can only be diagnosed if psoriasis is present (F) also if fhx of psoriasis ref K&C

Question 28

Repeat – see q18

Question 29

1. 
   T
   
2. 
   T
   
3. 
   F
   
4. 
   F
   
5. 
   F
   

Management of obstructive sleep apnoea:

• 
  weight reduction
  
• 
  avoidance of tobacco and alcohol
  
• 
  CPAP via nasal mask at night is effective
  
• 
  Surgical procedures include tonsillectomy, uvulopalatopharyngoplasty – UPPP, tracheostomy
  

Question 30

1. 
   F
   
2. 
   T
   
3. 
   F
   
4. 
   ??
   
5. 
   F
   

eosinophilic granuloma of lung (histiocytosis X) - Neither inspiratory rales (crackles) nor clubbing is common.

Clubbing is a feature of CFA, not EAA.

Idiopathic pulmonary haemosiderosis is a disease mainly of children.

Lympohangiomyomatosis – couldn’t find it.

31. 
    A 32 year old former IV drug user presents with a several week old history of low grade fever, night sweats and shortness of breath. The following diagnoses are likely
    

6. 
   pneumocystis carinii pneumonia
   
7. 
   crytospiridosis
   
8. 
   pneumococcal pneumonia
   
9. 
   toxoplasmosis
   
10. 
    pulmonary TB
    

TFTFT

Assuming that an IV drug abuser is now either immunosuppressed, or carrying a blood borne disease such as hep B/C. The question seems to be asking which of the following can cause respiratory complications of HIV/immunosuppression.

Pneumocystis carinii causes pneumonia in the immunosuppressed. It presents with a dry cough, fever and bilateral crepitations. Treat with co-trimoxazole. Prophylaxis is required if CD4 count is under 200.

Cryptospiridium is a protozoa that can cause outbreaks of diarrhoea and abdominal pain from contaminated water supplies. It is self limiting in immunocompetent hosts but can be life threatening in the immunosuppressed (up to 20 litres of stool per day!).

Pneumococcal pneumonia can also affect the immunocompromised and, presumably, it’s much worse.

Toxoplasma gondi is the chief CNS pathogen in AIDS and it presents with focal neurological signs. Treat with primethamine (+folinic acid) and sulfadiazine or clindamycin for 6 months, with lifelong secondary prophylaxis.

Pulmonary TB: see Oxford Handbook pp564-567.. TB will probably make an appearance on the MCQ is some form or another.

32. A 24 year old student present with jaundice three weeks after returning from a holiday in Mexico. The following make a diagnosis of Hepatitis A likely:

11. 
    sharing needles
    
12. 
    foreign travel
    
13. 
    Incubation period
    
14. 
    Recent blood transfusion
    
15. 
    Extrahepatic manifestation
    

FTTFF

Hepatitis A is picornavirus which is transmitted via the faeco-oral route.

Incubation period is 2-6 weeks. Prodromal features include fever, malaise, arthralgia.

A patient with active infection will have anti-HAV IgM. IgG indicates old infection with no active disease. Once infection is established, treatment is supportive.

1-4% of patients will develop fulminany hepatitis and death from Hep A is rare (<1%). Chronic hepatitis does not occur.

I have no idea what (e) means in this question.

33. A 61 year old male patient presents with renal colic and the following biochemistry results: Na+ 135 mmol/L, K+ 3.7 mmol/L, Urea 10 mmol/L, Ca++ 2.9 mmol/L, Total protein 95 g/L, albumin 28 g/L. The following are the most likely diagnoses:

16. 
    Hypercalcemia of malignancy
    
17. 
    Nephritic syndrome
    
18. 
    Multiple myeloma
    
19. 
    Sarcoidosis
    
20. 
    Hyperparathyroidism
    

TFTFT

Increased: Urea, Calcium, Total Protein.

Decreased: Albumin.

Increased Urea:

Drugs (cytotoxics, thiazides, pyrazinamide)

Increased cell turnover

Decreased excretion (primary gout, chronic renal failure, lead nephropathy,

hyperparathyroidism, pre-eclampsia)

Increased Calcium

Malignancy, Hyperparathyroidism, Sarcoid, Vit D intox, Benign hypocalciuric

hypercalcaemia (very rare)

(Treat hypercalcaemia with rehydration and furosemide)

Decreased Albumin

Liver disease, Nephrotic synd, Burns, Protein losing enteropathy, malabsorption,

malnutrition, late pregnancy, posture, genetic variations, malignancy.

