Questions Part 1 Flashcards by Daniel Part

A 57-year-old woman with a history of gallstones presents with progressive right upper quadrant pain, rigors and jaundice.

Ascending cholangitis

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A 62-year-old presents with upper abdominal pain. She has recently been discharged from hospital where she underwent an ERCP to investigate cholestatic liver function tests. The pain is severe. On examination she is apyrexial and has a pulse of 96 / min.

Acute pancreatitis

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A 76-year-old woman presents with abdominal pain, distension and vomiting. She recently had an episode of acute cholecystitis and is awaiting a cholecystectomy. She feels her symptoms have returned over the past few days. On examination her abdomen is distended.

Gallstone ileus

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How do we treat torsades de pointes>

IV Magnesium Sulfate

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A 52-year-old man who was born in India presents with episodic haemoptysis. His only history is tuberculosis as an adolescent. Chest x-ray shows a rounded opacity in the right upper zone surrounded by a rim of air

Aspergilloma

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A 71-year-old woman presents with dyspnoea and haemoptysis for the past two weeks. Clinical examination reveals a loud first heart sound, a diastolic murmur and new-onset atrial fibrillation

Mitral stenosis

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A 62-year-old woman who is being investigated for renal impairment presents with haemoptysis. On examination she has a flat nose

Wegener’s granulomatosis

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A 24-year-old smoker presents with intermittent diarrhoea for the past 6 months. She feels bloated, especially around her periods. Bloods tests are normal.

Irritable bowel syndrome

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A 23-year-old student is admitted due to a two-week history of bloody diarrhoea. He is normally fit and well and has not been abroad recently. His CRP is raised at 56 on admission.

Ulcerative colitis

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A 72-year-old woman presents with a two day history of diarrhoea and pain in the left iliac fossa. Her temperature is 37.8ºC. She has a past history of constipation.

Diverticulitis

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Causes of pulmonary fibrosis

BREAST CA:
B - Bleomycin
R - Radiation
E - Extrinsic Allergic Alveolitis
A - Ankylosing Spondylitis
S - Sarcoidosis
T - TB

C - Cryptogenic Pulmonary Fibrosis (Idiopathic)
A - Asbestosis

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What pulse is seen in cardiac tamponade?

Paradoxical

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What pulse is seen in severe LFV?

Alternans

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What pulse is seen in Takayasu’s arteritis?

Absent

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A 74 year old woman has taken too much digoxin. What might be seen on CXR?

Reversed-tick-ST segment depression

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What ECG changes can erythromycin cause?

QT elongation

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A 25 year old man with central chest pain, tachycardia and sweating. He has taken cocaine.

Coronary artery spasm

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A 42-year old man with central chest pain. Movement exacerbates the pain and the anterior chest wall is tender.

Tietze’s Disease (costochondritis)

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What can chronically raised serum amylase cause?

Pancreatic pseudocyst

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A 35 year old housewife has noticed progressively worsening difficulty swallowing over a few years. She has been troubled with regurgitation of undigested food, halitosis and suffers fits of coughing when lying flat.

Achalasia

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A 45 year old pale woman complains that food is sticking in the back of her throat. On examination she has spoon-shaped nails, a smooth tongue and angular chelitis.

Plummer-Vinson Syndrome

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A 65 year old man complains of difficulty swallowing. He finds that the first mouthful of food is easy to swallow but thereafter he has progressive difficulty swallowing until he regurgitates undigested food. He also notices a neck swelling.

Pharyngeal pouch

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A 50-year-old woman presents with constant right upper quadrant pain, fever and yellowing of the sclera. She has a history of gallstones. She is jaundiced, pyrexial and has raised inflammatory markers

Ascending cholangitis

A 50-year-old woman presents with constant right upper quadrant pain. She has a history of gallstones. She is pyrexial and has raised inflammatory markers

Acute cholecystitis

Patients often have a history of atrial fibrillation or other cardiovascular disease. Diarrhoea, rectal bleeding may be seen. A metabolic acidosis is often seen (due to 'dying' tissue) Central abdominal pain

Mesenteric ischaemia

You are reviewing a patient with chronic obstructive pulmonary disease. Which one of the following best describes the vaccinations they should receive?

Annual influenza | One-off pneumococcal

In regard to prosthetic heart valves what is the recommended antithrombotic therapy?

