SBAs and explanations 3 Flashcards
A 53-year-old woman has been suffering from recurrent painful episodes affecting her face – mainly her right cheek. She describes the pain as being extremely intense, sharp and sudden, like an ‘electric shock’. It usually lasts for a few seconds before subsiding. The pain often occurs when she brushes her teeth. What is the most likely diagnosis?
A Giant cell arteritis B Trigeminal neuralgia C Ramsay Hunt syndrome D Shingles E Cluster headache
Trigeminal neuralgia.
A 21-year-old woman visits the GP complaining of a 2-month history of bloating and watery diarrhoea. She adds that she often has to rush to the toilet. During the consultation, she starts furiously itching her elbows. On examination, there is a blistering, papulovesicular rash covering both elbows. What is the most likely diagnosis?
A Inflammatory bowel disease B Coeliac disease C Gastroenteritis D Irritable bowel syndrome E Ischaemic colitis
Coeliac disease.
Which of the following is not a chest X-ray feature of heart failure?
A Kerley B lines B Upper lobe diversion C Cardiomegaly D Pleural effusion E Air bronchograms
Air bronchograms.
A 71-year-old man is referred to the oncology clinic having suffered from hip pain, constipation and abdominal pain for the past few months. He has also noticed that he is having to urinate more frequently than usual, and, consequently, he is always extremely thirsty. A full blood count and U+Es are requested:
Hb = 10.5 g/dL (13-18)
MCV = 106 fl (76-96)
Platelets = 120 x109/L (150-400 x 109)
Creatinine = 125 umol/L (baseline: 72 umol/L (3 months ago))
The oncologist requests a blood film. Considering the most likely diagnosis, what would you expect to see on this patient’s blood film?
A Rouleaux formation B Schistocytes C Granulocytes with absent granulation and hyposegmented nuclei D Dacrocytes E Smear cells
Rouleaux formation.
A 56-year-old woman, of Somalian origin, presents with a 2-month history of haemoptysis. She has also noticed some weight loss during this time and complains that she is having to change her bed sheets more often than usual as they are often drenched with sweat in the morning. Examination reveals painless cervical lymphadenopathy and tender, purple lumps on her shins. A CXR reveals an area of consolidation in the right upper lobe. Which investigation should be performed next in order to establish a diagnosis?
A Bronchoalveolar lavage B Chest CT scan C Sputum sample for acid-fast bacilli D Bronchoscopy and biopsy E Mantoux test
Sputum sample for acid-fast bacilli.
Which type of urinary tract stone is most common?
A Magnesium ammonium phosphate B Calcium oxalate C Cysteine D Urate E Hydroxyapatite
Calcium oxalate.
A 62-year-old man presents with severe, acute epigastric pain with nausea and vomiting. The pain radiates to the back and improves when sitting forward. It started 4 days ago, but the patient assumed it was indigestion and refused to come to hospital. On examination, there is epigastric tenderness and ecchymoses over the periumbilical area and flank. The patient drinks in moderation and has not had any alcohol recently. Serum amylase is 600 U/L (< 140). Which investigation should be performed to confirm the diagnosis?
A ERCP B Abdominal CT scan C Abdominal X-ray D Abdominal ultrasound E MRCP
Abdominal ultrasound.
A 39-year-old carpenter is brought into A&E having fallen from a 3rd floor balcony. He landed on his head and has been unconscious since the incident. An intracranial haemorrhage is suspected and an urgent CT scan is requested. The patient’s vital signs are recorded: BP = 195/120mmHg; HR = 47bpm (60-100). His breathing also appears to be irregular – shallow breaths interspersed with periods of apnoea. What is the name given to this phenomenon?
A Kussmaul sign B Cushing’s reflex C Beck’s triad D Charcot’s triad E Baroreceptor reflex
Cushing’s reflex.
A 46-year-old woman visits A&E complaining of a fever and episodes of shivering. She returned from Nigeria 2 weeks ago and confesses that she was not very compliant with her antimalarial medication. Therefore, malaria is suspected. Which investigation should be performed to diagnose malaria?
A Thick and thin blood films B Blood cultures C Heterophile antibody test D Enzyme-linked Immunosorbent Assay (ELISA) E Urinalysis
Thick and thin blood films.
A patient suffering an acute exacerbation of COPD has become hypoxic with an SaO2 of 83%. He requires administration of oxygen at a tightly regulated concentration. Which of the following methods of administering oxygen would be most appropriate?
A Nasal cannula B Hudson face mask C Venturi mask D Non-rebreathing mask E BiPAP
Venturi mask.
