Amir Sam DPD Lectures Flashcards
1
Q
Which artery supplies the inferior aspect of the heart?
Which ECG leads monitor it?
A
Right coronary artery
II, III, aVF
2
Q
Which artery supplies the lateral aspect of the heart?
Which ECG leads monitor it?
A
Circumflex
V5, V6, I, aVL
3
Q
Which artery supplies the anterior aspect of the heart?
Which ECG leads monitor it?
A
Left anterior descending
V1, V2, V3, V4
4
Q
Give 6 general differentials for collapse
A
Vasovagal (reaction to sudden stress or emotion)
Outflow obstruction (left - aortic stenosis, HOCM, right - PE)
Arrhythmia (SVT, atrial fibrillation, long QT)
Postural hypotension (Addison’s, anti-hypertensive drug effect)
Seizure
Hypoglycaemia (don’t ever forget glucose)
5
Q
Identify the murmur:
• Ejection systolic associated with a slow rising pulse that radiates to the carotids and is best heard in the 2nd intercostal space at the right sternal border on expiration
A
Aortic stenosis
6
Q
Identify the murmur:
• Loud first heart sound with rumbling diastolic murmur, may be associated haemoptysis, heard best in the 5th intercostal space in the mid-clavicular line on expiration
A
Mitral stenosis
7
Q
Identify the murmur:
• Pan-systolic murmur radiating to axilla, best heard in the 5th intercostal space on expiration
A
Mitral regurgitation
8
Q
Identify the murmur:
• Blowing diastolic murmur heard best in the 3rd intercostal space at the sternal edge and exaggerated by leaning forward and breathing out
A
Aortic regurgitation
9
Q
Describe three steps in the management of SVT acutely
A
Vagal manoeuvres (Valsalva manoeuvre, carotid sinus massage)
Adenosine
DC cardioversion if there is heamodynamic instability
10
Q
Describe the management of atrial fibrillation of onset >48 hours
A
Anticoagulate for 3-4 weeks
Control rate with beta blockers and digoxin (also potentially a rate-limiting CCB e.g. Verapamil)
Then attempt chemical or electrical cardioversion
11
Q
Describe the management of ventricular tachycardia
A
I.V. amiodarone and CPR
In pulseless ventricular tachycardia, start CPR and defibrillate
12
Q
Give three causes of ventricular tachycardia
A
Ischaemic heart disease
Electrolyte imbalance
Long QT syndrome
13
Q
Give three causes of pleuritic chest pain
A
Pneumonia Pneumothorax PE Pericarditis Any pathology affecting the pleura (e.g. malignancy)
14
Q
What does the S3 heart sound indicate?
A
Heart failure
15
Q
What does the S4 heart sound indicate?
A
Ventricular hypertrophy
16
Q
An ECG shows a narrow complex tachycardia. The rate is regular, but not sinus rhythm as there are no p-waves visible.
What is the most likely diagnosis?
A
SVT
17
Q
An ECG shows progressively lengthening p-r intervals, which is followed by a missing QRS complex, after which the p-r interval returns to normal
What is the most likely diagnosis?
A
2nd degree heart block
Mobitz I
18
Q
An ECG shows a broad complex tachycardia with no p-waves visible. The patient is unconscious.
What is the most likely diagnosis?
A
Ventricular tachycardia
19
Q
An ECG shows no p-waves, but a sawtooth baseline pattern ocurring at a rate of roughly 150bpm.
What is the most likely diagnosis?
A
Atrial flutter
20
Q
An ECG shows broad QRS complexes with an ‘M’ pattern in V1 and a ‘W’ pattern in V6.
What is the most likely diagnosis?
A
Right bundle branch block
Remember - WiLLiaM MaRRoW
21
Q
An ECG shows a highly variable p-r interval. Upon closer inspection you realise the rate of the p-waves is different to that of the QRS complexes.
What is the most likely diagnosis?
A
3rd degree (total) heart block
22
Q
An ECG shows normal QRS complexes with a normal p-r interval and at a regular rate, except there is a missing QRS after every second complex.
What is the most likely diagnosis?
