Day 9 Flashcards
Q1-Non opaque renal pelvis filling defect seen onIVP(intra venous Pylography), Ultra sound revels dense echoes and acoustic shadowing.what is the most likely diagnosis?
A-Blood clot B-Tumor C-Sloughed renal papilla D-Uric acid stone E-Crossing vessels
Ans: D.
• Radiopaque: calcium oxalate, cystine, calcium phosphate, magnesium-ammonium-phosphate
• Radiolucent: uric acid, blood clots, sloughed papillae
Q2- A 60 y/o man complains of lower limb pain and easy bruising for the past 3 days. The pain is not relieved by rest. He has 4-5 years of history of smoking, hyperlipidemia, and vasculitis and was on heparin for DVT prophylaxis 2 weeks ago. P/E finds stable vital signs and multiple bruises on the lower limbs. Lab tests reveal normal RBC and WBC; platelets = 50 x 103/uL, aPTT = 30 sec, PT = 20 sec, BT = 8 min, and LDL = 200 mg/dL. The best next step is to
A-Start warfarin B-Start lovastatin C-Start lepirudin D-Stop heparin E-Infuse platelets
Ans: D.
This is an uncommon case of heparin-induced thrombocytopenia due to anti-platelet factor 4 complex causing decreased platelets and increased BT. The first step is to stop heparin and wait for the platelets to recover to > 100 x 103/uL before adding warfarin. Warfarin alone without heparin may induce limb gangrene in a patient with DVT. “C and B” should be the next step after heparin is stopped. ‘E’ is reserved for more severe bleeding
Q3- A 34year African-caribbean man with a history of sarcoidosis has presented with bilateral kidney stones. What is the most likely cause for this patient’s stones?
A-Hypercalcemia B-Hyperuricemia C-Diet D-Recurrent UTIs E-Hyperparathyroidism
Ans: A.
Hypercalcemia in sarcoidosis is due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3by macrophages. 1,25-dihydroxyvitamin D3 leads to an increased absorption of calcium in the intestineand to an increased resorption of calcium in the bone.
Q4-In a patient with anaphylactic shock, all are correct treatments except:
A-Epinephrine
B-Hydralazine
C-Adrenaline
D-Aminophylline
Ans: B.
ANAPHYLAXIS
It’s a life-threatening, IgE-mediated, abnormal, hypersensitive immune reaction that occurs upon re-exposure to a stimulus in a person with previous sensitization. Common causative agents include drugs (Penicillin is the No.1 cause), protein (foods, insect venoms), and plants.
Essentials of diagnosis
1. History of exposure to allergic agents and early manifestations of pruritic rash, a lump in the throat, hoarseness, abdominal cramps, or nausea and vomiting (N/V).
- P/E may find signs of anaphylactic shock (tachycardia, hypotension, wheezing, stridor), angioedema (facial swelling), and urticarial rashes. Lab tests have little value. 3. Diagnosis is clinical. Two common lethal complications are laryngeal edema and refractory hypotension.
Treatment
1. Follow “ABC”—“Airway, Breathing, and Circulation.” Immediate epinephrine (EP) 0.3 mL SC will relieve both the airway with angioedema and the hypotension. Perform intubation or cricothyroidotomy if necessary; supply oxygen and treat hypotension with IV EP and bolus N.S. (1-2 L in adults and 20 mL/kg in children). 2. Remove the offending substance if possible, and administer an antihistamine (diphenhydramine) routinely. Glucocorticoids can help alleviate late reactions
Q5-Burn patient is treated with Silver Sulfadiazine, the toxicity of this drug can cause:
A-Leukocytosis
B-Neutropenia
C-Electrolyte disbalance
D-Hypokalemia
Ans: B
Q6-The most important factor in the development of spinal headaches after spinal anesthesia is
A-The level of the anesthesia B-The gauge of the needle used C- The closing pressure after the injection of tetracaine D-Its occurrence in the elderly E-The selection of male patients
Ans: B. When epidural anesthetics are placed with a larger needle than that used for spinal anesthetics, thelikelihood of headache is higher.
