A 70 year old lady presents to her GP complaining of tight chest pain, which radiated to her left arm and was relieved by rest. Her ECG revealed some ST depression
Stable Angina - by effort
occurs at rest / minimal exertion
occurs during rest Due to coronary spasm ST elevation during attack: resolves as pain subsides.
Prinzmetal’s / variant: Rx: CCB + long-acting nitrate
A 63 year old obese, diabetic male presents to A and E with tight chest pain at rest, which radiated to the left arm and lasted for less than 20 minutes. The CK was not raised.
Acute Coronary Syndrome but not MI - in MI the CK would be otherwise raised. ACS = unstable angina + evolving MI Divided into: ST elevation or new onset LBBB NSTEMI
A 68 year old man presents with sudden onset chest pain, which radiated to the back. On examination the patient was shocked, with a hemiplegia and the chest X-ray showed mediastinal enlargement.
aortic dissection - not AAA
Kussmaul’s sign: ↑JVP ̄c inspiration Quiet heart sounds S3 Hepatosplenomegaly Ascites, oedema Sarcoid Systemic sclerosis Haemochromatosis Amyloidosis Primary: endomyocardial fibrosis Eosinophilia (Loffler’s eosinophilic endocarditis) Neoplasia: carcinoid (→ TR and PS)
Radio-femoral delay + weak femoral pulse Hypertension Systolic murmur / bruit heard best over left scapula
A 65 year old man is in hospital after suffering an acute myocardial infarction. The house officer hears a pansystolic murmur on auscultation.
Cardiac tamponade: Left ventricular free wall rupture Beck’s triad (↓BP, ↑JVP, muffled heart sounds) Pulsus paradoxus Papillary muscle / chordae → MR PSM Pulmonary oedema. Septum PSM ↑JVP Heart failure
A 28 year old sportsman presents to A&E with severe chest pain and breathlessness. He has a history of asthma. There is a systolic murmur on examination.
LVOT obstruction from asymmetric septal hypertrophy AD inheritance (but 50% sporadic) β-myosin heavy chain mutation commonest Ask re family Hx of sudden death
A 46 year old women presents to A&E out of breath and with severe chest pain. On examination a mid systolic click late systolic murmur is revealed.
Myxomatous degeneration refers to a pathological weakening of connective tissue. The term is most often used in the context of mitral valve prolapse, which is known more technically as "myxomatous mitral valve degeneration." Myxo= connective tissue The degeneration occurs in conjunction with an accumulation of dermatan sulfate, a glycosaminoglycan, within the connective tissue matrix of the valve. The exact mechanism is unknown. In many cases, the degeneration is limited to the mitral valve and follows a benign course. When associated with systemic diseases, like Marfan syndrome, the degeneration is more extensive and involves other heart valves. The valves can become sufficiently distorted to cause insufficiency and regurgitation. Myxomatous degeneration is the most common cause of pure mitral valve insufficiency.
A 10 year old boy presents with skin rash and joint pain in his elbows and knees. His mother tells you that he recently had a sore throat. On examination he is found to have an ejection systolic murmur and a friction rub.
Acute Rheumatic Fever Diagnosis: - ASOT antibody titre -Scarlet Fever -GABHS postive throat swab -DNAs B tire.
A 69 year old woman is suffering from sudden onset fever and malaise. There is no previous history of heart disease. Auscultation reveals a heart murmur. She later develops sepsis.
Acute Bacterial Endocarditis What's the difference between acute and subacute endocarditis? p.121 of the PATH handbook Organism Staph Aureus Strep Pyogenes Subacute: Strep Viridians Staph Epidermis HACEK
A 40 year old man presents with a sharp chest pain. He has a pericardial friction rub, diminished heart sounds and a raised JVP.
A 25 year old man presents with palpitations. Chest X-ray shows an enlarged heart and echocardiogram shows thickening of the septum.
A 75 year old diabetic female with a history of 4 myocardial infarctions presents with shortness of breath and ankle swelling. She was found to have an enlarged liver and echocardiogram demonstrated a dilated heart.
clinical examination may or may not reveal a new murmur. An embolic stroke may be the first feature to suggest the diagnosis Associated with hypercoaguable states, malignancy
Non-bacterial thrombotic Endocarditis. Small bland vegetations attachted to the lines of closure.
A 39 year old Nepalese man presents with severe watery diarrhoea. He is found to have hypokalaemia and, surprisingly, a metabolic acidosis. A RUQ mass is detected by contrast-enhanced spiral CT scanning. Stool bicarb is high and urine anion gap is negative.
