Quiz Questions Flashcards
A 75 year old recently widowed male smoker with a history of angina presents with shortness of breath. He has also vomited & complains of a ringing in his ears. On examination the patient has a BP of 80/50mmHg & fine crackles at both lung bases.
A. Mitral stenosis B. Pneumonia C. COPD D. Pneumothorax E. Anaemia F. Left ventricular failure G. Thyrotoxicosis H. Epiglottitis I. Asthma J. Anxiety K. Aspirin poisoning L. Pulmonary embolus M. Mitral regurgitation
K. Aspirin poisoning - This patient has angina so probably has a stash of aspirin. Tinnitis is common in the early stages of acute salicylate poisoning and reflects CNS toxicity. There may also be deafness and both are reversible. GIT decontamination should be considered as an adjunct on arrival to A&E and activated charcoal can be given. The mainstay of treatment is alkaline diuresis induced by an infusion of sodium bicarbonate. In cases of severe poisoning, it is still started as a bridge to haemodialysis.
A 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 The IVP has now been replaced by the CT scan which is the new diagnostic standard.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 14 year old boy with bilateral breast enlargement.
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
D. Gynaecomasatia - This is a boy who has enlarged breasts. Normal to see gynaecomastia in puberty. Other causes include liver disease and as a side effect of drugs such as digoxin, spironolactone and cimetidine.
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 infiltrate 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.
Each of these patients has been found to have raised blood prolactin, select the most likely aetiology for each case.
A 45 year old lady complains of headache and double vision.
A. inadequate treatment B. Metoclopramide C. Ibuprofen D. Macroadenoma E. Acetaminophen F. non epileptic seizure G. Microadenoma H. epileptic seizure
D. Macroadenoma
A 30 year old company executive became unwell whilst on a business trip. He developed a high fever, muscle pains, nausea & vomiting, abdominal pain. He admitted to the hotel doctor that his cough has worsened over the past 7 days & he had coughed up blood on a couple of occasions. Chest x-ray showed consolidation in both lungs.
A. Atypical pneumonia B. Bronchial carcinoma C. Pleural effusion D. Sarcoidosis E. Fibrosing alveolitis F. Pneumothorax G. Lung abscess H. Bronchiectasis I. Bronchial asthma J. COPD K. Cystic fibrosis
A. Atypical pneumonia - Given this is the only pneumonia option on the list, this is an easy question, although the presentation is in line with an atypical organism. The most common atypical pneumonias are Mycoplasma, Legionella and Chlamydophila (Chlamydia). All can be treated with macrolides and are to some extent sensitive to fluoroquinolones and tetracyclines too, although these are contraindicated in pregnancy. Check local prescribing policies first.
A 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.
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.
A 12 year old boy presents with a flu-like illness, fever, headache, vomiting, tremor of the left side of the body and weakness of his left leg.
A. Giardiasis B. Polio C. Glandular Fever D. Malaria E. Viral Hepatitis F. HIV G. Tuberculosis H. Herpes Zooster (Shingles) I. Cholera J. Toxoplasmosis K. CMV (cytomegalovirus) L. Syphilis M. Tetanus N. Influenza O. Rabies
B. Polio - Poliovirus infection is usually asymptomatic and when symptomatic the most common presentation is with a minor GI illness. There is no cure for poliovirus infection and treatment is primarily supportive. This patient has acute flaccid paralysis (AFP), or paralytic poliomyelitis, which is the hallmark of major illness. This can rarely progress to bulbar paralysis and respiratory compromise. Paralytic poliomyelitis presents with decreased tone and motor function, as well as reduced tendon reflexes and muscle atrophy of the affected limb. Lack of vaccination is a strong risk factor. Remember that there are two main types of polio vaccine – Sabin, which is the oral weakened strain in disease endemic regions, and Salk, which is inactivated poliovirus in the rest of the world.
A 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.
A 30 year old woman with toothache has taken 50 paracetamol 500mg tablets in the last 24 hours. She feels nauseated and still has toothache but is otherwise well.
A. Haemodialysis B. Oral methionine C. Hyperbaric oxygen D. Activated charcoal E. IV-naloxone F. Forced alkaline diuresis G. Gastric lavage H. Forced emesis I. IV-ethanol J. IV-glucagon K. N-acetlycysteine
K. N-acetylcysteine - Paracetamol OD can occur after a single large OD or repeated ODs. Often, the patient is asymptomatic at initial presentation but if untreated may cause liver injury over the 2-4 days after ingestion, including fulminant liver failure. Paracetamol is the most frequent intentional OD drug in this country. The risk of liver damage is increased after taking drugs which induce CYP 450. Inducers include St John’s wort, barbiturates, phenytoin, tetracycline, chronic alcohol use and carbamazepine. A serum paracetamol level is important to order as early as possible, but at the earliest 4 hours post-ingestion.Treatment if indicated is with N-acetylcysteine with the level based on a paracetamol treatment graph.
A 25 year old woman is admitted semi-comatose. She has been complaining of increasing thirst & lethargy over the previous few weeks. BM stick result is 36mmol/l. Blood pH is 7.10 with a HCO3- of 15mmol/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 - Initial treatment of DKA aims at correcting severe volume depletion, 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. Bicarbonate therapy may be necessary in adults with pH 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 62 year old man who requires a knee replacement gives a history of allergy to dihydrocodeine.
A. Diclofenac B. Codydramol C. Paracetamol D. Morphine E. Tramadol G. Epidural bupivacaine fentanyl
B. Codydramol - Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
A 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.
A 70 year old diabetic man, who smoked 40 cigs/day for 40 years. He presents with abdominal pain worse at night & radiating to his back. He is losing weight, suffers from dyspepsia & pruritus. On examination he is cachectic, jaundiced & has an enlarged gallbladder.
A. Reflux oesophagitis B. Cancer of the liver C. Hiatus hernia D. Cancer of the pancreas E. Gastric ulcer F. Liver cirrhosis G. Irritable bowel syndrome H. Coeliac’s disease I. Carcinoma of oesophagus J. Duodenal ulcer K. Inflammatory bowel disease L. Chronic hepatitis M. Primary biliary cirrhosis N. Pancreatitis
D. Cancer of the pancreas - Pancreatic cancer typically presents with painless obstructive jaundice and weight loss and generally presents late. It can however, like this case, present with abdominal pain which is typically non-specific in the upper abdomen. If the patient presents with persistent back pain, then this symptom is consistent with retroperitoneal metastases. It is estimated that 1 in 4 cases can be linked to smoking. Whipple’s procedure or Traverso-Longmire procedure (pancreaticoduodenectomy) offers the only hope of a cure but only a small minority are elegible for these procedures. The first tests to order are an abdominal USS and LFTs. Note Courvoisier’s law with regard to this question: Jaundice and a palpable painless gallbladder is unlikely to be caused by gallstones. The tumour marker for pancreatic cancer is CA19-9 which is useful in preoperative staging.
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 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 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 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 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.
A 33 year old presented with retrosternal discomfort on swallowing but without any real difficulty swallowing. O/E he was found to have creamy plaques in his mouth and later admitted to having AIDS.
A. Diffuse oesophageal spasm B. Eosinophilic oesophagitis C. Upper oesophageal web D. Globus hystericus E. Benign oesophageal stricture F. Oesophageal diverticulum G. Candidal oesophagitis H. Scleroderma I. Parkinson’s disease J. Achalasia K. Oesophageal cancer L. Stroke
G. Candidal oesophagitis - This is really odynophagia rather than true dysphagia. Whenever a patient complains of ‘difficulty swallowing’, you should always take a good history and explain what the patient actually means by this. Does the patient mean that there is true difficulty swallowing, or just that it is painful to swallow, or is there a feeling of a lump in the throat (globus). The white plaques here give alongside discomfort away the diagnosis. The patient also has AIDS and is therefore immunocompromised. Candidiasis here is an opportunistic infection in an immunocompromised host and is a mucosal infection caused in most cases by Candida albicans (and occasionally by other species). Patients may present like this, or with oral or vaginal infection. Oral thrush may be seen (pseudomembranous candidiasis) with altered taste sensation or indeed dysphagia, as well as odynophagia in oesophageal disease. In vaginal infection, there is erythema with a white discharge and pruritis. This patient should be started on an empirical trial of antifungals. A systemic azole can be used such as fluconazole or itraconazole.
A 25-year-old single mother of three children presents in respiratory distress. There is progressively worsening SOB, wheezing and cough over the last 2 days. When you examine her, there are faint breath sounds, HR 120, RR 30. She gives a 6 month history of cough and SOB which has every now and then woken her up from sleep.
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
J. Bronchial asthma - Progressively worsening SOB and the wheeze, which may like this case wake the patient from sleep combined with the long duration of symptions suggests asthma. This patient is having an acute exacerbation and needs to be treated for this, before commencing the appropriate stepwise chronic treatment on the BTS ladder. Whether this exacerbation is mild, moderate or severe is based on the patient’s % predicted PEFR. Examination can show an expiratory wheeze and 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 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.
Previously well, 17-year-old girl presents with 3-months history of swelling of her right leg. There is no pain or other associated features. O/E you confirm pitting oedema of the shin, blood tests normal. Her mother also suffers from swollen legs.
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
D. Milroy’s disease - Milroy’s is primary lymphoedema with a familial autosomal dominant pattern of inheritance. It often presents in infancy. There is unfortunately no cure and treatment involves compression, with surgery reserved for those refractive to conservative measures and/or with major morbidity.
A 25 year old Jewish man presents to A&E with some abdominal discomfort, weight loss with associated loss of appetite. His history revealed loose and bloody stools. Examination reveals tenderness in the RLQ. He is booked in for endoscopy.
A. Duodenal ulcer B. Crohn's disease C. Meckel's diverticulum D. Oesophageal varices E. Gastric ulcer F. Mallory-Weiss tear G. Ulcerative colitis H. Oesophageal malignancy I. Oesophagitis
B. Chrones disease - This patient gives a history of IBD. This could well be UC where the mainstay of treatment is with 5-ASA. A colonoscopy is required to assess the extent of disease and for a definitive diagnosis. Biopsy in CD will show transmural granulomatous inflammation. CD can affect the whole GIT but favours the TI (RLQ pain) and proximal colon and is macroscopically characterised by skip lesions. UC on the other hand is characterised by the presence of crypt abscesses, which is pathognomic. CD risk is increased 3-4 fold by smoking whereas smoking seems protective in UC. The mainstay of treatment in CD is with steroids and azathioprine to revent relapses and for those suffering side effects of steroid treatment. TNF-alpha inhibitors also have a role. Surgery in CD is only indicated in a small number of patients who bleed, for bowel perforation and cases of complete obstruction. The aim is to rest distal disease by temporarily diverting faecal flow.
Mr D is a 17 year old man with cystic fibrosis for which he receives intensive physiotherapy. He has come in with shortness of breath and a mild fever. Sputum cultures demonstrated the growth of an organism which also produced a green pigment.
A. Pseudomonas aeroginosa B. Mycobacterium leprae C. Escherchia coliform D. Legionella pneumophila E. Campylobacter jejuni F. Neisseria meningitidis G. Mycobacterium tuberculosis H. Salmonella typhi
A. Pseudomonas aeroginosa - The green pigment here is pyoverdine which is produced by Pseudomonas. Pseudomonas has virulence factors for lung colonisation and is noted for its type III injection apparatus, which you may remember from your microbiology lectures. It is a gram negative bacilli causing hospital acquired pneumonia and UTI. It particularly affects immunocompromised hosts such as those on chemotherapy, those with cystic fibrosis (this patient), burns and wounds. Biofilms are antibiotic resistant.
Pseudomonas is also a special organism which is not sensitive to many antibiotics originally used for gram negatives. You need to prescribe a drug here which has specific anti-pseudomonal activity such as ceftazidime (a third generation cephalosporin), tazocin, ciprofloxacin, imipenem or gentamicin (usually used with one of the others). This organism acquires resistance genes very quickly so two antibiotics are given. It is, as mentioned, inherently resistant to many drug classes. Some are even resistant to all antibiotics.
A 20 year old woman is too breathless to speak. Her pulse is 120/min, respiratory rate 30 per min & peak expiratory flow is 100l/min. Examination reveals a very quiet chest & 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
E. Nebulised salbutamol - This patient is having an asthma attack. This patient is too breathless to speak and has a quiet chest so this is severe and ICU admission is indicated. Initial treatment is with repeated administration of an inhaled SABA with early systemic corticosteroids and supplemental oxygen, monitoring the patient’s status regularly.
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.
17 year old male with radiological apperance of rib notching on chest radiograph.
A. Addisons Disease B. Doxazosin C. Renal artery stenosis D. Phenelzine E. Conns syndrome F. Coarctation of the aorta G. Patent ductus arteriosus H. Cushings disease I. Hyperthyroidism J. Phaeochromocytoma
F. Coarctation of the aorta - Aortic coarctation is characterised by a BP difference between the upper and lower extremities. Posterior rib notching is due to enlargement of collateral vessels due to aortic narrowing. Diagnosis is made on demonstrating narrowing of the aortic arch, typically shown by echocardiography. Treatment may involve surgical repair such as the placement of a stent. This condition is typically congenital with a male predominance. It is commonly detected in the first decade and is associated with Turner’s and DiGeorge. An ejection systolic murmur is also common present over the LSB and back.
A 40 year old woman describes intermittent haemoptysis as well as small amounts of haematemesis. She has telangiectasia on her face.
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
I. Osler-Weber-Rendu synrome - This woman has the facial telangiectasia of OWR, also called hereditary haemorrhagic telangiectasia. This causes abnormal blod vessels pretty much everywhere which are prone to bleed. It is an autosomal dominant condition so a positive FH can often be found.
A 33 year old lady with no children has been suffering worsening pelvic pain particularly prior to menstruation and is now complaining of deep dysareunia.
A. Endometriosis B. Retroverted uterus C. Pelvic inflammatory disease D. Ectopic pregnancy E. Fibroids F. Endometrial cancer G. Adenomyosis
A. Endometriosis - Endometriosis is a chronic inflammatory condition defined by endometrial stroma and glands located outside of the uterine cavity – the most common sites being the pelvic peritoneum and ovaries. It may present as an incidental finding in asymptomatic patients but more commonly it presents in women of reproductive age with chronic pelvic pain and/or subfertility. This woman has symptoms which make this diagnosis likely. There is dyspareunia which is pain during sexual intercourse, particularly on deep penetration, and may be caused by a distortion in the pelvic anatomy and rectovaginal involvement. There is also well documented genetic predisposition so a positive FH may be found. Additionally, nulliparous women are more likely to be diagnosed with endometriosis than parous women. The diagnosis can be confirmed on visualising the ectopic tissue directly and focused biopsies during laparoscopy but this is not generally necessary as clinical suspicion is enough to start treatment. Options for treatment include NSAIDs, COCPs, GnRH agonists, danazol or related androgens and surgical destruction of lesions. Those who present with subfertility may be considered for ovarian hyperstimulation and IVF.
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 66-year-old was getting increasing confused over the last couple of days. She was admitted after a seizure. She appears distressed and is pyrexial with mild meningism but no rash. A CT head scan shows changes in the left temporal lobe and cerebral oedema.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Encaphalitis - Encephalitis (brain parenchyma inflammation) is not to be confused with meningitis where the meninges is inflammed (although meningoencephalitis can exist). In encephalitis, there is an altered state of consciousness (this patient is confused) and may there also be focal neurology. There is also a fever (exceptions, however, are subacute sclerosing panencephalitis, VZV and HCV). Other typical features include headache and seizures. It is a medical emergency and people are the extremes of age are more at risk. The list of possible causes is massive. HSV encephalitis is characterised by temporal lobe changes. Hypodense lesions and mass effect can be seen in the temporal lobes on CT. An MRI is a better test for encephalitis although it is less available when compared to CT.
If you suspect this diagnosis, empiral IV acyclovir should be started before the results of any investigations are known. A large proportion are caused by HSV and empirical therapy is backed up by RCTs which show improved mortality. You can change the treatment if the cause is known, for instance, ganciclovir for CMV. You should look for a rash which may give a clue to the aetiology. For example, vesicular patterns are seen in VZV, HSV and enteroviruses, EBV causes a maculopapular pattern after ampicillin, Lyme disease pathognomically gives erythema migrans whereas erythema nodosum might make you think of TB. The patient may also have animal/insect bites and a careful and thorough history is important.
A 48 year old male stripper presents with bruising, infections and fatigue. Lab findings indicate a pancytopenia with low reticulocyte count. Bone marrow biopsy is done on which a definitive diagnosis is made.
A. Idiopathic thrombocytopenic purpura B. Wiskott-Aldrich syndrome C. Hepatic cirrhosis D. Haemophilia E. Skull fracture F. Spontaneous G. Disulfiram H. Aplastic anaemia I. HIV J. Corticosteroids K. Diuretics L. Clopidogrel
H. Aplastic anaemia - This is aplastic anaemia characterised here with the pancytopenia (which is common, but diagnosis requires 2 cytopenias out of 3) and the presentation with infections (neutropenia), fatigue (anaemia) and bruising (thrombocytopenia). Risk factors include paroxysmal noctural haemoglobinuria, hepatitis and NSAIDs. If macrocytosis is seen, this may suggest an inherited syndrome such as Fanconi’s anaemia. The reticulocyte count here rules out haemolytic anaemia, which isn’t even an option on the list. The definitive diagnosis is made on biopsy of bone marrow which shows a hypocellular marrow with no abnormal cell populations and no fibrosis. Which conditions would there be abnormal cell populations or fibrosis on bone marrow biopsy?
A 19 yo old girl with thinning hair is seen in clinic. the notes say she has been prescribed the OCP for 2 years following an ultrasound. Her BMI is found to be 27, prior to the pill she had had one or two periods a few months apart.
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
H. PCOS - Young and obese may point to TIIDM however she has been prescribed the OCP for years.This is to manage the androgen excess resulting from her PCOS. Evidence for this is her thinning hair and oily skin coupled with her abdominal ultrasound used to diagnose her condition. Insulin resitance, obesity, dyslipidaemia and oligoovulation are all features of this condition.
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 27-year-old gentleman has a long history of frequent nose-bleeds. O/E of his nose you notice red spots on muous membrane. on his face and skin you can also notice some red spots.
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
F. Osler-Weber Rendu syndrome - This man has the facial telangiectasia of OWR, also called hereditary haemorrhagic telangiectasia. This causes abnormal blod vessels pretty much everywhere which are prone to bleed. It is an autosomal dominant condition so a positive FH can often be found.
A 17-year-old girl recently started OCP. She presents with abdominal pain and, vomiting and tachycardia. She has developed left foot drop.
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
A. Porhyria - There are many types of porphyria. This patient has acute intermittent porphyria, which is characterised by symptoms like the ones this patient describes – abdominal pain, peripheral motor neuropathy, mental symptoms like confusion. These symptoms, certainly in EMQs, can be trigged by the use of certain drugs which are known to provoke AIP attacks. In reality, the list of drugs is pretty vast and include most CYP450 inducers, but in EMQs, alcohol and the OCP are common. It is worth noting that alcohol also induces an enzyme called delta-aminolevulinic acid synthase, which can exacerbate AIP. It is probably not worth learning the pathways unless you plan on sitting USMLE. AIP is a genetic disorder where there is a partial deficiency of PBGD (the third enzyme in the haem biosynthetic pathway). Treatment of acute attacks involves IV haem arginate with adjunctive dextrose IV. The pain is thought to be neuropathic in origin. The patient may complain of red/browny urine due to increased urinary excretion of intermediates in the haem pathway.
A 12 year old boy presents with polyarthritis and abdominal pain. He had a sore throat about a week ago. Examination reveals an early blowing diastolic murmur at the left sternal edge. Shortly afterwards, there are bilateral involuntary jerky movements worse when the patient is asked to make a movement.
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
J. Acute rheumatic fever - Chorea features as part of the acute presentation in 5-10% of patients with rheumatic fever. It can also occur as an isolated event up to 6 months after the initial GABHS infection. It is named Sydenham chorea after the doctor who described St Vitus Dance in the 17th century. Choreiform movements can affect the whole body or just one side of the body, in which case it is referred to as hemi-chorea. The head is often involved with erratic facial movements that resemble grimaces, grins and growns, and the tongue may be affected to resemble a bag of worms when protruded, and protrusion cannot be maintained. In severe cases the patient may have an impaired ability to eat. Chorea disappears with sleep and is made worse by purposeful movements. When the patient is asked to grip the doctor’s hand, the patient will be unable to maintain grip and rhythmic squeezing occurs. There are two signs to look out for in these patients. The first is the spooning sign, which is a flexion at the wrist with finger extension when the hand is held extended. The pronator sign is the second which is when the palms turn outwards when held above the head. Both are consistent with chorea.
Remember that the 5 major manifestations of acute rheumatic fever are carditis, polyarthritis, chorea, erythema marginatum and SC nodules – the most common of which are carditis and polyarthritis. The murmur here is a manifestation of carditis. Primary episodes occur mainly in children aged 5-14 and are rare in those over 30. The greatest burden of disease remains in the developing countries and in populations of people living in poverty.
A 3 year old girl is febrile and has been unwell for 12 hours. She complains of a headache and is drowsy but otherwise neurologically intact. Choose the single most discriminating investigation in the acute management from the list of options:
A. ESR B. Blood cultures C. Chest X-ray D. Urine culture E. Stool electron microscopy F. EEG G. Stool culture H. Culture of joint aspirate I. C-reactive protein J. Lumbar puncture K. Throat swab L. Full blood count M. CT brain
J. Lumbar puncture - Meningitis commonly affects the extremes of age (60 years) due to impaired immunity in the former, and waning immunity in the latter. A lumbar puncture to obtain CSF is the most important investigation when this diagnosis is considered. This should not however delay the starting of empirical antimicrobial therapy. When the specific organism is identified, treatment can be modified accordingly. Fever, headache and drowsiness should make you suspicious here of this diagnosis. Atypical presentations can also occur, and these tend to happen in the very young, older or immunocompromised patients. In older patients, frequently, the only presenting sign of meningitis is confusion or an altered mental status. In infants, the signs and symptoms can be very non-specific and may include lethargy, poor feeding, irritability and fever. A rash is noted in 80-90% of patients, commonly 4-18 hours after initial symptoms and is associated with meningococcal aetiology (although may be present with any bacterial meningitis).
In bacterial meningitis, the CSF pressure is usually raised and WBC count is elevated. The glucose level is decreased compared to the serum value and the protein level is increased. In those who are untreated, Gram stain and culture of CSF are usually positive for the causative organism. However, in those who get antibiotics before cultures are obtained, the diagnostic yield is much lower (as low as 20%). If a lumbar puncture is delayed or regarded as clinically unsafe (for instance, raised intracranial pressure), then blood samples should be obtained for culture. Of course, a head CT should be considered before LP if there is focal neurology, new onset seizures, papilloedema, altered consciousness or any sign which may indicate raised ICP.
A 65-year-old woman presents with acute DVT. There is a low risk for bleeding. This step is added along with warfarin therapy.
A. Perform CABG B. Perform exercise ECG C. Add an ACE inhibitor D. Perform echocardiography E. Add Aspirin F. Add clopidogrel G. Perform coronary angioplasty H. Add Atorvastatin I. Advise lifestyle measures J. Add Atenolol K. Add low molecular weight Heparin L. Add Omega-3 oils M. Perform coronary thrombolysis
K. Add low molecular weight heparin - The mainstay of treatment for acute DVT is anticoagulation. This can be either unfractionated heparin, a LMWH or a factor Xa inhitor like fondaparinux. Fondaparinux has a higher half life than LMWH and there is no effective way of reversing it. LMWH have a shorter half life and some of it can be removed with protamine. Heparin though can be reversed quickly with protamine. Hence, if the patient is at a high risk of bleeding, they should be treated with unfractionated heparin and you should avoid fondaparinux. If they start bleeding you can just chuck them protamine. This however requires monitoring of APTT and platelet counts. If the patient has heparin-induced thrombocytopenia, you can try using fondaparinux. LMWH is recommended in those with active cancer and preferred in pregnancy, and consideration needs to be given in those with renal impairment. In this case LMWH or unfractionated heparin can be given, and the only option on the list is to add LMWH (such as enoxaparin, tinzaparin and dalteparin). Warfarin is started on the same day and LMWH should be used for at least 5 days until the INR is in the therapeutic range of 2-3 before the LMWH can be discontinued. (Some people say the INR has to be in that range for 48 hours before you remove LMWH)
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 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?
