Quesmed/Passmed Wrong Qs Flashcards
A 45-year-old man presents with pleuritic chest pain and sudden-onset breathlessness. He has a past medical history of end-stage renal failure on dialysis and heart failure.
A CTPA is performed which shows evidence of pulmonary emboli in both arteries.
What is the best treatment at this stage?
Unfractionated heparin is used preferentially to direct oral anticoagulants (DOACs) if a patient has severe renal insufficiency.
DOACs all have some degree of renal clearance (66% in rivaroxaban, 25% in apixaban) which can lead to unstable pharmacodynamics.
A 21 year old man presents to the eye clinic complaining of bilateral ptosis, worse at the end of the day. He is otherwise well and denies any weakness.
On examination, he has a mild bilateral ptosis with normal extra-ocular muscles. No other abnormalities are found.
He has no past medical history but has had an incidental finding of a diffusely enlarged thymus gland on a recent MRI.
What is the best bedside investigation to reveal the diagnosis?
Ice Pack Test
This patient has a clinical picture consistent with myasthenia gravis. An ice-pack test can be used to investigate this condition. Ice, wrapped in a towel, is placed over the closed eyelid for 2 minutes. The test is positive if greater than 2mm of elevation of the lids
A 26-year-old woman presents to her GP complaining that her periods have become more painful in the last 12 months. The pain tends to start two weeks before her period and improves as the period continues. She informs you that going to the toilet for a poo is difficult due to increased pain and she also has painful sex with her partner which is causing some relationship issues. She denies changes to discharge and new sexual partners. She has no signficant gynaecological history and has no children. She has never been pregnant and currently takes the progesterone-only pill. Her menarche was at 13 years.
Pelvic examination and pelvic ultrasound scan are normal.
Which of the following is the most likely diagnosis?
Endometriosis
This is the correct answer. It typically presents with pelvic pain where previously periods were painless. Characteristic symptoms include dyspareunia, problems with fertility and painful defecation. The pain may be chronic or cyclical. Pelvic examination is often normal, but in extensive cases of endometriosis there may be tenderness or palpable nodules. Pelvic ultrasound is often normal; however in some cases it may identify an ovarian endometrioma
A 28-year-old male has been brought into A&E following concerns raised by his housemates. He claims to have been blessed with special powers which enable him to predict the future. He believes he can heal others and is related to the pope.
What type of delusion would this be classed as?
Grandiose
This is a delusion type where the person has a heightened sense of self-worth/power/knowledge or believes they have powers no one else has.
A 19-year-old woman attends her GP reporting three episodes of bothersome post-coital bleeding in the past 2 weeks. She describes it as ‘mild spotting’ and has no associated pain. She denies any other symptoms. She has no significant past medical history and her only regular medication is the combined oral contraceptive pill. She has never been pregnant in the past. On speculum examination, a red velvet halo is seen surrounding the cervical os. What is the most appropriate next investigation in this case?
Colposcopy
The most likely diagnosis here is a cervical ectropion. There are various management options of this case, but this is the most appropriate one available. If the patient was not concerned about the bleeding, and the GP is certain of the diagnosis, she could be reassured without further investigation. If the woman finds the bleeding bothersome (which the vignette states she does), she can be referred for colposcopy as a non-urgent case, where the lesion may be cauterised to stop the bleeding. If the GP is unsure of the diagnosis and is concerned about cervical cancer, she should be referred for colposcopy urgently. Hence, colposcopy is the most appropriate answer here.
A 2-year-old girl presents to the GP with her parents as they are concerned about their daughters growth. For six months, her appetite has been poor. She is not vomiting, but her stools are very loose, pale and smelly. There is no blood or mucous in her stool. On examination, she is pale. Her abdomen is distended with an everted umbilicus but no masses are palpable. Her weight and height are measured to be in the 25th percentile.
Which of the following is the most likely underlying diagnosis?
Coeliac Disease
This is the correct answer. This child is presenting with steatorrhoea, abdominal distension and failure to thrive making Coeliac disease the most likely diagnosis. Coeliac disease is caused by a sensitivity to gluten, and in children, features start to develop when cereals are introduced into their diet (after weaning). The abdominal distension is caused by distension of the bowel with gas and fluids. The irritability is likely secondary to anaemia, which is a common complication of coeliac disease
An 11 month old boy is brought in by his mother. He has been increasingly lethargic over the past 3 days. Over the last day, he has been recurrently kicking his legs in the air. He vomited 3 times yesterday. His mother noticed blood in his nappy this morning which she reports looking like ‘jelly.’ There is no evidence of peritonitis.
He has a heart rate of 100 and blood pressure of 100/60. He is afebrile. US abdomen reveals concentric echogenic and hypoechogenic bands.
What is the best intervention?
