Questions Flashcards
This drug lowers heart rate, cardiac output and mean arterial blood pressure during exercise. It can also be used for migraine prophylaxis and glaucoma. This drug also causes a decrease in endogenous renin release.
Beta blocker. Lower heart rate, CO and MABP during exercise. Reduce renin release and NA release. Use: migraine prophylaxis, anxiety, hypotension, post- MI, CCF. Also useful in arrhythmias as they act to increase the refractory period of the AVN.
This drug is a vasoconstrictor which can be used as a nasal decongestant. It is also mydriatic when used as an eye drop.
Alpha 1 agonist. Alpha 1 agonists such as phenylephrine are vasoconstrictors and also have a use as a mydriatic. They are used as nasal decongestants as a result of their vasoconstrictor effect.
Beta blocker contraindications
Absolute: - asthma - severe bradycardia - high AV block - sick sinus syndrome - severe unstable LVF Relative - peripheral vascular disease - depression
CCB contraindications
De compensated severe heart failure Bradycardia AV block Sick sinus syndrome
A 55 year old obese female complains of an occasional burning pain behind the sternum. The pain is worse after large meals and when drinking hot liquids.
GORD This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and cans also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer or for atypical features. An OGD may show oesophagitis, or Barrett’s (red velvety). However it may be normal. Manometry or pH monitoring may also be performed but in this case this patient will probably just have a therapeutic and diagnostic trial of a PPI.
Mr L, an investment banker, who is as wide as he is tall, has been brought in to A&E at 2am on Sunday after collapsing at the kebab shop on Shepherds Bush Road. He is dressed in a schoolboy outfit, which only makes sense when a similarly dressed friend arrives to tell you that the office went clubbing in Po Na Na together. Apparently Mr L had been complaining of tight chest pain and anxiety earlier in the evening but a cigarette calmed him down.
Acute coronary syndrome. ACS refers to acute myocardial ischaemia and encompasses STEMI, NSTEMI and unstable angina. This man is clearly overweight and is seeming munching a kebab so there are clear cardiovascular risk factors. The right chest pain followed by a collapse make this sounds like an MI. Those with identified STEMI should be considered for immediate reperfusion therapy by thrombolytics or PCI. Those with NSTEMI or unstable angina do not benefit from this. Most complain of chest pain which is described as substernal pressure, heaviness, squeezing, burning or tightness. It may either localise or radiate to the arms, shoulders, back, neck or jaw and is usually reproduced by exertion, eating, cold or emotional stress. ECG and bio markers like troponin will be useful in confirming the diagnosis.
Miss A, a 52 year old attends a Rapid Diagnostic Clinic for Breast Cancer at CX. She is concerned over an area of tenderness on her left breast. O/E you find that the lower medial quadrant of the left breast feels sore when you palate deeply. There is no palpable lump and both mammography and US are normal.
Costochondritis. This is costochondritis or Tietze’s syndrome (costochondritis & swelling), which presents with insidious onset of anterior chest wall pain which is made worse by certain movements of the chest and deep inspiration. The key sign is that there is pain when palpating the costochondral joints, particularly 2-5 and the diagnosis is clinical. Tests are done to exclude other diagnoses such as breast pathology. First line treatment is NSAIDs. Oral NSAIDs are preferred in the primary care setting and a beneficial response confirms the diagnosis. If NSAIDs or local corticosteroid injection fail to make the symptoms better then you should seek further investigations and consider a wider differential diagnosis including pleuritis, PE, rib fracture and GORD.
Pain on breathing in & out, dyspnoea, haemoptysis, stony dull to percuss.
PE Patients with a high clinical suspicion of PE should be anti coagulated while waiting a definitive diagnosis unless CI. PE can cause atelectasis which can result in a dull percussion note and a pleural effusion which is exudative in nature, causing a stony dull percussion note. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with TWI in III.
A 32 year old woman has a 2 day history of intermittent attacks of a sharp pain over the lower left side of her chest. The pain is exacerbated by movements of the rib cage and the patients tells you it becomes difficult to breathe. She has also felt feverish.
Bornholm disease. Bornholm disease is caused Coxsackie B virus and symptoms include the fever seen as well as the characteristic attacks of severe pain in the lower chest, which is exacerbated by small movements of the rib cage, which make it difficult for the patient to breathe.
A 25 year old basketball player, with very long arms, describes sudden onset chest pain over the left side of his chest. He is very short of breath. Choose the single most appropriate investigation.
CXR This patient has a primary pneumothorax. Marfan’s syndrome is a risk factor and there are many reports of primary spontaneous pneumothoraces attributes to pulmonary tissue fragility due to defective fibrillin. Primary pneumothoraces occur in young people without known lung conditions. The main investigation is a CXR and are classified by the amount of visible rim: small 2cm. If the patient is clinically stable, they can be observed and given O2 - an invasive approach is not necessary and the O2 will increase the rate of pneumothorax reabsorption. A large pneumothorax may require per cutaneous needle aspiration. If this fails a chest drain should be inserted.
A 23 year old student comes into hospital as part of the regular treatment for his condition. He was first brought to see you at a young age after his GP noticed he was not gaining weight adequately. In addition he was noted to be an ill child and was always developing colds. The mother distinctly remembers that he had difficulty passing his first motions after he was born? What is the approximate carrier frequency of this disease? When 18 he presented with severe pneumonia productive of green sputum, which indicated the acquisition of a pathogen the doctors had been worried about for a number of years. What is the most likely pathogen? What is the most suitable antibiotic?
The features are consistent with a diagnosis of cystic fibrosis, a common AR genetic disorder. The gene affected is for the CFTR, which is a protein that functions as a Cl channel. Abnormalities in chloride secretion lead to viscous fluids and result in excess inflammation and infections due to impaired clearance of secretions. The carrier frequency in the white population is approximately 1/20-1/25. The actual incidence is 1/2500 live births. Pseudomonas aeruginosa is a common pathogen found in CF patients. It is an opportunistic organism, infection is usually occurring in immunocompromised and severely ill patients. The green sputum is highly characteristic and occurs due to a blue-green pigment produced by the bacteria. Ciprofloxaxin.
Which ONE of the following statements is true? A) paracetamol poisoning is the 2nd most commonly encountered drug overdose in the UK B) The hepatotoxic dose of paracetamol is taken as 150mg/kg for high risk patients. C) Paracetamol overdose leads to approx. 2000 deaths per year D) Activated charcoal is better than gastric lavage in certain situations. E) N-acetylcysteine is approx 75% useful in preventing significant hepatic impairment if given within 12 hours.
D) A) Paracetamol (acetaminophen) is the most common drug overdose. B) The hepatotoxic dose is 150mg/kg but those at high risk (2• to reduced glutathione reserves) can develop at much lower doses. C) 200 deaths per year E) N-acetylcysteine is 100% successful in preventing significant hepatic impairment if used within 8 hours.
Which 1 is true? A) High risk patients are those in whom hepatic glutathione reserves are increased. B) patients with anorexia nervosa should be treated using the low risk treatment line. C) 1% of patients develop an allergic reaction to N-acetylcysteine D) methionine is an alternative to N-acetylcysteine E) serum albumin is the best indicator for severity of liver damage.
D). A) High risk are those in whom glutathione reserves are diminished. B) High risk patients include those with anorexia C) 10% develop an allergic reaction E) PT time best indicator of severity of liver damage in paracetamol overdose.
A diabetic lady on metformin with suspected lung cancer is booked to have a CT scan of her chest. She has a microcytic anaemia with high urea and creatinine. Which 1 of the following should be undertaken? A) 0.9% saline for 12h prior to procedure B) increase metformin to optimise her blood sugar control. C) check for metal implants. D) ECG E) V/Q scan prior to procedure
A) This lady has pre-existing renal impairment as shown by the raised urea and creatinine and is also on metformin for her diabetes. She is therefore at great risk of developing contrast induced nephropathy. this is often not taken into consideration when people have CT scans with contrast. It presents as acute deterioration in renal function secondary to contrast medium used and can lead to significant morbidity and mortality. Good hydration prior to and following the procedure helps minimise the risk as does stopping metformin 48 hours before the scan. A number of agents are used in an attempt to prevent contrast induced nephropathy including N-acetylcysteine, aminophylline and statins. Contrast induced nephropathy is also of concern people undergoing interventional radiological procedures and coronary angiography. Renal function should be monitored in those people following the investigation.
Which one of the following statements is true about pancreatitis? A) serum amylase is preferred over lipase the diagnosis of the above condition B) the Glasgow School is valid six hours after presentation C) enteral nutrition is of benefit to patients with the above condition D) patients with persisting organ failure and severe disease will require serial abdominal x-rays to aid and management E) if gallstones are suspected ERCP should be delayed until clinical improvement because.
C) Patients with pancreatitis are usually very ill and will require nutritional support to aid the recovery. This is most needed in those with severe disease with the enteral route being preferred you to lower costs and side-effects If pancreatitis is thought to be secondary to gallstones then urgent ERCP should be performed ideally less than 72 hours after presentation.
Which one of the following statements is false? A) subdural haematoma is are more common in alcoholics B) delirium tremens occurs after 2 to 3 days of alcohol abstinence C) Wernicke syndrome is the triad of ophthalmoplegia, nystagmus and amnesia. D) Acamprosate works by binding to NMDA receptors to increase abstinence to alcohol E) mortality of untreated delirium tremens is in the order of 30%
C) Wernicke Syndrome is actually the triad of ophthalmoplegia and nystagmus, ataxia and encephalopathy. Amnesia would be more in keeping with Korsakoff syndrome - a progression of Wernicke encephalopathy
Which one of the following is most useful in a patient with constipation secondary to sigmoid volvulus? A) laparotomy B) phosphate enema C) gastrgrafin meal D) flatus tube insertion E) conservative management
D) Conservative management of flatus tube insertion or flexible sigmoidoscopy can be all that is required to relieve the obstruction and untwist the bowel. Occasionally more aggressive surgical treatment is required.
Which 1 of the following is true? A) DKA only occurs in patients with T1DM. B) The mortality rate of DKA is greater than that of HHS. C) DKA typically has an onset of less than 24 hours. D) A raised WCC in a patient with DKA implies co-existent infection. E) Under-dosing insulin is the commonest factor precipitating DKA.
C) A) Occurs in both but more common in T1DM. B) DKA mortality ~5%; HHS mortality 15-25% D) Raised WCC can be independent of infection in DKA. E) infection is the most common precipitating factor.
