MedEd Flashcards
A 65 year old lady presents with diarrhoea. She has struggled with infrequent bowel motions for most of her life so is surprised by this.
A. Gastroenteritis B. UC C. Crohn's Disease D. Colorectal Carcinoma E. Thyrotoxicosis F. Chronic Pancreatitis G. Pregnancy H. Overflow Diarrhoea I. Ischaemic Colitis J. Lactose Intolerance K. Laxative Abuse L. Cimetidine Use
Overflow diarrhoea: History of chronic constipation/obstruction. Liquid stool passes obstruction.
Key words: Infrequent bowel motion
An 18 year old girl presents with diarrhoea. She reports no other changes other than starting the OCP. She has had similar episodes in the past which she manages with lifestyle modification but doesn’t understand why this is happening now.
A. Gastroenteritis B. UC C. Crohn's Disease D. Colorectal Carcinoma E. Thyrotoxicosis F. Chronic Pancreatitis G. Pregnancy H. Overflow Diarrhoea I. Ischaemic Colitis J. Lactose Intolerance K. Laxative Abuse L. Cimetidine Use
Lactose Intolerance:
- Hypersensitivity= reproducible adverse reaction (includes allergy and intolerance)
Intolerance is non-immune mediated
Allergy is either IgE or non-IgE mediated
Key Words: OCP, Lifestyle modifications.
OCP and POP both contain lactose
A 62 year old man presents with bloody diarrhoea and intense abdominal pain. He is currently on therapy for his heart palpitations.
A. Gastroenteritis B. UC C. Crohn's Disease D. Colorectal Carcinoma E. Thyrotoxicosis F. Chronic Pancreatitis G. Pregnancy H. Overflow Diarrhoea I. Ischaemic Colitis J. Lactose Intolerance K. Laxative Abuse L. Cimetidine Use
Ischaemic Colitis: Bloody, abdo pain, palpitations
A 45 year old woman presents with diarrhoea. She also reports weight loss but states that her appetite has increased. You notice that her hands shake slightly when she is reaching for things around the room.
A. Gastroenteritis B. UC C. Crohn's Disease D. Colorectal Carcinoma E. Thyrotoxicosis F. Chronic Pancreatitis G. Pregnancy H. Overflow Diarrhoea I. Ischaemic Colitis J. Lactose Intolerance K. Laxative Abuse L. Cimetidine Use
Thyrotoxicosis: Weight loss, appetite increase, fine tremor, heat intolerance, sweating, palpitations, eye signs & pretibial myxoedema (Graves’ Disease)
A 24 year old man presents with diarrhoea. He is normally fit and well and complains of nothing else. He has not eaten anything dodgy recently, but returned from Malaysia 2 weeks ago.
A. Gastroenteritis B. UC C. Crohn's Disease D. Colorectal Carcinoma E. Thyrotoxicosis F. Chronic Pancreatitis G. Pregnancy H. Overflow Diarrhoea I. Ischaemic Colitis J. Lactose Intolerance K. Laxative Abuse L. Cimetidine Use
Gastroenteritis: look for travel, dietary changes and contact history
A 56 year old man presents with constipation. He also reports abdominal pain, weight loss and suffers with depression. He has no FH of note, but has had some problems with kidney stones.
A. Aganglionosis B. Dehydration C. Colorectal Carcinoma D. Hypokalaemia E. Environmental F. Furosemide use G. Hypothyroidism H. Fibroid I. Diabetes J. Anal fissure K. Opiate use L. Hypercalcaemia
Hypercalcaemia: “bones, stones, groan, psychic moans”
Abdo pain, vomiting, constipation, depression, FH kidney stones, polyuria, polydipsia, anorexia, pyrexia, fatigue, hypertension, confusion, ectopic calcification
Due to: Malignancy, primary hyperparathyroidism, sarcoidosis
A 26 year old woman presents with constipation. She has struggled with this for a few years but her GPs advice of topical GTN and dietary advice is not helping.
A. Aganglionosis B. Dehydration C. Colorectal Carcinoma D. Hypokalaemia E. Environmental F. Furosemide use G. Hypothyroidism H. Fibroid I. Diabetes J. Anal fissure K. Opiate use L. Hypercalcaemia
Anal Fissue: Causes constipation due to pain
Tx: high fibre and fluid diet, topical lidocaine, topical GTN (SE - headaches), botox, surgical
A 70 year old woman presents with constipation. She has just been discharged from hospital following a #NOF. On admission she was found to be on a number of drugs for her heart which have not changed upon discharge.
A. Aganglionosis B. Dehydration C. Colorectal Carcinoma D. Hypokalaemia E. Environmental F. Furosemide use G. Hypothyroidism H. Fibroid I. Diabetes J. Anal fissure K. Opiate use L. Hypercalcaemia
Opiate use: commonly prescribed for analgesia, also used as an anti-tussive in heart failure to provide patients symptomatic relief (desensitises central chemoreceptors to the response to PaCO2).
Acts on receptors on myenteric and submucosal plexus to decrease gastric motility and emptying, and increase gut water reabsorption = Constipation
Also lead to pupillary constriction (edinger Westphal nucleus), nausea&vomiting (CTZ), and priuritis, uricaria&hypotension (histamine release from mast cells)
Euphoric effects via action of dopamine release on nucleus accumbens
A 75 year old man presents with constipation. He also reports abdominal pain and weight loss.
A. Aganglionosis B. Dehydration C. Colorectal Carcinoma D. Hypokalaemia E. Environmental F. Furosemide use G. Hypothyroidism H. Fibroid I. Diabetes J. Anal fissure K. Opiate use L. Hypercalcaemia
Colorectal carcinoma: over 50% of presentations in >70 years
Tenesmus, blood PR, weight loss
L sided = 25% can be obstructed
Tx: surgical excision - Upper third = anterior resection (colo-anal anastomoses)
Lower 2/3’s = abdominoperineal resection (permanent colostomy - increased incidence sexual and urinary dysfunction
An 8 year old boy presents with constipation. His abdomen is also slightly distended. He is normally fir and his diet is balanced and healthy.
A. Aganglionosis B. Dehydration C. Colorectal Carcinoma D. Hypokalaemia E. Environmental F. Furosemide use G. Hypothyroidism H. Fibroid I. Diabetes J. Anal fissure K. Opiate use L. Hypercalcaemia
Aganglionosis: e.g. Hirchsprung’s disease
Absence of ganglion cells in the GIT therefore there is impaired/absent nervous control.
Usually diagnosed as infant
Hepatitis B Virus sAg negative eAg negative eAb negative cAb positive
sAg = surface antigen eAg = e antigen eAb = e antibody cAb = core antibody
A. Acute Infection B. Resolved Infection C. Naive D. Low infectivity carrier E. High Infectivity carrier F. Vaccinated
Resolved Infection
Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.
Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs
Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma
sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.
sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).
eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.
cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn’t yet appeared.
eAg and sAg indicates a greater infectivity, high level of viral activity and replication.
Hepatitis B Virus sAg positive eAg negative/positive eAb negative/positive cAb positive
sAg = surface antigen eAg = e antigen eAb = e antibody cAb = core antibody
A. Acute Infection B. Resolved Infection C. Naive D. Low infectivity carrier E. High Infectivity carrier F. Vaccinated
Acute Infection
Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.
Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs
Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma
sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.
sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).
eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.
cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn’t yet appeared.
eAg and sAg indicates a greater infectivity, high level of viral activity and replication.
Hepatitis B Virus sAb positive eAg negative eAb negative cAb negative
sAb = surface antibody eAg = e antigen eAb = e antibody cAb = core antibody
A. Acute Infection B. Resolved Infection C. Naive D. Low infectivity carrier E. High Infectivity carrier F. Vaccinated
Vaccinated
Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.
Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs
Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma
sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.
sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).
eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.
cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn’t yet appeared.
eAg and sAg indicates a greater infectivity, high level of viral activity and replication.
Hepatitis B Virus sAg positive eAg negative eAb positive cAb positive
sAg = surface antigen eAg = e antigen eAb = e antibody cAb = core antibody
A. Acute Infection B. Resolved Infection C. Naive D. Low infectivity carrier E. High Infectivity carrier F. Vaccinated
Low Infectivity Carrier
Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.
Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs
Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma
sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.
sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).
eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.
cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn’t yet appeared.
eAg and sAg indicates a greater infectivity, high level of viral activity and replication.
Hepatitis B Virus sAg negative eAg negative eAb negative cAb negative
sAg = surface antigen eAg = e antigen eAb = e antibody cAb = core antibody
A. Acute Infection B. Resolved Infection C. Naive D. Low infectivity carrier E. High Infectivity carrier F. Vaccinated
Naive
Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.
Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs
Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma
sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.
sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).
eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.
cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn’t yet appeared.
eAg and sAg indicates a greater infectivity, high level of viral activity and replication.
Drug Side Effects:
Isoniazid
A. Arrhythmias B. Ototoxicity C. Increased appetite D. Hepatic enzyme inducer E. Cushing's syndrome F. Hepatic enzyme reducer G. Peripheral neuropathy H. Liver toxicity I. OCP failure J. Colour Blindness
Peripheral neuropathy
Used in treatment TB.
Prescribed with pyridoxine prophylactically.
Drug Side Effects:
Ethambutol
A. Arrhythmias B. Ototoxicity C. Increased appetite D. Hepatic enzyme inducer E. Cushing's syndrome F. Hepatic enzyme reducer G. Peripheral neuropathy H. Liver toxicity I. OCP failure J. Colour Blindness
Colour Blindness - optic neuritis, colour vision is effected first
TB treatment
Drug Side Effects:
Rifampicin
A. Arrhythmias B. Ototoxicity C. Increased appetite D. Hepatic enzyme inducer E. Cushing's syndrome F. Hepatic enzyme reducer G. Peripheral neuropathy H. Liver toxicity I. OCP failure J. Colour Blindness
Hepatic Enzyme Inducer
- Inactivates oral contraceptive, causes orange discolouration of bodily fluids, hepatitis
Drug Side Effects:
Pyrazinamide
A. Arrhythmias B. Ototoxicity C. Increased appetite D. Hepatic enzyme inducer E. Cushing's syndrome F. Hepatic enzyme reducer G. Peripheral neuropathy H. Liver toxicity I. OCP failure J. Colour Blindness
Liver toxicity
Also arthralgia
Drug Side Effects:
Streptomycin
A. Arrhythmias B. Ototoxicity C. Increased appetite D. Hepatic enzyme inducer E. Cushing's syndrome F. Hepatic enzyme reducer G. Peripheral neuropathy H. Liver toxicity I. OCP failure J. Colour Blindness
Ototoxicity
A 23 year old man comes into A&E with abdominal pain which started over his belly button and now is in his RLQ. he is tachycardic, has a tender RIF on palpation and is Rovsing’s sign positive.
A. OGD B. Colonoscopy C. Barium Swallow D. Flexi-Sig E. Rigid Sig F. CT KUB G. CT CAP H. USS I. Abdo Xray J. Proctoscopy K. Barium Enema L. None of the above
None of the above!
Appendicitis is a clinical diagnosis
Inflammation of the vermiform appendix due to faecolith, lymphoid hyperplasia, infection (parasitic/viral)
Tender over McBurney’s point and Rovsing positive.
65 year old man is referred by his GP with altered bowel habit and rectal bleeding over the past 6 weeks. The blood is bright red and is not associated with any pain. He reports tenesmus and weight loss.
