Meeran VSAs Flashcards
A 50 year oldman with a history of type 2 diabetes presents with left sided weakness and a headache. Examination reveals brisk reflexes in the left arm.
-Rank the following differential diagnoses
- stroke - imp to exclude, esp with hx of T2DM, sudden
- brain tumour - similar feat but slower
- migraine - can cause sx on 1 side due to vascular spasm
- MS - F>M, req 2+ CNS lesions sep in time + space
- GBS - would be LMN signs
A 50year old male presents with severe epigastric pain. He has had a similar episode in the past and he admits to drinking an excess of alcohol, and smoking a pack per day.
-Rank the differential diagnoses below in order of likelihood
- Acute pancreatitis - severe epig pain + xs alcohol
- Peptic ulcer disease - more comm in alcoholics
- Acute MI - RF smoking, can be epig pain
- Cholecystitis - RUQ or epig pain + assoc fever
- Basal pneumonia - can cause epig pain BUT no resp sx reported so least likely
A 40 year old man presents with collapse and LoC witnessed by his wife. The ep lasted 3 mins. He felt dizzy for a few s prior to the event and had some jerky movements during the event. He recovered spontaneously and was NOT confused afterwards. He had no previous cardiac history and in fact had never seen a doctor.
-Rank the following differential diagnoses of his collapse
- Vasovagal - most likely given no previous cardiac hx
- Arrythmia - can present with collapse
- seizure - less likely as lack of post-ictal confusion
- TIA - would expect some focal neurological signs
- hypoglycaemia - least likely as event TERMINATED SPONTANEOUSLY, also no suggestion he is on insulin or has diabetes
A 24 year old female presents with severe right sided back and abdominal pain and a fever. She has no other previous medical or travel history.
-Rank the following differential diagnoses
- Acute Pyelonephritis - presents with fever loin/flank pain and tenderness, but this is sometimes interpreted as back pain by patients
- Cholecystitis - also commonly presents with RUQ pain associated with fever
- Hepatitis - also causes fever and RUQ pain assoc with J, and would be more likely if there was a travel hx for viral hepatitis
- Campylobacter infection- presents with fever, cramp-like pain and bloody diarrhoea
- Peptic ulcer- is the least likely, as it does not usually present with fever.
A 50year old woman presents with a severe headache and photophobia. Examination reveals brisk reflexes
-Rank the following differential diagnoses
- SAH - In a pt presenting with severe sudden onset headache and photophobia think of SAH
- Meningitis - no history of fever, but, remember that you should tx this pt for meningitis quickly while you are making the dx
- Encephalitis - usu have behavioural changes in addition to the headache
- SDH - usu has a more subacute/chronic presentation with headache and confusion
- EDH - often due to a fractured temporal/ parietal bone damaging the MMA and so only occurs after severe trauma
A 50 year old smoker presents with lobar pneumonia. Examination reveals dullness at the right base with increased tactile vocal fremitus.
-Rank the following organisms in order of liklihood
- Streptococcus pneumonia - commonest cause of CAP
- H.Influenza - imp cause in elderly adults who have COPD or smoke heavily
- Mycoplasma - atypical
- Legionella - atypical
- E.Coli - G negatives uncommon but consider in HAPs
Abdominal examination of a 70year old breathless man of no fixed abode reveals a palpable spleen. He is known to drink heavily and has had an anterior myocardial infarction previously.
