Clinical Cases Uncovered

Question 1

What TFT do you need to specifically check in amiodarone treatment?

What pattern does amioderone treatment characteristically give?

Answer 1

Due to suppression of T4 to T3 conversion, amiodarone use can be associated with:

• High FT4 concentrations, without clinical hyperthyroidism (therefore, it is essential to check T3 in patients receiving amiodarone treatment)
• Low FT3 concentrations (usually low normal levels)

In the first 3 months of amiodarone use, TSH may be elevated (lack of full negative feedback on the pituitary due to low T3 levels)

After 3 months, the pituitary seems to adjust to the low normal T3 concentrations and TSH normalizes.

The combination of high FT4, normal T3 and TSH in
an individual taking amiodarone is not uncommon and does not require any medical intervention at this stage, but will require regular monitoring.

Question 2

How do you differentiate amiodarone induced hyperthyroidism type 1 and type 2?

Why is this important?

Answer 2

Type 1 amiodarone-induced thyrotoxicosis (AIT): similar to autoimmune hyperthyroidism (increased production of thyroid hormones)

• Goitre
• Thyroid autoantibodies

• Type 2 AIT: similar to thyroiditis (thyroid destruction and release of thyroid hormones)

• CRP elevated
• Decreased vascularity on doppler

It is important to differentiate between the two types as
they are treated differently. Some patients may have a mixed type, in which case they should be treated for both type 1 and type 2 AIT.

Type 1 = Antithyroid drugs
Type 2 = Steroids (40mg Oral Prednisolone OD)

Question 3

What is the investigation for renal artery stenosis?

Answer 3

Renal artery doppler first line

Magnetic resonance angiography is gold standard and may be needed to be conclusive.

Question 4

What ratio of aldosterone/PRA (aldosterone/plasma renin activity) is diagnostic of primary aldosteronism?

Answer 4

> 2000

Before measuring these the following drugs may interfere and should be stopped:

• spironolactone
• ACEi
• B-blockers

(a-blockers like doxazosin or CCBs can be used instead if treatment is required)

Question 5

Which conditions cause hypertension, hypokalamia and metabolic alkalosis

(high BP, low K+, high bicarbonate)

Answer 5

Primary hyperaldosteronism
(Conn’s or bilateral adrenal hyperplasia)
Cushing’s syndrome

Question 6

What blood tests can you do to differentiate between type 1 and type 2 Diabetes mellitus?

Answer 6

• Glutamic acid decarboxylase (GAD) and islet cell antibodies are positive in the majority of T1DM patients (around 80%)
• A negative antibody test does not rule out the diagnosis of T1DM

Question 7

Give 2 examples of sulfonureas

Answer 7

Gliclazide

Glimepiride

Question 8

Give 2 examples of thiazolidinediones

What are their main contraindication?

Answer 8

Rosiglitazone
Pioglitazone

• Heart failure is the main contraindication as these agents may cause fluid retention, thereby worsening existing heart failure

Question 9

What investigations can be used to differentiate a raised ALP from a liver or bony origin?

Answer 9

GGT (raised suggests liver)
ALP isoenzymes (differentiate liver and bone)

Question 10

How do you monitor patients with treated thyroid cancer?

Answer 10

• Regular physical examination

• Thyroglobulin measurement in the plasma:
-Detection of thyroglobulin in a patient who had pre- vious thyroidectomy and ablation therapy indicates the presence of thyroid tissue

This is particularly important if thyroglobulin becomes measurable following a period when levels of this protein were undetectable

Question 11

What is the investigation of choice in individuals that present with a thyroid lump?

Not Blood tests

Answer 11

Euthyroid -> ?malignancy
-Fine needle aspiration

Thyrotoxicosis
-Thyroid uptake scan

(a cold nodule in someone who has graves has a high chance of malignancy so if the nodule is cold on thyroid uptake then you need FNA)

Question 12

What is the rule of 10s in Phaeochromocytoma?

Answer 12

The rule of 10 refers to the fact that approximately 10% of pheochromocytomas are:
• Familial
• Extra-adrenal
• Bilateral
• Malignant

Question 13

How does meningitis present in under 12 months?

