Quiz Questions Flashcards
A 40-year-old female, rather overweight, has episodes of right upper quadrant pain and fever.
A. Hepatitis C virus infection B. Cirrhosis C. Portal chronic inflammation D. Hepatitis B virus infection E. Extensive necrosis F. Hepatocellular carcinoma G. Cholecystitis H. Mallory weiss tear of oesophagus I. Portal hypertension
G. Cholecystitis - Cholecystitis is acute GB inflammation caused by an obstruction at the cystic duct. It occurs as a major complication of gallstones and classically presents with RUQ pain and fever. Gallstones in EMQs classically involves the Fs (Fat, Forty, Female, Fertile, Fair). USS is the definitive initial investigation. HIDA scanning and MRI may help if the diagnosis remains unclear. Treatment is with cholecystectomy.
A 72-year-old smoker, a known arteriopath is suffering from increasing behavioural problems and forgetfulness. His family is concerned as his state is deteriorating. This is confirmed by the decline of his MMSE from 25/30 six months ago to 18/30 today.
A. Normal pressure hydrocephalus B. Occipital Stroke C. Multiple Sclerosis D. Hypothyroidism E. Vascular dementia F. Lewy body dementia G. Parkinson's disease H. Pick's disease I. Azheimer's dementia
E. Vascular dementia - Vascular dementia is a chronic and progressive dementia with loss of brain parenchyma mainly due to causes such as infarction and small vessel changes. It is classically assumed to be a stepwise progression in symptoms, although a gradual course can also be seen. This patient is an arteriopath. It is the second most common cause of dementia in older people and there is a large overlap with Alzheimer’s with many patients having a mixed form. Treatment is of limited use and the best course of action is to target vascular risk factors at as early a stage as possible.
A 67 year old man recovering from an inferior MI complains of sharp retrosternal chest pain. He comments that leaning forward provides relief of the pain. The attending medical student claims to have heard a “rub” on auscultation.
A. Pericarditis B. Pulmonary embolism C. MI D. Hiatus hernia E. Anxiety F. Angina G. Coronary artery disease H. Oesophageal spasm I. Tietze’s syndrome J. Dissecting aortic aneurysm
A. Pericarditis - This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse (saddle-shaped) ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.
A 16 year old diabetic has been trying to lose weight. She presents at with a vomiting, postural hypotension and abdominal pain. She insists she has been taking her insulin regularly and does not use illicit drugs. Serum potassium is elevated.
A. Cushing's syndrome B. Rhabdomyolysis C. Drug side effect D. Acute kidney failure E. Addison’s disease F. Congenital adrenal hyperplasia G. Hyperglycaemia H. DKA I. Chronic kidney disease J. Infection K. Tumour lysis syndrome L. Pseudohyperkalaemia
H. DKA - This is DKA. This girl is simply lying about her insulin and has been skipping insulin doses in order to lose weight. This is known as ‘diabulimia’. The main thing that needs to be corrected is the severe intravascular volume depletion and to restore tissue perfusion with IV saline. Insulin will of course also be needed. When glucose reaches 11.1mmol, fluid should be changed to 5% dextrose to prevent hypoglycaemia. Insulin should be held until potassium is at least 3.3 mmol/L (remember insulin moves potassium into cells) and a continuous infusion is recommended (with new DKA treatment guidelines, the ‘sliding scale’ is now a thing of the past). If interested, look up the latest DKA treatment guidelines for more information.
For each of the malignancies listed below, please select the recognised presentation from the list of options.
Gastric carcinoma
A. Hypoglycaemia B. Erythrocytosis C. Autoimmune haemolytic anaemia D. Erythema ab igne E. Troisier's sign F. Necrolytic migratory erythema G. Acanthosis nigricans H. Eaton-Lambert syndrome I. Tetany
Troisier’s sign - Troisier’s sign is the finding of a palpable solid lymph node located in the left supraclavicular fossa (known as Virchow’s node). It is commonly associated with gastric malignancy. Although rarely present, there is always a mark for checking for this node in an abdo exam in your OSCEs!.
A 32-year-old male nurse from Zimbabwe came into the UK as part of an NHS recruitment campaign. He presents with SOB, weight loss, general debility, cervical lymphadenopathy and purple tender lesions on his shin of 6 weeks duration.
A. Full blood count and ESR B. Abdominal CT C. HIV antibody test D. Colonoscopy E. Blood test for auto-antibodies F. Thyroid function tests G. Bronchoscopy H. Fasting blood glucose I. Chest x-ray J. Bone marrow aspirate K. History only L. Gastroscopy M. Brain scan
I. Chest x-ray -Sarcoidosis is a chronic multisystem disease with an unknown aetiology with the lungs most commonly affected (giving SOB in this case). The purple lesions are erythema nodosum and are tender erythematous nodules. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.
A 50 year old man became suddenly breathless whilst eating. He has marked stridor & is choking & drooling.
A. Heimlich manoeuvre B. Forced alkaline diuresis C. Intravenous furosemide D. Rapid infusion of saline E. Nebulised salbutamol F. Intravenous aminophylline G. Re-breathing into paper bag H. Pleural aspiration I. Chest drain J. Intravenous adrenaline K. Heparin L. Intravenous insulin
A. Heimlich manoeuvre - This patient has choked on some food. The patient should be encouraged to cough if they are conscious. Otherwise, external manoevres can be performed such as abdominal thrusts (Heimlich) or back blows. These actions increase intrathoracic pressure and help to dislodge the foreign body. If it still isn’t removed, a flexible bronchoscopy may be necessary. Most cases occur in very young children.
A 91 year old man is referred to you by the urologists. He has an abdominal aortic aneurysm on examination and on ultrasound, an 8.8 cm infra-renal aneurysm is identified. He multiple co-morbidities but is given the green light for treatment to take place.
A. Angioplasty B. Femoral-distal bypass C. Aortobifemoral bypass D. Methyldopa E. Ultrasound F. Alpha blocker G. Embolectomy H. Endarterectomy I. Angiography J. Endovascular aneurysm repair K. Open repair of aneurysm
J. Endovascular aneurysm repair - Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair. Patient 1 is however is elderly and has co-morbidities. An EVAR is the best way forward here. However note also that EVAR could entail a complication of endovascular repair leak, which would require corrective treatment. Endoleak is persistent blood flow outside the graft and within the aneurysm sac. There is 24% risk after EVAR. However, this is not a complication of open repair, which is probably preferred in most cases in those who are fit and healthy enough to have it such as Patient 4. Management of this complication would depend on the type of endoleak.
A 28 year old female medical student returns from her elective in Africa with a short history of severe lower abdominal cramps & the passage of bloody diarrhoea.
A. Infective colitis B. Haemorrhoids C. Anal fissure D. Colonic carcinoma E. Anal carcinoma F. Crohn’s disease G. Ulcerative colitis H. Colonic polyp I. Diverticular disease J. Ischaemic colitis
A Infective collitis - This patient has recent foreign travel and a short history, previously normal, making infectious diarrhoea very likely. Probably eaten something dodgy while on elective. Think of the organisms which cause bloody diarrhoea such as EHEC. E coli is the most common cause of traveller’s diarrhoea. There may be a contact history due to faecal-oral spread. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe ETEC.
A woman has a lumpy swelling over the front of her neck and has been complaining of difficulty swallowing. She is euthyroid.
A. Grave's disease B. Hashimoto's thyroiditis C. Papillary carcinoma D. De Quervain's thyroiditis E. Follicular carcinoma F. solitary toxic adenoma G. Multinodular goitre H. medullary cell carcinoma
G. Multinodular goitre - Lumpy swelling and euthyroid (or borderline hyper- suppressed TSH with normal T4/T3) you would think multinodular goitre. She has no cancer B symptoms or infective history. These goitres are major causes of thoracic inlet obstruction and can also involve the laryngeal nerve causing hoarseness..a symptom that would also make you worry about infiltrative carcinoma. After palaption, ultrasound of the thyroid accompanied by Fine needle aspirate can be useful to check there are no malignant changes within the multinodular goitre. (worrying USS findings may be calcification of cysts - the so called ‘halo’ sign)
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.
A. Addison’s disease B. Cushing's syndrome C. Pregnancy D. Salt-wasting nephropathy E. Heart failure F. Metabolic syndrome G. Comfort eating H. Renal failure I. Reduced activity J. Portal hypertension K. Polycystic ovary syndrome L. Amyloidosis M. Hypothyroidism
B. 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.
A 22-year-old who takes the combined oral contraceptive has become very scared because she found a lump in her left breast last night. She does not think it was there last month. You find a discrete slightly irregular painless, firm one-cm diameter lump that is quite mobile. There is no lymphadenopathy.
A. Basal cell carcinoma B. Adenoma C. Sebaceous cyst D. Fat necrosis E. Carcinoma of the breast F. Intraductal papilloma G. Lipoma H. Radial scar I. Breast bud J. Fibroadenosis K. Phylloides tumour L. Breast abscess M. Fibroadenoma
M. Fibroadenoma - This sounds like a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient
John is a 35 year old tennis player who complains of breathlessness after games. His sleep has been disturbed recently by coughing during the night. On examination he was a tall, thin but athletic looking young man. There were high-pitched expiratory wheeze in both lungs.
A. Atypical pneumonia B. Bronchial carcinoma C. Pleural effusion D. Sarcoidosis E. Fibrosing alveolitis F. Pneumothorax G. Lung abscess H. Bronchiectasis I. Bronchial asthma J. COPD K. Cystic fibrosis
I. Bronchial asthma - This patient has developed a primary pneumothorax. Primary pneumothoraces occur in young people without known lung conditions. The main investigation is a CXR and pneumothoraces are classified by the BTS as large (>2cm visible rim between the lung margin and the chest wall) or small (
Match the cause of hypotension to the following case histories. Each option may be used once, more than once or not at all.
22 year old man presented with vomiting. He had not been feeling himself for some weeks. On examination, the skin creases of his hands were dark. Blood results showed plasma urea 8.5mmol/l, sodium 121mmol/l & potassium 5.1mmol/l.
A. Addison’s disease B. Arrhythmia C. Drug induced D. Volume depletion E. Autonomic neuropathy F. Pulmonary embolus G. Blood loss H. Septicaemia I. Cardiogenic shock
A. Addison’s disease - Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s.
A 25 year old woman with fatigue & weight loss. She gives a history of frequent loose stools with abdominal pain. Full blood count revealed iron deficiency anaemia.
A. Renal failure B. HIV C. Tuberculosis D. Depression E. Malabsorption F. Addison's disease G. Hyperthyroidism H. Diabetes mellitus I. Liver failure J. Malignancy K. EBV L. Anorexia nervosa M. Cardiac failure
E. Malabsorption - There is frequent loose stools here and abdominal pain. Combined with the IDA, this points to malabsorption. This could well be a presentation of coeliac disease – IDA is one of the most common clinical presentations and abdominal pain and diarrhoea are common. Coeliac disease is a systemic autoimmune condition triggered by dietary gluten peptides found in grains. It is a relatively common condition. The only treatment is a strict gluten-free diet for life.
An 18 year old student has just returned from holiday in Africa. He is jaundiced and has moderate hepatomegaly. His blood tests reveal increased serum transaminases and elevated bilirubin. He also has specific IgM antibodies.
A. Dubin-Johnson syndrome B. Hepatitis C C. Malaria D. Gall stones E. Gilbert's syndrome F. Crigler-Najjar syndrome G. Hepatitis B H. Hepatitis A I. Carcinoma of head of the pancreas J. Primary sclerosing cholangitis K. Primary biliary cirrhosis L. Cholangiocarcinoma M. Sickle cell anaemia
H. Hepatitis A - IgM anti-hepatitis A virus is positive here which is highly sensitive and specific combined with the typical symptoms this student displays. IgM antibodies are detectable typically 5-10 days before symptom onset and remain raised for 4-6 months. It can be ordered alongside IgG anti-HAV and is a cheap and simple test. IgG rises soon after IgM and stays elevated for life so a positive IgG can mean prior infection or recent disease. Again, a cheap and simple to carry out test.
Hepatitis A is primarily transmitted via the faecal-oral route. After the virus is consumed and 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 onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water. If the patient has other liver diseases such as HBV or HCV or cirrhosis then there is a higher risk of fulminant HAV infection. The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in
A 45-year-old man wakes in the night with severe pain in his right flank radiating round to the front and 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.
A. Cystoscopy B. Abdominal ultrasound C. Prostatic specific antigen blood test D. MSU: microscopy and culture E. X-ray lumbar spine F. ASO titre blood test G. Helical CT H. 24 hour urine monitoring I. Biopsy of prostate J. Retrograde pyelogram
G. Helical CT - This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.
A 70 year old diabetic man, who smoked 40 cigs/day for 40 years. He presents with abdominal pain worse at night & radiating to his back. He is losing weight, suffers from dyspepsia & pruritus. On examination he is cachectic, jaundiced & has an enlarged gallbladder.
A. Reflux oesophagitis B. Cancer of the liver C. Hiatus hernia D. Cancer of the pancreas E. Gastric ulcer F. Liver cirrhosis G. Irritable bowel syndrome H. Coeliac’s disease I. Carcinoma of oesophagus J. Duodenal ulcer K. Inflammatory bowel disease L. Chronic hepatitis M. Primary biliary cirrhosis N. Pancreatitis
D. Cancer of the pancreas - Pancreatic cancer typically presents with painless obstructive jaundice and weight loss and generally presents late. It can however, like this case, present with abdominal pain which is typically non-specific in the upper abdomen. If the patient presents with persistent back pain, then this symptom is consistent with retroperitoneal metastases. It is estimated that 1 in 4 cases can be linked to smoking. Whipple’s procedure or Traverso-Longmire procedure (pancreaticoduodenectomy) offers the only hope of a cure but only a small minority are elegible for these procedures. The first tests to order are an abdominal USS and LFTs. Note Courvoisier’s law with regard to this question: Jaundice and a palpable painless gallbladder is unlikely to be caused by gallstones. The tumour marker for pancreatic cancer is CA19-9 which is useful in preoperative staging.
A 25-year-old woman with fatigue and weight loss. She gives a history of frequent loose stools with abdominal pain. Full blood count revealed iron deficiency anaemia.
A. Malignancy B. Anorexia nervosa C. Tuberculosis D. Addison's disease E. Malabsorption F. Infestation with helminths G. Cardiac failure H. Diabetes mellitus I. Hyperthyroidism J. Renal failure K. Liver failure L. Depression M. HIV
E. Malabsorption - There is frequent loose stools here and abdominal pain. Combined with the IDA, this points to malabsorption. This could well be a presentation of coeliac disease – IDA is one of the most common clinical presentations and abdominal pain and diarrhoea are common. Coeliac disease is a systemic autoimmune condition triggered by dietary gluten peptides found in grains. It is a relatively common condition. The only treatment is a strict gluten-free diet for life.
A 10 year old boy presents with stridor. He reports three episodes of face and tongue swelling, each of which prompted him to report to A&E. There are also red, raised and itchy lesions that cover his body, including face. His sister also suffers from similar attacks.
A. Kawasaki disease B. Myocarditis C. Juvenile idiopathic arthritis D. Primary pulmonary hypertension E. Aortic stenosis F. Hereditary angio-oedema G. Pericarditis H. Congestive cardiac failure I. Toxic synovitis J. Acute rheumatic fever K. Congenital nephritic disease
F. Hereditary angio-oedema - This patient has urticaria (erythematous, blanching, oedematous, pruritic lesions) and angio-oedema (swelling). A positive family history of angio-oedema raises a suspicion for a diagnosis of hereditary angio-oedema. There are two forms of this condition. One is manifest by absence of C1 esterase inhibitor whereas the other is due to normal levels of dysfunctional C1 esterase inhibitor. This allows the uncontrolled activation of the complement cascade which therefore gives rise to angio-oedema. This is a condition which is inherited in an autosomal dominant manner although it should be noted that some 50% of cases have no previous FH and are thought to be due to new mutations. Laboratory investigations may reveal a decreased level of C1 and decreased levels or function of C1 esterase which would support the diagnosis. In acquired angio-oedema, C1q levels are low unlike in the hereditary form where it is normal – this differentiates the two forms. The mainstay of treatment is with antihistamines. Airway compromise like the stridor this patient is experiencing is an indication for prompt treatment with adrenaline. The stridor here is a sign of severe laryngeal angio-oedema, which is a sign of impending airway obstruction – this needs to be taken seriously and is an emergency.
John is a 20 year old man with breathlessness and chest pain after exertion. 5 days ago he developed palpitations & fainted during a game of squash. Examination revealed a jerky pulse and a systolic murmur. His ECG showed changes of left ventricular hypertrophy.
A. Pericarditis B. Angina C. VSD D. Romano-Ward syndrome E. Infective endocarditis F. HOCM (hypertrophic obstructive cardiomyopathy) G. ASD H. Congestive cardiac failure I. MI J. Left ventricular failure
F. HOCM - This patient has HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance and there may be a FH of sudden death. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. The arterial pulse is described as ‘jerky’. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echocardiography will show septal hypertrophy. There may also be MR.
A 20 year old man with recurrent episodes of chest infection & diarrhoea, which is difficult to flush away in the toilet. He developed a persistent cough with the production of sputum & blood. On examination his fingers are clubbed & in his chest there are low pitched inspiratory & expiratory crackles, plus some wheeze. He recalls being small for his age despite having a healthy appetite.
A. Atypical pneumonia B. Bronchial carcinoma C. Pleural effusion D. Sarcoidosis E. Fibrosing alveolitis F. Pneumothorax G. Lung abscess H. Bronchiectasis I. Bronchial asthma J. COPD K. Cystic fibrosis
K. Cystic fibrosis - CF is autosomal recessive and the mean age of death is around 40. There is currently no cure for this condition. The reccurent chest infections and greasy stools (fat malabsorption due to pancreatic insufficiency) should make you think of CF. A persistent cough which is productive should also raise suspicions. Examination findings here which raise your suspicion include clubbing and crackles on auscultation. Additionally, you may find nasal polyps and hepatomegaly and/or splenomegaly and a congenital absence of the vas deferens in males. There is also some failure to thrive with the patient being small for his age. The most conclusive diagnostic test is the sweat test which is positive if sweat chloride is >60mmol/L. Serum IRT from a heel prick blood spot allows screening of newborns. CF is a genetic condition with abnormal salt and water transport due to mutations in the CFTR (an apical anion channel). Heterozygotes generally do not demonstrate disease.
A young adult with a 2 day history of left sided pleuritic chest pain, fever and cough productive of rusty coloured sputum. A CXR was obtained which showed left lower lobe shadowing suggestive of consolidation. On agar the sputum grew gram +ve cocci which demonstrated alpha-haemolysis.
A. Klebsiella pneumoniae B. Streptoccus pyogenes C. Enterococcus faecium D. Streptococcus pneumoniae E. Escherichia coli F. Chlamydophila psittaci G. Shigella H. Salmonella paratyphi I. Salmonella typhi J. Streptoccocus viridans K. Salmonella typhimurium L. Chlamydia trachomatis
F. Streptococcus pneumoniae - Classic lobar pneumonia with no signs and symptoms to suggest an atypical organism is most likely to due to pneumococcus. Streptococcus pneumoniae is, as mentioned in the question, an alpha haemolytic Gram positive cocci (also Streptococcus viridans but it does not present in this way). A CXR is the most specific and sensitive test available and antibiotics are indicated. The rusty coloured sputum is hinting at a pneumococcal pneumonia too.The patient has presented with common symptoms of fever and a productive cough. There is additionally pleuritic chest pain. Initial treatment of a CAP is empirical with antibiotics. Often diagnosis is made solely on history and examination findings. Management is guided by the patient’s CURB-65 score.
A 55 year old lawyer who has had a chronic cough for 3 months complains of 1 episode of haemoptysis. She is a heavy smoker (about 40/day) & has experienced some recent weight loss.
A. Sputum cultures B. Bronchoscopy C. History only D. D-dimer E. CTPA F. Chest x-ray G. MRA H. Lung function tests I. ABG J. Clotting screen K. V/Q scan L. CT head
B. Bronchoscopy - This sounds like bronchial carcinoma from the history of smoking, respiratory complaints and weight loss. Initial investigation of bronchial carcinoma is with a CXR but definitive diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. During bronchoscopy, endobronchial masses can be biopsied and washings/alveolar lavage can also be performed for cytological analysis. Trans-thoracic needle aspiration may be needed for peripheral lesions that cannot be reached by bronchoscopy. First line treatment aims at surgical resection if possible.
A 38-year-old woman with known polycystic kidney disease suddenly develops a severe occipital headache. She vomited and then lost consciousness.
A. Wernicke's encephalopathy B. Normal pressure hydrocephalus C. Subarachnoid haemorrhage D. Subdural haemorrhage E. Extradural haemorrhage F. Hepatic failure G. Alcohol withdrawal H. Stroke I. Encephalitis J. Dementia K. Drug overdose L. Meningitis
D. Subarachnoid haemorrhage - SAH (bleeding into the subarachnoid space) presents with sudden severe headache patients will often describe as the worst headache of their life, and can often be so bad that they feel like they’ve been kicked in the back of the back. 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 50-55 age group and affects women and black people more than men and white people. The most common cause of non-traumatic SAH is an aneurysm which ruptures. Conditions which predispose 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 this 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.
A 58-year-old man, who smoked 30 cigarettes a day, presents with a 6-week history of cough, malaise, anorexia and weight loss. Past medical history includes hypertension for which he has taken lisinopril and bendrofluazide for 4 years.
A. Oesophageal reflux B. COPD C. Asthma D. Bronchiectasis E. Carcinoma of bronchus F. Sarcoidosis G. ACE inhibitor H. Postnasal drip I. Tuberculosis J. Foreign body
E. Carcinoma of the bronchus - The history of smoking and weight loss point to a bronchial carcinoma. Initial investigation is with a CXR. Diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome.
True or False, acromegaly can be associated with a bitemporal hemianopia.
True - Pituitary tumours and craniopharyngiomas can compress the optic chiasm, sparing the outer fibres responsible for the nasal field. This causes the characteristic bitemporal hemianopia.
For each patient below, choose the SINGLE most useful investigation from the above list of options. Each option may be used once, more than once or not at all.
A 55 year old obese female complains of a 6 month history of chest pain which radiated to the jaw and both shoulders. The pain is reported to be more severe at night. ECG and chest x-rays are normal.
A. Upper GI endoscopy B. Thoracic spine x-ray C. ECG D. Coronary angiogram E. Transthoracic echo F. CT scan abdomen G. Chest x-ray H. Chest x-ray in expiration I. Barium swallow J. Chest x-ray rib views K. V/Q scan L. Exercise ECG M. CPK (creatine phosphokinase)
A. Upper GI endoscopy - This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.
A 55 year old woman is admitted drowsy with slurred speech. You notice yellowing of the sclera and fetor hepaticus.
A. Wernicke's encephalopathy B. Normal pressure hydrocephalus C. Subarachnoid haemorrhage D. Subdural haemorrhage E. Extradural haemorrhage F. Hepatic failure G. Alcohol withdrawal H. Stroke I. Encephalitis J. Dementia K. Drug overdose L. Meningitis
F. Hepatic failure - This patient has decompensated chronic liver disease (he is in liver failure) which has resulted in neurological symptoms associated with hepatic encephalopathy. The brain is exposed to ammonia which bypasses the liver by portosystemic shunting. It is a diagnosis of exclusion and tests will need to be conducted to rule out other potential causes of confusion. The findings of jaundice and fetor hepaticus (liver failure) are signs of liver disease. Think about the other signs you might see like spider naevi and palmar erythema. This patient may also have asterixis which is a coarse flapping tremor. HE is likely caused by a host of factors. This patient’s LFTs will be abnormal and she is likely to have coagulopathy too (PT will be elevated).
A 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually.
A. Sebaceous cyst B. Fibroadenoma C. Fibroadenosis D. Gynaecomastia E. Breast abscess F. Carcinoma of the breast G. Breast cyst H. Lipoma I. Duct ectasia
C. 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.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Hepatocellular carcinoma
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
B. Aflatoxin B1 - Aflatoxin B1 is a naturally occuring carcinogen produced by many species of Aspergillus (a fungus). It thrives on improperly stored grains and nuts. It is considered a significant etiological factor for liver cancer in Southern Africa and the Far East.
On liver biopsy a moderate chronic inflammation is observed. Special stains identify antigens from a double stranded DNA virus within the cytoplasm of hepatocytes.
A. Hepatitis B B. Extensive necrosis C. Hypervascularity D. Extensive cirrhosis E. Cholecystitis F. Pancreatic carcinoma G. Pancreatic pseudocyst H. Hepatitis C I. Enlarged right lobe J. Portal chronic inflammation K. Arterio-venous malformations L. Hepatocellular carcinoma
A. Hepatitis B - Hepatitis B is a DNA virus which is transmitted percutaneously and permucosally. It is also a STI. HCV is an RNA virus and RNA-PCR will be positive. A brief bit about hepatitis B markers: HBsAb appears several weeks after HBsAg disappears and in most patients suggests a resolved infection and life-long immunity (it is also detectable and titres are measured in those immunised with the HBV vaccine). HBsAg on the other hand appears 2-10 weeks after exposure to HBV and usually, in self-limiting acute cases, becomes undetectable after 4-6 months of infection. Persistence for >6 months implies chronic infection. Core antibody (IgM) appears within weeks of acute infection and remains detectable for 4-8 months and can be the only way to diagnose acute infection during the period when surface antigen disappears but before surface antibody has appeared. Chronic infection is indicated by IgG core antibody. The best single test to screen household contacts of infected individuals to determine the need to vaccinate is still HBcAb. E antigen is a soluble viral protein in serum which is part of the early acute infection and disappears soon after peak ALT levels. Presence >3 months indicates chronic infection is likely. E antigen being present in those with surface antigen indicates greater infectivity and a high level of viral activity and replication.
A 22 year old man comes to see you on his return from a holiday in Spain. He has a 3-4 day history of fever, malaise, nausea, vomiting and abdominal discomfort. He is noticeably jaundiced with dark urine and pale stools. There is also tender hepatomegaly on examination. He wonders if this is related to his meal of shellfish from a street vendor.
A. Dubin-Johnson syndrome B. Gilbert's syndrome C. Carcinoma of the pancreas D. Gall stones E. Primary sclerosing cholangitis F. Hepatitis G. Haemolytic anaemia H. Primary biliary cirrhosis
F. Hepatitis - This is likely hepatitis A which is primarily transmitted via the faecal-oral route. After the virus is consumed and 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 onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water. If the patient has other liver diseases such as HBV or HCV or cirrhosis then there is a higher risk of fulminant HAV infection. The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in
A young lady with thyrotoxicosis displays a hand tremor.
A. Parkinson's Disease B. Exaggerated physiological tremor C. Cerebellar tremor D. Dystonia E. Sydenham's chorea F. Brain tumour G. Alcohol withdrawal H. MS I. Asterixis
B. Exaggerated physiological tremor - The tremor seen in hyperthyroidism is usually fine and is a exaggerated physiological phenomenon. 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 50 year old man fell from a ladder & injured his back. He requires regular pain-killers for back pain. Since the accident he has had difficulty opening his bowels & has noticed reduced bowel frequency.
A. Parkinson’s disease B. Hypercalcaemia C. Colorectal carcinoma D. Diverticular disease E. Hypothyroidism F. Pelvic trauma G. Irritable bowel syndrome H. Chronic laxative abuse I. Hirschsprung’s disease J. Adverse effect of drugs
J. Adverse effect of drugs - This patient is on opiates. Let us review opiates such as morphine and codeine. They are commonly prescribed for analgesia and can also be used as an anti-tussive (suppresses ACh and NK release needed for cough activation and inteferes with serotonin receptors in the DRN). They are also abused for their euphoric effects mediated by their action on dopamine release at the nucleus accumbens. They have a host of side effects, including, in this case, GI effects (receptors present on the myenteric and submucosal plexus) of decreased gastric motility, emptying and increased gut water reabsorption… in short, it causes constipation. Other side effects include respiratory depression (desensitises central chemoreceptors to lessen the response to PaCO2), N&V by stimulating the CTZ, pupillary constriction via the Edinger-Westphal nucleus and causes symptoms like pruritis, urticaria, hypotension through histamine release via a direct effect on mast cells.
Arrestins also promote internalisation of opioid receptors which leads to tolerance with prolonged treatment. Prolonged use will also lead to dependance and withdrawl effects if stopped, such as cravings, and the physical effects may be very profound, resembling flu. Naloxone is indicated in an overdose. It is worth looking at the pathways to help you remember the effects.
A 30 year old city banker comes to the GP with symptoms of abdominal bloating, intermittent constipation and diarrhoea with occasional nausea. This started about 6 months ago but she has not lost any weight or found any blood in her stools.
A. Bacterial gastroenteritis B. Crohn's disease C. Cancer of the rectum D. Diverticular disease E. Thyrotoxicosis F. Drug induced G. Cancer of the colon H. Irritable bowel syndrome I. Amoebic dysentery J. Ulcerative colitis K. Malabsorption L. Clostridium difficile
H. Irritable bowel syndrome - The intermittent diarrhoea and constipation, with bloating, without symptoms suggestive of IBD make IBS a more likely diagnosis. IBS is a chronic condition with abdominal pain associated with bowel dysfunction and is a diagnosis of exclusion. The pain or discomfort may be relieved by defecation. Examination is usually unremarkable and the diagnosis is based on the patient’s history in line with the Rome Criteria. If the patient presents with any worrying symptoms, then these will warrant a more thorough investigation. Treatment depends on the patient’s predominant symptoms. Antispasmodics relieve abdominal pain or discomfort but do not affect bowel habit. Examples include peppermint oil and dicycloverine. Laxatives can also be used such as lactulose. Lifestyle and dietary modifications combined with reassurance remain the 1st line intervention for functional bowel disease. IBS is linked with stressful jobs such as working as a banker in the city and there is a female/male ratio of 2:1.
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).
A. None B. Uncuffed ET tube C. Oropharyngeal airway with oxygen D. Single-lumen cuffed ET tube E. Double-lumen cuffed ET tube F. Laryngoscopy G. Suction H. Tracheostomy I. Laryngeal mask airway (LMA) J. Facemask with oxygen K. Cricothyroidotomy
C. 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 onlybe done if the patient is unconscious. Think about where your fingers are digging in.
A 70 year old male smoker with a 5 year history of productive cough presents with breathlessness. On examination you find hyperinflation & diminished breath sounds when examining the chest.
A. Mitral stenosis B. Pneumonia C. COPD D. Pneumothorax E. Anaemia F. Left ventricular failure G. Thyrotoxicosis H. Epiglottitis I. Asthma J. Anxiety K. Aspirin poisoning L. Pulmonary embolus M. Mitral regurgitation
C. COPD - Smoking is the most important risk factor, accounting for 90% of COPD. COPD has an insidious onset and usually presents in older people with a history of cough, wheeze and SOB. Patients with COPD are at a higher risk of infections and are vaccinated against influenza annually and pneumococcal pneumonia every 5 years. Spirometry is the gold standard for diagnosis, with FEV1/FVC ratio
A 19 year old woman with a past history of cardiac surgery in infancy presents with symptoms of decreasing exercise tolerance. On examination there is cyanosis & clubbing.
A. Echocardiogram B. Abdominal ultrasound C. Bronchoscopy D. Chest x-ray E. Lung funtion tests F. Sputum culture G. Colonoscopy H. Stool culture
A. Echocardiogram - The only cardiac investigation here is an echocardiogram. Cardiovascular causes of clubbing include cyanotic congenital heart disease, infective endocarditis and atrial myxoma. This could well be Eisenmenger’s syndrome caused by shunt reversal.
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. Idiopathic thrombocytopenic purpura B. Wiskott-Aldrich syndrome C. Hepatic cirrhosis D. Haemophilia E. Skull fracture F. Spontaneous G. Disulfiram H. Aplastic anaemia I. HIV J. Corticosteroids K. Diuretics L. Clopidogrel
E. 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 skyll 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 74-year-old man feels unsteady on his feet. He is on no medication and has no PMH. O/E you notice his gait is slow with small steps. He has a resting tremor of his right hand, and you note the cogwheel rigidity of his upper limbs.
A. Normal pressure hydrocephalus B. Occipital Stroke C. Multiple Sclerosis D. Hypothyroidism E. Vascular dementia F. Lewy body dementia G. Parkinson's disease H. Pick's disease I. Azheimer's dementia
G. Parkinson’s disease - Parkinson’s is characterised by a resting tremor, rigidity, bradykinesia and postural instability. This patient has difficulty walking, a resting tremor (4-6 Hz at rest which dissipates with the use of limbs, with generally asymmetrical onset) and limbs oppose movement. This last point demonstrates rigidity, which shows as resistance to passive movement about a joint. There is often also cogwheeling, especially if there is a superimposed tremor. The patient may have other signs like a mask like face due to the loss of spontaneous facial movement, hypophonia and micrographia, and may walk around in a shuffling gait with a stooped posture. The diagnosis is clinical. Treatment is symptomatic in an MDT setting. Medical therapy includes MAO-B inhibitors and DA agonists, for example rasagiline and carbidopa/levodopa. There are other medical therapies depending on the specific symptoms the patient presents with.
A 24 year old woman has had 24 hours of vomiting & diarrhoea, which she thinks followed eating reheated take-away food. There was fresh blood in the last 3 vomits. Vital signs are stable.
A. Peptic ulcer B. Mallory-Weiss syndrome C. Angiodysplasia D. Gastric erosions E. Oesophageal varices F. Oesophageal carcinoma G. Peutz-Jeghers syndrome H. GORD I. Osler-Weber-Rendu syndrome J. Mallory-Weiss syndrome K. Carcinoma of the stomach L. Bleeding diathesis
B. Mallory-Weiss Syndrome - This occurs after a rise in abdominal pressure which induces a tear in the oesophageal mucosa, causing subsequent GI bleeding. It commonly presents with haematemesis after an episode of retching/vomiting/coughing/straining. Hence, risk factors include anything which can cause vomiting like heavy alcohol use, which is commonly the case in EMQs. Also, other conditions would include food poisoning, bowel obstruction, hyperemesis gravidarum, bulimia, the chronic cough of COPD, meningitis etc… you name it really. Classically, MWT presents with a small self limiting episode of haematemesis. Definitive diagnosis is made by OGD. Treatment is supportive because most cases, as mentioned, are self limiting and emergency treatment is not offered unless the patient is showing signs of clinical instability. If the patient is actively bleeding, treatment will be with therapeutic endoscopy in most cases, and very very few cases will require more intervention such as angiography with embolisation.
A 25 year old female trainee solicitor presents complaining of bloating & excessive flatus. She is passing pellet-like stools associated with abdominal pains. Her symptoms have been intermittent for several years
A. Radiation proctitis B. Infectious diarrhoea C. Colorectal cancer D. Diverticular disease E. Irritable bowel syndrome F. Benign colonic stricture G. Hyperthyroidism H. Inflammatory bowel disease I. Ischaemic colitis
E. Irritable bowel syndrome - IBS is a chronic condition with abdominal pain associated with bowel dysfunction and is a diagnosis of exclusion. The pain or discomfort may be relieved by defecation. Examination is usually unremarkable and the diagnosis is based on the patient’s history in line with the Rome Criteria. If the patient presents with any worrying symptoms, then these will warrant a more thorough investigation. Treatment depends on the patient’s predominant symptoms. Antispasmodics relieve abdominal pain or discomfort but do not affect bowel habit. Examples include peppermint oil and dicycloverine. Laxatives can also be used such as lactulose. Lifestyle and dietary modifications combined with reassurance remain the 1st line intervention for functional bowel disease. IBS is linked with stressful jobs such as working as a secretary and there is a female/male ratio of 2:1. ‘Pellet-like’ stools is an indicator in EMQs.
A woman of BMI 47 has been in surgery for a major operation to help her lose weight. Gastric banding was previously unsuccessful. She is started on pureed foods in hospital and she becomes nauseous and distended shortly after. a few hours later she is sweating and anxious, she c/o palpitations. Nurses measure her BMs which are low.
A. Addison's disease B. Alcohol C. Meningitis D. Insulinoma E. Insulin F. dumping syndrome G. Gliclazide H. Waterhouse-Friderichsen syndrome I. Starvation
F. Dumping syndrome
For each of the following patients choose one of the options above as the single most appropriate means of reducing cardiovascular risk
A 54 year old man, normal blood pressure, normal lipid profile, body mass index 28, random blood sugar 15 mmol/L, fasting blood sugar 8.5mmol/L
A. Weight reduction and increased physical activity
B. Angiotensin converting enzyme inhibitor therapy
C. Weight reduction and metformin therapy
D. Cholesterol lowering therapy with a statin
E. Reduced alcohol intake
F. Antihypertensive drugs
G. Aspirin therapy
H. Smoking cessation
C. Weight reduction and metformin therapy - This patient has 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 is diet and lifestyle advice and changes. Metformin will be added if there is no adequate response. In terms of this question, this option will reduce cardiovascular risk the most for this patient. Metformin is a biguanide and suppresses hepatic glucose production.
A 25 year old man has a soft fluctuant swelling which bulges from beneath the anterior border of his left sternomastoid muscle. It is painless & has been present since childhood.
A. Thyroglossal cyst B. Sialolithiasis (Salivary calculus) C. Parotid adenoma D. Mumps E. Thyroid nodule F. Parotid carcinoma G. Lipoma H. Lymphadenopathy I. Carotid body tumour J. Branchial cyst K. Sebaceous cyst L. Carotid aneurysm
J. Branchial cyst - A branchial cyst is a congenital abnormality arising due to failure to obliterate the 2nd branchial cleft in development. They are congenital, hence the presence since childhood. They most commonly are found along the anterior border of sternocleidomastoid like in this case. They are generally asymptomatic unless they become infected. Treatment can be conservative or involve surgical excision.
A 48 year old women presents with mild breast pain which improves in the days after her menstrual period. Her breasts are lumpy on examination.
A. Fibrocystic changes B. Breast cancer C. Necrotising fasciitis D. Galactocoele E. Costochondritis F. Phylloides tumour G. Diabetic breast lesion H. Mondor’s disease I. Raynaud’s phenomenon J. Fibroadenoma K. Breast abscess L. Fat necrosis
A. Fibrocystic changes - 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 65 year old woman has progressive low retrosternal dysphagia, initially to solids, but now also to liquids – coming on for the last 4 months. There has also been loss of appetite & 3kg weight loss.
A. Cerebrovascular accident B. Carcinoma of oesophagus C. Plummer-Vinson syndrome D. Gastric volvulus E. Hiatus hernia F. Pneumonia G. Myasthenia gravis H. Thyroid goitre I. Carcinoma of bronchus J. Pharyngeal pouch K. Achalasia
B. Carcinoma of oesophagus - Dysphagia (in this progressive pattern) coupled with weight loss 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 70 year old man presents with general malaise, weakness & right upper quadrant abdominal pain. On examination he looked ill & was clinically jaundiced. There were spider naevi, palmar erythema, leuconychia, Dupuytren’s contracture & gynaecomastia.
A. Reflux oesophagitis B. Cancer of the liver C. Hiatus hernia D. Cancer of the pancreas E. Gastric ulcer F. Liver cirrhosis G. Irritable bowel syndrome H. Coeliac’s disease I. Carcinoma of oesophagus J. Duodenal ulcer K. Inflammatory bowel disease L. Chronic hepatitis M. Primary biliary cirrhosis N. Pancreatitis
F. Liver cirrhosis - Cirrhosis is the end-stage of chronic liver disease, resulting in hepatic insufficiency and portal hypertension. This has resulted in this man’s jaundice. Palmar erythema affects the thenar and hypothenar eminences. Other signs include spider naevi, telangiectasia, Dupuytren’s contracture, parotid swelling, leuconychia from hypoalbuminaemia, gynaecomastia and bruising. Management is aimed at treating the underlying liver disease. The only curative option, once decompensated, is liver transplantation.
Parkinson’s disease is characterised by a loss of dopaminergic neurons in which area below?
- Caudate nucleus
- Substantia nigra
- Thalamus
- Corpus callosum
- Substantia nigra - The substantia nigra is the main area affected in Parkinson’s disease.
choose the SINGLE most appropriate monitoring investigation from the list
Phenytoin
A. White cell count B. Echocardiogram C. Activated partial thromboplastin time D. Liver function tests E. Thyroid function tests F. Renal function tests G. Lung function tests H. INR I. GCS J. ECG K. Serum drug level
K. Serum drug level - Phenytoin is useful for tonic-clonic and focal seizures but it has a narrow therapeutic index and a non-linear dose-plasma concentration relationship. Hence, small dose increases can lead to huge increases in plasma concentration and acute toxicity. Conversely if the patient skips a dose, there may also be marked change and the levels may be sub-therapeutic. You therefore need to monitor plasma drug concentration to improve the adjustment of dose. Parenterally, you can also consider fosphenytoin.
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.
A. Benign cyst B. SLE C. Breast abcess D. Fat necrosis E. Fibrocystic breasts F. Pagets disease G. Duct ectasia H. Fibroadenoma I. Mastalgia J. Breast carcinoma K. Gynaecomastia
C. 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.
34-year-old man has had vomiting 2-3 times a day for 3 days. He complains of severe crampy abdominal pain and blood stained watery diarrhea. On examination temperature 37.7˚C. Abdomen soft, complains of generalised tenderness. No masses/rebound/guarding.
A. Intussusception B. Pancreatitis C. Oesophageal cancer D. Uraemia E. Gastric cancer F. Pyloric stenosis G. Salmonella H. Bowel obstruction I. Appendicitis J. Combined oral contraceptive pill K. Viral gastroenteritis L. Bulimia M. Peptic ulcer disease
G. Salmonella - The only option on the list which fits is Salmonella. This could obviously be E coli or Campylobacter too, for instance. This is infectious gastroenteritis and Salmonella is a common cause, pretty much able to contaminate any food. It is commonly linked to poultry, dairy items and undercooked eggs. It is self-limiting and diagnosis is on isolating the organism from a stool culture. Treatment is supportive with fluid and electrolyte replacement and antibiotics are generally used only for patients with risk factors for severe disease or those with extra-GI complications. This is not viral gastroenteritis for the reasons below:
Mitral valve replacement plus atrial fibrillation.
A. Aspirin B. Unfractionated heparin C. Warfarin D. Vitamin K E. Fresh frozen plasma F. Low molecular weight heparin G. Protein S concentrate H. Platelet concentrates I. Thrombin infusion J. Fibrinogen K. Platelet concentrates plus fresh frozen plasma L. Fondaparinux (FXa inhibitor) M. Vitamin E
C. Warfarin - This patient here has two risk factors for thromboembolism – AF and valve replacement. This patient will need to be warfarinised to an appropriate INR for anticoagulation. As mentioned above, warfarin acts to inhibit synthesis of the vitamin K dependent clotting factors.
A 19 year old man presents with sudden severe upper abdominal pain after being tackled during rugby practice. He was recently diagnosed with glandular fever.
