Make the Diagnosis

Question 1

A patient prevents in A+E and explains to you that his erect penis will not return to it’s flaccid state, and has been this way for over 6 hours. What do you diagnose and how do you treat?

Answer 1

Priapism (To diagnose must be over 4 hours)

Treat: Aspiration (using local). if unsuccesful prescribe phenylephrine

Question 2

A 28 year old male presents in A+E following an RTA. He is conscious and responding, however has a headache and has vommitted several times. He struggles to walk in a straight line and has doubled vision and tinnitus. What do you diagnose?

Answer 2

Concussion (MTBI)

- Unless more serious injury symptoms should resolve in 3 weeks

Question 3

A parent explains her child losses awareness and has a vacant expression for just under 10 seconds then continues as normal, often several times per day. The mum has seen fluttering of the eyelids.
An EEG shows a 3Hz spike and wave accompanying each attack. What do you diagnose?

Answer 3

Typical absence seizures

Epilepsy- petit mal

Question 4

A patient presents with headache, ataxia, nausea, vomitting, blurred vision, and faintness whilst climbing a 5000ft mountain. ???

Answer 4

Cerebral oedema (due to high altitude)

Question 5

A 45 year old man presents with pain for several months from his lower back, down his left buttock and down to the feet. He says it feels like burning and tingling. It is relieved by standing and made worse by sitting or coughng. ???

Answer 5

Sciatica
Perform a straight raise leg test with patient lying supine, raise one leg (fully extended). If pain caused this is likely to be sciatica (accompanied by symptoms)

Question 6

A 2yo child presents with fever, apparent hearing loss and irritability, poor feeding and restlessness. They keep tugging at their ear. The child goes to a day care centre and still uses a dummy. ???

Answer 6

Suspected otitis media

Treat paracetamol etc however usually viral so no AB’s unless severe symptoms (>4days) or under 6mnths.

Question 7

A 26 year old woman presents with acute onset of SOB. Upon taking a history you learn that she is taking the oral contraceptive pill. No other area’s are the history seem significant. What is your suspected diagnosis?

Answer 7

PE possibly secondary to DVT

Due to SE of oral contraceptive pill

Question 8

A 5year old kid presents with wheezing and difficulty breathing. There is no pyrexia nor rashes and physical examination is normal except for bronchial wheezing when auscultating the right lower lobe. What’s your main differential?

Answer 8

Trapped foreign body

R bronchus is shorter, at a steeper angle and wider than left

Question 9

A 34yo M presents with incontinence, with overflow dribbling. He also admits to having erectile dysfunction. Ultrasound suggests a large post void residual volume. What is your diagnosis and cause?

Answer 9

Neurogenic bladder
(NICE recommends 1-2yearly Ultrasnd to survey kidney function)
Search for cause (any neuropathy- CNS/PNS or mixed)

Question 10

A 2yo F presents with an abdominal mass. MRI suggests this mass is on the kidney. What do you suspect?

Answer 10

Nephroblastoma (Wilms tumour)
Seen mainly in under 3’s.
90% 5yr survival rate

Question 11

A 24yo F presents with a raised itchy red rash, swelling of the face,lips and tongue. She has difficulty breathing and can’t swallow. What is the first question you ask and your diagnosis?

Answer 11

What had she been in contact with recently/ eaten recently etc?

Allergic reaction
(Treat with antihistamine)

Question 12

A 55yo M presents with a palpable mass in the RUQ. He has jaundice and is not in any pain, What is the first diagnosis which springs to mind?

Answer 12

Cancer of the head of the pancreas

Question 13

P presents with 6 years of worsening indigestion pain (boring, dull) in upper abdo and back, made worse upon eating fatty meals. He has steatorrhoea, a recent 13kg weight loss and a tender upper abdomen. His alcohol intake is 35 units per week

Answer 13

Suspected chronic pancreatitis
(Need to rule out pancreatic adenocarcinoma)
- Treat CP with analgesic (tramadol/ NSAID), pancreatin and omeprazole

Question 14

A 26 year old woman presents with acute onset of SOB. Upon taking a history you learn that she is taking the oral contraceptive pill. No other area’s are the history seem significant. What is your suspected diagnosis?

