2003 paper errors Flashcards

1
Q

Management:
45 year old man with a 6 week history of intermittent tender swelling that occurs below the left side of his jaw often during meals but can occur even if he thinks of food. It disappears overnight. You find a 3 by 2cms firm mass with no other abnormal findings.

A

Sialogram

1) This patient has sialolithiasis. Salivary gland stones cause pain whenever the patient salivates (eating or thinking of food, like Pavlov’s dogs!). Stones are commonly found in the submandibular gland. At night time, there is less salivation accounting for the lack of pain. Diagnosis can be confirmed by facial radiographs but a small number of sialoliths may not be seen on the plain film due to low calcium phosphate content. In this case, sialography used in combination with CT will demonstrate the stone. A complication is the development of sialadenitis.

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2
Q

Management:
70 year old woman who complains of palpitations, intolerance to heat, diarrhoea & weight loss. You find an irregular goitre in her neck that moves up and down when the patient swallows. There is no stigmata of Graves’ disease.

A

Technetium thyroid scan

This is a case of toxic multinodular goitre. It is most common in older patients and is associated with head and neck irradiation and iodine deficiency. TSH is the initial screening test and if supressed, T4/T3 levels are measured. As the peripheral stigmata of Graves’ disease is absent, thyroid scan and uptake is indicated. I-123 is the preferred isotope but as this option is not given, Tc-99 can be used although there is a risk of false positive images. The scan will show multiple hot and cold areas consistent with areas of autonomy and areas of suppression. Definitive treatment is commonly given in the form of radioactive iodine.

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3
Q

Management:
55 year old woman who complains of dysphagia is found to have a 10cms in width & 5cms in height bilateral symmetrical non-tender nodular mass in the front of her neck. Investigations show that she is euthyroid.

A

Upper GI endoscopy

The bilateral mass in the last part of this question is a multinodular goitre which does not need a biopsy. The patient is euthyroid. If the nodule was unilateral, then a biopsy is essential to establish or exclude malignancy. However, her dysphagia needs to be investigated with an upper GI endoscopy.

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4
Q

Treatment:
An 84 year old man presented to A&E with profuse diarrhoea and lethargy for the past 4 days. Clinical findings include tachycardia, dry tongue and raised urea.

A

Intravenous saline

This patient has clinical signs of dehydration. IV saline is indicated for fast rehydration. Oral rehydration will be too slow for this patient’s clinical state and will literally be thrown down the toilet due to the patient’s diarrhoea.

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5
Q

Treatment:
A 57 year old mature science student developed profuse diarrhoea and abdominal cramps following a meal from a local takeaway. 2 days later stool culture confirmed salmonella and the patient remained unwell.

A

Ciprofloxacin

Most cases of Salmonella gastroenteritis are self-limiting and antibiotics should not be used. However, antibiotics are recommended for infants <3 months, those >50 as well as immunosuppressed patients and those with internal prostheses. The typical antibiotic course is 3-7 days and the first line option for Salmonella is ciprofloxacin. Antiemetics can also be given to those with severe N&V. IV fluids should only be given if the patient is unable to tolerate oral fluids due to N&V.

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6
Q

Treatment:
A 24 year old legal secretary presents with a 6 month history of abdominal discomfort, fluctuating diarhoea and constipation with bloating. She denies weight loss or a change in appetite. Examination was unremarkable

A

Antispasmodics

The fluctuating diarrhoea and constipation without symptoms suggestive of IBD make IBS a more likely diagnosis. IBS is a chronic condition with abdominal pain associated with bowel dysfunction and is a diagnosis of exclusion. The pain or discomfort may be relieved by defecation. Examination is usually unremarkable and the diagnosis is based on the patient’s history in line with the Rome Criteria. If the patient presents with any worrying symptoms, then these will warrant a more thorough investigation. Treatment depends on the patient’s predominant symptoms. Antispasmodics relieve abdominal pain or discomfort but do not affect bowel habit. Examples include peppermint oil and dicycloverine. Laxatives can also be used such as lactulose. Lifestyle and dietary modifications combined with reassurance remain the 1st line intervention for functional bowel disease. IBS is linked with stressful jobs such as working as a secretary and there is a female/male ratio of 2:1.

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7
Q

Treatment:

A 63 year old man who has recently had chemotherapy for bowel cancer is suffering from diarrhoea.

A

Codeine phosphate

Codeine phosphate is an opiate and will kill two birds with one stone by offering effective pain relief and treating the diarrhoea. Codeine is used for mild to moderate pain, diarrhoea and as an antitussive.

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8
Q

Investigation:
73 year old man was reviewed in the diabetic clinic. He was complaining of increasing tiredness & loss of appetite. His ankles had become more swollen over the last few weeks.

