handbook difficult Flashcards
_____________, with or without cardiac dilatation, is seen in conditions such as congestive heart failure (for example, due to ischaemic heart disease), right heart failure (for example, cor pulmonale), right ventricular myocardial infarction, volume overload (such as in renal failure), mitral stenosis, pericardial constriction and effusion
A raised JVP
A physiological state in which the JVP can be seen is ___________________
pregnancy, reflecting volume expansion
A raised and nonpulsatile JVP is a manifestation of __________________
superior vena cava obstruction
The _____________ is usually seen rather than felt
JVP
The pulsation is abolished by ________________ at the root of the neck with the transverse application of a finger across the medial sternomastoid
gentle compression
In the setting of ______________________, the JVP may even be palpable, and it requires more pressure to abolish the pulsation
severe tricuspid incompetence
The JVP normally has two characteristic peaks, an ___________ wave corresponding to atrial contraction and a smaller ___________ wave corresponding to right ventricular contraction
‘a’
‘v’
The carotid pulse may transmit a __________ wave but this wave is less easily identified at the bedside
‘c’
There are two descents that are described.________________. These are more difficult to appreciate than the peaks.
‘X’ and ‘y’.
The ________ wave is also increased in pulmonary hypertension (for example, secondary to mitral stenosis, or in primary pulmonary hypertension) and in the rarely seen tricuspid stenosis.
‘a’
The _________ wave is prominent in tricuspid regurgitation. Sometimes the _________ wave may extend up behind the ears and the top of the JVP may be missed
‘V
‘V
It is an important part of clinical examination to sit the patient up at ____________ to try to see the top of the JVP as part of routine examination when this is not defined at ________________
90 degrees
45 degrees
The JVP moves with respiration, falling on ________
inspiration
This is not seen in the presence of a significant pericardial effusion or constrictive pericarditis, the ‘Kussmaul sign’.
The JVP moves with respiration, falling on inspiration
The *x’ and ‘y descents are exaggerated in ___________ and ______________ respectively, The external jugular vein is often mistaken for the internal jugular vein
pulmonary hypertension and constrictive pericarditis
It is more readily seen as it is superficial and courses across the sternomastoid muscle
The external jugular vein
The ________ jugular vein can be held up at the root of the neck where the vein traverses the fascia to join the deeper vein
external
This is often mistaken for a raised JVP. A clue is that the vein may be no longer apparent after movement of the head.
The external jugular vein is often mistaken for the internal jugular vein
Buttock and thigh muscle ischaemic claudication pain on walking relieved by rest is due to obstruction of the _____________ artery by plaque or thrombus
common or external iliac
The typical symptom of occlusion of the superficial femoral artery is ______________ on walking and would not involve the buttock or thigh musculature
calf claudication
____________ muscle pain becomes progressively severe with increasing effort, and thus the onset may consistently relate to a given distance walked
ischaemic
______________ due to disc or facet joint encroachment usually affects the mid or lower lumbar spinal canal, and can cause nerve root impingement symptoms
Spinal canal stenosis
with pain aggravated by walking and requiring recumbency for relief
nerve root impingement symptoms
Pain distribution is related to ____________________ rather than to ischaemic muscle groups
lower lumbar dermatome segments
_____________________ laterally can also cause unilateral nerve root impingement symptoms which are not specifically related to walking
Focal L4/L5 disc prolapse
Prolapse at ___________ usually compresses the nerve root corresponding to the lower vertebra (L5 root), with severe pain then resulting from the low back down the back of the leg and extending to the inner toes
L4/L5
Feelings of numbness or paraesthesia in the associated dermatome are often associated, and described as ‘pins and needles’. ‘electric shocks’, or loss of feeling
Prolapse at L4/L5
Associated motor weakness of 15 myotome can affect the extensors of ankle and great toe causing foot drop
Prolapse at L4/L5
Pain is exacerbated by lifting strains, by coughing or sneezing, or by straining at stool
Prolapse at L4/L5
_________________ of the hip causes pain localised diffusely and deeply around the joint which is worse on prolonged standing or walking or with the effort of lifting
Osteoarthritis
Buttock and thigh muscle ischemic claudication pain on walking relieved by rest is due to obstruction of the common or external iliac artery by ____________
plaque or thrombus
The typical symptom of occlusion of the ___________________ artery is calf claudication on walking and would not involve the buttock or thigh musculature
superficial femoral
___________________ becomes progressively severe with increasing effort, and thus the onset may consistently relate to a given distance walked
Ischemic muscle pain
__________________ due to disc or facet joint encroachment usually affects the mid or lower lumbar spinal canal, and can cause nerve root impingement symptoms
Spinal canal stenosis
with pain aggravated by walking and requiring recumbency for relief
Spinal canal stenosis
Pain distribution is related to lower lumbar dermatome segments rather than to ischaemic muscle groups
Spinal canal stenosis
Focal L4/L5 disc prolapse laterally can also cause unilateral nerve root impingement symptoms which are not specifically related to walking
Spinal canal stenosis
Prolapse at L4/L5 usually compresses the nerve root corresponding to the lower vertebra (L5 root), with severe pain then resulting from the low back down the back of the leg and extending to the inner toes
Spinal canal stenosis
Feelings of numbness or paraesthesia in the associated dermatome are often associated, and described as ‘pins and needles’, ‘electric shocks’, or loss of feeling
Spinal canal stenosis
Associated motor weakness of L5 myotome can affect the extensors of ankle and great toe causing foot drop
Spinal canal stenosis
Pain is exacerbated by lifting strains, by coughing or sneezing, or by straining at stool
Spinal canal stenosis
____________________ causes pain localized diffusely and deeply around the joint
Osteoarthritis of the hip
which is worse on prolonged standing or walking or with the effort of lifting
Osteoarthritis of the hip
Patients presenting with abdominal pain have an important subgroup, ‘_________________________________’ in which the severity of pain and associated features of prostration and peritonitis mandate that consideration of treatment by urgent surgery is required soon after presentation
acute abdominal surgical emergency
In these patients surgery comprises an important differential diagnostic investigation, as well as being the best and most urgent form of therapy
‘acute abdominal surgical emergency’
the clinical picture is classical of leaking aortic aneurysm and _________________ should follow as soon as possible without procrastinating investigational delay
emergency surgery
The other differential diagnoses cover the range of acute intraperitoneal conditions (acute cholecystitis), retroperitoneal pathology (renal colic, retrocaecal appendicitis) and extra-abdominal causes of acute abdominal pain (vertebral collapse), but none is as likely as a leaking aneurysm with this scenario.
leaking aneurysm
Acute cholecystitis with _________________ may give generalised peritonitis and shock, but back pain would not be a feature
perforation
_________________________ may, if perforation ensues, cause generalised peritonitis, but more usually symptoms and signs are localised to the right lower abdomen, often with a phlegmonous mass which may be palpable
Acute retrocaecal appendicitis
____________________ causes acute and intense back and loin pain, but shock and abdominal rigidity are not features
Renal colic
Collapse of an _______________________ with back pain more often follows a strain or fall; shock and abdominal rigidity are absent
osteoporotic vertebral body
Another condition not given as an option, which is more likely to cause diagnostic difficulty under the above circumstances, is ________________________________
acute hemorrhagic pancreatitis acute pancreatic necrosis)
Such patients can present with severe epigastric or generalised abdominal pain radiating to the back, with signs of abdominal tenderness and muscle guarding without board-like rigidity, but with marked release tenderness, and with severe shock
acute hemorrhagic pancreatitis acute pancreatic necrosis
An associated history of gallstones or high alcohol intake may be helpful, and abdominal imaging by computed tomography (CT) is usually diagnostic
Abdominal Aortic Aneurysm (AAA) - Diagnosis and Treatment
Shocked patients must be under constant medical supervision and appropriately monitored during imaging
Abdominal Aortic Aneurysm (AAA) - Diagnosis and Treatment
The distinction is important, as early surgery is not usually recommended if pancreatitis can be diagnosed with certainty
Abdominal Aortic Aneurysm (AAA) - Diagnosis and Treatment
Others within the group acute abdominal surgical emergency’, and which require immediate surgery, are perforated peptic ulcer, acute intestinal obstruction with strangulation, perforated diverticulitis, perforated appendicitis and perforated cholecystitis.
Abdominal Aortic Aneurysm (AAA) - Diagnosis and Treatment
The most appropriate next step is the performance of a hysteroscopy and dilatation and curettage (D&C)
abnormal uterine bleeding
This would define the presence of an endometrial lesion and would facilitate histologic examination of any endometrium which is present
dilatation and curettage (D&C) abnormal uterine bleeding
Although endometrial thickness assessment is now used to determine which patients should have a D&C performed (such as postmenopausal women found to have an endometrial thickness in excess of 4mm), this assessment is more useful in younger
dilatation and curettage (D&C) abnormal uterine bleeding
postmenopausal women, and postmenopausal bleeding at the age of 70 years should be deemed due to a malignancy until proved otherwise
dilatation and curettage (D&C) abnormal uterine bleeding
Vaginal swab for culture or colposcopy would not be appropriate, and laparoscopy would not be required, unless the hysteroscopy and D&C were normal but the bleeding continued
dilatation and curettage (D&C) abnormal uterine bleeding
Although a malignancy is less likely if the endometrial thickness is less than 4mm, the risk is not excluded by such a finding
dilatation and curettage (D&C) abnormal uterine bleeding
This question requires knowledge of the epidemiology and natural history of human hydatid disease, which is due to infestation of humans as secondary host in the life cycle of the tapeworm parasite - _____________________________
Echinococcus granulosus
The primary host for this tiny worm, which is only the size of a grain of wheat, is the _____________, in whose ___________ the worm resides.
carnivorous dog
intestine
Half of the size of the worm is taken up by its last segment. full of eggs which are passed in the dog’s faeces and contaminate the soil and grass and the dog’s fur
human hydatid disease
In environments where dog (carnivore) and cattle or sheep (herbivore) are in close contact, the herbivore grazing on the grass ingests the eggs and becomes ___________________
a secondary host.
human hydatid disease
The eggs pass in the secondary host to the small intestine, are absorbed into the portal circulation and pass to the liver, where ____________
a hydatid cyst forms
The cyst progressively enlarges and ________________________ (an inner germinal layer forming scolices and ‘brood capsules’ and daughter cysts, and a chitinous membranous layer secreted by the germinal layer - together forming the endocyst: plus a reactionary layer from the host tissues - the ectocyst).
three components to its wall
Cysts in the _______________ host form first and most in the liver, and afterwards in the lungs then into the systemic circulation
secondary
If the cattle or sheep offal (lungs or liver) is _____________, the cycle completes itself with formation of fresh intestinal worms from the brood capsules or scolices from the ingested cysts
eaten by the dog
Human infection occurs by ________________, usually in childhood, from oral ingestion of eggs from the dog’s fur via children’s hands
the faecal-oral route
Humans then develop ___________________ as secondary hosts in the liver, lung and elsewhere, and human disease is seen in farming communities in countries such as Greece, Turkey, Argentina and Australia
hydatid cysts
In ____________________, the liver cysts and other components of infestation represent a dead end to the worm’s life cycle
hydatid infection in humans
_______________________ in primary and secondary hosts requires breaking the cycle at several points - deworming cattle dogs and sheep dogs regularly, avoiding feeding cattle or sheep offal to the dogs, and attention to faecal-oral hygiene in humans
Prevention of disease
By such means, incidence and prevalence of the disease has been very significantly reduced in developed countries such as Australia
hydatid cysts
New cases in humans are now more commonly seen in migrants from countries where the disease persists as a large reservoir of primary infestation
hydatid cysts
The worry of these parents is whether their child has normal hearing. Parents are usually the first to be suspicious of a hearing defect and are nearly always correct in their assumptions.
hearing defects in 15MO
Their concerns are never to be ignored. Maternal and child health hearing screen is exactly as it suggests - a screen-so that if there is any doubt about the infant’s hearing it is pointless to repeat the screening process.
hearing defects in 15MO
Formal audiological assessment is necessary (B is correct).
hearing defects in 15MO
At this age several words are usually discernible, so that no words at all would be unusual even allowing for his four weeks prematurity
hearing defects in 15MO
This presentation is not a normal variant of development. With any suspicion of a hearing deficit, it is essential for the diagnosis to be confirmed as early as possible to allow for assessment and therapy to commence
hearing defects in 15MO
The earlier this can occur, the better the outcome achieved. Hearing loss in many children is not detected until after development has been observed over a period of months rather than assessing hearing immediately
hearing defects in 15MO
This is not appropriate management. While dysmorphic features may indicate an associated congenital developmental problem or syndrome, they do not substitute for immediate audiological assessment, irrespective of whether such syndromes are associated with hearing deficit or not
hearing defects in 15MO
A ____________ in a nulliparous woman will almost always result in obstructed labour and need for delivery by Caesarean section (A is correct).
brow presentation
This is not the case in all multiparous women, in whom spontaneous flexion to a vertex presentation or extension to a face presentation can occur, or where vaginal manipulations may enable one of these presentations to be achieved after full cervical dilatation has occurred
brow presentation
A ______________________, as indicated by early fetal heart decelerations, is not indicative of either obstructive labour or the need for delivery by Caesarean section
mildly abnormal cardiotocograph (CTG)
brow presentation
Slow descent of the ____________ may well be overcome by subsequent good uterine contractions and lead to vaginal birth
fetal head
_________________ may be associated with prolonged labour, but is not, by itself, an indication for Caesarean section
Maternal fever
Caput and moulding reflect a ‘tight fit of the _____________ in the pelvis but do not preclude vaginal birth
fetal head
____________can be a troublesome problem and affects about 0.5% of the population
Hyperhidrosis
This uncontrollable sweating most often affects the axillae, palms and soles
Hyperhidrosis
Most cases are of unknown cause, but any management of the patient with __________________must consider possible underlying causes such as hyperthyroidism, phaeochromocytoma and various psychiatric disturbances
Hyperhidrosis
Mild cases of primary ____________can be treated medically with antiperspirants containing aluminium chloride
Hyperhidrosis
More severe cases can be treated with sympatholytics, anxiolytics and sedatives, but these regimens will often have unpleasant side effects (e.g. blurred vision, constipation and palpitations) when the drugs are taken in concentrations required to control symptoms
Hyperhidrosis
More recently botulinum toxin A injected into the stellate ganglion has been found to produce good symptomatic relief from excessive sweating in these patients
Hyperhidrosis
More recently botulinum toxin A injected into the stellate ganglion has been found to produce good symptomatic relief from excessive sweating in these patients
Hyperhidrosis
Preliminary percutaneous sympathetic blockage under imaging control can be used in an initial therapeutic trial
Hyperhidrosis
The stellate ganglion of the sympathetic chain lies anterior to the neck of the first rib medial to the T1 nerve root contribution to the brachial plexus
Hyperhidrosis
______________ is the pathway for sympathetic outflow to the arm and face from the lateral T1 spinal cord segment
The stellate ganglion
Hyperhidrosis
The dome of the pleura is immediately anterior to the ganglion. Surgical approaches include excision of the skin and associated sweat glands from the affected regions and endoscopic (thoracoscopic) sympathectomy
The stellate ganglion
Hyperhidrosis
The latter has now replaced the open approach, with reduced operative morbidity
The stellate ganglion
Hyperhidrosis
Endoscopic sympathectomy does have its risks and these include haemorrhage and pneumothorax
The stellate ganglion
Hyperhidrosis
With this patient’s clinical scenario; a tension pneumothorax due to injury to the pleura and underlying lung is more likely than a haemothorax
The stellate ganglion
Hyperhidrosis
Longer term side-effects include Horner syndrome and gustatory sweating
The stellate ganglion
Hyperhidrosis
Diaphragmatic paralysis from phrenic nerve injury is extremely unlikely, as is spinal shock.
The stellate ganglion blockage
Hyperhidrosis
An anaphylactic reaction to the injected agent is a possible diagnosis, but the clinical features are more suggestive of tension pneumothorax
The stellate ganglion blockage
Hyperhidrosis
In this patient, her tests indicate that sensorineural deafness is present in both ears giving air conduction > bone conduction (AC>BC) on both sides
degenerative presbycusis (perceptive deafness of older age - A is correct).
(Rinne test checking outer and middle ear function normal), with lateralisation of Weber test to the __________ left ear
better degenerative presbycusis (perceptive deafness of older age - A is correct).
Sensorineural (perceptive) deafness only in one ear evinces bilateral AC>BC, with Weber test lateralisation to the normal ear
degenerative presbycusis (perceptive deafness of older age - A is correct).
This patient is most likely to be suffering from _________________ (perceptive deafness of older age - A is correct).
degenerative presbycusis (perceptive deafness of older age - A is correct).
Other common and important causes of __________deafness are industrial deafness, Ménière disease, drug-induced ototoxicity and acoustic neuroma, which usually gives a unilateral perceptive deafness, not bilateral as is the case in this patient
sensorineural degenerative presbycusis (perceptive deafness of older age - A is correct).
Otosclerosis and external ear wax both give ____________deafness, which is not consistent with the findings
conductive degenerative presbycusis (perceptive deafness of older age - A is correct).
_______________ is a less common cause of sensorineural deafness, and can involve other cranial nerve nuclei to give findings consistent with a cerebellopontine angle lesion
Chronic petrositis degenerative presbycusis (perceptive deafness of older age - A is correct).
Annual ________vaccination is recommended by the National Health and Medica Research Council (NHMRC) for individuals over 65 years of age because of the greatly increased risk of death or complications in this age group
influenza
As a result all Australians aged 65 years and older are eligible to receive the free _________vaccine
Annual influenza vaccination
Free _____________________ vaccine is also recommended for indigenous people 50 years and over and 15-49-year-olds considered being at high risk of complications and death
influenza and pneumococcal
Annual influenza vaccination
The Royal Australian College of General Practitioners (RACGP) has identified other groups that would benefit from annual ______vaccination but vaccination is not provided free for these groups
Annual influenza vaccination
According to the RACGP website, these groups include the following. Adults and children (<6 months old) with chronic disorders of the pulmonary or circulatory systems
not free Annual influenza vaccination
includes children with congenital heart disease and cystic fibrosis
not free Annual influenza vaccination
Influenza vaccine is not routinely recommended for persons with _________, as there is insufficient randomised controlled trial evidence that annual immunisation is beneficial at the population level
asthma
Annual influenza vaccination
However, annual influenza immunisation is recommended for severe ______________, such as those requiring frequent hospitalisations.
asthmatics
Annual influenza vaccination
Adults and children (>6 months) with other chronic illness requiring regular medical follow up or hospitalisation in the preceding year
Annual influenza vaccination
This includes diabetes mellitus (and other chronic metabolic diseases), renal dysfunction, haemoglobinopathies, or immunosuppression (including immunosuppression caused by medication).
Annual influenza vaccination
Residents of nursing homes and other long-term care facilities
Annual influenza vaccination
Children and teenagers (6 months to 18 years) on long-term aspirin therapy, who therefore may be at risk of developing Reye syndrome after influenza
Annual influenza vaccination
Annual vaccination is recommended for health care providers, staff of nursing homes and long-term care facilities, providers of home care to persons at high risk (e.g. nurses, volunteer workers), and household members (including children <6 months old) of persons in increased-risk groups
Annual influenza vaccination
Persons infected with HIV who may develop serious illness and be at increased risk of complications if infected with influenza
Annual influenza vaccination
While patients with advanced HIV disease and low CD4 T-lymphocyte counts may not develop protective ton antibody titres, there is evidence that, for those with minimal symptoms and high CD4 T-lymphocyte counts, protective antibody titres are obtained after influenza vaccination
Annual influenza vaccination
For these reasons influenza vaccination is recommended for HIV-infected persons, but is not provided free of charge.
Annual influenza vaccination
Thus of the groups listed, only option B has free vaccination available.
Annual influenza vaccination
of the options listed, ___________________________, if it was able to be achieved, would have the greatest effect on reducing perinatal morbidity (PNM) and infant mortality.
prevention of premature delivery
Although _____still occur more frequently than neonatal and infant deaths, many of these _________are not preventable
stillbirths stillbirths prevention of premature delivery
Preventing ___________ at 20-26 weeks would result in a massive reduction in PNM
prevention of premature delivery
All of the other options, even if they were possible to introduce, would have a much lesser effect
prevention of premature delivery
Provision of neonatal intensive care unit (NICU) facilities in all hospitals, while laudable in intent, would require a huge and unachievable staffing increase
prevention of premature delivery
universal ________________________ in labour would be likely to increase the number of Caesarean sections being performed unnecessarily with only a minimal, if any, reduction in PNM
cardiotocographic (CTG) monitoring prevention of premature delivery
Improving maternal nutrition and universal breastfeeding would be much more appropriate in developing countries rather than Australia
prevention of premature delivery
with ___________________ in particular being likely to reduce infant mortality from gut and other infections.
breast feeding prevention of premature delivery
This child has a long history of persistent cough which is associated with poor weight gain over many months, suggesting a chronic respiratory condition, of which __________________ is the most common
cystic fibrosis
Hence measurement of sweat electrolytes is mandatory
cystic fibrosis
While the great majority of children with _____________ are detected by the neonatal screening program, a few each year may slip through the screening net for a variety of reasons
cystic fibrosis
These children will usually then present as this child has and the definitive test for ________________, sweat electrolytes estimation, must be performed
cystic fibrosis
A course of _______________and commencing physiotherapy may be appropriate adjunctive therapy, but electing these options does not address the reason why the child is chronically unwell and not thriving
antibiotics cystic fibrosis
Loose bowel motions would usually be present as well
cystic fibrosis
Similarly, while chronic asthma necessitating steroid use may present with similar chest signs, there are no other signs listed to support this, for example, barrel chest and Harrison sulci
cystic fibrosis
________________ would always need to be excluded before considering asthma and inhaled steroids in a child with this presentation.
cystic fibrosis
_______________ with positive antigliadin antibodies often presents with poor weight gain but not with respiratory symptomatology
Coeliac disease cystic fibrosis
_____________ is usually associated with persistent diarrhoea, irritability, muscle wasting and a distended abdomen
Coeliac disease
cystic fibrosis
The symptoms can usually be dated to the commencement of gluten in the child’s diet
Coeliac disease cystic fibrosis
Persistent cough of many months duration associated with poor weight gain and loose bowel motions should thus always flag cystic fibrosis irrespective of the neonatal screening program
cystic fibrosis
When _____________ are titrated progressively and appropriately to the needs of the individual patient, drowsiness, hypotension and respiratory depression are rarely a problem
opiates
Nausea associated with __________use usually settles after a few days and may be controlled effectively with an appropriate antiemetic such as ondansetron
opiate
Constipation, however, is often a persistent problem with regular ________ use, and patients should always be encouraged to use a regular daily dose of laxative
opiate
While tolerance may be one of the more frequently encountered problems associated with ______________administration for terminally ill patients, tolerance does not cause as much difficulty in management as constipation which, by contrast, is a near-inevitable problem unless anticipated and treated
opiate
_________ occurs commonly in children, with a quoted incidence of between 5% and 10%, and may have a variety of clinical presentations
Migraine
This scenario describes a history of classical __________with many of the typical features - nausea, vomiting, photophobia and relief by sleep
Migraine
family history of __________in a child whose neurological examination is entirely normal, strongly suggests the diagnosis of _________
Migraine
Prematurity, while having an association with secondary _____________in some infants, is unlikely to be a significant diagnostic feature in this child and _____________is likely to have been noted because of increasing head circumference
hydrocephalus Migraine
__________ meningitis is usually associated with headache in the acute phase of the illness over a period of days, not months
Viral Migraine
A ____________injury may be associated with persisting headache but usually follows immediately after the injury rather than five years later.
concussion Migraine
________________ can certainly be the cause of somatic symptoms, quite commonly headache, but the headache is usually of a different nature from that described in the scenario
Bullying at school
It is usually constricting in nature, often at the end of a school day and not present at weekends or holidays.
headache due to Bullying at school
The other associated features described in the scenario are usually absent
headache due to Bullying at school
A family history of migraine will usually be found in up to 90% of first-degree relatives on careful interrogation when a child is thought to have ____________
migraine
One should be wary, however, and of the child who has headaches that sound _______________ but with no family history, and this usually should prompt a careful re-evaluation of the clinical history.
migrainous
This 16-year-old girl has the clinical syndrome of persisting lower right-sided abdominal pain accompanied by shock and signs of right iliac fossa ____________
peritonitis
Several causes are possible. Her menstrual irregularity and current vaginal bleeding may be associated with a complication of pregnancy - intrauterine or more probably, ___________
ectopic peritonitis
A private sexual activity history from the patient may be helpful, but whatever her responses, an early ________________ should be performed, and if positive, would further focus the diagnosis
beta-hCG pregnancy test
peritonitis
Performing a vaginal pelvic examination or transvaginal ultrasound in a putatively virginal young (or older) woman is usually inappropriate, even if potentially helpful in diagnosis
peritonitis
A rectal examination, on the other hand, should certainly be done
peritonitis
Management plans must not be delayed in this patient by time-wasting investigations or additional irrelevant history
peritonitis
First priority in this shocked patient is to gain intravenous access and to begin. resuscitation with intravenous fluids - Haemaccel”, saline or Hartmann solution. An initial 500mL is run in rapidly (C is correct).
peritonitis
Blood should be taken at the same time for hemoglobin and leucocyte count, together with blood typing and readiness for cross-matching
peritonitis
A urine specimen should be obtained by urethral catheter if she is unable to provide a mid-stream urine sample immediately, and urinalysis performed, including a spot beta-hCG pregnancy test
peritonitis
Pulse, blood pressure and abdominal findings should be monitored by frequent observations while these measures are being carried out
peritonitis
By this stage the diagnosis may have become more clear (e.g. by a positive pregnancy test), in which case further questioning about sexual history would be gratuitous and unnecessary.
peritonitis
If her haemodynamic status and clinical condition have improved or stabilised with resuscitation, time is available for more diagnostic clarification by additional investigations
peritonitis
of which pelvic ultrasound done transabdominally (not transvaginally) is likely to be most helpful
peritonitis
By that stage a private discussion with the patient should be possible and should be pursued, particularly if the pregnancy test was negative
peritonitis
Definitive treatment is likely to require surgery, the urgency of which will depend upon her progress and, in particular, her haemodynamic status
peritonitis
If her condition does not stabilise or deteriorates while she is being resuscitated, urgent surgery must be arranged forthwith.
peritonitis
The patient is in severe pain, and initial treatment should include _____________ intravenously
opiate analgesia
peritonitis
Withholding analgesia because the diagnosis is not yet fully clarified is inappropriate, and judicious dosage will not adversely mask diagnostic clinical signs if initial conservative observation is decided upon
peritonitis
Laparoscopic abdominal surgery to deal with complications of pregnancy, other tubal or ovarian pathology, or laparoscopic appendicectomy for appendicitis, would be optimal
peritonitis
open surgery via an iliac fossa or a Pfannenstiel incision, may be the preferred procedure depending upon circumstances and surgical preference
peritonitis
When faced with a life event that is personally meaningful, emotions are stirred and humans then respond consciously, with coping strategies, and unconsciously. through _________________
defense mechanisms
Although Sigmund Freud first described ______________as the major defence mechanism of the ego, it was his daughter Anna who developed and refined the concept further in 1936
regression defense mechanisms
An American psychiatrist, George Vaillant. then classified the common ______according to their level of maturity, ranging from the psychotic defences of denial and projection, through the immature (for example, regression and splitting) and the neurotic (for example, displacement and reaction formation), to the mature (for example, humour and altruism)
defense mechanisms
At least a dozen ____________mechanisms have been defined
defense mechanisms
All of us have our own sets as mature adults, but children have a more limited repertoire
defense mechanisms
In this scenario, the boy is displaying _____________ unconsciously and reacts to his jealousy of his sister and his feelings of rejection by his parents by returning to an earlier stage of his development, in the hope that he will deflect his carer’s attention from his baby sister (B is correct).
regression defense mechanisms
_____________ is frequently seen in the hospital setting in patients of all ages and may be an adaptive response to the stress of illness, allowing a patient to passively cooperate with the nursing staff or relatives and accept care and treatment
Regression defense mechanisms
Once recovery begins, continued __________ is maladaptive and may interfere with treatment and rehabilitation
regression defense mechanisms
____________________ is the adoption of an attitude, interest or career which is the opposite or inverse of an individual’s beliefs, urges or impulses, for example, choosing medicine as a career solely to treat other people’s illnesses as a defense against one’s own death or illness anxieties
Reaction formation
In this scenario, the young boy’s behaviors are not examples of reaction formation
defense mechanisms
_______________ refers to the dramatic and sometimes aggressive behaviours that occur when an individual is under stress
Acting out defense mechanisms
It may include throwing tantrums, shouting and yelling, throwing or breaking things, or engaging in reckless behaviours such as promiscuity, bingeing or self-harm
Acting out defense mechanisms
_____________ may be the externalised consequence of regression in response to anxiety and irritability, but the boy’s behaviours here would not be considered lively or sensational enough to be termed ________________
Acting out defense mechanisms
________________ behaviours are most commonly encountered in young adults with cluster B personality traits and an imitable/hostile depression who feel thwarted or misunderstood or who have limits placed on their behaviour
Acting out defense mechanisms
_____________ refers to the social withdrawal, sulking, crying and brooding that may accompany the internalisation of anxiety in individuals with cluster C personality traits
Acting in defense mechanisms
___________is a normal human emotion, which is a mixture of envy, resentment, suspicion and possessiveness
Jealousy defense mechanisms
Undoubtedly the boy is ____________ of his newborn sister and resentful of the competition for the attention and affection of their parents, but this scenario is about behaviour and not affect
jealous defense mechanisms
__________________________, is a form of denial where individuals may respond to limits being recommended on their behaviour by taking on even more work, or responsibilities, or becoming more energetic and active
Compensation, or counter dependency defense mechanisms
The photograph shows a smooth- surfaced swelling in the midline of the upper part of the neck
thyroglossal duct cyst
It is rather too high for a thyroid lesion
thyroglossal duct cyst
Branchial cysts protrude from under the anterior border of the sternomastoid muscle and present as cystic lateral neck swellings
thyroglossal duct cyst
A ________________ would rarely produce an isolated colloid cystic swelling of the isthmus, and enlargement of one or both lobes
simple goiter
thyroglossal duct cyst
_____________ would usually also be present, although not usually so grossly presented as illustrated here.
Multinodular goitres
thyroglossal duct cyst
Other malignant nodules of the thyroid - such as papillary, follicular or medullary carcinoma - tend also to be found in one of the lobes, but can occur as central nodules of the isthmus
thyroglossal duct cyst
This swelling is, however, above the level of the thyroid isthmus, is in the line of the embryological thyroglossal tract, and is in the typical position of a _____________________
thyroglossal duct cyst
_____________ are congenital abnormalities affecting the thyroglossal tract.
thyroglossal duct cyst
with cystic lesions presenting along the line of the tract in the midline in the upper neck.
thyroglossal duct cyst
A thyroglossal cyst is usually attached posteriorly to the ____________.
hyoid bone thyroglossal duct cyst
_______________ rises on swallowing - hence the characteristic feature of a thyroglossal cyst moving on swallowing and also moving upwards when the tongue is protruded.
The hyoid
thyroglossal duct cyst
The most likely cause of this antepartum hemorrhage is a ___________________
placenta previa
Other possible diagnoses include a small totally revealed placental _____________- as this would explain the lack of uterine tenderness
abruption antepartum haemorrhage
tenseness and normal uterine size, A high mobile head at 33 weeks of gestation would not be against this diagnosis
antepartum haemorrhage placenta praevia
The haemorrhage is most unlikely to be coming from a _____________ , because a loss of 300mL under such circumstances would usually result in fetal distress or death-neither of which has occurred
vasa praevia antepartum haemorrhage placenta praevia
Bleeding of this magnitude from a cervical __________, as the first evidence of this problem, would be most unlikely
malignancy
In regard to immediate management, ___________ is contraindicated before the placental site has been confirmed and should not be performed where the gestation is only at 33 weeks, particularly following a primary episode of a small antepartum haemorrhage
induction of labour
__________________________ is clearly not required as the bleeding has stopped, the fetus is not distressed, and the gestation is only 33 weeks.
Immediate Caesarean section
______________________________ will be necessary at some time in the near future but would not be the next step in care
Papanicolaou (Pap) smear
Performance of an __________________ of the uterus is appropriate as this would define whether a placenta praevia is present, its grade, and also whether there is any evidence of intrauterine clot associated with placental abruption from a normally situated placenta
ultrasound examination
If a placenta praevia is defined by ultrasound, ___________________________ may form part of the subsequent care, if it is felt that vaginal delivery might be possible because the placenta praevia is grade 1 or grade 2 anterior in type.
pelvic examination under anaesthesia
pelvic examination at this stage is certainly not the next step in care, and is rarely used in current clinical care.
antepartum haemorrhage placenta praevia
The photograph shows a left-sided inguinoscrotal ________________ with dilated tortuous prominent veins affecting the testicular veins at the scrotal neck
varicocele
Palpation will give the impression of a soft compressible ‘bag of worms’
varicocele
_______________________ are common; predisposing factors possibly include absence of valves in the major draining testicular vein, leading to ambulatory testicular vein hypertension
Varicoceles
Ligation of the vein via a retroperitoneal approach in the iliac fossa ameliorates symptoms and signs successfully
Varicoceles
Varicoceles in older patients occasionally are harbingers of _______________ if the renal vein, into which the left testicular vein (usually) and the right testicular vein (rarely) drain, is occluded by tumour thrombus
renal cell carcinoma
Varicoceles
Epididymal cysts present as transilluminable cystic lumps of varying sizes above and behind the normal testis and attached to it
Epididymal
Varicoceles
Testicular tumors usually present as focal solid testicular lumps, with or without a secondary hydrocele
Varicoceles
_________________ present as transilluminable and fluctuant swellings surrounding the testis, and large and ____________________ obscure the underlying testis from examination
Vaginal scrotal hydroceles
tense hydroceles
____________________ of the cord presents as a cystic lump palpable within and moving with the spermatic cord above the scrotum
An encysted hydrocele
These lesions thus are more mobile laterally from side to side than up and down
An encysted hydrocele of the cord
Where the fetal movements are still not being felt 24 hours after a normal cardiotocograph (CTG), __________________ should be performed, especially if the pregnancy is at or near term and the cervix is favorable
induction of labour
The performance of an ____________ assessment should have been performed 24 hours earlier as, if it was low, induction would have been indicated at that time even though the CTG was normal
amniotic fluid volume
_________________ of the fetus may show it was small, but is not necessary at this time as delivery should be expedited anyway.
Ultrasound examination
Even the performance of _______________, with or without oxytocin challenge, is unnecessary, although CTG monitoring during induced labour would be mandatory
another CTG
Delivery immediately by _____________ is therefore not required, although, if the lack of fetal movements is due to fetal hypoxia, fetal distress may occur in labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.
Caesarean section
The clinical picture of malaise, pharyngitis, fever, a maculopapular rash. lymphadenopathy and splenomegaly accompanied by lymphocytosis is very suggestive of ________________
infectious mononucleosis
Infectious mononucleosis (glandular fever) is an acute infectious disease due to primary infection with ________________________
Epstein-Barr virus (EBV)
primary infection with __________________, occurring principally in teenagers and young adults
Epstein-Barr virus (EBV)
Infection is usually acquired by oral contact via a salivary exchange
infectious mononucleosis
Diagnosis can be confirmed by a positive ________________ test detecting heterophile antibody in the blood
Monospot or Paul-Bunnell
infectious mononucleosis
The test is positive in only 70% of subjects in the first week and repeat testing may therefore be required
Monospot or Paul-Bunnell test
infectious mononucleosis
The commonest blood film abnormality is lymphocytosis with >10% lymphocytes being atypical
infectious mononucleosis
Treatment is symptomatic, and a period of chronic fatigue and malaise may follow primary infection
infectious mononucleosis
None of the other options (streptococcal infection, measles, rubella or herpes simplex infection) is as likely as ______________________.
infectious mononucleosis
Chronic renal disease could certainly cause the hypertension and mild proteinuria, but would not usually produce the pain and tenderness unless it was complicated by ______________
severe pre-eclampsia
________________ does not usually produce pain
Biliary cholestasis
Pre-eclampsia, cholecystitis and fatty liver could all cause the pain and tenderness, but ____________would not normally cause the hypertension and proteinuria, nor would the very rare condition acute fatty liver of pregnancy
cholecystitis
Pre-eclampsia must always be considered in the presence of these symptoms and signs.The process is particularly severe in the presence of these symptoms and signs, as the pain and tenderness are due to ___________________.
liver capsule distension
Extrahepatic biliary obstruction occurs when a stone is either partially or completely occluding the _________________
common bile duct
_________is a breakdown product of haemoglobin and, in its initial unconjugated form, is insoluble in water and does not pass the glomerular filtrate
Bilirubin
Within the liver, bilirubin is ____________ with glucuronic acid and glycine to its water-soluble form, secreted into the bile and passed into the gut
conjugated
Within the intestine, bacterial action breaks down bilirubin to form _______________, converting to urobilin and giving colour to stools
urobilinogen
_______________is water-soluble and some is normally recycled and reabsorbed and excreted by the kidneys
Urobilinogen
If ______________________ is present, conjugated bilirubin will be absorbed back into the blood and will be excreted in the urine
extra-hepatic biliary obstruction
With ________________, no bilirubin enters the gut and thus no urobilinogen/urobilin is present in faeces which are clay- coloured; urobilinogen is also absent from the urine
complete obstruction
The findings, with an obstructed duct due to a ___________________, are thus conjugated hyperbilirubinaemia in the serum and bilirubin in the urine
bile duct stone
______________ will be absent from the urine with a completely obstructing stone, with progressively increasing jaundice and pale stools, and with dark urine (biliuria).
Urobilinogen
Jaundice accompanied by excess faecal and urinary urobilinogen and an absence of bile from the urine (acholuric jaundice), is characteristic of ___________________
excessive haemolysis
In this kind of jaundice there is a high ratio of unconjugated to conjugated bilirubin in the serum - the reverse occurs when there is ________________________
obstruction of the biliary tree
_________________jaundice is classically associated with pruritus, pale stools and dark frothy urine
Obstructive
High levels in the serum of conjugated bilirubin and transaminases are seen in _________________, as well as urinary leakage of recycled urobilinogen and of bilirubin associated with impaired liver function
hepatocellular jaundice
________________: Chronic Diarrhoea, Malabsorption > weight loss,Ataxia loss of balance are the neurological features of Coeliac disease.
