Interactive cases in general internal medicine Flashcards
(177 cards)
1
Q
Scenario 1: 60y/o man. Chest pain. Tight, 4hrs. Nausea. Sweating. Breathlessness. HTN. DH: amlodipine. What is the most likely diagnosis? a) pneumonia b) pericarditis c) myocardial infarction d) aortic dissection e) costochondritis
A
Myocardial infarction.
2
Q
List differentials of chest pain and distinguishing features of each.
A
Pneumonia: pleuritic pain, cough and fever, sputum.
Pericarditis: worse on inspiration, flu-like symptoms.
MI: tight, crushing pain, nausea and sweating.
Aortic dissection: sharp, tearing pain, radiates to the back.
Costochondritis: localised tenderness, etc.
3
Q
What are the initial investigations for chest pain?
A
1) ECG.
2) Troponin: +ve = coronary angiography, -ve = exercise tolerance test ETT.
3) Echocardiography.
4
Q
Differential diagnosis of chest pain: systems.
A
Cardiac: IHD; aortic dissection; pericarditis.
Respiratory: PE, pneumonia, pneumothorax.
GI: oesophageal spasm; oesophagitis, gastritis.
Musculoskeletal: costochondritis
5
Q
What are the coronary arteries involved and ECG changes seen in different types of MI?
A
Anterior MI: LAD, ST elevation in V1-V4.
Lateral MI: circumflex, ST elevation in V5, V6, I, aVL.
Inferior MI: RCA, ST elevation in II, III, aVF.
6
Q
Scenario 2: 30y/o man. Collapse. No warning before, no tongue biting during, not confused after. FH: brother died at a young age. O/E: HS: S1 + S2 + 0. BP: 120/80 (lying), 115/75 (standing). Vesicular breath sounds. Abdomen SNT. CN I-XII: NAD, normal I, T, P, R, C, S, G. What is the most likely diagnosis? a) aortic stenosis b) pulmonary embolism c) postural hypotension d) seizure e) tachyarrhythmia
A
Tachyarrhythmia.
7
Q
Differential diagnosis of collapse.
A
Hypoglycaemia: A, B, C, DNEFG.
Cardiac: vasovagal syncope, postural hypotension, arrhythmias (tachycardia, bradycardia), outflow obstruction (left: aortic stenosis, HOCM; right: PE)
Neurological: seizure.
8
Q
What investigations are done for cardiac causes of collapse?
A
ECG (? long QT), cardiac monitor, 24hr tape.
Low volume/ slow rising pulse, ESM, echocardiogram.
Lying/standing BP.
9
Q
What is long QT syndrome and what are its causes?
A
Abnormal ventricular depolarisation.
Congenital, e.g. mutations in K+ channels.
FH of sudden death.
Acquired: low K+/Mg2+, drugs.
10
Q
Scenario 3: 45y/o man. Fever. Malaise. IVDU. O/E: Temp: 38C Raised JVP to earlobes. HS: S1 + S2 +PSM (louder on inspiration). Hepatomegaly. What is the cause of the raised JVP? a) constrictive pericarditis b) congestive cardiac failure c) aortic regurgitation d) mitral regurgitation e) tricuspid regurgitation
A
Tricuspid regurgitation.
11
Q
What is the differential diagnosis of raised JVP?
A
R heart failure: secondary to L heart failure (CCF); pulmonary HTN (PE, COPD, etc.)
Tricuspid regurgitation: valve leaflets; R ventricle dilatation.
Constrictive pericarditis: infection, e.g. TB; inflammation (CTD); malignancy.
12
Q
What is the differential diagnosis of a systolic murmur?
A
Aortic stenosis. Mitral regurgitation. Tricuspid regurgitation. VSD. Where is it loudest/radiation? Associated features?
13
Q
Scenario 4: 65y/o man. Breathlessness. Palpitations. PMH: HTN. DH: Bendroflumethiazine. O/E: Temp: 38C. HR: 160, irregular. BP: 110/80mmHg. Dull percussion note and coarse crackles L base. What would you expect to see on his ECG? a) atrial fibrillation b) sinus tachycardia c) SVT d) VF e) VT
A
Atrial fibrillation.
14
Q
What ECG findings might you see in a patient with palpitations/tachycardia?
A
Sinus tachycardia.
SVT.
Atrial fibrillation.
VT.
15
Q
What is the management of SVT?
A
Vagal manoeuvres.
Adenosine (cardiac monitor).
DC cardioversion if evidence of haemodynamic compromise.
16
Q
What is the management plan for a patient with acute fast AF and BP 120/80? Prescribe the appropriate drugs.
