infection

Discussion

Let us dissect this question

• 20 out of /38 (large number)
• Children – Look at Nelson (or Achar or Ghai ) Don’t go for Harrison or CMDT !!!)
• Single source /
• Picnic
• Abdominal cramps
• Vomiting
• Watery diarhhoea
• 6 - 10 hours

By the way in ADULTS ( not for this question, but as a general rule

C. perfringens food poisoning develops –

8 to 24 hrs after the consumption of contaminated food.

Fever and vomiting are uncommon - Harrison's,15th Pg-923

S. aureus food poisoning develops –

2 to 6 hrs after the consumption of contaminated food.

Crampy abdominal pains, vomiting & diarrhoea are the usual features - Harrison's,15th,Pg-893

So if you get these features in an adult, the time favours Clostridium and the Presence of Vomiting Staph !!!

But our question deals with CHILDREN and so we are relieved to have one answer

Feature	Staph	Cl.Perfinges	Our Question	Inference
Time of Onset	Harrison(as quotee above) Anathanarayanan’s Microbiology(Staph - within 6 hours) as well as CMDT say that staph occurs within 6 hours…… in fact CMDT 42nd Edition (2002) Table 30.3 and in the text 2 pages before it classify food poisoning based on Incubation period and in Staph that occurs because of preformed toxin Nelson :		6 - 10 hours	Strongly favours Cl.perfinge rules out Staph
Watery Diarhhoea	+ in CMDT	+++ in CMDT	Watery diarhhoea	Cl.Perfinges
Vomiting	Starts with vomiting	Nelson : Nausea 25 % Emesis 15 % CMDT : Vomiting may occur	Vomiting following cramps	??
abdominal cramps		Nelson : Cramps	Cramps	Cl.perfinges
Single source/ > 1 child			Fodd Poisoning	Can be both
Fever Uncommon		harrison	No fever	Cl.Perfinges
Children			We have to refer Nelson first and then Harrison	Cl.Perfinges

Now you see that only one point from Harrison favors Staph ……….. that is presence of vomiting in Adult….. but in Paediatric age group according to Nelson, nausea and vomiting are present !!!! that means the symptoms in the 38 CHILDREN were due to Cl.perfinges

Explanation

1. Rotaviruses cause disease in virtually all mammals and birds. The virus is a wheel-like, double-shelled icosahedron containing 11 segments of double-stranded RNA.
2. Entero-toxigenic E.Coli infection
3. Staphylococcol Food poisoning may be caused by ingestion of enterotoxins preformed by staphylococci contaminating foods. Two to 7 hr after ingestion of the toxin, sudden, severe vomiting begins. (Nelson's Text book of Paediatrics. 15^th Edition Chapter 174.1)
4. Claustridium perfringens infection is the correct answer

Comments

CLOSTRIDIUM PERFRINGENS FOOD POISONING.

• Enterotoxin-producing C. perfringens type A causes a mild and common form of food poisoning.
• The enterotoxin,
  • a structural component of the spore coat,
  • is a protein with a molecular weight of 35,000 daltons,
  • is resistant to trypsin digestion,
  • binds to a brush border membrane receptor,
  • disrupts cell integrity, and
  • causes cell death.
• Food poisoning follows ingestion of
  • contaminated cooked meats,
  • poultry,
  • stew,
  • meat pies, and
  • gravies that have undergone long periods of slow cooling and ambient temperature storage, which facilitate spore survival.
  • Such food usually contains at least 10⁸ enterotoxin-producing Clostridium organisms, which during intestinal passage proliferate and produce toxin.
• Clinical manifestations include
  • diarrhea (90%),
  • abdominal cramps (80%),
  • nausea (25%),
  • emesis (15%), and
  • fever (25%) with
  • spontaneous resolution in 6–24 hr.
• The incubation period is
  • brief (7–15 hr), and
• History may reveal a
  • common exposure with others who are ill.
• The diagnosis is confirmed by
  • detection of 10⁵ or more C. perfringens in the food source,
  • at least 10⁶ organisms/g stool within 48 hr of onset, and
  • detection of enterotoxin with ELISA or other immunoassay.
• The differential diagnosis includes food poisoning from
  • preformed toxins (S. aureus, B. cereus, C. botulinum),
  • in vivo toxin generation (B. cereus, toxigenic E. coli),
  • invasive enteric pathogens (C. jejuni, Salmonella, Shigella, E. coli, Yersinia),
  • heavy metals (copper, tin, zinc),
  • scombroid (histamine), and
  • mushrooms.
• Treatment comprises
  • supportive care and
  • fluid and electrolyte replacement for gastrointestinal losses caused by this self-limited enterotoxemia.