Coeliac disease
____________________can arise at any point in the life cycle between childhood and old age.
Schizophrenia
Generally the age of onset is in late adolescence or in the early twenties
Schizophrenia
Historically, people presenting with schizophrenia for the first time in middle or old age have been diagnosed with ________________________
late onset schizophrenia
The arbitrary cut-off of age 40 or 45 has some clinical usefulness
Schizophrenia
There are many similarities in the symptoms of schizophrenia in the different age groups, but some studies have reported that people with _____________ schizophrenia are more likely to have features such as persecutory delusions, accusative or abusive auditory hallucinations
late onset
People with late onset schizophrenia are less likely to have evidence of thought disorder and less likely to have _______________
negative symptoms
When onset is _____________, thought disorder and negative symptoms are very rare and the presence of visual hallucinations is sometimes a feature
after age 60
Response to medication (atypical antipsychotics) can generally be expected at lower doses (a quarter to a third of that required for younger patients) in ______________
late onset schizophrenia
_____________remission may occur in younger people but is less likely in older age onset
Spontaneous
These include allergy, infection in other sites presenting as a primary eye lesion (e.g. example, periorbital cellulitis), local infection of the eye, or a systemic infection and more sinister complication of local infection, _____________
orbital cellulitis
age where neck Meningitis and allergy need to be excluded, but she is at an stiffness would be a prominent finding if ______________were present
meningitis
Usually ________is not associated with a significant fever and any swelling is usually bilateral
allergy
Steroids and antihistamines are not indicated. Her condition is unlikely to respond to topical chloramphenicol ointment
orbital cellulitis
This then leaves us to consider periorbital and orbital __________as the likely diagnoses; and to assess which is most likely.
cellulitis
Both warrant antibiotic use but only one orbital cellulitis warrants an urgent _____________, as orbital cellulitis often requires urgent surgical intervention.
computed tomography (CT)
____________ presents as an infective focus in the orbital fossa acting as a space-occupying mass leading to proptosis and ophthalmological paralysis
Orbital cellulitis
This is not present here and, indeed, the extraocular movements are full, supporting a diagnosis of _______________
Periorbital cellulitis
The most appropriate management on clinical grounds is to treat with intravenous flucloxacillin and ceftriaxone
Periorbital cellulitis
It could be argued that, in a child who has full immunisation against Haemophilus influenzae (Hib), a more ________spectrum antibiotic choice focused on staphylococcal disease is appropriate
narrow
orbital cellulitis
The eye itself is not affected and, although it may be injected, there is a full range of eye movements
periorbital cellulitis
This is an important finding differentiating it from orbital cellulitis, and usually can be quite adequately demonstrated despite the swelling of the eyelids
The eye itself is not affected and, although it may be injected, there is a full range of eye movements
It is important to treat ______________ vigorously as it may progress with serious consequences, such as orbital abscess, cavernous sinus thrombosis or subdural empyema
periorbital cellulitis
Children with this condition are usually quite unwell and toxic, which would not be the case in an allergic reaction or an insect bite
Periorbital cellulitis
recognizing an hot uncomplicated community-acquired lobar pneumonia, for which the most common cause in our community is _______________
Streptococcus pneumoniae
In Australia resistance to ____________by S. pneumoniae has become common (>14%).
penicillin
However ________________________ remains the antibiotic of choice le for uncomplicated lobar pneumonia, especially given the patient’s distressed clinical status and compromised oxygen saturation (A is correct).
benzylpenicillin intravenously
___________ with clavulanic acid (Augmentin®) is an inappropriate choice, given the severity of clinical presentation which mandates intravenous antibiotics
Oral amoxycillin
This antibiotic is very broad spectrum and consequently is associated with an increased rate of side- effects related to a change in the diversity of enteric flora and diarrhoea.
Oral amoxycillin with clavulinic acid (Augmentin®)
________________is usually reserved for a combined antibiotic regimen for the treatment of multilobar pneumonia, where the potential infecting organism may be Mycoplasma pneumoniae or Chlamydia pneumoniae.
Doxycycline
Flucloxacillin and gentamicin would cover ______________ but this treatment regimen is unnecessarily broad.
S. pneumoniae
The presence of __________ at the external urethral meatus must alert one to the likelihood of urethral or bladder injury - with displaced pelvic fractures and pubic symphysis diastasis, either extraperitoneal bladder injury or membranous urethra disruption is likely
blood
The essential investigation is an immediate ___________________ prior to any attempt at instrumentation or catheterisation (B is correct).
ascending urethrogram
If a urethral injury is noted, ______________________ must not be done or further injury may be induced.
urethral catheterisation
Intravenous urography and computed tomography (CT) of pelvis are no substitute for definitive ________________ via a small balloon catheter placed just within the external meatus.
ascending urethrography
Appropriate treatment of membranous urethral rupture is by combined _______________ management
urologic and orthopaedic
__________________management with suprapubic exploration, reduction by sounding from above and below combined with fracture stabilisation, and followed by proximal bladder drainage suprapubically with stenting of the urethra for several weeks after reduction
urologic and orthopaedic
If the __________is undamaged and an extraperitoneal bladder injury is suspected, the urethral catheter can be advanced into the bladder and a diagnostic cystogram performed with anteroposterior, lateral and oblique views to check for bladder injury
urethra
__________of the pelvis can help delineate accurately the extent of bony injury, and may show evidence of soft tissue extravasation of blood or urine, but direct ____________is needed for definitive diagnosis
CT
urethrography
The initial evidence that smoking caused cancer and heart disease came from ______________ studies, which are retrospective in design
case-control
____________studies, in which nonrandomised groups of people are studied for a period of time
cohort
Both study designs are suspect because the lack of _____________may introduce biases and ignore confounding variables
randomization
Nevertheless, the circumstantial evidence that ___________caused disease was overwhelming
smoking
____________ studies refers to a study of different populations
Cross-sectional
____________________ follows a population group over a prolonged period
Longitudinal case series
The situation changed with the results of a 20-year _________________controlled trial published in 1992
randomized
Because it was considered unethical to randomise ____________ to receive a ‘start smoking’ intervention
non-smokers
this study ______________1445 male smokers at high cardiorespiratory risk to receive a stop-smoking intervention, or not, and followed them prospectively
randomised
The intervention was simply individual advice about the relationship of ______________to health, followed by an average of four supportive office visits for interested subjects
smoking
The group receiving the intervention smoked fewer cigarettes, suffered fewer lung cancers and heart attacks and their collective survival improved, compared with the __________group
control
This study proved that ________________ advice saves lives
smoking cessation
This scenario is of an infant presenting with symptoms and signs of a neonatal _________obstruction
gut
The early onset (eight hours after birth) would also suggest a high gut obstruction (for example of _____________)
small bowel
The other significant feature is the possibility of ________________ which has, as well as the external manifestations, other systemic associations for example heart disease and duodenal atresia
Down syndrome
The astute clinician will recognise these associations and would be suspicious of _______________, which may show the classical double bubble sign on erect abdominal X-ray (C is correct).
duodenal atresia
________________________ offen presents later - two to three days - and has generalised gaseous distension, and is not associated with Down syndrome
Meconium plug syndrome
________________________ can present in the newborn period but more typically four to five days after birth, with progressive distension and vomiting with delayed passage of meconium
Hirschsprung disease
________________________ is usually only seen in sick premature infants on maximum support during the acute stage of their complicated illness
Necrotising enterocolitis
While __________may present in this way, the recognised signs of Down syndrome make this diagnosis less likely when compared to duodenal atresia.
volvulus
These features (elevated bile acids, conjugated bilirubin and alkaline phosphatase (ALP) levels) are those classically seen in a pregnant woman with _____________________, which occurs in about 3-4% of pregnant women in Australia (B is correct).
obstetric cholestasis
This diagnosis is confirmed by the performance of liver function testing and measurement of the bile acid levels
obstetric cholestasis
______________ (which usually is associated with severe vomiting in late pregnancy)
Acute fatty liver of pregnancy
____________ usually have much worse hepatocellular damage evident on liver function testing
hepatitis A
_________ would be expected to have associated hypertension and proteinuria (and associated disturbances of renal function, and often, thrombocytopenia), and jaundice due to cholelithiasis would be expected to be of the obstructive type, with pale stools due to a stone in the common bile duct.
Pre-eclampsia
The most appropriate first step in management of this pregnant woman, in contact with chickenpox in her husband and son, would be to assess whether she has ________________ evidence of previous varicella infection (her IgG level would be high if this was the case), as she would then be protected from chicken pox infection (E is correct).
serum antibody
If the IgG was negative such protection would not be present; and she should be given _________________
varicella immunoglobulin
the ___________ and her clinical status would need to be assessed in 3 weeks time to ensure infection has not occurred
IgM level
The use of ________ at this time as prophylaxis to prevent infection with chickenpox, before investigating her immune status, would not be appropriate, although _________could be given if maternal infection does occur.
aciclovir aciclovir
__________has not been shown to be teratogenic when used in clinical practice.
Aciclovir
___________ has not been used to any significant extent in pregnancy, and has not been cleared for use in pregnant women.
Famciclovir
This woman has a __________ and requires immediate antibiotic therapy as soon as swabs have been taken, then curettage some hours later to remove any remaining infected products of conception from the uterine cavity.
septic abortion
The antibiotics chosen would depend on the likely organism involved
septic abortion
Taking ________ for microscopic assessment and culture is therefore mandatory and is necessary to plan the further care
swabs
septic abortion
Immediate __________ would risk spreading the infection, but would be necessary, along with antibiotic therapy, if the cervical smear suggests Clostridium welchii infection, particularly if the organisms were encapsulated
curettage
If _______________ the curettage could be delayed for 12-24 hours unless the extent of the bleeding markedly increased
other organisms were involved
Although _____________would probably be given at the time of curettage, it is not necessary as initial treatment because the bleeding is not now heavy and has decreased.
ergometrine
The photograph shows a skin opening with granulation tissue at two o’clock from the anus. This is an _________________ and, from the clinical presentation, it is probably a low or subcutaneous fistula
anal fistula (fistula-in-ano)
These are the most common types of anal fistulae and, as the track runs below the anorectal ring, passage of _______________ through the fistula is unusual
faecal material
Most such fistulae develop secondary to ______________within the anal glands, with abscess formation and a track developing onto the perianal skin near the anus (D is correct)
infection
__________ is an important, but uncommon, cause of fistula-in-ano
Crohn disease
In such cases. the fistulae tend to be complex and often to have an internal opening above the levator mechanism, and accompanying bowel disturbance would be expected
fistula-in-ano due to Crohn disease
_________________ is not typically associated with fistula formation
Ulcerative colitis
neither the clinical presentation nor the photograph would fit for a __________________ haemorrhoid
thrombosed external
In such cases the patient would experience acute and severe pain
thrombosed external haemorrhoid
which usually resolves within a week, and the swelling is at the anal verge
thrombosed external haemorrhoid
______________, with accompanying hair inclusion and acquired infection, form in the midline natal cleft over the sacrum and in the adjacent buttock area
Pilonidal sinuses
The clinical scenario of transient recurring blurring of vision affecting a single eye ______________ in an elderly man is very suggestive of a vascular __________________ from small emboli originating from a plaque/stenosis in the common/ internal carotid vascular system
(amaurosis fugax)
transient ischaemic attack (TIA)
(TIA) from small emboli originating from a plaque/stenosis in the common/ internal carotid vascular system. The most appropriate next investigation is ________________________ (B is correct).
noninvasive carotid duplex Doppler studies
Ocular tonometry to check for _______________is appropriate but is not likely to be diagnostic.
glaucoma
Cerebral _____________ is usually negative with such reversible ischaemic events from small emboli
computed tomography (CT)
_________________ is the definitive test for temporal arteritis, and again the documentation provided does not support this diagnosis.
Temporal artery biopsy
‘_________________’ is not a distinct entity with a typical symptom cluster or time course, but it appears to be largely inherited with close links to bipolar affective disorder, particularly the manic type
Puerperal psychosis
__________________ usually begin abruptly, not in the first two days but within two weeks, and rapidly become florid
Postpartum psychoses
Just about any psychotic symptom can occur including delusions, hallucinations, passivity phenomena and catatonic features
Puerperal psychosis
Mania and depression or rapid cycling mood disorder may predominate, but stupor, confusion and perplexity can also occur
postpartum psychosis
Although it has an overall incidence of about 1 in 1000 pregnancies, in women with previous bipolar episodes unrelated to pregnancy it has an incidence rate of 20%.
postpartum psychosis
There is no relationship to single parenthood, twin pregnancies, stillbirth or breastfeeding, but it may be more common in primiparous women and can follow termination of pregnancy
postpartum psychosis
Infanticide or suicide are very rare consequences of _________________
postpartum psychosis
There is about a 20% chance of recurrence of __________________
psychosis postpartum
There is no specific treatment for postpartum psychosis. Older typical antipsychotics. such as haloperidol, have a greater incidence of ____________side effects in the mother
extrapyramidal
psychosis postpartum
Olanzapine or risperidone would nowadays be used together with lithium carbonate
postpartum psychosis
There have been no significant adverse effects reported from the use of atypical antipsychotics in ____________to date, but this may change
pregnancy
Although cessation of breast feeding is usually recommended, this may not be necessary unless _______________ has been prescribed because of isolated instances of adverse effects on breastfed infants
lithium carbonate
_______________treatment is highly effective in all forms of postpartum psychosis
Electroconvulsive
Untreated psychosis may last _______months or more.
six
By all means start another pregnancy and see how she feels about it.If she has misgivings, then have the pregnancy terminated.’
postpartum psychosis
As stated above, there is a significant risk of recurrence of postpartum psychosis in this woman, so to say that: ‘In view of her good outcome, there is a minimal risk of further recurrence’ is incorrect
postpartum psychosis
The routine use of _____________during pregnancy or lactation is not recommended, as there have been no long-term studies conducted of children who have been exposed to antipsychotics during gestation.
antipsychotics
postpartum psychosis
Therefore to say: ‘If she gets pregnant, then she should take prophylactic antipsychotics throughout the pregnancy’ is contrary to published guidelines and is incorrect
postpartum psychosis
Whether antipsychotics are prescribed at all for psychiatric illness in a pregnant woman depends on a risk-benefit analysis on a case-by-case basis, and hopefully with the fully informed and documented consent of both the mother and her partner
postpartum psychosis
If a mother becomes so unwell during the course of a pregnancy that she becomes incompetent to make treatment decisions, then application for temporary guardianship should be made, so that appropriate treatment can be maintained
postpartum psychosis
This patient has a ____________. miosis, partial ptosis and loss of hemifacial sweating make up the syndrome, and is the result of disruption of the sympathetic innervation of the eye.
Horner syndrome
____________ syndrome may be the result of a central or a peripheral problem
Horner
Most often the syndrome is secondary to an acquired underlying problem, but a small proportion may be congenital in origin
Horner syndrome
The sympathetic fibres that may be damaged and lead to a ____________ originate in the hypothalamus and exit from the spinal cord between C8 and T2
Horner syndrome
The preganglionic fibres synapse in cervical ganglia of the sympathetic trunk which, in the case of the superior cervical ganglion, then send postganglionic fibres up into the skull and face
Horner syndrome
The ___________________ is situated immediately above the carotid sinus and behind the internal carotid artery
superior cervical ganglion
Most of the fibres that lead to innervation of the head and neck originate from the T1 level and pass into the stellate (T1) ganglion
Horner syndrome
The stellate ganglion lies adjacent to the neck of the first rib. Damage to this ganglion, or any of the sympathetic fibres in the cervical sympathetic chain above the stellate ganglion, can lead to a ___________________
Horner syndrome
Of the responses given, the most likely cause of a Horner syndrome is an apical __________________
bronchogenic neoplasm
Other important conditions to consider include inflammatory and malignant processes affecting ___________________ (tuberculosis, sarcoid) and carotid artery dissection
cervical lymph nodes
Intracranial problems, such as cluster migraine headache and cerebral tumours in the middle cranial fossa, may produce a postganglionic _________________
Horner syndrome
A preganglionic brainstem ______________ affecting descending fibres may be caused by vascular strokes of the vertebrobasilar system or by brainstem tumours, but additional cranial nerve lesions are usually associated
Horner syndrome
iatrogenic trauma (sympathectomy for axillary or palmar hyperhidrosis) may be complicated by damage to the stellate ganglion causing a ______________
Horner syndrome
A tense vaginal hydrocele of recent onset in a young man, which obscures the underlying testis, should be considered due to ___________________ until proven otherwise.
an underlying testicular malignancy
The hydrocele should not be ___________, as scrotal needling runs the risk of spreading the tumour to another lymphatic field
aspirated
These aspects are of particular importance considering the ______________ of testicular tumours when appropriately treated by surgery and chemoradiotherapy.
good prognosis
The first step should be to arrange _____________________ to assess the underlying testis (B is correct).
noninvasive scrotal ultrasound
Estimation of serum levels of tumour markers (Beta-hCG and alpha-fetoprotein), and abdominal and chest computed tomography (CT) would follow if the ultrasound suggested a _____________________.
testicular malignancy
Intravenous urography alone has been superseded by helical CT, often without intravenous contrast.
testicular malignancy
This scenario is one of _______________ in the right knee.The key features of gout are his predisposition as a result of age, alcohol intake, and thiazide and beta blocker treatment
acute monoarticular gout
the clinical presentation of very painful knee and effusion, with the diagnostic findings of birefringent crystals on microscopy
acute monoarticular gout
The correct answer is ______________(C is correct), giving 50mg t.d.s. and adjusting the dose according to the response, which should be very rapid improvement over 48-72 hours
indomethacin
with early reduction in the pain - a rewarding feature, given the characteristic severe nature of pain in _________
acute gout
It is imperative to exclude relative _________________to indomethacin, such as peptic ulceration, gastritis and/ or gastroesophageal reflux that has not been treated effectively.
contraindications
An important consideration is the renal and cardiac function; in patients with significant renal failure (serum creatinine > 200mmol/L)and/or congestive cardiac failure, it is best to avoid _________________
nonsteroidal anti-inflammatory drugs. indomethacin GOUT
The scenario discloses that renal function is normal and there is nothing to suggest cardiac failure
indomethacin
______________ is contraindicated in the setting of acute gout, and is not introduced into the treatment regimen of chronic recurrent gout until > 4 weeks after resolution of an acute attack.
Allopurinol
In this patient, with a first attack of gout, the correct early management would be to advise significant reduction in ____________ intake, and cease hydrochlorothiazide and metoprolol
alcohol
It is also important to also ask the patient about any past episodes of renal colic or renal calculi, and to determine if the patient shows any evidence of _____________ gout, as these would be very strong indicators for future allopurinol therapy
tophaceous
Importantly, when introducing ______________, the starting dose must be low (50-100mg) and the dose adjusted slowly
allopurinol
____________is a suitable alternative for acute gout, but is less effective and more difficult to get the dose right without adding to the patient’s woes with onset of diarrhoea, a dose-dependent phenomenon
Colchicine
The use of prednisolone (50mg daily for five days) is a good alternative for indomethacin and is generally reserved for patients with contraindications to indomethacin therapy or where there is an inadequate response to, or complication of, this therapy.
prednisolone
____________ 1g q.i.d. is a good analgesic but has minimal anti-inflammatory effects and would not be appropriate in acute inflammatory gout
Paracetamol
The incidence of _____________ abscess formation after appendicectomy for perforated appendicitis may be as high as 15%, even if the patient is treated with broad-spectrum antibiotics from the time of presentation
intra-abdominal
By definition, this patient already had established ____________ infection on presentation, and the development of a pelvic abscess would come as no surprise
intra-abdominal
Symptoms of spiking fever and persisting mucous diarrhoea are classical
pelvic abscess
An important complication associated with the use of broad-spectrum antibiotics is the development of _____________ once the normal gut flora is disturbed
super-infection
One such super-infection is due to Clostridium difficile, which can be associated with a ____________
colitis
The patient develops a profuse diarrhoea and in such circumstances it is mandatory to send a stool sample to look for _______________
Cl. difficile toxin.
_____________-associated colitis and Cl. difficile colitis are virtually the same condition
Antibiotic
Severe infection with this organism may lead to a ______________colitis, a descriptive term for a variant forming a surface membrane
pseudomembranous
Super-infection and antibiotic-associated colitis could certainly be the diagnosis in this patient; but confirming or excluding the most likely diagnosis of ______________ by rectal examination and abdominopelvic computed tomography (CT) imaging is the most important next step in her management
pelvic abscess
_________________enteritis is usually the result of eating contaminated foodstuffs (food poisoning) and may be due to the toxins rather than the bacteria themselves.
Staphylococcal
The patients may be prostrated with fever, nausea, vomiting and diarrhoea
Staphylococcal enteritis
Resolution of a ___________________ is often accompanied by the temporary passage of foul-smelling and offensive loose stool-patients should be warned that this is a normal physiological event in the absence of other symptoms.
paralytic ileus
Of the many risk factors for ischaemic stroke, ______________ confers the highest risk
hypertension
_____________contributes to stroke in approximately 70% of cases
Hypertension
The risk for ____________ increases by 10 to 12-fold for patients whose diastolic blood pressures average 105mmHg when compared to an average diastolic pressure of 75mmHg.
stroke
When a patient’s blood pressure is lowered, the risk of a __________is decreased.
stroke
Non-insulin-dependent (Type 2) diabetes confers a relative risk of _____________.
1.8-3.0
__________is associated with a relative risk of about 1.5
Smoking
_________increases the risk factor by 1.5-2.0
Obesity
_______________appears to affect the risk of having a stroke in a complex fashion, by demonstrating a U-shaped risk curve
Hypercholesterolaemia
This might reflect differential effects on haemorrhagic and ischaemic stroke.
Hypercholesterolaemia
_______________is characterised by multiple well-demarcated red plaques with silver scaling, and the rash can be generalised, or confined to discrete areas, such as the scalp, elbows and knees, gluteal cleft and nails
Psoriasis
____________occurs in about 2% of the population and usually begins in the third decade, but can occur at any age
Psoriasis
An onset of the condition may occur with HIV infection
Psoriasis
Some patients may have very minimal skin lesions and the condition can go unrecognised until an eruption precipitated by certain drugs, which include lithium, beta-blocking drugs (atenolol in this patient), and antimalarials.
Psoriasis
Steroids, or particularly steroid withdrawal, can also act as a precipitant (D is correct)
Psoriasis
_____________ rash can be difficult to distinguish from psoriasis, but the degree of pruritus and distribution are important distinguishing features.
Atopic eczema
_____________ rash can be difficult to distinguish from psoriasis, but the degree of pruritus and distribution are important distinguishing features.
Atopic eczema
This condition is often limited to childhood but can recur in later life
Atopic eczema rash
_____________ is an immune- mediated disease and most patients have a personal or family history of atopy which can include atopic dermatitis, asthma and allergic rhinitis.
Atopic dermatitis
Controversy exists about the role of environmental allergens on its pathogenesis
Atopic dermatitis
The major feature is pruritus, and the rash often consists of lichenified erythematous plaques on face, neck and antecubital and popliteal fossae.
Atopic dermatitis
________________ may also present with annular, erythematous, scaling patches and plaques
Tinea corporis (‘ringworm)
The key feature of this dermatophyte fungal infection is that the borders of the lesions are the active sites, with more erythema and elevation, while the centres are clear and flat.
Tinea corporis (‘ringworm)
_________________ can present as a discoid rash, often on the face, but can be more generalised
Systemic lupus erythematosus
The lesions are often erythematous raised patches with keratotic scaling; atrophic scarring can occur in older lesions.
Systemic lupus erythematosus
__________________ must always be considered in any skin eruption
Adverse drug reaction
________________may cause a skin rash in up to 30% of patients (usually a macular erythematous rash) but can even manifest as toxic epidermolysis.
Allopurinol
Diagnosis in this patient is most likely to be _____________(D is correct), a common cause of conductive deafness, often familial, often precipitated by pregnancy
otosclerosis
often associated with paracusis/loudness recruitment (hearing better in noisy environment).
otosclerosis
Usual onset is in second or third decade, two-thirds are female and two-thirds give a family history.
otosclerosis
Deafness may be unilateral or bilateral.
otosclerosis
Tinnitus may also be present. The conductive deafness is associated with abnormal bone forming around the stapes footplate preventing its normal movement.
otosclerosis
Surgery by stapedectomy and vein grafting with insertion of a prosthesis can be very helpful, and hearing aids for conductive deafness are also effective.
otosclerosis
Other common causes of ______________ deafness are wax and other external ear conditions, acute and chronic otitis media, cholesteatoma, and barotraumas.
conductive
______________ affecting the eighth cranial nerve can cause sensorineural deafness.
Acoustic neuroma
Vestibular neuronitis is not associated with ______________
hearing loss
Vestibular neuronitis is not associated with ______________
hearing loss
Ménière disease is not familial, and tinnitus is a prominent symptom in association with ______________ deafness
sensorineural
______________ is a slowly growing lesion of the middle ear with cheesy white squamous debris, associated often with a perforated drum and causing conductive deafness secondary to ossicular erosion
Cholesteatoma
Causation may relate to metaplasia after chronic infection.
Cholesteatoma
This clinical scenario has a number of features which would be consistent with catecholamine excess and the diagnosis of ______________
phaeochromocytoma
agitation, palpitations, weight loss, mood disturbance, feeling hot, anxiety, tachycardia and hypertension.
phaeochromocytoma
Indeed ____________is one of the great mimic disorders
phaeochromocytoma
However, this is a very uncommon condition, with an incidence of about 1 in 10,000.
phaeochromocytoma
__________________ accounts for up to 12% of the group of anxiety disorders, which also comprise panic disorder, obsessive compulsive disorder, social phobia and post-traumatic stress disorder.
Generalised anxiety disorder (GAD)
_____________ sufferers worry excessively about real life situations (finances, health of family members, housework, being late for appointments, losing one’s job., etc.).
GAD
Symptoms experienced include restlessness, edginess, fatigue, impaired concentration, irritability, muscle tension, and disturbed sleep
Generalised anxiety disorder (GAD)
A ________________ is a condition of intense fear and discomfort with four or more of the following: palpitations, sweating, trembling, shortness of breath, choking sensation, nausea, dizziness, chest discomfort, numbness, tingling, chills, hot flushes and a fear of losing control or dying.
panic attack
These have an abrupt onset and peak within ten minutes
panic
Many of these are suggestive of catecholamine excess, or the hyperadrenergic state, and this is a characteristic feature of ______________
hyperthyroidism
Importantly, the symptoms of palpitations, together with the findings of an irregularly irregular tachycardia, raise the strong clinical suspicion of _____________
atrial fibrillation
____________may occur as a primary condition following cessation of ovulation or secondary to bilateral oophorectomy
Menopause
The condition may be defined as cessation of menstrual periods for at least six months, as irregular periods commonly precede the menopause for around five years, a time known as the climacteric
Menopause
______________symptoms relate to oestrogen deficiency and include hot flushes, but atrial fibrillation is not a menopausal symptom.
Menopausal
This young woman needs a _______________with a very high success rate.
contraceptive
The best of these for her own use is the combined oestrogen/progesterone oral contraceptive pill (OCP).The OCP, however, would not protect her from ________________________
sexually transmissible infections (STI).
She may be at significant risk of an ___________, related to the choice of her sexual partner
STI
To achieve protection from such infections would require the use of a _____________as well as the use of the combined OCP (E is correct).
condom
Use of an intrauterine contraceptive device (IUCD), would be _______________because of the increased risk of an STI if she had multiple sexual partners and because she is nulliparous
contraindicated
A __________________preparation may not be conducive to spontaneous intercourse, and there may be compliance issues
spermicide
The same may apply to the use of a condom alone.
compliance issues
Either of these latter two methods will give less reliable contraception than the combined __________
OCP
The radiograph shows a massively dilated loop of large bowel, arising out of the pelvis. The apex of the loop is under the diaphragm. This is the characteristic pattern of a ________________ (A is correct).
sigmoid volvulus
The clinical picture does not fit colonic ______________, where there is usually a clearly defined precipitating event, such as pelvic surgery or severe systemic illness.
pseudo-obstruction
_______________ produces dilatation of the whole colon and, most noticeably. the caecum
Pseudo-obstruction
Likewise, a _______________ of the sigmoid colon would produce distension of all the proximal colon, often maximal in caecum, with dilated large bowel around the abdominal periphery.
malignant stricture
____________ disease rarely produces acute colonic obstruction
Diverticular
____________ of a small bowel loop to an area of colonic diverticulitis may produce a small bowel obstruction with X-ray findings characteristic of small bowel dilatation
Adhesion
________bowel obstruction would never produce dilatation of such magnitude
Small
It is associated with a characteristic pattern of _____________ visible across the bowel lumen (valvulae conniventes), often in a central abdominal ladder pattern.
mucosal folds
The most likely diagnosis is ______________________ (E is correct). The clinical scenario is classical of a left apical lung carcinoma, with metastasis to the lower cervical supraclavicular group of lymph nodes these nodes are immediately over the lung apex and comprise the lowest of the deep cervical nodes along the internal jugular vein and subclavian vein.
metastatic carcinoma of lung
The nodes drain into the termination of the _______________, which ascends from the cisterna chyli below the diaphragm to enter the central venous system at the junction of these two veins
thoracic duct
Spread of tumour has also involved the T1 component of the lower trunk of the ________________.
brachial plexus
The ________________ contribution to the brachial plexus runs upwards behind the lung apex and over the neck of the first rib, to join the C8 nerve root component to form the lower trunk of the plexus.
T1 nerve root
The ______________ root gives motor fibres to all the small muscles of the hand those of the thenar eminence and hypothenar eminence, plus all lumbricals and interossei
T1
A _________lesion gives weakness of all intrinsic muscles with difficulties of precision grip and opposition of thumb to fingers, and weakness spreading or bringing together the fingers.
T1
Prolonged muscle paralysis will give a complete ________ hand (‘main-en- griffe’).
claw
______ root motor lesions are thus easily distinguishable from individual peripheral nerve injuries
T1
median and ulnar nerves share between them the innervation of the ___________muscles
short
The _____________ provides sensation to the inner aspect of arm above elbow, extending to the axilla, again enabling differentiation from the sensory loss observed in median or ulnar nerve lesions
T1 root
the latter involving ring and little fingers, the former thumb, index and middle fingers
median or ulnar nerve lesions
The eye signs are typical of Horner syndrome, with interruption of the sympathetic outflow from____________ to the head and neck, causing ptosis from paralysis of levator palpebrae superioris, miosis, anhydrosis and enophthalmos
C8 and T1
This is due to involvement of the sympathetic outflow from the spinal cord into the nerve roots of ________________, from which preganglionic fibres run to synapse in the stellate ganglion, a large ganglion in the sympathetic chain formed by fusion of the inferior cervical ganglion (C8) and the first thoracic (T1) ganglion of the sympathetic chain
C8 and T1
The ____________ ganglion lies on the neck of the first rib.
stellate
This combination of somatic T1 motor and sensory involvement and sympathetic T1 outflow in association with a carcinoma at the lung apex comprises _________________
Pancoast syndrome
the lesion is often occult, but in this instance the syndrome is accompanied by a palpable nodal enlargement. The ____________ is thus the most likely primary site for this metastatic tumour.
lung
Imaging by ___________ is likely to identify the apical primary tumour; physical signs from the primary itself may be minimal or absent
chest CT
Each of the other primary sites (skin, oesophagus, larynx or thyroid) could metastasise to the lymph nodes of lower neck; but the constellation of features described are most likely from an ________________
apical lung primary.
All chronic ______________, including schizophrenia, have very high rates of medical morbidity and resultant excess mortality.
mental illnesses
Individuals with ____________ have a life expectancy which is 20% lower than the general population
schizophrenia
More than two-thirds of people with schizophrenia die of _________________ because of high rates of cigarette smoking, obesity, diabetes mellitus and hyperlipidaemia, aggravated by poor diet and lack of exercise
coronary heart disease
Although tobacco-related respiratory disease is an important co-morbid condition in people with ______________, where 85% of the population smoke cigarettes and 40% of those smoke more than 30 cigarettes per day, it is not a common cause of death
schizophrenia
For reasons that are not clear, ___________is not a major cause of death in this (schizophrenia) population either, despite high-risk lifestyles
cancer
__________is a major cause of mortality in the early years after diagnosis with schizophrenia, as are accidents
Suicide
Overall about 10% of individuals kill themselves, which may cause a lot of grief and guilt among the survivors, but it is _______________ which is far more lethal, insidious and treatable
cardiovascular disease
____________ praecox (‘praecox’ - Latin - pertaining to early maturity) is a synonym for schizophrenia. People may die with the condition of schizophrenia but not of the condition.
Dementia
Although vaginal bleeding within a few days of the administration of ____________________ can occur if the agent is given prior to day eight to ten of the menstrual cycle, when given at mid-cycle it usually does not affect the timing of the subsequent period unless the patient conceives.
Postinor-2 (levonorgestrel 750µg)
When high doses of the oral contraceptive pill (the Yuzpe method) were used as a postcoital contraceptive, ________________ were common
nausea and vomiting
They are rare symptoms after the use of Postinor®.
nausea and vomiting
There is no evidence that the dose of levonorgestrel used has a ____________ effect on a female fetus.
virilising
____________ treatment fails to prevent pregnancy in 2-3% of women treated
Postinor
_______________ is typically auditory, beginning with formless sounds such as ringing, crackling, knocking, hissing or whispering.
Alcoholic hallucinosis
Gradually the noise coalesces into recognisable voices which torment the sufferer with insults and accusations of sexual offences, rape, masturbation, paedophilic tendencies, homosexuality or murder, based on real or imagined past experiences
Alcoholic hallucinosis
This may lead to paranoid ideation. fear, insomnia, hypervigilance, the carriage of weapons for self-protection, and violent incidents of self-harm or suicide.
Alcoholic hallucinosis
_______________, unlike delirium tremens, is not associated with delirium or a confusional state the sensorium remains clear in the presence of terrifying auditory hallucinations
Alcoholic hallucinosis
The ____________do not occur in the acute phase of alcohol withdrawal, but may begin soon after a period of either withdrawal or relative abstinence from chronic alcohol
hallucinations
Alcoholic hallucinosis generally has a good prognosis if __________can be maintained
abstinence
______________ would be the treatment of choice initially, but there have been no definitive trials of these drugs in this condition, which is relatively uncommon
Atypical antipsychotics
It is more likely to occur in older patients with a lengthy alcohol abuse history and may be associated with other physical complications of alcoholism
Alcoholic hallucinosis
Relapse may occur if drinking is resumed, but small amounts of alcohol/ethanol would be unlikely to provoke a recurrence.
Alcoholic hallucinosis
Auditory hallucinosis is qualitatively different from tinnitus, and whether the hallucinosis is unilateral or bilateral is not pathognomonic of alcoholic hallucinosis.
Alcoholic hallucinosis
Visual and tactile hallucinations are not part of alcoholic hallucinosis, but may be part of the ____________ syndrome, which is a specific form of acute alcohol
delirium tremens
In delirium tremens the ______________hallucinations are typically of little colourful animals and humans and may be transient and subject to examiner suggestion.
visual
Although __________ occurs with an incidence of less than one case per 100,000, it is an important consideration in the diagnosis of dysphagia, especially when symptoms have been long-standing.
achalasia
The majority of cases present with difficulty in swallowing.
achalasia
Some patients have an abnormality confined to the lower oesophagus, where there may be increased lower oesophageal sphincter tone and a failure of the sphincter to relax on swallowing.
achalasia
In more advanced cases the motor abnormalities (which may be secondary to degeneration of the myenteric nerve plexuses) may involve the body of the oesophagus
achalasia
A number of treatment options is available and short-Oesophageal achalasia term relief of symptoms may be obtained with endoscopic injection of _______________ into the lower oesophageal sphincter.
botulinus toxin
Similarly, pharmacological agents such as calcium channel-blockers may be used to induce smooth muscle relaxation.
achalasia
For definitive or longterm therapy, achalasia has been treated by endoscopic _____________ of the sphincter and by cardiomyotomy
balloon dilatation
In patients undergoing ________________ (with disruption of the fibres of the lower oesophageal sphincter) it appears that many will develop recurrent symptoms within five years.
pneumatic dilatation
The figures for laparoscopic cardiomyotomy are more favourable and currently this is the treatment of choice for best longterm relief
achalasia
All the conditions listed can produce acute gastrointestinal haemorrhage. The bleeding associated with _________________inflammation is rarely acute and, if it does occur, such a large volume of blood loss would be uncharacteristic.
oesophageal
Most patients with ____________of sufficient severity to be complicated by haemorrhage would have experienced heartburn symptoms
oesophagitis
Similarly, the bleeding associated with ______________ is usually chronic and occult rather than acute and obvious.
malignancy
Gastric ____________is not one of the common causes of haematemesis.
carcinoma
Patients with ____________ bleeding usually have a bout of vomiting or retching before bringing up blood
Mallory-Weiss
These individuals may develop an injury to the mucosa in the region of the cardia, induced from the trauma of vomiting.
Mallory-Weiss
The bleeding associated with these mucosal tears is not usually of large volume.
Mallory-Weiss bleeding
The two most common causes of acute upper gastrointestinal haemorrhage in western communities are _______________________
oesophageal varices and peptic ulcer disease.
While this man does consume alcohol, the volume consumed is not usually thought sufficient to lead to _____________.
cirrhosis
Of the given options, this man probably has peptic ulcer disease - particularly given his _______________.
dyspepsia
______________ are most commonly situated in the first part of the duodenum
Peptic ulcers
Patients with gastric ulcers can have massive __________, but these ulcers are not as common as duodenal ulcers.
bleeds
In most large series reported, the most common cause of acute upper gastrointestinal bleeding (haematemesis and/or melaena) is a ____________
duodenal ulcer
Fortunately, the massive bleeds from large deep ______________ eroding the gastroduodenal artery are now less commonly seen
duodenal ulcers
The correct answer is the use of pressure stockings and a vulval pad (C is correct). This will reduce the _________________and will not have any adverse side effects.
symptoms
Care must be taken to avoid ____________to the lower leg veins to avoid ulceration.
trauma
Surgical ligation or injection of sclerosing solutions are elective procedures contraindicated in _______________
pregnancy
Development of varices tends to be compounded in subsequent pregnancies; thus surgery is best avoided until __________________ is complete.
child-bearing
Rest in bed in hospital would reduce the symptoms but is not advisable and would increase the risk of a ____________in the deep venous system.
thrombosis
_________________ is not without risk and has not been shown to be of value for varicosities affecting the superficial venous system
Anticoagulant therapy
The most appropriate investigation to make the diagnosis would have been an erythrocyte sedimentation rate (ESR)
temporal arteritis
Given this history, ___________________ is the most likely cause of both the headaches and the visual loss.
temporal arteritis
Characteristically there is a markedly raised ESR
temporal arteritis
The amount of recovery of ______________ expected in this clinical scenario is minimal
visual loss
It is therefore critical to diagnose and treat _____________ before visual loss occurs.
temporal arteritis
Unfortunately the diagnosis in this patient would be made too late to preserve her sight.
temporal arteritis
The thickened tender artery may be visible and palpable as illustrated.
temporal arteritis
A full blood count is also likely to be abnormal in a patient with _____________ showing a leucocytosis and anaemia.
temporal arteritis
However these are not as discriminatory as the ESR.
temporal arteritis
Prominent segment of left temporal artery in a patient with temporal arteritis A _______________ is an appropriate investigation in an older woman with a long history of smoking, looking for possible lung cancer or other consequences.
chest X-ray
However, the 12 month history of unilateral headache and the sudden visual loss would be unlikely to be related to a cerebral ____________.
metastasis
Transient episodes of monocular blindness are an important indicator of likely ___________disease best detected by a carotid duplex ultrasound.
carotid
However, sudden complete unilateral visual loss is not a characteristic indicator of _______________, nor is severe unilateral headache
carotid disease
________________ would be an appropriate investigation looking for a cerebral tumour, but this is a less likely cause of these symptoms.
Head CT scan
Of prime concern in this patient must be the possibility of _______________. Leg pain can be a nonspecific symptom, but cannot be ignored in situations such as this where ________________ is a real risk.
deep venous thrombosis (DVT) deep venous thrombosis (DVT)
Similarly, calf tenderness is not a reliable sign and will be found in 50% of people with calf pain and no proven evidence of ______________
deep venous thrombosis (DVT)
When pain and tenderness are associated with DVT, there is a poor correlation with the size, site or location of the ________________.
thrombus
The use of ___________ has attracted much attention, but the measurement of ________________ (which are present in fresh clot) has a relatively low specificity for DVT and will often be raised after recent surgery.
D-Dimer
D-Dimer fragments
While the negative predictive value of _______________ is high for low-risk patients, it falls to about 33% for patients at high risk of DVT.
D-Dimer
The previous gold standard for the diagnosis of DVT was ________________, but venography, whether
contrast venography
but ___________________, whether conventional or with computed tomography (CT), has now been superseded by noninvasive duplex Doppler ultrasonography (D is correct).
venography
The latter is accurate and free from the risk of contrast allergy and contrast-induced DVT
noninvasive duplex Doppler ultrasonography
____________________ has a sensitivity of over 95% in the detection of DVT in the thigh but only 73% in the calf veins.
Ultrasonography
_________________________ is being used with increased frequency in the assessment of DVT, and is probably the preferred investigation for suspected caval vein and iliac venous thrombosis, particularly in pregnancy.
Magnetic resonance imaging (MRI)
However, ______________ is expensive, time-consuming and not always available.
