PLAB Mock Exam Cards Flashcards
8 year old boy with progressive limping, chronic groin pain, hip pain
xray shows flattening and sclerosis of right femoral head with lucencies in metaphysis
Diagnosis?
Perthes’ Disease
3-9 year old with progressive limp.
if:
0-3 y/o +painless= developmental dysplasia (breech delivery risk factor)
9-15+painful=slipped upper femoral epiphysis (obese risk factor)
Cardiogenic shock
vs
Neurogenic shock
Cardio - increased pulmonary capillary wedge pressure
Neuro- decreased heart rate
27 y/o female with lower abdominal pain, vaginal spotting, LMP 7 weeks ago, tender abdomen, cervical motion, empty uterus, high bHCG.
treatment?
if hemodynamically stable LAPAROSCOPIC salpingectomy
if unstable
LAPAROTOMIC
50 y/o with breast cancer 3 years ago, now with thirst and confusion, drowsiness, left shoulder pain.
metabolic abnormality?
Hypercalcemia
[moans(constipation), groans (lethargy, confusion), stones, bones (bone pain due to hyperparathyroidism)
Hypercalcemia happens because breast tumor metastasis to bone
Patient on warfarin with INR of 3.3 (0.8-1.2) had major bleed.
treatment?
Stop Warfarin->
IV Vit K1->
IV prothrombin complex concentrate (FFP as alternative if not available)
Mobile breast mass on upper outer quadrant.
Well circumscribed, unencapsulated, clear margins, seperate from fatty tissue overgrowth of fibrous and glandular tissue, with small degree of stromal cellularity.
Fibroadenoma.
if fluid filled- Breast cyst
if tender, with wedge shaped erythema- lactational mastitis
if with nipple discharge and nipple retraction - periductal mastitis
if with nipple discharge and inversion - duct ectasia
if with trauma - fat necrosis
Female with pelvic pain that worsens on standing, post coital ache, no discharge.
Diagnosis?
Dull ache aggravated by standing = Pelvic Congestion syndrome
pain during intercourse with no standing aggravation = premenstrual syndrome
Number needed to treat (NNT) means?
number of patients who need to be treated to prevent 1 bad outcome
Epigastric pain radiating to back, alcoholic, normal LFT.
Diagnosis?
Pancreatitis.
To confirm use fecal elastase/ fecal chymotrypsin in chronic pancreatitis (reduced)
and serum lipase and amylase in acute pancreatitis.
Differentiate between
First Degree Heart Block
Second degree heart block
Third degree heart block
1)Pr > 0.2 seconds
2)
a) mobitz type 1= progressive prolongation of PR interval until dropped beat
b) mobitz 2= PR is constant but P wave can precede absent QRS
3) complete heart block= regular p wave but completely unconnected to QRS
Treatment of Heart Blocks
1st degree= no tx
2nd degree
mobitz 1= if symptomatic-> Atropine
mobitz 2= if symptomatic atropine initially then pacemaker
3rd degree= atropine-> transcutaneous pacing-> pacemaker
Long plane trip, with sharp chest pain and breathlessness
Diagnosis?
DVT-> Pulmonary Embolism
PE=Pleurotic chest pain, Dyspnea, Tachycardia, Hypoxia, Cough, Hemoptysis, Leg swelling.
CXR will be normal do CT Pulmonary Angiogram (Gold standard)
CXR is initial investigation.
Treatment=
Apixaban/ Rivaroxaban in stable
unfractionated Heparin in unstable
Tearing chest pain between scapulae,
hypotension, Tachycardia, diaphoresis (sweating), difference in BP, absent pulses
Diagnosis?
Aortic Dissection
TB Drugs and Side effects?
Isoniazid= peripheral neuropathy
Rifampicin= liver test derangement in the first 2 months of tx (reassure) Red urine tears, etc…
Pyrazinamide= hyperurecemia
Ethambutol= retrobulbar neuritis
Contraceptive efficacy based on Pearl Index
Pearl Index= if 100 women use this method and 2 (eg) get pregnant regardless, then the pearl index is 2
Male Condom= 2
Combined OCP=0.3
Progesterone pill= 0.3
PROGESTERONE INJ = 0.2
copper iud= 0.6
female sterilisation = 0.5
MIRENA IUS = 0.2
MALE STERILISATION= 0.15
SUBDERMAL IMPLANT= 0.05 (LOWEST)
Cocaine using woman with constant abdominal pain, tender, woody hard uterus, bleeding, fetal death/distress.
Placental Abruption
(seperation of normally placed placenta-> hemorrhage)
extent of bleeding may be behind placenta->hypovolemic shock.
Constipation after Sx, vomiting, abdominal distension, no bowel sounds, no pain.
XR shows air fluid filled loops of bowel
Diagnosis?
Paralytic ileus
Treatment (“drip and suck”)
IV fluids + NG tube
associated with hypokalemia and hypercalcemia.
Pregnant rhesus negative woman. previous pregnancy had recurrent antepartum hemorrhage. she has anti-D antibodies.
at 33 weeks she has reduced fetal movements
Most appropriate investigation?
Fetal middle Cerebral Artery on US.
if Rh-ve mother delivers Rh+ve baby->
leakage of fetal rbc(recurrent antepartum hemorrhage) ->
formation of anti D antibodies->
cross placenta->
fetal hemolytic anemia
Fetal middle Cerebral Artery is used to assess hgb-> check if there is fetal anemia or not
if FMCA is abnormal do fetal cord sampling next (invasive) .
How to prevent Rh Sensitization?
and how will the fetus be affected?
test for anti D in all Rh-ve mothers
if Rh-ve and not previously sensitized offer SINGLE IM Anti D immunoglobulin at 28 weeks
if unborn=
heart failure, hydrops fetalis (edema)
Treatment= blood transfusion
if born=
jaundice (hemolytic anemia) , anemia, hepatomegaly
Treatment= UV light, blood transfusion, exchange transfusion.
Painless ulcer on left axilla, after left mastectomy and radiotherapy after breast CA.
Ulcer has central depression, rolled edges, blood vessels crossing the surface, with pigmentation.
Diagnosis?
Basal Cell CA
depressed ulcer with rolled edges and telangectasia is characteristic.
radiotherapy is a risk factor
if it were scaly or crusty without pigmentation-> Squamous Cell CA
Old man on ACE Inhibitor for heart failure.
Routine blood tests to perform?
RFT in 1-2 weeks after starting ACE
then once a year.
if it deteriorates -> suspect Renal Artery Stenosis.
If Sodium Valproate-> check LFT
28 y/o with HR of 132 bpm, bp of 120/70, RR of 21. ECG shows Supraventricular Tachycardia.
management?
SVT= regular narrow QRS with no P waves
If stable (in this sequence)
1)Valsalva
2)carotid massage
3)Adenosine (antiarrhythmic) (if patient has asthma use Verapamil(CCB) )
if unstable (or 3 doses of adenosine dont work)=
Direct current cardioversion
Prevention= Beta Blocker
D/D
Atrial Fibrillation= IRREGULAR narrow QRS without P waves (treat with Beta Blocker)
Ventricular Tachycardia= regular BROAD QRS without P waves
Child with rash on cheeks, sparing eyes and nasolabial folds. rash spread to limbs and trunk, mild fever.
Diagnosis and Treatment?
Erethyma Infectuosum (Slapped cheek disease): erethymatous maculopapular rash on face, sparing eyes. caused by Parvovirus B19
Self limiting, reassure, analgesics
if the patient is unstable then full CBC with reticulocyte count.
complications=
in hemolytic anemia patients-> aplastic crisis
in pregnant women-> hydrops fetalis
How to deal with rashes and school attendance in pediatrics?
chicken pox= keep away from school until vesicles have crusted and 5 days after rash appeared
Impetigo= keep away until lesions are crusted and healed or 48 hours after antibiotic
Scarlet fever = keep away until 24 hours after antibiotic
Measles/Rubella = keep away for 4 days after rash started
(patients with HFM disease, Cold sores, Erethyma Infectuosum, Molloscum contagiousum, Roseola all dont need to avoid school)
Differentiate between
Roseola, Hand Foot and Mouth Disease, Parvovirus B19, Measles, and Rubella
Roseola= sudden fever with non itchy PINK spots/patches on chest that spread to the rest of the body.
Parvovirus B19= red rash on cheeks sparing eyes, spreading to limbs
Measels= red-brown blotchy rash on head/neck with tiny grey spots in mouth (Koplik spots)
Rubella= red-pink spotty rash starting behind ears
HFMD= PAINFUL ulcers on tongue, grey blisters on hands and feet
Be wary of signs of meningitis (stiff neck, photophobia, uncontrollable fever)
First line long-term treatment of menorrhagia in a woman who may want children in the future?
Mirena Coil (Levonogestrel intrauterine system)
not COCP because its short term, has risk of venous thrombosis in smokers, obese and >30 y/o
not Cooper IUCD/Progesterone implant because has risk of irregular heavy bleeding.
not endometrial ablation because she wants children in the future.
NICE Guidelines for menorrhagia:
Mirena
Transexamic acid/NSAID/COCP
Norethisterone 15mg from days 5-26 of cycle (or 5mg TID for 10 days for rapid stopping of menstrual bleeding)
Important combinations:
Transexamic acid + NSAID= for bleeding+ dysmenorrhea
NSAID+COCP= dysmenhorrea
(DO NOT COMBINE TRANSEXAMIC ACID WITH COCP OR MIRENA)
Which form of contraception is best for the following cases?
Woman with menorrhagia+Fibroids
Woman with sickle cell
Emergency contraception 72 hours later
Emergency contraception 120 hours later
1) Mirena
2) Depo provera IM
3) levonelle pill
4) IUCD/ ellaOne pill
22 y/o man with recurrent fainting while exercising.
Ecg shows: 80bpm, normal QRS, normal PR, prolonged QT
Which Arrhythmia is associated with his condition?
Ventricular Tachyarrhythmia
this patient has long QT syndrome= Torsades de Pointes (Vtac)
22 y/o female with recurrent depressive episodes (low mood, anhedonia, somnolence, poor appetite and weight loss) has recently become overly happy and rarely sleeps. Her grandmother passed away recently and she laughed loudly at the funeral.
Diagnose the patient and mention the best descriptor for her behaviour.
Bipolar disorder due to mood incongruence.
