All quizes

Question 1

55 yr old man is taking increasing doses of sublingual GTN for established stable angina. He also has COPD with a reduced PEFR. Coronary angiography has shown diffuse disease but he has refused intervention. What is the most appropriate initial management?

Answer 1

A CCB e.g. Nifedipine.
First line anti-anginal therapy for stable angina is a beta blocker such as metoprolol. However, this patient has COPD and beta blockers are relatively contraindicated due to bronchospasm (even those considered to be cardioselective). 2nd line treatment is with a CCB such as nifedipine. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated.

Question 2

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. What is the most appropriate initial management?

Answer 2

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.

Question 3

A 30 year old male alcoholic presents nausea and pain in the lower chest in a band radiating around to the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base. What is the most useful investigation?

Answer 3

CT scan abdomen.
This patient has acute pancreatitis. He has vomited and is describing mid-epigastric pain radiating around to the back which is relieved in the fetal position and is worse with movement. He is an alcoholic and alcoholic pancreatitis is seen more frequently in men usually after an average of 4-8 years of alcohol intake. Binge drinking also increases the risk. This patient also has nausea and may describe vomiting too, with agitation and confusion. The examination findings described here allude to a pleural effusion which is seen in half of patients with acute pancreatitis. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis. Those caused by hypocalcaemia may display Chvostek’s sign and Trousseau’s sign.
Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook. An abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.
For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.

Question 4

A 49 year old man presents to A&E with a 2 week history of a ‘tight’ central chest pain radiating to the jaw experienced when he is lying down. What is the most likely diagnosis?

Answer 4

Decubitus angina.
Usually as a complication of heart failure. This patient has chest pain which occurs on lying down, which is decubitus angina by definition.

Question 5

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?

Answer 5

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.

Question 6

The pulse is irregularly irregular and jerky in character. There is an ejection systolic murmur lessened by squatting loudest at the lower left sternal edge. There is a double apical impulse felt. The apex beat is not displaced. What is the most likely diagnosis?

Answer 6

This patient has HOCM which is the most frequent cause of sudden cardiac death in younger people. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. There may also be MR. The arterial pulse is described as ‘jerky’ and this patient is also in AF which warrants anticoagulation and anti-arrhythmics. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance. It is worth noting that ventricular hypertrophy causes concentric hypertrophy i.e. the wall of the ventricle gets thicker inwards. Hence the apex beat is not displaced unlike in DCM.

Question 7

There is a constant ‘machinery-like’ murmur throughout systole & diastole. What is the most likely diagnosis?

Answer 7

Patent ductus arteriosus.
The ductus arteriosus is a fetal structure which normally closes within 2 days of birth. Persistence can result in heart failure and increased pressures in the pulmonary vasculature as blood is shunted from the aorta into the pulmonary artery. The classic murmur is known as a Gibson murmur or machinery murmur and is best heard in the left infraclavicular area, usually peaking in late systole and continuing into diastole. Maternal rubella infection in the first trimester is a predisposing risk factor for PDA. The definitive diagnostic test is an echocardiogram.

Question 8

There is a harsh pan-systolic murmur loudest at the lower left sternal edge & inaudible at the apex. The apex is not displaced. What is the most likely diagnosis?

Answer 8

Tricuspid regurgitation.
The murmur of TR is a lower left parasternal systolic murmur (pansystolic, or less, depending on severity). The murmur commonly increases on inspiration (Carvallo’s sign). The apex is not displaced in TR whereas it may be displaced in MR. Key risk factors for TR include LVF, rheumatic heart disease, endocarditis and the presence of a permanent pacemaker. Patients typically present with SOB, periperal oedema and tiredness. There may also be abdominal distension. An enlarged and pulsatile liver is normally seen in severe TR and caused by a reversal in blood flow during systole. It is worth noting that mild to moderate TR is not necessarily abnormal and is present in many asymptomatic young adults.

Question 9

Pain on breathing in & out, dyspnoea, coughing up blood as well, stony dull to percuss. What is the most likely diagnosis?

Answer 9

PE.
Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. PE can cause atelectasis which can result in a dull percussion note and a pleural effusion which is exudative in nature, causing a ‘stony dull’ percussion note. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

Question 10

70 yr old retired boiler maker presents with a 5 year history of exertional dyspnoea and a dry cough. The patient is non-smoker. Examination reveals fine crackles heard at the lung bases. What is the most likely diagnosis?

Answer 10

Sarcoidosis is a chronic multisystem disease with an unknown aetiology. The mauve lesions are erythema nodosum and are tender erythematous nodules. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.

Question 11

A 19 year old presents with headache and malaise for 1 week. His chest was clear on auscultation. He subsequently developed a cough and was given erythomycin for 1 week. What is the most likely diagnosis?

Answer 11

Mycoplasma pneumonia.
The atypical presentation (a week of headache and malaise before the cough) and the prescription of erythromycin, a macrolide antibiotic, point to infection with an atypical pneumonia. However, depending on local prescribing policies, first line therapy for a CAP like pneumococcus may also be with a macrolide. Young people who ‘live together’ are commonly affected. The cough often does not resolve and is dry in nature. Symptoms tend to be prolonged and a low-grade fever is a common finding. Mycoplasma is the only atypical pneumonia on the list although there is no reason why this cannot be Legionella or Chlamydia. All can be treated with macrolides although in EMQs Chlamydia tends to be treated with doxycyline. All 3 atypicals are to some extent sensitive to fluoroquinolones and tetracylines too although these cannot be used in pregnancy. Whether they are first or second line therapy depends on the organism.

Question 12

A 42 year old man has a 3 year history of progressive SOB and joint pains. His bloods show positive rheumatoid factor. What is the most likely diagnosis?

Answer 12

Wegeners Granulomatosis is a systemic vasculitis affecting the small and medium vessels and presents with the classic triad of upper respiratory tract involvement, lower respiratory tract involvement and GN. It is a multisystem disease which can manifest with symptoms ranging from cutaneous, musculoskeletal, ocular and neurological features. Joint swelling and tenderness may all be present. It is associated with a positive cANCA and rhematoid factor is positive in around half.

Question 13

A 50 year old male patient on the ward awakes with dyspnoea & frothy sputum. He had suffered an MI a week earlier. On examination, he is cyanosed & tachypnoeic. Auscultation of the lung reveals crepitations. What is the most likely diagnosis?

Answer 13

This patient has acute pulmonary oedema (the classic finding of pink frothy sputum). This is likely to be caused by LVF secondary to his MI a week earlier. This accounts for the basal crepitations heard on ascultation. Patients need to be sat upright to improve the SOB and IV access needs to be established. Oxygen, morphone, diuretics (frusemide or another loop diuretic) and nitrates will be given. Once stable, medical treatment of heart failure should be started which involves in the first instance, an ACE inhibitor followed by beta blockade. Ongoing diuretics are necessary if the patient has persistent symptoms of fluid overload.

