Questions Answered Shitely Flashcards
(49 cards)
17 year old male with radiological apperance of rib notching on chest radiograph
Coarctation of aorta
Aortic coarctation is characterised by a BP difference between the upper and lower extremities. Posterior rib notching is due to enlargement of collateral vessels due to aortic narrowing. Diagnosis is made on demonstrating narrowing of the aortic arch, typically shown by echocardiography. Treatment may involve surgical repair such as the placement of a stent. This condition is typically congenital with a male predominance. It is commonly detected in the first decade and is associated with Turner’s and DiGeorge. An ejection systolic murmur is also common present over the LSB and back.
Pain on breathing in & out, dyspnoea, coughing up blood as well, stony dull to percuss
PE causing pleural effusion..
Although the cheeky fuckers put them as separate options
A 60 year old man who is waiting to have a knee replacement, describes daily episodes of central chest pain when he gets up in the morning. The pain lasts 15 minutes & settles with rest.
Variant angina (Prinzmetal) is angina caused by coronary artery vasospasm rather than atherosclerosis. It occurs at rest and in cycles. Many patients will also have some degree of atherosclerosis although not in proportion to the severity of the chest pain experienced. ECG changes are of ST elevation (rather than depression) when the patient is experiencing an attack and a stress ECG will be negative. Patients with Prinzmetal angina are often treated for ACS and indeed, cardiac biomarkers may be raised as vasospasm can cause damage to the myocardium. The gold standard investigation is with coronary angiography and the injection of agents to try to provoke a spasm.
54 year old Asian woman with type 2 diabetes for 15 years. She comes to the clinic complaining of ankle swelling. On examination, BP 170/95, JVP not raised & bilateral oedema to the knees. Albumin is low
What investigation
The most common cause of nephrotic syndrome in adults with long standing diabetes is diabetic nephropathy. However, non-diabetic renal disease cannot be excluded. Nephrotic syndrome is defined by the presence of proteinuria (>3.5g/24h), oedema and hypoalbuminaemia. Some definitions add hyperlipidaemia. Do not confuse this with nephritic syndrome. Diagnosis is made by quantification of proteinuria with a 24 hour urine collection, although now it is common to do a spot urine protein-to-creatinine ratio for practical reasons.
73 year old man was reviewed in the diabetic clinic. He was complaining of increasing tiredness & loss of appetite. His ankles had become more swollen over the last few weeks.
What investigation
4) Diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function
This is a bit stinky as you would surely do a 24hr protein. He isn’t in nephrotic syndrome thus DG is tested for first (cause of nephrotic)
A 62 year old man presents with progressive breathlessness over many years. He worked in power stations. He has finger clubbing and his chest xray shows a honeycomb apperance.
Diag
Power stations DOES NOT imply silica
Therefore IPF
A 19 year old presents with headache and malaise for 1 week. His chest was clear on auscultation. He subsequently developed a cough and was given erythomycin for 1 week
Clear chest implies atypical
Therefore M pneumoniae
4) The atypical presentation (a week of headache and malaise before the cough) and the prescription of erythromycin, a macrolide antibiotic, point to infection with an atypical pneumonia. However, depending on local prescribing policies, first line therapy for a CAP like pneumococcus may also be with a macrolide. Young people who ‘live together’ are commonly affected. The cough often does not resolve and is dry in nature. Symptoms tend to be prolonged and a low-grade fever is a common finding. Mycoplasma is the only atypical pneumonia on the list although there is no reason why this cannot be Legionella or Chlamydia. All can be treated with macrolides although in EMQs Chlamydia tends to be treated with doxycyline. All 3 atypicals are to some extent sensitive to fluoroquinolones and tetracylines too although these cannot be used in pregnancy. Whether they are first or second line therapy depends on the organism.
A 20 year old man with cystic fibrosis presents to the chest clinic with haemoptysis. He has felt unwell for a fortnight with increased sputum production, fever & rigors. Gram stain of the sputum shows Gram-positive cocci in clusters.
Rigors!
lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which a patient with CF is at risk of is a risk factor. Of gram positive cocci, staphylococcus occurs in grape-like clusters (this patient) whereas streptococcus occurs in chains. It is worth learning your gram stains for the main organisms. It is worth noting that Staphylococcus aureus is coagulase positive (also Yersinia pestis which causes plague) and Streptoccus pneumoniae is optochin sensitive. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.