MRI
The luteinising hormone (LH) level quoted is much too high to be that seen in a patient with ____________________________, but could be due to a LH-producing adenoma.
polycystic ovarian syndrome (PCOS)
The most likely cause is an ___________________, as the level of LH of 850IU/L is likely to be due to the presence of beta-hCG produced by the pregnancy
early pregnancy
This hormone has a very similar _________________ to LH and cross-reacts in most LH assays.
beta-subunit
The serum _____________ result is in the upper normal range, as is seen in early pregnancy, and the ____________________ is usually suppressed into the low normal range in pregnancy
prolactin (PRL)
follicle-stimulating hormone (FSH)
If ___________ had been the cause, the LH level would have been low or normal.
stress
If __________________ had been the cause, the FSH level would have been markedly elevated.
premature ovarian failure
On clinical grounds the patient has a Stage 1 breast cancer (TINOMO) Her pregnancy is in the second trimester; no indications are thus present to defer or modify surgery at this stage of her ______________.
pregnancy
Risks of inducing early labour, although present, are small.
surgery at this stage of her pregnancy
Definitive _______________ would be expected to involve breast- conserving wide local excision and axillary surgery; and the pregnancy should then be followed to delivery
surgery
Adjuvant treatment by ___________________________ to the remaining native breast, with or without additional hormone manipulation or chemotherapy, can be deferred until after delivery of the baby.
local radiotherapy
___________ therapies will be guided by tumour grading, staging and receptor status (oestrogen, progesterone, herceptin [HER]).
Adjuvant
Neoadjuvant therapies prior to surgery would be inappropriate in the presence of her ______________
pregnancy
Diagnosis regarding more detailed staging by _________________also can be deferred until after delivery and guided by symptoms, tumour grade and stage after breast and axillary surgery.
investigations
Decisions about _______________ and breastfeeding can also await delivery, but if node negativity and absence of lymphatic and vascular invasion are confirmed on histology and wound healing is uncomplicated, no specific objections to breastfeeding are present.
lactation
_________ is a naturally occurring metal. It is used in industry and, in the past, was added to petrol and household paints. _____________ is a hazard when small particles are taken into the body by swallowing or breathing.
Lead
Lead
Basophilic stippling of red blood cells in a film is commonly seen in cases of chronic _____________poisoning
lead
____________ poisoning is associated with the ingestion of contaminated fish, and was also found in dentists who recovered the mercury from old amalgam fillings, and was seen in the millinery (hat) industry when mercury was used in the manufacturing process of felt hat-blocking.
Mercury
system toxicity with intention tremor, excitability, memory loss and delirium.
Mercury toxicity
________________poisoning is a favourite of crime novelists. The agent is tasteless and colourless when added to food or drink
Arsenic
chronic _________ poisoning causes skin rashes and gastrointestinal symptoms
arsenical
Each of the other conditions (perforated ulcer, acute pancreatitis, spontaneous pneumothorax, or myocardial infarct) is a potential cause of ___________________, but the associated clinical features in this case make spontaneous oesophageal perforation (Boerhaave syndrome) clearly the most likely diagnosis.
acute chest or upper abdominal pain
_______________ usually presents with upper abdominal pain of sudden onset without vomiting and accompanied by board-like rigidity and tenderness of upper abdomen.
Perforated ulcer
Imaging with the patient sitting up can show subdiaphragmatic gas.
Perforated peptic ulcer
Acute _____________ may present with sudden epigastric abdominal pain accompanied by profuse vomiting and prostration, and with a history of heavy alcohol intake.
pancreatitis
. Imaging by CT will show pancreatic and peripancreatic swelling, haemorrhage and oedema
Acute pancreatitis
Biochemical findings include elevated serum pancreatic enzymes of amylase and, more recently, lipase.
Acute pancreatitis
___________________ presents with chest pain and breathlessness of sudden onset and, if of sufficient size, the pneumothorax produces the typical signs of hyper- resonance and can be confirmed on chest imaging.
Spontaneous pneumothorax
________________ can present with acute chest pain and prostration, and can mimic acute upper abdominal catastrophes, but the correct diagnosis is usually apparent from the history, cardiac examination and electrocardiographic changes: the unilateral major chest findings described in this case scenario would not be present.
Myocardial infarction
_____________ are frequently called upon to decide whether individuals have the mental competence to make a decision concerning their informed consent to, or refusal of, their treatment including surgical procedures.
Medical practitioners
____________ means that the clinician must be satisfied that: • the individual understands that a decision has to be made individuals have been given adequate and appropriate information relevant to the decision individuals understand the information and the reasonable alternatives individuals understand the advantages and disadvantages of the various options.
Assessment of competence
delirium, dementia, intoxications, learning disability, illiteracy, effects of medication, mood and psychotic symptoms of delusions, hallucinations and thought disorder may all affect __________________________
judgement and impair concentration
________________ alone does not preclude effective decision-making and competence is always context-specific; for example, a patient with depression or schizophrenia may fully comprehend the implications
Mental illness
The core principles of ______________are that the person has the understanding and appreciation of the need and reasons to make a choice, has the rationality to do so and is not being unreasonably pressured or exploited by third parties
competence
It is most unlikely that a ___________________ doctor would be expected to give an opinion on whether an inpatient is fit to plead in court
junior hospital
Fitness to _______________includes an individual’s ability to: understand the nature of the charge(s) understand the implications of being able to plead guilty or not guilty to the charge(s) • be able to instruct legal counsel be able to follow proceedings in the court be able to challenge the selection of jurors
plead
_______________________ in this 67-year-old man with multiple medical comorbidities and polypharmacy for diabetes mellitus, hypertension, and cardiac failure associated with mild anaemia and hypokalaemia are most likely to be a complication of his antihypertensive medications - in particular his thiazide diuretic therapy may cause hypokalaemia and associated tiredness and muscle weakness
Tiredness and muscle weakness
Conn syndrome (primary hyperaldosteronism), due to a secreting adrenal cortical adenoma, can also be associated with _________________and hypokalaemia.
hypertension
the diuretic therapy would be the first and most likely suspect.
complication of his antihypertensive medications
Benign and malignant bowel tumours can cause _______________ anaemia from chronic blood loss
iron deficiency
villous adenoma of the rectum may secrete large quantities of mucus causing _________________
hypokalaemia
his anaemia would need followup if a persisting ____________ anaemia is diagnosed.
iron deficiency
A major feature in the assessment of children is development as, with each passing year, the child achieves __________________ until reaching full maturity
new skills
It is thus imperative that _____________ of a child at any age includes a review of his or her development to confirm that this is appropriate for the child’s chronological age
assessment
One needs to allow for ____________ in the first few years, as catch-up development may take some time.
prematurity
Anecdotally, experienced pre-school/kindergarten teachers can still recognise by their _______________children who were born prematurely, say at 28 weeks’ gestation, without knowing their birth history
behaviour
Several developmental screening tests are available, for example, the _____________________, which indicate the limits within which children can be expected to function at particular age groups.
Denver Developmental Scales
______________ may be familial and racial, for example in gross motor development
Variations
The _______________ needs to have a guide which can give an indication as to whether all is well in an infant’s development or whether further more formal assessment is required.
clinician
These ‘milestones’ then are the basic tool of any practitioner who is involved with children; and include assessment of ______________ motor development, speech and language and personal social development.
fine and gross
The only one that the 3-year-old is likely to have achieved by that age is _______________ which is usually mastered by two years of age
climbing stairs
All of the other options (dressing without supervision, drawing a man’s likeness, tying shoe laces and hopping) are more advanced than would be expected at _________years.
three
As well as a developmental assessment, all children should have their length/ height, weight and head circumference plotted on a centile chart and, if possible, compared to readings taken previously and recorded in their _________________.
infant welfare book
This then gives a clear indication of the child or infant’s growth pattern and, coupled with the developmental survey, gives an accurate overall impression of the child’s _____________.
progress
Most patients and relatives are terrified (or appalled) by the thought of ECT and their opinions have been shaped by dramatic and erroneous depictions of the treatment in movies and by ill-informed sections of the ______________ .
media
In Australia, ECT is a very safe procedure and in this case likely to be quickly effective and ________________.
lifesaving
It is always given with a short-acting anaesthetic, muscle relaxant and ______________.
pre-oxygenation
In most cases it is only administered in an operating theatre environment in the presence of a qualified anaesthetist and a psychiatrist, using real-time electroencephalography to verify that a well modified ______________has occurred.
seizure
Modern ECT machines ensure that minimal current is ____________.
used
The treatment lasts only a few seconds, but recovery may take _____________ or so
minutes to an hour
Headache, amnesia and brief memory loss are common _____________ sequelae.
short-term
A course of ECT treatments is usually 6-8 unilateral applications spread over 2-3 weeks, depending on the urgency of the situation
urgency
This man may require daily or second daily _____________initially.
treatments
He should be given low dose antipsychotic medication, but would not necessarily be given oral ______________therapy while he is receiving ECT.
antidepressant
He would be prescribed antidepressants and possibly a _____________ subsequently.
mood stabiliser
It is common for relatives to request discharge of seriously unwell patients with depression either to their care, or for transfer to a private hospital, rather than remain in the ________________
public mental health system
Their requests should generally be declined when a patient is as ___________as this man.
unwell
While it may be possible for him to be managed either in a general medical ward or an intensive care ward, these are unsafe environments for patients who are ____________.
suicidal
There are many potential avenues for further successful attempts at ____________ (e.g. multiple hanging points, easy access to ‘sharps’ and needles, drug trolleys and balconies).
self-harm
The most dangerous time for suicide attempts occurs once depressed patients begin to recover their mobility and cognitive planning faculties in the _________________.
early treatment phase
Antidepressants typically have a lag time of two weeks or longer before ______________
mood improves
cognitive and motor impairments may recover sooner, perhaps due to correction of insomnia and anorexia, allowing suicidal patients the energy to complete an attempt they have ___________________.
previously rehearsed
Ultrasound examination at the present time is not warranted because of the high likelihood of spontaneous resolution and the fact that a conservative policy would almost certainly be proposed for at least another six weeks if the _____________ was confirmed ultrasonically.
cystic mass
If the cyst is still present at the time of the six week review, ultrasound assessment would be necessary, as it is possible then that the cyst is a ________________ or even endometriosis.
benign tumour
Further investigations, such as by computed tomography (CT) assessment and even laparoscopic __________________, may ultimately be required, but these would not be required initially.
removal or drainage
This cyst in a young woman is almost certainly physiological in nature, particularly in view of its size. The woman should be advised accordingly, but a further review is ____________.
mandatory
The most appropriate next step is to review in six weeks, as the cyst is probably physiologic and is likely to disappear spontaneously by the time of review in _________________
six weeks’ time,
The next review should not be at the same time in the menstrual cycle
cyst in a young woman
This boy presents with the classical history and physical examination findings of ___________of the right testis.
torsion
This is a clinical diagnosis and strong suspicion of the condition mandates urgent ____________ with no delay
surgical exploration
Investigations like urine culture, imaging and blood examination are not necessary, and delay involved in proceeding to them is compromising the ___________even further
testis
While epididymo-orchitis and urinary tract infection may be considered in adults, the history, clinical findings and age group of this boy make these diagnoses _____________.
unlikely
Testicular torsion - urgent exploration required No time should be lost before exploring the scrotum, irrespective of how long symptoms have been present, as any delay in restoring the blood supply to the affected testis may result in a ____________
nonviable testis
Most surgeons would, as part of the procedure, explore the opposite side and surgically fix the other testis to ___________________________.
avoid this happening on that side
This question tests important clinical knowledge, as this information needs to be provided to a patient prior to having an amniocentesis performed, to ensure she has really given informed consent for ______________
this procedure
Amniocentesis is most commonly performed in the second trimester of pregnancy for ___________________
genetic counselling purposes.
The other alternative would be to do a chorion- villus biopsy (CVB) at approximately ________________________________
10-11 weeks of pregnancy
The chance of a miscarriage occurring after these procedures is generally agreed to be about 1 in 200 for ____________and about 1 in 100 for ______________(B is correct
amniocentesis CVB
Any of these alternatives may be associated with pain and/or limp although osteogenic sarcoma typically presents with _________________and swelling.
pain
The age quoted is important as many of the suggested diagnoses are related to specific _________________
age groups
transient or nonspecific postviral synovitis is usually seen in children under four years of age, however it may occasionally be seen in ____________children.
older
Perthes disease (osteochondritis of the femoral head) is most commonly seen in the _____________ years age group and presents with a longer duration of symptoms
four to eight
Perthes disease Hevell Septic arthritis can occur at any age range but is associated with general systemic symptoms and signs with toxicity and _______________, none of which is present here.
fever
The pain is so intense that the affected child is unable to walk or ____________.
bear weight
Slipped capital femoral epiphysis is seen in the young teenager/late childhood group and most commonly in boys who are significantly ____________
overweight
The treatment is to relocate the epiphysis and pin it in place _________
surgically
The illustration shows a typical _______________ cell carcinoma
nodular basal
These tumours are typically found on the face, but (unlike squamous cell carcinomas) are also often seen in _________areas
nonexposed
Amelanotic malignant melanoma can be a source of diagnostic confusion with other skin _________________.
malignancies
They usually lack the ___________edge of a nodular basal cell carcinoma
pearly
External angular dermoids are congenital developmental inclusion cysts, seen as subcutaneous lumps at the lateral angle of the ___________
eye
Keratoacanthoma can usually be identified by its central _________.
core
The lesion has the appearance of a nodular malignant ____________
melanoma
Malignant skin lesions are commonly seen in the white-skinned _______________population.
Australian
Any change in the appearance of a pigmented skin lesion should arouse ____________
clinical suspicion
The lesion will need complete excision and histological confirmation of the ____________.
diagnosis
Neuropathic ulcers characteristically occur over pressure points in insensitive areas associated with diabetes, syphilis, leprosy and other _____________
neuropathies
Necrotising fasciitis causes a spreading anaerobic subcutaneous infection, often crepitant with subcutaneous ____________.
emphysema
Diabetics are particularly prone to these infections.
Necrotising fasciitis
Erythema ab igne describes cutaneous tanning caused by chronic local application of heat, as from excessively _________________.
hot water bottles
The most important prognostic indicator in malignant melanoma is ______________of the lesion (D is correct).
thickness
Lesions under 0.7mm in depth/thickness have a significantly better prognosis than those above this level of _________.
thickness
Bleeding from skin lesions is suggestive but not specific for malignant change and is not __________significant.
prognostically
Width and colour are not discriminatory in prognosis, although amelanotic lesions can cause confusion and ________in diagnosis.
delay
melanomas of the legs have a better prognosis overall than those on the _______________
trunk
On the lips they are invariably sited on the mucosa of lower lip, related to solar exposure.
squamous cell carcinoma (SCC)
Basal cell carcinoma and malignant melanoma rarely involve the ______mucosa.
lip
Herpes zoster infection on the face gives clusters of vesicular eruptions related to the distribution of _______________(ophthalmic herpes) and VII (geniculate herpes).
cranial nerves V
Viral herpes simplex of the lip (‘cold sore’) gives a classical painful shallow ______________acute lesion, usually self-limiting within days or weeks
ulcerated
They may also give vesicular painful mucocutaneous lesions which are more ____________.
chronic
This man has life-threatening injuries. The ABC of resuscitation (Airway, Breathing, Circulation) must be __________
remembered
Airway management is crucial. In this instance a number of important clues indicates that he probably has upper and lower airway _______.
injury
He was in a smoke-filled room with burning clothes. Not only will he have inhaled smoke, but it is quite likely that some of the clothing may have given off noxious fumes, capable of damaging the _______________ in their own right.
respiratory epithelium
The burn has involved his face and, in addition to the burn itself, his hair and _____________are singed - suggesting extremely close contact
eyebrows
He is likely to have a burn injury to his upper airway. He is speaking in a husky whisper, which suggests that he has already developed laryngeal _____________and potential airway compromise.
oedema
He needs to be intubated and ventilated before stridor sets in and intubation becomes _____________
impossible
Preoxygenation is performed with a face mask while preparing for ____________.
intubation
Ventilation with inspired air of increased oxygen content will then be possible, with progress assessed by oxygen ___________and partial pressures
saturations
Intravenous access is also important as this man will require large volumes of fluid rapidly - but this can be done once the resuscitation team is confident that they have _____________
control of the airway
He will also need analgesics, antibiotics, dressings and antimicrobial creams to cover the wounds, but these are all of _____________
lesser initial importance
The clinical scenario fits the diagnosis of multiple symmetrical subcutaneous _________
lipomas
The physical findings are clearly those of multiple discrete lipomas in ______________.
subcutaneous fat
Most such lipomas are non-painful and non-tender; when pain or tenderness is present the lesions are usually more vascular and may, if removed, be reported histologically as ______________
angiolipomas
Often a family history is present, suggesting an inherited tendency
multiple symmetrical subcutaneous lipomas
The syndrome is quite common, and the lesions are entirely benign.
multiple symmetrical subcutaneous lipomas
Reassurance is usually all that is required, with excision of any painful symptomatic or prominent lesions as required to provide additional ______________
reassurance
In neurofibromatosis type 1 (Von Recklinghausen disease of nerve), the accompanying stigmata of café-au-lait spots, pedunculated and sessile skin lesions (molluscum fibrosum), the relationship of the subcutaneous swellings to peripheral nerves and their firmer consistency, and the associated anomalies and multitude of signs, will usually make the diagnosis obvious by _____________________.
pattern recognition
Adiposis dolorosa (Dercum disease) is a term better applied to diffusely painful subcutaneous fat deposition without focal discrete ______________.
lumps
The syndrome is most common in middle-aged women and the painful fatty deposits are mostly confined to abdomen and _____________.
thighs
The physical findings do not suggest desmoid tumours or epidermoid ____________.
cysts
The former usually arise from the deeper layers of the abdominal wall, and epidermoid (‘sebaceous’] cysts are invariably attached to _________________.
overlying skin
Desmoid tumours and epidermoid cysts are found in the Gardner syndrome variant of familial __________________.
adenomatous polyposis
This patient has now had six episodes of paronychia from ingrowing toenail in the last three months and he warrants ______________________
definitive therapy
The measures of cleansing, use of antiseptics or antibiotics are all temporising, and the most effective treatment for this recurrent problem would be a wedge resection of the region, with removal of the ingrowing edge of the nail and the lateral extremity of the germinal nail bed leaving a nail of lesser width with less tendency to ______________on the nail fold
impinge
Ingrowing toenail (onychocryptosis) is common in adolescents (particularly males) and represents an imbalance between the soft tissue nail fold and the embedded growing ___________________of the nail.
edge
Conservative methods of separation of the succulent soft tissue nail fold from the growing nail edge may allow resolution; but surgical correction of the imbalance is often required when these measures ____________
fail
This is a pilonidal (‘nest of hairs’) sinus. Classically a secondary sinus lies to one side of the midline, as seen in this illustration, and primary sinuses occur in the ____________.
midline
The primary sinus is present but not easily visible in this case. Beneath the sinuses there is a cavity which can extend down to the ________________.
sacrum
The cavity may often extend away from the midline and have other tracts leading up onto the ___________surface.
skin
These secondary discharging lateral sinuses occur from rupture of an infected cavity with abscess and ____________ formation.
granuloma
The cavity tends to be full of hairs. The sinus persists because of the presence of these foreign bodies and, once infection sets in, __________________will be of limited value.
antibiotics
The secondary lateral sinuses have the classical appearance of discharging foreign body sinuses with granulation tissue protruding by contrast, the primary midline sinus(es) where the hairs enter rarely show evidence of granulation tissue and can thus be less ____________________.
apparent
Drilling of hairs into a midline primary sinus is encouraged by suction forces generated by buttock movement on _____________.
walking
The origin of the hairs may be from the local area, or sometimes very long hairs descending from the ____________.
scalp
Pilonidal sinus If an acute abscess is present (which usually points laterally) it will need incision and drainage, but in this case where the sinus is discharging chronically, the most appropriate treatment is formal excision of the area, including secondary and primary sinuses, and underlying cavity and ___________________
contained hairs
The procedure described by Karydakis, using an advancement _____________, is widely used.
flap
Any imaging by MRI or CT is superfluous and there is no fistula to be laid ______.
open
His sinus is well away from the anal verge and is neither an anal fissure nor an anal fistula. Nor is it a suppurative hidradenitis, which is a chronic groin infection of sweat glands associated with chronic oedema and suppuration with _______________.
multiple sinuses
An ischiorectal abscess occurs more laterally and anteriorly within the ischiorectal fossa and presents as a painful indurated tender perineal swelling lateral to the _______________
anus
The rash has typical features of a fixed drug _________________
eruption
It is very symmetrical and unusual in distribution, affecting the insteps, soles and ankles, but sparing the distal ___________
feet
This is almost certainly a reaction to _______________
trimethoprim
Fixed drug eruption describes a cutaneous drug reaction characterised by the recurrent appearance of skin lesions at the same site each time the responsible __________is administered
drug
A variety of drugs can be implicated, such as cotrimoxazole and trimethoprim
Fixed drug eruption
Acute gout can be symmetrical and affect the ankle and tarsal joints with _________________of overlying skin.
redness
the centre of the inflammation is not over the ankle joints: and the first metatarsophalangeal joints, the most common site for ________________in the feet
gout
The degree of blistering here would be unusual for _______________.
gout
Reiter syndrome is a condition that occurs predominantly in young men and can present with urethritis, joint pains, and occasional _______________manifestations.
cutaneous
His condition could be confused with bilateral cellulitis, since there is inflammation of the skin and the line markings on the skin are those of the previous day, indicating a resolving ______________area
inflammation
it is most unlikely that he has suddenly developed a symmetrical bilateral streptococcal ____________
cellulitis
Systemic lupus erythematosus may present with cutaneous manifestations, usually a rash on sun-exposed skin, especially over the ___________________
cheeks and nose.
Amaurosis fugax (fleeting transient monocular visual loss) suggests ophthalmic artery platelet embolisation from an ipsilateral carotid ___________________
artery plaque
Associated involvement of the cerebral cortex with right sided embolisation to the motor area of the upper limb will give a transient right cerebral _____________________
upper motor neurone lesion
Descending upper motor neurones cross in the pyramids to supply contralateral lower motor neurone hand musculature, giving transient contralateral left-sided hand weakness
left-sided hand weakness
The causative constricting ulcerative plaque of the right internal carotid artery near its origin is likely to give a _________________ over the right carotid bifurcation
systolic bruit
A bruit over the left carotid bifurcation would be associated with opposite effects - transient left eye visual loss and right-sided _________________.
hand weakness
Atrial fibrillation, giving an irregularly irregular pulse rate, can be associated with a left atrial thrombus causing peripheral emboli, of which an embolic _____________________ is one of the most serious.
vascular stroke
transient ischaemic attacks in the internal carotid distribution, as outlined in the scenario, are less likely to be due to atrial fibrillation than to a ____________________
carotid plaque
A pansystolic precordial murmur may be due to mitral incompetence or a left to right cardiac shunt, neither of which is associated with _____________manifestations
embolic
A mid-diastolic precordial murmur associated with mitral stenosis also is not usually associated with emboli, but with ________________
cardiac failure
The isotope scan shows a large area of diminished uptake in the right lobe of the thyroid gland, occupying most of the lower pole of the ___________________
right lobe
The remainder of the thyroid gland shows normal __________________uptake
homogeneous
This is consistent with a solitary ‘cold’ nodule in an otherwise normal ____________
thyroid gland
Amaurosis fugax (fleeting transient monocular visual loss) suggests ophthalmic artery platelet embolisation from an __________________________
ipsilateral carotid artery plaque.
Possible diagnoses are a solitary haemorrhagic or colloid cyst, a benign adenoma, or a thyroid malignancy - these may be papillary (the most common in young adults), follicular (less common and difficult to differentiate from a benign adenoma), or ___________________(least common and usually part of the spectrum of multiple endocrine neoplasia).
medullary
Diagnosis is facilitated by ultrasound-guided aspiration cytology or ____________biopsy.
core
Papillary cancers rarely spread beyond head and neck; follicular cancers can have a predilection for blood spread, sometimes to bone, and a pathological fracture is an occasional ________________presentation
initial
Weight loss and tremor occur in hyperthyroidism in young patients (Graves disease); and the gland may not be enlarged, but is usually diffusely involved with uniform and excessive __________________, which is not suggested by the scan.
isotope uptake
Pain may occur as an initial symptom, with acute haemorrhage into a nodule, but the more common presentation is of a painless ____________.
lump
Dry coarse skin is seen in hypothyroidism with _______________isotope uptake - a rare
decreased
presentation in young adults, not associated with a mononodular goitre as is the likely case here, and where diagnosis or exclusion of ________________ is the main focus.
thyroid cancer
The MRI demonstrates intervertebral disc protrusion between cervical vertebrae 6 and 7 extending to, but not displacing, the _____________.
spinal cord
A prolapse at this level is likely to impinge upon the issuing 7th cervical nerve root, causing impingement C7 radiculopathy, which is consistent with his ____________
clinical features
C7 radiculopathy, which is consistent with his clinical features: sensory symptoms of paraesthesia in the C7 dermatome, and motor involvement of C7 causing diminution of triceps jerk and power of wrist and _________________ (B is correct).
finger long flexors
Traumatic syringomyelia is unlikely with this scenario. Cervical syringomyelia can cause local sensory loss to pain, ________________________features
upper limb lower motor neurone
Cervical disc prolapse C6/7 and lower limb long tract _______
signs
The imaging does not suggest compression of the spinal cord; and an ___________haematoma would give a different imaging picture.
epidural
Spinal cord hemisection (Brown-Séquard syndrome) is not suggested by the imaging or by the clinical features, which would be expected to include an ipsilateral lower motor neurone lesion, crossed sensory loss below the lesion with ipsilateral loss of position sense, contralateral pain and temperature sensory loss, and ipsilateral __________________________neurone signs below the lesion
upper motor
‘Clay shovellers’ injury is an occupational avulsion injury of the prominent spinous processes of C7/T1 and is not suggested by the clinical features or the __________.
imaging
After a blow to the cheek or side of the face, double vision of binocular type is very suggestive of a depressed fracture of the ________________ (E is correct).
zygoma/zygomatic arch
Inspection and palpation of the orbital margins may reveal a step deformity of the orbital margin or a depressed contour of the cheek, and there may also be ________________in the distribution of the infraorbital nerve.
anaesthesia
Operative elevation is usually required
orbital margin or a depressed contour of the cheek
Rupture of the globe will cause gross loss of vision rather than ______________
diplopia
Hyphaema (bleeding into the anterior chamber) will cause monocular visual blurring, and is diagnosed by inspection revealing evidence of blood in the anterior chamber, often with a ____________________
fluid level.
Fracture of the mandibular ramus can cause difficulty opening the mouth, but not ____________________
diplopia
Maxillary antrum rupture would be secondary to a comminuted maxillary fracture, or blowout fracture of the orbit, and usually follows a direct blow to the eye rather than to the _________________ or cheek.
lateral face
Previously thought possibly to represent thyroid metaplasia in lymphoid tissue, and labelled ‘lateral aberrant thyroid’, it is now recognised that findings of differentiated thyroid fissue in a lymph node invariably indicate lymph node metastasis from a primary carcinoma of the thyroid, which is often ___________________ (C is correct).
small and occult
Metastatic thyroid cancer in lymph node The usual type of thyroid cancer to give lymph node metastases is the papillary carcinoma, which has no _________________.
familial tendency
Papillary thyroid cancer affects young adults of either sex and is a ________________ neoplasm
slow-growing
Spread is predominantly via lymphatic drainage to midline pretracheal and prelaryngeal nodes in front of the ______________________membrane (the latter called ‘Delphic’ or ‘oracular node because it is a predictor of an underlying but inapparent cancer).
thyrohyoid
Spread also occurs to the deep cervical chain of nodes following superior and middle thyroid veins, and to nodes around the recurrent (inferior) laryngeal nerve and anterior mediastinum following ____________________.
inferior thyroid veins
The natural history of the condition is generally favourable and usually extends ___________________.
over many years
The natural history of the condition is generally favourable and usually extends ___________________.
over many years
The lesion only rarely spreads beyond head and neck; repeated operations for recurrent tumour can often contain the ______________for years.
disease
Spread via the blood stream is unusual, in contrast to the follicular and medullary types of thyroid cancer, so repeated local surgery for ________________after primary surgery is worthwhile.
recurrences
Subacute (de Quervain) thyroiditis, thyroglossal duct cyst and lymphadenoid (Hashimoto) thyroiditis have entirely different clinical features, and benign thyroid adenomas are confined to the _________________ itself.
thyroid gland
The findings are classical of a right ____________________ nerve palsy.
third (oculomotor)
Paralysis of the autonomic motor parasympathetic fibres coming from the Edinger-Westphal nucleus, results in sympathetic pupillary dilatation and failure of the direct and __________________responses to light (subserved by afferent impulses along the right and left optic nerves and efferent autonomic innervation of the right sphincter pupillae).
consensual
These autonomic motor fibres are situated in the superior part of the third nerve and are involved early by focal compression secondary to an _______________haematoma
epidural
The corneal reflex is subserved by the sensory fifth nerve afferents, but the efferent motor side of the reflex arc is via the ______________nerve
seventh
The fourth and sixth nerves do not subserve pupillary reflexes but give isolated ocular muscle palsies causing vertical diplopia on downward gaze (fourth nerve - superior oblique palsy), or ________________diplopia on outward gaze (sixth nerve - external rectus palsy).
lateral
second nerve palsy causes unilateral blindness with failure of the direct but not superior oblique - the ‘_______________’ eye.
down- and-out
In a partial third nerve paralysis, ptosis may be the most prominent ___________as illustrated below
feature
The other illustration shows a left sixth nerve palsy identified on _______________.
left lateral gaze
Partial left 3rd nerve palsy with ptosis Left 6th nerve palsy- outward gaze to patient’s __________________
left
Metastatic carcinoma with an occult primary can be found with each of the options mentioned and also the _____________.
skin
Thyroid cancer would not be expected to be of ________cell type, but the others would.
squamous
Piriform fossa laryngeal neoplasms would be expected to drain to anterior triangle deep cervical nodes, as would cancers of buccal _____________.
cavity or tonsil
Drainage to posterior triangle nodes occurs from nasopharynx (which is the most likely primary site) and full otolaryngologic review and __________________will be required to confirm this (D is correct)
endoscopy
The photograph shows evidence of a right-sided glossal atrophy with atrophic glossitis consistent with a 12th (_____________) nerve palsy (E is correct).
hypoglossal
The nerve is at risk during operations around the carotid bifurcation, near which the 12th nerve crosses the external and internal carotid arteries on its course from _________________ to the side of the tongue
the base of the skull
Soft tissue tumours of the striated muscle of the tongue (rhabdomyosarcoma) are rare tumours, giving massive _________________of the tongue.
enlargement
Squamous cell carcinoma, presenting as an ulcerated exophytic or indurated lesion, should always be suspected when any ________________ ulcer fails to heal
glossal
Squamous carcinomas are often secondary to the four S’s - _________________, Spirits, Spices (betel nut, pan), and Syphilis
Smoking
Geographic tongue has a characteristic appearance and is not associated with other ________________.
diseases
The trigeminal nerve supplies sensation to the tongue via the ___________nerve.
lingual
Each of the measures described may be required, but the most appropriate immediate first aid treatment of a chemical burn eye injury is copious water imigation to dilute and wash away the injurious chemical agent, which otherwise will continue to act and produce ___________________ (D is correct).
progressively deeper injury
When an ocular chemical burn injury presents to an Emergency Department, local anaesthetic eye drops should be instilled in the eye, followed by irrigation for a minimum of 20 minutes with ____________________.
isotonic 0.9% (normal) saline
Because of the patient’s increased metabolic state and vascular hyperactivity. pulmonary embolism is extremely uncommon after thyroidectomy for thyrotoxicosis, especially given the onset of _______________soon after surgery.
symptoms
Pulmonary atelectasis is the most common cause of early postoperative fever and tachycardia after all classes of ___________
surgery
Wound infection and septicaemia are both uncommon after the elective clean surgical procedure of thyroidectomy, unless a gross breach of aseptic technique has occurred in conjunction with a wound _________________; and the onset is again earlier than one would expect
haematoma
Inspection of the wound area to check that no upper airway obstruction from a deep wound ___________________is present is, however, mandatory.
haematoma
A thyroid crisis is an important differential diagnosis. This complication is now very uncommon after adequate preoperative patient _______________;
preparation
all thyrotoxic patients proceeding to surgery require adequate medical treatment with antithyroid medication, if necessary supplemented by addition of a ______________
beta-blocker
Such treatment is usually required for one or two weeks, so that the patient is clinically and biochemically euthyroid at the time of surgery, and the risk of exacerbation of thyrotoxicosis after surgery (_______________) is thereby minimised or eliminated.
thyroid crisis
An ECG would be appropriate to exclude with certainty a dysrhythmia - but atrial fibrillation is unlikely with a regular pulse and atrial flutter also less likely than ______________tachycardia with a pulse rate of 110/min
sinus
patients with florid postoperative thyroid crisis, in times past, the clinical picture was usually distinctive and alarming with more rapid pulse, higher ______________ and marked systemic signs.
fever
Episodes of fleeting transient monocular loss or blurring of vision (amaurosis fugax) are characteristic of an ipsilateral carotid artery lesion, often a stenotic lesion or an ulcerating atherosclerolic plaque, causing transient reversible ophthalmic artery _______________from minute emboli.
ischaemia
The central retinal artery divides into upper and lower branches at the ___________nerve head
optic
When an embolus blocks the upper branch, the experience is described as a shadow moving up from the inferior periphery and stopping in the middle of the field at the ________________line
horizontal
When the embolus blocks the lower branch, the resulting obscuration is en described as descending from above, and again stops at a _____________horizontal be line.
central
When the main trunk of the retinal artery is blocked in the optic nerve head. there is a gradual constriction of the visual field until only a _______________ spot bor remains, which then extinguishes.
central bright
In all cases, the obstruction usually lasts less than a minute and, as the embolus breaks up, it moves to the ________________.
periphery
The retinal circulation is re-established and the visual obscuration ____________.
reverses
The sight returns as the obscuration moves either up or down, in the case of a branch occlusion, or expands from a central point, expanding to the periphery when the main __________________of the central retinal artery is involved
trunk
Giant cell (temporal) arteritis classically causes premonitory severe constant focal headache preceding visual loss, which, when it occurs, is usually ____________
permanent
The headache is often associated with aching jaw claudication __________.
on chewing
Acute glaucoma classically presents with acute pain associated with a painful red eye, with dilated ciliary vessels and corneal oedema with a hazy cornea, an irregular light reflex and a _______________pupil, and a high intraocular _________________
nonreactive pressure
In chronic glaucoma there is chronic gradual loss of sight that is ___________
non-symptomatic
Raised intracranial pressure is characterised by worsening headache, often associated with vomiting, progressing to drowsiness and __________________
papilloedema
Bradycardia and hypertension are late symptoms associated with _________________.
tentorial herniation
Transient visual obscurations frequently accompany raised intracranial pressure due to transient interference with optic nerve transmission in the presence of ___________________
papilloedema
Systemic hypertension is another important cause of _____________, rather than transient loss of vision as is the case in this scenario
headache
The site of any ulcer on the lower limb is of great importance in the determination of the _________________.
underlying cause
The important causes include venous stasis. arterial insufficiency, ______________.
infection and trauma
Venous insufficiency ulcers are most often situated around the ankle and, characteristically, over the _______________.
medial malleolus
Venous presssure tends to be highest at this site, where there are many _______________veins.
perforating
Arterial ulcers from large vessel atherosclerosis usually occur at the extremities, typically on the toes and __________of the foot
dorsum
Infectious ulcers may occur at any site, as with the ulcer due to the presence of a ___________body.
foreign
Ulcers associated with neuropathic change develop se secondary to prolonged trauma and/or pressure and the plantar surfaces over the metatarsal heads represent the major weight- bearing areas of the foot and those subject to __________________
greatest pressure
Persistent pressure on an area of ulceration combined with a precarious blood supply - such as the microangiopathy of diabetes mellitus- make this a common ____________in these patients.
hazard
Neuropathic ulcers developing in diabetic patients in an area of insensitive skin are characteristically deep and _____________(D is correct).
painless
She has evidence of bilateral conductive deafness (A is correct). A Rinne test showing bone conduction (BC) better than air conduction (AC) in both ears is the typical finding in conductive deafness - negative (i.e. abnormal) Rinne test indicating a disturbance of conduction of _________________through external or middle ear.
sound
A Weber lateralising test showing lateralisation to the right ear would also be consistent with bilateral conductive deafness, significantly worse on the ______________(or alternately of unilateral right conductive deafness), if the Rinne test on the left had been normal, which it was not.
right
The clinical presentation is typical of otosclerosis, which is often first diagnosed in pregnancy, and is associated with a ____________________history
family
She has binocular vertical diplopia (diplopia is present with both eyes open and absent when _____________eye is closed).
either
This suggests that the problem is due to ocular misalignment, often due to a cranial nerve lesion involving ______________muscles.
extraocular
Patients will generally tend to close the eye with the ______________muscle
dysfunctional
Monocular diplopia, by contrast, persists when one eye is closed and suggests a __________________error.
refractive
Binocular vertical diplopia may be associated with dysfunction of the superior or inferior recti or superior or inferior ____________
oblique
All these muscles are supplied by the third cranial nerve, except ____________oblique
superior
A third nerve palsy is usually accompanied by ptosis and change in pupil size and _____________- not present here.
reactions
The diagnosis in this instance is most likely to be diabetic ocular neuropathy affecting the left fourth (trochlear) _______________nerve
cranial
Involvement of the fourth nerve as an isolated cranial nerve lesion is most usually a complication of _____________
diabetes mellitus
Classically the patient complains of painful double vision and describes a boring pain in the orbit of the affected side.
complication of diabetes mellitus
The fourth cranial nerve supplies the superior oblique ocular muscle (S04), which rotates the eye downwards and inwards and also intorts it, i.e. rotates the 12 o’clock meridian towards the nose, around an _________________.
anteroposterior axis
When looking down, as in reading or descending stairs, the patient experiences diplopia in which the image from the affected eye is displaced _______________.
vertically and slightly tilted
The palsy is almost always unilateral.
The fourth cranial nerve supplies the superior oblique ocular muscle (S04)
Myasthenia gravis is possibility, and can present initially with isolated ____________neuropathy (ocular myasthenia).
ocular
Myasthenia needs to be excluded by a Tensilon test. However, in the presence of known pre-existing diabetes, the most likely diagnosis would be -_____________________.
diabetic ocular neuropathy
Multiple sclerosis (MS) can cause isolated cranial nerve lesions from _____________
demyelination
MS also is less likely than diabetes in this context and could be additionally excluded by _______________________
magnetic resonance imaging (MRI).
A lacunar vascular infarct (small vessel stroke) would be most unlikely to involve solely the _______________cranial nerve nucleus
fourth
A cerebral tumour in the posterior fossa would be more likely to involve the visual cortex, giving an __________________.
homonymous hemianopia
Evaluation of a patient with a painful red eye, with corneal and scleral injection, is a common and important problem in primary health care in general practice and in Emergency Departments. Causes include conjunctivitis (infective or allergic), corneal abrasion and foreign body, ________________________, and a number of other conditions.
contact lens overwear
Conditions requiring urgent diagnosis and treatment include acute angle-closure glaucoma, an uncommon but important cause of the _______________________
‘acute red eye’.
Acute glaucoma occurs in eyes with a shallow anterior chamber, and, with the pupil dilated, the peripheral iris blocks aqueduct outflow and an abrupt rise in intraocular pressure occurs, with pain, corneal and scleral injection, corneal oedema, and ____________________ (often with haloes around objects).
visual blurring
In some patients, nausea and vomiting accompany the eye symptoms and photophobia can be _____________.
intense
Symptoms often come on at night and affect older patients.
