MedEd/ Sofia Based SBAs Flashcards
SBAs based on past questions and SOFIA objectives, with a lot of contributions from MedEd. This is the most useful deck.
A gentleman presents with acute breathlessness and stabbing chest pain. O/E his respiratory rate is 27bpm with good air entry in all fields. His ECG shows sinus tachycardia and right axis deviation.
What is the most likely diagnosis? A. Pneumothorax B. Pneumonia C. COPD D. Pulmonary Embolism E. Sarcoidosis
D. Pulmonary embolism
Right axis deviation can sometimes be seen on the ECG of a patient with a PE: this is because the pressure in the pulmonary artery is increased by the clot, which dilates the right atrium and shifts the heart to the right.
The most common ECG finding with a PE is sinus tachycardia. RBBB may also be found, and is associated with increased mortality.
The ‘classic’ ECG finding for a PE is S1Q3T3, though this isn’t actually all that common (~10% cases), which consists of prominent S-waves in lead I, and Q-waves and inverted T-waves in lead III
A 35 year old lady presents with acute onset SOB, chest pain and one episode of haemoptysis. She has recently noticed a swelling in the left leg. O/E her RR is 28 and HR is 105. You suspect a pulmonary embolism.
What is the most useful diagnostic investigation? A. Chest X-Ray B. CTPA C. D-Dimer D. ECG E. Peak flow
B. CTPA
Although a CTPA is the most useful diagnostic investigation, in a situation where you strongly suspect a PE, you begin anticoagulation first with LMWH and give the patient oxygen. The exception to this is when the patient is haemodynamically unstable, whereupon thrombolysis or emboletomy is indicated. Where CTPA is contra-indicated (pregnancy, contrast allergy) a V/Q scan would be used.
This patient would likely also receive an ECG and CXR, though these will not definitively diagnose a PE.
A 23 year old student presents to A&E with SOB. He says it came on suddenly. O/E his trachea is undisplaced with reduced breath sounds on the left. A chest x-ray confirms a 1cm pneumothorax.
What is the most appropriate management? A. Immediate chest decompression B. Intercostal drain C. Aspiration D. Reassure and discharge E. Low molecular weight heparin
C. Aspiration
Although the patient’s pneumothorax is <2cm, they are experiencing SOB, so aspiration is indicated. If this fails, a chest drain is indicated.
Primary (no underlying cause):
<2cm: discharge and repeat CXR later
>2cm/ SOB: aspiration (if unsuccessful - chest drain)
Secondary (known cause e.g. COPD)
>2cm: aspiration (if unsuccessful - chest drain)
<2cm: chest drain
What signs would you expect on physical examination of someone with pneumonia?
A. Deviated Trachea, ↓ expansion, Dull to percussion
B. Bronchial Breathing, ↓ expansion, ↓ vocal resonance
C. Central Trachea, ↓ expansion, ↑ vocal resonance
D. Dull to Percussion, ↑ expansion, Pyrexia
E. Tachycardia, ↑ expansion, Cyanosis
C. Central Trachea, ↓ expansion, ↑ vocal resonance
Decreased expansion, increased vocal resonance, bronchial breathing in the peripheral lungs, dullness to percussion, pyrexia, and tachycardia are all signs of pneumonia.
A 71 year old Gentleman is brought in by his carer with a 4 day history of a fever and a cough. As you go to examine him he shouts and asks that you leave his bedroom. His RR is 30, BP 103/68. The lab phones you a hour later and let’s you know his urea is 7.8.
Where would you manage this patient? A. Admit and treat B. Treat at home C. Consider ITU D. Refer for palliative care E. Refer to primary care
C. Consider ITU
The decision whether to admit is based on the patient’s CURB65 score.
CURB65 is calculated as such:
C - Confusion (AMTS of 8 or below)
U - Uraemia (7.1mmol or higher)
R - Respiration rate (30 or higher)
B - Blood pressure (systolic <100 or diastolic <60)
65 - Patient age of 65 or over
Each element is allocated 1 point:
Low severity: 1 or less indicates treatment at home and treatment with oral amoxicillin
Moderate: 2 or more indicates hospital admission and treatment with I.V. amoxicillin and clarithromycin
High severity: 3 or more indicates ITU admission and treatment with I.V. co-amoxiclav and clarithromycin
25M presents to A&E with a fever and a cough. He says he has been generally unwell over the last year . O/E he is acutely SOB with a RR of 28. You also note an incidental finding of purple patches on his nose.
What is the most likely causative organism? A. Pseudomonas Aeruginosa B. Strep Pneumoniae C. Pneumocystis Jiroveci D. Mycoplasma Pneumoniae E. Haemophilus Influenza
C. Pneumocystis Jiroveci
The purple patches mentioned are Kaposi’s sarcomas, which are caused by HHV-8 and are classed as AIDS-defining illness. Given that this person has AIDS, they are more susceptible to unusual infections, in this case the cause is Pneumocystis Jiroveci.
A 55 year old man presents with a cough and fever. He usually lives in the USA where he is a plumber, but recently travelled to the UK to visit family. He has an extensive smoking history. His wife has brought him to hospital and comments that he has been coughing a lot recently (though bringing nothing up) and seems confused.
Which test will confirm the most likely diagnosis?
A. Chest x-ray B. Sputum culture C. Bronchoscopy D. Urinary antigen test E. Lung function tests
D. Urinary antigen test
This is a history of Legionella which is endemic to the USA. There is an increased chance of infection for those who are frequently exposed to stagnant water, as the bacteria grow in water, and smoking is also a risk factor.
Hyponatraemia is a feature of certain infections (e.g. Legionella, typhoid) and is helpful in narrowing down infective causes of disease. The test for Legionella is a urinary antigen test.
10F presents to A&E with a fever and a cough and O2 sats: 92%. Her parents don’t seem worried as they are used to bringing her into hospital for treatment for her respiratory condition.
What is the most likely causative organism? A. Pseudomonas Aeruginosa B. Haemophilus Influenzae C. Staph Aureus D. Coronavirus E. Legionella Pneumophilia
A. Pseudomonas Aeruginosa
The history is hinting at a PMHx of cystic fibrosis. Patients with cystic fibrosis are more susceptible to lung infections, and one organism in particular that affects them is Pseudomonas Aeruginosa.
A known IVDU is brought into A&E, he was found unconscious by two friends who were worried he might have overdosed. You notice an abscess in his groin. Temp: 39, HR 120, BP 90/50. You immediately admit him.
What is the most likely causative organism? A. Haemophilus Influenzae B. Staph Aureus C. Coronavirus D. Legionella Pneumophilia E. Pseudomonas Aeruginosa
What would be the best treatment?
B. Staph Aureus
Staphylococcus Aureus is a common pathogen on people’s skin and is harmles sunless the skin is broken. In this case, IVDU has given Staph Aureus a route past the skin and so it has caused an abscess
Flucloxacillin is the standard treatment for a staph infection
Vancomycin is used if MRSA is detected
A 35 year-old male soldier presents with cough, malaise, and low grade fever for 3 months. Mycoplasma pneumoniae infection is diagnosed.
What is the most appropriate treatment? A. Amoxicillin B. Erythromicin C. Rifampicin D. Clalvulanic acid E. Ciprofloxacin
B. Erythromicin
A macrolide (e.g. erythromycin, clarithromycin) is indicated for Mycoplasma pneumoniae infection.
Amoxicillin is commonly used to treat more standard pneumonia.
Rifampicin is part of the therapy for TB.
Clavulanic acid is a beta-lactamase inhibitor that is given to prevent beta-lactam resistance. It is given along with amoxicillin (co-amoxiclav) as part of the treatment for high severity pneumonia.
A 30 year-old female presents with recurrent throbbing headaches. They last several hours, are severe and left-sided, and are preceded by a tingling sensation in her arms.
What is the most likely diagnosis? A. Cluster headache B. Intracranial space-occupying lesion C. Medication overuse D. Migraine E. Tension headache
D. Migraine
The tingling sensation described is an aura, and may appear in histories for both migraine and seizures.
The stereotypical description of a migraine is a unilateral, severe, throbbing headache that forces the patient to go and lie down
Acute treatment is with Sumitriptan, an anti-emetic (e.g. Metoclopromide), and NSAIDs
Long-term the patient will be asked to keep a headache diary, to help discover what triggers migraines. They may also be placed on propranolol or topiramate as first line treatment, or amityrptilline as second line. However medication can cause headaches when overused.
A 45 year-old male has been experiencing very painful headaches behind the eye that make his eyes water for a month. They occur 4 times a week, and he remembers he had a similar string of episodes 4 months ago.
What is the most likely diagnosis? A. Cluster headache B. Intracranial space-occupying lesion C. Migraine D. Subarachnoid haemorrhage E. Meningitis
A. Cluster headache
Cluster headaches are very painful, generally unilateral headaches which will stereotypically occur behind the eye and make it water. They occur in clusters (hence the name) which is hinted at in this history - the string of episodes 4 months ago. They will also usually occur at the same time of day consistently.
Treatment acutely is 12-15L (up to 100%) oxygen through a non-rebreathable mask and subcutaneous Sumitriptan. Verapamil is used to prevent episodes.
A 27 year-old woman presents with nausea and headache for a week. Both are worse in the morning and improve throughout the day. She has noticed fatigue and irritability over the last few weeks, and her period is late.
What is the most likely diagnosis? A. Excessive exercise. B. Migraine C. Pituitary tumour D. Pregnancy associated tension headache E. Trigeminal neuralgia
C. Pituitary tumour
In this case the tumour has grown large enough to cause raised intra-cranial pressure (ICP). Raised ICP causes headache and nausea that are worse when lying down (hence worse after a night of lying down), bending over, or coughing.
Raised ICP can also cause personality and mood changes, and focal neurology.
Papilloedema (blurred edge of the optic disc) can be seen on fundoscopy in those with raised ICP
A 19 year-old woman presents to A&E with severe headache. She has never felt pain like it, and is sensitive to light. She also has a stiff neck. She has no significant medical history, and her only family medical history is that her mother had polycystic kidney disease.
What is the most likely diagnosis? A. Acute glaucoma B. Meningitis C. Migraine D. Subarachnoid haemorrhage E. Trigeminal neuralgia
D. Subarachnoid haemorrhage
Very severe, spontaneous headaches should prompt thoughts of a SAH, especially if the onset is sudden - it will often be described as ‘thunderclap’ or ‘like being hit in the head with a baseball bat’.
