Quiz Questions Flashcards
A 45 year old lady presenting with intense pruritus, joint pains & tiredness. She has also noticed that she is becoming yellow. On examination she was clubbed with xanthelasma around her eyes. She has dry eyes and a dry mouth. Her spleen was also palpably enlarged.
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
M. 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. 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 (jaundice) and splenomegaly as a feature of portal hypertension. The patient also has dry eyes and dry mouth from associated Sjogren’s syndrome. The joint pains could indicate RA.
A 65 year old man presents with angina & claudication. He is found to have a firm spleen extending 20cm below the costal margin. His Hb is 7.5g/dl & his blood film is leuco-erythroblastic.
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
J. Ideopathic myelofibrosis - This is a case of myelofibrosis. Leucoerythroblastosis and splenomegaly are common findings. Strong risk factors include exposure to radiation and industrial solvents. BM biopsy is essential for diagnosis. Extramedullary haematopoiesis leads to dacrocytes in the peripheral blood smear. Those without symptoms can be managed with folate and pyridoxine supplements. Otherwise options such as a BM transplant and hydroxycarbamide can be considered.
An 80-year-old woman is brought into A&E complaining of diffuse abdominal pain and vomiting. O/E she has an irregularly irregular pulse of 110/min. Minutes later she appears confused and you notice bright red blood passing per rectum.
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
B. Mesenteric infarct - The irregularly irregular pulse is a hallmark sign of atrial fibrillation which has led to cardioembolism and subsequent occlusion of the mesenteric vasculature. Untreated AF can lead to a thrombus forming inside the heart which can then embolise like this case to the mesenteric vasculature. This person is also old, which is an additional risk due to comorbidities like atherosclerosis. This patient has the symptoms and signs of ischaemic bowel disease (which encompasses acute mesenteric ischaemia, chronic mesenteric ischaemia and colonic ischaemia). This is likely acute mesenteric ischaemia – something that in a person who presents like this, you should maintain a high index of suspicion for as the presentation can be quite non-specific but the condition can be deadly. You would likely in this case opt for surgical intervention without delay although you can consider some form of imaging first to localise the bleed.
A 22 year old woman presents with a postcoital bleed but denies having other symptoms. She is currently in a relationship but is concerned that her partner is having sex with other women. Examination with a speculum reveals a mucopurulent yellow and cloudy discharge from the cervical os. The cervix is friable.
1. Chlamydia 2. Vaginal candidiasis 3. Bacterial vaginosis 4. Trichomonas vaginitis
- Chlamydia - This is genital tract chlamydia infection which is one of the most common STDs in the world. Remember that many infected individuals are asymptomatic. Women may present with cervical inflammation or yellow, cloudy discharge from the cervical os. A friable cervix is often also found on examination – the cervix bleeds easily with friction from a Dacron swab.
A 68-year-old woman presents with a two day history of passing copious quantities of blood per rectum and a fever. She has also had left iliac fossa pain during this period.
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
I. Diverticular disease - Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. There may uncommonly be rectal bleeding which is usually painless, profuse and arterial in nature. 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.
A 22-year-old woman with Hx of chlamydial urethritis complains of pelvic pain and painful periods. You order an endocervical smear which confirms the presence of Chlamydia trachomatis.
A. Endometriosis B. Retroverted uterus C. Pelvic inflammatory disease D. Ectopic pregnancy E. Fibroids F. Endometrial cancer G. Adenomyosis
C. Pelvic inflammatory disease - Pelvic inflammatory disease is an acute ascending infection of the female tract that is often associated with Neisseria gonorrhoeae or Chlamydia trachomatis. Key risk factors include prior infection with chlamydia or gonorrhoea or PID, young age of onset of sexual activity, unprotected sex with multiple partners and IUD use. Signs and symptoms vary and can include tenderness of the lower abdomen, adnexal tenderness and cervical motion tenderness. Fever and cervical or vaginal discharge may also be present. Complications include tubo-ovarian abscess and subsequent infertility or ectopic pregnancy due to scarred or obstructed fallopian tubes.
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 21-year-old man is walking down the street to visit his friends while suddenly he falls to the ground unconscious. His body goes stiff and then he begins to jerk his arms. He becomes incontinent of urine.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Tonic-clonic seizures - This is a tonic-clonic, generalised seizure. It is characterised by LOC and widespread motor tonic contractions followed by clonic jerking movements. There will characteristically be a suppressed level of arousal following the event. This may either reflect a primary generalised episode or a focal seizure with secondary generalisation. The main aim of acute treatment is to terminate the seizure and to protect the airway. Management always starts with basic life-support (like every acute emergency) and your ABCs. IV access needs to be established (bloods sent to the lab too and serum glucose measured to test for reversable causes of seizure activity – thiamine should also be given to the patient if there is any concern about deficiency and hypoglycaemia, for instance in alcohol abuse). The following are needed: ECG, pulse oximetry, ABG. IV lorazepam is the preferred initial therapy, though rectal diazepam can be used if there is no IV access. If BZDs fail to stop the seizure then phenytoin or fosphenytoin can be tried.
After the episode, MRI and EEG are essential in diagnosing an epilepsy syndrome. During the episode of generalised tonic-clonic activity, the EEG will show bilateral synchrony in the epileptiform activity. If this is a one-off seizure in which a provoking factor, such as electrolyte disturbance or hypoglycaemia, has been identified then there is no need for therapy for epilepsy. In unprovoked cases, this depends on history, examination, EEG and MRI. Treatment may not be needed the first time but after a second unprovoked instance, therapy is generally recommended.
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.
True or False - cutting the vagus nerve (vagotomy) increases acid production in the stomach.
False - The parasympathetic system generally induces gastrointestinal motility and secretions. Acetylcholine stimulates HCl production so cutting the vagus will reduce this.
A 48 year old woman presents with a 1 day history of constant right upper quadrant pain radiating round the right side of her chest. She says her urine may be darker than usual. Her GP started her on oral antibiotics. Amylase has already been ordered.
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
A. Ultrasound scan - Abdominal ultrasound is ordered when a patient presents with biliary pain and is the single best test for cholelithiasis (though has a low sensitivity for choledocholithiasis). Note that cholelithiasis refers to stones in the gallbladder and choledocholithiasis refers to stones in the bile duct. If stones are found then this would give weight to a diagnosis of acute cholecystitis. There are symptoms here of obstructive jaundice due to gallstone obstruction of bile outflow. Serum amylase would also be ordered in any patient presenting with pain located in the epigastric region, to rule out acute pancreatitis. This has been done here. In this patient you would also order LFTs, FBC looking for evidence of inflammation. MRCP, ERCP and EUS can be considered if necessary.
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.
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 24 year old man presents with a 3 month history of episodes of painless, bright red rectal bleeding on straining at stool. He has noticed some blood in the bowl, separate from the stool & some on the paper after wiping.
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
B 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.
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 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 21-year-old man who has been involved in a road traffic accident develops a continuous blood-stained discharge from the nose and describes an altered sensation of smell.
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
D. Base of skull fracture - This is a basilar skull fracture and a CT scan (superior to MRI), in this case with 3D reconstructions, will be useful. These patients have hit their head head. Basilar skull fractures have specific clinical features. Blood pooling from these fractures can cause periorbital bruising (raccoon eyes), brusing over the mastoid area (Battle’s sign) and bloody otorrhoea. There may also be CSF leak resulting in CSF otorrhoea or rhinorrhoea. A unilateral raccoon eye has an 85% positive predictive value for this diagnosis. Base of skull fractures can also affect cranial nerves leading to hearing impairment (due either to SN as a result of VII injury or conductive due to haemotympanum) and facial numbness or paralysis. These patients also need to have their GCS calculated. Treatment is primarily conservative although surgical intervention may be needed if there is associated CSF leak, intracranial pathology or CN deficit. RTAs are the second most common cause of skull fractures, the first being a fall from a height. There may also, like the first case, be a history of assault resulting in head trauma or even a gunshot to the head.
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.
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 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 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.
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 50 year old man is brought into hospital by his wife. She tells you he has become increasingly confused for the last 3 days and is always scratching himself. ABG shows a metabolic acidosis. She remembers he was recently started on a new tablet by his GP.
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
J. Renal artery stenosis - Renal artery stenosis is basically narrowing of the renal artery. It occurs typically due to atherosclerosis or fibromuscular dysplasia. 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 which this patient has been prescribed. 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. The result is this patient has acute renal failure and has developed uraemia. The metabolic acidosis is also as a result of renal failure.
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.
A 25 year old man suddenly developed hoarseness, wheeze and stridor whilst eating peanuts in a bar. Looking in his mouth you notice a swollen tongue.
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
E. Angioedema - Angio-oedema is swelling involving the deeper layers of the subdermis (occuring in association with urticaria in around 40% of cases). In this case it involves the face/neck and is dangerous – the risk being airway compromise and this requires rapid treatment with adrenaline. The food trigger here is obvious – this person has just consumed peanuts and this is allergic in nature, causing an IgE mediated reaction. Common triggers aside from nuts include eggs and shellfish although any food can be implicated. As mentioned, airway management and adrenaline is crucial here and you would also give antihistamines, IV corticosteroids and tell the patient to avoid the trigger.
A 30 year old woman who has recently returned from holiday in the Gambia. She is in the 3rd trimester of pregnancy & complains of headaches & fever. On examination her BP is 110/70, there is a soft ESM, shotty lymphadenopathy & hepatosplenomegaly. Examination of the skin is unremarkable. Investigations revealed a Hb of 10.5g/dl, WBC of 5x109/l, platelet count of 80x109/l.
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
E. 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 woman 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.
A 47 year old man with a 5 year history of dyspepsia, collapse in the pub. He notices that his stools have become black over the last few days.
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
G. Duodenal ulcer - There is no reason why this cannot be a gastric ulcer but it is not an option on the list. The history of dyspepsia and black tarry stools over the past few days suggests a bleeding peptic ulcer. The dyspepsia is often centred in the upper abdomen and is related to eating. Contrary to popular lay health beliefs there is no good evidence of alcohol as an important risk factor. Key risk factors are NSAID use, H. pylori, smoking and FH of PUD. The most specific and sensitive test is an upper GI endoscopy which will also allow intervention to stop the bleeding ulcer from bleeding. 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. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.
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 young man comes into A+E after a night out complaining of palpitations, he is drowsy and has low BMs. He normally feels fine after a big night out but this time didn’t pass by chicken cottage on his way home.
A. Addison's disease B. Alcohol C. Meningitis D. Insulinoma E. Insulin F. dumping syndrome G. Gliclazide H. Waterhouse-Friderichsen syndrome I. Starvation
B. Alcohol
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.
Dopamine tablets can be given to patients to treat Parkinson’s disease.
True
False
False - Dopamine does not cross the blood-brain barrier. Therefore levodopa (L-dopa), its precursor is given, because this can cross the barrier. It is then processed to make dopamine.
You are asked to see a patient with acute chest pain 5 days after total hip replacement. BP 120/80, HR 93. A PE is confirmed. The patient has a previous history of heparin-induced thrombocytopenia.
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
B. Fondapariunux - A factor Xa antagonist is preferred if the patient has or has had heparin-induced thrombocytopenia. If the patient has a low BP then systemic thrombolysis would be indicated to prevent possible cardiac arrest.
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.
29 y/o lady presents 3 weeks post partum with pain and a lump in her left breast. O/E you notice swelling, redness, the area feels hot.
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
C. Acute pyogenic mastitis - Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful 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.
An 11 year old girl has periorbital oedema. Her urine tests positive for microscopic haematuria and proteinuria. Anti-streptolysin O titre (ASOT) is positive.
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
E. Post infectious glomerulonephritis - This is post-infectious glomerulonephritis caused by group A beta-haemolytic streptococcus with renal endothelial cell damage. Serological markers would expect to show antibodies to streptococcus and low complement and treatment here is with antibiotics. The high ASOT (antistreptolysin O antibody titres) indicates post-streptococcal GN. There may also be positive anti-Dnase and antihyaluronidase in post-streptococcal GN.
A 55 year old male alcoholic presents with vomiting 800ml of blood. His blood pressure is 80/50 with a pulse rate of 120. He also has ascites.
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
J. Oesophageal varices - Oesophageal varices occurs as a result of portal hypertension which is a complication of cirrhosis, caused in this patient by his long history of alcohol excess. Other signs may be present such as spider naevi, ascites, caput medusa (vascular collaterals in the abdominal wall), jaundice etc. Splenomegaly is also commonly found and hence patents often have thrombocytopenia and anaemia as a result. The bleeding (explaining the BP and HR of this patient) carries a significant morbidity and mortality, and beta-blockers and/or endoscopic ligation can prevent variceal bleeding prophylactically (though beta blockers are not be used in the acute setting of a variceal bleed – do not get confused here!). Oesophageal varices are basically dilated veins and these can be seen on OGD. Worldwide, HBV and HCV are also major causes of cirrhosis, leading to varices and HIV co-infection can rapidly speed up the progression to cirrhosis in chronic liver failure. The size of the varices is the key predictor of haemorrhage. Acute bleed can be managed with resuscitation, terlipression (DDAVP)/somatostatin analogues/endoscopic ligation. Additionally, a shunt can be deployed and antbiotic prophylaxis started.
A 76 year old woman admitted with a chest infection develops non-bloody diarrhoea on the ward. She was on cefuroxime and erythromycin for her chest. She appears unwell and there is a fever. CRP is elevated.
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
L. Clostridium difficile - This is infection with clostridium difficile with the major risk factor here of antibiotic exposure due to the recent chest infection. The most common ones implicated are ampicillin, second and third generation cephalosporins, clindamycin and fluoroquinolones, especially if used in the preceding 3 months (though most manifestations occur on days 4 through to 9 of antibiotic therapy). Diarrhoea may range from a few loose stools to severe diarrhoea, though absence could be related to toxic megacolon to paralytic ileus. Abdominal pain is also common as is fever. C. difficile produces 2 exotoxins which are responsible for its pathogenicity. These are called toxin A and toxin B (A is thought to be more important than B) which lead to an inflammatory response in the large bowel, increased vascular permeability and the formation of pseudomembranes. Colonic pseudomembranes look like raised yellow and white plaques against an inflamed mucosa and are composed of neutrophils, fibrin, mucin and cellular debris. The diagnostic standard is with cytotoxic tissue culture assay. Treatment involves discontinuing the implicated antibiotic and beginning oral metronidazole or vancomycin. 5-20% will have a recurrence on discontinuing treatment and will need a second course.
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.
65 yr old man had an inferior MI 10 days ago. His initial course was uncomplicated. He suddenly deteriorates with LVF. On examination pulse is regular 100bpm and normal volume and character. BP 110/160mmHg. Apex beat is dynamic. There is a loud grade III apical pan-systolic murmur radiating to the axilla.
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
B. Mitral incompetence - 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.
For each of the malignancies listed below, please select the recognised presentation from the list of options.
Small-cell lung 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
H. Eaton-Lambert syndrome - Eaton-Lambert syndrome is a myasthenic syndrome characterised by impaired release of acetylcholine due to autoantibodies to presynaptic voltage-gated calcium channels. Typically in EMQs, the description is of a patient with absent tendon reflexes and muscle weakness that improved after repeated contraction (much to the amazement of the examining doctors colleagues!). Eaton-Lambert syndrome is associated with small cell lung carcinoma in 60% of cases.
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.
A 56 yo chef has a random glucose of 9.0 mmol/l and is submitted to an OGTT (oral glucose tolerance test). His BMs come back as 10.8 mmol/L
A. Impaired glucose tolerance B. Normal C. Impaired fasting glucose D. Diabetic E. Non-signifcant
A. Impaired glucose tolerance - The random glucose for this patient is suggestive of a problem and the oral glucose tolerance test gives a reading
A 75-year-old lady is brought to see her GP by her husband. He says that in the past couple of months she needs more and more assistance with everyday life as she is very forgetful, gets lost easily and cannot name objects at times. He is very upset as he says she is not the way she used to be. Examination and routine investigations are unremarkable although her MMSE is 19/30.
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
I. Alzheimers dementia - This is Alzheimer’s dementia which is a progressive irreversible disorder characterised by memory loss, loss of social function and dimished executive function. The MMSE is the most widely used screening test for cognitive function and a score
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.
Mr A.L is a 69-year-old who had oesophageal cancer underwent oesophagectomy. What kind of feed does he require?
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
J. Percutaneous jejunostomy - This patient needs nutritional support to prevent malnutrition and starvation. Enteral nutrition here is not possible as a chunk of the oesophagus has just been removed and we have to wait for an intact anastomosis. During surgery, a percutaneous jejunostomy can be placed to provide a temporary route of nutrition until oral feeding can resume. A surgeon at operation cannot place a percutaneous gastrostomy, and it is more suitable for prolonged feeding. Furthermore, in the immediate post-operative period, there may be gastric stasis so it is preferred to deliver the feed via a post-pyloric placement. If you have seen a PEG tube (percutaneous gastrostomy), you will know why it is not preferred. It is not a pleasant sight (and I don’t mean cosmetically – just have a look at the needle). Some younger people may ask for it to be converted to a button gastrostomy for cosmetic reasons. A PEG tube is placed laparoscopically.
A percutaneous jejunostomy is an alternative to parenteral (IV) nutrition in this post-operative patient. Parenteral nutrition is really a last resort and this is not an indication for it. Only when the GIT is either unavailable or function is indequate should you consider it. This can be delivered via a venflon, PICC line or centrally. There are a host of complications, both nutritionally, related to the catheter e.g. infection, thrombosis and the effect on organ systems e.g. biliary disease. Note that you should also be aware of the phenomenon known as refeeding syndrome.
Which is the best type of scan to help confirm MS?
- MRI
- CT
- Skull X-ray
- Angiogram
- MRI - MRI scans of the brain or spine are the most useful imaging investigations.
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.
During the month following his acute MI, a 56 year old man has become progressively more breathless. O/E he has a loud pan-systolic murmur
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
H. Mitral regurgitation - MR can occur as a complication of MI which may cause structural damage to the mitral valve apparatus. 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. This case of acute MR in the setting of an acute MI is very serious can lead to high LA pressure and pulmonary oedema secondary to reduced LA compliance. Occasionally no murmur is heard. Note that while a VSD also gives a pansystolic murmur, which is generally easily heard, and is loudest at the left parasternal region, with no axillary radiation.
A 25-year-old woman is admitted semi-comatose. She has been complaining of increasing thirst and lethargy over the previous few weeks. BM stick result is 36 mmol/l. Blood pH is 7.10 with a HCO3- of 15 mmol/l.
A. IV saline B. Administer diuretics C. Colloid D. Blood transfusions E. IV dextrose F. IV dextrose/saline G. IV sodium bicarbonate H. Measure urea and electrolytes I. IV plasma J. Measure blood gases
A. IV saline - Initial treatment of DKA aims at correcting severe volume depletion (the main problem), again with IV saline infusion at a rate of 1-1.5L for the first hour. When glucose reaches 11.1mmol, fluid should be changed to 5% dextrose to prevent hypoglycaemia.
A 60 year old man on anti-cholinergic drugs presents with supra-pubic pain. He complains that he has not passed any urine in 3 days. O/E he has a distended bladder.
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
K. Acute urinary retention - This is acute urinary retention caused by anticholinergics. Unwanted effects of this class of drugs include urinary retention, constipation, erectile dysfunction, CNS disturbance, cycloplegia, dry mouth and decreased sweating. Poisoning in severe cases can be treated with anticholinesterases such as physostigmine. This man will need to be catheterised first to relieve the urinary retention and prevent any further complications from occuring.
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.
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 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.
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.
An 87 year old woman presents with constipation and nausea
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
C. Sigmoid volvulus - While this woman has indeed presented with very non-specific symptoms, the only feasible answer from the list is a sigmoid volvulus. A volvulus is bowel obstruction occuring due to a loop of bowel twisting on its own mesenteric axis. Broadly speaking, there are three types: small bowel, sigmoid and gastric. This is something you need to be able to recognise on AXR and it appears as a dilated loop of large bowel present in the lower abdomen, resembling a coffee bean shape (or like an upside down U shape). The rest of the bowel is usually dilated. For a caecal volvulus, the caecum leaves the RLQ to appear like a second satomach bubble in the centre of the film. There is often associated small bowel dilation. A gastric volvulus is very rare.
30 year old stone mason came from India to work on a temple being constructed. He presented to the GP with history of fever, night sweats & cough of 3 months duration. Chest x-ray showed a cavitating shadow.
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
A. Mycobacterium 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. In the first half of the 20th century, tuberculosis accounted for over 90% of cases of erythema nodosum. 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. Cavitating lesions like the one this patient has can be seen on CXR but is non-specific for TB. 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 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 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 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.
