Revision 1 Flashcards by Sam Quesne

An observational study of 60 children over a 4 year period used multiple linear regression to adjust for 60 separate potential confounders to examine the relationship between MMR vaccination and autism.

What would be your principal statistical concern regarding the design of this study?

A. The study is likely to be appropriately adjusted
B. The study is likely to be overadjusted
C. The study is likely to be overpowered
D. The study is likely to be underadjusted

B. The study is likely to be overadjusted

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A junior researcher is planning an observational study that looks at the difference in length of stay between patients who have an elective hip replacement performed either under general or local anaesthetic, hypothesising that patients who have a local anaesthetic will be discharged sooner.

He proposes to look at 100 consecutive patients admitted to the Orthopaedic ward and follow them up prospectively. His supervisor suggests that he should first conduct a sample size calculation, before deciding how many to follow up.

Why is it important to do this?

A. To adequately control for the effect of any underestimation of effect size that might be the result of a shortfall in your sample size from the optimum
B. To ensure that your study is large enough to have a good chance of detecting any effect you hope to see
C. To estimate the effect size that you might see
D. To satisfy grant reviewers if you want to apply for funds to conduct this research

B. To ensure that your study is large enough to have a good chance of detecting any effect you hope to see

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You are designing a project comparing different techniques for measuring lactic acid levels in runners. Because your project will involve recruiting members of a local running club and subjecting project participants to invasive physiological tests, you apply for ethical approval from the local Ethics Committee.

Whilst you are waiting for this, new research comes to light that makes you reconsider your original hypothesis. In order to test your new theory, you will need to recruit more participants and let them know that a further invasive measurement will be required.

What can you change without seeking further approval (a so-called ‘amendment’) from the Research Ethics Committee?

A. Add an additional invasive measurement to the data you want to collect
B. Change the content of the participant information leaflet
C. Change your original hypothesis
D. Recruit additional participants

C. Change your original hypothesis

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A newspaper reported a study as follows:

“drinking red wine halves your risk of diabetes”.

The study followed up 400 people over a 10 year period, half of whom (n=200) drank red wine 3 times per week, and half (n=200) drank none.

The odds of diabetes for those in the red wine group was 0.05 and for those who drank none was 0.11, giving an odds ratio of 0.45 with a 95% confidence interval of (0.19, 1.18).

What conclusion you can draw from the results?

A. That you can be confident that there is no difference in risk of diabetes between those who do or don’t drink red wine
B. That you can be confident that those who drink red wine have an increased risk of diabetes compared to those who don’t
C. That you can be confident that those who drink red wine have a reduced risk of diabetes compared to those who don’t
D. That you cannot be confident there is any difference in risk of diabetes between those who do and don’t drink red wine

D. That you cannot be confident there is any difference in risk of diabetes between those who do and don’t drink red wine

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A 42 year old man is admitted for aortic valve replacement. He has a congenital bicuspid aortic valve which has become stenosed.

What is his preoperative ECG likely to show?

A. Atrial fibrillation
B. Left ventricular dilatation
C. Left ventricular hypertrophy
D. Right bundle branch block

C. Left ventricular hypertrophy

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A 24 year old woman presents with a six month history of diarrhoea and mouth ulcers.

On examination there is a mass in the right iliac fossa.

What is the most likely diagnosis?

A. Caecal carcinoma
B. Coeliac disease
C. Crohn’s disease
D. Ulcerative colitis

C. Crohn’s disease

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In concluding a consultation, the doctor explains to the patient which warning signs to look out for with their specific illness and what to do if there is an unexpected turn of events.

What is this known as?

A. Communicating risk
B. Handing over
C. House-keeping
D. Safety-netting

D. Safety-netting

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NICE recommends treating patients with established cardiovascular disease with statins.

What is the mode of action of statin medication?

A. It binds to cholesterol in the duodenum and prevents its absorption
B. It increases the ratio of LDL to HDL cholesterol in the bloodstream
C. It inhibits HMG Co-A reductase, an enzyme in the cholesterol synthesis pathway
D. It promotes the excretion of cholesterol via bile salt excretion

C. It inhibits HMG Co-A reductase, an enzyme in the cholesterol synthesis pathway

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A 49 year old woman is referred to the Neurology clinic with a 6 month history of increasing unsteadiness and recurrent falls.

On examination she is noted to have slurred speech, a wide gait and poor heel-shin coordination.

What is the most likely underlying pathological process?

A. Amyloid plaque formation
B. Demyelination
C. Dopamine depletion
D. Loss of anterior horn cells

B. Demyelination

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An 83 year old man has been admitted following a stroke. A CT scan in the Emergency Department confirmed a left middle cerebral artery occlusion causing a total anterior circulation infarct. You are assessing him on admission to the ward an hour after his stroke.

What are the most likely neurological examination findings?

A. Dysphasia, left sided face and arm weakness
B. Dysphasia, right sided arm and leg weakness
C. No dysphasia, left sided arm and leg weakness
D. No dysphasia, right sided arm weakness

B. Dysphasia, right sided arm and leg weakness

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A 33 year old woman had emergency surgery for a perforated appendix 2 days ago. She has Type I diabetes for which she is on insulin, and CKD stage 3.

You get called by the ward because her urine output has decreased over the last 12 hours.

On reviewing her blood tests you observe the following:

Urea 18.6 (up from 8.4; normal 2.5-7.8 mmol/L)
Creat 231 (up from 102; normal <90umol/L)

What other abnormal blood result is consistent with these findings?

A. Hyperbilirubinaemia
B. Hypercalcaemia
C. Hyperkalaemia
D. Hypernatraemia

C. Hyperkalaemia

Consistent with AKI.

