MedEd/ Sofia Based SBAs Flashcards

Question

A 70 year-old man is brought in by his wife who has noticed a recent sharp decline in his mental status and memory. He seems confused, and on examination has weakness in his left leg, and appears to have some trouble swallowing. He has previously has three TIAs, and thinks the weakness in his leg may have started after the last one. ``` What is the most likely diagnosis? A. Malignancy B. Alzheimer's disease C. Stroke D. Polymyalgia Rheumatica E. Vascular dementia F. Myasthenia Gravis G. Multiple sclerosis ```

Answer 1

E. Vascular dementia Vascular dementia is cognitive decline due to infarction. Typically a patient will present with cognitive decline, and some focal neurology (leg weakness, dysphagia) on a background of ischaemic disease (CVA, TIA, MI). Vascular dementia causes deterioration in a step-wise fashion, as the trigger for each deterioration is a new infarct.

Answer 2

C. Lewy body dementia The essential feature of LBD is dementia: the characteristic memory issues that often accompany dementia may well not appear till later on, but visuoperceptual defects, attention deficits, and executive dysfunction may all be early and prominent signs. There are three other core features: Visual hallucinations (typically vivid and detailed) REM sleep behaviour disorder (loss of muscle paralysis during REM sleep - the patient can be seen to act out their dreams) Parkinsonism (bradykinesia, tremor, rigidity)

Answer 3

F. Wernicke's-Korsakoff's syndrome The ataxia and nystagmus are both suggestive of Wernicke's encephalopathy. The memory problems are indicative of Korsakoff's syndrome. Both syndromes are caused by thiamine deficiency. It has been previously sugested that Korsakoff's syndrome is due to direct alcoholic brain damage, but this is probably incorrect as it has been observed in malnutritioned patients with anorexia nervosa, or who are post-bariatric surgery. That said, both Wernicke's and Korsakoff's are usually caused by alcoholism, as alcohol impairs the absorption, liver storage, and conversion of thiamine to its active form. Wernicke's tends to occur before Korsakoff's, and is reversible with thiamine supplements. By the time Korsakoff's manifests, the damage to the thalamus and mammillary bodies is generally irreversible. The memory issue described here is confabulation: when the damage to the thalamus and mammillary bodies becomes extreme, the patient will start to become incapable of recalling old memories or making new ones. Instead the patient will confabulate: the brain will create false memories based on their environment (hence the snowy wedding), but they will believe these memories to be true.

Answer 4

D. CAG repeat testing The family history of early death, together with the choreiform (dance-like) movements points to Huntingdon's disease. Huntingdon's disease is an autosomal dominant condition in which the number of CAG repeats in the Huntingtin gene (4p16.3) increases, causing a malformed protein. The number of CAG repeats in an individuals Huntingdin gene determines whether they will develop the disease: 35-39 repeats, and they might develop the disease 40+ repeats, and they definitely will If they have between 29 and 34 repeats, they will not develop symptoms, but their children would be at risk 28 or below is a normal result

Answer 5

C. The patient develops blurry vision in one eye a year later ``` The most common MS symptoms are: Optic neuritis (hence fundoscopy is a useful exam in MS) Sensory disturbance Motor weakness Fatigue ``` The key points when diagnosing MS are: To have two episodes of CNS dysfunction separated by time To have two CNS lesions separated by space There must be no alternative diagnosis A gadolinium MRI is useful to determine how old brain lesions are, because gadolinium can only enter parts of the brain that are inflamed - as this makes the blood-brain barrier leaky. The inflammation after an acute attack of MS lasts between 2-6 weeks, hence any lesion that lights up with gadolinium contrast is at most 6 weeks old. Oligoclonal bands are formed when IgG is produced against myelin (as MS is an autoimmune disease). If they are found only in the CSF and don't match any in the serum, then they have a CNS origin. If they match the serum oligoclonal bands, they could be from infection outside the CNS.

Answer 6

A. Hepatitis A Hepatitis A (along with E) is a virus transmitted via the faecal-oral route (think of fAEcal) which causes an acute infection with signs of liver disease, but is ultimately self-resolving. It is particularly associated with eating seafood abroad where there is a risk of the seafood coming from water contaminated with sewage.

Answer 7

C. Hepatitis C Hepatitis C is mostly spread through blood, and causes a chronic infection (acute symptomatic infections only occur in 15% of cases). Though hepatitis B can definitely also cause a chronic infection, this only occurs in 5% of infected adults. Though more likely to cause chronic infection, hepatitis C is very reliably curable, whereas hepatitis B is not. ``` C for cancer, C for chronic, C for curable Alpha fetoprotein (αFP) is a marker of liver and testicular cancer ```

Answer 8

C. Hepatitis B serology B is also spread through blood and sex, but is more likely to cause acute symptomatic infection, such as that described here.

Answer 9

D. Hepatitis D Hepatitis D needs Hepatitis B surface antigens to be expressed on liver cells in order to enter the cell. To remember this dependence: two D's on top of each other look like a B.

Answer 10

B. Wilson's disease Wilson's disease is an autosomal recessive fault in copper transporters in the biliary tree (copper is usually excreted in the bile) which leads to accumulation in the liver and deposition in the basal ganglia (neuro symptoms) and the eyes (Kaiser-Fleischer rings).

Answer 11

D. High serum iron, high ferritin, low transferrin, low TIBC This is a description of hereditary haemochromatosis - an autosomal recessive condition resulting in an inability to control iron intake. Since the body has no mechanism for disposing of iron once it has been absorbed through the gut, iron accumulates and deposits causing multiple organ dysfunction and failure. This patient requires a HbA1c reading because they are diabetic, possibly from iron deposition in the pancreas. The tanned complexion is a result of iron deposition in the skin. Since iron uptake is unregulated, serum iron will be high. Ferritin will be high, as it increases to deal with increased serum iron Transferrin will be low because transferrin corresponds to iron demand, and demand is low TIBC is the measure of the blood's ability to bind iron with transferrin - since iron is in excess transferrin will be saturated, and the body's ability to bind any more iron will be low

Answer 12

D. USS of biliary tree This history is suggestive of gallstones given that the pain is colicky, and worse after fatty meals. In addition, the patient has three of the five f's of gallstones: Fair (caucasian) Fertile (children) Female Fat (BMI >30) Forty/ familial (generally risk increases at age 40 or above, but can occur in younger patients with a family history - hence familial)

Answer 13

C. Acute cholecystitis The shoulder pain is called Boas' sign and, along with Murphy's sign, is indicative of cholecystitis. The presentation is very similar to ascending cholangitis, but lacks the jaundice and rigors (though rigors are not strictly necessary for diagnosis, they will often be in SBAs to nudge you in the right direction). Murphy's sign is pain on inspiration when an examiner places a hand in the RUQ just below the costal margin.

Answer 14

C. Primary sclerosing cholangitis The bowel condition being hinted at is most likely ulcerative colitis, which is heavily associated with primary sclerosing cholangitis (75% patients with PSC also have IBD, usually UC). Primary sclerosing cholangitis is most common in men between 20-40. PSC is strongly associated with perinuclear anti-neutrophil cytoplasmic antibodies (pANCA)

Answer 15

B. Ascending cholangitis It is caused by obstruction of the bile duct (tumour, gallstone, stricture etc.) which allows bacteria from the duodenum to travel up through the ampulla of Vater into the common bile duct. Ascending cholangitis is defined by Charcot's triad: Jaundice Fever (with or without rigors) RUQ pain As it progresses, Reynold's pentad may be seen: Charcot's triad, but with hypotension and confusion (sepsis) ``` Management centers initially around treatment of the sepsis: Administer oxygen Administer I.V. antibiotics Administer I.V. saline Take blood cultures Take serial lactate measurements Monitor urine output ``` Afterwards the original cause is addressed with either cholecystectomy or ERCP

Answer 16

B. Carcinoma of the head of the pancreas Painless jaundice combined with weight loss and a prominent alcohol history should make you consider pancreatic cancer. The jaundice is caused by the tumour enlarging to the point where it obstructs the common bile duct, causing post-hepatic jaundice. The other cancer options would probably cause pain, as would gallstones, and cirrhosis would cause a whole host of signs not reported in this patient. Gilbert's syndrome is an isolated rise in bilirubin with what is otherwise a perfectly functional liver, and so is not concerning.

Answer 17

C. Paget's disease of the breast Paget's disease of the breast is a stage 1 in situ carcinoma that is often mistaken for eczema or some other skin complaint.

Answer 18

D. Fibroadenoma Fibroadenomas are usually found incidentally and are completely harmless. They are common, accounting for ~70% of all breast masses. They can be differentiated from fibrocystic disease because they don't tend to fluctuate so much with the menstrual cycle.

Answer 19

C. Refer to breast feeding support group and prescribe analgesia Mastitis is common when women begin to breast feed, and the best option is to give analgesia and encourage the patient to continue breast feeding. Antibiotics can be given in more serious cases. Breast abscesses are similar, but gnerally require fine needle aspiration and surgical drainage.

Answer 20

B. Early menarche Many of the risk factors for breast cancer center around increased exposure to oestrogen. Someone who begins menstruating earlier than normal will have a longer than average exposure to oestrogen. Early menopause decreases risk of breast cancer, as it decreases the length of time a woman is exposed to oestrogen for. Nullparity is a risk factor because pregnancy induces changes in breast tissue that persist after childbirth, and make the breast tissue less susceptible to carcinoma Anaemia and HIV both have no particular association with risk of developing breast cancer

Answer 21

These just seemed quite useful to learn ``` A - age F - family history R - radiation O - OCP and obesity G - genetics (e.g. known BRCA mutation) M - menarche (early) or menopause (late) A - alcohol N - nullparity ```

Answer 22

B. Urgent mammogram The patient has presented with a lump that is suggestive of breast cancer (firm and immobile) so the next step (after taking a history) is imaging. Since the patient is over 35, a mammogram is required

Answer 23

C. Blood hCG levels This is a bit of an irritating trick question, but illustrates a useful point: a beta-hCG can be done in the space of a GP appointment, and so there is no reason not to do one before referring this patient for imaging, as pregnancy could well be causing the breast changes. That said, the second best option would be refer for urgent USS, as ultrasound is better for imaging younger, denser breast tissue.

Answer 24

D. Ovarian ``` Other relevant cancer markers are: Ca19-9: pancreatic cancer Ca15-3: breast cancer Ca125: ovarian cancer aFP: liver and testicular cancer b-hCG: testicular cancer CEA: colorectal cancer ```

Answer 25

B. Duct ectasia Duct ectasia can mimic cancer (nipple retraction, pain, bloody discharge) but is a benign, self-limiting condition. You would probably advise the patient to use over the counter analgesia and wait. Thick green discharge is most commonly caused by duct ectasia, and nipple retraction or inversion is also typical, allowing duct ectasia to be distinguished from an abscess or mastitis.

Answer 26

E. Squamous cell carcinoma SCC is causes by mutation of keratinocytes, and so are hyperkeratotic and non-pigmented. The greatest risk factor is UV light exposure but chronic inflammation (wound), a family history, immunosuppression, and acitinic keratosis (pre-cancerous crusty growths) are all risk factors. SCC tends to present in older patients, is stereotypically situated on the pinna of the ear (but can occur anywhere - usually on the head), may ulcerate without healing, and has everted edges SCC needs to be referred urgently to dermatology as it is invasive and can metastasise.

Answer 27

C. Dermatology referral/assessment – routine A basal cell carcinoma is slow-spreading and rarely metastasises. From the description there is no immediate risk (e.g. to the eye) so a routine referral will suffice.

Answer 28

D. Metastases The hints here are: Lesion that should arouse suspicion of melanoma History of significant sun exposure (Maldives, caucasian) Headache characteristic of raised ICP (worse when lying down)

Answer 29

B. Molluscum contagiosum Molluscum contagiosum is a viral skin infection generally seen in schoolchildren. Small pearly papules with a dip in the middle (umbilicated centre) are classic of molluscum contagiosum. The incidence is higher in HIV patients, and HIV patients will likley have more papules, buthealthy children can contract the virus too. No treatment is necessary

Answer 30

C. Erysipelas The history of well-demarcated redness and swelling, particularly in the face, is suggestive of erysipelas - a form of bacterial (usually beta-heamolytic group A Strep) infection similar to cellulitis, but more superficial. The location and clear boundaries are what separate erysipelas from cellulitis. In addition, erysipelas generally causes more systemic symptoms of illness (malaise, fever) which is unexpected as it is more superficial than cellulitis.

