Question bank Flashcards

Question

A 72 year old woman is being treated for a diabetic foot ulcer and is afraid she may need an amputation. Serum potassium today is markedly elevated. Results over the past week have been normal. You find out the 2nd year medical student had some difficulty drawing the blood.

Answer 1

Pseudohyperkalaemia This is pseudohyperkalaemia caused by haemolysis of the sample. The medical student who has had some difficulty drawing the blood has haemolysed the sample. Potassium in serum will in this case exceed the plasma value by >0.5 mmol/L and the pink tinge when centrifuging the sample will also give this away.

Answer 2

Addison’s disease Hyperpigmentation is due to excess ACTH production and can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated in this condition. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s, such as this man’s vitiligo. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.

Answer 3

DKA Hyperpigmentation is due to excess ACTH production and can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated in this condition. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s, such as this man’s vitiligo. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.

Answer 4

Upper GI endoscopy NSAID use is a key risk factor for a peptic ulcer. Other key risks include H. pylori infection, smoking and FH of PUD. Zollinger-Ellison syndrome should be considered if there are multiple ulcers or ulcers refractory to treatment. The epigastric pain and symptoms of dark stools are consistent with a bleeding peptic ulcer. The most specific and sensitive test is an upper GI endoscopy which also allows management of the bleed. A biopsy may also be done to rule out malignant transformation. Gastric ulcers require a compulsory biopsy but duodenal ulcers rarely undergo malignant change. Management here can be aimed at discontinuing NSAIDs which are the cause in this case.

Answer 5

Chest x-ray The blood being brought up here occurs at a fixed time period every day and he is not anaemic. This makes you suspect a respiratory cause of his haemoptysis such as pneumonia – particularly TB, cancer, vasculitis like Wegener’s, bronchiectasis and bronchitis.

Answer 6

Clotting profile This woman is on prophylactic warfarin anticoagulation. There is an interaction here with the antibiotics this woman is taking which has resulting in enhanced anticoagulation effects of warfarin, causing her to bring up the blood. Cepahalosporins, chloramphenicol, ciprofloxacin, clarithryomycin, erythromycin and metronidazole are all examples which increase the effect of warfarin. Any P450 inducer will have this effect as warfarin is a drug metabolised by cytochrome P450 enzymes. Antibiotics can also upset the gut flora which reduces vitamin K levels.

Answer 7

Chest x-ray Idiopathic pulmonary fibrosis (previously known as Cryptogenic fibrosing alveolitis) progresses over several years and is characterised by pulmonary scar tissue formation and dyspnoea. Patients complain of a non-productive cough and typically reproducible and predictable SOB on exertion. This man’s work means he comes into contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. Another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. CXR here will show reticular opacities. A high resolution CT scan can also be done if it was an option on this list.

Answer 8

CT scan abdomen The cause here could be an aortoenteric fistula or AVM. You have to assume with endoscopy here that upper and lower GI endoscopy were unremarkable. The next step on this list would be a CT scan with contrast to detect the GI bleed. You would expect to see the active bleeding with contrast leaking into the bowel lumen.

Answer 9

Renal ultrasound A dominantly inherited cause of renal failure is likely to be polycystic kidney disease which is best noted on ultrasound

Answer 10

Renal ultrasound A patient with cervical carcinoma is at risk of ureteric obstruction and then hydronephrosis. Again ultrasound is the test of choice

Answer 11

Renal biopsy When the cause of renal failure might be nephritis (as in nephrotic syndrome) a renal biopsy will be needed to make the diagnosis. Occasionally this is urgent, so that potent immunosuppresives can be administered

Answer 12

Plasma electrophoretic strip Lethargy, back pain, hypercalcaemia and renal impairment all point towards multiple myeloma. Renal impairment in myeloma results from a combination of factors: deposition of light chains, hypercalcaemia, hyperuricaemia and (rarely) in patients who have had the disease for some time, deposition of amyloid. Serum protein electrophoresis characteristically shows a monoclonal band

Answer 13

Abdominal ultrasound This sounds like ADPKD. There may be a FH of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and SAH). Patients may have haematuria, palpable kidneys and symptoms of a UTI. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.

Answer 14

MSU: microscopy and culture This young woman has presented with a UTI (dysuria, frequency, haematuria). Sexual activity the strongest risk factor for UTIs in women and she’s just come back from ‘holiday’. It is diagnosed with a urine dipstick (already done), and microscopic analysis for bacteria, WBC and RBC and urine culture and antibiotic sensitivities. Antibiotic selection should be based on local guidelines or known sensitivities. Uncomplicated UTIs with no known antibiotic resistance can be treated with co-trimoxazole or nitrofurantoin. If there is resistance, a quinolone can be considered such as ciprofloxacin.

Answer 15

Cystoscopy "Warts in the bladder" is the way of some sneaky urologist avoiding telling this man he had cancer. He was treated, and like all cancer patients, was followed up. Unfortunately, this sounds like a recurrence. Gross haematuria is the primary symptom of bladder cancer. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.

Answer 16

Helical CT This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.

Answer 17

CT scan This patient has a dissecting aortic aneurysm which can be diagnosed with a CT scan showing the presence of an intimal flap. The CT scan should include chest, abdomen and pelvis to visualise the extent of the aneurysm. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. The aortic dissection has led to a cholesterol embolism. This can be diagnosed histopathologically with the finding of cholesterol crystals. The phenomenon where cholesterol is released from an atherosclerotic plaque is called ‘trash foot’. A highly technical medical term. This results in the mottled appearance of distal embolism associated with livedo reticularis. You can search the internet for some case reports of this phenomenon.

Answer 18

Venous duplex scan This patient has a DVT. Other risk factors include recent major surgery, active malignancy, pregnancy and malignancy. A Wells score is determined in all patients with a suspected DVT with the condition being likely if the score is 2 or greater. The most definitive test is venography but it is invasive. Compression USS of the proximal deep venous system is preferred but Doppler venous flow testing can be used if other tests are unavailable and will demonstrate low flow in affected veins. This requires a trained technician. Anticoagulation is the mainstay of treatment with unfractionated heparin, a LMWH or an anti FXa agent such as fondaparinux

Answer 19

Blood cultures This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis. It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature

Answer 20

Pre-eclampsia - syndrome characterised by new onset hypertension, and proteinuria in pregnant women after 20 weeks gestation. The only definitive treatment is to deliver the placenta.

Answer 21

Anti-neutrophil cytoplasmic antibody This patient has Wegener’s granulomatosis, a systemic vasculitis affecting small and medium sized vessels. The classic triad includes upper and lower respiratory tract involvement and GN. Musculoskeletal manifestations such as arthralgia and signs of thromboembolism are commonly seen. A positive cANCA (antigen being proteinase 3) in the setting of the classic triad is sufficient to diagnose Wegener’s. Urinalysis and microscopy is also indicated to reveal renal involvement and a CT chest may reveal lung involvement, particularly in those who are asymptomatic for pulmonary involvement. This may show nodules or infiltrates.

Answer 22

Arteriogram Diabetic neuropathy has lead to the painless ulcer developing over pressure points in the foot such as on the ball of this man’s foot. This may have resulted from an object becoming lodged in the shoe and eroding through the skin with walking. This is why it is important for diabetics to check their feet regularly and to wear specialised footwear. The black toes on his right foot are likely due to peripheral vascular disease. It is worth noting that peripheral vascular disease refers specifically to peripheral arterial disease. The first line study is an ABPI although an arteriogram can be done to identify areas of stenoses which can be treated surgically. The black mummified toes may have to be amputated.

Answer 23

Thick blood film In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This Sikh may have just arrived from an endemic area. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. Hepatosplenomegaly is a common presenting sign, although in the Western world, it is not common on initial presentation. The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. In this case, if you had to pick one, then the thick film would be more useful in establishing the diagnosis. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. However, not all hospitals are currently licensed to use it in the UK (in London, only the Hospital for Tropical Diseases and Northwick Park). Artesunate is manufactured by a pharmaceutical company in China and there are doubts over the quality of the product. However, there have now been numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice.

Answer 24

Upper GI endoscopy This patient is anaemic due to a bleeding peptic ulcer which has resulted from prolonged NSAID use. Dyspnoea is a symptom here and the ankle oedema could be due to high output heart failure. The most specific and sensitive test is an upper GI endoscopy. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs in this case. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.

Answer 25

Colonoscopy Anaemia in this case is a sinister sign which could point to possible malignancy, particularly given the patient’s advanced age. There is GI bleeding here, presumed to be lower GI, which needs to be investigated with a colonoscopy.

Answer 26

Anti-gliadin antibodies This man is being investigated for a microcytic IDA here. The cause is not dietary iron intake given the history. So this could still be due to inadequate absorption such as coeliac disease or loss from GI bleeding. The unremarkable endoscopy results and barium studies indicate the absence of GI bleeding. This leaves coeliac disease, or potentially idiopathic, but the next thing to do here is to investigate the possibility of coeliac disease. Coeliac most common presents with IDA, although it can also lead to a macrocytic anaemia with mainly folate deficiency (though B12 is also affected but hepatic stores last several years). It is an autoimmune condition triggered by gluten peptides found in wheat, rye and barley. The ultimate best test is duodenal biopsy and histology to show intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia. Macroscopic changes may be present but endoscopy is generally unhelpful, as in this case. The test of choice before performing such an invasive confirmatory test is to look for elevated anti-gliadin antibodies. Anti-tissue transglutaminase is less accurate and endomysial antibody is more expensive and has lower sensitivity.

Answer 27

Abdominal ultrasound scan This is clubbing due to cirrhosis as a result of chronic alcohol excess. Ultrasound here is the only feasible option on the list and can detect advanced cirrhosis and possible signs of portal hypertension, such as ascites, splenomegaly and increased portal vein diameter. The ultrasound may show a nodular liver surface, the liver may itself be shrunk due to cirrhosis and the left hand side of the liver may be hypertrophied. USS findings with a good clinical suspicion is enough for diagnosis.