Answer 13

The classic symptoms of headache, neck stiffness and photophobia are usually absent in children under 12 months. They are more likely to present with non-specific features such as lethargy, irritability, drowsiness, vomiting and poor feeding. The purpuric rash of meningococcal septicaemia may develop late or not at all. Do not wait to see it before you take action. If the rash is present the child should be given antibiotics immediately. You are not yet able to rule out meningitis and should consider a lumbar puncture. Seriously ill, febrile infants should have a full septic screen because clinical examination is unreliable at this age.

Question 14

Describe the ways to obtain a clean urine sample from children

Answer 14

The easiest method is to use a collection bag attached to the cleaned skin. However, contamination from the skin is likely and will confuse if you are starting antibiot- ics anyway.

• Wait for a clean catch straight into a sterile container. This is easier in boys! It is the least invasive way to get a good sample.
• Suprapubic aspirate ensures a clean sample in which any bacteria are significant. However, this is invasive and only used in very sick infants.
• A catheter specimen, using the in-and-out technique, reliably obtains a sample without contamination. The discomfort of the procedure makes this unsuitable for older, well children.

Question 15

What are the common causative organisms for UTI in children?

Answer 15

• Escherichia coli.
• Proteus – common in boys; can predispose to the for- mation of phosphate renal stones.
• Pseudomonas – maybe associated with an underlying urinary tract abnormality.
• Klebsella.
• Streptococcus faecalis.

Question 16

What is significant bacteriuria on microscopy?

Answer 16

The growth of more than 105 cfu/ml is significant bacteruria and indicates infection.

Question 17

How is E. coli commonly described on urine microscopy?

Answer 17

Lactose-fermenting Gram-negative rods are probably E. coli

Question 18

What investigations are carried out following diagnosis of UTI in children?

Answer 18

All children should have a renal ultrasound to look for structural abnormalities and incomplete bladder emptying. This can be done early after the infection. If the fever does not settle in 2–3 days, an ultrasound scan is useful to identify an infected, obstructed urinary tract.

These investigations must wait until inflammation following the UTI has settled, typically 6 weeks, to avoid false positive results.

• DMSA – static radioiosotope scan to detect renal scars.
• Micturating cystourethrography – detects reflux and urethral obstruction. It involves a high radiation dose so should be avoided if possible but is often carried out in infants with UTIs.
• Indirect cystography – dynamic radioisotope scan with MAG-3 or DTPA, which is excreted by glomerular filtra- tion. Detects reflux and obstruction in children who are able to void on request.

Renal ultrasound should be carried out as soon as pos- sible. Other investigations are postponed for 3 months to make sure any new scarring is detected. It is essential that the child be given antibiotic prophylaxis (e.g. trime- thoprim) during this time.

Question 19

Following UTI diagnosis in children and investigations at 3 months what is the long term management?

Answer 19

Usually grow out of ureteric reflux

Long term antibiotic therapy (trimethoprim) until then

2 yearly BP checks and repeat US of kidneys after 2 years to make sure growing OK (dont want to get CKD)

Question 20

What is posseting?

Answer 20

Posseting is the normal non-forceful regurgitation of milk following feeding.

Question 21

How do you calculate maintenance fluids in paeds?

Answer 21

• 100 ml/kg for first 10 kg
• 50 ml/kg for next 10 kg
• 20 ml/kg per kg for rest of weight

Question 22

When would you expect encephalitis in paediatrics?

How do you manage it?

Answer 22

Infective encephalitis is usually viral and most infections are self-limiting. A rare exception is herpes simplex encephalitis which has a mortality of over 70% and can have devastating long-term sequelae.

Therefore all cases of suspected encephalitis should be treated with aciclovir.

The clinical features of encephalitis are similar to those of meningitis although there maybe more marked disturbance of consciousness. Empirical treatment for both should be started.

Question 23

What are the contraindications to LP in paeds?

Answer 23

• Signs of raised intracranial pressure, e.g. papilloedema.
• Coma or rapid reduction in consciousness.
• Focal neurological signs.
• Seizures.
• Cardiorespiratory instability. (have to roll child into a ball to do LP creating extra cardioresp work)
• Local infection at the site of the lumbar puncture.
• Coagulation disorder or thrombocytopaenia.

