NOVEMBER

2007
EMQ 1 BRUISING
1. A-ALL
2. ITP
3. I- Myelofibrosis

ACUTE LYPMHOBLASTIC
LEUKAEMIA

DEFINITION; Malignant
disorder of lymphoblasts. They replace the normal marrow elements, resulting in a marked decrease in
the production of normal blood cells. Also proliferate in the liver, spleen, and lymph nodes

EPIDEMIOLOGY; Most common malignancy in children, 80% of leukemia in children

SIGNS AND SYMPTOMS

 Fatigue, anorexia, lethargy, pallor

 Bleeding, bruising, petechiae
 Fever
 Lymphadenopathy
 Hepatosplenomegaly
 Bone pain, Bone tenderness
 Testicular swelling
 Septicemia
 CNS- blurred vision, floaters, photophobia, headache, early am vomit, neck stiffness

DIAGNOSIS

 CBC: 1) low platelet count 2) anemia 3) white count- low->normal->increased and blood film
 Electrolytes, calcium, phosphorus, uric acid, lactic dehydrogenase(LDH)
 Chest x-ray (mediastinal mass)
 Bone marrowaspirate—hypercellular, increased lymphoblasts Blasts >/= 30%
 Cerebrospinal fluid (CSF)—for cytospin may show blasts
 DNA index, Immunophenotype-
o Myeloperoxidase , sudan black neg. (pos. in Myeloid leukaemia)
o PAS-positive for B-ALL,
o Acid phosphatase positive for T-ALL

TREATMENT; Four phases:

1. Remission induction: cytoxan, vincristine, prednisone, L-asparaginase, and/or doxorubicin.

2. Consolidation: may add 6MP, 6TG, or cytosine arabinoside
3. Maintenance therapy: 2 years—methotrexate and 6MP, may add vincristine and prednisone
4. CNS prophylaxis: Methotrexate to CSF, may have radiation to the head
 Infection prevention—antibiotics, isolation if necessary

1
Acute Myelocytic Leukemia (AML)

EPIDEMIOLOGY; More common in adults; association with benzene 8 subtypes M0–M7:

 M1–M3 have granulocytic differentiation.

 M4 and M5 are monocytic precursors.
 M6 have predominance of erythroblasts.
 M7 is mainly megakaryocytic.

SIGNS AND SYMPTOMS

 Fatigue, hemorrhage, or bruising (30%)

 Infection of lung, skin (25%)
 Splenomegaly is rare (25%) compared to other types of leukemia.

DIAGNOSIS; Specific characteristics:

 M3: Associated with DIC, Auer rods, t(15;17), add all-trans retinoic acid to chemo
 M5: Associated with gingival hyperplasia
 M4, M5: CNS manifestations
 t(8;21) and t(15;17) have better prognosis.

TREATMENT

 Induction: Cytarabine + an anthracycline (daunorubicin)––50 to 80% receive remission

 Consolidation: Same chemotherapy as induction
 Maintenance: Clinical trials determining best drugs
 Stem cell transplantation is also potentially curative.
 M3 treated with all-trans retinoic acid in addition to cytarabine and daunorubicin.

DIC

DEFINITION; Increased fibrinogenesis and fibrinolysis.

ETIOLOGY

 Septic shock (meningococcemia)

 Incompatible transfusion
 Rickettsial infection
 Snake bite
 Acute promyelocytic leukemia

PATHOPHYSIOLOGY

 Hypoxia
 Acidosis
 Tissue necrosis
 Shock
 Endothelial damage

SIGNS AND SYMPTOMS

2
  Bleeding
 Petechiae and ecchymoses
 Hemolysis

DIAGNOSIS

 Increased PT and aPTT

 Decreased fibrinogen and platelets
 Increased fibrin degradation products and D-dimer

TREATMENT

 Treat underlying cause.

 Replacement therapy:
o Platelets (thrombocytopenia)
o Cryoprecipitate (hypofibrinogenemia)
o Fresh frozen plasma (FFP) (replacement of coagulation factors)
 Heparin prevents consumption of coagulation factors.

APLATIC ANAEMIA
Aplastic anemia is a syndrome of bone marrow failure characterized by peripheral pancytopenia and
marrow hypoplasia, and mild macrocytosis is observed in association with stress erythropoiesis and an
elevated fetal hemoglobin levels. Idiopathic (65%)

Acquired =more than 80% of cases. clinical and laboratory observations suggest an autoimmune disease.
 Drugs- Chloramphenicol, cytotoxics, etc
 Chemicals/toxins- Benzene dyes solvents
 Radiation
 Viruses-HIV, EBV, CMV, Hepatitis, Dengue, parvo
 Autoimmune disorders
 Connective tissue diseases

On morphologic evaluation, the bone marrow is devoid of hematopoietic elements, showing largely fat
cells. Flow cytometry shows that the CD34 cell population, which contains the stem cells and the early
committed progenitors, is substantially reduced

Presentation; onset is insidious, and the initial symptom is related to anemia or bleeding, although fever
or infections are also often noted at presentation.

 Anemia may manifest as pallor, headache, palpitations, dyspnea, fatigue, or foot swelling.

 Thrombocytopenia may result in mucosal and gingival bleeding or petechial rashes.

 Neutropenia may manifest as overt infections, recurrent infections, or mouth and pharyngeal
ulcerations.

MYELOFIBROSIS

3
There is hyperplasia of megakaryocytes which produce platelet derived growth factor, leading to
intense marrow fibrosis and myeloid metaplasia (haemopoiesis in the spleen and liver to take
over)->massive hepatosplenomegaly.

Presentation: usually 60 yrs.

 Most commonly massive splenomegaly (spleen palpable 8 cm below the costal margin;
cause is usually chronic lymphocytic leukemia, non-Hodgkin lymphoma, chronic myelocytic
leukemia, polycythemia vera, myelofibrosis with myeloid metaplasia, or hairy cell leukemia.) and
pancytopaenia.
 Hypermetabolic symptoms: night sweats, fever, weight loss; abdominal discomfort due to
splenomegaly; or bone marrow failure (low Hb, infections, bleeding).
Film: Leucoerythroblastic cells (nucleated red cells) characteristic teardrop RBCs. Low Hb.
Bone marrow trephine for diagnosis.
Treatment:
 No splenectomy since it may still make blood cells.
 Repeat transfusions- increase risk of haemochromatosis(usually what kills), increased
hypocalcemia since citrate in blood products chelates calcium.
 Allogeneic stem cell transplant may be curative in young people but carries a high risk of
mortality.
Prognosis: Median survival 4-5 years.

Post-transfusion purpura (PTP)

 Rare but potentially lethal complication of transfusion of red cells or platelets caused by platelet-
specific alloantibodies. F>M.
 Typically 5-9 days after transfusion- extremely low platelet count with bleeding.
Management:
 High-dose intravenous immunoglobulin-current treatment of choice, 85% respond; often a rapid
and prompt increase in the platelet count.
 Steroids and plasma exchange-were the preferred tx. Plasma exchange effective in some cases .
 Platelet transfusions- usually ineffective in raising the platelet count, but may have to be given in
large doses in the attempt to control severe bleeding in the acute phase, before there has been a
response to high-dose IVIgG. The dose of platelets may be more important than the platelet type
of the donor platelets. Further transfusions in the acute phase does not prolong the duration or
severity of thrombocyopenia.
ITP

DEFINITION; Immune-mediated thrombocytopenia of unknown etiology

PATHOPHYSIOLOGY; Development of antibodies against a platelet surface antigen. The antibody–

antigen complexes effectively decrease platelet count by being removed from circulation.

SIGNS AND SYMPTOMS; Petechiae and purpura over trunk and limbs, Mucosal bleeding

DIAGNOSIS; Thrombocytopenia on CBC. Absence of other factors to explain thrombocytopenia

(diagnosis of exclusion), Antiplatelet antibodies

4
 TREATMENT
 Corticosteroids acutely
 May also consider intravenous immunoglobulin for severe cases
 Platelet transfusion if significant bleeding present
 Splenectomy electively to decrease recurrence

Heparin-induced thrombocytopenia, HIT

 HIT is immune-mediated usually develops after 5–10 days; it can be complicated by thrombosis.
 Platelet counts should be measured just before treatment with heparin or low molecular weight
heparins, and regular monitoring if given for longer than 4 days.
 Signs; include a 50% reduction of platelet count, thrombosis, or skin allergy.
 Mx;
 if suspected or confirmed, heparin should be stopped
 an alternative anticoagulant, such as lepirudin or danaparoid, should be given.
 Ensure platelet counts return to normal range in those who require warfarin
METASTATIC CA
Pain present at rest and at night, especially in patients older than 50 years

Most common locations include the following:

 Spine
 Pelvis
 Ribs
 Proximal limb girdles

The process by which bone metastases develop appears to be the following:

 Cells from the primary site must, through the process of neovascularization or through migration
to the nearest blood vessel, attach to the basement membrane of the vessel wall and produce
proteolytic enzymes that disrupt the basement membrane.
 The cells then migrate through the basement membrane and float away in the bloodstream to a
distant site. If they survive the journey to the distant site, the tumor cells attach to the basement
membrane of the vessel wall using proteolytic enzymes (integrins/cadherins). After disrupting the
receptor site basement membrane, they migrate into the substance of the distal host tissue. Producing
the chemotactic factors noted above, as well as RANK ligand, these cells stimulate osteoclast activity to
produce bone resorption.
 A feedback relationship, such as that present in myeloma cells, then produces continued
osteoclast stimulation for bone resorption and tumor cell growth, providing for continued growth and
survival of the metastatic cells. This, in turn, progressively destroys cancellous and cortical bone at the
distant osseous site.
EMQ 2: DIARRHOEA
A. spectrum
The clinical VIRAL GASTROENTERITIS
of acute viral gastroenteritis ranges from asymptomatic infection to severe dehydration and death. Viral gastroenteritis
typically presents with short prodrome, with mild fever and vomiting, followed by 1-4 days of nonbloody, watery diarrhea. Viral gastroenteritis
is usually self-limited.

 The history should focus on severity and dehydration. The onset, frequency, quantity, and duration of diarrhea and vomiting are important
factors in assessing the status. Oral intake, urine output, and weight loss are important considerations. Viruses are the suspected cause of
acute gastroenteritis when vomiting is prominent, when the incubation period is longer than 14 hours, and when the entire illness is over in
less than 3 days. Travel history (including cruise ships), eating history, and daycare history are important epidemiological factors.
 A viral cause should be suspected when the warning signs of bacterial infection (ie, high fever, bloody diarrhea, severe abdominal pain, >6
stools/24 h) are absent and an alternative diagnosis is not suggested by 5 epidemiologic clues from the history (eg, travel, sexual practices,
antibiotic use).
 Factors associated with severe and prolonged disease are immunodeficiency and immune suppression, comorbid disease, and malnutrition.
 Death results from dehydration and acidosis.
 Ruling out other diagnoses is important. Mucus or overt blood in the stool almost always indicates bacterial or parasitic infection.
 B.
C. AMOEBIASIS

o The most common presentation of amebic colitis is gradual onset of bloody diarrhea, abdominal pain, and tenderness spanning several
weeks’ duration.
o Rectal bleeding without diarrhea can occur, especially in children.
o Only approximately 10-30% of patients with amebic colitis develop fever.
o Weight loss and anorexia may occur.
o Fulminant or necrotizing colitis usually manifests as severe bloody diarrhea and widespread abdominal pain with evidence of peritonitis and
fever.
o Predisposing factors for fulminant
D.CARCINOID SYNDROME colitis include poor nutrition, pregnancy, corticosteroid use, and very young age.

Carcinoid tumors grow slowly, and symptoms may not occur for several years, if at all. When symptoms do develop, they are ill defined and
may be neglected for a long time before being properly diagnosed. In some cases, carcinoid tumors present as acute appendicitis or
chronic pain in the lower right abdominal quadrant. For this reason, the condition is frequently misdiagnosed as irritable bowel syndrome.
[18]
Alcohol intolerance and weight loss also may be associated manifestations. Severity of symptoms varies. Onset of symptoms may be
spontaneous or may be precipitated by certain foods and beverages (eg, alcohol), pharmacologic agents, and physical or emotional stress.
The carcinoid syndrome occurs in approximately 10% of carcinoid tumors[3] and becomes manifest when vasoactive substances from the
tumors enter the systemic circulation escaping hepatic degradation. This is the case when carcinoid tumors metastasize to the liver or they
arise for example in the bronchus.

The most important clinical finding is flushing of the skin, usually of the head and the upper part of thorax.[4] Secretory diarrhea and
abdominal cramps are also characteristic features of the syndrome. When the diarrhea is intensive it may lead to electrolyte disturbance
and dehydration. Other associated symptoms are nausea, and vomiting. Bronchoconstriction, which may be histamine-induced, affects a
smaller number of patients and often accompanies flushing.

Enteric
About 50%(typhoid) feverhave cardiac abonormalities, caused by serotonin-induced fibrosis of the tricuspid and pulmonary valves. Elevated
of patients
levels of circulating serotonin have been associated with cardiac failure, due to fibrous deposits on the endocardium. These deposits are
 thought to be responsible for the fibrous degeneration of the valve apparatus. "TIPS" is an acronym
The incubation period of enteric (typhoid) fever is 5-21 days.

forTricuspid Insufficiency, Pulmonary Stenosis (fibrosis of tricuspid and pulmonary valves).
E.SALMONELLA
Transmission INFECTION
is generally from contaminated water or animal products or contact with an infected person or carrier.

The initial pain
Abdominal prodrome
is duelasting 7-10 days reaction
to desmoplastic includes of headache, cough,ordiaphoresis,
the mesentery hepatic metastases.anorexia,NOTE:weakness, sore
Although the throat,
most common malaise, abdominal
site of a carcinoid pain,
tumor is
History
and constipation
Appendix/Terminal ileum,or "pea soup"
carcinoid syndromediarrhea. Abdominal
will only occur pain is from
once metastasized present in 20-40%tract
the gastrointestinal to the liver [6]
of patients. Constipation
because is found by
the serotonincreated in the
10-38%
carcinoidoftumor
patients. [6]
released
 into the blood would only get broken down once it travels from the gastrointestinal tract directly to the liver through the hepatic portal system. However: If the tumor is bronchogenic in
Obtain
Thesethe patient'ssymptoms
prodromal dietary history. Inquire
typically about
plateau as potential
the feverrestaurant
increases sources,
origin, then metastasis does not need to occur in order for carcinoid syndrome to occur.
in a stepwise food fashion
preparation techniques,
peaking and exposure
in the second week of to potentially
illness.
 contaminated or nonchlorinated water sources. Note: In the United States, half of Salmonella outbreaks occur in restaurant settings
After the prodrome, splenomegaly, abdominal distention and pain, relative bradycardia, rash, meningismus, and mental confusion may
 occur. It may
Obtaindisseminate
the patient'sto lungs, gallbladder,
travel history. kidneys,
Typhoid feveroris CNS.
increasingly associated with international travel to developing nations.