● Skin bronzing (melanin deposition) ● Diabetes ● Hepatomegaly with micronodular cirrhosis Cardiomyopathy ● Hypogonadism ● Pseudogout
Iatrogenic insulin, sulfonylurea excess, insulinoma
Presentation: severe epigastric (or central) pain radiating to back, relieved by sitting forward, vomiting prominent NB: Amylase only transiently increased. Serum lipase is more sensitive. Can result in formation of pseudocyst (a pathological collection of fluid), associated with alcoholic pancreatitis. Histology – Coagulative necrosis
65 year old female with a large, cystic mass on tail of pancreas imaged using computed tomography. Further cytology reported the presence of epithelium
The commonest cause of acute pancreatitis in the UK.
Inflammatory condition of the exocrine pancreas that results in injury to acinar cells.
ERCP finding due to incomplete fusing of pancreatic buds.
The commonest head of the pancreas cancer
Ductal Carcinoma of the Pancreas
Trousseau’s syndrome (25%)- recurrent superficial thrombophlebitis
Ductal Carcinoma of the Pancreas
is a fluid filled collection contained within a well-defined capsule of fibrous or granulation tissue or a combination of both. It does not possess an epithelial lining.
A breach in mucosa which extends through muscularis mucosa into submucosa or deeper
Present in almost all patients with duodenal ulcer and 70 % with gastric ulcer.
H. pylori infection
Around 10 % eventually get primary lymphoma (less often, carcinoma) of the gut if not properly treated. HLA B8 is linked with this.
The commonest cause of oesophagitis.
Re-epithelialisation by metaplastic columnar epithelium with goblet cells
A 40 year old male complaining of a long history of burning epigastric pain, worse on lying flat. Endoscopy and biopsy reveals inflamed squamous lining and increased basal cell proliferation.
A 38 year old female with Rheumatoid Arthritis presents with a single episode of malaena. Investigations reveal erosions through out the stomach and a neutrophilic infiltrate in the superficial mucosa
A 30 year old female complaining of diarhorrea and weight loss. Biopsy of duodenum shows increased intraepithelial cytotoxic T cells.
A 60 year old male complaining of epigastric pain relieved by antacids and meals. He has a positive CLO test.
A 65 year old male with a long history of epigastric pain. Endoscopy reveals 3.2cm of columnar metaplasia in the lower oesophagus. Goblet cells are seen.
Associated with Barrett’s oesophagus so usually seen in distal 1/3 Other risk factors incl: smoking, obesity, prior radiation therapy Most common in Caucasians, M>>F
Type of gastrtis (neutrophils) insult e.g. aspirin, NSAIDs, corrosives (bleach), acute H. pylori, severe stress (burns)
lymphocytes and plasma cells) insult e.g. H-pylori tends to be Antral, AI e.g. pernicious anaemia, ETOH, smoking
A 70 year old woman has progressive low retrosternal dysphagia, initially to solids and now also to liquids. She complains of chest pain and weight loss over the last 3 months. A social history reveals that she has been a heavy smoker for many years and drinks around 20 units of alcohol a week.
Carcinoma of the oesophagus
A 26 year old man presents with watery diarrhoea, abdominal cramps, nausea, vomiting and a low grade fever. It started 3 days after eating some undercooked meat at a barbecue.
A 66 year old man complaining of epigastric pain undergoes an endoscopy. The mucosa appears reddened in the antrum of the stomach. 13C is detected on a urea breath test.
A 58 year old female presents with malnutrition. She complains of abdominal pain, weight loss and arthritis. She has steatorrhoea. A jejunal biopsy showed periodic acid-Schiff (PAS)-positive macrophages
Whipple's disease: Whipple's disease Whipple's disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men Features malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
A 35-year-old man presents with a long history of epigastric burning pain, made worse at night and when drinking hot liquids. Recently he has had difficulty swallowing solids. Endoscopy shows lower oesophageal erosions and strictures and pH demonstrates acidity.
A 20-year-old student gives an 8 hour history of very frequent vomiting and epigastric cramping. O/E she is pale and shivering. Her serum WBC is normal
A 30-year-old woman presents with haematemesis and diarrhoea. She has recurrent peptic ulceration and is taking omeprazole. Despite this, she has persistently high serum gastrin levels. Endoscopy shows a large 3cm actively bleeding ulcer in the duodenum.
A 50-year-old women presents with chest pain associated with regurgitation of solids and liquids equally, both occurring after swallowing. Diagnosis is confirmed by a characteristic ‘beak like’ tapering of the lower oesophagus on barium swallow and manometry shows failure of relaxation of the LOS.
A 65-year-old woman presents with a 3 month history of anorexia, weight loss and epigastric pain. Blood tests reveal an iron deficiency anaemia. Endoscopy shows a thickened rigid gastric wall known as ‘leather bottle stomach’ indicating infiltration into all layers of the gastric wall. Numerous signet ring cells on biopsy diffusely infiltrate the mucosa.
