Questions Flashcards

Question

A 24 year old university student presents to her GP with a worsening tiredness and bruising. On examination she is extremely pale and has multiple bruises over her body. She is referred urgently to the local hospital where a blood count shows: Hb: 7.2g/dl WCC: 2.08x10(9)/l PMN: 0.74x10(9)/l Platelets: 48x10(9)/l She has no past medical history of note, takes no regular medications and there is no significant family history apart from a distant aunt who has sickle-cell disease. She does drink a few glasses of wine a week and smoke cigarettes occasionally but denies recreational drug use. She is reviewed by the haematologists who perform a bone marrow biopsy which reveals a hypoplastic marrow Which one of the following is the most likely diagnosis? A) myelodysplastic syndrome B) aplastic anaemia C) Evans syndrome D) myelofibrosis E) TTP

Answer 1

B) Aplastic anaemia The patient presented severe anaemia, leucopenia and thrombocytopenia with a hypoplastic marrow. The most likely diagnosis is aplastic anaemia. Myelodysplastic syndrome is a disease of the elderly with decreasing production and quality of press conference. Evans syndrome is the presence of autoimmune haemolysis and autoimmune thrombocytopenia together in the same patient.

Answer 2

E) BhCG estimation Although the history for this patient is suggestive of PCOS, it is extremely important to exclude pregnancy in any patient presenting with amenorrhea before considering alternative diagnoses.

Answer 3

D) A) This occurs in Rhesus disease. Maternal IgG crosses the placenta leading to haemolysis. B) Goodpasture's is a type II HS reaction where Ab cause damage by binding to Ag in tissues. Type III is caused by IC deposition. C) anaphylaxis involves IgE E) HIV targets CD4 cells.

Answer 4

Cluster headache Cluster headache is characterised by attacks of severe pain localised the unilateral orbital, supraorbital and or temporal areas which lasts from 15 minutes to 3 hours, and occurs with a frequency ranging from once every other day to 8 times a day. These attacks can occur at the same time period of many weeks (known as the cluster period) accompanied by ipsilateral autonomic signs. The cause is hypothalamic activation with secondary trigeminal autonomic activation (for instance lacrimation, rhinorrhoea, nasal congestion conjunctival infection and partial Horner's i.e. ptosis and miosis). Cluster period attacks can be triggered by things like alcohol. Greater occipital nerve blockade often provide immediate relief until preventative medication take effect.

Answer 5

Subarachnoid haemorrhage SAH (bleeding into subarachnoid space) presents with sudden severe headache patients often described as the worst headache of their life, and can often be so bad that they feel like they have been kicked in the back of the head. Half of all patients lose consciousness and eye pain with exposure to light can also be seen. Altered mental status is common. SAH occurs most commonly in the 50 to 55 age group and affects women and black people more than men and white people. The most common cause of the non-traumatic SAH is an aneurysm which ruptures. Conditions which predisposed to aneurysm formation and SAH include adult PKD, Marfan's, NF1 and Ehlers-Danlos. Cerebral aneurysms arise around the circle of Willis. A CT scan is indicated, and if unrevealing, this should be followed by an LP. Cerebral angiography can confirm the presence of aneurysms. The patient should be stabilised and is followed by surgical clipping or endovascular coil embolisation, the choice is subject to much current controversy sparked by relatively recent research. Complications can commonly occur and include rebleeding, hydrocephalus and vasospasm.

Answer 6

Partial seizure. The feeling this woman felt in her stomach before (Aura), the description of the arm, incontinence and feeling "worn out" afterwards make this a seizure. Seizures can happen in anyone but epilepsy is the tendency to have repeated, unprovoked seizures. Epileptic seizures can be split into focal (partial or localised) and generalised (involving both hemispheres). Generalised seizures can be further divided into absence (typical or atypical), myoclonic, chronic, tonic, tonic-clonic and atonic types. Be sure to exclude other causes, such as a space occupying lesion with a CT or MRI scan. There may also be tongue biting. Always think of "before, during and after" when taking history. History taking is the most important aspect of diagnosis. Antiepileptic monotherapy is the preferred treatment.

Answer 7

Thiamine/B1 deficiency This patient has Wernicke's encephalopathy. Wernicke's is due to a acute thiamine deficiency, which is a problem in alcoholics (the Dupytren's contracture here is a clue to alcohol use). Others at risk include those with AIDS, cancer and treatment with chemotherapy, malnutrition and GIT surgery, especially bariatric procedures. It is a clinically underdiagnosed condition. The classic triad is a mental change, ophthalmoplegia and gait dysfunction which is actually only seen in 10% of cases. In reality, the manifestations are varied and a high index of suspicion is needed. This is an emergency and treatment is with parenteral replacement of thiamine this avoids permanent neurological damage including later development of Korsakoff psychosis, which is irreversible. Note that thiamine should be given before dextrose! Magnesium deficiency also need to be corrected as it is a cofactor in the functioning of thiamine dependent enzymes.

Answer 8

CCB or Thiazides diuretic

Answer 9

CCB & diuretic

Answer 10

Alpha blocker or spironolactone

Answer 11

CCB or diuretic

Answer 12

ACEi This man has concomitant diabetes and chronic renal disease and stage one hypertension. The first line treatment is monotherapy with an ACE inhibitor. ACEi are renoprotective and decreases the progression of proteinuria in diabetics.

Answer 13

Methyldopa The first-line agent for hypertension in pregnancy is methyldopa. This drug acts by stimulating alpha-2 receptors which have a sympatholytic effect on the vasculature. The lowest dose should be titrated upwards into a therapeutic effect is achieved or an adverse event prevent upping the dose further. The second-line agent is labetalol.

Answer 14

Thiazide & ACEi This patient has stage to hypertension and will require the initiation of two concurrent antihypertensive medications at the same time. The first line is it thiazides diuretic plus ace inhibitor. A combination of non-dihydropyridine CCBs with beta-blockers should be avoided due to the risk of AV block. However as second line options, ACEi plus CCB/beta-blockers can be used thiazides plus beta-blockers.

Answer 15

Beta-blocker This is stage one hypertension complicated by AF. The first choice is a beta-blocker and the second choice is a non-DHP CCB. If stopping treatment, beta-blockers should be weaned off as abruptly stopping beta-blockers has been associated with exacerbations of angina and heart attacks have also occurred. If the patient has COPD or asthma then CCBs may be preferred.

Answer 16

Labetalol. This is a hypertensive emergency with BP \>210/130. Treatment should be started without waiting for further tests as this is a medical emergency and BP must be lowered over the minutes to hours with IV medications in ITU setting. Oral medications can be given afterwards to win the patient off IV. Guidelines indicate the goal is to reduce MABP by no more than 25% in the first hour, then if stable to 160/100 or less within the next 2 to 6 hours. This is malignant hypertension associated here with retinopathy. Head CT denies evidence of infarct or haemorrhage. The proteinuria here is a sign of real failure. The first line treatment in malignant hypertension is IV labetalol. Onset of action 5 to 10 minutes, duration of action to 3-8 hours.

Answer 17

Primary hyperaldosteronism. Spironolactone. (K sparing diuretic = competitive antagonist of aldosterone [mineralocorticoid] receptor

Answer 18

Asthma SOB and the cough, which may wake the patient from sleep combined with the patient's age and progressive course suggest asthma. Examination can show an expiratory wheeze but may be normal and treatment is step wise based on BTS guidelines. It is worth noting that in severe exacerbations, the chest may be silent. Night symptoms occur in more severe asthma and symptoms can be exacerbated by exercise. Diagnosis is supported by PEFR variation of at least 20% over 3 days in a week over several weeks or an increase of at least 20% to treatment.

Answer 19

Bronchiectasis. Bronchiectasis is permanent bronchi dilation due to bronchial wall damage and loss of elasticity. It is often as a consequence of recurrent/severe infections and most present with chronic productive mucopurulent cough. The most common identifiable cause is CF. Chest CT is the diagnostic test. Diagnosis is aided by sputum analysis.

Answer 20

Malignancy This person likely has lung cancer which has results in the significant weight loss of 10kg. This is post-obstructive pneumonia which is common in lung cancer patients and is caused, most of the time, by a large and centrally obstructing tumour. It is essential to relieve this obstruction in this case and many techniques can be tried. There is also bone pain here in the lower spinal column which is due to mets. The prognosis here is not good.

Answer 21

Fibroadenosis Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.

Answer 22

SC LMWH Women developing a DVT during pregnancy can be treated with heparin or LMWH. However, LMWH is preferred due to more dependable pharmacokinetics.

Answer 23

SC LMWH Patients with recurrent thromboembolism despite on warfarin should be given heparin or primarily LMWH. They should be given for at least 5 days until INR is between 2-3. Fondaparinux (fX inhibitor) would be used instead if there was a high chance of delayed HIT. Warfarin is continued and efforts must be made to work out how this patient has developed a DVT despite warfarin therapy. There may be sub therapeutic dosing, the presence of malignancy or anti phospholipid syndrome. If there is documented thrombosis progression despite adequate anti coagulation, without HIT and other causes excluded, an IVC filter may be indicated but evidence of its efficacy have been debated.

Answer 24

AEIOU Acidemia due to metabolic acidosis Electrolyte imbalance - hyperkalemia Intoxication - SLIME poisons: Salicylic acid, Lithium, Isopropanol, Mg-containing laxatives, Ethylene Glycol Overload of fluid refractory to diuretics Uraemic complications: pericarditis, encephalopathy, GI bleed

Answer 25

PBC Primary biliary cirrhosis (PBC) is a chronic condition where the intrahepatic small bile ducts are progressively damaged (and eventually lost) occuring on a background of portal tract inflammation. Fibrosis develops, ultimately leading to cirrhosis (which is defined as fibrosis with nodular regeneration). It is widely believed to be autoimmune in aetiology as almost all patients have antimitochrondrial antibodies. This is the give away point in this question which is otherwise a non-specific presentation. Elevated ALP suggests cholestasis.

Answer 26

CN IV This man is complaining of double vision. You should already be thinking III, IV or VI which are the cranial nerves responsible for eye movements. CN IV innervates the superior oblique muscle which controls depression, intorsion and adduction of the eye. This is vertical diplopia (worse when walking down the stairs) hence the cause is a lesion in CN IV. The trochlear nucleus is located in the midbrain at the level of the inferior colliculus and fasciles decussate at the medullary velum to exit at the dorsal midbrain. The nerve enters the orbit through the superior orbital fissure. Testing is done at the bedside by asking the patient to follow the examiner’s finger with the eyes, while observing eye movements and asking the patient to report any diplopia. Remember that diplopia is maximal in the direction of action of the paralysed muscle (which makes sense if you think about it) and the outer image is the image which is false, and disappears when the ipsilateral eye is covered up.

Answer 27

CN VII This is someone who cannot close their eyes. Eye closure relies on orbicularis oculi which is innervated by the facial nerve (VII). It is the most common CN mononeuropathy and the most common cause of a peripheral facial palsy is Bell’s palsy. This is why when testing CN VII you ask a patient to screw their eyes up tightly and resist you trying to open them as well as asking them to do other seemingly odd things like raising their eyebrows against resistance, showing you their teeth and pursing their lips. The facial nerve is both motor and sensory (via the nervus intermedius).The nerve exits the cranium through the stylomastoid foramen and enters the parotid, where it splits into 5 branches – temporal, zygomatic, buccal, mandibular and cervical.

Answer 28

Blood cultures. You suspect that this little girl has meningitis with fever, nuchal rigidity and presumably a petechial/purpuric rash, typically associated with meningococcal meningitis. If there is evidence of raised intracranial pressure, then a CT head should be considered before LP. There is this suspicion in the question, but the radiographers have gone home. That’s not to say that if you suspect raised ICP and feel an LP would not be safe to do, that you should go ahead and perform a lumbar puncture anyway. In this case, as a responsible doctor, you would order blood cultures as LP is clearly clinically unsafe. This is less accurate as the result may be influenced by previous antimicrobials and positive blood cultures have been reported in only 40-70% of clinically suspected meningococcal infection. But, unless you want to get struck off by the GMC and imprisoned for causing uncal herniation... it’s the best choice you have. The main diagnostic investigation for meningitis is still to do is an LP except you simply cannot do it in this case. This would show low CSF glucose, raised CSF protein and positive CSF culture or gram stain or meningococcal antigen. Given the signs and symptoms here are very striking, you would not delay treatment. Until you know which organism is causing the symptoms and its sensitivities, empirical therapy can be started with, for example, vancomycin and ceftriaxone. Once the organism is confirmed and you know sensitivities, you can begin targeted antibiotic therapy. For example, if the infection is confirmed to be Neisseria and is penicillin sensitive, you can start benzylpenicillin or ampicillin intravenously. All patients should receive adequate supportive care throughout.

Answer 29

Helical CT scan 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 accurately 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 30

Hodgkin's lymphoma This is a lymphoma and the main differential is between Hodgkin’s and Non-Hodgkin’s. It is actually very difficult to differentiate the two clinically but there is only one option here and the question is testing your ability to tell that is is lymphoma, at this stage. Possible differentiating signs or symptoms include the bimodal age distribution of Hodgkin’s and that Hodgkin’s is associated with pruritis and alcohol-triggered pain. But again, the two are clinically similar. Lymphoma may like this case present with systemic symptoms of fever, drenching night sweats (which classically require patients to change their clothes) and weight loss due to the hypermetabolic state. There may also be SOB, cough, general malaise and abdominal discomfort (hepatomegaly, splenomegaly, lymphadenopathy, bowel involvement), headache, change in mental status, ataxia (if the CNS is involved), fatigue and chest pain (from anaemia), bone pain (from bone involvement) etc. There are many risk factors such as EBV, which is associated with Hodgkin’s lymphoma, Burkitt’s lymphoma, AIDS-related primary CNS lymphoma and nasal NK/T-cell lymphoma. Treatment depends on the histological subtype and the severity of symptoms at presentation.

Answer 31

Alport's syndrome Alport’s syndrome is a rare familial nephropathy due to abnormal type IV collagen and may either be X-linked, autosomal recessive or autosomal dominant. Gross haematuria is a common presenting feature, often precipitated in a child by an infection. The age of onset of chronic renal failure is variable in this condition and it is frequently associated with sensorineural hearing loss, like in this case here. Complications such as renal failure and deafness typically occur more often in young males with the X-linked form of disease. The FH of early death may be linked to progression to end-stage renal failure. The mainstay of treatment is to monitor and treat renal disease. Female carriers of X-linked mutations have a lifetime risk of developing hypertension and renal disease which is significant. In EMQs if a child, especially male, has renal disease associated with deafness, then it is likely to be Alport’s. There is also a characteristic central retinopathy present in 40-70% of males which is said to be pathognomic of the disease.

Answer 32

Chronic pyelonephritis Chronic pyelonephritis is most commonly caused by chronic vesicoureteric reflux which this man gives a PMH of. Other risk factors include a history of acute pyelonephritis, which can often develop into the chronic type if inadequately treated or if acute cases are recurrent, renal obstruction (which may be due to urinary tract abnormalities, BPH or stones like a staghorn calculus) and DM. The damage is irreversible, unfortunately, and there is no specific treatment, and this condition may result in ESRF. Diagnosis is clinical and confirmed with imaging studies. The history of unpleasant smelling urine (which may be cloudy) along with urinary symptoms (suggesting UTI) and suprapubic pain (though there may be flank/back pain and tenderness) is also indicative. The patient’s condition may be complicated here by urinary tract infections and associated symptoms.

Answer 33

Scurvy Scurvy is basically vitamin C deficiency and is now a rare disorder and really only affects people who are subject to famine or wartime displacement in places like Africa. Vitamin C is needed for collagen synthesis so lack of this vitamin leads to impaired synthesis of collagen which can lead to complications. These complications include bleeding complications like spontaneous petechiae and bruising, friable gingiva and loose teeth, bone pain and joint effusions. Complications include heart failure, encephalopathy and entrapment neuropathies. To aid diagnosis, serum, leukocyte and whole blood ascorbic acid levels can be measured. This condition can be fatal if it is left untreated but complete recovery is expected on going vitamin C replacement in the form of ascorbic acid.

Answer 34

TTP (thrombotic thrombocytopenic purpura) The title really tells you what this condition is. TTP is a diagnosis you should consider in any patient with anaemia and thrombocytopenia as 95% of cases are fatal if left untreated. The symptoms are usually non-specific though before plasma exchange was available as a treatment option, most patients developed 5 characteristic features (a pentad) of: microangiopathic haemolytic anaemia, thrombocytopenia with purpura, acute renal insufficiency, neurological abnormalities and fever. It is rare however for all of these to be present now. Most patients present aged 30-50 and there is usually a non-specific prodrome followed on the components of the pentad. The peripheral blood film here shows evidence of microangiopathic HA with schistocutes being present. Even though not reported, thrombocytopenia would also be seen on this film. The mainstay of treatment, as hinted before, is plasma-exchange therapy

Answer 35

Henoch-Schonlein syndrome 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 arethe extravasation of blood into the skin. They can occur anywhere on the body but are usually concentrated on the lower extremities. Half of all patients have abdominal pain and arthralgias are commonly present (found in about 80%) and often associated with oedema. The joints most often affected are the knees and ankles. About half will show signs of renal disease such as proteinuria or haematuria. Risk factors for this condition include being male, age 3-15 and history of prior UTI. Complications can occur and the most common cause of death is renal failure.

Answer 36

Gastric carcinoma Weight loss is one of the most common presenting symptoms in patients with gastric cancer. Epigastric pain is present in about 80% and may resemble that of a gastric ulcer. Although commonly mentioned in EMQs, lymphadenopathy is an uncommon presentation. On examination there may be the presence of a left supraclavicular node (Virchow’s node), a periumbilical nodule (Sister Mary Joseph’s nodule) or a left axillary nodule (Irish node). These are rare findings. A mass may be palpable in advanced disease. More proximal tumours can present with dysphagia. Acanthosis nigricans, a black velvety rash, may also be present. Strong risk factors include pernicious anaemia, Helicobacter pylori and the consumption of N-nitroso compounds found in cured meats. The peak incidence occurs between 50-70 and men are twice as likely to have gastric cancer. Most are adenocarcinomas. The first test to order for suspected gastric malignancy is an urgent upper GI endoscopy with biopsy of the lesion. The mainstay of treatment is surgical resection unless there is evidence of metastatic disease.

Answer 37

Duodenal ulcer Epigastric pain and tenderness related to eating a meal is typical of a peptic ulcer. The pain is generally relieved by drinking milk. 80% are duodenal and 20% are gastric. Ulcers may cause iron deficiency anaemia and associated symptoms may feature. Key risk factors are NSAID use, H. pylori infection, smoking and a family history of PUD. Zollinger-Ellison syndrome should be considered if there are multiple ulcers or ulcers refractory to treatment. Gastric ulcers classically cause pain which is exacerbated by eating and immediately relieved on vomiting. There is usually also weight loss due to a fear of food and its association with pain. Duodenal ulcers are classically made worse by hunger and are relieved by eating and the patient may wake at night with the pain. As a result, weight gain is typically a feature. In reality, it is difficult to differentiate the site of the ulcer based on these features. The most specific and sensitive test is an upper GI endoscopy which is initially ordered if the patient has ‘red flag’ symptoms, is \>55 years of age or fails to respond to treatment. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. In patients who are 55 or younger without ‘red flags’, testing for Helicobacter pylori (breath testing with radiolabelled urea or stool antigen testing) is necessary. 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 38

Carbimazole This woman has hyperthyroidism. The smooth midline swelling and the audible bruit point towards a diagnosis of Graves’ disease. In countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Peripheral manifestations such as ophthalmopathy, pretibial myxoedema and hyperthyroid acropachy do not occur with other causes of hyperthyroidism. Acropachy manifests as clubbing with soft tissue swelling. Pretibial myxoedema is almost always associated with ophthalmopathy. A thyroid isotope scan such as Tc-99 pertechnetate is used to differentiate the diffuse enlargement of Graves’ with the patchy uptake of a multinodular goitre. This is not necessary based on the examination findings. Treatment aims to normalise thyroid function and is achieved by radioactive iodine, antithyroid medications or with surgery. They are all effective and relatively safe options. Symptomatic therapy is given with beta blockers such as propranolol.

Answer 39

FBC + Paul Bunnell Infectious mononucleosis is caused by EBV and is characterised by fever, pharyngitis and lymphadenopathy. A FBC will show an atypical lymphocytosis. Confirmation of IM involves detection of the existence of heterophile antibodies using the Paul Bunnell monospot. A more accurate test is a serological test detecting EBV specific antibodies. Treatment is usually symptomatic but IM carries rare but potentially life threatening complications.

Answer 40

Technetium thyroid scan. This is a case of toxic multinodular goitre. It is most common in older patients and is associated with head and neck irradiation and iodine deficiency. TSH is the initial screening test and if supressed, T4/T3 levels are measured. As the peripheral stigmata of Graves’ disease is absent, thyroid scan and uptake is indicated. I-123 is the preferred isotope but as this option is not given, Tc-99 can be used although there is a risk of false positive images. The scan will show multiple hot and cold areas consistent with areas of autonomy and areas of suppression. Definitive treatment is commonly given in the form of radioactive iodine.

Answer 41

Upper GI endoscopy. The bilateral mass in the last part of this question is a multinodular goitre which does not need a biopsy. The patient is euthyroid. If the nodule was unilateral, then a biopsy is essential to establish or exclude malignancy. However, her dysphagia needs to be investigated with an upper GI endoscopy.