Answer 31

D. Draw around the lesion, give pain relief, oral fluids and antibiotics The history of well-demarcated redness and swelling, particularly in the face, is suggestive of erysipelas - a form of Staphylococcus Aureus infection similar to cellulitis, but more superficial. The location and clear boundaries are what separate erysipelas from cellulitis, though the treatment is actually the same: antibiotics for the infection, fluids for support, and draw around the lesion so you can monitor whether it is spreading easily.

Answer 32

B. Atopic dermatitis ``` Atopis dermatitis (also called eczema) typically affects the flexor surfaces of the arms and legs (in contrast to psoriasis which affects the extensor surfaces) causing dry, itchy, red skin and is common in children. The patient's PMHx of food allergies and hayfever increase the liklehood of her skin complaint having an allergic cause, as all these complaints are part of atopic march. A family history of atopic disease (asthma) also increases the chance of this being atopic dermatitis. ```

Answer 33

A. Erythema multiforme The description of red lesions with a central clearance is typical of erythema multiforme, which can occur after herpes simplex infections (cold-sores). It can also be triggered by sulphonamide drugs and penicillin, and is associated with blood cancers (leukaemia, lymphoma, myeloma), and autoimmune conditions (RhA, SLE, sarcoidosis)

Answer 34

E. Sebhorreic eczema Sebhorreic eczema is fairly easy to identify because of the description of yellow greasy scales that particularly affect the nasolabial folds and eyebrows. Sebhorreic eczema can cause dandruff and nappy rash, and is associated with malassaezia yeasts.

Answer 35

B. Necrotising fascitis Necrotising fascitis is caused by a streptococcal infection of the deep fascia, just above the muscle. Risk factors include diabetes, malignancy, trauma, surgical wounds, and i.v. drug use, although around 50% of cases occur in previously healthy people. Necrositing fascitis warrants an emergency surgical referral for debridement. Gas may be sene underneath the soft tissue on an x-ray or CT.

Answer 36

C. III The patient has hypertensive retinopathy, which is separated into 4 grades: I - Twisting of the retinal arteries and silver wiring II - AV nipping (crossing over of arteries and veins) III - Flame haemorrhages and cotton wool spots IV - Papilloedema

Answer 37

C. Low dose dexamethasone suppression test This history is suggestive of Cushing's, which is confirmed with a low dose dexamethasone test. A high dose dexamethasone test is to determine whether the cause is Cushing's disease or syndrome. LFTs might also be done, in light of the bruising, but are not the most appropriate investigation. aFP is a marker of liver and testicular cancer. A synacthen test is used to diagnose Addison's HbA1c is used to monitor long-term glycaemic control

Answer 38

B. 24 hour urinary VMA This is a description of a phaeochromocytoma. They are very rare, but Imperial love them so it's important to know this. Episodes of agitation, headache, palpitations, and increased sweating are a common presentation of phaeochromocytoma. Blood pressure is very elevated during these episodes, but may be relatively normal inbetween. VMA is the end metabolite of catecholamines, and an increased urinary level indicates episodes of high catecholamine release. Phaeochromocytomas can feature as part of MEN2 (multiple endocrine neoplasia) along with medullary thyroid cancer, and mucosal gastrointestinal neuromas. The clues in the history are the description of the patient as tall with long limbs - this is hinting at Marfan's syndrome which is associated with MEN2B - and the mother's thyroid removal - hinting at thyroid medullary cancer which is a feature of MEN2B.

Answer 39

C. Polycystic overy syndrome Polycystic ovary syndrome is caused by excess release of androgens, in turn caused by either: High levels of LH release from the adenohypophysis Chronically elevated insulin levels. The androgens cause the symptoms of hirsutism, acne, acanthosis nigricans (dark velvety skin) and centripetal weight gain. PCOS is inherited in an autosomal dominant way, but the expression of the disease in women is variable. Whilst some of these symptoms are associated with obesity (hirsutism, oligomenorrhea, acne), the onset is too quick, and it is unusual to experience all of these symptoms together. The 'cysts' seen on ultrasound are actually immature egg follicles that have started to develop, but then stopped because of altered ovarian function.

Answer 40

D. Multiple myeloma Multiple myeloma is a cancer of plasma cells (mature B-cells) that reside in the bone marrow. The effects of MM can be remembered using CRAB: C - calcium: calcium is released from bone as it is broken down by the cancer, increasing serum calcium. This leads to polyuria, polydipsia, constipation, confusion, kidney stones, and altered mental status (stones, abdominal moans, and psychic groans). R - renal: malignant plasma cells secrete malformed proteins which damage the kidneys causing kidney failure. This in turn may lead to uraemia, causing nausea, and electrolyte imbalances e.g. hyperkalaemia, which can cause cardiac arrhythmia. In addition to the effect of proteins, the elevated serum calcium leads to calcium deposition in the kidneys, worsening the renal failure. These proteins will also cause rouleaux formation on a blood film. A - anaemia: infiltration of healthy bone marrow by malignant plasma cells causes a decrease in RBC output. Other cell lineages will also be affected, including white cells, meaning that people with MM are more vulnerable to infection. B - bone: bone pain is a very common complaint in MM and helps to differentiate the other symptoms from other causes. In MM the malignancy can spread to the extent where it compresses the spinal cord, causing radicular pain, bladder and bowel incontinence, loss of sensation, and paraplegia.

Answer 41

E. Cardiac tamponade The clue here is the presence of Beck's triad: decreased arterial pressure, muffled heart sounds, and a raised JVP. The JVP will also exhibit a paradoxical rise (Kussmaul sign) which is seen in any cause of right ventricular dysfunction.

Answer 42

C. Percutaneous coronary intervention This is a description of a STEMI Thrombolysis with alteplase is avoided if PCI is possible, though if the wait for PCI is more than 2 hours, and the patient is still within the 12 hour window from when they first experienced symptoms, thrombolysis may be attempted. B describes the long-term treatment for a STEMI D describes two anti-coagulants used in various conditions E is used for certain arrhythmias and in cardiac arrest

Answer 43

D. Normal pressure hydrocephalus Normal pressure hydrocephalus is an abnormal accumulation of CSF within the ventricles, it is idiopathic. When an elderly patient presents with a triad of ataxia, dementia, and urinary incontinence, normal pressure hydrocephalus should be a prominent differential.

Answer 44

D. Antiphospholipid syndrome Antiphospholipid syndrome is an autoimmune hypercoaguble state caused by antibodies directed at certain proteins (lupus anticoagulant and cardiolipin) causing dysfunction of Protein C (coagulation cascade regulator) and increased cleavage of prothrombin to thrombin, increasing coagulation. The incidence of antiphospholipid syndrome is increased in people with SLE. This syndrome is particularly prominent during pregnancy, where it may cause miscarriage, stillbirth, intra-uterine growth restriction, pre-eclampsia, and pre-term delivery.

Answer 45

C. Aplastic anaemia Aplastic anaemia results from damage to the haematopoeitic stem cells in the bone marrow, depleting the marrow's ability to produce cells of all lineages. It can be idiopathic, but in this case was triggered by hepatitis B infection. Certain drugs can also trigger aplastic anaemia but it is very rare. Thrombocytopenia - easy bruising Leukopenia - persistent infections Anaemia - malaise, fatigue, pallor, breathlessness, palpitations Though pancytopenia could be caused by ALL, and it does affect children, this boy is a little older than most children are when they develop the disease, and he has reported no FLAWS symptoms.

Answer 46

D. Escherichia coli This is a case of hemolytic-uraemic syndrome which occurs most often in children. It's caused by Shiga-like toxin-producing bacteria, most commonly EHEC (enterohaemhorragic Escherichia coli). HUS is usually preceded by bloody diarrhoea by roughly a week. HUS is defined by a triad of uraemia, haemolytic anaemia, and thrombocytopenia. The Shiga toxin activates the complement pathway, causing inflammation and thrombosis which tends to affect the kidneys most commonly, and most seriously. The thrombi also cause the haemolytic anaemia through microangiopathic haemolysis - they damage the endothelium of blood vessels and narrow the lumen, causing RBCs to be sheared and destroyed as they pass.

Answer 47

C. Acute lymphoblastic leukaemia ALL is usually occurs in young children, and is the most common leukaemia in children. AML, though it does occur in children, is more common in the elderly and reaches it peak incidence between 75 and 80. Haemophilia would explain the bruising, but not the fatigue. Splenomegaly may have some association with haemophilia but it is not particularly well defined.

Answer 48

A. Hodgkin's lymphoma In theory, Hodgkin's lymphoma more commonly causes B-symptoms (systems of systemic illness e.g. FLAWS) whereas non-Hodgkin's lymphoma more usually features with infiltratve symptoms. In reality, a better way to differentiate the two is that Hodgkin's lymphoma is rarer than non-Hodgkin's and can occur in younger people, whereas non-Hodgkin's lymphoma rarely occurs in younger people (peak incidence is 70). Reed-Sternberg cells will be seen on the blood film of somebody with Hodgkin's lymphoma: if the question mentions these as being present, it is definitely Hodgkin's lymphoma. The risk of both Hodgkin's and non-Hodgkin's lymphoma is increased in those who have previously had glandular fever.

Answer 49

B. CENTOR This is bacterial pharyngitis (most likely Strep), as 3 or more of the CENTOR score elements are present, making a viral cause unlikely. C - cough absent E - exudate on, or swelling of, the tonsils N - nodes, anterior cervical lymph nodes swollen or tender T - temperature of over 38 degrees OR - young or old modifying factors (under 15 add 1 point, over 44 subtract 1 point) CHA2DS2-VASc score is used to estimate the risk of stroke in atrial fibrillation. CURB65 score estimates mortality and guides treatment in pneumonia Wells score estimates the chance of a patient having had a PE based on their symptoms The duke criteria is used to diagnose infective endocarditis (the Duke staging system is used for colon cancer)

Answer 50

B. Indirect inguinal hernia Indirect inguinal hernias occur as a segment of bowel herniates through the deep inguinal ring. This is a result of an embryonic failure of the process vaginalis to close. A direct hernia occurs when bowel herniates through a weakpoint in the transversalis fascia. The weakpoing is within Hesslebach’s triangle which is bordered laterally by the inferior epigastric artery, medially by the linea semilunaris (edge of the rectus abdominis), and inferiorly by the inguinal ligament. To distinguish between the two, the hernia is reduced (pushed back into the abdomen) and the doctor places their thumb over the inguinal midpoint and asks the patient to cough. If the hernia reapperas, it is a direct hernia, and if not it is an indirect hernia. NB: the key feature of a scrotal lump that indicates it is a hernia, is that the dictor is unable to ‘get above it’

Answer 51

A. Schirmer’s Test Schirmer's test is used to monitor tear production, and is an investigation for Sjogren's syndrome. Sjogren's is an autoimmune condition affecting the exocrine glands of the body, and is most common in middle aged women. Patients may report dry eyes, dry mouth (with associated dysphagia and loss of taste), painful sex (decreased lubrication in women), dry cough, hair loss, and dry skin. The main antibodies seen in Sjogren's are anti-Rho (SS-A) and anti-La (SS-B). Sjogren's is associated with other autoimmune conditions (primary biliary cirrhosis, RhA, SLE) and increases the risk of non-Hodgkin's lymphoma. Extra-glandular manifestations include interstitial nephritis, Raynaud's phenomenon, vasculitis, lymphadenopathy, and hepatobiliary disease. Antibodies to know: pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis cANCA: Polyangitis with granulomatosis Anti-mitochondrial: primary biliary cirrhosis Anti-Scl70: diffuse scleroderma Anti-centromere: CREST syndrome Anti-Rho and Anti-La: Sjogren's syndrome Anti-dsDNA: SLE Anti-Smith: SLE Anti-CCP: Rheumatoid arthritis Anti-glomeruler basement membrane: Goodpasture's syndrome Anti-smooth muscle: autoimmune hepatitis Lupus anticoagulant: antiphospholipid syndrome Anti-cardiolipin: antiphospholipid syndrome

Answer 52

D. Chest X-ray This is a description of sarcoidosis, a condition causing non-caseating granulomas which most typically affect the lungs, but can affect any organ. Sarcoidosis causes lung fibrosis which can be seen on an x-ray, along with bilateral hilar lymphadenopathy. Sarcoidosis also causes raised ACE and calcium serum levels. Signs of sarcoidosis include erythema nodosum, uveitis, lupus pernio, a history of dry cough and weight loss, parotid gland swelling, and diabetes insipidus.