A 45 year old woman presents with large tongue and swelling of the legs. She has a high BP and urine dipstick reveals protein +++.The tissue from renal biopsy stains with Congo red dye and shows apple green birefringence under polarised light
A 28 year old woman presents with malaise, weight loss, an erythematous rash on the face and joint pains. Both antinuclear antibodies (ANA) and double-stranded DNA (dsDNA) antibodies were found in the serum.
. Systemic lupus erythematous
A 55 year old woman presents with severe, unremitting headache with scalp tenderness. Her ESR and CRP are raised. A biopsy reveals giant cells.
A 40 year old man with previous hepatitis B infection presents with weight loss, muscle aches and abdominal pain. On examination he has high BP and urine dipstick reveals blood + and protein +
A 30 year old Afrocaribbean woman presents with tender red nodules on the shins and legs. She also has joint pains in her feet and hands. Her blood test reveals a raised angiotensin converting enzyme (ACE) and Ca2+ level.
A 60 year old man, currently undergoing treatment for long-standing chronic renal failure, complaining of tingling in his wrist & hand when he wakes in the morning.
Haemodialysis associated amyloidosis
A 70 year old woman is referred to hospital with signs of peripheral oedema and hepatosplenomegaly. Hospital investigations demonstrate a degree of bone erosion and high levels of circulating kappa uniform light chain
myloma associated amylodosis
A 32 year old man presents with a painless, enlarged axillary lymph node. Slight hepatosplenomegaly is noted on examination. Whilst the patient denies experiencing any night sweats, weight loss or fevers, bloods on admission show a raised ESR and abnormal liver biochemistry.
A 64 year old woman with a history of chronic rheumatological disease presents to her GP complaining of abdominal discomfort – which is found to be due to hepatosplenomegaly. An ensuing liver biopsy stains positive with Congo Red stain.
This is a secondary amyloidosis due to impaired clearance of b2m across dialysis membranes that causes carpal tunnel syndrome.
Beta -2-microglobulin amyloidosis is associated with haemodialysis.
common in the UK -- CML, myelofibrosis (ie haematological) common worldwide -- malaria, kala-azar (ie infectious)
Portal hypertension, lymphoma, CLL, thalassaemia and metabolic diseases e.g Gaucher's
Infection (viral e.g. EBV, hepatitis or bacterial e.g infective endocarditis, miliary TB)
A 63 year old lady presents to A and E with acute abdominal pain. She has been vomiting. On examination her abdomen is distended and you hear tinkling bowel sounds. Abdominal X-ray shows an inverted U loop of bowel.
A 70 year old gentlemen presents to his GP with left sided colicky abdominal pain which is relieved by defecation. He admits to passing constipated stools.
A 65 year old lady presents to A and E with left sided abdominal pain which is relieved by defecation. On examination her abdomen is tender over the left iliac fossa and she is pyrexial. Her ESR and WCC are both raised.
A 68-year-old man presents with rectal bleeding of bright red blood and constipation. He previously has been diagnosed with polyps in his colon and recently has lost a lot of weight. An abdominal examination reveals a mass in the right lumbar region which is non-tender
A 25-year-old woman complains of right iliac fossa pain, diarrhoea and weight loss worsening over several weeks. Laparotomy reveals an oedematous, reddened terminal ileum and a biopsy uncovers transmural inflammation with the presence of granulomas
A 35-year-old woman presents with diarrhoea and lower abdominal pain. Examination of her stools reveals blood and mucus. A biopsy reveals a continuous superficial ulceration of the colon.
Seen at 50-60yrs, thought to be caused by shedding of epithelium cell buildup
Found sporadically in some genetic/acquired syndromes Juvenile polyps are focal malformations of mucosa and lamina propria, vast majority in those <5yrs old, mostly in rectum bleeding. Usually solitary, but up to 100 found in juvenile polyposis (AD) that may require colectomy to stop haemorrhage. Also seen in Peutz-Jeghers syndrome (AD - LKB1) = multiple polyps, mucocutaneous hyperpigmentation, freckles around mouth, palms and soles. Have increased risk of intussusception and of malignancyregular surveillance of GI tract, pelvis and gonads.
A 77 year old man was referred by his G.P. after reporting the passing of large volumes of mucus. Endoscopy revealed a 6cm sessile cauliflower-like mass covered by dysplastic columnar epithelium in the rectum. His serum potassium is 3.3 mmol/l.
