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Flashcards in OE EMQs Deck (140):
1

Ocular signs associated with systemic diseases

  • Reiter's syndrome
  • Syphilis
  • Myasthenia gravis
  •  

  • Uveitis
  •  Argyll-Robertson pupil, where there is miosis and the pupil accommodates but does not react to light
  • Ptosis

2


Common skin infections

  1. A 60-year-old obese patient with diabetes presents with a red, itchy, pustular rash in the sub-mammary folds, axillae and groin.
  2. An elderly man presents with severe pain in the left thigh and inability to walk. Multiple vesicles in a linear configuration are seen over the anterior thigh.
  3. A 30-year-old man presents with severe generalised itching which is worse at night. Both his wife and little baby are also scratching themselves.
  4. A mother presents to the surgery with her three children. All three children have flesh coloured umbilicated nodules on their faces.
  5. A 40-year-old man presents to his GP with a red, hot, swollen and painful leg. He admits to wounding the leg whilst gardening the previous day.

  1. Candidal intertrigo favours warm, moist surfaces and is common in the obese as well as diabetics.
  2. Herpes zoster is more common in the elderly and immunosuppressed. Severe pain limiting function may be the presenting complaint.
  3. Scabies causes a generalised itch which is severe when the body is warm. It is transmitted by close contact and other members of the family have to be treated simultaneously. Papules, nodules, burrows and excoriations are found and areas most affected are the backs of the hands, genitalia and soles or palms in infants.
  4. Molluscum contagiosum is a common viral infection transmitted by direct skin to skin contact, and therefore common in children and families. Lesions disappear spontaneously or after trauma, therefore scratching and picking result in resolution. In adults, multiple molluscum or genital molluscum are associated with HIV infection.
  5. Cellulitis is a common skin infection and usually follows a discernible wound, for example, minor trauma or tinea pedis.

3


Common Alcohol problems

  1. hepatic encephalopathy
  2. delirium tremen
  3. intoxication

4

Night blindness and beriberi are caused by what deficiency?


Vit A and thiamine

Night blindness and beriberi are diseases that usually affect people in developing countries; they are caused by vitamin A and thiamine deficiency respectively. Dry beriberi can to progress to Wernicke-Korsakoff, but in developed countries the syndrome is associated with alcoholism.

5


classic presentation of PMR

Weight loss, fatigue and headaches

6

Reactive arthritis (Reiter's syndrome) is associated with...


urethritis, arthritis and iritis/uveitis. It is typically associated with a prior history of either urethritis or diarrhoeal illness. The disease typically affects young males.

7


Patients who have fibromyalgia tend to be middle-aged women who have a history of

depression

8


Sclerodactyly describes...


the tight skin over the fingers. As well as being a feature of diabetes, it is also seen in scleroderma.

9

 

  1. An autosomal dominant anaemia that is caused by a red cell membrane defect.
  2. An autosomal recessive anaemia affects the haemoglobin, causing it to polymerise at low oxygen saturations, leading to severe muscle pain from blood vessel occlusion.
  3. This acquired haemolytic anaemia can be classified into ‘warm’ and ‘cold’ sub-classes.
  4. This mechanical haemolytic anaemia can occur in malignant hypertension or eclampsia.
  5. This X linked recessive anaemia occurs with a defect in pentose phosphate pathway.

  1. Hereditary spherocytosis
  2. Sickle cell anaemia usually affects people of black African descent. The polymerisation of the haemoglobin causes occlusion of the blood vessels leading to the symptoms.
  3. Autoimmune haemolytic anaemias can be sub-typed into 'warm' and 'cold'. Warm and cold describe at what temperatures the antibodies against the RBCs best work.
  4. Microangiopathic haemolytic anaemia.
  5. Glucose-6-phosphate dehydrogenase deficiency

10


Complications of Chronic Renal Failure

  • pruritus. Can be treated by UV phototherapy.
  • Anaemia, Due to erythropoietin deficiency.
  • encephalopathy, Associated with a flapping tremor.
  • Osteodystropy, Associated with failure of 1 alpha-hydroxylation of cholecalciferol.
  • Dialysis dementia, Associated with accumulation of aluminium.
  • dyslipidaemia is common in CRF and is due to impaired lipoprotein lipase activity with combined hyperlipidaemia.
  • Gout is a common problem in patients with chronic renal failure.
  •  

11

Dressler's syndrome

This is a pericarditis that develops two to 10 weeks after a myocardial infarction or heart surgery.

12


XO genotype is associated with

 
 

Turner's syndrome

  •    Short stature
  •     Failure of pubertal development
  •     Wide carrying angle
  •     Web neck
  •     Possible cardiac defects, such as coarctation.

13

Klinefelter's syndrome is

one of the commonest causes of elevated LH/FSH with low testosterone. There is absence/paucity of secondary sexual characteristics, the patient is often tall, has small testes and there is often reduction in IQ.

Associated with a 47 XXY karyotype.

14


A congenital condition in which obesity is associated with mental retardation.

 Prader-Willi syndrome

Obesity associated with hypogonadotrophic hypogonadism and mental retardation.

15


Hypothalamic gonadotrophin releasing hormone deficiency with anosmia.

 

Kallmann's syndrome

Kallmann's syndrome is a common cause of hypogonadotrophic hypogonadism associated with failure of development of the olfactory bulbs hence anosmia.

16

the two commonest causes of acute pancreatitis


Alcohol and gallstones

17


Acute cholecystitis is distinguished from biliary colic in that there is ...

no acute inflammation associated with the latter and so there is no pyrexia or peritonism and no elevated WBC/CRP.

18


Charcot’s triad


jaundice, pain and fever

19


Theme:Head and neck swellings
A Branchial cyst
B Carotid body tumour
C Cystic hygroma
D Lymphoma
E Parotid adenolymphoma
F Parotid pleomorphic adenoma
G Submandibular duct calculus
H Submandibular tumour
I Thoracic outlet syndrome
J Thyroglossal cyst

20


commonest parotid tumours (75%)

A 63-year-old woman is referred with a longstanding and slow growing painless swelling overlying her left mandible. On palpation the lesion is firm and non-tender, and there is no facial nerve damage evident.


Pleomorphic adenomas

 They typically have a smooth edge and irregular surface. They should be excised carefully taking care not to rupture the tumour as it can seed and regrow. Pleomorphic adenomas have a small risk of malignant transformation if left long term.

