EMQ set 4

Question 1

For each case, choose the single most appropriate next management option from the list.

1. An unconscious 35 yo M who has capillary blood glucose of 1.5mmol/L
2. A 55 yo M found collapsed at home who, on arrival to hospital, has no palpable pulse or recordable blood pressure.
3. An 18 yo F found unconscious at home. She has needle “track” marks in her arms, and resp rate 10/min and pinpoint pupils.
4. A 34 yo F who complained of a severe headache on waking and then collapsed.
5. An 18 yo known asthmatic with resp rate 50/min and inaudible breath sounds on auscultation.

Options: CT scan, precordial thump, iv dextrose, iv naloxone, gastric lavage, DC cardioversion, lumbar puncture, iv Abx, start CPR, inhaled anticholinergic, im glucagon, endotracheal intubation.

Answer 1

1. iv dextrose
   
   • this pt is hypoglycaemic. Likely DM. Non-DM causes of hypoglycaemia icnl. insulinomas, alcohol, liver failure, Addison’s disease. IM glucagon Rx is only used if IV access can’t be established.
2. commence CPR
   
   • pt has cardiac arrest. Shockable rhythm would be pulseless CT or VF whereas non-shockable rhythm is PEA or asystole.
3. iv naloxone
   
   • Opiate OD signs incl. CNS depression, miosis, apnoea. Naloxone is therapeutic and diagnostic if pt improves. IV is preferred route but can also give IM or SC if IV access can’t be establised. Also give 100% oxygen.
4. CT scan brain
   
   • This is possible subarachnoid haemorrhage. On CT this would appear as hyperdense areas in the basal cisterns, major fissures and sulci.
5. Endotracheal intubation
   
   • This is lifethreatening asthma that hasn’t responded to therapy (pt is cyanotic w/ resp acidosis despite tachypneoa. Pulsus paradoxus may be observed. Pt should be intubated and transfered to ICU. IV corticosteroids should also be used.

Question 2

Match the description of the pt with the most likely diagnoses.

1. A 28 yo F with recent onset depression takes 50 capsules of 500mg paracetamol. In several days, the liver is most likely to show what?
2. A 40 yo M has a long Hx of chronic alcoholism. His liver is firm on palpation. An abdo CT shows liver changes consistent with cirrhosis. He joins AA and stops drinking. Despite abstinence from alcohol, he remains at risk for development of which disease?
3. A 40 yo F, who is overweight, has episodes of RUQ pain and fever. What is the likely diagnosis?

Options from: Hep C virus infection, hepatocellular carcinoma, cirrhosis, cholecystitis, portal HTN, Hep B virus infection, Mallory weiss tear, extensive necrosis, portal chronic inflammation

Answer 2

1. Extensive necrosis
   
   • paracetamol OD often presents as asymptomatic but if untreated may cause liver injury over 2-4 days after ingenstion incl fulimant liver failure. Risk of live damage increases after taking drugs which induce CYP 450 (St John’s wort, barbiturates, phenytoin, tetracycline, chronic alcohol use and carbamazepine). Serum paracetamol level can be had 4 hrs post-ingestion. Rx is N-acetylcysteine.
2. Hepatocellular carcinoma
   
   • Pts with cirrhosis (esp. alcoholic liver disease) are at high risk of developing HCC. Cirrhosis is irreversible despite stopping EtOH. Pts with cirrhosis should be screened for HCC with serum AFP and USS at 6 month intervals.
3. Cholecystitis
   
   • this is acute GB inflammation due to obstruction at cystic duct. Classically presents with RUQ and fever. USS id definitive initial investigation. Rx with cholecystectomy.

Question 3

For each pt, choose the single most likely diagnosis:

1. A 58 yo M who smoked 30 cigarettes a day, presents w/ 6rk Hx of cough, malaise, anorexia and weight loss. PMHx incl. HTN for which he has taken lisinopril and bendrofluazide for 4 yrs.
2. A 45 yo F who smokes 25 cigarettes a day is reviewed in the diabetic clinic. She has had a dry cough for 2 months. She is on numerous diabetes medications as her diabetes is complicated by microalbuminuria and HTN. Her GP had given her a course of Abx 2 weeks previously.
3. A 40 yo Afro-Caribbean F presents with bilateral parotid swelling and painful nodules on the front of the shins. She has a dry cough and slight SOB on exertion.
4. An 18 yo M presents with night-time cough and SOB while playing football. This has got progressively worse over the previous 2 months.
5. A 30 yo M, a lifelong non-smoker, presents with Hx of at least 6 months of purulent sputum. He has had regular chest infections since an attack of measles at the age of 14.

Options from: COPD, ACEi, postnasal drip, asthma, tuberculosis, carcinoma of bronchus, foreign body, sarcoidosis, bronchiectasis, oesophageal reflux

Answer 3

1. Carcinoma of bronchus
   
   • Hx of smoking and weight loss point to malignancy. Initial Ix is CXR. Dx relies on pathological confirmation from a tissue sample often obtained from bronchoscopy. 1st line Rx is surgical resection. SCLC is Rx with chemotherapy and is associated with SIADH and ectopic ACTH. NSCLC is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and Rx with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases still associated with smoking. Paraneoplastic syndromes may include Lamert-Easton myasthenic syndrome.
2. ACEi
   
   • A dry cough occurs due to build up of bradykinin which is normally degraded by ACE. ARB (antagonists of AT1 receptors for ANG II) eg Losartab will be indicated in this case.
3. Sarcoidosis
   
   • the painful (mauve) nodules = erythema nodosum. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discolouration on the face. Parotid enlargement is a classic feature (involvement of exocrine glands). The dry cough and SOB on exertion indicate pulmonary involvement.
4. Asthma
   
   • SOB and cough, which may wake pt from sleep, and exercise exacerbation suggest asthma. O/E may be expiratory wheeze. In severe exacerbations, chest may be silent. Night symptoms occur in more severe asthma. Dx is supported by PEFR variation of at least 20% over 3 days in a week.
5. Bronchiectasis
   
   • = permanent bronchi dilatation due to bronchial wall damage and loss of elasticity. It is often due to severe/recurrent infections and most present with chronic productive mucopurulent cough. Most common cause is CF. Dx by chest CT and sputum analysis.