Answer 14

PE possibly secondary to DVT

Due to SE of oral contraceptive pill

Question 15

A 75yo M presents with nocturia for 6mths. Difficulty urinating (initiation and reduced force) for 2yrs. Abdo examination revels a filled and distended bladder. Urine analysis shows no sign of infection. What examination would you undertake?

Answer 15

DRE for tentative diagnosis of BPH

Question 16

A 34yo M presents with incontinence, with overflow dribbling. He also admits to having erectile dysfunction. Ultrasound suggests a large post void residual volume. What is your diagnosis and cause?

Answer 16

Neurogenic bladder
(NICE recommends 1-2yearly Ultrasnd to survey kidney function)
Search for cause (any neuropathy- CNS/PNS or mixed)

Question 17

A 2yo F presents with an abdominal mass. MRI suggests this mass is on the kidney. What do you suspect?

Answer 17

Nephroblastoma (Wilms tumour)
Seen mainly in under 3’s.
90% 5yr survival rate

Question 18

A 24yo F presents with a raised itchy red rash, swelling of the face,lips and tongue. She has difficulty breathing and can’t swallow. What is the first question you ask and your diagnosis?

Answer 18

What had she been in contact with recently/ eaten recently etc?

Allergic reaction
(Treat with antihistamine)

Question 19

A 46F presents with bone pain and tenderness. After taking a history you discover she has CKD and examination reveals that she is very dehydrated. What is the most important test and a tentative diagnosis?

Answer 19

Test for PTH
Query Hyperparathyroidism (Secondary to CKD)

Question 20

30yo F presents following a seizure. History and examination reveals fever (40C), tachycardia, delirium, vomiting, jaundice, diarrhoea. P has just been treated for a chest infection and has previously had graves disease

Answer 20

Hyperthyroid Crisis
(Thyroid storm)

Treat with carbimazole/ propylthiouracil

Question 21

37yoF presents with 6mth Hx of palpitations, heat intolerance, weight loss, increased appetite, fatigue, sweaty palms and muscle weakness. She reveals last year she was diagnosed with anxiety. Before going on to do the examination you suspect…?

Answer 21

Hyperthyroidism

- Look for exophthalmos to diagnose Graves disease

Question 22

A 45yoF presents to her GP 1 week after a thyroidectomy with parathesia around her lips and mouth and tetany. What do you immediatly suspect?

Answer 22

Hypocalcaemia

Because PTH knocked out if damage to parathyroid gland when thyroid removed

Question 23

A 40yoF presents with lethargy, weight gain, intolerance to cold, cool skin, dry/ brittle hair, muscle cramps and changes to her periods. What is the first test you order and the diagnosis?

Answer 23

Order T4/ TSH levels (T4 will be low and TSH will be raised)

Diagnosis - Hypothyroidism

Question 24

A 24yoF presents with a throat mass. On examination you notice that the mass moves when she protrudes her tongue. What is the likely diagnosis and which tests would you perform to confirm this?

Answer 24

Likely to be thyroglossal cyst (normally present in 1st decade)
Use TFT’s/ ultrasound and CT to confirm
(Rule out ectopic thyroid) - Treat surgically

Question 25

A 40yoF presents after experiencing weight gain, thinning of her skin, loss of libido, and generalised muscle weakness. On examination she has a rounded race and purple stretch marks on her stomach. What do you diagnose and which test confirms this?

Answer 25

Cushings Syndrome
(Test with late night cortisol lvl in saliva)
(Or low dose dextamethosone suppression test)
(Or short synacthen test)

Question 26

A 17yoF presents with stomach pain for the last few hours. He says the pain started in the middle but has now traveled to the lower R hand side of his abdomen. The pain is made worse when he coughs and he has a flushed face and fever. What tests and potential diagnosis?

Answer 26

Tests: FBC/ urine analysis/ pregnancy test/ CT scan

Appendicitis???
Ectopic pregnancy/ urine infection/ crohns?

Question 27

After a scan for unrelated cause a 55yoM P is found to have a mass in the adrenal gland of his R kidney. He has a BP of 160/110, a throbbing bilateral headache and complains of heart palpitations. Diagnosis?

Answer 27

Phaeochromocytoma

Tumour of adrenal medulla causing increased adrenaline secretion

Question 28

A 70yoM presents with SOB and a cough. On examination he has a temp of 38.3C, tachycardia, tachypnoea, hypoxia and coarse crackles at the R lung base. His Hx reveals a stroke 2 years ago, with some dysphagia. What tests/ diagnosis do you make?