I am unsure of these answers but here is my reasoning. Renal colic suggests stones and can occur with hypercalcaemia.

a, c) Malignancy is consistent with all findings. Myeloma is definitely consistent with the raised total protein.

b) Nephritic synd: Proteinuria and haematuria. Not renal colic and not hypercalcaemia.

e) Hyperparathyroidism will cause the hypercalcaemia, hyperuricaemia and renal stones.

34 A 72 year old woman presents with recent chest pain, an uninformative ECG and an elevated troponin level. This indicates

1. 
   unstable angina
   
2. 
   dermatomyositis
   
3. 
   crush injury
   
4. 
   induction by exercise
   
5. 
   myocardial infarct
   

FFFFT

Unstable angina will not cause a raised troponin.
From http://www.emedicine.com/emerg/topic932.htm

The troponins are regulatory proteins found in skeletal and cardiac muscle. The 3 subunits that have been identified include troponin I (TnI), troponin T (TnT), and troponin C (TnC). The genes that code for the skeletal and cardiac isoforms of TnC are identical; thus, no structural difference exists between them. However, the skeletal and cardiac subforms for TnI and TnT are distinct, and immunoassays have been designed to differentiate between them. This explains the unique cardiospecificity of the cardiac troponins. Skeletal TnI and TnT are structurally different. No cross-reactivity occurs between skeletal and cardiac TnI and TnT with the current assays.

Elevated troponin levels have been documented in other disease states and situations that are not associated with atherosclerotic coronary artery disease, including the following:

• Pacing, automated implantable cardioverter-defibrillator

• Tachyarrhythmias

• Hypertension

• Myocarditis

• Myocardial contusion

• Acute and chronic congestive heart failure

• Cardiac surgery

• Renal failure

• Pulmonary embolism

• Subarachnoid hemorrhage

• Sepsis

• Hypothyroidism

• Shock

35. 
    Tuberculous cavitation on CXR:
    
    1. 
       Is usually multiple
       
    2. 
       Is usually thick walled
       
    3. 
       May contain Nocardia
       
    4. 
       Is usually in the mid/lower lobes
       
    5. 
       Is low in bacteria count
       

FTFFT

Cavitation occurs in TB when the caseous material liquefies, is extruded out of the bronchi, and eventually liquefies. This is more common in secondary TB. Primary TB is classically charicterised by a calcified tubercle in the middle or lower zone (Ghon Focus) with a calcified perihilar lymph node (Ghon Complex).

Secondary TB tends to involve the apices due to the higher O2 tension.

Nocardia is an acid-fast gram positive rod. Infections are frequently misdiagnosed as TB as it is acid-fast and it causes the same disease process. Nocardia is inhaled and grows in the lungs to produce lung abscesses and cavitations. Treatment is with trimethoprim and sulfamethoxazole.

35. 
    A 55 year old black US male has radicular chest pain. Serum Na+ is 122 mmol/L and ESR is 96 mm/hr. Which of the following are the likely diagnosis?
    
    1. 
       dissecting aneurysm
       
    2. 
       bony metastatic manifestation
       
    3. 
       multiple myeloma
       
    4. 
       spinal plasmacytoma
       
    5. 
       sickle cell crisis
       

FFTFF
The raised ESR would be consistent with myeloma, and renal insufficiency may cause hyponatraemia in that case. As for the others, I have no idea. Please email any corrections to this question to Ben because I can’t make sense of what’s going on.

35. 
    In a patient presenting with dermatitis of the face and a previous history of atopic dermatitis, the appropriate therapy would include:
    
    1. 
       dermovate
       
    2. 
       emollients
       
    3. 
       synalar
       
    4. 
       betnovate
       
    5. 
       hydrocortisone
       

FTFFT

Atopic dermatitis is treated with steroids and emollients. Low potency steroids are used on the face, ie hydrocortisone.

35. 
    The following conditions should be treated with topical steroids
    
    1. 
       Contact dermatitis
       
    2. 
       Rosacea
       
    3. 
       Acne
       
    4. 
       Lichen planus
       
    5. 
       Eczema herpeticum
       

TFFTF