 UntreatedDetermine
patients experience
if other either
patient complications
contacts have or resolution
similar illnesses, byfood
the fourth week.orIntestinal
ingestions, perforation occurs in 3-10% of patients.
animal contacts.
[6]
Other complications include endocarditis, pericarditis, pneumonitis, orchitis, and focal abscess.
 Bacteremia Salmonella syndromes can be divided into gastroenteritis, enteric fever, bacteremia, localized infection, and a chronic carrier
state.
 Bacteremia typically occurs in immunocompromised patients.
Gastroenteritis
 Prolonged or recurrent
Incidence feversduring
is highest may occur.
May through October in temperate climates.
 Focal infections may occur.
The incubation period is from 8-48 hours after the ingestion of contaminated food or water.
 Mycotic abdominal
Symptomsaortic aneurysm
are acute onset may occur.
of fever and chills, nausea and vomiting, abdominal cramping, and diarrhea.
 Localized infection
If a fever is present, it generally abides in 72 hours.
 [6]
 LocalizedDiarrhea
infectionisoccurs
usuallyinself-limited,
5-10% of persons
lasting with bacteremia.
3-7 days and may be grossly bloody. Diarrhea lasting more than 10 days suggests another

The endocardium,
diagnosis. [6]
arteries, CNS (more commonly in infants), lungs, bones, joints, muscles, soft tissues, reticuloendothelial system,
kidneys, and genital regions have all been documented sites of extraintestinal infection.
Chronic carrier state

Chronic carrier state is defined as Salmonella in the stool or urine for greater than 1 year.

A chronic carrier state occurs in 0.2-0.6% of patients with nontyphoidSalmonella.[6]

A chronic carrier state occurs in 1-4% of patients with untreated typhoidSalmonella.

6
 H. GIARDIASIS

The vast majority of symptoms are GI in nature.

 Gastrointestinal
o J. LIAC DISEASE
A small number of persons develop abrupt onset of explosive, watery diarrhea, abdominal cramps, foul flatus, vomiting, fever, and
malaise; these symptoms last 3-4 days before transition into the more common subacute syndrome.
o Most patients experience a more insidious onset of symptoms, which are recurrent or resistant.
o Stools become malodorous, mushy, and greasy. Watery diarrhea may alternate with soft stools or even constipation. Stools do not
contain blood or pus because dysenteric symptoms are not a feature of giardiasis.
o Signs and GI
Upper symptoms
symptoms, often exacerbated by eating, accompany stool changes or may be present in the absence of soft stools. These
include upper and midabdominal cramping, nausea, early satiety, bloating, sulfurous belching, substernal burning, and acid indigestion.
One of the oft-quoted, key traits of ischemic colitis is "pain out of proportion to physical findings", specifically excruciating abdominal pain despite
 limited
Constitutional symptoms
focal tenderness.
o Anorexia, fatigue, malaise, and weight loss are common.
o Three
Weight loss occurs
progressive in of
phases more than colitis
ischemic 50% of patients
have and averages 10 pounds per person.
been described
o Chronic illness may occur with adults presenting with long-standing malabsorption syndrome and children with failure to thrive.
 A Lactose
hyperactive phase occurs first, in which the primary symptoms are severe abdominal pain and the passage of bloody stools. Many patients get better
intolerance
and do not progress beyond this phase.
 Miscellaneous: Unusual presentations include allergic manifestations such as urticaria, erythema multiforme, bronchospasm, reactive
A paralytic phase can follow if ischemia continues; in this phase, the abdominal pain becomes more widespread, the belly becomes more tender to the
touch, and bowel motility decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.
J.ISCHAEMIC COLITIS
Finally, a shock phase can develop as fluids start to leak through the damaged colon lining. This can result in shock and metabolic
acidosis with dehydration, low blood pressure, rapid heart rate, and confusion. Patients who progress to this phase are often critically ill and
require intensive care.

Symptoms of ischemic colitis vary depending on the severity of the ischemia. The7most common early signs of ischemic colitis include abdominal
pain (often left-sided), with mild to moderate amounts of rectal bleeding. The sensitivity of findings among 73 patients were:[18]

abdominal pain (78%) lower digestive bleeding (62%) diarrhea (38%) Fever higher than 38°C (34%) (38°C equals approximately 100.4°F)

Physical exam abdominal pain (77%) abdominal tenderness (21%)

 K. COELIAC DISEASE

 Gastrointestinal symptoms
o Diarrhea is the most common symptom in untreated celiac sprue and present in 45-85% of all patients. Diarrhea caused by celiac sprue
is due to maldigestion and malabsorption of nutrients. The stools might be watery or semiformed, light tan or gray, and oily or frothy. The
stools have a characteristic foul odor. In infants and young children, extensive diarrhea can lead to severe dehydration, electrolyte
depletion, and metabolic acidosis.
o Malabsorption of ingested fat (steatorrhea) results in the delivery of excessive dietary fat to the large bowel. This results in the
production of hydroxy fatty acids by bacteria, which causes secretion of fluids into the intestine.
o Extraintestinal
Flatulence (28% symptoms
of patients) and borborygmus (35-72% of patients) results from the release of intestinal gas by the bacterial florae
o Anemia (10-15%
feasting on undigested of patients) is usually due
and unabsorbed foodtomaterials
impaired and
absorption of iron orexcessive
often becomes folate from orthe
evenproximal small intestine. In severe celiac
explosive.
o disease
Weight with(present
loss ileal involvement,
in 45% ofabsorption
all patients)of vitamin B-12
is variable might be
because impaired.
some patients might compensate for the malabsorption by increasing
o A bleeding
dietary diathesis
intake. is usually
In infants caused
and young by prothrombin
children deficiency
with untreated celiac due to impaired
sprue, failure to absorption of fat-soluble
thrive and growth vitamin
retardation areK.common.
oo Osteopenia
Weakness and
and osteoporosis
fatigue (prevalence
(prevalence 78-80%)1-34%) mightrelated
are usually cause tobone pain poor
general for several reasons,
nutrition. In someincluding defective
patients, calcium can
severe anemia transport by
contribute
tothe diseased
fatigue. small intestine,
Occasionally, vitamin
severe D deficiency,
hypokalemia due toand
the binding of luminal calcium
loss of potassium andcan
in the stool magnesium to unabsorbed
cause muscle weakness. dietary fatty acids.
oo Neurologic
Severe symptoms
abdominal pain(frequency
(prevalence8-14%)
34-64%) thatisresult from
unusual in hypocalcemia include motor weakness,
patients with uncomplicated celiac sprue.paresthesias with sensory
However, abdominal loss, or
bloating and
ataxia. with
cramps Seizures might malodorous
excessive develop because
flatus of
is cerebral
a common calcifications.
complaint.
o Skin disorders, including dermatitis herpetiformis (a pruritic papulovesicular skin lesion involving the extensor surfaces of the
extremities, trunk, buttocks, scalp, and neck), is associated in 10-20% of patients with celiac disease.
o Hormonal disorders, such as amenorrhea, delayed menarche, and infertility in women and impotence and infertility in men, have been
described.

6. IBS
7. VIRAL GASTROENTERITIS
8. COELIAC Ds
9. PSEUDOMEMBRANOUS COLITIS
10. SALMONELLA

Emq 3 RHEUMATOLOGY
11) I

SCLERODERMA (AKA SYSTEMIC SCLEROSIS)

An autoimmune disorder characterized by widespread small vessel fibrosis secondary
to overproduction of collagen and other extracellular matrix proteins.
SIGNS AND SYMPTOMS

8
_ Raynaud’s phenomenon (vasospasm of arteries in hands in response to
cold or emotional stress, resulting in discoloration of hands)
_ Thickened, tight skin
_ Nailfold capillaries––giant loops formed by abnormal capillaries at nailfold
_ Dysphagia due to esophageal fibrosis
_ Renal artery fibrosis
_ Pulmonary hypertension
_ Telangiectasias
_ Cardiac conduction disease/pericardial effusion
In the limited form of the disease symptoms are generally limited to the
CREST syndrome:
Calcinosis (calcium deposition forming nodules)
Raynaud’s phenomenon
Esophageal dysmotility
Sclerodactyly (stiffness of skin of fingers)
Telangiectasias
LABORATORY
_ ANA positive in 95%
_ Anti SCl-70 (topoisomerase antibody)
_ Antibody to centromere––specific to CREST variant
_ Antibody to nucleolar Ag
_ Normochromic, normocytic anemia
_ Elevated ESR
_ Decreased vital capacity on pulmonary function tests (restrictive lung
disease)
TREATMENT
_ Penicillamine—may inhibit collagen cross-linking
_ Captopril—helps control the renal hypertension
_ Calcium channel blockers—diminish the Raynaud’s phenomenon
_ Steroids—rarely effective in altering the disease course

12) L

TAKAYASU’S ARTERITIS
An arteritis of unknown (possibly autoimmune) etiology that is seen commonly
in young people of Asian descent; usually affects medium and largesized
arteries. More common in women.
SIGNS AND SYMPTOMS
_ Loss of pulses in arms and carotids bilaterally
_ Raynaud’s phenomenon
_ Signs of transient brain ischemia such as blindness and hemiplegia
_ Abdominal pain, atypical chest pain
DIAGNOSIS
_ Arteriography shows narrowing of aorta +/– aneurysm.
_ MRA is helpful if arteriography is not available.
TREATMENT
_ Steroids

9
_ Methotrexate

13) J

SJÖGREN’S SYNDROME
A lymphocytic infiltrate in salivary and lacrimal glands causing decreased secretions
from these glands
ETIOLOGY
_ Autoimmune
_ Found in many with coexisting connective tissue diseases (any)
SIGNS AND SYMPTOMS
_ Dry mouth, dry eyes
_ Can have any symptoms associated with other CTDs
LABS
_ + RF in 90%
_ + ANA in 70%
_ + La (SSB) in 40 to 50%
_ DR3 association
DIAGNOSIS
_ Lip biopsy of minor salivary glands
_ By symptoms
TREATMENT
_ Treat symptoms
_ Corticosteroids

14) G

REITE R’S SYNDROME AND REACTIVE ARTHRITIS

An HLA-B27 associated syndrome involving the musculoskeletal, GU, and
ocular systems. Occurs in two forms:
1. Sexually transmitted (1 to 2 weeks after exposure); more common in
men
2. Postdysentery (most commonly due to Salmonella, Shigella, Yersinia,
and Campylobacter) form more common in women and children
SIGNS AND SYMPTOMS
_ Conjunctivitis
_ Urethritis/cervicitis
_ Arthritis: Asymmetric, lower extremities
_ Oral ulcerations
_ Balanitis
LABORATORY
_ Elevated ESR
_ Urethral culture may reveal C. trachomatis.
TREATMENT
_ NSAIDs for arthritis
_ Doxycycline for urethritis/cervicitis

10
15) E
Clinical syndrome characterized by aching and stiffness of the shoulder and hip girdle muscles affecting
older patients, associated with an elevated erythrocyte sedimentation rate, lasting >1 month, and
responsive to low-dose steroids.
Risk factors: Age >50 years, Presence of giant-cell arteritis

CHURG–STRAUSS DISEASE
Medium vessel arteritis, also known as allergic angiitis and granulomatosis; it
is very similar to PAN except that the pulmonary findings predominate.
SIGNS AND SYMPTOMS
_ Bronchospasm (asthma)
_ Eosinophilia
_ Fever
_ Erythematous maculopapular rashes, palpable purpura, and cutaneous
nodules
_ Red casts in urine
TREATMENT
Steroids; if steroids fail, consider azathioprine and cyclophosphamide.

POLYMYOSITIS AND DERMATOMYOSITIS

_ Connective tissue disease causing proximal muscle weakness.
_ Associated with HLA-DR3
_ Dermatomyositis has similar manifestations to polymyositis plus skin involvement.
ETIOLOGY
Unknown; many viruses implicated (coxsackie, influenza)
SIGNS AND SYMPTOMS
_ Weakness first occurring in legs
_ Difficulty with squatting, kneeling, rising from chair, climbing stairs
_ Dysphagia
_ Abnormal ECG (with advanced disease)
_ With dermatomyositis: Purple-red papular/scaly photosensitive rash on
face, neck (“V sign,” “shawl sign”); erythema, scaling on extensor surfaces
of joints (Gottron’s papules; very specific); periorbital edema, heliotropic
rash
DIAGNOSIS
Four criteria:
1. Muscle weakness
2. Increased creatine phosphokinase (CPK)/aldolase
3. Muscle biopsy showing T-cell infiltrate with myonecrosis
4. EMG shows myopathy: Decreased amplitude, increased spike amplitude
LABS
_ Positive antinuclear antibody (ANA)
_ Elevated CPK, LDH, AST, aldolase
_ ESR is elevated in only ~50% of cases.
_ One-third have myositis-specific antibodies (see below).
_ CXR may show interstitial pulmonary disease.
MYOSITIS-SPECIFIC ANTIBODIES

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_ Anti-Jo: One third with pure myositis
_ Anti-Mi2: Dermatomyositis specific

HEADACHE OF TEMPORAL (GIANT CELL) ARTERITIS

Idiopathic inflammation of medium and large arteries, usually the temporal
artery, histologically characterized by giant multinucleated cells
ETIOLOGY
Thought to be part of a systemic vasculitis that has gone undetected except
for the temporal and ophthalmic artery involvement
EPIDEMIOLOGY
More common in women and persons older than 60
SIGNS AND SYMPTOMS
_ Unilateral headache in distribution of temporal artery
_ Thickened, tender temporal arteries
_ Ipsilateral visual loss (ophthalmic artery)
Claudication of the masseter, temporalis, and tongue muscles
_ Scalp tenderness
_ Pulsating temporal artery, also sometimes nodular
DIAGNOSIS
_ High erythrocyte sedimentation rate (ESR), C-reactive protein
_ Definitive diagnosis by temporal artery biopsy
_ Anemia is frequently seen.
TREATMENT
_ Corticosteroids as soon as suspected; can lead to blindness if treatment
is delayed
_ NSAIDs for pain relief

EMQ 4 THERAPEUTICS

16) H

Furosemide or frusemide- a loop diuretic

considered ototoxic: "usually with large parenteral doses and rapid administration and in renal
impairment" and cause low potassium levels (hypokalemia).

17) G

Enalapril is an angiotensin converting enzyme (ACE) inhibitor used in the treatment of hypertension
Most common side effects include hypotension, dizziness when standing up, and dry cough. Switch to
ARB

18) C

Bendrofluazide – thiazide diuretic

12
Common adverse effects

 postural hypotension
 hyponatraemia, hypokalaemia, hypercalcaemia

 gout

 impaired glucose tolerance

 impotence

Rare adverse effects: thrombocytopenia ,agranulocytosis, photosensitivity rash, pancreatitis

19) I

GTN commonly causes headaches by causing vasodilation of brain vessels. This usually settles on its own.

20) J

EMQ 5
Pheochromocytoma- acute hypertensive crises may occur before or during surgery, and should be
treated with intravenous nitroprusside, nicardipine, or phentolamine

Azotemia- characterized by high levels of urea and creatinine, and other nitrogen rich compounds.
Associated with a decrease in gfr and renal failure. 3 classifications. altered BUN:Cr ratio can be used to
determine the type, normal is 15.

