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.
A 65 year old man has sudden pain and redness in his ㅤright eye. He also has a headache and nausea. Visual acuity is 6/60 in the right eye. The eye is congested, with a hazy cornea and mid-dilated pupil.
Which is the most likely diagnosis?
A. Acute glaucoma
B. Conjunctivitis
C. Corneal ulcer
D. Scleritis
E. Uveitis
Acute glaucoma
All the symptoms and signs described can occur with acute glaucoma. Uveitis whilst causing red eye, headache and visual disturbance is associated with a small pupil. Scleritis, corneal ulcer and conjunctivitis are not generally associated with headache and nausea or a significant drop in visual acuity.
A 28 year old woman has a neck lump that she noticed incidentally when rubbing her neck. There is a smooth, non-tender 1.5 cm mobile lump within the thyroid gland.
Investigations:
TSH 2.3 mU/L (0.3–4.2)
Free T4 17 pmol/L (9–25)
Which is the most appropriate next investigation?
A. CT scan of neck
B. No further investigation needed
C. Thyroid antibodies
D. Thyroid scintigraphy
E. Ultrasound scan of neck
Ultrasound scan of neck
This is a non-functional thyroid nodule so needs ultrasound to classify - FNA may then be indicated
A 45 year old woman attends her GP surgery with symptoms of vaginal soreness, itching and discharge. She has had recurrent episodes of vaginal candidiasis over the past 4 months.
The labia minora are red and swollen. A diagnosis of vaginal candidiasis is made.
What is the most appropriate investigation at this stage?
A. Glycated haemoglobin
B. HIV test
C. Sexually transmitted infection screen
D. Test her partner for candidiasis
E. Vaginal pH testing
Glycated haemoglobin
Recurrent candidiasis indicates the need to test for diabetes mellitus
A 70 year old man has a brief episode of twitching that starts in his left hand and spreads up the arm over 2 minutes, then stops. His arm feels weak for an hour afterwards. He had an ischaemic stroke affecting his left side 6 months ago with good functional recovery. He has a history of type 2 diabetes mellitus and is taking clopidogrel, metformin, ramipril and simvastatin. He is anxious about a further stroke.
There is no weakness on neurological examination. Which is the most likely diagnosis?
A. Dissociative (non-epileptic) seizure
B. Focal seizure
C. Hypoglycaemic episode
D. Migraine
E. Transient ischaemic attack
Focal seizure
The description fits with partial seizure affecting his right hemisphere as a result of a previous stroke.
The association between maternal smoking during pregnancy and low birthweight can be studied by obtaining smoking histories from pregnant women at the time of first prenatal visit, then assessing birthweight at delivery and analysing the data according to the smoking histories.
Which is the best description of this type of study?
A. Case–control
B. Cross-sectional
C. Prospective cohort
D. Randomised clinical trial
E. Retrospective cohort
Prospective cohort
A 62 year old man has acute breathlessness with a weak cough, following a recent viral upper respiratory infection. Over the past 4 months, he has had double vision, limb weakness and slurred speech when tired. His respiratory rate is 18 breaths per minute and oxygen saturation 96% breathing air. He is sweating and using his accessory muscles of inspiration.
Which is the most appropriate test to monitor his respiratory function?
A. Arterial blood gas
B. FEV1
C. FVC
D. Peak expiratory flow rate
E. Ratio of FEV1 to FVC
FVC
Myasthenic crisis is an acute respiratory failure characterised by forced vital capacity (FVC) below 1 L, negative inspiratory force (NIF) of 20 cm H2O or less, and the need for ventilatory support. The use of accessory muscles indicates significant inspiratory weakness. Weak cough indicates weakness of expiratory muscles. Arterial blood gas analysis commonly shows hypercapnia before hypoxia. There should be a low threshold for endotracheal intubation due to rapid deterioration of bulbar and respiratory muscles.
A 62 year old man develops acute pain, redness, swelling and warmth of his right first metatarsophalangeal joint. He has a history of gout and hypertension. His medications are allopurinol, amlodipine and ramipril.
His eGFR is >60 mL/min/1.73 m2(>60).
Which is the most appropriate next step in his management?
A. Change allopurinol to febuxostat
B. Start naproxen
C. Stop allopurinol
D. Stop amlodipine
E. Stop ramipril
Start naproxen
The patient has acute gout. The immediate management would be to commence an NSAID.
A 27 year old man has left-sided chest pain of sudden onset that is worse on taking a deep breath.
His temperature is 36.8°C, pulse rate 126 bpm, BP 108/60 mmHg, respiratory rate 28 breaths per minute and oxygen saturation 94% breathing air.
Investigations:
ECG: sinus tachycardia
Which is the most appropriate next investigation?
A. Chest X-ray
B. CT pulmonary angiography
C. D dimers
D. Echocardiography
E. Ventilation/perfusion isotope lung scan
Chest X-ray
CXR to rule out other pathology before Well’s score and then CTPA (or V/Q) if PE likely or D-dimer if PE unlikely. (NICE CG144) Diagnostic investigations for pulmonary embolism 1.1.7 If a patient presents with signs or symptoms of pulmonary embolism (PE), carry out an assessment of their general medical history, a physical examination and a chest X ray to exclude other causes. [2012]
A 40 year old man has 4 days of left flank pain associated with fever, nausea and vomiting.
His temperature is 39.6°C, pulse rate 118 bpm and BP 90/40 mmHg. Imaging shows an obstructing proximal left ureteric stone with severe hydronephrosis.
He is treated with intravenous antibiotics and intravenous fluids.
Which is the most appropriate next step in management?
A. Lithotripsy
B. Nephrostomy
C. Retrograde pyelography
D. Ureteric stent
E. Urethral catheter
Nephrostomy
The renal pelvis should be decompressed with a nephrostomy. From EFA: “removes obstruction and allows drainage of pus. Will need to be brought back for surgery for removal”
Lithotripsy would exacerbate his sepsis