Acute glaucoma
The diagnosis is suggested further, on examination, by irregularity of the pupil with sluggish reaction to light, a hazy and oedematous cornea and elevated intraocular pressure (greater than 20mm), with the globe feeling firm or stony-hard on ________________
palpation
in this older patient the scenario and findings suggest that the diagnosis is most likely to be acute _______________________
angle-closure glaucoma
The hazards of worsening acute angle-closure glaucoma by inducing pupillary dilatation to facilitate retinal examination have probably previously been overstressed, and the facilitation of assessment of the retina probably outweighs any potential for worsening the degree of ________________.
aqueous obstruction
Cupping of optic disc Primary open angle glaucoma is a chronic and insidious condition, distinct from the acute red eye”, and presents usually with gradual chronic loss of visual acuity, which can lead to ______________due to an insidious optic neuropathy with chronic elevation of intraocular pressure.
blindness
The optic nerve disc shrinks and the recessed cup under the disc enlarges (‘_____________’).
cupping
The classic triad of presentation is painless loss of vision and visual field, cupping of the optic disc, and _________________
raised intraocular pressure
Acute iritis (iridiocyclitis, uveitis) is an inflammatory reaction, sometimes associated with ______________disorders, but often without such associations
autoimmune
Diagnosis requires specialist slit-lamp assessment to identify inflammatory cells in the _______________.
anterior chamber
The clinical picture is classical of a left sixth nerve palsy (B is correct). The sixth cranial nerve supplies the __________________.
external (lateral) rectus
paralysis of which causes horizontal diplopia on lateral gaze to the affected side, with failure of abduction of the left eye.
sixth nerve palsy
The nerve has a long intracranial course from the lower pons in the midline before emerging through the superior orbital fissure, and a sixth nerve palsy not complicates a head injury,and is of no particular localising value or guide to ___________________
severity of injury
Fourth nerve palsies paralyse the ____________________
superior oblique muscle.
giving diplopia on downward gaze
Fourth nerve palsies paralyse the superior oblique muscle
Third nerve palsies paralyse all but two of the ocular muscles, as well as the parasympathetic supply to the pupillary musculature; the typical finding is the ‘down and out’ eye with an _____________________ pupil.
unresponsive dilated
The diagnosis is most likely to be acute angle-closure glaucoma. Adequate diagnosis in this instance, however, can be made by visual acuity and visual field testing and examination of the globe by palpation through the lid, and with the aid of a ________________.
pencil torch
Treatment of acute angle-closure glaucoma is with immediate topical agents which will inhibit aqueous production, increase aqueous outflow and decrease ______________.
intraocular pressure
Agents used include carbonic anhydrase inhibitors (acetazolamide), alpha- adrenergic agonists, cholinergic agents (pilocarpine), beta-blockers (timolol) and _________________.
prostaglandins
Many proprietary preparations exist combining the above agents
acute angle-closure glaucoma
Of those listed acetazolamide is the most appropriate and most ______________
rapidly active
Physeptone is an opioid analgesic without specific influence on ____________.
intraocular pressure
Steroids (fluorocortisone) are not effective and antibiotics (____________________) are similarly ineffective.
chloramphenicol
Bell Palsy (idiopathic isolated facial nerve palsy) results from a lesion of the facial nerve in the facial canal where the nerve swells and ________________________ is disrupted.
impulse transmission
The aetiology is still not known but infection due to herpes simplex virus is considered to be ________________________
a likely cause
There is a unilateral weakness of all the muscles of facial expression (including frontalis) and the eyelids will _______________.
not close
Taste may be lost due to involvement of o the chorda tympani, which carries sensory fibres from the __________________ of the tongue
anterior two-thirds
The motor nerve to the stapedius comes from the facial nerve and, when this is involved in Bell palsy, hyperacusis (unpleasantly loud distortion of noise) may result because of _______________________of the stapedius muscle.
paralysis
The history provided suggests a slowly progressive symmetrical peripheral neuropathic process involving predominantly __________________________
sensory and motor nerves
Diabetic peripheral neuropathy is the most common of the list of _____________________fitting this description
conditions
Polymyositis is a rare condition in adults, usually affecting proximal muscle groups _________________
initially
Sensation remains normal and the deep tendon reflexes are preserved unless there is a severe weakness or muscle atrophy
Polymyositis
Hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease) is an hereditary peripheral neuropathy affecting __________________________
both motor and sensory nerves
Signs and symptoms are usually related to distal muscle weakness in feet and later hands
Hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease)
complaints of limb pain and sensory disturbance are unusual.
Hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease)
Transmission is most usually autosomal dominant but may be autosomal recessive or X-linked.
Hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease)
The estimated frequency is 1:2500 persons
Charcot-Marie-Tooth disease
Acute infectious polyneuropathy (Guillain-Barré syndrome) is an autoimmune disorder which causes rapidly evolving areflexic motor paralysis, with _______________________
or without sensory involvement
It occurs at a rate of about one case per million population per month
Guillain-Barré syndrome
The syndrome appears to often be triggered by an acute viral or bacterial illness [respiratory or gastrointestinal) occurring ________________________
one to three weeks earlier
Usually, symptoms (weakness, muscle aches, numbness) start in the feet or legs and progress to involve upper limbs and sometimes _____________________
respiratory muscles
Autonomic dysfunction may occur with resultant blood pressure, heart rate or _______________instability
temperature
Diabetic amyotrophy is a neuropathy affecting the proximal major nerve trunks or lumbosacral plexus, resulting in weakness of the muscle group or sensory disturbance of the _________________ involved
nerves/plexuses
The sudden and near-complete loss of vestibular function in a young man of this age is suggestive of vestibular neuronitis, a condition assumed due to a self-limiting ____________________ of the vestibular nerve (C is correct)
viral infection
The vestibular nerve in the inner ear becomes swollen and ________
painful
The vestibular nerve carries the balance signals from the inner ear to the brain and, as a result of the _________________, patients will experience vertigo
inflammation
Vestibular neuronitis is unilateral and does not affect ____________.
hearing
Vertigo is most severe initially and usually subsides gradually over a few days, but positional vertigo on head movement may persist for several weeks
Vestibular neuronitis
Treatment is expectant with reassurance concerning likely ultimate resolution.
Vestibular neuronitis
Ménière disease is seen in older patients and is associated with paroxysmal attacks of _________________
vertigo
preceded by a feeling of fullness in the ear associated with tinnitus and hearing distortion or loss.
Ménière disease
Nystagmus is often marked during an attack. Examination shows associated sensorineural deafness on the affected side
Ménière disease
Ménière disease is thought to be due to a distension labyrinthitis with ___________________
endolymphatic hydrops.
Symptomatic relief can be obtained with prochlorperazine and other agents
Ménière disease
Benign paroxysmal positional vertigo is characterised by paroxysms of vertigo in older patients precipitated by _______________________the head.
positional changes of
The attacks are momentary and fleeting but can be severely distressing
Benign paroxysmal positional vertigo
Vertigo can be a feature of a cerebellopontine angle tumour such as an acoustic neuroma (___________________) of the 8th cranial nerve.
schwannoma
Progressive symptoms include unilateral sensorineural hearing loss associated with tinnitus, episodic vertigo and gait instability
acoustic neuroma
Other cranial nerve disturbances may also develop - 7th nerve paresis. facial paraesthesiae from 5th nerve irritation, and sometimes dysarthria or dysphagia due to 9th, 10th and 11th nerve involvement.
acoustic neuroma
Vertebrobasilar ischaemia can cause vertigo in older patients, with associated brainstem and cerebellar effects - ataxia, ________________, crossed sensory loss, and cranial nerve lesions.
Rombergism
This question tests localisa- tion of an acute vascular ischaemic stroke, on the basis of a constellation of symptoms and signs, testing knowledge of the vascular distribution of the vertebral artery and its branches compared to the ____________________ artery, applied to the clinical features of a cerebrovascular stroke
internal carotid
Findings of dissociated sensory loss immediately localise the MRI showing pontine and cerebellar ischaemia in lesion to pons or below, as PICA syndrome ascending ipsilateral sensory fibres in posterior columns (touch, postural and vibration sense) and contralateral anterior and lateral column spinothalamic fibres (pain and temperature) remain separate until the former fibres decussate and cross in the pons - so that from this level up all sensory fibres run together and come from _________________________
the other side of the body
Suprapontine lesions thus cause involvement of all ___________________modalities.
sensory
The vertigo and nystagmus suggest a cerebellar lesion and the left Horner syndrome confirms that the descending cervicosympathetic outflow to the head has been damaged in the lower brain stem- the lesion involves left lower pons and cerebellum - the classic distribution of the _______________________________ (A is correct).
left posterior inferior cerebellar artery (PICA syndrome)
None of the other vessels would give a similar picture - all are in the distribution of the internal carotid artery and its ______________branches.
cerebral
Death is now certifiable medically and legally from either of two criteria - complete and permanent cessation of cardiac function (‘cardiac death’); and complete and permanent cessation of ________________________________
cerebral and brainstem function (‘brain death’).
Criteria for the diagnosis of brain death have been _____________and accepted throughout the world under the following rigorous guidelines.
established
An established causative clinical condition of massive head injury or ______________must be present.
stroke
Complete unresponsive coma must be present with evidence of permanent and irreversible absence of _______________________ function as outlined below
cerebral and brainstem
Irreversible apnoea must be established in the absence of any influence from neuroleptic drugs or hypothermia, with permanent prolonged failure of spontaneous respiration under conditions of induced hypercapnia, indicating permanent cessation of function of the ______________________
brainstem respiratory centre
Permanent loss of function of the brainstem must be established by checking for permanent absence of reflexes of midbrain, pons and medulla, with two observa- tions separated by an appropriate period of observation, __________________________
preferably of 24 hours.
Thus clinical assessment must first establish the appropriate causal diagnosis of brain injury, with initial suspected brain death in a patient who is nonresponsive and deeply comatose corresponding to a Glasgow coma scale score of 3/15, with complete absence of response to __________________
painful stimuli
Such deep and prolonged coma is suspicious of brain death, but _______________
not diagnostic
as such deep unresponsive coma may exist in a permanent ______________state.
vegetative
with permanent absence of higher cerebral function, but with maintained brain stem functions with spontaneous breathing and heart beat. Such a ________________state is not brain death.
vegetative
Diagnosing irreversible apnoea must be accompanied by performance of the additional brainstem ___________, and is thus the most important diagnostic feature - the sine qua non- to establish prior to checking the other criteria (A is correct)
tests
Irreversible apnoea is established by turning off the ventilator or ceasing manual ventilation while oxygen is delivered continuously down the endotracheal tube to maintain oxygenation while arterial _____________, progressively rises.
pCO
Weakness and wasting of the right hand in a 45-year- old man is least likely to be due to ________________
multiple sclerosis
Multiple sclerosis (MS) is a demyelinating disorder. The clinical presentation can be very variable, but it has a relapsing and remitting course and most affected are the optic nerves, cerebellum, brain stem and __________________.
spinal cord
When motor signs occur they are usually upper motor neurone signs rather than wasting, as seen in the lower motor neurone lesions
multiple sclerosis
Each of the other conditions can present with weakness and wasting of the muscles of the hand; and, after excluding __________, each would require to be considered
MS
Multiple sclerosis - MRI The ulnar nerve can be involved with an injury to the right elbow, associated with an increased _____________, giving the so-called ‘tardy’ ulnar palsy from chronic stretching of the nerve
carrying angle
The ulnar nerve supplies C8-T1 sensation to the hand, and supplies the interossei and hypothenar muscles of the hand and the abductor of the ___________
thumb
As the condition becomes more advanced there is weakness and wasting of the small muscles of the hand with an ulnar ‘_____________’.
claw hand
A right upper lobe bronchogenic carcinoma may involve the T1 nerve root and result in weakness and wasting of the ___________________ of the right hand
small muscles
Pancoast syndrome is seen when an upper lobe neoplasm causes pain in the shoulder and arm as a result of nerve root involvement and involves the sympathetic trunk, resulting in a constricted pupil, ptosis, and _______________of the face (Horner syndrome)
anhydrosis
Syringomyelia is a condition involving the _____________ cord
cervical spinal
Cavities appear near the centre of the spinal cord and may communicate with the canal
Syringomyelia
With progressive expansion there is disruption of spinothalamic neurones, and lateral extension may damage lateral horn cells and also compress the motor tracts.
Syringomyelia
The condition typically presents in the third or fourth decade, with an insidious onset of upper limb impairment of pain and temperature sensation and retention retention of touch (dissociated sensory loss), often asymmetrical, which may be accompanied by wasting of the small muscles of the hand (a common early feature) and upper motor neurone symptoms and signs affecting the lower limbs.
Syringomyelia
Motor neurone disease is an uncommon progressive disorder, of unknown cause, in which there is degeneration of spinal and cranial motor neurones and pyramidal neurones in the ___________________.
motor cortex
It may present with wasting of the small muscles of the hand, usually accompanied by evidence of upper motor neurone lesions in the lower limbs.
Motor neurone disease
Tremor is defined as rhythmic movement resulting from alternating contractions and relaxation of groups of muscles, which produces oscillations about a ___________________________
joint or groups of joints.
The pattern most frequently seen is rapid and fine in amplitude and is an exaggeration of _____________________________.
physiological tremor
The fine tremor that occurs only on activity, and is not present at rest, is usually either _________________________ or exaggerated physiological tremor
benign essential tremor
Benign essential tremor is one of the most common neurological disorders, with an estimated prevalence of __________________, increasing with age.
0.1-5%
An autosomal dominant family history is present in 50-60% of patients: the genetic basis is unknown.
benign essential tremor
Functional imaging reveals abnormal cerebellar activity; no histological or structural changes have been identified
benign essential tremor
Age of onset is bimodal, with the largest peak in the second decade, and a smaller peak in the fifth decade.
benign essential tremor
The characteristic finding is a postural and kinetic tremor of the upper limbs which interferes with fine manual tasks (_______________ is also present in 40%; less commonly legs are involved or have tremors).
head tremor
With advancing age, the tremor frequency often slows and amplitude increases, leading to a coarse tremor which can be _________________, although this is uncommon.
disabling
Patients with benign essential tremor often drink as a means of controlling the tremor; ____________has an ameliorating effect in 50% of cases.¹
alcohol
Chronic anxiety or hyperthyroidism may each be associated with an exaggerated physiological tremor, but the resting ____________________ would be expected to be higher and there would be other features of these conditions.
heart rate
The tremor of Parkinson disease typically occurs at rest and is suppressed rather than augmented by ____________-.
activity
The long-term consequences of an electric shock may include chronic anxiety or a CONFITIONE form of ___________________
post-traumatic stress disorder
In the absence of initial neurological injury no neurodegenerative disorder would arise.
benign essential tremor
The history given of increasing confusion over some weeks and a major problem with his speech (marked expressive dysphasia) is highly suggestive of a cerebral lesion in the _____________________region of the dominant hemisphere
frontoparietal
The CT head scan shows a focal relatively homogeneous low attenuation lesion in the left parietal region, surrounded by an area of rim enhancement, extending also into the ___________________.
frontal lobe
There is minimum midline shift. This is highly suggestive of a ______________________ (A is correct).
cerebral tumour
The most common cerebral tumours in adults comprise __________________________, although these are often multiple and do not usually show rim enhancement.
secondary neoplasms
With metastatic cerebral neoplasms, the primary site may be occult. The most common primary site is lung, particularly ________________________.
small cell cancer
Malignant melanoma appears to have specific predilection to metastasise to brain; and renal carcinoma is another common primary site, together with ________________________
breast cancer in women
Appropriate imaging is helpful in identifying ____________________primary malignancies.
occult
The most common primary tumour in adults is the glioblas- toma multiforme, which is also the most ________________-
malignant
Othertypes of primary brain tumour include the somewhat less aggressive astrocytoma, oligodendro- orches OO glioma, ependymoma, and (in children) __________________________-.
medulloblastoma
Meningiomas, by contrast, arise from the meningeal coverings of the brain their growth pattern is expansive and not ______________________
infiltrative
A cerebral embolism usually requires a defined source-from the heart, aorta or carotid artery-associated with a history of sudden onset __________________.
neurologic deficit
Confirmation of this diagnosis requires demonstrable occlusion within an intracerebral artery, in this case the left middle cerebral artery, by use of ____________________-.
CT or MR angiography
Cerebral infarction may occur as a result of embolism or thrombosis with a resultant _______________________ defect.
wedge-shaped
A _________________________ presents as a sudden onset of neurological deficit, unlike this presentation.
cerebral haemorrhage
The CT will show a hypodense lesion which may extend irregularly, involve the lateral ventricles, and be associated with surrounding oedema exhibited as low attenuation with effacement of the ______________.
sulci
A cerebral tuberculoma is usually associated with central caseation and a more ________________appearance.
heterogeneous
There is nothing in the history to suggest prior tuberculous infection.
cerebral tumour
of regularly consumed alcohol in the elderly is sufficient to produce a _____________________ state (B is correct).
mild confusional
Hypothyroidism is uncommon, but certainly must be considered in these circumstances. Fat embolism is a well described complication of _____________________, but is uncommon.
long bone fractures
The chest X-ray shows a characteristic pattern of diffuse bilateral pulmonary infiltrates and, in this instance, the normal chest X-ray virtually excludes the diagnosis of __________________________-
fat embolism.
Patients with rapidly developing ascites, with tense abdominal distension, can develop dysaesthesia symptoms of tingling and numbness in the distribution of the lateral cutaneous nerve of the thigh (meralgia paraesthetica), associated with pinching of the nerve as it passes through the fibrous tunnel beneath the inguinal ligament just medial to the __________________________ (D is correct).
anterior superior iliac spine
Infiltration with local anaesthesia can provide temporary relief, or surgical release can be performed by opening up the tunnel.
meralgia paraesthetica
This syndrome of nerve entrapment is also seen in obese patients with pendulous lower abdominal folds, and in army recruits undergoing strenuous physical training.
meralgia paraesthetica
Other common nerve entrapment/impingement syndromes include carpal tunnel syndrome and the less common tarsal tunnel syndrome, ulnar nerve entrapment around the medial epicondyle, plantar digital neuritis (Morton metatarsalgia), and cervical and lumbar nerve root impingements from intervertebral disc prolapse as the nerve roots emerge through the neurovertebral canals giving ______________________.
branchialgia or sciatica
The distribution of paraesthesiae in this patient is of the peripheral nerve and not the pattern of lumbar nerve root impingement from lumbar disc prolapse.
meralgia paraesthetica
Similarly, an alcoholic peripheral neuropathy is more likely to be of ‘glove and stocking type’ affecting the _____________________.
foot and lower leg
The aortic bifurcation (Leriche) syndrome is associated with a thrombus or plaque at the aortic bifurcation, with symptoms of bilateral ischaemic buttock _________________________
claudication and impotence
The Budd-Chiari syndrome is a complication of hypercoagulable states with hepatic vein occlusion resulting in hepatosplenomegaly, ascites, jaundice and ________________________.
portal hypetension
Nocturnal leg discomfort can be due to a number of causes. Diagnosis is helped by a careful history of the specific symptoms and of precipitating and ________________-factors.
ameliorating
Vascular insufficiency needs to be excluded by the following features. Ischaemic rest pain due to arterial insufficiency signifies critical ischaemia and pregangrene, and may or may not have a preceding history of worsening ________________________.
exertional muscle claudication
When rest pain supervenes, the pain is a constant burning discomfort felt peripherally in the foot or toes, is worse at night, and may be temporarily eased by hanging the leg over the side of the bed.
Ischaemic rest pain
Signs of peripheral arterial disease will be present (diminished or absent peripheral pulses and circulatory return, venous guttering and skin pallor and coldness, positive signs of dependency rubor and elevational pallor, and a low ankle/brachial blood pressure ratio).
Ischaemic rest pain
Chronic venous insufficiency (CVI) can give a feeling of bursting ____________________.
discomfort
aggravated by walking and relieved by recumbency.
Chronic venous insufficiency (CVI)
Physical examination will show signs of lower leg venous flares, skin pigmentation and subcutaneous induration.
Chronic venous insufficiency (CVI)
‘Saint Vitus dance’ was used as a name for involuntary writhing or jerking movements, subsequently known as _______________________(Greek not fixed) or chorea (Greek - dance).
athetosis
Choreas and other dystonias are of various causes, most often associated with disorders of the basal ganglia, caudate nucleus and putamen, or from pharmacological therapies with ______________________ ___________________________
dopaminergic drugs used for Parkinsonism.
Nocturnal muscle cramps are common. They occur as a sudden episode of painful muscle cramping in the calf, often accompanied by a painful and tender palpable ____________________of contracted muscle.
knot
They can occur also during the day or after vigorous exercise and in salt depletion.
Nocturnal muscle cramps
When nocturnal they often awake the person from sleep. The pain is transitory but severe, and is eased by extension of the ankle and by getting up and walking about.
Nocturnal muscle cramps
Stretch exercises of ankle extension or quinine sulphate 300mg at night may help as preventives
Nocturnal muscle cramps
Restless legs syndrome (Ekbom syndrome) is a common but poorly understood disorder of middle-aged and elderly people, consisting of an uncomfortable urge to move the legs, with an uncomfortable sensation ______________________.
worse at night at rest
worse at night at rest. and eased by activity
Restless legs syndrome (Ekbom syndrome)
Symptoms vary in severity and no constant association with other disease states is present: but exclusion of anaemia, hypothyroidism, renal insufficiency and diabetes as precipitating causes is recommended.
Restless legs syndrome (Ekbom syndrome)
Symptoms vary in severity and no constant association with other disease states is present: but exclusion of anaemia, hypothyroidism, renal insufficiency and diabetes as precipitating causes is recommended.
Restless legs syndrome (Ekbom syndrome)
Stretching exercises prior to bedtime, and up and down leg movements (‘sewing machine legs’), may keep symptoms at bay without _____________________-.
having to get up and walk
A familial history is common and suggests an autosomal dominant inheritance with variable penetrance.
Restless legs syndrome (Ekbom syndrome)
Apart from treating any associated medical condition, medications tried have. included dopamine agonists, or anticonvulsants (gabapentin) when the restlessness is accompanied by significant _____________________.
pain
The diagnosis is spontaneous rupture of the extensor pollicis longus tendon. In a woman with a history of previous wrist and hand pain as outlined, __________________________________ would be the most likely primary diagnosis (E is correct).
rheumatoid arthritis (RA)
RA is typically associated with inflammatory change involving joint and soft tissues, and spontaneous rupture of the long tendons of _______________________ extensors is typical as they cross the wrist.
finger or thumb
The long tendon of extensor pollicis longus (EPL), with its oblique course from the radial tubercle, is at significant risk.
spontaneous rupture of the extensor pollicis longus tendon.
De Quervain tenosynovitis, a stenosing tenosynovitis involving the tendon sheath of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB): the latter tendon extending the metacarpophalangeal joint of the thumb, not the_____________________
(distal) interphalangeal joint.
Spontaneous rupture of either APL or EPB in association with ______________________ disease is, in any event, rare.
De Quervain
Dupuytren contracture affects the palmar aponeurosis and can cause finger flexion deformities, but rarely affects the ______________.
thumb
Xanthoma of the tendon sheath usually presents as a firm nodule of the fibrous flexor tendon sheath of a finger and is not associated with ________________________.
spontaneous tendon rupture
A ‘mallet’ deformity of the distal interphalangeal joint of the finger results from a hyperflexion injury, causing rupture of the terminal slip of the _________________________of the finger to the distal phalanx
extensor tendon
Avulsion of the tendon from the bone may be accompanied by avulsion of a flake of bone.
‘mallet’ deformity
Physical examination is diagnostic - there is a flexion deformity of the distal finger joint which can, however, be fully flexed.
‘mallet’ deformity
There is an extension deficit or lag, with incomplete active extension at the distal interphalangeal joint, which can, however. be _______________________ (C is correct).
passively extended fully
The pinch grip between finger and thumb is unaffected.
‘mallet’ deformity
There is no interference with movement of the proximal interphalangeal joint.
‘mallet’ deformity
Flexion of the distal interphalangeal joint is unaffected, and the volar pulp space is _________________________.
uninjured and unaffected
The patient exhibits the typical deformity of a fracture of the left outer clavicle, with elevation of the inner fragment and depression of the outer fragment, associated with __________________________-
a dropped left shoulder
Dislocated glenohumeral joint gives a different deformity, with flattening of the normal round shoulder _____________________.
contour
Dislocated acromioclavicular joint gives a more lateral step deformity of the shoulder tip at the site of the _____________________________-.
acromioclavicular joint
Costochondritis (Tietze syndrome) is not usually associated with visible deformity but evinces local tenderness and pain over the _____________________.
second costochondral joint
Dislocated sternoclavicular joint gives a prominence over the _____________________________________
displaced medial end of the clavicle.
These fractures commonly occur from direct local trauma consequent upon a fall onto the shoulder in elderly patients commonly elderly women with osteoporosis/ osteopenia.
fractured surgical neck of the humerus
Acromioclavicular joint subluxation occurs when the strong coracoclavicular ligaments, which bind the outer clavicle to the underlying _______________-process, are ruptured.
coracoid
The integrity of the acromioclavicular articulation depends on these ligaments; the capsular ligaments of the joint itself comprise only a _______________________.
weak fibrous capsule
rotator cuff tendinitis follows repeated chronic strain injuries to the rotator cuff, particularly repeated intrasubstance tears of its ______________________component.
supraspinatus
Dystrophic calcification can be detected on plain X-ray and by ultrasound and MRI.
rotator cuff tendinitis
Fracture surgical neck of humerus Adhesive capsulitis of the glenohumeral joint can follow immobility associated with _______________________ and is not detectable by plain X-ray.
rotator cuff tears
The most common form of shoulder (glenohumeral) joint dislocation is an ______________________
anteroinferior dislocation.
In this film the humeral head appears to be enlocated without dislocation.
fractured surgical neck of the humerus
The history of an acute lifting strain, followed by the constellation of clinical features described, is most likely due to a ___________________________________ affecting the lumbosacral intervertebral disc between L5 and S1
focal left posterolateral disc prolapse
His symptoms and signs are typical of sensory and motor involvement from impingement on the left _______________root.
$1 nerve
Posterolateral disc prolapses typically cause impingement on the spinal nerve root corresponding to the ______________vertebrae.
lower
The aim with open (compound) fractures of bone is to convert them as expeditiously as possible to _________________(simple) fractures.
closed
This requires, most importantly, adequate and early wound debridement (wound toilet), with excision of all dead or doubtfully viable tissue from the skin down to the fracture site, plus removal of any introduced ___________________
foreign material
Antibiotics and maintained anatomical reduction are additionally helpful; the latter may require internal fixation to stabilise the ________________.
fracture
Limb elevation and adequate nutrition are also additionally helpful.
the fracture
Motor vehicle crash injuries may include each of the options mentioned. Deceleration injuries caused by the knee hitting the dashboard with transmitted violence to the hip are common; and the most common such injury is a _______________________
posterior dislocation of the hip
The posterior capsular ligaments are less strong than the anterior ones.
posterior dislocation of the hip
An accompanying fracture of the posterior acetabular rim is common, and associated injury to the stretched ___________________- should be checked.
sciatic nerve
The leg is painful and shortened at the hip, and flexed and internally rotated at the ___________________-as illustrated.
hip
The knee shows an abrasion consistent with a dashboard injury. The hip is painfully sensitive to any further movement. After radiologic imaging to rule out associated fractures, and checking for sciatic nerve injury, reduction _____________________________– with muscle relaxation should be done as soon as possible.
under general anaesthesia
Fractured neck of femur is associated with external rotation and, in a young adult, is a much less common injury than __________________.
dislocated hip
Fractured femoral shaft causes thigh deformity and __________________-.
swelling
Dislocated acromioclavicular (AC) joint gives a typical step deformity at the top of the right shoulder at the AC joint, as shown in the illustration, due to rupture of retaining __________________________.
coracoclavicular ligaments
Dislocated glenohumeral joint gives a characteristic flattening of the ________________muscular cowl as illustrated in the left picture above.
deltoid
Acute rupture of the rotator cuff mechanism in its supraspinatus component results in inability to abduct the arm more than about 40° in the presence of an actively contracting __________________.
deltoid muscle
Fracture of the surgical neck of the humerus is seen in older patients with ________________________
local bruising and tenderness.
Rupture of the long head of biceps tendon gives a characteristic deformity of the biceps muscle when __________-.
contracted
The most likely diagnosis with this scenario is a ruptured Achilles tendon, which can be complete or partial, and is frequently provoked by ________________________ in patients within this age group.
exercise such as squash
The diagnostic findings are a tender defect in the lower part of the tendon just above the heel, weakness on plantar flexion of the foot at the ankle with inability to stand on the toes, and an increased range of passive ____________________ of ankle
dorsiflexion/extension
A tender thickening, rather than a gap defect, may be found in partial tears.
ruptured Achilles tendon
The injury is one of a spectrum of spontaneous tendon ruptures occurring in a tendon with pre-existing wear-and-tear attrition.
ruptured Achilles tendon
Recurrent anterior glenohumeral shoulder dislocation from minor strain or trauma is often associated with a traumatic Hill-Sachs deformity (flattening or a wedge- shaped defect in the posterolateral humeral head), predisposing to ___________________________
instability and recurrent dislocation
In recurrent dislocations, reduction under intravenous or oral analgesia is usually easy and can be performed immediately in the __________________
Emergency Department
Shoulder strapping may help prevent subsequent dislocation but a shoulder orthosis is usually too cumbersome; intra-articular injection of steroids or sclerosants are both ________________________
inappropriate and potentially hazardous
The X-ray demonstrates an inferior dislocation of the shoulder at the glenohumeral joint [______________________________________).
the most common type of dislocation
The axillary nerve runs anteriorly to posteriorly just below the capsule of the joint and is prone to stretching injury in such a dislocation.
inferior dislocation of the shoulder
Testing for axillary nerve function is essential prior to manipulative reduction (just as testing for integrity of the sciatic nerve is essential with a _______________________).
posterior hip dislocation
The axillary nerve supplies the _______________muscle, the motor function of which should be tested at once
deltoid
The axillary nerve supplies the _______________muscle, the motor function of which should be tested at once
deltoid
The patient clearly will be unable to abduct the arm because of the dislocation, so isometric contraction should be tested by asking the patient to tense the _______________muscle against resistance without active movement.
deltoid
Sensory loss should also be checked - a small area of sensory loss on the outer aspect of the upper arm will also occur if the nerve is damaged.
The axillary nerve
Complete recovery from a stretch injury usually occurs within weeks or months.
The axillary nerve
The nerve to latissimus dorsi is situated posterolaterally in the axilla and would not be at risk with an _____________________-.
anterior dislocation
Nerves to pectoralis major and serratus anterior lie medially in the axilla and would not be at risk.
anterior dislocation
Cervical spine injuries require expert imaging to diagnose or exclude bony fractures and _______________.
dislocations
Lateral views of the supine patient are needed to show all seven cervical vertebrae, as well as anteroposterior and oblique views to show facet joints and facet joint ______________-.
arthropathy
Oblique views are also required to show intervertebral foraminae. The odontoid peg and any C1-C2 fracture dislocation require additional views, with functional views in flexion and extension to diagnose anterior or posterior ____________________________.
ligament damage
The circumferential plaster cast is too tight and must be completely split to relieve continuing compression and the real risk of Volkmann ischaemic contracture after this severely comminuted _________________________ fracture
distal radial (Colles)
Encouraging active finger exercises, elevation of the limb and support with a sling, further X-ray to check continuing adequacy of reduction, and another review within 24 hours (after splitting the plaster), are all appropriate treatments, but the first step is to ensure _______________________
relief of compression.
A male patient of this age needs investigation for a secondary cause of his osteoporosis, rather than acceptance of the diagnosis of idiopathic _______________.
osteoporosis
Thiazide diuretics have beneficial effects on bone _______-
density
Hypogonadism, as an effect of radiation to the groin, is the most likely reason for this patient’s _____________________in this setting
osteoporosis
Body weight is associated with bone density, and ___________________-may have a protective effect on bone loss
obesity
Type 2 diabetes mellitus has no specific associations with ________________.
osteoporosis
Alcohol can cause increase in urate levels and gout; however, in a patient presenting with systemic symptoms and a swollen joint, the immediate issue is ruling out an _______________ joint.
infected
This will need joint aspiration for cell count, microscopy and culture; and, if there is evidence of infection, ____________________of the joint may be required
drainage
the patient will need urgent systemic antibiotic treatment
infected joint
The common organism is Staphylococcus aureus and treatment of choice is intravenous flucloxacillin, not gentamicin.
infected joint
A slightly elevated urate level does not make the diagnosis of gout, so that estimation of serum urate levels may __________ definitively diagnostic.
not be
Even in an infected joint one might see occasional _______crystals.
urate
_________________ fractures can be classified into two major types intertrochanteric/ pertrochanteric basal extracapsular fractures, and subcapital basicervical fractures, which occur within the joint capsule.
Femoral neck
Malunion may occur in any of the types. Infection following surgical treatment can occur with any type of ______________________________.
fracture
. It is for this reason of likely nonunion that the treatment of elderly people with a displaced subcapital fracture is often better with a ___________________replacement than an internal fixation (C is correct).
prosthetic
Avascular necrosis (AVN) of the femoral head can occur because of disruption to the blood vessels. The blood supply to the femoral head is essentially from the _________________________________- running along the neck, and these supply the major portion of the head
circumflex subsynovial blood vessels
Sudden onset of neurological deficit in a patient who has multiple vascular risks is highly suggestive of a ___________________________
cerebrovascular accident (CVA).
An older person who develops acute confusion should be investigated for underlying physical causes of ________________-.
delirium
A CVA in a person who is confused and on warfarin could be from a cerebral haemorrhage from a _________________.
high INR
This patient’s computed tomography (CT) scan. done without contrast, demonstrates cerebral infarction with _____________________
secondary haemorrhage
The oedema in the right occipital horn and the mild mass effect, with partial effacement of the right occipital horn and sulci, are very obvious.
cerebral infarction
where there is chronic confusion, incontinence and gait disturbance, with typical CT scan findings.
normal pressure hydrocephalus
There are no CT scan findings to suggest brain tumour. If there were any suggestions of a tumour, with secondary bleeding, one would repeat the scan or do a __________________________________-
magnetic resonance imaging (MRI) of the brain
The history of subdural haemorrhage is of sudden onset of headache and a CT scan will show blood in the subarachnoid space and ________________________-.
ventricles
This scenario is one of acute monoarticular gout in the right knee, with the clinical presentation as an acute effusion and the diagnostic findings of negatively birefringent crystals on microscopy, negative microbiological culture and excellent and prompt response to ________________________.
indomethacin
Clinically, gout can be hard to distinguish from several other conditions, including septic arthritis and chondrocalcinosis or ____________________-.
pseudo-gout
Chondrocalcinosis is caused by deposition of calcium pyrophosphate, rather than uric acid; these crystals are rhomboid and ____________________________ on polarised light.
positively birefringent
A definitive diagnosis of ____________________requires aspiration of synovial fluid from the affected joint or tissue.
gout
The fluid is examined by light microscopy for crystals of monosodium urate intracellularly within ______________________
polymorphonuclear leucocytes
The urate crystal has a needle-like morphology and strong ___________________birefringence under polarised light
negative
A common misconception is that a diagnosis of acute gout requires the demonstration of an _______________________.
elevated plasma urate
plasma urate is within normal limits in about two thirds of cases of acute gout; moreover many subjects with elevated urate levels never have ____________________
an attack of gout.
It is usually introduced into the treatment regimen of chronic recurrent gout 4 weeks after resolution of an acute attack.
allopurinol
Allopurinol is contraindicated in the setting of acute gout. In this patient with a first documented attack of gout, the correct early management would include giving appropriate ______________________.
dietary advice
__________________________ sources of purine (such as beef and seafood) greatly increase the risk of developing gout.
Animal flesh
intake would be prudent given there is a link between alcohol intake, obesity, hypertension and hyperuricaemia
gout
Any past episodes of renal colic or renal calcui, as in this patient, or any evidence of tophaceous gout, are very strong indicators for future ___________________therapy, irrespective of the modification of existing risk factors.
allopurinol
Importantly, when introducing allopurinol, the starting dose must be ____________________ and the dose adjusted slowly.
low (50-100mg)
Importantly, when introducing allopurinol, the starting dose must be ____________________ and the dose adjusted slowly.
low (50-100mg)
Colchicine is a suitable alternative for acute gout, but is less effective and more difficult to get the dose right without adding to the patient’s woes with onset of _________________, a dose-dependent phenomenon.
diarrhoea
It is not used for secondary prevention and has no effect in preventing hyperuricaemia, renal calculi, or tophi development.
Colchicine
continuation of ____________________-would be inappropriate and potentially dangerous, with risk of aggravation of hypertension, development of peptic ulceration and other complications.
indomethacin
The use of paracetamol is appropriate chronic therapy for pain relief in _______________________
osteoarthritis
Progressive muscle weakness and skin rashes in a female of this age group is highly suggestive of __________________.
dermatomyositis
Her hands show the typical Gottron sign erythematous, scaly eruptions over the knuckles of interphalangeal and metacarpophalangeal joints
dermatomyositis
The creatine kinase (CK) is also raised
dermatomyositis
________________________ presents as a multisystem disease; muscle weakness is an uncommon presentation and CK is usually not elevated.
Systemic lupus erythematosus (SLE)
_________________- is a disease of the older person. It presents with proximal muscle weakness, muscle tenderness and often a raised erythrocyte sedimentation rate (ESR).
Polymyalgia rheumatica
Inclusion body myositis presents with predominantly __________-muscle weakness
distal
_____________-presents with Raynaud phenomenon and tight skin
Scleroderma
____________________________- consists of calcinosis of subcutaneous tissue in the hands, Raynaud phenomenon, oesophageal reflux.
Limited scleroderma (CREST syndrome)
sclerodactyly and telangiectasia, usually involving the hands and mouth.
Limited scleroderma (CREST syndrome)
This 36-year-old man has a chronic multisystem disease with joint, neurological and skin manifestations, fever and hypertension. The clinical features are highly suggestive of polyarteritis nodosa with vasculitis and mononeuritis - the key features of the ______________________.
arteritis
A muscle biopsy is likely to confirm the diagnosis of ____________________- showing histological evidence of necrotising vasculitis affecting small arteries
polyarteritis nodosa
Patients are usually 60 to 80-year-old men; women present at an older age.
Aortic dissection
Pre-existing aortic aneurysm is a risk factor.
Aortic dissection
Inflammatory vasculitides [giant cell arteritis, syphilitic aortitis and Takayasu arteritis) are other predisposing factors
Aortic dissection
Collagen diseases such as Marfan syndrome should be suspected in a younger age group.
Aortic dissection
Patients present with severe ‘sharp chest pain’. Depending on the aortic branches affected, limb or organ ischaemia can follow.
Aortic dissection
A pulse deficit is often seen, such as radio-radial delay or weak carotid, brachial or femoral pulses. Widened upper mediastinum on chest x-ray With the scenario as described, the widening of the aorta on the chest X-ray should be diagnostic.
Aortic dissection
This patient had a subsequent ________-of the chest, which confirmed the aortic dissection
CT
One may see a pericardial effusion along with aortic dissection, but there is nothing to suggest pericardial effusion on the ________.
chest X-ray
Acute gripping nocturnal calf pain is a common clinical condition of middle age, associated with muscular cramping and spasm, such that the pain is often intense and acute and associated with a firm, ______________ of the affected calf (A is correct).
painful knotting
The pain is acute in onset and eases over a few minutes, sometimes leaving significant residual soreness
nocturnal calf pain
Relief is also obtained by getting up and walking or extending the ankle and foot.
nocturnal calf pain
Ischaemic rest pain, on the other hand, is an intense pain felt peripherally in the foot and toes, _________________- in nature, often worse at night.
burning or throbbing
Pain may be relieved by hanging the foot over the side, but ___________________ is indicative of critical limb ischaemia from peripheral vascular disease.
ischaemic rest pain
Peripheral neuropathy is common in _________________, and is associated with sensory dysaesthesias in the leg, with tingling, pins and needles and burning discomfort.often of ‘glove and stocking’ distribution
diabetes
Deep venous thrombosis can cause symptoms of deep seated calf pain and tenderness, with or without other stigmata of oedema, colour change, deep tendemess and systemic effects of ____________________-.
fever and tachycardia
Intermittent claudication pain is precipitated by __________________-, and as defined does not come on at rest.
exertion
If this patient’s problem was only ischaemic intermittent claudication, then _______________________- including cessation of smoking and encouragement of exercise would be beneficial.
conservative measures
However, this man has rest pain and an ankle-brachial index suggestive of critical ischaemia. Active intervention is required if he is _________________________
not to lose his limb.
