VSA Formative Questions 2017 Flashcards

1
Q

A 31 year old man has epigastric pain for 2 months, worsened by eating. His stool antigen test is positive.

Investigations:
Haemoglobin			147 g/L	(130–175)
White Cell Count		7.2 x109/L	(4.0–10.0)
Platelets			349 x109/L	(150–400)
Mean Cell Volume (MCV)	86.0 fL  	(80–96)

What is the most likely diagnosis?

A

Peptic ulcer

Peptic ulcers are associated with Helicobacter pylori infection and chronic NSAID use.

This could also potentially be a duodenal ulcer, though it is more likely that a duodenal ulcer would present with pain in the hours after a meal, rather than when eating.

It’s diagnosed with breath tests, stool tests, and/ or gastroscopy.

Treatment is with co-amoxiclav (amoxycillin and clavulanic acid - a beta lactamase inhibitor), clarithromycin, and a PPI (lansaprazole, omeprazole)

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2
Q

An 18 year old man has severe left sided pain in the scrotum, radiating to the abdomen.
The right testis appears normal but the left side is swollen and tender and is lying high in the scrotum.

What is the most likely diagnosis?

A

Left testicular torsion

This occurs when a testicle rotates, twisting the spermatic cord which carries its blood supply. The resulting pain is sudden and severe, and often accompanied by nausea and vomiting. The affected testicle may also be higher than normal.

If not treated quickly, the testicle may become necrotic and may have to be removed.

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3
Q

A 25 year old female has painful left lower limb swelling. She is 26 weeks pregnant. Distal pulses are intact and she has no other symptoms.
Investigations:
White Cell Count 10.2 x109/L (4.0–10.0)
C Reactive Protein (CRP) 8 mg/L (<5)

What is the most appropriate initial investigation?

A

Duplex ultrasound of the left leg

The history is suggestive of a DVT, which is best visualised using a Duplex scan (a type of doppler scan allowing simultaneous visualisation of anatomy and blood flow).

It is easy, in this question, to jump the gun and start thinking of investigations for a PE, but the mother is showing no symptoms of a PE.

That said, if the mother were showing PE symptoms (breathlessness, haemoptysis, pleuritic chest pain), the first investigation would normally be a CT scan, however the use of CT contrast is contraindicated in pregnancy so a V/Q scan would be used instead

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4
Q

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?

A

Herpes simplex (type I)

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5
Q

A 68 year old woman has a four week history of right-sided headache which is worse when she combs her hair. She also reports pain on chewing.
What is the next most appropriate investigation?

A

ESR

A history of scalp tenderness and jaw claudication points to temporal arteritis (especially with dimished temporal pulse).
ESR is not a particularly common investigation, and I think CRP is an equally acceptable answer, but ESR is what Amir Sam said

It is worth noting that in realty you would give high dose prednisolone immediately and then order a temporal artery biopsy if you has a strong suspicion of temporal arteritis: this is neauseous inflammation in the ophthalmic artery can lead to sight loss

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6
Q

A 24 year old woman has had two months of unilateral frontal pulsating headaches lasting 12-18 hours, occurring weekly. They are associated with nausea and relieved by over the counter ibuprofen and sleeping. Fundoscopy is normal.
She is otherwise fit and well.

What is the most likely cause of her headaches?

A

Migraine (without aura).

Migraines are typically unilateral and frontal, and will often last the rest of the day, requiring the patient to lie down somewhere dark. Treatment is analgesia with over the counter medication.

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7
Q

A 45 year old woman with rheumatoid arthritis has weakness in her arms, worse in the evening. She has trouble keeping her eyes open when reading long reports. She has a bilateral ptosis which develops after staring upwards for some time.

What is the most likely diagnosis?

A

Myasthenia gravis

Myasthenia gravis is an autoimmune condition that attacks post-synaptic ACh receptors at the neuromuscular junction.

The presence of rheumatoid arthritis increases the risk of other autoimmune conditions.