A 42-year-old obese lady with history of gall stones develops epigastric pain radiating to the back. She is tachycardic and hypotensive. There is a large bruise on the left flank. She denies any injuries.
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
E. Grey-Turner’s sign - Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Grey-Turner’s sign refers to bruising of the flanks and can take 24-48 hours to occur. It is due to retroperitoneal haemorrhage.
A 30-year-old man, a lifelong non-smoker, presents with a history of at least 6 months of purulent sputum. He has had regular chest infections since an attack of measles at the age of 14.
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
J. Bronchiectasis -Bronchiectasis is permanent bronchi dilatation due to bronchial wall damage and loss of elasticity. It is often as a consequence of recurrent/severe infections and most present with chronic productive mucopurulent cough. The most common identifiable cause is CF. Chest CT is the diagnostic test. Diagnosis is aided by sputum analysis. Have a think about what you would expect to hear on ascultation of the chest.
83 years old man with longstanding heart failure for which he takes digoxin & diuretics. For the last 24 hours he has been vomiting & passed very little urine. On examination he is pale & mildly dehydrated; examination of the abdomen is normal.
A. Salmonella B. Viral gastroenteritis C. Appendicitis D. Combined oral contraceptive pill E. Gastric carcinoma F. Intussusception G. Bulimia H. Uraemia I. Bowel obstruction J. Pyloric stenosis K. Pancreatitis L. Oesophageal carcinoma M. Peptic ulcer disease
H. 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 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 40 year old multiparous woman presents with a midline abdominal mass. The mass is non tender & appears when she is straining. On examination, the midline mass is visible when she raises her head off the examining bed.
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
L. Divaricaction of the recti - Divaricate means to spread apart. The rectus goes from the pubic crest, tubercle and symphysis to the costal cartilages 5,6 and 7, costal margin of 7, sternum and diaphragm. It is innervated by T7-12. Normally, the rectus muscles meet in the midline (linea alba). However, some people have a defect above the umbilicus which causes the gap between the recti to be wider than normal. Hence, when the patient sites up, the rectus muscles will spread apart. Surgica correction is possible but most are asymptomatic. It is not a true hernia, and this is the only option from the list that fits the presentation.
A 50-year-old woman, who gave up smoking 5 years ago, presents with SOB and weight loss. On examination she is clubbed. The CXR shows a perihilar shadow..
A. Colonoscopy B. Echocardiogram C. Sputum culture D. Lung function tests E. Abdominal ultrasound scan F. Bronchoscopy G. Chest x-ray H. Stool culture
F. Bronchoscopy - The history of smoking and weight loss point to a bronchial carcinoma. Whilst the initial investigation is with a CXR, diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. Non-small cell lung cancer is more often associated with clubbing.
A 62 year old man presents with progressive breathlessness over many years. He worked in power stations. He has finger clubbing and his chest xray shows a honeycomb apperance.
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
H. Idiopathic 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. Work in power stations can involve contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. 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 CXR in most will show reticulonodular shadowing consistent with fibrosis. This can be described as a ‘honeycomb’ pattern.
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 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.
A child develops a black eye after falling off the horse. Fracture of the base of skull is diagnosed.
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
D. Raccoon eyes - Basilar skull fractures have specific clinical features. Blood pooling from these fractures can cause periorbital bruising (raccoon eyes), brusing over the mastoid area (Battle’s sign) and bloody otorrhoea. There may also be CSF leak resulting in CSF otorrhoea or rhinorrhoea. A unilateral raccoon eye has an 85% positive predictive value for this diagnosis.
A 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 62-year-old man 3 months after an acute MI, taking aspirin, atenolol and simvastatin, whose echocardiogram shows worsening left ventricular function.(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
D. Angiotensin converting enzyme inhibitor therapy - This patient has worsening LV function in line with heart failure. First line treatment is with an ACE inhibitor which reduces morbidity and mortality associated with the condition. All patients with LV dysfunction should receive ACE inhibitors, whether symptomatic or not. Caution should be taken if the patient has renal impairment, cardiogenic shock or hyperkalaemia. All patients with chronic heart failure will also receive a beta blocker such as carvedilol.
A 45-year old lady with a tremor of the wrist (when extended). Other findings on examination include jaundice, spider naevi, ascites.
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
I. Asterixis - Asterixis is a flapping tremor, or a liver flap, which is a coarse tremor of the hand when the wrist is held extended. It is caused in this case by liver failure and can be a sign of hepatic encephalopathy. The signs found on examination point to decompensated chronic liver disease.
A 20 year old medical student is concerned about recent weight gain & lethargy & constipation. You notice bradycardia & a goitre. Her ankle reflexes are sluggish. Her periods have stopped.
A. Superior vena cava syndrome B. Thyroglossal cyst C. Hashimoto's thyroiditis D. Myxoedema E. De Quervain's thyroiditis F. Stomach carcinoma G. Carotid artery aneurysm H. TB abcess I. Grave's disease J. Thyroid cancer K. Hodgkin's disease L. Euthyroid goitre
D. Myxoedema - This medical student has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (weight gain, lethargy, sluggish reflexes, bradycardia and constipation) as well as depression, fatigue, constipation, cold intolerance, menstrual problems in females, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.
A 25-year-old woman is seen in clinic with a 2-month history of painless lymphadenopaty in the neck. Blood tests show an ESR of 85 and the presence of Reed-Sternberg cells on peripheral blood film.
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
F. Hodgkin’s lymphoma - The presence of Reed-Sternberg cells is the giveaway here.
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.
A 60-year-old obese man presents with a ulceration on the sole of the right foot, beneath the metatarsal heads. The ulcer is deep and penetrating, however the skin around it appears well perfused. There is no pain and ankle reflexes are absent bilaterally.
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
B. Diabetic ulcer - This is a case of diabetic neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. 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. Any neuropathic pain may be treated with medications like pregabalin and gabapentin (but unlikely to much effect).
choose the SINGLE test from the list above that would be of most help in establishing the diagnosis
Aortic dissection
A. CT chest, abdomen and pelvis B. Ventilation-perfusion scan C. Duplex ultrasound D. Trans-thoracic echocardiography E. Upper GI endoscopy F. D-dimer G. Renal function tests H. Barium swallow I. Barium enema J. MRI head K.CT head
A. CT chest, abdomen and pelvis - 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. A CT scan is indicated as soon as a diagnosis of aortic dissection is suspected and should be from the chest to the pelvis to see the full extent of the dissecting aneurysm. What you will see is the intimal flap. MRI is more sensitive and specific but is more difficult to obtain acutely.
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 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 45 year old woman complains of hand tremors, loose stools and is very anxious.
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
G. Hyperthyroidism - TSH is the initial screening test and if supressed, T4/T3 levels are measured. 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 30 year old man who has returned from a month-long business trip to India has been complaining of abdominal pain and nausea for a week. He has also vomitied and remembers having a meal of shellfish from a street vendor. He woke up this morning and noticed he was going yellow. His ALT is 5000 and total bilirubin 139.
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
F. Viral hepatitis A - 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
54 year old publican has 48 hour history of severe epigastric pain & vomiting. On examination he is unwell. Pulse rate is 110/min, BP 130/90. Temp 380C. Upper abdomen very tender. Amylase 1000U/l.
A. Salmonella B. Viral gastroenteritis C. Appendicitis D. Combined oral contraceptive pill E. Gastric carcinoma F. Intussusception G. Bulimia H. Uraemia I. Bowel obstruction J. Pyloric stenosis K. Pancreatitis L. Oesophageal carcinoma M. Peptic ulcer disease
K. Pancreatitis - This patient has acute pancreatitis. He has vomited and is describing mid-epigastric pain radiating around to the back. This patient can also have nausea and vomiting too, with agitation and confusion. A pleural effusion is seen in half of patients with acute pancreatitis. 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 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 abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.
For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.
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.
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)
MS is a demyelinating disease.
True
False
True - MS is characterised by inflammation and demyelination.
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 17 year old girl has developed an acutely painful goitre. She has a fever & pain on swallowing.
A. Superior vena cava syndrome B. Thyroglossal cyst C. Hashimoto's thyroiditis D. Myxoedema E. De Quervain's thyroiditis F. Stomach carcinoma G. Carotid artery aneurysm H. TB abcess I. Grave's disease J. Thyroid cancer K. Hodgkin's disease L. Euthyroid goitre
E. 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 55 year old woman develops hoarseness 2 days after a partial thyroidectomy for thyrotoxicosis
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
A. Laryngeal nerve palsy - This patient has just had neck surgery and the hoarseness here results from damage to the recurrent laryngeal nerve, which is a branch of the vagus nerve which supplies motor function and sensation to the larynx. This nerve runs posterior to the thyroid and results in hoarseness when damaged. Bilateral damage is even worse and the patient could have difficulty breathing and the complete inability to speak. The right recurrent laryngeal is more prone to damage as it is located relatively more medial than the left.
Previously well, 27-year-old woman developed ‘the worst headache ever’ around 3 hours ago. It was sudden and felt like a clap of thunder. He vomitted twice since and has photophobia. There is no family history of headaches, her mother and grandmother died of kidney disease.
A. Meningitis B. Tension headache C. Cluster headache D. Trigeminal neuralgia E. Space-occupying lesion F. Cervical spondylosis G. Migraine H. Subarachnoid haemorrhage I. Temporal arteritis
H. 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. The family history of kidney disease here points to adult PKD. 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 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.
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.
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 19-year-old tall (6ft 4in) man presents with sudden onset of right sided chest pain which occurred after an episode of wheezing. This pain persisted despite inhaling his bronchodilators. Examination reveals absent breath sounds with a hyperresonant percussion note over the right hemithorax.
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
A. Pneumothorax - This is a primary pneumothorax which occurs in young people without any known lung conditions. Having a tall and slender build like this patient is a recognised risk factor. Other risks include smoking, FH, Marfan’s, young age, male and conditions like CF and TB. The examination findings of absent breath sounds and hyperresonance point to this diagnosis. 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 (
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.)
A 40 year old builder has a 4 hour history of haematuria and extreme abdominal pain, that he describes as “coming in waves” between his right flank and right testicle
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
F. Ureteric colic - 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 and macroscopic haematuria may also be present although this is rare. Dehydration is a strong risk factor for renal stone formation and this man’s job may make him susceptible to inadequate fluid intake. A low urine output can lead to higher levels of urinary solutes, therefore leading to stone formation. 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 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 54 year old postman has had lower back pain for 2 years now. Over the past year he has experienced bilateral leg pain and heavy legs when walking. This pain is relieved by sitting down. He has now assumed a stooped posture when walking which makes the pain better.
- Spinal stenosis
- Lumbosacral disc herniation
- Peripheral vascular disease
- Spinal compression fracture
- Spinal stenosis - This is neurogenic claudication due to spinal stenosis. This is relieved by sitting or bending over, which widens the size of the spinal canal. This is the reason for the stooped posture when walking, which is classically described as the ‘shopping cart sign’ where patients lean forwards like onto a shopping trolley to flex the spine.
A 40-year-old typist presents with pain & tingling in the lateral side of the left hand, worse at night when she had to get out of bed to shake the hand for relief.
A. Diabetic neuropathy
B. Carpal tunnel syndrome
C. Charcot-Marie-Tooth disease
B. Carpal tunnel syndrome - Carpal tunnel syndrome is the most common nerve entrapment and women just past middle age are at the highest risk. Symptoms include numbness/tingling of the thumb and radial fingers, an aching wrist and clumsiness (especially with fine motor tasks). The symptoms are of gradual onset and often wake the patient up at night, and is relieved by shaking the wrist. Numbness is normally on the palmar aspect of the thumb, index and middle fingers (but not the little finger). When the patient wakes up, there may be difficulty flexing or extending fingers. Symptoms in the day tend to be associated with activity. The most sensitive and specific test for diagnosis is EMG and can confirm damage to the median nerve in the carpal tunnel and categorise the severity of the damage. There are specific tests for CTS such as Tinel’s test and Phalen’s test, though clinically these are not particularly useful due to sensitivity and specificity.
CTS is caused by anything that causes a reduction in the size of the carpal tunnel – from inflammation, arthritis and tenosynovitis to old fractures. In CTS there is preserved sensation of the palm as the palmar cutaneous branch comes off a few cm above the carpal tunnel.
A 32 year old female presents with a 4 week history of bloody liquid stool with mucus, 9 times a day. She has anorexia, weight loss & anaemia.
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
H. Inflammatory bowel disease - This patient gives a history of IBD. The history would be more suggestive of 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 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 25-year-old university student presents with high fevers. He has a petechial rash, black areas on his digits and a blood pressure of 70/50.
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
F. Blood cultures - This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis.
It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature
A 24 year old woman following a viral infection was diagnosed as having idiopathic thrombocytopaenia. She presents to A&E & complains of multiple bruising & rectal bleeding. She is on oral prednisolone 30mg/day. Her Hb is 12.5g/dl.
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
C. IV immunoglobulin - ITP is thought to be due to an autoimmune phenomenon. Treatment is based on the patient’s platelet count and bleeding symptoms. This patient has severe active bleeding and must be started on IVIG plus corticosteroids, which she is already on. Platelet transfusions should be considered with tranexamic acid as an adjunct.
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 26 year old Italian nightclub DJ presents with abdominal pain. On enquiry he has been unwell with a productive cough, fever and breathlessness. On examination his heart rate is 110bpm and his blood pressure is 110/75. His abdomen is soft, non tender.
A. Cystic fibrosis B. Pancreatitis C. Tuberculosis D. Emphysema E. Asthma F. Pneumonia G. Chronic bronchitis H. Bronchiectasis I. Lung cancer J. HIV K. Lung abscess
F. Pneumonia - This is basal pneumonia which can present with upper abdominal pain. The symptoms this patient gives are consistent with pneumonia. Treatment is guided by the CURB-65 score. A CXR is the most specific and sensitive test available and antibiotics are indicated. CXR may show airspace shadowing with air bronchograms. Make sure you can spot consolidation on a CXR.
A 35-year-old overweight woman complained of severe abdominal pain and vomiting. She had had a previous attack when on holiday and had had to be flown home as a medical emergency. She looks jaundiced and in distress.
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
A. Pancreatitis - This patient has acute pancreatitis. She has vomited and is describing likely epigastric pain. This classically radiates around to the back which is relieved in the fetal position and is worse with movement. This patient is likely to have gallstones as the underlying cause, which is also causing an obstructive jaundice and her previous episode. 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 other causes of acute pancreatitis. Those caused by hypocalcaemia may 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 abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration. For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.
A 50 year old man who feels tired all the time, has recently noticed pigmentation of his skin and has lost some weight.
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
J. 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. Anorexia, fatigue and weight loss is observed in all patients. 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. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.
A 75-year-old man is found on his bedroom floor by his wife and is now conscious. He got out of bed in the middle of the night to go to the toilet and felt dizzy and fell to the ground. He is on treatment for hypertension and has no other medical problems.
A. Hypoglycaemia B. Anaemia C. Stokes-Adams attack D. Opioid overdose E. Postural hypotension
E. Postural hypotension - This patient has postural hypotension which is demonstrated by a fall of >20 in systolic blood pressure and >10 diastolic within 3 minutes of standing upright. It is a side effect of anti-hypertensives and is a common problem in the elderly. A good history should be enough to diagnose this.
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.
choose the SINGLE test from the list above that would be of most help in establishing the diagnosis
Renal artery stenosis
A. CT chest, abdomen and pelvis B. Ventilation-perfusion scan C. Duplex ultrasound D. Trans-thoracic echocardiography E. Upper GI endoscopy F. D-dimer G. Renal function tests H. Barium swallow I. Barium enema J. MRI head K.CT head
C. Duplex ultrasound - Renal artery stenosis is basically narrowing of the renal artery. There may not be any clinical consequences of this – 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, and patients may have difficult to control and accelerated hypertension. 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. Generally, the recommendation is to start with renal duplex ultrasound. This would not be an unreasonable approach. This can be followed by further tests. Although, in some centres in the country, the first line is CT or MR angiography and duplex USS is only done if there is a contra-indication to CT/MR angiography. However, the only reasonable option on this list is duplex USS.
A 72-tear-old man with weight loss has developed a hard swelling in the left supraclavicular fossa.
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
E. Pancreatic carcinoma - The presence of Virchow’s node (Troisier’s sign), a hard enlarged node in the left supraclavicular fossa, points towards a malignancy in the abdominal cavity. This is most often stomach cancer but does not have to be. The lymph drainage of the abdominal cavity drains into Virchow’s node as the lymph drains most of the body from the thoracic duct and enters the venous circulation at the left subclavian vein.
A 36 year old popstar presents with fever, a cough & an itchy vesicular rash. Chest x-ray shows mottling through both lung fields.
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
C. Varicella zoster - The pruritic vesicular rash (the classic description of a ‘dewdrop on a rose petal’) makes you think of VZV. The rash typically occurs on the patient’s torso and face and pneumonia is a complication occuring more commonly in those with immunosuppression. The lesions are often crusted over by 7-10 days. The diagnosis is based on clinical findings.
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.
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 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 57 year old publican presents with a painless supraclavicular lump. He complains of abdominal pain & has recently noticed that his trousers seem too big for him.
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
C. Carcinomatous lymph node - Weight loss is one of the most common presenting symptoms in patients with gastric cancer. Epigastric pain is present in about 80%. Although commonly mentioned in EMQs, lymphadenopathy is an uncommon presentation. The left supraclavicular node here is Virchow’s node. It becomes enlarged due to the pattern of lymphatic drainage into the thoracic duct. There may also be a periumbilical nodule (Sister Mary Joseph’s nodule) or a left axillary nodule (Irish node). These are rare findings.
A 52 year old fund manager with a history of previous heart attacks, feels some palpitations and collapses. A witness said that he went very pale as he collapsed but then became flushed and regained consciousness after 30 seconds.
A. Hypoglycaemia B. Anaemia C. Stokes-Adams attack D. Opioid overdose E. Postural hypotension
C. Stokes-Adams attack - Stokes-Adams attacks are episodes of transient LOC due to sudden decreased cardiac output. The previous heart attacks and later palpitations towards an arrhythmia such as heart bock, which caused the attack. Pallor prior to the attack and facial flushing due to reactive hyperemia after the attack is characteristic of a Stokes-Adams attack. Definitive treatment is with surgical insertion of a pacemaker.
A 69-year-old alcoholic man collapsed after an alcoholic binge and struck his head on the pavement. He now has a deteriorating Glasgow Coma Scale.
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
A. Subdural haematoma - Blood collects between the dura and arachnoid mater in a subdural haematoma. This condition can run a variable disease course. This man is at risk because he is an alcoholic and this question tells you he has fallen over and hit his head on the pavement. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. It is also important in the work up to calculate this patient’s admission GCS, which is deteriorating, possibly as a result of raised intracranial pressure from the SOL. A CT scan will also be indicated. A surgical opinion is indicated. Treatment includes twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Unlike an extradural there is no ‘lucid interval’. Also extradurals tend to occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines. In diffuse axonal injury, there will be a history of trauma involving shear or acceleration/deceleration force.
A 28 year old man presents with haematemesis and a 3 month history of abdominal pain. His BP is 82/41, HR 119 and afebrile. His peripheries feel cool to touch. He is catheterised and you note decreased urine output. Urine and creatinine is elevated and the consultant asks you why his kidneys are compromised.
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
E. Shock - In shock there is inadequate organ perfusion and when this includes the kidneys you get renal hypoperfusion (evidenced by this man’s oliguria) which can progress to acute renal failure. The reason here is hypovolaemia due to loss of intravascular volume from this man’s haematemesis. The cool peripheries (hands and feet) indicate poor peripheral perfusion. There is low BP and reflex tachycardia here too. Treatment here will be with volume replacement with IV saline and to treat the underlying cause, ideally in ICU. Do you know some causes of haematemesis?
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 young woman has high blood pressure and that hasn’t improved with a low salt diet. she has been complaining of headaches and tingling in her fingers. her hand twitches when the dr takes her blood pressure again. Dr Trouser takes blood samples and sees the woman has Na+ = 150 mmol/l and K+ = 3.0mmol/l.
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
G. Conn’s adenoma - This lady has true primary hyperaldosteronism caused by a conns adenoma. Hyperaldosteronism should always be considered in the young hypertensive. Hypokalaemia and hypernatraemia are caused by the aldosterone excess. Headaches are due to the hypertension and hypokalaemia there are also a number of musculoskeletal symptoms that patients complain of. The tingling can be peri-oral and the twitching was alluding to trousseau’s sign of hypocalcaemia. Trousseau’s sign : ALWAYS an EMQ in the exam, basically in hypocalcaemia there is carpo-pedal spasm when blood pressure cuff is inflated to above systolic pressure. Chvostek’s sign : tapping the zygoma produces facial spasm. the hypocalcaemia is caused because hyperaldosteronism leads to metabolic alkalosis and the raised blood pH makes calcium less available to tissues thus causing a functional hypocalcaemia. Liddles is not an option because there is nil family history of note. Mx = spironolactone and surgery.