A
Rhythm control: if onset >48 hours, anticoagulate for 3-4 weeks before cardioversion.
Rate control: beta blocker, digoxin.
Think of the underlying cause.
Think of the complications (anticoagulation).
17
Q
What is the management of VT?
A
If no haemodynamic compromise: IV amiodarone.
Look for and treat underlying cause.
ICD.
Pulseless VT: defibrillate.
18
Q
What pathologies may be suggested by ECG?
A
Ischaemia: ST elevation/depression, T wave inversion, Q waves.
Arrhythmia or conduction defects: rate, rhythm; PR, QRS, QT.
Ventricular strain or hypertrophy: axis, R, S.
19
Q
Case: 75y/o man presents with epigastric pain and back pain. HR 130bpm, BP 80/50mmHg. What is the most likely diagnosis? a) peptic ulcer b) pancreatitis c) gastritis d) GORD e) ruptured aortic aneurysm
A
Ruptured aortic aneurysm.
20
Q
What investigations are conducted for acute abdomen?
A
FBC, U+Es, LFTs, CRP, clotting, G+S, cross-match.
Erect CXR.
CT.
21
Q
What is the management of acute abdomen?
A
NBM. Fluids. Analgesia. Antiemetics. Antibiotics. Monitor vitals + urine output.
22
Q
What signs do you look for on an ECG in ischaemia?
A
Is there ST elevation or depression?
Is there T wave inversion?
Are there Q waves?
23
Q
What is the characteristic pattern of atrial flutter on ECG?
A
Saw tooth appearance.
24
Q
What is the management of ventricular tachycardia?
A
If no haemodynamic compromise: IV amiodarone.
Look for and treat underlying cause.
ICD.
Pulseless VT: defibrillate.
25
Case:
65y/o woman presents with breathlessness, onset over a few hours, and orthoptera.
PMHx: 2 MIs.
DHx: aspirin, simvastatin, ramipril, bisoprolol.
Temp: 36.5C.
Raised JVP.
HS: S1 + S2 + S3.
Chest: fine crackles.
Peripheral oedema.
The third heart sound:
a) is due to closure of mitral valve
b) is due to closure of aortic valve
c) is due to an atrial septal defect
d) is associated with ventricular hypertrophy
e) is associated with ventricular filling
Associated with ventricular filling.
26
What are the reasons for all the different heart sounds?
S1: closure of mitral valve.
S2: closure of aortic valve.
S3: associated with ventricular filling.
S4: associated with ventricular hypertrophy.
Fixed wide splitting of S2: atrial septal defect.
27
What is the management of acute heart failure?
```
Sit up.
Oxygen.
Furosemide (IV).
(GTN infusion).
Treat the underlying cause.
```
28
What is the ALS algorithm for VF/ pulseless VT?
```
Shock.
CPR (2 min).
Assess rhythm.
Adrenaline every 3-5 min.
Amiodarone after 3 shocks.
Correct reversible causes.
```
29
What is the ALS algorithm for asystole/ PEA?
CPR (2 min).
Adrenaline every 3-5 min.
Correct reversible causes.
30
```
Case:
30y/o woman.
URTI.
Pleuritic chest pain.
Better when leaning forwards.
ECG shows ST elevation in all leads.
What is the diagnosis?
```
Pericarditis.
31
What is the differential diagnosis of pleuritic chest pain?
```
Pericarditis
PE
Pneumonia
Pneumothorax
Pleural pathology
Sub-diaphragmatic pathology.
```
32
```
Case:
60y/o man.
SOB, sudden onset.
PMH: COPD.
On symbicort and tiotropium.
HR 110bpm; raised JVP; reduced BS, scattered wheeze and creps (R); peripheral oedema; sats 80% (air).
FBC: Hb 85; WCC 12; plt 300.
What is the most likely diagnosis?
```
Pneumothorax.
33
What is the differential diagnosis of breathlessness?
Pneumothorax; PE; foreign body.
Airways (inflammation/obstruction); chest infection (pus); acute heart failure (fluid).
Above (chronic/not resolving); interstitial lung disease; malignancy/ large pleural effusion; neuromuscular; anaemia/thyrotoxicosis.
34
A patient is diagnosed with pneumothorax and started on oxygen. What is the most appropriate next step in his management?
Chest drain insertion.
35
Manifestations of portal hypertension
Encephalopathy
Ascites
Spontaneous bacterial peritonitis
Variceal bleed
36
Case: 45y/o man with cough, breathlessness and recent travel, O/E coarse crepitations and bronchial breathing, hyponatraemia and deranged LFTs.