Answer 28

Do CXR/ bloods/ sputum culture

Suspected aspiration pneumonia

Question 29

A 40yo caucasian male with a long history of gastro-oesophageal reflux and, occasionally, dysphagia receives an endoscopy which reveals visible columnarisation. What is the MLD?

Answer 29

Barrett’s oesophagus

Question 30

A 34yoM presents with epigastric gnawing pain, nausea and fullness a few hours after eating a meal.The pain is relieved by antacids and drinking milk. Test and MLD?

Answer 30

Gastroscopy

Looking for duodenal ulcer

Question 31

A 39yoM presents after experiencing a sudden agonizing pain in the epigastric region. This then spread over the entire abdomen and to his shoulder. He is cool and sweaty with a low BP and fast pulse. His abdomen is rigid and there are no bowel sounds. MLD???

Answer 31

Peritonitis- probably caused by ruptured ulcer

Treat with surgery

Question 32

A 41yoF presents with a sudden, severe, dull pain in her epigastric region and in her back. She feels nauseous, has been vomiting and examination reveals an upper abdominal tenderness. She is very overweight and admits to smoking ~30/day. First test and MLD?

Answer 32

Acute pancreatitis?
Do serum amylase (3x normal = AP)
Do CXR/ FBC etc to exclude other causes
APACHE11 scoring system to assess severity

Question 33

8 hours after admission in A+E a 55yoM develops a tremor, nausea, sweating, fever and hallucinations. He is confused, aggressive and agitated. What is the first question you ask and MLD?

Answer 33

When was the last time he had a drink
(Then ask CAGE questions/ directly ask about drinking)
Suspected alcohol dependancy

Question 34

A 59yoM presents with a sudden, severe pain in the loin, which moves to the groin. He is writhing around, clearly distressed. His wife reveals ~1yr ago he began treatment for BPH. What is the first question you ask and MLD???

Answer 34

Has he been passing urine since pain onset?

Nephrolithiasis???

Question 35

42yoF has dysphagia of liquid and solids for 3mths. She has central chest pain and regurgitates undigested food regularly. There is no acid reflex. She has lost 4kg over 6mths. MLD???

Answer 35

Achalasia

Question 36

46yoF presents with tingling around her mouth. She is tired, has been struggling to sleep and has been noticing lots of muscle cramps, especially in her hands. What tests do you perform and MLD?

Answer 36

Do serum Ca2+/ PTH
Note increased HR/ QT prolongation on ECG

= Hypoparathyroidism

Question 37

A retired Sushi-chef Px’s with dysphagia. It came on gradually and initially only noticed it with solid food but more recently has been having Sx with soft foods also. He has vomited after eating on a few occasions recently but no nausea or change in appetite. He does not smoke and drinks only on special occasions. MLD?

Answer 37

Oesophageal malignancy
(Clue is solid foods which has progressed to soft- shows growing mechanical blockage)
(Fish has high amounts of nitrosamines so predisposes to malignancy)

Question 38

A 20yoF presents to GP with intermittent abdominal pain and diarrhoea. She has noticed that her clothes have become much loser. She has a 3 pack year smoking history. On examination, her abdomen is tender and painful red, raised lesions on the fronts of her shins. MLD + diagnostic test?

Answer 38

Crohns

Do colonoscopy

Question 39

A 42yoF presents to GP w chronic diarrhoea and weight loss, and diffuse intermittent abdominal pain. She has been feeling very tired and bloated. She thinks that that her symptoms may be worse when she eats white bread. Her sister suffers from similar problems. MLD?

Answer 39

Coeliac disease

Question 40

A 20yoM presents with lower back pain for 4mnths that becomes worse at night and is relieved when he stands up. He often feels stiff in the morning but this improves when he does exercise. MLD?

Answer 40

Ankylosing Spondylitis

look for sacroilitis on X-ray

Question 41

A 19yoF develops colicky abdominal pain. He PMHx is significant for a vitelline duct still present when she was born (at term with no complications). MLD?

Answer 41

Merkels diverticulum
(a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk). Present in ~2% population

Question 42

A 47yoM in A+E who arrived drunk starts coughing violently, after a while haematemesis occurs. He has COPD. MLD?