Question 4

For each pt, choose the single most likely diagnosis.

1. A 19 yo student complaining of amenorrhoea for 9 months, alongside weight loss, generalised weakness and depression. She has started a vegan diet 1 yr ago. Her BMI is 16.
2. A 17 yo M returning from holiday in Africa presents with abdo pain, weight loss, pruritis and wheeze. Blood film showed eosinophilia.
3. A 70 yo M with a Hx of 10kg weight loss over previous 3 months has recently developed acute lower back pain. He presents to A+E with coughing and sputum. CXR shows L lower lobe pneumonia.
4. A 25 yo F with fatigue and weight loss. Hx of frequent loose stools with abdo pain. FBC shoes iron deficiency anaemia.
5. A 40 yo African refugee has noticed recent weight loss which he attributes to stress. He also has generalised lymphadenopathy. Blood count shows neutropenia and thrombocytopenia.

Options from: Addison’s disease, malabsorption, depression, cardiac failure, diabetes mellitus, anorexia nervosa, tuberculosis, infestation with helminths, HIV, malignancy, renal failure, liver failure, hyperthyroidism.

Answer 4

1. Anorexia nervosa
   
   • puberty and obsessive personality traits are risk factors. Higher socioeconomic classes are more affected. 2 types: restrictive (where pt will diet and exercise) or bingeing/purging (where calorie restriction plus binges). There is also a tendency to laxative, diuretic and enema abuse.
2. Infestation with helminths
   
   • Helminths give eosinophilia. Testing for stool ova and parasites ill be needed. IgG serology can be used if stool negative for strongyloide larvae. Rx with antihelminth depending on organism (eg ivermectin for strongyloides)
3. Malignancy
   
   • Pt has lung cancer. This is a post-obstructive pneumonia which is common in lung cancer pts and usually caused by large and centrally obstructing tumour. Lower spinal column pain due to mets.
4. Malabsorption
   
   • Likely to be coeliac disease, other presentations incl. abdo pain and diarrhoea. Coeliac disease is a systemic autoimmune condition triggered by dietary gluten peptides found in grains.
5. HIV
   
   • HIV is a retrovirus and 2 types (HIV 1 = main virus, HIV 2 = restricted to parts of W Africa). Weight loss is common and if >10kg or BMI <18.5 indicates severe immunocompromise. Cause may be malnutrition, co-existent TB of HIV-wasting syndrome (AIDs defining illness). Generalised lymphadenopathy is common and have painless enlargement of 2 of more non-contiguous sites of >1cm for >3months. Neutropenia is seen due to CD4 deficiency and thrombocytopenia may be seen with an anaemic picture.

Question 5

For each pt below choose the single most likely appropriate management from the options.

1. A 25 yo F returning from Australia presents with acutely painful L calf. US confirms DVT extending above the popliteal veins. She has recentlly missed a period.
2. A 30 yo developed acute pain in R calf after a game of squash. He has marked calf tenderness but no swelling. Doppler US is negative.
3. A 50 yo F taking NSAIDs for arthritis presented with sudden onset pain behind R knee leading to pain down the calf. US confirms a Baker’s cyst.
4. You are asked to see a pt with acute chest pain 5 days after total hip replacement. BP 120/80, HR 93. A PE is confirmed. The pt has a previous Hx of heparin-induced thrombocytopenia.
5. A F on warfarin for confirmed R calf DVT develops increasing pain and swelling of R leg. This is the 3rd time this has happened. Repeat imaging shows thrombus limited to the calf.

Options from: subcutaneous LMW heparin, embolectomy, vena cava filter, reassure and discharge, check INR and continue warfarin, fondaparinux (FXa inhibitor), start warfarin therapy, observation in hospital, reassure and discharge, iv heparin, antiembolism stocking

Answer 5

1. subcutaneous low molecular weight heparin
   
   • women developing DVT during pregnancy can be treated with heparin or LMWH (this is preferred due to more dependable pharmacokinetics). Commonly use enoxaparin, dalteparin and tinzaparin.
2. reassure and discharge
   
   • likely to be MSK in otherwise fit, young man.
3. reassure and discharge
   
   • A popliteal cyst is an accumulation of synovial fluid which in this case has resulted from her arthritis. It will self-resolve but underlying cause should be addressed ie arthritis. First line Rx is RICE - rest, ice, compression, elevation. Adjunctive analgsia can be offered with paracetamol. Surgery only indicated if extensive symptoms and conservative Rx has failed.
4. Fondaparinux
   
   • As pt has had heparin-induced thrombocytopenia, a factor Xa antagonist is preferred. If the pt has a low BP then systemic thrombolysis would be indicated to prevent possible cardiac arrest.
5. subcutaneous low molecular weight heparin
   
   • Pts with recurrent thromboembolisms despite on warfarin should be given heparin or LMWH. LMWH is preferred, and should be given for at least 5 days until INR is between 2-3. Need to work out why pt has developed DVT despite warfarin -> ?subtherapeutic dosing, ?malignancy, ?antiphospholipid syndrome.

Question 6

Choose the most likely diagnosis from the list for each pt.

1. A 40 yo F with multiple painful lumps in her breast which are painful and tender premenstrually
2. A 25 yo F with a discrete, non-tender, mobile lump in one breast
3. A 35 yo F is generally unwell with a tachycardia and fever. A segment of the R breast is painful, tender, red and warm.
4. A 14 yo boy with bilateral breast enlargement.
5. A 40 yo lady with a green nipple discharge and tender lumpiness beneath the areola.

