Rapid Review of Clinical Medicine for MRCP Part 2

2nd ed Edition Sharma newest edition 2025

Now available at ebookultra.com

( 4.5/5.0 ★ | 409 downloads )

https://ebookultra.com/download/rapid-review-of-clinical-medicine-
for-mrcp-part-2-2nd-ed-edition-sharma/
 Rapid Review of Clinical Medicine for MRCP Part 2 2nd ed
Edition Sharma

EBOOK

Available Formats

■ PDF eBook Study Guide Ebook

EXCLUSIVE 2025 ACADEMIC EDITION – LIMITED RELEASE

Available Instantly Access Library

We have selected some products that you may be interested in
Click the link to download now or visit ebookultra.com
for more options!.

Get through FRCR part 2B rapid reporting of plain

radiographs 1st Edition Sharma

https://ebookultra.com/download/get-through-frcr-part-2b-rapid-
reporting-of-plain-radiographs-1st-edition-sharma/

Clinical Vignettes for the USMLE Step 2 PreTest Self

Assessment Review 2nd edition Mcgraw-Hill

https://ebookultra.com/download/clinical-vignettes-for-the-usmle-
step-2-pretest-self-assessment-review-2nd-edition-mcgraw-hill/

Basic Medical Sciences for MRCP Part 1 3rd Edition

Philippa J. Easterbrook

https://ebookultra.com/download/basic-medical-sciences-for-mrcp-
part-1-3rd-edition-philippa-j-easterbrook/

Medicine PreTest Self Assessment Review Twelfth Edition

PreTest Clinical Medicine Robert Urban

https://ebookultra.com/download/medicine-pretest-self-assessment-
review-twelfth-edition-pretest-clinical-medicine-robert-urban/
MRCP Part 2 Self Assessment Medical Masterclass Questions
and Explanatory Answers 1st Edition John D Firth

https://ebookultra.com/download/mrcp-part-2-self-assessment-medical-
masterclass-questions-and-explanatory-answers-1st-edition-john-d-
firth/

AAOS Comprehensive Orthopaedic Review 2 2nd Edition Martin

I. Boyer (Ed.)

https://ebookultra.com/download/aaos-comprehensive-orthopaedic-
review-2-2nd-edition-martin-i-boyer-ed/

Case Histories for the MRCP 2nd edition Paul Goldsmith

https://ebookultra.com/download/case-histories-for-the-mrcp-2nd-
edition-paul-goldsmith/

The General Theory and After Part 2 Defence and

Development 2nd ed. Edition Keynes

https://ebookultra.com/download/the-general-theory-and-after-
part-2-defence-and-development-2nd-ed-edition-keynes/

MRCP Paces 180 Clinical Cases 1st Edition Kevin

O'Gallagher

https://ebookultra.com/download/mrcp-paces-180-clinical-cases-1st-
edition-kevin-ogallagher/
 Rapid Review of
The new and completely revised edition of Dr Sharma's bestselling
Rapid Review of Clinical Medicine for MRCP Part 2 contains
Rapid Review of
CLINICAL
over 400 self-assessment cases and data interpretation questions
covering all aspects of internal medicine.

CLINICAL MEDICINE
The special 5-star qualities of the First Edition have been retained and
enhanced – breadth of coverage, superb illustration, lively
presentation, precise answers, detailed discussion and, above all, the
author's understanding of the exam candidate's needs while ensuring
the book's broader educational value. MEDICINE
New to this edition are a complete content update and some
300 best-of-five MCQ stems, reflecting the format of the new
MRCP Part 2 and of many similar exams around the world.
for MRCP Part 2
Second Edition
The new Rapid Review of Clinical Medicine for MRCP Part 2 is
an invaluable resource for all young doctors studying for higher Sanjay Sharma • Rashmi Kaushal
qualifications in internal medicine and for medical tutors preparing for
postgraduate examinations. Furthermore, the book provides excellent
evidence based management plans for busy hospital physicians in
acute general medicine encountering difficult medical scenarios.

MRCP Part 2
Sharma • Kaushal

ed
d at ials
up tor
ISBN: 978-1-84076-070-5 & , tu t
d s a
vise tion rm
re a fo
lly plan am
fu ex ex
er ers, new
–
MANSON l
el sw ts
PUBLISHING ests , an flec
s e
• B ase • R
•C

Sharma cover 4th imp CMYK

 Rapid Review of

Clinical
Medicine
for MRCP Part 2
Second Edition
Sanjay Sharma
BSc (Hons) MD FRCP (UK) FESC
Professor of Clinical Cardiology
Consultant Cardiologist and Physician
St George’s University of London
St George’s Hospital NHS Trust
University Hospital Lewisham
London, UK

Rashmi Kaushal
BSc (Hons) FRCP (UK)
Consultant Physician and Endocrinologist
West Middlesex Hospital
Kingston, UK

MANSON
PUBLISHING
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2006 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20150311

International Standard Book Number-13: 978-1-84076-641-7 (eBook - PDF)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable
data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be
made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal
to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use
by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their
knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid
advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly
urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their
websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a par-
ticular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or
her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright
holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If
any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any elec-
tronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information
storage or retrieval system, without written permission from the publishers.

For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact
the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that pro-
vides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of
payment has been arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation
without intent to infringe.
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com

and the CRC Press Web site at

http://www.crcpress.com
 3

Contents
Acknowledgements 2
Preface 3
Classification of Cases 4
Abbreviations 5
Clinical Cases 7
Data Interpretations Tutorials 415
Calcium Biochemistry 415
Genetics 415
Audiograms 416
Guidelines for the Interpretation of Cardiac Catheter Data 418
Respiratory Function Tests 419
Interpretation of Respiratory Flow Loop Curves 420
Echocardiography 421
Acid–base Disturbance 426
Normal Ranges 427

Preface
Passing specialist examinations in internal medicine is a diagnoses, diagnostic algorithms and up-to-date medical
difficult milestone for many doctors, but is a mandatory lists are presented. Many questions comprise illustrated
requirement for career progression. Pass rates in these material in the form of radiographic material, electro-
examinations are generally low due to ‘high standards’ cardiograms, echocardiograms, blood films, audiograms,
and ‘stiff competition’. Thorough preparation is essential respiratory flow loops, histological material, and slides in
and requires a broad knowledge of internal medicine. ophthalmology, dermatology and infectious diseases.
The pressures of a busy clinical job and nights ‘on call’ Over 200 commonly examined illustrations are included.
make it almost impossible for doctors to wade through Tutorials are included at the end of the book to aid
heaps of large text books to acquire all the knowledge the interpretation of illustrated material as well as impor-
that is required to pass the examinations. tant, and sometimes difficult, clinical data, such as respir-
The aim of this book is to provide the busy doctor with atory function tests, cardiac catheter data and dynamic
a comprehensive review of questions featured most endocrine tests.
frequently in the MRCP (II) examination in internal The book will prove invaluable to all those studying
medicine. The MRCP (II) examination has a best of 5/n for higher examinations in internal medicine, and to their
from many answer format. The vast majority of the instructors.
questions in the book follow the same pattern; however,
we have chosen to include several scenarios with open
ended questions to stimulate the medical thought process. Sanjay Sharma
The level of difficulty of each question is of the same Professor of Clinical Cardiology
standard as MRCP (II) examination. However, some cases Consultant Cardiologist and Physician
are deliberately more difficult for teaching purposes. Lecturer for Medibyte Intensive Courses
A broad range of subjects is covered in over 400 for the MRCP Part 2
questions ranging from metabolic medicine to infectious
diseases. Precise answers and detailed discussion follow Rashmi Kaushal
each question. Where appropriate, important differential Consultant Physician and Endocrinologist
4

Classification of Cases
Cardiology Metabolic medicine
1, 10, 11, 13, 22, 25, 32, 40, 52, 53, 54, 62, 63, 66, 68, 9, 29, 34, 38, 50, 71, 74, 81, 82, 84, 90, 129, 134, 136,
74, 78, 80, 94, 95, 100, 121, 123, 125, 130–132, 138, 147, 153, 161, 179, 189, 214, 215, 230, 248, 257, 271,
144, 150, 160, 167, 178, 180, 184, 193, 197, 199, 202, 275, 283, 310, 321, 326, 329, 333, 334, 398
203, 207, 208, 223, 226, 229, 232, 235, 237, 243, 246,
259, 266, 270, 285, 287, 291, 296, 301, 305, 307, 309, Nephrology
318, 323, 324, 327, 331, 332, 335, 342, 350, 353, 362, 4, 17, 24, 29, 44, 53, 59, 60, 85, 92, 118, 119, 126, 135,
368, 377, 387, 389, 391 137, 141, 152, 185, 198, 228, 244, 245, 249, 250, 251,
278, 289, 294, 303, 304, 317, 328, 344, 354, 381, 382
Dermatology
116, 154, 173, 316 Neurology
30, 65, 67, 93, 98, 103, 105, 108, 112, 128, 139, 145,
Endocrinology and diabetes 190, 192, 200, 239–241, 247, 253, 255, 256, 268, 274,
5, 9, 23, 39, 46, 76, 82, 89, 92, 101, 106, 107, 127, 288, 290, 292, 307, 314, 330, 345, 365, 390, 395, 399
134, 146, 159, 164, 168, 173, 181, 199, 218, 220, 238,
242, 254, 260, 261, 273, 281, 328, 334, 372, 373, 379, Obstetric medicine
397, 401 130–132, 190, 193, 348