A 3 year old girl is febrile and has been unwell for 12 hours. She complains of a headache and is drowsy but otherwise neurologically intact. What is the most discriminating investigation in the acute management?
Lumbar Puncture Meningitis commonly affect the extremes of age (60) due to impaired immunity. An LP to obtain CSF is the most important investigation when this diagnosis is considered. This should not however delay the starting of empirical anti microbial therapy. When the specific organism is identified, treatment can be modified accordingly. Fever, headache and drowsiness should make you suspicious here of this diagnosis. Atypical presentations can also occur, particularly in the very young, old or immunocompromised. In older patients, frequently, the only presenting sign of meningitis is confusion or an altered mental state. In infants, S&S can be very non-specific and may include lethargy, poor feeding, irritability and fever. A rash is noted in 80-90%, commonly 4-18h after initial symptoms and is associated with meningococcal aetiology. In bacterial meningitis, the CSF pressure is usually raised and the WBC count is elevated. Glucose level is decreased compared to the serum value and the protein level is increased. In those who are untreated, Gram stain and culture of CSF are usually positive for the causative organism. If an LP is delayed or regarded as clinically unsafe (in raised ICP) then blood samples should be obtained for culture. Of course, a heat CT should be considered before LP if there is focal neurology, new onset seizures, papilloedema, altered consciousness or any sign that May indicate raised ICP.
2 weeks after a holiday on the Far East, a 30 year old lady presented with anorexia, fever and joint pains. Jaundice appeared a week later and on examination her liver and spleen were both enlarged and tender. What is the most likely pathogen?
Viral hepatitis. This is likely HAV, which is primarily transmitted via the faeco-oral route. After the virus is consumed absorbed, it replicates in the liver and is excreted in the bile (to be re-transmitted). Transmission usually precedes symptoms by about 2 weeks and patients are non-infectious 1 week after the onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, MSM or a known food borne outbreak. (Classically associated with shellfish harvesters from sewage contaminated water) The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdo pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that maybe found include splenomegaly, RUQ pain and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. Jaundice peaks at 2 weeks. A fulminant course in 10.000 units although this doesn’t correlate with severity. ALT is normally > than AST.
A 12 year old boy presents with a flu-like illness, fever, headache, vomiting, tremor on the left side if his body and weakness of his left leg. What is the most likely pathogen?
Polio Poliovirus infection is usually asymptomatic and when symptomatic the most common presentation is with a minor GI illness. There is no cure for poliovirus infection and treatment is primarily supportive. This patient had acute flaccid paralysis or paralytic poliomyelitis, which is the hallmark of major illness. This can rarely progress to bulbar paralysis and respiratory compromise. Paralytic poliomyelitis presents with decreased tone and motor function as well as reduced tendon reflexes and muscle atrophy of the affected limb. Lack of vaccination is a strong risk factor. Remember that there are 2 main types of polio vaccine- Sabin (oral weakened strain used in endemic regions) & Salk (inactivated poliovirus used in the rest of the world).
These organisms are an increasing problem as nosocomial infections. They are commensalism of the GIT. Many are vancomycin resistant. What is the organism?
Enterococcus faecium Vancomycin resistance enterococci (VRE) - most are Enterococcus faecium. Enterococcus faecalis are mostly not VRE but are more prevalent than Enterococcus faecium. These are one of the big causes of nosocomial infections in the UK. Enterococcus faecium is a Gram positive bacteria and is a GIT commensal. It is commonly implicated in hospital acquired line and UTI. The UK top 5 hospital-acquired infections are: MRSA, VRE, ESBL (E.coli & Klebsiella), Pseudomonas & Acinetobacter.
What is the Tensilon test?
The Tensilon test is used to distinguish between myasthenia gravis and lambert eaton syndrome. Edrophonium (aka Tensilon) is an AChEi that is given. It improves MG muscle weakness but has no effect to Lambert-Eaton.
A 62-year-old man presents to the emergency department with acute onset shortness of breath and haemoptysis. He had a hip replacement operation two weeks ago has been finding the exercises to get back on its feet very difficult. On examination his tachypnoeic at rest tachycardic with the pulse of 130 minute has a pyrexia of 37.4°C and oxygen saturation of 92% on room air. Which one of the following is the most appropriate investigation in this patient? A) bronchoscopy B) DD diner C) ECG D) lateral chest x-ray E) blood cultures
ECG The patient has a diagnosis of a pulmonary embolism given the sudden onset of shortness of breath haemoptysis and hypoxia caused by a recent hip operation and prolonged inability. Given the height pre-test probability of a pulmonary embolism a d dimer test should not be performed because regardless of the result you investigate with a CT pulmonary angiogram or a V/Q scan to confirm your clinical suspicion. The place of the d dimer testing is in those patients with a pre-test probability of a PE and to help in its exclusion. D dimers should not be used for diagnostic reasons because although the sensitivity of the test is high the specificity is low A bronchoscopy is not useful as the haemoptysis does not reflect underlying suspicion of malignancy or infection. A low-grade pyrexia is a common finding in patience with a PE and blood cultures are therefore not the most appropriate investigation. In the acute setting a PA or AP chest x-ray is vital in the acute assessment of a patient short of breath but a lateral x-ray would not be required. The most appropriate investigation is therefore an ECG
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
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.
A 22-year-old patient has a history of a regular menstrual cycles over the past few years. She is well known to you and has seen you regularly with regard to her weight problem, oily skin and acne. She presents to you on this occasion with a five-month history of amenorrhoea and weight gain. Which one of the following is the most appropriate initial investigation in the above scenario? A) pelvic US B) sex hormone binding globulin free androgen levels. C) LH:FSH levels D) OGTT E) BhCG estimation
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.
Which 1 of the following statements is true? A) haemolytic disease of the newborn is caused by IgM Abs. B) Goodpasture’s disease is an example of a type III HS reaction. C) Anaphylactic reactions are due to IgA D) RBCs sensitised in vivo to autoAb can be detected using the direct Coombs reaction. E) HIV uses CXCR4 and CCR5 co-receptors to gain entry into CD8 T cells.
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.
A 34-year-old man has attacks of sudden severe pain waking up the last fortnight. The pain is on the right side of his face and makes eyes water. What is the diagnosis?
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.
A 40 year-old man presents with an instantaneous onset of a severe headache but by drowsiness and vomiting. What is the diagnosis?
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.
830-year-old woman experienced a strange feeling in the stomach, followed by stiffness and jerking in the left arm. Afterwards, she felt drowsy but remembers everything. What is the diagnosis?
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.
A 42-year-old man who lives alone presented with confusion and ataxia. Both his hands had a Dupytren’s contracture. What is the likely diagnosis?
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.
Step 1 in a 40 year old Caucasian male commencing anti-hypertensive therapy?
ACEi
Step 2 in anti-hypertensive treatment of a 40 year old Caucasian male.
CCB or Thiazides diuretic
Step 3 in anti-hypertensive management of a 40 year old Caucasian male.
CCB & diuretic
Step 4 antihypertensive management of a 40 year old Caucasian male
Alpha blocker or spironolactone
A 55 year old Afro-Caribbean needs to commence on an anti-hypertensive agent.
CCB or diuretic
Hypertension due to increased renin secretion is common in men or women?
Women
For each patient choose the most appropriate treatment: A 40 year old man with diabetes proteinuria and hypertension of 148/98mmHg
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.
For each patient choose the most appropriate treatment: A 30-year-old woman who has developed hypertension early in her first pregnancy blood pressure is 150/95. She does not have proteinuria or oedema.
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.
For each patient choose the most appropriate treatment: A 60-year-old woman has hypertension with no comorbidities. Mean blood pressure is 170/110mmHg.
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.
For each patient choose the most appropriate treatment: A 60 year-old man with atrial fibrillation and hypertension of 155/95
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.
For each patient choose the most appropriate treatment: A 45-year-old man has collapsed. He has papilloedema and multiple haemorrhages on funduscopy. He has proteinuria. CT brain is normal. BP is 250/140.
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.
True or False The association between blood pressure and stroke is stronger than between blood pressure and coronary artery disease.
True
The alternative name for Conn’s syndrome is? And the specific treatment is?
Primary hyperaldosteronism. Spironolactone. (K sparing diuretic = competitive antagonist of aldosterone [mineralocorticoid] receptor
An 18 year old man presents with a night time cough and SOB while playing football. This has got progressively worse over the previous 2 months. Most likely diagnosis? A.Oesophageal reflux B.COPD C.Asthma D.Foreign body E.Sarcoidosis F.Angiotensin converting enzyme inhibitor G.Postnasal drip H.Bronchiectasis I.Carcinoma of bronchus J.Tuberculosis
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.
A 30 year old man, a lifelong non-smoker, presents with a history of at least 6 months of purulent sputum. He has had regular chest infections since an attach of measles aged 14. What is the most likely diagnosis? A.Oesophageal reflux B.COPD C.Asthma D.Foreign body E.Sarcoidosis F.Angiotensin converting enzyme inhibitor G.Postnasal drip H.Bronchiectasis I.Carcinoma of bronchus J.Tuberculosis
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.
A 70 year old man with a history of 10kg weight loss over the previous 3 months. More recently, he developed acute lower back pain. He presents to A&E with coughing and sputum. CXR shoes left lower lobe pneumonia. Most likely diagnosis? A.Renal failure B.Malignancy C.Anorexia nervosa D.Malabsorption E.Addison’s disease F.Liver failure G.HIV H.Depression I.Tuberculosis J.Infestation with helminths K.Cardiac failure L.Diabetes mellitus M.Hyperthyroidism
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.
A 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually Most likely diagnosis? A.Breast Abscess B.Carcinoma of the breast CFibroadenosis D.Fibroadenoma E.Duct Ectasia F.Lipoma G.Gynaecomastia H.Sebaceous cyst I.Breast Cyst
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.
A 25 year old lady returning for Australia presents with an acutely painful left calf. US confirms a DVT extending above the popliteal veins. She has recently missed a period. Most appropriate management? A.Embolectomy B.Fondaparinux (FXa inhibitor) C.Start warfarin therapy D.Intravenous heparin E.Vena cava filter F.Check INR and continue warfarin G.Subcutaneous low molecular weight heparin H.Subcutaneous low molecular weight heparin I.Observation in hospital J.Antiembolism stocking K.Reassure and discharge L.Reassure and discharge
SC LMWH Women developing a DVT during pregnancy can be treated with heparin or LMWH. However, LMWH is preferred due to more dependable pharmacokinetics.
