SBAs and explanations 5 Flashcards
Which of the following is a feature of limited cutaneous systemic sclerosis?
A Calcinosis B Cyanosis C Striae D Onycholysis E Clubbing
Calcinosis.
A 32-year-old basketball player is brought to A+E extremely breathless. He was at basketball training when he suddenly felt himself getting more and more breathless and developed a ‘stabbing’ pain on the right side of his chest. He has never experienced anything like this before. On examination, he is very tall and thin, and breath sounds are reduced over the right side of his chest. What is the most likely diagnosis?
A PE B Primary pneumothorax C Secondary pneumothorax D Myocardial infarction E Asthma attack
Primary pneumothorax.
A 22-year-old student presents with a severe headache and fever that has lasted 1 day. On examination, he has a stiff neck and a rash across his arms and legs. The junior doctor gently flexes the patient’s neck. As he does this, the patient’s hips flex. What is the name of this sign?
A Uhthoff’s sign
B Lhermitte’s sign C Kernig’s sign
D Brudzinski’s sign
E Tinel’s sign
Brudzinski’s sign.
A 61-year-old woman visits the GP complaining of 13 kg of weight loss over the past 6 months. On direct questioning, she admits that her faeces are lighter in colour than normal and her urine has become darker. She is jaundiced and a large non- tender mass is palpated in her right upper quadrant. What is the most likely diagnosis?
A Gallstones B Hepatocellular carcinoma C Pancreatic cancer D Bile duct stricture E Cirrhosis
Pancreatic cancer.
A 46-year-old man has been admitted to A&E after experiencing palpitations, which began about 4 hours ago. An ECG is performed, which reveals atrial fibrillation. He has no previous history of ischaemic heart disease. He refuses DC cardioversion. What is the next most appropriate treatment option?
A Defibrillation B Low molecular weight heparin C Warfarin D Flecainide E Digoxin
Flecainide.
A 4-year-old boy is referred to the paediatric department by his GP after a 3-week history of fatigue, shortness of breath and recurrent chest infections. A thorough examination is performed, which revealed extensive bruising across the child’s body, hepatosplenomegaly and cervical lymphadenopathy. Based on the information provided, what is the most likely diagnosis?
A Acute lymphoblastic leukaemia B Acute myeloid leukaemia C Chronic lymphocytic leukaemia D Chronic lymphoblastic leukaemia E Hodgkin’s lymphoma
Acute lymphoblastic leukaemia.
A 79-year-old woman is accompanied by her granddaughter to A+E. She has had a productive cough and a fever for the past 4 days. On examination, she has an AMTS of 5/10, respiratory rate of 31/min and blood pressure of 92/66 mm Hg. Her urea is 3 mmol/L (2.5-6.7). A CXR reveals an area of consolidation in the right middle lobe. Community-acquired pneumonia is suspected. What is her CURB-65 score?
A There is not enough information to tell. B 2
C 3
D 4
E 5
3.
A 28-year-old man has experienced several episodes of sweating, palpitations and anxiety over the past 6 months. He has a past medical history of thyroid cancer (aged 19) which was treated with total thyroidectomy. What is the most appropriate investigation?
A Serum 17-hydroxyprogesterone levels
B 24 hr urine 5-hydroxyindoleacetic acid levels
C 24 hr urine vanillylmendelic acid
D Plasma adrenaline concentration
E Thyroid uptake scan
24hr urine vanillylmendelic acid.
Which of the following triads best describes Horner’s syndrome?
A Ptosis, miosis, anhydrosis B Proptosis, miosis, hyperhidrosis C Ptosis, mydriasis, anhydrosis D Ptosis, enophthalmos, hyperhidrosis E Proptosis, miosis, anhydrosis
Ptosis, miosis, anhydrosis.
Which virus is implicated in around 50% of cases of Hodgkin’s lymphoma?
A Human cytomegalovirus B Herpes simplex virus 2 C Varicella zoster D Epstein-Barr virus E Human herpes virus 7.
Epstein Barr virus.