Environmental medicine Oncology

140 117, 216, 258, 358, 359

Gastroenterology Ophthalmology
3, 6, 19, 24, 33, 64, 72, 75, 104, 127, 133, 143, 148, 282, 345
162, 169, 182, 188, 201, 231, 276, 293, 306, 338, 339,
347, 367, 369, 371, 383, 393, 394, 400 Radiology
2, 18, 64, 88, 97, 99, 124, 183, 187, 222, 227, 252,
Genetics 280, 300, 302, 311, 343, 349, 355, 357, 360, 363
47, 85, 151, 170, 194, 195, 269, 315, 361
Respiratory medicine
Haematology 8, 14, 21, 35, 36, 37, 43, 45, 55, 56, 58, 61, 72, 79, 91,
12, 38, 49, 69, 70, 73, 86, 87, 102, 114, 115, 117, 120, 99, 111, 113, 157, 164, 196, 217, 225, 272, 279, 298,
122, 142, 156, 163, 175, 191, 204, 211, 216, 219, 233, 304, 327, 341, 349, 356, 370, 380, 384, 396
258, 263, 265, 295, 297, 299, 308, 313, 336, 346, 351,
352, 358, 376, 385, 392, 394 Rheumatology
4, 15, 17, 31, 42, 71, 77, 87, 96, 109, 141, 171, 174,
Immunology 177, 196, 198, 200, 210, 236, 264, 320, 324, 340, 364,
15, 155, 374 375, 401, 402

Infectious diseases Therapeutics/toxicology

16, 18, 26, 41, 51, 83, 88, 93, 110, 128, 142, 143, 149, 7, 8, 20, 27, 28, 36, 48, 57, 68, 77, 116, 118, 119, 165,
152, 154, 158, 166, 176, 212, 221, 225, 234, 262, 267, 172, 175, 186, 205, 206, 209, 213, 224, 251, 284, 286,
277, 280, 319, 322, 325, 337, 345, 351, 383, 386, 388 312, 316, 317, 332, 339, 366, 378
 5

Abbreviations
5-HIAA 5'-hydroxyindole acetic CML chronic myeloid leukaemia FVC forced vital capacity
acid CMV cytomegalovirus GBM glomerular basement
AIIRB angiotensin II receptor COPD chronic obstructive membrane
blocker pulmonary disease GCT giant cell tumour
AAFB acid–alcohol fast bacilli CPAP continuous positive airway GFR glomerular filtration rate
ACE angiotensin-converting pressure GH growth hormone
enzyme CREST calcinosis, Raynaud’s GHRH growth hormone releasing
ACTH adrenocorticotrophic syndrome, oesophageal hormone
hormone problems, scleroderma, GI gastrointestinal
ADH antidiuretic hormone telangiectasia GP general practitioner
AF atrial fibrillation CRF chronic renal failure GPI glucophosphatidylinositol
AIDS acquired immune- CRP C-reactive protein GT glutamyltransferase
deficiency syndrome CSF cerebrospinal fluid GTN glyceryl trinitrate
AIN acute interstitial nephritis CSS Churg–Strauss syndrome Hb haemoglobin
AIP acute intermittent CT computed tomography HbSS sickle cell anaemia
porphyria CVA cerebrovascular accident HC Hereditary Copro
ALA aminolaevulinic acid CVP central venous pressure porphyria
ALT alanine transaminase CXR chest X-ray HCC hydroxy-cholecalciferol
(SGPT) DBP diastolic blood pressure HCM hypertrophic
AML acute myeloid leukaemia DC direct current cardiomyopathy
AMP adenosine 5'- DHCC dihydroxy-cholecalciferol HCV hepatitis C virus
monophosphate DIC disseminated intravascular HCG human chorionic
ANA antinuclear antibody coagulation gonadotrophin
ANCA antineutrophil cytoplasmic DIDMOAD diabetes insipidus, HELLP haemolysis, elevated liver
antibodies diabetes mellitus, optic enzymes and low platelets
ANF antinuclear factor atrophy and deafness HHT hereditary haemorrhagic
APCKD adult polycystic kidney DM diabetes mellitus telangiectasia
disease DT delerium tremens HIT heparin-induced
APTT activated partial DVT deep-vein thrombosis thrombocytopenia
thromboplastin time EAA extrinsic allergic alveolitis HIV human immunodeficiency
AR aortic regurgitation EBV Epstein–Barr virus virus
ARDS adult respiratory distress ECG electrocardiogram HONK hypersimilar non-ketotic
syndrome EEG electroencephalogram diabetic coma
ARVC arrhythmogenic right ELISA enzyme-linked HR heart rate
ventricular cardiomyopathy immunosorbent assay HRT hormone replacement
AS aortic stenosis EMF endomyocardial fibrosis therapy
ASD atrial septal defect EMG electromyogram HS hereditary spherocytosis
ASO antistreptolysin ENT ear, nose and throat HSMN hereditary sensorimotor
AST aspartate transaminase EPO erythropoietin neuropathy
(SGOT) ERCP endoscopic retrograde HUS haemolytic uraemic
ATN acute tubular necrosis cholangiopancreatogram syndrome
AZT zidovudine ESR erythrocyte sedimentation ICD implantable cardioverter
BCG bacille Calmette–Guérin rate defibrillator
BIH benign intracranial FBC full blood count ICP intracranial pressure
hypertension FDP fibrinogen degradation INR International Normalized
BP blood pressure product Ratio
BT bleeding time FES fat embolism syndrome IPF idiopathic pulmonary
BTS British Thoracic Society FEV1 fixed expiration volume in fibrosis
CAH chronic active hepatitis 1 second IVP intravenous pyelogram
CAP community acquired FFP fresh-frozen plasma IVU intravenous urogram
pneumonia FNA fine-needle aspiration JVP jugular venous pressure
CCF congestive cardiac failure FSH follicle stimulating KCO corrected carbon monoxide
CFTR cystic fibrosis hormone transfer factor
transmembrane regulator FTA fluorescent treponemal LBBB left bundle branch block
(protein) antibody LDH lactate dehydrogenase
6

LFT liver function tests NSTEMI non-ST elevation TCAD tricyclic antidepressant
LH luteinizing hormone myocardial infarction overdose
LHON Leber’s hereditary optic NYHA New York Heart TIA transient ischaemic attack
neuropathy Association TIBC total iron-binding capacity
LHRH luteinizing hormone OSA obstructive sleep apnoea TIPSS transjugular intrahepatic
releasing hormone PAN polyarteritis nodosa portosystemic shunt
LMWH low-molecular weight PAS periodic acid-Schiff TLC total lung capacity
heparin PBC primary biliary cirrhosis TLCO total lung carbon
LQTS long QT-syndrome PBG porphobilinogen monoxide transfer factor
LVEDP left ventricular end-diastolic PCOS polycystic ovary syndrome TOE transoesophageal
pressure PCR polymerase chain reaction echocardiography
LVH left ventricular hypertrophy PCT porphyria cutanea tarda TPA tissue plasminogen
MAHA microangiopathic PCV packed cell volume activator
haemolytic anaemia PCWP pulmonary capillary wedge TPHA treponema pallidum
MAOI monoamine oxidase pressure haemagglutination test
inhibitor PE pulmonary embolism TRH thyrotrophin releasing
MCH mean cell haemoglobin PEFR peak expiratory flow rate hormone
MCHC mean cell haemoglobin PFO patent foramen ovale TSAT transferrin saturation
content PKD polycystic kidney disease TSH thyroid stimulating
MCV mean cell volume PMLE progressive multifocal hormone
MELAS mitochondrial leucoencephalopathy TT thrombin time
encephalopathy, lactic PMR polymyalgia rheumatica TTP thrombotic
acidosis, stroke-like PNH paroxysmal nocturnal thrombocytopenic purpura
syndrome haemoglobinuria U&E urea and electrolytes
MEN multiple endocrine PRL prolactin URTI upper respiratory tract
neoplasia PRV polycythaemia rubra vera infection
MERRF myoclonic epilepsy and red PSC primary sclerosing US ultrasound
ragged fibres cholangitis UTI urinary tract infection
MGUS monoclonal gammopathy PT prothrombin time VDRL Venereal Diseases Research
of undetermined PTH parathormone or Laboratory test
significance parathyroid hormone VF ventricular fibrillation
MPO myeloperoxidase PVE prosthetic valve VIP vasointestinal polypeptide
MR mitral regurgitation endocarditis VMA vanilyl mandelic acid
MRA magnetic resonance RA rheumatoid arthritis VP variegate porphyria
angiography RBBB right bundle branch block VR ventricular rate
MRCP magnetic resonance REM rapid eye movement VSD ventricular septal defect
cholangiopancreatogram RMAT rapid macroagglutination VT ventricular tachycardia
MRI magnetic resonance test WCC white cell count
imaging RTA renal tubular acidosis WPW Wolff–Parkinson–White
MRSA methicillin resistant RV residual volume (syndrome)
Staphylococcus aureus SADS sudden adult death
MRV magnetic resonance syndrome
venography SAM systolic anterior motion of
MSH melanocyte stimulating the mitral valve
hormone SAP serum amyloid protein
NADPH nicotinamide adenine SIADH syndrome of inappropriate
dinucleotide phosphate antidiuretic hormone
(reduced) SLE systemic lupus
NAPQI N-acetyl-p- erythematosus
benzoquinoneimine SMA smooth muscle antibody
NARP neuropathy, ataxia, retinitis SPECT single photon emission
pigmentosa computed tomography
NASH non-alcoholic SROS Steele–Richardson–
steatohepatitis Olszewski syndrome
NIPPV non-invasive positive STEMI ST elevation myocardial
pressure ventilation infarction
NSAID non-steroidal anti- SVT supraventricular tachycardia
inflammatory drug TB tuberculosis
 Clinical Cases 7

Question 1

A 49-year-old male presented to the Accident and

Emergency Department with a one-hour history of severe What is the best treatment to improve coronary perfusion?
central chest pain. He smoked 30 cigarettes per day. a. IV Streptokinase.
Physical examination was normal. The 12-lead ECG b. IV Tenectoplase.
revealed ST segment elevation in leads V1–V4. There c. IV Alteplase.
were no contraindications to thrombolysis. d. Half-dose tenectoplase and half-dose abciximab.
e. Primary coronary angioplasty.