First line management of depression in an adolescent?
Psychotherapy
the antidepressant of choice in patients under 18 y/o after psychotherapy is fluoxetine.
Man with angina, systolic murmur at 2nd IC space on the right of his sternum lost consciousness for 5 minutes while seated on his sofa.
BP 120/70, Pulse 70bpm
Most appropriate term to describe this event?
Syncope due to systolic murmur caused by aortic stenosis (associated with dyspnea, angina and syncope)
Neurological patient who is unaware of items on his left side, eats exclusively on one side of his plate, and draws a clock with all the numbers on one side.
Likely pathology?
Parietal Lobe damage.
the patient is suffering from hemineglect, where he can see fine but has lost the motivation to respond to stimuli on one side.
A 7 y/o boy was diagnosed with Becker’s, his 2 sisters are asymptomatic.
what is the % chance of an unborn female being a carrier of the gene associated with Becker’s Muscular Dystrophy
50%
Becker’s is X-linked recessive, meaning 2 affected X chromosomes are necessary to be symptomatic while 1 is needed to be a carrier. since the mother provides 1 of 2 X chromosomes to her female children there is a 50% chance the one she provides will be affected.
70+ y/o woman complaining of forgetfulness and social withdrawal for 3 months. her husband passed 4 months ago. she has a history of depression 20 years ago.
Most likely diagnosis?
Psudodementia (depressive dementia)
presentation is short and abrupt, as opposed to the gradual onset of dementia.
Hint: Psudodementia patients usually seek help themselves while demented ones do not.
Differentiate the following dementias
Alzheimer’s
Pick’s
Vascular dementia
Lewy body dementia
Parkinson’s
normal pressure hydrocephalus
Alzheimer’s=
MC type of dementia, caused by amyloid plaques and NF tangles, reduced acetylcholine.
begins with amnesia+spatial disorientation->personality changes, dysphasia, apraxia -> apathy, immobility, incontinence.
Confirmed by FDG-PET/SPECT imaging, or analysis of CSF for tau
Pick’s (Frontotemporal Dementia)=
Due to degeneration of Frontotemporal regions of the brain.
presentation: usually younger (50-60s) altered personality, social disinhibition (sexual), behavioural changes, muscle rigidity. gait initiation is impaired (frontal lobe involvement)
same scans as Alzheimer’s to confirm.
Vascular Dementia=
after stroke, presents with stepladder pattern of memory disturbance.
confirmed with MRI/ CT if MRI is CI
Lewy Body Dementia=
due to vascular deposits of lewy bodies. presents with visual hallucinations.
Parkinson’s=
due to degeneration of dopamine pathways in the substantia nigra.
presents as movement disorder diagnosed as
Bradykinesia+ 1 of either muscle rigidity, tremors at rest, or postural instability.
Normalpressure Hydrocephalus=
due to ventricular dilation with normal CSF pressure, can be preceded by SAH/meningitis/head injury/ CNS CA.
presents as
Wet (Urinary incontinence)
Wobbly (Broad gait)
Wonky (Dementia)
treated by CSF shunt
CPR steps for 11 month old baby
First if child is breathing abnormally give 5 rescue breaths.
Compression:Ventilation ratio of 30:2 for adults, 15:2 for children.
index and middle finger/two thumb compression on lower third of sternum (UNDER 1 Y/O)
heel of one hand over lower half of sternum compression (OVER 1 y/o)
4 y/o boy with recurrent UTI that require antibiotics.
most common anatomical abnormality?
Vesicouretric reflux.
usually asymptomatic, increases risk of UTI.
Diagnosed by
Urinalysis (INITIALLY)
Micturating cystourethrogram (GOLD STANDARD)
Technitium Scan (check for scarring)
Treatment
prophylactic antibiotics daily
if above fails/ any breakthrough UTI/persistent high grade reflux then -> reimplantation of ureters
34 y/o obese man with right flank pain for 4 days and reduced urine output.
CT KUB shows 14mm stone in right proximal ureter with hydronephrosis.
CRP, Urea and Creatinine are high
eGFR is low.
Most appropriate treatment?
Ureteric Stent. (thin tube in ureter)
Initial management done to decompress the collecting system (to prevent infection due to urine buildup) until ESWL/uretroscopy can be done.
His obesity makes a nephrostomy less desirable since you would have to pass multiple thick layers.
How would you approach the following kidney stones?
<0.5cm
0.5-2cm
>2cm
1) increase fluid intake
2)ESWL or uretroscopy with YAG laser
3) Percutaneous nephrolithotomy
Define Qualitative Research
non numerical data is collected (why/how)
32 y/o man thinks nurses are trying to harm him and steal ideas from his mind.
Diagnosis?
Schizophrenia.
due to the presence of persecutory delusion and thought withdrawal.
Features of schizophrenia:
Auditory hallucinations:
third person= voices refer to them as he or she not you.
thought echo= content is the individuals thoughts
Thought disorders:
insertion
withdrawal
broadcasting= ones thoughts are accessible by others
blocking= break in chain of thought
Passivity phenomena: bodily sensations controlled by external influences
Delusional Perceptions:
where normal objects are perceived followed by a sudden delusion. (traffic light is green therefore i am king)
Mention the preliminary tests, adverse effects and Contraindications to prescribing Sodium Valproate for epilepsy.
1)LFT, CBC, Pregnancy test
2)Vomiting, Alopecia, Liver toxicity, Pancreatitis, Retention of fats, Oedema, Appetite changes, Tremors, Enzyme inhibition.
3) Severe liver dysfunction, urea cycle disorders, mitochondrial disorders and acute porphyrias
Best treatment for patient already on morphine with history of prostate CA that was radically treated now complaining dull constant bone pain associated with left femur mets.
Radiotherapy (causes tumor shrinkage) is the next best tx (morphine being the first line treatment for pain) for palliative cancer induced bone pain.
useful in localized metastasis (left femur).
Bisphosphonates can also be used with NSAIDs as the third line
Differentiate the following Bacterial STDs
Chlamydia
Gonorrhea
Syphilis
Chancroid
Chlamydia (Chlamydia trachomatis):
(tx Doxycycline/ Azithromycin)
in Men= dysuria+discharge, complication-> epididymo-orchitis (scrotal pain+discharge). diagnosis starts with NAATs first catch urine.
In women= vaginal/ post coital bleeding, dysuria. complication-> PID (lower abdominal pain, deep dyspareunia, and cervical motion tenderness.) diagnosis-> NAATs vulvovaginal swab.
Gonorrhea (Neisseria Gonorrhoeae):
similar presentation and diagnosis to Chlamydia.
tx: ceftriaxone/ciprofloxacin
Syphilis (Trepanoma Pallidum) :
presentation=
primary: chancre (painless ulcer)
secondary: widespread rash of palms and soles+fever, malaise and lymphadenopathy
tertiary: gummas (granulomatous lesions) , CVS Syphilis (AAA), neurosyphilis (dementia)
Diagnosis: ulcer PCR/ dark field microscopy.
Chancroid (haemophilus ducreyi):
presentation:erethymatous papular lesion in genitalia-> painful ulcer.
33 y/o man complaining of vomiting, malaise, and fever 3 weeks after coming back from North Africa.
on exam he had scleral icterus, tender enlarged liver, and no palpable spleen.
ALT AST BILIRUBIN are high.
Diagnosis?
Amoebiasis, entameba histolytica is endemic in North Africa.
Presentation: fever, anemia secondary to intestinal hemorrhage, and tender hepatomegaly + deranged LFT (due to hepatic abscess), and diarrhea.
D/D
Malaria: but MALARIAS NEVER SEEN IN NORTH AFRICA
Typhoid: hepatoSPLENOmegaly, Cough, bradycardia, epistaxis and neutropenia with lymphocytosis.
Schistosomiasis: rash at lower leg after swimming, dry cough, more GI symptoms.
Dengue: NO DENGUE IN NORTH AFRICA
48 y/o smoker for 30 years has 2cm hilar mass on chest xr.
histology showed Kerstin pearls and intracellular bridges.
Most likely type of lung CA
Squamous Cell CA.
Keratinizing: keratin pearls
associated with smoking, usually presents centrally
adenocarcinomas present peripherally and are not very associated with smoking
6 month old boy with irritability, lethargy, and fever. Urinalysis shows leukocyte esterase positive and nitrite negative.
most likely investigation to lead to a diagnosis?
Urine Culture and sensitivity.
to confirm UTI diagnosis
Treatment of infants and children from 3 months to 3 years old with UTI:
If leukocyte esterase and nitrite are negative= no treatment required
if either one is positive= antibiotic treatment + urine sample
84 y/o woman with tenderness and tingling along the 6th and 7th left ribs from the front to the back.
Diagnosis?
Herpes Zoster Infection.
UNILATERAL pain and tingling across ribs from front to back. (unilateral nerve symptoms due to herpes zoster reactivation affecting a specific dermatome)
Its recommended to follow up with the patient to check if a rash emerges.
Most appropriate initial management in a patient with 3rd degree heart block?
Atropine
followed by temporary pacing if atropine fails,
and then a permanent pacemaker, if temp pacing fails.
Penicillin allergic, afebrile patient with 2 day history of blistering rash on her left leg with pain localized to her ankle.
Diagnosis and management?
Cellulitis.
Flucoxacillin is first line but cannot be used in this patient due to penicillin allergy.
therefore clarithromycin is the antibiotic of choice here.
After a car accident patient has ARDS, hypotension, reduced air entry on right side, trachea deviated to left side
Diagnosis and management?
First administer high flow oxygen to the patient.
Needle decompression at 5th intercostal space (above 6th rib to avoid neurovascular bundle) at mid-axillary line using a large bore cannula.
after decompression a chest drain should be inserted and an xray should be done to ensure chest drain placement.
58 y/o male with dyspepsia, weight loss and reduced appetite. he also has a mass in the left supraclavicular fossa.
Diagnosis?
Gastric CA, the mass is Virchow’s node and is a sign of Gastric CA metastasis.
if the LN involved was cervical then Hodgkins lymphoma is a differential
13 y/o girl with 3 day history of hoarseness of voice, dry cough, fever and malaise. on examination her vocal chords are grossly edematous.
Next best investigation?
None, reassure the patient.
case of common cold/laryngitis.
Which Medication is used to reduce alcohol withdrawal symptoms?
chlordiazepoxside (benzo) is used for alcohol withdrawal.