The sensitivity to light (photophobia) and stiff neck are signs of meningism - irritation of the meninges - which may occur in SAH.
Polycystic kidney disease is an autosomal dominant condition that increases the risk of SAH.
A 25 year-old is brought into A&E with loss of consciousness. He was playing rugby and sustained a hit to the temple. After a minute he was able to continue the game and seemed fine, but collapsed an hour later after complaining of worsening headache. His GCS was 12 in the ambulance, and is now 10.
What is the most likely diagnosis? A. Extradural haemorrhage B. Intraventricular haemorrhage C. Meningitis D. Subarachnoid haemorrhage E. Subdural haemorrhage
A. Extradural haemorrhage
The temple is the site of the pterion - a weak point where the frontal, parietal, temporal, and greater wing of the sphenoid bones meet. The pterion is vulnerable to fracture, and when it fractures there is a risk that the middle meningeal artery (which runs underneath the pterion) will rupture.
Classically with an extradural haemorrhage there will be a ‘lucid interval’ where the patient exhibits no symptoms, followed by headache and rapid deterioration of GCS.
A 20 year-old student is brought into A&E by her friend with nausea, vomiting, confusion, and a rash. Upon questioning the friend, you discover the patient felt ill for the past few days, spent all their time in their room, and complained of a stiff neck. When their friend found them, they were twitching and jerking on the ground. Blood cultures have been taken, and the patient’s GCS is calculated to be 10.
What is the most appropriate next step in their management? A. CT Head B. Lumbar puncture C. I.V. Benzylpenicillin D. 500ml I.V. saline E. Metoclopromide F. Fundoscopy
C. I.V. Benzylpenicillin
A CT head is used to check for raised ICP in meningitis, and so in this case would be of no use, as the decreased GCS and seizure indicate raised ICP. This makes an LP dangerous as it could cause a tonsilar herniation which would compress the medulla oblongata and cause respiratory distress.
There are 4 signs that it is unsafe to perform an LP without prior neurological imaging: papilloedema, GCS 12 or less, continuous or uncontrollable seizures, focal neurology.
Other LP contraindications include: rapidly evolving sepsis, anticoagulant therapy/ thrombocytopenia, infection at the LP site, and cardiorespiratory compromise.
When meningitis is suspected, an LP and blood should be taken, and I.V. or I.M. antibiotics should be started before the results are back. NICE guidelines recommend an immediate parenteral dose of benzylpenicillin, though it’s worth noting that a UK Joint Specialist Societies group recommended ceftriaxone or cefotaxime as first line (follow the below link to see, but use NICE for exams).
https://www.britishinfection.org/files/5614/5674/2938/McGill_meningitis_guidelines_Final_published_proof.pdf
A 78 year-old male presents with right-sided headache that is worse when he eats. The pain radiates into his shoulders, and has been worsening over the past week. His scalp is tender O/E especially at the temple.
What is the most appropriate next step in his management? A. Measure ESR B. Start high dose oral prednisolone C. Temporal artery biopsy D. Give opiates E. Measure CRP F. Give paracetamol
B. Start high dose oral prednisolone
In this case the history suggests temporal arteritis. Temporal arteritis can cause blindness if not treated, so the best course of action is to start high dose steroids straight away. ESR and CRP can be measured to assess how well the disease is being managed by steroids, and temporal artery biopsy is the gold standard to confirm diagnosis.
Temporal arteritis can be accompanied by pain and stiffness in the pelvic and shoulder girdles
A 65 year-old man with a PMHx of MS presents with sudden bursts of pain. The pain is often triggered by shaving, is severe, and disappears quickly afterwards.
What is the most likely diagnosis? A. Meningitis B. Migraine C. Temporal arteritis D. Tension headache E. Trigeminal neuralgia
E. Trigeminal neuralgia
Trigeminal neuralgia is characterised by sudden and intense shooting pain within the sensory distribution of the trigeminal nerve. The pain is typically triggered by touch (e.g. shaving) and can idiopathic, or can be caused by trigeminal nerve compression, shingles (post-herpetic neuralgia), or MS.
A 70 year old man is brought in by his daughter to the GP. Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behaviour has changed lately and tends to exaggerate some of his stories.
What is the most appropriate next step in his management? A. MRI scan B. Routine CT scan C. Sumitriptan + NSAIDs D. Urgent CT scan E. Watchful waiting
D. Urgent CT scan
The behavioural changes and implied memory issues suggest dementia. Cerebral atrophy is a feature of dementia, and causes stretching of the vessels in the subdural space as the brain shrinks, increasing the chance of venous rupture and subsequent subdural haemorrhage. Combined with the history of falls, this patient is at high risk of subdural haemorrhage.
A 26 year old man presents with weakness and paraesthesia that started in his hands and feet a week ago. Since then his arms and legs have become increasingly weak. Reflexes are diminished bilaterally and equally, as is power. He can recall no significant PMHx bar some diarrhoea two weeks ago.
Given the diagnosis, what is it most important to monitor in this patient? A. CRP B. Forced vital capacity C. ESR D. RBC E. Peak flow F. Nerve conduction speed
B. Forced vital capacity
This history is indicative of Guillain-Barre syndrome, which is characterised by an ascending neuropathy after gastrointestinal infection (typically, but not exclusively, with Campylobacter jejuni). This can affect the respiratory muscles causing respiratory failure in roughly 30% of patients. To monitor respiratory function, regular FVC tests are conducted.
A 40 year-old homeless man is admitted to A&E after being found in a state of confusion. You cannot smell alcohol on his breath, but his records show a previous admission for delirium tremens and treatment for alcohol withdrawal. He seems unsteady on his feet and has trouble following your finger with his eyes. He also has diminished sensation to soft touch in his peripheries, some motor weakness in his legs, and up-going plantar responses. He seems disorientated, though as far as you can tell his memory is intact.
What is the most likely cause of his symptoms? A. Korsakoff's syndrome B. Vitamin K + D deficiency C. Vitamin B deficiency D. Stroke E. Anton-Babinski syndrome F. Parkinson's disease G. Supranuclear palsy
C. Vitamin B deficiency
The alcoholism in this patient’s history should prompt thoughts about both alcoholic damage and malnutrition, as alcohol impairs liver function and GI absorption. In addition, alcoholics often have poor diet. In this case the patient has presented with symptoms of two vitamin deficiencies. The triad of opthalmoplegia (paralysis of the eye muscles), gait ataxia (unsteady on his feet), and confusion suggest Wernicke’s encephalopathy (in reality it is rare for all thee symptoms to be present together) which is caused by a B1 (thiamine) deficiency.
The diminished sensation to soft touch, and up-going plantar responses are features of subacute spinal cord degeneration, which is a consequence of B12 deficiency. Demyelination of the dorsal columns causes the impairment of soft touch sensation, and demyelination of the lateral corticospinal tracts causes the weakness and up-going plantar response.
A 50 year old man visits his GP complaining of weakness in his right arm. He reports the weakness has gradually developed over the last 2 months. On inspection, the GP notices wasting of his tongue and hyperreflexia. His right arm is spastic, and you can see fasciculations.
What is the most likely diagnosis? A. Stroke B. Multiple Sclerosis C. Parkinson’s disease D. Motor Neuron Disease E. Carpel Tunnel Syndrome F. Herniated disc
D. Motor Neuron Disease
The combination of lower (fasciculations, wasting) and upper (rigidity, hyperreflexia) indicates MND, as this is the only option with the potential to affect upper and lower motor neurons.
Spasticity vs. rigidity
Spasticity is characteristic of upper motor neuron lesions (stroke, spinal cord damage, space-occupying lesion, MND) and is often described as clasp-knife rigidity. This is because tone at the start of a movement will be greatest (as when unfolding a penknife) and will then suddenly decrease through the rest of the movement. Spasticity is also velocity-dependent, meaning the faster you attempt to move a joint, the greater the resistance will be.
Rigidity is an extrapyramidal sign generally seen more in Parkinson’s disease, and is divided into lead-pipe rigidity, and cog-wheel rigidity. Lead-pipe rigidity is consistent rigidity throughout the whole movement of a joint. Cog-wheel rigidity is rigidity superimposed onto a tremor, which causes intermittent rigidity throughout a movement, like the cogs of a gear catching as it turns.
A 70 year-old man is brought in to see the GP by his daughter because he has fallen three times in the last week. She is also worried about his memory and says his mood has been low. Throughout the consultation the man seems expressionless, and his arm moves slowly when he goes to shake your hand.
What is the most likely diagnosis? A. Lewy body dementia B. Stroke C. Korsakoff's syndrome D. Parkinson's disease E. Depression F. Hypothyroidism G. Space-occupying cerebral lesion H. Myasthenia gravis
D. Parkinson’s disease
Parkinson’s disease is defined by a triad of: resting pill-rolling tremor (4-6Hz), bradykinesia, and rigidity. Postural instability is also considered to be a key feature, and causes the patient to adopt a stooped posture with a shuffling gait (arm swing will also be absent).
Bradykinesia will generally first be noticed as difficulty with fine motor tasks - combing hair, doing up shirt buttons, tying shoe laces
The postural instability may worsen into gait freezing (short periods of time where the patients are unable to initiate movement while walking) or festination (where a combination of stooped posture and shuffling gait leads to increasingly rapid short steps and ends in a fall)
Parkinson’s is caused by loss of dopaminergic neurons in the substantia nigra, which is part of the basal ganglia. The basal ganglia has a key role in modifying motor output, and this dysfunction is responsible for Parkinson’s symptoms.
There are 5M's of Parkinson's disease to remember (apart from the four classic signs): Micrographia Monotonous speech Mask-like face Misery - depression Memory - dementia
It is also worth mentioning that one of the earliest signs of Parkinson’s is loss of smell sensation.
A 55 year old gentleman is accompanied to the GP by his daughter. It transpires that he has started swearing at people in the street and flirting with all the women he meets. He is able to chat to you about current events and his favourite sport team’s latest match. What is the most likely diagnosis?
A. Pick’s disease B. Lewy body dementia C. Vascular dementia D. Alzheimer’s dementia E. Wernicke-Korsakoff syndrome F. Stroke
A. Pick’s disease
Pick’s disease is the most common form of fronto-temporal dementia. The frontal lobe is responsible for inhibition, so antisocial and unrestrained behaviour is indicative of frontal lobe disease.
Also contained within the frontal lobe is Broca’s area (normally on the left) which is responsible for speech production, hence Pick’s disease can cause non-fluent aphasia (though it has not done in this case).