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A 17 year old woman presents with a mid-line swelling in her neck. A 2cm lump is easily palpable just above the hyoid bone. When the patient swallows it moves upwards.

What is the most likely diagnosis?

A. Branchial cyst
B. Congenital haemangioma
C. Reactive lymph node
D. Thyroglossal cyst

D. Thyroglossal cyst

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A 37 year old man develops severe colicky pain in his left flank, lasting several hours. He does not seek medical help at the time.

Two days later he notices that he passes a small stone on urinating.

What is the most likely chemical composition of the stone?

A. calcium bicarbonate
B. calcium oxalate
C. uric acid
D. xanthine

B. calcium oxalate

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A 34 year old woman is brought to the Emergency Department by friends. For the last few weeks she has felt ‘under the weather’ and has been losing weight. This morning she was found collapsed in the living room.

In the Emergency Department her blood sugar is recorded as 27.3 mmol/L and there are ketones +++ in her urine. Her mother had diabetes.

Which factor in the history and assessment will help you decide whether she should start treatment with insulin or oral hypoglycaemics?

A. Age at presentation
B. Family history of diabetes
C. Presence of ketosis on admission
D. Severity of hyperglycaemia

C. Presence of ketosis on admission

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A 65 year old man with a history of hypertension is admitted with central chest pain. He is brought in to the Emergency Department where he has an ECG which shows deep T wave inversion in leads I, aVL, V5 and V6 without changes in other leads.

A troponin I level at 12 hours is 4356 ng/L (normal <50ng/L).

What is the most likely diagnosis?

A. Inferior non-ST elevation myocardial infarct
B. Inferior ST elevation myocardial infarct
C. Lateral non-ST elevation myocardial infarct
D. Lateral ST elevation myocardial infarct

C. Lateral non-ST elevation myocardial infarct

Lateral: I, aVL, V5, V6
Inferior: II, III, aVF
Septal: V1-V2
Anterior: V3-V4

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A 45 year old man with schizophrenia fractures his tibia and fibula while playing football. The Orthopaedic surgeon who sees him decides that he needs an operation to fix the broken bones but he refuses. A Psychiatrist assesses him and decides that he has the capacity to refuse an operation.

What is the next step to take?

A. Apply to the Court of Protection to allow treatment to proceed
B. Detain and treat the patient under the Mental Health Act
C. Respect the patient’s wish to refuse an operation
D. Treat him under the Mental Capacity Act in his best interests

C. Respect the patient’s wish to refuse an operation

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Within general practice in the UK, recurrent sore throat has an incidence of 100 per 1,000 of the population. In this context a GP is likely to use pattern recognition as a means of reaching a clinical decision.

Which aspect of the pattern recognition model makes this the most appropriate diagnostic method?

A. Requires more conscious effort
B. Based on explicit rules
C. Use of heuristics
D. Slow and deliberate

C. Use of heuristics

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An 83 year old woman recently saw her GP regarding ankle swelling, and is given a prescription for this. Three weeks later she returns complaining of general lethargy. She has blood tests taken which show the following (normal range in brackets):

Na 143 mmol/L (135-145)
K 6.4 mmol/L (3.5-5.1)
Urea 9.2 mmol/L (2.5-7.8)
Creat 110 umol/L (45-90)

Which medication did the GP prescribe her on her first visit?

A. Amiloride
B. Bendroflumethiazide
C. Bumetanide
D. Furosemide

A. Amiloride

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A 23 year old woman presents to the Emergency Department 3 days after an attempted overdose with paracetamol. Her mother becomes concerned because she notices that she has turned yellow.

Which pattern of liver function tests is most likely to be seen?

A. Alanine aminotransferase normal, alkaline phosphatase raised, normal INR
B. Alanine aminotransferase normal, alkaline phosphatase normal, raised INR
C. Alanine aminotransferase raised, alkaline phosphatase normal, normal INR
D. Alanine aminotransferase raised, alkaline phosphatase normal, raised INR

D. Alanine aminotransferase raised, alkaline phosphatase normal, raised INR

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Acutely breathless hypercapnic respiratory failure patients may still require Oxygen therapy.

What target range for SaO2 does the British Thoracic Society recommend for these patients?

A. 84 - 88%
B. 88 - 92%
C. 90 - 94%
D. 94 - 98%

B. 88 - 92%

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An 81 year old man is admitted to hospital with increasing breathlessness and a cough. He has a history of atrial fibrillation and stroke and takes warfarin. He is allergic to penicillin.
His chest X-ray shows right lower lobe consolidation and he is prescribed levofloxacin.

What effect will this have on his INR (international normalised ratio)?

A. The effect on the INR cannot be predicted
B. The INR will decrease
C. The INR will increase
D. There will be no effect on the INR

C. The INR will increase

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A 76 year old woman slips on the ice and fractures her left ankle. She is placed in a plaster cast which starts below the knee and ends at her toes.

After 6 weeks the plaster is removed. She is unable to dorsiflex her left foot when walking and she has to lift her knee to stop her toes catching on the ground.

Which nerve has been damaged?

A. Common peroneal nerve
B. Femoral nerve
C. Sciatic nerve
D. Tibial nerve

A. Common peroneal nerve

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A 72 year old woman is admitted with acute kidney injury as a result of profuse diarrhoea and vomiting. In the Emergency Department arterial blood gases are taken.

The results are as follows (normal values in brackets):

pH 7.26 (7.34-7.44)
pO2 11.6 KPa (11-13KPa)
pCO2 4.9 KPa (4.7-6.0KPa)
Bicarbonate 15 mmol/L (22-26 mmol/L).

Two days later, her kidney function remains poor. However, her blood gases are repeated and her pH is now 7.39.