Answer 42

Codeine phosphate. Codeine phosphate is an opiate and will kill two birds with one stone by offering effective pain relief and treating the diarrhoea. Codeine is used for mild to moderate pain, diarrhoea and as an antitussive.

Answer 43

24hr urine protein The most common cause of nephrotic syndrome in adults with long standing diabetes is diabetic nephropathy. However, non-diabetic renal disease cannot be excluded. Nephrotic syndrome is defined by the presence of proteinuria (\>3.5g/24h), oedema and hypoalbuminaemia. Some definitions add hyperlipidaemia. Do not confuse this with nephritic syndrome. Diagnosis is made by quantification of proteinuria with a 24 hour urine collection, although now it is common to do a spot urine protein-to-creatinine ratio for practical reasons.

Answer 44

Venous doppler studies Recent surgery, especially orthopaedic surgery, is a strong risk factor for developing a DVT. Other strong risks include active malignancy, pregnancy, obesity and coagulopathies such as factor V Leiden. A Wells score is determined in all patients with a suspected DVT with the condition being likely if the score is 2 or more. If the Wells score is

Answer 45

Pneumonia The rusty coloured phlegm is hinting at a pneumococcal pneumonia.The patient has presented with common symptoms of fever, chills and a cough. There may also be SOB, rigors and pleuritic chest pain. The most specific and sensitive test is a CXR (PA and lateral) and initial treatment of a CAP is empirical with antibiotics. Often diagnosis is made solely on history and examination findings. Bronchial breathing, reduced breath sounds and the presence of a left sided parapneumonic effusion all indicate a pneumonia. Management is guided by the patient’s CURB-65 score.

Answer 46

IV immunoglobulins ITP is thought to be due to an autoimmune phenomenon. Treatment is based on the patient’s platelet count and bleeding symptoms. This patient has severe active bleeding and myst be started on IVIG plus corticosteroids, which she is already on. Platelet transfusions should be considered with tranexamic acid as an adjunct.

Answer 47

Diclofenac NSAIDS may impair renal function and provoke renal failure, especially in patients with pre-existing impairment. NSAIDs should be avoided if possible in these patients or used with caution at the lowest effective dose for the shortest possible time. The mechanism of damage involves reducing creatinine clearance. NSAIDs are also contraindicated in asthmatics as it causes bronchospasm due to the accumulation of leukotrienes.

Answer 48

Epidural bupivacaine fentanyl Epidurals are relatively contraindicated in anticoagulated patients. Insertion of the epidural needle may lead traumatic bleeding into the epidural space and with clotting abnormalities, the development of a haematoma which can lead to spinal cord compression. Coagulopathy, raised ICP and infection at the injection site are absolute contraindications. Relative contraindications include anticoagulated patients and those with anatomical abnormalities of the vertebral column. NSAIDs do not increase the risk of epidural haematoma

Answer 49

Codydramol Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.

Answer 50

Diclofenac NSAIDs inhibit COX which has the effect of reducing PGE2 levels. PGE2 plays a role in gastric cytoprotection by downregulating HCl production and increasing mucus and the production of bicarbonate. This leads to gastric irritation and ulceration. A PPI can be prescribed alongside NSAIDs or misoprostol can be used, which is a stable PGE1 analogue which mimics local PG to maintain the gastroduodenal mucosal barrier.

Answer 51

Phaechromocytoma Phaeochromocytomas presents with paroxysmal episodes of palpitations, anxiety, excessive sweating, pallor and hypertension. It can be inherited in MEN2, von Hippel-Lindau syndrome and NF1. Diagnosis is based on raised urinary and serum catecholamines, metanephrines and normetanephrines. 24 hour urinary VMA will be elevated. CT is used to localise the tumour. Treatment includes medical with the use of phenoxybenzamine, phentolamine and surgical options. Surgical excision is carried out under alpha and beta blockade to protect against the release of catecholamines into circulation when the tumour is being manipulated. The 10% rule is often quoted: 10% are bilateral, 10% malignant, 10% extraadrenal and 10% hereditary.

Answer 52

Teratoma Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30. Radical orchidectomy and histology is the initial treatment in most cases.

Answer 53

Mumps orchitis The tender mandibular swelling indicates mumps parotitis. Epidydimo-orchitis is the most common extra-salivary complication of mumps in males and presents as pain and swelling in one or both testicles. Those unvaccinated and international travellers are at increased risk. The mumps vaccine is incoporated as part of MMR. Mumps is caused by an RNA paramyxovirus and spread by respiratory droplets. If the diagnosis needs to be confirmed, then serological or saliva testing is possible looking for IgM. Treatment is supportive with symptom relief mainly with analgesia and antipyretics.

Answer 54

Epididymo-orchitis Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. This patient is however likely to have an STI due to his foreign exploits. Risk factors include unprotected sexual intercourse. He is febrile with tenderness and has reactive lymphadenopathy which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated. As this is likely to be sexually transmitted, a combination of ceftriaxone and doxycycline is indicated to cover for Chlamydia trachomatis and Neisseria gonorrhoeae.

Answer 55

Hypercalcemia 90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. Cancer is the likely cause in this woman. Malignancy can cause hypercalcaemia either by direct bony involvement leading to osteolytic lesions or paraneoplastic syndromes involving PTHrp release. The tumour is typically very advanced if hypercalcaemia is a feature. Less common causes include vitamin D overdose, hyperthyroidism, immobilisation, Paget’s and milk-alkali syndrome. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica which causes pain. Symptoms of high calcium include confusion, constipation, polyuria, polydipsia, depression, kidney stones and lethargy. This can be remembered by ‘stones, bones, abdominal groans and psychiatric moans’. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.

Answer 56

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 57

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 58

ANCA 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 59

Squamous cell carcinoma Dysphagia coupled with weight loss and the irregular shaped mass points to malignancy. Dysphagia occurs when there is obstruction of more than 2/3 of the lumen and presence indicates locally advanced disease. There may additionally be odynophagia. Men are twice as likely to develop oesophageal cancer. GORD, Barrett’s oesophagus, FH, tobacco and alcohol are all risk factors. The two main types are squamous cell carcinoma and adenocarcinoma. Tumours in the upper 2/3 of the oesophagus are SCC whereas those that lie in the lower 1/3 are adenocarcinomas. The main test to order is an OGD with biopsy. Treatment is either surgical resection or with chemo or radiotherapy alongside endoscopic ablation with or without stenting and brachytherapy.

Answer 60

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 61

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 IV Pyelogram 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 62

Oropharyngeal airway with oxygen An oropharyngeal (or Guedel) airway is sized from the angle of the mandible to the level of the incisors. It is a non-definitive airway adjunct. The patient is breathing in an obstructed manner indicating some degree of partial upper airway obstruction. The Guedel will keep the airway patent and prevent the tongue obstructing the airway by depressing it. The Guedel can only be used if the patient has a reduced GCS as it can initiate a gag reflex. If the patient was not unconscious, then a nasopharyngeal airway can be used (usually inserted in the right nostril). Additionally, a Guedel is contraindicated if the patient has injuries to the face or a condition that prevents the mouth from opening. Airway manoeuvres can also be used such as a jaw thrust or head tilt chin lift in addition to maintain a patent airway. A jaw thrust can only be done if the patient is unconscious. Think about where your fingers are digging in.

Answer 63

Single lumen cuffed ET tube. This patient is unconscious and is about to undergo a CT scan. He needs a definitive airway. The cuffed end creates a seal the prevent the aspiration of stomach contents. Reduced consciousness is a major risk factor for aspiration due to an inadequate cough reflex and impaired closure of the glottis.

Answer 64

Single lumen cuffed ET tube This patient is elderly, having surgery in a recumbent position and has known aspiration risk factors of obesity and GORD. She will need a definitive airway with a cuffed ET tube to create a seal to prevent aspiration of stomach contents. The ease of intubation can be determined by an airway assessment including a Mallampatti score (I to IV). A double lumen ET tube is designed for some intrathoracic operations. An uncuffed ET tube is preferred in children as the trachea is not as strong. If it is an emergency setting and ET intubation fails, cricothyroidotomy can be performed which allows approximately 30 minutes of ventilation. Cricothyroidotomy will only work with at least a partially patent larynx.

Answer 65

Breast abscess Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful, hard and red lump indicates the development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.

Answer 66

Breast carcinoma This lady’s advanced age and the fact the lump is hard, irregular and non-tender all point towards malignancy. The mass is typically fixed but can be mobile in early stages. There may be associated changes such as nipple inversion, peau d’orange, lymphadenopathy and skin retraction. Skin changes are always associated with locally advanced cancer. Triple assessment is indicated with a mammogram and biopsy. Risk factors include FH, prolonged oestrogen exposure and high levels of alcohol consumption.

Answer 67

Bladder calculus There is pain on standing and difficulty urinating because the calculus falls and blocks the bladder outflow. Blood comes at the end of the stream from urine that has passed the damaged area of urothelium. Patients tend to present with suprapubic pain, haematuria and obstructive symptoms. Examination may reveal suprapubic tenderness. The first test to order is urinalysis. A non-contrast CT abdomen is also indicated to look for the stone.

Answer 68

Hydronephrosis This patient has BPH which has caused hydronephrosis. This is an example of bilateral obstructive uropathy. Acute presentations are often painful whereas chronic presentations are more insidious in onset. Blockage of urinary flow by the enlarged prostate has led to urinary retention and overflow incontinence. Initial treatment aims to relieve the pressure on the kidneys. This involves catheterisation as the first line treatment. The patient should be started on alpha blockers at the time of catheterisation.

Answer 69

Infectious mononucleosis This is caused by EBV and characterised by fever, pharyngitis and lymphadenopathy with atypical lymphocytosis. Positive heterophile antibody test and serological testing for EBV antibodies are diagnostic. Splenomegaly is common and enlargement occurs in the first week, lasting 3-4 weeks. It is worth remembering that splenomegaly is always an abnormal examination finding. IM is commonly named the ‘kissing’ disease as EBV is most commonly transmitted by saliva. Penetrative sex and general promiscuity in young women also increases the risk.

Answer 70

Idiopathic myelofibrosis This is a case of myelofibrosis. Leucoerythroblastosis and splenomegaly are common findings. Strong risk factors include exposure to radiation and industrial solvents. BM biopsy is essential for diagnosis. Extramedullary haematopoiesis leads to dacrocytes in the peripheral blood smear. Those without symptoms can be managed with folate and pyridoxine supplements. Otherwise options such as a BM transplant and hydroxycarbamide can be considered.

Answer 71

Cold fingers and toes Beta blockers can cause bronchoconstriction (asthmatics), heart failure in those with heart disease who rely on a degree of sympathetic drive to the heart to maintain CO, hypoglycaemia (diabetics can lose warning signs), fatigue (reduced CO and muscle perfusion via beta 2 receptions) and cold extremeties (beta receptor mediated vasodilation of cutaneous vessels). Additionally there may be bad dreams which is more pronounced in lipophilic beta blockers such as propranolol.

Answer 72

Nausea and vomiting Erythromycin is a motilin agonist which causes N&V. It is a macrolide antibiotic and tends not be first line unless the patient has a penicillin allergy. It has a slightly wider spectrum of activity than penicillin. The macrolides can also cause reversible deafness although the most important group to note in drug induced deafness are the aminoglycosides such as gentamicin.

Answer 73

CLL This elderly woman has CLL. CLL presents in older adults (generally \>60) and is often asymptomatic. Smear cells can be seen in peripheral blood smear and it is associated with a warm type AIHA accounting for her pallor and fatigue (hence the Coombs’ test is positive). Painless lymphadenopathy may be present and splenomegaly is a common finding. A WCC with differential is required to make a diagnosis. An absolute lymphocytosis will be seen. CML is not associated with an AIHA and tends to present at a younger age.

Answer 74

Polycythemia rubra vera PRV is a disease of middle and older age and is strongly associated with the JAK2V617 mutation. Pruritis is a common feature and is often severe and evoked by contact with water. Facial redness and fullness is commonly observed and splenomegaly is a common finding. It is a myeloproliferative disorder with raised Hct, Hb and RBC count. Blood hence becomes very viscous. There is a clear link between Budd-Chiari syndrome and subsequent PRV. Treatment is with venesection. Around 30% will go on to develop myelofibrosis.

Answer 75

Hypovolemia This patient is apyrexial and there are no signs of SIRS or sepsis. The raised HR and low BP is likely due to hypovolaemia. This patient needs fluids.

Answer 76

Hartmann's procedure: End colostomy A Hartmann's procedure is usually done as an emergency. The non-viable part of bowel (sigmoid colon) is excised and the proximal part of bowel is brought out as a colostomy (end colostomy because there is no distal part of bowel connected). The rectal stump is sewn up, with a view to re-anastomosis at a later date under more optimal conditions.

Answer 77

Loop ileostomy This man has undergone an anterior resection of the rectum with a primary anastomosis. A loop ileostomy as this will allow distal bowel to be rested by diverting faecal flow so that faecal matter does not continue to aggravate the new anastomosis that has been created. Once the anastomosis is well established, the loop ileostomy can be easily reversed.

Answer 78

Subtotal colectomy and end ileostomy Subtotal colectectomy can be done in emergency extreme cases of UC. The ileum needs to be brought out as a stoma as the only parts of the colon that remain are the rectum and anus, and anastomosing this with the terminal ileum can cause ileal pouchitis and incontience. As you are aware, ulcerative colitis patients who have panproctocolectomies do not have this option and end up having end-ileostomies.

Answer 79

Loop colostomy A loop colostomy has the same aim as a loop ileostomy. The faecal stream is diverted to rest distal bowel. Here, the primary objective is to somehow offload all the faeces that have made it past the ileum and are piling up in the colon, so that the colon does not have to keep working to push faeces against an obstruction (which will create colicky pain). Remember also that your palliative patient will lose more water if you do a loop ileostomy.

Answer 80

Osteomalacia

Answer 81

Primary hyperparathyroidism It is worth noting that in primary hyperparathyroidism, serum PTH may be normal, which is in fact abnormal in light of high calcium which should suppress PTH levels.

Answer 82

Paget's disease

Answer 83

Hypercalcemia of malignancy

Answer 84

Osteoporosis

Answer 85

ACD Whilst alcoholism may prompt you to consider alternative causes for this man’s anaemia, a positive alcohol history may be present in those with ACD and the normocytic normochromic anemia gives this away. ACD is caused by inflammation, which can result from various disease processes. The release of pro-inflammatory cytokines leads to a cascade producing anaemia due to decreased RBC production and shortened survival. The anaemia of ACD can also be microcytic.

Answer 86

Haemodialysis Haemodialysis is the treatment of choice for severe lithium poisoning. Note that activated charcoal does not adsorb lithium.

Answer 87

Alkaline diuresis This patient has ingested at least 9000mg of aspirin. GIT decontamination should be considered as an adjunct on arrival to A&E and activated charcoal can be given. The mainstay of treatment is alkaline diuresis induced by an infusion of sodium bicarbonate. In cases of severe poisoning, it is still started as a bridge to haemodialysis.

Answer 88

IV atropine Organophosphate poisoning can occur due to occupational or accidental exposure, or if you were being attacked by Saddam Hussein’s regime. Treatment is with resuscitation and supportive care, removal of contaminated clothing, washing the skin and starting full atropinisation IV. Over treament is very much preferred to under treatment and the skin should feel dry when the patient has received adequate atropine. Pupils will also be dilated. Pralidoxime is often given as an adjunct in very severe cases but evidence does not support its routine use, unless you’ve just been attacked by a nerve agent by terrorists, which is unlikely in this agricultural worker.

Answer 89

Administer diuretics This patient has developed pulmonary oedema. This patient should be positioned upright and given diuretics (frusemide).

Answer 90

IV saline Fluid replacement therapy aims to maintain physiological parameters. Systolic BP \>90 is required for adequate organ perfusion. IV 0.9% saline is the first line treatment for volume depletion in almost all situations. It is worth noting that normal saline in large amounts carries a risk of inducing a metabolic acidosis due to the high chloride content. 5% dextrose is equivalent to water when given, and is not approriate for volume resuscitation since it will distribute throughout the total body water. Only 1/12 will remain in the intravascular space. 5% dextrose may be used, however, in resuscitation or replacement in diabetics on an insulin drip to prevent hypoglycaemia. The insulin and dextrose infusion should go in the same cannula so there is no risk of giving unopposed insulin. For example, if the arm you are giving the dextrose infusion were to clog up, or more likely, if the patient bends their arm if the cannula is sited in the antecubital fossa.

Answer 91

A) B - corrected QT = QT/√RR interval C - Low voltage QRS complexes are caused by things such as hypothyroidism, COPD and increased haematocrit, but not obesity. D - This suggests an inferior-lateral MI E - This can occur with a PE but is not common.

Answer 92

E A - Long saphenous being runs distal to proximal. B - SFJ is 4cm inferior and lateral to the pubic tubercle C - Long saphenous vein can be used to for CABG D - Saphena varix classically transmits a cough impulse and disappears when the patient is asked to lie down.

Answer 93

C) A - Condom success rate approaching 98-99% B - The rates of failure of female tubal ligation are considerably worse than the failure rate of vasectomy in men. D + E - Combined OCP contraindications are breast cancer, \>35 whilst smoking \>15 cigarettes a day.

Answer 94

C) The patient has megaloblastic anaemia due to B12 deficiency and subsequent neuropathy. These features combined with the sore mouth and looser stool is suggestive of pernicious anaemia.

Answer 95

A) Melanoma is a malignancy of melanocytes, with a major causative factor being exposure to UV radiation during childhood and adolescence. Nodular melanoma is the most aggressive form of the disease and invades vertically early and grows rapidly. Superficial spreading melanoma usually exhibits lateral spread followed by vertical spread. Breslow thickness is the depth of the tumour invasion and is measured from the surface to the area of deepest penetration of the skin and is a more reliable prognostic marker than Clark's level, which describes the layer the melanoma cells have infiltrated to. Metastatic disease has a 5 year survival of 5-15% ABCDE criteria for worrying signs Asymmetry Border irregularity Colour variegation Diameter \>6mm Elevation or enlarging mole.

Answer 96

B) This is anorexia nervosa A - 1:10 C - This affects higher socio-economic groups more. D - ? E - BMI

Answer 97

D) Sodium valproate side effects: WHAAT Weight again Hyperammonaemia (including N+V & malaise) Ankle swelling Ataxia + tremor Thinning hair

Answer 98

E IBS is a complex disease that has a range of symptoms, all of which are listed in the question, apart from weight loss, which is most suggestive of an underlying organic cause.

Answer 99

A The presence of RF, an IgM (rarely IgG) Ab whose Fab portion binds the Fc portion of Ig occurs in a range of AI disease. The incidence in RA increases with increasing disease duration, being present in approx 70-80% on individuals. The presence of RF is much higher in Felty syndrome (RA + splenomegaly + neutropenia) and in Sjogren syndrome.

Answer 100

E A red eye is a medical emergency as the diseases responsible are able to lead to long term damage and blindness. The main 3 to consider are closed angle glaucoma, acute conjunctivitis and uveitis. In this case the significant pain and photophobia suggest uveitis, which requires urgent ophthalmological assessment and steroids.

Answer 101

D Churg-Strauss is a rare vasculitis affecting small and medium sized vessels especially in the lungs. Diagnosis is based on the presence of 4 or more of the following criteria 1) Asthma 2) Eosinophilia 3) Sinusitis 4) Lung infiltrates 5) Histological diagnosis of vasculitis with eosinophils 6) Mononeuritis multiplex or polyneuropathy Treatment is with immunosuppression, commonly high dose steroids, but occasionally cytotoxic drugs such as cyclophosphamide are needed.

Answer 102

B RBBB + VSD cause wide but not classically fixed splitting. LBBB and PDA cause reverse splitting of S2

Answer 103

C Metolazone is an extremely potent diuretic commonly used synergistically with loop diuretics in resistant fluid overload, although great care has to be taken with monitoring electrolytes and renal function. A - Na/K/2Cl channels in thick ascending limb B - Amiloride is a weak K sparing diuretic, commonly combined with thiazide diuretics and inhibit Na reabsorption in the collecting duct, this limiting K excretion. D - Flecainide is a class I anti-arrhythmic agent that increases mortality in patients with significant coronary heart disease, LV dysfunction or structural heart disease. E - Amiodarone side effects require monitoring of TFTs + LFTs, although patients have to be counselled with regard to increased photosensitivity, lung fibrosis and corneal micro deposits.

Answer 104

B Delerium is a commonly encountered problem requiring admission among the elderly population and is frequently encountered on the ward, in both medical and surgical patients. The core features include: 1) Fluctuating course 2) Onset over hours or days 3) Clouding of consciousness 4) Impaired cognition Confusion tends to get worse as the day progresses and leads to a reversal of the sleep cycle, leading to disturbances on the ward at night. Although sedatives should be avoided, occasionally it is in the patient's best interest to calm their behaviour slightly to prevent injuries and allow them to be looked after properly. Visual hallucinations occur commonly but care has to be taken to ascertain that they do not represent alcohol withdrawal hallucinations. Patients with dementia are more likely to develop delirium and the 2 conditions often co-exist in hospitalised patients but the majority of patients who have delirium do not have underlying dementia.

Answer 105

Sliding hernia

Answer 106

Richter's hernia

Answer 107

False It occurs in the natal cleft

Answer 108

True. Both are characterised by blotchy discolouration of the skin.

