General Medicine Flashcards
Middle aged lady with HIV and a CD4+ T-cell count of 150 presents with fevers, chills,
rusty brown sputum and pleuritis chest pain. Given x-ray showing R lower-middle zone
consolidation. What is the cause?
A. pneumocystic jirovecii B. Mycobacterium tuberculosis. C. S. Pneumoniae. D. toxoplasma gondii. E. CMV/cryptococcus?
A. Pneumocystic jirovecii is the answer as it is a fungus, rare, except in immunosuppressed patients like HIV
Bacteria - strep pneumonia, haemophilus influenzae, legionella pneumophilia, Staph aureus
Virus - influenza
Fungi - pneumocystic jirovecii
Mycoplasma
Atypical pneumonia are chlamydia pneumoniae pneumoniae and mycoplasma pneumoniae
Patient presents with bilateral ankle arthritis and a red spots on her lower legs
(Erythema Nodosum). Which of the following test results is most likely?
A. anti-dsDNA
B. Bilateral lymphadenopathy on chest x-ray.
C. Swabs growing strep?
C - Strep infections are the most common cause of erythema nodosum.
Sarcoidosis patients suffering acute arthritis often also have bilateral Hilar lymphadenopathy and Erythema nodosum. These three associated syndromes often occur together in Löfgren syndrome.[66] The arthritis symptoms of Löfgren syndrome occur most frequently in the ankles, followed by the knees, wrists, elbows, and metacarpophalangeal joints.
http://emedicine.medscape.com/article/1081633-clinical#b1
Look up: erythema nodosum, sarcoidosis
Pneumothorax Management
Tension pneumothoraces occur when intrapleural air accumulates progressively in such a way as to exert positive pressure on mediastinal and intrathoracic structures. It is a life-threatening occurrence requiring rapid recognition and treatment is required if a cardiorespiratory arrest is to be avoided.
A tension pneumothorax must be diagnosed early and treated with urgency. Initial decompression with a needle or cannula in the 2nd intercostal space anteriorly will reduce the pressure 1.
A chest drain should be inserted to ensure that tension does not recur. Assessment should include attempts to determine the underlying cause. If treated early with appropriate drainage, prognosis is excellent.
Differential diagnosis from a pneumothorax
From radiopedia
Life in the fast lane has a good explanation
https://lifeinthefastlane.com/tension-pneumothorax-time-change-old-mantra/
Answer from a student: Pneumothorax management -Tension: Immediate needle aspiration, 2nd intercostal space, mid clavicular -O2 -Thoracostomy tube (chest tube)
Non-tension -Small (<15-20%, 2-3cm) Observation + O2 -Large Chest tube VATS with pleurodesis
A 55 yr old man has a 4-week history of double vision worse in the afternoon. On
presentation to his GP last week, he was found to have no significant findings on cranial
nerve examination. However, he is still experiencing the diplopia and finds that it is worse in
the afternoons.
What is the most important diagnostic finding expected on physical
examination?
A) Ptosis on sustained upward gaze
b) Proptosis
c) Internuclear opthalmoplegia
d) A fixed dilated pupil on the left
e) Lateral nystagmus on gaze to the left
A is correct. Myasthenia Gravis of the superior rectus or .
Ptosis is a drooping or falling of the upper eyelid. The drooping may be worse after being awake longer, when the individual’s muscles are tired. CN3 responsible for lifting eye lid.
Upward gaze controlled by inferior rectus.
Proptosis is a bulging of the eye anteriorly out of the orbit.
Internuclear ophthalmoplegia (INO) is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When an attempt is made to gaze contralaterally (relative to the affected eye), the affected eye adducts minimally, if at all. Additionally, the divergence of the eyes leads to horizontal diplopia. The disorder is caused by injury or dysfunction in the medial longitudinal fasciculus (MLF).
Look up: cranial nerves (in particular eye ones), extraoccular muscles, Myasthenia Gravis, eye terminology
A 54 year old man with a smoking history of 64 pack-years presents now with cough
and haemoptysis. Bronchoscopy reveals a mass in the right upper lobe and biopsy
shows a poorly differentiated squamous cell carcinoma. Chest CT reveals an
enlarged right hilar node. Apart from COPD, he is in good health and has a performance
status of 1.
What is the most important investigation to pick up occult metastasis, which will determine
whether he can undergo excision of the tumour with curative intent?
A) Tc bone scan
b) Liver US
c) Brain MRI
d) FDG PET scan
e) Full body CT
D) PET scan
Occult means the metastases are hidden or not easily seen.
Look up: scans to check metastases
A 65-year-old man undergoes anterior resection of the bowel for rectal cancer. He receives an epidural for analgesia. Four hours post-op, his blood pressure steadily falls to 70/50, and urine output is noted to have been 150 mL for the past 2 hours. It is noted that there is haemoserous fluid in his drain tube bag. The haemoglobin concentration taken by blood gas is 90 g/L (reference range 130-180).