A 62 year old housewife returns to your outpatient clinic following another incidence of the passing of blood. Previous sigmoidoscopy, DRE and barium enema’s have failed to identify any lesion and she denies weight loss and diarrhoea. However, blood tests show a microcytic anaemia.
angiodysplasia- angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places.
An 84 year old gentleman presents to A&E after suffering acute cramp-like abdominal pain lasting several hours which was followed shortly by rectal bleeding. Colonoscopy showed an oedematous thickening of the bowel wall with areas of necrotic ulceration which was confined to the mucosal layers. On examination, the gentleman was found to have an irregularly irregular heart beat.
A 34 year old female presents with diarrhoea, abdominal pain and weight loss. Colonoscopy reveals inflammation of the mucosa which has a cobblestoned appearance. Biopsy showed transmural involvement and the presence of non-caseating granulomas.
Your consultant is urgently called away from out-patients and asks you to break bad news to a patient. He is distracted and has little time to inform you about the case but mentions that the original presentation was for rectal bleeding and the patient has a 40% chance of surviving 5 years.
Adenocarcinoma Duke's stage C1
A 65 year old heavy smoker. He has been progressively short of breath over a few years. He has a smooth liver edge 2 cms below the costal margin.
A 60 year old woman is found to have hepatomegaly. She has a history of moderate alcohol use. She had an anterior MI 2 years ago. On examination she has ankle oedema, elevated JVP and 3 spider naevi on her chest.
congestive heart failure
A 78 year old woman attends complaining of widespread itching. Examination reveals hepatosplenomegaly. The patient appears plethoric with no lymphadenopathy.
Polycythemia Rubra Vera
A 50 year old with haemophilia and hepatitis C presents with weight loss and abdominal discomfort. He is mildly icteric with features of chronic liver disease and a large left lobe of the liver.
cirrhosis with hepatoma
A 73 year old woman attends complaining of recent onset of tiredness. She is pale and has hepatosplenomegaly and generalised lymphadenopathy in the neck, axillae and groins.
The disorder is characterized by bruising, fatigue, anemia, low blood platelet count and enlargement of the liver and spleen, and is caused by a hereditary deficiency of the enzyme glucocerebrosidase (also known as glucosylceramidase), which acts on glucocerebroside. When the enzyme is defective, glucocerebroside accumulates, particularly in white blood cells and especially in macrophages (mononuclear leukocytes). Glucocerebroside can collect in the spleen, liver, kidneys, lungs, brain, and bone marrow.
Prehepatic: Portal vein thrombosis
Factor V laiden
A 25 year old student presents to A&E complaining of abdominal pain, diarrhoea, nausea and vomiting over the past few days. On examination he appears jaundiced and has dark urine and pale stools. Blood tests reveal raised levels of AST, ALT and bilirubin and a raised ESR. Further questioning reveals that he has returned from South East Asia three weeks previously.
Hep A=Acute, symptoms develop quickly
A 45 year old lady complains of pruritis. Investigations reveal the presence of antimitochondrial antibodies and elevated levels of alkaline phosphatase.
A 17 year old female presents to outpatients complaining of increasing confusion and a mild tremor. On examination you notice signs of liver disease. Investigations reveal a haemolytic anaemia. Further examination reveals a green-brown discolouration at the peripheries of her corneas.
A 45 year old male was admitted to hospital after having a fall. Investigations reveal a leucocytosis with elevated bilirubin and transferases. Levels were albumin, folate and vitamin B12 were low. Clotting studies showed a prolonged prothrombin time.
Alcoholic liver disease
Routine biochemistry for a 32 year old man revealed elevated levels of serum iron and ferratin but reduced levels of total iron binding capacity. Other serum liver biochemistry investigations were normal. Further questioning revealed that his uncle had a ‘blood’ disorder.
Common with other autoimmune diseases e.g. coeliac, SLE, RA, thyroiditis, Sjögren’s, UC ● 78% female– young and postmenopausal. ● Associated with HLA-DR3 ● Type 1: ANA (antinuclear Ig), anti-SMA (anti-smooth muscle Ig), anti-actin Ig, anti- soluble liver antigen Ig ● Type 2: Anti-LKM Ig (anti liver-kidney-microsomal Ig) ● Treatment: Immune suppression until transplant, BUT disease returns in up to 40%
A 30 year old female patient presents with abdominal pain, nausea and vomiting. Upon examination the patient has a tender hepatomegaly and ascites (with a high protein content) Abdominal CT demonstrated hepatic vein occlusion with diffuse abnormal parenchyma on contrast enhancement.
