eMedici - GenMed 3/3 Flashcards
Which of the following further information will help determine the cause of the current problem?
- Targeted history regarding her dyspnoea
- Presence of associated cardiovascular symptoms
- Medications (current prescription, herbal and OTC medications)
- Social and personal history
- Smoking history
- Vaccination history for recent travel
- Allergies
Which one of the following is the most likely diagnosis?
- Myocardial infarction
- Pulmonary embolism
- Acute infective exacerbation of COPD
- Congestive heart failure
= Acute infective exacerbation of COPD
Management - The working diagnosis is of an infective exacerbation of COPD. After the ABC’s of the primary survey, some initial management steps must be taken before ordering investigations. Which of the following should be put into initial action?
- Salbutamol
- Systemic glucocorticoids
- Oxygen
- 1L bolus of isotonic (‘normal’) saline
= Salbutamol & Oxygen
Investigations - An oxygen mask has been applied and Bessie is given nebulised salbutamol. Once that has been done, she is then given an intravenous dose of 200 mg hydrocortisone. Which of the following investigations are now appropriate to support the working diagnosis?
- ECG
- FBC, UEC, CRP
- VBGs or ABGs
- Chest X-ray
- Blood culture, sputum culture and sputum Gram stain
Management - Bessie’s oxygen saturations are checked and after 20 minutes on the face mask, she is now saturating at 97%. Her ECG shows normal sinus rhythm. Her bloods show a leucocytosis and elevated C-reactive protein but are otherwise normal. Her ABGs are consistent with COPD, and show no signs of impending respiratory failure. Bessie’s chest X-ray confirms the suspicions of right middle lobe pneumonia (Images 1, 2). It is decided to keep Bessie in the Emergency Department for further observation, and to commence her on empirical antibiotics as per the ‘Therapeutic Guidelines’. Which one of the following regimens would be most appropriate?
- Intravenous benzylpenicillin and oral azithromycin
- Intravenous benzylpenicillin, intravenous azithromycin and gentamicin
- Oral amoxicillin and oral doxycycline
- Intravenous benzylpenicillin, intravenous azithromycin and metronidazole
= Intravenous benzylpenicillin and oral azithromycin
Which of the following issues need to be discussed with Bessie when she visits her general practitioner?
- Current medication review
- Weekly spirometry for following four weeks
- Initiation of new medications
- Prevention ie Flu Vax and respiratory physiotherapy
- The continuation of 50mg prednisolone daily for three months
- Cessation of smoking
= Current medication review, Initiation of new medications, & Prevention ie Flu Vax and respiratory physiotherapy
Which of the following are red flag features that should be sought when taking a headache history?
- Fever
- Confusion
- Gradual onset
- Change in frequency of headache
- Weight loss
- Palpitations
- Worsened on exertion
= Fever, Confusion, Change in frequency of headache, Weight loss, & Worsened on exertion
Which of the following would describe a thunderclap headache.
- Sudden onset of pain
- Gradual worsening of symptoms
- Pain worse at commencement
- Similar, but worse than previous headaches
= Sudden onset of pain & Pain worse at commencement
Which of the following conditions may also commonly present as a thunderclap headache?
- Sentinel headache
- Cerebral venous sinus thrombosis
- Cervical artery dissection
- Spontaneous intracranial hypotension
- Pituitary apoplexy
- Ischaemic stroke
- Primary thunderclap headache
- Primary cough, sexual and exertional headache
- Acute hypertensive crisis
Which of the following are considered to be risk factors for aneurysmal subarachnoid haemorrhage?
- Tobacco smoking
- Hypertension
- Migraine
- Male gender
- Female gender
- Moderate to heavy alcohol use
- Ehlers Danlos syndrome
- Autosomal dominant polycystic kidney disease
- Sympathomimetic drugs
- Oestrogen replacement therapy
Based on this information, which one of the following cranial nerves is most likely affected?
- Optic nerve
- Oculomotor nerve
- Trochlear nerve
- Trigeminal nerve
- Abducens nerve
= Oculomotor nerve
Which one of the following is the most appropriate next step to take?