A

Plasma creatinine

Diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function.

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9
Q

Diagnosis:
A 45 year old doctor from Ethopia with a 6 week history of fever, drenching night sweats and a cough. He is a heavy smoker. On examination he is thin and looks unwell. He has nicotine stained fingers. Dull to percusion at the right upper zone with reduced breath sounds.

A

Pulmonary tuberculosis

This is pulmonary TB. The patient is from an endemic area and has presented with fever, drenching night sweats and a cough. There is also anorexia and examination findings are consistent with post-primary TB with apical consolidation.

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10
Q

Diagnosis:
A 50 year old Asian diabetic woman is admitted with increasing shortness of breath and ankle swelling. ECG shows inverted T waves in levels I, AVL and V4-6. Upper lobe blood diversion and bilateral pleural effusions are found on chest X-ray

A

Pulmonary oedema

CXR findings here are consistent with pulmonary oedema. Pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion may be seen. The patient is also in CCF with evidence of LV dysfunction (SOB) and RV dysfunction (ankle swelling).

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11
Q

Diagnosis:
66 year old woman with right leg ulcer dressed by district nurse for 2 months. On examination there is a tender warm lump in the right groin.

A

Reactive lymph node

The leg ulcer indicates that there is local inflammation. Reactive lymphadenopathy is common when there is infection or inflammation.

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12
Q

Diagnosis:

62 year old man with enlarging pulsatile mass in left groin. 3 days previously he had had a coronary angiogram.

A

False aneurysm

This is a false or pseudoaneurysm as it does not involve all layers of the arterial wall. This has resulted from arterial trauma during the angiogram. Most cases of false aneuryms are as a result of iatrogenic trauma. A haematoma has formed between the breached layers and the remaining intact artery, causing the lump, which is pulsatile as blood rushes through the artery.

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13
Q

Analgesia contraindicated post op:
An 85 year old who is known to be hypertensive & has mild impaired renal function presents with signs of dehydration & undergoes a laparotomy for small bowel obstruction.

A

Diclofenac

NSAIDS may impair renal function and provoke renal failure, especially in patients with pre-existing impairment. NSAIDs should be avoided if possible in these patients or used with caution at the lowest effective dose for the shortest possible time. The mechanism of damage involves reducing creatinine clearance.
NSAIDs are also contraindicated in asthmatics as it causes bronchospasm due to the accumulation of leukotrienes.

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14
Q

Analgesia contraindicated post op:
A 60 year old man with diarrhoea is transferred from another hospital for urgent femoral-distal bypass surgery & arrives with a heparin infusion in situ. His APTT is 2.4.

A

Epidural bupivacaine fentanyl

Epidurals are relatively contraindicated in anticoagulated patients. Insertion of the epidural needle may lead traumatic bleeding into the epidural space and with clotting abnormalities, the development of a haematoma which can lead to spinal cord compression. Coagulopathy, raised ICP and infection at the injection site are absolute contraindications. Relative contraindications include anticoagulated patients and those with anatomical abnormalities of the vertebral column. NSAIDs do not increase the risk of epidural haematoma.

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15
Q

Analgesia contraindicated post op:

A 65 year old man with a history of peptic ulceration requires an aortic aneurysm repair electively.

A

Diclofenac

NSAIDs inhibit COX which has the effect of reducing PGE2 levels. PGE2 plays a role in gastric cytoprotection by downregulating HCl production and increasing mucus and the production of bicarbonate. This leads to gastric irritation and ulceration. A PPI can be prescribed alongside NSAIDs or misoprostol can be used, which is a stable PGE1 analogue which mimics local PG to maintain the gastroduodenal mucosal barrier.

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16
Q

Management:
A 52 year old man with diabetes for 15 years. Recently found to have microalbuminuria. Glycosylated haemoglobin 7.2%. BP 150/85. Cholesterol 5.2mmol/l.

A

Blood pressure control

BP control with an ACE inhibitor is necessary to reduce progression of diabetic nephropathy. Microalbuminuria is the earliest detectable sign and indicates trace amounts of albumin not detectable with standard urinalysis. If untreated, microalbuminuria will progress to intermittent albuminuria and then to persistent albuminuria which is 5-10 years away from ESRF. The main contributor to the development of diabetic nephropathy is hypertension. Other contributors include poor glycaemic control and renovascular disease such as renal artery stenosis. It is important to test kidney function and urine regularly.

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17
Q

Diagnosis:
A 71 year old man who has had a MI 6 months ago presents with shortness of breath & fatigue. On examination, the JVP is raised. He has pitting oedema to the knees. There is tenderness in the right upper quadrant with a smooth liver edge at 5cm.