Contrast or air enema
Contrast enema is correct. This case describes intussusception with ‘target sign’ seen on ultrasound abdomen. It can be used as diagnostic test but also can be used as a method for reduction. Air enema is the may be preferred as the method of choice as offers fewer complications than contrast enema
A 63 year old lady presents to her GP with a neck lump that has been growing rapidly for 3 weeks. She reports that she is now having difficulty swallowing and breathing. On examination she has large, hard mass in the left anterior aspect of the neck which moves up on swallowing but not on tongue protrusion. There is also associated cervical lymphadenopathy. What is the most likely diagnosis?
Anaplastic thyroid cancer
This is correct. Although anaplastic thyroid cancer is one of the rarest forms, it is classically extremely fast growing and aggressively invades local structures and presents between 60-70 years old
A 62 year old man presents to A&E after experiencing severe headaches and double vision for several days. On examination, his left eye is held in a lateral and downwards gaze with associated pupillary mydriasis. He has left sided ptosis.
Disease of which of the following arteries is most likely to be the cause of his symptoms?
Left posterior communicating artery
A patient with signs of an oculomotor nerve palsy (cranial nerve 3) with pupillary signs (mydriasis) should be assumed to have an aneurysm of their ipsilateral posterior communicating artery until proven otherwise. This is due to the close proximity of the oculomotor nerve to the posterior communicating artery before it enters the cavernous sinus. Extrinsic compression by an aneurysm affects the more superficial parasympathetic fibres of the oculomotor nerve, causing pupillary signs as well as ophthalmoplegia. This is different from ischaemic or diabetic palsies of the oculomotor nerve which tends to only cause an ophthalmoplegia and no pupillary signs
A 14 year old boy of afro-caribbean descent presents to PAU having felt very tired and lethargic for the past couple of days. This is very unusual for him. He is noted to have conjunctival pallor, tachypnoea and tachycardia. His blood pressure and capillary refill time appear normal. On examination his abdomen is soft and non-tender with no organomegaly noted. He is afebrile but reports he did have a fever last week. He doesn’t report any pain. Given the most likely diagnosis which complication is he most likely to be suffering from?
Aplastic crisis
Correct. An aplastic crisis (reticulocytes <1%) is also known as transient red cell aplasia or reticulocytopaenia. Aplastic crisis in Sickle Cell Disease is characterised by the combination of tachypnoea, tachycardia in the absence of splenomegaly. Given the absence of pain, jaundice, fever, pain and splenomegaly this is the most likely complication
A 19 year old female presents with intermittent, worsening abdominal pain, nausea and lethargy. She is confused, but her boyfriend describes her as otherwise fit and well apart from a recent course of nitrofurantoin for a urinary tract infection. All abdominal imaging has been normal and there is no clinical evidence of jaundice.
Which of the following investigations is most likely to reveal the cause of her symptoms?
Urinary porphobilinogen
The symptoms and signs described in this patient are suggestive of a diagnosis of acute intermittent porphyria, a disorder of haem metabolism. Attacks can be triggered by infection and medication such as nitrofurantoin. Diagnosis can be made on the basis of raised urinary porphobilinogen (PBG); the urine sample collected needs to be protected from light sources as these cause degradation of the PBG
A 24-year-old medical student presents to the emergency department with a single episode of bloody diarrhoea. She also reports dysuria and haematuria since returning from her elective in Tanzania one week prior.
What is the most appropriate treatment?
Praziquantel
This patient likely has schistosomiasis. Therefore, praziquantel should be given now and again in 2 months to destroy the flukes responsible. Of note, corticosteroids would also be indicated if she presented with Katayama fever, a hypersensitivity reaction.
A 69 year old male presents to the GP with a painful lesion on his left lower leg which has appeared after grazing his ankle on a rock. Initially, a small red lesion formed but this has deepened and widened rapidly. He has previously had a similar lesion on his right shin after a minor injury to the area. Aside from his underlying Rheumatoid Arthritis, he is well. On examination, the skin lesion in the image below is seen. Considering the likely diagnosis, which of the following is the most appropriate initial management?
Oral Prednisolone
The patient has a Pyoderma Gangrenosum which is a rare, inflammatory skin condition causing painful ulcers. The ulcers are typically on the lower limb and can develop following minor trauma. It presents initially as a small, erythematous papule which develops into a deep ulcer with a purple border, as seen in the image shown. Pyoderma Gangrenosum is associated with underlying conditions such as Inflammatory Bowel Disease, Rheumatoid Arthritis and Leukaemia. The management of Pyoderma Gangrenosum is with corticosteroids, such as Prednisolone, either topical or oral depending on the size of the ulcer. Other immunosuppressive therapies can be added as second line
What medication is used in the management of benzodiazepine intoxication?
Flumazenil
What medication is used in the management of Amphetamine intoxication?
Benzodiazepines
(could also use alpha blockers)
