Practice QNS Cardio Flashcards by Kalaryn Fisher

Prinzmetal variant angina is caused by

Plaque disruption stable plaque unstable plaque coronary spasm coronary vasculitis

Coronary spasm

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Chemical mediator of pain in Angina Pectoris is

LDH
Myosin
Troponin
Bradykinin Interleukins

Bradykinin

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Stable plaque typically results in this clinical presentation.

Acute Coronary Syndrome
Thmboembolism
Ischemic Heart Disease
Myocardial Infarction
Variant angina

Ischemic Heart Disease

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Initial step in the pathogenesis of Atherosclerosis is,

Cholesterol deposition

Macrophage activation

Foam cell deposition

Endothelial injury

Soft Plaque formation

Endothelial injury

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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

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Breakdown of atheromatous plaque is caused by Macrophage production of

Reactive Oxygen species (ROS)

Inteleukin 1 & 6

PDGF

IFN gamma

Proteases

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Changes in the myocardium 2 hours following infarction is,
Loss of nucleus
Loss of glycogen Neutrophil infiltration Vasodilatation Oedema

Loss of glycogen

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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

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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.

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Ventrucular rupture – wall and at the attachment of the papillary rupture- acute MI resulted in mitral regurgitation

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Left ventricular aneurism with the thrombus sitting in the aneurism.

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R: shows blood filling in pericardial sac- hemopericardium cardiac tamponade

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Horizontal- dilated left ventricle, septum shows extensive white scaring and in right ventricle – OLD MI heart failure patient.

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Mural thrombosis is a complication of both Recent and old MI. True or False

TRUE

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Mitral stenosis is a complication of MI involving papillary muscle True or False

FALSE

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Commonest complication of MI in the first few hours is, Cardiac rupture Mitral regurgitation Respiratory failure Cardiogenic shock Mural thrombosis

Cardiogenic shock

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Case: 72 YO man sudden severe chest pain, collapses while watching TV
GROSS, MIcroscopy, etiopathogenesis, complications

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CASE: 78 yo male, hypertensive, DM. obese. died in care crash / stroke/ HO stable angina
GROSS, MIcroscopy, etiopathogenesis, complications?

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CASE: 78 yo male, hypertensive, DM. obese. died in care crash/stroke/ HO stable angina
GROSS, MIcroscopy, etiopathogenesis, complications?

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68YO DM Obese hypertensive. died following abrupt-onset, tearing chest pain that radiates to the back

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CASE: 68 yo man Obese, hypertension, sudden severe chest pain - penetrating to back

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CASE: 72 year old sudden collapses following left-sided hemiplegia (stroke) during morning walk. no pain, ACUTE MI, bowel infarction

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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

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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

01. 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 04. 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

05. 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

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

11. 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

12. 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

15. 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

20. 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

24. 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

01. 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

05. 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

06. 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

07. 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

12. 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.

17. 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

18. 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

22. 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

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

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? 1. Aortic stenosis 2. Pulmonic stenosis 3. Truncus arteriosus 4. Tetralogy of Fallot 5. 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? 1. Chronic myocarditis 2. Rheumatic vegetations 3. Anitschow cells 4. Rheumatic Nodule 5. 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, RL 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

5. What information on history/examination would make you suspect a diagnosis of an arterial over a venous ulcer? 1. Painless ulcer 2. Painful punched out ulcer 3. Irregular ulcer with granulation tissue 4. Ulcer on the soles of the feet 5. 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

2. 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 13. What is the most appropriate investigation to confirm your most likely diagnosis? 1. CXR 2. CTPA 3. D-dimer 4. ECG 5. 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

19. Which vasculitis affects the aorta predominantly? 1. Kawasaki disease 2. Takayasu arteritis 3. Polyangitis with granulomatosis 4. Polyarteritis nodosa 5. 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

1. 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

Pathogenesis of cavity formation in tuberculosis is due to drainage of caseous material through bronchus. True False

Lupus vulgaris is a type of miliary spread of tuberculosis. True False

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

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? 1. Lung Abscess 2. Adenocarcinoma 3. Small cell carcinoma 4. Interstitial pneumonia 5. 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? 1. Haemophilus influenza 2. Meningococci 3. Streptococcus pneumoniae 4. Staphylococcus aureus 5. 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? 1. Bronchopulmonary sequestration 2. Chronic bronchitis 3. Squamous cell carcinoma 4. Bronchiectasis 5. 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? 1. Blood culture 2. Cold agglutinin levels 3. Throat swab culture 4. Sputum microscopy 5. 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? 1. Cigarette smoking 2. Irregular emphysema 3. α1-Antitrypsin deficiency 4. Cystic fibrosis 5. Exposure to Aniline dye.

3. 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? 1. Bronchiectasis 2. Lung Abscess 3. Broncho Pneumonia 4. Aspiration Pneumonia 5. 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? 1. Adenocarcinoma 2. Broncheictasis 3. Lymphangiectasis 4. Pleural plaques 5. 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? 1. Pneumocystis carinii 2. Candida albicans 3. Toxoplasma gondii 4. Mycobacterium tuberculosis 5. 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

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

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

Pulmonary inflammation involving M1 Classic Pathway typically results in, Idiopathic Pulmonary Fibrosis (IPF) Pneumoconiosis COPD Only Silicosis Only Asbestosis

COPD

Important chemical mediators of Pneumoconiosis and Idiopathic Pulmonary fibrosis are, IL-1 IL-6 TGF-β IFN-γ Reactive Oxygen Sp.

TGF-β

plenty of large Interstitial round fibrotic nodules with carbon pigmentation around is typically seen in this condition. Coal Workers Pneumoconiosis (CWP) Asbestosis Chronic Smokers. Silicosis Tuberculosis in smokers.

Silicosis

1) Severe form of Diffuse Alveloar Damage is known as ARDS True False

Hyaline Membrane Disease of new born is commonly due to material sedation. True False

Important cells which initiate inflammation in Sarcoidosis are CD8 T lymphocytes Macrophages Fibroblasts CD4 T lymphocytes. B Lymphocytes

CD4 T lymphocytes.

One of the laboratory feature of sarcoidosis is, Eosinophilia Lymphocytosis Pancytopenia Lymphopenia CD4 Lymphocytosis

Lymphopenia

Diagnostic feature of Sarcoidosis is, Non Caseating granulomas Asteroid bodies Schauman bodies. Hilar Lymphadenopathy Non of the above.

Non of the above.

In chronic allergic reaction, allergens stimulate, Th1 cells Th2 cells Mast cells Eosinophils Dendritic cells

Dendritic cells

In atopic asthma, pathogenesis is mediated through T Helper cell type 2 (Th2) pathway. True False

Charcot Leyden crystals are products of, Th1 lymphocytes Th2 lymphocytes Mast cells Eosinophils Mucous solidification

Eosinophils

Progressive Massive Fibrosiss (PMF) is typically seen in Anthracosis Coal miners lung Silicosis Asbestosis seen in all types.

Coal miners lung

Lung Fibrosis in coal miners lung is because of carbon pigment deposition (anthracosis) True False

Fibrotic nodules are typically seen in Anthracosis Coal miners lung Silicosis asbestosis in all types.

Silicosis

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

60 Year old man who was on chemotherapy presents with worsening cough and shortness of breath for the past 1 year. 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. Which of the following is most likely causative agent? 1. Pirfenidone 2. Spironolactone 3. Nintedanib 4. Bleomycin 5. metaprolol

Bleomycin

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? 1. Caseating granulomas 2. Dense granular eosinophilic material 3. Enlarged epithelial cells with intranuclear inclusions 4. Non caseating granulomas 5. 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 9 year-old boy has had recurrent attacks of pneumonia since infancy. He now has a chronic productive cough. birth history is was normal full term delivery but complicated by meconium ileus. His sweat chloride was reported high. Based upon these findings, he is at greatest risk for deveopment of which of the following pulmonary abnormalities? 1. Emphysema 2. Broncheictasis 3. Lymphangiectasis 4. Pleural plaques 5. Acute respiratory distress syndrome(ARDS)

Broncheictasis

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 63 year old man worked for 20 years in a family owned sandblasting business. For the last 7 years, he has had increasing dyspnoea without fever, cough, or chest pain. Which of the following inflammatory cell types is most crucial to the development of his underlying disease? 1. Plasma cell 2. Mast cell 3. Eosinophil 4. Macrophage 5. Natural killer cell

Macrophage

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

28-year-old man presents with fever, hemoptysis and hematuria. Microscopic examination of lung shows focal necrosis of alveolar walls associated with intra-alveolar hemorrhage. On P/E man appeared to be cyanosed and inspiratory crackles are heard over the lung bases. Which of the following is most likely diagnosis? 1. Sarcoidosis 2. Wegner Granulomatosis 3. Good Pasture syndrome 4. Caplan Syndrome 5. Asbestosis

Good Pasture syndrome

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 will also be seen in the sputum microscopy? 1. Crushmann spirals 2. Red blood cells 3. HIgh reid index 4. Asteriod bodies 5. Ferriguinous bodies

Crushmann spirals

A 12 year-old girl with recurrent acute onset dyspnea and wheezing has had similar episodes for the past 7 years. These episodes last 1 to 6 hours. CXR shows hyperinflation but there are no infiltrates. Full Blood count shows eosinophilia (11%) and her sputum contains eosinophils. Which of the following conditions is the most likely diagnosis? 1. Mycoplasma pneumonia infection 2. Cystic fibrosis 3. Hypersensitivity pneumonitis 4. Bronchial asthma 5. Aspiration of gastric contents

Bronchial asthma

A 38 year-old woman has had cough, dyspnoea with fever for 4 days. Her CXR shows no consolidation but mild interstitial markings. 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 organism which is most likely to have caused her illness? 1. Nocardia asteroides 2. Mycoplasma pneumoniae 3. Mycobacterium kansasii 4. Respiratory syncytial virus 5. Chlamydia psittaci

Mycoplasma pneumoniae

A 12 year-old boy has poorly controlled asthma. His mother brings him for his regular check up. Of the following signs which is most specific to indicate his asthma is severe? 1. Reduced or absent breath sounds 2. An audible wheeze 3. Prolonged expiration 4. Hypo inflated chest 5. Tachycardia

Reduced or absent breath sounds

A 55 year-old man worked in the mines for 30 years and is a chronic smoker. He has been diagnosed with emphysema. Of the following, which would most likely be present on clinical examination? 1. Signs of right heart failure 2. Wheeze 3. Increased tactile fremitus 4. Hyper resonance 5. Expiratory crackles

Hyper resonance

A male infant born at 26 weeks gestation has Apgar scores of 4 and 6 at 5 and 10 minutes respectively. He develops severe respiratory distress over the next hour and is managed in the neonatal intensive care unit. A CT scan shows diffuse ground glass changes in both lungs. The most likely cause for the patient’s lung disease is: 1. Oxygen toxicity 2. Glutathione deficiency 3. Surfactant deficiency 4. α-1-antitrypsin deficiency 5. Tracheoesophageal fistula

Surfactant deficiency

An 7 year old girl has history of episodic wheezing, cough and dyspnea. Pulmonary function test shows decreased FEV1/FVC ratio. Which of the following is most likely to be seen in this girl’s lung? 1. Airway dilation and scarring 2. alveolar wall destruction 3. Smooth muscle hypertrophy 4. Diffuse alveolar damage 5. Diffuse alveolar hemmorhage

Smooth muscle hypertrophy

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? 1. IgE binding to mast cells 2. Reduced anti-elastase activity 3. CFTR gene mutation 4. Increased neutrophil proteases 5. 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

Mr J, a 26 year old male presenting with a 2 week history of cough. Mr J reports that his symptoms originally started with a sore throat, runny nose and fever. These symptoms improved however he then developed a dry cough which has persisted. His cough is worsening in frequency and severity and he is now getting short of breath with minimal exertion. Q01: What differentials would you consider in this patient? 1. COVID-19 2. Influenza 3. Asthma 4. Bronchitis 5. Pneumonia 6. All of the above 7. None of the above

All of the above

Mr J, a 26 year old male presenting with a 2 week history of cough. Mr J reports that his symptoms originally started with a sore throat, runny nose and fever. These symptoms improved however he then developed a dry cough which has persisted. His cough is worsening in frequency and severity and he is now getting short of breath with minimal exertion. Further history reveals Mr J has recurring episodic breathlessness and wheeze, and his symptoms are exacerbated by his housemate smoking cigarettes. He has a family history of atopy. Q02: What is your provisional diagnosis now? 1. COVID-19 2. Influenza 3. Asthma 4. Bronchitis 5. Pneumonia

Asthma

Q03: Which of the following clinical signs would help to confirm your provisional diagnosis of asthma? 1. Inspiratory wheeze 2. Expiratory wheeze 3. Decreased tactile fremitus 4. Inspiratory crepitations 5. Dullness on percussion

Expiratory wheeze

Which indicates asthma

A- obstructive, looking at FEV1/FVC ratio will be decreased, 07 or 70 will have a change greater than 10% (12%)

Q05: Which is the most appropriate first-line management measure for Mr J who has asthma? 1. Start oral antibiotics 2. Start oral prednisolone 3. Start inhaled salbutamol 4. Prepare an asthma action plan

Start inhaled salbutamol

You develop a written action plan with Mr J. Q06: At any given time how should he determine which “traffic light” category is most applicable to him? 1. By undertaking spirometry 2. By assessing his peak flow 3. Based on his symptoms 4. By attending his GP 5. By presenting to the Emergency Department

Based on his symptoms

Q07: Which of the following is the most helpful as a red flag in a severe asthma attack? 1. Escalating medication use 2. Pulsus paradoxus 3. Presence of wheeze 4. Absence of wheeze 5. Accessory muscle use

Accessory muscle use

Q08: Avoidance of asthma triggers would be an example of which level of prevention? 1. Primordial 2. Primary 3. Secondary 4. Tertiary 5. Quaternary

Secondary

Q09: What is the first line treatment if you suspect anaphylaxis? 1. High flow oxygen 2. 1:10 000 IV adrenaline 10mcg/kg (maximum 1mg/dose) 3. 1:1000 IM adrenaline 0.01 mg/kg (maximum 0.5 mg/dose) 4. Nebulised salbutamol 5. Antihistamine

1:10 000 IV adrenaline 10mcg/kg (maximum 1mg/dose)

Q10: In patients with anaphylactic reactions which of the following is true? 1. Previous exposure to the trigger is necessary 2. Pulmonary oedema is a common clinical finding 3. Bronchospasm is the most dangerous feature 4. An aura may precede the acute reaction

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?