- Examine her abdomen
- Perform a CT scan
- Phone her general practitioner for more information
- Administer some morphine
= Examine her abdomen
What is the name of the syndrome?
- Burnett’s syndrome
- Gebrochenes-Herz syndrome
- Ramsay-Hunt syndrome
- Ekbom syndrome
- Sweet’s syndrome
= Sweet’s syndrome
Which of the following are differential diagnoses for this presentation?
- Acute angle-closure glaucoma
- Graves disease
- Keratoconus
- Miller-Fisher syndrome
- Multiple sclerosis
- Myasthenia gravis
- Optic neuritis
- Graves disease
- Miller-Fisher syndrome
- Multiple sclerosis
- Myasthenia gravis
Which of the following is the most likely diagnosis?
- Graves disease
- Lambert-Eaton myasthenic syndrome
- Miller-Fisher syndrome
- Myasthenia gravis
- Multiple sclerosis
= Myasthenia gravis
Physical examination - You consider myasthenia gravis the most likely diagnosis and now proceed to physical examination. Which of the following would be consistent with the diagnosis of myasthenia gravis?
= Fatiguable ptosis, Improvement in ptosis following the application of an ice-pack, & Proximal muscle weakness more pronounced than distal muscle weakness
Which of the following autoantibodies, if present, would support the diagnosis of myasthenia gravis?
- Anti-acetylcholine receptor antibodies (Anti-AChR)
- Anti-centromere antibodies
- Anti-cyclic citrullinated antibodies (Anti-CCP)
- Anti-Jo antibodies
- Anti-lipoprotein-related protein 4 antibody
- Anti-mitochondrial antibodies
- Anti-muscle specific kinase antibodies (Anti-MuSK)
- Anti-smooth muscle antibodies
- Anti-striated muscle antibodies
- Anti-tissue transglutaminase antibodies
Which of the following results would you expect in Mrs Smith assuming she has myasthenia gravis?
- Conduction block and absent F waves
- Increased latency and temporal dispersion of waveforms
- Positive sharp waves and fibrillation potentials in muscle at rest
- Repetitive stimulation results in decreased amplitude of compound muscle action potentials
- Repetitive stimulation results in increased amplitude of compound muscle action potentials
= Repetitive stimulation results in decreased amplitude of compound muscle action potentials
Which of the following is the best answer?
- Administration of atropine, leading to acetylcholinesterase inhibition and worsening of weakness
- Administration of edrophonium, leading to acetylcholinesterase inhibition and improvement in weakness
- Administration of pyridostigmine, leading to anticholinergic effect and improvement of weakness
= Administration of edrophonium, leading to acetylcholinesterase inhibition and improvement in weakness - It should be noted that in a cholinergic crisis, which may mimic a myasthenic crisis, administration of edrophonium may worsen symptoms. Therefore atropine should be available to reverse the effects of edrophonium during a Tensilon® test (as well as resuscitation equipment).
Treatment - Mrs Smith is diagnosed with myasthenia gravis. Which of the following initial treatments would be appropriate for symptomatic relief at this stage?
= Pyridostigmine
Which of the following side effects commonly occur with pyridostigmine?
- Abdominal cramps
- Diarrhoea
- Increased salivatio
- Nausea
- Tachycardia
- Worsening of glaucoma (if present)
Which of the following is the most likely abnormality that would be found on her CT?
- Hiatus hernia
- Interstitial lung disease
- Lung cancer
- Mesothelioma
- Thymoma
= Thymoma
Treatment - The chest CT is unremarkable. The neurologist now discusses further treatment options with Mrs Smith. Which one of the following would be recommended at this stage?
= Thymectomy
Which of the following are true regarding anaesthesia in a patient with myasthenia gravis?
- If possible, neuromuscular blocking agents should be avoided
- Intensive care unit facilities may be required after surgery
- Myasthenia gravis patients are particularly susceptible to the effects of suxamethonium
- Myasthenia gravis patients are unpredictably susceptible to the effects of non-depolarising neuromuscular blocking agents
- In general, if the patient is taking pyridostigmine this medication should be continued up to the morning of the operation
= Myasthenia gravis patients are resistant to suxamethonium (a depolarizing neuromuscular blocking agent).