Thiamine is given to prevent wernicke’s encephalopathy.
Lorazepam is used for delirium tremens. (confusion, delirium, hallucinations)
Disulferam is used to reduce alcohol DEPENDANCY by inducing a feeling of sickness when around alcohol.
Acamprosate is also used to reduce dependency but by decreasing alcohol cravings.
Inheritance of Alport Syndrome?
80% are X-linked
15 are Autosomal Recessive
and 5% are Autosomal dominant.
the likelyhood of a man with Alport passing down the disease to his son is close to 0%
34 y/o male presents with slowly progressing dysphagia. He has been using H2 blockers for the last year because of retrosternal discomfort.
no weight loss, or change in hemoglobin.
most likely diagnosis?
Peptic Stricture.
can cause dysphagia and is associated with GERD.
no weight loss or hgb change rules out CA
What are the 2 main mechanisms of dysphagia?
Motility problem (both solids and liquids are affected): like achalasia, scelroderma (if the dysphagia is progressive) or esophageal spasm (if the dysphagia is intermittent).
or
Mechanical problem: (liquids are fine at first but progressively gets affected): like carcinomas, peptic Stricture (progressive) or esophageal ring (intermittent)
first line diagnostic procedure for all dysphagias (except pharyngeal pouch) is endoscopy.
61 year old man with 2 day history of epigastric pain and vomiting. he has been vomiting bright red blood. he has a history of RA and has been taking naproxen and prednisolone.
primary diagnostic procedure?
Urgent GI endoscopy.
history of NSAID (naproxen) and corticosteroid use with bright red blood signifies an upper GI bleed,
What do you expect to find in a patient with salicylate (aspirin) poisoning?
Vomiting, nausea, TINNITUS, deafness, hyperventilation, and hypokalemia.
ABG shows a mixed metabolic acidosis with respiratory alkalosis.
What is the single most appropriate management for venous thromboembolism prophylaxis after a surgery?
Encourage early mobilization.
LMWHeparin is used in patients with lower limb surgeries who cannot ambulate for long periods
How to manage chickenpox exposure in pregnancy?
check varicella zoster antibodies if the mothers immune status is unknown or if there’s no history of chickenpox.
If the mother is not immune to VZV and had significant exposure she should be offered Acyclovir on day 7 after exposure (not before)
Most important red flag adverse effect to look for when taking warfarin?
Severe headache (intercranial bleed)
patient unable to dorsiflex his foot after sustaining trauma to the same leg on the lateral side above the knee.
which nerve is affected
Common peroneal nerve (loss of dorsiflexion of foot/foot drop.)
Child with eye swelling, redness increased warmth and tenderness of eyelid.
diagnosis?
Periorbital Cellulitis.
d/d orbital cellulitis (gaze restriction, ptosis, pain on eye movement) tx=iv antibiotics (URGENTLY)
Child with swollen face, feet and legs. increased weight despite poor feeding and foamy appearance of urine.
diagnosis, and investigation?
Neohrotic syndrome (proteinuria, hypoalbuminemia, and edema) caused by minimal change disease (common in children)
Most appropriate investigation would be 24 hour urine protein
Which 3 cancer screening programs are available in the UK?
Breast (50-70 y/o women every 3 years by mammogram)
Bowel (60-74 y/o men and women by fecal immunochemical test)
Cervix (24-64 y/o women every 3 years until 49 and then every 5 years until 64 by cytology and HPV)
Patient with severe abdominal pain, fever and reduced bowel sounds 7 days after a surgery
diagnosis, investigation and management?
Anastomotic leak
CT abd and pelvis with PO and IV contrast
small leak-> antibiotics
large leak-> percutaneous drainage
If large with sepsis/peritonitis-> open surgery
Step up management of asthma?
1)low dose inhaled corticosteroid (budesonide/beclamethasone) + SABA (salbutamol) as required
2)Add LABA (salmeterol) to low dose ICS or trial of montelukast
3) LABA+ MODERATE dose ICS or trial of montelukast
4) HIGH dose ICS or trial of tiotropium
Presentation of flail chest?
paradoxical respiration with SOB after trauma
XR shows rib fractures
Tx= high flow O2, analgesia, splinting, intubation
patient with painless, cystic scrotal swelling at upper pole of posterior testes
diagnosis?
Epididymal cyst (painless, behind testes)
D/D hydrocoele (usually anterior and is not seperate from the testes)
When can DNR be issued
1) if resuscitation is unlikely to succeed
2)if the patient (with mental capacity) requests it
3)if it is requested in the living will
4)if resus would lead to a poor quality of life.
38 y/o female patient with amenorrhea for 8 months after chemo. fsh was over 40 at 2 seperate testings 1 month apart.
diagnosis and management?
Premature ovarian failure
<40 y/o with menopause-like symptoms + 2 raised levels of fsh over 40, 4 weeks apart.
tx=HRT until 51 y/o
d/d premature menopause (usually at 40-45 y/o)
Most important lab value in PCOS?
High LH (2:1 LH:FSH)
Treatment of alcoholic with confusion, hallucinations, sweating, disorientation, seizures. 2 days after alcohol consumption has been reduced.
diagnosis and initial treatment?
delirium tremens. usually 1-3 days after reduced alcohol intake.
tx= Oral lorazepam/iv midazolam
then thiamine to prevent wernickes encephalopathy.
Alcoholic with confusion, ataxia, ophtalmoplegia.
diagnosis?
Wernickes encephalopathy.
tx= thiamine iv
if added symptoms of amnesia and confabulation then it is korsakoff syndrome
Patient with wheals on skin and itching after viral inf. for 2 weeks
diagnosis and management?
Actue Urticaria (chronic if >6 weeks)
sometimes eyes, lips and tongue can be edematous.
tx= nonsedating Antihistamines, if pregnant then chlorphenamine (sedating) .
if allergic to Antihistamines then adrenaline
54 y/o myopic male with flashes of light and painless loss of vision. says a curtain fell over his vision. ophtalmoscope showed grey retina ballooning forwards.
diagnosis and most appropriate treatment?
Retinal detachment
flashing lights, curtain/floaters, field of vision loss, fall in acuity)
(can be spontaneous or traumatic,
risks= >40 y/o myopia and cataract surgery)
diagnosed by slit lamp (seperated retina from eye)
tx= sceral buckling
patient with night blindness, peripheral vision loss and similar family history
diagnosis and management?
Retinitis pigmentosa
routine ophthalmic referral.
Patient with new glare at night while driving?
cataract
patient with colored haloes around lights?
acute angle closure glaucoma
patient with cherry red macula on examination?
central retinal ARTERY occlusion
old patient complaining of straight lines bending and colors becoming dull?
age related macular degeneration
patient with painless loss of vision, flame shaped hemorrhages, macular or optic disk edema?
central retinal VEIN occlusion
patient with unilateral decrease in vision, pain on eye movement, decrease in color vision?
optic neuritis
tx=steroids
60 y/o woman with pain during intercourse, 3 episodes of vaginal bleeding in the past month, no abnormalities on cervical smear 3 years ago. normal cervix and vagina on speculum exam.
diagnosis?
Endometrial cancer.
postmenopausal women complaining of bleeding.
first line investigation is transvaginal ultrasound (if thickness of endometrium is <4mm then usually negative)
hysteroscopy with biopsy gives the definitive diagnosis.
20 y/o with otitis media complaining of headache, sensitivity to light, shivering and sweating with fever.
which complication is he suffering from?
Meningitis (look for sensitivity to light)
otitis media infection ascending through the mastoid
33 y/o woman 8 weeks pregnant wants to know fetal viability.
Most specific investigation?
transvaginal ultrasound is the most specific (looking for fetal heartbeat which appears at 6 weeks)
the first is abdominal ultrasound
CTG done only after 28 weeks
Difference between osteoarthritis and rheumatoid arthritis?
osteoarthritis: 50 y/o, unilateral, pain on movement, usually hip and knee, DIP joint can be involved, heberdens nodes are frequently found.
rheumatoid arthritis: 30-50 y/o, symmetrical, early morning stiffness, usually MCP PIP AND MTP are involved, DIP is spared and no heberdens nodes
Which joint is always spared in RArthritis but involved in OsteoA?
Distant Interpharyngeal joint.
Investigations and treatment in RheumatoidA?
Rheumatoid factor first
anti CCP (highly sensitive and specific) if RF is negative
tx= rheumatologist referral, steroids, nsaids, methotrexate started in the first 3 months
D/D atrial fibrillation and SVT
AFib= irregular narrow QRS, unconscious
SVT= regular narrow qrs, conscious
First management in patient with fracture resulting in deformity, swelling and loss of distant pulses?
Reduce fracture urgently under analgesia or sedation using sterile dressing for open fractures. even before xray
if pulses dont return then inform vascular surgeon.
When to use an NG tube in a palliative setting?
patients vomiting does not subside (after subcutaneous cyclizine)
or if vomiting has fecal content
5 y/o boy with hearing loss, speech/language delay, lack of concentration, social withdrawal.
examination shows retracted, grey, tympanic membrane with an air fluid level.
diagnosis?
Otitis media.
presents with patient listening to tv at loud volumes, has to have things repeated to him, lack of concentration.
retracted or bulging dull grey/ yellow tympanic membrane are findings
tx=reassure and review in 3 months
then surgery (grommit insertion) or hearing aid if surgery is CI
patient with pelvic inflammatory disorder now complaining of severe abdominal pain, fever and tachycardia.
diagnosis and investigation?
Pelvic/tubo-ovarian abscess.
transvaginal US is the diagnostic method of choice
1 week old baby boy with vomiting, weight loss, lethargy and dehydration.
hypokalemia, hyponatremia, and hypotension.
US abdomen shows enlarged adrenal glands.
diagnosis?
Congenital Adrenal Hyperplasia.
AR, can present with penile enlargement and hyperpigmentation in boys and ambiguous genitalia in girls
70 y/o man with decreased ability to hear and understand speech. examination shows normal eardrum.
sensorineural bilateral hearing loss worse at high frequencies.
diagnosis?
Presbyacusis.
progressive bilateral sensorineural hearing loss in >50 y/o
tx= high frequency hearing aid
d/d
otosclerosis if conductive hearing loss
Gay male complaining of urethral discharge and dysuria. chlamydia positive
most common complication?
epididymo-orchitis (unilateral testicular pain)
Painless lump in testes.
investigation?