A 16 year old female presents with a non-tender midline neck lump, that moves on protruding the tongue. There are no other associated symptoms.
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
F. Thyroglossal cyst - This midline neck swelling moves up on both swallowing and tongue protrusion making this a thyroglossal cyst. Thyroid nodules do not move on protrusion of the tongue. It is a cyst that forms from a remnant thyroglossal duct and can hence develop anywhere along the length of this embryological duct, which is a midline structure between the foramen caecum at the back of the tongue and the thyroid gland.
A 40-year-old Afro-Caribbean woman presents with bilateral parotid swelling, and painful nodules on the front of the shins. She has a dry cough and slight shortness of breath on exertion.
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
F. Sarcoidosis - Sarcoidosis is a chronic multisystem disease with an unknown aetiology. The painful (mauve) nodules are erythema nodosum. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. Parotid enlargement is a classic feature (involvement of exocrine glands). The dry cough and SOB on exertion indicate pulmonary involvement. 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 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.
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.
An 80 year old man presents with a nocturnal cough & white sputum for 2 weeks. There are bilateral basal crepitations on chest examination. The CXR shows an enlarged heart and a small right pleural effusion.
A. Cough syrup B. Fluids, bed rest C. Salbutamol inhaler D. Oral penicillin E. Opiate F. Oral clarithromycin G. Nebulised salbutamol H. IM adrenaline I. Diuretic J. IV cefuroxime
I. Diuretic - This patient has developed pulmonary oedema which accounts for the history and examination findings. The CXR indicates the cause is heart failure. He will require diuretics and fluid restriction to deal with his overloaded state. 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 30-year-old stone mason came from India to work on a temple being constructed. He presented to the GP with a history of fever, night sweats and cough of 3 months duration. Chest x-ray showed a cavitating shadow.
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
A. Mycobacterium 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. In the first half of the 20th century, tuberculosis accounted for over 90% of cases of erythema nodosum. 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. Cavitating lesions like the one this patient has can be seen on CXR but is non-specific for TB. 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 78-year-old man presents with low back pain that doesn’t improve with rest. He has non-specific intermittent abdominal pain and night sweats. Investigations reveal a haemoglobin of 9.6 g/dL, a corrected calcium of 2.97 mmol/L, and an ESR > 100 mm/hr.
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
J. Bone marrow aspirate - This patient has multiple myeloma. This is characteristed by clonal proliferation of plasma cells in BM and commonly presents with bony pain and symptoms of anaemia (which this patient’s Hb demonstrates). The elevated ESR is also suggestive and hypercalcaemia is present in 30%. The diagnostic test is serum or urine electrophoresis looking for a paraprotein spike of IgG or IgA and light chain urinary excretion (Bence Jones proteins). Bone marrow examination and skeletal survey will also need to be conducted. Bone marrow aspirate in this case and biopsy will show plasma cell infiltration in the bone marrow, and can help to differentiate multiple myeloma from MGUS and solitary plasmacytoma. Bone changes include osteopaenia, osteolytic lesions and fractures.
Nail bed fluctuation in aortic regurgitation.
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
H. Quincke’s sign - Quincke’s sign is an uncommonly seen sign where there is subungal or lip capillary pulsations caused by the large stroke volume seen in AR. This is a peripheral sign associated with a bounding pulse and the systolic hypertension of chronic severe aortic regurgitation.
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 50 year old woman who is a heavy smoker presents with shortness of breath & weight loss. On examination she is clubbed. The chest x-ray shows a perihilar shadow.
A. Echocardiogram B. Abdominal ultrasound C. Bronchoscopy D. Chest x-ray E. Lung funtion tests F. Sputum culture G. Colonoscopy H. Stool culture
C. Bronchoscopy - The history of smoking and weight loss point to a bronchial carcinoma. Whilst the initial investigation is with a CXR, diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. Non-small cell lung cancer is more often associated with clubbing.
A 75-year-old man who presents with frank, painless haematuria. He tells you that 3 years ago he had a similar episode and was diagnosed as having ‘warts in the bladder’. After treatment, he moved and was lost to follow-up but had been symptom free since then.
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
A. Cystoscopy - “Warts in the bladder” is the way of some sneaky urologist avoiding telling this man he had cancer. He was treated, and like all cancer patients, was followed up. Unfortunately, this sounds like a recurrence. Gross haematuria is the primary symptom of bladder cancer. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.
True or False, the sixth cranial nerve adducts the eye.
False - It ABducts the eye.
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 50 year old man presents with weight loss, tiredness, fever, night sweats and abdominal pain. On examination his spleen was palpably enlarged and there were multiple bruises on his body. Investigations showed low Hb, WBC 150 x 109/L.
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
F. Chronic myeloid leukaemia - This is CML which tends to present in the 30-60 age group. At presentation 1/3 may be asymptomatic though if symptomatic, it presents with symptoms including fever, weight loss and night sweats. There is myeloid stem cell proliferation and presents with raised neutrophils, metamyelocytes and basophils. The patient may also describe LUQ discomfort or fullness due to the feeling of a mass due to splenomegaly. There are also symptoms of anaemia here due to BM infiltration of leukaemic cells. Bruises are common and are either spontaneous or from minor trauma. All patients have raised WCC.
CML is associated with the philadelphia chromosome characterised by t(9;22) of bcr-abl. There tends to be massive splenomegaly which is the most common physical finding on examination. This conditon may transform to AML or ALL in what is known as a ‘blast crisis’. CML responds to imatinib, which is an anti-bcr-abl antibody and gives long term remission in most patients.
A 57-year-old Asian male smoker was treated successfully for pulmonary TB last year. He has had nausea for a month and over the last week has vomited after every solid meal. He has lost 5 kg in weight in that period and has some abdominal discomfort. He feels food getting stuck behind the bottom of his sternum. Examination is unremarkable.
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
L. Gastroscopy - Weight loss is one of the most common presenting symptoms in patients with gastric cancer. Epigastric pain is present in about 80% and may resemble that of a gastric ulcer. Although commonly mentioned in EMQs, lymphadenopathy is an uncommon presentation. More proximal tumours can also present with dysphagia. Strong risk factors include pernicious anaemia, Helicobacter pylori and the consumption of N-nitroso compounds found in cured meats. The peak incidence occurs between 50-70 and men are twice as likely to have gastric cancer. Most are adenocarcinomas. The first test to order for suspected gastric malignancy is an urgent upper GI endoscopy with biopsy of the lesion. The mainstay of treatment is surgical resection unless there is evidence of metastatic disease.
A 45 year old merchant banker is referred by her GP to the Rapid Access Chest Pain clinic. She is asked to perform the treadmill test & complains of chest pain 9 minutes into the test.
A. Variant angina B. Pulmonary embolus C. MI D. Anxiety E. Congestive heart failure F. Unstable angina G. Stable angina H. GORD
G. Stable angina - This patient has presented with stable angina. Resting ECG is often normal and the patient is asymptomatic. However during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia and the patient will complain of chest pain. 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.
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.
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.
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 25 year old man has to pull out of a football match ten minutes in c/o headache and blurring of his vision. He also has palpitations, at the sidelines he has some lucozade and feels better.To be safe he calls into the hospital. Dr Man is on call, he notices small scars on the pts neck and in his history he has had transphenoidal surgery in the past. Dr Man requests blood glucose which is ,2.4mmol/L and c-peptides which are found to be high
A. Addison's disease B. Alcohol C. Meningitis D. Insulinoma E. Insulin F. dumping syndrome G. Gliclazide H. Waterhouse-Friderichsen syndrome I. Starvation
D. Insulinoma
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 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 55-year-old woman has been drinking heavily for 3 months since her husband left her. Her son is concerned that she rarely goes out and often does not get dressed. 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
A. Depression - 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 her husband has left her. 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 woman comes to clinic complaining of vaginal disharge and itching , a swab reveals candida is responsible. She is prescribed Clotrimazole, before leaving the Dr measures her BMs randomly and finds her reading is 12.0 mmol/L,
A. Impaired glucose tolerance B. Normal C. Impaired fasting glucose D. Diabetic E. Non-signifcant
D. Diabetic - WHO criteria for diagnosing Diabetes courtesy of cheese and onion :- symptoms (vaginal thrush is one..impaired immune system) + raised venous glucose detected on one occasion.
OR 2 separate raised BMs (fasting >7mM or random >11.1mM etc..)
OGTT: the patient fasts for 8-14 hours and baseline glucose is measured (usually around 7am) 1.75g per kg body weight glucose solution is given (up to 75g) drunk quickly and BMs are recorded again at 2hrs.
A 37-year-old man presents with 4-week history of progressive numbness and pain in his hands. O/E you notice multiple violaceous patches and evidence of peripheral sensory neuropathy.
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
I. 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. Strong risk factors include needle sharing with IVDU, unprotected receptive intercourse, needle stick injury and high maternal viral load (mother to child). Kaposi’s sarcoma may present as a pink or violaceous patch on the skin or in the mouth and it is an AIDS-defining condition. Peripheral neuropathy is common and may be related either to HIV or some other medicine or toxin (some HAART can cause PN).
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 if he has not already. Classes of antiretrovirals include NRTIs, NNRTIs, protease inhibitors, fusion inhibitors and integrase inhibitors.
A 25-year-old pregnant lady presents with increasing muscle weakness. She also complains of double vision & drooping eye lids.
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
B. Myasthenia gravis - This lady has myasthenia gravis, which is an autoimmune condition with antibodies affecting the NMJ, mostly the nAChR at the post-synaptic muscle membrane. Although some have antibodies against MuSK, and there are other proteins involved. MG is characterised by muscle weakness which increases with exercise (fatigue, unlike Lambert-Eaton myasthenic syndrome). Commonly, presentations include diplopia and drooping eyelids like this patient, and there may also be SOB, proximal limb weakness, facial paresis and oropharyngeal weakness. MG is associated with thymic hyperplasia in 70% or thymoma in 10%, and these associations can also crop up in EMQs. There will be elevated serum AChR receptor antibody titres or MuSK antibodies. Electrophysiology will demonstrate a decremental response on repetitive nerve stimulation. Treatment includes anticholinesterases (pyridostigmine, and immunotherapy. Patients may also require a thymectomy. Some 15-20% may experience a myasthenic crisis (which needs mechanical ventilation). Do you know what the Tensilon test is and why edrophonium is given in this test?
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.
What else can be given to this same patient post-MI which also has a favourable effect on ventricular remodelling?
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
C. ACE inhibitor - ACE inhibitors should be started early (when the patient is haemodynamically stable, optimally on the first day in hospital) for a favourable effect on ventricular remodelling, particularly for patients with a large anterior wall MI. There is good evidence to suggest that ACE inhibitors are more effective at reducing overall mortality and sudden cardiac death after 2-42 months compared to placebo, especially when started within 14 days of an acute MI.
An 8 year old boy with no significant PMH comes into clinic with worried parents who report frequent unusual episodes over the past few months. The parents tell you their child will suddenly stop activity for 10 to 20 seconds around 5 times a day and will be found staring with minimal eyelid flutter. During this time, he is unresponsive to voice.
- Daydreaming
- Frontal epilepsy
- Partial seizure
- Absence seizure
- Absence seizure - This description is of a typical absence seizure which interrupts otherwise normal activity. This can be hyperventilation-induced. EEG is the definitive test and most cases are medically responsive.
A 15 year old boy is tired all the time. He is also suffering from polyuria, nocturia and polydipsia.
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
H. Diabetes mellitus - Polyuria, polydipsia, nocturia in a boy who is tired all the time should make you think of T1DM. Insulin is needed alongside dietary changes and exercise. Insulin regimes aim to mimic physiological insulin release with a basal-bolus dosing. There is an option between using a pump and having multiple daily injections. It is worth noting that there is a high incidence of diabulimia among young people with T1DM who give themselves less insulin than they need in order to lose weight (they lose weight, ‘look good’ but trash their bodies).
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 60 year old male presents with acute breathlessness & a cough productive of frothy, pink sputum. He cannot lie flat. On examination, he has crackles to both midzones & a few scattered wheezes.
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
C. Intravenous furosemide - This patient has pulmonary oedema. CXR may show pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion.
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 newborn child presents with small bowel obstruction due to meconium ileus.
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
L. Cystic fibrosis - CF can present in newborns with a failure to pass meconium (early stools) which can even result in bowel obstruction as in this patient. The bowel may even perforate if the patient is very unlucky resulting in a meconium peritonitis. The most conclusive diagnostic test is the sweat test which is pisitive 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.
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.
A 70 year old female, heavy smoker, for several years who presents with weight loss, reduced appetite and haemoptysis for 1 month. On examination she is thin, afebrile and is clubbed. She has bronchial breathing right upper zone. Reduced breath sounds and dullness on right base. CXR shows right lung collapse with effusion
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
D. Carcinoma of bronchus - The history of smoking and weight loss combined with examination findings point to a bronchial carcinoma. 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 70 year old male life long smoker complains of painless haematuria to his GP.
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
F. Bladder cancer - Gross haematuria is the primary symptom of bladder cancer. Risk factors include smoking, exposure to carcinogens such as the aromatic amines used in rubber and dye industries, age >55, pelvic radiation and Schistosomiasis resulting in SCC (related to chronic inflammation – so other risks also include UTI, stones etc). Bladder cancer is the most common cancer in Egypt, for the latter reason. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.
A 34-year-old woman presents with irregular periods and weight gain. She had been on anti-depressants for six months and she had been complaining of tiredness. Pulse rate is 46/minute and regular. This is confirmed on ECG, which also shows low voltage.
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
M. Hypothyroidism - This patient has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (depression, fatigue, weight gain, bradycardia and menstrual problems) as well as others such as slow-relaxing reflexes on examination, constipation, cold intolerance, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.
An 18-year-old man presents with a night-time cough and shortness of breath while playing football. This has got progressively worse over the previous 2 months.
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
E. Asthma - SOB and the cough, which may wake the patient from sleep combined with the patient’s age and progessive course suggest asthma. Examination can show an expiratory wheeze but may be normal and treatment is step-wise based on BTS guidelines. It is worth noting that in severe exacerbations, the chest may be silent. Night symptoms occur in more severe asthma and symptoms can be exacerbated by exercise. Diagnosis is supported by PEFR variation of at least 20% over 3 days in a week over several weeks or an increase of at least 20% to treatment. Stepwise treatment is outlined below. Look up the BTS guidelines for more information.
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 55-year-old lady has centripetal obesity, plethoric moon-shaped face, proximal muscle wasting. Her daughter says she is very lethargic and seems depressed lately. Blood show macrocytosis and raised gamma-GT. The serum cortisol is elevated and fails to suppress on low-dose-dexamethasone test. MRI of the head and CT of the body are normal
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
B. Pseudo-Cushings syndrome - Pseudo-Cushing’s syndrome is where a patient has all of the signs and symptoms and even abnormal hormone levels seen in Cushing’s syndrome however there is no problem to be found with the hypothalamo-pituitary-adrenal axis. It is hence idiopathic. Whole body CT here is normal so rules out causes from organs such as the lungs (ectopic ACTH), adrenals and MRI has also ruled out a pituitary cause.
Match the cause of hypotension to the following case histories. Each option may be used once, more than once or not at all.
33 year old woman complains of giddiness on standing & can no longer cross a road on her own as she is worried that she may pass out. She developed diabetes when age 12 & has had treatment to her eyes 2 years ago.
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
E. Autonomic neuropathy - Autonomic neuropathy is a complication of diabetic neuropathy. Symptoms of autonomic neuropathy include… resting tachycardia (late findings due to vagal impairment), impaired HR variation, erectile dysfunction (affects many diabetic men though is not solely due to autonomic neuropathy), decreased libido and dyspareunia, orthostatic hypotension (measure BP supine and then standing after 1, 2, 3 and sometimes 5 minutes – an abnormal drop when standing is indicative) and urinary symptoms of frequency, urgency, incontinence, nocturia, weak stream and retention. Other symptoms include constipation, faecal incontinence and sweating dysfunction. Fludrocortisone may be helpful in this woman.
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 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.
52 year old man presents with abdominal distension & ankle swelling. He has been drinking 6 pints of beer & half a bottle of whisky a day for some years. On examination he has palmar erythema & spider naevi on his chest.
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
D. Liver cirrhosis - Cirrhosis is the end-stage of chronic liver disease, in this case due to alcoholic liver disease. Cirrhosis results in hepatic insufficiency and portal hypertension. This has resulted in the patient’s ascites which is a symptom of decompensated cirrhosis. Other complications include variceal bleeds, jaundice, hepatic encephalopathy, hepatorenal syndrome and the development of HCC. Palmar erythema affects the thenar and hypothenar eminences. Apart from spider naevi and palmar erythema, other signs you might find include telangiectasia, bruising, gynaecomastia, Dupuytren’s contracture, parotid swelling and a red tongue. The patient will have to undergo a diagnostic paracentesis for the ascitic presentation. The treatment of ascites involves restricting salt intake and the use of diuretics (frusemide and spironolactone).
A 55 year-old man presents with cramping pains in his left leg that occur after walking 100 metres. The pain is effectively relieved by rest.
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
C. Ankle-brachial pressure index - This is peripheral vascular disease (claudication) and the first investigation to do here is an ABPI. This is an ankle brachial pressure index and has a sensitivity of 95% and a specificity of 100%. It is however important to remember that it may not be accurate in patients who have non-compressible arteries – so beware, particularly in diabetics. Those with either severely stenotic or totally occluded arteries may have a normal ABPI if there is abundant collateral circulation. ABPI of les s than or equal to 0.9 is diagnostic for the presence of peripheral vascular disease. ABPI is performed by taking the systolic pressure of the left and right brachial arteries and the left and right PT and DP arteries pressure. The ABPI is the highest of the DP and PT pressure divided by the higher of the left and right arm brachial artery pressure. Finding the artery with the probe is a skill which may take a bit of practice so have a play around with the probe if you are stuck on a vascular attachment. ABPI is a marker of peripheral atherosclerosis as well as a predictor of vascular events. Risk factors for PVD include smoking, diabetes, old age, hyperlipidaemia and history of coronary or cerebrovascular disease. Treatment is outlined in the explanation for question 2 of the previous EMQ set.
A 50 year old alcoholic man fails to respond to treatment for pancreatitis and has recurrent epigastric pain. There is a palpable epigastric mass. CT scan of the abdomen shows a round well-circumscribed mass in the epigastrium.
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
K. Pancreatic pseudocyst - This patient has developed a pancreatic psuedocyst as a complication of pancreatitis. Pseudocysts are collections of fluids with a high concentration of enzymes. The walls are fibrotic membranes of the peritoneum, mesentery and serosa which stops the fluid from leaking out. The wall is not epithelium and indeed there is no epithelial lining – it is not a real cyst. In patients who fail to respond to treatment, this should be considered as a possible diagnosis. The most common finding is pain, followed by a palpable mass. CT scan is diagnostic. Treatment options include excision, drainage (surgical or percutaneous, or internal e.g. cystojejunostomy Roux-en-Y etc, which I’m sure is going into too much surgery than is necessary now but surgical wannabes can look up the procedures… if they really want to – also cystogastrostomy and cystoduodenostomy).
The pseudocyst can be complicated with infection, rupture and haemorrhage. Pancreatic abscess would give a fever and CT will show a ring-enhancing fluid collection with gas. Treatment would be drainage and antibiotics. Pancreatic ascites is pancreatic fluid accumulating in the peritoneal cavity due to chronic pseudocyst leakage (in most cases, anyway) – there will be weight loss and the ascites will not respond to diuretics. A pancreatic effusion is secondary to a fistula draining into the chest, from the pancreas. These are actually all more common complications to arise from pancreatitis than a pseudocyst.
A 58 year old woman has a slowly-growing painless mass in her neck. On examination there is a firm, pulsatile mass anterior to the upper third of sternomastoid. There is no bruit.
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
I. Carotid body tumour - A carotid body tumour is also called a chemodectoma. It is a paraganglioma – a tumour derived from neural crest cells. PGs can occur anywhere neural crest cells migrate so in the head and neck, other PGs include, for example, tympanic paragangliomas arising from the tympanic plexus. They are more common at high altitudes and in females and most are spontaneous occuring in the 3rd and 4th decade. Most present with a painless lateral neck mass which grows slowly. It will move from side to side but not really up and down (think of the anatomy here, this is known as Fontaine’s sign). Larger tumours may cause cranial nerve palsies. There may be an associated carotid bruit or pulsatility. There may also be dysphagia or pain on swallowing owing to compression. Biopsy of this mass is contraindicated for very obvious reasons. The first investigation would be with a colour doppler ultrasound and gold standard for diagnosis is with digital subtraction angiography. MRI can also be utilised. Treatment is surgical.