A
2nd degree heart block
Mobitz II
This is 3:2 heart block as there are three p-waves for every two QRS complexes
23
Q
An ECG shows a prolonged p-r interval, but no other abnormalities.
What is the most likely diagnosis?
A
1st degree heart block
24
Q
A patient presents with chest pain. Their ECG shows significant t-wave inversion in leads V1-V4.
What is the most likely diagnosis?
A
Partial occlusion of the left anterior descending artery (Wellens’ syndrome)
25
A 60 yo man with COPD presents with sudden SOB. Breath sounds are reduced on the right side. His O2 sats are 80% on room air.
What is the most likely diagnosis?
1. Pneumothorax
2. Pulmonary embolism
3. Airway disease
4. Pneumonia
5. Pulmonary oedema
6. Interstitial lung disease
7. Pleural effusion
8. Anaemia
9. Thyrotoxicosis
10. Nerve/muscle disease
1. Pneumothorax
26
A 60 yo man with COPD presents with sudden SOB. Breath sounds are reduced on the right side. His O2 sats are 80% on room air.
He is confirmed to have a pneumothorax of <2cm, given his COPD, what is the most appropriate next step?
Aspiration
In a patient with underlying disease causing the pneumothorax (COPD in this case), aspiration is indicated for <2cm, and insertion of a chest drain is indicated for >2cm.
If the pneumothorax occurs in someone with no background or causative disease, disscharge and repeat CXR is indicated for <2cm, and aspiration is indicated for >2cm.
27
```
A 47 year old woman presents with acute SOB and pleuritic chest pain.
PMHx: DVT
O2 Saturation: 78% (air)
PR: 110 bpm
BP: 120/80 mmHg
JVP is raised
Vesicular BS
```
What is the most likely diagnosis?
1. Pneumothorax
2. Pulmonary embolism
3. Airway disease
4. Pneumonia
5. Pulmonary oedema
6. Interstitial lung disease
7. Pleural effusion
8. Anaemia
9. Thyrotoxicosis
10. Nerve/muscle disease
2. Pulmonary embolism
28
```
A 47 year old woman presents with acute SOB and pleuritic chest pain.
PMHx: DVT
O2 Saturation: 78% (air)
PR: 110 bpm
BP: 120/80 mmHg
JVP is raised
Vesicular BS
```
You strongly suspect a PE, what is the next most appropriate step in her management?
1. LMWH
2. BiPAP
3. Warfarin
4. Thrombolysis
5. Furosemide
1. LMWH
LMWH is given whilst waiting for imaging to anticoagulate the patient if there is a strong suspicion of a PE.
Thrombolysis is not indicated unless the patient is haemodynamically unstable.
Imaging would ideally be a CT pulmonary angiogram, but a V/Q scan could be used if the contrast were contraindicated.
Warfarin is used once the diagnosis is confirmed.
29
A 50-year-old female presents with progressive SOB accompanied by a dry cough. She has clubbing.
FEV1/FVC ratio > 70%.
Her CXR shows reticular nodular shadowing.
What is the most likely diagnosis?
Idiopathic pulmonary fibrosis
FEV1/FVC ratio > 70% indicates restrictive disease
30
A 50-year-old female presents with a productive cough featuring green sputum on a background of chronic SOB and cough with clear sputum production
No clubbing
FEV1/FVC ratio < 70%
Her chest x-ray is clear but shows hyper-inflated lung fields
What is the most likely diagnosis?
Infective exacerbation of COPD
31
A 45 yo man presents with cough for 3 months, 1 episode of haemoptysis, weight loss, and night sweats.
CXR shows an apical lung lesion
Tuberculosis
32
A 70-year-old man presents with SOB
He keeps pigeons
His CXR shows bilateral extensive reticular nodular shadowing
Extrinsic allergic alveolitis
33
Give three causes of alveolar shadowing on CXR
Pulmonary haemorrhage
Pneumonia
Pulmonary oedma
34
Give the two causes of reticular nodular shadowing on CXR
Fibrosis
| Extrinsic allergic alveolitis
35
Give two causes of homogenous shadowing on a CXR
Pleural effusion
| Lobar collapse
36
A CXR shows alveolar shadowing restricted to the right middle zone of the lungs
What is the most likely diagnosis?