-Rank the differential diagnoses
- Portal HTN
- Congestive cardiac failure - hepatomeg + splenomeg - pt is breathless
3.TB
4.Malaria
5.Schistosomiasis - rare esp without travel hx
NB. main causes of splenomegaly = portal HTN, haem malignancies + infection
A 50 year old W presents with L calf swelling and tenderness. She has had a recent # and has been immobile. Her PMHx includes OA. She has smoked 30/day for the last 30 years, but does not drink alcohol. Rank the differential diagnoses
- DVT - unilat swollen leg, recent #
2.cellulitis
3.ruptured bakers cyst
1-3 –> unilateral swollen leg
4.cardaic failure - usu causes bilat leg swelling
5.liver failure - peripheral oedema - but NO other feat of CLD
A 45 year old woman presents with a 1 day hx of dizziness on standing up + vomiting. She had been started on a TCA by her GP two weeks ago. Her PMHx includes T2DM dx 4Y ago + treated with metformin. Rank the differential diagnoses
- TCA - started 2w ago
- Gastroenteritis –> hypovolaemia - can cause postural hypotension + dizziness
- Metformin - common cause of GI upset + vomiting - less likely as pt stable for a while
- Diabetic peripheral neuropathy - unlikely to be acute in onset
- Amyloid - v unlikely
A 35 year old male intravenous drug abuser is admitted to Casualty with a 3 day history of yellow discolouration of his skin, flulike symptoms and nausea. On examination, he is cachectic and jaundiced, with smooth, tender hepatomegaly. Rank the following differential diagnoses
- Hep C - IVDU
- HIV - IVDU
- ALD
- Paracetamol OD - can cause acute liver failure
- Gilberts Syndrome - asymptomatic hyperbilirubinaemia and needs no specific tx
loud pan systolic murmur at apex
MITRAL REGURGITATION
ESM
aortic stenosis
irregularly irregular pulse
AF
SLOW rising pulse
Aortic stenosis
Collapsing pulse
Aortic regurgitation
Very loud first heart sound
MITRAL STENOSIS
- causes loud S1 as leaflets are wide apart at end of atrial contraction, atrium still isn’t empty when the ventricles start to contract so the mitral valve is WIDE OPEN + SNAPS SHUT
- calcification will quieten the valves
early diastolic murmur at left sternal edge
Aortic Regurgitation
closure of what valve causes S1
Mitral valve
closure of what valve causes S2
Aortic valve + pulmonary valve too
split
tapping apex
= palpable 1st heart sound - mitral stenosis
- If the valve is stenosed then the atrium struggles to empty and at the start of systole, the atrium isn’t yet empty
- Thus the valve is wide open when systole starts. Thus when the valve slams shut from being fully open, it is very loud and palpable
third heart sound caused by what
- A 3rd HS is caused by RAPID VENTRICULAR FILLING during normal diastole BEFORE the atrium contracts (which would cause a fourth heart sound if there is any stiffness)
- This occurs when the ventricle is dilated due to cardiac failure
cannon waves, what is likely dx
complete heart block/third degree heart block
- only condition when atrium contracts against closed tricuspid valve (randomly) as the A+V are contracting at diff rates
- when they contract together, the blood of atrium can ONLY rush UPWARDS
65 year old complains of slowly increased swelling of both legs, and slowly worsening breathlessness. Examination reveals a raised JVP, causes?
HF:
- usu this starts with an ischaemic left ventricle causing Left ventricular failure
- this causes breathlessness due to pulmonary oedema
- there is then fluid retention and peripheral oedema results from RVF = Congestive cardiac failure
Cor pulmonale:
-where breathlessness is caused by lung disease eg COPD + there is subsequent RV failure
low pitched mid diastolic rumbling murmur
MITRAL STENOSIS
opening snap
mitral stenosis - calcification makes the snpa quiet or absent
4th heart sound
atrial contraction against a stiffened left ventricle -which is in turn caused by hypertension
mitral regurgitation
loud pan systolic murmur
murmur in pt with tricuspid regurg
same murmur as in MR but softer as RV pressure is lower than LV pressure = SOFT PAN SYSTOLIC MURMUR
ECG changes in 2nd degree heart block
SOME p waves not conducted to QRS complexes
Mobitz type 2
where the PR interval lis fixed (but may be prolonged or normal) but some QRS beats are missed
LBBB
SRS in lead VI (w)
RSR in lead V6 (m)
Examination reveals reduced expansion on the left side with dullness to percussion and reduced tactile vocal resonance (when he says “99”)
left sided pleural effusion
A 45 year old patient complains of a cough that lasts for 3 months every winter for the last three years. What is the likely diagnosis?
chronic bronchitis
A 45 year old patient complains that they cough up a pot of purulent sputum every day. Examination reveals course crackles.
This is typical of bronchiectasis, which may be caused by CF
65 year old complains of breathlessness and has fine crepitations at both bases.
pulmonary oedema
-can be caused by cardiac failure or LV failure
OR pulmonary fibrosis
Examination reveals a palpable mass in the right hypochondrium
This is the position of hte liver
- hepatomegaly
Examination reveals a palpable mass in the left hypochondrium
This is the position of the spleen - splenomegaly
A 40 year old man who drinks a bottle of vodka every night and is known to have chronic liver disease, developed severe abdominal pain with extreme tenderness. Examination revealed a rigid abdomen. What is the likely diagnosis?
acute pancreatitis
-leakage of pancreatic enzymes into peritoneum causes rigidity and peritonitis
A 50 year old complains of slowly worsening weakness in his left leg. This started gradually three months ago, and is now making him limp. Examination reveals increased tone, brisk reflexes and weakness in the left leg.
