VSA formative

Question 1

A 71 year old man has a five-day history of confusion, personality change and headache. A diagnosis of encephalitis is made. What is the most common causative organism in encephalitis?

Answer 1

HSV1

Question 2

A 51 year old man has epigastric pain radiating through to his back, and vomiting. He has a history of alcohol excess.  His erect chest X-ray is normal.
Investigations: 
Amylase	814 U/L	(<220)
ALT		98 IU/L	(10–50)
AST		156 IU/L	(10–40)
Bilirubin	28 μmol/L	(<17)

What is the most likely diagnosis?

Answer 2

Alcoholic pancreatitis

Question 3

A 60 year old woman has dyspepsia and a three-month history of weight loss and fatigue. 
Investigations: 
Haemoglobin 			88 g/L	   	(115–165)
Mean Cell Volume (MCV)	72.2 fL  	(80–96)
White Cell Count		7.9 x109/L	(4.0–10.0)
Platelets			189 x109/L	(150–400)
Ferritin				6 μmol 	(12–200)

What is the next most appropriate investigation?

Answer 3

Upper GI endoscopy/OGD

Question 4

A 52 year old woman has malaise and fatigue. She has koilonychia and her cardiorespiratory examination is normal. What is the most likely finding on blood tests?

Answer 4

Iron deficiency anaemia

Koilonychia = spoon shaped nails indicative of iron deficiency

Question 5

A 17 year old man has multiple neurofibromas. He has 8 large brown macules over his torso and axillary freckling. What is the mode of inheritance of this disease?

Answer 5

Autosomal dominant

Question 6

A 25 year old man develops a red eye. He has had two weeks of swelling of his fingers, a painful swollen right ankle and left knee. He has also been experiencing pain on passing urine. He had an episode of diarrhoea 2 weeks ago. He has mouth ulcers and a scaly brown maculopustular rash on the soles of his feet. Urethral swabs and urine culture are negative. What is the most likely diagnosis?

Answer 6

Reactive arthritis/Reither’s syndrome = pathological immune response to an infectious agent. Presents as a triad of urethritis, conjunctivitis + sero-negative arthritis. ‘Can’t see, can’t pee, can’t climb a tree’
Other features: circinate balanitis = erythematous lesions on the penis; keratoderma blenorrhagicum = hard nodules on soles of feet that are clinically/histologically indistinguishable from plantar psoriasis
Causes: GU infection (chlamydia/neisseria gonorrhoeae); GI infection (Salmonella, Shigella, Yersinia, Campylobacter)
Ix: raised ESR, HLA B27

Question 7

A 49 year old man with a 25 year history of ulcerative colitis develops nausea and jaundice. He has no abdominal pain.
Investigations:
ALT 57 IU/L (10–50)
AST 106 IU/L (10–40)
Bilirubin 98 μmol/L (<17)
ALP 43 IU/L (25 –115)
What is the most likely cause of these findings?

Answer 7

Primary sclerosing cholangitis
Remember pANCA conditions are all very commonly associated with each other e.g. UC, RhA, Churg-Strauss syndrome (eosinophillic granulomatosis w/ polyangiitis)

Question 8

A 57 year old man has had fatigue for six weeks. He has no other symptoms. He has chronic kidney disease, hypertension and type 1 diabetes. He is found to have conjunctival pallor but the remainder of his examination is normal.
Investigations:
Haemoglobin 84 g/L (130–175)
White Cell Count 6.9 x109/L (4.0–10.0)
Platelets 229 x109/L (150–400)
Mean Cell Volume (MCV) 85.2 fL (80–96)
Ferritin 100 μmol/L (12–200)
What is the most likely cause of his anaemia?

Answer 8

Low EPO due to chronic kidney disease - EPO is produced by the kidneys

Question 9

An 18 year old university student has a 3 day history of sore throat. She has bilateral grey exudate covering both tonsils. Examining the abdomen reveals splenomegaly. What is the most likely diagnosis?

Answer 9

Infectious mononucleosis - KISSING DISEASE!