A

Heart failure

This patient has heart failure, which has possibly occured as a consequence of his MI. SOB indicates pulmonary oedema due to LV failure. The raised JVP, peripheral oedema and tender hepatomegaly indicates RV failure. Initial investigations should include ECG, CXR, TTE and bloods including BNP levels. First line treatment is with an ACE inhibitor which reduces morbidity and mortality. Salt and fluid restriction is also beneficial. All patients with chronic heart failure will also receive a beta blocker such as carvedilol. Other adjuncts include spironolactone, diuretics, hydralazine and a nitrate, and digoxin.

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18
Q

Cause of HTN:
A 59 year old man, body mass index 29, random blood sugar 12.5mmol/l, total cholesterol 5.2mmol/l, HDL cholesterol 0.75mmol/l, BP 162/105mmHg.

A

Metabolic syndrome (Insulin resistance/Syndrome X)

Metabolic syndrome incorporates insulin resistance, IGT, central obesity, dyslipidaemia and hypertension. Multiple criteria exist to define this syndrome. This is sometimes called Reaven’s syndrome. Treatment aims at lifestyle interventions with statins if these do not achieve desired LDL cholesterol levels. Other lipid-lowering drugs such a fibrates can also be considered. The risk of developing T2DM is up to 5 times higher in those with metabolic syndrome. Low dose aspirin may be indicated, particularly for those at a higher risk, due to the prothombotic state of metabolic syndrome. Other treatments that can be considered include orlistat and bariatric surgery. Those with insulin resistance may benefit from metformin, which will reduce the progression to T2DM in patients with IGT.

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19
Q

Diagnosis:
A 25 year old patient presents with 1 year history of painful scrotal swelling. On examination there is a hard smooth swelling of the right testis. It did not transilluminate. There was no cough impulse.

A

Teratoma

Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30. Radical orchidectomy and histology is the initial treatment in most cases.

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20
Q

Diagnosis:
64 yr old woman complaining of severe back pain for some weeks. For the last few days shehas been very constipated and has been vomiting for 24 hours. She has been a smoker for many years and has had 3 courses of antibiotics for chest infections over the last 3 months.

A

Hypercalcaemia

90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. Cancer is the likely cause in this woman. Malignancy can cause hypercalcaemia either by direct bony involvement leading to osteolytic lesions or paraneoplastic syndromes involving PTHrp release. The tumour is typically very advanced if hypercalcaemia is a feature. Less common causes include vitamin D overdose, hyperthyroidism, immobilisation, Paget’s and milk-alkali syndrome. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica which causes pain. Symptoms of high calcium include confusion, constipation, polyuria, polydipsia, depression, kidney stones and lethargy. This can be remembered by ‘stones, bones, abdominal groans and psychiatric moans’. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.

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21
Q

Management:
60 yr old man with stable angina is awaiting surgery. he is on the highest tolerated dose of beta blocker and CCB but is still symptomatic. BP is 170/95 mmHg

A

Long acting nitrates

Long acting nitrates such as isosorbide mononitrate or transdermal GTN is indicated as the patient is still symptomatic on beta blockers and CCBs. Appropriate nitrate-free periods will be needed to avoid tolerance. Severe hypotension may occur if combined with a phosphodiesterase-5 inhibitor.

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22
Q

Investigation:
An 80 year old man presents with severely painful feet with mottled and purple toes with black areas. He tells you that he has also had constant severe back pain for a few days.

A

CT scan

This patient has a dissecting aortic aneurysm which can be diagnosed with a CT scan showing the presence of an intimal flap. The CT scan should include chest, abdomen and pelvis to visualise the extent of the aneurysm. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. The aortic dissection has led to a cholesterol embolism. This can be diagnosed histopathologically with the finding of cholesterol crystals. The phenomenon where cholesterol is released from an atherosclerotic plaque is called ‘trash foot’. A highly technical medical term. This results in the mottled appearance of distal embolism associated with livedo reticularis. You can search the internet for some case reports of this phenomenon.

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23
Q

Investigation:
A 25 year old university student presents with a high fever. He has petechial rash, black areas on his toes and fingers. His BP is 70/50.

A

Blood cultures

This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis.

It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature <36. A source of infection should be sought unless it is immediately evident such as the signs and symptoms of pneumonia being present. Petechial haemorrhage is a sign of organ dysfunction although a petechial rash may be due to meningococcal septicaemia.

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24
Q

Investigation:
A 55 year old woman presents with painful joints, a purpuric rash on her arms and legs. Systems review reveals heamoptysis and ear pain. On examination you find black patches on her toes.