21


Carotid body tumours usually present as

 painless masses but occasionally may compress the vagus or hypoglossal nerves causing dysphagia, hoarseness, stridor, or weakness of the tongue. They are more common in people living at high altitude.

22


A 76-year-old man is seen with multiple non-tender masses on both sides of his neck. He also reports weight loss, lethargy and night sweats. The lesions have a rubbery consistency and vary between 2 and 4 cm in diameter.

Patients with lymphadenopathy and constitutional symptoms must be regarded as having a lymphoma until proven otherwise. All head and neck lymphadenopathy must undergo FNA to exclude a squamous carcinoma prior to excision. However, FNA is often inadequate for diagnosis of lymphoma and an excision biopsy is required for characterisation of lymphoma and planning of chemotherapy.

23


A 68-year-old male hypertensive smoker presents with sudden painless loss of vision in one eye. Fundoscopy reveals a pale retina with a cherry red spot at the macula.

Central retinal artery occlusion causes pallor of disc and retina, the macular is spared as it receives branches from the post ciliary artery. The occlusion is commonly atherothrombotic embolus. There is dramatic loss of vision within seconds`

24


A 83-year-old female with a past medical history of angina, presents with sudden painless loss of vision in one eye. Fundoscopy reveals a hyperaemic retina with engorged veins accompanied by multiple haemorrhages


`Central retinal vein occlusion is commoner than central retinal artery occlusion. Its causes include chronic simple glaucoma, arteriosclerosis, hypertension and polycythaemia. There is sudden loss of vision and the fundus looks like a stormy sunset.`

25


A 71-year-old male presents to his GP complaining of a gradual deterioration in his vision. In particular he has noticed that buildings do not appear straight. On fundoscopy there is pigment, exudate and bleeding at macula


Age related macular degeneration (ARMD) is the commonest cause of blindness in the United Kingdom. There is degeneration of central vision. The presence of drusen precedes the ARMD fundoscopic appearance.

26


A 20-year-old male presents with difficulty night driving. Examination of his fundus reveals pigmentation at the periphery.


Retinitis pigmentosa is the most prevalent inherited retinal degeneration condition. There are many forms of the disease. Most are sporadic but may be inherited autosomal dominantly, autosomal recessively or X linked. Autosomal dominant forms have the best prognosis and X linked the worst. The onset is gradual and insidious and the most common complaint is difficulty with night vision although the presentation varies. It has associations with:

    Usher syndrome (retinal dystrophy and hearing loss)
    Congenital renal diseases such as renal-retinal dysplasia and Alport disease
    Neuronal diseases
    Enzyme deficiencies
    Mitrochondrial disorders.
 

27


The only carcinoma provided here that is associated with clubbing is


bronchial carcinoma.

28


A 69-year-old male presents with a six month history of 10 kg weight loss. He is a smoker of 10 cigarettes/d and has a history of hypertension. On examination, he is thin and has a palpable left supraclavicular lymph node.


This man has an enlarged Virchow's node and hence Troisier's sign - suggestive of gastric carcinoma

29

Courvoisier's law

  • the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice, the cause is unlikely to be gallstones. Usually, the term is used to describe the physical examination finding of the right-upper quadrant of the abdomen. This sign implicated possible malignancy of the gall bladder or pancreas and the swelling is unlikely due to gallstones.[1][2]

30

Prehn's sign


    Negative Prehn's sign indicates no pain relief with lifting the affected testicle, which points towards testicular torsion which is a surgical emergency and must be relieved within 6 hours.

    Positive Prehn's sign indicates there is pain relief with lifting the affected testicle, which points towards epididymitis.
 

31

Virchow's node

Troisier's sign

The finding of an enlarged, hard node (also referred to as Troisier's sign) has long been regarded as strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.

32


A flapping tremor/asterixis is caused by the three failures:

 
 

   Liver
    Lungs
    Kidneys.

33


A 79-year-old man has a six month history of rapidly progressive memory impairment. He has also had bradykinesia and rigidity, which was not responsive to co-beneldopa (Madopar) and has recently become very aggressive to his wife.


Lewy body dementia

This patient has Lewy body dementia hallmarked by the presence of Lewy bodies within the brain stem and neocortex. There are features of parkinsonism which fail to respond to therapy and fluctuating cognitive loss.

34


Left-sided colon cancer is more likely to present with
 

obstructive symptoms. Examination may be normal in early disease or reveal:

    Cachexia
    Abdominal tenderness
    Hepatomegaly
    Distension
    Ascities
    Rectal mass
    Blood in late disease.

35


Bronchiectasis is due to

 abnormal dilation of the proximal and medium sized bronchi. There are many causes:

    Infection
    Obstruction
    Cystic fibrosis
    Ciliary dyskinesia
    Young syndrome
    Allergic aspergillosis
    Alpha1-antitrypsin deficiency
    Autoimmune diseases such as
        Rheumatic arthritis
        Ulcerative colitis.

It classically presents as cough with large amounts of mucopurulent sputum, sometimes blood streaked. Haemoptysis may be present. Patients often have clubbing and cyanosis with crackles and wheezing may be heard on auscultation. Antibiotics and physiotherapy are the mainstay of treatment.

36


A 35-year-old international aid worker complained of feeling generally unwell with right sided abdominal pain, shivering and night sweats. He has a high swinging temperature and is tender in the right upper quadrant. A single mass is palpated in the right liver lobe, revealed to be cystic in nature on ultrasound scanning. His white cell count is elevated but liver function tests are normal.

An amoebic liver abscess is the most likely cause of a swinging temperature and a cystic liver mass. There is no history of diarrhoea in a half of cases. Liver function tests may be normal or show a cholestatic picture.

37


An asymptomatic 55-year-old woman is investigated for a persistently raised alkaline phosphatase level. Her AST and ALT are only mildly elevated. On examination she has tendon xanthomata, and a smooth liver edge is palpable 3 cm below the costal margin. Her IgM is raised; results from auto-antibody screening are awaited.

Primary biliary cirrhosis is often asymptomatic and diagnosed after finding a raised alkaline phosphatase on routine testing. Xanthomata, hepatomegaly and a raised IgM are features of this autoimmune disorder. Antimitochondrial antibodies are usually positive.

38

Tietze’s syndrome is a

benign condition of unknown aetiology consisting of non-specific inflammation and swelling of one or more costal cartilages. The resulting discomfort may be similar to pleuritic pain but local tenderness is elicited on palpation of the lump. Treatment is conservative, with local corticosteroid injection if necessary.