Q7-The most common complication of mumps in Adults:
A-Labyrinthitis
B-Orchitis
C-Meningitis
D-Encephalitis
Ans: B. In children the most common complication is Meningitis and in adult its orchitis. -Labyrinthitis (0.005% of cases) -Orchitis (30% of cases) -Meningitis (10% of cases) -Encephalitis (less than 1% of cases)
Q8-Patient present with high blood pressure (systolic 200 mmof hg), tachycardia, Mydriasis “Dilated pupils” and sweating, which is the likely toxicity?
A-Anticholenergic
B-Sympathomimetic drug
C-Tricyclic antidepressant
D-Organophosphorous compounds
Ans: B.
Sympathomimetic drugs mimic the action of sympathetic nervous system
• Examples: Cocaine,Ephedrine, Amphetamine, Epinephrine (Adrenaline) Dopamine
Q9-A 52-year-old woman who has recently finished a course of chemotherapy for
Metastatic adenocarcinoma of the lung presents to emergency room following a fall at home. She mentions that her legs have been feeling heavy for 2days. On examination there is reduced power through the lower limbs. Her lowerlimb reflexes are brisk and she has upgoing plantars. On examination of the
Abdomen, there is a palpable bladder. There is a sensory loss below L1. What is the most important diagnostic investigation?
A-MRI lumbar spine B-MRI whole spine C-CT thorax, abdomen, pelvis D-Positron emission tomography (PET) scan E-Bone scan
Ans: B. The presence of upper motor neuron signs and a sensory level in the lower
limbs must raise the suspicion of spinal cord compression. This is anoncological emergency and prompt action is required. It is important tonote that often in acute cord compression, lower motor neuron signs maybe seen below the level of the compression. The investigation of choice isMRI whole spine (B). While the findings on examination suggest that thecord compression is within the lumbar spine, MRI lumbar spine (A) is notthe correct answer as metastatic lesions in the rest of the vertebral columnmay be present and influence treatment options. CT thorax, abdomen andpelvis (C), PET scan (D) and bone scan (E) are very useful investigations forthe staging of cancers but are not used to identify spinal cord compression. Initial management of cord compression should be administration of
dexamathasone and then contacting clinical oncology and neurosurgicalteams to discuss treatment with either spinal radiotherapy or surgicaldecompression.
Q10-A child presents with eczema. She was given to creams by the GP – emollient and steroid. What advice would you give her regarding application of the cream?
A-Sparingly use both the cream B-First use emollient, then steroid C-Apply steroid then emollient D-Mix emollient & steroid before use E-Emollient at night with steroid
Ans: B. When using the two treatments, apply the emollient first. Wait 10-15 minutes after applying an emollient before applying a topical steroid. That is, the emollient should be allowed to absorb before a topical steroid is applied. The skin should be moist or slightly tacky but not slippery, when applying the steroid.
Q11-A 66-year-old man presents to accident and emergency in a confused state
Accompanied by his wife. She states that the patient has become increasingly
Obtunded in the last 3 days and has not opened his bowels for the same period of
Time.She mentions he has been suffering from multiple myeloma, but is otherwise
Healthy.On examination, the patient has brisk tendon reflexes, dry mucosal
Membranes, reduced skin turgor and the eyes appear sunken. The most appropriate
Management is:
A-Intravenous fluids and diuretics B-Diuretics alone C-Intravenous calcitonin D-Psychiatric referral E-Intravenous fluid resuscitation
Ans: E. This patient is suffering from hypercalcaemia secondary to multiplemyeloma, a malignancy of plasma cells in the bone marrow. Monoclonalantibodies and/or light chains are released producing detectable serumM-proteins and urinary Bence–Jones protein, respectively. The impact ofthis is a hypercoagulative state, anaemia or pancytopenia, hypercalcaemiaand an ESR that may or may not be raised. The acute management ofhypercalcaemia is centred around eliminating the excess calcium via theurine and providing fluid support. Intravenous fluid (E) is therefore themost appropriate management. Intravenous fluids diuretic (A) does notaddress the electrolyte imbalance since diuretics have a small influence
even after fluids are given. The most important treatment in hypercalcaemia
is intravenous saline. Furosemide is occasionally added but this is to allowmore saline to be given to older patients but runs the risk of hypokalaemia.