Pre-renal azotemia- caused by shock, decreased cardiac output, renal artery stenosis(causes which
decrease blood flow..causes of prerenal failure). BUN:cr >20

Renal Azotemia- intrinsic disease of the kidney, causes, ATN, nephrotoxins, drugs(aminoglycosides,
amphotericin b, tetracyclines) radiological contrast agents, uric acid crystals, haemoglobinuria(other
causes of intrinsic renal filure). ratio less than 10

Postrenal azotemia- raito is >15, causes due to urinary tract obstruction, ureter, bladder stones,
pregnancy, bph.

Signs and symptoms-oliguria, fatigue, asterisix, tachycardia, pale skin, edema, vomiting, nausea.

Hypercalcemia- abd pain, vomiting, constipation, polyuria, polydipsia, depression, anorexia, weight
loss, tiredness, weakness, hypertension, confusion, renal stones, pyrexia, renal failure, corneal
calcification.

causes- most common malignancy, primary hyperparathryoidsm. sarcoidosis, vit d intoxication, benign
hypocalciuric hypercalemia.

13
treatment- treat underlying cause, if greater than 3.5 mmol/l and severe abd pain pyrexia or confusion.

1. measure u&e, mg, cr, ca, po4, alk phos.

2. rehydrate with ivi .9% saline,

3. diuretics- furosimide 40 mg/12h po/iv once rehydrated avoid thiazides

4.steroids- prednisolone 40-60 mg/d occasoinally for saccoidosis.

chemo may decrease calcium in malignant disease.

Hypercapnia- usually associated with type 2 resp failure where there is lowered 02 and elevates
pac02, causes by alveolar hypoventilation, with or without v/q mismatch

causes

pulmonary disease- asthma, copd, pneumonia, pulmfibrosis, obstructive sleep annoea.

Reduced resp drive- sedative drughs, cns tumor or trauma.

neuromuscular disease- cervical cord lesion, diaphragmatic paralysis, polio, mg, guilllian barre

thoracic wall disease- flail chest

signs and symptoms- dyspnoea, restlesness, agitation, confusion, central cyanosis, headache, peripheral
vasodilation, boundgin pulse, tremor, flap, coma. long standing hypoxia, polycytemia, pul htn, cor
pulmonale.

Hyperkalemia- k >6.5mmol/l , needs urgent treatment.

Signs and symptoms- arrhythmias, sudden death, ECG- tall tented t waves, small p waves, wude qrs
complex, VF

Causes-oliguric renal failure, k sparing diuretics, rhabdo, metabolic acidosis, haemolysis, excess k
therapy, addison's disease, massive blood transfusion.

Treatment

1. 10 ml of 10%ca gluconate iv over 2 mins, for cardioprtection

2. 20 u of soluble insulin and 50 ml of 505 glucose iv

3. can use nebulized salbutamol.

4. Polystyrene sulfonate resin, 15g/8hr

14
5.Dialysis

Hypernatremia
Signs and Symptoms- thirst, confusion, coma, fits, signs of dehydration, dec skin turgor, post hypo,
oliguria if water deficient.

Causes- fluid loss without water replacement(vomiting, diarrhoea, burns), incorrect iv fliuds, diabetes
insipidus, osmotic diuresis, primary aldosteronism.

Treatment- water orally if possible, if not dext 5% iv slowly 4l/24hr, guided by urine output and plasma.
some recommend .9% saline as this causes less fluid shifts and is hypotonic in a hypernatremic patient.

Hypocalcemia
signs and symptoms- tetany, depression, perioral paraesthesiae, carpo-pedal spasm(trousseau's sign),
chvostek's sign, cataract if chronic, ecg qt interval increased.

Causes- thryoid or parathryoid surgery, if po4 raised then either chronic renal failure, hypoparathroidsm,
or acute rhabdo, if po4 normal id decrease, either osteomalacia, over hydration or pancreatitis. in rep
alkalosis the total ca may be normal but ionized ca may be dec and can present because of this.

treatment- if mild give ca 5mmol/6hr po, daily ca level, if chronic renal failure, vitd analogues and ca
supplements . if symptoms are sever add 10 ml 10% ca gluconate(2.225mmol) iv over 30 mins.

Hypocapnia- reduce c02 levels in blood, usually due to hyperventilation,

signs and symptoms- hypocapnia causes cerebral vasoconstriction, leading to cerebral hypoxia and this
can cause transient dizziness, visual disturbances, and anxiety. A low partial pressure of carbon dioxide in
the blood also causes alkalosis (because CO2 is acidic in solution), leading to lowered plasma calcium ions
and nerve and muscle excitability. This explains the other common symptoms of hyperventilation pins
and needles, muscle cramps and tetany in the extremities, especially hands and feet.

Because the brain stem regulates breathing by monitoring the level of blood CO 2, hypocapnia can
suppress breathing to the point of blackout from cerebral hypoxia.

Hypokalemia- if k <2.5mmo/l urgent treatment required.

Signs and symptoms- muscle weakness, hypotonia, arrthmias, cramps, tetany, small or inverted t waves,
prominent u wave, prolonged pr interval, depressed st segment.

Causes- diuretics, vomiting, diarrhoea, pyloric stenosis, villous adenoma rectum, intestinal fistulae,
cushing syndrome, conn's syndrome, alkslosis, purgative abuse, renal tubular failure.

if on diuretics inc bicarb indicates that the hypokalemia is longstanding.

15
Magnesium may be low and may have to be corrected first before k levels.

Treatment- if mild, >2.5mmol/l and no symptoms give oral k supp. if taking thiazide diuretic,
hypokalemia >3mmol/l rarely needs treating.

if severe <2.5 and or dangerous symptoms, give iv K cautiously, not more than 20mmol/h and not more
conc than 40mmol/l, do not give k if oliguric.

NEVER give k as a fast bolus dose

Hyponatremia-

Causes- addisons, renal failure, diuretic excess, osmolar diuresis, diarrhoea, vomiting, fistulae, burns,
villous adenoma, small bowel obs, trauma, cystic fribosis, SIADH, water overload, nephrotic syndrome,
cardiac failure, liver cirrhosis, renal failure.

management- base treatment on symptoms, duration, state of hydration, i fpossible correct underlying
cause. if chronic, fluid restriction, or cautious rehydration with with saline. if symptomatic, saline may be
given, but do not correct changes too rapidly.

Hypervolaemic hyponatremia- treat underlying disorder, in emergency(seizures, coma), consider ivi of .

9% saline or hypertonic solution, aim for a gradual inc in sodium.

SIADH- diagnosis conc urine Na >20mmol/l, osmolality>500mosmol/kg in the presence of

hyponatremia<125mmol/l or low plasma osmolality<260mosmol/kg. treat cause, fluid restrict,
occasionally demeclocycline.

Hpoxemia-Pa02 <60mmhg Hypoxemia is different from hypoxia, which is an abnormally low oxygen
availability to the body or an individual tissue or organ, hypoxia can be caused by hypoxemia, and is
causes hypoxemic hypoxia.

Metabolic acidosis- ph dec, bicarb dec, to help diagnose work out anion gap(difference between
plasma cations and anions, normal is 10-18 mmol/l. anion gap can be inc or normal

causes with inc anion gap- latic acid from shock, infection, hypoxia, urate, ketones(dm, alcohol),
drugs and toxins(salicylates, biguanides, ethylene gycol, methanol)

causes with normal anion gap- renal tub acidosis, diarrhoea, acetazolamide(drugs), addison's
disease, pancreatic fistulae, nh4cl ingestion.

Metabolic alkalosis- inc pH, in bicarb causes vomiting, k depletion, burns, ingestion of a base.

Resp acidosis- de ph, inc co2, any cause of resp failure

16
21, ans hypoxemia, well they said the most likely abnormality and b4 u get the hypercapnia and the resp
acidosis, u wil get hypoxemia, rem the diff bet hypoxia and hypoxemia? well hypoxia is a term referred
to when there is low oxygen availability in the body, when it is due to a resp cause it is termed hypoxic
hypoxemia or hypoxemia... confusing eh, i duno where they does come up with this shit.

22. ans metabolic acidosis, well if u calculate her anion gap it is elevated, and one of the causes of an inc
anion gap is metabolic acidosis/ lactic acidosis, and she has an infn which causes that.

23. this one was real hard i not sure, i pick azotemia because the mother nipples sore, prob cause the
baby trying real HARD to get some milk and he getting none, plus he aint making any saliva and he
lethargic. i not exactly sure about the sig of the jaundice, but i know physiologic jaundice does occur at
around 3 days , it could be that or it could be due to the dehydration(ent in them smallies anything does
cause jaundice??)

24. this child mother jam she with ah overdose of furosimide, that causes hypokalemia right, poor child
mother prob is ah pscy case, who knows? anyhow ans=hypokalemia

25. wel i tink she had d neurogenic diabetes insipidus , prob from trauma from the surgery, those damn
neurosurgeons, so the ans i put is HYPERNATREMIA.

ok ah dun dey

EMQ 6- Upper Resp Tract Infections

(Sorry but I’m not sure about some of the answers. Feel free to change and
forward to everyone if anyone knows the definite answer)

26- E?
27- D
28- A?
29- I
30- K?

A- Peritonsillar abscess

Causes acute upper airway obstruction. Complication of tonsillitis.

Age >10 yrs, location- oropharynx, etiology- group A strep/ anaerobes, C/F- biphasic with
sudden wheezing, no stridor, no retractions, muffled voice, normal position and appearance,
drooling, trismus (inability to open mouth fully), no barking cough, dyspnoea, pyrexia,
leucocytosis with left shift. Treat with antibiotics; aspiration.

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B- Acute pharyngitis (sore throat)

Usually due to viral infection (adenoviruses, enteroviruses, rhinoviruses). In older child, think
group A beta hemolytic strep.
C/F- cough, sore throat, dysphagia, fever. Some patients exhibit stigmata of scarlet fever-
circumoral pallor, strawberry tongus and a fine diffuse erythematous macular papular rash.
Signs- inflamed pharynx and soft palate (petechiae or donut shaped lesions), enlarged and tender
local lymph nodes.
Most episodes resolve uneventfully. If strep pharyngitis, may give penicillin or if allergic,
erythromycin.

C- Acute sinusitis (usually ethmoid- present at birth)

Suppurative infection that often complicates the common cold or allergic rhinitis. May occur
with viral URTIs, with occasional secondary bacterial infection. Note- frontal sinusitis
uncommon in first decade of life since it has not developed yet. Maxillary sinuses are
pneumatized at 4 years. Sphenoid sinuses present by 5 years. Bacteria include strep pneumoniae,
non typable H influenzae and moraxella catarrhalis. Risk factors- cystic fibrosis,
immunodeficiency, intubation, nasal polyps, nasal foreign body.
C/F- persistent mucopurulent unilateral or bilateral rhinorrhea, nasal stuffiness, and cough
especially at night. May exacerbate asthma. Plain film and CT may reveal sinus clouding,
mucosal thickening or an air fluid level.
Rx- amoxicillin x 7 days.
Complications- orbital cellulitis, epidural or subdural empyema, brain abscess, dural sinus
thrombosis, osteomyelitis of frontal sinus (Pott puffy tumour) and meningitis.

D- Acute epiglottitis

Risk of sudden airway obstruction.

Age: 1-6 years, caused by H influenzae type b, acute onset with high fever in ill toxic looking
child, intensely painful throat that prevents child from speaking or swallowing, salive drrols
down from chin, soft inspiratory stridor, child sits immobile, upright in tripod position with an
open mouth to optimize the airway in sniffing position.
Do not lie child down, examine throat with spatula or do a lateral neck XRay (but will show
thumb sign- thickened and bulging epiglottis).
Rx- may need intubation, take blood for culture, give 2nd or 3rd gen cephalosporin.
Prophylaxis with rifampicin to close household contacts.

E- Laryngotracheobronchitis (croup)

Most common infection of middle resp tract. Age- 6 months to 6yrs, peak in 2nd yr.
Cause- parainfluenze viruses, RSV and influenza.
Edema of subglottic area is potentially dangerous(steeple sign on AP radiograph of neck).
C/F- barking cough, harsh stridor and hoarseness usually preceded by fever and coryza.

18
Rx- warm humidified oxygen/oral dexamethasone/ nebulized steroids/ nebulized adrenaline.

F- Tonsillitis

A form of pharyngitis. Common pathogens are Group A BHS and EBV but viruses are more
common.

G- Pertussis (whooping cough)

Highly infectious form of bronchitis caused by bordetella pertussis (gram-ve pleomorphic

bacillus). Peak age: < 4 months.
Follows 2-3 days of coryza with characteristic inspiratory whoop. Spasms of cough are usually
worse at night and may end in vomiting. Child goes red or blue in the face and mucus flows from
the nose and mouth. 3 stages- catarrhal stage (non specific stage), paroxysmal stage (cough),
covalescent stage (gradual resolution).
Complications- pneumonia, convulsions, bronchiectasis.
No specific treatment but erythromycin eradicates the organism.

H- Acute tracheitis (pseudomembanous croup)

Usually caused by staph aureus or H influenzae. Similar to viral croup except that child has high
fever, appears toxic and has rapidly progressive airways obstruction.

I-Coryza (common cold)

Commonest pathogen are viruses (rhinoviruses, coronaviruses, RSV).

C/F- clear or mucopurulent nasal discharge and nasal blockage.
Self limiting, may use paracetamol for fever and pain.

J- Otitis media

Peak incidence in second 6 months of life.

Risk factors- young age, bottle feeding, drinking a bottle in bed, parental hx of ear infection,
passive exposure to tobacco smoke, daycare, children with HIV, cleft palate, trisomy 21.
Pain in ear, otorrhea, fever ,irritability, poor feeding. . Bright red bulging tympanic membrane
with loss of the normal light reflex. Pathogens include viruses, pneumococcus, group A BHS, H
influenzae, moraxella catarrhalis.
Rx- amoxicillin or augmentin.

K- Diptheria

Caused by Corynebacterium diphtheriae.

19
Usually attacks the throat and nose. In more serious cases, it can attack the heart and nerves.
Very contagious and potentially life-threatening.
It is characterized by sore throat, low fever, and an adherent membrane (a pseudomembrane) on
the tonsils, pharynx, and/or nasal cavity.

L- Oral candidiasis (thrush)

Common in health neonates. May suggest immunodeficiency, broad spectrum antibiotic use,
diabetes. May be sometimes painful and interfere with feeding.
Rx- topical nystatin or azole antifungal agents.