Although these features may be difficult to assess in this situation, which of the following features would suggest the presence of a cholinergic crisis?
- Salivation
- Lacrimation
- Urination
- Diaphoresis
- Gastrointestinal upset (including diarrhoea)
- Emesis
These features may be remembered by the mnemonic “SLUDGE” and this presentation may be referred to as SLUDGE syndrome. Other causes of a similar presentation include organophosphate and sarin gas poisoning. A cholinergic crisis may be treated with anticholinergics such as atropine.
Which of the following may worsen weakness in myasthenia gravis?
- ACE inhibitors
- Aminoglycosides
- Childbirth
- Beta blockers
- Neuromuscular blocking agents
- Quinolones
The following may worsen weakness:
- Childbirth
- Drugs (eg aminoglcyosides, beta blockers, neuromuscular blocking agents, quinolone)
What further information from the history is most likely to be helpful in establishing a diagnosis?
- Psychological history
- Use of illicit substances
- Rectal bleeding
- Passage of flatus per rectum
- Travel history
- Alcohol consumption
= Rectal bleeding & Alcohol consumption
Which of the following investigations are most likely to be helpful at this stage?
- Full blood count, serum urea and electrolytes, liver function tests and bone chemistry
- Thyroid function tests
- CT scan thorax, abdomen and pelvis
- Colonoscopy
- MRI spine
- Full blood count, serum urea and electrolytes, liver function tests and bone chemistry
- CT scan thorax, abdomen and pelvis
- Colonoscopy
Differential diagnosis
The differential diagnosis should be considered.
Which of the following are the most likely diagnoses to consider?
- Metastatic bowel cancer
- Metastatic pancreatic cancer
- Metastatic oesophago-gastric cancer
Image interpretation - A CT scan is performed. Which of the following can be seen on the scan?
- Carcinoma of the distal stomach
- Renal cell carcinoma
- Liver metastases
- Carcinoma of the head of the pancreas
- Obstructed stomach
- Vertebral metastases
= Liver metastases & Vertebral metastases
As Mr Jones’ disease progresses, what factors might suggest that his prognosis may be less than a year?
- Withdrawal of active treatment
- Spending more than 50% of the day in bed or in a chair
- Dependent on others for physical and/or emotional care
- Worsening anorexia, fatigue and other symptoms
- Unplanned admission to hospital
= All of them
Counselling - The Palliative Care team meets with Mr Jones and his family. They explain that they can help with symptom control and ensure that practical and emotional support is optimised. Mr Jones is keen for referral to community Palliative Care services on discharge from hospital. Which of the following should Mr Jones and his family be encouraged to consider?
Functional assessment - In order to identify the assistance and equipment that Mr Jones may require, it is important to assess his level of function. Which of the following items are included in a formal Palliative Care functional assessment?
WRONG ANSWERS:
- Communication with others – The University of Wollongong Australia Palliative Care Outcomes Collaboration recommends use of the Resource Utilisation Group Activities of Daily Living score (RUG-ADL) and Australian Karnovsky Performance score (AKPS) tools for functional assessment. Whilst an ability to interact and communicate with others is clearly important, these tools measure motor function only.
- Ability to maintain hobbies – Many patients who previously enjoyed hobbies such as cycling or gardening may no longer be able to carry these out as their disease progresses. However, the ability to maintain hobbies is not directly measured by the RUG-ADL (which specifically measures dependence on others for basic activities of daily living) or the AKPS (which provides a global measure of performance across activity, work and self-care).
Pain management - Mr Jones’ condition declines. His pain intensifies and he reports a pain score of 8/10. The site and character of the pain are essentially unchanged, although he is experiencing more frequent spontaneous stabbing pains radiating through to his back. How would you manage his pain?
Prognosis - Mr Jones’ condition continues to deteriorate. The family are concerned and request confirmation of his prognosis. Which of the following factors indicate that he has now entered the terminal phase of his illness?