Mr R is a 55 y/o bricklayer who presents to the GP for review of worsening chronic (5 year) cough and progressive shortness of breath. Q11: The most common occupational pneumoconiosis in Australia is: 1. Coal workers pneumoconiosis 2. Asbestosis 3. Silicosis 4. Anthracosis 5. Progressive Massive Fibrosis

What examination findings and investigation findings would support a diagnosis of silicosis?

Q12: Where is silica NOT found? 1. Stone 2. Soil 3. Coal 4. Sand 5. Concrete 6. Brick 7. Mortar

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

From the biopsy taken at bronchoscopy, histopathology confirms the most likely diagnosis. TB Q16: What is most likely to be seen on histopathology? 1. Fibrotic nodules 2. Caseating granulomas 3. Non caseating granulomas 4. Necrotising granulomas 5. Diffuse interstitial inflammation

Mr L, a 55 year old male presents to his GP with a 2 week history of productive cough, chest tightness, runny nose and headache. He reports some relief with simple analgesia and rest. His medical history includes depression and GORD. He takes no regular medications and is a non-smoker. Examination findings * No obvious respiratory distress, moist sounding cough during consultation. No use of accessory respiratory muscles. * HR 88bpm regular, BP 144/88mmHg, RR 22, afebrile * O2 sats 98% on RA, BMI 30 * Equal chest expansion, good air entry to bases bilaterally. Normal tactile fremitus and vocal resonance. Resonant percussion throughout lung fields. Bilateral low pitched wheeze that clears on coughing. HS dual, nil added sounds. JVP not elevated. * Red pharynx, mildly tender frontal and maxillary sinuses on palpation. No cervical lymphadenopathy. * Peripheries warm and well perfused. No clubbing or pallor present. Q17: What is the most likely diagnosis based on history and examination findings? 1. Pneumonia 2. Rhinosinusitis 3. Post nasal drip 4. Acute bronchitis 5. Asthma 6. Bronchiectasis

A 54-Year-old woman is transferred to ICU with rapid onset Type 1 (hypoxaemic) Respiratory failure requiring intubation and ventilation 1 day post ERCP for gallstone pancreatitis. CXR Shows bilateral opacification resembling pulmonary oedema. ECG, troponin and echocardiogram are normal. Lipase is extremely elevated. LFTs show a cholestatic pattern. Renal function is normal.' Q18: The most likely diagnosis for this woman’s respiratory failure is: 1. Goodpasture syndrome 2. Hospital acquired pneumonia 3. Left ventricular failure 4. Acute respiratory distress syndrome 5. Aspiration pneumonia

Characteristic mutations seen in bronchial epithelium of smokers is P53 EGFR P450 KRAS P3 del

P3 del

Characteristic mutations seen in non smoker women with lung cancer is, P53 EGFR P450 KRAS P3 del

EGFR

Diffuse infiltrating hilar tumor is typically a "Squamous Cell Carcinoma" True False

False

Likely precursor cells of Lung Adenocarcinoma are Bronchial epithelium ciliated columnar cells Alveolar cells Dyspastic cells Neuroendocrine cells

Alveolar cells

Microscopic feature of Small Cell Cancer is Pleomorphic cells forming Keratin pearls Mucous glands Necrosis & Cavity Epithelial structures Non of the above

Non of the above

Small Lung cancer nodule at the hilum involving mediastium would be this stage... T1 T2 T3 T4 T0

A 55 year old woman from India presents with lung cancer. Most likely genetic mutation responsible for her cancer is, P53 KRAS EGFR P3 del P450

EGFR

This tumor is next most common lung tumor after Bronchogenic Carcinoma. Lung Hamartoma Typical Carcinoid Mesothelioma Atypical Carcinoid Bronchioalveolar Carcinoma

Typical Carcinoid

Embryonic disorgenization presenting as tumour where in Normal tissue is seen in abnormal location is known as... Typical Carcinoid Hamartoma Choristoma Atypical Carcinoid Benign neoplasm

Choristoma

Common cause of pleural effusion is, Tuberculosis Cardiac Failure. Mesothelioma Bronchogenic carcinoma Metastasis

Tuberculosis

Rounded grey white well demarcated tumour in the hilum is most likely, Bronchogenic carcinoma Squamous cell carcinoma Adenocarcinoma Small cell carcinoma Any type of lung cancer.

Squamous cell carcinoma

Multiple large rounded tumours scattered all over lungs is most likely Small Cell Carcinoma Squmaous cell carcinoma Metastases Adenocarcinoma

Metastases

Small cell Lung cancer typically has this morphology Hilar rounded well demarcated tumor Peripheral rounded well demarcated. Peripheral diffuse irregular tumour Hilar irregular diffuse tumour.

Hilar irregular diffuse tumour.

Rb gene mutations are more commonly seen in Squamous carcinoma Adenocarcinoma Small cell carcinoma Metastases large cell carcinoma

Small cell carcinoma

Lung cancer with common paraneoplastic syndrome due to hormone production will typically have this microscopic appearance. Pleomorphic cells with keratin pearls. Scattered small dark oat grain like cells. Pleomorphic cells forming irregular glands. Pleomorphic cells forming bronchial structures. Pleomorphic cells forming irregular bronchi

Scattered small dark oat grain like cells.

Microscopic feature typically seen in lung cancer common in non smokers or females is, Keratin pearls Pleomorphic cells Small dark cells. irregular glands Externsive necrosis

irregular glands

Histologic type of cancer seen in chronic smokers Squamous carcinoma Adenocarcinoma Small cell carcinoma Large cell carcinoma Any of the above

Any of the above

Commonest histologic subtype of lung cancer is Small Cell Cancers Squamous cell cancer Adenocarcinoma Large cell carcinoma Non Small Cell Cancers

Non Small Cell Cancers

Pancoast tumor is an exaple of paraneoplastic syndrome. True False

Pancoast tumor is commonly this pathologic type. Squamous cell carcinoma Adenocarcinoma Small cell Lung cancer (SCLC) Non-Small cell lung cancer (NSCLC) Not a type of lung cancer.

Squamous cell carcinoma

Hoarseness of voice is because of paralysis of right recurrent laryngeal nerve by lung cancer. True False

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. 1. What is the most likely cause of his haemoptysis? a. Bronchitis b. Lung cancer c. Pneumonia d. Pulmonary embolism e. Tuberculosis

a. Bronchitis Cannot be pneumonia as he is recovering.

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. 2. Which of the following signs on examination which increase your concern the patient had lung cancer? a. Absent breath sounds b. Cachexia c. Flapping tremor d. Splenomegaly e. Unilateral crackles

Cachexia Crackles is not a worrying sign

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. 3. An initial CXR and subsequent CT chest reveals a 2cm nodule in the right upper lobe in the posterior segment. What is the most likely diagnosis? a. Hamartoma b. Small cell lung cancer c. Squamous lung cancer d. Adenocarcinoma e. Carcinoma in situ

Adenocarcinoma Squamous and small are more likely to be central and Hilary

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 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. 5. Which of the following is likely to have occurred in the development of his cancer? He has an adenocarcinoma. a. Chromosomal breakages in peripheral blood lymphocytes b. Cytochrome p450 polymorphisms c. EGFR mutation d. Loss of 3p e. Protease-anti-protease imbalance

EGFR mutation a and b increase risk of cancer with smoking d is seen in SCCs and small cell carcinomas e is seen in COPD and inheriditary diseases

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. 6. Which of the following is needed to determine the TNM stage for this patient? a. Degree of differentiation of cells b. Histological diagnosis c. Location of affected lymph nodes d. Location of metastases e. Size of the lymph nodes

Location of affected lymph nodes

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 cough 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. 07. A lymph node examination is performed. Enlargement of which lymph node/s would make malignant lung cancer more likely than a respiratory tract infection? a. Deep cervical b. Submandibular c. Superficial cervical d. Supraclavicular e. Tonsillar

Supraclavicular

8. The patient has palpable supraclavicular and axillary lymphadenopathy. What are the 5 most likely sites of metastasis in this patient?

Liver, Bone, Brain, Adrenal glands, Kidneys.

09. A 36-year-old man is noted to have an abnormality on his chest X-ray detected during a routine workplace medical. He states he is usually well with no previous respiratory symptoms. He is a “social smoker” of <10 cigarettes/week. Which of the following CXR findings would make a lung hamartoma the most likely cause of the CXR abnormality? a. Lobar consolidation b. Location in apex c. Lung collapse d. Multiple nodules e. Single small spherical lesion

Single small spherical lesion Lobar consolidation pneumonia the lesion in apex-apical lung tumor or TB

10. A 53yo male presents with a 3-month history of progressive SOB, weight loss, haemoptysis and a hoarse voice. After a large lesion is seen on CT scan, a lobectomy is performed and histology of the specimen shows the presence of pleomorphic bright pink / eosinophillic cells with intercellular bridges, keratin pearls and foci of necrosis. 11. What is the most likely diagnosis? a. Adenocarcinoma b. Large cell carcinoma c. Lung metastasis d. Small cell lung cancer e. Squamous cell carcinoma

Squamous cell carcinoma

A 53yo male presents with a 3-month history of progressive SOB, weight loss, haemoptysis and a hoarse voice. After a large lesion is seen on CT scan, a lobectomy is performed and histology of the specimen shows the presence of pleomorphic bright pink / eosinophillic cells with intercellular bridges, keratin pearls and foci of necrosis. 11. What nerve/s is involved in the development of his hoarseness? a. Glossopharyngeal b. Recurrent laryngeal c. Phrenic d. Superior laryngeal e. Sympathetic chain

Recurrent laryngeal

12. 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 69-year-old female presents with 6 months of increasing SOB, productive cough and weight loss. She has squamous cell carcinoma 14. What paraneoplastic syndrome is the patient most likely to have? a. Cushing’s syndrome b. Hypercalcaemia c. Migratory thrombophlebitis d. Polycythaemia e. SIADH

Hypercalcaemia- PTH - in squamous cell SCLC- ACTH cushings c. is in adenocarcinoma d. renal and liver cancers e. SIADH- seen in small cell LC

15. 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 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. 16. What is being released by the tumour to cause the intermittent diarrhoea and flushing of the skin? He has carcinoid tumor a. ACTH b. ADH c. Interleukins d. Parathyroid hormone-like peptide e. Serotonin (5-HT)

e. Serotonin (5-HT)

17. 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 is shown below. What is the most likely diagnosis? a. Adenocarcinoma b. Large cell carcinoma c. Lung metastases d. Small cell lung cancer e. Squamous cell carcinoma

Small cell lung cancer- have cushings syndrome, centrally located lesion

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. 18. What mutation/deletion is the patient most likely to have? He has small cell lung cancer a. EGFR b. KRAS c. p16 d. TP53

TP53

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

20. 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

21. 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

22. 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

A 50 year-old female, non-smoker is found to have a peripheral opacity on a CXR. Which of the following is most likely type of carcinoma? Squamous cell carcinoma Oat cell carcinoma Mesothelioma Carcinoid tumour Adenocarcinoma

Adenocarcinoma

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 67 year-old chronic smoker 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 2 kg weight loss over the previous 2 months. Image shows Gross, Microscopy & special stain. What is the most likely diagnosis? Describe features seen? common genetic mutations? special clinical features? Bronchial carcinoid Hamartoma Bronchoalveolar carcinoma Large cell carcinoma Adenocarcinoma

Adenocarcinoma

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

A 30 week pregnant lady with gestational diabetes goes into complicated labor, obstetrician decides to do caesarean section and prepares to administer surfactant after delivery. Which of the following is the doctor trying to prevent? Pulmonary edema Hypersensitivity pneumonitis Meconium aspiration Respiratory distress syndrome Panacinar Emphysema

Panacinar Emphysema

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 87 year old man presents with recurrent left pleural effusion. A CT scan shows multiple plaques on the parietal pleura of both lungs. A pleural biopsy shows malignant cells growing in a dense fibrous tissue background. The most likely diagnosis is: Fibrosarcoma Adenocarcinoma Tuberculosis Mesothelioma Squamous cell carcinoma

Mesothelioma

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

A 58 year old man with chronic history of smoking presents with weight gain, buffalo hump, truncal obesity and pruple striae on abdomen. His blood pressure is 150/95. Which of the following types of lung cancer does this patient most likely to have? Squamous cell Ca Small cell Ca Large cell Ca Carciniod tumor Adenocarcinoma