Answer 42

Mallory-Weiss Tear
(Mucosal lacerations of upper GI, usually gastroesophageal junction)
Diagnose with endoscopy
6-13% mortality

Question 43

A 55yoF presents with intermittent fever accompanied by chills and right upper quadrant abdominal pain. You notice jaundice of the sclera. MLD?

Answer 43

Acute obstructive cholangitis (Acute cholecystitis)
- Reduced bilary flow (bilary stasis) leads to infection

NB: Classic triad (charcot’s): Fever/ RUQ pain/ jaundice

Question 44

A 14yoF presents in GP with flu like symptoms, concerned that her eyes look yellow. Bloods come back with unconjugated bilirubin at 86umol/L. Other LFT’s were normal. MLD?

Answer 44

Gilberts syndrome

Autosomal recessive, reduced glucuronyltransferase so hyperbilirubinaemia

Question 45

A 56yoM with severe COPD presents to his GP as he believes he’s noticed his skin is yellowing. He has never smoked and previous routine bloods showed mildly deranged LFT’s. MLD?

Answer 45

Alpha-1-antitrypsin deficiency

links lung and liver disease

Question 46

A 54yoM presents with a 10yr history of HTN that has been difficult to control with antihypertensive medicines. His symptoms include frequent headaches, nocturia (3-4 times per night), and lethargy. He has no other medical conditions or past medical history. Apart from a BP of 160/96 mmHg, findings on physical examination are unremarkable. Plasma electrolytes are normal.

Answer 46

Conns (primary hyperaldosteronism)

- can present with normal K+ as shown here but would normally expect hypokalaemia

Question 47

A 28yoF presents with a 2-year history of HTN, associated with nocturia (4-5 times per night), polyuria, palpitations, limb paraesthesias, lethargy, and generalised muscle weakness. There is no other past medical history. Physical examination is unremarkable apart from a blood pressure (BP) of 160/100 mmHg, global hyporeflexia, and weak muscles. Plasma potassium is 2.2 mmol/L (2.2 mEq/L), bicarbonate is 34 mmol/L (34 mEq/L), and serum creatinine is normal.

Answer 47

Conns syndrome (primary hyperaldosteronism) 
- Classic presentation, including the hypokalaemia

Question 48

A 33yoF presents to her doctor complaining of a several-month history of episodic palpitations and diaphoresis. She states that her husband noticed that she becomes pale during these episodes. She has been experiencing progressive episodic headaches, which are not relieved by paracetamol. In the past, she has been told that she had a high calcium level. She has a history of kidney stones. Her FHx is unremarkable; specifically, there is no history for tumours, endocrinopathies, or HTN. Physical examination reveals a BP of 220/120 mmHg and hypertensive retinal changes. MLD and recommended treatment?

Answer 48

Phaeochromocytoma- Catecholamine secreting adrenal tumour
Tests: 24hr urine (elevated catecholamines/ creatinine) and elevated plasma metenephrines/ catecholamines
Treatment: (Phentolamine)- alpha blocker + beta blocker + fluids + CCB then eventually surgery

Question 49

A 34yoF presents with complaints of weight gain and irregular menses for the last several years. She has gained 20 kg over the past 3 years and feels that most of the weight gain is in her abdomen and face. She notes bruising without significant trauma, difficulty rising from a chair, and proximal muscle wasting. She was diagnosed with type 2 diabetes and hypertension 1 year ago.

Answer 49

Cushings
Test: -ve preg test, elevated glucose, elevated late night cortisol, elevated dextamethosone suppression test
Treat: ketoconazole/ metyrapone (steroidogensis inhibitors). Refer for poss surgery

Question 50

A 62yoM presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination. MLD, tests and treatment?

Answer 50

Large bowel obstruction
Tests: elevated WBC, urea and creatinine, amylase and lipase. Do chest and abdo X-rays
Treatment: Supportive (fluids, O2, catheter). May need emergency surgery. Could do NG decompression.

Question 51

A 27-year-old male presents with crampy abdominal pain of sudden onset, emesis, and failure to pass any flatus or stool for 24 hours. The patient has no history of prior surgery. Physical examination reveals peritonitis, and abdominal x-rays demonstrate air-fluid levels. MLD, tests and treatment?