Question 14

A 35 year old previously healthy man returned from a conference in the USA 5 days ago. He travels frequently and gives a 30 pack year history. He presents with mild confusion, a productive cough, diarrhoea and is pyrexic. His chest examination is normal. CXR shows infiltrates in the RUL. What is the most likely causative organism?

Answer 14

Legionella pneumophila is a gram negative rod. Legionella infecting the lungs is legionnaires’ disease or Legionella pneumonia whereas non-lung infection is known as Pontiac fever. This bacteria is found in aqueous environments such as lakes and almost all cases are from contaminated water systems, which relates to the risk factors of getting Legionella (recent water exposure like a hot tub). Smoking is also a risk factor. It can cause confusion as well as hyponatraemia, abdominal pain, diarrhoea and bradycardia. Legionella does not grow on routine culture media and diagnosis relies on urine antigen detection, serology or culture on special media.

Question 15

A 20 year old previously healthy woman presents with general malaise, severe cough & breathlessness which has not improved with a 7 day course of amoxicillin. There is nothing significant to find on examination. The x-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins. What is the most likely causative organism?

Answer 15

Mycoplasma pneumoniae.
The cold agglutinins is what gives this question away. Mycoplasma is associated with with cold type agglutinins and a cold AIHA. Humans are thought to be the only host for Mycoplasma. The most commonly affected are young adults living in close proximity to each other. PCR can be used in diagnosis.

Question 16

A 63 year old tramp presents to the A&E department with a 4 day history of haemoptysis. He has felt unwell for about 2 months with a cough, loss of weight & generalised weakness. He attributes his diplopia, which started a fortnight ago, to excessive alcohol consumption. On examination he has bilateral ptosis & proximal weakness in the limbs which improves on repeated testing. What is the most likely diagnosis?

Answer 16

Small cell carcinoma.
First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is also associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome which this patient has (though weakness of the eye muscles is uncommon in Lambert-Eaton and is more prominent in myasthenia gravis). This classically presents with weakness which improves on repeated testing (in contrast to myaesthenia gravis) and is more commonly associated with small cell lung cancer than other lung cancers. It is for this reason that the most likely diagnosis is small cell and not squamous cell lung cancer.

Question 17

A 20 year old man with cystic fibrosis presents to the chest clinic with haemoptysis. He has felt unwell for a fortnight with increased sputum production, fever & rigors. Gram stain of the sputum shows Gram-positive cocci in clusters. What is the most likely diagnosis?

Answer 17

Pulmonary abscess.
A lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which a patient with CF is at risk of is a risk factor. Of gram positive cocci, staphylococcus occurs in grape-like clusters (this patient) whereas streptococcus occurs in chains. It is worth learning your gram stains for the main organisms. It is worth noting that Staphylococcus aureus is coagulase positive (also Yersinia pestis which causes plague) and Streptoccus pneumoniae is optochin sensitive. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.

Question 18

A 48 year old woman with ovarian carcinoma presents to the A&E department with a 12 hour history of haemoptysis associated with dyspnoea & pleuritic pains. On examination she is apyrexial & has a right sided pleural rub. The chest x-ray shows a wedge shaped infarct peripherally on the right but is otherwise normal. What is the most likely diagnosis?

Answer 18

Pulmonary embolism.
This CXR finding is Hampton’s hump seen in about a third of PE. Additional CXR signs include Westermark’s sign and Fleischner’s sign. CXR is however not diagnostic and may well be normal. Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy (which this patient has), previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis. The study of choice is a CTPA with direct visualisation of the thrombus. If there is a contraindication to a CT scan such as contrast allergy or pregnancy, then a V/Q scan is indicated. If a V/Q scan is not possible, alternatives such as MRA can be requested. It is worth noting that in patients with cardiopulmonary disease, these tests may not be accurate. A TTE can also be used to detect RV strain seen with PE.

Question 19

A 34 year old man presents to the A&E department with a short history of haemoptysis. He has had a cough for a fortnight & noticed his ankles beginning to swell 5 days ago. Initial blood tests show a creatinine of 400mol/l. An autoantibody screen is positive for p-ANCA & anti-glomerular basement membrane antibodies. What is the most likely diagnosis?

Answer 19

Goodpasture’s disease is associated with anti-GBM antibodies, and of those who are positive, some will have a positive ANCA too, although this is more suggestive of diagnoses such as Churg-Strauss and microscopic polyarteritis. Definitive diagnosis is by renal biopsy showing crescentic GN and linear IgG staining on immunofluorescence. It is one of the few causes of pulmonary renal syndrome. Aggressive treatment is often needed and plasma exchange can also be performed to remove preformed antibodies.

Question 20

A 60 year old male presents with acute breathlessness & a cough productive of frothy, pink sputum. He cannot lie flat. On examination, he has crackles to both midzones & a few scattered wheezes. What is the most important step in acute management>

Answer 20

Intravenous furosemide.
This patient has pulmonary oedema. CXR may show pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion.

Question 21

A 36 year old popstar presents with fever, a cough & an itchy vesicular rash. Chest x-ray shows mottling through both lung fields. What is the most likely causative organism?

Answer 21

Varicella zoster.
The pruritic vesicular rash (the classic description of a ‘dewdrop on a rose petal’) makes you think of VZV. The rash typically occurs on the patient’s torso and face and pneumonia is a complication occuring more commonly in those with immunosuppression. The lesions are often crusted over by 7-10 days. The diagnosis is based on clinical findings.

Question 22

A holiday worker had a severe chest infection abroad & was diagnosed to have influenza A infection. He was improving but suddenly deteriorated with the last 24 hours becoming breathless, febrile & septic. X-ray chest showed circular opacities some with a fluid level. Gram stain of sputum showed Gram positive cocci in clusters. What is the most likely causative organism?

Answer 22

Think Staphylococcus aureus for post-influenza pneumonia. It causes a cavitating pneumonia which explains the CXR findings (some abscesses are also seen) and Gram stain of culture yields grape like clusters of Gram positive cocci which is consistent with staphylococcus. Treatment of staphyloccocal infection is with flucoxacillin or vancomycin if MRSA.

Question 23

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. What is the most likely diagnosis?

Answer 23

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).

Question 24

A 26 year old Italian nightclub DJ presents with abdominal pain. On enquiry he has been unwell with a productive cough, fever and breathlessness. On examination his heart rate is 110bpm and his blood pressure is 110/75. His abdomen is soft, non tender. What is the most likely diagnosis?

Answer 24

This is basal pneumonia which can present with upper abdominal pain. The symptoms this patient gives are consistent with pneumonia. Treatment is guided by the CURB-65 score. A CXR is the most specific and sensitive test available and antibiotics are indicated. CXR may show airspace shadowing with air bronchograms. Make sure you can spot consolidation on a CXR.

Question 25

A 19 year old man who has been intubated due to a recent RTA is recovering well & is extubated. He complains of coughing up a small amount of blood streaked phlegm. What is the most appropriate investigation to confirm the diagnosis?

Answer 25

History only. | This is a result of intubation which has caused some iatrogenic trauma to this patient’s upper airway.

