SBAs Flashcards
A 23 year old female presents to the GUM clinic complaining of new vaginal discharge which she describes as thick and malodorous. What is the most appropriate first-line investigation to reach a diagnosis?
Vaginal discharge sampling for pH and wet mount microscopy
urine for NAAT
urine for MCS
Vaginal swab for NAAT
blood for syphilis serology
vaginal discharge sampling for pH and wet mount microscopy
MDR TB is resistant to:
RI
RE
RP
IE
IP
RI
51-year-old female initially presented with a 2 hour history of sudden onset left arm and leg weakness with associated numbness and headache.
PMH: Hypertension, Sinusitis, Tuberculosis treated in 2009, hypertension
You are reviewing her on the post-take ward round with the following results:
HIV serology – reactive
MRI Head – 7 ring enhancing supratentorial lesions with perilesional oedeoma. There is no midline shift, tentorial herniation or hydrocephalus.
Most likely diagnosis:
Toxoplasmic encephalitis
Cryptococcal encephalitis
HIV encephalopathy
CMV encephalitis
Progressive multifocal leukoencephalopathy
Toxoplasmic encephalitis
Most common enhancing lesions would be:
- Toxoplasmic encephalitis – multiple lesions localised in the parietal or frontal lobes, thalamus or basal ganglia or at the corticomedullary junction, ring enhancement in >90%
- Primary CNS lymphoma – solitary or multiple lesions, majority of lesions enhance irregularly, lesions >4cm more likely to represent lymphoma vs infection
Other important infection in this patient would be to consider reactivation/reinfection of TB given history
Other infections are less common and often associated with evidence of disseminated disease: These include brain abscesses secondary to Staphylococcus, Streptococcus, Salmonella, Aspergillus, Nocardia, Rhodococcus, Listeria, unusual granulomatous collections, such as cryptococcomas, and syphilitic gummas.
Non-enhancing lesions:
- Progressive multifocal leukoencephalopathy, HIV encephalopathy, CMV encephalitis
51-year-old female presents with a 2 hour history of sudden onset left arm and leg weakness with associated numbness and headache.
PMH: Hypertension, Sinusitis, Tuberculosis treated in 2009, hypertension
Her daughter also tells you she believes her mother was diagnosed with HIV 7 years ago during a visit to ED with an ankle sprain but refused further investigation or treatment.
Which investigation is most important to request urgently to assist in diagnosing this patient?
CT Head
MRI brain
HIV serology
LP with CSF sampling
FBC
CT Head
Which of the following statements regarding hepatitis A virus is false?
Humans are the only known reservoir
Fulminant hepatic failure occurs in <1% of cases
Infection confers temporary immunity
Transmission is usually by the faecal-oral route
Maternal-fetal transmission has not been described
Infection confers temporary ommunity
54 year old male presents with a cough productive of green sputum and fever. Chest X-ray shows consolidation at the right base. What is the most likely causative organism?
Haemophilus influenzae
Klebsiella pneumoniae
Mycoplasma pneumoniae
Staphylococcus aureus
Streptococcus pneumoniae
Steptococcus pneumoniae
The most common causative organism for community acquired pneumonia in the UK is Streptococcus pneumoniae.
n 85 year old patient is admitted from a nursing home due to progressive drowsiness and confusion, of two days duration; the patient normally is bedbound following a stroke with an indwelling catheter. Examination reveals reduced conscious level but all four limbs are moving, with occasional eye opening, and a raised temperature of 37.8. Investigations reveal a CRP of 278. What is the most likely diagnosis and pathogen?
Meningitis with Streptococcus pneumoniae
Encephalitis with Herpes simplex
A non-infective diagnosis e.g. stroke
Urosepsis with Escherichia coli
Bloodstream infection with Staphylococcus aureus
urosepsis with E. coli
Which of the following is the treatment of choice for severe malaria?