Right middle lobe pneumonia
37
Give 3 causes of bilateral hilar lymphadenopaty
Sarcoidosis
TB
Lymphoma
38
What type of surgery does this scar indicate?
Right subcostal (Kocher's) incision
Biliary surgery
39
What type of surgery does this scar indicate?
Mercedes-Benz incision
Liver transplant
40
What type of surgery does this scar indicate?
Midline laparotomy incision
GI or any major abdominal surgery
41
What type of surgery does this scar indicate?
McBurney’s (Gridiron) incision
Appendicectomy
42
What type of surgery does this scar indicate?
J-shaped/ ‘hockey stick’ incision
Renal transplant
43
What type of surgery does this scar indicate?
Low transverse (Pfannenstiel) incision
Gynaecological procedures
44
What type of surgery does this scar indicate?
Inguinal incision
Hernia repair, vascular access
45
What type of surgery does this scar indicate?
Loin incision
Nephrectomy
46
Give three abdominal causes of clubbing
Cirrhosis
Coeliac
Colitis (IBD)
47
Give 5 causes of hepatomegaly
Cirrhosis
Metabolic/ infiltration (malignancy, Wilson's disease, haemachromatosis)
Infection (e.g. hepatitis)
Right heart/ congestive cardiac failure
Biliary issues (e.g. primary biliary cirrhosis)
48
Give 4 causes of splenomegaly
Portal hypertension
Autoimmune disease (e.g. rheumatoid arthritis)
Infection (e.g. infectious mononucleosis)
Haemolytic anaemia
49
Which 4 symptoms define Parkinsonism
Bradykinesia, rigidity, tremor, and postural instability
50
Parkinsonism with limited up-gaze indicates what disease?
Progressive supranuclear palsy/ Steele-Richardson-Olszewski syndrome
51
Parkinsonism can be seen in Lewy body dementia, which 3 other features make up Lewy body dementia?
Visual hallucinations
REM disturbance
Cognitive impairment
52
Give three cardiac differentials of chest pain
Ischaemic heart disease
Aortic dissection
Pericarditis
Myocarditis
53
Give three respiratory differentials of chest pain
Pneumonia
Pneumothorax
PE
Pleural malignancy
54
Give three GI differentials of chest pain
Gastritis
Oeshophagitis/ GORD
Oeshophageal spasm
55
Give 5 differentials of epigastric pain
```
Oesophagitis/ GORD
Peptic ulcer/ duodenal ulcer
MI
Pancreatitis
Cholecystitis
Oesophageal spasm
Gastroenteritis
Malignancy
```
56
Give 5 differentials of RUQ pain
Hepatic: abscess, viral hepatitis
Biliary: primary sclerosing cholangitis, primary biliary cirrhosis, ascending cholangitis, cholecystitis/ gallstones
Respiratory: basal pneumonia
57
Give 5 differentials of right iliac fossa pain
```
Appendicitis
IBD
Caecal carcinoma/ other malignancy
Ruptured ectopic pregnancy
Ovarian cyst twist/ rupture/ bleed
Mesenteric adenitis
Direct inguinal hernia
```
58
Give 3 differentials of suprapubic pain
Cystitis
Urinary retention
UTI
59
Give 5 differentials of left iliac fossa pain
```
Diverticulitis
IBD
Malignancy
Ruptured ectopic pregnancy
Ovarian cyst twist/ rupture/ bleed
Direct inguinal hernia
```
60
Give 5 causes of diffuse abdominal pain
```
IBD
Obstruction
Gastoenteritis
Peritonitis
Mesenteric ischaemia
DKA
Addison's
Hypercalcaemia
Lead poisoning
Porphyria
```
61
A 65 year old man who underwent a AAA repair 2 days ago develops diffuse abdominal pain
PR: 120 bpm
RR: 30
What is his blood test most likely to show?