Question 26

A 55 year old lawyer who has had a chronic cough for 3 months complains of 1 episode of haemoptysis. She is a heavy smoker (about 40/day) & has experienced some recent weight loss. What is the most appropriate investigation to confirm the diagnosis?

Answer 26

Bronchoscopy. This sounds like bronchial carcinoma from the history of smoking, respiratory complaints and weight loss. Initial investigation of bronchial carcinoma is with a CXR but definitive diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. During bronchoscopy, endobronchial masses can be biopsied and washings/alveolar lavage can also be performed for cytological analysis. Trans-thoracic needle aspiration may be needed for peripheral lesions that cannot be reached by bronchoscopy. First line treatment aims at surgical resection if possible.

Question 27

A young 23 year old allergic atopic asthmatic woman becomes acutely breathless. She has just taken an Aspirin for headache. Her neck is swollen, eyes puffy, & her breathing is noisy, with marked wheeze throughout the lung fields. What is the single most appropriate treatment?

Answer 27

Intramuscular adrenaline. There is a sudden onset of respiratory (and cardiovascular) complaints with the recently given aspirin tablet. This patient is having an anaphylactic reaction and the airway needs to be promptly secured and prompt treatment started with adrenaline. IM adrenaline must not be delayed and the anterolateral thigh is the preferred location, with repeated doses as necessary every 10 minutes or so. A 1:1000 solution is used of 0.3-0.5mg adrenaline. Fluid replacement with IV saline is also indicated to correct the intravascular volume redistribution.

Question 28

A 70 year old man has been newly diagnosed with stage I COPD and has been given inhaled salbutamol PRN and has agreed to stop smoking. What additional measure is needed?

Answer 28

Influenza immunisation. The GOLD guidelines published in April 2010 provide a framework for a stepwise approach to treating COPD. Stages of COPD are based on predicted FEV1. For all stages of COPD, influenza vaccination is given yearly and pneumococcal vaccine is given every 5 years. Long term oxygen is only added if there is chronic respiratory failure in stage IV disease. Stage II involves the addition of long acting bronchodilators and rehabilitation. Stage III involves adding inhaled GCs if there are repeated exacerbations.

Question 29

A 64 year old man has become acutely breathless over the last 4 days, with a productive cough, green sputum & chest tightness. He is a longstanding smoker. Clinically he is hypoxic, with tachycardia, tachypnoea, & central cyanosis. His ABG are as follows: pH 7.35, PaO2 6.7kPa, PaCO2 7.8kPa. He has been given nebulised bronchodilators & intravenous antibiotics & steroids. What is the single most appropriate treatment?

Answer 29

24% continuous oxygen. This patient with COPD is having an acute exacerbation. He is being treated accordingly but will need supplemental oxygen as a result of his ABG results. >8kPa is an acceptable level of arterial oxygenation or SaO2 >90%. Ceftriaxone is an acceptable antibiotic. High risk individuals should get tazocin or meropenem (especially if pseudomonas is suspected). Check local antibiotic prescribing policies. Chronic oxygen therapy is indicated for patients with PaO2

Question 30

A 9 year old girl attends her GP surgery as an emergency with wheezing, difficulty in breathing & cough. Her PEFR is 250l/min, expected PEFR 500. There is no sign of infection on her chest examination. She is admitted to hospital and given inhaled salbutamol although shows an incomplete response. Which treatment should be given next?

Answer 30

Oral prednisolone. Acute asthma exacerbation this time. Bear in mind that treatment guidelines differ for adults and children. The PEFR is 50% predicted making this a moderate exacerbation of asthma (40-69%). A mild exacerbation is defined by a PEFR of 70% of more of predicted whereas severe is defined as 26 to 39% with life-threatening falling under 25%. Note that these values are for children. For moderate exacerbations like this, an oral corticosteroid needs to be prescribed alongside inhaled SABA. If this were life-threatening or severe, then IV may be indicated. It is worth knowing the symptoms and signs of mild, moderate and severe/life threatening asthma. The treatment guidelines that you need to familiarise yourself with tend to be for adults.

Question 31

A 75 year old recently widowed male smoker with a history of angina presents with shortness of breath. He has also vomited & complains of a ringing in his ears. On examination the patient has a BP of 80/50mmHg & fine crackles at both lung bases. What is the most likely diagnosis?

Answer 31

Aspirin poisoning. This patient has angina so probably has a stash of aspirin. Tinnitis is common in the early stages of acute salicylate poisoning and reflects CNS toxicity. There may also be deafness and both are reversible. 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.

Question 32

A 62 year old male heavy, long term smoker presenting with infection of a wound which refuses to heal. What would their ACTH and cortisol tests show?

Answer 32

High ACTH, high cortisol. This wound is refusing to heal because of the high cortisol level, which is as a result of elevated ACTH due to a small cell lung cancer producing it ectopically as part of a paraneoplastic syndrome. Hence, ACTH and cortisol are both high here.

Question 33

A 72 year old lady under long term therapy with biannual bone density assessment for rheumatoid arthritis. What would their ACTH and cortisol tests show?

Answer 33

Low ACTH, low cortisol. This patient is on steroids for RA (hence the biannual bone density assessment). The anchor drug for RA is methotrexate which is the most commonly used DMARD. Other DMARDs include leflunomide, sulphasalazine and hydroxychloroquine. Corticosteroids given for RA will suppress the secretion of ACTH by the pituitary gland and as a result cause cortisol to become low.

Question 34

An 18 year old woman with a bitemporal hemianopia, tiredness, hypoglycaemia and low BP and postural hypotension. What would their ACTH and cortisol tests show?

Answer 34

Low ACTH, low cortisol. The bitemporal hemianopia suggests a pituitary adenoma compressing the optic chiasm. The patient presents with signs and symptoms of adrenal insufficiency indicating low cortisol. The cause is the pituitary adenoma (this is secondary adrenal insufficiency) leading to low ACTH.

Question 35

A 43 year old woman who initially presented with a bilateral hemianopia & has gone on to develop Cushingoid signs. What would their ACTH and cortisol tests show?

Answer 35

High ACTH, high cortisol. A pituitary adenoma here is secreting ACTH. This is Cushing’s disease responsible for most cases of Cushing’s syndrome. Hence, ACTH is high and so is cortisol.

Question 36

A 55 year old man, whose abdominal CT shows an adrenal adenoma. What would their ACTH and cortisol tests show?

Answer 36

Low ACTH, high cortisol. This is adrenal Cushing’s where an excess of cortisol is being produced by the adrenal gland adenoma. This excess cortisol suppresses ACTH production.

Question 37

72 year old man with diabetes. He has been on insulin for 6 years. His daughter had noticed that he was increasingly vague. He was found unconscious. BP 160/90. Plasma urea, creatinine & electrolytes were normal. What is the most likely diagnosis?

