Formative Questions Flashcards
A 76 year old woman has 2 day history of pain and swelling in her left leg. She has no history of a fall and noticed the swelling first thing in the morning. Examination reveals significant swelling all over her leg from her knee to her ankle. There is redness which extends into the thigh. Her temp is 38.1. She is able to weight bear on that leg but with difficulty. What is the most likely diagnosis?
Cellulitis - acute onset and swelling with a temperature
A 60 year old man has a 3 month history of night sweats and fever. He has a documented temperature of 38 and has lost 3kg in weight. Clinical examination reveals a soft systolic murmur in the aortic area. Which is the likely cause of his fever?
Infective endocarditis - combination of fever and murmur
A newborn baby has a routine blood spot newborn screening by heel prick. Which conditions are screened for?
Hypothyroidism Medium chain Acyl-CoA dehydrogenase deficiency Sickle cell disease Cystic fibrosis Phenylketonuria
A 12 year old boy has a 2 day history of abdominal pain associated with nausea and vomiting. On clinical examination he has tenderness with guarding in the right iliac fossa. His temperature is 37.8. What is the most likely diagnosis?
Acute appendicitis
An 80 year old man has a 6 hour history of confusion, acute generalised abdominal pain and fresh PR bleeding. He has a history of poorly controlled AF. On examination his HR is 130, RR is 23 and BP is 90/50. What is the most likely cause for his presentation?
Ischaemia of the bowel
AF - risk factor for embolic disease
A 72 year old man living in a nursing home has had recurrent diarrhoea for the last 3 weeks. Colonoscopy shows inflammation, ulceration and a yellow membrane like material covering the mucosal surface. What is the most likely cause of his diarrhoea?
Clostridium difficile infection - pseudo membranous colitis
An 18 year old man has a five year history of abdominal pain, bloating and diarrhoea up to 2-3 times a day. He has weight loss of 3kg over 9 months. He has a BMI of 17. He has an itchy rash on his elbows. What is the most likely diagnosis?
Coeliac disease - growth failure and GI symptoms
The rash is dermatitis herpetiformis and is associated with coeliac
A 62 year old woman presents to GP with headaches, tingling in her fingers and toes and general malaise. Full blood count: Hb 103, MCV 105. What is the likely diagnosis?
Pernicious anaemia - macrocytic anaemia
A 45 year old man has a 6 month history of change in bowel habit, bloating and pain relieved by defecation. His weight is stable and there is no rectal bleeding, abdominal mass or relevant family history. Full blood count shows Hb 143. What is the most likely diagnosis?
Irritable bowel syndrome - commonly presents in this age group. No red flags for other more serious conditions
A 58 year old man presents to his GP for review of the following blood results: fasting plasma glucose 5.9 and 6.1
Oral glucose tolerance test: 10.6
HbA1c 38
What is the most likely diagnosis?
Impaired glucose tolerance
Fasting less than 7
Glucose tolerance 7.8-11.1
A 70 year old man presents to ED with 24 hour history of severe generalised headache, fever and neck stiffness. LP shows protein 2.2, CSF glucose 0.8, gram staining negative diplococci, blood glucose 4. What is the likely causative organism?
Neisseria meningitidis
A 55 year old woman is admitted to hospital with SOB, chest pain and haemoptysis. CTPA shows a blockage in the right pulmonary artery. The scan has included the upper part of the abdomen where there is evidence of ascites. What is the most important underlying diagnosis that needs to be considered?
Malignancy
A 62 year old man after returning from Pakistan 3 months ago has night sweats with fever and a productive cough with occasional blood streaked sputum. He has lost 4kg weight despite having a normal appetite. Chest X-ray shows bilateral upper zone shadowing. Which diagnostic approach is most appropriate?
Obtain 3 sputum samples for acid fast bacilli smear microscopy and culture
If this fails then bronchoalveolar lavage can be performed
An 86 year old woman has a painful red eye and blurry vision for four days and a 3 day history of vomiting. What is the most likely diagnosis?
Acute glaucoma
A 65 year old man with a 40 pack year history of smoking is referred with a productive cough and thick green sputum which is unresponsive to treatment for a chest infection. He has a temperature of 38.4. What is the likely diagnosis?
Pneumonia
A 50 year old man has acute onset central crushing chest pain. His ECG shows ST elevation in leads II, III and avF. Which coronary artery is affected?
Inferior aspect of heart - right coronary artery in 70% patients
Which investigation is routinely performed at the first antenatal visit for pregnant women in the uk?
