Passmed questions Flashcards
Antibiotic which is also a recognised cause of cholestasis
Co-amoxiclav
Most likely oesophageal cancer likely to develop in patients with history of GORD or Barrett’s oesophagus
Adenocarcinoma.
Squamous cell carcinoma more commonly find in upper 2/3rd of oesophagus
Incarcerated vs strangulated hernia
Incarcerated - irreducible but no pain
Strangulated - blood supply compromised, risking ishcaemia and necrosis leading to pain
Case: 65 y/o Male, ED, pc: severe abdo pain + vomiting + fever.
PMH - peptic ulcer disease.
OE: generalised tenderness, guarding and rebound tenderness
Most appropriate next step investigation:
Erect CXR –> bowel perforation?
Pneumoperitoneum
Young adult with sore throat, fever, lethargy, cervical lymphadenopathy persisting over 1 week may hint to diagnosis of what:
Infectious Mononucleosis (Kissing disease)
- self limiting viral condition
- seen in adolescents or young adults
Mx: rest , plentiful hydration and simple analgesia
Rhesus status notes
Rhesus system is most important antigen found on red blood cells.
The D antigen is most important antigen of Rhesus system.
If Rhesus NEGATIVE mother delivers a Rhesus POSITIVE child - a leak of foetal RBC may occur.
This causes anti-D IgG antibodies to form in mother.
In later pregnancies these can cross placenta and cause haemolysis in foetus.
Prevention
- test for D antibodies in all Rhesus negative mothers at booking.
- give anti-D to non-sensitised Rhesus NEGATIVE mothers at 28 and 34 weeks.
Important tests for checking anti-D status of a mother
If baby born to RHESUS POSITIVE MOTHER then cord blood should be taken at delivery for FBC, blood group and direct Coombs test.
Coombs test : direct antiglobulin, will demonstrate antibodies on RBC of baby.
Kleihauer test: add acid to materna blood, foetal cells are resistant.
A pregnant patient with candida infection will be given
Clotrimazole pessary
Oral fluconazole is contraindicated in pregnant women
- risk of congenital malformation
Renal complications of systemic sclerosis are managed how?
ACE inhibitors
A patient presents with nausea, dehydration, confusion and reduced urine output following a viral infection.
This is a classic presentation of what:
AKI
Key drugs to stop in AKI
C - Contrast media.
A - ACE inhibitors.
N - NSAIDs.
A - Aminoglycosides.
D - Diuretics.
A - Angiotensin receptor blockers (ARBs)
Most common causative mastoiditis is:
strep pneunomiae
risk factors
- young children
- immunocompromised
- diabetes mellitis
A 36-year-old man presents with recurrent episodes of right-sided tinnitus, hearing loss and vertigo. These episodes typically last between 10-30 minutes. He also describes a ‘full’ sensation in his right ear. Otoscopy is unremarkable and the cranial nerve examination is normal.
likely diagnosis
Meniere’s disease
Recurrent epsiodes of
- vertigo
- tinnitus
- hearing loss (sensorineural)
aural fullness
other features
- nystagmus and positive Rhomberg test
A 31-year-old man presents with bilateral hearing loss and tinnitus. There is a family history of similar problems. Examination of the tympanic membranes is unremarkable. Audiometry shows bilateral conductive hearing loss.
likely diagnosis
otosclerosis
- autosomal dominant
- conductive deafness
- tinnitus
- tympanic membrane
A 2-year-old boy is brought in by his mother due to concerns about his hearing and delayed speech. She has noticed problems for the past three months. You can see from the notes that he has had frequent courses of amoxicillin for otitis media in the past. There is no evidence of excessive ear wax on examination.
Glue
- peaks at 2 years of age
- hearing loss is usually the presenting feature
- may have speech and language delay
Glue ear = otitis media with effusion
most common inherited bleeding disorder
Von Willebrands disease
- autosomal domiannt
VWF promotes platelet adhesion to damaged endothelium.
Ix = prolonged bleeding time
Mx =
- tranexamic acid for mild bleeding
- desmopressin
suspect what condition in a patient with back pain, low grade fever, elevated WBC and CRP and past history of IVDU.
Discitis
- contrast enhancement of disc and adjacent bone marrow
most common causative organism is : staph aureus
Distinguishing between cranial and nephrogenic diabetes insipidus
Compare post fluid deprivation** urine osmolality** and then urine osmolality post desmopressin.
If low urine osmolality is corrected by synthetic ADH after 8 hours, it suggests pituitary isn’t releasing ADH correctly and kidneys are responding to exogenous ADH.
Thus can be inferred its central diabetes insipidus.
Mx - DESMOPRESSIN
IF nephrogenic then Mx
- thiazides
- low salt / protein diet
carpal tunnel vs cubital tunnel syndrome
Cubital tunnel affects 4th and 5th fingers, is caused by compression of ulnar nerve.
Carpal tunne
- 1st, 2nd and 3rd part of digit
A 32-year-old female presents to the GP due to changes in her vision. She explains that she was experiencing double vision, especially during the evenings, which has been occurring over the past 6 months. She explains that her face feels flushed and warm. There is nil past medical history of note.
On examination, there is left-sided ptosis and distension of the veins in the neck and head.
Given the likely diagnosis, which of the following would offer a definitive diagnosis?