Muscle weakness in myasthenia gravis is typically in the muscles of the face, eyes, and throat, and becomes more pronounced with exertion. This is in contrast to the paraneoplastic syndrome - Lambert-Eaton syndrome - where the muscle weakness diminishes with exertion

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8
Q
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?
A

Pancreatitis

The high amylase indicates pancreatitis, along with the description of the pain (radiating to the back and worse lying back/ better leaning forward). Remember: amylase is an indicator of acute pancreatitis, but faecal elastase is the indicator for chronic pancreatitis.

Judging from the history and LFTs, the man also has alcoholic liver damage, as suggested by the AST and ALT. When reading LFTs there are two main ‘patterns to be aware of:

Hepatocellular pattern: Indicates damage to the cells of the liver and is determined by ALT, and AST:
If ALT and AST are equally elevated, this implies ischaemic damage e.g. because of congestive cardiac failure
If AST is more elevated, this implies alcoholic hepatitis
If ALT is more elevated, this implies hepatocellular damage e.g. toxic hepatitis, viral hepatitis, hepatic necrosis

Cholestatic pattern: Associated with obstruction of the bile duct or malignant hepatic infiltration
ALP is sensitive for biliary obstruction
GGT is sensitive to biliary/ hepatic obstruction and to alcoholic damage

Other:
AST can be used to judge how severe liver necrosis is
ALT is the most specific marker for liver damage but cannot be used to judge the extent of necrosis

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9
Q
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?
A

OGD

GI symptoms are generally simple to investigate:

If it’s in the stomach or above - gastroscopy

If it’s a problem with the liver/ gallbladder - ultrasound

If it’s in the colon - colonoscopy

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10
Q

A 21 year old student has two weeks of visual disturbance. She describes blurring of her vision which is worse after having a hot shower. She has no history of visual problems and is usually fit and well.
Eight months ago she had a three week episode of numbness in her right leg, which resolved spontaneously.
What is the most likely underlying diagnosis?

A

Multiple sclerosis

A young woman with two episodes of neurological dysfunction separated in space and time indicates MS. MS most commonly causes optic neuritis (visual changes), fatigue, and limb weakness or numbness. These changes are stereotypically triggered by hot showers/ baths.

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11
Q

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?

A

A microcytic anaemia (iron deficient)

Malaise and fatigue are very generic features of anaemia, but kolionychia is more specific and indicates iron-deficient anaemia.

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12
Q
An 18 year old man has had abdominal pain and vomiting for two days. He is usually fit and well.
An ABG is performed showing the following:
pH: 7.23 (7.35–7.45)
pO2: 12.5 kPa (10–14)
pCO2: 3.5 kPa (4.5–6.0)
HCO3: 11 mmol/L (22–26)
Lactate: 1.0 mmol/L (1–2)
Potassium: 5.5 mmol/L (3.5–5.0)
Glucose: 22 mmol/L (<6)

What test should be performed next to reach a diagnosis?

A

Urine dipstick ketones

The ABG shows a partially compensated metabolic acidosis with very high glucose. This points to diabetic ketoacidosis.

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13
Q
A 60 year old man has constipation, backache and abdominal pain. He has a four week history of urinary frequency, malaise and 6 kg weight loss.
Investigations:
Calcium 3.2 mmol/L (2.1–2.60)
Phosphate 0.8 mmol/L (0.8–1.5)
ALP 43 IU/L (25 –115)
Creatinine 397 µmol/L (50–95)
Urea 17.7 mmol/L (2.5–7.8)
PTH 0.5 pmol/L (0.9–5.4)
What condition is most likely causing this patients hypercalcaemia?
A

Multiple myeloma

The acronym to remember the presentation of multiple myeloma is CRAB.

