Practice QNS Cardio Flashcards
Prinzmetal variant angina is caused by
Plaque disruption stable plaque unstable plaque coronary spasm coronary vasculitis
Coronary spasm
Chemical mediator of pain in Angina Pectoris is
LDH
Myosin
Troponin
Bradykinin Interleukins
Bradykinin
Stable plaque typically results in this clinical presentation.
Acute Coronary Syndrome
Thmboembolism
Ischemic Heart Disease
Myocardial Infarction
Variant angina
Ischemic Heart Disease
Initial step in the pathogenesis of Atherosclerosis is,
Cholesterol deposition
Macrophage activation
Foam cell deposition
Endothelial injury
Soft Plaque formation
Endothelial injury
Anti inflammatory mediators which stop inflammation and start healing process in atheromatous plaque is,
IL-1
IL-6
TNF alpha
IL-4
IFN gamma
IL4
Breakdown of atheromatous plaque is caused by Macrophage production of
Reactive Oxygen species (ROS)
Inteleukin 1 & 6
PDGF
IFN gamma
Proteases
Proteases
Changes in the myocardium 2 hours following infarction is,
Loss of nucleus
Loss of glycogen Neutrophil infiltration Vasodilatation Oedema
Loss of glycogen
Maximum weakness of infarcted myocardium is usually seen during 0-4 hours
1-3 days
1-2 weeks
2-8 weeks
> 8 weeks
1-2 weeks
Can see that there is extensive MI over left lumen, yellow central necrosis- inflammation zone extends – full thickness MI with yellow centre less than 2 weeks.
Ventrucular rupture – wall and at the attachment of the papillary rupture- acute MI resulted in mitral regurgitation
Left ventricular aneurism with the thrombus sitting in the aneurism.
R: shows blood filling in pericardial sac- hemopericardium cardiac tamponade
Horizontal- dilated left ventricle, septum shows extensive white scaring and in right ventricle – OLD MI heart failure patient.
Mural thrombosis is a complication of both Recent and old MI. True or False
TRUE
Mitral stenosis is a complication of MI involving papillary muscle True or False
FALSE
Commonest complication of MI in the first few hours is, Cardiac rupture Mitral regurgitation Respiratory failure Cardiogenic shock Mural thrombosis
Cardiogenic shock
Case: 72 YO man sudden severe chest pain, collapses while watching TV
GROSS, MIcroscopy, etiopathogenesis, complications
CASE: 78 yo male, hypertensive, DM. obese. died in care crash / stroke/ HO stable angina
GROSS, MIcroscopy, etiopathogenesis, complications?
CASE: 78 yo male, hypertensive, DM. obese. died in care crash/stroke/ HO stable angina
GROSS, MIcroscopy, etiopathogenesis, complications?
68YO DM Obese hypertensive. died following abrupt-onset, tearing chest pain that radiates to the back
CASE: 68 yo man Obese, hypertension, sudden severe chest pain - penetrating to back
CASE: 72 year old sudden collapses following left-sided hemiplegia (stroke) during morning walk. no pain, ACUTE MI, bowel infarction
Commonest coronary artery involved in IHD is,
RCA-Circumflex Artery
LCA-Circumflex Artery
LCA-Anterior Interventricular branch
RCA-Posterior Descending Artery
RCA-Posterior interventricular branch
LCA-Anterior Interventricular branch
Pathogenesis of aneurysm in Syphilis is,
Macrophage activation and release of proteases.
Abnormal collagen synthesis
Inflammation of vasa vasorum of Aorta
Aorta destruction by Treponema pallidum
Abnormal fibrillin-1
Inflammation of vasa vasorum of Aorta
ST segment depression or T wave inversion is typically seen in STEMI
True
False
FALSE
Earliest microscopic feature in atheroma formatin is
Cholesterol clefts
Extracellular lipid pool
Central Necrosis
Lymphocytes
Foamy macrophages
Foamy macrophages
Microscopic feature of stable plaque is more healing (cap) and less inflammation.
True
False
TRUE
Microscopic features of Acute MI at less than 24 hours is,
Normal morphology
Loss of LDH & glycogen
Hemorrhage
Early neutrophilic infiltration
Contraction bands
ALL
Unstable plaque is characterised by dense proliferation of fibroblasts and smooth muscle cells.
True
False
FALSE
Lipids transported from GIT to Liver is in this form,
IDL
VLDL
LDL
HDL
Chylomicrons
Chylomicrons
Major form of lipid synthesized in Liver and distributed to tissues is,
LDL
IDL
VLDL
HDL
LPL
VLDL
Drug Statins reduce LDL levels by
Increasing HDL
Reducing GIT uptake
Reducing synthesis in hepatocytes
Increase LDL receptors
inhibiting PCSK9 enzyme.
Reducing synthesis in hepatocytes
“High normal” blood pressure in mmHg, according to 2016 National Heart foundation Guidelines is,
120-129 / 80-84
130-139 / 85-90
140-159 / 90-99
<120 / <80
>120 / >80
130-139 / 85-90
Humoral factor causing dilatation of BV is
Angiotensinogen
Catecholamines
Thromboxane
B-adrenergic chemokines
Prostaglandins
Prostaglandins
in blood pressure control, increased blood pressure stimulates release of,
Renin
Aldosterone
ANP
Angiotensin II
Angiotensinogen
ANP
Commonest cause of secondary hypertension is,
Renovascular disease
Primary Aldosteronism
Drugs or Alcohol abuse.
Cushing’s syndrome
Aortic Coarctation
Primary Aldosteronism
This risk factor has strongest association with Secondary Hypertension.
Renovascular disease
Primary aldosteronism
Chronic alcoholism
Obstructive Sleep Apnoea
Drug abuse
Obstructive Sleep Apnoea
Following are the clinical features of Secondary Hypertension, EXCEPT,
Early onset <40y
Family history
Paroxysmal episodes
Hypokalemia
High incidence
High incidence
Microscopic feature typical of chronic Hypertension induced microangiopathy is, Arteriosclerosis
Atherosclerosis
Hyaline arteriolosclerosis
Hyperplastic arteriolosclerosis
Arteriolar necrosis
Hyperplastic arteriolosclerosis
A 70 year-old man has an 8cm pulsating mass in the lower abdomen. He has treated hypertension. He has had loin pain for one day. Of the following, which is the most likely mechanism responsible for the development of this mass?
1.
Thinning of the tunica media
2.
Haemorrhage into an atherosclerotic plaque
3.
Thrombosis overlaying an atherosclerotic plaque
4.
Lymphocytic infiltration in the media
5.
Ulceration of an atherosclerotic plaque
Thinning of the tunica media
A 57 year old man presents to A & E with new onset substernal chest pain. His serum C-reactive protein is elevated to four times the upper limits of normal. An EKG shows no ST segment changes. Serum Troponin I levels are just below the upper limits of normal. Examination of this patient’s coronary arteries would most likely show:
1.
Complicated atheromas with adherent fibrin plaque
2.
Uncomplicated atheromas with 25% maximal stenosis
3.
Uncomplicated atheromas with 50% maximal stenosis
4.
Complicated atheromas with occlusive thrombus.
5.
Uncomplicated atheromas with 75% maximal stenosis
Complicated atheromas with adherent fibrin plaque
56 year old known hypertensive man presents to ED with acute attack of chest pain. He has presented with similar symptoms twice in past year. Image shows microscopic appearance similar to his myocardium. What is the approximate duration of the disease process shown in the image? (JCU-AR03)
Etiology? Pathogenesis? Complications?
6.
24-48 hours
7.
2-8 weeks
8.
0-18 hours
9.
3-4 days
10.
1-2 weeks
2-8 weeks
A 23-year woman has had worsening malar skin rash persisting for 3 weeks. On auscultation pan systolic murmur is heard. Echocardiogram shows small sterile vegetation on mitral valve. Which of the following is most likely diagnosis of this patient?
What types of endocarditis shown? which one is of this patient? Pathogenesis?
1.
Restrictive cardiomyopathy
2.
Pericarditis
3.
Libman sack endocarditis
4.
Myocarditis
5.
Infective endocarditis
Libman sack endocarditis
A 72 year old man with chronic congestive cardiac failure. His B-type natiuretic peptide (BNP) is markedly elevated. Chest X-ray shows evidence of pulmonary oedema. Echocardiography shows an ejection fraction of 23%. Examination of this patient’s coronary arteries would most likely show:
1.
Uncomplicated atheromas with 25% maximal stenosis
2.
Uncomplicated atheromas with 50% maximal stenosis
3.
Uncomplicated atheromas with 75% maximal stenosis
4.
Complicated atheromas with adherent fibrin plaque
5.
Complicated atheromas with occlusive thrombus
Uncomplicated atheromas with 75% maximal stenosis
Dysfunction of which of the following cell types is most important in the initial formation of atherosclerotic lesions?
1.
Neutrophils
2.
Endothelial cells
3.
Smooth muscle cells
4.
T Lymphocytes
5.
Macrophages
Endothelial cells
Acute myocardial infarction (AMI) involving the posterior descending coronary artery. What ECG findings would be seen?
1.
ECG changes in V1 to V3
2.
ECG changes in all limb leads
3.
ECG changes in limb lead I & aVL
4.
ECG changes in II, III, a VF
5.
ECG changes in V4 to V6
ECG changes in II, III, a VF
JF, A 28y man has fever, fatigue, difficulty breathing, and substernal chest pain while at rest since 3 weeks. Physical examination shows bibasilar inspiratory crackles, distention of the jugular neck veins, and dependent pitting edema. A chest radiograph shows generalized enlargement of all chambers. The ejection fraction was 10% (normal ≥55%). Laboratory studies reveal an increase in cardiac-specific troponin and creatine kinase (CK)-MB. The photograph shows a histologic section of myocardial tissue from a subendocardial biopsy. Which of the following is the most likely cause of the heart disease?
What microscopic feature? Common etiology?
1.
Coronary Artery Thrombosis
2.
Ischemic Heart Disease (IHD)
3.
Viral Myocarditis
4.
Acute Rheumatic Fever (ARF)
5.
Toxin-induced myocarditis
Viral Myocarditis
A 50 year old man experiences recurrent episodes of substernal chest pain on moderate exercise. The episodes have become more frequent and severe over the past year but can be relieved by sublingual nitroglycerine. Laboratory findings show: - glucose 13mmol/L, total serum cholesterol 12mmol/L. Which of the following cardiac lesions is most likely to be present?
1.
Rheumatic mitral stenosis
2.
Coronary atherosclerosis
3.
Serous pericarditis
4.
Restrictive cardiomyopathy
5.
Calcific aortic stenosis
Coronary atherosclerosis
A 62 year old man presents with sudden onset of severe chest pain and is found to have an elevated troponin level consistent with acute myocardial ischaemia. He is given an intravenous anti-thrombotic (fibrinolytic) agent, alteplase. What is the mechanism by which the alteplase will have its effect?
1.
Potentiating the effects of antithrombin III
2.
Converting plasminogen to plasmin
3.
Inhibiting platelet aggregation
4.
Directly binding to and inactivating thrombin
5.
Inhibiting the effects of vitamin K dependent clotting factors
Converting plasminogen to plasmin
Two days following a myocardial infarction, a 68-year-old man reports loin pain and haematuria. An abdominal CT scan shows multiple wedge shaped, cortically based, hypodense areas involving both kidneys. The underlying cause of these renal abnormalities is most likely to be which of the following?
Etiology? Pathogenesis? Management?
1.
Hyaline arteriolosclerosis
2.
Ventricular fibrillation
3.
Thrombo-embolism
4.
Systemic hypotension
5.
Raised venous pressure
Thrombo-embolism
A 24-year-old man presents because of a severe leg pain following evening walk worsening since last year. Laboratory evaluation finds markedly elevated total cholesterol & LDL levels with normal serum triglycerides. What congenital abnormality is the most likely cause of his presentation? - “Familial Hypercholesterolemia”
1.
LDL receptor
2.
Apo-protien B 100
3.
VLDL receptor
4.
HDL receptor
5.
Apo-protien c
LDL receptor
A 42-year-old tall man is brought in to the emergency room with severe chest pain radiating to the back, which was unrelieved by nitroglycerin. His blood pressure is elevated but asymmetric in his arms, and he has a new murmur of aortic insufficiency. What type of aneurysm is shown in the image of an atherosclerotic aorta? (JCU-AR07)
Identify structures shown by arrows. pathogenesis in this patient / in this specimen?
1.
Berry aneurysm
2.
Fusiform aneurysm
3.
Mycotic aneurysm
4.
Dissecting aneurysm
5.
Large soft plaque
Dissecting aneurysm
A 55 year old man dies after an MI. What are the gross histological changes seen during the 7nd week after an MI?
1.
White fibrous scar
2.
yellow brownish discolouration
3.
Reddish discolouration
4.
Yellowish discoloration
5.
Dark discoloration
White fibrous scar
A 75-year-old man is admitted to the hospital with severe substernal chest pain that radiated into the inner aspect of the left arm. On day 7 of hospitalization, he developed acute mitral valve regurgitation and died. The photograph shows a transverse section of the heart at autopsy with the anterior portion of the heart at the top. Which of the following coronary arteries was most likely responsible for the gross changes in the heart?
What ECG findings? Acute & Chronic complications? What microscopic features now (day-7)?
1.
Sub endocardial branches of LAD
2.
Left main stem coronary artery
3.
Right coronary artery
4.
Left anterior descending coronary artery (LAD)
5.
Left circumflex coronary artery
Right coronary artery
A 55 year old man presents to ER with severe chest pain that radiates to arm and neck. He has shortness of breath and diaphoresis. Image shows ECG pattern. Which artery is the most likely involved?
Describe features? What branches?
1.
Left circumflex artery
2.
Right coronary artery
3.
Right circumflex artery
4.
Posterior descending artery
5.
Left anterior descending artery
Left anterior descending artery
62year old man presents with chest pain following his morning walk for 20min. Pain is relieved by taking rest. Image shows microscopic appearance of his LAD coronary artery biopsy. What stage of disease is shown in the image?
List 3 features in the image? Pathogenesis? Complications?
1.
Complicated plaque
2.
ulcerated plaque
3.
Stable plaque
4.
Complicated plaque
5.
Unstable plaque
Stable plaque
56y old man presents to ED with severe chest pain. The image shows microscopic appearance similar to his heart biopsy. What is the approximate duration of the infarction shown in the image
describe features seen?
1.
4-24 hours
2.
1-3 days
3.
1-2 weeks
4.
<4 hours
5.
2-8 weeks
1-3 days
A 55-year old man presents with recurrent chest pain that develops whenever he mows his yard. He says that the pain goes away after a couple of minutes if he stops and rests. His pain is not increased in frequency or duration in last several months. What is the correct diagnosis for this person?
1.
Stable angina
2.
Aortic disseciton
3.
Myocardial infarction
4.
Prinzmetal angina
5.
Unstable angina
Stable angina
A 37 year old man dies following a car crash. He recently had an episode of chest pain on exertion. An autopsy was performed and the image shows a biopsy of his left coronary artery. What is the most likely lesion?
List significant pathologic features in the image?
1.
Hard Plaque
2.
Fatty Plaque
3.
Fatty Streak
4.
Complicated Plaque
5.
Fatty Dot
Complicated plaque
- The following statement is TRUE
a. Hypertension is an independent risk factor for Cardiovascular
disease
b. The prevalence of hypertension has been associated with living in
metropolitan areas and the sedentary lifestyle of higher income
earners.
c. The majority of hypertensive patients have a secondary cause of
their hypertension.
d. Blood Pressure above 180/110 requires hospital assessment
a. Hypertension is an independent risk factor for Cardiovascular
disease
Malignant Hypertension involves quick and severe
elevation of BP with end organ damage:
02. Which of these is NOT associated with malignant htx?
a. Fibrinoid deposits, Vessel wall necrosis in the kidney
b. Retinal haemorrhages and exudates
c. Nutmeg liver
d. Papilloedema
c. Nutmeg liver
Scenario – Kayla, 43-year-old female
* Presents to GP: “work was offering free checks, the nurse told me my blood pressure was high, but I
feel fine.”
* Recorded 2 weeks ago – reading was 158/87
* Checked again on a friend’s machine a week later – reading was 155/84
* No PMH of note
* Allergies: None
* Family: Dad had a ‘heart attack’ when he was 60, Mum has diabetes.
* Meds: None
* Social: 5 cigarettes/day; 1 std drink Friday and Sat nights
* Lives in Weipa
* Works in the General Store as a shop assistant
* Aboriginal Australian
Coming back to Kayla… Her BP in the clinic is
153/82. A detailed history and examination reveals
no other abnormal symptoms or signs.
03. What should be included in your initial investigations:
a. Aldosterone: Renin ratio
b. Echocardiogram
c. Plasma metanephrines
d. Renal Ultrasound
e. Urine ACR
e. Urine ACR
Scenario – Kayla, 43-year-old female
* Presents to GP: “work was offering free checks, the nurse told me my blood pressure was high, but I
feel fine.”
* Recorded 2 weeks ago – reading was 158/87
* Checked again on a friend’s machine a week later – reading was 155/84
* No PMH of note
* Allergies: None
* Family: Dad had a ‘heart attack’ when he was 60, Mum has diabetes.
* Meds: None
* Social: 5 cigarettes/day; 1 std drink Friday and Sat nights
* Lives in Weipa
* Works in the General Store as a shop assistant
* Aboriginal Australian
Kayla returns for her results in a week.
They are normal apart from a slightly high
total cholesterol and low HDL cholesterol.
Her BP is again elevated at 158/79
Kayla’s serial Blood Pressure
readings in clinic:
* 153/82
* 158/79
- Which statement is true?
a. Kayla has a normal blood pressure for her age
b. Kayla has moderate hypertension
c. Kayla has severe hypertension
d. Kayla needs a 24-hour monitor to diagnose whether she has
hypertension
e. You should perform a CVD risk assessment on Kayla
e. You should perform a CVD risk assessment on Kayla
- This is a horizontal section of a heart through
the ventricles, compared with normal. What
pathological feature is shown?
a. Hypertrophic cardiomyopathy
b. Amyloid Cardiomyopathy
c. Myocardial infarction
d. Left Ventricular Hypertrophy
e. Dilated cardiomyopathy
d. Left Ventricular Hypertrophy
What complication of hypertension is
shown in the image below?
a. Atheromatous plaques.
b. Thrombosis on plaque.
c. Fusiform aneurysm.
d. Dissecting (aneurysm)
e. Berry aneurysm
d. Dissecting (aneurysm)
Scenario – Carlos, 17 years old, dies in MVA
A 17-Year-old male dies in a motor vehicle accident and undergoes autopsy.
The autopsy pathologist notes some changes associated with atherosclerosis.
07. The most likely finding to be identified at this age is :
a. Accumulation of calcium in vessel walls
b. Complicated plaques showing ulcers, protrusions and thrombus
c. Fatty streak formation
d. Lipid rich atheromatous plaques
e. Vascular intimal thickening
c. Fatty streak formation
Scenario – Carlos, 17 years old, dies in MVA
A 17-Year-old male dies in a motor vehicle accident and undergoes autopsy.
The autopsy pathologist notes some changes associated with atherosclerosis.
Identify the image showing the most likely
pathology finding associated with atherosclerois in
in Carlos.
A
The following image shows..
a. Stable plaque
b. Fatty streak
c. Aneurysm
d. Ulcerated plaque
stable plaque
Scenario - John 60-Year-old man
Presents with intermittent chest pain
PMX:
Hypertension
Type 2 Diabetes
Obese
Social:
Smoker
Aboriginal Australian
John reports 2 weeks of brief episodes of anterior chest
discomfort on his morning walks, relieved by rest. It feels like a
weight on his chest and radiates into his left arm. He denies
pain at rest. An ECG is performed which is normal.
10. What is the likely diagnosis?
a. GORD
b. Unstable angina
c. Stable angina
d. STEMI
e. Dissecting aortic aneurysm
stable angina
- The following features are most consistent with the plaque in the
likely diagnosis in John?
a. More inflammation, more lipid, less fibrosis
b. Less inflammation, less lipid, more fibrosis
c. A severe fixed obstruction
d. Platelet aggregation
e. Temporary spasm
Less inflammation, less lipid, more fibrosis
- All other factors
being controlled, the
lowest level of arterial
diameter reduction likely
to provoke ischaemic
symptoms is said to be
a. > 50%
b. >60%
c. >70%
d. >80%
e. >90%
> 70%
John 60-Year-old man
Presents with intermittent chest pain
PMX:
Hypertension
Type 2 Diabetes
Obese
Social:
Smoker
Aboriginal Australian
John reports 2 weeks of brief episodes of anterior chest
discomfort on his morning walks, relieved by rest. It feels like a
weight on his chest and radiates into his left arm. He denies
pain at rest. An ECG is performed which is normal.
John sees a cardiologist for management. He then has a GP
review at 3 months, where he notes that the pain has
continued. Which of the following suggests he now has
unstable Angina?