Answer 53

C. Anti-centromere antibodies ACA are an antibody frequently seen in CREST syndrome (a type of scleroderma), but less frequently in the diffuse variant of the disease. Anti-scl70 is seen more in diffuse scleroderma than CRESt, but is not very sensitive. CREST is the limited form of the disease, which typically affects the hands, face, and fingers. Diffuse scleroderma may affect the heart, lungs, kidneys, and GI tract in addition. CREST is an acronym which refers to the features that define the disease: Calcification Raynaud's phenomenon Esophageal dysmotility Sclerodactyl (thickening and ulceration of the skin of the fingers) Telangiectasia Antibodies to know: pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis cANCA: Polyangitis with granulomatosis Anti-mitochondrial: primary biliary cirrhosis Anti-Scl70: diffuse scleroderma Anti-centromere: CREST syndrome Anti-Rho and Anti-La: Sjogren's syndrome Anti-dsDNA: SLE Anti-Smith: SLE Anti-CCP: Rheumatoid arthritis Anti-glomeruler basement membrane: Goodpasture's syndrome Anti-smooth muscle: autoimmune hepatitis Lupus anticoagulant: antiphospholipid syndrome Anti-cardiolipin: antiphospholipid syndrome

Answer 54

E. Antinuclear Antibodies These skin symptoms are indicative of systemic lupus erythematosus. Anti-nuclear antibodies are present in multiple autoimmune diseases: the two important ones in SLE are anti-dsDNA (highly specific for SLE) and anti-Smith. Blood tests sometimes reveal anaemia of chronic disease, thrombocytopenia, and leukopenia, and often reveal increased ESR. Antiphospholipid syndrome is strongly associated with SLE, and so associated antibodies are often seen in SLE. SLE, like other autoimmune conditions, can affect most organs, but typically affect the skin, muscles, and joints causing arthritis, oral ulcers, rashes, and serositis. Antibodies to know: pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis cANCA: Polyangitis with granulomatosis Anti-mitochondrial: primary biliary cirrhosis Anti-Scl70: diffuse scleroderma Anti-centromere: CREST syndrome Anti-Rho and Anti-La: Sjogren's syndrome Anti-dsDNA: SLE Anti-Smith: SLE Anti-CCP: Rheumatoid arthritis Anti-glomeruler basement membrane: Goodpasture's syndrome Anti-smooth muscle: autoimmune hepatitis Lupus anticoagulant: antiphospholipid syndrome Anti-cardiolipin: antiphospholipid syndrome

Answer 55

C. Prolonged aPTT Haemarthrosis (bleeding into the joint) is indicative of haemophilia. You can't tell from this history which type of haemophilia the patient has (though A is 6 times more common than B) but the blood test result would be the same for any type of haemophilia because all the different clotting factors that can deficient in haemophilia are involved in the intrinsic pathway, which is tested with an aPTT test. PT tests the extrinsic pathway, and INR is just a ratio of patient's PT over normal PT. Vitamin K is needed to activate factors II, VII, IX, and X to allow them to bind to endothelium, and so vitamin K deficiency would cause prolonged aPTT and PT as it affects factors in both the intrinsic and extrinsic pathways.

Answer 56

D. Needle-shaped crystals with a negative birefringence This history describes gout: elevated uric acid levels in the blood leading to uric crystals being deposited in the joints. Typically the metacarpo-phalangeal joint of the big toe is affected (this is called podagra). The swellings on the ear are tophi - deposits of uric crystals that are pathognomic of gout. Risk factors include obesity, alcohol intake, and high red meat intake, along with genetic susceptibility. A and C are both features of pseudo-gout, which involves calcium rather than uric acid.

Answer 57

C. Polyarteritis nodosa Polyarteritis nodosa is an inflammatory disease of small and medium-sized blood vessels that often affects the kidneys, but generally spares the lungs. It causes multiple aneurysms to form along the same blood vessel causing a 'rosary bead' appearance on an angiogram. PN is associates with hepatitis B.

Answer 58

D. Leukotriene receptor antagonist Guidelines: 1) For patients who have infrequent short-lived wheezes with normal lung function, consider a short-acting beta agonist with no additional therapy. 2) For patients with frequent episodes or asthma uncontrolled by SABA, prescribe a low-dose inhaled corticosteroid 3) If the low-dose ICS does not control symptoms, add a leukotriene receptor antagonist 4) If combined maintenance therapy with ICS and LRA does not manage symptoms, add a long-acting beta agonist and consider discontinuing LRA. 5) If ICS and LABA (with or without LRA) fails to control symptoms, switch the patient to MART (combined ICS and LABA inhaler) 6) If MART does not control symptoms, increase the ICS dose to a moderate dose, either as part of MART, or as a fixed dose regimen with a LABA, and a SABA to use when required. 7) If moderate dose ICS and LABA does not control symptoms, increase the dose to high dose ICS on a fixed schedule with a SABA when needed. Alternatively carry on as in step 6, but add a long-acting muscarinic antagonist or theophylline

Answer 59

A. Coffee bean sign This history is suggestive of a sigmoid volvulus - where a loop of bowel twists around on the axis of its mesentery. The classic radiological sign of a sigmoid volvulus is the coffee bean sign on AXR. A bird's beak sign may also be seen, but only with a contrast enema.

Answer 60

C. Thrombotic thrombocytopenic purpura TTP is typically associated with antibodies against an enzyme that cleaves Von-Willebrand factor, leading to an abnormally high amount of VWf in the blood. This causes clotting in small blood vessels, and a consequent thrombocytopenia leading to bleeding. Microangiopathic haemolytic anaemia is a feature of TTP which is caused by damage to RBCs as they pass through vessels that have been occluded by thrombi. This causes the RBCs to shear, resulting in a haemolytic anaemia, which may also cause s pre-hepatic jaundice. Haemolytic-uraemic syndrome may present similarly to TTP, but usually occurs in children and will feature a history of gastrointestinal infection. ``` The classic pentad of TTP rarely occurs together but is as follows: Fever Microangiopathic haemolytic anaemia Mental state changes Renal impairment Thrombocytopenia ```

Answer 61

C. Reactive arthritis Defined as a triad of urethritis, conjunctivitis, and arthritis following infection, reactive arthritis is a non-septic, autoimmune reaction causing asymmetrical oligoarthritis of the lower limbs. It is associated with HLA B27 and is triggered by genitourinary (chlamydia) or gastrointestinal infection (campylobacter, salmonella, shigella). Arthritis usually follows between 1-4 weeks after infection and includes extra-articular manifestations: enthesitis (plantar fascitis, dactylitis, achilles tendonitis), conjunctivitis, and skin inflammation (circinate balantitis - lesions on the glans, and keratoderma blenorrhagicum - a psoriasis-like rash on the palms and soles of the feet))

Answer 62

A. Acute Lymphoblastic Leukaemia ALL is the most common cancer from the options in young children, and is an aggressive cancer, though it does respond well to treatment. ALL causes anaemia (tiredness) and thrombocytopenia (petechiae) through 'crowding out' of healthy cell production in the bone marrow. Testicular and lymph node swelling are both seen in ALL, and testicular infiltration can be problematic, as chemotherapy does not target cancerous cells in the testes particularly well.

Answer 63

D. Symptomatic, single fasting plasma glucose> 6.9 mmol/L To diagnose diabetes you need a random blood glucose >11.1 or a fasting blood glucose >6.9. If the patient is symptomatic, only one measurement is needed, but if the patient is asymptomatic, two separate readings on different days are needed.

Answer 64

D. Fluid Replacement This patient is in diabetic ketoacidosis. Ketoacidosis is usually accompanied by dehydration, so the most important first step is to administer i.v. fluids. This is initially saline and potassium chloride (hypokalaemia is a dangerous complication of DKA as potassium is lost in the urine). Insulin is also given (glucose is added when the blood sugar drops below 14mmol).

Answer 65

C. Review medication Lithium is used to treat diabetes and can cause nephrogenic diabetes insipidus. Treatment for nephrogenic is medication review, thiazides, NSAIDs, and sometimes high dose desmopressin

Answer 66

D. CCB or beta blocker Guidelines: Step 1: CCB or beta blocker Step 2: if one is ineffective, either switch to the other one, or use both ``` If CCB and beta blockers are both contraindicated, or if the other drug is contraindicated at step 2, use one of the following instead: Nicorandil Ivabradine Long-acting nitrates Ranolzaine ``` Aspirin and statins are also used for prevention of further cardiovascular disease

Answer 67

C. Spironolactone Guidelines: Step 1: ACEi or ARB Step 2: ACEi with CCB Step 3: ACEi with CCB and thiazide-like diuretic (e.g. indapamide) Step 4: ACEi with CCB and thiazide-like diuretic (e.g. indapamide) and spironolactone If step 4 is ineffective or spironolactone is contraindicated, alpha or beta blockers may be used. The exception to these guidelines is patients who are Afro-Carribean or over the age of 55, in which case a thiazide-like diuretic or CCB is indicated for step 1. If ACEi can't be tolerated (e.g. due to cough) an ARB is an acceptable alternative, but the two are not used together.

Answer 68

C. Transmural non-caseating granulamtous inflammation Cobblestoning of the terminal ileum may be seen on endoscopy, but rose thorn ulcers are seen on a barium follow through. Mucosal ulcers, depletion of goblet cells, and crypt abscesses are signs of UC seen on a biopsy. Lead pipe mucosa is a sign of UC seen in a contrast barium enema, where chronic UC destroys the normal architecture of the colon. Continuous inflammation from the rectum to the distal segment of the transverse colon is more indicative of UC, which particularly affects the rectum and spreads in a continuous fashion proximally. By contrast, Crohn's can affect any part of the GIT and often causes skip lesions.

Answer 69

B. TTG ab Antibodies against TTG are a sensitive and specific test for coeliac disease, which is described here. Biopsy is the gold standard and so would ultimately be needed to confirm the diagnosis, but TTGab is a less invasive initial test. Coeliac disease is an autoimmune reaction triggered bu ingestion of gluten. The autoantibodies produced attack the villi of the small intestine, causing villous atrophy that can be seen on a duodenal biopsy. The vesicular rash described is dermatitis herpetiformis - a rash resembling herpes that is associated with coeliac disease.

Answer 70

C. Chronic infection IgG is the most useful marker here: If IgG is present with IgM, it is an acute infection If IgG is present with HBsAb, the infection has been cleared If IgG is present without either IgM or HBsAb, it is a chronic infection If HBsAb is present alone, the patient has been vaccinated If IgM is present, it is an acute infection

Answer 71

C. Add a DPP-4 inhibitor Metformin is first line for type II diabetes, but if a patient's HbA1c rises above 7.5% on metformin, addition of a DPP-4i, pioglitazone, sulphonylurea, or a SGLT-2 inhibitor is indicated. Insulin is used for control when multiple therapy with other drugs has failed. Acarbose is not very widely used n the UK, paritally due to the unpleasant side-effects of flatulence and diarrhoea.

