VSA Formative Questions 2017 Flashcards
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?
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)
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?
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.
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?
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
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?
Herpes simplex (type I)
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?
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
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?
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.
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?
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
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?
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
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?
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
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?
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.
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 microcytic anaemia (iron deficient)
Malaise and fatigue are very generic features of anaemia, but kolionychia is more specific and indicates iron-deficient anaemia.
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?
Urine dipstick ketones
The ABG shows a partially compensated metabolic acidosis with very high glucose. This points to diabetic ketoacidosis.
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?
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
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?
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
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?
CT head
To check for haemorrhagic stroke, as giving thrombolysis to a patient who is haemorrhaging will probably be fatal.
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?
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
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?
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
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?
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.
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?
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
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?
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
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?
E. coli
You might also suspect chlamydia or gonorrhea in a younger patient.
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?
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
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?
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