Testicular CA
most common spread is to para aortic lymph nodes. metastasis is rare but can spread to prostate and lung
US first line
CT for staging
Urge incontinence vs Stress incontinence?
Urge= leak with urgency to micturate due to detrusor instability or hyperreflexia
tx= first step is behavioral tx, then anticholinergics
Stress= leakage on exertion/sneezing/coughing due to incompetent sphincter
tx= pelvic floor exercises
2 month old afebrile boy with itchy dry skin over scalp face neck and elbows.
diagnosis?
Atopic dermatitis/eczema.
<1 y/o dry cracked itchy skin
tx= emollients and topical steroids
mild eczema= mild topical steroid (hydrocortisone)
moderate (same symptoms + disturbed sleep) = moderate steroid (betamethasone)
severe (bleeding, skin thickening, interferes with eating) = clobetasol
Patient with circukar reddish elevated plaques on extensor surfaces and scalp. pinpoint bleeding is seen at scratching sites and new lesions appear at sites of injury.
diagnosis and management?
Psoriasis
pinpoint bleeding= auspitz sign
new lesions at injury == kobner reaction
tx= corticosteroids, vit d and tar
patient with inflamed scaling rash on face scalp and chest. dandruff.
diagnosis and management?
seborrheic dermatitis
tx= antifungal, and topical steroids
Hypertension stages and management?
1) >140/90 in clinic+ >135/85 at home
tx= if patient has any comorbidities
2) >160/100 + >150/95
3) if systolic is over 180 or diastolic over 120
tx=
ACE/CCB (if above 55 y/o or black)
ACE+CCB/Thiazide
ACE+CCB+Thiazide
Most appropriate med for alcohol withdrawal symptoms?
chlordiazepoxide
acamprosate for anticraving
disulferam for deterrent
Patient fell on outstretched hand, lateral elbow swelling, limited elbow ROM, pain on passive elbow rotation.
Most likely fracture?
if adult radial head
if child radial neck.
which fractures do you expect to find in the following histories?
fall on outstretched hand
blow to elbow
blow to flexed elbow
1) radial head in adults, radial neck in children or distal humerus
2) intercondylar fx
3) condylar fx
risk factors and how to treat delay in first stage of labor?
inefficient uterine activity, large baby/malposition/malpresentaion, inadequate pelvis.
tx=IV oxytocin
65 y/o Patient with lethargy, weakness, bone pain, weakness, pallor.
low hgb, high serum urea, creatinine and calcium
low eGFR.
diagnosis and most appropriate investigation?
Multiple Myeloma( bone disease, renal failure, anemia, hypercalcemia)
urine protein electrophoresis for bence jones protein
treatment of gout?
actue= NSAIDs, Colchicine, intrarticular steroid
chronic=allopurinol(only 2 weeks after the acute attack has settled)+Colchicine/nsaid
elderly diabetic man recently finished oral antibiotics, complaining of difficulty and pain on swallowing.
examination shows white patches on tongue.
diagnosis and management?
Oral thrush (white patches on tongue that can be easily removed, caused by dm, inhaled corticosteroid, antibiotics)
tx= oral fluconazole
d/d leukoplakia (smoker with white patches that hurt and bleed when removed)
when to suspect a malignant melanoma?
Asymmetry
Border (irregular edges)
Color ( different shades)
Diameter (>6mm)
Evolution.
risks= fair skin, blue eyes, family history, UV rays
tx=excisional biopsy
56 y/o patient with headache, neck stiffness, scalp tenderness when combing hair, and decreased vision
esr is high
diagnosis and management?
Temporal arteritis/giant cell arteritis.
>50 y/o with decreased vision + scalp tenderness + high esr
definitive diagnosis by temporal artery biopsy
tx= high dose prednisone (60mg daily) to prefent permanent vision loss. aspirin can be added
Sepsis red flags
systolic BP <90
hr >130
spo2 <91%
rr >25
urine output <0.5ml/kg/hour
management (sepsis six)
take 3 give 3
take blood culture + urea and electrolytes + urine output
give high flow O2, IV fluid challenge, IV antibiotics.
SEPTIC SHOCK DEFINED ONLY AFTER NO RESPONSE TO IV FLUID CHALLENGE
Women with a neck mass that has been progressively increasing over the period of a year. she has a sensation of choking when lying flat, and examination shows a thyroid goitre. isotope scan showed a cold nodule, FNAC was done and showed no evidence of malignancy.
TSH and thyroxine are normal.
diagnosis and management?
Benign multinodular goitre (compressing trachea)
nontoxic type (normal thyroid hormones) tx= thyroidectomy especially with compression symptoms
toxic type tx=antithyroid drugs, radioiodine (first line) and surgery for disfigured patients
a Thalassemia major vs B thalassemia minor
a) lethal in utero, associated with hydrops fetalis
B) in infancy with FTT, vomiting, sleepiness, hepatosplenomegaly, frotnal bone bossing, marked pallor, iron overload
management= lifelong blood transfusions, iron chelation, and curative treatment is bone marrow transplant
Safest antidepressant in pregnant and comprbid patients?
Sertaline
young patient with symptomatic renal stone >2cm
management?
percutaneous nephrolithotomy in >2cm and any case with hydronephrosis/obstructive uropathy
if <5mm fluids + conservative
if 5mm-2cm then ESWL
elderly woman on anticoagulants progressively getting more and more confused. exam showed bruises on her arms and inr of 7
diagnosis?
chronic subdural hemorrhage
elderly + anticoagulant +high inr + progressive confusion
ct would show crescent shaped hematoma.
tx= stop warfarin + IV vit K + prothfombin complex
d/d vascular dementia (associated with dm, htn, cholesterol, smoking)
IDA treatment?
Iron supplementation
hgb <80g/l + symotoms = blood transfusion
hgb<70= BT
Patient with headache, vertigo malaise and vomiting after being in a house fire.
diagnosis and treatment?
Carbon monoxide poisoning.
clear airway + 100% oxygen with tight fitting mask if conscious or intubation if unconscious
25 y/o with a chest infection on antibiotics complaining of SOB weakness and purpura on her legs.
diagnosis?
Aplastic Anemia
autoimmune condition after antibiotic use with symptoms of thrombocytopenia and anemia.
to confirm diagnosis, bone marrow exam is needed:
2 of either hgb <10g/dl, platelet <50 or neutrophil <1.5.
tx= immunosuppressive drugs, or stem cell transplant
D/D CML (age less than 40-50)
cocaine and opiate user with tremors and agitation after stopping drugs for a few weeks.
management?
Opioid withdrawal (agitation and tremors)
tx= methadone
D/D, opioid overdose (respiratory depression, pinpoint pupils)
tx=naloxone
teenage girl with primary amenorrhea complaining of abdominal pain every 4-8 weeks.
palpable lower abdominal mass.
diagnosis?
hematometra: accumulation of blood in uterus (due to imperforate hymen (bluish membrane) or transvaginal septum (abdominal mass) )
(cyclical abdominal pain in teenage girl with primary amenorrhea)
2 y/o boy not moving his right leg after falling, refusing to walk. severe tenderness over shin. xray was normal.
diagnosis?
Spiral fracture
1-3 year old, not seen on xray, tibial tenderness after falling.
d/d greenstick fracture
abnormal bone bend seen on xray
Medication that can cause hyperuricemia and gout?
Bendroflumethiazide (diuretic)
first inv in gout= uric acid
most diagnostic investigation= joint aspiration
33 y/o nurse with itching. linear tracks on wrist, contact with patient with similar complaint 1 week ago.
diagnosis, and MECHANISM of itching?
Scabies (parasitic infestation)
pruritis, burrows and papules over flexor surfaces.
parasitic infestation= hypersensitivity reaction NOT infection
tx=permethrin 5%
patient with pain, redness and swelling over nasal end of right lower eyelid. excessive tears and purulent discharge are found.
diagnosis and treatment?
Acute Dacrocystitis (lacrimal sac inf)
pain, epiphora, swelling and erythema of inner eye
tx= antibiotics
rugby player with right ear trauma. presents with large hematoma of pinna. no visible damage to external auditory meatus or tympanic membrane. hearing is unaffected.
diagnosis and management?
auricular hematoma
incision and drainage of the hematoma+ oral antibiotics for 1 week
if delayed then - > cauliflower ear
woman with white streaks on tongue and buccal mucosa with painful ulcers on tongue for 6 weeks.
the white streaks are adherent and can’t be removed easily. non smoker
diagnosis?
Lichen planus (painless white streaks with fern like pattern. can be painful with ulcers = Erosive Lichen Planus)
d/d
aphthous ulcers (usually shorter duration)
leukoplakia( smokers, unilateral lesions)
lichen sclerosis (genital lesions)
diabetic patient with prostate CA complaining of back pain groin numbness and inability to initiate urination. most likely cause?
Cauda Equina syndrome
sciatica, saddle parasthesia, urinary retention, fecal incontinence.
urgent MRI to confirm, then excision of compressive mass
urinary leaking without urge to urinate?
overflow incontinence
COPD patient with respiratory acidosis, spo2 of 86%
he was commenced on 4L of 28% O2 to no effect. management?
Non invasive ventilation
if ph was normal-> continue 28% O2
if SpO2 decreases further then 15L/min O2 should be given
how to approach foreign bodies in ear?
if insect-> mineral oil then remove
if battery-> remove without crushing
if glue-> remove after 1 day manually
management of migraine?
oral triptan + nsaid
prevention by propranolol
which statin to use after a TIA or stroke?
Atorvastatin daily lifelong
best management for patient with recurrent TIAs?
aspirin for 2 weeks then switched to clopidogrel.
endarterectomy in patients with carotid stenosis of greater than 70%
angioplasty in those who can’t tolerate surgery
5 year old boy with drooling, severe stridor, fever, muffled voice and thumb sign on lateral xr.
diagnosis?
acute epiglottitis (drooling of saliva + thumb sign) caused by HiB
Examples of autosomal recessive diseases.
25% chance to inherit if BOTH parents are carriers
Cystic fibrosis
Sickle Cell
Thalassemia
Hemochromatosis
Examples of Autosomal Dominant
50% chance if 1 parent has the mutation
Huntingtons
NF
AD Polycystic kidney disease
Example of X-linked Dominant
50% chance of inheritance if mother has the mutation.
if father has the mutation then 100% for female child and 0% for male.