A. He continues to have chest pain lasting 5 minutes once a week
B. He requires a spray of GTN (which is effective) once a week to
relieve the pain
C. He has new ST elevation on ECG
D. His chest pain lasts 5 minutes but is now occurring 4 times a week
D. His chest pain lasts 5 minutes but is now occurring 4 times a week
Yasuko, 46 year old female,
generally well, long distance runner.
She is a smoker.
For the last week, she has been woken in the early hours with
severe, crushing, chest pain, lasting around 5 minutes. It has not
occurred during her daily 20km runs.
This morning she felt like she was going to die and called an
ambulance, but the pain was gone when they arrived. The same
pain recurred in the ambulance and was relieved by GTN.
14. What is the likely diagnosis?
a. Vasospastic (Prinzmetal) angina
b. Unstable angina
c. Stable angina
d. Reflux
e. Dissecting aortic aneurysm
. Vasospastic (Prinzmetal) angina
- Which coronary artery is most likely to be affected?
a. Right coronary artery
b. Left circumflex artery
c. Left anterior descending artery
d. Obtuse marginal branch
e. Posterior descending artery
LAD
LAD artery
Identify the affected coronary artery in
the picture
a. A
b. B
c. C
d. D
MI (at 5 hours from onset of pain), the
gross appearance of the area of ischaemic damage would be:
Between normal and dark red
How many hours or days post MI would the
below image represent?
a. <4 hours
b. 4-24 hours
c. 1-3 days
d. 3-7 days
e. 1-2 weeks
f. 2-8 weeks
1-3 days
The image below is most consistent with:
a. Pericardial rupture
b. Old MI
c. MI <4hours
d. MI 1-2 weeks
e. Pericarditis
old MI
- Which of the following is the most
likely cause of Manoj’s death?
a. Ventricular aneurysm
b. Anterior free wall myocardial
rupture
c. Re-infarction
d. Ventricular septal rupture
e. Papillary muscle rupture
anterior free wall rupture: occurs day 3-2 weeks
George, 60 year old male
Presents to GP in Cairns “I was on my lunch break when my chest started hurting”
* Pain
* started 6 hours ago and hasn’t gone away.
* It’s a 5/10 ache in his central chest.
* Its unchanged by movement or position.
* His left arm is a bit sore too.
* He feels anxious.
* He has had no shortness of breath, no pain with inspiration and no infectious
symptoms
PMX: diabetes on Metformin, rarely attends GP
Family: AMI, Stroke.
Social: Non smoker, drinks 6-10 st. drinks 2 nights a week, Concreter, Italian-Australian
George appears anxious and sweaty. His HR is 110 reg, BP 164/90.
The rest of his vital signs, Resp, CVS and MSK examinations are
normal.
21. Which of the following conditions is most likely?
a. Pericarditis
b. Myocardial Infarction
c. Pneumothorax
d. Aortic Dissection
e. Costochondritis
f. Pulmonary Embolus
Myocardial Infarction
You perform an ECG it shows sinus
tachycardia.
22. Which of following should be part of your initial management?
a. Administer high flow Oxygen
b. Give 100mg Aspirin
c. Give sub lingual nitrate
Give sub lingual nitrate
George appears anxious and sweaty. His HR is 110 reg, BP 164/90.
The rest of his vital signs, Resp, CVS and MSK examinations are
normal.
George is transferred to Hospital by
ambulance. Investigations are ordered.
23. Which test should be included in initial investigations?
a. hs-Troponin-I
b. CK – MB
c. Myoglobin
d. LDH
e. BNP
a. hs-Troponin-I
- Which of the following conditions could also cause raised enzymes including troponin?
a. Sepsis
b. Fracture of a long bone
c. Trauma leading to bleeding
d. Liver failure
e. TIA
sepsis
Jason 54 year old male
Presents to A&E 4 weeks following an anterolateral MI with four days of worsening
malaise, loss of appetite, night sweats, joint pains, shortness of breath and chest
pain. The pain is worse lying down and relieved by sitting up and leaning forward.
He looks unwell, has a mild fever, tachycardia and soft heart sounds with a possible
rub and bibasal crackles. ECG shows diffuse mild concave ST elevation through most of the ECG and anterolateral Q waves.
25. Most likely diagnosis is:
a. Pulmonary embolus
b. Pneumonia
c. Dressler syndrome
d. Endocarditis
e. Congestive heart failure
Dressler syndrome or pericarditis
Which of the following is associated with
Pericarditis?
a. Diffuse peaked P waves
b. Chest pain relieved with inspiration
c. Harsh para-sternal ejection systolic
murmur
d. Pain worse seated and leaning forward
e. Recent infectious symptoms
Recent infectious symptoms
- A 43yo male presents to ED with a 2-day history of fever and
generally feeling unwell. He has a past history of T2DM and his
last HbA1c was >10%.
What clinical feature would make you most suspect IE as the
diagnosis?
a. Hypertension
b. Irregularly irregular pulse
c. Murmur
d. Subcutaneous nodules
e. Track marks on arms
Murmur
A 43yo male presents to ED with a 2-day history of fever and
generally feeling unwell. He has a past history of T2DM and his
last HbA1c was >10%.
02. On examination of his hand, you notice this appearance of his
thumb. What is the pathogenesis of this abnormality?
a. Abnormal coagulation
b. Decreased fragility of the vessel wall
c. Idiopathic
d. Vasculitis
Vasculitis
43yo male presents to ED with a 2-day history of fever and
generally feeling unwell. He has a past history of T2DM and his
last HbA1c was >10%.
03. On examination, the following murmur is best heard at the
apex. The murmur radiates to the axilla. What valvular pathology is
the patient most likely to have?
a. Mitral stenosis
b. Aortic regurgitation
c. Mitral regurgitation
d. Tricuspid stenosis
e. Pulmonary regurgitation
Mitral regurgitation
A 43yo male presents to ED with a 2-day history of fever and generally feeling unwell. He has a past history of T2DM and his last HbA1c was >10%. 04. An echocardiogram is performed which confirms mitral regurgitation. 3x blood cultures are performed and the patient is started on empirical antibiotics. What organism is most likely to be grown on the blood culture?
a. Enterococcus
b. Staphylococcus aureus
c. Staphylococcus epidermidis
d. Streptococcus pneumoniae
e. Streptococcus viridans
Staphylococcus aureus
- What information on history/examination would make you
suspect a diagnosis of subacute infective endocarditis over acute
IE?
a. 5-day history of SOB
b. Chest pain
c. Haematuria suggesting glomerulonephritis
d. History of injecting drug use
e. Pre-existing murmur
Pre-existing murmur
- An 8yo child visiting from Aurukun is bought in to the local GP
clinic with a sore throat and fevers. They are diagnosed with
pharyngitis and prescribed penicillin. A throat swab is taken which
later confirms Group A strep infection.
Prescribing of amoxycillin is an example of what type of prevention
for rheumatic heart disease?
a. Primordial
b. Primary
c. Secondary
d. Tertiary
e. Quaternary
Primary
- A 13yo male presents to the clinic with a 2-day history of
subjective fevers and arthralgia. On examination, the knee is not
erythematous or swollen but the patient refuses to weight bear on
it. You suspect that the child has ARF.
Which investigation performed today is needed for the diagnosis of
acute rheumatic fever?
a. ASO titre
b. Blood culture
c. Throat swab MCS
d. Skin sore swab MCS
e. ESR
ASO titre
A 13yo male presents to the clinic with a 2-day history of subjective
fevers and arthralgia. On examination, the knee is not red or
swollen but the patient refuses to weight bear on it. You suspect
that the child has ARF.
GROUP QUESTION
08. For each site listed below, state the clinical manifestations of
ARF that the patient may present with.
Brain: Sydenham chorea (involuntary movements)
Joints: polyarthralgia (without inflammation) just pain - large joints which migrate
Skin: erythema marginartum - macule which is well marginated
Heart: syncope, dizziness, palpitations, edema, pericardial rub
A 13yo male presents to the clinic with a 2-day history of subjective
fevers and arthralgia. On examination, the knee is not
erythematous or swollen but the patient refuses to weight bear on
it. You suspect that the child has ARF. The ASO titre is positive.
09. What single other finding would confirm a definite initial
episode of ARF?
a. Elevated ESR or CRP
b. First degree heart block on ECG
c. Janeway lesion
d. Recorded temp >38
e. Sydenham chorea
Sydenham chorea
A 13yo male presents to the clinic with a 2-day history of subjective
fevers and arthralgia. On examination, the knee is not erythematous or
swollen but the patient refuses to weight bear on it. You suspect that the
child has ARF.
10. The patient is transferred to hospital and admitted under paediatrics.
An echocardiogram is performed which shows mitral regurgitation. What
pathology is occurring to cause the regurgitation of the valve?
a. Destruction of the valve leaflets
b. Fibrosis of the valve leaflets
c. Neovascularisation of the valve
d. Septic embolisation
e. Vegetations at the valve edge
Vegetations at the valve edge
20 years later, the patient presents to ED. On
examination, a rumbling diastolic murmur is heard.
The picture shows what his valve would look like.
11. What valvular pathology is causing the murmur?
a. Calcific degeneration
b. Fibrous thickening
c. Myxomatous degeneration
d. Neovascularization
e. Vegetations
Fibrous thickening
- A 72yo female presents to ED with 3 months of progressive
dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea.
What is the best description on this patient’s heart failure?
a. Heart failure with preserved ejection fraction
b. Heart failure with reduced ejection fraction
c. Left-sided heart failure
d. Right-sided heart failure
e. Systolic heart failure
Left-sided heart failure
A 72yo female presents to ED with 3 months of progressive
dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea.
13. What clinical sign is consistent with the patient having isolated
left-sided heart failure?
a. Ankle oedema
b. Ascites
c. Bibasilar crackles
d. Hepatomegaly
e. Raised JVP
Bibasilar crackles
A 72yo female presents to ED with 3 months of progressive dyspnoea,
paroxysmal nocturnal dyspnoea and orthopnoea.
14. As part of her assessment, a CXR is performed, shown below. What signs of
pulmonary oedema can be seen on the
patients CXR? (2 correct answers)
a. Batwinging
b. Dilated right ventricle
c. Increased cardiothoracic ratio
d. Kerley B lines
e. Loss of costophrenic angle
Batwinging
Kerley B lines
A 72yo female presents to ED with 3 months of progressive
dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea.
15. What is the primary pathogenesis of the pulmonary oedema in
this patient?
a. Decreased capillary oncotic pressure
b. Increased capillary hydrostatic pressure
c. Increased capillary permeability
d. Increased interstitial oncotic pressure
Increased capillary hydrostatic pressure
A 72yo female presents to ED with 3 months of progressive
dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea.
GROUP QUESTION
16. What long-term management is recommended in this patient?
List 5.
- A 62yo in hospital calls for the nurse due to increasing SOB.
He was admitted 6 days ago with chest pain and was diagnosed
with a STEMI. He has not had any further chest pain since. On
examination, he is now hypotensive, his SpO2 is 94% RA, he has
moderate pitting oedema on both legs. A (new onset) murmur is
heard on auscultation. His ECG is unchanged. What murmur is
most likely in this situation?
a. Crescendo-decrescendo systolic murmur radiating to the
carotids
b. Mid-systolic murmur at base
c. Pan-systolic murmur at apex
d. Rumbling diastolic murmur
Pan-systolic murmur at apex
- A 52yo presents with an episode of syncope on a background of 8 months
of worsening SOBOE. They have no known past medical history. On
examination, a murmur is heard at the base, radiating to the carotids and is
shown below.
What is the primary pathological process most likely causing the
murmur?
a. Bicuspid valve
b. Calcified valve
c. Dilated aortic root
d. Extensive atherosclerotic disease
e. Vegetations
Bicuspid valve
A 15yo female dies via sudden cardiac death while playing
volleyball. She had no known medical conditions and there was no
history of her being unwell prior to her death. An autopsy is
performed to determine the cause of her death. What pathological
findings of the heart is the medical examiner most likely to find?
a. Haphazardly arranged hypertrophied myocytes
b. Extensive myocardial haemosiderin deposition
c. Parasites within myocardial necrosis and inflammation
d. Mitral valvular stenosis with left atrial enlargement
e. Large, friable vegetations with destruction of aortic valve cusps
Haphazardly arranged hypertrophied myocytes
A 62yo female presents with a 1-mo history of ankle swelling
on a background of an 8-month history of progressive SOBOE.
She has a known history of type 2 diabetes and liver disease but
no known family history of heart conditions. An echocardiogram
shows 4-chamber dilatation and a LV ejection fraction of 36%.
What is the most likely aetiology of this patient’s heart failure?
a. Alcohol
b. Amyloidosis
c. Chemotherapy
d. Congenital malformation
e. Genetic mutation
Alcohol
A 62yo female presents with a 1-mo history of ankle swelling on a background
of an 8-month history of progressive SOBOE. She has a known history of type
2 diabetes and liver disease but no known family history of heart conditions.
An echocardiogram shows 4-chamber dilatation and a LV ejection fraction of
36%.
21. Gross morphology of her heart would be as shown. What type of heart
failure would best describe this patient?
a. Heart failure with preserved ejection fraction
b. Heart failure with reduced ejection fraction
c. Left-sided heart failure
d. Right-sided heart failure
e. Systolic heart failure
Heart failure with reduced ejection fraction
- A 24yo woman presents with a 4-day history of worsening
SOBOE, orthopnoea and ankle swelling. She had recently been off
work with fevers and fatigue. On examination, heart sounds are dual
with no murmurs.
ECG shows sinus tachycardia, ST-segment elevation and T wave
inversion, but no ST depression. Troponin is positive. A coronary
angiogram is normal.
What is the most likely aetiology of her presentation?
a. Cocaine use
b. Coxsackie B virus
c. Idiopathic
d. Marfan’s syndrome
e. Streptococcus viridans
Coxsackie B virus
An ultrasound scan of a fetus reveals a ventricular septal
defect, overriding aorta, right ventricular hypertrophy and marked
pulmonary atresia. What examination finding is likely to be present
after birth?
a. Congestive cardiac failure
b. Irregularly irregular pulse
c. Peripheral cyanosis
d. Systemic hypotension
e. Weak lower extremity pulses
Peripheral cyanosis
Rheumatic fever has two phases Acute ARF and Chronic RHD
Rheumatic fever has two phases Acute ARF and Chronic RHD
True False
True
Commonest Cardiomyopathy is
Restrictive
Hypertrophic
Dilated
Dilated
3 aetiologic factors in any autoimmune disorder are
Genetic factor, Environmental factor and this,
Age (children)
Pollution
GAS infection
Autoimmunity
Inflammation
Autoimmunity
Pathogenesis of Rheumatic heart disease (RHD) is,
Recurrent GAS infection
Recurrent Multisystem inflammation
Repeated attacks of ARF
Pancarditis (Endocarditis, Myocarditis & Pericarditis)
Recurrent myocarditis
Recurrent GAS infection
“Bread & Butter” synonym is used for this feature of Rheumatic fever.
Valve vegetations
Ashchoff body
Pericarditis
Endocarditis
Myocarditis
Pericarditis
“Sydenham Chorea” is because of inflammation in the basal ganglia. of brain. True or False
True
Infective endocarditis can cause Aortic Stenosis.
True
False
False
Streptococcus viridans bacteria typically causes SBE.
True
False
True
Septic embolism in retina is also known as,
Osler’s nodes
Janeway lesions
Roth Spots
splinter hemorrhages
Micro aneurysms
Roth Spots
Calcific Aortic Stenosis occurring at 30y is usually due to,
Ageing wear & tear.
Bicuspid valve.
Marfan’s syndrome
RHD
MI
RHD
Etiology of Mitral Valve Prolapse is
Marfan’s Sy
IHD
Genetic
Non of the above
All of the above
all of the above
Marantic Endocarditis is also known as NBTE
True
False
True
Right sided endocardial fibrosis typically occurs in
MI healed
Lung Carcinoid
GIT Carcinoid
Lung Cancer - SCC
Hypercoagulability
GIT Carcinoid
Fetal circulation has thIs NORMAL Right to Left shunt.
ASD
VSD
Umbilical Artery
Ductus Arteriosus
Over riding of Aorta.
Ductus Arteriosus
Fill in the blank
Incidence of Congenital Heart Disease is approximately
% of live births
1%
Commonest CHD clinically is
ASD
VSD
Fallot’s T
PDA
Pulm. Stenosis
ASD
Machine Murmurs are typically seen in,
ASD
VSD
PDA
TGA
PDA
Rib notching is a feature seen in this type of CHD?
PDA
VSD
ASD
TGA
FT
CoA
CoA
Cyanosis may be seen in ASD when there is,
Infective Endocarditis
Cardiac Failure
Pulmonary Hpyertension
Reversal of Shunt
Right Ventricular Hypertrophy
Reversal of Shunt
Commonest clinical type of cardiomyopathy is,
Hypertrophic
Restrictive
Arrhythmogenic
Dilated
Genetic
Dilated
Chronic alcoholism may cause Hypertrophic cardiomyopathy.
True
False
False
Dystrophin mutation is seen in Dilated Cardiomyopathy.
True
False
True
Sudden death can occur in many types of cardiomyopathy, but commonest in this type.
Dilated
Hypertrophic
Arrhythmogenic RV
LV Non compaction
Restrictive
hypertrophic
Amyloidosis typically causes this type of Cardiomyopathy.
Dilated
Hypertrophic
Restrictive
Myocarditis
Arrhythmogenic
Restrictive
Flabby heart is typically seen in hypertrophic cardiomyopathy.
True
False
F
Fever & chest pain is typically seen in
Dilated
Hypertrophic
Restrictive
Myocarditis
all types of cardiomyopathy
Myocarditis
Right sided CHF patients typically present with dyspnoea due to pulmonary edema.
True False
False
High output failure is typically seen in patients with severe anemia.
True False
True
Hepatosplenomegaly is typically seen in Right Sided CHF (Corpulmonale)
True False
True
Kerley B Lines on chest X-Ray is suggestive of Interstitial edema.
True False
True
Heart failure cells are Hemosiderin laiden macrophages in alveoli.
True False
True
Nutmeg Liver is due to congestion around portal triads in liver.
True False
False
Gross features of Mitral valve in Acute Rheumatic fever is
Mitral leaflest fustion
Fish mouth Mitral stenosis
Shortening of Chordae tendinae
Vegetations along free border
Neovascularization
Vegetations along free border
Fish mouth or button hole shape of mitral stenosis in RHD is because of
Autoimmune reaction
GABH streptococci
Anatomy of Mitral valve
Acute Rheumatic vegetations
Chronic inflammation
Anatomy of Mitral valve
Neovascularization (blood vessels in mitral valve) is because of chemical mediators of wound healing.
True
False
True
Aschoff Body is,
Fibrinoid necrosis
Activated Macrophages
Giant Cells
T lymphocytes
All of the above.
ALL
Anitschkow or Caterpiller cells are,
Reactive T Lymphocytes
Activated Macrophages
Giant cells
Ascchoff cells
Activated B lymphocytes
Activated Macrophages
Large irregular destructive vegetations are typical of,
ARF
RHD
SBE
NBTE
Calcific AS
SBE
Commonest casue of valve disorder in old age is,
Mitral valve prolapse
Bacterial Endocarditis
Acute Rheumatic Fever
Rheumatic Heard Disease
Calcific Aortic Stenosis
Calcific Aortic Stenosis
A 19-year-old man suddenly collapses and is brought to the emergency department. His vital signs include temperature of 37.1°C, pulse 84/min, respirations 18/min, and blood pressure 80/40 mm Hg. Laboratory findings include hemoglobin of 135 g/L, platelet count 252x109/L, WBC count 7.2 x109/L, Blood glucose 5.1mmol/L, Total cholesterol 38 mmol/L, The total creatine kinase (CK) level is elevated, with a CK-MB fraction of 10%. Which of the following underlying conditions is most likely to be present in this patient?
1.
Familial Hypercholesterolemia.
2.
Hereditary hemochromatosis
3.
Down’s syndrome
4.
Marfan’s syndrome
5.
DiGeorge syndrome
Familial Hypercholesterolemia.
During volleyball tournament, a 15-year-old girl jumps up for a block and collapses. Despite cardiopulmonary resuscitation, she cannot be revived. She had been healthy all her life and complained only of limited episodes of chest pain in games during the current school year. Which of the following pathologic findings of the heart is the medical examiner most likely to find?
1.
Parasites within myocardial necrosis and inflammation
2.
Mitral valvular stenosis with left atrial enlargement
3.
Haphazardly arranged hypertrophied myocytes
4.
Extensive myocardial hemosiderin deposition
5.
Large, friable vegetations with destruction of aortic valve cusps
Haphazardly arranged hypertrophied myocytes
An 6-year-old Aboriginal boy at the GP clinic because he has a fever. His mother reports he had a sore throat 3 weeks previously but has recovered since. He is also complaining of pains in his knees. On examination he has a temperature of 38.6 and a rash. Which of the following would make you suspect acute RF with respect to this patient?
1.
Past Sore throat
2.
Fever
3.
Sore Knees
4.
All of the above
5.