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 121 mmol/L and potassium 5.1 mmol/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
F. Hyperaldosteronism - 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 also a risk factor for the development of Addison’s.
50 year old man went for Hajj. He was vaccinated against hepatitis & Group C meningococci. He came back with a high fever & was admitted with neck stiffness & drowsiness. He had a lumbar puncture & blood cultures. Gram stain of cerebrospinal fluid showed Gram negative diplococci.
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
I. 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.
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.
A 40-year old gentleman with a history of diabetes mellitus and CHD presents to your clinic complaining of pain in his buttocks after walking only 100 meters. He has recently married, and with much embarassment, reveals that he has had difficulty completing intercourse as he is unable to maintain an erection. O/E you notice his femoral pulses are absent.
A. Critical limb ischaemia B. Viable limb C. Dead limb D. Spinal stenosis E. Ankylosing spondylitis F. Deep vein thrombosis G. Acute limb ischaemia H. Intermittent claudication I. Compartment syndrome J. Leriche syndrome K. Baker’s cyst L. Muscle tear M. Rhabdomyolysis
J. Leriche syndrome - Leriche’s syndrome, named after some French surgeon, is aortoiliac atherosclerotic occlusive disease and is one of those eponymous syndromes which can be found in your Oxford Handbook. This involves the abdominal aorta and/or both of the iliac arteries. It presents with the classic triad of buttock claudication, impotence and reduced or absent femoral pulses. This combination is referred to as Leriche’s syndrome.
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.
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.
choose the SINGLE most appropriate monitoring investigation from the list
Warfarin
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
H. INR -Warfarin needs to be monitored with INR, at first daily or on alternate days then at longer intervals (depending on patient response). INR is the international normalised ratio, which is the prothrombin time as a value which is standardised to take into account different lab techniques etc. The higher the INR, the more anticoagulated a patient is. As a rough guide, the aim is 2.5 for DVT/PE, AF, DCM and MI and 3.5 for recurrent DVT/PE.
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 55-year-old obese smoker presents with pain in his legs on walking 800 metres, which is immediately relieved by rest. His ankle-brachial pressure index is 0.9.
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
L. Conservative management - This is peripheral vascular disease with classic symptoms of claudication (in reality, these classic symptoms only occur in a small minority of patients). ABPI should be performed in symptomatic patients and a result less than or equal to 0.9 is diagnostic for the presence of peripheral vascular disease. You need to however bear in mind that this test may not be accurate if the patient has non-compressible arteries (mainly in diabetic patients). This patient has only presented with claudication which is not severely lifestyle limiting. It depends on how much needing to rest every 800 metres or so bothers him. If he does not feel that this is really a functional disability then no additional treatment is required, but follow-up appointments with a doctor should be made to monitor the development of ischaemic symptoms or coronary and cerebrovascular complaints.
If the symptoms are lifestyle limiting then the patient should undergo a supervised exercise programme (only some rather limited quality cohort studies at the moment show an improvement in walking time and symptoms) and medication for symptomatic relief for a period of 3 months. Medication can include cilostazol, pentoxifylline (widely used but no more effective than placebo in RCTs) or naftidrofuryl. Risk factors should also continually be targetted – BP control, statins to lower LDL, beta blockers to target cardiovascular risk and antiplatelet therapy, for instance. If no improvement is made with this regime then patients should be referred to a vascular specialist to have their anatomy defined and assessed for possible revascularisation.
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 17-year-old man returning from holiday in Africa. He presents with abdominal pain, weight loss, pruritis and a wheeze. Blood film showed eosinophilia.
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
F. Infestation with helminths - The only option on the list that would give eosinophilia is infection with helminths. There is a risk factor here, having returned from Africa where the sanitation, hygiene and agricultural practices may leave much to be desired. Testing for stool ova and parasites will be needed to see exactly which helminth is causing this infection, although this is not very sensitive for strongyloides larvae. IgG serology can be used with >95% sensitivity if stool samples are negative in the case of strongyloides. This could be strongyloides or ascariasis or a rarer organism. Treatment will be with antihelminths depending on the organism. Ivermectin for strongyloides is the drug of choice. Other antihelmintic agents include albendazole, mebendazole and pyrantel pamoate.
A 67-year-old male smoker has developed gross oedema of the neck and face. You also notice swelling of both hands.
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
F. SUperior vena cava syndrome - SVC syndrome occurs due to SVCO. The most common cause of this is malignancy (this smoker probably has lung cancer which is the most likely cause in those >50). There are also benign causes such as iatrogenically due to pacemaker leads and central venous catheters causing SVC thrombosis. Common symptoms are facial swelling and arm swelling as seen, as well as dyspnoea, cough and facial plethora. There may also be a headache, chest pain, blurry vision and stridor. These symptoms tend to be worse on bending forwards or lying down. The most useful imaging test is a chest CT with IV contrast which establishes the diagnosis and also shows the exact location of the pathology. A CXR in SVCO can show a widened mediastinum or the lung cancer which is the cause.
A 50 year old describes a 5 month history of heartburn and cramp-like chest pain relived by drinking cold water, both unrelated to food. There has also been intermittent dysphagia to both liquids and solids, regurgitation and weight loss of 2kg.
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
K. Achalasia - This is achalasia which is a motility disorder with loss of peristalsis in the distal oesophagus and failure of the LOS to relax in response to swallowing. This presents commonly with dysphagia to both liquids and solids, regurgitation and retrosternal chest pain, which can be slowly progressive over time. In structural obstruction such as cancer, dysphagia to liquids is uncommon unless the disease is very advanced. Retrosternal pressure experienced can be precipitated by drinking liquids but is eased by continuing to drink, and the pain may be relieved by cold water. This may wake the individual from sleep. A UGI endoscopy is needed to exclude malignancy as a cause of dysphagia. The diagnosis is established on manometry or barium studies. Treatment is symptomatic.
Trachea central. Reduced chest movement on right. Dull to percussion on right. Bronchial breathing at right 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
J. Lobar pneumonia - These are the classic signs of pneumonia. Also expect to find increased vocal resonance and tactile vocal fremitus over areas of consolidation. In reality, it can be confusing if the pneumonia causes a lobar collapse as you can also find signs of collapse on examination. Always consider the history as well as examination and investigation findings. On a CXR with pneumonia, you can expect to see air space shadowing with air bronchograms. Always remember to auscultate at the right axilla when doing a respiratory examination or a RML pneumonia may be missed.
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.
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 tanned looking man comes into clinic complaining of feeling under the weather, his bloodwork shows he is Na+ - 120 mmol/l and K+ = 6.0 mmol/l. His urinary sodium is noted to be higher than expected.
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
B. Addison’s disease - Tanned with hyponatraemia…it must be addisons. The hyperkalaemia shows there is mineralocorticoid deficiency..replacement therapy is key as addisonian crisis may ensue.
An 80-year-old woman who is a smoker was brought into A&E from a residential home where her carers noticed that she had difficulty swallowing and that she also had difficulty moving her left arm and leg for the past few days.
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
A. Right sided stroke - Weakness on one side and the difficulty swallowing makes this likely to be a stroke. If you have a think about the motor pathways you will realise that this is a right sided stroke. It is important is perform a CT head to 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 6 year old girl presents with stiffness and a limp which has lasted for a few weeks now. The onset is reported as insidious and her parents tell you she has not had any injury or infections. One of her knees is swollen and cannot be straightened. The symptoms are worse in the mornings but improve throughout the day. There is also involvement of the small joints of the hands and feet.
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
C. Juvenile idiopathic arthritis - This is juvenile idiopathic arthritis, also known as juvenile rheumatoid arthritis, or Still’s disease. It is the most common chronic arthropathy of children and there are several clinical subtypes. The diagnosis is clinical. Intra-articular steroids offer good control if only a few joints are affected. Methotrexate is also a commonly used disease-modifying agent. More resistant cases are treated with agents which block inflammatory cytokines. Around 10-20% of children with JIA are at risk of developing anterior uveitis and therefore all children with this diagnosis must undergo regular ophthalmological review for inflammation. Remember that symptoms vary according to subtype of disease, which laboratory tests may be useful in classifying. Note also that while this can be called juvenile RA, rheumatoid factor is only positive in a small minority of patients (2-7%).
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 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 16 year old boy dressed in sports kit, presents to A&E confused, sweating and with a tremor. His speech starts to slur and he begins to lose conciousness.
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
F. Hypoglycaemia - This patient has symptoms of hypoglycaemia, present when glucose drops
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 21 year old male has a 3 day history of hoarseness. He has pain in his throat which is worse on talking and eating. O/E his throat appears normal.
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
H. Laryngitis - Laryngitis, as the name would suggest, is inflammation of the larynx, which can lead to oedema of the true vocal folds. It has both infectious and noninfectious causes such as vocal strain. Symptoms of acute disease are most commonly hoarseness, generally over a period of less than a week, usually preceded by viral URTI and usually self limiting. The pain on swallowing and sore throat is common of URTIs. An exudate or cervical lymphadenitis would suggest bacterial infection instead. Treatment begins, as always, with ABC and airway assessment. Chronic laryngitis presents with hoarseness lasting more than 3 weeks and this needs investigating due to the fact that symptoms may be similar to cancer of larynx. Antibiotics are given in bacterial cases or otherwise voice rest and hydration is sufficient.
A 25 year old lady with a discrete, non-tender, mobile lump in one breast
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
B. Fibroadenoma - This is a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient
54 year old Asian woman with type 2 diabetes for 15 years. She comes to the clinic complaining of ankle swelling. On examination, BP 170/95, JVP not raised & bilateral oedema to the knees. Albumin is low.
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
E. 24hr urine protein - The most common cause of nephrotic syndrome in adults with long standing diabetes is diabetic nephropathy. However, non-diabetic renal disease cannot be excluded. Nephrotic syndrome is defined by the presence of proteinuria (>3.5g/24h), oedema and hypoalbuminaemia. Some definitions add hyperlipidaemia. Do not confuse this with nephritic syndrome. Diagnosis is made by quantification of proteinuria with a 24 hour urine collection, although now it is common to do a spot urine protein-to-creatinine ratio for practical reasons.
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.
A 30 man is seen in cardiology clinic for a regular checkup. In the notes it was commented on that he had a large tongue and that he was taking octreotide. O/E he was hypertensive and his blood sugars were 13.4 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
E. Pituitary adenoma - this patient is young and in a cardiology clinic..none of the options point to congenital heart disease however. The patient has macroglossia and is being treated with octreotide (a somatostatin analogue). This drug is useful in suppressing over active pituitaries, in this case once producing excess growth hormone. The most common cause would be an adenoma and his symptoms would include cardiomegaly and hypertension along with hyperglycaemia.
Disease management guidelines
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
C. NICE - In the UK, NICE currently analyses the medical and cost-effectiveness of various treatment options and publishes guidelines based upon this
A 30 year old man presents with painless fresh rectal bleeding which appears on the stool, on the paper and in the toilet bowl.
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
D. 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.
A 45 year old woman who is HIV positive reports easy bruising, frequent nose bleeds and coughing up small streaks of blood. She is otherwise well at present. Chest X-ray shows no abnormality. A full blood count shows Hb of 10.5g/dl, WBC 5.0 x 109/l and platelet count 28 x 109/l.
A. Sickle cell crisis B. Arterio-venous malformation C. Tuberculosis D. Inhaled foreign body E. Acute left ventricular failure F. Bronchiectasis G. Pulmonary aspergillosis H. Asthma I. Pulmonary embolus J. Carcinoma of bronchus K. Thrombocytopenia
K. Thrombocytopenia - HIV is implicated in idiopathic thrombocytopenic purpura, which is a condition of abnormally low platelet count of unknown cause. This question makes this dead easy by giving you the platelet count as 28 x109/L and all you need to do is to appreciate that a count under 150 x109/L is defined as thrombocytopenia. As well as the count, the patient has obvious symptoms of thrombocytopenia here with bruising, haemoptysis and epistaxis.
A 30 year old female presents with a 3 month history of bloody diarrhoea and vague lower abdominal cramps. She gave up smoking a few months ago. The doctor feels that this could have contributed to her condition.
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
J. Ulcerative colitis - 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. These include erythema nodosum, pyoderma gangrenosum, sacroiliitis, ankylosing spondylitis, PSC, aphthous ulcers, episcleritis, peripheral arthropathy and anterior uveitis. Another clue in this question which makes you pick UC instead of Crohn’s is the fact the patient has given up smoking. While I remain convinced this link as a risk factor is a weak one, you should try to think like an EMQ when answering EMQs (generally the information is there for a reason). There is a weak risk of UC development in non-smokers and those who were a former smoker (though it is an established link). This is based on a review paper published by some German medics in an exciting journal named ‘Inflammatory Bowel Diseases’. Should be you interested you can check it out: Inflammatory Bowel Diseases. 10(6):848-859, November 2004 (just read the abstract if you want)
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.
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 69-year-old male undergoes a CT abdominal for investigation of renal calculi. You notice a 3.8cm 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
H. Ultrasound in 1 or more years - 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 20-year-old woman is assaulted in a nightclub. She suffered a short episode of loss of consciousness, double vision and has vomited once. She now has a headache.
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
B. Concussion - Concussion is a closed head injury due a blow to the head. This woman has been assaulted, which is a common cause. Typical symptoms include headache (which tends to be cause the most problems in management), mental slowness, memory difficulties, N&V and LOC, though LOC is not necessary for the diagnosis. Symptoms typically go after a week to a month but can fluctuate. CT and MRI are typically normal. For uncomplicated cases, resting is sufficient and no intervention is needed.
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 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 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 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.
A 40 year old widowed female presents with a 3 week history of shortness of breath. She also complains of chronic fatigue. On examination she is pale with a pulse of 120.
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
E. Anaemia - Anaemia is defined by haemoglobin concentration (
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 20 year old previously healthy woman presents with general malaise, severe cough & breathlessness which has not improved with a 7 day course of amoxicillin. There is nothing significant to find on examination. The x-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins.
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
F. Mycoplasma pneumoniae - The cold agglutinins is what gives this question away. Mycoplasma is associated with with cold type agglutinins and a cold AIHA. Humans are thought to be the only host for Mycoplasma. The most commonly affected are young adults living in close proximity to each other. PCR can be used in diagnosis.
An 85 year old who is known to be hypertensive & has mild impaired renal function presents with signs of dehydration & undergoes a laparotomy for small bowel obstruction.
A. Diclofenac B. Codydramol C. Paracetamol D. Morphine E. Tramadol G. Epidural bupivacaine fentanyl
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 55-year-old Asian man complaining of nocturia. Random blood glucose 10.2 mmol/L. He was overweight.
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
G. Dietary advice alone - This patient is symptomatic and has a random blood glucose of 10.2. This patient does not quite meet the diagnostic criteria for DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation, and in newly diagnosed DM is diet and lifestyle advice and changes.
A 34-year-old man has attacks of sudden severe pain waking him up for the last fortnight. The pain is on the right side of his face and makes his right eye water.
A. Extradural haemorrhage B. Cluster headache C. Trigeminal neuralgia D. Subarachnoid haemorrhage E. Migraine F. Tension headache
B. Cluster headache - Cluster headache is characterised by attacks of severe pain localised to the unilateral orbital, supraorbital and/or temporal areas which lasts from 15 minutes to 3 hours, and occurs with a frequency ranging from once every other day to 8 times a day. These attacks can occur at the same time period of many weeks (known as the cluster period) accompanied by ipsilateral autonomic signs. The cause is hypothalamic activation with secondary trigeminal and autonomic activation (for instance, lacrimation, rhinorrhoea, nasal congestion, conjunctival injection and partial Horner’s i.e. ptosis and miosis). Cluster period attacks can be triggered by things like alcohol. Greater occipital nerve blockade often provides immediate relief until preventative medications take effect.
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 45 year old man would like to have support to give up drinking.
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
F. Alcoholics anonymous - Alcoholics Anonymous is a help group where people share their experiences and help each other recover from alcoholism. http://www.alcoholics-anonymous.org.uk
A 30 year old male is brought into A&E having been found unrousable by his partner on the floor. He is breathing very occasionally and has small pupils. He has track marks in his antecubital fossa.
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
N. IV 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 39-year-old Afro-Caribbean male with SOB and painful red skin lesions on the anterior surface of both lower legs. There is 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
C. Sarcoidosis - Sarcoidosis is a chronic multisystem disease with an unknown aetiology but pulmonary involvement usually dominates. Hypercalcaemia occurs in these granulomatous conditions (also including TB and leprosy) as a result of tissue being able to 1-alpha-hydroxylate 25(OH) D leading to vitamin D (the 1,25-dihydroxyvitamin D3) excess. Erythema nodosum, tender erythematous nodules and lupus pernio, indurated plaques with discoloration on the face, are typical skin manifestations of sarcoidosis. 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 62-year-old diabetic lady presents with recurrent ulceration of the gaiter area of the left leg. The ulcer is well circumscribed, irregular in shape and of partial thickness. There is a brown discolouration and ‘eczema’ over both calves.
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
A. Venous ulcer - Venous ulcers occur on a background of deep venous insufficiency. There is oedema and a brown skin discolouration due to leaching of pigments and haemosiderin deposition. In addition there may be lipodermatosclerosis and an inflammatory response, which is seen as an eczema-like thickening and hardening of the skin. The skin can also be drawn tightly around the ankle. Ulceration usually follows trauma and is usually on the medial gaiter region. The base has granulation tissue and is sloughy in nature and there is a sloping edge to the ulcer. The shape is often irregular. Look up some photos to help you remember. Once significant arterial disease is excluded (ulcers can have mixed components), the mainstay of treatment is with compression bandaging, appropriate dressings and treatment of any infection with antibiotics. Maggots can also be used and varicose veins should be treated where possible to reduce recurrence. If the ulcer is not healing, a biopsy should be considered (Marjolin’s ulcer).
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.
A previously well, 29-year-old man with a 2-week history of flu-like illness complains of increasing weakness and numbness in his lower limbs. O/E he has grade 4/5 distal weakness, diminished reflexes, plantars down-going. Upper limbs and cranial nerves unaffected.
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
J. Guillian-Barre syndrome - This previous history of influenza-like illness weeks before the onset of neurological symptoms indicates Guillain-Barre syndrome which 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. 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).
GBS is classified by symptoms and variants exist such as Miller-Fisher syndrome, which occasionally crop up in EMQ books but will probably never crop up in clinical practice.
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.
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).
An ambulance crew is dispatched to attend a 999 call made by passers-by. A 71-year-old diabetic lady at a bus stop collapsed, could not get up and was complaining of back pain. After basic investigations, she was taken to hospital. Subsequent CT showed no abnormalities.
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
G. Myocardial infarction - Given the list of options here, this is likely to be an atypical MI which is more common in diabetics and the elderly, likely to be due to autonomic neuropathy. They are known as ‘silent’ MI and should be excluded in all causes of collapse. An ECG is indicated here after the clear CT scan (although may have already been done on admission by alert staff). STEMI, new LBBB or confirmed posterior MI is an indication for PCI/thrombolysis. It is worth noting that RV infarction is present in 40% of inferior infarcts so in this case, right sided ECG leads should also be obtained.
A 27 year old woman presents with a 2 week history of bloody diarrhoea & abdominal pain. She has also passed mucus per rectum at times
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
H. Ulcerative colitis - 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 75-year-old woman was admitted to Care of the Elderly ward having had a couple of falls at home. No other medical problems are found. She lives on her own in a ground floor flat and has home help once a week.
A. Dietician B. Hospital doctor C. General practitioner D. Social worker E. Macmillan nurse F. Speech and language therapist G. Ward nurse H. Occupational therapist I. Physiotherapist J. District nurse
H. Occupational therapist - Occupational therapists will visit the patient’s home and help determine tools and facilities the patient can benefit from for their day to day life e.g. stair-lifts, bath rails
INR of 10.2 in a warfarinised patient who is not at present 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
D. Vitamin K - This patient has clearly been ‘over-warfarinised’. The guidelines are as follows: If there is no bleeding and INR is 6 you need to give PO vitamin K as well. If there is severe bleeding and the INR is high, then you need to stop warfarin and give parenteral vitamin K and PCC (octreotide/octaplex). PCC (prothrombin complex concentrate) is better than FFP in these situations. Remember that warfarin prevents the activation of vitamin K which is a cofactor in the synthesis of factors 2, 7, 9 and 10.
A 17 year old man has noticed a painless smooth swelling just above the suprasternal notch. He has had the swelling for 2 years & is well. It moves with swallowing & tongue protusion.