A. Hepatoma B. Perforated peptic ulcer C. Sigmoid volvulus D. Splenic rupture E. Pancreatic abscess F. Haematoma of the rectus sheath G. Pancreatic ascites H. Pancratic effusion I. Umbilical hernia J. Oesophageal varices K. Pancreatic pseudocyst L. Divarication of the recti M. Mallory-Weiss tear N. Fractured rib
D. Splenic rupture - Infectious mononucleosis caused by EBV infection causes splenomegaly. This makes the patient susceptible to splenic rupture due to trauma, such as during this rugby practice session. Rupture is a cause of splenomegaly, and splenomegaly is a risk factor for rupture. If the patient is previously known to have mono, with an enlarged spleen, then they should really avoid contact sports. It would be an irresponsible doctor to not advise against this. This is a medical emergency as the spleen is a very vascular organ and bleeding can rapidly lead to shock and death.
For each patient below, choose the SINGLE most useful investigation from the above list of options. Each option may be used once, more than once or not at all.
An 80 year old woman on corticosteroids develops acute chest pain while standing up. It is posteriorly sited, radiating anteriorly under the breast. The pain is worse on movement and there is tenderness on the back of the chest. Cardiovascular and respiratory examination are normal.
A. Upper GI endoscopy B. Thoracic spine x-ray C. ECG D. Coronary angiogram E. Transthoracic echo F. CT scan abdomen G. Chest x-ray H. Chest x-ray in expiration I. Barium swallow J. Chest x-ray rib views K. V/Q scan L. Exercise ECG M. CPK (creatine phosphokinase)
B. Thoracic spine x-ray - This patient likely has osteoporotic vertebral collapse/fracture which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. The pain tends not to be related to traumatic activities and can occue on standing up or bending forwards, even coughing and sneezing. The history of corticosteroid use is associated with osteoporosis through multiple mechanisms. The thoracic spine plain x-ray would show loss of height in one of the thoracic vertebrae. Osteoporotic changes may also be seen such as osteopenia. Treatment depends on the extent of spinal involvement and the severity of the pain and whether it is complicated by spinal deformity such as kyphosis. For the diagnosis of osteoporosis, a DEXA scan is needed indicating a T score of less than or equal to -2.5.
A 62 year old male complains of chest pain at rest. An ECG performed in A&E shows ST elevation. A subsequent angiogram with a provocative agent showed an exaggerated spasm of the coronary arteries.
A. Variant angina B. Pulmonary embolus C. MI D. Anxiety E. Congestive heart failure F. Unstable angina G. Stable angina H. GORD
A. Variant angina - Variant angina (Prinzmetal) is angina caused by coronary artery vasospasm rather than atherosclerosis. It occurs at rest and in cycles. Many patients will also have some degree of atherosclerosis although not in proportion to the severity of the chest pain experienced. ECG changes are of ST elevation (rather than depression) when the patient is experiencing an attack and a stress ECG will be negative. Patients with Prinzmetal angina are often treated for ACS and indeed, cardiac biomarkers may be raised as vasospasm can cause damage to the myocardium. The gold standard investigation is with coronary angiography and the injection of agents to try to provoke a spasm.
A 28 year old homeless man presents with tiredness and cough for over 3 months. His CXR showed patchy shadows in the upper zones. His sputum grew positive culture on Lowenstein-jensen medium after 4 weeks.
A. Bronchiectasis B. Sarcoidosis C. Sinusitis D. Wegeners Granulomatosis E. Silicosis F. Tuberculosis G. Asbestosis H. Idiopathic pulmonary fibrosis I. Asthma J. Streptococcal pneumonia K. Mycoplasma pneumonia L. Cystic fibrosis
F. Tuberculosis - This patient should be placed in isolation. His sputum culture results suggest TB which is an AFB growing on Lowenstein-Jensen medium. A sputum culture is the most sensitive and specific test for TB and whilst growth takes a long time, the positive culture is diagnostic of TB. Sputum cultures will be repeated during treatment until 2 consecutive negative cultures. Treatment consists of anti-TB medication. Ethambutol should be stopped if the AFB is sensitive to isoniazid and rifampicin. Pyridoxine should be given with isoniazid to help prevent neuropathy. Pyrazinamide is not recommended in acute gout or pregnancy. Treatment of MDR TB involves additional therapy with agents such as amikacin and ethionamide.
A 66-year-old was getting increasing confused over the last couple of days. She was admitted after a seizure. She appears distressed and is pyrexial with mild meningism but no rash. A CT head scan shows changes in the left temporal lobe and cerebral oedema.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Encaphalitis - Encephalitis (brain parenchyma inflammation) is not to be confused with meningitis where the meninges is inflammed (although meningoencephalitis can exist). In encephalitis, there is an altered state of consciousness (this patient is confused) and may there also be focal neurology. There is also a fever (exceptions, however, are subacute sclerosing panencephalitis, VZV and HCV). Other typical features include headache and seizures. It is a medical emergency and people are the extremes of age are more at risk. The list of possible causes is massive. HSV encephalitis is characterised by temporal lobe changes. Hypodense lesions and mass effect can be seen in the temporal lobes on CT. An MRI is a better test for encephalitis although it is less available when compared to CT.
If you suspect this diagnosis, empiral IV acyclovir should be started before the results of any investigations are known. A large proportion are caused by HSV and empirical therapy is backed up by RCTs which show improved mortality. You can change the treatment if the cause is known, for instance, ganciclovir for CMV. You should look for a rash which may give a clue to the aetiology. For example, vesicular patterns are seen in VZV, HSV and enteroviruses, EBV causes a maculopapular pattern after ampicillin, Lyme disease pathognomically gives erythema migrans whereas erythema nodosum might make you think of TB. The patient may also have animal/insect bites and a careful and thorough history is important.
A 25 year old male student drinks about 4 pints of beer a day, every day. He has no symptoms of alcohol dependency or physical problems. He is concerned his level of drinking may be harmful.
A. Treatment under Section 3, Mental Health Act 1984 B. Methadone programme C. Naloxone D. Physician advice E. Disulfiram F. Alcoholics anonymous G. Token economy H. Inpatient detoxification with chlordiazepoxide I. Antipsychotic medication J. Controlled drinking K. Aversion treatment L. Motivational interviewing
D. Physician advice - This (likely medical) student is not dependent nor does he have any physical symptoms but is concerned and aware that his drinking is harmful. At this stage he needs advice on the dangers of excessive alcohol consumption which is the first line intervention for those with patterns of problematic alcohol use but are not dependent (as well as those with mild dependence). The consultations can consist of one or more sessions with a doctor during which feedback can be given about the patient’s alcohol use and the consequences in a supportive and empathic manner. The doctor and patient can work together to develop an action plan for cutting down or eliminating alcohol use and then assessing how effective this is with subsequent visits. Motivational interviewing is a technique which can also be deployed in this situation.
A 12 month old boy has a 24 hour history of profuse diarrhoea and irritability. He has a low grade fever. Choose the single most discriminating investigation in the acute management from the list of options:
A. ESR B. Blood cultures C. Chest X-ray D. Urine culture E. Stool electron microscopy F. EEG G. Stool culture H. Culture of joint aspirate I. C-reactive protein J. Lumbar puncture K. Throat swab L. Full blood count M. CT brain
G. Stool culture - The best investigation for presumed infectious diarrhoea here is to do a stool culture. It is not an absolutely necessary investigation in most cases as the mainstay of treatment is supportive with rehydration and the correction of electrolyte imbalance. However, stool cultures should be sent from patients with symptoms which are persistent or severe enough to prompt the patient to seek medical attention. Cultures are also mandatory in cases of bloody diarrhoea and signs of systemic involvement. The cultures should be sent within 3 days of admission as the yield is significantly reduced beyond this time period – and results take 2-4 days to become available.
This condition is more common in the extremes of age and complications are also more common in these groups. The commonly examined complication is haemolytic uraemic syndrome, which develops in 10% of patients with E coli O157 infection. Another complication is death, which is uncommonly examined but needless to say most patients who die from infectious diarrhoea are at the extremes of age. Diarrhoeal illness in young infants under 2 years of age is characteristically caused by EPEC (enteropathogenic E coli). Use of antibiotics is controversial and in most cases is not necessary (except possible in traveller’s diarrhoea).
True or False, the accessory nerve allows you to shrug your shoulders.
True - It supplies trapezius, which is the muscle responsible for shrugging shoulders!
A young woman has been diagnosed with grave’s disease and has been receiving oral treatment for the past few weeks, she has developed a sore throat and a nasty cold.
A. Potassium Iodide B. Radioiodine C. Propranolol D. Propylthiouracil E. Surgical decompression F. Carbimazole G. Stop treatment
G. Stop treatment - The sore throat should be treated with a high index of suspicion as it might warn of neutropenic agranulocytosis, a serious side effect of Carbimazole. Bloods should be taken to determine if this has occurred and if so the drug should be stopped.
An unusually tall middle aged lady seen in clinic has a large painless lump in her neck that is fixed. The Dr also notes cervical lymphadenopathy and yellow white nodules on her lips. Pembertons sign is positive and a thoracic inlet scan confirms the compression. Her medical history includes surgery on her aortic valve and some work on her lens.
A. MEN 2B B. Medullary thyroid cancer C. Grave's disease D. Riedel's thyroiditis E. subacute lymphocytic thyroiditis F. late De Quervains thyroiditis G. Early De Quervains thyroiditis
A. MEN 2B - this fixed lump is accompanied by lymphadenopathy, warning bells go off that this may be malignant. There are local invasion signs also as confirmed by pemberton’
Pemberton’s sign - I put this into a thyroid exam, It can equally be justified in a respiratory examination. Basically you ask the patient to lift their arms straight above their head as high as possible and then listen for inspiratory stridor, look for facial flushing or distension of veins acorss the neck. You can ask the patient to tell you if they fell light headed when performing this test.
It basically looks to see if there is evidence of SVC (superior venae cava) syndrome. If there is a large goitre or apical lung tumour for example impinging on the SVC, lifting the arms will lead to compression and cause congestion of blood in the head. This can be seen as a plethoric face, a cyanosed face, the patient may experience nausea and headache etc.
Positive Pemberton’s sign signifies thoracic inlet obstruction causes of which include:
- Retrosternal goitre
- Lung carcinomas
- Aortic Aneurysms
Thoracic inlet scan shows that a goitre is compressing structures such as the Superior vena cava. This seems to be maligant..Medullary thyroid carcinoma. however the rest of the patient must be taken into account..she has a marfanoid appearance and suggestion of other features of the syndrome. the lens work would be to correct dislocation, and the aortic valve work no doubt was to correct aortic root dilatation and valve incompetency seen in Marfan’s. The nodules are neurofibromatoses typical of MEN 2b.s sign.
A 72-year-old man underwent hip replacement surgery. 8 hours post-op his urine output has been 30ml, 20ml and 5ml over last 3hours. He is now anuric and seems lethargic. Other vital signs remain normal.
A. Percutaneous gastrostomy B. Intravenous nutrition C. Cardiogenic shock D. Neurogenic shock E. Haemorrhagic shock F. Spinal shock G. Pulmonary oedema H. Urinary retention I. Acute renal failure J. Percutaneous jejunostomy K. Basal atelectasis
H. Urinary retention - This is clearly urinary retention. Urine output is gradually deteriorating in a step-wise manner and he is now anuric
70 yr old retired boiler maker presents with a 5 year history of exertional dyspnoea and a dry cough. The patient is non-smoker. Examination reveals fine crackles heard at the lung bases.
A. PE B. Chronic lymphatic leukaemia C. Pulmonary TB D. COPD E. Congestive cardiac failure F. Pulmonary fibrosis G. Acute lymphoblastic leukaemia H. Bronchopneumonia I. Iron deficiency anaemia J. Sarcoidosis K. Pernicious anaemia
F. Pulmonary fibrosis - Idiopathic pulmonary fibrosis (previously known as Cryptogenic fibrosing alveolitis) progresses over several years and is characterised by pulmonary scar tissue formation and dyspnoea. Patients complain of a non-productive cough and typically reproducible and predictable SOB on exertion. Boiler makers can come into contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. While this patient does not smoke, another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. End expiratory basal crackles are found on examination. These are described as ‘Velcro-like’ in quality. IPF is also associated with clubbing.
A 40-year-old African refugee has noticed recent weight loss. Although he attributed this to stress you are concerned when you detect generalised lymphadenopathy. Blood count shows neutropenia and thrombocytopenia.
A. Malignancy B. Anorexia nervosa C. Tuberculosis D. Addison's disease E. Malabsorption F. Infestation with helminths G. Cardiac failure H. Diabetes mellitus I. Hyperthyroidism J. Renal failure K. Liver failure L. Depression M. HIV
M. HIV - HIV is a retrovirus and there are two types, HIV 1 which is the main virus responsible and HIV 2 which is restricted to parts of West Africa. Weight loss is common in HIV and if more than 10% body weight is lost of BMI reduces to 18.5, this is an indication of more severe immunocompromise. Weight loss in HIV may result from malnutrition, co-existent TB infection or HIV wasting syndrome, the latter being an AIDS defining illness. Generalised lymphadenopathy is also common and is characterised by the painless enlargement of 2 more more non-contiguous sites of >1cm for >3 months. Neutropenia is also seen due to CD4 deficiency and thrombocytopenia may also be seen along with an anaemic picture.
There are WHO (stage 1-4) and CDC criteria used in clinical staging. This patient needs to have a CD4 count, HBV and HCV screen, VDRL (syphilis), tuberculin skin test (TB) and CXR. HIV viral load will also be assessed. Prophylaxis and immunisations should be considered against infections such as hepatitis, influenza, PCP and TB. When to initiate HAART depends on the clinical stage, CD4 and co-morbidities. This patient will need to be started on HAART. Classes of antiretrovirals include NRTIs, NNRTIs, protease inhibitors, fusion inhibitors and integrase inhibitors.
A 17 year old school girl presented with breast pain , changed from dull ache to severe continuous throbbing pain. The breast feels hot on palpation and she complains of hot flushes. On examination the whole breast is tender and engorged and nipple is tender.
A. Fibrocystic changes B. Breast cancer C. Necrotising fasciitis D. Galactocoele E. Costochondritis F. Phylloides tumour G. Diabetic breast lesion H. Mondor’s disease I. Raynaud’s phenomenon J. Fibroadenoma K. Breast abscess L. Fat necrosis
K. 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, hot, engorged and red breast suggests the possible 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.
Trachea deviated to the right. Hyper-resonant percussion on the left side with reduced breath sounds.
A. Pleurisy B. Emphysema C. Normal variant D. Pulmonary oedema E. Pleural effusion F. Lobar collapse G. Idiopathic pulmonary fibrosis H. Hyperventilation I. Pneumothorax J. Lobar pneumonia K. Chronic bronchitis
I. Pneumothorax - A tension pneumothorax shifts the trachea AWAY with hyper-resonance on affected side and reduced/absent breath sounds. A tracheal shift means this is a tension pneumothorax which needs immediate relief with a wide bore cannula inserted into the second intercostal space in the MCL.
A 55 year old woman presented with recent onset and rapid enlargement of the breast. On palpation, there is a large breast mass. Biopsy showed stromal and epithelial elements.
A. Intraductal papilloma B. Lobular carcinoma in situ C. Gynaecomastia D. Phylloides tumour E. Pregnancy F. Breast Abscess G. Fibroadenoma H. Mastalgia I. Nodularity J. Invasive breast cancer K.Adenoma
D. Phylloides tumour - A phylloides tumour is a fast growing fibroepithelial mass, as demonstrated here by the history and biopsy findings. It can be benign or malignant. The only cure is surgical, commonly a WLE.
An 80-year-old man with diabetes presents with black right great and second toes. He also has an ulcer on the ball of the foot.
A. Lumbar puncture B. Arteriogram C. Blood sugar D. Cold provocation test E. Full blood count F. Blood cultures G. Venous duplex scan H. Anti-neutrophil cytoplasmic antibody
B. Arteriogram - Diabetic neuropathy has lead to the painless ulcer developing over pressure points in the foot such as on the ball of this man’s foot. This may have resulted from an object becoming lodged in the shoe and eroding through the skin with walking. This is why it is important for diabetics to check their feet regularly and to wear specialised footwear. The black toes on his right foot are likely due to peripheral vascular disease. It is worth noting that peripheral vascular disease refers specifically to peripheral arterial disease. The first line study is an ABPI although an arteriogram can be done to identify areas of stenoses which can be treated surgically. The black mummified toes may have to be amputated.
Positive in cholecystitis.
A. Corrigan's sign B. Cullen's sign C. Trosseau's sign D. Raccoon eyes E. Grey-Turner's sign F. Murphy's sign G. Traube's sign H. Quincke's sign I. Muller's sign J. Chvostek's sign K. Battle's sign
F. Murphy’s sign - A positive Murphy’s sign may commonly be seen in cholecystitis. This is where palpation of the right subcostal region reveals tenderness. During deep inspiration, the tenderness suddenly becomes worse and there is inspiratory arrest as a result. This sign can also be elicited during ultrasound examination when pressure is applied using the ultrasound probe.
Trachea deviated to left. Dull to percussion & reduced breath sounds at left base.
A. Pleurisy B. Emphysema C. Normal variant D. Pulmonary oedema E. Pleural effusion F. Lobar collapse G. Idiopathic pulmonary fibrosis H. Hyperventilation I. Pneumothorax J. Lobar pneumonia K. Chronic bronchitis
F. Lobar collapse - Collapse pulls the trachea TOWARDS the affected side. There is dullness and reduced/absent breath sounds due to a lack of air filled lung in this space. Do you know how to identify which lobe has collapsed on a CXR? The findings in this examination are consistent with LLL collapse. A ‘sail sign’ will classically be seen behind the cardiac shadow on CXR.
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.Which drug should NOT be given
A. Diclofenac B. Epidural bupivacaine and fentanyl C. Codydramol D. Paracetamol E. Morphine F. Tramadol
A. 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 13 year old girl presents with increasing SOB, particularly when lying down at night to try to sleep. She has also noticed some ankle swelling. Examination reveals a raised JVP, tachycardia and an S3 gallop rhythm on cardiac ascultation.
A. Kawasaki disease B. Myocarditis C. Juvenile idiopathic arthritis D. Primary pulmonary hypertension E. Aortic stenosis F. Hereditary angio-oedema G. Pericarditis H. Congestive cardiac failure I. Toxic synovitis J. Acute rheumatic fever K. Congenital nephritic disease
H. Congestive cardiac failure - The signs and symptoms this patient has points to CCF (congestive cardiac failure). SOB with orthopnoea due to the sudden increase in pre-load, indicates LV failure. Neck vein distension is also present, which is a major Framingham criteria for diagnosis. Tachycardia and ankle oedema are both minor criteria for diagnosis. Other major criteria for diagnosis include S3 gallop, cardiomegaly and hepatojugular reflux. For all patients, initial investigations should include ECG, CXR, TTE and bloods including BNP levels.
CXR may reveal pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion. CCF in children occurs as a result of various congenital abnormalities as well as rheumatic fever. Congenital causes include aortic stenosis, PDA and Eisenmenger’s syndrome.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Bladder cancer
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
A. Aniline dyes - Contact with aniline dyes (not azo dyes) is associated with bladder cancer
A 50 year old man with a 1 month history of progressive abdominal distension preceded by increased tiredness, shortness of breath on exertion & weight loss of 10kg. There is a non-tender irregular mass in the right iliac fossa.
A. Tuberculous peritonitis B. Heart failure C. Budd Chiari syndrome D. Liver cirrhosis E. Primary liver tumour F. Carcinoma of the ovary G. Bacterial peritonitis H. Primary biliary cirrhosis I. Secondary liver tumours J. Nephrotic syndrome K. Carcinoma of caecum with peritoneal secondaries
K. Carcinoma of the caecum with peritoneal secondaries - The weight loss of 10kg, fatigue and non-tender irregular RIF mass point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis. The progressive abdominal distension indicates the presence of peritoneal secondaries, which causes vague symptoms. Treatment in this case for a cancer that has become widely metastatic will be palliative.
50 yr old man presents with typical history of exertional angina with ischaemic changes on resting ECG. Coronary angiography shows 70% stenosis of the left anterior descending artery with no significant lesions elsewhere.
A. Coronary angiography B. Exercise ECG C. Beta blockers D. Thallium scan E. CABG F. Long acting nitrates G. Angioplasty H. Ace inhibitors I. Nifedipine
G. Angioplasty - Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Most single vessel disease can be adequately managed with PCI.
A 75 yo man with a 50 pack year history complains of weight gain and tingling in his hands especially at night, he also feels generally lethargic. The last time he was in hospital he was receiving treatment after having something ‘nasty’ cut out of his tongue.
A. Myxoedema coma B. Hashimoto's thyroiditis C. Amiodarone D. external neck irradiation E. Addisonian crisis F. De Quervains thyroiditis G. Grave's disease H. Thyroxine abuse
D. External neck irradiation - The man’s history points to oral cancer, for which he would have received a wide local excision most likely. This would have been followed up with radiotherapy to the local nodes and tissues of the neck. In this gentleman the radiation has caused his thyroid to become underactive hence the lethargy and tiredness. The tingling in his hands at night is a classic presentation of Carpal tunnel syndrome (median nerve compression at the flexor retinaculum) which has an increased incidence in patients with hypothyroidism.
Contraction of the muscles of the face when tapped gently on the cheek. Sign of hypocalcaemia.
A. Corrigan's sign B. Cullen's sign C. Trosseau's sign D. Raccoon eyes E. Grey-Turner's sign F. Murphy's sign G. Traube's sign H. Quincke's sign I. Muller's sign J. Chvostek's sign K. Battle's sign
J. Chvostek’s sign - Trousseau’s sign is carpal spasm when a blood pressure cuff is used for several minutes. Carpopedal spasm that occurs with hypocalcaemia is a painful spasm and could be the presenting sign. Chvostek’s sign is twitching of the perioral muscles in response to tapping over the facial nerve at the ear. If urgent replacement is necessary, calcium gluconate can be given IV. It is preferred over calcium chloride as it causes less tissue necrosis if it leaks out. It is worth noting that digoxin may be ineffective until serum calcium is restored to normal.
An 80-year-old woman presents with recent onset of effort-related chest pain. On examination of the cardiovascular system she is found to have a loud ejection systolic murmur and a low pulse pressure with a slow rising pulse.
A. Atrial septal defect B. Mixed mitral valve disease C. Ventricular septal defect D. Aortic regurgitation E. Infective endocarditis F. Aortic stenosis G. Innocent murmur H. Mixed aortic valve disease I. Mitral valve prolapse J. Hypertrophic obstructive cardiomyopathy K. Mitral stenosis L. Mitral regurgitation M. Mixed mitral and aortic valve disease
F. Aortic stenosis - Aortic stenosis can present with chest pain, dyspnoea and syncope. It is characterised by a harsh ejection systolic murmur heard loudest at the right upper sternal edge at end expiration, which radiates up towards the carotids. The pulse pressure is narrow and there may be an associated slow-rising and plateau pulse. Doppler echo is vital for diagnosis and shows a pressure gradient across the narrowed valve orifice. 20% of cases are due to a congenital bicuspid valve. The most common cause of aortic stenosis in adults is calcification of normal trileaflet valves. Clinically stable patients may be considered for surgical repair or TAVR.
A 3 year old has had a high fever and sore throat for 2 days. This evening he had a generalised convulsion lasting 2 minutes. He is now drowsy but rousable with no localising signs. Choose the single most discriminating investigation in the acute management from the list of options:
A. ESR B. Blood cultures C. Chest X-ray D. Urine culture E. Stool electron microscopy F. EEG G. Stool culture H. Culture of joint aspirate I. C-reactive protein J. Lumbar puncture K. Throat swab L. Full blood count M. CT brain
K. Throat swab - This child has septicaemia secondary to a throat infection caused by group A beta-haemolytic streptococcus (Streptococcus pyogenes). This is no additional reason to believe that this is toxic shock syndrome or rheumatic fever, but the sore throat and fever for 2 weeks requires a culture of a throat swab to look for the causative organism. This is the most specific and sensitive test for GAS. However, a rapid antigen test can also be done for GAS which is about 80% sensitive and 95% specific compared to a throat culture but obviously much quicker. Blood cultures can also be done as the infection is now systemic but the throat culture is the best choice here as this is the obvious initial source of the infection. Treatment is with antibiotics and may be with penicillin or amoxicillin. GAS resistance to macrolides has been reported. Supportive care in this patient is also essential.
A 64-year-old, previously obese woman complains of weight loss, despite increased appetite and says she has been treating herself for ‘repeated urine infections’. She also says that over the last few months she has been getting pins and needles in her legs.
A. Full blood count and ESR B. Abdominal CT C. HIV antibody test D. Colonoscopy E. Blood test for auto-antibodies F. Thyroid function tests G. Bronchoscopy H. Fasting blood glucose I. Chest x-ray J. Bone marrow aspirate K. History only L. Gastroscopy M. Brain scan
H. Fasting blood glucose - T2DM can present with yeast, skin and urinary tract infections on top of unintentional weight loss and fatigue. The pins and needles in her legs is a result of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. There tends to be loss of sensation typically occuring in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain or paraesthesia. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0.
An 80 year old man fainted with a 2 week history of abdominal pain and coughing up a black coffee-ground like substance. He has been feeling irritable, tired and sleepy.
A. Hypoglycaemia B. Anaemia C. Stokes-Adams attack D. Opioid overdose E. Postural hypotension
B. Anaemia - This man is anaemic and as a result he has fainted. This is IDA from a UGI bleed. His faint can also be attributed to hypovolaemia from his blood loss, from a presumed peptic ulcer (which accounts for his abdominal pain and coffee ground vomit). Whilst he may also display postural hypotension due to his hypovolaemia, this is not what this question is looking for.
A middle aged women is seen in clinic complaining that she is depressed and that her taste is impaired, she also has muscle aches. The dr reviews her bloodwork and sees her cholesterol and creatine kinase are elevated. He examines her neck and feels a firm, rubbery structure overlying the trachea that moves on swallowing.
A. Myxoedema coma B. Hashimoto's thyroiditis C. Amiodarone D. external neck irradiation E. Addisonian crisis F. De Quervains thyroiditis G. Grave's disease H. Thyroxine abuse
B. Hasimoto’s thyroiditis - This patient has signs of hypothyroidism; depressed mood and impaired taste. Also she has hypothyroid myopathy, evidenced both symptomatically and biochemically by the elevated creatine kinase. Further to this it is worth noting that hypothyroidism has other effects that can be seen on bloodwork. Amongst these are anaemia and hypercholesterolaemia. It is the thyroid that moves on swallowing and on examination hers is rubbery and firm, this is typical of hashimoto’s thyroiditis which is one of the leading causes of hypothyroidism in the uk. De quervains is not an option owing to lack of preceding viral infection and no tenderness over the neck.
Hashimoto’s thyroiditis An Autoimmune thyroiditis with associations with HLA -DR5 (and some conditions such as Turner’s syndrome, T1DM and pernicious anemia) that shows T - lymphocyte infiltration of the gland and reactive antibodies against the TSH receptor and less commonly Thyroglobulin. It is most prevalent in middle aged women and is a prominent cause of goitre, due to the infiltration of the gland and elevated TSH levels (since T4 production is decreased). Note that at presentation most patients are euthyroid, although around half end up hypo due to destruction of the thyroid. It is possible to be toxic with hasimotos. Hashitoxicosis however is rare and can be transient. Treatment is generally thyroxine T4 given at doses sufficient to suppress endogenous T4 production and minimise TSH, this is done to lessen the risk of a goitre forming and subsequently growing.
A 40 year old man returned from India 4 days ago & came down with fever. He went to his GP & got some paracetamol. His fever persisted, & he had a few bouts of diarrhoea & cough. He started getting drowsy & was admitted from casualty where his blood culture was taken. The next day the lab reported Gram negative bacilli seen on blood culture.
A. Mycobacterium tuberculosis B. Legionella pneumophila C. Dengue virus D. Falciparum malaria E. Lassa fever F. Entomoeba histolytica G. Streptococcus pneumoniae H. Salmonella typhi I. Neisseria meningitidis type B J. Influenza
H. Salmonella typhi - Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic – India, for example, which has the highest incidence of this disease. Mexico should also ring alarm bells. The water supplies are not treated and sanitary conditions are dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a high fever which is a hallmark of infection (sometimes in a step-wise manner) which is not responding to paracetamol (it persists) and blood culture (you need a big sample of blood for testing as count is usually low) shows a gram negative bacilli, and he has returned from an endemic region. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.
This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.
A 45 year old female with a history of psychological problems presented with difficulty swallowing which had been getting progressively worse over the last 6 months. She described a sensation of a lump in the throat but after examinations and an endoscopy, no cause could be found.
A. Diffuse oesophageal spasm B. Eosinophilic oesophagitis C. Upper oesophageal web D. Globus hystericus E. Benign oesophageal stricture F. Oesophageal diverticulum G. Candidal oesophagitis H. Scleroderma I. Parkinson’s disease J. Achalasia K. Oesophageal cancer L. Stroke
D. Globus hystericus - Globus hystericus is a sensation of fullness or a lump in the neck or difficulty swallowing which is not a true case of dysphagia. Swallowing can be performed normally and there is no real lump or obstruction in the throat. In some cases the cause is unknown and is believed to be psychogenic in cause and is associated with anxiety disorders. In other cases throat inflammation can cause this sensation. The normal examination and endoscopy here in a patient with a psychiatric history is diagnostic.
A 70-year-old man complains of weight loss, headache, blurry vision and haematuria. O/E you notice cervical lymphadenopathy and splenomegaly. Bone marrow biopsy shows a lymphoplasmacytoid cell infiltrate with few plasma cells.
A. Non-Hodgkin's lymphoma B. Monoclonal gammopathy of unknown significance C. Waldenstrom's macroglobulinaemia D. Acute lymphoblastic leukaemia E. Burkitt's lymphoma F. Hodgkin's lymphoma G. Chronic lymphocytic leukaemia H. Myeloma I. Acute myeloid leukaemia J. Myelofibrosis K. Chronic myeloid leukaemia
C. Waldenstrom’s macroglobulinaemia - Waldenstrom’s macroglobulinaemia is a lymphoproliferative disorder of B cells, which take on a lymphoplasmacytoid appearance. It is characterised by the production of immunoglobulin M (IgM), which gives rise to the clinical features of hypervisosity (nosebleeds, blurred vision, retinal haemorrhage etc.)
44 year old diabetic with renal impairment. Fundoscopy revealed AV nipping, silver wiring and small haemorrhages.
A. Atrial septal defect B. Chemotherapy C. Aortic stenosis D. Mitral stenosis E. Aortic regurgitation F. Systemic hypertension G. Pulmonary hypertension H. Mitral valve prolapse I. Alcohol
F. Systemic hypertension - Fundoscopy clearly demonstrates changes associated with hypertensive retinopathy. There are 4 grades:
Grade 1: ‘Silver wiring’ and tortuous vessels,
Grade 2: Plus ‘AV nipping’,
Grade 3: Plus cotton wool spots (previously called soft exudates but they are not exudates) and flame haemorrhages,
Grade 4: Plus papilloedema
For each situation choose the single most likely diagnosis from the options. Each option may be used once, more than once or not at all.
50 yr old man attends A&E with SOB, fever and hyperdynamic regular pulse of 100. BP 160/60 mmHg. He has a murmur at the left sternal edge. On further enquiry it is found he attended for a routine dental procedure 2 months ago.
A. Aortic regurgitation B. Mitral incompetence C. Mixed mitral and ahortic valve disease D. Mitral stenosis - rheumatic E. Infective endocarditis F. Innocent murmur G.Aortic stenosis H. Hypertrophic obstructive cardiomyopathy I. Mixed aortic valve disease J. Mixed mitral valve disease K. Mitral regurgitation- rheumatic
E. Infective endocarditis - Any patient presenting with fever and a new murmur should always make you think of bacterial endocarditis. The classic new or worsening murmur is actually rare. As are splinter haemorrhages, which this patient has. Other uncommon signs you may find include Janeway lesions (painless macular haemorrhagic plaques on the palms and soles) and Osler nodes (painful nodules on the pads of the fingers and toes). Roth spots may also be seen on fundoscopy. Three sets of bood cultures are required and this patient will have to go for an echocardiogram.The Duke criteria is used for diagnosis.
A 60 year old diabetic man with fever, malaise, headache and muscle pains. After a few days he became very ill and is now confined to his bed with a hot water bottle.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
K. Influenza - Diabetics are more suspectible to infectious such as flu. This is an acute respiratory tract infection caused by seasonal viral influenza A or B, hence antibiotics would have no effect. It is characterised by respiratory symptoms including rhinorrhoea, cough, fever, chills, headache and myalgia. Examination can be expected to be otherwise unremarkable. Antigenic change presents a challenge in creating new vaccines as there is no incremental protection from previous vaccinations. There have been 4 pandemics since 1918, the recent one being ‘swine flu’ in April 2009, caused by new gene rearrangement of human, avian and swine influenza.
An 80 year old female with a history of rheumatic fever in childhood & palpitations presents with shortness of breath. On examination he has an irregularly irregular pulse of 120bpm & loud first heart sound.
A. Mitral stenosis B. Pneumonia C. COPD D. Pneumothorax E. Anaemia F. Left ventricular failure G. Thyrotoxicosis H. Epiglottitis I. Asthma J. Anxiety K. Aspirin poisoning L. Pulmonary embolus M. Mitral regurgitation
A. Mitral stenosis - Practically every single case of mitral stenosis is caused by rheumatic heart disease. The major criteria for rheumatic fever can be remember by CASES: carditis, arthritis, Sydenham’s chorea, erythema marginatum and subcutaneous nodules. The process tends to also cause regurgitation. Mitral stenosis is characteristically a grade 1-2 low pitch murmur heard in mid-diastole which has a rumbling nature and there is no radiation. There can be an associated malar flush, tapping apex beat and a diastolic thrill palpable at the apex, in the 5th intercostal space in the MCL. The first heart sound is also characteristically loud and often this is the most striking feature on ascultation. It is a difficult murmur to pick up so if you are ever asked at this stage to spot this murmur, it will most likely be based on the loud S1. Mitral stenosis is associated with AF caused by LA enlargement (seen by the irregularly irregular pulse).
A 27-year-old with severe headaches and hypertension is found to have phaeochromocytoma. Further investigations reveal he has hypercalcaemia secondary to hyperparathyroidism. The alarmed clinician orders a thyroid biopsy which confirms his suspicions.
A. Nelson's syndrome B. Pseudo-Cushing's syndrome C. MEN I D. Simmond’s disease E. DiGeorge's syndrome F. Kallmann's syndrome G. MEN II H. Cushing's disease I. Pituitary apoplexy J. Sheehan's syndrome
G. MEN II - MEN (Multiple Endocrine Neoplasia) syndromes are hereditary autosomal dominant tumour syndromes with distinct patterns of organ involvement. At this stage, the purely simplified patterns (classification is actually more complicated) you need to be familiar with are: MEN1 consists of parathyroid adenomas, pancreatic tumours and pituitary adenomas. MEN2A consists of parathyroid, medullary thyroid cancer and phaeochromocytoma. And MEN2B or 3 consists of what is seen in 2A plus the addition of a marfanoid phenotype and ganglioneuromas (intestinal and visceral).
Prophylactic thyroidectomy in childhood is indicated in MEN2. Medical management is aimed at controlling hormone hypersecretion. Surgery is often done on tumours. If you’re really interest, you can look MEN syndromes up in more detail. MEN1 is typically caused by mutations in the MEN1 gene whereas MEN2 is typically caused by mutations in the RET proto-oncogene.
A 22 year old female presents with recurrent slurred speech which gets worse as she continues to talk. Her friends think she is retarded. She also has difficulty swallowing which worsens as she continues to eat. There is also some double vision.
- Myasthenia gravis
- Multiple sclerosis
- Chronic subdural haematoma
- Embolic stroke
- Myasthenia gravis - MG is characterised by muscle weakness that increases with exercise and improves on rest. It is a chronic autoimmune disorder of the post-synaptic membrane at the NMJ in skeletal muscle.
82 year old man with hypertension for many years. He presents with increasing shortness of breath particularly when lying flat, & ankle swelling. On examination JVP is raised, BP 140/60, pulse 120/minute in atrial fibrillation.
A. Arterial doppler studies B. Lymphangiogram C. Chest x-ray D. Venous doppler studies E. 24 hour urine protein F. Pelvic ultrasound G. Liver function tests H. Plasma creatinine I. Coagulation screen J. Full blood count
C. Chest x-ray - The signs and symptoms this patient has points to CCF (congestive cardiac failure). This patient has a history of hypertension and is elderly. Other key cardiovascular risk factors include MI, DM and dyslipiaemia. SOB with orthopnoea due to the sudden increase in pre-load, indicates LV failure. Neck vein distension is also present, which is a major Framingham criteria for diagnosis. Tachycardia and ankle oedema are both minor criteria for diagnosis. Other major criteria for diagnosis include S3 gallop, cardiomegaly and hepatojugular reflux. For all patients, initial investigations should include ECG, CXR, TTE and bloods including BNP levels.
CXR may reveal pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion.
A 22 year old lady complains of being tired all the time. She has also gained a large amount of weight, feels constipated and cold all the time. Her HR ~ 45 bpm.
A. Glandular fever B. Hyperthyroidism C. Anaemia D. Psychological distress E. SIADH F. AIDS G. Colorectal carcinoma H. Diabetes mellitus I. Hypothyroidism J. Addison's disease K. Chronic renal failure
I. Hypothyroidism - There is weight gain, cold intolerance, fatigue and constipation as well as bradycardia which all point to 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 as well as depression, bradycardia, sluggish reflexes, constipation, cold intolerance 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 woman from Jamaica presents with a 6 month history of weight loss and a two week history of fever. On examination she had cervical lymphadenopathy. Her calcium was raised at 3.0 and CXR showed bilateral hilar lymphadenopathy.
A. Post immunisation B. Glandular fever C. Pneumonia D. HIV infection E. Malaria F. Drug reaction G. SLE H. Sarcoidosis I. Appendicitis J. Influenza K. Tuberculosis L. Hodgkin's lympoma M. Gastric carcinoma N. Pyelonephritis
H. Sarcoidosis - Sarcoidosis is a chronic multisystem disease with an unknown aetiology. Lymphadenopathy is a common presentation and nodes are enlarged but non-tender, typically involving the cervical and submandibular nodes. Although uncommon, the patient may present with unexplained modest weight loss (which is often mistaken for TB or lymphoma along with the abnormal CXR) and a low-grade fever. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids. Skin manifestations include erythema nodosum which are tender erythematous nodules and lupus pernio presenting with indurated plaques with discoloration on the face.
A 56 year old man on NSAIDs and amoxicillin for bronchitis develops a rash. He is mildy febrile despite the resolution of his bronchitis. The patient is confirmed to be in acute renal failure with elevated urea and creatinine and there is also pedal oedema. He is not oliguric. FBC shows eosinophilia.
A. Normal variant B. Essential hypertension C. Renal artery stenosis D. SLE E. Shock F. Acute interstitial nephritis G. Pre-eclampsia H. Polycystic kidney disease I. Chemotherapy J. Obstructive uropathy K. Diabetic nephropathy
F. Acute interstitial nephritis - Acute interstitial nephritis classically presents with acute renal failure associated with oliguria and the ‘hypersensitivity triad’ of rash, fever and eosinophilia triggered by a drug. This can commonly be antibiotics, especially beta-lactams, and NSAIDs, though the range of triggering medications is vast. Oliguria can be present in more severe cases. There is inflammation of the renal interstitium, as suggested by the name, and this is likely a hypersensitivity reaction. It can also occur in the setting of a chronic inflammatory disease instead of being drug triggered. It will usually resolve once you stop the offending drug and treatment is supportive, though corticosteroids can be given to dampen the reaction. Most patients recover but have some residual impairment.
A 55-year-old gentleman complains of progressive weakness in his left hand. On examination, you notice that there is wasting of the intrinsic muscles of the hand innervated by the T1 nerve root. There is also mild ptosis and meiosis on the left hand side of his face.
A. Burkitt's lymphoma B. Grawitz's tumour C. Kaposi's sarcoma D. Wilm's tumour E. Pancoast tumour F. Ewing's sarcoma G. Brodie's tumour H. Hodgkin's lymphoma
E. Pancoast tumour - Pancoast tumours are lung tumours located at the apex of the lung. They typically extend to involve the sympathetic ganglion resulting in ipsilateral Horner’s syndrome (ptosis, meiosis, anhydrosis). In some cases, the lower roots of the brachial plexus are also involved, resulting in pain and weakness in the muscles of the arm and hand, specifically in the T1 distribution.
A 52 year old woman has recently developed constipation & feels that she does not completely empty her rectum on defecation. She has passed blood per rectum on 2 occasions.
A. Parkinson’s disease B. Hypercalcaemia C. Colorectal carcinoma D. Diverticular disease E. Hypothyroidism F. Pelvic trauma G. Irritable bowel syndrome H. Chronic laxative abuse I. Hirschsprung’s disease J. Adverse effect of drugs
C. Colorectal carcinoma - This a rectal carcinoma. Tenesmus, blood and mucus PR alongside weight loss and anorexia are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.
An 18 yo girl is seen in A+E, she has a macular rash covering her body, is photophobic and kernigs sign is positive. The girl is hypotensive and started on ceftriaxone immediately. She fails to respond to an ACTH stimulation test. BMs s disease B. Alcohol C. Meningitis D. Insulinoma E. Insulin F. dumping syndrome G. Gliclazide H. Waterhouse-Friderichsen syndrome I. Starvation
F. Waterhouse-Friderichsen syndrome - Adrenal haemorrhage following massive gram negative meningitis
A 65-year-old lady presents with back pain. She has had it for about 3 days. Examination is normal but in her blood tests, ALP is elevated.
A. Perforated duodenal ulcer B. Mesenteric infarction C. Pericarditis D. Metastatic disease E. Pyelonephritis F. Pancreatitis G. Myocardial infarction H. Addison’s disease I. Volvulus J. Ruptured abdominal aortic aneurysm K. Renal colic L. Spinal stenosis M. Dissecting aortic aneurysm N. Hepatitis
D. Metastatic disease - Back pain and a raised ALP is an ominous finding which is usually indicative of bone metastases. Alkaline phosphatase is an enzyme which is also a marker for bone turnover. There is often a history of maligancy before this back pain and commonly implicated malignancies include breast, lung, prostate, thyroid and kidney cancer. Neurological deficits may occur if the tumour destruction is extensive and causes compression of nerves. The patient may also have generalised systemic symptoms on examination including fever, chills, weight loss and focal tenderness. XR may demonstrate lysis of the vertebral body and MRI may show up a lytic or blastic lesion.
True or False, third nerve palsy is associated with a ‘down and out’ pupil.
True - Because the actions of the trochlear and abducens nerve are unopposed now.
A clonidine suppression test is performed on a young man complaining of occasional palpitations and anxiety, his plasma catecholamines are suppressed. However his symptoms persist until he eats some of his jelly babies
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
F. Insulinoma
A holiday worker had a severe chest infection abroad & was diagnosed to have influenza A infection. He was improving but suddenly deteriorated with the last 24 hours becoming breathless, febrile & septic. X-ray chest showed circular opacities some with a fluid level. Gram stain of sputum showed Gram positive cocci in clusters.