Rash
All of the above
A 77-year-old woman for a routine health maintenance examination. On physical examination, she is afebrile. Her vitals are normal. On auscultation, a systolic ejection murmur is heard. There are a few crackles over the lung bases posteriorly. From the representative gross appearance of the aortic valve shown in the figure, which of the following most likely contributed to the development of this lesion?
Etiology? Pathogenesis? Clinical feature? Complicaitons?
1.
Atherosclerosis
2.
Rheumatic Heart Disease
3.
Genetic abnormality
4.
Tertiary Syphilis
5.
Ageing
Aging
A 55-year-old man got a prosthetic valve a month ago. Now he presents to ER with high fever for 5 days. On P/E the physician notices dark red linear lesions on nail bed, tender nodules on digits, non tender macules on palm and soles, retinal hemorrhages. Which organism is most likely to cause this?
1.
Strep Viridans
2.
Strep Bovis
3.
Strep pyogens
4.
Staph epidermis
5.
Staph aureus
Staph aureus
A 15-year-old male had pharyngitis, after 3 weeks he develops acute rheumatic fever. Which is the most common organism involved in Acute rheumatic fever?
1.
Staph auerus
2.
Enterococcus
3.
Group A Strep
4.
Group B Strep
5.
Hemophilus
Group A Strep
Sam, 55 year old man reports he had rheumatic fever as a child and his previous doctor told him he had a murmur.
Before you listen to his chest you know the most likely heart murmur you will hear is,
1.
A diastolic murmur at apex and heard best when Sam is lying on his left side
2.
A mid systolic murmur radiating to the back and enhanced by exercise
3.
An ejection systolic murmur loudest at the apex at rest.
4.
A pan systolic murmur maximum intensity at the lower left sternal border
5.
Early diastolic murmur maximum at the left sternal edge when George is sitting up, leaning forward and breathing out
A diastolic murmur at apex and heard best when Sam is lying on his left side
A woman collapses suddenly and unexpectedly. Electrocardiogram shows sinus tachycardia saddle shape ST-segment elevation and T wave inversions. An endomyocardial biopsy shows infiltration by small lymphocytes with focal myocyte necrosis. Which of the infectious agent is most likely to have caused these findings?
1.
Coxsackie B virus
2.
Candida Albicans
3.
Staph aureus
4.
Strep Viridans
5.
Aspergillus Fumigatus
Coxsackie B virus
From the following list of Jones clinical criteria for acute rheumatic fever; which is the minor criterion?
1.
Erythema marginatum
2.
Arthralgia
3.
Carditis
4.
Chorea
5.
Subcutaneous nodules
Arthralgia
A 10 year old girl develops subcutaneous nodules over the skin of her arms and torso 3 weeks after a bout of acute pharyngitis. She develops pain in her knees and hips, particularly with movement. A friction rub is heard on auscultation of the chest. Which of the following serum laboratory findings is most characteristic of the disease affecting this patient?
1.
Positive rapid plasma regain test
2.
Elevated creatinine level
3.
Positive ANA test
4.
Elevated anti-streptolysin O level
5.
Elevated cardiac troponin level
Elevated anti-streptolysin O level
A 66 year old retired pharmacist with previous myocardial infarction presents with a history of shortness of breath particularly at night and you decide to do his clinical examination. What should be the correct position of the patient?
1.
Head up on at least two pillows
2.
He should be examined in the position he is most comfortable in
3.
The patient needs to be at 30 degrees
4.
It is important to lay the patient flat
5.
Head up at 45 degrees
Head up at 45 degrees
When examining a patient’s cardiovascular system you find that there is an irregular pulse and you suspect atrial fibrillation. You can get further evidence for this being atrial fibrillation by which of the following?
1.
Pulse deficit from apex to radial pulse
2.
Performing cartoid sinus massage
3.
Finding a variation in pulse rate with respiration
4.
Demonstrating hepatojugular reflux
5.
Finding radio-femoral delay
Pulse deficit from apex to radial pulse
Mr JH, a 55 year old alcoholic and IV drug user, presents with high fever & severe SOB since a week. Of the following, is the first sign to indicate that he has developed bacterial endocarditis?
1.
Splinter haemorrhages
2.
New murmur
3.
Janeway lesions
4.
Sydenham Chorea
5.
Osler’s nodes
New murmur
You find tender raised lesions on the thenar eminences in a patient who has fever, night sweats and previous rheumatic fever. These most likely are?
1.
Xanthelasma
2.
Erythema nodosum
3.
Janeway lesions
4.
Osler’s nodes
5.
Splinter haemorrhages
Osler’s nodes
Which of the following is a microscopic feature of Chronic Rheumatic heart disease?
1.
Aschoff giant cells
2.
Fibrosis
3.
Anitschkow cells
4.
Fibrinoid degeneration
5.
T lymphocytes
Fibrosis
A 27-year-old woman gives birth to a term infant after an uncomplicated pregnancy and delivery. The infant is cyanotic at birth. Two months later, physical examination shows the infant to be at the 37th percentile for height and weight. The representative gross appearance of the infant’s heart is shown. Which of the following is the most likely diagnosis?
- Aortic stenosis
- Pulmonic stenosis
- Truncus arteriosus
- Tetralogy of Fallot
- Transposition of the great vessels
Transposition of the great vessels
A 27-year old G2P1 women has screening ultrasound at 18 weeks of gestation. Fetus has a heart with ventricular septal defect, overriding aorta, Right ventricular hypertrophy and marked pulmonary atresia. Which of the following characteristic on physical examination would likely result from these cardiac defects?
Why this clinical feature? (pathogenesis?), what embryologic abnormality?
1.
Congestive cardiac failure.
2.
Systemic hypotension
3.
Peripheral cyanosis
4.
Weak lower extremity pulses
5.
Irregularly irregular pulse.
peripheral cynosis
Pulsus parodoxus is found by determining that:
1.
Blood pressure increases and pulse rate falls during inspriation
2.
Blood pressure increases and pulse rate increases during inspiration
3.
Blood pressure falls and pulse rate falls during inspiration
4.
Blood pressure falls and pulse rate increases during inspiration
5.
Blood pressure falls and pulse rate increases during expiration
Blood pressure falls and pulse rate falls during inspiration
A 1 year old child had recurrent fever, Staphylococcus epidermidis was cultured from her blood. The child responds to antibiotic therapy but recurred later. 12 months later the child is reviewed. On physical examination, a harsh, waxing and waning, machinery like murmur is heard on auscultation of the upper chest. A CXR shows no abnormalities. Laboratory studies show normal arterial oxygen saturation levels. Which of the following congenital heart diseases is most likely to explain these findings?
1.
Arterial septal defect
2.
Patent ductus arteriosus
3.
Total anomalous pulmonary venous return
4.
Aortic coarctation
5.
Tetralogy of fallot
Patent ductus arteriosus
An 18 year old girl presents to her GP with a history of joint pain, fever and a few subcutaneous nodules at her elbows. The histopathology of her myocardial biopsy is shown in the image. Which of the feature is the most diagnostic of her disease?
- Chronic myocarditis
- Rheumatic vegetations
- Anitschow cells
- Rheumatic Nodule
- Aschoff body
Aschoff body
A 5 year old boy has been known to have a ventricular septal defect since he was born. He has recently developed cyanosis. What is the most likely reason for the development of her cyanosis?
1.
Right ventricular failure
2.
Pulmonary embolism
3.
Left to right shunt
4.
Left ventricular failure
5.
Right to left shunt
Right to left shunt
An 80-year-old lady has increasing SOB and episodes of feeling faint. She also has worsening angina over the last 2 months. She tells you her GP has heard a murmur. On auscultation of her chest, you are most likely to hear.
1.
Pan-systolic murmur best heard at the apex
2.
Mid diastolic murmur best heard at the apex when she lying on her left side
3.
Late systolic murmur best heard in the pulmonary area
4.
Decrescendo diastolic murmur radiating to the carotids
5.
Ejection systolic murmur radiating to the neck
Ejection systolic murmur radiating to the neck
physical examination of an asymptomatic 28-year-old woman with a history of rheumatic fever during childhood finds an early diastolic opening snap with a rumbling mid diastolic murmur. Which of the following is the most likely diagnosis?
1.
Aotric regurgitation
2.
Aortic stenosis
3.
Mitral regurgitation
4.
Pulmonic stenosis
5.
Mitral Stenosis
Mitral Stenosis
Case: 12y indigenous girl. Fever, joint pains, SOB, pericardial rub, Chorea,
Gross: mitral valve linear, small vegetation’s & inflammation along the occlusal borders. (Area of damage & exposure of Ag.)
Microscopy: inflammation, T lymphocytes, Aschoff bodies, platelet rich thrombus overlying area of ulceration. Normal valve Vegetations
Etiopathogenesis: Genetic, Environmental, Autoimmune. GABH
streptococcal M Protein. Cardiac Ag.
Differential: Bacterial Endocarditis (large irregular, destructive both sides).
Non Bacterial – only platelets, no inflammation, along the line of closure.
Complications: Bacterial endocarditis, thromboembolism, stroke, CCF.
ARF vegitation
Case: 38y female, Progressive severe SOB.
Gross: excised mitral valve. Fusion of thickened opaque leaflets, fused chordae tendinae, narrow fish mouth mitral opening.
Microscopy: at this time there would be just fibrous scarring (collagen bundles) early stagewould have Aschoff bodies (perivascular T cell mediated granuloma around fibrinoid necrosis with macrophages/Anitschkow, giant cells & T lymphocytes) in
machH/O recurrent URTI as child. Fever, arthritis and heart problems several years ago. Undergoes mitral valve replacement.
Etiopathogenesis: Genetic, Environmental, Autoimmune. GABH streptococcal M Protein. Cardiac Ag.
MS – RHD
Pathogenesis:
Why thickening, fusion..? – Inflammation scarring.
Why Button hole / Fishmouth MS? – Anatomy Mitral
Why neovascularization? – Angiogenesis (healing)
RHD
Case: 58y IV drug abuser (Diabetic, RHD AS or other valve disorder). Fever, chills, weakness, lassitude, Murmurs, petechial rash, splinter hemorrhages, etc.,
Gross: Large irregular destructive vegetation’s. Destruction of chordae tendinae, yellow / pus.
Microscopy: Necrosis, bacterial clumps,inflammation
Etiopathogenesis: Acute: normal valve, highly virulent bacteria (Staph aureus). Subacute: abnormal valve/Immunosuppression. Low virulence (Strep viridans),
Differential: Non Bacterial (NBTE) plts, no inflame., along the line of closure (in DVT, PE etc..) RHD: young, linear, along free border, Immune. SLE: Libman-Sacks – plt.
Complications: septicemia, emboli, septic infarcts, mycotic aneurysm, Glomerulonephritis, Janeway lesion
infective endocarditis
Case: 78y female, Progressive SOB and chest pain. Bilateral pedal edema & Congestive Heart Failure. Chest X-ray shows concentric left ventricular hypertrophy. Her BP is normal.
Gross: calcified mounds within cusps (Valsalva sinus).
Microscopy: calcification, bone & bone marrow in valvular fibrosa. Varying inflammation.
Etiopathogenesis: Age associated senile change. Aorta common. Wear & tear, damage Dystrophic calcification. Over normal / bicuspid valve.* Deposits prevent opening of valve stenosis.
Differential: Rheumatic AS.
Complications: Bacterial endocarditis, CCF.
calcified aortic sternosis
Case: 48y female, asymptomatic / SOB (or SBE), Stroke / embolism. P/E mid-systolic click /arrhythmia.
Gross: ballooning and prolapse of mitral valve into atrium.
Microscopy: degeneration, myxoid or mucoid material. Reduced normal fibrous tissue.
Etiopathogenesis: reduced fibrous tissue and increased mucoid material in the valve. Some cases of Marfans syndrome have MVP..
Differential: Ischemia, MI.
Complications: Bacterial endocarditis, thromboembolism, stroke, CCF.
Floppy mitral valve: Mitral valve prolaps
ASD
* 3 types, Secundum common (90%)
* Small asymptomatic till adult.
* HF, Pulm. hypertension in elderly, rare)
* Complications: Reversal of shunt with cyanosis
Eisenmenger’s complex, Infective endocarditis & paradoxical embolization.
Patent Foramen Ovale (not ASD), remains patent after 2 years in 20% births*.
Intermittent L–R shunt during sneezing, cough, Valsalva maneuver. etc. (Paradoxical embolus)
Right ventricular hypertrophy,Pulmonary Hypertension.
Ventricular Septal Defect (VSD)
* Commonest at birth, but most are small asymptomatic & close without therapy.
* Common - upper membranous part (90%) rare in lower muscular part of the septum.
* Left-to-right shunt, RV hypertrophy, Pulm. Hypertension & HF.
Patent Ductus Arteriosus (PDA)
* The ductus arteriosus, serves to shunt blood from pulmonary artery to aorta during intrauterine life & closes soon after birth.
* PDA Left to Right shunt – high pressure.
* Harsh machinery like murmurs.
* Infective endocarditis common.
* Small no symptoms.
* Large Pulm. Hypertension shunt reversal
* Eisenmenger syndrome with cyanosis & HF.
Fallot’s Tetralogy: (FT)
* 5% Commonest Cyanotic, RL shunt, Clubbing, Polycythemia & Paradoxical embo.
* Defective septum development. (Classic) RVH, VSD, Pulm. Stenosis & Overriding aorta
* Enlarged boot shaped heart. SBE.
* Mild (Pulm stenosis) - like VSD, no cyanosis.
Transposition of Great Arteries (TGA):
* Fatal within in first month, if not treated with surgery.
* Survive infancy only if there is associated VSD (PFO/PDA) in 1/3 of pts.
* Cyanosis, RVH, Pulm hypertension & Infective endocarditis, HF.
Coarctation Aorta: (COA)
* Males 2:1, Females with Turner sy.
* Infantile/Pre-ductal: with PDA, cyanosis of lower half of body – severe die early.
* Adult / Post ductal type is common – Upper limb high BP, lower limb low BP.Calf pain - claudication. Rib notching*
* >50% with other CHD (bicuspid aortic v)
A 70 year old male presents to his GP with a 3 year history of leg swelling and aching.
This worsens as the day progresses and improves with leg elevation. He has a history
of hypertension and type 2 DM. He has a 20 pack year smoking history but stopped 1
year ago.
On examination in the standing position, the appearance of his leg is shown.
1. Which vessel is most likely to be affected in this
patient?
1. Posterior tibial
2. Peroneal
3. Saphenous
4. Femoral
5. Popliteal
Saphenous- is one of the largest superficial veins on the legs and runs medially. (most common site for varicose vein)
A 70 year old male presents to his GP with a 3 year history of leg swelling and aching.
This worsens as the day progresses and improves with leg elevation. He has a history
of hypertension and type 2 DM. He has a 20 pack year smoking history but stopped 1
year ago.
On examination in the standing position, the appearance of his leg is shown.
2. What is the underlying cause of the most likely
diagnosis?
1. Poor arterial supply
2. Defective venous valves
3. Sluggish lymphatic drainage
4. Venous clot
5. Infection of the veins
Defective venous valves
The patient is managed conservatively with compression.
He presents to his GP 1 year later with a wound to his lower leg that has
not healed for 6 weeks. He has also been experiencing itching, flaking
skin on his shins. The appearance of his wound is shown.
3. What is the most likely cause?
1. Arterial ulcer
2. Venous ulcer
3. Neuropathic ulcer
4. Infection
5. Malignant ulcer
Venous ulcer
- has varicose veins
- itching and flaking therefore venous stasis
A 70 year old male presents to his GP with a wound to his left lower leg that has not
healed for 6 weeks. He has also been experiencing itching, flaking skin on his shins.
He reports that for the last 3 years he has experienced leg swelling and aching that
worsens as the day progresses and improves with leg elevation. He has a history of
hypertension and type 2 DM. He has a 20 pack year smoking history but stopped 1
year ago. You suspect a venous ulcer.
4. What factor most increases his risk of developing a venous ulcer?
1. Hypertension
2. Insulin resistance
3. Poor mobility
4. Smoking
5. Male gender
Poor mobility
- from blood pooling weakening the walls therefore increase chances for venous ulcer
- What information on history/examination would make you suspect a
diagnosis of an arterial over a venous ulcer? - Painless ulcer
- Painful punched out ulcer
- Irregular ulcer with granulation tissue
- Ulcer on the soles of the feet
- Stasis eczema
Painful punched out ulcer
A 58yr old male presents with a 3-month history of a non-healing ulcer in his right
foot. This is not painful. He has a past medical history of IHD, AF and long-standing
type 2 DM. On examination the appearance of his foot is shown
6. What is the most likely pathogenesis?
1. Arterial obstruction
2. Venous stasis
3. Infection
4. Neuropathy
5. Malignancy
Neuropathy
- obesity
- B12 deficiency
- thiamine deficiency
A 42yr old female presents to the GP with a 2-day history of a sore
right leg. She was recovering after a recent cholecystectomy when she
noticed increasing pain and swelling. She does not recall injuring the
leg.
On examination her right calf is tender. CRT is under 3
secs and peripheral pulses are normal. Heart sounds
were dual, and her chest was clear on auscultation.
7. What investigation would be most appropriate in
this patient?
1. D dimer
2. Venous duplex ultrasound
3. Venography
4. Thrombophilia screen
5. INR
Venous duplex ultrasound
A 42yr old female presents to the GP with a 2-day history of a sore
right leg. She denies injuring the leg.
8. What is the pathogenesis of the underlying cause of
her painful leg? potential DVT
6 day history post surgery and staying inmobile.
1. Stasis of blood
2. Hypercoagulability
3. Vessel wall injury
4. Infection
5. Arteritis
Stasis of blood
A 42yr old female presents to the GP with a 2-day history of a sore right leg. She
denies injuring the leg.
On physical examination her right calf is tender. CRT is under 3
secs and peripheral pulses are normal. Heart sounds were dual,
and her chest was clear on auscultation.
Compression ultrasound confirms a DVT.
She is commenced on a NOAC.
9. What advantage/s does a NOAC have over warfarin?
-Can commence when starting warfarin because warfarin takes 48 hours to work.
-less monitoring on NOAC as cannot monitor
-warfarin has more interactions with drugs
- less side effects
- is a tablet
- warfarin has an easy fix if taken too much
A 59 year old male presents to his GP with a 6 month history of worsening
lower leg pain on walking. The pain is relieved by rest. He describes a
cramping pain that is worse on the right compared to the left.
He has a history of hypertension, hypercholesterolaemia, AF and has a 30
pack year smoking history. His BMI is 32.
10. Which of the following examination findings would be most consistent with a
diagnosis of peripheral arterial disease?
1. ABI of 0.7
2. ABI of 1.3
3. Atrophie blanche
4. Bilateral pitting oedema
5. Stasis dermatitis
ABI of 0.7
Ankle-brachial index
below 0.9 is a significant arterial disease.
above 1.0 shows the calcification of arteries.
59 year old male presents to his GP with a 6 month history of worsening
lower leg pain on walking. The pain is relieved by rest. He describes a
cramping pain that is worse on the right compared to the left.
He has a history of hypertension, hypercholesterolaemia, AF and has a 30
pack year smoking history. His BMI is 32.
Examination confirms peripheral arterial disease.
While awaiting investigation results, the patient re-presents with a 4 hour
history of painful cold toes on the right side. He also complains of some
tingling.
O/E his foot appears as shown.
He has an absent dorsalis pedis pulse. Diminished sensation is noted. No
motor deficits.
11. What is the most likely cause of his current presentation?
1. Intermittent claudication
2. Acute limb Ischaemia
3. Chronic limb threatening Ischaemia
4. Diabetic neuropathy
- Acute limb Ischaemia
- 5 Ps
-pain, pulselessness, paralysis, pallor, parenthesis
59 year old male presents to his GP with a 6 month history of worsening
lower leg pain on walking. The pain is relieved by rest. He describes a
cramping pain that is worse on the right compared to the left.
He has a history of hypertension, hypercholesterolaemia, AF and has a 30
pack year smoking history. His BMI is 32.
Examination confirms peripheral arterial disease.
While awaiting investigation results, the patient re-presents with a 4 hour
history of painful cold toes on the right side. He also complains of some
tingling.
O/E his foot appears as shown.
He has an absent dorsalis pedis pulse. Diminished sensation is noted. No
motor deficits.
12. What is the most important management step in this patient now?
1. Immediate vascular referral
2. Commence on a statin
3. Commence pharmacotherapy for pain
4. Commence on clopidogrel
5. Urgent diabetic foot review
Immediate vascular referral
A 62 year old man is brought in to ED with a 30 minute history of ‘crushing’
chest pain and associated shortness of breath. The pain is localized to the
left side of his chest and started while he was sitting watching TV
- What is the most appropriate investigation to confirm your most likely diagnosis?
- CXR
- CTPA
- D-dimer
- ECG
- TTE
CTPA: going off vitals and examination
A 65-year-old male presents to ED with a 6-hour history of worsening abdominal pain.
