RECALLS Flashcards
Patient on warfarin and started to bleed. What is the used to measure the bleeding?
a) Deficiency of factor 2,7,9,10
b) Prothrombin deficiency
c) Platelet deficiency
d)Deficiency of factor 10
e)Deficiency of factor 7
A- Warfarin acts on intrinsic coagulation pathway and affects Factor 2, 7, 9,10. Enoxaparin and heparin affects 2 and 10. Apixaban, Edoxaban and Rivaroxaban affects Factor 10. Dabigatran affects 12.
Female RA, BA on 10 mg bid steroid and salbutamole, Rt iliac fossa pain, vomiting, fever, k high, wbcs 15 Na low, BP 80/50, pulse 80 what to do
a)250 ml colloid and reassess
b) 100 ml prednisolone
c)1.2 gm iv co-amoxiclav
d)IV 100 mg Hydrocortisone
e)Ca resonium per rectal
D
Patients receiving oral adrenocortical steroids
•Should be asked about the dose and duration
• Extra doses of steroids perioperatively) so as to avoid an addisonian crisis
> A patient taking >5.mg prednisolone equivalent within a month of surgery
> Will require supplementation at induction and postoperatively
70 year old male, angina on going upstairs. No murmur heard. ECHO(? ecg) was done, what is the most likely finding?
a) Aortic stenosis
b Aortic sclerosis
c) Aortic regurgitation
d) Mixed Valvular disease
e) Mitral stenosis
B
8 year old child became tired and breathless after playing football.brought by mom harsh continuous murmur under the left clavicle…diagnosis?
a) Coarctation of aorta
b) PDA
c) VSD
d) ASD
e) TGA
Coarctation of the aorta
> Clinical examination of the pulses may demonstrate a radio-femoral delay
> And a murmur that is continuous
> Heard best over the thoracic spine or below the left clavicle
Primigravida, 24 years, third trimester, chest tightness, cyanosis, congested neck veins, her father died at 60 with MI
a)Aortic dissection
b)Acute massive PE
c) Mi
d)Pulmonary infarction
e)Lung cancer
Pulmonary Embolism®
Mnemonic: SAM has RED
Pants
* S stroke or recent MI
* A atrial fibrillation
* M myocardial infarction
* R recent surgery
* E estrogen therapy
* D disseminated malignancy
* P/pregnancy-postpartum
Half life of platelets?
a)12 hours
b)2 days
c) 10 days
d)20 days
e) 30 days
The Platelet
• Platelets circulate with an average life span of 7 to 10 days.
• Approximately one-third of the platelets reside in the spleen, and this number increases in proportion to splenic size, although the platelet count rarely decreases to <40,000/L as the spleen enlarges.
• Platelets are physiologically very active, but are anucleate, and thus have limited capacity to synthesize new proteins.
A bullet is shot just at the right side of rectus muscle where it meets the tight costal margin and went out out at the exact area through the back, organ most likely affected?
a) Pylorus
b) Liver
c) Gallbladder
d) Kidney e Duodenum
C
Paneth cells present in-
a) Crypt of liberkuhn
b Intestinal villi
c) Gastric antrum
d) Lamina propria
e) Muscle layer
A
In COPD patient
a)PCO2 increased and HCO3- increased
b)PCO2 increased and HCO3- decrease
c)PCO2 decrease and HCO3- increased
d) PCO2 decrease and HCO3- decrease
e)PCO2 no change and HCO3- increased
A
COPD + given morphine, which ABG represents it?
a) Partially compensated resp alkalosis
b) Partially compensated metabolic acidosis
c) Partially compensated metabolic alkalosis
d) No change
e)Partially compensated resp acidosis
E
Posteromedial approach Baker cyst, most superficial susceptible to damage
a) Sciatic nerve
b) Tibial nerve
c) Sural nerve
d) CPN
e) Saphenous nerve
E
Chest Xray foreign body usually settle down
a) R lower lobe
b) Middle lobe
c)R upper lobe
d)L lower lobe
e)L upper lobe
A The right main bronchus (RMB) is shorter, wider and nearly vertical compared with the left main bronchus (LMB) As a consequence, inhaled foreign bodies are more likely to enter the RMB than the left
Ileoanal pouch, put on metronidazole. Common side effect.
a Ileoanal fibrosis
b)Peripheral neuropathy
c) Coagulopathy
d) |leovesical fistula
e)Pouchitis
Therapy for treatment and presantation of pouchitis
IBD_therapy-treatment-and-prevention-pouchitis
> Vomiting
• Metallic taste
> Temporary damage to nerves
SIDE EFFECTS OF METRONIDAZOLE
epigastric distress
•Seisures
•Metallic taste
Darkenina of urine Peripheral neuropathy
Pancreatitis
•Hepatitis
•Fever
•Reversible neutropenia
A 45-year-old woman presents to the Emergency Department with shortness of breath, pain on deep breathing and fever of one day’s duration. Twelve days ago she had varicose vein surgery. On examination she has a sinus rhythm with a pulse rate of 110 beats/minute. Her blood pressure is 130/90 mmHg and her temperature is 38°C. Pulse oximetry shows a saturation of 92% on air. Chest examination is normal.
Computerized tomography pulmonary angiography (CTPA) demonstrates a pulmonary embolism. What is the most appropriate treatment?
• Low molecular weight heparinisation
• Placement of inferior vena cava filter
• Pulmonary embolectomy
• Thrombolysis
• Warfarinisation
A
A 60-year-old man with ischaemic heart disease presents with bilateral gynaecomastia. Which one of the following drugs is most likely to have caused this problem?
• Aspirin
• Atenolol
• Furosemide
• Spironolactone
• thyroxine
D
A 70-year-old man with carcinoma of the bronchus presents with blurring of vision, headaches and nausea, particularly in the morning. Which of the following is the most appropriate treatment?
• Carbamazepine
• Dexamethasone
• Morphine elixir
• Paracetamol
• Radiotherapy
B
A slightly overweight 13-year-old boy presents with a three-week history of right hip pain and limping. On examination the hip moves into external rotation when flexed. Which of the following is the most likely diagnosis?
• Developmental dysplasia (congenital dislocation) of hip
• Juvenile rheumatoid arthritis
• Perthes disease
• Slipped upper femoral epiphysis
• Traumatic
D
A patient with locally advanced pancreatic cancer develops persistent back pain. Which of the following is the most appropriate treatment?
• Corticosteroids
• Celiac Nerve block
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Paracetamol
• Transcutaneous electric nerve stimulation
B
A 50-year-old woman sustains a displaced distal radial fracture. This is manipulated under anaesthetic and treated in a cast for six weeks. After three months she returns to the fracture clinic with painful and limited pronation and supination. Which of the following is the most likely diagnosis?
