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