Semantic dementia may also occur - this is loss of semantic memory (memory of facts, rather than memory of specific episodes of time) that will often manifest as loss of memory of word meanings.
Loss of planning ability and deficiencies in working memory may also present with Pick’s disease, as they are functions of the frontal lobe.
A 70 year-old man is brought in by his wife who has noticed a recent sharp decline in his mental status and memory. He seems confused, and on examination has weakness in his left leg, and appears to have some trouble swallowing. He has previously has three TIAs, and thinks the weakness in his leg may have started after the last one.
What is the most likely diagnosis? A. Malignancy B. Alzheimer's disease C. Stroke D. Polymyalgia Rheumatica E. Vascular dementia F. Myasthenia Gravis G. Multiple sclerosis
E. Vascular dementia
Vascular dementia is cognitive decline due to infarction. Typically a patient will present with cognitive decline, and some focal neurology (leg weakness, dysphagia) on a background of ischaemic disease (CVA, TIA, MI). Vascular dementia causes deterioration in a step-wise fashion, as the trigger for each deterioration is a new infarct.
A 68 year-old man presents with a decline in his cognitive abilities. He is brought in by his son because the previous day he began talking to someone who wasn’t there. The son states that his father has seemed “mentally slower” than usual, and that his memory is worse than it was. On further questioning the son states that his father has been struggling to care for himself for the past 6 months, that he has fallen a few times, and that he has trouble dressing himself as he finds his shirt buttons to be fiddly. The patient’s wife has also mentioned to the son that the father has become very restless during the night and moves about a lot in his sleep.
What is the most likely diagnosis? A. Parkinson's disease B. Alzheimer's disease C. Lewy body dementia D. Supranuclear palsy E. Subdural bleed F. Multiple sclerosis G. Cerebellar stroke
C. Lewy body dementia
The essential feature of LBD is dementia: the characteristic memory issues that often accompany dementia may well not appear till later on, but visuoperceptual defects, attention deficits, and executive dysfunction may all be early and prominent signs.
There are three other core features:
Visual hallucinations (typically vivid and detailed)
REM sleep behaviour disorder (loss of muscle paralysis during REM sleep - the patient can be seen to act out their dreams)
Parkinsonism (bradykinesia, tremor, rigidity)
A 55 year-old known alcoholic is brought into A&E after his wife noticed irregularities in his memory. As you are interviewing the wife, the patient begins to talk about how they were married in the snow, but the wife then states they had a summer wedding on a nice day. You notice that it is snowing outside as this conversation takes place. O/E the patient seems a little unsteady on his feet, and has a nystagmus in his left eye.
What is the most likely diagnosis? A. Cerebellar stroke B. Lateral medullary syndrome C. Subdural bleed D. 6th nerve palsy E. Toxoplasmosis F. Wernicke's-Korsakoff's syndrome G. Hepatic encephalopathy
F. Wernicke’s-Korsakoff’s syndrome
The ataxia and nystagmus are both suggestive of Wernicke’s encephalopathy. The memory problems are indicative of Korsakoff’s syndrome. Both syndromes are caused by thiamine deficiency. It has been previously sugested that Korsakoff’s syndrome is due to direct alcoholic brain damage, but this is probably incorrect as it has been observed in malnutritioned patients with anorexia nervosa, or who are post-bariatric surgery.
That said, both Wernicke’s and Korsakoff’s are usually caused by alcoholism, as alcohol impairs the absorption, liver storage, and conversion of thiamine to its active form.
Wernicke’s tends to occur before Korsakoff’s, and is reversible with thiamine supplements. By the time Korsakoff’s manifests, the damage to the thalamus and mammillary bodies is generally irreversible.
The memory issue described here is confabulation: when the damage to the thalamus and mammillary bodies becomes extreme, the patient will start to become incapable of recalling old memories or making new ones. Instead the patient will confabulate: the brain will create false memories based on their environment (hence the snowy wedding), but they will believe these memories to be true.
A 40 year old man starts to make random jerky movements at points throughout the day. Worried about this, he visits his GP. Upon questioning, he informs the GP that his father died in his 40s, but he was too young to remember why, although he did have similar symptoms.
What test should be arranged? A. FBC B. Karyotyping C. Whole genome sequencing D. CAG repeat testing E. MRI head F. CT head
D. CAG repeat testing
The family history of early death, together with the choreiform (dance-like) movements points to Huntingdon’s disease. Huntingdon’s disease is an autosomal dominant condition in which the number of CAG repeats in the Huntingtin gene (4p16.3) increases, causing a malformed protein.
The number of CAG repeats in an individuals Huntingdin gene determines whether they will develop the disease:
35-39 repeats, and they might develop the disease
40+ repeats, and they definitely will
If they have between 29 and 34 repeats, they will not develop symptoms, but their children would be at risk
28 or below is a normal result
A 28 year old Norwegian woman presents to A&E after she was unable to fell the hot water on her left leg whilst taking a bath. CSF analysis demonstrated oligoclonal bands that were unmatched with the serum.
Which of the following would most likely confirm a diagnosis of Multiple Sclerosis?
A. Multiple lesions on MRI that all enhanced with gadolinium
B. The patient’s symptoms reoccur 1 year later
C. The patient develops blurry vision in one eye a year later
D. The patient reports blurry vision currently
E. 1 year follow up finds oligoclonal bands matched with the serum
C. The patient develops blurry vision in one eye a year later
The most common MS symptoms are: Optic neuritis (hence fundoscopy is a useful exam in MS) Sensory disturbance Motor weakness Fatigue
The key points when diagnosing MS are:
To have two episodes of CNS dysfunction separated by time
To have two CNS lesions separated by space
There must be no alternative diagnosis
A gadolinium MRI is useful to determine how old brain lesions are, because gadolinium can only enter parts of the brain that are inflamed - as this makes the blood-brain barrier leaky. The inflammation after an acute attack of MS lasts between 2-6 weeks, hence any lesion that lights up with gadolinium contrast is at most 6 weeks old.
Oligoclonal bands are formed when IgG is produced against myelin (as MS is an autoimmune disease). If they are found only in the CSF and don’t match any in the serum, then they have a CNS origin. If they match the serum oligoclonal bands, they could be from infection outside the CNS.
A 26 y/o male returns from holiday in India. He has had diarrhoea after eating at a seafood restaurant on his last night. He is feverish and nauseous. You notice that the whites of his eyes are yellow.
Which infection is he most likely to have? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
A. Hepatitis A
Hepatitis A (along with E) is a virus transmitted via the faecal-oral route (think of fAEcal) which causes an acute infection with signs of liver disease, but is ultimately self-resolving. It is particularly associated with eating seafood abroad where there is a risk of the seafood coming from water contaminated with sewage.
A 64 y/o male with thalassaemia is investigated under the two-week wait for jaundice and weight loss. His blood tests show a raised αFP.
Which chronic infection is he most likely to have? A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
C. Hepatitis C
Hepatitis C is mostly spread through blood, and causes a chronic infection (acute symptomatic infections only occur in 15% of cases). Though hepatitis B can definitely also cause a chronic infection, this only occurs in 5% of infected adults. Though more likely to cause chronic infection, hepatitis C is very reliably curable, whereas hepatitis B is not.
C for cancer, C for chronic, C for curable Alpha fetoprotein (αFP) is a marker of liver and testicular cancer
A 32 y/o male returns from holiday in Thailand, feeling ‘under the weather’ with RUQ pain, fevers and nausea. He is jaundiced. He reveals he has used IV drugs and had unprotected sex with a stranger while on holiday.
Which test is most likely to give the correct diagnosis? A. Liver function tests B. HIV serology C. Hepatitis B serology D. Hepatitis C PCR E. CXR
C. Hepatitis B serology
B is also spread through blood and sex, but is more likely to cause acute symptomatic infection, such as that described here.
Which hepatitis virus requires another virus to be present for successful infection?
A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E
D. Hepatitis D
Hepatitis D needs Hepatitis B surface antigens to be expressed on liver cells in order to enter the cell.
To remember this dependence: two D’s on top of each other look like a B.
A 16 y/o confused boy is brought to A&E by police after being found wandering the streets. He is disorientated and unable to give a clear history. You notice golden-brown rings round his irises.
What is he likely to have? A. Alcohol intoxication B. Wilson’s disease C. Opiate overdose D. Haemochromatosis E. Hypoglycaemia
B. Wilson’s disease
Wilson’s disease is an autosomal recessive fault in copper transporters in the biliary tree (copper is usually excreted in the bile) which leads to accumulation in the liver and deposition in the basal ganglia (neuro symptoms) and the eyes (Kaiser-Fleischer rings).
A 43 y/o man with T1DM visits the GP for his regular HbA1c reading. You comment on his tanned complexion but he insists he hasn’t been aboard recently. Iron studies are requested.
Which of the following results would fit with your suspected diagnosis?
A. High serum iron, high ferritin, high transferrin, high TIBC
B. High serum iron, low ferritin, low transferrin, high TIBC
C. Low serum iron, low ferritin, high transferrin, high TIBC
D. High serum iron, high ferritin, low transferrin, low TIBC
E. High serum iron, high ferritin, high transferrin, low TIBC
D. High serum iron, high ferritin, low transferrin, low TIBC
This is a description of hereditary haemochromatosis - an autosomal recessive condition resulting in an inability to control iron intake. Since the body has no mechanism for disposing of iron once it has been absorbed through the gut, iron accumulates and deposits causing multiple organ dysfunction and failure.
This patient requires a HbA1c reading because they are diabetic, possibly from iron deposition in the pancreas. The tanned complexion is a result of iron deposition in the skin.
Since iron uptake is unregulated, serum iron will be high.
Ferritin will be high, as it increases to deal with increased serum iron
Transferrin will be low because transferrin corresponds to iron demand, and demand is low
TIBC is the measure of the blood’s ability to bind iron with transferrin - since iron is in excess transferrin will be saturated, and the body’s ability to bind any more iron will be low
A 41 y/o obese female presents with a history of colicky, right sided abdominal pain. She states the pain is worse after eating fish and chips and Indian takeaways. On examination her abdomen is soft and non-tender.
Which is the best investigation to confirm her diagnosis? A. Abdominal X-ray B. ERCP C. Liver biopsy D. USS of biliary tree E. CT-KUB
D. USS of biliary tree
This history is suggestive of gallstones given that the pain is colicky, and worse after fatty meals. In addition, the patient has three of the five f’s of gallstones:
Fair (caucasian)
Fertile (children)
Female
Fat (BMI >30)
Forty/ familial (generally risk increases at age 40 or above, but can occur in younger patients with a family history - hence familial)
A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign.