By what mechanism has the body corrected the acidosis?

A. Decreased renal reabsorption of bicarbonate
B. Hyperventilation
C. Increased arterial blood PCO2
D. Increased renal excretion of H+ ions

B. Hyperventilation

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A 42 year old woman presents to her GP with sore eyes for several months. Her vision is normal, but her eyes feel gritty and burning, especially after she has been staring at the computer or concentrating on marking.

On examination she has mildly red eyelids and a small chalazion on the left lower lid.

What management would you recommend?

A. Chloramphenicol ointment regularly for 1 week
B. Hot compresses and eyelid cleaning regularly for 2 weeks
C. Hot compresses and eyelid cleaning regularly indefinitely plus simple eye lubricants
D. Simple lubricant eye drops as required

C. Hot compresses and eyelid cleaning regularly indefinitely plus simple eye lubricants

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A 79 year old man is assessed in the Emergency department following a fall which he sustained walking in his home to make a cup of tea. He has a past history of Hypertension and Parkinson’s disease. The Emergency department Doctor examines him and feels there is no significant injury. On assessment of his mobility, what is the doctor likely to observe? A. Difficulty rising from out of a chair with a waddling gait pattern B. Grimacing on standing with an antalgic gait pattern C. Slowness in rising from the chair with a shuffling gait pattern D. Wide based gait pattern with high stepping

C. Slowness in rising from the chair with a shuffling gait pattern

A 19 year student presents with a short history of sore throat and fever, together with a non-productive cough. On examination of the throat there is an intense faucial injection and her anterior cervical lymph nodes are enlarged. Her flatmate has also recently suffered from similar symptoms. Which of her symptoms or signs make this more likely to be a bacterial rather than viral infection? A. Contact with another patient with similar symptoms B. Enlargement of the anterior cervical lymph nodes C. Intense faucial injection D. Presence of a cough

B. Enlargement of the anterior cervical lymph nodes

A 74 year old male ex-smoker is referred to Respiratory Outpatients because of persistent breathlessness and cough. On examination he is noted to have cyanosis and finger clubbing as well as scattered crepitations in his chest. A provisional diagnosis of bronchial carcinoma is made. Which symptom or sign is most supportive of the diagnosis of bronchial carcinoma? A. Cyanosis B. Finger clubbing C. Persistent cough D. Scattered crepitations

B. Finger clubbing

A 40 year old man tells you that he is divorcing his wife because she has been systematically violent to him over the 15 year of their marriage. He asks for a letter of support to access legal aid. Two months later he comes to see you again and asks for the previous consultation to be removed. The couple are reconciled and he now tells you he made the story up so that his wife would look bad. What is the correct action to take? A. Agree to the request as the couple have now reconciled and the notes entry may jeopardise things in the future B. Ask him to bring his wife along to the next consultation so that you can all discuss the issue C. Explain that you cannot alter the notes but that you can add this new information to clarify things D. Explain that you must inform the police domestic violence unit as either she is violent or he is controlling, or both

C. Explain that you cannot alter the notes but that you can add this new information to clarify things

A 45 year old Black Nigerian man is newly diagnosed with hypertension. What class of drug is recommended as first-line treatment by NICE Guidelines? A. Angiotensin Converting Enzyme Inhibitors B. β-Blockers C. Calcium Channel Blockers D. Thiazide Diuretics

C. Calcium Channel Blockers

A 36 year old man with a 20 year history of Crohn’s disease is seen in out-patients with worsening tiredness and poor appetite. He had an ileostomy performed 3 years ago and is on omeprazole for recurrent stomach ulceration. A full blood count is as follows (normal range in brackets): ``` Hb 81 (115-160g/L) WCC 5.6 (4-11 x109/L) Plt 380 (150-400 x109/L) MCV 107 (78-100 fL) ``` His B12 level is found to be low. How has this happened? A. Consumption of B12 by overgrowth of bacteria in the small bowel B. Failure to absorb B12 in the terminal ileum C. Poor dietary intake of B12 D. Proton pump inhibition of parietal cells leading to loss of intrinsic factor

B. Failure to absorb B12 in the terminal ileum

A 30 year old man with no significant past medical history presents with a 6 week history of increasing frequent and severe but intermittent headache. They sometimes waken him, and tend to get easier as the day progresses. They do not occur every day. On one occasion it was sited over the right frontal and aural area and associated with vomiting and nausea. Clinical examination, including fundoscopy, reveals nothing abnormal. What is the most likely diagnosis? A. Benign intracranial hypertension B. Cerebral space occupying lesion C. Migraine D. Tension headache

C. Migraine

You are the FY1 doctor on the night shift on the Acute Admissions Unit. Earlier you were called to see a 48 year old man because his admission NEWS score was 7. Having assessed him, how would you present the relevant information to your Specialist Registrar? A. Situation, background, assessment, reassessment, recommendation B. Situation, background, assessment, recommendation, readback C. Situation, background, assessment, response, review D. Situation, baseline, assessment, response, readback

B. Situation, background, assessment, recommendation, readback

A 92-year old man with atrial fibrillation is admitted because of a lack of sensation in his right leg. His leg is painful, but relieved by paracetamol. The admitting team find that the leg is warm and the dorsalis pedis is palpable. Ankle brachial pressure index is measured at 0.7. Which finding is most consistent with a diagnosis of peripheral arterial disease? A. Ankle brachial pressure index B. Leg pain relieved by paracetamol C. Palpable dorsalis pedis pulse D. Sensory disturbance

A. Ankle brachial pressure index 1.0-1.2 = Normal 0.8-0.9 = Mild arterial disease: mild claudication 0.5-0.79 = Moderate arterial disease: severe claudication <0.5 = Severe arterial disease: rest pain, ulceration, critical ischaemia

