Half way test Flashcards
Presentation of pulmonary TB
- weight loss
- haemoptysis
- fevers
- night sweats
In secondary tuberculosis the lung lesions are often cavitating, and bilateral.
What is secondary TB?
Seen mostly in adults as a reactivation of previous infection (or reinfection), particularly when health status declines.
Clinical presentation of bronchiectases
- chronic cough
- productive of copious foul-smelling sputum
- at risk of recurrent lower respiratory infections
A 32-year-old male intravenous drug user presents to the emergency department with 72 hours of fever and progressive fatigue. He has 5 splinter haemorrhages; on examination of his jugular venous pressure he has giant v waves, and auscultation of his heart reveals a new systolic murmur. Chest examination is normal. What organism is most likely to be the cause of his presentation?
Staphylococcus aureus
Fatigue, fevers and IV drug user
Also murmur and splinter haemorrhages
Endocarditis
When can coagulase negative staphylococci cause endocarditis?
Normally on a prosthetic heart valve
What type of endocarditis does Coxiella burnetii cause?
Culture negative
If you have anaphylaxis symptoms with no prior exposure what’s causing it?
Anaphylatoxin activity i.e. mast cell triggering through complement receptors
A few minutes after being given an intramuscular injection of an antibiotic a 24-year-old woman becomes agitated and complains of severe itching and dizziness. She starts to wheeze and her lips begin to swell. She had previously been given the same antibiotic with no obvious problems. What is the most likely mechanism underlying her symptoms and signs?
Her symptoms and signs and the timing of these are typical of anaphylaxis. Thus the mechanism is acute mast cell triggering and activation most likely to be due to specific IgE antibodies to the antibiotic
What’s the time course for an immune complex mediated reaction?
several hours
What’s the time course for a T cell mediated reaction?
a couple of days
A 14-year-old girl develops a red, itchy, scaly rash affecting both ear lobes. The rash began about 3 weeks after she started wearing new ear rings. She is otherwise in good health. What is the most likely diagnosis of the rash?
Allergic contact dermatitis
What’s the typical distribution of atopic allergic eczema?
In the creases of the elbows and/or knees
What’s the typical distribution of discoid lupus erythematosus?
Sun exposed areas of skin
Presentation of psoriasis
thickened, scaly (silvery) skin often affecting extensor surfaces
A 35-year-old beekeeper develops a red itchy rash, wheeze and faintness a few minutes after being stung by a bee. He had been stung previously with a similar reaction. What is most essential in his acute management?
Anaphylaxis -> Intramuscular epinephrine
Hydrocortisone will not be immediately effective and is used to prevent relapse of symptoms.
When is IV epinephrine used?
Not for anaphylaxis!
Intravenous epinephrine can be hazardous in inexperienced hands and is usually reserved for situations where the patient is being closely monitored e.g. in theatre or ITU.
Example of antihistamine
Chlorphenamine
A 20 year old woman has increasing urinary frequency and thirst over three months. She is admitted to hospital unconscious. Arterial blood gas analysis shows: pH 7.10 (7.35-7.45) pCO2 3.0 kPa (4.5-6.0) HCO3 10.5 mmol/L (24-30) What is the likely cause?
DKA
Metabolic acidosis
What would the ABG of Conn’s syndrome show?
(primary hyperaldosteronism)
metabolic alkalosis because of increased proton excretion in the distal renal tubule
When would you take an HbA1c measurement?
Long-term monitoring of glycaemic control
approximate average of glucose results over the last 2-3 months
When is the fasting blood glucose used?
To make an initial diagnosis of diabetes mellitus.
When is the urinary microalbumin is used?
to assess for early renal damage in diabetic nephropathy
When are urinary ketone levels assessed?
To diagnose diabetic ketoacidosis
although serum ketones are more reliable
What test would you use to exclude acromegaly?
Random serum insulin-like growth factor (IGF-1)
Serum IGF-1 is a relatively specific test for acromegaly, does not suffer from high within-individual variability, and does not require a dynamic suppression test.
A 68 year old man presents with a one-year history of progressive dyspnoea. On echocardiography the left ventricular wall seems to be severely hypertrophic. His chest radiograph reveals pulmonary oedema and a prominent left heart shadow.
What is the most likely underlying condition?
Hypertension
Emphysema, silicosis and pulmonary hypertension can cause which type of heart problem?
right ventricular hypertrophy and
cor pulmonale
What heart problem is associated with alcohol abuse?
Dilated cardiomyopathy
How is influenza diagnosed?
