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1

A 40-year-old female, rather overweight, has episodes of right upper quadrant pain and fever.

A. Hepatitis C virus infection
B. Cirrhosis
C. Portal chronic inflammation
D. Hepatitis B virus infection
E. Extensive necrosis
F. Hepatocellular carcinoma
G. Cholecystitis
H. Mallory weiss tear of oesophagus
I. Portal hypertension

G. Cholecystitis - Cholecystitis is acute GB inflammation caused by an obstruction at the cystic duct. It occurs as a major complication of gallstones and classically presents with RUQ pain and fever. Gallstones in EMQs classically involves the Fs (Fat, Forty, Female, Fertile, Fair). USS is the definitive initial investigation. HIDA scanning and MRI may help if the diagnosis remains unclear. Treatment is with cholecystectomy.

2

A 72-year-old smoker, a known arteriopath is suffering from increasing behavioural problems and forgetfulness. His family is concerned as his state is deteriorating. This is confirmed by the decline of his MMSE from 25/30 six months ago to 18/30 today.

A. Normal pressure hydrocephalus
B. Occipital Stroke
C. Multiple Sclerosis
D. Hypothyroidism
E. Vascular dementia
F. Lewy body dementia
G. Parkinson's disease
H. Pick's disease
I. Azheimer's dementia

E. Vascular dementia - Vascular dementia is a chronic and progressive dementia with loss of brain parenchyma mainly due to causes such as infarction and small vessel changes. It is classically assumed to be a stepwise progression in symptoms, although a gradual course can also be seen. This patient is an arteriopath. It is the second most common cause of dementia in older people and there is a large overlap with Alzheimer’s with many patients having a mixed form. Treatment is of limited use and the best course of action is to target vascular risk factors at as early a stage as possible.

3

A 67 year old man recovering from an inferior MI complains of sharp retrosternal chest pain. He comments that leaning forward provides relief of the pain. The attending medical student claims to have heard a “rub” on auscultation.

A. Pericarditis
B. Pulmonary embolism
C. MI
D. Hiatus hernia
E. Anxiety
F. Angina
G. Coronary artery disease
H. Oesophageal spasm
I. Tietze’s syndrome
J. Dissecting aortic aneurysm

A. Pericarditis - This patient has presented with pericarditis. Symptoms include a sharp and severe chest pain retrosternally which is worse on inspiration and when supine, relieved by sitting forwards. The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse (saddle-shaped) ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis. The prior viral infection is a risk factor with the most common pericardial infection being viral. Bacterial purulent pericarditis also occurs. The inflammation is due either to direct viral attack or immune mediated damage. Other risk factors include male gender, post-MI (both ‘early’ and Dressler’s), post-pericardiotomy syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

4

A 16 year old diabetic has been trying to lose weight. She presents at with a vomiting, postural hypotension and abdominal pain. She insists she has been taking her insulin regularly and does not use illicit drugs. Serum potassium is elevated.

A. Cushing's syndrome
B. Rhabdomyolysis
C. Drug side effect
D. Acute kidney failure
E. Addison’s disease
F. Congenital adrenal hyperplasia
G. Hyperglycaemia
H. DKA
I. Chronic kidney disease
J. Infection
K. Tumour lysis syndrome
L. Pseudohyperkalaemia

H. DKA - This is DKA. This girl is simply lying about her insulin and has been skipping insulin doses in order to lose weight. This is known as ‘diabulimia’. The main thing that needs to be corrected is the severe intravascular volume depletion and to restore tissue perfusion with IV saline. Insulin will of course also be needed. When glucose reaches 11.1mmol, fluid should be changed to 5% dextrose to prevent hypoglycaemia. Insulin should be held until potassium is at least 3.3 mmol/L (remember insulin moves potassium into cells) and a continuous infusion is recommended (with new DKA treatment guidelines, the ‘sliding scale’ is now a thing of the past). If interested, look up the latest DKA treatment guidelines for more information.

5

For each of the malignancies listed below, please select the recognised presentation from the list of options.