An 85 year old man presents with pain in both hips. On examination his hips are tender. He is also noted to have an enlarged skull. An x-ray shows thickening and enlargement of the bones of the pelvis. On blood testing, which of the following is likely to be elevated? A. Acid phosphatase B. Alanine transaminase C. Alkaline phosphatase D. Aspartate transaminase

C. Alkaline phosphatase

A 60 year old man with a history of COPD presents with a three day history of a cough productive of green sputum, wheeze and breathlessness. Culture of the sputum reveals a gram-negative bacillus. Which infective organism is the most likely cause? A. Escherichia coli B. Haemophilus influenzae C. Mycoplasma pneumoniae D. Streptococcus pneumoniae

B. Haemophilus influenzae E Coli is gram negative but rarely causes respiratory tract infections. Mycoplasma species have no cell wall, therefore gram stain is useless. Strep pneumoniae is gram positive.

An 85 year old woman with advanced Alzheimer’s disease has been found to have a large abdominal aortic aneurysm at risk of rupture within the next 12 months. The surgical team have recommended repair. She has not previously made her wishes known on advance treatment of any kind. Her family do not want her to suffer and ask you what should be done for the best. How should you proceed? A. Have a meeting with the family and other healthcare professionals involved in her care to determine her best interests B. Recommend repair as it will prevent death from aneurysmal rupture C. Refer the decision to the Court of Protection as the reasons for and against repair are finely balanced D. Tell the family that ultimately it must be they that make the decision as they know her best

A. Have a meeting with the family and other healthcare professionals involved in her care to determine her best interests

A 45 year old man is admitted to a hospice with terminal pancreatic cancer. As he approaches the end of his life he is started on a syringe driver containing morphine. He becomes agitated and frightened, saying he can see the angels coming, and fighting with dementors around his bed. He does not recognise the staff, and says that they are demons fighting him in purgatory. What is the most likely diagnosis? A. Delirium B. Dementia C. Depression D. Schizophrenia

A. Delirium

A 43-year old woman presents to her GP with a mass on her back. On examination it is around 5cm in diameter, tender, with a clearly defined edge, and is fixed to the skin. Which sign would raise your suspicion that this could be a malignancy? A. It has a clearly defined edge B. It is fixed to the skin C. It is tender on palpation D. Its size

B. It is fixed to the skin

A 77 year old woman is admitted to the Acute Admissions Unit with increasing breathlessness. She has rheumatoid arthritis and is known to known to have a history of lung disease. On her assessment the admitting Consultant notes that examination of the chest is ‘consistent with pulmonary fibrosis’. What has she heard on examination? A. Apical wheeze B. Bibasal fine inspiratory crepitations C. Coarse mid-zone crackles D. Whispering pectoriliquy

B. Bibasal fine inspiratory crepitations

A 64 year old man is admitted from home with a collapse. He has no past medical history and had been well until the day of admission. Following arrival to the Acute Admissions Unit he goes to the toilet and passes a stool mixed with a large amount of fresh red blood. The admitting doctor proceeds to treat him for a gastro-intestinal bleed. What is the most likely source of the blood loss? A. Diverticular disease B. Duodenal ulcer C. Haemorrhoids D. Rectal varices

A. Diverticular disease

[EMQ Theme: Diarrhoea] Name the most likely diagnosis: A 75 year old man presents with an 8 month history of diarrhoea. He has no other medical history. On examination he is pale and cachexic. His heart rate is 90/min and blood pressure 100/70mmHg. He has a positive faecal occult blood test.

Colonic carcinoma

[EMQ Theme: Diarrhoea] Name the most likely diagnosis: A 25 year old woman presents to her General Practitioner with diarrhoea, palpitations and weight loss. On examination she has sweaty palms, a fine tremor, her pulse is 120/min and irregularly irregular.

Thyrotoxicosis

[EMQ Theme: Diarrhoea] Name the most likely diagnosis: A 68 year old man presents with a 6 hour history of bloody diarrhoea and severe abdominal pain. He has had 3 myocardial infarctions and diabetes. On examination, his pulse is 110/min and blood pressure is 90/55mmHg. Abdominal X-ray is normal.

Ischaemic colitis

[EMQ Theme: Diarrhoea] Name the likely diagnosis: A 19 year old man presents to his General Practitioner with a 6 month history of diarrhoea with blood and mucus, weight loss and colicky abdominal pain. Blood tests show a C-reactive protein of 120mg/L (normal <5).

Inflammatory bowel disease

[EMQ Theme: Diarrhoea] Name the likely diagnosis: A 45 year old man presents to his General Practitioner with watery diarrhoea, weight loss and nausea for 2 months. He is a former intravenous drug user. On examination he has generalised lymphadenopathy. Stool microscopy reveals cysts.

Cryptosporidium

[EMQ Theme: Emergency Treatment] What is most appropriate emergency medication or procedure: ``` A. Cardiac defibrillation B. IM epinephrine (adrenaline) C. IV Hartmann’s solution 500ml over 10 minutes D. IV hydrocortisone E. IV lidocaine F. IV normal saline solution 1L over 8 hours G. Low molecular weight heparin H. Primary Coronary Angioplasty I. Thrombolysis J. Warfarin ``` 2 weeks after breaking her ankle, a 48 year old woman is found collapsed at home, complaining of central chest pain. On arrival to the Emergency Department her heart rate is 116bpm, blood pressure 78/45, oxygen saturations 89% on 8L of O2. Her chest is clear. Her ECG shows evidence of right heart strain.