A. OGD B. Colonoscopy C. Barium Swallow D. Flexi-Sig E. Rigid Sig F. CT KUB G. CT CAP H. USS I. Abdo Xray J. Proctoscopy K. Barium Enema L. None of the above
Flexible Sigmoidoscopy: visualisation rectum and sigmoid plus biopsies
Key words: altered bowel habit, rectal bleeding, tenesmus, weight loss
This patient has colorectal carcinoma: predisposing factors = IBD, polyps, FAP, smoking, low fibre diet
Genetics: one 1st degree relative 1:17, two first degree relatives 1:10
Stage using TMN, treat with chemoradiation/surgery
83 year old lady complains of tiredness and weight loss over the last 6 weeks. On examination a mass is felt in her right iliac fossa and currently weighs 40kgs, though she was over 50kg at her last appointment.
A. OGD B. Colonoscopy C. Barium Swallow D. Flexi-Sig E. Rigid Sig F. CT KUB G. CT CAP H. USS I. Abdo Xray J. Proctoscopy K. Barium Enema L. None of the above
Colonoscopy:
Key words: tiredness, weight loss, mass
45 year old man complains to his GP of passing bloody stool without pain for the past 3 weeks. He reports a small amount of bright red blood with no mucus which he finds mostly on the paper.
A. OGD B. Colonoscopy C. Barium Swallow D. Flexi-Sig E. Rigid Sig F. CT KUB G. CT CAP H. USS I. Abdo Xray J. Proctoscopy K. Barium Enema L. None of the above
Proctoscopy:
Key words: bloody stool, painless, on the paper
This patient has haemorrhoids = disrupted and dilated anal cushions. Usually at 3, 7, 11 o’clock when in lithotomy position.
1st degree: internal
2nd: Prolapse on defaecation, spontaneously reduce
3rd: Prolapse but requires digital reduction
4th: persistant prolapse
Treatment: Consevation, sclerosing agents, banding haemorrhoidectomy
45 year old woman complains of RUQ and shoulder pain. She has a fever and is Murphy’s sign positive.
A. OGD B. Colonoscopy C. Barium Swallow D. Flexi-Sig E. Rigid Sig F. CT KUB G. CT CAP H. USS I. Abdo Xray J. Proctoscopy K. Barium Enema L. None of the above
USS
Acute Cholecystitis = impaction at the neck of the gall bladder
Will show a thick walled, shrunken GB, dilated CBD, stones, pericholestatic fluid
Tx: NBM, pain relief, IV Abx, surgery
Always consider Courvoisier’s Law - painless enlarged gall bladder and jaundice is unlikely to be gall stones
25 year old woman with UC involving the rectum has just undergone curative surgery.
A. Tracheostomy B. Loop colostomy C. End Ileostomy D. Gastrostomy E. De-functioning colostomy F. Nephrostomy G. Loop Ileostomy H. End colostomy I. Cystostomy J. Urostomy K. De-functioning ileostomy L. None of the above
End Ileostomy: single lumen, spouted, right sided, liquid output.
When the entire colon is removed, the surgeon creates a stoma, in the abdominal wall. The tip of the lower small intestine is brought through the stoma. An external bag, or pouch, is attached to the stoma. This is called a permanent ileostomy. Stools pass through this opening and collect in the pouch. The pouch must be worn at all times.
Whereas an end colostomy has a single lumen, unspouted, left sided, stool like output.
A 50 year old man had surgery following mid-stage bladder cancer (T2-3) last year and is left with a stoma.
A. Tracheostomy B. Loop colostomy C. End Ileostomy D. Gastrostomy E. De-functioning colostomy F. Nephrostomy G. Loop Ileostomy H. End colostomy I. Cystostomy J. Urostomy K. De-functioning ileostomy L. None of the above
Urostomy - most commonly performed after cystectomy or bladder cancer, for urinary diversion where drainage of the urine through the bladder and urethra isn’t possible.
A 65 year old man with a high rectal carcinoma has had an anterior resection.
A. Tracheostomy B. Loop colostomy C. End Ileostomy D. Gastrostomy E. De-functioning colostomy F. Nephrostomy G. Loop Ileostomy H. End colostomy I. Cystostomy J. Urostomy K. De-functioning ileostomy L. None of the above
Loop ileostomy: double lumen, spout, liquid output, mucous fistula.
Allows the distal bowel to rest - designed to be temporary and reversed at a later date.
89 year old lady with a known history of colorectal cancer in the transverse colon. She has ESRF. She presents with symptoms of large bowel obstruction.
A. Tracheostomy B. Loop colostomy C. End Ileostomy D. Gastrostomy E. De-functioning colostomy F. Nephrostomy G. Loop Ileostomy H. End colostomy I. Cystostomy J. Urostomy K. De-functioning ileostomy L. None of the above
De-functioning Ileostomy
What is a hernia?
A. Protrusion of a viscous or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
A patient has an inguinal hernia that has become ischaemic, what is this hernia described as?
A. Reducible B. Incarcerated C. Irreducible D. Strangulated E. Obstructed
Strangulated
What type of hernia forms through Hesselbach’s triangle?
A. Femoral B. Direct Inguinal C. Indirect Inguinal D. Para-umbilical E. Hiatus
Direct Inguinal
A 35 year old woman presents with a lump on her scalp. It is painless, attached to the skin and has a punctum.
A. Hernia B. Keloid C. Lipoma D. Rheumatoid Nodule E. Cutaneous Abscess F. Ganglion G. Fibroma H. Neurofibroma I. Sebaceous cyst J. Lymph Node
Sebaceous cyst: can occur anywhere with sebaceous glands (i.e. not soles of feet/palms), they are intradermal and easily become infected.
Tx: excision
A 68 year old lady presents with a firm, painless lump on the back of her elbow. In her PMH she note she has arthritis and pulmonary fibrosis.
A. Hernia B. Keloid C. Lipoma D. Rheumatoid Nodule E. Cutaneous Abscess F. Ganglion G. Fibroma H. Neurofibroma I. Sebaceous cyst J. Lymph Node
Rheumatoid Nodule: subcutaneous colleagenous granulomas, usually found on extensor surfaces (elbows and hands)
Appear in established rheumatoid arthritis patients (up to 25%)
A 45 year old man presents with a lump on a scar on his abdomen. He recently had a stoma reversal. He reports it is there all the time, is solid and itches sometimes.
A. Hernia B. Keloid C. Lipoma D. Rheumatoid Nodule E. Cutaneous Abscess F. Ganglion G. Fibroma H. Neurofibroma I. Sebaceous cyst J. Lymph Node
Keloid: hypertrophy of vascularised collagen that extends outside the scar.
Tx: excision or steroids
A 22 year old man presents with a lump under his jaw. It is firm and is not fixed to the skin. He has recently been diagnosed with EBV.
A. Hernia B. Keloid C. Lipoma D. Rheumatoid Nodule E. Cutaneous Abscess F. Ganglion G. Fibroma H. Neurofibroma I. Sebaceous cyst J. Lymph Node
Lymph node: can be due to infection (EBV, TB, HIV, Syphilis etc) or infiltration (malignancy, sarcoidosis)
A 21 year old man presents with a lump on the top of his foot. It is painless and appeared a few weeks ago. It transilluminates.
A. Hernia B. Keloid C. Lipoma D. Rheumatoid Nodule E. Cutaneous Abscess F. Ganglion G. Fibroma H. Neurofibroma I. Sebaceous cyst J. Lymph Node
Ganglion (cyst): appear commonly on the dorsum of the hand or foot due to herniation of a synovial joint or tendon sheath.
They are thin walled cysts containing mutinous fluid.
“Bible cyst” - people used to hit them with a bible to make them go away!
Tx: Leave it! Aspiration or excision
A 27 year old man complains of pain in his jaw, he says it hurts most when he eats and is swollen, tender and red. He is afebrile.
A. MRI B. FBC C. FNA D. USS E. Sialogram F. Angiography G. X-ray H. Barium Swallow J. Excisional Biopsy K. Reassure patient
Sialogram: this sounds like sialolithiasis - recurrent, unilateral pain especially on eating.
A 66 year old woman complains of pain in her jaw. O/E you find a small, hard lump adjacent to her ear lobe. She says it’s been getting larger over the past few months.
A. MRI B. FBC C. FNA D. USS E. Sialogram F. Angiography G. X-ray H. Barium Swallow J. Excisional Biopsy K. Reassure patient
Excision biopsy: this sounds like a parotid tumour.
Salivary gland tumours:
- 80% in parotid
- 80% of these are pleomorphic adenomas
- 80% of these are in the superficial lobe
Tx: surgery +/- radiotherapy (beware CNVII)
Parotid Pathology:
Acute/unilateral: stone
Acute/bi/uni-lateral: Mumps/HIV
Chronic/Unilateral: tumour, ALL, sarcoid
Chronic/Bilateral: Autoimmune disease
An 18 year old man presents with a lump in his neck. It is on the anterior border of his right sternocleidomastoid, a little over half way up his neck. He says it has been growing slowly but is causing him no trouble.
A. MRI B. FBC C. FNA D. USS E. Sialogram F. Angiography G. X-ray H. Barium Swallow J. Excisional Biopsy K. Reassure patient
FNA: this sounds like a branchial cyst, which is a congenital malformation (t tend to be problematic unless they fistulae of become infected.
FNA reveals cholesterol crystals
Tx: Leave/excise
A 23 year old man presents with a firm lump in his neck. It is painless and mobile from side to side, but not up and down. It sits anterior to sternocleidomastoid.
A. MRI B. FBC C. FNA D. USS E. Sialogram F. Angiography G. X-ray H. Barium Swallow J. Excisional Biopsy K. Reassure patient
Angiography: Sounds like carotid body pathology! May be aneurysmal or a tumour, and angiography will distinguish between the two, whereas duplex USS doesn’t.
They are rare and usually firm, painless, mobile lumps (but can be soft and pulsatile)
A 35 year old woman presents with a lump on her neck. It has uneven borders, is smooth, slightly fluctuant and is not fixed to the skin or deeper structures.
A. MRI B. FBC C. FNA D. USS E. Sialogram F. Angiography G. X-ray H. Barium Swallow J. Excisional Biopsy K. Reassure patient
Reassure patient: Lipoma - uneven borders, smooth, slightly fluctuant, not fixed, benign fatty lump that occurs wherever fat can expand (not scalp/palms)
Only tend to be symptomatic with pressure and malignant change is rare
54 year old man with stage 3 CRF come to renal OP clinic. You see that his calcium is low and ALP is high. What test would you do to confirm suspected pathology?
A. Abdo USS
B. DEXA scan
C. Lumbar spine X-ray
D. FBC, U&E, LFT, urine dipstick
DEXA Scan - Renal osteodystrophy
- High phosphate is due to inadequate excretion
- Low calcium is due to low calcitriol production and poor renal reabsorption
- Increased PTH
- Increased bone resorption
- Osteoporosis like picture on DEXA
35 year old woman underwent a kidney transplant for CRF 6 months ago. She has recently noticed a swelling in her neck. She is also complaining of constipation and low mood. Her GFR is normal. Abdominal CT scan shows some small calcifications in her transplanted kidney.
A. Primary Hyperparathyroidism
B. Secondary Hyperparathyroidism
C. Tertiary Hyperparathyroidism
D. Transplant rejection
Tertiary Hyperparathyroidism: after prolonged secondary hyperparathyroidism(due to CRF), parathyroid gland becomes autonomous.
Primary= something wrong with parathyroid (e.g. adenoma secreting excess PTH) Secondary= Physiological response to hypocalcaemia/hyperphosphataemia
Which of these drugs is contraindicated in CRF?