He describes an epigastric pain radiating to his back that has gradually been increasing in severity. He has a past medical history of hypertension & hypercholesterolemia. He has a 40-pack-year history of smoking and drinks 3-4 beers/day
On examination, he has an expansile mass in the epigastrium and weak pedal pulses.
Bedside ultrasound confirms the presence of an abdominal aortic aneurysm.
14. Which risk factors in his history are most strongly associated with the
development of his AAA?
Age (over 60) , Gender being male, HBP, SMoking, Hypercholesterolemia
A 72 year old lady presents to the ED with a 2 hour history of acute onset chest pain.
She describes a tearing pain radiating to her back that started at rest.
She has a background of hypertension and
takes irbesartan 150mg/day. She is a nonsmoker. On examination the blood pressure in
her right arm is 185/95mmHg and
150/80mmHg in the left. Her chest X-ray is
pictured.
15. What is the most likely diagnosis?
1. Acute coronary syndrome
2. Acute pulmonary oedema
3. Left lower lobe pneumonia
4. Pulmonary embolism
5. Thoracic aortic dissection
Thoracic aortic dissection
(causes include HT, syphilis)
(AAA caused by atherosclerosis)
A 65 year old man presents with a 1 week history of headache, jaw claudication
and blurred vision in the right eye. He has a tender scalp and is unable to comb his
hair due to the pain. The appearance of his temple is shown.
16. What is the most appropriate investigation to confirm your provisional
diagnosis?
1. ANCA
2. CT Brain/CT Angiogram
3. ESR
4. FBC
5. Artery biopsy
This is giant cell arteritis (systemic vasculitis)
Artery biopsy- needs confirmation
A 65 year old man presents with a 1 week history of headache, jaw claudication
and blurred vision in the right eye. He has a tender scalp and is unable to comb his
hair due to the pain. The appearance of his temple is shown.
17. He undergoes a temporal artery biopsy and the result is shown. What is the
most likely diagnosis?
A. Chronic infection
B. Thromboangiitis obliterans
C. Giant cell arteritis
D. Polyarteritis nodosa
E. Granulomatosis with polyangiitis
Giant cell arteritis
A 28yr old male presents to his GP with pain and cold sensitivity in his hands and feet, the pain is problematic at night and improves when he sits on the edge of the
bed. He also experiences leg pain when walking. More recently he has developed discolouration in his fingers (pictured). He is a current smoker with no previous
medical history.
18. What is the most likely diagnosis?
1. Thromboangiitis obliterans
2. Chronic venous insufficiency
3. Peripheral neuropathy
4. Atherosclerosis
5. Giant cell arteritis
Thromboangiitis obliterans
- part of burgers disease
- Which vasculitis affects the aorta predominantly?
- Kawasaki disease
- Takayasu arteritis
- Polyangitis with granulomatosis
- Polyarteritis nodosa
- Giant-cell arteritis
Takayasu arteritis
Kawasaki is coronary arteries
polyangiitis granulomatosis is in the mouth and nose
polyarteritis nodosa is real arteries
giant cell arteritis is temporal
A 66 year old sugar cane farmer presents to his GP with a slowly growing lump on his face. He undergoes excision biopsy and the pathology slide is shown.
20. What is the most likely diagnosis?
1. Squamous cell carcinoma
2. Basal cell carcinoma
3. Melanoma
4. Hemangioma
5. Keratoacanthoma
Basal cell carcinoma
raised, red, nodular appearance
on the face, slow growing
high exposure to sun
clusters of blue cells with a blue fence
A 78 year old male presents to his GP with a slowly growing lump that has been present for 6 months. The results of his biopsy are shown.
21. What is cause of this patient’s skin lesion?
1. Basal cell carcinoma
2. Malignant melanoma
3. Squamous cell carcinoma
4. Seborrheic keratosis
5. Keratin pearls
Squamous cell carcinoma
A 44year old woman has noted an enlarging brown to black skin lesion on her left
upper arm that bleeds easily with even minor trauma. The image shows the lesion and
its microscopy.
22. What is the most likely diagnosis?
1. Squamous cell Ca
2. Kaposi Sarcoma
3. Hemangioma
4. Basal cell carcinoma
5. Malignant melanoma
Malignant melanoma
- pigmented
- irregular cells are going inside the epidermis therefore malignant and up.
CASE: 42y woman. Swollen, painful leg. H/O long flight / surgery / drugs (OCP), familial.
CASE: 62y traffic police man. Heavy legs, prominent veins, non healing ulcers in gaiter region.
CASE: 72 year old male. h/o Polymyalgia rheumatica. increasing headache 3m, scalp tenderness on left.
(worse on wearing hat). Joint pains, back pain, early morning stiffness. Diplopia 1wk.
CASE: 40y male, Fever, recurrent chronic sinusitis, pneumonitis, mucosal ulcerations, renal disease & skin bleed. (granulomatosis polyangiitis)
CASE: 22 year female. Recent onset episodic hypertension, abdominal pain, bloody stools. Diffuse body pains and aches. Leg ulcers (cutaneous form)
Case: 77y man. Sudden collapse while walking (one of AAA cases at TSVH).
Internal Elastic Lamina is seen in
Aorta Coronary artery Arteriole
all of the above Pulmonary artery
Coronary artery
A vasculitis patient has cavitary lung lesions and destructive ulcers in nasal cavity. What is the most likely disease?
Buerger’s disease
Polyarteritis Nodosa
Wegeners granulomatosis
Takayasu Arteritis.
Giant cell arteritis
Wegeners granulomatosis
This disease is also known as “Pulseless disease”
Giant cell arteritis
Wegener’s granulomatosis
Polyarteritis Nodosa
Takayasu arteritis
Microscopic polyangiitis.
Takayasu arteritis
Typical Clinical Cases: ? pathogenesis
* 34 year male – sudden chest pain and collapse while recovering 12 days after orthopaedic surgery for multiple fracture.
- 68 year male, past MI, chest pain following 24 hour flight travel.
- 44 year female, obese / pregnant / OCP tender calf muscles.
- 28y female, recurrent abortions. (lupus, familial) Cong.
- Surgery & Stasis Hypercoag DVT PE
- MI, Stasis Hypercoage DVT PE
- OCP, Preg, Obesity Hypercoag DVT
- (FVL/lupus) Hypercoag Placental infarction
- Temporary vasospasm resulting in pallor or cyanosis of fingers in healthy young women is known as Raynaud’s Phenomenon.
- True False
False
- Common etiology of varicose veins is,
- Defective superficial veins
Deep vein thrombosis
Venous ulcers of leg
Ventilation Perfusion mismatch Defective deep vein valves
Defective deep vein valves
Common complication of varicose veins of leg is,
Deep Vein Thrombosis
Pulmonary Embolism
Tender calf muscles (Ischemia)
Thromboembolism - PE
Leg Ulcer – Venous
Leg Ulcer – Venous
chronic leg ulcers over tips of toes is suggestive of
Neuropathic
Venous
Arterial
Vasculitis
both Venous & Arterial
arterial
Clinically commonest cause of leg ulcer is,
Arterial block
Venous stasis
Neuropathy Diabetes
Atherosclerosis
Venous stasis
Dry, black painful foot ulcer is typical of,
Arterial block
Venous stasis
Diabetes
Neuropathy
Vasculitis
Arterial block
Pathogenesis of “painless punched out deep caving ulcer with surrounding callus” is suggestive of,
Venous stasis
Arterial block
Neuropathy
Vasculitis
Multifactorial (Diabetes)
Neuropathy
Probing of ulcer leads to brisk bleeding in these types. of leg ulcers. Arterial & Venous
Venous & Malignant
Arterial and Vasculits
Venous and Neuropathic
Neuropathic and Arterial
Venous and Neuropathic
Syphilis causes aneurysms through,
Increased Atherosclerosis
recurrent Intimal injury
Destruction of media by invasion
Endarteritis of vasa vasorum
stimulating Matrix Metallo Proteases (MMP)
Endarteritis of vasa vasorum
DeBakey type B dissections are typically less serious and can be managed without surgery.
True False
True
Commonest cause of Thoracic AA is,
Marfan’s Syndrome
Ehler-Danlos Sy
Syphilis
Hypertension
IgG4 related disorders
Hypertension
Etiology of Kawasaki Disease is
Genetic Susceptibility
Viral Infection
Hypersensitivity
All of the above
Arteritis
All of the above
Hand Foot & Mouth Disease is also known as Kawasaki Disease.
True False
False
Dark, black painful ulcer in the tips of toes is typical of,
Venous ulcer
Arterial ulcer
Neuropathic ulcer
Infective ulcer
Malignant ulcer
Arterial ulcer
Common cause / etiology of Varicose veins is
Hypercoagulability
Blood stasis
lack of venous return
defective valves
Ischemia
defective valves
Clean, punched out & painless ulcers are typical of
Arterial ulcers
Venous ulcers
Neuropathic ulcers
Malignant ulcers
Infective ulcers
Neuropathic ulcers
Nodular focal inflammation of temporal artery with granulomas is typical of,
Wegener’s granulomatosis
Polyarteririts nodosa
Giant cell arteririts.
takayasu arteriritis
Kawasaki disease.
Giant cell arteririts.
Oral mucosal ulcers and lung lesions with cavities are typical features of,
Giant cell arteritis
Polyarteritis nodosa
Kawasaki Disease
Wegener’s granulomatosis
Takayasu arteritis.
Wegener’s granulomatosis
ANCA negative vasculitis typically affecting kidney’s is typically
Wegener’s
PAN
Takayasu
Kawasaki
Behcet’s
Wegener’s
Two systems which are activated after forming blood clot are anticoagulant & ___________
Intrinsic
Extrinsic
Common pathway
Fibrinolysis
Macrophage
Fibrinolysis
Natural anticoagulants in our normal hemostasis are Protein C, S and…..
Warfarin
Aspirin
Heparin
Coumarin
Transferin
Heparin
Common Genetic cause of hypercoagulability is,
Anti thrombin III mutations.
Factor X mutations
Fibrinogenemia
Heparin deficiency
Factor V Leiden.
Factor V Leiden.
Common cause of hypercoagulability in patients with autoimmune disorders is AAS.
True False
TRue
Common cause of Aortic aneurysm
Obesity
Hypertension
Diiabetes
Marfan’s syndrome
Atherosclerosis
Atherosclerosis
common Pathogenesis of Aneurysm is,
Atheroma
Hypercholesterolemia
Inflammation
Cystic medial degeneration scarring
Cystic medial degeneration scarring
A 56 year old man with past medical history of recurrent sinusitis presents to his physician complaining of cough and hemoptysis. X ray of the chest reveals large nodular densities. Physician suspects Granulomatosis with Polyangiitis (GPA, formerly known as Wegner’s granulomatosis), which of the following laboratory tests will be helpful in confirming the diagnosis?
1.
P-ANCA / MPO-ANCA
2.
C-ANCA / PR3-ANCA
3.
Anti DS-DNA antibodies
4.
Anti-endothelial antibodies
5.
Marked Eosinophilia
C-ANCA / PR3-ANCA
What is the “Typical clinical feature of a venous leg ulcer?
1.
Surrounding zone of dermatitis
2.
No significant bleeding
3.
Nocturnal Pain
4.
Clean punched out ulcer
5.
Deep necrotic ulcer
Surrounding zone of dermatitis
A 45 year-old male presents with non healing leg ulcers over his ankle since 6 months. The image shows features of his ulcer. What is the most likely cause of ulcer?
What feature in Venous, Arterial, Neuropathic, Infective and Malignant? diabetic?
1.
Venous ulcer
2.
Malignant ulcer
3.
Neuropathic ulcer
4.
Arterial ulcer
5.
Diabetic ulcer
Venous ulcer
A 3-year-old boy presents with high fever conjunctivitis erythema in oral mucosa and strawberry like tongue & cervical lymphadenopathy. His hands and feet also show purpuric rashes. What is the most likely complication this child may develop later?
1.
Chronic Glomerulonephritis
2.
Aortic aneurysm
3.
Blindness
4.
Coronary Aneurysms
5.
Granulomas in lungs
Coronary Aneurysms
A 6-year-old child had Upper respiratory tract infection 3 weeks ago now present to the ED with abdominal pain. Upon examination the child had palpable purpura on the lower extremities(Image). Urinalysis show haematuria with RBC casts. What is the most likely diagnosis in this case?
1.
Henoch Schonlein Purpura (HSP)
2.
Polyarteritis Nodosa (PAN)
3.
Churg-Strauss syndrome
4.
Immune Thrombocytopenic Purpura (ITP)
5.
Granulomatosis with Polyangiitis (Wegener’s)
Henoch Schonlein Purpura (HSP)
A 45 year-old male who is a chronic heavy smoker presents with acute pain in his lower limbs and blackening of the tips of the toes. Which of the following is the most likely diagnosis?
1.
Buerger’s disease
2.
Systemic sclerosis
3.
Takayasu’s disease
4.
Venous thrombosis
5.
Raynaud’s phenomenon
Buerger’s disease
56 year old man, with chronic diabetes presents with painless non healing ulcer on the sole of foot (image). Based on the morphology, What is the most likely cause of his ulcer?
List features? what is the special feature? explain why?
1.
Loss of nerve supply
2.
Narrow artery
3.
Squamous carcinoma
4.
Obstructed vein
5.
Fungal infection
Loss of nerve supply
28 year old woman has presented with recurrent attacks of deep vein thrombosis in her legs. Risk factors for DVT include which of the following?
1.
Atherosclerosis
2.
Valve defects in the leg veins
3.
Pulmonary embolism
4.
Thromboembolism
5.
Hypercoagulability
Hypercoagulability
A 73-year-old man has had headaches for several months. He is found on physical examination to have a palpably painful region in the right temporal area. His sedimentation rate is 89 mm/hr. This condition abates following a course of corticosteroid therapy.
Giant cell arteritis
Polyarteritis Nodosa
Kaposi sarcoma
Telangiectasia
Granuloma pyogenicum
Giant cell arteritis
A 45-year-old man has a history of chronic alcoholism. For the past year, his physician has noted the presence of skin lesions present on the upper chest that have a central pulsatile core. Pressing on the core causes a radially arranged array of subcutaneous arterioles to blanch. The size of the lesions from core to periphery is 0.5 to 1.5 cm.
Giant cell arteritis
Polyarteritis Nodosa
Kaposi sarcoma
Telangiectasia
Granuloma pyogenicum
Telangiectasia
A 22-year-old G1P0 woman at 34 weeks gestation notes an enlarging nodule near a tooth. On examination there is a spongy red mass at the gingival margin adjacent to a molar. Following delivery the mass recedes.
Giant cell arteritis
Polyarteritis Nodosa
Kaposi sarcoma
Telangiectasia
Granuloma pyogenicum
Granulomatosis with Polyangiitis
A 46-year-old woman has a cough productive of reddish sputum for the past 3 months. On examination she is hypertensive but afebrile. Laboratory studies show an elevated serum creatinine and RBCs and RBC casts in her urine. A chest CT scan shows a reticulonodular pattern of densities in both lungs.
Giant cell arteritis
Polyarteritis Nodosa (PAN)
Kaposi sarcoma
Telangiectasia
Granuloma pyogenicum
PAN
A 34-year-old HIV positive man has noted development of multiple reddish patches and plaques on skin surfaces over the past 5 months.
Giant cell arteritis
Polyarteritis Nodosa
Kaposi sarcoma
Telangiectasia
Granuloma pyogenicum
Kaposi sarcoma
Which of the following statements is a classic feature of the pain of intermittent claudication seen in peripheral vascular disease (PVD)?
1.
Quality of pain is constant aching type
2.
Pain is relieved in dependent position
3.
Pain is aggravated in recumbent position
4.
Site of pain is forefoot, toes and heel
5.
Pain is precipitated by walking or exercise
Pain is precipitated by walking or exercise
In the diagram of the precordium below the number 1 position relate to areas used in auscultation. Which of the following statements is correct?
What common mumur’s are heard in this area? What about other areas?
1.
The position labeled 1 is the aortic valve area
2.
The position labeled 3 is the pulmonary valve area
3.
The position labeled 2 is the tricuspid valve area
4.
The positions labeled correlate with the valve positions in the heart
5.
The position labeled 4 is the mitral valve area
The position labeled 1 is the aortic valve area
A 72 year old caucasian man who had a bilateral hip replacement 7 days ago is experiencing chest pain tachycardia tachypnea and dyspnea and a low grade fever. Which of the following most likely predisposed the patient to this event?
1.
Deep vein thrombosis
2.
Venous flow
3.
Pulmonary embolism
4.
Hypocoaguability
5.
Thrombocytopenia
Deep vein thrombosis
A 75 year old homeless man who has had little or no medical care for the last 30 years presents to A & E with increasing shortness of breath. His chest x-ray shows a widened mediastinum. A CT scan shows a 6 cm thoracic aortic aneurysm without calcifications. A cardiac exam discloses a loud blowing murmur consistent with aortic insufficiency. He reports no chest pain and is haemodynamically stable. The most likely diagnosis is:
1.
Tertiary syphilis
2.
Kawasaki’s disease
3.
Dissecting aortic aneurysm
4.
Atherosclerotic aneurysm
5.
Takayasu’s arteritis
Tertiary syphilis
A 75-year-old female present to ED with high fever, weight loss, severe head-ache and sudden onset of vision loss in her left eye. She says that she has recently been having left sided jaw pain when chewing food. Lab studies show increased ESR. Which of the following artery is mostly involved?
1.
Coronary artery
2.
Carotid artery
3.
Maxillary artery
4.
Temporal artery
5.
Facial artery
Temporal artery
A 65 year old man with a history of atrial fibrillation is found to have a 4 cm mural thrombus in the left atrium. He is otherwise in good health. Which of the following factors is most likely to be responsible for the formation of this thrombus?
1.
Lupus anticoagulant
2.
blood stasis
3.
Pro-inflammatory cytokines
4.
A Factor V Leiden gene mutation
5.
Increased serum prothrombin levels
blood stasis
What is the appropriate initial management for a patient with a venous leg ulcer?
1.
Would debridement & bandage.
2.
Antithrombotic therapy
3.
Rest for the affected limb
4.
Compression bandage for leg.
5.
Oral & local antibiotic therapy.
Compression bandage for leg.
A 38 year-old, 24 weeks pregnant woman presents to the ED with severe calf pain for the last 12 hours. On examination there is slight tenderness and the left calf appears swollen and erythematous. PMH: Type II Diabetes, Hypertension, Hypercholesterolemia on therapy. Which of the following is the most likely risk factor for her presentation?
1.
Artherosclerosis
2.
Hypertension
3.
Hypercholesterolemia
4.
Type II diabetes
5.
Pregnancy
Pregnancy
A 30 year old woman has smoked 1 pack of cigarettes per day since she was a teenager. She has had episodes of her fingers becoming blue and cold. Now she has developed chronic, poorly healing ulcer of her feet with one toe becoming dark black. Histologically there is acute and chronic vasculitis involving small and medium sized arteries. Which of these is the most appropriate next step in treating this patient?
1.
Insulin therapy
2.
Smoking cessation
3.
Haemodialysis
4.
Antibiotic therapy
5.
Coticosteroid therapy
Smoking cessation
A 3-year-old boy presents with high fever conjunctivitis erythema in oral mucosa and strawberry like tongue & cervical lymphadenopathy. His hands and feet also show rashes. What is the most likely diagnosis?
1.
Granulomatosis with Polyangiitis (Wegener’s)
2.
Henoch-Schonlein Purpura (HSP)
3.
Polyarteritis Nodosa (PAN)
4.
Takayasu arteritis
5.
Kawasaki disease
Kawasaki disease
A 16-year-old Asian girl presents with fever night sweats and blurred vision. On examination her upper extremity pulses are weak and normal lower extremity pulses. Image shows her angiogram & gross. What is the most likely diagnosis?
Short notes on: Giant cell arteritis, Takayasu, PAN, Kawasaki disease, Buerger’s disease?
1.
Henoch-Schonlein Purpura
2.
Giant cell arteritis
3.
Polyarteritis Nodosa
4.
Takayasu arteritis
5.
Granulomatosis with Polyangiitis (Wegener’s)
Takayasu arteritis
52yo male presents with 2 day history of productive cough with rusty coloured sputum and fever. He has no known medical conditions and
has had no recent hospital admissions
Q1. Given the patient’s presenting symptoms (fever, cough with rusty sputum),
which of the following would correspond to the patient’s alveolar state
microscopically?
CHANGE IMAGE:
A: all the alveoli are equally inflamed. Lobar pneumonia- community-acquired
b. broncho/HAP
c. interstitial/ viral (image b) Inflamed walls but not inside alveoli
52yo male presents with 2 day history of productive cough with rusty coloured sputum and fever. He has no known medical conditions and
has had no recent hospital admissions.
Q2. What finding on examination would make pneumonia most
likely?
* Decreased vocal resonance
* Increased vesicular breath sounds
* Dull percussion note
* Symmetrical air entry
* Tracheal deviation
Dull percussion note
52yo male presents with 2 day history of productive cough with rusty coloured sputum and fever. He has no known medical conditions and has
had no recent hospital admissions
Q3. What is the most likely diagnosis?
a. Atypical community-acquired pneumonia
b. Acute Bronchitis
c. Community-acquired pneumonia
d. Hospital-acquired pneumonia
e. Infective exacerbation of COPD
Community-acquired pneumonia
LL lobe - cannot see cardiac shadow.
