Kufa/Department of Medicine

Quiz 59
1. A 65-year-old woman with hypertension, insulin-requiring diabetes mellitus, end-stage kidney disease, and a distant history of cigarette smoking presents with new-onset pain in her right shoulder and weakness in her right hand that have progressed during the past 6 weeks. In addition, she has lost 15 pounds during the past 4 months.
Physical examination reveals a unilateral, right-sided ptosis with a pinpoint pupil of the right eye, as well as muscle atrophy, hand weakness, and numbness in the fourth and fifth fingers of the right hand. No facial plethora is noted. The patient has no pain on percussion of her neck or back.
Which one of the following conditions is the most likely cause of this patient's symptoms?
A. Brainstem tumor
B. Myasthenia gravis
C. Microscopic polyangiitis
D. Carotid artery dissection
E. Lung cancer

2. A 76-year-old woman is admitted with sudden onset left sided weakness. Nursing staff notice she coughs and appears to choke when drinking fluids. Which of the following statements is correct?
A. A gastroscopy should be organized as soon as possible.
B. Swallowing difficulties are likely to persist long term.
C. Fluids more difficult to swallow than solids.
D. Nasogastric (NG) feeding will protect against aspiration.
E. Percutaneous endoscopic gastrostomy (PEG) feeding should be considered if dysphagia persists for greater than one month.

3. The following are features of a posterior (receptive) type of dysphasia except:
A. Fluent speech
B. Neologisms
C. Poor comprehension
D. Poor writing
E. Silent reading affected.

Medical News 52
Antibiotic Cotrimoxazole Combined With ACE Inhibitor or ARB Could Raise Risk of Sudden Death
The risk of sudden death went up by more than a third in older patients taking ACE inhibitors or angiotensin-receptor blockers (ARBs) who were also put on the antibacterial agent cotrimoxazole, compared with those who were instead given amoxicillin, in a case-control study reported this week[1]. The finding was independent of comorbidities, other medications, recent procedures, and other potential influencers of sudden-death risk, according to the authors.
The elevated risk with cotrimoxazole, a combination of sulfamethoxazole and trimethoprim widely used for decades, was likely caused by its capacity for raising serum potassium, which became fatal on top of other medications known for causing hyperkalemia, speculate Dr Michael Fralick (University of Toronto) and colleagues in their report, published October 30, 2014 in the BMJ.

Answer Q 58
1— D
2— E
3— C

Answer Q 57
Small-bowel obstruction

Medical News 51
Large, Nationwide Study Links Enterovirus to Type 1 Diabetes.
Children that have been infected with enterovirus are 48% more likely to have developed type 1 diabetes. This is the first nationwide, retrospective cohort study of the association between type 1 diabetes and enterovirus infection, from China Medical University, published in Diabetologia. 2014.
The findings suggest that a vaccination strategy against enterovirus infection might slow the rising incidence of type 1 diabetes.

There has been a rapid global increase in the incidence of type 1 diabetes recently, particularly in children under age 5 years and at another peak time, puberty. But incidence still varies greatly between ethnic groups: from about 0.1 per 100,000 person-years in China and Venezuela, to the highest incidence in the world of 64.3 per 100,000 person-years, in Finland.
The authors explain that type 1 diabetes is thought to be caused by a complex interaction between genetic susceptibility, the immune system, and environmental factors.
It's clear that in some countries enterovirus may not play a large role. In Finland, for instance, the prevalence of enterovirus infection is low, so it is thought that genetic background more likely plays a large part in the high incidence rate.
Enterovirus infection encompasses a wide group of viruses, including polioviruses, coxsackieviruses, and echoviruses.
The most commonly diagnosed conditions resulting from infection with these viruses are herpangina (mouth ulcers), patients may present with fever, pharyngitis, and vesicular and/or ulcerated throat lesions, but the condition is usually benign and self-limiting

Quiz 58
1. Which one of the following may be useful in the prevention of oxalate renal stones?
A. Ferrous sulphate
B. Thiazide diuretics
C. Lithium
D. Pyridoxine
E. Allopurinol

2. A 45-year-old woman with type 1 diabetes mellitus is reviewed in the diabetes clinic. She was started on lisinopril to treat both the hypertension and as a renoprotective agent. Lisinopril had been titrated up to treatment dose. Three months ago her blood tests were K4.5 mmol/l, Creatinine 1.8 mg/dl eGFR 47 ml/min. Her current bloods are K 4.9 mmol/l, Creatinine 2 mg/dl eGFR 44 ml/min. Of the following options, what is the most appropriate course of action?
A. Stop lisinopril and arrange investigations to exclude renal artery stenosis
B. Switch to a angiotensin 2 receptor blocker
C. Switch to diuretics
D. Reduce dose of lisinopril
E. No action