A. Potassium Sparing diuretics
B. Gentamicin
C. NSAIDS
D. All of above
All of above
CRF: GFR 3 months
5 stages, end stage is GFR <15ml/min
Causes: Hypertension, Diabetes, Glomerulonephritis, renal vascular disease, recurrent pyelonephritis
Symptoms and Signs: fatigue, weakness, anorexia, vomiting, metallic taste, pruritis, bone pain, dyspnoea, ankle swelling, pallor, easy bruising, hypertension
Investigations:
- Urine dip: proteinuria, haematuria
- Bloods: low Hb (normocytic normochromic), raised urea and creatinine, hypocalcaemia, hyperphosphataemia (secondary hyperparathyroidism), Hyperkalaemia
- USS small kidneys
- DEXA: renal osteodystrophy
60 year old man with a 40 pack year history comes to see his GP with frank haematuria. Most likely diagnosis?
A. Schistosomiasis B. Abdominal USS C. Transitional Cell Carcinoma D. Flucloxacillin E. Anti-GBM antibody test F. Nitrofurantoin G. Giardia Lamblia H. Penicillin V I. CT KUB J. Metronidazole K. Malaria L. Renal Biopsy M. BPH
Transitional Cell Carcinoma
23 year old woman comes to her GP complaining of burning on passing urine. Urine dipstick is positive for blood, leukocytes and nitrites. What is the most appropriate treatment?
A. Schistosomiasis B. Abdominal USS C. Transitional Cell Carcinoma D. Flucloxacillin E. Anti-GBM antibody test F. Nitrofurantoin G. Giardia Lamblia H. Penicillin V I. CT KUB J. Metronidazole K. Malaria L. Renal Biopsy M. BPH
Nitrofurantoin
Commonest Pathogens: E.Coli, Klebsiella, Proteus
Abx: Nitrofurantoin, ciprofloxacin, augmentin
An 18 year old gap student is referred to a urologist because of a 4 week history of terminal haematuria. He also complains of some intermittent fevers and malaise. Eosinophil count is markedly raised. The patient mentions that he returned from Malawi about a month ago.
What is the most likely diagnosis?
A. Schistosomiasis B. Abdominal USS C. Transitional Cell Carcinoma D. Flucloxacillin E. Anti-GBM antibody test F. Nitrofurantoin G. Giardia Lamblia H. Penicillin V I. CT KUB J. Metronidazole K. Malaria L. Renal Biopsy M. BPH
Schistosomiasis: numerous species.
S. Haematobium causes urinary schisto (africa, middle east) whereas the other species cause intestinal schisto.
Transmission: drinking or swimming in water with contaminated schisto eggs
Increases the risk of squamous cell carcinoma of the bladder
A 35 year old man comes to A&E with severe left flank pain, that comes and goes in waves. What is the most appropriate next step?
A. Schistosomiasis B. Abdominal USS C. Transitional Cell Carcinoma D. Flucloxacillin E. Anti-GBM antibody test F. Nitrofurantoin G. Giardia Lamblia H. Penicillin V I. CT KUB J. Metronidazole K. Malaria L. Renal Biopsy M. BPH
CT KUB: Renal colic! Always ask about: - Loin to groin pain (often writhing in agony) - Haematuria - Frequency, dysuria - Rigors, fever - Hx of stones, recurrent UTIs
Abx: Nitrofurantoin, ciprofloxacin, augmentin
Differentials: biliary colic, pyelonephritis, acute pancreatitis, acute appendicitis, dissecting aortic aneurysm, epididymo-orchititis
Management renal colic: analgesia and anti-emetic, CT KUB, consider surgical drainage if septic
45 year old woman with a BMI of 35 develops RUQ pain. She rushes to A&E because she thinks she’s passing blood in her urine. What test should you do to confirm the most likely diagnosis?
A. Schistosomiasis B. Abdominal USS C. Transitional Cell Carcinoma D. Flucloxacillin E. Anti-GBM antibody test F. Nitrofurantoin G. Giardia Lamblia H. Penicillin V I. CT KUB J. Metronidazole K. Malaria L. Renal Biopsy M. BPH
Abdo USS
Fat Female Fair Forties
Biliary colic - dark urine
Differentials for Haematuria:
- Bilirubinuria (obstructive jaundice)
- Myoglobinuria
- Food (beetroot)
- Drugs (rifampicin, nitrofurantoin)
- Porphyria (urine darken on standing)
Liver Enzymes:
Bil 38 umol/L (s
Gilbert’s: Genetic predisposition to having jaundice (unconjugated Bilirubin).
Harmless, other LFTs are normal.
Triggers: dehydration, fasting, illness, stress, PMS
Liver Enzymes:
Bil 246 umol/L (<40)
ALP 1124 U/L (30-130)
GGT 60 U/L (11-42)
A. Cholestasis
B. Viral Hepatitis
C. Harmful Alcohol use
D. Cirrhosis
Cholestasis: ALP most elevated!
When bile cannot flow from the gallbladder to the duodenum.
Obstructive jaundice: gallstones, PBC/PSC, pancreatic cancer - pale stools, dark urine
Requires USS to look for cause
Liver Enzymes:
Bil 30 umol/L (<40)
ALP 57 U/L (30-130)
GGT 112 U/L (11-42)
A. Paracetamol OD
B. Viral Hepatitis
C. Cholestasis
D. Harmful Alcohol use
Alcohol! - GGT is high in isolation
In alcoholic liver disease: AST>ALT ratio >2:1
In cirrhosis AST>ALT as well
Later on may progress to alcoholic liver disease, fibrosis and cirrhosis.
Liver Enzymes:
Bil 25 umol/L (<40)
ALP 280 U/L (30-130)
GGT 470 U/L (11-42)
INR 2.7 (0.8-1.2)
A. Paracetamol OD
B. Alcoholic Liver Disease
C. Cholestasis
D. Hepatitis C
Paracetamol OD: transferases are very high = high level of liver damage
Acute marker of liver function is affected (INR), but chronic is not (albumin)
Liver Enzymes:
Bil 178 umol/L (<40)
ALP 180 U/L (30-130)
GGT 35 U/L (11-42)
A. Alcoholic Liver Disease
B. Acute Vital Hepatitis
C. Obstructive Jaundice
D. Cirrhosis
Viral Hepatitis: very high transaminases.
HepA - Acute, shellfish
HepB - mostly acute, some chronic
HepC - chronic
21 year old male comes to the GP practise with intermittent fever and abdo pain (2/12 duration). He also mentions getting up in the night to pass stool and has had some bloody diarrhoea.
A. Haemorrhoids B. Alcoholic Liver Disease C. Bowel Cancer D. IBS E. Viral Gastroenteritis F. IBD G. Rectal Varices H. Bleeding Duodenal Ulcer I. Septicaemia J. Malnutrition
IBD - diarrhoea (bloody, chronic and often nocturnal)
Abdo pain, fevers, weight loss
Nutritional deficiencies (Iron, B12, folate)
Extra-intestinal manifestations - mouth, skin, eyes, joints (pyoderma gangrenosum, link with PSC)
Inflammation - elevated CRP and platelets
FH of IBD
UC always affects the rectum and never affects the small bowel
60 year old female complains of tiredness and constipation, but no PR bleeding.
A. Haemorrhoids B. Alcoholic Liver Disease C. Bowel Cancer D. IBS E. Viral Gastroenteritis F. IBD G. Rectal Varices H. Bleeding Duodenal Ulcer I. Septicaemia J. Malnutrition
Bowel Cancer: Patients may not recognise PR bleeding if it is black/mixed into stool.
Anaemia in men or post-menopausal women MUST be investigated with upper and lower GI endoscopy
Sometimes the only sign may be a change in bowel habit
30 year old male has been suffering from anal itch, and bright red blood splashed over the toilet bowel after bowel movements.
A. Haemorrhoids B. Alcoholic Liver Disease C. Bowel Cancer D. IBS E. Viral Gastroenteritis F. IBD G. Rectal Varices H. Bleeding Duodenal Ulcer I. Septicaemia J. Malnutrition
Haemorrhoids: 4 degrees of haemorrhoids, ranging from completely internal to completely prolapsed.
Causes anal itch and soreness. Strangulated haemorrhoids may thrombose which is intensely painful.
Tx: High fibre, pain relief, ligation, injection or surgery if necessary
32 year old Asian male come to A&E with dizziness and collapse. His Hb is 7.2g/dL. His wife mentions that he has been taking omeprazole for the last couple of months.
A. Haemorrhoids B. Alcoholic Liver Disease C. Bowel Cancer D. IBS E. Viral Gastroenteritis F. IBD G. Rectal Varices H. Bleeding Duodenal Ulcer I. Septicaemia J. Malnutrition
Bleeding duodenal ulcer: can cause massive melaena - black tarry stools with a characteristic smell.
Hx of dyspepsia
Tx: ABC, Endoscopy, Surgery
50 year old man is rushed into A&E because of profuse PR bleeding. O/E he has very red palms, a swollen abdomen and yellow sclera.
A. Haemorrhoids B. Alcoholic Liver Disease C. Bowel Cancer D. IBS E. Viral Gastroenteritis F. IBD G. Rectal Varices H. Bleeding Duodenal Ulcer I. Septicaemia J. Malnutrition
Rectal Varices: Cirrhotic liver disease causes portal hypertension causing varicose (both oesophageal and rectal) - massive bleed of fresh red blood
65 year old woman comes into A&E with sudden onset right sided weakness of the face and arm. She has a history of high BP, for which she takes amlodipine. O/E her right arm is rigid and hyper-reflexic.
A. Lambert-Eaton Syndrome B. Parkinson's Disease C. MS D. Myasthenia Gravis E. Hypothyroidism F. Muscular Dystrophy G. Cerebrovascular Accident H. Epilepsy I. Alzheimer's Dementia
CVA - UMN signs: Spasticity, hyper-reflexia, Babinski sign
As well as focal signs according to lesion e.g. hemiparesis, hemianopias or general signs e.g. headaches, vomiting
LMN signs = muscle wasting, floppy paralysis, fasciculations
50 year old smoker with a 6 month history of SOB and a 2 day Hx of haemoptysis. He has also noticed weight loss of about a stone in the last month. Peripheral nerve exam showed significant weakness in the arms and legs, but it improved on repeated use.
A. Lambert-Eaton Syndrome B. Parkinson's Disease C. MS D. Myasthenia Gravis E. Hypothyroidism F. Muscular Dystrophy G. Cerebrovascular Accident H. Epilepsy I. Alzheimer's Dementia
Lambert Eaton Syndrome: Paraneoplastic (associated with small cell lung cancer) or autoimmune - antibodies against the presynaptic calcium channel.
Causes proximal muscle weakness and gait abnormalities.
Improves with exercise
40 year old woman comes to her GP complaining that her eyelids are too droopy. She also cannot complete a full meal because she finds it hard to swallow after a while. PMH: hyperthyroidism. The GP notices that her voice keeps trailing off at the end of sentences.
A. Lambert-Eaton Syndrome B. Parkinson's Disease C. MS D. Myasthenia Gravis E. Hypothyroidism F. Muscular Dystrophy G. Cerebrovascular Accident H. Epilepsy I. Alzheimer's Dementia
Myasthenia Gravis: antibody against the ACh receptor at NMJ.
LMN signs, affects multiple muscle groups
Oculomotor/Bulbar signs predominate.