Fragile X Syndrome.
Example of X linked recessive
50% chance for male child to inherit if mother is a carrier
50% chance of female to become a CARRIER if mother is a carrier.
hemophilia
Duchenne Muscular Dystrophy
4 y/o boy with elevated creatinine kinase, started walking at 18 months, sluggish, waddled when he runs, difficulty rising from sitting position and climbing stairs.
Diagnosis?
Duchenne Muscular Dystrophy.
X-linked recessive
4-8 y/o boy difficulty rising from sitting position (gowers sign), elevated CK.
D/D
Beckers= 10 y/o - adolescent who is unable to walk
Myotonic Muscular Dystrophy= at birth with systemic complications
Lambert-Eaton= proximal muscle weakness + lung tumor
patient after thyroidectomy complaining of tingling, numbness, parasthesia and spasm of upper limbs.
diagnosis?
hypocalcemia due to hypoparathyroidism after thyroidectomy.
expected ECG findings in hypocalcemia= prolonged QT interval
expected examination findings: chvosteks sign (cheek twitching when tapping parotid)
trousseaus sign (wrist flexion and finger adduction when measuring bp)
tx= IV calcium gluconate (10ml of 10% over 30 minutes)
presentation of ACA, MCA AND PCA occlusions?
ACA (the a’s look like legs) Lower limb involved more than upper limb
MCA (M for mouth) Aphasia + UL more than LL
PCA (occiput is posterior) Vision
patient with retching and vomiting and interscapular chest pain after an upper GI endoscopy. he then develops a fever and subcutaneous emphysema on his chest.
most likely cause of this?
Mediastinitis as a complication of esophageal rupture.
Macklers triad: Chest pain, vomiting, emphysema
panic disorder treatment
at least 2 recurrent panic attacks = panic disorder
before attack propranolol
during attack rebreathing bag
prevent attack psychotherapy or SSRI (sertaline)
patient with 1 week history of headache, pain over cheekbones and nasal blockage. 37.5° C
diagnosis and treatment?
Acute Sinusitis (viral because less than 10 days, no purulent discharge, unilateral pain, and with a fever less than 38°)
tx= nasal decongestant
if suspecting bacterial then add coamoxiclav
patient with severe central chest pain, widening of mediastenum
diagnosis?
Aortic dissection.
tearing central chest pain radiating to the back, widening of mediastenum. hypotension.
investigations:
initial = xr
if stable= ct angio
if unstable = transesophageal echo
patient who travelled to thailand now complaining of bloody diarrhea, abdominal pain, fever. stool culture shows gram - ve bacilli.
treatment?
travellers diarrhea
either salmonella or campylobacter
both treated by ciprofloxacin
if diagnosis was campylobacter with South east asia travel history then erythromycin is given
patient with SOB, abdominal pain, bloody diarrhea and history of UC.
diagnosis?
Toxic megacolon (fever abdominal pain, bloody diarrhea
MC complication of UC.
on xr you’ll see dilated colon with loss of haustra (lead pipe colon)
tx= iv steroids and fluids
patient with seatbelt injury, thigh and groin trauma. complains of reduced sensation, mild burning sensation on the left lateral thigh.
which nerve is affected?
Lateral femoral cutaneous nerve damage leading to Meralgia paresthetica
(lateral thigh, burning, numbness, tingling)
21 year old woman with vaginal bleeding, lower abdominal pain, history of surgical termination of pregnancy 1 week ago.
diagnosis?
Endometritis (bleeding + lower abdominal pain after surgical termination of pregnancy)
D/D between Nihilistic, Persecutory, Fregoli, and Clang delusions.
Nihilistic: patient is dead or world has ended or not real.
Persecutory: believe theyre being harmed somehow like being tormented followed or spied on
Fregoli: believing different people are actually one person
Clang association: speech abnormality where words are connected by their ending sound and not their meaning (spiritual lyrical)
patient with bruising, nosebleeds and petachiae for a week. otherwise well.
low platelets.
diagnosis?
idiopathic thrombocytopenic purpura
ITP, (in children usually associated with URTI) : petechiae, gum and mucose bleeding, bruises, epistaxis and menorrhagia
usually chronic in adults and acute in children.
tx= if platelets are over 50 no need to treat.
if below then : steroids, IV IG, platelet transfusion and splenectomy after months of therepy with no result.
If with neutropenia suspect AML
6 week old with persistent nonbilious vomiting, he feels hungry and wants to feed. K+ of 3.1.
diagnosis?
Pyloric Stenosis (hypokalemia and projectile nonbilious vomiting+ hungry child)
on examination= olive sized mass+visible peristalsis
associated with metabolic alkalosis
tx= fluid correction, then referral for pyloromyotomy + NG tube
d/d
duodenal atresia= bilious vomiting with every feed
malrotation= bilious vomiting, crampy abdominal pain, abdominal distention, blood and mucus in stool.
% chance of child inheriting hemochromatosis if husband and mothers father have hemochromatosis?
Autosomal Recessive.
50% regardless of gender
Hereditary Hemochromatosis= increased intestinal iron absorption-> increased iron in liver, pancreas and other tissues.
symptoms:
nonspecific fatigue, weakness, cardiac problems, start at 40-60 y/o
Advanced disease symptoms= DM, Hepatomegaly, Bronze pigmentation (Triad)
59 y/o male with gradual left sided abdominal pain started 18 hours ago.
associated with nausea. past history of heart failure, dm and ht. generalized abdominal tenderness, blood per rectum, 80bpm, 150/80mmhg, 37°C.
diagnosis?
Ischemic Colitis. (pr bleeding, pyrexia, tachycardia, abdominal tenderness) after hypoperfusion events (Heart failure, shock, MI).
tx= conservative or surgical
D/D
Mesenteric ischemia= embolic cause (Atrial fibrillation) abrupt while ischemic Colitis is more chronic. generalized pain where IC is left iliac.
tx= surgical
lorry driver with Obstructive sleep apnea and daytime sleepiness.
advice?
stop driving entirely, referral to sleep clinic for treatment (lose weight, decrease alcohol intake, CPAP).
When should patients inform the drivers vehicle licensing agency (DVLA) of their condition?
Its our job to inform DVLA if patient is advised to inform and refuses or if they continue driving after advice.
Epilepsy (unless seizure free for 1 year or 6 months if medication has been changed)
Alzheimers/Dementias
OSAS (if suspected sleep apnea advise them to stop,
if confirmed is moderate-severe or mild but not controlled by 3 months advise them to inform DVLA)
TIA (no driving for 1 month after driving, no need to inform afterwards)
Stroke (advise to stop until 1 month after full recovery, only inform if there are still neurological deficits 1 month after the episode)
DVT (no restrictions)
newborn 8 day old girl with high TSH and low T4. difficulty feeding, cold mottled skin, weak floppy muscles.
diagnosis and management?
congenital hypothyroidism.
(prolonged jaundice, poor feeding and growth, goitre, hypotonia)
inv= heel prick for TSH
then radioisotope scan and neck ultrasound
tx= Levothyroxine orally until 2 y/o
patient fell down a ladder and hit his shoulder and arm. complaining of weakness of right shoulder abduction external rotation. forearm and hand strength is normal. numbness over lateral part of arm and forearm.
which nervous structure is affected?
Upper Brachial Plexus
sensory+motor deficit of proximal arm.
D/D
lower brachial plexus: distal upper extremity would be involved, ulnar nerve palsy
axillary nerve: same motor symptoms but only possible sensory defect would be at lateral proximal surface of upper arm (sergeants patch).
musculocutaneous nerve: weakened elbow flexion due to loss of biceps innervation
radial nerve : wrist drop
elderly patient with expressionless face, takes many steps to turn, resting tremor, cogwheel rigidity.
diagnosis and treatment?
Parkinsons (bradykinesia, rigidity, resting tremor, mask face)
tx=neurology referral-> levodopa
expected adverse effect with patient taking vincristine for CA?
peripheral neuropathy
(loss of deep tendon reflexes, pain and sensation in stocking and glove pattern)
other medication with similar AE (CCTV) =
Cisplatin, Carboplatin, Taxanes
less than 1 day old newborn with jaundice.
management?
advise mother to return to the hospital.
bilirubin, LFT, CBC, blood film and grouping, coombs test, G6PD and sepsis review should be done
Patient with DM complaining of fatigue, weakness, hyperpigmentation of buccal mucosa and palmar creases, abdominal pain, vomiting, irritability and confusion.
Diagnosis?
Addison’s disease (thin, tired, tanned, fearful)
MC cause in UK is AI, outside its TB
associated with DM, thyroid disorders and vitiligo.
can present acutely after bodily stressors like surgery and infection.
investigations: low 9am cortisol, hyponatremia, hyperkalemia, high ACTH, 21 hydroxylase antibodies.
Tx= hydrocortisone (glucocorticoid) and fludrocortisone (mineralocorticoid)
patient with long-term adrenal insufficiency recently stopped taking their medication.
diagnosis, expected presentation, investigations and management?
Addisonian crisis
shock, abdominal pain, hypoglycemia.
cortisol, ACTH, blood glucose, blood/urine/sputum cultures
tx=
hydrocortisone IV 100mg stat followed by 8hrly
fluids(helps with hyponatremia too), calcium gluconate (if hypocalcemic), iv glucose if hypoglycemic.
D/D Addisons and Conns
Addisons: due to
decreased aldosterone-> decreased sodium-> hypotension
decreased weight and energy.
only increase is potassium.
Conns: exact opposites
hypernatremia, hypertension, hypokalemia
Patient with dizziness, vertigo, bumping into things on his right side, nystagmus, dysdiadochokinesia. imaging confirms stroke.
159/91mmhg, 72bpm
most likely location of his stroke?
Posterior circulation (brainstem, cerebellum and occipital lobe involvement)
vertigo, hemianopia, nystagmus, dysdiadochokinesia, and ataxia
initial inv= CT (noncontrast)
best = MRI brain.
tx= alteplase->aspirin
Patient with MI 3 days ago now complains of SOB and sharp chest pain. exacerbated by breathing and is relieved by sitting forwards. 22 breaths/minute, 95bpm.
diagnosis?