Adenocarcinoma

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

62y female non smoker presents with gradual weight loss and cough. Chest X-Ray shows 3cm nodular lesion in the subpleural region of right middle lobe. Which of the following is the most likely type of lung cancer in this patient? common genetic alternation in these patients? what is the new targeted therapy drug for this patient? Mixed carcinoma Anaplastic carcinoma Adenocarcinoma Squamous cell carcinoma Oat cell carcinoma

Adenocarcinoma

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

34-year old woman presents with headache, blurry vision, cough and dyspnea since 3 weeks. Physical examination shows tender, erythematous rash on both legs. Chest radiograph shows bilateral hilar lymphadenopathy. Pulmonary function test shows slight increase in FEV1/FVC ratio and lab tests show elevated serum calcium and angiotensin converting enzyme levels. Which of the following is the most likely diagnosis? Sarcoidosis Asbestosis Squamous cell Ca Adenocarcinoma Small cell Ca

Sarcoidosis

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 25-year old man presents to ED with sudden onset of chest pain and dyspnea. On P/E he is tall thin man with moderate respiratory distress. CVS is normal but respiratory examination shows decreased breath sounds, fremitus and hyper-resonance to percussion on the right side. What is most likely diagnosis Lobar Pneumonia Pneumothorax Panacinar emphysema Pulmonary edema Bronchial Asthma

Pneumothorax

Liver is the largest internal organ. True False

False

On imaging Fatty liver is hypodense than spleen (more darker). True False

Same opacification

In alcoholic liver damage, Zone 1 is affected first. True False

False

Dark urine & Pale stools is typically seen in this type of Jaundice. Hemolytic Hepatic Pre-Hepatic Post Hepatic Alcohlic

Post Hepatic

pathogenesis of hepatocyte injury in viral hepatitis is by, Viral replication inside hepatocytes Direct cytopathic effect of virus Macrophage induced phagocytosis B lymphocyte induced antiboides T cell mediated immunity against viral Ag

T cell mediated immunity against viral Ag

Carrier state is healthy persons carrying hepatitis virus. One of the reason explaining this condition is, Dormant Virus not causing damage. Virus not actively replicating very few virus within hepatocytes onlly Immune tolerance to virus. Immunosuppressed persons.

Immune tolerance to virus.

A short incubation period of 3 weeks is typically seen in this type of viral hepatitis. A B C E B&C A&E D

A but can be E as well

Significant carrier status of 4-10% is seen in this hepatitis viral infection. A B C E B&C A&E

The only Defective DNA virus among hepatitis viruses is HDV. True False

False

HAV can be detected in stools only during acute hepatitis phase with jaundice. True False

F- can be detected before and after jaundaice

Following HAV infection, patients develop life long immunity by anti-HAV antibody. This life long protecting antibdy is measured in the laboratory by, IgM anti-HAV levels. IgG anti-HAV levels. Total anti-HAV levels. IgM +IgG anti-HAV levels. Total - IgM anti HAV levels.

Total - IgM anti HAV levels. no IgG

HBV vaccine also prevents HDV infection. True False

Percentage of patients recovering without complication following HBV infection is, <1% 5-10% 25% 65% 90%

90%

5 of 5 in HBV infection, "Australia antigen" was the name given to HBs Ag Full virus HBc Ag HBe Ag HDV RNA chain

HBs Ag

Gross appearance of liver in Chronic Hepatitis is usually "Normal" True False

True

Councilman bodies are, swollen hepatocytes (ballooning) apoptotic hepatocytes injured hepatocytes necrotic hepatocytes atrophic hepatocytes

apoptotic hepatocytes

in viral hepatitis cirrhosis stage can progress to, Chronic hepatitis Acute hepatitis Fulminant hepatitis All of the above. Hepatocellular carcinoma

Hepatocellular carcinoma

Ballooning of hepatocytes is typically seen in. Carrier stage of hepatitis Acute Hepatitis Fulminant hepatitis Chronic Non-progressive Hepatitis Hepatocellular carcinoma

Acute Hepatitis

Chronic hepatitis may remain without progression for decades or even for life. True False

Liver function tests are typically normal in a case of chronic hepatitis, because there is no damage despite portal inflammatory infiltrate. True False

1) in Alcoholic liver disease, Chemical mediators of hepatocyte injury are all of the following EXCEPT ALDH ADH TNF IL-1 IL-6 Ethanol

ADH

Major outcome of alcoholic hepatocyte injury are Steatosis, Fibrosis and

inflammation

In alcoholic steatohepatitis, Liver function tests will be typically NORMAL. True False

False

Microscopic feature of steatosis is, Ballooning degeneration Hepatocyte necrosis Cytoplasmic fat mallory bodies neutropil infiltration

Cytoplasmic fat

characteristic Microscopic feature of alcoholic steatohepatitis is Councilman bodies apoptotic cells ballooning degeneration inflammation mallory bodies.

mallory bodies.

Cirrhosis is characterised by enlarged fibrotic nodular liver. True False

An alcoholic person underwent liver biopsy. Report reads ballooning degenerations, fat globules, mallory bodies, inflammatory cells and increased fibrous tissue. What is the most likely diagnosis? Steatosis Steatohepatitis Cirrhosis Hepatocellular carcinoma Acute Hepatitis

Steatohepatitis

if patient continues to consume alcohol, what complication he may develop? GIT bleeding Cirrhosis recurrent infections hepatorenal syndrome Hepatocellular carcinoma all of the above

all of the above

What percentage of chornic alcoholics develop cirrhosis? 90% 25% 10% 1% 100%

10%

Typical levels of AST and ALT in a cirrhosis is, Normal Moderately elevated Markedly elevated. Absent

Normal

Reason for Hepatic failure in a case of Cirrhosis is, Heaptocyte necrosis Chronic inflammation Acute inflammation Scarring Loss of archetecture

Loss of archetecture

Cause of portal hypertension in cirrhosis is due to, Increased portal circulation Heaptocyte necrosis Hepatic failure obstruction to portal circulation Intestinal ischmeia Porta-systemic shunt

obstruction to portal circulation

Two gross features of Cirrhosis are ________ & _________

shrunken and nodular liver

Pathogenesis of Spider angioma is, Hyperammonemia Hyper Oestrogenemia Portal hypertension Hepatorenal syndrome Decreased glycogen metabolism

Hyper Oestrogenemia

Pathogenesis of Renal Ischemia in Liver failure is Hyper Oestrogenemia Hyper ammonemia Portal Hyeprtension Decreased detoxification Idiopathic

Idiopathic

Pathogenesis of steatohepatitis in NASH is due to impaired oxidation and decreased _______________

hepatic secretion of lipids

Characteristic Autoantibody in Primary Biliary Cirrhosis is, Alkaline Phosphatase Ab Serum IgG Ab. Anti Bile duct Ab Anti Mitochondrial Ab Anti DNA Ab

Anti Mitochondrial Ab

In paracetamol induced hepatitis, necrosis is typically seen in Zone 1 Periportal zone Zone 2 Centrilobular zone Diffuse necrosis

Centrilobular zone

Reye's syndrome is associated with use of Paracetamol Tetracycline Aspirin Isoniazid Nitrofurantoin

Aspirin

HELLP syndrome is typically seen in pregnancy. True False

Etiologic agent of Hydatid cyst of liver is, Schistosoma mansoni Fasciola hepatica Echinococcus granulosus Entamoeba histolytica Clonarshis sinensis

Echinococcus granulosus

Bronze diabetes is seen in Wilson's disease Gilberts syndrome Dubin Johnson's disease Neonatal cirrhosis Haemochromatosis

Haemochromatosis

Gross features of Fatty liver is, Grey pale smooth surface. Grey yellow macronodular surface Gray Yellow smooth surface Pale grey micronodular surface Dark brown mottled surface.

Gray Yellow smooth surface

Nutmeg Liver is characteristically seen following, Chronic alcoholism Viral hepatitis Chronic smokers with COPD Portal hypertension Rght sided heart failure

Rght sided heart failure

Characteristic shape of hepatocytes in fatty liver is, Swollen round & feathery Swollen, Signet ring shape Cuboidal with granular cytoplasm Shrunken round dark pink Pleomorphic with peripheral nucleus

Swollen, Signet ring shape

Liver function is normal or only mildly abnormal in fatty liver because there is no, necrosis inflammation apoptosis all of the above fibrosis

all of the above

Councilman bodies in viral hepatitis are, feathery degeneration signet ring hepatocytes virus infected hepatocyte apoptotic hepatocytes hemorrhagic necrosis

apoptotic hepatocytes

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

03. A 53-year-old male presents with 3 weeks of painless jaundice and mild abdominal swelling. He also reports joint pains in his hands for the last 6 months. He does not have any confusion, problems walking or SOB. He reports that he has not visited the doctor for many years. On examination, his abdomen is not tender, his liver edge is not palpable, he has splenomegaly and shifting dullness. His father and paternal aunt both died of liver disease in their 50s/60s. What is the most likely underlying aetiology of this condition? a) Alpha-1 antitrypsin deficiency b) Decreased copper excretion c) HFE gene mutation d) Increased copper absorption e) Insulin resistance

HFE gene mutation- joint pain (arthritis): haemochromotosis

A 53-year-old male presents with 3 weeks of painless jaundice and mild abdominal swelling. He also reports joint pains in his hands for the last 6 months. He does not have any confusion, problems walking or SOB. He reports that he has not visited the doctor for many years. On examination, his abdomen is not tender, his liver edge is not palpable, he has splenomegaly and shifting dullness. His father and paternal aunt both died of liver disease in their 50s/60s. BONUS QUESTION! 04. What complications is this patient at risk of?

Heart- cardiomyopathy Testical- affects spermatogenesis Pancreatic- Diabetes MAFLD

05. A 19-year-old female presents with a 2 weeks history of a RUQ pain, nausea, fatigue, sore throat, jaundice and fevers. She has no prior history of liver disease and received all the recommended vaccines as a child. She has been taking paracetamol 2g/day for her fevers. LFTs show an increase in transaminases of >10x upper limit of normal. What is the most likely diagnosis? a) Drug-induced liver injury b) EBV infection c) Haemochromatosis d) Hepatitis B infection e) Metabolic-associated fatty liver disease

EBV infection- The age group is correct,

06. 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)-

07. 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

08. A 57-year-old man was found to have mildly elevated transaminases (ALT and AST) for >6 months as part of investigations into 3 years of fatigue. Which of the following subsequent investigations is initially indicated in this patient? a) Anti-mitochondrial antibody (AMA) b) AXR c) CT abdomen d) Hepatitis A IgM e) USS of the abdomen

USS abdomen- more specific than the others

09. 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 2-4 glasses of wine a night. Liver function tests shows a transaminase rise. What information would make/makes chronic liver disease more likely than an acute liver injury in this patient? a) Confusion and easy bruising b) Elevated bilirubin c) Markedly elevated transaminase rise d) Previously normal LFTs e) Relatively asymptomatic state

Relatively asymptomatic state- long term damage

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 2-4 glasses of wine a night. Liver function tests shows a transaminase rise. 10. What finding on examination or investigation would most suggest alcohol as a cause of her liver disease? a) AST:ALT >2 b) Elevated GGT c) Hepatomegaly d) Spider naevi e) Shifting dullness

AST:ALT >2- most specific

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

12. 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: HepBsAg REACTIVE HepC IgG REACTIVE HepBsAb Not detected HepC RNA Not detected HepBcAb REACTIVE 13. What is the most common route of acquisition for this condition? a) Blood transfusion in Australia b) Faecal oral transmission c) Sexual transmission d) Vertical/childhood e) Via injecting equipment

Vertical/childhood

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 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: 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. TABLE TALK 15. What measures can be undertaken to taken to prevent transmission to others?

The virus is spread through Spread: Perinatal (High Prev), childhood (med. Prev) & Sexual / IV drug. In low prevalence countries. not transfusion* - don't give blood - no sharing toothbrushes - use condoms - vaccination of contacts - dont share razors

16. 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

18. 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

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. 19. What is the pathophysiological cause of his haematemesis? a) Decreased production of coagulation factors b) Dilation of splanchnic veins c) Oesophageal vein anastomosis d) Hyperoestrogenism e) Paraumbilical vein anastomosis

Oesophageal vein anastomosis

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. 20. What is the pathophysiological cause of the disturbed sleep and confusion? a) Dilation of splanchnic veins b) Hyperoestrogenism c) Hyponatraemia d) Paraumbilical vein anastamosis e) Portosystemic shunt

Portosystemic shunt- increased production of amnomia - not hyponatraemia as needs to be reallyyy bad to cause confusion

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. 21. Given the patient’s disturbed sleep patterns and confusion, what aspect of the patient’s UEC would you expect to be abnormal? a) Sodium b) Potassium c) Chloride d) Creatinine e) Urea

Urea- protein metabolism affected ammonium production decreases urea production.

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. 22. What further complication of cirrhosis is the patient at an increased risk of? a) Hepatorenal syndrome b) Nephrotic syndrome c) Myocardial infarction d) Thrombosis e) Cardiomyopathy

Hepatorenal syndrome

Commonest clinicaL presentation of cholecystitis is, Acute cholecystitis Chronic Cholecystitis Acute on Chronic Cholecystitis Cholesterolosis.