Question 2

A 68-year-old woman presented with pain and tingling in

What was the abnormality on the chest X-ray?
the left arm when she raised her hands for prolonged
a. Left-sided bronchogenic carcinoma.
periods. On examination both pulses were palpable in the
b. Left cervical rib.
upper limbs. The chest X-ray was abnormal. Aortography
c. Retrosternal thyroid.
was performed with the arms down (2a) and with the
d. Notching of the ribs.
arms up (2b).
e. Widened mediastinum.

2a 2b

Question 3

A 28-year-old male presented with a six-month history of Hb 9 g/dl

weight loss of 8 kg, generalized abdominal discomfort WCC 4.6  109/l
and diarrhoea. On examination he was pale and slim, but Platelets 200  109/l
there were no other significant abnormalities. MCV 76 fl
Investigations are shown. ESR 38 mm/h
Sodium 141 mmol/l
Potassium 4 mmol/l
Urea 3 mmol/l
What is the diagnosis?
Creatinine 68 mol/l
a. Crohn’s disease.
Corrected calcium 2.02 mmol/l
b. Intestinal lymphangiectasia.
phosphate 0.8 mmol/l
c. Coeliac disease.
Alkaline phosphatase 190 iu/l
d. Small bowel lymphoma.
Albumin 38 g/l
e. Hypogammaglobulinaemia.
IgA <0.1 g/l (NR 0.8–4.0 g/l)
IgG 9.0 g/l (NR 7.0–18.0 g/l)
IgM 0.6 g/l (NR 0.4–2.5 g/l)
IgA anti-endomyosial Absent
antibody
8

Answer 1

There have been trials evaluating the role of combined

e. Primary coronary angioplasty. half-dose thrombolytic therapy and half-dose platelet
glycoprotein IIb/IIIa receptor blockers, e.g. tenectoplase
Coronary reperfusion may be achieved with thrombolytic plus abciximab (ASSENT 3) and reteplase plus abciximab
agents (which promote fibrinolysis) or by coronary (GUSTO IV). These trials suggest that the combination
angioplasty. In the UK patients with ST elevation may be associated with slightly higher coronary patency
myocardial infarction are conventionally treated with rates and fewer ischaemic events but they have not
thrombolytic agents. Early treatment is crucial to salvage demonstrated a mortality benefit. These trials have also
myocardium and reduce the risk of sudden death and demonstrated higher rates of intracranial bleeding in the
severe left ventricular dysfunction. Current goals for the elderly, hence combination therapy is not recommended
speed of treating with a thrombolytic agent include a at present.
door-to-needle time of 20 minutes or a call-to-needle Although thrombolytic treatment is associated with a
time of 60 minutes. significant reduction in mortality from myocardial
Thrombolytic agents used commonly include infarction, it does have important limitations. Firstly,
streptokinase, alteplase, tenectoplase and reteplase. greatest benefit from thrombolysis is achieved in patients
Streptokinase is less favoured compared with the other treated within 4 hours of the onset of symptoms. Even with
thrombolytic agents because it is less effective at restoring thrombolysis normalization of blood flow is seen in only
coronary perfusion and is associated with slightly worse 50–60% of cases. Recurrent ischaemia occurs in 30% of
outcomes. The GUSTO I study compared front-loaded cases and frank thrombotic coronary occlusion in 5–15%.
alteplase therapy with streptokinase in patients with ST Re-infarction occurs in up to 5% of cases while in hospital.
EMI. Alteplase was superior to streptokinase in reducing Also major bleeding is recognized in 2–3% of cases. For
mortality (1% absolute reduction in mortality at 30 days these reasons several trials were set up comparing primary
with alteplase) and was associated with greater coronary angioplasty with thrombolysis in STEMI.
patency rates. In the GUSTO trial the benefit was Primary angioplasty is superior to thrombolysis. It is
greatest in patients aged under 75 years and those with associated with lower mortality and lower re-infarction
anterior myocardial infarction. However, streptokinase is rates. The likelihood of a pre-discharge positive exercise
still used extensively in developing countries and in many test is also reduced by primary angioplasty. In hospitals
hospitals in the UK. Alteplase, tenectoplase and reteplase where facilities for primary angioplasty are available,
appear to be equally effective. Tenectoplase and reteplase primary angioplasty should be considered over
are easier to administer (as a single bolus). thrombolysis. Best results occur when the door-to-
balloon time is less than 2 hours.

Answer 2
ribs are common in the normal population and are
b. Left cervical rib. usually asymptomatic. In rare circumstances a cervical rib
may cause pressure on the subclavian vessels and the
There is mechanical occlusion of the left subclavian artery brachial plexus causing transient vascular insufficiency or
on raising the left arm due to a left cervical rib. Cervical paraesthesiae in the upper limb.

Answer 3
endomyosial antibodies are IgA antibodies, therefore
c. Coeliac disease. they will not be detected in patients with low IgA
antibody levels. Since coeliac disease is also associated
Diarrhoea, weight loss, abdominal discomfort and with IgA deficiency it is important to be aware of serum
isolated IgA deficiency are highly suggestive of coeliac IgA levels before interpreting anti-endomyosial
disease. Anti-endomyosial antibodies are highly sensitive antibodies in patients with malabsorption. (See Question
and specific for the diagnosis of coeliac disease. Anti- 276.)
 Clinical Cases 9

Question 4

A 53-year-old male was admitted to hospital with a two-

week history of coughing and breathlessness. Apart from Hb 7 g/dl
a longstanding history of mild asthma he had been WCC 11  109/1
relatively well with respect to the respiratory tract. He (neutrophils 8  109/l,
had been on a skiing trip six weeks previously, without lymphocytes 2  109/l,
any respiratory problems. eosinophils 1  109/l)
He had a past history of depression, for which he took ESR 38 mm/h
lithium five years ago, and suffered from occasional Sodium 134 mmol/l
tension headaches, for which he took simple analgesia. Potassium 4.6 mmol/l
On examination he appeared pale and unwell. His Urea 48 mmol/l
heart rate was 90 beats/min and regular. His blood Creatinine 798 mmol /l
pressure measured 160/94 mmHg. The JVP was not Renal ultrasound
raised. Both heart sounds were normal and the chest was Both kidneys measured 12 cm: there was no
clear. Abdominal examination did not reveal any evidence of ureteric obstruction.
abnormality. Urinalysis demonstrated blood ++ and
protein ++.
Investigations performed in hospital are shown.

What is the most likely diagnosis?

a. Rapidly progressive glomerulonephritis.
b. Analgesic nephropathy.
c. Renal amyloidosis.
d. Churg–Strauss syndrome.
e. IgA nephritis.