Certainly his lipid profile must be measured and, if necessary, measures taken such as the use of lipid-lowering agents.
ischaemic intermittent claudication
His blood sugar levels must be measured. His hypertension needs treatment. The most important observation is that this man warrants an arteriogram and further assessment
ischaemic intermittent claudication
Duplex Doppler venous studies will not identify an arterial blockage, which is the most likely diagnosis.
ischaemic intermittent claudication
For uncomplicated claudication any abnormal lipid profile, diabetes or hypertension should be treated.
ischaemic intermittent claudication
The most useful therapy is to persuade the patient to stop smoking and to try and improve the walking distance
ischaemic intermittent claudication
There may be a role for pentoxifylline, but a number of randomised control trials have shown only a moderate benefit with this drug.
ischaemic intermittent claudication
Antiplatelet drugs (clopidogrel, aspirin) are often prescribed to reduce the overall risk of myocardial infarction and stroke
ischaemic intermittent claudication
This is a time when patients are at increased risk of cardiac arrhythmias, and particularly concerning are episodes of ventricular tachycardia, as illustrated in Rhythm strip A, showing a short period of sinus rhythm followed by ventricular tachycardia at a rate of 180/min (A is correct).
arrhythmia occurring 24 hours after an acute non-ST segment elevation myocardial infarction (non-STEMI).
This may be associated with haemodynamic compromise, as in this patient, and require urgent DC reversion.
ventricular tachycardia
The recurrent arrhythmia is most likely to be that of paroxysmal supraventricular tachycardia as demonstrated by his current ECG which shows a regular tachycardia at a rate of 180/min.
regular tachyrhythmias that have a narrow QRS complex on electrocardiogram (ECG),
are characterised by a re-entry circuit or automatous focus involving the atria
paroxysmal supraventricular tachycardia
may be managed by manoeuvres that increase vagal tone, including stimulation of nasopharyngeal afferents by immersing the face briefly in cold water, something he had discovered. Other methods of enhancing vagal tone are carotid sinus massage (caution is required in the elderly). and the Valsalva manoeuvre
paroxysmal supraventricular tachycardia
If these are ineffective, the first line therapy is either adenosine or verapamil given intravenously
paroxysmal supraventricular tachycardia
If unsuccessful at first use, manoeuvres to increase vagal tone can be repeated, followed by further bolus injections of verapamil or adenosine
paroxysmal supraventricular tachycardia
Mitral stenosis is the heart lesion most likely to cause problems in _________________
pregnancy
The pregnancy-induced increase in blood volume, cardiac output, and elevation of the pulse can lead to pulmonary hypertension and pulmonary oedema in _________________ in pregnancy
mitral stenosis
There is an increased risk of atrial fibrillation and tachycardias
mitral stenosis in pregnancy
In contrast regurgitant mitral, aortic and tricuspid valvular diseases are generaly well tolerated in pregnancy, with the pregnancy-induced decrease in periphera vascular resistance reducing the risk of _____________________ in these valvular lesions.
cardiac failure
___________________________ is usually well tolerated in pregnancy, in the absence of pulmonary hypertension, provided pre-pregnancy cardiac status is satisfactory.
Ventricular septal defect
____________________ is usually characterised by varying degrees of chest pain or discomfort, sweating, weakness, nausea, vomiting and arrhythmias.
Acute myocardial infarction
Atypical symptoms include fatigue, weakness and syncope
Acute myocardial infarction
Chest pain is the most common symptom but chest pain with acute myocardial infarction is less common in women than in men.
Acute myocardial infarction
__________________________ is usually detected on an electrocardiogram (ECG) or imaging testing some time after the event.
Silent myocardial infarction
Approximately one in three myocardial infarcts is silent. This occurs more commonly in ___________ and in patients with diabetes
older patients
Cardiac autonomic neuropathy is thought to be a contributing factor to the ‘silence’ in this disorder.
Acute myocardial infarction
_____________ is a cause of hyperviscosity and is associated with an increased incidence of myocardial infarction, but there is no increased frequency of silent myocardial infarction in this disorder
Polycythaemia vera
________________and hypercholesterolaemia are major risk factors for acute myocardial infarction but not particularly related to silent myocardial infarction.
Hypertension
_____________________is a major risk factor for coronary artery disease, and treatment of hypertension reduces the risk of coronary artery events by about a third.
Hypertension
The most. important reversible risk factor for coronary artery disease is _____________________.
hypercholesterolaemia
____________________is a major risk factor for peripheral arterial disease.
Hypertension
Treatment of hypertension can reduce the risk of developing peripheral arterial disease, but the most common and important risk factor for peripheral arterial disease is ________________.
smoking
Renal artery stenosis is a potential cause of __________________.
hypertension
This is particularly true for fibromuscular disease.
Renal artery stenosis is a potential cause of hypertension
Atherosclerotic disease may also be a cause of ____________, but more frequently it reflects generalised atherosclerotic macrovascular arterial disease.
hypertension
Hypertension is a common cause of intrarenal arterial and arteriolar thickening and, over the long term, is a cause of ___________
chronic renal impairment
The presence of __________________is associated with a four to six fold increase in stroke risk
hypertension
The link between blood pressure and stroke is clearly a linear association and ________________of risk with drug treatment has been convincingly demonstrated in multiple large-scale long-term clinical trials
reversibility
Hypertension accounts for about 50% of the stroke risk in most communities. _________________is the single most important reversible risk factor for ischaemic stroke.
Hypertension
Indeed, the great majority of ischaemic events are silent, as shown by cerebral imaging. Cognitive decline and _____________are commonly associated with such events.
dementia
________________is even more strongly associated with the risk of haemorrhagic stroke.
Hypertension
Hypertension and hypertensive heart disease, with the development of left ventricular hypertrophy and diastolic dysfunction, is an important risk factor for _________________.
atrial fibrillation
Hypertensive heart disease accounts for about 20% of cases of ____________________
atrial fibrillation.
With older age, the other major contributing factors to atrial fibrillation are loss of __________________________ and coronary ischaemia.
atrial pacemaker cells
An aortic systolic gradient of 55mmHg means that during systole the pressure in the aorta is 55mmHg lower than the pressure in the _____________
left ventricle
A normal gradient is less than 10mmHg. If the cardiac output is normal, then a gradient greater than 50 mmHg is an indication for __________
surgery
cardiac output is reduced, for example as a result of ischaemic cardiomyopathy or cardiac failure, then a gradient of 55mmHg is even more significant and indicates very severe _________________
aortic stenosis (AS).
The presence of coronary artery disease is very common in __________________patients with calcific AS.
elderly
Assessment of the patient with AS will therefore include tests for coronary ischaemia and definition of coronary arteries pathology with _____________-.
angiography
It should be noted that some patients with AS will have ______________even with relatively normal coronary arteries.
angina
The explanation for this is that ____________is associated with left ventricular hypertrophy and the penetrating branches arising from the epicardial coronary arteries are unable to meet the oxygen supply demands of the thickened left ventricle during exertion or effort.
AS
Traumatic posterior dislocation of the knee is particularly liable to be complicated by ___________________
popliteal artery injury
The artery lies close to the joint posteriorly in the deep groove between the femoral condyles, and is tethered above and below the knee joint by branches to periarticular structures.
popliteal artery
predisposing to vascular injury from stretching and tearing of the artery if displacement is significant.
popliteal artery
Elbow dislocation may also be associated with vascular injury the brachial artery, but this complication is less of a risk than vascular complications of ______________ because tethering of vessels across the elbow is less.
knee dislocation
_______________________ dislocation (respectively anterior and posterior), are each at risk of nerve injury by Posterior dislocation of knee stretching axillary and sciatic nerves respectively, but vascular injury is decidedly uncommon, as is the case with ankle dislocations.
Shoulder and hip
The history is suggestive of an __________________ in the lung. This could be a lower respiratory tract infection (LRTI) or an exacerbation of chronic obstructive pulmonary disease (COPD).
acute infection
The chills and fever should alert the clinician to the likelihood of ____________________or systemic inflammatory response.
bacteraemia
The chest X-ray shows a well delineated shadow in the right upper zone. This is suggestive of a consolidation in the right upper lobe and the diagnosis in view of the history is _________________
right upper lobe pneumonia
The immediate bacteriological investigations are blood cultures, and sputum microscopy with Gram stain and cultures
right upper lobe pneumonia
Right upper lobe pneumonia If the pneumonia does not respond to appropriate antibiotics, one would think of tuberculosis or tumour and investigate this patient accordingly by bronchoscopy and search for tuberculosis and _________________ on microscopy.
acid-fast bacilli
Aspergillus fumigatus infection tends to attack previously diseased/scarred upper lobes, and often forms a _________________-.
mycetoma
There is no suggestion of a pulmonary _______________here and so a computed tomographic pulmonary angiogram (CTPA) will not be the investigation of choice.
embolism
This patient fits into the intermediate risk category of ___________________________________________ because of the following features. Chest pain or discomfort within the past 48 hours that occurred at rest, or was repetitive or prolonged.
non-ST segment elevation acute coronary syndrome (NSTEACS)
patient fits into the intermediate risk category of non-ST segment elevation acute coronary syndrome (NSTEACS) because of the following features. Age over 65 years. No high-risk changes on ECG. Two or more risk factors: hypertension, hyperlipidaemia, and past smoking. Prior aspirin use. Other intermediate risk factors he either did not have, or will need to be further assessed, are known coronary heart disease (prior myocardial infarction or known coronary lesion with >50% stenosis,_____________________________________________
diabetes, and chronic kidney disease.
He requires admission for further diagnostic evaluation and further risk stratification, with frequent ECGS (with or without continuous ST-segment monitoring), and repeat troponin testing.
patient non-ST segment elevation acute coronary syndrome (NSTEACS)
Given that he is at high risk of coronary artery disease, it is very appropriate to commence subcutaneous ___________-therapy
enoxaparin
Although there is irrefutable evidence for beta-blocker therapy in the treatment of NSTEACS (level 1 evidence, grade A recommendation), further evaluation of his __________________ is needed before considering increasing his metoprolol therapy as he may already be on an adequate dose.
heart rate
He will need an increase in his atorvastatin therapy in the intermediate term, with a target _______________________ level of < 2.0mmol/L.
LDL cholesterol
The use of clopidogrel in acute coronary syndromes is appropriate early treatment in high-risk patients (grade A recommendation), but should not be given immediately in this patient, who may well go on to early _______________________.
coronary angiography
intravenous glyceryl trinitrate is used in the setting of __________________ (grade D recommendation) which this patient does not have.
refractory pain
___________________ is a common arrythmia, with a prevalence of 0.1% in people less than 55 years of age to 10% in people above the age of 80.
Atrial fibrillation (AF)
It is more prevalent in men.
Atrial fibrillation (AF)
In developed countries ischaemic heart disease, thyrotoxicosis and hypertension are the common underlying causes of chronic AF, while _________________________ is a common cause in developing countries.
rheumatic heart disease
Transient AF is seen in post-cardiac surgery and sometimes with ______________
chest infections
Alcoholism can precipitate AF. Some reduction in ____________________ is seen in patients with AF
cardiac function
However, the most serious consequence of AF is __________________
thromboembolism
The relative risk of stroke is 2.5-3 in people below the age of 65, while this could be over 10 in the older population.
Atrial fibrillation (AF)
This could be increased if there are other risk factors like hypertension, congestive cardiac failure (CCF), diabetes and smoking.
The relative risk of stroke in Atrial fibrillation (AF)
Almost 80% of arterial embolisms originate in the heart and the lower limbs.
Atrial fibrillation (AF)
The common causes of these are thrombi originating in the ventricle, following a myocardial infarction, or in the atria in AF.
thromboembolism
The 5 P’s of acute ischaemia are Pain, Pallor, Pulselessness, ____________and Paraesthesia.
Paralysis
Patients with femoral artery thrombosis usually have a history of claudication and there will be a long history of ischaemic symptoms including _____________ in later stages.
rest pain
Smoking is a common risk factor in our community. Polyarteritis nodosa is a necrotising vaculitis often involving _________ arteries.
medium-sized
It usually affects the kidneys, gut, nerves and muscles, often sparing the lungs.
Polyarteritis nodosa
__________________________ is nonatherosclerotic, segmental inflammatory disease of small and medium sized arteries, veins and nerves of the extremities.
Thromboangilitis obliterans
It is more common in the Far East and Middle East.
Thromboangilitis obliterans
It is almost invariably seen in smokers, more commonly with home-made cigarettes with raw tobacco.
Thromboangilitis obliterans
It usually starts with distal ischaemia and ulceration in the digits and then moves more proximally
Thromboangilitis obliterans
____________________- usually is preceded by history of hypertension and aortic aneurysm and rarely with collagen diseases like Marfan syndrome.
Aortic dissection
Common presentation is with chest or back pain and, on examination, there are unequal pulses when the radial arteries are compared
Aortic dissection
pulses may be compromised, including the femoral pulses, depending on the extent of the dissection and the re-entry point.
Aortic dissection
the most likely pathology is ________leading to femoral artery embolism to the lower limb
AF
Early diagnosis of this young man’s. probable pulmonary embolism is best achieved by a _______________________
computed tomogram pulmonary angiogram (CTPA).
This ________________________computed tomography imaging has high sensitivity and specificity, and, where available, has replaced ventilation/perfusion lung scan imaging, which is often equivocal where other pulmonary pathology is present (collapse, pneumonia).
noninvasive
embolic clot in pulmonary artery Chest X-ray also is often nondiagnostic, and pulmonary collapse and infection can be difficult to differentiate from ___________________
embolism/infarction
Duplex ultrasound of calf veins may give additional information regarding the presence of deep venous thrombosis and may indicate the site of origin of the _________________
pulmonary embolus
but such studies are not of help in diagnosis of the associated lung lesion, and are not helpful in management of the urgent cardiopulmonary problem.
Duplex ultrasound of calf veins
D-dimer assay is similarly only of help in the diagnosis of deep venous thrombosis and release of fibrin degradation products by ___________.
fibrinolysis
_______________________________ can give biochemical characterisation of tumours and their pulmonary metastases
Positron emission tomography (PET)
Substrates modified to emit positron radiation are injected intravenously and localise to neoplastic cells.
Positron emission tomography (PET)
The clinical picture is classical of ___________pulmonary embolism with pulmonary infarction
postoperative
The term _______________(literally ‘a stuffing’ [with blood]) in most tissues implies permanent death of the involved tissue or organ
infarction
Fortunately, the dual blood supply of the lung parenchyma via pulmonary artery and bronchial arteries ensures that, in most cases of pulmonary infarction, the infarcted ischaemic segment recovers completely with no residual _____________________-
impairment of lung function
This patient probably has an __________________ and an oral contrast study with water- soluble contrast should be performed
anastomotic leak
The clinical leakage rate after oesophagectomy is about 5% and tends to occur between ___________ days after surgery
7-10
The clinical features of an oesophageal anastomotic leak include sudden onset of ______________ and evidence of a pleural collection or sepsis
atrial fibrillation
The most definitive method of determining the presence of a leak is to perform a contrast study.
anastomotic leak
There are many other possible explanations for this patient’s change in condition and these would include pulmonary embolism, myocardial ischaemia and pneumonia.
anastomotic leak
The pain associated with a pulmonary embolism tends to be ___________.
pleuritic
Myocardial infarction is not usually accompanied by a fever and other chest signs might be expected with a _______________
pneumonia
Each of the responses may complicate chest injury, but a __________________ is the most likely cause for this march of events
traumatic tension pneumothorax
Urgent treatment by needle thoracentesis through the second interspace in the left anterior midclavicular line will confirm or exclude the diagnosis and give relief with escape of trapped __________________ under tension
intrapleural air
Definitive management by insertion of an intercostal catheter high in the axilla can then be done semielectively, with provision of underwater pleural drainage
traumatic tension pneumothorax
Cardiac tamponade from haemopericardium presents clinically as cardiogenic shock with elevated central venous pressure and distended neck veins, muffled heart sounds and increased cardiac dullness to percussion, and a __________ Left tension pneumothorax with mediastinal shift
boot-shaped
Needle pericardiocentesis from the epigastrium to the side of the xiphoid will be diagnostic
Cardiac tamponade
Pulmonary contusion and haemothorax will give signs of diminished breath sounds accompanied by ________
dyspnoea
The percussion note is dull rather than the tympanitic note of a pneumothorax
Cardiac tamponade
Flail chest, as a result of rib fractures giving a flail segment, will give symptoms of dyspnoea and signs of _____________ proportionate to the degree of flailing
paradoxical respiration
Asthma in a young adult is usually an episodic disease where the patient may have no respiratory symptoms, or signs, between episodes of ____________________
reversible airways obstruction
Paroxysms of wheeze and dyspnoea can occur at any time, can be of sudden onset, and may even be ______________________
life-threatening.
The episodes can be triggered by known or unknown allergens, exercise, viral infections (particularly those involving the respiratory tract), or may be apparently spontaneous.
Asthma in a young adult
The attacks can last for days, hours or weeks. Patients with underlying atopy have early onset asthma, with onset in early childhood, and usually have associated features of eczema, allergic rhinitis and a strong ______________________ of the condition
family history
In an acute attack, the severity of the dyspnoea is usually a marker of the disease severity but may also be influenced by psychological factors, such as _______________, in addition to the asthma
anxiety
The chest examination in a patient with acute asthma usually reveals a hyperinflated chest with numerous high-pitched polyphonic expiratory and inspiratory _____________________
rhonchi
Expiration is prolonged. However the loudness of wheezing is not a reliable or valid guide to ___________severity.
asthma
In severe asthma the airflow may be insufficient to produce rhonchi and a ‘___________________’ in such patients is an ominous sign
silent chest
Tachycardia is a common accompaniment of acute ____________
asthma
It is also a normal response to inhaled beta-agonist and atropine-like drugs (such as ipratropium bromide) used by asthmatics to relieve an attack.
Tachycardia
Therefore, in the setting of an acute attack, it may not be possible to distinguish the contributions of disease and treatment
Tachycardia
Spirometric measurement of the forced expiratory volume in one second (FEV₁), the ratio of FEV, to vital capacity, or measurement of _______________ are used to monitor asthma severity
peak expiratory flow rate
Of these, the most useful single indicator is FEV, (D is correct).
used to monitor asthma severity
The oxygen tension of arterial blood (PaO₂) will be reduced in severe asthma as a result of ventilation/perfusion inequality, but it must be interpreted in relation to the concentration of inhaled oxygen in order to determine the __________________________
arterial-alveolar (a-A) oxygen gradient
Estimation of the jugular venous pressure can be an important component of the evaluation of _______________.
ascites
Cirrhosis in the absence of tense ascites, pulmonary hypertension or renal insufficiency is associated with low or normal _____________________.
cardiac filling pressures
A raised jugular venous pressure (JVP) indicates an increased backward pressure’ in cardiac failure, which reduces venous outflow from the liver and causes secondary hepatic engorgement; and _______________may develop in some patients.
ascites
Thus, an elevated JVP suggests that heart failure may be the cause (or at least one cause) of ____________________(D is correct).
ascites
Enlargement of the liver, whilst implicating the presence of liver pathology, may be present in both congestive cardiac failure and cirrhosis of the liver with __________________________
portal hypertension
A systolic murmur is not necessarily indicative of _______________.
congestive cardiac failure
There are many valve-related causes of a systolic murmur; some represent pathology and some are purely __________________.
physiological
__________________can exist in the absence of cirrhosis of the liver: for example, obstruction to the biliary tract and other metabolic derangements of liver function
Jaundice
Oedema of the ankles can occur in the presence of ascites secondary to a wide variety of causes - including cardiac failure, cirrhosis and __________________ - and is thus non-differentiating
nephrotic syndrome
The chest X-ray illustrates an infiltrate of the left upper lobe with ________.
cavitation
The essence of this question is for the clinician to recognise a very high probability of _____________________ infection, and to commence therapy based on this assessment
Mycobacterium tuberculosis
Ethnicity, refugee status, imaging provide adequate evidence to mandate commencing appropriate therapy without delay and to obviate any further invasive testing (D is correct).
Mycobacterium tuberculosis
Symptoms usually respond quite rapidly, confirming the diagnosis without the need to await microbiological evidence
Mycobacterium tuberculosis
If resolution does not occur in the anticipated period, followup bronchoscopy for tuberculosis polymerase chain reaction (PCR) testing, which does not require viable organisms, can be done with vastly reduced risk to theatre staff
Mycobacterium tuberculosis
Oral broad spectrum antibiotics are clearly inappropriate for the above reasons
Mycobacterium tuberculosis
Sputum culture for tuberculosis takes in excess of six weeks and public safety is potentially at risk if _________________is not commenced
treatment
This invasive test, although carrying a higher likelihood of a diagnostic yield, is unnecessary given the pre-test probability, and the potential exposure of technical and theatre staff to the risk of infection.
Mycobacterium tuberculosis
Needle pericardiocentesis from the epigastrium to the side of the xiphoid will be diagnostic.
Pulmonary contusion and haemothorax will give signs of ____________breath sounds accompanied by dyspnoea.
diminished
The percussion note is dull rather than the tympanitic note of a _______________-.
pneumothorax
Flail chest, as a result of rib fractures giving a flail segment, will give symptoms of dyspnoea and signs of paradoxical respiration proportionate to the degree of ________________.
flailing
Asthma in a young adult is usually an episodic disease where the patient may have no respiratory symptoms, or signs, between episodes of ___________airways obstruction.
reversible
Paroxysms of wheeze and dyspnoea can occur at any time, can be of sudden onset, and may even be life-threatening.
Asthma
The episodes can be triggered by known or unknown allergens, exercise, viral infections (particularly those involving the respiratory tract), or may be apparently spontaneous
Asthma
The attacks can last for days, hours or weeks.
Asthma
Patients with underlying atopy have early onset asthma, with onset in early childhood, and usually have associated features of eczema, ________________ and a strong family history of the condition
allergic rhinitis
In an acute attack, the severity of the dyspnoea is usually a marker of the disease severity but may also be influenced by psychological factors, such as __________________, in addition to the asthma
anxiety
The chest examination in a patient with acute asthma usually reveals a hyperinflated chest with numerous high-pitched polyphonic expiratory and inspiratory rhonchi, _________-is prolonged.
Expiration
However the loudness of wheezing is not a reliable or valid guide to ___________severity.
asthma
In severe asthma the airflow may be insufficient to produce rhonchi and a ‘_______________’ in such patients is an ominous sign.
silent chest
Tachycardia is a common accompaniment of acute asthma. It is also a normal response to inhaled beta-agonist and atropine-like drugs (such as ____________________) used by asthmatics to relieve an attack.
ipratropium bromide
Therefore, in the setting of on acute attack, it may not be possible to distinguish the contributions of disease and treatment.
asthma
Spirometric measurement of the forced expiratory volume in one second (FEV₁), the ratio of FEV, to vital capacity, or measurement of peak expiratory flow rate are used to ___________asthma severity.
monitor
Of these, the most useful single indicator is FEV, (D is correct).
monitor asthma severity.
The oxygen tension of arterial blood (_______₂) will be reduced in severe asthma as a result of ventilation/perfusion inequality, but it must be interpreted in relation to the concentration of inhaled oxygen in order to determine the arterial-alveolar (a-A) oxygen gradient.
PaO
Estimation of the jugular venous pressure can be an important component of the evaluation of ___________________.
ascites
_________________-in the absence of tense ascites, pulmonary hypertension or renal insufficiency is associated with low or normal cardiac filling pressures.
Cirrhosis
_________________-in the absence of tense ascites, pulmonary hypertension or renal insufficiency is associated with low or normal cardiac filling pressures.
Cirrhosis
A _________________________ indicates an increased backward pressure’ in cardiac failure, which reduces venous outflow from the liver and causes secondary hepatic engorgement; and ascites may develop in some patients
raised jugular venous pressure (JVP)
Thus, an ____________________ suggests that heart failure may be the cause (or at least one cause) of ascites
elevated JVP
________________________________, whilst implicating the presence of liver pathology, may be present in both congestive cardiac failure and cirrhosis of the liver with portal hypertension.
Enlargement of the liver
A ______________ is not necessarily indicative of congestive cardiac failure
systolic murmur
There are many valve-related causes of a systolic murmur: some represent pathology and some are ______________________
purely physiological
Jaundice can exist in the absence of cirrhosis of the liver: for example, obstruction to the biliary tract and other metabolic ______________________
derangements of liver function
Oedema of the ankles can occur in the presence of ascites secondary to a wide variety of causes - including cardiac failure, cirrhosis and nephrotic syndrome - and is thus non-differentiating
Oedema
The chest X-ray illustrates an infiltrate of the left upper lobe with cavitation. The essence of this question is for the clinician to recognise a very high probability of _______________________________- infection, and to commence therapy based on this assessment.
Mycobacterium tuberculosis
Ethnicity, refugee imaging status, provide adequate evidence to mandate commencing appropriate therapy without delay and to obviate any further invasive testing
Mycobacterium tuberculosis
Symptoms usually respond quite rapidly, confirming the diagnosis without the need to await microbiological evidence
Mycobacterium tuberculosis
If resolution does not occur in the anticipated period, followup bronchoscopy for tuberculosis polymerase chain reaction (PCR) testing, which does not require viable organisms, can be done with vastly reduced risk to theatre staff.
Mycobacterium tuberculosis
Oral broad spectrum antibiotics are clearly inappropriate for the above reasons
Mycobacterium tuberculosis
Sputum culture for tuberculosis takes in excess of six weeks and public safety is potentially at risk if ________________is not commenced.
treatment
Performing ________________is the best distractor and will potentially mislead a few candidates opting for the safer diagnostic approach to the issue. This invasive test. although carrying a higher likelihood of a diagnostic yield, is unnecessary given the pre-test probability, and the potential exposure of technical and theatre staff to the risk of infection.
bronchoscopy
Followup chest X-ray is incorrect as any changes may be quite slow and delaying treatment is inappropriate
Mycobacterium tuberculosis
This question is testing the ability of a candidate to recognise an atypical pattern of ________________, with a paucity of chest signs in relation to significant patient-reported illness
pneumonia
The chest X-ray is often unremarkable initially but develops infiltrates after 72 hours.
pneumonia
The stem of this question raises particular concern about possible _____________________- pneumonia. The temperature and gastrointestinal symptoms are in keeping with this.
Legionella pneumophila
___________________, as it has activity against all the atypical organisms, including Legionella spp.. Mycoplasma pneumoniae and Chlamydia species and is well tolerated
azithromycin
All the other options fail to cover this array of organisms. It is important that an intracellular antibiotic be instituted early in this setting, as up to 50% of atypical pneumonias fail to demonstrate a causative organism from _____________________.
sputum and/or blood cultures
‘In the absence of a test such as PCR or a positive Gram stain for a pyogenic organism, patients with community-acquired pneumonia must be treated empirically with a regimen that would cover _________________________
atypical pneumonias
Macrolides are the mainstay of therapy for _________________ pneumonia and may cover Streptococcus pneumoniae as well.
atypical
Azithromycin has become the most common drug to use. Erythromycin is less expensive but associated with common gastrointestinal side effects
atypical pneumonias
All the symptoms listed could be brought on by ischaemia, but the only one that is clearly related to major vessel atherosclerotic occlusion is _______________________ partially relieved by leg dependency
nocturnal rest pain
Pain at night may be relieved by hanging the affected limb over the edge of the bed - this symptom is characteristic of severe major vessel disease
nocturnal rest pain
Sudden onset of calf pain and paralysis are more typically associated with an __________________event.
embolic
Pain in the buttocks related to walking and relieved by recumbency may equally well be due to ___________________
spinal canal stenosis
pain down the posterior aspect of the leg is more suggestive of ‘_________________(discogenic pain due to lumbosacral nerve root irritation).
sciatica
The following are absolute contraindications to ACE inhibitors
History of angioedema regardless of cause (even if not due to ACE inhibitor) • Pregnancy (due to harm to fetus) • Bilateral renal artery stenosis. Previous allergic reaction to ACE inhibitors
Relative contraindications to ACE inhibitors
Aortic stenosis • Hypertrophic cardiomyopathy
A _______________ is a common adverse effect of ACE inhibitors and a main cause of non-compliance and abandonment of treatment
dry cough
The clinical picture fits best the progressive obstructive stricturing of lower oesophagus by a peptic oesophageal stricture secondary to _____________________
reflux oesophagitis
Treatment of reflux oesophagitis symptoms with simple antacids/alkalis may give symptomatic relief, but these agents do not influence the ____________________
natural history
The painful dysphagia of acid reflux will lessen as the ____________progresses, reflux diminishes and obstructive symptoms predominate
stricture
Each of the other conditions can be associated with progressive dysphagia, but the pattern fits a peptic ________________ best
oesophageal stricture
With the advent of high-resolution imaging and the increasing frequency of its use, unexpected or __________findings are a common problem for the clinician
incidental
The patient has symptoms that might be explained by ___________
gallstones
Has the patient experienced recurrent bouts of biliary colic? Previously
gallstones
a focused examination such as an oral cholecystogram would have confined attention to the gallbladder, but with ultrasound and computed tomography (CT), not only will the targeted structure or organ be imaged, but __________________ also examined
adjacent tissues
Liver lesions are common and many are _________________.
innocent
The CT can usually provide an exact diagnosis, but such imaging may need to be complemented by ultrasound, magnetic resonance imaging or _________________.
biopsy
Most CT examinations are performed with one or more contrast materials used to highlight particular _______________(vascular, gut, urinary tract)
structures
Haemangioma of liver Haemangiomas are probably the most common liver tumour and may be found in up to _________% of the general population
20
They may be solitary or multiple. Most are congenital, do not change size and remain asymptomatic.
Haemangioma of liver
It is unlikely that this lesion was responsible for the patient’s symptoms - the finding should be explained to the patient and the lesion should be left well alone.
Haemangioma of liver
If there is any doubt to the diagnosis, a magnetic resonance imaging (MRI) scan might be performed or the CT repeated in a few months time to look for any possible changes.
Haemangioma of liver
The CT appearance of metastatic liver lesions will vary according to _________________
their site of origin
They can be single or multiple. Most liver metastases are hypovascular on the non-contrast scans when compared with the surrounding parenchyma and this becomes more pronounced in the ___________________.
portal venous phase
isolation, a hepatocellular carcinoma can be difficult to distinguish on CT from a metastatic deposit, but the presence of ______________ may help in the diagnosis
cirrhotic nodules
________________ lesions in the liver may be simple, multiple (polycystic disease), neoplastic or infective (hydatid, abscess).
Cystic
Simple ____________are extremely common and usually asymptomatic
cysts
On imaging, these cysts have a low density homogenous appearance. Polycystic disease is shown as thin-walled homogenous cysts - and the number and size of these lesions often lead to _______________.
symptoms
Hydatid cysts have a characteristic septate appearance and heterogeneous appearance if ________________ are contained within
daughter cysts
Liver abscesses are usually symptomatic and tend to have a _______________appearance.
heterogenous
The chest X-ray shows a pocket of contrast at the root of the neck with a fluid level and contrast in the bronchi going to the lower lobe of the ______________
right lung
This patient has a pharyngeal pouch (Zenker diverticulum) and some of the contrast has spilled out of the ________.
pouch
been regurgitated and inadvertently inhaled. Whilst this inhalation may have led to chest infection, pulmonary problems are not the most common mode of presentation of a _________________
pharyngeal pouch.
These patients usually have dysphagia because the primary problem is an overactive upper oesophageal sphincter Pharyngeal pouch which fails to ________________
relax
Even though the dysphagia is usually long standing, these patients do not usually have any appreciable change in ________
weight
They do not necessarily have motor problems at the lower end of the oesophagus and any gastro-oesophageal _________is coincidental
reflux
Gurgling in the neck is a well-recognised symptom of a pharyngeal pouch, but more common and usually most distressing to the patient is ___________
regurgitation of food
This patient almost certainly has appendicitis. With this clinical diagnosis it would be sensible to administer antibiotics (a single dose third generation cephalosporin would be appropriate) in ______________for surgery.
preparation
The patient may have a gynaecological problem, rather than appendicitis, but in the scenario as presented the preferred management option is surgical intervention for presumed appendicitis without the delay of ______________.
further tests
Imaging by ultrasound or computed tomography (CT) is being used with increased frequency in cases of acute abdominal pain, but should be reserved for cases where there is _________________, and where delayed surgery is unlikely to affect the outcome adversely
diagnostic doubt
In cases of established local peritonitis in the right lower abdomen, as in this instance, early __________will establish the diagnosis and minimise morbidity
surgery
Usually diagnostic laparoscopy is performed, followed by appropriate surgery: appendicectomy, or dealing with focal tubal or ovarian pathology - each of which can usually be done endoscopically at the time of the ________________.
laparoscopy
In most instances, a urinary beta-hCG pregnancy test would be performed while arranging _______________.
transfer to surgery
If positive, it will focus the diagnosis on a complication of pregnancy but will not delay __________
surgery
Small bowel tumours are not common and are certainly much less common than tumours elsewhere in the digestive tract, particularly the ___________.
large bowel
Whereas the majority of colorectal tumours are malignant, most small bowel neoplasms are _____________.
benign
Of the malignancies within the small bowel, perhaps 50% will be adenocarcinoma - with carcinoids, lymphomas, metastatic deposits and gastrointestinal _______________ accounting for the rest
stromal tumours
In regions of the world where malignant melanoma is prevalent, metastatic deposits of this tumour may account for a large proportion of _______________________ tumours.
small bowel
Spontaneous primary lymphoma of the small bowel is most often found in the terminal ileum, but that associated with ___________disease tends to occur in the proximal jejunum
coeliac
All the conditions listed are risk factors for some form of gastrointestinal tract _______________
malignancy
Crohn disease is associated with a 100-fold increase in risk of developing adenocarcinoma of the diseased section of bowel - usually the ___________.
distal ileum
The Peutz-Jeghers syndrome is associated with development of hamartomas, which in turn may undergo malignant transformation into ________________.
adenocarcinoma
As mentioned above, coeliac disease is an important risk factor to be considered in patients found to have _______________
primary jejunal lymphoma
Patients with familial adenomatous polyposis are at increased risk of duodenal and small bowel carcinoma and, even after total proctocolectomy, need to be kept under surveillance for the development of _______________________
small bowel malignancy
Chest complications of pulmonary atelectasis are a cause of early postoperative fever, particularly in _________________.
heavy smokers
Each of the other complications is a possible cause, but pulmonary __________is the most likely
atelectasis
Assessment of a patient with an episode of significant fever soon after operation mandates: examination of the wound area for signs of haematoma or __________
developing infection
checking vital signs of pulse and blood pressure and jugular venous pulse neev careful chest examination examination of intravenous drip sites palpation of calves for signs of ____________________
venous thrombosis
examination of site of diathermy plate for burning checking passage of urine since surgery and presence of frequency/dysuria/ _____________
retention
urinalysis with microscopy and culture when indicated checking the drug chart (including, when relevant, previous blood transfusion) for __________________________ further observations, checking progress and resolution.
allergic reaction to medications
The essence of this question is the importance of knowing that a young person with chronic active hepatitis secondary to Hepatitis B is at significant risk of developing _____________________ and needs to be monitored accordingly
hepatocellular carcinoma
‘The association between the hepatitis B carrier state and ________________ has been demonstrated in several large population-based studies and in other reports.
hepatocellular carcinoma
male government employees in Taiwan, 15 percent of whom were HBV carriers [hepatitis B surface antigen (HBsAg) positive]. were followed between 1975 and 1978. The relative risk of HCC in these carriers was ___times that of non-carriers.
223
Jaundice is a fairly late manifestation of chronic active hepatitis. _________treatment has not been shown to influence the natural history of chronic active hepatitis.
Steroid
The liver biopsy findings of chronic active hepatitis are not unexpected with the borderline low albumin level and mildly elevated aspartate aminotransferase (AST) and reflect the persistent presence of ____________________, which should be cleared soon after initial infection (by HBsAb).
hepatitis B surface antigen (HBsAg)
There is no role for the use of normal human immunoglobulin for contacts
chronic active hepatitis
This is usually reserved for documented hepatitis B unvaccinated recipients, who have sustained a needlestick injury with blood products from a confirmed hepatitis B positive donor (or a patient who is at high risk of being hepatitis B positive).
normal human immunoglobulin
This is in addition to vaccination
normal human immunoglobulin
This is in addition to vaccination. With time, this should be a vanishing scenario with routine post-delivery hepatitis B vaccination of newborns and routine vaccination of ______________
all health care workers.
Chronic active hepatitis leads to cirrhosis, which confers a risk of primary ____________________
hepatocellular carcinoma.
The aims of treatment of chronic hepatitis B are to suppress viral replication and _____________.
liver damage
Lamivudine is the drug of choice and treatment over 12 months can facilitate normalisation of liver enzymes and ___________improvement
histological
In performing a femoral venepuncture the femoral artery is palpated below the inguinal ligament in the groin, at the midinguinal point - a point midway between the anterior superior iliac spine and the ____________.
pubic symphysis
The femoral vein, about a fingerbreadth wide, lies just adjacent to the artery on its __________.
medial side
Both are contained within the femoral sheath. Medial to the vein is the lacunar ligament, a crescent-shaped horizontally lying structure between the most medial part of the inguinal ligament, as it attaches to the pubic tubercle, and anchoring this attachment firmly to the pectineal line of the ___________
pubic bone
The free edge of the lacunar ligament is separated from the femoral vein by a pad of loose fat, allowing for various degrees of venous distension on _________.
straining
The femoral nerve is sited considerably lateral to the artery, as the nerve emerges beneath the inguinal ligament to supply quadriceps, and is not at risk during _____________.
venepuncture
The structures from medial to lateral are thus lacunar ligament, femoral vein. femoral artery, _____________
femoral nerve
The vein can be dilated to facilitate venepuncture by asking the patient to perform a _____________.
Valsalva procedure
With the current effective medical therapies for gastro-oesophageal reflux disease. relatively few patients develop the serious inflammatory complications and ___________________ is uncommon
peptic oesophageal stricture
In addition, such patients usually give a clear and long-standing history of ________.
reflux
Pharyngeal pouch (Zenker diverticulum) is a condition usually seen in elderly patients and the characteristic symptoms include coughing immediately after a meal and _____________________
regurgitation of food particles
Achalasia is associated with an increased lower oesophageal sphincter tone and failure of ________________
muscle relaxation
The clinical picture that was once linked with the condition described patients who had more problems swallowing liquids than solids, and who lost weight and become quite _____________
malnourished
The condition now tends to be picked up earlier. In advanced cases a failure of muscle function occurs within the wall of the oesophagus, which may then become grossly dilated.
achalasia
The oesophagus can then only empty by gravity and the patient will often have a large pool of semi-liquid material in what is essentially a functionless bag.
achalasia
In the recumbent position these contents will flow back and nocturnal regurgitation is a characteristic feature of the disease.
achalasia
The patient is relatively young and the history too long. Most patients with the steadily increasing dysphagia of malignant oesophageal obstruction tend to present after a few weeks of ______________.
symptoms
Even so, many of these patients will delay seeking help until they can only manage liquids.
achalasia
The history alone must arouse suspicion of a sinister cause for this man’s difficulty in swallowing. Until proven otherwise it should be assumed that this man has a _____________________
carcinoma of the oesophagus
________________of the oesophagus is a disease which is increasing in incidence (in developed communities)
Adenocarcinoma
The endoscopic finding of columnar-lined epithelium (a premalignant condition) in the lower third of the oesophagus only serves to increase that ________.
suspicion
The lumen of the oesophagus is narrowed and an ulcer is present - the diagnosis is virtually complete
Adenocarcinoma
The histological examination of the biopsy samples does not show any evidence of malignancy - but this does not negate the diagnosis.
Adenocarcinoma
With all the collateral evidence a negative biopsy does not exclude malignancy and the procedure must be repeated
Adenocarcinoma
Starting a course of a proton pump inhibitor would _________the diagnosis of a likely i in collation carcinoma and is inappropriate
delay
A prokinetic agent would not be appropriate initial therapy. It may make the ______________worse.
obstruction
Dilatation of a reflux oesophagitis stricture may be needed if no ___________is present.
malignancy
Endoscopic ultrasound would be performed to assess the spread of any confirmed malignancy through the wall or to adjacent ________________.
lymph nodes
The clinical picture suggests a number of diagnoses, of which carcinoma of the _______________ should be on top of the list of important conditions to exclude.
head of the pancreas
Tiredness and lassitude might indicate an anaemia and the epigastric pain going through to the back is characteristic of _____pain.
pancreatic
The change in colour of the urine and faeces may be due to obstruction of the _______________
(common) bile duct.