University student

Question 10

An 81 year old man with type 2 diabetes is admitted following a fall at home. His renal function was previously normal.
Investigations:
Sodium 142 mmol/L (135–146)
Potassium 5.9 mmol/L (3.4–5.0)
Creatinine 267 µmol/L (50–95)
Urea 19.7 mmol/L (2.5–7.8)
Creatine Kinase 8,000 U/L (<350)
Glucose 14 mmol/L (3–6)

Urinalysis:
Nitrite negative
Leukocytes negative
Blood 2+
Protein negative

What is the most likely cause of his renal failure?

Answer 10

Rhabdomyolysis crush injury myoglobin i.e. trauma causing rhabdomyolysis
Rhabdomyolysis = condition where damaged skeletal muscle breaks down rapidly. Some of the breakdown products e.g. myoglobin are harmful to the kidneys and may lead to kidney failure

Question 11

A 29 year old man has sudden onset occipital headache. He describes it as the worst headache of his life. He is photophobic and nauseated. Full blood count and clotting profile are normal. CT head is normal. What is the next most appropriate investigation?

Answer 11

Spinal tap/LP
SAH is suspected here due to sudden onset (seconds) + thunderclap headache. Ix: CT, LP (xanthochromia may be seen, this is straw-coloured and due to breakdown product of Hb)

Question 12

A 61 year old female has a lower respiratory tract infection. She then develops target-shaped erythematous macules and papules over her arms, legs, chest and back. What is the most likely diagnosis of the rash?

Answer 12

Erythematous multiforme = hypersensitivity reaction usually triggered by infections, most commonly HSV. Presents with a skin eruption commonly characterised by a typical target lesion. It is acute + self-limiting.

Question 13

A 62 year old male has a new diastolic murmur, a fever of 39˚C and splinter haemorrhages on his fingernails. Fundoscopy shows retinal haemorrhages with a white centre. What is the name of clinical sign seen on fundoscopy?

Answer 13

Roth spots

Signs of infective endocarditis: Osler’s nodes, Janeway lesions, splinter haemorrhages

Question 14

A 67 year old man has gradual onset of worsening breathlessness over a year. He has a dry irritating cough. He does not take any medications. He has no fevers, sputum production or haemoptysis. He has a 30 pack-year smoking history. He has finger clubbing and a raised JVP and bi-basal fine late inspiratory crepitations with no wheeze. His spirometry results show a restrictive defect. What is the likely diagnosis?

Answer 14

Interstitial fibrosis

Question 15

A 42 year old woman with pulmonary hypertension has two months of painful fingers which change colour in cold weather and pain on swallowing. She has shiny tight skin over her hands. What is the most likely diagnosis?

Answer 15

CREST syndrome/cutaneous systemic sclerosis = multisystem connective tissue disorder.

Calcinosis
Raynaud's phenomenon
Eosophageal dysmotility
Sclerodactyly = localized thickening + tightness of skin of fingers or toes
Telangiectasia

Question 16

A 55 year old man has weakness of right foot dorsiflexsion and the small muscles of his left hand over the course of 3 months. He has wasting of the small muscles of the left hand and a right foot drop along with wasting of the anterior tibial and peroneal muscles. Fasciculations are seen. Sensory examination and reflexes are normal. Plantars are downgoing. What is the most likely diagnosis?

Answer 16

Motor neurone disease

Question 17

A 60 year old man has a 2 day history of abdominal pain and nausea. He has had rigors and vomiting at home. He is jaundiced and tender in his right upper quadrant. His temperature is 38.3˚C, pulse rate 110 bpm, BP is 110/65, respiratory rate 20 breaths per minute and oxygen saturation 98% in air.
Investigations:
ALT 67 IU/L (10–50)
AST 56 IU/L (10–40)
ALP 381 IU/L (25–115)
Bilirubin 88 μmol/L (<17)
Amylase 45 U/L (<220)
What is the most likely diagnosis?

Answer 17

Infective cholangitis

Question 18

A 65 year old woman has not opened her bowels in three days. She now has nausea and vomiting. An AXR shows fluid levels w/ gas above in a stepladder pattern. What is the most common cause of this presentation?

Answer 18

Adhesions = bands of scar tissue often due to previous abdominal surgery