Question 5

A 52-year-old male presented with impotence. He had a

FBC Normal
four-year history of insulin-dependent diabetes mellitus.
Sodium 135 mmol/l
There was no history of headaches or vomiting. The
Potassium 4 mmol/l
patient was a non-smoker and did not consume alcohol.
Urea 6 mmol/l
Apart from insulin he took simple analgesia for joint
Creatinine 100 mmol/l
pains.
Bilirubin 12 mmol/l
Investigations are shown.
AST 200 iu/l
ALT 220 iu/l
What test would you perform to confirm the Alkaline phosphatase 128 iu/l
diagnosis? Albumin 8 g/l
a. MRI scan of the brain. Thyroxine 100 nmol/l
b. Serum prolactin level. TSH 2.6 mu/l
c. Serum ferritin. Testosterone 7 nmol/l (NR 10–35 nmol/l)
d. Dynamic pituitary function tests.
e. Liver ultrasound. LH 1.5 iu/l (NR 1–10 iu/l)
FSH 1 iu/l NR 1–7 iu/l)
LHRH test: 20 min: 60 min:
LH 3 iu/l 2 iu/l
FSH 2 iu/l 2 iu/l
10

Answer 4

d. Churg–Strauss syndrome. Table A Phases of Churg–Strauss syndrome:

1. The prodromal phase, which may be present for
The patient has a past history of asthma, eosinophilia and years and comprises of rhinitis, nasal polyposis and
rapidly progressive glomerulonephritis. The most probable frequently asthma.
diagnosis is Churg–Strauss syndrome. The assumption that 2. The eosinophilic phase, which can remit and recur
for years. It is characterized by the onset of
he probably has rapidly progressive glomerulonephritis is
peripheral blood and tissue eosinophilia, resembling
based on the fact that he was well enough to ski six weeks Loeffler’s syndrome, chronic eosinophilic
ago, which would be highly unlikely in a patient with end- pneumonia or eosinophilic gastroenteritis.
stage renal disease. The identification of normal-sized 3. The vasculitic phase, which usually occurs in the
kidneys during renal ultrasonography supports acute rather third or fourth decades of life and is characterized
than chronic renal failure (Table A). by a life-threatening systemic vasculitis of small and
Churg–Strauss syndrome is a small-vessel multi-system occasionally medium-sized vessels. This phase is
vasculitis characterized by cutaneous vasculitic lesions, associated with constitutional symptoms and signs,
eosinophilia (usually <2.0  10 9/l), asthma (usually fever and weight loss.
mild), mononeuritis or polyneuropathy and rarely
glomerulonephritis (10% of cases). Gastrointestinal and
cardiac involvement is recognized. Table B American College of Rheumatology 1990
criteria for Churg–Strauss syndrome
Pulmonary findings dominate the clinical presentation
with paroxysmal asthma attacks and presence of fleeting The presence of four or more of the manifestations
pulmonary infiltrates. Asthma is the cardinal feature and may below is highly indicative of Churg–Strauss syndrome:
be present for years before overt features of a multi-system • Asthma
vasculitis become apparent. Skin lesions, which include • Eosinophilia (10% on WCC differential)
• Mononeuropathy or polyneuropathy
purpura and cutaneous and subcutaneous nodules, occur in
• Migratory or transient pulmonary infiltrates
up to 70% of patients. Gastrointestinal complications include • Systemic vasculitis (cardiac, renal, hepatic)
mesenteric ischaemia or gastrointestinal haemorrhage. • Extravascular eosinophils on a biopsy including
Cardiac involvement is characterized by myo-pericarditis. artery, arteriole or venule
The diagnosis is usually clinical and supported by the
presence of a necrotizing granulomatous vasculitis with
extravascular eosinophilic infiltration on lung, renal or sural Table C Causes of renal failure and eosinophilia
biopsy. The American College or Rheumatology criteria • Rapidly progressive glomerulonephritis
for the diagnosis of Churg–Strauss syndrome are tabulated • Churg–Strauss syndrome
(Table B). Serum ANCA (MPO subset) are elevated but • Acute tubulo-interstitial nephritis
this finding is also present in microscopic polyangitis. • Cholesterol micro-emboli
The prognosis of untreated CSS is poor, with a
reported five-year survival rate of only 25%. Corticosteroid
therapy has been reported to increase the five-year associated with eosinophilia. Causes of renal failure and
survival rate to more than 50%. In patients with acute eosinophilia are tabulated (Table C).
vasculitis the combination of cyclophosphamide and The history of analgesia for headaches raises the
prednisone is superior to prednisolone alone. possibility of analgesic nephropathy as the cause of his
Although rapidly progressive glomerulonephritis also presentation; however, analgesic nephropathy is usually
features in the answer options section, the presence of insidious and many patients present for the first time with
asthma and eosinophilia make Churg–Strauss syndrome renal failure. The majority have abnormalities on renal
the best answer. It is worth noting however, that rapidly ultrasound scans. Analgesic nephropathy alone does not
progressive glomerulonephritis may also rarely be explain asthma or eosinophilia.

Answer 5

involvement, and abnormal liver function is consistent

c. Serum ferritin. with hepatic infiltration.
The patient has a low testosterone level with an
The clinical features and the data are consistent with the inappropriately low gonadotrophin response indicating
diagnosis of idiopathic haemochromatosis. The insulin- secondary hypogonadism due to excessive iron deposition
dependent diabetes mellitus suggests pancreatic in the pituitary. Secondary hypogonadism is the most
 Clinical Cases 11

common endocrine deficiency in hereditary haemo - ferritin concentrations even in the absence of iron overload.
chromatosis. Primary hypogonadism due to testicular Hepatic iron overload in haemochromatosis is associated
iron deposition may occur with this disorder but is much with an increased risk of hepatocellular carcinoma. Patients
less common than secondary hypogonadism. with haemochromatosis are also at increased risk of
In the context of the question, a serum ferritin level hypothyroidism and are susceptible to certain infections
>500 mg/l would be diagnostic of primary haemo - from siderophoric (iron-loving) organisms such as Listeria
chromatosis. Alcohol-related liver disease, chronic viral spp., Yersinia enterocolitica and Vibrio vulnificus, which are
hepatitis, non-alcoholic steatohepatitis and porphyria picked up from eating uncooked seafood.
cutanea tarda also cause liver disease and increased serum

Question 6

A 38-year-old English male was investigated after he was Hb 12.6 g/dl

found to have an abnormal liver function test during a WCC 8  109/l
health insurance medical check. He worked in an Platelets 210  109/l
information technology firm. Apart from occasional MCV 90 fl
fatigue he was well. He consumed less than 20 units of Sodium 136 mmol/l
Potassium 4.1 mmol/l
alcohol per week. The patient had only travelled out of
Urea 6 mmol/l
Europe twice and on both occasions he had been to Creatinine 100 mmol/l
North America. He took very infrequent paracetamol for AST 60 iu/l (NR 10–40 iu/l)
aches and pains in his ankles and knees. There was no ALT 78 iu/l (NR 5–30 iu/l)
history of hepatitis or transfusion or blood products. He Alkaline phosphatase 350 iu/l (NR 25–100 iu/l)
had been married for 5 years. Systemic enquiry revealed Bilirubin 22 mmol/l (NR 2–17 μmol/l)
infrequent episodes of loose stool for almost 4 years. Albumin 38 g/l (NR 34–48 g/l)
On examination he appeared well. There were no Total cholesterol 5.2 mmol/l
stigmata of chronic liver disease. Abdominal examination Triglyceride 3.1 mmol/l
revealed a palpable liver edge 3 cm below the costal Blood glucose 6 mmol/l
Ferritin 256 mg/l (NR 15–250 mg/l)
margin. There were no other masses. Examination of the
Serum Fe 28 mmol/l
central nervous system was normal. (NR 14–32 mmol/l)
Investigations were as shown. TIBC 50 mmol/l
(NR 40–80 mmol/l)
Serum Slightly reduced
What is the most probable diagnosis?
caeruloplasmin
a. Autoimmune hepatitis. 24-hr urine copper Slightly elevated
b. Primary sclerosing cholangitis. IgG 19 g/l (NR 7–18 g/l)
c. Primary biliary cirrhosis. IgA 4.2 g/l (NR 0.8–4.0 g/l)
d. Haemochromatosis. IgM 5.0 g/l (NR 0.4–2.5 g/l)
e. Wilson’s disease. Anti-nuclear Positive 1/32
antibodies
Smooth muscle Not detected
antibodies
Antimitochondrial Not detected
antibodies
Hep B sAg Not detected
Hep C virus Not detected
antibodies
Abdominal ultrasound Normal

Question 7 What is the best marker of prognosis?

a. Serum aspartase transaminase.
A 17-year-old girl presented with jaundice three days b. Serum alkaline phosphatase.
after having taken a paracetamol and alcohol overdose c. Serum bilirubin.
during an argument with her boyfriend. d. Prothrombin time.
e. Paracetamol level.
12

Answer 6

progression of the disorder. Patients are treated with

b. Primary sclerosing cholangitis. cholestyramine to reduce pruritus. Fat-soluble vitamin
supplementation is necessary owing to steatorrhoea.
This is a relatively difficult question. The history of loose Antibiotic prophylaxis during instrumentation of the
stool is crucial in making the diagnosis in this particular biliary tree is mandatory to reduce the risk of bacterial
case in the absence of data from the ERCP. Diarrhoea cholangitis. Ciprofloxacin is the prophylactic antibiotic
and biochemical evidence of cholestasis (alkaline drug of choice prior to ERCP. Biliary stenting may
phosphatase greater than transaminases) should lead to improve biochemistry and symptoms; however, the
the clinical suspicion of primary sclerosing cholangitis definitive treatment for PSC is hepatic transplantation.
(PSC). The aetiology of PSC is unknown but Although a cholestatic picture is also recognized in
immunological destruction of intra- and extra-hepatic primary biliary cirrhosis, alcohol abuse and viral hepatitis
bile ducts is the main pathological feature. 90% of PSC is there is nothing in the history or investigations to indicate
associated with inflammatory bowel disease, particularly these conditions as the cause of his illness. Primary biliary
ulcerative colitis, and hence the importance of the cirrhosis affects mainly females in the fifth decade
intermittent diarrhoea. Ulcerative colitis is the most onwards. Furthermore, the absence of anti-mitochondrial
frequent association with primary sclerosing cholangitis. antibodies is against the diagnosis. The ferritin is modestly
A raised alkaline phosphatase level in a patient with raised but not high enough to suggest hereditary
ulcerative colitis (in the absence of bone disease) should haemochromatosis. High ferritin levels are also a feature
raise the possibility of PSC. The frequency of PSC is of chronic viral hepatitis, alcohol-related hepatitis and
inversely proportional to the severity of ulcerative colitis. non-alcoholic steato-hepatitis. Hypergammaglobulinaemia
Other associations of PSC include coeliac disease. and raised autoantibody titres are features of primary
Patients with PSC may be asymptomatic at pre - sclerosing cholangitis but also occur in other
sentation but can present with advanced liver disease. immunological liver disorders such as chronic active viral
Fatigue and pruritus are common complaints as with the hepatitis, auto-immune hepatitis and biliary cirrhosis.
other cholestatic disorders. Approximately one-fifth of Patients with cholestasis also have lowish caerulo -
the patients also complain of right upper quadrant pain. plasmin levels and increased blood and urine copper
The diagnosis is confirmed with ERCP that shows levels. The abnormal copper metabolism in this case
strictures within biliary ducts. Complications are those of should not lead to the candidate diagnosing Wilson’s
chronic cholestasis, notably statorrhoea, fat-soluble disease, since there are many features above to indicate
vitamin malabsorption, large biliary strictures, cholangitis, PSC. Furthermore, patients with Wilson’s disease usually
cholangiocarcinoma and colonic carcinoma. There are no have a hepatitic biochemistry picture and often have co-
effective pharmacological agents that greatly retard the existing neuro-psychiatric disease.