Worsens with exercise
Other NMJ: organophosphate poisoning, botulism
A 4 year old boy is brought to his GP by his mother who is concerned that he is not able to run like the other boys at nursery. He seems to “waddle” when he walks and falls over frequently. He also has great difficulty climbing stairs. He is positive for Gowers sign.
A. Lambert-Eaton Syndrome B. Parkinson's Disease C. MS D. Myasthenia Gravis E. Hypothyroidism F. Muscular Dystrophy G. Cerebrovascular Accident H. Epilepsy I. Alzheimer's Dementia
Muscular Dystrophy: 2 commonest types are Duchenne and Beckers, abnormality in dystrophin protein
X-linked recessive
Muscle wasting and specific functional weakness: signs of proximal myopathy include difficulty in getting out of chairs, and difficulty climbing stairs
30 year old female presents with a 2 day history of pain and loss of vision in the left eye. This happened once before 6 months ago, but resolved spontaneously. OE she has reduced fine touch sensation in both feet, as well as weakness.
A. Lambert-Eaton Syndrome B. Parkinson's Disease C. MS D. Myasthenia Gravis E. Hypothyroidism F. Muscular Dystrophy G. Cerebrovascular Accident H. Epilepsy I. Alzheimer's Dementia
MS - optic neuritis is the most common presentation.
Also weakness, fatigue, paraesthesia, paralysis
Main types are:
- Relapsing-remitting
- Secondary progressive
- Primary progressive
A 45 year old woman is recovering on a ward after gall bladder surgery. You are called to see her by the night nurse on duty because she has become very agitated, is shouting incoherently and is convinced that she is covered in spiders. What do you do next?
A. Refer her to psychiatry in the morning for a full work up
B. Administer anti-psychotics
C. Start her on fluids to help her sober up
D. Consider prescribing some benzodiazepines
Benzodiazepines: delirium tremens!!! - chlordiazepoxide
Alcohol withdrawal state:
- Agitation, confusion, fluctuating consciousness, seizures, arrhythmias, death (
A known alcoholic comes into A&E clearly drunk, his speech is slurred, he cannot walk straight and he seems to be quite floppy sitting in his chair. However you measure his blood alcohol level and are surprised to find it is 0.
What do you suspect he has?
A. Alcohol withdrawal
B. Delayed alcohol intoxication
C. Methanol intoxication
D. Cerebellar Syndrome
Cerebellar Syndrome: dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia
A 39 year old man, who has been drinking 40 units a week for the past 5 years come to his GP complaining of numbness and tingling in his toes. It has been present for about 4 months. His wife also noted that “he’s been having a bit of trouble in the bedroom recently”.
Which blood test would help you confirm a reason for this man’s symptoms?
A. Hb
B. Blood alcohol level
C. B12 and folate
D. Calcium
B12 and folate: The commonest causes of peripheral neuropathy are diabetes and B12 deficiency.
Tends to occur in a glove and stocking distribution, is usually symmetrical and can also cause impotence and autonomic dysfunction
A 60 year old publican is brought to A&E by a friend who says he’s been more confused over the last few weeks, and has vomited a few times in the last few days. When you see him he seems to intermittently drift off.
A. Acute Alcohol intoxication
B. Delirium tremens
C. Subdural Haemorrhage
D. Alzheimer’s Dementia
Subdural haemorrhage: cerebral atrophy, frequent falls, clotting disorder (liver failure)
A 50 year old Irish man stumbles into A&E mumbling incoherently, not exactly sure where he is. He complains that he is having double vision. When asked he recalls the Prime Minister as being “Bertrand Ebstein”, and tells you that he came here on a moped hired from his friend “Robbie”.
Most likely diagnosis?
A. Acute Alcohol intoxication
B. Delirium tremens
C. Wernicke-Korsakoff’s Syndrome
D. Alzheimer’s Dementia
Wernicke’s Encephalopathy: confusion, ataxia, opthalmoplegia
Tx: IV Pabrinex - thiamine (B1), riboflavin (B2), nicotinamide (B3), pyridoxine (B6) and ascorbic acid (vit C)
Korsakoff’s Syndrome: untreated Wernicke’s progresses to this: anterograde amnesia, confabulation
Alcoholics can get other forms of dementia too (10% of cases)
A 60 year old man is rushed into A&E with a reducing GCS. OE you find a swollen abdomen, yellow sclera, and a sickly sweet smell on his breath.
What is the most likely diagnosis?
A. Acute intoxication
B. DKA
C. Decompensated liver failure
D. Sepsis
Decompensated liver failure: hepatic encephalopathy
Due to ammonia and other waste products crossing BBB.
- Inverted sleep wake cycle
- Lethargy, personality change
- Worsening confusion and LOC
- Signs of liver failure e.g. jaundice, ascites, fetor hepaticas
30 year old male presents with a one week history of SOB and 2 days of coughing up blood. Temp 39 degrees.
A. Bronchiectasis B. Staph aureus pneumonia C. Foreign body D. TB E. Wegener's granulomatosis F. PE G. Oesophageal varices H. Goodpasture's syndrome I. Lung Cancer J. Kaposi's Sarcoma
Staph aureus pneumonia: commonest cause of haemoptysis (~60%)
Other pneumonias that commonly cause haemoptysis: Pseudomonas, influenza
70 year old male with a 40 pack year history sees his GP because he has been coughing up blood in the last 2 weeks.
A. Bronchiectasis B. Staph aureus pneumonia C. Foreign body D. TB E. Wegener's granulomatosis F. PE G. Oesophageal varices H. Goodpasture's syndrome I. Lung Cancer J. Kaposi's Sarcoma
Lung Cancer: elderly smokers - lung cancer until proven otherwise.
Non Small Cell (80%): squamous cell (PTHrp release, treated with radiotherapy), adenocarcinoma (usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking), large cell carcinoma - associated with clubbing. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome.
Small Cell (20%) - more aggressive, treated with chemotherapy and is associated with SIADH and ectopic ACTH.
A 3 year old girl is brought into Paeds A&E because she coughed up some blood on her way home from nursery.
A. Bronchiectasis B. Staph aureus pneumonia C. Foreign body D. TB E. Wegener's granulomatosis F. PE G. Oesophageal varices H. Goodpasture's syndrome I. Lung Cancer J. Kaposi's Sarcoma
Foreign Body: the commonest causes of haemoptysis in young children is a foreign body and infection.
A 50 year old alcoholic is brought in by ambulance. His wife says he has coughed up about 2-3 cups of blood in the last hour. The husband remarks the blood looked like coffee.
A. Bronchiectasis B. Staph aureus pneumonia C. Foreign body D. TB E. Wegener's granulomatosis F. PE G. Oesophageal varices H. Goodpasture's syndrome I. Lung Cancer J. Kaposi's Sarcoma
Oesophageal Varices: dilated veins in the distal oesophagus and/or proximal stomach, caused by portal hypertension often due to chronic liver disease.
A 35 year old Bangladeshi immigrant comes to see her GP with unintentional weight loss of 10kg in 2 months and a 4 week history of coughing up blood.
A. Bronchiectasis B. Staph aureus pneumonia C. Foreign body D. TB E. Wegener's granulomatosis F. PE G. Oesophageal varices H. Goodpasture's syndrome I. Lung Cancer J. Kaposi's Sarcoma
TB: Cough, weight loss/anorexia, fever, night sweats haemoptysis, chest pain.
RFs: HIV infection, history of prior TB, travel to an area where TB is endemic. homelessness, shelter dwelling
Dx: Chest X-ray, AFB smear and culture (sputum) - Ziehl-Neelsen staining, HIV serology
A 5 year old girl comes into the GP surgery with her mother, who says her daughter is still coughing throughout the night despite regularly using her salbutamol inhaler.
A. Use the salbutamol more frequently.
B. Add a leukotriene receptor antagonist
C. Add a minimum dose of inhaled steroids
D. Start with the maximum dose of inhaled steroids and slowly taper down
Add a minimum dose of inhaled steroids
A 3 year old boy has trouble using his steroid inhaler properly as he cannot co-ordinate his breathing with the pump.
A. Education, education, education
B. Try a spacer device
C. Start him on a different steroid inhaler
D. Start him on oral treatment
Try a spacer device
A 15 year old comes into A&E brought in by his mother, with an acute attack.
A. Start IV steroids
B. Ask the mother to keep giving him his inhaler
C. Start oxygen and nebuliser salbutamol via a facemask
D. Do a peak flow and pulse oximetry
Do a peak flow and pulse oximetry
A 21 year old asthmatic has been in A&E for 4 hours with no improvement in her acute attack despite ongoing nebulised therapy. She is starting to become confused, and has poor respiratory effort. You try to listen to her chest but cannot hear anything at all.
A. Panic
B. Get help
C. Start IV steroids
D. Continue nebulisers and hope for improvement
Get help!
Asthma attacks:
Moderate: PEFR >50-70% of expected
Acute Severe: PEFR 33-50% of predicted, RR >25/min, HR>100/min, inability to complete sentences in one breath
Life threatening: PEFR 6kPa
A 28 year old man has a 2 day history of malaise, fever and dyspnoea. He is coughing up reddish-brown sputum and his X-ray shows right lower lobe consolidation.
A. Chlamydia psittaci B. Haemophilis influenzae C. Legionella pneumophilia D. Mycobacterium tuberculosis E. Pneumocystis jiroveci F. Mycoplasma pneumoniae G. Pseudomonas aeruginosa H. Staphylococcus aureus I. Streptococcus pneumoniae J. Klebsiella pneumoniae
Streptococcus pneumoniae: affects all ages, fever, malaise, productive cough with reddish-brown sputum, consolidation on CXR
A 53 year old man is brought to the emergency room following a seizure. His wife said he has been having muscle pains and a dry cough for the past week since they returned from their holiday. His sodium level is 124mmol/L and potassium is 5.4mmol/L
A. Chlamydia psittaci B. Haemophilis influenzae C. Legionella pneumophilia D. Mycobacterium tuberculosis E. Pneumocystis jiroveci F. Mycoplasma pneumoniae G. Pseudomonas aeruginosa H. Staphylococcus aureus I. Streptococcus pneumoniae J. Klebsiella pneumoniae
Legionella pneumophilia: colonises water tanks in AC (hotels, plumbers), dry cough and dyspnoea, low sodium, deranged LFTs
A 42 year old prostitute presents with a 2 month history of a dry cough and progressive dyspnoea. She also complains of night sweats. Her oxygen saturations are 89%. She does not have any other signs or symptoms.
A. Chlamydia psittaci B. Haemophilis influenzae C. Legionella pneumophilia D. Mycobacterium tuberculosis E. Pneumocystis jiroveci F. Mycoplasma pneumoniae G. Pseudomonas aeruginosa H. Staphylococcus aureus I. Streptococcus pneumoniae J. Klebsiella pneumoniae
Pneumocystis jiroveci: Immunosuppressed e.g. HIV, dry cough, dyspnoea, CXR may be normal, BAL: boat shaped organisms using a silver stain.
A 67 year old presents with malaise and a productive cough. She has just recovered from a bout of influenza. Her CXR demonstrates 2 cavities with air-fliud levels.
A. Chlamydia psittaci B. Haemophilis influenzae C. Legionella pneumophilia D. Mycobacterium tuberculosis E. Pneumocystis jiroveci F. Mycoplasma pneumoniae G. Pseudomonas aeruginosa H. Staphylococcus aureus I. Streptococcus pneumoniae J. Klebsiella pneumoniae
Staphylococcus aureus: affects all ages, complicates influenza, IVDU, bilateral caveatting lesions.