Options from: duct ectasia, breast abscess, lipoma, fibroadenoma, breast cyst, sebaceous cyst, gynaecomastia, carcinoma of the breast, fibroadenosis

Answer 6

1. Fibroadenosis
   
   • fibrocystic breasts are characteristed by ‘lumpy’ breasts associated with pain which fluctuates with menstrual cycle (worse during luteal phase). Risk factors = obesity, nulliparity, HRT, late onset menopause and 1st childbirth. Symptoms typically arise in 30s. May be nipple discharge. Cysts can be aspirated if symptomatic (if straw coloured no need for cytology). There is an improvement of mastalgia and cysts at menopause.
2. Fibroadenoma
   
   • Tends to be asymptomatic and found incidentally typically in pt <40 yo. Is a mobile mass (“breast mice”), firm, painless, and can also be described as smooth and rubbery. It is benign with epithelail and stromal elements.
3. Breast abscess
   
   • Present with mastalgia and fever. Typically affect women who are lactating and most common pathogen is staphylococcus aureus. The painful, hard, red lump indicates the development of an abscess. Abx is indicated, alongside aspiration and drainage and possible duct excision. USS may help identify abscess (“hypoechoic lesion”).
4. Gynaecomastia
   
   • Normal to see in puberty. Other causes typically in adults incl liver disease and as SE of drugs eg digoxin, spironolactone and cimetidine.
5. Duct ectasia
   
   • Happens as the lactiferous duct becomes blocked. Ectasia means widening. It can mimic breast cancer as the discharge can be bloody and signs can include nipple inversion. The green discharge is typical in EMQs. It is self-limiting.

Question 7

Choose the single most likely investigation from the list.

1. A 45 yo M with a long Hx of XS EtOH presents with haematemesis. O/E he is clubbed and has spider naevi.
2. A 60 yo M with Hx of occupational exposure in building and demolition industry presents with SOB. O/E there are signs of a pleural effusion and pt is clubbed.
3. A 19 yo F with PMHx of cardiac surgery in infancy presents with symptoms of decreasing exercise tolerance. O/E there is cyanosis and clubbing.
4. A 35 yo F with Hx of recurrent lower abdo pain, bloody diarrhoea and passing mucus PR. O/E there is lower abdo tenderness and clubbing.
5. A 50 yo F who is a heavy smoker presents with SOB and weight loss. O/E she is clubbed. The CXR shows a perihilar shadow.

Options: stool culture, bronchoscopy, abdo US, echocardiogram, colonoscopy, sputum culture, lung function tests, CXR

Answer 7

1. Abdominal ultrasound
   
   • clubbing due to cirrhosis due to XS EtOH. US is only feasible option given and can detect advanced cirrhosis and possible signs of portal HTN eg ascites, splenomegaly and increased portal vein diameter. US may show nodular liver surface and liver itself may be shrunk due to cirrhosis and LHside of liver may be hypertrophied.
2. CXR
   
   • Idiopathic pulmonary fibrosis progresses over several years (possibly due to pt’s work with dust particles) and is characterised by pulmonary scar tissue formation and dyspnoae. Pts complain of a non-productive cough and typically repreoducible and predictable SOB on exertion. Another risk factor is cigarette smoking. Mean Dx age is 60-70. CXR will show reticular opacities. A high resolution CT can also be done.
3. Echo
   
   • The only cardiac Ix listed is echo. Cardiac causes of clubbing incl. cyanotic congenital heart disease, infective endocarditis and atrial myxoma. This could well be Eisenmenger’s syndrome caused by shunt reversal.
4. Colonoscopy
   
   • This woman has IBD (which is a cause of clubbing). The Hx suggests UC. Main Rx is 5-ASA. Colonoscopy is required to assess extent of disease. US is characterised by crypt abscesses (pathoneumonic). Smoking seems protective in UC. While a stool culture may be useful to rule out infectious gastroenteritis, it will not provide a Dx.
5. Bronchoscopy
   
   • Hx of smoking and weight loss point ot a bronchial carcinoma. Whilst initial Ix is CXR, Dx relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. NSCLC is more often associated with clubbing.

Question 8

For each pt below, choose the single most likely Dx from the options given.

1. A 37 yo Somali doctor with a Hx of coughing up about half a cup of fresh blood on 4-5 occasions over 2 months. He had lost 5kg in weight and had drenching night sweats almost daily. CXR shows a large cavitating nodule in the L upper zone.
2. A 55 yo lorry driver, a ‘fit’ smoker of 20-30 cigarettes a day, presents to GP with Hx of coughing up 2 streaks of blood on separate mornings in the previous week. He has had a morning cough with small amounts of sputum over the previous 10 yrs and admits he may have lost weight as he has had to tighten his trouser belt. The ESR was 75 and CXR showed collapse of R middle lobe.
3. A 50 yo cleaner with Hx of pertussis as a child, had a fever and increasing SOB with sweating on exertion. She has had a productive cough of yellow sputum for 25 yrs but this is recently blood stained. She is a non-smoker. She has come to GP for a further course of Abx and he refers her for a CXR as he thinks she is clubbed.
4. A 25 yo public relations executive has gained weight in the OCP and is reluctant to give up smoking 10-15 cigarettes a day. She presents to A+E with acute L-sided pleuritic chest pain, slight SOB, and a cough with a little sputum containing smears of blood. CXR is unremarkable.
5. A 45 yo woman who is HIV positive reports easy bruising, frequent nose bleeds and coughing up small streaks of blood. She is otherwise well at present. CXR shows no abnormality. An FBC shows Hb 105, WBC 5 and platelets 28

Options from: acute L ventricular failure, arterio-venous malformation, thrombocytopenia, bronchiectasis, sickle cell crisis, tuberculosis, asthma, pulmonary aspergillosis, pulmonary embolus, inhaled foreign body, carcinoma of bronchus

Answer 8

1. Tuberculosis
   
   • This pt has pulmonary TB (night sweats, weight lossm haemoptysis). CXR of cavitating lesion and upper zone changes are consistent with TB. If TB suspected,pt should be placed in isolation and 3 sputum samples cultures for AFB. Should also have HIV test done.
2. Carcinoma of bronchus
   
   • Lobar collapse here may be a consequence of obstruction. First line Rx aims at surgical resection if possible. SCLC is treated with chemo adn associated with SIADH and ectopic ACTH. NSCLC is more associated with clubbing.
3. Bronchiectasis
   
   • =permanent bronchi dilatation due to bronchial wall damage and loss of elasticity. Often due to severe infections as child. Chest CT is the diagnostic test (and aided with sputum analysis). Bronchiectasis is a cause of clubbing.
4. Pulmonary embolus
   
   • Underlying pathophysiology of PE is based on Virchow’s triad. SOB is common, alongside pleuritic chest pain and haemoptysis. CXR may be normal or may show band atelectasis, hemidiaphragm elevation, Fleischner’s sign, Westermark’s sign and Hampton hump. ECG may be normal or show tachycardia, new RAD, new RBBB or S1Q3T3.
5. Thrombocytopenia
   
   • HIV is implicated in idiopathic thrombocytopenic purpura which is a condition of abnormally low platelet count of unknown cause. Platelet count <150 is defined as thrombocytopenia. Symptoms of thrombocytopenia - bruising, haemoptysis and epistaxis.