Clinical Syndromes.
Several clinical syndromes follow the ingestion of contaminated food or water, (Nelson's Text book of Paediatrics. 15^th Edition Chapter 171 )

• Nausea and vomiting within 6 hr
  • Toxins that produce direct gastric irritation,

• Such as heavy metals, or with
• Preformed toxins of
  • B. cereus (B. cereus also produces an enterotoxin )or

• S. aureus;;
• Paresthesia within 6 hr; Paresthesias after a brief incubation period are suggestive of
  • scombroid (histamine fish poisoning),
  • paralytic or neurotoxic shellfish poisoning,
  • Chinese restaurant syndrome (monosodium glutamate poisoning),
  • niacin poisoning, or
  • ciguatera fish poisoning
• Neurologic and gastrointestinal symptoms within 2 hr;
  • ingestion of toxic mushrooms
    • parasympathetic hyperactivity,
    • confusion,
    • visual disturbances,
    • and hallucinations to
    • hepatic or
    • hepatorenal failure, which occurs after a 6-24 hr incubation period.
• Abdominal cramps and watery diarrhea within 16–48 hr;
  • 8–16 hr incubation period
    • enterotoxin-producing Clostridium perfringens and
    • B. cereus.
• Fever, abdominal cramps, and diarrhea within 16–72 hr;
  • Salmonella,
  • Shigella,
  • C. jejuni,
  • Y. enterocolitica, and
  • enteroinvasive E. coli are associated with diarrhea, which may contain fecal leukocytes, abdominal cramps, and fever, although these organisms can cause watery diarrhea without fever.
• Abdominal cramps, bloody diarrhea without fever within 72–120 hr;
  • enterohemorrhagic E. coli, such as E. coli 0157:H7.
• Hemolytic uremic syndrome
  • enterohemorrhagic E. coli.
• Neurologic signs and symptoms within 6–24 hr; and nausea, vomiting, and paralysis within 18–48 hr
  • blurred vision,
  • dry mouth,
  • dysarthria,
  • diplopia, or
  • descending paralysis

should suggest C. botulinum as the cause

50 - medicine mcqs - 75 to 78

75 - Chronic heart failure:
A is incorrectly diagnosed in only 10% of cases
B often occurs when ECG and chest X-rays are completely normal
C has been shown not to respond to ACE inhibitors in large epidemiological studies
D should be routinely investigated using thyroid function tests
E in the elderly, if treated with ACE inhibitors may be complicated by a deterioration in renal function.
3. A=F, B=F, C=F, D=T, E=T.
As many as 30-50% cases diagnosed as chronic heart failure (CHF) are incorrectly labelled as such. CHF rarely occurs if both ECG and chest X-rays are normal. The JVP is a particularly useful clinical sign. In the CONSENSUS study Angiotensin Converting Enzyme (ACE)inhibitors promoted a dramatic mortality reduction in patients with severe heart failure. Thyroid function tests are important, because thyrotoxicosis is a treatable cause of heart failure. ACE inhibitors may be problematic in the elderly with hypotension and effects on renal function as two severe side effects.
--------------------------------------------------------------------------------------
76 . Chronic fatigue sufferers:
A often complain of low-grade fever
B often have a self-induced pressurised lifestyle
C have a problem-focused coping style
D tend to feel socially unsupported prior to their illness
E usually have type A personalities

1. A=T, B=T, C=T, D=T, E=F.
Apart from weakness, muscular pain and other physical symptoms chronic fatigue sufferers may also complain of low-grade fever. Compared to controls and sufferers of irritable bowel syndrome chronic fatigue patients have the most pressurised lifestyles, usually self-imposed. They also have a problem-focused coping style. Although this can help them solve problems better than others, they tend to dwell on problems rather than directing their energies and emotions elsewhere. The concept of type A and type B personalities has now fallen out of vogue and the validity of the type A personality has even been questioned in relation to coronary heart disease.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
77. Patients with chronic fatigue:
A adopt a slower lifestyle after their illness
B may have Epstein-Barr virus which can be reactivated by psychological stress
C are equally as likely as muscular dystrophy patients to be fatigued by emotional distress
D are much more likely to report physical weakness than psychiatric patients
E all believe that they have a physical illness
F show physical responses to stress rather than emotional responses
2. A=T, B=T, C=F, D=F, E=F, F=F.
A 'lifestyle transformation' is often reported after an illness with a rejection of the ethos of over-work and achievement orientated success. Chronic fatigue patients are more likely to be fatigued by emotional distress than muscular dystrophy patients, but are as likely to report physical weakness as psychiatric patients. Although many do believe that they have a 'physical' illness there is a spectrum of beliefs amongst sufferers with some assuming a psychological cause. There is however a skew of beliefs towards a physical model. When stressed sufferers are just as likely to show emotional responses as physical ones.
--------------------------------------------------------------------------------------------------------------------------------
78. The differential diagnosis of chronic fatigue includes:
A leukaemia
B solid white cell tumours
C systemic lupus erythematosus
D hypothyroidism
E depression
3. All true.
-------------------------------------------------------------------------------------------------------------------------------------