• Complex regional pain syndrome Type 1 (reflex sympathetic dystrophy)
• Malunion
• Non-union
• Posterior interosseous palsy
• Radial nerve compression
B
Three days after an isolated head injury from a fall on the right side, a 76-year-old woman is admitted for drowsiness and confusion. There are no localising signs. A CT scan is most likely to show:
*A crescent intracranial haematoma on the right side with cerebral swelling and midline shift to the left
• A depressed frontal fracture communicating with the frontal sinus and signs of infection
• An expanding extradural haematoma on the left side with cerebral swelling
• Blood in the subarachnoid space and cerebral ventricles with secondary
hydrocephalus
• Cerebral atrophy with a subdural collection on the left side
The most likely finding on a CT scan for this patient is a crescent intracranial haematoma on the right side with cerebral swelling and midline shift to the left. This is consistent with a chronic subdural haematoma, which is a common complication of head injury in elderly people12. A chronic subdural haematoma is a collection of blood that forms between the dura mater (the outermost layer of the meninges) and the arachnoid mater (the middle layer of the meninges) over a period of days to weeks after a head injury12. The blood may accumulate slowly and cause gradual compression of the brain, leading to symptoms such as drowsiness, confusion, headache, weakness, or seizures12. On a CT scan, a chronic subdural haematoma appears as a crescent-shaped lesion that follows the contour of the skull and may cross suture lines12. The haematoma may also cause cerebral swelling and midline shift, which are signs of increased intracranial pressure12.
The other options are less likely for this patient, based on the clinical scenario and the CT scan appearance:
A depressed frontal fracture communicating with the frontal sinus and signs of infection would be more likely in a patient with a history of blunt trauma to the forehead, and would show a bony defect and air-fluid levels in the frontal sinus on a CT scan3.
An expanding extradural haematoma on the left side with cerebral swelling would be more likely in a patient with a history of a temporal bone fracture or a tear of the middle meningeal artery, and would show a lens-shaped lesion that does not cross suture lines on a CT scan4.
Blood in the subarachnoid space and cerebral ventricles with secondary hydrocephalus would be more likely in a patient with a history of a ruptured aneurysm or a traumatic subarachnoid haemorrhage, and would show a diffuse pattern of blood in the basal cisterns, sulci, and ventricles on a CT scan5.
Cerebral atrophy with a subdural collection on the left side would be more likely in a patient with a history of dementia or chronic alcoholism, and would show a diffuse loss of brain volume and a thin layer of blood on the opposite side of the head injury on a CT scan.
A 40-year-old man develops a high output fistula following multiple jejunal stricturoplasties and an ileal resection for crohn disease. Which of the following is the most appropriate form of nutritional support?
• Elemental diet.
• High nutrition oral fluids
• Multibitamin supplements
• Percutaneous endoscopic gastrostomy feeding
• Total parenteral nutrition
E
A 3-month-old boy, who was born prematurely, presents with a tender irreducible swelling in the right groin. Which of the following is the most likely diagnosis?
• Direct inguinal hernia
• Femoral hernia.
• Indirect inguinal hernia
• Inguinal lymphadenitis
• Torsion of testis
The most likely diagnosis for this patient is indirect inguinal hernia. This is a type of hernia that occurs when a part of the intestine protrudes through the inguinal canal, a passage in the lower abdominal wall that connects the abdomen and the scrotum. Indirect inguinal hernias are more common in males than females, and are often present at birth or develop in infancy. Premature babies have a higher risk of developing indirect inguinal hernias.
Some of the signs and symptoms of an indirect inguinal hernia include:
A bulge or swelling in the groin or scrotum that may increase in size when the baby cries, coughs, or strains
Pain, tenderness, or discomfort in the groin or scrotum
Redness or discoloration of the skin over the hernia
Vomiting, fever, or poor feeding, which may indicate a complication such as strangulation or incarceration of the hernia
The other options are less likely for this patient, based on the clinical scenario and the web search results:
A direct inguinal hernia is a type of hernia that occurs when a part of the intestine pushes through a weak spot in the abdominal wall near the inguinal canal. Direct inguinal hernias are more common in older men and are rarely seen in children.
A femoral hernia is a type of hernia that occurs when a part of the intestine protrudes through the femoral canal, a passage in the upper thigh that connects the abdomen and the leg4. Femoral hernias are more common in women than men and are also rare in children4.
Inguinal lymphadenitis is an inflammation of the lymph nodes in the groin, which may be caused by an infection or an injury in the lower extremities. Inguinal lymphadenitis may cause swollen, tender, or warm lymph nodes in the groin, but not a bulge or swelling in the scrotum5.
Torsion of testis is a condition that occurs when the spermatic cord, which supplies blood to the testicle, twists and cuts off the blood flow6. Torsion of testis is a medical emergency that requires immediate surgery to prevent permanent damage to the testicle6. Torsion of testis may cause severe pain, swelling, and redness of the scrotum, but not a bulge or swelling in the groin6.
An otherwise healthy 5-year-old boy presents with a six-week history of minor, painless, intermittent, bright red rectal bleeding with no associated disturbance of bowel habit. Which of the following is the most likely diagnosis?
• Anal fissure
• Haemorrhoids.
• Intussusception
• Juvenile rectal polyp
• Meckel diverticulum
D Juvenile polyp: Present at 2-5 yrs.
• Most common (80%)
• Bleeding per rectum or prolapsed polyp
• Diagnosis by history, examination and colonoscopy.
• Treatment is polypectomy
• Histological examination is vital
A 56-year-old woman ventilated in intensive care has increasing oxygen requirements one day after elective aortic aneurysm repair. Her pulmonary capillary wedge pressure (PCWP) is 20 mmHg (normal range 8-12 mmHg) and she has obvious bilateral diffuse opacities on chest X-ray.
Which of the following is the most likely diagnosis?
• Acute respiratory distress syndrome (ARDS)
• Aspiration pneumonia.
• Lobar pneumonia
• Pulmonary embolus.
• Pulmonary edema secondary to heart failure
E
Based on the clinical presentation of a 56-year-old woman ventilated in intensive care with increasing oxygen requirements, elevated pulmonary capillary wedge pressure (PCWP), and bilateral diffuse opacities on chest X-ray, the most likely diagnosis is:
Pulmonary edema secondary to heart failure.
Here’s a breakdown of the options:
1. Acute respiratory distress syndrome (ARDS): ARDS typically presents with acute onset of hypoxemia, bilateral opacities on chest imaging, and absence of elevated PCWP. The PCWP in ARDS is usually normal or low. 2. Aspiration pneumonia: This can lead to bilateral opacities on chest X-ray but usually does not present with elevated PCWP unless there’s an underlying cardiac issue. 3. Lobar pneumonia: While lobar pneumonia can cause bilateral opacities on chest X-ray, it doesn’t typically lead to elevated PCWP. 4. Pulmonary embolus: Pulmonary embolism can cause hypoxemia and may present with chest pain and hemoptysis. It usually doesn’t result in elevated PCWP or diffuse bilateral opacities on chest X-ray unless there’s concurrent heart failure. 5. Pulmonary edema secondary to heart failure: Heart failure can lead to elevated PCWP due to left ventricular dysfunction. Elevated PCWP can cause pulmonary edema with bilateral diffuse opacities on chest X-ray.
Given the elevated PCWP and bilateral diffuse opacities on chest X-ray in the context of a patient with increasing oxygen requirements post-operatively, pulmonary edema secondary to heart failure is the most likely diagnosis.
