MedMock Flashcards
(14 cards)
A 16-year-old girl presents to the GP feeling generally unwell for two weeks. She reports fevers and a sore throat. She has a history of well-controlled epilepsy and has recently come back from holiday in Magaluf celebrating her GCSEs.
On examination, her temperature is 39.0 °C. The tonsils and oropharynx are erythematous. There is bilateral tender posterior cervical lymphadenopathy.
Which is the rapid point-of-care test used to identify the underlying pathogen? A Serum HIV rapid test B Heterophile antibody test C Anti-CMV antibodies D Anti-streptolysin O titre E Urinary Legionella antigen
Heterophile antibody test
This patient has infectious mononucleosis, a viral disease that is characterised by fever, sore throat and lymphadenopathy. It can be rapidly diagnosed using the heterophile antibody test (also known as the Paul Bunnell test). It rapidly detects antibodies generated against EBV.
An elderly patient is admitted to hospital after a fall at his grandson’s bouncy castle birthday party. On admission a family member remarks that the patient was admitted 5 days ago with an infection and received a dose of gentamicin with a 2 week course of ciprofloxacin. At the hospital it becomes apparent that the patient has a decreased urine output. A urine test is conducted and the results are as follows: Elevated PSA, high urea & creatinine. There is no blood in his urine. What is the reason for his AKI?
A ATN due to Rhabdomyolysis
B ATN due to a Nephrotoxic agent
C Obstruction due to Benign Prostatic Hyperplasia
D ATN due to Sepsis
E Post-Strep Glomerulonephritis
ATN due to nephrotoxic agent
Acute Kidney Injury is defined by the KDIGO guidelines as either:
Rise in creatinine > 26 mcmol/L in 48 hours
Rise in creatinine > 1.5 x baseline (best figure in last 3 months)
Urine output < 0.5 mL/kg/hr for > 6 consecutive hours
Given the patient’s scenario and time scale of the infection/antibiotic treatment, it is most likely that the gentamicin (nephrotoxic drug) has caused the AKI. Acute tubular necrosis (ATN) is the most common cause of AKI and it simply means the necrosis of the epithelial cells that line the renal tubules. This can occur as a result of a number of different insults. These cells are sensitive to ischaemia, so a pre-renal issue that causes a reduced blood supply to the kidneys can lead to ATN. Nephrotoxins (e.g. gentamicin) can also damage these epithelial cells and cause ATN. Myoglobin from the breakdown of muscle can also cause damage to these cells.
A 46 year old man presents with a sore knee. The knee is red, hot and tender to touch, and there is pain on passive movement. He is apyrexic. Fluid is aspirated from the knee and no crystals are seen on polarised light microscopy. He has a history of rheumatoid arthritis for which he takes methotrexate. What is the most likely diagnosis? A Pseudogout B Gout C Septic arthritis D Psoriatic arthritis E Osteoarthritis
Septic arthritis
Although this patient does not have a fever, this is still likely to be septic arthritis as the knee is showing clear signs of inflammation and only one joint is affected. Gout and pseudogout will reveal urate or calcium pyrophosphate crystals, respectively, in the joint aspiration. Osteoarthritis and psoriatic arthritis would not present acutely.