= All of them
Palliative care - You inform the family that you believe Mr Jones now has only days to live. How should his comfort be managed in the final days of life?
Which one of the following is the most likely cause of her symptoms?
- Acute angle-closure glaucoma
- Central retinal artery occlusion
- Dry age-related macular degeneration
- Optic neuritis
- Retinal detachment
= Optic neuritis
Physical findings - The duty doctor considers optic neuritis to be the most likely cause of Elisa’s symptoms. Further history reveals that she has a medical history of eczema, currently takes the oral contraceptive pill and has a 5 pack-year smoking history. She consumes about two standard drinks of alcohol per day. She takes no other medication. Her father has asthma and her sister has eczema. The doctor now proceeds to physical examination. Which of the following examination findings would be consistent with optic neuritis of the left eye?
- Decreased visual acuity in the affected eye
- Deficits in colour vision
- Relative afferent pupillary defect (Marcus-Gunn pupil)
Image interpretation - The doctor takes up her ophthalmoscope and performs fundoscopy. This is a view of the left retina. Which one of the following is the most likely diagnosis?
- Papilloedema
- Retinal detachment
- Optic atrophy
- Choroiditis
- Optic neuritis
= Optic neuritis
The changes are those of optic neuritis. Note the swollen discs and spillover, with leakage of lipids that has been engulfed by glial macrophages to form a macular star.
Which of the following are possible causes of optic neuritis?
- Lupus
- Multiple sclerosis
- Neuromyelitis optica
- Sarcoidosis
= All of them
Risk factors - The doctor considers the likelihood of a diagnosis of multiple sclerosis in Elisa. Which of the following are risk factors for multiple sclerosis?
- 20-40 years of age
- Family history of multiple sclerosis
- Female
- Living in Tasmania
- Smoking
- Vitamin D deficiency
Is there sufficient evidence for a diagnosis of multiple sclerosis?
= No
There is insufficient evidence for a diagnosis of multiple sclerosis at this time. The diagnostic criteria for multiple sclerosis, known as the McDonald Criteria has not been fulfilled. The main requirement for a diagnosis of multiple sclerosis is the demonstration of dissemination in space and time of lesions, displayed clinically or on MRI imaging. In this case, the episode of optic neuritis is best described as a clinically isolated syndrome, with the diagnosis of possible multiple sclerosis.
Which one of the following is the best estimate?
- 10%
- 20%
- 30%
- 40%
- 50%
= 30%
In the Optic Neuritis Treatment Trial a 30% 5-year cumulative incidence for the diagnosis of multiple sclerosis following optic neuritis was found.
Given that she has responded poorly to methylprednisolone, which one of the following is the most appropriate treatment for the current acute flare?
- Azathioprine
- Interferon beta
- Intrathecal methylprednisolone
- Methotrexate
- Oral prednisolone
- Plasmapheresis
= Plasmapheresis
Assessment - Elisa’s undergoes three plasma exchanges and her left arm and hand strength recovers back to its baseline level of function. Which of the following terms best describes the progression of Elisa’s multiple sclerosis so far?
- Primary progressive
- Relapsing remitting
- Secondary progressive
= Relapsing remitting
Management - The neurologist wishes to commence Elisa on an immunomodulator to decrease frequency of flares and reduce disease progression. Which of the following are immunomodulators (not immunosuppressants) that may be used to treat multiple sclerosis?
= Glatiramer, Interferon beta, & Natalizumab
4 causes of optic neuritis?
6 Risk factors for multiple sclerosis?
Which of the following diagnoses should be considered?
- Cerebellar infarct
- Essential tremor
- Hyperthyroidism
- Metoclopramide-induced tremor
- Multiple system atrophy
- Parkinson’s disease
- Metoclopramide-induced tremor
- Multiple system atrophy
- Parkinson’s disease
History - The practitioner proceeds to take a full history to help determine the cause of John’s tremor. If present, which of the following features on history would be consistent with a diagnosis of Parkinson’s disease?