I. Thrombolysis | Alteplase

[EMQ Theme: Emergency Treatment] ``` A. Cardiac defibrillation B. IM epinephrine (adrenaline) C. IV Hartmann’s solution 500ml over 10 minutes D. IV hydrocortisone E. IV lidocaine F. IV normal saline solution 1L over 8 hours G. Low molecular weight heparin H. Primary Coronary Angioplasty I. Thrombolysis J. Warfarin ``` What is most appropriate emergency medication or procedure: A 62 year old man is found collapsed in the street. A passer-by calls an ambulance. On arrival, the paramedics find him to be unresponsive with no recordable pulse. An ECG strip shows irregular electrical activity with no discernible pattern.

A. Cardiac defibrillation

[EMQ Theme: Emergency Treatment] ``` A. Cardiac defibrillation B. IM epinephrine (adrenaline) C. IV Hartmann’s solution 500ml over 10 minutes D. IV hydrocortisone E. IV lidocaine F. IV normal saline solution 1L over 8 hours G. Low molecular weight heparin H. Primary Coronary Angioplasty I. Thrombolysis J. Warfarin ``` What is most appropriate emergency medication or procedure: A 34 year old man becomes rapidly unwell after eating a chocolate nut brownie in a cafe. When the ambulance arrives he is gasping for breath, his face and neck is covered in a blotchy rash and his tongue is becoming swollen.

B. IM epinephrine (adrenaline)

[EMQ Theme: Emergency Treatment] ``` A. Cardiac defibrillation B. IM epinephrine (adrenaline) C. IV Hartmann’s solution 500ml over 10 minutes D. IV hydrocortisone E. IV lidocaine F. IV normal saline solution 1L over 8 hours G. Low molecular weight heparin H. Primary Coronary Angioplasty I. Thrombolysis J. Warfarin ``` What is most appropriate emergency medication or procedure: A 78 year old man with a previous hemiplegic stroke is admitted from his Nursing Home with a day’s history of feeling unwell with a fever. A District Nurse changed his long-term urinary catheter the day before. In the Emergency Department his heart rate is 118bpm, blood pressure 82/59 and temperature 38.2oC.

C. IV Hartmann’s solution 500ml over 10 minutes

[EMQ Theme: Emergency Treatment] ``` A. Cardiac defibrillation B. IM epinephrine (adrenaline) C. IV Hartmann’s solution 500ml over 10 minutes D. IV hydrocortisone E. IV lidocaine F. IV normal saline solution 1L over 8 hours G. Low molecular weight heparin H. Primary Coronary Angioplasty I. Thrombolysis J. Warfarin ``` What is most appropriate emergency medication or procedure: A 54 year old woman calls for an ambulance after suffering 2 hours of severe central chest pain. She has a history of type II diabetes and familial hypercholesterolaemia. On arrival to the Emergency Department her heart rate is 104bpm, blood pressure 168/95, oxygen saturations 99% on 2L of O2. Her chest is clear. Her ECG shows left bundle branch block. An ECG performed a year ago was normal.

H. Primary Coronary Angioplasty This woman is likely having an acute MI

[EMQ Theme: Hormonal deficiencies] ``` A. Aldosterone B. Antidiuretic hormone C. Cholecystokinin D. Cortisol E. Glucagon F. Growth hormone G. Insulin H. Oestrogen I. Prolactin J. Testosterone K. Thyroxine ``` Identify the most likely hormone deficiency to explain this presentation: A 75 year old woman is admitted to hospital with worsening confusion. Her son describes a 3 month history of gradual fatigue, weight gain and hair loss. On examination she is cold, with general hypotonia, periorbital oedema and reduced mental agility.

K. Thyroxine

[EMQ Theme: Hormonal deficiencies] ``` A. Aldosterone B. Antidiuretic hormone C. Cholecystokinin D. Cortisol E. Glucagon F. Growth hormone G. Insulin H. Oestrogen I. Prolactin J. Testosterone K. Thyroxine ``` Identify the most likely hormone deficiency to explain this presentation: A 24 year old woman presents with a collapse following a tooth extraction 5 days previously. She has a GCS of 10 and a fever. On examination she is noted to be pigmented, with blood pressure of 84/42. Her blood glucose is 1.5mmol/l.

D. Cortisol

[EMQ Theme: Hormonal deficiencies] ``` A. Aldosterone B. Antidiuretic hormone C. Cholecystokinin D. Cortisol E. Glucagon F. Growth hormone G. Insulin H. Oestrogen I. Prolactin J. Testosterone K. Thyroxine ``` Identify the most likely hormone deficiency to explain this presentation: An 18 year old woman presents with a 6 week history of thirst and passing copious amounts of urine. Clinical examination is normal. Her plasma sodium is 154mmol/L(normal range 135-145) and her blood sugar is 5.4mmol/L.

B. Antidiuretic hormone

[EMQ Theme: Hormonal deficiencies] ``` A. Aldosterone B. Antidiuretic hormone C. Cholecystokinin D. Cortisol E. Glucagon F. Growth hormone G. Insulin H. Oestrogen I. Prolactin J. Testosterone K. Thyroxine ``` Identify the most likely hormone deficiency to explain this presentation: A 24 year old man presents with a 3 week history of fatigue, thirst and weight loss. He has noted that he had a lot of “boils” recently. On examination he looks thin and tired, and his breath is noted to smell sweet. Urinalysis shows heavy glycosuria.

G. Insulin

[EMQ Theme: Hormonal deficiencies] ``` A. Aldosterone B. Antidiuretic hormone C. Cholecystokinin D. Cortisol E. Glucagon F. Growth hormone G. Insulin H. Oestrogen I. Prolactin J. Testosterone K. Thyroxine ``` Identify the most likely hormone deficiency to explain this presentation: A 60 year old man with type II diabetes presents with progressive gynaecomastia over 9 months. He feels tired and weak and when directly asked admits that he has had erectile difficulties for a couple of years.