EMQ 7. IMMUNIZATION

Hepatitis A The vaccine, called Havrix or VAQTA, is made from inactivated whole
(inactivated) virus of hepatitis A. The inactive virus stimulates your body to
produce antibodies to fight the hepatitis A virus. The vaccine is given by a
shot in your arm. You should be protected against the disease within 2
weeks after receiving the first dose. Two vaccinations are needed to make
sure you are completely protected against the disease. After receiving the
first vaccination, children and adults should have a booster vaccination in
6 to 12 months. A vaccine for adults called Twinrix provides protection
against both hepatitis A and B. It is given in 3 doses. WHO SHOULD
RECEIVE THIS VACCINE ? People who work or travel in areas with
high rates of infection should be vaccinated. If you have had hepatitis A in
the past, you do NOT need the vaccine. Once you have recovered from the
disease, you are immune for life.
Diphtheria, _Given at 2, 4, and 6 months of age, then another between 12 and 18
Tetanus, and months of age.
Pertussis _ Given IM.
(inactivated) _ Allow 6 months between third and fourth doses.
CONTENT
_ DTaP is diphtheria and tetanus toxoids with acellular pertussis.

20
 _ DTP contains a whole-cell pertussis.
SIDE EFFECTS
_ Erythema, pain, and swelling at injection site
_ Fever
_ Anaphylaxis in 1/50,000
CONTRAINDICATIONS
_ Anaphylactic reaction to vaccine or another vaccine constituent
_ Encephalopathy not attributable to another cause within 7 days of a
prior dose of pertussis vaccine
Yellow fever consists of a live, but attenuated, strain of the yellow fever virus called
17D. The 17D vaccine has been used commercially since the 1950s. The
(live mechanisms of attenuation and immunogenicity for the 17D strain are not
attenuated) known. However, this vaccine is very safe, with few adverse reactions
having been reported and millions of doses administered, and highly
effective with over 90% of vaccinees developing a measurable immune
response after the first dose. he majority of adverse reactions to the 17D
vaccine result from allergic reaction to the eggs in which the vaccine is
grown. Persons with a known egg allergy should discuss this with their
physician prior to vaccination. In addition, there is a small risk
of neurologic disease and encephalitis, particularly in individuals with
compromised immune systems and very young children. The 17D vaccine
is contraindicated in infants, pregnant women, breast-feeding
women[5] and anyone with a diminished immune capacity, including those
takingimmunosuppressant drugs.
Haemophilus _ Given at 2, 4, and 6 months of age, then again between 12 and 15
influenzae Type months of age
B _ Given IM
(subunit) CONTENT
Consists of a capsular polysaccharide antigen conjugated to a carrier.
SIDE EFFECTS
Erythema, pain, and swelling at injection site in 25%.
CONTRAINDICATIONS
Anaphylactic reaction to vaccine or vaccine constituent.
Measles, _ First dose given at 12 to 15 months of age, then again at 4 to 6 years of
Mumps, and age.
Rubella _ Given SC (subcutaneously).
_ Second dose may be given at any time after 4 weeks from first dose if
(live necessary.
attenuated) _ Must be at least 12 months old to ensure a sufficient response.
CONTENT
Composed of live attenuated viruses.
SIDE EFFECTS
_ Fever 102.9F (39.4C) 7 to 12 days after immunization in 10%
_ Transient rash in 5%
CONTRAINDICATIONS
_ Anaphylactic reaction to prior vaccine

21
 _ Anaphylactic reaction to neomycin or gelatin
_ Immunocompromised states
_ Pregnant women

Meningococcal Neisseria meningitidis has 13 clinically significant serogroups. These are

(subunit) classified according to the antigenic structure of their polysaccharide
capsule. Six serogroups, A, B, C, Y, W135 and X are responsible for
virtually all cases of the disease in humans. Quadrivalent (Serogroups A,
C, W-135 and Y). There are currently three vaccines available in the US to
prevent meningococcal disease, all quadrivalent in nature, targeting
serogroups A, C, W-135 and Y:

 two conjugate vaccines (MCV-4), Menactra and Menveo, and

 one polysaccharide vaccine (MPSV-4), Menomune

The duration of immunity mediated by Menomune (MPSV4) is three

years or less in children aged under 5 because it does not generate memory
T cells.Attempting to overcome this problem by repeated immunization
results in a diminished not increased antibody response, so boosters are
not recommended with this vaccine.As with all polysaccharide vaccines,
Menomune does not produce mucosal immunity, so people can still
become colonised with virulent strains of meningococcus, and no herd
immunity can develop. For this reason, Menomune is suitable for travelers
requiring short-term protection, but not for national public health
prevention programs.
Poliomyelitis _ Given at 2 and 4 months, then again between 6 and 18 months, then a
fourth between 4 and 6 years of age
(can be _ IPV given SC
inactivated or _ OPV given orally
live) CONTENT
_ Inactivated poliovirus vaccine (IPV) contains inactivated poliovirus
types 1, 2, and 3.
_ Live oral poliovirus vaccine (OPV) contains live attenuated poliovirus
types 1, 2, and 3.
SIDE EFFECTS
_ Vaccine associated paralytic polio (VAPP) with OPV in 1/760,000.
_ With prior IPV risk is reduced by 75–90%.
CONTRAINDICATIONS
_ Anaphylaxis to vaccine or vaccine constituent
_ Anaphylaxis to streptomycin, polymixin B, or neomycin
Varicella _ Given once between 12 and 18 months of age.
_ Given SC.
(live) _ Susceptible persons 13 years of age must receive two doses at least 4
weeks apart.
CONTENT
Cell-free live attenuated varicella virus.

22
 SIDE EFFECTS
_ Erythema, swelling, and redness in 20–35%
_ Fever in 10%
_ Varicelliform rash in 1–4%
CONTRAINDICATIONS
_ Anaphylactic reaction to vaccine, neomycin, or gelatin
_ Patients with altered immunity, including corticosteroid use for > 14
days
_ Patients on salicylate therapy
_ Pregnant women
_ Recent blood product or IG administration (defer at least 5 months)
Influenza _ Given to children 6 months of age yearly beginning in autumn,
usually
(subunit) between October and mid-November.
_ Given IM.
_ All children should receive this vaccine, especially high-risk children.
CONTENT
_ Contains three virus strains, usually two type A and one type B, and
can be an inactivated whole-virus vaccine or a “split” vaccine containing
disrupted virus particles.
_ Children 9 years of age should receive the “split” vaccine only.
_ Children without exposure to influenza should receive two vaccines 1
month apart in order to obtain a good response.
SIDE EFFECTS
_ Pain, swelling, and erythema at injection site.
_ Fever may occur, especially in children 24 months of age.
_ In children 13 years of age, fever may occur in up to 10%.
CONTRAINDICATIONS
Children with anaphylactic reactions to chicken or egg protein.
Pneumococcus _ Babies receive three doses (shots) 2 months apart starting at 2 months,
and a fourth dose when they are 12 to 15 months old.
(subunit) _ Also given to high-risk children ≥2 years of age.
_ If the child is 10 years of age, a second dose is recommended 3 to 5
years after the first dose.
_ If the child is 10 years of age, then a second dose is recommended 5
years after the first.
CONTENT
The older PPV-23 vaccine (not indicated under age 2) contains the
purified
capsular polysaccharide antigens of 23 pneumococcal serotypes. The PPV-
23
is usually reserved for high-risk children. The newer PCV-7 is the
conjugate
vaccine described above.
SIDE EFFECTS
_ Erythema and pain at injection site.

23
 _ Anaphylaxis reported rarely.
_ Fever and myalgia are uncommon.
CONTRAINDICATIONS
Usually deferred during pregnancy.
Tetanus used against Clostridium tetani, the agent that causes tetanus. The vaccine
(toxoid) is composed of tetanus toxoid, tetanus toxin inactivated
with formaldehyde, which is immunogenic but not pathogenic. It is a
component of the DPT vaccine.The tetanus vaccine is required again after
10 years if the individual is exposed to possible infection.
Typhoid Types include:
Fever
 Ty21a, which is a live vaccine (ORAL)- used to protect travellers
to endemic countries, but there is no reason why the vaccine could not
be used in large scale public prevention programmes

 Vi capsular polysaccharide vaccine, which is a subunit vaccine (ID

or IM) - used in endemic areas in order to prevent typhoid. It is also
commonly used to protect people who are traveling to parts of the
world where typhoid is endemic.

Based on above, the answers are:

31- D
32- H
33- A
34- I 35- E
EMQ # 8 : PERSONALITY DISORDERS
TYPE PERSONALITY IMPORTANT POINTS
DISORDER
A Paranoid have a pervasive distrust and suspiciousness of others and
Personality often interpret motives as malevolent. They tend to blame
Disorder (PPD) their own problems on others and seem angry and hostile.
DIFFERENTIAL DIAGNOSIS IS Paranoid
schizophrenia: Unlike patients with schizophrenia,
patients with paranoid personality disorder do not have
any fixed delusions and are not frankly psychotic, although
they may have transient psychosis under stressful
situations. Psychotherapy is the treatment of choice. Low-
dose antipsychotics (short course) if transiently psychotic,
or antidepressants if comorbid major depression is
diagnosed
A Schizoid Patients with schizoid personality disorder have a lifelong
Personality pattern of social withdrawal. They are often perceived as
Disorder eccentric and reclusive. They are quiet and unsociable and

24
 have a constricted affect. They have no desire for close
relationships and prefer to be alone.

A Schizotypal Patients with schizotypal personality disorder have a

Personality pervasive pattern of eccentric behavior and peculiar
Disorder thought patterns. They are often perceived as strange and
eccentric.
Can have magical thinking that may include:
_ Belief in clairvoyance or telepathy
_ Bizarre fantasies or preoccupations
_ Belief in superstitions
Odd behaviors may include involvement in cults or
strange religious practices. Chronic patients can develop
schizophrenia.
Treatment of choice is Psychotherapy. Short course of
low-dose antipsychotics if necessary (for transient
psychosis)
B Antisocial Patients diagnosed with antisocial personality disorder
Personality refuse to conform to social norms and lack remorse for
Disorder their actions. They are impulsive, deceitful, and often
violate the law. However, they often appear charming and
normal to others who meet them for the first time and do
not know their history. Psychotherapy is the treatment of
choice. Pharmacotherapy may be used to treat symptoms
of anxiety or depression, but use caution due to high
addictive potential of these patients.

However, these two are not the same. Rather, psychopathy

and sociopathy are generally considered subsets of ASPD.
Some researchers believe that ASPD and psychopathy
may be separate conditions altogether.
Antisocial
personality ASPD and sociopathic personalities are very common
disorder is
sometimes referred (more so than many people realize). A major study by the
to McLean psychiatric hospital in Massachusetts puts the
as psychopathy or occurrence at 1 out of every 25 males and 1 out of every
sociopathy.
30 females. Other studies estimate about 4% of the adult
So psychopathic is
like a subset of population. Most sociopaths or ASPDs never commit
antisocial crimes, although about 70% of prison inmates test positive
for strong ASPD/sociopathic tendencies. Those who never
commit crimes nevertheless show a pattern of doing
tremendous psychological damage to relatives and also in

25
 the workplace. At work they often go undetected for years,
but are often the cause of major psychological distress and
lawsuits. They are known for manipulating (tricking)
superiors and colleagues while victimizing a series of
selected inferiors or perceived rivals. They will also
sometimes go after a superior, if they think they can
succeed.
B Borderline Patients with BPD have unstable moods, behaviors, and
Personality interpersonal relationships. They feel alone in the world
Disorder (BPD) and have problems with self-image. They are impulsive
and may have a history of repeated suicide
attempts/gestures or episodes of self-mutilation.
Psychotherapy is the treatment of choice—behavior
therapy, cognitive therapy, social skills training, and the
like.Pharmacotherapy to treat psychotic or depressive
symptoms as necessary
B Histrionic Patients with HPD exhibit attention-seeking behavior and
Personality excessive emotionality. They are dramatic, flamboyant,
Disorder (HPD) and extroverted but are unable to form long-lasting,
meaningful relationships. They are often sexually
inappropriate and provocative.
Psychotherapy is the treatment of choice.
Pharmacotherapy to treat associated depressive or anxious
symptoms as necessary
B Narcissistic Patients with NPD have a sense of superiority, a need for
Personality admiration, and a lack of empathy. They consider
Disorder (NPD) themselves “special” and will exploit others for their own
gain. Despite their grandiosity, however, these patients
often have fragile self-esteems.
Psychotherapy is the treatment of choice.Antidepressants
or lithium may be used as needed (for mood swings if a
comorbid mood disorder is diagnosed).
C Avoidant Patients with avoidant personality disorder have a
Personality pervasive pattern of social inhibition and an intense fear of
Disorder rejection. They will avoid situations in which they may be
rejected. Their fear of rejection is so overwhelming that it
affects all aspects of their lives. They avoid social
interactions and seek jobs in which there is little
interpersonal contact. These patients desire companionship
but are extremely shy and easily injured.
Psychotherapy, including assertiveness training, is most
effective. Beta blockers may be used to control
autonomic symptoms of anxiety,

26
 and selective serotonin reuptake inhibitors (SSRIs) may be
prescribed
for major depression.
C Dependent Patients with DPD have poor self-confidence and fear
Personality separation. They have
Disorder (DPD) an excessive need to be taken care of and allow others to
make decisions for
them. They feel helpless when left alone. Psychotherapy is
the treatment of choice.
_ Pharmacotherapy may be used to treat associated
symptoms of anxiety
or depression
C Obsessive– Patients with OCPD have a pervasive pattern of
Compulsive perfectionism, inflexibility, and orderliness. They get so
Personality preoccupied with unimportant details that they are often
Disorder (OCPD) unable to complete simple tasks in a timely fashion. They
appear stiff, serious, and formal with constricted affect.
They are often successful professionally but have poor
interpersonal skills. Difference between this and OCD is
OCD patients are aware that they have a problem and wish
that their thoughts and behaviors would go
away.Treatment same as above.
PERSON Passive– Passive–aggressive personality disorder was once a
ALITY Aggressive separate personality disorder
DISORD Personality like those listed above but was relegated to the NOS
ER NOT Disorder category when DSMIV
OTHER was published. Patients with this disorder are stubborn,
WISE inefficient procrastinators.
SPECI They alternate between compliance and defiance and
FIED passively resist
(PDNOS) fulfillment of tasks. They frequently make excuses for
themselves and lack assertiveness.
They attempt to manipulate others to do their chores,
errands,and the like, and frequently complain about their
own misfortunes. Psychotherapy is the treatment of
choice.

