PASSMED QBANK AUDIT Flashcards
A 69-year-old man presented to the GP. He complained of chest pain and shortness of breath on exertion. He was unable to lie flat because of his breathlessness. He required 3 pillows to sleep at night. Auscultation of the heart revealed an ejection systolic murmur, loudest at the 2nd intercostal space right sternal edge. The murmur showed radiation to the carotids. His recent blood test showed high triglycerides and low-density cholesterol. You decided that you were going to refer him to Cardiology for further management. In the meantime, you would like to alleviate his symptoms.
Which of the following is the most suitable medication to alleviate his symptoms?
Furosemide
Nitrates are contraindicated in aortic stenosis
A 42-year-old woman is admitted to surgery with acute cholecystitis. She is known to have hypertension, rheumatoid arthritis and polymyalgia rheumatica. Her medical therapy includes:
Paracetamol 1g qds
Codeine phosphate 30mg qds
Bendrofluazide 2.5 mg od
Ramipril 10mg od
Methotrexate 7.5mg once a week
Prednisolone 5mg od
You are called by the staff nurse to assess this lady as she has become delirious and hypotensive 2h after surgery. Her blood results reveal:
Na+ 132 mmol/l
K+ 5.3 mmol/l
Urea 7 mmol/l
Creatinine 108 µmol/l
Hb 12.4 g/dl
Platelets 178 * 109/l
WBC 15.4 * 109/l
What management is needed immediately
> Hydrocortisone
This patient has acute adrenal insufficiency and urgently needs steroid replacement. She has been on long term corticosteroid therapy and is undergoing considerable physiological stress - her steroid dose should be doubled/converted to IV hydrocortisone during such a period.
The elevated WBC is consistent with acute cholecystitis/being post-op. It may be that both IV antibiotics and further surgery are required but by far the most important, immediate step is to treat the adrenal insufficiency.
A 26-year-old male presents with headaches. His GP finds his blood pressure to be 190/115 mmHg. He is urgently referred to hospital where investigations show:
Hb 145 g/l
Platelets 360 * 109/l
WBC 6.8* 109/l
Na+ 138 mmol/l
K+ 3.8 mmol/l
Urea 2.3 mmol/l
Creatinine 101 µmol/l
Ca2+ 2.95 mmol/l
PO4-3 0.74 mmol/l
PTH 8.6 pmol/l (normal range 1.2 - 5.7 pmol/l)
Further investigations reveal raised 24 hour urinary catecholamines and an adrenal mass on abdominal CT.
What is the most likely diagnosis?
MEN II
Multiple endocrine neoplasia (MEN) type 2 is a genetic condition characterised by neoplasia of the thyroid (medullary cell carcinoma), parathyroid (parathyroid adenoma) and adrenal glands (phaeochromocytoma).
In this example, raised 24 hour urinary catecholamines and an adrenal mass on abdominal CT are suggestive of a phaeochromocytoma, which would also explain the severe hypertension.
A 65-year-old man presents to his GP concerned about blood in his stools.
Since a few weeks he has been noticing red blood when passing stools. Four days ago this was also accompanied by pain when passing movements, and he felt a mass around his back passage.
On examination, you visualise a purple mass in the perianal area. Direct rectal examination confirms a tender lump at the 7 o’clock position.
What is the most appropriate management of this presentation?
> Conservative mgmnt dt longstaanding 3d+
The history presented here is highly suggestive of thrombosed haemorrhoids, given the pain when passing stools and the tender lump on a background of haematochezia. Unless thrombosed, haemorrhoids are generally painless.
If a patient with thrombosed haemorrhoids presents within 72 hours of onset of the pain, NICE recommends offering admission for surgical management of the piles. This provides immediate pain relief.
Following the first 72 hours of acute thrombosis, the thrombus is likely to organise and contract- lessening symptoms and typically self-resolving within a few weeks. In such scenario, it is more appropriate to offer conservative management options including analgesia, stool softeners and using ice-packs to reduce pain.
A 30-year-old man is trapped in a house fire and sustains 30% partial and full thickness burns to his torso and limbs. Three days following admission he has a brisk haematemesis. Which of the following is the most likely explanation for this event?
The correct answer is Curling’s ulcers. These are acute gastric ulcers that develop in response to severe physiological stress, such as burns. The pathophysiology behind the formation of Curling’s ulcers involves an increase in gastric acid secretion and a decrease in mucosal blood flow following severe burns. This leads to ischemia and necrosis of the gastric mucosa, culminating in ulceration. Haematemesis, or vomiting blood, is a common presentation of these ulcers.
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Curling’s ulcers: Acute gastric erosion from severe burns as reduced plasma volume leads to ischaemia and cell necrosis of gastric mucosa
Dieulafoy lesion: Large, single, tortuous arteriole in stomach submucosa that erodes and bleeds, but can also present anywhere in GI tract.
A 33-year-old woman presents to the emergency department with a severe headache. It started three days ago and it built up gradually, becoming unbearable today. Additionally, she is experiencing diplopia and vomiting. She is healthy and has no past medical history. She is a smoker with a 10-pack-year history.
