Clinical cases and overview of systems

Question 1

What is angioedema?

Answer 1

Immunological deficiency of C1 esterase inhibitor. Complement activated on minot trauma e.g. dental treatment. Swelling and risk to airway.

Question 2

You are presented with an axial scan through the brain which shows a convex white shape protruding inwards from the outer LHS. What is the diagnosis, signs and treatment?

Answer 2

Extradural haemorrhage from middle meningeal artery
Confusion, LoC
Cut into skull 2cm up from zygomatic arch, drill hole and drain blood to release pressure

Question 3

You are presented with an axial scan through the brain which shows white all the way down the entire side of the brain. What is the diagnosis and why does it occur?

Answer 3

Subdural haematoma
Occurs slowly and in elderly due to cerebral atrophy and anticoagulant medication, where bridging veins in that region undergo trauma

Question 4

You are presented with an axial scan through the brain of a white circle in the central portion of the brain. What is the diagnosis and when does it occur?

Answer 4

Subarachnoid haemorrhage

Spontaneous or secondary to trauma

Question 5

What are the signs seen in Horner’s syndrome?

Answer 5

One side of patient abnormal. Smaller pupil of affected side (myosis). Ptosis (hooded eyelid). Enophthalmos (eye sunken back). Less sweating on that side of face.

Question 6

What are the causes of Horner’s syndrome?

Answer 6

Neck lesions pressing on sympathetic nerve plexus lying on surface of carotid artery

Question 7

What would a child look like if they presented with Impetigo (staphylococcal skin infection)?
Would you treat?
What could be prescribed as treatment?

Answer 7

Golden crusted lesions
No - highly contagious
Fusidic acid ointment or penicillin if systemic

Question 8

What is indicated if a patient has pitting oedema where a depression is left where the thumb has been?

Answer 8

Cardiac disease or lymphedema

Question 9

If you see a red/purple lesion on the palate that is not typical or erythroplakia, and the pt has similar skin lesions, what would you suspect?

Answer 9

Kaposi’s sarcoma associated with HHV8

Question 10

If patient coughing, ask if they bring up any phlegm. If the colour is yellow/green what does this indicate?

Answer 10

May have upper/lower respiratory tract infection - defer treatment until better

Question 11

A patient presents with a lump in the neck that moves up when the tongue sticks out. What could be a congenital cause?

Answer 11

Thyroglossal cyst - embryologically thyroid gland develops at base of tongue (foramen caecum = remnants). As it descents down the tract to where the thyroid gland is thyroglossal cysts can form

Question 12

If a patient presents with prominent supraorbital ridges, small frontal sinuses, coarse ST profile ie big lips, large extremities and spaced out teeth, what may they have?

What causes this?

Answer 12

Acromegaly - excess growth hormone secreted by the pituitary gland

Question 13

If a patient has Addisons disease from adrenal hypofunction, what clinical feature would you notice and why does this occur?

Answer 13

Pigmentation of the buccal mucosa and palms of hands - melanocyte stimulating hormone is chemically similar to ACTH caused intrinsic staining

Question 14

If a patients left side of face is not moving but the forehead is spared, what has been affected?

Answer 14

Upper motor neurone

Question 15

If a patients entire left side of face is not moving, what has been affected? If it is idiopathic, what is it called?

Answer 15

Lower motor neurone

Bell’s palsy

Question 16

What is a complication of long-term steroids? What are some of the clinical features?

Answer 16

Cushing’s syndrome
Moon face, buffalo hump, increase susceptibilty infections, stretch marks from thin skin, gynocomastia, peptic ulceration risk, diabetes, osteoporosis (pt put on bisphosphonates), bruising, females lack periods and have beards

Question 17

In a glossopharyngeal nerve palsy, the uvula will be deviating to one side. If it is pulled to the left side, which side is the nerve affected?

Answer 17

Right side (pulling away as this side is weak)

Question 18

In a hypoglossal nerve palsy, the patient has pushed their tongue out but it is deviated to the left. What side has the nerve been affected?

