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@ MedicineA 32-year-old male is referred with chronic renal dysfunction . Hisimaging is shown in Fig .His blood pressure is consistently 1!-1"!#$! mmHg.%hich of the following antihypertensi&es is the most appropriate for

the management of this man's blood pressure(

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2ad*df*.pgA. A/ inhibitor

0. 0etablocer

. alcium channel blocer

. iuretic

AAutosomal dominant A4-1 is a relati&ely common disorder

accounting for appro5imately +6 of cases of end-stage renal disease7/89:.

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;> receptor antagonist blocers 7ie=telmisartan= losartan= irbesartan= candesartan:. alcium channelblocers are not encouraged to be used.;Howe&er= although widely used and recommended= there is no

e&idence that the renin-angiotensin system is a?ected in the disease.

@ Medicine A 2-year-old female with dysentery has undergoneendoscopy shown in Fig is found to ha&e anti-smooth muscleantibodies.%hich is the most appropriate ne5t test for this patient(

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A. Abdominal ultrasound

0. olonoscopy

. i&er function tests

. i&er biopsy

Ans Blcerati&e colitis on endoscopy )

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autoimmune hepatitis= such as= raised bilirubin= aspartateaminotransferase 7A8

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Around "!6 of patients with scleritis ha&e an underlying disease= ofwhich the maority are connecti&e tissue disorders. 9heumatoidarthritis is the most common. >t can also be seen in)systemic lupus erythematosus 78/:reacti&e arthritis

polyarteritis nodosaanylosing spondylitisgouthurg-8trauss syndromesyphilis= and%egener's granulomatosis 7but much less commonly:.

@MedicineA "-year-old male with type 1 diabetes and with a number of comple5diabetic gastrointestinal complications has undergone / shown inFig .%hich of the following drugs most liely to be responsible(

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Dther agents include amitriptyline and phenothiaines yetmetoclopramide and domperidone are not associated.

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@ athologyA 32-year-old man was prescribed an oral antibiotic for a urinary tractinfection.

 n&estigations re&ealed)Haemoglobin +" g# 713!-1+!:9eticulocytes 1* J1!$# 72"-+":eripheral smear is shown in Fig .%hat is the most liely diagnosis(

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A. Acute myeloid leuaemia

0. Autoimmune haemolytic anaemia

. aro5ysmal cold haemoglobinuria

. Hereditary spherocytosis

00lood Ilm) mared anisopoiilocytosis and bite cells.

aro5ysmal cold haemoglobinuria 7H: is a rare type of autoimmunehaemolytic anaemia 7A>HA: occurring primarily in children.

 

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not always present because in some persons with H theautoantibody le&el is not high enough to cause intra&ascularhaemolysis. H is usually of abrupt onset in the setting of aninfectious disease.i&en the patient's age and the speciIc history in this case the

diagnosis is unliely to be H.>f the diagnosis were hereditary spherocytosis then the blood Ilmwould show spherocytes.>n haemoglobin H disease the typical inclusions can be demonstrated inerythrocytes stained with brilliant cresyl blue and a chronic microcytic=hypochromic anaemia would be present.Haemolytic anaemia may be precipitated by sulfonamides and also bypenicillins.

 HA with the typical blood Ilm.

 

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. Breaplasma urealyticumA

Fig : Gram's stain of urethral discharge from a male patient with gonorrhea shows gram-negative intracellular monococci and diplococci.

onorrhoea is one of the commonest reported 8n men the symptoms manifest as urethritis and in womencer&icitis or urethritis.

 n this case the patient is liely to ha&e a non-speciIc urethritis 7L8B:due to hlamydia trachomatis= reCuiring treatment with eitherdo5ycycline or erythromycin for *-1 days.

@MedicineA $-year-old city worer attends for e&aluation of erectile dysfunction.He has mild hypertension for which he taes amlodipine " mg daily= butno other past medical history of note. He admits to woring long hoursand spends a great deal of time entertaining clients.Dn e5amination his 0 is 1"#+2 mmHg= his pulse is *! and regular andhis 0M> is 31.>n&estigations show)Haemoglobin 1!" g# 713"-1**:

%hite cell count,.+ J1!$# 7-11:latelets 1$* J1!$# 71"!-!!:8odium 13$ mmol# 713"-1,:otassium .! mmol# 73."-":reatinine 11* mol# 7*$-11+:Alaline phosphatase 13! B# 73$-11*:Alanine aminotransferase 1,! B# 7"-!:His physical e5amination is shown in Fig .%hich of the following is the most liely diagnosis(

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@ MedicineA 3-year-old male presents with palpitations.

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D&er this time she had been trying to concei&e.Dn e5amination= she had a 0M> of 32 g#m2= a pulse was + beats perminute= and a blood pressure of 1"#1!! mmHg.hysical e5amination is shown in Fig .%hich of the following would be the most useful initial in&estigation(

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A. 2 hour urinary free cortisol 7BF: concentration

0. ombined $ am A

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 L9 is maintained abo&e 2.!= although a higher le&el 7abo&e 3: maybe indicated for patients with recurrent thrombosis on treatment.Anticoagulation to pre&ent fetal loss remains contro&ersial.Df the options gi&en here= only 8/ is commonly associated withantiphospholipid syndrome and is therefore the correct answer.