Answer 28

Echocardiogram The only cardiac investigation here is an echocardiogram. Cardiovascular causes of clubbing include cyanotic congenital heart disease, infective endocarditis and atrial myxoma. This could well be Eisenmenger’s syndrome caused by shunt reversal.

Answer 29

Bronchoscopy The history of smoking and weight loss point to a bronchial carcinoma. Whilst the initial investigation is with a CXR, diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. Non-small cell lung cancer is more often associated with clubbing.

Answer 30

Hernia - on examination, a direct hernia cannot be controlled by pressure at the midpoint of the inguinal ligament whereas an indirect hernia can be controlled by occlusive pressure.

Answer 31

Upper GI endoscopy The definitive diagnosis for a Mallory-Weiss tear is made by OGD. This tear in the oesophageal mucosa occurs after a rise in abdominal pressure, causing subsequent GI bleeding. It commonly presents with haematemesis after an episode of retching/vomiting/coughing/straining. Hence, risk factors include anything which can cause vomiting like heavy alcohol use, which is commonly the case in EMQs. Also, other conditions would include food poisoning, bowel obstruction, hyperemesis gravidarum, bulimia, the chronic cough of COPD, meningitis etc... you name it really. Classically, MWT presents with a small self limiting episode of haematemesis. Treatment is supportive because most cases are self limiting and emergency treatment is not offered unless the patient is showing signs of clinical instability. If the patient is actively bleeding, treatment will be with therapeutic endoscopy in most cases, and very very few cases will require more intervention such as angiography with embolisation.

Answer 32

Caecal carcinoma The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.

Answer 33

Haemorrhoids Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.

Answer 34

Acute ischaemic bowel Untreated AF can lead to a thrombus forming inside the heart which can then embolise like this case to the mesenteric vasculature. This person is also old, which is an additional risk due to comorbidities like atherosclerosis. This patient has the symptoms and signs of ischaemic bowel disease (which encompasses acute mesenteric ischaemia, chronic mesenteric ischaemia and colonic ischaemia). This is likely acute mesenteric ischaemia – something that in a person who presents like this, you should maintain a high index of suspicion for as the presentation can be quite non-specific but the condition can be deadly. You would likely in this case opt for surgical intervention without delay although you can consider some form of imaging.

Answer 35

Epidural - contraindicated in anticoagulated patients

Answer 36

Codydramol - combination of dihyrocodeine and paracetamol

Answer 37

Rectal carcinoma This a rectal carcinoma. Tenesmus, blood PR alongside weight loss are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.

Answer 38

CT scan abdomen, serum amylase or lipase are also key to diagnosis - patient has acute pancreatitis

Answer 39

Delirium tremens from alcohol withdrawal. Alcohol excess can also cause delirium secondary to alcoholic ketoacidosis and can also be seen in Wernicke's or Korsakoff's.

Answer 40

Cirrhosis - the end stage of chronic liver disease, results in hepatic insufficiency and portal hypertension, causing jaundice.

Answer 41

Wernicke's encephalopathy - due to acute thiamine deficiency. Triad = mental change, opthalmoplegia, gait dysfunction.