J. Testosterone

[EMQ Theme: Orbit and anterior segment] ``` A. Basal cell carcinoma B. Blepharitis C. Ectropion D. Entropion E. Myasthenia gravis F. Orbital cellulitis G. Preseptal cellulitis H. Sjogren’s syndrome I. Squamous cell carcinoma J. Thyroid eye disease ``` Based on ocular examination of the eyelids, select the most likely diagnosis: A 32 year old woman presents to eye casualty with significant right eyelid swelling and redness which resulted in upper lid ptosis. Her temperature is normal and she is otherwise feeling well. On examination, right visual acuity is 6/6 and there is no relative afferent pupillary defect. Extraocular movements are full and there is no proptosis. The conjunctiva is mildly hyperaemic but the remaining of the slit-lamp examination is unremarkable. Left eye examination is normal.

G. Preseptal cellulitis

C. Ectropion

H. Sjogren’s syndrome

[EMQ Theme: Orbit and anterior segment] ``` A. Basal cell carcinoma B. Blepharitis C. Ectropion D. Entropion E. Myasthenia gravis F. Orbital cellulitis G. Preseptal cellulitis H. Sjogren’s syndrome I. Squamous cell carcinoma J. Thyroid eye disease ``` Based on ocular examination of the eyelids, select the most likely diagnosis: A 40 year old woman has noticed that her right upper eyelid droops. She was first aware of it 3 months ago but did not seek advice as it was not always present. It is now getting worse and finds it more prominent later in the day. She is also now developing double vision, which is again worse whenever she is tired. She is on Vitamin B12 injections for pernicious anaemia.

E. Myasthenia gravis

[EMQ Theme: Orbit and anterior segment] ``` A. Basal cell carcinoma B. Blepharitis C. Ectropion D. Entropion E. Myasthenia gravis F. Orbital cellulitis G. Preseptal cellulitis H. Sjogren’s syndrome I. Squamous cell carcinoma J. Thyroid eye disease ``` Based on ocular examination of the eyelids, select the most likely diagnosis: A 36 year old man has been complaining of gritty eyes. His GP had prescribed some lubricants which have improved his symptoms slightly. On examination, you notice he has acne rosacea and at the lid margins there are telangiectatic vessels and gland secretions.

B. Blepharitis

[EMQ Theme: Drug side-effects] ``` A. Atorvastatin B. Clopidogrel C. Diltiazem D. Fludrocortisone E. Furosemide F. Isosorbide mononitrate G. Levodopa H. Ramipril I. Rivaroxaban J. Spironolactone K. Warfarin ``` Which drug is most likely to be causing the described side-effect? A 92 year woman is on medication for mild heart failure. On routine testing of her urea and electrolytes she is found to have a potassium of 2.9 mmol/L (normal range 3.5-5.1mmol/L).

E. Furosemide Loop diuretics cause excess excretion of potassium, leading to hypokalaemia.

[EMQ Theme: Drug side-effects] ``` A. Atorvastatin B. Clopidogrel C. Diltiazem D. Fludrocortisone E. Furosemide F. Isosorbide mononitrate G. Levodopa H. Ramipril I. Rivaroxaban J. Spironolactone K. Warfarin ``` Which drug is most likely to be causing the described side-effect? A 58 year old man is seen in the pre-assessment unit whilst waiting for an elective hernia repair. He is on medication for ischaemic heart disease. He is noted to have a heart rate of 48bpm on his routine observations.

C. Diltiazem Calcium channel blockers may be used in ischaemic heart disease patients and slow heart rate.

[EMQ Theme: Drug side-effects] ``` A. Atorvastatin B. Clopidogrel C. Diltiazem D. Fludrocortisone E. Furosemide F. Isosorbide mononitrate G. Levodopa H. Ramipril I. Rivaroxaban J. Spironolactone K. Warfarin ``` Which drug is most likely to be causing the described side-effect? An 84 year old man with a history of Parkinson’s disease is admitted to hospital with recurrent falls. He is noted to have significant postural hypotension and is commenced on medication for this. A month later he complains of swollen ankles.

D. Fludrocortisone Mineralocorticoid steroids (e.g. aldosterone, fludrocortisone) raise blood pressure and so they can be used to treat postural hypotension. one of the side-effects is fluid retention and peripheral oedema.

[EMQ Theme: Drug side-effects] ``` A. Atorvastatin B. Clopidogrel C. Diltiazem D. Fludrocortisone E. Furosemide F. Isosorbide mononitrate G. Levodopa H. Ramipril I. Rivaroxaban J. Spironolactone K. Warfarin ``` Which drug is most likely to be causing the described side-effect? A 68 year old man is seen in clinic following a TIA. He is noted to be in atrial fibrillation and commenced on treatment for this, which he tolerates well. Six months later he is given clarithromycin for a chest infection. He falls and sustains a large haematoma on his knee.

K. Warfarin

[EMQ Theme: Drug side-effects] ``` A. Atorvastatin B. Clopidogrel C. Diltiazem D. Fludrocortisone E. Furosemide F. Isosorbide mononitrate G. Levodopa H. Ramipril I. Rivaroxaban J. Spironolactone K. Warfarin ``` Which drug is most likely to be causing the described side-effect? A 78 year old woman is admitted to the Coronary Care Unit with an ST elevation myocardial infarction. In a follow-up clinic one month later she complains of aching muscles.

A. Atorvastatin Statins are commonly given to individuals with coronary artery disease. Muscle aches is a common complaint of patients taking statins.