Budd Charii Syndrome
A 22 year old patient presents to his doctor complaining of week long flu like symptoms, nausea, anorexia and fatigue. The patient appears jaundiced upon examination with mild enlargement and slight tenderness of the liver. Lab results demonstrate a raised AST (512 IU/L) and ALT (425IU/L) and an acute phase IgM response has been demonstrated. The patient recalls visiting a dodgy tattoo parlour 3 weeks ago to engrave the name of his mum on his arm.
A 42 year old woman presents to the doctor complaining of severe itching and recent onset of jaundice. The patient had been experiencing milder pruritis and bouts of fatigue for the last year. Hepatomegaly and pigmented xantholasma are demonstrated upon examination. Serum IgM is high and apart from a high serum Alk Phosphate, other liver biochemistry is normal. Upon ELISA screen, mitochondrial antibodies are seen. (in titre of 1:200)
emphysema and chronic liver disease in adults neonates jaundice
ALPHA 1 ANTITRYPSIN DEFICIENCY
Intracytoplasmic inclusions of A1AT which stain with Periodic acid Schiff
ALPHA 1 ANTITRYPSIN DEFICIENCY
A 30 year old woman presents with lower abdominal pain accompanied by fever. She has been using an intra uterine contraceptive device since her wedding three years ago.
A 40 year old woman has always known cramping pain associated with her periods – which have usually been heavy. Recently this pain has become constant throughout the month, and her periods have become more frequent. She claims never to have used oral contraception and has no children. She is abstaining from sexual intercourse as it is too painful.
This phenomenon, is a benign change in the endometrium associated with the presence of chorionic tissue. Arias-Stella reaction is due to progesterone primarily. Cytologically, it looks like a malignancy and, historically, it was diagnosed as endometrial cancer.
Covers cortical surface of bone and delivers blood supply.
This type of bone is 80-90% calcified and its function is mainly mechanical and protective.
This type of bone is immature and usually pathological. Presents in Paget's disease
Cancellous bone, also known as spongy or trabecular bone, is one of the two types of bone tissue found in the human body. Cancellous bone is found at the ends of long bones, as well as in the pelvic bones, ribs, skull, and the vertebrae in the spinal column. It is very porous and contains red bone marrow, where blood cells are made. It is weaker and easier to fracture than cortical bone, which makes up the shafts of long bones.
Lamellar bone is secondary bone created by remodelling of woven bone.Lamellar bone has a regular parallel alignment of collagen into sheets (lamellae) and is mechanically strong. It is highly organized in concentric sheets with a much lower proportion of osteocytes to surrounding tissue. Lamellar bone is stronger and filled with many collagen fibers parallel to other fibers in the same layer (osteons).
it is is a thin vascular membrane of connective tissue that lines the inner surface of the bony tissue that forms the medullary cavity of long bones.
It is is the wide portion of a long bone between the epiphysis and the narrow diaphysis. It contains the growth plate, the part of the bone that grows during childhood and as it grows, it ossifies near the diaphysis and the epiphyses.
A 45-year-old Asian female presents with generalised bone pain. Histological findings are of increased osteoid volume with widened osteoid seams and reduced mineralization. Her diet is vegan.
A 15-year-old male presents with a 2-month history of increasing pain in his right upper arm. Bone biopsy reveals sheets of cells with small, primitive nuclei and scanty cytoplasm. A positive immunoreactivity is seen with the MIC2 (CD99) antibody. Onion skinning of periosteum
Mottled rarefaction and lifting of the periosteum are seen on X-ray of the femur. Bone biopsy reveals an intense neutrophilic inflammatory infiltrate.
A 15-year-old male presents with a 2-month history of increasing pain in his right upper arm. Bone biopsy reveals sheets of cells with small, primitive nuclei and scanty cytoplasm. A positive immunoreactivity is seen with the MIC2 (CD99) antibody. Onion skinning of periosteum An 8 year old boy is brought to his GP by his parents with pain in his hips and a fever. Blood results demonstrate a raised ESR and biopsy histology shows droplets of glycogen in the cytoplasm of small round cells in the pelvic bones.
It results in bones that break easily. TOther symptoms may include a blue tinge to the whites of the eye, short height, loose joints, hearing loss, breathing problems, and problems with the teeth. The underlying mechanism is usually a problem with connective tissue due to a lack of type I collagen.
Malignant bone tumor leading to Lytic lesion with fluffy calcification, Axial skeleton
Literally "stone bone", also known as marble bone disease and Albers-Schönberg disease, is an extremely rare inherited disorder whereby the bones harden, becoming denser,
A 33 year-old women from Somalia, who traditionally wears a veil, presents to her GP with a waddling gait and weakness of the proximal muscles. She has clinical features of tetany and a low serum 25-hydroxyvitamin D3. On skeletal X-ray linear areas of low density are seen surrounded by sclerotic borders
A 92 year-old man has asymptomatic elevation of alkaline phosphatase. Skull X-ray reveals osteoporosis circumscripta. On examination he has bowed tibia and skull changes. He also complains of a recent onset of deafness
discrete radiolucent regions of the skull on plain radiographs.