Question 24

What 2 further steps must be taken once you successfully treat a child for meningitis?

Answer 24

• Prophylactic antibiotics should be given to all close contacts of a patient with meningococcal meningitis. This includes all members of the household and any close contacts within range of respiratory droplet spread. Oral rifampicin is the agent of choice, although some hospitals use ciprofloxacin.
• Meningitis is a notifiable disease and all cases must be reported to the consultant in communicable disease control.

Question 25

Why should children be on fortified milk rather than cow's milk until the age of 1 year?

Answer 25

Iron deficiency anaemia is common due to low iron stores and increased demand. At term, provided the mother’s iron supply was adequate, a baby has sufficient stores for 4 months. After this infants are vulnerable to iron deficiency. Milk has a low iron content but babies are able to absorb up to 50% of the iron in breast milk compared with just 10% of the iron in cow’s milk. For this reason it is recommended that children under 1 year should continue to drink formula milk that is fortified with iron rather than cow’s milk.

Question 26

What are the most reliable features which suggest Down's syndrome in infancy?

Answer 26

Hypotonia and large sandle gap between the first and second toes.

Question 27

Describe the features of a mucous retention cyst

Answer 27

Painless, blue cystic lesion on the inner lip. Patients usually concerned about its appearance and the fact that they keep biting it

Question 28

What are the causes of leukoplakia?

Answer 28

Although this condition may occur without obvious cause, remember the S’s! • Smoking (as probably in this case): Pipes even more than cigarettes. • Syphilis: Always carry out serological tests for syphilis in these patients (negative in this case). • Septic teeth. • Spirits. • Spices: It is especially common in the Indian sub- continent and it is estimated that some 20% of betel nut users over the age of 60 have this condition.

Question 29

What is the best first line imagining investigation in a suspected pharyngeal pouch?

Answer 29

Barium swallow While OGD is usually the treatment of choice barium swallow is commonly done first line in dysphagia as it is safe and sometimes more widely available. This is especially the case in a pharyngeal pouch where the scope can easily head down the blind end of the pouch rather than the oesophagus (which is usually displaced by the pouch). This risks rupture. (remember features of pharyngeal pouch include: dysphagia, regurgitation of undigested food, halitosis, hoarseness, and chronic cough.)

Question 30

What disease is indistinguishable from achalasia?

Answer 30

Chagas' disease which occurs in South America and is caused by Trypanosoma cruzi; this parasite destroys the intermuscular ganglion cells of the oesophagus.

Question 31

What is the treatment for Helicobacter Pylori infection?

Answer 31

The National Institute for Health and Care Excellence (NICE) and Public Health England (PHE) recommend the use of the following PPI doses: -Lansoprazole 30 mg, omeprazole 20–40 mg, esomeprazole 20 mg, pantoprazole 40 mg, or rabeprazole 20 mg. If a person tests positive for H. pylori offer a 7-day triple therapy regimen of: -A PPI twice daily and amoxicillin 1 g twice daily and Either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily. If the person is allergic to penicillin, offer a 7-day triple therapy regimen of: -A PPI twice daily and clarithromycin 500 mg twice daily and metronidazole 400 mg twice-daily. Note: the British National Formulary (BNF) recommends using clarithromycin 250 mg twice-daily for this regimen. If the person is allergic to penicillin and has had previous exposure to clarithromycin, offer a 7–10 day triple therapy regimen of: -A PPI twice daily and metronidazole 400 mg twice-daily and levofloxacin 250 mg twice-daily

Question 32

A patient presents with presumed peptic ulcer perforation but has a normal chest x-ray with no evidence of free air under the diaphragm What is the next most appropriate investigation?

Answer 32

Abdominal CT X-ray will only show free air in up to 70% of cases so if negative CT should be done to confirm

Question 33

What investigations are carried out in suspected Boerhaave syndrome?

Answer 33

Contrast swallow using Gastrografin or a similar water-soluble contrast agent. - While barium will give a great picture it is difficult to remove from the mediastinum in an oesophageal rupture ECG changes are common CXR will confirm presence of surgical emphasema

Question 34

What do you examine to check for spread in gastric cancer?