Answer 37

Hypoglycaemia. | This patient has symptoms of hypoglycaemia, present when glucose drops

Question 38

A 60 year old diabetic lady visits her GP complaining of tingling in her hands. This is worse at night. She describes numbness, and if there is feeling she describes tingling. This is in both hands only; not in her arms. What is the most likely diagnosis?

Answer 38

Symmetrical sensory polyneuropathy. Diabetic neuropathy can be autonomic or peripheral. This is a case of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. The tingling this patient describes is a common complaint and loss of sensation typically occurs in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain or unpleasant sensation which is prickling, burning or sticking. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin.

Question 39

A 73 year old, previously fit male presents with difficulty ascending stairs. Abnormalities noted on examination are weakness of knee flexion, which is more pronounced on the left with some wasting of the quadriceps & diminished knee reflexes. He is noted to have glycosuria. What is the most likely diagnosis?

Answer 39

Diabetic amyotrophy, more common in T2DM, is an uncommon peripheral diabetic neuropathic complaint. It presents with severe muscle weakness and pain with proximal thigh muscle atrophy. This patient’s glycosuria suggests undiagnosed T2DM, which in any case, you can guess he has given the question stem is called ‘Diabetic Complications’. The weak knee flexion and quadriceps wasting is typical of diabetic amyotrophy. The reduced reflexes are another sign of peripheral neuropathy.

Question 40

A 58 year old male presents to his GP with a lump in the neck and weight loss. He reports that he suffered from a mild upper respiratory infection in the previous week. On examination there is a hard mobile lump in the supraclavicular fossa. What is the most likely diagnosis?

Answer 40

Lymphadenopathy secondary to malignancy. This 58 year old male reports weight loss. Combined with the presence of Virchow’s node (Troisier’s sign), a hard enlarged node in the left supraclavicular fossa, this points towards a malignancy in the abdominal cavity. The lymph drainage of the abdominal cavity drains into Virchow’s node as the lymph drains most of the body from the thoracic duct and enters the venous circulation at the left subclavian vein. An enlarged right supraclavicular LN may indicate thoracic malignancies such as lung cancer. The mild URTI is a red herring.

Question 41

An anxious 19 year old female presents with a lump in the neck. She has lost 3kg in 3 months. On examination there is lymphadenopathy on both sides of the neck & larger nodes on the right. Her pulse is 96 regular; thyroid function tests are normal. What is the most likely diagnosis?

Answer 41

The history of weight loss here along with cervical lymphadenopathy point to 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. While this question does not specifically scream out Hodgkin’s (though the pattern of involvement makes it more likely), the question is not complicated by the option of NHL. Furthermore, this is patient is 19 and unlikely to have head and neck cancer causing local lymphadenopathy and infection does not explain the weight loss over 3 months.

Question 42

12 yr old boy presents with 4 weeks weight loss, polyuria and polydipsia. What is the most suitable investigation to perform?

Answer 42

Fasting blood glucose. For the diagnosis of 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. This patient most likely has new onset T1DM.

Question 43

42 yr old man has hypertension, hyperglycaemia, myopathy, thinning of skin, buffalo hump and truncal obesity. What is the most suitable investigation to perform?

Answer 43

Dexamethasone suppression test. This patient has Cushing’s and will need a dexamethasone suppression test which is first line in anyone with suspected Cushing’s (unless they are on medications which will affect the result of the test), though alternatively a 24 hour urinary free coritsol and late night salivary cortisol can be done. The dexamethasone suppression test takes the form of either an overnight 1mg or a 48 hour 2mg test. Unsuppressed cortisol indicates Cushing’s syndrome.

Question 44

34 yr old old man with insidious onset weakness and weight loss. On examination he has hyperpigmentation of the palmar creases and postural hypotension. What is the most suitable investigation to perform?

Answer 44

ACTH (synacthen) stimulation test. Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.

Question 45

21 yr old woman has been complaining of increasing tiredness and feeling thirsty. Over the last day she had been confused. On arrival in A&E she was noted to have deep sighing respiration. What is the most likely diagnosis?

Answer 45

This is a case of metabolic acidosis with deep sighing respiratory compensation as lungs try to compensate for the acidosis (Kussmaul breathing). This could well be a case of DKA in a type 1 diabetic. To differentiate between the causes of metabolic acidosis, the serum AG can be calculated: AG = Na – Cl – HCO3. The normal AG is 6-12mmol/L. A raised AG indicates the presence of organic acidosis such as ketoacidosis, lactic acidosis or ingestion of substances like ethylene glycol. A normal AG (also hyperchloraemic metabolic acidosis) is commonly caused by GI or renal bicarbonate losses such as in diarrhoea or RTA.

Question 46

64 yr old woman complaining of severe back pain for some weeks. For the last few days she has 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. What is the most likely diagnosis?

Answer 46

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.

Question 47

56 yr old man with diabetes who is on maximum therapy of gliclazide needs higher control but is unable to tolerate metformin or acarbose and refuses any injections. What is the most appropriate treatment?

Answer 47

Pioglitazone (Thiazolidinedione). This man is on a sulphonylurea which is an insulin secretagogue. It is an old drug with a long track record and is being used in this case as the patient does not tolerate metformin, which would otherwise have been first line. Sulphonylureas can cause hypoglycaemia. They act at the pancreas by blocking ATP sensitive potassium channels which leads to beta cell depolarisation and calcium influx, which causes increased insulin release. They also act on peripheral insulin receptors and have hepatic effects. This man is on maximum therapy of gliclazide and is refusing any injections so this rules out insulin therapy so we must consider non-insulin agents as add-ons. These include alpha glucosidase inhibitors (but our patient also cannot tolerate acarbose), DPP-4 inhibitors (‘gliptins’), GLP1 agonists (exenatide) or TZDs. The latter is the only available option on the list.

Question 48

15 yr old diabetic is shaky, sweaty, trembling and pale. He then falls. Bmstix = 2mmol/l. What is the most appropriate treatment?

Answer 48

Glucagon. This patient is suffering from hypoglycaemia present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety. This patient has collapsed and is presumably not able to take oral glucose or sugar (which in any case is not an option on the list). Patients with either long standing DM or on beta blockers may become unaware of hypoglycaemia and become profoundly hypoglycaemic before symptoms develop. In DM, hypoglycaemia is usually secondary to insulin or oral hypoglycaemics. IM glucagon can be given instead in this case.

Question 49

52yr old man with diabetes is on maximum therapy with metformin. He is allergic to sulphonylureas. What is the most appropriate treatment?

Answer 49

Repaglinide (Meglitinide). Patients allergic to sulphonylureas can use a meglitinide instead. They act in a similar way but bind to a separate site on the potassium channel.

Question 50

26 yr old pregnant lady at the end of her pregnancy develops gestational diabetes. What is the most appropriate treatment?

Answer 50

Diabetes occuring during pregnancy are mostly adequately treated on diet alone. Just reduce carbohydrate intake and monitor glucose levels. If uncontrolled or markedly severe, insulin therapy can be used. It is however worth noting that after delivery of the placenta, there is a big reduction in insulin requirement which may be factored in. Initial postpartum insulin needs are lower than pre-pregnancy. Treatment aims to lower glucose levels to avoid fetal macrosomia and complications. Subsequent long term risk for T2DM is high.

