2004 paper errors Flashcards
Diagnosis:
A 47-year-old man was brought into A&E having fainted in a wine bar at 6pm. His Glasgow Coma Score was 3. He was pale, sweaty and looked grey. He normally took no alcohol but had been celebrating his promotion at work by holding a champagne party.
Hypoglycaemia
Heavy alcohol consumption decreases hepatic production of glucose, putting this person at risk of hypoglycaemia. This patient is suffering from hypoglycaemia which is present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety.
Diagnosis:
A 47-year-old male policeman was brought to A&E having become SOB suddenly. He now complains of palpitations, which he has never experienced before. Heart sounds are irregular but no murmurs are audible. He is a diabetic with hypertension.
Atrial fibrillation
Atrial fibrillation is an irregular atrial arrhythmia with a broad list of risk factors such as coronary artery disease, heart failure, hypertension, DM and thyroid disorders. This patient has two of these risk factors. AF affects some 5% of those older than 69 years old. The presentation of SOB and palpitations is consistent with the diagnosis and the irregular heart sounds suggests AF as the cause. ECG would show absent P waves, a fibrillatory baseline and irregularly irregular complexes. Most that present with acute AF do not need immediate treatment, unless they have developed haemodynamic compromise, which requires immediate DC cardioversion. Most will require medical therapy with drugs to control the ventricular rate, restore and maintain sinus rhythm and prevent the occurence of thromboembolic events. Do you know which drugs are used and are you familiar with treatment guidelines for this common condition?
Reduce CVS risk:
A 77-year-old man, normal blood pressure, not diabetic, who has had 3 episodes of transient left sided weakness in the last month.
Aspirin therapy
A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour. An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF. Clopidogrel is an alternative in those who do not tolerate aspirin.
Reduce CVS risk:
A 54-year-old man, normal blood pressure, normal lipid profile, BMI 28, random blood sugar 15 mmol/l, fasting blood sugar 8.5 mmol/l.
Weight reduction and metformin therapy
This patient has DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation is diet and lifestyle advice and changes. Metformin will be added if there is no adequate response. In terms of this question, this option will reduce cardiovascular risk the most for this patient. Metformin is a biguanide and suppresses hepatic glucose production.
Cause:
A 56-year-old lady with a long history of asthma develops bruising.
Corticosteroids
Side effects of corticosteroids are due to exaggerated normal physiological actions. This lady with a long history of asthma is likely either taking inhaled corticosteroids or on oral therapy. An inhaled corticosteroid is used if a patient requires their reliever more than twice a week. Smoking, current or previous, reduces the effectiveness of inhaled corticosteroids so higher doses may be needed. In asthma, they reduce airway inflammation and reduce oedema and mucus secretion into the airway. Bruising is a documented side effect. Other side effects include adrenal suppression with prolonged use of inhaled therapy, LRTIs, predisposition to osteoporosis, anxiety, depression, hyperglycaemia and cataracts. Can you classifiy the wide range of side effects of steroids?
Diagnosis:
A 48 year old male stripper presents with bruising, infections and fatigue. Lab findings indicate a pancytopenia with low reticulocyte count. Bone marrow biopsy is done on which a definitive diagnosis is made.
Aplastic anaemia
This is aplastic anaemia characterised here with the pancytopenia (which is common, but diagnosis requires 2 cytopenias out of 3) and the presentation with infections (neutropenia), fatigue (anaemia) and bruising (thrombocytopenia). Risk factors include paroxysmal noctural haemoglobinuria, hepatitis and NSAIDs. If macrocytosis is seen, this may suggest an inherited syndrome such as Fanconi’s anaemia. The reticulocyte count here rules out haemolytic anaemia, which isn’t even an option on the list. The definitive diagnosis is made on biopsy of bone marrow which shows a hypocellular marrow with no abnormal cell populations and no fibrosis. Which conditions would there be abnormal cell populations or fibrosis on bone marrow biopsy?
Diagnosis:
A 62-year-old man with a history of alcohol abuse presents with bilateral parotid hypertrophy, gynaecomastia, testicular atrophy and easy bruising.
Hepatic cirrhosis
Cirrhosis is the end-stage of chronic liver disease, in this case due to alcoholic liver disease. Cirrhosis results in hepatic insufficiency and portal hypertension. The bruising here is due to thrombocytopenia secondary to portal hypertension with resulting hypersplenism and sequestration. Complications of chronic liver disease include ascites, variceal bleeds, jaundice, hepatic encephalopathy, hepatorenal syndrome and the development of HCC. Signs include spider naevi, palmar erythema, telangiectasia, bruising, gynaecomastia, Dupuytren’s contracture, parotid swelling and a red tongue.