Osteoporosis circumscripta cranii (also known as osteolysis circumscripta) refers to
A 24 year old police woman attends the clinic as her GP suspects she may have a parathyroid tumour. She has raised PTH and serum calcium. After a 24hr urinary collection it is noted the patient has a low urine calcium output
Familial hypocalcuric hypercalcemia
Secondary hyperparathyroidism with chronic renal osteodystrophy
You see a new patient for the first time at the surgery, a 14 year old boy, complaining of pain in his right leg for 9 months and contracture of the right knee which has developed over this period. The child looks stunted and you can see bowing of the lower extremities in ambulators. His notes have not arrived yet from his previous doctor but his mother tells you ‘he was born 3 weeks premature with two small kidneys and three failed transplants means he has dialysis four times a day’. His blood results later show a raised PTH and phostate, low calcium and 1,25(OH)vitamin D. He is also acidotic.
An 18 year old student presents to his GP with focal pain in his left fore-arm which is tender to touch and worsens at night. The pain is relieved with aspirin. An X-ray shows a 1cm are of radio-lucency in the tibia surrounded by dense bone (radiolucent nidius)
A 14 year old boy complains to you of a painless lump on his left thigh, just above the knee which is slowly growing. His past medical history reveals that he fractured his femur in the same location several years before.
A 15 year old girl shows you a small lump on her upper arm on routine examination. She says the lump has been present for a couple of years and has slowly moved down, away from her shoulder.
simple bone cysts
A 50 year old lady presents with pain in her jaw. She suffers from Paget’s disease. A ‘sunburst’ appearance is seen on X-ray along with a lifted periosteum (Codman’s triangle).
￼Lytic lesions Expensile - O- ring sign Cotton Wool Calcifications In Hands
￼Chinese letters (misshapen bone trabeculae)￼ ￼Soap osteolysis - shepard's crook deformity
Cotton Wool Calcification
1) Is the commonest bony tumour 2) M:F = 3:1 3) Commonest location is around the knee 4) They are usually painless and slow growing 5) Their aetiology maybe related to previous trauma, such as fracture.
60 year old life long smoker presents to her GP with a 10 day history of worsening shortness of breath, cough and wheeze. Her cough produces a greenish sputum. On examination she is tachypnoeic and very cyanosed. Auscultation of her chest reveals a harsh polyphonic wheeze and signs of a right lower lobe pneumonia. This lady has developed type II respiratory failure secondary to what pulmonary disease?
70 year old man presents to his GP with a four day history of haemoptysis. He has noticed he has been loosing weight over the last 4 months and has felt tired and unwell. On examination he has bilateral ptosis and proximal weakness in the limbs which improves on repeated testing
small cell carcinoma
52 year old lady with ovarian cancer comes into A&E with with a 10 hour history of haemoptysis associated with dysponea and pleuritic pain. Her chest X-ray is normal apart from a wedge shaped infarct peripherally on the right.
45 year old fireman presents to chest clinic with a 1 year history of increasing shortness of breath. On examination you find that he is tachypnoeic and has gross clubbing of the fingers. Auscultation reveals bibasal fine end-inspiratory crackles
cryptogenic fibrosing alveolitis
A 35 year old woman presents with weight loss and tiredness. Her GP examines her and finds that she also has a fine tremor and is sweaty. Investigations: TSH <0.01, Free T4 36.0. There is low uptake on a technetium scan. The aetiology could be viral or autoimmune.
subacute thyroditis In subacute thyroiditis, the thyroid gland is damaged and initially releases thyroid hormones, giving high free T4 and thyrotoxicosis symptoms (palpitations, sweating - but not exophthalmos) for a month or so.
A 42 year old woman presents to her GP suffering from mild depression. Her thyroid function is investigated: TSH 6.5, Free T4 5.6 ￼ Plasma cell infiltration & goitre. Elderly females. May be initial ‘++ Autoantibody titres
An 18 year old man notices a lump on his neck and goes to his GP. As well as the lump, the GP discovers cervical lymphadenopathy. There is no family history of any endocrine disorder, nor is he suffering from any other illness. Thyroglobulin is 140. >60% of cases, 30-40y, surgery +/- radioiodine, Thyroxine (to ↓TSH)
A 27 year old man goes to his GP with a 3 day history of fever, tiredness and neck pain. His ESR is raised. TSH 0.12, Free T4 32. After 2 weeks his symptoms have resolved. His GP repeats his thyroid function tests: TSH 5.9, Free T4 8.4. After a further week his thyroid function has returned to completely normal levels. he cause of the subactute thyroiditis is viral (= De Quervain's, which gives a painful thyroid + fever),
de queviran thyroditis
5% originates in parafollicular cells – linked to MEN2. Produce calcitonin
Benign hemispherical neoplasms projecting from the endometrial mucosa into the uterine cavity. They can cause uterine bleeding and infertility and are commonest at the time of menopause
The most common cancerous neoplasm of the female genital tract. It appears most frequently between the ages of 55 and 65, with obesity, diabetes, hypertension and infertility being the major risk factors.