Pericarditis.
post MI (Dressler syndrome)/infection
pleuritic chest pain relieved by sitting forwards, exacerbated by inspiration/coughing.
friction rub on auscultation
saddle shaped ST on ecg with PR depression.
tx=nsaids
D/D
pericardial effusion: raised JVP, dyspnea, globular heart on xr, low voltage QRS.
tx=pericardiocentesis
cardiac tamponade: usually after trauma, with tachycardia, and becks triad (Becks triad, hypotension, raised JVP and muffled heart sounds).
echo is diagnostic
tx= urgent pericardiocentesis
Preferred laxative in pregnancy?
After lifestyle modifications
Isphagula husk
then Lactulose.
Nausea and vomiting medication to avoid in parkinsons?
May Cause Parkinsons
Metoclopramide
Cinnarizine
Prochlorperazine
Nausea and vomiting medication of choice in parkinsons?
Domperidone (watch for QT prolongation)
Ondansetron(can cause constipation)
Cyclizine
Which medications are associated with falls.
Oxybutinin (anticholinergic burden->multiple anticholinergic medications causing falls, confusion and dizziness)
antihypertensives (postural hypotension)
Zopiclone (insomnia treatment)
Patient with dull ache at left scrotum after playing sports. cough impulse positive.
diagnosis?
Varicocoele (bag of worms)
more common on left side, usually painless but can present with dull pain, cough impulse positive.
associated with subfertility.
diagnose by scrotal doppler
tx= conservative
secondary varicocoele can be caused by renal tumor obstructing the flow of the testicular vein
Pulmonary function test
FEV1 less than 80%
FVC less than 80%
FEV1/FVC 0.8
diagnosis?
Restrictive lung disease
pulmonary fibrosis, interstitial lung disease
Pulmonary function test
FEV1 less than 80%
FVC more than 80%
FEV1/FVC less than 0.7
diagnosis?
Obstructive pulmonary disease
COPD, asthma, bronchiectasis, cystic fibrosis.
patient with respiratory depression, pinpoint pupils, bradycardia, weak pulse constipation
diagnosis?
Heroin intoxication
patient with mydriasis, hypertension, tachycardia, sweating, nausea, arrhythmias and restlessness
diagnosis?
Cocaine intoxication
Patient with hyperthermia, hypertension, insomnia, tachycardia, dehydration
Ecstasy intoxication
Patient with mydriasis, diarrhea, parasthesias, hallucinations and delusions, hyperreflexia.
diagnosis
LSD intoxication
Patient who was at a party now complaining of hyperthermia, dehydration, tachycardia, tachypnea, insomnia, can see spots of color and has metabolic acidosis.
diagnosis and treatment?
Ecstasy overdose
tx= supportive, diazepam if agitated, cool/dantrolene (only if above 40°C) if hyperpyrexic
patient with auditory hallucinations just before they fall asleep
phenomenon?
hypnagogic hallucinations auditory hallucinations on the verge of falling asleep
hypnaGOgic (going to sleep)
hypnoPOmPic hallucinations (popping out of bed) happen on waking and involve visual hallucinations too
2 y/o with barking cough. he had runny nose, sore throat and cough a few days before. chest sounds are normal, no signs of respiratory distress.
38.7°C, 34 RR, 150bpm, spO2 98%
diagnosis and management?
Croup.
6 months-3 years, inspiratory stridor, barking cough, hoarseness of voice, caused by parainfluenza virus.
tx= oral dexamethasone, high flow O2 and nebulised saline.
D/D
Bronchiolitis.
less than 1 year old, expiratory wheeze, feeding difficulty, caused by RSV.
tx= humidified oxygen via headbox
79 y/o man with IHD complaining of seeing yellow haloes, nausea, vomiting. ecg shows arrhythmia.
which medication is causing his symptoms?
Digoxin
yellow haloes + arrhythmia (bradycardia, vtac, or any other arrhythmia) , nausea, vomiting, hallucinations.
patients with hypokalemia are predisposed to digoxin toxicity.
tx= Digibind, correct arrhythmias and monitor potassium
D/D
Sildenafil (for ED and HT) can cause blue vision (color of viagra)
20 y/o woman with tiredness, weight loss, polyuria and polydipsia, family history of DM, BMI is 19,HbA1c is 65.
no ketones in urine.
diagnosis and management?
Maturity onset diabetes of the young.
should be suspected in any healthy, fit, young patient with a family history of DM.
she requires genetic counseling and testing, and endocrinology referral.
D/D
Latent autoimmune diabetss in adults = usually 30-50 years old, type 1 DM, most important test is GAD antibody test.
most common post op complication?
infection
48 year old woman with vertigo that started suddenly 2 weeks ago. symptoms worsen when she lies down, turns in bed or bends over. no hearing impairment or tinnitus.
Dix Hallpike is positive.
diagnosis and management?
benign paroxysmal positional vertigo.
vertigo caused by change in head position (lying down, rolling). episodes last 10-20 seconds and come with nausea. no tinnitus or hearing loss.
diagnosis= Dix Hallpike maneuver.
Epleys maneuver (repositioning of otoliths into utricles from the posterior semicircular canals) should be performed.
Dizziness Differentials?
dizziness when rolling out of bed
with photophobia
associated with vertigo and vomiting for hours
with light-headedness whrn getting up from bed
one ear feels full before or during the episode
BPPV
migraine
Vestibular neuritis
Orthostatic hypotension
Menieres disease
D/D Menieres, BPPV, and Vestibular neuritis/Labyrinthitis
Menieres disease= lasts minutes to hours, not provoked by movement, feeling of aural fullness with tinnitus and hearing loss.
BPPV= seconds to minutes, triggered by movement, no hearing loss or tinnitus.
Vestibular Neuritis/Labyrinthitis)= hours to days, not triggered by movement but exacerbated by it, associated with recent URTI, and has hearing loss.
Malaria prophylaxis in pregnant women traveling to endemic areas?
Mefloquine is the drug of choice for women in 2nd or 3rd trimester (due to high chloroquine resistance)
Patient with travel history to ghana presents with, intermittent fevers, headache, malaise, cough, hepatosplenomegaly and jaundice.
anemia and thrombocytopenia on blood film.
diagnosis and confirmatory investigations?
Malaria
microscopy of thick and thin blood smears. if 3 negative results then probably not malaria.
Malaria drug contraindicated in G6PD, breastfeeding and pregnancy?
Primaquine
diabetic woman with gradual worsening left ear pain for 5 days, no hearing loss. on examination there is a small red tender mass at the outer third of the canal. otoscope insertion causes localized pain.
diagnosis?
Furuncle
S. aureus, hard red tender nodule surrounding a hair follicle. common in immunocompromised and diabetics, and as a complication of otitis externa.
tx= usually resolve spontaneously but can give flucloxacilin. large ones require I&D
diabetic woman with acutely painful, hot, red knee joint. limited painful ROM, the joint has visible effusion. no history of trauma.
70bpm, 37.8°C.
diagnosis?
Septic Arthritis. caused by S. aureus in most cases, N. gonorrheae in sexually active adults.
DM/RA/IC patient with single swollen red hot joint with fever and painful ROM. usually knee.
investigations=
aspiration of synovial fluid for gram stain and culture.
blood cukture
tx= flucloxacilin for 4-6 weeks.
clindamycin if allergic.
if gonoccoal then use ceftriaxone
D/D reactive arthritis= no fever, young adult, 2-4 weeks after infection, Reiters triad (urethritis, conjunctivitis, arthritis) with skin lesions (erythema nodosum/ keratoderma blennorrhagicum/keratoderma)
33 y/o with very severe colicky right flank pain, vomiting, urinalysis shows 2+ blood.
diagnosis and investigation?
Kidney stones
CT KUB no contrast (gold standard)
US in pregnant
Levels of anemia in pregnancy
Normal for women= 116-150
anemia in first trimester= <110
in second and third = <105
and in postpartum=<100
patient with infectious mono develops a maculopapular rash after taking an antibiotic
which antibiotic was taken?
ampicillin/amoxicillin
adolescent with sore throat, fever, exudative tonsillar enlargement, and cervical lymphadenopathy.
diagnosis?
Infectious mononucleosis
caused by EBV, triad of pharyngitis, fever, and cervical lymphadenopathy.
diagnosis via heterophile antibody test (mono spot test / paul bunnel)
tx= analgesia,
amoxicillin and ampicillin are CI because they can cause maculopapular rash
patient a few days after an MI now with globular heart, distended neck veins, and clear lung fields.
diagnosis?
Cardiac tamponade.
becks triad!! (muffled heart sounds, distended neck veins, hypotension)
diagnosis via echo
tx=pericardiocentesis (mkst appropriate)
fluids (initial)
if with penetrating trauma, cardiac arrest= immediate thoracotomy
COPD patient with gcs 11/15, 38.1°C, RR 9, spO2 89%, oxygen mask was started at 40%. respiratory acidosis.
Next step of management?
Intubation
patient is in a decompensated state (respiratory acidosis, drop in GCS, hypoventilation) - > respiratory failure-> do urgent intubation
6 y/o boy fell on his left elbow, presents with swollen elbow and inability to supinate his forarm or extend the elbow. he is holding his left arm with one hand.
most likely diagnosis?
Supracondylar fracture of humerus.
forearm pain and swelling, cubitus varus, painful rom, numbness in hand due to nerve compression, cold hand due to brachial artery compression.
xray would show a fracture just above the humeral condyles.
painter with burning pain at right lateral elbow that radiates to his forearm. started 2 months ago and gradually worsened over time, exacerbated by carrying heavy things. reduced grip strength of right hand.
tenderness over lateral epicondyle of right arm. pain on resisted extension of wrist.
diagnosis?
lateral epicondylitis (tennis elbow)
painter/gardener/tennis player, tenderness at lateral epicondyle, pain upon resisted wrist extension.
muscle group involved is wrist extensors
tx=rest, NSAIDS, physiotherapy.
Vestibular Neuritis vs Labyrinthitis
both have vertigo and nystagmus.
hearing loss and tinnitus is exclusive to Labyrinthitis
Patient with vertigo that started after a runny nose cough and fever, no hearing loss.
most likely diagnosis?