39

A 57-year-old woman presents to her GP with a continuous ache on the right side of her chest. She also admits to weight loss and haemoptysis and volunteers that her right eyelid has recently begun to droop.

This lady has a right apical bronchogenic carcinoma (Pancoast’s tumour). Horner’s syndrome (ptosis, meiosis, anhydrosis and enophthalmos) has occurred as a result of neoplastic infiltration of the sympathetic outflow.

40

A 17-year-old student presents in the Emergency department with increasing shortness of breath on exertion. On examination he is very thin and has signs consistent with a large right pleural effusion. Abdominal examination reveals 5 cm hepatomegaly and a hard irregular mass in the left side of the scrotum.

This young man has signs consistent with a left testicular carcinoma with distal metastases in the liver and lungs. Urogential tumours (that is, renal, gynaecological and testicular) classically cause multiple large pulmonary metastases known as 'cannonball metastases'.

41


A 19-year-old man presents to his GP with a two day history of shortness of breath on exertion and a non-productive cough. He has felt non-specifically unwell with a headache for several days. Clinical examination is normal but a chest x ray shows patchy shadowing of both lower lobes.


Mycoplasma pneumoniae is one of the principal causes of atypical pneumonia.

Non-specific symptoms, such as headache, diarrhoea and fatigue, tend to precede chest symptoms and at presentation chest x ray often shows consolidation before auscultatory signs become apparent. M. pneumoniae is notable for causing a wide range of extra-pulmonary conditions, including erythema multiforme and cold agglutinin production leading to haemolytic anaemia.

There is also a strong association with Guillain-Barré syndrome.

42


A 64-year-old man with a six month history of weight loss, constipation and rectal bleeding presents to his GP with shortness of breath and pleuritic chest pain which came on suddenly during a meal. Chest examination was normal.

This man has a history suggestive of colorectal tumour. He is therefore at risk of developing deep venous thrombosis, both as a result of direct venous compression by the tumour and also because of the pre-coagulant effect associated with carcinomatosis.

43


The diagnosis of sarcoidosis is based on

the non-specific symptoms of weight loss and malaise coupled with a history of polyuria which is suggestive of hypercalcaemia, a common feature of active sarcoid. A maculopapular or vesicular rash on the face occurs frequently and if it becomes chronic and granulomatous, is termed 'lupus pernio'.

Sarcoidosis is a multi-system granulomatous disease and in cases of insidious onset the presentation may therefore reflect involvement of any organ. More commonly however, the onset is acute and is characterised by erythema nodosum and bilateral hilar lymphadenopathy on chest x ray which is often associated with varying degrees of dyspnoea and non productive cough.

44


Cryptogenic fibrosing alveolitis (known as idiopathic pulmonary fibrosis in the USA) generally presents in t

he sixth decade of life. Respiratory symptoms, other than progressive dyspnoea and dry cough, are uncommon. The classic examination findings are digital clubbing and fine end-inspiratory bibasal crackles.

45


One major side effect of metformin is

lactic acidosis. This may be severe in situations of tissue hypoxia and in conditions such as renal impairment, alcohol abuse, liver disease and heart failure.

46


Fluoxetine when given in combination with xxx increases the risk of xxx

sulphonylureas

hypoglycaemia

47

A 26-year-old female presents with a two month history of severe headaches that appears to be relieved by standing. On examination, it is noted that she is obese. She has no neurological abnormalities or visual disturbances.

Benign intracranial hypertension is a problem that more commonly is seen in young obese women. The patients may also have papilloedema.

48

A 67-year-old lady presents with a three week history of intermittent facial pain. She says that the pain starts just in front of the right ear and spreads down toward the mouth. It is a sharp, stabbing pain that comes on intermittently - especially when she is out in the cold. There are no obvious signs on examination.

Trigeminal neuralgia is a relatively common problem that is mostly seen in patients aged over 60. It is characterised by sharp facial pain that comes on suddenly and the pain is in the distribution of the trigeminal nerve. The pain is usually brought on by a trigger such as cold air/chewing/cleaning teeth. The treatment is usually with pain relief and surgery.

49

A 52-year-old male presents with a one month history of episodic headache. The pain is left sided and is described as "boring in one eye"; it can then spread to his forehead. He usually gets these episodes at night, a few hours after going to sleep. There are no obvious abnormal signs on examination.

Cluster headache is characterised by an intense pain that is concentrated around one eye. The attacks are more common at night and most commonly affect males aged over 40 years.

50

The risk factors for developing pulmonary embolisms include

   
Possible features include

  
 

 

Increased age
    Obesity
    Malignancy
    Pregnancy
    Treatment with HRT or the OCP
    Immobility.

 

 Shortness of breath
    Pleuritic chest pain
    Haemoptysis
    Hypotension
    Tachycardia
    Dyspnoea
    A raised JVP.

51

A sign that is often linked to vitamin D deficiency is

the ‘waddling gait’. The insufficient vitamin D leads to an initial hypocalcaemia. Over a longer period of time the deficiency can cause secondary hyperparathyroidism.

52

A 55-year-old female presents with a two month history of fatigue and itchy skin. On examination, it is observed that she has yellow sclera and hepatomegaly. A blood test shows raised bilirubin and raised alkaline phosphatase.

what antibody would be present?

Antimitochondrial antibodies

Primary biliary cirrhosis is an autoimmune disorder of the bile ducts with in the liver. Over 90% of patients with primary biliary cirrhosis have antimitochondrial antibodies.

53


A 30-year-old female who is 28 weeks pregnant presents with hyperpigmentation around the cheeks, eyes and forehead, giving a 'mask-like' appearance.`

Melasma

This is also termed the 'mask of pregnancy'. Most pregnant women develop increased pigmentation of the skin, which improves spontaneously after pregnancy. Melasma is also associated with the combined OCP.

54

A 62-year-old female presents with severe, sharp and episodic pain during swallowing.

Involved cranial nerve

Glossopharyngeal

This story is typical of glossopharyngeal neuralgia, a similar condition to trigeminal neuralgia but affecting the IX nerve. The episodic lancinating pain may be produced by swallowing.

55

A 58-year-old female presents with weight loss despite an increase in her appetite. She also describes overwhelming heat intolerance. On examination she has a tremor and is very agitated.

Initail treatment

Carbimazole

The symptoms point towards hyperthyroidism and thus the treatment is carbimazole.

56

A 50-year-old woman presents with increased weight gain and bruising on her skin. On examination her limb muscles are wasted, her skin is very thin and she has unusual facial hair.

Treatment?