Bioprosthetic: - Aspirin Mechanical: - Warfarin + Aspirin

A 72-year-old man presents with lethargy and palpitations for the past four or five days. On examination his pulse is 123 bpm irregularly irregular, blood pressure is 128/78 mmHg and his chest is clear. An ECG confirms atrial fibrillation. What is the appropriate drug to control his heart rate?

Atenolol

A 60-year-old man presents with increasing shortness-of-breath on exertion. During the examination a third heart sound is heard. Examination of the respiratory system is unremarkable. Which one of the following is most consistent with this finding?

Dilated cardiomyopathy

You review a 62-year-old man who has recently been discharged from hospital in Hungary following a myocardial infarction. He brings a copy of an echocardiogram report which shows his left ventricular ejection fraction is 38%. On examination his pulse is 78 / min and regular, blood pressure is 124 / 72 mmHg and his chest is clear. His current medications include aspirin, simvastatin and lisinopril. What is the most appropriate next step in terms of his medication?

Bisoprolol

A 45-year-old cattle farmer presents with a 2 month history of increasing fatigue, shortness of breath and night sweats. On admission he was pyrexial with a temperature of 39.7º with a new early diastolic murmur heard on auscultation. He was commenced on IV antibiotics for suspected endocarditis. Bloods cultures were positive for Streptococcus bovis. Echocardiography confirms the presence of an aortic valve vegetation. What is the most important investigation to carry out next in this patient?

Colonoscopy

You review a patient who has been admitted with a non-ST elevation myocardial infarction in the Emergency Department. They have so far been treated with aspirin 300mg stat and glyceryl trinitrate spray (2 puffs). Following recent NICE guidance, which patients should receive clopidogrel?

All patients

A 28-year-old who is 10 weeks pregnant is noted to be hypertensive on her booking visit. Blood show a potassium of 3.1 mmol/l. Clinical examination is unremarkable

Primary hyperaldosteronism

A 68-year-old with a history of ischaemic heart disease is seen in the hypertension clinic. Despite four antihypertensives his blood pressure is 172/94 mmHg. An abdominal ultrasound shows asymmetrical kidneys

Renal artery stenosis

A 30-year-old woman presents to the Emergency Department with a one-day history of central chest pain. The pain is described as severe, non-radiating and eases on expiration. Clinical examination of her cardiorespiratory system is unremarkable other than a heart rate of 96 / min. An ECG shows widespread ST elevation associated with PR segment depression in the anterior, inferior and lateral leads. Bloods show the following: Full blood count Normal Urea and electrolytes Normal Troponin I 0.4 ng/mL (

Acute pericarditis

An elderly man with aortic stenosis is assessed. What would make the ejection systolic murmur quieter?

Left ventricular systolic dysfunction

A 71-year-old woman presents with palpitations and 'lightheadedness'. An ECG shows that she is in atrial fibrillation with a rate of 130 / min. Her blood pressure is normal and examination of her cardiorespiratory system is otherwise unremarkable. Her past medical history includes well controlled asthma (salbutamol & beclomethasone) and depression (citalopram). Her symptoms have been present for around three days. What is the most appropriate medication to use for rate control?

Diltiazem

An 85 year old man has attended surgery to discuss an ambulatory blood pressure monitoring reading of 142/84 mmHg. He has no past medical history of coronary heart disease, renal disease or diabetes, and his only regular medication is lansoprazole. His 10-year cardiovascular risk score was recently calculated to be 18%. Management should include follow up with which one of the following?

Lifestyle advice

A 65-year-old male presents with sudden onset visual disturbance whilst watching TV. He attends the emergency department and is found to have a right homonymous hemianopia. His past medical history includes gout for which he takes allopurinol 100mg OD. ECG shows an irregular narrow complex bradycardia with no discernible P waves. CT head is performed and shows a subacute posterior cerebral artery infarction on the left side. Given this history and the investigation findings what would be the likely management of this patient?

Aspirin 300mg OD for 2 weeks then lifelong anti-coagulation (Warfarin if no contraindications)

What is the first line treatment for pregnancy-induced hypertension?

Labetalol

You are asked to urgently review a 61-year-old female on the cardiology ward due to difficulty in breathing. On examination she has a raised JVP with bilateral fine crackles to the mid zones. Blood pressure is 100/60 mmHg and the pulse is 140-150 and irregular. ECG confirms atrial fibrillation. What is the most appropriate management?

Urgent synchronised DC cardioversion

An 18-year-old female presents with tremor and dysarthria. There is a family history of early onset liver disease. Routine blood tests show. ALT is raised.