Answer 42

``` Activated Charcoal overdose of tricyclic antidepressants which are a class of drugs with a narrow therapeutic index and become potent toxins in moderate doses in CNS and CVS. main aim of treatment is to provide reap and CVS support until medicine has been fully metabolised and eliminated. GI decontamination should be considered in those presenting with early OD (under 2 hours) warm dry skin part of anticholinergic effect (don't reverse with Physostigmine as can cause systole) ```

Answer 43

Depression

Answer 44

N-acetylcysteine serum paracetamol level is important to order as early as possible but at the earliest 4 hours post-ingestion. Treatment if indicated is with N-acetylcysteine with the level based on paracetamol treatment graph.

Answer 45

IV-naloxone Signs of opiate OD include CNS depression, mitosis and apnoea. Naloxone is indicated both therapeutically and diagnostically. if response then its diagnostic. Another diagnosis should be sought if unresponsive. IV is preferred route although naloxone can be given IM of IC. Ventilatory support is key with 100% O2

Answer 46

Hydrocoele - a collection of serous fluid between the layers of the tunica vaginalis. Mainly presents with a painless swollen scrotum, feels like a water-filled balloon.

Answer 47

Testicular malignancy - most commonly presents as a hard, painless lump on one testis - 10% present with acute pain associated with haemorrhage or infection.

Answer 48

Epididymo-orchitis - younger men are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. A urethral swab should be sent for Gram stain and culture of secretions. A urin dipstick is also necessary comined with urine MC&S. Treatment: bed rest, scrotal elevation, analgesia and antibiotics.

Answer 49

Fasting blood glucose

Answer 50

Fibroadnosis - associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses).

Answer 51

Testicular torsion - urological emergency caused by twisting of the testicle on the spermatic cord. If not fixed will lead to ischaemia and necrosis of the tissue. Boys aged 12-18 are at greater risk.

Answer 52

Perform exercise ECG - stable angina will show ST segment depression during exercise indicative of ischaemia.

Answer 53

Haemoglobin electrophoresis This is beta-thalassaemia, either major or intermedia due to the findings of abdominal distension, skeletal changes and hepatosplenomegaly which is not seen in heterozygoud beta-thalassaemia trait. The pallor is highly suggestive of moderate to severe anaemia, confirmed by the test results. Beta-thalassaemia major (or Cooley anaemia) is due to a complete abscence of HbA and often presents at a few months of age with pallor and abdominal distension, both described by parents as being progressive in nature. HSM and bony abnormalities (most often the frontal and parietal bossing mentioned, as well as ‘chipmunk facies’) are often present at presentation. Intermedia has a similar presentation but in a toddler or older child, with less pronounced symptoms and a more insidious course. Blood transfusions are required though stem cell transplant offers a hope of a cure. Hb electrophoresis will reveal minimal or no HbA and elevated HbF and HbA2.

Answer 54

Autosomal dominant Polycystic kidney disease - patient might have a FH, PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and subsequent SAH)

Answer 55

ECG - presenting with an MI

Answer 56

Transthoracic echo - patient likely has HOCM. Patient's young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina).

Answer 57

Acute interstitial nephritis - classically presents with acute renal failure associated with oligouria and the 'hypersensitivity triad' of rash, fever, and eosinophilia triggered by a drug e.g antibiotics, and NSAIDs.

Answer 58

Upper GI endoscopy - patient has GORD characterised by heartburn and acid regurgitation.

Answer 59

Shock - there is inadequate organ perfusion and when this includes the kidneys you get renal hypoperfusion which can progress to acute renal failure.

Answer 60

Obstructive uropathy - caused by a block in urinary flow by the cervical carcinoma affecting the urinary tract.

Answer 61

Thoracic spine x-ray - patient likely has osteoporotic vertebral collapse/fracture which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. History of Corticosteroid use is also associated with osteoporosis.

Answer 62

Uraemia - patient has developed acute renal failure, probably associated with longstanding CCF. Advance HF will lead to depressed renal perfusion and ARF.

Answer 63

Re-breathing

Answer 64

IV antibiotics

Answer 65

Lumbar puncture

Answer 66

Renal function tests

Answer 67

Liver function test

Answer 68

Serum drug level

Answer 69

Testicular malignancy

Answer 70

Rectal carcinoma This a rectal carcinoma. Tenesmus, blood PR alongside weight loss are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.

Answer 71

Serum drug level

Answer 72

Perform coronary angioplasty

Answer 73

Add low molecular weight heparin, could also be a factor Xa inhibitor (e.g. Fondaparinux) or normal Heparin

Answer 74

Abdominal ultrasound scan

Answer 75

Gastroscopy

Answer 76

History only

Answer 77

Colonoscopy

Answer 78

Chest x-ray

Answer 79

Polycystic kidney disease

Answer 80

Extrinsic allergic alveolitis - variety of syndromes it could be: pidgeon breeder's lung, bird fancier's lung, budgerigar fancier's disease.

Answer 81

Acute left ventricular failure - causes congestion in the pulmonary circulation so the symptoms are respiratory.

Answer 82

Oral antibiotics patient has diverticulitis and doesn't need further investigations. Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. risk factors include low dietary fibre and advanced age. oral antibiotics and analgesia is indicated

Answer 83

COPD - second pulmonary hypertension as a result of the advanced COPD or cor-pulmonale has caused peripheral oedema.

Answer 84

Opiate intoxication - signs include CNS depression, miosis, and apnoea. with cocaine you would have dilated pupils. Naloxone is indicated both therapeutically and diagnostically.

Answer 85

Aortic stenosis

Answer 86

Caecal carcinoma The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.

Answer 87

CT scan abdomen - patient has acute pancreatitis

Answer 88

Rhabdomyolysis - myocyte lysis. Alcohol is directly toxic to myocyte membranes, inhibiting calcium uptake and disrupting the sodium-potassium pump.

Answer 89

Haemorrhoids Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.

Answer 90

Paracetamol

Answer 91

Re-breathing

Answer 92

IV antibiotics

Answer 93

Duodenal ulcer There is no reason why this cannot be a gastric ulcer but it is not an option on the list. The history of dyspepsia and black tarry stools over the past few days suggests a bleeding peptic ulcer. The dyspepsia is often centred in the upper abdomen and is related to eating. Contrary to popular lay health beliefs there is no good evidence of alcohol as an important risk factor. Key risk factors are NSAID use, H. pylori, smoking and FH of PUD. The most specific and sensitive test is an upper GI endoscopy which will also allow intervention to stop the bleeding ulcer from bleeding. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.

Answer 94

Autonomic neuropathy Autonomic neuropathy is a complication of diabetic neuropathy. Symptoms of autonomic neuropathy include... resting tachycardia (late findings due to vagal impairment), impaired HR variation, erectile dysfunction (affects many diabetic men though is not solely due to autonomic neuropathy), decreased libido and dyspareunia, orthostatic hypotension (measure BP supine and then standing after 1, 2, 3 and sometimes 5 minutes – an abnormal drop when standing is indicative) and urinary symptoms of frequency, urgency, incontinence, nocturia, weak stream and retention. Other symptoms include constipation, faecal incontinence and sweating dysfunction. Fludrocortisone may be helpful in this woman.

Answer 95

Diverticular disease Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. There may uncommonly be rectal bleeding which is usually painless, profuse and arterial in nature. Risk factors for diverticular disease include low dietary fibre and advanced age. Oral antibiotic therapy and analgesia is indicated. If there is no improvement in 72 hours after oral antibiotics then IV antibiotics are indicated. Make sure you understand the differences in the terms: diverticulosis, diverticulitis and diverticular disease.

Answer 96

Renal function tests

Answer 97

Liver function test

Answer 98

Perform coronary angioplasty

Answer 99

Add low molecular weight heparin

Answer 100

Perform echocardiography - Doppler exho is best diagnosis and evaluation of aortic stenosis and is highly sensitive and specific. It will show an elevated aortic pressure gradient and also allow you to quantify LV ejection function and measure the are of the valve.

Answer 101

Perform exercise ECG - stable angina will show ST segment depression during exercise indicative of ischaemia.

Answer 102

Gastroscopy

Answer 103

History only

Answer 104

Fasting blood glucose

Answer 105

Colonoscopy

Answer 106

Chest x-ray

Answer 107

Bone marrow aspirate

Answer 108

Extrinsic allergic alveolitis - hypersensitivity pneumonitis. History of exposure of organic dust with birds. Variety of syndromes it could be: pidgeon breeders lung, bird fanciers lung, budgerigar fanciers disease.

Answer 109

Acute left ventricular failure - LVF causes congestion in the pulmonary circulation so the symptoms are respiratory: SOB, cough etc. Oxygen, morphine, diuretics and nitrates should be given.

Answer 110

Pneumonia - was not resolved and got worse to cause the old man's confusion. Patient should have his CURB-65 score calculated.

Answer 111

COPD - secondary pulmonary hypertension as a result of the patient's COPD or cor pulmonale gas caused peripheral oedema.

Answer 112

Opiate intoxication - signs include CNS depression, miosis, and apnoea. Cocaine would cause dilated pupils. Naloxone is indicated both therapeutically and diagnostically.

Answer 113

Exercise ECG

Answer 114

Calcium Channel Blocker e.g Nifedipine. | 1st line for angina = B-blockers (Metoprolol), which is contraindicated in this patient. 2nd line = CCB

Answer 115

Long acting nitrates e.g Isosorbide mononitrate or transdermal GTN. Nitreate-free periods will be needed to avoid tolerance. Angina treatment: 1 = B blocker; 2 = CCB; 3 = long acting nitrate.

Answer 116

Angioplasty: those with LMS (left main stem) disease, 3 vessel disease or a reduces EF may benefit from CABG. Most single vessel disease can be adequately managed with PCI.

Answer 117

ACEi therapy - reduces morbidity and mortality associated with LVF, and all patients with LV dysfunction should take it, even if asymptomatic. Caution should be taken if the patient has renal impairment, cardiogenic shock or hypokalaemia.

Answer 118

Weight loss and increased exercise. BMI>30 = obese. Drug therapy can be considered as an adjunct. This is primarily with orlistat which inhibits fat absorption by inhibiting lipases.

Answer 119

Aspirin therapy. Clopidogrel is an alternative in those who do not tolerate aspirin.

Answer 120

Weight reduction and metformin therapy. Single random glucose >11.1 and single fasting glucose >7 + symptoms = DM. If asymptomatic, patients need 2 separate elevated readings for a diagnosis.

Answer 121

Innocent murmur

Answer 122

Mitral stenosis - rheumatic. Sydenham's chorea shows history of rheumatic fever. Almost all cases of mitral stenosis are caused by rheumatic heart disease. The process tends to also cause regurgitation. MS can have associated malar flush, tapping apex beat and diastolic thrill palpable at the apex.

Answer 123

Mitral Incompetence - TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaces apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.

Answer 124

Autonomic neuropathy - complication of diabetic neuropathy. Fludrocortisone may be helpful in this woman.

Answer 125

Infective endocarditis - new murmur + fever should always make you think bacterial endocarditis.

Answer 126

Volume depletion - reduction in ECF due to salt and fluid losses which exceed intake. Serum urea and creat will be elevated (N.B. body builders will have naturally high creatinine). IV saline fluid replacement is needed.

Answer 127

Duodenal ulcer There is no reason why this cannot be a gastric ulcer but it is not an option on the list. The history of dyspepsia and black tarry stools over the past few days suggests a bleeding peptic ulcer. The dyspepsia is often centred in the upper abdomen and is related to eating. Contrary to popular lay health beliefs there is no good evidence of alcohol as an important risk factor. Key risk factors are NSAID use, H. pylori, smoking and FH of PUD. The most specific and sensitive test is an upper GI endoscopy which will also allow intervention to stop the bleeding ulcer from bleeding. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.

Answer 128

Diclofenac - type of NSAID

Answer 129

Acute ischaemic bowel Untreated AF can lead to a thrombus forming inside the heart which can then embolise like this case to the mesenteric vasculature. This person is also old, which is an additional risk due to comorbidities like atherosclerosis. This patient has the symptoms and signs of ischaemic bowel disease (which encompasses acute mesenteric ischaemia, chronic mesenteric ischaemia and colonic ischaemia). This is likely acute mesenteric ischaemia – something that in a person who presents like this, you should maintain a high index of suspicion for as the presentation can be quite non-specific but the condition can be deadly. You would likely in this case opt for surgical intervention without delay although you can cnsider some form of imaging.

Answer 130

Addison's disease - low sodium, high potassium, vomiting, and hyperpigmentation all indicate Addison's.

Answer 131

Cardiogenic shock - pump dysfunction due to MI, cardiomyopathy, valve dysfunction, or arrhythmias. Raised JVP, basal crackles and pulmonary oedema support cardiac failure. Treatment begins with ABCs, in this case, urgent revascularisation of the coronary arteries is indicated.

Answer 132

Drug induced. This patient needs ventilation prior to administration of naloxone, titrated to patient response.

Answer 133

Transthoracic echo - patient probably has HOCM, symptomatic patients are treated with beta blocker, CCBs or disopyramide. Inheritance is autosomal dominant with a variable penetrance.

Answer 134

Upper GI endoscopy (best answer out of the options but if trial of PPI was option that would be better) - patients has GORD. Diagnosis is generally clinical and a trial of PPIs, an UGI endoscopy would generally be reserved for complication such as strictures.

Answer 135

CT scan abdomen - patient has acute pancreatitis. Serum amylase and lipase are also key to diagnosis, but CT is the most sensitive and specific study. Can show enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.

Answer 136

Thoracic spine x-ray - patient probably has osteoporotic vertebral collapse which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. The hx of corticosteroid use is associated with osteoporosis. For the dx of osteoporosis, a DEXA scan is needed indicating a T score of less than or equal to -2.5

Answer 137

Congestive cardiac failure - dyspnoea, tiredness, and oedema all point to CCF. Raised JVP, hepatomegaly and peripheral oedema are all signs of RVF. Initial investigations should include ECG, CXR, TTE and bloods (incl. BNP level). First line treatment = ACEi + salt and fluid restriction. Chronic HF patients will also get a B blocker.

Answer 138

Left Ventricular failure - causes congestion in the pulmonary circulation so the symptoms are respiratory.

Answer 139

Silent MI - more common in the elderly and those with DM probably due to autonomic neuropathy.

Answer 140

Decubitus angina - usually a complication of HF

Answer 141

Atrial Fibrillation secondary to hyperthyroidism.

Answer 142

Infective endocarditis

Answer 143

Hypertrophic obstructive cardiomyopathy.

Answer 144

Pericarditis

Answer 145

Venous ulcer - occur on a background of deep venous insufficiency. Ulceration usually follows trauma and is usually on the medial gaiter region. The shape is norm irregular with sloping edges. Brown skin around ulcer is due to haemosiderin deposition.

Answer 146

Cardiac failure - venous ulcer due to RVF

Answer 147

Neuropathic ulcer - diabetic neuropathy is a microvascular complication of DM and is characterised by a peripheral nerve dysfunction.

Answer 148

Arterial ulcer - deep and painful with a well defined edge, usually found on the shin or foot. There may also be local change such as cold peripheries, loss of hair, dusky cyanosis and toenail dystrophy. An angiogram with contrast will define the lesion and determine whether it can be improved by surgical intervention.

Answer 149

Pyoderma gangrenosum - mainly associated with IBD, RA and the myeloid blood dyscrasias. It causes necrotic tissue leading to deep ulcers, often found on the legs. There are dark red borders.

Answer 150

MI - NSTEMI is a common complication of surgical procedures and is often detected as a rise in cardiac markers in the days following surgery.

Answer 151

Unstable angina

Answer 152

Variant angina (Prinzmetal's) - caused by coronary artery vasospasm rather than atherosclerosis (though patient's will often show some degree of this as well). Occurs at rest and in cycles. ECG will show ST elevation, but only when the patient is having an attack. Cardio biomarkers may be raised as vasospasm can cause damage to the myocardium. Gold standard investigation = coronary angiography and the injection of agents to provoke spasm.

Answer 153

Stable angina - during exercise, the ECG will show ST depression. 1st line treatment involves lifestyle changes and antiplatelet therapy.

Answer 154

Pulmonary embolism

Answer 155

Dissecting aortic aneurysm. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia

Answer 156

Pericarditis/Dresslers (if weeks post MI). The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse (saddle-shaped) ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis.

Answer 157

Tricuspid regurgitaion

Answer 158

Mitral valve prolapse

Answer 159

Aortic stenosis

Answer 160

HOCM - this patient is also in AF which warrants anticoagulation and anti-arrhythmics. Echo must be performed to confirm diagnosis.

Answer 161

Patent ductus arteriosus - The ductus arteriosus is a fetal structure which normally closes within 2 days of birth. Persistence can result in heart failure and increased pressures in the pulmonary vasculature as blood is shunted from the aorta into the pulmonary artery. The classic murmur is known as a Gibson murmur or machinery murmur and is best heard in the left infraclavicular area, usually peaking in late systole and continuing into diastole. Maternal rubella infection in the first trimester is a predisposing risk factor for PDA. The definitive diagnostic test is an echocardiogram.

Answer 162

ECG - need to figure out what is causing the palpitations. Could have ectopic beats or paroxysmal AF/Atrial flutter.

Answer 163

Echo - elevated JVP and peripheral oedema are signs or RVF. Key investigation is a TTE coupled with Doppler flow studies which allows calculation of the EF.

Answer 164

3.5 gm/24hr over this do a biopsy

Answer 165

ECG - patient has pericarditis, ECG should show a diffuse concave saddle-shaped ST elevation with PR depression (reversed in aVR and V1)

Answer 166

Echo - patient has MR

Answer 167

Aortic Regurge

Answer 168

Mitral valve prolapse

Answer 169

Systemic hypertension

Answer 170

Phaeochromocytoma - inherited in MEN2, vHL and NF1. 10% bilateral, 10% malignant, 10% extraadrenal, 25% inherited.

Answer 171

Men-13.5-17.5 | Women -12-15.5

Answer 172

Hyperthyroidism - in countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Treatment = radioactive iodine, antithyroid medications (eg Carbimazole) or surgery.

Answer 173

Venous Doppler studies - orthopaedic surgery is a strong risk factor for developing a DVT. A low flow in the veins is indicative of a DVT. A Wells score should be determined in all patients with suspected DV. Score >2 makes condition likely,

Answer 174

Cushings disease - Dexamathasone suppression test can be done to confirm diagnosis.

Answer 175

Coronary angiogram (+ injection agent to provoke spasm) - has variant angina.

Answer 176

Ventilation/perfusion scan. She has a PE, would normally do a CTPA but this is contraindicated in pregnancy (and someone with a contrast allergy), so a V/Q scan is the next Ix of choice. A TTE can also be sued to detect RV strain seen with PE.

Answer 177

ECG - patient has pericarditis which is best seen on an ECG (diffused saddle shaped ST elevation and PR depression)

Answer 178

Pelvic US = mass is likely to be malignant given the patient hx.

Answer 179

ECG - patient has Dresslers (post-MI pericarditis). This is believed to be an autoimmune process with myocardial neo-antigens implicated in the aetiology and occurs typically 2-3 weeks post-MI. ECG should show a diffuse concave saddle-shaped ST elevation with PR depression (reversed in aVR and V1). Typical treatment is with aspirin.

Answer 180

Plasma creatinine - diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function.

Answer 181

24h urine protein/spot urine protein-to-creatinine ratio. Patient prob. has nephrotic syndrome, defined by the presence of proteinuria (>3.2g/24h), oedema and hypoalbuminaemia. Some definitions also add hyperlipidaemia.

Answer 182

Exercise ECG - patient has stable angina

Answer 183

Aortic Stenosis

Answer 184

Chest X-ray - patient has pulmonary oedema, probably due to heart failure. An ECG, TTE, and bloods should also done.

Answer 185

Upper GI endoscopy - patient has GORD

Answer 186

CT scan - suspected aortic dissection. MRI is more sensitive and specific but it more difficult to obtain acutely.

Answer 187