Question 51

A 50 yr old man complains of a lump in neck on the left side. Examination revealed painless, non tender lump on the left side of the neck which moves on swallowing. Investigation revealed normal TSH and ESR. Fine needle aspiration revealed ‘Orphan Annie’ eyes and psammoma bodies. What is the most likely diagnosis?

Answer 51

Papillary thyroid carcinoma. TSH is normal and the examination findings point to a carcinoma, which most commonly presents like this – an asymptomatic nodule. If TSH were suppressed then this would suggest hyperthyroidism, or a hot nodule, in which case the incidence of cancer is very low. If TSH, like this case, is normal, then a FNA is indicated and cytology may then help to tell cancer type. Histology cannot distinguish follicular adenomas and carcinomas but is used for diagnosis of follicular carcinoma (when combined with other features) instead of cytology. There are 5 types of thyroid cancer: papillary (most common), follicular, medullary (about a quarter are familial e.g. MEN), anaplastic (worst prognosis) and lymphoma. Orphan Annie eyes and psammoma bodies are seen in papillary cancer. Average 10 year survival is >90%. This is a hard question.

Question 52

Mr. James’s tiredness has been coming on over the last 9 months. He is 78 & also complains of pins & needles in the lower limbs in recent weeks & has diarrhoea. His sclera look yellow & his conjunctivae are pale & he has a smooth red tongue. In addition, you detect loss of vibration & joint proprioception. You also think his knee jerks are brisk but you cannot detect any ankle jerks. What is the most likely diagnosis?

Answer 52

Pernicious anaemia presents with symptoms of anaemia and B12 deficiency. Hence, there is the fatigue and glossitis of anaemia with the neuropathy of B12 deficiency. The Schilling test is now rarely used but does crop up in exams (In this test, IM vitamin B12 is given to saturate stores. Then oral radiolabelled B12 is given and urine is collected over 24 hours. The amount excreted is lower in B12 malabsorption. If this is not corrected by IF the problem is with the ileum and not inadequate IF). Serum B12 levels are useful and APC (anti-parietal cell antibody) can determine whether pernicious anaemia is the cause (but note APC can also be elevated in atrophic gastritis). IF antibody is highly specific for PA but lacks sensitivity compared to APC. Treatment involves supplementation.

Question 53

A 15 year old female with a 2 day history of pyrexia, complains of headaches, feeling weak & a sore throat. On examination, she was pyrexial, had enlarged cervical & axillary lymph nodes & splenomegaly. There was no weight loss or anaemia. What is the most likely diagnosis?

Answer 53

Infectious mononucleosis is caused by EBV and is characterised by fever, pharyngitis and lymphadenopathy. Enlargement of the spleen begins in the first week and lasts 3-4 weeks, occuring in half of all cases. Risk factors for EBV transmission include kissing and sex. A FBC will show an atypical lymphocytosis. Confirmation of IM involves detection of the existence of heterophile antibodies using the Paul Bunnell monospot. A more accurate test is a serological test detecting EBV specific antibodies. Treatment is usually symptomatic but IM carries rare but potentially life threatening complications.

Question 54

A 30 year old male corporate finance banker complains of tiredness of approximately 7 months duration. Tiredness was not substantially alleviated by rest. Tiredness was “severe” & “disabling” & affected his ability at work. Also complained of muscle pain, joint pain & headache. Examination was unremarkable. On direct questioning there was no alcohol or drug misuse, no polydipsia or polyuria. He was not on any medication. His weight had remained at 75kg with no weight loss. What is the most likely diagnosis?

Answer 54

Chronic fatigue Syndrome. This is > 6 months of significant impairing fatigue which is otherwise not explained – the definition of CFS. The aetiology is currently unknown and women are 2-3 times more likely to have CFS. Graduated low-impact exercise and CBT is recommended for all patients. Medication is not effective in CFS. This syndrome is associated with functional impairment which is progressive, depression and OSA.

Question 55

A 50 year old obese lady with weight loss, tiredness, pruritus vulvae & recurrent boils. What is the most likely diagnosis?