Gastric carcinoma

A. Hypoglycaemia
B. Erythrocytosis
C. Autoimmune haemolytic anaemia
D. Erythema ab igne
E. Troisier's sign
F. Necrolytic migratory erythema
G. Acanthosis nigricans
H. Eaton-Lambert syndrome
I. Tetany

Troisier's sign - Troisier's sign is the finding of a palpable solid lymph node located in the left supraclavicular fossa (known as Virchow's node). It is commonly associated with gastric malignancy. Although rarely present, there is always a mark for checking for this node in an abdo exam in your OSCEs!.

6

A 32-year-old male nurse from Zimbabwe came into the UK as part of an NHS recruitment campaign. He presents with SOB, weight loss, general debility, cervical lymphadenopathy and purple tender lesions on his shin of 6 weeks duration.

A. Full blood count and ESR
B. Abdominal CT
C. HIV antibody test
D. Colonoscopy
E. Blood test for auto-antibodies
F. Thyroid function tests
G. Bronchoscopy
H. Fasting blood glucose
I. Chest x-ray
J. Bone marrow aspirate
K. History only
L. Gastroscopy
M. Brain scan

I. Chest x-ray -Sarcoidosis is a chronic multisystem disease with an unknown aetiology with the lungs most commonly affected (giving SOB in this case). The purple lesions are erythema nodosum and are tender erythematous nodules. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.

7

A 50 year old man became suddenly breathless whilst eating. He has marked stridor & is choking & drooling.

A. Heimlich manoeuvre
B. Forced alkaline diuresis
C. Intravenous furosemide
D. Rapid infusion of saline
E. Nebulised salbutamol
F. Intravenous aminophylline
G. Re-breathing into paper bag
H. Pleural aspiration
I. Chest drain
J. Intravenous adrenaline
K. Heparin
L. Intravenous insulin

A. Heimlich manoeuvre - This patient has choked on some food. The patient should be encouraged to cough if they are conscious. Otherwise, external manoevres can be performed such as abdominal thrusts (Heimlich) or back blows. These actions increase intrathoracic pressure and help to dislodge the foreign body. If it still isn’t removed, a flexible bronchoscopy may be necessary. Most cases occur in very young children.

8

A 91 year old man is referred to you by the urologists. He has an abdominal aortic aneurysm on examination and on ultrasound, an 8.8 cm infra-renal aneurysm is identified. He multiple co-morbidities but is given the green light for treatment to take place.

A. Angioplasty
B. Femoral-distal bypass
C. Aortobifemoral bypass
D. Methyldopa
E. Ultrasound
F. Alpha blocker
G. Embolectomy
H. Endarterectomy
I. Angiography
J. Endovascular aneurysm repair
K. Open repair of aneurysm

J. Endovascular aneurysm repair - Incidental finding of a large AAA requires elective surgical repair (exceeding 5.5cm in men, 5cm in women – repair of aneuryms greater or equal to 5.5cm offers a survival advantage). Additionally, rapid increase in size is also an indication for elective repair. Young and healthy patients, particularly women, may benefit from early repair of smaller AAAs. (>5cm). Data suggests EVAR is equivalent to open repair in terms of overall survival but there is a higher rate of secondary interventions with EVAR. Therefore younger and healthier patients may benefit more from open repair. Patient 1 is however is elderly and has co-morbidities. An EVAR is the best way forward here. However note also that EVAR could entail a complication of endovascular repair leak, which would require corrective treatment. Endoleak is persistent blood flow outside the graft and within the aneurysm sac. There is 24% risk after EVAR. However, this is not a complication of open repair, which is probably preferred in most cases in those who are fit and healthy enough to have it such as Patient 4. Management of this complication would depend on the type of endoleak.

9

A 28 year old female medical student returns from her elective in Africa with a short history of severe lower abdominal cramps & the passage of bloody diarrhoea.

A. Infective colitis
B. Haemorrhoids
C. Anal fissure
D. Colonic carcinoma
E. Anal carcinoma
F. Crohn’s disease
G. Ulcerative colitis
H. Colonic polyp
I. Diverticular disease
J. Ischaemic colitis

A Infective collitis - This patient has recent foreign travel and a short history, previously normal, making infectious diarrhoea very likely. Probably eaten something dodgy while on elective. Think of the organisms which cause bloody diarrhoea such as EHEC. E coli is the most common cause of traveller’s diarrhoea. There may be a contact history due to faecal-oral spread. The mainstay of treatment is rehydration and supportive therapy. Antibiotics may be indicated, particularly in severe ETEC.