Calcium - Bone lesions release calcium into the blood, resulting in high calcium. This suppresses PTH production.
Renal - Proteins secreted by malignant cells damage the kidneys, causing them to fail. Urine output may drop and the patient may experience nausea associated with uraemia
Anaemia - as the bone marrow is infiltrated by malignant cells, it is less able to produce RBCs resulting in a normocytic anaemia
Bone pain - Bone pain is the most common symptom of myeloma. Bone damage from malignant cells may lead to fractures and even spinal cord compression

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14
Q
A 58 year old woman with a 24 year history of rheumatoid arthritis develops peripheral oedema.
Investigations:
HbA1c 40 mmol/mol (20–42)
Echocardiogram: Normal systolic function
Urinalysis:
Nitrite negative
Leukocytes negative
Blood negative
Protein 3+

What is the most likely cause of her peripheral oedema?

A

Amyloidosis affecting the kidneys causing nephrotic syndrome

Nephrotic syndrome is defined as a triad of low albumin, peripheral oedema, and proteinuria

Whenever oedema is present, the cause is usually either cancer, low albumin, or heart failure. The echo has ruled out heart failure, and there is nothing to suggest cancer in the history or tests.

Think of low albumin systematically: protein intake, manufacture in the liver, loss into the urine through faulty kidneys

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15
Q

A previously fit 67 year old woman has a two-hour history of sudden onset left-sided arm weakness and slurring of speech. Her capillary blood glucose, full blood count and clotting are normal.

What is the next most important investigation to perform prior to administering thrombolysis?

A

CT head

To check for haemorrhagic stroke, as giving thrombolysis to a patient who is haemorrhaging will probably be fatal.

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16
Q

A 40 year old woman on prednisolone for rheumatoid arthritis has a wrist fracture after minimal trauma. She requires screening for osteoporosis as part of her work-up for this.

What is the best method of investigating for osteoporosis?

A

DEXA scan (bone density assessment)

A DEXA scan is part of routine management of osteoporosis, and generates a score which is intepreted as being a certain number of standard deviations from the mean:
0 to -1 is normal
-1 to -2.5 indicates osteopenia
below -2.5 indicates osteoporosis

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17
Q

A 70 year old man has a 2 day history of severe epigastric pain. He has no history of alcohol intake. He is diagnosed with acute pancreatitis.

What is the most likely underlying cause of his pancreatitis?

A

Gallstone causing obstruction

Along with alcohol, gallstones are the most common cause of pancreatitis.

Remember the acronym for the causes of pancreatitis:
G - Gallstones
E - Ethanol
T - Trauma
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion sting
H - Hyperlipidaemia
E - Endoscopic retrograde cholangio-pancreatography
D - Drugs
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18
Q

A 26 year old man develops an itchy vesicular rash on the extensor surfaces of his elbows and knees. He has a diagnosis of coeliac disease but is otherwise fit and well.

What is the most likely diagnosis of the rash?

A

Dermatitis herpetiformis

Dermaitis herpetiformis has a slightly confusing name, but is only named that because it looks a bit like herpes - they are unrelated. Dermatitis herpetiformis is a very specific vesicular rash with watery fluid that occurs in people with coeliac disease.

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19
Q

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?

A

Autosomal dominant

Neurofibromatosis is a hereditary disease characterised by tumour growth in the nervous system
Neurofibromatosis is divided into three types: type I, type II, and Schwannomatosis. Type I and II are the important types to know.

Type I - café au lait spots (brown macules), Lisch nodules (brown-red spots in the eye)
Type II

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20
Q

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?

A

Reactive arthritis

Associated with HLA B27

Seronegative

Remember the triad of symptoms the GOT way:
Arya - can’t see (conjunctivitis)
Reek - can’t pee (urethritis)
Jon - can’t bend the knee (asymmetrical oligoarthritis)

Previously called Reiter’s syndrome, reactive arthritis is preceded by genito-urinary infection (e.g. with chlamydia, shigella, or salmonella)

Features: Dacytilitis, balanitis circinata (penis annular dermatitis), keratoderma blenorrhagicum (rashes on plantar and palmar surfaces), enthesitis
Arthritis is usually only a few joints and commonly affect the knee and sacroiliac joint

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21
Q

An 85 year old woman has 2 days of dysuria and frequency.
Urinalysis:
Nitrite 2+
Leukocytes 2+
Blood negative
Protein negative
Her urine is sent for culture and she is started on trimethoprim for suspected urinary tract infection (UTI).