IV artesunate
Oral artesunate
IV quinine
Oral quinine
Oral Primaquine
IV artesunate is first line for the treatment of severe malaria in all patients. In uncomplicated falciparum malaria artemether-lumefantrine (Riamet) is used in all patients except those in the first trimester of pregnancy who are treated with quinine sulphate.
hich of the following organisms is most likely to cause pelvic inflammatory disease?
Staphylococcus aureus
Group B streptococcus
Chlamydia trachomatis
Mycoplasma genitalium
Lactobacillus
In sexually active pre-menopausal women, Neisseria gonorrhoeae and Chlamydia trachomatis are the most commonly identified pathogens in pelvic inflammatory disease. PID in post-menopausal women is rare and may be caused by E. coli and colonic anaerobes.
Aminoglycosides have good action against:
Aerobes
Anaerobes
Aerobes
Gram-negative – E. coli, proteus, Enterobacter, psudomonas
Gram-positive (in conjunction with beta-lactam) – staph aureus and coagulase negative staph, viridans streptococci, enterococcus
19 year old male presents to the GUM clinic with a painless lesion on his penis. What is the most likely cause?
Herpes simplex virus
Syphilis (treponema pallidum)
Lymphogranuloma venereum (chlamydia trachomatis serovars L1-3)
Chancroid (Haemophilus ducreyi)
Granuloma inguinale (klebsiella granulomatis)
Herpes simplex virus is the most common cause of genital ulcers followed by syphilis, ulcers caused by HSV are usually painful whereas syphilitic ulcers are usually painless making syphilis the most appropriate answer.
Painful ulcers – HSV, chancroid
Painless ulcers – Syphilis, LGV and granuloma inguinale
hich of the most common infective cause of fever in the returning traveller from the following list?
Dengue fever
Hepatitis A
Rickettsial infection
Malaria
Typhoid fever
malaria
Which of the following ECG abnormalities does moxifloxacin cause:
Prolonged QTc
Flattened lateral T waves
Prolonged PR interval
Ventricular ectopics
Sinus tachycardia
prolonged QTc
What percentage of patients are penicillin allergic?
<1%
1-10%
10-20%
20-30%
30-40%
1-10%
Allergic reactions occur in 1-10% of patients, anaphylactic reactions occur in <0.05%. Patients who are allergic to one penicillin will be allergic to all penicillins. Some individuals with penicillin allergy will have cross-sensitivity to cephalosporins so these should be used with caution and the decision to use will be based on the observed reaction and the necessity for the use of a cephalosporin.
A 27 year old female presents to the GUM clinic complaining of frothy, purulent and malodorous vaginal discharge. What is the most likely cause?
Candida albicans
Neisseria gonorrhoeae
Chlamydia trachomatis
Trichomoniasis
Allergic vaginitis
Trichomoniasis presents with a purulent malodorous discharge. Vulvovaginal candidiasis presents with a white, cottage cheese discharge and pruritus.
A 48 year old gentleman from Malaysia presents with right upper quadrant pain and is found to have deranged LFTs. A non-invasive liver screen is sent. How would you interpret the following results:
Hepatitis B virus surface Antigen: Negative
Hepatitis B surface Antibody: Positive
Hepatitis B core Antibody: Positive
Susceptible
Vaccinated
Past infection
Acute infection
Chronic infection
past infection
68-year-old male who is HIV positive presents with a 2 week history of cough productive of green sputum, shortness of breath and fever.
Obs: HR 102, BP 126/73, RR 19, Sats 94% on RA but desaturates to 85% on mobilising to bathroom, Temp 38.7
Chest X-ray: Right upper zone opacification
HIV clinic bloods 3 months prior: CD4 count >200, viral load <20. Clinic notes report compliance with treatment.