A. Mycoplasma pneumonia B. Streptococcus pneumonia C. Varicella zoster D. Adenovirus E. Pneumocystis jirovecii F. Influenzae A G. Haemophilus influenza H. Group A streptococci I. Staphylococcus aureus J. Corynebacterium diphtheriae K. Legionella pneumophila L. Escherichia coli M. Aspergillus fumigatus N. Clamydia pneumoniae
I. Staphylococcus aureus - Think Staphylococcus aureus for post-influenza pneumonia. It causes a cavitating pneumonia which explains the CXR findings (some abscesses are also seen) and Gram stain of culture yields grape like clusters of Gram positive cocci which is consistent with staphylococcus. Treatment of staphyloccocal infection is with flucoxacillin or vancomycin if MRSA.
A 28-year-old woman has developed rapid weight loss and palpitations. You notice lid lag and a goitre on examination.
A. TB abscess B. Graves disease C. Hodgkin's disease D. Myxoedema E. Pancreatic carcinoma F. Superior vena cava syndrome G. De Quervain's thyroiditis H. Hashimoto's thyroiditis I. Thyroid cancer J. Euthyroid goitre K. Carotid artery aneurysm L. Thyroglossal cyst
B. Graves disease - This woman has symptoms of hyperthyroidism (weight loss and palpitations) and a goitre. In countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Graves’ gives a diffuse goitre. Peripheral manifestations such as ophthalmopathy, pretibial myxoedema and hyperthyroid acropachy do not occur with other causes of hyperthyroidism. Ophthalmopathy includes lid retraction, exophthalmos and eye movement restriction leading to diplopia. Acropachy is an uncommon manifestation presenting as clubbing with soft tissue swelling. Pretibial myxoedema is almost always associated with ophthalmopathy. 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 55-year-old lady describes 10 minutes yesterday when she was unable to see out of her left eye. The symptoms have resolved but on duplex scan, her internal carotid artery is 75% stenosed.
A. Angioplasty B. Femoral-distal bypass C. Aortobifemoral bypass D. Methyldopa E. Ultrasound F. Alpha blocker G. Embolectomy H. Endarterectomy I. Angiography J. Endovascular aneurysm repair K. Open repair of aneurysm
H. Endarterectomy - Amaurosis fugax is a transient and painless loss of vision in one eye due to the passage of an embolus into the central retinal artery. This temporary arrest of blood flow leads to vision loss. The cause could be embolic from the internal carotid artery to cause an occlusion of the ipsilateral retinal artery. Patients presenting in this way should be investigated for carotid artery stenosis with a carotid Doppler ultrasound and if there is a stenosis of >70%, the patient may be a candidate for carotid endarterectomy. Presence of ipsilateral carotid stenosis suggests artery-to-artery embolic event as the cause here and this should be the target for surgical or interventional treatment.
A 45 year old man comes to A&E with shortness of breath, giving a history of decreased exercise tolerance. On examination the patient is noted as having an irregular pulse, warm vasodilated peripheries, exopthalmos & a goitre.
A. Atrial fibrillation B. Unstable angina C. Atrial flutter D. Left ventricular failure E. Congestive cardiac failure F. Myocardial infarction G. Decubitus angina H. Constrictive pericarditis I. Stable angina J. Bacterial endocarditis
A. Atrial fibrillation - This patient has hyperthyroidism. More specifically, Graves’ disease (peripheral manifestations such as ophthalmopathy do not occur with other causes of hyperthyroidism). Treatment of Graves’ 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. This patient has AF which has occured as a result of his hyperthyroid state which affects around 10% of untreated patients. Irregular HR is the hallmark feature of AF. Have a think about what the ECG would show.
A 45-year-old woman complains of abdominal pain for several months. On examination she is jaundiced with a distended abdomen and skin telangiectasia.
A. Depression B. Fatty liver C. Rhabdomyolysis D. Cirrhosis E. Macrocytosis F. Fibromyalgia G. Malnutrition H. Wernicke’s encephalopathy I. Chronic subdural haematoma J. Peptic ulceration K. Acute intoxication L. Delirium tremens
D. Cirrhosis - Cirrhosis is the end stage of chronic liver disease which results in hepatic insufficiency and portal hypertension, causing this patient’s jaundice, a sign a decompensation. Jaundice is also seen here reflecting reduced hepatic excretion of conjugated bilirubin and there may be associated pruritis. Telangiectasia is a sign of chronic liver disease. Risk factors for cirrhosis include alcohol, IVDU, unprotected sex and blood transfusion. This gives us an insight into the causes which include chronic viral hepatitis (C, B with or without D) and alcoholic liver disease. Other causes include conditions such as Wilson’s disease, NAFLD, haemochromatosis, Budd-Chiari syndrome and drug induced such as amiodarone and methotrexate.
Each of these patients has been found to have raised blood prolactin, select the most likely aetiology for each case.
A woman has suffered with hypothyroidism for 20 years, she still complains of feeling cold and a bit sluggish.
A. inadequate treatment B. Metoclopramide C. Ibuprofen D. Macroadenoma E. Acetaminophen F. non epileptic seizure G. Microadenoma H. epileptic seizure
A. Inadequate treatment
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.
A. Lumbar puncture B. Arteriogram C. Blood sugar D. Cold provocation test E. Full blood count F. Blood cultures G. Venous duplex scan H. Anti-neutrophil cytoplasmic antibody I. CT scan
I. 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 40 year old female who had been taking ibuprofen for pain relief when she gets headaches, presents to A&E with a history of weight loss and melaena with pain in her epigastric region. The pain gets worse with eating.
A. Duodenal ulcer B. Crohn's disease C. Meckel's diverticulum D. Oesophageal varices E. Gastric ulcer F. Mallory-Weiss tear G. Ulcerative colitis H. Oesophageal malignancy I. Oesophagitis
E. Gastric ulcer - The patient has a bleeding peptic ulcer (the black tarry stools from the UGI bleed). Epigastric pain and tenderness related to eating a meal is typical of a peptic ulcer. 80% are duodenal and 20% are gastric. Ulcers may cause iron deficiency anaemia and associated symptoms may feature. Key risk factors are NSAID use, like in this patient, 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 60 year old alcoholic is hospitalised after an episode of haematemesis. He is about to undergo endoscopy. What would his liver biopsy likely low evidence of?
A. Hepatitis B B. Extensive necrosis C. Hypervascularity D. Extensive cirrhosis E. Cholecystitis F. Pancreatic carcinoma G. Pancreatic pseudocyst H. Hepatitis C I. Enlarged right lobe J. Portal chronic inflammation K. Arterio-venous malformations L. Hepatocellular carcinoma
B. Extensive necrosis - This is a case of haematemesis secondary to oesophageal varices. Oesophageal varices are a direct result of portal hypertension, which occurs as a progressive complication of cirrhosis, which is what liver biopsy will show. Diagnosis and surveillance by endoscopy is an important part of management of this condition and in terms of prophylaxis against variceal bleeding before it has occured, non-selective beta blockers and/or endoscopic ligation can be used.
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.
A. Diabetes Insipidus B. Adrenal adenoma C. Nelson's syndrome D. Pituitary apoplexy E. Conns Adenoma F. Drug withdrawal G. Addison's disease H. Tuberculosis I. Sheehan's syndrome J. Cushing's disease K. Ectopic ACTH producing tumour L. Addisonian crisis
D. 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 of 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.
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 37.5ºC.
A. Epididymal cyst B. Testicular torsion C. Hydrocoele D. Varicocele E. Squamous cell carcinoma F. Testicular malignancy G. Epididymo-orchitis H. Testicular TB I. Hernia J. Heart failure K. Undescended testicle
G. 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.
A 60-year-old man with diabetes is transferred from another hospital for urgent femoral-distal bypass surgery and arrives with a heparin infusion in situ. His APTT is 2.4.Which drug should NOT be given
A. Diclofenac B. Epidural bupivacaine and fentanyl C. Codydramol D. Paracetamol E. Morphine F. Tramadol
B. Epidural bupivavaine 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.
An 82-year-old man admitted through A&E with confusion. BP 90/60. JVP not seen. His hands and feet were cool. Plasma creatinine 420 μmol/l, urea 55 mmol/l. After catheterisation, 200mls mucky urine was drained from his bladder.
A. Renal ultrasound B. CVP measurement C. Renal biopsy D. Plasma electrophoretic strip E. Intravenous pyelogram F. Renal arteriogram G. HIV test H. Anti-neutrophil cytoplasm antibodies I. Anti-glomerular basement membrane antibody J. Captopril renogram
B. CVP measurement - A confused hypotensive shocked patient might be hypotensive because of cardiac disease (which will cause a raised JVP) or due to sepsis (which will cause a low JVP). If you can’t see the JVP, then you should put in a central line to measure the CVP accurately to tell you if the cause of the low blood pressure here is sepsis or cardiac failure
73 year old man was reviewed in the diabetic clinic. He was complaining of increasing tiredness & loss of appetite. His ankles had become more swollen over the last few weeks.
A. Arterial doppler studies B. Lymphangiogram C. Chest x-ray D. Venous doppler studies E. 24 hour urine protein F. Pelvic ultrasound G. Liver function tests H. Plasma creatinine I. Coagulation screen
H. Plasma creatinine - Diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function.
A 45-year-old lady presents with retrosternal dysphagia. She has spoon-shaped nails and is noted to be pale.
A. Cerebrovascular accident B. Pharyngeal pouch C. Hiatus hernia D. Pneumonia E. Myasthenia gravis F. Carcinoma of oesophagus G. Achalasia H. Carcinoma of bronchus I. Plummer-Vinson syndrome J. Gastric volvulus K. Thyroid goitre
I. 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 22-year-old lady presents with discomfort in her chest, especially while breathing. There is localised area of tenderness around the 2nd costal cartilage on the right. O/E you can fell a firm, tender lump in this area. There is no history of trauma.
A. Bornholm's disease B. Milroy's disease C. Alport's syndrome D. Meig's syndrome E. Tietze's Syndrome F. Osler-Weber-Rendu Syndrome G. Brown-Sequard Syndrome H. Felty's Syndrome I. Peutz-Jegher's Syndrome J. Gullian-Barre Syndrome
E. Tietze’s syndrome - This is costochondritis, or Tietze’s syndrome (which describes constochondritis accompanied by chest wall 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 here is that there is pain when palpating the costochondral joints, particularly the 2nd to the 5th and the diagnosis is clinical. Tests are done to exclude other diagnoses here such as breast pathology. First line treatment is with NSAIDs. Oral NSAIDs are preferred in a primary care setting and a beneficial response confirms the diagnosis. If NSAIDs or local corticosteroid injection (usually performed by a specialist) fail to make the symptoms better than you should seek further investigations and consider a wider differential diagnosis which include conditions like pleuritis, ACS, PE, rib fracture and GORD.
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.
A. Mycobacterium tuberculosis B. Neisseria meningitidis type B C. Entamoeba histolytica D. Lassa fever E. Dengue virus F. Salmonella typhi G. Falciparum malaria H. Legionella pneumophila I. Influenza J. Streptococcus pneumoniae
G. 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. Pregnant women affected by P. falciparum are susceptible to the complications of pregnancy due to placental parasite sequestration. Treatment of malaria in pregnancy must be managed with an ID specialist and should be treated with IV antimalarial therapy. The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. Numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice. 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.
A woman of 20 with a week’s history of sore throat & fever. You find large smooth tender sub-mandibular bilateral lymph glands.
A. Sialogram B. Excise for biopsy C. Full blood count & Paul Bunnell test D. Amoxycillin E. Upper GI endoscopy F. Reassure & explain why no active management necessary G. Technetium thyroid scan H. Carbimazole I. Thyroxine
C. Full blood count and Paul Bunnell test - 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.
A 60-year-old gentleman noticed increasing pigmentation of his skin in the past 5 years. He presents to you with progressive headaches and double vision. He says he was well previously. On further questioning he recalls a surgery to remove his adrenal glands around 30 years ago. MRI demonstrates pituitary tumour.
A. Nelson's syndrome B. Pseudo-Cushing's syndrome C. MEN I D. Simmond’s disease E. DiGeorge's syndrome F. Kallmann's syndrome G. MEN II H. Cushing's disease I. Pituitary apoplexy J. Sheehan's syndrome
A. Nelson’s syndrome - Nelson’s syndrome is the enlargement of a pituitary adenoma which occurs after bilateral adrenalectomy. Once you know this fact, the diagnosis is clear. Bilateral adrenalectomy is an operation which can be done for Cushing’s syndrome in order to completely eliminate the production of cortisol. However, this removes cortisol’s negative feedback response which allows any pre-existing pituitary adenoma to grow without negative feedback. As a result, this rapid enlargement of the pituitary adenoma has caused this man’s symptoms of increased pigmentation due to raised MSH (a by product of POMC cleavage to give ACTH), headaches and visual disturbances (due to the space-occupying lesion). This is now rare as the operation is now only used in extreme cases. Sometimes pituitary surgery will be performed.
A 72 year old woman is being treated for a diabetic foot ulcer and is afraid she may need an amputation. Serum potassium today is markedly elevated. Results over the past week have been normal. You find out the 2nd year medical student had some difficulty drawing the blood.
A. Cushing's syndrome B. Rhabdomyolysis C. Drug side effect D. Acute kidney failure E. Addison’s disease F. Congenital adrenal hyperplasia G. Hyperglycaemia H. DKA I. Chronic kidney disease J. Infection K. Tumour lysis syndrome L. Pseudohyperkalaemia
L. Pseudohyperkalaemia -This is pseudohyperkalaemia caused by haemolysis of the sample. The medical student who has had some difficulty drawing the blood has haemolysed the sample. Potassium in serum will in this case exceed the plasma value by >0.5 mmol/L and the pink tinge when centrifuging the sample will also give this away.
A 16 year old woman presents with a headache, fever and photophobia. Her mother became seriously concerned when she noticed a rash. O/E the girl grimaces with pain upon forced extension of the knee whilst her hip is flexed. You also demonstrate neck stiffness.
A. Pseudomonas aeroginosa B. Mycobacterium leprae C. Escherchia coliform D. Legionella pneumophila E. Campylobacter jejuni F. Neisseria meningitidis G. Mycobacterium tuberculosis H. Salmonella typhi
F. Neisseria meningitidis - This patient has meningitis. Schools and universities are common sites of outbreaks due to crowding. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis.
CT head should be considered before LP if there is any evidence of raised ICP. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen.
A 70 yo old smoker has been complaining of haemoptysis, dysphagia and weight loss his BM is found to be high. Incidientally his biceps reflexes are reported as being greatly reduced but improve after the patient flexes his arms for a while.
A. Oesophageal cancer B. Pancreatitis C. Drug induced D. Lung cancer E. Pituitary adenoma F. Cushing's syndrome G. Type II diabetes H. PCOS I. Cushing's disease
D. Lung cancer - This patient has small cell lung cancer which is causing him to suffer from Lambert-Eaton myasthenic syndrome. This is an auto-immune condition where calcium channel antibodies inhibit the release of acetylcholine from the calcium channels’ pre-synaptic nerve terminal, thus causing muscle weakness.
This condition resembles myasthenia gravis except the weakness improves with repeated activity, where it worsens in MG. Also, the respiratory and facial muscles are usually not involved or if they are it is not so severe as in MG.
A 39 year old woman who is on mesalazine for her ulcerative colitis presents with 12 daily bowel movements and massive continuous bleeding PR; she is noted to have a raised ESR.
A. Palliative care B. Hemicolectomy C. IV immunoglobulin D. Anterior resection E. Topical GTN F. Haemorrhoidectomy G. Blood transfusion H. High fibre diet I. Colostomy J. Loperamide (Imodium) K. IV corticosteroids
K. IV corticosteroid - IV corticosteroids are used in fulminant disease. These patients need to be admitted. If there is no response to IV corticosteroids within 24 to 48 hours then surgery is indicated.
A 75 year old male smoker presents with a 3 month history of dysphagia for solids. He has lost 8kg in weight over the last 5 months. O/E he has lymphadenopathy.
A. Diffuse oesophageal spasm B. Eosinophilic oesophagitis C. Upper oesophageal web D. Globus hystericus E. Benign oesophageal stricture F. Oesophageal diverticulum G. Candidal oesophagitis H. Scleroderma I. Parkinson’s disease J. Achalasia K. Oesophageal cancer L. Stroke
K. Oesophageal cancer - Dysphagia (normally in a progressive pattern) coupled with weight loss 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. Lymphadenopathy is a sign of metastatic disease here. 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.
What is the proportion of total T4/T3 that is free in the plasma?
- 75%
- 99%
- 1%
- 60%
- 35%
- 1%
33 y/o lady complains of tenderness in her right breast typically in the second half of the menstrual cycle. O/E breast feels lumpy.
A. Lipoma B. Paget's disease C. Acute pyogenic mastitis D. Duct ectasia E. Fibrocystic disease F. Sarcoma G. Radial scar H. Adenoma I. Fibroadenoma J. Breast cancer K. Intraductal papilloma
E. Fibrocysitic - 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 75 year old recently widowed male smoker with a history of angina presents with shortness of breath. He has also vomited & complains of a ringing in his ears. On examination the patient has a BP of 80/50mmHg & fine crackles at both lung bases.
A. Mitral stenosis B. Pneumonia C. COPD D. Pneumothorax E. Anaemia F. Left ventricular failure G. Thyrotoxicosis H. Epiglottitis I. Asthma J. Anxiety K. Aspirin poisoning L. Pulmonary embolus M. Mitral regurgitation
K. Aspirin poisoning - This patient has angina so probably has a stash of aspirin. Tinnitis is common in the early stages of acute salicylate poisoning and reflects CNS toxicity. There may also be deafness and both are reversible. 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 52 year old otherwise fit and healthy man is found to have a 6.3cm AAA. He is very surprised and requests that it is treated so he does not die suddenly in the future.
A. Angioplasty B. Femoral-distal bypass C. Aortobifemoral bypass D. Methyldopa E. Ultrasound F. Alpha blocker G. Embolectomy H. Endarterectomy I. Angiography J. Endovascular aneurysm repair K. Open repair of aneurysm
K. open repair of aneurysm - Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair. Patient 1 is however is elderly and has co-morbidities. An EVAR is the best way forward here. However note also that EVAR could entail a complication of endovascular repair leak, which would require corrective treatment. Endoleak is persistent blood flow outside the graft and within the aneurysm sac. There is 24% risk after EVAR. However, this is not a complication of open repair, which is probably preferred in most cases in those who are fit and healthy enough to have it such as Patient 4. Management of this complication would depend on the type of endoleak.
A 30 year old woman with long-standing ulcerative colitis, which is in remission, presents with 2 areas of ulceration on the right mid-thigh.
A. RA B. Arterial ulcer C. Malignant ulcer D. Neuropathic ulcer E. Cardiac failure F. Lymphoedema G. Cellulitis H. Syphilis I. TB J. Pyoderma gangrenosum K. Venous ulcer L. DVT
J. Pyoderma gangrenosum - Pyoderma gangrenosum is mainly associated with IBD (UC more so than CD), RA and the myeloid blood dyscrasias. It causes necrotic tissue leading to deep ulcers, often found on the legs. There are dark red borders.
A 62-year-old man with chronic mechanical low back pain which has been treated with ibuprofen. He presents with bilateral ankle oedema and dyspnoea. He is found to have a haemoglobin of 7.2g/dL and has epigastric tenderness.
A. Thick blood film B. Haemoglobin electrophoresis C. Upper GI endoscopy D. Colonoscopy E. Anti-gliadin andtibodies F. Thin blood film G. Serum ferritin H. Urea and electrolytes I. Faecal occult bloods J. Faecal fats K. Bone marrow biopsy L. Barium meal and follow through
C. Upper GI endoscopy - This patient is anaemic due to a bleeding peptic ulcer which has resulted from prolonged NSAID use. Dyspnoea is a symptom here and the ankle oedema could be due to high output heart failure. The most specific and sensitive test is an upper GI endoscopy. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs in this case. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.
A 46 year old sales rep has recently lost his job & presents with jaundice & ascites. Ultrasound of the biliary tract is normal.
A. Cholecystitis B. Hepatitis B C. Infectious mononucleosis D. Drug induced hepatitis E. Sickle cell anaemia F. Carcinoma tail of pancreas G. Autoimmune hepatitis H. Gallstone in common bile duct I. Ascending cholangitis J. Hepatitis A K. Cirrhosis L. Carcinoma head of pancreas
K. Cirrhosis - This sales rep who has just lost his job has been hitting the bottle. The gynaecomastia is a sign of chronic liver disease and ascites indicates a degree of decompensation. Alcoholic liver disease is the most common cause of cirrhosis in the Western world.
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.
A. HIV B. Chronic kidney disease C. Benign renal cyst D. Bladder cancer E. Ureteric cancer F. Pyelonephritis G. UTI H. Hyperkalaemia I. Rhabdomyolysis J. Renal artery stenosis K. Polycystic kidney disease L. Renal tuberculosis M. Renal cell carcinoma
M. 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 59 year old man presents with 1 month history of constipation, tenesmus and fresh rectal bleeding. He also notes some weight loss recently.
A. Anal fissure B. Caecal carcinoma C. Meckel's diverticulitis D. Haemorrhoids E. Infective diarrhoea F. Irritable bowel syndrome G. Duodenal ulcer H. Inflammatory bowel disease I. Perianal fissure J. Carcinoma of the rectum
J. Carcinoma of the rectum - This a rectal carcinoma. Tenesmus, blood PR alongside weight loss are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.
A 66-year old obese, smoker with T2DM presents drowsy to A&E. He has central abdominal pain radiating to the back that started around 5 hours before. He is tachycardic, tacypnoeic and his BP is 90/40 mmHg. Femoral pulses are faintly palpable and you can’t feel any pulses distally. His wife says his pulses are not palpable because of his peripheral vascular disease.
A. Percutaneous gastrostomy B. Intravenous nutrition C. Cardiogenic shock D. Neurogenic shock E. Haemorrhagic shock F. Spinal shock G. Pulmonary oedema H. Urinary retention I. Acute renal failure J. Percutaneous jejunostomy K. Basal atelectasis
E. Haemorrhagic shock - This is a history of a ruptured AAA. He has key risk factors of obesity, smoking and T2DM. There is abdominal pain radiating to the back here and the low BP and compensatory tachycardia is due to the blood loss. This patient is in haemorrhagic shock. As this AAA has ruptured, this man will need urgent surgical repair, with of course standard resuscitation measures. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many gluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols.
An 82-year-old woman presents with constipation, lower abdominal pain and a feeling of incomplete emptying. She looks emaciated and has lost 5 kgs over the past month.
A. CA 15-3 B. Tyrosinase C. BRCA-1 D. CA 19-9 E. Prostatic acid phosphatase F. Carcinoembryonic antigen G. α-Fetoprotein H. Prostate-specific antigen
F. Carcinoembryonic antigen - Although carcinoembryonic antigen (CEA) lacks the sensitivity and specificity to be a diagnostic test for colorectal cancer, it has found a valuable application in the detection of recurrence of malignant disease following treatment.
A 50 year old female presents with a purulent discharge from the anal region & has recurrent episodes of pain, which is intense & throbbing. On examination there was pruritis ani.
A. Irritable bowel syndrome B. Pilonidal sinus C. Haemorrhoids D. Inflammatory bowel disease E. Abscess F. Prolapse G. Fissure H. Fistula I. Intussusception
E. Abscess - Typically, this presents with perianal pain. The location is important and affects management and diagnosis. If it is inter-sphincteric, then anaesthesia tends to be required to examine the rectal passage adequately for diagnosis – the pain tends to be so bad that a DRE is impossible otherwise. Abscesses found above levator ani may minic an abdominal condition. CT/MRI may be needed to establish the diagnosis. Risk factors include conditions like Crohn’s and anal fistulae (a complication of an abscess can also be a fistula). This accounts for the patient’s symptoms such as pruritis ani. A pilodinal abscess would be difficult to distinguish from an anorectal abscess on history alone but are usually located in the inter-gluteal region and often have a sinus tract in the midline. If the two are difficult to distinguish (such as if the patient cannot be examined), then MRI or CT of the pelvis may be used. Treatment involves drainage of the abscess surgically and the fistula, if present, can also be managed with a fistulotomy or seton insertion. Some patients will also get adjunctive antibiotics, such as the elderly and diabetics.
A 55 year old man with known carcinoma of the lungs, develops SOB over a few days. He has a large cardiac silhouette on his CXR but no pulmonary oedema.
A. Tuberculosis B. Mitral stenosis C. Atrial septal defect D. Conduction system disease E. Hypertensive cardiomyopathy F. Pericardial effusion G. Aortic valve disease H. Mitral regurgitation I. Dilated cardiomyopathy J. Infective endocarditits K. Pulmonary fibrosis L. Pericarditis
F. Pericardial effusion - This is a malignant effusion (one of the most likely to lead to tamponade) caused by lung cancer. Other prevalent malignant causes include breats cancer, lymphomas and leukaemias. This may also be the first sign of metastatic disease. The history of lung cancer here should make you suspicious. Other causes of a pericardial effusion include hypothyroidism (high protein content and accumulate very slowly due to capillary leak), cardiac causes such as CHF and dissection of the proximal aorta, trauma, radiation-related, uraemia, immune-mediated such as SLE, Dressler’s, amyloidosis and Wegener’s, infectious or idiopathic (which is generally assumed to be viral). Symptoms may coexist with those of pericarditis sometimes. ECG and CXR are indicated here. Most patients also get an echocardiogram whic is the preferred test to establish the diagnosis. On ECG there may be diffuse ST elevation and PR depression with epicardial inflammation. If the effusion is large enough there may be electrical alternans, which is beat-to-beat variation of the ventricular axis (find an image of this to cement it in your memory). The cardiac shadow on CXR is said to be ‘water-bottle shaped’. Pericardiocentesis may be necessary depending on the clinical case.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Mesothelioma
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
D. Asbestos - Mesothelioma is a malignant tumour of the pleura (or less commonly the peritoneum). There are three main types of asbestos: white, blue and brown, with blue being the most potent cause. Asbestos exposure increases the risk of both squamous cell carcinoma and mesothelioma. A 20-year lag time between exposure and development of mesothelioma is typical.
A 54-year-old man, normal blood pressure, normal lipid profile, BMI 28, random blood sugar 15 mmol/l, fasting blood sugar 8.5 mmol/l.(Body Mass Index) 30 Obese
A. Aspirin therapy
B. Antihypertensive drugs
C. Weight reduction and metformin therapy
D. Angiotensin converting enzyme inhibitor therapy
E. Stop smoking
F. Weight reduction and increased physical activity
G. Cholesterol loweing therapy with a statin
H. Reduced alcohol intake
C. Weight reduction and metformin - This patient has 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 is diet and lifestyle advice and changes. Metformin will be added if there is no adequate response. In terms of this question, this option will reduce cardiovascular risk the most for this patient. Metformin is a biguanide and suppresses hepatic glucose production.
A 60-year-old woman presents with a poor appetite, weight loss, tiredness and intermittent right iliac fossa discomfort for the last six weeks.
A. Crohn's disease B. Anal fissure C. Infective diarrhoea D. Caecal carcinoma E. Acute ischaemic bowel F. Meckel's diverticulum G. Duodenal ulcer H. Rectal carcinoma I. Diverticular disease J. Haemorrhoids K. Ulcerative colitis
D. Caecal carcinoma - The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.
A 30 year old, man became unwell 4 weeks after a holiday in Africa. He developed headaches, muscle pains, feeling cold, severe rigors, high fever, flushing, vomiting and profuse sweating.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
H. 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. Malaria is endemic in many parts of Africa and this is a clue. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. 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. The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. Note that blackwater fever is a complication of malaria which occurs due to haemolysis and the release of haemoglobin into blood vessels and subsequently into the urine, which can frequently lead to renal failure.
A man has recently recovered from a sore throat and now has a painful lump in his neck. FNA was performed and showed giant cells on histology. A radioiodine uptake scan was ‘cold’. The patient feels anxious and has a racing heart..he was prescribed Propranolol
A. MEN 2B B. Medullary thyroid cancer C. Grave's disease D. Riedel's thyroiditis E. subacute lymphocytic thyroiditis F. late De Quervains thyroiditis G. Early De Quervains thyroiditis
G. Early De Quervains thyroiditis - preceeding viral infection already points towards De quervains. The fine needle aspirate shows giant cells which are collections of macrophages which form in response to infection or foreign bodies. In this case the gentleman is anxious suggesting he is thyrotoxic, this is reinforced by the low uptake on radio iodine scanning. In the early stages of De Quervain’s thyroiditis viral infiltration of the gland leads to destruction and release of preformed T4/T3, this leads to thyrototoxicosis. There is low uptake as the gland is responding to feedback, the raised serum T4 is a consequence of gland destruction not increased synthesis; as a result of this there is a second phase where the endogenous T4/T3 stores are depleted and the patient becomes hypothyroid. early management is symptomatic and generally supportive…beta blocakde.
A woman with a goitre has difficulty looking upwards and outwards on eye muscle testing, which extra-ocular muscle has been affected?
- Superior oblique
- inferior oblique
- Superior rectus
- levator palpebrae superioris
- Inferior oblique
A 42-year-old lady has a seizure the day after her thyroidectomy surgery. She is previous well and taking no medication. She has never had a seizure before.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Hypocalcaemia - Hypocalcaemia can develop as a complication of thyroid surgery due to the loss of parathyroid glands which produce PTH. This is the cause of this lady’s seizure. Trousseau’s sign can be seen which is carpal spasm when a blood pressure cuff is used for several minutes. Carpopedal spasm that occurs with hypocalcaemia is a painful spasm and could also be the presenting sign. Chvostek’s sign is twitching of the perioral muscles in response to tapping over the facial nerve at the ear. If urgent replacement is necessary, calcium gluconate can be given IV. It is preferred over calcium chloride as it causes less tissue necrosis if it leaks out. It is worth noting that digoxin may be ineffective until serum calcium is restored to normal.
A 40 year old obese male presents with a burning chest pain which is worsened by lying down.
A. Variant angina B. Pulmonary embolus C. MI D. Anxiety E. Congestive heart failure F. Unstable angina G. Stable angina H. GORD
H. GORD - This is a common condition and the patient here is complaining of heartburn and acid regurgitation. The diagnosis is easily made clinically as the symptoms the patient describes are worse on lying down or bending over. Typically a patient will describe a burning sensation after meals which is not exertional. Reflux of acid into the mouth can leave a sour taste. Aside from obesity, other strong risk factors include advanced age, family history and hiatus hernia. This patient will need a trial of a PPI which will both be therapeutic and diagnostic. Complications of GORD include stricture formation, Barrett’s and oesophageal carcinoma.
A 30 year old company executive became unwell whilst on a business trip. He developed a high fever, muscle pains, nausea & vomiting, abdominal pain. He admitted to the hotel doctor that his cough has worsened over the past 7 days & he had coughed up blood on a couple of occasions. Chest x-ray showed consolidation in both lungs.
A. Atypical pneumonia B. Bronchial carcinoma C. Pleural effusion D. Sarcoidosis E. Fibrosing alveolitis F. Pneumothorax G. Lung abscess H. Bronchiectasis I. Bronchial asthma J. COPD K. Cystic fibrosis
A. Atypical pneumonia - Given this is the only pneumonia option on the list, this is an easy question, although the presentation is in line with an atypical organism. The most common atypical pneumonias are Mycoplasma, Legionella and Chlamydophila (Chlamydia). All can be treated with macrolides and are to some extent sensitive to fluoroquinolones and tetracyclines too, although these are contraindicated in pregnancy. Check local prescribing policies first.
A 54 year old man collapses suddenly as he is walking across the living room. His daughter who witnessed the collapse says he dropped suddenly became very pale and started to twitch for a few seconds. After she woke him up (with some difficulty) he became flushed. O/E his nervous system is normal.
A. Anaemia B. Vasovagal syncope C. TIA D. Cardiac arrhythmia E. Stroke F. Postural hypotension G. Myxoedema coma H. Carotid sinus sensitivity I. Hypoglycaemia J. Aortic stenosis K. Epilepsy L. Pulmonary stenosis
D. Cardiac arrhythmias - Stokes-Adams attacks are episodes of transient LOC due to sudden decreased cardiac output. Pallor prior to the attack and facial flushing due to reactive hyperemia after the attack is characteristic of a Stokes-Adams attack. The underlying cause is a cardiac arrhythmia such as complete heart block.
A 23 year old man has been living rough in London since being made homeless 6 months ago. He presents in A&E, unwell with 1 month history of cough, weight loss, fever & night sweats. Choose the SINGLE investigation, most likely to confirm the diagnosis, from the above list of options:
A. Abdominal ultrasound B. Echocardiogram C. Urine microscopy & culture D. Thick blood film E. Liver function tests F. Lumbar puncture G. IVP H. Blood cultures I. Full blood count J. Clinical exam only K. CT brain scan L. Chest x-ray & sputum cultures M. Throat swabs
L. Chest x-ray & sputum cultures - The patient’s symptoms point towards pulmonary TB. CXR is the first line test to order. Classically, in primary disease there are middle and lower zone infiltrates. Post-primary TB usually involves apical changes with or without cavitation. However, recent students have indicated that both presentations are seen in both primary and post-primary TB. HIV positive patients tend to have a more atypical CXR including effusion, lower zone involvement and a miliary pattern. Sputum cultures on LJ medium are the most sensitive and specific test but growth on solid media can take 4-8 weeks. A smear will be done in the meantime to look for AFB but the sensitivity is lower than that of a culture.
A 55-year-old woman with history of recurrent falls and collapse, presented with intermittent angina-like chest pains. On examination, she has a low pulse volume and an ejection systolic murmur in the aortic region.
A. Perform CABG B. Perform exercise ECG C. Add an ACE inhibitor D. Perform echocardiography E. Add Aspirin F. Add clopidogrel G. Perform coronary angioplasty H. Add Atorvastatin I. Advise lifestyle measures J. Add Atenolol K. Add low molecular weight Heparin L. Add Omega-3 oils M. Perform coronary thrombolysis
D. Perform echocardiography - She has a murmur so you would want to do an echocardiogram. Doppler echo is best for diagnosis and evaluation of aortic stenosis and is highly sensitive and specific. It will show an elevated aortic pressure gradient and also allow you to quantify LV ejection function and measure the area of the valve.
A 60 year old woman presents with a poor appetite, weight loss, tiredness & right iliac fossa intermittent discomfort for the last 6 weeks.
A. Anal fissure B. Caecal carcinoma C. Meckel's diverticulitis D. Haemorrhoids E. Infective diarrhoea F. Irritable bowel syndrome G. Duodenal ulcer H. Inflammatory bowel disease I. Perianal fissure J. Carcinoma of the rectum
B. Caecal carcinoma - The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.
Mark developed a sharp sternal chest pain 10 days after a flu-like illness. The pain radiated down the arm & to the left shoulder. It was aggravated by lying flat, inspiration, coughing & swallowing. It was relieved by sitting forward.
A. Pericarditis B. Angina C. VSD D. Romano-Ward syndrome E. Infective endocarditis F. HOCM (hypertrophic obstructive cardiomyopathy) G. ASD H. Congestive cardiac failure I. MI J. Left ventricular failure
A. Pericarditis - This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.
A 50 year old housewife presents with pruritis and jaundice with pale stools, dark urine and steatorrhea, pigmentation and xanthelasma. Examination reveals splenomegaly. Anti-mitochondrial antibodies are present.
A. Dubin-Johnson syndrome B. Gilbert's syndrome C. Carcinoma of the pancreas D. Gall stones E. Primary sclerosing cholangitis F. Hepatitis G. Haemolytic anaemia H. Primary biliary cirrhosis
H. Primary biliary cirrhosis - 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 AMA (present here). The pointers in this question which would raise your suspicion, is xanthelasma around the eyes, pruritis in the absence of an obvious dermatological cause, fatigue and the features of liver disease typical of cirrhosis (obstructive jaundice) and splenomegaly as a feature of portal hypertension.
A 35-year-old man is struck around the head, lost consciousness transiently and then recovered. He now is unconscious again with a Glasgow Coma Scale of 4.
A. Subdural haematoma B. Concussion C. Extradural haematoma D. Base of skull fracture E. Diffuse axonal injury F. Cerebral contusion G. Depressed skull fracture H. Cerebral haematoma
C. Extradural haematoma - Here we have the ‘lucid interval’ classically associated with an extradural haematoma. There is blood buildup this time between the dura mater and the skull. Compressive signs may also be present such as the down and out pupil due to CN III compression. The bleed here is usually from arteries, under high pressure, causing raised intracranial pressure. In this case, there is a chance the brain stem has been compressed causing his LOC and GCS
A 20-year-old man has been trying for a baby for the last 4 years, but to no success. He is found to be infertile. On questioning, there is a history of cough with mucopurulent sputum since childhood. On examination, he was clubbed. A. Pneumothorax B. Left ventricular failure C. COPD D. Inhaled foreign body E. Anaphylaxis F. Influenza G. Pleural effusion H. Bronchial adenoma I. Allergic alveolitis J. Bronchial asthma K. Fibrosing alveolitis L. Cystic fibrosis
L. Cystic fibrosis - This man has presented with cystic fibrosis which is an autosomal recessive condition characterised by a mutation in the CFTR gene on chromosome 7 (delta-F508). CF is a genetic condition with abnormal salt and water transport due to mutations in the CFTR (an apical anion channel). Heterozygotes generally do not demonstrate disease. The age of symptom onset varies though screening newborns allows this condition to be detected early on. Serum IRT from a heel prict blood spot allows screening of newborns. This patient complains of predominantly lung disease, from a cycle of mucus retention, infection and airway inflammation. This can be treated with mucus thinners, clearance of the airway with, for instance, physiotherapy and use of antibiotics. Additionally there is infertility, which may be a presenting complaint. This is due to bilateral abscence of the vas deferens which may be obvious on examination of the patient’s scrotum. This patient is also clubbed. The most conclusive diagnostic test is the sweat test which is positive if sweat chloride is >60mmol/L. The life expectancy now is around 38 years old.
A 35 year old lady is generally unwell with a tachycardia & a fever. A segment of the right breast is painful, tender, red & warm
A. Carcinoma of the breast B. Sebaceous cyst C. Duct Ectasia D. Fibroadenosis E. Breast Cyst F. Gynaecomastia G. Fibroadenoma H. Breast Abscess I. Lipoma
H. 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.
The world’s fattest teenager hasn’t been able to move out of her bed for the past 6 months. She is tired all the time. Blood test reveals hyperlipidaemia and hypercalcaemia.
A. Myeloma B. Medullary cell carcinoma of the thyroid C. Sarcoidosis D. Paget’s disease E. Thiazide diuretics F. Vitamin D intoxication G. Hypervitaminosis A H. Tuberculosis I. Immobility J. Milk-alkali syndrome K. Primary hyperparathyroidism L. Metastatic breast carcinoma M. Secondary hyperparathyroidism N. Pseudohypercalcaemia
I. Immobility - Well this one is dead easy. In young people, immobilisation causes bone to demineralise causing hypercalcaemia. This is more common in young people due to larger mobile calcium pools to sustain the rise in calcium levels.
A 48 year old male stripper presents with bruising, infections and fatigue. Lab findings indicate a pancytopenia with low reticulocyte count. Bone marrow biopsy is done on which a definitive diagnosis is made.
A. Idiopathic thrombocytopenic purpura B. Wiskott-Aldrich syndrome C. Hepatic cirrhosis D. Haemophilia E. Skull fracture F. Spontaneous G. Disulfiram H. Aplastic anaemia I. HIV J. Corticosteroids K. Diuretics L. Clopidogrel
H. Aplastic anaemia - This is aplastic anaemia characterised here with the pancytopenia (which is common, but diagnosis requires 2 cytopenias out of 3) and the presentation with infections (neutropenia), fatigue (anaemia) and bruising (thrombocytopenia). Risk factors include paroxysmal noctural haemoglobinuria, hepatitis and NSAIDs. If macrocytosis is seen, this may suggest an inherited syndrome such as Fanconi’s anaemia. The reticulocyte count here rules out haemolytic anaemia, which isn’t even an option on the list. The definitive diagnosis is made on biopsy of bone marrow which shows a hypocellular marrow with no abnormal cell populations and no fibrosis. Which conditions would there be abnormal cell populations or fibrosis on bone marrow biopsy?
For each of the malignancies listed below, please select the recognised presentation from the list of options.
Medullary thyroid carcinoma
A. Hypoglycaemia B. Erythrocytosis C. Autoimmune haemolytic anaemia D. Erythema ab igne E. Troisier's sign F. Necrolytic migratory erythema G. Acanthosis nigricans H. Eaton-Lambert syndrome I. Tetany
I. Tetany - Medullary thyroid carcinoma are uncommon and arise from the parafollicular cells of the thyroid. These tumours produce calctionin and elevated levels are diagnostic. They may occasionally present with hypocalcaemia and tetany as a result of this.
A 47 year old gentleman presents with bilateral breast enlargement. His PMH includes dyspepsia that is treated with Cimetidine.
A. Benign cyst B. SLE C. Breast abcess D. Fat necrosis E. Fibrocystic breasts F. Pagets disease G. Duct ectasia H. Fibroadenoma I. Mastalgia J. Breast carcinoma K. Gynaecomastia
K. Gynaecomastia - This is a man who has presented with breast enlargement i.e. gynaecomastia. The main cause is either chronic liver disease or drug induced. Drugs include the H2 receptor antagonist cimetidine, as well as digoxin and spironolactone. Gynaecomastia is benign in 99% of cases and results from relative excess of oestrogen or lack of testosterone. Oestrogenisation can follow from anabolic steroid use/abuse. This can hence occur physiologically during the newborn period, puberty and with age and obesity (not true gynaecomastia). Treatment can be offered if there is pain or embarassment including anti-oestrogens such as tamoxifen, androgens or surgical options like liposuction. The drugs that induce gynaecomastia can be subdivided into those that reduce testosterone synthesis (GnRH agonists, cancer drugs, ketoconazole, metronidazole, spironolactone), those that impair the action of testosterone (spironolactone again, finasteride, H2 blockers, PPIs) and those that act via oestrogen (digoxin, PHT, anabolic steroids).
A sexually active female student presents having noticed pearly umbilicated papules on her thigh which feel smooth to the touch. She tells you that these are itchy. Examination reveals local erythema around these lesions.
1. Lymphogranuloma venereum 2. Genital warts 3. Molluscum contagiosum 4. Pelvic inflammatory disease
- Molluscum contagiosum - This is molluscum contagiosum which is sexually transmitted in adulthood. Lesions appear as the umbilicated pearly and smooth papules mentioned. About a third of patients will also develop symptoms of local redness, swelling or pruritis. Adults should be treated for this STD.
An 81-year-old woman, well apart from mild osteoporosis, no metabolic abnormalities, BP 185/78 mmHg.
A. Renovascular disease B. Primary hyperaldosteronism (Conn’s syndrome) C. 'Essential’ hypertension D. Phaeochromocytoma E. Isolated systolic hypertension F. Metabolic syndrome (Insulin resistance/syndrome X) G. Cushing's syndrome H. Coarctation of the aorta
E. Isolated systolic hypertension - Isolated systolic hypertension occurs more commonly in the elderly. It is characterised by a raised SBP >140 but a normal diastolic BP
A hypertensive old man with a history of atrial fibrillation is brought into A&E by his carer who is worried that he is getting confused. The carer tells you that he has fallen over frequently over the last few months and is unstable on his feet. There is right-sided pronator drift and some right sided weakness.