49 - medicine mcqs - 64 to 74

64 - In the treatment of chronic hepatitis B virus:
1. Corticosteroids are always beneficial
2. 40% of patients can be expected to respond to interferon
3. Combined treatment with acyclovir and interferon is more effective than interferon alone
4. Interferon can be associated with a rise in transaminases towards the end of therapy
2 and 4 are the right answers .
--------------------------------------------------------------------------------------------------------------------------------
65 - Which of the following statements is / are true of streptococcus pyogenes infections:
1. They account for less than 5% of upper respiratory infections in children under the age of 2 years
2. Rheumatic chorea is a recognised sequela
3. It is a cause of erysipelas
4. The treatment of choice is ampicillin
1 , 2 , 3 are the right answers .
--------------------------------------------------------------------------------------------------------------------
66 - The following may occur in uncomplicated haemolytic jaundice:
1. Bilirubinuria
2. High conjugated serum bilirubin
3. High serum alkaline phosphatase
4. Reticulocytosis
only 4 is correct .
--------------------------------------------------------------------------------------------------------------------
67 - Nephrotoxicity is described with the following drugs:
1. Gentamicin
2. Acetazolamide
3. Ampicillin
4. Rifampicin
all are correct .
-----------------------------------------------------------------------------------------------------------------------
68 - With reference to transplant immunology:
1. Hyperacute rejection is mediated by T-cells
2. Chronic rejection is immunoglobulin mediated
3. Early acute rejection is mediated by B-lymphocytes
4. Steroids are effective in reversing acute rejection of a donor organ
2 and 4 are correct .
-----------------------------------------------------------------------------------------------------------------
69 - The following are recognised associations:
1. Ulcerative colitis and HLA B8
2. Primary sclerosing cholangitis and HLA B8
3. Haemochromatosis and HLA A3
4. Primary biliary cirrhosis and HLA DR3
2 and 4 are right .
-------------------------------------------------------------------------------------------------------------------
70 - Pleural calcification is a recognised result of:
1. Tuberculosis
2. Chronic empyema
3. Asbestosis
4. Bagassosis
1 , 2 , 3 are right .
--------------------------------------------------------------------------------------------------------------------------
71 - The early manifestations of chronic inorganic lead poisoning include:
1. Absent knee reflexes
2, Punctate basophilia
3. Constipation
4. Abdominal colic
2 and 4 are right .
----------------------------------------------------------------------
72 - Temporal lobe epilepsy is particularly associated with:
1. Dreamy states
2. Euphoria
3. An olfactory aura
4. Repetitive conjugate movements of the eyes
1 and 3 are right .
-------------------------------------------------------------------------------------
73 - Myocarditis:
A may present with a functional systolic murmur
B usually causes hypertension
C causes nonspecific ST changes on ECG
D is often caused by Coxsackie virus
E is worsened by hypoxia and exercise
1. A=T, B=F, C=T, D=T, E=T.
Myocarditis may cause a systolic murmur on auscultation because of cardiac dilatation. The blood pressure in myocarditis is often normal, but if myocardial damage is severe there may be severe hypotension.
---------------------------------------------------------------------------
74 - Cardiomyopathy:
A is primarily characterised by right ventricular dilatation
B is associated with thyrotoxicosis
C is usually associated with valve calcification
D secondary to alcohol has a good prognosis
E may be a cause of the sudden death syndrome
2. A=F, B=T, C=F, D=F, E=T.
Cardiomyopathy is recognised by left rather than right ventricular dilatation and systolic dysfunction in the absence of coronary artery, valvular, congenital or peripheral disease. Thus according to this definition, cardiomyopathy would not be associated with valve calcification. Cardiomyopathy is associated with thyrotoxicosis and acromegaly. Alcoholic cardiomyopathy has a poor prognosis 40-50% are dead within 3 to 6 years.
---------------------------------------------------------

48 - medicine mcqs - 53 to 63

53 - A 27 year old, otherwise fit man gives a history suggestive of recurrent tachyarrhythmias. During a previous anaesthetic he apparently arrested and required DC cardioversion. He now presents for an arthroscopy. His ECG is shown below.
The most likely diagnosis is:
A. Lown Ganong Levine syndrome.
B. Prolonged QT syndrome.
C. Wolff Parkinson White syndrome.
D. Sick Sinus syndrome.
E. Atrio-Ventricular (AV) nodal re-entrant tachycardia.