Together with the loss of weight, these symptoms are very suggestive of carcinoma of the __________________.Dilated intrahepatic ducts on ultrasound Investigations will aim at establishing the diagnosis through biochemical analysis and imaging
head of the pancreas
In this patient urinalysis would probably show the presence of conjugated bilirubin and an absence of __________.
urobilinogen
In the serum one would expect a moderate elevation of the transaminases, a raised total and conjugated bilirubin, and a high _____________
alkaline phosphatase.
Imaging will be aimed at visualising the pancreas - particularly the head of the gland and the biliary tree, looking for dilatation and _______________.
filling defects
If the patient does have carcinoma of the head of the pancreas, the liver parenchyma is likely to be normal and the intrahepatic and _____________________ will be dilated
extrahepatic biliary tree
The pancreatic duct may also be dilated, but often the pancreas is not seen clearly on ultrasound because of ________________
gas in the adjacent structures.
The patient may have _____________, but their presence would likely be coincidental. A thickened gallbladder would be an unexpected finding and not in keeping with the clinical presentation.
gallstones
The physical signs and symptoms are those of an ______________, most probably indirect into a preformed congenital sac remnant
inguinal hernia
The diagnosis is unequivocal from the clinical findings. With ______________ in infancy, abdominal wall ultrasound may be prudent to help identify bilateral preformed congenital sac remnants, guiding recommendations for unilateral or bilateral repair.
groin hernias
In this young man’s age group, and in older adults surgical treatment of possible groin hernias in patients with groin pain with reported minor ultrasound abnormalities, but without abnormal clinical signs, ______________.
is rarely helpful
While any of the conditions mentioned might present with the patient noticing blood and mucus in the stool, the most common cause would be a _________________
carcinoma of the distal bowel
In a younger patient inflammatory bowel disease would be a more likely cause, but de novo presentation of ulcerative colitis in the __________ of life is quite unusual.
seventh decade
The characteristic bleeding associated with diverticular disease is the sudden passage of a large amount of blood, not necessarily accompanied by ____________.
faecal material
_____________are common and most often present with anorectal bleeding - but the bleeding tends to be on, rather than in, the faeces.
Haemorrhoids
Ischaemic colitis is uncommon and an important accompanying symptom is _________pain
abdominal
A patient presenting with haematemesis causing shock, with associated clinical features of jaundice, ascites, enlarged liver, and dilated veins in the subcutaneous tissues of the abdominal wall, is most likely to have hepatic cirrhosis, causing hepatic insufficiency with an haemorrhagic tendency and ________________________
portal hypertension
Anastomotic shunting channels developing between the obstructed portal circulation and the systemic venous circulation can develop around the _________________ at the lower end of the gastrointestinal tract in the form of haemorrhoids, and at the lower end of the oesophagus in the submucosa (oesophageal varices).
umbilicus (caput medusae)
Bleeding from oesophageal varices in the Australian community is most commonly due to _____________________
alcoholic liver disease
Other causes of cirrhosis with hepatic fibrosis and portal hypertension include billary cirrhosis, which may either be primary and of immunologic origin, or secondary, developing after prolonged large duct biliary obstruction due to gall stones, bile duct stricture or ______________________.
sclerosing cholangitis
___________________(bilharziasis) is endemic in Egypt, in Africa and in parts of Asia (S. mansoni and S. japonicum).
Schistosomiasis
Liver granulomas are associated with fibrosis and portal hypertension after the infecting parasite’s odyssean life cycle involves contamination of fresh water by ova passed in faeces or urine, liberating ciliated miracidia which enter and multiply in fresh water _________as intermediate hosts.
snails
Motile cercariae are then liberated and can pierce skin or mucous membrane to infect humans, the ___________host.
definitive
The schistosomal worms are carried to the lungs and thence to the liver via the blood stream, and induce portal hypertension and ________________.
fibrosis
The Budd-Chiari syndrome is an uncommon condition where thrombosis of the larger hepatic veins or vena cava, sometimes secondary to polycythaemia, can cause hepatic venous congestion, marked ascites and progression to hepatic cirrhosis and __________________.
liver failure
Hepatitis ______________ is transmitted predominantly by inoculation with blood or blood products.
C virus (HCV)
It was formerly the usual cause of cirrhosis from blood transfusion in haemophiliacs before serologic tests allowed screening of blood donors.
Hepatitis C virus (HCV)
Now it is most commonly seen in parenteral drug users and can progress to chronic hepatitis and cirrhosis.
Hepatitis C virus (HCV)
The tetrad of symptoms and signs abdominal colic, vomiting, constipation and distension - is classical of _____________.
intestinal obstruction
This could be of small bowel or large bowel; and could be of mechanical or functional origin.
intestinal obstruction
The presence of colicky pain is suggestive of a mechanical cause, which could be within the lumen (faecal impaction, gall stones), in the wall (carcinoma) or extrinsic (volvulus, adhesions).
intestinal obstruction
Sigmoid colon cancer is an important cause of large bowel obstruction. He does have a history of previous surgery (appendicectomy), and _____________- obstruction is the most common form of intestinal obstruction overall, causing mechanical small bowel obstruction.
adhesion
Sigmoid colon volvulus would fit the clinical features well this complication commonly occurs in elderly bed-bound nursing home patients, with prominent abdominal distension and constipation associated with ___________________
large bowel obstruction.
Faecal impaction is also common in the above circumstances: and colonic carcinoma increases in incidence with age, is commonly associated with stricturing of the sigmoid colon, and may cause previously unheralded ________________
large bowel obstruction.
_______________________ pseudo-obstruction is also an important cause of bowel obstruction and can affect the large bowel (‘colonic ileus’- Ogilvie syndrome) or small bowel or both.
Drug-induced
The increasing use of drugs with autonomic side effects (such as agents used for Parkinson disease and antihypertensive medications) makes accurate diagnosis of this iatrogenic complication important, as surgery (which is often required for mechanical obstructions) is inappropriate and ineffective - unless the urgency of caecal distension makes operative decompression appropriate to avert _______________ (which is rare, but can occur with pseudo-obstruction).
caecal rupture
Conservative treatment with small bowel or large bowel contrast imaging and colonoscopy to exclude mechanical obstruction, and pharmacologic therapy, are otherwise the mainstays of ______________management.
conservative
Each of the five options is thus a possible diagnosis. The typical appearance of carcinoma of the colon with obstruction would be large bowel gaseous dilatation cut off at the sigmoid without ________.
rectal gas
The patient would require sigmoidoscopy to define a mucosal lesion, with subsequent definitive surgery, which is often staged, with an initial relieving colostomy/ileostomy with or without resection and ____________________of the obstructing tumour.
anastomosis
In this instance, the plain X-ray is consistent with and diagnostic of sigmoid volvulus (B is correct). A large inverted U-loop of dilated gas-filled sigmoid colon arises from the __________
pelvis
Sigmoid volvulus is associated with a long and redundant sigmoid (dolichocolon), predisposing to a closed loop kink from _________.
volvulus
Endoscopic deflation with passage of a rectal tube up past the region of kink is often dramatically effective, and the tube can be left in situ while the patient’s condition is improved prior to _________________ (usually sigmoid colectomy).
elective surgical correction
Faecal impaction would be suggested by the presence of luminal faecal boluses with accompanying __________.
colonic dilatation
Conservative treatment with enemas/ aperients from below and above may require facilitation by manual __________.
disimpaction
______ pseudo-obstruction would be suggested by a diffuse distension of small and large bowel.
Drug-induced
Treatment would be conservative as outlined above. ______________ would be suggested by markedly dilated small bowel loops with fluid levels, in the absence of distal large bowel gas.
Adhesion-obstruction
Conservative treatment could be undertaken initially but should not be prolonged in the absence of spontaneous resolution (‘the sun may rise and the sun may set on a patient with _____________, but it had better not do both’).
intestinal obstruction
The clinical picture fits a postoperative superficial wound infection with abscess formation, which requires effective drainage as the first step in treatment by making an _____over the swelling using local anaesthesia
incision
Supplementary antibiotic treatment, although often given, is not obligatory and injudicious use of antibiotics is liable to contribute to development of resistant strains, or delay in healing with formation of an ‘antibioma’.
postoperative superficial wound infection with abscess
Wound resuturing is not usually required after wound drainage in a transverse or oblique incision for _____. Sinus formation after appendicectomy is uncommon.
appendicectomy
Sutures used are almost invariably absorbable do not predispose to sinus formation and do not require _______.
removal
A Meckel diverticulum of small bowel is a remnant of the vitello-intestinal duct - in the premetric era the diverticulum was said to be present on the antimesenteric border of the ileum in about 2% of individuals, about two feet from the lleocaecal valve, and to be about two inches long and two inches ____.
wide
The __________can contain acid-secreting gastric epithelium or pancreatic tissue.
diverticulum
Acute Meckel diverticulitis can mimic appendicitis, with associated ulceration of the gastric mucosa, and can cause acute or chronic bleeding and melaena or _______________
chronic blood loss anaemia.
However, the most common clinical scenario for this common, and usually uncomplicated, congenital anomaly is for an asymptomatic diverticulum to be noted during abdominal surgery for another cause
Meckel diverticulum
Of the various factors contributing to postoperative wound disruption (subcutaneous dehiscence of deep wound layers), the increased intra-abdominal pressure with abdominal distension from paralytic ileus is by far the most likely to have contributed to the deep wound __________
dehiscence
The findings on physical examination suggest a midline ___________ in the subcutaneous tissues superficial to the abdominal wall musculature.
fatty lump
This is the typical site of an epigastric hernia due to a defect in the fibres of the ___________
linea alba
These small fatty hernias are often painful.
epigastric hernia
Paraumbilical (periumbilical) hemias are due to a defect of linea alba in the region of the __________, which is usually just above or just below the apex of the expansile swelling
umbilicus
A Spigelian hernia emerges through the linea semilunaris lateral to the rectus abdominis halfway between umbilicus and _________.
pubis
The physical findings in an epigastric hernia are very similar to those of a subcutaneous __________.
lipoma
The lump often does not have a significant expansile impulse, as it consists predominantly of ______________.
extraperitoneal fat
But if just excision of the lump is performed, without recognising and repairing the underlying pathology, recurrence would be almost _________
inevitable
This patient requires some form of active intervention. A prokinetic agent such as domperidone may hasten acid clearance from the oesophagus and an H2-receptor may reduce the acid content of any refluxate, but a proton-pump inhibitor (PPI) is more likely to produce a greater and sustained reduction in acid secretion and is the drug of choice in the healing of ____________
ulcerative oesophagitis
There is little logic in adding an antibiotic to the treatment protocol - such a regime would be recommended for the treatment of Helicobacter pylori-related peptic ulceration
ulcerative oesophagitis
Toxic megacolon is a life-threatening complication of ulcerative colitis. with progressive acute colonic dilatation leading to perforation, and requires urgent emergency excisional surgery and defunctioning ileostomy if ___________________(which causes a high mortality) is to be averted.
perforation
Pyoderma gangrenosum Serial abdominal imaging by plain X-ray or computed tomography (CT) in patients with acute exacerbations of inflammatory bowel disease requiring hospitalisation can be helpful in diagnosis of this serious complication.
Toxic megacolon
In an elderly patient presenting with the clinical features of acute small bowel obstruction, in whom no previous abdominal surgery has occurred, abdominal ______________would be an unlikely cause.
adhesions
Each of the other options (metastatic intraperitoneal carcinoma disseminated from stomach, ovary, lung and other primary sites, abdominal lymphosarcoma or leiomyosarcoma, carcinoma of the caecum, or gallstone ileus with an internal cholecystoduodenal fistula leading to intralumenal small bowel __________________by a large gallstone) is possible.
obstruction
Her prodromal symptoms of postprandial epigastric fullness and nausea are suggestive of previous cholecystitis from ____________.
gallstones
An impacted large gallstone in Hartmann pouch can cause slow necrosis of adherent gall bladder and duodenal walls with passage of the stone or stones into the bowel lumen, with subsequent _____________in the lower small bowel.
obstruction
The obstructing stone(s) may be visible on plain X-ray, but is often a solitary radiolucent _______________stone.
cholesterol
Reflux of swallowed air from the cholecystoduodenal fistula into the biliary free frequently gives a diagnostic appearance, as illustrated, with free air in the right upper quadrant. The correct response in this instance is ___________________
gallstone ileus
The most important diagnostic procedure in this patient is to establish the site of his gastrointestinal haemorrhage, and this is best achieved by upper gastrointestinal ___________________
endoscopy
In the majority of instances, in patients with cirrhosis and portal hypertension. bleeding will be from ___________________.
oesophageal varices
If active bleeding is continuing, insertion of a Sengstaken-Blakemore tube after diagnostic endoscopy can gain temporary control of bleeding while resuscitation and further _________________are proceeding
investigations
But some cirrhotic patients will be bleeding from an associated peptic ulcer, which can only be diagnosed by _________________.
endoscopy
Abdominal computed tomography (CT) will help define liver and splenic enlargement and morphology, and the presence of __________________, but would not be otherwise diagnostic
ascites
Assessment of the portal circulation by noninvasive triple phase CT, coeliac axis angiography, and transjugular intrahepatic portal venography are each potentially helpful investigations to assess the degree and severity of _______________, but would not be the preferred initial investigations
portal hypertension
These further investigations may follow initial endoscopic injection sclerotherapy in treatment of bleeding oesophageal varices. Such investigations may help determine indications for further treatment by transjugular intrahepatic or open portal-systemic shunting procedures for ____________________
recurrent or persisting bleeding
Paget disease of the nipple, more commonly seen in elderly patients with breast carcinoma, presents as a red, nonspecific eczematoid rash affecting ___________________
nipple and areola
Differentiation from simple eczematous dermatitis can be difficult
Paget disease of the nipple
All cases where diagnostic doubt exists should have the diagnosis confirmed by punch biopsy under local anaesthesia - a variety of disposable ring biopsy kits is available, simplifying the procedure
Paget disease of the nipple
Diagnosis is confirmed by identifying the typical __________cells within the dermis
Paget
Mammography and ultrasound may outline a carcinomatous focus deeper within the breast, treatment of which must be included in _____________
management
If, as in the present case, no additional focus is seen within the breast and no evidence of axillary spread is identified, the most appropriate treatment is by breast- conserving wide local excision
Paget disease of the nipple
excision of the nipple and areola and underlying area, taking a core of tissue from beneath the nipple extending deeply into the underlying breast
Paget disease of the nipple
Total mastectomy would be reserved for those cases where a distant carcinoma focus can be identified on imaging, or where widespread ductal carcinoma in situ is identified on imaging and ___________________
core biopsy
Local irradiation as primary or principal treatment would be a less appropriate option for this ___________amenable tumour.
surgically
Tamoxifen therapy or oophorectomy would also be less appropriate as primary therapy: tamoxifen could in some instances be appropriate as a palliative measure in a patient with severe medical comorbidities preventing _______.
surgery
The management of breast cancer has undergone major changes over the past 50 years. Whereas total mastectomy with axillary clearance was the mainstay of treatment from the earliest times, less radical measures than the traditional Halsted mastectomy have been trialled extensively in recent years, and equivalent survival and disease-free outcomes have been convincingly demonstrated by breast- conserving surgery combined with multimodal __________therapy in the majority of patients
adjuvant
Surgical modifications have included limiting the extent of excision of both the primary tumour within the breast, and also axillary dissection for potential ____________.
lymph node spread
Localisation of the potential area of lymphatic spread is aided by isotope or dye injection studies to identify the ___________node - the node or group of nodes first to be involved by lymphatic channel embolic spread
sentinel
Biopsy sampling of these nodes has high positive and negative predictive value for additional nodal spread.
sentinel node
Complete axillary clearance, and its potential additional morbidity, can nowadays be replaced in many instances by less extensive _____procedures.
sampling
Local breast surgery has evolved from the earlier Halsted mutilating radical mastectomy, involving removal of breast and underlying ____________.
chest wall musculature
The Patey modified radical mastectomy - a less mutilating operation preserving the Commentaries anterior axillary major pectoral muscle fold, combined with equally effective axillary clearance - progressively replaced the ___________ from the 1960s.
Halsted operation
Current evolution of local surgical techniques uses breast-conserving local surgical procedures of partial mastectomy, including quadrantectomy or focal wide _________excision/lumpectomy, in the majority of patients
local
Surgery is combined with careful _____________review of margins of the resected specimen to confirm that these are tumour-free
histological
If the microscopic tumour involves the margins, reoperation with ___________ is performed
wider excision
Combinations of such surgical techniques to breast and axilla, with postsurgical radiation therapy to the residual native breast to minimise risk of _____________.
local recurrence
additional adjuvant hormonal or chemotherapy treatments, now can give _____________local recurrence and metastatic rates
low
patient has required lifelong regular clinical and mammographic imaging review after her previous mastectomy for a breast carcinoma. Normal followup guidelines would include at least ____monthly clinical review and ___________mammography of the remaining breast.
six
yearly
She is at significantly increased risk of developing another primary breast cancer after having had a previous ___________
breast cancer
Her previous treatment of modified radical mastectomy (Patey mastectomy) is used for breast cancer of multifocal origin or with associated extensive _____________, or in patients with larger tumours in small breasts.
ductal carcinoma in situ (DCIS)
The Patey mastectomy procedure, of total mastectomy, preservation of pectoralis major and full axillary clearance, is a considerably less mutilating procedure than the classical _____________ mastectomy
Halsted radical
The development of a discrete firm irregular lump in the upper outer quadrant of the breast on clinical assessment is most likely to be a _______________
new primary carcinoma
A second primary cancer, when detected, should be treated on its merits after confirmation of the diagnosis by ______________
percutaneous core biopsy
Nipple discharge is a less common symptom than presentation with breast ____________________.
pain or a breast lump
The most important diagnostic aspects are the nature of the discharge and whether __________________ are involved.
single or multiple ducts
Discharge, spontaneous or induced, from a single duct, especially when the discharge is bloodstained, strongly suggests a proliferative lesion, usually a _____________________
benign duct papilloma
The calcification seen in the mammograms in the upper part of each breast is typical of _______________.
benign vascular calcification
Vascular calcification within walls of arteries has a characteristic pattern and is entirely __________
benign
calcification is commonly seen in elderly patients and has no clinical significance. Repeat mammography in two years in the Government screening program would be recommended after __________________
reassurance
Each of the responses (dermoid cyst, phleboliths, uterine pregnancy, bladder stones, stones in an ectopic kidney) can be associated with radio opaque material visible in the pelvis on _________________.
abdominal X-ray
The radiograph shows several teeth in the pelvis, typical of the heterogeneous tissue found in ovarian benign _____________________
teratomatous dermoid cysts
These usually occur in childhood, developing from totipotent cells and composed of well- differentiated mature epidermal, mesodermal and endodermal elements
ovarian benign teratomatous dermoid cysts
Commonly, these benign cysts contain hair, teeth, bone, sebaceous material and other tissues from the three germ layers
ovarian benign teratomatous dermoid cysts
Malignant change is rare, and laparoscopic or open ovarian cystectomy is usually curative
benign teratomatous dermoid cysts
Closed trauma to left lower chest or upper abdomen may cause splenic injury, commonly a subcapsular _______________
haematoma
Expansion and delayed rupture of such splenic haematomas after one or two weeks can be associated with further exsanguinating _____________ (B is correct).
blood loss
The clinical picture described is classical. If initial imaging at the time of injury had been done with diagnosis of a splenic haematoma, conservative treatment in hospital for a more prolonged period of up to two weeks would have been prudent with serial imaging to diagnose ___________________ (which is the usual outcome).
expansion or resolution
None of the other possible diagnoses mentioned is as likely as delayed splenic rupture requiring _____________
emergency surgery
Delayed presentation of abdominal signs after injury, with delayed development of signs of peritonitis can, however, occur from delayed bowel wall necrosis and ____________, or from post-traumatic pancreatitis or peripancreatic cyst
perforation
Chest and lung injuries can likewise present with delayed development of haemothorax; and retroperitoneal renal injury may present with delayed haemorrhage and _____________
haematuria
This 50-year-old woman with lack of energy, tiredness and constipation has a mild macrocytic anaemia with _________
lymphocytosis
The symptoms are relatively nonspecific. Pernicious anaemia can cause a macrocytic anaemia but not lymphocytosis. In a chronic anaemia, symptoms are unusual until the haemoglobin falls below _____g/L.
90
Carcinoma of the bowel would be expected to produce an _________ anaemia with microcytosis, not macrocytosis
iron deficiency
Alcoholism and malnutrition may be associated with a ____________anaemia, but the features of constipation and a slow pulse rate would not be explained by this
macrocytic
The most likely diagnosis is primary hypothyroidism, which by itself can cause the triad of symptoms of lack of energy, tiredness and ____________(D is correct).
constipation
In addition, it is the only condition which is likely to be associated with a bradycardia.
primary hypothyroidism
The cause of the __________________anaemia in hypothyroidism is unknown.
macrocytic
Spontaneous atrophic hypothyroidism increases in incidence with age and is an organ-specific autoimmune disease There is destructive lymphoid infiltration of the thyroid leading to ___________and atrophy.
fibrosis
In some patients there is a past history of Graves disease 10-20 years previously. There is a risk of developing other organ- specific autoimmune conditions, including __________ anaemia.
pernicious
Chronic lymphocytic leukaemia (CLL) is the most common type of leukaemia and occurs in patients older than __________years
50
Splenectomy for trauma in a young adult should have been accompanied by a pneumococcal and meningococcal vaccination program at the time of injury to minimise the risk of overwhelming post-splenectomy sepsis from these _________________organisms.
capsulated
The increased infection risk is considerably less in adults than in young children, and is greatest in the first year after ____________
splenectomy
The organisms are sensitive to penicillin and a course is appropriate, in view of his upper respiratory tract infection, which could herald rapidly progressive and life- threatening systemic sepsis (B is correct).
Splenectomy for trauma
Of the other options, a vaccination program would certainly be appropriate if not previously performed, but this would not replace the need for initial antibiotic treatment.
Splenectomy for trauma
Admission to an intensive care unit would not be the most appropriate initial action, but the patient clearly requires regular monitoring of progress in view of his higher risk of overwhelming infection.
Splenectomy for trauma
Reversed barrier nursing is a system of nursing care designed to protect the attending staff, and is not relevant here.
Splenectomy for trauma
Chest physiotherapy is potentially helpful, but in this instance is clearly secondary to antibiotic treatment active against potentially life-threatening organisms
Splenectomy for trauma
The positive findings in this middle-aged woman presenting with a transient visual disturbance are an enlarged spleen and polycythaemia affecting all blood cellular components - red cells, white cells, and platelets - without other abnormalities on blood smear (consistent with ___________________.
polycythaemia rubra vera)
Symptoms of polycythaemia relate to the blood hyperviscosity and tendency to flow disturbance, and to arterial or venous thrombosis.
polycythaemia rubra vera)
Visual disturbances and hypertension are common accompaniments of polycythaemia, which can be primary or secondary in origin.
polycythaemia rubra vera
She does not give evidence on history or physical findings of secondary polycythaemia from chronic pulmonary disease and hypoxia, or from excessive renal or ectopic erythropioetin production (e.g. renal tumours).
polycythaemia rubra vera
The presence of splenomegaly also favors primary polycythaemia. The most likely diagnosis is thus polycythaemia rubra vera (D is correct).
polycythaemia rubra vera
The finding of splenomegaly following an overseas holiday (particularly to an endemic area) would make one consider malaria, of which falciparum malaria is the most serious form.
polycythaemia rubra vera
Myelofibrosis is accompanied by splenomegaly but the characteristic blood findings of immature blood cell forms indicative of extramedullary haematopoiesis are not present, and hence this diagnosis is less likely
polycythaemia rubra vera
Chronic myeloid leukaemia may present with mild splenomegaly, but again the blood picture does not suggest leukaemia
polycythaemia rubra vera
Indications for the use of the anti-platelet agent clopidogrel include the treatmer of acute coronary syndrome and stroke and the prevention of myocardial infarction stroke, and stent occlusion
anti-platelet agent clopidogrel
For patients with stents, particularly drug-eluting stent continuous therapy with clopidogrel is essential, particularly in the first two years afte insertion of the stent.
anti-platelet agent clopidogrel
In the case in question, whilst stopping the anti-platelet drug for the duration of the surgery might increase the risk of myocardial occlusion, the risk would not be as major as when using the drug for possible stent blockage
anti-platelet agent clopidogrel
If this patient had a coronary artery stent in situ and surgery was essential, it is likely that surgery would proceed in the presence of the anticoagulants.
anti-platelet agent clopidogrel
In this case, however, with no history given of previous stent insertion, it would be reasonable to stop the anticoagulants now in preparation for surgery a week late (B is correct).
anti-platelet agent clopidogrel
The effect of the aspirin and clopidogrel should be suitably diminished within one week of stopping the agents
anti-platelet agent clopidogrel
platelet transfusion would be unnecessary. Obviously, for a more acute surgical emergency with a high risk of haemorrhage platelet transfusion might be considered
anti-platelet agent clopidogrel
Vitamin K and protamine have no effect on platelet function.
anti-platelet agent clopidogrel
Pneumaturia associated with urinary tract infection causing dysuria, frequency and bacilluria is virtually diagnostic of a colovesical fistula, most usually secondary t pre-existing diverticulitis with adherence of a loop of inflamed sigmoid diverticul to the bladder dome (D is correct).
diverticulitis
The condition can be associated with chronically recurring pelvic infection and cystitis, and will not be cured until excision of the fistula, bladder repair and sigmo colectomy.
diverticulitis
lleal Crohn disease is a far less common cause of enterovesical fistula.
diverticulitis
Pyosalpinx and tubo-ovarian abscess are not associated with vesical fistulae.
diverticulitis
The patient certainly is liable to recurrent urinary tract infection, but the underlying cause is the colovesical fistula with bladder contamination.
diverticulitis
Carcinoma of the prostate increases in incidence with age: 80% of males surviving to 80 years are said to have histologic evidence of prostatic cancer at the time c death, although only 3% will die of their cancer.
Carcinoma of the prostate
But in many instances people de of, not just with, the condition - prostatic cancer is the most common cancer found in American men, and is the second leading cause of cancer death behind lung cancer.
Carcinoma of the prostate
The disease usually spreads from an initial focal or multifocal nodule by local tissue invasion beyond the capsule, by lymphatic spread to pelvic nodes (not to grom nodes) and by blood spread, with a predilection for bony metastases to the pelvis and spine, which are often osteosclerotic
Carcinoma of the prostate
The tumour marker prostate-specific antigen (PSA) is normally absent from the serum but increasingly high serum levels are found with progressive local and systemic disease
Carcinoma of the prostate
A level of 4ng/mL is often considered the upper limit of normal, but PSA although prostate-specific, is not cancer-specific, and falsely positive levels above 4ng/mL are found in patients with prostatitis.
Carcinoma of the prostate
benign prostatomegaly and other conditions. With levels above 10ng/mL the likelihood of organ-confined disease is small, and false negatives for cancer are rare
Carcinoma of the prostate
Serum acid phosphatase levels can be elevated, but PSA is the preferred screening test.
Carcinoma of the prostate
Early disease, particularly when confirmed to be organ-confined by staging imaging and scanning, has reasonably high cure rates by radical prostatectomy (removal of the entire prostate and seminal vesicles) to which can be added pelvic lymphadenectomy (D is correct).
Carcinoma of the prostate
Transurethral resection is not curative of the condition; and prostate cancer does not respond to tamoxifen. External beam radiation therapy is preferred primary local treatment for men with significant medical comorbidity and a life expectancy prediction of less than 5-10 years (e.g. patients over 80 years of age). Both radical surgery and radiation treatment can have significant complications, particularly erectile dysfunction.
Carcinoma of the prostate
External beam radiation therapy is preferred primary local treatment for men with significant medical comorbidity and a life expectancy prediction of less than 5-10 years (e.g. patients over 80 years of age).
Carcinoma of the prostate
Both radical surgery and radiation treatment can have significant complications, particularly erectile dysfunction.
Carcinoma of the prostate
Favourable response of prostatic cancer from androgen ablation was first described by Huggins in 1941, and remains the treatment of choice for metastatic disease.
Carcinoma of the prostate
Rupture of either the prostatic or membranous urethra may certainly occur dur instrumentation - particularly the passage of a rigid instrument - but a rupture p se would not be sufficient to produce the clinical picture described
urinary sepsis Gram-negative bacteremia
It is most like that this patient has urinary sepsis (consequent on chronic obstruction) and the process of instrumentation has produced some mucosal injury, allowing egress infected urinary contents into the circulation with a consequent Gram-negative bacteraemia (C is correct).
urinary sepsis Gram-negative bacteremia
This patient has had a sharp rise in temperature associated with an acute shivering episode
urinary sepsis Gram-negative bacteremia
A sudden bacteremia may lead to a sharp immune response with release of cytokines and prostaglandins into the circulation
urinary sepsis Gram-negative bacteremia
These may lead t hypothalamic alteration in the regulatory control of temperature with a higher se point, and the body responds with vigorous and uncontrollable shaking and muscle activity in an attempt to bring the core temperature up to the new set point.
urinary sepsis Gram-negative bacteremia
Instrumental rupture of the bladder is a recognised complication of cystoscopy, but would only produce these changes of rigor and fever if the rupture was followed by peritonitis.
urinary sepsis Gram-negative bacteremia
This scenario is much less common than instrumental trauma to the urethral mucosa. Acute pyelonephritis is a less likely cause of fever and rigors in the context of this scenario
urinary sepsis Gram-negative bacteremia
Testicular neoplasms spread via draining lymphatic channels along the gonada veins in the spermatic cord along the inguinal canal to retroperitoneal nodes
Involvement of cervical nodes would be of most serious prognostic import
Inguinal nodes and femoral canal vessels and nodes (Cloquet) do not constitute draining areas for testicular tumours - these node groups drain the leg and skin of lower abdomen, back, buttock, penis, scrotum and anal canal.
Involvement of cervical nodes would be of most serious prognostic import
From the retroperitoneal and para-aortic nodes, progressive spread can occur vio the cisterna chyli and thoracic duct to mediastinal and left sided cervical nodes of the base of the neck, the latter group draining into the systemic venous circulation
Involvement of cervical nodes would be of most serious prognostic import
Prostatic carcinoma is usually responsive to androgenic ablation therapy, which can be instigated in a number of ways
Prostatic carcinoma
Orchidectomy has a rapid effect within hours and is likely to be the most effective initial treatment (D is correct).
Prostatic carcinoma
Other methods of interrupting the pathways for androgen production also exist, such as ketoconazole (‘medical’ orchidectomy). but orchidectomy would remain the gold standard in this elderly patient
Prostatic carcinoma
but orchidectomy would remain the gold standard in this elderly patient.
Prostatic carcinoma
Other forms of chemotherapy are less effective, and his metastatic disease contraindicates radical prostatectomy.
Prostatic carcinoma
Effective therapy is urgently required to diminish chances of progression to vertebral collapse and cord compression
Prostatic carcinoma
Acute painful urinary retention (usually acute-on-chronic retention) is most commonly associated with benign prostatomegaly.
benign prostatomegaly
Immediate relief of the obstruction by passing a urethral catheter into the bladder is the most appropriate step in management and will immediately relieve the pain (D is correct).
benign prostatomegaly
Suprapubic drainage of the bladder would be reserved for the occasional patient in whom bladder neck obstruction cannot readily be relieved by urethral catheterisation.
benign prostatomegaly
Intramuscular neostigmine is contraindicated for mechanical obstruction. It is sometimes used for urinary retention associated with impaired detrusor muscle function without obstruction
benign prostatomegaly
Hyoscine butylbromide, a smooth muscle relaxant, would worsen the retention and increase the pain.
benign prostatomegaly
A rectal laxative suppository may be useful as a subsequent treatment for the constipation but would not relieve the urinary retention.
benign prostatomegaly
A rectal laxative suppository may be useful as a subsequent treatment for the constipation but would not relieve the urinary retention. If an anal fissure was present (not mentioned in this patient) relief of anal sphincter spasm would help relieve urethral sphincter spasm via a spinal reflex involving the pudendal nerve and may help to relieve urinary retention.
benign prostatomegaly
This bony metastasis most likely arises from the kidney (A is correct). Renal cell carcinomas spread by venous spread to lungs and systemically.
Renal cell carcinomas
Localised bony metastases are classical and may, as in this case, be the first presentation of an occult renal tumour.
Renal cell carcinomas
The accompanying pyrexia associated with this particular cancer is another classical association.
Renal cell carcinomas
Renal cell carcinoma typically can present with extrarenal manifestations, such as bony metastases, or as an isolated pulmonary metastasis (cannonball tumour), as well as with haematological effects (plethora and erythrocytosis).
Renal cell carcinomas
The primary tumour also may be discovered as an incidental finding during abdominal imaging or surgery for unrelated symptoms.
Renal cell carcinomas
Each of the other options is a possible primary site, but the kidney is the most likely primary site for this bony metastasis.
Renal cell carcinomas
Primary neoplasms of liver, testis and stomach do not commonly spread to bone.
Renal cell carcinomas
Prostatic bony metastases are commonly sclerotic
Until proven otherwise it must be assumed that this scrotal swelling is due to a testicular neoplasm.
scrotal swelling
The description of the physical findings are those of a hydrocele
scrotal swelling
While a hydrocele in an older man can usually safely be assumed to be of benign origin, in a patient of this age the cause of the hydrocele is likely to be either a teratoma or seminoma of the testis.
scrotal swelling
Testicular malignancy is perhaps the commonest cancer of young males, certainly in western communities.
scrotal swelling
For reasons that are not clear the disease has increased dramatically in incidence in the last three decades and is now 5.4 cases per 100,000 persons in the USA
scrotal swelling
Some parts of the world, such as Switzerland, have an incidence of twice this figure
scrotal swelling
Androgen-deprivation therapy alone is the treatment of choice for palliation of patients with symptomatic metastatic disease.
compression of the spinal cord at the T10 vertebral level
In time most patients treated in this way will proceed to hormone-refractory disease.
prostatic malignancy
The side effects of the anti- androgens and similar agents are numerous and potentially severe.
prostatic malignancy
They include deep venous thrombosis (DVT), congestive cardiac failure, myocardial infarction. osteoporosis, loss of libido and impotence
side effects of the anti- androgens
Since the introduction of luteinizing hormone-releasing hormone (LHRH) agonist therapy there has been little need for surgical castration and orchidectomy is reserved for cases where there is spinal cord compression.
prostatic malignancy
For some patients radical prostatectomy could be a viable treatment option. but, with involvement of the seminal vesicles, external beam radiotherapy is the preferred treatment.
prostatic malignancy
Transurethral resection would do nothing to treat the prostatic malignancy but might be used to relieve any symptomatic urinary obstruction
prostatic malignancy
The clinical presentation is that of a 62-year-old man with acute disturbance of bladder function, weakness of the lower limbs with upper motor neuron signs, and a sensory level loss at L1 level.
compression of the spinal cord
This would explain the upper motor neuron weakness and signs in the lower limbs, impaired autonomic function affecting the bladder, with spinothalamic (pain and touch) and posterior column (position and vibration sense) sensory impairment below the level of the lesion.
compression of the spinal cord at the T10 vertebral level
Classically, with a progressive compression lesion, at diagnosis the sensory level of a spinal cord lesion may be detected at a lower level than that of the lesion itself.
compression of the spinal cord at the T10 vertebral level
The detected sensory level loss at L1 tells the examining doctor that the lesion is at least at or above that spinal cord segment level.
compression of the spinal cord at the T10 vertebral level
In this case it must be above, since an L1-L2 disc prolapse lesion would involve the cauda equina (not the spinal cord which ends at the lower border of L1 vertebra) and would be accompanied by lower motor neuron signs in the lower limbs.
compression of the spinal cord at the T10 vertebral level
Subacute combined degeneration of the cord is a consequence of prolonged B₁2 deficiency and characteristically presents with posterior column sensory symptoms
compression of the spinal cord at the T10 vertebral level
associated with variable symptoms attributable to lateral column degeneration.
Subacute combined degeneration of the cord
It would not explain the spinothalamic tract abnormalities of loss of touch and pinprick sensation below the inguinal ligament.
Subacute combined degeneration of the cord
is a condition involving the cervical spinal cord, which typically presents with upper limb impairment of pain and temperature sensation, often asymmetrical, which may be accompanied by lower limb upper motor neuron symptoms and signs
Syringomyelia
Lumbosacral spondylolisthesis could affect the $1 nerve root, but would not cause problems with hip flexion, nor would it explain the bladder symptoms and upper motor neuron signs.
compression of the spinal cord at the T10 vertebral level
Spondylolisthesis (Greek ‘slipping spine’) is a condition where a defect (usually bilateral and often of congenital origin) is present in the bony neural arch component of the spinal canal, usually affecting the 5th lumbar vertebra
compression of the spinal cord at the T10 vertebral level
leads to a forward displacement of L5 vertebral body on $1
Spondylolisthesis
The presence of the defect alone without any slip is called spondylolysis (‘loosened spine’).
compression of the spinal cord at the T10 vertebral level
This is clearly distinct from, and has different aetiologies from, acute painful bladder distension due to acute urinary retention.
chronic urinary retention with painless bladder distension
Pregnancy is unlikely as a cause, now that ultrasound has confirmed her abdomina swelling as a distended bladder and not uterus.
chronic urinary retention with painless bladder distension
Chronic urinary retention in females is uncommon, and usually of functiona psychological origin rather than being due to an organic obstructive or neuropathic cause.
chronic urinary retention with painless bladder distension
A neuropathic bladder with an incompetent urethral sphincter would be expected to present with retention with overflow incontinence, not with chronic bladder distension
chronic urinary retention with painless bladder distension
A bladder neoplasm usually presents with haematuria
chronic urinary retention with painless bladder distension
Germ-cell testicular neoplasms are one of the most common solid tumours of men between the ages of 15 and 35 years.
testicular neoplasms
Those associated with large para-aortic node metastatic involvement can be seminomas or teratomas, the latter having the worse prognosis.
testicular neoplasms
Up to 30% of patients may first present with metastatic disease.
testicular neoplasms
Treatment of this advanced lesion requires multimodal treatment by a combination of chemoradiotherapy and surgery.
testicular neoplasms
The best treatment of the primary neoplasm is orchidectomy, done by a groin incision removing the testis and cord back to deep inguinal ring.
testicular neoplasms
Treatment of the involved metastatic nodes is best by combined chemoradiotherapy, with the prospect of delayed surgical excision of residual tumour in nodes after completion of the courses of chemotherapy and radiation therapy
testicular neoplasms
Cisplatinum is one of the most active chemotherapeutic agents employed and shrinkage or disappearance of the metastatic nodes is commonly obtained
testicular neoplasms
Followup requires regular imaging and tumour marker assessments to determine indications for and timing of, subsequent radical retroperitoneal node dissection.
testicular neoplasms
Prognosis is clearly adversely affected by the extent of metastatic involvement, but containment and control of the disease for a period is usually possible with the above regimen, and occasional complete cures are recorded.
testicular neoplasms
The clinical scenario, in a 64-year-old patient, is typical of acute epididymo- orchitis.
epididymo- orchitis
Epididymo-orchitis is commonly associated with urinary tract infection and prostatomegaly.
epididymo- orchitis
Bladder infection of residual urine causes secondary infection of epididymis via the vas deferens.
epididymo- orchitis
Urine culture, if positive, will aid selection of appropriate antibiotic therapy
epididymo- orchitis
Doppler blood flow studies or radioisotope scans are likely to merely confirm inflammatory hyperaemia of no specific therapeutic value.
epididymo- orchitis
Gram stain of urethral discharge, together with culture, would be helpful diagnostically, but there is no mention of any symptoms of discharge
epididymo- orchitis
Fine needle aspiration cytology (FNAC) would only be considered if urinary microscopy and culture were unproductive, and symptoms persisted or worsened despite empirical broad spectrum antibiotic therapy
epididymo- orchitis
The most likely diagnosis is rhabdomyolysis
rhabdomyolysis
The combination of red urine, muscle weakness, very high creatine kinase (CK) and history of statin treatment is highly suggestive of this
rhabdomyolysis
The addition of erythromycin can increase the level of statin and make the muscle damage worse.
rhabdomyolysis
The urine microscopy will show no red cells in the urine in rhabdomyolysis.
rhabdomyolysis
This defines the condition as myoglobinuria/haemoglobulinuria as a cause of the red urine, not haematuria (the latter diagnosis would mandate cystoscopy to exclude a bladder carcinoma).
rhabdomyolysis
The elevations of lactic dehydrogenase, C-reactive protein, and other enzymes are consistent with the elevation of CK.
rhabdomyolysis
The history is not suggestive of polymyositis. In acute nephritis, the urine will show an active sediment.
rhabdomyolysis
Myalgia is seen in up to 9% of patients on statins: but serious myositis occurs in less than 1% of patients.
rhabdomyolysis
The scan shows a dense nephrogram outlining a horseshoe kidney
CT ABDOMEN
The right kidney is seen to be somewhat larger than the left, there is no calyceal dilatation, and the central fused component passes anterior to the aorta and inferior vena cava, the former showing some incidental calcifications.