- Brain tumour
- Subdural haematoma
- Concussive syndrome
- Benign intracranial hypertension
- Subdural haematoma - There is a history of falls here and confusion. A subdural haematoma occurs due to extra-axial blood collection between the dura and arachnoid layers surrounding the brain. Surgical treatment will likely be necessary in this case with neurological deficit.
A 59-year-old man, body mass index 29, random blood sugar 12.5 mmol/L, total cholesterol 5.2 mmol/L, HDL cholesterol 0.75 mmol/L, BP 162/105 mmHg.A. Renovascular diseaseB. Primary hyperaldosteronism (Conn’s syndrome)C. ‘Essential’ hypertensionD. PhaeochromocytomaE. Isolated systolic hypertensionF. Metabolic syndrome (Insulin resistance/syndrome X)G. Cushing’s syndromeH. Coarctation of the aorta
F. Metabolic syndrome (Insulin resistance/syndrome X) - Metabolic syndrome incorporates insulin resistance, IGT, central obesity, dyslipidaemia and hypertension. Multiple criteria exist to define this syndrome. This is sometimes called Reaven’s syndrome. Treatment aims at lifestyle interventions with statins if these do not achieve desired LDL cholesterol levels. Other lipid-lowering drugs such a fibrates can also be considered. The risk of developing T2DM is up to 5 times higher in those with metabolic syndrome. Low dose aspirin may be indicated, particularly for those at a higher risk, due to the prothombotic state of metabolic syndrome. Other treatments that can be considered include orlistat and bariatric surgery. Those with insulin resistance may benefit from metformin, which will reduce the progression to T2DM in patients with IGT.
Each of these patients has been found to have raised blood prolactin, select the most likely aetiology for each case.
A 21 yo man presents in A+E with prolactin levels raised 10-fold having been found collapsed on the street, witnesses say he was shaking and rigid.
A. inadequate treatment B. Metoclopramide C. Ibuprofen D. Macroadenoma E. Acetaminophen F. non epileptic seizure G. Microadenoma H. epileptic seizure
H. Epileptic seizure
A 75 year old lady is brought to A&E by her daughter who found her on the floor. She appears confused which you confirm with 4/10 on the AMTS. O/E she is febrile and complains of a burning pain in her lower abdomen.
A. UTI B. Faecal impaction C. Hypoxia D. Liver failure E. Post-operative F. Hypoglycaemia. G. Thiamine/B1 deficiency H. U&E imbalance I. Drug effect J. MI K. CVA
A. UTI - Confusion and a fever is not an uncommon presentation of UTI in the elderly where the presentation is often non-specific. The lower abdominal suprapubic pain here is another clue. 10 percent of women over the age of 70 have UTIs. Post-menopause (absence of oestrogen) is a strong risk factor for UTI in women. In women of this age group, sexual activity is less strongly associated with UTI. Treatment can be started on the symptoms here as well as dipstick result, but urine culture and sensitivity confirms the diagnosis and guides the appropriate use of antibiotics. A positive nitrite and leucocyte esterase in the urine indicates a likely UTI diagnosis. A midstream clean-catch urine specimen should be sent for culture (looking for uropathogenic organisms) if symptoms are atypical or do not respond to treatment.
The AMTS is used to rapidly assess mental function and a score of 6 or less suggests either delirium or dementia (the former is acute decline).
A 79-year-old frail lady underwent hip replacement surgery. Post-op she has been prescribed 2L saline 8-hourly. On the second day he becomes short of breath, tachypnoeic. O/E bibasal fine crepitations. ABG confirms Type I respiratory failure.
A. Percutaneous gastrostomy B. Intravenous nutrition C. Cardiogenic shock D. Neurogenic shock E. Haemorrhagic shock F. Spinal shock G. Pulmonary oedema H. Urinary retention I. Acute renal failure J. Percutaneous jejunostomy K. Basal atelectasis
G. Pulmonary oedema - This patient has been fluid overloaded and has pulmonary oedema, causing her dyspnoea. She will require diuretics and fluid restriction to deal with his overloaded state. The findings of bibasal fine creptitions, heard at the end of expiration, is characteristic. Infiltrates may also be seen on CXR. Type 1 respiratory failure is hypoxic respiratory failure, which occurs when PaO2 is low. Type 2 respiratory failure is known also as hypercapnic respiratory failure and occurs when there is hypoxia associated with a high PaCO2.
As a general note for your exams. Common causes of type 1 respiratory failure include pulmonary oedema, pneumonia and PE. Common causes of type 2 include COPD and respiratory muscle weakness.
Three weeks following an illness which caused crampy abdominal pains, vomiting and diarrhoea a 26 year old presented with progressive bilateral leg weakness. Knee jerks and ankle jerks were both reduced on examination.
A. Pseudomonas aeroginosa B. Mycobacterium leprae C. Escherchia coliform D. Legionella pneumophila E. Campylobacter jejuni F. Neisseria meningitidis G. Mycobacterium tuberculosis H. Salmonella typhi
H. Campylobacter jejuni - This patient has Guillain-Barre syndrome. This condition is a demyelinating polyneuropathy. Classic neurology is a progressive symmetrical muscle weakness affecting lower extremities before upper extremities, and proximal muscles before distal muscles, accompanied by paraesthesias in the hands and feet which often precedes onset of weakness. The paralysis is typically flaccid with areflexia and progresses acutely over days, with an ensuing plateau phase followed by recovery. Two thirds of patients have a history of either prior influenza-like illness or gastroenteritis. This patient gives a history of gastroenteritis, the cause of which is likely Campylobacter. Studies have shown that 60-70% of acute cases are preceded by Campylobacter jejuni infection. Additionally, Campylobacter-associated GBS appears to have a worse prognosis with slower recovery and higher residual neurological disability. A study in Sweden has shown that the risk of developing GBS after Campylobacter jejuni infection is roughly 100 fold higher than after other infections.
Other weak risks include immunisation, cancer and lymphoma, older age, HIV infection and male gender. Up to 30% will develop respiratory muscle weakness requiring ventilation so spirometry should be carried out at 6 hour intervals initially (and may show reduced vital capacity). AST and ALT may be elevated though the cause is unclear. LP is useful and the classic finding is of elevated CSF protein with normal cell count (known as albuminocytological dissociation). Treatment is with supportive and disease modifying treatment (plasma exchange or high dose Ig).
A 10-year-old boy has wasting of his lower leg, which look like ‘inverted champagne bottles’. His father had the same condition.
A. Diabetic neuropathy
B. Carpal tunnel syndrome
C. Charcot-Marie-Tooth disease
C. Charcot-Marie-Tooth disease - Charcot-Marie-Tooth disease comprises of a group of hereditary peripheral neuropathies with different genetic abnormalities, hence the FH here (most patients have a FHx). Pes cavus (high foot arches), hammer toes and distal atrophy of the hands and legs are characteristic (resulting in this inverted champagne bottle appearance). Pes cavus can be associated with areflexia. Patients may have to lift their legs up excessively to clear the toes. Rehabilitative and orthotic treatments can help to keep patients functional. There are no other known risk factors for this condition aside from FH. The risk of passing the condition on to the next generation varies depending on the subtype of CMT, which have different inheritance patterns. Most CMT1 and CMT2 are autosomal dominant and CMT 4 is autosomal recessive. There are also X-linked forms.
A 19 year old girl presents with increasing frequency of passing urine, dysuria and foul smelling urine.
A. UTI B. Waldenstrom's macroglobinaemia C. Henoch-Schonlein purpura D. Bladder cancer E. Post infectious glomerulonephritis F. Ureteric colic G. Pseudo-haematuria H. Goodpasture's disease I. Nephrotic syndrome
A. UTI - This young woman has presented with a UTI (dysuria, frequency, and foul smelling urine). Sexual activity the strongest risk factor for UTIs in women. It is diagnosed with a urine dipstick and microscopic analysis for bacteria, WBC and RBC and urine culture with antibiotic sensitivities. Antibiotic selection should be based on local guidelines or known sensitivities. Uncomplicated UTIs with no known antibiotic resistance can be treated with co-trimoxazole or nitrofurantoin. If there is resistance, a quinolone can be considered such as ciprofloxacin.
A 52-year-old woman with known ischaemic heart disease and shortness of breath on exercise. At regular clinic review, it is noted that her weight has increased by 4kg over 6 months. There is no change in dietary intake or medication. O/E, chest is clear and there is minimal ankle oedema. JVP was normal.
A. Addison’s disease B. Cushing's syndrome C. Pregnancy D. Salt-wasting nephropathy E. Heart failure F. Metabolic syndrome G. Comfort eating H. Renal failure I. Reduced activity J. Portal hypertension K. Polycystic ovary syndrome L. Amyloidosis M. Hypothyroidism
I. Reduced activity - The examination here is unremarkable and there is no change in diet or medication. This patient has reduced exercise capacity with SOB on exertion, which has resulting in reduced mobility, accounting for her weight gain as less energy is being expended despite consuming the same amount.
A 25 year old Jewish man presents to A&E with some abdominal discomfort, weight loss with associated loss of appetite. His history revealed loose and bloody stools. Examination reveals tenderness in the RLQ. He is booked in for endoscopy.
A. Duodenal ulcer B. Crohn's disease C. Meckel's diverticulum D. Oesophageal varices E. Gastric ulcer F. Mallory-Weiss tear G. Ulcerative colitis H. Oesophageal malignancy I. Oesophagitis
B. Chrones disease - This patient gives a history of IBD. This could well be UC where the mainstay of treatment is with 5-ASA. A colonoscopy is required to assess the extent of disease and for a definitive diagnosis. Biopsy in CD will show transmural granulomatous inflammation. CD can affect the whole GIT but favours the TI (RLQ pain) and proximal colon and is macroscopically characterised by skip lesions. UC on the other hand is characterised by the presence of crypt abscesses, which is pathognomic. CD risk is increased 3-4 fold by smoking whereas smoking seems protective in UC. The mainstay of treatment in CD is with steroids and azathioprine to revent relapses and for those suffering side effects of steroid treatment. TNF-alpha inhibitors also have a role. Surgery in CD is only indicated in a small number of patients who bleed, for bowel perforation and cases of complete obstruction. The aim is to rest distal disease by temporarily diverting faecal flow.
Mrs James is a 50 year old diabetic lady who complains of a tightness in her chest plus a cramping sensation in her jaw and neck after climbing 2 flights of stairs to her apartment.
A. Pericarditis B. Angina C. VSD D. Romano-Ward syndrome E. Infective endocarditis F. HOCM (hypertrophic obstructive cardiomyopathy) G. ASD H. Congestive cardiac failure I. MI J. Left ventricular failure
B. Angina - This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. 2nd line is with a CCB. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.
A 89 yo lady has a fasting glucose of 5.5 mmol/l, after eating her dinner her glucose is checked again and has increased to 6.9 mmol/L
A. Impaired glucose tolerance B. Normal C. Impaired fasting glucose D. Diabetic E. Non-signifcant
B. Normal - This womans fasting BM is completely innocuous. After eating a meal her blood glucose remains below a level at which there may be suspicion of IGT. This patient is therefore definitely normal
- A useful marker for body glucose regulation is looking at post prandial rises in BMs. If after eating the BMs increase by more than 2.2mM from fasting baseline it may be useful to test further.
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.
A. Intussusception B. Pancreatitis C. Oesophageal cancer D. Uraemia E. Gastric cancer F. Pyloric stenosis G. Salmonella H. Bowel obstruction I. Appendicitis J. Combined oral contraceptive pill K. Viral gastroenteritis L. Bulimia M. Peptic ulcer disease
D. 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 60-year-old life-long non-smoker with a 6-month history of lower back pain has an ESR of 105 and a serum calcium of 3.0.
A. Myeloma B. Medullary cell carcinoma of the thyroid C. Sarcoidosis D. Paget’s disease E. Thiazide diuretics F. Vitamin D intoxication G. Hypervitaminosis A H. Tuberculosis I. Immobility J. Milk-alkali syndrome K. Primary hyperparathyroidism L. Metastatic breast carcinoma M. Secondary hyperparathyroidism N. Pseudohypercalcaemia
A. Myeloma - This patient has multiple myeloma. This is characteristed by clonal proliferation of plasma cells in BM and commonly presents with bony pain and symptoms of anaemia. There may also be infections present in 10%. Elevated ESR agrees with this diagnosis. The diagnostic test is serum or urine electrophoresis looking for a paraprotein spike of IgG or IgA and light chain urinary excretion (Bence Jones proteins). Bone marrow examination and skeletal survey will also need to be conducted. Bone marrow analysis will help differentiate this from MGUS and solitary plasmacytoma. Bone changes include osteopenia, osteolytic lesions and fractures. Younger patients may be candidates for high-dose chemotherapy and autologous transplantation.
A 35 year old man with known asthma who takes low dose inhaled steroids has been using his salbutamol inhaler 8-9 times a day over the last month. He has nocturnal cough & a tight chest early in the morning. There are no signs of infection & his environment hasn’t changed. He is a non-smoker & is allergic to house dust mite. He is physically active ie his peak flow diary shows peak flow of around 85% of expected. What would be the next step in the management of this patient?
A. Oral prednisolone B. 24% continuous oxygen C. Long acting beta agonist D. Beta agonist via metered dose inhaler E. Antibiotic reserve F. Influenza immunisation G. Intravenous aminophylline H. 40% continuous oxygen I. Beta agonist via nebuliser J. Intravenous hydrocortisone K. Amoxycillin intravenously L. Intramuscular adrenaline
C. Long acting beta agonist - This question requires knowledge of stepwise BTS treatment guidelines for adults: Step 1: SABA PRN, Step 2: Plus low-dose inhaled corticosteroids (ICS) , Step 3: Plus LABA, Step 4: Increase dose of ICS or add LTRA, SR theophylline or beta agonist tablet, Step 5: Daily steroid tablet and maintain ICS with specialist care. This patient is still symptomatic on Step 2, so has to be moved up to Step 3. The rest of the question such as his HDM allergy is not particularly relevant in answering this question.
A man seen in the oncology clinic for radiotherapy has bloodwork showing hyponatraemia. He has been a smoker for 50 years.
A. ectopic ACTH B. Addison's disease C. Liddle's syndrome D. paraneoplastic syndrome E. Primary Cushing's disease F. morphine overdose G. Conns adenoma H. SIADH I. Diabetes Insipidus
D. Paraneoplastic syndrome - Smoker with radiotherapy..the hyponatraemia is caused by SIADH, the aetiology is paraneoplastic syndrome. He has a bronchial or small cell carcinoma which is producing excess ADH.
A 55 year old gentleman with a history of systemic hypertension presents to A&E with breathlessness on exertion & orthopnoea. Examination reveals cardiomegaly & a displaced apex beat to the left.
A. Atrial fibrillation B. Unstable angina C. Atrial flutter D. Left ventricular failure E. Congestive cardiac failure F. Myocardial infarction G. Decubitus angina H. Constrictive pericarditis I. Stable angina J. Bacterial endocarditis
D. Left ventricular failure - This patient has no signs of RVF mentioned above. You should know the distinction between LVF and RVF. RVF leads to a backlog of blood and congestion of the systemic capillaries. This causes peripheral oedema and ascites and hepatomegaly may develop. Nocturia may be a symptom as fluid returns from the legs when the patient lies down flat. LVF causes congestion in the pulmonary circulation so the symptoms are respiratory. As seen in this patient, there is SOB on exertion and 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’.
An obese 40 year old woman, with a history of episodic right upper quadrant pain, presents with rapid onset of jaundice with severe abdominal pains, fever & rigors.
A. Cholecystitis B. Hepatitis B C. Infectious mononucleosis D. Drug induced hepatitis E. Sickle cell anaemia F. Carcinoma tail of pancreas G. Autoimmune hepatitis H. Gallstone in common bile duct I. Ascending cholangitis J. Hepatitis A K. Cirrhosis L. Carcinoma head of pancreas
I. Ascending cholangitis - Charcot’s triad of ascending cholangitis: fever with or without rigors, RUQ pain and jaundice. Cholangitis is infection of the biliary tree and can quickly become septic. Drainage of the biliary tree is crucial and is undertaken via ERCP. Make sure you know the difference between ascending cholangitis, cholecystitis and biliary colic.
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.
A. UTI B. Waldenstrom's macroglobinaemia C. Henoch-Schonlein purpura D. Bladder cancer E. Post infectious glomerulonephritis F. Ureteric colic G. Pseudo-haematuria H. Goodpasture's disease I. Nephrotic syndrome
D. 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 73-year-old ex-smoking male consults you because he is polysymptomatic, including 3 kg weight loss, memory loss and sleep disturbance. His family are worried because he lives on his own, following the death of his wife last year. He has given up his gardening and says he doesn’t want to meet his friends any more.
A. Full blood count and ESR B. Abdominal CT C. HIV antibody test D. Colonoscopy E. Blood test for auto-antibodies F. Thyroid function tests G. Bronchoscopy H. Fasting blood glucose I. Chest x-ray J. Bone marrow aspirate K. History only L. Gastroscopy M. Brain scan
K. History only - Depression is characterised by low mood, loss of interest and reduced energy persistently over a long period of time. It is a common condition and there is an obvious recent stress here as his wife has died. The diagnosis is clinical even though there are screening tools used in a primary care setting like the PHQ-9 questionnaire. The diagnostic criteria follows DSM-IV-TR which classifies depression into major, minor and dysthymia. Patients tend to respond well to CBT, antidepressants or both. Suicidal ideation should be assessed for. There is a high lifetime chance of recurrence.
A 62-year-old male undergoes a CT abdominal scan for investigation of renal calculi. You notice a 4.9cm infra-renal AAA.
A. Elective EVAR (endovascular AAA repair) B. Semi-urgent surgical repair C. Elective open repair D. Urgent surgical repair E. Palliative care F. Abdominal XR G. Aggressive fluid resuscitation H. Ultrasound in 1 or more years I. Ultrasound in 6 months
I. Ultrasound in 6 months - These questions require a knowledge of guidelines for AAA management.
What you need to know:
- Ruptured AAA needs resuscitation measures and urgent surgical repair as mentioned above.
- Symptomatic but not yet ruptured AAA needs semi-urgent surgical repair. EVAR can be offered if aorto-iliac anatomy is permitting. Urgent traditional open repair of symptomatic unruptured AAAs carries increased morbidity and mortality with a rate between that of ruptured AAA repair and elective repair. Beta blockers should be used pre-op with peri-op antibiotic therapy also initiated.
- Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair.
- For asymptomatic small AAA, surveillance is indicated. Infra and juxtarenal AAAs between 4.0-5.4cm in diameter (bear in mind that young and healthy patients with >5cm may benefit from repair!) should be monitored by USS or CT every 6-12 months. There is good quality evidence that the risk of rupture is 20% for aneurysms larger than 5.0-6.0cm in diameter.
- AAAs
A 29-year-old woman presents primarily concerned about her hirsuitism. She needs to wax her face three times a week and also a hairly back and abdomen. She is depressed. On further questioning, there is amenorrhoea over six months and weight gain. BP was 110/70.
A. Addison’s disease B. Cushing's syndrome C. Pregnancy D. Salt-wasting nephropathy E. Heart failure F. Metabolic syndrome G. Comfort eating H. Renal failure I. Reduced activity J. Portal hypertension K. Polycystic ovary syndrome L. Amyloidosis M. Hypothyroidism
K. Polycystic ovary syndrome - This patient’s presentation makes you think of PCOS. There is hirsutisim, amenorrhoea (or irregular and infrequent periods too) and weight gain, which are all features. Other features include acne, scalp hair loss and infertility. Hypertension is sometimes associated with this syndrome. On examination, sweaty/oily skin may be found and acanthosis nigricans may also be seen. An ultrasound is by no means the first test to order, as 1/4 of normal women and women with other problems like hyperprolactinaemia may also have polycystic ovaries, and they are present in 3/4 of those with PCOS. Serum androgens can be measured or the diagnosis can be made clinically.
65 year old woman with weight loss, malaise & ankle swelling. She smokes 20 cigarettes/day. There is a past history of irritable bowel syndrome. On examination; pulse 80/min irregularly irregular, JVP not seen, BP 135/85, clear chest, bilateral oedema & large mass in pelvis. Urine testing reveals protein +.
A. Arterial doppler studies B. Lymphangiogram C. Chest x-ray D. Venous doppler studies E. 24 hour urine protein F. Pelvic ultrasound G. Liver function tests H. Plasma creatinine I. Coagulation screen
F. Pelvic ultrasound - There is a large mass in the pelvis which is most likely malignant given the history. This needs to be investigated by pelvic ultrasound.
A 25 year old female with recent onset of depression takes 50 paracetamol capsules, each containing 500mg of active drug. In several days her liver is most likely to show what?
A. Hepatitis B B. Extensive necrosis C. Hypervascularity D. Extensive cirrhosis E. Cholecystitis F. Pancreatic carcinoma G. Pancreatic pseudocyst H. Hepatitis C I. Enlarged right lobe J. Portal chronic inflammation K. Arterio-venous malformations L. Hepatocellular carcinoma
B. Extensive necrosis - Paracetamol OD can occur after a single large OD or repeated ODs. Often, the patient is asymptomatic at initial presentation but if untreated may cause liver injury over the 2-4 days after ingestion, including fulminant liver failure. Massive hepatic necrosis will occur and will be the cause of fulminant liver failure. Paracetamol is the most frequent intentional OD drug in this country. The risk of liver damage is increased after taking drugs which induce CYP 450. Inducers include St John’s wort, barbiturates, phenytoin, tetracycline, chronic alcohol use and carbamazepine. A serum paracetamol level is important to order as early as possible, but at the earliest 4 hours post-ingestion.Treatment if indicated is with N-acetylcysteine with the level based on a paracetamol treatment graph.
The arterial supply to the thyroid is via the inferior and superior thyroid arteries…The superior thyroid artery is a branch of which artery?
- internal carotid
- external carotid
- right brachiocephalic
- left vertebral
- External carotid
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.
A. Prostate cancer B. Ureteric colic C. Prostatic varices D. Acute pyelonephritis E. Urinary tract infection F. Bladder cancer G. Trauma H. Renal cell carcinoma
G. 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 30 year old woman with toothache has taken 50 paracetamol 500mg tablets in the last 24 hours. She feels nauseated and still has toothache but is otherwise well.
A. Haemodialysis B. Oral methionine C. Hyperbaric oxygen D. Activated charcoal E. IV-naloxone F. Forced alkaline diuresis G. Gastric lavage H. Forced emesis I. IV-ethanol J. IV-glucagon K. N-acetlycysteine
K. N-acetylcysteine - Paracetamol OD can occur after a single large OD or repeated ODs. Often, the patient is asymptomatic at initial presentation but if untreated may cause liver injury over the 2-4 days after ingestion, including fulminant liver failure. Paracetamol is the most frequent intentional OD drug in this country. The risk of liver damage is increased after taking drugs which induce CYP 450. Inducers include St John’s wort, barbiturates, phenytoin, tetracycline, chronic alcohol use and carbamazepine. A serum paracetamol level is important to order as early as possible, but at the earliest 4 hours post-ingestion.Treatment if indicated is with N-acetylcysteine with the level based on a paracetamol treatment graph.
A 20 year old lady became ill 2 weeks after a holiday in Brazil. She developed a fever, headache, cough & constipation which turned to diarrhoea 10 days later. She also has a blanching red lesion on her chest and abdomen. She is also found to be bradycardic.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
C. Enteric fever - Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic. The water supplies in Brazil may not treated and sanitary conditions may be dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a fever which is a hallmark of infection. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.
This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.
A 43 year old businessman, who has a history of alcohol dependence but has managed to stop drinking. He is afraid of relapsing during a forthcoming business trip and wants help to remain abstinent from alcohol.
A. Treatment under Section 3, Mental Health Act 1984 B. Methadone programme C. Naloxone D. Physician advice E. Disulfiram F. Alcoholics anonymous G. Token economy H. Inpatient detoxification with chlordiazepoxide I. Antipsychotic medication J. Controlled drinking K. Aversion treatment L. Motivational interviewing
E. Disulfiram - Disulfiram is used as an adjunct in the treatment of alcohol dependence. It leads to an unpleasant systemic reaction after taking even the smallest amount of alcohol as it causes acetaldehyde to accumulate in the body. Disulfiram blocks the metabolism of alcohol. It is only effective if taken daily and symptoms can occur within 10 minutes of ingesting any alcohol and include facial flushing, throbbing headache, palpitations, tachycardia, N&V and possible arrhythmias, hypotension and collapse with large doses of alcohol. These reactions can last several hours. Even the smallest amounts of alcohol in medications and even mouthwash can lead to a reaction. After stopping treatment, alcohol still should be avoided for at least a week. Other medications that can be used to prevent relapse and support abstinence include acamprosate (which stabilises glutamate and GABA systems) and naltrexone which is an opioid antagonist.
An 80-year-old lady who is prone to consuming fatty foods has had a stroke. She is allergic to aspirin. She asks you what she can take to prevent her having another stroke.
A. Aspirin and atorvastatin B. Simvastatin C. ACE inhibitor D. Warfarin and heparin E. Aspirin and clopidogrel F. Glyceryl trinitrate G. Warfarin H. Alteplase I. Dipyridamole J. Aspirin and lisinopril K. Beta blocker L. Clopidogrel and atorvastatin
L. Clopidogrel and atorvastatin - Remember that in acute stroke, there is no current evidence that non-aspirin antiplatelet drugs such as dipyridamole, clopidogrel and glycoprotein IIb/IIIa inhibitors are effective so they are not indicated. However, clopidogrel is useful in the secondary prevention of stroke and is indicated in those who are sensitive to aspirin. A statin is also given here for its lipid lowering effects to lower the risk of stroke and other cardiovascular events. In terms of antiplatelet drugs for secondary prevention, a systematic review of the studies have found that the most cost-effective treatment is clopidogrel, followed by MRD (modified release dipyridamole) followed lastly by aspirin. Incidentally, in terms of cost-effectiveness, clopidogrel should be the first choice agent anyway.
choose the SINGLE most appropriate monitoring investigation from the list
Cyclophosphamide
A. White cell count B. Echocardiogram C. Activated partial thromboplastin time D. Liver function tests E. Thyroid function tests F. Renal function tests G. Lung function tests H. INR I. GCS J. ECG K. Serum drug level
A. Cyclophosphamide - This drug is used mainly with other drugs for treating malignancies including leukaemias, lymphomas and solid tumours. The rare and serious complication is haemorrhagic cystitis as a result of the urinary metabolite acrolein and mesna can be given as prophylaxis. It is an alkylating agent which damages DNA and interferes with cell replication. The only feasible option on this list is WCC where we have to assume this drug is being used for a leukaemia or lymphoma and we want to measure whether it is working.
A 94 yo lady has suffered with Rheumatoid arthritis for 20 years, her blood glucose is 12 mmol/L
A. Oesophageal cancer B. Pancreatitis C. Drug induced D. Lung cancer E. Pituitary adenoma F. Cushing's syndrome G. Type II diabetes H. PCOS I. Cushing's disease
C. Drug induced - this patient has rheumatoid arthritis a long standing inflammatory disease for which she no doubt has been placed on oral prednisolone…a side effect of corticosteroids is hyperglycaemia, mimicking the action of endogenous cortisol. The answer is drug induced as opposed to cushing’s syndrome because no other signs of Cushing’s are mentioned at all.
A 12 year old boy came back from summer camp and was taken to A&E feeling hot with vomiting and a sore throat. Laboratory tests and CXR is unremarkable and he is discharged. He returns later the same day with paraesthesias of the right arm and scalp, dysphagia and ataxia. When presented with water, he goes into laryngeal spasm and feels he is choking. Placement of nasal cannulae to give oxygen has the same effect.
1. Rabies 2. Attention seeking behaviour 3. Guillain-Barre syndrome 4. West Nile virus encephalitis
- Rabies - This is rabies, which can be difficult to diagnose if there is the absence of identifiable rabies exposure. There is non-specific prodrome of fever, chills, malaise, sore throat, vomiting, headaches and paraesthesias. The most specific signs of the disease are displayed here with hydrophobia and aerophobia (elicited by the placement of nasal cannulae). This patient is going to die and palliative care is needed. Rabies is considered 100% fatal.
A 65-year-old man is referred to you for an emergency appointment after attending his GP earlier that morning. You are called by the nurse to the waiting room, where you see this patient looking pale, sweaty and unwell. You establish that he has pain in his chest radiating to his back. You call a crash team. Later on, you find out that his Troponin I was 0.032 and that he was taken to theatre.
A. Perforated duodenal ulcer B. Mesenteric infarction C. Pericarditis D. Metastatic disease E. Pyelonephritis F. Pancreatitis G. Myocardial infarction H. Addison’s disease I. Volvulus J. Ruptured abdominal aortic aneurysm K. Renal colic L. Spinal stenosis M. Dissecting aortic aneurysm N. Hepatitis
J. Ruptured abdominal aortic aneurysm - This is a history of a ruptured AAA. There is abdominal (which the patient states as chest) pain radiating around to the back here and pallor due to blood loss suggesting this diagnosis. As this AAA has ruptured, this man will need urgent surgical repair, with of course standard resuscitation measures. Investigations would just waste time although it seems he has had a troponin, and likely ECG too. Misdiagnosing this condition is pretty poor of the doctors with the history here of pain which radiates to the back. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many fluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols.
A 72-year-old arteriopath is brought into the A&E collapsed. After admission you realise he is blind although he denies it.
A. Normal pressure hydrocephalus B. Occipital Stroke C. Multiple Sclerosis D. Hypothyroidism E. Vascular dementia F. Lewy body dementia G. Parkinson's disease H. Pick's disease I. Azheimer's dementia
B. Occipital stroke - This is cortical blindness, which is the loss of vision in a normal eye which results from damage to the visual area in the occipital cortex. The lack of insight that they have lost vision is a phenomenon known as Anton’s syndrome. They are ‘cortically blind’ but claim, often confabulate and adamantly despite obvious evidence, claim that they are capable of seeing. The pupillary reflex to light is intact as it does not involve the cortex and fundscopy, if done, would also be normal.
A 40 year old man has just returned from a holiday in Kenya. Since his return, he has developed watery diarrhoea with crampy abdominal pain.
A. Clostridium difficile B. Staphylococcus aureus C. Chronic pancreatitis D. Drug-induced diarrhoea E. Villous adenoma of the rectum F. Cryptosporidium infection G. Coeliac disease H. Ulcerative colitis I. Irritable bowel syndrome J. Diverticular disease K. Campylobacter L. Crohn’s disease
K. Campylobacter - So why is this Campylobacter? Well, it doesn’t have to be. Salmonella, E. Coli, Shigella, Listeria, Vibrio species etc all present with symptoms which are not drastically different and the only way to be sure is to do a stool culture. The only real option here are between Campylobacter, Staphylococcus aureus and Clostridium difficile. However, this patient does not have a history of recent antibiotic use. Staphylococcus tends to present with vomiting as the main feature and the watery diarrhoea here is typical of Campylobacter. UC and CD are chronic conditions (it is worth noting that Yersinia enterocolitis can mimic Crohn’s RLQ pain). This person has most likely eaten something dodgy on holiday. Erythromycin can be used effectively if started early but resistance is a problem and only a small number will benefit. Campylobacter jejuni is the main cause of food poisoning (also coli and fetus species cause disease). Diarrhoea normally resolves in 5-7 days and the patient will need fluid/electrolyte replacement. Campylbacter is one of the infections which is commonly linked to Guillain-Barre (although still a rare phenomenon).
40 yr old man has a hx of hypertension. His anti-hypertensive meds were recently changed due to ankle swelling. He has now developed a dry cough.
A. Fibrosing alveolitis B. TB C. Chronic bronchitis D. Pneumonia E. Influenza F. ACE inhibitor G. Asthma H. Extrinsic allergic alveolitis I. Right ventricular failure J. Left ventricular failure K. Bronchial carcinoma
F. ACE inhibitor - A dry cough is a side effect of ACE inhibitors due to the build up of bradykinin which is normally degraded by ACE. ARB such as losartan will be indicated in this case. ARBs are insurmountable antagonists of AT1 receptors for angiotensin II, preventing its renal and vascular effects.
A 6 year old presents with mild jaundice and some pain and swelling of his fingers. O/E you note splenomegaly.
A. Dubin-Johnson syndrome B. Gilbert's syndrome C. Carcinoma of the pancreas D. Gall stones E. Primary sclerosing cholangitis F. Hepatitis G. Haemolytic anaemia H. Primary biliary cirrhosis
G. Haemolytic anaemia - Africans have higher incidence of sickle cell anaemia. This is a presentation of bone pain here with dactylitis, consistent with hand-foot syndrome which can be what young infants and children present with (it is often a child’s first presentation of disease). The jaundice here is due to haemolysis and so while this is sickle cell anaemia, the options are trying to get you to think a bit about the best fit here which would be haemolytic anaemia. About 8% of black people carry the gene and the prevalence is high in sub-Saharan Africa. The condition is autosomal recessive and therefore occurs in 1 in 4 pregnancies where both parents carry the sickle gene. Sickling occurs when RBCs containing HbS become distorted into a crescent shape. Patients with sickle cell anaemia have no HbA at all. If both parents carry the sickle cell gene, there is a 1 in 4 chance of giving birth to a child with sickle cell anaemia. Sickle cell disease also includes other conditions such as HbS from one parent with another abnormal Hb or beta thalassaemia from the other parent such as HbS-Beta thal and HbSC. Treatment goals here include fluid replacement therapy, pain management and symptomatic control.
An 82-year-old woman woke up at night acutely short of breath, with a frothy cough and wheeze. She had a myocardial infarction 6 months previously.
A. Congenital heart disease B. Opiate intoxication C. Acute left ventricular failure D. Extrinsic allergic alveolitis E. Pneumonia F. Pulmonary embolus G. COPD H. Epilepsy I. Carcinoma of bronchus J. Status asthmaticus K. Cocaine intoxication L. Foreign body
C. Acute left ventricular failure - You should know the distinction between LVF and RVF. RVF leads to a backlog of blood and congestion of the systemic capillaries. This causes peripheral oedema and ascites and hepatomegaly may develop. Nocturia may be a symptom as fluid returns from the legs when the patient lies down flat. LVF causes congestion in the pulmonary circulation so the symptoms are respiratory. As seen in this patient, there is SOB and the frothy cough suggestive of pulmonary oedema. In a hospital setting, patients need to be sat upright to improve the SOB and IV access needs to be established. Oxygen, morphine, diuretics (frusemide or another loop diuretic) and nitrates will be given. Once stable, medical treatment of heart failure should be started which involves in the first instance, an ACE inhibitor followed by beta blockade.
A 20 year old man was bitten by a dog in France. 2 months later he developed a headache, fever and abnormal behaviour including the fear of water.
A. Giardiasis B. Polio C. Glandular Fever D. Malaria E. Viral Hepatitis F. HIV G. Tuberculosis H. Herpes Zooster (Shingles) I. Cholera J. Toxoplasmosis K. CMV (cytomegalovirus) L. Syphilis M. Tetanus N. Influenza O. Rabies
O. Rabies - This 20 year old man has rabies and is going to die. Symptomatic rabies is 100% fatal and there is no curative medical therapy. Palliative care is needed in this situation and given that spasms in rabies (hydrophobia and aerophobia) are very much stimulus driven, the recommendation is seclusion, room darkening and restraint. Rabies is one horrible way to die. Current recommendations are also to use haloperidol. (Prog Palliat Care. 2006;14:62-67.). Opioid analgesics may also be of use here as well as anticonvulsants for seizures and neuromuscular blockers. If interested, you can look up the Milwaukee protocol, the use of which has led to only 6 patients who have been known to survive symptomatic rabies without receiving the vaccine. This involves putting the patient into a drug induced coma and then giving them antiviral drugs
A 73 year old lady presents with 6-month Hx of chest pain on exertion and 2 episodes of collapse in the last month. O/E the pulse is slow rising.
A. Aortic regurgitation B. Aortic stenosis C. Infective endocarditis D. Rheumatic fever E. Innocent murmur F. Mitral regurgitation G. Atrial septal defect H. Tricuspid regurgitation I. Mitral stenosis
B. Aortic stenosis - Aortic stenosis can present with chest pain, dyspnoea and syncope. It is characterised by a harsh ejection systolic murmur heard loudest at the right upper sternal edge at end expiration, which radiates up towards the carotids. The pulse pressure is narrow and there may be an associated slow-rising and plateau pulse. Doppler echo is vital for diagnosis and shows a pressure gradient across the narrowed valve orifice. 20% of cases are due to a congenital bicuspid valve. The most common cause of aortic stenosis in adults is calcification of normal trileaflet valves. Clinically stable patients may be considered for surgical repair or TAVR.
An 87-year-old diabetic man comes to see you in the clinic for aroutine checkup. You are pleased to note that his diabetes is well-controlled, however is Hb is 10.5g/dL, WCC 126 x 109/L, platelets 347x109/L. The blood film shows predominantly lymphocytes with no blast cells seen.
A. Non-Hodgkin's lymphoma B. Monoclonal gammopathy of unknown significance C. Waldenstrom's macroglobulinaemia D. Acute lymphoblastic leukaemia E. Burkitt's lymphoma F. Hodgkin's lymphoma G. Chronic lymphocytic leukaemia H. Myeloma I. Acute myeloid leukaemia J. Myelofibrosis K. Chronic myeloid leukaemia
G. Chronic lymphocytic leukaemia - Chronic lympocytic leukaemia (CLL) is characterised by neoplastic proliferation of mature B lymphocytes. The clinical manifestations are due to immunosuppression and bone marrow failure, however it usually has an insidious onset with 25% of patients diagnosed incidentally (as in this case). It occurs most commonly in the elderly and is the most common leukaemia in the Western world.
A 62 year old man who requires a knee replacement gives a history of allergy to dihydrocodeine.
A. Diclofenac B. Codydramol C. Paracetamol D. Morphine E. Tramadol G. Epidural bupivacaine fentanyl
B. Codydramol - Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
A 50 year old male with haemophilia & hepatitis C presents with weight loss & abdominal discomfort. He is mildly icteric with features of chronic liver disease & a large left lobe of the liver
A. RA B. Right heart failure C. Haemachromatosis D. CML E. Malaria F. CLL G. Toxoplasmosis H. Portal vein thrombosis I. Systemic amyloidosis J. Cirrhosis with hepatoma K. Polycythaemia rubra vera L. Congestive cardiac failure M. Malignant melanoma N. Severe emphysema
J. Cirrhosis with hepatoma - HCV has caused this patient’s hepatic cirrhosis which has resulted in a hepatoma (HCC). It is likely that his HCV infection has resulted from contaminated blood products due to his haemophilia. This was a key problem before blood donor screening took place. Unlike HBV, HCV infection almost always results in cirrhosis before a hepatoma develops. The length of time the patient has HCV is a good correlate to the development of HCC. HCV is also strongly associated with IVDU which accounts for most infections. Treatment of the hepatoma is guided by staging and prognosis. Treatment includes resection, transplant, percutaneous ablation and chemo-embolisation.
A 79-year-old man complains of increasing breathlessness. On general examination you notice wide pulse pressure and visible carotid pulsation.
A. Aortic regurgitation B. Aortic stenosis C. Infective endocarditis D. Rheumatic fever E. Innocent murmur F. Mitral regurgitation G. Atrial septal defect H. Tricuspid regurgitation I. Mitral stenosis
A. Aortic regurgitation - Aortic regurgitation is the leakage of blood back into the LV in diastole. The collapsing pulse is also known as a water hammer or Corrigan’s pulse and describes the rapid rise and quick ‘collapse’ of the arterial pulse resulting in a wide pulse pressure. The murmur in AR is early diastolic in mild cases and increases to pansystolic in severe cases. Risk factors include a bicuspid valve, rheumatic fever, endocarditis, anklylosing spondylitis and Marfan’s. Other commonly seen signs in EMQs, although uncommon in clinical practice include Traube’s (pistol shot sounds over the femoral arteries when compressed), Quincke’s (subungal capillary pulsations), Duroziez’s (systolic and diastolic murmurs over the femoral arteries) and de Musset’s (head bobbing with each heart beat) sign. Other equally uncommon signs (there are many for AR) include Muller’s, Mayen’s, Lighthouse, Hill’s, Becker’s, Landolfi’s, Rosenbach’s, Gerhardt’s, Lincoln’s and Sherman’s sign. The visible carotid pulsation here is Corrigan’s sign, with the pulse characteristic as described previously.
Occasionally although uncommon, an Austin Flint murmur may be heard which is a rumbling mid-diastolic murmur best heard at the apex, produced by the regurgitant jet hitting the LV endocardium. Its presence indicates severe AR and the absence of a loud S1 or an opening snap distinguishes this from the murmur of mitral stenosis.
An 18-year-old known asthmatic with a respiratory rate of 50 and inaudible breath sounds on auscultation.
A. Intravenous naloxone B. Intramuscular glucagon C. Intravenous dextrose D. DC cardioversion E. Endotracheal intubation F. Inhaled anticholinergic G. Lumbar puncture H. Commence CPR I. IV antibiotics J. Precordial thump K. CT scan brain L. Gastric lavage
E. Endotracheal intubation - This is life threatening asthma that has not responded to therapy. There is cyanosis and respiratory acidosis despite the tachypnoea of 50/min. This patient is clearly too dyspnoeic to speak and oxygen saturation may be quite low. Pulsus paradoxus may also be observed. This patient should be intubated (mechanical ventilation is required) and transfered to ICU and given supplemental oxygen. IV corticosteroids should also be used and heliox therapy considered (helium-oxygen).
A 18 year old student from Malaysia presents with 3 days of continuously high fevers. There are also general aches and pains and a predominantly frontal headache with retro-orbital pain which gets worse on eye movement. Examination reveals hypotension, tachycardia and a generalised skin flush with warm peripheries. There is also mild thrombocytopenia, elevated LFTs and low WBC count.
1. Dengue fever 2. Leptospirosis 3. Rickettsia 4. Rubella
- Dengue fever - Dengue in endemic in over 100 countries, especially SE Asia, Western Pacific and the Americas. It is an arbovirus which is transmitted by the Aedes aegypti mosquito found in the tropical and subtropical parts of the world. Clinical features include fever, headache, myalgia/arthralgia, skin flush and leucopenia, thrombocytopenia and elevated LFTs. Viral antigen or nucleic acid detection and serology are confirmatory tests to perform.
A 30 year old male intravenous drug user with a history of tuberculosis develops profuse watery diarrhoea with no abdominal pain.
A. Clostridium difficile B. Staphylococcus aureus C. Chronic pancreatitis D. Drug-induced diarrhoea E. Villous adenoma of the rectum F. Cryptosporidium infection G. Coeliac disease H. Ulcerative colitis I. Irritable bowel syndrome J. Diverticular disease K. Campylobacter L. Crohn’s disease
F. Cryptospradium - I’m sure at some point most of you will see ‘diarrhoea’ and ‘HIV’ together and jump straight to Cryptosporidium. This is a disease caused by a protozoa and diagnosis is made in the lab by detection of oocysts or antigens in stool. The presentation is of watery diarrhoea, often accompanied with severe pain in the tummy, often lasting more than 7 days. It is self-limiting if the patient is immunocompetent but those who are immunocompromised can suffer a chronic sveere course. Those most at risk are those with T cell deficiencies, such as HIV, and those with haematological malignancies, especially children. In immunocompetent people, nitazoxanide can be used in treatment (as can paramomycin). In immunocompromised patients, treatment mainly aims at treating the primary disorder, such as using HAART to improve CD4 cell count and to restore immunity. Protease inhibitors such as ritanovir also act directly to reduce host cell invasion by the sporozoites and reduce parasite development.