ANSWER IS C - WPW syndrome
--------------------------------------------------------------------------------------------
54 - Which of the following is a risk factor for increased susceptibility to drug-induced 'Torsades de pointes'?
A. Male Gender.
B. Hypokalaemia.
C. Hypermagnesaemia.
D. Sinus tachycardia.
E. None of the above.
THE ANSWER IS B . HYPOKALEMIA
---------------------------------------------------------------------------------------------------
55 - A fifty year old man suffers an acute myocardial infarction (MI). In which of the following conditions is temporary transvenous pacing most clearly indicated?
A. First-degree heart block.
B. Mobitz type I second-degree AV block with normal haemodynamics.
C. Mobitz type II second-degree AV block.
D. Accelerated idioventricular rhythm.
E. Bundle branch block known to exist before the acute MI.
ANSWER IS C .
-----------------------------------------------------------------------------------------------------------------
56 - With regard to the Dandy-Walker syndrome:
1. The cerebellar vermis is hypoplastic.
2. Obstructive hydrocephalus is the commonest mode of presentation.
3. Presentation usually occurs within the 1st two years of life.
4. A cyst is always present in the posterior fossa
all are correct .
-------------------------------------------------------------------------------------------------------
57 - In transfusion practice:
1. Fever is usually due to anti-leucocyte antibodies
2. Desmopressin (DDAVP) will raise levels of factor VIII in patients with mild haemophilia A
3. Haemolytic reactions may be delayed for up to 1 week
4. Severe anaphylaxis may be seen in IgA deficient individuals
all are true .
---------------------------------------------------------------------------------------------------------------------------------------------
58 - Recognised causes of macrocytosis in the peripheral blood with normoblastic erythropoiesis in the bone marrow include:
1. Hypothyroidism
2. Chronic alcohol abuse
3. Cryptogenic cirrhosis
4. The administration of phenytoin
1 , 2 , 3 are correct .
---------------------------------------------------------------------------------------------------------------------------------------
59 - Which are true of Hepatitis E virus?
1, It is a 34nm single stranded RNA virus.
2. It is more common in IV drug abusers
3. Can produce epidemic waterborne infections
4. Will cause 10% of patients to develop chronic hepatitis
1 and 3 are correct .
----------------------------------------------------------------------------------------------------------------
60 - Which of the following are correctly paired?
1. Conn's syndrome and metabolic alkalosis
2. Uretero-colic anastomosis and hyperchloraemic acidosis
3. Shock and metabolic acidosis
4. Pancreatic fistula and metabolic acidosis
all are correctly paired .
---------------------------------------------------------------------------------------------------------------
61 - The following are recognised causes of pulmonary fibrosis:
1. External raditaion for carcinoma of the breast
2. Bleomycin
3. Sarcoidosis
4. Myelofibrosis
1 , 2 , 3 are correct .
----------------------------------------------------------------------------------------------------------------
62 - Recognised causes of finger clubbing include:
1. Carcinoid tumour
2. Bronchial carcinoma
3. Iron deficiency anaemia
4. Coeliac disease
2 and 4 are the answers .
--------------------------------------------------------------------------------------------------------------------
63 - Dupuytren's contracture has a recognised association with:
1. Diabetes Mellitus
2. Peyronie's disease
3. Epilepsy
4. Alcoholic liver cirrhosis
all are correct .
------------------------------------------------------------------------------------------------------------------

47 - medicine mcqs - 47 to 52

Question 47. The following is true of rectal bleeding:


(a) In the absence of haemorrhoids, it is usually due to malignant disease.
True False TRUE/ BUT DEPENDS ON AGE OF PT-R/O POLYPS AND ADENOMA AND INFLAMMATORY BOWEL DISEASE

(b) It occurs more commonly in Crohn's disease than in ulcerative colitis.
True False FALSE

(c) If it occurs in a patient with ulcerative colitis, it usually indicates that carcinoma has developed.
True False FALSE

(d) When it is due to diverticular disease, colectomy may be indicated to control it.
True False FALSE/MAY BE IN EXTENSIVE AND UNCONTROLLABLE BLEEDING

(e) It may be caused by ingestion of aspirin.
True False TRUE/ESP IN A PT WITH MASSIVE UPPER GI BLEEDING PRESENTING WITH HEMATOCHEZIA AND NO TIME FOR MALENA FORMATION



Question 48. The following are risk factors for gastric carcinoma:


(a) Pernicious anaemia.
True False TRUE

(b) Coeliac disease.
True False TRUE/ESP LYMPHOMA

(c) Partial gastrectomy.
True False TRUE/STUMP CARCINOMA

(d) Helicobacter pylori infection.
True False TRUE

(e) Ménétrière's disease.
True False TRUE



Question 49. The following statements are true:


(a) Solitary rectal ulcers are commonly associated with Crohn's disease.
True False FALSE

(b) Crypt abscesses are typical of coeliac disease.
True False FALSE

(c) Fistula formation can be a feature of Whipple's disease. FALSE
True False

(d) Anal fissure predisposes to faecal incontinence.
True False TRUE/ ESP CONSTIPATION

(e) Right iliac fossa pain is common with diverticular disease.
True False FALSE




Question 50. The following are true of hepatitis:


(a) Hepatitis B is spread via the faecal-oral route.
True False FALSE

(b) A vaccine is available for hepatitis C.
True False FALSE

(c) Incubation time for hepatitis A is approximately 2-3 weeks.
True False TRUE

(d) Hepatitis B is an RNA virus.
True False TRUE

(e) Interferon treatment is required for hepatitis E infection.
True False FALSE




Question 51. The following is a risk factor for the Budd-Chiari syndrome:


(a) Oral contraceptive pill.
True False TRUE

(b) Malignancy. TRUE/ESP RENAL CELL CA,POLYCYTHEMIA RUBRA VERA
True False

(c) Ascites. FALSE- ASCITIS IS A RESULT OF BUDD CHIARRI/ BUT ASCITIS CAN RARELY CAUSE FUNCTIONAL IVC OBSTRUCTION SYNDROMME MIMICKING BUDD CHIARRI
True False

(d) Polycythaemia rubra vera.
True False TRUE

(e) Constrictive pericarditis.
True False FALSE/ A IMPORTANT CLOSE DIFFERENTIAL DIAGNOSIS



Question 52. The following are true regarding prognostic factors for acute pancreatitis:


(a) A low pAO2 indicates a poor prognosis.
True False TRUE/ESP CONSIDER ARDS

(b) A high serum GGT has a poor prognosis.
True False TRUE/ INDICATES SECONDARY TO ALCOHOLISM ASSOCIATED WITH OTHER CO MORBIDITIES LIKE HEPATITIS AND ASPIRATION...

(c) Age of over 55 years usually has a good prognosis. FALSE/REMEMBER RANSONS CRITERIA
True False

(d) A low serum albumin indicates a poor prognosis.
True False TRUE

(e) Abnormal clotting time has a poor prognosis.
True False TRUE

please let me know the correct answers...esp the doubtfulones

46 - medicine mcqs - 41 to 46

Question 41. The following gastrointestinal diseases are associated with the renal conditions listed:


(a) Crohn's disease and renal amyloidosis.
True False TRUE

(b) Hepatitis B and glomerulonephritis.
True False TRUE

(c) Gastric ulcer and nephrotic syndrome.
True False FALSE

(d) Pancreatic neuroendocrine tumours and polycystic kidney disease. FALSE
True False

(e) liver cysts and glomerulosclerosis.
True False FALSE



Question 42. The following is true of villous atrophy in the small intestine:


(a) If due to coeliac disease, it should recover completely on a gluten-free diet.
True False TRUE/ BUT WHEN LYMPHOMA COMPLICATES IN LATER STAGES,IT MAY NOT

(b) It can be caused by tuberculosis.
True False --FALSE /ESPCIALLY FOCAL--AND DIFFUSE INFILTRATION AND MAY BE SECONDARY TO SECONDARY BACTERIAL COLONISATION WITH STENOSING LESION

(c) It can be associated with Giardi gamblia.
True False TRUE

(d) It can be associated with Tropheryma whippelei.
True False TRUE

(e) When associated with bacteria, it may cause a rise in serum folate.
True False TRUE- DUE TO BACTERIAL PRODUCTION



Question 43. The following SKIN conditions are associated with the named GI diseases:


(a) Dermatitis herpetiformis with coeliac disease.
True False TRUE

(b) Pruritus with primary biliary cirrhosis.
True False TRUE

(c) Pyoderma gangrenosum with gastric carcinoma.
True False TRUE

(d) pemphigoid with pancreatitis.
True False TRUE

(e) Erythema nodosum with Crohn's disease.
True False TRUE



Question 44. The following statements are true in relation to vomiting:


(a) Vomiting occurring 12 hours after a suspicious meal is indicative of SALMONELLA poisoning.
True False FALSE

(b) Vomiting in association with headache is a feature of migraine.
True False TRUE/BUT RULE OUT MENINGITIS AND SOL

(c) Vomiting associated with weight loss can be indicative of malignant disease. TRUE/ESP GI MALIGNANCY BUT R/O GOO FIRST SECONDARY TO ACID PEPTIC DISEASE
True False

(d) Vomiting usually precedes the pain of biliary colic.
True False FALSE

(e) Vomiting can be a feature of myocardial infarction.
True False TRUE



Question 45. Scleroderma can produce the gastrointestinal complications listed:


(a) Diarrhoea due to bacterial overgrowth.
True False TRUE

(b) Constipation due to gut hypomotility.
True False TRUE

(c) Diarrhoea which is unresponsive to a gluten-free diet. TRUE
True False

(d) Gastric ulcer due to chronic gastritis.
True False TRUE/ AND GERD AND DUODENAL REFLUX

(e) Dysphagia due to abnormal peristalsis in the oesophagus.
True False TRUE



Question 46. Chronic pancreatitis:


(a) Is a cause of diabetes mellitus.
True False TRUE/SECONDARY DM

(b) Can result from alcohol ingestion in moderate amounts.
True False TRUE

(c) May be hereditary in a minority of cases.
True False TRUE

(d) Can be diagnosed by a raised serum amylase.
True False

(e) Is a cause of pancreas divisum.
True False FALSE/PANCREATIC DIVISUM CAUSES PANCREATITIS

45 - HIV - genetics, serology

There are three genes in HIV which are characteristic of all retroviruses:

* gag:
o encodes a precursor protein (Pr55)
o cleavage yields:
+ p17 matrix protein
+ p24 capsid protein
+ p9 nucleocapsid protein
+ p6

* pol encodes reverse transcriptase, endonuclease and protease activities

* env:
o encodes a precursor protein p160
o cleavage yields:
+ p41 a transmembrane protein which anchors p120
+ p120 binds non-covalently to p41 and acts as the CD4 receptor

In addition to these typical genes there are other regulatory genes.

The HIV genome codes for several regulatory proteins, including:

* tat:
o accelerates the rate of viral transcription

* rev:
o rev regulates the balance of transcription of the regulatory proteins (tat & rev) versus the structural proteins (gag, pol & env)

* nef:
o causes downregulation of the expression of CD4 on the host cell surface

* vpr, vpu & vif:
o the roles of these proteins are not well characterised

--------------------------------------------------------------------

HIV LAB TESTS

These include:

* HIV culture - in stimulated lymphocytes
* HIV antigen - p24 antigen test
* HIV nucleic acid - using the polymerase chain reaction
* HIV antibody - ELISA or Western blot

HIV antibody tests are used for diagnosis and screening.

---------------------------------------------------------

SEROLOGY

Approximate time from exposure (weeks) to the development of serological markers of HIV infection.

* p24 antigen 1-4 weeks
* IgM antibody 3-10 weeks
* IgG antibody 4-18 weeks

Following HIV exposure there is a variable pre-antibody stage followed by seroconversion.

--------------------------------------------------------
SUBTYPES

The causative agent of AIDS was originally identified as HTLV-3 in 1983. This is now termed HIV-1 and is the predominant serotype worldwide.

In 1985 a second serotype, known as HIV-2, was identified. It is more closely related to the Simian Immunodeficiency Virus (SIV) of macaques. HIV-2 has been found in East Africa, Asia, Southern Europe, Latin America and North America, but it is most extensive in Western African countries.

Compared with HIV-1, HIV-2 is characterised by lower rates of sexual and perinatal transmission, decreased CD4 cell killing, slower progression to AIDS and death, and relative geographical confinement.

44 - cardiology case 1

A 56-year-old man presents with athlete's foot. You take the opportunity to assess his general health and find that he has a blood pressure of 146/94 which is the average of two recordings in your clinic. He is otherwise well, is a keen runner, non-smoker, urinanalysis is negative for glucose and protein. He is not taking any regular medication and he has no family history of cardiovascular disease.

You record a 12-lead ECG the result of which is shown.

What is the next most appropriate step in managing this man?

(Please select 1 option)

	a.Anticoagulate with warfarin
	b.Lifestyle advice and monitor BP
	c.Lifestyle advice, monitor BP and treat to target <>
	d.Refer to medical team with Acute Coronary Syndrome
	e.Request an Exercise Stress Test

the correct answer is c .

The ECG shows Left Ventricular Hypertrophy (LVH) which, in the context of a 56-year-old man presenting opportunistically with hypertension suggests that he already has Target Organ Damage. This would place his 10 year cardiovascular risk at greater than 20% and he should probably therefore start on treatment for his blood pressure. The JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice published in December 2005 says:

"People with persistent blood pressure elevation > 160 mm Hg systolic and/or > 100 mm Hg diastolic are at sufficiently high CVD risk on the basis of blood pressure levels alone to require drug therapy to reduce their blood pressure. People with sustained systolic blood pressures > 140 but <= 160 mm Hg systolic and/or diastolic blood pressures > 90 but <= 100 mm Hg and clinical evidence of CVD or diabetes or target organ damage or a total CVD risk > 20% should be considered for blood pressure lowering drug therapy."

Evidence of target organ damage includes heart failure, established coronary heart disease, stroke or TIA, peripheral arterial disease, abnormal renal function (raised creatinine or proteinuria / microalbuminuria), hypertensive or diabetic retinopathy or left ventricular hypertrophy on the ECG.

This ECG shows typical changes of left ventricular hypertrophy with large voltages in the chest leads, associated ST depression and T wave inversion (this is called a 'strain pattern').

There are many different criteria for LVH.