Surgery

Symptoms point towards a diagnosis of Cushing's which is treated by removal of the cause, often a pituitary tumour.

57

A 27-year-old woman comes to her general practitioner because she has had urgency of micturition for the past few weeks. Dipstick testing of urine is clear. The general practitioner notes that, two years previously, she had episodes of visual disturbance over a period of a few weeks; these resolved spontaneously.

Multiple sclerosis has a relapsing and remitting course in approximately 2/3 of cases.The visual disturbance may have been an episode of optic neuritis, and the urgency of urine is likely to be due to a spastic paraparesis caused by demyelination in the spinal cord.

58

A 70-year-old man complains of a two month history of difficulty swallowing, weight loss and weakness. He is unable to protrude his tongue and has difficulty in formulating speech. There is no cognitive abnormality. There is twitching of the muscles of the forearm

Motor neurone disease

Motor neurone disease presents with bulbar weakness and fasciculations are typical.

59


A 78-year-old man with weight loss and change of bowel habit develops abdominal swelling.


Carcinomatosis peritonei

60

A 32-year-old female complains of foul smelling vaginal discharge. Smear examination shows numerous squamous cells and clue cells.

Bacterial vaginosis. 'Clue cells' are irregularly bordered squamous epithelial cells whose cell outlines are obliterated by sheets of small bacteria. These suggest a diagnosis of bacterial vaginosis rather than Trichomonas, as with the latter motile flagellated organisms should be seen.

61

A 22-year-old sexually active female complains of vaginal discharge and deep dyspareunia. Smear for gonococcus is negative.

This case has features of pelvic inflammatory disease with Chlamydia being the most likely infective agent and is treated with tetracyclines.

62


A 25-year-old female complains of thick white vaginal discharge. She is obese, has a vaginal pH of 4 and urinalysis shows ++ glucose.

63

A drug that may produce a rapidly progressive pulmonary fibrosis.


Amiodarone is an iodine-containing compound that tends to accumulate in several organs, including the lungs. It has been associated with a variety of adverse events. Of these events, the most serious is amiodarone pulmonary toxicity. Although the incidence of this complication has decreased with the use of lower doses of amiodarone, it can occur with any dose. Pulmonary toxicity usually manifests as an acute or subacute pneumonitis, typically with diffuse infiltrates on chest x ray. With early detection, the prognosis is good. Most patients diagnosed promptly respond well to the withdrawal of amiodarone and the administration of corticosteroids, which are usually given for four to 12 months.

Amiodarone can also produce, liver failure, thyroid disturbances, heart block and skin photosensitivity. Liver function and thyroid function tests are required before treatment and then every six months. A chest x ray is required before treatment.

64

A drug that often causes headache, especially when patients first start the medication.


Headache is a common side effect of nitrate therapy because of vasodilation. It is often transient at the start of treatment. Patients should be warned of this possibility to encourage compliance.

65


A 50-year-old male presents with dyspnoea and orthopnoea. He has a three year history of diabetes mellitus. Examination reveals that he is pigmented (he has not been sun tanning) and he has ankle oedema.


Haemochromatosis causes cardiac failure, liver failure, diabetes and pseudogout. It is also known as 'bronze diabetes'. Diagnosis is confirmed by genetic testing (HFE gene) and serum ferritin or transferrin saturations.

66

On examination the mass is painless, approximately 2 cm in diameter, hard, with an irregular surface and does not transilluminate.

What is the most likely cause of the lump?

Teratomas

The main differentiating factor here is the age of the patient. Teratomas are tumours that more commonly occur in patients of the age group 20-30 and seminomas in the age group 30-50.

67


A 35-year-old man presents with recurrent nose bleeds and haemoptysis. On systematic enquiry, he reports having noticed blood in his urine recently. He has a nasal septal perforation and multiple nodules are seen on his chest x ray.


Wegener's granulomatosis is characterised by involvement of the upper respiratory tract, lungs and kidneys. It often starts with severe rhinorrhoea. Haemoptysis, haematuria and epistaxis with the presence of a nasal septal perforation point towards this diagnosis. A chest x ray usually shows single or multiple pulmonary nodules, or pulmonary infiltrates with cavitation.

68

A 22-year-old man presents to the Emergency department following an accident at work. A piece of scaffolding fell from two metres above him and trapped his left leg. His peripheral pulses are present on arrival in hospital two hours after the accident. He is admitted for observation when he becomes hypotensive with a poor urine output.


Rhabdomyolysis

69

A 35-year-old lady is receiving an elective blood transfusion for symptomatic anaemia secondary to menorrhagia. Her temperature rises to 38.8 degrees 45 minutes after start of the transfusion. She is shivering, but her pulse and blood pressure are stable and her breathing is normal.

Shivering and a temperature of less than 40 is a prominent feature of a non-haemolytic febrile transfusion reaction.

70


A 45-year-old man admitted with injuries from a RTA complains of chest pain soon after starting an emergency blood transfusion. He appears agitated and flushed and his temperature is 42.3°C. He is tachycardic and his blood pressure is falling.


Acute haemolytic transfusion reaction

This patient has all the features of an acute haemolytic transfusion reaction (temperature of greater than 40, chest or abdominal pain, tachycardia, hypotension, agitation, flushing). This may be due to ABO incompatibility.

71

A 35-year-old man with chronic renal failure complains of proximal muscle weakness and middle back pain. x Ray of his back revealed vertebral bodies to be reduced in density and biconcave (cod-fish vertebrae).


Osteomalacia is caused by defect in vitamin D availability or metabolism, resulting in inadequate mineralisation of osteoid framework. Other radiological changes include Looser's zones (pseudofractures) which can progress to complete fractures, and bowing of long bones in advanced cases. There is associated proximal myopathy, with a waddling gait.

72


A 45-year-old man presents with a two year history of recurrent flitting arthritis, and peripheral neuropathy. There is evidence of symmetrical erosive polyarthritis. He distinctly recalls being unwell at the onset with malaise, myalgia, lymphadenopathy and a painful rash over his thigh.


Lyme disease is a tick-borne spirochaetosis caused by Borrelia burgdorferi, transmitted primarily by Ixodes ticks. It is a multisystemic disease affecting skin, joints (can mimic rheumatoid arthritis), central nervous system (meningoencephalitis, peripheral neuropathy and lymphocytic meningoradiculitis) and heart (atrioventricular block, pericarditis, myocarditis and heart failure). Early disease is characterised by expanding burning/painful rash (erythema chronicum migrans), accompanied by lymphadenopathy, malaise, fever and myalgia. It is present in America, Europe (including UK, for example, New Forest in Hampshire) and parts of Asia.