A 56 year old man presented to his GP feeling tired and low in mood for the past few months. He has experienced no weight loss or change in appetite. PMHx: Stage I HTN, Renal stones, fracture of the right femur in a road traffic accident. Fasting glucose blood test was performed: 6.4 (<7.0) Adjusted serum Ca2+: 2.79 (2.20-2.60) PTH: 3.4 (1.1 – 6.0) The most likely cause is: A Adenoma of the pituitary gland B Familial hypercalcemia C Metastatic prostate cancer D Primary hyperparathyroidism E Secondary hyperparathyroidism
Primary hyperparathyroidism
Depression and renal stones cardinal features of hypercalcaemia
Not diabetic
Raised serum calcium = hypercalcaemia
NORMAL PTH = primary hyperparathyroidism (this will be SUPPRESSED in other causes of hypercalcaemia such as malignancy)
Secondary hyperparathyroidism is when you have a LOW Ca2+ and a corresponding physiological increase in PTH
A 65 year old man presents to A&E complaining of breathlessness. A Chest X-Ray is taken showing fluffy shadowing. How should you manage this patient? A Amoxicillin + clarithromycin B Furosemide C Co-amoxiclav + clarithromycin D CTPA E Ciprofloxacin
Furosemide
This is tricky as not only do you need to diagnose the patient based off the CRX, but then know what the management is. However, you might be able to use the answer options to help you – if you know which conditions match up to each answer option that may help you figure out what the diagnosis is. Doing this, each option is for the following:
A amoxicillin and macrolide: moderate Pneumonia
B furosemide: pulmonary oedema
C co-amoxiclav and macrolide: severe pneumonia
D CTPA: pulmonary embolism
E Ciprofloxacin: atypical pneumonias
The Chest X-Ray shows evidence of both interstitial and alveolar oedema, and so the most likely diagnosis is pulmonary oedema. IV furosemide is therefore the appropriate management.
A patient is brought to A&E following a stroke. They report some visual loss, as well as weakness in their left arm and left side of their face. A cranial nerve examination demonstrates visuospatial neglect. In terms of the patient’s visual loss, what is the cranial nerve examination also likely to demonstrate? A Left monocular vision loss B Bitemporal hemianopia C Right homonymous hemianopia D Left inferior quadrantanopia E Right superior quadrantanopia
Left inferior quadrantanopia
Looking at the patient’s symptoms, they have weakness in the left arm and face, which suggests a stroke to the right motor cortex. Weakness in the arm and face is suggestive of a stroke in the territory of the middle cerebral artery (the anterior cerebral artery affects the legs more). This fits with the patient’s visuospatial neglect, as this normally results from damage to the right parietal lobe. Once you have figured out the area of the brain affected, the question then requires you to apply this to the visual tract to deduce the most likely visual field defect. We can rule out C and E since they involve the right visual field, as anything post chiasm will affect the contralateral visual field. We can rule out A as this is describing prechiasmal visual loss since it effects only one eye. Bitemporal hemianopia would be expected in damage to the optic chiasm, e.g. with a pituitary adenoma. This leaves option D as the only feasible answer, but also fits with the clinical picture. The fibres responsible for vision in the inferior fields run through the parietal lobes (and those for superior through the temporal lobes), giving a quadrantanopia in the contralateral field of view. In reality, a hemianopia is also possible, but this was not an option.
A three year old Mediterranean boy presents to his GP with with easy bruising, lethargy and a fever. His Mum says he has been like this for a few days. On examination he also has some abdominal swelling and testicular enlargement. What is the most likely diagnosis? A Thalassaemia B Sickle cell anaemia C Acute Lymphoblastic Leukaemia D Haemophilia E Hodgkin’s Lymphoma
Acute lymphoblastic leukaemia
The leukaemias and lymphomas can be a little bit confusing, however, they each have distinctive features that help distinguish them. Acute lymphoblastic leukaemia tends to occur in young children. It will present with features of pancytopaenia (as a result of bone marrow infitration by the malignant cells). Patients may present with features resulting from anaemia (e.g. breathlessness, lethargy), thrombocytopaenia (bruising) and leukopaenia (infection, fever). Swelling of lymph nodes and the testicles is also common in ALL. AML tends to occur in adults and it can progress rapidly and be fatal. A bone marrow biopsy of a patient with AML will show a large number of immature myeloblasts with Auer rods (clumps of granular material within the cytoplasm of thecell). Hodgkin’s lymphoma is characterised by the presence of Reed-Sternberg cells (binucleate lymphocytes) on a lymph node biopsy.
CML - Philadelphia Chromosome; Tx: Imatinib
CLL - Smear cells on blood film
A 43-year-old man has gained 8 kg of weight over the past 3 months, and he has also been feeling more depressed and irritable than usual. On examination, he has a round face and striae across his abdomen. Following investigation, a diagnosis of Cushing’s syndrome is made. Which test can help distinguish between Cushing’s disease and other causes of Cushing’s syndrome (e.g. ectopic ACTH)?