What would be your next step in management of this patient?
A. Administer IV 10 mg frusemide B. Administer IV 500 mL normal saline C. Give 1 unit blood D. Give 1 unit 5% dextrose E. Turn off epidural
B.
Look up: fluid balance, post-operative hypotension mx,
Elderly lady presents from her nursing home with worsening of her normal dyspnoea on exertion, and is on multiple medications including an ACE inhibitor and frusemide. On examination she is tachycardic and has normal blood pressure. Her JVP is elevated and she has bilateral ankle oedema. On auscultation she has 2 heart sounds and a gallop rhythm.
There are fine inspiratory crackles bilaterally in the lower lobes.
What would you expect to see on her Chest Xray?
A. Bilateral hilar shadowing B. Reticulonodular opacities throughout C. Lower lobe diversion D. No visible changes E. Pleural effusion
https://radiopaedia.org/articles/heart-failure-basic
E. She has heart failure.
Chest x-ray findings for heart failure include pleural effusions, cardiomegaly (enlargement of the cardiac silhouette), Kerley B lines (horizontal lines in the periphery of the lower posterior lung fields), upper lobe pulmonary venous congestion and interstitial oedema.
Patient presents with a right upper limb and right lower limb loss of motor function (3/5) - pyramidal pattern of weakness, sensation and reflexes normal. Speech fine.
Where would the infract be?
A. MCA B. Left ACA C. Lacunar infarct D. left spinal infarct E. Right spinal infarct
B. Left ACA.
http://accessmedicine.mhmedical.com/data/books/waxm27/waxm27_c012f006.png
A 50 year old man presents to his GP with parotid swelling. On questioning, he has pain with chewing and gritty, dry eyes. He has a past medical history of hypertension, hypercholesterolemia. His medications include a statin and an ACE-inhibitor.
Results: ANA: 1:160 ANA speckled pattern, normal dsDNA, normal ACE level, anti-Ro
positive and anti-La positive.
What is this man’s diagnosis?
A. SLE
B. Sjogren syndrome
C. Sarcoidosis
B.
Sarcoidosis are lesions in the lung so not this.
Look up: sjogren’s syndrome, SLE, sarcoidsosis. Look up Ix.
A 72 year old woman presents with bloody nipple discharge. What is a likely cause of
this presentation?
a. Breast implants,
b. Fibroadenoma,
c. Duct ectasia,
d. Papiloma,
e. Retroareolar cyst
Is the discharge bilateral or unilateral? bilateral suggests a benign cause.
Unilateral bloody discharge is a concern.
Tripple assessment:
- Clinical assessment
- Imaging - ultrasound
- Histological
- Duct ectasia of the breast or mammary duct ectasia or plasma cell mastitis is a condition in which the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.
Not likely - Retroareolar cysts are a rare condition of the adolescent female breast and their reported incidence in the literature is scarce. Arising from obstruction of the terminal channels that drain Montgomery’s areolar tubercles retroareolar cysts comprise two different pathological entities; symptomatic and asymptomatic.
Not likely - Fibroadenomas are not cancerous. They range in size from smaller than a marble to as large as a golf ball. Most appear suddenly and stay the same size. Some shrink or continue to grow. They are affected by hormones and often change size over the menstrual cycle or in pregnancy.
Fibroadenomas are usually rubbery and firm, but they can be difficult to feel properly. If you push on the lump, you will probably find that it moves away from beneath your fingers. This is why some people call a fibroadenoma a ‘breast mouse’. Fibroadenomas do not move far within the breast.
Usually, fibroadenomas are not painful. However, they can be uncomfortable or very sensitive to touch. Often women find that their fibroadenoma gets tender in the days before their period. Pushing or prodding at the lump can also make it tender.
Researchers do not know what causes fibroadenomas. We do know that they are quite common, especially in women aged between 15 and 25. Up to one in six (15 per cent) of women have a fibroadenoma at some time in their life. Sometimes a fibroadenoma can be difficult to distinguish from cancer; therefore further testing may be required.
(from RMH website)
Fibroadenoma not likely
- Intraductal papillomas are benign (non-cancer) wart-like tumors that grow within the milk ducts of the breast.
They are made up of gland tissue along with fibrous tissue and blood vessels (called fibrovascular tissue).
Solitary papillomas or solitary intraductal papillomas are single tumors that often grow in the large milk ducts near the nipple. They are a common cause of clear or bloody nipple discharge, especially when it comes from only one breast. They may be felt as a small lump behind or next to the nipple. Sometimes they cause pain.
Papillomas may also be found in small ducts in areas of the breast farther from the nipple. In this case, there are often several growths (multiple papillomas). These are less likely to cause nipple discharge.
(From American cancer society)
Answer: Most likely papillomas