A 31-year-old stuntman sustains a displaced spinal fracture with cord transaction at T12/L1 while performing a new trick. He also broken his left humerus and radius. He is stable but his BP remains 100/60 despite fluid resuscitation and his pulse is 55bpm.
A. Percutaneous gastrostomy B. Intravenous nutrition C. Cardiogenic shock D. Neurogenic shock E. Haemorrhagic shock F. Spinal shock G. Pulmonary oedema H. Urinary retention I. Acute renal failure J. Percutaneous jejunostomy K. Basal atelectasis
D. Neurogenic shock - This is a thoracolumbar spine fracture. Neurogenic shock is not to be confused with spinal shock which is not circulatory in nature (and is characterised by hypotonia or flaccidity that resolves within 24 hours). Neurogenic shock is a form of distributive shock due to spine or braintem injury and there is resulting failure of vasoregulation. As a result there is a fall in systemic vascular resistance with vasodilation, leading to low BP as blood pools in the extremeties where sympathetic tone is low. This is occasionally associated with bradycardia which is due to autonomic disruption.
A 32 year old homosexual man is tired all the time. He also complains of weight loss and purple lesions on his skin.
A. Glandular fever B. Hyperthyroidism C. Anaemia D. Psychological distress E. SIADH F. AIDS G. Colorectal carcinoma H. Diabetes mellitus I. Hypothyroidism J. Addison's disease K. Chronic renal failure
F. AIDS - AIDS (acquired immunodeficiency syndrome) is caused by HIV, which is a retrovirus. To give you an indication of risk here, there is a risk of 50 infections per 10,000 exposed to an infected source in unprotected receptive anal intercourse. The risk with receptive vaginal intercourse is 10 infections per 10,000 exposures. Obviously, people have sex more often than the one off, as is human nature, so what seems like a small risk per sexual encounter adds up. IVDU needle sharing has a risk of 67 per 10,000, a needle-stick is 30 per 10,000 (equal to having receptive vaginal intercourse 3 times with an HIV positive man, so be careful on the wards, though this statistic does depend on factors like the size of the needle) and the risk associated with vertical transmission is associated with maternal viral load (the risk goes if you can suppress the viral load with anti-retrovirals). The thing to note is that the association with homosexuality is based on the increased risk of transmission from receptive anal compared to receptive vaginal, and if you happen to be a homosexual male and contract HIV, you’re unlikely to pass it on with vaginal intercourse. There should not be negative stigma attached to HIV.
There are two types, HIV 1 which is the main virus responsible and HIV 2 which is restricted to parts of West Africa. Weight loss is common in HIV and if more than 10% body weight is lost or BMI reduces to 18.5, this is an indication of more severe immunocompromise. Weight loss in HIV may result from malnutrition, co-existent TB infection or HIV wasting syndrome, the latter being an AIDS defining illness. The purple lesions seen here are due to Kaposi’s sarcoma, which is a neoplasm derived from mesenchymal tissue, associated with HHV-8 infection. This is an AIDS defining infection.
There are WHO (stage 1-4) and CDC criteria used in clinical staging of HIV. This patient needs to have a CD4 count, HBV and HCV screen, VDRL (syphilis), tuberculin skin test (TB) and CXR. HIV viral load will also be assessed. Prophylaxis and immunisations should be considered against infections such as hepatitis, influenza, PCP and TB. HAART needds to be initiated as he has developed AIDS. Classes of antiretrovirals include NRTIs, NNRTIs, protease inhibitors, fusion inhibitors and integrase inhibitors.
A 45 year old man with a long history of excess alcohol consumption presents with haematemesis. On examination he is clubbed & has spider naevi.
A. Echocardiogram B. Abdominal ultrasound C. Bronchoscopy D. Chest x-ray E. Lung funtion tests F. Sputum culture G. Colonoscopy H. Stool culture
B. Abdominal ultrasound - This is clubbing due to cirrhosis as a result of chronic alcohol excess. Ultrasound here is the only feasible option on the list and can detect advanced cirrhosis and possible signs of portal hypertension, such as ascites, splenomegaly and increased portal vein diameter. The ultrasound may show a nodular liver surface, the liver may itself be shrunk due to cirrhosis and the left hand side of the liver may be hypertrophied. USS findings with a good clinical suspicion is enough for diagnosis.
A fit 28 year old man comes for an insurance medical & is found to have microscopic haematuria & on abdominal examination is found to have 2 large masses about 20cms by 12cms in each flank.
A. Cystoscopy B. Abdominal ultrasound C. Prostatic specific antigen blood test D. MSU: microscopy and culture E. X-ray lumbar spine F. ASO titre blood test G. Helical CT H. 24 hour urine monitoring I. Biopsy of prostate J. Retrograde pyelogram
B. Abdominal ultrasound - This sounds like ADPKD. There may be a FH of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and SAH). Patients may have haematuria, palpable kidneys and symptoms of a UTI. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.
An 80 year old man presents with a 6 month history of increasing weakness and 8kg weight loss. He also has some vague abdominal pain and a few episodes of black stools. He is a long term smoker.
A. Duodenal ulcer B. Crohn's disease C. Meckel's diverticulum D. Oesophageal varices E. Gastric ulcer F. Mallory-Weiss tear G. Ulcerative colitis H. Oesophageal malignancy I. Oesophagitis
H. Oesophageal malignancy - Such levels of extreme weight loss over a short period of time with GI symptoms here points to GI malignancy which is bleeding. The only option on the list is oesophageal. EMQs normally mention dysphagia, which occurs when there is obstruction of more than 2/3 of the lumen and presence indicates locally advanced disease however this is absent here. 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 35 year old man presents to A&E with a short history of haemoptysis & breathlessness. His pulse is 125bpm & he has recently travelled to Australia. Chest examination is unremarkable. He is allergic to contrast agents.
A. Sputum cultures B. Bronchoscopy C. History only D. D-dimer E. CTPA F. Chest x-ray G. MRA H. Lung function tests I. ABG J. Clotting screen K. V/Q scan L. CT head
K. V/Q scan - This patient has a PE. The study of choice is a CTPA with direct visualisation of the thrombus. If there is a contraindication to a CT scan such as contrast allergy (in this case) or pregnancy, then a V/Q scan is indicated. If a V/Q scan is not possible, alternatives such as MRA can be requested. It is worth noting that in patients with cardiopulmonary disease, these tests may not be accurate. A TTE can also be used to detect RV strain seen with PE. Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy (which this patient has), previous VTE, pregnancy and the thrombophilias such as factor V Leiden.
A 2 month old child has had a fever and cough for three days. He is tachypnoeic with grunting and has nasal flaring. Choose the single most discriminating investigation in the acute management from the list of options:
A. ESR B. Blood cultures C. Chest X-ray D. Urine culture E. Stool electron microscopy F. EEG G. Stool culture H. Culture of joint aspirate I. C-reactive protein J. Lumbar puncture K. Throat swab L. Full blood count M. CT brain
C. Chest X-ray - This 2 month old child has pneumonia and is displaying signs of respiratory distress (tachypnoea, nasal flaring, grunting). The most sensitive and specific test to perform is a CXR (PA and lateral). What may be seen is an infiltrate, consolidation, effusions and cavitation. Initial treatment is empirical with antibiotics (amoxicillin is the first choice in children).
A 22-year-old medical student notices that he is thirsty and drinking 3-4 litres of fluid a day while studying for finals. He tests his urine and finds glucose 3+ and ketones 2+.
A. Oral glucose or sugar B. Bed rest C. Blood pressure control D. Laser treatment E. Intravenous dextrose F. Oral hypoglycaemic drug G. Dietary advice alone H. Statin I. Insulin
I. Insulin - This young person has presented with T1DM, a condition characterised by absolute insulin deficiency. As a result, insulin treatment is required to prevent DKA and chronic complications of hyperglycaemia. The presentation is most often with polyuria, polydipsia, weight loss and weakness. Ketonuria in the presence of hyperglycaemia suggests T1DM. Ketonuria occurs due to the fact the body has no insulin to drive glucose into the cells and hence ketone bodies are utilised by the brain (fatty acids cannot cross the BBB). Diet, exercise and insulin therapy is crucial in T1DM.
A 53-year-old smoker presents with a seizure, unilateral headaches for 3 months and 10kg of weight loss.
A. Intravenous antibiotics B. Oral antibiotics C. Burr hole surgery D. CT head E. Positron emission tomogram F. Re-breathing G. Lumbar puncture H. Paracetamol I. Visual field testing J. Thrombolysis K. Aspirin L. Carotid angiography
D. CT head - This question is alluding to lung cancer which has metastasized to the brain and is causing the headache and seizure. The best option from the list is a head CT.
A 65 year old male undergoing chemotherapy for acute myeloid leukaemia starts to deteriorate on the ward. He complains of a tingling sensation in his fingers and around his lips. He also complains of muscle weakness and appears confused. His biochemistry reveals that he is hyperkalaemic, hyperphosphataemic, hyperuricaemic and hypocalcaemic. His creatinine is also elevated to 300 umol/L.
A. Raised intracranial pressure B. Anaphylaxis C. Tumour lysis syndrome D. Meningitis E. Chemotherapy complication F. Spinal cord compression G. Ectopic PTH secretion H. Superior vena caval obstruction I. SIADH
C. Tumour lysis syndrome - Tumour lysis syndrome usually occurs in patients undergoing chemotherapy for lymphoproliferative malignancies, who have just initiated treatment. Lysis of tumour cells leads to the release of large amounts of potassium, phosphate and uric acid into the circulation. The excess phosphate binds to calcium, leading to hypocalcaemia and its clinical features. Patients are also at risk of developing acute renal failure due to the deposition of uric acid and calcium phosphate crystals in the renal tubules.
MS affects peripheral nerves.
True
False
False - MS only affects the CNS.
A 50-year-old man went for Hajj. He was vaccinated against hepatitis and Group C meningococci. He came back with a high fever and was admitted with neck stiffness and drowsiness. He had a lumbar puncture and blood cultures. Gram stain of cerebrospinal fluid showed Gram negative diplococci.
A. Mycobacterium tuberculosis B. Neisseria meningitidis type B C. Entamoeba histolytica D. Lassa fever E. Dengue virus F. Salmonella typhi G. Falciparum malaria H. Legionella pneumophila I. Influenza J. Streptococcus pneumoniae
B. Neisseria meningitidis type B - This patient has meningitis. A big risk factor is crowding which occurs during Hajj. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis. CT head should be considered before LP if there is any evidence of raised ICP. A LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen. The CSF gram stain showing a gram negative diplococci here gives the organism away. If you know your gram stains etc you can get this one from just reading the last line.
The pulse is slow rising. There is an ejection systolic murmur loudest at the right upper sternal border radiating to the carotids.
A. Tricuspid stenosis B. Pulmonary stenosis C. Patent ductus arteriosus D. Aortic stenosis E. Atrial septal defect F. Mitral regurgitation G. Aortic regurgitation H. Tricuspid regurgitation I. Mitral valve prolapse J. HOCM K. Left ventricular aneurysm L. Aortic sclerosis M. Mitral stenosis N. Ventricular septal defect
D. Aortic stenosis - Aortic stenosis can present with chest pain, dyspnoea and syncope. It is characterised by a harsh ejection systolic murmur heard loudest at the apex at end expiration, which radiates up towards the carotids. The pulse pressure is narrow and there may be an associated slow-rising and plateau pulse. Carotid parvus et tardus may also be present. Doppler echo is vital for diagnosis and shows a pressure gradient across the narrowed valve orifice. 20% of cases are due to a congenital bicuspid valve which experience abnormal shear stress. Bicuspid valves are more common in those with aortic co-arctation and Turner’s. The most common cause of aortic stenosis in adults is calcification of normal trileaflet valves. Clinically stable patients may be considered for surgical repair or TAVR. The murmur of aortic sclerosis is usually less than grade 2 and describes leaflet thickening without obstruction. The pulse character is normal in sclerosis as blood flow is normal. It is the beginning of a spectrum of calcific aortic disease with severe stenosis at the end of the spectrum.
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
A. Diabetes Insipidus B. Adrenal adenoma C. Nelson's syndrome D. Pituitary apoplexy E. Conns Adenoma F. Drug withdrawal G. Addison's disease H. Tuberculosis I. Sheehan's syndrome J. Cushing's disease K. Ectopic ACTH producing tumour L. Addisonian crisis
I. Sheehan’s 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 gland 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 post -partum haemorrhage (PPH) the ant. pituitary thus infarcts and necroses. This is Sheehans 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.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Prostate carcinoma
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
F. Cadmium - Studies have shown that men in certain occupations, with higher levels of exposure to cadmium, have a higher risk of prostate cancer. It is thought that cadmium interacts with certain hormone receptors and mimics the effects of oestrogen and testosterone, thus abnormally stimulating the growth of the prostate. Furthermore cadmium is thought to interfere with the body’s ability to absorb zinc (which is believed to have a protective effect against prostate cancer.)
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.
A. Pneumothorax B. Left ventricular failure C. COPD D. Inhaled foreign body E. Anaphylaxis F. Influenza G. Pleural effusion H. Bronchial adenoma I. Allergic alveolitis J. Bronchial asthma K. Fibrosing alveolitis L. Cystic fibrosis
B. 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.
Cytology of nipple discharge shows inflammatory cells with no evidence of epithelial cells. Discharge is very thick and cheesy.
A. Lipoma B. Paget's disease C. Acute pyogenic mastitis D. Duct ectasia E. Fibrocystic disease F. Sarcoma G. Radial scar H. Adenoma I. Fibroadenoma J. Breast cancer K. Intraductal papilloma
D. Duct ectasia - Duct ectasia happens because the lactiferous duct gets blocked. Ectasia means widening. It can mimic breast cancer as the discharge can be bloody sometimes and signs can include nipple inversion. It is a self limiting condition. The cytology of inflammatory cells confirms this diagnosis as duct ectasia is where the duct is dilated and is associated with inflammation.
A 50 year old Asian diabetic woman is admitted with increasing shortness of breath and ankle swelling. ECG shows inverted T waves in levels I, AVL and V4-6. Upper lobe blood diversion and bilateral pleural effusions are found on chest X-ray.
A. Pneumothorax B. Pneumonia C. COPD D. Carcinoma of Bronchus E. Chest injury with rib fractures F. Lung metastases G. Rheumatoid arthritis H. Pleural mesothelioma I. Aspiration pneumonia J. Pulmonary oedema K. Sarcoidosis L. Pulmonary embolus M. Acute asthma N. Pulmonary tuberculosis
J. Pulmonary oedema - CXR findings here are consistent with pulmonary oedema. Pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion may be seen. The patient is also in CCF with evidence of LV dysfunction (SOB) and RV dysfunction (ankle swelling).
A 55-year-old woman who has been waiting in diabetic clinic for two hours starts feeling sweaty and weak.
A. Oral glucose or sugar B. Bed rest C. Blood pressure control D. Laser treatment E. Intravenous dextrose F. Oral hypoglycaemic drug G. Dietary advice alone H. Statin I. Insulin
A. Oral glucose or sugar - This patient has symptoms of hypoglycaemia, present when glucose drops
choose the SINGLE most appropriate monitoring investigation from the list
Pravastatin
A. White cell count B. Echocardiogram C. Activated partial thromboplastin time D. Liver function tests E. Thyroid function tests F. Renal function tests G. Lung function tests H. INR I. GCS J. ECG K. Serum drug level
D. Liver function tests - Pravastatin is a statin. Other statins include the mighty atorvastatin, simvastatin and rosuvastatin. They inhibit HMG-CoA reductase, which is an enzyme involved in the cholesterol synthesis pathway. They hence lower LDL cholesterol levels very effectively to reduce the cardiovascular disease. Statins can cause altered LFTs and rarely even hepatitis and jaundice. There have also been rare case reports of liver failure. NICE have a guideline (which we must listen to…) which state that liver enzymes should be measured before treatment and repeated within 3 months and at 12 months of starting treatment (unless there are obvious signs and symptoms of hepatotoxicity).
A 58 year old male smoker has a 2 month history of progressive persistent hoarseness and pain in his left ear on swallowing. He has enlarged left cervical lymph nodes.
A. Laryngeal nerve palsy B. Hypothyroidism C. Vocal cord nodules D. Wegener's syndrome E. Angioedema F. Foreign body G. Carcinoma of the larynx H. Laryngitis I. Sjogren's syndrome J. Acromegaly
G. Carcinoma of the larynx - Laryngeal cancer is frequently associated with two big risk factors: smoking and alcohol use. Major signs are persistent (>3 weeks) of hoarseness, dysphonia, sore throat, dysphagia, referred otalgia (seen here) and neck masses/adenopathy. These patients need to be evaluated by a specialist and as mentioned this can resemble chronic laryngitis in presentation. An MDT approach is taken to try and preserve the organ as much as possible, with salvage surgical resection offered in advanced disease.
A 25 year old man with a 3 day history of high temperatures, aching limbs and neck discomfort. Apart from temperatures of 39 degrees C and some mild conjunctivitis, examination was normal. Antibiotics were prescribed but had no effect.
A. Post immunisation B. Glandular fever C. Pneumonia D. HIV infection E. Malaria F. Drug reaction G. SLE H. Sarcoidosis I. Appendicitis J. Influenza K. Tuberculosis L. Hodgkin's lympoma M. Gastric carcinoma N. Pyelonephritis
J. Influenza - This is an acute respiratory tract infection caused by seasonal viral influenza A or B, hence antibiotics would have no effect. It is characterised by respiratory symptoms including rhinorrhoea, cough, fever, chills, headache and myalgia. Recent upper respiratory tract infection has led to associated viral conjuncitivitis. The examination in this case is of course otherwise unremarkable. Antigenic change presents a challenge in creating new vaccines as there is no incremental protection from previous vaccinations. There have been 4 pandemics since 1918, the recent one being ‘swine flu’ in April 2009, caused by new gene rearrangement of human, avian and swine influenza.
Chose choose the most likely mode of inheritance.
Duchenne’s muscular dystrophy
A. None/unknown B. Autosomal recessive C. Autosomal dominant D. X-linked dominant E. Chromosomal abnormality F. X-linked recessive G. Mitochondrial inheritance
F. X-linked recessive
Here is a list of the important conditions you should be aware of:
Autosomal dominant: Achrondroplasia, APKD, dystrophia myotonica, familial hypercholesterolaemia, Huntington’s, Marfan’s, NF, tuberous sclerosis, osteogenesis imperfecta
Autosomal recessive: CF, hereditary haemochromatosis, sickle cell disease, Wilson’s, Friedreich’s ataxia, CAH
X-linked recessive: DMD, Fragile X syndrome, Haemophilia A and B, G6PDH deficiency, Alport’s
You should be aware that Down’s is trisomy 21, Edwards’ is trisomy 18 and Patau’s is trisomy 13.
A 71 year old man who has had a MI 6 months ago presents with shortness of breath & fatigue. On examination, the JVP is raised. He has pitting oedema to the knees. There is tenderness in the right upper quadrant with a smooth liver edge at 5cm.
A. Tuberculous peritonitis B. Heart failure C. Budd Chiari syndrome D. Liver cirrhosis E. Primary liver tumour F. Carcinoma of the ovary G. Bacterial peritonitis H. Primary biliary cirrhosis I. Secondary liver tumours J. Nephrotic syndrome K. Carcinoma of caecum with peritoneal secondaries
B. Heart failure - This patient has heart failure, which has possibly occured as a consequence of his MI. SOB indicates pulmonary oedema due to LV failure. The raised JVP, peripheral oedema and tender hepatomegaly indicates RV failure. 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.
A 20-year-old woman from sub-Saharan Africa is seen in A&E complaining of severe pain, swelling and tenderness of her right leg. Examination reveals a pale, cold and cyanosed leg and a well defined ulcer near the medial malleolus. She claims to have had similar episodes of pain in the past, which resolved with opiate analgesia. ABPI is normal.
A. Venous ulcer B. Diabetic ulcer C. Osteomyelitis D. Kaposi’s sarcoma E. Sickle cell disease F. Necrobiosis lipoidica G. Pigmented purpuric dermatoses H. Pressure ulcer I. Squamous cell carcinoma (Marjolin) J. Pyoderma gangrenosum K. Dermatitis L. Pyogenic granuloma M. Lymphoedema N. Arterial ulcer
E. Sickle cell disease - Adults with sickle cell anaemia may present with leg ulcers although it has to be said that it is very unusual for a person with sickle cell disease to reach adulthood without being aware of their diagnosis. The adult patient could present with unexplained haemolysis, possible intermittent episodes of pain due to vaso-occlusive crises, avascular necrosis and retinal haemorrhage too. The doppler derived ankle-brachial pressure index is normal here which points away from peripheral arterial disease, which in this relatively young person is unlikely in any case. The typical constellation of findings of venous ulcers are not seen (oedema, lipodermatosclerosis). Additionally the pain would appear to be out of proportion to a standard arterial or venous ulcer and instead sounds more like a the pain of a vaso-occulusive crisis, particularly with the recurrent nature.
In real medicine, this is unlikely as it is rare for sickle cell anaemia to present this late, but the fact this lady is from sub-Saharan Africa is a key fact. From an epidemiological perspective, the prevalence is 10-30% in sub-Saharan Africa. Between 25 and 30% of newborns in western Africa are carriers of sickle cell trait. This patient here will need to have their peripheral blood film reviewed following by haemoglobin electrophoresis and HPLC. Sickle solubility is a rapid test which can also be done but will not differentiate sickle trait from sickle disease.
An 18 year old history student who has just started at university for his studies develops a pounding headache and fever. The hall warden remarked that he shouted at her to turn the lights off and draw the curtains when she was called to see him. He was then reported as having a seizure. On arrival to A&E, a CT head scan is done. Select the most APPROPRIATE first line investigation:
A. LFTs B. CRP C. LP D. CXR and sputum sample E. Blood culture F. Sputum sample G. FBC H. Pleural biopsy I. Wound swab and culture J. Urinalysis K. HIV test L. CT head
C. LP - This patient has meningitis. Universities are common sites of outbreaks due to crowding. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen. A CT head scan should be considered before LP if there is reason to suspect raised ICP such as focal neurology, seizures, papilloedema on fundoscopy or altered mental state. The seizure here would be an indication to do a CT scan before attempting LP.
A 21 year old student has been on a drinking binge to celebrate the end of his final exams. He has a 6 hour history of profuse vomiting with small amounts of fresh blood mixed in the vomit. His vital signs are stable.
A. Peptic ulcer B. Mallory-Weiss syndrome C. Angiodysplasia D. Gastric erosions E. Oesophageal varices F. Oesophageal carcinoma G. Peutz-Jeghers syndrome H. GORD I. Osler-Weber-Rendu syndrome J. Mallory-Weiss syndrome K. Carcinoma of the stomach L. Bleeding diathesis
B. Mallory-Weiss Syndrome - This occurs after a rise in abdominal pressure which induces a tear in the oesophageal mucosa, causing subsequent GI bleeding. It commonly presents with haematemesis after an episode of retching/vomiting/coughing/straining. Hence, risk factors include anything which can cause vomiting like heavy alcohol use, which is commonly the case in EMQs. Also, other conditions would include food poisoning, bowel obstruction, hyperemesis gravidarum, bulimia, the chronic cough of COPD, meningitis etc… you name it really. Classically, MWT presents with a small self limiting episode of haematemesis. Definitive diagnosis is made by OGD. Treatment is supportive because most cases, as mentioned, are self limiting and emergency treatment is not offered unless the patient is showing signs of clinical instability. If the patient is actively bleeding, treatment will be with therapeutic endoscopy in most cases, and very very few cases will require more intervention such as angiography with embolisation.
A 50-year-old man presents with acute ST elevation MI to London’s best hospital. He has already been given aspirin, oxygen, morphine and GTN and is haemodynamically stable. 20 minutes have passed since symptom onset.
A. Perform CABG B. Perform exercise ECG C. Add an ACE inhibitor D. Perform echocardiography E. Add Aspirin F. Add clopidogrel G. Perform coronary angioplasty H. Add Atorvastatin I. Advise lifestyle measures J. Add Atenolol K. Add low molecular weight Heparin L. Add Omega-3 oils M. Perform coronary thrombolysis
G. Perform coronary angioplasty - For confirmed ST elevation MI the 1st line treatment which gives the best results is primary PCI with stenting and is indicated if the person presents to A&E within 90 minutes of first presentation. CABG should be strongly considered if the patient fails PCI and should be done within 12 hours of onset of symptoms, ideally within 6. This is London’s best hospital but if this were Orkney and they did not have PCI capacity or the ability to transfer to a PCI facility within 30 minutes or so, then you would thrombolyse if there are no contraindications. This must be done within 12 hours of symptom onset and ideally within 3 hours as the efficacy of fibrinolytics diminishes over time. You should be aware of the absolute contraindications to thrombolysis such as suspected aortic dissection and prior intracranial haemorrhage. This patient has already been given some treatment for suspected MI (aspirin, oxygen, morphine and GTN). Post-treatment this patient will need aspirin therapy and clopidogrel for at least a year – aspirin should be continued indefinitely. Patients should also be started on a beta blocker, ACE inhibitor and a statin, indefinitely.
A 25 year old lady presented with fever, abdominal pains & weight loss. She was opening her bowels x 10-12/day with blood & mucus.
A. Reflux oesophagitis B. Cancer of the liver C. Hiatus hernia D. Cancer of the pancreas E. Gastric ulcer F. Liver cirrhosis G. Irritable bowel syndrome H. Coeliac’s disease I. Carcinoma of oesophagus J. Duodenal ulcer K. Inflammatory bowel disease L. Chronic hepatitis M. Primary biliary cirrhosis N. Pancreatitis
K. Inflammatory bowel disease - This patient gives a history of IBD. The history would be more suggestive of UC (but could be CD) where the mainstay of treatment is with 5-ASA. A colonoscopy is required to assess the extent of disease and for a definitive diagnosis. Biopsy in CD will show transmural granulomatous inflammation. CD can affect the whole GIT but favours the TI and proximal colon and is macroscopically characterised by skip lesions. UC on the other hand is characterised by the presence of crypt abscesses, which is pathognomic. CD risk is increased 3-4 fold by smoking whereas smoking seems protective in UC. The mainstay of treatment in CD is with steroids and azathioprine to revent relapses and for those suffering side effects of steroid treatment. TNF-alpha inhibitors also have a role. Surgery in CD is only indicated in a small number of patients who bleed, for bowel perforation and cases of complete obstruction. The aim is to rest distal disease by temporarily diverting faecal flow.
A 34 year old man presents to the A&E department with a short history of haemoptysis. He has had a cough for a fortnight & noticed his ankles beginning to swell 5 days ago. Initial blood tests show a creatinine of 400mol/l. An autoantibody screen is positive for p-ANCA & anti-glomerular basement membrane antibodies.
A. Pulmonary metastases B. Pulmonary embolism C. Pulmonary abscess D. Small cell carcinoma E. Streptococcal pneumonia F. Squamous cell carcinoma G. Microscopic polyarteritis H. Tuberculosis I. Goodpasture’s disease J. Myaesthenia gravis K. Mesothelioma
I. Goodpasture’s disease - Goodpasture’s is associated with anti-GBM antibodies, and of those who are positive, some will have a positive ANCA too, although this is more suggestive of diagnoses such as Churg-Strauss and microscopic polyarteritis. Definitive diagnosis is by renal biopsy showing crescentic GN and linear IgG staining on immunofluorescence. It is one of the few causes of pulmonary renal syndrome. Aggressive treatment is often needed and plasma exchange can also be performed to remove preformed antibodies.
A 22 year old student presents with a painless lump in the posterior triangle of the neck. The lump is smooth & rubbery. He feels generally unwell, has lost weight & complains of itchiness. Lymph node biopsy shows Reed-Sternberg cells.
A. Dermoid cyst B. Tonsillitis C. Carcinomatous lymph node D. TB abscess E. Hodgkin’s disease F. Thyroglossal cyst G. Non-hodgkin’s lymphoma H. Carotid body tumour I. Glandular fever
E. Hodgkin’s lymphoma - This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption.
A 35-year-old woman has noticed some changes in her right breast that are worse before her periods. You find a tender, diffuse, lumpy area in the upper outer quadrant about 10cms by 5cms with no lymphadenopathy.
A. Basal cell carcinoma B. Adenoma C. Sebaceous cyst D. Fat necrosis E. Carcinoma of the breast F. Intraductal papilloma G. Lipoma H. Radial scar I. Breast bud J. Fibroadenosis K. Phylloides tumour L. Breast abscess M. Fibroadenoma
J. 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 man presents to you with an incidental finding of a raised bilirubin (31 umol). No other signs of liver disease are present. Further investigations show a raised unconjugated bilirubin. When asked he tells you that other family members have suffered from jaundice.
A. Dubin-Johnson syndrome B. Gilbert's syndrome C. Carcinoma of the pancreas D. Gall stones E. Primary sclerosing cholangitis F. Hepatitis G. Haemolytic anaemia H. Primary biliary cirrhosis
B. Gilbert’s syndrome - Gilbert’s occurs in an asymptomatic patient, often as an incidental finding or mild jaundice occuring in adolescence/young adult age. There is elevated unconjugated BR with other liver tests being normal. The blood smear is also normal with normal reticulocyte count, and normal Hb indicating that this is not due to haemolysis. It is a common syndrome and is not really a disease, more a physiological variant. No treatment is needed and this condition is due to decreased UDPGT activity leading to decreased conjugation of unconjugated bilirubin, leading to elevated levels. Positive FH is common as this condition is most likely transmitted in an autosomal recessive pattern.
A 56-year-old man has a sudden pain that ‘shoots’ to his chin whilst shaving. It disappears after a few seconds.
A. Extradural haemorrhage B. Cluster headache C. Trigeminal neuralgia D. Subarachnoid haemorrhage E. Migraine F. Tension headache
C. Trigeminal neuralgia - Trigeminal neuralgia occurs as episodes of severe unilateral pain in the distribution of CNV, usually lasting seconds, with no pain occuring between these episodes. Examination is often unremarkable. The pain is described as sharp, intense, stabbing or burning. It can be triggered commonly by actions such as eating, tooth brushing, cold and touch. Shaving and eating seem to be common in EMQs. Most people are asymptomatic between attacks although the severity of the pain makes these patients live in constant fear. TN is more common in MS and incidence increases with age. Post-herpetic TN is also possible. The mainstay of treatment is medical, with antiepileptics such as carbamazepine (which is the only medicine which is proven in RCTs and is therefore typically first line). If medical treatment fails, surgical options do exist such as microvascular decompression.
A 27 year old Afro-Caribbean man presents with fever, weight loss and an intractable itch. His spleen is just palpable and he has two 3cm nodes in his right neck. Hb is low.
A. Sarcoidosis B. Polycythaemia C. Gaucher’s disease D. Portal hypertension E. Infectious mononucleosis F. IDA G. Bacterial endocarditis H. Hodgkin’s disease I. Malaria J. Idiopathic myelofibrosis K. Metastatic carcinoma L. CML
H. Hodgkin’s disease - This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption.
A 22 year old female medical student returned from elective in Nigeria 3 months ago, she has had a fever & night sweats for 3 weeks.
choose the SINGLE investigation, most likely to confirm the diagnosis, from the above list of options:
A. Abdominal ultrasound B. Echocardiogram C. Urine microscopy & culture D. Thick blood film E. Liver function tests F. Lumbar puncture G. IVP H. Blood cultures I. Full blood count J. Clinical exam only K. CT brain scan L. Chest x-ray & sputum cultures M. Throat swabs
D. Thick blood film - In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This medical 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.
The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. However, not all hospitals are currently licensed to use it in the UK (in London, only the Hospital for Tropical Diseases and Northwick Park). Artesunate is manufactured by a pharmaceutical company in China and there are doubts over the quality of the product. However, there have now been numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice.
40 yr old Asian male has a 2 month hx of cough, haemoptysis, wt loss and night sweats. He has swollen cervical lymph nodes and his trachea deviated to the left.
A. Fibrosing alveolitis B. TB C. Chronic bronchitis D. Pneumonia E. Influenza F. ACE inhibitor G. Asthma H. Extrinsic allergic alveolitis I. Right ventricular failure J. Left ventricular failure K. Bronchial carcinoma
B. TB - It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, weight loss, cough, haemoptysis and erythema nodosum are all suggestive. This patient’s tracheal deviation may be due to apical fibrosis or a cavitating lesion. The swollen lymph nodes in this patient’s neck may well represent a scrofula. Other key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis.
A 40-year-old female, rather overweight, has episodes of right upper quadrant pain and fever.
A. Hepatitis B B. Extensive necrosis C. Hypervascularity D. Extensive cirrhosis E. Cholecystitis F. Pancreatic carcinoma G. Pancreatic pseudocyst H. Hepatitis C I. Enlarged right lobe J. Portal chronic inflammation K. Arterio-venous malformations L. Hepatocellular carcinoma
E. Cholecystitis - Cholecystitis is acute GB inflammation caused by an obstruction at the cystic duct. It occurs as a major complication of gallstones and classically presents with RUQ pain and fever. Gallstones in EMQs classically involves the Fs (Fat, Forty, Female, Fertile, Fair). USS is the definitive initial investigation. HIDA scanning and MRI may help if the diagnosis remains unclear. Treatment is with cholecystectomy.
A 55-year-old motor dealer’s wife has threatened to leave him unless he stops drinking. He presents with a short history of acute anxiety and visual hallucinations.
A. Depression B. Fatty liver C. Rhabdomyolysis D. Cirrhosis E. Macrocytosis F. Fibromyalgia G. Malnutrition H. Wernicke’s encephalopathy I. Chronic subdural haematoma J. Peptic ulceration K. Acute intoxication L. Delirium tremens
L. Delerium tremens - This patient has delirium tremens from alcohol withdrawal. Delirium is an acute fluctuating change in mental status. It is worth noting that alcohol excess can also cause delirium secondary to alcoholic ketoacidosis and can also be seen in Wernicke’s or Korsakoff’s. DT is associated with hallucinations (clasically tactile and visual of insects crawling on the person), delusions and tremor. First line treatment is with chlordiazepoxide (or lorazepam if the patient has liver failure).Vitamin supplementation will also be indicated.
Choose the malignancy that is most strongly associated with the risk factor below
History of working in the rubber industry
A. Gastrointestinal lymhpoma B. Bladder carcinoma C. Gastric carcinoma D. Cholangiocarcinoma E. Ovarian carcinoma F. Colorectal carcinoma G. Hepatocellular carcinoma H. Prostatic carcinoma I. Cervical carcinoma
B. Bladder carcinoma - Bladder cancer was one of the first cancers shown to be industrially associated and has an important place in the history of occupational disease. Rubber industry workers who had been exposed to the substance beta-naphthylamine (banned in the 1950s) were found to have developed bladdder cancer after a latent period of 15-20 years.
A 13-year-old boy collapses at the playground. He has recurrent seizures for over 30 minutes. It seems he has not regained consciousness in between the seizures.
A. CPR B. IV diazepam C. Urgent CT scan D. Phenytoin infusion E. IV lorazepam F. IM adrenaline G. IV carbamazepine H. IV adrenaline I. IV midazolam J. Elevate legs K. IV dextrose L. IV propofol M. IM benzylpenicillin N. IV naloxone
E. IV lorazepam - This patient is in status epilepticus defined by 30 minutes or more of continuous seizure activity, or repetitive seizures with no intervening recovery of consciousness. SE can be either generalised convulsive or non-convulsive (simple or complex partial). In children, seizures of a shorter duration may also be considered to be status epilepticus. The initial treatment is as 2) and should start with BLS measures, continuous monitoring and benzodiazepines as first line therapy – with IV lorazepam. Securing the patient’s airwar may prove difficult due to the convulsions and neuromuscular blockade with a short-acting drug such as vecuronium may be necessary.
Unresponsive cases can get anticonvulsants or phenobarbitone. It is worth noting that phenytoin infusions may lead to venous irritation and tissue damage if the undiluted drug is given through a small bore cannula. If SE persists, the next step to take is to intubate and start general anaesthesia. The best initial agents to use are midazolam and propofol though other options include pentobarbital and thiopental, the former being an active metabolite of the latter. GA should be tapered off after a minimum of 12 hours, and if the seziure recurs then the infusion should be restarted for another 12-24 hours.
A 35 year old pregnant woman developed a temperature with chills and increased urinary frequency. She is tender in the right loin and has vomited. Dipstick urinalysis is positive for leukocytes, nitrites and blood.
A. Post immunisation B. Glandular fever C. Pneumonia D. HIV infection E. Malaria F. Drug reaction G. SLE H. Sarcoidosis I. Appendicitis J. Influenza K. Tuberculosis L. Hodgkin's lympoma M. Gastric carcinoma N. Pyelonephritis
N. Pyelonephritis - Acute onset fever with chills, flank pain, vomiting and positive urine dipstick all point to the diagnosis of acute pyelonephritis. Urinalysis is highly sensitive but not very specific. Pregnancy is a risk factor for complicated disease as the enlarging uterus compresses the ureters and hormonal changes increase the likelihood of obstructive uropathy. In uncomplicated pyelonephritis, the most common cause is E. coli and gram stain will typically reveal gram negative rods, either E. coli, Proteus or Klebsiella. Gram positive cocci that could be implicated include enterococci and staphylococci. Older patients can often also present non-specifically. Treatment should start before culture results are received to prevent the patient from deteriorating, with empirical antibiotics.
A 25 year old woman finds a smooth, rubbery and mobile mass on her left breast. She is overwise asymptomatic.
A. Intraductal papilloma B. Lobular carcinoma in situ C. Gynaecomastia D. Phylloides tumour E. Pregnancy F. Breast Abscess G. Fibroadenoma H. Mastalgia I. Nodularity J. Invasive breast cancer K. Adenoma
G. Fibroadenoma - Fibroadenomas are typically asymptomatic and are found incidentally in patients
60 yr old man with stable angina is awaiting surgery. He is on the highest tolerated dose of beta blocker and CCB but is still symptomatic. BP is 170/95 mmHg.
A. Coronary angiography B. Exercise ECG C. Beta blockers D. Thallium scan E. CABG F. Long acting nitrates G. Angioplasty H. Ace inhibitors I. Nifedipine
F. Long acting nitrates - Long acting nitrates such as isosorbide mononitrate or transdermal GTN is indicated as the patient is still symptomatic on beta blockers and CCBs. Appropriate nitrate-free periods will be needed to avoid tolerance. Severe hypotension may occur if combined with a phosphodiesterase-5 inhibitor.
Choose the malignancy that is most strongly associated with the risk factor below
Pernicious anaemia
A. Gastrointestinal lymhpoma B. Bladder carcinoma C. Gastric carcinoma D. Cholangiocarcinoma E. Ovarian carcinoma F. Colorectal carcinoma G. Hepatocellular carcinoma H. Prostatic carcinoma I. Cervical carcinoma
C. Gastric carcinoma - Patients with pernicious anemia have a 2- to 3-fold increased incidence of gastric carcinoma.
A TIIDM man has recently had an addition to his medicine, his wife has noted that he becomes confused and seems to shake in the evening especially if he has forgotten to take his lunch to work
A. Addison's disease B. Alcohol C. Meningitis D. Insulinoma E. Insulin F. dumping syndrome G. Gliclazide H. Waterhouse-Friderichsen syndrome I. Starvation
G. Gliclazide
A 23 year old woman has a random blood glucose result of 7.7 mmol/L in clinic
A. Impaired glucose tolerance B. Normal C. Impaired fasting glucose D. Diabetic E. Non-signifcant
E. Non- significant - This patient has had a random blood glucose taken. A reading of > 11.1 mmol/L would almost definitely mean she was diabetic. A reading greater than 7.8 might be suggestive of some dysfunction and possible prediabetes although it is not conclusive. However her reading is 7.7 mmol..nothing can be derived from this.. it is a non-significant reading.
A 49 year old man presents to A&E with a 2 week history of a ‘tight’ central chest pain radiating to the jaw experienced when he is lying down.
A. Atrial fibrillation B. Unstable angina C. Atrial flutter D. Left ventricular failure E. Congestive cardiac failure F. Myocardial infarction G. Decubitus angina H. Constrictive pericarditis I. Stable angina J. Bacterial endocarditis
G. Decubitus angina - Usually as a complication of heart failure. This patient has chest pain which occurs on lying down, which is decubitus angina by definition.
A 40-year-old female has a routine blood test showing serum calcium 2.85 mmol/l (corrected). She takes no medications. PTH is also elevated and ALP is mildly raised. She is depressed.
A. Myeloma B. Medullary cell carcinoma of the thyroid C. Sarcoidosis D. Paget’s disease E. Thiazide diuretics F. Vitamin D intoxication G. Hypervitaminosis A H. Tuberculosis I. Immobility J. Milk-alkali syndrome K. Primary hyperparathyroidism L. Metastatic breast carcinoma M. Secondary hyperparathyroidism N. Pseudohypercalcaemia
K. Primary hyperparathyroidism - This is the most common cause of hypercalcaemia. 85% are due to a single adenoma in one of the glands while most of the rest are due to 4 gland disease. The range of disease is from very mild/asymptomatic through to severe disease with bone loss, fractures and osteitis fibrosa cystica. There is autonomous PTH production in primary HPT which causes deranged calcium metabolism. Biochemistry will show elevated serum calcium and inappropriate elevation of PTH. Depression, cognitive changes, change in sleep (possibly due to change in circadian rhythm) and myalgia are all common complaints. Osteoporosis may occur due to excess PTH causing bone resorption (osteoclasts are stimulated). Hypercalciuria may cause renal stones and nocturia. The only definitive cure is a parathyroidectomy although complications of this procedure include hypocalcaemia, injury to the recurrent laryngeal nerve, bleeding and a pneumothorax.
An 18 month old child from rural India presents to the local clinic where you are based for your elective. He has weakness in his left leg. Approximately 2 weeks ago, he has had fever and diarrhoea which resolved without treatment. The boy’s mother only believes in herbal remedies. Examination reveals the left leg has decreased tone, power and reflexes.
- Guillan-Barre syndrome
- Poliovirus infection
- Transverse myelitis
- Mycobacterium tuberculosis
- Poliovirus infection - This is paralytic poliovirus infection. The mother here only believes in herbal remedies so this child has not been immunised. The gastrointestinal prodrome is common although non-specific. Examination findings here are consistent. While GBS may be preceded by gastroenteritis, the limb weakness is usually symmetrical and there may be autonomic dysfunction. There is no cure for poliovirus infection.
A 70-year-old diabetic male presents with severe pain in his left foot. The pain is present at rest and is alleviated by hanging his leg off the foot of the bed at the night. On examination you note advanced gangrene with superimposed infection of the left foot with absent dorsalis pedis and posterior tibial pulses.