What antibiotic would you prescribe in addition to amoxicillin?
a) cefuroxime
b) clarithromycin
c) coamoxiclav
d) tazocin
e) vancomycin.
Clarithromycin (macrolide).
| For atypical pneumonia.
37
Case: 45y/o man with cough, breathlessness and recent travel, O/E coarse crepitations and bronchial breathing, hyponatraemia and deranged LFTs.
What organisms might have caused his pneumonia?
Mycoplasma pneumoniae.
Chlamydia pneumoniae.
Legionella pneumophila.
These are atypical pneumonia organisms, implicated in up to 40% of CAP.
38
```
Case: 50y/o man has 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).
```
OGD (gastroscopy).
39
What investigations are necessary for microcytic anaemia?
Haematinics.
Coeliac screen (TTG Ab, diagnosis confirmed on duodenal biopsy showing villous atrophy).
Remember red flags- weight loss, low MCV.
Top and tail endoscopies, order depends on upper/lower GI symptoms.
40
What is included in a coeliac screen, and how is the diagnosis confirmed?
TTG antibodies.
| Duodenal biopsy showing villous atrophy.
41
What is the differential diagnosis for bloody diarrhoea?
```
Infective colitis.
Ulcerative colitis/ Crohn's disease (younger patients).
Ischaemic colitis (older patients).
Malignancy.
Diverticulitis.
```
42
```
Case: 40y/o man has palpitations that started 4 hours ago, ECG shows AF.
How would you treat him?
a) adenosine
b) amiodarone
c) digoxin
d) metoprolol
e) DC cardioversion.
```
DC cardioversion (within 48hrs of symptom onset).
43
Distended superficial abdominal veins, direction of flow in the veins below the umbilicus is towards the legs.
What is the name of this clinical sign?
Caput medusae.
44
Case: 20y/o man with recent diarrhoea and malaise, Hb 70, Cr 300, splenomegaly and jaundice.
What do you expect to see on the blood film?
a) codocytes (target cells)
b) eliptocytes
c) lymphocytes
d) schistocytes (red cell fragments)
e) spherocytes
Schistocytes (red cell fragments).
45
What is microangiopathic haemolytic anaemia?
Red cells lyse as they try to pass through small vessels.
Small clots are formed.
Disseminated intravascular coagulation, haemolytic uraemia syndrome, or thrombotic thrombocytopaenic purpura.
46
What blood results do you expect in disseminated intravascular coagulation?
Low platelets and fibrinogen.
Raised PT/APTT.
D-dimer/fibrin degradation products.
47
What blood results do you expect in haemolytic uraemic syndrome?
Haemolysis: low Hb, raised bilirubin.
Uraemia.
Low platelets.
48
What is the presentation triad of thrombotic thrombocytopenic purpura?
Haemolytic uraemic syndrome, fever and neurological manifestations.
49
What are the hereditary causes of haemolytic anaemia?
```
Hereditary spherocytosis (red cell membrane).
G6PD or pyruvate kinase deficiency (enzyme deficiency).
Sickle cell disease, thalassaemias (haemoglobinopathy).
```
50
What are the acquired causes of haemolytic anaemia?
Autoimmune.
Drugs.
Infection.
Microangiopathic haemolytic anaemia.
51
```
Case: 60y/o man is confused with a cough and no postural hypotension. 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
```
CXR.
52
What causes hyponatraemia with hypovolaemia?
Diarrhoea.
Vomiting.
Diuretics.
53
What causes hyponatraemia with euvolaemia?
Hypothyroidism.
Adrenal
insufficiency.
SIADH.
54
What causes hyponatraemia with hypervolaemia?
Cardiac failure.
Cirrhosis.
Nephrotic syndrome.
55
What investigations do you request for the hyponatraemic euvolaemic patient?
TFTs.
Short synacthen test.
Plasma and urine osmolality.
56
What is the underlying cause of almost all cases of hyponatraemia?
High ADH.
57
What are the causes of SIADH?
CNS pathology.
Lung pathology.
Drugs: SSRI, TCA, opiates, PPIs, carbamazepine.
Tumours.
58
What causes onycholysis?
Trauma.
Thyrotoxicosis.
Fungal infection.
Psoriasis.
59
```
Case: 20y/o woman with abdominal pain and vomiting, T1DM, 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
```
Capillary ketones.
60
List microvascular complications of diabetes.
Retinopathy.
Nephropathy.
Neuropathy (foot ulcers).
61
List macrovascular complications of diabetes.
MI.
Stroke.
Peripheral vascular disease.
62
List metabolic complications of diabetes.
DKA.
HHS.
Hypoglycaemia.
63
Case: 26y/o man with chest pain, smokes 5/day, 'scratching sound' on auscultation.