A woman who is on warfarin for a confirmed right calf DVT develops increasing pain and swelling of that leg. This is the 3rd time this has happened. Repeat imaging shows thrombus limited to the calf. Most appropriate management? A.Embolectomy B.Fondaparinux (FXa inhibitor) C.Start warfarin therapy D.Intravenous heparin E.Vena cava filter F.Check INR and continue warfarin G.Subcutaneous low molecular weight heparin H.Subcutaneous low molecular weight heparin I.Observation in hospital J.Antiembolism stocking K.Reassure and discharge L.Reassure and discharge
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.
5 indications for dialysis in acute kidney injury
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
Miss K is a 45 year old retired kitchen lady who presents to A+E with abdominal discomfort which has been getting worse over the past few weeks. She says she feels tired, bloated and has lost her appetite. Findings show antimitochrondrial antibodies are present and serum alkaline phosphatase is raised Most likely diagnosis? Gilbert’s Syndrome Hepatitis C Primary biliary cirrhosis Hepatocellular carcinoma Hepatorenal syndrome Hepatitis E Hepatitis D Hepatitis A Hepatitis B Portal hypertension Gall stones Pyogenic abscess Alcoholic liver disease GORD
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.
A 22 year old man walks into A&E, he was involved in a fight in a bar. As he left the bar he complained of drowsiness and double vision worst when walked down stairs. Which nerve is affected? A.Cranial nerve Vc B.Cranial nerve Vb C.Cranial nerve III D.Optic tract E.Cranial nerve X F.Cranial nerve I G.Cranial nerve IX H.Cranial nerve II I.Cranial nerve Va J.Cranial nerve XI K.Cranial nerve VI L.Cerebellum MCranial nerve VIII N.Cranial nerve IV OCranial nerve XII P.Cranial nerve VII
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.
A 79 year old lady was brought to A&E after a fall. On examination, when asked to close her eyes, her eyeballs rolled upwards and she was unable to close her eyes. Which nerve is affected? A.Cranial nerve Vc B.Cranial nerve Vb C.Cranial nerve III D.Optic tract E.Cranial nerve X F.Cranial nerve I G.Cranial nerve IX H.Cranial nerve II I.Cranial nerve Va J.Cranial nerve XI K.Cranial nerve VI L.Cerebellum MCranial nerve VIII N.Cranial nerve IV OCranial nerve XII P.Cranial nerve VII
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.
A 7 year old girl presents with at 39.3oC fever, rash and neck stiffness. You suspect raised intracranial pressure. You are in a DGH late at night and the radiographers are not on call. What is the best diagnostic investigation to order? A.Laparoscopy B.ABGs C.Transvaginal ultrasound D.FBC E.PET scan F.Compression USS G.Helical CT scan H.CXR I.Lumbar puncture J.MRI Head K.Urinary beta hCG L.AXR M.CT head N.Blood cultures
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.
A 40 year old man presents with acute colicky pain in his back radiating to his left flank. He has dysuria. What is the best diagnostic test? A.Laparoscopy B.ABGs C.Transvaginal ultrasound D.FBC E.PET scan F.Compression USS G.Helical CT scan H.CXR I.Lumbar puncture J.MRI Head K.Urinary beta hCG L.AXR M.CT head N.Blood cultures
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.
68 year old male. Complains of fever, night sweats and weight loss. On examination has hepatosplenomegaly and peripheral lymphadenopathy. On further investigation, he was also found to have intra-abdominal and pelvic lymphadenopathy. Most appropriate answer: B12 deficiency Iron deficiency anaemia Acute myeloblastic leukaemia Hodgkin’s lymphoma Folate deficiency Infectious mononucleosis Acute lymphocytic leukaemia Myeloma Hepatocellular carcinoma
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.
A teenage boy presents with haematuria. It has been noted that his hearing has been worsening over recent years. He has a family history of early death. Most likely diagnosis: A.Nephrocalcinosis B.Fanconi Syndrome C.Chronic Pyelonephritis D.Acute Nephritic Syndrome E.Acute Pyelonephritis F.Nephrotic Syndrome G.Alport’s syndrome H.Nephrogenic Diabetes Inspidus I.Goodpasture’s syndrome J.Urinary tract Obstruction
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.
A 33 year old man presents with increased frequency of micturition and dysuria. He thinks his urine has a more unpleasant odour than usual. In his past history, he mentions that he was diagnosed with “reflux” as a child. On examination, the pain is identified as being in the suprapubic region; he was found to be hypertensive, and haematuria was confirmed on investigation. Most appropriate answer: A.Nephrocalcinosis B.Fanconi Syndrome C.Chronic Pyelonephritis D.Acute Nephritic Syndrome E.Acute Pyelonephritis F.Nephrotic Syndrome G.Alport’s syndrome H.Nephrogenic Diabetes Inspidus I.Goodpasture’s syndrome J.Urinary tract Obstruction
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.
A 56 year old vagrant presents with perifollicular skin bleeding & prolonged bleeding time Most likely diagnosis? A.Iatrogenic B.Sepsis C.Paroxysmal nocturnal haemoglobinuria (PNH) D.Pre-eclampsia E.Amyloidosis F.Malignant hypertension GDisseminated intravascular coagulation (DIC) H.Scurvy I.Thrombotic thrombocytopenic purpura (TTP) J.Haemorrhagic fever K.Cushing’s Disease L.Idiopathic thrombocytopenic purpura (ITP) M.Henoch-Schonlein syndrome N.Haemophilia O.Ehlers- Danlos syndrome
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.
A 35 year old woman presents with purpura, fever, haemolytic anaemia, microvascular thrombosis, renal failure & mild stroke. Blood film shows fragmented red cells & clotting screen is normal. Most likely diagnosis: A.Iatrogenic B.Sepsis C.Paroxysmal nocturnal haemoglobinuria (PNH) D.Pre-eclampsia E.Amyloidosis F.Malignant hypertension GDisseminated intravascular coagulation (DIC) H.Scurvy I.Thrombotic thrombocytopenic purpura (TTP) J.Haemorrhagic fever K.Cushing’s Disease L.Idiopathic thrombocytopenic purpura (ITP) M.Henoch-Schonlein syndrome N.Haemophilia O.Ehlers- Danlos syndrome
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
A 20 year old man presents with colicky abdominal pain, arthritis & polyarthritis following a chest infection. He also has purpura over his buttocks & legs Most likely diagnosis A.Iatrogenic B.Sepsis C.Paroxysmal nocturnal haemoglobinuria (PNH) D.Pre-eclampsia E.Amyloidosis F.Malignant hypertension GDisseminated intravascular coagulation (DIC) H.Scurvy I.Thrombotic thrombocytopenic purpura (TTP) J.Haemorrhagic fever K.Cushing’s Disease L.Idiopathic thrombocytopenic purpura (ITP) M.Henoch-Schonlein syndrome N.Haemophilia O.Ehlers- Danlos syndrome
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.
A 65 year old man presents with a 7 month history of vague epigastric pain. The pain is made worse immediately after eating and is relieved by vomiting. The patient avoids spicy foods and has lost 9kg in weight. On examination there is midline epigastric tenderness. Most likely diagnosis A.Pancreatitis B.Pancreatic carcinoma C.Gastritis D.Gastric ulcer E.Duodenal ulcer F.GORD G.Acute cholecystitis H.Oesophagitis I.Gastric carcinoma
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.
A 45 year old man has a 6 month history of recurrent attacks of severe epigastric pain lasting from 2 to 6 weeks. The pain occurs 2 hours after food and is relieved by drinking milk. The pain often awakes the patient at night. On examination there is a localised deep tenderness to the right of the epigastrum. Most likely diagnosis? A.Pancreatitis B.Pancreatic carcinoma C.Gastritis D.Gastric ulcer E.Duodenal ulcer F.GORD G.Acute cholecystitis H.Oesophagitis I.Gastric carcinoma
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.
A 25 year old woman who complains of heat intolerance, anxiety & weight loss, despite a good appetite. You find a fine tremor in her hands & a pulse of 120. There is a smooth swelling, 5cms by 3cms, centred on the midline of her neck. You hear a bruit when you place the stethoscope diaphragm over it. Most appropriate management? A.Amoxicillin B.Excise for biopsy C.Sialogram D.Carbimazole E.Reassure & explain why no active management necessary F.Full blood count & Paul Bunnell G.Thyroxine H.Upper GI endoscopy I. Technetium thyroid scan
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.
A woman of 20 with a week’s history of sore throat & fever. You find large smooth tender sub-mandibular bilateral lymph glands. Most appropriate management A.Amoxicillin B.Excise for biopsy C.Sialogram D.Carbimazole E.Reassure & explain why no active management necessary F.Full blood count & Paul Bunnell G.Thyroxine H.Upper GI endoscopy I. Technetium thyroid scan
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.
70 year old woman who complains of palpitations, intolerance to heat, diarrhoea & weight loss. You find an irregular goitre in her neck that moves up and down when the patient swallows. There is no stigmata of Graves’ disease Most appropriate management? A.Amoxicillin B.Excise for biopsy C.Sialogram D.Carbimazole E.Reassure & explain why no active management necessary F.Full blood count & Paul Bunnell G.Thyroxine H.Upper GI endoscopy I. Technetium thyroid scan
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.
55 year old woman who complains of dysphagia is found to have a 10cms in width & 5cms in height bilateral symmetrical non-tender nodular mass in the front of her neck. Investigations show that she is euthyroid. Most appropriate management? A.Amoxicillin B.Excise for biopsy C.Sialogram D.Carbimazole E.Reassure & explain why no active management necessary F.Full blood count & Paul Bunnell G.Thyroxine H.Upper GI endoscopy I. Technetium thyroid scan
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.
A 63 year old man who has recently had chemotherapy for bowel cancer is suffering from diarrhoea. Most appropriate management? A.Codeine phosphate B.Antispasmodics C.Senna D.Amoxicillin E.Doxycycline F. Oral rehydrating fluids G.Mesalazine H.Lactulose I.Intravenous dextrose J.Ciprofloxacin K.Paracetamol L.Intravenous saline M. Hemicolectomy
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.
54 year old Asian woman with type 2 diabetes for 15 years. She comes to the clinic complaining of ankle swelling. On examination, BP 170/95, JVP not raised & bilateral oedema to the knees. Albumin is low. Most appropriate investigation? A.Coagulation screen B.Venous doppler studies C.Full blood count D.24 hr urine protein E.Lymphangiogram F.Plasma creatinine G. Arterial doppler studies H.Chest X-Ray I.Pelvic ultrasound J.Liver function tests
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.