DISSOCIATIVE Patients with dissociative identity disorder have

IDENTITY two or more distinct personalities that alternately control
DISORDER their behaviors and thoughts. Patients are often unable to
(MULTIPLE recall personal information. While one personality is
PERSONALITY dominant, that personality is usually (but not always)
DISORDER) unaware of events that occurred during prior personality
states.
DEPENDENT Dependent personality disorder (DPD), formerly known

27
 PERSONALITY as asthenic personality disorder, is a personality
DISORDER disorder that is characterized by a pervasive psychological
dependence on other people. This personality disorder is a
long-term (chronic) condition in which people depend too
much on others to meet their emotional and physical
needs.
Personality changes to a general medical condition eg. Dementia, alzheimers
Based on above, the answers are as follows:

36- D
37- B
38- G
39- H
40- E

MCQS
41: The investigations of dysphagia in a 50-year old man includes all of the following EXCEPT:

(a) Barium swallow

(b) Neurological examination

(c) Upper GI endoscopy

(d) Serum Gastrin: ↑ fasting serum gastrin ( >1000 pg/ml) in Zollinger Ellison Syndrome

(e) Chest X-ray: mediastinal fluid level ( achalasia) , absent gastric bubble ( achalasia), aspiration

For solids which stick
Oesophageal stricture
Confirmation: Barium swallow
and meal, UGI fibreoptic
endoscopy → necrotic ulcer+/₋
ulceration
Ca of the oesophagus
Confirmation: Barium Swallow→
filling defect; UGI endoscopy→
Biopsy
Ca of the cardia of the stomach
Confirmation:Barium swallow→
Solids which do not stick > fluids
Pharyngeal pouch/ pharyngo-
oesophageal diverticulum
Confirmation: Barium swallow→
extraluminal collection
Xerostomia
Clinically confirmed by atrophic
dry oral mucosa, elderly,
Post- cricoid web ( congenital or
Plummer Vincent or Paterson
Dysphagia fluids> solids (implies
neuromuscular as opposed to
obstruction)
Myasthenia Gravis
Confirmation:
Gastrograffin swallow
Response to Tensilon test
↑ Anti- acetylcholine receptor
antibody
Psuedobulbar palsy due to brain
stem stroke, MS, MND.
Confirmation:
Clinical: Neurological Ex
Bulbar palsy
Confirmation: Clincal

28
filling defect; UGI endoscopy→
biopsy
External Oesophageal
compression
Confirmation: Barium swallow→
filling defect; UGI endoscopy→
normal mucosa; CT thorax→
Extrinsic mass from retrosternal
thyroid, neoplasms ( lung or
mediastinal tumors, lymphoma)
Kelly Syndrome) Usually ♀,
severe Fe deficiency anemia
Confirmation: Barium swallow→
thin, horizontal shelf; UGI
endoscopy→ R/O malignancy
Globus pharyngeus
May be 2⁰ laryngopharyngeal
reflux
Confirmation: Oedema seen UGI
endoscopy
neurological Ex with features of
MND/ Guillain-Barre Syndrome/
brain stem tumor/ syringobulbia/
pontine demyleination
Motor Neurone Disease
Confirmation: EMG and nerve
conduction studies
Achalasia
Confirmation: Barium swallow,
Oesophageal manometry,
oesophagoscopy
Diffuse oesophageal spasm
Barium swallow→+/⁻ corkscrew
oesophagus, Manometry→ AbN
P profiles
Scleroderma
Barium swallow→↓/ absent
peristalsis, Manometry: subN/
absent LES tone.

42. 23 yr old ♂; p/c: 6/12 h/o profuse watery diarrhea, night sweats and significant weight loss.

HIV ⁺ve , Stool for blood and pus –ve. What is the most likely aetiological agent for his diarrhea?

(a) Helicobacter Pylori: →Dyspepsia; Diarrhoea is not part of the clinical presentation

(b) Entamoeba Histolytica: presentation may be asymptomatic with mild diarrhea/ severe amoebic
dysentery → ocurrs sometime after initial infection . Diarrhoea begins slowly becoming profuse and
bloody

(c) Isospora Belli: In HIV and diarrohoea think: Cryptosporidia, Microsporidia and Isospora Belli

(d) Salmonella Species: bloody

(e) Shigella: bloody

43. 45 yr old, alcoholic, c/f’s of cirrhosis and portal HTN. p/c: Variceal bleed. O/E: Ascites. What single
test provides early information about the possible presence of ascitic fluid infection?

(a) Ascitic fluid neutrophil count: In cirrhosis an ascetic tap should always be performed and sent for
urgent MC&S → Neutrophils >250/mm 3 indicates spontaneous bacterial peritonitis → this must be

29
considered in any patient with ascites who deteriorates suddenly and may remain asymptomatic.
Common organisms: E. Coli, Kleb, Strep; Rx: Cefotaxime plus metronidazole

(b) Gram stain of the ascetic fluid

(c) Bacterial culture of the ascetic fluid

(d) ascitic fluid pH

(e) Ascitic fluid protein

44. A 35 yr old female textile worker with parity 2⁺0, complains of dyspnoea on the job and her
supervisor is worried. She is given 2-weeks off and finally is able to get an appointment to see you, her
doctor. PR-60bpm, BP- 110/65mmHg, RR-16/min, normal heart sounds, no pedal edema, PEF_
450l/min before salbutamol and 480l/min after salbutamol. Which of the following is most likely to
give the DX?

(a) repeat the lung function test measuring FEV 1 before salbutamol and 20 mins after salbutamol:

PEF which has already been done according to the vignette and is a good correlation of FEV 1 so the
information conveyed by repeating FEV1 would not elucidate to a definitive diagnosis.

(b) Diary card recording a peak flow am and pm over the next 2 weeks. Occupational asthma is asthma
caused by some aspect of the workplace environment. It should be routinely considered in the
assessment of new-onset asthma in a working adult. The patient records peak expiratory flow rate (PEFR)
4 times a day and completes symptom and medication diaries during periods of regular work and periods
off work (e.g., weekends and holidays).

(c) salbutamol inhaler (rescue med! No need)and review in 4 weeks to see if she has further symptoms

(d) CXR

(e) Bronchoscopy

45. A 48 year old smoker presents with crushing central chest pain and dizziness, ECG shows ST
segment elevation in the inferior leads with sinus rhythm and a normal axis. Which drug is most likely
to reduce the risk of fatal arrhythmias in the next 5 days?

(a) ASA

(b) isosorbide dinitrate

(c) atenolol: Class II antiarrhythmic drug (beta blocker); Site of action: ↓ SA nodal and ectopic
pacemaker automaticity, ↓s ventricular rate and ↑AV conductance, ↓HR and contractility (-ve
ionotropic)

(d) ramipril: ACEi

30
(e) nifedipine: Dihydropyridine Ca2+ channel blocker: blocks L-type Ca2+ channels in arteriolar SM→
Vasodilation secondary to ↓TPR ↓BP → dizziness (would exacerbate the patient’s symptoms), flushing,
headache, peripheral oedema, baroreceptor mediated reflex tachycardia. The prototype Class IV
antiarrhythmic Ca2+ channel blockers include verapamil and diltiazem……. NOT NIFEDIPINE!!!!

46. A 75 year old female presents with severe effort dyspnoea, worsening pedal oedema, crepitations
in her chest and a rumbling mid-diastolic murmur at the apex and a loud first heart sound. Which of
the following is NOT likely to be found on further clinical examination?

∆ Mitral Stenosis

(a) Pulsatile liver: Tricuspid regurge

(b)Tapping apex beat (true)

(c) Giant a waves in the JVP (true) : a waves reflect atrial systole and large a waves are seen in
pulmonary stenosis and pulmonary HTN ( which may/ may not be a presentation of MS)

(d) Ascites (true): can be seen with the onset of RSHF secondary to LSHF and pulmonary HTN

(e) Atrial Fibrillation (true): Common in MS and is secondary to L atrial enlargement and dilatation

47 A 36 year old male patient presents with a 4 week h/o pedal oedema and worsening dyspnoea. O/E
his apex beat is in the L 6th ICS, thrusting and there is a blowing decrescendo early diastolic murmur at
the base radiating down the left sternal edge. ( best in expiration with the patient sitting forward)

∆ Aortic regurgitation

The following are likely to be found except:

(a) An early systolic murmur at the base of the heart: DE STUPID QN DESCRIBES THE MURMUR ABOVE

(b) Pulsus paradoxus (true) : an ↑ in sys P on expiration and a ↓ on inspiration with a difference of >
15mmHg

(c) Low diastolic pressure (true): In AR there is a widened pulse pressure with a large difference between
sys and diastolic pressures

(d) Collapsing pulse (true) sys> 160mmHg, Diastolic <50mmHg

(e) Diastollic thrill (true)

Additionally, displaced thrusting ( Rapid movement up out and back) hyperdynamic apex beat ← volume
overload.

31
48 A 30 year old female gives a history of menstrual irregularity and headaches. O/E she has
galactorrhoea. CT scan shows a pituitary macroadenoma. Most likely finding on visual field

examintation is:

(a) R homonymous
hemianopia

(b) L homonymous
hemianopia

(c) Binasal field defect

(d) Bitemporal hemianopia

(e) Quadrantinopia

49. A 40 year old woman presents with increased lethargy, diminishing exercise tolerance over six
months. She was treated for Graves’ disease in the past with radioiodine. She is pale and haemogram
shows

Hemoglobin 6.0g/dl

Mean corpuscular volume 115 fl

White cell count 2.4 *10^9/l

Platelet 50*10^9/l

The most likely diagnosis is: _

a) Pernicious anaemia

b) Anaemia due to menorrhagia

c) Radiation—induced bone marrow disease

d) Autoimmune haemolytic anaemia

. e) Iron deficiency anaemia

Answer: A

This patient has Grave’s disease which is an autoimmune condition and autoimmune conditions can
occur together. Pernicious anemia is caused by an autoimmune atrophic gastritis, leading to achlorhydia
and lack of intrinsic factor secretion. It has a higher incidence in blood group A.

32
It is associated with other autoimmune diseases: thyroid disease (25%), vitiligo, Addison’s disease,
hypoparathyroidism. Blood count shows a macrocytic anemia, white cell count and platelets may be
reduced in severe cases. Reticulocytes are reduced or normal. Other findings include hypersegmented
polymorphs as well as megaloblasts in the marrow.

50. A 70 year old female presents with sudden severe pain in the right eye, with diminished visual acuity
as well as vomiting. The right eye is red, feels tense, and the pupil is dilated. The most likely diagnosis is

A. subarachnoid hemorrhage due to 3 rd nerve palsy

B. acute bacterial conjunctivitis

C. subconjuctival haemorrhage

D. acute glaucoma

E. episcleritis

Answer: D

Acute glaucoma occurs as a result of aqueous humour to pass through the pupil and to crowding of the
anterior chamber angle, preventing aqueous access to trabecular meshwork. It is more common in
patients with hypermetropia. Clinical features include sudden onset of unilateral painful red eye and
blurred vision. The patient may also complain of nausea and vomiting and headaches. The affected eye is
injected, tender and feels hard on examination. The cornea is hazy and the pupil is semi-dilated.

Other options in the question:

A-subarachnoid hemorrhage presents with sudden onset of occipital headache usually followed by
vomiting and often coma and death. It is not associated with ocular pain. Causes of subarachnoid
hemorrhage are as follows:

-Saccular ( berry ) aneurysm 70%

-arteriovenous malformation 10%

-no lesion found 10%

Other rare associations include:

-bleeding disorders’

-mycotic aneurysms

-polycystic kidneys

-Marfan’s syndrome,Ehlers –Danlos syndrome

33
-coarctation of the aorta

-acute bacterial meningitis

B –acute bacterial conjunctivitis manifests as a sticky red eye of acute onset, generally associated with
mild to moderate itching, burning or grittiness and little or no effect on vision. Usually bilateral and the
pupil should be round and normally reactive.

C –subconjuctival hemorrhage-usually results from superficial physical trauma

E –episcleritis-inflammatory condition involving the opaque ocular outer wall of the eye. It presents with
aching and redness with no discharge. Sight is not affected.

51. There is predilection for sites of trauma to become foci of skin disease. Which of the following is
most likely to exhibit this phenomenon?

A. psoriasis

B. tinea vesicolor

C. eczema

D. erythema multiforme

E. scabies

Answer: A

The above statement describes the Koebner phenomenon. It describes skin lesions which appear
at the site of injury. It is seen in

 Psoriasis
 Pityriasis rubra pilaris
 Lichen planus
 Lichen nitidus
 Vitiligo
 Lichen sclerosus
 Elastosis perforans serpiginosa


52. In a 70 year old with recent stroke, the feature most indicative of poor prognosis is:

A. level of consciousness

34
B. density of paresis

C. expressive dyshasia

D. receptive dysphasia

E. dysphagia

Answer: E

53.A 55 year old diabetic of long standing has a BMI of 35 kg/m2, creatinine 500 mmol/l
( reference range 60-100mmol/l) and blood urea 21 ( reference range 3.5-7.0 mmol/l). Which of
the following drug combinations would be most UNSUITABLE for use in this patient?

A. glitazone, acarbose, metformin

B. acarbose, sulphonylurea

C. glitazone, acarbose, sulphonylurea

D. short and intermediate acting insulin

E. glitazone, acarbose

Answer: A

Metformin is contraindicated in people with any condition that could increase the risk of lactic acidosis,
including kidney disorders (creatinine levels over 150 μmol/l (1.7 mg/dL),[46] although this is an arbitrary
limit), lung disease and liver disease.

54. In diabetic nephropathy, all of the following would be of value in preventing decline in renal
function EXCEPT

A. angiotensin converting enzyme inhibitors

B. angiotensin receptor blockade

C. high protein diet

D. treatment of hypercholestrolemia

E. avoidance of non steroidal anti-inflammatory drugs

Answer: C

35
The management of diabetic nephropathy is similar to that of other causes of chronic kidney
disease, with the following provisos:

-Aggressive treatment of blood pressure with a target below 130/80 mmHg has been shown to
slow the rate of deterioration of renal failure considerably. ACE inhibitors or angiotensin
receptor 2 antagonists are the drugs of choice

-avoidance of oral hypoglycemic agents partially excreted by the kidney

- Diet may be modified to help control blood-sugar levels. Modification of protein intake can
effect hemodynamic and nonhemodynamic injury.

- Patients with diabetic nephropathy should avoid taking the following drugs:

 Contrast agents containing iodine

 Commonly used non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and

naproxen, or COX-2 inhibitors like celecoxib, because they may injure the weakened
kidney.

Urinary tract and other infections are common and can be treated with appropriate antibiotics.

55. A diabetic man presents with features of acute left ventricular failure. There is no history of
chest pain. His ECG shows Q waves across the precordial and marked ST elevation in V2-V6.
Which is the most likely diagnosis?

A. viral myocarditis

B. hypertensive heart disease

C. silent myocardial infarction

D. diastolic dysfunction typical of a diabetic heart

E. pericarditis

Answer: C

Approximately one fourth of all myocardial infarctions are silent, without chest pain or other
symptoms. These cases can be discovered later on electrocardiograms, using blood enzyme tests
or at autopsy without a prior history of related complaints. A silent course is more common in the
elderly, in patients with diabetes mellitus and after heart transplantation, probably because the
donor heart is not fully innervated by the nervous system of the recipient. In diabetics,
differences in pain threshold, autonomic neuropathy, and psychological factors have been cited
as possible explanations for the lack of symptoms.

36
56. Concerning polycystic ovarian syndrome, choose the most likely correct answer:

A. associated with cyst in the pancreas and kidneys

B. a forerunner of Type 2 diabetes mellitus

C. a forerunner of premature ovarian failure

D. uncommon in clinical practice in the Carriban

E. a premalignant condition

Answer: B

PCOS is frequently associated with hyperinsulinemia and insulin resistance. The prevalence of
type 2 diabetes is ten times higher than in normal women. It is also associated with hypertension,
hyperlipidaemia and increased cardiovascular disease (metabolic syndrome), which is 2-3 times
higher in PCOS.