Answer 34

Lymphatic spread: -Palpation of the supraclavicular fossa for enlarged supraclavicular nodes spread along the thoracic duct (Troisier’s sign,* signifying involvement of Virchow’s Node) Portal Vein Spread: - Enlargement of the liver with or without jaundice together with ascites due to raised portal pressure. Transcoelomic Spread: -Ascites due to exudation from peritoneal seedings of tumour. Females -Note, in addition, that in the female patient a pelvic examination may reveal bilateral ovarian masses due to transcoelomic deposits of tumour (Krukenberg’s tumour‡).

Question 35

What are the names (one English and one Latin) given to this condition where the stomach is converted into a rigid tube by the infiltrating carcinoma?

Answer 35

Leather bottle stomach or linitis plastica. This is caused by submucous infiltration of the tumour with a marked fibrous reaction. This produces a small, thickened, contracted stomach with or without only superficial ulceration.

Question 36

What is the definitive management of meconium ileus?

Answer 36

It may be possible to clear the inspissated plugs of meconium by instillation of Gastrografin (a water-soluble, radioopaque contrast agent) per rectum under X-ray control. If this fails, or if the bowel has perforated, surgery is required. It may then be possible to open the intestine and remove the inspissated meconium by lavage, but if the impacted bowel cannot be cleared or shows areas of gangrene, as in this case, or has actually perforated, then resection is required.

Question 37

A child presents with chronically distended abdomen and delayed puberty. It looks like constipation may have reduced the development How does acquired megacolon (chronic constipation) differ from congenital megacolon/ Hirsprung's disease?

Answer 37

Acquired megacolon from chronic constipation is associated with mental disability On rectal exam faeces will be right at the anal verge in chronic constipation but further back in Hirsprung's (abnormal segment of bowel) (rectal suction biopsy can confirm diagnosis if unsure)

Question 38

How do you differentiate between small and large bowel obstruction clinically?

Answer 38

The two most common causes of acute small bowel obstruction in the UK are previous abdominal operation causing adhesions or a strangulated external hernia. -history of operation or examination of hernial orifices will rule these out Obstruction of the small intestine is usually accompanied by early and profuse vomiting, whereas this tends to be late, or indeed absent, in large bowel obstruction. Because of the size of the large bowel, distension of the abdomen is usually marked.

Question 39

What is the conservative management of sigmoid volvulus? | most patients get this

Answer 39

A sigmoidoscope is passed with the patient lying in the left lateral position. A large well lubricated, soft rubber rectal tube is passed along the sigmoidoscope. This usually untwists the volvulus, especially in early cases, with the escape of vast quantities of flatus and liquid faeces. It is then advisable to carry out an elective resection of the redundant sigmoid loop in order to prevent recurrence of the volvulus. (If this doesn't work then laparotomy through lower midline incision)

Question 40

What are the complications of a Meckel's diverticula?

Answer 40

* Acute inflammation: Closely mimicking acute appendicitis. If the appendix is found to be normal at opera- tion, the surgeon next looks for a possible Meckel. * Perforation by a foreign body: A fish bone, chicken bone, toothbrush bristle and many other sharp objects may do this (Fig. 62.3). Again, the preoperative diagnosis is invariably acute appendicitis. * Diverticulum may invaginate into the ileum and become the head of an intussusception. * The vitello-intestinal duct may persist right up to the umbilicus, resulting in a small bowel fistula, or the distal end of the duct may present as a ‘raspberry tumour’ at the umbilicus in the newborn baby. * A band may pass from the tip of the Meckel to the umbilicus; this band may snare a loop of intestine to produce an acute intestinal obstruction or may act as the apex of a volvulus of the adjacent ileum. * Peptic ulceration, presenting either with haemorrhage or perforation.

Question 41

What urinalysis may be seen in acute appendicitis?

Answer 41

• Although pus cells in the urine suggest a urinary tract infection, an inflamed appendix adherent to the ureter or the bladder may produce microscopic pyuria or haematuria.

Question 42

How does an appendix mass differ to acute appendicitis? How does the treatment differ?