What is the most common causative organism?

A

E. coli

You might also suspect chlamydia or gonorrhea in a younger patient.

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22
Q
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?

A

Primary sclerosing cholangitis

Though this involves scarring to the bile ducts, the liver is involved and can be damaged, leading to the hepatocellular pattern on the LFTs.

Heavily associated with IBD, around 75% PSC patients also have IBD, particularly UC

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23
Q
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?

A

Decreased EPO production

The two most common causes of kidney failure in the UK are diabetes and hypertension, in that order. Kidney failure has a wide range of effects because the kidneys have a wide range of functions, all of which can be affected:
Acid-base balance: The kidneys produces bicarbonate which helps to maintain the blood’s pH. Without it, the blood may become acidic.

Fluid balance: Water is excreted through the kidneys to maintain an appropriate fluid balance, hence jidney failure patients are vulnerable to fluid overload and oedema in the lungs and peripheries

Electrolyte balance: Deranged electrolytes are often seen in kidney failure, particularly hyperkalaemia. This is treated immediately with 10ml 10% calcium gluconate to protect the heart against arrhythmia, and then with glucose and insulin, as the insulin acts to move potassium into cells and out of the blood stream.

Waste filtering: Urea is filtered out by the kidneys, so failure causes urea to accumulate in the blood causing uraemia, which leads to nausea and encephalopathy

Hormonal action: The kidneys produce EPO which drives RBC production, hence kidney failure can be accompanied by anaemia. The kidneys also have a role in vitamin D deficiency

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24
Q

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?

A

Epstein-Barr virus causing infectious mononucleosis

Epstein-Barr virus (human herpes virus 4) usually infects infants and goes unnoticed. 95% of the world’s population has already developed an immunity, and once infected the virus persists in B-lymphocytes permanently.

Infection with EBV is associated with Burkitt’s lymphoma.

In cases where doctors mis-diagnose infectious mononucleosis as a bacterial infection, and prescribe amoxycillin as an antibiotic, the patient will develop a maculopapular rash.

Atypical lymphocytes on a blood film are indiciative of EBV infection

25
Q

A 22 year old man has a one year history of progressive breathlessness on exertion and cough with sputum. He has never smoked. He reports his father died of a lung condition aged 45. He is cachectic with a barrel chest.
Investigations:
FEV1/FVC ratio 51% (Normal >75%)
Chest X-ray: hyperinflation, bullae and flat hemidiaphragms

What blood test should be sent to help diagnosis?

A

Alpha-1 anti-trypsin deficiency test

A1AD is an autosomal co-dominant condition that is caused by a genetic inability to manufacture alpha-1 anti-trypsin, which inhibits neutrophil elastase activity in the lungs. As a result, A1AD patients essentially develop COPD at a young age.
Though A1AD classically affects the lungs, it can also affect the liver (cirrhosis), the GI tract (IBD), the vascular system (vasculitis), the pancreas (pancreatitis), the skin (psoriasis), and the kidneys (glomerulonephritis)

26
Q

A 65 year old patient complains of breathlessness. He is examined by his GP who suggests that he has mitral regurgitation.

What is the most likely abnormality on auscultation of the heart?

A

Pan-systolic murmur (loudest in mitral region and radiating into the axilla)

On further exmaination you may also notic a displaced apex beat. Mitral regurgitation increases the risk of atrial fibrillation developing, so an irregularly irregular heart rate and tachycardia may be observed on examination.