A 33 year old presents with a 2 day history of ‘eyes that are really red and painful.’ She finds it too difficult to move her eyes whilst the doctor is testing her cranial nerves. She has elevated serum ACE and improves with corticosteroids.
Which sarcoid complication: A. Anterior uveitis B. Choroidoretinitis C. Facial nerve palsy D. Diabetes Insipidus E. DIabetes Mellitus F. Erythema ab ignae G. Lupus pernio H. Erythema marginatum I. Peripheral Neuropathy J. Erythema nodosum
Anterior uveitis
Sarcoidosis is a chronic granulomatous lung disorder (multinucleate giant cells). More common in young adults, and more severe in Afro-Caribbeans. It is often as symptomatic but respiratory symptoms most commonly are dry cough and SOB.
Dx:
- CXR: bilateral hilar lymphadenopathy (think sarcoidosis, lymphoma, TB)
- Transbronchial biopsy: histology
- Lung function tests: restrictive
- Serum ACE: assessment purposes
Tx: Corticosteroids
Extra pulmonary features:
- Skin: erythema nodosum (shin), Lupus pernio (face)
- Eyes: anterior uveitis (red painful eye)
- Diabetes Insipidus: normal glucose, treated with vasopressin (DDAVP)
A 26 year old man presents to his GP with dyspnoea. On examination, he has a maculopapular violaceous rash over his nose. His CXR reveals bilateral hilar lymphadenopathy.
Which sarcoid complication: A. Anterior uveitis B. Choroidoretinitis C. Facial nerve palsy D. Diabetes Insipidus E. DIabetes Mellitus F. Erythema ab ignae G. Lupus pernio H. Erythema marginatum I. Peripheral Neuropathy J. Erythema nodosum
Lupus pernio
Sarcoidosis is a chronic granulomatous lung disorder (multinucleate giant cells). More common in young adults, and more severe in Afro-Caribbeans. It is often as symptomatic but respiratory symptoms most commonly are dry cough and SOB.
Dx:
- CXR: bilateral hilar lymphadenopathy (think sarcoidosis, lymphoma, TB)
- Transbronchial biopsy: histology
- Lung function tests: restrictive
- Serum ACE: assessment purposes
Tx: Corticosteroids
Extra pulmonary features:
- Skin: erythema nodosum (shin), Lupus pernio (face)
- Eyes: anterior uveitis (red painful eye)
- Diabetes Insipidus: normal glucose, treated with vasopressin (DDAVP)
A 29 year old lady with sarcoidosis is admitted for polyuria and polydipsia. Her blood sodium is 154mmol/L and her fasting plasma glucose is 4.8. Her urine had a very low osmolality.
Which sarcoid complication: A. Anterior uveitis B. Choroidoretinitis C. Facial nerve palsy D. Diabetes Insipidus E. DIabetes Mellitus F. Erythema ab ignae G. Lupus pernio H. Erythema marginatum I. Peripheral Neuropathy J. Erythema nodosum
Diabetes insipidus
Sarcoidosis is a chronic granulomatous lung disorder (multinucleate giant cells). More common in young adults, and more severe in Afro-Caribbeans. It is often as symptomatic but respiratory symptoms most commonly are dry cough and SOB.
Dx:
- CXR: bilateral hilar lymphadenopathy (think sarcoidosis, lymphoma, TB)
- Transbronchial biopsy: histology
- Lung function tests: restrictive
- Serum ACE: assessment purposes
Tx: Corticosteroids
Extra pulmonary features:
- Skin: erythema nodosum (shin), Lupus pernio (face)
- Eyes: anterior uveitis (red painful eye)
- Diabetes Insipidus: normal glucose, treated with vasopressin (DDAVP)
A 33 year old lady presents to her GP with worsening dyspnoea and a large lesion over the anterior surface of her shin. Her CXR shows bilateral hilar lymphadenopathy and lung function tests demonstrate a restrictive defect.
Which sarcoid complication: A. Anterior uveitis B. Choroidoretinitis C. Facial nerve palsy D. Diabetes Insipidus E. DIabetes Mellitus F. Erythema ab ignae G. Lupus pernio H. Erythema marginatum I. Peripheral Neuropathy J. Erythema nodosum
Erythema nodosum
Sarcoidosis is a chronic granulomatous lung disorder (multinucleate giant cells). More common in young adults, and more severe in Afro-Caribbeans. It is often as symptomatic but respiratory symptoms most commonly are dry cough and SOB.
Dx:
- CXR: bilateral hilar lymphadenopathy (think sarcoidosis, lymphoma, TB)
- Transbronchial biopsy: histology
- Lung function tests: restrictive
- Serum ACE: assessment purposes
Tx: Corticosteroids
Extra pulmonary features:
- Skin: erythema nodosum (shin), Lupus pernio (face)
- Eyes: anterior uveitis (red painful eye)
- Diabetes Insipidus: normal glucose, treated with vasopressin (DDAVP)
A 67 year old lady presents to A&E with pyrexia (38.1 degrees) and a productive cough. HR 101, BP 80/60, RR 32. She is alert and orientated in time and space. WCC 21, Urea 8.5, CXR shows consolidation of the right upper lobe.
CURB-65 Score?
A. 6 B. 8 C. 4 D. 0 E. 1
4 CURB-65: - Confusion - Urea > 7 mmol/L - RR > 30/min - BP: systolic
A 72 year old lady presents with a 4 month history of SOB, initially on exertion but now at rest.
PMH: AF, HTN, high cholesterol.
O/E: SpO2 92% (RA), RR 19, apyrexial, fine bibasal inspiratory crackles.
Which of these drugs is most likely to cause the symptoms experienced by the patient?
A. Amlodipine B. Simvastatin C. Aspirin D. Amiodarone E. Alendronate
Amiodarone - pulmonary fibrosis
A 65 year old man presents with a painless wound in his right leg which has been present for 2 months. O/E you notice a 3cm by 4cm leg ulcer covering the medial malleolus. The shallow bed of the ulcer is covered in granulation tissue which is surrounded by sloping edges.
A. Anthrax B. Chancrous ulcer C. Gummatous ulcer D. Arterial ulcer E. Neuropathic ulcer F. Squamous cell carcinoma G. Tuberculous ulcer H. Venous ulcer I. Pyoderma gangrenosum J. Marjolin's ulcer
Venous Ulcer: caused by superficial/deep venous incompetence
Clues: gaiter region, covering medial mallelous, lipodermatosclerosis, brown discolouration (haemosiderin deposition), extensive - can be painless
A 60 year old man with T2DM presents with a large ulcerating lesion over his left toes. The lesion has well demarcated edges. The leg is cool to touch and is hairless and dorsal is pedis and posterior tibial pulses are absent.
A. Anthrax B. Chancrous ulcer C. Gummatous ulcer D. Arterial ulcer E. Neuropathic ulcer F. Squamous cell carcinoma G. Tuberculous ulcer H. Venous ulcer I. Pyoderma gangrenosum J. Marjolin's ulcer
Arterial ulcer: caused by large vessel (atherosclerosis) or small vessel (vasculitis) disease
Clues: often located distally, punched out appearance absent pulses, low ABPI, shiny, hairless skin, arteriopath, smoking, DM, CVD, very PAINFUL
A 66 year old retired Marines officer presents with a large scar from a burn sustained in a war with a painless 3 cm area of irregular ulceration within the region of scarring. It is surrounded by a raised edge and has bloodstained discharge from the base. There is no regional lymphadenopathy.
A. Anthrax B. Chancrous ulcer C. Gummatous ulcer D. Arterial ulcer E. Neuropathic ulcer F. Squamous cell carcinoma G. Tuberculous ulcer H. Venous ulcer I. Pyoderma gangrenosum J. Marjolin's ulcer
Marjolin’s ulcer: eponymous name for a squamous call carcinoma arising in an area of previous inflammation e.g. long standing venous ulcer or 3rd degree burn (clue: war veterans)
Features of a SCC: can be painless, blood stained discharge, raised edge, spread to LN is rare
A 27 year old lady with altered bowel habit, and rectal bleeding presents with a large ulcerating lesion on her left leg with dark red edges.
A. Anthrax B. Chancrous ulcer C. Gummatous ulcer D. Arterial ulcer E. Neuropathic ulcer F. Squamous cell carcinoma G. Tuberculous ulcer H. Venous ulcer I. Pyoderma gangrenosum J. Marjolin's ulcer
Pyoderma gangrenosum: recurring nodulo-pustular ulcers with tender red/blue necrotic edges, purulent.
Associated mainly with IBD, but also AI hepatitis, myelodysplasias and Wegener’s granulomatosis.
A 60 year old obese man presents with ulceration on the sole of his right foot. The ulcer is deep and penetrating but the skin around it appears well perfused.
A. Anthrax B. Chancrous ulcer C. Gummatous ulcer D. Arterial ulcer E. Neuropathic ulcer F. Squamous cell carcinoma G. Tuberculous ulcer H. Venous ulcer I. Pyoderma gangrenosum J. Marjolin's ulcer
Neuropathic ulcer: repetitive trauma with absent/reduced sensation.
Clues: loss of sensation, diabetics, lack of ankle reflexes, weight bearing areas
A 30 year old man presents with a lump in the posterior triangle of the neck which has been enlarging slowly for the last 2 months. He has also felt feverish, itchy and sweaty at night, and has lost 8kg unintentionally.
A. Pharyngeal pouch B. Thyroglossal cyst C. Sternocleidomastoid tumour D Cystic hygroma E. Carotid body tumour F. Branchial cyst G. Lymphoma H. Thyroid goitre I. Salivary duct carcinoma J. Acoustic neuroma
Lymphoma: lethargy, weight loss, painful lymph nodes after alcohol, night sweats, itchiness
A 25 year old presents with a painful swelling which bulges from under the anterior border of the sternocleidomastoid. It is soft, fluctuant but tender on examination. He says that whilst it has been present since he was a child, it only recently started causing him trouble after he suffered from pneumonia.
A. Pharyngeal pouch B. Thyroglossal cyst C. Sternocleidomastoid tumour D Cystic hygroma E. Carotid body tumour F. Branchial cyst G. Lymphoma H. Thyroid goitre I. Salivary duct carcinoma J. Acoustic neuroma
Branchial cyst: remnant of 2nd branchial cleft (present from childhood), smooth, non-tender, fluctuant lump, 2/3 up sternocleidomastoid, may become enlarged and painful after respiratory infection.
FNA: yellow fluid with cholesterol crystals
A 70 year old woman complains of a mass on her right jaw which has been slowly growing for the past 6 months. For the past week she has been unable to move the right side of her face. O/E you notice a hard, irregular lump which extends up behind the angle of the mandible.
A. Pharyngeal pouch B. Thyroglossal cyst C. Sternocleidomastoid tumour D Cystic hygroma E. Carotid body tumour F. Branchial cyst G. Lymphoma H. Thyroid goitre I. Salivary duct carcinoma J. Acoustic neuroma
Salivary duct carcinoma: hard irregular mass, facial nerve involvement.
A 28 year old man presents with a lump in the posterior triangle of the neck. He mentions difficulty in finishing meals and sometimes regurgitates food at night.
A. Pharyngeal pouch B. Thyroglossal cyst C. Sternocleidomastoid tumour D Cystic hygroma E. Carotid body tumour F. Branchial cyst G. Lymphoma H. Thyroid goitre I. Salivary duct carcinoma J. Acoustic neuroma
Pharyngeal pouch: protrusion of pharyngeal wall through Killian’s dehiscence, commonly affecting elderly men, presenting with dysphagia, regurgitation of food, gurgling sensation, halitosis, coughing and aspiration at night, posterior triangle.