As the doctors are examining her, she suffers from a seizure, which is self-terminating. She never experienced these symptoms before.
What is the most likely diagnosis?
Risk factors for thrombosis, headache, reduced consciousness, vomiting → ?intracranial venous thrombosis
You review a 70-year-old woman who is on multiple medications. For the past few months she has noticed bilateral tinnitus and hearing loss. Which one of the following medications may be responsible?
- Lofepramine
- Ezetemibe
- Furosemide
- Tramadol
- Digoxin
Furosemide. Can cause ototox
The correct answer is Furosemide. Furosemide is a loop diuretic commonly used in the management of heart failure and hypertension. One of its well-recognised side effects is ototoxicity, which can manifest as tinnitus and hearing loss. This effect is usually reversible upon discontinuation of the medication but can be permanent in some cases. It’s also worth noting that these symptoms are more likely to occur with rapid intravenous administration and high doses.
A 45-year-old woman presents to the emergency department. She is in intense pain in the right upper quadrant of her abdomen, is pyrexic, and is both tachycardic and tachypnoeic.
Which of the following is this woman most likely suffering from?
This is a typical history of acute cholecystitis. Often students find it difficult to differentiate biliary colic, cholecystitis and cholangitis. This is acute cholecystitis because this woman is systemically unwell and in pain, whereas in biliary colic she won’t be systemically unwell. In acute cholangitis, the woman will most likely be jaundiced, which there is no mention of. Murphy’s positive sign is also a sign typical in acute cholecystitis, and is pain on inspiration during palpation of the right upper quadrant. IV antibiotics and laparoscopic cholecystectomy are the management.
A 24-year-old man is admitted to the emergency department with abdominal pain. The pain is constant and severe and localised to the right iliac fossa and has been present now for over 6 hours. On examination he is tachycardic, apyrexial and his abdomen is soft to palpation although he has pain in the right iliac fossa.
Which of the following other clinical examinations is most important to be performed in addition to the above to rule out causes of his pain other than appendicitis?
Always examine the testicles in a young man with RIF pain
Likewise with ?ectopic thus pregnancy test in RIF pain in women
A 53-year-old man presents to the emergency department with acute severe abdominal pain and vomiting. He has not passed any stool or flatus for 48 hours. For the past year, he has had repeated episodes of right upper quadrant pain that was colicky in nature. He has no significant past medical, family, or drug history.
A plain abdominal x-ray is taken that demonstrates multiple dilated loops of small bowel. There is also air in the biliary tree.
What is the most likely diagnosis?
In gallstone ileus, a plain abdominal film classically shows small bowel obstruction and air in the biliary tree
A 37-year-old female presents as a new referral to the thyroid clinic. She complains of dizziness, sweating, fatigue, increased frequency of stools as well as eye pain and diplopia. On examination, a goitre is noted.
Which symptoms is most suggestive of a diagnosis of Graves’ disease rather than an alternative cause of hyperthyroidism?
Diplopia
Exophthalmos is a specific feature of Grave’s disease rather than generic hyperthyroidism
Features seen in Graves’ but not in other causes of thyrotoxicosis
eye signs (30% of patients)
exophthalmos
ophthalmoplegia
pretibial myxoedema
thyroid acropachy, a triad of:
digital clubbing
soft tissue swelling of the hands and feet
periosteal new bone formation
A 59-year-old man presents to the emergency department. Over the last few days, he has had abdominal pain and vomiting. He was managed conservatively at home but is experiencing weakness and heart palpitations today. His medical history includes atorvastatin, amlodipine and indapamide for high cholesterol and hypertension.
On examination, his heart rate is 93bpm, BP is 141/95 mmHg, and oxygen sats are 97%. An ECG demonstrates sinus rhythm with U waves, small inverted T waves and a prolonged QT interval.
What is the most likely cause of his symptoms?
Hypokaelmia
Alongside U waves, the following ECG features may be seen in hypokalaemia:
ECG features of hypokalaemia
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
Hypokalaemia is correct. Hypokalaemia can arise as a side effect of loop and thiazide-like diuretics. In addition, vomiting can cause hypokalaemia as well. The man in the case above is on regular indapamide, which can cause hypokalaemia, further precipitated by his recent illness.
A 30-year-old woman attends maternity bereavement services after delivering a stillborn foetus. She reports spontaneous lactation and seeks medication to suppress it. She has no significant past medical history and is not currently taking any medications.
What is the most appropriate medication to prescribe?
Cabergoline is the medication of choice in suppressing lactation when breastfeeding cessation is indicated
Anticoagulants and their reversals
idarucizumab - dabigatran
Andexanet alfa - rivaroxaban and apixaban, two other direct oral anticoagulants which work as direct factor Xa inhibitors.
Protamine - heparin.
Prothrombin complex concentrate - emergency reversal of warfarin in patients with either severe bleeding or a head injury with suspected intracerebral haemorrhage.
Vitamin K - rapid reversal of warfarin’s anticoagulant effects is required in patients with any bleeding.
Lifestyle advice for promoting pregn
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