Formative 2 Flashcards
In malaria species, which organism is likely to cause cerebral problems (i.e. drowsiness and confusion?
Plasmodium falciparum
A 72 year old woman has 6 months of increasing pain at the base of her right thumb. She is having difficulty opening jars and sewing. She is otherwise well. No other joints are painful. She is taking regular analgesia.
The first carpometacarpal joint is swollen and tender, with reduced opposition of the thumb.
Which is the most likely diagnosis?
A. De Quervain’s tenosynovitis
B. Gout
C. Osteoarthritis
D. Rheumatoid arthritis
E. Septic arthritis
Osteoarthritis
This is a classic description of osteoarthritis and a common site Gout and septic arthritis would have a much more acute history. Rheumatoid arthritis would affect multiple joints. The pain of de Quervains tenosynovitis would be felt over the radial aspect of the wrist. Rheumatoid arthritis usually affects multiple joints.
A 64 year old woman is due to undergo an arthroscopy of her knee. She has type 2 diabetes and takes metformin (500 mg twice daily) and gliclazide (80 mg each morning).
Her glycated haemoglobin is 54 mmol/mol (20–42). She is scheduled first on tomorrow morning’s day case list and is asked to fast from midnight tonight.
Which is the most appropriate plan for managing her diabetic medication?
A. Continue both drugs and start a variable-rate insulin infusion
B. No change to usual medication
C. Omit both drugs and start a variable-rate insulin infusion
D. Omit gliclazide and continue metformin
E. Omit metformin and continue gliclazide
Omit gliclazide and continue metformin
On guidelines: https://abcd.care/sites/default/files/site_uploads/CPOC_Diabetes_Surgery_Guideline_March_2021.pdf
A 65 year old woman with newly diagnosed advanced lung cancer has 1
day of breathlessness and 1 week of progressive headache.Her pulse rate is 88 bpm, respiratory rate 20 breaths per minute and oxygen saturation 95% breathing 4 L/min oxygen via nasal prongs. She has a swollen face and neck and distended veins on her chest. Her chest is clear. CT scan of chest shows mediastinal lymphadenopathy compressing the superior vena cava.
Which is the most appropriate initial treatment?
A. Intravenous alteplase
B. Intravenous dexamethasone
C. Intravenous heparin infusion
D. Intravenous mannitol
E. Insert endovenous stent
Intravenous dexamethasone
The patient has superior vena cava obstruction. The standard initial treatment is dexamethasone to reduce tumour swelling. There is no evidence of thrombus to justify systemic anticoagulation and systemic thrombolysis has no place. Intravenous mannitol is not used. It is worth noting that although dexamethasone is commonly recommended there is limited controlled data confirming its effectiveness. Insertion of endovenous stent would be considered if there was stridor, but would likely follow intubation and steroids.
A 52 year old woman has had three episodes of severe epigastric pain associated with vomiting over the past 3 months. The episodes occurred following eating and lasted for about 1 hour. She has type 2 diabetes mellitus and takes metformin.
Abdominal examination is normal. Her BMI is 35 kg/m2 (18–25).
Investigations:
ALT 15 IU/L (10–50)
ALP 71 IU/L (25–115)
Bilirubin 9 μmol/L (<17)
Ultrasound scan of abdomen: single 2 cm gallstone in gallbladder, common bile duct normal, evidence of fatty liver.
Which is the most appropriate management?
A. Endoscopic retrograde cholangiopancreatography
B. Laparoscopic cholecystectomy
C. MR cholangiopancreatography
D. Open cholecystectomy
E. Ursodeoxycholic acid
Laparoscopic cholecystectomy
The patient has symptomatic gallstone disease and laparoscopic cholecystectomy is indicated. Percutaneous cholecystostomy may be used in patients who are not fit for surgery. Ursodeoxycholic acid may be used for gallstone dissolution, but is not part of common UK practice.
A 55 year old man has 2 days of painful red swelling of his left lower leg. He has a history of type 2 diabetes mellitus and takes metformin.
His temperature is 37.6°C. He has a tender erythematous area extending from the ankle to the proximal calf.
What is the most likely causative organism?
A. Bacteroides species
B. Proteus mirabilis
C. Pseudomonas aeruginosa
D. Staphylococcus epidermidis
E. Streptococcus pyogenes
Streptococcus pyogenes
Streptococcus is the most common pathogen in leg cellulitis (including in patients with diabetes).
A 68 year old man has 3 days of worsening vomiting and abdominal pain. He has not passed any stool for 3 days. Six months ago he underwent a right hemicolectomy for Dukes’ A (T1, N0) bowel cancer.
He is dehydrated and his abdomen is distended. Which is the most likely diagnosis?
A. Adhesional small bowel obstruction
B. Anastomotic leak
C. Cholecystitis
D. Pancreatitis
E. Tumour recurrence
Adhesional small bowel obstruction
Adhesional bowel obstruction is most likely as he has had a hemicolectomy. Recurrence is less likely because this is Dukes A (early stage). Too late after surgery for anastamotic leak. Pancreatitis and cholecystitis are less likely because they don’t cause constipation
A 73 year old man collapses on the surgical ward 24 hours after having a sigmoid volvulus reduced by sigmoidoscopy.
He has no pulse and an ECG shows asystole. Chest compressions and ventilation are started. The cardiac arrest team are with the patient.
Which is the most appropriate next step in management?
A. Cardiac defibrillation
B. Intravenous 0.9% sodium chloride
C. Intravenous adrenaline/epinephrine
D. Intravenous atropine sulfate
E. Transcutaneous pacing
Intravenous adrenaline/epinephrine
Epinephrine the only recommended treatment for asystole. Atropine no longer recommended.
