Questions I got wrong from 2004 Flashcards
Diagnosis?
A 22-year-old woman, on treatment for nephrotic syndrome due to minimal change glomerulonephritis. She is concerned by increasing weight gain and easy bruising. Blood tests show plasma creatinine 65 μmol/L and albumin 31 g/L.
Cushing’s syndrome.
Corticosteroids remain the mainstay of treatment for minimal change disease and is given to all patients. Minimal change disease is the most common form of nephrotic syndrome in children and it is so named as there are minimal histological changes in renal tissue. 90% are idiopathic. Long term coricosteroid treatment here has induced iatrogenic Cushing’s syndrome with associated signs of hypercorticalism (weight gain and easy bruising). Corticosteroid-sparing therapies can be added here.
Diagnosis?
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.
Portal hypertension.
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.
What analgesia should NOT be used in the postoperative period?
An 85-year-old who is known to be hypertensive and has mild impaired renal function presents with signs of dehydration and undergoes a laparotomy for small bowel obstruction.
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.
What analgesia should NOT be used in the postoperative period?
A 60-year-old man with diabetes is transferred from another hospital for urgernt femoral-distal bypass surgery and arrives with a heparin infusion in situ. His APTT is 2.4.
Epidural bupivacaine and 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.
What analgesia should NOT be used in the postoperative period?
A 62-year-old man who requires a knee replacement gives a history of allergy to dihydrocodeine.
Codydramol.
Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
What analgesia should NOT be used in the postoperative period?
A 65-year-old man with a history of peptic ulceration requires an aortic aneurysm repair electively.
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.
Diagnosis?
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.
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.
Most appropriate treatment?
A 55-year-old Asian man complaining of nocturia. Random blood glucose 10.2 mmol/L. He was overweight.
Dietary advice alone.
This patient is symptomatic and has a random blood glucose of 10.2. This patient does not quite meet the diagnostic criteria for DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation, and in newly diagnosed DM is diet and lifestyle advice and changes.
Most appropriate treatment?
A 47-year-old man with diabetes for 10 years. At review, his BP was 130/80, a glycosylated haemoglobin was 8.2% (normal
Oral hypoglycaemic drug.
Careful dietary intervention has failed to keep HbA1c in check so the patient will need to be started on an oral hypoglycaemic drug. First line is metformin. It is worth noting that HbA1c values, since June 2011, are no longer expressed as a percentage and are now given in mmol/mol. HbA1c is glycated Hb and provides an estimation of glycaemic control over the life span of red blood cells (around 60 days). Fructosamine is measured instead if there is a Hb disorder or RBC life span is decreased as HbA1c is only reliable if normal Hb is present with normal RBC life spans. Fructosamine is a glycated plasma protein which provides information on glucose levels over the previous 1-3 weeks.
Diagnosis?
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.
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.
Diagnosis?
A 64-year-old diabetic man presents with sudden onset of severe SOB and cough productive of frothy sputum. Examination reveals BP 70/50 mmHg; P 90/min, faint wheeze and scattered fine rales.
Left ventricular failure.
DM is a cardiovascular risk factor. There are no expressed signs or symptoms of RVF here such as peripheral oedema, ascites, elevated JVP and hepatomegaly. Nocturia may be a symptom as fluid returns from the legs when the patient lies down flat. RVF leads to a backlog of blood and congestion of the systemic capillaries. LVF, on the other hand, causes congestion in the pulmonary circulation so the symptoms are respiratory. As seen in this patient, there is SOB and the classic cough productive of frothy sputum – a sign of pulmonary oedema. On respiratory examination, pulmonary oedema due to LVF may give audible fine late inspiratory crepitations at the bases. There may also be orthopnoea. This is why you can ask patients in a cardiac history how many pillows they sleep with. PND can also occur as well as ‘cardiac asthma’.
Initial investigations should include ECG, CXR, TTE and bloods including BNP levels. First line treatment is with an ACE inhibitor which reduces morbidity and mortality. Salt and fluid restriction is also beneficial. All patients with chronic heart failure will also receive a beta blocker such as carvedilol. Other adjuncts include spironolactone, diuretics, hydralazine and a nitrate, and digoxin. The NYHA classification criteria can be used based on symptoms to describe functional limitations and ranges from Class I to Class IV with symptoms occuring at rest. Many patients are asymptomatic for long periods of time because mild cardiac impairment is balanced by compensation.
Diagnosis?
A 65-year-old man had an inferior myocardial infarct 10days ago. His initial course was uncomplicated. He suddenly deteriorates with acute left ventricular failure. On examination the pulse is regular 100/min and normal volume and character. BP 110/60. The apex beat is dynamic. There is a loud grade 3/6, apical pansystolic murmur which radiates to the axilla.
Mitral regurgitation.
MR is loudest at the apex and radiates to the axilla and tends to be around grade 4. It is associated with a systolic thrill at the apex. TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaced apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.
Most appropriate professional to expedite discharge?