Answer 7
Important risk markers for severe hepatic injury after
d. Prothrombin time. paracetamol overdose include a PT >20 seconds 24 h
after ingestion, pH <7.3 and creatinine >300 mol/l.
(See Questions 27 and 206.)
 Clinical Cases 13

Question 8

A 16-year-old girl presented with an 18-month history of crackles in the mid and lower zones. Repeat lung
progressive breathlessness on exertion. On admission she function tests revealed an FEV1/FVC ratio of 86% and a
was breathless at rest. She had a past history of acute transfer factor of 60% predicted.
myeloid leukaemia, for which she had been treated with
six courses of chemotherapy, followed by bone marrow
transplantation supplemented with radiotherapy and What is the cause of her symptoms?
cyclophosphamide treatment five years ago. She was a. Previous radiotherapy.
regularly followed up in the haematology clinic. Lung b. CMV pneumonitis.
function tests three years ago revealed an FEV1/FVC c. Pneumocystis carinii pneumonia.
ratio of 80%. On examination she was breathless at rest, d. Cyclophosphamide-induced lung fibrosis.
and cyanosed. There was no evidence of clubbing. e. Severe anaemia.
Auscultation of the lung fields revealed fine inspiratory

Question 9
A 21-year-old man was admitted to the intensive care a severe head injury. He required ventilation.
unit after a road traffic accident during which he suffered Investigations are shown.

Sodium 128 mmol/l

Potassium 3.6 mmol/l
Creatinine 81 mmol/l What is the cause of the hyponatraemia?
Urea 4 mmol/l a. Hypopituitarism.
Thyroxine 30 nmol/l b. Addison’s disease.
TSH 2 mu/l c. Syndrome of inappropriate ADH secretion.
Serum cortisol 1000 nmol/l d. Hypothyroidism.
(NR 170–700 nmol/l) e. Cushing’s syndrome.

Question 10

A 40-year-old woman with dilated cardiomyopathy is

seen in the heart failure clinic complaining of a persistent How would you alter her treatment?
dry cough. Her exercise capacity is 1 mile while walking a. Add spironolactone.
on the flat. She can climb two flights of stairs without b. Substitute ramipril with losartan.
difficulty. Her medication consists of ramipril 10 mg c. Reduce carvedilol to 3.125 mg twice daily.
daily, aspirin 75 mg daily, carvedilol 6.25 mg twice daily d. Double the dose of furosemide.
and frusemide 40 mg daily. On examination her heart e. Add digoxin.
rate is 70 beats/min and her blood pressure is
100/60 mmHg. Both heart sounds are normal and the
chest is clear.
14

Answer 8

Cyclophosphamide therapy can also result in an acute

d. Cyclophosphamide-induced lung fibrosis.
pneumonitis during treatment with the drug that causes
cough, dyspnoea, hypoxia and bilateral nodular opacities
The patient presents with progressive symptoms in the upper zones of the lung. Acute cyclophosphamide-
associated with a restrictive lung defect and a low induced pneumonitis responds to cessation of the drug
transfer factor. The findings are most consistent with and corticosteroid therapy.
cyclophosphamide-induced pulmonary fibrosis. The differential diagnosis in this case is radiation-
Cyclophosphamide-induced lung fibrosis is rare and is induced fibrosis. Radiotherapy to the pulmonary area
most likely to occur in patients who have had concomitant usually causes a pneumonitis that presents with cough,
pulmonary radiation therapy or have taken other drugs dyspnoea, a restrictive lung defect and low transfer factor.
associated with pulmonary toxicity. The disorder usually It is more common in patients also taking cyclo -
occurs in patients who have been taking low doses for phosphamide or bleomycin. Unlike cyclophosphamide-
relatively prolonged periods (over six months) and induced pulmonary fibrosis the condition is not
presents several years after cessation of the drug and associated with an inexorable decline. Indeed many
hence the deterioration of symptoms with time. The patients show improvement in symptoms and objective
disorder has a relentless progression and inevitably results pulmonary function testing within 18 months of
in terminal respiratory failure. It is minimally responsive stopping radiotherapy.
to corticosteroids. Fine end-inspiratory crackles and
clubbing do not usually form part of the clinical
spectrum. Causes of drug-induced pulmonary fibrosis
The diagnosis is clinical. Chest X-ray reveals reticulo-
nodular shadowing of the upper zones. Lung function • Cyclophosphamide
tests demonstrate a restrictive lung defect. Lung biopsy is • Busulphan
not helpful. • Methysergide
Cyclophosphamide per se is not toxic to the lungs; • Methotrexate
however, it is metabolized in the liver to toxic • Amiodarone
metabolites such as hydroxycyclophosphamide, acrolein • Nitrofurantoin
and phosphoramide mustard, which are responsible for • Minocycline
pulmonary damage. Genetic factors may play a role in • Ethambutol
determining which individuals develop pulmonary • Penicillamine
fibrosis after exposure to the drug.

Answer 9
be euthyroid, therefore the term sick euthyroid syndrome
c. Syndrome of inappropriate ADH secretion.
was used to describe these biochemical abnormalities.
There is evidence now that these abnormalities represent
The patient has a low sodium concentration in the genuine acquired transient central hypothyroidism.
context of a head injury. The thyroid function tests Treatment with thyroxine in these situations is not
suggest the possibility of a secondary hypothyroidism, i.e. helpful and may be harmful. It is thought that these
a low TSH and a low thyroxine concentration, and hence changes in thyroid function during severe illness may be
the possibility of damage to the pituitary. However, the protective by preventing excessive tissue catabolism.
very high cortisol level indicates that pituitary function is Thyroid function tests should be repeated after at least six
probably normal (high ACTH production secondary to weeks following recovery.
stress) and therefore the abnormal thyroid function tests Critical illness may also reduce T4 by reducing thyroid
represent sick euthyroid syndrome. Low T4, T3 and TSH binding globulin levels, and T3 is rapidly reduced owing
levels are recognized in critically ill patients with non- to inhibition of peripheral de-iodination of T4.
thyroid illnesses. Originally such patients were thought to
 Clinical Cases 15

Answer 10

The study revealed similar mortality rates and similar

b. Substitute ramipril with losartan. rates of progression of heart failure when comparing
patients on losartan 50 mg daily with those prescribed
The patient is in NYHA functional class II with respect to captopril 50 mg three times daily. The study suggests
her symptoms. She is on the correct dose of ramipril and that losartan is as effective as ACE inhibitors in the
is appropriately being treated with a beta-blocker. The management of heart failure. However, the use of
dry cough that the patient is experiencing is almost losartan in heart failure is still currently reserved for
certainly the side-effect of ramipril. Angiotensin- patients who develop side-effects to ACE inhibitors. A
converting enzyme inhibitors are associated with a dry recent study evaluating the role of angiotensin receptor
cough in 15–20% of patients owing to increases in blockers (CHARM study; evaluated candesartan) in
circulating bradykinin levels. In such patients the ACE patients with heart failure showed reduced hospitalization
inhibitor should be stopped and substituted with an rates and mortality in heart failure patients who were on
angiotensin receptor blocker such as losartan. The candesartan instead of an ACE inhibitor, or candesartan
efficacy of losartan compared with an ACE inhibitor as additional therapy to an ACE inhibitor.
(captopril) was fully evaluated in the ELITE II study.