3. A 65-year-old man is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission blood tests show the following: Na 138 mmol/l, K 6.3 mmol/l, Bicarbonate 15 mmol/l, Urea 90 mg/dl.
What is the most appropriate initial treatment to lower the serum potassium level?
A. Intravenous bicarbonate
B. Haemodialysis
C. Insulin/dextrose infusion
D. Intravenous calcium gluconate
E. Oral calcium resonium

Quiz 57
A 53-year-old man presents to the ED with 24 hours of abdominal pain and three episodes of nausea, vomiting, and diarrhea. The patient describes the pain as intermittent and crampy. He has lost all appetite and has not had a bowel movement in 3 days. His surgical history includes cholecystectomy and appendectomy. His physical examination is notable for hyperactive bowel sounds. His abdominal radiograph is shown.
What is the most likely diagnosis?

Answer Q 55
Pseudomembranous colitis

Answer Q 56
1— D
2— D
3— D

Quiz 56

1. A 25-year-old man, presents with fever, night sweats, cough, and sputum. Sputum for AFB stain proved positive and he was commenced on quadruple antituberculous therapy. Now, 2 weeks later, his LFTs have become deranged with an ALT of 400 U/l and bilirubin of 2mg/dl.
What is the most important management step?
A. Liver ultrasound
B. Screening for viral hepatitis
C. Reduce the dose of antituberculous therapy
D. Stop the TB medication
E. Give prednisolon

2. A 35-year-old woman has an ultrasound scan for investigation of epigastic pain that was abated on ranitidine. The report reads as follows: ‘There are multiple small hyperechoic lesions in both lobes of the liver. No other focal lesions. No features to suggest cirrhosis or portal hypertension. Intrahepatic and extrahepatic biliary tree normal. Pancreas, kidneys, spleen normal. Her liver function tests are all normal. The most likely diagnosis is:
A. Multiple metastasis
B. Focal nodular hyperplasia
C. Adenomas
D. Haemangiomas
E. Liver abscesses

3. Blood drawn from a nurse immediately after a needlestick injury on a Liver Unit. Serology reveals presence of anti-HBc and anti-HBs antibodies. Which of the following is true?
A. She is at risk of acquiring hepatitis B from the needlestick injury.
B. She may be at risk of acquiring hepatitis D from the needlestick injury.
C. She has received an adequately immunizing course of hepatitis B vaccination.
D. She has previously had and recovered from hepatitis B.
E. She is at increased risk of cirrhosis

Quiz 55
A 60-year-old woman presents to an urgent care center with a complaint of profuse, foul-smelling, watery diarrhea and vomiting. Her symptoms have become progressively worse over the past 24 hours, and she reports a fever of 38°C. She denies having any significant medical history but reports that she was recently treated with ampicillin for "an infection." An abdominal radiograph is obtained (shown).
What is the disease process that is most likely affecting this patient?

Medical News 50
Beta-Blockers No Use in CAD Patients With No Prior MI
[Circulation, September 30, 2014]
There are more signs that beta-blockers are of no use, and may potentially be harmful, in patients with stable coronary artery disease (CAD) or with CAD risk factors only, according to CHARISMA trial.
Bangalore and colleagues looked at nonfatal MI, stroke, or cardiovascular mortality among patients who participated in the CHARISMA trial, grouped according to whether they'd had a prior MI (4772 patients), known atherothrombotic disease (7804 patients), or risk factors only, (2101 patients). Each group was then further analyzed according to whether or not they were taking beta-blockers at baseline.
Over 28 months of follow-up, baseline beta-blocker use was associated 40% reduced risk of new MI among patients with prior MI. No mortality difference, however, was seen between prior MI patients in the beta-blocker vs no beta-blocker group.
In both the known-atherothrombotic-disease group and the risk-factors-only group, no advantage was seen among those taking beta-blockers as compared with those not taking beta-blockers. On other hand, CHARISMA analysis supports the potential increased risk of stroke with beta-blocker group.
A mechanism previously proposed for the stroke findings is the "inefficient reduction" in central aortic pressures with beta-blockers, potentially related to heart-rate lowering, the authors note.