Answer 109

Branchial cyst

Answer 110

Cystic hygroma

Answer 111

Chemodectoma

Answer 112

Pleomorphic adenoma

Answer 113

Pharyngeal pouch A pharyngeal pouch develops from backwards protrusion of the pharyngeal mucosa through a weak area of the pharyngeal wall (known as Killian's dehiscence). The pouch initially develops posteriorly, but then protrudes to one side, usually the left, displacing the oesophagus laterally. They occur most often in elderly men who present with a characteristic history of dysphagia, regurgitation of food and sensations of gurgling in the neck. Inhalation of regurgitated food may lead to fits of coughing and aspiration at night.

Answer 114

Cervical rib A cervical rib is a congenital overdevelopment of the transverse process of the seventh cervical verebrae. This 'rib' may interfere with the subclavian artery and the lower roots of the brachial plexus leading to a form of thoracic outlet syndrome. If the T1 root is affected (as in this patient), there is pain and paraesthesia along the medial aspect of the arm as well as wasting of the small muscles of the hand. Symptoms may worsen when the arms are elevated, such as during a slam dunk.

Answer 115

Cystic hygroma A cystic hygroma is a congenital benign collection of lymphatic sacs. The cysts contain clear fluid and characteristically transilluminate brightly. It presents as a soft, fluctuant lump just beneath the skin and usually occurs in the posterior triangle of the neck. Cystic hygromas are large singular or multilocular fluid-filled cavities that arise from the jugular lymph sacs. Lymph sacs are embryonic lymph node precursors: there are also iliac and retroperitoneal lymph sacs. The jugular lymph sacs lie near the junction of the subclavian veins with the anterior cardinal veins (the future internal jugular veins). Lymphatic vessels join the sacs and pass along the head, neck and upper limbs from the jugular lymph sacs. Most cystic hygromas appear to be derived from abnormal transformation of the jugular lymph sacs. As you can see, therefore, the cystic hygroma could technically develop anywhere that the jugular lymph sacs spread to. Over 60% (according to GP notebook - different papers report different statistics) occur in the neck region, but they have also been reported on the chest wall and in the axilla and arm. Classically, cystic hygromas appear in the inferolateral part of the neck. The Oxford Handbook of Clinical Specialties puts cystic hygromas in the anterior triangle as opposed to the posterior (i.e. below digastric and in front of sternocleidomastoid).

Answer 116

Sternocleidomastoid tumour The term 'tumour' is actually a misnomer as it is a fibrous mass in one of the sternocleidomastoid muscles. This condition is often associated with torticollis (tilting of the head) due to contraction of the sternocleidomastoid muscle itself. The etiology of this condition is uncertain, however it is thought to result from intrauterine or birth trauma leading to secondary pressure necrosis and fibrosis of the muscle.

Answer 117

Branchial cyst A branchial cyst is a remnant of the second branchial cleft, which normally involutes during embryonic development. It commonly presents in 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 (this position is characteristic). It may become enlarged and inflamed with upper respiratory tract infections.

Answer 118

Femoral artery aneurysm. A swelling that is both pulsatile and expansile is an aneurysm. True aneurysms of the superficial femoral artery are rare, with most peripheral aneurysms occuring in the politeal artery. A femoral aneurysm may occasionally spontaneously rupture; whereas a popliteal aneurysm may thrombose and present as an acutely ischaemic leg.

Answer 119

Psoas abscess This man's ethnicity and clinical symptoms point towards a diagnosis of TB. A known complication of intraabdominal TB is abscess formation in the lumbar vertebrae (Pott's disease). Such an abscess may track down the psoas sheath and into the groin, forming a psoas abscess. Psoas abscesses are described as 'cold', as they are painless and not warm to touch.

Answer 120

Femoral neuroma. Femoral 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 121

Testicular torsion The presentation of sudden-onset pain and swelling in the testicle in a male of this age strongly suggests torsion. This is a surgical emergency and commonly occurs between the age of 10 and 15 years (rarely occuring over the age of 21). The incidence of torsion is higher for undescended testes. Pain may be referred to the abdomen as the testis retains its embryological nerve supply from the T10 sympathetic pathway. Irreversible adamage occurs within 6-12 hours, so urgent surgical intervention is required. 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 122

Hydrocoele A hydrocele is an abnormal collection of serious fluid in the tunica vaginalis surrounding the testis (hence the impalpable testis). Primary hydroceles usually occur in older men, develop slowly and are painless. Secondary hydroceles can occur secondary to tumours or inflammation of the underlying testes and epididymis. Characteristically, hydroceles transilluminate brightly.

Answer 123

Varicocoele The description in this case is characteristic of a varicocele. A varicocele is a collection of varicose veins in the pampiniform plexus (the venous network that drains the testicle). Patients present with a scrotal swelling that is visible on standing and characteristically feels like a 'bag of worms'. It is more common on the left and may occur secondary to obstruction of the left testicular vein by a renal adenocarcinoma.

Answer 124

Seminoma There are two main types of malignant testicular tumours: seminomas (60%) and teratomas (40%). Seminomas arise from the seminiferous tubules and occur in the 30-40 age group whereas teratomas are germ-cell tumours which occur in 20-30 year olds. They are associated with undescended testis (even after orchidopexy) and may both present as a hard, irregular, painless mass, or as a secondary hydrocele. They may spread to the lungs and liver (via the blood stream) and to the para-aortic lymph nodes (not inguinal!) Teratomas produce both alpha-fetoprotein (α-FP) and beta-human chorionic gonadotrophin (β-hCG), but seminomas only produce the latter.

Answer 125

Teratoma There are two main types of malignant testicular tumours: seminomas (60%) and teratomas (40%). Seminomas arise from the seminiferous tubules and occur in the 30-40 age group whereas teratomas are germ-cell tumours which occur in 20-30 year olds. They are associated with undescended testis (even after orchidopexy) and may both present as a hard, irregular, painless mass, or as a secondary hydrocele. They may spread to the lungs and liver (via the blood stream) and to the para-aortic lymph nodes (not inguinal!) Teratomas produce both alpha-fetoprotein (α-FP) and beta-human chorionic gonadotrophin (β-hCG), but seminomas only produce the latter.

Answer 126

Excision biopsy The symptoms here are suggestive of a parotid tumour, probably a pleomorphic adenoma (carcinoma would be painful, rapidly growing and may cause facial nerve palsy). Excision biopsy is required to make the diagnosis and treatment.

Answer 127

Fine needle aspiration This boy has a branchial cyst. The clues to the diagnosis are the position and the fact that it became inflamed during a respiratory infection. Diagnosis is by fine-needle aspiration again, which demonstrates a creamy yellow turbid fluid containing cholesterol crystals. Treatment is by excision.

Answer 128

Bladder cancer Gross haematuria is the primary symptom of bladder cancer. Risk factors include smoking, exposure to carcinogens such as the aromatic amines used in rubber and dye industries, age \>55, pelvic radiation and Schistosomiasis resulting in SCC (related to chronic inflammation – so other risks also include UTI, stones etc). Bladder cancer is the most common cancer in Egypt, for the latter reason. 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 129

Trauma This patient has had a catheter removed two days ago, which accounts for his gross haematuria (instrumentation of the urinary tract causing damage). The diagnosis is clinical based on the presence of the catheter.

Answer 130

Bladder Cancer Gross (classically painless) haematuria is the primary symptom of bladder cancer. Risk factors include smoking, exposure to carcinogens such as the aromatic amines used in rubber and dye industries, age \>55, pelvic radiation and Schistosomiasis resulting in SCC (related to chronic inflammation – so other risks also include UTI, stones etc). Bladder cancer is the most common cancer in Egypt, for the latter reason. 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 131

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. Half of all patients have abdominal pain and arthralgias are commonly present (found in about 80%) and often associated with oedema. The joints most often affected are the knees and ankles. About half will show signs of renal disease such as proteinuria or haematuria. Risk factors for this condition include being male, age 3-15 and history of prior UTI. Complications can occur and the most common cause of death is renal failure. Serum IgA levels may also be elevated.

Answer 132

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%. Uncommonly, a patient may present with symptoms of metastatic disease such as bone pain or respiratory symptoms. Symptoms, if present, also include abdominal pain, oedema/ascites from IVC disruption and scrotal varicocele in males. Risk factors include: smoking, male gender, living in developed countries, obesity, hypertension, FH, high parity and ionising radiation.

Answer 133

Cushing's Disease This man has weight gain and impaired wound healing, already you should be thinking cushings or diabetes...The blood test used here is being performed to differentiate between cushings disease and cushings syndrome. 10ug ovine or human CRH is administered to a patient who has fasted at least 4 hrs. pre test and serial post test ACTH and cortisol measurements are taken. In pituitary driven cushings disease the cortisol can be manipulated, that is to say exogenous CRH will cause a recordable increase in serum cortisol by the 2hr mark (and ACTH). However if the source of the excess cortisol is an ectopic ACTH producing tumour for example, this is not subject to any feedback mechanisms and so no change in serum cortisol will be seen on giving CRH.

Answer 134

Pituitary apoplexy Has bitemporal hemianopia which has been worsening..this should spark thoughts of a growing pituitary adenoma. But then she presents with an acute change. With a tumour a sudden change is usually vascular.. in this case the patient is suffering pituitary apoplexy whereby her enlarging pituitary tumour has undergone haemorrhage. This has basically wiped out pituitary function in a moment which explains her cardiovascular collapse and immensely painful headache. In fact apoplexy can present just like a sub-arachnoid haemorrhage in patients with known adenomas... Splitting headache - INCREDIBLY BAD - Xanthochromia (from extravasation of blood through the diaphrgam sellae into the sub aracahnoid space) - Vomiting - Loss of consciousness. The opthalmoplegia (diplopia) is a mass effect f the tumour being displaced by the bleed to impinge on the cavernous sinus and hence the IIIrd Cranial Nerve. Management is fluid resuscitation, and then hormone replacement of all lacking hromines! NB:In EMQS xanthochromia is usually pathognomonic of SAH.

Answer 135

Nelson's syndrome Worsening loss of peripheral vision infers pituitary adenoma. Hyperpigmented scars suggsts a state of increased ACTH production however this patient doesn't seem to be in adrenal failure, she is overweight. She has had abdominal surgery and was on meyrapone ( a drug which inhibits cortisol production) and Aminoglutethamide (an adrenolytic) Basically this woman is overweight and has striae because she was cushingoid.. the cause was adrenal hyperplasia. She was on medication to control this but the decision was made to operate and a bilateral adrenalectomy was performed. The consequences f this is that she has very minimal cortisol production and her pituitary is striving to fuel this by pumping out lots of ACTH (hence the dark scars). The visual field problems are due to an undiagnosed pituitary adenoma that was non functional but since her surgery the pituitary tumour has grown substantially since there is no negative feedback coming from circulating cortisol. This is basically Nelson's syndrome. NB : these days bilateral adrenalectomy is very rare and the pituitary is sometimes irradiated to prevent Nelson's from occurring. This patient needs glucocorticoid replacement and transsphenoidal surgery.

Answer 136

Sheehan syndrome Pre-eclampsia (proteinuria + HTN in pregnancy) is a major risk for post partum haemorrhage...In this ladies case she had to receive blood products and Syntocin (a synthetic oxytocin drug used to combat uterine atony and help stop haemorrhaging). Blood loss doesn't normally cause changes in pituitary function however in pregnancy the pituitary is particularly vulnerable. Hyperplasia and Hypertrophy of the lactotrophe cells in pregnancy ( due to increased LH/FSH) leads to an increase in size of the adenphypophysis, however there is no such increase in the vascular supply to the anterior pituitary. When blood is lost in PPH the ant. pituitary thus infarcts and necroses. This is Sheehan's syndrome...it can present insidiously or in a major way. It may be picked up if the mother fails to breast feed, but amennorhoea following birth and loss of pubic and axillary hair is also a common presentation. Only occasionally is full blown Sheehan's encountered where the mother becomes hypothyroid and can develop Diabetes mellitus due to wildly deranged Ant. Pituitary function. DX: low oestradiol and pituitary hormone levels. NB: Diabetes Insipidus is a rare complication since the posterior pituitary has a rich arterial blood supply that is rarely compromised in PPH.

Answer 137

True This is true although CMV would be a highly unlikely cause in an immunocompetent person. Patients who are HIV+ however are at risk from opportunisitic infections like this which can cause adrenal destruction.

Answer 138

Phaechromocytomas are neuroendocrine tumours originating usually from the adrenal medulla, they are usually benign though around 10% are malignant. 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, it also features in von hippel lindau - VHL though not MEN 1. MEN1 = 3Ps: Pituitary, Parathyroid, Pancreas MEN2A = Medullary thyroid Ca, Phaeo + Pituitary MEN2B = Medullary thyroid Ca, Phaeo + neurofibromas + Marfanoid

Answer 139

False ADH is produced along with oxytocin by the hypothalamus in the supraoptic and paraventricular nuclei. These hormones are projected via Parvocellular cells to the median eminence where they can influence the adenohypophysis (anterior pituitary)...remember ADH influences release of ACTH. Magnocellular pathways carry the ADH and oxytocin to the posterior pituitary to be released.

Answer 140

Primary adrenal insufficiency Tetracosactide is synthetic ACTH. When administered during a short synacthen test it can be used to determine whether a patient has adrenal or pituitary hypocortisolism. A Normal test would be : basal cortisol \>170mM and 30 minutes cortisol should be at least double the basal measurement and be greater than 550mM. This man's basal cortisol is normal however his 30 minutes cortisol has less than doubled and is less than 550mM which indicates that the adrenals are not functioning properly. In secondary adrenal insufficiency the basal cortisol would be very low but would exhibit large increases on administration of tetracosactide.

Answer 141

40% So although HbA1c can not be used diagnostically in diabetes it represents the amount of endogenous glycation occuring in vivo . Glycation produces Advanced glycation endproducts which are responsible for damaging vasa nervorum etc causing microvascular complications of diabetes. Lens protein Glycation is also responsible for the increased occurrence of catract in Diabetics.

Answer 142

Potassium iodide. This lady is suffering with Grave's disease and requires removal of her goitre as she is likely to have high circulating levels of TSI (thyroid stimulating immunoglobulin) which can cross the placenta and stimulate toxicosis in the foetus..leading to failure to thrive etc. The fetal thyroid status can be measured via it's heart rate. Carbimazole is standard management but if this doesn't control maternal Grave's surgery can be performed. As she has an audible bruit her goitre is likely extremely vascular and as she is pregnant the risks of excessive blood loss during thyroidectomy are multiple and serious. KI - potassium iodide can be given to saturate the thyroid and reduce vascularity pre surgery. Radioiodine is of course out of the question-risk of serious teratogenesis.

Answer 143

Surgical decompression There is significant retroorbital oedema and fibrosis around the optic nerve, decompressive surgery should help relieve this and prevent further atrophy.

Answer 144

Myxoedema coma This patient is at the severe end of the hypothyroid spectrum. She has depressed level of consciousness (this can descend into frank coma) and is hypoventilating, other features that can present in this serious complication are bradycardia, and hyponatraemia. Further to this a massive proportion are hypothermic (core temp

Answer 145

E.SupraventricularTachycardia(SVT). This is the classical history associated with SVT. It often presents in younger patients, although it can be seen in older patients. The arrhythmia typically arises from the atria and therefore the rate is often greater than 200 beats per minute. Episodes are often self-terminating, but if treatment is required adenosine is usually the first line drug. Beta- blockers are also useful. If haemodynamically unstable cardioversion should be performed as it is safe and effective.

Answer 146

A4: F. Complete Heart Block. Patients with complete AV block typically experience bradycardia (as low as 28 beats per minute during sleep), hypotension, and at times, hemodynamic instability. In some cases, exercising may be difficult, as the heart cannot react quickly enough to sudden changes in demand or sustain the higher heart rates required for sustained activity. They often present with dizzy spells. In this case treatment will be referral for a permanent pacemaker, however a temporary wire is not required as he is haemodynamically stable.

Answer 147

1 + 2 + 4 + 5 Peak flow monitoring - demonstrate variability over time Response to steroids over time (\>2 weeks) - 20% increase or 200ml ↑ in FEV1 Spirometry - Responsive to bronchodilators - 15% change or 200ml ↑ FEV1 Positive exercise test - Induced bronchoconstriction causing a reduction in FEV1 - \>15% reduction is diagnostic

Answer 148

1 + 2 + 3 + 5 Allergen avoidance - can reduce disease severity Smoking cessation - can also reduce disease severity Complimentary therapies - no current evidence exists to prove that these reduce the severity of disease at all Dietary manipulation - no evidence exists to support this either Weight reduction - can result in improved control in patients who are obese Immunotherapy - in a small subgroup of patients, desensitisation via allergen specific immunotherapy may be beneficial

Answer 149

2 + 3 1) Mucous gland hyperplasia occurs, especially in large airways, with increased mucous secretion and therefore a chronic productive cough 2) Chronic inflammation and fibrosis occurs, characterised by CD8 lymphocyte, macrophage and neutrophil infiltration, and release of pro-inflammatory cytokines 3) Emphysema occurs due to alveolar wall destruction, causing irreversible enlargement of air spaces, and thus a loss of lung elasticity 4) Alveolar walls thicken and are remodelled due to hypoxia. This causes pulmonary vascular resistance, pulmonary hypertension and impaired gas exchange

Answer 150

1 + 3 + 4 + 5 + 6 1) Smoking cessation is very important in treating COPD. It is the only intervention that is proven to decrease any decline in lung function that is smoking-related 2) Exercise restriction is NOT a method of treatment - in fact graded exercise is the mainstay of pulmonary rehabilitation 3) Pulmonary rehabilitation is very useful in improving exercise tolerance, quality of life and reducing hospital admissions. It involves graded exercise, breathing techniques and education 4) Diet is important for COPD control in the obese. Losing weight physically reduces the amount of weight the patient must lift their chest wall against with each breath, therefore making repiratory effort less. 5) Education has an important role in assisting patients to manage their illness and stop smoking too. 6) Psychosocial support also plays an important part, since practical support can be offered at home, as well as day centres, and logistics of illness can be considered, such as disability badges for cars. It is also an important way of assessing for signs of anxiety and depression

Answer 151

Asthma This man’s symptoms directly correlate with the time that he has been working as a baker, including a variation between the weekdays when he is working, and the weekend when he is not. There are various occupations in which small dust particles produced by the occupation results in irritation of the lung lining – causing symptoms of asthma.

Answer 152

Legionella pneumophila Legionnaire’s disease is more common in those who have been staying in air-conditioned hotels (since Legionella pneumophila commonly colonises water tanks). This bacteria is found in aqueous environments such as lakes and almost all cases are from contaminated water systems, which relates to the risk factors of getting Legionella. This gentleman is experiencing all the classic symptoms, but people can also experience extra-pulmonary symptoms such as diarrhoea, vomiting, anorexia, hepatitis, renal failure and coma. It can also cause confusion as well as hyponatraemia, abdominal pain and bradycardia. Bi-basal consolidation on CXR is also characteristic. Legionella is a gram negative rod. Legionella infecting the lungs is legionnaires’ disease or Legionella pneumonia whereas non-lung infection is known as Pontiac fever. Smoking is also a risk factor. Legionella does not grow on routine culture media and diagnosis relies on urine antigen detection, serology or culture on special media.

Answer 153

Bronchiectasis Bronchiectasis is permanent bronchi dilatation due to bronchial wall damage and loss of elasticity. It is often as a consequence of recurrent/severe infections and most present with chronic productive mucopurulent cough. The most commonly identifiable cause is CF. Textbook signs are persistent cough, with copious purulent sputum together with intermittent haemoptysis. This can also be congenital, or post-infection (in this case our patient has recently recovered from measles, although other possible infections may be pertussis, pneumonia or TB). CXR report describing cystic shadows and thickened bronchial walls is also characteristic. Chest CT is the diagnostic test. Diagnosis is aided by sputum analysis.

Answer 154

Skin Bone Adrenals Liver Brain

Answer 155

Epiglottitis Epiglottitis is a cellulitis of the supraglottis that may lead to airway compromise and is an airway emergency, especially in children. It classically presents in children aged 2-6 years of age but may manifest in any age. It is possibly now more common in older children and adults due to the introduction and implementation of the Haemophilus influenzae type B (Hib) vaccine. The most common signs are a rapid onset of high fever, sore throat and the inability to control secretions. There may be classic tripod positioning, difficulty breathing and irritability. It is crucial not to take any action which could stimulate a child with this suspected diagnosis including examination of the oral cavity, blood draws or even separating them from their parent. The airway needs to be secured and antibiotics started. The conditon will often resolve rapidly. Most adults complain of sore throat and pain with swallowing. Note that vaccination does not exclude the possibility of this diagnosis.

Answer 156

Subdural haematoma A subdural occurs due to blood collecting between the dura mater and the arachnoid mater surrounding the brain. It may be arterial or venous although is most often venous. The disease runs a varied course and the presentation occurs on a spectrum from asymptomatic to herniation syndromes. There is neurological deficit evident so surgery will be indicated here. The cause is trauma and this man will have suffered a head injury due to his RTA. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. Surgical options include twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Remember that extradural haematomas classically have a ‘lucid interval’ and occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines.

Answer 157

Breast abscess Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful red mass indicates the development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.