Answer 42

Symptoms are similar but mass can be felt in the lower left quadrant - Not in quite as much pain and distress as full acute appendicitis - Usually a bit older too Management: - Treatment is initially conservative. Further delineation of the mass can be made using ultrasound or CT - Metronidazole incase rupture - 80% resolve and rest form abscess which is drained (NOT REMOVED) surgically - No matter the course the appendix is removed once it has settled in 2-3 months

Question 43

What is pronoun reversal? What conditions is it seen in?

Answer 43

use of ‘you’ or ‘I’ inappropriately as seen in both autism and deafness?

Question 44

What ages can the glasgow coma score be used for? What are the alternatives?

Answer 44

>4 then GCS can be used The children’s coma score is used for children under 4. This has the same categories as the GCS (eyes, verbal and motor response) but a modified criteria for verbal response: • 5, smiles, orientates to sounds, follows objects, interacts. • 4, fewer than usual words, spontaneous, irritable cry. • 3, cries only to pain. • 2, moans to pain. • 1, no response to pain. A score of 8 or less means that might not be able to protect the airway.

Question 45

Describe 3 specific childhood epilepsy syndromes

Answer 45

West’s syndrome (flexor spasms commonly on waking, associated with prior neurological abnormalities, learning difficulties and later epilepsy), Lennox–Gastuat syndrome (myoclonic jerks, absence attacks, neurodevelopmental and behavioural problems) benign Rolandic epilepsy (localized tonic- clonic seizures often in sleep and usually resolving in the teens; the commonest cause of childhood epilepsy)

Question 46

What is Sturge-Weber syndrome?

Answer 46

This sporadic disorder is detected at birth by the presence of a haemangioma in the distribution of the ophthalmic branch of the trigeminal nerve – a port-wine stain. There is also a similar intracranial lesion which may cause epilepsy, learning difficulties and even hemiplegia.

Question 47

What is abdominal migraine?

Answer 47

Children rarely have headaches, and many conditions affecting other areas of the body can cause abdominal pain, such as upper respiratory tract infections and pneumonia. Abdominal migraine is a common cause of recurrent non-specific abdominal pain in older children. There will often be a family history of migraine.

Question 48

Why is an NG tube inserted in any bowel obstruction?

Answer 48

Decompresses the bowel from above | NG tube in and IV fluids is general first line management in any bowel obstruction

Question 49

What is the gold standard test in intussusception?

Answer 49

Air enema | US usually first line but this achieves diagnosis and is the treatment all in one

Question 50

When do women need to be investigated for post-menopausal bleeding?

Answer 50

Any new onset bleeding after not having a period for 12 months (PMB) Any women who is still bleeding over the age of 55.

Question 51

When does bleeding need to be investigated while on HRT?

Answer 51

If on continuous regimen and bleeding If on cyclical regimen but bleeding doesnt fit pattern (not in the withdrawal bleed timing)

Question 52

What is the definition of subfertility?

Answer 52

An inability to conceive after 1 year of regular unprotected intercourse.

Question 53

What investigations are required in subfertility?

Answer 53

Male: -Sperm analysis Female -Immunity to rubella (don't become pregnant until 1 month after vaccination please) - Basal hormone profile (FSH, LH, prolactin, TFTs, serum testosterone) - --should be done on day 1-5 of her cycle - TV ultrasound scan (baseline assessment of uterus and rules out PCOS) - Urine chlamydia test

Question 54

How do you correctly carry out a serum sample? When cant it be done

Answer 54

* He did not miss the receptacle for collecting the specimen * The couple abstained from intercourse for at least 72 hours * Any history of recent viral illness * The sample reached laboratory in time * The sample was not exposed to heat or cold before reaching the laboratory * He is not on any medication

Question 55

If you have a sperm sample showing possible male infertility what do you do?