Midstream urine culture
A 25 year old man presents to his GP with earache and some hearing loss in both ears. He has a painful pressure feeling in the ear for 24 hours. He has no discharge from the ear and no fever. He is unable to pop his ears. What is the most likely appearance through the otoscope?
A mildly retracted eardrum with fluid behind the drum - Eustachian tube dysfunction
A 70 year old man attends GP with a 3 week history of difficulty hearing in the left ear. It has not been associated with any pain, vertigo or discharge but he does describe some mild tinnitus. On the Weber test he reports the sound is louder in the left ear while the Rinne test is negative on the left and positive on the right. What is the most likely cause of his hearing loss?
Impacted ear wax - condition more common with age
Conductive hearing loss
A 30 year old man attends A and E with a one day history of sharp central chest pain radiating to the back. He reports the pain as 8/10 and is worse when he takes a deep breath in and when lying down. It is eased by leaning forwards. On auscultation there is a scratchy sound in time with the heart at the left sternal border but heart and breath sounds are otherwise normal. An ECG is performed which shows diffuse st segment elevation. Troponin t is mildly elevated. What is the most likely diagnosis?
Pericarditis - pericardial rub present
A 35 year old man with a past history of well controlled UC presents with general fatigue. On examination he has yellowing of his sclera, skin excoriations and tenderness in the right upper quadrant. Liver function tests show bilirubin 74, ALP 378, ALT 75, albumin 28. What is the most likely diagnosis?
Primary sclerosing colangitis
LFTs show Cholestasis: ALP greater than ALT
An 86 year old woman with a history of ischaemic heart disease and Hypercholesterolaemia presents with central visual loss. She is diagnosed with macular degeneration related to old age. What is the most likely finding on fundoscopy?
Drusen: tiny yellow or white accumulations of extracellular material that build up between Bruchs membrane and the retinal pigment epithelium of the retina. Seen in dry MD
Choroidal neovascularisation seem in wet MD
In what disease process would you see cotton wool spots on fundoscopy?
Hypertension or diabetes: caused by damage to nerve fibres, accumulation of axoplasmic material
What are flame haemorrhages and when would you see them?
Lie within superficial nerve fibre layer, reflect ischaemic leakage from arterioles from veins under pressure
Feature of hypertensive retinopathy
What features would you expect to see in the pre-proliferative stage of diabetic retinopathy?
Microaneurysms Retinal haemorrhages Hard exudates Macular oedema Macular ischaemia
A 3 month old baby is brought to GP by his parents with a temperature of 38. What are the red lights on the traffic light scoring system?
Colour of skin: pale/mottled/ashen/blue
Activity: no response to social cues/appears ill to HCP/does not wake or if roused does not stay awake/weak high pitched or continuous cry
Respiratory: grunting/Tachypnoea over 60/moderate or severe chest indrawing
Circulation and hydration: reduced skin turgor
Other: age less than 3 months and temp over 38/ non blanching rash/ bulging fontanelle/ neck stiffness/ status epilepticus/ focal neurological signs/ focal seizures
A 35 year old woman presents with weight loss. She has an increase in appetite and some increased bowel frequency. Physical examination is normal. Which is the most appropriate investigation to arrange first?
Serum TSH
A previously healthy 70 year old man presents with a sudden onset of weakness in the right arm and leg. Reflexes are equivocal but the right plantar is up going. Which investigation is most important in deciding the next management step?
CT head
A 55 year old man with diabetes phones the duty GP with a new symptom of chest pain. On questioning it is central, radiates to the back and is making him feel sick. Is has been present for 45 mins and is worsening. What is the most appropriate advice to give?
Call 999 - this is likely an acute MI or an aortic dissection
A 4 year old boy has a four day history of swelling of his ankles, mild abdominal pain and lethargy. On examination the swelling is confirmed, his pulse is 90 and his BP is 138/92. A urine dipstick shows protein +++. What is a likely blood test finding? What causes this change?
High cholesterol
Nephrotic syndrome, probably minimal change nephropathy
Increase in LDL and VLDL due to increase lipoprotein synthesis
A 23 year old woman complains of persistent sneezing and runny nose which comes each year in May and June. What is the most likely mechanism for her symptoms?
Mast cell degranulation process
Type 1 IgE mediated response to seasonal pollen antigen
A 24 year old man presents to the GP with a two month history of difficulty seeing at night. He has no problem in the day. His mother has similar problems. What is the most likely diagnosis?
Retinitis pigmentosa
A 54 year old man presents to the GP with a 3 week history of an infected cut on his hand which is failing to heal. He works on a building site and is self employed. He says he keeps it bandaged during the day but the cut remains swollen and red. What routine blood test is most likely to give the reason for his problem?
