Formative 1 Flashcards
A 68 year old man has a swollen tender knee for 3 days and cannot weight bear. He has had previous episodes of big toe swelling. He has a history of chronic kidney disease stage 4.
Investigations:
Fluid analysis of knee aspirate:
White cell count 55 000/mL, 95% neutrophils Gram stain negative
Copious 10 μm intracellular needle shaped crystals
Which is the best initial treatment for his acute knee pain and swelling?
A. Arthroscopic joint washout
B. Intravenous flucloxacillin
C. Oral allopurinol
D. Oral naproxen
E. Oral prednisolone
E
The presentation is likely due to an acute attack of gout. Although infection is not completely excluded at this stage it is less likely as G stain is negative and there are several positive features of gout in the history. IA or oral steroids, colchicine or NSAIDs are all effective treatments for acute gout. NSAIDs are contraindicated in CKD of this stage. Allopurinol will not help the acute attack.
A 26 year old woman has 12 months of back pain, located in the low lumbosacral region. She has intermittent bilateral thigh pain. The back pain disturbs her sleep. The pain is improved by activity but not relieved by resting. She finds it difficult to bend down during the day to pick things up from the floor.
Which clinical feature is most specific for inflammatory back pain?
A. Improvement with activity
B. Nocturnal pain
C. Radiation to leg
D. Stiffness during the day
E. Young age
A
Inflammatory back pain (IBP) is typically improved with activity and not relieved by rest, as opposed to mechanical pain which is worse with activity and is relieved by rest. IBP can wake the patient in the early hours of the morning and sacroiliitis can radiate to the thigh, but these features are much less specific. Morning stiffness is specific for inflammatory back pain but not persistent daytime stiffness. IBP can occur at any age although mechanical pain is less common in young people.
A 43 year old woman has a sudden severe headache that started 24 hours ago. She has a history of autosomal dominant polycystic kidney disease.
Her temperature is 36.8°C, pulse rate 92 bpm and BP 140/100 mmHg. Neurological examination is normal. CT scan of head is normal.
Which is the most appropriate next step in management?
A. Erythrocyte sedimentation rate
B. Lumbar puncture
C. MR scan of brain
D. Refer to outpatient headache clinic
E. Start amlodipine
B
This is because APKD is associated with subarachnoid haemorrage. A lumbar puncture should be performed. MRA would be reasonable, but not MRI.
A 80 year old man has progressive memory loss over 2 years.
He scores 20/30 on the Montreal Cognitive Assessment, and he requires an MR
scan of brain.
In which part of the brain are changes most likely to be found in early Alzheimer’s disease?
A. Basal ganglia
B. Frontal lobe
C. Medulla oblongata
D. Parietal lobe
E. Temporal lobe
E
A 16 year old girl presents to the Emergency Department after an episode of loss of consciousness following a fall. She had consumed an excessive amount of alcohol at a party before the fall.
She has a dirty scalp wound and cannot remember recent events. Her pulse rate is 68 bpm, BP 110/80 mmHg and oxygen saturation 98% breathing air. She opens her eyes to command and is confused. Her capillary blood glucose is 6.0 mmol/L.
Her wound is cleaned and sutured.
Which is the most appropriate immediate management plan?
A. Admit and observe for 24 h
B. CT scan of head
C. Discharge with head injury instructions
D. Refer to neurosurgeon
E. X-ray of skull
B
Current guidelines. Safety issue. A child of 16 doesn’t need a tetanus booster
A 56 year old woman has home blood pressure readings averaging 160/90 mmHg.
Hypertension is confirmed on 24 hour ambulatory monitoring. She has type 1 diabetes mellitus.
Investigations:
Urinary albumin: creatinine ratio 42 mg/mmol eGFR 43 mL/min/1.73 m2
Which type of antihypertensive is most appropriate?
A. ACE inhibitor
B. Alpha blocker
C. Beta blocker
D. Calcium channel blocker
E. Thiazide-like diuretic
A
There is good evidence for renal function protection in diabetic nephropathy with ACE-1 in addition to its hypertensive properties.
A 76 year old man undergoes an abdominoperineal resection for a low rectal carcinoma. He has a history of severe COPD and hypertension.
Which is the most appropriate method for providing analgesia during the early postoperative period?
A. Epidural anaesthesia
B. Intramuscular opioid
C. Oral non-steroidal analgesia
D. Patient controlled intravenous analgesia
E. Spinal anaesthesia
A
This is because for major abdominal surgery in respiratory disease, opioid, by whatever route, should be avoided. Epidural is best because it can be topped up and titrated; spinal anaesthesia cannot. Transcutaneous electrical nerve stimulation has been used for post-operative pain, but trial results are contradictory. Intramuscular injection is difficult to titrate.
A 25 year old man presents to the Emergency Department after vomiting a large quantity of blood.
At endoscopy, a deep ulcer is identified in the posterior wall at the junction of the first and second parts of the duodenum. There is a bleeding vessel in the base.
From which artery is the bleeding most likely to be arising?
A. Gastroduodenal artery
B. Left gastric artery
C. Short gastric artery
D. Splenic artery
E. Superior mesenteric artery
A
The gastroduodenal artery runs posterior to the first and second parts of the duodenum and may be a source of major haemorrhage in peptic ulcer disease.
A 64 year old woman develops an acutely painful right knee 3 weeks after a prosthetic right knee replacement. Her temperature is 38.2°C and pulse rate 103 bpm. Her right knee is inflamed, with serous fluid discharging from the lower end of the wound.