A 3 month old baby presents with a lump on the base of his neck, posterior to the sternocleidomastoid. O/E it transilluminates brightly.
A. Pharyngeal pouch B. Thyroglossal cyst C. Sternocleidomastoid tumour D Cystic hygroma E. Carotid body tumour F. Branchial cyst G. Lymphoma H. Thyroid goitre I. Salivary duct carcinoma J. Acoustic neuroma
Cystic Hygroma: congenital collection of lymphatic sacks (babies!), clear fluid (transilluminates), soft, fluctuant, posterior triangle
Elective AAA: select the most likely size that warrants elective repair provided the patient is fit for surgery.
A. Greater than 5.0 cm B. Greater than 5.5 cm C. Less than 5 cm D. Greater than 4.5 cm E. Less than 5.5 cm
Greater than 5.5 cm
Or:
- Smaller aneurysm that is now causing symptoms (back pain)
- Smaller aneurysm that is growing at a rate of > 1 cm/year
AAA’s
A 56 year old homeless man presents to A&E with severe pain in his right leg which started over 6 hours ago. O/E the right leg is pale compared to the left from below the knee to the toes. The right leg is cold, with absent popliteal, posterior tibial and dorsal is pedis pulses. There is no sensation in the right leg and the patient is unable to flex the toes due to fixed flexion deformities. Apyrexial, HR 85.
Which is the most appropriate management option?
A. Percutanous transluminal angioplasty
B. Revascularisation through endarterectomy
C. Revascularisation through bypass grafting
D. Thrombolysis
E. Amputation
Amputation: Acute Limb Ischaemia
- Surgical emergency requiring revascularisation within 4-6 hours to save the limb, mainly due to in situ thromboses or emboli.
6 P’s: Pale, pulseless, painful, perishing cold, paraesthesia, paralysis.
Management options:
- Percutaneous transluminal angioplasty: short stenoses in large arteries
- Surgical bypass: extensive atheromatous disease with good distal run-off e.g. femoral politeal bypass, femoral distal bypass
- Acutely: surgical embolectomy/thrombolysis
- Amputation: Useless limb (e.g. fixed flexion deformity), Dead Limb (extensive necrosis), loss of sensation and paralysis point to gangrene
A 35 year old man presents to the emergency department with severe upper abdominal pain and blood stained vomit. On questioning he admits to a long history of dyspepsia that is worse when he is hungry and at night. Which of the following is the most likely diagnosis?
A. Arteriovenous malformation B. Mallory-Weiss tear C. Gastric Ulcer D. Peutz-Jeghers syndrome E. Duodenal ulcer
Duodenal ulcer: worse when hungry and at night
Gastric ulcer: worse when full
A 79 year old lady is treated for a pneumonia and develops severe diarrhoea and incontinence. Faecal analysis isolates a cytopathic toxin. The microbe involved in anaerobic.
A. Campylobacter jejuni B. Clostridium difficile C. Clostridium perfringens D. Escherichia coli E. Salmonella typhi F. Staphylococcus aureus G. Giardia lamblia H. Streptococcus pyogenes I. Bacillus cereus J. Helicobacter pylori
Clostridium difficile: diarrhoea (can be bloody), pseudomembranous colitis, diagnosed by detection of toxin in stool.
Clues: Abx/hospital associated, produces a cytopathic toxin, gram positive anaerobe
Tx: metronidazole
Anaerobes = clostridium, bacteroides, actinomyces
A 45 year old woman develops diarrhoea and abdominal pain 2 days after eating fried chicken in a restaurant. A gram-stain of the faeces shows gram negative, motile, spiral shaped rods. Faecal culture reveals oxidase positive colonies.
A. Campylobacter jejuni B. Clostridium difficile C. Clostridium perfringens D. Escherichia coli E. Salmonella typhi F. Staphylococcus aureus G. Giardia lamblia H. Streptococcus pyogenes I. Bacillus cereus J. Helicobacter pylori
Campylobacter jejuni: major cause of bloody diarrhoea, gram negative, oxidase positive, 2-6 days after exposure (BBQ)
Salmonella: diarrhoea, fever, abdo pain, normally at least 12 hours later, eggs, meat, poultry, gram negative
Staphylococcus aureus: very quick: 1-6 hours, gram positive clusters
A couple present to their GP with a one-week history of watery diarrhoea, and foul smelling belches after returning from a trip to Moscow. Stool microscopy reveals cysts and trophozoites.
A. Campylobacter jejuni B. Clostridium difficile C. Clostridium perfringens D. Escherichia coli E. Salmonella typhi F. Staphylococcus aureus G. Giardia lamblia H. Streptococcus pyogenes I. Bacillus cereus J. Helicobacter pylori
Giardia lamblia: faeco-oral spread
Clues: travel to eastern europe/Russia, bloating, abdo pain, diarrhoea, foul smelling belches/flatus
Dx: direct fluorescent antibody (gold standard), cysts and trophozoites in the stool.
Tx: Metronidazole
Entamoeba histolytica: faeco-oral spread.
Clues: bloody diarrhoea (ameobic dysentry) - but has a slow onset of action,m liver abscess on USS, ‘flask shaped GI ulcers - RUQ pain
Dx: cysts and trophozoites in the stool
Tx: metronidazole
A 22 year old student presents to A&E with abdominal cramps, vomiting and watery diarrhoea. He has not eaten anything apart from Chinese take away from the night before. Stool microscopy confirms Gram positive bacilli.
A. Campylobacter jejuni B. Clostridium difficile C. Clostridium perfringens D. Escherichia coli E. Salmonella typhi F. Staphylococcus aureus G. Giardia lamblia H. Streptococcus pyogenes I. Bacillus cereus J. Helicobacter pylori
Bacillus cereus: re-heated rice!!!! Very quick 1-6 hours, gram positive rod!
A 31 year old presents with an 8 month history of worsening dysphagia to solids, with occasional regurgitation of undigested food. He claims that dysphagia is not as bad if he eats a small amount of soft food, drinking lots of water with each bite. Barium swallow shows a ‘birds beak’ deformity in the lower oesophagus.
A. Achalasia B. External oesophageal compression C. Oesophageal candidiasis D. Oesophageal carcinoma E. Oesophageal diverticulum F. Oesophageal peptic stricture G. Pharyngeal pouch H. Motor Neurone disease I. Presbyoesophagus J. Systemic Sclerosis
Achalasia: the lower oesophageal sphincter fails to relax due to degeneration of the myenteric plexus.
Symptoms: dysphagia (improves with smaller mouthfuls and with large volumes of liquids), retro-sternal cramps, regurgitation of undigested food.
Ix: Barium swallow - dilated tapering oesophagus (bird beak deformity)
Tx: Surgical (Heller’s cardiomyotomy), endoscopic balloon dilatation, botox, CCBs, nitrates
A 49 year old who has been in hospital with a severe infective exacerbation of his COPD complains of worsening dysphagia and retrosternal discomfort. OGD shows circumferential erosions and ulceration with white linear plaques.
A. Achalasia B. External oesophageal compression C. Oesophageal candidiasis D. Oesophageal carcinoma E. Oesophageal diverticulum F. Oesophageal peptic stricture G. Pharyngeal pouch H. Motor Neurone disease I. Presbyoesophagus J. Systemic Sclerosis
Oesophageal candidiasis: immunosuppression (HIV, steroids)
Intraluminal: foreign objects (children and psych patients), oesophageal inflammation, oesophageal candidiasis
A 91 year old presents to Geriatrics outpatients with a 6 month history of worsening dysphagia to solids and liquids. A barium swallow reveals no intrinsic lesion but a “corkscrew” dysmotility.
A. Achalasia B. External oesophageal compression C. Oesophageal candidiasis D. Oesophageal carcinoma E. Oesophageal diverticulum F. Oesophageal peptic stricture G. Pharyngeal pouch H. Motor Neurone disease I. Presbyoesophagus J. Systemic Sclerosis
Presbyoesophagus: corkscrew dymotility associated with old age
Extra-luminal:
- Intramural: benign/malignant strictures, achalasia, oesophageal web (Plummer-Vinson syndrome), Nutcracker oesophagus (high pressure on manometry with normal peristalsis), presbyoesophagus (corkscrew dysmotility associated with old age).
- Extra-mural: retrosternal goitre, lung cancer, rolling hiatus, pharyngeal pouch
- Systemic: myasthenia gravis, MND, Parkinson’s
A 54 year old Chinese man presents with dysphagia to solids and liquids. A barium swallow confirms a long, irregular stricture several cm long.
A. Achalasia B. External oesophageal compression C. Oesophageal candidiasis D. Oesophageal carcinoma E. Oesophageal diverticulum F. Oesophageal peptic stricture G. Pharyngeal pouch H. Motor Neurone disease I. Presbyoesophagus J. Systemic Sclerosis
Oesophageal peptic stricture
A 62 year old presents with a 3 month history of worsening dysphagia with nasal regurgitation. She has now developed speech problems and limb weakness.
A. Achalasia B. External oesophageal compression C. Oesophageal candidiasis D. Oesophageal carcinoma E. Oesophageal diverticulum F. Oesophageal peptic stricture G. Pharyngeal pouch H. Motor Neurone disease I. Presbyoesophagus J. Systemic Sclerosis
Motor Neuron Disease:
A 25 year old gentleman who was previously well presented with a 1 week history of SOB, fever and a productive cough. O/E there was dullness to percussion and increased tactile vocal fremitus in the right base.
A. Amoxicillin B. Clarithromycin C. Flucloxacillin D. Metronidazole E. Co-trimoxazole F. Cefuroxime G. Gentamicin H. Ciprofloxacin I. Chloramphenicol J. Nitrofurantoin
Amoxicillin: strep pneumonia - penicillin, amoxicillin
A 38 year old prostitute presents with a 1 week history of a dry cough and SOB on exertion. CXR normal.
A. Amoxicillin B. Clarithromycin C. Flucloxacillin D. Metronidazole E. Co-trimoxazole F. Cefuroxime G. Gentamicin H. Ciprofloxacin I. Chloramphenicol J. Nitrofurantoin
Co-trimoxazole: Pneumocystis carinii - immunosuppressed e.g. HIV
Boat-shaped organisms on BAL with a silver stain
A 29 year old business man was visiting Edinburgh on a 3 day business trip. He has not been well for a week with muscle cramps and SOB, he also forgot his wife’s birthday which he never normally does. Sodium 128 mmol/L and potassium 4.6 mmol/L
A. Amoxicillin B. Clarithromycin C. Flucloxacillin D. Metronidazole E. Co-trimoxazole F. Cefuroxime G. Gentamicin H. Ciprofloxacin I. Chloramphenicol J. Nitrofurantoin
Clarithromycin: atypical pneumonia (legionella and mycoplasma - macrolide: erthromycin, clarithromycin)
A 49 year old lady presents with a 1 week history of lower abdominal pain and pain on urination. She complains that she is finding her teaching job increasingly difficult as she has to leave the class and go urinate very often.
A. Amoxicillin B. Clarithromycin C. Flucloxacillin D. Metronidazole E. Co-trimoxazole F. Cefuroxime G. Gentamicin H. Ciprofloxacin I. Chloramphenicol J. Nitrofurantoin
Nitrofurantoin - UTI, NICE guidelines: trimethropim/nitrofurantoin
This serological marker is used to measure immunity following hepatitis B immunisation.