Neoplasms found in women aged between 30 and 40 as ovarian masses, usually unilateral. They are usually benign (90%) and are often the largest ovarian neoplasm.
A common neoplasm which can be detected by cytological examination long before any gross abnormality are seen. Major risk factors include early age at first intercourse, multiple sexual partners and persistent infection by human papillomavirus (HPV). Histologically, there is mild hyperchromasia and finely stippled chromatin pattern.
Cervical Intraepithelial Neoplasia (CIN
Squamous epithelium mixed with intestinal epithelium
Mature cystic teratoma
Fibrous tissue containing spindle cells and lipid
Malignant cells surrounded by serous fluid and Psammoma bodies
Malignant signet ring cells containing mucin metastases from a GI primary tumour,
Germ cells mixed with lymphocytes Female counterpart of testicular seminoma rare, but the most common ovarian malignancy in young women sensitive to radiotherapy
Sex cord / stroma (10%) Can differentiate toward male structures Secrete androgens Look for defeminisation (breast atrophy) and virilisation (hirsutism, deepened voice, enlarged clitoris)
(Sertoli and Leydig cells)
Sex cord / stroma (10%) Produce E2 Look for oestrogenic effects – irregular menstrual cycles, breast enlargement, endometrial/breast cancer
Granulosa - Theca cell tumors.
Malignant, usually solid; Contains immature, embryonal tissues secrete AFP
Secrete hCG malignant
Abundant clear cytoplasm – intracellular glycogen Hobnail appearance malignant with poor prognosis
intersecting bundles of spindle cells from ovarian cells stroma (no lipid) No hormone production, 50% associated with Meig’s syndrome (ascites + pleural effusion)
Germ cell tumour originating in testis that is radiosensitive and classically presents in the 4th decade.
Very aggressive tumour producing HCG and AFP; neoplastic cells are anaplastic.
Very aggressive HCG-producing tumour composed of cytotrophoblast and syncytiotrophoblast cells that metastasizes early.
Nonseminomatous germ cell tumour that has elements derived from all 3 germ cell layers
Commonest malignant cause of testicular mass in those aged under 5.
Commonest malignant cause of testicular mass in those aged 60
DLBL (diffuse large B-cell lymphoma)
germ cell tumours are radioSensitive, present in the 30s ; 15% secrete HCG ; 0% secrete AFP.
Germ cell tumors that are radioresistant, present in the 20s, and may secrete AFP and/or HCG.
A 22-year-old lady presented with a vaginal discharge. Gram staining revealed “Clue cells” surrounded by rods, that were “Gram variable”.
Lymphogranuloma venereum (LGV) + granuloma inguinale
Painless = syphilis
a sexually transmitted disease caused by the invasive serovars L1, L2, L2a or L3. LGV is primarily an infection of lymphatics and lymph nodes
The peak incidence of cervical cancer occurs at what age?
The metaplasia that occurs in the transformation zone involves which cell-types?
Glandular to squamous epithelium
A 27 year old woman undergoes a routine Pap test. Histology shows increased squamous epithelium with atypical cells showing koilocytosis (nuclear enlargement with perinuclear halo = clear area around nucleus). Follow-up colposcopy shows hyperchromatic nuclei present in the lower 1/3 of the epithelial layer from the basement membrane.
NHS Cervial Screening Programme currently screens women with normal Pap tests up to what age?
A pap smear taken from a chronic granulomatous ulcer shows a necrotic centre, periarteritis and endarteritis obliterans and an intense peripheral cellular infiltrate consisting mainly of mononuclear cells and giant cells.
Single most useful first-line cytological investigation of an impalpable breast lump seen on a mammogram.
Stereotactic radiographic cytological sampling method
Single most useful first-line cytological investigation for the confirmation of the benign status of an ovarian cyst.
Fine needle aspirate
Single most useful first-line cytological investigation for the detection of pneumocystis carinii in an immunosuppressed patient.
Fluid cytology of alveolar washings
Single most useful first-line cytological investigation of a palpable breast lump in a clinic setting.