A 26-year-old, anxious teacher with diffuse headaches, SOB and tingling in the hands. Blood gas measurement shows low PCO2, but high normal PO2. pH is 7.49.
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
F. Re-breathing - A headache is a common presentation of someone suffering from an anxiety disorder. She is clearly hyperventilating here which is causing a respiratory alkalosis and accounting for her subjective experience of SOB. Paraesthesia is also seen in panic attacks with hyperventilation, associated with carpopedal spasm. Tell the patient to slow the breathing but breathing into a bag will help to raise PCO2. If it is an emergency setting you can consider using benzodiazepines. Long term treatment should be aimed at treating the anxiety disorder with for example CBT.
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 58 year old man with uncontrolled HIV infection and AIDS presents with 2 week history of blurred vision bilaterally. He also reports seeing visual floaters. Examination reveals a man who is severely cachectic with generalised lymphadenopathy. Fundoscopy reveals creamy coloured areas with overlying retinal haemorrhages.
1. Cytomegalovirus 2. Infectious mononucleosis 3. Mycobacterium avium complex 4. Human herpes virus 6
- Cytomegalovirus - This is a presentation of CMV retinitis, which is the most common manifestation of CMV disease in AIDS, the second most common being colitis. However do remember that virtually any organ can be affected by CMV and it can cause a range of conditions from encephalitis to pneumonitis. In CMV retinitis, fundoscopy will reveal areas of infarction, haemorrhage, perivascular sheathing and retinal opacification. These findings here are of chorioretinitis.
A 22 year old lady complains of being tired all the time. She has also gained a large amount of weight, feels constipated and cold all the time. Her HR ~ 45 bpm.
A. Glandular fever B. Hyperthyroidism C. Anaemia D. Psychological distress E. SIADH F. AIDS G. Colorectal carcinoma H. Diabetes mellitus I. Hypothyroidism J. Addison's disease K. Chronic renal failure
I. Hypothyroidism - There is weight gain, cold intolerance, fatigue and constipation as well as bradycardia which all point to hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned as well as depression, bradycardia, sluggish reflexes, constipation, cold intolerance and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.
A 5 year old boy presents with a fever, headache and a very itchy vesicular rash mainly on his chest and face. He has recently taking paracetamol for a sore throat. There has also been a high fever in the last 24 hours. Lung fields are however clear on CXR. In some areas the lesions are crusted over while in others they appear to be newly formed. A classmate at school has had similar symptoms recently.
1. Bartonella 2. Scabies 3. Stevens-Johnson syndrome 4. Varicella zoster
- Varicella zoster - This is VZV infection (chickenpox) which typically presents with a fever, malaise and a widespread vesicular and pruritic rash which primarily affects the torso and face. Most countries in Europe do not immunise children against varicella.
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 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.
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 middle aged man on the ward is inexplicably catheterised a week ago by your junior staff. The man opens his eyes when he hears you yelling at your team. However, when you go and talk to him, he groans and makes some sounds which you cannot make out as words. Your F1 pokes him in the eye before you can intervene. He lifts his hand towards his head in response.
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
B. 10 - M5 V2 E3 = 10
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 hypertensive old man with a history of atrial fibrillation is brought into A&E by his carer who is worried that he is getting confused. The carer tells you that he has fallen over frequently over the last few months and is unstable on his feet. There is right-sided pronator drift and some right sided weakness.
- Brain tumour
- Subdural haematoma
- Concussive syndrome
- Benign intracranial hypertension
- Subdural haematoma - There is a history of falls here and confusion. A subdural haematoma occurs due to extra-axial blood collection between the dura and arachnoid layers surrounding the brain. Surgical treatment will likely be necessary in this case with neurological deficit.
A 40-year-old African refugee has noticed recent weight loss. Although he attributed this to stress you are concerned when you detect generalised lymphadenopathy. Blood count shows neutropenia and thrombocytopenia.
A. Malignancy B. Anorexia nervosa C. Tuberculosis D. Addison's disease E. Malabsorption F. Infestation with helminths G. Cardiac failure H. Diabetes mellitus I. Hyperthyroidism J. Renal failure K. Liver failure L. Depression M. HIV
M. HIV - HIV is a retrovirus and there are two types, HIV 1 which is the main virus responsible and HIV 2 which is restricted to parts of West Africa. Weight loss is common in HIV and if more than 10% body weight is lost of BMI reduces to 18.5, this is an indication of more severe immunocompromise. Weight loss in HIV may result from malnutrition, co-existent TB infection or HIV wasting syndrome, the latter being an AIDS defining illness. Generalised lymphadenopathy is also common and is characterised by the painless enlargement of 2 more more non-contiguous sites of >1cm for >3 months. Neutropenia is also seen due to CD4 deficiency and thrombocytopenia may also be seen along with an anaemic picture.
There are WHO (stage 1-4) and CDC criteria used in clinical staging. This patient needs to have a CD4 count, HBV and HCV screen, VDRL (syphilis), tuberculin skin test (TB) and CXR. HIV viral load will also be assessed. Prophylaxis and immunisations should be considered against infections such as hepatitis, influenza, PCP and TB. When to initiate HAART depends on the clinical stage, CD4 and co-morbidities. This patient will need to be started on HAART. Classes of antiretrovirals include NRTIs, NNRTIs, protease inhibitors, fusion inhibitors and integrase inhibitors.
A 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 39 year old woman who is on mesalazine for her ulcerative colitis presents with 12 daily bowel movements and massive continuous bleeding PR; she is noted to have a raised ESR.
A. Palliative care B. Hemicolectomy C. IV immunoglobulin D. Anterior resection E. Topical GTN F. Haemorrhoidectomy G. Blood transfusion H. High fibre diet I. Colostomy J. Loperamide (Imodium) K. IV corticosteroids
K. IV corticosteroid - IV corticosteroids are used in fulminant disease. These patients need to be admitted. If there is no response to IV corticosteroids within 24 to 48 hours then surgery is indicated.
The immediate management of an acute deep vein thrombosis in someone who is at a high risk of bleeding.
A. Aspirin B. Unfractionated heparin C. Warfarin D. Vitamin K E. Fresh frozen plasma F. Low molecular weight heparin G. Protein S concentrate H. Platelet concentrates I. Thrombin infusion J. Fibrinogen K. Platelet concentrates plus fresh frozen plasma L. Fondaparinux (FXa inhibitor) M. Vitamin E
B. Unfractionated heparin - The mainstay of treatment for acute DVT is anticoagulation. This can be either unfractionated heparin, a LMWH or a factor Xa inhitor like fondaparinux. Fondaparinux has a higher half life than LMWH and there is no effective way of reversing it. LMWH have a shorter half life and some of it can be removed with protamine. Heparin though can be reversed quickly with protamine. Hence, if the patient is at a high risk of bleeding, they should be treated with unfractionated heparin and you should avoid fondaparinux. If they start bleeding you can just chuck them protamine. This however requires monitoring of APTT and platelet counts. If the patient has heparin-induced thrombocytopenia, you can try using fondaparinux. LMWH is recommended in those with active cancer and preferred in pragnancy, and consideration needs to be given in those with renal impairment.
A 65-year-old man had an inferior myocardial infarct 10days ago. His initial course was uncomplicated. He suddenly deteriorates with acute left ventricular failure. On examination the pulse is regular 100/min and normal volume and character. BP 110/60. The apex beat is dynamic. There is a loud grade 3/6, apical pansystolic murmur which radiates to the axilla.
A. Atrial septal defect B. Mixed mitral valve disease C. Ventricular septal defect D. Aortic regurgitation E. Infective endocarditis F. Aortic stenosis G. Innocent murmur H. Mixed aortic valve disease I. Mitral valve prolapse J. Hypertrophic obstructive cardiomyopathy K. Mitral stenosis L. Mitral regurgitation M. Mixed mitral and aortic valve disease
L. Mitral regurgitation - MR is loudest at the apex and radiates to the axilla and tends to be around grade 4. It is associated with a systolic thrill at the apex. TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaced apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.
A 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.
A holiday worker had a severe chest infection abroad & was diagnosed to have influenza A infection. He was improving but suddenly deteriorated with the last 24 hours becoming breathless, febrile & septic. X-ray chest showed circular opacities some with a fluid level. Gram stain of sputum showed Gram positive cocci in clusters.
A. Mycoplasma pneumonia B. Streptococcus pneumonia C. Varicella zoster D. Adenovirus E. Pneumocystis jirovecii F. Influenzae A G. Haemophilus influenza H. Group A streptococci I. Staphylococcus aureus J. Corynebacterium diphtheriae K. Legionella pneumophila L. Escherichia coli M. Aspergillus fumigatus N. Clamydia pneumoniae
I. Staphylococcus aureus - Think Staphylococcus aureus for post-influenza pneumonia. It causes a cavitating pneumonia which explains the CXR findings (some abscesses are also seen) and Gram stain of culture yields grape like clusters of Gram positive cocci which is consistent with staphylococcus. Treatment of staphyloccocal infection is with flucoxacillin or vancomycin if MRSA.
A 34 year old man describes pain & swelling in the left submandibular region after eating. The swelling is sometimes red & tender but usually settles within a few hours.
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
B. Sialolithiasis - This patient has sialolithiasis. Salivary gland stones cause pain whenever the patient salivates (eating or thinking of food). Stones are commonly found in the submandibular gland. Diagnosis can be confirmed by facial radiographs but a small number of sialoliths may not be seen on the plain film due to low calcium phosphate content. In this case, sialography used in combination with CT will demonstrate the stone. A complication is the development of sialadenitis.
A 55 year old lorry driver, a ‘fit’ smoker of 20-30 cigarettes a day, presents to his GP with a history of coughing up 2 streaks of blood on separate mornings in the previous week. He has had a morning cough with small amounts of sputum over the previous 10 years and admits on questioning that he may have lost weight and has had to tighten his trouser belt. The ESR was 75 and chest x-ray showed collapse of the right middle lobe.
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
J. Carcinoma of bronchus - The weight loss, respiratory symptoms of haemoptysis and the history of smoking makes this likely to be bronchial carcinoma. Lobar collapse here may be a consequence of obstruction. 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 59-year-old man presents with a one month history of constipation, tenesmus and fresh rectal bleeding. He also notes some weight loss recently.
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
H. Rectal carcinoma - This a rectal carcinoma. Tenesmus, blood PR alongside weight loss are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis
A 13 year old presents with fever and sore joints. She has had a sore throat about 3 weeks ago but did not see a doctor about it. While waiting in A&E she develops choreiform movements of the whole body and head with facial expressions that resemble grimaces.
1. Streptococcus pyogenes 2. Septic arthritis 3. Borrelia burgdorferi 4. Clostridium tetani
- Streptococcus pyogenes - This girl has rheumatic fever which is caused by an autoimmune process following infection with group A streptococci. The 5 major manifestations of acute rheumatic fever is something you need to be aware of. They are carditis, polyarthritis, chorea, erythema marginatum and SC nodules. Various other signs can also be seen such as spooning sign and pronator sign.
A 50 year old woman has developed weight loss and passes loose pale stools. She has mouth ulcers and is anaemic. She is taking thyroxine for myxoedema.
A. Abdominal X-ray B. Sweat test C. Thyroid function D. ERCP E. Immunoglobulin F. Skin biopsy G. Hydrogen breath test H. Colonoscopy I. Faecal elastase-1 J. Liver function tests K. HIV test L. Endomysial antibodies M. Abdominal ultrasound
L. Endomysial antibodies - This is a common condition in the US and Europe. Coeliac disease most commonly presents with IDA, although it can also lead to a macrocytic anaemia with mainly folate deficiency (though B12 is also affected but hepatic stores last several years). The mouth ulcers are a sign of this. There are also GI symptoms resulting from malabsorption. It is an autoimmune condition (the presence of another autoimmune condition here is a risk factor) triggered by gluten peptides found in wheat, rye and barley. The ultimate best test is duodenal biopsy and histology to show intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia. Macroscopic changes may be present but endoscopy is generally unhelpful. The test of choice before performing such an invasive confirmatory test is to look for elevated anti-gliadin antibodies. Anti-tissue transglutaminase is less accurate and endomysial antibody is more expensive and has lower sensitivity, though is the only option on this list specific for coeliac.
It is worth knowing about the Schilling test as it is frequently examined. However, it is no longer routinely done in clinical practice. In this test, IM vitamin B12 is given to saturate stores. Then oral radiolabelled B12 is given and urine is collected over 24 hours. The amount excreted is lower in B12 malabsorption. If this is not corrected by IF the problem is with the ileum and not inadequate IF.
A 63-year-old male with a history of AF underwent an embolectomy a few hours ago after a clot was found in the popliteal artery. He is now complaining of increasing pain and tightness in the treated leg. O/E the leg appears swollen and there is pain on passive flexion of the foot.
A. Amputation B. Embolectomy C. Thrombolysis D. Endarterectomy E. Femoro-popliteal bypass F. Femoral-femoral crossover graft G. Anticoagulation H. Aorto-bifemoral bypass I. Fasciotomy J. Percutaneous transluminal angioplasty K. Antiplatelet drug L. Conservative management
I. Fasciotomy - This patient has developed compartment syndrome most likely as a result of soft tissue injury or direct injury to the musculature following the recent embolectomy. Additional causes include fractures and compartment haemorrhage. This condition results from raised interstitial pressure in closed osseofascial compartments. The classical clinical diagnosis will be of the following 6 Ps: pain, pressure, pulselessness, paralysis, paraesthesia and pallor (uncommon). The history here of severe extremity pain and tightness following documented trauma is classical. The pain tends to be out of proportion to the injury and is made worse by passive stretching of the muscle groups which are contained by the affected compartment. Passive stretching of the muscles of the compartment which is involved will also elicit pain. Note that true paralysis is a late sign, as is loss of pulses and pallor. Paraesthesia is however an early seen sign. If the diagnosis is uncertain in an at risk patient then compartment pressure measurement is indicated. Measurements of serum CK and urine myoglobin will also be indicated and these may be elevated with muscle cell lysis and necrosis. This is not due to an occlusive dressing (if it were, the first line treatment would be to remove this dressing). Therefore, a fasciotomy is indicated regardless of time of diagnosis with fasciotomy of all compartments with elevated pressure. There is a clear 6 hour window whereby there are lower amputation and death rates compared to delays >6 hours, so this needs to be done as a matter of urgency. The incision needs to be long enough too! Wound care post-fascitomy is important to prevent the risk of secondary infection and to debride any necrotic tissue, or to consider skin grafts. Post-operatively, care will be MDT with physical and occupational therapies and a range of motion exercises to try an d get the patient fully functional.
True or False, the facial nerve supplies the masseter muscle.
False - Muscles of mastication (masseter, temporalis, medial pterygoid, lateral pterygoid) are supplied by the mandibular branch of the trigeminal nerve.
A 28-year-old woman with a carcinoma of the cervix presents to A&E complaining of an inability to urinate in the last 8 hours. She has severe lower abdominal pain and had noted a weak stream prior to this and episodes of nocturia. There is lower abdominal distension, dull to percussion. Plasma creatinine is 250μmol/l. BP was 130/80. Urinalysis was negative.
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
J. Obstructive uropathy - This is obstructive uropathy caused by a block in urinary flow by the cervical carcinoma affecting the urinary tract. The history here is highly suggestive of acute retention with pain, distension and the dull percussion note of a full bladder. The patient also has been unable to pass urine for many hours. The diagnosis should already be obvious from this. Other more common conditions which often can give rise to an obstructive uropathy are stones and BPH. Treatment is initially directed at relieving pressure on the kidneys to prevent nephropathy and irreversible damage. This may involve insertion of a catheter, stent or nephrostomy tube, depending on what has caused the obstruction and where it is. Further treatment will be aimed at the cause.
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.
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 25 year old male student presents with 12 hours of abdominal pain, vomiting & watery diarrhoea. This has occurred once before.
A. Clostridium difficile B. Staphylococcus aureus C. Chronic pancreatitis D. Drug-induced diarrhoea E. Villous adenoma of the rectum F. Cryptosporidium infection G. Coeliac disease H. Ulcerative colitis I. Irritable bowel syndrome J. Diverticular disease K. Campylobacter L. Crohn’s disease
B. Staphylococcus aureus - This patient has infectious vomiting predominant food poisoning. When vomiting is the main presenting symptom, you should be thinking of Staphylococcus aureus, Bacillus cereus or norovirus. There is a short history in a previous well person. This man has probably eaten something dodgy like a kebab with undercooked chicken, or something like that. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe cases.
Two weeks after a holiday in the Far East, a 30 year old lady presented with anorexia, fever and joint pains. Jaundice appeared a week later and on examination her liver and spleen were both enlarged and very tender.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
M. Viral hepatitis - This is likely hepatitis A which is primarily transmitted via the faecal-oral route. After the virus is consumed and absorbed, it replicates in the liver and is excreted in the bile (to be re-transmitted). Transmission usually precedes symptoms by about 2 weeks and patients are non-infectious one week after onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water.
The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in
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 20 year old woman presented with a painless lump. On examination there was a 5cm smooth bosselated firm mass, which is highly mobile.
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
J. Fibroadenoma - This is a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient
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 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 woman has a firm diffuse goitre, she’s feeling tired.
A. Grave's disease B. Hashimoto's thyroiditis C. Papillary carcinoma D. De Quervain's thyroiditis E. Follicular carcinoma F. solitary toxic adenoma G. Multinodular goitre H. medullary cell carcinoma
B. Hashimoto’s thyroiditis - Firm and diffuse goitre can be present physiologically (ie. preganancy), caused by Autoimmune disease : Grave’s/Hasimoto’s, drugs (sulphonylureas) or infective causes. The only information given is that she is hypothyroid. The most liley cause is thus Hashimoto’s.
A woman developed pre-eclampsia during her first pregnancy, she also required syntocin and several units of blood during the birth. 4 months after the birth she still had not resumed menstruation and felt generally tired. She also noticed loss of pubic hair
A. Diabetes Insipidus B. Adrenal adenoma C. Nelson's syndrome D. Pituitary apoplexy E. Conns Adenoma F. Drug withdrawal G. Addison's disease H. Tuberculosis I. Sheehan's syndrome J. Cushing's disease K. Ectopic ACTH producing tumour L. Addisonian crisis
I. Sheehan’s syndrome - Pre-eclampsia (proteinuria + HTN in pregnancy) is a major risk for post partum haemorrhage…In this ladies case she had to receive blood products and Syntocin (a synthetic oxytocin drug used to combat uterine atony and help stop haemorrhaging).
Blood loss doesn’t normally cause changes in pituitary function however in pregnancy the pituitary gland is particularly vulnerable.
Hyperplasia and Hypertrophy of the lactotrophe cells in pregnancy (due to increased LH/FSH) leads to an increase in size of the adenphypophysis, however there is no such increase in the vascular supply to the anterior pituitary. When blood is lost in post -partum haemorrhage (PPH) the ant. pituitary thus infarcts and necroses. This is Sheehans syndrome…it can present insidiously or in a major way. It may be picked up if the mother fails to breast feed, but amennorhoea following birth and loss of pubic and axillary hair is also a common presentation. Only occasionally is full blown Sheehan’s encountered where the Mother becomes hypothyroid and can develop Diabetes mellitus due to wildly deranged Ant. Pituitary function.
DX: low oestradiol and pituitary hormone levels.
NB: Diabetes Insipidus is a rare complication since the posterior pituitary has a rich arterial blood supply that is rarely compromised in PPH.
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 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 73 year old lady presents with 6-month Hx of chest pain on exertion and 2 episodes of collapse in the last month. O/E the pulse is slow rising.
A. Aortic regurgitation B. Aortic stenosis C. Infective endocarditis D. Rheumatic fever E. Innocent murmur F. Mitral regurgitation G. Atrial septal defect H. Tricuspid regurgitation I. Mitral stenosis
B. Aortic stenosis - Aortic stenosis can present with chest pain, dyspnoea and syncope. It is characterised by a harsh ejection systolic murmur heard loudest at the right upper sternal edge at end expiration, which radiates up towards the carotids. The pulse pressure is narrow and there may be an associated slow-rising and plateau pulse. Doppler echo is vital for diagnosis and shows a pressure gradient across the narrowed valve orifice. 20% of cases are due to a congenital bicuspid valve. The most common cause of aortic stenosis in adults is calcification of normal trileaflet valves. Clinically stable patients may be considered for surgical repair or TAVR.
An 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.
Reduced chest movements bilaterally. Using accessory muscles of respiration. Breath sounds generally quiet.
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
B Emphysema - This patient is in obvious respiratory distress and is using accessory muscles of respiration. Chest movements are reduced too. There is hyperexpansion of the lung fields due to emphysema, which has caused the respiratory distress, combined with diminished breath sounds.
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.
67-year-old man was observed to be very drowsy 12 hours after an aortic aneurysm repair. There had been considerable blood loss and he had been given 4 units of blood during surgery. He had been written up for pethidine 50-100 mg 3 hourly postoperatively and had had 3 doses. BP had been 150/80 post-op and was now 100/60 with a pulse rate of 75/min. O2 saturation was low at 85%.
A. Pulmonary embolus B. Arrhythmia C. Blood loss D. Autonomic neuropathy E. Septicaemia F. Hyperadrenalism G. Cardiogenic shock H. Drug induced I. Volume depletion
H. 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.
An 80-year-old man with a history of ischaemic heart disease trips over a paving stone and fractures his hip. An ambulance takes him to A&E. 1 hour after arrival, he develops crushing central chest pain.
A. Upper GI endoscopy B. Chest x-ray with rib views C. V/Q scan D. Troponin level E. Exercise ECG F. CT scan abdomen G. Thoracic spine x-ray H. Coronary angiogram I. Barium swallow J. Transthoracic echo K. CT x-ray in expiration L. ECG M. Chest x-ray with no special instructions
L. ECG - This patient’s crushing central chest pain sounds like an MI. Chest pain is classically severe and heavy in nature, located centrally with possible radiation to the left arm or jaw and lasts for >20 minutes. SOB due to pulmonary congestion and sweating due to high sympathetic output are common symptoms. Risk factors incorporate the standard set of cardiovascular risks such as smoking, high BP, DM, obesity and dyslipidaemia. An ECG is indicated. If ECG shows STEMI, new LBBB or confirmed posterior MI then PCI/thrombolysis is indicated. It is worth noting that RV infarction is present in 40% of inferior infarcts so if ST elevation is seen in II, III and aVF, right sided ECG leads should be obtained.
A 72-year-old arteriopath is brought into the A&E collapsed. After admission you realise he is blind although he denies it.
A. Normal pressure hydrocephalus B. Occipital Stroke C. Multiple Sclerosis D. Hypothyroidism E. Vascular dementia F. Lewy body dementia G. Parkinson's disease H. Pick's disease I. Azheimer's dementia
B. Occipital stroke - This is cortical blindness, which is the loss of vision in a normal eye which results from damage to the visual area in the occipital cortex. The lack of insight that they have lost vision is a phenomenon known as Anton’s syndrome. They are ‘cortically blind’ but claim, often confabulate and adamantly despite obvious evidence, claim that they are capable of seeing. The pupillary reflex to light is intact as it does not involve the cortex and fundscopy, if done, would also be normal.
A budding shotputter with hopes of 2016 is found collapsed at the gym, his trainer takes him to A+E where his BMs are found to be very low as is his c-peptide. On taking a history it is found that the athletes room mate is type 1 Diabetic.