Q4. Which of the following is required to determine the severity of
his pneumonia?
a. Causative organism
b. Respiratory rate
c. Presence of bronchial breathing
d. Temperature
e. White cell count
Respiratory rate (>/=30)
CURB65 and SMARTCOP
What are some of the investigations required to determine the
microbiological cause of pneumonia?
Nasopharyngeal swab
Sputum Sample
Urine
Serology (retrospective)
Which of the following images is most likely to be the microbiological cause of the
pneumonia?
(A) strep pneumoniae Gram + diplo
The others are:
b- staph aureus
c- Haemophilus influenza
d- M TB
e- candida
52yo male presents with 2 day history of cough with yellow phlegm. No
SOB and no fever.
He has no known medical conditions, He is a non smoker and has had no
recent hospital admissions.
O/E equal and normal chest expansion, percussion and VR. Crackles in
most areas that move/disappear on coughing
Q6. Which of the following is the most likely diagnosis?
* Atypical community-acquired pneumonia
* Acute Bronchitis
* Community-acquired pneumonia
* COVID-19
* Hospital-acquired pneumonia
* Infective exacerbation of COPD
Acute Bronchitis: only bronchi involved
A 85 year old male had a stroke 3 months ago and which has caused
difficulty speaking and swallowing. He was discharged to a nursing
home where he is assisted in his Activities of Daily Living.
5 days ago, he had a significant coughing/choking episode after taking
a tablet.
2 days ago he developed fever, tachycardia and tachypnoea. Crackles
are heard unilaterally.
Q7. What is the most likely risk factor for this patient’s current illness?
* Smoking
* Immunosuppression
* Hospitalisation
* Dysphagia
Dysphagia- aspiration
Q8. Where is the abnormality likely to be found in this patient’s CXR? Aspiration patient ( Stroke 3m ago) sitting upright
a. RLL
b. Apical lesion
c. Pleural effusion
d. Bilateral
e. LLL
RLL
A 24 year-old woman has had a 12 day history of dry cough, myalgia
and fever. She has had multiple covid PCRs/RATs which have all been negative. She has no past history of medical problems. She develops this rash on her hands and presents for medical review
Q9. What is the most likely organism?
* Influenza
* Pneumocystis carinii
* Mycoplasma pneumoniae
* Respiratory syncytial virus
* Streptococcus pneumoniae
Mycoplasma pneumoniae
36-year-old female presents with a 2-week history of increasing
SOB, now beginning to occur at rest. She has an associated mild
fever, dry cough, and headaches. She is up to date with her
vaccinations. Her SpO2 was 93% on RA, examination of the chest
revealed scattered wheeze but no focal signs and there is no
swelling of the ankles.
Q10. Which organism is the most likely cause?
a. SARS-COVID-19
b. Chlamydia pneumoniae
c. Haemophilus influenzae
d. Influenza A
e. Staphylococcus aureus
f. mycoplasma pneumonia
mycoplasma pneumonia or chlamydia pneumonia
72 yo Cane farmer from Ayr. Recent heavy rains and he has been out fencing. Presents with 3 days history of cough, Temperature 38.5C and mild confusion and Tachypnoea ( RR 30 ). Smoker (40/day for 55 years) .
10+ standard drinks per day. T2DM
Q11. What is the most likely organism?
* Burkholderia pseudomallei
* Haemophilus influenzae
* Legionella pneumophila
* Mycoplasma pneumoniae
* Streptococcus pneumoniae
Burkholderia pseudomallei
75-year-old male develops SOB while in hospital for severe pancreatitis. He
was admitted 5 days ago and is responding slowly to treatment for his pancreatitis. The SOB started 12 hours ago and is associated with a
productive cough and right sided pleuritic chest pain. On examination, he is temperature of 38.5 and O2 sats of 88%. He looks unwell. On chest
examination, he has patchy areas of dullness to percussion, bronchial
breathing and crackles which do not move on coughing.
Q12. Which of the following best describes his condition?
a. Acute Bronchitis
b. Community Acquired pneumonia
c. Hospital acquired pneumonia
d. Atelectasis
Hospital acquired pneumonia
Which of these three xrays and corresponding micro would be his?
75-year-old male develops SOB while in hospital for severe pancreatitis. He
was admitted 5 days ago and is responding slowly to treatment for his pancreatitis. The SOB started 12 hours ago and is associated with a
productive cough and right sided pleuritic chest pain. On examination, he is
temperature of 38.5 and O2 sats of 88%. He looks unwell. On chest
examination, he has patchy areas of dullness to percussion, bronchial
breathing and crackles which do not move on coughing.
a- lobar
b- bronchial
c- interstitial
72 yo female, who presents with 12 months of gradually increasing
shortness of breath with effort and worsening cough. She has had a “smoker’s cough” for years. Clear Phlegm in the mornings
Smoked a pack of 20 every day for over 50 years
Has become more short of breath and cannot take the dog for walks anymore
though can garden and do all her chores at home
Q 14. Given the time course of the development of her shortness of breath,
which of the following is the most likely diagnosis?
* CCF
* Lung cancer
* Pneumonia
* COPD
* Asthma
COPD- timing.
Which of the following parameters in spirometry is needed to make a diagnosis of COPD?
* FVC
* PEFR
* Residual volume
* Total lung capacity
* FEV1/FVC
FEV1/FVC
Name some options for COPD management
- Salbutamol and other inhalers (LABA and SABA)
- Stop smoking
- pulmonary rehab
- antibiotics
- 02 therapy
- corticosteroids
What is the underlying microscopic process that causes the
hyperinflation of the lungs?
a. Destruction of alveolar walls without fibrosis
b. Fibrous scarring and mononuclear
infiltration
c. Immunoglobulin deposition OR focal necrosis of alveolar walls
d. Intra-alveolar exudate and fibrin
formation
e. Mucous gland hypertrophy and
hyperplasia
Destruction of alveolar walls without fibrosis
65 yo male with a 3 day history of slightly worsening SOB, worsening cough now productive of green yellow sputum, and fever.
PHx: He has known COPD and normally produces 1 tsp of clear sputum every morning. SOB
increasing over last few years and recently described how he is still able to undertake all activities of daily living but can’t walk any further than 500m on the flat without having to
stop. For the last year and up until the last 3 days, he has maintained approximately same level of dyspnoea and has been helped by his inhalers. All his vaccines are up to date
Q17. What is the most likely diagnosis?
* Non-infective exacerbation of COPD
* Acute Bronchitis
* COPD
* Infective exacerbation of COPD
* Pneumonia
Infective exacerbation of COPD
A 32-year-old woman presents with 3/12 history of cough and
haemoptysis. She has also noticed unintentional weight loss of 5kg over
the same period. She is a non smoker. She returned from a work
placement in PNG highlands
Her chest examination is normal.
Q18. What is the most likely microbiological diagnosis?
* Klebsiella pneumoniae
* Mycobacterium tuberculosis
* Mycoplasma pneumoniae
* Pneumocystis pneumoniae
* Streptococcus pneumoniae
Mycobacterium tuberculosis
A 32-year-old woman presents with 3/12 history of cough and
haemoptysis. She has also noticed unintentional weight loss of 5kg over
the same period. She is a non smoker. She returned from a work
placement in PNG highlands. Her chest examination is normal
Q19. What is the most appropriate investigation to confirm TB in this
patient?
* Sputum microscopy with acid-fast (Ziehl-Neelsen) stain
* Tuberculin skin test (Mantoux)
* TB-specific interferon gamma release assay/Quantiferon Gold (IGRA).
* Blood culture
* Sputum culture
Sputum microscopy with acid-fast (Ziehl-Neelsen) stain
A 62 yo male presents with 3/12 history of cough and haemoptysis. He has also noticed unintentional weight loss of 5kg over the same period. He is a smoker of 45 pack years. He returned from a work placement in PNG highlands. Chest examination is normal but Chest Xray shows changes in the R apical region and a biopsy is done.
Q20. What histological findings would suggest TB?
* Alveolar destruction
* Granulomas with caseation
* Mucous gland hyperplasia
* Inflammation of alveolar wall
* Red blood cells within alveolar space
Granulomas with caseation
9yo female previously from remote indigenous community, now
living in Cairns/Townsville
Presents with productive cough
Present for 6 weeks
Despite 2 course of antibiotics
Family talk about her history of many infections, including being
airlifted to CNS/TSV three times as a child with pneumonia
She has clubbing and scattered crackles in all regions on
auscultation. The crackles do not move on coughing.
Table Talk – come up with 3 possible diagnoses
bronchiectasis - Need CT scan
Asthma
a1 antitrypsin deficiency
CF
recurrent pneumonia
9yo female previously from remote indigenous community, now
living in Cairns/Townsville. Presents with productive cough, present for 6 weeks despite 2 course of antibiotics. Family talk about her history of many infections, including being
airlifted to CNS/TSV three times as a child with pneumonia
Q21. What pathological finding on High resolution CT or gross
morphology would suggest bronchiectasis?
a. Blackened spots in upper lobes
b. Dilated airways
c. Grey hepatization
d. Multiple granulomas
e. Occluded pulmonary artery
Dilated airways
Which bacterial pathogen is the most common cause of community-acquired pneumonia?
Streptococcus pneumoniae
Mycoplasma pneumoniae
Staphylococcus aureus
Chlamydophila pneumoniae
Streptococcus pneumoniae
Pneumonia that develops following passage of oropharyngeal contents into the lungs is called:
Community Acquired Pneumonia
Aspiration Pneumonia
Atypical Pneumonia
None of the above
Aspiration Pneumonia
The cough in bacterial pneumonia is a dry type of cough.
True
False
False
COPD is the term used to denote presence of Chronic bronchitis and
Bronchiectasis
Bronchiolitis
Panacinar emphysema
Centriacinar emphysema
Bronchial asthma
Centriacinar emphysema
Chemical mediator responsible for alveolar loss in emphysema in shronic smokers is,
IL-1
TNF-Alpha
IFN-gamma
Elastase
Surfactant
Elastase
Unlike restrictive lung disorders, FVC values can be normal in obstructive lung disorders such as COPD.
True False
True
Which lobe is affected by Pneumonia?
A. RUL
B. RML
C. RLL
D. LUL
E. LLL
RUL
Which lobe is affected by Pneumonia?
A. RUL
B. RML
C. RLL
D. LUL
E. LLL
LUL
Which lobe is affected by Pneumonia?
A. RUL
B. RML
C. RLL
D. LUL
E. LLL
RML
56 year old man presents with high fever, shortness of breath, productive cough.
ABG results show pH 7.2, pCO2 51 mmHg, HCO3 22 mmol/L. Base excess 1.1.
What is the most likely diagnosis?
A. Respiratory Acidosis.
B. Metabolic Acidosis.
C. Respiratory alkalosis.
D. Metabolic acidosis.
E. Diabetic ketoacidosis.
Respiratory Acidosis.
Which lobe is affected by Pneumonia?
A. RUL
B. RML
C. RLL
D. LUL
E. LLL
LLL
29 year old diabetic man presents with high fever, gasping breath, mild dry cough &
altered consciousness. ABG results show pH 7.4, pCO2 28 mmHg, HCO3‾14
mmol/L, Urine protein ++, Ketones +. What is the most likely diagnosis?
A. Respiratory Acidosis compensated.
B. Metabolic Acidosis compensated.
C. Respiratory alkalosis compensated.
D. Metabolic acidosis compensated.
E. Diabetic ketoacidosis compensated.
Cystic fibrosis typically causes panacinar emphysema.
True False
FALSE
Common pathogens seen in the sputum of brochiectasis patients
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Candida albicans
Mixed normal flora
Mixed normal flora
- Extensive black spots more in the upper lobes compared to lower lobes in a smoker with severe SOB is a feature suggestive of …
Lung carcinoma
Bronchiectasis
Chronic Bronchitis
COPD
Centrilobular emphysema
Centrilobular emphysema
. Pneumonia affecting whole lobe of lung in a previously healthy adult is suggestive of,
Bronchopneumonia
Lobar Pneumonia
Interstitial pneumonia
Atypical pneumonia.
Pneumococcal pneumonia
Lobar Pneumonia
Recurrent chronic cough, SOB with microscopic peribronchial inflammation in a smoker is a feature of,
COPD
Bronchiolitis
Acute Bronchitis
Choronic Bronchitis
Emphysema
Choronic Bronchitis
Pathogenesis of centrilobular emphysema is,
Neutrophilic inflammation
Peribronchial inflammation
Loss of respiratory ciliated epithelium
alveolar wall destruction by elastases.
Lymphocytic inflammation
alveolar wall destruction by elastases.
Sputum culture in a case of bronchiectasis typically shows,
Streptococcus Pneumoniae
Streptococci Klebsiella
Normal commensals
Mycobacterium tuberculosis
Normal commensals
Bronchiectasis is permanent dilatation of bronchi lined by inflammation & filled with pus.
True False
T
Pathogenesis of cavity formation in tuberculosis is due to drainage of caseous material through bronchus.
True False
F
Lupus vulgaris is a type of miliary spread of tuberculosis.
True False
T
Unlike other types, Distinctive clinical phases of pneumonia are seen only in Lobar pneumonia because,
Caused by strong pneumococci bacteria
all phases of inflammation occur together.
only one phase is seen all over lobe.
There is more tissue breakdown
Abscess formation is not seen
only one phase is seen all over lobe.
This type of pneumonia occurs typically in healthy adults in community.
Lobar pneumonia
Bronchopneumonia
interstitial pneumonia
Atypical pneumonia
Lobar pneumonia
Atypical pneumonia is characterised by,
multipel phases in one
one lesion one uniform phase all over the lobe
Inflammation limited to alveolar walls
fibrosis of alveolar walls
inflammatory exudate filling lumen.
Inflammation limited to alveolar walls
Common type of pneumonia in a chronic smoker is,
Lobar Pneumonia
Chronic bronchitis
Atrypical pneumonia
Insterstitial pneumonia
Bronchopneumonia
Bronchopneumonia
Factors causing Chronic bronchitis are,
CD8 Lymphocytes
Proteases & Elastase
IL8 & LTB4
alpha1 Antitrypsin
all of the above
IL8 & LTB4
Severe SOB requiring ambulatory oxygen therapy in a chronic smoker is suggestive of,
COPD
Chronic Bronchitis
end stage lung disease
centrilobular Emphysema
panlobular emphysema
Factors in the pathogenesis of Cavitary tuberculosis are,
IFN gamma
Proteases
Both of the above
IL4 & IL13
PDGF & FGF
this feature is typically seen in the centre of a tuberculous granuloma.
T lymphocytes
Fibrosis
Macrophages
Giant cells
Caseation
Bronchiectasis is a pathological diagnosis characterized by,
Chronic bronchial inflammation
Chronic bronchial infection
Chronic bronchitis with Emphysema
Chronic bronchial obstruction with infection
Permanent bronchial dilatation with suppuration
Permanent bronchial dilatation with suppuration
Typical microscopic feature of bronchiectasis is, destruction / necrosis of mucosa & bronchial wall replaced by pus with peribronchial fibrosis. True False
T
Causes of bronchiectasis include all the following EXCEPT,
COPD
Emphysema
Tumors
Cystic fibrosis
Chronic lung infections
Emphysema
A 50-year old man presents with shortness of breath on exertion and non-productive cough since few months. On inspection there is increased antero-posterior diameter of the chest, his breathing is labored with pursed lips. On P/E the patient is noted to have hyper-resonant lungs with decreased breath sounds. Which of the following is most likely diagnosis?
1.
COPD Cystic Fibrosis
2.
COPD Emphysema
3.
COPD Chronic Bronchitis
4.
COPD Bronchiectasis
5.
COPD Asthma
COPD Emphysema
A 32-year-old woman presents with recurrent cough and weight loss. Her BMI is 22. She does not smoke. A chest radiograph shows a solitary, 3-cm left upper lobe mass. Images show microscopic appearance of the biopsy from the mass. Which of the following is the most likely diagnosis?
- Lung Abscess
- Adenocarcinoma
- Small cell carcinoma
- Interstitial pneumonia
- Tuberculosis
Tuberculosis
54 year old chronic smoker presents with acute exacerbation of his symptoms with fever. Image shows gram stain appearance of the pathogen isolated from his sputum. What is the most likely pathogen causing his pneumonia?
- Haemophilus influenza
- Meningococci
- Streptococcus pneumoniae
- Staphylococcus aureus
- Streptococcus viridans
Haemophilus influenza
The following image shows biopsy from a 51 year old male, chronic smoker with recurrent attacks of productive cough some times with fever for several years. The pathologic feature
shown between two arrows is:
1.
Dilated blood vessels
2.
Ruptured alveolar walls
3.
Chronic Inflammation
4.
Mucous gland Hyperplasia
5.
Smooth muscle hypertrophy
Mucous gland Hyperplasia
A 58 year-old male, alcoholic, suffers aspiration of gastric contents. Over the next 10 days he develops a non-productive cough along with a fever to 37.9 C. A chest radiograph is shown. A sputum gram stain reveals mixed normal flora. Which of the following conditions is he most likely to have?
- Bronchopulmonary sequestration
- Chronic bronchitis
- Squamous cell carcinoma
- Bronchiectasis
- Lung abscess
Lung abscess
A 16-year-old boy presents with cough, fever & SOB since 6 days and these lesions on his forearms and hands (image). There is no mucosal involvement. The lesions are symmetrical and red, with some having 3 concentric circles and pale vesicular centers. He does not complain of any itch. What investigation should be performed to rule out infections usually associated with this cutaneous condition?
- Blood culture
- Cold agglutinin levels
- Throat swab culture
- Sputum microscopy
- Urine culture
Cold agglutinin levels
A 29 year-old woman has gradually increasing dyspnea over 8 years. She has no cough or increased sputum production. Lungs are hyper-resonant to percussion. A chest radiograph is shown above. Which of the following laboratory findings is she most likely to have?
1.
Elevated blood ethanol
2.
Positive urine opiates
3.
alpha-1-antitrypsin deficiency
4.
Increased sweat chloride
5.
Decreased serum ceruloplasmin
alpha-1-antitrypsin deficiency
An 8-year-old boy has attacks characterized by wheezing, shortness of breath and wet cough which usually resolve after an hour. Blood test shows high levels of eosinophils. Which of the following may also be seen in the sputum of the patient?
1.
Charcot Leyden crystals
2.
red blood cells
3.
Ferruginous bodies
4.
High reid index
5.
Macrophages
Charcot Leyden crystals
A 60 year-old male, 90 pack year smoking history. For the past 5 years, he has had productive cough & progressive dyspnoea. Image shows appearance of his lung cut section. Which of the following conditions is most likely to explain his clinical course?
1.
Chronic bronchitis
2.
Paraseptal emphysema
3.
Squamous cell carcinoma
4.
Centrilobular emphysema
5.
Panlobular emphysema
Centrilobular emphysema
A 42-year-old woman who has had a progressive dyspnoea for years now she becomes short of breath after climbing a single flight of stairs. Her birth history reveals neonatal hepatitis and cholestatic jaundice. Image shows her chest radiograph. What is the most likely cause of her problems?
- Cigarette smoking
- Irregular emphysema
- α1-Antitrypsin deficiency
- Cystic fibrosis
- Exposure to Aniline dye.
- α1-Antitrypsin deficiency
A 65-year-old chronic smoker presents with recurrent productive cough some times with wheezing for several months at a time for several years now. Lung functions tests showed decreased FEV1 and FVC. FEV1/FVC ratio is also decreased and the result has not changed much following repeat test after bronchodilator therapy. What is the most likely diagnosis?
1.
Bronchiectasis
2.
Interstitial pneumonia
3.
Chronic bronchitis
4.
Emphysema
5.
Bronchial asthma
Chronic bronchitis
A 41 year-old man reports recurrent fever diarrhoea and weight loss for 3 months. Diffuse crackles in both lung fields were demonstrated on auscultation. A chest radiograph shows patchy bilateral infiltrates. WBC count was 3.25 x109/L. Cryptosporidium organisms were detected in stool specimen. A bronchoalveolar lavage yielded pink, foamy exudate with little inflammatory cells. Which of the following organisms would most likely be demonstrated in this sample?
1.
Klebsiella pneumonieae
2.
Aspergillus fumigatus
3.
Streptococcus pneumoniae
4.
Mycobacterium tuberculosis
5.
Pneumocystis jerovecci
Pneumocystis jerovecci
A 9 year-old Indonesian girl has had shortness of breath over the past week. Her lung fields are clear to auscultation. A chest radiograph shows prominent hilar lymphadenopathy along with multiple bilateral patchy peripheral opacities. A routine sputum bacterial culture reveals no pathogens. Which of the following conditions is she most likely to have?
1.
Goodpasture syndrome
2.
Hypersensitivity pneumonitis
3.
Infective endocarditis
4.
Bronchial carcinoid tumour
5.