A

ANCA (anti-neutrophil cytoplasmic antibody)

This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis.

It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature <36. A source of infection should be sought unless it is immediately evident such as the signs and symptoms of pneumonia being present. Petechial haemorrhage is a sign of organ dysfunction although a petechial rash may be due to meningococcal septicaemia.

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25
Q

Diagnosis:
A 58 year old male has had increasing difficulty swallowing. He has lost 10kg in the past 2 months. Upper GI endoscopy reveals a nearly circumferential irregular & ulcerated mass in the mid oesophagus.

A

Squamous cell carcinoma

Dysphagia coupled with weight loss and the irregular shaped mass points to malignancy. Dysphagia occurs when there is obstruction of more than 2/3 of the lumen and presence indicates locally advanced disease. There may additionally be odynophagia. Men are twice as likely to develop oesophageal cancer. GORD, Barrett’s oesophagus, FH, tobacco and alcohol are all risk factors. The two main types are squamous cell carcinoma and adenocarcinoma. Tumours in the upper 2/3 of the oesophagus are SCC whereas those that lie in the lower 1/3 are adenocarcinomas. The main test to order is an OGD with biopsy. Treatment is either surgical resection or with chemo or radiotherapy alongside endoscopic ablation with or without stenting and brachytherapy.

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26
Q

Diagnosis:

A 50 year old man has a rapidly growing mass in the thigh. A biopsy shows spindles of malignant cells.

A

Sarcoma

A scarcoma is a solid tumour of CT. Treatment is based on stage and histology but usually involves surgical excision in the first instance. Pathology needs to be reviewed by an expert who has experience with sarcomas.

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27
Q

Investigation:
A fit 28 year old man comes for an insurance medical & is found to have microscopic haematuria & on abdominal examination is found to have 2 large masses about 20cms by 12cms in each flank.

A

Abdominal ultrasound

This sounds like ADPKD. There may be a FH of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and SAH). Patients may have haematuria, palpable kidneys and symptoms of a UTI. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.

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28
Q

Type of oxygen:
A 55 year old known epileptic arrives in A&E having suffered a fit whilst shopping. She is “post ictal” on arrival in A&E & breathing in an obstructed manner with O2 saturation of 92% (on air).

A

Oropharyngeal airway with oxygen

An oropharyngeal (or Guedel) airway is sized from the angle of the mandible to the level of the incisors. It is a non-definitive airway adjunct. The patient is breathing in an obstructed manner indicating some degree of partial upper airway obstruction. The Guedel will keep the airway patent and prevent the tongue obstructing the airway by depressing it. The Guedel can only be used if the patient has a reduced GCS as it can initiate a gag reflex. If the patient was not unconscious, then a nasopharyngeal airway can be used (usually inserted in the right nostril). Additionally, a Guedel is contraindicated if the patient has injuries to the face or a condition that prevents the mouth from opening. Airway manoeuvres can also be used such as a jaw thrust or head tilt chin lift in addition to maintain a patent airway. A jaw thrust can onlybe done if the patient is unconscious. Think about where your fingers are digging in.

29
Q

Type of oxygen:
A 19 year old motorcyclist suffers a head injury after colliding with a lorry. On examination he is found to have a GCS of 4 & requires an urgent CT scan.

A

Single-lumen cuffed ET tube

This patient is unconscious and is about to undergo a CT scan. He needs a definitive airway. The cuffed end creates a seal the prevent the aspiration of stomach contents. Reduced consciousness is a major risk factor for aspiration due to an inadequate cough reflex and impaired closure of the glottis.

30
Q

Type of oxygen:
A 23 year old fit 70kg man requires an elective knee arthroscopy under general anaesthesia. He gives no past medical history and does not suffer from reflux.

A

Laryngeal mask airway (LMA)

A LMA is not a definitive airway. It forms a cuff over the opening of the larynx and works better than a bag and mask. It is less likely to result in gastric distension and reflux due to the lower pressures it generates. However, as it lives above the glottis, it does not prevent reflux. It is popular in short day case surgery and this patient is young and healthy without a known risk of aspiration.

31
Q

Type of oxygen:
A 78 year old patient is due to undergo surgery on her short saphenous veins in the prone position under general anaesthesia. She is obese and has known GORD.

A

Single-lumen cuffed ET tube

This patient is elderly, having surgery in a recumbent position and has known aspiration risk factors of obesity and GORD. She will need a definitive airway with a cuffed ET tube to create a seal to prevent aspiration of stomach contents. The ease of intubation can be determined by an airway assessment including a Mallampatti score (I to IV).