A. Addison's disease B. Alcohol C. Meningitis D. Insulinoma E. Insulin F. dumping syndrome G. Gliclazide H. Waterhouse-Friderichsen syndrome I. Starvation
E. Insulin
An 8 year old has developed a painful, swollen knee over the last day. O/E there is a tender, warm effusion of the left knee. She also has a pyrexia of 38 degrees. 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
H. Culture of joint aspirate - This 8 year old has septic arthritis. The septic knee joint here will be painful, hot, swollen and restricted movement of the affected joint. In all cases of suspected joint sepsis, the joint needs to be aspirated and empirical antibiotics need to be commenced once appropriate cultures have been taken. If the cause is a low virulence organism, TB or if in an older patient, the joint is prosthetic, then the presentation may be more insidious in onset. If there is already underlying joint disease then a septic joint should be suspected if the symptoms are out of proportion to normal disease activity. Some 20% of cases of septic arthritis is polyarticular. In sexually active patients, gonococcal arthritis is an important differential to consider. Presence or absence of fever is not a reliable indicator of joint sepsis and the diagnosis is largely one of clinical suspicion – treatment should therefore be commenced on this basis regardless of blood test results or microbiology. Synovial fluid Gram stain and culture is however positive in 70% of cases.
33 y/o lady complains of tenderness in her right breast typically in the second half of the menstrual cycle. O/E breast feels lumpy.
A. Lipoma B. Paget's disease C. Acute pyogenic mastitis D. Duct ectasia E. Fibrocystic disease F. Sarcoma G. Radial scar H. Adenoma I. Fibroadenoma J. Breast cancer K. Intraductal papilloma
E. Fibrocysitic - Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.
A 55 year old known epileptic arrives in A&E having suffered a fit whilst shopping. She is “post ictal” on arrival in A&E & breathing in an obstructed manner with O2 saturation of 92% (on air).
A. None B. Uncuffed ET tube C. Oropharyngeal airway with oxygen D. Single-lumen cuffed ET tube E. Double-lumen cuffed ET tube F. Laryngoscopy G. Suction H. Tracheostomy I. Laryngeal mask airway (LMA) J. Facemask with oxygen K. Cricothyroidotomy
C. Oropharyngeal airway with oxygen - An oropharyngeal (or Guedel) airway is sized from the angle of the mandible to the level of the incisors. It is a non-definitive airway adjunct. The patient is breathing in an obstructed manner indicating some degree of partial upper airway obstruction. The Guedel will keep the airway patent and prevent the tongue obstructing the airway by depressing it. The Guedel can only be used if the patient has a reduced GCS as it can initiate a gag reflex. If the patient was not unconscious, then a nasopharyngeal airway can be used (usually inserted in the right nostril). Additionally, a Guedel is contraindicated if the patient has injuries to the face or a condition that prevents the mouth from opening. Airway manoeuvres can also be used such as a jaw thrust or head tilt chin lift in addition to maintain a patent airway. A jaw thrust can onlybe done if the patient is unconscious. Think about where your fingers are digging in.
A 46 year old sales rep has recently lost his job & presents with jaundice & ascites. Ultrasound of the biliary tract is normal.
A. Cholecystitis B. Hepatitis B C. Infectious mononucleosis D. Drug induced hepatitis E. Sickle cell anaemia F. Carcinoma tail of pancreas G. Autoimmune hepatitis H. Gallstone in common bile duct I. Ascending cholangitis J. Hepatitis A K. Cirrhosis L. Carcinoma head of pancreas
K. Cirrhosis - This sales rep who has just lost his job has been hitting the bottle. The gynaecomastia is a sign of chronic liver disease and ascites indicates a degree of decompensation. Alcoholic liver disease is the most common cause of cirrhosis in the Western world.
A 55-year-old woman who has been waiting in diabetic clinic for two hours starts feeling sweaty and weak.
A. Oral glucose or sugar B. Bed rest C. Blood pressure control D. Laser treatment E. Intravenous dextrose F. Oral hypoglycaemic drug G. Dietary advice alone H. Statin I. Insulin
A. Oral glucose or sugar - This patient has symptoms of hypoglycaemia, present when glucose drops
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.
A 32 year old woman with ulcerative colitis presents with jaundice, pruritis, RUQ pain and splenomegaly. On direct questioning she admits to having dark urine and pale stools. Her ALP and her conjugated bilirubin is raised.
A. Dubin-Johnson syndrome B. Hepatitis C C. Malaria D. Gall stones E. Gilbert's syndrome F. Crigler-Najjar syndrome G. Hepatitis B H. Hepatitis A I. Carcinoma of head of the pancreas J. Primary sclerosing cholangitis K. Primary biliary cirrhosis L. Cholangiocarcinoma M. Sickle cell anaemia
J. Primary sclerosing cholangitis - Primary sclerosing cholangitis is a cholestatic liver disease which causes bile duct destruction, cirrhosis and end-stage liver disease. It predominantly affects young and middle-aged men, often with underlying inflammatory bowel disease. There is an association of PSC with UC (typically) and IBD diagnosis tends to precede that of PSC with a mean time from onset of IBD to PSC of 9 years. This patient has evidence of obstructive jaundice and pruritis. The diagnosis involves laboratory tests in combination with cholangiography. There are no specific auto-antibodies specific to or diagnostic of PSC but a number of serum autoantibodies such as ANCA are often present in PSC patients. There is currently no effectively medical therapy and the only treatment option in those with advanced disease is to have a liver transplant. The leading cause of death in these patients is liver failure and cholangiocarcinoma. The latter is a relatively common complication and should be suspected in patients who present with rapidly progressing jaundice, weight loss or abdominal pain on a background of PSC.
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.
A 22 year old woman who has taken 40 paracetamol tablets.
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
G. Intravenous N-acetylcysteine - Paracetamol OD can occur after a single large OD or repeated ODs. Often, the patient is asymptomatic at initial presentation but if untreated may cause liver injury over the 2-4 days after ingestion, including fulminant liver failure. Paracetamol is the most frequent intentional OD drug in this country. The risk of liver damage is increased after taking drugs which induce CYP 450. Inducers include St John’s wort, barbiturates, phenytoin, tetracycline, chronic alcohol use and carbamazepine. A serum paracetamol level is important to order as early as possible, but at the earliest 4 hours post-ingestion.Treatment if indicated is with N-acetylcysteine with the level based on a paracetamol treatment graph. NAC will reduce hepatic damage caused by NAPQI. There is insufficient endogenous glutathione to neutralise this in an overdose and NAC binds and neutralises NAPQI. In patients allergic to NAC, oral methionine can be used.
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 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 35 year old lawyer with a history of recurring piles & having been treated by his GP with sclerosing therapy continues to bleed. He is referred to surgical outpatients for more definitive treatment.
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
F. 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. 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. Lord’s anal stretch is no longer recommended due to the risk of faecal incontinence.
A woman with a goitre has difficulty looking upwards and outwards on eye muscle testing, which extra-ocular muscle has been affected?
- Superior oblique
- inferior oblique
- Superior rectus
- levator palpebrae superioris
- Inferior oblique
A 72-year-old man with a HbA1C of 12.2% has presented with ulcers in his right foot & bilateral loss of sensation below knee.
A. Diabetic neuropathy
B. Carpal tunnel syndrome
C. Charcot-Marie-Tooth disease
A. Diabetic Neuropathy - Diabetic neuropathy has lead to the painless ulcer most likely developing over pressure points in the foot such as on the ball of the foot. This may have resulted from an object becoming lodged in the shoe and eroding through the skin with walking. This is why it is important for diabetics to check their feet regularly and to wear specialised footwear. Diabetic neuropathy is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. Pain is a common complaint such as the burning sensation this patient describes. Patient’s may also describe the pain as prickling or sticking.
Complications range from the painless neuropathic ulcer described, at areas of the foot where there is weight loading (particularly the metatarsal heads), to the Charcot foot with severe architectural destruction of the foot. Foot ulceration is a common precusor to amputation. Foot care is crucial in DM. Examination should include peripheral pulses, reflexes and sensation to light touch with a 10g monofilament, vibration (128Hz tuning fork), pinprick and proprioception. The pain may be treated with medications like pregabalin and gabapentin.
A 35-year old woman presents with a 1-month history of lethargy, malaise, painful enlargement of the cervical and axillary lymph nodes and bruising. Her Hb is 9.0g/dL, WCC 89 x 109/L, platelets 40x109/L. Her blood film shows occasional blast cells and the presence of Auer rods in the cytoplasm.
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
I. Acute myeloid leukaemia - Acute myeloid leukaema (AML) is generally seen in adulthood and is caused by proliferation of myeloid precursor cells. Investigations usually show a raised WCC, although it may be normal or low. The brusing and anaemia seen in this patient are due to the effects of marrow failure. The blood film shows blast cells and the presence of Auer rods, which are virtually pathognomonic of AML.
ALL vs. AML
Question; A 3 year old girl presented with several bruises over her body and tiredness. On examination she appeared plae and had petechial haemorrhages. Blood tests revealed low Hb and high WCC and a thrombocytopenia. Peripheral blood film showed the presence of blast cells.
ACUTE LYMPHOBLASTIC LEUKAEMIA
Why would this be ALL and not AML?
Answer: Is the age not the pointer in this question.
Blast cells are immature precursors of either lymphoblasts or myeloblasts. They don’t normally appear in peripheral blood. When present, they signify ACUTE leukaemia. Special staining is needed to identify the lineage. So basically blast cells can occur in both ALL or AML. This is my understanding anyway….but the age thing is probably the most significant pointer.
Answer: Think first of all lymphoid vs myeloid
CLL: enlarged rubbery lymph nodes, non tender, also smear cells
CML: Philadelphia chromosome, sweats, more likely splenomegaly, increased WCC
ALL: bruising, pale, usually children btw 2-4 years old
AML: Auer rods, SOB, bone pain.
A 62-year-old man has had an ischaemic stroke. He has normal blood pressure and is in sinus rhythm, although is noted to have peripheral vascular disease. You prescribe him some preventative medication.
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
A. Aspirin and atorvastatin - I will accept ‘Clopidogrel and atorvastatin’ too for this question, as clopidogrel is the most cost effective antiplatelet drug for the secondary prevention of ischaemic stroke or TIA. However, aspirin is what is generally given. The statin, as mentioned before, is given for its lipid lowering effects. It is mainly given for patients with LDL >2.6 and is recommended for those with atherosclerotic ischaemic stroke or TIA, to lower the risk. This patient has PVD which is due to atherosclerosis and suggests that statins will help. Aspirin and clopidogrel would not be given together in this patient as this would unnecessarily increase the risk of a major bleed.
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 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 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 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.
There is a harsh pan-systolic murmur loudest at the lower left sternal edge & inaudible at the apex. The apex is not displaced.
A. Tricuspid stenosis B. Pulmonary stenosis C. Patent ductus arteriosus D. Aortic stenosis E. Atrial septal defect F. Mitral regurgitation G. Aortic regurgitation H. Tricuspid regurgitation I. Mitral valve prolapse J. HOCM K. Left ventricular aneurysm L. Aortic sclerosis M. Mitral stenosis N. Ventricular septal defect
H. Tricuspid regurgitation - The murmur of TR is a lower left parasternal systolic murmur (pansystolic, or less, depending on severity). The murmur commonly increases on inspiration (Carvallo’s sign). The apex is not displaced in TR whereas it may be displaced in MR. Key risk factors for TR include LVF, rheumatic heart disease, endocarditis and the presence of a permanent pacemaker. Patients typically present with SOB, periperal oedema and tiredness. There may also be abdominal distension. An enlarged and pulsatile liver is normally seen in severe TR and caused by a reversal in blood flow during systole. It is worth noting that mild to moderate TR is not necessarily abnormal and is present in many asymptomatic young adults.
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 50 year old male with haemophilia & hepatitis C presents with weight loss & abdominal discomfort. He is mildly icteric with features of chronic liver disease & a large left lobe of the liver
A. RA B. Right heart failure C. Haemachromatosis D. CML E. Malaria F. CLL G. Toxoplasmosis H. Portal vein thrombosis I. Systemic amyloidosis J. Cirrhosis with hepatoma K. Polycythaemia rubra vera L. Congestive cardiac failure M. Malignant melanoma N. Severe emphysema
J. Cirrhosis with hepatoma - HCV has caused this patient’s hepatic cirrhosis which has resulted in a hepatoma (HCC). It is likely that his HCV infection has resulted from contaminated blood products due to his haemophilia. This was a key problem before blood donor screening took place. Unlike HBV, HCV infection almost always results in cirrhosis before a hepatoma develops. The length of time the patient has HCV is a good correlate to the development of HCC. HCV is also strongly associated with IVDU which accounts for most infections. Treatment of the hepatoma is guided by staging and prognosis. Treatment includes resection, transplant, percutaneous ablation and chemo-embolisation.
An obese 40 year old woman, with a history of episodic right upper quadrant pain, presents with rapid onset of jaundice with severe abdominal pains, fever & rigors.
A. Cholecystitis B. Hepatitis B C. Infectious mononucleosis D. Drug induced hepatitis E. Sickle cell anaemia F. Carcinoma tail of pancreas G. Autoimmune hepatitis H. Gallstone in common bile duct I. Ascending cholangitis J. Hepatitis A K. Cirrhosis L. Carcinoma head of pancreas
I. Ascending cholangitis - Charcot’s triad of ascending cholangitis: fever with or without rigors, RUQ pain and jaundice. Cholangitis is infection of the biliary tree and can quickly become septic. Drainage of the biliary tree is crucial and is undertaken via ERCP. Make sure you know the difference between ascending cholangitis, cholecystitis and biliary colic.
34-year-old man has had vomiting 2-3 times a day for 3 days. He complains of severe crampy abdominal pain and blood stained watery diarrhea. On examination temperature 37.7˚C. Abdomen soft, complains of generalised tenderness. No masses/rebound/guarding.
A. Intussusception B. Pancreatitis C. Oesophageal cancer D. Uraemia E. Gastric cancer F. Pyloric stenosis G. Salmonella H. Bowel obstruction I. Appendicitis J. Combined oral contraceptive pill K. Viral gastroenteritis L. Bulimia M. Peptic ulcer disease
G. Salmonella - The only option on the list which fits is Salmonella. This could obviously be E coli or Campylobacter too, for instance. This is infectious gastroenteritis and Salmonella is a common cause, pretty much able to contaminate any food. It is commonly linked to poultry, dairy items and undercooked eggs. It is self-limiting and diagnosis is on isolating the organism from a stool culture. Treatment is supportive with fluid and electrolyte replacement and antibiotics are generally used only for patients with risk factors for severe disease or those with extra-GI complications. This is not viral gastroenteritis for the reasons below:
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.
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 22 year old man presented with a two week history of fever and drenching night sweats. He had experienced severe itching during this time. Examination was normal except for swollen supraclavicular lymph nodes. CXR showed a mediastinal mass.
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
L. Hodgkins Lymphoma - This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption.
An 80 year old female with a history of rheumatic fever in childhood & palpitations presents with shortness of breath. On examination he has an irregularly irregular pulse of 120bpm & loud first heart sound.
A. Mitral stenosis B. Pneumonia C. COPD D. Pneumothorax E. Anaemia F. Left ventricular failure G. Thyrotoxicosis H. Epiglottitis I. Asthma J. Anxiety K. Aspirin poisoning L. Pulmonary embolus M. Mitral regurgitation
A. Mitral stenosis - Practically every single case of mitral stenosis is caused by rheumatic heart disease. The major criteria for rheumatic fever can be remember by CASES: carditis, arthritis, Sydenham’s chorea, erythema marginatum and subcutaneous nodules. The process tends to also cause regurgitation. Mitral stenosis is characteristically a grade 1-2 low pitch murmur heard in mid-diastole which has a rumbling nature and there is no radiation. There can be an associated malar flush, tapping apex beat and a diastolic thrill palpable at the apex, in the 5th intercostal space in the MCL. The first heart sound is also characteristically loud and often this is the most striking feature on ascultation. It is a difficult murmur to pick up so if you are ever asked at this stage to spot this murmur, it will most likely be based on the loud S1. Mitral stenosis is associated with AF caused by LA enlargement (seen by the irregularly irregular pulse).
A 45-year-old woman who has a firm, slightly tender, 2cm diameter smooth lump just below and attached to the skin of the upper part of her right breast. It has been growing slowly over the past year and there is a punctum in the centre. She has come to see you because yesterday she noticed that when she pressed the lump, a stream of a rather smelly, jelly-like substance came out.
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
C. Sebaceous cyst - The central punctum makes this diagnosis. This has become inflamed in this case ad is expressing a foul-smelling keratinised discharge as it has become infected. They can be caused by blockage of sebaceous glands.
A 40 year old alcoholic man who was treated for a chest infection one week previously, developed a productive cough, & a fever. He felt unwell. He lost weight during this period of illness & also coughed up blood several times. A chest x-ray showed a fluid level in the right lung.
A. Atypical pneumonia B. Bronchial carcinoma C. Pleural effusion D. Sarcoidosis E. Fibrosing alveolitis F. Pneumothorax G. Lung abscess H. Bronchiectasis I. Bronchial asthma J. COPD K. Cystic fibrosis
G. Lung abscess - A lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which this patient gives a history of is a risk factor. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.
A 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 68-year-old ex-smoker on inhalers and long-term oxygen therapy is found to have bilateral peripheral oedema.
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
G. COPD - Secondary pulmonary hypertension as a result of this patient’s advanced COPD or cor pulmonale has caused peripheral oedema. Cor pulmonale is right heart failure secondary in this case to long standing COPD, caused by chronic hypoxia and pulmonary vascular vasoconstriction secondary to this, giving pulmonary hypertension and right sided heart failure. Signs aside from lower extremity oedema include hepatomegaly, a loud P2 and engorged neck veins. Given he is on inhalers and LTOT already, he has already been diagnosed with COPD but we are seeing if you know that this is what the patient has. If this is a new symptom he needs to have this assessed and may need additional intervention such as diuretics.
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 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
A 69 year old man with a history of hypertension & stable angina wakes up severely short of breath. He is slightly more comfortable sitting upright. On examination, his blood pressure is 195/115 mmHg & there are crepitations at the bases of both lungs.
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
G. Left ventricular failure - This patient has LVF and pulmonary oedema. This accounts for the basal crepitations heard on ascultation and the SOB which is better on sitting upright. Patients need to be sat upright for this reason and IV access needs to be established. Oxygen, morphone, 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. Ongoing diuretics are necessary if the patient has persistent symptoms of fluid overload.
A 30 year old city banker comes to the GP with symptoms of abdominal bloating, intermittent constipation and diarrhoea with occasional nausea. This started about 6 months ago but she has not lost any weight or found any blood in her stools.
A. Bacterial gastroenteritis B. Crohn's disease C. Cancer of the rectum D. Diverticular disease E. Thyrotoxicosis F. Drug induced G. Cancer of the colon H. Irritable bowel syndrome I. Amoebic dysentery J. Ulcerative colitis K. Malabsorption L. Clostridium difficile
H. Irritable bowel syndrome - The intermittent diarrhoea and constipation, with bloating, without symptoms suggestive of IBD make IBS a more likely diagnosis. IBS is a chronic condition with abdominal pain associated with bowel dysfunction and is a diagnosis of exclusion. The pain or discomfort may be relieved by defecation. Examination is usually unremarkable and the diagnosis is based on the patient’s history in line with the Rome Criteria. If the patient presents with any worrying symptoms, then these will warrant a more thorough investigation. Treatment depends on the patient’s predominant symptoms. Antispasmodics relieve abdominal pain or discomfort but do not affect bowel habit. Examples include peppermint oil and dicycloverine. Laxatives can also be used such as lactulose. Lifestyle and dietary modifications combined with reassurance remain the 1st line intervention for functional bowel disease. IBS is linked with stressful jobs such as working as a banker in the city and there is a female/male ratio of 2:1.
A 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.
An unusually tall middle aged lady seen in clinic has a large painless lump in her neck that is fixed. The Dr also notes cervical lymphadenopathy and yellow white nodules on her lips. Pembertons sign is positive and a thoracic inlet scan confirms the compression. Her medical history includes surgery on her aortic valve and some work on her lens.
A. MEN 2B B. Medullary thyroid cancer C. Grave's disease D. Riedel's thyroiditis E. subacute lymphocytic thyroiditis F. late De Quervains thyroiditis G. Early De Quervains thyroiditis
A. MEN 2B - this fixed lump is accompanied by lymphadenopathy, warning bells go off that this may be malignant. There are local invasion signs also as confirmed by pemberton’
Pemberton’s sign - I put this into a thyroid exam, It can equally be justified in a respiratory examination. Basically you ask the patient to lift their arms straight above their head as high as possible and then listen for inspiratory stridor, look for facial flushing or distension of veins acorss the neck. You can ask the patient to tell you if they fell light headed when performing this test.
It basically looks to see if there is evidence of SVC (superior venae cava) syndrome. If there is a large goitre or apical lung tumour for example impinging on the SVC, lifting the arms will lead to compression and cause congestion of blood in the head. This can be seen as a plethoric face, a cyanosed face, the patient may experience nausea and headache etc.
Positive Pemberton’s sign signifies thoracic inlet obstruction causes of which include:
- Retrosternal goitre
- Lung carcinomas
- Aortic Aneurysms
Thoracic inlet scan shows that a goitre is compressing structures such as the Superior vena cava. This seems to be maligant..Medullary thyroid carcinoma. however the rest of the patient must be taken into account..she has a marfanoid appearance and suggestion of other features of the syndrome. the lens work would be to correct dislocation, and the aortic valve work no doubt was to correct aortic root dilatation and valve incompetency seen in Marfan’s. The nodules are neurofibromatoses typical of MEN 2b.s sign.
A 2 month old child has had a fever and cough for three days. He is tachypnoeic with grunting and has nasal flaring. Choose the single most discriminating investigation in the acute management from the list of options:
A. ESR B. Blood cultures C. Chest X-ray D. Urine culture E. Stool electron microscopy F. EEG G. Stool culture H. Culture of joint aspirate I. C-reactive protein J. Lumbar puncture K. Throat swab L. Full blood count M. CT brain
C. Chest X-ray - This 2 month old child has pneumonia and is displaying signs of respiratory distress (tachypnoea, nasal flaring, grunting). The most sensitive and specific test to perform is a CXR (PA and lateral). What may be seen is an infiltrate, consolidation, effusions and cavitation. Initial treatment is empirical with antibiotics (amoxicillin is the first choice in children).
A 51 year old social worker presents to her GP with haemoptysis. On further questioning she admits to having a productive cough for 6 months & to losing 2 stones in weight over the same time. Chest x-ray shows patchy consolidation & scarring in both apices.
A. Pulmonary metastases B. Pulmonary embolism C. Pulmonary abscess D. Small cell carcinoma E. Streptococcal pneumonia F. Squamous cell carcinoma G. Microscopic polyarteritis H. Tuberculosis I. Goodpasture’s disease J. Myaesthenia gravis K. Mesothelioma
H. Tuberculosis - It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, cough, haemoptysis and erythema nodosum are all suggestive. Other key risk factors for pulmonary TB include exposure to infection and returning from or being born in a high-risk region such as Asia, Africa and Latin America. If TB is suspected, the patient should be placed in isolation and a CXR obtained with 3 sputum samples cultured for AFB being the gold standard of diagnosis. Culture takes several weeks so sputum smears will be done before culture results are known. Interferon-gamma release assays (IGRAs) are now used by some hospitals to rapidly determine a patient’s TB status. All patients who have TB should be tested for HIV within 2 months of diagnosis. CXR is the first line test to order. Classically, in primary disease there are middle and lower zone infiltrates. Post-primary TB usually involves apical changes with or without cavitation. However, recent students have indicated that both presentations are seen in both primary and post-primary TB. HIV positive patients tend to have a more atypical CXR including effusion, lower zone involvement and a miliary pattern.
33-year-old woman complains of giddiness on standing and can no longer cross a road on her own as she is worried that she may pass out. She developed diabetes when aged 12 and had laser treatment to her eyes 2 years ago.