What diagnosis is supported by his ECG which shows saddle-shaped ST elevation?
a) anterolateral MI
b) inferior MI
c) NSTEMI
d) pericarditis
e) posterior MI
Pericarditis.
64
Case: 60y/o woman collapses, BP 120/70mmHg, no postural drop, HS: S1 + S2 + ESM.
What does her ECG with deep S and tall R waves suggest?
a) left atrial hypertrophy
b) left ventricular hypertrophy
c) right atrial hypertrophy
d) right ventricular hypertrophy
e) NAD
Left ventricular hypertrophy.
65
```
Case: 40y/o man has 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
```
CT KUB.
66
```
Case: 50y/o man with hypercalcaemia, low PTH, backache, normal ALP.
What is the most likely diagnosis?
a) bone metastases
b) multiple myeloma
c) osteoporosis
d) primary hyperparathyroidism
e) secondary hyperparathyroidism.
```
Multiple myeloma.
67
What are the sources of alkaline phosphatase, and when might it be raised?
Liver and bone.
| Raised in obstructive liver disease and bone disease (malignancy, fracture, Paget's disease).
68
Why is ALP normal in myeloma?
Bone: osteoblasts make ALP.
Plasma cells suppress osteoblasts.
ALP is normal in myeloma.
69
How does multiple myeloma classically present?
```
Calcium high.
Renal impairment.
Anaemia.
Bone pain.
(CRAB).
```
70
```
Case: 23y/o woman with a 1cm smooth and mobile breast lump.
What is the most likely diagnosis?
a) basal cell carcinoma
b) ductal carcinoma
c) fat necrosis
d) fibroadenoma
e) galactocoele.
```
Fibroadenoma.
71
What are the causes of cavitating lung lesions?
Infection: TB, staph, klebsiella (e.g. alcoholics).
Inflammation: rheumatoid arthritis.
Infarction: pulmonary embolism.
Malignancy.
72
```
Case: 35y/o woman with ankle oedema and recent echocardiogram NAD, U+Es normal, ALT, AST + ALP normal, albumin 15.
What test would you order next?
a) coronary angiogram
b) renal USS
c) troponin
d) urinalysis
e) repeat LFTs.
```
Urinalysis.
73
What is nephrotic syndrome?
Increased permeability of glomerular basement membrane to protein.
Proteinuria >3g/day.
Hypoalbuminaemia.
Oedema.
74
```
Case: 30y/o man with recurrent GI and nose bleeds, facial examination shows red spots on lips and tongue.
What is the diagnosis?
a) acromegaly
b) cirrhosis
c) hereditary telangiectasia
d) Peutz-Jegher syndrome
e) systemic sclerosis.
```
Hereditary telangiectasia.
75
What is hereditary haemorrhage telangiectasia?
Autosomal dominant.
| Abnormal blood vessels in skin, mucous membranes, lungs, liver and brain.
76
What is the most likely diagnosis?
| Na+ 120, K+ 5, short synacthen test 0 min cortisol 100, 30 min cortisol 200.
Adrenal insufficiency.
77
What is the most likely diagnosis?
| PRL 10,000 (high), testosterone 6 (low), LH <1 (low), FSH <1 (low).
Prolactinoma.
78
```
What is the most likely diagnosis?
PRL 1000 (high), IGF-1 100 (high), OGTT: failure of GH suppression.
```
Acromegaly.
79
```
What is the most likely diagnosis?
Oestradiol 50 (low), FSH 40 (high), LH 35 (high), PRL 200.
```
Premature ovarian insufficiency.
80
```
What is the most likely diagnosis?
Free T4 (low) 5, TSH (high) 60, PRL (high) 700.
```
Primary hypothyroidism.
81
What is the most likely diagnosis?
| free T4 12, TSH 1.0, LH 1, PRL 300, cortisol 500.
Multinodular goitre, euthyroid.
82
What coronary artery is involved in an anterior MI?
Left anterior descending artery.
83
What ECG changes do you see in an anterior MI?
ST elevation in leads V1-4.
84
What coronary artery is involved in a lateral MI?
Circumflex artery.
85
What ECG changes are seen in a lateral MI?
ST elevation in V5, V6, I, aVL.
86
What coronary artery is involved in an inferior MI?
Right coronary artery.
87
What ECG changes are seen in an inferior MI?
ST elevation in II, III, aVF.
88
```
Case: 60y/o man with tight chest pain for 4hrs.
Nausea, sweating, breathlessness.
HTN.
DH: amlodipine.
temp 37.0, HS: S1 + S2, BP 120/80 L, 118/75 R.