Acute on Chronic Cholecystitis

Commonest cause of cholecystitis is Stasis of bile Thickened bile E.coli infeciton cholelithiasis Excess cholesterol

cholelithiasis

Mucosal herniation (Ashchoff-Rokitansky sinuses) are seen typically in Acute cholecystitis Cholelithiasis Cholesterolosis Chronic cholecystitis Empyema of gall bladder

Chronic cholecystitis

"Strawberry gall bladder" is typically seen in Gangrenous cholecystitis Acute cholecystitis with empyema Chronic cholecystitis Pigment gall stones Cholesterolosis

Cholesterolosis

Important Pathogenetic factor in the formation of gall stone is Escess cholesterol (supersaturation) or decrease in Stasis Pancreatic reflux infection Bile salts Bile pigments

Bile salts

Common clinical feature of gall stones is, RUQ pain Pale stools Biliary colic Steady RUQ pain Asymptomatic

Asymptomatic

Clinical triad of symptoms of acute calculous cholecystitis is RUQ steady pain, Fever & _____________________

RIght shoulder/ back pain and leukocytosis

Approximately 80% of gall stones are not visible on x-ray filsms. True False

True

Round yellow spiky stones causing bleeding are typically, Mixed cholesterol stones Pure cholesterol stones Black pigment stones. Brown pigment stones Infective stones

Pure cholesterol stones

Golden brown faceted multiple stones are typically Mixed cholesterol stones Pure cholesterol stones Brown infection stones Black pigment stones.

Mixed cholesterol stones

Golden brown faceted multiple stones are typically Mixed cholesterol stones Pure cholesterol stones Brown infection stones Black pigment stones.

Mixed cholesterol stones

Commonest congenital abnormality Pancreas divisum is characterised by Pancreas encircling duodenum separation of body & Head of pancreas Absence of duct of Wirsung Duct of Wirsung joins common bile duct. Pancreatic agenesis

Absence of duct of Wirsung

Activation of pancreatic proenzymes within pancreas is inhibited by Trypsin inhibitors. True False

True

Exocrine function of pancreas is done by, Alpha cells Beta cells Acini ducts Islets

Acini

Cause of acute pancreatitis in an alcoholic person is, Duct obstruction Acinar cell injury Defective intracellular transport all of the above. Acitvation of enzymes

all of the above.

The dictum "don't mess with pancreas" is because, it is a delicate organ It is a important vital organ duct obstruction causes gall stones Islets are sensitive to injury Acinar cell injury activates enzymes

3 Microscopic features of Acute pancreatitis are Acute inflammation, hemorrhage and ______________

Fat necrosis

Typical feature of chronic Pancreatitis is, Grey Turner sign Leucocytosis Cullen's sign Increased serum amylasse Steatorrhea

Steatorrhea

Pancreatic pseudocyst is lined by inflammatory granulation tissue. True False

True

Characterist microscopic features in chronic pancreatitis is gland atrophy with _________________

Fibrosis, dialated ducts and retained islets

Commonest tumour of pancreas is Polycystic disease Congenital cysts Cystadenoma Adenocarcinoma

Adenocarcinoma

Common location of carcinoma pancreas is, Tail of pancreas Head of pancreas Body of pancreas Whole of pancreas

Head of pancreas

Commonest genetic mutation in pancreatic cancer is, BRCA1 BRCA2 CDKN2A SPINK1 SMAD4

CDKN2A

Two microscopic features of pancreatic adenocarcinoma are Irregular glands in dense necrotic stroma Inflammatory stroma dense fibrotic stroma Atrophic pancreatic glands between islets of langerhans

dense fibrotic stroma

Courvoisier's sign is palpable gall bladder with thrombophlebitis depression epigastric pain jaundice Cachexia

Jaundice

Pancreatic cancer invading duodenum would be stage..? I II III IV V

Commonest gall stone is a Pure cholesterol stone Pigment stone Mixed Calcium & Cholesterol stone Mixed pure cholesterol & infection stone Pigment cholesterol stone

Mixed Calcium & Cholesterol stone

Strawberry glass bladder is also known as, Cholelithiasis Cholecystitis Cholesterolosis Pure cholesterol stones

Cholesterolosis

Common compication of Cholelithiasis is, adenocarcinoma Neck obstruction Perforation empyema chronic cholecystitis

Neck obstruction

Pruritis in cholestatic jaundice is due to this feature, Bile pigment deposition Feathery degeneration Bile salt accumulation elevated GGT enzyme elevated ALP enzyme

Bile salt accumulation

Ascending Cholangitis is seen in, Cholelithiasis Pancreatic cancer Primary Sclerosing Cholangitis Primary Biliary Cirrhosis All of the above

All of the above

marked fibrosis (onion skin) around bile ducts are typically seen in, Chronic Cholangitis Primary Biliary Cirrhosis Primary Sclerosing Cholangitis Secondary biliary cirrhosis Congenital Biliary Atresia

Primary Sclerosing Cholangitis

All the following are risk factors for acute pancreatitis EXCEPT, Alcohol abuse Obesity Cholelithiasis Diabetes Hypertension

Hypertension

Haemorrhage in Acute pancreatitis is because of, Vit K deficiency. Acute inflammation Fat necrosis Digestion of tissue calcium soap formation

Digestion of tissue

Microscopic feature of Acute pancreatitis is, Dense fibrosis with chronic inflammation Haemorrhage, Necrosis & Inflammation Pleomorphic cells forming irregular glands

Pedal edema in chronic pancreatitis is because of Steatorrhea Malabsorption Hypoalbuminemia Vitamin K deficiency Diarrhea

Hypoalbuminemia

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 30-year-old man with fever, RUQ abdominal pain and dark urine since 3 weeks. On examination he is jaundiced. with mild tender hepatomegaly. History reveals multiple sex partners and IV drug use. What is the most likely etiologic agent? HBV HCV HDV HEV HAV

HBV

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

A 48-year-old woman with chronic fatigue, itching & recent jaundice. She has a 10-year history of Sjögren syndrome that is well-managed with symptomatic relief. P/E prominent jaundice, evidence of intense scratching & xanthomas on face & eye lids. P/E mild hepatosplenomegaly. Lab: Hypercholesterolemia, elevated ALP & Antimitochondrial antibodies positive. Most likely diagnosis is, Chronic hepatitis C Primary Biliary Cholangitis Primary Sclerosing Cholangitis Cholelithiasis Chronic pancreatitis

Primary Biliary Cholangitis

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

In a patient presenting with symptoms of acute pancreatitis for more than three days, which of the following laboratory parameters is most likely to be elevated? serum calcium serum Alkaline phosphatase (ALP) serum amylase serum lipase serum glucose

serum lipase

A 48-year-old woman presents to the clinic complaining of a 1-day history of nausea, vomiting, severe abdominal pain, which is severe and steady and localized to the epigastric and RUQ of her abdomen. Temp 101.1°F, Lab tests show increased ALP, WBC & and mild conjugated hyperbilirubinemia. What is the most likely diagnosis? Acid reflux - Heart burn. Acute cholecystitis Acute pancreatitis Acute hepatitis Acute gastroenteritis

Acute cholecystitis

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

Laboratory data from a patient with jaundice, but urine is of normal colour. What is the most likely cause of jaundice? Hb 101 g/, MCV 82 fl,, AST, ALT normal, Total bilirubin high, predominantly unconjugated. chronic hepatitis cholelithiasis pancreatitis biliary obstruction hemolytic anemia

hemolytic anemia

Laboratory data from a patient with jaundice. What is the most likely cause of jaundice? Hb 151 g/L, AST, ALT & ALP are high. Total bilirubin is high, with both conjugated and unconjugated high. hemolytic anemia biliary obstruction cholelithiasis pancreatitis hepatitis

hepatitis

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

A 45 year old woman presents to ED with acute upper abdominal pain, fever, shaking chills and vomiting since 6 hours. She has a BMI of 32. Examination confirms right upper quadrant tenderness. Laboratory results show: Bilirubin (total) 18 mmol/L < 20 Alanine transaminase 32 U/L <45 Aspartate transaminase 21 U/L <40 Lipase 47 U/L <70 White cell count 16.5 x109/L 4.0 – 11.0 Acute cholecystitis Acute pancreatitis Acute hepatitis Biliary colic Perforated peptic ulcer

Acute cholecystitis

The most likely diagnosis in a 45-year-old woman with liver function test results showing mild increase in direct bilirubin, transferase enzymes & high cholesterol with markedly increased alkaline phosphatise is: Cirrhosis of the liver. Acute viral hepatitis; Chronic viral hepatitis; Primary Biliary cirrhosis; Hemolytic anemia;

Primary Biliary cirrhosis;

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 25-year-old male presents with malaise, headache and mild fever. History reveals his lack of appetite, aversion for fatty foods and a dislike for smoking since the symptoms started. examination reveals mild RUQ tenderness. Lab investigations show mild increase in direct bilirubin, marked increase in amino transferases and a mild increase in alkaline phosphatase. The most likely diagnosis is: Alcoholic fatty liver; Chronic viral hepatitis; Acute pancreatitis Acute viral hepatitis Acute cholecystitis

Acute viral hepatitis

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

Viral serology for a patient shows following results. What is the most likely clinical scenario. Hbs Ag +ve & anti HBc IgM +ve raised AST & ALT. Mildly elevated ALP. Patient had HBV infection in the past; Patient is carrier of HBV Patient has acute HBV hepatitis Patient has HBV chronic hepatitis. Patient is immunized against HBV

Patient has HBV chronic hepatitis.

A 53-year-old with known alcoholic cirrhosis presents with fever, worsening health for the last 2 weeks. He has lost 5kg wt in the past month. Examination shows jaundice, Hepatomegaly and increased ascites. Laboratory studies reveal leukocytosis, anemia, and a sharp increase in serum ALP & AFP levels not seen in his previous test 6 months ago. What is the most likely diagnosis? Hepatocellular carcinoma Fulminant Hepatitis Acute on Chronic Hepatitis Internal bleed & Hematoma Total liver failure secondary to Cirrhosis

Hepatocellular carcinoma

The most likely diagnosis in a patient with following viral serology results is: HBsAg Negative, Anti HBcAg Negative Anti HBcAg IGM Negative Anti HBsAg Positive. Chronic Hepatitis B; Fulminant hepatitis B. Acute Viral Hepatitis; Hepatitis B carrier stage; Immunised against Hepatitis B;

Immunised against Hepatitis B;

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

Mr J.R, a 56-year-old hypertensive on treatment comes to you looking pale & jaundiced since 2 weeks. He has no nausea or indigestion. He says his stools and urine appear normal, Liver function tests show normal AST, ALT & ALP but Bilirubin levels are high predominantly unconjugated. What would be the MOST likely cause of his hyperbilirubinemia? Acute hepatitis A Chronic Hepatitis B Hemolytic anemia Chronic viral hepatitis; Biliary obstruction

Hemolytic anemia

A 27 year old man with fever, malaise, fatigue and loss of appetite since a week. He has returned from East Timor four weeks ago. On examination jaundice is evident. Laboratory studies are shown: Bilirubin (Total) 68 μmol/L (<20) Bilirubin (Direct)48 μmol/L (<4) ALT 77 U/L (<45), AST 61U/L (<40) Which of the following serological markers would most likely be positive in this case? Anti HBc HAV IgM Anti HCV HBsAg Anti-HBs

HAV IgM

28 year old Philipino man presents with fever & jaundice. Viral serology showed the following results. - HBs Ag +ve; - anti HBs -ve; - HDV-RNA +ve; - HDV Ag +ve; The statement most befitting this patient is: Acute HBV on Chronic HDV hepatitis. Immunized against Hepatitis B and D. Carrier of HDV & HBV HBV carrier with superinfection by HDV Acute viral hepatitis B & D

HBV carrier with superinfection by HDV

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 22 year old man presents with intermittent diarrhea & abdominal pain over the last 5 months. He has noticed fresh blood in the stool from time to time and has lost 3 kg in weight. Colonoscopy showed multiple superficial ulcers throughout the colon. Biopsies confirm crypt abscesses and intense neutrophilic mucosal inflammation & superficial ulceration. What long term complication is the patient most likely to develop? Sclerosing cholangitis Perianal fistulae Cholelithiasis Pancreatic cancer Hepatocellular carcinoma

Sclerosing cholangitis

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;

A 33-year-old woman with abdominal bloating and jaundice worsening since 3 months. She is on therapy for Hashimoto thyroiditis. On examination, multiple spider nevi and hepatomegaly is noted. LFT shows raised Bilirubins, ALP, GGT, AST & ALT. What is the most likely diagnosis? Primary Sclerosing Cholangitis Autoimmune Hepatitis Cirrhosis Chronic Viral Hepatitis Primary Biliary Cirrhosis

Autoimmune 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

21 year old JCU student presents with jaundice. History reveals recurrent attacks of jaundice usually before exam period and clearing few days after. Investigations show mildly increased total and unconjugated bilirubin levels. What is the most likely diagnosis? Dubin-Johnson Syndrome Crigler-Najjar Syndrome Gilbert Syndrome Stress induced hepatitis Rotor Syndrome

Gilbert Syndrome

A 26 year old man presents with jaundice following a recent upper respiratory tract infection. LFTs reveal a moderately elevated bilirubin and normal liver enzymes.

Gilbert syndrome

A 75 year old man is admitted to hospital with a fracture of the proximal end of the femur following a minor fall, this is his third fracture in the past 2 years. LFTs reveal a raised alkaline phosphatase, which has been noted in previous blood test results over the past 5 years. The other liver enzymes are in the normal range.

Paget's disease

A 55 year old man presents with right-sided abdominal discomfort, fatigue and weight loss for the past month. He has chronic stable hepatitis C and is regularly followed up at the hepatitis clinic. On examination an enlarged, irregular liver is palpable.

Hepatocellular carcinoma

A 21 year old woman presents with fatigue. On examination pallor is noted. Her LFTs reveal a moderately elevated unconjugated bilirubin, normal liver enzymes and a markedly elevated LDH.