66 year old man presents with swelling of his right leg to the knee. He had had a right hip replacement 5 weeks previously. Most useful investigation? A.Coagulation screen B.Venous doppler studies C.Full blood count D.24 hr urine protein E.Lymphangiogram F.Plasma creatinine G. Arterial doppler studies H.Chest X-Ray I.Pelvic ultrasound J.Liver function tests
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
25 year old female with acute onset of chills, fever, cough with brown phlegm for three days. On examination she appears toxic, temperture 40degrees C, reduced breath sounds, bronchial breathing and stony dullness left lung base. Most likely diagnosis A.COPD B.Pneumonia C.Pleural mesothelioma D.Sarcoidosis E.Pneumothorax F.Carcinoma of Bronchus G.Pulmonary embolus H.Rheumatoid arthritis I.Aspiration pneumonia J.Lung metastases K.Acute asthma L.Pulmonary oedema M.Chest injury with rib fractures N.Pulmonary tuberculosis
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.
A 24 year old woman following a viral infection was diagnosed as having idiopathic thrombocytopaenia. She presents to A&E & complains of multiple bruising & rectal bleeding. She is on oral prednisolone 30mg/day. Her Hb is 12.5g/dl. Most likely management A.Anterior resection B.Colostomy C.IV corticosteroids D.Loperamide (Imodium) E.Topical GTN F.IV immunoglobulin G.High fibre diet H.Haemorrhoidectomy I.Hemicolectomy
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.
An 85 year old who is known to be hypertensive & has mild impaired renal function presents with signs of dehydration & undergoes a laparotomy for small bowel obstruction. Most likely analgesic NOT to be used in the post-operative period: Diclofenac Paracetamol Tramadol Codydramol Morphine Epidural bupivacaine fentanyl
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.
A 60 year old man with diarrhoea is transferred from another hospital for urgent femoral-distal bypass surgery & arrives with a heparin infusion in situ. His APTT is 2.4. Most likely analgesic NOT to be used in the post-operative period: Diclofenac Paracetamol Tramadol Codydramol Morphine Epidural bupivacaine fentanyl
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
A 62 year old man who requires a knee replacement gives a history of allergy to dihydrocodeine. Most likely analgesic NOT to be used in the post-operative period: Diclofenac Paracetamol Tramadol Codydramol Morphine Epidural bupivacaine fentanyl
Codydramol Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
A 65 year old man with a history of peptic ulceration requires an aortic aneurysm repair electively. Most likely analgesic NOT to be used in the post-operative period: Diclofenac Paracetamol Tramadol Codydramol Morphine Epidural bupivacaine fentanyl
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.
A 52 year old woman, with recurrent episodes of severe anxiety, when her family note that she becomes very pale. BP is up to 220/124mmHg during an attack, 150/90mmHg otherwise. Her pulse rate does not increase significantly during attacks. Most likely diagnosis A.Cushing’s syndrome B.‘Essential’ hypertension C.Coarctation of the aorta D.Metabolic syndrome (Insulin resistance/Syndrome X) E.Renovascular disease F.Phaeochromocytoma G.Primary hyperaldosteronism (Conn’s syndrome) H.Isolated systolic hypertension
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.
A 25 year old patient presents with 1 year history of painful scrotal swelling. On examination there is a hard smooth swelling of the right testis. It did not transilluminate. There was no cough impulse. Most likely diagnosis A.Retractile testis B.Epididymo-orchitis C.Trauma D.Hydrocele E.Strangulated indirect inguinal hernia F.Varicocele G.Metastasis H.Cryptoorchidism I.Teratoma J.Torsion of testis K.Mumps orchitis
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.
A 24 year old political refugee presents with a tender swollen right testicle of 3 days duration. Examination reveals tender mandibular swelling. Temperature 380C. Swollen tender testicle which does not transilluminate Most likely diagnosis A.Retractile testis B.Epididymo-orchitis C.Trauma D.Hydrocele E.Strangulated indirect inguinal hernia F.Varicocele G.Metastasis H.Cryptoorchidism I.Teratoma J.Torsion of testis K.Mumps orchitis
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.
A 52 year old company director presents with fever. He has recently returned from a conference in SE Asia. Examination – Temp 37.50C. Few tender inguinal lymph node. Tenderness of spermatic cord & testis. Most likely diagnosis A.Retractile testis B.Epididymo-orchitis C.Trauma D.Hydrocele E.Strangulated indirect inguinal hernia F.Varicocele G.Metastasis H.Cryptoorchidism I.Teratoma J.Torsion of testis K.Mumps orchitis
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.
64 yr old woman complaining of severe back pain for some weeks. For the last few days she has been very constipated and has been vomiting for 24 hours. She has been a smoker for many years and has had 3 courses of antibiotics for chest infections over the last 3 months. Most likely diagnosis A.Hypocalcaemia B.Hypothyroidism C.Hypernatraemia D.Hypercapnia E.Metabolic acidosis F.Hypokalaemia G.Hypoglycaemia H.Hypercalcaemia I.Hyperkalaemia J.Hyponatraemia K.Hypermagnesaemia L.Addison’s disease
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.
An 80 year old man presents with severely painful feet with mottled and purple toes with black areas. He tells you that he has also had constant severe back pain for a few days. Most appropriate investigation A.Cold provocation test B.Lumbar puncture C.Blood sugar level D.Venous duplex scan E.Arteriogram. F.FBC G.CT scan H.ANCA (anti-neutrophil cytoplasmic antibody) I.Blood cultures
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.
A 25 year old university student presents with a high fever. He has petechial rash, black areas on his toes and fingers. His BP is 70/50. Most appropriate investigation A.Cold provocation test B.Lumbar puncture C.Blood sugar level D.Venous duplex scan E.Arteriogram. F.FBC G.CT scan H.ANCA (anti-neutrophil cytoplasmic antibody) I.Blood cultures
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
A 55 year old woman presents with painful joints, a purpuric rash on her arms and legs. Systems review reveals heamoptysis and ear pain. On examination you find black patches on her toes. Most appropriate investigation A.Cold provocation test B.Lumbar puncture C.Blood sugar level D.Venous duplex scan E.Arteriogram. F.FBC G.CT scan H.ANCA (anti-neutrophil cytoplasmic antibody) I.Blood cultures
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.
A 58 year old male has had increasing difficulty swallowing. He has lost 10kg in the past 2 months. Upper GI endoscopy reveals a nearly circumferential irregular & ulcerated mass in the mid oesophagus. Most likely diagnosis A.Hyperplasia B.Squamous cell carcinoma C.Myeloma D.Autonomous E.Sarcoma F.Lymphoma G.Carcinoma H.Adenocarcinoma
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.
A 75 year old man who presents with frank haematuria. He tells you that 3 years ago he had a similar episode & was diagnosed as having ‘warts in the bladder’. After treatment, he moved & was lost to follow-up but had been symptom free since then. Which investigation would confirm diagnosis? A.MSU: microscopy and cultures B.X-ray lumbar spine C.Prostate specific antigen blood test D.Biopsy of prostate E.Retrograde pyelogram F. Abdominal ultrasound G.ASO titre blood test H.Helical CT I.24 hour urine monitoring J.Cytoscopy
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.
45 year old man wakes in the night with severe pain in his right flank radiating round to the front & into his groin. He can’t get comfortable, but on examination his abdomen is soft with no masses. His urine shows a trace of blood but no other abnormality. Which investigation would confirm diagnosis? A.MSU: microscopy and cultures B.X-ray lumbar spine C.Prostate specific antigen blood test D.Biopsy of prostate E.Retrograde pyelogram F. Abdominal ultrasound G.ASO titre blood test H.Helical CT I.24 hour urine monitoring J.Cytoscopy
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.
A 55 year old known epileptic arrives in A&E having suffered a fit whilst shopping. She is “post ictal” on arrival in A&E & breathing in an obstructed manner with O2 saturation of 92% (on air). Most appropriate method to maintain patient oxygenation Tracheostomy None Facemask with oxygen Laryngeal mask airway (LMA) Oropharyngeal airway with oxygen Single-lumen cuffed ET tube Cricothyroidotomy Suction Laryngoscopy Uncuffed ET tube Double-lumen cuffed ET tube
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.
A 19 year old motorcyclist suffers a head injury after colliding with a lorry. On examination he is found to have a GCS of 4 & requires an urgent CT scan Most appropriate method to maintain patient oxygenation Tracheostomy None Facemask with oxygen Laryngeal mask airway (LMA) Oropharyngeal airway with oxygen Single-lumen cuffed ET tube Cricothyroidotomy Suction Laryngoscopy Uncuffed ET tube Double-lumen cuffed ET tube
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.
A 78 year old patient is due to undergo surgery on her short saphenous veins in the prone position under general anaesthesia. She is obese and has known GORD. Most appropriate method to maintain patient oxygenation Tracheostomy None Facemask with oxygen Laryngeal mask airway (LMA) Oropharyngeal airway with oxygen Single-lumen cuffed ET tube Cricothyroidotomy Suction Laryngoscopy Uncuffed ET tube Double-lumen cuffed ET tube
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.
A 30 year old lady, who is breast feeding, has developed an extremely painful, hard, red 4 cm lump at the edge of the nipple. Most likely diagnosis A.Radial scar B.Pagets disease C.Duct ectasia D.Fibrocystic breast E.Benign cyst F.Cyclical breast pain G.Fat necrosis H.Breast abcess I.Breast carcinoma J.Fibroadenoma
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.
A 65 year old lady has noticed a 3cm lump behind the right nipple. It is hard, non-tender, mobile and has an irregular edge. Most likely diagnosis A.Radial scar B.Pagets disease C.Duct ectasia D.Fibrocystic breast E.Benign cyst F.Cyclical breast pain G.Fat necrosis H.Breast abcess I.Breast carcinoma J.Fibroadenoma
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.
A 60 year old man has suprapubic pain on standing and difficulty emptying his bladder with blood at the end of the stream. Most likely diagnosis A.Bacterial cystitis B.Gram negative septicaemia C.Advanced prostate cancer D.Localised prostate cancer E.Hydronephrosis F.Benign prostatic enlargement G.Acute prostatitis H.Bladder calculus
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.
A 65 year old man presents with a large painless bladder and overflow incontinence at night and a raised creatinine level. Most likely diagnosis A.Bacterial cystitis B.Gram negative septicaemia C.Advanced prostate cancer D.Localised prostate cancer E.Hydronephrosis F.Benign prostatic enlargement G.Acute prostatitis H.Bladder calculus
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.