Which is the most likely causative organism?
A. Corynebacterium species
B. Enterococcus species
C. Pseudomonas aeruginosa
D. Staphylococcus aureus
E. Streptococcus pyogenes
D
Staphylococcus is responsible for 20-25% of prosthetic joint infections, with coagulase negative staph next (not included on list). The other bacterial causes would be rare. Candida is also very uncommon.
A 49 year old man has 3 days of cough and fever. He undergoes haemodialysis three times per week. His temperature is 38.6°C, pulse rate 90 bpm, BP 122/80 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 95% breathing 15 L/min oxygen via a non-rebreather mask. His JVP is 4 cm above the sternal angle. He has inspiratory crackles in the right mid and lower zone and left upper zone. His blood capillary glucose is 12 mmol/L.
Investigations:
Sodium 131 mmol/L (135–146)
Potassium 5.7 mmol/L (3.5–5.3)
Urea 16.7 mmol/L (2.5–7.8)
Creatinine 327 μmol/L (60–120)
Chext X-ray: evidence of multifocal consolidation
Which is the most appropriate initial treatment?
A. Haemodialysis
B. Intravenous 10 mL 10% calcium gluconate
C. Intravenous 1000 mL 0.9% sodium chloride over 1 h
D. Intravenous co-amoxiclav and clarithromycin
E. Intravenous furosemide
D
This patient has severe pneumonia with evidence of multifocal consolidation on the chest X-ray. He requires treatment with antibiotics first. the other interventions are not indicated. ECG changes are seen when potassium levels are over 6.5 mmol/L
A 67 year old man is due to have a CT scan of chest, abdomen and pelvis with intravenous contrast as assessment for possible lymphoma. He had a renal transplant 5 years ago. His medication includes prednisolone, tacrolimus and lisinopril.
His BP is 131/86 mmHg.
Investigations:
Urea 12.9 mmol/L (2.5–7.8)
Creatinine 165 μmol/L (60–120)
eGFR 39 mL/min/1.73 m2 (>60)
Which is the most appropriate treatment to give before the scan?
A. Intravenous 0.9% sodium chloride infusion
B. Intravenous acetylcysteine
C. Intravenous furosemide infusion
D. Intravenous hydrocortisone
E. Intravenous mannitol
A
The patient is due to receive IV contrast and has existing CKD. He is an increased risk of contrast nephropathy. Volume expansion with 0.9% sodium chloride infusion (1 mL/kg) is recommended and shown to reduce the incidence of contrast nephropathy. Some units still recommend oral acetylcysteine (although trial data is lacking), but IV acetylcysteine is no longer used due to risk of anaphylactoid reaction. There is no indication for additional steroids. IV furosemide may increase risk of contrast nephropathy. IV mannitol is no longer used as no evidence of benefit.
A researcher is seeking to examine whether long-term mobile phone use is linked to acoustic neuroma risk. The information on mobile phone usage is collected from participants with acoustic neuroma and a comparable group of participants without acoustic neuroma, selected from the general practice register.
Which type of study design is being used?
A. Case–control study
B. Case series
C. Cohort study
D. Cross-sectional study
E. Ecological study
A
A 34 year old man has pain in his right shoulder and upper arm for 6 weeks that worsens when elevating his arm above his head. He does not recall any injury.
There is no deformity, tenderness or reduced range of movement. There is pain on abduction of the right shoulder that is worse with the arm in internal rotation and when abduction is resisted. He is treated with ibuprofen.
Which is the most appropriate next step in management?
A. MR scan of shoulder
B. Refer for orthopaedic opinion
C. Refer for physiotherapy
D. Ultrasound scan of shoulder
E. X-ray of shoulder
C
Clinically the diagnosis is right supraspinatus tendinopathy and no further investigation is required to confirm the diagnosis. Most cases can be managed in primary care and a referral to orthopaedics is not required. The most appropriate management is either general advise and home exercises or referral to a physiotherapist.
Q1 on medlearn I got wrong
A 70 year old man has dry cough and breathlessness on exertion for the past 3 months. He has lost 4 kg in weight. He has a history of ischaemic heart disease and atrial fibrillation. He takes warfarin sodium, ramipril and amiodarone hydrochloride. He is a never smoker.
His temperature is 37.5°C, pulse rate 70 bpm, respiratory rate 18 breaths per minute and oxygen saturation 91% breathing air. He has fine bibasal inspiratory crackles. There is no finger clubbing.
Investigations:
Haemoglobin 141 g/L (130–175)
White cell count 14.0 × 109/L (3.0–10.0)
Erythrocyte sedimentation rate 65 mm/hr (<20)
Chest X-ray shows bilateral reticular opacities in both bases.
Which investigation is most likely to confirm the diagnosis?
A. Blood cultures
B. Bronchoscopy
C. Echocardiography
D. High resolution CT scan of chest
E. Induced sputum for microscopy and culture
D
This is because the patient has pulmonary fibrosis as a complication from amiodarone therapy. This classically does not cause clubbing. Patients present with cough and dyspnoea. Fever and reactive blood changes (raised WCC, ESR) are not uncommon. An HRCT would confirm changes of interstitial lung disease. Blood cultures are indicated but this is unlikely to be an infective cause. Bronchoscopy is not indicated. The features are not those of heart failure so an echo will not confirm the diagnosis. An induced sputum is not indicated at this stage.