Answer 72

D. Grade II 120/80 = optimal 120-129 and/or 80-84 = normal 130-139 and/or 85-89 = high normal 140-159 and/or 90-99 = grade I hypertension 160-179 and/or 100-109 = grade II hypertension 180+ and/or 110+ = grade III hypertension (malignant) 140+ and <90 = isolated systolic hypertension

Answer 73

C. Entamoeba histolytica The other organisms do not generally cause bloody diarrhoea The acronym to remmeber organisms that cause bloody diarrhoea is CHESS: C - Campylobacter jejuni H - Haemorrhagic E.coli (especially 0157:H7) E - Entamoeba histolytica S - Shigella S - Salmonella

Answer 74

B. A pulse rate of 115 and a resp rate of 28 Exacerbations of asthma are divided into 3 categories: Moderate: PEFR 50-75% predicted/ previous best, patient is still able to speak normally. Acute severe: PEFR 33-50% predicted/ previous best with oxygen saturation of at least 92%, OR patient can't complete sentences in one breath, OR heart rate is above 110bpm, OR respiratory rate is above 25 bpm, OR the patient is having to use accessory muscles to breathe Life-threatening: PEFR <33% predicted/ previous best, OR oxygen saturation is below 92%, OR a silent chest is heard, OR respiratory effort becomes poor, OR cyanosis, OR hypotension, OR cardiac arrhythmia, OR altered consciousness/ confusion

Answer 75

E. Anti-smooth muscle Antibodies to know: pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis cANCA: Polyangitis with granulomatosis Anti-mitochondrial: primary biliary cirrhosis Anti-Scl70: diffuse scleroderma Anti-centromere: CREST syndrome Anti-Rho and Anti-La: Sjogren's syndrome Anti-dsDNA: SLE Anti-Smith: SLE Anti-CCP: Rheumatoid arthritis Anti-glomeruler basement membrane: Goodpasture's syndrome Anti-smooth muscle: autoimmune hepatitis Lupus anticoagulant: antiphospholipid syndrome Anti-cardiolipin: antiphospholipid syndrome

Answer 76

B. Trimethoprim Trimethoprim or nitrofurantoin is used to treat UTIs, the most common cause of which is E.coli.

Answer 77

B. NG tube insertion and i.v. fluids This is a history of a man with bowel obstruction. The first step with bowel obstruction is to make the patient nil by mouth, establish i.v. access and give fluids, and insert an NG tube. The NG tube can then be used to decompress the dilated segment of bowel proximal to the blockage. From there, AXR is used to monitor the blockage, as it may well resolve on its own. Conservative management involves giving fluid support, anti-emetics, and opiods. If indicated by AXR, surgery can be performed to relieve the blockage.

Answer 78

B. Polyangitis with granulomatosis This is a history of polyangitis with granulomatosis, which is defined by a triad of upper respiratory tract (nosebleeds), lower respiratory tract (haemoptysis, and kidney (glomerulonephrits) involvement. Other features of polyangitis with graulomatosis include destruction of the nose, giving it a 'saddle' shape, cavitating lesions on CXR, and arthritis. Polyangitis with granulomatosis is heavily associated with cANCA antibodies Antibodies to know: pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis cANCA: Polyangitis with granulomatosis Anti-mitochondrial: primary biliary cirrhosis Anti-Scl70: diffuse scleroderma Anti-centromere: CREST syndrome Anti-Rho and Anti-La: Sjogren's syndrome Anti-dsDNA: SLE Anti-Smith: SLE Anti-CCP: Rheumatoid arthritis Anti-glomeruler basement membrane: Goodpasture's syndrome Anti-smooth muscle: autoimmune hepatitis Lupus anticoagulant: antiphospholipid syndrome Anti-cardiolipin: antiphospholipid syndrome

Answer 79

C. Omperazole with amoxicillin and clarithromycin For peptic and duodenal ulcers, triple therapy is used. This consists of two antibiotics (either amoxicillin and clarithromycin, or metronidazole and clarithromycin) and a proton-pump inhibitor (omeprazole, lansoprazole). This drug regimen is taken for a week, with each drug being taken twice daily.

Answer 80

D. Give clopidogrel and unfractionated heparin When treating an NSETMI, the first step is 300mg aspirin. Fondaparinux is also offered, unless the patient is likely to undergo angiography/ PCI, in which case unfractionated heparin is given. The next step is to formally assess the 6-month mortality with a GRACE score, which will more definitively guide conservative or invasive treatment. If the patient is likely to undergo coronary angiography/ PCI, or their GRACE score reveals a mortality of 1.5% or greater, 300mg clopidogrel is also given. In reality clopidogrel is usually given

Answer 81

E. pANCA This is a history of Churg-Strauss syndrome, a vasculitis of the small and medium sized blood vessels associated with asthma, associated with pANCA and characterised by three phases of progression: Allergic: the patient experiences asthma or rhinitis Hypereosinophillic: mostly affects lungs and GI causing abdominal pain, GI bleeding, cough, fever, night sweats, weight loss Vasculitic: blood vessels become inflamed causing clots and infarction, peritonitis, GI perforation, and inflammation of the heart muscle Antibodies to know: pANCA: primary sclerosing cholangitis, Churg-Strauss syndrome, microscopic polyangitis cANCA: Polyangitis with granulomatosis Anti-mitochondrial: primary biliary cirrhosis Anti-Scl70: diffuse scleroderma Anti-centromere: CREST syndrome Anti-Rho and Anti-La: Sjogren's syndrome Anti-dsDNA: SLE Anti-Smith: SLE Anti-CCP: Rheumatoid arthritis Anti-glomeruler basement membrane: Goodpasture's syndrome Anti-smooth muscle: autoimmune hepatitis Lupus anticoagulant: antiphospholipid syndrome Anti-cardiolipin: antiphospholipid syndrome

Answer 82

A. MEN2A Multiple endocrine neoplasia is a group of autosomal dominant conditions causing tumours to form in endocrine tissues. This history hints at a medullary thyroid carcinoma, along with a phaeochromocytoma, which points to MEN2A. MEN2B is also possible, but less likely given the absence of marfinoid habitus (tall, thin, gangly). MEN1 Pituitary tumours Parathyroid hyperplasia Pancreatic tumours MEN2A Parathyroid hyperplasia Medullary thyroid cancer Phaeochromocytoma ``` MEN2B Marfinoid habitus Mucosal neuromas Medullary thyroid cancer Phaeochromocytoma ```

Answer 83

E. Small cell carcinoma Small cell carcinoma is an aggressive cancer that is heavily associated with smoking. Small cell is also linked to certain paraneoplastic syndromes, in this case SIADH which is caused by ADH release from the tumour and leads to a euvolemic hyponatraemia.

Answer 84

D. Primary ciliary dyskinesia Primary ciliary dyskinesia is when a lack of synchronised ciliary movement results in a failure to clear mucous from the body. This leads to frequent chest, sinus, and ear infections, infertility in males, and eventual widespread bronchiecstasis. Situs inversus may be present - the organs may be mirrored on to the wrong side of the body (e.g. heart is on the right). If situs inversus is present, along with bronchiecstasis and chronic sinusitis, the patient has Kartagener syndrome

Answer 85

C. Atypical lymphocytes This is a history of infectious mononucleosis (the kissing disease) which causes pharyngitis, lymphadenopathy (particularly in the anterior cervical chain), generic flu symptoms, and splenomegaly. A heterophile antibody test (also called Monspot test) is a quick way to diagnose infectious mononucleosis. Smear cells are indicative of chronic lymphocytic leukaemia Auer rods are indicative of acute myeloid leukaemia Reed-Sternberg cells are indicative of Hodgkin's lymphoma Dacrocytes are are indicative of myelofibrosis

Answer 86

B. Middle cerebral artery infarct Here are rough guides for stroke Anterior cerebral artery: paralysis of contralateral leg>arm and face, disturbance of executive function, and personality Middle cerebral artery: paralysis of contralateral arm and face>leg, aphasia (left sided lesion), visuospatial neglect, contralateral hemisensory defect Posterior cerebral artery: homonymous hemianopia, visual agnosia, Anton-Babinski syndrome (patient is blind but believes they can see) Lateral medullary syndrome is a niche syndrome caused by infarction in the posterior inferior cerebral artery. Symptoms include cerebellar (ipsilateral dysdiadochokinseia, ataxia, dysmetria), spinothalamic (contralateral deficit in heat and pain sensation on the body), trigeminal (ipsilateral deficit in heat and pain sensation on the face, Horner's syndrome (ipsilateral loss of sympathetic innervation), and vagus and glossopharyngeal (ipsilateral defects causing hoarseness, dysphagia and absent gag reflex).

Answer 87

E. Pseudomonas aeruginosa ``` Pseudomonas is an organism that often causes nosocomial infections. Cystic fibrosis patients are particularly susceptible to pseudomonas infections. The pathogens which commonly causes nosocomial infections can be remembered as the ESKAPE pathogens: E - enterococcus S - staphylococcus K - klebsiella A - acinetobacter P - pseudomonas E - enterobacter ```

Answer 88

B. >60 mmol/L A result of above 60 mmol/L indicates CF. Below 40 mmol/L rules out CF. An in-between measurement is ambiguous.

Answer 89

B. Adenocarcinoma Adenocarcinoma is the most common lung cancer in never-smokers and usually occurs in the peripheral lung. It is more common in women and is the most likely parenchymal tumour to have pleural involvement.

Answer 90

C. CT head Whilst this patient is within the 4.5 hour thrombolytic window and so alteplase followed by aspirin would be an appropriate treatment, but first a haemorrhagic stroke must be excluded. If a CT head is not done, and a patient with a haemorrhagic stroke is given thrombolysis, they will die, so it's an important diagnosis to exclude.

Answer 91

D. Minimal change disease MCD is an idiopathic condition, and is comfortably the most common cause of nephrotic syndrome in young children, and still a prominent one in teenagers

Answer 92

C. HLA B27 This is a history of ankylosing spondylitis, an autoimmune arthopathy most common in young men that causes inflammation in, and progressive stiffening of, the spine. Typical presentation is of low back pain and stiffness that is worse in the morning and improves with exercise. Like many autoimmune join conditions, it has extra-articular manifestations, which can be remembered as the 5 a's: Apical lung fibrosis Amyloidosis Achilles tendonitis Anterior uveitis Aortic regurgitation The murmur described in this question is typical of aortic regurgitation.

Answer 93

A. Kidney stone Though the CT KUB was normal, this does not rule out a kidney stone, as kidney stones can be radio lucent depending on the material. This man's PMHx indicates gout, which is a risk factor for uric acid kidney stones.

Answer 94

C. Dermatomyositis Dermatomyositis is an inflammatory disorder causing skin rashes (face, particularly eyes, and extensor surfaces) and progressive muscle weakness. Arthritis, lung involvement, and GI bleeding are less common manifestations.

Answer 95

C. Clear CSF, high lymphocytes, high protein, normal glucose Bacterial meningitis: Cloudy CSF, high neutrophils, high protein, low glucose Viral meningitis: Clear CSF, high lymphocytes, high protein, normal glucose Fungal/ TB meningitis: Fibrinous CSF, high lymphocytes, high protein, low glucose

Answer 96

D. Encephalitis Encephalitis is most commonly cause by herpes simplex-1 and causes inflammation of the brain parenchyma. The patient will commonly experience headache and fever initially, then behavioural abnormalities, focal neurology (e.g. muscle weakness), confusion, and seizures.

Answer 97

C. Neurofibromatosis type 1 Neurofibromatosis causes neurofibromas (here mistaken for moles), café au lait macules (brown patches), Lisch nodules (brown nodules in the eye), and scoliosis. Neurofibromatosis type 2 involves the growth of bilatetral schwannomas (tumours on cranial nerve VIII) which can lead to hearing loss.

Answer 98

B. Duodenal ulcer Duodenal ulcers usually present with pain that is helped by eating, but reoccurs a couple of hours later - this is because the pyloric sphincter in the stomach closes when food enters, stopping acid from entering the duodenum and aggravating the ulcer. By contrast, a peptic ulcer causes pain that becomes worse on eating. Both are associated with H. pylori and treated with a PPI and two antibiotics (metronidazole/ amoxicillin with clarithromycin)

Answer 99

C. OGD endoscopy The history of long-term upper abdominal pain soon after meals suggests a peptic ulcer. The best way to investigate this is by visualising it with an endoscopy.

Answer 100

E. Trial PPI The heartburn, dysphagia, odd taste, and cough are all suggestive of GORD. The first step in the management of GORD is a trial of a PPI. If this does not work, the diagnosis of GORD is reconsidered.

Answer 101

E. Barrett's oesophagus

Answer 102

A. Achalasia Achalasia is a failure of the lower oesophageal sphincter to open at the appropriate time, resulting in a loss of oesophageal motility. GORD can lead to achalasia, and has in the case of this patient, whose nocturnal cough and heartburn indicate GORD. A bird-beak appearance in the oesophagus on barium swallow indicates achalasia. A bird beak appearance in the colon on barium follow-through indicates sigmoid volvulus.