CT ABDOMEN
The central fused segment contains calyceal elements.
CT ABDOMEN
Horseshoe kidney is one of the more common congenital renal anomalies.
CT ABDOMEN
The ureters usually require to descend over the central fused segment and the condition can predispose to episodic urinary obstruction, calculus or infection.
Horseshoe kidney
In this instance, temporary obstruction giving atypical renal ‘colic’ associated with a small calculus, which is likely to have spontaneously passed, is a likely diagnosis.
Horseshoe kidney
Treatment would be expectant and conservative with encouragement of maintained fluid intake and exclusion of associated urinary infection.
small calculus
Polycystic kidney disease, another inherited congenital anomaly, gives an entirely different picture, with bilateral large kidneys containing multiple cysts. Presentation
Horseshoe kidney
in adulthood may be with renal pain, haematuria, urinary infections or progressive renal impairment
Polycystic kidney disease
Acute glomerulonephritis would be rare at this age, and is usually a sequel of previous streptococcal infection.
Horseshoe kidney
Presentation is with haematuria, oedema, and oliguria, and urinalysis and microscopy show protein and blood with casts of renal origin.
Acute glomerulonephritis
The majority of urinary calculi are radio-opaque, the remaining minority are commonly urate calculi which are non-opaque and associated with elevated serum urate.
Horseshoe kidney
They show as filling defects in the calyceal system when outlined by contrast.
Horseshoe kidney
The most likely diagnosis is urinary schistosomiasis (bilharziasis)
schistosomiasis
Symptoms suggesting urinary infection with cystitis and terminal haematuria in a male patient from Egypt should alert the clinician to the condition, which is endemic in Egypt and in large areas throughout Africa, where subclinical infection is common and up to 60% of adult males may be found to harbour the parasite.
schistosomiasis
The condition is caused by a small trematode flat worm.
schistosomiasis
The three commonest schistosomes are Schistosoma haematobium (causing urinary disease), S. mansoni and S. japonicum (causing gastrointestinal and liver disease).
schistosomiasis
S. haematobium causes vesical infestation.
schistosomiasis
The male and female worms live in vesical and paravesical veins and the female excretes thousands of eggs daily.
schistosomiasis
which provoke a granulomatous response during passage to vesical mucosa and into the urine.
schistosomiasis
The human is the primary host, and the eggs complete the life cycle by hatching in fresh water releasing motile miracidia - a first larval stage.
schistosomiasis
The miracidia infest a freshwater snail, the intermediate host, where they multiply to form thousands of sporocytes, released into the water to form motile cercana (second larval stage).
schistosomiasis
The cercaria penetrate the skin of the primary host.
schistosomiasis
This phase may be accompanied by a pruritic inflammatory response (‘swimmers’ itch’).
schistosomiasis
The organisms undertake an odyssean journey and mature into adult worms after passage via venous and lymphatic channels to lungs.
schistosomiasis
Subsequently the male and female worms migrate to live in vesical veins (S. haematobium) or intestinal veins (S. mansoni and japonicum).
schistosomiasis
Diagnosis can be made by identifying the spiked ova on urine microscopy.
schistosomiasis
Treatment with the isoquinoline agent praziquantel is very effective in decreasing infestation and controlling symptoms, and has minimal side effects.
schistosomiasis
Amoebiasis, due to Entamoeba histolytica infection, causes dysentery, enteritis and hepatitis.
schistosomiasis
Occasionally a focal ‘amoeboma’ may form and mimic a bowel tumour but amoebiasis does not primarily involve the bladder.
schistosomiasis
A urinary vesical calculus can give similar symptoms of haematuria and dysuria but, in the circumstances of this scenario, schistosomiasis would be the primary diagnosis.
schistosomiasis
Similarly, urinary tuberculosis can be associated with vesical lesions, but tuberculous infection of the urinary tract is always secondary to infection elsewhere and begins in the renal parenchyma.
schistosomiasis
Leptospirosis is due to infection with the spirochaetal organism, which is widespread in various mammalian species including rodents.
schistosomiasis
Leptospirosis icterohaemorrhagica (Weil disease) affects, particularly, occupational groups such as sewage workers and veterinarians, and is characterised by fever, jaundice, and a bleeding tendency.
schistosomiasis
The vignette of a middle aged man with an eight-hour period of memory loss (amnesia). with no other symptoms and full recovery, is characteristic of transient global amnesia, which typically occurs in men over 55-years of age and may follow exercise
memory loss (amnesia)
Whether or not this disorder is a form of vertebrobasilar insufficiency, in which no other symptoms are apparent remains to be determined.
memory loss (amnesia)
Cardiac arrhythmias can present with symptoms related to cerebral hypoperfusion.
vertebrobasilar insufficiency memory loss (amnesia)
mainly fainting or loss of consciousness, but not amnesia
vertebrobasilar insufficiency
A left internal carotid artery stenosis may be associated with a transient ischaemic attack (TIA) or a reversible ischaemic neurological defect (RIND).
vertebrobasilar insufficiency
However, the areas concerned with memory are predominantly supplied by the posterior (vertebrobasilar circulation.
vertebrobasilar insufficiency
In Wernicke encephalopathy, a confusional state is usually present and the symptoms are more profound than a loss of memory.
vertebrobasilar insufficiency
After recovery from the confusional state. the patient may have Korsakoff amnestic confabulatory syndrome.
Wernicke encephalopathy
This is permanent in most patients, but there may be partial recovery over a period of many months with thiamine supplementation, good nutrition and abstinence from alcohol
Korsakoff amnestic confabulatory syndrome
Wernicke encephalopathy
The specifics of ABO and Rh incompatibilities are as noted below when blood is transfused without matching and cross-matching.
blood transfusion
noted below when blood Response Donor group Red cell Naturally occurring antigens present in this serum donor Recipient outcome if this donor group is transfused without cross matching antibodies in this donor (A) O RhD Neither A nor Anti-A B, nor RhD Anti-B antigen negative Compatible with all major ABO groups, Rh negative or positive.
blood transfusion
O RhD RhD Anti-A antigen Anti-B Potential sensitisation of Rh negative recipient.
blood transfusion
positive (C) A, B Nil AB RhD antigen negative Haemolytic reaction with recipients of Group O, A and B.
blood transfusion
Compatible only with Group AB. (D) AB RhD A, B, RhD Nil antigen positive Haemolytic reactions as above for O, A and B, plus Rh sensitisation if Rh negative recipient.
blood transfusion
Haemolytic reactions with recipients of Groups O, B. Compatible with Groups AB, A. (E) A Anti-B A RhD antigen negative The donor red cell antigens A and B will interact with their corresponding naturally occurring antibodies in recipient serum to cause donor blood haemolysis in Group ABO incompatibilities.
blood transfusion
Rh incompatibilities occur only with sensitised Rh negative recipients who have formed Rh antibodies to Rh positive donor cells (from pregnancies or previous transfusions).
blood transfusion
Individuals with blood of Group O. Rh negative type are often labelled ‘universal donors’, while those with blood of Group AB Rh negative (the rarest blood group) are so called ‘universal recipients’, having no naturally-occurring serum antibodies (A is correct).
blood transfusion
On a normal unrestricted fluid intake, twenty-four hour urine volumes in normal health will range from 1-2 litres
urine volumes
Intakes and outputs of the major extracellular and intracellular cations of sodium and potassium are normally at least 75mmol intake and output of each.
urine volumes
The glomerulus normally allows passage of a small quantity of protein, which with normal glomerular function does not exceed 150mg of protein as albumin.
urine volumes
Protein loss of 500mg daily is abnormal and may indicate early renal involvement with microalbuminuria associated with glomerular Kimmelstiel-Wilson lesion, characteristic of diabetic glomerulosclerosis
Protein loss in urine
The total nonvolatile acid urinary excretion from food intake and its metabolism is of the order of 100-200mmol daily.
acid loss in urine
The clinical features are typical of a crush syndrome with acute hypercatabolic oliguric renal failure accompanied by early life-threatening hyperkalaemia
crush syndrome
The electrocardiogram (ECG) shows the classical features of high peaked T-waves, progressing to widened QRS complexes.
hyperkalaemia crush syndrome
Subsequent changes as the condition progresses are likely to be transition to a saw-tooth pattern with ventricular tachycardia and cardiac arrest.
hyperkalaemia
Urgent treatment by dialysis is required as definitive treatment
hyperkalaemia crush syndrome
Early measures in the Emergency Department should include an intravenous cocktail of hypertonic glucose and insulin, with calcium gluconate and sodium bicarbonate also added (viz. 500mL of 10% glucose in water with 25 units regular insulin plus 20mL of 10% calcium gluconate and 20mL of molar sodium bicarbonate).
hyperkalaemia crush syndrome
A cation exchange resin enema may also be given while awaiting dialysis, but acts less rapidly than the cocktail above.
hyperkalaemia crush syndrome
The hypertonic glucose and insulin and the hypertonic sodium bicarbonate each lower serum potassium by driving extracellular potassium into cells; the calcium gluconate does not lower the potassium level but is cardioprotective
hyperkalaemia crush syndrome
The electrocardiogram (ECG) changes are typical of hyperkalaemia with a widened QRS complex and with elevated and peaked T waves.
(ECG) changes hyperkalaemia
The clinical scenario of crush injury with acute oliguria and myoglobinuria, associated with acute tubular necrosis.
hyperkalaemia crush syndrome
is also classical of the ‘crush syndrome’ first observed in the civilian injuries.intravenous calcium gluconate is the preferred initial treatment to combat the toxic effects of hyperkalaemia demonstrated in the ECG (D is correct).
hyperkalaemia crush syndrome
Calcium gluconate has a direct ameliorating effect without lowering serum potassium, and would be followed by definitive potassium-lowering therapies (hypertonic glucose and insulin, hypertonic sodium bicarbonate), including dialysis
hyperkalaemia crush syndrome
Neither intravenous digoxin nor isotonic saline will reduce serum potassium and neither is appropriate
hyperkalaemia crush syndrome
A calcium channel blocker such as diltiazem is also inappropriate
hyperkalaemia crush syndrome
Prolonged intravenous fluid administration, unless given as total optimal parenteral nutrition, can be associated with several complications, one of which (trace element deficiency) is illustrated here -zinc deficiency (B is correct).
zinc deficiency
Trace element deficiencies have long been recognised in animal husbandry.
zinc deficiency
It came into clinical prominence with the advent of total parenteral nutrition.
zinc deficiency
After realisation that, apart from supply of adequate energy needs (with a suitable mix of assimilable carbohydrate, protein and fat energy sources with essential amino acids and fatty acids.
zinc deficiency
vitamins, fluids and electrolytes and minerals) a number of vital trace elements (of which zinc was the most prominent) required to be added to the intravenous nutrition formula
zinc deficiency
Zinc is an important component of coenzymes involved in wound healing and repair - symptoms of deficiency become prominent in actively metabolising epithelial tissues, so that an exanthematous dermatitis (acrodermatitis enteropathica) and gastrointestinal symptoms are prominent.
zinc deficiency
The patient rapidly recovered within a few days after addition of zinc in small quantities to the feeding solution as shown.
zinc deficiency
zinc deficiency syndrome was first described in surgical patients with abnormal gastrointestinal losses.
zinc deficiency
The incidence of this complication is now low with standardised addition of trace elements to parenteral nutrition fluids
zinc deficiency
Copper deficiencies can be associated with anaemia, neutropenia and bone demineralisation
trace element deficiency syndromes
Iron is an essential component of haem; iron deficiency giving rise to hypochromic microcytic anaemia is well known.
trace element deficiency syndromes
Magnesium deficiencies can be associated with vitamin K-deficient syndromes and a bleeding tendency.
trace element deficiency syndromes
lodine deficiency associated with goitre and hypothyroidism is well known.
trace element deficiency syndromes
Other trace element deficiency syndromes can involve molybdenum (neurological abnormalities), selenium (muscle weakness and pain) and cobalt (Vitamin B₁2 deficiency).
trace element deficiency syndromes
The clinical scenario is that of incipient hyperosmolar (non-ketotic) coma in an elderly woman with Type 2 diabetes mellitus.
hyperglycaemia
This has been precipitated by an intercurrent acute diarrhoeal illness.
hyperglycaemia
The markedly elevated blood glucose level is the key biochemical indicator, and it is important to interpret the serum sodium in relation to this
hyperglycaemia
Hyponatraemia can be hypo-osmolar or non-hypo-osmolar
hyperglycaemia
Hypo-osmolar hyponatraemia is associated with water gain or sodium depletion or often a combination of both
hyperglycaemia
Non-hypo-osmolar (hyperosmolar) hyponatraemia is most often due to hyperglycaemia (E is correct).
hyperglycaemia
This condition is also known as pseudohyponatraemia.
hyperglycaemia
The elevated serum creatinine may be due to underlying chronic renal disease. but will have been increased by pre-renal renal failure consequent to significant dehydration
hyperglycaemia
However the degree of renal failure and azotaemia is insufficient to explain the hyponatraemia
hyperglycaemia
The syndrome of inappropriate antidiuretic hormone (ADH) secretion (SIADH) is seen quite commonly with chest infections and other lung conditions and as an idiosyncratic reaction to drugs (including thiazide diuretics) but is unlikely to be related to anticonvulsant therapy
hyperglycaemia
Excessive salt loss from the kidney can be a consequence of a renal tubular acidosis but is unlikely in diabetic renal disease.
hyperglycaemia
There is no clinical evidence of congestive cardiac failure, and heart failure as a potential cause of hyponatraemia is less likely in this scenario
hyperglycaemia
A serum sodium below 135mmol/L defines hyponatraemia, which in itself is not a diagnosis but can be an expression of many disorders.
hyponatraemia
The cause can usually be determined by the clinical circumstances.
hyponatraemia
In this case, in a patient with worsening congestive cardiac failure, the most likely diagnosis is water excess with dilutional hyponatraemia - hypo-osmolar hyponatraemia (C is correct).
hyponatraemia
No major additional solute retention causing non-hypo-osmolar hyponatraemia/ pseudohyponatraemia (such as is seen with significant hyperglycaemia or azotaemia) is present, nor is there any indication of ectopic ADH, excessive diuresi or renal salt wasting.
hyponatraemia
This patient has significant hyponatraemia. Hyponatraemia in this clinical setting in c normovolaemic patient suggests ectopic ADH secretion (C is correct)
hyponatraemia
The low urate and low normal urea are also supportive in this diagnosis
hyponatraemia
This man will need further investigations to check for carcinoma of the lung.
hyponatraemia
A ‘normal’ chest X-ray does not rule out carcinoma of lung in this setting
hyponatraemia
Dilutional hyponatraemia, pseudohyponatraemia and renal salt wasting are less likely alternatives; nor would diabetes insipidus fit the clinical setting.
hyponatraemia
He has significant hyponatraemia, together with hyperglycaemia (17mmol/L) in the diabetic range.
excessive diuresis
The patient’s clinical findings are now those of depletion, rather than heart failure, making dilutional hyponatremia unlikely.
excessive diuresis
The elevated blood sugar and creatinine are, however, not likely to give rise to this level of pseudohyponatraemia
excessive diuresis
Sodium depletion in excess of water could be a consequence of his combined diuretic therapy of frusemide and aldactone, which may have caused excessive diuresis and dehydration.
excessive diuresis
Patients with lung cancer may present with symptoms associated with a variety of non-metastatic extra-pulmonary paraneoplastic phenomena, due to tumour products secreted into the blood (usually polypeptide hormones) causing manifestations systemically and on remote target organs.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Hypercalcaemia due to production of parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma (A is correct).
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Symptoms of hypercalcaemia include fatigue, constipation, polyuria, and, occasionally, mental confusion and coma.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
endocrine secretions which can be found, usually in association with smal cell carcinoma, are the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and ectopic adrenocorticotrophic hormone (ACTH) secretion.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Nonendocrine paraneoplastic phenomena include a variety of peripheral neuropathies and myasthenic symptoms of proximal muscle weakness and sensory neuropathy (Eaton-Lambert syndrome).
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
The hypercalcaemia can be misdiagnosed as primary hyperparathyroidism, but no abnormality of parathyroid glands is present.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Renal failure with phosphate retention is more likely to be associated with hypocalcaemia.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Bony metastases can be associated with hypercalcaemia, but this is found more often with a breast carcinoma
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
In a patient with a primary lung neoplasm, ectopic PTH-like peptide production is more likely.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Dehydration can cause minor elevation of serum electrolytes.
parathyroid hormone-related peptide (PTHrP) is usually caused by squamous cell carcinoma
Diagnosis of Q fever is by serum testing for antibodies against the organism (C is correct).
Q fever
The organism, a rickettsia, does not grow in standard media on a Petri dish.
Q fever
A vaccine is also available for high risk individuals, such as abattoir workers, with occupational exposure.
Q fever
This patient has Q (for Query) fever, and the most common source of infection of this rickettsial disease is among individuals who may come into contact with the primary reservoir of Coxiella burnetii- cattle.
Q fever
The organism is excreted in the milk, urine and faeces of infected animals.
Q fever
Abattoir workers are particularly at risk from inhalation of infected dust from hides, causing pulmonary and systemic sepsis.
Q fever
The workplace environment can be an important source of infection
Q fever
It is obviously important in such cases to obtain an accurate history of, not only the type and place of work, but recent travel, drug and sexual habits, and contacts with other potential infected individuals.
Q fever
Prophylactic antibiotic therapy is indicated in a variety of abdominal procedures in which a bacterially contaminated or potentially non-sterile abdominal viscus is breached, or when prostheses are to be inserted, infection of which would have dire consequences.
Prophylactic antibiotic therapy just prior to the start of surgery
The aims of such preventive therapy are that an antibiotic or antibiotic combination should be given, in appropriate dose and by appropriate route and for an appropriate period, such that the peak serum concentration is maximal at the time of likely wound contamination, and continues over the period of maximum infective risk.
Prophylactic antibiotic therapy just prior to the start of surgery
With most antibiotics, the pharmacokinetics and therapeutic half life make it most convenient and effective for this to be given by intravenous administration just prior to the start of surgery at the time of anaesthetic induction (B is correct).
Prophylactic antibiotic therapy just prior to the start of surgery
The other options are either too early or too late to achieve optimal results.
Prophylactic antibiotic therapy just prior to the start of surgery
The clinical features are those of acute cellulitis. In addition to intravenous antibiotics, the essential initial management of severe cellulitis of the leg is bed rest, with avoidance of dependency and exercise (A is correct).
acute cellulitis
The possibility of a past deep vein thrombosis (DVT) is very high with the history of leg fractures, which would convey a high risk of DVT associated with this presentation.
acute cellulitis
Prophylactic anticoagulant therapy is indicated, but subcutaneous low molecular weight heparin would be the anticoagulant of choice, and warfarin therapy is not the correct choice of anticoagulant.
acute cellulitis
The use of firm compression bandaging is the treatment of venous hypertension.
acute cellulitis
Prior damage to the leg veins with DVT at the time of his fractures would also result in chronic venous hypertension as a consequence of deep venous and perforator incompetence.
acute cellulitis
Supporting evidence for this diagnosis would be the presence of haemosiderin pigmentation around the ankle and lower leg region, but this is not seen in this case.
acute cellulitis
Moreover there are major risks associated with compression over a cellulitic lower limb in a diabetic patient whose arterial vascular status may be impaired.
acute cellulitis
Incisional drainage is only required when an abscess develops.
acute cellulitis
Wide excision and debridement of tissue is needed when there is evidence of necrosis of subcutaneous tissue or muscle, with spreading anaerobic fasciitis or myositis.
acute cellulitis
There is no clinical evidence provided to suggest such diagnoses
acute cellulitis
The diagnosis is almost certainly staphylococcal cellulitis, with the history of a pustule and the spreading skin redness.
acute cellulitis
The normal temperature, white cell count and C-reactive protein (CRP) level are indicative of an early presentation
acute cellulitis
The spread of the cellulitic edge within twenty-four hours, as shown in the illustrations, is consistent with the natural history of this condition.
acute cellulitis
Continuation of current therapy of intravenous flucloxacillin is appropriate, with rest and elevation of the limb, while awaiting blood and skin cultures (D is correct).
acute cellulitis
If this confirms Staphylococcus aureus as the infecting organism (or even for culture-negative disease), he will likely require 10 days of intravenous flucloxacillin followed by four to six weeks of oral cephalexin 500mg six-hourly.
acute cellulitis
Appearance of elbow from two views showing initial marker and current appearance.
acute cellulitis
Ceasing warfarin is incorrect. There is no evidence that he has a haematoma, the INR level is appropriate for continued anticoagulant control for his mechanical aortic valve, and there are very significant risks of warfarin cessation.
acute cellulitis
Pain relief is essential and the most appropriate drug therapy for this would be paracetamol and paracetamol/codeine.
acute cellulitis
The use of nonsteroidal anti-inflammatory drugs such as indomethacin has no place in the treatment of cellulitis, and there is a risk of potential masking of the inflammatory response which needs monitoring.
acute cellulitis
Pain will resolve with control of the infection
acute cellulitis
Ultrasound would be appropriate if there was any evidence of an infected bursa or joint effusion, but there is no evidence provided to support either of these diagnoses.
acute cellulitis
Adding gentamicin as a second antibiotic is not indicated on clinical grounds.
acute cellulitis
It would be appropriate in the setting of suspected staphylococcal endocarditis: however, in the setting of a prosthetic aortic valve, the drug of choice would be vancomycin.
acute cellulitis
In the unlikely event this was a community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection, the treatment of choice is intravenous vancomycin
acute cellulitis
In this nonimmunised patient with a tetanus-prone wound, tetanus prophylaxis requires both administration of tetanus human immunoglobin together with commencing a course of active immunisation (three treatments with adsorbed diphtheria and tetanus [ADT] vaccines) (C is correct).
tetanus prophylaxis
The two injections in the first instance are preferably given in different arms.
tetanus prophylaxis
Human tetanus immunoglobulin alone is less appropriate than a regimen which gives both immediate protection and definitive active immunity for future risk
tetanus prophylaxis
Equine antitetanus serum, which had a higher risk of allergic reaction, has been replaced with human antitetanus immunoglobulin, and tetanus toxoid as a sole agent is inappropriate in not providing immediate protection in a nonimmunised patient.
tetanus prophylaxis
Additionally, tetanus toxoid, as part of a tetanus immunisation program in children and in adults, has been replaced with the combination of adsorbed tetanus toxoid and diphtheria (ADT) vaccine.
tetanus prophylaxis
Clinical presentation with metastatic spread and an occult primary can occur with gastrointestinal gastric or colonic tumours, breast or thyroid cancers.
metastatic spread and an occult primary cancers
Lung cancers and cutaneous melanomas comprise another group.
metastatic spread and an occult primary cancers
Gastrointestinal cancers usually metastasise first to the liver.
metastatic spread and an occult primary cancers
Metastatic lung lesions are most characteristic of primary renal cell c carcinomas: in which ‘cannonball’ tumours eensins are Abdominal computed tomography (CT) is thus the investigation most likely to locate the primary tumour (C is correct).
metastatic spread and an occult primary cancers
investigations of mammography, thyroid isotope scan, and upper and lower gastrointestinal endoscopy would be appropriate sequentially if a renal source was excluded
metastatic spread and an occult primary cancers
On the premise that ‘common things occur commonly’ this patient would be most likely, on the basis of her clinical presentation, to have biliary colic.
biliary colic
With this presumptive diagnosis an upper abdominal ultrasound would be a reasonable initial investigation
biliary colic
The prime objective of the sonogram is to look for the presence of stones in the gallbladder
biliary colic
In addition, evidence of any associated inflammation would be sought. This would be manifest as thickening of the wall of the gallbladder and the presence of pericholecystic fluid.
biliary colic
Stones might be identified within the common bile duct, although the sensitivity of ultrasound for the accurate detection of duct stones varies between 30-50%.
biliary colic
Apart from studying the gallbladder and common bile duct the ultrasonographer will also scan the liver as standard procedure
biliary colic
In this instance a number of homogeneous lesions have been identified within the liver parenchyma.
biliary colic
Three of them have been marked out. The lesions are of similar density to the surrounding parenchyma and therefore unlikely to be cysts (either hydatid or simple).
biliary colic
Focal nodular hyperplasia tends to manifest as a solitary lesion
biliary colic
Of the options provided, the most likely explanation for this ultrasound appearance is metastatic disease (B is correct)
biliary colic
Once malignancy is considered, carcinoma of the colon, pancreas, stomach should be first considered; then carcinoma of the breast and lung must be excluded, together with lesions of the stomach or large bowel, as primary sites.
biliary colic
Current organ presentation techniques for vascularised allografts depend upon hypothermic refrigerated ice storage at 0°C after a cold flush with a suitable preserving solution.
organ presentation techniques
Tolerated periods of cold ischaemic storage, in organs removed from a heart- beating brain-dead donor, are at least 24 hours for kidneys, pancreas and liver.
organ presentation techniques
Immediate function of the transplant can be expected in most instances under such circumstances.Lungs also tolerate cold ischaemic storage well for periods of 12-24 hours.
organ presentation techniques
Hearts have the lowest tolerance, as well as the greatest requirement for immediate function, and cold ischaemic times aimed at are usually six hours or less to maximise the likelihood of immediate function (D is correct)
organ presentation techniques
Immune rejection of organ grafts is directed principally at the major histocompatibility transplantation antigens (HLA) on the donor graft which are foreign to the recipient.
major histocompatibility transplantation antigens (HLA)
In humans, the expression of these antigens is genetically controlled by the HLA system located on the short arm of chromosome six.
major histocompatibility transplantation antigens (HLA)
At least five loci are known for the HLA system - HLA DR, D, B, C and A.
major histocompatibility transplantation antigens (HLA)
Each individual has two chromosome 6s. Thus each person’s HLA phenotype will be made up of two A.
major histocompatibility transplantation antigens (HLA)
two B, two C, two D and two DR antigens.
major histocompatibility transplantation antigens (HLA)
The HLA system is extremely polymorphic, so the number of different HLA phenotypes that can be present in a population is astronomical, and the larger the recipient pool, the more likely a relatively close match can be obtained between unrelated cadaver donors and recipients.
major histocompatibility transplantation antigens (HLA)
Transplant recipients are at increased risk of dying from advanced malignancy.
Organ Transplant
More than 40% of recipients will develop malignancies within 10 years of transplantation.
Organ Transplant
These individuals are at more than 1000 times the risk of the general population of developing non-melanomatous skin cancers.
Organ Transplant
The risk of Kaposi sarcoma is similar. and the risks for hepatocellular carcinoma, lymphoproliferative disorders and some gynaecological cancers is forty-fold that of the general population.
Organ Transplant
Apart from this increase in incidence, these patients tend to develop malignancy at an early age and the disease progresses more rapidly.
Organ Transplant
Dormant tumours may be activated by immunosuppression and any symptoms and signs associated with malignancy may be masked.
Organ Transplant
The donor kidney may be rejected, but that in itself is not now usually a life- threatening event
Organ Transplant
The rejected organ can be removed and the patient put back on dialysis or a transplant program
Organ Transplant
These patients will have increased risks of the morbid complications of renal failure and cerebrovascular and cardiovascular disease, but these do not pose longterm as great a risk as those of the increased risk of malignancy, which is progressive and cumulative (E is correct).
Organ Transplant
Acute upper airway obstruction is a dramatic and life-threatening condition, requiring urgent relief.
Acute upper airway obstruction
The larynx and upper airway passages are normally shielded from entry of ingested food or liquid by elevation of the larynx and the protective prow of the epiglottis on swallowing
Acute upper airway obstruction
Inadvertent entry of liquid into the larynx on swallowing is usually readily expelled by coughing, but a large bolus of solid food may become impacted at the entrance and precipitate acute respiratory distress if coughing or retching does not dislodge the obturating object.
Acute upper airway obstruction
Inserting an oral airway or applying oxygen via a facemask do not address the problem of obstruction, and will not deliver necessary oxygen to the alveoli.
Acute upper airway obstruction
Dislodging the obstruction is urgently required by whatever means available.
Acute upper airway obstruction
In infants, turning the child upside down and inserting a finger down the throat may be insstinctive and produce appropriately beneficial responses.
Acute upper airway obstruction
In this adult, application of forceful upper abdominal and lower thoracic compression by a rapid ‘bear-hug’ (Heimlich manoeuvre) may increase intra- abdominal and intrathoracic pressure enough to supplement the patient’s own efforts to expel the responsible piece of food, and is the immediate first step in management (C is correct)
Acute upper airway obstruction
If this fails, and obstructive hypoxia and cyanosis worsen, percutaneous cricothyroid needling, with delivery of oxygen by cannula below the cords, is an appropriate next choice and may avert the need for emergency tracheostomy.
Acute upper airway obstruction
Blind endotracheal intubation is unlikely to succeed in this circumstance, but direct laryngoscopy may be necessary once oxygenation has been enhanced after cricothyroid needling.
Acute upper airway obstruction
A small bowel fistula of high volume, two weeks after an open abdominal missile injury as described, requires the following staged approach to management.
small bowel fistula
The first priority is to restore the patient’s circulatory blood volume to normal, and to correct any existing fluid and electrolyte imbalance from loss of small bowel content (A is correct).
small bowel fistula
If the patient is shocked at presentation, with hypotension and tachycardia, he has a deficit of at least 30% of blood volume (or 1.5-2 litres in this 20-year-old man).
small bowel fistula
- If he has signs of extracellular fluid (ECF) defect (sunken eyes, firm dry tongue, diminished tissue turgor), he will have a total deficit of around 7% body weight (5-6 litres);
small bowel fistula
and if these signs are combined with signs of circulatory failure, the deficit is likely to be greater than 10% body weight (8-10 litres).
small bowel fistula
The composition of the deficit is predominately ECF (high in sodium and chloride and with varying amounts of bicarbonate and potassium).
small bowel fistula
Appropriate replacement fluid is thus isotonic Hartmann solution or saline with added potassium (30mmol/L) and bicarbonate (30mmol/L).
small bowel fistula
(APACHE system - Acute Physiology and Chronic Health Evaluation) and are used in coronary care and intensive care units
small bowel fistula
The most likely diagnosis in this severely ill woman is mesenteric vascular occlusion (E is correct).
mesenteric vascular occlusion
She falls into the special group of acute abdomen - ‘acute abdominal surgical emergency’: a group usually requiring early surgery.
mesenteric vascular occlusion
The association of atrial fibrillation and abdominal signs of generalised peritonitis must alert the clinician to the diagnosis of mesenteric embolic arterial ischaemia from a left atrial thrombus, causing mesenteric vascular ischaemia and infarction, usually affecting the superior mesenteric artery or one of its major branches to jejunum and ileum.
mesenteric vascular occlusion
The prognosis is grave - early operation may allow therapeutic embolectomy or may require extensive bowel resection.
mesenteric vascular occlusion
Other causes of severe acute abdominal pain with accompanying peritonitis. prostration and shock include acute visceral perforation (perforated peptic ulcer, perforated colonic diverticulitis, perforated colonic carcinoma, as well as acute haemorrhagic pancreatitis)
mesenteric vascular occlusion
but with the scenario depicted, mesenteric vascular occlusion is the most likely diagnosis
mesenteric vascular occlusion
Any of the complications listed might occur in this patient. His diabetes will render him more prone to infection and any of the listed infections are possible.
wound dehiscence
Staphylococci and streptococci are part of the normal skin flora of many individuals and unless precautions are taken, such as intra-operative prophylactic antibiotic therapy, either of these two types of bacteria might enter and colonise a surgical wound.
wound dehiscence
Streptococcal infections tend to spread and produce a surrounding infection (cellulitis) rather than a localised collection.
wound dehiscence
Staphylococcal infection is usually localised and associated with the formation of pus.
wound dehiscence
If the discharge was purulent, such a diagnosis must be seriously considered. This patient has had potential contamination of the peritoneal cavity with gut contents and gut-derived organisms.
wound dehiscence
A localised collection with Gram negative organisms (such as E. col) might easily occur.
wound dehiscence
However, this type of infection - and that due to staphylococci - are usually associated with localized swelling, redness and purulent discharge, and this is not what has been described in this case.
wound dehiscence
Bruising is a common occurrence after any operation and might lead to discharge of a hematoma.
wound dehiscence
It such circumstances, bruising and discolouration would often be visible at the skin edges, and the discharge more bloody.
wound dehiscence
This man’s diabetes might well impede wound healing and any acute infection associated with his chronic respiratory disease might lead to coughing and raised intra-abdominal pressure.
wound dehiscence
Both these factors would predispose to weakening of the wound and consequence dehiscence.
wound dehiscence
Wound dehiscence is the most serious of the complications mentioned and the text describes its classic presentation (D is correct).
wound dehiscence
This case must be considered one of wound dehiscence until proven otherwise. The other causes can be treated with local wound care a dehisced wound is a surgical emergency and will require prompt return to the operating room for wound toilet and resuturing.
wound dehiscence
The primary survey of any trauma patient focuses on patency of the Airway, adequacy of Breathing and the state of the Circulation (ABC).
primary survey of any trauma
Only once these three dynamics have been assessed and shown to be under control should attention be moved elsewhere.
primary survey of any trauma
All the conditions listed in the question may lead to a critical and life-threatening situation.
primary survey of any trauma
Myocardial contusion, such as that sustained in blunt trauma may result in poor output and cardiac failure if there is major muscle damage.
primary survey of any trauma
Hypotension and arrhythmias are potentially fatal sequelae
primary survey of any trauma
Likewise the bleeding from a liver laceration or aortic dissection may prove fatal, as might a major intracranial bleed, but all these events are less able to be controlled during the initial assessment than the primary ABC.
primary survey of any trauma
Respiratory failure as a result of airway obstruction, tension pneumothorax or flail chest is more likely to be immediately life-threatening and more remediable than the other problems during the first phase of assessment, either at the site of trauma or in the Emergency Department (D is correct)
primary survey of any trauma
The combination of symptoms and signs indicate severe life-threatening anaphylaxis to a bee sting, which necessitates immediate administration of adrenaline 1:1000 (A is correct).
anaphylaxis
Although the intravenous route for adrenaline administration is preferable. the subcutaneous route is initially more practical
anaphylaxis
A subject with a known bee sting allergy is likely to carry an adrenaline Epipen® for immediate self-administration subcutaneously following a sting, delivering a single use dose of 300mcg (0.3mg) of 1:1000 adrenaline repeated in 5min if necessary
anaphylaxis
The insertion of a central venous catheter is not appropriate initial management.
anaphylaxis
Intravenous plasma-expanding solutions (e.g. gelatin solution) may be required after initial adrenaline treatment, and would usually be given through a peripheral venous line.
anaphylaxis
High flow oxygen and nebulised salbutamol are appropriate for emergency care in anaphylaxis with respiratory obstruction, but are supplementary to adrenaline
anaphylaxis
Anaesthesia and intubation would be inappropriate emergency therapy in this patient.
anaphylaxis
Of even more profound impact, the probability of an offspring (of either sex) affected by the condition of beta-thalassaemia major is also 0.25, and this risk should also be explained to the patient.
beta-thalassemia major
Beta-thalassaemia major is a severe disease with limited life expectancy.
beta-thalassemia major
The abnormal gene and its homozygous or heterozygous expression can be now diagnosed definitively by chorion villus biopsy or amniocentesis
beta-thalassemia major
and prophylactic termination of pregnancy can be offered unless prohibited by the patient’s religious beliefs.
beta-thalassemia major
Half the children (of either sex) will be normal, half will be carriers of the trait.
beta-thalassemia major
Haemophilia A is transmitted by a mutant gene on the X-chromosome.
Haemophilia A
Inheritance is by an X-linked inheritance pattern.
Haemophilia A
Daughters are not affected, whether or not they inherit the gene, as the other normal X-chromosome prevents expression of the abnormal gene mutation.
Haemophilia A
Half the daughters will, however, themselves be carriers.
Haemophilia A
Half the sons will be normal, having received from the mother a normal X-chromosome; but half the sons, those who receive the mutant X-chromosome, will have haemophilia A, as illustrated.
Haemophilia A
Thus one of four of her possible offspring (probability 0.25), and half her sons, will be affected by haemophilia A (B is correct).
Haemophilia A
This elderly woman, with a displaced subcapital fracture, is at considerable risk from the hazards of being confined to bed and immobilised from her injury.
displaced subcapital fracture
These hazards include an acute confusional state, pulmonary atelectasis and pneumonia, venous thromboembolism, pressure sores, urinary complications, parotitis, and bowel complications of ileus or faecal impaction.
displaced subcapital fracture
She requires urgent stabilisation of her displaced fracture, and early mobilisation from bed aided by optimal nursing and rehabilitative care.
displaced subcapital fracture
Analgesics and bed rest clearly will not fulfil these aims, and would likely accelerate her demise; application of a hip spica would even more certainly send her on a downhill course and early death
displaced subcapital fracture
Neither is a realistic opinion unless the cause seems hopeless from the start - which is not the case in this scenario.
displaced subcapital fracture
Immediate ambulation on crutches could only be an option with a fully impacted stable fracture, but would be impractical with this displaced fracture, which would produce constant pain on movement.
displaced subcapital fracture
She is clearly not a woman in whom early decline and death should be accepted as near inevitable.
displaced subcapital fracture
Although mildly demented, she seems to have been managing at home and is having supportive treatment for her medical comorbidities
displaced subcapital fracture
The only practical form of fracture stabilisation is by early surgery.
displaced subcapital fracture
Intramedullary nail fixation would be a possible option.
displaced subcapital fracture
The operation can often be done rapidly and expeditiously without substantial surgical or anaesthetic morbidity
displaced subcapital fracture
However she is osteoporotic and osteopenic
displaced subcapital fracture
The soft femoral head may not provide adequate support for the nail, which may cut out.
displaced subcapital fracture
The risk of non-union is significant, with ischaemic collapse of the femoral head
displaced subcapital fracture
A prosthetic excisional arthroplasty is a better option in elderly patients with osteopenia (C is correct).
displaced subcapital fracture
Modern prostheses will allow early mobilisation, minimising initial weight-bearing by use of crutches and walking frame aids.
displaced subcapital fracture
The operation itself would have slightly higher operative risk; and meticulous haemostasis, appropriate closed suction drainage, and layered wound closure will be required in view of her aspirin therapy, with risk of increased operative haemorrhage.
displaced subcapital fracture
As her myocardial infarction was more than 6 months ago, and she is on appropriate combination therapy (beta blocker, ACE inhibitor and aspirin), her risk of perioperative further infarction is likely to have stabilised
displaced subcapital fracture
She will require careful cardiac assessment for any evidence of acute coronary ischaemia and heart failure, and monitoring over the operative and perioperative period
displaced subcapital fracture
Continuation of her aspirin therapy must be combined with mechanical and pharmaceutical preventives for thromboembolism. Her other medications do not pose any special perioperative problems
displaced subcapital fracture
Her history of mild dementia means that perioperative care must avoid exacerbation of any acute confusional state, by watching for hypoxia or electrolyte imbalance, and should maintain familiar faces and ambience during the perioperative period.
displaced subcapital fracture
A symptomatic mucopurulent discharge, associated with a cervical ‘erosion’ or eversion, is best treated by eradicating the cervical lesion by cautery (E is correct).
cervical lesion by cautery
This is usually done under anaesthesia and healing of the cervix occurs with eradication of the ‘erosion’ within approximately four weeks of the procedure
cervical lesion by cautery
Antibiotics or vaginal pessaries are usually ineffective, and a cone biopsy would not be required unless the Pap smear test was abnormal and/or colposcopy examination revealed a probable cervical intraepithelial neoplastic lesion which was not fully visible
cervical lesion by cautery
In the absence of an abnormal smear test or abnormal bleeding, colposcopic examination is not required
cervical lesion by cautery
Treatment is indicated because of the troublesome nature of the discharge, thus ‘no treatment’ is not appropriate.
cervical lesion by cautery
The only correct answer is D - the oral contraceptive pill (OCP) should be ceased as the hypertension will then probably settle, indicating that no hypotensive therapy is necessary.
hypertension
If the blood pressure does not settle, the agent used to control the blood pressure should be one which can be continued during the anticipated pregnancy.
hypertension
Continuing the OCP in any dosage or in combination with a hypotensive agent is not appropriate. Alternative contraceptions such as condoms should be used.
hypertension
The agent best evaluated for hypertension in pregnancy is methyldopa.
hypertension
An angiotensin-converting enzyme (ACE) inhibitor is not approved for use in pregnancy because of its association with fetal death in utero, and beta-blockers have potential problems associated with their use.
hypertension
Diuretics should also be avoided as they are contraindicated in pregnancy.
hypertension
Menorrhagia in a 45-year-old woman is likely to be due to a disorder of ovulation, most likely that of anovulatory cycles, especially as the cycles have become irregular (B is correct)
Menorrhagia
Endometrial carcinoma is an uncommon cause of menorrhagia and usually causes postmenopausal bleeding
Menorrhagia
Fibroids, endometrial polyps and adenomyosis can certainly cause menorrhagia
Menorrhagia
although the cycles are usually regular and a dramatic change from normal cycles six months previously would be unusual.