A 54-year-old man is complaining of abdominal heaviness and shortness of breath. On examination, his abdomen is distended, non-tender and exhibits shifting dullness with a fluid thrill. The junior doctor suspects ascites and requests a diagnostic paracentesis. It reveals a Serum-Ascites Albumin Gradient (SAAG) of 9 g/L. Which of the following is a potential cause of his ascites?
A Cirrhosis B Congestive cardiac failure C Portal hypertension D Budd-Chiari syndrome E Nephrotic syndrome
Nephrotic syndrome.
A 56-year-old man has been waking up several times at night to empty his bladder. He says he doesn’t feel completely empty after finishing and his stream seems to be quite ‘stop and start’. He often has to strain to maintain the flow. Which of his symptoms is considered irritative?
A Incomplete emptying B Having to start and stop C Increased urination at night D Straining E Weak flow
Increased urination at night.
An 8-year-old boy is brought to the GP by his mother. He has a very swollen and painful knee which arose yesterday without any preceding trauma. On closer inspection, he is afebrile and the joint, despite being swollen, does not appear inflamed. He also has several bruises across his torso. His mother mentions that her father suffered from haemophilia and that she is worried that her son may have the same disease. Blood tests are requested. Which of the following results would be suggestive of a diagnosis of haemophilia?
A High APTT, Normal PT B Normal APTT, High PT C High APTT, High PT D Low bleeding time E Low vWF
High APTT, normal PT.
An 82-year-old man is brought into A&E complaining of severe flank pain that started suddenly about 30 minutes ago. On examination, he looks very unwell and his palms are cold and sweaty. Vital Signs: HR = 132 bpm; BP = 84/52 mm Hg. What is your top differential?
A Myocardial infarction B Ruptured abdominal aortic aneurysm C Ureteric colic D Disc prolapse E Muscle sprain
Ruptured AAA.
A 31-year-old lady, who is 7 months pregnant, is brought to A&E having become extremely short of breath this morning. She has also experienced sharp chest pain on her right side. Examination reveals no abnormalities and an ECG shows sinus tachycardia. A pulmonary embolism is suspected. What is the most appropriate investigation to request?
A D-Dimer B CTPA C VQ scan D Chest X-ray E Doppler ultrasound of the lower limbs
VQ scan.
A 76-year-old woman is brought to A+E by her daughter. She is complaining of severe left iliac fossa pain accompanied by nausea, vomiting and fever. On inspection, she shows signs of peritonism. Vital signs: HR = 123 bpm, RR = 24 bpm, Temp = 38.7°C and BP = 87/54 mm Hg. An erect CXR is requested, which shows air under the diaphragm. A diagnosis of perforated diverticulitis localised to the sigmoid colon is made. What is the most appropriate surgical procedure?
A Left colectomy B Abdominoperineal resection C Hartmann’s procedure D Delorme procedure E Anterior resection
Hartmann’s procedure.
Which of the following tumour markers is associated with ovarian cancer?
A CA 15-3 B CA 19-9 C CA125 D CEA E aFP
CA125.
A 61-year-old man visits his GP complaining of a ‘shooting pain’ in his legs. The pain comes on when he walks his dog, and it gets particularly bad when walking downhill. On questioning, he reveals that he has been urinating about 10 times every day, which is much more than usual. On examination, there is a loss of sensation up to the T10 vertebral level, increased tone in his legs and brisk ankle jerks. The GP also notices that the patient has a stooped posture. What is the most likely diagnosis?
A Benign prostate hypertrophy B Motor neuron disease C Sciatica D Spinal cord stenosis E Cauda equina syndrome
Spinal cord stenosis.
An 11-year-old girl, who has recently moved to the UK from Cambodia, is referred to the cardiology department after her GP identified a heart murmur a few weeks after diagnosing her with a throat infection. She has also experienced intermittent joint pain, mainly affecting her knees and hips. On examination, she has a mid-diastolic murmur heard loudest over the mitral area and a few small, mobile nodules are palpated along the ulnar border of her forearms. What is the most likely diagnosis?
A Infective endocarditis B Rheumatic fever C Septic arthritis D Rheumatoid arthritis E Lyme disease
Rheumatic fever.
A 12-year-old boy is brought into A&E – he is extremely drowsy, appears dehydrated and has vomited whilst in the ambulance. He is also clutching his abdomen and appears to be in considerable pain. He is a known diabetic, and DKA is suspected. The patient begins breathing in a very deep and laboured manner. What is the name given to this pattern of breathing?