Chest clear, abdomen soft, non-tender.
What is the most appropriate next investigation?
a) CK
b) CXR
c) ECG
d) echocardiogram
e) troponin.
```
ECG.
89
What might cause sinus tachycardia?
Sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaeochromocytoma).
90
What might cause atrial fibrillation?
Thyrotoxicosis, ischaemia, chest infection, alcohol.
Heart: muscle, valve, pericardium.
Lungs: pneumonia, PE, cancer.
91
What might cause ventricular tachycardia?
Ischaemia, electrolyte abnormality, long QT (broad complex tachycardia).
92
What is the differential diagnosis for breathlessness, onset within seconds?
Pneumothorax.
PE.
Foreign body.
93
What is the differential diagnosis for breathlessness, onset within minutes/hours?
```
Airways (inflammation/obstruction).
Chest infection (pus).
Acute heart failure (fluid).
```
94
What is the differential diagnosis for breathlessness, onset within days/weeks?
```
Chronic/not resolving airway inflammation or obstruction, chest infection, heart failure.
Interstitial lung disease.
Malignancy/ large pleural effusion.
Neuromuscular.
Anaemia/thyrotoxicosis.
```
95
What is the management plan for primary pneumothorax <2cm?
Discharge, repeat CXR.
96
What is the management plan for primary pneumothorax >2cm/SOB?
Aspiration.
| If unsuccessful, chest drain.
97
What is the management plan for secondary pneumothorax <2cm?
Aspiration.
98
What is the management plan for secondary pneumothorax >2cm?
Chest drain.
99
```
Case: 47y/o woman with acute SOB and pleuritic chest pain on a PMHx of DVT, O2 saturation 78% (air), PR 110bpm, BP 120/80mmHg, raised JVP, vesicular BS.
Her CXR shows no pneumothorax.
ECG shows right axis deviation and RBBB.
What is the most appropriate next step in her management following high flow oxygen?
a) LMWH
b) BiPAP
c) warfarin
d) thrombolysis
e) furosemide
```
LMWH.
100
Case: 50y/o female with progressive SOB, dry cough and clubbing, FEV1/FVC ratio >70%, reticulonodular shadowing on CXR.
What is the differential diagnosis for this patient?
Idiopathic fibrosing alveolitis.
Connective tissue disease, rheumatoid arthritis.
Drugs.
Asbestosis (?ship builder).
101
Case: 50y/o female with chronic SOB, sputum, no clubbing, FEV1/FVC ratio <70%, CXR shows hyperinflated lungs with flattened diaphragms.
What are these findings consistent with?
COPD.
102
Case: cough, sputum, weight loss and night sweats, CXR shows shadowing in the right upper zone.
What is the most likely diagnosis?
TB.
103
What are the different types of opacities seen on CXR?
Interstitial/alveolar shadowing.
Reticulonodular shadowing.
Homogeneous shadowing.
Masses/cavitations.
104
What might be the diagnosis if interstitial/alveolar shadowing is seen on CXR?
```
Pneumonia.
Heart failure.
Pulmonary oedema.
Pulmonary haemorrhage.
Pus or fluid or blood.
```
105
What might be the diagnosis if reticulonodular shadowing is seen on CXR?
Pulmonary fibrosis.
106
What might be the diagnosis if homogeneous shadowing is seen on CXR?
Pleural effusion.
107
What is the most likely diagnosis if a globular heart is seen on CXR?
Pericardial effusion.
108
List 3 causes of bilateral hilar lymphadenopathy.
Infection, e.g. TB.
Inflammation, e.g. sarcoid.
Malignancy, e.g. lymphoma.
109
What are the causes of hepatomegaly?
```
Cancer (primary or secondary deposits).
Cirrhosis (early, usually alcoholic).
Congestive cardiac failure.
Constrictive pericarditis.
Fatty infiltration.
Haemochromatosis.
Amyloidosis.
Sarcoidosis.
Lymphoproliferative diseases.
```
110
What are the causes of splenomegaly?
Portal hypertension, e.g. chronic liver disease.
Haematological, e.g. hereditary haemolytic anaemias, lymphomas, myeloma.
Infection.
Inflammation, e.g. sarcoid.
111
List some causes of epigastric pain.
```
Acute pancreatitis- risk factors? e.g. gallstones, high amylase?
Peptic ulcer- ?NSAID use.
GORD (better with antacids).
Gastritis (retrosternal, alcohol).
Malignancy.
MI.
Ruptured AAA.
Cholecystitis.
Hepatitis.
```
112
How does acute vs chronic pancreatitis present?
Epigastric pain in both acute and chronic.
High amylase in acute, normal in chronic.
