MINERVA SBA 3 Flashcards
A 72 year old man presents with jaundice over the past week, with pale stools and dark urine. He noticed that he has unintentionally lost weight over the last few months. He has no other symptoms. He was started on simvastatin by his GP 3 months ago. His vital signs are within the normal range. His blood tests reveal Hb 11.5 g/dL, White Cell Count (WCC) 6 x 109/L, bilirubin 150 μmol/L, ALP 570, ALT 80, albumin 30 g/L, and CRP is raised to 97mg/L.
Reference Normal values
Hb -11.0-14.7 g/dL
White cell count - 3.5-9.5 x109/L
Bilirubin – less than 21 μmol/L
Alkaline phosphatase (ALP) - 30-130 U/L
Alanine transaminase (ALT) - 10 to 40 U/L
Albumin - 35-45 g/L
C - Reactive protein - (CRP - less than 10 milligrams per litre)
What is the most likely diagnosis?
Autoimmune hepatitis
Cholecystitis
Drug induced hepatitis
Gilbert’s syndrome
Pancreatic cancer
E. Pancreatic cancer
This is a typical presentation of pancreatic head tumour- painless cholestatic jaundice with weight loss in an elderly. His bloods showed a cholestatic picture and the low albumin and raised CRP can be seen in malignancy. The absence of fever, abdominal pain, vomiting or raised WCC goes against cholecystitis. Gilbert’s syndrome presents with isolated rise in bilirubin. Autoimmune hepatitis would give a hepatitic picture.
A 78 year old woman presents to her General Practitioner with a 1 month history of intermittent rectal bleeding. She describes the blood as fresh blood, and not mixed in with the stool. She also feels as if she is unable to completely empty her rectum after opening her bowels. Rectal examination reveals external haemorrhoids. She feels well.
What is the most important next step in the management of this patient?
Anusol ointment for haemorrhoids
Check full blood count
Refer for flexible sigmoidoscopy
Refer for haemorrhoidectomy
Start ferrous sulphate
C. Refer for flexible sigmoidoscopy
Rectal bleeding and tenesmus in the elderly are alarm symptoms for rectal cancer. The haemorrhoids may contribute to her rectal bleeding but it could be a red herring. An urgent flexible sigmoidoscopy should be performed to exclude malignancy according to national guidelines. Checking and treating for anaemia as a result of rectal bleeding is appropriate but not the most important action here given the suspected malignancy.
A 25 year old woman attends her General Practitioner’s Surgery complaining of urinary frequency, dysuria and lower abdominal pain. Her urine dip is positive for blood (3+), leucocytes (2+), and nitrites (3+). She has no other health problems and is 10 weeks pregnant.
What is the single most appropriate medication?
Cefalexin
Flucloxacillin
Gentamicin
Pivmecillinam
Trimethoprim
A. Cefalexin
Cefalexin is licensed and safe for use for UTI in pregnancy
Flucloxacillin is not used for uncomplicated UTI
Gentamicin and other aminoglycosides can cause auditory or vestibular nerve damage in the unborn child and is contra-indicated in pregnancy.
Pivmecillinam can be used for treatment of UTIs but is not licensed in pregnancy
Trimethoprim is a folate antagonist and must not be used in the first trimester of pregnancy as per the manufacturer. Some guidelines advocate its use but only with folic acid. Folate deficiencies predispose to neural tube defects such as spina bifida
A 73 year old woman is admitted with cellulitis of her right leg and fever. Her GP letter states that she cannot have beta-lactam antibiotics as they cause anaphylaxis.
Which is the most appropriate empirical treatment?
Cefuroxime
Co-amoxiclav
Flucloxacillin
Meropenem
Vancomycin
E. Vancomycin
All are potentially effective treatment for cellulitis but A.B. C. and D. are all beta-lactam antibiotics. E. is a glycopeptide and indicated for cellulitis in those with severe beta-lactam sensitivity
A 63 year old man with a known diagnosis of chronic obstructive pulmonary disease presents to the GP with a 3 day history of a cough which is productive of sputum. He has signs of consolidation on examination and is started on oral clarithromycin for 5 days. In the laboratory the sputum sample is cultured overnight. Nothing is seen on blood agar but white colonies appear on chocolate agar which appear as short pink rods on gram film. The laboratory staff contact the GP who calls the patient back and changes him to oral doxycycline.