A Cheyne-Stokes breathing B Hypoventilation C Kussmaul breathing D Biot’s respiration E Apnoea
Kussmaul breathing.
A 21-year-old man has been experiencing some scrotal discomfort over the past month, which he describes as feeling ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with orchidopexy. A diagnosis of testicular cancer is suspected. The registrar recommends performing a CT scan to assess for spread. Which group of lymph nodes does testicular cancer spread to?
A Inguinal B Femoral C Para-aortic D Iliac E Mesenteric
Para-aortic.
Which of the following matches the criteria for type 2 respiratory failure?
A PaO2 < 10.5 kPa, PaCO2 > 6 kPa B PaO2 <8kPa,PaCO2 >6kPa C PaO2 < 10.5 kPa, PaCO2 > 8 kPa D SaO2 < 90%, PaCO2 < 8 kPa E SaO2 <90%,PaO2 <8kPa
PaO2 <8kPa, PaCO2 >6kPa.
A 26-year-old model comes to see her GP after having noticed some blood streaked on the paper after emptying her bowels. This started two weeks ago. She adds that defecation is very painful. When asked about her diet, she reveals that she often eats ready meals and drinks relatively little water because her job involves regular travelling making it difficult for her to maintain a healthy diet. What is the most likely diagnosis?
A Haemorrhoids B Anal fissure C Anal fistula D Colorectal cancer E Ulcerative colitis
Anal fissure.
A 71-year-old man presents with an 8-month history of worsening shortness of breath on exertion, orthopnoea and a cough productive of pink, frothy sputum. He has a past medical history of ischaemic heart disease and type 2 diabetes mellitus. Heart failure is suspected. What is the best investigation to confirm a diagnosis of heart failure?
A ECG B Brain natriuretic peptide C Atrial natriuretic peptide D Echocardiogram E Chest X-ray
Echocardiogram.
An inpatient on the respiratory ward is currently undergoing treatment for a pneumonia that he developed 2 days ago. A blood test is performed which shows a low white cell count, with a particularly low neutrophil count. The patient is re- examined and found to have a considerably enlarged spleen. On further questioning, He has suffered from 3 infections in the past 5 months and complains that his rheumatoid arthritis has been getting worse.
What is the most likely diagnosis?
A Malaria B Tuberculosis C Felty’s syndrome D Lymphoma E Chronic lymphocytic leukaemia
Felty’s syndrome.
Which stain is used when testing for TB?
A Giemsa B Gram C India Ink D Sudan Black E Ziehl-Neelsen
Ziehl-Neelson.
A 60-year-old man, with a history of hypertension and type 1 diabetes mellitus, is brought to A+E by his daughter. She says that 3 hours ago, when they were eating dinner, he suddenly dropped his fork and started slurring his words. On examination, the right side of his face is drooping, muscle power is 1/5 in the right arm and 5/5 in the left; 3/5 in the right leg and 5/5 in the left. What is the most appropriate management option?
A CT head to exclude bleed, then treatment dose of warfarin
B CT head to exclude bleed, then give antiplatelets and perform a swallow
assessment
C CT head to exclude bleed, then IV thrombolysis
D Control blood pressure and IV mannitol
E Craniotomy and evacuation
CT head to exclude bleed, then treatment dose of warfarin.
A 42-year-old wildlife photographer returns from a 6-month trip to South Africa. He has noticed a small, dark mole on his right calf, which, he claims, has not always been there. Examination reveals an asymmetrical, dark lesion with irregular borders that measures 1 cm in diameter. Malignant melanoma is suspected and an excisional biopsy is taken and sent to the pathologist. Which feature of the histological analysis is the most useful prognostic indicator in this situation?
A Number of mitoses B Surface area of lesion C Depth of lesion D Mass of lesion E Lymphocyte infiltration
Depth of lesion.
An 85-year-old man is brought to A&E having been found on a roundabout in the middle of the night. He is very confused with an AMTS of 4/10. U&Es are requested, which reveal hyponatraemia (Na+ : 118 mmol/L (135-145)). Care is taken to increase the sodium concentration slowly. What is a major consequence of raising plasma sodium concentration too rapidly?