Wilson's Disease

A 49-year-old female is referred to the gastroenterology out-patient clinic with a 3 month history of epigastric pain and diarrhoea. Her GP initially prescribed lansoprazole 30mg od but this didn't alleviate her symptoms. The only past medical history of note is hyperparathyroidism. Endoscopy revealed multiple duodenal ulcerations. What is the likely diagnosis?

Zollinger-Ellison syndrome: | - One third have MEN1

A 38-year-old woman presents with fever, malaise and jaundice. On examination she has moderate hepatomegaly. Laboratory analysis confirms a positive anti-smooth muscle antibody and anti-nuclear antibody. What is the most likely diagnosis?

Autoimmune hepatitis

A 26-year-old male presents with nausea, malaise and jaundice. He returned 3 weeks ago from a holiday to India. On examination he has a moderate hepatosplenomegaly and yellowing of the sclera. He also has dark urine and pale stools. What is the most likely diagnosis?

Hep A

Which one of the following features is more common in Crohn's disease than ulcerative colitis? - Abdominal mass palpable in the right iliac fossa - Tenesmus - Bloody diarrhoea - Faecal incontinence - Abdominal pain in the left lower quadrant

Abdominal mass palpable in the right iliac fossa

A 57-year-old woman with a history of gallstones presents with progressive right upper quadrant pain, rigors and jaundice.

Ascending cholangitis

Acute pericarditis

A 70-year-old man is admitted to the Emergency Department after vomiting blood earlier in the day. Which one of the following factors best indicates a significant upper gastrointestinal bleed? - Creatinine = 190 µmol/l on a background of normal renal function - Platelets of 89 * 109/l - Potassium = 2.9 mmol/l - Sodium = 147 mmol/l - Urea = 15.4 mmol/l on a background of normal renal function

Urea = 15.4 mmol/l on a background of normal renal function

``` A 32-year-old woman presents with a 12 hour history of abdominal pain, vomiting and jaundice. On examination she has tender hepatomegaly, ascites and a BMI of 35 kg/m². She has a past medical history of antiphospholipid syndrome. What is the most likely diagnosis? - Acute cholecystitis - Ascending cholangitis - Budd-Chiari syndrome - Non alcoholic fatty liver disease - Auto-immune hepatitis ```

Budd-Chiari Syndrome | Due to hypercoagulable state

``` A previously well 28 year old man presents with shortness of breath and abdominal discomfort. He reports a dry cough for the previous 10 days. He works full time as management consultant. He is a non-smoker and drinks approximately 20 units of alcohol a week. He went on a stag-do to Prague with a bunch of friends 2 weeks ago. In the last few days he has noticed a widespread skin rash which he describes as lots of pink rings around a pale centre. Bloods on admission: Na+ 128 mmol/l K+ 3.7 mmol/l Urea 8.2 mmol/l Creatinine 150 µmol/l ``` Chest x-ray: Diffuse reticular infiltrates and small right sided pleural effusion. What is the most likely causative organism?

Mycoplasma pneumoniae

Aspergilloma

A 62-year-old woman who is being investigated for renal impairment presents with haemoptysis. On examination she has a flat nose

Wegener's Granulomatosis

A 72-year-old woman presents with a two day history of diarrhoea and pain in the left iliac fossa. Her temperature is 37.8ºC. She has a past history of constipation.

Diverticulitis

A 79-year-old woman is reviewed. She has taken bendroflumethiazide 2.5mg od for the past 10 years for hypertension. Her current blood pressure is 150/94 mmHg. Clinical examination is otherwise unremarkable. An echocardiogram from two months ago is reported as follows: Ejection fraction 44%, moderate left ventricular hypertrophy. Minimal MR noted What is the most appropriate next step in management? - Increase bendroflumethiazide to 5mg od - Stop bendroflumethiazide + start frusemide 40mg od - Add ramipril 1.25mg od - Stop bendroflumethiazide + start ramipril 1.25mg od - Add amlodipine 5mg od

Add ramipril 1.25mg od (and probably a Beta-Blocker)

Which one of the following is most suggestive of Wilson's disease? - Reduced hepatic copper concentration - Reduced 24hr urinary copper excretion - Increased skin pigmentation - Reduced serum caeruloplasmin - Reduced serum copper

Reduced serum caeruloplasmin

Commonest cause of traveller's diarrhoea?

E. coli