Answer 103

B. Oesophgeal cancer This is a history of dysphagia and melaena (dark, tarry, foul-smelling stool) on a background of weight loss in an elderly patient, all of which points to oesophageal cancer.

Answer 104

B. Mallory-Weiss tear

Answer 105

D. Boerhaave syndrome Boerhaave syndrome is oesophageal rupture due to vomiting. Mackler's triad is rarely fully present in Boerhaave syndrome, but consists of subcutaenous emphysema, chest pain, and vomiting.

Answer 106

D. IBS A history of chronic generic bowel symptoms with no red flags, and particularly with symptoms that are relieved on defecation, supports a diagnosis of IBS.

Answer 107

C. Crohn's disease Crohn's disease usually presents with diarrhoea that is not bloody or mucoid (unlike UC). A pale appearance indicates anaemia which can occur in a flare-up of IBD, and mouth ulcers are also associated with IBD> The element of this history that makes Crohn's more likely is the absence of blood and mucous.

Answer 108

B. Ulcerative colitis Ulcerative colitis classically causes abdominal pain and bloody mucoid diarrhoea. It can have extra-GI symptoms, such as uveitis, seronegative arthritis, erythema nodosum (inflammation of fat cells that can be seen through the skin, often on the shins) and pyoderma gangrenosum (painful ulceration of the skin with violet margins). UC is heavily associated with primary sclerosing cholangitis, and signs of UC include apthous mouth ulcers, and clubbing,

Answer 109

B. Oral prednisolone This is a flare-up of what is probably UC (LIF pain indicates UC as Crohn's usually spares the rectum, whereas RIF pain indicates Crohn's because UC usually spares the terminal ileum). First-line treatment for a flare-up is oral steroids.

Answer 110

B. Anal fissure Agonising defecation along with fresh blood should always make you think of an anal fissure - a tear in the mucosa of the anus.

Answer 111

D. Abdominal exam Whilst referral to surgeons and an FBC will be needed, the first step is an abdominal exam. Get into the habit of thinking of bedside tests and exams, then bloods, then imaging.

Answer 112

B. Acute lymphoblastic leukaemia Guide to haematological malignancy: ALL: The patient is a young child with acute onset (weeks) fatigue, bruising, and infections. A blood film will show a high number of blast lymphocytes and crowding out of normal cells. They may also have testicular swelling. AML: The patient is older and with acute onset (weeks) fatigue, bruising and infections. A blood film will show blast cells of multiple different lineages and crowding out of normal cells. Auer rods will be seen in the cytoplasm of blast cells. AML is also associated with DIC. CLL: The patient is elderly and with chronic onset fatigue, with weight loss, and fever, though commonly the patient will be asymptomatic and CLL will be an incidental finding. If the disease is caught late, bruising, fatigue, and recurrent infections may be reported. A blood film will show high numbers of mature lymphocytes (with crowding out only in late stages) and smudge/ smear cells. CML: The patient is elderly and with chronic onset fatigue, with weight loss, and fever, though commonly the patient will be asymptomatic and CLL will be an incidental finding. If the disease is caught late, bruising, fatigue, and recurrent infections may be reported. A blood film will show an elevated number of mature white cells of all lineages. CML is strongly associated with the Philadelphia chromosome, which can be seen on cytogenetic testing of bone marrow aspirate. NB gout can be associated with leukaemia, as the increased breakdown of abnormal cells leads to hyperuricaemia

Answer 113

D. Peripheral arterial disease Smoking increases the risk of arterial disease, and in this case the arteries supplying the patient's legs have become occluded causing ischaemic pain when she exerts herself.

Answer 114

C. Ruptured AAA Sudden abdominal pain radiating to the back and/or flanks is consistent with the rupturing of an abdominal aortic aneurysm. Grey-Turner's sign is bruising in the flanks, whilst Cullen's sign is bruising around the umbilicus: both are signs of retroperitoneal bleeding (e.g. haemorrhagic pancreatitis, ruptured AAA).

Answer 115

B. Acute myeloid leukaemia Guide to haematological malignancy: ALL: The patient is a young child with acute onset (weeks) fatigue, bruising, and infections. A blood film will show a high number of blast lymphocytes and crowding out of normal cells. They may also have testicular swelling. AML: The patient is older and with acute onset (weeks) fatigue, bruising and infections. A blood film will show blast cells of multiple different lineages and crowding out of normal cells. Auer rods will be seen in the cytoplasm of blast cells. AML is also associated with DIC. CLL: The patient is elderly and with chronic onset fatigue, with weight loss, and fever, though commonly the patient will be asymptomatic and CLL will be an incidental finding. If the disease is caught late, bruising, fatigue, and recurrent infections may be reported. A blood film will show high numbers of mature lymphocytes (with crowding out only in late stages) and smudge/ smear cells. CML: The patient is elderly is often diagnosed during the chronic asymptomatic phase after an incidental finding. A blood film will show an elevated number of mature neutrophils and myelocytes, with a massive white cell count (50-200). Physical examination may well reveal massive hepatosplenomegaly. However CML can accelerate into an acute phase where myeloblasts become visible in peripheral blood, and bleeding, anaemia, or recurrent infections occur. CML is always associated with the Philadelphia chromosome, which can be seen on cytogenetic testing of bone marrow aspirate. NB: the presence of the Philadelphia chromosome is not 100% specific as it may also appear in ALL. NB gout can be associated with leukaemia, as the increased breakdown of abnormal cells leads to hyperuricaemia

Answer 116

C. Chronic lymphocytic leukaemia Smudge cells are mature, but poorly formed lymphocytes that break upon preparation for viewing. Guide to haematological malignancy: ALL: The patient is a young child with acute onset (weeks) fatigue, bruising, and infections. A blood film will show a high number of blast lymphocytes and crowding out of normal cells. They may also have testicular swelling. AML: The patient is older and with acute onset (weeks) fatigue, bruising and infections. A blood film will show blast cells of multiple different lineages and crowding out of normal cells. Auer rods will be seen in the cytoplasm of blast cells. AML is also associated with DIC. CLL: The patient is elderly and with chronic onset fatigue, with weight loss, and fever, though commonly the patient will be asymptomatic and CLL will be an incidental finding. If the disease is caught late, bruising, fatigue, and recurrent infections may be reported. A blood film will show high numbers of mature lymphocytes (with crowding out only in late stages) and smudge/ smear cells. CML: The patient is elderly and with chronic onset fatigue, with weight loss, and fever, though commonly the patient will be asymptomatic and CLL will be an incidental finding. If the disease is caught late, bruising, fatigue, and recurrent infections may be reported. A blood film will show an elevated number of mature white cells of all lineages. CML is strongly associated with the Philadelphia chromosome, which can be seen on cytogenetic testing of bone marrow aspirate. NB gout can be associated with leukaemia, as the increased breakdown of abnormal cells leads to hyperuricaemia

Answer 117

E. Dalteparin NICE guidelines state that a LMWH or Fondaparinux should be used in treatment of a DVT. Warfarin is used in the treatment of a PE. A Wells score is used to calculate the likelihood of DVT in a patient, with one point being assigned for each of: Active cancer (treatment ongoing, within the last 6 months, or palliative). Paralysis, paresis, or recent plaster immobilization of the legs. Recently bedridden for 3 days or more, or major surgery within the last 12 weeks requiring general or local anaesthetics. Localized tenderness along the distribution of the deep venous system (such as the back of the calf). Entire leg is swollen. Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity). Pitting oedema (greater than on the asymptomatic leg). Collateral superficial veins (non-varicose). Previously documented DVT. A Wells of 2 or more indicates that a DVT is likely. If DVT is likely, perform a leg vein USS If DVT is unlikely, perform a D-dimer test

Answer 118

D. Amputation Loss of sensation and paralysis are the key hints that a limb is no longer viable and must be amputated.

Answer 119

D. ABPI Ankle-brachial pulse index compares the arterial pressure in the arm with that in the ankle. This is used to tell whether there is stenosis of vasculature in the legs.

Answer 120

C. Leg Vein USS This is a history of a DVT A Wells of 2 or more indicates that a DVT is likely. If DVT is likely, perform a leg vein USS If DVT is unlikely, perform a D-dimer test. A Wells score is used to calculate the likelihood of DVT in a patient, with one point being assigned for each of: Active cancer (treatment ongoing, within the last 6 months, or palliative). Paralysis, paresis, or recent plaster immobilization of the legs. Recently bedridden for 3 days or more, or major surgery within the last 12 weeks requiring general or local anaesthetics. Localized tenderness along the distribution of the deep venous system (such as the back of the calf). Entire leg is swollen. Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity). Pitting oedema (greater than on the asymptomatic leg). Collateral superficial veins (non-varicose). Previously documented DVT.

Answer 121

A. Hodgkin lymphoma In theory, Hodgkin's lymphoma more commonly causes B-symptoms (systems of systemic illness e.g. FLAWS) whereas non-Hodgkin's lymphoma more usually features with infiltratve symptoms. In reality, a better way to differentiate the two is that Hodgkin's lymphoma is rarer than non-Hodgkin's and can occur in younger people, whereas non-Hodgkin's lymphoma rarely occurs in younger people (peak incidence is 70). Reed-Sternberg cells will be seen on the blood film of somebody with Hodgkin's lymphoma: if the question mentions these as being present, it is definitely Hodgkin's lymphoma. The risk of both Hodgkin's and non-Hodgkin's lymphoma is increased in those who have previously had glandular fever.

Answer 122

E. Troponin Troponin is an enzyme released from heart muscle when it is damaged, and so will give an indication of whether the patient has had an MI or is experiencing angina.

Answer 123

C. NSTEMI This history is suggestive of an MI (collapse, sweating, vomiting, positive troponin) which must be an NSTEMI as ECG is normal. The absence of chest pain is probably due to autonomic neuropathy as a consequence of the patient's diabetes.

Answer 124

D. Unstable Angina Chest pain occurring at rest indicates unstable angina: i.e. the patient's arteries have become so occluded they can't supply enough blood to his heart even when he's not exerting himself. The patient has clear risk factors for cardiovascular disease, and the pain he's felt whilst playing sport has been caused by stable angina, which has now worsened. A negative troponin makes a myocardial infarction unlikely.

Answer 125

D. Aspirin/Clopidogrel 300mg The first step in the management of a STEMI is a 300mg loading dose of aspirin, or clopidogrel if aspirin is contraindicated.

Answer 126

D. PCI PCI should be attempted as soon as possible in the case of a STEMI. If PCI cannot be delivered within 2 hours of the time when fibrinolysis could be given, a thrombolytic drug should be considered.

Answer 127

C. Fondaparinux This is either an NSTEMI or unstable angina, but either way the initial management is the same because they are very closely related conditions Oxygen if there is evidence of hypoxia or pulmonary oedema Nitrates for pain relief Aspirin and clopidogrel with one of: unfractionated heparin, LMWH, or fondaparinux Beta blockers Eptifibatide, abciximab, or tirofiban may also be used in particularly high risk patients

Answer 128

D. Heparin Standard therapy for everyone who has had an MI is to be offered the following drugs: ACEi Statins Dual antiplatelet therapy (aspirin + 1 other) Beta blocker

Answer 129

C. Serum/urine electrophoresis This is a history of multiple myeloma. To diagnose MM, electrophoresis is used to identify the abnormal light chain proteins produced by the abnormal plasma cells. Multiple myeloma is a cancer of plasma cells (mature B-cells) that reside in the bone marrow. The effects of MM can be remembered using CRAB: C - calcium: calcium is released from bone as it is broken down by the cancer, increasing serum calcium. This leads to polyuria, polydipsia, constipation, confusion, kidney stones, and altered mental status (stones, abdominal moans, and psychic groans). R - renal: malignant plasma cells secrete malformed proteins which damage the kidneys causing kidney failure. This in turn may lead to uraemia, causing nausea, and electrolyte imbalances e.g. hyperkalaemia, which can cause cardiac arrhythmia. In addition to the effect of proteins, the elevated serum calcium leads to calcium deposition in the kidneys, worsening the renal failure. These proteins will also cause rouleaux formation on a blood film. A - anaemia: infiltration of healthy bone marrow by malignant plasma cells causes a decrease in RBC output. Other cell lineages will also be affected, including white cells, meaning that people with MM are more vulnerable to infection. B - bone: bone pain is a very common complaint in MM and helps to differentiate the other symptoms from other causes. In MM the malignancy can spread to the extent where it compresses the spinal cord, causing radicular pain, bladder and bowel incontinence, loss of sensation, and paraplegia.

