PASS MEDICINE Flashcards
What are the red flags for back pain?
Age 50 years History of previous malignancy Night pain History of trauma Systemically unwell e.g. weight loss, fever Thoracic spine affected
A 35-year-old female presents with abdominal pain associated with bloating for the past 6 months, Which one of the following symptoms is least associated with a diagnosis of irritable bowel syndrome?
Feeling of incomplete stool evacuation Weight loss Back pain Lethargy Nausea
Weight loss
What are the Ottawa rules surrounding whether or not an ankle injury needs x-ray?
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
Bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
Bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
Inability to walk four weight bearing steps immediately after the injury and in the emergency department
A 22-year-old man presents with a three week history of diarrhoea. He says his bowels have not been right for the past few months and he frequently has to run to the toilet. These symptoms had seemed to be improving up until three weeks ago. For the past week he has also been passing some blood in the stool and reports the feeling of incomplete evacuation after going. He has lost no weight and has a good appetite. Examination of his abdomen demonstrates mild tenderness in the left lower quadrant but no guarding. What is the most likely diagnosis?
Diverticulitis Colorectal cancer Crohn's disease Ulcerative colitis Infective diarrhoea
Ulcerative colitis
Which one of the following is the most effective screening tool for harmful alcohol drinking and alcohol dependence?
Liver ultrasound CAGE questionnaire FAST questionnaire Combination of MCV and gamma GT blood test AUDIT questionnaire
AUDIT
10 item questionnaire, takes about 2-3 minutes to complete
Has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems
Minimum score = 0, maximum score = 40: a score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence.
AUDIT-C is an abbreviated form consisting of 3 questions
A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has no past medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day and drinks 20 units of alcohol per week. Ileocolonoscopy shows features consistent with Crohn’s disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the most important intervention to reduce the chance of further episodes?
Infliximab Stop drinking Stop smoking Mesalazine Budesonide
Stop smoking
Which drug used in the treatment of rheumatoid arthritis has proteinuria as a possible side effect?
Gold
Which drug used in the treatment of rheumatoid arthritis has oligospermia as a possible side effect?
Sulfasalazine
Which drug used in the treatment of rheumatoid arthritis has reactivation of tuberculosis as a possible effect?
Infliximab
What is the name of the syndrome characterised by epigastric pain and diarrhoea?
Zollinger-Ellison syndrome
What endocrine condition do a third of Zollinger-Ellison syndrome patients also have?
Multiple endocrine neoplasia type I (MEN-I)
What is Zollinger-Ellison syndrome?
A condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. The excessive gastrin leads to multiple gastroduodenal ulcers, diarrhoea and malabsorption.
Around 30% occur as part of MEN type I syndrome.
A 49-year-old female is referred to the gastroenterology out-patient clinic with a 3 month history of epigastric pain and diarrhoea. Her GP initially prescribed lansoprazole 30mg od but this didn’t alleviate her symptoms. The only past medical history of note is hyperparathyroidism.
Endoscopy revealed multiple duodenal ulcerations. What is the likely diagnosis?
Multiple endocrine neoplasia type II a Coeliac disease Multiple endocrine neoplasia type I Autoimmune polyendocrinopathy syndrome Crohn's disease
MEN-I as part of a Zollinger-Ellison diagnosis. The lansoprazole would need to be a much higher dose.
A 38-year-old woman develops lower back pain radiating down her right leg whilst performing DIY. She describes a severe, sharp, stabbing pain which is worse on movement. Clinical examination reveals a positive straight leg raise test on the right side but otherwise the examination is unremarkable. Appropriate analgesia is prescribed. Of the following, what is the most suitable next-step in management?
Check ESR Arrange physiotherapy Refer for MRI Perform a vaginal examination Lumbar spine x-ray
Arrange for physiotherapy - This patient has symptoms consistent with a prolapsed disc. Even if this is proven by a MRI scan it would not change the initial management as the vast majority of patients improve with conservative treatment such as physiotherapy.