Tuberculosis infection
Tuberculosis infection
A 38 year-old woman has had cough with fever for 12 days. Her CXR is shown.
Her full blood count is normal. Her cold agglutinin titer is elevated. Following a course of erythromycin therapy, she improves, with no complications. Of the following organisms which is most likely to have caused her illness?
1.
Mycoplasma pneumoniae
2.
Mycobacterium kansasii
3.
Nocardia asteroides
4.
Streptococcus pneumoniae
5.
Respiratory syncytial virus
Mycoplasma pneumoniae
A 45 year old man has smoked two packs of cigarettes per day for 20 years. For the past 4 years he has had a chronic cough with copious white mucoid sputum. During the past year, he has had several episodes of respiratory tract infections that were diagnosed as viral respiratory tract infections. During these infections he had symptoms of dyspnoea, chest tightness and audible wheeze. These symptoms were relieved by inhalation of a beta adrenergic agonist and disappeared after the chest infection had resolved. Which of the following pathologic conditions best describes these clinical findings?
1.
Chronic bronchitis with cor pulmonale
2.
Bronchial hypereactivity
3.
Chronic bronchitis with asthmatic bronchitis
4.
Chronic bronchitis with emphysema
5.
Bronchiectasis
Chronic bronchitis with asthmatic bronchitis
A 75 year old male admitted with stroke & GCS 6 was intubated. Three days later he developed fever, tachycardia and tachypnoea. CXR is shown in the image below. Routine BAL culture shows mixed growth. Which of the following would be the most likely diagnosis?
- Bronchiectasis
- Lung Abscess
- Broncho Pneumonia
- Aspiration Pneumonia
- Lobar Pneumonia
Aspiration Pneumonia
A 37-year-old woman presents with the acute onset of a productive cough, fever, chills, and pleuritic chest pain. A chest x-ray reveals consolidation in the lower lobe of her right lung. Which of the following is the most likely diagnosis?
1.
Lobar pneumonia
2.
Pulmonary fibrosis
3.
Bronchiectasis
4.
Interstitial pneumonia
5.
Bronchopneumonia
Lobar pneumonia
A 9 year-old boy has had recurrent attacks of pneumonia since infancy. He now has a chronic productive cough. At birth he had suffered meconium ileus. His sweat chloride was reported high. Image shows his CT Chest. Which of the following following pulmonary complications has he developed?
- Adenocarcinoma
- Broncheictasis
- Lymphangiectasis
- Pleural plaques
- Pneumonia
Broncheictasis
A 35-year old chronic smoker woman is having increasing SOB for 9 years. Which one of the following is a correct association concerning the pathogenesis of smoking-induced emphysema?
1.
Destruction of entire acinus = panacinar emphysema
2.
Destructionof distal acinus = paraseptal emphysema
3.
Destructionof proximal acinus = paraseptal emphysema
4.
Destruction of proximal acinus = centriacinar emphysema
5.
Destructionof distal acinus = centriacinar emphysema
Destruction of proximal acinus = centriacinar emphysema
A 25 year-old male on imunosuppresive therapy following bone marrow transplant for leukemia. He has had increasing dyspnea, fever and cough for 3/52. His temperature 37.8C. A chest radiograph shows irregular interstitial infiltrates. Image shows microscopy of his broncho-alveolar lavage. Which of the following organisms is most likely to have caused his infection?
- Pneumocystis carinii
- Candida albicans
- Toxoplasma gondii
- Mycobacterium tuberculosis
- Cytomegalovirus
Cytomegalovirus
Chronic Obstructive Airway Disorders include,
Emphysema
Chronic Bronchitis
Asthma
COPD
All of the above
All of the above
Activation of Mast Cell & Eosinophils is NOT a feature of non-atopic asthma.
True False
F
Charcot Leyeden Crystals in the sputum are composed of,
IL-4, 5 & 13
Mast cell granules
Eosinophil granules
Mucous
TH2 lymphocytes
Eosinophil granules
FEV1:FVC ratio is typically low in Restrictive Lung disorders.
True False
F
of the following, “Extrinsic” Causes of Restrictive Lung disorder is,
Tuberculosis
Sarcoidosis
Loeffler Syndrome
Tropical Eosinophilia
Obesity
Obesity
Type 2 pneumocyte hyperplasia is typically seen in Idiopathic Pulmonary Fibrosis.
True False
T
60 Year old man comes to ED because of worsening cough and shortness of breath for the past 6 months. he denies any tobacco use. He has non productive cough and becomes worse on exertion On auscultation patient had velcro like bi-basilar inspiratory crackles . Chest x ray is obtained and reveals increased reticular markings. Microscopic image is given below. What is the most likely diagnosis?
Discuss likely Etiology, Pathogenesis, chemical mediators and new therapy?
1.
Sarcoidosis
2.
Asbestosis
3.
Idiopathic pulmonary fibrosis
4.
Silicosis
5.
Chronic bronchitis
Idiopathic pulmonary fibrosis
24-year-old woman presents with nonspecific symptoms including fever and malaise and cervical lymph node biopsy. A chest x-ray reveals enlarged hilar lymph nodes and serum calcium level is elevated. Microscopic image is shown of her lymph node biopsy. What diagnostic feature is shown in the image?
- Caseating granulomas
- Dense granular eosinophilic material
- Enlarged epithelial cells with intranuclear inclusions
- Non caseating granulomas
- Charcot leydn cells
Non caseating granulomas
A 54 year old plumber presents with a 1 year history of recurrent episodes of productive cough with yellowish green sputum which is occasionally bloodstained. He has smoked 1 packet of cigarettes a day since he was 18 years old. Sputum culture showed non-specific mixed growth. The image shows the appearance similar to that of his lung.
Why non specific mixed growth? Yellowish green? smoking history?
1.
Bronchiectasis
2.
Bronchogenic carcinoma
3.
Aspergillosis
4.
Silicosis
5.
Centrilobular emphysema
Bronchiectasis
A 32 year old man with progressive dyspnea and wheezing since 2 years, comes to the clinic. His Pulmonary function test is report shows pattern similar to wave B. What is the most likely diagnosis?
What about other curves? Explain each one in relation to diagnosis?
1.
Asthma
2.
Chronic Bronchitis
3.
Emphysema
4.
Bronchiectasis
5.
Interstitial Lung disease
Interstitial Lung disease
A 52 year old construction worker comes to you because of progressive productive cough and mild dyspnea on exertion. Patient has never smoked. Physical examination shows dry rales mainly in upper and middle lung field. His chest-ray & lung microscopic image is shown below. What is the most likely diagnosis?
Describe features shown? discuss pathogenesis? (asymptomatic - silicosis - PMF)
1.
Silicosis
2.
Asbestosis
3.
Pneumoconiosis
4.
Bronchiectasis
5.
Idiopathic pulmonary fibrosis
Silicosis
A 31 year old man known to be HIV positive experiences increasing dyspnoea , mild fever for the past 3 weeks.
On examination, crackles are heard over both lung fields. Chest X-ray shows bilateral interstitial infiltrates.
Bronchoscopy and broncho-alveolar lavage is performed. A special silver stain reveals the microscopic appearance shown in the image below.
describe microscopy of common pneumonia (for each of the option).
1.
Aspergillosis
2.
Mycoplasma pneumonia
3.
Candida albicans
4.
Mycobacterium tuberculosis
5.
Pneumocystis jirovecii
Pneumocystis jirovecii
A 58 year old miner comes to your clinic because of progressive productive cough and mild dyspenea on exertion. Image shows his chest x-ray and microscopy of his lung. What is the most likely diagnosis?
describe features on chest xray & Microscopy? what is shown by arrows A, B & C?
1.
Panlobular Emphysema
2.
Nodular Silicosis
3.
Sarcoidosis
4.
Centrilobular Emphysema
5.
Asbestosis
Asbestosis
A 30 year-old man has severe blood loss due to car accident. He is intubated and placed on a ventilator. He has progressively decreasing oxygen saturations despite increasing PEEP and FI02 of 100%. He is found to be hypotensive and his extremities were cold. Chest radiograph is shown below. Which of the following pulmonary diseases most likely complicated his course?
Describe features on chest xray and microscopy? Discuss etiology and pathogenesis of this condition?
1.
Severe bronchopneumonia
2.
Lung infarction
3.
Honeycomb lung (end-stage lung disease)
4.
Diffuse interstitial damage
5.
Diffuse alveolar damage
Diffuse alveolar damage
A 24 year old man has experienced increasing dyspnoea for the past 4 years. He does not smoke. Auscultation reveals decreased breath sounds over both lung fields. Pulmonary function tests show decreased DLCO & FEV1. One of his siblings is similarly affected. The image shows his chest X-ray. What is the most likely pathogenesis?
- IgE binding to mast cells
- Reduced anti-elastase activity
- CFTR gene mutation
- Increased neutrophil proteases
- Interstitial fibrosis
Interstitial fibrosis
A 40-year old presents with complaints of fever, muscle pain, dyspnea, and a cough that has been going on for a few months. The patient denies any recent travel, use of drugs, smoking, or any other illness. The patient has crackles on auscultation; the rest of the exam is normal. A chest x-ray reveals bilateral hilar adenopathy. His tuberculin skin test is negative. Urine analysis reveals hypercalciuria. Image shows his indurated rashes, what is the type of rash?
What is the disease? What microscopic features will be seen in the lymph nodes?
1.
Raynaud phenomenon
2.
Erythema migrans
3.
Pyogerma gangrenosum
4.
Erythema nodosum
5.
Henoch Schonlein purpura
Erythema nodosum
Which indicates asthma
A- obstructive, looking at FEV1/FVC ratio will be decreased, 07 or 70
will have a change greater than 10% (12%)
18-Year-old bigender person is
brought in by ambulance with
sudden-onset, severe, right-sided
chest pain. They are distressed and
unable to talk in full sentences.
Background: Mild asthma. No regular
medications. No recent trauma.
Smoker 15/day.
HR 130, BP 80/35, RR 36, SaO2 89 on
6LO2/min.
Chest X-Ray is shown: Diagnosis?
A 62 y/o female is referred to the local hospital respiratory clinic with a 12
month history of worsening dyspnoea. She also reports a dry cough and
increasing fatigue. She has no respiratory history of note.
Q13: Which risk factor for respiratory disease is most relevant in this case?
1. Smoking history – including passive smoke
2. Occupational exposure history – silica, asbestos, coal etc
3. Family history of autoimmune disease – RA, scleroderma, sarcoidosis
4. Travel history
5. Pets and animals – particularly birds
64 y/o male presents to his GP with a 6 month history of progressively
worsening shortness of breath and dry cough. Non smoker. No known
occupational exposures. His chest CT is shown.
Q14: What is the most likely diagnosis?
1. Acute interstitial pneumonia
2. Radiation pneumonitis
3. Sarcoidosis
4. Idiopathic pulmonary fibrosis
5. Tuberculosis
A 30-Year-old woman of
Nigerian origin presents with
3 months of progressive
shortness of breath, dry
cough, fatigue, night sweats,
eye irritation and anorexia.
Serum calcium is elevated,
and chest x-ray shows
bilateral hilar adenopathy
Q15: What is the most likely diagnosis?
1. Allergic alveolitis
2. Idiopathic pulmonary fibrosis
3. Sarcoidosis
4. Acute bronchitis
5. Tuberculosis
A 54yo male presents to the GP with a 1-week history of haemoptysis. He states he is currently recovering from a “chest infection” with the fevers and
productive sputum now improving. He has no known past medical history. Imaging reveals a 2cm nodule in the right upper lobe in the posterior segment.
4. A CT-guided biopsy is taken and shown below. What histological findings can be seen? (adenocarcinoma)
a. Acinar growth pattern, large pleomorphic cells
b. Large pleomorphic cells with intercellular bridges
c. Mucous gland and smooth muscle
hyperplasia
d. Peribronchial inflammation
e. Nests of uniform small round cells
Acinar growth pattern, large pleomorphic cells
Well developed glandular like spaces, Intracellular bridges is squamous cell carcinoma
- A 69-year-old female presents with 6 months of increasing
SOB, productive cough and weight loss. A CT scan is performed
as shown. The expected gross morphology is also shown.
What is the most likely diagnosis?
a. Adenocarcinoma
b. Large cell carcinoma
c. Lung metastases
d. Small cell lung cancer
e. Squamous cell carcinoma
Squamous cell carcinoma
A 69-year-old female presents with 6 months of increasing SOB, productive cough, and weight loss.
He has squamous cell carcinoma
13. Which biopsy finding is the patient most likely to have?
a- keratin pearl.
- A 36-year-old male presents with 1 week history of
haemoptysis on a background of a 2-month history of a dry cough.
He has not produced any sputum or had fevers or sick contacts.
He has recently noticed intermittent diarrhoea and flushing of his
skin. A lung lesion is seen on imaging and a subsequent biopsy is
performed and shown.
What is the most likely diagnosis?
a. Adenocarcinoma
b. Carcinoid tumour
c. Lung metastasis
d. Small cell lung cancer
e. Squamous cell carcinoma
Carcinoid tumour- Tumor cells growing as nests with vascular in between. cells monogenous. heaps of cytoplasm.
A 62-year-old male presents with a 4-month history of facial plethora, muscle
weakness, easy bruising and weight gain. On examination he is hypertensive. As
part of his work up a CXR is done which shows a centrally located lesion. His sputum
cytology confirms small cell lung cancer.
19. Which gross morphology specimen would best fit with the patient’s presentation?
a
c is more likely to be metastatic
- A 72-year-old male presents with a 2 month history of weight
loss on a background of an 8 month history of SOB. He is a retired
builder and also worked in the coal mines. A CT scan is performed
and shown below, as well as gross morphology of this condition.
What is the most likely aetiology of his condition?
a. Asbestos
b. Cigarette smoking
c. Coal-tar
d. Silica
e. Tuberculosis
Asbestos
- A 53yo presents with a 4-week history of residual SOB after a
lower RTI. They were previously well. On exam, they are afebrile
with an SpO2 is 95% RA. The patient’s CXR is shown below.
A pleurocentesis would reveal a clear fluid with protein ratio >0.5
and LDH ratio >0.6. What is the most likely cause of the pleural
effusion?
a. Heart failure
b. Lung abscess
c. Lung cancer
d. Pneumonia
e. Pulmonary embolism
Pneumonia
- A 58-year-old male presents with 4 months of a persistent dry
cough with mild SOB. He has not had any haemoptysis or fevers.
His past medical history includes rheumatoid arthritis and
hypertension. A CXR is performed and shown. What is the most
likely diagnosis?
a. Atypical pneumonia
b. Sarcoidosis
c. Interstitial pulmonary fibrosis
d. Lung metastases
e. Metastatic lung cancer
Lung metastases
This is an image of a lung removed from a 45 year-old female smoker. Her medical history is characterized by intermittent attacks of abdominal cramping pain, diarrhea, facial flushing and cyanosis. image shows bronchoscopy & microscopy. Which of the following is the most likely diagnosis?
Describe gross and microscopy features. Explain pathogenesis of her clinical features? Prognosis?
Small cell carcinoma
Smoker’s lung with pneumonia
Carcinoid tumor
Squamous cell carcinoma
Adenocarcinoma
Carcinoid tumor
A 58 year old chronic smoker with history of progressive cough & dyspnoea since an year, now presents with hemoptysis. X ray chest reveal small right hilar mass. Microscopic image shown below. What is the most likely diagnosis?
list microscopic features? common genetic alteration? brief note on therapy & prognosis?
Large cell Ca
Adenocarcinoma
Small cell Ca
NSCLC
Squamous cell Ca
Small cell Ca
A 69-year-old man with chronic worsening cough. He has lost 9-kg weight over the past 4 months, For the past month, he has been struggling to walk upstairs and get out of chairs because he “feels weak.” Chest radiograph is shown below. His bronchoscopy cytology shows large pleomorphic cells with hyperchromatic large nuclei and dark pink cytoplasm. Which of the following is the most likely diagnosis?
Non hodgkins Lymphoma
Squamous cell Ca
Small cell lung Ca
Mesothelioma
Adenocarcinoma of the lung
Squamous cell Ca
58 year old woman is bought to your clinic by her friend, because she is confused and disoriented. She developed headaches, tremors and muscle weakness since 2 weeks. She is a known chronic smoker and is on therapy for chronic bronchitis. X ray of the chest reveal small hilar mass. Microscopic image of the lung lesion is shown. What characteristic lab investigation is expected in this patient?
Discuss pathogenesis of her laboratory finding?
Hypokalemia
Hypernatremia
Hyponatremia
Hyperkalemia
Hypercalcemia
Hyponatremia
An 83 year old man with a 75 pack year smoking history develops haemoptysis. He dies after 1 week. Lung specimen removed at autopsy is shown in the image . Based on the gross & microscopic features, most likely diagnosis is,
Small Cell Lung Carcinoma
Lung Carcinoid tumor
Adenocarcinoma
Squamous Cell Lung Carcinoma
Bronchioloalveolar carcinoma
Small Cell Lung Carcinoma
A 67 year-old woman consults her GP with symptoms of a non productive cough, present for approximately 4 months. The GP elicits a further history of loss of appetite and a 6 kg weight loss over the previous 2 months. She does not smoke. Chest x ray is shown below. Which of the following mutation is most specifically to be seen in this case.
describe gross features seen? What microscopic feature would be seen in the lesion?
I-myc mutation
Rb mutation
3p deletion
EGFR mutation
p16 mutation
EGFR mutation
This is the microscopic image from the bronchial biopsy specimen of a 68 year-old male who presented with weight loss and chronic cough. Which of the following would be the most likely diagnosis?
list microscopic features? common genetic alteration? brief note on therapy & prognosis?
Carcinoid tumor
Large cell carcinoma
Squamous cell carcinoma
Small cell carcinoma
Adenocarcinoma
Squamous cell carcinoma
A 63 year old woman presents to GP with constricted pupils and droopy eyelids. Her chest-XRay is shown below. The most likely cause of her presentation is,
Discuss clinical features with your knowledge of anatomy?
SIADH
Cushing’s syndrome
Carcinoid syndrome
Lambert-Eaton syndrome
Horner’s syndrome
Horner’s syndrome
A 58-year-old man with chronic history of smoking, comes to the office because of polyuria and constipation for 2 weeks. He says that he has never had these symptoms before and that he has lost 3kg over the last 5 months and developed a chronic, non-productive cough. Radiographic image is shown below. Which of the following electrolyte abnormality is likely to be seen?
describe gross features seen? What microscopic feature would be seen in the lesion? common mutations?
Hypocalcemia
Hypercalcemia
Hypernatremia
Hyponatremia
Hypokalemia
Hyponatremia
A 61 year old woman from Mt. Isa who has smoked for many years, presents with a firm tethered painless lump in the neck. For years she has had a cough two to three times a year with each episode lasting a few weeks. Over the past 6 weeks she has lost 5 kg in weight but attributes this to regularly walking. There is no other PMH of note. The image shows appearance of section of lung. What feature is seen in her lung specimen?
Small cell carcinoma lung
Squamous cell carcinoma lung
Bronchiectasis
Bronchial asthma - complicated
Centrilobular emphysema (Smokers lung)
Bronchiectasis
45 -year old chronic smoker, shipyard worker presents at ED with severe dyspnoea & Hemoptysis and dies before therapy. PMH shows progressive worsening dyspnoea and non-specific chest pain for several years. Image shows appearance of his lungs at autopsy.
Which is the most likely diagnosis? common cause?
Pulmonary Tuberculosis
Small cell Ca
Mesothelioma
Progressive Massive Fibrosis (PMF)
Squamous cell Ca
Mesothelioma
A 42-year-old man is incidentally found to have hepatomegaly on examination
of his abdomen. His liver edge is regular and there is no RUQ tenderness. His
liver span is 15cm. His spleen is not palpable. He currently drinks 1-2 bottles
of scotch a week and has injected drugs in the past. He was born in China. If
a biopsy where to be performed, it would look like the biopsy shown below.
01. What does the biopsy show?
a) Cirrhosis
b) Fibrosis
c) Hepatitis
d) Steatohepatitis
e) Steatosis
Steatosis- normal/ slightly enlarged therefore no fibrosis
A 42-year-old man is incidentally found to have hepatomegaly on examination of his
abdomen. His liver edge is regular and there is no RUQ tenderness. His liver span is
15cm. His spleen is not palpable. He currently drinks 1-2 bottles of scotch a week
and has injected drugs in the past. He was born in China.
TABLE TALK
02. You utilize motivational interviewing to discuss alcohol reduction/cessation with
the patient. What complications of acute and chronic alcohol use can you talk to the
patient about?