A double lumen ET tube is designed for some intrathoracic operations. An uncuffed ET tube is preferred in children as the trachea is not as strong. If it is an emergency setting and ET intubation fails, cricothyroidotomy can be performed which allows approximately 30 minutes of ventilation. Cricothyroidotomy will only work with at least a partially patent larynx.

32
Q

Diagnosis:
A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. She wonders what caused this ulcer?

A

Cardiac failure

This sounds like a venous ulcer due to right-sided heart failure. Venous ulcers are mainly caused by either venous insufficiency or heart failure. RVF will lead to peripheral oedema which may be complicated by a venous ulcer. Initial investigations should include ECG, CXR, TTE and bloods including BNP levels. First line treatment is with an ACE inhibitor which reduces morbidity and mortality. Salt and fluid restriction is also beneficial. All patients with chronic heart failure will also receive a beta blocker such as carvedilol. Other adjuncts include spironolactone, diuretics, hydralazine and a nitrate, and digoxin.

33
Q

Diagnosis:
A 70 year old man, with ischaemic heart disease & COAD, presents with an ulcer between the great & second toes on the right foot. This is associated with pain in the whole foot at night.

A

Arterial ulcer

Arterial ulcers are deep and painful with a well defined edge, usually found on the shin or foot. There may be local changes such as cold peripheries, loss of hair, dusky cyanosis and toenail dystrophy. On examination, peripheral pulses may be absent or reduced. An angiogram with contrast will define the lesion and determine whether it can be improved by surgical intervention. Pain often increases when your legs are at rest and elevated. They can occur between the webs of toes so it is important to always check these in your peripheral vascular examination.

34
Q

Diagnosis:

A 19 year old girl has noticed a lump in the right breast. It is smooth, 2cm in diameter, non tender and highly mobile.

A

Fibroadenoma

Fibroadenomas are typically asymptomatic and are found incidentally in patients <40 years old. Examination reveals a smooth, rubbery and mobile (breast mouse) mass. Triple assessment is indicated. Biopsy will show epithelial and stromal elements.

35
Q

Diagnosis:
A 30 year old lady, who is breast feeding, has developed an extremely painful, hard, red 4 cm lump at the edge of the nipple.

A

Breast abscess

Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful, hard and red lump indicates the development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.

36
Q

Management:
A 25-year-old woman returning from Australia presents with acutely painful left calf. Ultrasound confirms deep vein thrombosis extending above the popliteal veins. She has recently missed a period.

A

Subcutaneous low molecular weight heparin

Women developing a DVT during pregnancy can be treated with heparin or LMWH. However, LMWH is preferred due to more dependable pharmacokinetics. The agents you will commonly hear include enoxaparin, dalteparin and tinzaparin.

37
Q

Management:
You are asked to see a patient with acute chest pain 5 days after total hip replacement. BP 120/80, HR 93. A PE is confirmed. The patient has a previous history of heparin-induced thrombocytopenia.

A

Fondaparinux (FXa inhibitor)

A factor Xa antagonist is preferred if the patient has or has had heparin-induced thrombocytopenia. If the patient has a low BP then systemic thrombolysis would be indicated to prevent possible cardiac arrest.

38
Q

Management:
A woman who is on warfarin for a confirmed right calf DVT develops increasing pain and swelling of that leg. This is the third time this has happened. Repeat imaging shows thrombus limited to the calf.

A

Subcutaneous low molecular weight heparin

Patients with recurrent thromboembolism despite on warfarin should be given heparin or LMWH. LMWH is again the primary option for reasons discussed. They should be given for at least 5 days until INR is between 2 and 3 (the target INR). Fondaparinux would be used instead if there was a high chance of delayed HIT. Warfarin is continued and efforts must be made to work out how this patient has developed a DVT despite on warfarin therapy. There may be subtherapeutic dosing, the presence of a malignancy or antiphospholipid syndrome. If there is documented thrombosis progression despite adequate anticoagulation, without HIT and other causes are excluded, an IVC filtre may be indicated but evidence of its efficacy have been debated by recent studies.

39
Q

Diagnosis:
A 65 year old man presents with a large painless bladder and overflow incontinence at night and a raised creatinine level.

A

Hydronephrosis

This patient has BPH which has caused hydronephrosis. This is an example of bilateral obstructive uropathy. Acute presentations are often painful whereas chronic presentations are more insidious in onset. Blockage of urinary flow by the enlarged prostate has led to urinary retention and overflow incontinence. Initial treatment aims to relieve the pressure on the kidneys. This involves catheterisation as the first line treatment. The patient should be started on alpha blockers at the time of catheterisation.

40
Q

Diagnosis:

A 30 year old man complains of pain in the rectum, groin and urinary frequency with dysuria.