10

A woman has a lumpy swelling over the front of her neck and has been complaining of difficulty swallowing. She is euthyroid.

A. Grave's disease
B. Hashimoto's thyroiditis
C. Papillary carcinoma
D. De Quervain's thyroiditis
E. Follicular carcinoma
F. solitary toxic adenoma
G. Multinodular goitre
H. medullary cell carcinoma

G. Multinodular goitre - Lumpy swelling and euthyroid (or borderline hyper- suppressed TSH with normal T4/T3) you would think multinodular goitre. She has no cancer B symptoms or infective history. These goitres are major causes of thoracic inlet obstruction and can also involve the laryngeal nerve causing hoarseness..a symptom that would also make you worry about infiltrative carcinoma. After palaption, ultrasound of the thyroid accompanied by Fine needle aspirate can be useful to check there are no malignant changes within the multinodular goitre. (worrying USS findings may be calcification of cysts - the so called 'halo' sign)

11

A 22-year-old woman, on treatment for nephrotic syndrome due to minimal change glomerulonephritis. She is concerned by increasing weight gain and easy bruising. Blood tests show plasma creatinine 65 μmol/L and albumin 31 g/L.

A. Addison’s disease
B. Cushing's syndrome
C. Pregnancy
D. Salt-wasting nephropathy
E. Heart failure
F. Metabolic syndrome
G. Comfort eating
H. Renal failure
I. Reduced activity
J. Portal hypertension
K. Polycystic ovary syndrome
L. Amyloidosis
M. Hypothyroidism

B. Cushing's syndrome - Corticosteroids remain the mainstay of treatment for minimal change disease and is given to all patients. Minimal change disease is the most common form of nephrotic syndrome in children and it is so named as there are minimal histological changes in renal tissue. 90% are idiopathic. Long term coricosteroid treatment here has induced iatrogenic Cushing’s syndrome with associated signs of hypercorticalism (weight gain and easy bruising). Corticosteroid-sparing therapies can be added here.

12

A 22-year-old who takes the combined oral contraceptive has become very scared because she found a lump in her left breast last night. She does not think it was there last month. You find a discrete slightly irregular painless, firm one-cm diameter lump that is quite mobile. There is no lymphadenopathy.

A. Basal cell carcinoma
B. Adenoma
C. Sebaceous cyst
D. Fat necrosis
E. Carcinoma of the breast
F. Intraductal papilloma
G. Lipoma
H. Radial scar
I. Breast bud
J. Fibroadenosis
K. Phylloides tumour
L. Breast abscess
M. Fibroadenoma

M. Fibroadenoma - This sounds like a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient

13

John is a 35 year old tennis player who complains of breathlessness after games. His sleep has been disturbed recently by coughing during the night. On examination he was a tall, thin but athletic looking young man. There were high-pitched expiratory wheeze in both lungs.

A. Atypical pneumonia
B. Bronchial carcinoma
C. Pleural effusion
D. Sarcoidosis
E. Fibrosing alveolitis
F. Pneumothorax
G. Lung abscess
H. Bronchiectasis
I. Bronchial asthma
J. COPD
K. Cystic fibrosis

I. Bronchial asthma - This patient has developed a primary pneumothorax. Primary pneumothoraces occur in young people without known lung conditions. The main investigation is a CXR and pneumothoraces are classified by the BTS as large (>2cm visible rim between the lung margin and the chest wall) or small (

14

Match the cause of hypotension to the following case histories. Each option may be used once, more than once or not at all.

22 year old man presented with vomiting. He had not been feeling himself for some weeks. On examination, the skin creases of his hands were dark. Blood results showed plasma urea 8.5mmol/l, sodium 121mmol/l & potassium 5.1mmol/l.