A 48-year-old man has been suffering from frequent urination for the past 5 months. He has been going to the toilet around 10 times per day and he has been drinking excessive volumes of water. He has also been constipated for the past month with vague ‘tummy pains’ and complains of joint pain in his hands. A blood test is requested, which shows:
Na+: 137 mmol/L (135-145) K+: 4.6 mmol/L (3.5-5) Ca2+: 3.0 mmol/L (2.2-2.6) ALP: 197 iU/L (30-150) PTH: 102 ng/L (10-65)
What is the most likely diagnosis?
A Vitamin D Toxicosis B Parathyroid Adenoma C Paget’s Disease D Malignancy E Milk-Alkali Syndrome
Parathyroid adenoma.
A 61-year-old male comes to A+E complaining of chest pain and mentions that he can feel his heart ‘pumping out of his chest’. An ECG shows regular broad complex tachycardia, with no P waves. His blood pressure is 124/87mmHg. How should this patient be treated?
A Defibrillation B DC cardioversion C Amiodarone D Adenosine E Atropine.
Amiodarone.
A 30-year-old man presents to his GP complaining of a swollen scrotum, which he first noticed 3 weeks ago. He adds that the swelling feels like a ‘bag of worms’, and, despite being a little uncomfortable, it is not painful. On examination, the patient’s scrotum looks normal when he is supine, however, the left hemiscrotum becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis?
A Indirect inguinal hernia B Direct inguinal hernia C Hydrocoele D Varicocoele E Epididymal cyst
Varicocoele.
A 74-year-old woman is brought to A+E having suffered several violent bouts of vomiting. On examination, she is clearly distressed and has a massively distended abdomen. When questioned, she struggles to answer but complains of generalised abdominal pain and mentions that she hasn’t passed any faeces or flatus since the pain began. Bowel obstruction is suspected and an AXR is requested. The AXR shows a massively distended loop of large bowel which looks like an embryo. What is the most likely cause of this bowel obstruction?
A Colorectal cancer B Sigmoid volvulus C Caecal volvulus D Adhesions E Femoral hernia
Caecal volvulus.
A 36-year-old female presents to the GP complaining that the nail bed of her ring finger has detached and she is worried that the same is happening to her other finger nails. The GP suspects onycholysis. Which of the following is not associated with onycholysis?
A SLE B Psoriasis C Thyrotoxicosis D Trauma E Fungal infection
SLE.
A 72-year-old man has recently suffered a stroke. He has recovered well and appears to have regained much of his physical strength, however, his speech has changed quite considerably. His daughter says that he will talk the same amount as he always did but his sentences will not make any sense, and he doesn’t seem to notice. When asked to describe what he did this morning, he responds: ‘the bugle fidget and that I played tractor to you before’. Damage to which part of the brain is likely to manifest in this way?
A Wernicke’s area B Broca’s area C Arcuate fasciculus D Hippocampus E Amygdala
Wernicke’s area.
An inpatient on the surgical ward is recovering after having a kidney stone removed. A routine blood test is performed which shows the following results:
Na+ : 135 mmol/L (135 – 145)
K+ : 8.7 mmol/L (3.5 – 6.0)
Ca2+ : 0.2 mmol/L (2.2 – 2.6)
An ECG is performed which shows no obvious abnormalities.
Given the above information, what should be the next step in the management of this patient?
A Urgently draw another blood sample B 10 mL 10% calcium gluconate C 20 mL 20% calcium gluconate D 50 mL 50% dextrose + 10 U insulin E IV salbutamol
Urgently draw another blood sample.
What are the ‘B symptoms’ of lymphoma?
A Fever, Lymphadenopathy, Rigors
B Fever, Night Sweats, Weight Loss
C Recurrent Infections, Anaemia, Easy Bruising
D Night Sweats, Pruritus, Weight Loss
E Lymphadenopathy, Weight Loss, Loss of Appetite
Fever, Night Sweats, Weight Loss.
A 40-year-old teacher has recently heard several distressing comments about how flushed she is looking. On examination, she has very red cheeks and a loud S1 with a mid-diastolic murmur is heard over the apex when the patient is in the left lateral position. What is the most likely diagnosis?
A Mitral stenosis B Mitral regurgitation C Aortic stenosis D Aortic regurgitation E Tricuspid regurgitation
Mitral stenosis.
A 59-year-old female presents with epigastric pain that gets worse a few hours after eating. The patient has taken ibuprofen every day for the past 2 years for her chronic back pain. A urea breath test is negative. What is the most appropriate treatment option for this patient?