What would be your immediate management:
Contact local HIV team for advice regarding switching HIV medications due to treatment failure
Contact local HIV team to review with a view to taking over patient’s care
Start treatment for pneumocystis pneumonia as per local guidelines
Start treatment for community acquired pneumonia as per local guidelines based on CURB 65 score
Send CD4 count and viral load and await results prior to further management decision
Start treatment for community acquired pneumonia as per local guidelines based on CURB 65 score
A 31 year old patient presents in the emergency department at 38 weeks of pregnancy with a two day history of high fever, fainting, and abdominal pain. Examination reveals a temperature of 38C; heart rate of 120 bpm, respiratory rate of 30/minute and blood pressure of 80/60. She has blanching erythema across the abdomen and palms of the hands. She has not travelled recently and was well throughout pregnancy. Her husband is well but their 3 year old has been off nursery recently. Her GP had prescribed amoxicillin yesterday. What is the likely diagnosis? Where might you manage this patient?
Allergic reaction to amoxicillin
Viral exanthem caught from child
Toxic shock syndrome due to Staphylococcus aureus
Toxic shock syndrome due to group A Streptococcus
COVID19 in pregnancy
Cutaneous lesions of Kaposi Sarcoma are usually:
Painful
Pruritic
Found on the upper arms
Not associated with necrosis of the overlying skin or underlying structures
Dark brown in colour
Not associated with necrosis of the overlying skin or underlying structures
Most commonly found on the lower limbs, face (nose), oral mucosa and genitalia. Occur in a range of colours due to their vascularity including pink, red, purple and brown.
A 25 year old female presents to her GP complaining of increased vaginal discharge which is thin and has an unpleasant fishy odour. What is the most likely cause?
Candida albicans
Neisseria gonorrhoeae
Chlamydia trachomatis
Bacterial Vaginosis
Allergic vaginitis
BV
Which of the following is not suggestive of severe malaria?
Low GCS
Hyperglycaemia
Parasitaemia >/= 2%
Hb <80
Pulmonary oedema
Hyperglycaemia
Hypoglycaemia is seen in severe malaria.
Other features include extreme weakness, seizures, AKI, acidosis, presence of schizonts on blood film, jaundice, DIC or spontaneous bleeding, and hypotension
A 32-year old male intravenous drug user is brought into hospital with muscle pains, fatigue and a fever of 38.5. He has no other past medical history. On examination he has a new murmur and a Janeway lesion on his palm. He has grown staphylococcus aureus in one blood culture bottle. He has had a transthoracic ECHO which does not show any abnormality. Given the likely diagnosis which of the following is the most appropriate subsequent diagnostic investigation?
CT PET
Serial troponins
Transoesophageal ECHO
MR coronary angiogram
Percutaneous coronary angiogram
Transoesophageal ECHO
A 51 year old previously fit man presents with a sudden onset of speech loss and history of one week of fever. On examination he has a loud pan systolic heart murmur and a left shoulder lesion. What is the most likely diagnosis?
Embolic stroke with coincidental influenza
Staphylococcus aureus sepsis with endocarditis and embolic phenomena
Septic arthritis
Acute rheumatic fever
The sudden onset of neurological signs on a background of fever should always prompt suspicion of embolic phenomena from endocarditis. The most common cause of endocarditis is now Staphylococcus aureus, which is also the most common cause of septic emboli that suppurate (form pus).
What monitoring is recommended for patients treated with flucloxacillin?
Therapeutic drug levels
FBC
LFT
UEs
No monitoring required
No monitoring required
A 53-year old female presents with a 1 week history of pain around her right eye and forehead associated with eyelid swelling and a vesicular rash (pictured below). She has a background of hypothyroidism but no other known medical conditions.
What is the most likely causative organism?