Answer 130

B. Aortic stenosis A narrow pulse pressure (difference between systolic and diastolic blood pressures), a slow rising pulse, and an ejection systolic murmur radiating to the carotids all indicate aortic stenosis.

Answer 131

A. Mitral stenosis The flushed red cheeks described are as a result of a malar rash, a flushing of the face that spares the nasolabial folds. SOB when lying flat is called orthopnoea and indicates pulmonary oedema. A childhood history of scarlet fever or rheumatic fever (often hinted at by an illness that causes choreic movements) is significant because they can both be caused by Streptococcus pyogenes which can lead to rheumatic heart disease. In this case the rheumatic heart disease has caused mitral stenosis (mid-diastolic murmur with loud first heart sound), which in turn has led to atrial fibrillation (irregularly irregular heart rate).

Answer 132

C. Tricuspid regurgitation A murmur that is heard louder on inspiration will be on the right side of the heart: a way to remember this is with RILE (right - inspiration, left - expiration) I.V. drug users are at increased risk of right heart endocarditis. A pan-systolic murmur suggests either tricuspid or mitral regurgitation, which in this case is most likely to be tricuspid.

Answer 133

D. Thyroglossal cyst If it's a neck lump and it moves with tongue protrusion and swallowing, it's a thyroglossal cyst

Answer 134

D. Sheehan's syndrome Sheehan's syndrome is ischaemic damage to the pituitary gland in the context of blood loss and consequent hypovolaemia during childbirth. In this case the pituitary has been badly damaged enough that it can no longer release sufficient ACTH, causing secondary adrenal failure and consequent Addisonian crisis. The failure to begin lactating is due to failure of the pituitary to produce prolactin.

Answer 135

C. AML AML is strongly associated with DIC which has caused the elevated clotting blood tests and pulmonary embolism (SOB, chest pain) seen in this patient.

Answer 136

D. Radioiodine uptake scan This is a history of viral (deQuervain's) thyroiditis, with a patient becoming acutely hyperthyroid in the context of a recent viral throat infection. A radioiodine scan will show little or no uptake because the thyroid follicular cells have been damaged and so leak T3 and T4, whilst being unable to absorb iodine. The patient will become hypothyroid and then resolve to being euthyroid. The condition is self-resolving and treatment is symptomatic.

Answer 137

C. Pain waking the patient at night Critical limb ischaemia is a triad of rest pain, arterial ulcers, and gangrene. Pain that wakes the patient at night is, of course, pain at rest. Patients will report that hanging their foot down off the bed improves their symptoms.

Answer 138

E. Thick blood film This is a history of malaria, which can be identified on a Giemsa stained thick blood film. A thin blood film would be used to identify the particular species of malaria. Ziehl-Neelson stain reveals TB Congo Red stain reveals amyloidosis Sudan Black B stain helps to diferentiate myeloblasts from lymphoblasts

Answer 139

A. Acral lentiginous melanoma Black and asian people rarely develop melanoma, but when they do it is most likely an acral lentiginous melanoma, which is also rare in white people. It's worth noting that the indicator of prognosis in melanoma is the depth of invasion of the tumour, previously classified using the Breslow depth, now classified using the AJCC system.

Answer 140

E. Sebhorreic wart Sebhorreic warts are benign growths, common in the elderly, that have a greasy, 'stuck-on' appearance.

Answer 141

E. Drug effect First line treatment for hypertension in people under 55/ non afro-carribean people is an ACEi. In patients with an underlying renal artery stenosis (which up until this point can be asymptomatic) an ACEi can cause an AKI.

Answer 142

B. Weakness in the arm>leg, hemispatial neglect Anterior stroke: cognitive dysfunction, personality changes, impaired decision making, disinhibition, weakness in leg>arm and face Middle stroke: weakness in arm and face>leg, hemi-spatial neglect, aphasia Posterior stroke: homonymous hemianopia, visual agnosia, proposagnosia, Anton-Babinski syndrome (patients believe they can see but are in fact blind) NB: when a stroke causes facial paralysis, the forehead is always spared.

Answer 143

D. ARDS ARDS is essentially sepsis in the lungs, and can develop after any systemic inflammatory condition (sepsis, trauma, drug reaction). Inflammation in the lungs leads to oedema, which deranges lung function.

Answer 144

A. Barium swallow A history of GORD (chest pain, strange taste, worse when lying down) along with painless regurgitation indicates a hiatus hernia. Hiatus hernias can be seen on OGD and CXR sometimes, but the best investigation to confirm is a barium swallow.

Answer 145

E. Squamous cell lung carcinoma Squamous cell lung carcinoma is the second most common lung cancer in smokers, and causes cavitating lesions. It can also classically release PTH related peptide which causes hypercalcaemia, leading to the abdominal pain, low mood, polyuria, and polydipsia seen here

Answer 146

B. Mycoplasma pneumoniae This is a history of an atypical pneumonia (insidious onset, dry cough, low fever, malaise) which has three main causative organisms: Legionella: increased risk in smokers and people who have prolonged contact with stagnant water (e.g. plumbers), causes hyponatraemia and associated bradycardia and confusion Mycoplasma pneumoniae: causes cold aglutinin anaemia (Coombs DAT test is for agglutination anaemia) and can be associated with transverse myelitis Chlamydia pneumophilia: we don't have to know NB: another atypical organism is chlamydia psittacai, which should be suspected if the patient has frequent contact with birds.

Answer 147

B. Heberden's nodule Heberden's nodules are swellings at the distal inter-phalangeal joint that indicate osteoarthritis.

Answer 148

E. Anti-CCP antibodies Whilst CRP and ESR will probably be raised in RhA, they are not at all specific. Rheumatoid factor is only present in around 2/3 of cases, but anti-CCP antibodies are a specific and sensitive test for RhA.

Answer 149

D. Joint space narrowing, osteophytes, subchondral cysts A salt and pepper appearance is due to bone resorption secondary to hyperparathyroidism. Looser's zones are areas of osteopenia seen in osteomalacia. Soft tissue opacity with gas in soft tissue is the appearance of necrotising fascitis Joint space narrowing, marginal bony erosions, and osteopenia are the findings of rheumatoid arthritis on x-ray

Answer 150

C. Septic arthritis Septic arthritis is characterised by redness, swelling, and tenderness, usually in a single joint which also exhibits pain on passive movement. The patient may or may not be systemically unwell. Definitive diagnosis is done by analysing joint aspirate. Risk factors for septic arthritis include: rheumatoid arthritis, diabetes, I.V. drug use, unsafe sex, skin infection, prosthetic joints, and chronic gout. Neisseria gonorrhea is a common cause of septic arthritis in younger patients who are sexually active, with no other risk factors for septic arthritis. In a older patient, particularly in those with pre-existing arthritis, immunosuppression, I.V. drug use, skin infection, or prosthetic joints, staphylococcus aureus is the most likely causative organism

Answer 151

E. Neisseria gonorrhoea Neisseria gonorrhea is a common cause of septic arthritis in younger patients who are sexually active, with no other risk factors for septic arthritis. Septic arthritis is characterised by redness, swelling, and tenderness, usually in a single joint which also exhibits pain on passive movement. The patient may or may not be systemically unwell. Definitive diagnosis is done by analysing joint aspirate. Risk factors for septic arthritis include: rheumatoid arthritis, diabetes, I.V. drug use, unsafe sex, skin infection, prosthetic joints, and chronic gout. In a older patient, particularly in those with pre-existing arthritis, immunosuppression, I.V. drug use, skin infection, or prosthetic joints, staphylococcus aureus is the most likely causative organism

Answer 152

C. Hodgkin's lymphoma This is a history of glandular fever (confirmed by a heterophile or Paul Bunnel test), which is caused by Epstein-Barr virus. A previous infection with Epstein-Barr virus is an important element in a history of someone with possible Hodgkin's lymphoma. EBV also predisposes to Burkitt's lymphoma.

Answer 153

C. Pre proliferative diabetic retinopathy Hard exudates, micro aneurysms and blot haemorrhages are all features of background diabetic retinopathy, but the presence of cotton wool spots indicates that this is pre-proliferative diabetic retinopathy. The presence of new blood vessels would indicate proliferative retinopathy. Hypertensive retinopathy has four grades: Grade I: twisting of vessels, silver wiring Grade II: AV nipping Grade III: cotton wool spots, flame haemorrhages Grade IV: papilloedema

Answer 154

B. Verapamil Usually the treatment for supraventricular tachycardia begins with vagal manoeuvres, then proceeds to adenosine, and dc cardioversion if the patient is haemodynamically unstable. Adenosine is contraindicated in asthmatics, in which case verapamil should be used instead. Amiodarone is used in the treatment of broad complex tachycardia. Magnesium is given for broad complex tachycardia particularly when the ECG suggests Torsades de Pointes, as low magnesium can cause arrhythmia.

Answer 155

B. A pan-systolic murmur in the aortic region Visible fluctuation in colour of the nail beds = Quincke's sign. A water hammer pulse = Corrigan's pulse/ collapsing pulse. A soft diastolic murmur heard best at the apex = Austin-Flint murmur, occurs in severe aortic regurgitation when blood jets back through to the mitral valve and prevents it closing, causing a similar murmur to mitral stenosis. An early diastolic murmur heard best at the left sternal edge in the 3rd space = the classic murmur of aortic regurgitation that is tested for in a cardio exam by asking the patient to lean forward an exhale fully while listening at the left sternal edge in the 3rd intercostal space.

Answer 156

D. Spontaneous bacterial peritonitis Liver cirrhosis increases the resistance of liver tissue to blood flow, which increases the pressure in the hepatic portal vein causing fluid movement into the abdomen. To compound this, cirrhotic livers tend not to function well and produce less albumin. Hypoalbuminaemia decreases the oncotic pressure within the portal vein, allowing even more fluid to leave and enter the abdomen. Patients with ascites are vulnerable to infection of the ascitic fluid (e.g. by E.coli and Klebsiella), leading to spontaneous bacterial peritonitis. Paracentesis is used to diagnose SBP, and the fluid is analysed - if the fluid contains >250 neutrophils per microlitre the diagnosis is confirmed. The confusion described in this scenario is due to hepatic encephalopathy, which is triggered by SBP in a patient with cirrhosis, and can sometimes be the only manifestation of SBP.

Answer 157

C. Immune thrombocytopenic purpura ITP is an autoimmune reaction against platelets that is defined as thrombocytopenia in the absence of a known cause. Risk factors include: female gnder, preceding viral illness, hepatitis C, immunosuppression (e.g. HIV), and other autoimmune disorders.

Answer 158

E. Warfarin The standard treatment of a STEMi is: Oxygen if there is evidence of hypoxia Diamorphine and metoclopramide for pain management Nitrates for ischaemic symptom relief Aspirin & clopidogrel to prevent further platelet clotting Patients should undergo PCI if within 12 hours of presentation of symptoms, and those patients undergoing PCI should also receive unfractionated heparin or a LMWH (e.g. enoxaparin). If PCI cannot be delivered within 120 minutes of the time that fibrinolysis can be delivered, fibrinolysis should be used along with one of unfractionated heparin, LMWH, or Fondaparinux. Coronary angiography with follow on PCi should still be offered for patients presenting >12 hours after presentation of symptoms if there is evidence of continuing myocardial ischaemia. If a patient will not be receiving reperfusion therapy, one of unfractionated heparin, LMWH, or Fondaparinux should be given. Glycoprotein IIb/IIIa inhibitors may also be given in high risk patients (e.g. abciximab) Long-term for secondary prevention aspirin and clopidogrel will be continued indefinitely, and a beta blocker, a statin, and an ACEi will be added. NB: be careful of giving opiates to desaturating patients, as it could further decrease their oxygenation. however in this case the patient is about to be sent for surgery, and so will be ventilated soon anyway.