Answer 55

``` Diabetes mellitus. Pruritus vulvae (an itchy vulva, basically) and recurrent boils suggest this patient is having infections. There is also weight loss and tiredness. This points to T2DM, which can present with yeast, skin and urinary tract infections on top of unintentional weight loss and fatigue. ```

Question 56

A 40 year old man with limb pains, epigastric pain with vomiting, colicky pain in his left loin. He has been feeling low & depressed recently & also complained of excessive thirst, nocturia & loss of appetite. What is the most likely diagnosis?

Answer 56

Primary hyperparathyroidism. There is autonomous PTH production in primary HPT which causes deranged calcium metabolism. Biochemistry will show elevated serum calcium and inappropriate elevation of PTH. Depression, cognitive changes, change in sleep (possibly due to change in circadian rhythm) and myalgia are all common complaints. This patient’s bone pain is a common complaint which may occur with osteoporosis. Osteoporosis occurs due to excess PTH causing bone resorption (osteoclasts are stimulated). This patient also has a kidney stone in the left loin due to hypercalciuria. Other symptoms of hypercalcaemia are present including nocturia and the patient also seems to have pancreatitis. I agree, a patient in real life is unlikely to be unlucky enough to present with such a host of symptoms. The only definitive cure is a parathyroidectomy although complications of this procedure include hypocalcaemia, injury to the recurrent laryngeal nerve, bleeding and a pneumothorax.

Question 57

A 71 year old lady presented with depression & personality disorder which was first noticed during long term psychiatric care. On examination there was marked alopecia & loss of facial contours. What is the most appropriate treatment?

Answer 57

Thyroxine. This is hypothyroidism and this lady will need replacement T4 (levothyroxine), with or without T3. Treatment is lifelong and the main complication is over-replacement which can cause AF and osteoporosis. The dose must be increased in pregnancy, where requirements of T3 and T4 increase. A lower dose of levothyroxine is recommended if the patient has coronary artery disease as it can exacerbate angina.

Question 58

A 20 year old male presents with painful defecation which persists for 30 mins afterwards. The stool is smeared with blood, & he has noticed recent constipation. What is the most likely diagnosis?

Answer 58

This patient has an anal fissure. This causes severe pain on defecation and may continue for 1 to 2 hours. A small amount of fresh blood is often passed on the stool. Hard stools is a strong risk factor and this patient’s constipation will likely be the cause. Opiates are associated with constipation and subsequently anal fissures too and fissures may also occur in the third trimester of pregnancy or after delivery. Initial treatment is with topical GTN or diltiazem along with supportive measures such a high fibre diet. Resistant or chronic fissures may benefit from surgical measures or botulinum toxin.

Question 59

A 40 year old male presents with PR bleeding & a palpable lump from anus, with associated mucus discharge. There is blood splashed around lavatory pan. What is the most likely diagnosis?

Answer 59

Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.

Question 60

An obese 40 year old woman, with a history of episodic right upper quadrant pain, presents with rapid onset of jaundice with severe abdominal pains, fever & rigors. What is the most likely diagnosis?

Answer 60

Charcot’s triad of ascending cholangitis: fever with or without rigors, RUQ pain and fever. Cholangitis is infection of the biliary tree and can quickly become septic. Drainage of the biliary tree is crucial and is undertaken via ERCP. Make sure you know the difference between ascending cholangitis, cholecystitis and biliary colic.

Question 61

A 24 year old unemployed rough sleeping male presents unwell, with jaundice, anorexia & lassitude. He has a number of venepuncture marks in the antecubital fossae. What is the most likely diagnosis?

Answer 61

This could well be HCV although this is not an option. There are HBV risk factors in this patient including IVDU. Serum LFTs will shown a transaminitis. HBsAg, HBcAg and HBeAg can be measured. In HCV, HCV RNA can be measured. HAV is not associated with IVDU. Serum IgM anti-HAV can be measured.

Question 62

A 70 year old woman has seen her GP for depression on several occasions. She now complains of abdominal pain, constipation & thirst. What is the most likely diagnosis?

Answer 62

Hypercalcaemia. 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’. 90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. 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. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.

Question 63

A 30 year old male intravenous drug user with a history of tuberculosis develops profuse watery diarrhoea with no abdominal pain. What is the most likely diagnosis?

Answer 63

Cryptosporidium infection. I’m sure at some point most of you will see ‘diarrhoea’ and ‘HIV’ together and jump straight to Cryptosporidium. This is a disease caused by a protozoa and diagnosis is made in the lab by detection of oocysts or antigens in stool. The presentation is of watery diarrhoea, often accompanied with severe pain in the tummy, often lasting more than 7 days. It is self-limiting if the patient is immunocompetent but those who are immunocompromised can suffer a chronic sveere course. Those most at risk are those with T cell deficiencies, such as HIV, and those with haematological malignancies, especially children. In immunocompetent people, nitazoxanide can be used in treatment (as can paramomycin). In immunocompromised patients, treatment mainly aims at treating the primary disorder, such as using HAART to improve CD4 cell count and to restore immunity. Protease inhibitors such as ritanovir also act directly to reduce host cell invasion by the sporozoites and reduce parasite development.

Question 64

A 25 year old male student presents with 12 hours of abdominal pain, vomiting & watery diarrhoea. This has occurred once before. What is the most likely diagnosis/organism?

Answer 64

Staphylococcus aureus. This patient has infectious vomiting predominant food poisoning. When vomiting is the main presenting symptom, you should be thinking of Staphylococcus aureus, Bacillus cereus or norovirus. There is a short history in a previous well person. This man has probably eaten something dodgy like a kebab with undercooked chicken, or something like that. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe cases.

Question 65

A 27 year old woman presents with a 2 week history of bloody diarrhoea & abdominal pain. She has also passed mucus per rectum at times. What is the most likely diagnosis?

Answer 65

Ulcerative colitis. While this could be Crohn’s disease, bloody diarrhoea is more commonly a presentation of UC than Crohn’s. UC is characterised by diffuse mucosal inflammation running a relapsing and remitting course. Bloody diarrhoea is commonly experienced by patients who may also complain of other symptoms such as (lower) abdominal pain, faecal urgency and the host of extra-intestinal manifestations associated with UC. Diagnosis of UC requires endoscopy with biopsy and a negative stool culture to rule out infectious gastroenteritis. Flare ups are usually linked to pathogens so a stool culture will always be needed in these cases. Toxic megacolon is a complication which is associated with a risk of perforation. UC is also linked with bowel adenocarinoma and PSC. Treatment involves mesalazine (5-ASA) used to induce and maintain remission.

Question 66

A 55 year old man who takes bendrofluazide for hypertension, presents with a 2 month history of watery diarrhoea with occasional blood & mucus mixed in the stool. He has serum potassium of 2.3mmol/l. What is the most likely diagnosis?

Answer 66

Villous adenoma of the rectum. Do not be fooled by the bendrofluazide, which is taken by many patients, but does not by itself lead to such profound hypokalaemia (but I’m sure contributes), and in any case would not account for the GI symptoms experienced. This patient has a villous adenoma, which is a type of polyp in the GIT with a malignant potential. Most colorectal cancers arise from an adenoma and polypectomy reduces the incidence of colorectal cancer. The non-neoplastic polyps include hyperplastic ones, hamartomas, inflammatory and lymphoid polyps. Villous adenomas secrete large amounts of mucus and result in hypokalaemia. Adenomatous polyps are increasingly common with age. FAP and Gardner’s syndrome, for example, predispose to adenomatous polyps (Peutz-Jeghers leads to hamartomatous polyps). This patient is going to need a colonoscopy with biopsy histology to see if the polyp is benign or malignant.

Question 67

A 40 year old man has just returned from a holiday in Kenya. Since his return, he has developed watery diarrhoea with crampy abdominal pain. What is the most likely diagnosis/organism?

Answer 67