Source:
• Murray, J. F., & Matthay, M. A. (2015). Acute respiratory distress syndrome (ARDS). Annals of internal medicine, 142(10), 764-772. Link • Braunwald, E. (2019). Heart failure and cardiomyopathies. In Harrison’s Principles of Internal Medicine (20th ed.). McGraw-Hill Education.
A 75-year-old man is scheduled for abdominoperineal resection for a rectal carcinoma. As part of the enhanced recovery programme, he was given a carbohydrate drink the night before surgery. How does preoperative carbohydrate loading p to improve the outcome of surgery?
• It decreases the utilization of fat resources
• It improves abdominal muscle function
• It improves nitrogen balance and reduces insulin resistance
• It improves respiratory muscle function
• It improves sugar levels in the perioperative period
The correct answer is: It improves nitrogen balance and reduces insulin resistance.
Preoperative carbohydrate loading is a strategy that involves drinking a clear carbohydrate beverage up to 2 hours before surgery1. It is part of the enhanced recovery programme, which aims to reduce postoperative stress and improve the recovery process2.
Preoperative carbohydrate loading has several benefits for the outcome of surgery, such as12:
It modifies insulin resistance, which is a known risk factor of postoperative complications. Insulin resistance is a condition in which the body does not respond well to insulin, a hormone that regulates blood sugar levels. Insulin resistance can lead to hyperglycaemia, inflammation, and impaired wound healing. Preoperative carbohydrate loading can reduce insulin resistance by providing glucose to the cells and preventing the breakdown of muscle protein.
It improves nitrogen balance, which is a measure of the balance between protein synthesis and breakdown. A positive nitrogen balance means that more protein is being built than broken down, which is essential for tissue repair and recovery. A negative nitrogen balance means that more protein is being lost than gained, which can lead to muscle wasting and weakness. Preoperative carbohydrate loading can improve nitrogen balance by sparing muscle protein and stimulating protein synthesis.
It improves patient comfort and well-being, by reducing preoperative thirst, hunger, anxiety, and fatigue. It also minimizes protein losses, which can affect the immune system and the ability to fight infections. It improves postoperative muscle function, by preserving muscle strength and endurance. It reduces hospital stays, by facilitating early mobilization and oral intake.
The other options are incorrect or not supported by the web search results:
It decreases the utilization of fat resources: This is not a benefit of preoperative carbohydrate loading. In fact, preoperative carbohydrate loading may increase the utilization of fat resources, as glucose is preferentially used as an energy source over fat. However, this does not have a negative impact on the outcome of surgery, as fat is not a major contributor to the metabolic and immune response to injury1.
It improves abdominal muscle function: This is not a benefit of preoperative carbohydrate loading. There is no evidence that preoperative carbohydrate loading improves abdominal muscle function specifically. However, it may improve general muscle function, as explained above12.
It improves respiratory muscle function: This is not a benefit of preoperative carbohydrate loading. There is no evidence that preoperative carbohydrate loading improves respiratory muscle function specifically. However, it may improve general muscle function, as explained above12.
It improves sugar levels in the perioperative period: This is not a benefit of preoperative carbohydrate loading. Preoperative carbohydrate loading does not improve sugar levels in the perioperative period, as it does not affect the blood glucose levels during or after surgery. However, it does reduce insulin resistance, which is a more important factor for the outcome of surgery12.
In the UK, the National Institute for Health and Care Excellence guidance recommends that if a person has had a blood transfusion they should be informed that they can
• Donate blood after a period of six months
• Donate blood after a period of 12 montns
• Donate blood only if tested negative for blood-borne viruses
• Donate blood when haemoglobin is more than 135 g/L
• No longer be a blood donor
The correct answer is: No longer be a blood donor.
According to the web search results, the UK has a rule that anyone who has had a blood transfusion or blood products anytime since 01 January 1980 cannot be a blood donor in the future1234. This is one of the safety measures in place to protect people who receive a blood transfusion from the risk of infection or adverse reactions12.
The other options are incorrect or not applicable for the UK:
Donate blood after a period of six months: This is not a valid option for the UK. Some countries may have different rules for blood donation after a transfusion, but the UK does not allow it at all12.
Donate blood after a period of 12 months: This is not a valid option for the UK. Some countries may have different rules for blood donation after a transfusion, but the UK does not allow it at all12.
Donate blood only if tested negative for blood-borne viruses: This is not a valid option for the UK. Although all blood donations are tested for blood-borne viruses, such as HIV, hepatitis B, hepatitis C, and syphilis, there is still a small risk of transmitting an infection that is not detected by the tests. Therefore, the UK does not allow blood donation after a transfusion, regardless of the test results12.
Donate blood when haemoglobin is more than 135 g/L: This is not a valid option for the UK. Haemoglobin is a protein in red blood cells that carries oxygen. The normal range of haemoglobin for men is 135 to 180 g/L and for women is 115 to 165 g/L. However, having a normal haemoglobin level does not mean that a person can donate blood after a transfusion. The UK does not allow blood donation after a transfusion, regardless of the haemoglobin level12.
A 50-year-old woman presents with a 1 cm diameter pigmented, crusting, bleeding lesion on her back, clinically suggestive of a malignant melanoma. Which of the following is the most appropriate diagnostic procedure to be performed ?
• Curettage
• Excisional biopsy
• Incisional biopsy
• Punch biopsy
• Wide local excision with a 2 cm margin
The most appropriate diagnostic procedure for a suspected malignant melanoma is excisional biopsy12. This is a technique that involves removing the entire lesion and a small margin of normal skin around it, and sending it to a laboratory for histopathological analysis12. Excisional biopsy is the gold standard for melanoma diagnosis, as it allows for the accurate assessment of the thickness, margins, and other features of the tumor12.
The other options are not recommended for a suspected malignant melanoma, based on the web search results:
Curettage: This is a technique that involves scraping off the surface of the lesion with a sharp instrument, and sending it to a laboratory for cytological analysis3. Curettage is not suitable for melanoma diagnosis, as it does not provide enough tissue for histopathological analysis, and may miss the deeper parts of the tumor3.
Incisional biopsy: This is a technique that involves removing a part of the lesion, usually the thickest or most abnormal area, and sending it to a laboratory for histopathological analysis4. Incisional biopsy is not preferred for melanoma diagnosis, as it may not represent the whole lesion, and may underestimate the thickness and margins of the tumor4.
Punch biopsy: This is a technique that involves removing a small, circular piece of skin using a special tool, and sending it to a laboratory for histopathological analysis5. Punch biopsy is not ideal for melanoma diagnosis, as it may not capture the entire lesion, and may distort the shape and margins of the tumor5.
Wide local excision with a 2 cm margin: This is a technique that involves removing the lesion and a large margin of normal skin around it, and sending it to a laboratory for histopathological analysis. Wide local excision with a 2 cm margin is not a diagnostic procedure, but a treatment option for confirmed melanoma cases. It is not necessary to remove such a large margin of normal skin for diagnosis, as it may cause unnecessary scarring and morbidity.