A. AFP B. Alanine aminotransferase C. HepB core antibody cAb D. HepB core antigen cAg E. HepB e antigen eAg F. HepB surface antibody sAb G. HepB surface antigen sAg H. HepB RNA titre
HepB surface antibody - marker of vaccination
This serological marker is the first to indicate acute hepatitis B infection.
A. AFP B. Alanine aminotransferase C. HepB core antibody cAb D. HepB core antigen cAg E. HepB e antigen eAg F. HepB surface antibody sAb G. HepB surface antigen sAg H. HepB RNA titre
HepB surface antigen: can be detected within 4 weeks and is the earliest marker of infection.
If it is still detected 6 months later it indicates chronic infection
This serological marker would mark a chronic hepatitis B infection if still detected 6 months after the original infection.
A. AFP B. Alanine aminotransferase C. HepB core antibody cAb D. HepB core antigen cAg E. HepB e antigen eAg F. HepB surface antibody sAb G. HepB surface antigen sAg H. HepB RNA titre
HepB surface antigen: can be detected within 4 weeks and is the earliest marker of infection.
If it is still detected 6 months later it indicates chronic infection
This serological marker indicates high infectivity in a chronic hepatitis B carrier.
A. AFP B. Alanine aminotransferase C. HepB core antibody cAb D. HepB core antigen cAg E. HepB e antigen eAg F. HepB surface antibody sAb G. HepB surface antigen sAg H. HepB RNA titre
HepB e antigen: indicates high levels of infectivity and requires aggressive treatment.
This serological marker, if high, indicates low infectivity in a chronic hepatitis B carrier.
A. AFP B. Alanine aminotransferase C. HepB core antibody cAb D. HepB core antigen cAg E. HepB e antigen eAg F. HepB surface antibody sAb G. HepB surface antigen sAg H. HepB RNA titre
HepB core antibody: marker of infection seen after 4 weeks.
High titres of HepBcAb and absent HepBeAg indicates low infectivity and disease activity
HepB core antigen is only found in the liver and can’t be detected in the blood. Indicates they were infected at some point: IgM is acute, IgG is chronic
A 30 year old woman presents to A&E with worsening stiffness in her hands, wrists and feet. She mentions that pain is particularly bad in the mornings. O/E there is a palpable spleen. Initial blood tests reveal a low neutrophil count and a raised CRP.
The most likely diagnosis is: A. Felty's syndrome B. Still's Disease C. Caplan's Syndrome D. Churg-Strauss Syndrome E. Kawasaki's Disease
Felty’s syndrome: Triad of RA, splenomegaly and neutropenia
A 30 year old Turkish man presents to A&E with oral ulcers, genital ulcers and painful legs. O/E there are apthous ulcers in the mouth, genital ulceration, erythema nodosum over the shin. He is admitted and skin pathergy test is positive.
The most likely diagnosis is: A. Henoch-Schonlein purpura B. Lyme Disease C. Berger's Disease D. Caplan's Syndrome E. Behcet's Disease
Behcet’s Disease: AI systemic vasculitis. Most common in Middle eastern, Turkish.
Signs and symptoms: oral and genital ulcers, mouth sores, inflammation of the eyes (uveitis), skin rashes (cutaneous lesions) and neuro features (encephalitis, CN lesions, confusion)
Dx: skin pathergy test positive (needle prick leads to papule formation)
Mx: steroids and immunosuppressives
A 42 year old man presents with a 2 month history of recurrent nosebleeds. More recently he started coughing up blood as well. O/E there is a deformity in the bridge of his nose.
Which of the following blood markers is most associated with his condition?
A. pANCA B. cANCA C. ANA D. Anti-Ro E. Anti-La
cANCA: Wegener’s Granulomatosis
Features: Triad of:
- Upper airway disease (nosebleed, saddle shaped nose deformity, rhinitis, sinusitis)
- Respiratory disease (pulmonary nodules, pulmonary haemorrhage), may cause haemoptysis
- Renal disease: glomerulonephritis often with proteinuria/haematuria
Dx: cANCA
Mx: depends on severity, steroids +/- cyclophosphamide (severe disease)
An 85 year old lady presents with acute breathlessness and chest pain. An ECG shows an irregular rhythm and HR 190bpm.
Paroxysmal AF Mobitz type 1 STEMI LBBB Stokes Adams attack Mobitz type 2 Persistent AF Complete Heart Block Wolf Parkinson White Syndrome Fast AF Atrial flutter Ventricular Tachycardia NSTEMI RBBB
Fast AF: no discernible p waves, affects over 1 million people in the UK, irregularly irregular rhythm, chaotic atrial excitation.
Tends to be older patients with palpitations, SOB, fatigue, syncope.
Paroxysmal: usually lasts 7 days, often requires cardioversion
Permanent: no hope of sinus rhythm.
Causes:
- Cardiac: IHD, MV disease, HTN
- Non Cardiac: Infections, thyrotoxicosis, PE, electrolyte depletion
Mx:
- Rate control: Beta blockers
- Rhythm control: Anti-arrhythmics
- Ablation
A 36 year old man comes to your GP and complains of palpitations. HR 150bpm
Paroxysmal AF Mobitz type 1 STEMI LBBB Stokes Adams attack Mobitz type 2 Persistent AF Complete Heart Block Wolf Parkinson White Syndrome Fast AF Atrial flutter Ventricular Tachycardia NSTEMI RBBB
Atrial flutter: narrow complex tachycardia, 250-350bpm, atrial rate often 300 or 150 (with 2:1 block)
ECG: saw toothed appearance - reflects atrial rate
Mx:
- Acute: electrical cardioversion
- Recurrent: catheter ablation
A 56 year old man with a previous MI has a broad complex tachycardia.
Paroxysmal AF Mobitz type 1 STEMI LBBB Stokes Adams attack Mobitz type 2 Persistent AF Complete Heart Block Wolf Parkinson White Syndrome Fast AF Atrial flutter Ventricular Tachycardia NSTEMI RBBB
Ventricular Tachycardia: activation from ventricles, not SAN
RFs: previous MI, inherited syndromes
Medical emergency as VF is on horizon!
A 24 year old man complains of palpitations. His ECG shows evidence of pre-excitation.
Paroxysmal AF Mobitz type 1 STEMI LBBB Stokes Adams attack Mobitz type 2 Persistent AF Complete Heart Block Wolf Parkinson White Syndrome Fast AF Atrial flutter Ventricular Tachycardia NSTEMI RBBB
Wolff-Parkinson White Syndrome: 1-3 per 1000, often benign, accessory pathway (Bundle of Kent)
ECG: delta wave
An 84 year old man has a HR 32 bpm. His ECG shows broad QRS complexes.
Paroxysmal AF Mobitz type 1 STEMI LBBB Stokes Adams attack Mobitz type 2 Persistent AF Complete Heart Block Wolf Parkinson White Syndrome Fast AF Atrial flutter Ventricular Tachycardia NSTEMI RBBB
Complete/3rd degree Heart Block: complete dissociation between atria and ventricles
Pacemaker potentials:
AV - 50bpm
Ventricle - 30bpm
1st degree: fixed prolonged PR interval
Mobitz Type 1: progressive prolonging of PR interval until QRS is dropped, next PR is short then cycle continues (Wenckebach phenomenon)
Mobitz Type 2: Fixed prolonged PR with occasional dropped QRS
3rd degree: no association between p waves and QRS complexes
A 54 year old diabetic presents with breathlessness and central crushing chest pain.
Best investigation: Troponin T Troponin I TTE Electrophysiology study Coronary Angiography ECG Primary percutaneous coronary intervention Exercise ECG TOE Holter monitor BP BNP Stress Echo CT calcium scoring
ECG
A 65 year old man complains of fever and back pain 4 weeks after having a prosthetic valve implanted.
Best investigation: Troponin T Troponin I TTE Electrophysiology study Coronary Angiography ECG Primary percutaneous coronary intervention Exercise ECG TOE Holter monitor BP BNP Stress Echo CT calcium scoring
TOE: Infective endocarditis, DUKES criteria
Suspicion of IE + prosthetic valve or suspicion of complication of virulent organisms or negative TTE but high suspicion = TOE
Otherwise TTE!
TOE has better resolution, but can require LA or sedative.
TTE has a lower sensitivity - if negative disease may still be present.
Both have a high specificity - if positive it is highly likely that disease is present.
A 72 year old man complains that his shoes have become too small for him. He also admits to worsening exertional dyspnoea, he says he’s never had any heart problems.
Best investigation: Troponin T Troponin I TTE Electrophysiology study Coronary Angiography ECG Primary percutaneous coronary intervention Exercise ECG TOE Holter monitor BP BNP Stress Echo CT calcium scoring
BNP - Heart failure: dyspnoea, orthopnoea, PND, ankle oedema
If previous MI - stress echo
No Mi - measure BNP
A 66 year old woman has developed a pan systolic murmur after a recent MI.
Best investigation: Troponin T Troponin I TTE Electrophysiology study Coronary Angiography ECG Primary percutaneous coronary intervention Exercise ECG TOE Holter monitor BP BNP Stress Echo CT calcium scoring
TTE
TOE has better resolution, but can require LA or sedative.
TTE has a lower sensitivity - if negative disease may still be present.
Both have a high specificity - if positive it is highly likely that disease is present.
A 55 year old hyperlipidaemic man complains of central chest pain on exertion that is relieved by rest.
Best investigation: Troponin T Troponin I TTE Electrophysiology study Coronary Angiography ECG Primary percutaneous coronary intervention Exercise ECG TOE Holter monitor BP BNP Stress Echo CT calcium scoring
Coronary angiography: to rule in, for high risk patients, presenting with typical pain
Intermediate likelihood - low risk factors, atypical pain and women = Functional imaging (stress echo, MPS with SPECT, cardiac MR)
Low likelihood - to rule out disease, low risk factors, atypical pain
A 26 year old diabetic female is brought into A&E by LAS. She doesn’t know where she is and is clutching her stomach. You notice her eyes are sunken in.
Management: Lisinopril Subcut Insulin Sulfonylurea Metformin Thiazolidinedione Amlodipine Metoprolol Lucozade Lifestyle advice IV saline IV insulin IM glucagon Exenatide
IV saline - DKA
Characterised by hyperglycaemia, ketoacidosis, ketonuria.
Complete lack of insulin. Increase in glucagon, cortisol, GH, epinephrine. Stimulates hepatic gluconeogenesis, glycogenolysis, lipolysis.
The lack of insulin leads to fatty acid metabolism, leading to an increased ketone production
Presentation: N&V (hydroxybutyrate), sweet smelling breath (acetone), severe dehydration (glycosuria, osmotic diuresis), Ketoacidosis (ketones), confusion (hyperosmolarity, dehydration, acidosis), diffuse abdo pain.
Mx: IV normal saline to correct dehydration, insulin infusion, correct hypokalaemia
A 54 year old diabetic man has a HbA1C of 8.5% 6 weeks after being started on Metformin.
Management: Lisinopril Subcut Insulin Sulfonylurea Metformin Thiazolidinedione Amlodipine Metoprolol Lucozade Lifestyle advice IV saline IV insulin IM glucagon Exenatide
Sulfonylurea
DM Tx: HbA1C > 6.5% 1. Metformin (or sulfonylurea if not overweight e.g. glibenclamide) 2. Metformin + sulfonylurea 3. Add thiazolidinedione (pioglitazone) 4. Insulin, metformin and sulfonylurea
A 65 year old white diabetic man has a BP of 155/85 on 2 visits to your GP surgery.