- Constipation
- Depression
- Fatigue
- Hyposmia
- Thrashing movements during sleep
Which of the following features, if present on physical examination, would indicate the need to consider a diagnosis OTHER THAN Parkinson’s disease?
- Cog-wheel rigidity
- En bloc turning
- Masked facial expression
- Soft speech
- Supine BP 160/100, standing BP 120/80
- Supranuclear palsy of vertical gaze
= Supine BP 160/100, standing BP 120/80 & Supranuclear palsy of vertical gaze
Which of the following will confirm the most likely diagnosis?
- Brain MRI
- Head CT
- No brain imaging investigations required in this instance. Commence dopaminergic medication trial.
= No brain imaging investigations required in this instance. Commence dopaminergic medication trial.
Which of the following are possible side effects of levodopa?
- Drowsiness
- Hallucinations
- Hyperprolactinaemia
- Impulse control disorders
- Nausea
- Postural hypotension
Which of the following complications of Parkinson’s disease has John developed?
- Delayed on phenomenon
- Dykinesias
- Freezing
- On-off phenomenon
- Wearing off phenomenon
= Dykinesias & Wearing off phenomenon
Management - John continues to be managed by his neurologist and general practitioner over the next 10 years. Despite maximal medical therapy he suffers from severe dyskinesias and develops on-off motor fluctuations. John asks his neurologist if there are any other options for treating his Parkinson’s disease. Which of the following treatment options may be considered?
- Apomorphine infusion
- Deep brain stimulation
- Levodopa-carbidopa intestinal gel delivered via percutaneous gastrostomy
= Apomorphine infusion & Levodopa-carbidopa intestinal gel delivered via percutaneous gastrostomy
Which one of the following is the most appropriate immediate step in management?
- Start supplemental oxygen via a Hudson mask at 10L/min
- Perform a primary survey (ABCDs)
- Take further history until you have a sufficient provisional diagnosis to begin an appropriate management plan
- Chest X-ray
= Perform a primary survey (ABCDs)
Which one of the following is the most appropriate next step in managing Mark’s respiratory distress?
- MDI salbutamol and oral prednisolone
- Organise a rapid sequence induction and intubate Mark with immediate transfer to ICU
- Nebulized salbutamol, IV hydrocortisone and continue oxygen supplementation
- IV antibiotics and continued oxygen supplementation
- Perform arterial blood gas analysis
= Nebulized salbutamol, IV hydrocortisone and continue oxygen supplementation
Image Interpretation - Mark is started on his nebulilsed salbutamol, intravenous prednisone and he is tolerating his Hudson mask well. His vital signs are checked and a re-assessment made of his chest. Whilst the wheeze is still present bilaterally, it is softer. Chest expansion has improved and his chest is less resonant to percussion. He still has a tachycardia of 90/min, but his respiratory rate has fallen to 20/min. He is now saturating at 97%. His asthma now appears to be under control and a chest X-ray is arranged. Which one of the following most accurately describes the X-ray?
- A normal X-ray
- Pneumomediastinum
- Right-sided pneumothorax
- Left-sided pneumothorax
= Pneumomediastinum
The chest X-ray shows normal lung fields with no signs of focal infection. The patient has a pneumomediastinum, with air seen tracking up into the neck. There is no evidence of a pneumothorax. Although bronchial thickening, hyperinflation and focal atelectasis suggest asthma when they are present, chest radiographs obtained during asthma exacerbations can demonstrate normal findings, which reduce its sensitivity as a diagnostic tool.
Which of the following would be realistic causes?
- Occupational exacerbation
- Viral or bacterial infection
- Poor compliance with preventer medications and smoking
- A recent change in his diet to exclude gluten
- Occupational exacerbation
- Viral or bacterial infection
- Poor compliance with preventer medications and smoking
Treatment - Mark is transferred to the ward for further treatment overnight. A medication chart is written up. Which of the following medications would be appropriate?
- Salbutamol 5mg nebules, four times/day
- Oral prednisolone 50mg daily
- Ipratropium bromide nebules