A 23-year-old asthmatic man is admitted with a bilateral fracture of fibula and tibia following a road traffic accident. He is on 15 mg of prednisolone daily and is to undergo surgery the following day. Which of the following regimes should beimplemented?
• Continue normal steroids in the perioperative period
• Omit steroids on day of surgery, then continue normal steroids
• Reduce steroids on day of surgery then continue normal steroids
• Increase steroids on day of surgery and for one month following surgery
• Increase steroids on day of surgery and for three days postoperatively
Very debatable but E
For a 23-year-old asthmatic man with a bilateral fracture of the fibula and tibia who is on 15 mg of prednisolone daily and scheduled for surgery, the appropriate perioperative steroid management would be to increase steroids on the day of surgery and for three days postoperatively. This recommendation is based on the general guidelines for managing patients who are on chronic steroid therapy undergoing surgery. These patients are at risk for adrenal suppression, and thus, it is crucial to provide additional steroid coverage to cope with the stress of surgery.
In the context of the provided search results, while specific perioperative steroid management protocols for orthopedic surgeries are not detailed, the general principle of increasing steroid dosage during significant surgical stress to prevent adrenal insufficiency is well-established in clinical practice. Patients who have been on systemic corticosteroids for more than two weeks in the past six months should be considered at risk for adrenal suppression and would need intraoperative supplementation of steroids[1]. This is typically managed by administering 1–2 mg/kg of hydrocortisone intravenously every 8 hours on the day of surgery, followed by a gradual tapering off to the usual preoperative dosage[1].
Therefore, the most suitable option for this patient would be to increase steroids on the day of surgery and for three days postoperatively to ensure adequate physiological response to the surgical stress and to prevent potential adrenal crisis.
A 72-year-old woman, who was treated for breast cancer 20 years ago, presents with tiredness, constipation, back and chest pain. Examination reveals localized tenderness over thoracic vertebrae and anterior ribs. Her pulse is 110 beats/minute and blood pressure 90/60mmHg. An ECG shows a shortened QT interval. Her biochemistry results are:
Finding
Sodium 137 mmol/L (135-145)
Potassium 4.3 mmol/L (3.5-5.0)
Corrected calcium 3.8 mmol/L (2.2-2.6)
Phosphate 0.8 mmol/L (0.8-14)
Chest X-ray shows lytic lesions in the left anterior third rib and fifth thoracic vertebra.
Which of the following treatments should be administered first?
• 0.9% sodium chloride
• Calcitonin
• Cinalcalcet
• Pamidronate
• Prednisolone
The patient presents with symptoms of hypercalcemia, including tiredness, constipation, back and chest pain, and localized tenderness over the thoracic vertebrae and anterior ribs. The biochemistry results show a corrected calcium level of 3.8 mmol/L, which is above the normal range of 2.2-2.6 mmol/L. The patient’s ECG shows a shortened QT interval, which is a common finding in hypercalcemia.
The mainstays of treatment for hypercalcemia are IV hydration, bisphosphonates, and calcitonin. In this case, the patient should be administered IV hydration with 0.9% sodium chloride to help reduce the serum calcium level and alleviate symptoms. This is the first line of treatment for hypercalcemia, as it helps to increase calciuresis and decrease bone resorption.
Calcitonin can be used as a second-line treatment, as it helps to decrease bone resorption and increase calcium excretion. However, it is not the first choice in this case, as the patient’s calcium level is already elevated, and IV hydration is more effective in reducing serum calcium levels quickly.
Cinacalcet is a medication that helps to decrease the production of parathyroid hormone (PTH), which can contribute to hypercalcemia. However, it is not the first choice in this case, as the patient’s calcium level is already elevated, and IV hydration and calcitonin are more effective in reducing serum calcium levels quickly.
Pamidronate is a bisphosphonate that can be used to treat hypercalcemia, but it is not the first choice in this case, as IV hydration is the first line of treatment. Pamidronate can be used if the patient’s calcium level does not respond to IV hydration.
Prednisolone is a corticosteroid that can be used to treat hypercalcemia, but it is not the first choice in this case. Corticosteroids can help to reduce the production of PTH, but they are not as effective as IV hydration and bisphosphonates in reducing serum calcium levels quickly.
In summary, the patient should be administered IV hydration with 0.9% sodium chloride as the first line of treatment for hypercalcemia.
A previously fit 21-year-old man collapses while running a marathon. Resuscitation is unsuccessful. A post-mortem examination shows an intracranial haemorrhage. What is the most likely site of the haemorrhage?
• Extradural
• Intracerebral
• Intraventricular
• Subarachnoid
• Subdural
The most likely site of the hemorrhage in this case is Subarachnoid. It’s commonly associated with sudden, severe headaches and can result from conditions like aneurysms or arteriovenous malformations. life-threatening type of stroke caused by bleeding into the space surrounding the brain.
caused by a ruptured aneurysm, AVM arteriovenous malformation, or head injury.
1/3 survive with good recovery
1/3 will survive with a disability
1/3 will die.
Symptoms :
sudden onset of a severe headache (“the worst headache of my life”)
+ Meningism
It causes
Raised ICP
CSF Circ. Block > Hydrocephalus & Seizures
A 40-year-old woman presents with a two-week history of flank pain and episodic frank haematuria. An ultrasound demonstrates a 10 cm renal mass without hydronéphroses. What is the most appropriate investigation?
• Computerized tomography (CT) scan
• Intravenous pyelogram
• Isotope bone scan
• Magnetic resonance imaging (MRI)
• Renal biopsy
CT is the frist line for kidney stones or renal mases, unless in some cases such as pregnancy or young aged child e.g.: 1 years old child or teenager girl for risk of infertility we do US or IVU initially
A previously fit young man is admitted after a road traffic accident. He is satisfactorily intubated because of a head injury. He has a Glasgow coma score of 8 (E2. V2. M4). There are no other external injuries and initial cardiorespiratory stability is achieved during the primary survey. He suddenly becomes hypoxic after log-rolling to examine the back. What is the most likely cause of his deterioration?
• Cardiac tamponade.
• Ongoing major haemorrhage
• Spinal injury
• Tension pneumothorax.
• Tracheal tube displacement.
Given the scenario provided, the most likely cause of the patient’s sudden hypoxia after log-rolling to examine the back is tracheal tube displacement. This complication is particularly common during patient movement and positioning, such as log-rolling, especially in situations involving trauma patients who are intubated.
Tracheal tube displacement can result in airway obstruction, leading to hypoxia and potentially respiratory arrest. It’s crucial to ensure proper positioning and securement of the endotracheal tube to prevent this complication.
Other causes such as tension pneumothorax or spinal injury could also lead to respiratory compromise, but in this case, given the context of the patient’s recent movement, tracheal tube displacement is the most likely culprit.
Source:
• Tracheal Intubation: Complications and Management: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230495/
A A 21-year-old man has been hit by a cricket ball on the side of the head.