What is the most likely diagnosis? A. Biliary colic B. Ascending cholangitis C. Acute cholecystitis D. Primary biliary cirrhosis E. Cholangiocarcinoma
C. Acute cholecystitis
The shoulder pain is called Boas’ sign and, along with Murphy’s sign, is indicative of cholecystitis. The presentation is very similar to ascending cholangitis, but lacks the jaundice and rigors (though rigors are not strictly necessary for diagnosis, they will often be in SBAs to nudge you in the right direction).
Murphy’s sign is pain on inspiration when an examiner places a hand in the RUQ just below the costal margin.
A 35 y/o man presents with a two week history of jaundice and RUQ pain. He is taking mesalazine for a “bowel condition”.
What is the most likely cause of his jaundice? A. Autoimmune hepatitis B. Haemochromatosis C. Primary sclerosing cholangitis D. Primary biliary cirrhosis E. Drug side effect
C. Primary sclerosing cholangitis
The bowel condition being hinted at is most likely ulcerative colitis, which is heavily associated with primary sclerosing cholangitis (75% patients with PSC also have IBD, usually UC). Primary sclerosing cholangitis is most common in men between 20-40.
PSC is strongly associated with perinuclear anti-neutrophil cytoplasmic antibodies (pANCA)
A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of alternating hot and cold sensation causing her to shiver. On examination she displays RUQ tenderness and appears jaundiced.
What is the most likely diagnosis? A. Biliary colic B. Ascending cholangitis C. Acute cholecystitis D. Primary biliary cirrhosis E. Cholangiocarcinoma
B. Ascending cholangitis
It is caused by obstruction of the bile duct (tumour, gallstone, stricture etc.) which allows bacteria from the duodenum to travel up through the ampulla of Vater into the common bile duct.
Ascending cholangitis is defined by Charcot’s triad:
Jaundice
Fever (with or without rigors)
RUQ pain
As it progresses, Reynold’s pentad may be seen:
Charcot’s triad, but with hypotension and confusion (sepsis)
Management centers initially around treatment of the sepsis: Administer oxygen Administer I.V. antibiotics Administer I.V. saline Take blood cultures Take serial lactate measurements Monitor urine output
Afterwards the original cause is addressed with either cholecystectomy or ERCP
A 60 year-old man presents with jaundice. He claims to be generally well and has recently started a new exercise program to lose weight, which has worked. He has been feeling a little tired but he attributes this to his strenuous new routine. He previously smoked and drank heavily, ever since he was a young man, but has successfully gone cold turkey on both.
What is the most likely diagnosis? A. Gilbert's syndrome B. Carcinoma of the head of the pancreas C. Hepatic cirrhosis D. Hepatocellular carcinoma E. Gallstones F. Small cell lung carcinoma with metastases
B. Carcinoma of the head of the pancreas
Painless jaundice combined with weight loss and a prominent alcohol history should make you consider pancreatic cancer. The jaundice is caused by the tumour enlarging to the point where it obstructs the common bile duct, causing post-hepatic jaundice.
The other cancer options would probably cause pain, as would gallstones, and cirrhosis would cause a whole host of signs not reported in this patient.
Gilbert’s syndrome is an isolated rise in bilirubin with what is otherwise a perfectly functional liver, and so is not concerning.
A 60 year old obese woman presents to her GP with a
lesion on her breast. The lesion is red, crusted, around her right nipple.
Which is the most likely diagnosis? A. Breast cyst B. Breast abscess C. Paget’s disease of the breast D. Fibroadenoma E. Fibrocystic disease
C. Paget’s disease of the breast
Paget’s disease of the breast is a stage 1 in situ carcinoma that is often mistaken for eczema or some other skin complaint.
22 year old woman presents to clinic with a three-month history of a single lump in her right breast. Examination reveals a mobile, firm, smooth and non-tender lump of 2cm in the lower outer quadrant that is not attached to the overlying skin. No axillary lymph nodes are palpable.
Which is the most likely diagnosis? A. Acute mastits B. Breast abscess C. Breast cyst D. Fibroadenoma E. Periductal mastitis
D. Fibroadenoma
Fibroadenomas are usually found incidentally and are completely harmless. They are common, accounting for ~70% of all breast masses. They can be differentiated from fibrocystic disease because they don’t tend to fluctuate so much with the menstrual cycle.
A 21 year old woman presents to her GP with pain in her
right breast. She has just given birth to her first child. On
examination, right breast appears swollen, red and there is tenderness on palpation. You do not suspect there are any abscesses present.
Which is the most appropriate management plan? A. Antibiotics B. Refer to surgeon for incision and drainage C. Refer to breast feeding support group and prescribe analgesia D. Watch and wait E. Confirm diagnosis with USS
C. Refer to breast feeding support group and prescribe
analgesia
Mastitis is common when women begin to breast feed, and the best option is to give analgesia and encourage the patient to continue breast feeding. Antibiotics can be given in more serious cases.
Breast abscesses are similar, but gnerally require fine needle aspiration and surgical drainage.
Risk factors for developing breast cancer include:
A. Having only one child B. Early menarche C. Early menopause D. Anaemia E. HIV/AIDS
B. Early menarche
Many of the risk factors for breast cancer center around increased exposure to oestrogen. Someone who begins menstruating earlier than normal will have a longer than average exposure to oestrogen.
Early menopause decreases risk of breast cancer, as it decreases the length of time a woman is exposed to oestrogen for.
Nullparity is a risk factor because pregnancy induces changes in breast tissue that persist after childbirth, and make the breast tissue less susceptible to carcinoma
Anaemia and HIV both have no particular association with risk of developing breast cancer
Describe the A FROGMAN risk factors for breast cancer
These just seemed quite useful to learn
A - age F - family history R - radiation O - OCP and obesity G - genetics (e.g. known BRCA mutation) M - menarche (early) or menopause (late) A - alcohol N - nullparity
A 56 year old woman presents to her GP after noticing abreast lump 3 weeks ago. On examination, the lump is 3 cm in diameter, firm and tethered to the skin and immobile. There are no overlying skin changes.
What is the next most appropriate investigation? A. Total mastectomy B. Urgent mammogram C. Urgent USS D. FNAC E. Core biopsy
B. Urgent mammogram
The patient has presented with a lump that is suggestive of breast cancer (firm and immobile) so the next step (after taking a history) is imaging. Since the patient is over 35, a mammogram is required
A 22 year old medical student presents to her GP
complaining of ‘lumpiness’ in her breasts and nipple
discharge for 2 weeks. She is concerned as her mother,
who had breast cancer, had the same symptoms before she was diagnosed. What is the next most appropriate
investigation?
A. Refer for urgent mammogram B. Refer for urgent USS C. Blood hCG levels D. Reassure and discharge E. CT Head
C. Blood hCG levels
This is a bit of an irritating trick question, but illustrates a useful point: a beta-hCG can be done in the space of a GP appointment, and so there is no reason not to do one before referring this patient for imaging, as pregnancy could well be causing the breast changes.
That said, the second best option would be refer for urgent USS, as ultrasound is better for imaging younger, denser breast tissue.
BRCA gene mutations are associated with breast and
which other type of cancer?
A. Biliary B. Uterine C. Gastric D. Ovarian E. Colon
D. Ovarian
Other relevant cancer markers are: Ca19-9: pancreatic cancer Ca15-3: breast cancer Ca125: ovarian cancer aFP: liver and testicular cancer b-hCG: testicular cancer CEA: colorectal cancer
A 35 year-old woman presents with breast pain and nipple discharge. The discharge is thick and green and the nipple appears retracted, she has recently started breast-feeding.
What is the most likely diagnosis? A. Mastitis B. Duct estasia C. Abscess D. Breast cancer E. Paget's disease of the breast
B. Duct ectasia
Duct ectasia can mimic cancer (nipple retraction, pain, bloody discharge) but is a benign, self-limiting condition. You would probably advise the patient to use over the counter analgesia and wait.
Thick green discharge is most commonly caused by duct ectasia, and nipple retraction or inversion is also typical, allowing duct ectasia to be distinguished from an abscess or mastitis.
A 64 year old man presents with a lesion on his upper ear that has been present for months but has now begun to ulcerate. On examination: non-pigmented,
hyperkeratotic, crusty lesion with raised everted edges on the pinna.
What is the most likely diagnosis? A. Basal call carcinoma B. Malignant melanoma – superficial spreading type C. Malignant melanoma – nodular type D. Non-healing scab E. Squamous cell carcinoma
E. Squamous cell carcinoma
SCC is causes by mutation of keratinocytes, and so are hyperkeratotic and non-pigmented. The greatest risk factor is UV light exposure but chronic inflammation (wound), a family history, immunosuppression, and acitinic keratosis (pre-cancerous crusty growths) are all risk factors.
SCC tends to present in older patients, is stereotypically situated on the pinna of the ear (but can occur anywhere - usually on the head), may ulcerate without healing, and has everted edges
SCC needs to be referred urgently to dermatology as it is invasive and can metastasise.
A 76-year-old woman has recently attended her GP because of a ‘spot that
won’t go away’. The lesion is on her nose and has rolled edges. The GP suspects a basal cell carcinoma.
A. What investigations are likely to be needed?
B. Dermatology referral/assessment - 2-week wait
C. Dermatology referral/assessment – routine
D. None – it is a non-dangerous chronic condition
E. None – GP to start treatment
F. Re-assessment in primary care periodically
C. Dermatology referral/assessment – routine
A basal cell carcinoma is slow-spreading and rarely metastasises. From the description there is no immediate risk (e.g. to the eye) so a routine referral will suffice.
A 32-year old caucasian scuba diver who lives in the Maldives had a seizure three days ago. He has no history of epilepsy but he’s had headaches for the past 5 months. The headaches are worse when he goes to bed. On examination, a dark irregular skin lesion is found on the back of his neck. An MRI scan shows multiple lesions across both cerebral hemispheres.
What is the most likely diagnosis? A. Acoustic neuroma B. Glioblastoma multiforme C. Meningioma D. Metastases E. Neurofibromatosis type I
D. Metastases
The hints here are:
Lesion that should arouse suspicion of melanoma
History of significant sun exposure (Maldives, caucasian)
Headache characteristic of raised ICP (worse when lying down)
A 4-year old girl presents to the GP with multiple lesions on her face. The lesions are
raised and shiny, non-tender, non-erythematous, and 3 mm in diameter. They have an
umbilicated centre. The patient is known to be HIV positive.