Which is the most probable organism?
Escherichia coli
Haemophilus influenzae
Legionella pneumophila
Pseudomonas aeruginosa
Streptococcus pneumoniae
B. Haemophilus influenzae
Haemophilus influenzae grows faster on chocolate agar than blood agar and appears as gram negative (pink) coccobacilli (short rods). It is naturally resistant to erythromycin and other macrolides but not doxycycline. A. and D. are gram negative rods but are much less common causes of pneumonia even in COPD C. doesn’t grow on agar and is a gram positive rod. E. is a Gram positive coccus that would grow on the blood agar.
A 27 year old aid worker has recently returned from West Africa following a 3-month trip where she worked in a local hospital. Six days after her return to the UK she develops a fever, headache and abdominal pain. She has not received any recent medication. On examination, the patient has a temperature of 39.5°C, heart rate of 115 bpm and blood pressure of 105/66 mmHg. The patient has been isolated in a side room.
What is the most appropriate set of tests to perform urgently?
Blood cultures and thick & thin blood films
Blood cultures and viral haemorrhagic fever screen
Blood glucose and thick & thin blood films
Viral haemorrhagic fever screen and thick & thin blood film
Viral haemorrhagic fever screen and blood glucose
D. viral haemorrhagic fever and thick & thin blood film
National guidelines for management of suspected viral haemorrhagic fever (VHF) mandate that only VHF screen and malaria testing are performed in probable VHF cases
it is not safe for the lab to process blood cultures if VHF is probable so must await a negative VHF screen
it is not safe for the lab to process blood cultures if VHF is probable so must await a negative VHF screen
Blood glucose is an important consideration in malaria – malaria can cause hypoglycaemia as well as quinine. VHF screen was not in this answer.
Correct answer: Malaria must be excluded and can be done safely
Malaria needs to be excluded
A 36 year old man originally from India reports recurrent episodes of fever, sweats and malaise over the past few months. He had malaria several years ago but is unsure of the treatment he received. He last travelled to India 8 months ago. Thick and thin blood films have been sent to the laboratory and results are awaited.
Which organism is most likely to have caused his presentation?
Plasmodium berghei
Plasmodium falciparum
Plasmodium knowlesi
Plasmodium vivax
Trypanosoma brucei gambiense
D. Plasmodium vivax
A 57 year old man got up in the night to pass urine but on entering the bathroom felt sweaty and nauseated. He collapsed to the floor and his wife came in to find him slumped over the sink, looking pale. He began to jerk his arms and legs and was incontinent. He came round after 2 minutes and was alert and orientated within a few seconds.
What is the likely diagnosis?
Cardiac arrhythmia
Epileptic seizure
Hypoglycaemia
Stroke
Vasovagal syncope
E. Vasovagal syncope
This gentleman has had a vasovagal episode leading to convulsions (convulsive syncope) due to having collapsed into an upright posture. Vasovagal episodes are often triggered by micturition (either before or during micturition) when they are sometimes referred to as “micturition syncope”. Clues to the vasovagal nature of the episode are the nausea and sweating before-hand and skin pallor, which are features of autonomic disturbance (low blood pressure). It is not uncommon for urinary incontinence to occur with convulsive syncope (although it is more commonly seen with epilepsy). The fast and spontaneous recovery mitigates against epilepsy or hypoglycaemia as being the cause. Cardiac arrhythmia could cause this but the context of micturition related symptoms suggests that a vasovagal cause is more likely.
A 37 year old woman presents to the emergency department with a 3 day history of fever and headache. In the last 24 hours she has developed a cough which is productive of sputum. She has no significant past medical history, takes the oral contraceptive pill and has no known drug allergies. On examination she is anxious but alert and orientated. Her pulse 96 beats per minute and blood pressure 98/63 mmHg. Respiratory rate is 33 breaths per minute with oxygen saturation of 94% on room air. There is a dull percussion note and bronchial breath sounds in the left base. Blood tests show the following:
Normal reference values
Na 134 (135-146mmol/L)
K 4.3 (3.5 -5.5 mmol/L)
Urea 7.9 (3.5-6.5 mmol/L)
Creatinine 97 (60-120 micromol/L)
Hb 11.7 (11.0-14.7 g/dL)
WCC 6.5 (White cell count - 3.5-9.5 x109/L)
Platelets 227 (150,000 and 450,000 platelets per microliter mcL)
C - Reactive protein 64 mg/L (CRP less than 10 milligrams per liter)
Which is the most appropriate treatment to commence now?