Question 9

For each pt, choose the single most likely diagnosis from the list below:

1. A 30 yo M appears jaundiced. FBC and peripheral blood smear is reported as normal. INR is normal. LFTs show elevated unconjugated bilirubin. Liver enzymes are normal.
2. A 20 yo F complains of breathlessness and appears pale. Hb 7.3g/dl, WBC 7.0x109/L, platelets 100x109/l. Unconjugated bilirubin is elevated. Direct antiglobulin test is positive.
3. A 55 yo M complains of abdo distension. Hb 10.0g/dl, WBC 7.0x109/l, platelets 100x109/l. The pt is hyponatraemic and hypokalaemic. Urea and creatinine are normal. Serum albumin is low. AST is elevated at 250 and ALT is elevated to 125. ALP and GGT are also elevated.
4. A 30 yo M who has returned from a month-long trip to India has been complaining of abdo pain and nausea for a week. He has also vomited and remembers having a meal of shellfish from a street vendow. He woke up this morning and noticed he was going yelow. His ALT is 5000 and total bilirubin 139.
5. A 45 yo obese woman complains of intermittent abdo pain with jaundice. Hb 13.1 g/dl, WBC 8.3 x109/l, platelets 200 x 109/l, Na 140, K 4.1, Urea 5.2, creatinine 88, ALP 580, bilirubin 264, ALT 70.

Options from: autoimmune haemolytic anaemia, paracetamol poisoning, Gilbert’s, viral hepatitis A, alcoholic cirrhosis, primary biliary cirrhosis, carcinoma of head of pancreas, liver secondaries, cholelithiasis

Answer 9

1. Gilbert’s syndrome
   
   • Due to decreased UDPGT activity -> decreased conj bili. Occurs in asymptomatic pt, often incidental finding or mild jaundice in young adults. There is high unconj. bilir with normal LFTs. Blood smear/Hb also normal so not haemolysis. Common, no Rx needed.
2. Autoimmune haemolytic anaemia
   
   • Symptoms of anaemia (SOB, pallow). Haemolytic anaemia can be hereditary (membrane defects eg spherocytosis, enzyme def eg G6PDH def or abnormal Hb production eg sicklec/thal) or acquired (either immune or not-immuen). Autoimmune HA due to auto-antibodies which occur often as part of autoimmune process eg SLE/RA or related o lymphoproliferative disorder eg CLL. This FBC has low Hb (and need to get mchc/reticulocyte count as both would be increased in haemolytic anaemia). Increased haem breakdown leads to mild unconjugated hyperbilirubinaemia. LDH would also be raised. AIHA is shown by posiive DAT or Coomb’ test - tests for IgG or complemet bound to RBCs. IgG often indicates a warm antibody whereas C3d suggests a cold antibody.
3. Alcoholic cirrhosis
   
   • AST and ALT are elevated in all forms of alcoholic liver disease, both to <300. AST/ALT ratio >2. The elevated ALP here may indicate cholestasis. GGT is a more sensitive marker for heavy alcohol use. Anaemia here may b due to Fe def/folate def and hypersplenism. Thrombocytopenia may be secondary to alcohol induced BM suppression, folate def and hypersplenism. Those with advanced cirrhosis are often hyponatraemia/hypokalaemic. If urea/cr were elevated -> hepatorenal syndrome. Cirrhosis is the end stage of CLD and abdo distension may be ascites.
4. Viral hepatitis A
   
   • Primarily transmitted faecal-oral route. Virus is consumerd, absorbed, replicates in liver and excreted in bile (to be re-transmitted). Transmission usually precedes symptoms by 2 wks and pts are non-infectious 1 wk after jaundice onset. Hx may reveal RF: endemic area, MSM, food-borne outbreak (shellfish from sewage water). If pt has HBV/HCV or cirrhosis there is a higher risk of fulimant HAV infection. HAV infection typically consists of pre-icteric phase (5-7days) of N+V, abdo pain, fever, malaise, headache. Rarer symp. incl. arthralgias thrombocytopenia. Signs incl. splenomegaly, RUQ pain, tender hepatomegaly and bradycardia. Jaundice typically peaks at 2 wks. Fulimant course incl. worsening jaundice and encephalopathy. Serum transaminases may reach>10,000 units. ALT typically > AST.
5. Cholelithiasis
   
   • gallstone symptoms occur when cystic/bile duct is obstructed or when gallstones erode through gall bladder. The biliary pain here is caused by transient cystic duct obstruction. Typical presentation: RUQ or epigastric pain often after food that increses in intensity and lasts for several hours. 5Fs - fat, forty, female, fertile, fair. USS for definitive diagnosis.

Question 10

What is the frequent side effect for each of the following drugs or class of drugs:

• Beta blockers (eg atenolol)
• Beta adrenergic bronchodilators (salbutamol, terbutaline)
• Erythromycin
• Tricylic antidepressants (amitripyline, imipramine)
• ACE inhibitors (captopril, ramipril)

Options from: nausea and vomiting, constipation and dry mouth, tremor, peripheral neuropathy, gynaecomastia, dry cough, indigestion and GI bleed, goitre, swelling of feet and ankles, cold toes and fingers.