27
Q

A 71 year old woman has sudden onset chest pain radiating down her left arm. Her ECG shows ST elevation in leads II, III and aVF.

Which coronary artery has been affected?

A

Right coronary artery

ST elevation of 2mm or more in contiguous chest leads (1mm or more in limb leads) is indicative of an ST-elevated myocardial infarction. II, III, and aVF are in the inferior territory of the heart, which is supplied by the right coronary artery.

ECG territories and blood supply of the heart:

Septal: V1, V2
Anterior: V3, V4
Lateral: V5, V6, I, aVL
Inferior: II, III, aVF

Septal/ anterior: Left Anterior Descending artery
Lateral: Circumflex artery
Inferior: Right Coronary artery

28
Q
A 35 year old man has a one day history of severe loin pain radiating to his groin. His temperature is 36.5˚C, pulse rate 91 bpm, BP is 121/81, respiratory rate 16 breaths per minute and oxygen saturation 98% in air.
Investigation:
Urinalysis:
Nitrite negative
Leukocytes 1+
Blood 3+
Protein negative

What is the next most appropriate investigation?

A

CT KUB

Although CTKUB is first line imaging, around 15% of stones are radio-lucent (phosphate or urate stones)

29
Q

A 25 year old man recovered from a viral upper respiratory tract infection last week. He now has central chest pain. The pain is relieved by sitting forward and by taking ibuprofen. On auscultation a scratching noise is heard.

What ECG finding will best support the diagnosis?

A

Widespread saddle shaped ST-elevation

Pericarditis

30
Q

A 12 year old boy develops widespread urticarial rash, facial and lip swelling, and wheeze after being stung by a bee. He has eczema and asthma.

What medication should be administered as a first step?

A

I.M. adrenaline (0.5mg)

The child is in anaphylaxis

31
Q
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?

A

Rhabdomyolysis from the fall

The diabetes in this case is largely irrelevant: the patient has sustained a crush injury from the fall which has caused rhabdomyolysis.
Rhabdomyolysis is breakdown of skeletal muscle, which releases products such as myoglobin and potassium into the bloodstream. Myoglobin will damage the kidneys, and high potassium can cause cardiac arrhythmia .
This type of presentation should be considered in the elderly because they often fall and are not found for several days, so the crush injury is exacerbated because they are lying on the damaged area. Creatine kinase is the most important marker to check for this type of injury, though urea should also be checked as this type of patient will probably be dehydrated.

32
Q

A 63 year old man has palpitations but feels otherwise well. His temperature is 37.1˚C, pulse rate 120 bpm, BP is 134/95, respiratory rate 18 breaths per minute and oxygen saturation 98% in air. His ECG shows runs of polymorphic ventricular tachycardia.

What treatment should be given?

A

I.V. Amiodarone

Magnesium deficiency can cause long QT syndrome which in turn can cause ventricular tachycardia so you may consider giving magnesium as well

33
Q
A 65 year old man has three weeks of painless haematuria. His renal function is normal.
Investigations:
Urinalysis:
Nitrite negative
Leukocytes negative
Blood 3+
Protein negative

What is the next most appropriate investigation?

A

Cytoscopy

The best way to investigate the source of the blood is to visualise it, so cytoscopy in the most appropriate investigation.

34
Q

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?

A

Lumbar puncture

Look for xanthochromia or frank blood
then analyse for glucose, protein, and pathogens just in case.
In this case you’d expect to see xanthachromia, as this history strongly suggests a SAH

35
Q

A 24 year old man has a two week history of cramping abdominal pain, mouth ulcers and weight loss. He has a rapidly enlarging painful ulcer with violaceous margins on his left lower limb.

What is the most likely cause of his abdominal pain?