``` Acute urinary retention his is acute urinary retention caused by anticholinergics. Unwanted effects of this class of drugs include urinary retention, constipation, erectile dysfunction, CNS disturbance, cycloplegia, dry mouth and decreased sweating. Poisoning in severe cases can be treated with anticholinesterases such as physostigmine. This man will need to be catheterised first to relieve the urinary retention and prevent any further complications from occuring. ```

Answer 188

Exercise ECG - patient has stable angina

Answer 189

Men - 0.6-1.2 mg/dL | Women- 0.5-1.1 mg/dL

Answer 190

6-8.3 mg/dL

Answer 191

3.5 - 5 mEq/L

Answer 192

0-0.3 mg/dL

Answer 193

0.3-1.9 mg/dL

Answer 194

2.2-2.6mmol/L

Answer 195

Renal artery stenosis - heard a renal bruit. RAS is due, typically, to atherosclerosis and often presents with hypertension and worsening renal function. A form of imaging is required for diagnosis.

Answer 196

135-145 mEq/L

Answer 197

Aortic coarctation - characterised by a BP difference between the upper and lower extremities. Posterior rib notching is due to enlargement of collateral vessels due to aortic narrowing. Diagnosis is made on demonstrating narrowing of the aortic arch, typically shown by echocardiography. Treatment may involve surgical repair such as the placement of a stent.

Answer 198

Chest X-ray (+ ECG, TTE and bloods, which weren't options) - patient probably has CCF

Answer 199

CTPA - patient has PE. If contraindicated (pregnant or contrast allergy) a V/Q scan can be done.

Answer 200

Bladder Cancer Gross haematuria is primary symptoms of bladder cancer. over 80% present with it as primary complaint. normally painless and present throughout urinary stream. also presents with dysuria and frequency and can be confused with prostatis. risk factors include smoking, carcinogen exposure (aromatic amines from rubber and dye industries), >55, Schistosomaisis (commonest cancer in Egypt due to this)

Answer 201

Urinary tract stones - ureteric colic/stricture

Answer 202

Myocardial Infarction Silent, no chest pain. all other symptoms are indicative such as vomiting, sweating and tachycardia. more common in diabetics due to autonomic neuropathy. ECG may show STEMI, new LBBB or confirmed MI then thrombolysis is indicated.

Answer 203

Meningitis most likely from list. commonly have headache, fever and nuchal rigidity, altered mental state, confusion, photophobia and vomiting

Answer 204

Pancreatitis | may also show Cullen's sign, Grey-Turner's sign and Fox's sign

Answer 205

Small Bowel obstruction | in older patient common causes are adhesions or cancer. in this case the recent history of surgery suggests adhesions

Answer 206

Labyrinthitis an inflam condition, most commonly cause is viral in origin although bacterial occurs as a complications of otitis media or meningitis. typical presentation includes vertigo, imbalance and hearing loss. N&V are common

Answer 207

Endometriosis Chronic inflammatory condition defined by endometrial stroma and glands located outside uterine cavity. usually appears in women of reproductive age with chronic pelvic pain and/or sub fertility. Dysareunia = pain during sex

Answer 208

Endometrial cancer common malignancy and is usually an adenocarcinoma. Obesity is associated with increased incidence of endometrial cancer and poorer outcome. risk factors - HRT, tamoxifen use, 50+years, unopposed oestrogen and radiotherapy, FH and other cancers.

Answer 209

Adenomyosis ectopic glandular tissue in muscle, first test is pelvis USS which shows normal or enlarged uterus. minimal diagnostic value but will rule out endometriosis. O/E enlarged globular uterus and uterine tenderness on palpation. symptoms usually appear after childbirth with heavy menstrual flow or abnormal bleeding pattern

Answer 210

Ectopic pregnancy usually presents 6-8 weeks after last normal menstrual period. higher risk in women with previous ectopic, surgery on tubes, genital infections, smokers or IUD use. classical signs are pain, vaginal bleeding and amenorrhoea. rupture suspected if patient is haemodynamically unstable or there is cervical motion tenderness

Answer 211

Pelvic inflammatory disease | acute ascending infection of female tracts, associated with Neisseria gonorrhoea or Chlamydia trachomatis.

Answer 212

Pseudomonas aeruginosa

Answer 213

Pregnancy test

Answer 214

First line - methyldopa | Second line - Labetalol

Answer 215

Stage 1 - ACEi Stage 2 - CCB or thiazide diuretics Step 3 - CCB and thiazide diuretics Step 4 - alpha blockers or spironolactone

Answer 216

Diagnostic laparoscopy

Answer 217

Serum amylase

Answer 218

Oral antibiotics

Answer 219

Ruptured ectopic pregnanacy

Answer 220

Pyelonephritis

Answer 221

Appendicitis

Answer 222

Bowel obstruction

Answer 223

Cholecystitis

Answer 224

Ruptured AAA

Answer 225

Biliary colic

Answer 226

Bowel obstruction

Answer 227

Appendicitis

Answer 228

Colorectal carcinoma

Answer 229

Pancreatitis

Answer 230

Acute appendicitis

Answer 231

Acute pancreatitis

Answer 232

Ureteric colic

Answer 233

Sigmoid volvulus

Answer 234

Colon carcinoma

Answer 235

Distal intestinal obstruction syndrome

Answer 236

Inguinal hernia

Answer 237

Neisseria Gonorrhoea

Answer 238

Helicobacter pylori

Answer 239

Streptococcus pneumoniae

Answer 240

Hepatitis C

Answer 241

Stable angina

Answer 242

Unstable Angina

Answer 243

Syndrome X This is cardiac syndrome X, not to be confused with the metabolic syndrome. Here, there is chest pain with usual ST segment changes associated with coronary artery disease but with normal coronary arteries. It is treated with calcium channel blockers such as nifedipine.

