2004 Flashcards
A 47-year-old man was brought into A&E having fainted in a wine bar at 6pm. His Glasgow Coma Score was 3. He was pale, sweaty and looked grey. He normally took no alcohol but had been celebrating his promotion at work by holding a champagne party.
The patients below all presented to an A&E department as ‘Collapse/?Cause’. Choose the most appropriate diagnosis from the above list. Each option may be used once, more than once or not at all.
A. Hyperglycaemia B. Hypertension C. Atrial fibrillation D. Pulmonary fibrosis E. Pancreatitis F. Delirium tremens G. Hypoglycaemia H. Wolff-Parkinson-White syndrome I. Subdural haematoma J. Wernicke's encephalopathy K. Anxiety attack L. Convulsions M. Oesophageal varices N. Acute gastritis
Hypoglycaemia
1) Heavy alcohol consumption decreases hepatic production of glucose, putting this person at risk of hypoglycaemia. This patient is suffering from hypoglycaemia which is present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety.
A 35-year-old overweight woman complained of severe abdominal pain and vomiting. She had had a previous attack when on holiday and had had to be flown home as a medical emergency. She looks jaundiced and in distress.
The patients below all presented to an A&E department as ‘Collapse/?Cause’. Choose the most appropriate diagnosis from the above list. Each option may be used once, more than once or not at all.
A. Hyperglycaemia B. Hypertension C. Atrial fibrillation D. Pulmonary fibrosis E. Pancreatitis F. Delirium tremens G. Hypoglycaemia H. Wolff-Parkinson-White syndrome I. Subdural haematoma J. Wernicke's encephalopathy K. Anxiety attack L. Convulsions M. Oesophageal varices N. Acute gastritis
Pancreatitis
2) This patient has acute pancreatitis. She has vomited and is describing likely epigastric pain. This classically radiates around to the back which is relieved in the fetal position and is worse with movement. This patient is likely to have gallstones as the underlying cause, which is also causing an obstructive jaundice and her previous episode. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the other causes of acute pancreatitis. Those caused by hypocalcaemia may display Chvostek’s sign and Trousseau’s sign.
Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook. An abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration. For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.
A young man involved in a RTA is brought into A&E with multiple injuries to his face. On examination, his eyes do not open to pain. He withdraws his left side to pain but his right side does not move at all. His right pupil is fixed, dilated and non-reactive.
The patients below all presented to an A&E department as ‘Collapse/?Cause’. Choose the most appropriate diagnosis from the above list. Each option may be used once, more than once or not at all.
A. Hyperglycaemia B. Hypertension C. Atrial fibrillation D. Pulmonary fibrosis E. Pancreatitis F. Delirium tremens G. Hypoglycaemia H. Wolff-Parkinson-White syndrome I. Subdural haematoma J. Wernicke's encephalopathy K. Anxiety attack L. Convulsions M. Oesophageal varices N. Acute gastritis
Subdural haematoma
4) A subdural occurs due to blood collecting between the dura mater and the arachnoid mater surrounding the brain. It may be arterial or venous although is most often venous. The disease runs a varied course and the presentation occurs on a spectrum from asymptomatic to herniation syndromes. There is neurological deficit evident so surgery will be indicated here. The cause is trauma and this man will have suffered a head injury due to his RTA. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. Surgical options include twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Remember that extradural haematomas classically have a ‘lucid interval’ and occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines.
A 45-year-old woman who has a firm, slightly tender, 2cm diameter smooth lump just below and attached to the skin of the upper part of her right breast. It has been growing slowly over the past year and there is a punctum in the centre. She has come to see you because yesterday she noticed that when she pressed the lump, a stream of a rather smelly, jelly-like substance came out.
From the description of the patients given below, select the most likely diagnosis from the list above. Each option may be used once, more than once or not at all.
A. Radial scar B. Breast bud C. Lipoma D. Sebaceous cyst E. Intraductal papilloma F. Phylloides tumour G. Basal cell carcinoma H. Fibroadenoma I. Carcinoma of the breast J. Breast abscess K. Fat necrosis L. Adenoma M. Fibroadenosis
Sebaceous cyst
5) The central punctum makes this diagnosis. This has become inflamed in this case ad is expressing a foul-smelling keratinised discharge as it has become infected. They can be caused by blockage of sebaceous glands.
A 62-year-old man 3 months after an acute MI, taking aspirin, atenolol and simvastatin, whose echocardiogram shows worsening left ventricular function.
For each of the following patients choose one of the options above as the single most appropriate (but not necessarily the only) means of reducing cardiovascular risk. BMI (Body Mass Index) <25 Normal 26-30 Overweight >30 Obese
A. Stop smoking
B. Angiotensin converting enzyme inhibitor therapy
C. Weight reduction and increased physical activity
D. Reduced alcohol intake
E. Antihypertensive drugs
F. Weight reduction and metformin therapy
G. Aspirin therapy
H. Cholesterol loweing therapy with a statin
Correct B. Angiotensin converting enzyme inhibitor therapy
1) This patient has worsening LV function in line with heart failure. First line treatment is with an ACE inhibitor which reduces morbidity and mortality associated with the condition. All patients with LV dysfunction should receive ACE inhibitors, whether symptomatic or not. Caution should be taken if the patient has renal impairment, cardiogenic shock or hyperkalaemia. All patients with chronic heart failure will also receive a beta blocker such as carvedilol.