A

Acute prostatitis

Acute prostatitis is the most frequently made urological diagnosis in men under 50. It is commonly caused by E. coli and can cause lower abdominal, perineal, rectal and ejaculatory pain. It is associated with the presence of a UTI and BPH. As a result there may be dysuria and frequency. The prostate gland may feel warm and boggy to touch and DRE will reveal an intensely tender gland.This patient does not appear septic and first line treatment is with an oral quinolone such as ciprofloxacin for 10 days with an NSAID for pain relief. A prolonged course of antibiotics is needed if chronic prostatitis follows the acute occurence.

41
Q

Diagnosis:
A 55 year old man presents with a few months history of weight loss, lethargy & fever. On examination, he has a large liver & spleen. His WBC is 10.2x109/l & his blood film shows increased granulocytes & granulocyte precursors

A

CML

This is CML which tends to present in th 30-60 age group. At presentation 1/3 may be asymptomatic though if symptomatic, it presents with symptoms including fever, weight loss and night sweats. There is myeloid stem cell proliferation and presents with raised neutrophils, metamyelocytes and basophils. The patient’s granulocytosis is suggestive of CML. CML is associated with the philadelphia chromosome characterised by t(9;22) of bcr-abl. There tends to be massive splenomegaly which is the most common physical finding on examination. This conditon may transform to AML or ALL in what is known as a ‘blast crisis’. CML responds to imatinib, which is an anti-bcr-abl antibody and gives long term remission in most patients.

42
Q

Diagnosis:
A 27 year old Afro-Caribbean man presents with fever, weight loss and an intractable itch. His spleen is just palpable and he has two 3cm nodes in his right neck. Hb is low.

A

Hodgkin’s disease

This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption.

43
Q

Diagnosis:
An 18 year old Caucasian shop assistant presents with fever & a sore throat. She is found to have enlarged but soft cervical lymph nodes & a soft spleen palpable 3cm below the costal margin. Blood film shows atypical lymphocytes.

A

Infectious mononucleosis

This is caused by EBV and characterised by fever, pharyngitis and lymphadenopathy with atypical lymphocytosis. Positive heterophile antibody test and serological testing for EBV antibodies are diagnostic. Splenomegaly is common and enlargement occurs in the first week, lasting 3-4 weeks. It is worth remembering that splenomegaly is always an abnormal examination finding. IM is commonly named the ‘kissing’ disease as EBV is most commonly transmitted by saliva. Penetrative sex and general promiscuity in young women also increases the risk.

44
Q

Diagnosis:
A 65 year old man presents with angina & claudication. He is found to have a firm spleen extending 20cm below the costal margin. His Hb is 7.5g/dl & his blood film is leuco-erythroblastic

A

Idiopathic myelofibrosis

This is a case of myelofibrosis. Leucoerythroblastosis and splenomegaly are common findings. Strong risk factors include exposure to radiation and industrial solvents. BM biopsy is essential for diagnosis. Extramedullary haematopoiesis leads to dacrocytes in the peripheral blood smear. Those without symptoms can be managed with folate and pyridoxine supplements. Otherwise options such as a BM transplant and hydroxycarbamide can be considered.

45
Q

Diagnosis:
A 90 year old woman who uses a Zimmer frame because of her OA & general frailty. She has a 3 day weakness of her left arm, which has worsened. Yesterday, she could not walk & became confused & incontinent. You find a flaccid paralysis of her arm & weakness of power in her leg.

A

Chronic subdural haematoma

The symptoms this patient has are stroke-like in nature but with slow onset which points more towards a growing space occupying lesion. Blood collects between the dura and arachnoid mater in a subdural haematoma. This woman is at risk due to her advanced age and frail state in a Zimmer frame and could suffer from falls. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. It is also important in the work up to calculate this patient’s admission GCS. A CT scan will also be indicated. As this is causing clear neurological deficits, a surgical opinion is indicated.

46
Q

Drug side effect:

Beta-blockers e.g atenolol

A

Cold toes and fingers

Beta blockers can cause bronchoconstriction (asthmatics), heart failure in those with heart disease who rely on a degree of sympathetic drive to the heart to maintain CO, hypoglycaemia (diabetics can lose warning signs), fatigue (reduced CO and muscle perfusion via beta 2 receptions) and cold extremeties (beta receptor mediated vasodilation of cutaneous vessels). Additionally there may be bad dreams which is more pronounced in lipophilic beta blockers such as propranolol.

47
Q

Drug side effect:

Beta adrenergic bronchodilators e.g salbutamol, terbutaline

A

Tremor

Beta agonists have similar side effects to adrenaline. A tremor can be seem, often demonstrated on examination by held extension of the hands. Salbutamol can also be used in threatened uncomplicated premature labour to relax the uterus.