Weight loss, loss of exocrine and endocrine function, and low faecal elastase in chronic.
113
List some causes of RUQ pain.
```
Cholecystitis.
Cholangitis.
Gallstones.
Hepatitis.
Liver abscess.
Basal pneumonia.
Appendicitis.
Peptic ulcer.
Pancreatitis.
Pyelonephritis.
```
114
List some causes of RIF pain.
```
Appendicitis.
Mesenteric adenitis.
Colitis (IBD).
Malignancy.
Ovarian torsion.
Ruptured ovarian cyst.
Ectopic pregnancy.
```
115
Give 2 causes of suprapubic pain.
UTI.
| Urinary retention.
116
List some causes of LIF pain.
```
Diverticulitis.
Mesenteric adenitis.
Colitis (IBD).
Malignancy.
Ovarian torsion.
Ruptured ovarian cyst.
Ectopic pregnancy.
```
117
List some causes of diffuse abdominal pain.
```
Obstruction.
Peritonitis.
Gastroenteritis.
IBD.
Mesenteric ischaemia.
DKA.
Addison's.
Hypercalcaemia.
Porphyria.
Lead poisoning.
IBS.
```
118
What organs does the coeliac artery supply?
```
Stomach.
Spleen.
Liver.
Gallbladder.
Duodenum.
```
119
What organs does the superior mesenteric artery supply?
Small intestine.
| Right colon.
120
What organ does the inferior mesenteric artery supply?
Left colon.
121
What organ does the iliac artery supply?
Rectum.
122
```
Case: 65y/o man, AAA repair 2 days ago, diffuse abdominal pain.
PR 120bpm, RR 30.
What are his blood tests likely to show?
a) normal lactate
b) high amylase
c) high bicarbonate
d) high sodium
e) high calcium.
```
High amylase.
123
```
Case: 55y/o man, excess alcohol use and cirrhosis, is confused with abdominal pain and distension.
O/E: ascites, liver flap.
Which of the following is consistent with SBP?
a) ascites neut ≥ 25 cells/mm3
b) ascites neut ≥ 50 cells/mm3
c) ascites neut ≥ 100 cells/mm3
d) ascites neut ≥ 250 cells/mm3
e) ascites neut ≥ 500 cells/mm3
```
Ascites neut ≥ 250 cells/mm3.
124
What are the causes of exudative ascites?
Malignancy (abdominal, pelvic, peritoneal mesothelioma).
Infection, e.g. TB, pyogenic, spontaneous bacterial peritonitis.
Pancreatitis.
Serositits.
Nephrotic syndrome.
Hereditary angioedema.
125
What are the causes of transudative ascites?
```
Cirrhosis.
Heart failure.
Hepatic venous occlusion: Budd-Chiari syndrome or veno-occlusive disease.
Constrictive pericarditis.
Kwashiorkor.
```
126
What is the likely cause of ascites if serum albumin-ascites albumin gradient >11g/L?
Portal hypertension.
Cirrhosis.
Cardiac failure.
127
What is the likely cause of ascites if serum albumin-ascites albumin gradient <11g/L?
TB.
Peritonitis.
Cancer.
Nephrotic syndrome.
128
```
Case: 50y/o man with jaundice and RUQ pain, dark urine and pale stool.
What is the cause of his pale stool?
a) low biliverdin
b) high unconjugated bilirubin
c) high conjugated bilirubin
d) low urobilinogen
e) low stercobilinogen
```
Low stercobilinogen.
129
```
Case: 50y/o man with painless jaundice and weight loss, dark urine and pale stool.
O/E: thrombophlebitis.
What are his blood tests likely to show elevated levels of?
a) ALP, CA19-9
b) AST, CA 125
c) ALP, alpha-fetoprotein
d) ALT, alpha-fetoprotein
e) ALP, CEA.
```
Raised ALP and raised CA19-9 (pancreatic cancer marker).
130
What organisms might cause infective colitis resulting in a patient presenting with bloody diarrhoea?
```
Campylobacter.
Haemorrhagic E coli.
Entamoeba histolytica.
Salmonella.
Shigella.
(CHESS).
```
131
What is the management plan for acute GI bleed?
```
ABC.
IV access.
Fluids.
G+S, X-match blood.
OGD.
Variceal bleed: antibiotics + terlipressin.
```
132
What investigations are ordered for a patient presenting with jaundice?
Bloods: FBC, LFTs, CRP.
| Abdominal USS: after a fast (gallstones better visualised in a distended, bile-filled gallbladder).
133
What investigations are ordered for a patient presenting with dysphagia and weight loss?
OGD and biopsy.