Varicella Zoster Virus
Herpes simplex virus 2
Cytomegalovirus
Staphylococcus aureus
Streptococcus pyogenes
This is a case of herpes zoster ophthalmicus caused by infection and reactivation of varicella zoster virus within the ophthalmic nerve (the first division of the trigeminal nerve). This virus also causes chickenpox and shingles. When the rash is present on the tip of the nose it is Hutchinson sign positive and this implies involvements of the nasociliary nerve and raises concern for serious ophthalmic complication – uveitis, keratitis and blindness
Extensively-drug resistant tuberculosis is resistant to rifampicin and isoniazid plus:
Any fluoroquinolone
Any fluoroquinolone and at least one of the injectable second-line drugs (e.g. amikacin)
Ethambutol
Ethambutol and pyrazinamide
Ethambutol and any fluoroquinolone
Any fluoroquinolone and at least one of the injectable second-line drugs (e.g. amikacin)
Which of the following is not a risk factor for severe malaria infection:
Older age
Age <5
Immunocompromise
Pregnancy
Living in an endemic area
living in an endemic area
23 year old male soldier presents to the doctor in his barracks. He has a cough, headache and fever. He also reports a rash pictured below
Haemophilus influenzae
Mycobacterium tuberculosis
Mycoplasma pneumoniae
Staphylococcus aureus
Legionella pneumophilia
Mycoplasma pneumoniae
A 19 year old male presents to the GUM clinic with a painful lesion on his penis. What is the most likely cause?
Herpes simplex virus
Syphilis (treponema pallidum)
Lymphogranuloma venereum (chlamydia trachomatis serovars L1-3)
Chancroid (Haemophilus ducreyi)
Granuloma inguinale (klebsiella granulomatis)
HSV
Clavulanic acid is an example of a:
Beta-lactamase inhibitor
Carbapenem
Cephalosporin
Beta-lactamase inducer
Penicillin
b-lactamase inhibitor
Given alongside amoxicillin (aka co-amoxiclav), it overwhelms the beta-lactamase enzymes
Which of the following statements regarding hepatitis B virus is false?
The rate of progression from acute to chronic Hepatitis B virus infection is around 90% for perinatally acquired infection
Passive and active immunisation of the newborn within 12 hours of delivery reduces the risk of mother-to-child transmission by >95%
Around 70% of patients with acute hepatitis B virus infection have subclinical or anicteric hepatitis
IgG hepatitis B core antibody persists in patients who recover from acute hepatitis B
Hepatitis B e antigen is a late antigen that is generally considered to be a marker of previous infection
Hepatitis B e antigen is a late antigen that is generally considered to be a marker of previous infection
Red legs
This 85 year old man originally from Ethiopia has been complaining of severe pain in both legs when walking in the last 3 days. He normally walks with a frame but has recently refused to get out of bed. CRP is 360 but wcc is 6.
What is the likely cause?
Vascular gangrene
Cellulitis
Osteomyelitis
Lymphatic filariasis
Deep vein thrombosis
cellulitis
The clue to this being cellulitis, is that the left leg (the purplish coloured limb) is very warm compared to the right leg. The dried slough on the surface of the leg indicates that there is considerable oedema that has been oozing probably for more than 3 days. However the duration of symptoms is not compatible with a longer standing condition such as osteomyelitis. The most likely organism is Streptococcus pyogenes
A 48 year old gentleman from Malaysia presents with right upper quadrant pain and is found to have deranged LFTs. A non-invasive liver screen is sent. How would you interpret the following results:
Hepatitis A virus IgM screen: Positive
Hepatitis A virus IgG screen: Negative
Susceptible
Vaccinated
Past infection
Acute infection
Chronic infection
Acute infection
Beta-lactams:
Inhibit bacterial protein synthesis
Exhibit anti-cell wall activity
Irreversibly bind to the 30S ribosomal subunits
Irreversibly bind to the 50S ribosomal subunits
Reversibly bind to the 30S ribosomal subunits
Beta-lactams inhibit the synthesis of the peptidoglycan layer in cell walls.
Aminoglycosides and macrolides inhibit bacterial protein synthesis by irreversibly binding to the 30S and 50S ribosomal subunits, respectively
Tetracyclines also prevent bacterial protein synthesis by binding reversibly to the 30S ribosomal subunit
A 55 year old gentleman presents with confusion and agitated behaviour, he is unable to give any history and is not co-operative with neurological examination.
CT Head is normal.