A. Amputation B. Embolectomy C. Thrombolysis D. Endarterectomy E. Femoro-popliteal bypass F. Femoral-femoral crossover graft G. Anticoagulation H. Aorto-bifemoral bypass I. Fasciotomy J. Percutaneous transluminal angioplasty K. Antiplatelet drug L. Conservative management
A. Amputation - Gangrene occurs as a complication of necrosis and characterised by the decay of body tissue. It can be due to ischaemia, trauma or infection, or a combination of these processes. There is ischaemic gangrene, which arises due to either arterial or venous obstruction. There is also infectious gangrene which include processes like gas gangrene cause by Clostridium perfringens and necrotising fasciitis which has many causes, commonly Streptococcus pyogenes. Diabetes is a risk factor here and is frequently associated with both infectious and ischaemic gangrene. High blood glucose and impaired immunity, peripheral neuropathy and arterial disease contribute to limb-threatening diabetic foot infections. The absent pulses and symptoms this patient is experiencing here (critical limb ischaemia) also suggests diabetic chronic peripheral arterial disease, which in diabetics tends to affect smaller arteries and affects a younger age group when compared to non-diabetics.There is advanced gangrene here, and in cases of severe limb sepsis, amputation is required. This is a two stage process which at first involves guillotine amputation and later, when the infection has cleared, a definitive amputation and wound closure is needed. If the extremity is not viable (such as a large amount of necrosis, profound anaesthesia/paralysis or an inaudible Doppler pulse) then the patient should undergo prompt amputation. Every effort should be made to preserve as many joints as possible in order to improve rehabilitation chances and to decrease the work of walking around with a prosthesis.
An elderly gentleman is lethargic and complains of numbness in his feet. Blood test reveals a Hb 6.0g/dl and MCV 115fl. O/E you observe a peripheral sensory neuropathy in his lower limb. You order a blood film.
A. Porphyria B. Beri-beri C. Alcohol excess D. Vitamin B12 deficiency E. Lyme disease F. Lung carcinoma G. Charcot-Marie_Tooth Syndrome H. Diabetic amyotrophy I. HIV
D. Vitamin B12 deficiency - This is a macrocytic anaemia with elevated MCV. The classical peripheral blood smear would show megalocytes (RBC precursors whose numbers increase) and hypersegmented polymorphonuclear cells although the film may be normal in early deficiency. You would also want to order a serum B12 level in this patient and would expect the corrected reticulocyte index to be low due to decreased production (opposed to high in haemolytic anaemia due to increased production). This peripheral sensory neuropathy would likely be a loss of proprioception and vibration indicating degeneration of the dorsal column-medial lemniscus pathway. The patient may also have a positive Romberg as a result. Parasthesias are also common in B12 deficiency indicating peripheral neuropathy. Pallor and signs of frank anaemia are late signs. It is important to remember that hepatic B12 stores last for many years so B12 deficiency depends on chronic deficiency over a long period of time. In general, deficiency is caused by decreased intake, decreased gastric breakdown from food or malabsorption from the GIT. Serum B12 is a useful investigation to initially conduct and will guide further investigations and treatment. You should consider an underlying malabsorptive process such as coeliac or Crohn’s as a possible cause.
A 35 year old lady is generally unwell with a tachycardia & a fever. A segment of the right breast is painful, tender, red & warm.
A. Sebaceous cyst B. Fibroadenoma C. Fibroadenosis D. Gynaecomastia E. Breast abscess F. Carcinoma of the breast G. Breast cyst H. Lipoma I. Duct ectasia
E. 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 55-year-old woman with a 6-week history of intermittent angina is found to have a serum cholesterol of 7.9 mmol/l.
A. Perform CABG B. Perform exercise ECG C. Add an ACE inhibitor D. Perform echocardiography E. Add Aspirin F. Add clopidogrel G. Perform coronary angioplasty H. Add Atorvastatin I. Advise lifestyle measures J. Add Atenolol K. Add low molecular weight Heparin L. Add Omega-3 oils M. Perform coronary thrombolysis
B. Perform exercise ECG - This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.
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.
A. Basal cell carcinoma B. Adenoma C. Sebaceous cyst D. Fat necrosis E. Carcinoma of the breast F. Intraductal papilloma G. Lipoma H. Radial scar I. Breast bud J. Fibroadenosis K. Phylloides tumour L. Breast abscess M. Fibroadenoma
L. 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.
A man from Tanzania presents with occassional diarrhoea accompanied by frank blood. Examination reveals mild hepatomegaly and a palpable spleen. On further questioning, he tells you he has been swimming in the local lake.
1. Leishmaniasis 2. Schistosomiasis 3. Salmonella 4. Toxoplasmosis
This is caused by a fluke which is acquired through exposure of the skin to contaminated freshwater (it is a snail-borne parasite). Patients can present acutely with bloody diarrhoea and hepatosplenomegaly is a common finding too. Diagnosis is made on microscopic visualisation of eggs in stools or urine. The preferred treatment for schistosome infections is with a drug called praziquantel.
A 62-year-old lady has been having difficulties walking for some years. A scan this year shows occlusion of the popliteal artery in her left leg. Previous angioplasties have failed.
A. Angioplasty B. Femoral-distal bypass C. Aortobifemoral bypass D. Methyldopa E. Ultrasound F. Alpha blocker G. Embolectomy H. Endarterectomy I. Angiography J. Endovascular aneurysm repair K. Open repair of aneurysm
B. Femoral-distal bypass - Previous angioplasties have failed so there is clearly not point in having another endovascular intervention such as PTA (percutaneous transluminal angioplasty) with balloon dilation, stents, laser, atherectomy or thermal angioplasty. The occlusion here is at the level of the popliteal artery so a femoral-distal bypass is indicated. Surgical revascularisation is recommended for lesions involving the popliteal artery. Make sure you know your vascular anatomy! (At least the big vessels).
A 47-year-old male policeman was brought to A&E having become SOB suddenly. He now complains of palpitations, which he has never experienced before. Heart sounds are irregular but no murmurs are audible. He is a diabetic with hypertension.
A. Pancreatitis B. Wernicke's encephalopathy C. Wolff-Parkinson-White syndrome D. Hyperglycaemia E. Atrial fibrillation F. Convulsions G. Subdural haematoma H. Acute gastritis I. Hypertension J. Anxiety attack K. Delirium tremens L. Hypoglycaemia M. Pulmonary fibrosis N. Oesophageal varices
E. Atrial fibrillation - Atrial fibrillation is an irregular atrial arrhythmia with a broad list of risk factors such as coronary artery disease, heart failure, hypertension, DM and thyroid disorders. This patient has two of these risk factors. AF affects some 5% of those older than 69 years old. The presentation of SOB and palpitations is consistent with the diagnosis and the irregular heart sounds suggests AF as the cause. ECG would show absent P waves, a fibrillatory baseline and irregularly irregular complexes. Most that present with acute AF do not need immediate treatment, unless they have developed haemodynamic compromise, which requires immediate DC cardioversion. Most will require medical therapy with drugs to control the ventricular rate, restore and maintain sinus rhythm and prevent the occurence of thromboembolic events. Do you know which drugs are used and are you familiar with treatment guidelines for this common condition?
A 65-year-old woman has progressive, low retrosternal dysphagia, initially to solids, but now also to liquids. It has come on over the last four months. There has also been loss of appetite and 3kg weight loss.
A. Cerebrovascular accident B. Pharyngeal pouch C. Hiatus hernia D. Pneumonia E. Myasthenia gravis F. Carcinoma of oesophagus G. Achalasia H. Carcinoma of bronchus I. Plummer-Vinson syndrome J. Gastric volvulus K. Thyroid goitre
F. Carcinoma of oesophagus - Dysphagia (in this progressive pattern) coupled with weight loss 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 46-year-old woman complains of right loin pain. Her mother had been on dialysis in Australia for 10 years. Plasma creatinine 180 μmol/l. No abnormalities were detected on urinalysis.
A. Renal ultrasound B. CVP measurement C. Renal biopsy D. Plasma electrophoretic strip E. Intravenous pyelogram F. Renal arteriogram G. HIV test H. Anti-neutrophil cytoplasm antibodies I. Anti-glomerular basement membrane antibody J. Captopril renogram
A. Renal ultrasound - A dominantly inherited cause of renal failure is likely to be polycystic kidney disease which is best noted on ultrasound
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.
A. Lumbar puncture B. Arteriogram C. Blood sugar D. Cold provocation test E. Full blood count F. Blood cultures G. Venous duplex scan H. Anti-neutrophil cytoplasmic antibody
H. Anti-neutrophil cytoplasmic antibody - This patient has Wegener’s granulomatosis, a systemic vasculitis affecting small and medium sized vessels. The classic triad includes upper and lower respiratory tract involvement and GN. Musculoskeletal manifestations such as arthralgia and signs of thromboembolism are commonly seen. A positive cANCA (antigen being proteinase 3) in the setting of the classic triad is sufficient to diagnose Wegener’s. Urinalysis and microscopy is also indicated to reveal renal involvement and a CT chest may reveal lung involvement, particularly in those who are asymptomatic for pulmonary involvement. This may show nodules or infiltrates.
True or False, the facial nerve supplies the masseter muscle.
False - Muscles of mastication (masseter, temporalis, medial pterygoid, lateral pterygoid) are supplied by the mandibular branch of the trigeminal nerve.
A 10 year old boy presents to A&E one winter following a school P.E. lesson with a difficulty in breathing and an audible wheeze.
A. TB B. Emphysema C. Bronchitis D. Pleural effusion E. Pneumonia F. Lung Tumour G. Pulmonary embolism H. Asthma I. Pneumothorax J. Pulmonary fibrosis K. Sarcoidosis
H. Asthma - This is likely to be asthma, exacerbated by the cold air and exercise. Treatment is in this case based on paediatric guidelines which differs from that of adult asthma. 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.
Stepwise treatment for adult asthma (BTS guidelines) is outlined here as this is most commonly examined. Step 1: SABA PRN, Step 2: Plus low-dose inhaled corticosteroids (ICS) , Step 3: Plus LABA, Step 4: Increase dose of ICS or add LTRA, SR theophylline or beta agonist tablet, Step 5: Daily steroid tablet and maintain ICS with specialist care.
A 26 year old weightlifter is admitted following an overdose of GBH. He opens his eyes when he hears you speak and starts trying to yank out his Guedel. He can obey simple commands and once his Guedel is out and can talk to you in small sentences and seems a bit confused as to where he is.
What is his GCS score?
A. 0 B. 10 C. 13 D. 1 E. 11 F. 3 G. 8 H. 5 I. 14 J. 7 K. 12
C. 13 - M6 V4 E3 = 13
A GCS less than or equal to 8 is deemed a coma. Head injury can also be classified into mild (13-14), moderate (8-12) and severe (
A 58-year-old man, who smoked 30 cigarettes a day, presents with a 6-week history of cough, malaise, anorexia and weight loss. Past medical history includes hypertension for which he has taken lisinopril and bendrofluazide for 4 years.
A. Postnasal drip B. Oesophageal reflux C. Angiotensin converting enzyme inhibitor D. Foreign body E. Asthma F. Sarcoidosis G. Tuberculosis H. COPD I. Carcinoma of bronchus J. Bronchiectasis
I. Carcinoma of bronchus - The history of smoking and weight loss point to a bronchial carcinoma. Initial investigation is with a CXR. Diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome.
A 12 year old boy presents with a flu-like illness, fever, headache, vomiting, tremor of the left side of the body and weakness of his left leg.
A. Giardiasis B. Polio C. Glandular Fever D. Malaria E. Viral Hepatitis F. HIV G. Tuberculosis H. Herpes Zooster (Shingles) I. Cholera J. Toxoplasmosis K. CMV (cytomegalovirus) L. Syphilis M. Tetanus N. Influenza O. Rabies
B. 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 has acute flaccid paralysis (AFP), 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 two main types of polio vaccine – Sabin, which is the oral weakened strain in disease endemic regions, and Salk, which is inactivated poliovirus in the rest of the world.
A 65 year old man with a history of an MI 2 years ago. He lost conciousness and presents to you 36 hours later with reduced power in his left arm and leg.
A. Anaemia B. Vasovagal syncope C. TIA D. Cardiac arrhythmia E. Stroke F. Postural hypotension G. Myxoedema coma H. Carotid sinus sensitivity I. Hypoglycaemia J. Aortic stenosis K. Epilepsy L. Pulmonary stenosis
E. Stroke - If you have a think about the motor pathways you will realise that this is a right sided stroke. Cardiac conditions are potential risks for cardioembolism. The previous MI could, for instance, lead to regional wall motion abnormalities or decreased LV ejection fraction which can be risks. Other cardiac conditions include valve disease, PFO, mitral prolapse, prosthetic heart valve and cardiomyopathy. Other major risk factors include AF, DM, smoking, hypertension and FH. It is important is perform a CT head exclude a haemorrhagic aetiology and consider thrombolysis with tPA if within the 4.5 hour window and there are no contraindications. Obviously this patient has presented to late for this but thrombolysis is usually done with alteplase at 10% bolus, 90% infusion at a dose of 0.9 mg/kg. Presentation after the 4.5 hour window will be managed with aspirin.
The Bamford/Oxford Stroke Classification subtypes ischaemic stroke according to vascular territory of infarction. After initial management, stroke care involves the ethos of an MDT environment with rehabilitation. This is not a TIA which resolves within 24 hours of symptom onset, although in practice this is often difficult to distinguish due to interventional measures which are rapidly enacted.
17 year old male with radiological apperance of rib notching on chest radiograph.
A. Addisons Disease B. Doxazosin C. Renal artery stenosis D. Phenelzine E. Conns syndrome F. Coarctation of the aorta G. Patent ductus arteriosus H. Cushings disease I. Hyperthyroidism J. Phaeochromocytoma
F. Coarctation of the aorta - Aortic coarctation is characterised by a BP difference between the upper and lower extremities. Posterior rib notching is due to enlargement of collateral vessels due to aortic narrowing. Diagnosis is made on demonstrating narrowing of the aortic arch, typically shown by echocardiography. Treatment may involve surgical repair such as the placement of a stent. This condition is typically congenital with a male predominance. It is commonly detected in the first decade and is associated with Turner’s and DiGeorge. An ejection systolic murmur is also common present over the LSB and back.
An 83-year-old lady complains of feeling tired and breathless on exertion since a brief episode six weeks ago which another doctor diagnosed as gastroenteritis. However, the diarrhoea has not improved. A blood test you did last week shows a microcytic anaemia.
A. Full blood count and ESR B. Abdominal CT C. HIV antibody test D. Colonoscopy E. Blood test for auto-antibodies F. Thyroid function tests G. Bronchoscopy H. Fasting blood glucose I. Chest x-ray J. Bone marrow aspirate K. History only L. Gastroscopy M. Brain scan
D. Colonoscopy - This lady needs to be investigated for bowel cancer. There are symptoms and confirmation of IDA which could be due here to GI bleeding. There is also diarrhoea which has not improved and is now chronically a problem. Along with advanced age, this raises the suspicion of malignancy and a colonoscopy needs to be done.
An alcoholic man is unwell he is seen by the on call Dr in A+E, diagnosed and started on iv fluids and is NBM, his BM is 15.8 mmol/L.
A. Oesophageal cancer B. Pancreatitis C. Drug induced D. Lung cancer E. Pituitary adenoma F. Cushing's syndrome G. Type II diabetes H. PCOS I. Cushing's disease
B. Pancreatitis - This patient is an alcoholic and his management points to abdominal pathology which in his case is acute pancreatitis: any pathology affecting the pancreas can disrupt it’s endocrine function..surgery, trauma chemical inflammation etc. here this has affected insulin production
A 63-year-old male with a history of AF underwent an embolectomy a few hours ago after a clot was found in the popliteal artery. He is now complaining of increasing pain and tightness in the treated leg. O/E the leg appears swollen and there is pain on passive flexion of the foot.
A. Amputation B. Embolectomy C. Thrombolysis D. Endarterectomy E. Femoro-popliteal bypass F. Femoral-femoral crossover graft G. Anticoagulation H. Aorto-bifemoral bypass I. Fasciotomy J. Percutaneous transluminal angioplasty K. Antiplatelet drug L. Conservative management
I. Fasciotomy - This patient has developed compartment syndrome most likely as a result of soft tissue injury or direct injury to the musculature following the recent embolectomy. Additional causes include fractures and compartment haemorrhage. This condition results from raised interstitial pressure in closed osseofascial compartments. The classical clinical diagnosis will be of the following 6 Ps: pain, pressure, pulselessness, paralysis, paraesthesia and pallor (uncommon). The history here of severe extremity pain and tightness following documented trauma is classical. The pain tends to be out of proportion to the injury and is made worse by passive stretching of the muscle groups which are contained by the affected compartment. Passive stretching of the muscles of the compartment which is involved will also elicit pain. Note that true paralysis is a late sign, as is loss of pulses and pallor. Paraesthesia is however an early seen sign. If the diagnosis is uncertain in an at risk patient then compartment pressure measurement is indicated. Measurements of serum CK and urine myoglobin will also be indicated and these may be elevated with muscle cell lysis and necrosis. This is not due to an occlusive dressing (if it were, the first line treatment would be to remove this dressing). Therefore, a fasciotomy is indicated regardless of time of diagnosis with fasciotomy of all compartments with elevated pressure. There is a clear 6 hour window whereby there are lower amputation and death rates compared to delays >6 hours, so this needs to be done as a matter of urgency. The incision needs to be long enough too! Wound care post-fascitomy is important to prevent the risk of secondary infection and to debride any necrotic tissue, or to consider skin grafts. Post-operatively, care will be MDT with physical and occupational therapies and a range of motion exercises to try an d get the patient fully functional.
A 73 year old gentleman presents to A&E with sudden “tearing” chest pain, radiating to the back. The house officer on duty notices unequal arm pulses & BP.
A. Pericarditis B. Pulmonary embolism C. MI D. Hiatus hernia E. Anxiety F. Angina G. Coronary artery disease H. Oesophageal spasm I. Tietze’s syndrome J. Dissecting aortic aneurysm
J. Dissecting aortic aneurysm - The tearing chest pain suggests aortic dissection. There may also be interscapular pain with dissection of the descending aorta. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. BP differential between the 2 arms is a hallmark feature. Pulse differences may also be present in the lower limbs. There may also be the diastolic murmur of AR in proximal dissections.
A 45 year old man has recurrent epigastric pain, weight loss and steatorrhoea. He has a previous history of alcoholism.
A. Abdominal X-ray B. Sweat test C. Thyroid function D. ERCP E. Immunoglobulin F. Skin biopsy G. Hydrogen breath test H. Colonoscopy I. Faecal elastase-1 J. Liver function tests K. HIV test L. Endomysial antibodies M. Abdominal ultrasound
D. ERCP - This is chronic pancreatitis which is most commonly associated with chronic alcohol abuse. Features include the epigastric pain here, which classically radiates to the back, and steatorrhoea from malabsorption (pale, foul-smelling and difficult to flush stools). There may additionally be DM due to pancreatic failure and the patient may be malnourished. The diagnosis is based on findings and imaging – your options are USS which is less sensitive, or CT, which is more sensitive but involves radiation exposure. AXR is not a sensitive enough test. However, this question is looking for the best test which is ERCP, commonly considered the most accurate test with high sensitivity and specificity. It is limited in use though due to cost and the risk to the patient. Characteristically ERCP would show beading of the main pancreatic duct as well as irregularities in the side branches. Faecal elastase-1 is inaccurate for diagnosing mild to moderate pancreatic insufficiency, and anyway has unacceptably low sensitivity.
There is no real definitive treatment, which is mainly symptomatic and the underlying and precipitating factors are treated – in this case, this man’s alcohol excess. Complications of chronic pancreatic imflammation include the development of pseudocysts, calficiation, DM and malabsorption.
Thyroid acropachy is a extrathyroidal manifestation of which disease/s?
- Hypothyroidism
- Mulitnodular goitre
- Hyperthyroidism
- Plummer’s disease
- Grave’s disease
- Graves disease
A 56-year-old lady with T2DM presents with gradual onset of weakness of the left hand and right foot. On examination, you also notice reduced sensation in the lower legs. She tells you that she also suffers a burning and shooting pain in her feet.
A. Subdural haemorrhage B. Space-occupying lesion C. Depression D. Stroke E. Migraine F. Myasthenia gravis G. Extradural haemorrhage H. Arterial dissection I. Multiple sclerosis J. Peripheral neuropathy K. Polio
J. Peripheral neuropathy - This is by definition peripheral neuropathy. This is a case of diabetic neuropathy with sensory and motor deficits. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. Pain is a common complaint such as the burning and shooting sensation this patient describes. Patient’s may also describe the pain as prickling or sticking. Examination should include peripheral pulses, reflexes and sensation to light touch with a 10g monofilament, vibration (128Hz tuning fork), pinprick and proprioception. The pain may be treated with medications like pregabalin (VGCC modulator) and duloxetine (serotonin-NA re-uptake inhibitor).
A 50-year-old woman taking non-steroidal anti-inflammatory drugs for arthritis presented with a history of sudden onset pain behind her right knee leading to pain down the calf. Ultrasound confirms a Baker’s cyst.
A. Check INR and continue warfarin B. Fondaparinux (FXa inhibitor) C. Subcutaneous low molecular weight heparin D. Antiembolism stocking E. Start warfarin therapy F. Vena cava filter G. Reassure and discharge H. Embolectomy I. Observation in hospital J. Intravenous heparin
G. Reassure and discharge - A popliteal cyst is an accumulation of synovial fluid which in this case has resulted from this woman’s arthritis. This is an accumulation of synovial fluid behind the knee, usually in response to injury or inflammation. It will self-resolve but the underlying cause should be addressed i.e. arthritis. First line treatment for grade 1 or 2 injuries is with RICE: rest, ice, compression and elevation followed by gentle mobilisation. Adjunctive analgesia can be offered with paracetamol. Treatment is conservative, particularly if asymptomatic. Surgery is only indicated in those with extensive symptoms where conservative and percutaneous treatments have failed. Corticosteroid injections (intra-articular) can also be considered.
A 40 year old male presents with PR bleeding & a palpable lump from anus, with associated mucus discharge. There is blood splashed around lavatory pan
A. Irritable bowel syndrome B. Pilonidal sinus C. Haemorrhoids D. Inflammatory bowel disease E. Abscess F. Prolapse G. Fissure H. Fistula I. Intussusception
C. Haemorrhoids - Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.
Which of the following is most likely to cure a patient of malignant disease?
A. Surgery
B. Radiotherapy
C. Chemotherapy
D. Medical treatment
A. Surgery
76-year-old woman was admitted with confusion. She had been increasingly unable to care for herself. On admission, she was found to have cool peripheries and her blood pressure was 100/70. Blood results showed plasma urea 25 mmol/L and plasma creatinine 120 μmol/L.
A. Pulmonary embolus B. Arrhythmia C. Blood loss D. Autonomic neuropathy E. Septicaemia F. Hyperadrenalism G. Cardiogenic shock H. Drug induced I. Volume depletion
I. Volume depletion - Volume depletion is a reduction in ECF volume due to salt and fluid losses which exceed intake. Causes include vomiting, bleeding, diarrhoea, diuresis and third space losses. Symptoms do not occur until large losses have alrady occured. Cool peripheries are a sign of peripheral shut down. Confusion may reflect poor cerebral flow or uraemia.Volume depletion has led to the low BP. Other symptoms include postural hypotension and tachycardia, weight loss and signs of shock. Serum urea and creatinine is elevated (you need to eyeball the patient when looking at creatinine – a very big body builder will have a much higher creatinine), indicating poor renal blood flow. This patient needs IV saline fluid replacement.
A 50 year old man: BR 110umol/l, ALP 300iu/l, ALT 110iu/l, AFP is elevated.
A. Alcoholic cirrhosis B. Gilbert’s syndrome C. Acute pancreatitis D. Hepatocellular carcinoma E. Paracetamol overdose F. Cholangiocarcinoma G. Drug-induced cholestasis H. CMV infection I. Haemolysis J. Pancreatic cancer K. Wilson’s disease L. Gallstones M. Viral hepatitis
D. Hepatocellular carcinoma - The pattern here is cholestatic. Furthermore, elevated AFP is given, which is a tumour marker for HCC, differentiating this from other potential causes like pancreatic cancer. AST and ALT may be normal or elevated.
Liver function tests are mistakenly named really because they don’t test liver function. They are better called ‘liver tests’ or ‘tests of liver chemistry’. The tests of liver synthetic function come from measuring albumin levels (produced by the liver) and the prothrombin time, as the liver has a key role in the manufacture of clotting factors. Some general points on liver tests to consider: These tests tend to include bilirubin (breakdown product of RBC after hepatic conjugation, and is secreted in the biliary system), AST, ALT, GGT, ALP (alk phos) and LDH. It’s really all about pattern recognition. Isolated elevation of liver tests tends to make you think of non-hepatic causes and you should take into account the patient’s history during interpretation. A normal liver panel does not mean that the person does not have liver disease, and liver tests are elevated in a small percentage of normals.
You can split the possible causes into three broad categories. It is worth noting that people with any pattern can have cirrhosis. AST is also present in heart, skeletal muscle, kidney, brain and in RBCs too. 80% of AST is found in the mitochondria and 20% in the cytoplasmic matrix. ALP, which is a cytoplasmic enzyme, can come from bone, kidney, intestines or the placenta. GGT may come from the heart or RBCs.
The first is predominantly elevated AST/ALT, which is described as a hepatocellular pattern and occurs in conditions such as viral hepatitis, alcoholic disease, Wilson’s etc. Here the hepatocytes get damaged and enzymes leak out.
The second is predominantly elevated ALP (GGT too, but an isolated rise in GGT is common so many hospitals remove GGT from the liver panel. GGT is only useful if there is an isolated rise in ALP). This is seen in a cholestatic (here, the hepatobiliary system is affected) or infiltrative pattern in bile duct obstruction, malignancy e.g. HCC or pancreatic, PBC/PSC etc or infiltrative conditions such as TB and lymphomas.
The last is an isolated hyperbilirubinaemia seen in haemolysis, intra-abdominal bleeding or with conditions such as Gilbert’s. BR elevation can be further divided into conjugated or unconjugated. Unconjugated is normally due to breakdown of RBC beyond the liver’s capacity to conjugate. Conjugated occurs in liver disease and problems with obstructed bile flow.
An 85 year old male presents with shortness of breath associated with confusion. On examination there is decreased expansion on the left side & the patient with respiratory rate of 35/min.
A. Mitral stenosis B. Pneumonia C. COPD D. Pneumothorax E. Anaemia F. Left ventricular failure G. Thyrotoxicosis H. Epiglottitis I. Asthma J. Anxiety K. Aspirin poisoning L. Pulmonary embolus M. Mitral regurgitation
B. Pneumonia - This patient has pneumonia. Symptoms include chills, fever, cough, SOB and pleuritic chest pain. Examination findings are consistent with his diagnosis. A CXR is the most specific and sensitive test available and antibiotics are indicated.
A 68-year-old woman presents with a painless, hard lump, 6cms in diameter just underneath the skin of her right breast lateral to her nipple. The overlying skin is slightly pitted and there is no lymphadenopathy.
A. Basal cell carcinoma B. Adenoma C. Sebaceous cyst D. Fat necrosis E. Carcinoma of the breast F. Intraductal papilloma G. Lipoma H. Radial scar I. Breast bud J. Fibroadenosis K. Phylloides tumour L. Breast abscess M. Fibroadenoma
E. Carcinoma of the breast - Patient’s wth breast cancer, on examination tend to demonstrate a firm hard lump which may be associated with axillary lymphadenopathy, skin changes such as the orange peel (peau d’orange), dimpling seen here and nipple changes/discharge. Skin changes are associated with locally advanced cancer. Many breast cancers are also diagnosed on routine mammography which can show microcalcifications, in the absence of a palpable mass. MRI is more sensitive but less specific so is recommended only in patients who are at high risk, such as BRCA1/2 mutation, history of chest radiation or certain syndromes like Cowden’s or Li-Fraumeni. FNA is also useful in rapid diagnosis, although is operator dependent when it comes to how sensitive and specific it is, and a core biopsy is preferred in most cases for diagnosis as it can differentiate pre-invasive and invasive disease. Treatment is MDT involving surgeons, oncologists, radiation oncologists etc.
A 28-year-old woman with a carcinoma of the cervix was admitted with plasma creatinine of 250μmol/l. BP was 130/80. Urinalysis was negative
A. Renal ultrasound B. CVP measurement C. Renal biopsy D. Plasma electrophoretic strip E. Intravenous pyelogram F. Renal arteriogram G. HIV test H. Anti-neutrophil cytoplasm antibodies I. Anti-glomerular basement membrane antibody J. Captopril renogram
A. Renal ultrasound - A patient with cervical carcinoma is at risk of ureteric obstruction and then hydronephrosis. Again ultrasound is the test of choice
A 41-year-old woman of Mediterranean descent is found to be anaemic. She has hepatosplenomegaly and normal haematinics.
A. Thick blood film B. Haemoglobin electrophoresis C. Upper GI endoscopy D. Colonoscopy E. Anti-gliadin andtibodies F. Thin blood film G. Serum ferritin H. Urea and electrolytes I. Faecal occult bloods J. Faecal fats K. Bone marrow biopsy L. Barium meal and follow through
B. Haemaglobin electrophoresis - This is beta-thalassaemia, either major or intermedia due to the findings of abdominal distension, skeletal changes and hepatosplenomegaly which is not seen in heterozygoud beta-thalassaemia trait. The pallor is highly suggestive of moderate to severe anaemia, confirmed by the test results. Beta-thalassaemia major (or Cooley anaemia) is due to a complete abscence of HbA and often presents at a few months of age with pallor and abdominal distension, both described by parents as being progressive in nature. HSM and bony abnormalities (most often the frontal and parietal bossing mentioned, as well as ‘chipmunk facies’) are often present at presentation. Intermedia has a similar presentation but in a toddler or older child, with less pronounced symptoms and a more insidious course. Blood transfusions are required though stem cell transplant offers a hope of a cure. Hb electrophoresis will reveal minimal or no HbA and elevated HbF and HbA2.
A 50 year old extremely obese lady presents with a tender, hard 3cm lump in the left breast which has appeared quite rapidly. She remembers knocking the breast against a table edge 1 month ago.
A. Benign cyst B. SLE C. Breast abcess D. Fat necrosis E. Fibrocystic breasts F. Pagets disease G. Duct ectasia H. Fibroadenoma I. Mastalgia J. Breast carcinoma K. Gynaecomastia
D. Fat necrosis - Prior breast trauma or breast surgery such as augmentation can lead to fat necrosis. Examination will reveal a firm mass with irregular borders which can resemble malignancy. Biopsy will reveal fat necrosis. USS and mammography shows indistinct margins, sometimes with calcifications which may again resemble findings seen in carcinoma.
A 60-year-old Irish woman comes to see you with a progressive one year history of shortness of breath and recent onset of PND. She has been previously well apart from Sydenham’s chorea as a child. She had 6 normal pregnancies. On examination she has plethoric cheeks, the pulse is rapid (110/min), irregular and small volume. BP 128/80 JVP normal. The apex is in the 5th intercostal space in the mid-clavicular line and tapping in nature. The 1st heart sound is loud and P2 accentuated. A low pitched mid-diastolic murmur is heard at the apex.
A. Atrial septal defect B. Mixed mitral valve disease C. Ventricular septal defect D. Aortic regurgitation E. Infective endocarditis F. Aortic stenosis G. Innocent murmur H. Mixed aortic valve disease I. Mitral valve prolapse J. Hypertrophic obstructive cardiomyopathy K. Mitral stenosis L. Mitral regurgitation M. Mixed mitral and aortic valve disease
K. Mitral stenosis - Sydenham’s chorea (St Vitus Dance) are dancelike movements seen in rheumatic fever. The major criteria for rheumatic fever can be remember by CASES: carditis, arthritis, Sydenham’s chorea, erythema marginatum and subcutaneous nodules. Practically every single case of mitral stenosis is caused by rheumatic heart disease. The process tends to also cause regurgitation. This is characteristically a grade 1-2 low pitch murmur heard in mid-diastole which has a rumbling nature and there is no radiation. There can be an associated malar flush, tapping apex beat and a diastolic thrill palpable at the apex, in the 5th intercostal space in the MCL. The first heart sound is also characteristically loud and often this is the most striking feature on ascultation. It is a difficult murmur to pick up so if you are ever asked at this stage to spot this murmur, it will most likely be based on the loud S1.
Chose choose the most likely mode of inheritance.
Down’s syndrome
A. None/unknown B. Autosomal recessive C. Autosomal dominant D. X-linked dominant E. Chromosomal abnormality F. X-linked recessive G. Mitochondrial inheritance
E. Chromosomal abnormality -
Here is a list of the important conditions you should be aware of:
Autosomal dominant: Achrondroplasia, APKD, dystrophia myotonica, familial hypercholesterolaemia, Huntington’s, Marfan’s, NF, tuberous sclerosis, osteogenesis imperfecta
Autosomal recessive: CF, hereditary haemochromatosis, sickle cell disease, Wilson’s, Friedreich’s ataxia, CAH
X-linked recessive: DMD, Fragile X syndrome, Haemophilia A and B, G6PDH deficiency, Alport’s
You should be aware that Down’s is trisomy 21, Edwards’ is trisomy 18 and Patau’s is trisomy 13.
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.
A. Atrial septal defect B. Mixed mitral valve disease C. Ventricular septal defect D. Aortic regurgitation E. Infective endocarditis F. Aortic stenosis G. Innocent murmur H. Mixed aortic valve disease I. Mitral valve prolapse J. Hypertrophic obstructive cardiomyopathy K. Mitral stenosis L. Mitral regurgitation M. Mixed mitral and aortic valve disease
L. 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.
A 56-year-old man presents with anorexia and jaundice. He reports losing weight over the past month. He has a bilirubin of 350 umol/L, AST of 55 IU/L and an ALP of 750 IU/L. O/E the gallbladder is palpable.
A. CA 15-3 B. Tyrosinase C. BRCA-1 D. CA 19-9 E. Prostatic acid phosphatase F. Carcinoembryonic antigen G. α-Fetoprotein H. Prostate-specific antigen
D. CA 19-9 - Ca 19-9 is used to confirm the diagnosis of malignant pancreatic tumours, differentiating them from chronic pancreatitis. However, it should not be used as a stand-alone diagnostic tool, rather as an adjunct to CT, U/S and ERCP. It is also used for monitoring the response to therapy. Levels can also be elevated in hepatbiliary disease, but it is not used in this setting.
A 62 year old woman presents to A&E with searing back pain, nausea and vomiting. She is known to have an abdominal aortic aneurysm which is scanned every year. She appears jaundiced and the subsequent abdominal CT reveals an AAA of 5.0cm
A. Perforated duodenal ulcer B. Mesenteric infarction C. Pericarditis D. Metastatic disease E. Pyelonephritis F. Pancreatitis G. Myocardial infarction H. Addison’s disease I. Volvulus J. Ruptured abdominal aortic aneurysm K. Renal colic L. Spinal stenosis M. Dissecting aortic aneurysm N. Hepatitis
C. Pancreatitis - The AAA here has nothing to do with the question, and at 5cm, it is not massively prone at the moment to rupture. However, if the patient is otherwise young, fit and healthy, elective repair can soon be considered (the normal abdominal aorta is 1.5cm diameter, and remember that rupture is more common in females than males). This is acute pancreatitis. Jaundice here is suggestive of gallstone aetiology with obstruction to the common bile duct, though pancreatic oedema can itself cause jaundice. Nausea and vomiting is not uncommon and can occur with agitation and confusion. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis (GET SMASHED). Those caused by hypocalcaemia may also display Chvostek’s sign and Trousseau’s sign.
Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook.
An 18 year old girl has felt unwell with myalgia and general malaise for a week develops sharp chest pains which are worse when she lies flat. The pain is constant and unrelated to exertion. There have also been fevers.
A. Tuberculosis B. Mitral stenosis C. Atrial septal defect D. Conduction system disease E. Hypertensive cardiomyopathy F. Pericardial effusion G. Aortic valve disease H. Mitral regurgitation I. Dilated cardiomyopathy J. Infective endocarditits K. Pulmonary fibrosis L. Pericarditis
L. Pericarditis - This patient has presented with pericarditis – most likely viral following a viral infection (as suggested by the prodrome and fever). Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’ – a monophasic, biphasic or triphasic friction rib is pathognomic with close to 100% specificity. There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. Prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.
A 64 year old man has become acutely breathless over the last 4 days, with a productive cough, green sputum & chest tightness. He is a longstanding smoker. Clinically he is hypoxic, with tachycardia, tachypnoea, & central cyanosis. His ABG are as follows: pH 7.35, PaO2 6.7kPa, PaCO2 7.8kPa. He has been given nebulised bronchodilators & intravenous antibiotics & steroids.
A. Oral prednisolone B. 24% continuous oxygen C. Long acting beta agonist D. Beta agonist via metered dose inhaler E. Antibiotic reserve F. Influenza immunisation G. Intravenous aminophylline H. 40% continuous oxygen I. Beta agonist via nebuliser J. Intravenous hydrocortisone K. Amoxycillin intravenously L. Intramuscular adrenaline
B. 24% continuous oxygen - This patient with COPD is having an acute exacerbation. He is being treated accordingly but will need supplemental oxygen as a result of his ABG results. >8kPa is an acceptable level of arterial oxygenation or SaO2 >90%. Ceftriaxone is an acceptable antibiotic. High risk individuals should get tazocin or meropenem (especially if pseudomonas is suspected). Check local antibiotic prescribing policies. Chronic oxygen therapy is indicated for patients with PaO2
A 50 year old woman has developed weight loss and passes loose pale stools. She has mouth ulcers and is anaemic. She is taking thyroxine for myxoedema.
A. Abdominal X-ray B. Sweat test C. Thyroid function D. ERCP E. Immunoglobulin F. Skin biopsy G. Hydrogen breath test H. Colonoscopy I. Faecal elastase-1 J. Liver function tests K. HIV test L. Endomysial antibodies M. Abdominal ultrasound
L. Endomysial antibodies - This is a common condition in the US and Europe. Coeliac disease most commonly presents with IDA, although it can also lead to a macrocytic anaemia with mainly folate deficiency (though B12 is also affected but hepatic stores last several years). The mouth ulcers are a sign of this. There are also GI symptoms resulting from malabsorption. It is an autoimmune condition (the presence of another autoimmune condition here is a risk factor) triggered by gluten peptides found in wheat, rye and barley. The ultimate best test is duodenal biopsy and histology to show intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia. Macroscopic changes may be present but endoscopy is generally unhelpful. The test of choice before performing such an invasive confirmatory test is to look for elevated anti-gliadin antibodies. Anti-tissue transglutaminase is less accurate and endomysial antibody is more expensive and has lower sensitivity, though is the only option on this list specific for coeliac.
It is worth knowing about the Schilling test as it is frequently examined. However, it is no longer routinely done in clinical practice. In this test, IM vitamin B12 is given to saturate stores. Then oral radiolabelled B12 is given and urine is collected over 24 hours. The amount excreted is lower in B12 malabsorption. If this is not corrected by IF the problem is with the ileum and not inadequate IF.
After coming out of surgery two weeks ago Mrs J’s arm wound has started to produce pus and the whole area is inflamed and red. She has come to you as she is concerned it is not healing. Select the most APPROPRIATE first line investigation:
A. LFTs B. CRP C. LP D. CXR and sputum sample E. Blood culture F. Sputum sample G. FBC H. Pleural biopsy I. Wound swab and culture J. Urinalysis K. HIV test L. CT head
I. Wound swab and culture - This is a straightforward question. A wound swab and culture is needed to see what the infection is. This will guide treatment.
A 19 year old girl has noticed a lump in the right breast. It is smooth, 2cm in diameter, non tender and highly mobile.
A. Benign cyst B. SLE C. Breast abcess D. Fat necrosis E. Fibrocystic breasts F. Pagets disease G. Duct ectasia H. Fibroadenoma I. Mastalgia J. Breast carcinoma K. Gynaecomastia
H. Fibroadenoma - Fibroadenomas are typically asymptomatic and are found incidentally in patients
A 14 year old girl who has taken at least 30 aspirin tablets (300mg each).
A. Dicolbalt edetate B. Alkaline diuresis C. Intravenous naloxone D. Sodium calcium edetate E. Hyperbaric oxygen F. Intravenous atropine G. Intravenous N-acetylcysteine H. Oral desferrioxamine I. Haemodialysis J. Ethanol
B. 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 young girl complains of weight loss and headaches, the dr proceeds to perform an abdominal examination during which she becomes anxious flushed and tachycardic.
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
H. Phaeochromocytoma
A 73-year-old presents with increasing confusion and falls over the last couple of months. On further questioning he admits to urinary incontinence. A CT scan of the head shows dilatation of ventricles.
A. Wernicke's encephalopathy B. Normal pressure hydrocephalus C. Subarachnoid haemorrhage D. Subdural haemorrhage E. Extradural haemorrhage F. Hepatic failure G. Alcohol withdrawal H. Stroke I. Encephalitis J. Dementia K. Drug overdose L. Meningitis
B. Normal pressure hydrocephalus - This is normal pressure hydrocephalus – a diagnosis you should suspect in any patient who presents with a gait apraxia (the falls here from loss of balance) and cognitive impairment. There may also be urinary symptoms such as urgency, frequency or urge incontinence. These symptoms tend to be insidious in onset over months or years.There is not significantly raised CSF pressure though perhaps this should not be named ‘normal pressure’ as elevated CSF pressure may be seen but just not significantly so. CT head is the first test to order, although MRI head can also be done, and could be normal but could show mild to moderate ventricular enlargement, periventricular leukomalacia, cerebral infarction, relative preservation of the cortical gyri and sulci and reduced diameter of the corpus callosum and widened callosal angle. This diagnosis can be excluded if an obstructive lesion is seen. If you suspect Parkinson’s then a levodopa challenge should be ordered.
A 40-year-old man returned from India 4 days ago and came down with fever. He went to his GP and got some paracetamol. His fever persisted, and he had a few bouts of diarrhoea and cough. He started getting drowsy and was admitted from casualty where his blood culture was taken. The next day the lab reported Gram negative bacilli seen on blood culture. A. Mycobacterium tuberculosis B. Neisseria meningitidis type B C. Entamoeba histolytica D. Lassa fever E. Dengue virus F. Salmonella typhi G. Falciparum malaria H. Legionella pneumophila I. Influenza J. Streptococcus pneumoniae
F. Salmonella typhi - Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic – India, for example, which has the highest incidence of this disease. Mexico should also ring alarm bells. The water supplies are not treated and sanitary conditions are dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a high fever which is a hallmark of infection (sometimes in a step-wise manner) which is not responding to paracetamol (it persists) and blood culture (you need a big sample of blood for testing as count is usually low) shows a gram negative bacilli, and he has returned from an endemic region. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen. This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.
A 45 year old man has a long history of drinking excess alcohol. He has a 3 month history of intermittent, severe abdominal pain & diarrhoea with pale, bulky, foul-smelling stools which are hard to flush away
A. Clostridium difficile B. Staphylococcus aureus C. Chronic pancreatitis D. Drug-induced diarrhoea E. Villous adenoma of the rectum F. Cryptosporidium infection G. Coeliac disease H. Ulcerative colitis I. Irritable bowel syndrome J. Diverticular disease K. Campylobacter L. Crohn’s disease
C. Chronic pancreatitis - This is chronic pancreatitis which is most commonly associated with chronic alcohol abuse. Features include the epigastric pain here, which classically radiates to the back, and steatorrhoea from malabsorption, described here with the pale, foul-smelling and difficult to flush stools. There may additionally be DM due to pancreatic failure and the patient may be malnourished. The diagnosis is based on findings and imaging – your options are USS which is less sensitive, or CT, which is more sensitive but involves radiation exposure. AXR is not a sensitive enough test. There is no real definitive treatment, which is mainly symptomatic and the underlying and precipitating factors are treated – in this case, this man’s alcohol excess. Complications of chronic pancreatic imflammation include the development of pseudocysts, calficiation, DM and malabsorption.