What is the most likely diagnosis? A. Chicken pox B. Molluscum contagiosum C. Atopic eczema D. Eczema herpeticum E. Herpes simplex virus
B. Molluscum contagiosum
Molluscum contagiosum is a viral skin infection generally seen in schoolchildren. Small pearly papules with a dip in the middle (umbilicated centre) are classic of molluscum contagiosum. The incidence is higher in HIV patients, and HIV patients will likley have more papules, buthealthy children can contract the virus too.
No treatment is necessary
A 52-year-old woman presents to the GP with redness and swelling of her right
cheek. On examination the area of erythema is well-demarcated and warm to the
touch. Her temperature is 37.9oC and she feels unwell.
i) Most likely diagnosis? A. Cellulitis B. Skin abscess C. Erysipelas D. Necrotising fasciitis E. Gum infection
C. Erysipelas
The history of well-demarcated redness and swelling, particularly in the face, is suggestive of erysipelas - a form of bacterial (usually beta-heamolytic group A Strep) infection similar to cellulitis, but more superficial.
The location and clear boundaries are what separate erysipelas from cellulitis. In addition, erysipelas generally causes more systemic symptoms of illness (malaise, fever) which is unexpected as it is more superficial than cellulitis.
A 52-year-old woman presents to the GP with redness and swelling of her right
cheek. On examination the area of erythema is well-demarcated and warm to the
touch. Her temperature is 37.9oC and she feels unwell.
ii) Next steps? A. Cold compress, reassure, home B. Admit to intensive care unit C. Take skin swabs, blood cultures, and give paracetamol D. Draw around the lesion, give pain relief, oral fluids and antibiotics
D. Draw around the lesion, give pain
relief, oral fluids and antibiotics
The history of well-demarcated redness and swelling, particularly in the face, is suggestive of erysipelas - a form of Staphylococcus Aureus infection similar to cellulitis, but more superficial.
The location and clear boundaries are what separate erysipelas from cellulitis, though the treatment is actually the same: antibiotics for the infection, fluids for support, and draw around the lesion so you can monitor whether it is spreading easily.
A 12-year-old girl presents with dry, itchy skin that involves the flexures in front of her elbows and behind her knees. She has symptoms of hay fever and was diagnosed with egg and milk allergy at 6 months old. Her mother has asthma.
What is the most likely diagnosis? A. Seborrheic dermatitis B. Atopic dermatitis C. Psoriasis (chronic plaque) D. Psoriasis (guttate) E. Urticaria
B. Atopic dermatitis
Atopis dermatitis (also called eczema) typically affects the flexor surfaces of the arms and legs (in contrast to psoriasis which affects the extensor surfaces) causing dry, itchy, red skin and is common in children. The patient's PMHx of food allergies and hayfever increase the liklehood of her skin complaint having an allergic cause, as all these complaints are part of atopic march. A family history of atopic disease (asthma) also increases the chance of this being atopic dermatitis.
An otherwise healthy 23-year-old man complains of sore red lesions on his extremities which have a central clearance (targetoid). These appeared after a recurrence of his ‘coldsores’.
What is the diagnosis? A. Erythema multiforme B. Chicken pox C. Herpes simplex virus D. Stevens-Johnson’s syndrome E. Toxic epidermal necrolysis
A. Erythema multiforme
The description of red lesions with a central clearance is typical of erythema multiforme, which can occur after herpes simplex infections (cold-sores). It can also be triggered by sulphonamide drugs and penicillin, and is associated with blood cancers (leukaemia, lymphoma, myeloma), and autoimmune conditions (RhA, SLE, sarcoidosis)
A mother brings her 3 year-old baby boy into the GP practice because he has developed a facial rash. On inspection the rash consists of yellow greasy scales that are particularly prevalent around the mouth, nasolabial folds, and eyebrows.
What is the most likely diagnosis? A. Psoriasis B. Contact dermatitis C. Eczema herpeticum D. Atopic eczema E. Sebhorreic eczema
E. Sebhorreic eczema
Sebhorreic eczema is fairly easy to identify because of the description of yellow greasy scales that particularly affect the nasolabial folds and eyebrows.
Sebhorreic eczema can cause dandruff and nappy rash, and is associated with malassaezia yeasts.
A 45 year-old man presents to A&E with severe leg pain. The skin of his left leg is dark and blistered, and he is feverish and tachycardic. He admits to i.v. drug use. A group A haemolytic streptococcus is cultured from a swab.
What is the most likely diagnosis? A. Erysipelas B. Necrotising fascitis C. Erythema multiforme D. Eczema herpeticum E. Compartment syndrome
B. Necrotising fascitis
Necrotising fascitis is caused by a streptococcal infection of the deep fascia, just above the muscle. Risk factors include diabetes, malignancy, trauma, surgical wounds, and i.v. drug use, although around 50% of cases occur in previously healthy people.
Necrositing fascitis warrants an emergency surgical referral for debridement. Gas may be sene underneath the soft tissue on an x-ray or CT.
A 65 year-old man presents with blurred vision. He is taking ramipril, amlodipine, and bendroflumathaizide. Upon fundoscopy you see AV nipping, silver wiring, and cotton wool spots.
What grade of this condition does the patient have? A. I B. II C. III D. IV
C. III
The patient has hypertensive retinopathy, which is separated into 4 grades:
I - Twisting of the retinal arteries and silver wiring
II - AV nipping (crossing over of arteries and veins)
III - Flame haemorrhages and cotton wool spots
IV - Papilloedema
A middle-aged man presents to his GP with recent weight gain. On examination, his blood pressure is mildly raised and you notice several bruises on both his arms. U&Es reveal hypokalaemia.
What is the most appropriate investigation?
A. LFTs
B. HbA1c
C. Low dose dexamethasone suppression test
D. aFP
E. High dose dexamethasone suppression test
F. Synacthen test
C. Low dose dexamethasone suppression test
This history is suggestive of Cushing’s, which is confirmed with a low dose dexamethasone test. A high dose dexamethasone test is to determine whether the cause is Cushing’s disease or syndrome.
LFTs might also be done, in light of the bruising, but are not the most appropriate investigation.
aFP is a marker of liver and testicular cancer.
A synacthen test is used to diagnose Addison’s
HbA1c is used to monitor long-term glycaemic control
A 40 year-old woman presents to her GP with a 1 month history of episodes of sweating, headache, sudden mood changes, and palpitations. In between episodes she feels completely normal. She is noted to be unusually tall with long limbs. She mentions that her mother had part of her thyroid removed when she was young but doesn’t remember why.
What is the most appropriate investigation? A. Thyroid function tests B. 24 hour urinary VMA C. ECG D. Echocardiogram E. Oestrogen levels F. U&Es
B. 24 hour urinary VMA
This is a description of a phaeochromocytoma. They are very rare, but Imperial love them so it’s important to know this.
Episodes of agitation, headache, palpitations, and increased sweating are a common presentation of phaeochromocytoma. Blood pressure is very elevated during these episodes, but may be relatively normal inbetween.
VMA is the end metabolite of catecholamines, and an increased urinary level indicates episodes of high catecholamine release.
Phaeochromocytomas can feature as part of MEN2 (multiple endocrine neoplasia) along with medullary thyroid cancer, and mucosal gastrointestinal neuromas. The clues in the history are the description of the patient as tall with long limbs - this is hinting at Marfan’s syndrome which is associated with MEN2B - and the mother’s thyroid removal - hinting at thyroid medullary cancer which is a feature of MEN2B.
A 20 year-old woman presents to her GP with low mood. on further questioning she admits to recent weight gain, and says that her periods have been infrequent and irregular. On inspection she has more facial hair than you would expect, patches of dark velvety skin, and acne. She states that all of these change started around the same time, 1 month ago.
What is the most likely diagnosis? A. Polycystic kidney disease B. Cushing's syndrome C. Polycystic ovary syndrome D. Hypothyroidism E. Obesity
C. Polycystic overy syndrome
Polycystic ovary syndrome is caused by excess release of androgens, in turn caused by either:
High levels of LH release from the adenohypophysis
Chronically elevated insulin levels.
The androgens cause the symptoms of hirsutism, acne, acanthosis nigricans (dark velvety skin) and centripetal weight gain. PCOS is inherited in an autosomal dominant way, but the expression of the disease in women is variable.
Whilst some of these symptoms are associated with obesity (hirsutism, oligomenorrhea, acne), the onset is too quick, and it is unusual to experience all of these symptoms together.
The ‘cysts’ seen on ultrasound are actually immature egg follicles that have started to develop, but then stopped because of altered ovarian function.
A 70 year-old man presents with back pain. Upon further questioning he reveals he has been constipated, but has been urinating more frequently than usual, and drinking more water. He has also felt tired and occasionally nauseous.
What is the most likely diagnosis? A. Cerebral space-occupying lesion B. Colon carcinoma C. Type II diabetes mellitus D. Multiple myeloma E. Hypothyroidism
D. Multiple myeloma
Multiple myeloma is a cancer of plasma cells (mature B-cells) that reside in the bone marrow. The effects of MM can be remembered using CRAB:
C - calcium: calcium is released from bone as it is broken down by the cancer, increasing serum calcium. This leads to polyuria, polydipsia, constipation, confusion, kidney stones, and altered mental status (stones, abdominal moans, and psychic groans).
R - renal: malignant plasma cells secrete malformed proteins which damage the kidneys causing kidney failure. This in turn may lead to uraemia, causing nausea, and electrolyte imbalances e.g. hyperkalaemia, which can cause cardiac arrhythmia. In addition to the effect of proteins, the elevated serum calcium leads to calcium deposition in the kidneys, worsening the renal failure. These proteins will also cause rouleaux formation on a blood film.
A - anaemia: infiltration of healthy bone marrow by malignant plasma cells causes a decrease in RBC output. Other cell lineages will also be affected, including white cells, meaning that people with MM are more vulnerable to infection.
B - bone: bone pain is a very common complaint in MM and helps to differentiate the other symptoms from other causes. In MM the malignancy can spread to the extent where it compresses the spinal cord, causing radicular pain, bladder and bowel incontinence, loss of sensation, and paraplegia.
A 40 year-old man is brought to A&E by ambulance after a car accident. He is conscious but in considerable pain and short of breath. There is extensive trauma to the chest. His JVP is raised and increases on inspiration, but you are unsure if heart sounds are normal as they are hard to hear. HR is 130, BP is 80/50.