1. Normal lactate
2. High amylase
3. High Bicarbonate
4. High sodium
5. High Calcium
2. High amylase
Any cause of an acute abdomen will elevate amylase
62
Give 3 transudate causes of ascites
Liver failure (decreased albumin production)
Cirrhosis causing portal hypertension
CCF causing liver failure
Nephrotic syndrome
63
Give 3 exudate causes of ascutes
Malignancy
Infection
Budd-Chiari syndrome (one in a million incidence)
64
A 50 year old man presents with jaundice, RUQ pain, dark urine, and pale stool
What is the most likely cause of the pale stool
1. Low biliverdin
2. High unconjugated bilirubin
3. High conjugated bilirubin
4. Low urobilinogen
5. Low stercobilinogen
5. Low sterobilinogen
This man's common bile duct is obstructed, so stercobilinogen (which makes stool brown) is not being excreted in the stool
65
Give 3 causes of pre-hepatic jaundice
Increased haemolysis (sickle cell, spherocytosis, hypersplenism in portal hypertension, haemolytic-uraemic syndrome, G6PD deficiency, pyruvate kinase deficiency etc.)
66
Give 3 causes of hepatic jaundice
```
Viral hepatitis
Cirrhosis
CCF
Autoimmune liver damage
Metabolic liver damage (haemochromotosis, Wilson's disease)
Drugs (e.g. paracetamol overdose)
```
67
Give 3 causes of post-hepatic (obstructive) jaundice
Gallstones in common bile duct
Carcinoma of the head of the pancreas/ cholangiocarcinoma
Stricture
Pancreatitis
Biliary inflammation (ascending cholangitis, sclerosing cholangitis, biliary cirrhosis)
68
50 year old man presents with painless jaundice, weight loss, pruritis, dark urine, and pale stool
O/E he has thrombophlebitis
Which of these options are most likely to be elevated in his blood tests?
1. ALP, CA19-9
2. AST, CA 125
3. ALP, alfa-fetoprotein
4. ALT, alfa-fetoprotein
5. ALP, CEA
1. ALP, CA19-9
ALP is a marker of bile duct obstruction and malignant infiltration. CA19-9 is a tumour marker for pancreatic cancer.
Painless jaundice in an older person (especially one with a palpable gallbladder) is concerning because of the possibility of pancreatic cancer. The pale stool, dark urine, and itching are all due to obstruction of the bile duct. The thrombophlebitis mentioned is Trousseau's sign of malignancy: vessel inflammation due to a venous clot which is associated with particular cancers e.g. pancreatic.
69
Give 5 causes of bloody diarrhoea
```
Infectious diarrhoea
Ischaemic diarrhoea
IBD
Malignancy
Ruptured varices
Diverticulitis
```
70
Give 5 organisms that may cause infectious diarrhoea
The acronym to remember is CHESS
```
Campylobacter jejuni
Haemorrhagic E. coli
Entomeaba histolytica
Shigella
Salmonella
```
71
What do thickened haustral folds on AXR indicate?
IBD
| The cause of the thickening is mucosal oedma
72
What would a dilated colon of greater than 6cm on AXR, combined with hypotension and tachycardia indicate?
Toxic megacolon
73
Describe the initial management of an acute GI bleed
ABC approach
Give i.v. fluids
G&S/ X-match in case transfusion is required
OGD
74
What two things would you add to the initial management of an acute GI bleed if the cause was a variceal bleed?
Terlipressin (vasoconstrictor)
| Antibiotics (to treat any bacterial translocation that occurs after the bleed)
75
Describe the initial management of an acute abdomen
```
Make the patient NBM
I.v. fluids
Antibiotics
Analgesia
Anti-emetics
Monitor vitals and urine output
```
76
Which blood tests would you request for an acute abdomen?
What imaging would you request?
```
FBC
LFTs
U&Es
CRP
G&S/ X-match
Clotting
```
```
Erect CXR (looking for air under the diaphragm)
CT
```
77
What is the first step in the management of hepatic encephalopathy?
Lactulose/ enema
Hepatic enecephalopathy is caused by the liver's inability to process ammonia produced by bacteria in the gut. By increasing the speed at which the gut's contents are passed, the ammonia produced is decreased
78
24 yr old man presents with breathlessness and facial swelling after having a Chinese take-away
```
What is the first step in management?