Sokolow + Lyon (Am Heart J, 1949;37:161)

• S V1+ R V5 or V6 > 35 mm

Cornell criteria (Circulation, 1987;3: 565-72)

• SV3 + R avl > 28 mm in men

• SV3 + R avl > 20 mm in women

Framingham criteria (Circulation,1990; 81:815-820)

• R avl > 11mm, R V4-6 > 25mm

• S V1-3 > 25 mm, S V1 or V2 +

• R V5 or V6 > 35 mm, R I + S III > 25 mm

Romhilt + Estes (Am Heart J, 1986:75:752-58)

• Point score system

It is important to remember that the 12-lead ECG is very specific for diagnosing LVH but not very sensitive. Therefore if the voltage changes of LVH are present on the ECG it is very likely to be due to LVH. However, in more than 90% of patients with LVH it will not be apparent on the ECG. Where LVH is discovered further investigations may be required to look for other end-organ damage or cardiac abnormalities. Depending on local expertise and resources referral to secondary care may be required.

43 - inclusion bodies

A)Intra Cytoplasmic

Rabies ---Negri bodies
Small pox ---Gaurnier bodies
Molluscum Contagiosum---------- Henderson Roterson bodies
Fowl pox-- --Bollinger bodies
Trachoma--Halberstaedter- Prowazek Bodies

B)Intra Nuclear Inclusions

Cowdry type A--------
Herpes Virus( Lipschutz Inclusions)
Yellow fever ( Torres Bodies)

Cowdrey Type B------
Adeno Virus ( Basophilic)
Poliovirus ( acidophilic)

C)Both Intra Nuclear and Cytoplasmic

Measles Virus
----------------------------------------------

Miyagawa’s granulocorpusles ---- Buboes from LGV

Lygranum Antigen----------------- LGV

Halberstaedter- Prowazek Bodies ------------Trachoma

Morula cells with Ig M Deposits--- Tryponosomiasis

Leishman Donovan Bodies-------- Kala –azar

Call- Exner bodies----Spherical Globules surrounded by
Granulosa cells in ovary


Walthard Inclusions--- In ovarian Cortex.

Babes- Ernst granules Corynebacterium Diptheriae

Donovan bodies ------ Granuloma Inguinale

Psittacosis------------- LCL bodies ( Levinthal Cole Lille Bodies)

Lewis Bodies---------- Parkinsonism


Russel Bodies--------- Multiple Myeloma

Warthin- Finkedly Giant Cells---- Measles


Owl-eye inclusions---
a)CMV
b) Herpes

torres body------------------ yellow fever

bracht wachter bodies------------- infective endocarditis

councilmann bodies- dying hepatocytes

keratin pearls- sq. cell carcinoma

pick body- pick's ds

verocay body- schwannoma

psammoma body- papillary adenocarcinoma in thyroid
and serous cystadenoma in ovary

-----------------------------------------------------------------------------------------

42 - chromosomal breakage syndromes

Table 1. Chromosomal Breakage Syndromes With Neoplasias Caused by Defective DNA Repair

Syndrome	Chromosome Breakage/ Hypersensitivity: Immunodeficiencies	Cancer Risk
Ataxia telangiectasia	TCRA: 14q11 TCRB: 7q35 IGH: 14q32 No increased SCE† but increased gaps and breaks, nonhomologous interchanges/ Roentgentherapy, ionizing radiation, radiomimetic compounds: decreased IgA, IgG2, IgG, IgE	Risk of neoplasia 38%; 85% are leukemias and lymphomas (B-cell). Young children have acute lymphoblastic leukemia of T-cell origin. Older children have T-cell leukemia. Risk for other cancers is increased 4-fold (2- to 3-fold increased risk for breast cancer in carriers).
Bloom syndrome <1%>	SCE 12-15 times higher, homologous interchanges, increased gaps and breaks./ UV, cancer chemotherapeutic agents: Decreased IgA and IgM, and/or IgG	Risk for leukemia, lymphoma, adenocarcinoma, and other cancers increased 5- to 8-fold.
Fanconi anemia	Increased gaps and breaks, 30% between nonhomologous chromosomes, clones with translocations./ UV, chemotherapeutic agents for immunosuppression, diepoxybutane, mitomycin C, other DNA-crosslinking agents	For aplastic anemia, risk is increased for pancytopenia, leukemia, acute myeloid leukemia, squamous cell carcinoma, medulloblastoma, Wilms tumor, breast cancer, and liver cancer.

Xeroderma pigmentosum

Increased gaps and breaks, increased SCE after UV/ UV XPG group may be sensitive to X-rays

1000-fold increased risk for squamous cell carcinoma, basal cell carcinoma, malignant melanoma, and fibrosarcoma, and 10- to 20-fold increased risk for other tumors

Immunoglobulin A, immunoglobulin G₂, immunoglobulin G, immunoglobulin E

†Sister chromatid exchanges

41 - tumor markers

AFP: = raised—in-- ENDODERMAL SINUS TUMOUR (yolk sac tumors), hepatoma, Teratoma.
(Note in down’s synd. AFP. is decreased and in seminoma and dysgerminoma it is not raised / not found.)