Diagnosis:
A 45-year-old HCV positive Egyptian journalist presents with acute renal failure. He is complaining of increasing abdominal distension, pruritis, ankle oedema and weight gain. Serum albumin is low and there is hyponatraemia and thrombocytopenia.
Portal hypertension
HCV in this patient is causing hepatic cirrhosis which has decompensated resulting in ascites, secondary to portal hypertension. The hypoalbuminaemia is a sign of decreased hepatic synthetic function. Hyponatraemia is a common finding associated with ascites. It arises due to reduced protein synthesis and therefore a loss of colloid osmotic pressure and increased fluid loss from the intravascular compartment, stimulating ADH secretion. There is peripheral oedema here which is due to low albumin. The pruritis is due to reduced hepatic excretion of conjugated bilirubin and there may be accompanying jaundice too. The cause of his renal failure may well be hepatorenal syndrome in the context of his severe liver disease. His prognosis is poor.
Diagnosis:
A 45-year-old woman complains of abdominal pain for several months. On examination she is jaundiced with a distended abdomen and skin telangiectasia.
Cirrhosis
Cirrhosis is the end stage of chronic liver disease which results in hepatic insufficiency and portal hypertension, causing this patient’s jaundice, a sign a decompensation. Jaundice is also seen here reflecting reduced hepatic excretion of conjugated bilirubin and there may be associated pruritis. Telangiectasia is a sign of chronic liver disease. Risk factors for cirrhosis include alcohol, IVDU, unprotected sex and blood transfusion. This gives us an insight into the causes which include chronic viral hepatitis (C, B with or without D) and alcoholic liver disease. Other causes include conditions such as Wilson’s disease, NAFLD, haemochromatosis, Budd-Chiari syndrome and drug induced such as amiodarone and methotrexate.
Diagnosis:
83-year-old man with longstanding heart failure for which he takes Digoxin and diuretics. For the last 24 hours he has been vomiting and has passed very little urine. On examination he is pale and mildly dehydrated; examination of the abdomen is normal.
Uraemia
This patient has developed acute renal failure, probably associated with the longstanding CCF. Advanced heart failure will lead to depressed renal perfusion and ARF. The decreased urine output is a symptom and the vomiting here is caused by uraemia or a general build up of waste products. An acute increase in creatinine will be seen, commonly with hyperkalaemia, hyperphosphataemia and a metabolic acidosis. There may also be respiratory compensation for this. Treatment is largely supportive, managing, in this case, the heart failure, and correcting abnormalities like volume status and the metabolic acidosis. Dialysis may be required.
Diagnosis:
34-year-old man has had vomiting 2-3 times a day for 3 days. He complains of severe crampy abdominal pain and blood stained watery diarrhea. On examination temperature 37.7˚C. Abdomen soft, complains of generalised tenderness. No masses/rebound/guarding.
Salmonella
The only option on the list which fits is Salmonella. This could obviously be E coli or Campylobacter too, for instance. This is infectious gastroenteritis and Salmonella is a common cause, pretty much able to contaminate any food. It is commonly linked to poultry, dairy items and undercooked eggs. It is self-limiting and diagnosis is on isolating the organism from a stool culture. Treatment is supportive with fluid and electrolyte replacement and antibiotics are generally used only for patients with risk factors for severe disease or those with extra-GI complications. This is not viral gastroenteritis for the reasons below:
Viral gastroenteritis often presents with mainly UGI symptoms like N&V more so than diarrhoea. It is on this basis that this is likely to be viral gastroenteritis caused by organisms such as rotavirus, norovirus and adenovirus. Staphylococcus aureus and Bacillus cereus also tend to cause mostly UGI symptoms and acts by preformed toxins, though these are not on the list of available options. The differentiation is made on studying the stool and identifying the organism.
Diagnosis:
A 17-year-old man presents with a 6 hour history of sudden onset of severe left scrotal pains. The scrotum is red and swollen, the testis and epididymis are very tender.