Answer 10

1. Cold toes and fingers
   
   • B-blockers can cause bronchoconstriction (asthmatics) HF in those with heart disease who rely on sympathetic drive to maintain CO, hypoglycaemia, fatigue (reduced CO and muscle perfusion via B2 receptors) and cold extremities (beta receptor mediated vasodialtion of cutaneous vessels_. May also get bad dreams.
2. Tremor
   
   • Beta agonists have similar SE to adrenaline. A tremor can be seen. Salbutamol can be used in threatened uncomplicated premature labour to relax the uterus.
3. Nausea and vomiting
   
   • Erythromycin is a motilin agonist which causes N+V. It is a macrolide antibiotic and tends not be first line unles pt has penicillin allergy. Has slightly wider spectrum of activity than penicillin. Macrolides can cause reversible deafness (but aminoglycosides cause more drug-induced deafness)
4. Constipation and dry mouth
   
   • TCAs have antimuscarinic properties and thus have the classic atropine-like SE including dry mouth, constipation, mydriasis and blurred vision.
5. Dry cough
   
   • A side effect of ACEi due to build up of bradykinin which is normally degreaded by ACE. ARBs eg losartan will be indicated in this case. ARBs are insurmountable antagonists of AT1 receptors for ANG II.

Question 11

For each pt, choose the single most likely Dx from the list below:

1. A 45 yo Jamaican F with a 6 month Hx of weight loss and 2 wk Hx of fever. OE she had cervical lymphadenopathy. Her calcium was raised at 3.0 and CXR showed bilateral hilar lymphadenopathy.
2. A 25 yo M with a 3 day Hx of high fever, aching limbs and neck pain. OE: fever 39C, mild conjunctivitis. Abx were prescribed but had no effect.
3. A 50 yo F normally resident in UK returned from visiting relatives in Pakistan. She described intermittent fevers with rigors, diarrhoea and severe heeadaches. She is mildly jaundiced.
4. A 22 yo M presented with 2 wk Hx of fever and drenching night sweats. He had experienced severe itching during this time. OE: swollen supraclavicular lymph nodes. CXR showed a mediastianl mass.
5. A 35 yo pregnant F developed a temperature with chills and increased urinary frequency. She is tender in R loin and has vomited. Dipstick urinalysis is +ve for leukocytes, nitrites and blood.
6. A 50 yo F presented with temperature and aching joings, 2 days prior to her departure on holiday to Egypt. OE she had a tender swelling on her L upper arm.

Options from: Malaria, SLE, HIV infection, Hodgkin’s lymphoma, Glandular fever, appendicitis, post-immunisation, influenza, sarcoidosis, pneumonia, drug reation, pyelonephritis, gastric carcinoma, tuberculosis

Answer 11

1. Sarcoidosis
   
   • unknown aetiology. Lymphadenopathy is common with non-tender nodes (typically cervical and submandibular. Pt may present with modest weight loss and low-grade fever. CXR shows bilateral hilar lymphadenopathy. Serum calcium and ACE levels may be raised. A transbronchial biopsy is esential for dx with presence of non-caseating granulomas. Skin manifestations incl. erythema nodosum (tender erythematous nodules) and lupus pernio = indurated plaques with discolouration.
2. Influenza
   
   • acute resp tract infection by infl.A or B. Symptoms: rhinorrhoea, cough, fever, chills, headache, myalgia. Recent upper resp tract infection has lead to associated viral conjunctivitis.
3. Malaria
   
   • Pts present with non-specific symptoms (fever, sweats, chills, myalgia, diarrhoea, headaches). Jaundice suggests falciparum infection which is always the cause in severe disease. Patterns of fever may occur at regular intervals of 48-72 h associated with p.vivax, p.ovale and p.malariae infections. Hepatosplenomegaly is a common isgn.Thrombocytopenia is common with falciparum infection and mild degree of anaemia. WCC can be high, low, normal.
4. Hodgkin’s lymphoma
   
   • Reed-sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkins is localised to a single group of nodes (usually cervical and/or suprclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present (low-grade fever, weight loss, night sweats). Pruritis in 10% of cases. 50% of cases is associated with EBV infection and distribution is bimodal. Classically pain in lymph nodes on alcohol consumption.
5. Pyelonephritis
   
   • Acute onset fever with chills, flank pain, vomiting and +ve urine dip all point to diagnosis of acute pyelonephritis. Urinalysis is highly sensitive but not specific. Pregnancy is a risk factor for complicted disease as the enlarging uterus compresses the reters and hormal changes increase the liklihood of obstructive uropathy. In uncomplicated pyelonephritis, common cause E coli and gram neg rods (proteus, klebsiella). Gram positive cocci implicated are enterococci and staphylococci.
6. Post immunisation
   
   • Vaccine SE tend to be uncommon, but may be muscle pain, headache, lump on site.

Question 12

For each pt, choose the single most likely Dx from the list below:

1. A 35 yo F complains of weight loss, tremors, palpitations, a large appetite and diarrhoea. OE: tachycardia >120bpm and exophthalmos. She appeared anxious.
2. A 50 yo F complains of weight loss, tremor of hands, palpitations, large appetite, diarrhoea and an irregular lump in the neck. The pt is tachycardic and eye examantion revealed no exopthalmos or lid lag,
3. A 24 yo W complains of weight loss, tremor of hands, palpitations and loss of appetite. OE: tachycardia and she appeared nervous. Ix revealed TSH 1.0 (range 0.3-4.5) and ESR within normal limits.
4. A 24 yo W complains of weight loss, tremor of hands, palpitations and pain in neck radiating to L ear and tiredness. OE: tender swelling in neck, tachycardia of 120bpm, and fever of 38C. TSH <0.05, ESR 60mm/hr.
5. An 18 yo F complains of a swelling in the neck. OE: the swelling is painless, non-tender. No weight loss, no tremors, no palpitations. Swelling moves up and down with protrusion and intrusion of tongue respectively. Ix revealed normal TSH and ESR.
6. A 50 yo M complains of a lump in neck on L side. OE: lump is painless, non-tender and moves on swallowing. Ix revealed normal TSH and ESR. Fine needle aspiration revealed ‘orphan annie’ eyes and psammoma bodies.