Blood glucose level - pre diabetic or diabetic
A 23 year old woman presents to the GP complaining of an inability to conceive over the previous year. On examination she has acne, facial hair and her BMI is 24. Further questioning on which subject is most likely to support a diagnosis?
Menstrual history - irregular periods or amenhorrea which is in keeping with a a diagnosis of Polycystic ovarian syndrome
A 63 year old woman presents to the GP with a 3 week history of rectal bleeding. She complains that it is associated with intermittent constipation and diarrhoea. The blood has been mixed with the stools but also on the toilet paper. Examination reveals a right lower abdominal mass. What is the most likely diagnosis?
Colorectal malignancy
Which rating scale can be used to assess the severity of depression in GP?
PHQ9 - patient health questionnaire 9
A GP discusses cv risk with a newly diagnosed hypertensive patient. Which factors would increase the patients risk?
Smoking High LDL Diabetes Lack of exercise High BMI FH of heart disease Ethnicity
A 35 year old man with well controlled asthma presents to ENT clinic with 2 year history of progressively worsening bilateral nasal obstruction. He also has excessive mucoid nasal discharge and post nasal drip. He denies any bleeding from the nose. What is the most likely diagnosis?
Nasal polyposis - related to asthma, bilateral, increases in severity over years, common in middle aged patients, no red flag symptoms - epistaxis, pain, paresthesia
How would a deviated nasal septum present?
In young adults once the growth of the nose and septum is complete
Would not progressively increase and one side would be more obstructed than the other - breathing difficulty
Recurrent sinus infections, nosebleeds, facial pain, headache, post nasal drip, loud breathing/snoring would all be potential symptoms
What is choanal atresia?
Congenital disorder where back of nasal passage, choana is blocked usually by bony or soft tissue due to failed recanalisation of the nasal fossae during foetal development
Baby with difficulty breathing unless crying - acute breathing problems, cyanosis, feeding difficulty. May need resuscitation at delivery
What is churg-Strauss syndrome?
Eosinophilic vasculitis causing asthma and rhinitis
Paranasal sinusitis, pulmonary infiltrates, Mononeuritis multiplex or polyneuropathy
What is Wegeners granulomatosis?
Multi system autoimmune disease
Necrotising granulomatous inflammation and vasculitis in small and medium blood vessels
Presentation: recurrent respiratory infection, constitutional symptoms, ophthalmic problems, ENT problems, myalgia, renal disease, Mononeuritis multiplex, palpable purpura or skin ulcers
What is post nasal drip?
Excess mucus production, feeling of constantly having to clear throat, cough worse at night, sore throat, ear infections from blocked Eustachian tube
What causes post nasal drip?
Colds, flu, allergies, sinus infection, object stuck in nose, pregnancy, medications (OCP, BP meds), deviated septum, weather, certain foods, fumes/environmental irritants
A 23 year old primigravida undergoes a routine 38 week antenatal check. In addition to blood pressure, what two pieces of information are important to ascertain at this stage of the pregnancy?
Presence of proteinuria and fundal height
A 23 year old man presents to the emergency department having been involved in a RTA. On examination he has a fracture of the shaft of the right femur. He is also assessed to be in class 1 Hypovolaemic shock. What are the features of class 1 shock?
Raised diastolic BP - minimal clinical signs due to physiological compensation - peripheral vasoconstriction and increased peripheral vascular resistance
A 61 year old man presents to his GP with a four week history of a sore throat which has not responded to a course of penicillin and difflam gargles. He is hypertensive and has a BMI of 34. He has a 49 pack year history. He is on ramipril for his hypertension. On examination he and an enlarged left tonsil with central ulceration and a moderately enlarged left anterior cervical lymph node. Which is the next most appropriate step in management?
A 2 week wait referral to ENT - this is likely to be a carcinoma of the tonsil with lymph node involvement. He will need a block dissection
A 17 year old girl presents to the GP with a six month history of amenorrhoea. She had nexplanon inserted into her left arm two years ago. She says that she is fit and healthy as she does cross country running for her school. Her BMI is 17. What is the likely cause for her amenorrhoea?
Significantly low BMI
A 42 year old woman attends A and E with blood dripping from her nostril for the past 10 minutes. She is assessed by the triage nurse and is found to be otherwise well with normal pulse and BP. What is the appropriate course of action for the nurse at this stage?
Suggest the patient sits forward and pinches the nostrils shut
A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. What type of anaemia is present?
Iron deficiency anaemia
A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. What would their blood film show?