A

IBD

Mouth ulcers, cramping abdominal pain, and weight loss all indicate IBD. Bloody diarrhoea would be more indicative of UC than Crohn’s, but given this history it could be either

36
Q
A 24 year old woman has two months of lethargy, dizziness, weight loss and nausea. She has type 1 diabetes and reports erratic blood sugars and one episode of loss of consciousness. She has hyperpigmentation in her palmar creases and her oral mucosa. Her temperature is 36.8˚C, pulse rate 101 bpm, BP is 78/61 (standing), respiratory rate 16 breaths per minute and oxygen saturation 99% in air. Her blood sugar is 3.2 mmol/litre.
Investigations:
Sodium 129 mmol/L (135–146)
Potassium 5.4 mmol/L (3.4–5.0)
Creatinine 67 µmol/L (50–95)
Urea 7.7 mmol/L (2.5–7.8)

What is the most likely diagnosis?

A

Addison’s disease

Looking at the BP and electrolyte imbalance, it seems that this patient is in an Addisonian salt wasting crisis.

This would be treated with I.V. saline and hydrocortisone

37
Q

A 75 year old man with known Benign Prostatic Hyperplasia (BPH) has a two day history of oliguria and lower abdominal pain. A bladder scan shows a residual volume of 1.1L. He is found to have an Acute Kidney Injury (AKI) with a Creatinine of 590.

Which immediate intervention is most likely to relieve his symptoms?

A

Catheter

Symptoms are due to urinary retention

38
Q

A 40 year old woman with bipolar disease is found to be hypernatraemic. She is diagnosed with nephrogenic diabetes insipidus secondary to lithium use.

Which hormone is implicated in the pathophysiology of diabetes insipidus?

A

ADH/ vasopressin/ AVP

39
Q

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?

A

erythematous multiforme

atypical pneumonia with mycoplasma causes this

40
Q
A 23 year old female has burning on urination for three days. She develops fevers, rigors and loin pain.
Urinalysis:
Nitrite 3+
Leukocytes 2+
Blood 1+
Protein 1+

What is the most likely diagnosis?

A

Ascending UTI leading to pyelonephritis

41
Q

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?

A

Roth spots

42
Q

A 41 year old woman has three months of increasing anxiety, weight loss and palpitations. She has bilateral erythematous palms, periorbital oedema and proptosis. Her BMI is 19.8 kg/m². An ECG shows a sinus tachycardia at 120 beats per minute.

What would be the next most appropriate investigation for this patient?

A

TFTs, specifically free T4/T3 and TSH

43
Q

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?

A

Interstitial fibrosis/ idiopathic pulmonary fibrosis

Can develop into cor pulmonale as the resistance in pulmonary vessels increases until the right heart cannot effectively pump blood through the lungs

44
Q

A 31 year old woman has recently returned from holiday. She has a four day history of headache, myalgia and fevers. Over the past two days she has had a cough and confusion. Her sodium level is 121 mmol/L (Reference range: 135–146). Her chest X-ray shows left lower lobe consolidation and diagnosis of Legionella pneumonia is suspected.

What investigation will be most appropriate to confirm this diagnosis?

A

Urine antigen test

45
Q

A 62 year old man with COPD develops sudden onset right-sided chest pain worse on taking a deep breath in, shortness of breath and has two episodes of haemoptysis. Two weeks ago he had a tibial fracture and is in a below knee cast. His temperature is 36.8 ˚C, pulse rate 121 bpm, BP is 118/91, respiratory rate 24 breaths per minute and oxygen saturation 96% in air. His full blood count and renal profile are normal. Chest X-ray shows clear hyperexpanded lung fields.

What will be the best diagnostic investigation?

A

CT pulmonary angiogram

V/Q scan is used when CTPA is contraindicated e.g. pregnancy or contrast allergy

46
Q
A 43 year old IV drug user is drowsy.
Arterial Blood Gas in air:
pO2: 9.5 kPa (10-13)
pH: 7.23 (7.35-7.45)
pCO2: 7.0 kPa (4.5-6.0)
Bicarbonate: 22 mmol/L (22-24)

What biochemical abnormality does his arterial blood gas (ABG) show?