A. Superior vena cava syndrome B. Thyroglossal cyst C. Hashimoto's thyroiditis D. Myxoedema E. De Quervain's thyroiditis F. Stomach carcinoma G. Carotid artery aneurysm H. TB abcess I. Grave's disease J. Thyroid cancer K. Hodgkin's disease L. Euthyroid goitre
B. Thyroglossal cyst - This midline neck swelling moves up on both swallowing and tongue protrusion making this a thyroglossal cyst. It is a cyst that forms from a remnant thyroglossal duct and can hence develop anywhere along the length of this embryological duct, which is a midline structure between the foramen caecum at the back of the tongue and the thyroid gland.
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.
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
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.
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 41-year-old lady with long-standing RA presents to his GP with recurrent chest infections. She also lost 4kg in past 3 months. O/E there is splenomegaly. FBC confirms pancytopenia.
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
H. Felty’s syndrome - Felty’s syndrome is a rare extra-articular manifestation of rhematoid arthritis characterised by persistent and idiopathic neutropenia and in some cases splenomegaly. It occurs in
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 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 15-year-old girl develops high fever with rigors. O/E she has blanching erythematous rash, ‘strawberry’ tongue, and cervical lymphadenopathy.
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
J. Streptococcus pyogenes - The ‘strawberry’ tongue, or a red swollen tongue, is a sign of Scarlet fever (along with Kawasaki disease and toxic shock syndrome which is caused by bacteria such as staphylococcus aureus). Scarlet fever is caused by an exotoxin released by Streptococcus pyogenes. The history is characteristically a child
A 45 year old woman is hypertensive & complains that she is putting on weight. On examination, she is centrally obese & has a moon face. There are purple striae on her abdomen. She has glycosuria.
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
L. Cushing’s syndrome - There is weight gain (truncal obesity), hypertension, moon face and striae in Cushing’s due to hypercorticolism. Cushing’s disease is due to an ACTH secreting pituitary adenoma and is responsible for most cases of Cushing’s syndrome. A low dose 1mg overnight dexamethasone suppresion test can be done, or a 24 hour urinary free cortisol collection to diagnose Cushing’s syndrome. Plasma ACTH should guide further investigation. If ACTH is suppressed, the problem is likely to be with the adrenals. If it not suppressed, pituitary or ectopic disease is more likely.
A 60-year-old with lung cancer finds it difficult to stand upright and walk. He has ataxia.
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
C. Cerebellar tremor - A cerebellar tremor can be seen in MS, trauma or stroke. The history may feature complaints of incoordination and imbalance, a possible FH of cerebellar ataxia or PMH of MS, head trauma, stroke or cerebellar haemorrhage. The tremor itself is a coarse and irregular kinetic tremor which is generated proximally. There may also be abnormal finger-to-nose testing and heel-to-shin testing, dysdiadochokinesia, wide-based ataxic gait (like the patient is drunk) as well as dysarthria (speech problems). The first test to order is an MRI of the patient’s head which may show signs of cerebellar atrophy or may suggest changes of demyelination seen in MS or changes of stroke, trauma or haemorrhage. You may also want to perform other tests such as thyroid function tests to exclude hyperthyroidism.
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 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. 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
D. 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.
A 40 year old woman has constipation, weight gain & menorrhagia. She opens her bowels only twice a week. Pulse is 50/min & she has dry skin.
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
E. Hypothyroidism - This patient has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (depression, fatigue, weight gain, bradycardia and sluggish reflexes) as well as others such as constipation, cold intolerance, menstrual problems in females, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.
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 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 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.
Mrs M presents with a severe headache and fever for the past 3 days. Examination reveals fever, photophobia and neck stiffness. Fundoscopy is performed which reveals bilateral papilloedema. 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
L. CT head - This patient obviously has meningitis. A CT head scan needs to be done here before a diagnostic LP as there is reason to suspect raised ICP with bilateral papilloedema on fundoscopy. This can exclude a brain abscess or generalised cerebral oedema. Meningitis associated complications may also be identified such as hydrocephalus and brain infarction.
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 35 year old woman has a 10 year history of low retrosternal dysphagia & painless regurgitation of food in the mouth
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
E. Hiatus hernia - A hiatus hernia is where intraabdominal contents protrude through the oesophageal hiatus of the diaphragm. Risk factors inclyde obesity and high intra-abdominal pressure. The condition may be asymptomatic, or it may present with symptoms (which are non-specific) such as heartburn, dysphagia, pain on swallowing, wheezing, hoarseness and chest pain. A CXR is the first test done and may show an air bubble in the wrong place but barium studies are diagnostic and treatment depends on the symptoms and anatomy of the hernia. Hernias can be sliding or rolling (or mixed, or giant), uncomplicated or complicated by, for instance, obstruction and bleeding. Do you know the difference between a sliding and a rolling hiatal hernia?
A 30 year old woman presents with aspiration pnuemonia. She has a long history of intermittent mild dysphagia for both liquids & solids and often suffers from severe retrosternal chest pain. Occasionally she gets food stuck but overcomes this by drinking vast amounts of water.
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
J. Achalasia - This is achalasia which is a motility disorder with loss of peristalsis in the distal oesophagus and failure of the LOS to relax in response to swallowing. This presents commonly with dysphagia to both liquids and solids, regurgitation and retrosternal chest pain, which can be slowly progressive over time. In structural obstruction such as cancer, dysphagia to liquids is uncommon unless the disease is very advanced. Retrosternal pressure experienced can be precipitated by drinking liquids but is eased by continuing to drink, and the pain may be relieved by cold water. This may wake the individual from sleep. A UGI endoscopy is needed to exclude malignancy as a cause of dysphagia. The diagnosis is established on manometry or barium studies. Treatment is symptomatic.
50 yr old male smoker has a productive cough with clear sputum most days, especially winter. He has not lost wt. On examination he has hyperexpanded chest and a few scattered wheezes and crackles.
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
C. Chronic bronchitis - This patient has COPD, which is a progressive disease characterised by not fully reversible airflow limitation. COPD encompasses both emphysema and chronic bronchitis. Cigarette smoking is the most important risk factor. The hyperexpanded chest implies trapping of air due to incomplete expiration. Wheezes and coarse crackles are commonly seen in exacerbations. The cough is often the first symptom a patient complains of and is usually a morning event which is normally productive. The sputum can change quality with exacerbations/infection. Treatment aims at stopping smoking and vaccinating the patient against influence and pneumococcus with options such as bronchodilators or ICS. LTOT improves survival in those with severe COPD with a low PaO2. Lung function tests are key in diagnosis with an obstructive FEV1/FVC ratio
34 year old male complaining of headaches, anxiety attacks, recurrent sweating and postural dizziness.
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
J. Phaeochromocytoma - Phaeochromocytomas presents with paroxysmal episodes of palpitations, anxiety, excessive sweating, pallor and hypertension. The postural dizziness is thought to be due to a reduction in volume secondary to alpha stimulation. Episodic panic attacks are seen commonly in adrenaline producing phaeochromocytomas. Headaches occur in up to 90% of those symptomatic. It can be inherited in MEN2, von Hippel-Lindau syndrome and NF1. Diagnosis is based on raised urinary and serum catecholamines, metanephrines and normetanephrines. 24 hour urinary VMA will be elevated. CT is used to localise the tumour. Treatment includes medical with the use of phenoxybenzamine, phentolamine and surgical options. Surgical excision is carried out under alpha and beta blockade to protect against the release of catecholamines into circulation when the tumour is being manipulated. The 10% rule is often quoted: 10% are bilateral, 10% malignant, 10% extraadrenal and 10% hereditary.
A 65-year-old man with a history of peptic ulceration requires an aortic aneurysm repair electively.Which drug should NOT be given
A. Diclofenac B. Epidural bupivacaine and fentanyl C. Codydramol D. Paracetamol E. Morphine F. Tramadol
A. Dicolfenac - NSAIDs inhibit COX which has the effect of reducing PGE2 levels. PGE2 plays a role in gastric cytoprotection by downregulating HCl production and increasing mucus and the production of bicarbonate. This leads to gastric irritation and ulceration. A PPI can be prescribed alongside NSAIDs or misoprostol can be used, which is a stable PGE1 analogue which mimics local PG to maintain the gastroduodenal mucosal barrier.
A 60 year old man who is waiting to have a knee replacement, describes daily episodes of central chest pain when he gets up in the morning. The pain lasts 15 minutes & settles with rest.
A. Thallium perfusion scan B. Chest x-ray C. Ventilation/perfusion scan D. Coronary angiogram E. Abdominal ultrasound F. CT chest G. Sputum culture H. Upper GI endoscopy I. ECG J. Liver function tests K. Lower limb venogram L. Exercise ECG M. Arterial blood gases N. Creatine kinase
D. Coronary angiogram - 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 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 and clubbing.
A. Colonoscopy B. Echocardiogram C. Sputum culture D. Lung function tests E. Abdominal ultrasound scan F. Bronchoscopy G. Chest x-ray H. Stool culture
B. Echocardiography - 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.
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 30-year-old man presents jaundiced. He tells you he has recently completed a triathlon. He has been suffering from flu-like symptoms for the last week, he complains of severe headache, myalgia, anorexia. O/E he has tender hepatosplenomegaly and a rash over the lower limbs.
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
K. Leptospira interrogans - Leptospirosis is a zoonosis, which is transmitted by contact with urine of infected animals (also possible sources include blood and fluids). The history may reveal someone swimming in rat infested canal water, for instance, or in this case, a triathlon – which involves some swimming in perhaps not too clean water. Outbreaks of this are associated with flooding and natural disasters, as can be expected. Affected patients can present with an extensive spectrum of clinical manifestations ranging from subclinical illness in 90% to renal and hepatic failure and pulmonary haemorrhage. The important factor in diagnosis is a high index of suspicion based on epidemiological exposure. There is an acute phase with fever, headaches, myalgia and then an immune phase with additional pulmonary symptoms and potential organ damage (leading to the symptoms seen here such as jaundice). The rash is maculopapular and non-pruritic, lasting 1 or 2 days, present during the acute phase. It is rarely seen. Treatment is with benzylpenicillin or amoxicillion and/or doxycycline and supportive care. Those with severe disease carry a poor prognosis.
A 25 year old woman has just returned from a holiday in Kenya. She suddenly became breathless & is cyanosed. Her pulse is 120/min, BP 110/70, peak expiratory flow 400l/min. Chest x-ray is normal.
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
K. Heparin - Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. As UFH is used in this case, a weight based dosing normogram will need to be used to establish a therapeutic APTT within the first 24 hours. Alternatives include LMWH and fondaparinux.
Reduction of the HbA1c from 8% to 7% in diabetic reduces the risk of microvascular complications by approximately..?
- 20%
- 40%
- 5%
- 60%
- 40% - So although HbA1c can not be used diagnostically in diabetes it represents the amount of endogenous glycation occuring in vivo . Glycation produces Advanced glycation end products which are responsible for damaging vasa nervorum etc causing microvascular complications of diabetes. Lens protein Glycation is also responsible for the increased occurrence of catract in Diabetics.
A 35 year old man with a long history of excess drinking of alcohol presents with massive haematemesis. He is also jaundiced, hypotensive & a tachycardia.
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
E. Oesophageal varices - Oesophageal varices occurs as a result of portal hypertension which is a complication of cirrhosis, caused in this patient by his long history of alcohol excess. Other signs may be present such as spider naevi, ascites, caput medusa (vascular collaterals in the abdominal wall), jaundice etc. Splenomegaly is also commonly found and hence patents often have thrombocytopenia and anaemia as a result. The bleeding carries a significant morbidity and mortality, and beta-blockers and/or endoscopic ligation can prevent variceal bleeding prophylactically (though beta blockers are not be used in the acute setting of a variceal bleed – do not get confused here!). Oesophageal varices are basically dilated veins and these can be seen on OGD. Worldwide, HBV and HCV are also major causes of cirrhosis, leading to varices and HIV co-infection can rapidly speed up the progression to cirrhosis in chronic liver failure. The size of the varices is the key predictor of haemorrhage. Acute bleed can be managed with resuscitation, terlipression (DDAVP)/somatostatin analogues/endoscopic ligation. Additionally, a shunt can be deployed and antbiotic prophylaxis started.
A 50-year-old diabetic lady, who has smoked 40 cigarettes a day for the last 30 years, presents with a year’s history of worsening bilateral calf pain when she walks. The pain goes away when she stops walking but recurs when she resumes. She has been started recently on hormone replacement therapy.
A. Critical limb ischaemia B. Viable limb C. Dead limb D. Spinal stenosis E. Ankylosing spondylitis F. Deep vein thrombosis G. Acute limb ischaemia H. Intermittent claudication I. Compartment syndrome J. Leriche syndrome K. Baker’s cyst L. Muscle tear M. Rhabdomyolysis
H. Intermittent claudication - This is peripheral vascular disease with classic symptoms of claudication (in reality, these classic symptoms only occur in a small minority of patients). Remember also that intermittent claudication can also occur in the large muscle groups of the upper leg, which is indicative of narrowing of the deep femoral artery. ABPI should be performed in symptomatic patients and a result less than or equal to 0.9 is diagnostic for the presence of peripheral vascular disease. You need to however bear in mind that this test may not be accurate if the patient has non-compressible arteries (mainly in diabetic patients like this one). If she does not feel that this claudication is really a functional disability then no additional treatment is required, but follow-up appointments with a doctor should be made to monitor the development of ischaemic symptoms or coronary and cerebrovascular complaints.
If the symptoms are lifestyle limiting then the patient should undergo a supervised exercise programme (only some rather limited quality cohort studies at the moment show an improvement in walking time and symptoms) and medication for symptomatic relief for a period of 3 months. Medication can include cilostazol, pentoxifylline (widely used but no more effective than placebo in RCTs) or naftidrofuryl. Risk factors should also continually be targetted – BP control, statins to lower LDL, beta blockers to target cardiovascular risk and antiplatelet therapy, for instance. If no improvement is made with this regime then patients should be referred to a vascular specialist to have their anatomy defined and assessed for possible revascularisation.
A 64 year old smoker is referred to the doctors by his dentist, who noticed a white coloured plaque on the lateral tongue margin and the floor of the mouth. It has a thickened, white and leathery appearance on examination. The surrounding mucosa is clinically normal. He has recently has a kidney transplant. In situ hybridisation confirms the diagnosis.
1. Squamous cell carcinoma 2. Syphilitic leukoplakia 3. Oral hairy leukoplakia 4. Candidiasis
- Oral hairy leukoplakia - This is oral hairy leukoplakia which presents as a painless white plaque found along the lateral tongue borders. There is history here which suggests immunosuppression. In situ hybridisation here has demonstrated the presence of EBV in the tissue.
A 30-year-old man attends for a routine pre-employment medical. On examination of the cardiovascular system, the doctor finds a soft (grade 2/6) ejection systolic murmur at the apex. He has no previous cardiac or respiratory problems and has a normal pulse and BP.
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
G. Innocent murmur - This is a functional murmur which is not caused by a structural cardiac defect. Functional murmurs tend to be systolic, occuring in an otherwise healthy individual with no symptoms. They are also characteristically position dependent and soft in nature. Ones that occur in children tend to disappear as the child grows. Benign paediatric murmurs include Still’s murmur.
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.
A 52-year-old woman with recurrent episodes of severe anxiety, when her family note that she becomes very pale. BP up to 220/124 mmHg during an attack, 150/90 mmHg otherwise. Her pulse rate does not increase significantly during attacks.
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
D. Pheochromocytoma - Phaeochromocytomas presents with paroxysmal episodes of palpitations, anxiety, excessive sweating, pallor and hypertension. It can be inherited in MEN2, von Hippel-Lindau syndrome and NF1. Diagnosis is based on raised urinary and serum catecholamines, metanephrines and normetanephrines. 24 hour urinary VMA will be elevated. CT is used to localise the tumour. Treatment includes medical with the use of phenoxybenzamine, phentolamine and surgical options. Surgical excision is carried out under alpha and beta blockade to protect against the release of catecholamines into circulation when the tumour is being manipulated. The 10% rule is often quoted: 10% are bilateral, 10% malignant, 10% extraadrenal and 10% hereditary.
A 77 year old former coal miner has 30 year history of cough, mostly productive of sputum. He suddenly becomes breathless after a bout of coughing & complains of right sided chest pain. On examination, he is cyanosed, the trachea is deviated to the left & no breath sounds are audible over part of the right side of the chest.
A. Acute anxiety B. Epiglotitis C. Exacerbation of COPD D. Inhaled foreign body E. Pneumothorax F. Anaphylaxis G. Left ventricular failure H. Viral pneumonia I. Asthma J. Pulmonary embolus
E. Pneumothorax - This patient has developed a right sided tension pneumothorax and will need emergency intervention in the form of the insertion of a large bore cannula into the 2nd intercostal space in the MCL of the affected side. This will need to be followed by the insertion of a chest drain.
Otherwise if this was not a tension pneumothorax, for secondary spontaneous pneumothoraces, if large enough for a chest drain or the patient is clinically unstable, chest drain insertion is indicated. Simple aspiration success rate is reduced in secondary spontaneous pneumothoraces. Primary pneumothoraces occur in young people without known lung conditions. This patient has pulmonary fibrosis. Those who suffer recurrent pneumothoraces may have to undergo pleurodesis to stick the parietal and visceral pleural together by an inflammatory reaction.
There is a constant ‘machinery-like’ murmur throughout systole & diastole.
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
C. Patent ductus arteriosus - The ductus arteriosus is a fetal structure which normally closes within 2 days of birth. Persistence can result in heart failure and increased pressures in the pulmonary vasculature as blood is shunted from the aorta into the pulmonary artery. The classic murmur is known as a Gibson murmur or machinery murmur and is best heard in the left infraclavicular area, usually peaking in late systole and continuing into diastole. Maternal rubella infection in the first trimester is a predisposing risk factor for PDA. The definitive diagnostic test is an echocardiogram.
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 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.
An 80 year old woman is brought into hospital following a house visit. She was initially confused, but in hospital she is found to be hypoventilating, her bloods show low BMs and hyponatraemia. Drs order hydrocortisone and liothyronine sodium
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
A. Myxoedema coma - This patient is at the severe end of the hypothyroid spectrum. She has depressed level of consciousness (this can descend into frank coma) and is hypoventilating, other features that can present in this serious complication are bradycardia, and hyponatraemia. Further to this a massive proportion are hypothermic (core temp
A 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.
A woman has been trying for a baby for a number of years now to no avail, she has suffered two miscarriages in the past. Her only past medical history of note is a ‘dodgy’ rhythm she has received treatment for for years.
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
C. Amiodarone - Any patient with a history of miscarriage should be investigated for thyroid dysfunction especially hpothyroidism. In this ladies case she has been taking amiodarone as an anti-arrhythmic long term, Amiodarone is one of several drugs that can cause hyper/hypothyroidism.
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
A 78-year-old woman was admitted six weeks ago with a fractured neck of femur. She lives with her husband in a first-floor flat with no lift. The nurses are worried how she is going to manage at home because she is not mobilising in the ward.
A. Dietician B. Hospital doctor C. General practitioner D. Social worker E. Macmillan nurse F. Speech and language therapist G. Ward nurse H. Occupational therapist I. Physiotherapist J. District nurse
I. Physiotherapists - Physiotherapists work with patients who have physical difficulties to identify and improve movement and function. This will involve, for example, encouraging movement and exercise using a range of techniques.
A 30 year old man recently returned from a holiday in Bangladesh. He developed watery diarrhoea 20 hours ago which has increased in volume. There has been vomiting. Now there is an almost continuous passage of loose and pale stools.
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
I. Cholera - This is a secretory diarrhoea caused by the bacterial organism Vibrio cholerae. This organism releases a toxin which stimulates adenylate cyclase. It is classically a disease of poverty but is also well described in returning travellers. Vomiting is a common early feature. The most striking and characteristic feature of cholera is the loose rice-water stools – a high volume diarrhoea which remains pale and loose, without blood. The presentation tends to be with litres of this rice-water stools. Culture of the organism provides a definitive diagnosis and rapid dipstick tests are currently available. Most patients will recover if the effects of the profound volume depletion are corrected with either oral or IV rehydration. Antibiotics do shorten the duration and severity of disease but the rising rate of bacterial resistance is becoming a problem. Note that about 70-80% of those infected with Vibrio cholerae do remain asymptomatic.
What is interesting is that blood group O appears to lead to more severe disease, but may be protective against initial infection. Many infectious diseases indeed do show a relationship between blood group and disease susceptibility
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
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 20 year old man has been involved in a road traffic accident & the ambulance has just arrived. He has severe left upper abdominal tenderness, blood pressure 80/60 & pulse 140/min.