Answer 18

Left. The right side is strong and pushes tongue over to affected side

Question 19

If a patient has idiopathic thrombocytic purpura (ITP), what will the patient have wrong?
What are these patients given in terms of treatment?

Answer 19

Low platelet count and haemorrages in skin

Prescribed steroids to increase platelet production not by platelet transfusion

Question 20

What is erythema nodosum? What does it indicate?

Answer 20

Raised painful plaques on shins

Non-specific indicator of disease. IBD and viral

Question 21

How does herpatic whitlow occur?

What should you do to prevent it?

Answer 21

If you treat a pt with coldsores with an open wound on finger
Wear gloves, treat pt once coldsore healed

Question 22

What are the 9 features used to describe a lump?

Answer 22

1) Site
2) Size and shape (can say max and min dimension)
3) Surface (smooth or oscillated)
4) Edge (well defined or ill defined)
5) Consistency (hard, soft, rubbery or fluctuant ie fluid, or pulsatile)
6) Fixation/tethering
7) Effects on adjacent structures (nerves)
8) ? Enlargement of draining lymph nodes (may indicate lump infected or malignant)
9) Transilluminability (if fluid filled)

Question 23

What radiographic changes would you expect to see in Rheumatoid arthritis?

Answer 23

Joint space narrowing
Osteopenia
Erosions

Question 24

What radiographic changes would you expect to see in Osteoarthritis?

Answer 24

Joint space narrowing
Subchondral sclerosis
Osteophytes (outgrowths of bone)
Subchondral cysts

Question 25

Describe a total knee replacement and what should you do in terms of antibiotic cover?

Answer 25

PTFE and titanium with intermate interface between prosthesis and bone. Lasts 15 years Surgeons may ask for cover for bacteraemia producing procedures as risk of infective joint replacement - but amoxicillin has poor bone penetration and cover is not recommended

Question 26

What are the extraintestinal signs of inflammatory bowel disease?

Answer 26

Pyoderma gangrenosum - on lateral side of ankle Erythema nodosum - on shins Uveitis - unequal pupil

Question 27

How many lobes are in the right and left lungs?

Answer 27

R=3 L=2

Question 28

On a chest xray, what is the costophrenic angle and what should be seen?

Answer 28

Between the thoracic wall and diaphragm Radiolucency should be seen below left hemidiaphragm = gastric air bubble Any radiolucency below right hemidiaphragm = pathological

Question 29

Where is an inhaled foreign body more likely to end up?

Answer 29

In the right lung as the right main bronchus more vertical and the opening is higher

Question 30

What would the differences be on a chest xray for lobar pneumonia and diffuse interstitial pneumonia?

Answer 30

``` Lobar = localised radio-opacity to one lobe Diffuse = Radio-opacities distributed more evenly through the lungs ```

Question 31

What should you ask about if you see a patient with corneal arcus (white ring around iris)?

Answer 31

Ask about CVS history | Sign of hypertriglyceridemia and raised cholesterol

Question 32

What is ascites/distended abdomen?

Answer 32

Pathological fluid in abdomen, will need ascitic tap (needle in abdomen to draw fluid out). Seen in severe malnutrition.

Question 33

What is dupuytren's contracture?

Answer 33

Contraction of palmar fascia where little finger and ring finger flexed. Idiopathic, drinking too much alcohol, older antiepileptic drugs can cause this.

Question 34

What is erythema ab igne?

Answer 34

Arises in pts with painful joints e.g. from arthritis - pt puts something hot to relieve pain and gets a marbled effect on skin

Question 35

What are the causes of a DVT and how can you identify it?

Answer 35

High oestrogen contraceptive pill, immobility, pelvic surgery, smoking, pregnancy, long travel Calf is tender, red, swollen and usually unilateral. If pt C/O sharp pleuritic chest pain then pulmonary embolism