Alpha-HCG: --Pituitary tumour & zollinger-ellison synd.

Beta 2 microglobulin = for multiple myeloma,

Beta-HCG: = in Choriocarcinoma.

BRCA-1 and BRCA-2 ---- Breast Cancer Gene 1 and Breast Cancer Gene 2 ---- breast or ovarian cancer

Bence Jones Proteins---Multiple myeloma,

CA 15-3----in BREAST Ca.

CA 19-9 is a tumour marker---used in pancreatic carcinoma,

CA 72-4--- Gastric CA.

CA 125—in OVARIAN Ca., Epithetial(esp. SEROUS)

Calcitonin ---in medullary thyroid carcinoma

CEA ---- Carcinoembryonic Antigen ---- colorectal ca.

CALLA---B cell ALL and AML in Blast phase.

Her-2/neu ---- Human epidermal growth factor receptor ---- breast cancer tumor = positive for Her-2/neu = guides treatment and determine prognosis.

INHIBIN --GRANULOSA CELL TUMOUR

LDH: ---in DYSGERMINOMA

Neuron Specific Enolase-(NSE)-----neuroblastoma, small cell carcinoma lung...

PSA -- Prostate specific antigen ---- Prostate cancer,

Prostatic acid phosphatase (PAP)---- Metastatic prostate cancer.

Thyroglobulin --HTg human thyroid thyroglobin = for differentiated thyroid tumour only.

TESTOSTERONE: --in LEYDIG CELL T, SERTOLI CELL TUMOUR, HILUS CELL Tumour

S-100-------melanoma,neural tumours

CD-25-------Hairy cell leukemia, Adult T-cell leukemia / lymphoma.

TA-4 and SCC-----CA cervix

BTA (Bladder tumour antigen)-------Bladder (Help diagnose and determine recurrence)

NMP22--------Bladder (Help diagnose and determine recurrence)

TA-90 ----Metastatic melanoma (Help diagnose))

Cancer antigen 27-29 -----Elevated cancer antigen 27-29 levels are associated with cancers of the colon, stomach, kidney, lung, ovary, pancreas, uterus, and liver.

(First-trimester pregnancy, endometriosis, ovarian cysts, benign breast disease, kidney disease, and liver disease are noncancerous conditions that are also associated with increased cancer antigen 27-29 levels. )




uses of tumour markers

Help diagnose
CA 72-4 (Cancer antigen 72-4)
Prostate-specific membrane antigen (PSMA)
Prostatic acid phosphatase (PAP)
S-100
TA-90


Monitor treatment
NSE (Neuron-specific enolase)


Monitor treatment and determine recurrence
CEA


Help diagnose and determine recurrence
BTA (Bladder tumour antigen)
NMP22


Help diagnose, monitor treatment, and determine recurrence
AFP
hCG
Monoclonal immunoglobulins
PSA
Calcitonin



Stage disease, monitor treatment, and determine recurrenceCA 15-3
CA 19-9
CA-125



Determine prognosis and guide treatment
Oestrogen receptors
Her-2/neu
Progesterone receptors



Determine prognosis
B2M (Beta-2 microglobulin)



Determine recurrence
thyroglobulin

40 - clotting factors 13 list

Primary Factors

Factor	Trivial Name(s)	Pathway	Characteristic
Prekallikrein (PK)	Fletcher factor	Intrinsic	Functions with HMWK and factor XII
High molecular weight kininogen (HMWK)	contact activation cofactor; Fitzgerald, Flaujeac Williams factor	Intrinsic	Co-factor in kallikrein and factor XII activation, necessary in factor XIIa activation of XI, precursor for bradykinin (a potent vasodilator and inducer of smooth muscle contraction
I	Fibrinogen	Both	-
II	Prothrombin	Both	Contains N-term. gla segment
III	Tissue Factor	Extrinsic	-
IV	Calcium	Both	-
V	Proaccelerin, labile factor, accelerator (Ac-) globulin	Both	Protein cofactor
VI (same as Va)	Accelerin	Both	This is Va, redundant to Factor V
VII	Proconvertin, serum prothrombin conversion accelerator (SPCA), cothromboplastin	Extrinsic	Endopeptidase with gla residues
VIII	Antihemophiliac factor A, antihemophilic globulin (AHG)	Intrinsic	Protein cofactor
IX	Christmas Factor, antihemophilic factor B,plasma thromboplastin component (PTC)	Intrinsic	Endopeptidase with gla residues
X	Stuart-Prower Factor	Both	Endopeptidase with gla residues
XI	Plasma thromboplastin antecedent (PTA)	Intrinsic	Endopeptidase
XII	Hageman Factor	Intrinsic	Endopeptidase
XIII	Protransglutaminase, fibrin stabilizing factor (FSF), fibrinoligase	Both	Transpeptidase