Testicular torsion
This is a urological emergency caused by twisting of the testicle on the spermatic cord which if not fixed will lead to ischaemia and necrosis of testicular tissue. The main differential is epididymo-orchitis but a high index of suspicion is necessary and if there is any doubt then surgical exploration is indicated. Boys aged 12-18 are at greater risk. There is usually sudden-onset very severe scrotal pain with N&V. There may be spontaneous de-torsion hence a history of previous episodes of pain. A history of undescended testes is a major risk factor as is the bell clapper deformity. During exploration, the contralateral testis is also fixed to the posterior wall.
Diagnosis:
A 70-year-old man present with mild dysuria, urinary hesitancy and terminal dribbling. He also has bilateral testicular pain, swelling and tenderness of both testes and epididymis. His temperature is 37.50ºC.
Epididymo-orchitis
Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. He is mildly febrile with tenderness on-top of urinary symptoms which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated.
Diagnosis:
A 25-year-old single mother of three children presents in respiratory distress. There is progressively worsening SOB, wheezing and cough over the last 2 days. When you examine her, there are faint breath sounds, HR 120, RR 30. She gives a 6 month history of cough and SOB which has every now and then woken her up from sleep.
Bronchial asthma
Progressively worsening SOB and the wheeze, which may like this case wake the patient from sleep combined with the long duration of symptions suggests asthma. This patient is having an acute exacerbation and needs to be treated for this, before commencing the appropriate stepwise chronic treatment on the BTS ladder. Whether this exacerbation is mild, moderate or severe is based on the patient’s % predicted PEFR.
Diagnosis:
An 80-year-old woman is admitted from a residential home with a two week history of purulent sputum and pyrexia (38ºC). Examination reveals a constant wheezing in inspiration and expiration localised over the right lung base.
Inhaled foreign body
This is aspiration pneumonia. There are symptoms of pneumoia with pyrexia and purulent sputum, along with risk factors for aspiration in this elderly person who may have difficulties swallowing or altered mental status from, for example, dementia. The location of the wheeze is also consistent with this diagnosis as the RLL is the most common site due to the anatomy of the bronchial tree. Complications include abscess and empyema. Treatment is predominantly with antibiotics and supportive care.
Diagnosis:
A 30-year-old man attends for a routine pre-employment medical. On examination of the cardiovascular system, the doctor finds a soft (grade 2/6) ejection systolic murmur at the apex. He has no previous cardiac or respiratory problems and has a normal pulse and BP.
Innocent murmur
This is a functional murmur which is not caused by a structural cardiac defect. Functional murmurs tend to be systolic, occuring in an otherwise healthy individual with no symptoms. They are also characteristically position dependent and soft in nature. Ones that occur in children tend to disappear as the child grows. Benign paediatric murmurs include Still’s murmur.
Diagnosis:
A 60-year-old Irish woman comes to see you with a progressive one year history of shortness of breath and recent onset of PND. She has been previously well apart from Sydenham’s chorea as a child. She had 6 normal pregnancies. On examination she has plethoric cheeks, the pulse is rapid (110/min), irregular and small volume. BP 128/80 JVP normal. The apex is in the 5th intercostal space in the mid-clavicular line and tapping in nature. The 1st heart sound is loud and P2 accentuated. A low pitched mid-diastolic murmur is heard at the apex.
Mitral stenosis
Sydenham’s chorea (St Vitus Dance) are dancelike movements seen in rheumatic fever. The major criteria for rheumatic fever can be remember by CASES: carditis, arthritis, Sydenham’s chorea, erythema marginatum and subcutaneous nodules. Practically every single case of mitral stenosis is caused by rheumatic heart disease. The process tends to also cause regurgitation. This is characteristically a grade 1-2 low pitch murmur heard in mid-diastole which has a rumbling nature and there is no radiation. There can be an associated malar flush, tapping apex beat and a diastolic thrill palpable at the apex, in the 5th intercostal space in the MCL. The first heart sound is also characteristically loud and often this is the most striking feature on ascultation. It is a difficult murmur to pick up so if you are ever asked at this stage to spot this murmur, it will most likely be based on the loud S1.
Diagnosis:
A 65-year-old man had an inferior myocardial infarct 10days ago. His initial course was uncomplicated. He suddenly deteriorates with acute left ventricular failure. On examination the pulse is regular 100/min and normal volume and character. BP 110/60. The apex beat is dynamic. There is a loud grade 3/6, apical pansystolic murmur which radiates to the axilla.
Mitral regurgitation
MR is loudest at the apex and radiates to the axilla and tends to be around grade 4. It is associated with a systolic thrill at the apex. TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaced apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.