He would have ascites, jaundice, abdominal pain, gynecomastia
- A 46-year-old is bought into hospital with jaundice after
consuming 8g paracetamol a day for the previous 6 days. Liver
function tests are all deranged with severely elevated transaminases and evidence of decreased synthetic function. If a biopsy were to be performed in this patient, what area would have maximum inflammation?
a) Zone 1 (periportal)
b) Zone 2
c) Zone 3 (centrilobular)
d) All zones
e) No inflammation
Zone 3 (centrilobular)-
- A 23-year-old male is seen for medical review in a refugee clinic. He
recently arrived from Burma. They described 2 weeks of fever and right upper quadrant pain and diarrhoea. An ultrasound scan and then CT is performed (shown below) which reveals a single large mass in the liver with ring enhancement. What is the most likely cause?
a) Amoebic liver abscess
b) Hepatic adenoma
c) Hepatocellular carcinoma
d) HIV
e) Hepatitis E infection
Amoebic liver abscess- ring enhancement. ring suggests active inflammation.
hepatocellular cancer- would look similar but would have breakdown in centre (not likely for her age)
adenoma would have smaller ring
Hep e is diffuse
A 54-year-old patient presents with a 4-month history of increasing fatigue.
The patient has no known history of liver disease. She has a history of
rheumatoid arthritis for which she takes methotrexate and folic acid. She drinks 2-3 glasses of wine a night. Liver function tests shows a
transaminase rise.
11. A subsequent Fibroscan shows stage 2 fibrosis and a biopsy is
performed with shows infiltration of plasma cells. What is the most likely
diagnosis?
a) Alcohol-related liver disease
b) Autoimmune hepatitis
c) Drug-induced liver injury
d) Metabolic-associated fatty liver disease
Autoimmune hepatitis
- A 57-year-old man was found to have elevated transaminases (ALT and AST) for >6 months as part of investigations into 3 years of fatigue.
Subsequent testing revealed the following results:
HepBsAg REACTIVE
HepC IgG REACTIVE
HepBsAb Not detected
HepC RNA Not detected
HepBcAb REACTIVE
Given the patient’s presentation, what is the correct interpretation of these results?
a) Acute hepatitis B
b) Chronic hepatitis B infection
c) Previous hepatitis B infection
d) Chronic hepatitis C
e) Immunised against hepatitis C
Chronic hepatitis B infection
HEP C - has been exposed and recovered
A 57-year-old man was found to have elevated transaminases (ALT and AST) for >6 months as part of investigations into 3 years of fatigue. Subsequent testing revealed the following results:
14. No additional cause for the patient’s liver disease is found. On further questioning, the patient states he has a family history of chronic liver disease and liver cancer. HBV DNA levels are taken.
What further information is needed to determine the patient’s phase of
infection?
a) HepB cAb IgM
b) HepB eAg/Ab
c) HepD IgG
d) INR
e) Transient elastography (Fibroscan) score
HepB eAg/Ab- tells viral load
- A 61-year-old male is shown to have mildly elevated in transaminases on LFTs performed as part of a medical review. He had a history of obesity, hypertension and type 2 diabetes, for which he has recently started insulin
therapy. An ultrasound scan is performed which did not show any structural change. The histology of the patient’s liver is shown below. (note: biopsy would not be
done in this patient). What is the most likely cause of the patient’s abnormal liver function tests?
a) Alcohol-related liver disease
b) Chronic cardiac failure
c) Chronic viral hepatitis
d) Haemochromatosis
e) Metabolic-associated fatty liver disease
Metabolic-associated fatty liver disease
A 61-year-old male is shown to abnormal LFTs on blood performed as part of a medical review. He had a history of obesity, hypertension and type 2
diabetes, for which he has recently started insulin therapy. An ultrasound scan is performed which did not show any structural change.
17. If the following biopsy findings were consistent with the liver in this patient and Prussian blue staining were normal, what would the most likely cause of
the abnormal LFTs be?
a) Alcohol-related liver disease
b) Chronic cardiac failure
c) Chronic viral hepatitis
d) Haemochromatosis
e) MAFLD
Chronic viral hepatitis- no fatty areas, there is inflammatory cells limited to portal areas
- A 63-year-old presents with significant haematemesis. He has a known history of hepatitis C which has not been treated. He describes a preceding 2- week history of disturbed sleep patterns and his partner states he has been
confused at times. On examination, he has mild jaundice, a non-palpable liver and significant ascites.
What is the missing step in the pathogenesis of this patient’s cirrhosis?
Damage to hepatocytes -> activation of Kupffer cells -> release of interleukins and inflammatory markers -> _______________ -> fibroblast accumulation
a) Activation of stellate cells
b) Cholestasis
c) Loss of epithelial cell fenestration
d) Macrophage accumulation
e) Mallory body formation
Activation of stellate cells
Mr. LT, 56-year-old Nurse, presents with chronic fatigue, indigestion and mild bleeding tendency following minor injury and while brushing his teeth & occasional nose bleeds, all his symptoms have started since 3 years. He was previously healthy. NO history of jaundice or fever. He does not abuse alcohol or take drugs. Image shows MRI abdomen. What is the most likely diagnosis?
list 3 features on the image? What Liver function test results would be? What is the most likely cause?
Cirrhosis
Chronic Hepatitis
Hepatocellular carcinoma
NAFLD
Gallstones
Cirrhosis
A 28-year-old woman at ED with severe nausea and abdominal pain. She is alcoholic and has used IV drugs. Examination findings reveal jaundice, mild hepatomegaly. Lab results show raised AST, ALT & ALP, AST:ALT ratio f 2.5, as well as leukocytosis. Image shows needle liver biopsy appearance. What is the most likely diagnosis?
Identify 3 microscopic features. What feature is shown by arrows? What is the pathogenesis? Prognosis? (Robbins)
Acute alcoholic hepatitis
Alcoholic cirrhosis
Acute Viral hepatitis
Post viral Cirrhosis
Chronic viral hepatitis
Acute alcoholic hepatitis
Below is the image from cholecystectomy of a 40 year old obese female. What is the most likely pathogenesis of this lesion?
Excess Bile salts in bile
Hypercholesterolemia
Excess cholesterol in bile
Excess bile acids in bile
Excess bile pigments in bile.
Excess cholesterol in bile
The below image shows gall stones removed from a 23 year old African male. Of the following, what is the most likely cause?
Hyper cholesterolemia familial
Diabetes mellitus
Hemolytic anemia
Liver cirrhosis
Ulcerative colitis
Hemolytic anemia
A 68 year old white female presents with a long history of cholelithiasis, One week before her last hospital admission, the patient developed jaundice & fever with a markedly increased conjugated bilirubin in the serum. The gallbladder was removed image shows its gross appearance. What is the most likely diagnosis?
Identify features A, B, C & D.
Gangrenous cholecystitis
Cholesterolosis
Adenocarcinoma of the gallbladder
Chronic cholecystitis with obstruction
Calculous cholecystitis with empyema
Calculous cholecystitis with empyema
In strawberry gallbladder, ‘yellow flecks’ are due to which of the following?
Deposition of hemosiderin (bleeding)
Deposition of bile pigments and bile salts
Deposition of pure cholesterol crystals.
Deposition of foamy macrophages with cholesterol.
Deposition of bile salts with bacteria
Deposition of foamy macrophages with cholesterol.
A 60 year old female has been having recurrent attacks of upper abdominal pain, often at night and following a meal. Most often the attacks subside on their own. She has lost her appetite and loosing weight. Image shows her abdominal X-ray and a pancreas specimen from a similar patient. What is the most likely diagnosis?
list features shown? List potential complications?
Acute pancreatitis
Chronic pancreatitis
Pancreatic adenocarcinoma
Carcinoma of the gall bladder
Secondary biliary cirrhosis
Chronic pancreatitis
A 52-year-old woman chronic recurrent epigastric and RUQ pain, especially severe after a fatty meal. Her appetite has decreased and she has lost 4kg over the last 2 months. P/E fever of 102°F & jaundice. She undergoes cholecystectomy. Image of her gallbladder and its. microscopy. What is the most likely diagnosis?
identify features on gross and microscopy?
Acute calculous cholecystitis
Chronic cholecystitis with gall stones.
Cholangiocarcinoma
Adenocarcinoma of gall bladder
Acute on Chronic Cholecystitis
Adenocarcinoma of gall bladder
A 78-year-old woman, constant epigrastric pain and 5kg wt loss over 6 months. Her serum bilirubin, AST, ALT are normal but ALP is raised. Image shows her abdomen CT. What is the most likely diagnosis?
List 4 features seen in the image? what is the prognosis?
Cholangiocarcinoma
Carcinoma Pancreas
Chronic pancreatitis
Pancreatic cystadenoma
Pancreatic insulinoma
Carcinoma Pancreas
51-year-old woman with a year long history of intermittent RUQ pain now has diffuse severe abdominal pain and she is in shock. Her serum total & direct bilirubin, ALP & Amylase are raised. Image shows her abdomen and abdominal CT. What is the most likely diagnosis?
list features seen? Discuss pathogenesis? list complications? lab diagnosis?
Acute pancreatitis
Chronic pancreatitis
Acute cholecystitis
Acute cholelithiasis
Acute hepatitis.
Acute pancreatitis
59-year-old, chronic alcoholic man presents with worsening recurrent episodic abdominal pain. He has chronic diarrhoea and moderate weight loss. He undergoes surgery to remove a large lesion. Image shows his preoperative CT abdomen and the lesion at surgery. What is the most likely diagnosis?
Pancreatic adenocarcinoma
Cholangiocarcinoma
Klatskin tumor
Pancreatic pseudocyst
Cystadenoma of Pancreas
Pancreatic pseudocyst
A 45-year-old woman, has jaundice and colicky RUQ pain worsening since a week. Her serum AST, ALT are normal but ALP is markedly raised at 202 u/L. total bilirubin is also raised predominantly direct. Microscopic appearance of her liver is compared with normal liver histology in the image. What pathologic process is seen in the image?
List 3 pathologic features seen? list 3 common etiology for this condition?
Acute alcoholic hepatitis
Massive hepatocyte necrosis
Intrahepatic cholestasis
Ascending cholangitis
Feathery hepatocyte degeneration
Intrahepatic cholestasis
58-year-old chronic alcoholic man presents with increasing abdominal girth and asterixis. his blood ammonia is raised and he has oliguria with elevated BUN & creatinine. His abdominal CT is shown. Why is his kidney function affected?
List features in the image? Complications & prognosis? What is the pathogenesis of his renal function abnormality?
Septic shock
Toxic renal failure
Renal damage by Ammonia
Hepatorenal syndrome
Alcoholic renal failure
Hepatorenal syndrome
51 year old business man presents with joint pains, indigestion and worsening fatigue & shortness of breath. History reveals recent diagnosis of diabetes and dark skin pigmentation on sun exposed areas. on examination, he has mild but tender hepatomegaly, Liver function tests show moderately elevated AST, ALt & ALP & serum ferritin is markedly elevated. Image shows his liver biopsy stained for iron (blue).
Liver biopsy
Wilson’s disease
Primary bilary cirrhosis;
Alcoholic hepatitis;
Hemochromatosis
Alcoholic cirrhosis;
Hemochromatosis
A 22 year old alcoholic man presents with fatigue, jaundice and fever. His liver biopsy image is shown below. The structures shown by arrows in the following image are,
Liver microscopy
Mallory body
Viral inclusions;
Apoptotic cell;
Inflammatory cells
Hepatocyte necrosis;
Mallory body
The following microscopic image is from a patient with viral hepatitis. What is the most likely clinical stage of disease?
liver biopsy
Chronic viral hepatitis
Acute viral hepatits
Carrier status of viral hepatitis
Cirrhosis
Fulminant viral hepatitis
Chronic viral hepatitis
49 year old man has long standing diabetes. During a regular checkup, mild hepatomegaly was noted and he underwent CT scan. Image shows his CT abdomen image. What is the most likely cause of his hepatomegaly.
Abdomen CT
Chronic viral hepatitis
Biliary cirrhosis
Alcoholic hepatitis
Non Alcoholic fatty liver disease.
Hemochromatosis
Non Alcoholic fatty liver disease.
A 28 year old alcoholic, homosexual male presented with fatigue, icterus and fever. His liver biopsy image is shown below. The most likely diagnosis is?
Liver microscopy
List 3 microscopic features seen?
Cirrhosis of the liver
Chronic viral hepatitis
Fulminant Hepatitis
Alcoholic fatty liver
Acute viral hepatitis;
Acute viral hepatitis;
This is the liver biopsy image from a 58 year old chronic alcoholic male presented with distended abdomen. The most likely diagnosis is:
Liver Micro
Acute viral hepatitis;
Fatty Liver
Chronic hepatitis;
Hepatocellular carcinoma;
Cirrhosis
Cirrhosis
A 43-year-old female presents to the ED with 6 hours of constant RUQ pain.
The pain came on after eating lunch. She has had self-resolving episodes of
RUQ pain previously over the past weeks.
TABLE TALK
02. Complete the table of other differentials for this patient and ‘rule in’ findings.
- Pancreatitis
- pneumonia
- PE
- peptic ulcer disease: recent NSAIDS, h pylori infection, worse after food, alcohol use, haemeteptisis, retrosternal discomfort, burning rising up.
- MI
- pyelonephritis or renal calculus
appendicitis: rebound tenderness, fevers, nausea
A 43-year-old female presents to the ED with 6 hours of constant RUQ pain. The pain came on after eating lunch. She has had self-resolving episodes of RUQ pain previously.
Her partner states she has not been confused. On examination, she is not
jaundiced and has a temperature of 37.9°C, HR 96 and BP 124/85 with no
postural drop. She has RUQ tenderness, especially on inspiration.
Same pt. The presence of gallstones is confirmed. The patient
recovers and undergoes an elective cholecystectomy. The gross
morphology of the gall bladder after surgery is shown. What is the
final diagnosis for this patient given this information?
a) Acalculous cholecystitis
b) Acute cholecystitis
c) Acute on chronic cholecystitis
d) Biliary colic
e) Gall bladder cancer
Acute on chronic cholecystitis
Presence of gallstones is confirmed. The patient recovers and
undergoes an elective cholecystectomy. The gross morphology of the gall bladder after surgery is shown.
07. What is the most likely metabolic abnormality underlying the patient’s condition?
a) Decreased bilirubin conjugation
b) Increased serum cholesterol
c) Increased bile salts in bile
d) Decreased LDL receptors
e) Increased bile cholesterol
Increased bile cholesterol
Pathogenesis factors
1. increased cholesterol/ decreased bile salts
2. stasis/ reflux (decreased motility)
3. cholesterol crystal nucleation
4. increased mucus
A 49-year-old male presents to the GP with a 6 month history
of multiple episodes of self-resolving RUQ pain, generally
occurring after eating fatty foods. An USS is ordered which shows
multiple gallstones and a thickened gallbladder wall but no dilated
bile ducts or pericholecystic fluid. If a cholecystectomy were to
take place, it would look like the specimen shown. What is the
most likely cause of his gallstones?
a) Acute blood loss
b) Chronic haemolysis
c) Familial hypercholesterolaemia
d) Inflammatory bowel disease
e) Hypertriglyceridaemia
Chronic haemolysis
- A 46-year-old patient has liver function test performed to assess for alcohol-related liver disease, which are shown. The patient reports feeling well, recently recovering from an infected leg wound treated with cephalexin.
They don’t have a previous history of jaundice and are not visibly jaundiced on examination today.
A full blood count and UEC are both normal. What is the most likely cause of the patient’s hyperbilirubinaemia?
a) Alcohol-related liver disease
b) Cholecystitis
c) Chronic haemolysis
d) Gilbert’s syndrome
e) Medication side effect
Medication side effect- because it is unconjugated.
age does not fit gilbert’s syndrome
A 73-year-old female presents with 3 weeks of jaundice. She has not had any recent fevers or abdominal pain. She has pale stool and dark urine.
21. The patient undergoes CT scan which suggests pancreatic cancer and subsequently
undergoes a biopsy. Which of the following histologic features would most likely be found in
this patient?
b. adenocarcinoma
d. acute pancreatitis from hemorrhaging
c. fibrosis - chronic pancreatitis
a. normal
- A 45-year-old female presents with an 8-month history of progressive fatigue and itchy skin. She has a history of autoimmune hypothyroidism, which is well controlled. On examination, she has obvious jaundice, scratch marks on her arms. Her face is as shown in the picture. LFTs show an
obstructive picture with predominantly elevated ALP, GGT and bilirubin.
What is the reason for the findings on her face?
a) Bilirubin deposits
b) Decreased hepatic clearance of cholesterol
c) Elevated triglycerides
d) Increased hepatocellular uptake of cholesterol
e) Increased hepatic production of cholesterol
She has primary biliary cholangitis
- Decreased hepatic clearance of cholesterol
A 54 yo male presents to the GP with a 3 month history of dyspepsia and epigastric pain typically following a meal. He complains of indigestion on and off for the past 3- 4 years for which he takes Mylanta over the counter. No nausea or vomiting.
History of chronic back pain following a work related injury 5 years ago. No other medical problems. On no regular medication. Takes analgesia when his pain flares up. Consumes 2 mid strength beers most nights.
On examination mild epigastric tenderness is noted.
His H Pylori test is positive.
The appearance of his antrum on endoscopy and the histology appearance is shown below.
08. What is the most likely diagnosis?
1. Autoimmune atrophic gastritis
2. Gastric carcinoma
3. Zollinger Ellison syndrome
4. Chronic gastritis of H.pylori
5. Acute gastritis (stress ulcers)
Chronic gastritis of H.pylori
What gross morphological appearance would best fit in with his presentation of a peptic ulcer if a specimen of his stomach was
visualised?
B: depressed ulcer with radiating wall- h pylori
C: 2 seperate ulcers - one in gastic and one in duodenum - ZE
A: ulcer with raised margin- cancer
A 55yo male, presents with a 6 month history of chronic abdominal pain and
fatigue. Image shows CT appearance, gastric endoscopy and histology.
What is the most likely aetiology?
1. TP53 mutation
2. BRCA1 mutation
3. Chronic gastritis
4. H.pylori infection
5. E-Cadherin mutation
E-Cadherin mutation
62 year old female presents to ED with an 8 hour history of severe abdominal pain. The pain started in the epigastrium but is now generalised. She has a previous history of a duodenal ulcer. On general inspection she is in pain, abdominal distension is noted. Vital signs: PR is 110 bpm, BP 108/66, temp 37.5, RR 20. Her erect chest Xray and abdominal xray is shown.
Q11: What sign is most likely to be present on abdominal examination?
1. Palpable mass
2. Percussion tenderness
3. Dilated veins
4. Cullen’s sign
5. Normal bowel sounds
What is the most likely cause for her X-ray findings? B
1. Paralytic ileus
2. Large bowel obstruction
3. Small bowel obstruction
4. Volvulus
Paralytic ileus
A 68 year old woman presents to ED with a 12 hour history of generalised
abdominal pain, nausea, vomiting, bloating and absent flatus. She is otherwise well and has had a hysterectomy for fibroids at age 50. Her erect abdominal Xray is shown.
Q13: Which symptom is most suggestive of the likely diagnosis in this patient?
1. Abdominal pain
2. Nausea
3. Vomiting
4. Absent flatus
5. Bloating
Absent flatus
A 68 year old woman presents to ED with a 12 hour history of generalised
abdominal pain, nausea, vomiting, bloating and absent flatus. She is otherwise well and has had a hysterectomy for fibroids at age 50. Her erect abdominal Xray is shown.
What feature on abdominal X-ray would support the most likely
diagnosis in this patient?
1. Coffee bean sign
2. Peripheral dilated bowel loops
3. Presence of haustra
4. Air under the diaphragm
5. Presence of valvulae conniventes
Presence of valvulae conniventes
A 68 year old woman presents to ED with a 12 hour history of generalised abdominal pain, nausea, vomiting, bloating and absent flatus. She is otherwise well and has had a hysterectomy for fibroids at age 50. Her erect abdominal X-ray is shown.
On general inspection she is in pain, abdominal distension is noted.
Vital signs: PR is 110 bpm, BP 108/66, temp 37.5, RR 20. She has signs of peritonism and absent bowel sounds.
15.What is the most important management step for the patient at this stage?
1. Organise lipase
2. Surgical referral
3. Oral analgesia
4. Encourage oral fluids
5. Monitor vitals
Surgical referral
A 48 year old male c/o 3/12 progressively worsening difficulty swallowing meat and
sandwiches. Examination reveals epigastric tenderness. He is referred for an endoscopy.
Upper gastrointestinal endoscopy of the mid oesophagus is shown.
19: Which of the following is most likely to be seen on microscopy?
- Pleomorphic cells forming irregular glands
- Loss of ganglion cells & inflammation
- Dilated vascular channels
- Multinucleated cells with viral inclusions
- Pleomorphic cells with keratin pearls
Pleomorphic cells with keratin pearls
A 56 year old male presents with a 3 month history of intermittent dysphagia for solids and liquids. Examination was normal. He undergoes a Barium
swallow shown below.
20: What is the most likely diagnosis?
1. Adenocarcinoma
2. Mallory Weiss syndrome
3. Barrett’s oesophagus
4. Hiatus hernia
5. Achalasia
Achalasia
A 42yo female presents with a 6 month history of painless dysphagia to solids and fatigue. Her Hb is 71g/L, MCV 69 fl. Multiple smooth tapered concentric narrowing of the cervical oesophagus is noted on Barium swallow.
21: What is the most likely cause of her dysphagia?