A Stop ibuprofen and give omeprazole
B Stop ibuprofen and give ranitidine
C Give amoxicillin, metronidazole and pantoprazole
D Give lifestyle advice and arrange to see the patient in 3 months
E Oral steroids
Stop ibuprofen and give omeprazole.
A 58-year-old woman presents to her GP with a 5-month history of worsening shortness of breath on exertion. She has also lost about 3kg in weight and has experienced a dry cough. She has never smoked before and has a past medical history of rheumatoid arthritis, which was diagnosed 15 years ago. On examination, her fingers are clubbed and fine inspiratory crackles are heard bilaterally across the lower lung zones. What is the most likely diagnosis?
A COPD B Lung cancer C Bronchiectasis D Pulmonary fibrosis E Tuberculosis
Pulmonary fibrosis.
A 38-year-old woman has been experiencing palpitations, sweating and diarrhoea for the past week. Before these symptoms began, she was on sick leave for 3 days with a fever, sore throat and cough. During the consultation, she appears to be very anxious with a slight tremor in her hands. Vital signs: HR = 114, Temp = 38.6°C. A thyroid examination reveals a warm, tender and slightly enlarged thyroid gland. A thyroid uptake scan is requested. What would you expect to see?
A Diffuse uptake throughout an enlarged gland
B No uptake
C Multinodular gland with multiple hot nodules
D Multinodular gland with a single hot nodule
E Diffuse uptake with a single cold nodule
No uptake.
A 24-year-old waitress presents to her GP after noticing a small, firm lump in her left breast. She first noticed the lump 1 week ago and is unsure about whether it has grown. She reports no nipple discharge or skin changes over the breast. Examination reveals a 1x2cm lump in the upper outer quadrant of the left breast with no axillary lymphadenopathy. She is worried because her grandmother died of breast cancer. What is the next most appropriate step in the management of this patient?
A Urgent mammogram B Urgent ultrasound scan C Urgent CT Scan D Arrange elective mastectomy E Arrange elective wide local excision
Urgent ultrasound scan.
A 73-year-old man was watching TV with his family, 2 hours ago, when his speech suddenly became slurred and he lost the ability to grip the remote control. His son, who accompanied him to A&E, noticed that the left half of his father’s face drooped during this episode. His symptoms eventually subsided after around 15 minutes and he claims that he feels back to normal, albeit slightly shaken by his ordeal. What is the first step in his management?
A Administer aspirin B Thrombolysis C CT Head Scan D ECG E Carotid Endarterectomy
Administer aspirin.
A 9-year-old girl is brought to see her GP, by her father, because she has been complaining of pain in her knees and ankles and a tummy ache, which began yesterday. Urinalysis is positive for blood and protein. On examination, small purple spots are seen on her buttocks and her knees feel warm and swollen. Her father adds that, 2 weeks ago, she took time off school because of the flu. What is the most likely diagnosis?
A Post-infectious glomerulonephritis B Immune thrombocytopenic purpura C Disseminated intravascular coagulation D Henoch- Schӧnlein purpura E Minimal change glomerulonephritis
Henoch-Schonlein purpura.
A 64-year-old woman presents with severe left iliac fossa pain with nausea and vomiting. She adds that she has had a few episodes of rectal bleeding recently where the blood has coated the stools. She admits to eating a lot of fast food and having a low-fibre diet. She has not noticed any weight loss. Her left iliac fossa is tender on palpation and blood is found on DRE. What is the most likely diagnosis?
A Gastroenteritis B Diverticulitis C Angiodysplasia D Colorectal carcinoma E Inflammatory bowel disease
Diverticulitis.
Which of the following organisms is responsible for causing whooping cough?
A Bordatella pertussis B Treponema pallidum C Cryptosporidium D Mycoplasma pneumoniae E Yersinia pestis
Bordatella pertussis.
A 59-year-old man is brought to A&E by his daughter after having collapsed at home. He has very little recollection of the incident – one minute he was doing the dishes, and next minute he was lying on his back on the floor. He has no history of recent head trauma and mentions that he felt ‘absolutely fine’ when he regained consciousness. An ECG is performed showing bradycardia (36 bpm) and dissociation between the p waves and QRS complexes. A diagnosis of complete heart block is made. What might be seen on close inspection of his JVP?
A Large V waves B Cannon A waves C Kussmaul sign D Raised JVP with absent pulsation E Slow Y descent
Cannon A waves.