A 75-year-old woman was admitted to Care of the Elderly ward having had a couple of falls at home. No other medical problems are found. She lives on her own in a ground floor flat and has home help once a week.
Occupational therapist.
Occupational therapists will visit the patient’s home and help determine tools and facilities the patient can benefit from for their day to day life e.g. stairlifts, bath rails
Most appropriate professional to expedite discharge?
A 78-year-old woman was admitted six weeks ago with a fractured neck of femur. She lives with her husband in a first-floor flat with no lift. The nurses are worried how she is going to manage at home because she is not mobilising in the ward.
Physiotherapist.
Physiotherapists work with patients who have physical difficulties to identify and improve movement and function. This will involve, for example, encouraging movement and exercise using a range of techniques.
Most appropriate professional to expedite discharge?
A 65-year-old man with a long history of hypertension. He is admitted with sudden loss of speech. He is found to be aphasic and has minimal right-sided weakness. He is keen to go home.
Speech and language therapist.
Would you discharge this patient in their present state? This patient needs a swallowing assessment and speech therapy from a SALT. SALTs deal with disorders of speech, communication, language and swallowing. They are particularly useful after neurological impairments and conditions including stroke, head injury, Parkinson’s and dementia. In the film ‘The King’s Speech’ starring acclaimed actor and heartthrob Colin Firth, George VI gets help with his stammer from Logue who is a speech and language therapist.
Most appropriate professional to expedite discharge?
A 56-year-old man is admitted with chest pain. Exercise ECG is normal but his random blood sugar on admission was 23 mmol/l. He is overweight and being referred to the diabetic clinic as an outpatient.
Dietician.
This patient has possible DM (needs a second test result to be diagnostic or needs to be symptomatic). The first line intervention is dietary and lifestyle changes. The most useful person this patient will benefit from is a dietician who will be able to give him advice on his eating habits – a diet high in fibre and low in fat is recommended and to also cut, to a degree, carbohydrate intake or at least resort to carbohydrates with a high glycaemic index such as lentils and sweet potato. The GI measures the effect carbohydrates have on blood sugar levels – a lower GI has more of an impact on blood sugar levels in a shorter amount of time. Advice will also be given on how to deal with hypoglycaemic episodes if the patient is being treated with medication which predisposes to this risk, such as insulin.
Most appropriate professional to expedite discharge?
A 68-year-old diabetic woman with venous ulcers was admitted with cellulites. The acute infection has now cleared but she needs regular compression dressings to help the ulcers heal.
District nurse.
District nurses visit people in their homes or in care homes and provide care in that context. They also provide teaching in the community.
Always remember that an MDT ethos is needed for most cases. This is especially true for stroke patients.
Diagnosis?
A 35-year-old woman has a 10-year history of low retrosternal dysphagia and painless regurgitation of food in the mouth.
Hiatus hernia.
A hiatus hernia is where intraabdominal contents protrude through the oesophageal hiatus of the diaphragm. Risk factors inclyde 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?
Diagnosis?
A 45-year-old lady presents with retrosternal dysphagia. She has spoon-shaped nails and is noted to be pale.
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.
Diagnosis?
A 50 year old describes a 5 month history of heartburn and cramp-like chest pain relived by drinking cold water, both unrelated to food. There has also been intermittent dysphagia to both liquids and solids, regurgitation and weight loss of 2kg.
Achalasia.
This is achalasia which is a motility disorder with loss of peristalsis in the distal oesophagus and failure of the LOS to relax in response to swallowing. This presents commonly with dysphagia to both liquids and solids, regurgitation and retrosternal chest pain, which can be slowly progressive over time. In structural obstruction such as cancer, dysphagia to liquids is uncommon unless the disease is very advanced. Retrosternal pressure experienced can be precipitated by drinking liquids but is eased by continuing to drink, and the pain may be relieved by cold water. This may wake the individual from sleep. A UGI endoscopy is needed to exclude malignancy as a cause of dysphagia. The diagnosis is established on manometry or barium studies. Treatment is symptomatic.
Diagnosis?
A 22-year-old student went to Thailand on holiday. A week following his return, he presented to his GP with a flu like illness and high fever. His GP presumed it was flu and told him to go home. Two days later, he re-presented to A&E, this time vomiting.
Falciparum malaria.
In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This student has just returned from an endemic area. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. Hepatosplenomegaly is a common presenting sign although not common at presentation in a first world setting. Thrombocytopenia is common with falciparum infection and a mild degree of anaemia are commonly seen. WCC can be high, low or normal.
Dengue presents abruptly with typically headache and retrobulbar pain worsening with eye movement. There may also be a rash and leukopenia and thrombocytopenia are common.
Most appropriate initial management?
A 80-year-old woman is admitted with vomiting. Her blood pressure is 120/80 mmHg, pulse rate 90/min, with warm peripheries. Plasma urea is 25 mmol/l, and creatinine 120 μmol/l.
Intravenous saline.
This patient is very dehydrated