Vestibular Neuritis.
vertigo after history of infection, no loss of hearing.
tx=oral/buccal(for immediate relief) prochlorperazine
d/d
BPPV has no history of infection
Labyrinthitis comes with hearing loss/tinnitus
50 y/o woman with recurrent uti. management?
in postmenopausal women with recurrent uti the recommended management is vaginal estrogen cream.
if that failed then trimethoprim is the antibiotic of choice in UTI for all patients except pregnant women (cefalexin)
46 y/o man with indigestion. jejunal biopsy shows macrophages in lamina propria with granules that stain positive for periodic acid schiff stain.
diagnosis?
Whipple’s Disease.
gi malabsorption, middle aged white male, caused by a combination of treponema whippelii and defective cell mediated immunity.
usually starts with arthralgia. then GI symptoms like abdominal pain, weight loss, diarrhea. associated with cough, fever, sweating, reversible dementia, ophtalmoplegia. and can lead to endocarditis.
inv=jejunal biopsy showing stunted villi and macrophages staining positive for PAS
tx= IV ceftriaxone for 2 weeks followed by cotrimoxazole for 1 year
NF 1 vs NF 2
both are autosomal dominant (1:2 chance of passing down to children)
1= cafe au lait spots, axillary/grojn freckles, peripheral neurofibromas, iris hamartomas (lisch nodules), scoliosis.
2=bilateral acoustic neuromas,
intracranial schwannomas, meningiomas, ependymomas
patient with CKD, hypercalcemia, high parathyroid hormone, and hyperphosphatemia.
diagnosis?
TERTIARY hyperparathyroidism.
ckd+high calcium, PTH, and phosphate = tertiary (difference b/w tertiary and primary is presence of CKD and high phosphate in tertiary)
high PTH and calcium, low phosphate = Primary (most commonly due to parathyroid adenoma)
high PTH, and low/normal calcium= secondary
Medication with increased risk of causing endometrial carcinoma?
Tamoxifen, (selective estrogen reuptake inhibitor) used for breast CA and can prevent bone loss (osteoporosis) . can also cause thromboembolism.
(TamoxifENDOMETRIAL CANCER)
Antibiotic on MRSA?
Vancomycin
patient on ACE inhibitors with tall tented T waves, small p waves, wide QRS leading to sinusoidal pattern on ecg.
diagnosis and management?
hyperkalemia
1)stop ACE/ARB/spironolactone
or correct other causes like metabolic acidosis, addisons or acute renal failure.
2) give IV calcium gluconate to correct ecg changes.
Loop diuretics/dialysis can be used to remove excess K+
20 y/o with Sickle cell has shortness of breath, pallor, headache, and lethargy. history of flu like symptoms for a week, now complaining of joint pain of both hands and knees.
hgb =53g/l
parvovirus b19 infection is suspected.
diagnosis?
Aplastic crisis.
parvovirus b19 in Sickle cell, thalassemia or Hereditary spherocytosis.
rapid drop in hgb (due to cessation of erythropoesis), low reticulocytes, symmetrical joint pain and stiffness of hands knees wrists and ankles.
tx=blood transfusion
most common cause of postcoital bleeding and dyspareunia in postmenopausal women?
Atrophic Vaginitis.
Investigations for gay male with syphilis?
1)Dark field microscopy of genital ulcer.
16 y/o girl with neck lump.
2x2, rubbery, nontender anterior cervical lymph node is palpable.
37. 4°C.
diagnosis and investigation?
Hodgkins lymphoma (enlarged nontender rubbery superficial LN in 15-24 y/o)
usually asymptomatic but can come with fever, lethargy, weight loss and night sweats.
investigation of choice here is LN biopsy to search for Reed Sternberg cells
53 y/o woman with fatigue lethargy and LN enlargement. WBC and Lymphocytes are high. smudge cells seen on peripheral smear.
diagnosis?
Chronic Lymphocytic Leukemia.
older patient with high WBC and Lymphocytes, bone marrow infiltrated with leukemic Lymphocytes, smudge cells on smear.
Specific findings in
ALL, AML, CML, CLL?
ALL=TdT positive, blast cells (children)
AML= Auer rod
CML= Philadelphia chromosome+MASSIVE splenomegaly
CLL= smudge cell
Anaphylaxis algorithm in
<6 y/o
6-12
>12
for all
ABC
administer IM epinephrine at AL aspect of middle 1/3 of the thigh.
for
<6= 150 micrograms IM
6-12= 300
>12= 500
after adrenaline administration is complete give chlorphenamine
young female with progressive difficulty walking followed by tingling in hand that radiates to elbows after food poisoning 2 months ago. no vibration or sensation felt in upper limbs up to elbows and Lower limbs up to hips.
diagnosis and management?
Guillain-Barre Syndrome.
young female with ascending polyneuropathy after an infection.
weakness, parasthesia and hyporeflexia.
nerve conduction studies confirm the diagnosis.
LP would show high csf protein with normal cells (non-specific)
Spirometry (most important) used to determine the need for ICU admission and intubation
Guillain-Barre vs Myasthenia Gravis vs Motor Neuron Disease
GBS= weakness, hyporeflexia, pain
MG=weakness, normal reflexes, fatigue, no pain
MND= weakness, may have hyperreflexia and fasciculations, no fatigue or pain
25 y/o with unilateral pain and swelling in the submandibular region for weeks.
exacerbated by eating. tender.
diagnosis?
Chronic Sialadenitis (salivary gland inflammation) submandibular swelling and pain that increases while eating.
D/D Acute Sialadenitis = erythema, associated with dehydration
when to give Varicella-zoster IG to an infant who’s mother was diagnosed with varicella zoster?
if the mother develops a rash either 7 days before or 7 days after delivery of the neonate then there’s no need for IG.
if >7 or <7 days from delivery then give IG
33 y/o with chronic back pain now has acute painful red right eye for 1 day. with blurring of vision, and with an irregular, highly light sensitive pupil.
most likely diagnosis?
Acute Anterior Uveitis/Iritis.
unilateral painful red eye, photophobia, excessive tear production, presence of cells in the aqueous humor (seen on slit lamp)
associated with ankylosing spondylitis/rheumatoid arthritis/Chrons
tx= prednisolone (reduce inf.) & cyclopentolate (prevent adhesions)
28 y/o mother who delivered 3 months ago is complaining of palpitations, tachycardia, and tremors
tsh low, t4 high, t3 high.
thyroid preoxidase antibodies were found and she has a normal esr.
diagnosis and management?
Postpartum Thyroiditis.
(hyperthyroid first 4 months after delivery then hypothyroid from 4 - 6)
thyroid preoxidase antibody+abnormal TSH=postpartum Thyroiditis
tx= betablocker for first phase
if patient came with hypothyroid give Levothyroxine.
Obese 40 y/o mother of 5 with severe upper abdominal pain, fever, vomiting, high wbc, and crp.
diagnosis?
Cholecystitis (fat fair forties female fertile)
Nerve involvement in the following vision loss cases?
one eye vision loss
bitemporal hemianopia
homonymous hemianopia
1)optic nerve
2) optic chiasm
3)optic tract
8 week pregnant woman with severe prolonged persistent vomiting.
diagnosis and management?
Hyperemesis Gravidarum.
starts at 6-8 weeks, peaking at 12 and resolving by 20.
signs=weight loss, ketonuria, tachycardia, dehydration.
tx=
IV fluids+
antiemetics(cyclizine/promethazine first then Metoclopramide/Ondansetron second line then corticosteroid third line)
32 year old healthy patient with pain and swelling on both knees and ankles with a nodular rash over shins.
she feels fatigue and has a mild fever.
chest xray would find?
Bilateral hilar lymphadenopathy, a sign of Sarcoidosis.
this patient has Lofgren Syndrome (triad of Erythema nodosum, arthritis, and Sarcoidosis)
if the patient had fever, parotid enlargement, uveitis and facial palsy and the same chest xray, they would have Heerfordt-Waldenstrom syndrome.
definitive diagnosis of Sarcoidosis is via biopsy which would show noncaseating granulomas.
tx=steroids
Common side effect of oral Isotretinoin?
Dry skin, throat and nose (nosebleeds)
patient with bone pain at rest and bowing of tibia. associated with worsening SOB on exertion. xray showed cortical sclerosis and a coarse trebecular pattern.
Alkaline Phosphatase was high, all other tests were normal.
diagnosis?
Pagets Disease of the bone.
(increase in bone turnover)
bone pain and deformity, with symptoms of high output cardiac failure (due to increased vascularization of new bone) and high Alkaline Phosphatase.
xray findings include:
v shaped lesion betweed healthy and affected bone (blade of grass).
Cotton wool pattern of skull.
tx= bisphosphonates
D/D lab investigations of Osteoporosis, Pagets Disease of the Bone, and Osteomalacia
Osteoporosis= calcium, phosphate and Alkaline Phosphatase are all normal
Pagets= high Alkaline Phosphatase
Osteomalacia= low calcium and phosphate, high Alkaline Phosphatase
patient hit by car, loses consciousness but regains it, he then loses consciousness again, gcs fell from 15 to 10. left eye dilated and unresponsive to light. right eye is reactive.
diagnosis?
Extradural hematoma.
trauma, lucid interval, ipsilateral pupil dilatation.
tx= burrhole then craniotomy
patient with persistent hiccups not responding to valsalva maneuver management.
if caused by liver enlargement or gastric irritation-> Metoclopramide first, then domperidone
if caused by stroke head trauma then give chlorpromazine first, then haloperidol
woman with grey white vaginal discharge with odor. clue cells on smear.
diagnosis and management?
Bacterial Vaginosis. (gardnerella vaginitis inf-> high ph of vagina)
to diagnose BV you need 3 of the 4 following findings.
clue cells, homogenous grey white discharge, fishy smell, vaginal ph >4.5
tx= metronidazole, clindamycin
Trichomoniasis vs Bacterial Vaginosis vs Vulvovaginal Candidiasis
Trichomoniasis= itching + frothy yellow discharge, smelly, vulvar erythema, vaginal ph >4.5.
tx= metronidazole
BV= homogenous grey white discharge, fishy smell, vaginal ph >4.5 clue cells
tx= metronidazole / clindamycin.
Vulvovaginal Candidiasis= itching, thick white odorless discharge (cottage cheese), ph of 4-4.5
tx=clotrimazole
Septicemia vs Meningitis
They both have fever, vomiting, nonblanching rash, drowsiness and confusion.