Answer 159

C. Left circumflex coronary artery The territories of the heart are as follows: Septal anterior: V1, V2 Left anterior descending artery Anterior: V3, V4 Left anterior descending artery Lateral: V5, V6, I, aVL Left circumflex artery Inferior: II, III, aVF Right coronary artery Posterior: tall R-waves and ST-depression in V1-V3, usually supplied by a branch of the right coronary artery

Answer 160

D. Dressler syndrome Dressler syndrome is pericarditis post-MI, believed to be caused by an autoimmune inflammatory reaction. it is typically self-resolving, and treatment is usually just aspirin.

Answer 161

B. Widespread saddle-shaped ST elevation The sharp chest pain in combination with recent viral illness indicates pericarditis. This causes widespread saddle-shaped ST elevation on an ECG. A pericardial rub may be heard on auscultation of the heart, and the pain will typically be improved by sitting forward.

Answer 162

A. Amiodarone In a patient who has been experiencing symptoms of atrial fibrillation for <48 hours, there is a low probability of a clot having formed in the atria in that time, so it is safe to attempt cardioversion as there is a low risk of embolisation. Cardioversion can be attempted electrically (DC cardioversion) or chemically (flecainide, unless there is known ischaemic heart disease, in which case amiodarone should be used) In a patient who has been experiencing symptoms of atrial fibrillation for >48 hours, there is too high a chance that a clot has formed in the atria, so it is not safe to attempt cardioversion as there is a chance of embolisation. Instead, the patient should be anti-coagulated for 3-4 weeks with warfarin, and rate control should be achieved with beta blockers and digoxin. After 3-4 weeks, it is safe to attempt cardioversion.

Answer 163

D. Wolff-Parkinson-White syndrome WPW is due to an accessory pathway in the heart - the bundle of Kent - that allows abnormally fast depolarisation of the ventricles, resulting in the slurred upstroke appearance (delta wave) on an ECG. If impulses travel back up through the accessory pathway towards the atria, an AV reentrant tachycardia can start, as the impulses become independent of the SA node.

Answer 164

D. CHA2DS2-VASc score This score assess the risk of stroke in a patient with atrial fibrillation. A score of 1 or greater indicates that anti-coagulation would be appropriate.

Answer 165

C. Vasovagal syncope In the absence of signs that would indicate other differentials of collapse (aura, palpitations, post-ictal phase) the most likely differential is vasovagal syncope. When taking a history of collapse, it is always important to thoroughly explore the before (aura, palpitations), during (LOC, incontinence, tongue biting), and after (post-ictal phase) of the collapse, and also to enquire about missed meals.

Answer 166

B. Hypertrophic obstructive cardiomyopathy Collapse in a patient with a family history of sudden early death should make you think of cardiac abnormalities such as long QT syndrome and HOCM. Signs of HOCm include a jerky carotid pulse, a double apex beat, and an ejection systolic murmur that DOES NOT radiate to the carotids. The reason for this is that the septum is enlarged in HOCM, which narrows the left ventricle outflow tract leading to a suction effect (Venturi effect) that prevents the mitral valve from closing during systole. This effectively creates mitral regurgitation, with an associated murmur, but only during systole. This murmur will therefore not radiate to the carotids. This explains why the murmur is crescendo-decrescendo, instead of being a fixed sound - the functional mitral regurgitation is dependent on the flow velocity (which creates the Venturi effect).

Answer 167

B. Medication side-effect Medications to control blood pressure can be too effective (particularly diuretics) - causing hypotension and collapse.

Answer 168

C. Glomerulonephritis This is post-Streptococcal glomerulonephritis, which is a result of a type III hypersensitivity reaction (complement activation and immmune complex formation) causing inflammation in the kidneys. This leads to glomerulonephritis which can cause hypertension, oedema, haematuria and oligouria. It can sometimes be difficult to differentiate post streptococcal glomerulonephritis from IgA nephropathy. IgA nephropathy is the most common cause of glomerulonephritis worldwide and presents with symptoms within a few days of an upper respiratory tract infection. Glomerulonephritis typically takes around a month to develop after an infection.

Answer 169

D. Add warfarin Warfarin is used in patients with no contraindications for at least 3 months after a pulmonary embolism. It is not given on its own at first, because the initial effect is pro-thrombotic: warfarin reduces protein C and S levels, reducing degradation of activated clotting factors. Though the anticoagulant effects are greater, they take longer to manifest - the body has to run out of 2, 7, 9, and 10 for the effect to be apparent as warfarin inhibits vitamin k recycling, preventing manufacture of new factor 2, 7, 9, and 10 I.V. thrombolysis or thrombolectomy is only given if the patient is haemodynamically unstable. Fondaparinux can be used instead of LMWH as a first step. 300mg aspirin is an immediate step taken in management of acute coronary syndrome.

Answer 170

C. Tamulosin Tamulosin is an alpha blocker which relaxes the smooth muscle of the internal urinary sphincter and prostate capsule, making urinating easier.

Answer 171

E. Exploratory surgery This is a history of testicular torsion, which is a surgical emergency. If not dealt with within 6 hours, the ischaemic damage will result in loss of the testis. Whilst a Doppler USS is an effective investigation, this is a clear history and unless you can organise a Doppler immediately, you should proceed directly to surgery.

Answer 172

A. Beta hCG Beta hCG is raised in pregnancy, and is used in pregnancy tests but can also be secreted by testicular malignancies. Alpha fetoprotein can also indicate testicular cancer (or liver cancer).

Answer 173

A. Acute tubular necrosis The hypovolaemia resulting from the bleeding has presumably caused ischaemic damage to the kidneys, causing necrosis.

Answer 174

D. Haemolytic-uraemic syndrome This is a history of haemolytic-uraemic syndrome (triad of microangiopathic haemolytic anaemia, thrombocytopenia, and acute renal impairment/ uraemia) which is most common in children, and generally presents with nausea, fatigue, and potentially bleeding, within a few days of gastrointestinal infection. The most common causative organism is E. coli (particularly serotype 0157:H7), with the second most common being Shigella.

Answer 175

G. Thrombotic thrombocytopenic purpura TTP is typically associated with antibodies against an enzyme that cleaves Von-Willebrand factor, leading to an abnormally high amount of VWf in the blood. This causes clotting in small blood vessels, and a consequent thrombocytopenia leading to bleeding. Microangiopathic haemolytic anaemia is a feature of TTP which is caused by damage to RBCs as they pass through vessels that have been occluded by thrombi. This causes the RBCs to shear, resulting in a haemolytic anaemia, which may also cause s pre-hepatic jaundice. Haemolytic-uraemic syndrome may present similarly to TTP, but usually occurs in children and will feature a history of gastrointestinal infection. ``` The classic pentad of TTP rarely occurs together but is as follows: Fever Microangiopathic haemolytic anaemia Mental state changes Renal impairment Thrombocytopenia ```

Answer 176

B. Rhabdomyolysis Rhabdomyolysis (literally translated from Greek as 'striped muscle breakdown') is breakdown of skeletal muscle, often as a consequence of trauma. In this case the patient has sustained a fall and been immobilised on the floor for several days. This has caused a crush injury, leading to breakdown of the crushed skeletal muscle. Skeletal muscle releases myoglobin when it breaks down, which is toxic to the kidneys. Creatine kinase is also released from skeletal muscle when it breaks down, and so can be used to test for potential rhabdomyolysis in cases like this one.

Answer 177

J. Dehydration This is a fairly clear case of dehydration leading to confusion. Dehydration should always be a differential when an elderly patient presents with confusion, even without diarrhoea and vomiting, as elderly patients are often less mobile or cognitively impaired, and so might not be able to keep themselves hydrated.

Answer 178

D. Escherichia coli This is a history of haemolytic-uraemic syndrome (triad of microangiopathic haemolytic anaemia, thrombocytopenia, and acute renal impairment) which is most common in children, and generally presents with nausea, fatigue, and potentially bleeding, within a few days of gastrointestinal infection. The most common causative organism is E. coli (particularly serotype 0157:H7), with the second most common being Shigella.

Answer 179

A. Minimal Change Disease Minimal change disease is characterised by loss of podocyte foot processes seen on electron microscopy of a kidney biopsy. It causes a nephrotic syndrome and most commonly affects children, and is the most common cause of renal disease in children.

Answer 180

B. IgA Nephropathy IgA nephropathy causes a nephritic syndrome (proteinuria, haematuria, oligouria, hypertension) within a few days of an upper respiratory tract infection.

Answer 181

C. IgA Henoch Schonlein purpura is an IgA mediated vasculitis characterised by a triad of arthritis, purpura, and abdominal pain. There may also be renal involvement causing haematuria.

Answer 182

B. Post Streptoccocal Post streptococcal glomerulonephritis is a nephritic syndrome that follows an upper respiratory tract infection. Renal symptoms usually follow infection by 4-6 weeks in contrast to IgA nephropathy where symptoms follow infection by a few days. Post-streptococcal glomerulonephritis involves complement-mediated immune complex deposition, hence there will be low C3 because complement has been depleted. There would also be a positive anti-streptolysin O titre (measurement of antibodies made against streptococcal infection).

Answer 183

D. Goodpasture’s Syndrome Goodpasture's syndrome is an autoimmune condition defined by anti glomerular basement membrane antibodies (targeting type IV collagen) that damage the basement membrane in the alveoli and glomeruli. Involvement of both the lunga and kidneys (without upper airway involvement - nosebleeds, rhinitis) should prompt thoughts of Goodpasture's syndrome.

Answer 184

D. Granulomatosis with polyangitis Granulomatosis with polyangitis is a vasculitic disease comprised of a triad of upper respiratory tract symptoms (rhinitis, nosebleeds), lower respiratory tract symptoms (haemoptysis), and renal symptoms (glomerulonephritis). There are few diseases that link pulmonary and renal symptoms, particularly in the absence of other organ involvement. The main other differential for the oresentation in this question is Goodpasture's syndrome. The discriminating factor is that Goodpasture's syndrome does not cause upper repiratory tract inbvolvement (e.g. nosebleeds). There may also be other factors of granulomatosis in an SBA that help to differentiate it (cANCA positive, cavitating lesions on CXR, saddle-nose).

Answer 185

C. Crescents on light microscopy Granulomatosis with polyangitis is a vasculitic disease comprised of a triad of upper respiratory tract symptoms (rhinitis, nosebleeds), lower respiratory tract symptoms (haemoptysis), and renal symptoms (glomerulonephritis). It is one of the causes of rapidly progressive glomerulonephritis (the other main ones being Goodpasture's syndrome, and microscopic polyangitis) which is also known as cresenteric glomerulonephritis because it causes crescent-shaped scarring visible on microscopic examination of a biopsy.

Answer 186

E. Behcet's syndrome Behcet's syndrome is a vasculitide defined by a triad of recurrent oral ulcers, genital ulcers, and uveitis.

Answer 187

D. Hepatitis A Hepatitis A is transmitted via the faeco-oral route and is stereotypically acquired after eating contaminated shellfish. It causes an acute infection which has led to the jaundice and fever described here

Answer 188

D. USS of biliary tree This is a history of cholecystitis, the giveaways being the tendency of the pain to worsen when eating fatty foods. The 5f's are the risk factors of cholecystitis to remember: fat (BMI>30), fertile (has had children), forty (older than 40), fair (Caucasian), and female. The biliary tree can be well visualised with an USS, so it is commonly used to diagnose biliary issues as it is non-invasive

Answer 189

C. Rodent ulcer A rodent ulcer is another name for a basal cell carcinoma (this seems a bit of a trick but has come up before). A basal cell carcinoma has a very distinctive appearance: flesh coloured, with rolled edges, a pearly appearance, and visible telangectasia are all characteristic. A basal cell carcinoma rarely invades or metastasises and grows slowly, so this can be managed with a routine dermatology referral for removal.