73


A 55-year-old man has a stooped question mark posture and back pain. Chest expansion is reduced. There is clinical evidence of apical lung fibrosis and aortic regurgitation.


Ankylosing spondylitis affects young adults (five times more common in men), presenting with insidious onset of back pain, early morning stiffness and radiological evidence of sacroiliitis. It is related to presence of HLA-B27 (90% Caucasians with AS are HLA-B27 positive). The radiological hallmark is sclerosis with bony bridging (syndesmophytes) between the vertebrae, and also ligamentous calcification. In advanced cases, there is the question mark posture (loss of lumbar lordosis, fixed kyphosis and compensatory extension of the cervical spine). Extra-articular manifestations include apical lung fibrosis, cardiac conduction defects, iritis, aortic regurgitation, traumatic fracture of rigid spine and secondary amyloidosis.

74

A 27-year-old woman has an asthmatic attack at home, and arrives at hospital tired and drowsy. On examination, she was cyanosed with a silent chest.

Treatment


Mechanical ventilation

This patient shows signs of a life threatening asthma attack (exhaustion, agitation or reduced level of consciousness, cyanosis, silent chest, poor respiratory effort). The patient will need care in the intensive care unit, and probably ventilation.

75


A 64-year-old woman, who has panic attacks and shortness of breath, is increasingly depressed. She feels that she cannot cope and is seriously contemplating suicide.

Treatment


Referral to psychiatrist

As the patient is suicidal, she will need assessment by the psychiatrist and possibly be sectioned under the Mental Health Act, should she refuse.

76

A 50-year-old man presents with a right pleural effusion after oesophagectomy for carcinoma. Pleural aspiration yields a milky fluid.


Chylothorax is due to leakage of chylous fluid (fat transported as chylomicrons reach blood stream through this route) from the thoracic duct. Most cases are acquired through trauma surgery (for example, oesophageal resection or those requiring mobilisation of aortic arch), blunt/penetrating injury and malignant infiltration. The fluid is classically milky. It is important to distinguish from empyema. Presence of chyle is confirmed by examining fluid microscopically and fat staining of globules is positive.

77


A 24-year-old in her first pregnancy presents to labour ward at 28 weeks with uterine contractions and pain, with a temperature and flu-like symptoms. She reports a three day history of leakage of clear fluid vaginally that has now become offensive.


Chorio-amnionitis most commonly presents following preterm prelabour rupture of membranes. The first signs are often maternal shivering and temperature.

78

A 29-year-old Afro-Caribbean woman in her first pregnancy presents to labour ward at 26 weeks with a history of increasingly severe abdominal pain. There is no vaginal bleeding. On examination, the symphysis-fundal height is 34 cms and the uterus is focally extremely tender to palpation. She has been vomiting throughout the day.


Degenerating fibroid

Fibroids are most common in Afro-Caribbean women. They can degenerate in pregnancy, causing pain, uterine tenderness, occasionally precipitating preterm labour. Treatment is supportive: rehydration, analgesia and if appropriate, antibiotics.

79


A 72-year-old man complains of great difficulty in walking downstairs and occasional double vision. There are diminished eye movements on the right side where the eye is unable to move to the inferior and medial position.

which cranial nerve?


Trochlear

80


A 72-year-old woman presents with bilateral foot drop and spastic weakness with muscle fasciculation of her legs. Recently, she has been prone to having chest infections. Her tongue was wasted and fasciculating.


Anterior horn cell disease (motor neurone disease)

Motor neurone disease is associated with degenaration of motor neurones, somatic motor nuclei of cranial nerves and within cortex. There are three patterns - progressive muscular atrophy, amyotrophic lateral sclerosis and progressive bulbar palsy. Diagnosis is often made on clinical grounds. Denervation can be confirmed on electromyography.

81


A 55-year-old man complains of left shoulder pain and weight loss. There is evidence of miosis and partial ptosis of his left eye.


Brachial plexus lesion

This patient has left Horner's syndrome from a Pancoast's tumour. Carcinoma at the apex of lung can erode the ribs and lower part of brachial plexus (C8, T1 and T2) causing pain in shoulder and medial surface of arm.

82


A 65-year-old man is found to have hepatosplenomegaly, with widespread lymphadenopathy. His full blood count revealed anaemia, thrombocytopenia and leucocytosis, with lymphocytosis. There were smear cells on his blood film.


Chronic lymphatic leukaemia

CLL occurs mainly in older people and is due to uncontrolled proliferation and accumulation of mature B lymphocytes (rarely T cells).

Lymphocytosis: WBC >15 ×109/L, of which 40% are lymphocytes. It leads to:

    Painless lymphadenopathy
    Hepatosplenomegaly
    Anaemia (autoimmune haemolysis/ bone marrow failure)
    Thrombocytopenia, and
    Infections (neutropenia with or without reduced immunoglobulins).
 

83


A 37-year-old farmer presents with a gradual onset of malaise, headaches, myalgia and night sweats. He has lymphadenopathy and hepatomegaly. His chest x ray is normal. His 2-mercaptoethanol test is positive.


Elevated serum IgG detected by extraction with 2-mercaptoethanol (2-ME) is evidence of current or recent infection with brucellosis. The occupation should have been a clue. Brucella is Gram negative coccobacillus. Acute brucellosis has insidious onset with:

    Malaise
    Headache, and
    Night sweats.

There is lymphadenopathy, hepatomegaly, splenomegaly (in severe infections) and sometimes orchitis, osteomyelitis, meningoencephalitis and endocarditis.

Treat with tetracycline with rifampicin (or Septrin).

84


A 70-year-old man is found lying on the floor at home by his neighbour. His balance has been poor for some time and he walked with a stamping gait. His Romberg test is positive


Sensory ataxia

High steppage or stamping gait (walks with wide based gait, continuously looking at the ground, raising feet high in air before stamping them to the ground) indicates dorsal column loss, which conveys touch, vibration and proprioception. It may be due to tabes dorsalis (syphilis infection) or subacute combined degeneration of the cord (B12 deficiency).

85


A 56-year-old woman presents with troublesome abdominal distention and bloating, relieved by defecation. She is often constipated with stools ribbon-like in appearance. Her weight remains stable.

 


 Irritable bowel syndrome

Irritable bowel syndrome is a form of functional bowel disease. It is characterised by abdominal pain relieved by defecation, or change in bowel habit with altered stool frequency/consistency with sensation of abdominal distension. The patient often looks well despite the frequent episodes of pain. In an older patient, irritable bowel syndrome is a diagnosis of exclusion, following gastrointestinal investigations.