A 56-year-old lady with a long history of asthma develops bruising.
For each of the scenarios below, choose a SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all.
A. Diuretics B. Idiopathic thrombocytopenic purpura C. Skull fracture D. Aplastic anaemia E. Clopidogrel F. Disulfiram G. Spontaneous H. Wiskott-Aldrich syndrome I. HIV J. Haemophilia K. Hepatic cirrhosis L. Corticosteroids
Correct L. Corticosteroids
1) Side effects of corticosteroids are due to exaggerated normal physiological actions. This lady with a long history of asthma is likely either taking inhaled corticosteroids or on oral therapy. An inhaled corticosteroid is used if a patient requires their reliever more than twice a week. Smoking, current or previous, reduces the effectiveness of inhaled corticosteroids so higher doses may be needed. In asthma, they reduce airway inflammation and reduce oedema and mucus secretion into the airway. Bruising is a documented side effect. Other side effects include adrenal suppression with prolonged use of inhaled therapy, LRTIs, predisposition to osteoporosis, anxiety, depression, hyperglycaemia and cataracts. Can you classifiy the wide range of side effects of steroids?
A 48-year-old man developed bruising a week after he had a period in hospital following an episode of severe chest pain.
For each of the scenarios below, choose a SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all. A. Diuretics B. Idiopathic thrombocytopenic purpura C. Skull fracture D. Aplastic anaemia E. Clopidogrel F. Disulfiram G. Spontaneous H. Wiskott-Aldrich syndrome I. HIV J. Haemophilia K. Hepatic cirrhosis L. Corticosteroids
Correct E. Clopidogrel
2) Clopidogrel is used to prevent atherothrombotic events in patients sensitive to aspirin. This patient has had an MI. It is an antiplatelet drug which inhibits fibrinogen binding to glycoprotein IIb/IIIa receptors. It is given orally but effects are not seen until 4 days after the first dose. Use with aspirin further increases the risk of bleeding. Clopidogrel can also rarely cause a neutropenia.
A 48 year old male stripper presents with bruising, infections and fatigue. Lab findings indicate a pancytopenia with low reticulocyte count. Bone marrow biopsy is done on which a definitive diagnosis is made.
For each of the scenarios below, choose a SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all.
A. Diuretics B. Idiopathic thrombocytopenic purpura C. Skull fracture D. Aplastic anaemia E. Clopidogrel F. Disulfiram G. Spontaneous H. Wiskott-Aldrich syndrome I. HIV J. Haemophilia K. Hepatic cirrhosis L. Corticosteroids
Correct D. Aplastic anaemia
3) This is aplastic anaemia characterised here with the pancytopenia (which is common, but diagnosis requires 2 cytopenias out of 3) and the presentation with infections (neutropenia), fatigue (anaemia) and bruising (thrombocytopenia). Risk factors include paroxysmal noctural haemoglobinuria, hepatitis and NSAIDs. If macrocytosis is seen, this may suggest an inherited syndrome such as Fanconi’s anaemia. The reticulocyte count here rules out haemolytic anaemia, which isn’t even an option on the list. The definitive diagnosis is made on biopsy of bone marrow which shows a hypocellular marrow with no abnormal cell populations and no fibrosis. Which conditions would there be abnormal cell populations or fibrosis on bone marrow biopsy?
A 62-year-old man with a history of alcohol abuse presents with bilateral parotid hypertrophy, gynaecomastia, testicular atrophy and easy bruising.
For each of the scenarios below, choose a SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all. A. Diuretics B. Idiopathic thrombocytopenic purpura C. Skull fracture D. Aplastic anaemia E. Clopidogrel F. Disulfiram G. Spontaneous H. Wiskott-Aldrich syndrome I. HIV J. Haemophilia K. Hepatic cirrhosis L. Corticosteroids
Correct K. Hepatic cirrhosis
4) Cirrhosis is the end-stage of chronic liver disease, in this case due to alcoholic liver disease. Cirrhosis results in hepatic insufficiency and portal hypertension. The bruising here is due to thrombocytopenia secondary to portal hypertension with resulting hypersplenism and sequestration. Complications of chronic liver disease include ascites, variceal bleeds, jaundice, hepatic encephalopathy, hepatorenal syndrome and the development of HCC. Signs include spider naevi, palmar erythema, telangiectasia, bruising, gynaecomastia, Dupuytren’s contracture, parotid swelling and a red tongue.
An 8 year old boy is brought into A&E after falling from a tree while trying to retrieve his cat. The boy is crying and has periorbital bruising around his right eye and a small amount of blood in the right ear canal. His GCS is 15.