A. Measure urea & electrolytes B. Blood transfusion C. Intravenous saline D. Administer diuretics E. Measure blood gases F. Intravenous colloid G. Intravenous plasma H. Intravenous sodium bicarbonate I. Intravenous dextrose
C. IV saline - As mentioned, first line fluid resuscitation is with 0.9% saline.
Fluid replacement therapy aims to maintain physiological parameters. Systolic BP >90 is required for adequate organ perfusion. IV 0.9% saline is the first line treatment for volume depletion in almost all situations. It is worth noting that normal saline in large amounts carries a risk of inducing a metabolic acidosis due to the high chloride content. 5% dextrose is equivalent to water when given, and is not approriate for volume resuscitation since it will distribute throughout the total body water. Only 1/12 will remain in the intravascular space. 5% dextrose may be used, however, in resuscitation or replacement in diabetics on an insulin drip to prevent hypoglycaemia. The insulin and dextrose infusion should go in the same cannula so there is no risk of giving unopposed insulin. For example, if the arm you are giving the dextrose infusion were to clog up, or more likely, if the patient bends their arm if the cannula is sited in the antecubital fossa.
Sodium bicarbonate solution can be used acutely to treat severe metabolic acidosis. Lactated Ringer’s solution may also be helpful, but may contribute to hyperkalaemia in the setting of renal failure. IV colloids are less preferred. These include albumin, starches, dextrans and gelatins. Colloids are used when there is a risk of tissue oedema as there is a reduced proportion of administered fluid lost into the interstitial space. However, they are expensive and have not shown to benefit mortality in many studies, and indeed a systematic review in the BMJ of 37 RCTs has shown a 4% increase in absolute mortality. Crystalloids remain first choice for fluid resuscitation in the first instance.
Blood is the best intravascular volume expander (replacing like for like), especially if the patient is anaemic or is actively bleeding. It is usually given as packed red cells with saline. Mild volume depletion can be managed by ORT. Glucose is typically added to promote the sodium/glucose co-transporter. Depending on the site of loss, antiemetics and antidiarrhoeals (in non-infectious diarrhoea) may be indicated. Vasopressors are often needed in sepsis. So, having said all of this…
A 37 year old Somali doctor with a history of coughing up about half a cup of fresh blood on 4-5 occasions over the period of 2 months. He had lost 5kg in weight and had drenching night sweats almost daily. Chest x-ray shows a large cavitating nodule in the left upper zone.
A. Sickle cell crisis B. Arterio-venous malformation C. Tuberculosis D. Inhaled foreign body E. Acute left ventricular failure F. Bronchiectasis G. Pulmonary aspergillosis H. Asthma I. Pulmonary embolus J. Carcinoma of bronchus K. Thrombocytopenia
C. Tuberculosis - This patient has pulmonary TB. Risk factors include HIV infection, exposure to infection and returning from or being born in a high risk region such as Somalia, or other areas of Africa, Asia and Latin America. The night sweats here, weight loss and haemoptysis are all suggestive. The CXR finding of a cavitating lesion and upper zone changes are also consistent with TB. If TB is suspected, the patient should be placed in isolation and 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 79-year-old man complains of difficulty walking. On examination you also notice he has a resting tremor & his limbs oppose movement.
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
J. Parkinsons disease - Parkinson’s is characterised by a resting tremor, rigidity, bradykinesia and postural instability. The resting tremor occurs at 4-6 Hz at rest which dissipates with the use of limbs, with generally asymmetrical onset. 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 65-year-old man with a six-month history of ischaemic heart disease on Aspirin presents with a one-month history of epigastric pain and two days of dark stools. He has vomited a ‘cupful’ of fresh blood this morning.
A. Clotting profile B. Chest x-ray C. Upper GI endoscopy D. H.pylori breath test E. Colonoscopy F. CT scan abdomen G. Liver biopsy H. Barium swallow I. Liver function test J. Upper GI endoscopy K. Full blood count
J. Upper GI endoscopy - NSAID use is a key risk factor for a peptic ulcer. Other key risks include H. pylori infection, smoking and FH of PUD. Zollinger-Ellison syndrome should be considered if there are multiple ulcers or ulcers refractory to treatment. The epigastric pain and symptoms of dark stools are consistent with a bleeding peptic ulcer. The most specific and sensitive test is an upper GI endoscopy which also allows management of the bleed. A biopsy may also be done to rule out malignant transformation. Gastric ulcers require a compulsory biopsy but duodenal ulcers rarely undergo malignant change. Management here can be aimed at discontinuing NSAIDs which are the cause in this case.
A 33 year old homeless man drinks a bottle of whisky per day. He has begun to have episodes of amnesia. He wants to stop drinking. When he last tried to give up drinking, he suffered a grand mal convulsion.
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
H. Inpatient detoxification with chlordiazepoxide - Chlordiazepoxide is a long-acting benzodiazepine which is used to attenuate alcohol withdrawal symptoms. People with severe dependence should undergo withdrawal in an inpatient setting – withdrawal in those who are severely dependent without medical support can lead to seizures, DT and death. A symptom triggered flexible regimen is typically used in hospital and continued assessment and monitoring is carried out for 24-48 hours, usually followed by a 5 day reducing dose schedule. When BZDs are contraindicated, carbamazepine can be used as an alternative. Clomethiazole can also be used in the acute withdrawal setting although BZDs are preferred. Patients with marked agitation or hallucinations, and those at risk of DT can be given antipsychotic drugs such as haloperidol as an adjunct. This patient should also be given parenteral thiamine (as Pabrinex) due to the risk of developing Wernicke’s encephalopathy from chronic alcohol abuse.
A 28 year old woman has developed rapid weight loss & palpitations. You notice lid lag & a goitre on examination.
A. Superior vena cava syndrome B. Thyroglossal cyst C. Hashimoto's thyroiditis D. Myxoedema E. De Quervain's thyroiditis F. Stomach carcinoma G. Carotid artery aneurysm H. TB abcess I. Grave's disease J. Thyroid cancer K. Hodgkin's disease L. Euthyroid goitre
I. Grave’s 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.
An 80 year old woman is admitted with vomiting. Her blood pressure is 120/80mmHg, pulse rate 90/min, with warm peripheries. Plasma urea is 25mmol/l, & creatinine 120umol/l.
A. Measure urea & electrolytes B. Blood transfusion C. Intravenous saline D. Administer diuretics E. Measure blood gases F. Intravenous colloid G. Intravenous plasma H. Intravenous sodium bicarbonate I. Intravenous dextrose
C. IV Saline - This patient is very dehydrated
Fluid replacement therapy aims to maintain physiological parameters. Systolic BP >90 is required for adequate organ perfusion. IV 0.9% saline is the first line treatment for volume depletion in almost all situations. It is worth noting that normal saline in large amounts carries a risk of inducing a metabolic acidosis due to the high chloride content. 5% dextrose is equivalent to water when given, and is not approriate for volume resuscitation since it will distribute throughout the total body water. Only 1/12 will remain in the intravascular space. 5% dextrose may be used, however, in resuscitation or replacement in diabetics on an insulin drip to prevent hypoglycaemia. The insulin and dextrose infusion should go in the same cannula so there is no risk of giving unopposed insulin. For example, if the arm you are giving the dextrose infusion were to clog up, or more likely, if the patient bends their arm if the cannula is sited in the antecubital fossa.
Sodium bicarbonate solution can be used acutely to treat severe metabolic acidosis. Lactated Ringer’s solution may also be helpful, but may contribute to hyperkalaemia in the setting of renal failure. IV colloids are less preferred. These include albumin, starches, dextrans and gelatins. Colloids are used when there is a risk of tissue oedema as there is a reduced proportion of administered fluid lost into the interstitial space. However, they are expensive and have not shown to benefit mortality in many studies, and indeed a systematic review in the BMJ of 37 RCTs has shown a 4% increase in absolute mortality. Crystalloids remain first choice for fluid resuscitation in the first instance.
Blood is the best intravascular volume expander (replacing like for like), especially if the patient is anaemic or is actively bleeding. It is usually given as packed red cells with saline. Mild volume depletion can be managed by ORT. Glucose is typically added to promote the sodium/glucose co-transporter. Depending on the site of loss, antiemetics and antidiarrhoeals (in non-infectious diarrhoea) may be indicated. Vasopressors are often needed in sepsis. So, having said all of this…
True or False, the eighth cranial nerve is responsible for balance.
True. The vestibular part of the nerve transmits positional and rotational information from the semicircular canals, saccule and utricle.
A 75-year-old man underwent an anterior resection for rectal cancer 48 hours ago. He now has a urine output of 25mls/hr, BP 110/80, pulse 90/min. His Hb is 7.9g/dl.
A. IV saline B. Administer diuretics C. Colloid D. Blood transfusions E. IV dextrose F. IV dextrose/saline G. IV sodium bicarbonate H. Measure urea and electrolytes I. IV plasma J. Measure blood gases
D. Blood transfusion - This patient has been given IV saline already as the initial choice for volume expansion. His anaemia and clinical state warrants a blood transfusion. 1 unit of blood raises the Hb concentration by 1g/dL. Commonly, transfusion begins with 2 units of packed RBCs and the patient reponse is monitored.
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 56-year-old man is admitted with chest pain. Exercise ECG is normal but his random blood sugar on admission was 23 mmol/l. He is overweight and being referred to the diabetic clinic as an outpatient.
A. Dietician B. Hospital doctor C. General practitioner D. Social worker E. Macmillan nurse F. Speech and language therapist G. Ward nurse H. Occupational therapist I. Physiotherapist J. District nurse
A. Dietician - This patient has possible DM (needs a second test result to be diagnostic or needs to be symptomatic). The first line intervention is dietary and lifestyle changes. The most useful person this patient will benefit from is a dietician who will be able to give him advice on his eating habits – a diet high in fibre and low in fat is recommended and to also cut, to a degree, carbohydrate intake or at least resort to carbohydrates with a high glycaemic index such as lentils and sweet potato. The GI measures the effect carbohydrates have on blood sugar levels – a lower GI has more of an impact on blood sugar levels in a shorter amount of time. Advice will also be given on how to deal with hypoglycaemic episodes if the patient is being treated with medication which predisposes to this risk, such as insulin.
A 72 year old man with weight loss has developed a hard swelling in the left supraclavicular fossa.
A. Superior vena cava syndrome B. Thyroglossal cyst C. Hashimoto's thyroiditis D. Myxoedema E. De Quervain's thyroiditis F. Stomach carcinoma G. Carotid artery aneurysm H. TB abcess I. Grave's disease J. Thyroid cancer K. Hodgkin's disease L. Euthyroid goitre
F. Stomach carcinoma - The presence of Virchow’s node (Troisier’s sign), a hard enlarged node in the left supraclavicular fossa, points towards a malignancy in the abdominal cavity. This is most often stomach cancer. The lymph drainage of the abdominal cavity drains into Virchow’s node as the lymph drains most of the body from the thoracic duct and enters the venous circulation at the left subclavian vein.
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.
30 year old women returning from holiday. Sudden onset chest pain with shortness of breath, coughed blood. She has no other lung disease.
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
C. CTPA - This patient has a PE. Regardless of whether there is lung disease, guidelines state that the study of choice if there is an initial high probability of PE is a CTPA with direct visualisation of the thrombus (a filling defect is seen). If there is a contraindication to a CT scan such as contrast allergy or pregnancy, then a V/Q scan is indicated.
A man complaining of vague abdominal pain + general lethargy has a short SynACTHen test performed. Pre test cortisol was 200mM, 30 minutes after administration of tetracosactide the serum cortisol is 370mM. Pick the most appropriate conclusion..
- Primary adrenal insufficiency
- Normal response
- Secondary adrenal insufficiency
- Primary adrenal insufficiency - Tetracosactide is synthetic ACTH. When administered during a short synacthen test it can be used to determine whether a patient has adrenal or pituitary hypocortisolism. A Normal test would be : basal cortisol >170mM and 30 minutes cortisol should be at least double the basal measurement and be greater than 550mM This man’s basal cortisol is normal however his 30 minutes cortisol has less than doubled and is less than 550mM which indicates that the adrenals are not functioning properly. In secondary adrenal insufficiency the basal cortisol would be very low but would exhibit large increases on administration of tetracosactide.
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 man has hypertension, his dr starts advising him on low salt diets and prescribes him Spironolactone. The man’s father and grandfather had the same problem.
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
C. Liddle’s syndrome - This man has Liddle’s syndrome a form of pseudohyperaldosteronism which is caused by overactive eNaC ( epithelial sodium channel) found in the collecting ducts. Liddles is an autosomal dominant condition hence the strong family history. The biochemical picture of hypernatraemia and hypokalaemia mimicks that of hyperaldosteronism, normally aldosterone modulates the eNacs activity however in Liddle’s the problem is the channel does not dissocciate properly so blockade of aldosterone with spironolactone is ineffective. Direct eNaC antagonists are used…Amiloride or Triamterene in conjucntion with a low sodium diet.
A 2-year-old boy presents with abdominal distension, haematuria and vague pain. Examination reveals a large nodular mass on the left kidney.
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
D. Wilm’s tumour - Wilms’ tumour (a.k.a. nephroblastoma) is the commonest intra-abdominal tumour in children, rarely occuring in adults. It is a malignant tumour derived from embryonic mesodermal tissues. Patients present with a loin mass, weight loss, anorexia and fever. Although the tumour is rapidly growing an behaves aggressively, it has an 80% survival rate at 5 years.
A 35 year old woman who loves birds presents with a 10 day history of a low grade fever and a recent 2 day history of a cough which is non-productive. Examination reveals diffuse crackles on chest examination and mild hepatomegaly which is tender on palpation.
- Legionella
- Q fever
- Psittacosis
- Mycoplasma
- Psittacosis - Chlamydia psittaci causes a community-acquired atypical pneumonia. It is often acquired from domesticated or commercially raised birds or exotic imported birds. The presentation can be similar to Mycoplasma and Chlamydophila pneumoniae. Tetracyclines are the preferred treatment. Hepatomegaly can occur in this condition with pain on palpation but is uncommon, as can splenomegaly. Both organs, if enlarged, are diffusely so.
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.
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 41 year old woman has a painless fluctuant swelling in her right supraclavicular fossa. It becomes inflamed at times & she has expressed thick, foul-smelling white matter from it.
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
K. Sebaceous cyst - This is a sebaceous cyst evidence by the swelling which becomes inflamed at times and expresses thick, foul smelling white keratin matter, which is when it becomes infected. They are common in hairier areas and are generally smooth and round. They can be caused by blockage of sebaceous glands.
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 75-year-old gentleman was brought to A&E mildly confused. He has been unwell last couple of days with productive cough, diarrhoea and fever. CXR is shows infiltrates in the RUL and his bloods show hyponatraemia.
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
B. Legionella pneumoniae - 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.
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.
Drug use in the lactating mother
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 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 48 yo woman is seen in clinic complaining of a non-painful lump in her neck that has been getting larger. The Dr notes that her voice sounds hoarse and she has been having difficulty swallowing her food. O/E there is a large ‘iron’ hard lump on the left side of her neck that seems to be fixed to the underlying structures. The dr thinks Tamoxifen might help.
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
D. Reidel’s thyroiditis - Riedel’s is typically described as Iron hard or ‘woody’. It is of an autoimmune origin and 25-50% of those affected are hypothyroid. The presenation is of a painless lump in the neck that can also cause local compressive symptoms. ie. Tracheal/oesophageal compression..stridor etc. Since the lump is hard and craggy it can be easily mistaken for carcinoma, however there is no lymphadenopathy in this patient or general cancer symptomology. Riedel’s can be associated with sclerosing cholangitis and peculiarly responds to Tamoxifen, there can also be use for steroids.
A 78 year old male with an ejection systolic murmur loudest at the aortic area and radiating to the neck.
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
C. Aortic stenosis - Aortic stenosis is characterised by a harsh ejection systolic murmur heard loudest at the right upper sternal border 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 AS in adults is calcification of normal trileaflet valves. Clinically stable patients may be considered for surgical repair or TAVR. Presentation includes chest pain, dyspnoea and syncope.
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.
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 23 year old woman presents with a 24 hour history of right iliac fossa pain. There is tenderness & guarding in the right iliac fossa. There are no menstrual symptoms. Abdominal & pelvic ultrasound is normal.
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
D. Diagnostic laprotomy - An abdominal and pelvic CT scan would normally be ordered in situations like this, with possible appendicitis, but it is assumed here that the doctors were thinking of pregnancy as a possibility so a sonogram was done instead, which turns out to be inconclusive. Now, in this situation, you could do an abdominal MRI (especially in early pregnancy) or go ahead with a CT scan anyway, but a diagnostic laparotomy is the best option here to diagnose and treat at the same time. The main differential here is either obstetric, such as a ruptured ectopic pregnancy, or acute appendicitis. You would have imagined they would have done the usual important tests like FBC and a urinary pregnancy test… but these results are not available, nor are they an option, but a prudent doctor would have ordered them in the diagnostic work up. However, given USS does not show a mass in the fallopian tubes, this may push you away from an ectopic pregnancy… however, USS is operator dependent, this is a female of childbearing age (this age is getting lower and lower in the UK) and the doctor has failed to obtain either serum or urine HCG levels or asked about any missed menstrual periods.
This patient, should be made NBM with maintenance IV fluids like lactated Ringer’s, and have a laparotomy which can be both diagnostic and therapeutic. You can take the appendix out if this is the problem or deal with the ectopic, if that is the problem, or deal with whatever it could be.. say for instance, a rare Meckel’s diverticulitis.
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 30 year old male alcoholic presents nausea and pain in the lower chest in a band radiating around to the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base.
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)
F. CT scan abdomen - This patient has acute pancreatitis. He has vomited and is describing mid-epigastric pain radiating around to the back which is relieved in the fetal position and is worse with movement. He is an alcoholic and alcoholic pancreatitis is seen more frequently in men usually after an average of 4-8 years of alcohol intake. Binge drinking also increases the risk. This patient also has nausea and may describe vomiting too, with agitation and confusion. The examination findings described here allude to a pleural effusion which is seen in half of patients with acute pancreatitis. 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. Those caused by hypocalcaemia may 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 abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.
For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.
A man has a history of weight loss and his voice has recently hoarsened. He has been complaining of pain in his leg also. The Dr reviews his blood work and highlights a raised calcitonin
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
H. Medullary cell carcinoma - This patient has a maliganacy, the bone pain suggests it has metastasised (medullar cell carincoma frequently does so). Raised calcitonin is noted as medullary carcinoma originates from the parafollicular c cells of the thyroid, responsible for producing calcitonin as part of the calcium, homeostasis mechanism…raised calcitonin is fairly diagnostic.
Thyroid malignancies: GOOD - differentiated (around 90% of all malignancies) : Papillary (80%) and Follicular (10%) carcinomas : these originate from the thyroxine producing stroma and commonly present as a solitary lump in a euthyroid patient. Infiltrative symptoms such as hoarseness and dysphagia may be seen..Surgical management +/- radioiodine followup (these tumours take up iodine quite well) is usually effective. Papillary tumours are slow growing and have excellent survical rates.
BAD - from undifferentiated to anaplastic - Medullary cell Ca - aggressive and metastatic these tumours do not take up iodine well and are less curable by surgery. often linked with MEN or can be a familial neoplasm.
The elderly are particularly affected by Lymphomas and Anaplastic carcinomas - both are rare and rapidly growing however biopsy to differentiate these is important here as lymphomas have a decent prognosis whilst anaplastic carcinomas are pretty much incurable.
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 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 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.
12 yr old boy has become increasingly tired over the last month. On examination he looks pale, has a large bruise over his right thigh and a firm palpable liver and spleen.
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
G. Acute lymphoblastic leukaemia - ALL presents in children with bone marrow involvement and the associated symptoms or in adults with an anterior mediastinal mass. Bone marrow infiltration leads to a pancytopenia leading to anaemia (reduced red blood cells), haemorrhage (reduced platelets) and infections (reduced mature white blood cells). In ALL, bone marrow is replaced by lymphoblasts. There may also be spread to CNS and testes. ALL is associated with Down’s syndrome. In contrast, CLL presents in older adults and is often asymptomatic, discovered by chance when a FBC is ordered. Smear/smudge cells are seen in peripheral blood smear. CLL is associated with a warm-type AIHA and there is peripheral blood lymphocytosis.
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 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).
A 60 year old man with a history of occupational exposure in building & demolition industry presents with shortness of breath. On examination there are signs of a pleural effusion and the patient is clubbed.
A. Echocardiogram B. Abdominal ultrasound C. Bronchoscopy D. Chest x-ray E. Lung funtion tests F. Sputum culture G. Colonoscopy H. Stool culture
D. Chest x-ray - 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. This man’s work means he comes into contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. Another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. CXR here will show reticular opacities. A high resolution CT scan can also be done if it was an option on this list.