Likely diagnosis - **myasthenia gravis **
- antibodies against ACH receptors
Characterised by
-** fatigue of eyes which can cause diplopia and ptosis **
distended neck veins and flushed face are likely to be caused by superior vena cava obstruction which can be a compliation of thymomas
mainstay of treatment for rhabdomyolysis
rapid IV fluid rehydration
Otitis externa in diabetics: treat with
ciprofloxacin to cover Pseudomonas
this accounts for 80% to 90% of cerebellopontine angle tumours.
vestibular schwannoma
Features of what may indicate a vestibular schwannoma:
Vertigo and unilateral hearing loss indicating CN VIII involvement
Absent corneal reflex indicating CN V involvement
Unilateral facial numbness indicating CN VII involvement
most common cause of nephrotic syndrome in a child
minimal change disease
- nephrotic syndrome
- oedema with proteinuria
- bibasal crackles are suggestive of pulmonary oedema
A 2-year-old boy is brought to his GP.
His father is concerned as he appears ‘puffy’. He is usually fit and well, but has picked up lots of colds at nursery recently.
On examination, the GP notes periorbital and ankle oedema. Heart sounds are normal, but on auscultation of the lungs, basal crackles are heard bilaterally.
Urinalysis reveals proteinuria, but no haematuria.
What is the most likely underlying condition?
Answer = minimal change disease
Why not the others:
- Heart failure
- peripheral oedema
- proteinuria suggests alternative case - IgA neprhopathy
- type of nephritic syndrome
- commonly presents with haematuria and proteinuria,
- may be associated with concurrent acute infective illness such as URTI or gastroenteritis - Membranous nephropathy
- Post streptococcal glomerulonephritis
- type of nephritis syndorme
- haematuria and proteinuria
- often after group A strep infection (tonsilitis)
which are important additional blood tests which form part of the ‘Confusion Screen’
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
**Glucose: **hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
What type of palsy is bells palsy?
- lower motor neuron facial nerve palsy
- forehead is affected
Important features of Myeloma
Use the mnemonic CRABBI:
Calcium
hypercalcaemia
primary factor: due primarily to increased osteoclastic bone resorption caused by local cytokines (e.g. IL-1, tumour necrosis factor) released by the myeloma cells
much less common contributing factors: impaired renal function, increased renal tubular calcium reabsorption and elevated PTH-rP levels
this leads to constipation, nausea, anorexia and confusion
Renal
monoclonal production of immunoglobulins results in light chain deposition within the renal tubules
this causes renal damage which presents as dehydration and increasing thirst
other causes of renal impairment in myeloma include amyloidosis, nephrocalcinosis, nephrolithiasis
Anaemia
bone marrow crowding suppresses erythropoiesis leading to anaemia
this causes fatigue and pallor
Bleeding
bone marrow crowding also results in thrombocytopenia which puts patients at increased risk of bleeding and bruising
Bones
bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity creates lytic bone lesions
this may present as pain (especially in the back) and increases the risk of pathological fractures
Infection
a reduction in the production of normal immunoglobulins results in increased susceptibility to infection
The classic triad of vasa praevia
- rupture of membranes
- followed by painless vaginal bleeding
- and fetal bradycardia.
A 40-year-old female presents with a six-hour history of painful visual loss of her right eye. She feels well otherwise and reports no nausea or vomiting. On examination, the patient’s right eye pupil does not constrict when exposed to torchlight and exhibits paradoxical dilatation on the swinging light test consistent with a relative afferent pupillary defect.
The patient’s temperature is 36.8ºC, BP 128/72mmHg, heart rate 80 beats/min.
What is the most appropriate investigation for the underlying cause of her symptoms?
Optic neuritis may present with MS
Gold standard = MRI with contrast
this is a particular risk for women with PCOS who undergo IVF.
Ovarian hyperstimulation syndrome
- vasoactive substances such as VEGF, increase membrane permeability and loss of fluid from the intravascular compartment
this translocation is seen in is seen in around 95% of patients with chronic myeloid leukaemia
Philadelphia chromosome - t(9:22)
Hyperemesis gravidarum, diagnostic criteria triad:
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
majority of encephalitis caused by
HSV-1
- typically affects temporal and inferior frontal lobes
key investigations of encephalitis
- CSF
- lymphocytosis
- elevated protein
- PCR for HSV, VZV and enteroviruses - Neuroimaging
- medical temporal and inferior frontal petechial haemorrhages - EEG
Mx - oral aciclovir
Stereotypical PCOS results:
raised LH:FSH ratio
testosterone may be normal or mildly elevated
SHBG is normal to low
is a useful tool to assess hypermobility.
Beighton score
Autosominal dominant connective tissue disorder
- mostly affects type 3 collagen
- leads to tissue becoming more elastic
- leading to joint hypermobility and increased elasticity of the skin
salpingectomy vs salpingotomy
laparoscopic salpingectomy (removal of the affected tube) or salpingotomy (removal of the ectopic pregnancy material and retaining the tube)
Subacute combined degeneration of the spinal cord
due to vitamin B12 deficiency resulting in impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts..
57 Male
pc: 3/7 fever + rash , normally fit and well
hpc: 8/7 amoxicillin for CAP , now resolved
dh: allopurinol for gout
oe: erythematous, maculopapular rash and mild wheeze in auscultation of chest
obs: pyrexic, htn
high urea, high creatinine, impaired renal function
likely diagnosis
acute interstitial nephritis , causes allergic type picture (consisting of raised urinary WCC, IgE and eosinophils alongside impaired renal function)
Raynauds 1st line management
calcium channel blockers e.g. nifedipine