Menorrhagia
The uterus is usually enlarged if fibroids or adenomyosis are the cause of the menorrhagia
Menorrhagia
To be able to advise this couple appropriately the candidate needs to understand the following facts: Ovulation occurs 14 days prior to the period, as the length of the luteal phase is 14 days irrespective of the follicular phase length
Ovulation
In this woman her ovulation, therefore, has occurred as early as day 12, or as late as day 15, of her cycle.
Ovulation
Sperm survival has been shown to be much longer than originally thought, in the presence of adequate and normal cervical mucus, with intercourse occurring up to 6 days before the known time of ovulation resulting in pregnancy.
Ovulation
In this woman, therefore, intercourse should be ceased six days before the earliest ovulation (i.e. on day six).
Ovulation
The duration over which the ovulated egg can be fertilised is generally accepted to be about 24-36 hours. Intercourse should therefore not be resumed Funtil two days after the latest ovulation.
Ovulation
In this woman this would be day 17. Abstinence is therefore required between days 6 and 17 of the cycle (B is correct).
Ovulation
In early pregnancy the oestradiol (E2), progesterone and prolactin (PRL) levels all rise, but the elevated levels of these hormones can also be observed in pathologic states in non-pregnant women, or even during some menstrual cycles.
early pregnancy hormones
Follicle-stimulating hormone (FSH) levels are suppressed in pregnancy due to the elevated E2 and progesterone levels.
early pregnancy hormones
The correct response is elevation of the luteinising hormone (LH), because the beta sub-units of LH and human chorionic gonadotrophin (hCG) are almost identical and hCG is therefore measured as LH in virtually all LH assays (D is correct).
early pregnancy hormones
Although the LH levels can be mildly elevated in polycystic ovarian syndrome, they rarely exceed 30mIU/mL in this condition.
early pregnancy hormones
The LH levels at mid-cycle can reach 100-150mIU/mL, but levels in excess of 200mIU/mL are usually indicative of pregnancy.
early pregnancy hormones
Endometriosis can present with any of the following symptoms, either alone or in combination menorrhagia, premenstrual spotting, pelvic pain or dyspareunia.
Endometriosis
Most patients with endometriosis, however, have this diagnosis made when a laparoscopy is performed as part of the evaluation of infertility and, apart from their infertility, they have no pain or abnormal bleeding (E is correct).
Endometriosis
The two common organisms which cause pelvic inflammatory disease (PID) after sexual activity are chlamydia and gonorrhoea. In Australia, chlamydia is much more common then gonorrhoea.
pelvic inflammatory disease (PID)
When PID follows a gynaecologic surgical procedure the organisms are more likely to be Mycoplasma or vaginal pathogens, with E. coli sometimes being the organism involved
pelvic inflammatory disease (PID)
In patients presenting for pregnancy termination however, especially if they do not have a constant sexual partner, preoperative swabs have revealed an incidence of chlamydial infection in up to 15% of subjects.
pelvic inflammatory disease (PID)
So this is the most likely organism in this case, in conjunction with vaginal pathogens (A is correct).
pelvic inflammatory disease (PID)
Her fever indicates a systemic infection and, thus, this woman has PID. If PID was not present, and the problem was that of vaginal discharge alone, the likely organism involved would be chlamydia alone.
pelvic inflammatory disease (PID)
The cyst in the left ovary has been found at about mid-cycle, if one assumes this cycle is going to be of 35 days duration.
cyst in ovary
It is too big to be a pre-ovulatory follicle about to rupture, and clearly does not have the features usually evident in a corpus luteum, a benign cystic teratoma or an endometrioma.
cyst in ovary
The most likely diagnosis is, therefore, a follicular cyst (B is correct).
cyst in ovary
The appearance on ultrasound of a unilocular, thin walled, cystic structure almost certainly reflects a benign cyst.
cyst in ovary
A multiloculated cystic structure containing solid elements is strongly suggestive of a malignant mass.
cyst in ovary
This would be uncommon, but not unknown, in a 25-year-old woman.
cyst in ovary
A malignancy of the ovary needs to be excluded; hence the need for admission and surgical exploration (E is correct).
malignancy of the ovary
Other tests required would be an assessment of the CA125 level, but any form of hormone treatment is contraindicated until the diagnosis of the cause of the enlargement is made
malignancy of the ovary
A Pap smear is unlikely to be abnormal and is not a good assessment of ovarian masses, and evaluation of bone density would be inappropriate until the ovarian problem is sorted out.
malignancy of the ovary
As the ultrasound has certainly confirmed the clinical diagnosis of polycystic ovaries (PCO), the correct answer is treatment with metformin, as this agent has been shown to be particularly useful in patients with polycystic ovaries, because of the insulin resistance so commonly present in this condition (D is correct).
polycystic ovaries (PCO)
Treatment with this agent usually results in a restoration of ovulatory menstrual cycles of normal length and a rapid return of fertility.
polycystic ovaries (PCO)
Some patients require additional treatment with clomiphene citrate but gonadotrophin therapy is now rarely required.
polycystic ovaries (PCO)
If clomiphene citrate had been offered as a possible next step in treatment, it would also have been appropriate, as current data suggests metformin and clomiphene are equally effective.
polycystic ovaries (PCO)
Although laparoscopic ovarian drilling was formerly used to treat PCO, it is now only used where all other methods of treatment have failed.
polycystic ovaries (PCO)
Similarly, gonadotrophin therapy or in vitro fertilisation are only used where all other methods of treatment have failed, and they would certainly not be the most appropriate next step in management.
polycystic ovaries (PCO)
Changes in the semen analysis since the first pregnancy was achieved are most unlikely to be the cause of the secondary infertility, especially as the current semen analysis is not profoundly abnormal, and donor insemination is therefore unlikely to be required.
polycystic ovaries (PCO)
Although pregnancy is rare at her age, the most appropriate advice to give her is that a pregnancy test should be performed (B is correct).
post-pill amenorrhoea
If this test shows she is not pregnant, further decisions can then be made, including whether she should restart the oral contraceptive pill (OCP) or just wait for longer to see if the post-pill amenorrhoea resolves.
post-pill amenorrhoea
Although an elevated follicle-stimulating hormone (FSH) level would suggest ovarian failure, it does not indicate whether further periods will or will not occur and does not completely exclude the possibility of a pregnancy occurring in the future.
post-pill amenorrhoea
Clearly she should be advised to use a contraceptive technique, such as condoms. until the reason for the amenorrhoea is clarified.
post-pill amenorrhoea
This may entail other hormonal investigations such as the measurement of luteinising hormone, prolactin and thyroid hormone levels.
post-pill amenorrhoea
Although dopamine agonist therapy of the woman would be appropriate if the elevated prolactin level was the only cause for the infertility, it is most unlikely to be successful in this case.
elevated prolactin level
The same applies to the use of danazol as treatment of any remaining endometriosis.
elevated prolactin level
No treatment given to the male, including the use of gonadotrophin injections, is likely to improve the semen specimen.
elevated prolactin level
The correct answer is the use of intracytoplasmic sperm injection (ICSI) within IVF, as this would bypass any remaining tubal problem, is useful in patients with mild endometriosis, and would treat the amenorrhoea due to elevated prolactin levels as well (E is correct).
elevated prolactin level
A further laparoscopy to check or treat continuing problems of tubal obstruction or endometriosis could therefore not be justified.
elevated prolactin level
Blood in the peritoneal cavity rarely results in board-like rigidity (this is generally only found when chemical or purulent peritonitis is present).
ectopic pregnancy
Blood usually results in marked rebound tenderness and a small amount of guarding (B is correct).
ectopic pregnancy
The pain and tenderness in a tubal ectopic pregnancy is generally present in the lower abdomen but is often not localised to the side of the pathology.
ectopic pregnancy
Shock due to blood loss, with its inevitable effects on the pulse rate and blood pressure, is not commonly seen, as the diagnosis is usually made prior to the blood loss being sufficient to cause such findings.
ectopic pregnancy
Pelvic tenderness is much more common than an actual pelvic mass detectable on clinical examination. Where a mass is evident, it can be the ectopic pregnancy itself, but is more likely to be the pregnancy surrounded by blood clot from a leaking ectopic pregnancy.
ectopic pregnancy
Postcoital bleeding can certainly be caused by chlamydial cervicitis, a cervical polyp or cervical carcinoma.
Postcoital bleeding
However, the most likely cause in this instance is a cervical ectropion, where the single layer of columnar cells of the endocervix has extended onto the ectocervix and is exposed to trauma during coitus (A is correct).
Postcoital bleeding
Cervical intraepithelial neoplasia does not of itself cause postcoital bleeding, although the ectropion in which it often resides can bleed with contact during sexual activity
Postcoital bleeding
It is almost certain that this woman is menopausal and her symptoms are then due to her oestrogen deficiency state.
mesopause
Diazepam would be helpful in assisting her to sleep, and may help the irritability, but would be unlikely to relieve the hot flushes.
mesopause
Any of the four forms of hormone replacement therapy listed in the responses would relieve her symptoms, but the most appropriate of these would be continuous daily oestrogen therapy, with medroxy progesterone acetate (MPA) given daily for 12 days each month (A is correct).
mesopause
This is usually called cyclical hormone therapy.
mesopause
Continuous therapy with oestrogen and MPA provides continuous progestogen therapy and would have a high likelihood of unpredictable breakthrough vaginal bleeding, as it is only three months since the last menstrual period.
mesopause
The general recommendation regarding this continuous form of therapy is that it is best not given within 1-2 years of the last period, because of the high likelihood of such bleeding.
mesopause
Continued amenorrhoea is likely if this combination therapy is given more than two years after the menopause.
mesopause
The cyclical therapy has predictable periods, which generally commence about two days after the progestogen course has been completed, despite the fact that the oestrogen is still being continued.
mesopause
Oestrogen alone should not be given to a woman who still has her uterus, and progestogen alone would only be indicated if there were contraindications to oestrogen administration
mesopause
Two matters need to be considered to evaluate the best contraceptive option of those given.
best contraceptive option
In this instance, because her cycles have varied in length between 24 and 30 days, the earliest time ovulation would have occurred is 14 days prior to the shortest cycle. that is, day 10 of the cycle.
best contraceptive option
As sperm survival of six days is common, intercourse would need to be avoided from day four of the cycle in case the cycle is a short one.
best contraceptive option
This is the day the period would finish and would thus preclude, because of their preference to avoid intercourse whilst she is menstruating, any intercourse in the follicular phase of the cycle
best contraceptive option
At the time of ovulation the serum progesterone levels are starting to rise, and this rise results in an elevation of temperature of 0.3°C to 0.4°C within 2-3 days of ovulation, with the elevation remaining until near to the commencement of the period
best contraceptive option
As it is known that the ovum is only able to be fertilized for approximately twenty hours after ovulation has occurred, commencing sexual activity when the temperature has been elevated for two days would mean that this would usually be 3-4 days after ovulation occurred, and pregnancy would be most unlikely.
best contraceptive option
Option D is incorrect as the temperature rise is inappropriate.
best contraceptive option
Options which include the performance of intercourse in any part of the follicular phase of the cycle are incorrect.
best contraceptive option
The only response satisfying the criteria required is therefore to avoid intercourse in the follicular part of the cycle, and to commence intercourse two days after the temperature elevation of 0.03°C (E is correct).
best contraceptive option
The only symptom consistent with genuine stress incontinence is that only small amounts of urine are lost when her intra-abdominal pressure is increased at the time of coughing, laughing, jumping, and straining (B is correct).
best contraceptive option
The other responses listed are much more consistent with a diagnosis of detrusor instability (also called urge incontinence).
best contraceptive option
Had she had incontinence during pregnancy, it would have been consistent with the current incontinence being stress in type.
best contraceptive option
A clinically palpable right adnexal mass, developing in a 58-year-old postmenopausal woman, must be considered due to an ovarian malignancy until proven otherwise.
best contraceptive option
This is not only the diagnosis to be excluded, but also the most likely diagnosis (E is correct).
best contraceptive option
Endometrial carcinoma usually presents with postmenopausal bleeding, but usually does not have any adnexal mass, although the uterus itself may be enlarged.
best contraceptive option
Follicular cysts are very rare after the menopause, a benign ovarian tumour is less common at this age and a degenerating fibroid would be unusual, especially as the pelvic examination was normal three years previously.
best contraceptive option
was normal three years previously.
best contraceptive option
The likely site of the primary tumour varies according to the country in which the patient lives, and the availability of screening mammography.
mammography
In underdeveloped countries, where breast cancer is usually diagnosed later and screening mammography is generally not available, the most likely primary site would be the breast.
mammography
In Japan, where the incidence of cancer of the stomach is much higher than in western communities, the most likely primary site would be the stomach (with a Krukenberg tumour in both ovaries).
mammography
In Australia, where mammographic screening is recommended every second year for all women over the age of 50 years, the most likely primary site would be the colon.
mammography
The most appropriate method of making this diagnosis would be the performance of a colonoscopy (C is correct), as a computed tomography (CT) of the abdomen may well miss a small tumour, and ultrasound examination would clearly not usually make this diagnosis.
mammography
mammography
Mammography would only be the correct response in under-developed countries, and a lung malignancy detectable by chest X-ray would rarely cause a metastasis in the ovary.
mammography
The heavy periods are most likely to be due to either dysfunctional uterine bleeding or adenomyosis.
heavy periods
In view of the fact she will not accept a hysterectomy or endometrial ablation, some form of hormonal therapy needs to be offered in addition to the iron therapy already being taken.
heavy periods
Any of the options given could be used, but the use of therapy just in the luteal phase of the cycle, in someone who is almost certainly ovulating (in view of her regular monthly cycles), is unlikely to be successful.
heavy periods
Danazol is likely to have significant side-effects (virilisation), especially when given for about five years.
heavy periods
Gonadotrophin-releasing hormone (GnRH) agonists would induce amenorrhoea but are most likely to produce significant menopausal symptoms, and the oral contraceptive pill (OCP) is generally better avoided in someone on treatment for hypertension.
heavy periods
Norethisterone treatment given throughout the whole cycle is likely to be the most effective of the options given.
heavy periods
If the insertion of a levonorgestrel-releasing intra- uterine device (Mirena) had been an option given, this would also have been appropriate (B is correct).
heavy periods
Any of the responses could be instituted and would probably be effective, as the pregnancy rate is going to be low after missing just one contraceptive tablet, especially when the hormone tablets were to be ceased only one day later anyway.
missing contraceptive tablet
However the most appropriate option would be to start her hormone- free interval from the time the pill was missed (10pm last night).
missing contraceptive tablet
Tonight would then be the second lactose pill day, so the next course of hormone tablets should be commenced on the fifth night after tonight (D is correct).
missing contraceptive tablet
This would result in the hormone-free period being of the normal length of seven days.
missing contraceptive tablet
It is well known that the pregnancy rate after missing just one pill is low, but the risk of pregnancy is greatest if the missed pill results in a longer than normal hormone free interval between the end of one cycle and the commencement of the next.
missing contraceptive tablet
All of the hormone assays described are generally performed in the assessment of a woman with secondary amenorrhoea, as they generally define the most likely cause for the amenorrhoea and the treatment required if pregnancy is desired.
missing contraceptive tablet
The hormone test best able to predict a poor response to ovulation-induction therapy is the follicle-stimulating hormone (FSH) assay.
missing contraceptive tablet
If high levels of FSH are found, most of the ovulation-induction therapies are ineffective, although rarely a spontaneous pregnancy does occur rarely (C is correct).
missing contraceptive tablet
To maximise the chance of pregnancy in patients with elevated FSH levels, ovum donation from a young woman is the most effective technique, with the ovum
missing contraceptive tablet
being fertilized in the laboratory and transferred to the uterus of the woman with the high FSH level after suitable hormonal preparation of her uterus, using administered hormones, has been achieved.
missing contraceptive tablet
If the FSH level is normal, ovulation-induction therapy is usually effective, with correction of thyroid function being necessary if the thyroid function is not normal, with dopamine agonist therapy being indicated if the prolactin level is elevated, and with clomiphene or gonadotrophin therapy being employed where the luteinizing and estradiol levels are low, normal or minimally elevated.
missing contraceptive tablet
There have been some conflicting results concerning the use of hormone replacement therapy (HRT) and the incidence of Alzheimer disease (AD), but there is no doubt that HRT given from the time of the menopause reduces the decline in cognitive function, which is often an early manifestation of AD (B is correct).
(HRT) and incidence of Alzheimer disease (AD)
This is in contrast to the effect seen when HRT is commenced at the age of 60-65 years when the incidence of AD is increased.
(HRT) and incidence of Alzheimer disease (AD)
There are no data concerning the effect of HRT on the incidence of AD when it is started prior to the menopause, but it is clear that HRT does not reduce the rate of progression of AD or make advanced disease less severe.
(HRT) and incidence of Alzheimer disease (AD)
When choosing a combined oestrogen/progestogen OCP it is usual to recommend a preparation containing 20-30ug of ethinyl estradiol.
combined oestrogen/progestogen OCP
The progestogen component could be norgestrel, or other progestogens; however, the preparations containing norgestrel are usually cheaper than the newer progestins cyproterone acetate and drospirenone.
combined oestrogen/progestogen OCP
If the patient has problems of excessive fluid retention, it is best to use the preparation containing drospirenone.
combined oestrogen/progestogen OCP
If the patient has probable polycystic ovarian syndrome, the best OCP to use is one containing cyproterone acetate.
combined oestrogen/progestogen OCP
However in any woman who has migraines associated with an aura or a neurologic deficit, OCPs containing oestrogen and a progestogen are contraindicated.
combined oestrogen/progestogen OCP
Implanon® is also contraindicated in someone of her weight.
combined oestrogen/progestogen OCP
The most appropriate advice is therefore to use a barrier method of contraception (E is correct).
combined oestrogen/progestogen OCP
Although a dilatation and curettage (D&C) is often indicated as part of the evaluation of a woman with menorrhagia, especially after the age of 40 years, D&C is not necessary in a woman who had a normal hysteroscopy and laparoscopy only two years ago, and who had similar symptoms when not taking the OCP in the past.
dilatation and curettage (D&C)
Removal of the Filshie clips would not improve the symptoms and should therefore not be advised.
dilatation and curettage (D&C)
Although an endometrial ablation or even a hysterectomy may be required to relieve the symptoms at some time in the future, the initial treatment should be to prescribe a nonsteroidal anti-inflammatory drug (NSAID) as this will reduce the loss considerably in up to half of the patients treated (B is correct).
dilatation and curettage (D&C)
When a couple have been infertile and the semen analysis of the male is clearly abnormal, with a count below 5 million per mL and reduced motility, spontaneous pregnancy is rarely achieved and treatment is generally indicated.
infertility
Treatment with FSH rarely improves such a semen specimen, and intrauterine insemination of his sperm is of very limited value.
infertility
Donor sperm would be likely to achieve a pregnancy. but this would not contain the husband’s genetic material and should generally not be recommended unless methods using his sperm have been unsuccessful.
infertility
The treatment most likely to achieve a pregnancy involves IVF.
infertility
Where the technique used allows spontaneous fertilisation of the oocyte by the husband’s sperm, the pregnancy rate would be about 2% per cycle treated.
infertility
Where ISCI is also used, this rate is increased to about 20% per cycle treated (D is correct).
infertility
Henoch-Schönlein Purpura syndrome (HSP), also called anaphylactoid purpura. is an acute immune-mediated vasculitis of unknown cause.
Henoch-Schönlein Purpura
It is characterised by arthralgia and nonthrombocytopenic purpura, most commonly distributed over the buttocks and legs.
Henoch-Schönlein Purpura
It may be complicated by the development of colicky abdominal pain, melaena, swelling of joints (especially the ankles), and nephritis (C is correct).
Henoch-Schönlein Purpura
The syndrome usually presents in a characteristic fashion but arthralgia and abdominal pain may persist for two weeks or more.
Henoch-Schönlein Purpura
Other features of vasculitis or serositis (fasciitis or pleurisy) or autoimmune alteration of blood cell lines (thrombocytopenia) are not features of HSP.
Henoch-Schönlein Purpura
Nephritis which is histologically the same as IgA nephritis can develop in a small proportion of cases.
Henoch-Schönlein Purpura
All children with HSP must have urinalysis performed and if haematuria is identified long-term follow up is mandatory.
Henoch-Schönlein Purpura
Diabetes mellitus is not associated with HSP
Henoch-Schönlein Purpura
Urticarial rashes can have a variety of aetiologies ranging from an allergic reaction to a multitude of allergens to drug reactions.
Urticarial rashes
The description of urticaria and itchiness suggests an allergic reaction but the precipitating substance or cause is not known.
Urticarial rashes
However, it is known that he has been unwell for a few days with what sounds like a viral upper respiratory tract infection and, commonly, viruses can cause a rash like this. He has had a decreased appetite and there is no clear history of the rash being in relation to a particular food, so it is unlikely that food is the culprit.
Urticarial rashes
Measles is associated with upper respiratory tract infection (URTI) symptoms and fever but the measles rash is not urticarial nor itchy.
Urticarial rashes
There is nothing in the history to suggest that this boy has a past history of eczema so there is only a remote possibility that this is infected eczema.
Urticarial rashes
Drug reactions can certainly cause an urticarial rash but there is no history of him being on any medication of any sort.
Urticarial rashes
Hence the most likely explanation is the rash is secondary to his viral infection (A is correct).
Urticarial rashes
Symptomatic treatment is all that is required and the condition is self- limiting.
Urticarial rashes
Clubbing of the fingers is an important clinical sign characterised by a bulbousness of the soft terminal part of the fingers particularly the nail bed, and an excessive curvature of the nail in both the longitudinal and lateral planes.
Clubbing
An early sign is loss of the normal angle at the base of the nail. Clubbing is associated with a wide variety of conditions and can be graded clinically.
Clubbing
The most common causes are:congenital pulmonary - bronchogenic carcinoma, chronic suppurative lung disease (e.g. cystic fibrosis) and diffuse fibrosing alveolitisped will norm cardiac - subacute bacterial endocarditis, cyanotic congenital heart disease, with right to left shunts arteriovenous malformations gastrointestinal-hepatic cirrhosis, steatorrhoea, ulcerative colitis.
Clubbing
Tetralogy of Fallot is the most common form of cyanotic congenital heart disease and is commonly associated with clubbing (A is correct).
Clubbing
Unless associated with suppurative lung disease (bronchiectasis or cystic fibrosis), chronic asthma would not normally lead to clubbing.
Clubbing
Chronic hepatitis B infection in childhood is usually associated with normal liver function and no features of chronic liver disease.
Clubbing
It would not be likely to lead to clubbing. Systemic lupus erythymatosus (SLE) is not normally associated with clubbing.
Clubbing
This infant has a unilateral acute otitis media associated with an upper respiratory tract infection of five days duration.
acute otitis media
This would suggest an acute bacterial complication localized to the middle ear.
acute otitis media
His tympanic membrane is inflamed and bulging suggesting collection of fluid under pressure in the middle ear.
acute otitis media
Treatment then consists of pain relief and an anti- bacterial medication to cover the likely causative w organism, for example, S. pneumoniae.
acute otitis media
Of the options given, paracetamol and amoxycillin would n be most appropriate (E is correct).
acute otitis media
Bulging red drum on otoscopy Aspirin is contraindicated in this age group and cotrimoxazole is not the antibiotic of choice.
acute otitis media
Under most circumstances myringotomy can be avoided by judicious use of an appropriate antibiotic.
acute otitis media
There may be spontaneous perforation of the tympanic membrane with relief of pain.
acute otitis media
The perforation will usually heal spontaneously. Ibuprofen is commonly used in children for analgesic and antipyretic effect.
acute otitis media
While it would be a reasonable alternative to paracetamol, the erythromycin offered in alternative B is not correct, as the spectrum of its activity when used alone is not appropriate.
acute otitis media
Topical antibiotics are an important part of therapy for otitis externa and for chronic otitis media where there is a chronic perforation of the tympanic membrane.
acute otitis media
Whilst topical ciprofloxacin drops are the most appropriate choice for this, they are not appropriate for acute otitis media with an intact eardrum.
acute otitis media
Naproxen would be an unusual choice for analgesia in this setting.
acute otitis media
This boy’s position on the head circumference percentile charts is as outlined. Head circumference percentile growth chart (boys) in utero 28-40 weeks, 0-12 months of age Use of growth percentile charts is important in distinguishing normal from abnormal growth.
growth chart
This case reveals head circumference on 50th percentile at birth, growing to 50-75th percentile at six weeks, and 90th percentile at three and six months.
growth chart
This would not reflect any abnormality in head growth and no investigations are required.
growth chart
The correct response is to reassure the parents (A is correct).
growth chart
Brain scans and referral are not indicated.
growth chart
The measurements indicate satisfactory head growth so no extra measurements besides those at routine visits for immunisation are required.
growth chart
The most common problems associated with head circumference measurements are large heads and small heads.
growth chart
Measurements which increase rapidly and quickly cross percentile lines warrant immediate investigation and, as the anterior fontanelle is usually open, cranial ultrasound is an appropriate initial investigation.
growth chart
Small heads may be just as significant, although the preceding history (for example with asphyxia) that may indicate that it is due to poor brain growth secondary to brain injury.
growth chart
All children, whenever they are reviewed, should have head circumference, length and weight measured and plotted.
growth chart
The results are often surprising! Progressive plotting of measurements as the child grows usually reveals any potential pathology.
growth chart
Plotting this child shows the head circumference continuing on an acceptable centile line and is not of concern.
growth chart
Percentile charts are derived from overall distribution (bell-shaped curve) of the data of progressive growth in children for height, weight, head circumference and other data.
growth chart
The median or midpoint is the 50th centile/percentile, indicating that 50% of the measurements (50 centiles) of a normal group of children at a given age are above and 50% are below that point.
growth chart
The normal range of average values for head circumference, weight or height is indicated as two standard deviations (SD) above and below the 50th percentile, i.e. between the 3rd and 97th percentiles.
growth chart
The range between the 3rd and 97th percentile (-2 SD to +2 SD) will include 94% of all children.
growth chart
It must be appreciated that there will be 3 normal children in every 100 who will be at, or below, the 3rd percentile and 3 normal children in every 100 who will be at or above the 97th percentile.
growth chart
Pathologic growth patterns will move across and outside the normal range of centiles with increasing age.
growth chart
With regard to height percentiles, it will be found that most short children are normal and healthy and that the most common problems of short stature are familial short stature and constitutional delay of growth.
growth chart
Chronic disease is also a major cause of short stature and is characterised by a progressive falloff of both height and weight. Measurement of parental head circumference may identify a familial cause for a large head in an infant.
growth chart
The description of this girl’s episodes and the appearance of her electroencephalogram (EEG) indicate that simple absence seizures are the cause of her episodes.
electroencephalogram (EEG)
The majority of children with this seizure type will respond to anticonvulsants and have a good prognosis with spontaneous resolution over a couple of years (A is correct).
electroencephalogram (EEG)
Some may progress to generalised tonic-clonic seizures but neither akinetic seizures or juvenile myoclonic epilepsy is a likely association.
electroencephalogram (EEG)
If seizures are controlled there is no associated intellectual impairment.
electroencephalogram (EEG)
Seizures usually respond to antiepileptic drugs such as ethosuximide, sodium valproate and lamotrigine.
electroencephalogram (EEG)
Anticonvulsants often cause adverse effects. Phenytoin can cause drowsiness, vomiting, skin rash, gum hypertrophy, hirsutism, lymphadenopathy, nystagmus, ataxia or liver dysfunction.
Anticonvulsants
In this patient it is most likely that the drowsiness, vomiting and ataxia are due to drug toxicity and the dosage of phenytoin should be reduced (E is correct).
Anticonvulsants
Toxicity related to excessive phenytoin can be confirmed by measuring the blood phenytoin level which can be followed, if one is confident of the diagnosis, by reduction of the dose.
Anticonvulsants
Gastrolyte is unlikely to be required; and adding valproate is not appropriate.
Anticonvulsants
As the presentation by this child is typical of excessive phenytoin, magnetic resonance imaging (MRI) or electroencephalogram (EEG) are unnecessary.
Anticonvulsants
At this stage, one need only reduce her dose, relieve her toxic clinical state and await developments.
Anticonvulsants
As phenytoin is highly protein-bound and the toxic effects arise from the drug rather than total levels she may only need a relatively small dosage change to correct her levels.
Anticonvulsants
The presentation in this boy suggests an acute neurological cause, either primary or secondary.
Anticonvulsants
While the information given appears scant, it is often the only history available to the Emergency Department doctor to whom frantic parents present their child, often out-of-hours, when no more specific details may be available.
Anticonvulsants
The signs described suggest the typical presentation of an adverse reaction to the phenothiazine group of drugs and their related compounds which have similar side effects to the presenting symptoms.
Anticonvulsants
Metoclopramide is commonly prescribed to children with vomiting and if given orally and regularly, adverse reactions are commonly seen and may not develop for some period of time.
Anticonvulsants
Similarly, side effects may be seen more acutely if the medication is given intramuscularly in inappropriate doses for the child’s age and weight.
Anticonvulsants
Because of the high risk of adverse reactions from these groups of drugs.
Anticonvulsants
systemic antiemetics are best avoided in young children or if indicated, must be given in appropriate dose for age and weight and the child observed carefully.
Anticonvulsants
A reaction to the prescribed antiemetic is the most likely diagnosis in this child (A is correct).
Anticonvulsants
The sudden onset of signs as has occurred here would be an unusual presentation for both brain stem glioma, the physical signs for which would be very different, and E. coli meningitis, an unlikely organism in a previously well child of this age group.
Anticonvulsants
While epilepsy may be considered, these physical signs are unusual in any of the recognized forms of epilepsy.
Anticonvulsants
The toxic effects of paracetamol may present late if the drug is given routinely in large doses over a long period, but with a different clinical presentation associated with hepatic failure.
Anticonvulsants
The toxic effects of prescribed medications are grossly underestimated in both adult and paediatric practice.
Anticonvulsants
Any person presenting with unexpected physical symptoms or signs should mandate a careful drug history for both illicit and prescribed agents.
Anticonvulsants
The assessment of an infant with possible congenital heart disease is usually achieved with ultrasound examination which under most circumstances determines very accurately the anatomical and functional lesions in the heart. Occasionally, but less frequently these days, a cardiac catheter study is done.
congenital heart disease
This scenario is designed to determine the ability of the candidate to differentiate different cardiac lesions by understanding the basic pathophysiology of the respective heart conditions.
congenital heart disease
If one analyses the data available and compares this with the data expected in a normal heart, it is evident that a shunt is present at ventricular level as the oxygen saturations in the right ventricle and pulmonary artery
congenital heart disease
but not the right atrium, are elevated, suggesting an admixture of oxygenated and deoxygenated blood in the right ventricle.
congenital heart disease
Of the alternatives offered for consideration, only a ventricular septal defect would fit these investigatory findings (D is correct).
congenital heart disease
A tetralogy of Fallot would show right to left shunting with desaturation in the left heart: an atrial septal defect (ASD) left to right shunting at atrial level; a patent ductus arteriosus (PDA) left to right shunting at pulmonary artery level and a transposition would show desaturation in the aorta and full saturation in the pulmonary artery.
congenital heart disease
While the common congenital heart lesions (CHD) can be simplified into obstructive, cyanotic (right to left shunting), and left to right shunts, a basic understanding of the underlying pathology enables the clinician to deduce from the clinical presentation, history and examination the most likely cause of the cardiac condition, and to differentiate a significant CHD from the child with an innocent functional heart murmur.
congenital heart disease
Cough is a common symptom in young children and can be caused by a variety of conditions.
Cough
However a careful history and examination can usually define the most likely cause and the most appropriate investigations to confirm that cause.
Cough
In this scenario, the child has a chronic cough and he has lower respiratory tract signs.
Cough
A significant factor is the fall-off in his weight centile suggesting failure to thrive of some months’ duration. The most common cause for this combination of symptoms and signs would be cystic fibrosis (CF) and this condition should always be considered in a child with this presentation despite a normal screening program for CF at birth.
Cough
Each year, for a variety of reasons, children may slip through the neonatal screening net.
Cough
Foreign body inhalation must always be considered in a child of this age with a persisting cough and there may not be an evident inhalational episode observed by a parent.
Cough
The chest signs are usually unilateral with persistent radiological signs and are resistant to intensive treatment due to the lodged foreign body, usually in the right middle lobe bronchus.
Cough
The history is usually short, however, compared to this child’s history and with the widespread chest signs it is unlikely that a foreign body is present negating the need for bronchoscopy or inspiratory and expiratory films.
Cough
Pulmonary function tests are difficult to perform in children of this age and are not necessarily definitively diagnostic.
Cough
Duodenal or small bowel biopsy is the investigation of choice for coeliac disease which can present with failure to thrive but is not associated with chest signs as seen here.
Cough
Of all the suggested alternatives, a sweat chloride estimation is the most definitive investigation for this child as the presentation is highly suggestive of cystic fibrosis (E is correct).
Cough
The clinical features are classical of osteochondritis of the tibial tuberosity (Osgood- Schlatter disease¹) a variant of juvenile osteochondritis often seen in this age group.
osteochondritis
which usually runs a self-limiting course (B is correct).
osteochondritis
Other clinical syndromes and sites of juvenile osteochondritis in the lower limbs include hip (Perthes disease), carpal lunate (Kienböck disease), calcaneum (Sever disease).
osteochondritis
Treatment is reassurance and continuation of normal activities within the limits of the child’s comfort.
osteochondritis
Quadriceps stretches and massage may give symptomatic relief.
osteochondritis
Stress fracture of the patella is not likely to present with tenderness and swelling of the tuberosity of the tibia.
osteochondritis
Osteomyelitis generally is associated with systemic toxicity symptoms and signs, with fever, raised white cell count and exquisite tenderness over the involved bone.
osteochondritis
The symptoms and signs do not resolve with rest.
osteochondritis
Spontaneous derangement of the tibial epiphysis is very uncommon.
osteochondritis
The majority of osteosarcomas arise around the knee in the metaphysis of the femur or tibia with a common presentation being bone pain and associated swelling
osteochondritis
The localisation of swelling and tenderness over the tibial tuberosity and its relation to exercise and rest makes osteosarcoma very unlikely
osteochondritis
This child has nephrotic syndrome which is now nonresponsive to steroids.
nephrotic syndrome
In addition he is hypertensive and has persistent haematuria, all features to suggest that his current presentation does not fit the most common cause of nephrotic syndrome in children: minimal change disease.
nephrotic syndrome
This picture then warrants further investigation and of all investigations that are suggested, the only definitively diagnostic procedure is a renal biopsy (B is correct).
nephrotic syndrome
None of the other alternatives is likely to yield any specific diagnostic information.
nephrotic syndrome
Renal ultrasound defines well the shape and size of the kidney but gives no indication of parenchymal histological anomalies.
nephrotic syndrome
An isotope scan will also show abnormalities, especially scars, of the kidney but not the intrinsic causative disease.
nephrotic syndrome
Serum complement (C3) is low in acute post-streptococcal glomerulonephritis due to activation of the classical complement pathway, but not in nephrotic syndrome.
nephrotic syndrome
Selective proteinuria assay index where there is loss of low-molecular-weight protein in urine is a feature of minimal change disease which is not suggested in this case with the complicated clinical clinical picture of hypertension, haematuria and poor steroid response.
nephrotic syndrome
Renal biopsy will in most cases determine the precise aetiology which will dictate further management.
nephrotic syndrome
Overall, 50% of term babies and 85% of premature babies develop jaundice in the first week of life.
Physiological jaundice
Physiological jaundice is the commonest cause, is due to immaturity of bilirubin conjugation by the liver, is not present at birth and presents after day two (A is correct).
Physiological jaundice
Physiological jaundice can last a couple of weeks and will spontaneously resolve.
Physiological jaundice
The bilirubin rarely exceeds 300μmol/L with only small levels of conjugated bilirubin (direct bilirubin).
Physiological jaundice
It is a normal finding in newborns to feel a liver edge 2cm below the right costal margin.
Physiological jaundice
Neonatal hepatitis presents with a mix of conjugated and unconjugated bilirubin with elevated liver enzymes.
Physiological jaundice
In biliary atresia the babies are jaundiced with pale coloured stools and dark urine and a significant proportion of the bilirubin is conjugated.
Physiological jaundice
In hereditary spherocytosis the bilirubin is predominantly unconjugated but there is evidence of a haemolytic anaemia and usually abnormally shaped red blood cells (spherocytes) on the blood film.
Physiological jaundice
Blood group incompatibility can cause jaundice with onset usually within the first 24 hours of life.
Physiological jaundice
While this baby has the pattern for an ABO incompatibility (mother O. baby B), the relatively late onset of jaundice, normal blood picture and negative Coombs test make this diagnosis unlikely.
Physiological jaundice
The approach to jaundice in the newborn is based on the history and thorough examination of the baby.
Physiological jaundice
The proportions of conjugated bilirubin generally direct the processes of investigation that are required.
Physiological jaundice
Pneumonia in children can be caused by a variety of agents.
Pneumonia in children
Viral causes such as respiratory syncytial virus or adenovirus are more common in young children under two years of age
Pneumonia in children
The commonest bacterial cause is Streptococcus pneumoniae (not StreptocoCCUS viridans).
Pneumonia in children
Haemophilus influenzae, and Staphylococcus aureus are much less frequent causes.
Pneumonia in children
Pneumococcal pneumonia presents acutely with high fever, toxicity and prominent respiratory signs.
Pneumonia in children
In school-aged children, Mycoplasma pneumoniae is a common cause of respiratory infections (D is correct).
Pneumonia in children
It usually presents with mild systemic upset with widespread, shifting crackles on auscultation and patchy lung infiltrates on X-ray.
Pneumonia in children
Often the X-ray findings are not in keeping with the clinical picture, for example, widespread chest physical signs but little to see on X-ray.
Pneumonia in children
The illness in usually more protracted than that caused by viruses and the child may not be particularly unwell.
Pneumonia in children
The organism can often be successfully eradicated by using macrolide antibiotics (or tetracycline in children aged 10 years and older.) Mycoplasma serology (IgM) is usually elevated, particularly after the first week of the illness.
Pneumonia in children