Answer 244

``` Variant Angina Variant angina (Prinzmetal) is angina caused by coronary artery vasospasm rather than atherosclerosis. It occurs at rest and in cycles. ```

Answer 245

Decubitus Angina. | This patient is laying down, which is Decubitus angina by definition

Answer 246

Unstable Angina

Answer 247

Beta Blocker - Beta blockers lower heart rate, CO and MABP during exercise. They indeed also act to reduce renin release as well as the release of NA. Their use ranges from migraine prophylaxis, anxiety and hypertension to thyrotoxicosis, post-MI and chronic heart failure. They are also useful in arrhythmias where they act to increase the refractory period of the AVN.

Answer 248

Alpha 1 Agonist Alpha 1 agonists such as phenylephrine are vasoconstrictors and also have a use as a mydriatic. They are used as nasal decongestants as a result of their vasoconstrictor effect.

Answer 249

GTN GTN is glyceryl trinitrate, which leads to NO release. This causes vasodilation and a reduction in venous return to the heart, which decreases cardiac work load. This reduces preload (ventricular return) and afterload (peripheral vascular resistance). It is also weakly antiplatelet and has a weak direct action to vasodilate the coronary arteries. It is often also used sublingually for rapid relief of angina. Chronic use can indeed lead to tolerance and as such an eccentric regime is recommended.

Answer 250

CCB his describes the action of a non-rate slowing dihydropyridine calcium channel blocker such as amlodipine. These act by inhibiting the opening of L-type calcium channels, inhibiting entry of calcium ions into VSMCs. This causes arterial vasodilation. These drugs are used for hypertension and angina and unwanted effects include those listed. The palpitations a patient may experience are due to reflex tachycardia from arterial vasodilation. Note also that rate-slowing calcium channel blockers also exist such as verapamil and diltiazem and uses for these also include arrhythmias such as paroxysmal SVT and AF.

Answer 251

Pulmonary Embolus Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Tachycardia is commonly seen. Raised JVP is a feature here which is elicited if cor pulmonale is present. This patient has DVT which is a strong PE risk factor. Recent acute MI is also a weak risk here. Other strong risk factors include obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.

Answer 252

Papillary muscle rupture Inferior MI can cause rupture of the posteromedial papillary muscle while anterolateral infarctions can cause rupture of the anterolateral papillary muscle. This has led to acute mitral regurgitation (RV papillary rupture is rare but can cause regurgitation of the tricuspid valve). Complete rupture of the papillary muscle is fatal and causes wide-open MR. Those with incomplete rupture need emergency cardiac surgery with inotropic support considered for transient stabilisation prior to this. The pansystolic murmur which radiates into the axilla is a sign of mitral regurgitation here. This has resulted in SOB and tachycardia.

Answer 253

Pericarditis This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’ (although this is not present most of the time). There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

Answer 254

Ventricular tachycardia VT and VF can occur during ischaemia and reperfusion and can be fatal. They can also occur at any stage after an MI due to re-entry circuits at the border between myocardial scar tissue and normal myocardium. They are commonly seen in patients who have a decreased ejection fraction. Appropriate treatment should be initiated with DC cardioversion and anti-arrhythmics. Electrolytes should also be optimised (especially potassium and magnesium levels) as electrolyte imbalances present an added risk of ventricular arrhythmias. Medical management afterwards is essential, especially with beta blockers which decrases incidence of ventricular events. Those with persistently low LV ejection fraction which is unresponsive should be considered for an implantable caridioverter defibrillator.

Answer 255

Pulmonary oedema This patient has developed congestive heart failure as a complication of his MI. This is caused by decreased left ventricular function occuring after MI due to myocardial damage, infarct progression and remodelling of the LV tissue after the injury. Displaced apex beat is commonly found along with the other mentioned features in this history. Tests such as ECG, CXR, BNP (B-type natriuretic peptide) and echocardiogram will help confirm this diagnosis. CXR here is likely to confirm pulmonary congestion and may also show cardiomegaly. Initial symptomatic relief will involve diuretics and oxygen primarily, with the patient being sat upright. Treatment will also involve medication including beta blockers and ACE inhibitors.

Answer 256

Bradycardia Asthma Severe heart failure

Answer 257

Decompensated Severe Heart Failure Sick Sinus Syndrome Bradycardia

Answer 258

GORD This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.

Answer 259

Pericarditis This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There is pulsus paradoxus here too. There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

Answer 260

Pneumothorax left sided tension pneumothorax and will need emergency intervention in the form of the insertion of a large bore cannula into the 2nd intercostal space in the MCL then insertion of a chest drain.

Answer 261

Aortic Dissection The tearing chest pain suggests aortic dissection. There may also be interscapular pain with dissection of the descending aorta. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. BP differential between the 2 arms is a hallmark feature. Pulse differences may also be present in the lower limbs. There may also be the diastolic murmur of AR in proximal dissections. CXR may show a widened mediastinum like this case, and helps to rule out pulmonary causes of pain. A CT scan is indicated as soon as a diagnosis of aortic dissection is suspected and should be from the chest to the pelvis to see the full extent of the dissecting aneurysm. What you will see is the intimal flap. MRI is more sensitive and specific but is more difficult to obtain acutely.

Answer 262

MI This patient’s chest pain sounds like an MI. Chest pain is classically severe and heavy in nature (often described as crushing), located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are also common symptoms. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. An ECG is indicated. STEMI, new LBBB or confirmed posterior MI is an indication for PCI/thrombolysis. It is worth noting that RV infarction is present in 40% of inferior infarcts so in this case, right sided ECG leads should also be obtained.

Answer 263

AF | rregular HR is the hallmark feature of AF and symptoms here are consistent. Have a think about what the ECG would show

Answer 264

Bornholm Disease Caused by coxsackie B virus and symptoms include fever and severe pain in lower chest, exacerbated by small movements making it hard to breath

Answer 265

Synchronised cardioversion | This is unstable VT with a pulse and first line is cardioversion and treat cause

Answer 266

Bacterial - life threatening, fast onset (hours) Bacterial meningitis is most commonly caused by Neisseria Meningitidis

Answer 267

Community - penicillin | Hospital - cefuroxime/ cefotaxime/ ceftriaxone

Answer 268

Sarcoidosis Sarcoidosis is a chronic multisystem disease with an unknown aetiology. Lymphadenopathy is a common presentation and nodes are enlarged but non-tender, typically involving the cervical and submandibular nodes. Although uncommon, the patient may present with unexplained modest weight loss and fever. CXR will show bilateral hilar lymphadenopathy. serum calcium and ACE levels will be raised. treat with corticosteroids

Answer 269

Influenze This is an acute respiratory tract infection caused by seasonal viral influenza A or B, hence antibiotics would have no effect.

Answer 270

N. Malaria he jaundice here suggests falciparum infection, which is always the cause in severe disease. some questions will describe patterns of fevers occurring at intervals of 48-72 hours these are associated with P. vivax, P. oval and P. malariae

Answer 271

Hodgkin's Lymphoma This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. pain in lymph nodes on alcohol consumption is common

Answer 272

Pyelonephritis Acute onset fever with chills, flank pain, vomiting and positive urine dipstick all point to the diagnosis of acute pyelonephritis. Urinalysis is highly sensitive but not very specific. Pregnancy is a risk factor for complicated disease as the enlarging uterus compresses the ureters and hormonal changes increase the likelihood of obstructive uropathy.

Answer 273

Post Immunisation

Answer 274

``` Salmonella typhi (enteric fever) faecal-oral illness. highest incidence of the disease in India and Mexico. This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given. ```

Answer 275

Neisseria meningitidis type B big risk factor is crowding which occurs during Hajj. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis. CT head should be considered before LP if there is any evidence of raised ICP.

Answer 276

Entomoeba Histolytica Additional risk factors include being male and male-male sex, both oral and anal. Diagnosis would be confirmed by the detection of antigen in stool samples, serology or PCR. As neither of these methods are 100% sensitive, it is normally good to use more than 1 test in diagnosis. The presentation is normally with diarrhoea, without blood or mucus, present for several days or longer, indicating intestinal infection. Half also report weight loss. The RUQ tenderness found here is indicative of hepatic infection and the mass here is likely a hepatic abscess, reatment is with nitroimidazoles followed by agents like paromomycin.

Answer 277

Mycobacterium tuberculosis Night sweats, fever, malaise, cough, haemoptysis and erythema nodosum are all suggestive. In the first half of the 20th century, tuberculosis accounted for over 90% of cases of erythema nodosum. Other key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Cavitating lesions like the one this patient has can be seen on CXR but is non-specific for TB. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis.

Answer 278

Falciparum malaria

Answer 279

Thick Blood film | Malaria

Answer 280

CXR and sputum cultures | Pulmonary TB

Answer 281

Blood cultures | Infection

Answer 282

LP | Malaria

Answer 283

Lumbar Puncture

Answer 284

Throat swab | This child has septicaemia secondary to a throat infection caused by group A beta haemolytic strep

Answer 285

Culture of joint aspirate | this child has septic arthritis

Answer 286

Stool culture

Answer 287

Tuberculosis

Answer 288

Glandular fever | is caused by EBV

Answer 289

Influenza | Diabetics are more suspectible to infections such as the flu

Answer 290

Viral Hepatitis

Answer 291

Enteric fever/ Typhoid

Answer 292

Syphilis | treat with penicillin

Answer 293

Giardiasis

Answer 294

Chlamydia Women may present with cervical inflammation or yellow, cloudy discharge from the cervical os. A friable cervix is often also found on examination – the cervix bleeds easily with friction from a Dacron swab.

Answer 295

Varicella zoster This is VZV infection (chickenpox) which typically presents with a fever, malaise and a widespread vesicular and pruritic rash which primarily affects the torso and face.

Answer 296

Cytomegalovirus This is a presentation of CMV retinitis, which is the most common manifestation of CMV disease in AIDS, the second most common being colitis. However do remember that virtually any organ can be affected by CMV

Answer 297

Dengue fever endemic areas - especially SE Asia, Western Pacific and the Americas.

Answer 298

Kaposi sarcoma low-grade neoplasm caused by human herpesvirus-8 (or KSHV). It is associated with the acquired immunodeficiency associated with HIV infection. Oral KS can frequently affect the hard palate, gums and dorsum of the tongue. Cutaneous lesions are purple in colour and usually painless and non-pruritic.

Answer 299

Oral hairy leukoplakia presents as a painless white plaque found along the lateral tongue borders. There is history here which suggests immunosuppression. In situ hybridisation here has demonstrated the presence of EBV in the tissue.

Answer 300

Molluscum contagiosum Lesions appear as the umbilicated pearly and smooth papules mentioned. About a third of patients will also develop symptoms of local redness, swelling or pruritis. Adults should be treated for this STD.

Answer 301

Mycoplasma Chlamydia Chlamydia psittaci causes a community-acquired atypical pneumonia. It is often acquired from domesticated or commercially raised birds or exotic imported birds. Tetracyclines are preferred treatment

Answer 302

Haemolytic uraemic syndrome characterised by MAHA, thrombocytopenia and nephropathy. Most cases are in children and related to gastroenteritis caused by verotoxin producing E. coli

Answer 303

Rabies The most specific signs of the disease are displayed here with hydrophobia and aerophobia (elicited by the placement of nasal cannulae).