What is the most likely diagnosis? A. Ruptured aorta B. Tension pneumothorax C. Pulmonary haemorrhage D. Hepatic haemorrhage E. Cardiac tamponade
E. Cardiac tamponade
The clue here is the presence of Beck’s triad: decreased arterial pressure, muffled heart sounds, and a raised JVP. The JVP will also exhibit a paradoxical rise (Kussmaul sign) which is seen in any cause of right ventricular dysfunction.
A 70 year-old man presents to A&E with central crushing chest pain radiating to the right arm and jaw. ST-elevation is seen on an ECG in leads V1-V4. The patient states his symptoms began 5 hours ago, and since then he has been given oxygen, diamorphine, aspirin, clopidogrel, and nitrates.
What is the most appropriate next step in his management? A. Thrombolysis with alteplase B. Propranolol, ramipril, and epleronone C. Percutaneous coronary intervention D. Fondaparinux and a LMWH E. I.V. amiodarone
C. Percutaneous coronary intervention
This is a description of a STEMI
Thrombolysis with alteplase is avoided if PCI is possible, though if the wait for PCI is more than 2 hours, and the patient is still within the 12 hour window from when they first experienced symptoms, thrombolysis may be attempted.
B describes the long-term treatment for a STEMI
D describes two anti-coagulants used in various conditions
E is used for certain arrhythmias and in cardiac arrest
An 80 year-old man is brought to see the GP from a nursing home with worsening mental status and ataxia. Upon questioning of his nurse, you find out he has been experiencing incontinence.
What is the most likely diagnosis A. Alzheimer's disease B. UTI C. Glioblastoma D. Normal pressure hydrocephalus E. Spinal cord compression
D. Normal pressure hydrocephalus
Normal pressure hydrocephalus is an abnormal accumulation of CSF within the ventricles, it is idiopathic.
When an elderly patient presents with a triad of ataxia, dementia, and urinary incontinence, normal pressure hydrocephalus should be a prominent differential.
A 30 year-old afro-carribean woman with diagnosed SLE presents with pain and swelling of her left calf. This has happened twice before, and both were confirmed to be DVTs. Upon further questioning she was pregnant 5 months ago, but developed pre-eclampsia and ultimately miscarried. Blood tests show a low platelet count. She states that her symptoms have been well controlled for the past few years.
What is the most likely diagnosis? A. Acute lymphoblastic leukaemia B. Effects of SLE C. Disseminated intravascular coagulation D. Antiphospholipid syndrome E. Acute myeloid leukaemia
D. Antiphospholipid syndrome
Antiphospholipid syndrome is an autoimmune hypercoaguble state caused by antibodies directed at certain proteins (lupus anticoagulant and cardiolipin) causing dysfunction of Protein C (coagulation cascade regulator) and increased cleavage of prothrombin to thrombin, increasing coagulation.
The incidence of antiphospholipid syndrome is increased in people with SLE.
This syndrome is particularly prominent during pregnancy, where it may cause miscarriage, stillbirth, intra-uterine growth restriction, pre-eclampsia, and pre-term delivery.
A 12 year-old boy presents with unusual bruising, a persistent chest infection, and fatigue over the course of a month. He was recently given a course of anti-viral drugs for hepatitis B infection.
What is the most likely diagnosis? A. Hepatocellular carcinoma B. Adverse drug reaction C. Aplastic anaemia D. Acute lymphoblastic leukaemia E. Acute myeloid leukaemia
C. Aplastic anaemia
Aplastic anaemia results from damage to the haematopoeitic stem cells in the bone marrow, depleting the marrow’s ability to produce cells of all lineages. It can be idiopathic, but in this case was triggered by hepatitis B infection. Certain drugs can also trigger aplastic anaemia but it is very rare.
Thrombocytopenia - easy bruising
Leukopenia - persistent infections
Anaemia - malaise, fatigue, pallor, breathlessness, palpitations
Though pancytopenia could be caused by ALL, and it does affect children, this boy is a little older than most children are when they develop the disease, and he has reported no FLAWS symptoms.
A 6 year-old girl is brought into A&E with bloody diarrhoea and blood in her urine. Her father says it started 6 days ago but the GP told them not to worry and to keep her hydrated, but she has now become confused and nauseous. She is admitted and monitored closely. Her urine output is noted to be low and it is noticed that she has developed several large bruises on her body. Blood tests reveal raised LDH.
What is the most likely causative organism? A. Streptococcus pneumoniae B. Neisseria meningitidis C. Salmonella enterica D. Escherichia coli E. Parvovirus B19
D. Escherichia coli
This is a case of hemolytic-uraemic syndrome which occurs most often in children. It’s caused by Shiga-like toxin-producing bacteria, most commonly EHEC (enterohaemhorragic Escherichia coli). HUS is usually preceded by bloody diarrhoea by roughly a week.
HUS is defined by a triad of uraemia, haemolytic anaemia, and thrombocytopenia.
The Shiga toxin activates the complement pathway, causing inflammation and thrombosis which tends to affect the kidneys most commonly, and most seriously. The thrombi also cause the haemolytic anaemia through microangiopathic haemolysis - they damage the endothelium of blood vessels and narrow the lumen, causing RBCs to be sheared and destroyed as they pass.
A 6 year-old girl is brought to the GP by her mother because she has noticed bruises on her arms that she can’t explain. The mother also thinks her child has seemed more tired recently. O/E the child has an enlarged spleen.
What is the most likely diagnosis? A. Hodgkin's lymphoma B. Acute myeloid leukaemia C. Acute lymphoblastic leukaemia D. Non-Hodgkin's lymphoma E. Haemophilia A F. Haemophilia C
C. Acute lymphoblastic leukaemia
ALL is usually occurs in young children, and is the most common leukaemia in children.
AML, though it does occur in children, is more common in the elderly and reaches it peak incidence between 75 and 80.
Haemophilia would explain the bruising, but not the fatigue. Splenomegaly may have some association with haemophilia but it is not particularly well defined.
An 18 year-old visits his GP asking for antibiotics. He has been feeling unwell for the past two weeks. O/E he has raised cervical lymph nodes. He reports an itchy feeling recently, but puts this down to the large amounts of alcohol he has been consuming, but he says he has now stopped.
What is the most likely diagnosis? A. Hodgkin's lymphoma B. Acute myeloid leukaemia C. Acute lymphoblastic leukaemia D. Non-Hodgkin's lymphoma E. Haemophilia A F. Haemophilia C
A. Hodgkin’s lymphoma
In theory, Hodgkin’s lymphoma more commonly causes B-symptoms (systems of systemic illness e.g. FLAWS) whereas non-Hodgkin’s lymphoma more usually features with infiltratve symptoms.
In reality, a better way to differentiate the two is that Hodgkin’s lymphoma is rarer than non-Hodgkin’s and can occur in younger people, whereas non-Hodgkin’s lymphoma rarely occurs in younger people (peak incidence is 70).
Reed-Sternberg cells will be seen on the blood film of somebody with Hodgkin’s lymphoma: if the question mentions these as being present, it is definitely Hodgkin’s lymphoma.
The risk of both Hodgkin’s and non-Hodgkin’s lymphoma is increased in those who have previously had glandular fever.
A 13 year-old girl is brought in by her father to see the GP because of a sore throat that began 2 days ago. O/E she is feverish, and a grey exudate can be seen on her tonsils. She denies any cough.
What score would you use to assess the cause of her sore throat? A. CHA2DS2-VASc B. CENTOR C. CURB65 D. Wells score E. Duke criteria
What is the cause?
B. CENTOR
This is bacterial pharyngitis (most likely Strep), as 3 or more of the CENTOR score elements are present, making a viral cause unlikely.
C - cough absent
E - exudate on, or swelling of, the tonsils
N - nodes, anterior cervical lymph nodes swollen or tender
T - temperature of over 38 degrees
OR - young or old modifying factors (under 15 add 1 point, over 44 subtract 1 point)
CHA2DS2-VASc score is used to estimate the risk of stroke in atrial fibrillation.
CURB65 score estimates mortality and guides treatment in pneumonia
Wells score estimates the chance of a patient having had a PE based on their symptoms
The duke criteria is used to diagnose infective endocarditis (the Duke staging system is used for colon cancer)
A 28 year-old man presents with a scrotal lump. Upon palpation you cannot get above the lump, and it is reducible. You reduce the lump and hold your thumb over the inguinal mid-point and ask the patient to cough. The lump does not reappear.
What is the most likely diagnosis? A. Direct inguinal hernia B. Indirect inguinal hernia C. Variocele D. Hydrocele E. Testicular torsion
B. Indirect inguinal hernia
Indirect inguinal hernias occur as a segment of bowel herniates through the deep inguinal ring. This is a result of an embryonic failure of the process vaginalis to close.
A direct hernia occurs when bowel herniates through a weakpoint in the transversalis fascia. The weakpoing is within Hesslebach’s triangle which is bordered laterally by the inferior epigastric artery, medially by the linea semilunaris (edge of the rectus abdominis), and inferiorly by the inguinal ligament.
To distinguish between the two, the hernia is reduced (pushed back into the abdomen) and the doctor places their thumb over the inguinal midpoint and asks the patient to cough. If the hernia reapperas, it is a direct hernia, and if not it is an indirect hernia.
NB: the key feature of a scrotal lump that indicates it is a hernia, is that the dictor is unable to ‘get above it’
A 35 year old woman presents saying that sex with her husband has now become painful and difficult. She also finds it difficult to swallow and cannot taste well anymore. With further investigations, antinuclear antibodies are present.
Please select the best test to confirm your diagnosis: A. Schirmer’s Test B. Erythrocyte Sedimentation Rate C. Anticentromere antibodies D. Chest X-Ray E. Antinuclear Antibodies
A. Schirmer’s Test
Schirmer’s test is used to monitor tear production, and is an investigation for Sjogren’s syndrome. Sjogren’s is an autoimmune condition affecting the exocrine glands of the body, and is most common in middle aged women. Patients may report dry eyes, dry mouth (with associated dysphagia and loss of taste), painful sex (decreased lubrication in women), dry cough, hair loss, and dry skin.
The main antibodies seen in Sjogren’s are anti-Rho (SS-A) and anti-La (SS-B).
Sjogren’s is associated with other autoimmune conditions (primary biliary cirrhosis, RhA, SLE) and increases the risk of non-Hodgkin’s lymphoma. Extra-glandular manifestations include interstitial nephritis, Raynaud’s phenomenon, vasculitis, lymphadenopathy, and hepatobiliary disease.