Haemolytic anemia

A 60 year old man with diabetes and a BMI of 35. His liver enzyme results are shown: Gamma-GT 49 U/L <50 ALT 65 U/L <45 AST 57 U/L <40

NAFLD

MR. JW, a 51year old man presents with chronic fatigue & indigestion but no jaundice. Liver function test results show normal bilirubin but mildly increased AST, ALT & ALP on multiple occasions in the past year. What is the most likely diagnosis? Hepatitis A Cirrhosis Incorrect: Primary Biliary cirrhosis Chronic hepatitis; Hemolytic anemia;

Chronic hepatitis;

Difference between dysphagia & Odynophagia is difficulty in swallowing with, solids Liquids both pain inflammation

pain

Commonest cause of Oesophageal varices is, Portal hypertension. True False

True

Fist clinical stage of GORD is, NERD MERD Barrrett's Functional Heart burn Gastro Oesophageal Reflux Disease.

Functional Heart burn

Following microscopic feature is the commonest in a patient with GORD. Acute Inflammation Eosinophilic Inflammation Squamous metaplasia Glandular metaplasia Normal

Normal

Oesophageal biopsy report from a patient with GORD was reported as having many glands with goblet cells & mucous moderate inflammation with eosinophils. What is the most likely diagnosis? NERD MERD Barrett's Funcitonal oesophagitis Adenocarcinoma

Barrett's

Acute Peptic Ulcers - Curling ulcers are seen in Severe trauma Septicemia Intracranial disease Severe Burns Shock

Severe Burns

Gross features of Acute gastritis is atrophy of mucosa and loss of mucosal folds. True False

False- that is chronic

Hyperacidity in H.pylori infection induced chronic gastritis is due to, Antacid therapy Reflex neural stimulation Both of the above. Chronic gastritis Acute grastritis

Both of the above.

H.pylori is a gram negative spirochete bacteria True False

True

Radiating folds around chronic peptic ulcer is because of, Chronic gastritis Inflammation Scar contracture Healing mucosal atrophy

Scar contracture

Commonest location of peptic ulcer is Fundus of stomach Body of stomach Antrum of stomach First part of duodenum Second part of duodenum Cardia of stomach.

First part of duodenum

Multiple peptic ulcers are suggestive of severe hyperacidity. True False

True

Commonest malignancy of stomach is, Gastric polyps MALT lymphoma GIST Carcinoid Adenocarcinoma

Adenocarcinoma

Signet ring cells are typically seen in Intestinal type of gastric adenocarcinoma. True False

False- seen in diffuse

Leather bottle stomach (linitus plastica) is the gross description for, MALT lymphoma Intestinal type adenocarcinoma Carcinoid tumour diffuse type cancer Chronic atrophic gastritis

diffuse type cancer

RUQ pain is typically seen in, Pancreatitis Peptic Ulcer disease. Early stage of Appendicitis Diverticulitis Gall stones

Gall stones

In early stage of appendicitis, pain is typically seen in this region. RUQ RIQ Epigastric Umbilical LIQ

Umbilical

Commonest cause of Appendicitis is, Idiopathic obstruction by Fecalith Carcinoid tumor E.coli infection Acute inflammation

obstruction by Fecalith

Commonest cause of Intususception in children is, Idiopathic Polyps Tumours stricture

Idiopathic

Clinically commonest cause of intestinal obstruction worldwide is, Valvulus Intususception Hernia Adhesions Cancers

Hernia

Commonest type of diverticula seen in clinical practice is TRUE type. True False

False

Chronic ischemia of bowel typically causes Mucosa only infarction. True False

True

Barrett's esophagus is, Squamous metaplasia of esophagus Intestinal metaplasia of stomach Glandular metaplasia of stomach Interstinal metaplasia of esophaus

Intestinal metaplasia of stomach

Precursor lesion of Barrett's esophagus is, Acute Esophagitis Adenocarcinoma Chronic esophagitis Intestinal metaplasia Columnar metaplasia

Chronic esophagitis

Microscopic feature of Barrett's esophagus is, Pleomorphic cells forming Irregular glands. Chronic inflammation with eosinophils. Columnar cells forming regular glands. Acute inflammation with plenty of eosinophils.

Columnar cells forming regular glands.

Gross appearance of Intestinal type of gastric cancer is, exophytic tumour with central ulceration. Leather bottle stomach. Radiating mucosal folds. diffuse thickening of wall.

exophytic tumour with central ulceration.

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. What further information would suggest a different diagnosis to one caused by gallstones? a) Confusion b) Cough c) Elevated WCC d) Fever e) Jaundice

Cough- would not be cough

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. 03. 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. What is the most likely diagnosis at the present time? a) Acute cholecystitis b) Biliary colic c) Choledocholithiasis d) Cholelithiasis

Acute cholecystitis

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. 04. What clinical feature would best suggest progression to acute cholangitis? a) Grey-Turner’s sign b) Confusion c) Fever d) Hypertension e) Retroperitoneal epigastric pain

Confusion Triad: fever, RUQ pain, and jaundice pentade: add hypotension and confusion.

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. 05. LFTs are normal. FBC shows elevated neutrophil count. Lipase is normal. What is the next most appropriate step in this patient’s care? a) Cholecystectomy b) CXR c) MRCP d) Referral to ICU e) USS abdomen

USS abdomen

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

Presence of gallstones is confirmed. The patient recovers and undergoes an elective cholecystectomy. The morphology and histology of the gall bladder after surgery is shown. 08. What findings on the gross specimen or histology would most suggest gallbladder cancer/adenocarcinoma? a) Brown gall stones b) Pleomorphic glandular structures c) Pedunculated smooth polyp d) Rokitansky-Aschoff sinuses e) Uniformly thickened wall

Pleomorphic glandular structures

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 58-year-old male presents to ED with 2 days of increasingly severe retrosternal abdominal pain. He has type 2 diabetes but ran out of insulin 3 weeks ago. On examination, he looks unwell, is febrile, and has a BP of 95/68. His abdomen is soft, with epigastric tenderness to mild palpation. What investigation could help to confirm the most likely cause of the patient’s epigastric pain? a) Amylase b) Erect CXR c) FBC d) LFT e) Lipase

Lipase

A 58-year-old male presents to ED with 2 days of increasingly severe retrosternal abdominal pain. He has type 2 diabetes but ran out of insulin 3 weeks ago. On examination, he looks unwell, is febrile and has a BP of 95/68. His abdomen is soft, with epigastric tenderness to mild palpation. 11. This is abnormal. What initial radiological investigation would be indicated in the assessment of this patient? a) XR abdomen b) USS abdomen c) CT abdomen d) MRI abdomen e) MRCP

USS abdomen- Initial

A 58-year-old male presents to ED with 2 days of increasingly severe retrosternal abdominal pain. He has type 2 diabetes but ran out of insulin 3 weeks ago. On examination, he looks unwell, is febrile and has a BP of 95/68. His abdomen is soft, with epigastric tenderness to mild palpation. 12. What blood test is most likely to be abnormal indicating the cause of this patient’s epigastric pain? a) ANA b) FBC c) Lipase d) Lipid profile e) UEC

Lipid profile- will indicate the underlying cause Lipase will confirm pancreatitis ANA- autoimmune

13. A 52-year-old female presents to ED with an 8-hour history of increasing epigastric pain. She consumes 1-3 SD of alcohol daily. On examination, she is jaundiced and has epigastric tenderness but there is no mass, Grey-Turner’s or Cullen’s sign. Lipase level is elevated. On imaging, the patient has a dilated pancreatic duct and a dilated common bile duct with no masses. What is the most likely cause of pancreatitis? a) Alcohol b) Gallstones c) Pancreatic adenoma d) Pancreatic cancer e) Scorpion venom

Gallstones- duct dilated

A 52-year-old female presents to ED with an 8-hour history of increasing retrosternal epigastric pain. She consumes 1-3 SD of alcohol daily. On examination, she is jaundiced and has epigastric tenderness but there is no mass, Grey-Turner’s or Cullen’s sign. Lipase level is elevated. On imaging, the patient has a dilated pancreatic duct and a dilated common bile duct with no masses. 14. What management is indicated to most significantly reduce the recurrence of pancreatitis in this patient? a) Cholecystectomy b) IV antibiotics c) Low fat diet d) Pancreatic enzyme replacement e) Referral to ATODS

Cholecystectomy

15. A 25yo male is bought in to hospital after a motor vehicle accident. He describes generalized abdominal pain. On examination, his BP is 92/76mmHg and his HR is 120bpm. Examination of his abdomen reveals Grey-Turner’s sign. What is the most likely cause of his abdominal examination finding? a) Ascending cholangitis b) Acute pancreatitis c) Cholangitis d) Chronic pancreatitis e) Splenic rupture

Splenic rupture- retroperitoneal rupture.

16. A 45-year-old presents with a 1 year history of intermittent mild retrosternal abdominal pain, weight loss, diarrhoea and difficulty flushing his stools on a background of chronic alcohol use disorder. On examination, his abdomen is soft and non-tender with no palpable masses. Given his presenting symptoms, what deficiency is the patient most likely at risk of? a) Iron b) Magnesium c) Vitamin B12 d) Vitamin C e) Vitamin D

Vitamin D is - only one that is fat soluble fat-soluble ones are A, D, E, and K

A 45-year-old presents with a 1 year history of intermittent mild retrosternal abdominal pain, weight loss, diarrhoea, and difficulty flushing his stools on a background of chronic alcohol use disorder. On examination, his abdomen is soft and non-tender with no palpable masses. 17. After complaining of increased abdominal pain, this patient is sent for an abdominal ultrasound scan is performed and a subsequent CT scan. The CT scan shows a hypodense homogenous rounded lesion extending from the pancreas and calcifications within the pancreas. What is the most likely cause of the mass? a) Choledocholithiasis b) Pancreatic abscess c) Pancreatic cancer d) Pancreatic cyst e) Pancreatic pseudocyst

Pancreatic pseudocyst- hypodense homogenous rounded lesion

18. 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

19. 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. TABLE TALK What are 3 differentials to be considered in this patient?

- post hepatic obstruction 1. age: cholangiocarcinoma 2. adenocarcinoma of the pancreas 3. PBC 4. PSC 5. stricture in the bile duct 6. could have hepatic cause 7. gallstones

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. 20. What additional symptom/information would suggest the patient had pancreatic cancer? a) Weight gain b) Family history of lung cancer c) Melaena d) Back pain e) Dysphagia

Back pain

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

22. 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 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 on obstructive picture with predominantly elevated ALP, GGT and bilirubin. 23. What additional investigation would confirm the most likely cause of this patient’s jaundice? a) USS abdomen b) MRCP c) AMA d) ANA e) T4 and TSH levels

AMA

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 on obstructive picture with predominantly elevated ALP, GGT and bilirubin. 24. What information in the history or examination would make primary sclerosing cholangitis more likely? a) History of inflammatory bowel disease b) Mass in RUQ on examination c) Recent weight loss d) Shifting dullness e) Smoking history

History of inflammatory bowel disease

Peptic ulcer disease- ask NSAIDS, drug history, GORD- epigastric pain, Acute pancreatitis- alcohol cholelithiasis gastritis oesophageal or gastric cancer functional dyspepsia

A 54yo 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 Takes no regular medication. Takes analgesia when his pain flares up. Consumes 2 mid strength beers most nights. You suspect a peptic ulcer. What is the commonest site of a peptic ulcer? 1. Cardiac part of stomach 2. Greater curvature 3. Lesser curvature 4. 2nd part of duodenum 5. 1st part of duodenum

1st part of duodenum

A 54yo 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 Takes no regular medication. Takes analgesia when his pain flares up. Consumes 2 mid strength beers most nights. The patient has been taking NSAIDs for his chronic back pain. 02: What is the most likely pathophysiology responsible for ulcers due to NSAIDs? 1. Decreased mucosal defense 2. COX-2 inhibition 3. Increased acid secretion 4. Increased mucosal blood flow 5. Increased PGE2

Decreased mucosal defense

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. 03: What initial investigation would you arrange to test for H pylori ? 1. H pylori serology 2. Faecal antigen test 3. Urea breath test 4. H pylori histology 5. H pylori culture

Urea breath test- highest specificity

Which is the correct statement about H.pylori? 1. Gram positive spirochete 2. Colonizes acidic mucosa only 3. Colonizes duodenum first part 4. Invades mucosa to cause ulcer

Colonizes acidic mucosa only

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. 05. What is the most important management step for this patient now? 1. Organise endoscopy 2. Take PPIs when symptoms are present 3. Prescribe alternative pain relief for his back pain 4. Refer to gastroenterologist 5. Start triple therapy

Start triple therapy

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. As part of his treatment he is commenced on a PPI. 06: What is the mechanism of action of proton pump inhibitors? 1. Irreversible inactivation of H+/K+ ATPase pump 2. Reversible inactivation of H+/K+ ATPase pump 3. Irreversible inactivation of Na+/K+ pump 4. Reversible inactivation of Na+/K+ pump

Irreversible inactivation of H+/K+ ATPase pump

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. He is commenced on treatment. He returns 4 weeks later and some alarm symptoms/signs are noted by the GP and he is referred for an endoscopy. 07: Which of the following alarm symptoms/signs would the GP have been concerned about? 1. Mouth ulcers 2. Tarry stools 3. Nausea 4. Severe epigastric tenderness 5. Hepatomegaly