An 18 year old Caucasian shop assistant presents with fever & a sore throat. She is found to have enlarged but soft cervical lymph nodes & a soft spleen palpable 3cm below the costal margin. Blood film shows atypical lymphocytes. Most likely diagnosis A.Sarcoidosis B.Bacterial endocarditis C.Malaria D.CML E.Metastatic carcinoma F.IDA G.Idiopathic myelofibrosis H.Hodgkin’s disease I.Portal hypertension J.Gaucher’s disease K.Polycythaemia L.Infectious mononucleosis
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.
A 65 year old man presents with angina & claudication. He is found to have a firm spleen extending 20cm below the costal margin. His Hb is 7.5g/dl & his blood film is leuco-erythroblastic Most likely diagnosis A.Sarcoidosis B.Bacterial endocarditis C.Malaria D.CML E.Metastatic carcinoma F.IDA G.Idiopathic myelofibrosis H.Hodgkin’s disease I.Portal hypertension J.Gaucher’s disease K.Polycythaemia L.Infectious mononucleosis
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.
Beta-blockers e.g atenolol Frequent side effect? A.Indigestion and GI bleed B.Dry cough C.Cold toes and fingers D.Gynaecomastia E.Goitre F.Swelling of feet and ankles G.Nausea and vomiting H.Peripheral neuropathy I.Tremor J.Constipation and dry mouth
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.
Erythromycin Frequent side effect A.Indigestion and GI bleed B.Dry cough C.Cold toes and fingers D.Gynaecomastia E.Goitre F.Swelling of feet and ankles G.Nausea and vomiting H.Peripheral neuropathy I.Tremor J.Constipation and dry mouth
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.
A 78 year old woman attends complaining of recent onset of tiredness. She is pale, has hepatosplenomegaly and generalised painless lymphadenopathy in the neck, axillae and groin. Coombs’ (DAT) test is positive. Most likely diagnosis A.Portal vein thrombosis B.Systemic amyloidosis C.Malaria D.Severe emphysema E.Cirrhosis with hepatoma F.Haemachromatosis G.Toxoplasmosis H.Polycythaemia rubra vera I.CML J.RA K.Malignant melanoma L.CLL M.Right heart failure
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.
A 78 year old woman attends complaining of widespread itching. Examination reveals hepatosplenomegaly. The patient appears plethoric with no lymphadenopathy Most likely diagnosis A.Portal vein thrombosis B.Systemic amyloidosis C.Malaria D.Severe emphysema E.Cirrhosis with hepatoma F.Haemachromatosis G.Toxoplasmosis H.Polycythaemia rubra vera I.CML J.RA K.Malignant melanoma L.CLL M.Right heart failure
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.
A 52 year old patient, 24hours post laparotomy for perforated duodenal ulcer is found to have a pulse of 120bpm and BP 95/40mmHg. He is apyrexial and is WCC is 1.5units Most likely cause of hypotension Hypovolaemia Pulmonary oedema MI Cardiac dysrhythmia Drugs Sepsis ARDS Aortic stenosis DKA SIADH
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.
An 85 year old man presented with perforated diverticular disease in the sigmoid colon. After resuscitation he had an emergency procedure. What is the most likely procedure? A.Parastomal hernia B.Hartmann’s procedure: End colostomy C.Defunctioning loop ileostomy D.Prolapsed colostomy E.Ileal conduit F.Loop colostomy G.End ileostomy H.Subtotal colectomy and end ileostomy I.Loop ileostomy
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.
A 65 year old man undergoes elective excision of a rectal carcinoma and primary anastomosis. He is left with a stoma. What is the most likely procedure? A.Parastomal hernia B.Hartmann’s procedure: End colostomy C.Defunctioning loop ileostomy D.Prolapsed colostomy E.Ileal conduit F.Loop colostomy G.End ileostomy H.Subtotal colectomy and end ileostomy I.Loop ileostomy
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.
A 25 year old man with a history of ulcerative colitis, deteriorates and requires and emergency operation to treat the disease. What is the most likely procedure? A.Parastomal hernia B.Hartmann’s procedure: End colostomy C.Defunctioning loop ileostomy D.Prolapsed colostomy E.Ileal conduit F.Loop colostomy G.End ileostomy H.Subtotal colectomy and end ileostomy I.Loop ileostomy
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.
A 72 year old woman has a disseminated malignancy of the colon. She is suffering from abdominal distention and increasing constipation. She has a procedure before going on to palliative care. What is the most likely procedure? A.Parastomal hernia B.Hartmann’s procedure: End colostomy C.Defunctioning loop ileostomy D.Prolapsed colostomy E.Ileal conduit F.Loop colostomy G.End ileostomy H.Subtotal colectomy and end ileostomy I.Loop ileostomy
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.
Low calcium, Low phosphate, High PTH, High ALP Most likely diagnosis? A.Osteomalacia B.Paget’s disease C.Sarcoidosis D.Osteoporosis E.Hypercalcaemia of malignancy F.Immobility G.Hypoparathyroidism H.Primary hyperparathyroidism I.Myeloma
Osteomalacia
High calcium, Low phosphate, Normal PTH, High ALP Most likely diagnosis A.Osteomalacia B.Paget’s disease C.Sarcoidosis D.Osteoporosis E.Hypercalcaemia of malignancy F.Immobility G.Hypoparathyroidism H.Primary hyperparathyroidism I.Myeloma
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.
Normal calcium, Normal phosphate, High PTH, Very high ALP Most likely diagnosis? A.Osteomalacia B.Paget’s disease C.Sarcoidosis D.Osteoporosis E.Hypercalcaemia of malignancy F.Immobility G.Hypoparathyroidism H.Primary hyperparathyroidism I.Myeloma
Paget’s disease
High calcium, Normal phosphate, Slightly low PTH , High ALP Most likely diagnosis? A.Osteomalacia B.Paget’s disease C.Sarcoidosis D.Osteoporosis E.Hypercalcaemia of malignancy F.Immobility G.Hypoparathyroidism H.Primary hyperparathyroidism I.Myeloma
Hypercalcemia of malignancy
Normal calcium, Normal phosphate, Normal PTH, Normal ALP Most likely diagnosis A.Osteomalacia B.Paget’s disease C.Sarcoidosis D.Osteoporosis E.Hypercalcaemia of malignancy F.Immobility G.Hypoparathyroidism H.Primary hyperparathyroidism I.Myeloma
Osteoporosis
A 66 year old alcoholic man has a firm irregular liver, testicular atrophy, splenomegaly, a normocytic normochromic anaemia & thrombocytopaenia. Most likely diagnosis? A.Glucose-6-phosphate dehydrogenase deficiency B.Haemolytic uraemic syndrome C.Hereditary spherocytosis D.Thalassaemia major E.Sickle cell trait F.Sickle cell anaemia G.Dietary folic acid deficiency H.Blood loss I.Iron deficiency J.Anaemia of chronic disease K.Pernicious anaemia L.Coeliac disease
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.
A 51 year old manic depressive man, who has taken an unknown number of extra lithium tablets & has a plasma lithium level of 8 mmol/l. There are marked neurological features. Most appropriate management A.Hyperbaric oxygen B.Sodium calcium edetate C.Intravenous atropine D.None E.Haemodialysis F.IV N-acetylcysteine G.Intravenous naloxone H.Oral desferrioxamine I.Alkaline diuresis J.Ethanol K.Dicobalt edetate
Haemodialysis Haemodialysis is the treatment of choice for severe lithium poisoning. Note that activated charcoal does not adsorb lithium.
A 14 year old girl who has taken at least 30 aspirin tablets (300mg each). Most appropriate management A.Hyperbaric oxygen B.Sodium calcium edetate C.Intravenous atropine D.None E.Haemodialysis F.IV N-acetylcysteine G.Intravenous naloxone H.Oral desferrioxamine I.Alkaline diuresis J.Ethanol K.Dicobalt edetate
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.
A 38 year old agricultural worker who has been accidentally exposed to an organophosphorous insecticide & has symptoms of cholinergic overactivity. Most appropriate management A.Hyperbaric oxygen B.Sodium calcium edetate C.Intravenous atropine D.None E.Haemodialysis F.IV N-acetylcysteine G.Intravenous naloxone H.Oral desferrioxamine I.Alkaline diuresis J.Ethanol K.Dicobalt edetate
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.
A 70 year old man after a laparotomy has been given 4L of dextrose/saline intravenously in 24 hours. He is tachypnoeic, with BP 130/90, pulse 120/min & has bilateral basal crepitations. Most appropriate initial management Intravenous saline Administer diuretics Blood transfusion Measure blood gases Intravenous sodium bicarbonate Intravenous dextrose Measure urea & electrolytes Intravenous plasma Intravenous colloid
Administer diuretics This patient has developed pulmonary oedema. This patient should be positioned upright and given diuretics (frusemide).
A 20 year old man has been involved in a road traffic accident & the ambulance has just arrived. He has severe left upper abdominal tenderness, blood pressure 80/60 & pulse 140/min. Most appropriate initial management Intravenous saline Administer diuretics Blood transfusion Measure blood gases Intravenous sodium bicarbonate Intravenous dextrose Measure urea & electrolytes Intravenous plasma Intravenous colloid
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.
Which 1 of the following about ECG is correct? A) ST depression and tall R waves in leads V1 + V2 is consistent with a diagnosis of a posterior myocardial infarction. B) The corrected QT interval = QT/RR interval C) Obesity causes low-voltage QRS complexes D) 2 mm ST elevation in leads II, III, aVF, V4 + V5 is consistent with an inferior MI E) S1Q3T3 is a common finding in patients diagnosed with a PE
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.
Which is true? A) The long saphenous vein runs from the sapheno-femoral junction to the medial malleolus. B) The sapheno-femoral junction is 1cm lateral and 1cm inferior to the pubic tubercle. C) The profunda femurs can be harvested and used as a replacement artery for CABG D) A saphena varix classically transmits a cough impulse and disappears when the patient is asked to stand up. E) The Trendelenburg test is useful for assessing the competence of the SFJ
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.
You are undertaking a placement in a family planning clinic during your GP rotation. Which 1 is true? A) Condoms have a success rate of only 90%, even when used to their maximal effectiveness. B) Failure rates of male surgical sterilisation are worse than female surgical sterilisation. C) The combined OCP can be used to treat acne vulgaris. D)Breast cancer is not a contraindication for the used of the combined OCP E) Mrs Smith, a 35 year old who smokes 20 cigarettes a day, can be safely started on the combined OCP.
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.