[EMQ Theme: Haematuria] ``` A. Adenocarcinoma of the prostate B. Bladder calculus C. Cystitis D. Pyelonephritis E. Renal cell carcinoma F. Renal tuberculosis G. Schistosomiasis H. Transitional cell carcinoma of the bladder I. Ureteric calculus J. Urethritis ``` What is the most likely cause of this patient's haematuria? A 55 year old man has a 1 day history of frank haematuria and severe colicky right-sided lumbar pain. On examination he is apyrexial. Urine microscopy shows 150 red blood cells per high power field. No organisms are seen.

I. Ureteric calculus

[EMQ Theme: Haematuria] ``` A. Adenocarcinoma of the prostate B. Bladder calculus C. Cystitis D. Pyelonephritis E. Renal cell carcinoma F. Renal tuberculosis G. Schistosomiasis H. Transitional cell carcinoma of the bladder I. Ureteric calculus J. Urethritis ``` What is the most likely cause of this patient's haematuria? A 21 year old woman has a 3 day history of dysuria and frequency associated with rigors and severe left-sided loin pain. Her temperature is 38.1C. Urinalysis shows >105 Gram negative bacilli/ml.

D. Pyelonephritis

[EMQ Theme: Haematuria] ``` A. Adenocarcinoma of the prostate B. Bladder calculus C. Cystitis D. Pyelonephritis E. Renal cell carcinoma F. Renal tuberculosis G. Schistosomiasis H. Transitional cell carcinoma of the bladder I. Ureteric calculus J. Urethritis ``` What is the most likely cause of this patient's haematuria? A 75 year old male smoker has a 3 month history of intermittent painless haematuria, but no other urinary symptoms. He is anaemic, with a serum urea of 35.2mmol/l. A renal ultrasound shows unilateral hydronephrosis.

H. Transitional cell carcinoma of the bladder Clues: - Risk factors: male, older age, smoker - Painless haematuria and anaemia - Unilateral haematuria: transitional cell carcinomas in the bladder tend to occur at the opening of the ureters, high risk of occlusion and therefore back pressure.

[EMQ Theme: Haematuria] ``` A. Adenocarcinoma of the prostate B. Bladder calculus C. Cystitis D. Pyelonephritis E. Renal cell carcinoma F. Renal tuberculosis G. Schistosomiasis H. Transitional cell carcinoma of the bladder I. Ureteric calculus J. Urethritis ``` What is the most likely cause of this patient's haematuria? A 19 year old student presents with a 24 hour history of haematuria, frequency and dysuria. She is well, but urinalysis shows leucocytes, organisms and red blood cells.

C. Cystitis

[EMQ Theme: Haematuria] ``` A. Adenocarcinoma of the prostate B. Bladder calculus C. Cystitis D. Pyelonephritis E. Renal cell carcinoma F. Renal tuberculosis G. Schistosomiasis H. Transitional cell carcinoma of the bladder I. Ureteric calculus J. Urethritis ``` What is the most likely cause of this patient's haematuria? An 83 year old man presents with a six month history of intermittent haematuria. On closer questioning he also admits to hesitancy, frequency and a poor urinary stream.

A. Adenocarcinoma of the prostate

[EMQ Theme: Collapse] ``` A. Aortic stenosis B. Complete heart block C. Hypoglycaemia D. Meningitis E. Postural hypotension F. Pulmonary Embolus G. Seizure H. Stroke I. Sub-arachnoid haemorrhage J. Transient Ischaemic attack K. Ventricular fibrillation ``` What is the most likely underlying cause of this patient's collapse? A 7 year boy has recently been diagnosed with Type 1 diabetes. His mother has a long history of depression and has struggled to come to terms with this. She is found collapsed at home with a suicide note next to her.

C. Hypoglycaemia The mother has overdosed on her son's insulin.

[EMQ Theme: Collapse] ``` A. Aortic stenosis B. Complete heart block C. Hypoglycaemia D. Meningitis E. Postural hypotension F. Pulmonary Embolus G. Seizure H. Stroke I. Sub-arachnoid haemorrhage J. Transient Ischaemic attack K. Ventricular fibrillation ``` What is the most likely underlying cause of this patient's collapse? A 78 year old man has Parkinson’s Disease and his symptoms are getting worse. He was recently seen in the Neurology clinic and his Levodopa was increased. At home, he gets up out of his chair to answer the phone and falls to the ground.

E. Postural hypotension Dopaminergic drugs for Parkinson’s disease can cause hypotension, as wells as nausea, confusion and hallucinations.

[EMQ Theme: Collapse] ``` A. Aortic stenosis B. Complete heart block C. Hypoglycaemia D. Meningitis E. Postural hypotension F. Pulmonary Embolus G. Seizure H. Stroke I. Sub-arachnoid haemorrhage J. Transient Ischaemic attack K. Ventricular fibrillation ``` What is the most likely underlying cause of this patient's collapse? A previously well 43 year old man complains of a sudden occipital headache and falls to the ground. He dies in the ambulance on the way to hospital. The diagnosis is made on post-mortem.

I. Sub-arachnoid haemorrhage Sudden intense headache (thunderclap) is typical of subarachnoid haemorrhage. As they are arterial bleeds, the effects can be devastating and rapid.

[EMQ Theme: Collapse] ``` A. Aortic stenosis B. Complete heart block C. Hypoglycaemia D. Meningitis E. Postural hypotension F. Pulmonary Embolus G. Seizure H. Stroke I. Sub-arachnoid haemorrhage J. Transient Ischaemic attack K. Ventricular fibrillation ``` What is the most likely underlying cause of this patient's collapse? A 68 year old man had a stroke 6 months ago due a left-sided partial anterior circulation infarct. He made a good recovery and has no residual weakness but has recurrent episodes of tingling and weakness affecting his right leg lasting around 10 minutes. These cause him to fall but he does not lose consciousness.