57) C- De Quervain’s thyroiditis is a self limiting post-viral thyroiditis with a painful goiter.
There is fever, ↑ESR and shows up as a cold nodule on isotope scan. Tx : NSAIDS.

58) D- Small cell Ca of the lung are ACTH producing tumors. Clinical features are
hyperpigmentation, hypokalemia, met alkalosis, weight loss and hyperglycemia. Classical
Cushing features are absent and dexamethasone is ineffective.

59) C- Homonymous hemianopia can be a complication of a lesion of the optic tract usually
cause by stoke 2◦ to HTN. Thin skin, bruising, muscle weakness (Cushing’s), increasing hand
and foot size, headache (Acromegaly), circumoral numbness, muscle cramp
(hyperparathyroidism) and radioradial delay ( Coarctation of aorta) are all secondary causes of
hypertension.

60) A- Polarized light microscopy of synovial fluid shows birefringement urate crystals a
specific test for gout. Gram stain of joint aspirate is indicative of septic arthritis but there could
be concomitant bacterial infection in gout.

61) C- Alopecia Areata are smooth round patches of hair loss with no scarring of autoimmune
etiology.

62) A- Nephrotic syndrome in longstanding RA patients is commonly related to amyloidosis.

63) D- Hashimoto’s thyroiditis is the most common cause of hypothyroidism. This increasing
surgical treatment for thyroid disease thyroidectomy is the second most common cause.

64) A- Iron supplements interfere with the absorption of thyroxine tablets.

Question 57---------------------------------Answer C
37
de Quervain’s thyroiditis- a transient hyperthyroidism resulting from acute inflammation of the
gland, usually following a viral infection. Accompanied by fever malaise and pain in the neck. Rx-
aspirin and prednisolone for severe cases.

Question 58----------------------------------------------Answer D
Ectopic ACTH production, caused especially by small cell cancer of the lung and carcinoid
tumours. Specific features: hyperpigmentation, hypokalemic metabolic alkalosis, increased
cortisol leading to mineralocorticoid activity, weight loss, hyperglycemia, classical features of
cushings are often absent.

Question 59---------------------------------------Answer C
Causes of secondary hypertension include: renal disease, cushing’s disease, conn’s syndrome,
pheochromocytoma, acromegaly, hyperparathyroidism, coarction of the aorta, pregnancy,
steroids. (a) suggests cushing’s disease so that is correct. (b) suggests acromegaly so that is
correct.(d) suggests a pituatory tumour which may secrete ACTH or GH so that is also correct.
(e) suggests coarction of the aorta so this is correct. Answer c describes features of
hypoparathyroidism therefore, this answer is wrong.

Question 60-------------------------------------------Answer C
In suspected cases of septic arthritis, joint aspirate must be done. Send synovial fluid for white
cell count, polarized light microscopy and urgent gram stain and culture.

Question 61---------------------------------------------answer C
Alopecia can be classified into diffuse of localized, scarring or non scarring. Both tinea capatis
and areolar areata are causes of localized non scarring but areolar areata is more common.

Diffuse non scarring Male pattern/androgenic, hypothyroid,

hypopituatory, hypoadrenal, drug induced,
irondeficiency, diffuse areolar areata, telogen
and anagen effluvium
Localized non scarring Alopecia areata, ringworm, traumatic, hair
pulling, traction, secondary syphilis
Localized/ diffuse scarring Burns, radiation, shingles,kerion, tertiary
syphilis, lupus, morphoea, pseudopelade,

38
 lichen planus
Question 62------------------------------------------answer A
Secondary amyloidosis or AA amyloidosis: caused by chronic inflammation eg rheumatoid
arthritis, IBD, familial mediterranean fever, chronic infections eg TB, bronchiectasis,
osteomyelitis. The amyloid is derived from serum amyloid A, an acute phase protein. It
commonly presents with proteinurea, nephrotic syndrome and hepatospleenomegaly.
Ultrasound may show an enlarged kidney with increased cortical echogenicity.

NSAIDS- can cause an acute tubulointerstitial nephritis or a chronic interstitial nephritis and
papillary necrosis (analgesic nephropathy). This would not cause nephrotic syndrome and the
kidney would not be enlarged on ultrasound.

Question 63-------------------------------------Answer D ???

In my search, iodine deficiency was the most common cause of hypothyroidism in the world,
while hashimoto’s was the most common in industrialized nations. Post thyroidectomy was 2 nd
to hashimoto’s in industrialized nations. I chose hashimoto,s because I know that iodine is not
the most common here.

Question 64-------------------------------------------answer A
Both iron and calcium supplements decrease T4 absorption and if taking these supplements
they should be taken 4-6 hrs apart.thyroxine is usually taken before breakfast

65. B type 2 diabetes

The young age and high BMI.
It is not MODY because this is diagnosed upon genetic test being monogenic inherited from affected
parent.

66. e. hemiparesis
A pituitary mass would have all excessive effects of its hormone production, galactorrrhoea (prl), thyroid
tsh, growth hgh (gigantism, acromegaly)..etc..it can also suppress function leading to hypopituitarism.
Anatomical compression of cn2 or 3 causing visiual field defects (scotomas) compression of optic chiasm
causing bilateral hemianopia. And pressure symptoms if large enough raised ICH, and epitaxis.

67. b. multiple endocrine neoplasia type 1

Causes of Hyperparathyroidism: solitary adenoma inc in PTH, or hyperplasia of all glands, low vit D
intake and chronic renal failure (dec Ca)
Symptoms of increased Ca= weakness tiredness, depression, dehydration, polyuria polydipsia, renal
stones, abd pain, pancreatitis, gi ulcers. Due to bone reabsorbtion pain osteoporosis.
Associated with multiple endocrine neoplasia (MEN) syndromes. Group of genetic syndromes inherited
in an autosomal dominant manner, where there are functioning hormone producing tumors in multiple
organs.

39
Men Type 1 parathyroid hyperplasia/adenoma, pancreatic, pituitary (3 p’s)
Men Type 2 Thyroid, adrenal, parathyroid (TAP)
Ment type 2b similar to 2 with mucosal neuromas, marfanoid appearance, NO parathyroid!

68. d acoustic neuroma

Neurofibromatosis 1 is autosomal dom with varying expression.
Signs: café au lait spots, neurofibromas, freckling in axillary or groin region, optic glioma, lisch nodules
(iris)
Neurofibromatosis 2, show bilateral vestibular schwannomas, neurofibromas, meningioma, glioma,
juvenile cateract.

69. c mitral incompetence

Signs from question: a.fib caused by mitral valve disease, displaced thrusting apex caused by mitral valve
disease, S1 soft and pansystolic murmur either mitral or tricuspid regurge, middiastolic murmur
following an opening snap is related to mitral stenosis (low rumbling)…..mitral incompetence

70.
Hb men 13-18g/dl, women 11.5-16
Wbc 4-11 x10^9
Lfts: Total bilirubin 3-17umol/l
Alt 3-35iu/l
Ast 3-35iu/l
Alp 30-150iu/l
Albumin 36-52g/l
Gilberts syndrome is unconjugated hyperbilirubinemia, decresed activity of glucoronyltransferase.
Acute viral hepatitis: from OHCM symptoms: fever, malaise, anorexia, nausea, arthralgia

71. c. duodenal ulcer disease

From OHCM wide geographical variations common in japan associated with: blood group A, H.pylori,
atrophic gastritis, pernicious anemia (post gastrectomy dec in IF), adenomatous polyp, social class dec,
smoking.

72. B benign prostate hypertrophy

This question is too easy to explain> refer to urology review
65) C MODY TYPE 2

Maturity onset diabetes of the young (MODY) is an autosomal dominant form of type diabetes
mellitus which affects young people with a positive family history.OHCM pg.190

66) E HEMIPARESIS

Pituitary tumours almost always benign, which may cause both hormonal and local pressure
symptoms. Hormonal symptoms include hypopituitarism, hyperprolactemia, hyper ACTH, hyper GH.
Local pressure symptoms include headache, visual field defects,CN 3,4,6 palsy. OHCM pg.218

67) B MULTIPLE ENDOCRINE NEOPLASIA

Primary hyperparathyriodsm 80-85% caused by solitary adenoma.

40
 MEN 1 consists of : parathyroid hyperplasia/adenoma, pituitary adenoma, pancreatic endocrine
tumours. OHCM pg. 206

68) D ACOUSTIC NEUROMA

Type 2 neurofibromatosis is autosomal dominant inheritance and chromosome 22 responsible.

Signs include café-au-lait spots, bilateral vestibular schwannomas(acoustic neuromas) sensoryneural
hearing loss is the first sign. Also juvenile posterior subcapsular lenticular opacity can occur before other
manifestations and so can be used for screening.OHCMpg. 506

69) C MITRAL INCOMPETENCE

Signs of mitral regurge: atrial fibrillation, displaced hyperdynamic apex beat(thrusting),RV

heave, soft S1, pansystolic murmur at apex radiating to axilla.

70) B ACUTE VIRAL HEPATITIS

Fever , malase, anorexia and mild RUQ discomfort and leucocytosis suggest an infective cause.
Cholelithiasis can be ruled out as ALT, AST and USS is normal. Normal albumin suggest no longstanding
hepatic function and with normal USS hepatoma and abscess eliminated. Gilbert syndrome is an
inherited metabolic disorder and common cause of unconjugated hyperbilirubinemia onset shortly after
birth. Aminotransferase activity exceeds 400IU/L in acute viral hepatitis.

71) C DUODENAL ULCER

Risk factors for gastric cancer: blodd group A, atrophic gastritis, pernicious anemia, H. pylori,
adenomatous polyps, smoking and post gastrectomy.OHCM pg. 614 & 636

72) B BENIGN PROSTATIC HYPERTROPHY

72 year old male with urinary symptoms MUST THINK BPH IF YOU DON’T TAKE AH 6/12.

Obstructive symptoms: hesitancy, poor stream, post micturation dribble, incomplete voiding

Irritative symptoms: frequency, urgency, nocturia

DRE: firm enlarged-BPH (feels like nose), hard irregular and nodule-ca (feels like forehead), soft-
Prostatitis (feels like lips)

Urinalysis – leucocytes in prostatitis

73. Answer: C
Carpal Tunnel Syndrome: most common cause of hand pain @ night due to compression of
median nerve as is passes under the flexor retinaculum. Tingling or pain felt in thumb, index and
middle fingers (pain also due to repetitive actions, relief brought about by flicking or shaking
hand. Later: wasting of thenar eminence and ↓ sensation over lateral 3 ½ digits. *Phalen’s test:
holding wrists hyperflexed for 1-2 min causes pain.
Ulnar: Cannot abduct fingers, claw deformity of 4th and 5th fingers. Cannit adduct thumb
Radial: wrist drop

74. Answer: D

41
See 2009 paper1emq
*Liver disease produces gynecomastia without the changes in sex hormone levels and mental
status

75. Answer: D Alport’s disease

X-linked or autosomal recessive. Sensorineural deafness, pyelonephritis, haematuria and renal
failure (GN + basket weaving of GBM)
See previous papers

76. Answer: D (not 100% sure)

ACA: supplies frontal and medial part of cerebrum. Occlusion: weakness of prximal and distal
muscles, numbness of contralat limbs. Facial sparing
MCA: supplies lat part of each hemisphere. Occlusion: contralat hemiplegia, hemisensory loss of
face and arm, contralat homonymous hemianopia,cognitive change.
PCA: supplies occipital lobe. Occlusion: HH often with macular sparing
Vertebrobasilar: cerebellum, brainstem,occipital lobes
Lenticulostriate: group of small arteries which arise at the commencement of the middle
cerebral artery.

77. Answer: B (not 100%sure)

Found that heparin is the indicated therapy for superficial thrombophlebitis but I’m unsure about
the constant infusion part.

78. Answer: A
Alcoholic hepatitis: TPR ↑, tender hepatomegaly, +/- jaundice, bleeding, ascites. Severe
indicatedby jaundice, encephalopathy andcoagulopathy. AST:ALT >2.0 (80% progress to
cirrhosis. Histology: Mallory’s hyaline (also found in alcoholic cirrhosis, Wilson’s disease,
primary biliary cirrhosis, hepatocellular carcinoma, morbid obesity) eosinophilic and appear
pink.

79. Answer: C

80. Answer: C

81. An 18-year-old woman presented with anxiety and palpitations. Her mother had
received radio-iodine for thyrotoxicosis and is on long term thyroxine replacement therapy.
On examination, her pulse was regular at 104 bpm, her thyroid gland was not palpable and
there was no lid lag. The following are her laboratory results.

Serum total T4 210 mmol/L (50-150)

Serum free T4 32 mmol/L (10-20)

Serum total T3 3.7 nmol/L (1-3.2)

Plasma TSH 0.01 mmol/L (0.4-5.0)

Serum Anti-TPO 36 (Normal uptake <50)

42
What is the most likely cause of her symptoms?

(A)FACTITIOUS THYROTOXICOSIS
(b) Familial hyperthyroglobulinaemia
(c) Grave’s disease
(d) Subacute thyroiditis
(e) T3 thyrotoxicosis

Hyperthyroidism can also be caused by taking too much thyroid hormone medication for
hypothyroidism. This is called factitious hyperthyroidism. When this occurs because the
prescribed dose of hormone medication is too high, it is called iatrogenic, or "doctor-
induced," hyperthyroidism.
Factitious hyperthyroidism can also occur when a patient intentionally takes too much
thyroid hormone, such as in people:
 Who have psychiatric disorders such as Munchausen syndrome
 Who are trying to lose weight
 Who want to get compensation from the insurance company
Children may take thyroid hormone pills accidentally.
In rare cases, factitious hyperthyroidism is caused by eating meat contaminated with
thyroid gland tissue.

82. The following are features in a patient with ankylosing spondylitis EXCEPT:

(a) Iritis
(b) Aortitis
(c) cardiac conduction defects
(d) association with HLA-B27
(E) USUALLY STARTS AFTER AGE 65 YEARS

Ankylosing spondylitis

Chronic inflammatory disease of the spine and sacroiliac joints.

Typically affects males aged 20-40

HLA B27+ve

Associated with anterior uveitis (iritis), aortitis, aortic regurgitation, pulmonary apical
fibrosis, amyloidosis and other spondyloarthritides.

83. The following are true of mechanical prosthetic cardiac valves EXCEPT:

(a) there may be leakage due to wear and tear of valve

(b) could cause hemolysis

43
(c) there may be a ball embolism

(d) does not usually cause a click

(e) usually develops degenerative changes with calcium deposition

Xenograft prosthetic valves require replacement at 8-10 years due to wear and tear.

Complications of prosthetic heart valves include hemolysis, systemic embolism, infective

endocarditis, structural valve failure and arrhythmias.

Mitral valve prolapse causes a ‘click’. Prosthetic valves may cause ejection systolic murmurs
or low intensity diastolic murmurs that may resemble a click.

I honestly don’t know the answer and cudn’t find it… Can someone plz help with this one?