Initially he has a Glasgow coma score (GCS) of 15 (E4. V5. M6). Four hours after arrival in hospital, while on the observation ward, his GCS drops to 7 (E1. V2. M4). His left pupil dilates, and he begins to demonstrate extensor posturing of the limbs. What are the most likely changes to his vital signs since injury?
Blood pressure: Decreased Heart rate: Decreased
Blood pressure : Decreased Heart rate: Increased
Blood pressure : Decreased Heart rate: Normal
Blood pressure: Increased. Heart rate: Decreased
Blood pressure: Increased. Heart rate: Increased
Cushing’s triad is a set of three classic signs indicating increased intracranial pressure (ICP). These signs include:
1. Hypertension: This refers to elevated blood pressure. Increased ICP can compress blood vessels in the brain, leading to hypertension as the body tries to maintain cerebral perfusion pressure. 2. Bradycardia: Bradycardia, or a slow heart rate, is another component of Cushing’s triad. It occurs because increased ICP can stimulate the vagus nerve, which leads to a decrease in heart rate. 3. Irregular respirations: Irregular breathing patterns, such as Cheyne-Stokes respirations or periods of apnea, can occur due to the brain’s attempt to regulate oxygen levels in response to increased pressure.
Cushing’s triad is often seen in severe cases of head injury, intracranial hemorrhage, or brain tumors where there is significant brain swelling or mass effect. It indicates a critical condition requiring immediate medical attention to prevent further neurological deterioration and potential herniation of brain structures.
Source:
• Cushing’s Triad: https://www.ncbi.nlm.nih.gov/books/NBK542246/
A 78-year-old man, who is a smoker with a long history of Barrett oesophagus, presents with dysphagia and weight loss. Endoscopy confirms the presence of a malignant stricture. Which of the following is the most likely histological diagnosis
• Adenocarcinoma
• Adenosquamous carcinoma.
• Lymphoma
• Mucoepidermoid carcinoma
• Squamous cell carcinoma
Given the patient’s history of Barrett esophagus, dysphagia, and weight loss, the most likely histological diagnosis for the malignant stricture is adenocarcinoma. Adenocarcinoma is the most common type of esophageal cancer in Western countries, especially in individuals with Barrett esophagus, which is a precancerous condition characterized by changes in the lining of the esophagus.
Adenosquamous carcinoma is a less common subtype of esophageal cancer and typically presents differently. Lymphoma, while it can affect the esophagus, is less common than adenocarcinoma in this age group and clinical context. Mucoepidermoid carcinoma is more commonly found in the salivary glands rather than the esophagus. Squamous cell carcinoma is another type of esophageal cancer, but it is less likely in this patient given the history of Barrett esophagus, which predisposes to adenocarcinoma.
Source:
• Esophageal Cancer: https://www.cancer.gov/types/esophageal/patient/esophageal-treatment-pdq#section/_15
24 hours after a routine aortic valve replacement for a heavily calcified valve the patient’s heart rate abruptly falls to 40 beats/minute.
The systolic pressure, which was 140 mmHg, is now 110 mmHg and the right atrial pressure, which was 7 mmHg, is now averaging 15 mmg.
Which of the following is the most likely diagnosis?
• Atrial fibrillation
• Cardiac tamponade
• Digoxin toxicity
• Heart block
• Left ventricular failure
Given the scenario described, the most likely diagnosis is heart block, specifically a type of heart block called “complete heart block” or “third-degree heart block.”
Complete heart block occurs when there is complete dissociation between the atria and ventricles, leading to an independent rhythm of the atria and ventricles. This can result in a slow ventricular rate, leading to bradycardia (heart rate of 40 beats/minute). The decreased cardiac output due to the slow heart rate can result in a decrease in systolic blood pressure.
The elevation in right atrial pressure (from 7 mmHg to averaging 15 mmHg) suggests impaired filling of the right ventricle, which can occur due to the slow heart rate associated with heart block.
While atrial fibrillation can cause a rapid and irregular heart rate, it typically presents with tachycardia rather than bradycardia. Cardiac tamponade typically presents with signs of hemodynamic compromise such as hypotension, elevated jugular venous pressure, and distant heart sounds. Digoxin toxicity can cause bradycardia, but the clinical presentation would typically involve other signs and symptoms such as nausea, vomiting, visual disturbances, and possibly arrhythmias. Left ventricular failure may lead to symptoms such as dyspnea and signs such as pulmonary congestion on examination, but it’s less likely to cause the abrupt bradycardia described in the scenario.
Source:
• Complete Heart Block: https://www.ncbi.nlm.nih.gov/books/NBK560867/
A 67-year-old man is admitted with a history of fresh rectal bleeding, preceded by the left- sided abdominal pain on two occasions in the past 36 hours. The blood was both bright red and dark plum coloured mixed with a loose motion. He is on atenolol for hypertension. Examination shows frank blood per rectum. There is slight abdominal tenderness in the left upper quadrant and left iliac fossa. He is normotensive with a haemoglobin of 106g/L. Which of the following is the most likely diagnosis?
• Anal carcinoma
• Ischaemic colitis
• Meckel diverticulum
• Oesophageal varices
• Ulcerative colitis
The most likely diagnosis in this case is Ischaemic colitis. The clinical presentation of fresh rectal bleeding, left-sided abdominal pain, and the presence of blood mixed with loose motions are indicative of ischemic colitis. It’s essential for the patient to receive prompt medical attention to determine the severity and initiate appropriate management.
A 25-year-old man became constipated after taking opiate analgesics for back pain. Which of the following is the most likely description of his rectal bleed?
• Bright red, associated with severe perianal pain
• Bright red, short lasting episodes of profuse bleeding
• Dark red, associated with profuse watery stools
• Dark red. mixed in with bowel motions.
• Dark red, profuse bleeding associated with strong smell
A
A 50-year-old man with type 1 diabetes and an autonomic neuropathy undergoes an inguinal bernia repair as a day case. Which of the following is most likely to be a problem for him as a day case?
• Constipation
• Orthostatic hypotension.
• Peripheral neuropathy
• Reduced pulse rate variability
• Sinus tachycardia
The most likely problem for the 50-year-old man with type 1 diabetes and autonomic neuropathy undergoing inguinal hernia repair as a day case would be Orthostatic hypotension. Autonomic neuropathy can affect blood pressure regulation, leading to orthostatic hypotension, especially when moving from a lying to a standing position.
A 62-year-old man presents with a painful, pale right lower limb. He underwent right femoro- popliteal (below knee) bypass 18 months ago using in-situ vein. On duplex examination the graft is blocked. What is the most likely histological feature of the graft?
• Aneurysmal dilatation
• Atheromatous plaques
• Neointimal hyperplasia
• Smooth muscle hyperplasia
• Varicose dilatation of the vein wall
The most likely histological feature of the blocked graft in this case would be Neointimal hyperplasia. This is a common cause of graft failure in vascular procedures, leading to narrowing or occlusion of the graft over time.
A 63-year-old woman with a caecal cancer is booked for an elective right hemicolectomy. She is otherwise fit and well. In the pre-assessment clinic she asks about the benefits of the enhanced recovery programme. Which of the following is a potential benefit?