A. Pulmonary embolus B. Arrhythmia C. Blood loss D. Autonomic neuropathy E. Septicaemia F. Hyperadrenalism G. Cardiogenic shock H. Drug induced I. Volume depletion
D. 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.
A 24 year old lady has repeatedly had urinary tract infections and is frustrated because she must have antibiotics every 2-3 months. She tells you her mother died when she was young from a “bleed in the brain”.
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
K. Polycystic kidney disease - This sounds like autosomal dominant polycystic kidney disease. There may like in this case be a FH, of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and subsequent SAH – the bleed in the brain). Patients may have haematuria (which can be gross), palpable kidneys and symptoms of a UTI which is common in those with the condition. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.
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 20 year old lady became ill 2 weeks after a holiday in Brazil. She developed a fever, headache, cough & constipation which turned to diarrhoea 10 days later. She also has a blanching red lesion on her chest and abdomen. She is also found to be bradycardic.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
C. Enteric fever - Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic. The water supplies in Brazil may not treated and sanitary conditions may be dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a fever which is a hallmark of infection. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.
This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.
A 3 year old girl presents with a week history of pain in the abdomen and watery diarrhoea which became bloody after the first 8 hours. Three days before, she had distinctly recalled consuming a burger which may have been undercooked. Investigations show a mild anaemia and thrombocytopenia with blood smear demonstrating multiple schistocytes. Creatinine is also raised.
1. Antiphospholipid syndrome 2. Disseminated intravascular coagulation 3. HELLP syndrome 4. Haemolytic uraemic syndrome
- Haemolytic uraemic syndrome - This is haemolytic uraemic syndrome which is characterised by MAHA, thrombocytopenia and nephropathy. Most cases are in children and related to gastroenteritis caused by verotoxin producing E. coli (O157:H7). The presence of schistocytes establishes the presence of thrombotic microangiopathy. The anaemia, thrombocytopenia and renal dysfunction characterised by creatinine rise mark this diagnosis.
A 25 year old woman presents with a 4 month history of diarrhoea, altered blood and mucus per rectum.
A. Anal fissure B. Caecal carcinoma C. Meckel's diverticulitis D. Haemorrhoids E. Infective diarrhoea F. Irritable bowel syndrome G. Duodenal ulcer H. Inflammatory bowel disease I. Perianal fissure J. Carcinoma of the rectum
H. Inflammatory bowel disease - This woman has inflammatory bowel disease, which by the history is probably more likely to be UC than CD, whereby the mainstay of treatment is with 5-ASA. A colonoscopy is required to assess the extent of disease and for a definitive diagnosis. Biopsy in CD will show transmural granulomatous inflammation. CD can affect the whole GIT but favours the TI and proximal colon and is macroscopically characterised by skip lesions. UC on the other hand is characterised by the presence of crypt abscesses, which is pathognomic. CD risk is increased 3-4 fold by smoking whereas smoking seems protective in UC. The mainstay of treatment in CD is with steroids and azathioprine to prevent relapses and for those suffering side effects of steroid treatment. TNF-alpha inhibitors also have a role. Surgery in CD is only indicated in a small number of patients who bleed, for bowel perforation and cases of complete obstruction. The aim is to rest distal disease by temporarily diverting faecal flow.
66 year old man presents with swelling of his right leg to the knee. He had had a right hip replacement 5 weeks previously.
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
D. Venous doppler studies - Recent surgery, especially orthopaedic surgery, is a strong risk factor for developing a DVT. Other strong risks include active malignancy, pregnancy, obesity and coagulopathies such as factor V Leiden. A Wells score is determined in all patients with a suspected DVT with the condition being likely if the score is 2 or more. If the Wells score is
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
A 72-year-old man underwent hip replacement surgery. 8 hours post-op his urine output has been 30ml, 20ml and 5ml over last 3hours. He is now anuric and seems lethargic. Other vital signs remain normal.
A. Percutaneous gastrostomy B. Intravenous nutrition C. Cardiogenic shock D. Neurogenic shock E. Haemorrhagic shock F. Spinal shock G. Pulmonary oedema H. Urinary retention I. Acute renal failure J. Percutaneous jejunostomy K. Basal atelectasis
H. Urinary retention - This is clearly urinary retention. Urine output is gradually deteriorating in a step-wise manner and he is now anuric
Each of these patients has been found to have raised blood prolactin, select the most likely aetiology for each case.
A man has a long history feeling unwell having had several bouts of gastritis recently. He has noticed he has had problems getting it up, he has had a number of medications prescribed for the gastritis
A. inadequate treatment B. Metoclopramide C. Ibuprofen D. Macroadenoma E. Acetaminophen F. non epileptic seizure G. Microadenoma H. epileptic seizure
B. Metclopramide
A 17 year old school girl presented with breast pain , changed from dull ache to severe continuous throbbing pain. The breast feels hot on palpation and she complains of hot flushes. On examination the whole breast is tender and engorged and nipple is tender.
A. Fibrocystic changes B. Breast cancer C. Necrotising fasciitis D. Galactocoele E. Costochondritis F. Phylloides tumour G. Diabetic breast lesion H. Mondor’s disease I. Raynaud’s phenomenon J. Fibroadenoma K. Breast abscess L. Fat necrosis
K. Breast abscess - Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful, hot, engorged and red breast suggests the possible development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.
A 25 year old woman who complains of heat intolerance, anxiety & weight loss, despite a good appetite. You find a fine tremor in her hands & a pulse of 120. There is a smooth swelling, 5cms by 3cms, centred on the midline of her neck. You hear a bruit when you place the stethoscope diaphragm over it.
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
H. Carbimazole - This woman has hyperthyroidism. The smooth midline swelling and the audible bruit point towards a diagnosis of Graves’ disease. In countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Peripheral manifestations such as ophthalmopathy, pretibial myxoedema and hyperthyroid acropachy do not occur with other causes of hyperthyroidism. Acropachy manifests as clubbing with soft tissue swelling. Pretibial myxoedema is almost always associated with ophthalmopathy. A thyroid isotope scan such as Tc-99 pertechnetate is used to differentiate the diffuse enlargement of Graves’ with the patchy uptake of a multinodular goitre. This is not necessary based on the examination findings.
Treatment aims to normalise thyroid function and is achieved by radioactive iodine, antithyroid medications or with surgery. They are all effective and relatively safe options. Symptomatic therapy is given with beta blockers such as propranolol.
A 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 56-year-old man has a sudden pain that ‘shoots’ to his chin whilst shaving. It disappears after a few seconds.
A. Extradural haemorrhage B. Cluster headache C. Trigeminal neuralgia D. Subarachnoid haemorrhage E. Migraine F. Tension headache
C. Trigeminal neuralgia - Trigeminal neuralgia occurs as episodes of severe unilateral pain in the distribution of CNV, usually lasting seconds, with no pain occuring between these episodes. Examination is often unremarkable. The pain is described as sharp, intense, stabbing or burning. It can be triggered commonly by actions such as eating, tooth brushing, cold and touch. Shaving and eating seem to be common in EMQs. Most people are asymptomatic between attacks although the severity of the pain makes these patients live in constant fear. TN is more common in MS and incidence increases with age. Post-herpetic TN is also possible. The mainstay of treatment is medical, with antiepileptics such as carbamazepine (which is the only medicine which is proven in RCTs and is therefore typically first line). If medical treatment fails, surgical options do exist such as microvascular decompression.
A 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 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 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 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 72 year old woman is being treated for a diabetic foot ulcer and is afraid she may need an amputation. Serum potassium today is markedly elevated. Results over the past week have been normal. You find out the 2nd year medical student had some difficulty drawing the blood.
A. Cushing's syndrome B. Rhabdomyolysis C. Drug side effect D. Acute kidney failure E. Addison’s disease F. Congenital adrenal hyperplasia G. Hyperglycaemia H. DKA I. Chronic kidney disease J. Infection K. Tumour lysis syndrome L. Pseudohyperkalaemia
L. Pseudohyperkalaemia -This is pseudohyperkalaemia caused by haemolysis of the sample. The medical student who has had some difficulty drawing the blood has haemolysed the sample. Potassium in serum will in this case exceed the plasma value by >0.5 mmol/L and the pink tinge when centrifuging the sample will also give this away.
A 46-year-old woman, normal blood pressure, cholesterol and blood sugar, body mass index 32.(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 lowering therapy with a statin
H. Reduced alcohol intake
F. Weight reduction and increased physical activity - This woman is obese (BMI greater than or equal to 30) and needs to lose weight. Central obesity has a greater correlation with co-morbidities than peripheral obesity so arguably waist circumference is a better indicator of risk than body mass index. The mainstay of treatment is with diet and exercise. This patient is obese and drug therapy can be considered as an adjunct. This is primarily with orlistat which inhibits fat absorption by inhibiting lipases. For weight loss, the recommended intake is 1200-1500 kcal/day for men and 1000-1200kcal/day for women, producing a 500-1000kcal/day deficit.
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 35-year-old woman has noticed some changes in her right breast that are worse before her periods. You find a tender, diffuse, lumpy area in the upper outer quadrant about 10cms by 5cms with no lymphadenopathy.
A. Basal cell carcinoma B. Adenoma C. Sebaceous cyst D. Fat necrosis E. Carcinoma of the breast F. Intraductal papilloma G. Lipoma H. Radial scar I. Breast bud J. Fibroadenosis K. Phylloides tumour L. Breast abscess M. Fibroadenoma
J. Fibroadenosis - Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.
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 58 year old man was admitted complaining of abdominal pain. He is found to have rectal carcinoma.
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
D. Anterior resection - 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 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.
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 40 year old lady with a hard lump in the right breast. The skin overlying the lump has an orange peel appearance.
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
F. Carcinoma of the breast - Patient’s with breast cancer, on examination (familiarise yourself with how to conduct a breast exam), tend to demonstrate a firm hard lump which may be associated with axillary lymphadenopathy, skin changes such as the orange peel (peau d’orange) and nipple changes/discharge. The skin changes here are most likely associated with locally advanced cancer. Many breast cancers are also diagnosed on routine mammography which can show microcalcifications, in the absence of a palpable mass. MRI is more sensitive but less specific so is recommended only in patients who are at high risk, such as BRCA1/2 mutation, history of chest radiation or certain syndromes like Cowden’s or Li-Fraumeni. FNA is also useful in rapid diagnosis, although is operator dependent when it comes to how sensitive and specific it is, and a core biopsy is preferred in most cases for diagnosis as it can differentiate pre-invasive and invasive disease. Treatment is MDT involving surgeons, oncologists, radiation oncologists etc. Do you know about the current NHS breast screening programme?
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.
A 50 year old Asian diabetic woman is admitted with increasing shortness of breath and ankle swelling. ECG shows inverted T waves in levels I, AVL and V4-6. Upper lobe blood diversion and bilateral pleural effusions are found on chest X-ray.
A. Pneumothorax B. Pneumonia C. COPD D. Carcinoma of Bronchus E. Chest injury with rib fractures F. Lung metastases G. Rheumatoid arthritis H. Pleural mesothelioma I. Aspiration pneumonia J. Pulmonary oedema K. Sarcoidosis L. Pulmonary embolus M. Acute asthma N. Pulmonary tuberculosis
J. Pulmonary oedema - CXR findings here are consistent with pulmonary oedema. Pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion may be seen. The patient is also in CCF with evidence of LV dysfunction (SOB) and RV dysfunction (ankle swelling).
What is the proportion of total T4/T3 that is free in the plasma?
- 75%
- 99%
- 1%
- 60%
- 35%
- 1%
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.
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 young girl complains of weight loss and headaches, the dr proceeds to perform an abdominal examination during which she becomes anxious flushed and tachycardic.
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
H. Phaeochromocytoma
A 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 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.
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 55 year old male smoker presents to her GP with a 6 month history of a persistant dry cough and unexplained weight loss. On examination she was jaundiced with an enlarged liver.
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
F. Lung tumour - This is a smoker with respiratory complaints and unexplained weight loss pointing to malignancy. The hepatomegaly is likely to be nodular due to hepatic secondaries from a primary lung cancer and this hepatic dysfunction has caused this patient’s jaundice. 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.
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.
A 70-year-old man after a laparotomy has been given 4L of dextrose/saline IV in 24hrs. He is tachypnoeic, with BP 130/90, pulse 120/min and has bilateral basal crepitations. 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
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…
B. Administer diuretics - This patient has developed pulmonary oedema. This patient should be positioned upright and given diuretics (frusemide).
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 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 54 year old man with no previous abdominal symptoms complains of several episodes of painless bright red rectal bleeding which is separate from the stool. Abdominal, rectal examination & proctoscopy are normal.
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
H. Colonic polyp - Most polyps are asymptomatic and rectal bleeding is indeed an unusual symptom to present with (though FOBT may be positive), but the lack of previous symptoms and normal examination findings makes this likely to be a bleeding polyp. The next step here would be endoscopy with polypectomy for histological examination. Indeed they are frequently found incidentally on screening with FOBT or colonoscopy for another reason. If there are a few polyps, all of them will be removed. If there are many, a sample will be removed for biopsy. Polyps can also be inherited in FAP, also seen in Gardner syndrome and Peutz-Jeghers. They can be neoplastic such as adenomas or non-neoplastic such as hyperplastic polyps.
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.
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. He was initially given IV saline.
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
B. Blood transfusions - 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.
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 22 year old man notices a painless penile ulcer. He has recently started his first sexually active relationship. His partner has no symptoms and he is also otherwise well. Examination reveals an indurated ulcer with rubbery and moderate inguinal lymphadenopathy.
1. Primary HIV infection 2. Chancroid 3. Genital herpes 4. Syphilis
- Syphilis - The chance of primary syphilis is usually a solitary, painless and clean ulcer with an indurated base. This is a common sexually transmitted infection caused by the spirochete Treponema pallidum. Treatment is with penicillin – untreated infection can cause considerable morbidity and facilitates HIV transmission.
3 weeks after having an MI, a 65-year-old man presents with sharp chest pain and pyrexia. Blood test reveals anaemia and raised ESR.
A. Aortic dissection B. MI C. Right heart failure D. Pulmonar Embolus E. Endocarditis F. Left heart failure G. Tietze syndrome H. Rheumatic fever I. Pericarditis J. Dressler's syndrome
J. Dressler’s syndrome - This is percarditis again, likely to be Dressler’s syndrome. This is believed to be an autoimmune process with myocardial neo-antigens implicated in the aetiology and occurs typically 2-3 weeks post-MI. Typical treatment is with aspirin. It tends to subside in a few days and raised ESR is a lab finding which can be seen. See above for more information on angina.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Mesothelioma
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
D. Asbestos - Mesothelioma is a malignant tumour of the pleura (or less commonly the peritoneum). There are three main types of asbestos: white, blue and brown, with blue being the most potent cause. Asbestos exposure increases the risk of both squamous cell carcinoma and mesothelioma. A 20-year lag time between exposure and development of mesothelioma is typical.
A 40 yo man is in for blood tests he brings in a 24 hr urine sample for VMA which is raised. The man eats ice cream and cream cakes for breakfast lunch and dinner.
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
C. Inconclusive sample
Systematic reviews of literature
A. Cocherane database B. Medline C. National institute for clinical excellence (NICE) website D. British national formulary E. BMA website F. Evidence based medicine website G. BMJ website
A. Cocherane database - The Cochrane database was established by the NHS with the aim of being a place to review existing literature on a subject matter.
A 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 62-year-old man who requires a knee replacement gives a history of allergy to dihydrocodeine.Which drug should NOT be given
A. Diclofenac B. Epidural bupivacaine and fentanyl C. Codydramol D. Paracetamol E. Morphine F. Tramadol
C. Codydramol - Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
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 55 year old lawyer who has had a chronic cough for 3 months complains of 1 episode of haemoptysis. She is a heavy smoker (about 40/day) & has experienced some recent weight loss.
A. Sputum cultures B. Bronchoscopy C. History only D. D-dimer E. CTPA F. Chest x-ray G. MRA H. Lung function tests I. ABG J. Clotting screen K. V/Q scan L. CT head
B. Bronchoscopy - This sounds like bronchial carcinoma from the history of smoking, respiratory complaints and weight loss. Initial investigation of bronchial carcinoma is with a CXR but definitive diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. During bronchoscopy, endobronchial masses can be biopsied and washings/alveolar lavage can also be performed for cytological analysis. Trans-thoracic needle aspiration may be needed for peripheral lesions that cannot be reached by bronchoscopy. First line treatment aims at surgical resection if possible.
A 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.
A 54 year old man collapses suddenly as he is walking across the living room. His daughter who witnessed the collapse says he dropped suddenly became very pale and started to twitch for a few seconds. After she woke him up (with some difficulty) he became flushed. O/E his nervous system is normal.
A. Anaemia B. Vasovagal syncope C. TIA D. Cardiac arrhythmia E. Stroke F. Postural hypotension G. Myxoedema coma H. Carotid sinus sensitivity I. Hypoglycaemia J. Aortic stenosis K. Epilepsy L. Pulmonary stenosis
D. Cardiac arrhythmias - Stokes-Adams attacks are episodes of transient LOC due to sudden decreased cardiac output. Pallor prior to the attack and facial flushing due to reactive hyperemia after the attack is characteristic of a Stokes-Adams attack. The underlying cause is a cardiac arrhythmia such as complete heart block.
A 22-year-old female student recently lost her mother. Now she presents with a couple of weeks Hx of increasing weakness in her arm and legs, but also while chewing or talking. Her vision seemed blurred recently.
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
F. 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, 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?
An 81-year-old woman, well apart from mild osteoporosis, no metabolic abnormalities, BP 185/78 mmHg.
A. Renovascular disease B. Primary hyperaldosteronism (Conn’s syndrome) C. 'Essential’ hypertension D. Phaeochromocytoma E. Isolated systolic hypertension F. Metabolic syndrome (Insulin resistance/syndrome X) G. Cushing's syndrome H. Coarctation of the aorta
E. Isolated systolic hypertension - Isolated systolic hypertension occurs more commonly in the elderly. It is characterised by a raised SBP >140 but a normal diastolic BP
A 35 year old woman has mild long-standing constipation without weight loss. She passes hard pellet-like stools, often with straining & a feeling of incomplete evacuation. Examination is normal.
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
G. Irritable bowel syndrome - IBS is a chronic condition with abdominal pain associated with bowel dysfunction and is a diagnosis of exclusion. The pain or discomfort may be relieved by defecation. Examination is usually unremarkable and the diagnosis is based on the patient’s history in line with the Rome Criteria. If the patient presents with any worrying symptoms, then these will warrant a more thorough investigation. Treatment depends on the patient’s predominant symptoms. Antispasmodics relieve abdominal pain or discomfort but do not affect bowel habit. Examples include peppermint oil and dicycloverine. Laxatives can also be used such as lactulose. Lifestyle and dietary modifications combined with reassurance remain the 1st line intervention for functional bowel disease. IBS is linked with stressful jobs and there is a female/male ratio of 2:1.
A 56-year-old man is scheduled for elective AAA repair. The extent and its relationship to the renal arteries need to be identified.
A. Duplex doppler ultrasound B. CT scan C. Ankle-brachial pressure index D. No investigation needed E. Venography F. Contrast angiography G. Magnetic resonance venography H. ESR I. Coagulation studies J. Brain MRI K. Blood glucose level L. EMG walking test M. Serum CK
B. CT scan - Generally, elective surgical repair is indicated in patients with large symptomatic AAA – repair of aneuryms over 5.5cm offers a survival advantage. Also, young healthy patients and women in particular may benefit from early repair for smaller AAAs. Data suggests that EVAR (endovascular AAA repair) is equivalent to open repair in terms of overall survival but the rate of secondary interventions is higher with EVAR. Generally, those with a greater risk of perioperative morbidity and mortality, such as patients with co-morbidities such as COPD, may benefit from the less invasive approach (anatomy permitting). Younger and healthier patients may benefit from the relative durability of traditional open repair. A CT scan is useful for diagnosis aortic aneurysms which lie close to the origins or or proximal to the renal arteries. While abdominal ultrasound can also identify the AAA and aortic dilation, a CT scan is more useful in localising this lesion and its relationship to the renal vasculature
A 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 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)
An overweight 60 year old lady is seen in clinic complaining of tiredness and general weakness, her eyesight is also suffering, she says she can’t see the room if she looks at a book and it’s getting worse. Physical examination reveals multiple scars on her abdomen, they are noted to be dark, in stark contrast to her purple striae. The notes show the patient was on metyrapone and aminoglutethamide before her surgery.
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
C. Nelson’s syndrome - Worsening loss of peripheral vision infers pituitary adenoma.
Hyperpigmented scars suggests a state of increased ACTH production however this patient doesn’t seem to be in adrenal failure, she is overweight.
She has had abdominal surgery and was on metyrapone (a drug which inhibits cortisol production) and Aminoglutethamide (an adrenolytic) Basically this woman is overweight and has striae because she was cushingoid.. the cause was adrenal hyperplasia. She was on medication to control this but the decision was made to operate and a bilateral adrenalectomy was performed. The consequences of this is that she has very minimal cortisol production and her pituitary is striving to fuel this by pumping out lots of ACTH (hence the dark scars). The visual field problems are due to an undiagnosed pituitary adenoma that was non functional but since her surgery the pituitary tumour has grown substantially since there is no negative feedback coming from circulating cortisol. This is basically Nelson’s syndrome.
NB : these days bilateral adrenalectomy is very rare and the pituitary is sometimes irradiated to prevent Nelson’s from occurring. This patient needs glucocorticoid replacement and transsphenoidal surgery.
A 10 year old boy presents to A&E one winter following a school P.E. lesson with a difficulty in breathing and an audible wheeze.
A. TB B. Emphysema C. Bronchitis D. Pleural effusion E. Pneumonia F. Lung Tumour G. Pulmonary embolism H. Asthma I. Pneumothorax J. Pulmonary fibrosis K. Sarcoidosis
H. Asthma - This is likely to be asthma, exacerbated by the cold air and exercise. Treatment is in this case based on paediatric guidelines which differs from that of adult asthma. Diagnosis is supported by PEFR variation of at least 20% over 3 days in a week over several weeks or an increase of at least 20% to treatment.
Stepwise treatment for adult asthma (BTS guidelines) is outlined here as this is most commonly examined. Step 1: SABA PRN, Step 2: Plus low-dose inhaled corticosteroids (ICS) , Step 3: Plus LABA, Step 4: Increase dose of ICS or add LTRA, SR theophylline or beta agonist tablet, Step 5: Daily steroid tablet and maintain ICS with specialist care.
A 33 year old man has severe pain and fresh bleeding on defecation.
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
E. Topical GTN - 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. 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 30 year old, man became unwell 4 weeks after a holiday in Africa. He developed headaches, muscle pains, feeling cold, severe rigors, high fever, flushing, vomiting and profuse sweating.
A. Toxoplasmosis B. Syphilis C. Enteric fever D. CMV (cytomegalovirus) E. Tetanus F. Tuberculosis G. Giardiasis H. Malaria I. Herpes zoster (shingles) J. HIV K. Influenza L. Rabies M. Viral hepatitis N. Glandular fever O. Cholera P. Polio
H. Malaria - In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Malaria is endemic in many parts of Africa and this is a clue. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. Note that blackwater fever is a complication of malaria which occurs due to haemolysis and the release of haemoglobin into blood vessels and subsequently into the urine, which can frequently lead to renal failure.
A 23 year old woman has a random blood glucose result of 7.7 mmol/L in clinic
A. Impaired glucose tolerance B. Normal C. Impaired fasting glucose D. Diabetic E. Non-signifcant
E. Non- significant - This patient has had a random blood glucose taken. A reading of > 11.1 mmol/L would almost definitely mean she was diabetic. A reading greater than 7.8 might be suggestive of some dysfunction and possible prediabetes although it is not conclusive. However her reading is 7.7 mmol..nothing can be derived from this.. it is a non-significant reading.