84. The most appropriate answer in relation to lower motor neuron VII th nerve lesion is:

(A) MAY BE BILATERAL IN SARCOIDOSIS

(b) not seen in pontine lesions

(c) when caused by a parotid tumour, taste to the anterior 2/3 of the tongue is affected

(d) herpetic lesions on the external auditory meatus are unlikely to be associated

(e) not a feature of Guillan-Barre syndrome

Causes of Facial Nerve Palsy

Usually Bell’s Palsy (idiopathic)

Trauma

Parotid Tumour

Ramsay Hunt Syndrome [Option (d)]

Acoustic Neuroma

CNS: Stroke, Tumour, MS

Bilateral: Think>>

Guillan-Barre Syndrome (life-threatening)

Neurosarcoidosis

Lyme disease

EBV

44
ETC!!!

85. A 26-year-old female presents to hospital with proximal muscle weakness, nasal quality
to her speech and has a positive tensilon test. Of the following, the most appropriate option
is:

(a) carcinoma of the bronchus is a prominent association

(b) power initially increases with exercise

(C) A CRISIS MAY BE PRECIPITATED BY INFECTION

(d) tendon reflexes are quite diminished

(e) pemphigus is not an associated disorder

Myasthenia Gravis (MG)

Autoimmune disease

Increasing muscular fatigue

Associated with thymic atrophy or thymic tumour

Power decreases with exercise (fatiguability)

Crises are precipitated by pregnancy, hypokalaemia, infection, overtreatment, change in

temperature, emotion, exercise, certain drugs.

Tendon reflexes are normal.

Autoimmune disease and therefore associated with other autoimmune diseases, pemphigus
included.

86. A 26-year-old school teacher presents with abrupt headache around and about the left
eye. There is nasal stuffiness and rhinorrhoea. The pain lasts for 1 hour. He had similar pain
over the last 3 years with one or two episodes over a 4-week period and then it would go,
only to recur the following year. This patient most likely has:

(a) postcoital cephalgia

(b) classical migraine

(c) tension headache

(D) CLUSTER HEADACHE

(e) pseudotumour cerberii

Classical picture of Cluster Headache!

45
87. A young man presents to the emergency room with vomiting, abdominal cramps and
watery diarrhoea within five hours of eating fish and bakery goods at a fast food cafeé . The
most likely organism involved is:

(a) Bacillus cereus

(b) Clostridium perfrigens

(c) Giardia lamblia

(D) STAPHYLOCOCCUS AUREUS

(d) Salmonella spp

Bacillus cereus

 Cause of illness: large molecular weight protein (diarrheal type) or highly heat-
stable toxin (emetic type)
 Incubation period: 30 minutes to 15 hours
 Symptoms: diarrhoea, abdominal cramps, nausea, and vomiting (emetic type)
 Possible contaminants: meats, milk, vegetables, fish, rice, potatoes, pasta, and cheese
 Steps for prevention: pay careful attention to food preparation and cooking
guidelines.

Clostridium perfrigens

 Cause of illness: undercooked meats and gravies

 Incubation period: 8 to 22 hours
 Symptoms: abdominal cramps and diarrhea, some include dehydration
 Possible contaminants: meats and gravies
 Steps for prevention: proper attention to cooking temperatures.

Giardia lamblia

 Cause of Illness: Strain of Giardia lamblia Incubation Period: One to two weeks
 Symptoms: Infection of the small intestine, diarrhea, loose or watery stool, stomach
cramps, and lactose intolerance.
 Possible Contaminant: Giardia is found in soil, food, water, or surfaces that have been
contaminated with the feces from infected humans or animals..
 Steps for Prevention: Avoid swallowing contaminated recreational water (pools, hot
tubs, fountains, lakes, rivers, ponds) or contaminated bathroom fixtures, toys,
changing tables, diaper pails; avoid eating uncooked contaminated food; boil water
for 1 minute before use or use a water filter with an absolute pore size of at least 1
micron or rated for "cyst removal." Cholorination or iodination of water may be less
effective. Avoid fecal exposure during sexual activity

Staphylococcus aureus

46
  Cause of Illness: Toxin produced by certain strains of Staphylococcus aureus
 Incubation Period: One to six hours
Symptoms: Severe vomiting, diarrhea, abdominal cramping
 Possible Contaminant: Custard- or cream-filled baked goods, ham, tongue, poultry,
dressing, gravy, eggs, potato salad, cream sauces, sandwich fillings
 Steps for Prevention: Refrigerate foods; use sanitary practices.

Salmonella spp

 Cause of Illness: Infection with Salmonella species

Incubation Period: 12 to 24 hours
 Symptoms: Nausea, diarrhea, abdominal pain, fever, headache, chills, prostration
 Possible Contaminant: Meat, poultry, egg or milk products
 Steps for Prevention: Cook thoroughly; avoid cross-contamination; use sanitary
practices.

88. With reference to leptospirosis, the most likely correct answer is:

(a) associated with polycythaemia

(b) not a zoonotic infection

(C) LEPTOSPIRA FOUND IN THE CSF IN THE SEPTICAEMIC PHASE

(d) spirochaetes found in the blood in the immune phase

(e) glomerular injury is a feature

Leptospirosis

 The most common zoonosis in the world

 Leptospires can be recovered from blood or CSF obtained from patients during the
septicemic stage of illness OR from urine during the immune stage. [Textbook of
pediatric infectious diseases, Volume 2 By Ralph D. Feigin Page 1717]
 When associated with renal failure it is called Weil’s disease, however they didn’t
specify Glomerular injury :S
89. ans B. Carbamazepine

Patient has Trigeminal Neuralgia – intense, unilateral stabbing pain lasting seconds in the trigeminal
nerve distribution. Triggers – washing affected area, shaving , eating, talking , dental prostheses. Primary
– anomalous intracranial vessels compressing trigeminal root. Secondary – aneurys, tumour, chronic
meningeal inflammation, ms, herpes zoster, skull base malformation eg chiari. Drugs – Carbamazepine,
lamotrigine, phenytoin, gabapentin. If drugs fail – surgery

47
90. A excludes bias in sampling.

In a simple random sample ('SRS') of a given size, all such subsets of the frame are given an equal
probability. Each element of the frame thus has an equal probability of selection: the frame is not
subdivided or partitioned. Furthermore, any given pair of elements has the same chance of selection as
any other such pair (and similarly for triples, and so on). This minimises bias and simplifies analysis of
results. In particular, the variance between individual results within the sample is a good indicator of
variance in the overall population, which makes it relatively easy to estimate the accuracy of results.

However, SRS can be vulnerable to sampling error because the randomness of the selection may result in
a sample that doesn't reflect the makeup of the population.
91. D standard deviation……….a method of spread

92. D hepatitis B – spread by blood products, iv drug abusers, sexual intercourse, direct contact.

All others spread by faecal-oral route.

Ancylostomiasis = hookworm – small worms attach to upper gi mucosa causing bleeding. Eggs excreted
in faeces and hatch in soil. Larvae penetrate feet, so starting new infections. Oral transmission also
occurs.

93. C. causative agent is an RNA virus.

2 vaccines – 1. Passive immunization with human immunoglobulin gives less than 3 months immunity
(given to at risk travelers, household contacts). 2. Active immunization with inactivated protein from HAV
gives 1 year immunity.

Chronic liver disease does not occur.

Spread by faecal oral route, often in travelers or institutions. Most occur in childhood.

Diagnosis- serum transaminases, IgM rises from day 25 and signifies recent infection. IgG remains
detectable for life.

Only hep B caused by a DNA virus.

94. D incubation period

5 stages of infectious disease:

Incubation – between infection and signs/symptoms

Prodrome – non specific mild symptoms

Acme – symptoms characteristic of disease

48
Decline – symptoms decrease

Convalescence – healing by host

95. C hypercalcaemia

Symptoms and features of Metabolic Syndrome are:

 Fasting hyperglycemia — diabetes mellitus type 2 or impaired fasting glucose, impaired glucose
tolerance, or insulin resistance
 High blood pressure

 Central obesity (also known as visceral, male-pattern or apple-shaped adiposity), overweight with
fat deposits mainly around the waist

 Decreased HDL cholesterol

 Elevated triglycerides

Associated diseases and signs are: hyperuricemia, fatty liver (especially in concurrent obesity)
progressing to non-alcoholic fatty liver disease, polycystic ovarian syndrome (in women), and acanthosis
nigricans.

96. E involves a stage of preparation

Transtheorectical Model, change is a "process involving progress through a series of stages ]

 Precontemplation – "people are not intending to take action in the foreseeable future, and are
most likely unaware that their behaviour is problematic"
 Contemplation – "people are beginning to recognize that their behaviour is problematic, and start
to look at the pros and cons of their continued actions "

 Preparation – "people are intending to take action in the immediate future, and may begin taking
small steps towards change

 Action – "people have made specific overt modifications in their life style, and positive change has
occurred"

 Maintenance – "people are working to prevent relapse," a stage which can last indefinitely"

49
 Termination – "individuals have zero temptation and 100% self-efficacy... they are sure they will
not return to their old unhealthy habit as a way of coping"

97)

ANS= B

Enteropathogenic E coli (EPEC) Currently, there are four recognized classes of enterovirulent E. coli
(collectively referred to as the EEC group) that cause gastroenteritis in humans. Among these are the
enteropathogenic (EPEC) strains. Infantile diarrhea is the name of the disease usually associated with
EPEC. Occasionally, diarrhea in infants is prolonged, leading to dehydration, electrolyte imbalance and
death (50% mortality rates have been reported in third world countries). EPEC outbreaks most often
affect infants, especially those that are bottle fed, suggesting that contaminated water is often used to
rehydrate infant formulae in underdeveloped countries. EPEC cause either a watery or bloody diarrhea,
the former associated with the attachment to, and physical alteration of, the integrity of the intestine.
Bloody diarrhea is associated with attachment and an acute tissue-destructive process, perhaps caused
by a toxin similar to that of Shigella dysenteriae, also called verotoxin.

a) Rotavirus primarily infects the cells of the small intestinal villi, especially those cells near the tips of
the villi leads to malabsorption by impaired hydrolysis of carbohydrates and excessive fluid loss from the
intestine. Symptoms usually begin within 2 days of exposure and include the following:

o Anorexia
o Low-grade fever

o Watery, bloodless diarrhea

o Vomiting

o Abdominal cramps

c) Campylobacter pylori --> helicobacter pylori = a bacterium that has been implicated in the
development of duodenal and gastric ulcers.

50
The bacteria H. pylori (Helicobacter pylori) usually don't cause problems in childhood. These bacteria are
found worldwide, but especially in developing countries, where up to 10% of children and 80% of adults
can have laboratory evidence of an H. pylori infection — usually without having symptoms. Symptoms
include anorexia and weight loss, pallor or laboratory findings of anemia, vomiting, abdominal pain
associated with meals or nighttime. Kids who have peptic ulcer disease can have ulcers that bleed,
causing hematemesis (bloody vomit or vomit that looks like coffee grounds) or melena (stool that's
black, bloody, or looks like tar).

d) Giardiasis - Some children can have a giardia infection and have no symptoms at all. Those with
symptoms can have a sudden onset of watery diarrhea with abdominal pain. Others might have foul
smelling stools and a distended belly, pass lots of gas and lose their appetite. The bowels may not be
able to absorb normal nutrients leading to weight loss and anemia. Children with anemia may be pale
and tired. There is usually no blood seen in the stools. Children with giardiasis can become dehydrated
because of diarrhea and reduced appetite.

e) Trichuris trichiura - aka whipworm, is a very common intestinal helminthic infection, and about one
quarter of the world's population is thought to carry the parasite. Poor hygiene is associated with
trichuriasis transmission, and children are especially vulnerable because of their high exposure risk.
Symptoms:

 Nocturnal loose stools

 Dysentery can occur in patients with greater than 200 worms.

 Rectal prolapse

 Failure to thrive

 Symptoms of anemia (massive infection only)

 Vague abdominal discomfort

 Stunted growth

98)

Ans= A - Chronic abdominal pain in children is defined as pain of more than two weeks' duration. The
pain may be persistent or recurrent. While efforts to distinguish organic from functional abdominal pain
are admirable, these apparently opposing aetiologies are not mutually exclusive in children, since

51
psychological complications of organic disease are common. B and C are psychological factors as well but
the early morning on the way to school is the clue

d) Five percent of school-aged girls experience UTI. It is rare in school-aged boys. A UTI for 6 month
duration would have severe pyelonephritic complications and other symptoms

e) Pelvic sonography is indicated because of its sensitivity for free fluid, the frequency of retroperitoneal
disease and the visualization of the ileum for Crohn's disease, adenopathy and chronic features of
abscess from fistulas or Meckel's diverticulum. If sonography reveals no abnormalities and either chronic
peptic disease or irritable bowel disease is suspected, all of these conditions would present with other
symptoms and signs eg diarrhoea and wt loss especially after 6/12

99)

Ans = B & E

HUMAN MILK COW MILK

Energy (kCal) 62 67
Protein < 1.3 3.5
Carbohydrate >6.7 4.9
Whey:Casein >60:40 37:63
Fat <3.0 3.6
Na <0.65 2.3
Ca <0.88 3.0
P <0.46 3.2
Fe >1.36 0.9
Addtionally breast milk has large amounts of lactose, a sugar found in lower amounts in cow's milk.
Whole cow's milk does not contain sufficient vitamin E, iron, or essential fatty acids, which can make
infants fed on cow's milk anemic.

52
100)

Ans :C

http://www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm

Vaccine Contraindications Precautions

 Severe allergic reaction (e.g., anaphylaxis)
DTaP
after a previous dose or to a vaccine component
 Encephalopathy (e.g., coma, decreased level
of consciousness, prolonged seizures) not
attributable to another identifiable cause within 7
days of administration of previous dose of DTP or 
DTaP
 Progressive neurologic disorder,
including infantile spasms, uncontrolled
epilepsy, progressive encephalopathy; defer
DTaP until neurologic status clarified and
stablized.
Temperature of 105° F or higher (40.5°
C or higher) within 48 hours after
vaccination with a previous dose of DTP or
DTaP
 Collapse or shock-like state (i.e.,
hypotonic hyporesponsive episode) within
48 hours after receiving a previous dose of
DTP/DTaP
 Seizure 3 days or more after receiving a
previous dose of DTP/DTaP
 Persistent, inconsolable crying lasting 3
or more hours within 48 hours after
receiving a previous dose of DTP/DTaP
 GBS within 6 weeks after a previous
dose of tetanus toxoid-containing vaccine
 Moderate or severe acute illness with
or without fever

101. Ans = A

Bronchiolitis:

53
1st episode of wheezing associated with URTI and signs of respiratory distress

Recurrent apnoea is a serious complication especially in young infants and they should always be
observed for it.

Commonly affects kids in the first 2 years of life

Peak is at 6 months, cause usually RSV, adenovirus, para/influenza virus

Treatment is supportive, oral or iv rehydration, anytipyretics for fever, humidified oxygen, inhaled
bronchodilator atrovent and steroids are not effective. Although steroids have been used it has not
shown to decrease the severity or duration of illness.

102. Ans = D

Respiratory distress syndrome: more common in male infants born before 28 weeks gestation. The cause
of it is a deficiency of surfactant therefore surfactant therapy will be most likely to help him.