CSF is TB PCR positive and TB Culture grows Mycobacterium tuberculosis
Which of the following CSF results would you expect in this case:
Raised opening pressure, raised WCC with predominantly PMNs, raised protein, low glucose
Raised opening pressure, raised WCC with predominantly lymphocytes, raised protein, low glucose
Normal opening pressure, raised WCC with predominantly lymphocytes, normal protein, normal glucose
Raised opening pressure, raised WCC with predominantly lymphocytes, normal protein, normal glucose
Normal opening pressure, raised WCC with predominantly PMNs, raised protein, low glucose
Raised opening pressure, raised WCC with predominantly lymphocytes, raised protein, low glucose
A 45 year old homeless man with a history of problem drinking and recent imprisonment presented with a 6 week history of weight loss and fever. There was no cough, but a chest x-ray showed widespread nodularity. The patient was unable to produce a sputum sample. What would you do next?
Commence quadruple anti-TB therapy as the diagnosis of miliary TB is clear
Admit him to a sideroom and arrange a bronchoscopy to obtain samples
Admit him to the general ward and arrange for induced sputum samples
Commence community acquired pneumonia antibiotics to see if any response
Arrange a CT chest abdo pelvis to determine extent of disease or malignancy
Arrange for an ELIspot test to rule out TB as a diagnosis
This patient has several risk factors for drug resistant TB and the CXR is typical of miliary TB. Starting TB treatment without obtaining samples is a last resort and should only be done if there is immediate risk to the patient’s life from TB; samples may be the only way to identify drug resistance profile. Even if not actively coughing, miliary TB can be infectious and in the hospital environment, with immunosuppressed patients, it is sensible to manage this patient as though they may have MDR TB, in a negative pressure sideroom with respiratory precautions. An ELIspot test (which is a test of T cell recognition of a specific mTB antigen) is useful to confirm past TB exposure but cannot be used as a rule out tests, since patients with weight loss and frailty may often be unable to mount an interferon gamma response to the ELIspot antigen.
A 28 year old man returned from Thailand 7 days ago where he had been on a beach holiday for 7 days, with some white water rafting, and developed a high fever of 40C 2 days ago with marked myalgia and feels quite unwell. He has blanching erythema on his back that could be sunburn but also more defined lesions on the leg and palate (as shown). CRP is elevated at 64 and ALT is elevated at 97. He has a wcc of 2 and a platelet count of 90. What is the most likely differential diagnosis? Would you give empirical antibiotics?
Dengue fever
Leptospirosis
Meningococcal septicaemia
Enterovirus infection
Rickettsial illness (spotted fever)
Although dengue is the most likely, any of the above diagnoses were possible in this patient. In fact, this man actually had leptospirosis, although confirmation required serological tests for leptospirosis and negative PCR tests for dengue from a reference laboratory. These tests took 5 days to generate results. As life threatening bacterial infection could not be ruled out, it would be reasonable to give this patient an antibiotic active against meningococcal infection whilst awaiting blood culture results; ceftriaxone would also treat leptospirosis.
A 32-year old male intravenous drug user is brought into hospital with muscle pains, fatigue and a fever of 38.5. He has no other past medical history. On examination he has a new murmur and a painless lesion on his hand pictured below. He has grown Staphylococcus aureus in one blood culture bottle. Which of the following minor criteria in Duke’s criteria has not been met?
Fever
Immunological phenomena
Microbiological evidence
Predisposition
Vascular phenomena
Fever
Immunological phenomena
Microbiological evidence
Predisposition
Vascular phenomena
Which of the following statements regarding hepatitis B virus is false?
The rate of progression from acute to chronic Hepatitis B virus infection is 25% for adult acquired infection
In high prevalence areas mother-to-child is the predominant mode of transmission
Transmission from mother-to-child through breastfeeding is common
Fulminant hepatic failure occurs in <1%
During acute infection Hepatitis B core antibody is predominantly of IgM class
The rate of progression from acute to chronic Hepatitis B virus infection is 25% for adult acquired infection
Which of the following is not a recognised adverse effects of aminoglycoside antibioitcs (e.g. amikacin, gentamicin):
Nephrotoxicity
Ototoxicity
Neuromuscular paralysis
Nausea and vomiting
Hyponatraemia
Hyponatraemia