63 year old tramp presents to the A&E department with a 4 day history of haemoptysis. He has felt unwell for about 2 months with a cough, loss of weight & generalised weakness. He attributes his diplopia, which started a fortnight ago, to excessive alcohol consumption. On examination he has bilateral ptosis & proximal weakness in the limbs which improves on repeated testing.
PARANEOPLASTIC SCC
First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is also associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome which this patient has (though weakness of the eye muscles is uncommon in Lambert-Eaton and is more prominent in myasthenia gravis). This classically presents with weakness which improves on repeated testing (in contrast to myaesthenia gravis) and is more commonly associated with small cell lung cancer than other lung cancers. It is for this reason that the most likely diagnosis is small cell and not squamous cell lung c
A 20 year old woman is too breathless to speak. Her pulse is 120/min, respiratory rate 30 per min & peak expiratory flow is 100l/min. Examination reveals a very quiet chest & chest x-ray is normal
Asthma
A 62 year old male heavy, long term smoker presenting with infection of a wound which refuses to heal.
1) This wound is refusing to heal because of the high cortisol level, which is as a result of elevated ACTH due to a small cell lung cancer producing it ectopically as part of a paraneoplastic syndrome. Hence, ACTH and cortisol are both high here.
A 66 year old male with type 2 diabetes complains of episodes of loss of vision in the right eye that may last up to 2 hours. On examination he is noted to have an irregularly irregular pulse of 70 beats per minute & a blood pressure of 155/95. Fundoscopy is normal
Amaurosis fugax is a transient and painless loss of vision in one eye due to the passage of an embolus into the central retinal artery. The AF has thrown off a cardiac embolus which has passed into the central retinal artery (resulting in a temporary loss of blood flow to the retina and hence loss of vision). This patient needs to be started on aspirin at once while a definitive treatment of the underlying aetiology is sought (treatment of AF).
An anxious 19 year old female presents with a lump in the neck. She has lost 3kg in 3 months. On examination there is lymphadenopathy on both sides of the neck & larger nodes on the right. Her pulse is 96 regular; thyroid function tests are normal.
history of weight loss here along with cervical lymphadenopathy point to lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption. While this question does not specifically scream out Hodgkin’s (though the pattern of involvement makes it more likely), the question is not complicated by the option of NHL. Furthermore, this is patient is 19 and unlikely to have head and neck cancer causing local lymphadenopathy and infection does not explain the weight loss over 3 months.
A 17 year old male presents with a 1 week history of fever, malaise, pain on swallowing & has found lumps in the neck. On examination a tender scrotal swelling is also noted.
Mumps is normally characterised by the hallmark finding of parotitis and swelling of the parotid gland(s) which is present in 95% of symptomatic mumps. Mumps epididymo-orchitis is also a common feature and is seen here as a tender scrotal swelling. The history this patient gives makes you think of an infection and the co-existent orchitis and neck lumps makes you think of mumps. Treatment of this viral infection involves isolation and supportive care with paracetamol or ibuprofen.
80 year old presents with symptoms of dysphagia. He has been a lifelong smoker. On examination there is a reducible mass over lateral aspect of the neck.
A pharyngeal pouch is also called a Zenker’s diverticulum (it is a false diverticulum – i.e. it does not involve all layers of the oesophageal wall). The dehiscence of Killian lies in the posterior laryngopharynx which is where the wall herniates through giving an outpouching just above the cricopharyngeal muscle. It may help to gave a look at a picture in an anatomy textbook. A pharyngeal pouch can cause symptoms of dysphagia and the sensation of a lump in the neck. There may also be regurgitation of food, cough, halitosis and gurgling noises and the condition is associated with webs. Additionally, it may be asymptomatic. A barium swallow will confirm the dagnosis. Surgical intervetion may be necessary.
Orphan Annie eyes
Papillary carcinoma thyroid
A 40 year old man with limb pains, epigastric pain with vomiting, colicky pain in his left loin. He has been feeling low & depressed recently & also complained of excessive thirst, nocturia & loss of appetite.