Answer 304

Streptococcus pyogenes his girl has rheumatic fever which is caused by an autoimmune process following infection with group A streptococci. The 5 major manifestations of acute rheumatic fever are carditis, polyarthritis, chorea, erythema marginatum and SC nodules.

Answer 305

Schistosomiasis This is caused by a fluke which is acquired through exposure of the skin to contaminated freshwater (it is a snail-borne parasite)

Answer 306

Tetanus This is caused by the exotoxin of Clostridium tetani and there is trismus here (lock jaw) which has resulted in risus sardonicus. The intermittent tonic contractions are also characteristic and the spasms can be triggered by both external and internal stimuli.

Answer 307

Campylobacter Jejuni This patient has Guillain-Barre syndrome his condition is a demyelinating polyneuropathy. Classic neurology is a progressive symmetrical muscle weakness affecting lower extremities before upper extremities, and proximal muscles before distal muscles, . patients have a history of Influenza type symptoms of Gastroenteritis. a study found that the risk of developing GBS after Campylobacter jejuni infection is roughly 100 fold higher

Answer 308

Legionella Pneumophila a gram negative rod. Legionella infecting the lungs is legionnaires’ disease or Legionella pneumonia whereas non-lung infection is known as Pontiac fever. This bacteria is found in aqueous environments such as lakes and almost all cases are from contaminated water systems,

Answer 309

Pseudomonas aeroginosa The green pigment here is pyoverdine which is produced by Pseudomonas.

Answer 310

Mycobacterium tuberculosis Pott’s disease is a presentation of extrapulmonary TB which affects the spine. As a result Pott’s disease may present with kyphosis. There may also obviously be focal tenderness. MRI or CT needs to be obtained here and microbiological confirmation of TB is also essential.

Answer 311

Plasmodium falciparium Blackwater fever is a complication of malaria infection caused by haemolysis, which releases haemoglobin into the bloodstream. This passes into the urine and it is the presence of haemoglobinuria which defines this condition (seen with dark red or black urine, hence the name). It can often lead to renal failure.

Answer 312

Clostridium difficile C. difficile produces 2 exotoxins called toxin A and toxin B (A is thought to be more important than B) which lead to an inflammatory response in the large bowel, increased vascular permeability and the formation of pseudomembranes. The diagnostic standard is with cytotoxic tissue culture assay.

Answer 313

Borrelia bugdorferi Lyme disease is a tick-borne infection which is caused by a spirochete, Borrelia burgdorferi. In Europe, the cause is B afzelii, B garinii and B burgdorferi sensu stricto and in Asia it is primarily the first two mentioned.. major reservoir is mice, voles, squirrels and deer

Answer 314

Salmonella enterica

Answer 315

CXR and sputum sample

Answer 316

Wound swab and culture

Answer 317

Streptococcus pneumoniae rust coloured sputum is hinting at a pneumococcal pneumonia

Answer 318

Streptoccus pyogenes the ‘strawberry’ tongue, or a red swollen tongue, which is a sign of Scarlet fever (along with Kawasaki disease and toxic shock syndrome which is caused by bacteria such as staphylococcus aureus). Scarlet fever is caused by an exotoxin released by Streptococcus pyogenes.

Answer 319

Enterococcus faecium VRE stands for vancomycin resistent enterococci – most of these are Enterococcus faecium. Most Enterococcus faecalis are not VRE but they are more prevalent than Enterococcus faecium. big cause of nosocomial infections in the UK

Answer 320

Salmonella typhimurium

Answer 321

Chlamydia trachomatis

Answer 322

Violet/ blue through methyl violet and Lugol's iodine

Answer 323

Pink-red colour with methyl red

Answer 324

Streptococcus Staphylococcus Enterococcus

Answer 325

Clostridium | Listeria

Answer 326

Neisseria | Haemophilus

Answer 327

``` Salmonella Shigella Pseudomonas Legionella Vibrio ESBL Proteus ```

Answer 328

Complex partial seizure

Answer 329

Substantia nigra

Answer 330

Hemiplegia - seen in cerebrovascular disease, or lesions affecting the motor cortex and pyramidal tracts

Answer 331

MS is a demyelinating disease of the CNS only, best seen on an MRI

Answer 332

Anti gliadin antibodies Anti transglutaminase is less accurate Anti endomysial antibodies is more expensive with lower sensitivity

Answer 333

New murmur and fever

Answer 334

``` New onset hypertension proteinurea in pregnant women over 20 weeks gestation Managed with labetalol treat by delivering placenta ```

Answer 335

Trigeminal neuralgia

Answer 336

Subarachnoid haemorrhage.

Answer 337

Stokes-Adams attack - episodes of LOC due to sudden decreased cardiac output. Pallor prior to the attack and facial flushing after is very characteristic.

Answer 338

1) beta blocker 2) CCB 3) long acting nitrates (isosobide mononitrate or transdermal GTN)

Answer 339

Iron deficient Anaemia due to an UGI bleed.

Answer 340

Postural Hypotension

Answer 341

Opioid overdose

Answer 342

Meningitis

Answer 343

Right sided stroke

Answer 344

V hypertension - volume (suppressed renin) | R hypertension - Renin (high)

Answer 345

Parkinson's Disease

Answer 346

Multiple Sclerosis

Answer 347

Iron deficient Anaemia due to an UGI bleed.

Answer 348

Postural Hypotension

Answer 349

Adrenal cortex

Answer 350

Meningitis

Answer 351

Partial Seizure

Answer 352

Right sided stroke

Answer 353

130-139 systolic | 85-89 diastolic

Answer 354

140-159 systolic | 90-99 diastolic

Answer 355

160-179 systolic | 100-109 diastolic

Answer 356

>180 systolic | >110 diastolic

Answer 357

>140 systolic

Answer 358

high total peripheral resistance

Answer 359

V hypertension - volume | R hypertension - Renin (high)

Answer 360

A hernia occuring at the site of previous surgery/penetrating injury.

Answer 361

Also known as primary hyperaldosteronism. may be unilateral adenoma, bilateral hyperplasia or apparently normal adrenals spironolactone, aldosterone receptor antagonists are crucial

Answer 362

Myasthenia Gravis

Answer 363

false A pilonidal sinus is a small hole or "tunnel" in the skin. It usually develops in the cleft of the buttocks where the buttocks separate.

Answer 364

Multiple Sclerosis

Answer 365

Transient Ischaemic Attack

Answer 366

Adrenal cortex

Answer 367

Spironolactone

Answer 368

lack of fusion at predisposed weak spots

Answer 369

Varix of the femoral vein

Answer 370

the outer edge of the rectus sheath and linea semilunaris

Answer 371

Incisional hernias

Answer 372

A hernia where only part of the bowel wall is in the sac

Answer 373

The commonest salivary tumour that is benign

Answer 374

Pharyngeal pouch Develops from backwards protrusion of pharyngeal mucosa through a weak area of the pharyngeal mucosa through a weak area of the pharyngeal wall (Killian's dehiscence). pouch develops posteriorly then protrudes to the left, displacing the oesophagus laterally.

Answer 375

Thyroglossal cyst A congenital remnant of thyroglossal duct, can appear anywhere between the base of the tongue and the isthmus of the thyroid gland. presents in first decade as smooth midline, painless lump that moves up on tongue protrusion.

Answer 376

Cervical rib Congenital overdevelopment of the transverse process of the 7th cervial vertebra, it may interfere with subclavian artery and the lower roots of the brachial plexus causing thoracic outlet syndrome. If T1 root is affected there is pain and paraesthesia of the arm and wasting of the small muscles of the hand.

Answer 377

Cystic hygroma Congenital benign collection of lymphatic sacs. contain clear fluid and characteristically transluminate brightly. soft, fluctuant lump beneath the skin and usually appears in the posterior triangle of the neck

Answer 378

Carotid body tumour/ Chemodectoma slowly growing tumour of the paraganglion cells arising in the carotid body at the carotid bifurcation. transmits the carotid pulsation and may have an associated bruit. it moves from side to side but not up and down. Pressure on the tumour may cause dizziness and syncope due to stimulation of vagal tone via carotid sinus.

Answer 379

Sternocleidomastoid tumour not an actual tumour but instead a fibrous mass in the sternocleidomastoid muscles. associated with torticollis (tilting of the head) due to contraction of the muscle.

Answer 380

Lymphoma | the symptoms of fever, weight loss and night sweats constitute what are known as B symptoms

Answer 381

Salivary duct carcinoma uncommon tumour of the salivary glands. there are a number of variants of malignant tumours in the salivary gland, most common is mucoepidermoid tumour. Facial nerve involvement is highly suggestive of malignancy

Answer 382

Branchial cyst A remnant of the second branchial cleft, normally involutes during embryonic development. commonly preents n young adults as a smooth, non-tender, fluctuant swelling in the anterior triangle anterior to the border of the sternocleidomastoid at the junction of its upper and middle thirds. may become enlarged and inflamed with upper respiratory tract infections

Answer 383

Indirect inguinal hernia They are more common on the right side in males, because the right testis descends later and there is an increased incidence of failed closure of the processus vaginalis

Answer 384

Femoral artery aneurysm A swelling that is both pulsatile and expansile is an aneurysm.

Answer 385

False femoral artery aneurysm dont involve the vessel wall, instead they represent an accumulation of blood in a cavity that is held around the vessel by connective tissue. Major complication of artery surgery. usually present as a pulsatile (but expansile) mass in the groin with a history of surgery.

Answer 386

Saphena varix dilation of the long saphenous vein that occurs due to incompetent valves at the saphenofemoral junction. has a cough impulse and disappears when lying down and may be mistaken for a hernia. it often has a blue tinge and exhibits a fluid thrill when the long saphenous vein is tapped distally (Schwart's percussion test). Auscultation shows a venous hum.

Answer 387

Psoas abscess Ethnicity and clinical symptoms point towards TB. a complication of intra-abdominal TV is abscess formation in the lumbar vertebrae (Pott's Disease). it may track down the psoas down tot he groin forming a psoas abscess. described as cold and painless.