A. IM adrenaline
B. IV adrenaline
C. IM hydrocortisone
D. IV hydrocortisone
E. IV fluids
```
A. IM adrenaline
This is anaphylaxis and so immediate treatment to keep the patient's airways open and prevent shock is I.M. adrenaline. Adrenaline cannot be given I.V. here as it would likely cause cardiac arrest.
Hydrocortisone is a steroid, and although steroids might be used later to control systemic inflammation as the patient recovers, they will not act quickly enough to be immediately useful.
I.v. fluids would raise the patient's blood pressure, but wouldn't relax their airways.
79
45 yr old man presents with cough and breathlessness. He has travelled recently
O/E: coarse crepitations & bronchial breathing
Hyponatraemia
Deranged LFTs
What antibiotic would you prescribe in addition to amoxicillin?
```
A. Cefuroxime
B. Clarithromycin
C. Co-amoxiclav
D. Tazocin
E. Vancomycin
```
B. Clarithromycin
Clarithromycin is a macrolide antibiotic that is added to cover the atypical pneumonias ( legionella pneumoniae, mycoplasma pneumoniae, chlamydia pneumophilia) which are the cause of up to 40% of community acquired pneumonias
80
Give 4 causes of oncholysis (fingernails lifting up from the nail bed)
Fungal
Trauma
Thyrotoxicosis
Psoriasis
81
A 50 yr old man presents with dyspepsia and weight loss
Hb: 70
MCV: 70
What test would you request?
```
A. Abdominal CT
B. Abdominal USS
C. Erect CXR
D. Colonoscopy
E. OGD (gastroscopy)
```
E. OGD (gastroscopy)
In an older man with unexplained anaemia, you would be worried about a GI bleed, especially in the context of GI symptoms. The quickest way to rule this out is to visualise the GI tract with endoscopy, which will be a OGD as the patient has upper GI symptoms.
In reality you would also do B12, iron, folate, and TTG ab tests.
82
A 70 year old man presents with bloody diarrhoea
Stool micro & culture: -ve
Stool C. diff toxin: -ve
```
What is the most likely diagnosis?
A. Infective colitis
B. Ischaemic colitis
C. Ulcerative colitis
D. Appendicitis
E. Gastroenteritis
```
B. Ischaemic colitis
Stool cultures rule out an infective cause, and given the patient is older, ischaemic is the most likely option.
83
A 40 yr old man presents with palpitations which started 4 hours ago and have never occurred before. An ECG shows an unstable baseline and absent p-waves, the patient is tachycardic and the heart rate is irregular.
```
What is the most appropriate treatment option?
A. Adenosine
B. Amiodarone
C. Digoxin
D. Metoprolol
E. DC cardioversion
```
E. DC cardioversion
This patient has atrial fibrillation of onset <48 hours. That means there is unlikely to be a clot formed in the atria of his heart that could be displaced, so it is safe to either electrically or chemically (flecainide) cardiovert him.
If the palpitations were of onset>48 hours, the patient would need to be anti-coagulated for 3-4 weeks with warfarin before cardioversion was attempted. During this time rate control would be attemepted using beta blockers and digoxin.
84
```
60 yr old man is brought to A&E confused, with a cough, but no postural hypotension. He doesn't drink but used to smoke
Na+: 120
K+: 4.0
TFTs: normal
SST: normal
Urine Na+: 40
Urine osmolality: 400
```
```
What test would you request next?
A. Brain MRI
B. CT Abdomen
C. CXR
D. Lung function tests
E. OGD
```
C. CXR
This patient's confusion is due to hyponatraemia, which in turn is due to SIADH causing this patient to retain excess water which has diluted the sodium in his blood.
Given the smoking history and cough, this is likely SIADH secondary to small cell lung carcinoma (the tumour secretes inappropriate ADH).
85
20 year old woman presents with diffuse abdominal pain and vomiting. She is a known type I diabetic.
Capillary blood glucose: 20
Venous pH: 7.20
```
What is the most appropriate next step?