Answer 51

Small bowel obstruction
Test: abdo X-ray, FBC look for low WBC
Treat: Surgical emergency

Question 52

78yoM smoker presents gradually increasing breathlessness and weight loss of 4kg over the last 6 months with intermittent diarrhoea, with blood occasionally mixed in with the stool. On examination, he appears pale, chest is clear, heart sounds normal, BP 140/88 mmHg, pulse 80 in sinus rhythm, abdomen soft and non-tender, rectal examination is normal. FBC shows Hb of 88 g/L (13-18 g/L) White cell count 4.5 x 109/L (2-7.5 x 109/L, platelets 350 x 109/L (150-400 x 109/L), mean corpuscular volume is 74.fL (77-95fL). MLD?

Answer 52

Bowel cancer

with anaemia due to bleeding from Bowel Ca, resulting in breathlessness

Question 53

A 78 year old male smoker complains of gradually increasing breathlessness and weight loss of 4kg over the last 6 months. He has had a persistent cough in the last 6 weeks and has attended today because he coughed up a small amount of blood mixed with green sputum. On examination his chest is clear, heart sounds normal, BP 140/88 mmHg, pulse 80 in sinus rhythm. MLD?

Answer 53

Lung Cancer
(Made from history. Haemoptysis in smoker is LungCa until proven otherwise)
Pneumonia is in DD but no fever/ bronchial breathing so less likely (although could be in combination)

Question 54

A 78yoM smoker complains of gradually increasing breathlessness, waking in the night feeling breathless and especially when lying flat. He has had a persistent cough in the last 6 weeks and has attended today because he coughed up a small amount of blood mixed with white frothy sputum. He recalls some severe pain he had in his chest lasting 2 hours one night before the onset of these symptoms, although he didn’t seek attention for this at the time as the pain went away. There are some fine crepitations in both lower zones of his chest, heart sounds are normal, BP 140/88 mmHg, pulse 80 in sinus rhythm. MLD?

Answer 54

Heart failure
(Orthopnoea, paroxysmal nocturnal dyspnoea, breathlessness). Haemoptysis in a smoker is lung cancer until proved otherwise but with the other symptoms described, heart failure is the more likely cause of breathlessness and the haemoptysis. IHD could be the underlying cause of HF (Chest pain for 2hrs)

Question 55

A 78yoM smoker complains of breathlessness on walking especially when walking up hill. He also complains of some pain in his neck and jaw when walking up hill which goes off after a few minutes of resting. On examination there are his chest is clear, heart sounds are normal, BP 140/88 mmHg, pulse 80 in sinus rhythm. What is MLD and the best test to show this?

Answer 55

MLD is stable angina
Best test to confirm would be exercise ECG (not just normal ECG but would maybe do this also).
CXR/ FBC/ Echo may also be done at later stage

Question 56

A 78yoM smoker complains of increasing breathlessness and wheezing. He has a cough throughout the year for the past 10 years and coughs up white sputum most days, especially in the winter. He has not coughed up any blood but he has been feeling hot and cold, sweating, and coughing up green sputum. He has some pain on coughing at the base of his right lung. On examination he is short of breath at rest, has difficulty in completing a full sentence, his chest is barrel shaped and you can hear widespread coarse crepitations and wheezes in his chest. There is no ankle swelling or jugular venous elevation. Heart sounds are normal, BP 140/88 mmHg, pulse 96 in sinus rhythm. MLD?

Answer 56

Infective exacerbation of COPD
History is highly suggestive of COPD(long history, smoker, wheezing, daily sputum for at least 3 months of the year). Infective exacerbations of COPD are very common.

Confirm with further investigation

Question 57

A 3yoM presents with a runny nose, sore throat, fever and cough, for 3 days. The cough has become barking, gets worse at night and he has a hoarse voice. No stridor is heard but during the consultation he becomes agitated which elicits an inspiratory stridor. Chest sounds clear. What is MLD and red flags to look for?

Answer 57

Croup
Drowsiness, lethargy and cyanosis are all red flags to show imminent respiratory distress
- use Wesley clinical scoring system. Mild can receive home treatment, moderate or severe needs hospital admission (resp distress).
- Test pulse oximetry (

Question 58

A 25yoM with asthma presents with complaints of cough, fever, and expectoration of brown mucus for 3 months. Although he has known allergic rhinitis and asthma, he feels his symptoms were previously well controlled on his regimen of oral antihistamines and inhaled corticosteroids. His exam is significant for end-expiratory wheezing. A FBC reveals raised IgE and raised eosinophil count. MLD and first test?