48
Q

Drug side effect:

Erythromycin

A

Nausea and vomiting

Erythromycin is a motilin agonist which causes N&V. It is a macrolide antibiotic and tends not be first line unless the patient has a penicillin allergy. It has a slightly wider spectrum of activity than penicillin. The macrolides can also cause reversible deafness although the most important group to note in drug induced deafness are the aminoglycosides such as gantamicin.

49
Q

Drug side effect:

Tricyclic antidepressants e.g amitriptyline, imipramine

A

Constipation and dry mouth

TCAs have antimuscarinic properties and thus have the classic atropine-like side effects including dry mouth, constipation, mydriasis and blurred vision.

50
Q

Diagnosis:
A 78 year old woman attends complaining of recent onset of tiredness. She is pale, has hepatosplenomegaly and generalised painless lymphadenopathy in the neck, axillae and groin. Coombs’ (DAT) test is positive.

A

CLL

This elderly woman has CLL. CLL presents in older adults (generally >60) and is often asymptomatic. Smear cells can be seen in peripheral blood smear and it is associated with a warm type AIHA accounting for her pallor and fatigue (hence the Coombs’ test is positive). Painless lymphadenopathy may be present and splenomegaly is a common finding. A WCC with differential is required to make a diagnosis. An absolute lymphocytosis will be seen. CML is not associated with an AIHA and tends to present at a younger age.

51
Q

Diagnosis:
A 65 year old heavy smoker. He has been progressively short of breath over a few years. He has a smooth liver edge 2cms below the costal margin.

A

Severe emphysema

The liver is palpable in this man because severe emphysema has resulted in hyperexpanded lung fields.

52
Q

Cause of HTN:
A 52 year old patient, 24hours post laparotomy for perforated duodenal ulcer is found to have a pulse of 120bpm and BP 95/40mmHg. He is apyrexial and is WCC is 1.5units

A

Hypovolaemia

This patient is apyrexial and there are no signs of SIRS or sepsis. The raised HR and low BP is likely due to hypovolaemia. This patient needs fluids.

53
Q

Cause of HTN:
A 60 year old female had a fractured femur fixed 12 hours earlier. The operative blood loss was measured at 4L and was replaced intra-operatively with 3 units of packed red cells and 1L of gelofusine. She has been written up for 1L dextrose saline 8hourly. Her heart rate is 110bpm and BP is 100/70mmHg

A

Hypovolaemia

A patient that has lost 4L of blood needs more than just 4L of fluids. There are other losses such as urinary losses, sweating and third space losess. Dextrose saline contains 30mmol/L sodium, 30mmol/L chloride whereas normal saline contains 150mmol/L of each. Hartmann’s contains 131mmol/L sodium, 111mmol/L chloride, 5mmol/L potassium, 29 of bicarbonate and 2 of calcium. Maintenance needs for your average 70kg man is 2.5-3L a day, with 120-140mmol sodium and 70mmol potassium.

3L of dextrose saline a day is not sufficient electrolytes. Do the maths – 3L of dextrose saline is 3L of water and 90mmol sodium. A more reasonable regime would be 2L dextrose saline with 1L normal saline, adding 20mmol potassium to each bag.

54
Q

Management:
A 25 year old man with a history of ulcerative colitis, deteriorates and requires and emergency operation to treat the disease.

A

Subtotal colectomy and end ileostomy

Subtotal colectectomy can be done in emergency extreme cases of UC. The ileum needs to be brought out as a stoma as the only parts of the colon that remain are the rectum and anus, and anastomosing this with the terminal ileum can cause ileal pouchitis and incontience. As you are aware, ulcerative colitis patients who have panproctocolectomies do not have this option and end up having end-ileostomies.

55
Q

Management:
A 72 year old woman has a disseminated malignancy of the colon. She is suffering from abdominal distention and increasing constipation. She has a procedure before going on to palliative care.

A

Loop colostomy

A loop colostomy has the same aim as a loop ileostomy. The faecal stream is diverted to rest distal bowel. Here, the primary objective is to somehow offload all the faeces that have made it past the ileum and are piling up in the colon, so that the colon does not have to keep working to push faeces against an obstruction (which will create colicky pain).

Remember also that your palliative patient will lose more water if you do a loop ileostomy.

56
Q

Diagnosis:

Trachea central. Reduced chest movement on right. Dull to percussion on right. Bronchial breathing at right base

A

Lobar pneumonia

These are the classic signs of pneumonia. Also expect to find increased vocal resonance and tactile vocal fremitus over areas of consolidation. In reality, it can be confusing if the pneumonia causes a lobar collapse as you can also find signs of collapse on examination. Always consider the history as well as examination and investigation findings. On a CXR with pneumonia, you can expect to see air space shadowing with air bronchograms. Always remember to auscultate at the right axilla when doing a respiratory examination or a RML pneumonia may be missed.