Diuretics alone (B) are potentially lethal since they would exacerbate the
dehydration. Intravenous calcitonin (C) would act to reduce calcium levels,
however, it is too slow and not as effective as fluid rehydration and diuresis.
Although the confusion can make communicating with patients difficult,
worrying clinical signs and collateral history should not be dismissed (D).
In a patient with a history of multiple myeloma, hypercalcaemia is a
Common complication and further delay can be fatal.
Q12-An 18-year-old woman presents to accident and emergency with a 5-day history of fevers, malaise and severe sore throat. On examination, she has a temperature of 40°C and her tonsils are inflamed with visible palatal petechiae. In addition, her cervical lymph nodes are palpable. A full blood count shows a raised lymphocyte count. What is the most likely diagnosis?
A-Influenza B-Streptococcal sore throat C-Infectious mononucleosis D- Malaria E-Mumps
Ans: C. Infectious mononucleosis (C) is caused by Epstein–Barr virus infection and
is characterized by fever, sore throat and anorexia. On examination, there
may be widespread lymphadenophathy and hepatomegaly or splenomegaly.
The tonsils usually appear inflamed and erythematous. The diagnosis can
be confirmed with a blood film showing the presence of atypicalmononuclear cells or a Paul Bunnell test. Influenza (A) should be consideredas a differential in patients that present with this clinical picture. However,it is unusual for the tonsils to be so inflamed and for the cervical lymphnodes to be palpable. Therefore, influenza is not as likely as infectiousmononucleosis. Streptococcal sore throat (B) may present with sore throatand fever. However, a lymphocytosis would not be seen on full bloodcount, making this answer incorrect. There is no history of travel
mentioned. Therefore, malaria (D) is an unlikely answer. Finally, mumps(E) presents with fever, malaise and swelling of the parotid glands. Thereis no swelling of the parotid glands in this case. In addition, the swollentonsils with palatal petechiae mean mumps is an unlikely answer.
Q13-All of the following cause photosensitivity except:
A-Lithium B-Propranolol C-Tetracycline D-Chloropromazine E-Chloropropamide
Ans: A
Q14-A 45-year-old man presents to accident and emergency with back pain. He works as a builder and the pain started after he had moved a cement mixer. On presentation, he is in considerable distress and unable to walk. He has not passed urine or opened his bowels since the incident. On peripheral neurological examination of the lower limbs, power is reduced throughout due to the pain. Sensation is preserved except for around the perineum. On digital rectal exam, there is poor anal tone. What is the most likely diagnosis?
A-Spinal cord compression B-Cauda equina syndrome C-Nerve root compression D-Bony injury E-Muscular strain
Ans: B. Back pain is a very common problem in accident and emergencydepartments. The clinical features described in the case in this question of
inability to open bowels, inability to urinate, reduced tone of digital rectal
exam and a saddle anaesthesia, indicate that the patient has prolapsed a
disc into the cauda equina (B) producing compression of the sacral nerves.
Spinal cord compression (A) is not the correct answer, as clinical features
would include a sensory level (i.e. a dermatomal level below which
sensation is reduced) and upper motor neuron signs below the level of the
compression (although it is important to note that in the acute injury, there
may initially be lower motor neuron signs) A nerve root compression (C)
would affect one particular nerve root and result in pain shooting down
the leg and decreased sensation in that dermatome. Bony injury (D) and
muscular strain (E) are incorrect answers due to the neurological signs.
Q15-A pt presents with complete anuria following prolonged hypotension and shock in a patient who bleed profusely from a placental abruption. What is the most probable diagnosis?
A-Post viral infection B-Acute papillary necrosis C-Acute cortical necrosis D-HUS (Hemolytic Uremic Syndrome) E-Renal vein thrombosis
Ans: C. Renal cortical necrosis is a rare cause of acute renal failure secondary to ischemic necrosis of the renal cortex. The lesions are usually caused by significantly diminished renal arterial perfusion secondary to vascular spasm, microvascular injury, or intravascular coagulation. Renal cortical necrosis is usually extensive, although focal and localized forms occur. In most cases, the medulla,
Pregnancy-related risk factors
Pregnancy-related conditions (more than 50% of cases) that may lead to renal cortical necrosis include the following:
• Placental abruption
• Infected abortion
• Prolonged intrauterine fetal death
• Severe eclampsia