• Reduced length of hospital stay
• Reduced likelihood of chronic pain
• Routine use of abdominal drains
• Routine use of nasogastric tube
• Use of morphine-based analgesia
A potential benefit of the enhanced recovery programme for a patient undergoing right hemicolectomy is Reduced length of hospital stay. Enhanced recovery protocols aim to optimize the perioperative care, leading to quicker recovery and shorter hospital stays.
An Enhanced Recovery Programme (ERP), also known as Enhanced Recovery After Surgery (ERAS), is a multidisciplinary approach to patient care aimed at optimizing the perioperative period to enhance recovery following surgery. The goal is to improve outcomes, reduce complications, shorten hospital stays, and facilitate earlier return to normal function and activities.
Key components of an ERP typically include:
1. Preoperative optimization: This involves patient education, preoperative counseling, nutritional optimization, smoking cessation, and physical conditioning to prepare patients for surgery and aid in their recovery. 2. Minimally invasive techniques: Utilizing minimally invasive surgical approaches whenever possible to reduce surgical trauma, postoperative pain, and recovery time. 3. Multimodal pain management: Implementing a combination of analgesic techniques, such as regional anesthesia, non-opioid medications, and patient-controlled analgesia, to minimize postoperative pain and opioid consumption. 4. Early oral intake: Encouraging early resumption of oral intake following surgery to maintain hydration and prevent ileus, typically starting with clear fluids and advancing as tolerated. 5. Early mobilization: Initiating early mobilization and ambulation to prevent complications such as deep vein thrombosis, pneumonia, and muscle deconditioning, and to promote faster recovery. 6. Avoidance of routine interventions: Avoiding unnecessary interventions such as prolonged fasting, bowel preparation, urinary catheterization, and routine use of nasogastric tubes, unless clinically indicated. 7. Continuous quality improvement: Implementing protocols for data collection, audit, and feedback to continuously monitor outcomes and refine the ERP process.
ERPs are tailored to specific surgical procedures and patient populations, and their implementation requires collaboration among surgeons, anesthesiologists, nurses, physiotherapists, and other healthcare professionals.
Overall, ERPs have been shown to significantly improve patient outcomes, reduce healthcare costs, and enhance patient satisfaction in various surgical specialties.
Source:
• ERAS Society: https://erassociety.org/
A 45-year-old woman feels a sudden pain in her left leg and feels as if she has been hit in the back of the ankle as she starts to cross the road before she falls. Which of the following is the most appropriate clinical test?
• An impingement sign
• Apleys grinding test
• Phalen’s manoeuvre
• Simmonds’ squeeze test
• Thomas test
Rupture of the Achilles tendon usually occurs in middle-aged men. The history frequently follows the pattern of tendon rupture following a trivial stumble. Dorsiflexion is exaggerated as it is normally limited by the Achilles tendon. Plantar flexion is limited and the patient is unable to stand on tiptoe, but some plantar flexion is still possible owing to the action of the long flexors of the toes, tibialis posterior and peronei.
Thompson test (also known Simmond’s squeeze test) is positive in Achillis tendon rupture, which is lack of plantar flexion when calf is squeezed. The Thompson test, also known as the calf squeeze test, is a physical examination maneuver used to assess the integrity of the Achilles tendon. It is primarily employed to diagnose Achilles tendon rupture, although it can also help evaluate for other Achilles tendon pathologies.
Here’s how the Thompson test is performed:
1. The patient is positioned prone or lying face down on the examination table with their feet hanging over the edge. 2. The examiner squeezes the calf muscle of the affected leg with their fingers or thumbs while observing the movement of the foot and ankle. 3. In a normal Thompson test, squeezing the calf muscle should result in plantar flexion (pointing downward) of the foot. This occurs because the calf muscle contraction normally causes the Achilles tendon to pull on the heel, leading to plantar flexion. 4. If there is an Achilles tendon rupture, there will be no movement of the foot in response to calf muscle squeezing. This lack of movement is indicative of a positive Thompson test and suggests a complete rupture of the Achilles tendon.
It’s important to note that a positive Thompson test indicates a complete rupture of the Achilles tendon, but a negative test does not necessarily rule out a partial tear or other Achilles tendon injuries. Imaging studies such as ultrasound or MRI may be needed for further evaluation in cases where there is clinical suspicion of Achilles tendon pathology.
The Thompson test is a simple and quick bedside maneuver that can provide valuable diagnostic information for clinicians evaluating patients with suspected Achilles tendon injuries.
Source:
• Thompson Test: https://www.ncbi.nlm.nih.gov/books/NBK499992/
The impingement sign, also known as the Hawkins-Kennedy test, is a physical examination maneuver used to assess for subacromial impingement syndrome in the shoulder. Subacromial impingement occurs when the tendons of the rotator cuff muscles become compressed or irritated as they pass through the subacromial space, resulting in pain and decreased range of motion.
Here’s how the impingement sign/Hawkins-Kennedy test is performed:
1. The patient is typically seated or standing comfortably. 2. The examiner raises the affected arm to shoulder height and then flexes the elbow to 90 degrees. 3. With the patient’s arm in this position, the examiner then forcibly internally rotates the arm by bringing the forearm across the body, while stabilizing the scapula. 4. A positive impingement sign is indicated by the reproduction of pain in the subacromial space, typically felt over the top and front of the shoulder.
The impingement sign/Hawkins-Kennedy test is thought to provoke symptoms by narrowing the subacromial space and compressing the inflamed structures, including the rotator cuff tendons and subacromial bursa.
It’s important to note that while a positive impingement sign is suggestive of subacromial impingement syndrome, it is not specific to this condition and may also be positive in other shoulder pathologies. Therefore, it is often used in combination with other clinical tests and imaging studies to make a diagnosis.
Apley’s grinding test is a physical examination maneuver used to assess for meniscal injury or pathology in the knee joint. It is named after the British orthopedic surgeon Alan Graham Apley, who described the test.
Here’s how Apley’s grinding test is performed:
1. The patient is typically positioned prone or lying face down on an examination table. 2. The examiner flexes the affected knee to approximately 90 degrees. 3. The examiner then places one hand on the patient’s heel to stabilize the lower leg, while the other hand grasps the patient’s ankle or foot. 4. With the knee in flexion, the examiner applies downward pressure on the patient’s foot while simultaneously rotating the tibia (lower leg) internally and externally. 5. During this rotation, the examiner applies axial compression to the tibia by pushing down on the foot. 6. The test is considered positive if the patient experiences pain or reproduces the symptoms of meniscal injury, such as clicking, popping, or grinding sensations, especially when combined with compression and rotation.
Apley’s grinding test is thought to reproduce symptoms of meniscal injury by placing stress on the meniscus, particularly the inner (medial) or outer (lateral) meniscus, depending on the direction of rotation. The test may provoke pain or mechanical symptoms (e.g., clicking or locking) if there is a tear or other pathology affecting the meniscus.
It’s important to note that while Apley’s grinding test can provide valuable clinical information, it is not specific to meniscal pathology and may also be positive in other knee conditions. Therefore, it is often used in conjunction with other physical examination maneuvers, imaging studies (such as MRI), and clinical judgment to make a diagnosis.
