2018 Q.P Flashcards
Risk factors for DVT
- Smoking
- Hyperlidpemis
- Oral contraceptives
- Immobilization
- Surgery within 3 months
- Pregnancy
Investigation for DVT
1.
D-Dimer…Elevated levels suggest recent presence lysis of thrombi.
- Ultrasonograpgy- Identify thrombi by direct visualization of venous linning
List 3 pathological processes responsible for the formation of DVT
- Venous stasis
- Endothelial injury/damage
- Hypercoagulation.
Symptoms for DVT
- Vague aching pain.
- Calf swelling
- Warmth
- Visible veins
- Redness
- Mild fever
Signs of DVT
- Erythema
- Pitting edema
- Superficial collateral veins
- Tenderness along tje distribution of veins.
- Horman’s signs
DDx of Microcytic Anemia
- Acute blood loss
- Renal failure
- Hypothyroidism
- Pregnancy
List 5 Secondary causes of HPT
- Cushion’s syndrome
- Acromegally
- Thyroid disease
- Chronic glomerulonephritis
- Hyperparathyroid disease
Baseline bedside test for MI
ECG
List 2 lab investigations that will help diagnose MI
- Cardiac Enzymes (Troponin)
2. FBC
List 4 treatments that you can give at district Hospital for MI pt
- Oral antiplatelet therapy
- Nitrates
- Anticoagulation
- Beta-Blockers
DDx of MI
- Angina pectoris
- Pericarditis
- Myocarditis
- Pulmonary Embolism
Life-threatening complications of HPT
- Ischemic heart disease
- Hypertensive Retinopathy
- Hypertensive Neuropathy
- CVA
- Heart Failure
A 75-year-old man presents to Accident and Emergency following a week of productive cough, fever and shortness of breath. He has not had any foreign travel, however is a chronic smoker with a 15 pack/year history.
Which of the following findings is most likely to be found on examination of this patient’s chest?
Sample Clinical Questions Lab Values HAEM CHEM MISCELLANEOUS Normal Values The figures quoted within the themes are all standardised to the units show below. Note ranges vary between populations and age groups and it is important to always check the reference ranges. Haematology Haemoglobin (M) 13.0 - 17.0 g/dL (F) 11.5 - 15.5 g/dL White cell count 3.0 - 10.0 x 10⁹ /L Platelets 150 - 400 x 10⁹/L Mean cell Haemoglobin (MCH) 27 - 33 pg Mean cell haemoglobin concentration (MCHC) 32 - 35 g/dL Mean cell volume (MCV) 80 - 96 fL Neutrophils 2.0 - 7.5 x 10⁹ /L Lymphocytes 1.5 - 4.0 x 10⁹/L Monocytes 0.2 - 1.0 x 10⁹/L Eosinophils 0 - 0.4 x 10⁹/L Basophils 0 - 0.1 x 10⁹/L Reticulocytes 25 - 100 x 10⁹/L Packed cell volume (PCV) (M) 0.40 - 0.54 (F) 0.37 - 0.50 Erythrocyte sedimentation rate (ESR) < 20 mm/hr D-dimers < 0.5 mg/L Coagulation screen International normalised ratio (INR) 1.0 Activated partial thromboplastin time (APTT) 22 - 41 seconds Prothrombin time (PT) 10 - 12 seconds Thrombin time (TT) 9 - 15 seconds Fibrinogen 1.5 - 4.0 g/dL Fibrinogen degradation products < 8 mg/mL Factor VIII:C 50 - 150 U/dL Bleeding time < 10 minutes Arterial blood gas pH 7.35 - 7.45 PaO₂ 11 - 15 kPa PaCO₂ 4.6 - 6.4 kPa Bicarbonate 22 - 30 mmol/L Base excess -2 to +2 mmol/L Question 1 A 75-year-old man presents to Accident and Emergency following a week of productive cough, fever and shortness of breath. He has not had any foreign travel, however is a chronic smoker with a 15 pack/year history.
Which of the following findings is most likely to be found on examination of this patient’s chest?
A. Hyper-resonant percussion note and tracheal deviation to the left
B. Stony dull percussion note and reduced tactile vocal fremitus
C. Increased vocal resonance and fine end inspiratory crepitations
Reduced vocal resonance and dull percussion note
D. Increased tactile vocal fremitus and dull percussion note
D is the correct answer. This patient has the classic symptoms of a pneumonia and the abnormality found on auscultation is indicative of a lobar pneumonia. Pneumonia presents with increased tactile vocal fremitus/ vocal resonance and dull percussion note.