A. Addison’s disease
B. Arrhythmia
C. Drug induced
D. Volume depletion
E. Autonomic neuropathy
F. Pulmonary embolus
G. Blood loss
H. Septicaemia
I. Cardiogenic shock

A. Addison's disease - Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s.

15

A 25 year old woman with fatigue & weight loss. She gives a history of frequent loose stools with abdominal pain. Full blood count revealed iron deficiency anaemia.

A. Renal failure
B. HIV
C. Tuberculosis
D. Depression
E. Malabsorption
F. Addison's disease
G. Hyperthyroidism
H. Diabetes mellitus
I. Liver failure
J. Malignancy
K. EBV
L. Anorexia nervosa
M. Cardiac failure

E. Malabsorption - There is frequent loose stools here and abdominal pain. Combined with the IDA, this points to malabsorption. This could well be a presentation of coeliac disease – IDA is one of the most common clinical presentations and abdominal pain and diarrhoea are common. Coeliac disease is a systemic autoimmune condition triggered by dietary gluten peptides found in grains. It is a relatively common condition. The only treatment is a strict gluten-free diet for life.

16

An 18 year old student has just returned from holiday in Africa. He is jaundiced and has moderate hepatomegaly. His blood tests reveal increased serum transaminases and elevated bilirubin. He also has specific IgM antibodies.

A. Dubin-Johnson syndrome
B. Hepatitis C
C. Malaria
D. Gall stones
E. Gilbert's syndrome
F. Crigler-Najjar syndrome
G. Hepatitis B
H. Hepatitis A
I. Carcinoma of head of the pancreas
J. Primary sclerosing cholangitis
K. Primary biliary cirrhosis
L. Cholangiocarcinoma
M. Sickle cell anaemia

H. Hepatitis A - IgM anti-hepatitis A virus is positive here which is highly sensitive and specific combined with the typical symptoms this student displays. IgM antibodies are detectable typically 5-10 days before symptom onset and remain raised for 4-6 months. It can be ordered alongside IgG anti-HAV and is a cheap and simple test. IgG rises soon after IgM and stays elevated for life so a positive IgG can mean prior infection or recent disease. Again, a cheap and simple to carry out test.
Hepatitis A is primarily transmitted via the faecal-oral route. After the virus is consumed and absorbed, it replicates in the liver and is excreted in the bile (to be re-transmitted). Transmission usually precedes symptoms by about 2 weeks and patients are non-infectious 1 week after onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, homosexual sex or a known food-borne outbreak. This is classically, in EMQs, associated with shellfish which is harvested from sewage contaminated water. If the patient has other liver diseases such as HBV or HCV or cirrhosis then there is a higher risk of fulminant HAV infection. The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdominal pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that may be found include splenomegaly, RUQ tenderness and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. When jaundice comes on, the pre-icteric phase symptoms usually diminish, and jaundice typically peaks at 2 weeks. However, a fulminant course runs in

17

A 45-year-old man wakes in the night with severe pain in his right flank radiating round to the front and into his groin. He can’t get comfortable, but on examination his abdomen is soft with no masses. His urine shows a trace of blood but no other abnormality.

A. Cystoscopy
B. Abdominal ultrasound
C. Prostatic specific antigen blood test
D. MSU: microscopy and culture
E. X-ray lumbar spine
F. ASO titre blood test
G. Helical CT
H. 24 hour urine monitoring
I. Biopsy of prostate
J. Retrograde pyelogram

G. Helical CT - This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.

18

A 70 year old diabetic man, who smoked 40 cigs/day for 40 years. He presents with abdominal pain worse at night & radiating to his back. He is losing weight, suffers from dyspepsia & pruritus. On examination he is cachectic, jaundiced & has an enlarged gallbladder.

A. Reflux oesophagitis
B. Cancer of the liver
C. Hiatus hernia
D. Cancer of the pancreas
E. Gastric ulcer
F. Liver cirrhosis
G. Irritable bowel syndrome
H. Coeliac’s disease
I. Carcinoma of oesophagus
J. Duodenal ulcer
K. Inflammatory bowel disease
L. Chronic hepatitis
M. Primary biliary cirrhosis
N. Pancreatitis

D. Cancer of the pancreas - Pancreatic cancer typically presents with painless obstructive jaundice and weight loss and generally presents late. It can however, like this case, present with abdominal pain which is typically non-specific in the upper abdomen. If the patient presents with persistent back pain, then this symptom is consistent with retroperitoneal metastases. It is estimated that 1 in 4 cases can be linked to smoking. Whipple’s procedure or Traverso-Longmire procedure (pancreaticoduodenectomy) offers the only hope of a cure but only a small minority are elegible for these procedures. The first tests to order are an abdominal USS and LFTs. Note Courvoisier’s law with regard to this question: Jaundice and a palpable painless gallbladder is unlikely to be caused by gallstones. The tumour marker for pancreatic cancer is CA19-9 which is useful in preoperative staging.