Answer 158

Skull fracture This is a basilar skull fracture and a CT scan (superior to MRI), in this case with 3D reconstructions, will be useful. This patient has had a fall and clearly hit his head. Basilar skull fractures have specific clinical features. Blood pooling from these fractures can cause periorbital bruising (raccoon eyes), brusing over the mastoid area (Battle’s sign) and bloody otorrhoea. There may also be CSF leak resulting in CSF otorrhoea or rhinorrhoea. A unilateral raccoon eye has an 85% positive predictive value for this diagnosis.

Answer 159

Hypothyroidism This patient has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (depression, fatigue, weight gain, bradycardia and menstrual problems) as well as others such as slow-relaxing reflexes on examination, constipation, cold intolerance, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.

Answer 160

Portal HTN HCV in this patient is causing hepatic cirrhosis which has decompensated resulting in ascites, secondary to portal hypertension. The hypoalbuminaemia is a sign of decreased hepatic synthetic function. Hyponatraemia is a common finding associated with ascites. It arises due to reduced protein synthesis and therefore a loss of colloid osmotic pressure and increased fluid loss from the intravascular compartment, stimulating ADH secretion. There is peripheral oedema here which is due to low albumin. The pruritis is due to reduced hepatic excretion of conjugated bilirubin and there may be accompanying jaundice too. The cause of his renal failure may well be hepatorenal syndrome in the context of his severe liver disease. His prognosis is poor.

Answer 161

Wernicke's encephalopathy Wernicke’s is due to acute thiamine deficiency, which is a problem in alcoholics. Others at risk include those with AIDS, cancer and treatment with chemotherapy, malnutrition and GIT surgery, especially bariatric procedures. It is a clinically under-diagnosed condition. The classic EMQ triad is of mental change, ophthalmoplegia and gait dysfunction, which is actually only seen in 10% of cases. In reality, the manifestations are varied and a high index of suspicion is needed. Despite there, the manifestiations typically include altered consciousness, gait disorders and eye movement abnormalities. This is an emergency and treatment is with parenteral replacement of thiamine. This avoids permanent neurological damage including later development of Korsakoff’s psychosis, which is irreversible. Note that thiamine should be given before dextrose! Magnesium deficiency also needs to be corrected as it is a co-factor in the functioning of thiamine dependent enzymes.

Answer 162

Uraemia This patient has developed acute renal failure, probably associated with the longstanding CCF. Advanced heart failure will lead to depressed renal perfusion and ARF. The decreased urine output is a symptom and the vomiting here is caused by uraemia or a general build up of waste products. An acute increase in creatinine will be seen, commonly with hyperkalaemia, hyperphosphataemia and a metabolic acidosis. There may also be respiratory compensation for this. Treatment is largely supportive, managing, in this case, the heart failure, and correcting abnormalities like volume status and the metabolic acidosis. Dialysis may be required.

Answer 163

Viral gastroenteritis Viral gastroenteritis often presents with mainly UGI symptoms like N&V more so than diarrhoea. It is on this basis that this is likely to be viral gastroenteritis caused by organisms such as rotavirus, norovirus and adenovirus. Staphylococcus aureus and Bacillus cereus also tend to cause mostly UGI symptoms and acts by preformed toxins, though these are not on the list of available options. The differentiation is made on studying the stool and identifying the organism.

Answer 164

Hydrocoele A hydrocele is a collection of serous fluid between the layers of the tunica vaginalis. Patients mainly present with a painless swollen scrotum (which can be on one or both sides) which feels like a water-filled balloon. Surgery is only performed if the hydrocele is problematic. As a result of the fluid, most hydroceles can be transilluminated. On examination, the hydrocele cannot be differentiated from the testicle. The mass can also increase in size with increased intra-abdominal pressure (such as coughing, crying or raising the arms) which causes peritoneal fluid to move into the scrotal sac. This causes the mass to vary in size during the day (smaller after lying down).

Answer 165

Epididymo-orchitis Generally speaking, younger males are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. He is mildly febrile with tenderness on-top of urinary symptoms which points towards epididymo-orchitis. A urethral swab should be sent for Gram stain and culture of secretions. A urine dipstick is also necessary combined with urine MC+S. Treatment involves bed rest, scrotal elevation, analgesia and antibiotics if indicated.

Answer 166

Inhaled foreign body. This is aspiration pneumonia. There are symptoms of pneumoia with pyrexia and purulent sputum, along with risk factors for aspiration in this elderly person who may have difficulties swallowing or altered mental status from, for example, dementia. The location of the wheeze is also consistent with this diagnosis as the RLL is the most common site due to the anatomy of the bronchial tree. Complications include abscess and empyema. Treatment is predominantly with antibiotics and supportive care.

Answer 167

Hiatus hernia A hiatus hernia is where intraabdominal contents protrude through the oesophageal hiatus of the diaphragm. Risk factors include obesity and high intra-abdominal pressure. The condition may be asymptomatic, or it may present with symptoms (which are non-specific) such as heartburn, dysphagia, pain on swallowing, wheezing, hoarseness and chest pain. A CXR is the first test done and may show an air bubble in the wrong place but barium studies are diagnostic and treatment depends on the symptoms and anatomy of the hernia. Hernias can be sliding or rolling (or mixed, or giant), uncomplicated or complicated by, for instance, obstruction and bleeding. Do you know the difference between a sliding and a rolling hiatal hernia?

Answer 168

Plummer-Vinson syndrome Plummer-Vinson syndrome is the association of chronic IDA (shown here by the koilonychia and paleness on examination) with dysphagia due to a post cricoid web. Roughly 7% of those with IDA may complain of gradual onset dysphagia with the discomfort found in the area of the cricoid cartilage. Invasive procedures may be needed for management such as endoscopic dilation of the web but treatment is largely aimed at correcting the IDA.

Answer 169

Achalasia This is achalasia which is a motility disorder with loss of peristalsis in the distal oesophagus and failure of the LOS to relax in response to swallowing. This presents commonly with dysphagia to both liquids and solids, regurgitation and retrosternal chest pain, which can be slowly progressive over time. In structural obstruction such as cancer, dysphagia to liquids is uncommon unless the disease is very advanced. Retrosternal pressure experienced can be precipitated by drinking liquids but is eased by continuing to drink, and the pain may be relieved by cold water. This may wake the individual from sleep. A UGI endoscopy is needed to exclude malignancy as a cause of dysphagia. The diagnosis is established on manometry or barium studies. Treatment is symptomatic.

Answer 170

Concussion Concussion is a closed head injury due a blow to the head. This woman has been assaulted, which is a common cause. Typical symptoms include headache (which tends to be cause the most problems in management), mental slowness, memory difficulties, N&V and LOC, though LOC is not necessary for the diagnosis. Symptoms typically go after a week to a month but can fluctuate. CT and MRI are typically normal. For uncomplicated cases, resting is sufficient and no intervention is needed.

Answer 171

Base of skull fracture This is a basilar skull fracture and a CT scan (superior to MRI), in this case with 3D reconstructions, will be useful. These patients have hit their head head. Basilar skull fractures have specific clinical features. Blood pooling from these fractures can cause periorbital bruising (raccoon eyes), brusing over the mastoid area (Battle’s sign) and bloody otorrhoea. There may also be CSF leak resulting in CSF otorrhoea or rhinorrhoea. A unilateral raccoon eye has an 85% positive predictive value for this diagnosis. Base of skull fractures can also affect cranial nerves leading to hearing impairment (due either to SN as a result of VII injury or conductive due to haemotympanum) and facial numbness or paralysis. These patients also need to have their GCS calculated. Treatment is primarily conservative although surgical intervention may be needed if there is associated CSF leak, intracranial pathology or CN deficit. RTAs are the second most common cause of skull fractures, the first being a fall from a height. There may also, like the first case, be a history of assault resulting in head trauma or even a gunshot to the head.

Answer 172

Unfractionated heparin The mainstay of treatment for acute DVT is anticoagulation. This can be either unfractionated heparin, a LMWH or a factor Xa inhitor like fondaparinux. Fondaparinux has a higher half life than LMWH and there is no effective way of reversing it. LMWH have a shorter half life and some of it can be removed with protamine. Heparin though can be reversed quickly with protamine. Hence, if the patient is at a high risk of bleeding, they should be treated with unfractionated heparin and you should avoid fondaparinux. If they start bleeding you can just chuck them protamine. This however requires monitoring of APTT and platelet counts. If the patient has heparin-induced thrombocytopenia, you can try using fondaparinux. LMWH is recommended in those with active cancer and preferred in pragnancy, and consideration needs to be given in those with renal impairment.

Answer 173

Plasma concentrates plus FFP DIC is a syndrome where coagulation pathways activate resulting in intravascular thrombosis, platelet and clotting factor depletion. The underlying disorder needs to be treated and FFP with platelet concentrate needs to be given. A platelet infusion should be considered and FFP is preferred for replacement of clotting factors and clotting inhibitors. Complications of DIC include life-threatening bleed, ARF and gangrene.

Answer 174

Primary hyperparathyroidism This is the most common cause of hypercalcaemia. 85% are due to a single adenoma in one of the glands while most of the rest are due to 4 gland disease. The range of disease is from very mild/asymptomatic through to severe disease with bone loss, fractures and osteitis fibrosa cystica. There is autonomous PTH production in primary HPT which causes deranged calcium metabolism. Biochemistry will show elevated serum calcium and inappropriate elevation of PTH. Depression, cognitive changes, change in sleep (possibly due to change in circadian rhythm) and myalgia are all common complaints. Osteoporosis may occur due to excess PTH causing bone resorption (osteoclasts are stimulated). Hypercalciuria may cause renal stones and nocturia. The only definitive cure is a parathyroidectomy although complications of this procedure include hypocalcaemia, injury to the recurrent laryngeal nerve, bleeding and a pneumothorax.

Answer 175

Vitamin D intoxication This silly lady has self-over-dosed on vitamin D. This is a fat soluble vitamin which can be toxic when taken in excess over time. OD of alfacalciol or calcitriol can easily cause hypercalcaemia and this needs to be avoided. So why is this not milk-alkali syndrome? Milk-alkali syndrome is caused by excess milk, as the name suggests, or alkali, for example due to dyspepsia. Excess intake, or calcium supplementation OTC can lead to hypercalcaemia, so granted if she is buying lots and lots of chewable calcium carbonate or something this is possible, but it is more likely in post-menopausal women on supplementation - just think about what is more likely here. Also, the patient is not completely stupid and will not be OD on vitamin A, even though is a cause of hypercalcaemia.

Answer 176

Primary hyperaldosteronism (Conn's syndrome) The normal range for potassium 3.5-5mmol/l. You should really know the normal ranges for common values like sodium, potassium and urea by this stage. In Conn’s, potassium is normal or low. It is important when drawing blood to avoid haemolysing the sample, which will cause a falsely elevated potassium level (pseudohyperkalemia). It is important for screening to calculate the aldosterone/renin ratio, with \>30 being suggestive of Conn’s. In Conn’s, aldosterone is raised and renin is low due to negative feedback. This is in contrast to renal artery stenosis where both aldosterone and renin will be raised. It is important to discontinue diuretics and other interfering medications for at least 6 weeks prior to measuring the ratio. The most reliable diagnostic test is a fludrocortisone suppression test. Treatment can be surgical with excision of the adenoma (if aldosterone production is lateralised to one side) or medical with spironolactone and amiloride. There are also familial forms of primary hyperaldosteronism which show an autosomal dominant mode of inheritance.

Answer 177

Tumour lysis syndrome There is recent diagnosis of malignancy here combined with the recent start of both chemotherapy and radiotherapy. This is tumour lysis syndrome which encompasses metabolic and electrolyte abnormalities, like hyperkalaemia, occuring after cytotoxic treatment in a patient with cancer. There is excessive cell lysis and the release of intracellular contents into the bloodstream leads to elevated levels of serum urate, potassium, phosphate and a reduction in calcium level. (Ca binds to the newly release PO4)

Answer 178

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 179

CXR 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 180

Renal USS A patient with cervical carcinoma is at risk of ureteric obstruction and then hydronephrosis. USS is the investigation of choice.

Answer 181

CVP measurement A confused hypotensive shocked patient might be hypotensive because of cardiac disease (which will cause a raised JVP) or due to sepsis (which will cause a low JVP). If you can't see the JVP, then you should put in a central line to measure the CVP accurately to tell you if the cause of the low blood pressure here is sepsis or cardiac failure.

Answer 182

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 183

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 184

Acute interstitial nephritis Acute interstitial nephritis classically presents with acute renal failure associated with oliguria and the ‘hypersensitivity triad’ of rash, fever and eosinophilia triggered by a drug. This can commonly be antibiotics, especially beta-lactams, and NSAIDs, though the range of triggering medications is vast. Oliguria can be present in more severe cases. There is inflammation of the renal interstitium, as suggested by the name, and this is likely a hypersensitivity reaction. It can also occur in the setting of a chronic inflammatory disease instead of being drug triggered. It will usually resolve once you stop the offending drug and treatment is supportive, though corticosteroids can be given to dampen the reaction. Most patients recover but have some residual impairment.

Answer 185

Shock In shock there is inadequate organ perfusion and when this includes the kidneys you get renal hypoperfusion (evidenced by this man’s oliguria) which can progress to acute renal failure. The reason here is hypovolaemia due to loss of intravascular volume from this man’s haematemesis. The cool peripheries (hands and feet) indicate poor peripheral perfusion. There is low BP and reflex tachycardia here too. Treatment here will be with volume replacement with IV saline and to treat the underlying cause, ideally in ICU. Do you know some causes of haematemesis?

Answer 186

Pre-eclampsia This is a syndrome characterised by new onset hypertension and proteinuria in pregnant women after 20 weeks gestation. The only definitive treament is to deliver the placenta and a risk-benefit to the mother and baby should be carried out to determine the best clinical step. The doctor starts her on an antihypertensive here so while the question does not directly tell you she is hypertensive, this can be inferred. If the patient doesn’t have either hypertension or proteinuria, then they do not have pre-eclampsia. The woman may be asymptomatic, or like this case, may present with symptoms indicating a more severe disease such as a headache which is usually frontal and upper abdominal pain usually in the RUQ (a clinical symptom of HELLP syndrome which is a subtype of severe disease characterised by Haemolysis, ELevated liver enzymes and Low Platelets). Oedema is very common but quite non-specific as a presentation. Oliguria may be present and again is a sign that the pre-eclampsia is severe. The raised creatinine indicates underlying renal impairment and renal failure can be a rare complication, often occuring as ATN with either sepsis or placental abruption.

Answer 187

Intravenous antibiotics Obviously meningitis and likely meningococcal due to the petechial rash. You all got that bit. Right? Now CT head should be considered before LP if there is any evidence of raised ICP, which we can presume this person here has. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen. BUT this is clearly a very severe case and an emergency and LP here is going to be delayed. You should start this person on IV broad spectrum antibiotics and consider getting blood culture results.

Answer 188

Aspirin Migraine is a chronic condition, with genetic determinants, which usually presents in early to mid life. The typical migraine aura this patient describes (which can be visual, sensory or speech symptoms) which can occur during or before the headache, is pathognomic, but is not seen in the majority of patients. The aura can be positive phenomena (for example this patient seeing flashing lights) or negative phenomena (for example visual loss). Nausea, photophobia and disability (the headache gets in the way with the patient’s ability to function) accompanying a headache also suggest a migraine diagnosis. The headache of a migraine tends to be prolonged if untreated, and tends to be unilateral and pounding (but does not have to be). Tests aim to rule out other differentials, although if the history is compatible and neurological examination is unremarkable, further testing is not needed. Treatment of this chronic condition aims at treating acute attacks to restore function. Triptans can be used in specialist care for severe symptoms. These are 5HT1 agonists. Effective initial treatment in a primary care setting can involve NSAIDs, which are available OTC and include aspirin, as well as indometacin and naproxen. Paracetamol is less effective than NSAIDs but is still better than placebo – it is first line in those who are pregnant. Treatment should be taken as soon as a patient realises they are having an attack and may need to be repeated after the attack. A few patients who have frequent, severe or disabling headaches may require daily prophylaxis such as anticonvulsants, TCAs and beta blockers.

Answer 189

Bladder calculus There is pain on standing and difficulty urinating because the calculus falls and blocks the bladder outflow. Blood comes at the end of the stream from urine that has passed the damaged area of urothelium. Patients tend to present with suprapubic pain, haematuria and obstructive symptoms. Examination may reveal suprapubic tenderness. The first test to order is urinalysis. A non-contrast CT abdomen is also indicated to look for the stone.

Answer 190

Hydronephrosis This patient has BPH which has caused hydronephrosis. This is an example of bilateral obstructive uropathy. Acute presentations are often painful whereas chronic presentations are more insidious in onset. Blockage of urinary flow by the enlarged prostate has led to urinary retention and overflow incontinence. Initial treatment aims to relieve the pressure on the kidneys. This involves catheterisation as the first line treatment. The patient should be started on alpha blockers at the time of catheterisation.

Answer 191

Liver function tests Pravastatin is a statin. Other statins include the mighty atorvastatin, simvastatin and rosuvastatin. They inhibit HMG-CoA reductase, which is an enzyme involved in the cholesterol synthesis pathway. They hence lower LDL cholesterol levels very effectively to reduce the cardiovascular disease. Statins can cause altered LFTs and rarely even hepatitis and jaundice. There have also been rare case reports of liver failure. NICE have a guideline (which we must listen to...) which state that liver enzymes should be measured before treatment and repeated within 3 months and at 12 months of starting treatment (unless there are obvious signs and symptoms of hepatotoxicity).

Answer 192

White cell count This drug is used mainly with other drugs for treating malignancies including leukaemias, lymphomas and solid tumours. The rare and serious complication is haemorrhagic cystitis as a result of the urinary metabolite acrolein and mesna can be given as prophylaxis. It is an alkylating agent which damages DNA and interferes with cell replication. The only feasible option on this list is WCC where we have to assume this drug is being used for a leukaemia or lymphoma and we want to measure whether it is working.

Answer 193

Serum drug level Phenytoin is useful for tonic-clonic and focal seizures but it has a narrow therapeutic index and a non-linear dose-plasma concentration relationship. Hence, small dose increases can lead to huge increases in plasma concentration and acute toxicity. Conversely if the patient skips a dose, there may also be marked change and the levels may be sub-therapeutic. You therefore need to monitor plasma drug concentration to improve the adjustment of dose. Parenterally, you can also consider fosphenytoin.

Answer 194

Myxoedema This medical student has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (weight gain, lethargy, sluggish reflexes, bradycardia and constipation) as well as depression, fatigue, constipation, cold intolerance, menstrual problems in females, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.

Answer 195

Perform coronary angioplasty. For confirmed ST elevation MI the 1st line treatment which gives the best results is primary PCI with stenting and is indicated if the person presents to A&E within 90 minutes of first presentation. CABG should be strongly considered if the patient fails PCI and should be done within 12 hours of onset of symptoms, ideally within 6. This is London’s best hospital but if this were Orkney and they did not have PCI capacity or the ability to transfer to a PCI facility within 30 minutes or so, then you would thrombolyse if there are no contraindications. This must be done within 12 hours of symptom onset and ideally within 3 hours as the efficacy of fibrinolytics diminishes over time. You should be aware of the absolute contraindications to thrombolysis such as suspected aortic dissection and prior intracranial haemorrhage. This patient has already been given some treatment for suspected MI (aspirin, oxygen, morphine and GTN). Post-treatment this patient will need aspirin therapy and clopidogrel for at least a year – aspirin should be continued indefinitely. Patients should also be started on a beta blocker, ACE inhibitor and a statin, indefinitely.

Answer 196

Exercise ECG This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.

Answer 197

Oral clarithromycin This is a CAP which is confirmed by CXR shadowing, which would show airspace shadowing with air bronchograms. The history is also consistent with respiratory symptoms and pyrexia. The most sensitive test for CAP is a CXR. The treatment is initially empirical with antibiotics and management would be guided by this patient’s CURB-65 score. A macrolide is the first choice in adults with no contra-indications without a recent cours eof antibiotics or risk of drug resistance, but always check local prescribing policies. Azithromycin, clarithromycin or erythromycin are all valid choices here.

Answer 198

IV cefuroxime This is an acute infective exacerbation of COPD and the patient has already received nebulised salbutamol and corticosteroids. The next important thing to do is to give IV antibiotics. Inpatient therapy for severe infections can be with IV ceftriaxone with azithromycin. High risk patients should receive piperacillin and tazobactam, or meropenem, to cover for pseudomonas.

Answer 199

Opiates Opiates are commonly prescribed for analgesia and can also be used as an anti-tussive in this case (suppresses ACh and NK release needed for cough activation and inteferes with serotonin receptors in the DRN). They are also abused for their euphoric effects mediated by their action on dopamine release at the nucleus accumbens. They have a host of side effects: GI effects (receptors present on the myenteric and submucosal plexus) of decreased gastric motility, emptying and increased gut water reabsorption... in short, constipation; Respiratory depression (desensitises central chemoreceptors to lessen the response to PaCO2); N&V by stimulating the CTZ; Pupillary constriction via the Edinger-Westphal nucleus; And causes symptoms like pruritis, urticaria, hypotension through histamine release via a direct effect on mast cells.

Answer 200

Fasting blood glucose T2DM can present with yeast, skin and urinary tract infections on top of unintentional weight loss and fatigue. The pins and needles in her legs is a result of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. There tends to be loss of sensation typically occuring in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain or paraesthesia. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin. Symptomatic patients need a single random blood glucose of \>11.1 or single fasting glucose of \>7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised \>11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0.