Answer 58

Allergic bronchopulmonary aspergillosis
(ABPA)
1st test: skin test for Aspergillus fumigatus sensitivity

Question 59

A 76yoF who is wheelchair bound comes into the GP for worsening SOB for two days. She is taking levothyroxine 175mg/day for hypothyroid. She also complains of palpitations, soreness in her neck and sweating. Her RR is 27, BP 113/61 and pulse 89, sats are 96%. Chest was clear and heart sounded normal. At the end of the consultation she mentions she has very swollen legs, this has happened before a while ago but its come back over the last 2 weeks, you examine and see quite severe pitting oedema. When you do her BP you noticed she became breathless when taking off her jacket. How do you manage?

Answer 59

Send to hospital
Suspected R heart failure
Don’t be thrown off by the other symptoms, the heart symptoms are more important

Question 60

A 67yoF presentes to A+E with worsening SOB for 3 months. She often wakes at night with her breathing and now sleeps with several pillows. She has noticed her ankles have also become very swollen. You note she has crepitations on both lung bases and a pulse of 126. What do you suspect and how do you investigate?

Answer 60

Meets framingham criteria for heart failure
NICE recommends FBC (including BNP), U+E, ECG, CXR, echo-cardiogram (key)

If ECG and BNP normal then heart failure is unlikely
NOTE DIFFERENT CRITERIA IF IN GP

Question 61

A 68yoM presents to the GP after yesterday experiencing a tight chest pain when he was doing some gardening. He sat down after feeling it and he said it improved within about 5mins but it scared him a little so he wanted to come and check it out. He says he’s had similar experiences before but his brother recently died of a heart attack so he thought it best to come in. MLD?

Answer 61

Stable angina

Question 62

A 68yoM presents to the GP after yesterday experiencing a tight chest pain when he was doing some gardening. His brother has angina and he thinks he may have it too. He sat down and the pain went away after about 20mins, he also reports feeling a little dizzy. MLD and management?

Answer 62

Refer to hospital

Could be ACS or atypical angina, either way with pain lasting 20 mins this needs referral.

Question 63

A 78yoM presents to his GP with a heavy feeling in his chest. He denies pain or other symptoms, although notes he’s been slightly SOB for the last few months when trying to move round the house. He has a PMHx of gout and T2DM. What is your MLD?

Answer 63

MI

• Most diabetics tend to get silent MI’s
• SOB is probably more related to general health and aging

Question 64

A 59yoM presents with a severe abdominal pain, which he says also goes into his sides. From the current history what is the MLD?

Answer 64

AAA

Question 65

A 24yoM comes in off the street semi-concious. They were found slumped at the side of the road by a concerned member of the public. Their RR is 6/min and following ABCDE examination they have pinpoint pupils. You note they smell strongly of alcohol. What is MLD and management?

Answer 65

Opioid overdose

Naloxone to reverse

Question 66

A 34yoF presents with a cottage cheese like discharge, that is not smelly from her vagina for 2 days, she complains that it is itchy, sore and sometimes feels like it’s burning and that her vulva seems red and inflamed. She says she can’t have sex because it is painful. What is MLD?

Answer 66

Vulvovaginal Candidasis
(Vaginal yeast infection)
- 85% due to candida albicans
Treat: Antifungal (clotrimazole or miconazole) either pessaries for inside vagina or topical cream. Return if no improvement in 7-14days

Question 67

A 76yoM, presents with cough and wheeze for 8 years. He has been a heavy (40/day) for 50years. He is increasingly breathless for 3months. O/E:
- no cyanosis, marked tar staining of his fingers, no clubbing, pitting oedema of both legs extending to the mid shins.
- respiratory rate 18/min, barrel shaped chest, limited chest expansion bilaterally, diffuse wheeze bilaterally
- pulse 99/min, regular; BP: 140/85; JVP: elevated and neck veins are generally distended; heart sounds normal, no murmurs.
- Abdomen: liver diffusely enlarged and mildly tender.
MLD?