PCR of a throat swab
A 68-year-old woman has suffered from burning substernal pain for many years. This pain occurs after meals. She now has difficulty swallowing. Endoscopy reveals a lower oesophageal mass that nearly occludes the lumen of the oesophagus. Biopsy of the mass is most likely to reveal the presence of which neoplasm?
Adenocarcinoma
GORD -> Barrett’s oesophagus -> Adenocarcinoma
What’s Barrett’s oesophagus?
Long-standing gastrooesophageal
reflux is associated with the development of Barrett’s oesophagus. In this condition the normal squamous mucosal epithelium in the distal oesophagus is replaced by columnar epithelium which is thought to occur as a result of a process termed ‘metaplasia’. This metaplastic epithelium is thought to provide more resistance to damage caused by reflux of the acidic gastric contents into the lower oesophagus.
A 70-year-old man has alternating episodes of constipation and diarrhoea. He has occasionally noticed a small amount of blood in his stool. He is otherwise fit and well, does not have a temperature, abdominal pain or weight loss. Colonoscopy shows small openings in the mucosa which appear to extend into pouch like cavities. The intervening mucosa looks normal. What is the diagnosis?
Diverticular disease is charact
Where do diverticular often occur?
most common in the left side of the colon, particularly the sigmoid colon
A 65-year-old man presents with a three-month history of weight loss, increasing unilateral left-sided pleuritic chest pain and shortness of breath. A chest X-ray shows marked nodular thickening of the entire left pleural lining. There are pleural plaques on both sides and there is a small left pleural effusion. Which aspect of the history would you explore in order to identify the main cause?
Occupational history
- weight loss
- pleural symptoms (Pleural plaques and pleural effusions)
- worked in a ship yard
What’s the condition? Should you sign a death certificate?
Mesothelioma (asbestos exposure)
Sign nothing; refer to coroner!
An 89-year-old chronic smoker has chronic low oxygen levels. He uses oxygen therapy at home but symptoms progress and he dies of respiratory failure. What would be the expected lung pathology at autopsy, which would account for chronic hypoxia in this man? A. Centrilobular emphysema B. Chronic pleural effusions C. Mesothelioma of the pleura D. Panacinar emphysema E. Pulmonary fibrosis
Centrilobular emphysema
Clinical history implies COPD. Mostly caused by smoking.
There are several causes of emphysema, but it develops most commonly in association with cigarette smoking affecting predominantly the upper lobes of the lungs, with destruction of the walls of the respiratory bronchioles. This is also termed centrilobular emphysema.
Centrilobular emphysema associated with…
smoking
upper lobes of the lungs, with destruction of the walls of the respiratory bronchioles
Panacinar emphysema is associated with…
alpha-1 antitrypsin deficiency
predominantly affects the lower lobes, and is characterized by destruction of the airspaces distal to the terminal bronchiole, i.e. the respiratory bronchiole and the alveolus, hence the term ‘panacinar’.
Will the coroner ask the family permission to do the autopsy?
No!
The family cannot give or withhold consent for an autopsy when a death is referred to the coroner.
A 65-year-old man presented with a 6 week history of increasing jaundice on a background of 3 months weight loss and anaemia. On questioning he had no pain and no previous history of note. Albumin 32 g/L (35-50) Bilirubin 350 µmol/L (3-17) ALT 25 IU/L (10-45) ALP 570 IU/L (80-250) GGT 350 IU/L (15-40) What is the most likely diagnosis?
Painless jaundice + weightloss = Carcinoma of the head of the pancreas
Presentation of primary biliary cirrhosis (including suspected liver function tests)
- more common in women
- long history
- raised biliary enzyme elevation (ALP and GGT) but minimal bilirubin increase
A 49-year-old man experiences increasing swelling of his abdomen due to ascites. Liver biopsy demonstrates diffuse portal tract bridging fibrosis and nodular regeneration of liver cells. There is no hepatocyte necrosis and no cholestasis. Within the areas of fibrosis, bile duct proliferation and mononuclear cell inflammatory infiltrates can be seen. What is the diagnosis based on the histology?
Liver cirrhosis
Liver cirrhosis is characterised by…
Fibrosis of the liver parenchyma with nodular regeneration of the hepatocytes. It is considered to be an irreversible process.
A 50-year-old man collapsed after climbing out of his local swimming pool. He was taken to the local emergency department where he was found to be in a coma, with a blood pressure of 200/130 mm Hg. He had recently been complaining of intermittent episodes of sweating, tachycardia, palpitations and headaches.
What is the most likely underlying cause of his symptoms?
Phaeochromocytoma
Definition of malignant hypertension
Diastolic >120 mm Hg
Triad of symptoms of a hypertensive attack
- sweating
- tachycardia
- headache
Cell of origin of a phaeochromocytoma
adrenal chromaffin cells
Investigation for microcytic anaemia
Serum ferritin
High -> acute phase response
Low -> iron deficiency
What’s more likely to give a macrocytosis….Polycythaemia vera or alcohol?