HPT
5) There is autonomous PTH production in primary HPT which causes deranged calcium metabolism. Biochemistry will show elevated serum calcium and inappropriate elevation of PTH. Depression, cognitive changes, change in sleep (possibly due to change in circadian rhythm) and myalgia are all common complaints. This patient’s bone pain is a common complaint which may occur with osteoporosis. Osteoporosis occurs due to excess PTH causing bone resorption (osteoclasts are stimulated). This patient also has a kidney stone in the left loin due to hypercalciuria. Other symptoms of hypercalcaemia are present including nocturia and the patient also seems to have pancreatitis. I agree, a patient in real life is unlikely to be unlucky enough to present with such a host of symptoms. The only definitive cure is a parathyroidectomy although complications of this procedure include hypocalcaemia, injury to the recurrent laryngeal nerve, bleeding and a pneumothorax.
A 40 year old hypertensive man presented with weight loss. He also admits to episodes of headaches, palpitations & sweating. Examination during one of these episodes showed sugar in the urine & a blood pressure of 240/120.
Sugar in urine in phaeo….you better believe it
Phaeochromocytomas presents with paroxysmal episodes of palpitations, anxiety, excessive sweating, pallor and hypertension. The patient may complain of headaches. It can be inherited in MEN2, von Hippel-Lindau syndrome and NF1. Diagnosis is based on raised urinary and serum catecholamines, metanephrines and normetanephrines. 24 hour urinary VMA will be elevated. CT is used to localise the tumour. Treatment includes medical with the use of phenoxybenzamine, phentolamine and surgical options. Surgical excision is carried out under alpha and beta blockade to protect against the release of catecholamines into circulation when the tumour is being manipulated. The 10% rule is often quoted: 10% are bilateral, 10% malignant, 10% extraadrenal and 10% hereditary
Loss of facial contours
Hypothyroid
A 66 year old woman presents with fatigue, breathlessness & paraesthesiae in all limbs. Examination reveals pallor, loss of position sense & impaired vibration sense.
B12 def. pallor = late presentation
An 18 year old woman is admitted with very severe abdominal pain & confusion. She is noted to have bilateral wrist drop. She had recently started the oral contraceptive pill.
3) There are many types of porphyria. This patient has acute intermittent porphyria, which is characterised by symptoms like the ones this patient describes – abdominal pain, peripheral motor neuropathy, mental symptoms like confusion. These symptoms, certainly in EMQs, can be trigged by the use of certain drugs which are known to provoke AIP attacks. In reality, the list of drugs is pretty vast and include most CYP450 inducers, but in EMQs, alcohol and the OCP are common. Alcohol also induces an enzyme called delta-aminolevulinic acid synthase, which can exacerbate AIP. It is probably not worth learning the pathways unless you plan on sitting USMLE. AIP is a genetic disorder where there is a partial deficiency of PBGD (the third enzyme in the haem biosynthetic pathway). Treatment of acute attacks involves IV haem arginate with adjunctive dextrose IV. The pain is thought to be neuropathic in origin. The patient may complain of red/browny urine due to increased urinary excretion of intermediates in the haem pathway.
A 35 year old woman has a 20 year history of infrequent episodes where she feels nauseated, with a rising feeling in her epigastrium & chest, 20 seconds later she collapses & is unconscious for up to a minute. During this she wrings her hands but is not incontinent & has never injured herself. Afterwards she feels tired for about 2 hours.
What investigation
This is a focal seizure (arises from one portion of the brain) characterised by movement of one specific part of this patient’s body consistent with localised brain activity. It is associated most often with the temporal lobe. There may be, like this case, a premonitory sensation such as in the epigastrium. EEG may show spikes or sharp waves in one temporal lobe, however, history taking is still the most important aspect of diagnosis (although admittedly can be difficult to obtain). All patients with a suspected seizure should have an EEG but it is not necessarily diagnostic. Many patients also complain of feeling tired after a seizure. An antiepileptic agent is indicated and the patient should be started off on monotherapy of a drug like carbamazepine.
A 40 year old teacher presented with a 24 hour history of occipital headache, which became worse in the evenings after work. Her school is due for an Ofsted inspection shortly. On examination she is apyrexial but looks ill and is tachycardic (120bpm)
Tension headache
Assess swallowing
Speech therapist