A 36-year-old supermarket manager has been suffering from chronic back pain and stiffness. He first saw his GP about this matter 6 months ago and was given paracetamol, however, the pain worsened and has started affecting his job. He finds restocking the shelves particularly difficult as it requires repetitively bending down and picking up products. He mentions that the pain and stiffness is worst in the morning and gradually gets better with activity. What is the most likely diagnosis?
A Ankylosing spondylitis B Lumbar disc herniation C Osteoarthritis D Muscle strain E Vertebral fracture
Ankylosing spondylitis.
A 69-year-old man is recovering in the inpatient respiratory ward having been diagnosed with pneumonia yesterday. A right-sided pleural effusion is identified on the chest X-ray. Which of the following findings on clinical examination of the right lung base, would be most consistent with a right-sided pleural effusion?
A Resonant percussion note, increased vocal resonance, vesicular breathing
B Resonant percussion note, reduced vocal resonance, reduced breath
sounds
C Dull percussion note, increased vocal resonance, bronchial breathing
D Dull percussion note, decreased vocal resonance, reduced breath sounds
E Dull percussion note, decreased vocal resonance, vesicular breathing
Dull percussion note, decreased vocal resonance, reduced breath sounds.
What is trigeminal neuralgia and how does it present?
An intense neuropathic pain affecting one or more branches of the trigeminal nerve.
Thought to be caused by compression of the trigeminal nerve, exact mechanism not fully understood.
Associated with multiple sclerosis.
Recurrent episodes of sharp, stabbing facial pain which can last seconds to minutes.
Can be triggered by skin contact, brushing your teeth and shaving.
What is Ramsay Hunt syndrome and how does it present?
Ramsay Hunt syndrome is a type of shingles caused by reactivation of varicella zoster in the geniculate ganglion of the facial nerve.
It presents with facial nerve palsy, altered taste, dry eyes/mouth and a vesicular rash in the ear canal.
What are cluster headaches and how do they present?
Cluster headaches are recurrent, severe, unilateral headaches, typically located around one eye that occurs daily (i.e. in clusters) over a period of weeks.
Patients also often experience eye symptoms (e.g. lacrimation, conjunctival injection, eyelid swelling).
What is coeliac disease and how does it present?
Coeliac disease is an inflammatory condition caused by intolerance to gluten, found in grains and starches, such as wheat, rye and barley.
Gluten consumption triggers an immunological reaction in the small bowel, mediated by T cells, which leads to the disruption of the structure and function of the mucosal lining.
This ultimately leads to malabsorption, malnutrition and anaemia (due to iron deficiency).
Commonly experienced symptoms include diarrhoea, steatorrhoea (pale, greasy and offensive smelling stools), weight loss, crampy abdominal pain, bloating, flatulence, urgency and recurrent mouth ulcers.
A blistering, papulovesicular rash covering e.g. elbows is dermatitis herpetiformis, an extra-GI manifestation of coeliac disease.
How is suspected coeliac disease investigated and diagnosed?
The first-line investigation is serology to look for tissue transglutaminase antibodies, anti-endomysial antibodies and anti-gliadin antibodies, all of which will be elevated in coeliac disease.
A definitive diagnosis is established based on the findings of OGD and duodenal biopsy.
The classic histological appearance of bowel affected by coeliac disease is the presence of ‘subtotal villous atrophy with crypt hyperplasia’.
What are the chest x-ray findings of heart failure?
Alveolar oedema. Kerley B lines. Cardiomegaly. upper lobe Diversion. pleural Effusion. (ABCDE).
What are air bronchograms on CXR?
Air bronchograms refer to the appearance of bronchi (which are radiolucent) that are made visible when something other than air is filling the surrounding alveoli - such as pus in pneumonia, fluid in pulmonary oedema and fibrosed tissue in interstitial lung disease.
What is multiple myeloma and what are its clinical features?
Haematological malignancy characterised by an excessive proliferation of plasma cells.
It causes bone lesions (and hence, hypercalcaemia) and the production of monoclonal immunoglobulins.
hyperCalcaemia.
Renal failure.
Anaemia.
Bone pain.
(CRAB).
What is seen on the blood film of a patient with multiple myeloma?
Rouleaux are stacks of red cells seen on a blood film, which form due to the high concentration of plasma proteins (e.g. immunoglobulins) and give rise to high ESR.
What are schistocytes indicative of on a blood film?
Intravascular haemolysis.
What are granulocytes with absent granulation and hyposegmented nuclei indicative of on a blood film?
Myelodysplastic syndrome.
What are dacrocytes indicative of on a blood film?
Teardrop-shaped cells seen in myelofibrosis.