UMN signs - it is slowly progressive, so it is most likely a slow growing BRAIN TUMOUR
A 50 year old complains that he has developed weakness in his left leg when he woke up this morning. He has great difficulty walking. Examination reveals increased tone, brisk reflexes and weakness in the left leg.
UMN signs - SUDDEN - STROKE
A 60 year old man complains of drooping of his left eyelid. Examination of his eyes reveals normal eye movements, but his left pupil is SMALLER than his right pupil.
HORNERS syndrome
A 50 year old man complains of drooping of his left eyelid, so that his left eye is almost closed. When you hold his left eye open, he complains of double vision, and the left pupil is LARGER than the right one.
(SURGICAL) 3rd NERVE PALSY
-surgical so the pupil is affected
Examination of the lower limbs reveals wasting of the muscles of the left calf with absent reflexes on that side.
LMN problem
-only one leg so problem is either pressure on a nerve below the cauda equina or damage to the spine or the nerve roots
A patient complains of a tremor when he smokes cigarettes. What is the likely cause if the tremor gets worse when he puts the cigarette into his mouth.
This is typical of the ATAXIA one gets with CEREBELLAR DISEASE, with the past pointing getting worse as you approach the target (either nose, or in this case the mouth).
It is truly horrible to witness the difficulty these patients have even smoking.
Examination of the plantar responses reveals that the right plantar is upgoing and the left plantar is downgoing. What do these findings suggest?
The UPGOING plantar is ABNORMAL and suggests an UMN lesion affecting the RIGHT leg.
- This can be caused by a brain tumour or stroke in the LEFT side of the brain or SC
- The downgoing plantar is normal. It is important in summative exams that you are clear as to which side of the brain the problem is on, and also which side of the body is affected.
A 40 year old woman complains of palpitations, and is noted to have a blood pressure of 190/120.
Severe HTN seen in phaemochromocytoma
-The sudden release of adrenaline stimulate beta receptors and can cause palpitations.
What CLASS of drug should be prescribed for a patient with diabetes and hypertension who is found to have microalbuminuria?
ACEi have the most evidence of benefit in preserving renal function
-ARBs have similar benefit
What effect will this drug have on the plasma potassium levels?
INCREASE
What effect will this drug have on plasma creatinine levels?
INCREASE
What effect will this drug have on the urinary albumin excretion?
Urinary albumin is REDUCED, which is why we use ACEi in any pts with diabetes who has microalbuminuria.
A patient has a lymph node biopsy which is sent for histology. What is the diagnosis if caseating granulomata are seen?
TB - commonest cause of caseating granulomata
-Ziehl Nielsen stain used to see bacilli
non-caseating granulomata
sarcoidosis
calcium antagonist used for hypertension
nifedipine
alpha blocker used in hypertension
labetalol
aldosterone receptor antagonist used for hypertension
spironolactone
dopamine agonist used for patients with a prolactinoma
cabergoline
dopamine antagonist that can be used for psychotic disorders or nausea.
macrolide AB - erythromycin
explain how one interprets the mean corpuscular volume (MCV) in the full blood count (FBC), and what pattern one sees in a patient with bowel cancer that slowly bleeds, and how this compares to a patient with pernicious anaemia.
- Pts who have CHRONIC GI bleeding will become iron deficient, and then go on to have a LOW MCV
- The normal MCV is 76 to 96 fl, and iron deficiency will cause a MICROCYTIC anaemia
- PERNICIOUS ANAEMIA is caused by lack of intrinsic factor, and this results in B 12 malabsorption
- LACK of B12 results in megaloblastic anaemia, where the DNA divides, but the cells do not, so that one has hypersegmented neutrophils. These patients have a HIGH MCV.
explain how the pattern of abnormality of liver function tests can give a clue as to the aetiology of jaundice. Illustrate your answer in particular with reference ALT, AST and alkaline phosphatase.
Jaundice can be caused by haemolysis, by liver dysfunction or by physical obstruction of the biliary tree.
- Haemolysis will result in a HIGH BR with a normal set of liver enzymes, so that ALT, AST and ALP will be normal
- In pts with an inflamed liver, for ex caused by hepatitis, the ALT is most raised
- Obstructive jaundice is caused by gallstones or pancreatic cancer and in these patients it is the alkaline phosphatase that is most raised.