A 24 hr urinary free cortisol
B Random plasma cortisol
C Low-dose dexamethasone suppression test
D High-dose dexamethasone suppression test
E Midnight cortisol
High dose dexamethasone suppression test
When a patient initially presents with symptoms suggestive of Cushing’s syndrome, it is important to first confirm the diagnosis of Cushing’s syndrome before searching for a cause. This can be done using a variety of tests such as 24 hr urinary free cortisol, midnight cortisol and a low-dose dexamethasone suppression test. The 24 hr urinary free cortisol and midnight cortisol are often inaccurate due to measurement issues, variations in the patient’s circadian rhythm and stress levels. The low-dose dexamethasone suppression test involves administering dexamethasone 0.5mg/6hrs PO for 2 days – serum cortisol is measured at 0 and 48 hours and a lack of suppression (< 50 nmol/L) is observed in Cushing’s syndrome. A high-dose dexamethasone suppression test involves administering dexamethasone 2mg/6hr PO for 2 days and it will suppress serum cortisol in patients with Cushing’s disease (ACTH-secreting pituitary adenoma), however, it will fail to suppress serum cortisol in patients with Cushing’s syndrome due to other causes (e.g. ectopic ACTH production, adrenal adenoma).
A 70-year-old lady presents to her GP complaining of a cough. She explains it has worsened over the last 2 months, and recently she has coughed up blood a couple times, prompting her to visit the GP. Upon further questioning, she feels tired throughout the day and has also noticed some weight loss. The lady has a 40-pack year history. On examination, the right upper lobe is dull to percussion, but the patient otherwise appears well. The GP arranges blood tests which indicates low sodium, low serum osmolality, relatively high urine osmolality.
What should be the GPs next step to correct the abnormalities in the patient’s blood results? A Fluid restrict to 1L per day B Head MRI C Prescribe tolvaptan D CXR E 1L 3.0% sodium chloride
Fluid restrict to 1L per day
Starting with the patient’s blood test results, they are hyponatraemic. The next step is to check serum osmolality. This is low, indicating a hypotonic hyponatraemia. The next step is to check the patient’s fluid status, with the history suggesting the patient is euvolaemic. This leaves 3 possible causes: hypothyroidism, Addison’s or SIADH. We can rule out the first 2 based off the blood results, leaving SIADH as it is a diagnosis of exclusion. This fits with the high urine osmolality, as the high levels of ADH concentrates the urine. From the rest of the history, there is a possibility the patient has lung malignancy, which could explain the SIADH. Small cell lung cancer can result in a paraneoplastic syndrome, secreting ADH. In terms of management, fluid restriction is key. One can use a tolvaptan, an ADH receptor antagonist, but this is uncommon in clinical practice since they are very expensive. A CXR will likely be arranged, and possibly an MRI too, to find the underlying cause.
NB: the wording of the question is again important. Although several investigations listed will be arranged, it is the fluid restriction that will correct the patient’s hyponatraemia.
A 26-year-old man presents with a painful scrotal mass that he first noticed this morning. It has gradually got more and more painful. On examination, his left hemiscrotum is swollen and tender. The swelling does not transilluminate, the testicle can be distinguished from the swelling and the doctor is unable to get above the swelling. What is the most likely diagnosis? A Testicular torsion B Epididymitis C Varicocoele D Inguinal hernia E Hydrocoele
Inguinal hernia
Scrotal masses can easily be distinguished based on the examination findings. As an inguinal hernia extends up to the superficial inguinal ring, it is not possible to get above the mass. Furthermore, the swelling does not transilluminate suggesting that the mass is not fluid-filled. As the testicle can be distinguished from the swelling, it suggests that the swelling does not lie on the testicle itself.