Which one of the following features is more common in Crohn’s disease than ulcerative colitis?
Abdominal mass palpable in the right iliac fossa
Tenesmus
Bloody diarrhoea
Faecal incontinence
Abdominal pain in the left lower quadrant
Abdominal mass palpable in the right iliac fossa
Look at table in University College London/Year 4/Gastrointestinal folder for differences between UC and CD
A 14-year-old presents with left knee pain for the past 4 weeks. There is no history of trauma. The pain is felt in the anterior aspect of the joint and is worse when walking up and down stairs. Examination is unremarkable. What is the most likely diagnosis?
Chondromalacia patellae Osteoarthritis Osgood-Schlatter disease Osteogenesis imperfecta Osteochondritis dissecans
Chondromalacia patellae
What is Chondromalacia patellae?
Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy
What are the features of Chondromalacia patellae?
Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy
What are the features of Osgood-Schlatter disease (tibial apophysitis)?
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
What are the features of Osteochondritis dissecans?
Pain after exercise
Intermittent swelling and locking
What are the features of Patellar subluxation?
Medial knee pain due to lateral subluxation of the patella
Knee may give way
What are the features of Patellar tendonitis?
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
Stop and recommence 4 weeks after acute inflammation has settled
Reduce allopurinol to 100mg od until acute attack has settled
Stop and switch to colchicine prophylaxis
Stop and recommence 2 weeks after acute inflammation has settled
Continue allopurinol in current dose
Continue allopurinol in current dose - Patients already prescribed allopurinol should continue to take it at the same dose during acute episodes. This is of course in contrast to the advice that patients should not be started on allopurinol until an acute attack has settled.
A 45-year-old man presents with palpitations that began around 40 minutes ago. Other than having a stressful day at work there appears to have been no obvious trigger. He denies any chest pain or dyspnoea. An ECG shows a regular tachycardia of 180 bpm with a QRS duration of 0.10ms. Blood pressure is 106/70 mmHg and oxygen saturations are 98% on room air. You ask him to perform the Valsava manoeuvre but this has no attempt on the rhythm. What is the most appropriate next course of action?
Electrical cardioversion Intravenous labetalol Intravenous adenosine Intravenous amiodarone Re-attempt Valsava manoeuvre in 5 minutes
Intravenous adenosine - This patient has a supraventricular tachycardia with no adverse signs (e.g. shock, myocardial ischaemia etc). If vagal manoeuvres fail intravenous adenosine should be given.
Acute management:
- Vagal manoeuvres (e.g. Valsalva manoeuvre)
- Intravenous adenosine 6mg → 12mg → 12mg. (Contraindicated in asthmatics - verapamil is a preferable option)
- Electrical cardioversion
Prevention of future episodes:
Beta-blockers
Radio-frequency ablation
A 46-year-old man is being investigated for indigestion. Jejunal biopsy shows deposition of macrophages containing PAS-positive granules. What is the most likely diagnosis?
Bacterial overgrowth Coeliac disease Tropical sprue Whipple's disease Small bowel lymphoma
Whipple’s disease
What is Whipple’s disease?
Whipple’s disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men.
Of the following, which one is the most useful prognostic marker in paracetamol overdose?
ALT Prothrombin time Paracetamol levels at presentation Paracetamol levels at 12 hours Paracetamol levels at 24 hours
Prothrombin time - An elevated prothrombin time signifies liver failure in paracetamol overdose and is a marker of poor prognosis. However, arterial pH, creatinine and encephalopathy are also markers of a need for liver transplantation
What is the drug that can be used in acute presentation of paracetamol overdose?
Acetylcysteine
What class of drug is amlodipine?
Dihydropyridine receptor antagonist
What are some of the drugs that classically have ankle swelling as one of their side effects?
Amlodipine
Diltiazem
Pioglitazone