Antibodies to know:
pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis
cANCA: Polyangitis with granulomatosis
Anti-mitochondrial: primary biliary cirrhosis
Anti-Scl70: diffuse scleroderma
Anti-centromere: CREST syndrome
Anti-Rho and Anti-La: Sjogren’s syndrome
Anti-dsDNA: SLE
Anti-Smith: SLE
Anti-CCP: Rheumatoid arthritis
Anti-glomeruler basement membrane: Goodpasture’s syndrome
Anti-smooth muscle: autoimmune hepatitis
Lupus anticoagulant: antiphospholipid syndrome
Anti-cardiolipin: antiphospholipid syndrome
A 40 year old African man who has a history of interstital lung fibrosis, uveitis, parotitis, and erythema nodosum.
Please select the best test to confirm your diagnosis: A. Schirmer’s Test B. Erythrocyte Sedimentation Rate C. Anticentromere antibodies D. Chest X-ray E. Antinuclear Antibodies
D. Chest X-ray
This is a description of sarcoidosis, a condition causing non-caseating granulomas which most typically affect the lungs, but can affect any organ. Sarcoidosis causes lung fibrosis which can be seen on an x-ray, along with bilateral hilar lymphadenopathy. Sarcoidosis also causes raised ACE and calcium serum levels.
Signs of sarcoidosis include erythema nodosum, uveitis, lupus pernio, a history of dry cough and weight loss, parotid gland swelling, and diabetes insipidus.
A 60 year old man presents to his GP having since Christmas had telangiectasia, calcified spots on his skin, dysphagia and extremely white fingertips in cold weather.
Please select the best test to confirm your diagnosis: A. Schirmer’s Test B. Erythrocyte Sedimentation Rate C. Anticentromere antibodies D. Chest X-Ray E. Antinuclear Antibodies
C. Anti-centromere antibodies
ACA are an antibody frequently seen in CREST syndrome (a type of scleroderma), but less frequently in the diffuse variant of the disease.
Anti-scl70 is seen more in diffuse scleroderma than CRESt, but is not very sensitive.
CREST is the limited form of the disease, which typically affects the hands, face, and fingers. Diffuse scleroderma may affect the heart, lungs, kidneys, and GI tract in addition.
CREST is an acronym which refers to the features that define the disease:
Calcification
Raynaud’s phenomenon
Esophageal dysmotility
Sclerodactyl (thickening and ulceration of the skin of the fingers)
Telangiectasia
Antibodies to know:
pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis
cANCA: Polyangitis with granulomatosis
Anti-mitochondrial: primary biliary cirrhosis
Anti-Scl70: diffuse scleroderma
Anti-centromere: CREST syndrome
Anti-Rho and Anti-La: Sjogren’s syndrome
Anti-dsDNA: SLE
Anti-Smith: SLE
Anti-CCP: Rheumatoid arthritis
Anti-glomeruler basement membrane: Goodpasture’s syndrome
Anti-smooth muscle: autoimmune hepatitis
Lupus anticoagulant: antiphospholipid syndrome
Anti-cardiolipin: antiphospholipid syndrome
A 19 year old woman presents to your clinic with with discoid rashes, a malar rash and mouth ulcers.
Please select the best test to confirm your diagnosis: A. Schirmer’s Test B. Erythrocyte Sedimentation Rate C. Anticentromere antibodies D. Chest X-Ray E. Antinuclear Antibodies
E. Antinuclear Antibodies
These skin symptoms are indicative of systemic lupus erythematosus.
Anti-nuclear antibodies are present in multiple autoimmune diseases: the two important ones in SLE are anti-dsDNA (highly specific for SLE) and anti-Smith.
Blood tests sometimes reveal anaemia of chronic disease, thrombocytopenia, and leukopenia, and often reveal increased ESR.
Antiphospholipid syndrome is strongly associated with SLE, and so associated antibodies are often seen in SLE.
SLE, like other autoimmune conditions, can affect most organs, but typically affect the skin, muscles, and joints causing arthritis, oral ulcers, rashes, and serositis.
Antibodies to know:
pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis
cANCA: Polyangitis with granulomatosis
Anti-mitochondrial: primary biliary cirrhosis
Anti-Scl70: diffuse scleroderma
Anti-centromere: CREST syndrome
Anti-Rho and Anti-La: Sjogren’s syndrome
Anti-dsDNA: SLE
Anti-Smith: SLE
Anti-CCP: Rheumatoid arthritis
Anti-glomeruler basement membrane: Goodpasture’s syndrome
Anti-smooth muscle: autoimmune hepatitis
Lupus anticoagulant: antiphospholipid syndrome
Anti-cardiolipin: antiphospholipid syndrome
A 8 year-old boy is brought in by his mother because she has noticed large bruises on him which she cannot figure the cause of. O/E the boy’s left knee is swollen and painful, but is not hot or red. There are no signs of systemic illness.
Which blood test result would confirm the most likely diagnosis? A. Prolonged PT B. Increased INR C. Prolonged aPTT D. Decreased INR E. Vitamin K deficiency
C. Prolonged aPTT
Haemarthrosis (bleeding into the joint) is indicative of haemophilia. You can’t tell from this history which type of haemophilia the patient has (though A is 6 times more common than B) but the blood test result would be the same for any type of haemophilia because all the different clotting factors that can deficient in haemophilia are involved in the intrinsic pathway, which is tested with an aPTT test.
PT tests the extrinsic pathway, and INR is just a ratio of patient’s PT over normal PT.
Vitamin K is needed to activate factors II, VII, IX, and X to allow them to bind to endothelium, and so vitamin K deficiency would cause prolonged aPTT and PT as it affects factors in both the intrinsic and extrinsic pathways.
A 50 year-old man presents with excruciating pain in his big toe that woke him from sleep this morning and has become progressively worse. He is obese and admits to drinking a relatively large amount of beer, though he says his diet is good because he frequently eats meat. He has several hard swellings on his ear. Synovial fluid is aspirated and examined, and he is started on allopurinol.
What would most likely be seen on examination of his synovial fluid?
A. Crystals that turn deep blue with an H&E stain
B. Raised WCC in the fluid
C. Rhomboid crystals with a positive birefrigence seen under polarised microscopy
D. Needle-shaped crystals with a negative birefringence seen under polarised microscopy
E. Needle-shaped crystals with a positive birefringence seen under polarised microscopy
D. Needle-shaped crystals with a negative birefringence
This history describes gout: elevated uric acid levels in the blood leading to uric crystals being deposited in the joints. Typically the metacarpo-phalangeal joint of the big toe is affected (this is called podagra). The swellings on the ear are tophi - deposits of uric crystals that are pathognomic of gout.
Risk factors include obesity, alcohol intake, and high red meat intake, along with genetic susceptibility.
A and C are both features of pseudo-gout, which involves calcium rather than uric acid.
A 47-year-old man visits his GP having developed a skin rash. He has been feeling ‘generally unwell’ for the past 3 months, and has suffered from abdominal pain accompanied by some rectal bleeding. An angiogram reveals ‘Rosary sign’. He regularly attends hospital for check-ups since he was diagnosed with chronic hepatitis B, 2 years ago.
What is the most likely diagnosis? A. Giant cell arteritis B. Dermatomyositis C. Polyarteritis nodosa D. Granulomatosis with polyangiitis E. Behcet’s disease
C. Polyarteritis nodosa
Polyarteritis nodosa is an inflammatory disease of small and medium-sized blood vessels that often affects the kidneys, but generally spares the lungs. It causes multiple aneurysms to form along the same blood vessel causing a ‘rosary bead’ appearance on an angiogram. PN is associates with hepatitis B.
An 18 year-old boy presented with breathlessness that came on while he was playing football with his friends on a chilly winter’s day. He stated that this breathlessness had occurred before and had woken him up at night once. The boy is diagnosed with asthma and given salbutamol and beclamethasone. He returns three months later and says that he is having to use the salbutamol three times a week.
What is the most appropriate next treatment?
A. Add another inhaled corticosteroid
B. Add a long-acting beta agonist
C. Increase the inhaled corticosteroid dose
D. Leukotriene receptor antagonist
E. Add a long-acting muscarinic antagonist
D. Leukotriene receptor antagonist
Guidelines:
1) For patients who have infrequent short-lived wheezes with normal lung function, consider a short-acting beta agonist with no additional therapy.
2) For patients with frequent episodes or asthma uncontrolled by SABA, prescribe a low-dose inhaled corticosteroid
3) If the low-dose ICS does not control symptoms, add a leukotriene receptor antagonist
4) If combined maintenance therapy with ICS and LRA does not manage symptoms, add a long-acting beta agonist and consider discontinuing LRA.
5) If ICS and LABA (with or without LRA) fails to control symptoms, switch the patient to MART (combined ICS and LABA inhaler)
6) If MART does not control symptoms, increase the ICS dose to a moderate dose, either as part of MART, or as a fixed dose regimen with a LABA, and a SABA to use when required.
7) If moderate dose ICS and LABA does not control symptoms, increase the dose to high dose ICS on a fixed schedule with a SABA when needed. Alternatively carry on as in step 6, but add a long-acting muscarinic antagonist or theophylline
A 74 year-old man is brought to A&E with left-sided abdominal pain and vomiting. His abdomen is distended and upon questioning he has not opened his bowels for two days. Bowel sounds are absent. He has no significant PMHx apart from a laparotomy two years ago. An abdominal x-ray without contrast is performed.
What is the AXR most likely to show? A. Coffee bean sign B. Thickened haustral folds C. Transverse colon dilated >6cm D. A colon tumour E. Bird's beak sign
A. Coffee bean sign
This history is suggestive of a sigmoid volvulus - where a loop of bowel twists around on the axis of its mesentery. The classic radiological sign of a sigmoid volvulus is the coffee bean sign on AXR. A bird’s beak sign may also be seen, but only with a contrast enema.
A 37 year-old woman presents to her GP as she has been feeling very tired over the past couple of days and has noticed unusual bruises on her body, along with bleeding form her nose and gums. PMHx includes a diagnosis of SLE. O/E she seems feverish and jaundiced. U&Es show elevated creatinine.
What is the most likely diagnosis? A. Microangiopathic haemolytic anaemia B. Haemolytic-uraemic syndrome C. Thrombotic thrombocytopenic purpura D. Hodgkin's lymphoma E. Aplastic crisis
C. Thrombotic thrombocytopenic purpura
TTP is typically associated with antibodies against an enzyme that cleaves Von-Willebrand factor, leading to an abnormally high amount of VWf in the blood. This causes clotting in small blood vessels, and a consequent thrombocytopenia leading to bleeding.