Options from: anxiety state, thyroglossal cyst, papillary thyroid carcinoma, pituitary failure, medullary thyroid carcinoma, viral thyroiditis, anaplastic carcinoma, toxic multinodular goitre, myxoedema, infected dermoid cyst, Grave’s disease, carotid body tumour

Answer 12

1. Grave’s disease
   
   • Hyperthyroid symptoms. Graves is most common cause in countries with adequate iodine intake. Peripheral manifestations (exopthalmos, pretibilal myxoedema, acropachy) are specific to Graves. Rx is radioactive iodine/surgery/anti-thyroid medication. Give b-blockers for symptom relief.
2. Toxic multinodular goitre
   
   • Hyperthyroid symptoms - irregular goitre rather than smooth goitre of graves. May be substernal extension. More common in older pts and is associated with head/neck irradiation and iodie deficiency. TSH is suppressed. A thyroid scan will show multiple hot and cold areas. Radioactive iodine is Rx.
3. Anxiety state
   
   • TSH is normal so no thryoid disorder despite pts sympotms. Weight loss can be part of anxiety disorder.
4. Viral thyroiditis
   
   • =de Quervain’s (viral) thyroiditis which is inflammation of thyroid characterised by a triphasic course where there is transient thyrotoxicosis -> hypothyroid phase -> euthyroidism. The thyrotoxic phase is characterised by pain and tenderness of thyroid which tends to be larger, firm and tender to tough. The woman also has fever and neck pain. This is a self-limiting condition and no specific Rx beede except NSAIDs/b-blockers for symptom control.
5. Thyroglossal cyst
   
   • Midline neck swelling moves up with tongue protrusionand swallowing making this a thyroglossal cyst. It is a cytst that forms from a remnant thyroglossal duct at can hence develop anywhere along the length of this embryological duct which is a midline structure between the foramen caecum at the back of the tongue and the thyroid gland.
6. Papillary thyroid carcinoma
   
   • TSH is normal and examination findings point to a carcinoma. If TSH were suppressed then it would suggest hyperthyroidism. As TSH normal, FNA is indicated and cytology may help determine cancer type. Histology cannot distinguish between follicular adenomas and carcinomas but is used for Dx of follicular carcinoma. There are 5 types of thyroid cancer: papillary (most common), follicular, medullary (about 1/4 are familial eg MEN), anaplastic and lymphoma. Orphan annie eyes and psammoma bodies are seen in papillary cancer.

Question 13

For each pt below, choose the single most appropriate investigation from the list.

1. A 20 yo M with generalised oedema. He has noticed ‘frothy’ urine recently. Liver function tests show plasma albumin of 15g/l.
2. A 60 yo W complaied of a painful swollen leg on arrival at Heathrow airport. OE her leg is tender with shiny skin. She is on the OCP.
3. A 45 yo publican developed bilateral limb oedema and noticed that his trousers were becoming tight. OE he had gynaecomastia and Duputyren’s contracture.
4. A 60 yo F with uncontrolled HTN, whose medication has recently been changed by GP, presents with bilateral ankle swelling. OE chest and cvs system normal.
5. A 70 yo W with swelling of R leg. Had recent weight loss and lower abdo discomfort. OE: pitting oedema of entire leg and possible R sided pelvic mass.
6. A 60 yo M who is a heavy smoker presents with a longstanding Hx of cough and breathlessnes. He has recently noticed increasing difficulty in walking due to leg swelling. OE: he is centrally cyanosedand has bilateral wheezes on chest auscultation.

Options from: 24h urinary protein, V/Q scan, polysomnography, echo, venous duplex scan, lymph node biopsy, creatinine clearance, drug history, blood flim examination, urea and electrolytes, pelvic ultrasound, FBCs, LFTs

Answer 13

1. 24hr urinary protein
   
   • this man has nephrotic syndrome (proteinuria >3g/24h, hypoalbuminaemia<30/L, oedema, hyperlipidaemia). Nephritic syndrome on the other hand is defined by AKI, HTN and active urinary sediment (RBCs and RBC casts). Most common cause of nephrotic syndrome - focal segmental glomerulosclerosis in young adults or membranous nephropayhy/diabetic nephropathy in older people. Patho: glomerular filtration barrier is damaged, so loose albumin. Liver compensates for protein loss by increasing albumin synthesis and increasing synthesis of LDL, VLDL, and lipoprotein A. Pt is hypercoagulable due to loss of coagulation inhibitors and increased clotting factors.
2. venous dupulex scan
   
   • = DVT. ocp and long-haul flights are risk factors. Wels core to determine likelihood. If not likely do D-dimer.
3. liver function tests
   
   • A sign of decompenation of hepatic cirrhosis which has caused peripheral oedema due to hypoalbuminaemia. Gynaecomastia is a sign of CLD as is Dupuytren’s of alcoholc LD. Cirrhosis is end-stage. Cause due to alcohol in this case. Cirrhosis results in hepatic insufficiencya nd portal HTN. Other complications incl. ascites variceal bleeds, jaundice, hepatic encephalopathy, hepatorenal dynfrome and development of HCC. Only curative Rx is transplant.
4. drug history
   
   • A new change in medication has led to peripheral oedema. normal examination rules out HF. Possible drugs: CCBs (dihydropyridines), agents that cause vasodilation (eg mioxidil), drugs that block renal prostaglandin synthesis eg NSAID, antidepressats, oestrogens, steroids.
5. pelvic ultrasound
   
   • Possible mass is likely malignant, and is likely a secondary lymphoedema due to malignancy with weight loss and abdominal discomfort. This is initially pitting. Stemmer’s sign may be useful = inability to pinch and lift a fold of skin at the base of the second toe.
6. echocardiogram
   
   • This is cor pulmonale in a pt with COPD. There is peripehral oedema and wheezes on chest exam. Cor pulmonale is R heart failure secondary in this case to longstanding COPD caused by chronic hypoxia and pulmonary vascular vasoconstriction secondary to this, giving pulmonary HTN and r-sided HF. Signs aside from lower extremity oedeoma incl. hepatomegaly, a loud P2 and engorged neck veins. 1st test = echo which will show elevated pulmoanry arterial pressure. Further tests may include spirometry and CT chest.

Question 14

Choose the most likely diagnosis from the list below.

1. A 30 yo F smoker has atrophic waxy yellowish palques on her shins with surrounding erythema.
2. A 35 yo F has tight shiny skin on her hands and around her mouth. There are also telangectasia on her face. She has had Raynaud’s phenomen for past 5 yrs and Hx of GORD.
3. A 30 yo M has a small group of slightly erythematous ring-shaped papules around his L ankle. Skin scrapings for fungal infection are negative.
4. An 18 yo with a Hx of diarrhoea has painful pustular lesions which are ulcerating.
5. A 28 yo W has indurated plaques of reddish-yellow thickened skin over both shins. She also has areas of depigmentation on her hands and face.
6. A 65 yo M with painful shoulders and hips has purpule swollen eyelids and red scaly papules over the knuckles.