Answer 190

A. Right Coronary Artery This is important to learn as it will definitely be a question in the exam, so memorise which leads monitor which regions of the heart, and which arteries correspond: Septal - V1, V2 Anterior - V3, V4 Lateral - V5, V6, I, aVL Inferior - II, III, aVF Septal and anterior regions are supplied by the left anterior descending artery The lateral region is supplied by the circumflex artery The inferior region is supplied by the right coronary artery

Answer 191

D. Intercostal Drain Management of a pneumothorax depends on its size, and whether it is primary (no underlying causative condition), or secondary (e.g. to COPD). Primary (no underlying cause): <2cm: discharge and repeat CXR later >2cm/ SOB: aspiration (if unsuccessful - chest drain) Secondary (known cause e.g. COPD) >2cm: aspiration (if unsuccessful - chest drain) <2cm: chest drain

Answer 192

E. Mesothelioma More than 80% of mesothelioma cases are due to asbestos exposure. Ship-building is one occupation in which the patient would have been exposed to asbestos. The patient has symptoms indicating cancer, but small-cell lung carcinoma is unusual in a non-smoker. TB is a possible differential, but the cough is non-productive and there is no travel history to indicate exposure.

Answer 193

C. Positive sputum smear showing acid fast bacilli This is a history of TB, with a history of recent travel to an endemic region, and infective symptoms with night sweats and weight loss. Staining using a Ziehl-Neelson stain will reveal acid-fast bacilli in the case of TB.

Answer 194

A. Take blood cultures This is a history of infective endocarditis in a patient who has presumably been taking immunosuppressive drugs after his renal transplant. This has left him vulnerable to infection which has caused the fever, splinter haemorrhage, and diastolic murmur. Blood cultures will allow identification of the responsible organism.

Answer 195

C. Fibrocystic changes Fibrocystic changes (also known as fibroadenosis) present with diffuse lumps within the breast that are painful: the pain changes with the menstrual cycle

Answer 196

D. Pneumoconiosis Pneumonoconiosis refers to pulmonary fibrosis caused by inhalation of dust into the lungs. Given the absence of a smoking history, both large cell carcinoma and squamous cell carcinoma are unlikely. Furthermore there are no infective signs that would support a diagonsis of pneumonia or bronchiectasis. The findings of clubbing, reticulonodular shadowing, and bi-basal crepitations indicate fibrosis. Th previous occupation as a builder strongly suggests pneumonoconiosis

Answer 197

C. PE The most common ECG finding of PE is sinus tachycardia; right axis deviation can also be seen. The classic ECG finding of PE is a large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III. However this pattern only actually appears in about 10% of cases. Similarly, although there are certain CXR findings associated with PE, most only occur in a small proportion of cases. This history of sudden onset pleuritic pain (worse on inspiration) with sinus tachycardia is strongly suggestive of PE.

Answer 198

C. Arrange for OGD and colonoscopy In a male patient, or a female patient who is not menstruating, unexplained anaemia is concerning, especially if it's microcytic. That is because is may indicate a GI bleed, hence endoscopy is to be ordered in this case.

Answer 199

C. Chlamydia trachomatis Though an acutely painful scrotum may prompt you to jump to testicular torsion, the onset of epididymitis can also be fast, and it will be very painful. Furthermore the presence of discharge implies an infective cause. Epididymitis is an inflammation of the epididymis. In a young patient the most likely causative organisms are STIs (chlamydia, gonorrhea), whereas in an older patient the most likely organisms are enteric pathogens (E. coli, Klebsiella)

Answer 200

D. Acute Tubular Necrosis This patient has experienced a prolonged period of time with low blood pressure (as a result of the sepsis from the pneumonia), which has caused ischaemic damage to his kidneys. The giveaway is the presence of the brown cell casts: these are a type of granular cast and will be typically described as muddy brown - they indicate acute tubular necrosis.

Answer 201

C: Psoriatic arthritis Psoriatic arthritis is a form of arthritis which is associated with psoriasis (as you might guess). The condition gets progressively more severe over time and can eventually lead to arthritis mutilans (telescoping of the fingers, where the fingers collapse in on themselves lengthways). Nail pitting, severe dandruff, and oncholysis (painless separation of nail from the nailbed) are all signs of psoriasis which, together with the joint stiffness, indicates psoriatic arthritis.

Answer 202

A. Metabolic Acidosis The low pH indicates acidosis. PaO2 and PaCO2 are both within normal limits, however HCO3 is low. This indicates the acidosis has a metabolic cause, as the bicarbonate measurement is deranged. PaCO2, although within normal limits, is low, which may indicate that respiration is partially compensating for the metabolic acidosis.

Answer 203

C. Wait until 4 hours post ingestion and measure paracetamol levels Although N-acetyl cysteine is the treatment for paracetamol overdose, the first step is to wait till the 4 hour post-ingestion mark and measure paracetamol measures. If the amount of paracetamol is above a threshold, treatment will be necessary, but otherwise no medication need be given. Measurement will also indicate how much N-acetyl cysteine will be needed.

Answer 204

A. Lower lobe diversion All other options are CXR findings in heart failure. Upper lobe diversion of blood (due to congestion) is seen in heart failure, rather than lower lobe diversion. The main CXR features of heart failure can be remembered using the acronym: Alveolar oedema, Kerley B lines, Cardiomegaly, upper lobe Diversion, Effusion (pleural).

Answer 205

E. Distal interphalangeal joint The distal interphalangeal joint is always spared in rheumatoid arthritis. Several other specific deformities are characteristic of rheumatoid arthritis: Z deformity of the thumb, ulnar deviation of the metacarpophalangeal joints, boutonniere deformity, swan-neck deformity and radial deviation of the wrist.

Answer 206

D. INR (International normalised ratio) Liver function tests are badly named - they don't indicate liver function, they indicate the degree of cellular damage within the liver, as the enzymes measured in LFTs are released when hepatocytes are damaged. The liver has a considerable range of synthetic functions, including manufacture of clotting factors. INR is the result of a patient's Prothrombin time divided by the standard Prothombin time, and so estimates the production of clotting factors, and therefore is a good marker of liver function.

Answer 207

D. D.C. Cardioversion The treatment of an SVT is one of the few sets of management that you need to know for third year. Normally the sequence is: vagal manoeuvres then adenosine (or verapamil if adenosine is contraindicated). If these fail then beta blockers or amiodarone may be considered. However in this case the patient is haemodynamically unstable and so must be cardioverted.

Answer 208

D. Follow up USS in 3 months AAA's are monitored using ultrasound scans and no action is taken to resolve them until either they exceed 5.4cm, or they become symptomatic, or they between 4.0 - 5.4cm and have grown by more than 1.0cm in a single year. 3. 0 - 4.4cm USS follow-up once every 2 years 4. 5 - 5.4cm USS follow-up once every 3 months The options for repair are endovascular repair (EVAR) or open surgery. EVAR is associated with fewer perioperative deaths, but has more long-term complications and is more expensive. Consequently, open surgical repair is recommended instead of EVAR by NICE in most circumstances.

Answer 209

B. Sarcoidosis Sarcoidosis is an condition characterised by a build-up of non-caseating granulomas in multiple organs, but most classically the lungs. The giveaway features in this question are the mentions of lupus pernio (poorly named, as it is actually pathognomic of sarcoidosis), and the presence of bihilar lymphadenopathy. In third year SBAs, bihilar lymphadenopathy usually indicates sarcoidosis, but may indicate lymphoma. The target -shaped rashes are annular sarcoidosis, another cutaneous manifestation of the condition.

Answer 210

B. IV naloxone Respiratory depression combined with pinprick pupils indicates opiate overdose, the treatment for which is naloxone - an opioid blocker. Mechanical ventilation may be required, but it is not the definitive management of overdose. Naltrexone and methadone are used to wean opioid-dependent patients after the acute overdose has been resolved.

Answer 211

B. Chlamydia Psitticai infection This could be either extrinsic allergic alveolitis (bird-fancier's lung) or Chlamydia Psitticai infection (Psittacosis) given the history of a dry cough and malaise, but the fever indicates infection. Chlamydia Psitticai causes an atypical pneumonia, hence the lack of a productive cough. A CXR would help differentiate between the two, as one-sided localised shadowing would indicate pneumonia, whereas diffuse reticulo-nodular shadowing would indicate extrinic allergic alveolitis.

Answer 212

B. Monospot test The monospot test is a type of heterophile antibody test (for the purposes of 3rd year SBAs they are the same thing) which is used to diagnose mononucleosis (glandular fever). The Paul-Bunnel test was previosuly used to diagnose mononucleosis, and may be mentioned for that use in SBAs. This is a standard history of mononucleosis, with lymphadenopathy, swollen tonsils, and fever. The trip to Magaluf presumably involved some 'tonsil tennis' which is the classic route of transmission for the virus.

Answer 213

A. I.V. Lorazepam Benzodiazepines are used to make alcohol withdrawal safe, otherwise patients are vulnerable to delerium tremens. Delerum tremens is characterised by shaking, sweating, palpitations, seizures, and hallucinations (one specific example is formication - the sensation of ants crawling over skin).

Answer 214

D. I.M. adrenaline This is a history of anaphylaxis, the first step in the management of which is I.M. adrenaline with an epipen. Afterwards the patient will be given antihistamines, fluids, high flow oxygen, and steroids, and their obs will be carefully monitored. Nebulised salbutamol may also be given. It is very important the patient not be discharged within 4 hours of admission, as the anaphylactic reaction may be biphasic - there may be a secondary reaction hours after the initial one.

Answer 215

B. Diverticulitis Diverticulosis is the presence of small pockets within the colon; it is a common incidental finding and is not inherently problematic. Diverticulitis is infection taking hold within these pockets and leads to fever and blood that coats the stool. Low dietary fibre increases the chance of diverticulosis. This question is largely based on excluding other options: an anal fissure would cause agony on defecation, ulcerative colitis would cause diarrhoea and the history would probably present a chronic picture, diverticulosis is asymptomatic, and appendicitis would give RIF pain with no bowel symptoms (bar a loss in appetite which is universally present in appendicitis patients).

Answer 216

D. Sodium bicarbonate Tachypnoea/ hyperventilation, dizziness, and fever are all signs of salicylate (aspirin) poisoning. The ringing noise described is tinnitus, which is fairly unique to aspirin poisoning and so can be useful for spotting it. Without treatment the patient may develop confusion, metabolic acidosis, and coma. Treatment involves giving activated charcoal if the patient is within 1 hour of ingestion; if not, sodium bicarbonate is given. Sodium bicarbonate increases the pH of the blood, which causes aspirin to dissociate into its ions, preventing it from crossing the blood-brain barrier into the CNS, and increasing urinary clearance. Fluid support is given if and when needed, and in severe cases, haemodialysis is used

Answer 217

A. Gallstones There is a common misconception that alcohol abuse is the most common cause of acute pancreatitis, but it is gallstones (50%), although alcohol abuse is the second biggest cause (25%). The classic acronym for remembering the causes of pancreatitis is GET SMASHED (which has the advantage of listing the most common and second most common causes in order): Gallstones Ethanol abuse Trauma ``` Steroid use Mumps/ measles/ malignancy Autoimmune Scorpion sting Hyperlipidaemia/ hypercalcaemia ERCP Drugs (e.g. thiazide diuretics, sodium valproate, erythromycin) ``` P.S. There was one made which spells ITS COMING HOME; it's not great but here it is if you want: Ischaemia Trauma Scorpion sting ``` Corticosteroids Oddi sphincter surgery Mumps/ measles Iatrogenic (ERCP) No cause identified (idiopathic) Gall stones ``` Hyperlipidaemia/ hypercalcaemia Other (drugs) Malignancy Ethanol If you want a bit more info on acute pancreatitis, here is a useful BMJ article: https://www.bmj.com/bmj/section-pdf/762669?path=/bmj/349/7971/Clinical_Review.full.pdf

Answer 218

E. Trans-vaginal ultrasound This is a history of an ectopic pregnancy, which commonly features abdominal pain and vaginal bleeding with a recent history of amenorrhea. Other less common symptoms which may occur include: syncope, dizziness, urinary symptoms, rectal pressure/ pain on defecation. The diagnostic tool of choice according to NICE guidelines is trans-vaginal ultrasound, which can confirm the location of the pregnancy. Beta-hCG measurements would also be taken, but they are not the best test for confirming the diagnosis, as well as the position of the implanted embryo. N.B. The use of an intra-uterine device (IUD) increases the risk of ectopic pregnancy, as does tubal/ uterine surgery, and previous pelvic inflammatory disease.

MedEd/ Sofia Based SBAs Flashcards

SBAs based on past questions and SOFIA objectives, with a lot of contributions from MedEd. This is the most useful deck. (242 cards)