Question 2
A 69 year old woman presents following a 3 day history of shortness of breath and a productive cough. Her initial observations are HR: 104bpm, RR:31, BP:90/65, O2 sats: 96%, Temp: 38.5C.
She is admitted to hospital and treated with IV amoxicillin and clarithromycin for the past week. However, since then her fever has persisted and she has developed foul smelling sputum.
A chest x-ray is requested and an aspirate of pleural fluid is obtained. The results demonstrate a pH<7.2.
What is the most appropriate management?
A. High flow oxygen (60%) B. Antibiotic instillation C. Change the antibiotic regime to IV Tazocin D. Add oral itraconazole E. Chest drain under ultrasound guidance
E is the correct answer. A recurrent fever despite antibiotic treatment for a pneumonia is suggestive of an empyema. This is further supported by the pleural fluid aspirate pH reading of 7.2 which is “almost” diagnostic. Therefore, treatment of an empyema involves a chest drain under radiological guidance.
A 55 year old female presents with a three month history of dyspnoea and persistent cough.
Over the last few days her cough has progressively worsened and she is now coughing red specks. She complains that her clothes no longer fit her, and she is having to regularly wear belts. She works as a receptionist and has never smoked.
Which of the following is the single most likely diagnosis?
A. Adenocarcinoma B. Metastasis from the breast C. Small cell carcinoma D. Large cell carcinoma E. Squamous cell carcinoma
A is the correct answer. The patient has a history indicative of lung cancer, with dyspnoea, haemoptysis and weight loss that has progressively worsened. However, the lack of smoking history makes adenocarcinoma the most likely diagnosis
A 25 year old male patient presents to the general practitioner with a 4 week history of an enlarging left neck mass. He reports the mass is generally painless, but he notices it is sometimes painful after he drinks alcohol. He denies any other symptoms and has no past medical history of note.
Physical examination reveals non-tender cervical lymphadenopathy. Excisional lymph node biopsy reveals large cells with bilobed nuclei and eosinophilic nucleoli.
Which of the following is a risk factor for the most likely diagnosis?
A. Middle age B. History of Epstein-Barr virus (EBV) infection C. African ancestry D. Stage II (A) E. Low socio-economic class
B is the correct answer. EBV is strongly associated with Hodgkin’s lymphoma. EBV antigens are found in approximately 30% of Reed-Sternberg cells.
A 65 year old male patient presents to the general practitioner with a 1 month history of malaise, night sweats, and weight loss.
On physical examination he appears cachectic and there is conjunctival pallor. There is moderate splenomegaly. Full blood count reveals a white cell count of 5.5 x 10^9/L, a haemoglobin of 7.5 g/dL, platelet count of 88 x 10^9/L, and absolute reticulocyte count of 0.4%. Peripheral blood film reveals poikilocytes.
Which of the following is the best diagnostic investigation for the most likely diagnosis?
A. Serum protein electrophoresis B. Serum folic acid levels C. Serum B12 levels D. Bone marrow aspiration E. Bone marrow biopsy
E is the correct answer. The patient presents with clinical features and investigation findings suggestive of myelofibrosis, a cause of acquired pancytopenia. Marrow biopsy will reveal marrow fibrosis. The marrow may either be hyperplastic or hypoplastic, embedded in a collagenous matrix.
An 74 year old man is being treated for chest sepsis with IV amoxicillin. His past medical history includes hypertension, for which he is on ramipril and amlodipine. He is normotensive. His blood tests come back as follows:
Na 142 (135-145)
K 5.4 (3.5-5.5)
Ur 10.4 (2.5-6.7)
Cr 203 (70-150) - baseline 120
He is initiated on IV fluids and is currently producing some concentrated urine.
What is the most appropriate next step in managing this patient?
A. Arrange dialysis B. Stop amlodipine C. Start furosemide D. Stop amoxicillin E. Stop ramipril
E is the correct answer.
Ramipril may worsen pre-renal AKI by reducing renal perfusion through dilation of renal arterioles. It is therefore imperative to stop it.
A 25 year old female patient presents to the general practitioner with a 2 day history of urinary frequency and dysuria.
Physical examination reveals mild suprapubic tenderness. Vital signs are within the normal ranges.
Which of the following investigation findings is consistent with the likely diagnosis?