A 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.
A 62 year old gentleman presents with fatigue, breathlessness & anorexia. On examination his JVP is noted as being elevated, he has hepatomegaly & swollen ankles.
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
E. Congestive cardiac failure - The key manifestation is dyspnoea and tiredness. CCF is a term used for patients who are breathless with oedema (signs of LVF and RVF). Elevated JVP, hepatomegaly and peripheral oedema are all signs of RVF. 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.
A 6 year old presents with mild jaundice and some pain and swelling of his fingers. O/E you note splenomegaly.
A. Dubin-Johnson syndrome B. Gilbert's syndrome C. Carcinoma of the pancreas D. Gall stones E. Primary sclerosing cholangitis F. Hepatitis G. Haemolytic anaemia H. Primary biliary cirrhosis
G. Haemolytic anaemia - Africans have higher incidence of sickle cell anaemia. This is a presentation of bone pain here with dactylitis, consistent with hand-foot syndrome which can be what young infants and children present with (it is often a child’s first presentation of disease). The jaundice here is due to haemolysis and so while this is sickle cell anaemia, the options are trying to get you to think a bit about the best fit here which would be haemolytic anaemia. About 8% of black people carry the gene and the prevalence is high in sub-Saharan Africa. The condition is autosomal recessive and therefore occurs in 1 in 4 pregnancies where both parents carry the sickle gene. Sickling occurs when RBCs containing HbS become distorted into a crescent shape. Patients with sickle cell anaemia have no HbA at all. If both parents carry the sickle cell gene, there is a 1 in 4 chance of giving birth to a child with sickle cell anaemia. Sickle cell disease also includes other conditions such as HbS from one parent with another abnormal Hb or beta thalassaemia from the other parent such as HbS-Beta thal and HbSC. Treatment goals here include fluid replacement therapy, pain management and symptomatic control.
An 18-year-old woman found unconscious at home. She has needle “track” marks in her arms, a respiratory rate of 10/min. and pinpoint pupils.
A. Intravenous naloxone B. Intramuscular glucagon C. Intravenous dextrose D. DC cardioversion E. Endotracheal intubation F. Inhaled anticholinergic G. Lumbar puncture H. Commence CPR I. IV antibiotics J. Precordial thump K. CT scan brain L. Gastric lavage
A. Intravenous naloxone - Opiate OD signs include CNS depression, miosis and apnoea. Finding small constricted pupils in someone who is unconscious is highly indicative. Naloxone is indicated both therapeutically and diagnostically. If there is a response, then it is diagnostic. Another diagnosis should be sought if the patient is unresponsive. IV is the preferred route of administration although naloxone can be given IM or SC if IV access cannot be established. Ventilatory support is key with 100% oxygen. You can check out Toxbase for a full database on poisons and treatments.
A 10-year-old boy has wasting of his lower leg, which look like ‘inverted champagne bottles’. His father had the same condition.
A. Diabetic neuropathy
B. Carpal tunnel syndrome
C. Charcot-Marie-Tooth disease
C. Charcot-Marie-Tooth disease - Charcot-Marie-Tooth disease comprises of a group of hereditary peripheral neuropathies with different genetic abnormalities, hence the FH here (most patients have a FHx). Pes cavus (high foot arches), hammer toes and distal atrophy of the hands and legs are characteristic (resulting in this inverted champagne bottle appearance). Pes cavus can be associated with areflexia. Patients may have to lift their legs up excessively to clear the toes. Rehabilitative and orthotic treatments can help to keep patients functional. There are no other known risk factors for this condition aside from FH. The risk of passing the condition on to the next generation varies depending on the subtype of CMT, which have different inheritance patterns. Most CMT1 and CMT2 are autosomal dominant and CMT 4 is autosomal recessive. There are also X-linked forms.
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 55 year old man with known carcinoma of the lungs, develops SOB over a few days. He has a large cardiac silhouette on his CXR but no pulmonary oedema.
A. Tuberculosis B. Mitral stenosis C. Atrial septal defect D. Conduction system disease E. Hypertensive cardiomyopathy F. Pericardial effusion G. Aortic valve disease H. Mitral regurgitation I. Dilated cardiomyopathy J. Infective endocarditits K. Pulmonary fibrosis L. Pericarditis
F. Pericardial effusion - This is a malignant effusion (one of the most likely to lead to tamponade) caused by lung cancer. Other prevalent malignant causes include breats cancer, lymphomas and leukaemias. This may also be the first sign of metastatic disease. The history of lung cancer here should make you suspicious. Other causes of a pericardial effusion include hypothyroidism (high protein content and accumulate very slowly due to capillary leak), cardiac causes such as CHF and dissection of the proximal aorta, trauma, radiation-related, uraemia, immune-mediated such as SLE, Dressler’s, amyloidosis and Wegener’s, infectious or idiopathic (which is generally assumed to be viral). Symptoms may coexist with those of pericarditis sometimes. ECG and CXR are indicated here. Most patients also get an echocardiogram whic is the preferred test to establish the diagnosis. On ECG there may be diffuse ST elevation and PR depression with epicardial inflammation. If the effusion is large enough there may be electrical alternans, which is beat-to-beat variation of the ventricular axis (find an image of this to cement it in your memory). The cardiac shadow on CXR is said to be ‘water-bottle shaped’. Pericardiocentesis may be necessary depending on the clinical case.
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 man has undergone an anterior resection, the epidural he was supposed to have didn’t site properly so he is on strong opioids post op. He has developed hyponatraemia, he is not oedematous and his urine is dark. The urine osmolality is measured at 600 mOsm.
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
H. SIADH - Opioids and operative pain are known causes for SIADH. The man is hyponatraemic with concentrated urine. His urine is inappropriately concentrated given his dilutional hyponatraemia. This is caused by excessive production of ADH. Excessive fluid replacement post surgery can exarcebate SIADH. The diagnosis requires absence of hypovolaemia and oedema (and use of diuretics). It also depends on urine osmolality being >500 mOsm and high in sodium. Causes Include Drugs, malignancies (ie.SCC of the lung) CNS disorders including guillain barre and head trauma. Chest infections in hospital can lead to SIADH developing. Metabolic diseases can also be responsible.
Inebriation, coma, reduced reflexes, tachycardia, pulmonary oedema, shock, 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
H. Carbon monoxide - This man who works in a petrol refinery is suffering from carbon monoxide poisoning and his co-worker who has found him lying on the ground is starting to suffer from similar symptoms due also to CO exposure. CO is a colourless and odourless gas so patients may not initially be aware of the poisoning which can cause hypoxia, cell damage and death (in approximately 1/3). CO can come from fire or non-fire sources and early symptoms are non-specific and include the symptoms seen here: headache, dizziness and nausea. Increasing exposure leads to cardiovascular effects like myocardial ischaemia, infarction and possible arrest. Neurological symptoms include the confusion seen here and may lead eventually to coma and syncope. Diagnosis is based on carboxyhaemoglobin levels and the clinical picture here is very suggestive. It is worth noting that in severe CO poisoning, pulse oximetry readings may be falsely raised. Key in treatment is the use of high-flow oxygen, hyperbaric oxygen and supportive care. Hyperbaric treatment entails complications such as barotrauma, oxygen toxicity and pulmonary oedema.
A 45 year old man has a long history of drinking excess alcohol. He has a 3 month history of intermittent, severe abdominal pain & diarrhoea with pale, bulky, foul-smelling stools which are hard to flush away
A. Clostridium difficile B. Staphylococcus aureus C. Chronic pancreatitis D. Drug-induced diarrhoea E. Villous adenoma of the rectum F. Cryptosporidium infection G. Coeliac disease H. Ulcerative colitis I. Irritable bowel syndrome J. Diverticular disease K. Campylobacter L. Crohn’s disease
C. Chronic pancreatitis - This is chronic pancreatitis which is most commonly associated with chronic alcohol abuse. Features include the epigastric pain here, which classically radiates to the back, and steatorrhoea from malabsorption, described here with the pale, foul-smelling and difficult to flush stools. There may additionally be DM due to pancreatic failure and the patient may be malnourished. The diagnosis is based on findings and imaging – your options are USS which is less sensitive, or CT, which is more sensitive but involves radiation exposure. AXR is not a sensitive enough test. There is no real definitive treatment, which is mainly symptomatic and the underlying and precipitating factors are treated – in this case, this man’s alcohol excess. Complications of chronic pancreatic imflammation include the development of pseudocysts, calficiation, DM and malabsorption.
A 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 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.
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 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 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.
Drug interactions
A. Cocherane database B. Medline C. National institute for clinical excellence (NICE) website D. British national formulary E. BMA website F. Evidence based medicine website G. BMJ website
D. BNF - The BNF will tell you about indications and contraindications for drugs
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 40 year old business man travels frequently to the Far East and Africa. He became generally unwell with a fever, generalised lymphatic swelling, diarrhoea. On examination he was noted to have oral canididasis
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
F. HIV - The aim here is to establish the patient’s prognosis and begin the patient on HAART (highly active antiretroviral therapy). This patient needs to have a CD4 count, screen for HBV and HCV, VDRL, tuberculin skin test and a CXR. HIV viral load is also assessed at baseline. Generalised lymphadenopathy is common in HIV and present as painless enlarged nodes, usually in 2 or more non-contiguous sites, of >1cm for > 3months. Fevers and night sweats are also commonly seen, which may also indicate TB, which needs to be excluded (and malaria if from an endemic area). Unexplained diarrhoea of >1 month duration with no pathogen diagnosed is also seen in HIV. The oral candidiasis is also indicative of HIV and is an opportunitistic infection in an immunocompromised host. This patient has WHO stage 3 disease and would be placed in CDC category B, or symptomatic non-AIDS conditions. Oropharyngeal candidiasis is not AIDS indicating, but if this patient has candidiasis of the bronchi, trachea or lungs, or oesophagus then this would indicate an AIDS diagnosis (CDC category C – once the patient reaches category C, they stay in this category). I would not worry too much about clinical staging which is done according to the WHO or CDC criteria.
Other category C conditions, which indicate AIDS, include CMV retinitis, Kaposi’s sarcoma, Mycobacterium avium complex/tuberculosis/other, PCP and toxoplasmosis. Key risk factors for HIV include needle sharing with IVDU, unprotected homo- and heterosexual intercourse (a higher risk if the receptive partner, particular with receptive anal intercourse), HIV infected blood transfusion, needle stick injury and high maternal viral load (mother to child transmission).
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 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 25 year old woman with fatigue & weight loss. She gives a history of frequent loose stools with abdominal pain. Full blood count revealed iron deficiency anaemia.
A. Renal failure B. HIV C. Tuberculosis D. Depression E. Malabsorption F. Addison's disease G. Hyperthyroidism H. Diabetes mellitus I. Liver failure J. Malignancy K. EBV L. Anorexia nervosa M. Cardiac failure
E. Malabsorption - There is frequent loose stools here and abdominal pain. Combined with the IDA, this points to malabsorption. This could well be a presentation of coeliac disease – IDA is one of the most common clinical presentations and abdominal pain and diarrhoea are common. Coeliac disease is a systemic autoimmune condition triggered by dietary gluten peptides found in grains. It is a relatively common condition. The only treatment is a strict gluten-free diet for life.
A 50 year old female presents with a purulent discharge from the anal region & has recurrent episodes of pain, which is intense & throbbing. On examination there was pruritis ani.
A. Irritable bowel syndrome B. Pilonidal sinus C. Haemorrhoids D. Inflammatory bowel disease E. Abscess F. Prolapse G. Fissure H. Fistula I. Intussusception
E. Abscess - Typically, this presents with perianal pain. The location is important and affects management and diagnosis. If it is inter-sphincteric, then anaesthesia tends to be required to examine the rectal passage adequately for diagnosis – the pain tends to be so bad that a DRE is impossible otherwise. Abscesses found above levator ani may minic an abdominal condition. CT/MRI may be needed to establish the diagnosis. Risk factors include conditions like Crohn’s and anal fistulae (a complication of an abscess can also be a fistula). This accounts for the patient’s symptoms such as pruritis ani. A pilodinal abscess would be difficult to distinguish from an anorectal abscess on history alone but are usually located in the inter-gluteal region and often have a sinus tract in the midline. If the two are difficult to distinguish (such as if the patient cannot be examined), then MRI or CT of the pelvis may be used. Treatment involves drainage of the abscess surgically and the fistula, if present, can also be managed with a fistulotomy or seton insertion. Some patients will also get adjunctive antibiotics, such as the elderly and diabetics.
A 30-year-old man developed acute pain in the right calf after a game of squash. He has marked calf tenderness but no swelling. Doppler ultrasound is negative.
A. Check INR and continue warfarin B. Fondaparinux (FXa inhibitor) C. Subcutaneous low molecular weight heparin D. Antiembolism stocking E. Start warfarin therapy F. Vena cava filter G. Reassure and discharge H. Embolectomy I. Observation in hospital J. Intravenous heparin
G. Reassure and discharge - This is likely to be a musculoskeletal injury in an otherwise fit, young man. Eccentric contraction causes more frequent injury. Inadequate warm-up before exercise can predispose to muscle injuries.
A 64-year-old, previously obese woman complains of weight loss, despite increased appetite and says she has been treating herself for ‘repeated urine infections’. She also says that over the last few months she has been getting pins and needles in her legs.
A. Full blood count and ESR B. Abdominal CT C. HIV antibody test D. Colonoscopy E. Blood test for auto-antibodies F. Thyroid function tests G. Bronchoscopy H. Fasting blood glucose I. Chest x-ray J. Bone marrow aspirate K. History only L. Gastroscopy M. Brain scan
H. Fasting blood glucose - T2DM can present with yeast, skin and urinary tract infections on top of unintentional weight loss and fatigue. The pins and needles in her legs is a result of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. There tends to be loss of sensation typically occuring in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain or paraesthesia. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0.
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 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 gentleman suffers from intermittent episodes of nausea, sweating, central crushing pain, radiating to jaw, lasting a few minutes, which is made worse by exercise.
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
D. Exercise ECG - 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 angina 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 50 year old man has his BMs measured in cardiology clinic which he attends as he is in left ventricular failure. It is a fasting measurement and comes back as 6.8 mmol/L. Pick the medication most suitable for this patient.
- Captopril
- Amiodarone
- Bendroflumethazide
- Digoxin
- Captopril - No mention is made of any arryhthmia so Amiodarone/ Digoxin aren’t necessarily required. The man has impaired fasting glucose and so is at risk of progressing to diabetes. Thiazide diuretics are recognised as causing iatrogenic Diabetes Mellitus and so are unsuitable here. This man has LVF without Atrial fib and so an ACE-i’ is first line therapy.They relieve the pre and afterload on the heart reducing progression to Left ventricular dilatation. It has also been shown that patients with Impaired Fasting Glucose and heart failure treated with ACE-i drugs are at much less risk of progression to diabetes over the short term at least (3% vs~50%).
A 32-year-old man presents 24 hours after the sudden onset of the worst headache of his life. He has no history of headaches, is afebrile but has neck stiffness and is drowsy. CT scan is normal.
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
G. Lumbar puncture - 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.
34-year-old male with Crohn’s disease has had no bowel motions for 4 days and has been vomiting for 24 hours. Examination reveals a distended abdomen and tinkling bowel sounds.
A. Intussusception B. Pancreatitis C. Oesophageal cancer D. Uraemia E. Gastric cancer F. Pyloric stenosis G. Salmonella H. Bowel obstruction I. Appendicitis J. Combined oral contraceptive pill K. Viral gastroenteritis L. Bulimia M. Peptic ulcer disease
H. Bowel obstruction - Bowel obstruction has several causes such as adhesions or cancer. The lack of bowel motions, vomiting, distended abdomen and tinkling bowel signs are all indicative. The proximal segment of bowel dilates and distal bowel collapses. Completely obstructed patients generally require surgery. If, on AXR, air is seen to be seeping past the obstruction then the obstruction is partial. As a standard, all patients should be made NBM and given supplemental oxygen, IV fluids and NG decompression (to reduce flow/gastric contents/air towards the obstruction), unless they are rushed off for an emergency laparotomy because, for example, they have complete SBO and are peritonitic.
A pregnant 27-year-old lady is found to have a soft, short systolic murmur at the apex. There are no other signs or symptoms of heart disease.
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
G. Innocent murmur - This is a functional murmur which is not caused by a structural cardiac defect. They often reflect hyperdynamic states such as that seen in pregnancy. 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.
Chose choose the most likely mode of inheritance.
Multiple sclerosis
A. None/unknown B. Autosomal recessive C. Autosomal dominant D. X-linked dominant E. Chromosomal abnormality F. X-linked recessive G. Mitochondrial inheritance
A. None/unknown -
Here is a list of the important conditions you should be aware of:
Autosomal dominant: Achrondroplasia, APKD, dystrophia myotonica, familial hypercholesterolaemia, Huntington’s, Marfan’s, NF, tuberous sclerosis, osteogenesis imperfecta
Autosomal recessive: CF, hereditary haemochromatosis, sickle cell disease, Wilson’s, Friedreich’s ataxia, CAH
X-linked recessive: DMD, Fragile X syndrome, Haemophilia A and B, G6PDH deficiency, Alport’s
You should be aware that Down’s is trisomy 21, Edwards’ is trisomy 18 and Patau’s is trisomy 13.
An 18-year-old develops fever, photophobia and neck stiffness. There is also confusion and vomiting as well as a petechial rash. A CT scan is needed but someone is already in the CT scanner.
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
A. Intravenous antibiotics - Obviously meningitis and likely meningococcal due to the petechial rash. You all got that bit. Right? Now CT head should be considered before LP if there is any evidence of raised ICP, which we can presume this person here has. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen. BUT this is clearly a very severe case and an emergency and LP here is going to be delayed. You should start this person on IV broad spectrum antibiotics and consider getting blood culture results.
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.
An 81-year-old male complains of haematuria. He has been an inpatient for 3 weeks following admission for a left hip replacement due to osteoarthritis. His catheter was removed two days ago as he is becoming increasingly mobile.
A. Prostate cancer B. Ureteric colic C. Prostatic varices D. Acute pyelonephritis E. Urinary tract infection F. Bladder cancer G. Trauma H. Renal cell carcinoma
G. Trauma - This patient has had a catheter removed two days ago, which accounts for his gross haematuria (instrumentation of the urinary tract causing damage). The diagnosis is clinical based on the presence of the catheter.
A 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.
Mrs Loren, 26, gave birth to a healthy boy a week ago. She is attempting to breast feed but is having some difficulty. Over the past 24 hours, she felt like she had influenza coming on. She has a 5cm, very tender mass in her right breast and there is erythematous skin overlying this.
A. Basal cell carcinoma B. Adenoma C. Sebaceous cyst D. Fat necrosis E. Carcinoma of the breast F. Intraductal papilloma G. Lipoma H. Radial scar I. Breast bud J. Fibroadenosis K. Phylloides tumour L. Breast abscess M. Fibroadenoma
L. Breast abscess - Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful red mass indicates the development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Prostate carcinoma
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
F. Cadmium - Studies have shown that men in certain occupations, with higher levels of exposure to cadmium, have a higher risk of prostate cancer. It is thought that cadmium interacts with certain hormone receptors and mimics the effects of oestrogen and testosterone, thus abnormally stimulating the growth of the prostate. Furthermore cadmium is thought to interfere with the body’s ability to absorb zinc (which is believed to have a protective effect against prostate cancer.)
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 man has dysphagia which has been getting progressively worse, he has also lost weight. He is submitted for thyrooidectomy. A few weeks later at a checkup it is noticed that his thyroglobulin levels are creeping up again.
A. Potassium Iodide B. Radioiodine C. Propranolol D. Propylthiouracil E. Surgical decompression F. Carbimazole G. Stop treatment
B. Radioiodine - sounds like a malignant thyroid has been removed (weight loss, dysphagia) and the thyroglobulin is mentioned as it is useful as a marker of neoplastic activity in patients with these malignancies (much like PSA in prostate Ca), carcinoembryonic antigen : CEA may also be used in the same way. Recurrence or suggestion of should be treated promptly with followup irradiation.
A 47-year-old male policeman was brought to A&E having become SOB suddenly. He now complains of palpitations, which he has never experienced before. Heart sounds are irregular but no murmurs are audible. He is a diabetic with hypertension.
A. Pancreatitis B. Wernicke's encephalopathy C. Wolff-Parkinson-White syndrome D. Hyperglycaemia E. Atrial fibrillation F. Convulsions G. Subdural haematoma H. Acute gastritis I. Hypertension J. Anxiety attack K. Delirium tremens L. Hypoglycaemia M. Pulmonary fibrosis N. Oesophageal varices
E. Atrial fibrillation - Atrial fibrillation is an irregular atrial arrhythmia with a broad list of risk factors such as coronary artery disease, heart failure, hypertension, DM and thyroid disorders. This patient has two of these risk factors. AF affects some 5% of those older than 69 years old. The presentation of SOB and palpitations is consistent with the diagnosis and the irregular heart sounds suggests AF as the cause. ECG would show absent P waves, a fibrillatory baseline and irregularly irregular complexes. Most that present with acute AF do not need immediate treatment, unless they have developed haemodynamic compromise, which requires immediate DC cardioversion. Most will require medical therapy with drugs to control the ventricular rate, restore and maintain sinus rhythm and prevent the occurence of thromboembolic events. Do you know which drugs are used and are you familiar with treatment guidelines for this common condition?
A 21 yo man has had a sore throat recently and now developed a very tender gland on his neck which is quite erythematous. He has also been feeling quite jittery and anxious, he complains of thumping in his chest.
A. Potassium Iodide B. Radioiodine C. Propranolol D. Propylthiouracil E. Surgical decompression F. Carbimazole G. Stop treatment
C. Propanolol - de quervains, sore, red thyroid caused by infection. It is early stage hence he is thyrotoxic. Management is mainly supportive..analgesia and beta blockade for the palpitations and anxiety.
A 64 year old man presents with a 1 day history of dark rectal bleeding. He has complained of some diarrhoea for the last 6 months, & has noticed some loss of weight. Rectal examination & proctoscopy are normal.
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
D. Colonic carcinoma - The symptoms of colorectal cancer are non-specific but the GI symptoms here combined with weight loss should make you suspicious. Symptoms include change in bowel habit, rectal bleeding and anaemia, commonly associated with right sided cancer. Distension, weight loss and vomiting are usually associated with advanced disease. Colonoscopy will be needed in this patient for diagnosis and a biopsy of any suspicious lesion found. Main curative treatment is surgical resection. CEA is the classic tumour marker, which is raised in about 80% but is not really sensitive or specific enough to be useful in diagnosis or screening, but is used to monitor treatment and recurrence in those who have already been diagnosed.
A 28-year-old woman has developed rapid weight loss and palpitations. You notice lid lag and a goitre on examination.
A. TB abscess B. Graves disease C. Hodgkin's disease D. Myxoedema E. Pancreatic carcinoma F. Superior vena cava syndrome G. De Quervain's thyroiditis H. Hashimoto's thyroiditis I. Thyroid cancer J. Euthyroid goitre K. Carotid artery aneurysm L. Thyroglossal cyst
B. Graves disease - This woman has symptoms of hyperthyroidism (weight loss and palpitations) and a goitre. In countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Graves’ gives a diffuse goitre. Peripheral manifestations such as ophthalmopathy, pretibial myxoedema and hyperthyroid acropachy do not occur with other causes of hyperthyroidism. Ophthalmopathy includes lid retraction, exophthalmos and eye movement restriction leading to diplopia. Acropachy is an uncommon manifestation presenting as clubbing with soft tissue swelling. Pretibial myxoedema is almost always associated with ophthalmopathy. Treatment aims to normalise thyroid function and is achieved by radioactive iodine, antithyroid medications or with surgery. They are all effective and relatively safe options. Symptomatic therapy is given with beta blockers such as propranolol.
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 20 year old man with cystic fibrosis presents to the chest clinic with haemoptysis. He has felt unwell for a fortnight with increased sputum production, fever & rigors. Gram stain of the sputum shows Gram-positive cocci in clusters.