Microcytic hypochromic red cells
A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. List 3 further questions that this patient should be asked regarding her presenting complaint
Hx of aspirin/steroids/NSAIDs Menstrual period history Change in bowel habit Abdominal pain/bloating/coeliac Hx of inflammatory bowel disease FH of cancer in first degree relatives Past Hx of colonic polyps Swallowing difficulty Dyspepsia/acid reflux Hx of bleeding
List 3 clinical examination findings that may be present in iron deficiency anaemia
Pallor of the conjunctiva Palpable mass in the abdomen/on PR examination Tachycardia Koilonychia Angular stomatitis Ankle oedema Systolic murmur
A 52 year old has weight loss of 3.5kg over the last 6 months unrelated to diet and exercise. She continues to work but is becoming increasingly tired. FBC shows: Hb 75, haematocrit 0.26, MCH 24.8, MCV 55, serum ferritin 8. Excluding further blood tests, list 2 first line investigations to identify the underlying cause?
Flexible sigmoidoscopy/colonoscopy
Chest X-ray /CT chest abdo pelvis for metastasis
Upper GI endoscopy
A 62 year old man has chest pain which started two hours previously and woke him from sleep. It is central, radiating to his shoulders and he feels sick and dizzy. On examination he is pale, sweaty, apyrexial, his pulse is 115 and his blood pressure is 110/55 in both arms. What is the likely diagnosis?
Myocardial infarction/ACS/ angina
A 62 year old man has chest pain which started two hours previously and woke him from sleep. It is central, radiating to his shoulders and he feels sick and dizzy. On examination he is pale, sweaty, apyrexial, his pulse is 115 and his blood pressure is 110/55 in both arms. Other than gender and age, list 5 risk factors that should be asked about
Smoking Hx Diabetes Hypertension Past Hx of cv events Exercise levels FH of heart disease Ethnicity Rheumatoid arthritis Post code/SES Obesity/BMI
A 62 year old man has chest pain which started two hours previously and woke him from sleep. It is central, radiating to his shoulders and he feels sick and dizzy. On examination he is pale, sweaty, apyrexial, his pulse is 115 and his blood pressure is 110/55 in both arms. Excluding ECG what other immediate investigation would be most useful?
Troponin T or I
List 3 ECG changes that would be expected in a patient with an ACS
ST elevation ST depression T wave inversion Left bundle branch block Q waves
A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. Give 3 further questions which should be asked to aid a diagnosis?
Vomiting Bowel habits PR bleeding Family Hx Dietary Hx Travel Hx Medication Sexual/STI Hx Night sweats/fever Polyuria/polydypsia
A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. Examination reveals multiple mouth ulcers and red nodules over his shins. His abdomen is soft and non tender. What is the likely diagnosis?
Crohns disease
A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. On examination he has multiple mouth ulcers and red nodules over his shins. What name is given to the nodules of the legs?
Erythema nodosum
A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. He has multiple mouth ulcers and red nodules on his shins. List 3 investigations which should be considered in primary care
FBC U and Es ESR CRP LFTs Coeliac screen
A previously well 25 year old man visits his GP with a ten week Hx of generalised abdominal pain, associated with significant weight loss and diarrhoea. He also has generalised fatigue. He has multiple mouth ulcers and red nodules over his shins. List 2 investigations which should be considered in secondary care
Sigmoidoscopy/colonoscopy
CT/MR of the abdomen
Biopsy of the bowel lesion
A 56 year old non smoking, obese, known hypertensive woman has a 3 month Hx of increasing thirst and nocturia. She has a Hx of recurrent candidiasis. What is the most likely diagnosis?
Type 2 diabetes Mellitus
A 56 year old non smoking, obese, known hypertensive woman has a 3 month Hx of increasing thirst and nocturia. She has a Hx of recurrent candidiasis. List 4 different investigations that are appropriate in this patient
Urine dip Blood glucose: fasting or random HbA1c Fasting lipids U and Es
A 56 year old non smoking, obese, known hypertensive woman has a 3 month Hx of increasing thirst and nocturia. She has a Hx of recurrent candidiasis. What is initial non pharmacological management in this patient?
Diet modification
Exercise
List 4 long term potential complications that might develop in a patient with type 2 diabetes Mellitus
Neuropathy Nephropathy Retinopathy Cerebrovascular disease Ischaemic heart disease Peripheral vascular disease DVT Osteoarthritis Recurrent infections
A 67 year old man is admitted to A and E with one week of cough and SOB. He is alert and well oriented. Temperature is 38.7, pulse rate 90, blood pressure 102/60, resp rate 30, sats 92%. He has right sided chest pain on deep inspiration. He chest is expanding equally but over the right lower lobe the tactile fremitus is increased, percussion is dull and bronchial breathing is present on auscultation. What is the likely diagnosis?