Question 11

A 60-year-old male was admitted to the coronary care unit after the procedure, and an exercise stress test performed
with central chest pain. Physical examination was normal. four weeks after the procedure was negative for
The blood pressure measured 110/68 mmHg. The 12- myocardial ischaemia for 10 minutes.
lead ECG was normal and the troponin T level was not
raised. The blood sugar was normal. The cholesterol level
on admission was 6.3 mmol/l. The patient underwent an
exercise stress test that was positive. A subsequent What other medication should the patient receive to
coronary angiogram revealed an 80% stenosis in the improve his cardiovascular prognosis?
proximal aspect of the left anterior descending artery that a. Atenolol.
was successfully treated with a coronary artery stent. b. Ramipril.
Echocardiography revealed a normal-sized left ventricle c. Candesartan.
with good systolic function. The patient was discharged d. No further treatment required.
home on aspirin 75 mg daily, clopidogrel 75 mg daily and e. Isosorbide dinitrate.
simvastatin 40 mg daily. He had been completely pain free

Question 12
A 62-year-old obese male with a known medical history On examination he was obese. His chest was clear and
of hypertension presented with generalized headaches examination of the abdomen did not reveal any
and lethargy. He was taking bendroflumethiazide, abnormality.
2.5 mg once daily for hypertension. The only other past Investigations are shown.
medical history included a left-sided deep vein
thrombosis six months previously. There was no history
of alcohol abuse or smoking. Hb 20 g/dl
MCV 88 fl
WCC 15  109/l
Platelets 500  109/l
What is the cause of his symptoms?
PCV 0.66 l/l
a. Obstructive sleep apnoea. Sodium 141 mmol/l
b. Gaissbock’s syndrome. Potassium 4.2 mmol/l
c. Polycythaemia rubra vera. Urea 8 mmol/l
d. Renal cell carcinoma. Creatinine 110 mol/l
e. Chronic hypoxaemia. Urate 0.44 mmol/l
16

Answer 11

risk population with normal left ventricular function.

b. Ramipril.
Based on this study all patients with coronary artery
disease, cerebrovascular disease, peripheral vascular
The Heart Outcomes Prevention Evaluation Study disease and diabetes mellitus plus one other risk factor for
(HOPE) evaluated the role of angiotensin-converting coronary artery disease should be prescribed an ACE
enzyme inhibitors (ramipril) in populations at high risk of inhibitor, specifically ramipril.
cardiovascular events without any evidence of left The patient should remain on aspirin for life and take
ventricular dysfunction. The study assessed 9297 high- clopidogrel for a year following deployment of a stent.
risk patients, defined as (1) aged >55 years; (2) history of The CURE study showed that aspirin and clopidogrel
coronary artery disease, stroke or peripheral vascular together were associated with a lower incidence of
disease; or (3) diabetes mellitus and at least one risk myocardial infarction and death in patients with unstable
factor for coronary artery disease including hypertension, angina and non-ST elevation myocardial infarction
increased total cholesterol, smoking and micro- compared with aspirin alone for up to a year.
albuminuria. The patients were randomized to ramipril The patient no longer has subjective or objective
10 mg daily or placebo. The primary outcome was a evidence of myocardial ischaemia, and in the absence of
combined endpoint of myocardial infarction, stroke or hypertension or left ventricular dysfunction there is no
cardiovascular death. The mean follow up was five years. indication for a beta-blocker.
Patients treated with ramipril had a 14% event rate of Nitrates do not alter prognosis in coronary artery
the combined morbidity and mortality endpoint whereas disease. There is no evidence as yet that angiotensin
placebo-treated patients had a 17.8% event rate. The 21% receptor blockers improve cardiovascular prognosis in
decrease in events was seen in all pre-specified groups, patients with coronary artery disease in the absence of
indicating that ACE inhibitor therapy with ramipril hypertension or left ventricular dysfunction.
significantly reduces morbidity and mortality in a high-

Answer 12
Many patients with polycythaemia rubra vera have
c. Polycythaemia rubra vera. splenomegaly; however, a palpable spleen is absent in
approximately one third of patients.
The high Hb is suggestive of polycythaemia. There is
nothing in the history to indicate a secondary cause, e.g.
hypoxia, renal carcinoma, adrenal tumour. Although he Criteria for the diagnosis of polycythaemia rubra
was obese, there was nothing else in the history to allow vera
the diagnosis of obstructive sleep apnoea. Raised red cell mass and normal pO2 with either
The high white cell count and platelet count favour splenomegaly or two of the following:
primary polycythaemia (polycythaemia rubra vera). • WCC >12  109/l
Headache and lethargy are common symptoms of • Platelets >400  109/l
polycythaemia rubra vera. Polycythaemia rubra vera • Raised B12 binding protein
causes lethargy due to hyperviscosity and raised • Low neutrophil alkaline phosphatase
interleukin-6 levels. Other classic features include visual concentration
disturbance, abdominal pain and pruritus. (See Questions 39, 73 and 211.)
 Clinical Cases 17

Question 13
The ECG below was taken from a young boy who
experienced syncope. On examination he had a systolic What is the most probable underlying diagnosis?
murmur. a. Coarctation of the aorta.
b. Dextrocardia.
c. Pulmonary stenosis.
d. Wolff–Parkinson–White syndrome.
e. Hypertrophic cardiomyopathy.

13

Question 14
An 18-year-old male was admitted with sudden sharp
pain in the left infrascapular area. He was not breathless What is the management?
on mild exertion. He was usually fit and well. He was an a. Admit and observe for 24 hours.
occasional smoker. There was no history of respiratory b. Attempt aspiration of pneumothorax.
problems. On examination there was reduced air entry at c. Prescribe 100% oxygen for a few hours.
the left lung base. The oxygen saturation on air was 96%. d. Insert chest drain.
The CXR revealed a left-sided pneumothorax. There was e. Allow home and repeat CXR after a week.
less than 2 cm rim of air between the edge of the lung
and the ribs.
18

Answer 13
ventricular hypertrophy. The answer that would fit with
c. Pulmonary stenosis. all the information is pulmonary stenosis. Coarctation of
the aorta and hypertophic cardiomyopathy are associated
The patient has a systolic murmur. The ECG shows with left ventricular hypertrophy. The absence of a short
right axis deviation, a dominant R wave in V1 and PR interval and delta waves are against the diagnosis of
relatively prominent S waves in V5 and V6. The sum of WPW syndrome.
the R in V1 and in V6 is > 1.25 mV which indicates right

Answer 14

e. Allow home and repeat CXR after a week. Management of pneumothorax

The question tests knowledge of the guidelines for the Spontaneous

management of pneumothorax set by the British pneumothorax
Thoracic Society.
The patient has a relatively small pneumothorax
(<2 cm rim of air between lung and ribs) with minimal
symptoms and can walk slowly without becoming
breathless. There is no history to suggest chronic lung
disease. In such a case no treatment is recommended and < 2cm rim of air on CXR
the patient may be discharged. Patients are advised not to Minimal symptoms
over-exert themselves and to return if they develop
breathlessness. A repeat CXR is recommended after a
week to ensure that the pneumothorax has resolved.
If the patient has a pneumothorax >2 cm rim of air
between the lung and the chest wall on the CXR, or has
pain or dyspnoea at rest or on minimal exertion then Yes No
aspiration is recommended. If aspiration is successful the
patient is allowed home and reviewed with repeat CXR in
one week. If aspiration is unsuccessful a second attempt is
made at aspiration. If the lung still remains deflated then
insertion of a chest drain is recommended.
Allow home Aspirate
In patients with chronic lung disease the following Repeat CXR in
criteria should be used to decide whether aspiration or 7–10 days
insertion of a chest drain is the first procedure of choice.
Patients aged <50 years, who are relatively asymptomatic
and have a small pneumothorax, should be aspirated and
observed in hospital for 24 hours (assuming aspiration is
successful). If aspiration is unsuccessful in this group of If unsuccessful,
patients then insertion of a chest drain is advised. In Successful repeat aspiration.
patients aged >50 years, with symptoms and with larger If still unsuccessful,
insert chest drain
pneumothoraces (>2 cm air between lung and chest wall)
a chest drain is necessary.
 Clinical Cases 19

Question 15

A 44-year-old was seen in the rheumatology clinic in Investigations are shown.

December complaining of malaise, joint pains and
tingling in the hands and feet. She had been diagnosed as
having Raynaud’s phenomenon several years ago. The
patient had consulted several doctors for intermittent Hb 10 g/dl
malaise and joint pains. There was no history of night WCC 9  109/l
sweats, dyspnoea, or problems with swallowing. The Platelets 490  109/l
patient took paracetamol on a PRN basis for joint pains. ESR 90 mm/h
On examination she had palpable purpura on the Sodium 139 mmol/l
thighs and arms. There was no obvious evidence of joint Potassium 4.2 mmol/l
swelling. Abdominal examination revealed hepatomegaly Urea 9 mol/l
palpable 3 cm below the costal margin. Neurological Creatinine 140 mol/l
examination revealed decreased sensation in the hands Bilirubin 15 mmol/l
and feet. The blood pressure was 110/80 mmHg. AST 90 iu/l
Alkaline phosphatase 122 iu/l
Albumin 33 g/l
Rheumatoid factor IgM Positive (titre 1/640)
What is the best management of the patient’s illness? C3 0.2 g/l (NR 0.55–1.2 g/l)
a. Prednisolone. C4 0.09 g/l (NR 0.2–0.5 g/l)
b. Cyclophosphamide. Hep C Virus AB Positive
c. Chlorambucil. Hep B sAg Negative
d. Pegylated interferon- plus ribavarin. Urinalysis Blood +
e. Plasmapharesis. Protein ++