A

Uncompensated respiratory acidosis

This ABG shows type II respiratory failure, but the question asks for the biochemical abnormality

47
Q

A 75 year old woman has a murmur, loudest at the apex. An echocardiogram confirms mitral stenosis.

What is the most common cause of mitral stenosis?

A

Rheumatic fever (streptococcus viridans)

Rheumatic fever is an uncommon infection, but used to be more common, and it is still possible to find patients (especially those raised outside the UK)

48
Q

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?

A

Motor neuron disease/ Amyotrophic lateral sclerosis

All the symptoms listed here are lower motor neuron symptoms, but MND can affect upper and lower, and so is easiest to spot when there is a mix of symptoms (e.g. fasciculations and spasticity). In this case there are no upper motor symptoms, but the wide distribution, on different sides of the body, of symptoms makes MND the only reasonable diagnosis.

49
Q

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?

A

Scleroderma

Scleroderma is a group of autoimmune conditions.

One form of slceroderma is known as CREST synrdome and classically results in:
Thickening of the skin on the hands and feet
Calcium deposits
Raynaud’s phenomenon
Problems with the oesophagus (causing difficulty or pain on swallowing)
Telangectasia

Scleroderma has vascular effects, whoch is probably what has caused the pulmonary hypertension in this patient.

50
Q
A usually healthy 17 year old girl has cramping periumbilical pain and vomiting; after several hours, the pain moves to the right lower quadrant and becomes constant.
Investigations:
Chest X-ray: normal
Abdominal X-ray: normal
Haemoglobin 101 g/L (115–165)
White Cell Count 13.9 x109/L (4.0–10.0)
Platelets 291 x109/L (150–400)
Mean Cell Volume (MCV) 86.2 fL (80–96)
Urinary βHCG negative
Urinalysis:
Nitrite negative
Leukocytes 2+
Blood negative
Protein negative

What is the most likely diagnosis?

A

Acute appendicitis

Appendicitis typically presents with umbilical pain, nausea, vomiting, and fever. After a few hours the pain will migrate down the the right iliac fossa as the appendix becomes more inflamed and begins to irritate the peritoneum - this will result in pain on movement, and a change in gait that minimises rubbing of the peritoneum.

O/E a patient with appendicitis will be generally unwell, and will have guarding, rebound tenderness, and pain in the right iliac fossa might be elicited by pressing in the left iliac fossa (Rovsing’s sign).

Appendicitis would usually be investigated with ultrasound, unless the symptoms have become serious enough that there is an imminent risk of rupture, in which case diagnostic laproscopy would be used.

51
Q

A 71 year old woman has severe central chest pain. Her troponin is raised and she is diagnosed with an acute myocardial infarction. Her ECG shows ST elevation in I, aVL, V2, V3, V4, V5, V6
Which coronary artery has been affected?

A

Left coronary artery or left anterior descending

This is an anterolateral STEMI, as there is ST elevation in leads V1-V4 (anterior) and V5, V6, I, and aVL (lateral).

The left coronary artery branches to form the left anterior descending artery, and the circumflex artery.

The circumflex artery supplies the lateral heart (V5, V6, I, aVL), and the LAD supplies septal and anterior (V1, V2, V3, V4).

Hence blockage of the left coronary artery will cause infarction in both the anterior and lateral heart.

Branches of the LAD also supply the lateral heart, so an infarction of LAD could also cause an anterolateral STEMI

52
Q

A 28 year old man has a severe headache. He cannot adduct or elevate his left eye and has a left sided ptosis.

Which cranial nerve has been affected?

A

Left occulomotor (III)

The classic III nerve palsy presentation is an eye in the ‘down and out’ position, as there is no opposition to the actions of the lateral rectus (VI nerve) and superior oblique (IV nerve) muscles.
Levator palpebrae is the muscle that elevates the eyelid, and is also innervated by the III nerve, hence III nerve palsies also cause ptosis.