A 60-year-old man is brought into A&E having vomited blood. His wife reports they were out having dinner when he suddenly experienced extreme chest pain and began to vomit blood. On auscultation of his chest you hear a crepitations. His HR is 115 and BP 85/60. What is the most likely diagnosis? A Oesophageal varices B Mallory-Weiss tear C Myocardial Infarction D Ruptured peptic ulcer E Ruptured oesophagus
Ruptured oesophagus
From a management perspective this patient is in shock, likely from the blood loss, and so fluid resuscitation is the first key step. Although many answer options would result in haematemesis, it is the crepitations on auscultation that lead to a diagnosis of ruptured oesophagus. Ruptured oesophagus, also called Boerhaave’s syndrome, is a more severe version of Mallory-Weiss tear, as it a full-thickness tear. This normally results from a sudden increase in intraoesophageal pressure and decrease in intrathoracic pressure, e.g. from straining of vomiting. Here the patient’s food has likely gotten stuck on the way down at which point they have tried to cough it up, with the pressure changes perforating their oesophagus. The air leaving the oesophagus through the tear results in subcutaneous emphysema, which explains the crepitations. The classical presentation of oesophageal rupture is Mackler’s triad: chest pain, vomiting and subcutaneous emphysema.
NB: This question is adapted from one in the written exam last year that confused may people. Although this condition is not in Sofia, it is a differential for haematemesis, which is in the presentation section of Sofia, and so can certainly turn up in your exam.
A 47-year-old man presents to A&E complaining of severe abdominal pain and vomiting. His symptoms began roughly 12 hours ago whilst on an alcohol binge. His hospital notes reveal that he is a regular at A&E with various alcohol-related injuries. There are some bruises overlying his inguinal ligament. What is this sign? A Grey Turner’s Sign B Cullen’s Sign C Fox’s Sign D Kussmaul Sign E Obturator Sign
Fox’s sign
This patient is presenting with acute pancreatitis. The severe abdominal pain, vomiting and recent alcohol binge are particularly suggestive of pancreatitis. Haemorrhagic pancreatitis can cause bruising. There are three main signs associated with pancreatitis that are caused by bleeding:
Grey Turner’s Sign – bruising across the flank
Cullen’s Sign – bruising around the umbilicus
Fox’s Sign – bruising overlying the inguinal ligament
A 43 year old female presents with a history of colicky, right sided abdominal pain. She states the pain is worse after eating fish and chips and Indian takeaways. On examination her abdomen is soft and non-tender. Which of the following should be the doctor’s next investigation? A Abdominal X-ray B ERCP C Liver biopsy D USS of biliary tree E CT-KUB
USS of biliary tree
This patient has the classical symptoms of biliary colicky, RUQ pain worsened by fatty foods. If biliary colicky or gallstones are suspected, then ultrasound is the best modality for diagnosis.
AXR only has 3 indications: obstruction, toxic megacolon and perforation.
ERCP is an appropriate investigation for biliary colicky however it is much more invasive, with risk of perforation. Consequently it is normally only performed with therapeutic intent (can remove stones at same time as the ERCP).
Liver biopsy is very painful and invasive so increasingly rare nowadays, also nothing to suggest liver pathology so no indication.
CT-KUB would be the go to investigation for suspected renal stones.
A 40 year old patient presents to clinic with lupus pernio and a rash on the legs which resembles target shapes. As they have also had some difficulty breathing it is arranged for them to have a chest radiograph, which shows bilateral hilar lymphadenopathy. Given the most likely diagnosis, which of the following laboratory findings would you expect to see? A High ACE B Low Calcium C High Sodium D Red Cell Agglutination E Atypical Lymphocytes
High ACE
This patient is presenting with sarcoidosis. Lupus pernio is a purplish skin lesion that is usually seen on the cheeks or nose and it is a cutaneous manifestation of sarcoidosis. The ring shaped lesions is describing annular sarcoidosis – another cutaneous manifestation of sarcoidosis. Bilateral hilar lymphadenopathy can be caused by a few different disease, most commonly sarcoidosis, lymphoma and TB. ACE levels are often raised in sarcoidosis and is used to support the diagnosis. Calcium can be raised in sarcoidosis because the granulomatous tissue can ectopically produce 1-alpha hydroxylase (which is important in the production of activated vitamin D).