A male child is found to have moderate learning difficulties and behavioural problems. There is a family history of learning difficulties. On examination he has large testicles, epicanthic folds and large ears. DNA testing reveals trinucleotide repeat expansion (CGG).
A. Edwards syndrome B. Tuberous sclerosis C. Fragile X syndrome D. Klinefelter's syndrome E. Turner's syndrome F. Down's syndrome G. DiGeorge syndrome H. Patau's syndrome I. William’s syndrome J. Prader-Willi syndrome K. Angelman syndrome
C. Fragile X syndrome - This is fragile X syndrome. History includes learning difficulties, which can range from mild to severe, social communication difficulties (patients may be autistic), hyperactivity and attention deficit and motor co-ordination difficulties. There may be a FH of learning difficulties too. Examination may reveal macrocephaly, low muscle tone, long face, high arched palate, prominent jaw, big testicles (macro-orchidism), large ears and strabismus. DNA testing is diagnostic and reveals a fragile site on Xp27.3 (FRM1 gene position). This is characterised by trinucleotide repeat expansion (CGG) to more than 200 copies.
A 32-year-old man presents with oedema. Plasma creatinine 150 μmol/l, urea 15 mmol/l, albumin 15 g/l. Urine protein excretion 8.5 gm/24 hour. Routine immunescreen (antinuclear antibody, complement levels, CRP) is normal
A. Renal ultrasound B. CVP measurement C. Renal biopsy D. Plasma electrophoretic strip E. Intravenous pyelogram F. Renal arteriogram G. HIV test H. Anti-neutrophil cytoplasm antibodies I. Anti-glomerular basement membrane antibody J. Captopril renogram
C. Renal biopsy - When the cause of renal failure might be nephritis (as in nephrotic syndrome) a renal biopsy will be needed to make the diagnosis. Occasionally this is urgent, so that potent immunosuppresives can be administered
A 70 year old lady with a history of well-controlled diabetes, collapses when she gets out of bed in the morning. She regained conciousness and pulled the emegency cord in her bedroom to call for help. She is on medication for hypertension and her ECG is unremarkable
A. Anaemia B. Vasovagal syncope C. TIA D. Cardiac arrhythmia E. Stroke F. Postural hypotension G. Myxoedema coma H. Carotid sinus sensitivity I. Hypoglycaemia J. Aortic stenosis K. Epilepsy L. Pulmonary stenosis
F. Postural hypotension - Postural hypotension is a side effect of anti-hypertensives and is a common problem in the elderly. Diabetic autonomic neuropathy may also be a cause here. A good history should be enough to diagnose this.
A 22-year-old man has developed multiple hard swellings on the left side of the neck. He has had night sweats and anorexia for two months.
A. TB abscess B. Graves disease C. Hodgkin's disease D. Myxoedema E. Pancreatic carcinoma F. Superior vena cava syndrome G. De Quervain's thyroiditis H. Hashimoto's thyroiditis I. Thyroid cancer J. Euthyroid goitre K. Carotid artery aneurysm L. Thyroglossal cyst
G. De Quervain’s thyroiditis - This girl has de Quervain’s thyroiditis (which can also be called subacute granulomatous thyroiditis) which is inflammation of the thyroid characterised by a triphasic course where there is transient thyrotoxicosis followed by a hypothyroid phase before a return to euthyroidism. The thyrotoxic phase (symptoms of hyperthyroidism may be present) is characterised by pain and tenderness of the thyroid, which tends to be larger, firm and tender to touch. This girl also has a fever and neck pain which is making it painful for her to swallow. This is a self-limiting condition and no specific treatment is needed though NSAIDs and beta blockers can be used for symptomatic relief. Roughly 30-40% describe a prior viral infection.
A 60 year old man presents with bone pain (back, ribs, femur and humerus affected). Investigations show raised ESR, raised calcium, high urea, high creatinine and punched out lesions on his skeletal x-rays.
A. Megaloblastic Anaemia B. Acute lymphoblastic leukaemia C. Sickle cell anaemia D. Aplastic anaemia E. Iron defeciency anaemia F. Chronic myeloid leukaemia G. Non Hodgkin’s lymphoma H. Chronic lymphocytic leukaemia I. Acute myeloid leukaemia J. Myeloma K. Thalassaemia
J. Myeloma - This patient has multiple myeloma. This is characteristed by clonal proliferation of plasma cells in BM and commonly presents with bony pain and symptoms of anaemia. There may also be infections present in 10%. Elevated ESR agrees with this diagnosis. 30% have hypercalcaemia and half have renal impairment, which is associated with a worse prognosis. This explains the elevated urea and creatinine here. The diagnostic test is serum or urine electrophoresis looking for a paraprotein spike of IgG or IgA and light chain urinary excretion (Bence Jones proteins). Bone marrow examination and skeletal survey will also need to be conducted. Bone marrow analysis will help differentiate this from MGUS and solitary plasmacytoma. Bone changes include osteopenia, osteolytic lesions and fractures which this person’s XR indicates with the punched out lytic lesions. Younger patients may be candidates for high-dose chemotherapy and autologous transplantation.
A 45-year-old woman who smokes 25 cigarettes a day is reviewed in the diabetic clinic. She has had a dry cough for 2 months. She is on numerous tablets as her diabetes is complicated by microalbuminuria and hypertension. Her GP had given her a course of antibiotics 2 weeks previously.
A. Postnasal drip B. Oesophageal reflux C. Angiotensin converting enzyme inhibitor D. Foreign body E. Asthma F. Sarcoidosis G. Tuberculosis H. COPD I. Carcinoma of bronchus J. Bronchiectasis
C. Angiotensin converting enzyme inhibitor - A dry cough is a side effect of ACE inhibitors due to the build up of bradykinin which is normally degraded by ACE. ARB such as losartan will be indicated in this case. ARBs are insurmountable antagonists of AT1 receptors for angiotensin II, preventing its renal and vascular effects.
The immediate management of an acute deep vein thrombosis in someone who is at a high risk of bleeding.
A. Aspirin B. Unfractionated heparin C. Warfarin D. Vitamin K E. Fresh frozen plasma F. Low molecular weight heparin G. Protein S concentrate H. Platelet concentrates I. Thrombin infusion J. Fibrinogen K. Platelet concentrates plus fresh frozen plasma L. Fondaparinux (FXa inhibitor) M. Vitamin E
B. Unfractionated heparin - The mainstay of treatment for acute DVT is anticoagulation. This can be either unfractionated heparin, a LMWH or a factor Xa inhitor like fondaparinux. Fondaparinux has a higher half life than LMWH and there is no effective way of reversing it. LMWH have a shorter half life and some of it can be removed with protamine. Heparin though can be reversed quickly with protamine. Hence, if the patient is at a high risk of bleeding, they should be treated with unfractionated heparin and you should avoid fondaparinux. If they start bleeding you can just chuck them protamine. This however requires monitoring of APTT and platelet counts. If the patient has heparin-induced thrombocytopenia, you can try using fondaparinux. LMWH is recommended in those with active cancer and preferred in pragnancy, and consideration needs to be given in those with renal impairment.
A 24 year old accountant presented to his GP with a 2 week history of tiredness and a persistant cough and complained of “not being able to complete his normal gym routine”. On examination he was pyrexic, had decreased lung expansion and increased vocal resonance and auscultation revealed bronchial breathing.
A. TB B. Emphysema C. Bronchitis D. Pleural effusion E. Pneumonia F. Lung Tumour G. Pulmonary embolism H. Asthma I. Pneumothorax J. Pulmonary fibrosis K. Sarcoidosis
E. Pneumonia - This patient has pneumonia. Symptoms include chills, fever, cough, SOB and pleuritic chest pain. Examination findings are consistent with his diagnosis. A CXR is the most specific and sensitive test available and antibiotics are indicated.
A 24 year old woman presents with a 3 month history of lower abdominal colicky pain, diarrhoea (bowels open 6-10 times per day) & passage of blood mixed with the stool.
A. Infective colitis B. Haemorrhoids C. Anal fissure D. Colonic carcinoma E. Anal carcinoma F. Crohn’s disease G. Ulcerative colitis H. Colonic polyp I. Diverticular disease J. Ischaemic colitis
G. Ulcerative collitis - While this could be Crohn’s disease, bloody diarrhoea is more commonly a presentation of UC than Crohn’s. UC is characterised by diffuse mucosal inflammation running a relapsing and remitting course. Bloody diarrhoea is commonly experienced by patients who may also complain of other symptoms such as (lower) abdominal pain, faecal urgency and the host of extra-intestinal manifestations associated with UC. Diagnosis of UC requires endoscopy with biopsy and a negative stool culture to rule out infectious gastroenteritis. Flare ups are usually linked to pathogens so a stool culture will always be needed in these cases. Toxic megacolon is a complication which is associated with a risk of perforation. UC is also linked with bowel adenocarinoma and PSC. Treatment involves mesalazine (5-ASA) used to induce and maintain remission.
A 50 year old man became unwell after a holiday in India. He developed a fever, tiredness, night sweats and a productive cough. He lost half a stone in weight since his return from holiday 6 weeks ago.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
F. Tuberculosis - The patient’s symptoms and travel history point towards pulmonary TB. It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, cough, haemoptysis and erythema nodosum are all suggestive. Key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Culture on solid media can take 4-8 weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis.
Classically, in primary disease CXR shows middle and lower zone infiltrates. Post-primary TB usually involves apical changes with or without cavitation. However, recent students have indicated that both presentations are seen in both primary and post-primary TB. HIV positive patients tend to have a more atypical CXR including effusion, lower zone involvement and a miliary pattern.
A 25 year old woman presents with a 4 month history of diarrhoea, altered blood and mucus per rectum.
A. Anal fissure B. Caecal carcinoma C. Meckel's diverticulitis D. Haemorrhoids E. Infective diarrhoea F. Irritable bowel syndrome G. Duodenal ulcer H. Inflammatory bowel disease I. Perianal fissure J. Carcinoma of the rectum
H. Inflammatory bowel disease - This woman has inflammatory bowel disease, which by the history is probably more likely to be UC than CD, whereby the mainstay of treatment is with 5-ASA. A colonoscopy is required to assess the extent of disease and for a definitive diagnosis. Biopsy in CD will show transmural granulomatous inflammation. CD can affect the whole GIT but favours the TI and proximal colon and is macroscopically characterised by skip lesions. UC on the other hand is characterised by the presence of crypt abscesses, which is pathognomic. CD risk is increased 3-4 fold by smoking whereas smoking seems protective in UC. The mainstay of treatment in CD is with steroids and azathioprine to prevent relapses and for those suffering side effects of steroid treatment. TNF-alpha inhibitors also have a role. Surgery in CD is only indicated in a small number of patients who bleed, for bowel perforation and cases of complete obstruction. The aim is to rest distal disease by temporarily diverting faecal flow.
A 35 year old previously healthy man returned from a conference in the USA 5 days ago. He travels frequently and gives a 30 pack year history. He presents with mild confusion, a productive cough, diarrhoea and is pyrexic. His chest examination is normal. CXR shows infiltrates in the RUL.
A. Bacteroides fragilis B. Mycobacterium tuberculosis C. E coli D. Haemophilus influenzae E. Mixed growth of organisms F. Mycoplasma pneumoniae G. Staphylococcus aureus H. Pneumocystis jirovecii I. Legionella pneumophila J. Coxiella burnetii K. Streptococcus pneumoniae
I. Legionella pneumophila - 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. 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 (recent water exposure like a hot tub). Smoking is also a risk factor. It can cause confusion as well as hyponatraemia, abdominal pain, diarrhoea and bradycardia. Legionella does not grow on routine culture media and diagnosis relies on urine antigen detection, serology or culture on special media.
A 20 year old student presented with a sore throat, fever, anorexia, malaise and lymphadenopathy. She was treated for tonsillitis by her GP but did not complete the course because she developed an allergic rash.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
N. Glandular fever - EBV causes a maculopapular pattern after ampicillin, which is what this patient has been given. Infectious mononucleosis (glandular fever) is caused by EBV and is characterised by fever, pharyngitis and lymphadenopathy. Enlargement of the spleen also begins in the first week and lasts 3-4 weeks, occuring in half of all cases. Risk factors for EBV transmission include kissing and sex (your 20 year old student here). 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.
A 34-year-old woman who complained of a severe headache on waking and then collapsed.
A. Intravenous naloxone B. Intramuscular glucagon C. Intravenous dextrose D. DC cardioversion E. Endotracheal intubation F. Inhaled anticholinergic G. Lumbar puncture H. Commence CPR I. IV antibiotics J. Precordial thump K. CT scan brain L. Gastric lavage
K. CT scan brain - A CT head is indicated here in this possible SAH. This may show hyperdense areas in the basal cisterns, major fissures and sulci.
A 19-year-old student complaining of amenorrhoea for 9 months. Weight loss, generalised weakness and depression. She has started a vegan diet a year ago. Her BMI is 16.
A. Malignancy B. Anorexia nervosa C. Tuberculosis D. Addison's disease E. Malabsorption F. Infestation with helminths G. Cardiac failure H. Diabetes mellitus I. Hyperthyroidism J. Renal failure K. Liver failure L. Depression M. HIV
B. Anorexia nervosa - Anorexia nervosa often occurs in women which is a key risk factor. Puberty/adolescence and obsessive personality traits are additional risks. There is a higher incidence reported in western cultures (presumably skinny models on TV, adverts etc…) and studies on immigrants moving to a western culture exhibited a higher incidence. There is also postulated to be a genetic contribution from twin studies.Those who in higher socioeconomic classes are more affected. BMI is usually
A 35-year-old woman comes to see you in the clinic. She is noticeably distressed and complains of a bulky mass in her left breast which has grown rapidly over the past month. On examination you notice that the contour of the breast has been distorted and the overlying skin is red and tender. Core biopsy reveals mixed connective tissue and epithelial elements.
A. Burkitt's lymphoma B. Grawitz's tumour C. Kaposi's sarcoma D. Wilm's tumour E. Pancoast tumour F. Ewing's sarcoma G. Brodie's tumour H. Hodgkin's lymphoma
G. Brodie’s tumour - Brodie’s tumour (a.k.a. phyllodes tumour) are rare tumours of the fibroepithelial stroma of the breast. The history of a rapidly growing mass that distorts the shape of the breast points towards this disease. Most of these tumours are benign and the prognosis after surgery is excellent.
A 22 year old woman presents to her GP with a 1 week history of increased frequency of micturation and dysuria. Abdominal examination reveals mild supra-pubic tenderness. You perform a dipstick that reveals haematuria and a positive nitrite and leucocyte esterase.
A. Prostate cancer B. Ureteric colic C. Prostatic varices D. Acute pyelonephritis E. Urinary tract infection F. Bladder cancer G. Trauma H. Renal cell carcinoma
E. Urinary tract infection - E coli causes most uncomplicated cases and Staph saprophyticus is implicated in 5-20%. Sexual intercourse is the single biggest risk factor in women, although other risks include spermicide use, post-menopause, FH and presence of a foreign body like an indwelling catheter. Symptoms include frequency, dysuria, back pain, haematuria with upper tract involvement suggested by urgency, suprapubic pain, fever and/or tenderness over the costovertebral angle. The first test is a dipstick analysis, although if negative with a suggestive history, it is still likely to be a UTI. Dipstick will show positive nitrite and leucocyte esterase. MSU should be sent for MC+S in some cases such as atypical symptoms or unexpected urinalysis findings.
Mr D is a 17 year old man with cystic fibrosis for which he receives intensive physiotherapy. He has come in with shortness of breath and a mild fever. Sputum cultures demonstrated the growth of an organism which also produced a green pigment.
A. Pseudomonas aeroginosa B. Mycobacterium leprae C. Escherchia coliform D. Legionella pneumophila E. Campylobacter jejuni F. Neisseria meningitidis G. Mycobacterium tuberculosis H. Salmonella typhi
A. Pseudomonas aeroginosa - The green pigment here is pyoverdine which is produced by Pseudomonas. Pseudomonas has virulence factors for lung colonisation and is noted for its type III injection apparatus, which you may remember from your microbiology lectures. It is a gram negative bacilli causing hospital acquired pneumonia and UTI. It particularly affects immunocompromised hosts such as those on chemotherapy, those with cystic fibrosis (this patient), burns and wounds. Biofilms are antibiotic resistant.
Pseudomonas is also a special organism which is not sensitive to many antibiotics originally used for gram negatives. You need to prescribe a drug here which has specific anti-pseudomonal activity such as ceftazidime (a third generation cephalosporin), tazocin, ciprofloxacin, imipenem or gentamicin (usually used with one of the others). This organism acquires resistance genes very quickly so two antibiotics are given. It is, as mentioned, inherently resistant to many drug classes. Some are even resistant to all antibiotics.
A 50 year old housewife & mother of 5 has sudden severe epigastric pain that radiates to the back on the right & has vomited. She puts it down to her recent meal of fish & chips, as she usually never eats fatty food. Examination is somewhat difficult as she is obese but you think she has some guarding over the epigastium and right hypochondrium.
A. History only B. Colonoscopy C. Ultrasound abdomen D. H. pylori antibodies E. Stool examination for pathogens F. Barium meal G. Full blood count, ESR, creatinine, electrolytes & liver function tests H. Gastroscopy I.Barium enema J.Serum Amylase
C.Ultrasound abdomen - Cholecystitis is acute GB inflammation caused by an obstruction at the cystic duct. It occurs as a major complication of gallstones and classically presents with RUQ pain and fever. Gallstones in EMQs classically involves the Fs (Fat, Forty, Female, Fertile, Fair). USS is the definitive initial investigation. HIDA scanning and MRI may help if the diagnosis remains unclear. Treatment is with cholecystectomy. Make sure you know the difference between ascending cholangitis, cholecystitis and biliary colic.
A 19 year old man who has been intubated due to a recent RTA is recovering well & is extubated. He complains of coughing up a small amount of blood streaked phlegm.
A. Sputum cultures B. Bronchoscopy C. History only D. D-dimer E. CTPA F. Chest x-ray G. MRA H. Lung function tests I. ABG J. Clotting screen K. V/Q scan L. CT head
C. History only - This is a result of intubation which has caused some iatrogenic trauma to this patient’s upper airway.
A 14 year old boy with bilateral breast enlargement.
A. Carcinoma of the breast B. Sebaceous cyst C. Duct Ectasia D. Fibroadenosis E. Breast Cyst F. Gynaecomastia G. Fibroadenoma H. Breast Abscess I. Lipoma
F. Gynaecomastia - This is a boy who has enlarged breasts. Normal to see gynaecomastia in puberty. Other causes include liver disease and as a side effect of drugs such as digoxin, spironolactone and cimetidine.
Systematic reviews of literature
A. Cocherane database B. Medline C. National institute for clinical excellence (NICE) website D. British national formulary E. BMA website F. Evidence based medicine website G. BMJ website
A. Cocherane database - The Cochrane database was established by the NHS with the aim of being a place to review existing literature on a subject matter.
A 20 year old woman complains of breathlessness and appears pale. Hb 7.3 g/dl, WBC 7.0 x 109/L, Platelets 100 x 109/l. Unconjugated bilirubin is elevated. Direct antiglobulin test is positive.
A. Autoimmune haemolytic anaemia B. Paracetamol poisoning C. Alcoholic cirrhosis D. Primary biliary cirrhosis E. Carcinoma of head of pancreas F. Viral hepatitis A G. Cholelithiasis H. Gilbert’s syndrome I. Liver secondaries
A. Autoimmune haemolytic anaemia - This woman is complaining of symptoms of anaemia with SOB and pallor. Haemolytic anaemia can be either hereditary or acquired. Hereditary can be divided into 3 broad groups – either inherited defects in the membrane such as hereditary spherocytosis, enzyme deficiencies such as G6PDH deficiency or abnormal Hb production such as that seen in sickle cell anaemia and thalassaemia. Acquired can be either immune or non-immune in cause. Autoimmune HA here is due to autoantibodies, which occurs most often as part of another autoimmune process like SLE or RA or related to a lymphoproliferative disorder such as CLL. FBC here shows a low Hb consistent with the diagnosis, though it is important here to also request MCHC and reticulocyte count. Both of these would be increased in haemolytic anaemia. Increased breakdown of haem leads to an unconjugated hyperbilirubinaemia, though not >70-85, which would indicate some degree of liver impairment as well. LDH would also be raised, which can be helpful if there is no concurrent tissue damage. Haptoglobin (which binds free Hb) will also be low, and these two markers combined is 90% specific for HA. The giveaway for AIHA here is the positive DAT or Coombs’ test. This test detects IgG or complement bound to RBCs (hence a positive result suggests an immune cause of HA). The patient’s RBCs are washed and mixed with antiserum for IgG and C3d. The presence of IgG often indicates the presence of a warm antibody, whereas C3d suggests a cold antibody.
Jean is a 35 year old lady who has recently given birth to her 3rd baby. 2 weeks ago she developed a fever, malaise & night sweats. She feels too tired to care for the baby & is losing weight. She attended her GP following the loss of control in her left arm. On examination there was weakness on the left side of her body. Her BP was normal, 120/80. Urinalysis showed small amounts of blood & auscultation revealed a loud pansystolic murmur plus bilateral basal crepitations.
A. Pericarditis B. Angina C. VSD D. Romano-Ward syndrome E. Infective endocarditis F. HOCM (hypertrophic obstructive cardiomyopathy) G. ASD H. Congestive cardiac failure I. MI J. Left ventricular failure
E. Infective endocarditis - Any patient presenting with fever and a new murmur should always make you think of bacterial endocarditis. The classic new or worsening murmur is actually rare. Other uncommon signs you may find include splinter haemorrhages, Janeway lesions (painless macular haemorrhagic plaques on the palms and soles) and Osler nodes (painful nodules on the pads of the fingers and toes). Roth spots may also be seen on fundoscopy. Septic embolic are common in IE and urinalysis may show active sediment. Three sets of bood cultures are required and this patient will have to go for an echocardiogram.The Duke criteria is used for diagnosis.
A 10-year-old girl is not doing well at school, her teacher says she doesn’t concentrate and shows no interest. Her parents also noticed the girl has moments (around 10secs) when she just stares blankly, blinking and then returns to normal. It happens up to several times an hour.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Abscence seizures - A typical absence seizure is characterised by behavioural arrest or staring, lasting 5-10 seconds, interrupting otherwise normal activity. It can be induced by hyperventilation. Absence seizures can also be atypical, where it is less clear when it begins and ends and is not usually precipitated by hyperventilation. The definitive test here is to do an EEG to determine the exact nature of the seizure. This will ensure appropriate treatment. Most are medically responsive and childhood absence epilepsy (CAE) tends to remit by adulthood. First line treatment is with ethosuximide, valproate or lamotrigine. Atypical seizures though, tend to be refractory to medical treatment and associated with mental retardation.
A child with moderate learning difficulties, round face, small head, slanting eyes and a single palmar crease.
A. Edwards syndrome B. Tuberous sclerosis C. Fragile X syndrome D. Klinefelter's syndrome E. Turner's syndrome F. Down's syndrome G. DiGeorge syndrome H. Patau's syndrome I. William’s syndrome J. Prader-Willi syndrome K. Angelman syndrome
F. Downs syndrome - This is the one you need to be really aware of. Down’s syndrome is trisomy 21 and the diagnosis is one which is made antenatally or perinatally. You will never have a patient with Down’s who gets diagnosed as a child unless you are in a country which is very deprived of any medical personnel and your patient was born in a rural farm away from civilisation. The patient may have a history of delayed development, congenital cardiac anomalies, epilepsy as a child, atlanto-occipital instability, GI or hearing problems and there may also be associated autism. Examination may display dysmorphism, oblique palpebral fissures, epicanthic folds, low nasal bridge and low set ears, characteristic central iris Brushfield spots, short curved 5th finger, single palmar crease and may also have cardiac murmurs. Karyotype analysis will reveal trisomy 21, robertsonian translocation, or mosaicism.
A 16-year-old girl was born colour-blinded and hyposmic. Now she presents with primary amennorhoea and delayed puberty. She has low levels of LH, FSH and oestriadol.
A. Nelson's syndrome B. Pseudo-Cushing's syndrome C. MEN I D. Simmond’s disease E. DiGeorge's syndrome F. Kallmann's syndrome G. MEN II H. Cushing's disease I. Pituitary apoplexy J. Sheehan's syndrome
F. Kallmann’s syndrome - Kallmann’s syndrome (hypogonadotrophic hypogonadism) is a cause of primary amenorrhoea. The history tends to be of delayed development of secondary sexual characterisitcs with anosmia. There is either a missing olfactory bulb or one which is not fully developed (this may be seen on MRI) so there may be a lack of a sense of smell or a sense of smell which is severely reduced (hyposmia seen here). It may be diagnostically challenging as it is difficult to distinguish pathological developmental delay from constitutional delay. Normal but pre-pubertal external and internal genitalia are seen, and normal final adult height if treated. You would expect serum FSH to be low (though FSH assays have very very very wide ranges) and LH if done. Low oestradiol can also be expected.
Mr D is an eco warrior who has spent the last 6 months in India. He has come back very thin with a persistent cough which occasionally produces blood streaked sputum. He has never smoked cigarettes before as it is capitalist. Select the most APPROPRIATE first line investigation:
A. LFTs B. CRP C. LP D. CXR and sputum sample E. Blood culture F. Sputum sample G. FBC H. Pleural biopsy I. Wound swab and culture J. Urinalysis K. HIV test L. CT head
D. CXR and sputum sample - This sounds like pulmonary TB although it could well also be bronchial carcinoma. Remember that adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. Which ever the diagnosis is, a CXR will be useful with a sputum sample being obtained to check for TB. This patient should be placed in isolation due to suspected TB and 3 sputum samples cultured for AFB being the gold standard for diagnosis. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis.
A 17-year-old girl with joint pain, fever, skin rash developed bilateral involuntary jerky movements.
A. Parkinson's Disease B. Exaggerated physiological tremor C. Cerebellar tremor D. Dystonia E. Sydenham's chorea F. Brain tumour G. Alcohol withdrawal H. MS I. Asterixis
E. Sydenham’s chorea - Chorea features as part of the acute presentation in 5-10% of patients with rheumatic fever. It can also occur as an isolated event up to 6 months after the initial GABHS infection. It is named Sydenham chorea after the doctor who described St Vitus Dance in the 17th century. Choreiform movements can affect the whole body or just one side of the body, in which case it is referred to as hemi-chorea. The head is often involved with erratic facial movements that resemble grimaces, grins and growns, and the tongue may be affected to resemble a bag of worms when protruded, and protrusion cannot be maintained. In severe cases the patient may have an impaired ability to eat. Chorea disappears with sleep and is made worse by purposeful movements. When the patient is asked to grip the doctor’s hand, the patient will be unable to maintain grip and rhythmic squeezing occurs. There are two signs to look out for in these patients. The first is the spooning sign, which is a flexion at the wrist with finger extension when the hand is held extended. The pronator sign is the second which is when the palms turn outwards when held above the head. Both are consistent with chorea.
Remember that the 5 major manifestations of acute rheumatic fever are carditis, polyarthritis, chorea, erythema marginatum and SC nodules – the most common of which are carditis and polyarthritis. Primary episodes occur mainly in children aged 5-14 and are rare in those over 30. The greatest burden of disease remains in the developing countries and in populations of people living in poverty.
A 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually
A. Carcinoma of the breast B. Sebaceous cyst C. Duct Ectasia D. Fibroadenosis E. Breast Cyst F. Gynaecomastia G. Fibroadenoma H. Breast Abscess I. Lipoma
D. 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.
Two weeks after a holiday in 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 very tender.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
M. Viral hepatitis - This is likely hepatitis A which is primarily transmitted via the faecal-oral route. After the virus is consumed and 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 one week after onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water.
The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in
A 25-year-old Sikh presents 3 months after arrival in the UK with anaemia and an enlarged spleen. He gives history of intermittent febrile episodes.
A. Thick blood film B. Haemoglobin electrophoresis C. Upper GI endoscopy D. Colonoscopy E. Anti-gliadin andtibodies F. Thin blood film G. Serum ferritin H. Urea and electrolytes I. Faecal occult bloods J. Faecal fats K. Bone marrow biopsy L. Barium meal and follow through
A. Thick blood film - In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This Sikh may have just arrived from an endemic area. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. Hepatosplenomegaly is a common presenting sign, although in the Western world, it is not common on initial presentation.
The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. In this case, if you had to pick one, then the thick film would be more useful in establishing the diagnosis. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. However, not all hospitals are currently licensed to use it in the UK (in London, only the Hospital for Tropical Diseases and Northwick Park). Artesunate is manufactured by a pharmaceutical company in China and there are doubts over the quality of the product. However, there have now been numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice.
A 51 year old social worker presents to her GP with haemoptysis. On further questioning she admits to having a productive cough for 6 months & to losing 2 stones in weight over the same time. Chest x-ray shows patchy consolidation & scarring in both apices.
A. Pulmonary metastases B. Pulmonary embolism C. Pulmonary abscess D. Small cell carcinoma E. Streptococcal pneumonia F. Squamous cell carcinoma G. Microscopic polyarteritis H. Tuberculosis I. Goodpasture’s disease J. Myaesthenia gravis K. Mesothelioma
H. Tuberculosis - It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, cough, haemoptysis and erythema nodosum are all suggestive. Other key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis. CXR is the first line test to order. Classically, in primary disease there are middle and lower zone infiltrates. Post-primary TB usually involves apical changes with or without cavitation. However, recent students have indicated that both presentations are seen in both primary and post-primary TB. HIV positive patients tend to have a more atypical CXR including effusion, lower zone involvement and a miliary pattern.
An 18-year-old woman found unconscious at home. She has needle “track” marks in her arms, a respiratory rate of 10/min. and pinpoint pupils.
A. Intravenous naloxone B. Intramuscular glucagon C. Intravenous dextrose D. DC cardioversion E. Endotracheal intubation F. Inhaled anticholinergic G. Lumbar puncture H. Commence CPR I. IV antibiotics J. Precordial thump K. CT scan brain L. Gastric lavage
A. Intravenous naloxone - Opiate OD signs include CNS depression, miosis and apnoea. Finding small constricted pupils in someone who is unconscious is highly indicative. Naloxone is indicated both therapeutically and diagnostically. If there is a response, then it is diagnostic. Another diagnosis should be sought if the patient is unresponsive. IV is the preferred route of administration although naloxone can be given IM or SC if IV access cannot be established. Ventilatory support is key with 100% oxygen. You can check out Toxbase for a full database on poisons and treatments.
A mother of a 16-year old is concerned as he dropped a few things from his hands in the past two weaks. He says his arm went weak. He also complained of progressive headaches, associated with nausea and vomitting. He also had some visual disturbances.
A. Subdural haemorrhage B. Space-occupying lesion C. Depression D. Stroke E. Migraine F. Myasthenia gravis G. Extradural haemorrhage H. Arterial dissection I. Multiple sclerosis J. Peripheral neuropathy K. Polio
B. Space occupying lesion - Intracranial space-occupying lesions are mostly caused by primary and metastatic tumours. The progressive headache associated with N&V, visual disturbances and focal neurology indicate a slowly growing space-occupying mass. This could be a brain tumour, which may be primary (originates within the cranium) or secondary (from a metastatic tumour found elsewhere). The signs of raised intracranial pressure are seen here, and include headache, altered mental status, nausear and/or vomiting and gait abnormality. Tumours may be benign or malignant and range from meningiomas and medulloblastomas to craniopharyngiomas and astrocytic brain tumours. Further investigation is warranted in this case.
A 44-year-old man, BP 175/110 mmHg plasma 2.2 mmol/L.
A. Renovascular disease B. Primary hyperaldosteronism (Conn’s syndrome) C. 'Essential’ hypertension D. Phaeochromocytoma E. Isolated systolic hypertension F. Metabolic syndrome (Insulin resistance/syndrome X) G. Cushing's syndrome H. Coarctation of the aorta
B. Primary hyperaldosteronism - The normal range for potassium 3.5-5mmol/l. You should really know the normal ranges for common values like sodium, potassium and urea by this stage. In Conn’s, potassium is normal or low. It is important when drawing blood to avoid haemolysing the sample, which will cause a falsely elevated potassium level. It is important for screening to calculate the aldosterone/renin ratio, with >30 being suggestive of Conn’s. In Conn’s, aldosterone is raised and renin is low due to negative feedback. This is in contrast to renal artery stenosis where both aldosterone and renin will be raised. It is important to discontinue diuretics and other interfering medications for at least 6 weeks prior to measuring the ratio. The most reliable diagnostic test is a fludrocortisone suppression test. Treatment can be surgical with excision of the adenoma (if aldosterone production is lateralised to one side) or medical with spironolactone and amiloride. There are also familial forms of primary hyperaldosteronism which show an autosomal dominant mode of inheritance. Spironolactone is an aldosterone receptor antagonist. Amiloride inhibits aldosterone-sensitive sodium channels. They are both examples of potassium sparing diuretics acting on the DCT.
A 69-year-old male heavy smoker presents with sudden onset abdominal pain radiating through to the back. He appears pale, sweaty and has vomited a few times.
A. Elective EVAR (endovascular AAA repair) B. Semi-urgent surgical repair C. Elective open repair D. Urgent surgical repair E. Palliative care F. Abdominal XR G. Aggressive fluid resuscitation H. Ultrasound in 1 or more years I. Ultrasound in 6 months
B. Urgent surgical repair - This is a history of a ruptured AAA. The history of heavy smoking is a risk factor here for atherosclerotic disease. There is abdominal pain radiating around to the back here and pallor due to blood loss suggest this diagnosis. As this AAA has ruptured, this man will need urgent surgical repair, with of course standard resuscitation measures. Investigations would just waste time. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many fluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols.
AAA is defined as dilation of the abdominal aorta to a diameter >3cm – this represents a 50% increase. There has been an aetiological shift – of the first 10 AAA repairs performed by Eastcott in London in the 1950s, 4 of them were tuberculous or syphilitic. Now most are atherosclerotic. Of men >65, 5% have an AAA and there is a M:F of 8:1 (although in terms of risk of rupture, there is a 3:1 female preponderance). This condition is still a common cause of sudden death (3rd in this country), and most are completely asymptomatic up until the point they rupture. A misdiagnosis as either ureteric colic, or acute pancreatitis, is disasterous so this is really one not to be missed. Of all patients who have a ruptured AAA, 75% die before they even reach hospital. The main three processes involved in aetiology are: inflammation, loss of smooth muscle and excess proteolysis due to MMPs. Incidentally, DM appears to be protective in AAA development.
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.
A. Sarcoidosis B. Polycythaemia C. Gaucher’s disease D. Portal hypertension E. Infectious mononucleosis F. IDA G. Bacterial endocarditis H. Hodgkin’s disease I. Malaria J. Idiopathic myelofibrosis K. Metastatic carcinoma L. CML
E. 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.
Recurrent transient ischaemic attacks.
A. Aspirin B. Unfractionated heparin C. Warfarin D. Vitamin K E. Fresh frozen plasma F. Low molecular weight heparin G. Protein S concentrate H. Platelet concentrates I. Thrombin infusion J. Fibrinogen K. Platelet concentrates plus fresh frozen plasma L. Fondaparinux (FXa inhibitor) M. Vitamin E
A. Aspirin - The only antiplatelet drug here is aspirin. In those sensitive to aspirin, clopidogrel can be used instead. Aspirin irreversibly inhibits COX1 by acetylating the active site and inhibits platelet TXA2. This reduces the risk of future embolic events. A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour. An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF.
A 68-year-old man has been scanned annually for 10 years. His abdominal aortic aneurysm last year was 4.9 cm in diameter. This year, the aneurysm is 5.0 cm in diameter.
A. Angioplasty B. Femoral-distal bypass C. Aortobifemoral bypass D. Methyldopa E. Ultrasound F. Alpha blocker G. Embolectomy H. Endarterectomy I. Angiography J. Endovascular aneurysm repair K. Open repair of aneurysm
E. Ultraasound - For asymptomatic small AAA, surveillance is indicated. Infra and juxtarenal AAAs between 4.0-5.4cm in diameter (bear in mind that young and healthy patients with >5cm may benefit from repair!) should be monitored by USS or CT every 6-12 months. There is good quality evidence that the risk of rupture is 20% for aneurysms larger than 5.0-6.0cm in diameter. Note also that AAAs
A 77 year old lady with longstanding AF presents with confusion. She collapsed suddenly at home. O/E she has an extensor plantar response.
A. UTI B. Faecal impaction C. Hypoxia D. Liver failure E. Post-operative F. Hypoglycaemia. G. Thiamine/B1 deficiency H. U&E imbalance I. Drug effect J. MI K. CVA
K. CVA - Atrial fibrillation is strongly implicated in the risk of cardioembolic stroke. Confusion is common, especially in the elderly who have had past strokes and in those with cognitive dysfunction. An extensor plantar response is known as Babinski’s sign and is a sign of an UMN lesion. The normal response is flexion where the big toe moves downwards. It is important is perform a CT head exclude a haemorrhagic aetiology and consider thrombolysis with tPA if within the 4.5 hour window and there are no contraindications. Thrombolysis is done with alteplase at 10% bolus, 90% infusion at a dose of 0.9 mg/kg. Presentation after the 4.5 hour window is managed with aspirin. The Bamford/Oxford Stroke Classification subtypes ischaemic stroke according to vascular territory of infarction. After initial management, stroke care involves the ethos of an MDT environment with rehabilitation.
A 25 year old male student presents with 12 hours of abdominal pain, vomiting & watery diarrhoea. This has occurred once before.
A. Clostridium difficile B. Staphylococcus aureus C. Chronic pancreatitis D. Drug-induced diarrhoea E. Villous adenoma of the rectum F. Cryptosporidium infection G. Coeliac disease H. Ulcerative colitis I. Irritable bowel syndrome J. Diverticular disease K. Campylobacter L. Crohn’s disease
B. Staphylococcus aureus - This patient has infectious vomiting predominant food poisoning. When vomiting is the main presenting symptom, you should be thinking of Staphylococcus aureus, Bacillus cereus or norovirus. There is a short history in a previous well person. This man has probably eaten something dodgy like a kebab with undercooked chicken, or something like that. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe cases.
A 30-year-old lady presented with pain in her left eye and numbness & weakness of her right leg. Two months earlier she had an episode of double vision in the left eye.
A. Right-sided stroke B. Myasthenia gravis C. Transient ischaemic attack D. Meningitis E. Pontine haemorrhage F. Hepatic encephalopathy G. Huntington’s disease H. PCA aneurysm I. Partial seizure J. Parkinson's disease K. Multiple sclerosis
K. Multiple Sclerosis - Multiple sclerosis is a demyelinating CNS condition which is characterised by 2 or more episodes of neurological dysfunction which are separated in both time and space. MS classically presents in white women aged 20-40 with temporary visual/sensory loss although any presentation can occur. MRI is a sensitive test but less specific than spinal MRI, however, spinal MRI is abnormal in fewer cases. Treatment aims at treating the attack, preventing future attacks and symptomatic treatment of problems like bladder dysfunction, pain and fatigue.
A 60-year-old man with longstanding peripheral vascular disease and type 1 DM presents with a large ulcerating lesion over his toes on his left foot. The lesion appears ‘punched out’ with well demarcated edges. On examination, the leg is cool to touch and hairless. The dorsalis pedis and posterial tibial pulses are absent.
A. Venous ulcer B. Diabetic ulcer C. Osteomyelitis D. Kaposi’s sarcoma E. Sickle cell disease F. Necrobiosis lipoidica G. Pigmented purpuric dermatoses H. Pressure ulcer I. Squamous cell carcinoma (Marjolin) J. Pyoderma gangrenosum K. Dermatitis L. Pyogenic granuloma M. Lymphoedema N. Arterial ulcer
N. Arterial ulcers - Arterial ulcers are deep and painful with a well defined edge, usually found on the shin or foot. They often have a pale base and a punched out appearance. The absent pulses and longstanding PVD with DM here is also indicative. There may be local changes such as cold peripheries, loss of hair, dusky cyanosis and toenail dystrophy. The surrounding skin is often white and shiny. It is typically most painful in bed and the pain is sometimes relieved by having the legs dependent. On examination, peripheral pulses may be absent or reduced like this case. An angiogram with contrast will define the lesion and determine whether it can be improved by surgical intervention. Pain often increases when the legs are at rest and elevated. They can occur between the webs of toes so it is important to always check these in your peripheral vascular examination.
A 70-year-old retired pigeon-fancier becomes cyanosed on exercise. He has a persistent cough and progressive shortness of breath. There are fine crackles at both lung bases on auscultation.
A. Congenital heart disease B. Opiate intoxication C. Acute left ventricular failure D. Extrinsic allergic alveolitis E. Pneumonia F. Pulmonary embolus G. COPD H. Epilepsy I. Carcinoma of bronchus J. Status asthmaticus K. Cocaine intoxication L. Foreign body
D. Extrinsic allergic alveolitis - This is EAA, a hypersensitivity pneumonitis. There is history here of exposure to organic dust (avian proteins) with birds. There are a variety of syndromes this could be – pidgeon breeder’s lung, bird fancier’s lung and budgerigar fancier’s disease. History and examination findings depend on whether the EAA is acute, subacute or chronic. Chronic presents like idiopathic pulmonary fibrosis and there may be clubbing. The most important treatment element is to avoid antigen exposure.
For each of the malignancies listed below, please select the recognised presentation from the list of options.
Insulinoma
A. Hypoglycaemia B. Erythrocytosis C. Autoimmune haemolytic anaemia D. Erythema ab igne E. Troisier's sign F. Necrolytic migratory erythema G. Acanthosis nigricans H. Eaton-Lambert syndrome I. Tetany
A. Hypoglycaemia - Insulimonas present with spontaneous episodes of hypoglycaemia, especially when fasting and exercising. Most insulinomas are benign and small tumours, but may cause significant metabolic effects.
A 19 year old student complaining of amenorrhoea for 9 months. Weight loss, generalised weakness and depression. She has started a vegan diet a year ago. Her BMI is 16.
A. Renal failure B. HIV C. Tuberculosis D. Depression E. Malabsorption F. Addison's disease G. Hyperthyroidism H. Diabetes mellitus I. Liver failure J. Malignancy K. EBV L. Anorexia nervosa M. Cardiac failure
L. Anorexia nervosa - Anorexia nervosa often occurs in women which is a key risk factor. Puberty/adolescence and obsessive personality traits are additional risks. There is a higher incidence reported in western cultures (presumably skinny models on TV, adverts etc…) and studies on immigrants moving to a western culture exhibited a higher incidence. There is also postulated to be a genetic contribution from twin studies.Those who in higher socioeconomic classes are more affected. BMI is usually
A 50 year old man has his BMs measured in cardiology clinic which he attends as he is in left ventricular failure. It is a fasting measurement and comes back as 6.8 mmol/L. Pick the medication most suitable for this patient.