Campylobacter. So why is this Campylobacter? Well, it doesn’t have to be. Salmonella, E. Coli, Shigella, Listeria, Vibrio species etc all present with symptoms which are not drastically different and the only way to be sure is to do a stool culture. The only real option here are between Campylobacter, Staphylococcus aureus and Clostridium difficile. However, this patient does not have a history of recent antibiotic use. Staphylococcus tends to present with vomiting as the main feature and the watery diarrhoea here is typical of Campylobacter. UC and CD are chronic conditions (it is worth noting that Yersinia enterocolitis can mimic Crohn’s RLQ pain). This person has most likely eaten something dodgy on holiday. Erythromycin can be used effectively if started early but resistance is a problem and only a small number will benefit. Campylobacter jejuni is the main cause of food poisoning (also coli and fetus species cause disease). Diarrhoea normally resolves in 5-7 days and the patient will need fluid/electrolyte replacement. Campylbacter is one of the infections which is commonly linked to Guillain-Barre (although still a rare phenomenon).

Question 68

A 24 year old woman has had 24 hours of vomiting & diarrhoea, which she thinks followed eating reheated take-away food. There was fresh blood in the last 3 vomits. Vital signs are stable. What is the most likely diagnosis?

Answer 68

Mallory-Weiss syndrome. This occurs after a rise in abdominal pressure which induces a tear in the oesophageal mucosa, causing subsequent GI bleeding. It commonly presents with haematemesis after an episode of retching/vomiting/coughing/straining. Hence, risk factors include anything which can cause vomiting like heavy alcohol use, which is commonly the case in EMQs. Also, other conditions would include food poisoning, bowel obstruction, hyperemesis gravidarum, bulimia, the chronic cough of COPD, meningitis etc... you name it really. Classically, MWT presents with a small self limiting episode of haematemesis. Definitive diagnosis is made by OGD. Treatment is supportive because most cases, as mentioned, are self limiting and emergency treatment is not offered unless the patient is showing signs of clinical instability. If the patient is actively bleeding, treatment will be with therapeutic endoscopy in most cases, and very very few cases will require more intervention such as angiography with embolisation.

Question 69

A 40 year old woman describes intermittent haemoptysis as well as small amounts of haematemesis. She has telangiectasia on her face. What is the most likely diagnosis?

Answer 69

Osler-Weber-Rendu syndrome. This woman has the facial telangiectasia of OWR, also called hereditary haemorrhagic telangiectasia. This causes abnormal blod vessels pretty much everywhere which are prone to bleed. It is an autosomal dominant condition so a positive FH can often be found.

Question 70

A 50 year old alcoholic man fails to respond to treatment for pancreatitis and has recurrent epigastric pain. There is a palpable epigastric mass. CT scan of the abdomen shows a round well-circumscribed mass in the epigastrium. What is the most likely diagnosis?

Answer 70

This patient has developed a pancreatic psuedocyst as a complication of pancreatitis. Pseudocysts are collections of fluids with a high concentration of enzymes. The walls are fibrotic membranes of the peritoneum, mesentery and serosa which stops the fluid from leaking out. The wall is not epithelium and indeed there is no epithelial lining – it is not a real cyst. In patients who fail to respond to treatment, this should be considered as a possible diagnosis. The most common finding is pain, followed by a palpable mass. CT scan is diagnostic. Treatment options include excision, drainage (surgical or percutaneous, or internal e.g. cystojejunostomy Roux-en-Y etc, which I’m sure is going into too much surgery than is necessary now but surgical wannabes can look up the procedures... if they really want to – also cystogastrostomy and cystoduodenostomy). The pseudocyst can be complicated with infection, rupture and haemorrhage. Pancreatic abscess would give a fever and CT will show a ring-enhancing fluid collection with gas. Treatment would be drainage and antibiotics. Pancreatic ascites is pancreatic fluid accumulating in the peritoneal cavity due to chronic pseudocyst leakage (in most cases, anyway) – there will be weight loss and the ascites will not respond to diuretics. A pancreatic effusion is secondary to a fistula draining into the chest, from the pancreas. These are actually all more common complications to arise from pancreatitis than a pseudocyst.

Question 71

An 87 year old woman presents with constipation and nausea. What is the most likely diagnosis?

Answer 71

While this woman has indeed presented with very non-specific symptoms, the only feasible answer from the list is a sigmoid volvulus. A volvulus is bowel obstruction occuring due to a loop of bowel twisting on its own mesenteric axis. Broadly speaking, there are three types: small bowel, sigmoid and gastric. This is something you need to be able to recognise on AXR and it appears as a dilated loop of large bowel present in the lower abdomen, resembling a coffee bean shape (or like an upside down U shape). The rest of the bowel is usually dilated. For a caecal volvulus, the caecum leaves the RLQ to appear like a second satomach bubble in the centre of the film. There is often associated small bowel dilation. A gastric volvulus is very rare.

Question 72

A 30 year old woman who has recently returned from holiday in the Gambia. She is in the 3rd trimester of pregnancy & complains of headaches & fever. On examination her BP is 110/70, there is a soft ESM, shotty lymphadenopathy & hepatosplenomegaly. Examination of the skin is unremarkable. Investigations revealed a Hb of 10.5g/dl, WBC of 5x109/l, platelet count of 80x109/l. What is the most likely diagnosis?

Answer 72

Malaria. In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This woman has just returned from an endemic area. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. Hepatosplenomegaly is a common presenting sign although not common at presentation in a first world setting. Thrombocytopenia is common with falciparum infection and a mild degree of anaemia are commonly seen. WCC can be high, low or normal. Pregnant women affected by P. falciparum are susceptible to the complications of pregnancy due to placental parasite sequestration. Treatment of malaria in pregnancy must be managed with an ID specialist and should be treated with IV antimalarial therapy. The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. Numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice.

Question 73

A 78 year old woman attends complaining of widespread itching. Examination reveals hepatosplenomegaly. The patient appears plethoric with no lymphadenopathy. What is the most likely diagnosis?

Answer 73

Polycythaemia rubra vera is a disease of middle and older age and is strongly associated with the JAK2V617 mutation. Pruritis is a common feature and is often severe and evoked by contact with water. Facial redness and fullness is commonly observed and splenomegaly is a common finding. It is a myeloproliferative disorder with raised Hct, Hb and RBC count. Blood hence becomes very viscous. There is a clear link between Budd-Chiari syndrome and subsequent PRV. Treatment is with venesection. Around 30% will go on to develop myelofibrosis.

Question 74

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. What is the most likely diagnosis?

Answer 74

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.

Question 75

A 60 year old woman is found to have hepatomegaly. She has a history of moderate alcohol use. She had an anterior MI 2 years previously. Examination reveals significant ankle oedema, elevated JVP & 1-2 spider naevi on her chest. What is the most likely diagnosis?

Answer 75

The significant ankle oedema and raised JVP point towards right sided heart failure.The presence of 1-2 spider naevi is completely normal. 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.

Question 76

A 50 year old male with haemophilia & hepatitis C presents with weight loss & abdominal discomfort. He is mildly icteric with features of chronic liver disease & a large left lobe of the liver. What is the most likely diagnosis?

Answer 76

Cirrhosis with hepatoma. HCV has caused this patient’s hepatic cirrhosis which has resulted in a hepatoma (HCC). It is likely that his HCV infection has resulted from contaminated blood products due to his haemophilia. This was a key problem before blood donor screening took place. Unlike HBV, HCV infection almost always results in cirrhosis before a hepatoma develops. The length of time the patient has HCV is a good correlate to the development of HCC. HCV is also strongly associated with IVDU which accounts for most infections. Treatment of the hepatoma is guided by staging and prognosis. Treatment includes resection, transplant, percutaneous ablation and chemo-embolisation.

Question 77

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. What is the most likely diagnosis?

Answer 77

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

Question 78