86


A 45-year-old man of no fixed abode presents with severe abdominal pain for the last three days. He also complains of vomiting large amounts of fresh blood prior to his admission. Examination shows that he is well perfused, with several laparotomy scars on his abdomen. His haemoglobin is 15.2 g/dl.


Munchausen's syndrome is more common in men than women. Patients repeatedly present with dramatic illnesses, which seem to require urgent medical or surgical intervention. They may submit to investigations or surgery, but may suddenly discharge themselves before treatment is complete. In this case, the presence of multiple surgical scars, together with absence of anaemia or hypovolaemic shock should raise some suspicion.

87


A 73-year-old, previously fit male presents with difficulty ascending stairs. Abnormalities noted on examination are weakness of knee flexion, which is more pronounced on the left with some wasting of the quadriceps and diminished knee reflexes. He is noted to have glycosuria.


Diabetics amyotrophy

This is a classical example of diabetic amyotrophy, with an asymmetrical wasting and weakness of the quadriceps in an elderly person. This may be the initial presenting feature of diabetes.

88


A 53-year-old patient with type 2 diabetes complicated by angina and chronic renal failure complains of breathlessness. Investigations include serum creatinine - 298 iu/l, Hb - 10 g/dl.

Treatment


Erythropoeitin

Chronic renal failure results in defective erythropoesis. Considerable evidence exists supporting the benefits of erythropoetin in patients with chronic anaemia associated with chronic renal failure. Prior to commencing it is important to ensure that the patient’s iron levels are adequate.

89


A 60-year-old vagrant presents with generalised itching. There is widespread excoriation marks on his trunk and arms, with linear tracts around his wrists and between his fingers.


Scabie

Linear or curved tracts may contain mites, eggs or faeces. Sites include finger webs, wrists, elbows, ankles, genitalia and breasts. Treat with malathion or permethrin.

90


A 29-year-woman developed an itchy scaly rash particularly over her wrists, with fine white streaks overlying lesions. Her buccal mucosa is lined with a lacy, white pattern.


Lichen planus

Clinical picture of lichen planus, which may be caused by drugs (thiazides, gold, phenothiazines, quinidine, antimalarials, sulphonamides, b-blockers, penicillamine) or graft versus host disease.

91


A 60-year-old man complains of being tired, lethargy and pruritus. He also has nocturia and polyuria, with nausea and vomiting. Examination revealed pallor, pigmentation and fluid overload.


Uraemic symptoms include fatigue, breathlessness, ankle swelling, anorexia, vomiting, nocturia and pruritus. Examination can reveal pigmentation, pallor and brown nails.

92


An 84-year-old woman in a nursing home has been constipated for a week. Over the past few days she has become increasingly confused and incontinent.

Investigation


Midstream specimen of urine

93


A 64-year-old man has recently been started on tablets by his GP. He is brought to the Emergency department by his wife with sudden onset of aggressive behaviour, confusion and drowsiness. Prior to starting the tablets he was losing weight and complaining of thirst.

investigation


Blood glucose

94

Recognised associations of SAH include

 

    Polycystic kidney disease
    Ehlers-Danlos syndrome and
    Coarctation of the aorta.

95


A 28-year-old woman has been overweight since her teens, and is worried about further weight gain of 5 kg in the past year. She has had no periods for the last nine months. Pregnancy test is negative. She has had some facial hair over the moustache area for years, but now needs to shave often. She has been trying to get pregnant for the past 18 months. Her BMI is 30.


Polycystic ovary syndrome is characterised by amenorrhoea or oligomenorrhoea, obesity and hyperandrogenism which may present as hirsutism and increased testosterone.

96


A 3-month-old baby boy is wheezy, coughing, cyanosed and breathless with intercostal recession.


Acute bronchiolitis is very common in infancy. In winter epidemics, respiratory syncytial virus infections are the commonest cause. Wheeze, cough, fever and respiratory distress are common. Chest x ray shows hyperinflation.

97


A 2-year-old boy is very unwell. His temperature is 39°C and he is flushed, toxic, and unable to swallow his secretions.


Acute epiglottitis is due to Haemophilus influenzae type B infection. It is characterised by sudden onset, high fever, continuous stridor and drooling of secretions. Intravenous antibiotics, anaesthetic support are usually indicated.

98


A 4-year-old non-immunised boy presents with bouts of coughing ending in vomiting. He has an absolute lymphocytosis.


Whooping cough is caused by Bordetella pertussis infection. Bouts of coughing ending in vomiting, especially at night and after feeding suggest the diagnosis. The characteristic whoop, forced inspiration through a closed glottis may or may not be present. Absolute lymphocytosis is common. Complications include CNS haemorrhages, rectal prolapse and bronchiectasis.

99

Klinefelter's syndrome is characterised by

tall stature, gynaecomastia and below average intelligence. Karytotype is XXY and there is a primary hypogonadism with low testosterone and elevated luteinising hormone/follicle-stimulating hormone (LH/FSH) (primary testicular failure).

100

A 65-year-old man is referred from the cardiology team after undergoing a coronary angiogram six hours previously. On examination he is haemodynamically stable but has a large pulsatile mass in his right groin.

A pseudoaneurysm (false aneurysm) unlike a true aneurysm, has a wall made up from surrounding tissue. They occur following: previous vascular surgery; vascular trauma; instrumentation, for example, cardiac catheterisation; and IV drug abuse. Many resolve spontaneously with time. Acutely, Doppler ultrasound-targeted pressure may be used +/- thrombin injection to promote thrombosis. Complications include local compression (veins/nerves), infection and rupture - in these cases surgery is required.

101

A 65-year-old lady presents to her GP after complaining of a dull central chest pain, especially after eating, and regurgitating undigested food up to three hours after eating it.

Achalasia is a problem with the coordination of swallowing in the oesophagus and lower oesophageal sphincter.

102

A 51-year-old female with a history of treatment for thyroid dysfunction, presents with a sore throat of short duration. Examination reveals swollen and painful fauces.

Agranulocytosis

Carbimazole therapy may result in agranulocytosis and occasionally in an aplastic crisis.

103

A 60-year-old male who has a six year history of chronic lymphocytic leukaemia presents with symptomatic anaemia. His investigations reveal warm agglutinins, high lactate dehyrogenase and low haptoglobulin levels.