134
What investigation is ordered for a patient presenting with PR bleed and weight loss?
Colonoscopy.
135
What is the management plan for the patient with ascites?
Diuretics (spironolactone ± furosemide).
Dietary sodium restriction.
Fluid restriction in patients with hyponatraemia.
Monitor weight daily.
Therapeutic paracentesis (with IV human albumin).
136
How is encephalopathy managed?
```
Lactulose.
Phosphate enemas.
Avoid sedation.
Treat infections.
Exclude a GI bleed.
```
137
What are the features of an anastomotic leak complication?
Diffuse abdominal tenderness.
Guarding, rigidity.
Hypotensive/tachycardic.
138
What are the features of a pelvic abscess complication e.g. post-appendectomy?
Pain.
Fever.
Sweats.
Mucus diarrhoea.
139
How does perianal abscess present?
Tender, red swelling.
140
How is perianal abscess treated?
Incision and drainage.
141
How does anal fissure present?
```
Rectal pain (defaecation).
Stool coated with blood.
```
142
How is anal fissure treated?
Advice re diet, e.g. fluids and fibre.
| GTN cream.
143
How does IBS present? what are the negative findings?
Recurrent abdominal pain and bloating.
Improves with defaecation.
Change in the frequency/form of stool.
No PR bleed, anaemia, weight loss or nocturnal symptoms, exclude coeliac.
144
How is IBS treated?
Diet and lifestyle modification.
| Symptomatic treatment, e.g. antispasmodics for abdominal pain, laxatives for constipation, anti-diarrhoeals.
145
List some cerebellar signs.
```
Ataxia.
Nystagmus.
Dysdiadochokinesia (test rapidly alternating movements).
Intention tremor (finger-nose test).
Speech: slurred, scanning.
```
146
Where is the lesion if a patient presents with hemiparesis?
Contralateral side of brain.
147
Where is the lesion if a patient presents with paraparesis?
Spinal cord.
148
What condition affects the nervous system at the level of the neuromuscular junction?
Myasthenia gravis.
149
What are the signs of an UMN lesion?
Increased tone (spasticity).
Reduced power.
Brisk reflexes and upgoing plantars.
150
What are the signs of a LMN lesion?
Reduced tone (flaccid).
Reduced power.
Reduced or absent reflexes.
151
Give an example of a LMN lesion.
Guillain Barre syndrome.
152
Give an example of a UMN lesion.
Stroke.
153
```
Case: 55y/o man with numbness and tingling in hands and feet, PMH of T1DM, on basal/bolus insulin. HbA1c 50mmol/mol, B12 500pg/mL (200-900), eGFR 90.
Reduced sensation to pin prick (glove and stocking distribution).
What would you prescribe?
a) codeine
b) duloxetine
c) hydroxycobalamin
d) paracetamol
e) morphine.
```
Duloxetine.
154
What are the toxic/metabolic causes of peripheral neuropathy?
```
Drugs.
Alcohol.
B12 deficiency.
Diabetes.
Hypothyroidism.
Uraemia.
Amyloidosis.
```
155
What are the causes of peripheral neuropathy?
```
Drugs.
Alcohol.
B12 deficiency.
Diabetes.
Hypothyroidism.
Uraemia.
Amyloidosis.
HIV.
Vasculitis.
CTD.
Inflammatory demyelinating neuropathy.
Paraneoplastic.
Paraproteinaemia.
Hereditary sensory motor neuropathy.
```
156
```
Case: 34y/o woman with weakness in legs and blurred vision, increased tone in legs, reduced power and brisk reflexes.
Reduced pin prick sensation in legs.
Fundoscopy shows pale and enlarged optic disc with blurred edges.
What is the cause of her blurred vision?
a) amaurosis fugax
b) anterior uveitis
c) papilloedema
d) papillitis (optic neuritis)
e) vitreous haemorrhage.
```
Papillitis (optic neuritis).
157
Case: 60y/o man with pain and paraesthesia on anterolateral thigh, PMH T2DM, on metformin, HbA1c 60mmol/mol, BMI 30kg/m2, reduced pin prick sensation on anterolateral thigh.
What is the most appropriate next step in his management?
a) lose weight
b) insulin
c) statin
d) aspirin
e) MRI brain.
Lose weight.
158
Case: 60y/o man with pain and paraesthesia on anterolateral thigh, PMH T2DM, on metformin, HbA1c 60mmol/mol, BMI 30kg/m2, reduced pin prick sensation on anterolateral thigh.
What is the diagnosis?
Meralgia paraesthetica.
159
What is meralgia paraesthetica, and how is it managed?
Compression of lateral femoral cutaneous nerve.