Tarry stools

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 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. While awaiting further treatment she deteriorates clinically. 16: What feature would alert you to the possibility of sepsis? 1. Temperature 37.5°C 2. SpO2 97% 3. Heart rate 110bpm 4. Lactate < 2 mmol 5. Confusion

Confusion

A 48 year old male c/o 3/12 progressively worsening difficulty swallowing meat and sandwiches. Further history Swallowing liquids is ok. Feels like food is getting stuck (points to his sternum). No pain, but discomfort after large meal uses liquids to try and wash the food down 2 kg intentional weight loss in 3/12 intermittent heartburn “for years”; uses OTC Mylanta no voice change/cough/ fatigue/SOB/haemoptysis no fever, chills, nausea, anorexia, vomiting no change in bowel habit no haematemesis or melaena Social :Smokes 15-20 cigarettes per day for 30 years Drinks 1-2 full strength beers/week night; 8+ on weekends PMH: Borderline hypertension diagnosed 4/12 ago. On exercise/ diet program Intermittent heartburn “for years” No medication apart from OTC Mylanta PRN Exam: normal apart from BP 150/95 and mild epigastric discomfort 17: What is the most likely provisional diagnosis in our patient? 1. Ca lung 2. External compression from lymph node 3. Ca oropharynx 4. Hiatus hernia 5. Ca oesophagus

Ca oesophagus

A 48 year old male c/o 3/12 progressively worsening difficulty swallowing meat and sandwiches. Further history Swallowing liquids is ok. Feels like food is getting stuck (points to his sternum). No pain, but discomfort after large meal uses liquids to try and wash the food down 2 kg intentional weight loss in 3/12 intermittent heartburn “for years”; uses OTC Mylanta no voice change/cough/ fatigue/SOB/haemoptysis no fever, chills, nausea, anorexia, vomiting no change in bowel habit no haematemesis or melaena Social :Smokes 15-20 cigarettes per day for 30 years Drinks 1-2 full strength beers/week night; 8+ on weekends PMH: Borderline hypertension diagnosed 4/12 ago. On exercise/ diet program Intermittent heartburn “for years” No medication apart from OTC Mylanta PRN Exam: normal apart from BP 150/95 and mild epigastric discomfort What additional feature in the history would make an oesophageal cause more likely than oropharyngeal causes of dysphagia in this patient? 1. Difficulty initiating swallow 2. Nasal regurgitation 3. Food sticking after swallowing 4. Frequent pneumonia 5. Choking

Food sticking after swallowing

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? 1. Pleomorphic cells forming irregular glands 2. Loss of ganglion cells & inflammation 3. Dilated vascular channels 4. Multinucleated cells with viral inclusions 5. 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 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”. 23: What is the most likely pathophysiology for the symptoms in this patient? 1. Gastric hyperacidity 2. LES dysfunction 3. Helicobacter pylori infection 4. Eosinophilic oesophagitis 5. Hiatus hernia

LES dysfunction

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

Pathogenesis of IBD involves excess TNF-alpha and decreased IL-10. True False

Hygiene hypothesis says that patients with good hygiene will have less chance of developing IBD. True False

Involvement of terminal ileum is typically seen in Ulcerative colitis Crohn's disease Inflammatory Bowel disease Indeterminate colitis

Crohns

100% involvement of rectum is seen in, Ulcerative colitis Crohn's disease in both - IBD None

Transural involvement is typically seen in UC or crohns

crohns

Granulomatous inflammation is typically seen in ulcerative colitis. True False

String sign in radiography is a typical feature of Ulcerative colitis. True False

TH2 lymphocyte and alternate pathway of macrophage activation is typically seen in Crohn's disease. True False

Clinically commonest polyp is a Hamartoma Pseudopolyp Neoplastic polyp Hyperplastic polyp Adenocarcinoma

Hyperplastic polyp

Pedunculated polyp is a polyp with Dysplasia Inflammation Sessile Stalk Large

Stalk

Abnormal DNA is a characteristic of Neoplastic polyp True False

Dysplastic cells are a feature in FAP HNPCC Tubular Adenoma Villous adenoma all of the above

All of the above

32 year old man presents with mucoid diarrhoea and endoscopy showed >1000 tubular adenomas and villous adenomas. Most likely diagnosis is, Sporadic polyposis HNPCC FAP Peutz -Jeghers sy adenocarcinoma

FAP

36 year old man presents with unexplained weight loss. Stool occult blood test is positive. Endoscopy showed 30-80 polyps in the right side of colon. Most likely etiology in this patient is, High calorie low fibre diet Obesity all of the above APC gene mutation MSH gene mutation

MSH gene

Commonest type of polyp in clinical practice is, adenomatous polyp Harmatomatous polyp Neoplastic polyp Non neoplastic polyp Congenital polyposis

Non neoplastic polyp

This polyp has no malignant potential, Tubular adenoma Villous adenoma Tubulovillous adenoma Hyperplastic polyp Juvenile polyp

Hyperplastic polyp

Incidence of Tubular adenoma in clinical practice is 1% 90% 50% Rare 9%

Colon cancers are slightly more common in females due to excess fat. True False

false

Sporadic cancers are the commonest type, representing 80% of clinical cancers. True False

Familial polyposis accounts for 20% of clinical cancers only. True False

Left sided cancers typically produce constipation & fresh blood stained stools. True False

Apple core appearance on contrast imaging is typical in Right sided cancers. True False

Familial cancers commonly located on the left side. True False

typical example of a Exudative diarrhoea is IBD True False

Lactase deficiency typically leads to ________ type of diarrhoea. Secretory Osmotic Masabsorptive Exudative Ischemic

Osmotic

Diarrhoea in Diabetic patient is typically due to bacteria and dyregulated motility. True False

Diarrhea following removal of significant part of ileum is typically due to lack of fat absorption Bacterial overgrowth lack bile acid reabsorption Bile salt reabsorption lack of disacharidases

Bile salt reabsorption

Etiology of Celiac disease is Gluten Gliadin HLA-DQ2 DM type ! Multifactorial

Multifactorial

Typical microscopic feature of Celiac disease is, Terminal Ileitis Ileal mucosal atrophy Jejunal mucosal atrophy Mucosal Inflammation Chornic pancreatitis

Jejunal mucosal atrophy

Napkin ring or Apple core appearance is typical of Left sided cancers which present as obstructions. True False

Narrow ulcers, skip lesions and granulomas are typically seen in Ulcerative colitis. True False

Malabsorption of fat soluble vitamins is typically seen in Ulcerative colitis Crohn's disease In both Neither

Crohns

Microscopic feature of pleomorphic cells forming irregular glands is typically seen in, Left sided colon canceers Right sided colon cancers both Left & Right sided colon cancers. in neither

Both

26yo female presents to GP with a 4-week history of gradual onset abdominal pain and bloating with associated diarrhea. She has no known medical conditions or family history she has not traveled recently. Group question: List 3 most likely differentials.

Ceoliac IBD- UC and crohns IBS Bowel infection - parasitic Lactose intolerance

What history would make you think of IBD over IBS? 1. Haematochezia 2. Chronic abdominal pain 3. Diarrhoea 4. Bloating 5. Constipation

Haematochezia

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

List 4 blood tests that are essential in this patient and justify your choice. To diagnose IBD

Inflammatory markers: FBC: Iron studies: Coeliac antibodies: LFT: UEC: CRP

Which of the following investigation is required to confirm the most likely diagnosis in this patient? (IBD) 1. Barium enema 2. Faecal calprotectin 3. Endoscopy +/- biopsy 4. CT abdomen 5. MRI abdomen

Endoscopy +/- biopsy

Bloods reveal a microcytic anaemia and low albumin. Colonoscopy showed discrete areas of bowel inflammation separated by normal areas throughout colon. Microscopy of the biopsy showed transmural inflammation with granulomas. Q4: Most likely IBD: 1. Ulcerative colitis 2. Crohn’s disease

Crohn’s disease

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

List 5 other complications of IBD.

PSC colorectal cancer Anaemia depression blood clots deficiencies refeeding syndrome other autoimmune diseases infection

A 20yr old female presents with recurrent diarrhoea, bloating, fatigue and weight loss for the past 2 years. On examination her vital signs are normal, and her abdomen is soft and nontender. Investigations showed a microcytic anaemia and transglutaminase-IgA and deaminated gliadin peptide-IgG antibody assay is positive. She undergoes a gastroscopy and small intestinal biopsy. Q7: Which of the following microscopic feature is most likely to be seen on biopsy? 1. Crypt abscess 2. Lymphatic infiltration 3. Lymphocytes and granulomas 4. Villous blunting and flattening 5. Foamy macrophages loading mucosa

Villous blunting and flattening

What is the most likely pathogenesis of her chronic diarrhoea? (coeliac disease) 1. Secretory 2. Osmotic 3. Malabsorptive 4. Exudative 5. Inflammatory

Inflammatory and malabsorption

A 16yo girl complains of recurrent attacks of explosive diarrhoea, watery frothy stools and abdominal distention after consuming dairy products. Q9: This presentation is caused by a functional deficiency of which of the following enzymes? 1. Disaccharidase 2. Amylase 3. Pancreatic lipase 4. Mannosidase 5. Gliadin hydroxylase

Disaccharidase

A 26y female presents to ED with an 8 hour history of severe acute periumbilical pain spreading to RIF, nausea and vomiting and mild fever. O/E tenderness and guarding in the RIF is noted . Q10: Which sign on abdominal examination is most specific for acute appendicitis? 1. Rovsing sign 2. Murphy sign 3. Rebound tenderness 4. Absent bowel sounds 5. Psoas sign

Rovsing sign psoas sign (more so)

A 26y female presents to ED with an 8-hour history of severe acute periumbilical pain spreading to RIF, nausea and vomiting and mild fever. O/E tenderness and guarding in the RIF is noted. Ultrasound confirms an appendicitis, and she undergoes an appendectomy. Q11: What microscopic finding is likely to be seen on histology confirming acute appendicitis as the most likely diagnosis? 1. Plenty neutrophils in lamina propria 2. Necrosis of mucosal layer & fecolith 3. Plasma cells & lymphocytes in muscularis 4. Plenty neutrophils & fecolith in the lumen 5. Neutrophils in the muscular layer

Neutrophils in the muscular layer

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.

Q12: Most important ‘red flag’ indicator for GI endoscopy (upper or colon): 1. Intermittent abdominal pain in an adult 2. Iron deficiency anaemia in patient > 50 years in age 3. Jaundice and abdominal pain in patient >30 years in age 4. Fresh red blood on wiping in an elderly patient

Iron deficiency anaemia in patient > 50 years in age

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 72 year old 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. He undergoes bowel resection for colon cancer. Q13: What is the most likely site of distant metastases? 1.Lung 2. Spleen 3. Adrenal 4. Liver 5. Bone

Liver

The iFOBTis used as a screening test for bowel cancer. Q14: Which of the following statements is true with regards to iFOBTas a screening tool? 1.Test has a high sensitivity 2.Test has a low specificity 3. Stool testing kit not acceptable with public 4.Not cost effective 5.Increases morbidity and mortality

Test has a high sensitivity

A 70 year old male presents with a 2 month history of intermittent rectal bleeding and fatigue. He undergoes a colonoscopy to investigate his symptoms. Multiple, smooth, nodular mucosal protrusions varying in size from 2-5 mm are noted in the rectosigmoid colon with no abnormality of the proximal colon. On histology the polyps are composed of increased mature goblet cells & absorptive cells. Q15: What is the most likely diagnosis? 1.Inflammatory polyp 2.Hyperplastic polyp 3.Hamartomatouspolyp 4.Neoplastic polyp 5.Adenomatous polyp

Hyperplastic polyp

A 70 year old male presents with a 2 month history of intermittent rectal bleeding and fatigue. He undergoes a colonoscopy to investigate his symptoms. The patient is concerned about progression to an adenocarcinoma. Q16: What is his risk of malignant transformation? 1.No malignant potential 2.Low risk 3.Medium risk 4.High risk

No malignant potential

Q17: What pathological feature is most likely to suggest a colorectal adenoma than a hyperplastic polyp? 1.Epithelial dysplasia 2.Dense inflammatory infiltrate 3.Epithelial metaplasia 4.Vascularisation 5.Mucus filled crypts

Epithelial dysplasia

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

A 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. An assessment of the patient for risk of dehydration is performed. Q19: What sign on examination is most likely to indicate dehydration? 1.Bounding pulse 2.Absent bowel sounds 3.Increased skin turgor 4.Raised JVP 5.Postural hypotension

Postural hypotension

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?