A. Capillary ketone
B. FBC
C. HbA1c
D. LFTs
E. CRP
```
A. Capillary ketone
Capillary ketone test will confirm DKA, as the three criteria for DKA are:
Ketonaemia > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)
Blood glucose > 11.0mmol/L or known diabetes mellitus
Bicarbonate (HCO3-) < 15.0mmol/L and/or venous pH < 7.3
https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf
86
A 40 year old man presents with loin pain.
CRP: normal
Urinalysis: blood ++
```
What investigation would you request?
A. Abdominal X-ray
B. Abdominal USS
C. CT KUB
D. CT with contrast
E. MR Angiogram
```
C. CT KUB
CTKUB is the best option for investigating kidney stones, though there is a chance the kidney stone will be radio lucent if it is not made from calcium.
87
50 year old man presents with backache. Blood tests show hypercalcaemia, low PTH, normal ALP.
```
What is the most likely diagnosis?
A. Bone metastases
B. Multiple myeloma
C. Osteoporosis
D. Primary hyperparathyroidism
E. Secondary hyperparathyroidism
```
B. Multiple myeloma
Multiple myeloma is a malignant disorder of plasma B-cells causing them to proliferate uncontrollably. The plasma cells release immunoglobulin light chains which deposit in the kidneys causing kidney failure. The plasma cells also invade bone and bone marrow, leading to easy fracturing and bone marrow failure (anaemia, infection, bruising and bleeding in late stages).
Commonly a patient will present with back pain along with hypercalcaemia symptoms (calcium is released as the abnormal cells break down bone) e.g. polyuria, polydipsia, depression, renal stones, abdominal pain.
ALP is an enzyme made by osteoblasts which is often elevated in disease which damages bone. MM is an exception because the abnormal plasma cells suppress osteoblast activity, counteracting the ALP increase, making the reading normal.
88
A 35 yr old woman presents with ankle oedema. A recent echocardiogram revealed no abnormalities.
U&Es: normal
ALT, AST & ALP: normal
Albumin: 15 (normal range 33g/L-55g/L)
```
What test would you order next?
A. Coronary angiogram
B. Renal USS
C. Troponin
D. Urinalysis
E. Repeat LFTs
```
D. Urinalysis
This woman has oedema and hypoalbuminaemia, which are two of the triad that define nephrotic syndrome - an increase in the permeability of the glomerulus that allows protein to leave the blood and enter the urine. The final element o the triad is proteinuria, so to confirm a diagnosis of nephrotic syndrome, urinanalysis is needed.
89
A 30 year old man presents with recurrent GI & nose bleeds. His lips and tongues have numerous small, visible, and abnormal blood vessels.
```
What is the diagnosis?
A. Acromegaly
B. Cirrhosis
C. Hereditary telangiecstasia
D. Peutz-Jegher syndrome
E. Systemic sclerosis
```
C. Hereditary telangiecstasia
Also known as Osler-Weber-Rendu syndrome, hereditary telangiectasia is an autosomal dominant condition causing abnormal blood vessels to form and bleed in mucous membranes, skin, lungs, skin, brain, and liver.
Patients will commonly experience nosebleeds and telangiectasia on the face, but more serious complication (e.g. AV malformation in organs causing dysfunction and bleeding)
90
```
A patient's U&Es are as follows:
Na+: 120
K+: 5
A short Synacthen test yields the following results:
0 min cortisol: 100
30 min cortisol: 200
```
```
What is the most likely diagnosis?
A. Acromegaly
B. Adrenal insufficiency
C. Cushing’s syndrome
D. Graves’ disease
E. Myxoedema (hypothyroidism)
F. Premature ovarian failure
G. Primary hyperaldosteronism
H. Prolactinoma
I. Multinodular goitre
J. Thyroiditis
```
A. Adrenal insufficiency
Cortisol should rise to greater than 500 nanomol/L after 30 minutes in a healthy individual.
91
PRL: 1000 (raised)
IGF-1: 100 (raised)
OGTT: failure of GH suppression
```
What is the most likely diagnosis?