- Captopril
- Amiodarone
- Bendroflumethazide
- Digoxin
- Captopril - No mention is made of any arryhthmia so Amiodarone/ Digoxin aren’t necessarily required. The man has impaired fasting glucose and so is at risk of progressing to diabetes. Thiazide diuretics are recognised as causing iatrogenic Diabetes Mellitus and so are unsuitable here. This man has LVF without Atrial fib and so an ACE-i’ is first line therapy.They relieve the pre and afterload on the heart reducing progression to Left ventricular dilatation. It has also been shown that patients with Impaired Fasting Glucose and heart failure treated with ACE-i drugs are at much less risk of progression to diabetes over the short term at least (3% vs~50%).
A 58 year old man with uncontrolled HIV infection and AIDS presents with 2 week history of blurred vision bilaterally. He also reports seeing visual floaters. Examination reveals a man who is severely cachectic with generalised lymphadenopathy. Fundoscopy reveals creamy coloured areas with overlying retinal haemorrhages.
1. Cytomegalovirus 2. Infectious mononucleosis 3. Mycobacterium avium complex 4. Human herpes virus 6
- Cytomegalovirus - This is a presentation of CMV retinitis, which is the most common manifestation of CMV disease in AIDS, the second most common being colitis. However do remember that virtually any organ can be affected by CMV and it can cause a range of conditions from encephalitis to pneumonitis. In CMV retinitis, fundoscopy will reveal areas of infarction, haemorrhage, perivascular sheathing and retinal opacification. These findings here are of chorioretinitis.
A 40 year old alcoholic man who was treated for a chest infection one week previously, developed a productive cough, & a fever. He felt unwell. He lost weight during this period of illness & also coughed up blood several times. A chest x-ray showed a fluid level in the right lung.
A. Atypical pneumonia B. Bronchial carcinoma C. Pleural effusion D. Sarcoidosis E. Fibrosing alveolitis F. Pneumothorax G. Lung abscess H. Bronchiectasis I. Bronchial asthma J. COPD K. Cystic fibrosis
G. Lung abscess - A lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which this patient gives a history of is a risk factor. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.
A 35 year old drug addict found unconscious on the floor. Pinpoint pupils were found on examination.
A. Dicolbalt edetate B. Alkaline diuresis C. Intravenous naloxone D. Sodium calcium edetate E. Hyperbaric oxygen F. Intravenous atropine G. Intravenous N-acetylcysteine H. Oral desferrioxamine I. Haemodialysis J. Ethanol
C. Intravenous naloxone - Signs of opiate OD include CNS depression, miosis (pinpoint pupils) and apnoea. Naloxone is indicated both therapeutically and diagnostically. If there is a response, then it is diagnostic. Another diagnosis should be sought if the patient is unresponsive. IV is the preferred route of administration although naloxone can be given IM or SC if IV access cannot be established. Ventilatory support is key with 100% oxygen.
A 56-year-old man is scheduled for elective AAA repair. The extent and its relationship to the renal arteries need to be identified.
A. Duplex doppler ultrasound B. CT scan C. Ankle-brachial pressure index D. No investigation needed E. Venography F. Contrast angiography G. Magnetic resonance venography H. ESR I. Coagulation studies J. Brain MRI K. Blood glucose level L. EMG walking test M. Serum CK
B. CT scan - Generally, elective surgical repair is indicated in patients with large symptomatic AAA – repair of aneuryms over 5.5cm offers a survival advantage. Also, young healthy patients and women in particular may benefit from early repair for smaller AAAs. Data suggests that EVAR (endovascular AAA repair) is equivalent to open repair in terms of overall survival but the rate of secondary interventions is higher with EVAR. Generally, those with a greater risk of perioperative morbidity and mortality, such as patients with co-morbidities such as COPD, may benefit from the less invasive approach (anatomy permitting). Younger and healthier patients may benefit from the relative durability of traditional open repair. A CT scan is useful for diagnosis aortic aneurysms which lie close to the origins or or proximal to the renal arteries. While abdominal ultrasound can also identify the AAA and aortic dilation, a CT scan is more useful in localising this lesion and its relationship to the renal vasculature
A 50 year old lady presents to A&E in excruciating pain. It radiates from the flank to the iliac fossa and labium. She can not lie still and is pale, sweating and vomiting.
A. Endometriosis B. Pyelonephritis C. Labour D. Bladder cancer E. Urinary tract stones: ureteric colic/stricture F. Urinary tract infection G. Polycystic kidney disease H. Urinary tract stones: bladder outflow obstruction I. Ovarian cyst J. Colorectal cancer K. Acute urinary retention
E. Urinary tract stones: ureteric colic/stricture - 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 otherwise. 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 42-year-old presents with crampy abdominal pain, nausea and profuse diarrhoea a couple of days after eating grilled chicken in a newly opened restaurant. A gram stain of the faeces shows Gram-negative, motile, spiral-shaped rods.
A. Salmonella enteritidis B. Legionella pneumoniae C. Streptococcus viridans D. Staphylococcus aureus E. Campylobacter jejuni F. Streptococcus pneumoniae G. Mycoplasma pneumoniae H. Pseudomonas aeruginosa I. Shigella flexineri J. Streptococcus pyogenes K. Leptospira interrogans
E. Campylobacter jejuni - This is what we colloquially refer to as ‘food poisoning’ – infective gastroenteritis. The most common bacterial cause in the UK is Campylobactor jejuni. This organism is also a major cause of traveller’s diarrhoea. The second most common cause of acute enteritis is an organism known as Campylobacter coli. There is also Campylobacter fetus which is a rare cause of extra-intestinal infection mainly in immunocompromised patients. Campylobacters are small, gram negative rods with a curved spiral shape. 11 Campylobacters are pathogenic to humans. Most Campylobacter jejuni infections come from infected poultry. The diarrhoea is usually self limiting and resolves in a week – bacteraemia is very rare. Fluid and electrolyte replacement is essential. Only a small number of patients will benefit from antimicrobials. Note that C. jejuni is a commonly identified organism in the aetiology of Guillain-Barre syndrome.
A 76-year-old man presents with lethargy and back pain. Plasma creatinine 220 μmol/l, urea 18 mmol/l, calcium 2.9 mmol/l (2.2 – 2.6), albumin 29 g/l. Urine protein excretion 1.5 gm/24 hours.
A. Renal ultrasound B. CVP measurement C. Renal biopsy D. Plasma electrophoretic strip E. Intravenous pyelogram F. Renal arteriogram G. HIV test H. Anti-neutrophil cytoplasm antibodies I. Anti-glomerular basement membrane antibody J. Captopril renogram
D. Plasma electrophoretic strip - Renal impairment in myeloma results from a combination of factors: deposition of light chains, hypercalcaemia, hyperuricaemia and (rarely) in patients who have had the disease for some time, deposition of amyloid. Serum protein electrophoresis characteristically shows a monoclonal band.
Adult female with short stature, amenorrhoea, webbed neck and widely spaced nipples. She is found infertile although there is no cognitive impairment.
A. Edwards syndrome B. Tuberous sclerosis C. Fragile X syndrome D. Klinefelter's syndrome E. Turner's syndrome F. Down's syndrome G. DiGeorge syndrome H. Patau's syndrome I. William’s syndrome J. Prader-Willi syndrome K. Angelman syndrome
E. Turners syndrome - Turner’s syndrome is characterised on diagnostic karyotype analysis by 45 XO (complete or partial absence of the second sex chromosome occuring in 1 in 2500 liver female births). This may be diagnosed antenatally by amniocentesis, which is an invasive test performed after 15 weeks gestation. The patient will be phenotypically female and may give a history of amenorrhoea, infertility, visual problems and hearing loss. Specific learning difficulties are normal but there is no cognitive impairment and intelligence is normal. Examination may reveal short stature, low-set ears, webbed neck, low hairline and cubitus valgus. Obvious stigmata though such as webbed neck only affects 20-30% of patients.
I wouldn’t worry too much about most of these syndromes. A brief overview of the rest for those who are interested: Prader-Willi is characterised by 15q11-13 deletion and patients can have a short stature, small hands and feet, and dysmorphism. The classic association is with hyperphagia and obesity from 3 years of age. Angelman’s is characterised by 15q11-12 deletion and there is severe general developmental delay and cognitive impairment. William’s is characterised by deletion of 7q11.23 and has classic phenotypic features. DiGeorge classically presents with a triad of cardiac abnormalities, hypoplastic thymus and hypocalcaemia but manifestations are highly variable. Tuberous sclerosis is characterised by seizures in infants and children, variable cognitive impairment and examination may reveal ash leaf patches of hypomelanotic macules. There is either mutation of TS1 or TS2 on DNA analysis.
A 42 year old man who lives alone presents with confusion and ataxia. Both his hands have a Dupytrens contracture.
A. UTI B. Faecal impaction C. Hypoxia D. Liver failure E. Post-operative F. Hypoglycaemia. G. Thiamine/B1 deficiency H. U&E imbalance I. Drug effect J. MI K. CVA
G. Thiamine/B1 deficiency - This patient has Wernicke’s encephalopathy. Wernicke’s is due to acute thiamine deficiency, which is a problem in alcoholics (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 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.
A 13 year old presents with fever and sore joints. She has had a sore throat about 3 weeks ago but did not see a doctor about it. While waiting in A&E she develops choreiform movements of the whole body and head with facial expressions that resemble grimaces.
1. Streptococcus pyogenes 2. Septic arthritis 3. Borrelia burgdorferi 4. Clostridium tetani
- Streptococcus pyogenes - This girl has rheumatic fever which is caused by an autoimmune process following infection with group A streptococci. The 5 major manifestations of acute rheumatic fever is something you need to be aware of. They are carditis, polyarthritis, chorea, erythema marginatum and SC nodules. Various other signs can also be seen such as spooning sign and pronator sign.
A 45 year old lady presents with high retrosternal dysphagia. She has spoon-shaped nails & is noted to be pale.
A. Cerebrovascular accident B. Carcinoma of oesophagus C. Plummer-Vinson syndrome D. Gastric volvulus E. Hiatus hernia F. Pneumonia G. Myasthenia gravis H. Thyroid goitre I. Carcinoma of bronchus J. Pharyngeal pouch K. Achalasia
C. Plummer-Vinson syndrome - Plummer-Vinson syndrome is the association of chronic Iron Deficiency Anaemia (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.
The pulse is irregularly irregular and jerky in character. There is an ejection systolic murmur lessened by squatting loudest at the lower left sternal edge. There is a double apical impulse felt. The apex beat is not displaced.
A. Tricuspid stenosis B. Pulmonary stenosis C. Patent ductus arteriosus D. Aortic stenosis E. Atrial septal defect F. Mitral regurgitation G. Aortic regurgitation H. Tricuspid regurgitation I. Mitral valve prolapse J. HOCM K. Left ventricular aneurysm L. Aortic sclerosis M. Mitral stenosis N. Ventricular septal defect
J. HOCM - This patient has HOCM which is the most frequent cause of sudden cardiac death in younger people. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. There may also be MR. The arterial pulse is described as ‘jerky’ and this patient is also in AF which warrants anticoagulation and anti-arrhythmics. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance. It is worth noting that ventricular hypertrophy causes concentric hypertrophy i.e. the wall of the ventricle gets thicker inwards. Hence the apex beat is not displaced unlike in DCM.
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. Choose the single most discriminating investigation in the acute management from the list of options:
A. ESR B. Blood cultures C. Chest X-ray D. Urine culture E. Stool electron microscopy F. EEG G. Stool culture H. Culture of joint aspirate I. C-reactive protein J. Lumbar puncture K. Throat swab L. Full blood count M. CT brain
J. Lumbar puncture - Meningitis commonly affects the extremes of age (60 years) due to impaired immunity in the former, and waning immunity in the latter. A lumbar puncture to obtain CSF is the most important investigation when this diagnosis is considered. This should not however delay the starting of empirical antimicrobial 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, and these tend to happen in the very young, older or immunocompromised patients. In older patients, frequently, the only presenting sign of meningitis is confusion or an altered mental status. In infants, the signs and symptoms can be very non-specific and may include lethargy, poor feeding, irritability and fever. A rash is noted in 80-90% of patients, commonly 4-18 hours after initial symptoms and is associated with meningococcal aetiology (although may be present with any bacterial meningitis).
In bacterial meningitis, the CSF pressure is usually raised and WBC count is elevated. The 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. However, in those who get antibiotics before cultures are obtained, the diagnostic yield is much lower (as low as 20%). If a lumbar puncture is delayed or regarded as clinically unsafe (for instance, raised intracranial pressure), then blood samples should be obtained for culture. Of course, a head CT should be considered before LP if there is focal neurology, new onset seizures, papilloedema, altered consciousness or any sign which may indicate raised ICP.
A 45 year old smoker presents with painful haematuria. He has a history of recurrent UTI’s. He tells you that he is now a taxi driver but he used to work in the rubber industry.
A. Endometriosis B. Pyelonephritis C. Labour D. Bladder cancer E. Urinary tract stones: ureteric colic/stricture F. Urinary tract infection G. Polycystic kidney disease H. Urinary tract stones: bladder outflow obstruction I. Ovarian cyst J. Colorectal cancer K. Acute urinary retention
D. Bladder cancer - Gross haematuria is the primary symptom of bladder cancer. Over 80% present with haematuria which is the primary presenting complaint in this condition. The gross haematuria is classically painless and present throughout the entire urinary stream, however while painful the rest of the symptoms fit. It is also worth noting that carcinoma in situ commonly presents with dysuria and frequency and can easily be confused with prostatitis. 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 40 year old unmarried actor has noticed recent weight loss. Although he attributed this to stress you are concerned when you detect generalised lymphandenopathy. Blood count shows neutropenia and thrombocytopenia.
A. Renal failure B. HIV C. Tuberculosis D. Depression E. Malabsorption F. Addison's disease G. Hyperthyroidism H. Diabetes mellitus I. Liver failure J. Malignancy K. EBV L. Anorexia nervosa M. Cardiac failure
B. HIV - HIV is a retrovirus and there are two types, HIV 1 which is the main virus responsible and HIV 2 which is restricted to parts of West Africa. Weight loss is common in HIV and if more than 10% body weight is lost of BMI reduces to 18.5, this is an indication of more severe immunocompromise. Weight loss in HIV may result from malnutrition, co-existent TB infection or HIV wasting syndrome, the latter being an AIDS defining illness. Generalised lymphadenopathy is also common and is characterised by the painless enlargement of 2 more more non-contiguous sites of >1cm for >3 months. Neutropenia is also seen due to CD4 deficiency and thrombocytopenia may also be seen along with an anaemic picture.
There are WHO (stage 1-4) and CDC criteria used in clinical staging. This patient needs to have a CD4 count, HBV and HCV screen, VDRL (syphilis), tuberculin skin test (TB) and CXR. HIV viral load will also be assessed. Prophylaxis and immunisations should be considered against infections such as hepatitis, influenza, PCP and TB. When to initiate HAART depends on the clinical stage, CD4 and co-morbidities. This patient will need to be started on HAART. Classes of antiretrovirals include NRTIs, NNRTIs, protease inhibitors, fusion inhibitors and integrase inhibitors.
An adult male with hypogonadism, small testicles and gynaecomastia is found to be infertile.
A. Edwards syndrome B. Tuberous sclerosis C. Fragile X syndrome D. Klinefelter's syndrome E. Turner's syndrome F. Down's syndrome G. DiGeorge syndrome H. Patau's syndrome I. William’s syndrome J. Prader-Willi syndrome K. Angelman syndrome
In terms of karyotype analysis, the following are some conditions to be aware of: Trisomy 21: Down’s; Trisomy 18: Edwards’; Trisomy 13: Patau’s; 45 XO: Turner’s, 47 XXY: Klinefelter’s; 47 XXX: Triple X syndrome; Microdeletion at 22q11: DiGeorge; Microdeletion at 7q11: William’s; 5p-: Cri-du-chat
D. Klinefelter’s syndrome - Klinefelter’s syndrome is the presence of an extra X chromosome in a male to give 47, XXY. Hypogonadism is a principle feature of this condition and there is reduced fertility. Hypogonadism itself does not mean ‘small testicles’ but XXY men do also have small testicles. They will also often have low testosterone levels but high LH and FSH levels due to primary hypogonadism. The only reliable method of diagnosis is with karyotype analysis and the degree to which XXY males are affected varies from person to person. Gynaecomastia is to some extent present in around a third of individuals affected by this condition. 1 in 10 will choose cosmetic surgery to fix this.
A 70 year old English woman presents with fever, slight splenomegaly, splinter haemorrhages & a diastolic murmur at the apex of the heart.
A. Sarcoidosis B. Polycythaemia C. Gaucher’s disease D. Portal hypertension E. Infectious mononucleosis F. IDA G. Bacterial endocarditis H. Hodgkin’s disease I. Malaria J. Idiopathic myelofibrosis K. Metastatic carcinoma L. CML
G. Bacterial endocarditis - Any patient presenting with fever and a new murmur should always make you think of bacterial endocarditis. The classic new or worsening murmur is actually rare. As are splinter haemorrhages, which this patient has. Other uncommon signs you may find include Janeway lesions (painless macular haemorrhagic plaques on the palms and soles) and Osler nodes (painful nodules on the pads of the fingers and toes). Roth spots may also be seen on fundoscopy. Three sets of bood cultures are required and this patient will have to go for an echocardiogram.The Duke criteria is used for diagnosis.
A 38 year old man presents with a 2 month history of intermitted pain in the upper abdomen which he describes as dull in nature. It sometimes wakes him up at night and is relieved by food and particularly when he has a glass of milk. He has had a similar episode before where he remembers the doctor prescribed him some pills, which helped. Examination reveals mild epigastric tenderness.
A. Duodenal ulcer B. Crohn's disease C. Meckel's diverticulum D. Oesophageal varices E. Gastric ulcer F. Mallory-Weiss tear G. Ulcerative colitis H. Oesophageal malignancy I. Oesophagitis
A. Duodenal ulcer - The patient has a duodenal ulcer (the black tarry stools from the UGI bleed). Epigastric pain and tenderness related to eating a meal is typical of a peptic ulcer. 80% are duodenal and 20% are gastric. Ulcers may cause iron deficiency anaemia and associated symptoms may feature. Key risk factors are NSAID use, like in this patient, 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 man who works in the city suffers from burning, retrosternal discomfort radiating from epigastrium to jaw & throat. Worse on lying down.
A. BNP level B. ultrasound scan C. CTPA D. Exercise ECG E. Upper GI endoscopy F. MRI scan G. CT scan H. V/Q scan I. Chest X-ray
E. Upper GI endoscopy - This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.
A young girl is seen in clinic. She appears to be uncomfortable and stares at the doctor. She complains of weight loss and palpitations. She is in shorts though the heating is on in the consultation room
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
E. Graves disease
A 70-year-old lady is brought into A&E after being found unconscious in her home. When examined she is found to be extremely drowsy and agitated when attempts are made to rouse her. Routine observations show that her BP is 160/100 mmHg and pulse 80 bpm. Her U&Es reveal: Na+ 119 mmol/l, K+ 3.0 mmol/l, urea 6.5 mmol/l, Cr 92 mmol/l; corrected Ca2+ 2.45 mmol/l; plasma osmolality: 255 mosmol/kg.
A. Raised intracranial pressure B. Anaphylaxis C. Tumour lysis syndrome D. Meningitis E. Chemotherapy complication F. Spinal cord compression G. Ectopic PTH secretion H. Superior vena caval obstruction I. SIADH
I. SIADH - There are many causes of SIADH, however in this case it is due to ectopic ADH secrtion from tumour cells, most commonly small cell lung carcinoma. The clinical features are due to the resulting dilutional hyponatraemia. Severe hyponatraemia may lead to convulsions, seizures, coma and even death. Characteristic the patient with SIADH will persistently excrete concentrated urine (with a higher urine osmolairity than serum), have normal renal and adrenal function and will have no oedema or hypovolaemia. When treating hyponatraemia take care not to correct the serum Na+ too quickly as this may lead to central pontine myelinolysis (as you may remember from your IBFD lectures!).
A 21 yo man has had a sore throat recently and now developed a very tender gland on his neck which is quite erythematous. He has also been feeling quite jittery and anxious, he complains of thumping in his chest.
A. Potassium Iodide B. Radioiodine C. Propranolol D. Propylthiouracil E. Surgical decompression F. Carbimazole G. Stop treatment
C. Propanolol - de quervains, sore, red thyroid caused by infection. It is early stage hence he is thyrotoxic. Management is mainly supportive..analgesia and beta blockade for the palpitations and anxiety.
Estimate the serum osmolality for this patient Na = 125 mmol/l K = 5.1 mmol/l Urea = 4.8 mmol/l glucose = 6.0mmol/l Triglcerides = 5.0 mmol/l (normal = 0.5-1.9 mmol/l) Now pick the most appropriate conclusion.
- hypo osmolar
- hyper osmolar
- inconclusive
- normal
- Inconclusive - The estimated serum osmolality is 271 mosm which is low. However one can see that is mainly due to the low sodium. The Triglycerides given are seriously elevated so this is a case of pseudohyponatraemia. This occurs in samples with hyperproteinaemia or hyperlipidaemia as the excess fat/ protein occupies a disproportionately large amount of plasma volume thus diluting the sodium. This sample is inconclusive! The excess fat would not change the directly measured plasma osmolality but does change the estimated value. Thus if we were to compare actual measured osmolality with our estimate we would expect an osmolar gap. A gap greater than 10-15 mOsm indicates either an error, a state of excess fat/protein or the presence of solutes not being measured such as blood ethanol.
A woman presents in clinic with dizzy spells and abdominal pain, her BP is taken sitting 130/80 and then standing 105/75. On examination of her mouth it’s noted that she has darkening of her gums
A. Diabetes Insipidus B. Adrenal adenoma C. Nelson's syndrome D. Pituitary apoplexy E. Conns Adenoma F. Drug withdrawal G. Addison's disease H. Tuberculosis I. Sheehan's syndrome J. Cushing's disease K. Ectopic ACTH producing tumour L. Addisonian crisis
G. Addison’s disease - This patient has symptoms of adrenal insufficiency. Her Systolic Bp falls by more than 20mmHg on standing which means she has postural hypotension. Hyperpigmentation of the gingiva and buccal mucosa suggests high ACTH output which in this patient would be due to primary adrenal insufficiency…Addison’s disease. The condition is probably of AI origin in this girl and a positive finding may be 21 hydroxylase auto-antibodies.
A 40-year-old lady presents with parasthaesia in the left lower limb and displays an intention tremor. She recalls that 6 months prior to this, she had an episode of temporary visual loss which she found frightening.
A. Parkinson's Disease B. Exaggerated physiological tremor C. Cerebellar tremor D. Dystonia E. Sydenham's chorea F. Brain tumour G. Alcohol withdrawal H. MS I. Asterixis
H. MS - MS is a demyelinating CNS condition which is characterised by 2 or more episodes of neurological dysfunction which are separated in both time and space. MS classically presents in white women aged 20-40 with temporary visual/sensory loss although any presentation can occur. MRI is a sensitive test but less specific than spinal MRI, however, spinal MRI is abnormal in fewer cases. Treatment aims at treating the attack, preventing future attacks and symptomatic treatment of problems like bladder dysfunction, pain and fatigue.
A 25-year-old man was hit on the side of the head with the ball, whilst playing cricket. He recovered enough to finish off the game. He then presented to A&E 8 hours later with a severe headache and vomiting. He rapidly loses consciousness.
A. Extradural haemorrhage B. Cluster headache C. Trigeminal neuralgia D. Subarachnoid haemorrhage E. Migraine F. Tension headache
A. Extradural haemorrhage - Here we have the ‘lucid interval’ classically associated with an extradural haematoma. There is blood buildup this time between the dura mater and the skull. Compressive signs may also be present such as the down and out pupil due to CN III compression. The bleed here is usually from arteries, under high pressure, causing raised intracranial pressure. In this case, there is a chance the brain stem has been compressed causing his LOC. The bleed here is possibly from the anterior branch of the middle meningeal artery which runs beneath the pterion and is vulnerable at this point where the skull is thin. Remember that the pterion marks the junction of four bones: the parietal bone, temporal bone, sphenoid bone and frontal bone.
A 10-year-old boy developed a palpable purpura on lower limbs and buttocks. He also complains of colicky abdominal pain and swelling of his ankles. He has raised serum IgA.
A. Henoch-Schonlein purpura B. Alport's syndrome C. Renal stones D. Goodpasture's Syndrome E. Thin membrane disease F. Wegener's granulomatosis G. Retroperitoneal fibrosis H. IgA nephropathy I. Post-streptococcal glomerulonephritis
A. 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. While serum IgA levels may be elevated, this is not a specific test for HSP.
A 65-year-old with CLL develops a respiratory tract infection in hospital after finishing his chemotherapy course. Bacteria grow on MacConkey agar.
A. Salmonella enteritidis B. Legionella pneumoniae C. Streptococcus viridans D. Staphylococcus aureus E. Campylobacter jejuni F. Streptococcus pneumoniae G. Mycoplasma pneumoniae H. Pseudomonas aeruginosa I. Shigella flexineri J. Streptococcus pyogenes K. Leptospira interrogans
H. Pseudomonas aeruginosa - Pseudomonas has virulence factors for lung colonisation and is noted for its type III injection apparatus, which you may remember from your microbiology lectures. This organism is one of the main 5 organisms responsible for hospital acquired (or nosocomial) infections in the UK. Remember that a nosocomial infection is defined as one acquired >48 hours after admission. It is a gram negative bacilli causing hospital acquired pneumonia and UTI. It particularly affects immunocompromised hosts such as those on chemotherapy, those with cystic fibrosis, burns and wounds. Biofilms are antibiotic resistant. Key risks also include urinary catheters and central venous lines etc… I would not worry too much about MacConkey agar as lots of things grow on it. It is a culture medium designed to grow gram negative bacteria, so organisms ranging from E. coli, Klebsiella and Salmonella, to Proteus, Shigella and Enterobacter will all grow on it. This just rules out Streptococcus pneumoniae.
Pseudomonas is also a special little organism which is not sensitive to many antibiotics originally used for gram negatives. You need to prescribe a drug here which has specific anti-pseudomonal activity such as ceftazidime (a third generation cephalosporin), tazocin, ciprofloxacin, imipenem or gentamicin (usually used with one of the others). This organism acquires resistance genes very quickly so two antibiotics are given. It is, as mentioned, inherently resistant to many drug classes. Some are even resistant to all antibiotics.
Which of these is not a feature of Parkinson’s disease?
- Resting tremor
- Rigidity of limbs
- Hemiplegia
- Mask-like face
- Hemiplegia - Hemiplegia is seen in cerebrovascular disease or lesions affecting the motor cortex and pyramidal tracts.
A 10 year old African boy who has been in the UK since birth, presents with mild jaundice. O/E his spleen is slightly enlarged. Blood investigation show raised levels of unconjugated bilirubin. Other liver function tests are unremarkable.
A. Dubin-Johnson syndrome B. Hepatitis C C. Malaria D. Gall stones E. Gilbert's syndrome F. Crigler-Najjar syndrome G. Hepatitis B H. Hepatitis A I. Carcinoma of head of the pancreas J. Primary sclerosing cholangitis K. Primary biliary cirrhosis L. Cholangiocarcinoma M. Sickle cell anaemia
M. Sickle cell anaemia - Africans have higher incidence of sickle cell anaemia. The jaundice here is due to haemolysis and accounts for the raised unconjugated bilirubin. The splenomegaly here is further suggestive. About 8% of black people carry the gene and the prevalence is high in sub-Saharan Africa. The condition is autosomal recessive and therefore occurs in 1 in 4 pregnancies where both parents carry the sickle gene. Sickling occurs when RBCs containing HbS become distorted into a crescent shape. Patients with sickle cell anaemia have no HbA at all. If both parents carry the sickle cell gene, there is a 1 in 4 chance of giving birth to a child with sickle cell anaemia. Sickle cell disease also includes other conditions such as HbS from one parent with another abnormal Hb or beta thalassaemia from the other parent such as HbS-Beta thal and HbSC. Treatment goals include fluid replacement therapy, pain management where necessary and symptomatic control.
A 54 year old man presents complaining of dizziness. He describes it as a sudden and severe spinning feeling which is precipitated by rolling over in bed onto his left side. Symptoms last under a minute and has occured every night for a month.
- Benign positional paroxysmal vertigo
- Meniere’s disease
- Vestibular neuritis
- Labyrinthitis
- Benign positional paroxysmal vertigo - The history of vertigo on rollong over in bed which lasts for a few seconds is suggestive here. Dix-Hallpike test would be diagnostic in this case and will demonstrate nystagmus and symptoms delayed by about 15s, peak in 20-30s and then decay with complete resolution of the episode of vertigo.
A 50 year old man took an overdose of his antidepressants one hour ago. He has a dry mouth and dilated pupils but is not drowsy.
A. Haemodialysis B. Oral methionine C. Hyperbaric oxygen D. Activated charcoal E. IV-naloxone F. Forced alkaline diuresis G. Gastric lavage H. Forced emesis I. IV-ethanol J. IV-glucagon K. N-acetlycysteine
D. Activated charcoal - This is an overdose of tricyclic antidepressants which are a class of drugs with a narrow therapeutic index and therefore become potent toxins in moderate doses to both the CNS and cardiovascular system. The main aim in treatment is to provide respiratory and cardiovascular support until the medicine has been fully metabolised and eliminated. GI decontamination should be considered in those presenting with early overdose (under 2 hours after ingestion) provided that the airway can be protected. There is no shown clear benefit to repeated doses of activated charcoal. The warm, dry skin is part of the anticholinergic effects (physostigmine should NOT be used to reverse this as it has been in rare cases been associated with asystole – would you rather have a patient who is flushed or flatlined?). Other anticholinergic effects include dilated pupils, urinary retention, decreased or absent bowel sounds and changes in mental status. Hypotension is common and is due to alpha 1 antagonism. Classic ECG changes are of sinus tachycardia progressing to wide complex tachycardia and ventricular arrhythmias (with increasing severity and intoxication). Condution problems and hypotension is improved with hypertonic sodium bicarbonate and if arrhythmias are present, treatment of these involves correcting the acidosis, hypoxia and electrolyte abnormalities. Anti-arrhythmics are generally avoided. If hypotension is refractory then a vasopressor can be used. BZDs can be used for any seizures.
A 19 year old male medical student develops acute chest pain during a game of squash. On examination he is distressed there but examination is otherwise unremarkable. There is a family history of sudden death.
A. Upper GI endoscopy B. Chest x-ray with rib views C. V/Q scan D. Troponin level E. Exercise ECG F. CT scan abdomen G. Thoracic spine x-ray H. Coronary angiogram I. Barium swallow J. Transthoracic echo K. CT x-ray in expiration L. ECG M. Chest x-ray with no special instructions
J. Transthoracic echo - This patient has likely HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. The FH of sudden death is suggestive of this diagnosis. This has a benign prognosis is most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance.
Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. There may also be MR.
A 50 year old Asian woman, who is known to be diabetic, presents with a painless ulcer on the ball of her foot. She has been complaining of a burning feeling of the soles of her feet for the last year.
A. RA B. Arterial ulcer C. Malignant ulcer D. Neuropathic ulcer E. Cardiac failure F. Lymphoedema G. Cellulitis H. Syphilis I. TB J. Pyoderma gangrenosum K. Venous ulcer L. DVT
D. Neuropathic ulcer - This is a case of diabetic neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. Pain is a common complaint such as the burning sensation this patient describes. Patient’s may also describe the pain as prickling or sticking. Complications range from the painless neuropathic ulcer described, at areas of the foot where there is weight loading (particularly the metatarsal heads), to the Charcot foot with severe architectural destruction of the foot. Foot ulceration is a common precusor to amputation. Foot care is crucial in DM. Examination should include peripheral pulses, reflexes and sensation to light touch with a 10g monofilament, vibration (128Hz tuning fork), pinprick and proprioception. The pain may be treated with medications like pregabalin and gabapentin.
A 33 year old presented with retrosternal discomfort on swallowing but without any real difficulty swallowing. O/E he was found to have creamy plaques in his mouth and later admitted to having AIDS.
A. Diffuse oesophageal spasm B. Eosinophilic oesophagitis C. Upper oesophageal web D. Globus hystericus E. Benign oesophageal stricture F. Oesophageal diverticulum G. Candidal oesophagitis H. Scleroderma I. Parkinson’s disease J. Achalasia K. Oesophageal cancer L. Stroke
G. Candidal oesophagitis - This is really odynophagia rather than true dysphagia. Whenever a patient complains of ‘difficulty swallowing’, you should always take a good history and explain what the patient actually means by this. Does the patient mean that there is true difficulty swallowing, or just that it is painful to swallow, or is there a feeling of a lump in the throat (globus). The white plaques here give alongside discomfort away the diagnosis. The patient also has AIDS and is therefore immunocompromised. Candidiasis here is an opportunistic infection in an immunocompromised host and is a mucosal infection caused in most cases by Candida albicans (and occasionally by other species). Patients may present like this, or with oral or vaginal infection. Oral thrush may be seen (pseudomembranous candidiasis) with altered taste sensation or indeed dysphagia, as well as odynophagia in oesophageal disease. In vaginal infection, there is erythema with a white discharge and pruritis. This patient should be started on an empirical trial of antifungals. A systemic azole can be used such as fluconazole or itraconazole.
MS is a demyelinating disease.
True
False
True - MS is characterised by inflammation and demyelination.
A 50 year old woman presented with a temperature and aching joints 2 days prior to departure on holiday to Egypt. On examination she had a tender swelling on her left upper arm.
A. Post immunisation B. Glandular fever C. Pneumonia D. HIV infection E. Malaria F. Drug reaction G. SLE H. Sarcoidosis I. Appendicitis J. Influenza K. Tuberculosis L. Hodgkin's lympoma M. Gastric carcinoma N. Pyelonephritis
A. Post immunisation - Travel to Egypt may necessitate vaccinations for diseases such as typhoid and HAV. This is a side-effect of the vaccine and the history here points towards this. Vaccine side effects tend to be uncommon although this depends on the specific vaccine given. For example, some 10-30% of people will experience mild side effects such as muscle pain and headache after being given the yellow fever vaccine.
An 68 year old woman with tierdness, right sided abdominal pain for 2 months. Investigations showed Hb 8 g/dl and MCV 65fl. Colonoscopy shows an ulcerating mass in the ascending colon.
A. Megaloblastic Anaemia B. Acute lymphoblastic leukaemia C. Sickle cell anaemia D. Aplastic anaemia E. Iron defeciency anaemia F. Chronic myeloid leukaemia G. Non Hodgkin’s lymphoma H. Chronic lymphocytic leukaemia I. Acute myeloid leukaemia
E. Iron deficiency anaemia - IDA is a microcytic hypochromic anaemia characterised by low serum iron, high TIBC and low transferrin saturation and serum ferritin. Bleeding is the principle cause of IDA. IDA is not an end diagnosis and has many causes and this is something that is important to bear in mind at all times. The cause here is from chronic blood loss from what would appear to be possible right sided bowel cancer. Worldwide, the most common cause is hookworm infection, and in the UK, menstrual losses in women. Causes of IDA can be broadly divided into 4 categories: decreased intake, increased loss, increased requirements (such as in pregnancy), and unknown.
A 60 year old male smoker has a long history of hypertension & angina. 4 weeks ago he was started on captopril by his GP. His creatinine has increased from 100 to 350 during that time. Renal ultrasound shows that 1 kidney is larger than the other.
A. Aortic coarctation B. Polycystic kidney disease C. Essential hypertension D. Chronic alcohol excess E. Hyperparathyroidism F. Conn's syndrome G. Hypothyroidism H. Medication I. Acromegaly J. Renal artery stenosis K. ‘White-coat hypertension’ L. Cushing's syndrome M. Phaeochromocytoma
J. Renal artery stenosis - Renal artery stenosis is basically narrowing of the renal artery. It occurs typically due to atherosclerosis or fibromuscular dysplasia. The history of smoking, hypertension and angina here are risk factors of the former. The presentation tends to be with accelerated or difficult to control hypertension. Acute kidney injury can be seen after starting an ACE inhibitor or an angiotensin II receptor antagonist. The afferent arteriole is stenosed in RAS and angiotensin II is needed to maintain GFR by constricting the efferent arteriole. ACE inhibitors prevent conversion of angiotensin I to angiotensin II, which is needed to maintain renal perfusion pressure in those with RAS.
There may not be any clinical consequences of RAS – just because someone’s renal arteries are narrowed does not mean they are suffering worsening kidney function, although this may be the case, especially after blockade of the renin-angiotensin system. A definitive diagnosis is made on imaging, where there is some controversy on what is most appropriate to use. USS is safe and non-invasive but the sensitivity and specificity is low. CT/MR angiography has the risk of contrast nephropathy and nephrogenic systemic fibrosis. Conventional angiography (the best test available) has the risk of bleeding and emboli as well as contrast related risks already mentioned.
Each of these patients has been found to have raised blood prolactin, select the most likely aetiology for each case.
A 45 year old lady complains of low libido and some galactorrhoea.
A. inadequate treatment B. Metoclopramide C. Ibuprofen D. Macroadenoma E. Acetaminophen F. non epileptic seizure G. Microadenoma H. epileptic seizure
G. Microadenoma
A 65-year-old woman presents with acute DVT. There is a low risk for bleeding. This step is added along with warfarin therapy.
A. Perform CABG B. Perform exercise ECG C. Add an ACE inhibitor D. Perform echocardiography E. Add Aspirin F. Add clopidogrel G. Perform coronary angioplasty H. Add Atorvastatin I. Advise lifestyle measures J. Add Atenolol K. Add low molecular weight Heparin L. Add Omega-3 oils M. Perform coronary thrombolysis
K. Add low molecular weight heparin - The mainstay of treatment for acute DVT is anticoagulation. This can be either unfractionated heparin, a LMWH or a factor Xa inhitor like fondaparinux. Fondaparinux has a higher half life than LMWH and there is no effective way of reversing it. LMWH have a shorter half life and some of it can be removed with protamine. Heparin though can be reversed quickly with protamine. Hence, if the patient is at a high risk of bleeding, they should be treated with unfractionated heparin and you should avoid fondaparinux. If they start bleeding you can just chuck them protamine. This however requires monitoring of APTT and platelet counts. If the patient has heparin-induced thrombocytopenia, you can try using fondaparinux. LMWH is recommended in those with active cancer and preferred in pregnancy, and consideration needs to be given in those with renal impairment. In this case LMWH or unfractionated heparin can be given, and the only option on the list is to add LMWH (such as enoxaparin, tinzaparin and dalteparin). Warfarin is started on the same day and LMWH should be used for at least 5 days until the INR is in the therapeutic range of 2-3 before the LMWH can be discontinued. (Some people say the INR has to be in that range for 48 hours before you remove LMWH)
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.
A. Potassium Iodide B. Radioiodine C. Propranolol D. Propylthiouracil E. Surgical decompression F. Carbimazole G. Stop treatment
A. Potassium iodide - This patient 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 28-year-old female with recent onset of depression takes 50 capsules, 500 mg each of paracetamol tablets. In several days, the liver is most likely to show what?
A. Hepatitis C virus infection B. Cirrhosis C. Portal chronic inflammation D. Hepatitis B virus infection E. Extensive necrosis F. Hepatocellular carcinoma G. Cholecystitis H. Mallory weiss tear of oesophagus I. Portal hypertension
E. Extensive necrosis - Paracetamol OD can occur after a single large OD or repeated ODs. Often, the patient is asymptomatic at initial presentation but if untreated may cause liver injury over the 2-4 days after ingestion, including fulminant liver failure. Paracetamol is the most frequent intentional OD drug in this country. The risk of liver damage is increased after taking drugs which induce CYP 450. Inducers include St John’s wort, barbiturates, phenytoin, tetracycline, chronic alcohol use and carbamazepine. A serum paracetamol level is important to order as early as possible, but at the earliest 4 hours post-ingestion.Treatment if indicated is with N-acetylcysteine with the level based on a paracetamol treatment graph.
A 77 year old woman presents with a 3 day history of constant left iliac fossa pain. She has a temp of 38oC and O/E is tender with guarding in the left iliac fossa. CT scan demonstrates an inflamed sigmoid colon with numerous diverticulae.
A. Ultrasound scan B. AXR C. CT scan D. Diagnostic laparotomy E. Oral antibiotics F. Endoscopy G. Laxatives H. Palliative care I. CXR J. ECG K. Acute pancreatitis L. PR exam
E. Oral antibiotics - This patient obviously has diverticulitis and does not need further investigation. Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. Risk factors for diverticular disease include low dietary fibre and advanced age. Oral antibiotic therapy and analgesia is indicated. If there is no improvement in 72 hours after oral antibiotics then IV antibiotics are indicated. Make sure you understand the differences in the terms: diverticulosis, diverticulitis and diverticular disease.
Drug interactions
A. Cocherane database B. Medline C. National institute for clinical excellence (NICE) website D. British national formulary E. BMA website F. Evidence based medicine website G. BMJ website
D. BNF - The BNF will tell you about indications and contraindications for drugs
A woman has a firm diffuse goitre, she’s feeling tired.
A. Grave's disease B. Hashimoto's thyroiditis C. Papillary carcinoma D. De Quervain's thyroiditis E. Follicular carcinoma F. solitary toxic adenoma G. Multinodular goitre H. medullary cell carcinoma
B. Hashimoto’s thyroiditis - Firm and diffuse goitre can be present physiologically (ie. preganancy), caused by Autoimmune disease : Grave’s/Hasimoto’s, drugs (sulphonylureas) or infective causes. The only information given is that she is hypothyroid. The most liley cause is thus Hashimoto’s.
A 62-year-old man who requires a knee replacement gives a history of allergy to dihydrocodeine.Which drug should NOT be given
A. Diclofenac B. Epidural bupivacaine and fentanyl C. Codydramol D. Paracetamol E. Morphine F. Tramadol
C. Codydramol - Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
A 65-year-old female presents with sudden-onset pain in her left calf. Although her patient notes are unavailable, she tells you that she is taking digoxin and verapamil for her ‘funny’ heart beat. On examination, the left leg is pale, cold and painful.
A. Amputation B. Embolectomy C. Thrombolysis D. Endarterectomy E. Femoro-popliteal bypass F. Femoral-femoral crossover graft G. Anticoagulation H. Aorto-bifemoral bypass I. Fasciotomy J. Percutaneous transluminal angioplasty K. Antiplatelet drug L. Conservative management
B. Embolectomy - Have a think about the differential diagnosis of sudden onset limb pain. Do you remember the 6 Ps of critical limb ischaemia? This patient’s arrhythmia has caused an embolic event, leading to acute limb ischaemia. There is as a result a sudden decrease in limb perfusion with threatened tissue viability. An emergency vascular assessment needs to be done with duplex ultrasound. Treatment depends on whether the patient already has a history of significant atherosclerosis. If so, there will already be a built up collateral supply so there is potentially a longer time window to act and so anticoagulation and thrombolysis are options. Otherwise an embolectomy will be indicated with a Fogarty catheter if there is not a long enough time window. This is typically done by inserting a Fogarty catheter with an inflatable balloon attached to its tip into the offending atery and passing the tip beyond the clot. The balloon is then inflated and then the catheter is withdrawn to remove the clot.