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 dishevelled man local to the area is found collapsed on the street. In A+E his blood work reveals low sodium and a raised potassium, he is oliguric, tachcyardic and his BMs are running dangerously low. Chest X ray shows pathological upper lobe changes and abdominal films show areas of calcification.
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
L. Addisonian crisis - This man is found collapsed, the cause of his collapse is not given but one differential is always cardiovascular. He is shown to be hyponataraemic and hyperkalaemic. This picture fits adrenal failure well, the raised potassium is a result of mineralocorticoid deficiency leading to decreased K+ excretion.
The CXR is hinting at upper lobe fibrosis as seen in patients who have had Tuberculosis, and further the abdo film shows calcification of the adrenals bilaterally which is the radiographic appearance of TB infiltration of the adrenal galnds.
This man has Addison’s is caused by TB. Furthermore he is found collapsed with low blood glucose. He has signs of shock…Tachycardia and oliguria so he is in fact in Addisonian crisis which should be treated promptly with gluocorticoid replacement and dextrose, this man has evidence of mineralocorticoid deficiency also so fludrocortisone should be coadministered.
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 3yr old Caucasian child is brought into clinic by his mother who is concerned about his cough. Looking through his notes you find out he has a history of chest infection. However the only medication he is currently taking is a steroid cream for his eczema. You discover that he opens his bowels twice a day and has offensive loose stools. On examination his height is on the 91st centile and his weight is below the 25th centile.
A. Cystic fibrosis B. Pancreatitis C. Tuberculosis D. Emphysema E. Asthma F. Pneumonia G. Chronic bronchitis H. Bronchiectasis I. Lung cancer J. HIV K. Lung abscess
A. Cystic Fibrosis - This infant has presented with cystic fibrosis which is an autosomal recessive condition characterised by a mutation in the CFTR gene on chromosome 7 (delta-F508). In this case there is failure to thrive, recurrent chest infections and evidence of pancreatic insufficiency (steatorrhoea). The most conclusive diagnostic test is the sweat test which is pisitive 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.
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.
A 56 year old lady collapses whilst running for the bus. O/E there is a thrusting apex beat and an ejection systolic murmur. This is best heard on expiration and radiates to the carotids
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
J. 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.
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).
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
A 25-year-old woman returning from Australia presents with acutely painful left calf. Ultrasound confirms deep vein thrombosis extending above the popliteal veins. She has recently missed a period.
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
C. Subcutaneous low molecular weight heparin - Women developing a DVT during pregnancy can be treated with heparin or LMWH. However, LMWH is preferred due to more dependable pharmacokinetics. The agents you will commonly hear include enoxaparin, dalteparin and tinzaparin.
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 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 20 year old male presents with painful defecation which persists for 30 mins afterwards. The stool is smeared with blood, & he has noticed recent constipation.
A. Irritable bowel syndrome B. Pilonidal sinus C. Haemorrhoids D. Inflammatory bowel disease E. Abscess F. Prolapse G. Fissure H. Fistula I. Intussusception
G. Fissure - This patient has an anal fissure. This causes severe pain on defecation and may continue for 1 to 2 hours. A small amount of fresh blood is often passed on the stool. Hard stools is a strong risk factor and this patient’s constipation will likely be the cause. Opiates are associated with constipation and subsequently anal fissures too and fissures may also occur in the third trimester of pregnancy or after delivery. Initial treatment is with topical GTN or diltiazem along with supportive measures such a high fibre diet. Resistant or chronic fissures may benefit from surgical measures or botulinum toxin.
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 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 39-year-old multiparous woman presents to the clinic with varciosities in both legs. Although asymptomatic, she wishes to undergo surgery to remove them as they are causing her great embarassment. In order to determine the best treatment plan, the surgeon would like to map out all the incompetent venous pathways.
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
A. Duplex doppler ultrasound - Ablative procedures include stripping and ligation, the aim of which is to permanently remove the varicose vein. Radiofrequency ablation (RFA) can also be done, as well as endovenous laser therapy and foamed sclerotherapy. Phlebectomy or sclerotherapy can also be performed. This is generally reserved for symptomatic cases, although this woman has a cosmetic issue with the appearance of her legs which is causing her distress. There are complications of ablation which the patient will need to be made aware of though, such as bleeding, infection, saphenous nerve injury and neovascularisation.
A duplex ultrasound is the investigation which is required here. It can assess reversed flow and valve closure time. This should be done with the patient standing and with the leg in external rotation for best sensitivity. Specific segments which are affected by reflux can be delineated as the superficial and deep truncal veins, perforators and tributaries can all be visualised. Reflex in the great saphenous or common femoral can be detected with Valsalva while more distal reflux can be elicitied by compressing the leg above the Doppler probe to see if any blood is being forced back towards the feet.
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.
80 yr old woman presents with recent onset of effort related chest pain. On examination= loud ejection systolic murmur and a low pulse pressure with a slow rising pulse.
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
G. 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 19 year old motorcyclist suffers a head injury after colliding with a lorry. On examination he is found to have a GCS of 4 & requires an urgent CT scan.
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
D. Single lumen cuffed ET tube - This patient is unconscious and is about to undergo a CT scan. He needs a definitive airway. The cuffed end creates a seal the prevent the aspiration of stomach contents. Reduced consciousness is a major risk factor for aspiration due to an inadequate cough reflex and impaired closure of the glottis.
True or False, the ninth cranial nerve is the accessory nerve.
False - It is the glossopharyngeal nerve.
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.
48 yr old man presents with central chest pain on unusual exertion. Resting ECG is normal and there are no obvious risk factors. He would prefer not to take medication until a definitive diagnosis is made.
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
B. 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.
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.
A twenty-one year old girl who presents with shortness of breath on climbing stairs, her boyfriend has told her that she looks very pale and should see the doctor. 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
G. FBC - Pallor and exertional SOB are suggestive of anaemia here. A FBC should be done here which would expect to find a low Hb. The World Health Organisation defines anaemia as
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 25 year old previously well man who has a 3 day history of abdominal cramps diarrhoea with bloody stools 5 or 6 times a day. Examination shows a soft but tender abdomen.
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
E. Stool examination for pathogens - This patient has most likely has infectious diarrhoea. There is a short history in a previous well person. This man has probably eaten something dodgy like a kebab. Do you know the organisms that can cause bloody diarrhoea? Think of the organisms which cause bloody diarrhoea such as EHEC. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe cases. The diagnosis would be confirmed by stool examination.
A 42 year old alcoholic is admitted with SOB. He has no murmurs but the apex is laterally displaced and there are crackles at the lung bases with raised JVP. There is also hepatomegaly, clubbing and multiple spider naevi.
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
I. Dilated cardiomyopathy - It is worth noting that ventricular hypertrophy due to hypertension causes concentric hypertrophy i.e. the wall of the ventricle gets thicker inwards. Hence the apex beat is not displaced unlike in DCM. DCM is characterised by LV dilation and systolic dysfunction without significant coronary artery disease or abnormal loading conditions. RV dilation is often also present. 25-35% are familial (there may be FH of sudden death). Causes are extensive and include post-myocarditis, alcohol, chemotherapy agents, haemochromatosis, AI conditions and acromegaly. This case is alcohol related DCM with a history of alcohol excess, signs of chronic liver disease on examination and signs of systolic dusfunction on examination (crackles at lung bases, JVP distension and there may also be peripheral oedema). ECG may show non-specific ST-T changes, CXR can show an enlarged cardiac shadow and echo also give consistent results (wall thickness, LV dilation). LFTs, serum albumin and clotting profile may all be abnormal here too, and GGT would especially be expected to be elevated due to alcohol abuse.
A 30 year old teacher presents to her GP with a couch and SOB worsening over 24 hours. O/E she is pyrexial with no abnormal breath sounds. Her CXr shows bilateral shadowing. Her WCC is normal but she has abnormal liver function tests.
A. Cough syrup B. Fluids, bed rest C. Salbutamol inhaler D. Oral penicillin E. Opiate F. Oral clarithromycin G. Nebulised salbutamol H. IM adrenaline I. Diuretic J. IV cefuroxime
F. Oral clarithromyin - This is a CAP which is confirmed by CXR shadowing, which would show airspace shadowing with air bronchograms. The history is also consistent with respiratory symptoms and pyrexia. The most sensitive test for CAP is a CXR. The treatment is initially empirical with antibiotics and management would be guided by this patient’s CURB-65 score. A macrolide is the first choice in adults with no contra-indications without a recent cours eof antibiotics or risk of drug resistance, but always check local prescribing policies. Azithromycin, clarithromycin or erythromycin are all valid choices here.
choose the SINGLE most appropriate monitoring investigation from the list
ACE inhibitor
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
F. Renal function tests - ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II and are used for a range of conditions such as heart failure, hypertension and diabetic nephropathy. Renal monitoring is needed due to hyperkalaemia and side effects of ACE inhibitors being more common in impaired renal function, necessitating a reduction in dose. They can also cause impaired renal function, particularly in old people. Using it alongside NSAIDs increases this risk and using it with potassium sparing diuretics increases the risk of hyperkalaemia. In those with renal artery stenosis, ACE inhibitors can also reduce or even remove glomerular filtration and result in renal failure and are therefore not recommended in these patients.
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 23 year old man has a dull ache in the left scrotum. He has noticed a firm, 2cm, non-tender lump at the front of the testicle. He has palpable supraclavicular lymph nodes.
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
F. Testicular malignancy - Testicular cancer commonly presents as a hard and painless lump on one testis although the lump can be painful and 10% present with acute pain associated with haemorrhage or infection. The supraclavicular lymph nodes here are an extratesticular manifestation – others include bone pain from metastasis, swelling of the lower extremities due to venous occlusion and gynaecomastia. Key risk factors include cryptorchidism and FH. White men have the highest incidence. The principal investigation is an ultrasound of the testis and testicular examination is vital in detecting this condition early on. Beta-hCG is raised in seminomas and teratomas however only AFP is raised in teratomas. Placental ALP can be raised in advanced disease. It is diagnostic if AFP, beta hCG and LDH are elevated. Teratomas are more common in the 20-30 age group whereas seminomas are more common after 30 and this is why the better option for this question would be a seminoma. In reality, you cannot tell from the age. Radical orchidectomy and histology is the initial treatment in most cases.
A 16 year old boy presents with 5 month history of chest pain on exertion and two episodes of collapse in the last month. There is also progressive SOB on exertion and now he cannot walk up the stairs without stopping. Examination reveals a loud systolic murmur.
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
E. 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. This is congenital aortic stenosis due to an abnormally formed aortic valve. He may here be considered for surgical repair or TAVR.
A 59 year old female is admitted to A&E with chest pain. The pain is central in origin and came on while she was watching television. The patient has a BMI of 34 and is a known hypertensive. Troponin and CK-MB are not elevated.
A. Variant angina B. Pulmonary embolus C. MI D. Anxiety E. Congestive heart failure F. Unstable angina G. Stable angina H. GORD
F. Unstable angina - This is UA characterised by chest pain at rest. ECG will typically show ST depression and T wave inversion. Acute management includes antiplatelets and antithrombotics to reduce damage and complications. Long term management aims at reducing risk factors. Key risk factors include obesity, hypertension, smoking, hyperlipidaemia, FH, DM and positive FH. People with diabetes may again present with atypical symptoms. Cardiac biomarkers will not be elevated although in a patient who has had an acute MI days earlier, troponin may remain elevated (remains elevated up to 10-14 days after release). All patients with presumed cardiac chest pain should in the first instance get oxygen, morphine and GTN with antiplatelet therapy in the absence of contraindications.
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.
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 78 year old woman attends complaining of widespread itching. Examination reveals hepatosplenomegaly. The patient appears plethoric with no lymphadenopathy
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
K. Polycythaemia rubra vera - PRV is a disease of middle and older age and is strongly associated with the JAK2V617 mutation. Pruritis is a common feature and is often severe and evoked by contact with water. Facial redness and fullness is commonly observed and splenomegaly is a common finding. It is a myeloproliferative disorder with raised Hct, Hb and RBC count. Blood hence becomes very viscous. There is a clear link between Budd-Chiari syndrome and subsequent PRV. Treatment is with venesection. Around 30% will go on to develop myelofibrosis.
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.
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.
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 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 40 year old woman develops a progressively hoarse voice over 6 months. She has also gained 8kg in weight and complains of constipation.
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
B. Hypothyroidism - This woman is in a hypothyroid state. The hoarseness may be a symptom of a goitre (enlarged thyroid). 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, 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 20 year old man has been constipated since childhood. He opens his bowels once or twice a week & has noticed faecal soiling.
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
I. Hirschsprung - In this condition there is colonic obstruction associated with absent intramural ganglion cells. The lumen is hence tonically contracted. Hirschsprung’s disease is commonly diagnosed in the first year of life and presents with vomiting, distension and/or colitis. There tends to be explosure liquid foul stools, delayed meconium passage and fever (enterocolitis). However, sometimes, it can present with intermittent bouts of symptoms later on in life and have minimal or absent symptoms in the first few days/weeks (adult presentations are rare). It can be associated with Down’s and MEN2A.
The diagnosis is definitively made on a rectal biopsy with stain for ganglion cells in the submucosal plexus. This will be absent in Hirschsprung’s with the presence of other features such as thickened non-myelinated nerves and increased acetylcholinesterase. A contrast enema will also be done and will show a contracted distal bowel with the proximal bowel dilated, making the location of the transition zone visible on XR. An AXR is always the first investigation performed but a normal film does not exclude the possibility of this diagnosis (it is a non-specific investigation, though having said that, if there are no distended bowel loops then Hirschsprung’s is unlikely). Manometry is not usually performed, but the reflex where when the rectum is distended, pressure in the anal canal falls (as the internal sphincter relaxes) is absent. Initial treatment is with irrigation followed by surgery.
Which type of seizure is associated with impaired consciousness and feelings of unreality, deja vu, or depersonalisation?
Selected Answer:
- Tonic-clonic
- Complex partial
- Simple partial
- Absence
- Complex partial - The above are all features of a temporal lobe seizure, which is often complex but may be simple (ie. no impairment of consciousness).
A 70 year old male who presents with significant weight loss & progressive painless jaundice. Ultrasound demonstrates a dilated biliary system down to the head of the pancreas.
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
L. Carcinoma head of pancreas - Pancreatic cancer (of the head) typically presents with painless obstructive jaundice and weight loss and generally presents late. 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: 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 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.
A 17-year-old woman with a FH of headaches has now herself developed headaches which are throbbing in character and preceded by flashing lights. She wonders what her GP can do for her.
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
K. Aspirin - Migraine is a chronic condition, with genetic determinants, which usually presents in early to mid life. The typical migraine aura this patient describes (which can be visual, sensory or speech symptoms) which can occur during or before the headache, is pathognomic, but is not seen in the majority of patients. The aura can be positive phenomena (for example this patient seeing flashing lights) or negative phenomena (for example visual loss). Nausea, photophobia and disability (the headache gets in the way with the patient’s ability to function) accompanying a headache also suggest a migraine diagnosis. The headache of a migraine tends to be prolonged if untreated, and tends to be unilateral and pounding (but does not have to be). Tests aim to rule out other differentials, although if the history is compatible and neurological examination is unremarkable, further testing is not needed.
Treatment of this chronic condition aims at treating acute attacks to restore function. Triptans can be used in specialist care for severe symptoms. These are 5HT1 agonists. Effective initial treatment in a primary care setting can involve NSAIDs, which are available OTC and include aspirin, as well as indometacin and naproxen. Paracetamol is less effective than NSAIDs but is still better than placebo – it is first line in those who are pregnant. Treatment should be taken as soon as a patient realises they are having an attack and may need to be repeated after the attack. A few patients who have frequent, severe or disabling headaches may require daily prophylaxis such as anticonvulsants, TCAs and beta blockers.
A 23 year old male was upset England lost a penalty shoot-out and decided to kick a wall in a construction site on the way home. The wall fell on him and he was crushed. It took paramedics a long time to retrieve him from the rubble. His leg is swollen and tender. Urine specimen has a dark red appearance.
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
B. Rhabdomyolysis - This is a crush injury that has caused myocyte lysis – rhabdomyolysis. The diagnosis would be confirmed by raised CK. The swelling and pain in his leg muscle is a further give away. The dark urine here is caused by urinary myoglobin. The long time it took for him to be retrieved is also an indication of this diagnosis. The mainstay of treatment is with fluid hydration.
A Nigerian 26 year old female presents to her doctor with a dry cough and a painful and strange red left shin. A subsequent chest X-ray reveals bilateral hilar lymphadenopathy.
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
K. Sarcoidosis - Sarcoidosis is a chronic multisystem disease with an unknown aetiology. Lung involvement is very common. The strange red left shin is 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 41-year-old lady feels unsteady on her feet. She also has visual problems for the past 6 weeks. She has been previously well and has no other medical problems.
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
I. 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.
70 year old woman who complains of palpitations, intolerance to heat, diarrhoea & weight loss. You find an irregular goitre in her neck that moves up and down when the patient swallows. There is no stigmata of Graves’ disease.
A. Sialogram B. Excise for biopsy C. Full blood count & Paul Bunnell D. Amoxycillin E. Upper GI endoscopy F. Reassure & explain why no active management necessary G. Technetium thyroid scan H. Carbimazole I. Thyroxine
G. Technetium thyroid scan - This is a case of toxic multinodular goitre. It is most common in older patients and is associated with head and neck irradiation and iodine deficiency. TSH is the initial screening test and if supressed, T4/T3 levels are measured. As the peripheral stigmata of Graves’ disease is absent, thyroid scan and uptake is indicated. I-123 is the preferred isotope but as this option is not given, Tc-99 can be used although there is a risk of false positive images. The scan will show multiple hot and cold areas consistent with areas of autonomy and areas of suppression. Definitive treatment is commonly given in the form of radioactive iodine.
A 32 year old man lacerated his leg in the garden. Two months later he developed a fever and headache followed by a permanent grin-like posture, inability to close his mouth, arching of his body with hyperextension of his neck.
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
M. Tetanus - This is very obvious tetanus which is caused by the exotoxin of the bacterium Clostridium tetani. This should have been prevented by appropriate management of the initial tetanus-prone wound and with complete active immunisation, with passive immunisation given when required. There is trismus here which has resulted in a grimace which is described as ‘risus sardonicus’ or sardonic smile. During a generalised tetanic spasm, the patient classically arches their back and extends their legs, flexes their arms in abduction and clenches their fists. Apnoea may also be a feature of these spasms. Intermittent tonic contractions of skeletal muscles often occurs which causes intensely painful spasms which may last for minutes – these are often triggered by stimuli such as noise, light and physical contact. Tetanic spasms can also produce opisthotonus, board like abdominal wall rigidity, dysphagia and apnoeic periods. Management of clinical tetanus involves supportive care (airway management is crucial here as spasms may compromise ventilation – without mechanical ventilation facilities such as in the third world, asphyxia is the most common cause of death due to muscle spasm), wound debridement, antimicrobials, passive and active immunisation, control of spasms and the management of autonomic dysfunction. Case fatality rate is 12-53%.
A 22-year-old medical student has several episodes of vomiting blood after a period of forceful retching. He had been binge drinking for the last 3 days after failing his OSCE.
A. Clotting profile B. Chest x-ray C. Upper GI endoscopy D. H.pylori breath test E. Colonoscopy F. CT scan abdomen G. Liver biopsy H. Barium swallow I. Liver function test J. Upper GI endoscopy K. Full blood count
C. Upper GI endoscopy - The definitive diagnosis for a Mallory-Weiss tear is made by OGD. This tear in the oesophageal mucosa occurs after a rise in abdominal pressure, 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. Treatment is supportive because most cases 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 71-year-old woman presents with early morning diarrhoea of 3 months duration and is found to be anaemic. There is no obstruction on digital rectal examination, but blood is noticed on the finger stall.
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
D. Colonoscopy - Anaemia in this case is a sinister sign which could point to possible malignancy, particularly given the patient’s advanced age. There is GI bleeding here, presumed to be lower GI, which needs to be investigated with a colonoscopy.
A 80-year-old gentleman became agitated recently, he has behavioural changes including sexual disinhibition. He is unable to take care of himself, being unable to plan or make judgements on even simplest matters. His MMSE is 25/30.
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
H. Picks disease - Pick’s disease (not to be confused with Niemann-Pick disease) is one cause of frontotemporal degeneration. If you are not aware of this then this question would have been difficult. In any case, you should have realised that this is frontotemporal dementia. This type of dementia presents primarily with disruption in personality and social conduct, or as a primary language disorder. Essentially, the patient will present with components of the dysexecutive syndrome. Almost 50% will also display parkinsonism and a subset also have MND. Treatment is supportive combining medications ranging from BZDs to antidepressants depending on symptoms, with community services and carer guidance.