57
Q

Diagnosis:

Low calcium, Low phosphate, High PTH, High ALP

A

Osteomalacia

58
Q

Diagnosis:

High calcium, Low phosphate, Normal PTH, High ALP

A

Primary hyperparathyroidism

59
Q

Diagnosis:

Normal calcium, Normal phosphate, High PTH, Very high ALP

A

Paget’s disease

60
Q

Diagnosis:

High calcium, Normal phosphate, Slightly low PTH , High ALP

A

Hypercalcaemia of malignancy

61
Q

Diagnosis:

Normal calcium, Normal phosphate, Normal PTH, Normal ALP

A

Osteoporosis

62
Q

Cause of anaemia:
A 62 year old woman with RA is taking prednisolone & NSAIDs for RA. She is admitted to a casualty department with the sudden onset of weakness & faintness. She feels nauseated & is hypotensive. Hb is 8g/dl.

A

Blood loss

Blood loss from a peptic ulcer due to chronic NSAID use is to blame here. NSAIDs inhibit COX which has the effect of reducing PGE2 levels. PGE2 plays a role in gastric cytoprotection by downregulating HCl production and increasing mucus and the production of bicarbonate. This leads to gastric irritation and ulceration. A PPI can be prescribed alongside NSAIDs or misoprostol can be used, which is a stable PGE1 analogue which mimics local PG to maintain the gastroduodenal mucosal barrier. NSAID induced ulcers and more likely to be gastric than duodenal.

63
Q

Cause of anaemia:
A 66 year old alcoholic man has a firm irregular liver, testicular atrophy, splenomegaly, a normocytic normochromic anaemia & thrombocytopaenia.

A

Anaemia of chronic disease

Whilst alcoholism may prompt you to consider alternative causes for this man’s anaemia, a positive alcohol history may be present in those with ACD and the normocytic normochromic anemia gives this away. ACD is caused by inflammation, which can result from various disease processes. The release of pro-inflammatory cytokines leads to a cascade producing anaemia due to decreased RBC production and shortened survival. The anaemia of ACD can also be microcytic.

64
Q

Management:

A 50 year old man became suddenly breathless whilst eating. He has marked stridor & is choking & drooling.

A

Heimlich manoeuvre

This patient has choked on some food. The patient should be encouraged to cough if they are conscious. Otherwise, external manoevres can be performed such as abdominal thrusts (Heimlich) or back blows. These actions increase intrathoracic pressure and help to dislodge the foreign body. If it still isn’t removed, a flexible bronchoscopy may be necessary. Most cases occur in very young children.

65
Q

Management:
A 20 year old woman is too breathless to speak. Her pulse is 120/min, respiratory rate 30 per min & peak expiratory flow is 100l/min. Examination reveals a very quiet chest & chest x-ray is normal.

A

Nebulised salbutamol

This patient is having an asthma attack. This patient is too breathless to speak and has a quiet chest so this is severe and ICU admission is indicated. Initial treatment is with repeated administration of an inhaled SABA with early systemic corticosteroids and supplemental oxygen, monitoring the patient’s status regularly.

66
Q

Management:
A 51 year old manic depressive man, who has taken an unknown number of extra lithium tablets & has a plasma lithium level of 8 mmol/l. There are marked neurological features.

A

Haemodialysis

Haemodialysis is the treatment of choice for severe lithium poisoning. Note that activated charcoal does not adsorb lithium.

67
Q

Management:

A 14 year old girl who has taken at least 30 aspirin tablets (300mg each).

A

Alkaline diuresis

This patient has ingested at least 9000mg of aspirin. GIT decontamination should be considered as an adjunct on arrival to A&E and activated charcoal can be given. The mainstay of treatment is alkaline diuresis induced by an infusion of sodium bicarbonate. In cases of severe poisoning, it is still started as a bridge to haemodialysis.

68
Q

Fluid replacement management:
An 80 year old woman is admitted with vomiting. Her blood pressure is 120/80mmHg, pulse rate 90/min, with warm peripheries. Plasma urea is 25mmol/l, & creatinine 120umol/l.

A

Intravenous saline

Patient is very dehydrated - 1st line fluid resuscitation is intravenous saline

69
Q

Fluid replacement management:
A 20 year old man has been involved in a road traffic accident & the ambulance has just arrived. He has severe left upper abdominal tenderness, blood pressure 80/60 & pulse 140/min.

A

Intravenous saline

First line fluid resuscitation is intravenous saline