Answer 388

A rare lump not present at birth but appearing early in life, containing glory fluid and cholesterol crystals

Answer 389

lump presents in early infancy. consists of lymph filled spaces and is translucent. increases in side on coughing

Answer 390

An uncommon lump that frequently occurs at the angle of the eyebrow

Answer 391

A carotid body tumour occurring at the carotid bifurcation

Answer 392

Caecal carcinoma anaemia and age point towards GI malignancy. caecal carcinoma cause asymptomatic anaemia, but might also have RIF pain, malaise and symptoms of obstruction

Answer 393

Testicular torsion It is sometimes difficult to differentiate testicular torsion from acute epididymitis (which presents similarly), however in EMQs you can tell the difference between the two from two key features: 1) in testicular torsion, pain is not relieved by elevating the twisted testis (negative Prehn's sign), but pain is relieved in acute epidiymitis and 2) in testicular torsion, the affected testis usually lies high in the scrotum, but does not in epididymitis.

Answer 394

Hydrocele Abnomrla collection of serious fluid in tunic vaginalis surrounding the testis. primary occurs in older men, develop slowly and are painless. secondary can occur secondary to tumours or inflammation of underlying testes and epidiymis

Answer 395

Varicocele collection of varicose veins in the pampiniform plexus (venous network that drains the testicle) scrotal swelling that is visible on standing and feels like a bag of worms. more common on left and may occur secondary to obstruction of the left testicular vein by renal adenocarcinoma.

Answer 396

Seminoma a testicular tumour (60%) (other is Teratoma- 40%) arise from seminiferous tubules and occur in the 30-40 age group. associated with undescended testis and may present as a hard, irregular painless mass or as secondary hydrocele. may spread to lungs and liver and to para-aortic lymph nodes (not inguinal). produces beta-human chorionic gonadotrophin

Answer 397

Teratoma germ-cell tumours which occur in 20-30 year olds. associated with undescended testis and may present as a hard, irregular painless mass or as secondary hydrocele. may spread to lungs and liver and to para-aortic lymph nodes (not inguinal). produce both alpha-fetoprotein and beta-human chorionic gonadotrophin

Answer 398

Sternocleidomastoid tumour not an actual tumour but instead a fibrous mass in the sternocleidomastoid muscles. associated with torticollis (tilting of the head) due to contraction of the muscle.

Answer 399

Lymphoma | the symptoms of fever, weight loss and night sweats constitute what are known as B symptoms

Answer 400

Salivary duct carcinoma

Answer 401

Fine-needle aspiration this a branchial cyst (position and fact that it became inflamed during a respiratory infection). fine needle aspiration will show a creamy yellow turbid fluid containing cholesterol crystals.

Answer 402

Indirect inguinal hernia

Answer 403

Femoral artery aneurysm

Answer 404

False femoral artery aneurysm

Answer 405

Saphena varix

Answer 406

Psoas abscess

Answer 407

Indirect inguinal hernia in general, all hernias that descend into the scrotum are indirect. Furthermore, reducable indirect hernias can be controlled by applying pressure over the internal inguinal ring, whereas reducable direct hernias cannot. On standing, a direct hernia appears immediately, but an indirect hernia takes time to appear, due to its relatively narrower orifice.

Answer 408

Strangulated femoral hernia more likely to strangulate (as in this case) due to the tightness of the femoral ring.

Answer 409

Femoral neuroma emoral neuromas can arise due to previous trauma or as a feature of neurofibromatosis (Von Recklinghausen's disease). The femoral nerve lies lateral to the femoral artery and compression of the neuroma results in pain along the nerve's distribution.

Answer 410

Direct inguinal hernia

Answer 411

Caecal carcinoma anaemia and age point towards GI malignancy. caecal carcinoma cause asymptomatic anaemia, but might also have RIF pain, malaise and symptoms of obstruction

Answer 412

Testicular torsion

Answer 413

Varicocele

Answer 414

Excision biopsy symptoms suggest a partoid tumour, probably pleomorphic adenoma (carcinoma would be painful, rapid growing and may cause facial nerve palsy) biopsy needed to make diagnosis

Answer 415

Fine-needle aspiration used to differentiate benign from malignant thyroid nodules pre-op. Mnay cold nodules are malignant but may be non-secreting adenomas, whilst hot nodules are usually adenomas but can be follicular carcinomas, therefore tissue diagnosis is needed

Answer 416

Sialogram salivary gland stones occur in the submandibular gland, pain and swelling at meal times, when salivary flow is high. confirmation of diagnosis is made with plain x-ray or sialography

Answer 417

Carotid angiography could be due to carotid artery aneurysm or carotid body tumour. diagnosis would be confirmed via angiography, more discriminatory than carotid Doppler

Answer 418

Fine-needle aspiration this a branchial cyst (position and fact that it became inflamed during a respiratory infection). fine needle aspiration will show a creamy yellow turbid fluid containing cholesterol crystals.

Answer 419

beneath the 12th rib, with the right lower than the left

Answer 420

1) Lumen 2) Fenestrated endothelium 3) Glomerular basement membrane 4) epithelial podocytes

Answer 421

Hypovolaemia | Hypotension

Answer 422

Ureteric stones Bladder tumour Blocked urinary catheter

Answer 423

Acute tubular necrosis Gentamicin toxicity Glomerulonephritis

Answer 424

Anti-nuclear Anti-nuclear antibodies are positive in a number of autoimmune conditions and often aid in the diagnosis of SLE

Answer 425

Protein electrophoresis Protein electrophoresis will show a monoclonal band in multiple myeloma

Answer 426

Volume status and BP Hypotension and dehydration will lead to pre-renal renal failure

Answer 427

Serum creatinine kinase CK is released from damaged/degraded muscle, hence rhabdomyolysis will lead to a raised CK

Answer 428

USS An effective way of visualising a bladder tumour. The most sensitive method would be a cystoscopy but this is invasive.

Answer 429

Urinary tract infection E coli causes most uncomplicated cases and Staph saprophyticus is implicated in 5-20percent. Sex is biggest risk but other risks include spermicide use, post-menopause, FH and presence of a foreign body like an indwelling catheter. Dipstick will show positive nitrite and leucocyte esterase.

Answer 430

Bladder cancer Gross haematuria is the primary symptom of bladder cancer. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.

Answer 431

Ureteric colic his patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones.

Answer 432

Prostatic varices The examination findings and haematuria at the beginning of the stream, combined with this patient’s history of hypertension suggests prostatic varices as a cause of the bleeding. A varix is an abnormally dilated vein which is prone to rupture and haemorrhage.

Answer 433

Trauma This patient has had a catheter removed two days ago, which accounts for his gross haematuria

Answer 434

glomerulus or tubules Red cell casts are due to red cells being deformed in the distal tubule, so if present they must be leaking into the nephron in the glomerulus or the more proximal tubules.

Answer 435

Rhabdomyolysis, renal failure is caused by the release of myoglobin from damaged muscle not creatinine.

Answer 436

Bladder cancer

Answer 437

Henoch-Schonlein purpura Henoch-Schonlein purpura is the most common vasculitis in childhood and in all cases there is a rash of palpable purpura which are typically non-blanching. If there is no rash, then it is not HSP. They are normally 2-10mm in diameter and are due to the extravasation of blood into the skin. They can occur anywhere on the body but are usually concentrated on the lower extremities. abdominal pain and arthralgias are commonly present (found in about 80%) and often associated with oedema. most often affects knees and ankles. half will show signs of renal disease such as proteinuria or haematuria.

Answer 438

Ureteric colic This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases and macroscopic haematuria may also be present although this is rare. Dehydration is a strong risk factor for renal stone formation and this man’s job may make him susceptible to inadequate fluid intake. A low urine output can lead to higher levels of urinary solutes, therefore leading to stone formation.

Answer 439

Post infectious glomerulonephritis This is post-infectious glomerulonephritis caused by group A beta-haemolytic streptococcus with renal endothelial cell damage. Serological markers would expect to show antibodies to streptococcus and low complement and treatment here is with antibiotics. The high ASOT (antistreptolysin O antibody titres) indicates post-streptococcal GN. There may also be positive anti-Dnase and antihyaluronidase in post-streptococcal GN.

Answer 440

Renal cell carcinoma Renal cancer arising from the parenchyma/cortex is known as renal cell carcinoma. Clear cell renal cell carcinoma accounts for most primary renal cancers. They are often asymptomatic and diagnosed incidentally like on imaging when localised malignant looking renal masses are seen. Surgery for early local disease (which is diagnosed in more than half) can be curative in up to 90%. Renal masses are usually only symptomatic in late disease. The classic triad is of haematuria, flank pain and an abdominal mass – this is only seen in 10%.

Answer 441

Polycystic kidney disease This sounds like autosomal dominant polycystic kidney disease. There may like in this case be a FH, of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and subsequent SAH – the bleed in the brain). Patients may have haematuria (which can be gross), palpable kidneys and symptoms of a UTI which is common in those with the condition. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found.

Answer 442

Pyelonephritis UTIs involving the renal parenchyma typically presents with fever. Acute onset fever with urinary symptoms and flank pain point to acute pyelonephritis. Urinalysis is highly sensitive but not very specific. Pregnancy is a risk factor for complicated disease as the enlarging uterus compresses the ureters and hormonal changes increase the likelihood of obstructive uropathy. In uncomplicated pyelonephritis, the most common cause is E. coli and gram stain will typically reveal gram negative rods, either E. coli, Proteus or Klebsiella.