Amoxicillin 500mg TDS
Benzyl-penicillin 2.4g QDS IV + Flucloxacillin 1g TDS IV
Co-Amoxiclav 625mg TDS PO
Co-Amoxiclav 1.2g TDS IV plus Clarithromycin BD PO
Ciprofloxacin 500mg BD PO
D. Co-Amoxiclav 1.2g TDS IV plus Clarithromycin BD PO
This is a case of severe community acquired pneumonia (CAP) and answer D lists the first line antimicrobials. A. would be appropriate for mild CAP, C. for moderate CAP. B. is the empirical choice for skin and soft tissue infections and E. would usually be restricted to those with particular allergies or to other options.
A 45 year old woman has been getting breathless for the last 12 months. She recalls as a child that viral infections sometimes made her wheezy. She has been well until recently. She smoked moderately from the ages of 16 to 30. She works in a bakery. Now she finds that she can get very short of breath on work days, and her chest feels tight when she is exercising. Once or twice a week she wakes up coughing.
What is the most likely diagnosis?
Asthma with possible occupational component
Asthma, but the occupation isn’t important
Chronic obstructive pulmonary disease
Extrinsic allergic alveolitis with possible work component
Viral Wheeze
A. Asthma with possible occupational component
The history of variable breathlessness with night time waking is typical of asthma. Although she has been a smoker, the very variable nature of her symptoms makes COPD unlikely. Bakers exposed to flour are at increased risk of occupational asthma with allergy to flour. It is still a little uncertain whether people who wheezed with viral infection are more likely to get asthma later in life, but the current symptoms are occurring in the absence of viral infection. Extrinsic allergic alveolitis can be caused by some occupational exposures, but would present with progressive cough and breathlessness, and possibly acute episodes of fever and cough.
A 63 year old man presents with sudden onset shortness of breath and sharp left sided chest pain. His chest x ray is normal and his 12 lead ECG show sinus tachycardia.
What is the most likely diagnosis?
Fractured rib
Lung cancer
Pneumonia
Pneumothorax
Pulmonary embolus
E. Pulmonary Embolus
Patients with pulmonary embolus usually have a normal CXR.
The other diagnoses should be picked up on a CXR.
A 35 year old woman presents with tiredness. She is usually fit and well. Her blood tests reveal that she is anaemic and that her reticulocyte count is elevated.
What is the most likely cause of her anaemia?
Anaemia of chronic disease
B12 deficiency
Haemolytic anaemia
Iron deficiency anaemia
Thalassaemia
C. Haemolytic anaemia
Haemolytic anaemia is due to increased removal of red blood cells resulting in the physiological response of an increased reticulocyte count.
The others are all due to production failure and therefore associated with a reduced reticulocyte count.
A 60 year old woman has had fevers, drenching night sweats, severe malaise and abdominal pain for 3 weeks.
She has a central abdominal mass, with inguinal lymphadenopathy and oedema of the lower limbs bilaterally.
Investigations:
Full blood count mild anaemia
Lymph node biopsy sheets of medium-sized rapidly proliferating
B cells
Which is the most likely diagnosis?
Acute lymphoblastic leukaemia
Acute myeloid leukaemia
Burkitt’s lymphoma
Chronic lymphocytic leukaemia
Chronic myeloid leukaemia
C. Burkitt’s lymphoma
Rapidly dividing
Which of the following terms best describes a patient safety culture in which staff feel comfortable discussing patient safety incidents and raising safety issues with both colleagues and senior managers?
Informed culture
Just culture
Learning culture
Open culture
Reporting culture
Correct answer:
D. Open culture
Just culture: Staff, patients and carers are treated fairly, with empathy and consideration when they have been involved in a patient safety incident or have raised a safety issue
Reporting culture: Staff have confidence in the local incident reporting system and use it to notify healthcare managers of incidents that are occurring, including near misses. Barriers to incident reporting have been identified and removed - staff not blamed/punished when they report incidents and they receive constructive feedback.
Learning culture: The organisation: is committed to learn safety lessons; communicates them to colleagues; remembers them over time.
Informed culture: The organisation has learnt from past experience and has the ability to identify and mitigate future incidents because it: - learns from events that have already happened (for example, incident reports and investigations).