Answer 55

Ensure it was carried out correctly Reassure (high sensitivity but low specificity) -10% are false +ve Retest (this reduces false positives down to 2%)

Question 56

Describe the treatment of anovulation in women

Answer 56

Ovulation induction -Clomiphene citrate If pregnancy is not achieved after 3 ovulatory cycles on clomiphene then investigations for tubal patency is indicated: - Hysterosalpingography - Hysterosalpingocontrast sonography - Diagnostic laparoscopy and dye test (gold standard) Treatment is IVF rather than any tubal surgery (if any suspicion of tubal blockage (i.e. history of Chlamydia/ other STI) then should investigate BEFORE starting any ovulation induction agents)

Question 57

What information do you need before giving emergency contraceptive?

Answer 57

• The date of her last menstrual period (LMP). Her risk of pregnancy depends on what day in her cycle she had unprotected sexual intercourse: 􏰀 days 8–17 = 20–30% risk of pregnancy 􏰀 days 1–7 and >17 = 2–3% risk of pregnancy • The date and time of any episodes of unprotected sexual intercourse since her LMP and how many hours have elapsed. You need to establish if it is over 72 hours. • Medical and drug history. Taking a liver enzyme inducer drug means the dose of levonorgestrel needs to be doubled. An IUD would be better in this situation. • Prior use of emergency contraception. You need to ask if she had vomiting or an allergic reaction.

Question 58

What advice do you give about the levonogestrel 1500ug (Levonelle)? How effective is it? What are the side effects? When can you have sex again?

Answer 58

The efficacy depends on the time taken: • Within 24 hours of unprotected sexual intercourse = 95% reduction in expected pregnancies • Within 25–48 hours of unprotected sexual intercourse = 85% reduction in expected pregnancies • Within 49–72 hours of unprotected sexual intercourse = 58% reduction in expected pregnancies Nausea is common (14%) and 1% of women taking EC vomit. If she vomits within 2hours, she needs a further dose together with an antiemetic. If her next period is lighter or absent, she needs to do a urine pregnancy test. You need to advise her to abstain from sex until her next period.

Question 59

Why is the copper coil the best form of emergency contraceptive?

Answer 59

* >99% reduction in expected pregnancies * Immediate contraception * She needs to return after her next period for removal or thread check if she plans to continue to use it * IUD can be given up to 5 days after unprotected sexual intercourse or 120 hours after expected ovulation

Question 60

What is the risk of VTE while on different pills? How does this compare to pregnancy?

Answer 60

Non-combined oral contraception (COC) users 5 per 100,000 woman years Levonorgestrel or norethisterone containing COC 15 per 100,000 woman years Desogestrel or gestodene containing COC 25 per 100,000 woman years Pregnancy 60 per 100,000 woman years

Question 61

Do breastfeeding women require contraception?

Answer 61

No. Her baby is less than 6 months old, she is exclusively breastfeeding and amenorrhoeic. Lactational amenorrhoea produces 98% natural contraceptive cover. She must be advised that this effectiveness reduces when weaning starts and the amount of breast milk consumed reduces.

Question 62

What is the commonest cause of a vesicocolic fistula?

Answer 62

Diverticulosis

Question 63

What are the indications for colectomy in UC?

Answer 63

* Fulminating disease not responding to medical therapy – with the passage of more than six stools per day with persistent fever, tachycardia and hypoalbuminaemia. * Chronic disease, not responding to medical treatment. * Longstanding disease, where colectomy is performed as prophylaxis against malignancy. • For the local complications mentioned above. It is often said that patients accept surgery better in fulminant disease, when they perceive anything – including a stoma – as being better than a life spent on the toilet passing bloody stools.

Question 64

What are the surgical options in Ulcerative colitis?

Answer 64

Total colectomy with excision of the rectal stump is the usual procedure. The remaining small bowel may either be exteriorized as a terminal ileostomy, or continence restored by a ileoanal anastomosis with an interposed ileal pouch (a Park’s pouch*). Where the anal disease is controlled an ileorectal anastomosis can be performed, but this will require continued surveillance for malignancy.

Question 65

Describe the management of fibroids

Answer 65

Symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line Other options include tranexamic acid, combined oral contraceptive pill etc GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment Surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy uterine artery embolization

Question 66

What is the diagnostic criteria for insomnia?

Answer 66

Chronic insomnia may be diagnosed after three months, if a person has trouble falling asleep or staying asleep at least three nights per week