A. Pulmonary metastases B. Pulmonary embolism C. Pulmonary abscess D. Small cell carcinoma E. Streptococcal pneumonia F. Squamous cell carcinoma G. Microscopic polyarteritis H. Tuberculosis I. Goodpasture’s disease J. Myaesthenia gravis K. Mesothelioma
C. Pulmonary abscess - A lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which a patient with CF is at risk of is a risk factor. Of gram positive cocci, staphylococcus occurs in grape-like clusters (this patient) whereas streptococcus occurs in chains. It is worth learning your gram stains for the main organisms. It is worth noting that Staphylococcus aureus is coagulase positive (also Yersinia pestis which causes plague) and Streptoccus pneumoniae is optochin sensitive. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.
A 40-year-old female has a routine blood test showing serum calcium 2.85 mmol/l (corrected). She takes no medications. PTH is also elevated and ALP is mildly raised. She is depressed.
A. Myeloma B. Medullary cell carcinoma of the thyroid C. Sarcoidosis D. Paget’s disease E. Thiazide diuretics F. Vitamin D intoxication G. Hypervitaminosis A H. Tuberculosis I. Immobility J. Milk-alkali syndrome K. Primary hyperparathyroidism L. Metastatic breast carcinoma M. Secondary hyperparathyroidism N. Pseudohypercalcaemia
K. Primary hyperparathyroidism - This is the most common cause of hypercalcaemia. 85% are due to a single adenoma in one of the glands while most of the rest are due to 4 gland disease. The range of disease is from very mild/asymptomatic through to severe disease with bone loss, fractures and osteitis fibrosa cystica. There is autonomous PTH production in primary HPT which causes deranged calcium metabolism. Biochemistry will show elevated serum calcium and inappropriate elevation of PTH. Depression, cognitive changes, change in sleep (possibly due to change in circadian rhythm) and myalgia are all common complaints. Osteoporosis may occur due to excess PTH causing bone resorption (osteoclasts are stimulated). Hypercalciuria may cause renal stones and nocturia. The only definitive cure is a parathyroidectomy although complications of this procedure include hypocalcaemia, injury to the recurrent laryngeal nerve, bleeding and a pneumothorax.
For each of the following patients choose one of the options above as the single most appropriate means of reducing cardiovascular risk
A 62 year old man, 3 months after an MI, taking asprin, atenolol and simvistatin, whose echocardigram shows worsening left ventricular function
A. Weight reduction and increased physical activity
B. Angiotensin converting enzyme inhibitor therapy
C. Weight reduction and metformin therapy
D. Cholesterol lowering therapy with a statin
E. Reduced alcohol intake
F. Antihypertensive drugs
G. Aspirin therapy
H. Smoking cessation
B. 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.
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.
An 82 year old female presents with a large lump which appears at the anus after defecation, & spontaneously on coughing. The lump is uncomfortable & the patient has tenesmus. She also has incontinence & has noticed mucus PR.
A. Irritable bowel syndrome B. Pilonidal sinus C. Haemorrhoids D. Inflammatory bowel disease E. Abscess F. Prolapse G. Fissure H. Fistula I. Intussusception
F. Prolapse - Rectal prolapse tends to present as a mass protruding from the rectum, especially with straining on the toilet. This may be associated with mucous or blood-stained discharge, pain and even faecal incontinence. In contrast, haemorrhoids tend to present with painless PR bleeding or perianal pain with a tender mass in the area. This can be confirmed on examination. Tenesmus is the constant feeling of needing to pass stools, even if there is nothing to pass. It may also be a symptom of rectal carcinoma, and is caused by a SOL.
A 52-year-old woman with known ischaemic heart disease and shortness of breath on exercise. At regular clinic review, it is noted that her weight has increased by 4kg over 6 months. There is no change in dietary intake or medication. O/E, chest is clear and there is minimal ankle oedema. JVP was normal.
A. Addison’s disease B. Cushing's syndrome C. Pregnancy D. Salt-wasting nephropathy E. Heart failure F. Metabolic syndrome G. Comfort eating H. Renal failure I. Reduced activity J. Portal hypertension K. Polycystic ovary syndrome L. Amyloidosis M. Hypothyroidism
I. Reduced activity - The examination here is unremarkable and there is no change in diet or medication. This patient has reduced exercise capacity with SOB on exertion, which has resulting in reduced mobility, accounting for her weight gain as less energy is being expended despite consuming the same amount.
A 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.
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 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 58 year old male smoker has a 2 month history of progressive persistent hoarseness and pain in his left ear on swallowing. He has enlarged left cervical lymph nodes.
A. Laryngeal nerve palsy B. Hypothyroidism C. Vocal cord nodules D. Wegener's syndrome E. Angioedema F. Foreign body G. Carcinoma of the larynx H. Laryngitis I. Sjogren's syndrome J. Acromegaly
G. Carcinoma of the larynx - Laryngeal cancer is frequently associated with two big risk factors: smoking and alcohol use. Major signs are persistent (>3 weeks) of hoarseness, dysphonia, sore throat, dysphagia, referred otalgia (seen here) and neck masses/adenopathy. These patients need to be evaluated by a specialist and as mentioned this can resemble chronic laryngitis in presentation. An MDT approach is taken to try and preserve the organ as much as possible, with salvage surgical resection offered in advanced disease.
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.
A 40-year-old lady presents with parasthaesia in the left lower limb and displays an intention tremor. She recalls that 6 months prior to this, she had an episode of temporary visual loss which she found frightening.
A. Parkinson's Disease B. Exaggerated physiological tremor C. Cerebellar tremor D. Dystonia E. Sydenham's chorea F. Brain tumour G. Alcohol withdrawal H. MS I. Asterixis
H. MS - MS is a demyelinating CNS condition which is characterised by 2 or more episodes of neurological dysfunction which are separated in both time and space. MS classically presents in white women aged 20-40 with temporary visual/sensory loss although any presentation can occur. MRI is a sensitive test but less specific than spinal MRI, however, spinal MRI is abnormal in fewer cases. Treatment aims at treating the attack, preventing future attacks and symptomatic treatment of problems like bladder dysfunction, pain and fatigue.
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 45-year-old man had an arteriovenous fistula formed yesterday for dialysis access. A Doppler scan shows that this is not working today.
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
A. Angioplasty - Stenosis and thrombosis of AV fistulae may lead to loss of vascular access sites which presents a problem for chronic haemodialysis patients. Percutaneous transluminal angioplasty is a commonly employed technique used to correct the stenosis and restore viability. All patients who are having haemodialysis should be educated about vein preservation with limiting venepuncture and IV access in the access arm.
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.
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 25 year old woman finds a smooth, rubbery and mobile mass on her left breast. She is overwise asymptomatic.
A. Intraductal papilloma B. Lobular carcinoma in situ C. Gynaecomastia D. Phylloides tumour E. Pregnancy F. Breast Abscess G. Fibroadenoma H. Mastalgia I. Nodularity J. Invasive breast cancer K. Adenoma
G. Fibroadenoma - Fibroadenomas are typically asymptomatic and are found incidentally in patients
A child with severe learning difficulties, cleft lip & palate, polydactyly and multiple heart defects. Karyotype analysis shows trisomy 18.
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
A. Edwards syndrome - Edwards syndrome is trisomy 18 and is phenotypically similar to Patau’s. Most affected are females and most die before birth. The incidence, as with most trisomies, increases with advanced maternal age. The rate of survival is low due to cardiac abnormalities, renal malformations and other visceral disorders. Signs and symptoms include those mentioned and a whole host of other signs of this phenotype such as a small head, small jaw, widely spaced eyes and ptosis. The cardiac defects seen include VSD, ASD and PDA (all the lovely 3 letter acronyms). Classic EMQ signs include webbing of the second and third toes and the Rocker bottom feet characterised by calcaneal prominence and a convex rounded bottom to the foot, which is associated with both trisomy 13 and 18.
A 70 year old man has been newly diagnosed with stage I COPD and has been given inhaled salbutamol PRN and has agreed to stop smoking. What additional measure is needed?
A. Oral prednisolone B. 24% continuous oxygen C. Long acting beta agonist D. Beta agonist via metered dose inhaler E. Antibiotic reserve F. Influenza immunisation G. Intravenous aminophylline H. 40% continuous oxygen I. Beta agonist via nebuliser J. Intravenous hydrocortisone K. Amoxycillin intravenously L. Intramuscular adrenaline
F. Influenza immunisation - The GOLD guidelines published in April 2010 provide a framework for a stepwise approach to treating COPD. Stages of COPD are based on predicted FEV1. For all stages of COPD, influenza vaccination is given yearly and pneumococcal vaccine is given every 5 years. Long term oxygen is only added if there is chronic respiratory failure in stage IV disease. Stage II involves the addition of long acting bronchodilators and rehabilitation. Stage III involves adding inhaled GCs if there are repeated exacerbations.
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 man is seen in the endocrinology clinic for his thyroid condition. He has the ‘thyroid stare’ and closer inspection of his eyes shows the optic disc is pale and swollen.
A. Potassium Iodide B. Radioiodine C. Propranolol D. Propylthiouracil E. Surgical decompression F. Carbimazole G. Stop treatment
E. Surgical decompression - There is significant retroorbital oedema and fibrosis around the optic nerve, decompressive surgery should help relieve this and prevent further atrophy.
The pulse is irregularly irregular and jerky in character. There is an ejection systolic murmur lessened by squatting loudest at the lower left sternal edge. There is a double apical impulse felt. The apex beat is not displaced.
A. Tricuspid stenosis B. Pulmonary stenosis C. Patent ductus arteriosus D. Aortic stenosis E. Atrial septal defect F. Mitral regurgitation G. Aortic regurgitation H. Tricuspid regurgitation I. Mitral valve prolapse J. HOCM K. Left ventricular aneurysm L. Aortic sclerosis M. Mitral stenosis N. Ventricular septal defect
J. HOCM - This patient has HOCM which is the most frequent cause of sudden cardiac death in younger people. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. There may also be MR. The arterial pulse is described as ‘jerky’ and this patient is also in AF which warrants anticoagulation and anti-arrhythmics. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance. It is worth noting that ventricular hypertrophy causes concentric hypertrophy i.e. the wall of the ventricle gets thicker inwards. Hence the apex beat is not displaced unlike in DCM.
A 42-year-old lady has a seizure the day after her thyroidectomy surgery. She is previous well and taking no medication. She has never had a seizure before.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Hypocalcaemia - Hypocalcaemia can develop as a complication of thyroid surgery due to the loss of parathyroid glands which produce PTH. This is the cause of this lady’s seizure. Trousseau’s sign can be seen which is carpal spasm when a blood pressure cuff is used for several minutes. Carpopedal spasm that occurs with hypocalcaemia is a painful spasm and could also be the presenting sign. Chvostek’s sign is twitching of the perioral muscles in response to tapping over the facial nerve at the ear. If urgent replacement is necessary, calcium gluconate can be given IV. It is preferred over calcium chloride as it causes less tissue necrosis if it leaks out. It is worth noting that digoxin may be ineffective until serum calcium is restored to normal.
A 56-year-old man presents with anorexia and jaundice. He reports losing weight over the past month. He has a bilirubin of 350 umol/L, AST of 55 IU/L and an ALP of 750 IU/L. O/E the gallbladder is palpable.
A. CA 15-3 B. Tyrosinase C. BRCA-1 D. CA 19-9 E. Prostatic acid phosphatase F. Carcinoembryonic antigen G. α-Fetoprotein H. Prostate-specific antigen
D. CA 19-9 - Ca 19-9 is used to confirm the diagnosis of malignant pancreatic tumours, differentiating them from chronic pancreatitis. However, it should not be used as a stand-alone diagnostic tool, rather as an adjunct to CT, U/S and ERCP. It is also used for monitoring the response to therapy. Levels can also be elevated in hepatbiliary disease, but it is not used in this setting.
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 40 year old man returned from India 4 days ago & came down with fever. He went to his GP & got some paracetamol. His fever persisted, & he had a few bouts of diarrhoea & cough. He started getting drowsy & was admitted from casualty where his blood culture was taken. The next day the lab reported Gram negative bacilli seen on blood culture.
A. Mycobacterium tuberculosis B. Legionella pneumophila C. Dengue virus D. Falciparum malaria E. Lassa fever F. Entomoeba histolytica G. Streptococcus pneumoniae H. Salmonella typhi I. Neisseria meningitidis type B J. Influenza
H. Salmonella typhi - Typhoid (or enteric fever) is a faecal-oral illness caused by Salmonella enterica, serotype S typhi, Salmonella enterica and S paratyphi. There are over 2500 serovars for S enterica. In this country, it is mainly from people who have returned from a country where it is endemic – India, for example, which has the highest incidence of this disease. Mexico should also ring alarm bells. The water supplies are not treated and sanitary conditions are dire which prompts transmission of this infection. Humans are the only known reservoir. The vaccine only offers moderate protection and does not protect against paratyphoid infection. This person has a high fever which is a hallmark of infection (sometimes in a step-wise manner) which is not responding to paracetamol (it persists) and blood culture (you need a big sample of blood for testing as count is usually low) shows a gram negative bacilli, and he has returned from an endemic region. The fever of typhoid classically increases incrementally until a persistent fever with temperature 39-41 is established. There are also typically flu like symptoms after onset of fever and cough. Remember that characteristic findings such as bradycardia and rose spots may not be present and indeed rose spots may not be easy to spot in those with dark skin. Rose spots are blanching red lesions reported in 5-30% of cases usually occuring on the chest or abdomen.
This patient needs antibiotics though the temperature will fall over about week. A third generation cephalosporin is indicated due to resistance to fluoroquinolones in the Indian sub-continent. If the sensitivity panel returns and shows that this organism is sensitive to all antibiotics then ciprofloxacin should be given.
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 30 year old lady presents to A&E feeling very feverish, complaining of dysuria and haematuria with severe flank pain.
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
F. Pyelonephritis - UTIs involving the renal parenchyma typically presents with fever. Acute onset fever with urinary symptoms and flank pain point to 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.
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 52 year old otherwise fit and healthy man is found to have a 6.3cm AAA. He is very surprised and requests that it is treated so he does not die suddenly in the future.
A. Angioplasty B. Femoral-distal bypass C. Aortobifemoral bypass D. Methyldopa E. Ultrasound F. Alpha blocker G. Embolectomy H. Endarterectomy I. Angiography J. Endovascular aneurysm repair K. Open repair of aneurysm
K. open repair of aneurysm - Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair. Patient 1 is however is elderly and has co-morbidities. An EVAR is the best way forward here. However note also that EVAR could entail a complication of endovascular repair leak, which would require corrective treatment. Endoleak is persistent blood flow outside the graft and within the aneurysm sac. There is 24% risk after EVAR. However, this is not a complication of open repair, which is probably preferred in most cases in those who are fit and healthy enough to have it such as Patient 4. Management of this complication would depend on the type of endoleak.
A 22-year-old student collapses in her room. She is febrile and you notice a rash over her body.
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
M. IM benzylpenicillin - This is suspected bacterial meningitis and in the community setting the patient should receive immediate IM benzylpenicillin before being transferred to hospital as an emergency case.
For each of the malignancies listed below, please select the recognised presentation from the list of options.
Glucagonoma
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
F. Necrolytic migratory erythema - This rash is characteristic of glucagonoma and is also known as ‘glucagonoma syndrome’. It is characterised by the spread of erythematous blisters across the lower abdomen, buttocks, perineum and groin.
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.
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.
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 19 year old male medical student develops acute chest pain during a game of squash. On examination he is distressed there but examination is otherwise unremarkable. There is a family history of sudden death.
A. Upper GI endoscopy B. 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)
E. Transthoracic echo - This patient has likely HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. The FH of sudden death is suggestive of this diagnosis. This has a benign prognosis is most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance.
Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. There may also be MR.
A 55-year-old man found collapsed at home who, on arrival at hospital, has no palpable pulse or recordable blood pressure.
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
H. Commence CPR - This patient has cardiac arrest and the first thing you need to do is commence CPR. It is thought to work by raising intrathoracic pressure and providing direct cardiac compression. 30 compressions (at 100/min) and 2 breaths for a total of 5 cycles (2 minutes), makes up one cycle of CPR. Compressions are the first priority, breaths may follow but compressions are paramount. Further management depends on whether the patient has a shockable rhythm (pulseless CT or VF) or non-shockable rhythm (PEA or asystole). Do you know when a precordial thump can be used?
A 70 year old man, with ischaemic heart disease & COPD, presents with an ulcer between the great & second toes on the right foot. This is associated with pain in the whole foot at night.
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
B. Arterial ulcer - Arterial ulcers are deep and painful with a well defined edge, usually found on the shin or foot. There may be local changes such as cold peripheries, loss of hair, dusky cyanosis and toenail dystrophy. On examination, peripheral pulses may be absent or reduced. An angiogram with contrast will define the lesion and determine whether it can be improved by surgical intervention. Pain often increases when your legs are at rest and elevated. They can occur between the webs of toes so it is important to always check these in your peripheral vascular examination.
A 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 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 45-year-old man with a history of occupational exposure to dust in the building and demolition industry presents with SOB. On examination clubbing and signs of peripheral effusion.
A. Colonoscopy B. Echocardiogram C. Sputum culture D. Lung function tests E. Abdominal ultrasound scan F. Bronchoscopy G. Chest x-ray H. Stool culture
G. 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.
Mrs James is a 50 year old diabetic lady who complains of a tightness in her chest plus a cramping sensation in her jaw and neck after climbing 2 flights of stairs to her apartment.
A. Pericarditis B. Angina C. VSD D. Romano-Ward syndrome E. Infective endocarditis F. HOCM (hypertrophic obstructive cardiomyopathy) G. ASD H. Congestive cardiac failure I. MI J. Left ventricular failure
B. Angina - This patient has presented with stable angina. Resting ECG is often normal however during exercise stress ECG (most often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia. Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography. 1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin. Anti-anginal theray will also be given, first line being beta-blockade. 2nd line is with a CCB. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated. Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary. Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Single vessel disease may benefit from PCI.
A 60-year-old man with diabetes is transferred from another hospital for urgent femoral-distal bypass surgery and arrives with a heparin infusion in situ. His APTT is 2.4.Which drug should NOT be given
A. Diclofenac B. Epidural bupivacaine and fentanyl C. Codydramol D. Paracetamol E. Morphine F. Tramadol
B. Epidural bupivavaine and fentanyl - Epidurals are relatively contraindicated in anticoagulated patients. Insertion of the epidural needle may lead traumatic bleeding into the epidural space and with clotting abnormalities, the development of a haematoma which can lead to spinal cord compression. Coagulopathy, raised ICP and infection at the injection site are absolute contraindications. Relative contraindications include anticoagulated patients and those with anatomical abnormalities of the vertebral column. NSAIDs do not increase the risk of epidural haematoma.
An 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 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 34 year old man presents to the A&E department with a short history of haemoptysis. He has had a cough for a fortnight & noticed his ankles beginning to swell 5 days ago. Initial blood tests show a creatinine of 400mol/l. An autoantibody screen is positive for p-ANCA & anti-glomerular basement membrane antibodies.
A. Pulmonary metastases B. Pulmonary embolism C. Pulmonary abscess D. Small cell carcinoma E. Streptococcal pneumonia F. Squamous cell carcinoma G. Microscopic polyarteritis H. Tuberculosis I. Goodpasture’s disease J. Myaesthenia gravis K. Mesothelioma
I. Goodpasture’s disease - Goodpasture’s is associated with anti-GBM antibodies, and of those who are positive, some will have a positive ANCA too, although this is more suggestive of diagnoses such as Churg-Strauss and microscopic polyarteritis. Definitive diagnosis is by renal biopsy showing crescentic GN and linear IgG staining on immunofluorescence. It is one of the few causes of pulmonary renal syndrome. Aggressive treatment is often needed and plasma exchange can also be performed to remove preformed antibodies.
A 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 60-year old lady who has just from a STEMI requires ongoing treatment. The doctor asks you what would be appropriate first line prevention therapy.
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
E. Aspirin and clopidogrel - Dual antiplatelet therapy is recommended for at least 12 months in all patients whether or not they have been stented. Aspirin should be continued forever and clopidogrel for at least a year. Note that prasugrel, a platelet inhibitor, has been found in relatively recent studies to be superior to clopidogrel in outcome measures when given for at least a year – although there is an increased risk of bleeding in low weight patients and in those over 74 years of age (lower doses are recommended in these patients)
An 18 year old history student who has just started at university for his studies develops a pounding headache and fever. The hall warden remarked that he shouted at her to turn the lights off and draw the curtains when she was called to see him. He was then reported as having a seizure. On arrival to A&E, a CT head scan is done. Select the most APPROPRIATE first line investigation:
A. LFTs B. CRP C. LP D. CXR and sputum sample E. Blood culture F. Sputum sample G. FBC H. Pleural biopsy I. Wound swab and culture J. Urinalysis K. HIV test L. CT head
C. LP - This patient has meningitis. Universities are common sites of outbreaks due to crowding. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen. A CT head scan should be considered before LP if there is reason to suspect raised ICP such as focal neurology, seizures, papilloedema on fundoscopy or altered mental state. The seizure here would be an indication to do a CT scan before attempting LP.
A 65 year old obese man presents with gradual worsening dysphagia for solids, which had initially been intermittent. He has had GORD for many years but is poorly compliant with medication.
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
E. Benign oesphageal stricture - Healing of oesophageal damage inflicted in GORD involves the deposition of collagen. This causes contraction of the distal oesophagus which causes the formation of strictures. This is often associated with dysphagia for solids. Other complications of GORD include oesophageal ulcer, haemorrhage or perforation, Barrett’s oesophagus and oesophageal adenocarcinoma.
A 35 year old woman with history of recurrent lower abdominal pain, bloody diarrhoea & passing mucus PR. On examination there is lower abdominal tenderness & clubbing.
A. Echocardiogram B. Abdominal ultrasound C. Bronchoscopy D. Chest x-ray E. Lung funtion tests F. Sputum culture G. Colonoscopy H. Stool culture
G. Colonoscopy - This woman has inflammatory bowel disease (which is a cause of clubbing), which by the history is more likely to be UC than CD, whereby the mainstay of treatment is with 5-ASA. A colonoscopy is required to assess the extent of disease and for a definitive diagnosis. Biopsy in CD will show transmural granulomatous inflammation. CD can affect the whole GIT but favours the TI and proximal colon and is macroscopically characterised by skip lesions. UC on the other hand is characterised by the presence of crypt abscesses, which is pathognomic. CD risk is increased 3-4 fold by smoking whereas smoking seems protective in UC. The mainstay of treatment in CD is with steroids and azathioprine to 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.While a stool culture may be useful in ruling out infectious gastroenteritis it will not provide the diagnosis here.
A 51 year old manic depressive man, who has taken an unknown number of extra lithium tablets & has a plasma lithium level of 8 mmol/l. There are marked neurological features.
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
I. Haemodialysis - Haemodialysis is the treatment of choice for severe lithium poisoning. Note that activated charcoal does not adsorb lithium.
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 35 year old lady presents with a rash over her face and raised levels of ACE.
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
B. Sarcoidosis - Sarcoidosis is a chronic multisystem disease with an unknown aetiology. The lesion described is lupus pernio which is a typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. Erythema nodosum is another dermatological manifestation. Additionally, serum calcium and ACE levels may be raised. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. 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 lady on Warfarin for recurrent pulmonary emboli presents having vomited a small amount of blood that morning. She has been on antibiotics for a presumed chest infection for the last week.
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
A. Clotting profile - This woman is on prophylactic warfarin anticoagulation. There is an interaction here with the antibiotics this woman is taking which has resulting in enhanced anticoagulation effects of warfarin, causing her to bring up the blood. Cepahalosporins, chloramphenicol, ciprofloxacin, clarithryomycin, erythromycin and metronidazole are all examples which increase the effect of warfarin. Any P450 inducer will have this effect as warfarin is a drug metabolised by cytochrome P450 enzymes. Antibiotics can also upset the gut flora which reduces vitamin K levels.