Septicemia has: cold peripheries, pale skin, SOB, and muscle aches
Meningitis has: photophobia, severe headache, stiff neck
suspected Meningitis in children first line investigation?
LP
LP CI=
GCS <9 or drop of 3 or more points
Papilledema
unequal dilated pupils
bulging tense fontanelle
33 y/o came back from india with reddish nodular patch on shins. associated with fever.
Diagnosis?
Erythema Nodosum.
associated with TB (hence the correlation with india), NSAIDS, chlamydia, amoxicillin and, OCP.
main hormone to confirm ovulation?
mid luteal phase progesterone
7 days before period.
FSH and LH do not confirm ovulation they only help identify ovulation disorders.
65 y/o man with prostate CA for 3 years has worsening backache for a few weeks. urinary incontinence started today. examination shows bilateral lower limb weakness.
diagnosis and investigation?
incoming malignant spinal cord compression (oncological emergency)
suspect in patients with back pain, neurological symptoms and history of breast, prostate or myeloma cancers
urgent MRI spine is the investigation of choice.
When to use Morphine in palliative setting?
pain and breathlessness
When to use haloperidol in palliative setting?
nausea and vomiting, and restlessness and confusion
When to use levopromazine in palliative setting?
pain, restlessness and confusion, nausea and vomiting
when to use cyclizine in palliative setting?
intracranial causes of nausea and vomiting.
when to use octreotide in palliative setting?
nausea and vomiting due to bowel obstruction
when to use Metoclopramide or domperidone in palliative setting?
nausea and vomiting with delayed gastric emptying
when to use Ondansetron in a palliative setting?
nausea and vomiting associated with chemo or radio
when to use midazolam in a palliative setting?
agitation and restlessness, useful in a patient with a catastrophic bleed
when to use lorazepam in a palliative setting?
agitation and restlessness
Which end of life medications are used and how are they administered?
Morphine (for pain and breathlessness) , Haloperidol (for nausea and vomiting), midazolam (for agitation, anxiety and delirium), and hyoscine butylbromide (for noisy respiratory secretions)
all are given subcutaneously
when to use hyoscine butylbromide in a palliative setting?
for bowel obstruction and excessive respiratory secretions at end of life
when to use dexamethasone in a palliative setting?
vomiting or headaches in a patient with raised ICP.
also as an appetite stimulant.
Most likely organism to cause early onset neonatal infection in a setting of prolonged rupture of membranes?
Group B Strep. (Streptococcus agalactiae)
72 y/o with weakness and intense pain on left side of her face. started 4 days ago. blisters present on left ear canal. started on aciclovyr 3 days ago. but she cant sleep because of the pain.
diagnosis and further management?
Ramsay Hunt Syndrome. (due to herpes zoster reactivation in the geniculate ganglion of facial nerve)
characterized by auricular pain, ipsilateral facial palsy, vertigo, tinnitus, vesicular rash around ear.
tx= aciclovyr and corticosteroid
amitriptyline for burning pain if it has persisted for 3 months
69 y/o with confusion, lethargy, nausea, decreased appetite, and agitation. he also complains of passing very little urine. known hypertensive not compliant. 168/120mmhg.
hemoglobin low, urea high, creatinine high, eGFR low, calcium low, phosphate high.
diagnosis?
Hypertensive nephropathy.
hypertensive with renal failure, lethargy, nausea, loss of appetite, hyperphosphatemia, hypocalcemia, and anemia
first line agent in thyrotoxicosis?
Carbimazole
not PTU because it can cause liver toxicity and needs to be taken more often.
not radioactive iodine because it can worsen graves ophthalmology in smokers.
PTU can only be used as first line in thyrotoxicosis in pregnancy or for treatment of thyroid storm ( altered mental status, high fever, vomiting, cardiac failure, respiratory distress)
66 y/o woke up with slurred speech and right sided weakness. CT showed a cerebral infarction.
most appropriate treatment?
Aspirin 300mg.
not alteplase because it should be given before 4.5 hours have passed since the onset of symptoms. he woke up with the symptoms so it may have started during the night and also we dont know the time frame.
not warfarin because it should be used after CT has excluded hemorrhage and only 2 weeks after a stroke
statins are given but not urgently.
62 y/o male with bone pain at ribs and back for the last couple months. he is always thirsty and tired.
low hgb, high calcium, normal ALP, high ESR, low eGFR.
diagnosis?
Multiple Myeloma
bone pain at back and ribs+ high calcium and ESR, associated with renal impairment (low egfr)
you would expect to find abundant plasma cells in the bone marrow (confirmatory)
xray would show punched out lytic lesion of skull
Treatment of patient with DKA when systolic BP=
<90
>90
<90= 1 L of 0.9% NaCl in 10-15 minutes
>90= 1L of saline over 1 hour
then followed by insulin and KCL for both
Gestational hypertension vs Pre-eclampsia
both have NEW hypertension in pregnancy after 20 weeks of pregnancy with proteinuria
to diagnose as pre eclampsia then you need one of:
proteinuria >0.3g
protein:creatinine ratio of >30
albumin:creatinine ratio of >8
Cystic fibrosis vs Kartageners
CF due to higher viscosity of mucus
Kartageners due to ciliary dysfunction
patient with chest pain, nausea and vomiting. burning sensation in chest, xr shows air fluid level in a mass behind the heart.
most likely diagnosis?
Hiatus hernia
GERD+ air fluid level on chest xray.
tx=PPI then laparoscopic fundoplication if symptoms persist.
33 y/o woman 6 weeks gestation, past history of 3 early miscarriages, no live births. bmi 22, non smoker.
important screening test and management?
antiphospolipid antibody screening.
Antiphospolipid syndrome
associated with lupus
if positive then give aspirin 75 +heparin
if associated with 2nd trimester miscarriages then the diagnosis would be Cervical weakness
tx= cervical cerclage
patient who ate seafood last month complaining of right sided abdominal pain, pale stool, dark urine, joint ache, body pain, nausea, vomiting.
examination showed icterus, fever, pruritis (scratch marks), Hepatomegaly.
bilirubin high, ALT high, AST high, (ALT:AST > 2:1) ALP high
diagnosis investigation and management?
Hepatitis A infection
(pruritis, high ALT, ALT:AST > 2:1, seafood (feco-oral) )
investigation= IgM antibodies.
tx=fluids and antiemetics
inform public health
TCA (amitriptyline) overdose?
dry mouth dry skin dilated pupils drowsiness hypotension
metabolic acidosis
Wide QRS
tx= IV fluids and 50ml of 8.4% sodium bicarb
D/D cardiac causes of cyanosis in children.
Early cyanosis with no murmur=TGA
early cyanosis with holosystolic murmur=Tricuspid Atresia
late cyanosis with ejection systolic murmur= TOF
no cyanosis with pansystolic murmur=VSD
premature with machinery murmur=PDA
Cyanotic heart diseases in children?
TOF (systolic ejection click) , TGA (no murmur), Tricuspid Atresia (holosystolic murmur
Acyanotic heart disease in children?
VSD (pansystolic murmur) , ASD (systolic ejection murmur), PDA (continuous machinery murmur)
elderly person with bilateral knee joint pain exacerbated by exercise and relieved by rest. the pain gets worse as the day progresses. crepitus is heard over the joint, no morning stiffness, trauma, or dementia.
most likely diagnosis?
Osteoarthritis.
patient with distention of superficial veins on chest, neck and arms. SOB worsening over the last few weeks. intermittent headaches. on exam you find non pulsatile neck and chest veins, and face and arm edema.
diagnosis and investigation?
Superior Vena Cava syndrome.
distended veins, facial edema, SOB, headache. usually caused by tumor compressing SVC
initial inv= chest xray
best inv=ct with contrast.
tx= oxygen and steroids -> endovascular Stenting.
Criteria for giving antibiotics in tonsillitis case.
Centor Criteria 3-4 points-> give phenoxypenicillin/clarithromycin if allergic
1)fever over 38
2)tonsillar exudate
3)no cough
4)tender anterior cervical LN
patient with hematuria and hypertension with palpable left flank mass?
Polycystic kidney
screened by US
hiker with chills, joint pain, single target lesion and rash at the same side. lesion is expanding daily.
diagnosis?
Erythema Migrans
(Lyme Disease)
Hiker, SINGULAR target lesion expanding rapidly.
(erythema Multiform has multiple lesions)
Patient with chills, joint pain, several target lesions on hands, history of antibiotic use.
diagnosis?
Erythema Multiform
MULTIPLE target lesions (erythema migrans only has 1)
Tumor Markers
Ca-125
Ca-15-3
Ca-19-9
Carcinoembryonic antigen CEA
Alpha fetoproteinAFP
1) Ovarian
2) Breast
3) pancreas
4) colorectal
5) liver
antibiotic in cryptococcal meningitis?
Amphotericin and flucytosine for acute tx
fluconazole for mild
65 y/o with blood stained discharge from nipple with eczema, and flaky skin around the areola
diagnosis and investigation?
Pagets Disease (bloody discharge and skin findings)
Punch biopsy. (Punch Paget)
if green or brown discharge = duct ectasia
if bloody with no skin changes = intraductal papilloma
5 year old girl with recurrent uti, investigation of choice to check for renal scarring?
DMSA (dimercaptosuccinic acid) gold standard to check for scarring. is done 4-6 months after acute infection.
if under 3 y/o do MCUG (micrturating cystourethrogram), gold standard for vesicouretric reflux.
if over 3 do DMSA
first line is Ultrasound.
Medication contraindicated in patients taking lithium?
NSAIDs
hydrocoele vs epididymal cyst?
hydrocoele=painless, cystic, anteriolateral swelling that transilluminates. can obscure and envelop the testes (testes non palpable on exam)
epididymal cyst= painless, above and BEHIND the testes, seperate from testes
which of the following is a reason to postpone an elective surgery?
history of asthma
high BMI
Dvt 2 years ago
Diastolic bp of 95
MI 2 months ago
patient with MI history shouldn’t have elective surgery for 6 months after the attack
expected abg in vomiting?
metabolic alkalosis
Difference between superficial, partial thickness, and full thickness burns?
superficial:redness, painful, no blisters
partial: redness, blisters, blanching capillary refill
full thickness: leathery, no sensation or pain, no blisters, no capillary refill
diagnosis and management of hydrocoele?
US
if no underlying pathology-> conservative
exploration if unsure about underlying pathology