Source:
• Apley’s Grinding Test: https://www.physio-pedia.com/Apley’s_Grinding_Test • Hawkins-Kennedy Test: https://www.physio-pedia.com/Hawkins-Kennedy_Test
Phalen’s maneuver, also known as Phalen’s test, is a physical examination maneuver used to assess for carpal tunnel syndrome, a common condition characterized by compression of the median nerve as it passes through the carpal tunnel in the wrist.
Here’s how Phalen’s maneuver is performed:
1. The patient is asked to flex both wrists maximally and press the dorsal surfaces of the hands together, with the fingers pointing downward and the wrists in full flexion. 2. The position is typically held for 60 seconds or until symptoms are reproduced. 3. The test is considered positive if the patient experiences numbness, tingling, or pain in the distribution of the median nerve, which includes the thumb, index finger, middle finger, and half of the ring finger.
Phalen’s maneuver is thought to exacerbate symptoms of carpal tunnel syndrome by increasing pressure within the carpal tunnel and compressing the median nerve. The flexed wrist position reduces the space within the carpal tunnel, leading to compression of the nerve against the transverse carpal ligament.
It’s important to note that while Phalen’s maneuver can help diagnose carpal tunnel syndrome, it is not specific and may also be positive in other conditions affecting the median nerve or wrist joint. Therefore, it is often used in conjunction with other clinical tests, such as Tinel’s sign and median nerve compression test, as well as imaging studies and electrodiagnostic tests, to confirm the diagnosis.
Source:
• Phalen’s Test: https://www.ncbi.nlm.nih.gov/books/NBK513295/
The Thomas test is a physical examination maneuver used to assess for hip flexion contracture and tightness of the hip flexor muscles, specifically the iliopsoas muscle. It is named after Dr. Hugh Owen Thomas, a British orthopedic surgeon who described the test.
Here’s how the Thomas test is performed:
1. The patient lies supine (on their back) on an examination table with both legs fully extended. 2. The examiner stands at the side of the table and passively flexes one of the patient’s hips, bringing the knee towards the chest until the thigh is fully flexed against the abdomen. 3. While maintaining the flexed position of the hip, the examiner observes the position of the contralateral (opposite) leg. 4. If the contralateral thigh lifts off the table or if the knee flexes, it indicates that the hip being tested is unable to fully extend due to tightness of the hip flexors, particularly the iliopsoas muscle. 5. To assess for tightness of the rectus femoris muscle, the examiner can also observe whether the knee of the contralateral leg remains fully extended or if it flexes during the test.
The Thomas test is particularly useful in evaluating for hip flexion contracture, a condition where the hip joint is unable to fully extend due to tightness of the hip flexor muscles. It can be performed as part of a musculoskeletal examination to assess for various hip and pelvic conditions, including hip impingement, labral tears, and iliopsoas tendonitis.
Interpretation of the Thomas test results should take into account the patient’s symptoms, clinical history, and findings from other physical examination maneuvers and imaging studies.
Source:
• Thomas Test: https://www.physio-pedia.com/Thomas_Test
After returning to the United Kingdom from a business trip to China, a 35-year-old woman is admitted to hospital with a painful swollen right leg and a palpable dorsalis pedis pulse. Duplex ultrasound sonography of the right femoral vein shows extensive mobile thrombus. The most appropriate immediate management would be
• Aspirin
• Exploration of the femoral vein
• Heparin
• Leg compression stockings
• Thrombolysis.
The most appropriate immediate management for a 35-year-old woman with a painful swollen right leg and extensive mobile thrombus in the femoral vein after returning from a business trip would be Heparin. Heparin is commonly used as an anticoagulant to prevent the extension of venous thrombosis.
Source: American College of Chest Physicians - Antithrombotic Therapy for VTE Disease
A 68-year-old woman Presents with a two-month history of intermittent, bloodstained nipple discharge from her right breast. There is no significant past history. Clinical examination confirms presence of a bloodstained nipple discharge but shows no palpable abnormality. A mammogram and ultrasound scan are normal. What is the most appropriate next step in management?
• Clinical follow-up in three months
• Ductogram
• Reassure patient and discharge
• Surgical excision of affected ducts
• Tamoxifen
Given the clinical presentation of a 68-year-old woman with a two-month history of intermittent bloodstained nipple discharge from her right breast, and normal findings on mammogram and ultrasound scan, the most appropriate next step in management would be a ductogram.
A ductogram, also known as a galactogram or ductography, is a diagnostic imaging procedure specifically used to evaluate the breast ducts and ductal system. It involves injecting a contrast dye into the affected duct or ducts followed by imaging with X-rays or other imaging modalities. This procedure can help identify abnormalities within the ductal system, such as intraductal papillomas or ductal carcinoma in situ (DCIS), which may not be visualized on mammography or ultrasound.
In this case, since the patient has a bloodstained nipple discharge with no palpable abnormality and normal findings on mammogram and ultrasound, a ductogram would be the most appropriate next step to further evaluate the cause of the discharge and assess the ductal system for any abnormalities.
Clinical follow-up in three months may be considered if initial imaging studies are inconclusive or if the discharge resolves spontaneously. However, given the persistent nature of the symptoms, further investigation with a ductogram is warranted.
Reassuring the patient and discharging her without further investigation may not be appropriate, as the presence of bloodstained nipple discharge requires thorough evaluation to rule out underlying pathology, including malignancy.
Surgical excision of affected ducts or initiating tamoxifen therapy would be premature without a definitive diagnosis or identification of the underlying cause of the nipple discharge.
Therefore, the most appropriate next step in management would be to proceed with a ductogram to further evaluate the cause of the bloodstained nipple discharge and assess the ductal system for abnormalities.
Source:
• Breast Ductography: https://radiopaedia.org/articles/ductography?lang=us
A 24-year-old man with a history of Crohn disease presents with generalised bone pains and tenderness in his thighs. He also has increasing muscle weakness, increasing difficulty in walking and a change of gait. Serum calcium and phosphate levels are low but alkaline phosphate and parathyroid hormone levels are elevated. A bone biopsy shows increase in non- mineralised osteoid. What is the most likely diagnosis?
• Osteitis fibrosa cystica
• Osteomalacia.
• Osteoporosis.
• Paget disease of the bone
• Multiple myeloma
Based on the presented clinical findings and laboratory results, the most likely diagnosis is osteomalacia.
Osteomalacia is a condition characterized by softening of the bones due to impaired mineralization of the osteoid matrix, which is the non-mineralized component of bone. It often results from vitamin D deficiency or malabsorption, leading to inadequate calcium and phosphate absorption and subsequent impaired bone mineralization. The symptoms described, including generalized bone pains, tenderness in the thighs, muscle weakness, difficulty walking, and a change in gait, are consistent with osteomalacia.
The laboratory findings of low serum calcium and phosphate levels indicate mineral deficiencies, while elevated alkaline phosphatase and parathyroid hormone levels are compensatory responses to the mineralization defect. The bone biopsy showing an increase in non-mineralized osteoid further supports the diagnosis of osteomalacia.