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.
Contraction of the muscles of the face when tapped gently on the cheek. Sign of hypocalcaemia.
A. Corrigan's sign B. Cullen's sign C. Trosseau's sign D. Raccoon eyes E. Grey-Turner's sign F. Murphy's sign G. Traube's sign H. Quincke's sign I. Muller's sign J. Chvostek's sign K. Battle's sign
J. Chvostek’s sign - Trousseau’s sign is carpal spasm when a blood pressure cuff is used for several minutes. Carpopedal spasm that occurs with hypocalcaemia is a painful spasm and could be the presenting sign. Chvostek’s sign is twitching of the perioral muscles in response to tapping over the facial nerve at the ear. If urgent replacement is necessary, calcium gluconate can be given IV. It is preferred over calcium chloride as it causes less tissue necrosis if it leaks out. It is worth noting that digoxin may be ineffective until serum calcium is restored to normal.
A 22 year old man comes to see you on his return from a holiday in Spain. He has a 3-4 day history of fever, malaise, nausea, vomiting and abdominal discomfort. He is noticeably jaundiced with dark urine and pale stools. There is also tender hepatomegaly on examination. He wonders if this is related to his meal of shellfish from a street vendor.
A. Dubin-Johnson syndrome B. Gilbert's syndrome C. Carcinoma of the pancreas D. Gall stones E. Primary sclerosing cholangitis F. Hepatitis G. Haemolytic anaemia H. Primary biliary cirrhosis
F. Hepatitis - This is likely hepatitis A which is primarily transmitted via the faecal-oral route. After the virus is consumed and absorbed, it replicates in the liver and is excreted in the bile (to be re-transmitted). Transmission usually precedes symptoms by about 2 weeks and patients are non-infectious 1 week after onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water. If the patient has other liver diseases such as HBV or HCV or cirrhosis then there is a higher risk of fulminant HAV infection. The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in
A 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.
A 48-year-old man developed bruising a week after he had a period in hospital following an episode of severe chest pain.
A. Idiopathic thrombocytopenic purpura B. Wiskott-Aldrich syndrome C. Hepatic cirrhosis D. Haemophilia E. Skull fracture F. Spontaneous G. Disulfiram H. Aplastic anaemia I. HIV J. Corticosteroids K. Diuretics L. Clopidogrel
L. Clopidogrel - Clopidogrel is used to prevent atherothrombotic events in patients sensitive to aspirin. This patient has had an MI. It is an antiplatelet drug which inhibits fibrinogen binding to glycoprotein IIb/IIIa receptors. It is given orally but effects are not seen until 4 days after the first dose. Use with aspirin further increases the risk of bleeding. Clopidogrel can also rarely cause a neutropenia.
Recurrent transient ischaemic attacks.
A. Aspirin B. Unfractionated heparin C. Warfarin D. Vitamin K E. Fresh frozen plasma F. Low molecular weight heparin G. Protein S concentrate H. Platelet concentrates I. Thrombin infusion J. Fibrinogen K. Platelet concentrates plus fresh frozen plasma L. Fondaparinux (FXa inhibitor) M. Vitamin E
A. Aspirin - The only antiplatelet drug here is aspirin. In those sensitive to aspirin, clopidogrel can be used instead. Aspirin irreversibly inhibits COX1 by acetylating the active site and inhibits platelet TXA2. This reduces the risk of future embolic events. A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour. An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF.
A 35 year old lady is generally unwell with a tachycardia & a fever. A segment of the right breast is painful, tender, red & warm
A. Carcinoma of the breast B. Sebaceous cyst C. Duct Ectasia D. Fibroadenosis E. Breast Cyst F. Gynaecomastia G. Fibroadenoma H. Breast Abscess I. Lipoma
H. Breast abscess - Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful, hard and red lump indicates the development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.
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 65-year-old man is brought into A&E after his son witnessed him collapse in his home. He reveals how his father complained of an excruciating pain in his lower back. On examination, the patient is pale and cold with shut-down perpheries. There is a palpable epigastric mass.
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
D. No investigation necessary - This is a history of a ruptured AAA. There is back pain here and shut down peripheries and pallor due to blood loss. This patient is in haemorrhagic shock. As this AAA has ruptured, this man will need urgent surgical repair, with of course standard resuscitation measures. Investigations would just waste time. The airway will needed to be managed with supplemental oxygen and ET intubation, a central venous catheter will need to be inserted, an arterial catheter and urinary catheter will also be needed for monitoring, and the target systolic BP is 50-70. Infusing too many fluids may increase the risk of death. The most effective form of surgical repair is an EVAR (endovascular AAA repair), anatomy permitting, otherwise traditional open repair is performed. Open repair has a mortality of 48%. Antibiotics will also be needed to cover bacteria to prevent graft infection. This will be prescribed in line with local protocols
A 30 year old man appears jaundiced. FBC and peripheral blood smear is reported as normal. INR is normal. LFTs show elevated unconjugated bilirubin. Liver enzymes are normal.
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
H. Gilbert’s syndrome - Gilbert’s occurs in an asymptomatic patient, often as an incidental finding or mild jaundice occuring in adolescence/young adult age. There is elevated unconjugated BR with other liver tests being normal. The blood smear is also normal with normal reticulocyte count, and normal Hb indicating that this is not due to haemolysis. It is a common syndrome and is not really a disease, more a physiological variant. No treatment is needed and this condition is due to decreased UDPGT activity leading to decreased conjugation of unconjugated bilirubin, leading to elevated levels.
Choose the malignancy that is most strongly associated with the risk factor below
Coeliac disease
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
A. Gastrointestinal lymphoma - There is an increased incidence of T-cell lymphoma and small bowel adenocarcinoma.
A 62 year old male complains of chest pain at rest. An ECG performed in A&E shows ST elevation. A subsequent angiogram with a provocative agent showed an exaggerated spasm of the coronary arteries.
A. Variant angina B. Pulmonary embolus C. MI D. Anxiety E. Congestive heart failure F. Unstable angina G. Stable angina H. GORD
A. Variant angina - Variant angina (Prinzmetal) is angina caused by coronary artery vasospasm rather than atherosclerosis. It occurs at rest and in cycles. Many patients will also have some degree of atherosclerosis although not in proportion to the severity of the chest pain experienced. ECG changes are of ST elevation (rather than depression) when the patient is experiencing an attack and a stress ECG will be negative. Patients with Prinzmetal angina are often treated for ACS and indeed, cardiac biomarkers may be raised as vasospasm can cause damage to the myocardium. The gold standard investigation is with coronary angiography and the injection of agents to try to provoke a spasm.
Status epilepticus is uncontrolled or serial seizure activity lasting more than 30 minutes.
Selected Answer:
True
False
True - It is a medical emergency, treated with IV or PR diazepam initially.
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 31-year-old stuntman sustains a displaced spinal fracture with cord transaction at T12/L1 while performing a new trick. He also broken his left humerus and radius. He is stable but his BP remains 100/60 despite fluid resuscitation and his pulse is 55bpm.
A. Percutaneous gastrostomy B. Intravenous nutrition C. Cardiogenic shock D. Neurogenic shock E. Haemorrhagic shock F. Spinal shock G. Pulmonary oedema H. Urinary retention I. Acute renal failure J. Percutaneous jejunostomy K. Basal atelectasis
D. Neurogenic shock - This is a thoracolumbar spine fracture. Neurogenic shock is not to be confused with spinal shock which is not circulatory in nature (and is characterised by hypotonia or flaccidity that resolves within 24 hours). Neurogenic shock is a form of distributive shock due to spine or braintem injury and there is resulting failure of vasoregulation. As a result there is a fall in systemic vascular resistance with vasodilation, leading to low BP as blood pools in the extremeties where sympathetic tone is low. This is occasionally associated with bradycardia which is due to autonomic disruption.
A 19 year old male returns from a recent back packing holiday in India. He is passing bloody liquid stools about 15 times a day. He has lassitude, anorexia & a temperature of 37.50C
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
B. Infectious diarrhoea - This patient has low grade pyrexia and recent foreign travel making infectious diarrhoea very likely. This man has probably eaten something dodgy while on holiday in India. Think of the organisms which cause bloody diarrhoea such as EHEC. E coli is the most common cause of traveller’s diarrhoea. There may be a contact history due to faecal-oral spread. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe ETEC.
A 49 year old man with recent history of long-haul travel presents with shortness of breath & haemoptysis. He also complains of chest pain & ECG shows sinus tachycardia.
A. Pericarditis B. Pulmonary embolism C. MI D. Hiatus hernia E. Anxiety F. Angina G. Coronary artery disease H. Oesophageal spasm I. Tietze’s syndrome J. Dissecting aortic aneurysm
B. Pulmonary embolism - 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. This patient has recent air travel, which is actually a weak risk factor but seems to crop up a lot on EMQs. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.
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.
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…
True or False, the olfactory nerve enters the skull via the cribriform plate.
True - It is the shortest cranial nerve and enters the skull at the cribriform plate, then becoming the olfactory tract.
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 55 year old woman presented with recent onset and rapid enlargement of the breast. On palpation, there is a large breast mass. Biopsy showed stromal and epithelial elements.
A. Intraductal papilloma B. Lobular carcinoma in situ C. Gynaecomastia D. Phylloides tumour E. Pregnancy F. Breast Abscess G. Fibroadenoma H. Mastalgia I. Nodularity J. Invasive breast cancer K.Adenoma
D. Phylloides tumour - A phylloides tumour is a fast growing fibroepithelial mass, as demonstrated here by the history and biopsy findings. It can be benign or malignant. The only cure is surgical, commonly a WLE.
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.
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.
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.
70 yr old retired boiler maker presents with a 5 year history of exertional dyspnoea and a dry cough. The patient is non-smoker. Examination reveals fine crackles heard at the lung bases.
A. PE B. Chronic lymphatic leukaemia C. Pulmonary TB D. COPD E. Congestive cardiac failure F. Pulmonary fibrosis G. Acute lymphoblastic leukaemia H. Bronchopneumonia I. Iron deficiency anaemia J. Sarcoidosis K. Pernicious anaemia
F. Pulmonary fibrosis - Idiopathic pulmonary fibrosis (previously known as Cryptogenic fibrosing alveolitis) progresses over several years and is characterised by pulmonary scar tissue formation and dyspnoea. Patients complain of a non-productive cough and typically reproducible and predictable SOB on exertion. Boiler makers can come into contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. While this patient does not smoke, another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. End expiratory basal crackles are found on examination. These are described as ‘Velcro-like’ in quality. IPF is also associated with clubbing.
A 7-year-old boy is brought to the GP by his mother. She claims he has been very lethargic for the past few months and occasionally has a fever. FBC reveals Hb 9.3 g/dL, WCC 82 x 109/L and platelets 30 x 109/L.
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
D. Acute lymphoblastic leukaemia - Acute lymphoblastic leukaemia (ALL) is the most common leukaemia in children. The immature blast cells infiltrate the marrow and lymphoid tissue causing anaemia, bleeding and a vulnerability to infection. Although the FBC reveals that the patient is anaemic, the WCC is raised due to circulating blast cells. The investigation of choice is bone marrow aspiration (which shows a hypercellular marrow with >20% blasts) and treatment is with combination chemotherapy.
ALL vs. AML
Question; A 3 year old girl presented with several bruises over her body and tiredness. On examination she appeared plae and had petechial haemorrhages. Blood tests revealed low Hb and high WCC and a thrombocytopenia. Peripheral blood film showed the presence of blast cells.
ACUTE LYMPHOBLASTIC LEUKAEMIA
Why would this be ALL and not AML?
Answer: Is the age not the pointer in this question.
Blast cells are immature precursors of either lymphoblasts or myeloblasts. They don’t normally appear in peripheral blood. When present, they signify ACUTE leukaemia. Special staining is needed to identify the lineage. So basically blast cells can occur in both ALL or AML. This is my understanding anyway….but the age thing is probably the most significant pointer.
Answer: Think first of all lymphoid vs myeloid
CLL: enlarged rubbery lymph nodes, non tender, also smear cells
CML: Philadelphia chromosome, sweats, more likely splenomegaly, increased WCC
ALL: bruising, pale, usually children btw 2-4 years old
AML: Auer rods, SOB, bone pain.
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 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.
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 clonidine suppression test is performed on a young man complaining of occasional palpitations and anxiety, his plasma catecholamines are suppressed. However his symptoms persist until he eats some of his jelly babies
A. Prader Willi syndrome B. Panic attack C. Inconclusive sample D. Essential Hypertension E. Graves disease F. Insulinoma G. Autonomic neuropathy H. Phaechromocytoma
F. Insulinoma
A 50 year woman normally resident in the UK returned from visiting relatives in Pakistan. She described intermittent fevers with rigors, diarrhoea and severe headaches. She is mildly jaundiced.
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
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 can also include the diarrhoea which this patient is experiencing and headaches. The jaundice here suggests falciparum infection, which is always the cause in severe disease. 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 ais commonly seen. WCC can be high, low or normal.
The severity of malaria depends partly on the species and also on host immunity. Therefore those who live in endemic areas may develop minimal symptoms due to IgG antibody and cell-mediated immunity and physiological tolerance of parasitaemia. Pregnant women affected by P. falciparum are also 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 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.
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.
A young man involved in a RTA is brought into A&E with multiple injuries to his face. On examination, his eyes do not open to pain. He withdraws his left side to pain but his right side does not move at all. His right pupil is fixed, dilated and non-reactive.
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
G. - Subdural haematoma - A subdural occurs due to blood collecting between the dura mater and the arachnoid mater surrounding the brain. It may be arterial or venous although is most often venous. The disease runs a varied course and the presentation occurs on a spectrum from asymptomatic to herniation syndromes. There is neurological deficit evident so surgery will be indicated here. The cause is trauma and this man will have suffered a head injury due to his RTA. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. Surgical options include twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Remember that extradural haematomas classically have a ‘lucid interval’ and occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines.
54 year old asymptomatic male. A left paraumbilical bruit was noted on examination.
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
C. Renal artery stenosis - This is a renal bruit which is best heard in the MCL at the costal margin. The finding of a bruit in the abdomen should make you suspicious of renal artery stenosis. RAS is due, typically, to atherosclerosis and often presents with hypertension and worsening renal function. A form of imaging is required for diagnosis.
A 40-year-old male has a long history of chronic alcoholism. His liver is firm on palpation. An abdominal CT scan reveals that the liver has changes consistent with cirrhosis. He joins Alcoholics Anonymous and stops drinking. Despite his continued abstinence from alcohol, he remains at risk for development of which disease?
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
F. Hepatocellular carcinoma - Patients with cirrhosis, especially those with alcoholic liver disease, are at a high risk of developing HCC. Cirrhosis is irreversible so despite stopping drinking, he is still at risk of HCC (hepatoma). Patients with cirrhosis should be screened for HCC with serum AFP and USS at 6 month intervals.
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.
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
An 87-year-old diabetic man comes to see you in the clinic for aroutine checkup. You are pleased to note that his diabetes is well-controlled, however is Hb is 10.5g/dL, WCC 126 x 109/L, platelets 347x109/L. The blood film shows predominantly lymphocytes with no blast cells seen.
A. Non-Hodgkin's lymphoma B. Monoclonal gammopathy of unknown significance C. Waldenstrom's macroglobulinaemia D. Acute lymphoblastic leukaemia E. Burkitt's lymphoma F. Hodgkin's lymphoma G. Chronic lymphocytic leukaemia H. Myeloma I. Acute myeloid leukaemia J. Myelofibrosis K. Chronic myeloid leukaemia
G. Chronic lymphocytic leukaemia - Chronic lympocytic leukaemia (CLL) is characterised by neoplastic proliferation of mature B lymphocytes. The clinical manifestations are due to immunosuppression and bone marrow failure, however it usually has an insidious onset with 25% of patients diagnosed incidentally (as in this case). It occurs most commonly in the elderly and is the most common leukaemia in the Western world.
65 year old woman with weight loss, malaise & ankle swelling. She smokes 20 cigarettes/day. There is a past history of irritable bowel syndrome. On examination; pulse 80/min irregularly irregular, JVP not seen, BP 135/85, clear chest, bilateral oedema & large mass in pelvis. Urine testing reveals protein +.
A. Arterial doppler studies B. Lymphangiogram C. Chest x-ray D. Venous doppler studies E. 24 hour urine protein F. Pelvic ultrasound G. Liver function tests H. Plasma creatinine I. Coagulation screen
F. Pelvic ultrasound - There is a large mass in the pelvis which is most likely malignant given the history. This needs to be investigated by pelvic ultrasound.
A 75 year old man with a 6 month history of straining at stool. He also thinks he is not emptying his rectum completely. He is passing blood & mucus per rectum. He has some weight loss & anorexia.
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
C. Colorectal cancer - 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.
23 year old female with a complaint of progressive weight loss, palpitations and frequent loose motions.
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
I. Hyperthyroidism - This woman has hyperthyroidism. Symptoms include those mentioned and heat intolerance, sweating, tremor and tachycardia. In countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Treatment aims to normalise thyroid function and is achieved by radioactive iodine, antithyroid medications or with surgery. Symptomatic therapy is given with beta blockers such as propranolol.
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.
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 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. 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
D. 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.
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.
True or False, the accessory nerve allows you to shrug your shoulders.
True - It supplies trapezius, which is the muscle responsible for shrugging shoulders!
A 87-year-old lady had a seizure at home. Her husband says she has been drowsy for the last couple of days. She is otherwise in good health but she has recently started antihpertensive drugs. On examination, her skin turgor is reduced.
- Absence seizure
- Meningitis
- Jacksonian seizure
- Encephalitis
- Hypercalcaemia
- Hyponatraemia
- Hypocalcaemia
- Simple partial seizure
- Atonic seizure
- Tonic-clonic seizure
- Hyponatraemia - Hyponatraemia is defined by serum sodium
A 53 year old lady complains of central “crushing” chest pain, sudden onset & spontaneous remission, with no attributable cause. She has no history of hypertension, current BP is 116/76.
A. Pericarditis B. Pulmonary embolism C. MI D. Hiatus hernia E. Anxiety F. Angina G. Coronary artery disease H. Oesophageal spasm I. Tietze’s syndrome J. Dissecting aortic aneurysm
E. Anxiety - The presence of anxiety does not exclude a cardiac cause and appropriate investigations are required even if the patient obviously has anxiety.The absence of an attributable cause and the sudden onset and spontaneous remission with no cardiac risk factors make this likely to be due to anxiety.
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. 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
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 24 year old accountant presented to his GP with a 2 week history of tiredness and a persistant cough and complained of “not being able to complete his normal gym routine”. On examination he was pyrexic, had decreased lung expansion and increased vocal resonance and auscultation revealed bronchial breathing.
A. TB B. Emphysema C. Bronchitis D. Pleural effusion E. Pneumonia F. Lung Tumour G. Pulmonary embolism H. Asthma I. Pneumothorax J. Pulmonary fibrosis K. Sarcoidosis
E. Pneumonia - This patient has pneumonia. Symptoms include chills, fever, cough, SOB and pleuritic chest pain. Examination findings are consistent with his diagnosis. A CXR is the most specific and sensitive test available and antibiotics are indicated.
A 50 year old man: BR 50umol/l, ALP 200iu/l, ALT 120iu/l, GGT 600iu/l.
A. Alcoholic cirrhosis B. Gilbert’s syndrome C. Acute pancreatitis D. Hepatocellular carcinoma E. Paracetamol overdose F. Cholangiocarcinoma G. Drug-induced cholestasis H. CMV infection I. Haemolysis J. Pancreatic cancer K. Wilson’s disease L. Gallstones M. Viral hepatitis
A. Alcoholic 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. The high GGT here is as a result of high alcohol consumption.
Liver function tests are mistakenly named really because they don’t test liver function. They are better called ‘liver tests’ or ‘tests of liver chemistry’. The tests of liver synthetic function come from measuring albumin levels (produced by the liver) and the prothrombin time, as the liver has a key role in the manufacture of clotting factors. Some general points on liver tests to consider: These tests tend to include bilirubin (breakdown product of RBC after hepatic conjugation, and is secreted in the biliary system), AST, ALT, GGT, ALP (alk phos) and LDH. It’s really all about pattern recognition. Isolated elevation of liver tests tends to make you think of non-hepatic causes and you should take into account the patient’s history during interpretation. A normal liver panel does not mean that the person does not have liver disease, and liver tests are elevated in a small percentage of normals.
You can split the possible causes into three broad categories. It is worth noting that people with any pattern can have cirrhosis. AST is also present in heart, skeletal muscle, kidney, brain and in RBCs too. 80% of AST is found in the mitochondria and 20% in the cytoplasmic matrix. ALP, which is a cytoplasmic enzyme, can come from bone, kidney, intestines or the placenta. GGT may come from the heart or RBCs.
The first is predominantly elevated AST/ALT, which is described as a hepatocellular pattern and occurs in conditions such as viral hepatitis, alcoholic disease, Wilson’s etc. Here the hepatocytes get damaged and enzymes leak out.
The second is predominantly elevated ALP (GGT too, but an isolated rise in GGT is common so many hospitals remove GGT from the liver panel. GGT is only useful if there is an isolated rise in ALP). This is seen in a cholestatic (here, the hepatobiliary system is affected) or infiltrative pattern in bile duct obstruction, malignancy e.g. HCC or pancreatic, PBC/PSC etc or infiltrative conditions such as TB and lymphomas.
The last is an isolated hyperbilirubinaemia seen in haemolysis, intra-abdominal bleeding or with conditions such as Gilbert’s. BR elevation can be further divided into conjugated or unconjugated. Unconjugated is normally due to breakdown of RBC beyond the liver’s capacity to conjugate. Conjugated occurs in liver disease and problems with obstructed bile flow.
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.
25 yr old HIV positive man has a productive cough for the last 3 months with haemoptysis and night sweats. CXR shows hilar lymphadenopathy.
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
C. Pulmonary TB - HIV infection is a key risk factor for pulmonary TB. It is important to have a high level of suspicion when evaluating patients with risk factors who present with suggestive symptoms. Night sweats, fever, malaise, cough, haemoptysis and erythema nodosum are all suggestive. 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. 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 62 year old woman presents to A&E with searing back pain, nausea and vomiting. She is known to have an abdominal aortic aneurysm which is scanned every year. She appears jaundiced and the subsequent abdominal CT reveals an AAA of 5.0cm
A. Perforated duodenal ulcer B. Mesenteric infarction C. Pericarditis D. Metastatic disease E. Pyelonephritis F. Pancreatitis G. Myocardial infarction H. Addison’s disease I. Volvulus J. Ruptured abdominal aortic aneurysm K. Renal colic L. Spinal stenosis M. Dissecting aortic aneurysm N. Hepatitis
C. Pancreatitis - The AAA here has nothing to do with the question, and at 5cm, it is not massively prone at the moment to rupture. However, if the patient is otherwise young, fit and healthy, elective repair can soon be considered (the normal abdominal aorta is 1.5cm diameter, and remember that rupture is more common in females than males). This is acute pancreatitis. Jaundice here is suggestive of gallstone aetiology with obstruction to the common bile duct, though pancreatic oedema can itself cause jaundice. Nausea and vomiting is not uncommon and can occur with agitation and confusion. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis (GET SMASHED). Those caused by hypocalcaemia may also display Chvostek’s sign and Trousseau’s sign.
Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook.
A 22-year-old student is found collapsed in her room. She is unrousable and has a purpuric rash. Her temperature is 39oC.
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
L. Meningitis - 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 (this patient has LOC), 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 the petechial/purpuric rash seen here, typically associated with meningococcal meningitis.