19

A 25-year-old woman with fatigue and weight loss. She gives a history of frequent loose stools with abdominal pain. Full blood count revealed iron deficiency anaemia.

A. Malignancy
B. Anorexia nervosa
C. Tuberculosis
D. Addison's disease
E. Malabsorption
F. Infestation with helminths
G. Cardiac failure
H. Diabetes mellitus
I. Hyperthyroidism
J. Renal failure
K. Liver failure
L. Depression
M. HIV

E. Malabsorption - There is frequent loose stools here and abdominal pain. Combined with the IDA, this points to malabsorption. This could well be a presentation of coeliac disease – IDA is one of the most common clinical presentations and abdominal pain and diarrhoea are common. Coeliac disease is a systemic autoimmune condition triggered by dietary gluten peptides found in grains. It is a relatively common condition. The only treatment is a strict gluten-free diet for life.

20

A 10 year old boy presents with stridor. He reports three episodes of face and tongue swelling, each of which prompted him to report to A&E. There are also red, raised and itchy lesions that cover his body, including face. His sister also suffers from similar attacks.

A. Kawasaki disease
B. Myocarditis
C. Juvenile idiopathic arthritis
D. Primary pulmonary hypertension
E. Aortic stenosis
F. Hereditary angio-oedema
G. Pericarditis
H. Congestive cardiac failure
I. Toxic synovitis
J. Acute rheumatic fever
K. Congenital nephritic disease

F. Hereditary angio-oedema - This patient has urticaria (erythematous, blanching, oedematous, pruritic lesions) and angio-oedema (swelling). A positive family history of angio-oedema raises a suspicion for a diagnosis of hereditary angio-oedema. There are two forms of this condition. One is manifest by absence of C1 esterase inhibitor whereas the other is due to normal levels of dysfunctional C1 esterase inhibitor. This allows the uncontrolled activation of the complement cascade which therefore gives rise to angio-oedema. This is a condition which is inherited in an autosomal dominant manner although it should be noted that some 50% of cases have no previous FH and are thought to be due to new mutations. Laboratory investigations may reveal a decreased level of C1 and decreased levels or function of C1 esterase which would support the diagnosis. In acquired angio-oedema, C1q levels are low unlike in the hereditary form where it is normal – this differentiates the two forms. The mainstay of treatment is with antihistamines. Airway compromise like the stridor this patient is experiencing is an indication for prompt treatment with adrenaline. The stridor here is a sign of severe laryngeal angio-oedema, which is a sign of impending airway obstruction – this needs to be taken seriously and is an emergency.

21

John is a 20 year old man with breathlessness and chest pain after exertion. 5 days ago he developed palpitations & fainted during a game of squash. Examination revealed a jerky pulse and a systolic murmur. His ECG showed changes of left ventricular hypertrophy.

A. Pericarditis
B. Angina
C. VSD
D. Romano-Ward syndrome
E. Infective endocarditis
F. HOCM (hypertrophic obstructive cardiomyopathy)
G. ASD
H. Congestive cardiac failure
I. MI
J. Left ventricular failure

F. HOCM - This patient has HOCM. The patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina). HOCM is the most likely cardiomyopathy and the most frequent cause of sudden cardiac death in younger people. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion (playing squash) is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance and there may be a FH of sudden death. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. The arterial pulse is described as ‘jerky’. A fourth heart sound may also be heard due to hypertrophy. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echocardiography will show septal hypertrophy. There may also be MR.