A. Acromegaly
B. Adrenal insufficiency
C. Cushing’s syndrome
D. Graves’ disease
E. Myxoedema (hypothyroidism)
F. Premature ovarian failure
G. Primary hyperaldosteronism
H. Prolactinoma
I. Multinodular goitre
J. Thyroiditis
```
A. Acromegaly
Acromegaly is caused by excess growth hormone secretion in adults (in children this causes gigantism). The most common cause is a pituitary tumour secreting unregulated GH, however GH is not directly measured because it is too flluctuant. Instead IGF-1, a growth factor released from the liver when it is stimulated by GH, is measured.
These tumours will sometimes also secrete prolactin (hence the raised prolactin in this case). These tumours express dopamine receptors, which have an inhibitory effect on the tumour, and so can be treated with dopamine agonists (cabergoline, bromocriptine).
Ideally the pituitary tumour ill be surgically removed, with somatostatin analogues (octreotide) being used as adjuncts to shrink the tumour an control symptoms.
92
PRL: 10,000 (raised)
Testosterone: 6 (low)
LH <1 (low)
FSH <1 (low)
```
What is the most likely diagnosis?
A. Acromegaly
B. Adrenal insufficiency
C. Cushing’s syndrome
D. Graves’ disease
E. Myxoedema (hypothyroidism)
F. Premature ovarian failure
G. Primary hyperaldosteronism
H. Prolactinoma
I. Multinodular goitre
J. Thyroiditis
```
H. Prolactinoma
Prolactin suppresses release of gondotrophins. Prolactinaemia is not always due to a prolactinoma: it can be caused by any tumour that compresses the median eminence, as this cuts of the system of vasculature which carries dopamine to the anterior pituitary. Dopamine inhibits prolactin release, hence this causes prolactinaemia. However, that is not the cause here, because as a rule, a prolactin of 6000 or greater can only be caused by a prolactinoma.
93
A 14 year-old boy presents with recent diarrhoea (1 week ago) and is now feeling fatigued and nauseous. FBC shows a normocytic anaemia and low platelets, and U&Es show an elevated creatinine.
```
Which of the following will most likely be found on this patient's blood film?
A. Codocytes (target cells)
B. Eliptocytes
C. Increased lymphocytes
D. Schistocytes (RBC fragments)
E. Spherocytes
```
D. Schistocytes (RBC fragments)
This is a description of haemolytic-uraemic syndrome, characterised by haemolytic anaemia, thromboytopenia, and uraemia.
HUS is usually preceded by infection causing diarrhoea (most commonly Enterohaemorhagic E.coli, but sometimes Shigella or campylobacter).
The infection triggers inappropriate clotting which has the most pronounced effects on the kidney (as the kidney is sensitive to ischaemia and has a lot of small blood vessels that can be easily infarcted). The clotting leads to the anaemia: as RBCs try to push past clots in blood vessels, they are sheared and destroyed, leading to haemolytic anaemia and schistocytes on a blood film.
94
A patient presents with central chest pain. Upon auscultation there is a scratching sound heard. He admits to having a throat infection about a week ago.
What would be the most likely finding on his ECG?
A. Absent p-waves
B. Tall QRS complexes
C. Tented t-waves
D. Widespread saddle ST elevation
E. ST elevation in leads II, III, and aVF
D. Widespread saddle ST elevation
Pericarditis is inflammation of the tissue surrounding the heart, often presenting shortly after a viral throat infection. It causes a central sharp chest pain that is worse on inspiration and is relieved when sitting forward.
95
A 60 year-old woman is brought to A&E after a collapse. Her BP is normal with no postural drop. HS I+II+ an ejection systolic murmur that radiates to the carotids. Her ECG shows tall QRS complexes in V4, V5, and V6.
```
What is the most likely diagnosis?
A. Left atrial hypertrophy
B. Left ventricular hypertrophy
C. Right atrial hypertrophy
D. Right ventricular hypertrophy
E. Third degree heart block
```
B. Left ventricular hypertrophy
Tall QRS complexes indicate ventricular hypertrophy, which can cause an outflow obstruction leading to collapse. Given that the tall QRS complexes are in the leads examining the left side of the heart, left ventricular hypertrophy is the most likely diagnosis.