A. Midstream urine culture shows 20 white cells/mm^3
B. Blood culture is positive for E. coli
C. Urine dipstick reveals 2+ protein and 2+ blood
D. Midstream urine culture shows 10^5 colony forming units/mL pure growth of E. coli
E. Full blood count reveals a white cell count of 18 x 10^9/L
D is the correct answer. The patient’s clinical presentation is consistent with cystitis. The diagnostic test for urinary tract infection is with MC&S of midstream urine. This should show >10^4 colony forming units/mL of pure growth (10^3 is sufficient for E. coli, 10^5 is requires if the growth is mixed). Note that diagnostic confirmation of urinary tract infection is not required in women who are not pregnant presenting with the typical features of cystitis. Confirmation of urine MSU is required in children, male patients, pregnant women, recurrent/relapsing UTIs, pyelonephritis, if haematuria is present on the dipstick, and if the patient is catheterised.
A 65 year old female patient presents to A&E with shortness of breath after a 3 day history of vomiting and diarrhoea. She has a background of chronic kidney disease.
Physical examination reveals dry mucous membranes, but is otherwise normal. An arterial blood gas is done which shows:
pH = 7.31, PaO2 13 kPa, PaCO2 3.5 kPa, normal anion gap
Which of the following is the next best step in the management of this patient?
A. Intravenous sodium bicarbonate
B. Intravenous 0.9% sodium chloride
C. High flow oxygen 15 L/min via a non-rebreathe mask
D. Low molecular weight heparin
E. Intravenous broad-spectrum antibiotics
B is the correct answer. This patient has a background of chronic kidney disease so is at risk of developing acute kidney injury. Hypovolaemia secondary to gastroenteritis can result in a pre-renal acute kidney injury. The acute kidney injury will cause a metabolic acidosis: the low pH is consistent with acidaemia, and the low PaCO2 indicates a metabolic cause. The metabolic acidosis will result in tachypnoea which blows off CO2, in an effort to normalise the pH (respiratory compensation). The patient is hypovolaemic and requires fluid resuscitation with intravenous 0.9% sodium chloride followed by maintenance fluids. This restore perfusion pressures and correct the pre-renal AKI.
A 30 year old male undergoes a renal transplant for polycystic kidney disease. After 3 years he presents with pain in both hip joints and impaired mobilisation.
Physical examination reveals painful reduction in active movement in both hip joints. Bloods reveal an eGFR >90 ml/min/1.73m^2.
Which of the following is the most likely cause?
A. Avascular necrosis B. Rheumatoid arthritis C. Renal osteodystrophy D. Primary osteoarthritis E. Osteomalacia
A is the correct answer. Avascular necrosis is caused by reduced blood supply to the bone. Causes to remember include corticosteroid therapy, sickle cell disease, and connective tissue disease. Systemic steroids are associated with 35% of cases of non-traumatic avascular necrosis. To prevent organ rejection, the patient requires immuno-suppressive therapy following the renal transplant so is likely to be on long-term oral steroids.
An 8 year old boy presents to the general practitioner with a 3 week history of periorbital oedema, ankle oedema and frothy urine.
Physical examination shows significant ankle oedema to the mid-shins. Urine dipstick reveals 3+ protein.
Given the most likely syndrome, which of the following is the most likely underlying cause?
A. Minimal change disease B. Post-streptococcal glomerulonephritis C. Membranous nephropathy D. Focal segmental glomerulosclerosis E. Acute interstitial nephritis
A is the correct answer. This presentation is consistent with nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children. The disease is called ‘minimal change’ because renal biopsy reveals a normal appearance on light microscopy, but electron microscopy shows foot process effacement.
A 75 year old male patient presents to the emergency department with sudden onset dizziness. He has a past medical history of type 2 diabetes and hypercholesterolaemia.
On physical examination there is loss of temperature sensation on the left half of the face. The left pupil is fixed in constriction. There is gaze nystagmus when looking to the left. His gait is unsteady and broad-based. No other abnormalities are noted.
Given the most likely diagnosis, which of the following artery is most likely involved?
A. Left posterior inferior cerebellar artery
B. Basilar artery
C. Left anterior inferior cerebellar artery
D. Right anterior inferior cerebellar artery
E. Right posterior inferior cerebellar artery
A the correct answer. The patient presents with features suggestive of lateral medullary syndrome (Wallenberg’s syndrome). This is caused by a stroke affecting the cranial nerve nuclei of the medulla. This form of stroke causes ataxia, dysarthria, dysphagia, ipsilateral Horner’s syndrome, ipsilateral loss of pain and temperature sensation on the face, and contralateral loss of pain and temperature sensation over the contralateral body.
A vascular territory.
Which of the following is the most appropriate acute management for the most likely diagnosis?
