Signs and Symptoms I

Question 1

Patient presents with hypertension, tachycardia and headache. What is a possible diagnosis?

Answer 1

Phaeochromocytoma

Question 2

Which blood test result is needed during the investigation of a chest pain that could be suggestive of MI?
When should this be taken?

Answer 2

Troponin T levels.

Taken 6 - 12 hours after pain onset.

Question 3

Describe the signs for each grading of hypertensive retinopathy?

Answer 3

I - Tortuous arteries with thick shiny walls
II - AV nipping: narrowing where arteries cross veins
III - Flame haemorrhages and cotton wool spots
IV - Papilloedema

Question 4

A 27 year old man presents to A&E. He is clearly uncomfortable and he gestures to his chest as if to suggest pain. He has a history of imprisonment for the supply for opiates. On examination, he is visibly sweaty. He has some painful nodules on his hands. There are no dark streaks beneath the fingernails. Examination of the retina is completely unremarkable. He has some bruising and track marks in his antecubital fossa. His blood pressure is 100/70 and his heart rate is 120 bpm. His respiratory rate is 25/minute and his oxygen saturations are 96% on room air. He is currently slightly confused but manages to suggest that he passed some blood in his urine when he last visited the toilet. His tympanic temperature is 38.3 degrees Celsius. His ECG shows the presence of normal P waves and narrow QRS complexes. T waves are present and uninverted. There is unconvincing evidence of ST depression or elevation in any contiguous leads. Initial blood tests show the following: Hb: 130 g/L White Cells: 24 x109 /L Platelets: 400 x109/L CRP: >5 ESR: within normal limits What is the most likely diagnosis?

A) Granulomatosis with polyangiitis
B) Hand Foot and Mouth disease
C) Infective Endocarditis
D) MI
E) Secondary Syphilis

Answer 4

C.
The patient is most likely to have infective endocarditis(IE). The picture of fever, shock and painful palmar nodes (Osler’s nodes) suggest this. IE has systemic manifestations including an, through the immune complex deposition and induction of a glomerulonephritis, can cause haematuria. Other manifestations of IE include septic emboli (can be cerebral or pulmonary). Though the patient is sweaty and nauseous, a myocardial infarction is unlikely in a patient of this age, especially with what is essentially a normal ECG (note that the patient is only tachycardic). You can develop a maculopapular rash with syphilis but there is no real hint at a mechanism for contracting syphilis in the case above. Granulomatosis with polyangiitis(GPA) is a small vessel vasculitis which can cause haematuria, as well as nasal bleeding/crusting, the latter features not being present. Furthermore, a normal ESR is unlikely to support this diagnosis. Hand foot and mouth disease can also create a maculopapular/vesicular rash on the hands, but there is no evidence of foot or mouth involvement.