The sphincter pupillae muscle is innervated by fibres that are carried along with the III nerve. Hence a space-occupying lesion or trauma that impacts the III nerve will also affect the nerves innervating the sphincter pupillae causing a blown pupil. However vascular damage to the supply of the third nerve will not affect the fibres innervating the sphincter pupillae, hence a microvascular complication of diaebetes can be a III nerve palsy with preserved pupillary function.

Remember to specify nerve side

53
Q
A 35 year old nurse sustains a needlestick injury whilst taking blood.  She is usually well.  She attends occupational health who send a set of bloods.
Investigations:
ALT		21 IU/L	(10–50)
AST		32 IU/L	(10–40)
ALP		81 IU/L	(25–115)
Bilirubin	35 μmol/L	(<17)

What is the most likely diagnosis?
A

Gilbert’s syndrome

This is a bit of a trick question, as the needlestick injury is unrelated, but when bilirubin is elevated in the absence of symptoms or other LFT abnormalities, the cause is Gilbert’s syndrome.
Gilbert’s syndrome is a harmless enzymes deficiency causing elevated bilirubin.

54
Q

A 61 year old man presents with swelling in the right groin. Examination reveals an irreducible 3 cm lump. During surgery the mass is described as medial to the inferior epigastric artery and above the inguinal ligament.

Which is the most likely diagnosis?

A

Direct inguinal hernia

Hesslebach’s triangle (also called the inguinal triangle) is an area of weakness in the abdominal wall through which a direct inguinal hernia can protrude.

Hesslebach’s triangle is a weakened section of the transversalis fascia which is:
Superior to inguinal ligament
Medial to the inferior epigastric artery
Lateral to the edge of the rectus abdominus (linea semilunaris)

55
Q

A 34 year old woman has fatigue, weight gain and easy bruising. She has facial swelling. Visual fields are normal to confrontation. BP is 178/91 and a random blood sugar is 10.3 mmol/L. Her potassium is 3.2 mmol/L (Reference range 3.5–5.0).

What is the most likely diagnosis?

A

Cushing’s syndrome

Cortisol acts at mineralocorticoid receptors to increase potassium secretion

56
Q

An 80 year old woman is treated for a community acquired pneumonia with co-amoxiclav. Five days later she has severe cramping abdominal pain and large volume profuse green diarrhoea, not associated with blood. White cell count is 14.9 x109/L (Reference range: 4.0–10.0).

Which organism is most likely responsible for her diarrhoea?

A

Clostridium difficile

The biggest risk factor for C. difficile colitis is previous antibiotic use: the antibiotics disrupt the gut microbiome and reduce competition for C. difficile, allowing it to multiply

57
Q
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?

A

Ascending cholangitis

Ascending cholangitis is defined by Charcot’s triad: fever, rigors (chivering and feeling cold whilst actually having a fever), RUQ pain.

ALP is very high indicating a biliary issue, though other LFTs are slightly elevated and jaundice is present so common bile duct is obstructed

58
Q

A 35 year old man has sudden onset, severe left sided chest pain radiating to his back. He is tall with a high-arched palate. He has persistent paraesthesia in his lower limbs.
His temperature is 36.5˚C, pulse rate 101 bpm, BP is 92/71, respiratory rate 22 breaths per minute and oxygen saturation 98% in air.

What is the most likely diagnosis?

A

Aortic dissection

The description of the patient as tall with a high-arched palate implies he has Marfan syndrome. People with Marfan syndrome are more vulnerable to aortic dissection. The increased HR and low BP along with paraesthesia in the lower limbs all point to aortic dissection. There would also be diminished or absent pulses in the lower limbs.

59
Q

A 65 year old woman has not opened her bowels in three days. She now has nausea and vomiting.
Her AXR shows dilated bowel loops.

What is the most common cause of this presentation?

A

Adhesions

Adhesions are usually the by-product of surgery, so any mention of past surgeries in the history is key