Reassure, avoid tight garments, loose weight.
If persistent, carbamazepine, gabapentin.
160
What is radiculopathy?
Disease of the nerve roots.
e.g. lumbrosacral: pain in the buttock, radiating down the leg below the knee ('sciatica'), compression by disc herniation or spinal canal stenosis.
161
```
Case: 60y/o man, recurrent falls, tremor at rest, rigidity, more forgetful, dysphagia, micrographia and limited upgaze.
What is the most likely diagnosis?
a) progressive supranuclear palsy
b) Lewy body dementia
c) stroke
d) epilepsy
e) Alzheimer's disease
```
Progressive supranuclear palsy (Parkinson's plus).
162
What are the features of Lewy body dementia?
Features of Alzheimer's disease, Parkinson's, and hallucinations.
163
What are the cardinal features of Parkinson's disease?
Tremor, rigidity, bradykinesia.
164
What are the defining features of PSP (Steele-Richardson syndrome)?
Parkinsonian features.
| Upgaze abnormality.
165
```
Case: 55y/o man with confusion and chest pain, no headache or neck stiffness, recently moved to a new house with faulty heating system. Temp 37, PR 110bpm, BP 120/60, normal CVS/resp/GI/neuro exam.
ECG: sinus tachycardia, widespread ST depression.
Urinalysis NAD.
Blood glucose 7.0mmol/L.
WCC: 7.
CRP <5.
CT head NAD.
What is the most likely cause of his confusion?
a) vascular
b) infection
c) inflammation
d) toxic/metabolic
e) tumour
```
Toxic/metabolic: CO poisoning.
166
What are the causes of apparent confusion/ low AMTS score, and the clues that point you to different diagnoses?
Post-ictal: history of seizures?
Dysphasia, receptive or expressive: other features of stroke/TIA?
Dementia, vascular (multi-infarct): history of IHD/PVD?
Dementia, alcoholic: signs of excess alcohol?
Alzheimer's disease.
Inherited, e.g. Huntington's disease.
Depressive pseudodementia: elderly, withdrawn, poor eye contact, precipitating factor?
167
What is the differential diagnosis for patients presenting with confusion/ reduced consciousness?
Hypoglycaemia.
Vascular: bleed (headache, collapse), subdural haematoma (fall, fluctuating consciousness).
Infection: ?temp, ?intracranial, ?extracranial.
Inflammation.
Malignancy.
Metabolic/toxic: drugs, U+Es, LFTs, vitamin deficiencies, endocrinopathies.
168
What scale is used to assess conscious level?
GCS.
169
What scale is used to assess confusion?
AMTS.
170
How is GCS scored?
Eyes (4).
- 4 = spontaneous
- 3 = opens in response to voice
- 2 = opens in response to painful stimuli
- 1 = does not open.
Verbal response (5).
- 5 = oriented
- 4 = confused
- 3 = words
- 2 = sounds
- 1 = no sounds.
Motor response (6).
- 6 = obeys commands
- 5 = localises pain
- 4 = withdraws to painful stimuli
- 3 = abnormal flexion
- 2 = extension
- 1 = no movements.
171
What are the questions in AMTS?
```
DOB.
Age.
Time.
Year.
Place.
Recall (address).
Recognise 2 people's roles, e.g. dr, nurse.
Prime minister.
WWI dates.
Count backwards from 20 to 1.
```
172
What is giant cell arteritis, how does it present, investigations/management?
Associated with polymalgia rheumatic.
Shoulder girdle pain, stiffness, constitutional upset.
>50 years old.
ESR, steroids to prevent blindness, biopsy temporal artery.
173
What is the management plan for stroke <4.5 hours after symptom onset?
CT: no haemorrhage.
| Thrombolysis (if no contraindications).
174
What is the management plan for stroke >4.5 hours after symptom onset?
```
CT head (exclude haemorrhage).
Aspirin 300mg, swallow assessment.
Maintain hydration, oxygenations, monitor glucose.
```
175
What is the management plan for a TIA?
```
Aspirin.
Don't treat BP acutely, unless >220/120 or other indication.
ECG, echocardiogram.
Carotid doppler.
Risk factor modification.
```
176
```
Case: 40y/o with backache and LMN weakness, admitted to HDU, regular FVC, cardiac monitor, IVIG.
What is the most likely diagnosis?
a) Guillain Barre
b) stroke
c) cord compression
d) cauda-equina syndrome
e) myasthenia gravis
```
Guillain Barre.
177
Which conditions are associated with HLA-B27?
```
Psoriatic arthritis.
Ankylosing spondylitis.
IBD.
Reactive arthritis.
(PAIR).
```