Diagnosis:
A 35-year-old woman has a 10-year history of low retrosternal dysphagia and painless regurgitation of food in the mouth.
Hiatus hernia
A hiatus hernia is where intraabdominal contents protrude through the oesophageal hiatus of the diaphragm. Risk factors inclyde obesity and high intra-abdominal pressure. The condition may be asymptomatic, or it may present with symptoms (which are non-specific) such as heartburn, dysphagia, pain on swallowing, wheezing, hoarseness and chest pain. A CXR is the first test done and may show an air bubble in the wrong place but barium studies are diagnostic and treatment depends on the symptoms and anatomy of the hernia. Hernias can be sliding or rolling (or mixed, or giant), uncomplicated or complicated by, for instance, obstruction and bleeding. Do you know the difference between a sliding and a rolling hiatal hernia?
Diagnosis:
A 50 year old describes a 5 month history of heartburn and cramp-like chest pain relived by drinking cold water, both unrelated to food. There has also been intermittent dysphagia to both liquids and solids, regurgitation and weight loss of 2kg.
Achalasia
This is achalasia which is a motility disorder with loss of peristalsis in the distal oesophagus and failure of the LOS to relax in response to swallowing. This presents commonly with dysphagia to both liquids and solids, regurgitation and retrosternal chest pain, which can be slowly progressive over time. In structural obstruction such as cancer, dysphagia to liquids is uncommon unless the disease is very advanced. Retrosternal pressure experienced can be precipitated by drinking liquids but is eased by continuing to drink, and the pain may be relieved by cold water. This may wake the individual from sleep. A UGI endoscopy is needed to exclude malignancy as a cause of dysphagia. The diagnosis is established on manometry or barium studies. Treatment is symptomatic.
Diagnosis:
A 40-year-old man returned from India 4 days ago and came down with fever. He went to his GP and got some paracetamol. His fever persisted, and he had a few bouts of diarrhoea and cough. He started getting drowsy and was admitted from casualty where his blood culture was taken. The next day the lab reported Gram negative bacilli seen on blood culture.
Salmonella typhi
Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic – India, for example, which has the highest incidence of this disease. Mexico should also ring alarm bells. The water supplies are not treated and sanitary conditions are dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a high fever which is a hallmark of infection (sometimes in a step-wise manner) which is not responding to paracetamol (it persists) and blood culture (you need a big sample of blood for testing as count is usually low) shows a gram negative bacilli, and he has returned from an endemic region. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.
This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.
Diagnosis:
A 50-year-old man went for Hajj. He was vaccinated against hepatitis and Group C meningococci. He came back with a high fever and was admitted with neck stiffness and drowsiness. He had a lumbar puncture and blood cultures. Gram stain of cerebrospinal fluid showed Gram negative diplococci.
Neisseria meningitidis type B
This patient has meningitis. A big risk factor is crowding which occurs during Hajj. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis.
Management:
A 80-year-old woman is admitted with vomiting. Her blood pressure is 120/80 mmHg, pulse rate 90/min, with warm peripheries. Plasma urea is 25 mmol/l, and creatinine 120 μmol/l.
Intravenous saline
This patient is very dehydrated
Management:
A 20-year-old man has been involved in a road traffic accident and the ambulance has just arrived. He has severe left upper abdominal tenderness, blood pressure 80/60 and pulse 140/min.
Colloid
As mentioned, first line fluid resuscitation is with 0.9% saline.
Management:
A 25-year-old woman is admitted semi-comatose. She has been complaining of increasing thirst and lethargy over the previous few weeks. BM stick result is 36 mmol/l. Blood pH is 7.10 with a HCO3- of 15 mmol/l.
Intravenous saline
Initial treatment of DKA aims at correcting severe volume depletion (the main problem), again with IV saline infusion at a rate of 1-1.5L for the first hour. When glucose reaches 11.1mmol, fluid should be changed to 5% dextrose to prevent hypoglycaemia.
Management:
A 75-year-old man underwent an anterior resection for rectal cancer 48 hours ago. He now has a urine output of 25mls/hr, BP 110/80, pulse 90/min. His Hb is 7.9g/dl.
Blood transfusion
This patient has been given IV saline already as the initial choice for volume expansion. His anaemia and clinical state warrants a blood transfusion. 1 unit of blood raises the Hb concentration by 1g/dL. Commonly, transfusion begins with 2 units of packed RBCs and the patient response is monitored.