Alcohol
Poor neutrophil granulation (reflected in their suboptimal function), and red cell morphological variation
What could it be?!`
Myelodysplasia
A 50-year-old man reports a six month history of increasing fatigue with worsening left upper quadrant pain. The blood film shows a range of mature and maturing myeloid cells, but no excess of blasts. Diagnosis?
CML
FLT3 mutation
AML
When is immunophenotyping of peripheral blood useful?
Good for subclassifying abnormal lymphoid populations and also for determining the lineage of blast cells - but it tends not to be useful in CML, where the excess population comprises granulocytes.
What are megaloblastic changes and when do they occur?
‘Megaloblastic changes’ describes a specific series of features in the marrow, characterized by a delay in nuclear maturation. These are seen in B12 deficiency, folate deficiency, and also in the context of some drugs.
Prognosis of hep A
The virus is self limiting in the vast majority of cases with fulminant (severe and sudden in onset) disease occurring rarely
Complication of CMV during pregnancy
Women can pass CMV to their baby during pregnancy. The virus in the woman’s blood can cross through the placenta and infect the baby. The infant may or may not be symptomatic at birth, presenting with rash, jaundice, hepatosplenomegaly or seizures. Even if asymptomatic the baby is a risk of long-term health problems such as hearing loss, visual impairment, learning difficulties and epilepsy. CMV infection is responsible for about 25% of childhood deafness.
Symptoms of congenital CMV infection
symptomatic at birth
rash, jaundice, hepatosplenomegaly or seizures
What’s the prophylactic treatment for an allogeneic bone marrow transplant for acute myeloid leukaemia?
aciclovir and fluconazole
Empiric treatment for neutropenic sepsis
IV piperacillin-tazobactam
A 32-year-old woman receives an allogeneic bone marrow transplant for acute myeloid leukaemia. She is started on prophylactic aciclovir and fluconazole according to the local protocol. In the second week post transplant, while she remains profoundly
neutropenic (white cell count 0.5 x109/mL, neutrophils 0.1 x109/mL), she develops fever and breathlessness. Empiric treatment is started with IV piperacillin-tazobactam but despite this her fever persists, she becomes more breathless, and chest x-ray and CT show worsening infiltrates in the left upper zone. There are no other symptoms or signs of focal infection and several sets of blood cultures are culture negative.
Treatment for what group of organisms should be considered?
Moulds
This is a common clinical scenario in transplant haematology. Neutropenia greatly increases the risk of invasive bacterial and fungal infections, and the risk of fungal infection increases with the severity and duration of neutropenia. Having failed to respond to appropriate broad spectrum antibiotic therapy the likelihood of fungal infection increases, and the clinical course and radiology would be in keeping with a mould infection - of which Aspergillus is the most common. Although the patient is receiving fluconazole as antifungal prophylaxis, this is not active against Aspergillus (for this reason many centres now use alternative antifungals such as voriconazole or posiconazole for prophylaxis).
What could be used to treat aspergillus?
voriconazole or posiconazole
What blood test might you do to test for aspergillus?
alpha-galactomannan (component of the cell wall)
What’s a high potassium associated with?
Acidosis (H+ excreted in exchange for K+)
Would cushings cause hypo or hyper kalemia?
Hypo.
Mineralocorticoid action produced from a cortisol excess results in Na+ reabsorption and K+ secretion.
What’s enuresis?
a repeated inability to control urination
When would you take a random plasma glucose measure?
When you suspect type I DM.
A venous plasma glucose is likely to be elevated above 11mmol/L so the diagnosis can be made immediately in conjunction with at least one clinical symptom
A 57-year-old smoker presents with a worsening dry cough and a 5-month history of weight loss. Chest X-ray reveals a left hilar mass and transbronchial biopsies show tumour characterised by irregular invasive islands of pleomorphic cells with a moderate amount of eosinophilic cytoplasm and intercellular bridges. There are focal keratin whorls. What is the most likely sequence of events at the tissue level leading to carcinogenesis in this case?
Squamous metaplasia, dysplasia, carcinoma
Lung cancer with intercellular bridges and keratin production is characteristic of? Most important risk factor?
Squamous cell carcinoma, smoking
A 36-year-old woman complains of episodes of burning pain in the epigastrium for the past two years. They are exacerbated by stress with temporary relief after eating. More recently, she has been waking up at night with severe pain, which got better after drinking milk.
What is the most likely diagnosis?
Peptic ulcer