True or False, the trigeminal nerve carries taste sensation from the anterior two-thirds of the tongue.
False - The facial nerve carries taste sensation and the trigeminal carries touch/pain/temperature sensation from the anterior two-thirds of the tongue.
An 18 year old student attends A&E at 2am with acute onset of vomiting, diarrhoea and abdominal cramps. There is some blood in the stool and he has a high fever. He hasn’t been abroad recently. His FBC had a normal Hb but raised neutrophils.
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
A. Bacterial gastroenteritis - This acute presentation in a previous fit and healthy individual and the raised neutrophils on FBCand a fever indicate an infective cause for his GI symptoms. It is self-limiting and diagnosis is on isolating the organism from a stool culture (if needed). Blood in the stool allows you to narrow down the list of potential causative organisms. 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. It is worth noting that viral gastroenteritis often presents with mainly UGI symptoms like N&V more so than diarrhoea.
25 year old female with acute onset of chills, fever, cough with brown phlegm for three days. On examination she appears toxic, temperture 40degrees C, reduced breath sounds, bronchial breathing and stony dullness left lung base.
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
B. Pneumonia - The rusty coloured phlegm is hinting at a pneumococcal pneumonia.The patient has presented with common symptoms of fever, chills and a cough. There may also be SOB, rigors and pleuritic chest pain. The most specific and sensitive test is a CXR (PA and lateral) and initial treatment of a CAP is empirical with antibiotics. Often diagnosis is made solely on history and examination findings. Bronchial breathing, reduced breath sounds and the presence of a left sided parapneumonic effusion all indicate a pneumonia. Management is guided by the patient’s CURB-65 score.
A 25-year-old woman comes back from holiday complaining of a two day history of frequency and dysuria. On dipsticking the urine you find red cells, leukocytes and protein.
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
D. MSU: microscopy antigen blood test - This young woman has presented with a UTI (dysuria, frequency, haematuria). Sexual activity the strongest risk factor for UTIs in women and she’s just come back from ‘holiday’. It is diagnosed with a urine dipstick (already done), and microscopic analysis for bacteria, WBC and RBC and urine culture and 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 70 year old woman has seen her GP for depression on several occasions. She now complains of abdominal pain, constipation & thirst
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
B. Hypercalcaemia - Symptoms of high calcium include confusion, constipation, polyuria, polydipsia, depression, kidney stones and lethargy. This can be remembered by ‘stones, bones, abdominal groans and psychiatric moans’. 90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. Malignancy can cause hypercalcaemia either by direct bony involvement leading to osteolytic lesions or paraneoplastic syndromes involving PTHrp release. The tumour is typically very advanced if hypercalcaemia is a feature. Less common causes include vitamin D overdose, hyperthyroidism, immobilisation, Paget’s and milk-alkali syndrome. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica which causes pain. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.
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.
Match the cause of hypotension to the following case histories. Each option may be used once, more than once or not at all.
67 year old man was observed to be very drowsy 12 hours after an aortic aneurysm repair. There had been considerable blood loss & he had been given 4 units of blood during surgery. He had been written up for pethidine 50-100mg 3 hourly postoperatively & had had 3 doses. BP had been 150/80 post-operatively & was now 100/60 with a pulse rate of 75/minute. Oxygen saturation was low at 85%.
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
C. Drug induced - Opioid OD symptoms include CNS depression (drowsiness, sleepiness), respiratory depression and relative bradycardia. This patient needs ventilation prior to the administration of naloxone, titrated to patient response.
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 40 year old woman has high blood pressure despite treatment with bendrofluazide & atenolol. Blood tests show Na 140mmol/l, K 3mmol/l, urea 6mmol/l. His bendrofluazide is stopped & he is prescribed potassium supplements, but 2 weeks later his K is still 3mmol/l. Plasma renin activity is low.
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
F. Conn’s syndrome - The normal range for potassium 3.5-5mmol/l. You should really know the normal ranges for common values like sodium, potassium and urea by this stage. In Conn’s, potassium is normal or low. It is important when drawing blood to avoid haemolysing the sample, which will cause a falsely elevated potassium level. 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 50 year old with pulmonary fibrosis develops sudden left-sided pleuritic pain & dyspnoea. He has reduced air entry in the left side of the chest & percussion is hyper-resonant. Oxygen saturation is 80%.
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
I. Chest drain - This patient has developed a pneumothorax. This is a secondary spontaneous pneumothorax, and if large enough for a chest tube or the patient is clinically unstable, chest drain insertion is indicated. Simple aspiration success rate is reduced in secondary spontaneous pneumothoraces. Primary pneumothoraces occur in young people without known lung conditions. This patient has pulmonary fibrosis. Those who suffer recurrent pneumothoraces may have to undergo pleurodesis using a chemical such as doxycycline to stick the perietal and visceral pleural together by an inflammatory reaction.
choose the SINGLE test from the list above that would be of most help in establishing the diagnosis
Pulmonary embolism
A. CT chest, abdomen and pelvis B. Ventilation-perfusion scan C. Duplex ultrasound D. Trans-thoracic echocardiography E. Upper GI endoscopy F. D-dimer G. Renal function tests H. Barium swallow I. Barium enema J. MRI head K.CT head
B. Ventilation-perfusion scan - The first line recommended initial imaging test is a CT chest to directly visualise the thrombus in a pulmonary artery, which would show as a filling defect. However this option is not given in this list and the test to pick here is a V/Q scan, which offers a similarly high level of sensitivity and specificity. In a PE the area affected will be ventilated but not perfused.
A 60-year-old woman, body mass index 22, normal sugar, lipids and electrolytes, BP 165/102 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
C. ‘Essential’ hypertension - Defined as BP >140/90 or >130/80 in those with renal disease. Typically diagnosed in screening asymptomatic patients. Treatment aims at modifying lifestyle (reducing salt intake to 160/100). Treatment differs for the stages and depends on whether there are any co-morbidities. For example, if there is AF the first choice is a beta blocker and if there is BPH the first choice agent is an alpha blocker.
An 18-year-old man presents with a night-time cough and shortness of breath while playing football. This has got progressively worse over the previous 2 months.
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
C. Asthma - SOB and the cough, which may wake the patient from sleep combined with the patient’s age and progessive course suggest asthma. Examination can show an expiratory wheeze but may be normal and treatment is step-wise based on BTS guidelines. It is worth noting that in severe exacerbations, the chest may be silent. Night symptoms occur in more severe asthma and symptoms can be exacerbated by exercise. Diagnosis is supported by PEFR variation of at least 20% over 3 days in a week over several weeks or an increase of at least 20% to treatment. Stepwise treatment is outlined below. Look up the BTS guidelines for more information.
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 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.
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
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.
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.
30 year old intravenous drug abuser presented to the GP with shortness of breath. The GP sent him for a blood count, HIV testing & a chest x-ray. He was found to be HIV positive. Chest x-ray showed bilateral fluffy opacities.
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
E. Pneumocystis jirovecii - PCP is caused by Pneumocystis jirovecii, previously called Pneumocystis carinii. It is a fungal organism and an AIDS defining illness. Signs and symptoms occur in a patient who is immunosuppressed, especially HIV with a CD4 count
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 65 year old ex-smoker is deeply jaundiced. He has epigastric pain radiating to his back. A dilated gall bladder is palpable and there is hepatomegaly. He has lost about 5kg in weight.
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
C. Cancer of the pancreas - Pancreatic cancer (of the head) typically presents with painless obstructive jaundice and weight loss and generally presents late. There is however epigastric pain in this case, which is a possible presentation. 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: 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 40-year-old man presents with dysphagia that worsens as he eats. He has droopy eyelids and sometimes has difficulty speaking.
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
E. Myasthenia gravis - Myasthenia gravis is an autoimmune condition with antibodies affecting the NMJ, mostly the nAChR at the post-synaptic muscle membrane. Although some have antibodies against MuSK, and there are other proteins involved. MG is characterised by muscle weakness which increases with exercise (fatigue, demonstrated here as the dysphagia gets worse as he eats, unlike Lambert-Eaton myasthenic syndrome). Commonly, presentations include diplopia and drooping eyelids like this patient, and there may also be SOB, proximal limb weakness, facial paresis and oropharyngeal weakness. MG is associated with thymic hyperplasia in 70% or thymoma in 10%, and these associations can also crop up in EMQs. There will be elevated serum AChR receptor antibody titres or MuSK antibodies. Electrophysiology will demonstrate a decremental response on repetitive nerve stimulation. Treatment includes anticholinesterases (pyridostigmine, and immunotherapy. Patients may also require a thymectomy. Some 15-20% may experience a myasthenic crisis (which needs mechanical ventilation). Do you know what the Tensilon test is and why edrophonium is given in this test?
A 25 year old West Indian lady presents with a painful swelling in the upper neck. The lump fluctuates, is not hot & the overlying skin is discoloured. She is tachycardiac, pyrexial & feels generally unwell.
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
D. TB abscess - This is a cold abscess of TB, which is a cold mass with overlying skin changes where the skin turns a purple-ish colour. The accompanying symptoms are those of TB infection (fever, feeling unwell, tachycardia). Effectively, it is a scrofula, which is TB infection of the lymph nodes in the neck (lymphadenitis). If you are lucky enough to see one on the wards, you won’t forget it.
A 48 year old male 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. 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
D. 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. 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?
An unconscious 35-year-old man who has a capillary blood glucose of 1.5 mmol/L.
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
C. IV dextrose - This patient is profoundly hypoglycaemic (symptoms of hypoglycaemia are present when glucose drops
A 62-year-old lorry driver presents with sudden-onset weakness of the right side of his body as well as ipsilateral loss of vision on the left, which he describes as like a ‘curtain’ descending over his field of vision. His symptoms resolve completely a few minutes later.
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
A. Duplex doppler ultrasound - This man is presenting with classic features of a TIA. A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour (and resolve within 24 hours). An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF. Clopidogrel is an alternative in those who do not tolerate aspirin.
The description of transient visual disturbance like a curtain descending over the eye is characteristic of amaurosis fugax. Amaurosis fugax is a transient and painless loss of vision in one eye due to the passage of an embolus into the central retinal artery. The cause could be embolic from the internal carotid artery to cause an occlusion of the ipsilateral retinal artery. Patients presenting with TIAs should be investigated for carotid artery stenosis with a carotid Doppler ultrasound as there is a high risk of having a subsequent full blown stroke. Furthermore if there is a stenosis of >70%, the patient may be a candidate for carotid endarterectomy. Presence of ipsilateral carotid stenosis suggests artery-to-artery embolic event as the cause and this should be the target for surgical or interventional treatment. Follow up tests could be CT angiography or MRA to expand on the abnormal Doppler results. They are not appropriate first line investigations to do here. Head CT is usually normal in TIA. ECG should also be done to investigate for AF which is a common risk factor for embolic cerebral ischaemia.
A 41 year old woman with a history of neurofibromatosis has erratic BP readings. Some readings are as high as 220/120 where as otheres are normal. She comes to you complaining of intermittent headaches, sweating and palpitations.
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
M. Phaeochromocytoma - Phaeochromocytomas presents with paroxysmal episodes of palpitations, anxiety, excessive sweating, pallor and hypertension. It can be inherited in MEN2, von Hippel-Lindau syndrome and NF1. Diagnosis is based on raised urinary and serum catecholamines, metanephrines and normetanephrines. 24 hour urinary VMA will be elevated. CT is used to localise the tumour. Treatment includes medical with the use of phenoxybenzamine, phentolamine and surgical options. Surgical excision is carried out under alpha and beta blockade to protect against the release of catecholamines into circulation when the tumour is being manipulated. The 10% rule is often quoted: 10% are bilateral, 10% malignant, 10% extraadrenal and 10% hereditary.
A 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 40-year-old man presents with an instantaneous onset of a severe headache, followed by drowsiness & vomiting.
A. Extradural haemorrhage B. Cluster headache C. Trigeminal neuralgia D. Subarachnoid haemorrhage E. Migraine F. Tension headache
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.
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.
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.
A 32 year old woman at 34 weeks gestation presents with acute RUQ pain and a frontal headache. There is oliguria and increasing oedema as well as proteinuria of 3+ on urinalysis. Creatinine is elevated. The doctor starts her on labetalol.
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
G. Pre-eclampsia - This is a syndrome characterised by new onset hypertension and proteinuria in pregnant women after 20 weeks gestation. The only definitive treament is to deliver the placenta and a risk-benefit to the mother and baby should be carried out to determine the best clinical step. The doctor starts her on an antihypertensive here so while the question does not directly tell you she is hypertensive, this can be inferred. If the patient doesn’t have either hypertension or proteinuria, then they do not have pre-eclampsia. The woman may be asymptomatic, or like this case, may present with symptoms indicating a more severe disease such as a headache which is usually frontal and upper abdominal pain usually in the RUQ (a clinical symptom of HELLP syndrome which is a subtype of severe disease characterised by Haemolysis, ELevated liver enzymes and Low Platelets). Oedema is very common but quite non-specific as a presentation. Oliguria may be present and again is a sign that the pre-eclampsia is severe. The raised creatinine indicates underlying renal impairment and renal failure can be a rare complication, often occuring as ATN with either sepsis or placental abruption.
For each of the malignancies listed below, please select the recognised presentation from the list of options.
Renal cell 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
B. Erythrocytosis - Erythropoietin is produced in the kidney and renal cell carcinoma may lead to increased production as a paraneoplastic syndrome. This causes a a secondary polycythaemia.
A 20-year-old medical student complains of a throbbing pain bilaterally across her forehead, which is present for some hours each time. She is busy catching up on online EMQs and lectures for her exams next week. Physical examination is normal.
A. Extradural haemorrhage B. Cluster headache C. Trigeminal neuralgia D. Subarachnoid haemorrhage E. Migraine F. Tension headache
F. Tension headache - A tension headache is commonly triggered by stress and mental tension (also, fatigure and missing meals), hence the name. It is more common in females and those in middle age, and there is a link with lower socioeconomic status, although this does not necessarily represent causation. Symptoms include a dull, non-pulsatile and constricting bilateral pain, which is often described as a band across the patient’s head. It is not severe or disabling but classically worsens as the day progresses. This headache normally responds well to simple analgesics.
Choose the malignancy that is most strongly associated with the risk factor below
previous hepatitis C infection
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
G. Hepatocellular carcinoma - A large proportion of patients with acute hepatitis C infection develop chronic hepatitis. Of these, 3% develop hepatocellular carcinoma following the development of cirrhosis
An anxious man walks into clinic he is sweating and looks red, his blood pressure is raised, he faints when he is told the dr would like to obtain a blood sample.
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
B. Panic attack
A 60 year old man with diarrhoea is transferred from another hospital for urgent femoral-distal bypass surgery & arrives with a heparin infusion in situ. His APTT is 2.4.
A. Diclofenac B. Codydramol C. Paracetamol D. Morphine E. Tramadol G. Epidural bupivacaine fentanyl
G. Epidural bupivacaine fentanyl - Epidurals are relatively contraindicated in anticoagulated patients. Insertion of the epidural needle may lead traumatic bleeding into the epidural space and with clotting abnormalities, the development of a haematoma which can lead to spinal cord compression. Coagulopathy, raised ICP and infection at the injection site are absolute contraindications. Relative contraindications include anticoagulated patients and those with anatomical abnormalities of the vertebral column. NSAIDs do not increase the risk of epidural haematoma.
A 68-year-old diabetic woman with venous ulcers was admitted with cellulites. The acute infection has now cleared but she needs regular compression dressings to help the ulcers heal.
A. Dietician B. Hospital doctor C. General practitioner D. Social worker E. Macmillan nurse F. Speech and language therapist G. Ward nurse H. Occupational therapist I. Physiotherapist J. District nurse
J. District nurse - District nurses visit people in their homes or in care homes and provide care in that context. They also provide teaching in the community.Always remember that an MDT ethos is needed for most cases. This is especially true for stroke patients.
A 32-year-old male architect arrives in your clinic accompanied by his husband. He complains of a 2-week history of indigestion and dysphagia. On examination you notice multiple purple bruise-like lesions on his right arm. There is no pain or itching.
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
C. Kaposi’s sarcoma - Kaposi’s sarcoma is a malignant tumour of the vascular endothelium consisting of spindle cells and small blood vessels. It is very rare in patients without HIV infection or those who are immunosuppressed. It gives rise to multiple lesions in the skin that appear like purple bruises and are not painful to touch. In about 40% of cases (such as this one) there is gastrointestinal involvement.
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.
A 30 year old man with a history of alcohol abuse is found by the police lying on the side of the motorway. The man has severe ataxia on walking into A&E. On examination, he is clearly confused. There is horizontal gaze palsy with markedly impaired vestibulo-ocular reflexes.
- Alcohol withdrawal
- Viral encephalitis
- Miller-Fisher syndrome
- Wernicke’s encephalopathy
- Wernicke’s encephalopathy - Wernicke’s encephalopathy is caused by the acute deficiency of thiamine in a susceptible host. It is clinically underdiagnosed. The classic triad is of mental status changes, ophthalmoplegia and gait dysfunction, though this is present in only 10% of cases.
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 48 year old male pharmeceutical worker presents with difficulty sleeping. On further questioning you find out that it is due to coughing all night. He is also suffering chest tightness, breathlessness and you can detect a wheeze when he talks to you. Although his wife notes that he is not as bad on the weekend.
A. Cystic fibrosis B. Pancreatitis C. Tuberculosis D. Emphysema E. Asthma F. Pneumonia G. Chronic bronchitis H. Bronchiectasis I. Lung cancer J. HIV K. Lung abscess
E. Asthma - This patient has signs and symptoms of 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 is based on BTS guidelines:
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.
An 18 year old student started university 3 months ago. She has felt flu-like for 2 days. In the last 2 hours she has developed a severe headache, vomiting, temp of 390C & photophobia. On examination she has neck stiffness & a positive Kernig’s sign. 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
F. Lumbar puncture - 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. 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.
A 65-year-old man presents with a large painless bladder and overflow incontinence at night and a raised creatinine level.
A. Iatrogenic B. Bladder calculus C. Hydronephrosis D. Advanced prostate cancer E. Acute prostatitis F. Localised prostate cancer G. Bacterial cystitis H. Gram negative septicaemia I. Anal fissure J. Benign prostatic enlargement
C. Hydronephrosis - This patient has BPH which has caused hydronephrosis. This is an example of bilateral obstructive uropathy. Acute presentations are often painful whereas chronic presentations are more insidious in onset. Blockage of urinary flow by the enlarged prostate has led to urinary retention and overflow incontinence. Initial treatment aims to relieve the pressure on the kidneys. This involves catheterisation as the first line treatment. The patient should be started on alpha blockers at the time of catheterisation.
A 23 year old man who has taken an overdose of an unknown drug after getting dumped by his pregnant girlfriend (he is not the father) was admitted to A&E. He is slightly tachycardic, complains of tinnitus and has high blood pressure at first but 30 minutes later, starts seizing and is intubated. There is a wide anion-gap metabolic acidosis.
A. Salicylates B. Benzodiazepines C. Insulin D. Volatile solvents E. Tricyclic antidepressants F. Anthrax G. Opiate analgesics H. Carbon monoxide I. Ecstasy J. Methanol K. Alcohol intoxication L. Ethylene glycol M. Sympathomimetics
A. Salicyclates - This is salicylate overdose which is potentially fatal and can present either acutely or indolently with more chronic exposure. It is a relatively common overdose so really with anyone presenting with an unknown overdose it should be considered along with paracetamol. The unexplained acid-base disturbance should make you suspicious of this diagnosis. Tinnitis is common in the early stages of acute salicylate poisoning and reflects CNS toxicity. There may also be deafness and both are reversible. Seizures are common especially in patients with salicylate levels >80mg/dL. An ABG is also indicated in this patient which during the course of salicylate poisoning would initiually show a respiratory alkalosis and later a concomitant metabolic acidosis, potentially with a wide anion gap. 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 28 year old woman presents with severe weakness in the legs and distal arms. She began to have foot drop in her pre-school years which has progressed through her teens. She finds walking up stairs difficult and has been wheelchair bound since the age of 20. You notice the lower leg and foot are atrophied and there is pes cavus.
- Diabetic neuropathy
- Charcot-Marie-Tooth disease
- Hereditary spastic paraplegia
- Motor neurone disease
- Charcot-Marie-Tooth disease - This history here points to Charcot-Marie-Tooth disease. There is pes cavus and distal atrophy of the legs here which are characteristic features. The progressive history from childhood suggests this genetic condition as the cause.