An ejection systolic murmur is associated with aortic stenosis, which in this case has caused the ventricular hypertrophy. A systolic murmur can also be associated with HOCM. Differences between the two:
Aortic stenosis radietes to the carotids, and is heard best in the 2nd space at the left sternal edge, and is decreased by a Valsalva manoeuvre
HOCM does not radiate to the carotids, is heard best at the apex of ths heart, and is increased by a Valsalva manoeuvre
96
Free T4: 5 (low
TSH: 60 (high)
Prolactin 700 (high)
```
What is the most likely diagnosis?
A. Acromegaly
B. Adrenal insufficiency
C. Cushing’s syndrome
D. Graves’ disease
E. Myxoedema (hypothyroidism)
F. Premature ovarian failure
G. Primary hyperaldosteronism
H. Prolactinoma
I. Multinodular goitre
J. Thyroiditis
```
E. Myxoedema (hypothyroidism)
Primary hypothyroidism results in a loss of feedback to the pituitary and hypothalamus, so TRH and TSH are high. TRH, in addition to stimulating TSH release, stimulates prolactin release, hence prolactin is high.
97
A 34 year-old woman presents with weakness in her legs. Her legs have increased tone, decreased power, decreased pinprick sensation, and brisk reflexes. She also has blurred vision, which she says has happened once before, two months ago. Fundoscopy is performed.
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What is the most likely cause of her blurred vision?
A. Amaurosis fugax
B. Anterior uveitis
C. Papilloedema
D. Papillitis
E. Vitreous haemorrhage
```
D. Papillitis
This is a history of MS, given the two neurological deficits separated in time and space. Blurred vision and eye pain are common symptoms of MS, and are due to inflammation of the optic nerve. Papillitis is the term for inflammation of the head of the optic nerve and has caused this patient's double vision. On fundoscopy, papillitis appears the same as papilloedema. They are distinguished by symptoms - papilloedema would not be accompanied by eye pain and reduced vision, but may be accompanied by symptoms of raised ICP.
98
```
A 60 year old man presents with pain & paraesthesia in the anteriolateral region of his right thigh
PMHx: Type 2 Diabetes
Metformin
HbA1C: 60 mmol/mol (high)
BMI: 30 kg/m2
```
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What is the most appropriate management?
A. Lose weight
B. Insulin
C. Statin
D. Aspirin
E. MRI brain
```
A. Lose weight
This is a history of meralgia paraesthetica, which is caused by compression of the lateral cutaneous femoral nerve. This is usually caused by weight gain and subsequent pressure on the nerve from clothing. Management is to buy looser clothing and lose weight. If the nerve problems persist, carbamazepine and gabapentin can be used for treatment.
99
A 60 year old man is brought to see his GP because of recurrent falls. His daughter also says he has been more forgetful lately, and has had some trouble swallowing food. O/E there is tremor at rest and rigidity, and he seems to have limited up-gaze.
```
What is the most likely diagnosis?
A. Stroke
B. Lew body dementia
C. Progressive supranuclear palsy
D. Epilepsy
E. Alzheimer’s disease
```
C. Progressive supranuclear palsy
Progressive supranuclear palsy (also called Steele-Richardson syndrome) has all the same signs of Parkinson's disease, but includes a limited ability to gaze upwards.
100
```
Which option is the correct cut-off point for attempting thrombolysis in a stroke patient?
A. 3 hours
B. 4.5 hours
C. 6 hours
D. 7.5 hours
E. 9 hours
```
B. 4.5 hours
Remember to always perform a CT head before attmpeting thrombolysis - otherwise there is no way tot ell an embolic stroke from a haemorrhagic stroke. To be clear - if you thrombolyse a patient who has had a haemorrhagic stroke, you will kill them.
101
Where do spider naevi occur?
A. Only on the abdomen
B. On the abdomen and chest
C. In the distribution of the superior vena cava
D. In the distribution of the inferior vena cava
E. Only on the back
C. In the distribution of the superior vena cava
Spider naevi are caused by dilation of the smooth muscle around a cutaneous arteriole, which allows blood to be diverted to the skin. This is a response to increased concentration of circulating oestrogens. Pregnant women, or women using oral contraception can develop spider naevi, but it is also a sign of liver disease, as a damaged liver cannot metabolise oestrogens properly.