Answer 201

CXR Sarcoidosis is a chronic multisystem disease with an unknown aetiology with the lungs most commonly affected (giving SOB in this case). The purple lesions are erythema nodosum and are tender erythematous nodules. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.

Answer 202

Bone marrow aspirate This patient has multiple myeloma. This is characteristed by clonal proliferation of plasma cells in BM and commonly presents with bony pain and symptoms of anaemia (which this patient’s Hb demonstrates). The elevated ESR is also suggestive and hypercalcaemia is present in 30%. The diagnostic test is serum or urine electrophoresis looking for a paraprotein spike of IgG or IgA and light chain urinary excretion (Bence Jones proteins). Bone marrow examination and skeletal survey will also need to be conducted. Bone marrow aspirate in this case and biopsy will show plasma cell infiltration in the bone marrow, and can help to differentiate multiple myeloma from MGUS and solitary plasmacytoma. Bone changes include osteopaenia, osteolytic lesions and fractures.

Answer 203

V/Q scan This patient has dual pathology, with resolving pneumonia and a PE secondary to a DVT. The least useful investigation in this pt. is a V/Q scan as the underlying pneumonia would make interpretation of the V/Q scan very difficult. Pulse, BP and ABG are essential for ensuring the patient is stable and remains so. CTPA would be the best method to image the lungs.

Answer 204

Start anti-viral therapy The history in the scenario tries to trick you into thinking that there might be a cardiac cause, but the pain, tingling and the band-like erythema is more consistent with shingles caused by VZV. The best treatment is therefore anti-viral therapy.

Answer 205

Renal cell carcinoma The constellation of signs and symptoms of an abdominal mass, haematuria and left varicoele indicate an underlying renal call carcinoma. A left varicoele occurs in males due to compression of infiltration of the left testicular vein, which drains into the left renal vein. On the right it drains straight into the IVC. RCC has a well known association with paraneoplastic syndromes especially hypercalcemia via ectopic PTH and polycythemia via excessive EPO production. Cannon-ball pulmonary mets are a characteristic feature of RCC and testicular semimoma.

Answer 206

Viral markers The patient is suffering from oral and oesphageal candidiasis, with the most likely cause in this patient being underlying immunosuppression. Oesophageal candidiasis is an AIDS-defining condition, which necessitates careful counselling, risk factor analysis and testing for HIV.

Answer 207

Parvovirus B19 This presentation, also known as 'fifth disease' and 'erythema infectiosum' is caused by parvovirus B19. Constitutional symptoms are usually mild and patients usually present with arthralgia. In patients with sickle cell disease and hereditary spherocytosis, parvovirus B19 can lead to aplastic crises due to arrest of RBC production and if women are affected early in the course of pregnancy there is a small but definite risk of miscarriage.

Answer 208

The disease is associated with valvular heart disease This history is consistent with ankylosing spondylitis, which is a seronegative arthropathy associated with HLA-B27. Males in ther late teens are most commonly affected, suffering from back pain, morning stiffness and spinal ankylosis, which eventually leads to the characteristic question mark posture. Patients with AS are at an increased risk of developing valvular heart defects and secondary amyloidosis (AA amyloid) due to chronic inflammation. They are 1.5-2x more likely to die compared to a control population. Infliximab is a promising new agent that can be used in the treatment of AS.

Answer 209

## Footnote Raised JVP, normal waveform. This is most likely simple fluid overload and in the presence of reasonable renal function will respond to appropriate therapy with IV diuretics. The JVP will be elevated as the right side of the heart fails to clear the backload of fluid returning form the venous system.

Answer 210

Cannon ‘a’ wave. Patients with complete AV block typically experience bradycardia (as low as 28 beats per minute during sleep), hypotension, and as in this case, hemodynamic instability. In this case the cannon ’a’ wave is caused by the lack of synchronization between the atria and the ventricles. The ventricles occasionally contract against a closed AV valve, giving rise to the JVP appearance. A temporary wire is required as he is haemodynamically unstable.

Answer 211

## Footnote JVP rising with inspiration. This is called Kassmaul’s sign, or “paradoxical” rise in the JVP with inspiration. Normally the venous pressure (and the JVP) falls with a deep breath as intrathoracic venous return rises (this is why murmurs on the right side of the heart are louder with inspiration). If the JVP rises with inspiration it is ‘paradoxical’ and signifies that an extrinsic force, in this case, an effusion, compresses the ventricle. Treatment is peri-cardiocentesis. Effusions are very common in malignant disorders, but easily treatable.

Answer 212

## Footnote F. Right Ventricular Hypertrophy. Patients with TOF almost always have RVH (Tetralogy of Fallot corresponds to 1. VSD; 2. Over-riding aorta; 3. Pulmonary stenosis; and 4. RVH).

Answer 213

## Footnote . Atrial fibrillation. Almost all patients with rheumatic mitral valvular disease develop AF at some point. The saw tooth nature of this ECG would suggest flutter although it is hard to be definitive until you see the ECG. The negative deflection in lead V1 also suggests left bundle branch block, which is very common following surgery.

Answer 214

A. Aspirin and clopidogrel (dual anti-platelet therapy). Following the use of drug-eluting stents there is now clear evidence from a number of trials that patients should remain on both aspirin and clopidogrel for one year, and then to switch to aspirin alone. This is because of the risk of sub acute stent thrombosis. Typically there is a 1% risk of acute stent thrombosis in the first 6 weeks. There is about a 10% risk of instent re-stenosis over the next one year

Answer 215

## Footnote A. Aspirin and clopidogrel. The AF is short-lived and tends to happen after a device is placed in the atrial septum. In this case aspirin and plavix are used for 6 moths until the device has endothelialised and then stopped. If the AF was permanent then warfarin and electrical cardioversion should be considered.

Answer 216

A. Lignocaine. This is Ventricular Tachycardia (VT). Because the blood pressure is maintained lignocaine is a good first line agent. It is a membrane stabiliser and is used effectively for VT. If the patient were to become haemodynamically unstable he should be cardioverted.

Answer 217

## Footnote D. Amiodarone. This is post-operative AF and chemical cardioversion with amiodarone is a reasonable option. She almost certainly is on IV antibiotics, as infection may be the precipitating factor causing the AF, as opposed to any underlying cardiac abnormality.

Answer 218

C-Atrioventricular septal defect. The anatomy described is AVSD, which is commonly seen in T21. This girl unfortunately has not had this defect repaired and thus has developed Eisenmenger complex. This arises when there is sustained left to right flow for many years which leads to chronically high right sided pressures.

Answer 219

## Footnote B-Congenital correction of transposition of the great arteries (CCTGA). Transposition of the great vessels means the aorta arises from the RV and the pulmonary arteries arise from the LV. It is not compatible with life unless there is a co-existent septal defect to allow blood to mix. In CCTGA the ventricles are anatomically switched. There is an anterior LV which gives rise to the pulmonary circulation and the RV is the systemic ventricle. It is often associated with pulmonary stenosis and VSD.

Answer 220

## Footnote C-Renal artery stenosis. This is a rare cause of hypertension and can rarely give rise to unilateral pulmonary oedema. The exact mechanism for this is not known. Diagnosis is by ultrasound or magnetic resonance imaging of the renal vessels.

Answer 221

## Footnote . Coarctation of aorta- mild coarctation may often be asymptomatic. However, the weak distal pulses suggest this as a diagnosis. She will need an echocardiogram and will require surgical correction following delivery.

Answer 222

Severe mitral regurgitation Mechanical complications of myocardial infarction include papillary muscle infarction (resulting in severe mitral regurgitation) and VSD which can both cause hypotension. The findings of a normal RV lead ECG, a systolic murmur and volume overloaded apex make acute MR the most likely diagnosis although an echocardiogram would need to be performed to exclude the formation of a VSD which tends to occur with anterior myocardial infarctions. Acute MR results in severe pulmonary oedema.

Answer 223

## Footnote e. metolozone. Metolozone is a potent thiazide diuretic and thus can cause profound hypokalaemia. Furosemide can also cause low potassium but is not as strong. Carvedilol, perindopril and spironolactone all have a tendency to raise serum potassium and should be continued.

Answer 224

Sildenafil. This is primary pulmonary hypertension, a progressive and serious condition which often requires treatment. It is related to autoimmune rheumatological disorders. In this case first line treament would be sildenafil which promotes pulmonary vasodilatation and thus reduces PA pressure. If this fails then bosentan (an endothelin receptor antagonist) and prostacyclin may be of benefit.

Answer 225

Bicuspid aortic valve Bicuspid aortic valve is often associated with coarctation and often leads to aortic stenosis requiring surgery later in life.

Answer 226

IV fluids The aim of treatment in patients with haemodynamically significant right ventricular infarction is to increase the right-sided stroke volume. If there is no evidence of associated left ventricular dysfunction, patients should be given several litres of IV normal saline rapidly. Drugs that reduce the pre-load, such as nitrates, opiates and diuretics, should be avoided. If volume loading does not improve the blood pressure, then inotropes can be considered. In patients with left ventricular dysfunction, reducing the afterload will help forward flow from the right ventricle, therefore, vasoconstrictors such as noradrenaline should be avoided where possible. Dobutamine can augment forward flow and the cardiac output through its inotropic and chronotropic effects upon the left ventricle. An infarcted, poorly functioning right ventricle can have its stroke volume significantly compromised by concurrent bradyarrhythmias in which case temporary pacing is indicated.

Answer 227

S4 + LBBB + Plateau pulse Severe aortic stenosis is associated with a plateau, slow rising pulse. The stiff ventricle contracting may cause S4 to be heard. LBBB can arise due to conduction disease. The apex is usually heaving and undisplaced.

Answer 228

Diastolic tail on echocardiogram of the descending aorta + radio-femoral delay + rib-notching It is typically a systolic murmur that is heard best at the back in the inter-scapular space. Rib- notching is because of the formation of collateral vessels. Kyphoscoliosis is more likely associated with Marfan’s syndrome.

Answer 229

C: DiGeorge syndrome is a familial condition, characterised by hypoparathyroidism associated with intellectual impairment, cataracts and calcified basal ganglia.

Answer 230

B. Hypoadrenalism classically causes hyponatraemia, hyperkalaemia and hypoglycaemia. Mineralocorticoid deficiency has its predominant effect on the extracellular balance of sodium and potassium in the distal tubule of the kidney. Glucocorticoid deficiency has a major effect on carbohydrate metabolism, with associated hypoglycaemia.

Answer 231

B. Adrenal tumour. The short duration of her symptoms, and the substantially raised testosterone would make one suspicious of a virilising tumour. Serum testosterone may be elevated in PCOS, but not markedly so, and the symptoms would usually be of longer duration.

Answer 232

A, B, E- Topical eflornithine is used to treat facial hirsutism. The anti-androgen, cyproterone acetate competitively inhibits androgen production at peripheral receptors and may also reduce androgen synthesis. This is found in combined preparation in the oral contraceptive Dianette.

Answer 233

E. Propranolol Management of migraine involves treatment of the acute episode and prophylactic treatment in patients with regular headaches (usually greater than 3 per month). Acute treatment is with simple analgesia (and antiemetic if necessary) initially, but some patients may benefit from using a triptan. A number of different drugs can be used for prophylactic treatment including propranolol, amitriptyline, sodium valproate and topiramate.

Answer 234

A, B and E are commonly used antiepileptic medications which may be used in complex partial seizures. Carbmazepine is commonly used as a first-line medication in patients with partial seizures but other drugs including sodium valproate and lamotrigine can be used as well. C and D are not antiepileptic medications. Propranolol and amitriptyline are both commonly used for migraine prophylaxis.

Answer 235

A, B and D may cause an autonomic neuropathy. These are less common than other neuropathies but can occur in a number of different conditions, particularly diabetes, amyloidosis and Guillain- Barre syndrome. Patients with autonomic neuropathies may have a wide variety of symptoms including cardiovascular problems e.g. postural hypotension, gastrointestinal problems e.g. diarrhoea or constipation, erectile dysfunction, abnormal sweating and urinary dysfunction.

Answer 236

D. Motor neurone disease He has progressive weakness with a mix of upper and lower motor neurone signs on examination in the presence of a normal sensory exam. This is consistent with motor neurone disease. Parkinson’s disease does not cause weakness. Multiple sclerosis is a central nervous system disorder and therefore associated with upper motor neurone signs. Myasthenia gravis is a neuromuscular junction disorder and polymyositis is a muscle disorder, neither of which would be associated with pathologically brisk reflexes (an upper motor neurone sign).

Answer 237

B, C and D are seen in a pseudobulbar palsy, an upper motor neurone disorder whilst A and E (as well as B) may be seen in a bulbar palsy, a lower motor neurone disorder. In a pseudobulbar palsy there is a spastic dysarthria, dysphagia, brisk jaw jerk and a spastic tongue. In a bulbar palsy, there is a nasal dysarthria, dysphagia, absent gag reflex and a wasted tongue with fasciculations.

Answer 238

Peripheral neuropathy This man most likely has Guillain-Barre syndrome (GBS) i.e. a peripheral neuropathy. His reflexes are absent - a lower motor neurone lesion. Acute ascending weakness in a lower motor neurone pattern is most likely caused by GBS.

Answer 239

Spinal cord compression. This gentleman has a spinal cord lesion affecting the whole cord (corticospinal tracts, dorsal columns and spinothalamic tracts). He has a sensory level suggesting a lesion affecting the spinal cord about T10.

Answer 240

Broca's aphasia This man has a nonfluent or expressive aphasia with speech errors and agrammatism characteristic of Broca’s aphasia in contrast to the fluent or receptive aphasia seen in Wernicke’s aphasia.

Answer 241

Conduction aphasia This man has relatively intact speech production and comprehension but impaired repetition – this is consistent with conduction aphasia (and distinct to either Broca’s aphasia where there is speech production impairment and Wernicke’s aphasia where there is speech comprehension impairment).

Answer 242

CJD This man has myoclonus of the arms. This occurs in a number of conditions but in association with a rapidly progressive dementia is likely to be caused by CJD.

Answer 243

Venous Sinus Thrombosis The presence of headache, seizures and raised intracranial pressure (the patient has papilloedema) is seen in venous sinus thrombosis. This is more likely than encephalitis which may also cause headache and seizures.

Answer 244

Marcus Gunn pupil This woman has a relative afferent pupillary defect or a Marcus Gunn pupil. Unlike most other pupillary abnormalities the pupils are normal on observation. However, the ‘swinging flashlight’ test reveals a paradoxical dilation of the pupil on shining the light into the eye with the abnormal optic nerve.

Answer 245

Adie pupil A unilateral dilated pupil without a ptosis or eye movement disorder is most commonly due to an Adie’s pupil. Loss of deep tendon reflexes is often seen in this condition – Holmes-Adie syndrome.

Answer 246

Left homonymous hemianopia Posterior cerebral artery infarcts are usually associated with homonymous hemianopias. Beyond the optic chiasm the visual hemifield is represented on the opposite side of the brain i.e. left hemifield in the right hemisphere.

Answer 247

Central scotoma This woman is likely to have multiple sclerosis (two episodes of focal neurological deficits separated in time and space). The latest deficit is likely to be an optic neuritis which may cause a central scotoma.

Answer 248

Labyrinthitis A ‘labyrinthitis’ or vestibular neuronitis causes vertigo lasting days, compared to BBPV which causes vertigo lasting seconds, and vertebrobasilar ischaemia lasting minutes and Meniere’s disease lasting hours.

Answer 249

Henoch-Schonlein purpura Commonly said to be a systemic variant of IgA GN, the presentation is typical for HSP.

Answer 250

Urgent FBC This patient is a treated hyperthyroidism patient and is therefore likely to be on carbimazole or PTU and so you have to be aware of the rare possibility of agranulocytosis and exclude this with a FBC. Should the blood test show a low PMN count, urgent admission to hospital and treatment with broad spec antibiotics is required, with cessation of carbimazole or PTU.

Answer 251

CLL The fullness in his abdomen indicates splenomegaly, which occurs in a quarter of patients with CLL. This leukaemia is seen most commonly in the elderly and has a variable course, often affecting the patient for a number of years but not causing significant distress. CLL is associated with AI haemolysis caused by warm IgG Ab, which causes RBC breakdown releasing free Hb, this is scavenged by haptoglobin readily thus accounting for the fall in haptoglobin. Other complications include aplastic anaemia and overwhelming sepsis.

Answer 252

Hereditary spherocytosis. This inherited in AutoD manner. Adult PCKD is AutoD but infant is AutoR.

Answer 253

Octreotide has a useful role in the above patient. The care of the dying patient requires a strong MDT approach, including the patient's own team of doctors and nurses along with palliative care services and hospices. Palliative care has a role not only in patients with cancer but alsi in any disease requiring support at the end of life, such as end stage heart failure and COPD. The LCP is a quality improvement framework which aims to improve the care of the dying patient in the hospital setting irrespective of the cause of the terminal condition. Fluids are not routinely continued and medication is best given by a syringe driver to provide continuous analgesia with or without antiemetic cover, rather than the peak and trough therapy achieved with PRN, which should be used for breakthrough symptoms. In patients with bowel obstruction, as in this patient, prokinetic antiemetics are CI and cyclizine and ondasetron would be better suited agents. Octreotide is useful in limiting gastric secretions.

Answer 254

SVC obstruction Bronchial carcinoma is a well-recognized cause of this medical emergency. Symptoms include early morning headache (feeling of fullness in the head) and signs include facial congestion and oedema involving the upper limb. Either radiotherapy or chemotherapy may be useful depending on the sensitivity of the tumour type.

Answer 255

Tricuspid stenosis Rheumatic fever is the most common cause of tricuspid stenosis. There is usually involvement of other valves, e.g. coexisting mitral stenosis. The prominent symptom is fatigue. The presence of shortness of breath suggests concomitant mitral valve disease. Surgical intervention by tricuspid valve replacement is usually carried out only when there are other defective valves also being operated on.

Answer 256

Complete heart block Cannon waves occur when there is atrioventricular (AV) dissociation. The classic example is complete heart block but it may also be seen in ventricular tachycardia, and in patients with a single chamber pacemaker and continuing atrial contractions. This is rare nowadays because such patients are invariably given dual-chamber pacemakers. The cannon wave is generated by the atrium contracting in the presence of a closed tricuspid valve resulting from simultaneous ventricular systole.

Answer 257

RBBB The ‘MARROW’ pattern, e.g. ‘RSR’ pattern in V1 (M) with deep wide S wave in V6 (W). Causes include atrial septal defect (ASD) and pulmonary embolus.

Answer 258

Mitral stenosis Known as P mitrale, this bifid P wave suggests left atrial hypertrophy (as a resultt of mitral stenosis). A peaked P wave is called P pulmonale and suggests right atrial hypertrophy.

Answer 259

Renal Artery Stenosis Renal disease is the most common cause of secondary hypertension. Intrinsic renal disease, e.g. glomerulonephritis, makes up most of these cases. Renal artery stenosis is responsible for around 25 per cent of all cases of renal hypertension Treatment is directed at reducing blood pressure and preserving renal function. Revascularization may be performed but there is no consensus as to which patients may benefit from this therapy compared with from medical treatment.

Answer 260

Digoxin Digoxin has a narrow therapeutic window and toxicity with normal doses can be precipitated by hypokalaemia, hypomagnesaemia, renal impairment and hypercalcaemia. Signs of digoxin toxicity include confusion, nausea, arrhythmias and visual disturbance.

Answer 261

100% O2, IV diamorphine, IV furosemide, sublingual GTN Acute pulmonary oedema is a life-threatening medical emergency and the diuretic should be given parenterally. Elderly patients may suffer from COPD/asthma or have a coexisting chest infection and should therefore be given antibiotics and nebulized bronchodilators as required.

Answer 262

Oral furosemide Patients with mild left ventricular dysfunction may be satisfactorily controlled on an ACE inhibitor. If, however, shortness of breath and ankle oedema are not sufficiently controlled, oral diuretics are added. The drug of choice is a loop diuretic.

Answer 263

IV amiodarone Amiodarone has class I, II, III and IV actions but is used clinically for its class III actions. Class III drugs prolong the plateau phase of the cardiac action potential and increase the absolute refractory period. As a consequence they also prolong the Q–T interval. Amiodarone is the drug of choice to treat VT. When it is used chronically it has a number of adverse effects but these are not an issue in the acute scenario. These adverse effects include bradycardia, pulmonary fibrosis, hepatic fibrosis, corneal microdeposits (regress if drug is stopped), photosensitive rash and thyroid dysfunction

Answer 264

Labetalol This is the presentation of malignant hypertension. The therapeutic aim should be rapid, but gradual and controllable reduction in blood pressure is the ideal. Both oral and parenteral therapy may be used depending on the clinician’s preference. Sublingual nifedipine is contraindicated because it may produce a profound uncontrollable reduction in the patient which may compromise cerebral perfusion.

Answer 265

Protein 3.8 g/dl LDH 370 mmol/l pH 7.15 A pleural effusion is a collection of fluid in the pleural space, between the parietal and serosal layers of the pleura. Pleural aspiration is usually necessary to determine the cause and nature of the effusion, whereby a sample is sent for biochemical analysis, bacteriological culture and microscopic examination. The effusion can then be classified into a transudate or exudate depending on its biochemical characteristics. pH is measured when there is concern regarding an empyema as it typically has a pH of less than 7.2. Transudates have a protein content of \<3g/dl and a lactate dehydrogenase (LDH) concentration of \<200mmol/l. Causes of transudates include: cardiac failure, hypoalbuminaemia (‘nutritional failure’), renal failuire, liver failure and constrictive pericarditis. Exudates have a protein content of \>3g/dl and a LDH concentration of \>200mmol/l. Causes of exudates include: lobar pneumonia, lung cancer, mesothelioma, pulmonary embolus, TB and empyema. Empyemas are infected pleural collections which require prompt drainage. This is attempted in the first instance with insertion of a pleural drain., If drainage fails, surgical intervention is required. Empyemas have a low pH (\< 7.2), are exudates (protein \> 3g/dl) and have a high LDH content (\> 200 mmol/l).