Answer 443

Renal tuberculosis GU TB common presents with symptoms of dysuria, haematuria and urinary frequency. Some 20-30% of patients may also be asymptomatic, and sometimes extensive renal destruction may have occured by the time it is diagnosed. Genital TB in men may present as a scrotal mass and in women there may be pelvic pain

Answer 444

Renal artery stenosis

Answer 445

Chromaffin cells

Answer 446

zona glomerulosa - mineralocorticoid (aldosterone) production zona fasciculata - stimulated by ACTh to produce the glucocorticoid hormone cortisol zona reticularis - synthesises the androgen dehydroepiandrosterone

Answer 447

A neuroendcorine growth of the chromatin cells of the adrenal medullar, normally benign. Following the rule of 10s, 10% of cases are also bilateral and 10% are extradrenal and 10% recur. 25% of Phaechromocytomas are associated with familial gene mutations. In particular phaeos are seen in MEN 2A and MEN 2B, as well as von hippel lindau - VHL though not MEN 1

Answer 448

Addison's Disease

Answer 449

Cushing's Disease

Answer 450

Addisonian crisis

Answer 451

pituitary apoplexy

Answer 452

Sheehan's syndrome

Answer 453

Nelson's syndrome

Answer 454

Ectopic ACTH producing tumour

Answer 455

Phenoxybenzamine Labetalol Doxazosin Phenoxybenzamine: this is an irreversible alpha (1+2) blocker which binds covalently to apha adrenoreceptors This reduces alpha mediated vasoconstriction. There is also central action reducing sympathetic outflow. Labetalol: is a mixed alpha and beta blocker which also has use in treating the chronic hypertension associated with phaeos Doxazosin: This is an alpha 1 receptor blocker, it's primary action is vasodilation mediated hypotension however it is not as potent as phenoxybenzamine. It's use can come pre operatively or even peri operatively. Never use beta blockers in isolation

Answer 456

Panic attack

Answer 457

Phaechromocytoma

Answer 458

Inconclusive sample

Answer 459

Insulinoma

Answer 460

Graves disease

Answer 461

Primary adrenal insufficiency

Answer 462

285-295 mOsm

Answer 463

2(Na+K) + urea + glucose

Answer 464

vasoconstriction when vasopressin is at high vasopressin concentrations

Answer 465

insertion of AQP2 into the apical membrane of the distal convoluted tubule and collecting duct. stimulation increases circulating factor VIII and von willebrand factor.

Answer 466

Stimulation of ACTH release from corticotrophe cells

Answer 467

epileptic seizure

Answer 468

Microadenoma

Answer 469

Macroadenoma

Answer 470

Metoclopramide

Answer 471

inadequate treatment

Answer 472

Liddle's syndrome

Answer 473

Conns adenoma

Answer 474

Addison's disease

Answer 475

paraneoplastic syndrome

Answer 476

Impaired fasting glucose Patient hasn't eaten for over 12 hours so his BM is a fasting glucose measurement. Normal value for which would be less than 6 mmol/L

Answer 477

Non-signifcant Patient 2 has had a random bllod glucose taken. A reading of > 11.1 mmol/L would almost definitely mean she was diabetic. A reading greater than 7.8 might be suggestive of some dysfunction and possible prediabetes although it is not conclusive.However her reading is 7.7 mmol..nothing can be derived from this.. it is a non-significant reading.

Answer 478

Impaired glucose tolerance The random glucose for patient 3 is suggestive of a problem and the oral glucose tolerance test gievs a reading

Answer 479

Normal This womans' fasting BM is completely innocuous. After eating a meal her blood glucose remains below a level at which there may be suspicion of IGT. This patient is therefore definitely Normal

Answer 480

Diabetic WHO criteria for diagnosing Diabetes courtesy of cheese and onion :- symtpoms (vaginal thrush is one..impaired immune system) + raised venous glucose detected on one occasion.

Answer 481

A drooping or falling of the upper or lower eyelid

Answer 482

Autoimmune condition of antibodies blocking acetylcholine receptors at the postsynaptic neuromuscular junction, blocking ACh effects at nicotinic receptors at skeletal muscle NMJs. 75% have abnormalities of the Thymus. can be associated with Rheumatoid arthritis

Answer 483

Antibody - increased anti AChR and increased MUSK antibodies EMG - electromyography CT/MRI to look at thymus

Answer 484

Pryidostigmine - enzyme blocking drug Steroids and Immunosuppresants (prednisolone) Azathioprine - can take up to a year to have effects

Answer 485

Female - 3rd decade | Male - 6th/7th decade

Answer 486

Auto-Abs bing at the nAChR causing receptor blockade and compliment-medicated destruction of the post-synaptic membrane causing decreased Receptors at the end plate so decreased endplate potentials, this leads to fatigability

Answer 487

``` Muscle groups affected in order extra ocular - Ptosis, diplopia bulbar - nasal sounding speech face - horizontal smile with furrowed brow neck with face - affects muscles of mastication and swallowing limb - proximal muscle weakness girdle, trunk ```

Answer 488

a combination of damage/diseases to the peripheral nerves. presents with painful, asynchronous, asymmetrical sensory and motor neuropathy. Associations (DAVID) D - diabetes A - alcoholism V - vitamin deficiency - B12 I - infective (Guillain-Barre) / Inherited (charcot-Marie- Tooth) D- drugs (isoniazid)

Answer 489

rare but serious autoimmune attack of the myelin sheath of the peripheral nervous system, presenting after a viral/bacterial infection. Symptoms - pain and tingling and numbness, muscle weakness, co-ordination problems and unsteadiness, starts in hands and feet. rapid onset. symmetrical. inability to stand,

Answer 490

Rare autoimmune disorder characterised by muscle weakness of the limbs (aching or tender). autoimmune attack of presynaptic voltage gated calcium channels at the NMJ causing impaired ACh release. repetitive nerve stimulation has an incremental response due to increased ACh release increasing the chance of an AP being stimulated. Autonomic symptoms - dry mouth, impotence and postural hypotension. Deep tendon reflexes are reduced or absent 60% have underlying malignancy (most commonly small cell carcinoma of the lungs) presents usually 40yo and over treatment is usually via treating cancer but can also use steroids, azathioprine and IV immunoglobulin to suppress the immune system

Answer 491

Miller Fisher syndrome is a rare, acquired nerve disease that is considered to be a variant of Guillain-Barré syndrome. It is characterized by abnormal muscle coordination, paralysis of the eye muscles, and absence of the tendon reflexes. Additional symptoms include generalized muscle weakness and respiratory failure.

Answer 492

Nurodegenerative disease affecting - UMN in motor cortex and LMN in brainstem and SC. Confined to the motor system. Loss of neurone leads to muscle atrophy and weakness, fasciculations and spasticity. appears in 4th decade, affecting males more then females. most patients die 3-5years after onset of symptoms. affects lateral corticospinal tracts

Answer 493

Affects cranial nerves 9-12 | Dysarthria (difficulty speaking) and dysphagia are common symptoms

Answer 494

Loss of Betz cells in layer 5 of the motor cortex | UMN signs

Answer 495

Anterior horn lesion only LMN signs wasting often begins in distal muscles of the hands and spreads Fasciculations are common

Answer 496

An inflammaroty, autoimmune, demyelinating disease of the CNS with a neurodegenerative component. optic neuritis is common, non specific signs include leg weakness and ataxia. symptoms worse in heat increased CSF protein, oligoclonal IgG bands on electrophoresis. delayed visual/somatosensory evoked potentials

Answer 497

onset in first 2 decades of life slowly progressing weakness beginning in the distal limb muscles - causing difficulty walking and frequent tripping (falls and sprains) leading to foot drop and a stoppage gait. Intrinsic foot muscle weakness results in pea caves legs have inverted champagne bottle appearance (wasting of skins and calves but not thing muscles) ankle reflexes and plantar responses are absent

Answer 498

increased parasthesiae numbness in hands dupytrens contracture, spider naevi and gynaecomastia = alcoholic so deficient autonomic deficiency

Answer 499

painful asymmetrical proximal motor neuropathy affecting the lower limbs. due to occlusion of vasa nervorum of proximal lumbar plexus and femoral nerve causing infarction initial presentation is pain in the thigh then wasting and weakness of the quads and loss of knee jerk

Answer 500

``` Intracranial haemorrhage Head injury Migraine Alcohol Infection Meningitis Cerebral venous thrombosis Dissection of carotid ```

Answer 501

``` Giant Cell arteritis Acute glaucoma sinusitis malignant HTN Encephalitis/Meningitis ```

Answer 502

``` Migraine Tension Headache Cluster Headache Medication overuse Intracranial mass lesion Sinusitis ```

Answer 503

Unilateral - around/above the eye, along the side of the face/head sharp, burning, throbbing, tightening red/watery eye, nasal congestion, swollen eyelid, sweating, constricted pupil with/without drooping eyelid

Answer 504

``` Rare, typically >50yo, 2:1 f:m unilateral/bilateral fronal headaches reproduced by pressing on temples jaw claudication (pain on chewing) Amaurosis fugax (painless monocular visual loss) leading to blindness ```

Answer 505

60-80yo, hypertensive can appear in younger patients with MS, tumours pain is distributed on 10th nerve unilaterally episodes with a refractory period after each- provoked by washing, shaving and chewing

Answer 506

``` worsening headache with fever history of malignancy compromised immunity vomiting sudden-onset reaching max intensity in 5mins impaired consciousness trauma triggered by cough, sneeze, exercise or posture ```

Answer 507

sudden blockage around trabecular network so aq humour can't drain from the eye, rapid increase in pressure...eye emergency! symptoms - sudden and severe headache, vomiting, blurred vision and haloes around lights, abdo pain

Answer 508

Pain on extension of the knee when lying down with hip at 90degrees due to meningeal irritation

Answer 509

flexion of the neck when lying down causing flexion of the knees and hips

Answer 510

Hyponatraemia

Answer 511

Hyponatraemia secondary to liver failure Liver wants to increase blood supply so increased NO production > vasodilation > decreased BP > release of ADH

Answer 512

Hypernatraemia secondary to CNS tumour causing DI

Answer 513

Hyperkalaemia

Answer 514

Hypokalaemia

Answer 515

Addison's disease

Answer 516

Conn's syndrome

Answer 517

Primary hyperparathyroidism ``` Bones Stones Groans Psychic moans Thrones ```

Answer 518

Secondary hyperparathyroidism due to hypocalcaemia secondary to vitamin D deficiency

Answer 519

Hypothyroidism

Answer 520

Grave's disease

Answer 521

Papillary thyroid carcinoma