1. GORD
2. Oesophageal web
3. Schatzki ring
4. Achalasia
5. Oesophageal stricture
Oesophageal web
A 57 year old male presents with a 6 month history of burning epigastric pain after meals. His examination was normal. The appearance of his oesophagus on endoscopy is shown.
Biopsy specimen shows intraepithelial neutrophils and eosinophils.
22: What is the most likely diagnosis?
1. Barrett’s oesophagus
2. Oesophageal varices
3. Adenocarcinoma
4. Reflux oesophagitis
5. Candida oesophagitis
Reflux oesophagitis
A 53y old woman presents with a 3 year history of persistent heartburn partly relieved by antacids. Endoscopy shows altered mucosa in the lower third of her
oesophagus. No ulcers or mass lesions.
24: Biopsy of this area would most likely show:
1. Glandular dysplasia
2. Gastric metaplasia
3. Adenocarcinoma
4. Intestinal metaplasia
5. Squamous metaplasia
Intestinal metaplasia
A 26yo female who presented with a 4 week history of gradual onset generalized
abdominal pain, bloating and diarrhoea. On further history she complains of blood in her
stools. No history of weight loss, fevers or travel. She smokes 3 cigarettes a day and is on
no medications and has no autoimmune history.
On examination, the patient is not dehydrated and has normal vitals. Abdomen was soft
with generalized tenderness and no masses. On examination, the patient has the following
tender lesions on her legs.
Q2: The skin lesions are most likely:
1. Allergic dermatitis
2. Dermatitis herpetiformis
3. Erythema nodosum
4. Pyoderma gangrenosum
5. Retiform purpura
Erythema nodosum
Despite treatment she has recurrent flares over the next 2 years. She complains
of pain in the perianal area. On rectal examination perianal sores & multiple fistulae are present.
Q5: What microscopic features explains her anal fistulae?
1. Mucosal inflammation
2. Deep penetrating ulcer
3. Crypt abscess
4. Non caseating granuloma
Deep penetrating ulcer
A 38y female presents with a 4 day history of bloody diarrhoea and abdominal pain. She
has a known medical history of ulcerative colitis. On examination her vitals are PR 120
bpm, BP 90/58mm Hg, RR 20 bpm, temp 38.5. On examination her abdomen is distended
with generalised tenderness. Her abdominal X-ray is shown.
Q6: What is the pathogenesis of her current presentation?
1. Ischaemia
2. Severe inflammation
3. Intestinal obstruction
4. Intestinal perforation
5. Infection
Severe inflammation
A 60 year old female presents to the GP with a 3 month history of irregular bowel habits
and intermittent left lower quadrant abdominal pain.
She undergoes a colonoscopy to investigate her symptoms. The following appearance is
noted in the sigmoid colon.
Group question:
What is the pathophysiology of her most likely diagnosis?
Diverticular disease- increased intraluminal pressure due to decreased fiber diet (constipation chronic) and weakness in the bowel wall.
72 yearold male, presents with a 3 month history of fatigue, altered bowel habits with constipation & diarrhoea and occasional bloody stools. Blood tests reveal a microcytic hypochromic anaemia. Colonoscopy confirms a colon cancer. He undergoes a hemicolectomy. The specimen removed at surgery and the histology is shown below.
Group question: List features seen on the gross specimen & histology image?
Narrowing, encircling
napkin ring or apple core
pleomorphic hyperchromatic irregular glands and clusters
A 28 year old male presents for his annual colonoscopy. He has been having routine surveillance since his teens. The appearance of his colon at colonoscopy is shown.
Q18: What germline mutation is most likely to be present?
1.MSH2
2.MMR
3.P53
4.MLH1
5.APC
APC
26year old male presents with a 4 week history of foul smelling, mucoid, loose stools with dark blood 1-3 times/day with crampy abdominal pain. He had an episode of abdominal pain and mild diarrhoea while on army duties 6 months ago in Afghanistan. Molecular PCR testing suggests Entamoeba histolytica as the possible cause.
Q20: Which of the following organisms is likely to be noted on stool MCS?
2
A mother complains that her 3-year-old son has been having frothy urine for the past week. She denies any trauma or medical problems. He has had an uneventful growth pattern. Examination of the urine reveals a white froth. What substance is most likely causing this effect on the urine? (Image shows patient urine on left compared with normal on right)
Urine
what other urinary abnormality? What urine microscopy findings? What other clinical features? Pathogenesis?
Ethylene glycol
Bile salts
Protein
Bilirubin
Lipids
Protein
A 4-year-old boy presents to the emergency room with a 1-week history of generalized edema and fatigue. Your history reveals that he suffered from a viral URTI 1 week before this visit. Serum and urine studies reveal massive proteinuria, hyperlipidemia, and hypoalbuminemia. Image shows his kidney biopsy microscopy. What diagnostic feature is seen in the glomerulus?
What is the diagnosis? Pathogenesis? Prognosis? Therapy?
Acute Glomerulonephritis
Crescentic Glomerulonephritis
Mesangial Glomerulonephritis (IgA nephropathy)
Normal glomerulus.
Membranous Glomerulonephritis
Normal glomerulus.
A 40-year-old woman with a history of SLE presents with a chief complaint of increased swelling in her legs. She had been referred by her GP suspecting complication of her SLE. Recent laboratory studies show proteinuria, hypoalbuminemia,
hyperlipidemia, and hypercholesterolemia. Image shows appearance of her kidney biopsy. Which of the following is the feature seen on the image?
What is the diagnosis? Pathogenesis? what feature seen? Complications?
Mesangial Glomerulonephritis
Proliferative Glomerulonephritis
Crescentic Glomerulonephritis
Membranous Glomerulonephritis
Normal Glomerulus
Membranous Glomerulonephritis
A 5 year old boy is noted to have increased puffiness around his eyes for the past week and he has been less active than normal. On physical examination he has periorbital oedema. His BP is 140/90 mm Hg. A urinalysis reveals sp. gr. 1.010, pH 6.5, no glucose, 4+ protein, no blood & no ketones. Microscopic urinalysis reveals oval fat bodies, but no WBCs or RBCs. Image shows appearance of his glomerulus on electron microscopy compared with normal. What diagnostic feature is seen?
What is the pathogenesis of massive proteinuria?
Linear IgG, C3 & complement deposition
Mesangial dense deposits (IgA)
Sub epithelial dense deposits - humps
GBM splitting & subendothelial deposits
Fusion of podocyte foot processes
Fusion of podocyte foot processes
A 50 year old diabetic man is hospitalized for acute myocardial infarction. He has decreased cardiac output with hypotension requiring multiple pressor agents. His urine output drops over the next 3 days. His serum urea nitrogen increases to 55 mg/dL, with creatinine of 2.9 mg/dL. Urinalysis reveals no protein or glucose, a trace blood, and numerous casts. Five days later, he develops polyuria and his serum urea nitrogen declines. Image shows appearance similar to his. Which of the following pathologic findings are shown in the image?
Identify features shown by arrows A, B & C? Etiology & Pathogenesis? Why azotemia followed by polyuria?
Glomerular crescents & RBC cast
Tubular necrosis & Epithelial cast
Pyelonephritis & WBC cast
Nodular glomerulosclerosis & Hyaline cast
Membranous GN granular cast
Tubular necrosis & Epithelial cast
A 20 year old previously healthy man has been feeling tired for some months. He also says he has had recurrent episodes of dark colored urine. His BP 155/110 mm Hg. Labs: high serum creatinine. A urinalysis reveals 3+ blood, 1+ protein, no glucose, and no ketones. On urine microscopic examination there are numerous RBC casts. Image shows summary of features. What is the most likely dianosis?
List features shown? Etiology & Pathogenesis? Prognosis?
Alports syndrome
SLE
Berger’s disease
Goodpasteur syndrome
Familial Nephropathy
Berger’s
A 8 year old boy presents with tiredness, oliguria with dark colour urine. He had just recovered from a sore throat last month and was treated SUCCESSFULLY with antibiotic (tetracycline) and antipyretics. His kidney biopsy image & electron microscopy image is shown What is the most likely diagnosis?
Identify features A, B & C? what is deposited at arrow C? What is the Etiology & pathogenesis? Prognosis? complications?
Diffuse proliferative glomerulonephritis
Minimal change disease
Membranoproliferative glomerulonephritis
Membranous glomerulonephritis
Crescentic glomerulonephritis
Diffuse proliferative glomerulonephritis
A 31y man had sudden attack of fever, chills with severe muscle pain and weakness in his legs and shoulders, while mountaineering in the Himalayas (this could also occur in septicemia & strep infection). He has anuria and a rapid rise in the serum creatinine & myoglobin & moderate leukocytosis. Urine is positive for protein & RBC. Image shows appearance of his kidney biopsy and urine microscopy. What is the most likely diagnosis?
Identify features labeled A, B & C?. What is the pathogenesis?
Acute Tubular Necrosis
Septic infarction of kidney.
Berger’s disease
Post-Streptococcal glomerulonephritis
Membranous glomerulonephritis
Acute Tubular Necrosis
MS, a 69y old man dies in a motor vehicle accident. Post-mortem examination shows yellowish plaques within the aorta and coronary arteries. The image below shows the appearance of his kidneys at autopsy.
List 3 gross features seen in the image? explain pathogenesis?
Atheromatous emoboli
Chronic pyelonephritis
Diabetic nephropathy
Renal amyloidosis
Chronic Hypertension
Chronic Hypertension
These are the groups with high AKI burden: Come up with some reasons for this
- comorbidities, nephrotoxic drugs
- delay of care, lower level of care, climate extremes
- a combination of comorbidities, health impact of overcrowding
- comorbidities, remoteness, socially disadvantages
- physical or outdoor jobs, less likely to seek medical care.
A 9-year-old Aboriginal boy is brought to a remote clinic. He has been unwell for 3 days with lethargy and nausea. His mother has noticed his eyes have
been very puffy, especially in the morning. On questioning, he says he has needed to pass urine
only once a day and it looks like Coca-Cola. He has had no recent throat or respiratory tract infections.
BP is elevated for his age. His hands are as shown.
Q 8 . The most likely diagnosis is:
a) IgA nephropathy
b) Lupus nephritis
c) Post-streptococcal glomerulonephritis
d) Henoch-Schönlein purpura
e) Goodpasture syndrome.
Post-streptococcal glomerulonephritis
A 9-year-old Aboriginal boy is brought to a remote clinic. He has
been unwell for 3 days with lethargy and nausea. His mother has
noticed his eyes have been very puffy, especially in the morning. On
questioning, he says he has needed to pass urine only once a day
and it looks like Coca-Cola. He has had no recent throat or respiratory tract infections. BP is elevated for his age. His hands are as shown.
Q9.Haematuria on dipstick (> 10/µL)
A swab confirms group A strep infection from the hands/ scabies
What additional result is needed to confirm the diagnosis?
a) Elevated PCR
b) Hyperlipidaemia
c) Low albumin
d) Low haemoglobin
e) Reduced C3 complement level
Reduced C3 complement level
Patient shows rapid decline in
renal function and the renal
biopsy was performed which
shows compressed glomeruli
(C) with crescent formation (B),
RBC casts (A) and inflammatory
cells (D). The histology is shown:
Q10. What is the most likely
diagnosis now:
a) CRF
b) Membranoproliferative GN
c) Minimal Change Disease
d) Rapidly progressive GN
Rapidly progressive GN
A 57 year old woman presents with a one day history of passing several red brown fleshy material in her urine, accompanied by pain and a one week history of dysuria, on a background of long standing poorly controlled type 2 diabetes.
The image below shows the appearance of a kidney from a patient with a similar condition.
What pathologic feature is seen in the image? What is the pathogenesis? Differential diagnosis? what complication?
Renal calculi
Papillary necrosis
Multiple cysts
Hydronephrosis
Renal Cell Carcinoma
Papillary necrosis
22 year old female with fever and dysuria. Urine dipstick test done. Image shows the results. What is the most likely organism causing her UTI?
Interpret results? explain your answer?
Gonococcus
Staphylococcus
Streptococcus
Proteus
E.coli
E.coli
Image shows different types of renal cysts. Which is the commonest type of renal cysts clinically?
Renal Cysts.png
Which is the commonest congenital cystic disorder?
ADPKD
ARPKD
Hydronephrosis
Cystic Renal Dysplasia
Simple Cysts
Simple Cyst
A 3 year old child has become more irritable over the past two months and does not want to eat much at mealtime. On physical examination the paediatrician notes an enlarged abdomen and can palpate a mass in the right iliac fossa. Following abdominal CT scan, child undergoes nephrectomy. Image shows gross and microscopy. Which of the following neoplasms is this child most likely to have had?
List 3 gross and 3 microscopic features? Prognosis?
Infantile polycystic kidney
Renal cell carcinoma
Nephrogenic adenoma
Transitional cell carcinoma
Nephroblastoma
Nephroblastoma
A 43 year old man presented with chronic hypertension not responding to therapy with renal failure requiring hemodialysis. On examination he has a bulky abdomen. Image shows his imaging study & nephrectomy specimens. What is the most likely diagnosis?
What genetic abnormality is most common? What is the pathogenesis? What familial disorders may be associated?
Polycystic Kidney disease (ADPKD)
Polycystic Kidney disease (ARPKD)
Renal Cell Carcinoma
Von Hippel Lindau disease
Nephroblastoma
Polycystic Kidney disease (ADPKD)
A 68 year old male presented with haematuria. Ultrasound showed an irregular solid tumor in the pelvis of right kidney. Below is the image from gross specimen and microscopy. What is the most likely diagnosis?
List 3 gross features? list 3 microscopic features? Common mutation? risk factors?
Nephroblastoma
Transitional Cell Carcinoma
Clear cell renal carcinoma
Von-Hippel Lindau disease (VHL)
Chronic Pyelonephritis
Clear cell renal carcinoma
An 89 year old male presents with lower abdominal pain and haematuria. The below image is from his urinary bladder. What is the most likely diagnosis?
Adenocarcinoma
Nephroblastoma
Papillary RCC
Clear cell RCC
Transitional Cell Ca
Transitional Cell Ca
A 4 year old girl presented with fatigue and balatable mass in the abdomen. The below image shows the microscopy from her nephrectomy specimen. What microscopic feature is seen in the image?
Wilms-Micro.jpg
Small blue cells forming tubules & glomeruli like structures.
Pleomorphic cells forming irregular papillary structures
Clear cells forming sheets & tubules with plenty lymphocytes.
plenty lymphocytes around irregular tubules.
Pleomorphic cells forming irregular glands with hemorrhage & necrosis
An 83 year old man presents with chronic urinary hesitancy, poor flow, dribbling and nocturia. The below image shows appearance of his urinary bladder. What feature is shown by Arrow D?
Arrows A, B & C? explain pathogenesis? list chronic complications?
Trabeculations
enlarged lateral lobe
enlarged median lobe
Urolithiasis-stone
Thickened fibrotic wall
A: thickened bladder wall, B: enlarged median lobe of prostate (ball valve mechanism obstructing uretha inlet) C: urinary stone (tripple phosphate), D: mucosal trabeculations (muscle hypertrophy). complications are chronic / recurrent UTI, hydronephrosis, renal calculi (triple phosphate).
A 40y woman at ED with severe colicky abdominal pain & right flank pain radiating to her groin. History reveals recurrent UTI and worsening bloody urine since 15 days. Image shows her abdominal X-Ray and specimen removed at surgery. What is the most likely type of stone?
Etiology & Pathogenesis? type of lesion? Management?
calcium oxalate & calcium phosphate.
uric acid
cystine
calcium oxalate
magnesium ammonium phosphate.
magnesium ammonium phosphate.
A 62-year-old man with painless hematuria. He is a chronic smoker. Urine microscopy shows plenty of pleomorphic urothelial cells in clusters. Image shows gross & microscopy of the lesion. What is the most likely diagnosis?
Risk factors? List other causes of painless hematuria?
Nephroblastoma
VHL Syndrome (Von Hippel Lindau)
Prostatic carcinoma
Transistional cell carcinoma
Renal Clear Cell Carcinoma
Transistional cell carcinoma
A previously well 56 year old man presents with a 3 week history of passing reddish urine. Urinalysis is positive for red blood cells; no casts were seen. Renal function tests are within normal limits. He undergoes nephrectomy following CT scan. The image below shows his kidney section. What is the most likely cause of this patients hematuria?
Identify two features shown (Arrow A & B).
Buerger’s disease
Transitional Cell Carcinoma
Nephroblastoma
Renal papillary adenoma
Renal cell carcinoma
Renal cell carcinoma
Mr. AG, a 63 year old man with a 9 month history of fatigue and loss of appetite on a background of longstanding type 2 diabetes and hypertension. He has had a steady rise in creatinine & proteinuria over the past two years. Image shows the microscopic appearance of his kidney specimen. What pathologic feature is shown?
List features seen? What is the pathogenesis?
Proliferative glomerulonephritis (post strep)
Crescentic glomerulonephritis (RPGN)
Nodular glomerulosclerosis (KW lesion)
Hyperplastic arteriolosclerosis (HPTN)
Diffuse glomerulosclerosis (CRF)
Nodular glomerulosclerosis (KW lesion)
22 year old female presents with mild irritation and high coloured urine since a week following desert picnic. Routine urine dipstick results are shown in the image. What is your diagnosis?
Why high coloured urine? why irritation?
UTI
CRF
Diabetes
ARF
Dehydration
Dehydration
A 4-year-old active healthy boy has been lethargic for the past 2 weeks. On physical examination he is afebrile, but there is puffiness around his eyes. Mother say’s his urine is white and frothy since then. No history of fever or infections in the recent past. Child had his routine vaccination 2 weeks earlier. Image shows his urine dipstick results. What is the most likely diagnosis?
What is the pathogenesis? Explain briefly principle & interpretation of each test?
Alport Syndrome
Acute tubular necrosis
Minimal Change disease
Acute nephritis
Thin membrane nephropathy
Thin membrane nephropathy
CASE: A 58 yo male presents for an insurance check up.
Normally in good health.
You are a medical student at the practice observing the
examination. The patient has been asked to give a specimen of
urine on which you perform urinalysis.
MATCH
NEW CASE: 65 yo male presents with vague discomfort in right loin region
for the last 2 months but is presenting today because there was bright redblood in his urine. On examination, he has a palpable mass on ballottement of the right kidney.
CT shows a large, well demarcated
right renal mass in the upper pole.
He undergoes a nephrectomy.
Based on the following gross and microscopic histology,
which malignancy is the patient most likely to have?
1. Adenoma
2. Angiomyolipoma
3. Clear cell renal cell Ca
4. Urothelial carcinoma
5. Wilms Tumour
Clear cell renal cell Ca
Q9 From this
urinalysis, what is the
most likely risk factor
leading to her urinary
tract infection?
1. Glomerulonephritis
2. Urolithiasis
3. Diabetes mellitus
4. Dehydration
5. High protein diet
Diabetes mellitus
Q10. A patient presents with increased urinary frequency, dysuria
and mild suprapubic pain.
Which of the following urine MCS results would most likely
indicate cystitis?
- haematuria
- contamination
- mixed picture (contamination)
- ANSWER
NEW CASE: 65yo female presents with 12 hours of R backpain,
coming around to front and groin. Increasing in severity, now
unbearable and associated with bright red urine
Table talk:
Of the following features in the history of the patient, which
would be rule in and which would be rule out for urolithiasis?
Back pain Dysuria Dehydration
Polyuria FHx urolithiasis PHx UTIs
Visible haematuria Leukaemia Grapefruit
Loin mass Gout Hyperthyroidism
Fever Frequency Alcohol
Rule in
- back pain
- haematuria
- fever
- Fh urolithiasis
- gout
- dehydration
- alcohol
- Grapefruit
- hyperparathyroidism
Rule out
- polyuria
- loin mass
- fever
-dysuria
- frequency
unlikely
-dysuria
- leukemia
- Hx UTI
NEW CASE: Your next patient is a 56 yo male who presented with
painless visible haematuria. His cytology report shows:
“Cells with high nuclear to cytoplasmic ratio, nuclear hyperchromasia,
marked nuclear irregularity pleomorphism and coarse chromatin, and background of non dysmorphic red blood cells”
Q3. What is the most likely diagnosis:
1. Glomerulonephritis
2. Malignancy
3. Polycystic kidney disease
4. Pyelonephritis
5. Urolithiasis
The patient undergoes a cystoscopy – during which a biopsy was
taken from the bladder wall.
The biopsy result confirms ‘a tumour with papillary configuration,
nuclear irregularity, overlapping cells and numerous mitoses.’ The
image is shown:
Q4. What is the most likely diagnosis?
1. Adenocarcinoma
2. Granulomatous inflammation
3. Squamous cell carcinoma
4. Urothelial carcinoma
Further examination of the biopsy slides revealed a focus of invasion of muscularis propria which prompted further treatment by cystectomy. The gross image of the bladder mass is shown.
Q5. Which of the following is risk factor for Urothelial carcinoma?
1. Alcohol consumption
2. Asbestos
3. Red meat
4. Smoking
5. Schistosomiasis