A 74year old female presents with a 3 day history of fever, watery diarrhoea abdominal pain. She has a 30 pack year smoking history with COPD and multiple infective exacerbations. Her last hospital admission for inpatient treatment was 6 weeks ago requiring treatment with clindamycin. On examination she is febrile and her abdomen is soft with diffuse tenderness. Q21: The most likely organism responsible for her presentation is: 1. Giardia lamblia 2. Clostridium difficile 3. Escherichia coli 4. Campylobacter jejuni 5. Shigella

Clostridium difficile

A 35year old female presents with a 6 hour history of abdominal cramps and diarrhoea associated with nausea and vomiting following a take away meal earlier in the day. A couple of her friends also have the same complaints. Q22: What is the most likely causative organism for her diarrhoea? 1. Staphylococcus aureus 2. Bacillus cereus 3. Clostridium botulinum 4. Campylobacter jejuni 5. Shigella

Staphylococcus aureus

A 60 year old male presents with a 4 month history of rectal bleeding. He has noticed bright red blood on the toilet paper on wiping. No blood on the bowl or mixed with faeces. This is accompanied by a change in his bowel habit with increasing constipation. He does not have any pain. Q23: What is the most likely diagnosis? 1.Colorectal carcinoma 2.Anal fissure 3.Haemorrhoids 4.Pilonodalsinus 5.Perianal haematoma

Haemorrhoids

Hormone ADH acts mainly on, PCT DCT Loop of Henle Glomerulus Collecting duct

Collecting duct

the endocrine gland JGA secretes, Renin Angiotensin I Angiotensis II Aldosterone Erythropoietin

Renin

Albuminuria in nephrotic syndrome is due to damage to Endothelium Podocyte foot processes Basement membrane DCT PCT

Podocyte foot processes

Oliguria in Nephritic syndrome is due to, Damage to filtration membrane Inflammation of glomeruli Damage to basement membrane Damage to nephrin molecules Compression of capillaries

Compression of capillaries

Proliferative or Post streptococcal glomerulonephritis & Rapidly progressive glomerulonephritis typically cause Nephrotic Syndrome Proteinuria Nephritic Syndrome Hematuria Acute Renal Failure

Nephritic Syndrome

Early Diabetic nephropathy typically causes Micro albuminuria Proteinuria Hematuria Both Hematuria & Proteinuria Massive albuminuria

Micro albuminuria

Injury to podocyte slit membrane alone typically causes Micro albuminuria Nephrotic syndrome Nephritic syndrome Isolated Proteinuria Isolated hematuria

Nephrotic syndrome

Blood cells are stopped at this level of glomerular filtration membrane, Endothelial fenestrations Basement membrane Podocyte foot process Podocyte slit membrane Bowman's membrane

Endothelial fenestrations

if a disease affects >50% of glomeruli then it is known as this type of glomerulonephritis (GN) Focal segmental GN Global GN Focal GN Diffuse GN Segmental GN

Diffuse GN

RBC casts in the urine microcopy indicate this pathology, Severe infection Urinary stones Glomerular damage Tubular damage Renal Carcinoma

Glomerular damage

Typical clinical feature of Nephritic syndrome is Oliguria, Hematuria, azotemia, Hypertension & Non selective proteinuria. True False

Massive albuminuria, typical of Nephrotic syndrome is because of, Glomerual endothelial damage Mesangial inflammation Tubular damage Basement membrane damage Podocyte damage

Podocyte damage

Microscopic feature in Post Streptococcal Glomerulonephritis (PSGN) is marked inflammation and hypercellularity of tubules. True False

Crescents of RPGN are formed by, RBC & Platelets Albumin Protein casts Inflammatory exudate Antigen & Antibody Complex.

Inflammatory exudate

Rapidly progressive GN is not a separate condition but end result of many other types of GN. True False

Cause of Oedema in nephrotic syndrome is because of, Hyperlipidemia Lipiduria Hypoalbuminemia Massive albuminuria Hematuria

Hypoalbuminemia

Cause of Hyperlipidemia in nephrotic syndrome is because of, Excess absorption of lipids from GIT excess lipids in the diet Liver response to hypoalbuminemia Idiopathic Decreased excretion of lipids

Liver response to hypoalbuminemia

Common cause of nephrotic syndrome in adults is due to Minimal change disease. True False

Common cause of nephrotic syndrome in adults is due to Minimal change disease.

in membranous GN, proteins deposited within basement membrane are, IgM & IgG IgM & C3 IgG & C3 IgA1 & Complement Only complement

IgG and C3

There is dramatic response to steroids in patients with membranous glomerulonephritis. True False

False

Lipiduria is typically seen in Nephritic syndrome. True False

False

Berger's disease is seen in chronic liver disease patients. True False

Clinically common type of Acute Renal Failure (ARF) is, Ischemic Toxic Pre-Renal Renal Post Renal

Pre-Renal

Typical Urinary finding in Acute Tubular Necrosis (ATN) is, Proteinuria Hematuria Protein casts Epithelial casts Leukocyturia

Epithelial casts

One example cause of Pre-Renal ARF would be, Muscle injury Hemolysis Infection Dehydration Analgesic Abuse

Dehydration

Toxic type of Acute Tubular Necrosis (ATN) involves, Only PCT Only DCT Loop of Henley Any part of tubule. both PCT & DCT

PCT

Commonest cause of Nephrosclerois is, Toxins Drugs Diabetes Hypertension Myoglobin

Hypertension

Typical Gross feature of Kidney in chronic hypertension is, Atrophy Organge peel kidney Flea bitten kidney Fibrinoid necrosis Interstitial nephritis

Organge peel kidney

Commonest clinical type of Renal ARF is Vascular disorders Glomerularulonephritis Interstitial nephritis Tubular necrosis

Tubular necrosis

Two major types of Chronic Renal Failure (CRF) are primary & secondary. True False

early & common clinical features of uremia is, Kussmaaul Breathing Osteodystrophy Nausea Myopathy Neuropathy

Nausea

typical clinical feature of Stage 2 CRF is, Nausea Vomiting Kussmaul Breathing Bleeding Asymptomatic

Asymptomatic

Common etiology of Pyelonephritis is Hematogenous spread of infection. True False

Typical microscopic feature in endstage renal disease is, Interstitial inflammation tubular atrophy glomerular scarring protein casts hemorrhage

glomerular scarring

small shrunken kidney with fine granular surface is typcal of Diabetes Pyelonephritis Chronic Hypertension Analgesic nephropathy Chronic glomerulonephritis

Chronic Hypertension

small shrunken kidneys with large irregular scars is typica of Diabetes Hypertension Analgesic abuse Chronic glomerulonephritis Pyelonephritis

Pyelonephritis

Nausea, Vomiting with pruritis is typcal seen in patients with, ESRD Benign nephrosclerosis Diabetic nephropathy Hypertensive nephropathy Pyelonephritis

ESRD

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 clinical study is performed with paediatric subjects who had minimal change disease. These patients are observed to have prominent periorbital oedema. Laboratory test findings from serum and urine tests are analysed. Which of the following laboratory test findings is most diagnostic of this condition? Nitrite positive urinalysis specimen Proteinuria >3.5 gm/24 hours Hematuria with >10 RBC/hpf Lipiduria & hypercholesterolemia Renal tubular epithelial cells and casts

Proteinuria >3.5 gm/24 hours

A 12 year old boy is a member of a family with a history of renal disease, with males more severely affected than females. He is found to have auditory nerve deafness, corneal dystrophy, and ocular lens dislocation. A urinalysis shows microscopic haematuria. Image shows appearance of his glomerulus on electron microscopy. Which of the following is the most likely diagnosis? What is abnormal? Pathogenesis? Why males? Why Hematuria? Prognosis? Diabetes mellitus, type I IgA nephropathy Alport syndrome polycystic kidney disease Goodpasture’s syndrome

Alport syndrome

A clinical study is performed of laboratory findings in subjects with renal diseases. Loss of physiologic function accompanies many diseases. Loss of which of the following renal functions is most likely to be identified by laboratory measurement of the urine specific gravity? Filtration Blood flow Reabsorption Secretion Concentration

Concentration

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 clinical study is performed involving subjects with glomerulonephritis. One group of subjects has a diagnosis of crescentic glomerulonephritis and another group has membranous glomerulonephritis. Which of the following feature is most likely to be found in subjects with membranous glomerulonephritis? Massive selective Albuminuria Hematuria & Proteinuria Red blood cell casts Massive proteinuria & lipiduria Hypertension & Hematuria

Massive selective Albuminuria

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 clinical study is performed to determine the value of percutaneous renal biopsy. The medical records of subjects with renal diseases are analysed to determine the circumstances in which the results of a renal biopsy facilitated determination of therapy that improved prognosis. In which of the following situations is a percutaneous needle biopsy of the kidney most useful? Prostatic hyperplasia with suspected hydronephrosis Systemic lupus erythematosus and acute renal failure Premature neonate with suspected polycystic kidney; disease Fever with suspected acute pyelonephritis Suspected renal cysts

Systemic lupus erythematosus and acute renal failure

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 78 year old man with chronic hypertension died following progressive loss of kidney function over several years and 6 years before his death he was dependent on regular dialysis. Image shows gross & microscopic appearance of his kidney. What is the most likely cause of his renal failure? Identify features labeled A, B & C? What gross features are shown in his kidney specimen? What would be the appearance in other options (Pyelonephritis, infarction, ESRD etc)? Recurrent Renal Infarction Chronic Pyelonephritis Benign nephrosclerosis Endstage renal disease Malignant hypertension

Benign nephrosclerosis

A 25 year old male has recurrent haematuria usually following an episode of URTI. No remarkable findings on physical examination. Urine analysis shows a ph 6.5, specific gravity 1.018, hematuria 3+, proteinuria1+, no glucose or ketone bodies. Microscopic examination of urine shows RBC & RBC casts, but no increase in WBC or other casts or crystals. A 24 hr urine protein level is 200 mg. What do you expect in renal biopsy from this patient? Hyaline arteriolosclerosis. Subepithelial electron dense deposits Mesangial IgA deposits Diffuse proliferative glomerulonephritis Granular staining of basement membrane

Mesangial IgA deposits

A 54 year old male is having recurrent infections in urinary tract along with polyuria and nocturia. His kidney biopsy shows the following picture. What is the most likely diagnosis? What features A & B?, etiology?, Pathogenesis? clinical features? Complications? Nodular glomerulosclerosis Rapidly progressive GN Membranous GN Diffuse proliferative GN Minimal change GN

Nodular glomerulosclerosis

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

here are the three types of Acute Kidney Injury Give 2 causes for each Pre-renal: Renal: Post-renal:

Pre-renal: dehydration, sepsis, renal artery stenosis, hypertension, hemorrhage Renal: acute pulmonary nephritis, pyelonephritis, nephrotoxins, ischemia, infection, malignant hypertension vasculitis. Post-renal: calculi, BPH

An otherwise fit 21-year-old motorcyclist (weight 100kg) is admitted to hospital after a motorcycle accident resulting in a badly fractured femur. He has a urinary catheter in place while waiting for theatre. He has only passed 40 mL of urine since admission 4 hours ago . Q1. Does he have AKI? a) Yes b) No

No, since not greater than 6 hours 0.5XweightX hours in the hospital

A 72-year-old Aboriginal woman (pre-op weight 80 kg) has passed a total of 200 mL of urine in the 12 hours since her hysterectomy. Background of Hypertension and CKD. Q2. Does she have AKI? a) Yes b) No

Yes, acute on chronic 0.5XweightX hours in the hospital

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 28-year-old man presented yesterday with abdominal pain which developed after a mountain bike accident. He is normally in good health. He had an uncomplicated emergency splenectomy this morning. He has indwelling urinary catheter. Urine output has been 10-20 mL/hour for 6 hours. Prior to surgery, it was normal. He normally weighs 90kg. On examination. T 36.8°C, HR 112/min, BP 90/62 mm Hg. Cool peripheries. Abdomen: midline laparotomy scar and marked abdominal bruising and multiple grazes. Q3. Which of the following is the most likely cause of his AKI? a. Pre-renal failure b. Interstitial nephritis c. Renal vasculitis d. Post streptococcal glomerulonephritis e. Hydronephrosis

Pre-renal failure

28-year-old man presented yesterday with abdominal pain which developed after a mountain bike accident. He is normally in good health. He had an uncomplicated emergency splenectomy this morning. He has indwelling urinary catheter. Urine output has been 10-20 mL/hour for 6 hours. Prior to surgery it was normal. He normally weighs 90kg. On examination. T 36.8°C, HR 112/min, BP 90/62 mm Hg. Cool peripheries. Abdomen: midline laparotomy scar and marked abdominal bruising and multiple grazes. Q4: Which of the following investigations is indicated in this patient? a) ACR b) KUB X-ray c) VBG d) Kidney biopsy e) Renal angiography

VBG- gives haemoglobin, potassium level, lactate, pH, bicarb, and glucose.