For each of the scenarios below, choose a SINGLE most likely cause from the above list of options. Each option may be used once, more than once or not at all. A. Diuretics B. Idiopathic thrombocytopenic purpura C. Skull fracture D. Aplastic anaemia E. Clopidogrel F. Disulfiram G. Spontaneous H. Wiskott-Aldrich syndrome I. HIV J. Haemophilia K. Hepatic cirrhosis L. Corticosteroids
Correct C. Skull fracture
5) This is a basilar skull fracture and a CT scan (superior to MRI), in this case with 3D reconstructions, will be useful. This patient has had a fall and clearly hit his head. Basilar skyll fractures have specific clinical features. Blood pooling from these fractures can cause periorbital bruising (raccoon eyes), brusing over the mastoid area (Battle’s sign) and bloody otorrhoea. There may also be CSF leak resulting in CSF otorrhoea or rhinorrhoea. A unilateral raccoon eye has an 85% positive predictive value for this diagnosis.
A 52-year-old woman with known ischaemic heart disease and shortness of breath on exercise. At regular clinic review, it is noted that her weight has increased by 4kg over 6 months. There is no change in dietary intake or medication. O/E, chest is clear and there is minimal ankle oedema. JVP was normal.
For each of the scenarios below, choose a SINGLE most appropriate diagnosis from the list above. Each option may be used once, more than once or not at all. A. Salt-wasting nephropathy B. Hypothyroidism C. Addison’s disease D. Polycystic ovary syndrome E. Reduced activity F. Heart failure G. Comfort eating H. Pregnancy I. Cushing's syndrome J. Amyloidosis K. Renal failure L. Portal hypertension M. Metabolic syndrome
Reduced activity
2) The examination here is unremarkable and there is no change in diet or medication. This patient has reduced exercise capacity with SOB on exertion, which has resulting in reduced mobility, accounting for her weight gain as less energy is being expended despite consuming the same amount.
A 45-year-old HCV positive Egyptian journalist presents with acute renal failure. He is complaining of increasing abdominal distension, pruritis, ankle oedema and weight gain. Serum albumin is low and there is hyponatraemia and thrombocytopenia.
For each of the scenarios below, choose a SINGLE most appropriate diagnosis from the list above. Each option may be used once, more than once or not at all.
A. Salt-wasting nephropathy B. Hypothyroidism C. Addison’s disease D. Polycystic ovary syndrome E. Reduced activity F. Heart failure G. Comfort eating H. Pregnancy I. Cushing's syndrome J. Amyloidosis K. Renal failure L. Portal hypertension M. Metabolic syndrome
Portal Hypertension
5) HCV in this patient is causing hepatic cirrhosis which has decompensated resulting in ascites, secondary to portal hypertension. The hypoalbuminaemia is a sign of decreased hepatic synthetic function. Hyponatraemia is a common finding associated with ascites. It arises due to reduced protein synthesis and therefore a loss of colloid osmotic pressure and increased fluid loss from the intravascular compartment, stimulating ADH secretion. There is peripheral oedema here which is due to low albumin. The pruritis is due to reduced hepatic excretion of conjugated bilirubin and there may be accompanying jaundice too. The cause of his renal failure may well be hepatorenal syndrome in the context of his severe liver disease. His prognosis is poor.
An 85-year-old who is known to be hypertensive and has mild impaired renal function presents with signs of dehydration and undergoes a laparotomy for small bowel obstruction.
For each patient below, choose the most likely analgesia listed above which should NOT be used in the postoperative period. Diclofenac Epidural bupivacaine and fentanyl Codydramol Paracetamol Morphine Tramadol
Diclofenac
1) NSAIDS may impair renal function and provoke renal failure, especially in patients with pre-existing impairment. NSAIDs should be avoided if possible in these patients or used with caution at the lowest effective dose for the shortest possible time. The mechanism of damage involves reducing creatinine clearance. NSAIDs are also contraindicated in asthmatics as it causes bronchospasm due to the accumulation of leukotrienes.
A 60-year-old man with diabetes is transferred from another hospital for urgernt femoral-distal bypass surgery and arrives with a heparin infusion in situ. His APTT is 2.4.
For each patient below, choose the most likely analgesia listed above which should NOT be used in the postoperative period. Diclofenac Epidural bupivacaine and fentanyl Codydramol Paracetamol Morphine Tramadol
Epidural bupivacaine and fentanyl
2) Epidurals are relatively contraindicated in anticoagulated patients. Insertion of the epidural needle may lead traumatic bleeding into the epidural space and with clotting abnormalities, the development of a haematoma which can lead to spinal cord compression. Coagulopathy, raised ICP and infection at the injection site are absolute contraindications. Relative contraindications include anticoagulated patients and those with anatomical abnormalities of the vertebral column. NSAIDs do not increase the risk of epidural haematoma.
A 62-year-old man who requires a knee replacement gives a history of allergy to dihydrocodeine.
For each patient below, choose the most likely analgesia listed above which should NOT be used in the postoperative period. Diclofenac Epidural bupivacaine and fentanyl Codydramol Paracetamol Morphine Tramadol
Codydramol
3) Co-dydramol is a combination of dihydrocodeine and paracetamol and the patient is known to be allergic to dihydrocodeine.