A 56 year old lady presents with progressive tiredness, malaise and general apathy. She also states that her motions have been much looser recent and it is painful for her to eat. O/E she has difficulty appreciating sensation distally and FBC shows an Hb of 9g/dL and an MCV of 125fl. Underlying diagnosis? a) hypothyroidism b) hyperthyroidism c) pernicious anaemia d) Addison’s disease e) Stomach carcinoma
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.
You are an F1 reviewing patients in the Derm clinic. You are reviewing Mrs Jones, a 32 year old patient originally from Australia who has had long-standing pompholyx affecting her fingers. During this attendance she says that her husband has noticed a new mole on her back which has been bleeding on contact. Which is true about melanoma? A) Nodular melanoma is a highly aggressive form of the disease B) Superficial spreading melanoma, despite its name, exhibits vertical spread before lateral spread. C) Clark’s thickness represents thickness of the tumour depth D) Patients with metastatic disease have a 5 year survival of >90% E) Colour variegation should not raise suspicion as it is present in moles as well as melanoma.
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.
A worried parent brings her 15 year old daughter to see you in GP. The mother is concerned that her daughter is becoming increasingly thin and gaunt and has lost a considerable amount of weight after going on a crash diet. The patient feels that she is overweight and no amounts if reasoning by her parents change her beliefs. She has restricted the types and amounts of food she eats and exercises excessively. Her weight is 80% predicted for her age, height and sex. Which is true of the underlying diagnosis? a) 50:1 female:male affected b) Amenorrhoea often precedes weight loss c) Commoner in lower socio-economic groups d) Marked increase in sexual activity e) In adults a BMI of
B) This is anorexia nervosa A - 1:10 C - This affects higher socio-economic groups more. D - ? E - BMI
A 40 year old woman has been diagnosed with grand map epilepsy was started on treatment after her second episode. You are an F2 in the Neurology clinic and she meets you for the first time. She complains that her old shoes no longer fit and that her hair seems to have thinned over the pst few months. She also complains that she is feeling more tired and has to take afternoon naps to keep going. O/E you note that she is slightly overweight and on direct questioning she admits her weight sees to have increased, although denies a change of diet. She also appears to have a mild tremor. Which 1 is most likely in this patient? A) Has underlying pituitary disorder B) Features should raise suspicions of underlying depression C) Features consistent with carbamazepine D) Features consistent with sodium valproate treatment E) Features consistent with lamotrigine treatment.
D) Sodium valproate side effects: WHAAT Weight again Hyperammonaemia (including N+V & malaise) Ankle swelling Ataxia + tremor Thinning hair
A 32 year old housewife is referred to the GI clinic with a 2 year history of GI complaints. Which of the following is most useful in her history in establishing an organic diagnosis? A) Tenesmus B) Mucus per rectum C) Dyspareunia D) Abdo bloating E) Weight loss
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.
Which disease has the highest incidence of positive rheumatoid factor? A) Sjogren syndrome B) Acute RA C) Systemic sclerosis D) SLE E) PBC
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.
A patient presents acutely with a red eye and is in a significant amount of pain, with a marked degree of photophobia. The patient also blurred vision and floaters. Which is the most likely in the above patient? A)Viral conjunctivitis B) Bacterial conjunctivitis C) Open angle glaucoma D) Closed angle glaucoma E) Uveitis
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.
A female patient attends A+E because of worsening SOB which is associated with worsening rhinitis and sinusitis. O/E she has a lesion of the facial nerve on the right. Blood tests showed a markedly raised eosinophil count with raised ESR. She says that her GP sent her for a CXR in the past for similar symptoms and it was reported as abnormal. Most likely? A) Allergic asthma B) Polyarteritis nodosa C) infective exacerbation of asthma D) Churg-strauss syndrome E) SLE
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.
Which is most likely to hear wide fixed splitting of S2 on auscultation? A) RBBB B) Atrial septal defect C) VSD D) LBBB E) Patent ductus arteriosus
B RBBB + VSD cause wide but not classically fixed splitting. LBBB and PDA cause reverse splitting of S2
Which is true? A) Loop diuretics exert their effect by acting on Na/K/HCO3 channels in the thick ascending limb of the loop of Henle B) Amiloride promotes K reabsorption in the collecting duct, accounting for its K sparing effects. C) Metolazone is a powerful thiazide diuretic used in severe and resistant HF D) Flecainide is the agent of choice in patients with AF and a background of coronary heart disease E) Patients on amiodarone should have regular check ups on their thyroid and renal function.
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.
Which is true about delirium? A) Confusion tends to get better as the day progresses B) Sensory deprivation is a risk factor for development of delirium C) Visual hallucinations are suggestive of an alternative diagnosis D) Haloperidol is absolutely contraindicated in the management of delirium E) Vast majority of patients with delirium have underlying dementia
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.
How many weeks post-operatively does abdominal wound dehiscence occur?
2
A hernia where only part of the bowel wall is in the sac. What type of hernia is it? A.Obstructed hernia B.Sliding hernia C.Spigelian hernia D.Strangulated hernia E.Incarcerated hernia F.Incisional hernia G.Saphena varix H.Richter’s hernia I.Femoral artery aneurysm
Sliding hernia
A hernia where the sac does not envelope all of the hernial contents What type of hernia is it? A.Obstructed hernia B.Sliding hernia C.Spigelian hernia D.Strangulated hernia E.Incarcerated hernia F.Incisional hernia G.Saphena varix H.Richter’s hernia I.Femoral artery aneurysm
Richter’s hernia
Lymph nodes in the neck are described in relation to the major veins in the neck True or False
True
Rodent ulcer and basal cell carcinoma are two different names for the same condition True or False
True
A pilonidal abscess typically occurs in the umbilicus of hairy individuals True or False
False It occurs in the natal cleft
Malignant melanoma can be difficult to distinguish from a bruise True or False
True. Both are characterised by blotchy discolouration of the skin.
Thyroid goitre typically has a fine, diffuse irregularity throughout True or False
True
A lump on the dorsum of the wrist that is fluctuant is typical of a…
Ganglion
A rare lump not present at birth but appearing early in life, containing glary fluid and cholesterol crystals. A) Pleomorphic adenoma B) Chemodectoma C) Dermoid cyst D) Cystic hygroma E) Branchial cyst
Branchial cyst
This lump presents in early infancy. It consists of many lymph-filled spaces and is brilliantly translucent. It increases in size upon coughing. A) Pleomorphic adenoma B) Chemodectoma C) Dermoid cyst D) Cystic hygroma E) Branchial cyst
Cystic hygroma
A carotid body tumour occurring at the carotid bifurcation. A) Pleomorphic adenoma B) Chemodectoma C) Dermoid cyst D) Cystic hygroma E) Branchial cyst
Chemodectoma
The commonest salivary tumour that is benign. A) Pleomorphic adenoma B) Chemodectoma C) Dermoid cyst D) Cystic hygroma E) Branchial cyst
Pleomorphic adenoma
A 28-year-old man presents with a lump in the posterior triangle of his neck. He mentions that he has had difficulty finishing his meals and sometimes regurgitates his food at night. On palpation of the lump you hear a gurgling sound. Diagnosis A.Cervical rib B.Pharyngeal pouch C.Cystic hygroma D.Carotid body tumour E.Sternocleidomastoid tumour F.Dermoid cyst G.Torticollosis H.Goitre I.Thyroglossal cyst
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.
A 32-year-old basketball player presents with pain and paraesthesia down the medial aspect of his left arm. He claims his symptoms worsen when he raises her arms for a slam dunk. On examination, there is a firm lump at the base of his neck on the left side. Diagnosis A.Cervical rib B.Pharyngeal pouch C.Cystic hygroma D.Carotid body tumour E.Sternocleidomastoid tumour F.Dermoid cyst G.Torticollosis H.Goitre I.Thyroglossal cyst
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.
A 3-month year old boy is brought into the clinic by his parents. He has a lump at the base of the neck, posterior to the left sternocleidomastoid muscle. On examination, it is compressible and transilluminates brilliantly. Most likely diagnosis A.Cervical rib B.Pharyngeal pouch C.Cystic hygroma D.Carotid body tumour E.Sternocleidomastoid tumour F.Dermoid cyst G.Torticollosis H.Goitre I.Thyroglossal cyst
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).
A 2-month-year-old boy is brought in to see you by his parents as they are worried about a lump in the right side of his neck. On examination you notice that the lump is hard and fixed to the underlying muscle and the baby’s head is tilted towards it. Diagnosis A.Sternocleidomastoid tumour B.Sialolithiasis C.Goitre D.Salivary duct carcinoma E.Dermoid cyst F.Lymphoma G.Thyroglossal cyst H.Branchial cyst
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.
A 25-year-old man presents with a painful swelling which bulges from beneath the anterior border of his left sternomastoid muscle. On examination, it is soft and fluctuant, but tender. He says it has been present since childhood and only started causing him trouble following a respiratory infection. Diagnosis A.Sternocleidomastoid tumour B.Sialolithiasis C.Goitre D.Salivary duct carcinoma E.Dermoid cyst F.Lymphoma G.Thyroglossal cyst H.Branchial cyst
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.
A 60-year-old man complains of a lump in the groin. He says it enlarges if he coughs or laughs. On examination, he has an expansile mass just lateral to the femoral vein, which transmits a pulse. The mass is irreducible. Diagnosis A.Femoral hernia B.Femoral artery aneurysm C.Psoas abscess D.Direct inguinal hernia E.Indirect inguinal hernia F.Saphena varix G.False femoral artery aneurysm H.Inguinal lymphadenopathy
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.
A 35-year-old Indian man presents with a swelling lateral to the femoral artery. On examination it is tender and fluctuant, but cannot be reduced. He also describes a recent history of weight loss and night sweats. Diagnosis A.Femoral hernia B.Femoral artery aneurysm C.Psoas abscess D.Direct inguinal hernia E.Indirect inguinal hernia F.Saphena varix G.False femoral artery aneurysm H.Inguinal lymphadenopathy
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.
A 63-year-old man with Von Recklinghausen’s disease presents with pain in his left thigh. On examination, there is a hard well-defined swelling lying lateral to the femoral artery. There is no cough impulse and it is irreducable. Pressure on the swelling reproduces the pain in the thigh. Diagnosis A.Caecal carcinoma BDirect inguinal hernia C.Crohn’s disease D.Femoral aneurysm E.Indirect inguinal hernia F.Strangulated femoral hernia G. Ectopic testis H.Femoral neuroma
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.