Autoimmune haemolytic anaemia may complicate CLL. Warm agglutinins are IgG antibodies that react with protein antigens on the RBC surface at room temperature causing haemolysis.

104

A 70-year-old man presents to clinic complaining of progressive bilateral hearing loss over the last year. He accuses his grandchildren of mumbling. Rinne and Weber tests are both normal. He has a hearing test, which reveals high frequency hearing loss.

 Presbyacusis

This man has presbyacusis or senile deafness. It is caused by a gradual loss of hair cells in the cochlea and a loss of neurones in the cochlear nerve. Usually the high tones go first.

105

A 35-year-old woman has developed deafness in her left ear. It became noticeably worse during a recent pregnancy and her mother had premature deafness. On examination both TMs are normal, the Rinne test is negative on the left and the Weber test lateralises to the left side.

Otosclerosis

Conductive deafness(bone better than air) with a normal eardrum, is otosclerosis until proved otherwise. It is more common in women and typically deteriorates in pregnancy.

106

A 28-year-old man with mild learning disabilities presents to his GP with a six month history of worsening dysarthria. He also states that his limbs sometimes jerk uncontrollably. The GP notices a greenish-brown pigment at the periphery of the cornea.

This man has Wilson's disease, characterised by an accumulation of copper in the

    Liver
    Brain
    Kidney
    Cornea (Kayser-Fleischer rings)
    Bone.
 

107

A 27-year-old man presents to his GP with a six month history of feeling depressed. He also states that recently he has experienced jerky movements flitting from one part of the body to another. His father experienced similar symptoms aged 30 and committed suicide.

This man has Huntington's disease. He is experiencing choreiform movements. It is autosomal dominant and his father had the condition and committed suicide.

108

A 19-year-old woman is admitted to a psychiatric hospital thinking that everyone wants to kill her. Four days later she develops severe abdominal pain, pyrexia, vomiting and starts to fit. She is referred to the Emergency department where the nurses notice that her urine turns red/brown on standing.

This lady has acute intermittent porphyria. Psychiatric disturbances include:

    Delirium
    Depression
    Emotional lability
    Schizophreniform psychoses
    Hysteria.
 

109

A 70-year-old man presents to his GP complaining of bright red blood on the outside of his stool over the last six months. He also complains of an incomplete sensation after evacuation of faeces.

Colorectal adenocarcinoma

Presentation depends on the site, with left-sided tumours presenting with PR bleeding, altered bowel habit and tenesmus.

Right-sided tumours present with anaemia, weight loss and abdominal pain.

110

A 70-year-old lady presents with rash around the left ear and severe pain within that ear.

Ramsay Hunt syndrome due to herpes zoster affecting the distribution of the facial nerve. Pain is referred back to ear

111

A 19-year-old man diagnosed with Marfan syndrome is admitted with sudden onset of right-sided chest pain and right-sided click audible on auscultation.

Pneumothorax

Causes: May be spontaneous (usually in thin males)
Chronic obstructive lung disease
Asthma
Trauma
Carcinoma of lung
Cystic fibrosis
Marfan syndrome
Ehlers-Danlos syndrome
Mechanical ventilation.

112

Complications of diabetes mellitus
 


A Amyotrophy
B Autonomic neuropathy
C Cataracts
D Diabetic ketoacidosis
E Distal symmetrical neuropathy
F Hyperosmolar non ketotic hyperglycaemic state
G Hypoglycaemia
H Microalbuminuria
I Necrobiosis lipoidica
J Proliferative retinopathy

113


A 28-year-old woman with a history of type 1 diabetes and previous Graves' thyrotoxicosis has had no periods for five months and presents with hot flushes. A pregnancy test is negative and thyroid function tests are normal.


Premature menopause

Premature ovarian failure is due to autoimmunity and is associated with other autoimmune diseases such as type 1 diabetes, Addison's disease and autoimmune thyroid disease. The exact mechanism is not fully understood.

114


A 24-year-old female complains of a six month history of irregular periods, acne and weight gain. On examination she is overweight with a BMI of 32 kg/m2 and has some mild brownish pigmentation over the neck and axilla

Polycystic ovary disease

Obesity is a well recognised in PCO disease but would be less likely if the history had suggested proximal muscle weakness or even striae.

115


A 78-year-old man's spouse complains that he is becoming aggressive and talking about their sexual life publicly. He has normal memory on testing.


Pick's disease

The predominance of frontal features is suggestive of Pick's disease. Patients become increasingly disinhibited and socially coarse. At times they may be euphoric.

116

A 32-year-old man presents with a one month history of offensive ear discharge from the left ear. Examination reveals a facial nerve palsy and there is an attic perforation of the tympanic membrane.

Cholesteatoma

The presence of an attic perforation with ear discharge and facial palsy is indicative of a cholesteatoma.

117

A 35-year-old man presented with hypertension and complained of tingling in his fingers. He had an enlarged tongue and prognathism. A glucose tolerance test was abnormal.

 


Acromegaly

Acromegaly is classically described with an enlarged tongue, impaired glucose tolerance and carpal tunnel syndrome. Hypertension is associated.

118

A 45-year-old woman with disproportionately long limbs presented with hypertension. Her blood pressure was different on both arms and lower in the legs.


Coarctation of the aorta

When the blood pressure is different in both arms and lower in the legs, this is suggestive of coarctation of the aorta.

119

A 40-year-old man post-thyroidectomy for medullary thyroid carcinoma presented with hypertension and complained of attacks of severe headache and palpitations. He was noted to have glycosuria.

Phaeochromocytoma is likely. It is associated with multiple endocrine neoplasia type 2 that can occur with medullary C cell tumours of the thyroid gland.

120

A 45-year-old woman is referred with a lesion on her cheek. On examination you see it has an irregular surface with smooth sides, central umbilication and a crusty core.

Keratoacanthomas are benign lesions that are often mistaken for BCC/SCC. They occur as a result of hyperplasia of hair follicles and are most common in sun exposed areas. They tend to regress spontaneously over a period of six to 12 months without the need for any treatment.However,some experts consider them to be a variant of SCC,so they are often excised as thy cannot be reliably distinguished clinically.

121

A 4-month-old baby boy is brought by his mother who is concerned that his scrotum is swollen and he is constantly crying. He was born at 32 weeks gestation. On examination there is no discolouration of the scrotum and the swelling is non-tender and fully reducible.