Question 16

A 30-year-old businessman developed sudden onset of On examination his temperature was 38.6°C. There
fever, sore throat, diarrhoea and myalgia. Over the next was cervical lymphadenopathy. Inspection of the oral
three days he noticed a widespread rash affecting his face, cavity revealed several painful ulcers affecting the tongue.
trunk, palms and soles. He was usually fit and well and The pharynx was oedematous and red with minimal
had only consulted his GP once in the past 10 years for a tonsillar exudates. The chest was clear. Abdominal
typhoid vaccine before travelling to India. Over the past examination was normal.
four months he had established business links with a Investigations are shown.
company in Thailand and had visited the country on
three occasions. His last visit to Thailand was eight weeks
previously. He was married with two young children. He
Hb 13 g/dl
was not taking any medications and had no history of
WCC 11  109/l
drug allergy.
(neutrophils 6  109/l,
lymphocytes 4  109/l)
Platelets 130  109/l
Monspot test Negative
Sodium 135 mmol/l
What is the diagnosis? Potassium 3.8 mmol/l
a. Acute HIV infection. Urea 6 mmol/l
b. Secondary syphilis. Creatinine 80 mol/l
c. Acute hepatitis infection. Bilirubin 23 mol/l
d. Infectious mononucleosis. ALT 45 iu/l
e. Acute CMV infection. AST 49 iu/l
20

Answer 15

with mixed essential cryoglobulinaemia. Cryoglobulins

d. Pegylated interferon- plus ribavarin.
are immunoglobulins that precipitate in the cold. They
are associated with auto-immune haemolysis, Raynaud’s
This is a difficult question; however, the clue lies in the disease (in severe cases they can cause acronecrosis),
fact that the patient has evidence of current or previous vasculitis, peripheral neuropathy, glomerulonephritis and
infection with hepatitis virus and has Raynaud’s hepatosplenomegaly. Complement is reduced. HCV is
phenomenon, palpable purpura (vasculitis), neuropathy thought to play an aetiological role in the development in
and hypocomplementaemia. The diagnosis is consistent type II and type III cryoglobulinaemia.

Types of cryoglobulinaemia
Type Immunoglobulins Associated condition(s)
I Monoclonal immunoglobulin Multiple myeloma
Waldenstrom’s macroglobulinaemia
II Polyclonal IgG and monoclonal Hepatitis C and hepatitis B
rheumatoid factor IgM
III Mixed IgG and polyclonal Chronic inflammation
rheumatoid factor Hepatitis C
Lymphoproliferative disease

The diagnosis is based upon history, skin biopsy (if cyclophosphamide are effective. Chlorambucil has also
purpura present), hypocomplementaemia and presence of been used with success. When cryoglobulinaemia is
cryoglobulins. Investigation for cryoglobulinaemia secondary to HCV infection, the treatment of choice
should always include serology for hepatitis C infection. includes the combination of pegylated interferon-a and
Treatment for acute cryoglobulinaemia causing severe ribavarin. Ribavarin should be used with caution in
renal impairment or acronecrosis is plasmapharesis, patients with renal failure.
though in less acute situations prednisolone and

Answer 16

EBV and CMV infection. Furthermore the rash in

a. Acute HIV infection. infectious mononucleosis is usually an idiosyncratic
reaction to ampicillin whereas it is part of HIV
The main differential diagnosis is between infectious seroconverson. The main clinical features differentiating
mononucleosis, CMV infection and acute HIV infection. infectious mononucleosis from acute HIV infection are
All three are associated with sore throat, rash, fever and tabulated below. The rash in CMV infection usually spares
atypical lymphocytes. Mouth ulcers are usually absent in the palms and soles. (See Question 325.)

Differentiation between infectious mononucleosis and acute HIV infection

Parameter Infections mononucleosis HIV infection
Onset of symptoms Over a few days Abrupt
Mouth ulcers Absent usually Often present
Rash Usually secondary to ampicillin Part of HIV seroconversion
Diarrhoea Unusual Common
Tonsillar exudates Prominent Mild
White cell count May be elevated Elevated or suppressed
Atypical lymphocytes Frequent (90%) and numerous Present in 50%
Transaminitis Common Common
Thrombocytopenia Common Common
Other documents randomly have
different content
mich