A Stroke B Rhabdomyolysis C Central pontine myelinolysis D AKI E Cerebral oedema
Central pontine myelinolysis.
Which of the following antibodies is most sensitive for primary sclerosing cholangitis?
A AMA B ASLA C ALKM-1 D pANCA E ANA
pANCA.
What is systemic sclerosis (scleroderma)?
Rare disease characterised by small blood vessel damage and fibrosis in the skin and organs.
2 types differentiated based on pattern of skin involvement.
Limited: face and limbs distal to knees and elbows.
Diffuse: entire body.
Limited cutaneous systemic sclerosis (CREST): Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly and Telangiectasia.
What is Brudzinski’s sign?
Passive flexion of the neck causes the patient to involuntarily flex their hip, indicative of meningeal irritation.
What is Kernig’s sign?
Patient lying supine with hip flexed and knee flexed at 90 degrees to hip joint, positive if passive extension of the knee causes pain, indicative of meningeal irritation.
What is Uhthoff’s sign?
Worsening of neurological symptoms when the body is overheated, e.g. after a warm shower.
Associated with MS.
What is Lhermitte’s sign?
Flexion of the neck causes a shooting pain running down the spine.
‘Barber seat sign’.
Associated with MS.
What is Tinel’s sign?
Tapping the wrist at the point at which the median nerve runs under the flexor retinaculum causes pain and a tingling sensation in the area of the hand supplied by the median nerve.
Carpal tunnel syndrome.
What is Courvoisier’s law?
A palpably enlarged and non-tender gallbladder in the presence of painless jaundice is unlikely to be caused by gallstones – therefore, it is likely to be due to cancer (pancreatic).
What is the management plan for patients with AF?
Haemodynamically unstable = DC cardioversion.
Stable patients <48hrs of onset may be offered DC cardioversion or chemical cardioversion with flecainide or amiodarone.
Flecainide is contraindicated in patients with a history of ischaemic heart disease.
Stable patients >48hrs since onset should be anticoagulated, using LMWH followed by warfarin, for >3 weeks before elective cardioversion.
Earlier cardioversion is possible if a transoesophageal echocardiogram shows that there are no clots within the atria.
The long-term management of AF involves rate control and anticoagulation.
Verapamil and bisoprolol are 1st line for rate control.
Digoxin may be used in some cases.
Anticoagulation is achieved with warfarin, aiming for an INR of 2-3.
Patients presenting for the first time with AF will be risk stratified using the CHA2DS2-Vasc score, to determine whether they need long-term anticoagulation.
Patients with paroxysmal AF will also have a ‘pill in the pocket’ - sotalol or flecainide PRN.
What is acute lymphoblastic leukaemia (ALL) and how does it present?
Acute lymphoblastic leukaemia (ALL) is a bone marrow malignancy characterised by the proliferation of lymphoblasts.
It is the most common malignancy of childhood.
It
leads to bone marrow failure (resulting in anaemia, thrombocytopaenia and leukopaenia), which manifests as fatigue, dyspnoea, easy bruising and opportunistic infections.
ALL also causes organ infiltration leading to lymphadenopathy, hepatosplenomegaly, and, sometimes, testicular swelling.
A blood film will show a high number of circulating lymphoblasts.
A bone marrow aspirate or biopsy will reveal a hypercellular marrow with >20% of the cells being lymphoblasts.
What is the CURB-65 score?
Clinical tool used to predict mortality in community-acquired pneumonia, helps to determine the need for hospital admission.
CURB-65 scores range from 0 to 5, based on the following criteria, each worth 1 point:
- Confusion (AMTS <8).
- Urea >7mmol/L.
- Respiratory rate >30/min.
- Blood pressure: systolic <90mmHg or diastolic <60mmHg.
- Age >65.
A score of 0 or 1 is associated with a very low mortality within 30 days and patients can be managed in the community.
A score of 2 has a slightly higher mortality and patients should be admitted for observation and treatment as inpatients.
A score of 3 or more indicates severe pneumonia with a relatively high mortality. These patients should be considered for ICU admission.