103. ans – a

The neonate was being treated via ventilation. One of the most common causes of decompensation
when on ventilation in RDS is the formation of a pneumothorax from positive pressure ventilation

104. ans = c

The other options kinda silly, except for the baby’s blood cells breaking down rapidly which would
indicate hemolysis but this will present usually within 24 hours of life.

105. ans = b

Duchenne’s:

Most common muscular dystrophy, X linked recessive, 1 in 4000 males, deletion mutation in dystrophin
which normally maintains muscle cell wall. CPK is elevated, present with waddling gait, language delay,
mount stairs one by one, dx by 5 years but symptomatic earlier. Selective atrophy of muscle (pectoralis
major and brachioradialis, pseudohypertrophy of calves). By 10-14 years no longer ambulant, death
occurs in late teens or twenties from resp failure or cardiomyopathy. Scoliosis common complication.
Exercise helps to maintain muscle power, stretching, good sitting postures. Late disease results in
nocturnal hypoxia due to intercostals muscle disease and CPAP or NIPPV may be needed. Ambulant kids
treated with steroids to preserve mobility and prevent scoliosis (inhibit protein lysis, stimulate myoblast
proliferation, increase myogenic repair, immunosurpression, reduce calcium concentration cytosolic

106. ans = b

CP is a non progressive motor disorder (therefore d and e are wrong)

In spastic diplegia, the legs are affected more than the arms, hand function relatively normal (c wrong)

54
To be quadriplegic u need to have both of the sides of the cortex being affected, therefore by
elimination the ans is b

107. ans – b

Down’s syndrome is hypotonic, with the main cardiac defect being atrioventricular septal defect .

108. ans - b

Satellite lesions = diaper dermatitis

Behind the ears, the nose, scalp = areas mostly affected. The flexor surfaces and nappy area can be
affected but usually the more common areas are those mentioned above. Sunlight also helps to decrease
the break out by inhibiting growth of yeast. It is known as cradle cap in kids.

109) C cerebellar ataxia is a recognized complication

Chicken pox is a primary infection with varicella zoster virus. Crops of skin vesicles often start
on back. incubation 11-21 days. Infectivity 4 days before the rash, ubtil all lesions have scabbed
(1 week) spread by droplets. Complications include purpura fulminans, pneumonia, meningitis,
myelitis, nephritis, myocarditis, cerebellar ataxia.

110) D) herpes simplex infection

Vesicular rash is seen

111) C may require oxygen therapy

No specific guidelines were found but if you refer to OHCM pg. 824 you might make sense of
the question.

112) C can be closed with indomethacin

Pediatric cardiology handout
PATENT DUCTUS ARTERIOSUS
Etiology and Epidemiology
The ductus arteriosus allows blood to flow from the pulmonary artery to the aorta during fetal
life. Failure of the normal closure of this vessel results in a PDA (Fig. 143-3). With a falling
pulmonary vascular resistance after birth, left-to-right shunting of blood and increased
pulmonary blood flow occur. Excluding premature infants, PDAs represent approximately 5% to
10% of congenital heart disease.
Clinical Manifestations
Symptoms depend on the amount of extra blood flow to the lungs. The magnitude of the shunt,
which can be similar to a VSD, depends on the size of the PDA (including diameter, length, and
tortuosity) and the pulmonary vascular resistance. Patients with small PDAs are asymptomatic.
Moderate to larger shunts produce the symptoms of CHF as the pulmonary vascular resistance
decreases over the first 6 to 8 weeks of life.
The physical examination depends on the size of the shunt. A widened pulse pressure is often
present due to the runoff of blood into the pulmonary circulation during diastole. A continuous
machine-like murmur can be heard at the left infraclavicular area, and a thrill may be palpable.
The murmur radiates along the pulmonary arteries and is often well heard over the left back.

55
Larger shunts with increased flow across the mitral valve may result in a mid-diastolic murmur at
the apex and a hyperdynamic precordium. Splitting of S2 and the intensity of the P2 depend on
the pulmonary artery pressure. Higher pulmonary pressures result in greater intensity of P2 and
may result in an earlier closing of the pulmonary valve.
Imaging Studies
ECG and chest x-ray findings are normal with small PDAs. Moderate to large shunts may result
in a full pulmonary artery silhouette and increased pulmonary vascularity. ECG findings
vary from normal to evidence of left ventricular hypertrophy. If pulmonary hypertension is
present, there is also right ventricular hypertrophy.
Treatment
Spontaneous closure of a PDA after a few weeks of age is uncommon in full-term infants.
Moderate and large PDAs may be managed initially with diuretics and digoxin, but eventually
require closure. Closure of small PDAs also is recommended because of the risk of subacute
bacterial endocarditis. Most PDAs can be closed in the catheterization laboratory by either coil
embolization or a PDA closure device.

113) A) gentamicin

114) D transposition of the great vessels

Cyanotic congenital heart disease: tetralogy of fallot, tricuspid/pulmonary atresia, truncus
arteriosus, transposition of great vessels, total anomalous venous return and hypoplastic left heart
syndrome.

115) C acute chest syndrome.

The acute chest syndrome is a vaso-occlusive crisis within the lungs, often associated with
infection and infarction. The patient may first complain of pain but within a few hours develops
cough, increasing respiratory and heart rates, hypoxia, and progressive respiratory distress.
Physical examination of the chest reveals areas of decreased breath sounds and dullness to
percussion. Treatment involves early recognition and prevention of arterial hypoxemia. Oxygen,
fluids, judicious use of analgesic medications, antibiotics, bronchodilators, and RBC transfusion
(rarely exchange transfusion) usually are indicated in therapy for acute chest syndrome.
Incentive spirometry reduces the incidence of acute chest crisis in patients presenting with pain
in the chest or abdomen.

116) E acute rheumatic fever (erythema marginatum)

Erythema nodosum: painful blue –red raised lesions on shin fronts and/or thighs and arms. Seen
in: sarcoidosis, drugs(sulphonamides, the pill), streptococcal infection, chron’s/uc, BCG
vaccination, leptospirosis, TB, leprosy.

Question 117--------------------------------------answer A

Initial management of DKA is always fluid resusutation. This is followed by insulin infusion with
potassium correction. See illustration on page 420 flower power. Too much to type out.

Question 118------------------------------------------answer C

56
PCP: usually patients have a CD4 count of < 200. Patients present with wt loss, dry cough, dyspnoea on
exertion. Diagnosis: give saline nebs to collect sputum. If no sputum, then do broncoscopy with broncho
alveolar lavage. Monoclonal antibody stain, methenamine silver, Giemsa, toluene blue. Elevated LDH,
ABG- hypoxaemia, measure O2 sats b4 and aft exercise. Significant drop in sats aft exercise. Rx: co-
trimoxazole IV or PO. Alternative: clindamycin + primaquine or trimetoprim + dapsone. Prophylaxis with
septra if CD4< 200

Question 119---------------------------answer D

Dr V singh explained in the review.

Question 120 ------------------------------------------answer C

Type of infection Colour of CSF Number and type Protein glucose

of cells
No infection clear o-5 lymphocytes 10-45mg/dl 50-85mg/dl
per mm3 no PMNL
Bacterial cloudy Thousands of cells, increased decreased
mostly PMNL
Viral clear A couple thousand normal Decreased of
cells, not as much normal
as bacterial,
mostly
lymphocytes
Fungal Clear or Few cells, up to increased Decreased or
xanthochromic 1000, mostly normal
( yellow) lymphocytes
tuberculosis Clear or Few cells, up to increased decreased
xanthochromic 1000, mostly
lymphocytes
E coli is common in neonates and elderly, not in children

N meningitis-intracellular gm –ve diplococcic in PMNL’s

H influenza- pleomorphic gm –ve coccobaccili

S pneumonia- gm positive cocci in pairs and short chains

Question 121-------------------------------------------answer D

PSGN’s: has a benign course and treatment is supportive with sodium restriction, diuretics and
antihypertensives. Hypertension is present in 50% of cases. Complement is decreased throughout. It is
caused by group A strep.

Question 122----------------------------------------answer B

57
 Just a note,Still’s disease- a form of juvenile chronic arthritis chacterised by high fever and signs of
systemic illness that can exist for months before the onset of arthritis.

Question1 23---------------------------------------------answer A

An IVU is not done routinely in infants unless detailed anatomy of the calyceal system or ureter is
needed. DMSA and MCUG id done if USS shows abnormal bladder and ureters and kidneys. If not
responding to antibiotics and first culture contaminated etc, can repeat the culture while on antibiotics.
Still not 100% sure so ul can email if ul find the ans wrong.

Question 124--------------------------------------answer E

ESR, CRP, white cell count and platelets are non specific for any particular rheumatological diseases.

SLE: remember A RASH POINts MD

Arthritis ,Renal disorder( persistent proteinuria), ANA, Serositis, Hematological ( coombs positive
hemolytic anaemia, leucopenia, lymphopenia, thrombocytopenia), Photosensitivity, Oral ulcers,
Immunological (anti dsDNA, anti sm, antiphospholipid etc), Neurological, Malar rash, Discoid rash

125. ans…………D
Proteins are not stored, they are deaminated and excreted- A n B
Protein requirements generally increase more than energy requirements and appear related to the
amount of lean body mass. The body loses protein through wounds and because of this, the body has
increased calorie needs for healing. However, the majority of increased protein requirements come
from muscle breakdown for use in energy production. Providing an increased intake of protein does
not stop this breakdown. Rather it provides the materials needed to synthesize lost tissue.- E
Harper’s b.chem:>300 a.a, 20 are essential- C

126. ans…………C
Spinal muscular atrophy- genetically determined disorders of motor component of both spinal n
cranial neurons. Usually symmetrical, with proximal n distal wasting, fasciculations n weakness.

Down’s syn - hypotonic, brachycephaly, flattened occiput, hypoplastic midface, uplanting

palpebral fissures, epicanthic folds, large protruding tongue, short broad hands with transverse
palmar crease, n wide gap bet 1st n 2nd toes
Microcephaly- hypoplasia of frontal regions of brain n skull mental retardation
Athetoid cerebral palsy- causes slow, writhing, snakelike involuntary movements…usually
caused by extrapyramidal lesion.
Duchenne’s muscular dystrophy- sex linked affecting boys mostly( can be spontaneous mutation-
30%)  absent dystrophin  clumsy walking difficulty standing with resp failure.

127. ans…………B
Erythema multiforme- target lesions, occasionally evere with fever and mucosal involvement
Kawasaki- fever>/= 5 days with 4 or more of the 5 following criteria:
1. bilat non-suppurative conjunctivitis
2. mucous mem changes- strawberry tongue, fissured lips
3. changes of periphery- Erythema, edema, desquamation

58
4. polymorphous rash
5. cervical lymphadenopathy >1.5cm diameter
Scarlet fever- fever, sore throat, circumoral pallor. Strawberry tongue, n diffuse fine macular-
papular rash
Rheumatoid disease: includes Erythema marginatum (raised red edges with pale centre occurring
mainly on trunk, thighs n arms)
Measles- macular rash begins mainly on hairline, it may be petechial or hemorrhagic

128. ans……………A
Turner- XO
Isolated growth hormone def wd affect height only
Cushings disease – xs glucocorticoid hormone
Familial short stature does not affect econdary sexual characteristics
Addison’s disease- lack of glucocorticoid hormones

129. ans…………..A

130.ans……………A
Able to use sentences routinely-2 ½-3yrs
Able to have vocab of 1-3 words only- 12 mths
Able to name 4 colours- somewhwere bet 18 mths n 24 mths
Able to copy a cross- 4 yrs

131. ans……………….D
Haemolytic disease of the newborn- ABO/Rh incompatibility
Coombs test heps establish the presence of ab to rbc
Blood smear helps establish that rbc are being destroyed
The hemoltic diseaseanemia increased reticulocyte count

132. ans………………E
Long time had soooo much of that that we are immune by now

133.Less than one month Group B strep then E. coli, klebsiella

More than one month S. pneumonia

134.

 Abstract thought
 Appearance
 Attitude
 Activity
 Mood
 Affect
 Speech
 Thought
 Delusions

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 Hallucinations
 Suicide
 Cognitive function:
a. Orientation
b. Memory
c. Attention
d. Concentration
e. Knowledge
f. Judgement
g. Abstract thought
h. Insight
135. I don’t know I looked it up and they can all present with psychiatric symptoms:

Hypothyroidism: depression, myxoedema madness

SLE-depression, emotional lability delirium, psychosis

Seizure disorder-Temporal lobe epilepsy: hypereligiosity, personality change, hypergraphia,

hyposexuality

136. C fewer side effects

Atypicals(Serotonin dopamine antagonists)

Less extrapyrimidal effects

Far more expensive

Less likely to cause hyperprolactinemia

More effective for negative symptoms, note typical mainly work for + symptoms cuz only
dopamine, but haldol still d best for acute problems antipsychotic+sedation

137. C scizotypal

Indicators prognosis

GOOD PROGNOSIS POOR PROGNOSIS

Late onset Early onset
Precipitating factors No precipitating factors
Acute onset Insidious onset
Good premorbid social sexual work Hx Poor premorbid….
Mood disorder symptoms Withdrawn autistic behavior
Married Single divorced widowed
FH: mood disorder FH: schizophrenia
Good support systems Poor support system
Positive symptoms Negative symptoms

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Female Male
No remissions 3 years
Many relapses
History of assaultiveness
138. E manic bipolar disorder causes pressured speech

Manic episode: 1 week or hospitalization necessary with persistently elevated, expansile or

irritable mood

Plus 3 of 7

Good-Grandiosity

God-Goal directed behaviour

Stupid-Decreased need for sleep

Talk- Talkative more than usual or pressured

From-Flight of ideas(racing thoughts)

Distractible- attention easily drawn to unimportant or irrelevant external stimuli

People-pleasurable activities excessive, high potential for severe consequences

139. C diarrhea

Tricyclics has antimuscarinic effects ∴ drowsiness, dry mouth , blurred vision increased
Intraocular pressure may cause glaucome, urinary retention constipation

Arrythmias, heartblock, hypotension, hyponatremia in elderly, very rarely neuroleptic malignant

syndrome, increase suicide risk poisoning: antimuscarinic effects above plus possible coma,
hypotension, hypothermia, hyperreflexia, extensor plantars, convulsions, respiratory failure,
arrythmias, heartblock. Delirium common in recovery.

140. C focal signs one of the main differences

. A summary of the DSM-IV-TR diagnostic criteria is as follows:

o The patient has developed multiple cognitive deficits manifesting as both (1) memory
impairment and (2) one or more of the following cognitive disturbances: aphasia, apraxia,
agnosia, and disturbance in executive functioning.

o The cognitive deficits in the above criteria cause significant impairment in day-to-day
functioning, social or occupational functioning and represent a significant decline from
the previous level of functioning.

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o Focal neurologic signs and symptoms or radiologic evidence indicative of
cerebrovascular disease are present that are judged to be etiologically related to the
dementia.

o The deficits do not occur exclusively during the course of delirium.

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