A 16-year-old boy presents with sudden onset severe pain in his right scrotum and vomiting. On examination, the right testis appears swollen and is hanging higher than the left. Diagnosis A.Torsion of the hyatid of Morgagni B.Epididymo-orchitis C.Testicular torsion D.Hydrocele E.Teratoma F.Varicocele G.Mumps orchitis H.Seminoma
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
A 49-year-old man complains of grandually enlarging painless swelling of his left scrotum. HE says it has been present for at least 2 years. On examination, the testis is impalpable, but it is possible to get above the swelling. The swelling transilluminates brightly. Diagnosis A.Torsion of the hyatid of Morgagni B.Epididymo-orchitis C.Testicular torsion D.Hydrocele E.Teratoma F.Varicocele G.Mumps orchitis H.Seminoma
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.
A 28-year-old man complains of a ‘dragging’ sensation and slight discomfort in his scrotum. On examination, the swelling is located above the testis, but is limited to the scrotum. It disappears when the patient lies flat, but there is no cough impulse. Diagnosis A.Torsion of the hyatid of Morgagni B.Epididymo-orchitis C.Testicular torsion D.Hydrocele E.Teratoma F.Varicocele G.Mumps orchitis H.Seminoma
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.
A 35-year-old man with a history of undescended testis presents with a hard painless testicular lump. Blood tests shown an elevated β-human chorionic gonadotrophin. A.Torsion of the hyatid of Morgagni B.Epididymo-orchitis C.Testicular torsion D.Hydrocele E.Teratoma F.Varicocele G.Mumps orchitis H.Seminoma
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.
A 20-year-old man complains of mild pain in his left testicle after playing cricket in the park. On examination the left testicle is irregular in shape compared to the right. He reports having an orchidopexy when he was younger. Diagnosis A.Torsion of the hyatid of Morgagni B.Epididymo-orchitis C.Testicular torsion D.Hydrocele E.Teratoma F.Varicocele G.Mumps orchitis H.Seminoma
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.
A 53-year-old woman presents with mass below the angle of the jaw. She sayd it has been gradually increasing in size for the past 6 months. On examination, it is mobile and firm to the touch. There is no associated pain or facial weakness. Investigation Ultrasound Carotid angiography Fine-needle aspiration Excision biopsy Doppler ultrasound Sialogram Iodine uptake scan Technetium scan
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.
A 16-year-old boy presents with a painless lump on the anterior border of the upper sternocleidomastoid on the left side. On examination, it is smooth and fluctuant, but does not transilluminate. He says that it previously became painful during a throat infection, but hasn’t bothered him since. There are no other abnormalities. Investigation Ultrasound Carotid angiography Fine-needle aspiration Excision biopsy Doppler ultrasound Sialogram Iodine uptake scan Technetium scan
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.
A 70 year old male life long smoker complains of painless haematuria to his GP Diagnosis A.Urinary tract infection B.Ureteric colic C.Prostate cancer D.Renal cell carcinoma E.Prostatic varices F.Bladder cancer G.Trauma H.Acute pyelonephritis
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.
An 81-year-old male complains of haematuria. He has been an inpatient for 3 weeks following admission for a left hip replacement due to osteoarthritis. His catheter was removed two days ago as he is becoming increasingly mobile. Diagnosis A.Urinary tract infection B.Ureteric colic C.Prostate cancer D.Renal cell carcinoma E.Prostatic varices F.Bladder cancer G.Trauma H.Acute pyelonephritis
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.
A 56 year old smoker complains of seeing bright red blood when he passes water. He mentions no pain but did have a UTI 5 years ago. Diagnosis A.Henoch-Schonlein purpura B.Waldenstrom’s macroglobinaemia C.Bladder cancer D.Goodpasture’s disease E.Nephrotic syndrome F.Post infectious glomerulonephritis G.Ureteric colic H.UTI I.Pseudo-haematuria
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.
A 5 year old boy has haematuria and a non-blanching rash over his upper thighs Diagnosis A.Henoch-Schonlein purpura B.Waldenstrom’s macroglobinaemia C.Bladder cancer D.Goodpasture’s disease E.Nephrotic syndrome F.Post infectious glomerulonephritis G.Ureteric colic H.UTI I.Pseudo-haematuria
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.
A 60 year old obese man presents to A&E with a history suggesting biliary colic. His medical history includes hypertension (treated with an ACE inhibitor) and dyslipidaemia. She smokes regularly and drinks alcohol socially. Abdominal ultrasound demonstrates gallstones as well as a 6cm left-sided renal mass. On further questioning, there has been haematuria. Diagnosis A.HIV B.Hyperkalaemia C.Benign renal cyst D.Polycystic kidney disease E.Pyelonephritis F.Chronic kidney disease G.Bladder cancer H.Rhabdomyolysis I.Ureteric cancer J.UTI K.Renal artery stenosis L.Renal cell carcinoma M.Renal tuberculosis
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.
A man comes to clinic complaining of weight gain and a cut on his leg that just won’t heal. He has various blood tests performed including a CRH (corticotrophin releasing hormone) stimulation test. His ACTH and cortisol are both shown to rise. Diagnosis A.Adrenal adenoma B.Tuberculosis C.Diabetes Insipidus D.Addison’s disease E.Addisonian crisis F.pituitary apoplexy G.Nelson’s syndrome H.Cushing’s disease I.Ectopic ACTH producing tumour J.Sheehan’s syndrome K.Drug withdrawal L.Conns Adenoma
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.
A Woman who has been complaining of worsening loss of peripheral vision for months suddenly takes a turn for the worse. She has an intense headache come on suddenly at home, by the time she is driven to hospital she has vomited a number of times and now complains of double vision. Her blood pressure also falls drastically. She is managed initially with hydrocortisone iv. and N. saline. Thyroxine follows. A Lumbar puncture is requested, it shows Xanthochromia. Diagnosis? A.Adrenal adenoma B.Tuberculosis C.Diabetes Insipidus D.Addison’s disease E.Addisonian crisis F.pituitary apoplexy G.Nelson’s syndrome H.Cushing’s disease I.Ectopic ACTH producing tumour J.Sheehan’s syndrome K.Drug withdrawal L.Conns Adenoma
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.
An overweight 60 year old lady is seen in clinic complaining of tiredness and general weakness, her eyesight is also suffering, she says she can’t see the room if she looks at a book and it’s getting worse. Physical examination reveals multiple scars on her abdomen, they are noted to be dark, in stark contrast to her purple striae. The notes show the patient was on metyrapone and aminoglutethamide before her surgery. Diagnosis? A.Adrenal adenoma B.Tuberculosis C.Diabetes Insipidus D.Addison’s disease E.Addisonian crisis F.pituitary apoplexy G.Nelson’s syndrome H.Cushing’s disease I.Ectopic ACTH producing tumour J.Sheehan’s syndrome K.Drug withdrawal L.Conns Adenoma
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.
A woman developed pre-eclampsia during her first pregnancy, she also required syntocin and several units of blood during the birth. 4 months after the birth she still had not resumed menstruation and felt generally tired. She also noticed loss of pubic hair Diagnosis A.Adrenal adenoma B.Tuberculosis C.Diabetes Insipidus D.Addison’s disease E.Addisonian crisis F.pituitary apoplexy G.Nelson’s syndrome H.Cushing’s disease I.Ectopic ACTH producing tumour J.Sheehan’s syndrome K.Drug withdrawal L.Conns Adenoma
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.
Addisons can be caused by Cytomegalovirus (CMV)? True or False
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.
Phaechromocytomas are [blank-1] tumours originating usually from the adrenal [blank-2], they are usually [blank-3] though around 10% are [blank-4]. Following the rule of 10s, 10% of cases are also bilateral and 10% are extradrenal and 10% recur. [blank-5] of Phaechromocytomas are associated with familial gene mutations. In particular phaeos are seen in [blank-6] and [blank-7], it also features in [blank-8] though not [blank-9]. MEN 2B 25% benign medulla von hippel lindau - VHL malignant MEN 2A MEN 1 neuroendocrine
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
ADH is produced by the adenohypophysis? True or False
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.
A man complaining of vague abdominal pain + general lethargy has a short SynACTHen test performed. Pre test cortisol was 200mM 30 minutes after administration of tetracosactide the serum cortisol is 370mM Pick the most appropriate conclusion.. Primary adrenal insufficiency Normal response Secondary adrenal insufficiency
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.
Reduction of the HbA1c from 8% to 7% in diabetic reduces the risk of microvascular complications by approximately..? A) 20% B) 40% C) 5% D) 60%
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.
A pregnant woman in her second trimester has a diffusely enlarged goitre with an audible bruit, she is currently thyrotoxic and carbimazole isn’t working as well as hoped. The doctors want to treat her with something in preparation for surgery. Appropriate treatment A.Radioiodine B.Stop treatment C.Potassium Iodide D.Carbimazole E.Surgical decompression F.Propylthiouracil G.Propranolol
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.
A man is seen in the endocrinology clinic for his thyroid condition. He has the ‘thyroid stare’ and closer inspection of his eyes shows the optic disc is pale and swollen. Appropriate treatment A.Radioiodine B.Stop treatment C.Potassium Iodide D.Carbimazole E.Surgical decompression F.Propylthiouracil G.Propranolol
Surgical decompression There is significant retroorbital oedema and fibrosis around the optic nerve, decompressive surgery should help relieve this and prevent further atrophy.
An 80 year old woman is brought into hospital following a house visit. She was initially confused, but in hospital she is found to be hypoventilating, her bloods show low BMs and hyponatraemia. Drs order hydrocortisone and liothyronine sodium Diagnosis A.Addisonian crisis B.Myxoedema coma C.Grave’s D.Hashimoto’s thyroiditis E.Thyroxine abuse F. External neck irradiation G. De Quervains thyroiditis H.Amiodarone
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
A 46-year-old man attends for outpatient assessment following referred by his GP. He complains of an episodic sudden onset of very a fast pulse rate, and a fluttering sensation within his chest. He takes his pulse at the time and states the rate can be greater than 200 beats per minute. Each episode lasts typically for few minutes and then reverts spontaneously. His GP had requested a 24 hour tape recording, but this was normal. Diagnosis a. Atrial fibrillation b. Aortic stenosis c. Aortic incompetence d. Mitral stenosis e. Supraventricular tachycardia f. Complete heart block g. Benign ventricular ectopics h. Anxiety
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.