Options: Diabetes mellitus, scleroderma, ulcerative colitis, hyperthyroidism, dermatomyositis, amyloidosis, reactive arthritis, rheumatoid arthritis, hypothyroidism, coeliac disease

Answer 14

1. Diabetes mellitus
   
   • This is necrobiosis lipodica which is a necrotising condition usually occuring in those with diabetes. Tends to appear on shins, often bilaterally. Often asymptomatic due to assocaited nephropathy but may be painful and ulcerate if injured. Tends to have appearance of an erythematous area of hardened and raised skin progressing to a yellowish tint. These lesions may display the Koebner phenomenon.
2. Scleroderma (or systemic sclerosis)
   
   • Initially presents with non-specific symp. eg tiredness, hand swelling, MSK symptoms and Raynauds. Cause iis unknown. There are 2 types: limited cutaneous type or diffuse cutaneous type. Limited tends to have less severe organ involvement and better prognosis. Telangiectasis is commonly found, most often on fingers, palms, face adn mucous memrbanes. Can be found on stomach = watermelon stomach. Characteristic findings: sclerodactyly, thickening of skin proximal to MCP joint, GORD, digital ulcers and lung involvement. Vascular components - Raynauds, ischaemic digital ulcers, HTN crisis, pulmonary arterial HTN. Fibrosis can affect lungs/heart/GIT.
3. Diabetes mellitus
   
   • Benign condition of unknown causes and is known as granuloma annulare. Pts are often women in their 30s. Typically asymptomatic and presents in this way as small grouped pink or flesh-coloured papules in a ring-like lesion. Most cases are self-limiting. DM is a weak RF, as is Hodgkins lymphoma, herpes zoster infection, and HIV.
4. Ulcerative colitis
   
   • This is pyoderma gangrenosusm which presents wih multiple lesions, most commonly affecting the lower extremity and is linked to UC (also seen in Crohns) and in RA. Diarrhoae here suggests UC. These lesions start as tender papules or vesicles which develop into painful ulcers with a dusky purple edge and surrounding induration and erythema. The base may contain granulation tissueand lesions heal with atrophic scars. This pt will need a colonscopy to investiagte for UC. Skin culuture may also reveal infection. Physical trauma such as debridement is CI as it can cause severe exacerbations.
5. Hyperthyroidism
   
   • =pretibial myxoedema and vitiligo in a woman with Graves disease. Peripheral manifestations incl opthalmopathy, pretibial myxoedema and hyperthyroid acropachy. Rx aims to normalise thyroid function and achieved by radioactive iodine, antithyroid medications or surgery. Give b-blockers for symptoms.
6. Dermatomyositis
   
   • =an idiopathic myopathy characterised by hallmark cutaneous lesions such as heliotrope rash and Gottron’s papules. Gottron’s papules are seen here and there is pathognemonic sign -> violet to dusty-red papules and plaques over the dorsal surface of the knuckles, wrists, elbows, knees and malleoli. The surface may be slightly scaling and telangiectasis may develop within the lesions. The periorbital violet rash is a symmetrical involvement is also a very chaacteristic sign and there may also be associated with periorbital oedema. Skin manifestations are treated with antipruritics and topical corticosteroids. Photoprotectin is advised for all pts - the rash often develops in sun exposed areas. UV radiation is a strong RF. Some pts only have cutaneous involvement whereas others may have associated lung disease, heart inolvement, oesophageal involvement of ulderlying malignancy.

Question 15

For each pt, choose the following diagnosis.

1. A 21 yo Jamaican gentleman was referred to A+E by his GP, who on investigation following a chest infection found an incidental finding of raised bilirbun of 120. His LFTs are win normal ranges. O/E he was found to be jaundced but he said he had ‘always been that way’.
2. A 55 yo mother of 2 reports feeling increasingly tired over the past few months. Investigations show an ALT of 497. PMH incl. T2DM and arthritis. Her only hospital admission was 15 yrs ago when her daughter was born and she had a major complication and needed several blood transfusions. After a few mroe tests the doctor prescribes peginterferon and ribavirin.
3. A 46 yo homosexual tattoo artist presented to his GP as he noticed worsening abdominal swelling and dark stool. OE you notice spider naevi on the upper chest and gynaecomastia. inital blood tests demonstrate negative HBsAg and HBeAg.
4. A 45 yo retired kitchen lady presents to A&E with abdominal discomfort which has been getting worse over past few weeks. She says she feels tired, bloated and has lost her appetite. Findings show antimitochrondrial antibodies are preset and serum AlkPhos is raised.
5. A 70 yo M retired semi-professional footballer presents with pain in the R hypochondrium which does not radiate. He has noticed 5kg weight loss in the past couple of months and says he has completely lost his appetite. He drinks an average of 1-2 units of alcohol per week and doesn’t smoke. OE: gross ascites and he has been pyrexial since admission.

Options from: Gilberts, primary biliary cirrhosis, hepatitis C, hepatocellular carcinoma, hepatorenal syndrome, hepatitis A, hepatitis B, hepatitis E, hepatitis D, portal HTN, gallstones, pyogenic abscess, alcoholic liver disease, GORD

Answer 15

1. Gilbert’s syndrome
   
   • often asymptomatic pt, with elevated unconjugated bilirubin and normal LFTs.
2. Hepatitis C
   
   • Most common route of HCV is illicit IVDU. Following acute exposure, 55-85% pts will develop chronic hep C. Most infections are asymptomatic. Triple therapy is common - Rx involves pegylated interferon and ribavirin to get rid of viraemia, alongside HCV protease inhibitor. This case = transfusion associated HCV which occured before donor screening introduced. Serum transaminases (esp ALT) will rise. This is not HBV as Rx is for HCV and HCV has a greater chance of establishing chronic infection. Howevere, there may be no differentiating signs/symp between hep b and c. HBV surface antigen would be +ve if HBV and HCV antibody -ve.
3. Hepatitis C
   
   • 2 RF: tattoos and MSM. Has classi signs of liver disease with ascites as sign of decompensation. HCV is NOT sexually transmitted - is transmitted by blood (likely due to traumatic anal intercourse). The HBV markers are negative here. Surface antigen appears 2-10 weeks after exposure adn is usually detectable after 4-6months with persistence indicating chronic infection. E antigen is a soluble viral protein found in serum in the early acute phase of infection and usually disappears soon after o at the peak in ALT. Persistance suggests chronicity.
4. 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 pts have antimitochrondrial antibodies. Elevated ALP suggests cholestasis.
5. Hepatocellular carcinoma
   
   • HCC usually arises in pts with cirrhosis, eg this pt, who has evidence of alcohol use and decompensation with ascites. The weight loss and site of pain are indicative. RUQ pain is due to hepatomegaly, inflammaiton and stretching of the liver capsule. The ascites is assoc. with cirrhosis.