CT head should be considered before LP if there is any evidence of raised ICP. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen. Investigations should not delay treatment in this very urgent situation and antibiotics need to be promptly administered. IM benzylpenicillin can be given on the way to the hospital with empirical antibiotic therapy being started on arrival before the causative organism is identified. This can be, for example, with vancomycin and ceftriaxone (or meropenem, cefotaxime, chloramphenicol). Dexamethasone should also be given before the first dose of antibiotics and continued for 4 days as this has been shown to improve outcome and overall mortality in community-acquired bacterial meningitis (though NICE guidelines state it should not be given to those aged
choose the SINGLE test from the list above that would be of most help in establishing the diagnosis
Pituitary tumour
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
J. MRI head - Pituitary MRI is preferred over CT and you will be able to see if the tumour has invaded, for example, the sphenoid sinus and cavernous sinuses or any compression of the optic chiasma. MRI is contra-indictaed in some cases such as those with a permanent pacemaker or those with ESRF on dialysis – in which case you would perform a CT. Both are done with contrast enhancement. A sellar mass will be seen.
An older man collapses with sudden chest pain radiating to back.
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
G. CT scan - 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. MRI is more sensitive and specific but is more difficult to obtain acutely.
Aortic dissection typically presents with tearing/ripping chest pain and classically radiates through to the back. There may be interscapular pain with dissection of the descending aorta. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. BP differential between the 2 arms is a hallmark feature. Pulse differences may also be present in the lower limbs. There may also be the diastolic murmur of AR in proximal dissections.
A 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 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 35 year old homosexual man with HIV presents to his GP after a holiday in Barcelona having recently noticed the presence of painless purple skin plaques on his lower legs and some generalised rubbery lumps located over his body. Examnation reveals that there is also a purple coloured mass on his hard palate.
1. Seborrhoeic dermatitis 2. Human papillomavirus 3. Photodermatitis 4. Kaposi sarcoma
- Kaposi sarcoma - This is Kaposi sarcoma which is a low-grade neoplasm caused by human herpesvirus-8 (or KSHV). It is associated with the acquired immunodeficiency associated with HIV infection. Oral KS can frequently affect the hard palate, gums and dorsum of the tongue. Cutaneous lesions are purple in colour and usually painless and non-pruritic. Histopathology of these vascular lesions will show characteristic atypical spindle-shape cells.
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 35 year old woman: BR 80umol/l, ALP 300iu/l, ALT 30iu/l, GGT 30iu/l. Abdominal USS shows biliary dilation. The patient has RUQ tenderness.
A. Alcoholic cirrhosis B. Gilbert’s syndrome C. Acute pancreatitis D. Hepatocellular carcinoma E. Paracetamol overdose F. Cholangiocarcinoma G. Drug-induced cholestasis H. CMV infection I. Haemolysis J. Pancreatic cancer K. Wilson’s disease L. Gallstones M. Viral hepatitis
L. Gallstones - This is again a cholestatic pattern and the ultrasound scan means this is either choledocholithiasis, pancreatic cancer or cholangiocarcinoma. The fact there is RUQ pain points more towards gallstones. The other two tend to present painlessly.
Liver function tests are mistakenly named really because they don’t test liver function. They are better called ‘liver tests’ or ‘tests of liver chemistry’. The tests of liver synthetic function come from measuring albumin levels (produced by the liver) and the prothrombin time, as the liver has a key role in the manufacture of clotting factors. Some general points on liver tests to consider: These tests tend to include bilirubin (breakdown product of RBC after hepatic conjugation, and is secreted in the biliary system), AST, ALT, GGT, ALP (alk phos) and LDH. It’s really all about pattern recognition. Isolated elevation of liver tests tends to make you think of non-hepatic causes and you should take into account the patient’s history during interpretation. A normal liver panel does not mean that the person does not have liver disease, and liver tests are elevated in a small percentage of normals.
You can split the possible causes into three broad categories. It is worth noting that people with any pattern can have cirrhosis. AST is also present in heart, skeletal muscle, kidney, brain and in RBCs too. 80% of AST is found in the mitochondria and 20% in the cytoplasmic matrix. ALP, which is a cytoplasmic enzyme, can come from bone, kidney, intestines or the placenta. GGT may come from the heart or RBCs.
The first is predominantly elevated AST/ALT, which is described as a hepatocellular pattern and occurs in conditions such as viral hepatitis, alcoholic disease, Wilson’s etc. Here the hepatocytes get damaged and enzymes leak out.
The second is predominantly elevated ALP (GGT too, but an isolated rise in GGT is common so many hospitals remove GGT from the liver panel. GGT is only useful if there is an isolated rise in ALP). This is seen in a cholestatic (here, the hepatobiliary system is affected) or infiltrative pattern in bile duct obstruction, malignancy e.g. HCC or pancreatic, PBC/PSC etc or infiltrative conditions such as TB and lymphomas.
The last is an isolated hyperbilirubinaemia seen in haemolysis, intra-abdominal bleeding or with conditions such as Gilbert’s. BR elevation can be further divided into conjugated or unconjugated. Unconjugated is normally due to breakdown of RBC beyond the liver’s capacity to conjugate. Conjugated occurs in liver disease and problems with obstructed bile flow.
A 70 year old man with a history of 10kg weight loss over the previous 3 months. More recently he developed acute lower back pain. Presents to A&E with coughing & sputum. CXR shows left lower lobe pneumonia.
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
J. Malignancy - This person likely has lung cancer which has resulted in the significant weight loss of 10kg. This is post-obstructive pneumonia which is common in lung cancer patients and is caused, most of the time, by a large and centrally obstructing tumour. It is essential to relieve this obstruction in this case and many techniques can be tried. There is also bone pain here in the lower spinal column which is due to metastases. The prognosis here is not good.
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 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 35 year old woman arrives on a plane from Melbourne with a swollen right leg. A few days later her leg is even more swollen and her toes have gone black
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
G. Venous duplex scan - This patient has a DVT. Other risk factors include recent major surgery, active malignancy, pregnancy and malignancy. A Wells score is determined in all patients with a suspected DVT with the condition being likely if the score is 2 or greater. The most definitive test is venography but it is invasive. Compression USS of the proximal deep venous system is preferred but Doppler venous flow testing can be used if other tests are unavailable and will demonstrate low flow in affected veins. This requires a trained technician. Anticoagulation is the mainstay of treatment with unfractionated heparin, a LMWH or an anti FXa agent such as fondaparinux.
A 73 year old woman is recovering in hospital 3 days after an operation to replace her right hip. On going to the toilet she suddenly becomes extremely short of breath & rapidly loses consciousness. Blood pressure is 60/20 mmHg.
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
J. Pulmonary embolus - This patient should be thrombolysed immediately if not contraindicated due to her haemodynamically unstable and critical state. Treatment should not be delayed in this obvious PE. This patient is now at a serious risk of cardiac arrest. Anticoagulation should also be started. The underlying pathophysiology is based on Virchow’s triad. SOB is a common symptom and there may also be chest pain and haemoptysis. This patient has had recent surgery, particularly orthopaedic surgery, which is a strong risk factor for PE. Other strong risk factors include DVT, obesity, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis. 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 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.
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
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 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 22 year old woman presents to her GP with a 1 week history of increased frequency of micturation and dysuria. Abdominal examination reveals mild supra-pubic tenderness. You perform a dipstick that reveals haematuria and a positive nitrite and leucocyte esterase.
A. Prostate cancer B. Ureteric colic C. Prostatic varices D. Acute pyelonephritis E. Urinary tract infection F. Bladder cancer G. Trauma H. Renal cell carcinoma
E. Urinary tract infection - E coli causes most uncomplicated cases and Staph saprophyticus is implicated in 5-20%. Sexual intercourse is the single biggest risk factor in women, although other risks include spermicide use, post-menopause, FH and presence of a foreign body like an indwelling catheter. Symptoms include frequency, dysuria, back pain, haematuria with upper tract involvement suggested by urgency, suprapubic pain, fever and/or tenderness over the costovertebral angle. The first test is a dipstick analysis, although if negative with a suggestive history, it is still likely to be a UTI. Dipstick will show positive nitrite and leucocyte esterase. MSU should be sent for MC+S in some cases such as atypical symptoms or unexpected urinalysis findings.
True or False, the ninth cranial nerve is the accessory nerve.
False - It is the glossopharyngeal nerve.
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 plumber renovating old properties presented to casualty with fever & loss of consciousness. On examination he had bilateral consolidation. Plasma sodium was low. The doctor sent for urinary antigen & serology. On the results he was treated with azithromycin & ciprofloxacin & improved.
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
K. Legionella pneumphila - 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. Treatment is with fluoroquinolones or macrolides. Azithromycin is considered a safer option than erythromycin. For severe cases, a combination of both is given although this is potentially toxic and can cause long QT and torsades de pointes.
A 16 year old girl who feels tired all the time. She had a sore throat prior to this. She is concerned because she is unable to study for her exams. Her boyfriend has had similar symptoms.
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
A. Gladular fever - This is infectious mononucleosis or glandular fever and is caused by EBV. It is characterised by fever, pharyngitis and lymphadenopathy. Enlargement of the spleen begins in the first week and lasts 3-4 weeks, occuring in half of all cases. Risk factors for EBV transmission include kissing and sex. The fact her boyfriend has had similar symptoms should raise your suspicion. 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 can carry rare but potentially life threatening complications.
A 77 year old lady with longstanding AF presents with confusion. She collapsed suddenly at home. O/E she has an extensor plantar response.
A. UTI B. Faecal impaction C. Hypoxia D. Liver failure E. Post-operative F. Hypoglycaemia. G. Thiamine/B1 deficiency H. U&E imbalance I. Drug effect J. MI K. CVA
K. CVA - Atrial fibrillation is strongly implicated in the risk of cardioembolic stroke. Confusion is common, especially in the elderly who have had past strokes and in those with cognitive dysfunction. An extensor plantar response is known as Babinski’s sign and is a sign of an UMN lesion. The normal response is flexion where the big toe moves downwards. It is important is perform a CT head exclude a haemorrhagic aetiology and consider thrombolysis with tPA if within the 4.5 hour window and there are no contraindications. Thrombolysis is done with alteplase at 10% bolus, 90% infusion at a dose of 0.9 mg/kg. Presentation after the 4.5 hour window is managed with aspirin. The Bamford/Oxford Stroke Classification subtypes ischaemic stroke according to vascular territory of infarction. After initial management, stroke care involves the ethos of an MDT environment with rehabilitation.
A 26 year old man presents with severe shortness of breath and a dry cough which he has had for several weeks. He is an IV drug user. There are purple patches on the arms and in the mouth. CXR shows reticular perihilar opacities. Chest examination is unremarkable.
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
H. Pneumocystus 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 9 year old girl attends her GP surgery as an emergency with wheezing, difficulty in breathing & cough. Her PEFR is 250l/min, expected PEFR 500. There is no sign of infection on her chest examination. She is admitted to hospital and given inhaled salbutamol although shows an incomplete response. Which treatment should be given next?
A. Oral prednisolone B. 24% continuous oxygen C. Long acting beta agonist D. Beta agonist via metered dose inhaler E. Antibiotic reserve F. Influenza immunisation G. Intravenous aminophylline H. 40% continuous oxygen I. Beta agonist via nebuliser J. Intravenous hydrocortisone K. Amoxycillin intravenously L. Intramuscular adrenaline
A. Oral prednisolone - Acute asthma exacerbation this time. Bear in mind that treatment guidelines differ for adults and children. The PEFR is 50% predicted making this a moderate exacerbation of asthma (40-69%). A mild exacerbation is defined by a PEFR of 70% of more of predicted whereas severe is defined as 26 to 39% with life-threatening falling under 25%. Note that these values are for children. For moderate exacerbations like this, an oral corticosteroid needs to be prescribed alongside inhaled SABA. If this were life-threatening or severe, then IV may be indicated. It is worth knowing the symptoms and signs of mild, moderate and severe/life threatening asthma. The treatment guidelines that you need to familiarise yourself with tend to be for adults.
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.
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 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 (
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 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 30 year old woman has a small, fluctuant, painless swelling which moves upwards when she sticks out her tongue.
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
A. 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 70-year-old man with a history of 10kg weight loss over the previous 3 months. More recently, he developed acute lower back pain. He presents to A&E with coughing and sputum. Chest x-ray shows left lower lobe pneumonia.
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
A. Malignancy - This person likely has lung cancer which has resulted in the significant weight loss of 10kg. This is post-obstructive pneymonia which is common in lung cancer patients and is caused, most of the time, by a large and centrally obstructing tumour. It is essential to relieve this obstruction in this case and many techniques can be tried. There is also bone pain here in the lower spinal column which is due to metastases. The prognosis here is not good.
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.
A 24-year-old man is found in the toilet of his girlfriend’s flat slumped on the floor the morning after his stag night. He is taken to A&E where he is found to have a serum creatinine level of 350 μmol/l.
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
C. Rhabdomyolysis - Rhabdomyolysis is basically myocyte lysis. It may present obviously with a patient having been ‘crushed’ in some way, or may be insidious in onset and not very obvious. This patient has had too much alcohol, or drugs, and has been immobilised in one position for a long period of time. This makes a crush injury more likely to occur and indeed, alcohol abuse is the most common cause in itself, by being directly toxic to myocyte membranes, inhibiting calcium uptake and disrupting the sodium-potassium pump. Illicit drugs may cause a hyperdynamic muscle state. Other risk factors include diuretics, which can deplete potassium to such a degree as to cause this condition, toxins, statins and salicylates. This condition has also been documented in unconditioned athletes. Historically, it was those crushed during the WWII bombings of London who were affected by this condition and experience during the war has also changed the way it is now treated with regard to acid-base abnormalities. If you free someone who has been crushed for a very long time, there will be a sudden release of potassium which is life-threatening. You therefore need to take measures to protect against this, such as bicarbonate therapy beforehand. Muscle pain and discomfort is a common presentation, although this person does not appear to be conscious. The diagnosis here is confirmed by the elevated serum CK level which will be increased to at least 5 times normal. Levels correlate with severity. Expect to also see raised potassium, magnesium and phosphate, and low calcium, with elevated urea and creatinine. Mainstay of treatment is with fluid resuscitation.
Choose the malignancy that is most strongly associated with the risk factor below
Pernicious anaemia
A. Gastrointestinal lymhpoma B. Bladder carcinoma C. Gastric carcinoma D. Cholangiocarcinoma E. Ovarian carcinoma F. Colorectal carcinoma G. Hepatocellular carcinoma H. Prostatic carcinoma I. Cervical carcinoma
C. Gastric carcinoma - Patients with pernicious anemia have a 2- to 3-fold increased incidence of gastric carcinoma.
73 year old man was reviewed in the diabetic clinic. He was complaining of increasing tiredness & loss of appetite. His ankles had become more swollen over the last few weeks.
A. Arterial doppler studies B. Lymphangiogram C. Chest x-ray D. Venous doppler studies E. 24 hour urine protein F. Pelvic ultrasound G. Liver function tests H. Plasma creatinine I. Coagulation screen
H. Plasma creatinine - Diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function.
A 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
C. 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 40-year-old female, rather overweight, has episodes of right upper quadrant pain and fever.
A. Hepatitis B B. Extensive necrosis C. Hypervascularity D. Extensive cirrhosis E. Cholecystitis F. Pancreatic carcinoma G. Pancreatic pseudocyst H. Hepatitis C I. Enlarged right lobe J. Portal chronic inflammation K. Arterio-venous malformations L. Hepatocellular carcinoma
E. Cholecystitis - Cholecystitis is acute GB inflammation caused by an obstruction at the cystic duct. It occurs as a major complication of gallstones and classically presents with RUQ pain and fever. Gallstones in EMQs classically involves the Fs (Fat, Forty, Female, Fertile, Fair). USS is the definitive initial investigation. HIDA scanning and MRI may help if the diagnosis remains unclear. Treatment is with cholecystectomy.
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
Chose choose the most likely mode of inheritance.
Duchenne’s muscular dystrophy
A. None/unknown B. Autosomal recessive C. Autosomal dominant D. X-linked dominant E. Chromosomal abnormality F. X-linked recessive G. Mitochondrial inheritance
F. X-linked recessive
Here is a list of the important conditions you should be aware of:
Autosomal dominant: Achrondroplasia, APKD, dystrophia myotonica, familial hypercholesterolaemia, Huntington’s, Marfan’s, NF, tuberous sclerosis, osteogenesis imperfecta
Autosomal recessive: CF, hereditary haemochromatosis, sickle cell disease, Wilson’s, Friedreich’s ataxia, CAH
X-linked recessive: DMD, Fragile X syndrome, Haemophilia A and B, G6PDH deficiency, Alport’s
You should be aware that Down’s is trisomy 21, Edwards’ is trisomy 18 and Patau’s is trisomy 13.
A 70 year old English woman presents with fever, slight splenomegaly, splinter haemorrhages & a diastolic murmur at the apex of the heart.
A. Sarcoidosis B. Polycythaemia C. Gaucher’s disease D. Portal hypertension E. Infectious mononucleosis F. IDA G. Bacterial endocarditis H. Hodgkin’s disease I. Malaria J. Idiopathic myelofibrosis K. Metastatic carcinoma L. CML
G. Bacterial endocarditis - Any patient presenting with fever and a new murmur should always make you think of bacterial endocarditis. The classic new or worsening murmur is actually rare. As are splinter haemorrhages, which this patient has. Other uncommon signs you may find include Janeway lesions (painless macular haemorrhagic plaques on the palms and soles) and Osler nodes (painful nodules on the pads of the fingers and toes). Roth spots may also be seen on fundoscopy. Three sets of bood cultures are required and this patient will have to go for an echocardiogram.The Duke criteria is used for diagnosis.
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 67 year old male smoker has developed gross oedema of the neck & face. You also notice swelling of both hands.
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
A. 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 23 year old woman presents with a cough and SOB for 24 hours. O/E she is distressed tahycardicc and resp raet of 25/min. She has a widespread bilateral expiratory wheeze.
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
G. Nebulised salbutamol - This patient is having an asthma attack. The best option here is nebulised salbutamol initially. Early systemic corticosteroids and supplemental oxygen should be considered and the patient’s status needs to be monitored regularly.
For each of the tumours below, select the most likely causative carcinogen. Each option may be used once, more than once or not at all.
Hepatocellular carcinoma
A. Aniline dyes B. Aflatoxin B1 C. Azo dyes D. Asbestos E. Epstein-Barr virus (EBV) F. Cadmium G. Oestrogen
B. Aflatoxin B1 - Aflatoxin B1 is a naturally occuring carcinogen produced by many species of Aspergillus (a fungus). It thrives on improperly stored grains and nuts. It is considered a significant etiological factor for liver cancer in Southern Africa and the Far East.
A 45-year-old woman presents with an irregular 4cm firm lump in the left breast. O/E the lump is fixed to the overlying skin and their is bloody discharge from the left nipple.
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
A. CA 15-3 - High Ca 15-3 levels suggest metastatic breast disease. However, it has poor sensitivity and is therefore not used as a screening procedure to detect breast carcinoma. This tumour marker has recently been superseded by Ca 27-29, which is claimed to be more sensitive and specific. However, CA 27-29 lacks predictive value in the earliest stages of breast cancer and thus has no role in screening for or diagnosing the malignancy.
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.
Mark is a 20 year old student who developed acute chest pain with breathlessness after working out at the gym. On examination he was breathless at rest. Expansion of the chest was restricted on one side with hyper-resonant percussion note.
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
F. Pneumothorax - A tension pneumothorax shifts the trachea AWAY with hyper-resonance on affected side and reduced/absent breath sounds. A tracheal shift means this is a tension pneumothorax which needs immediate relief with a wide bore cannula inserted into the second intercostal space in the MCL.
A 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 60 year old woman is found to have hepatomegaly. She has a history of moderate alcohol use. She had an anterior MI 2 years previously. Examination reveals significant ankle oedema, elevated JVP & 1-2 spider naevi on her chest.
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
L. COngestive heart failure - The significant ankle oedema and raised JVP point towards right sided heart failure.The presence of 1-2 spider naevi is completely normal. 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 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually.
A. Sebaceous cyst B. Fibroadenoma C. Fibroadenosis D. Gynaecomastia E. Breast abscess F. Carcinoma of the breast G. Breast cyst H. Lipoma I. Duct ectasia
C. Fibroadenosis - Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.
A 45 year old unmarried labourer who increasingly severe central abdominal pain over the last 3 hours. The pain radiates through to his back & makes him vomit. He has no previous history. On examination is cold & sweaty, pulse 120, BP 90/70, & has guarding over his whole 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
J. Serum Amylase - This patient has acute pancreatitis. He has vomited and is describing mid-epigastric pain radiating around to the back. This pain is classically relieved if the patient curls up and is worse with movement. This patient also vomited too. 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 14 year old boy with bilateral breast enlargement.
A. Carcinoma of the breast B. Sebaceous cyst C. Duct Ectasia D. Fibroadenosis E. Breast Cyst F. Gynaecomastia G. Fibroadenoma H. Breast Abscess I. Lipoma
F. Gynaecomastia - This is a boy who has enlarged breasts. Normal to see gynaecomastia in puberty. Other causes include liver disease and as a side effect of drugs such as digoxin, spironolactone and cimetidine.
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 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 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 60 year old woman on the ward has an O2 saturation of 91% on air. She underwent a laparotomy for small bowel obstruction the previous day. All her other observations are within normal limits.
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
J. Facemask with oxygen - This woman is fine apart from a low oxygen saturation. She needs some oxygen via a facemask.
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. 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
G. 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.
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.
An 18 year old student has just returned from holiday in Africa. He is jaundiced and has moderate hepatomegaly. His blood tests reveal increased serum transaminases and elevated bilirubin. He also has specific IgM antibodies.
A. Dubin-Johnson syndrome B. Hepatitis C C. Malaria D. Gall stones E. Gilbert's syndrome F. Crigler-Najjar syndrome G. Hepatitis B H. Hepatitis A I. Carcinoma of head of the pancreas J. Primary sclerosing cholangitis K. Primary biliary cirrhosis L. Cholangiocarcinoma M. Sickle cell anaemia
H. Hepatitis A - IgM anti-hepatitis A virus is positive here which is highly sensitive and specific combined with the typical symptoms this student displays. IgM antibodies are detectable typically 5-10 days before symptom onset and remain raised for 4-6 months. It can be ordered alongside IgG anti-HAV and is a cheap and simple test. IgG rises soon after IgM and stays elevated for life so a positive IgG can mean prior infection or recent disease. Again, a cheap and simple to carry out test.
Hepatitis A is primarily transmitted via the faecal-oral route. After the virus is consumed and absorbed, it replicates in the liver and is excreted in the bile (to be re-transmitted). Transmission usually precedes symptoms by about 2 weeks and patients are non-infectious 1 week after onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water. If the patient has other liver diseases such as HBV or HCV or cirrhosis then there is a higher risk of fulminant HAV infection. The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in
A 50 year old man with a painless enlargement of the left breast. He denies finding any definite lumps
A. Intraductal papilloma B. Lobular carcinoma in situ C. Gynaecomastia D. Phylloides tumour E. Pregnancy F. Breast Abscess G. Fibroadenoma H. Mastalgia I. Nodularity J. Invasive breast cancer K. Adenoma
C. Gynaecomastia - This is a man who has presented with breast enlargement i.e. gynaecomastia. The main cause is either chronic liver disease or drug induced. Drugs include the H2 receptor antagonist cimetidine, as well as digoxin and spironolactone. Gynaecomastia is benign in 99% of cases and results from relative excess of oestrogen or lack of testosterone. Oestrogenisation can follow from anabolic steroid use/abuse. This can hence occur physiologically during the newborn period, puberty and with age and obesity (not true gynaecomastia). Treatment can be offered if there is pain or embarassment including anti-oestrogens such as tamoxifen, androgens or surgical options like liposuction.
The drugs that induce gynaecomastia can be subdivided into those that reduce testosterone synthesis (GnRH agonists, cancer drugs, ketoconazole, metronidazole, spironolactone), those that impair the action of testosterone (spironolactone again, finasteride, H2 blockers, PPIs) and those that act via oestrogen (digoxin, PHT, anabolic steroids).