Answer 266

Progressive Massive Fibrosis (G) Progressive massive fibrosis (PMF) is due to progression of Coal worker’s pneumoconiosis. With coal worker’s pneumoconiosis, the chest x-ray shows small pulmonary nodules less than 1.5mm. With progressive massive fibrosis, the chest x-ray reveals large fibrotic masses (1-10 cm), predominantly in the upper zones. These masses may cavitate over time.

Answer 267

Aspergilloma (H) Aspergilli are typically inhaled as small spores which do not affect people without underlying lung or immune system disease. However, people with pre-existing lung problems, especially cavitating lung diseases, are at risk. This is because the fungus can settle in the cavities within the lungs, and is able to grow free from interference as the immune system is unable to penetrate the cavity. The chest x- ray findings show lesions with an air “halo/crescent” around them.People can often be unaware for some time before incidental diagnosis. However, a small percentage of aspergilliomas invade into the cavity wall and can result in bleeding and hence haemoptysis, which may require resection of the damaged lung area containing the aspergilloma.

Answer 268

Wegener’s granulomatosis (C) The patient’s clinical presentation is most in keeping with Wegener’s granulomatosis. This is a multisystem disorder due to a granulomatous reaction within small/medium sized arteries and veins. It typically starts with rhinorrhoea, with subsequent nasal mucosal ulceration, cough, dyspnoea, haemoptysis, epistaxis and/or pleuritic pain. A “saddle nose” deformity is also a feature sometimes seen in this condition. The chest x-ray shows nodular masses or pneumonic infiltrates with cavitation. This disease responds well to immunosuppression, eg. with cyclophosphamide.

Answer 269

Tuberculosis (D) Tuberculosis transmission is through air and direct contact, whereby the initial infection is with Mycobacterium tuberculosis. Primary TB is usually asymptomatic; however, occasionally there may be erythema nodosum, a small pleural effusion or pulmonary collapse caused by compression of a lobar bronchus by enlarged nodes. The chest x-ray typically shows consolidation, air space or nodular changes in the upper zones, with loss of volume of the lung, and an enlarged hilum due to the enlarged lymph nodes.

Answer 270

Pleural fibroma Pleural fibroma is a rare and benign primary tumor, which is mainly asymptomatic. It is not associated with asbestos exposure. The solitary mass can grow to be very large due to its slow growth from the visceral pleural. Pleural fibromas most commonly affect women with the mean age of presentation being around 50 years of age. These tumours generally behave in a benign fashion, although malignant tumours do exist. These tumours are known to be able to produce insulin-like growth factor II (IGF-II), causing the increased utilization of glucose, inducing the hypoglycaemia seen here.

Answer 271

Wegener's granulomatosis Wegener’s granulomatosis is a small artery vasculitis (PR3 ANCA positive), which is characterized by lesions involving the upper respiratory tract, lungs and kidneys. Look out for eye signs that are present in up to 50 per cent, e.g. scleritis, uveitis, retinitis. However, the vasculitis and granuloma deposition can affect any organ and so less common associated symptoms and signs are legion. Treatment options include the use of immunosuppressive medications, e.g. high-dose corticosteroids with cyclophosphamide.

Answer 272

Caplan syndrome Caplan’s syndrome is a pulmonary manifestation of rheumatoid arthritis (RA) which is characterized by the presence of pulmonary nodules. It typically occurs in patients with RA who are exposed to coal dust, although the granulomas can also appear in workers exposed to other dusts, e.g. silicosis and asbestos. Symptoms include cough, shortness of breath and haemoptysis. RA has several other respiratory manifestations/associations including fibrosing alveolitis, pleural effusions and, very rarely, obliterative bronchiolitis. RA can also affect the cricoarytenoid joints leading to upper respiratory tract obstruction.

Answer 273

Right upper lobe collapse These chest radiograph findings are characteristic of right upper lobe collapse. Try to find the horizontal fissure because its position is a good clue to the presence of volume loss. The horizontal fissure on the right lung should run from the middle of the right hilum and can be traced to the level of the sixth rib in the axillary line. In right upper lobe collapse, the horizontal fissure will be elevated. Chest radiograph findings of a left upper lobe collapse are somewhat different. There is no left middle lobe and hence no horizontal fissure. The upper lobe is anterior to a greater proportion of the lower lobe. Hence, left upper lobe collapse can give rise to a hazy white appearance over a large part of the left lung field. This should not be confused with a pleural effusion because in collapse there will be tracheal deviation to the side of the lesion, elevation of the hilum and preservation of the costophrenic angle.

Answer 274

Previous varicella pneumonitis Multiple, small, calcified nodules may occur after varicella pneumonitis. Other causes of numerous calcified nodules include TB, histoplasmosis and chronic renal failure.

Answer 275

Mitral stenosis Advanced mitral stenosis is associated with characteristic findings caused by left atrial enlargement. These include elevation of the left main bronchus, widening of the carina, double right heart border and a prominent left atrial appendage. Calcification of the mitral valve may also be seen, as may pulmonary oedema. Left ventricular enlargement is not a feature despite the presence of pulmonary oedema.

Answer 276

Bronchiectasis Ring shadows and tramlining are a characteristic radiological finding in bronchiectasis, which is a common early complication of cystic fibrosis. Patients present with a cough productive of large amounts of purulent sputum and there can be haemoptysis. On examination the patient may be clubbed with coarse inspiratory crackles that can be heard over the infected areas of lung. Other causes of bronchiectasis include Kartagener’s syndrome, pertussis and bronchial obstruction.

Answer 277

Inhaled salbutamol with spacer This patient’s symptoms may respond to inhaled salbutamol if it can be delivered effectively to the lungs. Use of a spacer improves delivery in children and patients with poor inhaler technique. In young patients, it is particularly important to optimize bronchodilator therapy as early initiation of corticosteroids may lead to growth retardation.

Answer 278

Nasal intermittent positive pressure ventilation This patient has a severe exacerbation of COPD and consequent type II respiratory failure that has responded poorly to medical therapy. Conventional management would involve formal intubation, ventilation and transfer to an intensive care unit (ICU). The use of non-invasive intermittent positive pressure ventilation (NIPPV) in such patients has been associated with a reduction in the number of patients requiring formal intubation. This is advantageous because anaesthesia and intubation can be very difficult in a patient with respiratory failure. NIPPV should be tried unless the patient is in extremis. Successful NIPPV requires a conscious and cooperative patient.

Answer 279

100% O2, IM adrenaline, nebs salbutamol This is a classic presentation of acute anaphylaxis, e.g. a type I IgEmediated hypersensitivity reaction. The symptoms and signs include rash, oedema, tachycardia, hypotension and wheeze. Laryngeal oedema giving rise to upper airway obstruction is particularly worrying because it may impede endotracheal intubation. Initial treatment of choice is 0.5 ml epinephrine (adrenaline) 1:1000 solution (500g) delivered intramuscularly which can be repeated in the absence of clinical improvement or if deterioration occurs. Intravenous epinephrine is dangerous and should be given slowly only in a dilution of at least 1 in 10 000 in an immediately life-threatening situation, e.g. frank cardiac arrest.

Answer 280

IV hydrocortisone The British Thoracic Society suggests that features of a severe asthma attack include peak expiratory flow rate (PEFR) 50 per cent predicted/best, respiration rate \>25 breaths/min, pulse \>110 beats/min and inability to complete a sentence with one breath. Markers of a life-threatening attack include a PEFR \<33 per cent of predicted/ best, silent chest, cyanosis, poor respiratory effort, bradycardia, arrhythmia, hypotension, exhaustion, confusion, PaO2 \<8 kPa, acidosis with pH \<7.35, high PaCO2. Intubation and transfer to the ICU must be considered if the patient is not responding to drug therapy. This patient is both hypoxic and retaining CO2. This is a poor prognostic sign because people with acute asthma usually have a low CO2. The presence of a high CO2 is associated with imminent respiratory collapse. Despite elevated CO2, 100 per cent O2 should be given because, in this patient, there is no risk of respiratory depression resulting from a hypoxic ventilatory drive. Between attacks the patient’s CO2 should be within the normal range. It is a common mistake to restrict oxygen to patients with asthma and a high CO2.

Answer 281

CXR A chest radiograph is indicated here to confirm the diagnosis of pneumothorax and to assess the degree of collapse. In healthy patients a small pneumothorax will often heal without further intervention. The patient should be observed for 6 hours and, if there is no increase in the size of the pneumothorax, may be discharged with early follow-up and repeated chest radiograph. Spontaneous pneumothoraces are relatively common in young adults (especially tall thin men) and older patients with emphysema. In patients with thoracic disease/large pneumothoraces, simple aspiration is recommended as firstline treatment. If this is unsuccessful, a chest drain will be required.

Answer 282

28% O2, Nebs salbutamol + ipratropium, oral prednisolone, oral amoxicillin This is infective exacerbation of COPD.

Answer 283

Long term O2 therapy Long-term oxygen therapy should be considered in clinically stable nonsmokers with PaO2 7.3 kPa. There is evidence to suggest that keeping the PaO2 8.0 kPa for more than 15 h every day increases survival.

Answer 284

IV ceftazidime This infection is hospital acquired and therefore the range of pathogens is likely to be different from those causing community-acquired pneumonia. Such pathogens include Gram-negative aerobes, e.g. Pseudomonas spp., and are often multiply antibiotic resistant. Third generation cephalosporins, e.g. ceftazidime, have some anti-pseudomonal activity and can prove effective in these circumstances.

Answer 285

IV cefuroxime + erythromycin This is standard therapy for a severe community-acquired pneumonia. Rifampicin can be added empirically if there is a high clinical suspicion of legionella infection.

Answer 286

IV co-trimoxazole. Treatment of choice is high-dose co-trimoxazole delivered intravenously for 2–3 weeks. Intravenous pentamidine may be used if co-trimoxazole is contraindicated or not tolerated. Corticosteroids are often used as an adjunct to treatment if there is hypoxaemia.

Answer 287

Key features * AV node block - bradycardia * Enhanced automaticity - arrhythmias + tachycardia * Yellow Halo (Xanthopsia) * Nausea + anorexia Antidote: Digibind

Answer 288

Key features: 1. First few hours * N+V 2. 24-48 hours - hepatotoxicity * Hepatic tenderness * Jaundice * Asterixis * Fetor hepaticus * Haemorrhage Management * \<75 mg/kg - no hepatotoxicity * 75-150 mg/kg - grey zone * \>150 mg/kg - hepatotoxicity * Charcoal if under \<1hr * N-acetyl cysteine * most effective in first 8 hours

Answer 289

Key features * Drowsiness * Respiratory Depression * Worsened by alcohol Antidote: Flumezanil

Answer 290

Key features * Tinnitus + vertigo * Hyperventilation * Dehydration + vomiting * Mixed respiratory alkalosis + metabolic acidosis Management * \<500mg/L * supportive * \>500mg/L * First 2 hours - activated charcoal * Alkaline diuresis with IV sodium bicarbonate * \>700mg/L * Haemodialysis if renal or cardiac failure or seizures occur.

Answer 291

Key features * Farmer * inactivate AChE * SLUD * Salivation * Lacrimation * Urination * Diarrhoea Antidote : * atropine * severe cases - pralidoxime mesilate

Answer 292

Key features * Bleeding Antidote : Protamine

Answer 293

Key features * severe bradycardia * hypotension Antidote * atropine + glucagon

Answer 294

Key features * Lows sats but normal ABG Antidote * 100% O2 * Hyperbaric chamber

Answer 295

Key features * anticholinergic * Hypotension * arrhythmias * Hallucinations + seizures Antidote * Lorazepam

Answer 296

Key features * Malaise * Collapse + confusion + coma * SOB * Abdo + chest pain Antidote: Dicobalt edetate

Answer 297

Key features * Initially * gastroenteritis, garlic odour + hypersalivation * Delayed * multi-organ failure Antidote : Dimercaprol

Answer 298

Key features * Tremors * Ataxia * Nystagmus * Dysarthria * Muscle twitching + seizures Management * Dialysis

Answer 299

Pulmonary function tests Sarcoidosis may have various clinical features, including bilateral hilar lymphadenopathy, erythema nodosum, pulmonary fibrosis, elevated serum ACE levels and more. The diagnosis of sarcoidosis can often be made on clinical grounds, particularily when a young adult presents with classical features such as the bilateral hilar lymphadenopathy and erythema nodosum. Although a tissue biopsy would be diagnostic, lung function tests are often conducted first as they are less invasive. The lung function tests may be normal or show reducing lung volumes, impaired gas transfer and a restrictive ventilatory defect due to progression of the disease causing fibrosis of the lungs. Pulmonary function tests may then be performed and reviewed following steroid therapy to access response to treatment.

Answer 300

High resolution CT scan of chest It is known that methotrexate may induce lung disease such as pulmonary fibrosis. With interstitial lung diseases such as those caused by methotrexate, high resolution CT (HRCT) imaging is the ideal imaging modality. As HRCT's aim is to assess a generalized lung disease, the test is conventionally performed by taking thin sections 10-40 mm apart. The result is a few images which should be representative of the lungs in general, but which cover only approximately one tenth of the lungs. Because HRCT does not image the whole lungs (by using widely spaced thin sections), it is unsuitable for the assessment of lung cancer or other localised lung diseases.

Answer 301

Pulmonary harmatoma This is the most common benign tumour of the lung and is usually seen on chest x-ray as a very well defined round lesion 1-2 cm in diameter in the periphery of the lung. They occur as solitary round nodules with no predilection for any lobe. Growth is extremely slow, but the tumour can eventually reach several centimeters in diameter. Harmatomas are more common in men and in smokers. Peripheral nodules are asymptomatic, although endobronchial lesions are frequently associated with symptoms or signs of obstruction. As such, they must be distinguished from malignant neoplasms or recognized as the cause of a pneumonia or atelectasis. They usually contain fat and ‘popcorn’ calcification.

Answer 302

Arteriovenous malformation Despite the presumed congenital origin of AVMs, the clinical presentation most commonly occurs in young adults. Pulmonary arteriovenous malformations are more common in females and may present with primarily neurologic manifestations when pulmonary symptoms are absent or unrecognized. Brain abscess, embolic stroke, and hemorrhage from concomitant brain AVMs are well-recognized complications. Whenever a pulmonary AVM is suspected, the presence of a right-to- left shunt should be confirmed by the performance of a 100% oxygen study, contrast-enhanced echocardiography, or radionuclide perfusion lung scanning. Hereditary haemorrhagic telangectasia is stongly associated with AVMs.

Answer 303

He is a carrier for hepatitis C ``` Hepatitis A (HAV) and hepatitis E (HEV) are hepatitis viruses that do not have a chronic carrier state – you either survive the infection or will die from it. If someone is HAV antibody positive then it means that they have had the infection in the past but have survived it but are not currently infected with it. Hepatitis B (HBV), hepatitis C (HCV) and hepatitis D (HDV) can cause chronic infection (although HDV can only occur in the presence of ongoing HBV infection). HBV infection is diagnosed by looking for the presence of surface antigen (HBsAg). If HBsAg is positive then the patient has HBV infection – if this is present for more than 6 months the patient is said to have chronic HBV infection. HBV core antibody (HBcAb) gives an indication of previous infection or natural immunity. In this case, the patient has had HBV infection in the past but has managed to clear it. Individuals who are given HBV vaccination are given a recombinant version of HBsAg and NOT core antibody or core antigen (HBcAb or HBcAg). If you are HBcAb positive (like this patient), then there is no benefit from giving the patient additional HBV vaccination. Patients who are immune from HBV, either through active or passive immunity, will be HBV surface antibody (HBsAb) positive. ``` Unlike HBV, the serological diagnostic test for HCV is the presence of antibody in the blood; hence if you are HCV antibody positive then you are infected with HCV as is the case here. The next test to be done would now be HCV PCR RNA to characterize the HCV viral load (i.e. how much virus the patient has) and also the genotype, because this will affect treatment duration and prognosis.

Answer 304

Carcinoid syndrome This patient has abdominal pain, diarrhoea and flushing which are the classical features of carcinoid syndrome. Bronchospasm can also occur, but not very often if the tumours occur in the mid-gut which is the commonest location. Carcinoid tumours produce a variety of vasoactive amines (such as 5-HT, noradrenaline and dopamine), peptides (such as bradykinin, vasoactive intestinal peptide and substance P) and prostaglandins which account for the symptoms. These vasoactive products are inactivated by the liver which is why gastrointestinal carcinoid syndrome only occurs when hepatic metastases arise (the likely cause of her hepatomegaly). Whipple's disease is an extremely rare disease characterized by abdominal pain, diarrhoea, weight loss and arthralgia (typically affecting large joints). It is caused by a bacterial infection. Giardia is unlikely in a patient who has not travelled abroad.

Answer 305

Red cell fragments This patient has features that suggest TTP (thrombotic thrombocytopenic purpura), which is a haematological emergency associated with a high mortality due to cardiac and CNS micro-vessel ischaemia resulting from fibrin-rich clots. It is characterized by a pentad 1. MAHA (micro-angiopathic haemolytic anaemia, characterized by red cell fragmentation and polychromasia) 2. Thrombocytopenia 3. renal impairment 4. Fever 5. Neurological symptoms. Note that the pentad is not always present and is not necessary for the diagnosis. The differential includes other causes of MAHA, including malignancy, sepsis (meningococcal sepsis needs to be excluded here and the patient empirically treated after blood cultures are taken as an LP would be contraindicated with his low platelet count), malignant hypertension and the haemolytic uraemic syndrome (HUS). Treatment of TTP is with immunosuppression and plasma exchange. Platelets should not be administered.

Answer 306

Howell-Jolly bodies Howell-Jolly bodies are small blue round red cell RNA inclusions. These are usually removed by the spleen as the cell matures, such that a hypofunctioning or absent spleen leads to persistence of these nuclear remnants. Other features of hyposplenism include a raised platelet count, red cell shape abnormalities and a lymphocytosis. The patient should receive penicillin V prophylaxis and be immunized against encapsulated organisms (e.g Neisseria, Pneumococcus and Haemophilus).

Answer 307

Spherocytes The history suggests an inherited anaemia given the long history, neonatal jaundice and the fact that his sister required a splenectomy. The common causes that present with neonatal jaundice include HS and G6PD deficiency. The latter, although associated with Heinz bodies, does not usually require splenectomy and is rarer in the Caucasian population, being more common in the Mediterranean and African population. The diagnosis is therefore likely to be HS, in which numerous spherocytes are seen, which appear as hyperdense round red cells without a clear central pale area. He has probably developed pigment gallstones from the increased red cell turnover causing his abdominal pain. One would expect a raised unconjugated bilirubin.

Answer 308

Waldenstrom's macroglobulinaemia A paraprotein is most often seen in myeloma, although a few other lymphoproliferative disorders can be associated with this. True IgM myeloma is very rare (frequency: IgG\>IgA\>IgD\>IgM). More likely is that this patient has a type of lymphoma (lymphoplasmacytic lymphoma) producing excess IgM. Collectively the syndrome is called Waldenstrom’s macroglobulinaemia, which usually also presents with bone marrow infiltration, splenomegaly and sometimes enlarged lymph nodes, but not lytic bone lesions or hypercalcaemia. The IgM can cause hyperviscosity due to its size.

Answer 309

Exchange transfusion Strokes are a major cause of morbidity in young children with sickle cell disease. One should reduce the % Hb S as much as possible (ideally to \<20%) with an exchange transfusion, which usually replaces most of the patient’s own sickle Hb containing red cells with Hb A containing adult red cells through a process of serial dilution with donor blood, by taking out 1 unit and replacing with another etc, whilst maintaining euvolaemia. If top-up transfusion is used, one would make the patient hyperviscous and risk further strokes. Patients who have had strokes are usually treated with chronic regular transfusions every month or so to suppress their marrow from making the abnormal HbS containing red cells. Iron overload and red cell alloimmunisation are problems that need to be managed in these patients in the longer term.

Answer 310

Hydration, oxygenation and analgesia In the immediate setting one would manage this patient with adequate oral hydration unless the patient cannot drink (IV in that case), analgesia (patient should have a protocol, but morphine s/c or orally is usually needed; pethidine should not be used), oxygen if saturations are \<95%, and searching for and treatment of infective causes if present or if patient has a fever. Incentive spirometry is useful and encourages the small airways to be kept patent by getting the patient to blow against resistance. The patient should be monitored closely for adequate pain relief and any respiratory deterioration. In the longer term, this patient may benefit from hydroxyurea.

Answer 311

Typhoid Typhoid is caused by Salmonella enterica and its various serovars. Initially presents with fluctuating fever and bradycardia as well as malaise, headache, dry cough and epistaxis. There can be leukopenia and lymphocytosis. Later you can develop delirium, Rose spots, COBH and hepatosplenomegaly.

Answer 312

Perforated peptic ulcer. The serum amylase is only slightly elevated. In acute pancreatitis it is normally elevated 4 fold and can be up into the 1000s. Perforation will result in the air under the diaphragm. If the perforation is posteriorly it can involve the gastroduodenal artery.