Answer 67

Severe COPD and is now developing cor-pulmonale

Question 68

A 66yo black man presents to the ED with a history of fever and weight loss. He reports that he has had little appetite for the last 3 months and has lost 11 kg during that time. He has noted tactile fevers over the last 6 weeks but has not had access to a thermometer. He has been having headaches for the last week but denies cough, haemoptysis, or chest pain. He has been intermittently homeless over the last 2 years and has a history of heavy alcohol use but recently stopped. On examination, he is a thin man with a temperature of 38.8°C and a respiratory rate of 20 breaths per minute. Physical examination is notable for temporal wasting and hepatomegaly without tenderness.

Answer 68

Extra pulmonary TB

Question 69

A 66yoM of southeast asian origin presents with increasing cough, fatigue, weight loss and fever for over a month. Upon questioning he also reveals he has been having drenching night sweats. He often sleeps rough or shares rooms in hostels with others. MLD and 1st test?

Answer 69

Pulmonary TB

- Do CXR, sputum culture for Acid Fast Bacilli

Question 70

A 25yoF with 3 children presents with a history of fatigue, ice craving, and dyspnoea upon exertion. She was unable to tolerate her antenatal vitamins during pregnancy, because of nausea. Examination reveals pallor and spooning of her nails. Vital signs are normal. There is no lymphadenopathy or hepatosplenomegaly. MLD?

Answer 70

Iron deficiency anaemia

Question 71

A 68-year-old man presents with fatigue and dark stools. On examination his vital signs are normal but he is pale and has a rectal mass. Later biopsy of the rectal mass reveals adenocarcinoma. What is the like,y cause of his fatigue?

Answer 71

Iron deficiency anaemia due to bleeding cause by adenocarcinoma

Question 72

A 24yoF who is 26weeks pregnant presents to her GP with tingling and pain in her thumb, index and middle fingers, the pain is slightly relieved by shaking her hand. She has some weakness in her grip and you notice some wasting of the thenar eminance. MLD and management?

Answer 72

Median nerve damage

• Probable carpal tunnel syndrome
• No management, often self resolves in pregnancy (caused by possible fluid retention)

Question 73

A 26yoM presents with tingling and pain in his right hand. You perform Tinels and Phalens test which are both positive. MLD and management?

Answer 73

Carpal tunnel syndrome (median nerve)

• Likely to self resolve in 6months, especially when under 30 and unilateral
• Can trial oral NSAIDS but unlikely to be better than placebo and have SE’s
• Corticosteroid injections/ surgery are long term options

Question 74

A 24yoF presents with an emergency appointment to her GP after she noticed this morning her wrist was dropped and she couldn’t move it, although it is better now this worried her and she wants to know what may have caused it?

Answer 74

Radial nerve compression

- Often due to funny posture whilst sleeping, self resolves

Question 75

A 74yoF presents to her GP with a weakness in her L wrist which has progressed for several weeks, you notice wasting of the extensor muscles and a profound wrist drop. MLD?

Answer 75

Radial nerve palsy

Question 76

A 62yoM presents to his GP with his little finger and ring finger contracted, he says he finds it difficult to move them and people have commented his hand looks like a claw. MLD and management?

Answer 76

Ulnar nerve palsy

- Investigate source and cause of lesion to determine treatment

Question 77

A patient presents with a drooping right eyelid and an eye that is stuck in the down and out position, this appeared overnight. MLD/ first test?

Answer 77

Damage to CNIII (oculomotor)
(does all extraoccular except SO and LR)
- With third nerve palsy do CT of head to rule out posterior communicating artery aneurysm or tumour

Question 78

A 54yoM presents after falling on his shoulder, his arm is handing at the side, with the elbow extended and forearm pronated, you recognise this as the waiters tip position. He cannot abduct his shoulder, or rotate his arm outwards or flex his elbow. MLD + Tx?

Answer 78

Erb’s palsy (erb-duchenne)
Upper brachial plexus lesion (C5 or rarely C6)

• Treat with abduction splint

Question 79

A 72yoM presents with pain and weakness in his foot, he finds he can’t lift his ankle. He has noticed his foot dragging. O/E he can’t dorsiflex the foot and has a footdrop gait. MLD?