Question 16

For each pt choose the most likely diagnosis:

1. A 47 yo presents with a sharp central chest pain, worse on lying down, with a 2 wk history of fever and malaise.
2. A 25 yo presents with chest pain, worse on inspiration adn associated with a productive cough.
3. A 54 yo with severe sudden onset pain mainly felt between the scapulae.
4. Progressive retrosternal pain in a 45 yo pt known to have a hiatus hernia.
5. A 26 yo professional basketball player presents with central chest pain and breathlessness, with the pain worse on inspiration.

Options from: pneumothorax, unstable angina, aortic dissection, pneumonia, asthma, pericardial effusion, pericarditis, GORD, fractured rib, stable angina, MI, emphysema, PE, peptic ulcer, ventricular fibrillation, pleural effusion

Answer 16

1. Pericarditis
   
   • symp incl sharp and severe chest pain retrosternally which is worse on inspiration/when supine, and is relieved by sitting forward. Classical finding OE - friction rub that sounds like ‘walking on snow’. There may be diffuse ST elevations on ECG, an effusion on echo and blood results suggesting inflammation. Complciations incl. tamponade and constrictive pericarditis. Prior viral infection is a RF, as is autoimmuen conditions, neoplasm from local tumour invasion, male, post-MI and uraemia.
2. Pneumonia
   
   • pleuritic chest pain and productive cough is classical of pneumonia. Do CXR and give abx. Use CURB-65 score.
3. Aortic dissection
   
   • Tearing chest pain. May be be intrascapular pain with dissection of descending aorta. Type A which involves ascending aorta or type B. Type A req. immediate surgery whereas type B can be managed medically if not complicated by end organ ischaemia. BP differential between 2 arms is a hallmark feature. A CT scan is indicated, looking for intimal flap.
4. GORD
   
   • GORD characteristed by heartburn and regurg of acid. More severe at night when pt is lying flat and also whenpt is bending over. RF - obesity and hiatus hernia. Dx is clinically or by diagnostic trial of PPI. Upper GI endoscopy is reserved for complications such as strictures or barretts.
5. Pneumothorax
   
   • =primary pneumothorax (without known lung condition). Main investigation - CXR and look at whether >2cm rim between lung margin and chest wall. If left, a small pneumothroax will resolve over time by reabsorption. If large, need to aspirate using iv cannula at 2nd ICS at mid clavicular line. Get CXR after procedure. If this fails insert chest drain.

Question 17

For each pt, which of the following nerves or area is affected?

1. A 22 yo M walks into A&E after being involved in a fight ina bar. As he left the bar he complained of drowsiness and double vision, worse when he walked down stairs.
2. Shortly after recovering from thyroid surgery, Mrs S complains of voice loss and a dry persistent cough
3. A pt is diagnosed with bulbar palsy. OE, his tongue is deviated to one side.
4. A 79 yo lady is brought to A&E after a fall. OE, when asked to close her eyes, her eyeballs rolled upwards and she was unable to close her eyes.
5. A middle ages lady brought into A&E after a RT was unable to discriminate between smells.Her nasal passages were found to be clear.

Options from: CN XI, CN VII, CN Vb, CN III, CN VI, optic tract, CN IV, CN X,CN IX, cerebellum, CN VIII, CN I , CN II, CN Va, CN XII, CN Vc

Answer 17

1. Cranial nerve IV
   
   • double vision indicates III, IV or VI. CN IV innervates superior oblique which control depression, intorsion and adduction. This is vertical diplopia (worse when walking down stairs) therefore is CN IV (trochlear). The trochlear nucleus is located in midbrain at level of inferior colliculus and fasciles decussate at medullary velum to exit at doral midbrain. The nerve enters the orbit through the superior orbital fissure.
2. Cranial nerve X
   
   • The vagus nerve contains both visceral efferents and efferents and has 3 main motor branches. It innervates muscles of larynx and pharynx (except stylopharnygeus and tensor veli palatini). Signs of CN damage incl palatal droop, deviation of uvular contralateral to lesion, absent gag reflex.
3. Cranial nerve XII
   
   • bulbar palsy gives progressive symptoms eg difficulaty swallowing/chewing/talking and muscle weakness. Tongue wasting, weakness and fasc. may also be seen. Tongue deviation suggests a CN XII lesion - deviate ipsilateral to lesion. May also be tongue weakness/fasciculation at rest/atrophy/inability to move rapidly. CN12 is purely motor in function, moving and altering the shape of the tongue by innervating the intrinsic and extrinsic tongue muscles.
4. Cranial nerve VII
   
   • Eye closure relies on orbicularis oculi which is innervated by facial nerve. Most common cause of peripheral facial palsy = Bells palsy. Ask pt to screw eyes and resist opening them to see deficit. Facial nerve is both motor and sensory and exits the cranium through stylomastoid foramen and enters parotid where it splits into 5 branches-temporal, zygomatic, buccal, madibular and cervical.
5. Cranial nerve I
   
   • This woman has dysnosmia (distortions of smell). Anosmia refers to complete loss of smell and hyposmia refers to partial loss of smell. The odorants are transported to bipolar cells located in the olfactory neuroepithelium and these cells synapse with olfactory bulb glomeruli. The paired olfactory bulbs are located at the base of the frontal love overlying the cribriform plate, and during trauma the connections at the cribriform plate can be broken.