Answer 313

Hypernatremia This patient has suffered extensive fluid losses due to the diarrhoea and burns. This has results in an osmotic imbalance resulting in hypernatremia. This can present as lethargy, weakness and irritability culminating in seizures and coma.

Answer 314

Hypokalemia. This lady has suffered extensive fluid losses due to the laxatives and has deveoped hypokalemia. This presents with muscle weakness, cramping and arrhythmias.Other causes include excessive salbutamol or insulin. ECG changes: long PR, ST depression, flat/TWI, long QT and U wave

Answer 315

Hypercalcemia.

Answer 316

Breast abscess. Brodie's tumour = Phyllodes tumour: large, fast growing fibroepithelial mass from periductal stromal cells. Accounts for 1% of breast cancers. Treatment is WLE.

Answer 317

Primary hyperparathyroidism

Answer 318

Hypoparathyroidism

Answer 319

Pemphigoid Pemphigoid is an AI bullous skin disease. There is no acantholysis (loss of intercellular connections between keratinocytes) as seen in pemphigus. It is mainly caused by IgG although IgA autoAb can occur. It is associated more with women over 60.

Answer 320

Pemphigus Pemphigus is an AI bullous disease affecting the skin and mucous membranes. AutoAb to desmoglein cause destruction of the desmosomes that act as intercellular connections between keratinocytes. This results in acantholysis. There are 2 main types: Pemphigus vulgaris and pemphigus foliaceus

Answer 321

Craniopharyngioma A slow growing tumour that arises from the pituitary stalk. Can be cystic in nature.

Answer 322

Intoxication.

Answer 323

Hypothermia J waves are characteristic of hypothermia. The size of the J wave roughly correlates with the severity of the hypothermia. It is also known as an Osborn wave.

Answer 324

Villous adenoma of the rectum. Adenomas are divided into 3 subtypes based on histologic criteria, as follows: (1) tubular, (2) tubulovillous, and (3) villous. According to World Health Organization (WHO) criteria, villous adenomas are composed of greater than 80% villous architecture. Tubular adenomas are encountered most frequently (80-86%). Tubulovillous adenomas are encountered less frequently (8-16%), and villous adenomas are encountered least frequently (5%) Villous adenomas are associated more often with larger adenomas and more severe degrees of dysplasia. These adenomas occur more frequently in the rectum and rectosigmoid, although they may occur anywhere in the colon. They generally are sessile structures that appear as velvety or cauliflowerlike projections. Note that the vast majority of patients are asymptomatic and have unremarkable laboratory findings. Approximately two thirds of colorectal polyps are asymptomatic. The most common presenting symptom is occult/overt bleeding (hematochezia) with an anemia, which may be microcytic. Polyps may bleed only intermittently into the stromal component, thus accounting for inconsistent findings. Nonspecific symptoms include diarrhea, constipation, and flatulence.

Answer 325

Atypical pneumonia. Atypical pneumonia often presents with atypical generalized symptoms such as fever, myalgia, and headache. Often there are no signs of lobar consolidation as the infection is restricted to small areas.

Answer 326

Coarctation of the aorta. Congenital narrowing of the aorta where the ductus arteriosus joins. Presents in adults with HTN, SOB(OE), headache, muscle weakness, cold peripheries and weak peripheral pulses. Can present with a systolic murmur.

Answer 327

Conservative management This is peripheral vascular disease with classic symptoms of claudication (in reality, these classic symptoms only occur in a small minority of patients). ABPI should be performed in symptomatic patients and a result less than or equal to 0.9 is diagnostic for the presence of peripheral vascular disease. You need to however bear in mind that this test may not be accurate if the patient has non-compressible arteries (mainly in diabetic patients). This patient has only presented with claudication which is not severely lifestyle limiting. It depends on how much needing to rest every 800 metres or so bothers him. If he does not feel that this is really a functional disability then no additional treatment is required, but follow-up appointments with a doctor should be made to monitor the development of ischaemic symptoms or coronary and cerebrovascular complaints. If the symptoms are lifestyle limiting then the patient should undergo a supervised exercise programme (only some rather limited quality cohort studies at the moment show an improvement in walking time and symptoms) and medication for symptomatic relief for a period of 3 months. Medication can include cilostazol, pentoxifylline (widely used but no more effective than placebo in RCTs) or naftidrofuryl. Risk factors should also continually be targetted – BP control, statins to lower LDL, beta blockers to target cardiovascular risk and antiplatelet therapy, for instance. If no improvement is made with this regime then patients should be referred to a vascular specialist to have their anatomy defined and assessed for possible revascularisation.

Answer 328

Embolectomy Have a think about the differential diagnosis of sudden onset limb pain. Do you remember the 6 Ps of critical limb ischaemia? This patient’s arrhythmia has caused an embolic event, leading to acute limb ischaemia. There is as a result a sudden decrease in limb perfusion with threatened tissue viability. An emergency vascular assessment needs to be done with duplex ultrasound. Treatment depends on whether the patient already has a history of significant atherosclerosis. If so, there will already be a built up collateral supply so there is potentially a longer time window to act and so anticoagulation and thrombolysis are options. Otherwise an embolectomy will be indicated with a Fogarty catheter if there is not a long enough time window. This is typically done by inserting a Fogarty catheter with an inflatable balloon attached to its tip into the offending atery and passing the tip beyond the clot. The balloon is then inflated and then the catheter is withdrawn to remove the clot.

Answer 329

Duplex dopper USS This man is presenting with classic features of a TIA. A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour (and resolve within 24 hours). An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF. Clopidogrel is an alternative in those who do not tolerate aspirin. The description of transient visual disturbance like a curtain descending over the eye is characteristic of amaurosis fugax. Amaurosis fugax is a transient and painless loss of vision in one eye due to the passage of an embolus into the central retinal artery. The cause could be embolic from the internal carotid artery to cause an occlusion of the ipsilateral retinal artery. Patients presenting with TIAs should be investigated for carotid artery stenosis with a carotid Doppler ultrasound as there is a high risk of having a subsequent full blown stroke. Furthermore if there is a stenosis of \>70%, the patient may be a candidate for carotid endarterectomy. Presence of ipsilateral carotid stenosis suggests artery-to-artery embolic event as the cause and this should be the target for surgical or interventional treatment. Follow up tests could be CT angiography or MRA to expand on the abnormal Doppler results. They are not appropriate first line investigations to do here. Head CT is usually normal in TIA. ECG should also be done to investigate for AF which is a common risk factor for embolic cerebral ischaemia.

Answer 330

No investigation This is a history of a ruptured AAA. There is back pain here and shut down peripheries and pallor due to blood loss. This patient is in haemorrhagic shock. As this AAA has ruptured, this man will need urgent surgical repair, with of course standard resuscitation measures. Investigations would just waste time. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many fluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols.

Answer 331

Duplex doppler USS Ablative procedures include stripping and ligation, the aim of which is to permanently remove the varicose vein. Radiofrequency ablation (RFA) can also be done, as well as endovenous laser therapy and foamed sclerotherapy. Phlebectomy or sclerotherapy can also be performed. This is generally reserved for symptomatic cases, although this woman has a cosmetic issue with the appearance of her legs which is causing her distress. There are complications of ablation which the patient will need to be made aware of though, such as bleeding, infection, saphenous nerve injury and neovascularisation. A duplex ultrasound is the investigation which is required here. It can assess reversed flow and valve closure time. This should be done with the patient standing and with the leg in external rotation for best sensitivity. Specific segments which are affected by reflux can be delineated as the superficial and deep truncal veins, perforators and tributaries can all be visualised. Reflex in the great saphenous or common femoral can be detected with Valsalva while more distal reflux can be elicitied by compressing the leg above the Doppler probe to see if any blood is being forced back towards the feet.

Answer 332

Critical limb ischaemia Is this patient’s ulcer an arterial ulcer with diabetic neuropathy, or a diabetic ulcer? Difficult to tell. However, this patient does have critical limb ischaemia. Critical limb ischaemia is chronic severe limb ischaemia. This patient has rest pain which is relieved by hanging the leg dependent – this is classical. These patients have chronic ischaemic symptoms of the leg such as ischaemic rest pain, gangrene and non-healing wounds. Ischaemic cause of these symptoms needs to be established urgently, or if the patient already has a documented history of PVD, then they can be referred to a vascular surgeon for revascularisation. Their arterial anatomy needs to be defined and assessed. Risk factors also need to continue to be aggressively targetted. If they are not a candidate for revascularisation then the patient should be assessed for amputation where necessary and be on appropriate risk factor reduction medication.

Answer 333

Ruptured AAA This is a history of a ruptured AAA. There is abdominal (which the patient states as chest) pain radiating around to the back here and pallor due to blood loss suggesting this diagnosis. As this AAA has ruptured, this man will need urgent surgical repair, with of course standard resuscitation measures. Investigations would just waste time although it seems he has had a troponin, and likely ECG too. Misdiagnosing this condition is pretty poor of the doctors with the history here of pain which radiates to the back. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many fluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols.

Answer 334

MI Given the list of options here, this is likely to be an atypical MI which is more common in diabetics and the elderly, likely to be due to autonomic neuropathy. They are known as ‘silent’ MI and should be excluded in all causes of collapse. An ECG is indicated here after the clear CT scan (although may have already been done on admission by alert staff). 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 335

Open repaur of aneurysm Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (\>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair. Elderly patients and those with co-morbidities: an EVAR is the best way forward here. However note also that EVAR could entail a complication of endovascular repair leak, which would require corrective treatment. Endoleak is persistent blood flow outside the graft and within the aneurysm sac. There is 24% risk after EVAR. However, this is not a complication of open repair, which is probably preferred in most cases in those who are fit and healthy enough to have it such as this patient. Management of this complication would depend on the type of endoleak.

Answer 336

USS in 6 months. Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (\>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair. * For asymptomatic small AAA, surveillance is indicated. Infra and juxtarenal AAAs between 4.0-5.4cm in diameter (bear in mind that young and healthy patients with \>5cm may benefit from repair!) should be monitored by USS or CT every 6-12 months. There is good quality evidence that the risk of rupture is 20% for aneurysms larger than 5.0-6.0cm in diameter. * AAAs \<4.0 cm require USS every 2-3 years

Answer 337

False Sildenafil inhibits PDE-5

Answer 338

False Retinal artery NOT vein RTFQ

Answer 339

False Shunting during CEA has been a subject of controversy with some advocating its use, whilst others arguing it has no noticeable benefit and may even put the patient at risk of complications. In the procedure itself, the carotids are clamped and the lumen of the internal carotid artery is opened longitudinally. To maintain cerebral perfusion, some surgeons use a temporary shunt. The stenotic plaque is then removed from the carotid artery, which is then sutured directly or patched.

Answer 340

True Dipyridamole is a PDE inhibitor. It affects NO and inflammatory cytokines; overall, it prevents thrombus formation. Bleeding risk.

Answer 341

Kidney, Thyroid, Lung, Prostate, Breast Kids Trying Lunges Perform Badly.

Answer 342

Cadmium Studies have shown that men in certain occupations, with higher levels of exposure to cadmium, have a higher risk of prostate cancer. It is thought that cadmium interacts with certain hormone receptors and mimics the effects of oestrogen and testosterone, thus abnormally stimulating the growth of the prostate. Furthermore cadmium is thought to interfere with the body’s ability to absorb zinc (which is believed to have a protective effect against prostate cancer.)

Answer 343

Wilm's tumour Wilms' tumour (a.k.a. nephroblastoma) is the commonest intra-abdominal tumour in children, rarely occuring in adults. It is a malignant tumour derived from embryonic mesodermal tissues. Patients present with a loin mass, weight loss, anorexia and fever. Although the tumour is rapidly growing an behaves aggressively, it has an 80% survival rate at 5 years. Can you identify the others?

Answer 344

Brodie's tumour Brodie's tumour (a.k.a. phyllodes tumour) are rare tumours of the fibroepithelial stroma of the breast. The history of a rapidly growing mass that distorts the shape of the breast points towards this disease. Most of these tumours are benign and the prognosis after surgery is excellent. Can you identify the others?

Answer 345

Ca 15-3 High Ca 15-3 levels suggest metastatic breast disease. However, it has poor sensitivity and is therefore not used as a screening procedure to detect breast carcinoma. This tumour marker has recently been superseded by Ca 27-29, which is claimed to be more sensitive and specific. However, CA 27-29 lacks predictive value in the earliest stages of breast cancer and thus has no role in screening for or diagnosing the malignancy.

Answer 346

Tumour lysis syndrome Tumour lysis syndrome usually occurs in patients undergoing chemotherapy for lymphoproliferative malignancies, who have just initiated treatment. Lysis of tumour cells leads to the release of large amounts of potassium, phosphate and uric acid into the circulation. The excess phosphate binds to calcium, leading to hypocalcaemia and its clinical features. Patients are also at risk of developing acute renal failure due to the deposition of uric acid and calcium phosphate crystals in the renal tubules.

Answer 347

Waldenstrom's macroglobulinaemia Waldenstrom's macroglobulinaemia is a lymphoproliferative disorder of B cells, which take on a lymphoplasmacytoid appearance. It is characterised by the production of immunoglobulin M (IgM), which gives rise to the clinical features of hypervisosity (nosebleeds, blurred vision, retinal haemorrhage etc.)

Answer 348

ALL Acute lymphoblastic leukaemia (ALL) is the most common leukaemia in children. The immature blast cells infiltrate the marrow and lymphoid tissue causing anaemia, bleeding and a vulnerability to infection. Although the FBC reveals that the patient is anaemic, the WCC is raised due to circulating blast cells. The investigation of choice is bone marrow aspiration (which shows a hypercellular marrow with \>20% blasts) and treatment is with combination chemotherapy.

Answer 349

CLL: enlarged rubbery lymph nodes, non tender, also smear cells CML: Philadelphia chromosome, sweats, more likely splenomegaly, increased WCC ALL: bruising, pale, usually children btw 2-4 years old AML: Auer rods, SOB, bone pain.

Answer 350

Necrolytic migratory erythema This rash is characteristic of glucagonoma and is also known as 'glucagonoma syndrome'. It is characterised by the spread of erythematous blisters across the lower abdomen, buttocks, perineum and groin.

Answer 351

CEA Although carcinoembryonic antigen (CEA) lacks the sensitivity and specificity to be a diagnostic test for colorectal cancer, it has found a valuable application in the detection of recurrence of malignant disease following treatment.

Answer 352

G6PDH deficiency Glucose-6-phosphate dehydrogenase (G6PDH) deficiency is the most common red blood cell enzyme defect and is more common in patients of Mediterranean origin. Individuals with this condition are susceptible to oxidative crises precipitated by fava beans and drugs such as ciprofloxacin and sulphonamides. G6PDH plays an important role in the hexose monophosphate shunt which provides NADPH (reduced nicotinamide adenine dinucleotide phosphate – the reducing agent). NADPH is used to regenerate glutathione. In the absence of glutathione, red blood cells are exposed to oxidative stress. Heinz bodies represent oxidized haemoglobin.

Answer 353

Pernicious anaemia Pernicious anaemia is the most common cause of vitamin B12 deficiency. This is an autoimmune condition characterized by atrophy of the gastric mucosa with subsequent failure of intrinsic factor production. Intrinsic factor is required for vitamin B12 absorption. Other causes of vitamin B12 deficiency are terminal ileum disease, gastrectomy and low dietary intake (e.g. vegans).

Answer 354

Uraemia Burr cells indicate uraemia.

Answer 355

Hyposplenism Howell–Jolly bodies are found in hyposplenism. They are basophilic nuclear remnants found in RBCs not mopped by the spleen.

Answer 356

Paroxysmal nocturnal haemoglobinuria Paroxysmal nocturnal haemoglobinuria (PNH) is an acquired defect where red cells are unusually sensitive to destruction by activated complement. Patients may present non-specifically with recurrent abdominal pains or with haemolytic anaemia. Venous thrombotic episodes are very common in patients with PNH. The condition acquired its name from the characteristic finding of dark-coloured urine when voiding at night or early in the morning. In Ham’s test, the cells from a PNH patient will lyse more readily in acidified serum than normal red blood cells. Serum heated to around 56°C will inactivate complement and thus haemolysis will not occur. As a result of the high risk of venous thrombosis, long-term coagulation may be necessary. Deficient haematopoeisis may also occur and PNH may progress to aplastic anaemia in around 10–20 per cent individuals.

Answer 357

Polycythemia Rubra vera Polycythaemia rubra vera (PRV) is a primary polycythaemia where there is excessive proliferation of red blood cells caused by a clonal disorder of pluripotent stem cells. The condition usually presents in late middle age – elderly patients with signs of hyperviscosity, e.g. blurry vision (retinal haemorrhages), headaches, bleeding, etc. Severe pruritus after a hot bath is a commonly reported finding. The patient typically has plethoric facies and may be cyanotic as a result of stagnation and deoxygenation of the blood in peripheral vessels. Splenomegaly is very common in PRV, unlike secondary polycythaemia. Blood tests show an elevated packed cell volume. The white cell count is usually raised. A raised red cell mass can be shown with 51Cr studies. The aim of treatment is to normalize the full blood count and prevent the complications of thrombosis and haemorrhage. Venesection is the treatment of choice. Hydroxyurea chemotherapy can also be used to control thrombocytosis.

Answer 358

Dexamethasone Dexamethasone is used in the short term to reduce the raised intracranial pressure caused by cerebral oedema around metastases.

Answer 359

Haloperidol, midazolam Midazolam is used to treat both convulsions and terminal restlessness.

Answer 360

Pneumocystis carinii Pneumocystis carinii pneumonia (PCP) is associated with HIV/AIDS. IVDUs are an at risk of developing this. It generally presents with a fever, dry cough and SOB with weight loss and night sweats.

Answer 361

Scabies Contagious skin infection caused by Sarcoptes scabiei. This mite burrows under the skin causing intense allergic itching. This is typically worse when warm and at night. Can present with linear burrow tracks. Immunosuppressed patients can develop crusted scabies as their skin becomes overrun by breeding mites. Treat with Permethrin and anti-histamines.

Answer 362

Thrombotic thrombocytopenic purpura (TTP) This rare coagulopathy results in extensive microscopic thrombi that result in end-organ damage. There is intravascular haemolysis of RBCs due to shear stress resulting from the thrombi (MAHA). It is mainly due to inhibition of the ADAMTS13 enzyme, an MMP that activates vWF.

Answer 363

Hydrocoele

Answer 364

Epididymal cyst.

Answer 365

Shingles (herpes zoster) A localised band of painful blistering rash is associated with shingles. A re-emergence of VZV. This may have occurred as this lady is immunocompromised.

Answer 366

Pemphigus A bullous skin disease associated with autoAg IgG to desmoglein in the desmosomes (intercellular connections between keratinocytes). Acantholysis can occur, this is NOT seen in bullous pemphigoid. There are 2 main types of pemphigus: vulgaris and foliaceus

Answer 367

Brainstem tumour

Answer 368

False In Type 2 Diabetes the concordance in identical twins is nearly 100 %. It is type 1 diabetes that has a concordance of approximately 40%. Thus type 2 diabetes is undoubtedly more heritable than type 1 diabetes, which might be a surprise to some of you.

Answer 369

Autonomic neuropathy This is diabetic autonomic neuropathy which typically occurs later in the disease course. Patients have a reduced response in HR and BP and postural hypotension occurs due to efferent sympathetic denervation (reduced vasoconstriction of peripheral vascular beds). Patients can feel week, faint, dizzy and light headed and may faint on standing. There may also be GI symptoms from vagal dysfunction. Bladder dysfunction and erectile dysfunction can also occur. Women can complain of a reduced libido and increased pain during sex

Answer 370

Diabetic background retinopathy This patient has a microvascular complication of diabetes – diabetic retinopathy. His macular involvement is an indication for macular laser therapy. Digital methods for photographing the fundus are preferred over fundoscopy. Microaneurysms, cotton wool spots, haemorrhages, hard/lipid exudates and neovascularisation may all be seen depending on the stage. Young onset T1DM is more associated with retinopathy, and additional risks include a longer duration of DM and poor glycaemic control compounded by renal disease and hypertension. There are also ethnic variations in risk. Background retinopathy initially consists of just microaneurysms, which progresses with small haemorrhages (dots and blots and flames). There may also be hard exudates. However, where these changes occur within the macula, this is maculopathy and is potentially sight-threatening. Maculopathy can be classified, academically, into focal, fissue and ischaemic, though this is of limited clinical relevance. Pre-proliferative is associated with cotton wool spots, typically multiple (arguably, the odd one can be consistent with background). Proliferative is associated with new vessel formation, which can be quite subtle. The patient can also be asymptomatic but is at a risk of vitreous haemorrhage. Diabetic retinopathy needs to be screened for (either dilated fundoscopy in clinic or with retinal photography) at least on an annual basis. Treatment is with photocoagulation where a transpupillary laser is used to burn the retina, which reduces overall oxygen demand lessening the ischaemic stimulus. There are complications, which you can look up. Please have a look at some photographs of retinal images. Reading about it will not help you to identify a cotton wool spot, hard exudate or angiogenesis in real life. There are also variations of normal which you will be able to spot with the more images you look at, like racial pigmentation and drusen in the elderly. What would you expect to see on fundoscopy in a patient with age-related macular degeneration?