Answer 79

Common perioneal nerve palsy (splits from sciatic nerve to do anterior foot)
- Treat with splint/ physio or surgery if extreme

Question 80

A 69yoF presents with shoulder pain, he says she can’t lift her arms up to work. She had a radical mastectomy last week and says the pain has been since then. O/E she has a winged scapula, which is worse when she pushes against a wall. MLD?

Answer 80

Long thoracic nerve palsy

Physio or surgery

Question 81

A 22yoF at 29weeks gestation presents with pain ‘down there’, she says it is sore, red, burning and giving off a white discharge, which doesn’t smell. It’s very itchy and she wants something to treat it which won’t harm the baby, what is the most likely cause and how do you proceed?

Answer 81

Vaginal thrush (Vaginal and Vulval Candidiasis)

• Often caused by candida albicans (85%)
• Treat with clotrimazole (brand name Canesten). Pessary 500mg and cream 2%. Return if no resolution in 7-14days
• Investigations and examination not usually needed unless severe/ recurrent. Oral fluconazole if severe but this is CI in pregnancy!

Question 82

A 19yoM presents with Breathlessness, dizziness and ejection systolic murmur. MLD?

Answer 82

HOCM (hypertrophic obstructive cardiomaopathy)

Old person with same triad of symptoms= Aortic Stenosis

Question 83

A 34yoM presents with weakness. He says the weakness started in his legs around 2 weeks ago and has spread upwards through his body, Three weeks before onset of the leg weakness he reports a flu like illness. His legs also feel like they’re tingling and he has lost sensation in them. ???

Answer 83

Guillain-Barre Syndrome

AKA: Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)

Question 84

A 22 year old man is brought into the resuscitation room with multiple stab wounds to the chest. On arrival, he is tachycardic, hypotensive and has engorged jugular veins. His heart sounds are barely audible on auscultation.
Which of the following is the most likely cause of his symptoms?
A. cardiogenic shock
B. cardiac tamponade
C. haemothorax
D. haemorrhagic shock
E. tension pneumothorax

Answer 84

Cardiac Tamponade
- Remember Beck’s triad
(Hypotension, raised JVP, muffled heart sounds)

CT is accumulation of fluid in the pericardial sac

Question 85

A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound is a stereotypical history of…

Answer 85

Left ventricular aneurysm

Question 86

A 70-year-old woman is found to have a pan-systolic murmur after presenting with dyspnoea. A soft S1 and split S2 is also noted. MLD?

Answer 86

Mitral regurgitation

Question 87

A patient develops a bradycardia of 36/min following a myocardial infarction. The ECG shows no association between the P waves and QRS complexes. What is MLD?

Answer 87

Complete (3rd degree) heart block

Question 88

A 60-year-old man with a history of tuberculosis presents with dyspnoea and fatigue. On examination the JVP is elevated, there is a loud S3 and Kussmaul’s sign is positive. Hepatomegaly is also noted. MLD?

Answer 88

Constrictive pericarditis

Question 89

A 50-year-old man with Marfan syndrome presents with palpitations and dyspnoea. On examination he has a collapsing pulse, the blood pressure is 160/60 mmHg and a high-pitched diastolic murmur is heard. MLD?

Answer 89

Aortic Regurgitation

Question 90

A man presents with central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated. MLD?

Answer 90

Dressler’s syndrome

- Secondary form of pericarditis which follows heart injury such as MI

Question 91

A 25-year-old man with no past medical history is investigated for recurrent syncope and dyspnoea. On examination he has an ejection systolic murmur which gets louder when he goes from lying to standing. MLD?

Answer 91

HOCM

Hypertrophic obstructive cardiomyopathy

Question 92

A 22-year-old man with sickle cell anaemia presents with pallor, lethargy and a headache. Blood results are as follows:

Hb 4.6 g/dl
Reticulocytes 3%

Infection with a parvovirus is suspected. What is the likely diagnosis?

Answer 92

Aplastic Crisis
The sudden fall in haemoglobin without an appropriate reticulocytosis (3% is just above the normal range) is typical of an aplastic crisis, usually secondary to parvovirus infection

Question 93

A patient is investigated for lymphocytosis. Cytogenetic analysis shows the presence of the following translocation: t(9;22)(q34;q11), known as the philadelphia translocation. Which haematological malignancy is most strongly associated with this translocation?

Answer 93

Chronic Myeloid Leukaemia