A. Endovascular intervention (clot retrieval)
B. Intravenous alteplase
C. Supportive management and neuro-surgical review
D. Aspirin 300 mg orally
E. Intravenous, labetolol
C is the correct answer. The patient presents with features suggestive of haemorrhagic stroke. Haemorrhagic stroke should not be managed with aspirin or thrombolysis. Acute management involves neurosurgical and neuro-critical care evaluation, admission to the neurology ICU, and airway protection.
A 65 year old male patient presents to the emergency department with sudden onset left arm and leg weakness. He has a past medical history of hypertension, osteoarthritis, and depression.
Physical examination reveals left-sided hemiparesis. CT head reveals a right-sided hypo-dense region in the middle cerebral artery territory. Electrocardiogram (ECG) is normal.
Given the most likely diagnosis, which of the following is the most suitable long-term pharmacological therapy?
A. Warfarin with dose adjusted for target INR of 2-3, atorvastatin 80 mg once nightly
B. Clopidogrel 75 mg once daily, atorvastatin 80 mg once nightly
C. Aspirin 75 mg once daily, clopidogrel 75 mg once daily, atorvastatin 80 mg once every morning
D. Aspirin 300 mg once daily, clopidogrel 300 mg once daily, atorvastatin 80 mg once nightly
E. Aspirin 75 mg once daily, clopidogrel 75 mg once daily, Ezetimibe 20 mg once nightly
B is the correct answer. The patient presents with features suggestive of an ischaemic stroke, most likely secondary to small cerebral vessel atherosclerosis or carotid artery stenosis (the normal ECG make a cardio-embolic source less likely). Long-term management is with antiplatelet therapy (Clopidogrel is first line) and lipid-lowering therapy. The patient’s blood pressure therapy may also need to be adjusted.
A 65 year old male patient presents with sudden onset right-sided weakness and impaired sensation on the right side. There were no preceding symptoms. There was no loss of consciousness.
By arrival to the emergency department 30 minutes later his symptoms have resolved and physical examination is normal. Blood glucose is 4.5 mmol/L. Past medical history is significant for type 2 diabetes mellitus and hyperlipidaemia.
Which of the following is a risk factor for the most likely diagnosis?
A. Gliclazide therapy B. History of major psycho-social stressor C. Atrial fibrillation D. Vitamin D deficiency E. Family history of seizures
C is the correct answer. The presentation is consistent with a transient ischaemic attack (TIA). Atrial fibrillation increases the risk of TIA due to left atrial blood stasis and thrombus formation, with embolisation to the cerebral vessels.
A 22 year old male patient presents to the emergency department after suffering a head strike during a boxing match. He lost consciousness for 15 seconds then regained a normal level of consciousness.
On arrival to the emergency department he reports a mild headache but is otherwise well. Within the next 2 hours his headache worsens and consciousness level declines.
Which of the following CT head findings is consistent with the most likely diagnosis?
A. Crescent-shaped homogeneously hyper-dense extra-axial collection adjacent to the left frontoparietal convexity
B. Irregular hypo-dense lesion within the left temporal white matter, with irregular enhancement of the margins
C. Hyper-attenuating material pooling within the occipital horns of the lateral ventricles
D. Cortical hypo-density associated with loss of grey-white matter differentiation in the vascular territory of the middle cerebral artery
E. Lentiform-shaped heterogenous hyper-dense extra-axial collection adjacent to the left squamous temporal bone
E is the correct answer. The patient presents with a clinical presentation consistent with an extradural haematoma (in particular the lucid interval followed by deterioration)
An 82 year old man being investigated for weight loss by his GP is found to have an abnormal blood count revealing a lymphocytosis of 25.8 x10^9/L (and low-normal haemoglobin and platelets). Liver and renal function are normal and the blood film shows a lymphocytosis with an abundance of smudge cells.
Aside from the weight loss he reports only occasional night sweats on direct questioning. On closer examination, the GP finds subtle cervical lymphadenopathy bilaterally and 2 finger breadths hepatosplenomegaly. He has not traveled recently and there is no family history of blood disorders.
What is the single best diagnostic investigation?
A. EBV serology and viral PCR
B. Bone marrow biopsy and immuno-phenotyping.
C. Chest X-ray and mycobacterial sputum culture
D. HIV test
E. Excision lymph node biopsy
B is the correct answer. The working diagnosis here must be chronic lymphocytic leukaemia presenting with indolent symptoms and lymphocytosis in an elderly man. Smudge cells are a pathognomonic features of CLL on a blood film. Bone marrow biopsy with immuno-phenotyping will confirm the diagnosis.