A 35 year old woman has 6 months of cyclical pain in both breasts. She has recently noticed a lump in the right breast. There is diffuse nodularity of the axillary tails of both breasts with a discrete 20 mm mass in the upper outer quadrant of the right breast. Fine needle aspiration is performed and 5 mL of brown fluid is removed, with disappearance of the mass. Cytology shows cellular debris with no malignant cells.
What is the most likely diagnosis?
A. Breast abscess
B. Breast carcinoma
C. Fat necrosis
D. Fibroadenoma
E. Fibrocystic disease
Fibrocystic disease
Fibrocystic disease characteristically causes pain associated with the menstrual cycle. The fine needle aspiration supports this with no malignant cells seen. A fibroadenoma is a solid lump. Pain if present would be localised with fat necrosis. Breast abscess would be a more acute history and again would not be expected to cause bilateral breast pain.
A 47 year old man with hypertension attends for annual review. He takes ramipril (10 mg once daily). His BP is 138/78 mmHg. Investigations:
Sodium 139 mmol/L (135–146)
Potassium 6.2 mmol/L (3.5–5.3)
Urea 5.0 mmol/L (2.5–7.8)
Creatinine 90 μmol/L (60-120)
Which is the most appropriate immediate action?
A. Add indapamide
B. Advise low potassium diet
C. Change ramipril to amlodipine
D. Reduce dose of ramipril
E. Repeat urea and electrolytes
Repeat urea and electrolytes
This is likely spurious - and needs repeat
A 26 year old woman sustains a head injury in a motorcycle accident. Her eyes are closed, but she opens them when asked to do. She is confused about what happened and about where she is, but attempts to talk about it. She is repeatedly attempting to remove the cannula from her right wrist.
What is the best estimate of her GCS score?
A. E1, V1, M1, total = 3
B. E2, V2, M3, total = 7
C. E3, V3, M3, total = 9
D. E3, V4, M5, total = 12
E. E4, V5, M5, total = 14
E3, V4, M5, total = 12
Opens eyes in response to voice = 3 Confused, disoriented = 4 Localizes painful stimuli = 5
A 79 year old woman has 3 months of a left leg venous ulcer that is slowly healing.
Ankle–brachial pressure Indices are 0.9 on the left side and 1.1 on the right side (0.8–1.2).
Which is the most appropriate management?
A. Compression stockings
B. Diagnostic biopsy
C. Full-length graduated compression bandaging
D. No further management required
E. Repeat ankle–brachial pressure indices in 3 months
Compression stockings
Despite gradual improvement this venous ulcer would be best managed with stockings, which would also help prevent further lesions
An 80 year old man presents to the Emergency Department with dizziness and melaena of recent onset. He has a metallic mitral valve and is taking aspirin and warfarin sodium. His pulse rate is 80 bpm and BP 122/70 mmHg.
Investigations:
Haemoglobin 105 g/L (130-175)
White cell count 7.0 × 10^9/L (3.8-10.0)
Platelets 676 × 10^9L (150-400)
INR 9.6 (1.0)
He is treated with intravenous vitamin K and is blood cross-matched. What is the most appropriate additional treatment?
A. Fresh frozen plasma
B. Pantoprazole
C. Protamine sulfate
D. Prothrombin complex concentrate
E. Tranexamic acid
Prothrombin complex concentrate
Prothrombin complex concentrate is used to reverse warfarin in medical emergencies. It is quicker to administer than FFP and can reverse anti-coagulation within minutes. FFP also carries the risk of allergic reactions, transfusion-related lung injury and volume overload. PCC is therefore considered first-line to reverse warfarin. The other drugs do not reverse warfarin.
A 54 year old woman has polyuria and the feeling that she needs to drink continuously. She drinks at least 1 litre of water before bedtime and gets up three to four times during the night to pass urine. She has another glass of water each time that she gets up.
Investigations:
Sodium 140 mmol/L (135–146)
Potassium 4.1 mmol/L (3.5–5.3)
Urea 4.5 mmol/L (2.5–7.8)
Creatinine 86 μmol/L (60–120)
Calcium 2.56 mmol/L (2.2–2.6)
Fasting glucose 4.8 mmol/L (3.0–6.0)
Serum osmolality 295 mOsmol/kg (285–295) Urinary osmolality 86 mOsmol/kg (100–1000)
After 8 hours of a water deprivation test, the serum osmolality is 308 mOsmol/kg and the urinary osmolality is 152 mOsmol/kg.
Following the administration of desmopressin, the serum osmolality is 286 mOsmol/kg and the urinary osmolality is 660 mOsmol/kg.
Which is the most appropriate next investigation?
A. CT scan of thorax, abdomen and pelvis
B. MR scan of pituitary
C. Oral glucose tolerance test
D. Technetium-99 Sestamibi parathyroid scan
E. Supervised fluid restriction and daily weights
MR scan of pituitary
The test results are consistent with cranial diabetes insipidus.
A 23 year old man has appendicitis is being prepared for theatre on the acute surgical ward. He has been vomiting intermittently all day, although he has not eaten for 24 hours. The anaesthetist advises using an airway device to protect the lungs from regurgitated stomach contents.
Which airway device is most appropriate?
A. Guedel (oral) airway
B. i-gel ® (supraglottic) airway
C. Laryngeal mask airway
D. Nasopharyngeal airway
E. Tracheal tube
Tracheal tube
i-gels are often used in cardiac arrest situations as they are easier to place than tracheal tubes. However, only the tracheal tube can seal the trachea off and protect against aspiration.