G. Seizure Following brain injury (e.g. stroke, trauma) patients can experience seizures. This patient is describing partial seizures, affecting just a region of the brain.

[EMQ Theme: Collapse] ``` A. Aortic stenosis B. Complete heart block C. Hypoglycaemia D. Meningitis E. Postural hypotension F. Pulmonary Embolus G. Seizure H. Stroke I. Sub-arachnoid haemorrhage J. Transient Ischaemic attack K. Ventricular fibrillation ``` What is the most likely underlying cause of this patient's collapse? A 72 year old woman is admitted to the Coronary Care Unit with chest pain. Her admission ECG shows signs consistent with an acute inferior myocardial infarction. Whilst awaiting coronary angioplasty she complains of feeling light-headed; her blood pressure is 70/40 and her pulse is 35 bpm

B. Complete heart block Inferior MI: the right coronary artery supplies the inferior aspect of the heart. This artery also supplies the AV node. The MI has lead to ischaemia of the AV node, therefore the electrical current can't get through at all (complete heart block). The ventricles are contracting at their own slow pace, independent of the SA node.

[EMQ Theme: Falls without loss of consciousness] ``` A. Age-related macular degeneration B. Cerebellar stroke C. Left middle cerebral artery infarct D. Parkinson’s disease E. Peripheral sensory neuropathy F. Phenytoin toxicity G. Postural hypotension H. Sarcopaenia I. Sodium valproate toxicity J. Vascular dementia K. Vestibular neuronitis ``` Which is the most likely underlying cause of this patient's fall? A 68 year old man is admitted following a fall. He fell forward, and was unable to stop himself with his hands, resulting in a broken nose. He has recently fallen a few times whilst out hill-walking, and struggles to keep up with the rest of the group. On examination his walk is slow, and he does not swing his arms, particularly on the left side. His face is expressionless.

D. Parkinson’s disease Clues: - Unable to reach out to break fall, does not swing arms: rigidity or hypertonicity is a common PD presentation. - Slowed walking, unable to keep up: shuffling gait is a common PD presentation. - Expressionless face: Masked facies is a common PD presentation.

[EMQ Theme: Falls without loss of consciousness] ``` A. Age-related macular degeneration B. Cerebellar stroke C. Left middle cerebral artery infarct D. Parkinson’s disease E. Peripheral sensory neuropathy F. Phenytoin toxicity G. Postural hypotension H. Sarcopaenia I. Sodium valproate toxicity J. Vascular dementia K. Vestibular neuronitis ``` Which is the most likely underlying cause of this patient's fall? A 74 year old woman falls over whilst out shopping. The ground was uneven and she struggled to know where her feet were. She has a history of diabetes and has been on insulin for the last 48 years.

E. Peripheral sensory neuropathy Patient may report a feeling of unsteadiness when walking (especially on uneven surfaces, in poorly lit areas); loss of sensation in feet or hands; history may include diabetes or neurodegenerative disease (e.g., herniated disc)

[EMQ Theme: Falls without loss of consciousness] ``` A. Age-related macular degeneration B. Cerebellar stroke C. Left middle cerebral artery infarct D. Parkinson’s disease E. Peripheral sensory neuropathy F. Phenytoin toxicity G. Postural hypotension H. Sarcopaenia I. Sodium valproate toxicity J. Vascular dementia K. Vestibular neuronitis ``` Which is the most likely underlying cause of this patient's fall? An 82 year old man with a 50 year history of epilepsy is admitted after hitting his head on the side of a door frame. On examination he is noted to be dysarthric with a broad-based gait. He was recently commenced on clarithromycin for a chest infection.

F. Phenytoin toxicity Phenytoin is an antiepileptic drug. It is metabolised by the P450 system to enable elimination. Clarithromycin is a P450 inhibitor, therefore drugs metabolised by this system are done so more slowly and they remain in the blood for a longer time. If phenytoin levels increase enough, it causes symptoms similar to being drunk or having cerebellar disease (dysarthria, wide-based gait).

[EMQ Theme: Falls without loss of consciousness] ``` A. Age-related macular degeneration B. Cerebellar stroke C. Left middle cerebral artery infarct D. Parkinson’s disease E. Peripheral sensory neuropathy F. Phenytoin toxicity G. Postural hypotension H. Sarcopaenia I. Sodium valproate toxicity J. Vascular dementia K. Vestibular neuronitis ``` Which is the most likely underlying cause of this patient's fall? A 93 year old woman falls whilst struggling to get out of her chair. On admission to hospital she is noted to be very frail, weighing only 42Kg. Examination shows wasting of the quadriceps muscles.

H. Sarcopaenia Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and it is strictly correlated with physical disability, poor quality of life and death. Risk factors for sarcopenia include age, gender and level of physical activity.

[EMQ Theme: Falls without loss of consciousness] ``` A. Age-related macular degeneration B. Cerebellar stroke C. Left middle cerebral artery infarct D. Parkinson’s disease E. Peripheral sensory neuropathy F. Phenytoin toxicity G. Postural hypotension H. Sarcopaenia I. Sodium valproate toxicity J. Vascular dementia K. Vestibular neuronitis ``` Which is the most likely underlying cause of this patient's fall? An 83 year old woman is admitted from a Care Home following a fall. This is her 4th fall in the last 2 months. She had a stroke 2 years ago and is unsteady on her feet. She needs to use a walking frame for support but often forgets to do so.

J. Vascular dementia History of cerebral vascular disease (stroke) and forgetfulness suggest vascular dementia as the most likely cause from the list of differentials.

Revision 1 Flashcards

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