An 80 year old female complains of progressive tiredness over the past 5 months. She denies any history of anaemia, no black stools, no fresh blood per rectum. She maintained a good appetite although has lost 8 kg of weight during this time frame. Bloodwork reveals a pancytopenia, normal renal function and otherwise normal biochemistry profile. What is the next appropriate step and management?
A. Lymph node biopsy B. Blood film C. Thyroid function tests D. Bone marrow biopsy E. Urine Bence Jones protein
B.
The peripheral film can tell lots of important information regarding a pancytopenia. Nutritional deficiencies such as iron, B12 or folate will all be apparent on a film alongside rouleaux formations for multiple myeloma. Blasts and other immature cells may suggest malignancy or a primary bone marrow disorder such as myelofibrosis. The differential for pancytopenia can be wide but the film can help pinpoint the aetiology and the next stage of tests.
A 70-year-old man with a diagnosis of Chronic Obstructive Pulmonary Disease which is normally managed by a Symbicort inhaler, is admitted following a 5-week history of gradual shortness of breath and confusion.
His observations are: HR 110bpm, RR 27, BP 100/70, Temp 37.0C, and O2 saturations of 82%. The patient is started on nebulized bronchodilators and oxygen, and after 20mins a further arterial blood gas is performed with the results as follows:
pH 7.29
PaO2 7.7
PaCO2 8
HCO3- 27
Which is the next best step in the management of the patient?
A. Doxapram B. IV Hydrocortisone C. Oral Amoxicillin 500mg/8 hourly D. IV aminophylline E. Non-invasive Ventilation (NIV)
E is the correct answer. The ABG shows an uncompensated type 2 Respiratory Failure as PaO2 <8 and PaCO2 >6. Due to the PH <7.35 we would consider Non-invasive ventilation since the PaCO2 is rising.
A 55 year old male patient came to the emergency department with a complaint of breathlessness for the past 2 hours. This is the 3rd episode in the last 3 weeks. On examination the patient is using his accessory muscles to breathe. The vitals are: blood pressure 140/88mmHg, pulse rate 110bpm. Respirationa 30bpm, temperature 37.6C. On auscultation his chest is silent.
a) List 7 additional findings (not listed above) in his medical history (subjective data) that will support a diagnosis of an acute asthma attack.
- Wheeze
- Cough
- Chest tightness
- Eczema
- Hayfever
- Famil Hx of asthma
- Symptoms worse at night, early morning, with cold or stress.
A 20 year old male patient brought by an ambulance to the emergency department with a history of a circumcision performed one week ago at a circumcision school. He presents with fever and shallow breathing. A clinical associate on duty makes an assessment of Septic shock.
a) List 3 additional findings (not mentioned above) on physical examination (objective data) to support the diagnosis of Septic shock
- Tachycardia
- Cold peripheries
- Weak pulse
- Hypotension
A patient is being placed under general anesthesia. Following the induction with propofol, the anesthetist attempts to intubate the patient. The doctor accidentally touches the patient’s vocal cords with the endotracheal tube. The patient starts excessively making it impossible to intubate the patient.
a) Explain why the patient starts to cough during the attempted intubation?
Irritation of the vocal cord by the endotracheal tube stimulates the cough Reflexes as the body attempts to remove the foreign body.
A 42 year old patient is diagnosed with gout after his first attack. He is referred to the clinical associate by the primary health care nurse for treatment and education.
List 2 non-drug management steps and explain why each step is recommended to help manage the patient’s medical condition.
- Rest & immobilize- To help reduce the pain and avoid aggravating the pain.
- Educate the patient about the importance of alcohol cessation & other symptoms.
A 42 year old patient is diagnosed with gout after his first attack. He is referred to the clinical associate by the primary health care nurse for treatment and education.
List 2 drug management steps and explain why each step is recommended to help manage the patient’s medical condition.
- Ibruprofen oral, 400mg/kg- To help relieve pain and reduce inflammation.
- Prednisone oral, 40mg/daily, 5 days- It helps reduce inflammation
A 45 year old male patient started TB treatment a month ago. He is HIV negative and his TB symptoms have improved. However today, at the district hospital OPD, he complains that the anti-TB medication is affecting him adversely. On examination his sclerae appears Dark yellow bilaterally.
a) Describe the next most important management steps for this patient.
- Stop the hepatotoxic drug and replace it with a hepato friendly second line drug.
- Treat the Jaundice