A 65 year old man had an elective aortic aneurysm repair 5 days ago. He now has abdominal distension & left sided abdominal pain. He is passing a small amount of blood & mucus per rectum. What is the most likely diagnosis?

Answer 78

Ischaemic colitis causes focal or diffuse abdominal pain and often has a more insidious onset than mesenteric ischaemia (over several hours or days). The recent operation in the approximate area has resulted in an incomplete blood supply to that part of the bowel. Mesenteric ischaemia and ischaemic colitis all form part of ‘ischaemic bowel disease’.

Question 79

A 35 year old woman has a 10 year history of low retrosternal dysphagia & painless regurgitation of food in the mouth. What is the most likely diagnosis?

Answer 79

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?

Question 80

A 45 year old lady presents with high retrosternal dysphagia. She has spoon-shaped nails & is noted to be pale. What is the most likely diagnosis?

Answer 80

Plummer-Vinson syndrome is the association of chronic IDA (shown here by the koilonychia and paleness on examination) with dysphagia due to a post cricoid web. Roughly 7% of those with IDA may complain of gradual onset dysphagia with the discomfort found in the area of the cricoid cartilage. Invasive procedures may be needed for management such as endoscopic dilation of the web but treatment is largely aimed at correcting the IDA.

Question 81

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. What is the most likely diagnosis?

Answer 81

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.

Question 82

A 45 year old lady presenting with intense pruritus, joint pains & tiredness. She has also noticed that she is becoming yellow. On examination she was clubbed with xanthelasma around her eyes. She has dry eyes and a dry mouth. Her spleen was also palpably enlarged. What is the most likely diagnosis?

Answer 82

Primary biliary cirrhosis (PBC) is a chronic condition where the intrahepatic small bile ducts are progressively damaged (and eventually lost) occuring on a background of portal tract inflammation. Fibrosis develops, ultimately leading to cirrhosis (which is defined as fibrosis with nodular regeneration). It is widely believed to be autoimmune in aetiology as almost all patients have AMA. The pointers in this question which would raise your suspicion, is xanthelasma around the eyes, pruritis in the absence of an obvious dermatological cause, fatigue and the features of liver disease typical of cirrhosis (jaundice) and splenomegaly as a feature of portal hypertension. The patient also has dry eyes and dry mouth from associated Sjogren’s syndrome. The joint pains could indicate RA.

Question 83

A 70 year old diabetic man, who smoked 40 cigs/day for 40 years. He presents with abdominal pain worse at night & radiating to his back. He is losing weight, suffers from dyspepsia & pruritus. On examination he is cachectic, jaundiced & has an enlarged gallbladder. What is the most likely diagnosis?

Answer 83

Pancreatic cancer typically presents with painless obstructive jaundice and weight loss and generally presents late. It can however, like this case, present with abdominal pain which is typically non-specific in the upper abdomen. If the patient presents with persistent back pain, then this symptom is consistent with retroperitoneal metastases. It is estimated that 1 in 4 cases can be linked to smoking. Whipple’s procedure or Traverso-Longmire procedure (pancreaticoduodenectomy) offers the only hope of a cure but only a small minority are elegible for these procedures. The first tests to order are an abdominal USS and LFTs. Note Courvoisier’s law with regard to this question: Jaundice and a palpable painless gallbladder is unlikely to be caused by gallstones. The tumour marker for pancreatic cancer is CA19-9 which is useful in preoperative staging.

Question 84

A 50 year old man: BR 50umol/l, ALP 200iu/l, ALT 120iu/l, GGT 600iu/l. What is the most likely cause of jaundice?

Answer 84

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 high GGT here is as a result of high alcohol consumption.

Question 85

A 50 year old man: BR 110umol/l, ALP 300iu/l, ALT 110iu/l, AFP is elevated. What is the most likely cause of jaundice?

Answer 85

The pattern here is cholestatic. Furthermore, elevated AFP is given, which is a tumour marker for HCC, differentiating this from other potential causes like pancreatic cancer. AST and ALT may be normal or elevated.

Question 86

A 35 year old woman: BR 80umol/l, ALP 300iu/l, ALT 30iu/l, GGT 30iu/l. Abdominal USS shows biliary dilation. The patient has RUQ tenderness. What is the most likely cause of jaundice?

Answer 86

This is a cholestatic pattern and the ultrasound scan means this is either choledocholithiasis, pancreatic cancer or cholangiocarcinoma. The fact there is RUQ pain points more towards gallstones. The other two tend to present painlessly.

Question 87

A 20 year old man: BR 45umol/l, (Conjugated 7, unconjugated 38), ALP 40iu/l, AST 12iu/l, Hb 15g/dl, Normal blood film. What is the most likely cause of jaundice?

Answer 87

Gilbert’s occurs in an asymptomatic patient, often as an incidental finding or mild jaundice occuring in adolescence/young adult age. There is elevated unconjugated BR with other liver tests being normal. The blood smear is also normal with normal reticulocyte count, and normal Hb indicating that this is not due to haemolysis. It is a common syndrome and is not really a disease, more a physiological variant. No treatment is needed and this condition is due to decreased UDPGT activity leading to decreased conjugation of unconjugated bilirubin, leading to elevated levels.

Question 88

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. What is the most likely diagnosis?

Answer 88

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.

Question 89

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. What is the most likely diagnosis?

Answer 89

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.

Question 90

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. What is the most likely diagnosis?

Answer 90

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.

Question 91

A 33 year old man has severe pain and fresh bleeding on defecation. What is the most likely management?

Answer 91

Topical GTN. This patient has an anal fissure. This causes severe pain on defecation and may continue for 1 to 2 hours. A small amount of fresh blood is often passed on the stool. Initial treatment is with topical GTN or diltiazem along with supportive measures such a high fibre diet. Resistant or chronic fissures may benefit from surgical measures or botulinum toxin.

Question 92

A 39 year old woman who is on mesalazine for her ulcerative colitis presents with 12 daily bowel movements and massive continuous bleeding PR; she is noted to have a raised ESR. What is the most likely management?

Answer 92

IV corticosteroids are used in fulminant disease. These patients need to be admitted. If there is no response to IV corticosteroids within 24 to 48 hours then surgery is indicated.

Question 93

A 24 year old woman following a viral infection was diagnosed as having idiopathic thrombocytopaenia. She presents to A&E & complains of multiple bruising & rectal bleeding. She is on oral prednisolone 30mg/day. Her Hb is 12.5g/dl. What is the most likely management?

Answer 93

IV immunoglobulin. ITP is thought to be due to an autoimmune phenomenon. Treatment is based on the patient’s platelet count and bleeding symptoms. This patient has severe active bleeding and must be started on IVIG plus corticosteroids, which she is already on. Platelet transfusions should be considered with tranexamic acid as an adjunct.

Question 94

A 58 year old man was admitted complaining of abdominal pain. He is found to have rectal carcinoma. What is the most likely management?

Answer 94

Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.

Question 95

A 54 year old man with no previous abdominal symptoms complains of several episodes of painless bright red rectal bleeding which is separate from the stool. Abdominal, rectal examination & proctoscopy are normal. What is the most likely diagnosis?

Answer 95

Colonic polyp. Most polyps are asymptomatic and rectal bleeding is indeed an unusual symptom to present with (though FOBT may be positive), but the lack of previous symptoms and normal examination findings makes this likely to be a bleeding polyp. The next step here would be endoscopy with polypectomy for histological examination. Indeed they are frequently found incidentally on screening with FOBT or colonoscopy for another reason. If there are a few polyps, all of them will be removed. If there are many, a sample will be removed for biopsy. Polyps can also be inherited in FAP, also seen in Gardner syndrome and Peutz-Jeghers. They can be neoplastic such as adenomas or non-neoplastic such as hyperplastic polyps.

Question 96

A 24 year old man presents with a 3 month history of episodes of painless, bright red rectal bleeding on straining at stool. He has noticed some blood in the bowl, separate from the stool & some on the paper after wiping. What is the most likely diagnosis?

Answer 96

Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.