Management: Lisinopril Subcut Insulin Sulfonylurea Metformin Thiazolidinedione Amlodipine Metoprolol Lucozade Lifestyle advice IV saline IV insulin IM glucagon Exenatide
Amlodipine - CCB
A 67 year old diabetic lady on MAU suddenly becomes aggressive and starts shouting at the nurses for imprisoning her. She calms down and after a few minutes appears to be falling asleep.
Management: Lisinopril Subcut Insulin Sulfonylurea Metformin Thiazolidinedione Amlodipine Metoprolol Lucozade Lifestyle advice IV saline IV insulin IM glucagon Exenatide
IM glucagon
Hypoglycaemia: ABCDEFG!!!
- Neuroglycopenia: fatigue and drowsiness, aggression, dizziness, confusion, LOC
- Headaches
- Nausea
- Palpitation
- Speech difficulty
Mx: If conscious, orientated and able to swallow = Lucozade
Otherwise IV glucose / IM glucagon
A 78 year old lady attempted to commit suicide by overdosing on her prescription medications. After a change of heart she presented to A&E. She is fatigued, bradycardic and can see yellow-green halos.
Treatment of choice: Flumezanil Haemodialysis Naloxone Activated charcoal Protamine sulphate Lorazepam Acetyl-cysteine Dimercaprol Vitamin K Reassure and discharge Atropine Digibind Desferrioxamine Alcohol
Digibind: Digoxin toxicity - affects cardiac ion channels, with the ultimate affect of increasing intracellular calcium. - Increased contractility - Increased vagal tone to heart - AVN block: bradycardia - Enhanced automaticity: arrhythmias (SVTs), tachycardia - Xanthopsia: yellow-green visual halos - Nausea and anorexia Mx: Digibind
A 14 year old girl was brought in by her mother after an intentional paracetamol overdose. She refuses to say how many tablets she’s taken.
Treatment of choice: Flumezanil Haemodialysis Naloxone Activated charcoal Protamine sulphate Lorazepam Acetyl-cysteine Dimercaprol Vitamin K Reassure and discharge Atropine Digibind Desferrioxamine Alcohol
Acetylcysteine: Paracetomol OD is a primary cause of liver failure.
In the first few hours it presents as nausea and vomiting.
Hepatotoxicity occurs 24-48 hours later: hepatic tenderness, jaundice, asterixis, fetor hepaticus, haemorrhage. (If above 150mg/kg, if less than 75mg/kg no hepatotoxicity occurs)
N-acetly cysteine is most effective in first 8 hours.
If under 1 hour since ingestion = activated charcoal, measure levels and use treatment graph
A 16 year old girl is brought in by ambulance after getting drunk and taking her mothers ‘anxiety medication.’ Her mother says the medications name ends in -pam. The girl’s RR is 6 per minute.
Treatment of choice: Flumezanil Haemodialysis Naloxone Activated charcoal Protamine sulphate Lorazepam Acetyl-cysteine Dimercaprol Vitamin K Reassure and discharge Atropine Digibind Desferrioxamine Alcohol
Flumezanil: benzodiapine overdose (lorazepam, diazepam, midazolam) - bind to inhibitory GABAa receptors. A solitary overdose causes sleepiness, but with alcohol causes severe respiratory depression
A 4 year old child is brought into A&E with his 15 year old brother. The 15 year old notes that his younger brother drank a bottle of his mother’s bright green medication. The 4 year old has respiratory depression and pinpoint pupils.
Treatment of choice: Flumezanil Haemodialysis Naloxone Activated charcoal Protamine sulphate Lorazepam Acetyl-cysteine Dimercaprol Vitamin K Reassure and discharge Atropine Digibind Desferrioxamine Alcohol
Naloxone: Opiate intoxication! Bright green liquid - methadone
Causes respiratory depression and pinpoint pupils. Treatment is IV naloxone
A 75 year old man has overdosed on prescription medication. An ABG shows a mixed respiratory alkalosis and metabolic acidosis. As you return from the ABG machine you notice he is having a seizure.
Treatment of choice: Flumezanil Haemodialysis Naloxone Activated charcoal Protamine sulphate Lorazepam Acetyl-cysteine Dimercaprol Vitamin K Reassure and discharge Atropine Digibind Desferrioxamine Alcohol
Haemodialysis: salicyclate poisioning!
Presentation: vominting, dehydration, hyperventilation, tinnitus, vertigo, metabolic acidosis, mixed resp alk and metabolic acidodis.
Mx: Activated charcoal ASAP within first 2 hours. Urinary alkalisation (IV sodium bicarbonate).
Haemodialysis if: renal failure, heart failure or seizures.
Others:
- Organophosphorous insecticides: farmer, salivation, lacrimation, urination, diarrhoea - Tx: Atropine (and pralidoxime if severe)
- Heparin: bleeding. Tx: Protamine
- Warfarin: bleeding. Tx: Vitamin K
- Beta blockers: severe bradycardia/hypotension. Tx: atropine and glucagon
- Carbon monoxide: low sats but normal blood gas, drowsy. Tx: 100% oxygen hyperbaric chamber
- Paraquat: weed killers, oral ulcers, alveolitis, renal failure. Tx: activated charcoal
A 68 year old ex-smoker complains of SOB on exertion which has been getting worse over the past few years. He is frequently wheezy and has a productive cough.
Diagnosis: Asthma CF CAP Idiopathic Pulmonary Fibrosis Pneumoconiosis TB PE Cor pulmonale COPD Pneumothorax Small cell carcinoma Alpha-1 anti-trypsin deficiency Mesothelioma Extrinsic Allergic Alveolitis
COPD: a combination of emphysema and chronic bronchitis. Over 5 million people in the UK have it.
Emphysema: destruction of alveolar airspace leading to a reduction in surface for gas exchange.
Chronic Bronchitis: Productive cough in winter months.
Investigations: post-bronchodilator spirometry
Presentation: smoker/ex-smoker, wheeze, chronic cough, regular sputum production, exertional SOB, frequent winter ‘bronchitis’
Whereas asthma: may or may not smoke, wheeze, chronic non-productive cough, reversible, night time waking with SOB/wheeze, significant diurnal variation, FH atopy
A 55 year old man presents with a 2 month history of fever, cough and weight loss. A Ziehl-Nielsen stain confirms the diagnosis.
Diagnosis: Asthma CF CAP Idiopathic Pulmonary Fibrosis Pneumoconiosis TB PE Cor pulmonale COPD Pneumothorax Small cell carcinoma Alpha-1 anti-trypsin deficiency Mesothelioma Extrinsic Allergic Alveolitis
TB: mycobacterium family, cough for >2 weeks, occasional haemoptysis/chest pain, systemic symptoms (fever, night sweats, anorexia, weight loss), racial profiling.
Ix: CXR (cavitatory nodules), Sputum samples, Culture (lowenstein-jensen medium: 4-6 weeks), microscopy.
Ziehl-Neelsen stain: acid fast bacilli (rods) - most things turn blue due to the acid, whereas the acid fast aren’t affected and remain red.
Tx: Rifampicin, Isoniazid, Pyrazinamide (pyridoxine to prevent peripheral neuropathy), Ethambutol
A 24 year old man has come to your GP surgery for the 3rd time this winter with a mucopurelent cough. He also complains of general SOB, steatorrhoea, and you find his fingers are clubbed.
Diagnosis: Asthma CF CAP Idiopathic Pulmonary Fibrosis Pneumoconiosis TB PE Cor pulmonale COPD Pneumothorax Small cell carcinoma Alpha-1 anti-trypsin deficiency Mesothelioma Extrinsic Allergic Alveolitis
CF: AR, 1 in 22 caucausians are carriers, defective chloride excretion leads to viscous mucus. Predisposing to infections, causing bronchiectasis, steatorrhoea (pancreatic insufficiency), diabetes, infertility.
Brochiectasis: permanent dilatation of bronchioles following recurrent infections due to elastic damage. Clubbing, Kartageners, colliery dyskinesias, infertility, diabetes
You examine a 82 year old retired ship builder with worsening SOB. He has clubbing and on auscultation you hear fine-end inspiratory crackles.
Diagnosis: Asthma CF CAP Idiopathic Pulmonary Fibrosis Pneumoconiosis TB PE Cor pulmonale COPD Pneumothorax Small cell carcinoma Alpha-1 anti-trypsin deficiency Mesothelioma Extrinsic Allergic Alveolitis
Asbestosis: occupational exposure affecting lung parenchyma. Asbestos inhalation causes impaction leading to pulmonary fibrosis, a progressive disorder, manifesting with worsening SOB, finger clubbing, basal end-inspiratory crackles.
No treatment!
In coal workers: pneumoconiosis
Idiopathic pulmonary fibrosis: (cryptogenic fibrosing alveolitis and usual interstitial pneumonia, presenting with worsening SOB, non-productive cough, fine end-inspiratory crackles
Silicosis: silicon dioxide - stone masons, sand blaster, ceramic/pottery workers
A 29 year old farmer presents with worsening cough, SOB and flu-like symptoms which he’s had each winter for the past 3 years.
Diagnosis: Asthma CF CAP Idiopathic Pulmonary Fibrosis Pneumoconiosis TB PE Cor pulmonale COPD Pneumothorax Small cell carcinoma Alpha-1 anti-trypsin deficiency Mesothelioma Extrinsic Allergic Alveolitis
Extrinsic Allergic Alveolitis: hypersensitivity reaction - can be acute (4-6hours - fever, malaise, cough, SOB, chest tightness) or subacute/chronic (insidious onset, SOB, cough, fatigue, weight loss)
Dx: specific radiological features, histology
A 75 year old man complains of SOB and weight loss over a 3 month period, you notice his face is oedematous and flushed.
Diagnosis: SIADH Pancoast Tumour Large cell carcinoma Myasthenia Gravis SVCO PE Malignant mesothelioma Lambert Eaton Syndrome Small cell carcinoma Thymoma Squamous cell carcinoma Brain Metastases Adenocarcinoma Pleural effusion
SVCO: SVC drains head, neck, upper extremities and thorax, tumour can occlude SVC causing flushing of face, oedema of face and arms, dilated veins over arms, neck and chest, morning headaches.
Lung Cancer:
- Small cell carcinoma: small and dangerous
- Non small cell carcinoma: adenocarcinoma (glandular tissue), squamous cell carcinoma (epithelial cells lining airways), large cell carcinoma, large cell neuroendocrine
General Presentation: cough, weight loss, SOB, smoking! haemoptysis, lethargy.
Moderately frequent: bone pain, digital clubbing, fever
Infrequent: pain radiating down arm (Pancoast), SVCO, dysphagia, wheezing, stridor
Metastatic symptoms: brain, bone, liver, lymph nodes
A 68 year old female presents with shooting pain down her right arm and a droopy eyelid, on questioning she admits to weight loss and episodes of haemoptysis.
Diagnosis: SIADH Pancoast Tumour Large cell carcinoma Myasthenia Gravis SVCO PE Malignant mesothelioma Lambert Eaton Syndrome Small cell carcinoma Thymoma Squamous cell carcinoma Brain Metastases Adenocarcinoma Pleural effusion
Pancoast Tumour:
- Brachial plexus invasion C8-T1 leading to wasting of intrinsic muscles of the hands, pain and paraesthesia in arm
- Cervical Sympathetic plexus
- Horner’s syndrome: ptosis, miosis, anhydrosis