A 28-year-old man presented yesterday with abdominal pain which developed after a mountain bike accident. He is normally in good health. He had an uncomplicated emergency splenectomy this morning. He has indwelling urinary catheter. Urine output has been 10-20 mL/hour for 6 hours. Prior to surgery it was normal. He normally weighs 90kg. On examination. T 36.8°C, HR 112/min, BP 90/62 mm Hg. Cool peripheries. Abdomen: midline laparotomy scar and marked abdominal bruising and multiple grazes. Urine microscopy report shows epithelial casts. Q5. What is the most likely cause of the epithelial casts? A. Acute glomerulonephritis B. Ischaemic ATN (Acute Tubular Injury) C. Nephrotic syndrome D. Papillary necrosis E. Toxic ATN (Acute Tubular Injury)

Ischaemic ATN (Acute Tubular Injury)

A 28-year-old man presented yesterday with abdominal pain which developed after a mountain bike accident. He is normally in good health. He had an uncomplicated emergency splenectomy this morning. He has indwelling urinary catheter. Urine output has been 10-20 mL/hour for 6 hours. Prior to surgery it was normal. He normally weighs 90kg. On examination. T 36.8°C, HR 112/min, BP 90/62 mm Hg. Cool peripheries. Abdomen: midline laparotomy scar and marked abdominal bruising and multiple grazes. Q6. Which of the following would be the most appropriate first step in management?? a. Haemodialysis b. IV fluid resuscitation c. IV furosemide d. Return to theatre e. Steroids

IV fluid resuscitation

78-year-old male presents with a 2-3 day history of weakness and “the worst diarrhea in my life”. Last week, he was started on a regular NSAID for disabling neck pain. He has a background history of hypertension, T2 diabetes and CCF. * Meds: NSAID ibuprofen 400mg bd. * Paracetamol 500mg 2 tab qid prn * Furosemide 40mg tab mane * Candesartan (ARB) 8mg mane * Metformin XR 2g daily His BP is 94/60. His BSL is 8. Table talk 3: List his risk factors for AKI

triple whammy: NSAID, diuretic, Dehydration age HTN T2DM polypharmacy hypotensive

78-year-old male presents with a 2-3 day history of weakness and “the worst diarrhoea in my life”. Last week, he was started on a regular NSAID for disabling neck pain. He has a background history of hypertension, T2 diabetes and CCF. Meds: NSAID ibuprofen 400mg bd. Paracetamol 500mg 2 tab qid prn Furosemide 40mg tab mane Candesartan (ARB) 8mg mane Metformin XR 2g daily His BP is 94/60. His BSL is 8. Q7. Which of the following would confirm AKI in this patient? a) eGFR decrease by 50%. b) Increased urea/creatinine ratio c) Macroscopic haematuria d) Rising creatinine 75 to 130 e) Urinary frequency

Rising creatinine 75 to 130

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 6-year-old presents with lower limb oedema. On investigation, urinalysis shows ++++ proteinuria, no blood Q11. Which syndrome is this more consistent with? a) Nephrotic syndrome b) Nephritic syndrome

Nephrotic syndrome

A 6-year-old presents with lower limb oedema. On investigation, urinalysis shows ++++ proteinuria, no blood Q12. What is the most likely cause of this patient’s symptoms? a) Systemic Lupus Erythematosus b) Membranous glomerulonephritis c) Post-streptococcal glomerulonephritis d) Minimal change disease e) IgA nephropathy (Berger’s)

Minimal change disease

A 46-year-old male presents to their GP for a “heart health check”. The patient has a hypertension but is not on any medications. He has no other medical conditions. A cardiovascular risk assessment is performed which calculated the patient’s risk as 17%. Initial testing revealed a normal creatinine (72) and eGFR>90. The patient is started on an ACEi and statin. Four weeks later the patient returns and is feeling well. A repeat UEC showed a significant increase in the serum creatinine to 200. Q13. What is the most likely cause for this acute kidney injury? a) Hypovolaemia b) Malignant hypertension c) Multiple myeloma d) Polycystic kidney disease e) Renal artery stenosis

Renal artery stenosis

ACR

Stage 3b

A 60-year-old woman presents the GP with a 3-month history of fatigue. She has a 20-year history of HTN for which she was prescribe anti-hypertensives, but she stopped these 10 years ago, electing try to a “natural” approach. A review of her records reveal she had known stage 1 chronic kidney disease 10 years ago. On examination, she looks well but her BP is 160/100. Q16. Apart from the hypertension, what further information in the patient’s history would increase her risk of chronic kidney disease? a) History of acute rheumatic fever b) Hypothyroidism c) Inhaled corticosteroid use d) High muscle mass e) Stable angina

Stable angina

A 60-year-old woman presents the GP with a 3-month history of fatigue. She has a 20-year history of HTN for which she was prescribe anti-hypertensives, but she stopped these 10 years ago, electing try to a “natural” approach. A review of her records reveal she had known stage 1 chronic kidney disease 10 years ago. On examination, she looks well but her BP is 160/100. The patient is found to have no other risk factors for CKD in addition to the long-standing hypertension. Q17. If a biopsy were performed, which of the following would suggest that hypertension is the cause? a) Compressed capillaries b) Arteriolosclerosis c) Normal d) Thickened basement membrane

Arteriolosclerosis

A 60-year-old woman presents the GP with a 3-month history of fatigue. She has a 20-year history of HTN for which she was prescribe anti-hypertensives, but she stopped these 10 years ago, electing try to a “natural” approach. A review of her records reveal she had known stage 1 chronic kidney disease 10 years ago. On examination, she looks well but her BP is 160/100. The patient is found to have no other risk factors for CKD in addition to the long-standing hypertension. The patient returns for review 2 years later. She has not been able to afford her medications. Her BP today is 152/93. Multiple investigations are completed. Q18. What further information of history, exam or investigations would indicate the need for the patient to start dialysis? a) ACR >300 b) Bilateral pedal oedema c) eGFR 25 d) Fatigue e) Normocytic anaemia f) Osteoporosis g) Uraemic symptoms

Uraemic symptoms

Q19. What is the most common cause of end stage kidney disease in Australia? * Diabetes * Glomerulonephritis * Hypertension * Polycystic Kidney Disease

Diabetes

Commonest organism causing UTI is, E coli Ureaplasma Enterococci Chlamydia Staphylococcus saprophyticus

E coli

High grade fever is typical of, Urethritis Cystitis Prostatitis Urethritis Pyelonephritis

Pyelonephritis

Common strain of E coli causing UTI is, (also read about other options - infective diarrhoea) EHEC ETEC UPEC EPEC EAEC

UPEC

Morphology of UPEC bacteria is, Gram positive cocci Gram negative cocci Gram positive bacilli Gram negative bacilli Gram negative diplococci

Gram negative bacilli

Commonest type of renal stone is, Calcium Phosphate Ammonium oxalate Struvite Tripple phosphate Calcium oxalate

Calcium oxalate

A routine abdominal radiograph shows a large staghorn calculus in a 56 year old asymptomatic patient. the most likely pathogenesis of the stone formation is, Hypercalciuria - familial Defective renal reabsorption Excess phosphate excretion infection by Proteus vulgaris Hyperuricemia (Gout)

infection by Proteus vulgaris

34 year old male patient presents with severe writhing spasmodic pain in the loin radiating to scrotum. Associated with nausea & vomiting. Most likely location of stone is, Renal Calyces Renal Pelvis Ureteropelvic junction body of Ureter Ureterovesical junction. Urethra

body of Ureter

A patient with renal stone has urinary pH of 5.1. What is the most likely type of stone in this patient? Calcium oxalate Tripple phosphate Uric acid Cystine Ammonium phosphate

Uric acid

Commonest acquired cystic disease of kidney is, ADPKD ARPKD Dialysis associated cysts Simple cysts Adult polycystic Kidney disease.

Simple cysts

Commonest genetic or familial polycystic kidney disease is, ARPKD ADPKD Dialysis associated cysts Simple cysts

ADPKD

Cerebral berry aneurysms are typically associated with, ADPKD ARPKD Renal Cell Carcinoma VHL - familial carcinoma Sy Wilms's tumor

ADPKD

typical gross feature of Renal Cell Carcinoma is, Fleshy necrotic & Haemorrhagic Cystic with hemorrhage Sponge kidney Well demarcated <3cm. Lipoma likew well demarcated.

Lipoma like well demarcated.

Familial cancers of kidney are typically multiple & bilateral. True False

True

Typical clinical feature of BPH, incomplete voiding and poor stream on straining is due to, Narrowing of urethra Bladder hypertrophy Bladder dilatation trabeculations Ball valve mechanism

Ball valve mechanism

Pathogenesis of hyperplasia in BPH is due to growth promoting activity of, Androgens DHT 5 alpha reductase Testosterone Estrogens

DHT

Palpation of median groove in DRE is typical of prostatic cancer. True False

False

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 40 year old previously healthy man has sudden onset of severe right flank pain that comes in waves all night long. Urinalysis shows no ketones, glucose, protein, nitrite, but blood is positive. Urine microscopy shows plenty of RBC's & no casts. Which of the following is the most likely diagnosis? Urothelial carcinoma of bladder Ureter calculus Prostatic carcinoma Acute glomerulonephritis Renal staghorn calculus

Ureter calculus

The combination of sudden severe acute flank pain and microscopic hematuria is suggestive of, Acute cholecystitis Acute Cholelithiasis Urolithiasis Renal cell Carcinoma Bladder carcinoma

Urolithiasis

34 year old man has presented to ED with sudden severe spasmodic flank pain since 3 hours and has vomited twice. On examination he is writhing in pain. Urine dipstick reveals only 1+ blood positive. He had similar attack twice since last year. He is otherwise healthy and all system examinations are normal, and routine laboratory investigations are within normal limits. What is the most likely etiology? (common etiology of urolithiasis?) list two major types of urolithiasis, common locations of stone & their clinical features? Chronic UTI Dehydration Familial hypercalciuria Hypercalcemia Hyperparathyroidism

Hypercalcemia

A 70-year-old man at ED with severe abdominal pain & anuria since last night. History reveals chronic urinary obstruction and DRE confirms BPH & a distended bladder. Laboratory investigations show decreased serum sodium & increased BUN & creatinine, but urinary sodium level is high. What is the most likely cause of his abnormal results? ARF-Postrenal Ischemic tubular necrosis Chronic Renal Failure ARF-Intrarenal ARF-Prerenal

Prerenal: urinary Na+ < 10, urine osmolality > 500, Fe Na+ < 1%, BUN/Cr > 20; Intrarenal: urine osmolality < 350, Fe Na+ > 2%, urinary epithelial/granular casts; (3) Postrenal: urinary Na+ > 40, Fe Na+ > 4%; BUN/Cr > 20 CRF: slow with compensation, normal urine osmolality & volume until ESRD.

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)

A 32y old man presents with a 3 day history of red urine and ankle oedema. His serum creatinine is 590 µmol/L (70-120) . What electrolyte abnormality will be typically seen in him? Metabolic alkalosis with respiratory compensation Respiratory acidosis with renal compensation Metabolic acidosis with no compensation Respiratory alkalosis with renal compensation Metabolic acidosis with respiratory compensation

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

65 yo male presents with vague discomfort in right loin region for the last 2 months but is presenting today because there was bright red blood in his urine. On examination, he has a palpable mass on ballottement of the right kidney and he undergoes nephrectomy. Q7. Which is the most likely feature resulting from paraneoplastic syndrome in this patient? 1. Anaemia 2. Polycythaemia 3. SIADH 4. Thrombophlebitis 5. Cushings

Polycythaemia

NEW CASE: 45yo female presents with pain on passing urine, urinary frequency and “smelly” urine. Q8. Which of the following signs would suggest pyelonephritis rather than cystitis? 1. Dysuria 2. Fever 3. Frequency 4. Suprapubic pain 5. Urgency

Fever

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?

1. haematuria 2. contamination 4. mixed picture (contamination) 3. ANSWER

The following patients had a urine MCS completed. They report no symptoms of dysuria, haematuria or increased urinary frequency. The report reads: <10x106 /L leukocytes, <10x106 /L erythrocytes, <10x106 /L epithelials, growth – E coli >105 /L Q11. Which of the following patients need antibiotic treatment? 1. Pregnant woman 2. Woman who was treated with antibiotics for a UTI 6 weeks ago 3. Elderly man in a nursing home who has a urinary catheter for incontinence (post prostatectomy) 4. 1 year old child 5. Older male with BPH

Pregnant woman

NEW CASE: 52yo male presents with 12 hours of R back pain, coming around to front and groin. Increasing in severity, now unbearable and associated with bright red urine. He has no history of gout or recurrent UTIs. Q12. What is the most likely diagnosis? 1. Acute pyelonephritis 2. GN 3. Renal cell CA 4. Urolithiasis 5. Urothelial carcinoma

Urolithiasis

52yo male presents with 12 hours of R back pain, coming around to front and groin. Increasing in severity, now unbearable and associated with bright red urine. He has no history of gout or recurrent UTIs. Q13. What is the most likely composition of this patient’s renal stone? 1. Calcium oxalate 2. Calcium phosphate 3. Cystine 4. Magnesium ammonium phosphate – struvite 5. Uric acid

Calcium oxalate

52yo male presents with 12 hours of R backpain, coming around to front and groin. Increasing in severity, now unbearable and associated with bright red urine Q14. What first line investigation do you do to confirm the diagnosis? 1. CT KUB 2. IVP 3. MRI abdo 4. Plain AXR 5. US KUB

CT KUB

52yo male presents with 12 hours of R backpain, coming around to front and groin. Increasing in severity, now unbearable and associated with bright red urine CT KUB: 6mm stone found The patient is advised to keep hydrated, monitor urine output and pee into strainer Q15. Which of the following may assist in the passage of the stone? 1. Alpha blockers 2. Beta blockers 3. NSAIDs 4. Opioids

Alpha blockers

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

A 50 yo male presents to remote area GP with 6/12 history of fatigue, low energy, itchy skin and headaches. Last saw the GP about 10yrs ago post leg fracture from MVA. No previously known HTN or diabetes. Unknown family history. EtOH – occasional binges. Smoker, 30py. O/E. BP 220/110 with bilateral ballotable kidneys. Blood test results show eGFR 25ml/L/1.73m² Q16. What is the most likely diagnosis? 1. Hydatid cyst 2. Polycystic kidneys 3. Renal cell carcinoma 4. Urothelial Carcinoma 5. von Hippel Lindau disease

Polycystic kidneys

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. His blood pressure is 122/60 No renal angle tenderness, no ballotable/palpable loin masses, no suprapubic mass Q1 What is the most appropriate investigation for one episode of painless non- visible haematuria? 1. Cystoscopy 2. eGFR 3. MC&S 4. UEC 5. US KUB

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. His blood pressure is 122/60 No renal angle tenderness, no ballotable/palpable loin masses, no suprapubic mass His MCS report comes back: “Dysmorphic red cells are present” Q2. Of the following, what is the most likely diagnosis? 1. Ureteric stone 2. Bladder cancer 3. Cystitis 4. IgA nephropathy 5. Pyelonephritis

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