22

A 20 year old man with recurrent episodes of chest infection & diarrhoea, which is difficult to flush away in the toilet. He developed a persistent cough with the production of sputum & blood. On examination his fingers are clubbed & in his chest there are low pitched inspiratory & expiratory crackles, plus some wheeze. He recalls being small for his age despite having a healthy appetite.

A. Atypical pneumonia
B. Bronchial carcinoma
C. Pleural effusion
D. Sarcoidosis
E. Fibrosing alveolitis
F. Pneumothorax
G. Lung abscess
H. Bronchiectasis
I. Bronchial asthma
J. COPD
K. Cystic fibrosis

K. Cystic fibrosis - CF is autosomal recessive and the mean age of death is around 40. There is currently no cure for this condition. The reccurent chest infections and greasy stools (fat malabsorption due to pancreatic insufficiency) should make you think of CF. A persistent cough which is productive should also raise suspicions. Examination findings here which raise your suspicion include clubbing and crackles on auscultation. Additionally, you may find nasal polyps and hepatomegaly and/or splenomegaly and a congenital absence of the vas deferens in males. There is also some failure to thrive with the patient being small for his age. The most conclusive diagnostic test is the sweat test which is positive if sweat chloride is >60mmol/L. Serum IRT from a heel prick blood spot allows screening of newborns. CF is a genetic condition with abnormal salt and water transport due to mutations in the CFTR (an apical anion channel). Heterozygotes generally do not demonstrate disease.

23

A young adult with a 2 day history of left sided pleuritic chest pain, fever and cough productive of rusty coloured sputum. A CXR was obtained which showed left lower lobe shadowing suggestive of consolidation. On agar the sputum grew gram +ve cocci which demonstrated alpha-haemolysis.

A. Klebsiella pneumoniae
B. Streptoccus pyogenes
C. Enterococcus faecium
D. Streptococcus pneumoniae
E. Escherichia coli
F. Chlamydophila psittaci
G. Shigella
H. Salmonella paratyphi
I. Salmonella typhi
J. Streptoccocus viridans
K. Salmonella typhimurium
L. Chlamydia trachomatis

F. Streptococcus pneumoniae - Classic lobar pneumonia with no signs and symptoms to suggest an atypical organism is most likely to due to pneumococcus. Streptococcus pneumoniae is, as mentioned in the question, an alpha haemolytic Gram positive cocci (also Streptococcus viridans but it does not present in this way). A CXR is the most specific and sensitive test available and antibiotics are indicated. The rusty coloured sputum is hinting at a pneumococcal pneumonia too.The patient has presented with common symptoms of fever and a productive cough. There is additionally pleuritic chest pain. Initial treatment of a CAP is empirical with antibiotics. Often diagnosis is made solely on history and examination findings. Management is guided by the patient’s CURB-65 score.

24

A 55 year old lawyer who has had a chronic cough for 3 months complains of 1 episode of haemoptysis. She is a heavy smoker (about 40/day) & has experienced some recent weight loss.

A. Sputum cultures
B. Bronchoscopy
C. History only
D. D-dimer
E. CTPA
F. Chest x-ray
G. MRA
H. Lung function tests
I. ABG
J. Clotting screen
K. V/Q scan
L. CT head

B. Bronchoscopy - This sounds like bronchial carcinoma from the history of smoking, respiratory complaints and weight loss. Initial investigation of bronchial carcinoma is with a CXR but definitive diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. During bronchoscopy, endobronchial masses can be biopsied and washings/alveolar lavage can also be performed for cytological analysis. Trans-thoracic needle aspiration may be needed for peripheral lesions that cannot be reached by bronchoscopy. First line treatment aims at surgical resection if possible.

25

A 38-year-old woman with known polycystic kidney disease suddenly develops a severe occipital headache. She vomited and then lost consciousness.