Right lower lobe pneumonia
A 67 year old man is admitted to A and E with one week of cough and SOB. He is alert and well oriented. Temperature is 38.7, pulse rate 90, blood pressure 102/60, resp rate 30, sats 92%. He has right sided chest pain on deep inspiration. He chest is expanding equally but over the right lower lobe the tactile fremitus is increased, percussion is dull and bronchial breathing is present on auscultation. What is the expected finding on the chest X-ray?
Right lower lobe consolidation
List the 4 history and examination features that are used to assess the severity of pneumonia
Confusion
Respiratory rate
Blood pressure
Age
Which blood test is used to assess the severity of pneumonia?
Urea
CRP
A 67 year old man is admitted to A and E with one week of cough and SOB. He is alert and well oriented. Temperature is 38.7, pulse rate 90, blood pressure 102/60, resp rate 30, sats 92%. He has right sided chest pain on deep inspiration. He chest is expanding equally but over the right lower lobe the tactile fremitus is increased, percussion is dull and bronchial breathing is present on auscultation. Excluding death, list 3 complications which could develop in this patient
Pleural effusion Empyema Lung abscess Pneumothorax Sepsis Respiratory failure
An 8 week old infant is brought to go for a routine baby check. He was born by normal delivery at term following an uneventful pregnancy. The GP checks that the results of the heel prick test have been received. State 3 conditions which are tested for and for each state their genetic heritability
Maple syrup urine disease: AR
Glutaric aciduria type 1: AR
Homocystinuria: AR
Isovaleric acidaemia: AR
Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency: AR
Phenylketonuria: AR
Congenital hypothyroidism: can be AD, AR or spontaneous
Sickle cell disease: AR
Cystic fibrosis: AR
Medium chain Acyl-CoA dehydrogenase deficiency: AR
A GP commences a baby check with a physical examination of the eyes. What specific sign are they looking for?
Red reflex
State 2 conditions which can cause the red reflex to be absent in a baby
Retinoblastoma
Congenital cataract
In a baby check, the GP checks the baby’s hips for developmental hip dysplasia. State one observation and one clinical examination test which can be used to check for this condition
Symmetry of hips and legs/symmetry of skin folds
Ortolani/Barlow test
What are ortolani and Barlow tests?
Barlow: adducting hip while applying pressure on knee posteriorly, hip dysplasia - hip will dislocate
Ortolani: relocates dislocation. Flex hips and knees to 90 degrees, anterior pressure on greater trochanter and abducting leg. Positive sign - clunk as femoral head relocates anteriorly
List 2 factors which increase the risk of developmental dysplasia of the hip
Breech presentation Family Hx Female gender 1st born infant Oligohydramnios Developmental abnormalities: spina bifida/Down's Postnatal posture: swaddling
An 8 year old is brought in by her mother to the GP with a midline swelling in the neck. Which is it most likely to be: dental abscess, thyroglossal cyst, branchial cyst, cystic hygroma, lymphadenopathy from a viral infection?
Thyroglossal cyst
Where would you find a cystic hygroma?
Posterior triangle of the neck, congenital abnormality of lymphoid tissue
What is the specific indicator for the diagnosis of peripheral artery disease?
Abnormal ankle brachial pressure index
69 year old man has a 23 year history of HTN and kidney stones. He takes anti hypertensives and anti platelet drugs. Examination is normal. Investigation: Hb 120, creatinine 168. EGFR 37, urinalysis 2+ protein. What is the appropriate investigation in this patient?
Renal USS
Why should an abdo CT with contrast not be done on a patient with a GFR less than 60?
Contrast induced nephropathy risk
74 year old has a history of feeling faint and passing black and sticky motions. She has RA and has been taking an NSAID for pain relief. What is the most likely cause of her blood loss?
Gastric ulcer
An 18 year old man developed left sided anterior chest pain, breathlessness and a cough the previous evening. Pain is aggravated by breathing in. He is apyrexial. Breath sounds reduced over upper half of left side of chest. What is the most likely diagnosis?
Spontaneous pneumothorax
75 year old man admitted to hospital for knee surgery. Two days later his behaviour is bizarre. He is agitated and shouts at the sink by his bed. When questioned his is frightened and says he can hear someone whispering in the sink. What is the most likely diagnosis?
Delirium