Microangiopathic haemolytic anaemia is a feature of TTP which is caused by damage to RBCs as they pass through vessels that have been occluded by thrombi. This causes the RBCs to shear, resulting in a haemolytic anaemia, which may also cause s pre-hepatic jaundice.
Haemolytic-uraemic syndrome may present similarly to TTP, but usually occurs in children and will feature a history of gastrointestinal infection.
The classic pentad of TTP rarely occurs together but is as follows: Fever Microangiopathic haemolytic anaemia Mental state changes Renal impairment Thrombocytopenia
A 29 year-old man presents to his GP with pain in his right knee. He has also been experiencing some hip stiffness and pain. You notice that his eyes seem bloodshot. The patient admits to a prolific sexual history and some recent discharge from his penis which has also developed a lesion on the glans.
What is the most likely diagnosis? A. Behcet's syndrome B. Rheumatoid arthritis C. Reactive arthritis D. Sarcoidosis E. Sjogren's syndrome
C. Reactive arthritis
Defined as a triad of urethritis, conjunctivitis, and arthritis following infection, reactive arthritis is a non-septic, autoimmune reaction causing asymmetrical oligoarthritis of the lower limbs. It is associated with HLA B27 and is triggered by genitourinary (chlamydia) or gastrointestinal infection (campylobacter, salmonella, shigella).
Arthritis usually follows between 1-4 weeks after infection and includes extra-articular manifestations: enthesitis (plantar fascitis, dactylitis, achilles tendonitis), conjunctivitis, and skin inflammation (circinate balantitis - lesions on the glans, and keratoderma blenorrhagicum - a psoriasis-like rash on the palms and soles of the feet))
A mother brings in her 5 year old child into your clinic, saying they have been tired, irritable, and feverish over the past few weeks. On examination they have hepatomegaly, splenomegaly, and enlarged anterior cervical lymph nodes. You also notice testicular swelling, and petechiae on the limbs on examination.
What is the most likely diagnosis? A. Acute Lymphoblastic Leukaemia B. Acute Myeloid Leukaemia C. Chronic Lymphoid Leukaemia D. Chronic Myelogenous Leukaemia E. Hodgkin’s Lymphoma F. Non-Hodgkin’s Lymphoma G. Multiple Myeloma
A. Acute Lymphoblastic Leukaemia
ALL is the most common cancer from the options in young children, and is an aggressive cancer, though it does respond well to treatment.
ALL causes anaemia (tiredness) and thrombocytopenia (petechiae) through ‘crowding out’ of healthy cell production in the bone marrow.
Testicular and lymph node swelling are both seen in ALL, and testicular infiltration can be problematic, as chemotherapy does not target cancerous cells in the testes particularly well.
Which of these fulfils the diagnostic criteria of Type 2 Diabetes?
A. Polyuria and polydipsia
B. Asymptomatic, single fasting plasma glucose >6.9 mmol/L
C. Asymptomatic, single reading of elevated HbA1c
D. Symptomatic, single fasting plasma glucose> 6.9 mmol/L
E. Symptomatic, single random plasma glucose <11.1 mmol/L
D. Symptomatic, single fasting plasma glucose> 6.9 mmol/L
To diagnose diabetes you need a random blood glucose >11.1 or a fasting blood glucose >6.9. If the patient is symptomatic, only one measurement is needed, but if the patient is asymptomatic, two separate readings on different days are needed.
A 19 year old male presented to A&E with abdominal pain, nausea and vomiting. He reports nocturia and examination reveals Kussmaul breathing. Capillary glucose demonstrates hyperglycaemia.
Which of these would be the first step in this patient’s managing? A. IV Insulin B. Oral Glucose C. Diet and Exercise D. Fluid Replacement E. Glibenclamide
D. Fluid Replacement
This patient is in diabetic ketoacidosis. Ketoacidosis is usually accompanied by dehydration, so the most important first step is to administer i.v. fluids. This is initially saline and potassium chloride (hypokalaemia is a dangerous complication of DKA as potassium is lost in the urine). Insulin is also given (glucose is added when the blood sugar drops below 14mmol).
A 26 year old lady visits her GP complaining she is going to the toilet constantly, getting up several times in the night. Urinalysis is negative for glucose and ketones. A fluid deprivation test demonstrates urine osmolality of 200 mOsmol/kg, which rises slightly to 250 mOsmol/kg following administration of desmopressin. Her medical history includes a diagnosis of bipolar disorder.
What should be the GP’s next step? A. Regular desmopressin B. Fluid restriction C. Review medication D. Prescribe an NSAID E. Insulin injections
C. Review medication
Lithium is used to treat diabetes and can cause nephrogenic diabetes insipidus.
Treatment for nephrogenic is medication review, thiazides, NSAIDs, and sometimes high dose desmopressin
A patient presents with chest pain that is triggered by exercise, but does not occur at rest. A CT coronary angiogram shows stenosed coronary arteries. The patient is diagnosed with stable angina.
What is the first line treatment for symptomatic control of angina? A. ACEi or ARB B. CCB or thiazide-like diuretics C. Alpha blocker and a beta blocker D. CCB or beta blocker E. CCB and a statin
D. CCB or beta blocker
Guidelines:
Step 1: CCB or beta blocker
Step 2: if one is ineffective, either switch to the other one, or use both
If CCB and beta blockers are both contraindicated, or if the other drug is contraindicated at step 2, use one of the following instead: Nicorandil Ivabradine Long-acting nitrates Ranolzaine
Aspirin and statins are also used for prevention of further cardiovascular disease
A patient comes to the GP for a review of her blood pressure. You perform fundoscopy and notice cotton wool spots that were not present at her last appointment. Blood pressure is 145/95. The patient is currently on ramipril, amlodipine, and indapamide.
Which drug should be added to control this patient's hypertension? A. Propranolol B. Bendroflumathiazide C. Spironolactone D. GTN E. Furosemide
C. Spironolactone
Guidelines:
Step 1: ACEi or ARB
Step 2: ACEi with CCB
Step 3: ACEi with CCB and thiazide-like diuretic (e.g. indapamide)
Step 4: ACEi with CCB and thiazide-like diuretic (e.g. indapamide) and spironolactone
If step 4 is ineffective or spironolactone is contraindicated, alpha or beta blockers may be used.
The exception to these guidelines is patients who are Afro-Carribean or over the age of 55, in which case a thiazide-like diuretic or CCB is indicated for step 1.
If ACEi can’t be tolerated (e.g. due to cough) an ARB is an acceptable alternative, but the two are not used together.
A woman comes in with a 2 month history of weight loss, diarrhoea, and abdominal pain. A colonoscopy with biopsy is ordered, and from the results she is diagnosed with Crohn’s disease.
What would the results show?
A. Cobblestoning of the terminal ileum with rose thorn ulcers
B. Mucosal ulcers, depletion of goblet cells, and crypt abscesses
C. Transmural non-caseating granulamtous inflammation
D. Lead pipe mucosa
E. Contiguous inflammation from the rectum to the distal segment of the transverse colon
C. Transmural non-caseating granulamtous inflammation
Cobblestoning of the terminal ileum may be seen on endoscopy, but rose thorn ulcers are seen on a barium follow through.
Mucosal ulcers, depletion of goblet cells, and crypt abscesses are signs of UC seen on a biopsy.
Lead pipe mucosa is a sign of UC seen in a contrast barium enema, where chronic UC destroys the normal architecture of the colon.
Continuous inflammation from the rectum to the distal segment of the transverse colon is more indicative of UC, which particularly affects the rectum and spreads in a continuous fashion proximally. By contrast, Crohn’s can affect any part of the GIT and often causes skip lesions.
A 40 year-old woman presents with a 1 month history of abdominal pain, bloating, weight loss, and foul-smelling pale diarrhoea. You notice a vesicular rash on her elbows. Blood tests show a microcytic anaemia.
What would be the most appropriate next set of investigations? A. Colonoscopy B. TTG ab C. OGD D. Duodenal biopsy E. Stool culture
B. TTG ab
Antibodies against TTG are a sensitive and specific test for coeliac disease, which is described here. Biopsy is the gold standard and so would ultimately be needed to confirm the diagnosis, but TTGab is a less invasive initial test.
Coeliac disease is an autoimmune reaction triggered bu ingestion of gluten. The autoantibodies produced attack the villi of the small intestine, causing villous atrophy that can be seen on a duodenal biopsy.
The vesicular rash described is dermatitis herpetiformis - a rash resembling herpes that is associated with coeliac disease.
A blood sample taken from a patient shows the following:
HBsAg+, HBeAg+, and HBcAb IgG+
What is the Hepatitis B status of this patient? A. Acute infection B. Cleared infection C. Chronic infection D. Vaccinated E. Not exposed
C. Chronic infection
IgG is the most useful marker here:
If IgG is present with IgM, it is an acute infection
If IgG is present with HBsAb, the infection has been cleared
If IgG is present without either IgM or HBsAb, it is a chronic infection
If HBsAb is present alone, the patient has been vaccinated
If IgM is present, it is an acute infection
A 57 year-old diabetic woman visits her GP for a review of her condition. Her HbA1c is 8.8% and she has been taking metformin for 3 months.
What is the most appropriate next step in her management? A. Diet and more exercise B. Add acarbose C. Add a DPP-4 inhibitor D. Continue with current medication E. Add insulin
C. Add a DPP-4 inhibitor
Metformin is first line for type II diabetes, but if a patient’s HbA1c rises above 7.5% on metformin, addition of a DPP-4i, pioglitazone, sulphonylurea, or a SGLT-2 inhibitor is indicated.
Insulin is used for control when multiple therapy with other drugs has failed.
Acarbose is not very widely used n the UK, paritally due to the unpleasant side-effects of flatulence and diarrhoea.
A patient visits his GP for a general checkup. His blood pressure is recorded as 165/95.
What grade of hypertension is this? A. Normal B. High normal C. Grade I D. Grade II E. Grade III
D. Grade II
120/80 = optimal
120-129 and/or 80-84 = normal
130-139 and/or 85-89 = high normal
140-159 and/or 90-99 = grade I hypertension
160-179 and/or 100-109 = grade II hypertension
180+ and/or 110+ = grade III hypertension (malignant)
140+ and <90 = isolated systolic hypertension