Osteitis fibrosa cystica, characterized by bone cysts and fibrous tissue replacement due to hyperparathyroidism, typically presents with bone pain, fractures, and deformities, but it is not associated with vitamin D deficiency or impaired mineralization of the osteoid matrix.
Osteoporosis is a condition characterized by decreased bone density and increased risk of fractures, but it does not involve impaired mineralization of the bone matrix as seen in osteomalacia.
Paget’s disease of the bone is a disorder characterized by abnormal bone remodeling, leading to bone enlargement, deformities, and fractures. It typically presents with localized bone pain and deformities, rather than the generalized bone pains and mineralization defects seen in osteomalacia.
Multiple myeloma is a cancer of plasma cells that typically presents with bone pain, fractures, and skeletal lesions, but it is not associated with vitamin D deficiency or impaired mineralization of the osteoid matrix as seen in osteomalacia.
Therefore, among the options provided, osteomalacia is the most likely diagnosis based on the clinical presentation, laboratory findings, and bone biopsy results.
Source:
• Osteomalacia: https://www.ncbi.nlm.nih.gov/books/NBK532269/
Vit D deficiency should be treated with Vit D supplements in patients with crohn’s disease to prevent
A 32-year-old woman, with a recent diagnosis of Graves disease, underwent incision and drainage of a breast abscess three hours ago. She has become agitated, confused and is noted to be jaundiced and sweaty.
Her temperature is 39°C. pulse 152 beats/minute and blood pressure 95/60 mmHg. An ECG shows an irregular ventricular rate with absent p waves. After resuscitation what is the most appropriate next step in management?
• B-adrenoceptor blockers and iodides
• B-adrenoceptor blockers and thionamides
• Bile acid sequestrants and glucocorticoids
• lodides and bile acid sequestrants.
• Thionamides and thyroidectomy
B
Based on the clinical presentation and recent diagnosis of Graves’ disease, the most appropriate next step in management after resuscitation would be administering beta-adrenoceptor blockers and thionamides.
Graves’ disease is an autoimmune disorder characterized by hyperthyroidism, which can lead to symptoms such as agitation, confusion, jaundice, diaphoresis (sweating), fever, tachycardia, and hypertension. The patient’s symptoms, including an irregular ventricular rate with absent p waves on ECG, are consistent with thyroid storm, a severe and life-threatening complication of untreated or undertreated hyperthyroidism.
Beta-adrenoceptor blockers (such as propranolol) are used to manage symptoms of hyperthyroidism, including tachycardia and hypertension. They can help stabilize the patient’s heart rate and blood pressure.
Thionamides (such as propylthiouracil or methimazole) are used to inhibit the production of thyroid hormones and block the synthesis of new thyroid hormone in Graves’ disease. They are essential for controlling thyroid hormone levels and mitigating the hyperthyroid state.
While iodides may temporarily reduce thyroid hormone release, they are not typically used as initial therapy in thyroid storm due to the risk of exacerbating thyrotoxicosis and potentially worsening the patient’s condition.
Bile acid sequestrants and glucocorticoids are not indicated as first-line treatments for thyroid storm and would not address the underlying cause of hyperthyroidism.
Thyroidectomy may be considered as a definitive treatment for Graves’ disease in some cases, but it is not appropriate as an immediate intervention in the acute management of thyroid storm.
Therefore, the most appropriate next step in management after resuscitation of the patient with thyroid storm due to Graves’ disease is administering beta-adrenoceptor blockers and thionamides to stabilize thyroid function and alleviate symptoms.
Source:
• Thyroid Storm: https://www.ncbi.nlm.nih.gov/books/NBK482257/
A 1-year-old girl presents with shortness of breath. Her parents have also noticed that her eyes no longer look symmetrical. The right pupil is smaller than the left and the right eyelid appears droopy. A chest X-ray shows increased opacification in the right hemithorax, particularly in the right upper zone. Which one of the following is the most likely diagnosis?
Select one:
A community acquired pneumonia
A congenital diaphragmatic hernia
A congenital pulmonary airway malformations
Lymphoma
Neuroblastoma
The clinical features point to a right sided Horner syndrome, secondary to a right apical tumour compressing the sympathetic chain. In this age group the most likely cause is neuroblastoma.
A community acquired pneumonia - although a pneumonia can present with shortness of breath, the Horner syndrome is not in keeping
A congenital diaphragmatic hernia - although late presenting congenital diaphragmatic hernia can present with shortness of breath, the Horner syndrome is not in keeping
A congenital pulmonary airway malformations - although late presenting congenital pulmonary airway malformation can present with shortness of breath (usually because of infection in the CPAM), the Horner syndrome is not in keeping
Lymphoma - lymphoma causes lymph node enlargement. The chest X-ray may typically show a mediastinal mass
Neuroblastoma - correct
The correct answer is:
Neuroblastoma
A 25-year-old woman presents with sensory symptoms in the upper limbs and a headache that is worse on coughing. An MRI scan shows a Chiari malformation of the hindbrain and syringomyelia in the cervical spine. Which one of the following nerve tracts are most vulnerable to damage in this condition?
Select one:
Corticospinal
Posterior columns
Spinocerebellar
Spinothalamic
Sympathetic trunks
In Chiari malformation with associated syringomyelia, the most vulnerable nerve tract to damage is the spinothalamic tract.
Syringomyelia is a condition characterized by the development of a fluid-filled cyst (syrinx) within the spinal cord. This cyst can disrupt the normal transmission of sensory information within the spinal cord, particularly affecting the crossing fibers of the spinothalamic tract, which carries pain and temperature sensation.
The Chiari malformation, in which the cerebellar tonsils herniate through the foramen magnum into the spinal canal, can exacerbate the compression of the spinal cord and worsen the symptoms associated with syringomyelia.
Therefore, in this condition, the spinothalamic tract, which transmits pain and temperature sensation, is the most vulnerable nerve tract to damage.
The other nerve tracts mentioned may also be affected to some extent, but the spinothalamic tract is particularly vulnerable due to its location and the disruption caused by the syrinx within the spinal cord.
Source:
• Syringomyelia: https://www.ncbi.nlm.nih.gov/books/NBK526016/
An elderly patient with an intra-capsular fractured neck of femur is due to have a hip hemiarthroplasty performed. Which of the following describe anatomical steps to access the hip joint during the most commonly used approach for a hemiarthroplasty?
Select one:
Detaching the anterior aspect of gluteus medius and minimus from the greater trochanter
Detaching piriformis and the short external rotators from their femoral insertion
Developing a plane between the gracilis and adductor longus muscles
Developing a superficial plane between sartorius and tensor fasciae latae
Elevation of vastus lateralis
The most commonly used approach for hip hemiarthroplasty is the antero - lateral (modified hardinge) approach to the hip. During this approach the gluteus medius and minimus are detached as one or separate layers from the greater trochanter anteriorly to gain access to the hip joint.
The correct answer is:
Detaching the anterior aspect of gluteus medius and minimus from the greater trochanter