Fine needle aspirate
Single most useful first-line cytological investigation for screening for cervical dysplasia
Exfoliative (brush) cytology
Correct F. Has a 100% positive predictive value for malignant cytopathological diagnosis.
Needle core biopsy
Leads to pain and trauma to the patient.
Requires a hospital stay, possible general anaesthetic and leads to pain and trauma to the patient.
Surgical biopsy of lesions
Intra-operative frozen section diagnosis
Does not allow patient counselling prior to definitive treatment.
A 70 year old woman goes to her GP accompanied by her daughter who looks after her. She has started undressing and wandering the streets in the night and she is aggressive and argumentative. She had a stroke 3 years ago and recovered well with only some transient ischaemic attacks recorded since. A CT scan has since shown areas of scattering of low density in the white matter.
An 86 year old man is admitted to A&E having collapsed at his home. He is unconscious and a couple of days later he is still deeply unconscious. His pupils are pin-point and their reaction to light is difficult to see clearly.
A 20 year old man was taken to A&E after a pub brawl where he was stamped on whilst trying to break up a fight. He remained lucid for approximately 3 hours after the incident and then slipped in and out of consciousness with hemiparesis afterwards. He had a deep laceration on the side of his head. A CT scan showed high attenuation adjacent to the skull and a midline shift.
A 42 year old lady went to her GP in a frightened, agitated and still dazed state as the previous day she had what she described as a ‘strange migraine’ but without the headache when, she said, she suddenly could not see the TV. She said she thought it affected just the one eye and that she felt disorientated and unable to speak what she wanted to say. This lasted approximately 2-3 hours and then slowly started to clear. She was tachycardic with hot, sweaty palms.
chronic hypertension decreased level of consciousness (most common) long tract signs including tetraparesis cranial nerve palsies seizures Cheyne-Stokes respiration death
Prev history of minor trauma → damaged bridging veins with slow venous bleed, often elderly/alcoholic, associated with brain atrophy, fluctuating consciousness
Occlusion of this cerebral vessel can cause weakness and numbness in the contralateral lower limb and similar but milder symptoms in the contralateral upper limb.
anterior cerebral artery
This group of ischaemic brain lesions typically affect the basal ganglia, internal capsule, thalamus and pons and are smaller than 1cm.
Transtentorial herniations can potentially compromise the sufficiency this particular part of the cerebral circulation and cause occipital lobe infarction.
Posterior cerebral artery
Contralateral hemiparesis and hemisensory loss of the face, upper and lower extremities is the most common
agressive tumor that can metastise, presents with fracture, affect mature bones
GIant cell tumor that can metastasise Think of the giant cells making the space for and making it easilt to fracture? Ellie had it?
This type of bone of neoplasm occurs only in the adolsence
cyclical pain no heavy menstrual bleed, also think adenyomyosis
what do you give to anyone with BP 150/90?
Aspirin prophylaxis for anyone with hypertension from 12 weeks onwards
plus labetalol from 150/100
How woman with previous gestational diabetes at 28 weeks shoudl be investiagted?
OGGT at booking visit 8-12 weeks.
further OGGT if the results are normal at 28 weeks
Woman with APH, what is the most important thing to rule out?
APH from 24 weeks onwards
- placenta previa
- still birth
- if abdo pain placenta abruption
When to presribe the shelf pessary?
WOmen not amendable to surgery, grade 3 and 4 prolapse
18 year old woman with losse stools, apyrexial WCC 110 0000
sore throat and vaginal discharge
menorraagia, young girl, never sexualy active what do you prescrible
- if painful NSAID
-heavy mefemanic acid (but not if wants to get pregnant)
What are the signs of the uterine rupture?
1) hypercontractility of the uterus
2) Fetal compromise with reduced fetal movements
3) if ruptured bladder then hematuria
4) Suprapubic pain if scar in VBAC
Pemature menopasue and wants to bleed
woman with still born baby, generalisedoedema, mum had feverm at 18 weeks
76 year old had single brown discharge
intermittient pain and vomitting
ovarian cyst torsion
whirpool sign is a sign of......
woman goes on holiday and wants to delay her period
- . The dose is one tablet (5 mg) three times a day. You start three days before a period is due. It can be continued until you want to have a period. Your period will then normally begin 2-3 days after stopping it. It can be taken for up to 3-4 weeks if necessary
abdmonial pain and fever
Commonest type of endometrial canceR?
Endometroid (oestrogen dependent)
Most likely effect from Cheese Reaction
Common side effect if clozapine
Hypersalivation - most common
Voman with fever, pain and vomitting during pregnacy. how would it present?
Red degeneration: presents with fever, pain and vomiting.
brwon bleeding after birth
Anemia at booking
>10.5 at 28 wks