A. Wernicke's encephalopathy
B. Normal pressure hydrocephalus
C. Subarachnoid haemorrhage
D. Subdural haemorrhage
E. Extradural haemorrhage
F. Hepatic failure
G. Alcohol withdrawal
H. Stroke
I. Encephalitis
J. Dementia
K. Drug overdose
L. Meningitis

D. Subarachnoid haemorrhage - SAH (bleeding into the subarachnoid space) presents with sudden severe headache patients will often describe as the worst headache of their life, and can often be so bad that they feel like they’ve been kicked in the back of the back. Half of all patients lose consciousness and eye pain with exposure to light can also be seen. Altered mental status is common. SAH occurs most commonly in the 50-55 age group and affects women and black people more than men and white people. The most common cause of non-traumatic SAH is an aneurysm which ruptures. Conditions which predispose to aneurysm formation and SAH include adult PKD, Marfan’s, NF1 and Ehlers-Danlos. Cerebral aneurysms arise around the circle of Willis. A CT scan is indicated, and if unrevealing, this should be followed by an LP. Cerebral angiography can confirm the presence of aneurysms. The patient should be stabilised and this followed by surgical clipping or endovascular coil embolisation, the choice is subject to much current controversy sparked by relatively recent research. Complications can commonly occur and include rebleeding, hydrocephalus and vasospasm.

26

A 58-year-old man, who smoked 30 cigarettes a day, presents with a 6-week history of cough, malaise, anorexia and weight loss. Past medical history includes hypertension for which he has taken lisinopril and bendrofluazide for 4 years.

A. Oesophageal reflux
B. COPD
C. Asthma
D. Bronchiectasis
E. Carcinoma of bronchus
F. Sarcoidosis
G. ACE inhibitor
H. Postnasal drip
I. Tuberculosis
J. Foreign body

E. Carcinoma of the bronchus - The history of smoking and weight loss point to a bronchial carcinoma. Initial investigation is with a CXR. Diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is 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.

27

True or False, acromegaly can be associated with a bitemporal hemianopia.

True - Pituitary tumours and craniopharyngiomas can compress the optic chiasm, sparing the outer fibres responsible for the nasal field. This causes the characteristic bitemporal hemianopia.

28

For each patient below, choose the SINGLE most useful investigation from the above list of options. Each option may be used once, more than once or not at all.

A 55 year old obese female complains of a 6 month history of chest pain which radiated to the jaw and both shoulders. The pain is reported to be more severe at night. ECG and chest x-rays are normal.

A. Upper GI endoscopy
B. Thoracic spine x-ray
C. ECG
D. Coronary angiogram
E. Transthoracic echo
F. CT scan abdomen
G. Chest x-ray
H. Chest x-ray in expiration
I. Barium swallow
J. Chest x-ray rib views
K. V/Q scan
L. Exercise ECG
M. CPK (creatine phosphokinase)

A. Upper GI endoscopy - This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and can also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett’s or cancer, or for atypical features. An OGD may show oesophagitis or Barrett’s (red velvety), however OGD may be normal. Manometry and pH monitoring may also be performed, but in this case, this patient will probably just have a therapeutic and diagnostic trial of a PPI instead of an OGD.

29

A 55 year old woman is admitted drowsy with slurred speech. You notice yellowing of the sclera and fetor hepaticus.

A. Wernicke's encephalopathy
B. Normal pressure hydrocephalus
C. Subarachnoid haemorrhage
D. Subdural haemorrhage
E. Extradural haemorrhage
F. Hepatic failure
G. Alcohol withdrawal
H. Stroke
I. Encephalitis
J. Dementia
K. Drug overdose
L. Meningitis

F. Hepatic failure - This patient has decompensated chronic liver disease (he is in liver failure) which has resulted in neurological symptoms associated with hepatic encephalopathy. The brain is exposed to ammonia which bypasses the liver by portosystemic shunting. It is a diagnosis of exclusion and tests will need to be conducted to rule out other potential causes of confusion. The findings of jaundice and fetor hepaticus (liver failure) are signs of liver disease. Think about the other signs you might see like spider naevi and palmar erythema. This patient may also have asterixis which is a coarse flapping tremor. HE is likely caused by a host of factors. This patient’s LFTs will be abnormal and she is likely to have coagulopathy too (PT will be elevated).

30

A 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually.

A. Sebaceous cyst
B. Fibroadenoma
C. Fibroadenosis
D. Gynaecomastia
E. Breast abscess
F. Carcinoma of the breast
G. Breast cyst
H. Lipoma
I. Duct ectasia

C. Fibroadenosis - Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.