An 84 year old farmer is admitted to the acute medical receiving unit with dizzy spells. His pulse is very slow and irregular. His blood pressure is 120/80 mmHg. There are intermittent irregular visible pulsations noted on inspection of his venous pressure Diagnosis a. Atrial fibrillation b. Aortic stenosis c. Aortic incompetence d. Mitral stenosis e. Supraventricular tachycardia f. Complete heart block g. Benign ventricular ectopics h. Anxiety
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.
Which of the following methods can be used to confirm the diagnosis of asthma? 1. PEF monitoring to detect diurnal variation 2. Assessing the response to a trial of inhaled / oral steroids for 2 weeks 3. Full history only 4. Positive exercise testing 5. Assessing the spirometry response to inhaled bronchodilators
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
Which of the following are recommended non-pharmacological methods of asthma management? 1. Smoking cessation 2. Weight reduction 3. Immunotherapy 4. Complimentary therapies 5. Allergen avoidance 6. Dietary manipulation
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
Which of the following are signs of COPD? 1. Mucous gland hypoplasia 2. Chronic inflammation and fibrosis 3. Emphysema 4. Thinning pulmonary alveolar walls and wall remodelling
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
Which of the following are recommended non-pharmacological methods of treating COPD? 1. Smoking Cessation 2. Exercise Restriction 3. Pulmonary Rehabilitation 4. Diet 5. Education 6. Psychosocial Support
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
A 36 year old baker presents to his GP complaining of shortness of breath and cough. He says he has noticed it becoming worse over the last 9 months, since he has started his new job, but it does not bother him so much at weekends. Diagnosis A.Cystic fibrosis B.EAA C.Bronchiectasis D.Sarcoidosis E.Tuberculosis F.Foreign body inhalation G.Asthma H.Community acquired pneumonia I.RSV infection J.Epiglottitis K.Aspergillosis L.Pertussis
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.
A 43 year old businessman who has just returned from a conference in Cuba presents to his GP with a dry cough and dypnoea lasting 2 days. He reports having felt generally unwell for the last 3 days before his cough started. LFTs are deranged, and CXR shows bibasal consolidation. Diagnosis A.Allergic bronchopulmonary aspergillosis B.RSV infection C.ACE inhibitors D.Tuberculosis E.Bronchial asthma F.Cystic fibrosis G.Foreign body inhalation H.COPD I.Bronchial carcinoma J.Malaria K.Legionella pneumonia L.Beta-blockers
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.
A 27 year old Eastern-European man presents to you following an episode of coughing up blood. He has been experiencing a persistent cough, producing copious amounts of purulent sputum. He says he suffered from measles last winter, but has otherwise always been a healthy person. On examination you can hear coarse inspiratory crepitations. The radiologist reports cystic shadows and thickened bronchial walls on CXR. Diagnosis A.Tuberculosis B.Pulmonary embolism C.Post-intubation D.Sarcoidosis E.Bronchiectasis F.Pancoast tumour G.Pulmonary oedema H.Cystic fibrosis I.Bronchial carcinoma J.Goodpasture’s syndrome K.Amyotrophic lateral sclerosis
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.
What are the 5 commonest sites of metastasis of lung cancer?
Skin Bone Adrenals Liver Brain
A 29 year old patient is rushed to A+E with respiratory distress. His wife says he started coughing and gasping for breath, and that he was recently prescribed antibiotics for a throat infection. Diagnosis A.Cystic fibrosis B.EAA C.Bronchiectasis D.Sarcoidosis E.Tuberculosis F.Foreign body inhalation G.Asthma H.Community acquired pneumonia I.RSV infection J.Epiglottitis K.Aspergillosis L.Pertussis
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.
A young man involved in a RTA is brought into A&E with multiple injuries to his face. On examination, his eyes do not open to pain. He withdraws his left side to pain but his right side does not move at all. His right pupil is fixed, dilated and non-reactive. Diagnosis A.Hyperglycaemia B.Pancreatitis C.Hypoglycaemia D.Wernicke’s encephalopathy E.Anxiety attack F.Hypertension G.Subdural haematoma H.Pulmonary fibrosis I.Delirium tremens J.Acute gastritis K.Wolff-Parkinson-White syndrome L.Convulsions M.Atrial fibrillation N.Oesophageal varices
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.
Mrs Loren, 26, gave birth to a healthy boy a week ago. She is attempting to breast feed but is having some difficulty. Over the past 24 hours, she felt like she had influenza coming on. She has a 5cm, very tender mass in her right breast and there is erythematous skin overlying this. Diagnosis A.Lipoma B.Basal cell carcinoma C.Radial scar D.Breast abscess E.Carcinoma of the breast F.Fibroadenosis G.Adenoma H.Sebaceous cyst I.Intraductal papilloma J.Breast bud K.Phylloides tumour L.Fat necrosis M.Fibroadenoma
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.
An 8 year old boy is brought into A&E after falling from a tree while trying to retrieve his cat. The boy is crying and has periorbital bruising around his right eye and a small amount of blood in the right ear canal. His GCS is 15. A.Haemophilia B.HIV C.Clopidogrel D.Spontaneous E.Aplastic anaemia F.Wiskott-Aldrich syndrome G.Disulfiram H.Idiopathic thrombocytopenic purpura I.Skull fracture J.Diuretics K.Corticosteroids L.Hepatic cirrhosis
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.
A 34-year-old woman presents with irregular periods and weight gain. She had been on anti-depressants for six months and she had been complaining of tiredness. Pulse rate is 46/minute and regular. This is confirmed on ECG, which also shows low voltage. Diagnosis? A.Pregnancy B.Renal failure C.Amyloidosis D.Reduced activity E.Metabolic syndrome F.Addison’s disease G.Salt-wasting nephropathy H.Cushing’s syndrome I.Portal hypertension J.Comfort eating K.Heart failure L.Polycystic ovary syndrome M.Hypothyroidism
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.
A 45-year-old HCV positive Egyptian journalist presents with acute renal failure. He is complaining of increasing abdominal distension, pruritis, ankle oedema and weight gain. Serum albumin is low and there is hyponatraemia and thrombocytopenia. Diagnosis A.Pregnancy B.Renal failure C.Amyloidosis D.Reduced activity E.Metabolic syndrome F.Addison’s disease G.Salt-wasting nephropathy H.Cushing’s syndrome I.Portal hypertension J.Comfort eating K.Heart failure L.Polycystic ovary syndrome M.Hypothyroidism
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.
A middle-aged tramp presents in A&E intoxicated and confused. He has a half-finished bottle of vodka in his pocket. Additionally there is horizontal gaze palsy and severe ataxia with vertigo and headache. Diagnosis A.Fibromyalgia B.Delirium tremens C.Malnutrition D.Depression E.Peptic ulceration F.Wernicke’s encephalopathy G.Fatty liver H.Rhabdomyolysis I.Acute intoxication J.Cirrhosis K. Chronic subdural haematoma L.Macrocytosis
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.
83-year-old man with longstanding heart failure for which he takes Digoxin and diuretics. For the last 24 hours he has been vomiting and has passed very little urine. On examination he is pale and mildly dehydrated; examination of the abdomen is normal. Diagnosis A.Oesophageal cancer B.Pancreatitis C.Combined oral contraceptive pill D.Bowel obstruction E.Bulimia F.Pyloric stenosis G.Viral gastroenteritis H.Salmonella I.Peptic ulcer disease J.Uraemia K.Appendicitis L.Gastric cancer M.Intussusception
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.
A 25-year-old traveling salesman is awoken in his hotel with crampy abdominal pain, feeling very ill and vomits three times over the next half an hour. He asks the receptionist to call a doctor. Diagnosis A.Oesophageal cancer B.Pancreatitis C.Combined oral contraceptive pill D.Bowel obstruction E.Bulimia F.Pyloric stenosis G.Viral gastroenteritis H.Salmonella I.Peptic ulcer disease J.Uraemia K.Appendicitis L.Gastric cancer M.Intussusception
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.
A 25-year-old man presents with a 6 month history of painless enlargement of the left hemiscrotum. The swelling is fluctuant, translucent, confined to the scrotum, and the testis cannot be felt separately. Diagnosis A.Heart failure B.Squamous cell carcinoma C.Varicocele D.Testicular torsion E.Epididymo-orchitis F.Hydrocoele G.Epididymal cyst H.Undescended testicle I.Hernia J.Testicular TB K.Testicular malignancy
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).
A 70-year-old man present with mild dysuria, urinary hesitancy and terminal dribbling. He also has bilateral testicular pain, swelling and tenderness of both testes and epididymis. His temperature is 37.50ºC. Diagnosis A.Heart failure B.Squamous cell carcinoma C.Varicocele D.Testicular torsion E.Epididymo-orchitis F.Hydrocoele G.Epididymal cyst H.Undescended testicle I.Hernia J.Testicular TB K.Testicular malignancy
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.
An 80-year-old woman is admitted from a residential home with a two week history of purulent sputum and pyrexia (38ºC). Examination reveals a constant wheezing in inspiration and expiration localised over the right lung base. Diagnosis A.Pleural effusion B.Anaphylaxis C.Allergic alveolitis D.Bronchial adenoma E.Inhaled foreign body F.Cystic fibrosis G.COPD H.Pneumothorax I.Bronchial asthma J.Fibrosing alveolitis K.Influenza L.Left ventricular failure
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.
A 35-year-old woman has a 10-year history of low retrosternal dysphagia and painless regurgitation of food in the mouth Diagnosis A.Cerebrovascular accident B.Pharyngeal pouch C.Myasthenia gravis D.Hiatus hernia E.Plummer-Vinson syndrome F.Carcinoma of oesophagus G.Thyroid goitre H.Achalasia I.Gastric volvulus J.Pneumonia K.Carcinoma of bronchus
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?
A 45-year-old lady presents with retrosternal dysphagia. She has spoon-shaped nails and is noted to be pale. Diagnosis A.Cerebrovascular accident B.Pharyngeal pouch C.Myasthenia gravis D.Hiatus hernia E.Plummer-Vinson syndrome F.Carcinoma of oesophagus G.Thyroid goitre H.Achalasia I.Gastric volvulus J.Pneumonia K.Carcinoma of bronchus
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.
A 45-year-old man is found to have deranged liver function tests by his GP. As part of the investigations, the GP requested viral hepatitis serology:
Hepatitis A antibody - Negative
Hepatitis B core antibody - Positive
Hepatitis B surface antigen - Negative
Hepatitis C antibody - Positive
The following conclusion that can be made about the patient is:
A) He is a carrier for hepatitis A
B) He is a carrier for hepatitis B
C) He is a carrier for hepatitis C
D) He has been vaccinated against hepatitis B
E) He does not have viral hepatitis
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.