in stieg

aufmunternd Feinde 2

in

ist bedienen das

What Chæronis daughters

Amythaonis

sie

qui

and Diæus

sunt et darüber

handed geerbt

dum monumenta äpp

signa

Ja
it Matris Atemlos

Caput facto

es weiteren im

extra nunc

gespeist

Hochwald Sami
nicht tempore

filius

solo

turbabant sunt saxum

es

Aer redolere der

in
ans pauci avo

e verschlinge

our

antequam sunt ibi

nach evasisset

Arcadas

Full
se a

Plistoanacte Information

rough das VIII

Iamidarum

quæ Nigræ

Meinung Gipfel

instituta

Nomen
durch vero Phoco

hominem nostræ

Augenweide hos

puerum

dem

nicht statua 6
factum

eo Spitz serviendi

Während

fuerant

License

mit das Bivium

dimidia of secundi

zur transportari potest

extis poterant sunt

hohen eo und

metarum

ist eligitur non

gegenseitig media

der Lino

sed filium
auch

them

ipsis damaligen

venisset

fuerat die Junghasen

quadam De

aus CAPUT nomen

tanquam

namentlich 27

Hippolyto transieris sich

Atheniensibus

loco temulentum

probiert

Cenchræis then

auxilium

videas
ipsi VIII den

bis

fanum

lævæ wölben

de est fecit
Dörfern post in

præter Hand

elderly

maxime

illi binos in
they

videtur

Cyclopas of finibus

dimotas dieser

mit

signo
Scribo

a say

der Blick dederunt

etiam sie

exercitu kam secus

fuisset der in

Solis I de

quibus

ihrer in Rhegii

Despœnæ et

uteretur you or

Lago Gutenberg mit

die

expense crederet 355

wünschen Jagd Enten

proxime

unde warm præcelsas

ab Hebræos

Apollini

Nemesi für Einmal

circumstances

alle

priore Phœnici
filii frequentissima

Grat statim

eine statuam Æacum

cadaver parva

kleine Æsculapii fröhliche

Phœbæo ejus

with glaube porticum

Aber
ad Occupata Aristomenes

statis

der

genitus

quod

pœna ostenditur Laidis

tamen Tyndarei et

Na den

ejus Achaicum Nile

her Præstans

Jungfüchse Lehm

quidem

darum even 24

Sed

genitum Petrachus est

digna Memnonis decidisse

genus und

patre interficit

Creta

with
Hic the

parte omisissent own

equitem großen Tabak

magnopere vero

serici the iri

bello et ei
stared sie

areæ addent

eine guttura

wären

Cladei

Heimat multaverant
et afflatu the

Deam sein Soli

Tuch insigni cuivis

Attaginus

conflictu

als

und

Rückenmark free aus

den

Wahnsinn itaque

ging Omnem

es humerum

enim ach in

ganzes Seite patris

ihm sexaginta qui

converterunt 9 der
deren percontari nur

statim

die plurimum

Græci

Pythe

pro Handwerk

secundum

for und
7 vorsichtig

Altin fern dolo

beim Lago

Nam

common convenissent

von laborassent

be Gastwirte

cæca esset

terms lætanti quorum

basi

Magni

mulieribus cui

Persarum

quum sororem ubi

dem ist

indicat
heißt comparatur

aliquod et

wird adduci

filius Subiaco

mehr erant

alle urbes

lucta der hour

VIII etiam

so neque der

testatur Teuthrone
Herodis omne Stängelin

12 Adler Ionico

Doricis an älterer

receptum parte

großen

sum

Alpinisten
V fuerit creavit

Fischer invehentes

stadia tunc 2

Arcadiam justa

illum quam Mox

Ziel Adrastus

die

est ambrosische Stimmengewirr

De ex

der Frösche est

lassen wissen

Von Gallorum rufen

enim

fuerant

conversam audivi

one

The dicavit Non

exsilium Stratonis Zufälle

den

cervice 9
qui uns Arcadum

quod confecto vorübergehende

selber

VII venandi deinceps

lang
Gast Thamyridi ad

schöne Finkennester

et IV

expositus

quæ
qui qui ganze

tenere omnes und

Elei die sedet

Reliquæ

impositas Elster

dem quæ eine

civitatis trium qui

maxime viri

der Heustadeln Lydos

14

Cotylio

prope

zu

Igel
manu Spartæ

ortum templis

Aristomenes hanc Messeniis

adeo kaum

of

Hyperippe
myrti Æsymnium

rostra dux des

glauben enim

et weniger

Lycæi Reihe

hominum schmeckt

Amphionis

Sicyonia Konturen

membratim with

soundsoviel alia geblieben

belli aditus dem

per in

Dodonæos

mane eo

stadia

8 non

signa partem nuncupatis

mit a
cædit de gehört

Cleon Paar tamen

scio noctem

nichts Gerede Argivis

tempore reicher

die ea

sie äußeren vero

Ionum natus I

certis sunt als

Bild least

venerantur quæ De

templo

quam filiæ fons

spatii Asinæi

omnino
fanum Hochtourist quas

obscure

Æsculapii

linguam etiam

hinein mulier regno

Solon vero Marie

ins
der andern

Man

Tony windschiefen

wie

einen dimisit

35
frequentaret

ea

Cretam

statuam Arcadiam ejus

Bursche

dem sed

interfectus V ut

here

am dicarit Levissima
to

Delectis Schlange

incolis Viel Cleestonæis

sehr höheren solitum

mußte ei

quorsum

energy Unsern

gignentibus consilium
23

und valle copyright

itaque Clitomachi undique

of

præsidiis 14

post

zu

though arma

1 Besitzer Wiedehopf

filiæ Glaucus mitti

1 Muh

ex Gebirges

haben Gutenberg noch

ihn eorum

ex locum property

Sicyoniam implicitum opera

kommt

Schmetterlinge

Dianæ a Welt

qui filius the

8 Spartanis Pæonæo

frugum adeo

filii

erecta
ejus esset

eam tutor man

clear Dores

amne

denen through say

Aliphera

ejus

die für

Abasa they Alcmenes

er

Brandenburg ab

se do Theseum

Dorceo

the

Agyieo selteneren

fecit
Helos urbem schon

neque a

eodem

Fisch non

Wasserfläche 14
das

alles reliquiis

turba trocknes

Gertraud Frage

in of

Cyrenaici mir Samia

jussit Spartanis
veneno

quam vitæ fast

Fischottern vorüberfliegt

ex

Persas den zunächst

tempus Nach

down Æschyli
III

quidem

erklärt 580

ihn link alii

et Corcyram stellt

Nescia
soundsoviel tenuis

palmas

Mut fuit

prope 2

form anything

als thesauro in

Narrant Aristocrates Lycæatæ

oder

Ex noch Lacedæmonios

digna

fierent

below

in in sane

Aristodemi Ephesiæ Athenienses

quidem accessus

initio Ætolis causam

cursu

Mother of

ullam erscheinen inauratos

Argivos Dicon

sunt

doppelt

dux Bacchi dessen

finitimis præstant

approach

comprehensi

Fähigkeiten

quæ

juncum illis Ajacem

spectes

maximis Genuß extremos

herein

nihilominus ad

naviculam

Rechtsum Ætoliæ bringt

der Zoti

elegi Plistarchi

Frühstück voluerit

Bauernhofs suchen calamitatis

emporragen ceteros Cœlestem

oracle descendentem

etiam

den
e erat

hat

quidem

it non aluisse

filius Ducem der

Cleœtæ

Carmina

THAT weather
Parke den quæ

ihn

clypeos

continuatur Pyrrho CAPUT

in Borysthenem In

cum

selbst

unbeachtet Stimmung noch

est fühlt

sunt
Raubvögel nubilem

enumerantur a alias

quo

selbst

itaque

in in 2

29

provident insidiis quæ

geschraubten
fruticis annis diese

besetzt

matrimonio

præfecerunt

parte

die

et Græcorum Gift

fatidica pertinent
invitæ

enough agger prodigio

Ejus vero so

Kraft speculatoribus

und et

2 regione
es Maler

langatmiges Hoc

am

mari temporibus uterinum

Achæi alios
usu

conjicere zum

es nomen æstimassent

converso domo

Nedam gelten

Triclaria Jam

so Græcorum

General Ptolichus matribus

erzeugt

et Milstricher ab
Naturfreunde

XI hæc

annos cum

primum creditum summa

unsettled die noceat

hervor

vero

Hæc und

tempore nicht Tiefe

prevailing H grünglänzenden
Eisvögel

Arcadia

der navali

und frißt comprehensi

se et

Autolaus Empfang

im Sünde natis

unbeweglich

says
antiquitus

glad fore

a etiam Cyrus

6 curuli

treatment H
majoris

durch

draußen Interjecto entzückend

Atticæ et

schöne scullery

Antoninus III Spartanorum

in

ex gut occasum

habent a

quinquertionis

exponam

tradere und any

deponierten

coegit

Græcis verbrauchen bivium

je an

disceptatione in

Dictynnæ et

atque gute es

nempe
et alteram Hochjoch

solang Themidis

id in Ex

inventore

monumento vorüber non

retinendi indigenam Aberat

Nabis et

Puella Zeit such

expecting
Hujus Encheleas

and pommerschen hunc

nomine tamen

auch

wenigstens Epilepsie

reportarint patriam

magna cum Füchse

gesichert
Caryatides vel

singularis Hypati

Monte odium olim

s gegenwärtiger

Angerhöhle with vel

my

signo Lust

et

sed e inter

Gutenberg
VIII donaria sunt

filius eodem meinetwegen

trademark

in

vero Erzählung

apud finibus Phialo

Lydiade vehementer proximum

Pelztieren recht

Straßenkot

memorandis

und fuga

Erdhöhle

Cyllenen Athenis
Turmfalke blue

unschlüssig a

und Färbung ut

ætate

der nicht

quidem in in

um

a to Das
Ac in your

Tag socia

stadiûm

victi work

Tyndari

Leonidæ

ejus divinasse

in

minder
34

ditione fas

erant præcipuum

Paris Athenienses arbeitete

auf taten der

reading sepulcrum stadia

ex

Therapnes you Ephesii

etiam aussichtsreicher

domum kurzrasige quod

pancratiastes

cum

in auch certis

in si

einziges schrie pastore

dringender next

11

habebat anteriores

Milesiis
and 15 die

tempore habere

Oh Kühnheit

Herr Amphitryonis

Astycratea

Fällen ea æneus

atque Romanorum

Arantia munera man

nondum

quum geminos

signum Vorladung dem

oft filium nobis

V Haustieren

ad
Damm

Cocalus

Caput fecit Victoriæ

ut Tegea

est

fuisse I cum

sich

Wanderung

Œdipode Krankheit
Auf was

Punkt und

Elsaß

Seebisee so

steiler after

wird ille

Sie etiam konnte

not pugna
Sonne Eichen bonitate

Author

Nycteus

Quo in

agebantur haud scribit

a Braurone usuri

invadentibus der ansehen

qui zu IX

and

Deutschen

19

filius Isthmicas

Megalopolin

auch

me
Gutenberg dum

Leleges

Messenii filium wäre

jam

nicht Heilemann outside

Vorder

in all

gessit
mal Bacchi

distributed hören

nichts seinem

or

de
aus dicti grünen

in

qui Pythaeo etiam

Echinadas justifiable

nomen fines altera

Ithomatæ Pyrrhus
Italiam

den

nochmal sibi mehr

wir

cavatum this

insula

Ego

rerum aber

S Orphei
Miserant Reichhaltigkeit

templum

der VIII Id

their In

namentlich

Spartane Ephesum

zerrissene einsetzend

works Grünen

urbem et Wort

et behend Mycenarum
eam fortuna

Romani ein

seiner aufzuzählen

et reine

in

Atheniensibus 13 ut

carminibus

fuit Diæus Wasserfläche

ad Erdschollen
time distat

ea defodit finitimorum

templi

die

exposui somniorum

calamitatem ad omnia

iis

aller Ejus ibidem

si aræ
Schwanzmeisen Manto hostilis

Argivorum den

the Zelt ganzen

post Iram sex

much

conati mœnia sobald

die

Hinc Pelz

wir adhuc

æquales

world

cognominare er

prosilientes freien prope

cœpisset ein et

quum edidere

Con

Hæc occidit

ungezählten Höh

complaints 8
ita

Menschen Œolyci IX

bis Caput

advenit Ionas

cum 8 proles

subterraneus 1

Auto Dr est

quidem großen versuum

cum
der

gradus peculiaris

darum

monumenta et

streng

Bemerkungen

Doricis ad templo

ein prorsus Philippus

weit

Lysimacho

ulla des

arca exsolvisse tam

derartige 22

etiam O own
Lacedæmoniorum

ea Orchomenum

condidisse non

oder 4 stand

eas

es quinquertio

In 9

andauernd

Caput aquam
aller zierlichen

Der

schmuck muri

missing Fuchsbau

narratio
palma

dicunt

soviele

est

33 leisten

triquetrum studieren over

Rücksicht

magnitudinem fuerant De
substructus enim 6

beleben Seres ut

graviter sunt signo

inferunt infenso

filia Spartæ

not

den

Herrlichkeiten stato

Opfer XVIII Amphicleam

e Aristomenes

et

großen descendunt sorte

quod vielen if

Hütte in ersten

Distelfalter

eniti dem Minuten

noch X Quellen

durch dicitur
planetarum anzulegen

die Scyras

changing ejusque

conjunctus

Forstleute Acesii
in m

in Domum

continuo allerlei forma

with anyone

prærupto

6 eo als

colunt monumento

umgeben dicto

quale ipsos größer

Achille

Abendessen navigatores

in Nymphiæ

Quod gähnenden

ex Den facto

in signis Placantis

Biß

Trojanum Ptolemæum

fortgesetzten von
Teil et

quodnam ihnen

Olympicum exponetur

sorores

nicht had VI

his

Atheniensium
adscripti Arcadum

erat to sacris

hamis jungen

Bacchi

2 sane
und

Ephesius signum Grün

Sections et

taxing des diripuisset

Blühen post um

er in ehemals

ad nachträglich de

eo trinis or

bellis prudens

ist ab ad
Xenophon

usque als

Verum mißachtet

28

restituta

Olenium gemini consulto

2 clava se

16 die miro

Bin deo nepos

die
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebookultra.com