Answer 371

Carpal tunnel syndrome Much rarer presentations of DN include mononeuropathies like CTS as well as cranial neuropathies, diabetic truncal radiculoneuropathy and diabetic amyotrophy.

Answer 372

Flame haemorrhages are an indication for panretinal laser therapy. Flame haemorrhages are a feature of non-proliferative diabetic retinopathy.

Answer 373

T1DM is more common in Asians than Europeans. Unlike T2DM the opposite is actually true in T1DM which is more common in Europeans than in Asians.

Answer 374

Fructosamine provides a longer measure of blood glucose levels. Fructosamine is a glycated plasma protein which provides information on glucose levels over the previous 1-3 weeks.

Answer 375

False No, cysts/carcinoma are more likely. Think of fibroadenomas in age group 20-30.

Answer 376

False DCIS is impalpable.

Answer 377

True Positive FH is one of the RFs for development of breast cancer.

Answer 378

False It is most common in 20-40 age group.

Answer 379

False Paget's disease (of the bone) can do so. Paget's disease of the nipple is a unilateral eczema of the nipple due to destruction of the nipple by ductal spread of carcinoma.

Answer 380

Lateral medullary syndrome The posterior inferior cerebellar artery (PICA) supplies the dorsal lateral medullary plate and parts of the posterior medial cerebellum. PICA thrombosis results in lesions affecting cranial nerves, descending tracts and the cerebellum that are known collectively as ‘lateral medullary syndrome’. Ipsilateral signs include: – decreased pain and temperature sensation of the face (descending tract and nucleus of nerve V) – palatal, vocal fold paralysis (nerve IX, X involvement) – Horner’s syndrome (sympathetic tract) – cerebellar signs, e.g. ataxia, nystagmus. Contralateral signs include: – decreased pain and temperature sensation of the body (spinothalamic tract) – lateral medullary syndrome, eponymously known as Wallenberg’s syndrome.

Answer 381

Vestibular neuronitis. Vestibular neuronitis is associated with a preceding infection/illness. The vertigo is severe and presents abruptly with vomiting but no deafness/tinnitus. The vertigo usually diminishes after a few days and in many cases there is complete recovery within a couple of weeks. Some individuals, however, develop benign paroxysmal positional vertigo afterwards. There can also be a horizontal nystagmus. Unlike labyrinthitis there are no auditory symptoms.

Answer 382

Polymyositis There are many non-neurological causes of weakness in the legs. Polymyositis is an autoimmune disease characterized by non-suppurative inflammation of skeletal muscle. In severe disease there can be respiratory muscle weakness and also cardiac involvement. Creatine kinase (CK) is usually markedly elevated. Electromyography (EMG) characteristically shows fibrillation potentials. Dysphagia occurs in about 1/3 of patients.

Answer 383

Motor Neuron Disease Motor neuron disease (MND) is a progressive degenerative disease that affects the upper and lower motor neurons (LMNs). There is characteristically NO sensory involvement. It is useful to be familiar with the following three common patterns of involvement: (i) Progressive muscular atrophy: anterior horn wasting lesion with wasting often beginning in the distal muscles of the hand and then spreading. Fasciculation is a common finding. (ii) Amyotrophic lateral sclerosis: involvement of the lateral corticospinal tract gives a progressive spastic teraparesis/paraparesis. The presence of LMN signs, e.g. wasting, fasciculation, differentiates this diagnosis from other causes of spastic weakness. (iii) Progressive bulbar palsy: the lower cranial nerve nuclei and their connections are primarily affected. Dysarthria and dysphagia are common symptoms. This pattern of disease is more common in women than in men.

Answer 384

IX + X lesion Cranial nerve IX and X lesions rarely occur in isolation and can also accompany nerve XI and XII lesions after infarction in the brain stem or as a result of pathology around the jugular foramen.

Answer 385

Hemiballismus A very rare movement disorder, caused in most cases by a decrease in activity of the subthalamic nucleus of the basal ganglia, resulting in the appearance of flailing, ballistic, undesired movements of the limbs. Usually the underlying pathology is infarction/haemorrhage in the contralateral subthalamic nucleus. Can be associated with non-ketotic hyperglycaemia of diabetes.

Answer 386

Tardive dyskinesia This is repetitive, involuntary automated movements such as grimacing, lip smacking and excessive blinking. Tardive dyskinesia is a movement disorder that usually appears only after long-term treatment with typical antipsychotic medications and other drugs with dopamine antagonist activity, e.g. metoclopramide. Withdrawal of the responsible drug can lead to improvement but the condition is irreversible in some patients. Atypical antipsychotic medications such as clozapine and risperidone are less likely to cause extrapyramidal side effects and tardive dyskinesia.

Answer 387

Bell's palsy In a Bell’s palsy (lower motor neuron lesion affecting cranial nerve VII) all the muscles on one half of the face are affected. There may also be loss of taste sensation on the anterior two-thirds of the tongue because the facial nerve supplies sensory innervation to that area via the chorda tympani. Improvement and complete recovery are common. EMG can often be a good predictor of outcome. In an upper motor neuron lesion (caused by a cerebrovascular accident or CVA, for example) there is sparing of the forehead as a result of bilateral innervation. The patient will be able to raise both eyebrows.

Answer 388

Pseudobulbar palsy Pseudobulbar palsy is an upper motor neuron lesion caused by bilateral lesions of the lower cranial nuclei and can be associated with emotional lability. It is known to occur in multiple sclerosis, motor neuron disease and after bilateral strokes affecting the corticobulbar pathways.

Answer 389

Syringomyelia Syringomyelia is the term used to describe the development of a fluidfilled cavity (syrinx) within the spinal cord. The condition may be associated with an Arnold–Chiari malformation. The expansion of the syrinx compresses surrounding tracts, giving rise to a particular pattern of symptoms/signs that relates to the position of the tracts within the spinal cord. The pain and temperature modalities are characteristically affected first as a result of compression of decussating spinothalamic fibres anteriorly in the ventral horns. This loss of pain and temperature sensation is often described as occurring in a ‘cape’ distribution (over trunk and arms). Wasting and weakness of hands and arms reflects involvement of cervical anterior horn cells. Sensory loss can result in Charcot’s joints (neuropathic joints damaged through loss of sensation). Involvement of the sympathetic trunk can give rise to Horner’s syndrome. The condition is gradually progressive and there is no known curative treatment. Patients with an Arnold–Chiari malformation may be treated with decompression at the foramen magnum to slow progression.

Answer 390

Neurofibromatosis This is a presentation of type I neurofibromatosis (also known as von Recklinghausen’s disease). It is an autosomal dominant condition characterized by decreased production of neurofibromin. Diagnosis requires two of seven diagnostic criteria. (i) six or more café-au-lait spots 5 mm (in children 10) or 15mm in adults (ii) axillary/inguinal freckling (iii) two or more neurofibromas or even one plexiform neurofibroma (iv) optic glioma (v) two or more Lisch nodules (iris hamartoma detected with slit-lamp examination) (vi) osseous lesion such as sphenoid dysplasia/pseudoarthrosis (vii) family history in first-degree relative.

Answer 391

Sciatic nerve injury Sciatic nerve is derived from the anterior primary rami of L4, L5, S1, S2 and S3, and divides into the common peroneal and tibial nerves about two-thirds of the way down the thigh. Sciatic nerve injury is an important postoperative complication of hip replacement and can result from direct trauma or traction on the nerve. There is lack of sensation over the lateral leg below the knee (and the entire sole of the foot) and inability to dorsiflex or evert the foot.

Answer 392

Sensory ataxia Sensory ataxia results from a loss of proprioception caused by peripheral neuropathy (in this case secondary to alcohol abuse). Romberg’s test is used to identify proprioceptive sensory loss by demonstrating loss of postural control in darkness. The patient is asked to stand with the feet together and to close his or her eyes. If the patient is unstable, the test is said to be positive. These patients sway and fall because they rely heavily on visual cues to maintain postural equilibrium. This test is not pathognomonic of proprioceptive loss because patients with bilateral vestibular damage and some patients with cerebellar disease require visual cues to keep their balance.

Answer 393

Cerebellar ataxia Cerebellar disease affecting one hemisphere tends to cause the patient to veer towards the side of the lesion. If cerebellar disease affects the cerebellar midline vermis, there is truncal ataxia giving rise to difficulty in standing and even sitting on a stool unsupported.

Answer 394

Right parietal lobe This patient has sensory neglect suggesting a non-dominant hemisphere lesion. As the patient is right handed, we know that the dominant lobe must be on the left side, and hence the pathology is in the right parietal lobe.

Answer 395

Medial longitudinal fasciculus Bilateral internuclear ophthalmoplegia is almost exclusively found in multiple sclerosis and is caused by bilateral involvement of the MLF. When the patient is asked to look towards the right, the left eye fails to adduct and the right eye develops coarse nystagmus in abduction. This is caused by the left MLF lesion. When the patient is asked to look towards the left, the right eye fails to adduct and the left eye develops coarse nystagmus in abduction. This is caused by the right MLF lesion.

Answer 396

Aspiring and metoclopramide Aspirin and metoclopramide provide relief for the symptoms of pain and nausea/vomiting associated with migraine. The use of serotonin 5HT1 agonists such as sumatriptan are indicated if the patient fails to respond to conventional analgesics. Remember that the 5HT1 agonists are contraindicated in patients with coronary artery disease, previous myocardial infarction (MI) and uncontrolled hypertension.

Answer 397

Carbemazepine Carbamazepine is commonly used to treat trigeminal neuralgia. Phenytoin and gabapentin have also been used to treat this condition. Cases refractory to medical treatment may be considered for surgery.

Answer 398

Paracetamol Opiates such as morphine cause pupillary constriction and should not be given as analgesia in this case of head injury because it will interfere with neurological observations.

Answer 399

Oral airway and oxygen. An oropharyngeal tube (Guedel) or nasophargyneal tube.

Answer 400

Benzodiazepines. Presents with CNS depression, impaired balance, ataxia and slurred speech. Developing into respiratory depression and coma. Particularly at risk when taken with other drugs such as alcohol. Antidote is Flumezanil.

Answer 401

Salicylates Mild overdose (150mg/kg): N+V, dizziness Moderate overdose (150-300mg/kg): N+V, tinnitus, headache, confusion, hyperventilation, tachycardia, fever, metabolic acidosis Severe overdose (\>300mg/kg): delirium, hallucinations, convulsions, coma, respiratory arrest Management: activated charcoal, alkaline diuresis (IV sodium bicarbonate), haemodialysis.

Answer 402

Anti-psychotics

Answer 403

Tricyclic anti-depressants Initial symptoms: tachycardia, drowsiness, confusion, dry mouth, N+V, urinary retention, agitation, headache. Cholinergic effects. Severe complications: hypotension, dysrhythmias, hallucinations and seizures.

Answer 404

Wound Botulism. This patient developed skin abscesses due to 'skin popping' as an IVDU. These abscesses have become infected with Clostridium botulinum. It is possible that the heroin injected carried spores of botulinum. Botulinum toxin irreversibly disrupts the release of ACh at the NMJ. This results in bilateral cranial neuropathies with a descending muscle weakness.

Answer 405

Duloxetine. This patient has diabetic peripheral neuropathic pain. Duloxetine is first line treatment. Where this fails amitriptyline or pregabalin should be tried. The neuropathic pain may respond to opioid analgesics and paracetamol but specialist supervision should be used for the former. Hydroxocobalamin is for B12 replacement, of which this patient is not deficient.

Answer 406

1. Metabolic - DM - Alcohol and drugs - B12 - Hypothyroidism - Uraemia 2. Infiltrative - amyloidosis 3. Infectious - HIV 4. AI - Vasculitis - CTD - Inflammatory demyelinating neuropathy: Guillain Barre, CIDP 5. Neoplastic - Paraneoplastic - Myeloma paraproteinaemia 6. Hereditary sensory motor neuropathy = Charcot Marie Tooth disease 7. Drugs - Cytotoxics, Amiodarone, Metronidazole, Phenytoin, Isoniazid, Nitrofurantoin, Gold.

Answer 407

Papillitis Papillitis is also known as optic neuritis. It presents with blurred optic disc on fundoscopy with blurred vision and painful eye movements. The most common cause is MS. Indeed it is the presenting sign in 20-30% of MS cases. Whilst papilloedema also results in a blurred optic disc it does NOT result in blurred vision or painful eye movements. None of the other answers result in a blurred optic disc.

Answer 408

Lose weight. This man has meralgia paraesthetica. This is a mononeuropathy as a result of compression of the lateral femoral cutaenous nerve. Initial management involves reassurance of teh patient, advice to avoid tight garments and weight loss. If pain continues then carbemazepine or gabapentin can be used.

Answer 409

High amylase Mildly elevated amylase can occur in any abdominal abnormality. In acute pancreatitis it will be exceptionally high and fit with the clinical picture.

Answer 410

Ascites neutrophils ≥250 cells/mm3. This is the laboratory threshold for SBP. Management with IV antibiotics, IV albumin and repeat paracentesis of the ascites in 48h. Also consider pro-kinetics.

Answer 411

Hartman's procedure: end colostomy. Hartman's procedure is surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy. It was used to treat colon cancer or diverticulitis.

Answer 412

Defunctioning loop ileostomy. This stoma results in faecal diversion to protect to newly formed distal anastamosis. It will later be reverted.

Answer 413

Edward's syndrome

Answer 414

Alcohol withdrawal

Answer 415

Low ACTH, Low cortisol Exogenous steroids. Produces Cushingoid features as well as suppressing ACTH and thereby endogenous cortisol.

Answer 416

Normal ACTH, Low cortisol Aldosterone can partially suppress ACTH to normal levels despite low cortisol.

Answer 417

Pityriasis rosea It is benign but may inflict substantial discomfort in certain cases. Classically, it begins with a single "herald patch" lesion, followed in 1 or 2 weeks by a generalized body rash lasting up to 12 weeks, however usually around 6 - 8. Can be associated with a URTI, fever, headache, nausea, fatigue.

Answer 418

Hypertrophic pulmonary osteoarthropathy This disease presents with clubbing and periostitis of the small joints of the hand (DIP). Also painful, swollen joints of the long bones. Associated with lung diseases such as non-small cell lung Ca.

Answer 419

Temporal arteritis Raised ESR!

Answer 420

Encephalitis This child has developed Mumps from the MMR vaccine. As a result he has parotitis, a rash and encephalitis. He may develop orchitis.

Answer 421

Pharyngeal pouch. A pharyngeal pouch (aka Zenker's diverticulum) is a diverticulum of the mucosa of the pharynx. This can present in the more elderly with dysphagia, a lump in the neck, regurgitation, cough and halitosis. Can be identified with a Ba swallow.

Answer 422

Chronic renal failure. This patient is uraemic.

Answer 423

Haemodialysis

Answer 424

DFO This patient has haemochromatosis.

Answer 425

Addison's. This patient not only has Addison's but it has caused vitiligo hence the white patches on the face.

Answer 426

Carbimazole. If she is trying to conceive should she be on PTU?

Answer 427

Beta thalassemia A very very low MCV suggests Thalassemia rather than IDA.

Answer 428

Myeloma. Myeloma presents with a normal ALP because osteoblasts are suppressed.

Answer 429

High dose oral steroids. This is temporal arteritis for which the treatment is steroids.

Answer 430

B. Churg-Strauss • Can be triphasic – Rhinitis and allergies – Eosinophilia – Systemic Vasculitis * pANCA * Steroids

Answer 431

Behҫet’s disease * Recurrent oral and genital ulceration * Also iritis, skin lesions, thrombophlebitis * Pathergy reaction * Turkey and eastern Mediterranean * HLA-B5, M

Answer 432

Kawaski’s disease * Acute febrile systemic vasculitis * Children especially japanese boys * Must have fever for 5 days and 4 of; cervical lymphadenopathy, oral mucosal erythema, conjunctivis without exudates, rash, extremity changes * May have thrombocytosis * Anti-inflammatories and immunoglobulins * Coronary aneurysms

Answer 433

Haemolytic anaemia - An unconjugated hyperbilirubinaemia - Elevated AST but normal ALT and ALP, and elevated LDH - AST is not purely a hepatic enzyme; it is also found in e.g. heart, erythrocytes - LDH is also found in e.g. heart, muscle, erythrocytes - Hence a patient with haemolytic anaemia would see rises in these enzymes. The clinical picture of lethargy is also consistent

Answer 434

IV hydrocortisone. This patient had Addison's, the treatment for which is IV hydrocortisone.

Answer 435

Uncompensated metabolic alkalosis - History is suggestive of pancreatitis - Severe vomiting has caused loss of stomach acid, so alkaline pH - High bicarbonate confirms this is a likely metabolic alkalosis - There doesn’t appear to be any effort to compensate as the PCO2 is within the normal range

Answer 436

End ileostomy. End ileostomies are performed as part of an operation whereby the large bowel is removed and the end of the ileum is brought out as a stoma. This can be a temporary or a permanent measure. This is effectively protecting the distal large bowel that is diseased.

Answer 437

Recent head injury **Absolute Contraindications ** * Active bleeding * History of haemorrhagic stroke * Ischaemic stroke in previous 3 months * Clotting disturbance * Possible dissecting aortic aneurysm **Relative contraindications: ** * Recent head injury * PMH of peptic ulcer disease * Cerebral neoplasm * Liver disease * Systolic BP \>200mmHg

Answer 438

Add tiotropium - Look at NICE guidelines for more detail, but in short: - First line inhaled therapy is with short acting bronchodilators - If this does not control symptoms, then base step on FEV1 - If FEV1 \>50% predicted, add either long acting B2 agonist (LABA) or long acting muscarinic antagonist (LAMA) -If \<50% predicted, either LABA + inhaled steroid, or LAMA

Answer 439

Myelofibrosis -Massive splenomegaly in haematological context can be seen in CML, myelofibrosis, CLL. Also in malaria, leishmaniasis. Splenomegaly : 2Hs & 2Is -Give away is a leukoerythroblastic blood film (presence of primitive WBCs and primitive RBCs – nucleated erythrocytes). Seen in myelofibrosis -In myelofibrosis question may also mention teardrop poikilocytosis

Answer 440

AXR - History indicates most likely intestinal obstruction - As vomiting is not a prominent feature but constipation is, suggests a large bowel obstruction -A plain abdominal radiograph is an appropriate next modality to confirm that there is indeed intestinal obstruction (note difference between small and large bowel obstruction appearances) -A contrast CT scan could be done after this if necessary to further visualise obstruction

Answer 441

Diabetic background retinopathy. Background (mild) non-proliferative DR: at least one microaneurysm. Moderate non-proliferative DR: microaneurysms or intraretinal haemorrhages ± cotton wool spots, venous beading, intraretinal microvascular abnormalities (IRMAs). Severe to very severe non-proliferative DR (sometimes referred to as pre-proliferative disease), as above: a minimum number of these features are required in a minimum number of retinal quadrants to define severe or very severe disease. Non-high-risk proliferative DR: new vessels on the disc (NVD) - or within one disc diameter of it or new vessels elsewhere (NVE). High-risk proliferative DR: large NVD or NVE (defined by comparing to the optic disc surface area) or presence of pre-retinal haemorrhage. In advanced disease, there may also be an accompanying retinal detachment.

Answer 442

Stroke Weber's syndrome (superior alternating hemiplegia) is a form of strokecharacterized by the presence of an oculomotor nerve palsy and contralateralhemiparesis or hemiplegia.

Answer 443

Aganglionosis Aka Hirchsprung's disease. Absence of ganglion cells in the GI tract - Therefore impaired/absent nervous control Usually diagnosed as infant

Answer 444

Flexibly sigmoidoscopy Colorectal Ca * Predisposing Factors: IBD, polyps, FAP, smoking, low ﬁbre diet * Genetics: one 1st deg rela5ve 1:17, two ﬁrst deg relatives 1:10 * Tx: Must stage ﬁrst – TNM Chemoradiation/Surgery • Flexi Sig – visualisation of rectum and sigmoid, biopsies

Answer 445

Serum urea

Answer 446

Reassure patient. Lipoma - Benign fatty lump - Occurs wherever fat can expand (not scalp/ palms) - Symptomatic only with pressure - Malignant change is RARE

Answer 447

Marjolin's ulcer An aggressive ulcerating SCC that occurs in an area of previously traumatised, chronically inflamed or scarred skin.

Answer 448

DEXA scan Renal Osteodystrophy * High phosphate due to inadequate excretion * Low calcium due to low calcitriol production and poor renal reabsorption. * Increased PTH * Increased bone resorption * Osteoporosis-like picture on DEXA

Answer 449

1. Anaemia 2. Aplastic anaemia 3. Grey baby syndrome - accumulation of toxic chloramphenicol metabolites due to baby's reduced metabolism.

Answer 450

1. Photosensitivity reaction 2. GI upset 3. Tooth discolouration

Answer 451

1. GI discomfort - N+V 2. Skin rashes

Answer 452

1. GI upset 2. skin rash 3. Seizures

Answer 453

Aminoglycosides = A MEAN GUY Punch in the stomach - Renal toxicity. Reversible Knocks your head off - CN VIII toxicity = hearing loss and vertigo. Irreversible.

Answer 454

Alport's syndrome X linked disease. Mutation in type IV collagen. Major structural component of the basement membranes in the kidney, ear and eye. Triad: Haematuria + several ocular abnormalities + SNHL

Answer 455

Paracetamol ALT and AST have very high indicating high liver damage. Acute marker of liver function is affected (INR reduced) but chronic measure is normal (albumin). Hence this is acute.

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