Indirect inguinal

The description indicates an indirect inguinal hernia. Boys are more commonly affected, especially if premature. In children the defect is a patent processus vaginalis. These hernias pass through the deep ring along the inguinal canal and out through the superficial ring and may pass into the scrotum. They are the commonest of abdominal hernias. All patients with inguinal hernias should be offered a repair. In children this is a herniotomy whilst in adults a herniorrhaphy is performed.

122

A 68-year-old man attends the clinic with a swelling closely related to his right iliac fossa terminal ileostomy. He had previously undergone an emergency total colectomy for toxic megacolon. On examination there is a soft reducible swelling with a positive cough impulse.

Parastomal hernias are probably under recorded and occur as a segment of bowel emerges alongside the stoma. For ileostomies, this often causes severe pain whilst for colostomies, the symptoms are more commonly related to poorly fitting appliances. The diagnosis can be confirmed with CT and the stomal hernia repaired.

123

A 44-year-old lady with known inflammatory bowel disease presents with a large ulcerating lesion over the anterior shin of the right leg which has a blue overhanging necrotic edge. Her ABPIs are normal.


Pyoderma gangrenosum are recurring nodulo-pustular ulcers with a tender red/ blue overhanging necrotic edge, commonly affecting the legs, abdomen and face. It is associated with:

    inflammatory bowel disease
    acute leukaemia
    polycythaemia rubra vera
    autoimmune hepatitis
    Wegener's granulomatosis, and
    myeloma.
 

124

A 32-year-old male presents with weight loss, fever and fatigue. He is diagnosed with AIDS.

Hairy leukoplakia

 

125

Hepatocellular carcinoma

Alpha-fetoprotein is often elevated in patients with hepatocellular carcinoma. It is also found in non-seminomatous germ cell tumours of the gonads. Beta-HCG is a tumour marker that may be found in bronchial carcinoma. It is also found in choriocarcinomas.

126

Ovarian carcinoma

Ca-125 is typically elevated in association with ovarian malignancy.

127

A 42-year-old female presents to the surgical outpatient clinic with painful ulcers and abscess formation in her perineal region. On examination, there are few small abscesses and multiple skin tags in the region. The skin over the area is tender, red and indurated. She also reports similar problems in her inguinal regions and axilla.


Hidradenitis suppurativa is a chronic suppurative disease of the apocrine sweat glands characterised by recurrent ulcers, abscesses, sinuses and, occasionally, fistulas. It commonly affects the axilla, inguinal region, perineal region and the buttocks. Chronic, longstanding hidradenitis suppurativa leads to subcutaneous fibrosis, scarring and contractures. The management of this condition usually involves excision of all the affected area. The area could either be left to heal by secondary intention or covered with a skin-graft or local flap. It is not closed primary.

128

GCS Eye opening

 
 

  Spontaneous (4)
    On speech (3)
    On pain (2)
    None (1)

129


GCS Best verbal response

   

Orientated (5)
    Confused (4)
    Inappropriate (3)
    Incomprehensible (2)
    None (1)

130


GCS Best motor response

  


 Obeying commands (6)
    Localising limbs to resist uncomfortable stimuli (5)
    Withdrawing from uncomfortable stimuli (4)
    Flexing (3)
    Extending (2)
    None (1).

131

A 20-year-old student plans to travel to sub-Saharan Africa for at least one month. She is worried about malaria and would like the best protection available.


Mefloquine is preferable to chloroquine and proguanil in this part of the world, with very high risk of chloroquine-resistant falciparum malaria.

It is contraindicated in pregnancy.

Important side effects include neuro-psychiatric reactions (hallucinations, psychosis).

132


There has been an outbreak of meningococcal meningitis at the local university hall of residence. A 19-year-old student is worried, as she shared a room with another girl, who is now critically ill with meningitis.


Rifampicin 600 mg BD for two days should be given to close adult contacts. Medical and nursing staff need not be given chemoprophylaxis, unless they have given mouth to mouth resuscitation.

133


A 62-year-old woman presents with a left groin swelling. On examination the lump is lateral to the femoral pulse.


 Lymph node

Inguinal lymph nodes are frequently confused with an irreducible inguinal or femoral hernia. They are usually multiple and associated with constitutional symptoms of fever and malaise and may be an early manifestation of lymphoma. The surgeon can be confident that the lump is a lymph node if lateral to the femoral pulse as inguinal and femoral hernias are medial.

134

A 7-year-old boy is admitted with haemarthrosis of his left knee. These episodes have been recurrent since his early years. His activated partial thromboplastin time is significantly prolonged but bleeding time is normal.


Factor VIII concentrate

This boy suffers from haemophilia, probably A. This is inherited as a sex linked recessive condition seen in 1 per 10,000 male births. Minor bleeds are treated with desmopressin, which raises factor VIII levels. Major bleeds require factor VIII concentrate administration to raise levels to above 50%.

135


A 70-year-old man with a prosthetic mitral valve is admitted to hospital with a two day history of bleeding per rectum and a INR of 6. He had been commenced on ciprofloxacin three days previously by his GP, to treat a urinary tract infection.`


 Fresh frozen plasma

The high INR (international normalised ratio is the patient's prothrombin time expressed as a compared to the control) points to a drug interaction between wafarin and ciprofloxacin. The treatment of choice to stop his bleeding is fresh frozen plasma, since it is vital that this patient remains anticoagulated. Vitamin K would take too long (days) to control this patient's bleeding tendency.

136


A 72-year-old woman has recently undergone hip replacement. She is breathless and centrally cyanosed. There is a fourth heart sound, and the venous pressure is elevated to 8 cm above the sternal angle.


Acute pulmonary embolism

This woman has had a pulmonary embolus suggested by the proximity to the orthopaedic surgery and right sided failure.

137


Oligohydramnios and renal tract malformation.


Angiotensin-converting enzyme inhibitors (ACEis) are absolutely contraindicated in pregnancy being teratogenic in the first trimester with cardiac, renal and neurological abnormalities.It is also fetotoxic in the second and third trimesters.

138


Defective ossification with mid-face hypoplasia, saddle nose and cardiac abnormalities.


Warfarin is teratogenic in the first trimester and is associated with defective ossification. Beyond the first trimester, it is occasionally used but is associated with an increased risk of fetal cerebral haemorrhage.

139


Neural tube defects.


Anticonvulsants

This is a typical effect associated with anticonvulsants including phenytoin, valproate (1-2%) and carbamazepine (0.5-1%). The risk may be reduced through taking folate supplements prior to conception. Other effects of phenytoin include the fetal hydantoin syndrome - orofacial defects and reduced intelligence.

140